07/11/2016. Agenda. Role of ALL early providers. AAP Guidelines, Cont d. Early Communication Assessment

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1 Early Communication Assessment Early Social Communication Assessment: Models for Infant Siblings at Risk for ASD How early? 9-12 months we attempt to make critical observations of younger sibs, capturing both home and clinic snapshots Natalie Brane M.S. CCC-SLP, Children s Healthcare of Atlanta Marcus Summer Symposium 2016 The presenter has no relevant financial/nonfinancial relationships to disclose Agenda AAP Screening Guidelines, 2007, 2010 Measuring social engagement in infancy What are the earliest red flags to look for? Considering the natural environment Engaging parents ASD Red Flags identified: What s next? Early Social Interaction project Is this community viable? Surveillance at every visit Four risk factors for surveillance Routine ASD screen at 18 months and 24 months AAP Guidelines, Cont d Surveillance factors 1. Sibling with ASD 2. Parent concern, inconsistent hearing, unusual responsiveness 3. Other caregiver concern 4. Pediatrician concern If 2 or more, refer for EI, ASD Evaluation, and Audiology simultaneously. If 1 and child at least 18 months old, use ASD specific screening tool. When screen is positive, refer for EI, ASD Evaluation, and Audiology Role of ALL early providers ASD is presumably present at birth, with onset of symptoms before 36 months Accurate diagnosis possible at months, latest baby sibling studies suggest earlier Average age of first concern: 15 months (Chawarska, Paul, Klin et al., 2007). Parents note delays as early as 12 months, first voice concerns around 18 months, but diagnosis is typically not until 4 years or older Huge potential benefits of early treatment 1

2 DSM-5: Autism Spectrum Disorder Important to Consider Delays & deviance in the development of social communication skills, with the presence of restricted and/or repetitive behaviors, present in the early developmental period. Aiming to build capacity to diagnose at a younger age Diagnosis can occur reliably by 18 months- average closer to 4, the numbers are worse for the state of Georgia Earlier intervention increases potential for better outcomes Let s talk about all 3! SPEECH versus LANGUAGE versus COMMUNICATION SPEECH & LANGUAGE DEVELOPMENT is a primary area of delay in early autism symptomatology COMMUNICATION deficits are persistent in ASD throughout development Assessment & intervention for a child with ASD should be ongoing At-risk Cohort: Baby sibs ASHA (2006a) Ad hoc Committee on Autism Spectrum Disorders defines appropriate roles and responsibilities of SLP s in dx, assessment and treatment of ASD across the life span UC-Davis/Ozonoff et. al (2013) enrolled 294 infant sibs of children with ASD and 116 infant siblings of TD children. Time points of developmental/behavioral assessment at 6, 12, 18, 24 and 36 months. 1. SLPs play a critical role in screening, early detections of children at risk for ASD, and making referrals for dx and intervention 2. SLPs who acquire and maintain the necessary knowledge and skills can diagnose ASD, typically within a multidisciplinary diagnostic team 3. SLPs can make appropriate referrals to rule out other conditions and facilitate access to services Screening & referral American Speech-Language-Hearing Association. (2006). Roles and responsibilities of speech-language pathologists in diagnosis, assessment, and treatment of autism spectrum disorders across the life span [Position Statement]. Available from Assessment Intervention Nearly Half Diagnosed with ASD or show related issues By 36 months, 17 % of the baby sibs had been diagnosed with ASD. Another 28 % had related developmental issues including with communication delays and social vulnerabilities listed as extreme shyness, little eye contact or lack of pointing to share. Also noteworthy: The baby siblings who showed early delays didn t catch up over time. This counters the traditional wait-and-see approach still common among many healthcare providers. Nonverbal capacity for communication There were significant differences between the ASD & DD groups and the ASD & TD groups on the following 9 items: 1) lack of appropriate gaze 2) lack of warm, joyful expressions with gaze 3) lack of sharing enjoyment or interest 4) lack of response to name 5) lack of coordination of gaze, facial expression, gesture, and sound 6) lack of showing 7) unusual prosody 8) repetitive movements or posturing of body, arms, hands, or fingers 9) repetitive movements with objects There were significant differences between the ASD & TD groups but not the ASD & DD groups on the following 6 items: Typical Development Eye gaze, gaze shifting Response to name Orientation to speech Pointing Affect sharing Caregiver referencing Imitation Early Red Flags in Autism Gaze aversion Lack of response to name Limited response to adult speech Lack of Pointing Object focused Lack of/limited caregiver referencing Lack of imitation 1) lack of anticipatory posture or movement 2) lack of response to contextual cues 3) lack of pointing 4) lack of vocalizations with consonants 5) lack of playing with a variety of toys conventionally 6) difficulty calming when distressed. Joint attention, response and initiation Lack of/limited skills across these areas Symbolic play Lack of symbolic play after 18 mos Looking beyond typical speech milestones, there is a basis for social communication before words come along 2

3 Socially deviant behaviors ACE Infant Sibling Testing Protocol: combining experimental paradigm with direct assessment Can these be seen in toddlers? Important to understand the very early and emerging signs of social communication that are deviant in autism How are they expressed in toddlers? More importantly, how can they be assessed? months: monthly eye tracking visits 2. 9, 12, 15, 18, 24 months: eye tracking combined with behavioral assessment Assessment battery includes: Communication: SORF + Communication and Symbolic Behavior Scales (CSBS) 9, 12, 15*,18, 21*, 24 months Social-behavioral: ADOS- Toddler Module 12*, 24 months Early Development: Mullen Scales of Early Learning 12, 24 months Adaptive development: Vineland Adaptive Behaviors Scales months Treatment Eligibility at 12 months Communication Assessment Communication & Symbolic Behavior Scales- Development Profile (CSBS-DP) Amy Wetherby, Barry Prizant, 2002 Useful assessment tool for evaluating communication in toddlers ages 12 months to 24 months Effective way to assess early prelinguistic behaviors, and to examine social vulnerabilities as well Only a portion of a global developmental assessment Autism Diagnostic Observation Schedule- Toddler Module (ADOS-T: Luyster et al., 2009) Mullen Scales of Early Learning Development & Use of an ASD specific screener Quantifying RED FLAGS as early as possible The Systematic Observation of Red Flags (SORF): Observational screening measure designed to detect red flags for ASD in toddlers based on DSM-5 diagnostic criteria Based on a behavioral sample (vs. parent report) Work completed via early ASD studies at FSU & Michigan Tested and developed among month olds enrolled in the FSU First Words project (5,000 child broadband population screener) Screening Tool; currently being tested among 9-12 month olds in ACE project Ratings based on whether behavior exists, is delayed, or deviant Aligned with new DSM-5 criteria 3

4 Observing & Quantifying the earliest derailment of social attention We re measuring what babies see, but more importantly we re measuring what they don t see Warren Jones, Emory, Marcus Center. Baby s Gaze May Signal Autism, a Study Finds, New York Times, Nov. 13, Baby & Toddler communication Many areas develop together from infancy through toddlerhood: Early social engagement What are we examining? Functions of Communication 3 basic functions of communication to look for in toddler development: Gesture use Communication milestones include: Early understanding of language 1. regulatory functions, used to get others to do or not do things; (REQUESTS) 2. social interaction functions, used to greet, call attention to oneself or one s actions or to show off 3. joint attention functions, used to direct an adult s attention to objects or events for the purpose of sharing focus. Sound development 4

5 Joint Attention is the process of sharing one s experience of observing an object or event, by using gaze shifts and/or pointing gestures. It is critical for social development, language acquisition & cognitive development In other words: Joint attention is a child s way of pointing something out for the purpose of sharing. This is NOT requesting, and is purely a social behavior. Parent Report: Capturing a child s communication skills Parent Questionnaire CSBS Infant-Toddler Checklist Completed by parent at home/in a doctor s office/childcare facility or during intake process, prior to speech evaluation Considered a 1 st step screener, Normed at 9-24 months Available free online in 8 languages, Brookes Publishing Considering the Natural Environment What to capture in the home observation: Stability of Early Clinical Diagnosis Short term stability (2 nd year to 4 years) (Chawarska et al., 2007; 2009) Very good for ASD diagnosis (80-90%) Changes expected within spectrum due to shifts in number of symptoms and intensity Long term stability (2 to 4 to 9 years) (Lord et al., 2006) High stability of ASD diagnosis (90%) Shift from PDD-NOS to Autism Dx: ~20% Shift from Autism to PDD-NOS: ~10% ` We ve completed our assessment We ve identified enough red flags at 12 months, we present this information to families Now what? 5