Transcript Foundations of Autism - Ventura County SELPA

Foundations of Autism
(Autism Spectrum Disorder)
Steven M. Graff, Ph.D.
Director of Clinical Services
Tri-Counties Regional Center
&
Laura D. Valdez, M.S.
Camarillo Academy for Excellence
November 3, 2012
Clinical Definitions
Diagnostic and Statistical Manual (DSMIV-TR): Autism, Asperger syndrome,
and Pervasive developmental disorder
NOS are discrete disorders
They will be combined and called ASD with level of
severity specified in the new DSM-5.
.
Federal Educational Code
A wide variety of problems can earn the
same eligibility: autistic/autistic-like
Presentations of Classic
Autism
Birth to 24 months:
feeding problems; failure to thrive; poor
latch and suck; arching back; colic;
problems sleeping; poor eye contact;
not responding to name; loss of
previously acquired language.
Why does this get missed? (Subtle
oddities; first child; families moving
away from grandparents & family?)
Presentations of Late Onset
3 to 5 years old:
Jargon, echolalia, scripted language; lack
of imaginative play, fascination with
cause-and-effect toys, lights, mirrors or
fans; odd or perseverative interests;
lack of interest in others, especially
children (no parallel or interactive
play); severe tantrums (>60’)
Other Disorders That Are Commonly Mistaken
For Autism
Fragile X syndrome
Tuberous Sclerosis
Bipolar Disorder
Landau-Kleffner Syn.
Tourette’s Syn.
Fetal Alcohol Syn. (FAS)
Epileptic aphasia
Asperger Syn.
Pervasive developmental
disorder NOS
Communication Disorders
Neurofibromatosis
Intellectual Disability (Mental
Retardation)
Severe Abuse or Neglect
ADHD
Obsessive Compulsive Disorder
Social communication disorder
Childhood disintegrative disorder
Rhett’s disorder
Myths of Persons with Autism
Do not care about others
Do not feel emotions
Do not feel pain
Do not want relationships
All are savant geniuses
Epigenetics: interaction between
environmental exposure and genetic
material
Genetic predisposition EXTREMELY LIKELY
[over 60 genes identified so far and increasing]
+
Environmental exposure: pesticides heavy metal
pollutants; air pollutants; bisphenyl A
[plastics], flame retardants; and viruses
Vaccinations are not a cause according to most
scientific research
Theory of mind and Mirror Neurons
Ever wondered how some people can “put themselves into
another person's shoes” and some people cannot? Our ability
to empathize with others seems to depend on the action of
"mirror neurons" in the brain,
Mirror neurons activate when an action is observed, and
also when it is performed. Research reveals that there are
mirror neurons in humans that fire when sounds are heard. In
other words, if you hear the noise of someone eating an apple,
some of the same neurons fire as when you eat the apple
yourself. Subjects in the study who scored higher in empathy
tests also showed higher levels of mirror neuron activation.
(Gazzola, 2006)
Persons with autism seem to lack this Mirror system.
More thoughts on symptom causation: Reticular activating
system (the brain’s “alarm clock” is often hyper developed,
leading to sleep disorders which can lead to behavior
problems!
Higher incidence of allergies and sensitivities, leading to sinus
headaches and diarrhea, which lead to behavior problems!
Left supra orbital frontal cortex (social awareness center) is
underdeveloped-no Theory of Mind (T.O.M.) which leads to
social problems
Dopaminergic pathways tend to be underdeveloped, leading
to emotional dysregulation which leads to behavior problems!
Brain
Structure and organization of the brain is often different
than control studies.
Often see microcephaly at birth; yet macrocephaly at first
year check up (too rapid brain growth without apoptosis,
or normal death of unneeded cells).
Cerebellum: Punkinje (nourishment) cells-decreased
number.
Limbic System and Cortex-decreased neuron density.
Dendridic interconnectivity odd everywhere.
Embryology
Autism starts in the first trimester
[Thalidomide; viral infection history] in
the gastrula stage, when the neural
plate is forming the neural tube.
Normal axon migration is disruptedcells going in the wrong direction, with
too few/too many cells in nerve tracts,
and poor connectivity of synapses
“Red Flag” Indicators
NO babbling by 12 months
Lack of response to name at 12 months
NO back and forth gestures such as pointing,
showing, reaching, or waving
NO meaningful words by 16 months
NO 2-way meaningful phrases by 24 months
of age (excluding imitation)
ANY loss of speech, babbling, or social skills at
ANY age (but remember, new siblings often
bring loss of adaptive skills for a while in
typical kids)
How do we diagnosis
Autism?
Interdisciplinary Team
[IDT] is Best Practice
An IDT approach allows you to
evaluate and integrate the effects of
ASD on multiple areas of the child’s
development and provide a
comprehensive profile of the child
Domains of Observation
Reciprocal turn –
taking
Social reciprocity
Sustained
interaction
Spontaneous
giving/showing
Imitation of novel
acts
Shared attention
Pretend Play
Gaze aversion
Ability to have
examiner direct
attention
Use of toys and
objects
Cognitive Assessment
A careful examination of cognitive
functioning is needed to plan
meaningful interventions
Cognitive functioning is measured more
accurately using a combination of
formal and informal observational
methods.
The assessment of young children with
suspected ASD requires knowledge of
both normal child development as well
as the developmental issues of persons
with autism.
Adaptive Functioning
Adaptive functioning refers to the child’s
ability to use acquired skills and abilities
to cope with the demands of daily living.


Measures of adaptive functioning are
required to render a formal diagnosis of
mental retardation concomitant with ASD as
well as determine a baseline of acquired
skills for ASD or other differential diagnosis.
Children with ASD often display
discrepancies in certain facets of cognitive
abilities and adaptive functioning levels.
Social Deficits
Deficits of
interactivity
Poor eye contact
Flat/inappropriate
facial expression
Poor non-verbal
social skills
Lack of empathy
or blunted
emotional
responses
Delayed or absent
peer relationships
Delayed or absent
interest in others
Socialization Styles
Aloof-often described as “being in
his own world”
Passive-which can be ignored if not
a problem in the classroom
Interactive but odd
Communication
Severe delay or absence of useful
speech/nonverbal communication.
Receptive language skill level often
different than expressive skill level.
Use of evasive language is common.
Parent anticipation of communicative
intent/ using parents as tools
Communication Cont.
Echolalia, delayed echolalia
Jargon, idiosyncratic words
Scripted speech [TV, movies]
Prosody/pragmatics of speech
Pronoun reversal
Behavior
Stereotypic motor movements and
perseverations
Hand flapping, spinning, finger play,
fixation on themes, colors, numbers,
people, objects. [must differentiate
between “party behavior” vs. true
oddities]-not toe walking-very common
in all children.
Behavior Cont.
Difficulty with transitions
Routines, rituals, difficulties when they
are disrupted even from highly nonpreferred activities
Need for task completion or closure
Fixation with parts (wheels) versus
whole (car)
Sensory Differences
“It is likely there is a continuum of visual
and auditory processing problems for
most people with autism, which goes
from fractured, disjointed images at one
end to a slight abnormality at the other
end.”
Temple Grandin, Thinking in Pictures
Hyper/Hypo-sensitivities
(increased/decreased)
Sound
Taste
Touch
Movement
Light
Smell
Texture
Hyper/Hypo-sensitivities
They can co-exist:
“How come his pain tolerance is so
high yet he can’t stand to be
touched?”
“Why does he act like he’s deaf,
yet is bothered by the buzzing of
the lights in the classroom?”
Learning and Thinking in
Autism
Visual Learners mostly, but not always.
Auditory learning with comprehension is
not usually a strength (but mimicry is)
Often Kinesthetic learners (need
motoring through; can’t be told how to
do it)
Concrete thinkers, not abstract
A child with autism may look
like…..
Uneven pattern of development
Rote memory a relative strength, but
analysis and inference are weaknesses
Visual procession of information a
relative strength
Communication/social interactions
highly problematic
A child with autism may also
look like…
Generalization of knowledge/skills
is difficult
Skills available spontaneously, but
not on request
Resistance to change/desire for
sameness can be problematic
Attention difficulties
Sensory differences
Three Mainstream
Treatment Approaches
Intensive Behavioral Interventions-IBI
Discrete Trial Training (DTT), Applied Behavioral
Analysis (ABA), Lovaas and Pivotal Response
Therapy (PRT)
Treatment & Education of Autistic &
Communicationally Handicapped Children
(TEACCH)
Developmental: Greenspan/Floor time, DIRindividual difference, relationship-based model
Individuals with
Disabilities Education Act
The IDEA mandates that all
children with disabilities receive a
free, appropriate public education
in the least restrictive
environment, tailored to each
child’s individual needs.
Educational Needs of Persons
with Autism
1.
Preschool Age
Communication therapies in the
classroom and at home. (group and
individual)
Parent participation and training
1:1 as well as small group instruction
Child engaged in a variety of
developmentally appropriate activities
Educational Needs of Persons
With Autism
2. School Age Children
A variety of options with autism
specific services
Curriculum that focuses on
developing independence
Common School Age
Children Curriculum Areas:
Communication
Mobility
Social
Self Help
Community
Recreation/Leisure
Domestic
Vocational
Functional academics
Educational Needs of Persons
with Autism
3. High School Age
Same as school age but with
increased emphasis on vocational
and community based instruction.
Educational Needs of Persons
with Autism
4. Adult
College vs. vocational training
Need for appropriate housing
(ranging from living with family,
group home, or own apartment)
Independent living skills training
Social/recreational/dating support
National Autism Center- National
Standards Report
Includes the identification of
“Established, Emerging, and
Unestablished” treatments for children
with autism. [The report focuses on
ages 0-22 and not on adults].
The report on can be found at the
following link:
http://www.nationalautismcenter.org/af
filiates/reports.php
Established treatment
“Established” Treatments: treatments
that produce beneficial outcomes and
are known to be effective for individuals
on the autism spectrum. The report
identified 11 Established Treatments;
the majority of these are based on the
behavior therapy literature, and
include: Applied Behavior Analysis
(ABA), Discrete Trial Training (DTT), and
Pivotal Response Therapy (PRT).
Some non-Established
Autism “Therapies”
Auditory Integration
Therapy/Tomatis
method
Swimming with
Dolphins
Equestrian Therapy
Music Therapy
Speech therapy
Social Skills
RDI
Sensory Integration
Therapy
Facilitated
Communication
Hyperbaric Oxygen
Therapy (HBOT)
Surfing Therapy
Megavitamins
Vision/Irlen lenses
Psychosurgery
The Established therapies:
Behavior therapy
Medication to address symptoms
Choosing a Therapy
There are lots of “therapies” which
purport to cure, alleviate, or
improve autism. Beware of poor
research. Parents may believe that
one, or even 1000 hopeful
anecdotes outweigh negative
research. [No, it doesn’t].
Medications don’t “cure” autism, but
the symptoms may be treatable
CNS Stimulants (attention/hyperactivity)
Anti-Depressants (for agitation/mood)
Anti-Convulsants (mood stabilization)
Anti-Psychotics (impulsivity/agitation)
Anti-Opiates (“Stimming” or Self-Injurious
Behavior
Anxiolytics (anxiety)
Guidelines for Evaluating
Approaches
Be skeptical of any treatment that
provides a “magic” cure or any program
that represents only one option
Individualize programs are best
Goals should be to increase
independence/ functional skills
Programs should be structured and
geared toward developmental level
Number one rule of
intervention should be…
Focusing on the acquisition of skills
as well as the generalization of
functional, adaptive behaviors.
The End
Questions?