Screening/Assessment Language and Social Risk Factors for Autism in Young Infants Leslie Abney, BHS, MHS Candidate Research Supervisor: Ashleigh Ohmes Boyd, MHS, CCC-SLP Department of Communication Science and Disorders, University of Missouri MU Leadership Education in Neurodevelopmental Disabilities (LEND) Program Introduction Risk Factors Summary < 9 months: Lack of gestural communication is one of the first areas used to identify risk. Delays in gestural use may be detected before delays in language for children with ASD. [3] Gestural communication precedes spoken language and provides a foundation for the emergence of verbal language. In typically developing children, gestures develop spontaneously and in tandem with first words, which are usually spoken as early as approximately 9 months. 9 – 12 months: Delayed language – at 12 months vocalize significantly less than typically developing infants. Average age of first word for kids with ASD is 38 months. [1, 2] Receptive < Expressive (this is an unusual pattern). Language is no longer a core feature of ASD, but this pattern can help us identify those at risk. [1, 2] Approach caregivers less to share objects, give objects to caregivers less frequently, use locomotor skills (i.e., crawling) less to engage with caregivers in meaningful ways and more for non-social exploration. [6] As compared to typically developing infants: Share by approaching and giving significantly less often Crawl “elsewhere” instead of toward caregivers or objects more often But similar to typically developing infants in that once they start walking, rate of sharing increases Significant delays in communicative gestures at 12 months. [3] At 12 months, “high risk” infants later diagnosed with autism produced fewer early (giving, showing, pointing, lift arms to be picked up, shaking and nodding head) and late (eat with toy spoon, telephone to ear) gestures. 12 – 15 months: Using words to communicate at approximately 12-15 months and then regressing. [1] Approach caregivers less to share objects, give objects to caregivers less frequently, use locomotor skills (i.e., walking) less to engage with caregivers in meaningful ways and more for non-social exploration. [6] 15 – 18 months: Understand and produce fewer words than typically developing children. At 18 months the infants later diagnosed with ASD, reported to understand and produce fewer words than either non-ASD siblings or controls. (p. 74-77) [3] Importance of early intervention: Outcomes are better for children with autism spectrum disorder (ASD) the earlier treatment is provided. The sooner ASD can be identified and accurately diagnosed, the sooner treatment can be provided. Familial risk: In order to identify risk factors, many studies compare “high risk” infants (i.e., those with siblings who have ASD) to “low risk” infants (i.e., those without family history of ASD) and follow them until they have received a diagnosis of ASD or non-ASD. Siblings of children with ASD are at increased risk for ASD (~ 20%) [1, 2] Siblings of children with ASD are also at risk for ASD traits or “greater autism phenotype” and other developmental differences/disorders [1, 2] Significant number of “high risk” infants carry features of the broader autism phenotype: traits associated with ASD that differentiate these infants from “low risk” infants in the control group. In other words, family members of children diagnosed with ASD may present with characteristics associated with ASD, without having the disorder. (p. 145) [1] Before 12 months, few behavioral patterns are specific to ASD. Rather, patterns appear that signal risk of developmental delay. (p. 145) [1] Several language and social risk factors are present before 18 months of age: lack of gestures, delayed language, poorer receptive language than expressive, decline in spoken language abilities, less object sharing with caregivers, and more non-social exploration. More research is needed on remote eye tracking system for infants at risk for ASD. SLPs play a crucial role in identifying the early language and social risk factors for ASD in young infants, and where appropriate, administering autism-specific screeners. The gold standard for accurately diagnosing ASD is the ADOS-2 Toddler Module + Autism Diagnostic Interview, Revised (ADI-R) + judgement of expert clinician. Research Questions What are the language and social risk factors associated with ASD for children 18 months and younger? What are the best practice guidelines for assessing children for associated language and social risk factors of ASD? Research Methods References Search Terms: social, language, risk factors, ASD, young infants, assessment, screening, best practice, 18 months Databases: ASHAWire, EBSCOhost, PubMed, University of Missouri Library online database Screening/Assessment [1] Tager-Flusberg, H. (2016). Risk factors associated with language in autism spectrum disorder: Clues to underlying mechanisms. Journal of Speech, Language, and Hearing Research, 59(1), 143-154. [2] Drumm, E. & Brian, J. (2013). The developing language abilities and increased risks of ‘unaffected’ siblings of children with autism spectrum disorder. Neuropsychiatry, 3(5), 1-12. [3] Mitchell, S., Brian, J., Zwaigenbaum, L., Roberts, W., Szatmari, P., Smith, I., & Bryson, S. (2006). Early language and communication development of infants later diagnosed with autism spectrum disorder. Developmental and Behavioral Pediatrics, 27(2), 69-78. [4] Frazier, T. W., Klingemier, E. W., Beukemann, M., Speer, L., Markowitz, L., Parikh, S., ……… Strauss, S. M. (2016). Development of an objective autism risk index using remote eye tracking. Journal of the American Academy of Child & Adolescent Psychiatry, 55(4), 301-309. [5] Robins, D. L., Casagrande, K., Barton, M., Chen, C. A., Dumont-Mathieu, T., & Fein, D. (2014). Validation of the Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F). Pediatrics, 133 (1), 37-45. [6] Srinivasan, S. M. & Bhat, A. N. (2016). Differences in object sharing between infants at risk for autism and typically developing infants from 9 to 15 months of age. Infant Behavior and Development, 42, 128-141. [7] Swineford, L. (2017). Screening for ASD in toddlers: An update on recommendations and practices. Perspectives of the ASHA Special Interest Groups, 2 (1), 5-10. Role of SLP Screening with M-CHAT-R/F successfully identifies children at risk for ASD. According to the American Academy of Pediatrics, an autism-specific screener should be administered at a child’s 18 and 24 month well-child check. [5] M-CHAT-R is also available for free online: https://www.autismspeaks.org/what-autism/diagnosis/mchat Development of a remote eye tracking assessment, Autism Risk Index (ARI), for autism would provide the first objective measurement. [4] Still being tested in the research, but shows promising results with children aged 3-8; very good discrimination of ASD vs. non-ASD and was strongly correlated with ADOS-2 severity scores. [4] Research is needed on young infants. [4] ASD can accurately be diagnosed by age 2. The GOLD STANDARD of assessment: ADOS-2 Toddler Module + Autism Diagnostic Interview, Revised (ADI-R) + judgement of expert clinician [2] Very few appropriate pragmatic language assessments for infants 18 months and younger [3] Speech-language pathologists (SLPs) play a crucial role in every step of the diagnostic process for infants with ASD. [7] Screening: SLPs can play a direct role or indirect role [7] Direct role: actively screening infants with developmental screeners and autism-specific screeners Indirect role: encouraging mothers to advocate for developmental screening and autism-specific screening to be conducted by their child’s pediatrician at their child’s 18 month and 24 month well-child visits It is well within the scope of practice of an SLP to administer both developmental screeners and autism-specific screeners. [7] SLPs and other health professionals, should be directly screening or advocating for children to be screened at their well-child checks. [7] Acknowledgements This research was supported by the Training in Interdisciplinary Programs and Services for Kids, Missouri LEND (Leadership Education in Neurodevelopmental Disabilities) Author Contacts: Leslie Abney, BHS – lday95@mail.missouri.edu Ashleigh Ohmes Boyd, MHS, CCC-SLP – boyda@health.missouri.edu