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Evaluating Autism Spectrum Disorders with the ADOS

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  • SLI are pure language disorders, not caused by other condition
  • Not clear who what children are best suited for intervention

Evaluating Autism Spectrum Disorders with the ADOS Evaluating Autism Spectrum Disorders with the ADOS Presentation Transcript

  • Including Every Learner: How schools, families, and experts can better educate children with challenges
    David Black, PhD
    Pediatric Neuropsychologist
    Laura Kenealy, PhD
    Children’s National Medical Center
    Dr. Black’s presentation is based on his expertise with autism and as a pediatric neuropsychologist, and is not acting in an official capacity for the National Institutes of Health.
  • Including Every Learner:Why it matters
    Major trends in education
    Inclusion of special needs learners at every level
    Larger population in early education settings than ever before
    Stakes are higher than ever
  • Exploring barriers
    Teachers may feel unprepared to cope with special needs learners…
    Parents may wonder what is best for their child…
    Some students are less able to benefit from inclusion…
  • Making it Work
    Five factors associated with successful inclusion (Webber, 1997)
  • Making it Work
    Sense of Community and Social Acceptance
    “I am as good as others here”
    “Everyone makes a valuable contribution to our group”
  • 2. Appreciation for Diversity
    “I like to learn about how we’re different.”
  • 3. Attention to Curricular Needs
    “What I teach meets the needs of my learners”
  • 4. Effective Management and Instruction
    “I know what works”
    “Everything about my class helps me learn”
  • 5. Personnel Support and Collaboration
    “I have the support of my team.”
  • Overview
    Learning about our learners with special needs:
    * Autism Spectrum Disorders
    * Language Delays
    * Sensory Processing Problems
    * Learning Difficulties
    * Attention and Impulsivity Problems
  • Overview
    What it is
    What it looks like in the early education setting
    What the science tells us
    Classroom strategies that work: Tips and Tricks for all kinds of special needs kids
  • Autism Spectrum Disorders
  • Autism Spectrum Disorders
    Prevalence Rates
    What is Autism
    Recognizing Autism in the Classroom
    Latest Research
    Autism in inclusion classrooms
  • Prevalence of Autism
    • Rate of autism is ~1%
    • 2008: CDC Estimates 1/110 diagnosed with autism
    • 2007: UK Adult Psychiatric Comorbidity study estimate 1%
    • 2007: National Survey of Children's Health (sample size: 78,037)
    • Gender ratio: 4-5:1 male: female
    • No differences across racial/ethnic groups
    • Some research suggests African American children diagnosed later, however
    • 59% (range 49-70%) have IQ > 70
    • CDC, 2007; 2002 surveillance data
  • Prevalence Rates
    Rates have been steadily increasing over past 20+ years
    Recent study of special education enrollment data in Wisconsin suggest the increase may be leveling off in some areas (Maenner and Durkin, 2010).
  • Autism Prevalence: Past 15 Years
    Number (per 1,000) of children aged 6–17 who were served under the IDEA with a diagnosis of autism, from 1996 through 2007.
  • Maenner and Durkin, 2010, Pediatrics
  • What Causes Autism
    • ~90% of cases, we don’t know
    • ~10% of cases associated with known chromosomal or genetic disorders
    • Most heritable of all neuropsychiatric conditions
    • Identical twin concordance: 60-96%
    • Sibling risk: 2-8%
    • Poor parenting practices DO NOT cause autism
    • Research has NO LINK between vaccines and autism
    CDC.gov, 11.3.2010
  • Autism Spectrum Disorders Include …
    Autism/Autistic Disorder
    Asperger’s Syndrome
    Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS)
    Autism Spectrum Disorder
    **Nonverbal Learning Disability**
  • Social Impairment
    Repetitive Behaviors & Restricted Interests
    Speech/
    Communication Deficits
    Autism Spectrum Disorders: Symptoms in Three Main Areas
  • Social Impairment
    Repetitive Behaviors & Restricted Interests
    Speech/
    Communication Deficits
    Core Symptom Domains
    Asperger’s
    Autism
    Language Disorders
    Sensory Integration problems
  • ASD is Very Broad
    Broad range of….
    Intellectual functioning
    Social Interest and motivation
    Social competence
    Language ability
    Repetitive, unusual, challenging behaviors
  • http://www.cdc.gov/ncbddd/autism/signs.html
  • Impaired Social Interaction
    Includes:
    Deficits in nonverbal communication
    Failure to develop peer relationships
    Spontaneously seeking to share enjoyment
    Lack of social or emotional reciprocity
    Impaired social cognition
  • Impaired Nonverbal Communication
    Eye contact
    Communicative use of gestures/body language
    Directed facial expressions
    Flat or limited range of facial expression
    Inappropriate facial expressions
  • Failure to Develop Peer Relationships
    Unable to sustain reciprocal friendships
    Lack of interest/oblivious
    Lack of responsiveness when other children approach
    Avoidance of peer interactions
    Preference to play alone
    Overly rule bound in social interaction
    Lack of sharing
  • Lack of Shared Enjoyment
    Limited social initiation
    Lack of bringing or showing objects
    Unlikely to share interest or excitement of activities
    No reaction to praise
    No desire to please
  • Social Reciprocity
    Lack of social awareness
    Little interest in social interaction
    Tends to be more “object oriented” than “socially oriented”
    Excessively directive or rigid in social interactions
    Does not notice another’s lack of interest
  • Social Cognition: Social Thinking
    Impaired ability to …
    • Make social predictions
    • Grasp impact of actions on others
    • Imagine thoughts and feelings of others
    • Develop, maintain, and repair a social interchange
    • Recognize social mishaps
    • Recognize/follow social convention
    • Recognize distress in others
  • Impaired Communication
    Language delay
    Inability to sustain a conversation
    Stereotyped, repetitive, idiosyncratic language use
    Lack of varied make-believe, or social imitative play
  • Language Delay
    • Understanding spoken language
    • Communicating verbally
    • Lack of compensation through other means*
    • Gesture
    • Facial expression
    • Bringing of objects
    *Differs in children with ASDs and language delay
  • Reciprocal Conversation
    Conversation may be one-sided
    Limited in flexibility or range of topics
    Back and forth of interchange may be limited
    Minimal “social chat”
  • Stereotyped Speech
    Scripted, repetitive use of speech
    Echolalic speech
    Unusual use of language
    Neologisms
    Pedantic “little professor” speech
    Odd intonation, rhythm, or pitch to vocal quality
  • Limited Imaginative Play Skills
    Play tends to literal, functional, concrete
    Difficulty ascribing agency to figures
    E.g. Elmo feeding Buzz Light Year
    Impacts social play and cooperative play
    In young children, functional play skills may also be limited
  • Repetitive Behaviors and Restricted Interests
    Excessive preoccupation with stereotyped pattern of interest
    Inflexible adherence to routine and rituals
    Persistent preoccupation with parts of objects
    Stereotyped repetitive motor mannerisms
  • Stereotyped Pattern of Interests
    Fixated interest
    May be odd – doors, bumpers on cars
    May be a conventional interest but extreme – obsession with dinosaurs, maps, or a favorite movie
    Excessively perfectionistic
    Socially interfering, limiting other activities
  • Difficulty with Transition & Changes in Routine
    Rigid adherence to routines
    Transition between activities (even preferred activities) very difficult
    Unusual compulsion or rituals with routine events
    Catastrophic reaction to minor changes in environment
    Lining up objects
  • Hand and Whole Body Mannerisms
    Hand flapping
    Finger flicking
    Repetitively bouncing or spinning
  • Repetitive & Unusual Use of Objects
    Non-function use of a part of an object – spinning wheels, opening/closing doors
    Sensory interest in objects
    Smelling people or objects
    Preoccupation with texture
    Close visual inspection
    Seeking proprioceptive input
  • Cognitive Profile
    • Developmental delay/Intellectual deficits
    • Splinter strengths
    • Language deficits
    • Poor self-regulation
    • Weaknesses in executive functioning
    • Poor motor planning/graphomotor control
    • Sensory sensitivity/sensory integration weaknesses
  • Sensory Processing Problems
    Oversensitivity
    Undersensitivity
  • Sensory Processing Problems
    Difficulty with the processing of sensory input
    Sight, sound, taste, texture, proprioception
    Oversensitivity or undersensitivity
    No formal criteria to diagnosis
    Usually identified by an occupational therapist
  • Sensory Processing Problems
    Oversensitivity: Aversion to
    Texture (play dough, rice, finger paint, grass)
    Light (fluorescent light, bright sunlight)
    Sound (classroom noise, lots of children talking, loud music)
    Being touched
    Undersensitivity usually to pain, but also to hot and cold
  • What do we know…
    Higher rate of oversensitivity in clinical populations
    ASD – 56%
    ADHD – 69%
    Undersensitivity also very common in ASD
  • What do we know…
    Oversensivity has been associated with
    Anxiety/internalizing problems
    Difficulty modulating response to input
    If distracted by sensory input, then harder to respond in a socially appropriate, well-modulated manner
  • What do we know…
    Birth cohort study n=925
    Developmental disorders excluded
    16% of elementary children reported tactile sensitivity – 4 tactile sensations
    May not be impairing, however
    Oversensitivity 
    4-fold increase in internalizing problems
    Less social competence (empathy, prosocial behavior)
    Ben-Sasson, Carter, Briggs-Gowan, 2009, Journal of Abnormal Child Psychology
  • Language Disorders
    Comprehension of language
    Speech sound disorders
    Phonological disorders
  • Language Disorders
    Impairment in comprehension and/or use of language
    Speech sound disorders very common
    8% of kindergarteners have a specific language impairment (SLI)
    5% of 1st graders have a recognizable speech (phonological) disorder
    Range from sound substitutions to impaired communication
    http://www.nidcd.nih.gov/StaticResources/about/Plans/strategic/strategic06-08.pdf
  • Language Disorders
    Affects boys 1.5 times more than girls
    20-40% have family history of SLI
    Associated with future learning disorders
    Especially reading
    Phonological disorders associated with math and written language weaknesses
    Common in autism
    Early intervention effective in treating language disorders
    http://www.asha.org/research/reports/children.htm
  • Who Can Be Included
  • Reasonable Classroom Fit
    Consideration of:
    Cognitive functioning
    Receptive language
    Expressive language
    Self-regulation
    Social abilities
    Emotional maturity
  • Who can be included: Autism
    Social motivation: highly aloof children may not do as well
    Ability to follow basic social rules and direction
    Functional speech
    Repetitive behaviors can be redirected
    Ferraioli and Harris, 2010,
    Journal of Contemporary Psychotherapy
  • Outcomes of Inclusion Models in Autism
  • Research Cautions…
    Minimal research available
    Research is largely based on case studies and a handful of group studies
    Many studies are of children “trained” to produce a specific response
    Unknown whether behavior will generalize
    Not clear which children will benefit
  • General Observations
    • Inclusion better for younger than older kids (4th grade)
    • Older children Less tolerant of “differences”
    • Paradox: there is less peer acceptance of more socially competent ASD kids
    • Limited evidence of benefit for inclusion without additional support
    • With adequate support emerging research suggests inclusion models support social competence
  • Low Social Involvement: Mainstream setting/no support
    Rotheram-Fuller, Kasari, 2010,
    Journal of Child Psychology and Psychiatry
  • Reasons for Low Social Involvement
    Misperceptions of social involvement
    Typical peers become less tolerant of differences and aberrant behavior
    Limited cooperative play skills
    Poor motor skills – social involvement of boys is largely sports oriented
    Rotheram-Fuller, Kasari, 2010,
    Journal of Child Psychology and Psychiatry
  • What predicts social rejection?
    Low levels of cooperation
    Being regarded as shy
    More help-seeking
    Jones & Frederickson, 2010, Journal of Autism and Developmental Disorders
  • Will Inclusion Adversely Affect Typical Children?
    Concerns:
    Takes away teacher time
    Decreases classroom instruction
    Typical children may feel uncomfortable
    Research (limited):
    When done appropriately, typical children develop better social competence
    No adverse impact on learning
    Ongoing monitoring is important
  • Diary Study in ASD: General Observations
    School is stressful and anxiety provoking
    Social isolation & bullying are common
    High risk for deliberate teasing
    Anxiety worse in ASD than other groups
    Secondary to social deficits
    Need for order, consistency, and routine
    Humphrey and Lewis, 2008, Autism, 12, 23-46.
  • Diary Study in ASD:Take Home Points
    Quiet classrooms, hand-pick teachers
    Time out/break from busy classrooms
    Try not to treat ASD kids differently, especially as they get older
    Provide ‘behind the scenes’ support closely integrated with classroom teacher
    Leverage ‘special interests’ to motivate
    Humphrey and Lewis, 2008, Autism, 12, 23-46.
  • Diary Study in ASD:Take Home Points
    Peer relationships more important than teacher for inclusion success
    Facilitate development of peer relationships
    Stick up for kids with ASD
    Support positive sense of self
    Humphrey and Lewis, 2008, Autism, 12, 23-46.
  • Life in school, Student with ASDHumphrey & Lewis, 2008, Autism
  • Student with ASDHumphrey & Lewis, 2008, Autism
  • Diary Study in ASD:Teachers Need Support…
    Training to:
    Individualize instruction
    Modify curriculum
    Manage the social and self-regulation needs
    Disorder specific education, support and problem-solving resources
    Access to an ASD specialist
    Humphrey and Lewis, 2008, Autism, 12, 23-46.
  • When Does Inclusion Work?
    Explicit social instruction
    Education about differences
    Peer mediated intervention
    Teacher prompting, modeling, support
  • Peer Mediated Intervention
    Case study of two kids with ASD
    Intervention:
    4-5 minute training of whole classroom
    Adult prompting throughout day
    Explicit modeling, prompting, and reinforcement
    Increased peer to peer interaction & social skills
    Banda, Hart, Liu-Gitz, 2010,
    Research in Autism Spectrum Disorders
  • Facilitating Social Inclusion
    Select tasks that require social interaction – e.g. frequent requests for more materials
    Adult supported group activities
  • Learning Disability
  • “Sophia”
    • A little slow to talk
    • Unclear articulation, mixing up syllables (“aminals”)
    • Preschool:
    • Alphabet, nursery rhymes, memorized sequences
    • Letter and color names
    • Counting and 1:1 correspondence
  • By Kindergarten
    Not associating sounds with letters
    Trouble with rhyming
    Confusing similar-looking letters
  • End of first grade
    Delay in reading and writing skills
    Tested and found to have a learning disability
  • Learning Disabilities
    Definition – Controversies and Changes!
    * 1960’s: “minimal brain dysfunction”
    * 1970’s-2004:
    IQ-Achievement “discrepancy”
    * 2000’s: Low achievement, assess Response to Intervention (RTI)