Treating Children with Autism Spectrum Disorders Johanna Taylor, M.Ed., BCBA Kylan Turner, M.Ed., BCBA
Outline 1) Characteristics of autism spectrum disorders (ASDs) 2) Screening & Diagnostic Assessment 3) Talking with Families & Diagnostic Referral 4) Behavioral Management in the Clinic
Autism Spectrum Disorders What are Autism Spectrum Disorders? PERVASIVE DEVELOPMENTAL DISORDERS (PDD) Rett s Disorder Childhood Disintegrative Disorder PDD(NOS) Autistic Disorder Asperger s Disorder
Autism Spectrum Disorders What are Autism Spectrum Disorders? Lifelong developmental disorder SOCIAL Presence of symptoms determines severity Autism Asperger s Disorder COMMUNICATION BEHAVIORS
DSM-IV TR AD: Diagnostic Components 1) Qualitative abnormalities in reciprocal social interaction 2) Qualitative abnormalities in communication 3) Restricted, repetitive and stereotyped patterns of behavior 4) Abnormality of development before 36 months (3 years) American Psychiatric Association, 2001. Diagnostic and Statistical Manual IV-TR.
Understanding the Diagnosis: Social Impairment Qualitative impairment in social interaction as manifested by at least 2 of the following: SOCIAL American Psychiatric Association, 2001. Diagnostic and Statistical Manual IV-TR.
Understanding the Diagnosis: Social Impairment A) Marked impairment in the use of multiple nonverbal behaviors
Understanding the Diagnosis: Social Impairment B) Failure to develop peer relationships appropriate to developmental level
Understanding the Diagnosis: Social Impairment C) Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
Understanding the Diagnosis: Social Impairment D) Lack of social or emotional reciprocity
Understanding the Diagnosis: Communication Qualitative impairment in communication as manifested by at least 2 of the following: COMMUNICATION American Psychiatric Association, 2001. Diagnostic and Statistical Manual IV-TR.
Understanding the Diagnosis: Communication A) Delay in, or total lack of, the development of spoken language
Understanding the Diagnosis: Communication B) In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
Understanding the Diagnosis: Communication C) Stereotyped and repetitive use of language, or idiosyncratic language Stereotyped: Intensely fixates on one topic for extended period of time Repetitive: Echolalic speech (immediate/delayed) Idiosyncratic: (neologisms) use of words in strange ways or made-up words to convey meaning http://www.youtube.com/watch?v=txb7t2cdskm&feature=player_embedded#t=149
Understanding the Diagnosis: Communication D) Lack of varied, spontaneous makebelieve or social imitative play appropriate to developmental level
Understanding the Diagnosis: Behaviors Restricted repetitive and stereotypic patterns of behavior, interests and activities as manifested by at least 1 of the following: BEHAVIORS American Psychiatric Association, 2001. Diagnostic and Statistical Manual IV-TR.
Understanding the Diagnosis: Behaviors A) Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus http://www.youtube.com/watch?v=q7e4_of8cbu
Understanding the Diagnosis: Behaviors B) Apparently inflexible adherence to specific nonfunctional routines or rituals
Understanding the Diagnosis: Behaviors C) Stereotyped and repetitive motor mannerisms Repetitive movements with objects Repetitive movements or posturing of body, arms, hands, or fingers http://www.youtube.com/watch?v=grr9bxfljou&feature=related http://www.firstsigns.org/concerns/flags.html ; American Psychiatric Association, 2001. Diagnostic and Statistical Manual IV-TR.
Understanding the Diagnosis: Behaviors D) Persistent preoccupation with parts of objects http://www.youtube.com/watch?v=bolflozvb0a
SOCIAL Asperger s Disorder Autism COMMUNICATION BEHAVIORS
Understanding the Diagnosis: Delay Delays or abnormal functioning in at least one of the following areas (with onset prior to 3 years): 1) Social interaction 2) Language as used in social communication 3) Symbolic or imaginative play American Psychiatric Association, 2001. Diagnostic and Statistical Manual IV-TR.
Understanding the Diagnosis: ID Intellectual disability 75% of children diagnosed with an ASD have an intellectual disability This has increased as the diagnostic criteria has widened Towbin, K.E., Mauk, J.E., & Batshaw, M.L. (2007). Autism Spectrum Disorders. In M.L. Batshaw, Children with Disabilities (pp. 325-343). Baltimore, MD: Paul H. Brookes.
Assessment Potential screeners used: Toddlers: M-CHAT Screening tool for Autism in Two-Year-Olds Older kids: SCQ
Social- Communication Questionnaire Previously known as the Autism Screening Questionnaire
Social- Communication Questionnaire Purpose: Offers a quick, easy, and inexpensive way to routinely screen for autism spectrum disorders Ages / Grade: Over 4.0 years, with a mental age over 2.0 years Administration Time: Less than 10 minutes Format: Parent questionnaire with 40 yesor-no items. Current and Lifetime Forms Scores: Total score with cutoff points http://portal.wpspublish.com/portal/page?_pageid=53,70432&_dad=portal&_schema=portal
Assessment Potential assessments used: Autism Diagnostic Observation Scale (ADOS) Autism Diagnostic Interview-Revised (ADI-R)
Assessment ADOS Autism Diagnostic Observation Schedule ADOS portions Review protocol 4 modules One tool within a comprehensive assessment
Assessment ADI-R Autism Diagnostic Interview-Revised Gold-standard tool validated to evaluate the presence of an autism spectrum disorder per parent interview Review protocol
Assessment ADI-R: Components Background Overview of behavior Early development & milestones Current skill functioning Social development and play Interests and behaviors (rituals, routines, etc.) Clinically relevant problem behaviors
Talking with families Getting started Broaching the topic (read the situation) Provide supporting evidence for a need for further assessment Identify supports Avoid back-peddling
Talking with families Answering questions Who will diagnose my child? (What s better?) Medical specialist, school district, or EI evaluator? How can my child be assessed if they do not speak? Does a Dx of ASD mean that my child is mentally retarded? Exkorn, K.S. (2005)
Evaluation Equip families with supports! Utilize natural supports Offer to attend the visit with the family Provide written developmental information for the family to take Help take the fear out of the situation
Evaluation Asking questions Information will help families process a potential diagnosis later Have them draft questions to ask the evaluator Offer to review those questions with them
Evaluation Sites Diagnostic referral in Pennsylvania Hospital Child Development Units Early Intervention Agencies Private/Non-profit psychological/psychiatric practices See resource chart
What s next? If no diagnosis is provided Encourage families to follow through with referral process Encourage families to attend a later follow-up visit if Dx is still suspected Assist them in finding more information about the potential other explanations for atypical development Review recommendations from evaluation with family
What s next? If a diagnosis is made Provide support Be the family s point-person or accountability figure for the challenges of making those initial phone calls (Provide gentle reminders and praise)
Tips: extended family Parents could Give information on a need-to-know basis Offer friends/relatives resources to learn more Encourage other family members to discuss fears Not be offended Model how to accept and interact with the child Encourage others to expect the best from the child Exkorn, K.S. (2005)
Additional Resources At-a-glance information for the clinic: Main CDC Site: http://www.cdc.gov/ncbddd/actearly/index.html Developmental screening information: http://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs /DevelopmentalScreening.pdf ASD information: http://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs /AutismFactSheet.pdf
A note on sensitive communication At intake/initial phone call: Use family friendly person first language Say Individual with autism rather than Autistic person or the autistics
Behavioral Management At intake/initial phone call, determine the patient s: Sensitivities Problem behaviors Preferred interests, toys, games Other information that may make the child feel comfortable
Behavioral Management Scheduling the appointment Schedule patient for the first slot in the morning to prevent wait time Try to schedule for a longer appointment duration Allow patient to become familiar with the environment Ask parents/caregivers to bring items that will make the patient feel comfortable
Behavioral Management Prepare the patient using: Visuals: Pictures of office Books Social stories Reminders Prepare the caregivers: Describe events that will take place
Behavioral Management Be aware of sensory stimuli that may be overwhelming: Bright lights Loud instruments Tactile hyper- or hypo-sensitivity
Behavioral Management Suggestions to decrease sensitivities: Headphones Practice sessions with various instruments before the visit
Behavioral Management During the first visit Allow patient to explore and become comfortable with the environment Show the patient the exam chair and tools Allow patient to make choices: Bandage color? Arm for blood-pressure cuff? Each possible opportunity
Behavioral Management Depending on the patient s functioning level: Tell the patient what you are doing step by step Demonstrate/model the behavior Allow patient to practice behavior Determine that the patient is comfortable before moving on to the next step Prepare patient for transitions!!!
Behavioral Management Once the patient is comfortable and understands the expectations (e.g., being quiet, sitting in the exam table etc.), THEN begin to incorporate more steps. http://www.youtube.com/watch?v=artqfqd6osq
Behavioral Management Talk about and use preferred topics (e.g., animals, counting, etc.) to make sessions more enjoyable Set up a reward system for desired behaviors Encourage parents/caregivers to remain in the exam room Provide breaks when necessary
Behavioral Management If you are unable to help the patient: Anesthesia may be used for patients with high rates of problem behaviors Refer patient to a specialist
References American Psychiatric Association, 2001. Diagnostic and Statistical Manual IV-TR. Exkorn, K.S. The Autism Sourcebook: Everything you need to know about diagnosis, treatment, coping and healing. New York, NY: Collins, 2005. Towbin, K.E., Mauk, J.E., & Batshaw, M.L. (2007). Autism Spectrum Disorders. In M.L. Batshaw, Children with Disabilities (pp. 325-343). Baltimore, MD: Paul H. Brookes
Contact us! kylan.turner@gmail.com johannapatriciataylor@gmail.com