Corey Ray-Subramanian, PhD Integrated Development Services 2/25/2016 Engaging families in the Early Identification of Autism Spectrum Disorders Corey Ray-Subramanian, PhD Integrated Development Services

Learning objectives Recognize some early signs of ASD in toddlers Identify  tools and strategies for engaging families in developmental screening Have information on referral resources for young children with developmental concerns

Overview Defining ASD Importance of Early Identification Early Indicators Screening Referral for Further Evaluation Questions, Comments, Discussion

Autism spectrum disorder (ASD) 2/25/2016 Autism spectrum disorder (ASD) Considered a neurodevelopmental disorder, but does not have a biological marker and is defined and diagnosed by behavioral features Can be reliably diagnosed by 2 years of age (even younger in some cases) by an experienced clinician (Bishop et al., 2008; Lord & Luyster, 2005)

Diagnostic criteria (abbreviated) 2/25/2016 Diagnostic criteria (abbreviated) Persistent deficits in social communication and social interaction across multiple contexts Deficits in social-emotional reciprocity Deficits in nonverbal communicative behaviors used for social interaction Deficits in developing, maintaining, and understanding relationships Restricted, repetitive patterns of behavior , interests, or activities Stereotyped or repetitive motor movements, use of objects, or speech Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior Highly restricted fixated interests that are abnormal in intensity or focus Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (APA, 2013)

Asd Facts An estimated 1 in 68 children has ASD. Boys are nearly five times more likely than girls to have ASD (1 in 42). ASD prevalence continues to increase. Specific risk factors have been identified and there are likely many causes for multiple types of ASD. There is no link between vaccines and autism. (CDC, 2015)

Importance of early identification Early, intensive behavioral intervention has been shown to improve cognitive, language, and adaptive skills in children with ASD. Early, intensive intervention is associated with long-term financial cost savings. Access to autism-specific intervention services often requires a formal diagnosis. Video link (Koegel et al., 2014; Warren et al., 2011)

Early Social communication milestones (ASHA; CDC 2015) 3 months 6 months 9 months 12 months 18 months 24 months Smiles socially Coos Laughs or squeals Babbles Likes to look at self in mirror Enjoys playing peek-a-boo Understands “no” May point with finger Follows your point Responds to name More complex babbling Recognizes words for common objects Uses gestures to communicate Imitates different speech sounds 1-2 words around first birthday Begins to respond to requests Says more words every month Simple 1-step pretend play with doll or stuffed animal Points to request and to express interest in something Follows simple commands without gestures Points to a few body parts and pictures in a book when named Understands simple questions Puts two words together Interested in other children and plays beside them Simple 2-step pretend play

Early indicators (12-24 months) 2/25/2016 Early indicators (12-24 months) Limited shifting of eye contact between objects and people (joint attention) Fewer warm, joyful expressions with eye contact Limited showing of objects or sharing enjoyment or interests Lack of response to name Lack of coordination of nonverbal communication Limited use of gestures Fewer communication bids for requesting, seeking help Unusual prosody (e.g., rhythm and intonation of babbling) Repetitive movements with objects Repetitive movements or posturing of body, arms, hands, or fingers Limited combining of actions in play Any loss of speech, babbling, or social skills (Wetherby et al., 2004; Landa et al., 2007)

Video examples Early Signs of Autism Video Tutorial Kennedy Krieger Institute http://www.kennedykrieger.org/patient-care/patient-care-centers/center-autism-and- related-disorders/outreach-training/early-signs-of-autism-video-tutorial ASD Video Glossary Autism Speaks & First Signs http://autismspeaks.player.abacast.com/asdvideoglossary-0.1/autismspeaks/login

Screening for asd The American Academy of Pediatrics recommends that all children be screened by their primary health care providers at 18 and 24 months for ASD. In childcare settings or home visiting programs, this can be done in the context of broader developmental screening. (Johnson & Myers, 2007; Robins et al., 2013)

Resources for developing screening or monitoring programs Tip Sheets for Implementing Developmental Screening (Available in English and Spanish) Wisconsin Early Childhood Collaborating Partners http://www.collaboratingpartners.com/child-find-screening-screening.php Watch Me! Celebrating Milestones and Sharing Concerns Centers for Disease Control and Prevention http://www.cdc.gov/ncbddd/watchmetraining/index.html Birth to 5: Watch Me Thrive! U.S. Department of Health and Human Services & U.S. Department of Education https://www.acf.hhs.gov/sites/default/files/ecd/ece_providers_guide_march2014.pdf

M-CHAT The Modified Checklist for Autism in Toddlers (M-CHAT) is a widely used and well-validated screener for children ages 16 to 30 months. The most recent version (M-CHAT-R/F) includes a parent-completed checklist and brief, structured follow- up interview. Available for free at www.m-chat.org

Sharing concerns with families Schedule a time to meet with parents in a quiet, private setting. Discussion can also occur during regularly scheduled parent—teacher conferences or home visits. Share information on typical developmental milestones and activities for supporting young children’s development in a variety of domains (e.g., Milestones Moments booklet). List the specific developmental concerns without jumping to any suspected diagnostic labels (e.g., autism, ADHD). Consider parents’ individual and cultural beliefs about child development and offer them an opportunity to share their perspective. Encourage parents to talk with their child’s health care provider about the areas of concern. Provide information for Birth to 3 or Early Childhood evaluation services.

Referring for further evaluation Under Age 3 Ages 3 - 5 Pediatrician/primary care provider Bring completed M-CHAT to visit Birth to 3 Contact county-specific agency Will complete an evaluation and, if found eligible, develop an Individualized Family Support Plan (IFSP) Pediatrician/primary care provider Bring list of developmental concerns to visit Early Childhood Services Contact local school district Will complete an evaluation and, if found eligible, develop an Individualized Education Program (IEP)

BiRTH to 3 AND Early childhood special education services Birth to 3 Program Information: https://www.dhs.wisconsin.gov/birthto3/index.htm Department of Public Instruction Early Childhood Special Education: http://ec.dpi.wi.gov/ec_ecspedhm Introduction to Special Education (informational booklet for parents): http://sped.dpi.wi.gov/sites/default/files/imce/sped/pdf/intro-se.pdf

references American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th edition). Washington, DC: Author. American Speech-Language-Hearing Association (n.d.). How Does Your Child Hear and Talk? Retrieved from http://www.asha.org/public/speech/development/01/ Bishop, S. L., Luyster, R., Richler, J., & Lord, C. (2008). Diagnostic assessment. In K. Charwaska, A. Klin, & F. R. Volkmar (Eds.), Autism spectrum disorders in infants and toddlers: Diagnosis, assessment, and treatment (pp. 23-49). New York: Guildford. Centers for Disease Control and Prevention. (2015, April). Developmental Milestones. Retrieved from http://www.cdc.gov/ncbddd/actearly/milestones/index.html Centers for Disease Control and Prevention (2015, February). Facts About ASD. Retrieved from http://www.cdc.gov/ncbddd/autism/facts.html Johnson, C. P. & Meyers, S. M. (2007). Identification and evaluation of children with autism spectrum disorders. Pediatrics, 120, 1183-1215.

References (continued) Koegel, L. K., Koegel, R. L., Ashbaugh, K., & Bradshaw, J. (2014). The importance of early identification and intervention for children with or at risk for autism spectrum disorders. International Journal of Speech- Language Pathology, 16(1), 50-56. Landa, R. J., Holman, K. C., & Garrett-Mayer, E. (2007). Social and communication development in toddlers with early and later diagnosis of autism spectrum disorders. Archives of General Psychiatry, 64(7), 853-864. Lord, C. & Luyster, R. (2005, December). Early diagnosis and screening of autism spectrum disorders. Medscape Psychiatry & Mental Health, 10(2). Robins, D. L., Casagrande, K., Barton, M., Chen, C. A., Dumont-Mathieu, T., & Fein, D. (2013). Validation of the modified checklist for autism in toddlers, revised with follow-up (MCHAT-R/F). Pediatrics, 133, 37-45. Warren, Z. McPheeters, M. L., Sathe, N., Foss-Feig, J. H., Glasser, A., & Veenstra-VanderWeele, J. (2011). A systematic review of early intensive intervention for autism spectrum disorders. Pediatrics, 127(5), e1303- e1311. Wetherby, A. M., Woods, J., Allen, L., Cleary, J., Dickinson, H., & Lord, C. (2004). Early indicators of autism spectrum disorders in the second year of life. Journal of Autism and Developmental Disorders, 34, 473-493.

additional resources Learning Module on Early Identification of Autism Spectrum Disorder National Professional Development Center on Autism Spectrum Disorders http://asdtoddler.fpg.unc.edu/early-identification-autism-spectrum-disorders/early-identification-module-introduction Centers for Disease Control and Prevention Act Early Program Materials http://www.cdc.gov/ncbddd/actearly/ Milestone Moments Booklet for Families Available in English and Spanish http://www.actearly.wisc.edu/materials.php

Questions, comments, discussion Thank You! Contact Info: craysubramanian@ids-wi.com 608-410-0511