Chapter 7 Autism Spectrum Disorders

DSM-IV Definitions Autistic Disorder - marked by three defining features, with onset before age: 1) impaired social interaction, 2) impaired communication, and 3) restricted, repetitive, and stereotyped patterns of behavior, interests, and activities Asperger Syndrome - impairments in all social areas, particularly an inability to understand how to interact socially Rhett’s Syndrome - a distinct neurological condition that begins between 5 and 30 months of age, marked by a slowing of head growth, stereotypic hand movements, and severe impairments in language and coognitive abilities Childhood disintegrative disorder - shares characteristics with autistic disorder, but doesn’t begin until after the age of 2 and sometimes not until age 10 Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS) - diagnosis given to children who meet some, but not all, of the criteria for autistic disorder.

IDEA Definition Autism is a developmental disability affecting verbal and nonverbal communication and social interaction, generally before age 3, that adversely affects a child’s performance.

Characteristics Impaired social relationships Many children with autism do not speak. Echolalia is common among those who do talk Varying levels of intellectual functioning, uneven skill development Unusual responsiveness to sensory stimuli Insistence on sameness Ritualistic and stereotypic behavior Aggressive or self-injurious behavior

Screening Early diagnosis is highly correlated with dramatically better outcomes Autism can be reliably diagnosed at 18 months of age Checklist for Autism in Toddlers (CHAT) Modified Checklist for Autism in Toddlers (M-CHAT)

It is largely based on clinical judgment Diagnosis Childhood Autism Rating Scale (CARS) Autism Diagnostic Interview—Revised Gilliam Autism Rating Scale (GARS) Asperger Syndrome Diagnostic Scale (ASDS) It is largely based on clinical judgment

Prevalence and Causes Prevalence Recent estimates - Autism occurs in as many as 1 in 150 children (CDC, 2007) Boys are affected about 4 times more often than girls Autism is the fastest-growing category in special education (autism epidemic)

Prevalence and Causes Causes The cause of autism is unknown Controversial theories MMR vaccine Mercury (thimerosal) No evidence of childhood vaccinations causing autism There is a clear biological origin of autism in the form of abnormal brain development, structure, and/or neurochemistry Genes may be responsible for the abnormality Environmental factors may trigger the disorder

What is a science-based approach? and how is it different from pseudo-science?

Science reliable and valid measurements replication pre- post measures control/comparison group(s) “blind” or independent evaluators replication published in peer reviewed journals

Pseudoscience No scientifically valid evidence (no) controlled studies (in)consistent findings (not) published in peer reviewed journals Use “numbers” and graphs Ph.D.’s and M.D.s “Institutes” www.quackwatch.org

What does body of scientific research conclude about interventions with children with ASD?

Current unproven or disproven medical interventions Secretin peptide hormone that stimulates the secretion of digestive fluids, no benefits in 3 controlled studies Gluten Free/Casein Free Diet food allergies cause or contribute to autism has no sound scientific evidence supporting Hyperbaric oxygen The logic for using hyperbaric oxygen treatment for developmental disorders relates to the auto-immune and/or viral theory of these conditions. Encephalitis, in this theory, is thought to be part of developmental disorders. No data on the use of hyperbaric oxygen for developmental disorders

Current unproven or disproven medical interventions Vitamin B6 and magnesium Dimethylglycine (DMG) (Vitamin B 15) AZT (Terovir) Steroids Antibiotics Antifungal medications Behavioral Optometry Craniosacral therapy “The emphasis in Biodynamic Craniosacral Therapy is to help resolve the trapped forces that underlie and govern patterns of disease and fragmentation in both body and mind. This involves the practitioner "listening through the hands" to the body's subtle rhythms and any patterns of inertia or congestion. “

Current not yet validated or disproven nonmedical interventions DIR (Greenspan’s Floortime) “Floortime is your child’s practice time. Each time you get down on the floor and interact—spontaneously, joyfully, following your child’s interests and motivations—you help him build that link between emotion and behavior, and eventually words, and in doing so move forward on his journey up the developmental ladder” Sensory Integration is a complex disorder of the brain that affects developing children. Children with SPD misinterpret everyday sensory information, such as touch, sound, and movement. RDI (Guttstein) Higashi Method Music Therapy AIT (Auditory Integration Training) Hippotherapy/Dolphin therapy Occupational Therapy

Found harmful in scientific studies Facilitated Communication Auditory integration training Intravenous immune globulin withholding vaccinations

Evidence-Based Treatment Applied Behavior Analysis is the only treatment approach that has been documented to produce significant gains (comprehensive and long-lasting) for children with ASD U.S. Surgeon General’s Report New York State Department of Early Intervention Task Force 12+ well-designed, peer-reviewed comparison studies (with over 342 subjects) Hundreds of peer-reviewed studies documenting specific ABA procedures

Why Science? Wasted money, time, energy Basing decisions about interventions mainly on preconceptions, opinions, speculations, subjective impressions, and badly done studies has many risks: Wasted money, time, energy Exploitation of vulnerable people Physical and emotional injuries Lost opportunities to make real advances Reinforcement and perpetuation of practices that impede progress The most tried-and-true way to reduce those risks is to rely on careful scientific evaluation to separate opinions and beliefs from verifiable facts.

Educational Approaches Applied Behavior Analysis (ABA) Discrete Trial Training Picture Exchange Communication System (PECS) Peer-mediated interventions Errorless discrimination learning Generalization Functional assessment of challenging behavior Pivotal response intervention Naturalistic language strategies

Educational Approaches (continued) Social stories Picture activity schedules Educational Placement Alternatives Regular Classroom Resource Room

Where do we start? Imitation Attending to environment Eye contact Visual & auditory Eye contact Joint Referencing Exploratory behavior Shared attention Imitation: learning from peers Attending to environment- includes safety features and greeting opportunities Eye contact- learning about facial expression “missed opportunities” Exploratory behavior: reaching out- manipulating objects - easier to program for child who is exploring Environment than child who doesn’t reach (reinforcer assessments) - we say need 12 “good reinforcers” For child on DAILY basis Shared attention: Turn taking:

Howard, Sparkman, Cohen, Green, & Stanislaw (2005) Generic Early Intervention Autism Programs Intensive ABA parental preference most significant factor in placement

Children in the study <48 months of age Dx Autism or PDDNOS qualified, independent examiners Intervention No secondary medical condition English primary language No IQ “cut off”

Generic Early Intervention Programs 1:6 staffing ratio 15 - 17 hours per week >50% individual or group Speech Tx Curriculum developmentally appropriate language “rich” environments typical preschool activities

Autism Preschool Programs •1:1 or 1:2 staffing ratio •26 - 30 hours per week •Behavioral consultant •50% individual or group Speech Tx •Curriculum •Discrete trial component •PECs •TEACCH •typical preschool activities

Intensive ABA 1:1 staffing 35 hours per week errorless learning >800 trials/structured opportunities per day Joint attention, imitation, and initiation* Speech Pathologist consultant

Re-contacted 1 year after baseline Independent follow-up testers Procedure Re-contacted 1 year after baseline Independent follow-up testers IEP and file review educational placement hours and services

Participants at Baseline Generic EI (16) Autism (16) Intensive ABA (29) Age (mos) 35 39 31 IQ (SS) 60 54 59 Language (mos) 17 15 14 Autism Dx 72 81 82 Mother Ed (yrs) 13 28

Cognitive Functioning Standard Scores

Receptive Language Standard Scores