Diagnostic criteria: new guidelines-dsm V Must meet criteria A, B, C, D and E A Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following: 1. Deficits in social-emotional reciprocity 2. Deficits in nonverbal communicative behaviors used for social interaction 3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers) 4 Clinical Review of Autism Spectrum Disorders Steven L. Pastyrnak, Ph.D. Pediatric Psychology B DSM V revisions continued Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: 1. Stereotyped or repetitive speech, motor movements, or use of objects 2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change 3. Highly restricted, fixated interests that are abnormal in intensity or focus 4. Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of environment 2 5 Objectives Provide overview of autism spectrum disorders and cooccurring challenges Review strategies for navigating an office visit Review ASD related intervention strategies ASD case review Self stimulatory behavior Is used to soothe and calm, especially within anxiety provoking situations or is done for stimulation May include rocking, twirling, pacing, humming, other vocalizations, echolalia 3 4:3 Screen Ratio Template HDVCH October 2014 1
DSM V revisions continued C D Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) Symptoms together limit and impair everyday functioning E Symptoms are not better explained by intellectual disability or global developmental delay ASD fact sheet (cdc.gov) A child with ASD might: - not play pretend games - not point to objects to show interest - have trouble relating to others - avoid eye contact and want to be alone - prefer not to be held or touched - appear to be unaware when other people talk to him/her 7 10 Prevalence and relevance Recent estimates put ASDs in the range of 1 per 88. This means that most pediatricians are likely to care for children and adolescents with an ASD ASDs are not curable and chronic management is required. ASDs do not go away - most children with ASDs remain within the spectrum as adults, regardless of intellectual functioning or any other status. ASD fact sheet continued A child with ASD might: - be very interested in people but may not know how to talk, play or relate to them - repeat or echo words or phrases - have trouble expressing their needs using typical words - have trouble adapting when a routine is changed - have unusual reactions to the way things smell, taste, look, feel or sound 11 Medical complications and comorbidities Seizures (occurs in approximately 30% of autistic children) Gastrointestinal problems, reflux Nutritional deficits/growth issues Increased risk of injury due to impulsivity, pica, self stimulatory behaviors and low sensitivity to pain Untreated ear infections Dental problems due to restricted diet and tooth brushing refusal ASD assessment AAP recommends screening for ASD at 18 and 24 months of age Most common screening measure is the Modified Checklist for Autism in Toddlers-revised (M-CHAT-R) Appropriate for 16 to 30 months M-CHAT-R comprises 20 yes/no items If positive screen, then a more thorough evaluation by the pediatrician, parental education and/or referral to a specialist is advised (*high false positive rate) 12 4:3 Screen Ratio Template HDVCH October 2014 2
ASD assessment Assessment should include: - Health, developmental and behavioral history - Physical examination - Developmental/psychometric evaluation - Standardized assessment of symptoms - SCQ, ADI-R, ADOS-2 *- Laboratory investigation - genetic testing/counseling 13 Practice recommendations Move slowly when performing exams, distal to proximal Explain what you are doing in advance to the developmental level of the individual, not just their age Increased communication about staff and procedures will help reduce anxiety Solicit help from the caregivers whenever possible Be aware of sensory processing issues Band aids and other adhesive products can contribute to anxiety and aggression Try to minimize bright lights or loud sounds if possible Factors to consider in ASD Individuals with autism may be nonverbal despite their size and age Individuals may have an unusual sensory response to hot, cold, pain, itching, etc. (this response may be understated or overstated) Recommendations Use a calm voice and allow time for an individual to process what you say Be aware that the use of yes and no may not dictate true understanding For a developmentally delayed individual, simple toys and stickers may work as a distraction or to calm even if this doesn t appear to be age appropriate (ask caregivers) Practice recommendations: autism Be prepared Be patient Be flexible Allow the child to move around Use distraction techniques Minimize potential distractions during office visits (e.g., siblings, time restraints, toys, etc.) Realize that parents know their children best Ask questions Obtain and document a detailed history before the initial meeting and between visits Recommendations Validate good behavior and responses - nice job, you re doing great Remember that even a rough visit can be positive if the child has a positive association with the visit-for frequent visitors, what you do one visit may set up a smoother next visit Children with autism may ingest something without their parents realizing-look for less obvious causality and inspect carefully for other injuries Don t automatically presume a behavioral or psych etiology for a child s presenting discomfort Limit physical contact when possible, individuals with autism may be more likely to resist physical contact 4:3 Screen Ratio Template HDVCH October 2014 3
Common co-occurring challenges 1. Anxiety 2. ADHD 3. Sensory Processing 4. Behavior 5. Feeding difficulties 6. Sleep Goals of treatment for ASD Primary Goals of Treatment Include: Minimizing the core features and associated deficits Maximizing functional independence Maximizing quality of life Alleviating family stress 19 Anxiety A disorder of increased worry or fear Difficulty controlling the worry or fear Associated with feelings of: Restlessness Fatigue Difficulty concentrating Irritability Muscle tension Sleep disturbance Important principles in Interventions Entry into intervention should occur as soon as an ASD is diagnosed Low student-to-teacher ratio (dependent on a child s level of function/impairment) Inclusion of a family component Provide opportunities for interaction with peers Ongoing measurement of child s progress Incorporate a high degree of structure and routine Implementation of strategies allowing child to generalize learned skills Use of assessment-based curricula measuring: Communication, social skills, functional adaptive skills, reduction of maladaptive behavior, and readiness skills 20 ADHD Educational/early intervention A disorder of inattentiveness, over-activity, impulsivity, or a combination In order for these problems to be diagnosed, they must be out of the normal range for a child s age and development Children can qualify for early intervention support from day 1. Early On serves children from 0 to 36 months and can provide 1) Evaluation, 2) Individualized family service plan, 3) Service coordination and 4) Service implementation Early On and ISD support are free to those who qualify Treatment planning is based on identified needs of the child but can include SLP, OT, PT and parenting support 21 4:3 Screen Ratio Template HDVCH October 2014 4
Educational versus outpatient interventions Children diagnosed with an ASD can qualify for specific programming through their local intermediate school district However, a clinical diagnosis of ASD does not automatically qualify a child for special education programming based on that diagnosis Special education planning is based on the individual needs of a child rather than a specific diagnosis Educational strategies (cont.) 4. Applied Behavior Analysis (ABA) ABA is a set of concepts and principles used to create meaningful and functional behavior change in an individual in order for that individual to lead an independent and productive life as a member of society ABA focuses on the principles that explain how learning takes place. Positive reinforcement is one such principle. When a behavior is followed by some sort of reward, the behavior is more likely to be repeated ABA is the use of these techniques and principles to bring about meaningful and positive changes in behavior Applied behavior analysis Goals of ABA Increase positive behaviors Decrease negative behaviors Teach new skills Generalize and maintain learned skills Educational intervention Children referred to their local ISD typically will receive a multidisciplinary evaluation that can include MD, Psych, SLP, OT, PT, SW, audiologist, educational specialist Kids suspected of ASD may qualify for an ASD (Autism Spectrum Disorder) designation at any age but are not typically formally identified before the age of 3 Kids with ASD deficits can still qualify for specialized programming based on those deficits (SLP, OT, social support, behavioral support) Applied behavior analysis Concepts and principles that govern the use of ABA ABA views behaviors as a response to an event or object in the individual s environment or personal being Behaviors do not exist alone Stimuli that occur before a behavior is displayed are called antecedents Individuals continue displaying behaviors based on the feedback they receive upon completing the behavior Consequences can either increase or decrease behaviors 4:3 Screen Ratio Template HDVCH October 2014 5
Behavioral modification Most effective when used consistently Must have acceptance from the vast majority of child s caregivers ALL BEHAVIOR SERVES A GOAL (whether that goal is adaptive or maladaptive, whether the behavior is appropriate or inappropriate, whether the goal is initially clear or unclear) Most common goals of misbehavior are to get something (attention, control, objects, stimulation) or to escape something (attention, embarrassment, work, anxiety) Michigan autism insurance legislation Coverage for the treatment of ASD may be limited to member through 18 years of age Maximum annual benefit dollar limits apply based on child s age Member must receive diagnosis by licensed physician or psychologist Treatment of ASD must be evidenced based and includes the following: Behavioral health (ABA) Pharmacy care, Psychiatric care Psychological care and/or Therapeutic care (speech, occupational therapy) 34 Other therapies used 1. Speech and Language Therapy Treatment by a speech-language pathologist is usually appropriate for social communication deficits Most effective promoting communication in natural setting Picture Exchange Communication System (PECS) incorporates ABA and developmental-pragmatic principles (child is taught to initiate a picture request and persist with communication until partner responds) Michigan medicaid & MI-Child benefits Applies to children between 18 months through 5 years of age (will increase to 18 years in January 2016) If children qualify for the autism benefit, the family will have access to ABA therapy and may additionally qualify for speech therapy, occupational therapy, physical therapy, respite care, family training, community living supports Assessment typically begins with the family s local community mental health clinic 35 Other therapies used (cont.) Social Skills Instruction Should target responding to social overtures, initiating social behavior, minimizing stereotyped perseverating while using a flexible and varied set of responses and self-managing new and established skills Occupational and Sensory Integration Therapy Occupational therapy is used to promote development of self-care skills, academic skills, play skills, modifying classroom materials and routines to improve attention and organization and provide prevocational training. Sensory integration (SI) therapy s goal is to remediate deficits in neurologic processing and integration of sensory information. Autism case review Sean-age 2 Heather- age 16 36 4:3 Screen Ratio Template HDVCH October 2014 6
Sean Delayed speech Vocalizes but non-communicative (self stim) Inconsistent eye contact, lack of descriptive gestures Reaches for what he wants, does not point Does not coordinate reaching with eye contact Unresponsive to name Flapping behavior, toe walking, finger play No imitative play, likes to spin objects, spin wheels on cars References Myers, S. (2007). Management of children with autism spectrum disorders. American Academy of Pediatrics Clinical Report, October 29, 2007, 1-22. National Institute of Mental Health. Autism spectrum disorders (pervasive developmental disorders). Retrieved February 18, 2008 from http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-pervasivedevelopmental-disorders Rudy, L. (2007). Top 10 top treatments for autism. Retrieved February 18, 2008 from http://autism.about.com/od/treatmentoptions/tp/topdevandbehav.htm www.autismlink.com www.autism.org 37 Heather-age 16 Speaks in full sentences, makes eye contact well Engages well with adults but not peers (avoids interactions) Anxious, periodic sadness, periodically explosive Conversations circle back to Minecraft, anime Slightly odd tone to voice Cognitive and language skills developed within normal limits Doing well academically No evident repetitive behaviors 38 Questions 39 4:3 Screen Ratio Template HDVCH October 2014 7