11/22/10. The best tool is a trained and experienced examiner. Which is the Best Tool for Evaluating ASD?

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1 Toothpicks and Rubber Bands: Transdisciplinary Assessment of Autism Spectrum Disorders Which is the Best Tool for Evaluating ASD? Ruth Aspy, Ph.D., Barry Grossman, Ph.D., Penny Woods, M.S., Ed., Nicole Brin, M.A., CCC-SLP, and Susan Jamieson M.Ed., RPED The Ziggurat Group Workshop presented for OCALI Conference November 17, 2010 Test Error There are no objective measures that can be used for accurate diagnosis (Freeman & Cronin, 2002 p.1). Tests are tools. Which is the Best Tool for Evaluating ASD? Asperger s first appeared in DSM-IV in There were no tests to look at Asperger s. Clinicians used clinical judgment. So the best tool can t be the tests. The best tool is a trained and experienced examiner Freeman & Cronin (2002). Diagnosing autism spectrum disorder in young children: An Update. Infants and Young Children, 14(3), Administration vs. Interpretation There is a different set of knowledge required to administer and to interpret measures. There is a severe danger in staff who have the skills to administer instruments but lack the knowledge to properly interpret them. Without the prerequisite knowledge, these individuals lack clinical judgment and therefore rely heavily on cut-off scores to tell them if their client has ASD. Need for Quality Clinical Training cut-off scores should not be viewed as similar to a standard score, such as an IQ score. Rather, these scores should be used as a clinical guide and taken in the context of other information about the child... This issue alone emphasizes the critical importance of the need for school districts to invest in providing quality clinical training (p.270) Noland & Gabriels (2004). Screening and identifying children with autism spectrum disorders in the public school system: The development of a model process. Journal of Autism and Developmental Disorders, 34,

2 Example: ADOS and Cut-Off Scores Quote from ADOS Manual emphasizing that ADOS classification alone is not sufficient: Clinicians are encouraged to use all information, including ADOS scores and results of other assessments in final decisions (Lord, Rutter, DiLavore, & Risi, 2003, p. 104). Decision Making Process Clinical Judgment DSM Interview DSM Data DSM Diagnosis/Identification DSM DSM DSM DSM DSM DSM DSM DSM Test Data DSM DSM DSM Observations Need for Comprehensive Evaluation Best Practice and Federal Law Evaluation Procedures In evaluating each child with a disability under this rule, the evaluation shall be sufficiently comprehensive to identify all of the child s special education and related services needs, whether or not commonly linked to the disability category in which the child has been classified. [34 C.F.R (c) (6)] Evaluation Procedures Not use any single measure or assessment as the sole criterion for determining whether a child is a child with a disability and for determining an appropriate educational program for the child 34 Code of Federal Regulations Evaluation procedure Comprehensive IEP Planning Educational objectives for children with autism should include the development of: social skills; expressive verbal language, receptive language, nonverbal communications skills; a functional symbolic communication system; engagement and flexibility in developmentally appropriate tasks and play; fine and gross motor skills; cognitive skills (symbolic play and academic skills); conventional/appropriate behaviors; and independent organizational skills and skills for success in a regular classroom. U.S. GAO. Special Education: Children with Autism, 36. Washington, D.C., January

3 Areas of a Comprehensive Evaluation Developmental history Health history Adaptive skills Psychological evaluation Communication evaluation Cognitive and achievement evaluation Motor Sensory Types of Team Multidisciplinary, Interdisciplinary, & Transdisciplinary Multidisciplinary Let s play a game of telephone. The following characteristics often exhibited in individuals with an autism spectrum disorder were noted in an outside report derived from the case manager of a multidisciplinary assessment. Difficulty with the pragmatics of social language Difficulties with coordination Difficulties with handwriting Poor social skills Failure to make eye contact Nasal voice, husky voice Fine and gross motor delays Shy Refusing to interact Easily upset Hyperactivity Perseverative theme of animals in play No conversations with peers Failure to initiate interactions with peers History of enuresis Dyspraxia Hyperlexia Sensory integration dysfunction Grunting sounds when responding to questions Difficulty with transitions Types of Teams Multidisciplinary Interdisciplinary Transdisciplinary Types of Teams Multidisciplinary Interdisciplinary Transdisciplinary Testing Disciplines conduct evaluation in consecutive sessions and in isolation from one another Disciplines conduct evaluation in consecutive sessions and in isolation from one another Evaluation is collaborative with multiple team members present during evaluation sessions Decision Making Conclusions made by case manager or team leader based on compiled information Conclusions made through consensus with all team members Conclusions and recommendations made through collaboration and consensus 3

4 Types of Teams Multidisciplinary Interdisciplinary Transdisciplinary Types of Teams Multidisciplinary Interdisciplinary Transdisciplinary Recommendations Recommendations made by individual members and then compiled Recommendations are made through consensus Recommenda tions are made through collaboration and consensus Report Reports are Reports are compilation of combination of individual write ups compilation of individually written sections based on team consensus and collaborative writing Reports are combination of compilation of individually written sections based on team consensus and collaborative writing Team Member Responsibilities Participate in all aspects of team evaluation Parent interview Teacher interview Observations Evaluation Report writing Parent feedback Staffing and IEP preparation (goals and programming decisions) Need for a Transdisciplinary Team A Key Component to Comprehensive Autism Evaluation Comprehensive Evaluation Ideally, the definitive diagnosis of an ASD should be made by a team of child specialists with expertise in ASDs. (p.1202, emphasis added) Comprehensive Evaluation To thoroughly evaluate all relevant domains, different areas of expertise are required. Hence the clinical assessment of individuals with this disorder is most effectively conducted by an experienced interdisciplinary team (Klin & Volkmar, 2003, p. 4). Johnson, Myers, & Council on Children with Disabilities, 2007 Klin, A., & Volkmar, F. (2003) Asperger syndrome: diagnosis and external validity. Child and Adolescent Psychiatric Clinics of North America, 12,

5 Evaluation Procedures (c) Other evaluation procedures Need for Expertise Each public agency must ensure that (1) Assessments and other evaluation materials used to assess a child under this part (iv) Are administered by trained and knowledgeable personnel Essential Knowledge and Skills Required 34 Code of Federal Regulations Evaluation procedures (emphasis added) Team Members A job title or position is not a strong indicator of who is appropriately qualified... Evaluation professionals must have prior education, training, and supervised experience that includes extensive exposure to autism-spectrum disorders. Team Members Expertise in the area of autism spectrum disorders is much more important to a thorough, accurate diagnosis than particular credentials. (Ozonoff, Dawson, & McPartland, 2002, p.46) [emphasis added] (Monteiro, 2006, p.4) emphasis added Expert Having, involving, or displaying special skills or knowledge derived from training or experience. Considerations: Qualified Team Member How do you get expertise? What does extensive exposure to ASD mean? How are you going to know when you are there? Merriam-Webster 5

6 Possible Team Members Psychologist Speech Pathologist Educational Diagnostician Occupational Therapist Teacher Autism Specialist Team: Knowledge and Skills Prerequisite Knowledge Areas ASD characteristics Differential diagnosis/identification Typical development Meta-disciplinary synchronization Formal and informal tools Federal and state laws Effective interventions for ASD Skill Areas Preparation Session(s) Interpretation and Communication Select instruments Develop rapport Scoring Prepare environment Interview Analysis and Synthesis Prepare individual Observation Differential diagnosis or identification Administration Pattern identification Respond and revise Report writing Develop recommendations that match strengths and weaknesses Disseminate in manner that matches recipients needs/characteristics Grossman, Aspy, & Myles (in press). Prerequisite Knowledge Areas ASD characteristics Differential diagnosis/identification Typical development Meta-disciplinary synchronization Formal and informal tools Federal and state laws Effective interventions for ASD Novice Errors Myth: If you don t see it. it doesn t count Reality: Skilled examiners value observations of others. Value Observations of Others Research has shown that parents are accurate reporters (Glascoe & Sandler, 1995) Novice Errors Myth: If a noteworthy symptom occurs infrequently, it doesn t count Reality: There are low-threshold behaviors. Their presence, no matter how frequent, is significant Glascoe & Sandler (1995) 6

7 Echolalia Flapping Head banging Low-Threshold Behaviors Novice Errors Myth: If a skill is present one time, the student does not have a deficit Reality: You need to look at quality in addition to frequency Comments He is my most sensitive child. He is the one that comforts me when I cry. She has good communication skills. She spoke to me about the Titanic for 30 minutes. He looked at me when I gave him the top. Eye contact is not a problem. Team Evolution Goal Team Evolution Create designated team of experts for a district Give the experts the time required to function as a team Evaluate Case conceptualization Recommendations Team Evolution Identify experts to create initial team Training and supervision (perhaps by outside experts) may be required Training new teams Pair new team with existing team Split existing team to create new teams There is a learning curve for novice members Naïve questions Members should mentor one another Recognize members strengths 7

8 Team Process All members equal decisions are made by the team not by individuals Develop a plan in advance for how to resolve differences (e.g., consult with another team) Team Process Decision Making Process Active discussion Look at both sides Address complicating factors (e.g., history of multiple ear infections; dual language home; history of head injury, etc.) Emphasize these points in the report Consider the presence of comorbid or alternate diagnoses Parents Administration Resources Identification rate Support Staff Jealousy Sabotage the team Medical professionals/ outside assessments Bomb Squad Ziggurat Group Assessment Battery CARS2 CCC-2 SRS parent & teacher Vineland II (parent & teacher) BASC-2 Parent, teacher, self ADOS or PEP-3 Underlying Characteristics Checklist (UCC) Observations Sensory Profile Interviews & Informal assessments If Needed Psychological Speech-Language Motor Feeding/Oral motor Cognitive/Achievement Executive functioning Memory Toothpicks and Rubber Bands 8

9 Contact Information Ruth Aspy, Ph.D. Barry G. Grossman, Ph.D. Nicole Brin, M.A., CCC-SLP Penny C. Woods, M.S. Ed. Susan Jamieson, M.Ed., RPED 9