Autism spectrum disorders (ASD) General Definition

Transcription

1 What is Autism? Katherine Lamb, Ph.D., CCC/SLP Autism spectrum disorders (ASD) General Definition Complex neurodevelopmental disorders Social impairments Communication difficulties Restricted, repetitive, and stereotyped Overall Autism is a spectrum disorder Wide variety of combinations Can be very different from each other Still commonly used to refer to any of the 5 PDDs klamb16 2 klamb Diagnostics No definitive medical test Interviews, observation, and specific checklists Neurologist, psychologist, developmental pediatrician, SLP R/O: ID, HI, behavior or eccentric habits Research: Eye contact Orienting to name Joint attention Pretend play Imitation Nonverbal communication Language development are measurable by 18 months of age. Siblings klamb Communication Skills Broad range of abilities, Two common impairments A. Delayed language B. Echolalia klamb Social Interaction Hallmark 1. Impaired use of nonverbal behavior 2. Lack of peer relationships 3. Failure to spontaneously share 4. Lack of reciprocity ToM? klamb Behaviors Repetitive Impeding Positive behavior supports Self-injurious Aggression 4. Sensory and movement disorders Common Over- or under-sensitive Abnormal posture and movements eye movements Repeated gestures and mannerisms Can be detected very early 5. Predictability Change in routine Particular arrangements, foods Symmetry Preparing for change klamb16 7 klamb16 8 klamb

2 6. Intellectual functioning All levels of intelligence ID 75% below 70 Verbal and reasoning skills are difficult Savant syndrome Screening results Consistent with typical development No signs of developmental delays or risk factors identified Consistent with typical development; But: presence of risk factors Indicate a possible delay or disorder Risk factors may be identified Screenings in Autism klamb16 10 klamb16 11 klamb Developmental and Behavioral Screening Tools (B-36 Mo.) Wide application parent report hallmark developmental milestones lack the sensitivity to screen specifically for autism autism screening tool developmental screening raises concerns Ages and Stages Questionnaire (ASQ) Communication, gross motor, fine motor, problem solving, and personal-social 1 66 months 21 age-appropriate questionnaires for 2-60 mo. 30 items per questionnaire (child s abilities) minutes for parents to complete 2 3 minutes to score. 15,138 children reliable and valid Identifies children for further assessment Ages & Stages Questionnaires Social-Emotional 2 nd Ed (ASQ:SE-2 ) Parent-completed questionnaires to identify young children at risk for social or emotional difficulties Self-regulation, compliance, communication, adaptive behaviors, autonomy, affect, and interaction with people 1 72 mo. 9 age-appropriate questionnaires for use at 2, 6, 12, 18, 24, 30, 36, 48, and 60 months of age minutes for parents to complete 2 3 minutes to score 14,074 children and their families klamb16 13 klamb16 14 klamb The Infant Toddler Social-Emotional Assessment (ITSEA) Social or emotional problems and competencies in infants and toddlers Identify children with deficits or delays Scores on 4 domains: 1) Externalizing, 2) Internalizing, 3) Dysregulation, 4) Competence Scores on 3 clusters that include atypical behaviors: Maladaptive, Social Relatedness, and Atypical Parent Form and a Childcare Provider Form klamb16 16 ITSEA Anxiety/Mood Age Range: 1-3 # of Items: 166 Questionnaire Average Time to Complete (min): 25 Teacher/Day care provider Average Time to Score (min): 5 3-point scale: 0 = Not true/rarely, 1 = Somewhat true/sometimes, and 2 = Very true/often "No Opportunity" klamb16 17 The Brief Infant-Toddler Social and Emotional Assessment (BITSEA) standardized norm referenced instrument assess the social emotional problems and competencies aged 12 to 35 months 30 days. brief, screening tool drawn from the longer ITSEA first or second- stage screening tool measure certain areas such as externalizing problems, internalizing problems, dysregulation, maladaptive behaviors and atypical behaviors as well as competence klamb

3 BITSEA BITSEA Child Development Inventory 2 scales Problems scale and the Competencies scale 2 forms: parent form and a childcare provider form. Each contain 42 items Respondent rates each item on a 3 point scale (0=not true/rarely, 1=somewhat true/sometimes, 2=very true/always) Subscales 2 types of behaviors; social emotional problems and social emotional competencies. 31 items on the Problem scale externalizing problems internalizing problems problems of dysregulation maladaptive behaviors atypical behaviors 11 items on the Competence scale social-emotional: sustained attention Compliance mastery motivation prosocial peer relations, Empathy imitation/play skills social relatedness 3 separate instruments Infant Development Inventory, Early Child Development Inventory & Preschool Development Inventory 60 yes-no descriptions Measure development in 5 domains gross motor, fine motor, language, comprehension, and person-social (IDI)3-18 months (ECDI)18-36 months (PDI)36-60 months Mailed to families Waiting rooms Interview Direct elicitation klamb16 19 klamb16 20 klamb Communication and Symbolic Behavior Scales DP (CSBS-DP) Communicative competence of infants and toddlers Eye gaze, gestures, sounds, words, understanding, and play Infants and toddlers with functional communication between 6 mo and 24 mo (CA 6 mo to 6 yrs) Measures 7 language predictors emotion and eye gaze Communication gestures, sounds Words Understanding object use Caregivers and professionals trained to assess young children CSBS-DP 1-page Infant_Toddler Checklist 4-page follow-up Caregiver Questionnaire Behavior Sample (interacts with a parent) 5 10 minutes for the Infant-Toddler Checklist minutes for the Caregiver Questionnaire 30 minutes for the Behavior Sample validity and reliability with large samples of children The Temperament and Atypical Behavior Scale (TABS) Measure temperament and atypical behavior Normed on 1000 children; typical and atypical development Infants and young children between the ages of 11 and 71 mo 15-item TABS screener 55-item TABS assessment tool Atypical self-regulatory behavior in areas such as temperament attention attachment social behavior play vocal and oral behavior senses and movement self-stimulation and self-injury neurobehavioral state klamb16 22 klamb16 23 klamb TABS 4 categories of atypical temperament Detached Hyper-sensitive/active Underreactive Dysregulated Parents and professionals 5 minutes (screener) 15 minutes (assessment) Strong interrater and rating-rerating reliability Autism Spectrum Screening Questionnaire (ASSQ) 27-item checklist Layperson Characteristic of Asperger HFA normal intelligence or mild mental retardation Useful brief screening to identify of ASD disorders in clinical settings Assessments in Autism klamb16 25 klamb16 26 klamb

4 Dx Autism Diagnostic Interview Revised (ADI-R) Semi-structured, investigator-based Autism or pervasive developmental disorders is a possible diagnosis A standard diagnostic interview is conducted at home or in a clinic. High diagnostic accuracy. Several hours to administer and score Better standardized instruments Semi-structured interview Individual meets the DSM-MD (3rd., revised) criteria for autism DSM-IV criteria Interviews the child's parents in the home visit Parents' priorities Part of the in-clinic assessment Reliable and valid instrument for diagnosing autism in p/s children klamb16 28 Dx Prelinguistic Autism Diagnostic Observation Schedule (PL-ADOS) Semi-structured observation scale Not yet using phrase speech Suspected of having autism help of a parent. observe specific aspects of the child's social behavior Discriminate between CwA or nonautistic developmental disabilities Theoretically linked to International Classification of Diseases (10th revision) and DSM-IV criteria for autism klamb16 29 Dx Gilliam Autism Rating Scale Teachers, parents, and professionals To identify and diagnose autism 3-22 years Estimate the severity of the problem. Items based on the DSM-IV 4 subtests: 1. stereotyped behaviors 2. communication 3. social interaction 4. developmental disturbances 3 core subtests that describe specific and measurable behaviors Developmental Disturbances Parents contribute data (child's dev) during the first 3 years Validity and reliability of the instrument are high Entire scale can be completed in 5 to 10 minutes knowledge of the child's behavior observe child klamb Communication Assessment The Nonspeech Test for Receptive/Expressive Language Systematic way for observing recording summarizing Child may communicate Skills as a communicator speech or nonverbal Communication Assessment Assessing Semantic Skills Through Everyday Themes (ASSET) Receptive and expressive semantics pre- school and early elementary 6 common themes Everyday life Emphasize vocabulary that is meaningful and relevant 5 receptive and 5 expressive subtests Standardized analyses Receptive Expressive Overall vocabulary Communication Assessment Peabody Picture Vocabulary Test (III) Measures receptive vocabulary for SAE Measures vocabulary Relatively short period of time to administer Can be used for initial screening klamb16 31 klamb16 32 klamb Communication Assessment Expressive One- Word Picture Vocabulary Test Measures ability to verbally label objects & people Identify (word) a single object or a group of objects Based on a single concept Standardized Provides age equivalents, standard scores Communication Assessment The Receptive One-Word Picture Vocabulary Test Estimate of a child's one-word hearing vocabulary Home and school Ability to understand language Standardized test age equivalents, standard scores, scaled scores, percentile ranks Communication Assessment Preschool Language Scale (PLS 3rd ed.) 2 standardized subscales: Auditory Comprehension Expressive Communication Relative ability in receptive and expressive language Determine: deficiencies are primarily receptive or expressive in nature delay or disorder in communication. Precursors of receptive skills & precursors to expressive skills Supplemental Articulation Screener Language Sample Checklist Family Information and Suggestions Form klamb16 34 klamb16 35 klamb

5 Bayley Scales of Infant Development (2nd ed.) Diagnostic assessment at an earlier age Cognitive or motor delay Normed on a stratified random sample of 1,700 children 1 mo. to 42 mo. Variety of abilities: sensory-perceptual acuities, discriminations, and response acquisition of object constancy memory, learning, and problem solving, vocalization, beginning verbal communication, mental mapping, complex language and mathematical concept formation Motor Scale assesses degree of body control, large-muscle coordination, fine motor manipulatory skills, postural imitation, and motor quality. Mental and Motor scales 30-item scale rates test-taking behaviors attention, arousal, orientation, engagement, and emotional regulation Other Assessment Options Standardized videotape assessment Adaptive assessment Standardized Tests of Intelligence Tests of Nonverbal Intelligence Academic Screening Behavior Assessment Family Assessment Other Assessment Options Interventions for Autism Katherine Lamb, Ph.D., CCC/SLP klamb16 37 klamb16 38 klamb Treatments and Therapies Auditory Integration Sensory Integration ABA Discrete Trial Training Lovaas/UCLA Intervention Early Start Denver Model Holding Therapy Dolphin Assisted Therapy Facilitated Communication Augmentative Communication Vision Therapy Vitamins Hyperbaric Oxygen Psychopharmacological treatments 40 Floortime Music Therapy Social Skills Training Incidental Teaching TEACCH PECS Pivotal Response Therapy Son-Rise RDI Chelation Diets Drugs Supplements Evidence-Based Interventions Antecedent-Based Interventions (ABI) Speech Generating Devices/VOCA Computer-Aided Instruction Structured Work Systems Differential Reinforcement Task Analysis Discrete Trial Training Time Delay Extinction Video Modeling Functional Behavior Assessment Visual Supports Functional Communication Training Naturalistic Intervention Parent-Implemented Intervention Peer-Mediated Instruction and Intervention Picture Exchange Communication System (PECS) Pivotal Response Training Prompting Reinforcement Response Interruption/ Redirection Self-Management Social Narratives Social Skills Groups 41 Assessment Joint attention Social and communication assessed together Self-regulation Variety of settings How communicate (nonverbal) Who they communicate Consider level: comprehension functions of language Assessing Social Skills Want to socialize Uncomfortable in social settings Rude Difficulty understanding Humor Slang Figurative language Repetitive Patterns and Behavioral Differences Routine Repetition Eccentric or intense Preoccupation in own interests Repetitive questions Unmotivated by customary rewards Problems handling transition Closure or difficulty stopping (<finished) Common Antecedents Time of day Specific peers Specific classroom? Transition from more preferred to less preferred activity Change in routine-visual Request to STOP the behavior Medication, environmental or dietary changes Family circumstances

6 Visual strategies: Types and descriptions Visual Schedules Checklists Cue Cards Color-coded materials Visual Schedules Arranged vertically Photo/picture based along with print young Print based with older Some use computer/electronic versions Daily schedule or mini schedule Life long skill Checklists Entire day or an hour Homework list List of tasks Home Grocery shopping Errand helper Dry erase boards Erasable Colored markers help organization Cue Cards Script, phrase, word or picture C rings Cue for a situation Cafeteria Playground Circle time Library Greetings Color-Coded Materials Management of executive function File folders Colored stickers Calendar Plastic files Materials (visual supports) Calendar Colored dots Index cards Dry erase board and markers Hook and loop tape (velcro) Objects, photos, Boardmaker pictures, &/or print Treatment: Son-Rise Playroom without distractions Join child in their actions connection with the child accepted unconditionally Home-based, child-centered program Most effective to the individual s growth Relational and neurological Focusing on social relationships Option Institute Treatment: Son-Rise Pros: lack of distractions in the workroom rewards interpersonal relationships required self-analysis Cons: emphasis on the parents attitudes cure autism choose to come out of autism DIR: Developmental, Individualized, Relationships D = developmental Central focus is on functional emotional developmental levels (FEDLs) Attention and regulation Engagement and relating Two-way INTENTIONAL communication Complex problem solving Creative representations and ideas Representational differentiation and emotional thinking klamb

7 DIR I = Individual processing Sensory modulation hyper/hypo responsiveness to each sensory modality Sensory processing ability to register, decode, comprehend in each sensory modality Sensory-affective processing to process and react to affect/connect intent/affect to motor planning, sequencing, language, symbols Motor planning and sequencing capacity to sequence actions, behaviors, thoughts, words, visual images and spatial concepts DIR R = Relationships Description of C-CG interactions and family patterns Observe child with CG Determine parental style directive? Reading child cues? Floortime (DIR) Educational, social-emotional, mental health, and/or developmental challenges Build healthy foundations Follow natural emotional interests and challenge towards greater mastery On the floor (young) Conversations and interactions in other places Critical role of parents Tailored to unique challenges and strengths Natural emotions and interests klamb16 55 klamb16 56 klamb Treatment: FloorTime Non-invasive play therapy No current scientific documentation as treatment Pros: Human connection Less concern with when skill achieved Focus: emphasis appropriate play to build: interpersonal & communication skills Situational & generalized teaching Cons: Inability of child/parent to bond Only appropriate way to treat ASD behavioural methods are cruel Lack of emphasis on life skills and academic skills 58 PIVOTAL RESPONSE TREATMENT (PRT) Key pivotal behaviors Motivation Responsivity to multiple cues Self-initiations Self-management klamb16 59 Motivation Number of responses to social and envir. stimuli Decrease in latency Quality of affect Interspersing maintenance tasks and following child s lead Natural reinforcers klamb Responsivity to Multiple Cues Overselectivity Address: 1. Within stimulus prompting exaggerating characteristics/features 2. Extra-stimulus prompting uses enviro. obstructions and arrangements Self-initiations Independently access wide range of social/other reinforcers in environment Spontaneous initiations can predict educational outcomes Naturalistic teaching initiations of affection, spontaneous requests or directives, play, or social Self-management Monitor and adjust target behavior Recognize the occurrence behaviors Autonomy Decreasing problem behaviors Stereotypies Inappropriate vocalizations Disruptive behaviors klamb16 61 klamb16 62 klamb

8 Antecedent based PRT strategies Attention Create learning opportunity Multiple cues Intersperse maintenance tasks Sharing control Consequence-based PRT strategies Reinforce contingently and immediately Reinforce attempts Natural direct reinforcers PECS Picture Exchange Communication System klamb16 64 klamb Protocol Phase 1 = exchange picture for item/activities Phase 2 = exchange more pictures for more items/activities Phase 3 discrimination Phase 4 = use sentences Phase 5 = answer questions Phase 6 = comment Treatment and Education of Autistic and Communication Handicapped Children (TEACCH) Chosen as one of the best models (Randall & Parker 1999) because Respect for the person Inclusion of caregivers Knowledge of child development Long term data Service through adulthood Adaptability of approach Description Comprehensive treatment delivery system Not a technique Individualized treatment planning Main objective is to improve communication skills and autonomy klamb Principles Address underlying causes of aberrant behaviors Figure out the message and replace with acceptable Increase adaptation increasing skills Recognition that increasing communication skills decreases problem behavior IN box to OUT box Work to be done: placed in the IN box (left) Workspace is defined poster board or tape boarder Completed work is moved to the right (OUT) IN box is empty; work session is over File Folder Activities Created in a file folder that holds all necessary items Laminate for repeated use

9 Shoe Box Activities Similar to file folders larger items ALL materials are in the box Variation: is the FIRST; THEN box Social Movement Difficulties 1. Starting 2.Stopping 3.Switching 4.Combining Donnellan & Leary, 1995 Generalization Skill or behavior learned in one environment (person) to other environments and with others Taught and applying in new and different situations Miss the big picture Situations skill Too different from the learning situation STIMULUS RESPONSE Plan for generalization Consistent in one context continue Make small changes slowly Place People Prompt Words Materials Social Assimilation Changing the behavior Facilitates skill development Enhances skill acquisition Direct treatment Social Accommodation Modify the environment Changing the environment Social performance Indirect treatment Which works best? Both Teach skills and modify environment Based on developmental skills Peer-Mediated Instruction Intervention (PMII) Structure and formalize social skill play opportunities Interact with peers Taught to interact Activities and contexts Generalization Social validity Central Cohesion-Executive Functioning See the Big Picture Difficulty with central cohesion and executive functioning Practice identifying relevant vs. irrelevant information Categorizing activities Sorting give answers Identify main ideas

10 Interventions for Social Skills Common intervention, very social and involves reciprocity Must be taught in naturalistic settings functional routines generalization Social Stories Observation in the environment attention to the language used details of the learner s behavior specifics of the situation Used for teaching a variety of skills and behaviors Following sentence types (descriptive sentences, directive sentences, perspective sentences and control sentences Use photographs or pictures Text Age, reading ability, cognitive level How to write a social story Target a behavior or situation that is difficult Spend time other students doing? aspects of the situation not understand? Practice describing the situation student s perspective Social stories descriptive sentences directive sentences perspective sentences control sentences What are social stories? Why use social stories? Descriptions of social situations relevant social cues appropriate responses Misbehavior? confusion behavior expected? no wrong assumptions A social story is effective because it: information visually identifies relevant social cues describes expected behavior lessens social interference Advantages: Initiating interactions Organizing play Prompts and reinforcement Naturalistic Who benefits Across spectrum Limited communication Rarely initiate or respond to social interactions Not benefiting from group Skill acquired? Failure when the need to perform not acquired Shutdown Demands are beyond skill Fill the gap Consider 3 Social Skill Components Social: actions thinking feeling Positive = Overcoming negative

11 Rules 1-3 sentences per page 1 concept per page Use pictures or photographs Read the story often Immediately prior to the situation Rules Avoid negative statements Know comprehension level & write just below Try phrases like: I will try Make sure story defines when the event/situation is over Be flexible Social skills Social skills & relationships Central feature Predictor of diagnostics Distinguishing feature Vulnerable Integrate Social goals Support friendships & relationships Classroom routines Recess Lunch Playground Therapy Community activities Home Social Scripts Any social communication opportunity What to say if a teacher asks for your homework and you don t have it. Teacher-.Do you have your homework? Student- No, I don t Teacher- Why don t you have your homework? Student- Because I left it at home. Teacher- Well, bring it tomorrow, but remember, you won t get full credit. Student- I will and I remember I ll get 10 points taken off for it being late. Teacher- Is there some strategy you can use to remember to bring your homework back so you will get full credit in the future? Student- Maybe putting it in my backpack the night before? Teacher- Great idea Social Autopsies Richard Lavoie s book It s So Much Work to be Your Friend. In the moment following a social Identify the incorrect behavior or social response Child identifies how that response or behavior made other s feel Child identifies and practices Individualization No single intervention to strengthen social skills Combination Explore Selective Right fit Advantage: strengths and interests Generalization Applied outside of controlled conditions Deficit=has skills but does not perform it

12 Cannot or Will not Lack of motivation or refusal Skill acquisition deficit Generalization Confounding factors