Transcript Early Signs of Autism and Assessment in Identification of

Early Signs of Autism and Assessment in
Identification of Autism Spectrum Disorders
(ASD)
Ann Levine, Psy.D.
Neuropsychologist
Texas Child Study Center
Clinical Director of SHARE
[email protected]
Nuts and Bolts
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Early signs of Autism Spectrum
Disorders
Gold Standards for Assessment
Neuropspychological Assessment
Autism as a Culture
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“Autism is of course not truly a culture; it is a
developmental disability caused by neurological
dysfunction. Autism too, however, affects the ways
that individuals eat, dress, work, spend leisure time,
understand their world, communicate, etc. Thus, in a
sense, autism functions as a culture, in that it yields
characteristic and predictable patterns of behavior in
individuals with this condition…”
–
Gary Mesibov, Ph.D.
Why Talk about this?
Why does it matter
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Rates of ASD are increasing
Early intervention has been shown to improve outcomes for
children with ASD*
In order for children with ASD to receive intervention, first
they need to be identified
To care for a person with autism without early intervention
over his/her lifetime the estimated cost is $3.2 million.**
*Dawson, G. & Osterling, J.(1997). Early intervetnion in autism. In M.J. Guralnick (Ed.) The effectiveness of early intervention (pp. 307326). Baltimore: Paul H. Brookes Publishing Co.
**Ganx, M., “The Costs of Autism,” Understanding Autism: From Basic Neuroscience to Treatment,S. Moldin, J.L.R. Rubenstein,
eds., CRC Press, 2006, pg. 475-502. (As reported in the California Legislative Blue Ribbon Commission on Autism Report,
Sept. 2007: An Opportunity to Achieve Real Change for California with Autism Spectrum Disorders.)
Typical development
Atypical Development
Autism Spectrum Disorders
ASD
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Early emerging neuro-developmental
disorders that have an impact on most
domains of cognitive and adaptive
functioning.
Developmental disorder involving life-long
impairments in social interaction,
communication, and narrow
interests/repetitive behaviors
What is needed
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Coherent picture of early behavioral
profiles and developmental trajectories
that help distinguish very young
children with ASD from typical
developing children and from children
with other developmental delays.
History of Determining Early Signs of
ASD
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Retrospective studies
– Limitations include
Recall bias
 Possibility of isolated case reports
representing atypical or most severe cases
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Currently Determining Early Signs of
ASD
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Prospective studies:
– following infants that are at risk of
developing ASD
– Provides an opportunity to more
accurately characterize the development
of regression in ASD
Possible Areas of
Dysfunction in the 1st
Year
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0-3 months
– Preference for face like stimuli
– Sensitivity to speech like sound
3-6 months
– Development of social interactions with others
6-9 months
– Response to name
– Social games (peek-a-boo)
– Recognize identity, affect, gender with face processing
9-12 months
– Joint attention
– Social referencing
– Social imitation and monitoring
Results of following high risk infants
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9 infants followed prospectively starting at 6 months of
age.
– Symptoms not present at 6 months of age
– All infants at 6 months demonstrated:
 Interest in social interactions
 Showed social smile
 Sustained eye contact and affective responses to
mother
 Responsive to others
(Bryson, et.al 2006)
Results of following high risk infants
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Symptoms developed for some infants by 12
months of age and for others by 18 months
of age
7 of the 9 children given diagnosis of ASD
prior to 36 months of age
Findings of a Prospective Study of
50 infants
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No group differences at 6 months of
age
Between 12 and 18 months for the
group later diagnosed with ASD
displayed loss of skills
– Loss of social communication behaviors
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Gaze to face, smile, vocalizations
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(Ozonoff, et al 2010)
Discrepancy
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Changes in social communication
development assessed through
prospective research suggest a
different picture of symptom onset
from parents’ retrospective report.
Common Practice in Assessment
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Gather information about symptom
onset from parents, yet this practice
may not be a valid assessment of slow
decline in social communication that
can be observed prospectively.
Recent Findings from Prospective
Studies
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Signs of ASD emerge over the first
year or so of life in many children with
ASD rather than being present from
close to birth
Pattern of having ASD expressed prior
to 6 months may be less common than
once thought
Recent Findings from Prospective
Studies
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Traditionally defined categories of
early onset and regressive autism do
not paint the picture of how symptoms
develop
Social communicative behaviors
decrease rather than fail to progress
Recent Findings from Prospective
Studies
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Deficits and delays in emerging joint attention
Decreased response to name
Decreased imitation
Delays in verbal and non-verbal communication
Motor delay
Elevated frequency of repetitive behaviors, e.g. hand waving
Atypical visuo-motor exploration of objects
Extremes of temperament
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Bryson, S.E. et al. (2007), Landa, R. and Garrett-Mayer, E. (2006), Yoder, P. et
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al. (2009)
Take Home Message about
Prospective Studies
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Currently identification of autism may not be
possible in the majority of affected children
by 12 months of age
American Academy of Pediatrics
recommendations for screening at both 18
and 24 months is essential and may even
need to be supplemented by screens after
age 2 years.
C. P. Johnson, et al, May 2007,
Signs and Symptoms
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National Research Council in its 2001 report
Educating Children with Autism remarked “the
manifestation of autism vary considerably across
children and within an individual child over time.
There is no single behavior that is always typical of
autism and no behavior that would automatically
exclude an individual child from a diagnosis of
autism, even though there are strong and
consistent commonalities, especially relative to
social deficit.”
National Research Council, Committee on Interventions for Children with Autism. Educating Children
with Autism. Washington, DC: National Academies Press; 2001
Differential Diagnosis
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ASD
Intellectual Disability
Language Disorders
Obsessive Compulsive Disorder
Schizophrenia
Reactive Attachment Disorder
Making the Diagnosis
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Practice parameters published by the
American Academy of Neurology and the
American Academy of Child and Adolescent
Psychiatry indicated children who fail ASD
screeners should have a comprehensive
diagnostic assessment by experienced
clinicians.
Filipek, et al. 2000, Volkmar et al. 1999
Comprehensive Evaluation Model
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Interdisciplinary
Evaluates various areas of functioning
Gathers information across
environments
Provides an integrated perspective
Communicates with schools and other
providers
Provides recommendations
Components of a Comprehensive
Evaluation
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Developmental history
Physical exam
Establishing cognitive and language baselines
Assessment of social, communication, play, and
behavioral presentation
Assessment of motor skills and sensory functioning
Components of a Comprehensive
Evaluation
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Laboratory investigation to search for know
etiology or coexisting condition(s)
Medical concerns and co-morbidity
Adaptive functioning
Neuropsychological, educational, and vocational
assessments
Assessment of possible family/parent support
needs
Results of the Assessment Provides
– Diagnostic clarification
– Medical Findings
– Profile of child’s strengths and challenges
– Profile of child’s developmental level and
adaptive functioning
– Recommendations for evidenced-based
developmental and educational
interventions, as well as parent
recommendations
Variables Neuropsychologists Consider
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Information from multiple sources
Adaptive functioning
Social, communication, and behavioral
problems
Family systems and needs
Variables Neuropsychologists Consider
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Intellectual ability
Problem solving and learning style
Academic Functioning
Neuropsychological profile
– Memory
– Language
– Executive functions
– Motor
– Visual Spatial
Typical Referral
Questions
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Diagnostic Clarification
Treatment Planning
Evaluation of Treatment Response
Eligibility for Services
The process of assessing
autism
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No medical test
Behavioral diagnosis
General Impressions
Questionnaires/Screenings
“Gold-Standard”
measures
Assessment tools
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Autism Diagnostic Observation Scale-Generic (ADOS-G) Lord
et al. 2000
Autism Diagnostic Interview (ADI-R)
– Structured interview with parents Lord et al. 1994
ADOS and the ADI-R are considered the “gold standard” for
diagnosis
These instruments may lead to provisional diagnoses from as
early as 18 months of age but tend to be more reliable with
increasing age of the child
Western Psychological Services
http://portal.wpspublish.com/portal/page?_pageid=53,70384&_dad=portal&_schema=PORTAL
Autism Diagnostic Interview
Revised (ADI-R)
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Semi-structured based interview for
caregivers
Interview may take between tow to
three hours
ADOS
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This semi-structured assessment
assesses toddlers to adults, from
children with no speech to adults who
are verbally fluent who may have ASD.
Western Psychological Services
http://portal.wpspublish.com/portal/page?_pageid=53,70384&_dad=portal&_schema=PORTAL
ADOS
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The ADOS consists of various activities; the clinician observes social
and communication behaviors.
Look for target behaviors through specific use of toys, activities, and
questions
Repetitive behaviors, sensory sensitivities, restricted interests
observed and coded
The ADOS includes four modules, each requiring 35 to 40 minutes to
administer. Modules based on communication level.
Western Psychological Services
http://portal.wpspublish.com/portal/page?_pageid=53,70384&_dad=portal&_schema=PORTAL
ADOS
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ADOS activities for a child who is nonverbal to single word
utterances
Free play
Response to name
Joint Attention
Bubble Play
Anticipation of a Routine With Objects
Responsive Social Smile
Anticipation of Social Routine
Functional and Symbolic Imitation
Birthday Party
Snack
Usually sensory interest
in Play Material/Person
Free play
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Seek engagement
with examiner or
caregiver
Exploration of
materials
symbolic/functional
Length of time
engaged in activity
Bubble Play
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Elicit eye contact
and vocalization in
coordination with
pointing or reaching
in order to direct
the attention of
parent or examiner
Anticipation of a routine
with objects
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Child’s affect
Initiation of joint
attention
Shared enjoyment
Requesting
Motor behavior
Anticipation of a Social
Routine
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Assess the child’s
anticipation of,
request for, and
participation in a
social routine
Cognitive/Developmental
Assessment
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Children with an ASD also have signs of
intellectual disability, averaging 44% in
2004 and 41% in 2006
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http://www.cdc.gov/ncbddd/features/counting-autism.html
Level of intellectual functioning is
associated with severity of symptoms,
ability to acquire skills, level of
adaptive functioning, and outcome.
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Filipek et al. 1999
Intellectual Assessment
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Behaviors that interfere:
– High distractibility
– Off task behaviors
– Social difficulties
– Unusual use of language
– Anxiety
Training to help increase
responsiveness to testing
environment
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May need to teach the child how to sit
in a chair for 5 minutes
May need to teach a child how to
accept and trade toys
Addressing behavioral concerns
– Enhance the child’s motivation
– Conducted testing over multiple sessions
– Frequent reinforcement breaks
Intellectual Assessment
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Intelligence tests for children with
spoken language
– Wechsler Scales(WPPS-III, WISC-IV,
WASI, WAIS III)
– Differential Ability Scales, 2nd edition
– Stanford-Binet 5th edition
– Kaufman Assessment Battery for
Children, 2nd edition
Intellectual Assessment
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Nonverbal Children
– Leiter International Performance ScaleRevised
Developmental
Assessment
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Children under the age of five
– Bayley Scales of Infant Development-II
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Ages 1 to 42 months
– Mullens Scales of Early Learning
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Ages 1 to 60 months
Predictive Value of Intellectual
Assessments
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Research has consistently documented
that IQ at age 5 correlates with adult
outcomes
It is unclear if IQ at 2 or 3 correlates
with adult outcomes
Attention with ASD
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Focusing
– Tend to over focus on extraneous details
(Fein et al., 1990)
– Distracted by special interests
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Sustaining
– Children with ASD usually do not have a
problem with sustained attention
(Garretson, et al. 1990)
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Shifting
Attention with ASD
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Continuous performance tests
– TEA-Ch (Manly et al. 2001)
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Assess attention and activity level across
environments with questionnaires
– CBCL (Achenbach, 1991)
– BASC (Reynolds and Kamphaus, 1998)
– BRIEF (Gerard A. Gioia, 2002)
Executive Functions
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Executive Functions include:
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Planning
Inhibition
Organization
Self monitoring
Cognitive flexibility
Working memory
Deficits in executive functions common for
children with ASD
(Ozonoff and Jensen 1999, Russell 1997)
Executive Functions
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Delis Kaplan Executive Function
System (Delis et al. 2001)
– Trailmaking
– Verbal and Design Fluency
– Color Word Interference
– Tower
Tower_of_Hanoi
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* Only one disk may be moved at a time.
* No disk may be placed on top of a
smaller disk.
Wisconsin Cart Sorting
Task
Neuropsychological Assessments
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Results from neuropsychological
evaluations may provide greater clarity
of the child’s strengths and
weaknesses which helps with planning
for intervention
Neuropsychological testing is usually
not warranted for nonverbal and
intellectually deficit children.
Brain Based Findings
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Atypical Visual Scanning and
Recognition of Faces in 2 and 4-YearOld Children with Autism Spectrum
Disorder
Brain Based Findings
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Neural responses to faces
* Autistic children as young as 3 years of age
exhibit atypical ERPs to faces and facial
expressions but not to objects
Summary
* Children with ASD displayed a slow response to
faces and larger response to objects compared to
typical developing children
The Objective
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“Don’t underestimate persons with autism,
try to understand.”
http://lastcrazyhorn.wordpress.com/quotes-about-autism-and-everything-that-includes/