Transcript Autism Spectrum Disorder and Toddlers

Autism Spectrum
Disorder and Toddlers
Regional Autism Spectrum Team
Cork & Kerry
September 2013
Aims of this session
To increase your knowledge of:
1. Current best practise guidelines re
Assessment of toddlers with possible
ASD
2. Typical toddler development in the areas
of social interaction, play and
communication
3. Signs of an ASD in a toddler.
Autism Diagnostic Assessments
and Toddlers
• Parents generally identify concerns regarding
their’s child’s development between 12-18
months. (Zwaigenbaum et al,2009)
• Clinical guidelines on the early identification,
screening, and diagnosis of ASD recommend
that 18- and 24-month-olds be screened for an
ASD. (NICE guidelines,
1. Best Practise Guidelines on screening
and assessment with Toddlers.
• The following information is mainly based on:
– NICE Clinical guidelines: Autism diagnosis in children and young
people. Recognition, referral and diagnosis of children and
young people on the autism spectrum. (2011)
– Scottish Intercollegiate Guidelines Network (SIGN). (2007)
Assessment, diagnosis and clinical interventions for children and
young people with autism spectrum disorders. A national clinical
guideline.
– Also consulted the Canadian best practise, Californian Best
practise and the Vermont Best practise guidelines.
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Be aware that in some children and young people there may be uncertainty
about the diagnosis of autism, particularly in:
children younger than 24 months
children or young people with a developmental age of less than 18 months
children or young people for whom there is a lack of available information
about
their early life (for example some looked-after or adopted children)
older teenagers
children or young people with a complex coexisting mental health disorder
(for
example ADHD, conduct disorder, a possible attachment disorder), sensory
impairment (for example severe hearing or visual impairment), or a motor
disorder
such as cerebral palsy.
• The assessment of children and young people with
developmental delay, emotional and
• behavioural problems, or genetic syndromes should
include surveillance for ASD as part
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Healthcare professionals should consider informing
families that there is a substantial
• increased risk of ASD in siblings of affected children.
• C The use of an appropriate structured instrument
may be a useful supplement to the
• clinical process to identify children and young
people at high risk of ASD
• The evidence regarding the minimum age at which ASD
can be reliably diagnosed is not clear.
• Findings suggest that:
• the diagnosis of autism is always more reliable and
stable than the diagnosis of other autism
• spectrum disorders, regardless of age, and can be
reliably diagnosed between the ages of
• 2-3 years by experienced healthcare professionals.39,
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• in children later identified as having ASD, features
reported when they were under two
• years may have been non-specific.41
• Early identification is essential for early
therapeutic intervention and leads
• to a higher quality of life for the child
and family
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Social-communication, notably a lack of/atypicalities in
Eye gaze and shared/joint attention
Affect and its regulation (eg, less positive and more negative affect)
Social/reciprocal smiling
Social interest and shared enjoyment (in absence of physical contact such
as tickling)
Orienting to name called
Development of gestures (eg, pointing)
Coordination of different modes of communication (eg, eye gaze, facial
expression, gesture, vocalization)
Play, notably
Reduced imitation of actions with objects
Excessive manipulation/visual exploration of toys and other objects
Repetitive actions with toys and other objects
Language and cognition, notably a lack of/delays or atypicalities in
Cognitive development
Babbling, particularly back-and-forth social babbling
Language comprehension and production (eg, odd first words or
unusually repetitive)
Unusual prosody/tone of voice
Regression/loss of early words and/or social-emotional
engagement/connectedness
Visual/other sensory and motor, notably
Atypical visual tracking, visual fixation (eg, on lights) and unusual
inspection of objects
Underreactive and/or overreactive to sounds or other forms of sensory
stimulation
Decreased activity levels and delayed fine and gross motor skills
Repetitive motor behaviors and atypical posturing/motor mannerisms
Atypicalities in regulatory functions related to sleep, eating, and attention
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First, some children with ASDs, particularly those
with more intact language and intellectual development,
may have more subtle symptoms at an early age.44,50
Speech delays are often the concern that parents first
report, so for children without marked delays, early
symptoms may be less apparent. As well, a proportion of
children with ASD symptoms may show “plateauing,”
deceleration, or frank losses in cognitive and social development
or functioning in the second year.44,48,50 Thus,
mild symptoms and even an absence of symptoms at 18
months do not “rule out” a later diagnosis of ASDs.
Ongoing surveillance and follow-up are essential, particularly
for children who are referred because of early
concerns but do not initially receive an ASD diagnosis
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Second, it may be difficult to distinguish between
ASDs and other atypical patterns of development at an
early age. This may be especially true among infant
siblings of children with ASDs, who are at risk not only
for ASDs but also for a broader spectrum of delays including
but not limited to the areas of emotion expression
and referential communication.20,53,94–98 Similarly,
early diagnosis of ASDs may be difficult in toddlers with
severe developmental delays, or impairments in vision
and/or hearing, for whom standardized diagnostic instruments
have shown limited specificity.80,99
• Often, a misdiagnosis that
• results in a child failing to receive
necessary services is the greatest
concern. On the other
• hand, over-diagnosis has negative
consequences for individual children,
public health
• strategies and research.
• Toddlers diagnosed with an ASD according to
the DSM-5 were found to represent a more
impaired population compared to those who
qualified for a diagnosis of an ASD based on the
DSM-IV-TR, but not the DSM-5. The group
diagnosed according to the DSM-IV-TR
represented a population of toddlers who were
more impaired than atypically developing peers.
• Conclusions: The proposed changes to the DSM
will likely result in those diagnosed with an ASD
according to the new criteria representing a
more functionally impaired group
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Population screening for ASD is not recommended. False positive or false negative
results from
inappropriate use of screening tests may delay correct diagnosis. The decision about
the need
for referral and further assessment should be made on clinical grounds. As part of
the core programme of child health surveillance, healthcare professionals
can contribute to the early identification of children requiring further
assessment for
ASD, and other developmental disorders:
clinical assessment should incorporate a high level of vigilance for features
suggestive of ASD, in the domains of social interaction and play, speech and
language
development and behaviour
CHAT or M-CHAT can be used in young children to identify clinical features
indicative of an increased risk of ASD but should not be used to rule out ASD.
Autism in Infancy and Early
Childhood
• During the first 6-8 months babies who
later received a diagnosis show
diminished visual attention to people,
• They tend to seek others less frequently
and are less likely to engage in early
social communicative exchanges (i.e.
smiling at others, vocalising).
• No different from typical children exploring
and showing interest in objects.
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delay or absence of spoken language
looks through people; not aware of others
not responsive to other people’s facial expression/feelings
lack of pretend play; little or no imagination
does not show typical interest in or play near peers purposefully
lack of turn-taking
unable to share pleasure
qualitative impairment in non-verbal communication
does not point at an object to direct another person to look at it
lack of gaze monitoring
lack of initiation of activity or social play
unusual or repetitive hand and finger mannerisms
unusual reactions, or lack of reaction, to sensory stimuli
manifest as aggressive or disruptive behaviour)
lack of awareness of classroom ‘norms’ (criticising teachers,
overt unwillingness to cooperate
in classroom activities, inability to appreciate or follow
current trends)
easily overwhelmed by social and other stimulation
failure to relate normally to adults (too intense/no
relationship)
showing extreme reactions to invasion of personal space
and resistance to being hurried
Impairments of interests, activities and/or behaviours
lack of flexible cooperative imaginative play/creativity
difficulty in organising self in relation to unstructured space
(eg hugging the perimeter of
playgrounds, halls)
inability to cope with change or unstructured situations,
even ones that other children
enjoy (school trips, teachers being away etc)
Infants and toddlers with Autism vs. typical toddlers
Social
Interaction
Limited ability to
1st
year anticipate being
Communication
Stereotypical
Behaviours
Poor response to
name,
Excessive
mouthing
picked up,
Low frequency of
looking at people, Infrequent looking Aversive to
Little interest in
at objects held by social touch
interactive games, others
Little affection
toward familiar
people
Content to be
alone
Early Communicate intent
Typical developing child
Child with an ASD
By 12 months:
Recognise mothers voice
Less responsive to people speaking,
their mothers voice or to their name.
Synchronising their patterns of eye
gaze, movements, facial expressions
of affect
Vocal turn taking
Limited in the variety of
communicative behaviours
Requesting objects, rejecting offered
actions, calling attention to objects and
events and commenting on their
appearance using gestures such as
reaching, pointing, pushing away,
shaking head. (gradually accompanied
or replaced by sounds and words)
Beginning to understand words- esp
.in games/routines: show me your
Expressive language
skills developing at a slower rate
Frequency of initiation joint attention
and imitation are strong predictors for
language acquisition in children with
an ASD
Vocalisations less likely to be paired
with non-verbals
First words
Typically developing child
ASD
12 months: first recognisable
words
Enormous variation in the times and patterns
of acquisition in AS.
Clear understanding some words
and phrases, outside the context
of games and routine.
Most individual with ASD significant delays in
development of speech, develop at slow
rate.
18 months: 50-100 words.
Requests to adult to label things,
often after a single exposure. (no
longer by association but by
reference)
Losing words developed between 12-18
months. (unique to ASD- about 25%). Often
loss in social skills as well.
Objects and people
Relationships among objects (all
gone)
Social: greetings
Ideas: uh-oh, more
Regression is generally gradual in which
children do not learn new words and fail to
engage in communicate routines that they
did before. (Kurita, 1985). Usually before the
language explosion.
Only a minimal relationship between
language regression and later outcome-
First words cont
Typically developing child
Child with an ASD
16-19 months:
Able to use non-verbal cues, such as
an adult’s eye gaze, to make fine
distinctions between an object that an
adult is naming and another object
that’s present.
Research suggests that language
acquisition among verbal ASD children
progresses along similar lines of
typically developing peers.
This suggests they are now
understanding the intentions of others
within language contexts (Baldwin,
1991)
18-24 months
Combing words into telegraphic
speech
Begin to understand “conversational
obligation” to answer speech with
speech. They ask AND answer
Some children never acquire speechmany of these children have a very
low non-verbal IQ.
Less than 20% nonverbal (Lord et al,
2004)
(though it is not easy to disentangle
improvements in language skills
across the spectrum from an increase
in diagnosis in the higher functioning
population).
Articulation often normal.
Linguistic Structures
Typical developing child
Child with an ASD
2-5 years: fully grammatical forms.
Approximately more and more to
language spoken at home.
Often slower in development but same
path.
Content expands to allow reference to
events remote in time and space.
Confusion of personal pronounshowever can occur in children with SLI
and blind children: but MOST common
in ASD.
Children begin to use their language in
more diverse way to include
Pronoun confusion is seen as a
imaginative, nonliteral, interpretative
reflection of difficulties in notions of
and logical functions
self and other and in shifting roles
between the speaker and listener.
Maintain and add new information to a (perspective taking).
conversational topic, clarify and
request clarification of misunderstood
utterances, make request and
comments using polite or indirect
forms, choose appropriate speech
style on the basis of the speakers role
Echolalia
One of the most Salient features of an ASD but NOT
unique to ASD. Most common in ASD though.
Immediate or delayed and functional or nonfunctional.
Echolalia- also occurs in:
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blind children,
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children with language impairments,
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older people with dementia
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TYPICALLY DEVELOPING CHILDREN!
For all children will decline over the course of
development.