1. Early Identification of Autism: Early Characteristics, Onset of Symptoms, and Diagnostic Stability Authors: Sara Jane Webb, PhD and Emily J. H. Jones, PhD Infants & Young Children (2008) Vol. 22, No. 2, pp. 100-118 Article Review Southside Tidewater CoPA - June 2009

2. Overview Autism Spectrum Disorders include: Autism Pervasive Development Disorder – NOS Asperger’s Disorder DSM-IV: Impairments in social interaction & communication and the presence of a restricted repertoire of behavioral activities & interests Southside Tidewater CoPA - June 2009

3. Overview Affects boys 3-4 times more often than girls Typically diagnosed between ages of 3-4 years old Clear evidence of genetic involvement in etiology of ASD = risk factors are present from birth 30% of parents identify concerns prior to 1 yr 80% of parents identify concerns by 2 yrs of age Southside Tidewater CoPA - June 2009

4. Early Characteristics of ASD in Infants In general, there is relatively little research on ASD in infancy Theory – early characteristics may be affected by/reflective of “abnormal trajectories of brain development” Development is shaped by genes & environment Child’s behavior influences the environment the child experiences How do we study this? – Retrospective Studies – Prospective Studies Early Characteristics of ASD in Infants Southside Tidewater CoPA - June 2009

5. Early Characteristics of ASD in Infants Social Interest & Attention – Diminished social attention by age 1 Poor eye contact Lack of response to speech  Reaction to engagement in play or interaction  Social smiling & expression of positive emotion  Expressive communication Differences in affective responses to touch  Orientation to voices Poor imitation skills Southside Tidewater CoPA - June 2009

6. Early Characteristics of ASD in Infants Social Interest & Attention Difficulties with social interest & attention may diminish an infant’s “opportunity to learn about and from the people around them…” (p. 102) RED FLAG – Failure to respond to own name by 12 months of age may be linked to later diagnosis of ASD or other developmental delays Southside Tidewater CoPA - June 2009

7. Communication – Delays in sound production, vocal quality –  Babbling and language at 12 months –  Use of & response to gestures like pointing for shared attention Joint attention is critical to language development Early Characteristics of ASD in Infants Southside Tidewater CoPA - June 2009

8. Repetitive Behaviors & Other Domains – May be less commonly seen in infants/toddlers – Retrospective studies  Object mouthing & exploratory activities with objects 0-6 mo Unusual posturing/movement patterns,  mobility, abnormal muscle tone  Self-stimulatory behaviors Different sensory responses – hyper and hypo (also common in children with DD) – Prospective studies More limited toy play  Atypical motor mannerisms Early Characteristics of ASD in Infants Southside Tidewater CoPA - June 2009

9. Repetitive Behaviors & Other Domains – BOTH studies  Passivity – “too good” OR  Irritability Atypical growth in head circumference One of the first early biological risk factors – Birth – smaller to normal head circumference – 7-9 mo – accelerated head growth – Age 2 – enlarged head circum. & brain volume “Growth rate may slow down after 12 mo, correlated to a slowing in acquisition or loss in skills in infants with autism.” Elder, et. al. (2008) Early Characteristics of ASD in Infants Southside Tidewater CoPA - June 2009

10. Important to Remember: 1 in 5 children with ASD seem to develop typically during the 1 st year 20%-49% of children with ASD show significant regression or skill loss Absence of early risk factors does not rule out later diagnosis of ASD Southside Tidewater CoPA - June 2009

11. In general, there is a more information about ASD in toddlers because: – By 24 months, 90% of parents recognize concerns with child’s development – Most families express concerns to pediatrician by 18 months Early Characteristics of ASD in Toddlers Southside Tidewater CoPA - June 2009

12. Social Interaction –  Attention/orienting to faces and voices –  eye contact – Limited social engagement –  Tendency for isolation Early Characteristics of ASD in Toddlers Southside Tidewater CoPA - June 2009

13. Language & Communication – Language concerns/delays – most commonly reported by parents 20%-25% of children with ASD remain nonverbal Some children may not produce their 1 st word until 18+ mo –  Babbling, complex vocalization, vocal imitation –  Single words & phrases – Speech may be stereotyped or echolalic – Difficulties with receptive language & pragmatics – Prefer to listen to mechanical signals Early Characteristics of ASD in Toddlers Southside Tidewater CoPA - June 2009

14. Language & Communication –  Coordination of gestures with vocalizations & eye gaze for joint attention “2-4 yr olds with ASD may be equally likely to communicate to request or protest” (p. 104) – Difficulties in imitation; less likely to initiate – Less likely to show pleasure with JA experiences Difficulties in JA and Imitation – proposed as core components in ASD (p. 104) – Differences with Play Less complex & less purposeful Less symbolic Early Characteristics of ASD in Toddlers Southside Tidewater CoPA - June 2009

15. Repetitive Behavior & Other Domains – Repeated play with an object & repetitive body movements (12 mo – 3 yrs) – Motor skills may be delayed – “Repetitive behaviors around age 2 may predict later diagnosis” (p. 105) – Temperament & behavior concerns Early Characteristics of ASD in Toddlers Southside Tidewater CoPA - June 2009

16. Stability of Early Diagnosis Diagnosis of ASD is made via: – Clinical Judgment – Comprehensive Behavioral Assessments (dev. appropriate) See article for examples of assessments Diagnoses before age 3 – “provisional diagnosis” – 90%-100% of children diagnosed with ASD between 2-3 yrs old received same dx at 1- and 2-year follow-ups – 88% of children in another study had same dx at 9 yrs old Southside Tidewater CoPA - June 2009

17. Regression (or Skill Loss) Validated through analysis of home videos & prospective studies Regression or…skill “stagnation” (a failure to progress)? Mean reported age of regression – 19-21 mo Seen in both early and late onset ASD Rare for child to show truly typical development before regression Southside Tidewater CoPA - June 2009

18. Regression (or Skill Loss) NOT linked to socioeconomic status, birth order, gender, ethnicity, family risk, or vaccines HOWEVER, families often report regression followed an event such as illness or stressor Skill Loss: – Spoken language – Socioemotional reciprocity Sensory or temperament difficulties Southside Tidewater CoPA - June 2009

19. Important to Remember: Early loss of language does not necessarily = poorer language skills when child is older Most children appear to regain at least single words Southside Tidewater CoPA - June 2009

20. Evidence is mixed about effect of regression on long-term development: – Poorer outcomes vs. No differences between children who experienced regression and those who did not RED FLAG – Regression of Developmental Skills Regression (or Skill Loss) Southside Tidewater CoPA - June 2009

21. Implications for Practice RECOMMENDATIONS Monitoring socioemotional development & screening for ASD is critical Monitoring & screening should be more intensive when working with high-risk groups Advances in early detection require advances in early treatment Southside Tidewater CoPA - June 2009

22. Monitoring socioemotional development & screening for ASD is critical “Relatively high prevalence of ASD” – monitoring as a critical public health measure Use research-based screeners see article for examples & info Follow-up after screening so important: – 14% of parents of children who show positive results on screening waited 6 mo before seeking evaluation – 18% did not seek further evaluation at all Implications for Practice Southside Tidewater CoPA - June 2009

23. Monitoring & screening should be more intensive when working with high-risk groups Siblings of Children with ASD –  Risk of ASD –  Displaying delays/characteristics of “broader autism phenotype” i.e. “cognitive or neural characteristics of family members that resemble those found in individuals with ASD” (p. 107) – More than 10% of siblings show communication & social skill delays – Particular risk – difficulties in joint attention, language /gesture use Implications for Practice Southside Tidewater CoPA - June 2009

24. Monitoring & screening should be more intensive when working with high-risk groups Extreme Prematurity General neurological vulnerability & seizures Certain Disorders appear to show higher rates of ASD – Tuberous Sclerosis – Fragile X Syndrome – Down Syndrome – Neurofibromatosis Implications for Practice Southside Tidewater CoPA - June 2009

25. Advances in early detection require advances in early treatment 2001 – “National Research Council recommended that preschool-aged children with ASD receive at least 25 hours of structured intervention weekly” (p. 110) Due to difficulties evaluating interventions with infants/toddlers – little is known about “general effectiveness, or the impact of individual differences on treatment outcome” (p. 110) Early intervention seems to be more effective than receiving intervention later in development Implications for Practice Southside Tidewater CoPA - June 2009

26. “Increasing awareness of these early signs among parents and practitioners in critical in ensuring that symptoms of ASD are recognized and evaluated as soon as they appear, particularly for groups of children who may be at increased risk… Development and evaluation of treatment options for young children with ASD, and ensuring prompt access to currently available interventions for children with a new diagnosis, are critical goals as the field moves forward.” (p. 111) Summary Southside Tidewater CoPA - June 2009