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Autism and Pervasive Developmental Disorders
- 1. PervasiveDevelopmental Disorders Presented by: Emily Childress, M.A. & Amanda Gilmore, M.S. 1525 Airport Road,Suite 101 Ames, Iowa 50010 515-292-3023 Barclay and Associates, P.C.
- 2. What are PDDs? AKA Autism Spectrum Disorders(ASDs) Impairment in development; reciprocal social interaction skills, communication skills, or presence of stereotyped behavior, interests and activities Evident in first years of life Associated with some degree of Mental Retardation Range from a severe form called Autistic Disorder, through Pervasive Development DisorderNot Otherwise Specified), to a milder form, Asperger’s Disorder Includes Rett’s and Childhood Disintegrative Disorder
- 3. Autistic Disorder Six or more from 1, 2, and 3, with two from 1, and one each from 2 and 3 1. One impairment in social interaction marked impairment in the use of multiple nonverbal behaviors eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction failure to develop peer relationships appropriate to developmental level lack of spontaneous seeking to share enjoyment, interests, or achievements with other people No showing, bringing, or pointing out objects of interest lack of social or emotional reciprocity
- 4. Autistic Disorder 2. One impairment in communication Delay or lack of development of spoken language no attempt to compensate through alternative modes of communication (gestures, mimes) in individuals with adequate speech, impairment in ability to initiate or sustain a conversation Stereotyped and repetitive use of language or idiosyncratic language lack of varied, spontaneous make-believe play or social imitative play
- 5. Autistic Disorder 3. One restricted repetitive and stereotyped pattern of behavior, interests, or activities preoccupation with stereotyped and restricted patterns of interest that is abnormal in intensity or focus inflexible adherence to specific nonfunctional routines or rituals stereotyped and repetitive motor mannerisms hand/finger flapping or twisting complex whole-body movements persistent preoccupation with parts of objects
- 6. Rett’s Disorder Normal development for the first 5 months of life followed by a deceleration of head growth between 5 and 48 months Loss of previously acquired purposeful hand movement between 5 and 30 months Loss of social engagement, development of poorly coordinated gait or trunk movements Severely impaired expressive and receptive language development with severe psychomotor retardation
- 7. Childhood Disintegrative Disorder Normal development for the first 2 years Significant loss of 2 previously acquired skills: Expressive or receptive language Social skills Bowel or bladder control Play Motor skills Two abnormalities of functioning: Social interaction Communication Restricted, repetitive and stereotyped patterns of behavior, interests and activities
- 8. Asperger’s Disorder No significant delay in language or cognitive development Two social interaction impairments including: use of multiple nonverbal behaviors eye-to-eye gaze, facial expression, body postures, and gestures Failure to develop peer relationships Lack of spontaneous seeking to share enjoyment, interests or achievements with other people no showing, bringing or pointing out objects of interest Lack of social or emotional reciprocity
- 10. Stereotyped and repetitive motor mannerisms
- 11. Hand/finger flapping or twisting, or complex whole body movements
- 13. Does not babble or coo by 12 months
- 14. Does not gesture (point, wave, or grasp) by 12 months
- 15. Does not say single words by 16 months
- 16. Does not 2 word phrases on his/her own by 24 months
- 19. Symptoms of Autism: Repetitive Behaviors Odd repetitive motions set them apart from other children Behavior can be extreme (arm flapping, walking on toes, freezing in position) May spend hours lining up toys in a specific way Need/demand absolute consistency in environment Slight change in routines can be extremely stressful Intense preoccupation with certain things trains, lighthouses, fire hydrants, symbols
- 20. Signs and Symptoms of Asperger’s Inappropriate or minimal social interactions Conversations revolving around self versus others “Scripted”, “robotic” or repetitive speech Lack of common sense Problems with reading, math, or writing skills Obsession with complex topics such as patterns or music Average to below average nonverbal cognitive abilities though verbal cognitive abilities are usually average to above average Awkward movements Off behaviors or mannerisms
- 22. Strategies: Physical Environment Structure physical environment to facilitate learning and minimize frustration –visual/physical order assists in focusing Watch for peers who obviously/subtly annoy her Watch for peers who feed off and feedback inappropriate behaviors –she may like these peers but the relationships are not necessarily the best for either student Ensure that she is in a position of least distraction up front and away from visual and auditory “clutter” Consider isolating her for short periods to teach new concepts or build on pre-existing knowledge She may be defensive of personal space
- 23. Strategies: In Class Structure Create a predictable environment with routine and prepare student for changes Set behavioral limits and monitor to implement consequences or provide coping strategies Give brief and precise instructions that she understands State clearly what is expected-be concrete and allow time for her to process the information Break tasks up into manageable segments and train her to schedule and plan Teach her to ask for help and methods of doing so
- 24. Video Clip from Parenthood
- 25. Strategies: Presentational Issues Know and use the student’s strengths Present new concepts in a concrete manner Use activity based learning where possible Use visual prompts as appropriate Break work into small steps Have written instructions for students, include visual cues and mark clearly the things that need to be completed Show examples of what is required Keep chalk/whiteboard neat
- 26. Strategies: Teaching Issues Do not do for him what he can do for self Do not expect the him to automatically generalize instructions Use language to tie new situations to old learning Do not rely on emotional appeals or presume that he will want to please you Concentrate on changing unacceptable behaviors and do not worry about those that are “simply” odd Use the obsessive or preferred activity as a reward Use opportunities which arise to teach him about how other students feel and react when they are hurt or upset Be consistent and do not give options if there are no options
- 27. Strategies: Child Focused for Development Provide “peer support network/buddy system” for safety Teach safety phrases such as “are you pretending?” or “what do you mean?” or “why should I do that?” to help her gain information (this does not come naturally) so she can determine the situation’s nature and respond accordingly Teach rules of social conduct so she does not constantly interrupt Explain metaphors and avoid where possible (frog in your throat) Have a time out area for discipline (enforce consequences & ensure ‘time out’ isn’t more attractive than the activity) Have a strategy to employ when she cannot cope due to overstimulation or confusion Written timetables can help primary aged children stay on task
- 28. Strategies: Parent Focused If abnormal behaviors surface, touch base with parents to see if they are seeing these behaviors (parents prefer more information than less and often something minor points to a serious issue) Provide parents with a timetable to ensure rehearsal of what will be required the following day (equipment, activities) Have a daily planner to inform parents of successes and failures, ask for parental advice/information from parents It is vital that parents know what is happening at school so they can inform doctors and therapists of issues for future collaboration Give parents options regarding classroom modifications and the possibility of seeking outside help as an additional resource
- 30. While professionals do have experience, remember that parents posses unique knowledge about their child
- 31. When a treatment plan is in place, parents and professionals need to have good communication in order to monitor a child’s progress
- 32. Guidelines for working with professionals:
- 33. Be informed
- 34. Be prepared, ask for clarification
- 35. Be organized
- 36. Communicate Barclay and Associates, P.C. 1525 Airport Road, Suite 101 Ames, Iowa 50010 515-292-3023
- 37. Additional Resources Article Jackel, S (2006). “Asperger’s Syndrome-Educational Management Issues” Asperger’s Syndrome Survival Guide: www.aspergerssociety.org Autism Society of America: www.autism-society.org Autism Speaks: www.autismspeaks.org Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision Kid’s Health: http://kidshealth.org The Mayo Clinic: www.mayoclinic.com National Institute of Mental Health http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-pervasive-developmental-disorders/index.shtml Organization for Autism Research: www.researchautism.org
- 38. Questions?
Editor's Notes
- Share stats1 percent of the population of children in us age 3-17 have autism spectrum disorderAutism is four times more prevalent in boys than girlsFastest growi developmental disability with a 1,148% growth ratePrevelance is estimated at 1 in 110 births
- Also known as Autism Spectrum Disorders (ASD)Characterized by severe and pervasive impairment in several areas of development; reciprocal social interaction skills, communication skills, or the presence of stereotyped behavior, interests and activities Evident in the first years of lifeAssociated with some degree of Mental RetardationRange from a severe form called Autistic Disorder, through Pervasive Development Disorder not otherwise specified (PDD-NOS), to a much milder form, Asperger’s DisorderAlso include two rare disorders, Rett’s Disorder and childhood disintegrative disorder.
- A total of six or more from 1, 2, and 3, with at least two from 1, and one each from 2 and 31. At least 1 impairment in social interactionmarked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interactionfailure to develop peer relationships appropriate to developmental levellack of spontaneous seeking to share enjoyment, interests, or achievements with other people (lack of showing, bringing, or pointing out objects of interests)lack of social or emotional reciprocity
- 2. At least one impairment in communication delay in, or lack of development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gestures or mime)in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with othersstereotyped and repetitive use of language or idiosyncratic language lack of varied, spontaneous make-believe plat or social imitative play appropriate to developmental level
- 3. At least one restricted repetitive and stereotyped patterns of behavior, interests, and activities encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal in either intensity or focusapparently inflexible adherence to specific nonfunctional routines or rituals stereotyped and repetitive motor mannerisms (hand or finger flapping or twisting, or complex whole-body movements)persistent preoccupation with parts of objects
- Normal development for the first 5 months of life followed by a deceleration of head growth (between 5 and 48 months)Loss of previously acquired purposeful hand movement (between 5 and 30 monthsLoss of social engagement, development of poorly coordinated gait or trunk movementsSeverely impaired expressive and receptive language development with severe psychomotor retardation
- Normal development for the first 2 years Demonstration of significant loss of previously acquired skills in two of the following:Expressive or receptive languageSocial skillsBowel or bladder controlPlayMotor skillsAbnormalities of functioning in two of the following:Social interactionCommunicationRestricted, repetitive and stereotyped patterns of behavior, interests and activities
- At least two social interaction impairments including In the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interactionFailure to develop peer relationships appropriate to developmental levelLack of spontaneous seeking to share enjoyment, interests or achievements with other people (lack of showing, brining or pointing out objects of interest)Lack of social or emotional reciprocity Also PDD NOS-No clinically significant delay in language or cognitive development
- At least one restricted repetitive and stereotyped behavior, interests, and activities including:Encompassing preoccupation with one of more stereotyped and restricted patterns of interest that is abnormal in either intensity or focusApparently inflexible adherence to specific, nonfunctional routines or ritualsStereotyped and repetitive motor mannerisms (hand or finger flapping or twisting, or complex whole body movements)Persistent preoccupation with parts of objectsAlso PDD NOS-
- The characteristics behaviors of Autism Spectrum Disorders may or may not be apparent in infancy (18-24 months) but usually become obvious during early childhood (2-6 years old)5 behaviors that are red flags: Having any of these five "red flags" does not mean your child has autism. But because the characteristics of the disorder vary so much, a child showing these behaviors should have further evaluations by a multidisciplinary team. This team may include a neurologist, psychologist, developmental pediatrician, speech/language therapist, learning consultant, or other professionals knowledgeable about autism.Does not babble or coo by 12 monthsDoes not gesture (point, wave, or grasp) by 12 monthsDoes not say single words by 16 monthsDoes not 2 word phrases on his/her own by 24 monthsHas any loss of any language or social skill at any age
- Social SymptomsDifficulty interacting with othersAvoid eye contactPrefer being aloneResist attentionPassively may accept hugs and cuddlingMay fail to seek comfort or respond to a parent’s display of anger or affection in a typical wayUnusual and difficult attachment-lack of expected showing of affectionSlow to interpret what people are thinking/feelingPoor judgment or miss of social cuesDifficulty seeing things from another person’s perspectiveUnable to predict or understand other people’s actionsDifficulty regulating emotions (may cry, get angry, be disruptive)Tendency to lose controlCan show self destructive behavior
- Communication Difficulties Some may remain mute throughout lifetimeMost develop spoken languageAll learn to communicate in some way using pictures or sign languageMay repeat or parrot words (normally passes by age 3)Slight delays in language Precocious language or seemingly advanced vocabularyInability to understand body language, tone of voice, or phrases of speech Their tone of voice may not reflect real feelingsLess able to let others know what they needDo whatever they can to get through to othersAt a greater risk for becoming depressed or anxious
- Repetitive BehaviorsOdd repetitive motions set them apart from other childrenCan be extremearm flapping, walking on toes, freezing in positionMay spend hours lining up toys in a specific wayNeed and demand absolute consistency in environmentSlight change in routines can be extremely stressfulPersistent/intense preoccupation with certain things trains, lighthouses, fire hydrants, symbols
- Because the symptoms of AS are often hard to differentiate from other behavioral problems, it’s best to let a doctor or other health professional evaluate your child’s symptoms. It’s not uncommon for a child to be diagnosed with attention deficit hyperactivity disorder (ADHD) before a diagnosis of AS is made later.These signs and symptoms might be present in a child with ASInappropriate or minimal social interactionsConversations revolving around self versus othersScripted robotic or repetitive speechLack of common senseProblems with reading, math, or writing skillsObsession with complex topics such as patterns or music Average to below average nonverbal cognitive abilities though verbal cognitive abilities are usually average to above averageAwkward movementsOff behaviors or mannerismsIt’s important to note that, unlike kids with autism, those with AS might show no delays in language development; they usually have good grammatical skills and an advanced vocabulary at an early age. However, they typically do exhibit a language disorder--- they might be very literal and have trouble using language in a social context. Often there are no obvious delays in cognitive development or in age-appropriate self-help skills such as feeding and dressing themselves. Although kids with AS can have problems with attention span and organization, and have skills that seem well developed in some areas and lacking in others, they usually have average and sometimes above-average intelligence.
- Research has shown that lifelong care can be reduced by 2/3 with early diagnosis and intervention
- Some speculations include:Vaccinations :The Institute of Medicine (IOM) conducted a thorough review on the issue of a link between thimerosal (a mercury based preservative that is no longer used in vaccinations) and autism. The final report from IOM, Immunization Safety Review: Vaccines and Autism, released in May 2004, stated that the committee did not find a link..Until 1999, vaccines given to infants to protect them against diphtheria, tetanus, pertussis, Haemophilusinfluenzae type b (Hib), and Hepatitis B contained thimerosal as a preservative. Today, with the exception of some flu vaccines, none of the vaccines used in the U.S. to protect preschool aged children against 12 infectious diseases contain thimerosal as a preservative. The MMR vaccine does not and never did contain thimerosal. Varicella (chickenpox), inactivated polio (IPV), and pneumococcal conjugate vaccines have also never contained thimerosal.Genetic vulnerabilityBiologic Basis of ASDBecause of its relative inaccessibility, scientists have only recently been able to study the brain systematically. But with the emergence of new brain imaging tools—computerized tomography (CT), positron emission tomography (PET), single photon emission computed tomography (SPECT), and magnetic resonance imaging (MRI), study of the structure and the functioning of the brain can be done. With the aid of modern technology and the new availability of both normal and autism tissue samples to do postmortem studies, researchers will be able to learn much through comparative studies.Postmortem and MRI studies have shown that many major brain structures are implicated in autism. This includes the cerebellum, cerebral cortex, limbic system, corpus callosum, basal ganglia, and brain stem.29 Other research is focusing on the role of neurotransmitters such as serotonin, dopamine, and epinephrine.Research into the causes of autism spectrum disorders is being fueled by other recent developments. Evidence points to genetic factors playing a prominent role in the causes for ASD. Twin and family studies have suggested an underlying genetic vulnerability to ASD.30 To further research in this field, the Autism Genetic Resource Exchange, a project initiated by the Cure Autism Now Foundation, and aided by an NIMH grant, is recruiting genetic samples from several hundred families. Each family with more than one member diagnosed with ASD is given a 2-hour, in-home screening. With a large number of DNA samples, it is hoped that the most important genes will be found. This will enable scientists to learn what the culprit genes do and how they can go wrong. Abnormal Brain Development:Another exciting development is the Autism Tissue Program (http://www.brainbank.org), supported by the Autism Society of America Foundation, the Medical Investigation of Neurodevelopmental Disorders (M.I.N.D.) Institute at the University of California, Davis, and the National Alliance for Autism Research. The program is aided by a grant to the Harvard Brain and Tissue Resource Center (http://www.brainbank.mclean.org), funded by the National Institute of Mental Health (NIMH) and the National Institute of Neurological Disorders and Stroke (NINDS). Studies of the postmortem brain with imaging methods will help us learn why some brains are large, how the limbic system develops, and how the brain changes as it ages. Tissue samples can be stained and will show which neurotransmitters are being made in the cells and how they are transported and released to other cells. By focusing on specific brain regions and neurotransmitters, it will become easier to identify susceptibility genes.Recent neuroimaging studies have shown that a contributing cause for autism may be abnormal brain development beginning in the infant’s first months. This“growthdysregulationhypothesi” holds that the anatomical abnormalities seen in autism are caused by genetic defects in brain growth factors. It is possible that sudden, rapid head growth in an infant may be an early warning signal that will lead to early diagnosis and effective biological intervention or possible prevention of autism.31Larger brain sizeWe must understand how, when, and why the brains of individuals with autism are thrown off track during development. The creation of effective biologically-based treatments for autism will require knowledge of the underlying brain defects. Identifying what goes awry in the developing brain of children with autism is the first step. The search for the brain basis of autism started out as a hunt for a particular place in the brain where the problem could be located. Though the limbic system, cerebellum and other structures showed abnormalities in some studies, these findings were not always consistent or explanatory. Rather than any one structure being affected, researchers now think that the defect may lie within the neural circuitry, the way the brain is wired together. One critical link between brain circuitry may be the increasingly replicated finding of larger brain size in autism and increased white matter volume.Increased White Matter VolumeLead by Martha Herbert, M.D., Ph.D., of Massachusetts General Hospital, The Brain Development Initiative takes its impetus from a confluence of recent findings on abnormal brain development in autism. Although it's become well known that children with autism can have abnormally larger brains in early childhood, it's still unclear just what this observation may be telling us. Dr. Herbert's continued pursuit of an understanding for the basis of brain enlargement in autism. Her recently published findings show that most of the brain overgrowth can be accounted for by volume increases in the later-developing parts of white matter, especially those in the frontal lobes. If we can understand what it is that sets volume increases off, we may have the information necessary to intervene at an early enough stage to prevent this circuitry change. The Brain Development Initiative continues Cure Autism Now's tradition of focusing on promising but undeveloped scientific questions.As a direct result of our Brain Development Initiative and feedback from scientists at the 2005 White Matter Think Tank, in 2006 CAN formed a collaborative neuropathology workgroup to look more directly at how the brains of individuals with autism develop. Structural and functional imaging studies have consistently found particular brain regions to be atypical in individuals with autism. However, while such experiments are essential in identifying potentially abnormal brain regions, including changes in white matter, they cannot reveal the precise nature of the cellular and molecular defects that are causing those abnormalities. The only way to discover the underlying brain defects is to conduct studies directly on the brain tissue. Neuropathological experiments are the most direct path to providing answers to the myriad of questions surrounding the brain causes of autistic behavior. Yet, neuropathology remains one of the most under-funded areas of autism research. Coordinated, large-scale tissue analyses must absolutely be undertaken to determine what generates the anatomical and functional abnormalities witnessed in autism. The Neuropathology Workgroup is a collaborative effort organized by Cure Autism Now that combines unbiased stereology with modern molecular neuropathology to directly examine the frontal lobes of individuals with autism. The goal is to finally reveal what accounts for the structural and functional abnormalities, including the brain enlargement and white matter volume increases that have been observed by so many previous brain imaging studies. The workgroup represents a partnership across multiple institutes/organizations, bringing together researchers with different expertise, many of whom have never worked together before.Environmental Factors in Autism InitiativeEnvironmental A U.S. study looking at environmental factors including exposure to mercury, lead and other heavy metals is ongoing.The role of environmental factors in the development of autism is a crucial area of study. Although we know that genetics is an important factor, genetics alone may not account for all cases of autism. The increase in the reported number of autism cases has generated extreme concern over the potential involvement of toxins as well as infectious agents in our environment. For example, prenatal exposure to the chemicals thalidomide and valproic acid has been linked to a greater risk of a child being born with autism. This initiative targets research that seeks to understand and identify the potential role environmental factors play in triggering autism.
- The following Strategies were gathered from an article entitled “Asperger’s Syndrome-Educational Management Issues” written by Susan Jackel. Although the learning strategies below were specifically designed for children with Asperger’s, they can be utilized with all students within a classroom setting.Physical EnvironmentStructure physical environment to facilitate learning and minimize frustration visual and physical order assists in focusingWatch for peers who obviously/subtly annoy the student Watch for peers who feed off and feedback inappropriate behaviors -the student may like these peers but the relationships are not necessarily the best for either studentEnsure that the child is in a position of least distraction up front and away from visual and auditory “clutter” Consider isolating the student for short periods to teach new concepts or build on pre-existing knowledgeThe student may be defensive of personal space
- In class structureCreate a predictable environment with routine and prepare student for changesSet behavioral limits and monitor to implement consequences or provide coping strategiesGive brief and precise instructions and make sure that they understandState clearly what is expected-be concrete and allow time for the student to process the informationBreak tasks up into manageable segments and train the student to schedule and plan Teach the student to ask for help and appropriate methods of doing so
- Presentational IssuesKnow and use the student’s strengthsPresent new concepts in a concrete mannerUse activity based learning where possibleUse visual prompts as appropriateBreak work into small stepsHave written instructions for students, include visual cues and mark clearly the things that need to be completedShow examples of what is requiredKeep chalk/whiteboard as neat as possible
- Give handout as well: parents and classroom handoutTeaching IssuesDo not do for the student what he can do for himself Do not expect the student to automatically generalize instructions Use language to tie new situations to old learningDo not rely on emotional appeals or presume that the student will want to please youConcentrate on changing unacceptable behaviors and do not worry about those that are “simply” oddUse the obsessive or preferred activity as a rewardUse opportunities which arise to teach the student about how other students feel and react when they are hurt or upsetBe absolutely consistent and do not give options if there are no options
- Child focused to support developmentProvide formal “peer support network” or “buddy system” for the safety of the childTeach “safety phrases” such as “are you pretending?” or “what do you mean?” or “why should I do that?” to give the child a vocabulary of questions to help them gain information (they won’t know how to do it naturally) so they can determine the nature of a situation and respond accordinglyExplicitly teach rules of social conduct so that the child does not constantly interrupt Explain metaphors and avoid where possible (frog in your throat) Have a time out area for discipline when needed (enforce consequences and ensure that the ‘time out’ isn’t more attractive then the activity)Have a strategy to employ when the child can’t cope due to overstimulation or confusionA written timetable can help primary aged children to stay on task
- Parent FocusedIf abnormal behaviors/issues surface, touch base with the child’s parents to see if they are seeing these behaviors (parents prefer more information than less and often something minor points to a serious issue which has bearing on behavior at home )Provide parents with a timetable to ensure that the child can rehearse what will be required the following day (equipment, activities) Have a daily planner to inform parents of successes and failures, ask for parental advice and receive information from parents (It is difficult for parents to find out what is happening at school but it is vital that they know so they can inform the Doctors and therapists of issues for future collaboration)Give parents options regarding classroom modifications and the possibility of seeking outside help from a therapist as an additional resource
- It is important that parents and professionals work together for the child's benefit. While professionals will use their experience and training to make recommendations about your child's treatment options, you have unique knowledge about his/her needs and abilities that should be taken into account for a more individualized course of action.Once a treatment program is in place, communication between parents and professionals is essential in monitoring the child's progress. Here are some guidelines for working with professionals:Be informed. Learn as much as you can about your child's disability so you can be an active participant in determining care. If you don't understand terms used by professionals, ask for clarification.Be prepared. Be prepared for meetings with doctors, therapists, and school personnel. Write down your questions and concerns, and then note the answers.Be organized. Many parents find it useful to keep a notebook detailing their child's diagnosis and treatment, as well as meetings with professionals.Communicate. It's important to ensure open communication - both good and bad. If you don't agree with a professional's recommendation, speak up and say specifically why you don't.