Diagnosis of Autism Spectrum Disorders. Objectives. Autism Spectrum Disorders

Transcription

1 Diagnosis of Autism Spectrum Disorders Kristn Currans, PsyD Bridget Kent, MA, CCC-SLP The Kelly O Leary Center for Autism Spectrum Disorders (TKOC) Division of Developmental and Behavioral Pediatrics Cincinnati Children's Hospital Medical Center Objectives Review of Autism Spectrum Disorders Discuss best practice in ASD diagnosis Review components of a multidisciplinary evaluation Age related issues in assessment Red Flags Autism Spectrum Disorders Brain-based developmental disorders which: - appear during the first 3 years of life - cause difficulties with the following: - understanding language - understanding language - using language - relating to the environment - processing sensory information - are diagnosed by behavioral observation 1

2 Autism Spectrum Disorders Autistic Disorder Difficulties with social interaction. Difficulties with communication. Very limited pretend play. Occurs prior to age three years. Often have stereotyped behaviors. May have restricted interests and activities. Subgroup may have experienced regression. Asperger Syndrome Difficulties with social interactions. Presence of communication issues, but more subtle than those seen in autistic disorder. Restricted interests and activities. Intelligence ranges from average to well above average. 2

3 PDD-NOS (Pervasive Developmental Disorder Not Otherwise Specified) Diagnosis made when a child does not meet the criteria for a specific diagnosis (Autism, Asperger). There is generally a severe and pervasive impairment in communication, social interactions, or restricted interests. Autism Spectrum Disorders - Diagnosis Individuals are more unique than similar, which can make diagnosis a challenge Diagnosis encompasses a wide range of presentations If you ve met one person with autism, then you ve met one person with autism. -Stephen Shore Best Practice in ASD Diagnosis Best practice for diagnosis of ASD should be multidisciplinary, including a medical professional, psychologist, and speech language pathologist. (Other related fields as needed) Ozonoff, S., Goodlin-Jones, B., Solomon, M. (2005) 3

4 Best Practice: Roles of Team Members Physician: R/O other medical conditions, medical history, determine additional testing needed Psychologist: cognitive, R/O other mental health conditions, detailed history, behavior, autism specific tools, attention Speech-Language Pathologist: communication and social differences specific to ASD, strengths and weaknesses, some autism specific tools (at TKOC administer ADOS) Best Practice- Roles of Team Members Occupational Therapist: motor/sensory differences, sensory profile, arousal levels Education: academic functioning, behavior in different contexts Audiology: R/O hearing loss Neuropsychology: higher functioning to explore discrepancies, profile of strengths and weaknesses, executive functioning Diagnosing Autism at TKOC Multidisciplinary evaluation Pediatrics, psychology, speech pathology Neuropsychology, audiology, occupational therapy, and special education as needed 4

5 General Assessment Guidelines No one assessment measure should be used in isolation Autism is a diagnosis based on behavioral symptoms Good to include assessment across settings if possible (parent report, teacher report, and direct observation) Psychology Psychology Evaluation: Basic Components Relevant Background Information Child Interview (if possible) Behavioral Observations including play Cognitive Functioning Cognitive Functioning Adaptive Behavior Executive Functioning Behavior Checklists Autism Specific Measures 5

6 Relevant Background Information Pregnancy history Developmental Milestones Medical Concerns Past and current medications Sleep Feeding Relevant Background Information Family History School History Family Stressors/History of trauma and abuse Past treatment/services Relevant Background Information Communication Current level of communication and use of communication History of regression Disordered Communication (scripted language, echolalia, repetitive phrases, pronoun confusion, idiosyncratic use of words etc.) Nonverbal communication (gestures, pointing) 6

7 Relevant Background Information Sensory Concerns Adverse reaction to noise, smells, texture Seeking sensory input such as sniffing or mouthing objects, peering at objects or interest in the feel of objects Relevant Background Information Social Interaction Seeking to share enjoyment or interests Initiation of interaction Eye contact and facial expressions Peer play (cooperative, parallel etc.) Play skills (imaginative play, imitation, repetitive play) Be sure to get examples of play Relevant Background Information Stereotyped/Repetitive Behaviors Preoccupation with activity/objects Takes up a significant amount of time and interferes with functioning Inflexibility with routines and difficulty with transition Motor Mannerisms (hand flapping, rocking, spinning, complex body movements, finger flicking, twisting) Fascination with parts of objects 7

8 Relevant Background Information Behavioral Concerns Tantrums, aggression (frequency, intensity) Self injury Anxiety Mood related symptoms Strategies used to address behavior Cognitive Functioning: What are we looking for? General developmental level Strengths and weaknesses R/O mental retardation Split in verbal vs. non-verbal skills ASD: often higher non-verbal than verbal skills Asperger: often higher verbal skills and average to above average intelligence Cognitive Measures Stanford-Binet Intelligence Scale- Fifth Edition Age 2+ Mullen Scales of Early Learning -Birth to 68 months -Given when under 2 or cannot achieve basal on the SB-V Leiter-R Non-verbal test of intelligence 8

9 Adaptive Functioning: What are we looking for? Children with ASD often have deficits in adaptive functioning Particular focus on communication and social skills Also use to assist in diagnosis of mental retardation Adaptive Functioning Measure Vineland Adaptive Behavior Scales-Second Edition (VABS-II) Communication (receptive, expressive, written) Socialization (interpersonal relationships, play and leisure, coping skills) Daily Living Skills (personal, domestic, community) Motor Skills (fine and gross) Executive Functioning: What are we looking for? Compilation of skills required for problem solving, planning, and modulation of emotion and behavior Children with ASD often have deficits in one or more areas of executive functioning Valuable for treatment recommendations 9

10 Executive Function Measure Behavior Rating Inventory of Executive Function (BRIEF and BRIEF-P) BRIEF-P for age 2 years, 0 months to 5 years, 11 months BRIEF for age 5 years to 18 years Behavioral Checklists: What are we looking for? R/O co-morbid mental health conditions Can symptoms be explained by another diagnosis beside ASD On the CBCL look at withdrawn behaviors (younger) and social problems (older) Behavioral Checklists Achenbach Child Behavior Checklist Achenbach Teacher Report Form Anxiety, Depression, ADHD measures as needed d Conners Parent Rating Scale- Revised: Long Version, Screen for Anxiety Related Disorders, Beck Youth Inventory, Child Depression Inventory, Youth Self Report Form 10

11 Autism Specific Instruments Autism Diagnostic Interview-Revised (ADI-R) Semi-structured parent interview Administration time: 2 3 hours Current behavior and focused time between 4 5 years old Provides a diagnostic algorithm Classification of autism given when scores in all three content areas (communication, social interaction, and patterns of behavior) meet or exceed the specified cutoffs, and onset of the disorder is evident by 36 months of age Autism Specific Instruments Components of ADI-R Interview: Background, including family, education, previous diagnoses, and medications Overview of the subject's behavior Early development Language acquisition and loss of language or other skills Current functioning in regard to language and communication Social development and play Interests and behaviors Clinically relevant behaviors, such as aggression, self-injury Autism Specific Instruments Gilliam Autism Rating Scale-2 (GARS-2) Used for age 3-22 Informant should be someone who knows the behavior of the child well Normed on children with autism spectrum diagnoses Based on 3 subscales: stereotyped behaviors, communication, and social interaction Result in Autism Index which correlates to probability of an autism spectrum diagnosis Mean=100, SD=15 11

12 Autism Specific Instruments Childhood Autism Rating Scale (CARS) completed by psychologist based on observation and parent report behaviors are scored based on comparison to typical children range of scores 15 to 60 not intended to be a stand alone assessment Autism Specific Instruments (Asperger or High Functioning Autism) Gilliam Asperger Diagnostic Scale (GADS) Informant should be someone who knows the behavior of the child well Normed on children with Asperger diagnosis Based on 4 subscales: social interaction, restricted patterns of behavior, cognitive patterns, and pragmatic skills Result in Asperger s Disorder Quotient which correlates to probability of Asperger s Disorder Communication 12

13 Communication Evaluation: Basic Components Relevant Background Information Expressive Language Functioning Receptive Language Functioning Social/Pragmatic Language Functioning Autism Specific Measures Relevant Background Information Presence of normal audiologic evaluation History of recurrent ear infections Speech and Language Development Within Normal Limits Delayed History of regression Access to intervention services Feeding difficulties Receptive & Expressive Language Skills: What are we looking for? General language level Strengths and weaknesses Split in receptive and expressive language skills ASD: often higher expressive language skills than receptive language skills Presence of stereotyped language 13

14 Receptive & Expressive Language Skills Measures Preschool Language Scale Fourth Edition (Ages birth to 6 years, 11 months) Clinical Evaluation of Language Fundamentals Preschool 2 (Ages 3 years to 6 years, 11 months) Peabody Picture Vocabulary Test Fourth Edition (Norms for ages 2 years, 6 months to 90 years) Social/Pragmatic Language Skills: What are we looking for? Communicative functions Nonverbal language skills Turn taking (verbal and nonverbal) Maintenance of personal space Facial expressions Eye gaze Social overtures Maintenance of attention Providing clarification Social/Pragmatic Language Measures Common Measures Descriptive Pragmatics Profile from Clinical Evaluation of Language Fundamentals Preschool Second edition (Ages 3 years to 6 years, 11 months) Comprehensive Assessment of Spoken Language (Ages 3 years to 21 years) Observations of skills 14

15 Autism Specific Measures Autism Diagnostic Observation Schedule (ADOS) Semi-structured standardized assessment of communication, social interaction, and play/imaginative use of materials Consists of standard activities that allow the examiner to observe behaviors that have been identified as important to the diagnosis of ASD at different developmental levels and chronological ages Includes 4 modules based on language level Provides a diagnostic algorithm Results yield a score that falls into one of three ranges autism, autism spectrum, or neither Autism/Communication Related Concerns Lack of speech coupled with lack of desire to communicate and nonverbal compensatory efforts Scripted and stereotyped language Dissociation between advanced expressive skills and delayed receptive skills Hyperlexia or advanced verbal reading without corresponding comprehension skills Use of gestalt phrases Other prespeech deficits include Lack of appropriate gaze; warm, joyful expressions with gaze; lack of recognition of mother s voice; disregard for vocalizations, yet keen awareness of environmental sounds; delayed onset of babbling past 9 months; and decreased or absent use of prespeech gestures (Johnson & Myers, 2007) Assessing Social Behavior Eye Contact Joint Attention Directed Facial Expressions Showing Giving 15

16 Assessment of Social Behavior Children with ASD universally demonstrate deficits in social relatedness defined as the inherent drive to connect with others and share complementary feeling states (Johnson & Meyers, 2007) To ensure accuracy and consistency of observations, assessment of social behavior should occur across settings and clinicians Multi-disciplinary assessment allows for different viewpoints of social behavior Assessment of Social Behavior Deficits in joint attention (JA) seem to be one of the most distinguishing characteristics of very young children with ASD (Johnson & Myers, 2007) JA is a normal spontaneously occurring behavior At approximately 8 months infant will follow the parent s gaze and look in the same direction At approximately months infant will follow a point At approximately months child will begin to initiate a point to request At approximately months child will begin to point simply to comment or share an interest Additional Assessment Considerations 16

17 Age-Related Issues to Assessment Accurate assessment requires engaging a child s attention and motivation to demonstrate his or her skills (Koegel, Koegel, & Smith, 1997; Ozonoff, Rogers, & Hendren) Before the age of 3 years, skill assessment generally does not require intentional cooperation on the part of the child with ASD; it relies instead on observation of the child s exploration of standardized materials and reaction to events in the assessment setting (Shea & Mesibov, 2009) Issues Around Assessment of Young Children Experience Parent Report Behavior Typical Development Screening for ASD AAP formally recommends all children be screened for ASD at 10-mos and 24-mos Modified Checklist for Autism in Toddlers (M-CHAT) 17

18 Red Flags No babbling or pointing or other gesture by 12-mos No single words by 16 mos No two-word spontaneous (not echolalic) li phrases by 24-mos Loss of language or social skills at any age (Johnson & Myers, 2007) Early Signs Autism Society of America Lack of or delay in spoken language Repetitive use of language and/or motor mannerisms (e.g., hand-flapping, twirling objects) Little or no eye contact Lack of interest in peer relationships Lack of spontaneous or make-believe play Persistent fixation on parts of objects Referral Discuss concerns with family Recommend follow-up with pediatrician Evaluation with multi-disciplinary team, if appropriate 18

19 References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Goldstein, S., Naglieri, J. A., & Ozonoff, S. (Eds.). (2009). Assessment of autism spectrum disorders. New York: The Guildford Press. Johnson, C. P., Myers, S.M., & The Council on Children with Disabilities. (2007). Identification and evaluation of children with autism spectrum disorders. Pediatrics, 120, Koegel, L. K., Koegel, R., & Smith, A. (1997). Variables related to differences in standardized outcomes for children with autism. Journal of Autism and Developmental Disorders, 27, Ozonoff, S., Rogers, S. J., & Hendren, R. L. (2003). Autism spectrum disorders: A research review for practitioners. Washington, DC: American Psychiatric Publishing. Resources Autism Society of America Click on Resources then Downloads Autism Society of Ohio Click on Resources/Guidelines Autism Society of Greater Cincinnati Click on Calendar of Events or Links The Kelly O Leary Center for Autism Spectrum Disorders Resources Ohio Center for Autism and Low Incidence Disorders Click on Resources Click on Resources Organization for Autism Research Click on Educators & Service Providers 19

20 Questions? 20