AUTISM SPECTRUM DISORDERS Sue Mondak, M.A., CCC-SLP

PREVALENCE OF ASD Prior to 1990’s: 4-5 per 10,000 for autism 2003 California study: Doubling in last 4 years CDC 2007: 1 in 150 CDC 2009: 1 in 110 CDC 2012: 1 in 88 CDC 2012: 1 in 54 boys

PREVALENCE (con’t) More children will be diagnosed with autism this year than with AIDS, diabetes, or cancer combined. Autism is the fastest growing developmental disorder in the United States.

DEFINITION - Educational A brain development disorder characterized by impairments in social interaction, communication, and restricted and repetitive behavior, typically appearing during the first three years of life.

DEFINITION – CENTERS FOR DISEASE CONTROL (CDC) Autism Spectrum Disorders are a group of developmental disabilities that can cause significant social, communication, and behavioral challenges. Symptoms can range from mild to severe.

DEFINITION - DSM-IV Qualitative impairments in social interaction Qualitative impairments in communication Restricted repetitive and stereotyped patterns of behavior, interests, and activities

DEFINITION (con’t) Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3: Social Interaction Language as used in social communication Symbolic or imaginative play

ASPERGER SYNDROME DSM-IV Qualitative impairments in social interaction Restricted repetitive and stereotyped patterns of behavior, interests, and activities Clinically significant impairments in social, occupational, or other important areas of functioning

ASPERGER SYNDROM (con’t) No clinically significant general delay in language No clinically significant delay in cognitive development or in the development of age appropriate self help skills, adaptive behavior (other than social interaction) and curiosity about the environment in childhood

PROPOSED REVISION FOR DSM - V Rett’s disorder removed from autism category All pervasive developmental disorders will be called Autism Spectrum Disorder Minor changes to criteria

CAUSES OF AUTISM No one knows exactly why, but the brain develops differently in people with autism. It is now widely accepted by scientists that a predisposition to autism is inherited. It is likely that both genetics and environment play a role.

GENETICS Researchers have identified a number of genes associated with ASD. Identical twin studies show that when one twin is affected there is up to 90% chance the other twin will be affected. In families with one child with ASD, the risk of having a second child with the disorder is approximately 5%.

ENVIRONMENTAL FACTORS A number of pre or post-natal environmental factors have been claimed to contribute to ASD or exacerbate it’s symptoms with little evidence to support these claims Certain foods (Glutton free diets) Infectious disease Heavy metals (Detox methods) Solvents Diesel exhaust

ENVIRONMENTAL FACTORS (con’t) PCB’s Phthalates & phenols used in plastic products Pesticides Alcohol Smoking Illicit drugs Vitamin deficiencies (Supplements) Vaccines

A recent Danish study found that pregnant women who had the flu were 2x more likely to have a child with autism

EARLY WARNING SIGNS: No big smiles or other warm, joyful expressions by 6 months of age or after No back and forth sharing of sounds, smiles, or other facial expressions by 9 months of age No babbling by 12 months of age No back and forth gestures such as pointing, showing, reaching, or waving by 12 months of age

WARNING SIGNS (con’t) Lack of eye contact and response to name No words by 16 months of age No meaningful two word phrases (not including imitating or repeating) by 2 years of age Any loss of speech, babbling, or social skills at any age

SOCIAL RECIPROCITY Definition: The ability to initiate and respond in social interactions

SOCIAL RECIPROCITY IN CHILDREN WITH AUTISM Less frequent spontaneous bids for communication Fewer back and forth turns in interaction Fewer gestures Inability to recognize communication breakdowns More reliance on structured situations for conversation More passive conversational style

SOCIAL RECIPROCITY IN OLDER CHILDREN WITH AUTISM Difficulty maintaining conversations with relevant remarks, questions, or comments Difficulty providing necessary background information for conversations Difficulty engaging in conversations appropriate to social context or interests of others

NONVERBAL COMMUNICATION IN YOUNG CHILDREN WITH ASD Limited range of conventional gestures and vocalizations Reliance on contact gestures such as hand leading, pulling, or physical manipulation Delayed or absent conventional gestures or distal gestures (pointing) Use of problem behaviors to communicate (frequent tantrums)

NONVERBAL COMMUNICATION IN OLDER CHILDREN WITH ASD Literal understanding and use of verbal communication Limited understanding of sarcasm and nonliteral language Monotone speech or atypical prosody

SYMBOLIC PLAY Limited functional use of objects with younger children Repetitive or rigid play Limited ability to represent objects when younger and social situations when older

VERBAL COMMUNICATION IN CHILDREN WITH ASD Reliance on immediate or delayed echolalia Reliance on rote memory rather than semantic understanding for longer utterances Persistent difficulty with comprehension

VERBAL COMMUNICATION (con’t) Difficulty generalizing meaning of words beyond contexts in which they were learned Difficulty learning words other than nouns at early stages Difficulties with phonology or motor planning for speech

LITERACY SKILLS Difficulty observing or imitating functional use of books Limited understanding or use of story grammar Poor reading comprehension Hyperlexia

SENSORY DIFFICULTIES Difficulty processing sensory input Senses may be hyper-sensitive or hypo- sensitive; usually a combination Tastes Smells Touch Sounds Sights Movement and Balance Body Position/Muscle Control

SENSORY REGULATION Use of immature or atypical self-regulation strategies Chewing on clothing Carrying objects Vocal play Rocking Visual Stimulation Covering ears / or dropping objects to hear the sound Smelling toys or other objects frequently

ASSESSMENT Primary assessment is through observation of communication, behavior and social interaction Parental input and developmental history are essential components of the evaluation

ASSESSMENT (con’t) Screening tool: M-CHAT (doctors often complete in office) Used to identify children at risk, not to determine diagnosis Child who fails 3 total items or 2 critical items (2,7,9,13,14,15) fail the M-CHAT

ASSESSMENT (con’t) ADOS: Autism Diagnostic Observation Schedule A semi-structured, standardized assessment of communication, social interaction, and play or imaginative use of materials

DIAGNOSIS May obtain a medical diagnosis from child Psychiatrist, or behavioral pediatrician Educationally: must meet eligibility qualifications

EDUCATIONAL ELIGIBILITY See Michigan’s Definition of Autism Spectrum Disorder Handout

INTERVENTION STRATAGIES Visual Schedules Picture Exchange System (PECS) Sensory Integration Therapy (OT’s)

INTENSIVE INTERVENTIONS Behavioral / ABA (Applied Behavior Analysis) Developmental Greenspan/Weider DIR/Floortime 6 Functional Developmental Levels Combined Denver Early Start Model

DIR Framework (Greenspan/Weider) Developmental, Individual differences and Relationship based One-on-one intensive engagement Child centered-’meet them where they’re at’ DIR is the theory, “Floortime” the practice hour/week beside school 6 Functional developmental levels

6 FUNCTIONAL DEVELOPMENTAL LEVELS Self regulation and shared attention(FDL1) Engagement (FDL 2) Two-way Communication (FDL 3) Complex two-way Communication (FDL 4) Shared Meanings & Symbolic Play (FDL 5) Emotional Thinking (FDL 6)

P.L.A.Y. Project Model Play and Language for Autistic Youngsters Developed by Dr. Richard Solomon from the University of Michigan in 2000 Based on Greenspan’s Floortime/D.I.R. Model Developed due to no intensive services publicly in Michigan Community based, family centered, cost effective Now in 27 states and 9 countries Attempting to bring this to our area

P.L.A.Y. Project Values Family and child centered Interventions often in the natural environment of the home Parent empowerment model Relationship based Playful and fun Addresses the core deficit: Social Impairment

DEVELOPMENTAL METHODS AND OUTCOMES OF THE PROJECT Contingent, reciprocal, social interactions Follow the child’s lead, interests, and/or intent Shared social attention Joyful relating Simple and complex nonverbal gestures Long interactive sequences of spontaneous verbal communication Symbolic language related to affect

P.L.A.Y. Home Consultation Monthly half day visits Coach, model, and support parents to Play Video/written feedback

GOAL: To move the child out of their Comfort Zone, into interactional engagements with others To move the child from their current functional developmental level to the highest functional developmental level possible

COMFORT ZONE What the child does when you let them do whatever they want to do Focused on repetitive interests Tuned out; “In their own world” Examples: Lining up toys Visually self stimming on wheels, lines, objects Obsessed with numbers and letters Stuck on same topic: planets, Pokemon

ACTIVITIES FOR FUNCTIONAL DEVELOPMENTAL LEVELS 1 & 2 Rolling child up in a rug Swinging in a blanket Tickling Gentle wrestling Playing peek-a-boo Sensory Motor level

ACTIVITIES FOR FUNCTIONAL DEVELOPMENTAL LEVELS 3 & 4 Chase: “I’m gonna get you” Get the bubbles, balloon, etc. Ball play (rolling it back and forth) Very simple pretend play: phone to ear, cars crash Being silly

ACTIVITIES FOR FUNCTIONAL DEVELOPMENTAL LEVELS 5 & 6 Pretend play: Dress up, tea party Real Hide-n-Seek (not just peek-a-boo) Reading books – looking at pictures and a telling a simple story Duck, duck, goose

RESEARCH The P.L.A.Y. Project is a form of Intensive Developmental Intervention (IDI) Studies have found that Intensive Interventions that incorporate parent training, and focus on the core deficit of ASD (social impairment) show significant improvement in children with autism Demonstrated improvements in parents skill in interaction and child functional development EEG brain scans confirm improvements