Download Early Identification of Infants and Toddlers With Autism

Early Identification of Infants and Toddlers With
Autism and Other Developmental Disabilities
January 2012
Albany, New York
Autism Spectrum Disorders in
Young Children:
The Background, the Basics,
and the Behaviors
Patricia Towle, Ph.D.
Westchester Institute for Human
Development
The Background
•Current prevalence estimates
•Current push for early identification
•The validity of early
identification/diagnoses
•How early can we recognize or
diagnose?
The Background
•Current prevalence estimates
• 1/150 children
• 3-4 boys for every girl
• this includes the broad
spectrum from severe to mild
Source: CDC--Morbidity and Mortality Weekly
Dec 12, 2009
The Background
•Push for early intervention
• Early intervention works!
• The earlier, the better
• The closer to 2 years, the
better
Early detection:
Why is it so important?
 Early intervention works!
 Supports development ->better foundation->
supports higher levels of independence later
 Starts caregivers with their advocacy training-the
sooner, the better
 Understanding needs, learning the system,
accessing resources, impacting on the system
• Pediatrician,
family medicine and primary care
provider in key role to refer parents for
evaluations as early as possible
The Background
•Are early diagnoses reliable
and valid?
Summary of studies…
Author, Date
Goal
Subjects
Followed
From – To
Results
Cox, 1999
Predictive
validity of
ADI-R
45
Compared
different ASD
risk levels
20 mos –
42 mos
Diagnosis of ASD at 20
months is predicted to be
highly sensitive and stable
Diagnostic
stability in
children
under 3
years
25 Aut,
12 PDD-NOS
31.4 mos –
45.0 mos
Stability seen in 92+%
Comparison
of outcomes
between Aut
and Asp
46 Aut
20 Asp
4-6 years –
6-8 years
Diagnosis of Aut and Asp
remained stable
Follow-up
of children
with ASDlike
symptoms
18 with
language
delay and Aut
features
4 years 4 mos
–
8 years 7 mos
All were diagnosed with an
ASD
(Aut, Atyp Aut, Atyp Aut
with lang. delay)
Stone, 1999
Szatmari,
2000
Michelotti,
2002
Summary of studies cont…
Author, Date
Goal
Subjects
Followed
From – To
Results
Moore, 2003
Diagnostic
stability
16 Aut
3 Atyp Aut
1 Lang disorder
2 years 10 mos
–
4 years 5 mos
All diagnosed with Aut or Atyp
Aut retained ASD diagnosis
59 ASD
Freeman, 2003
Diagnostic
stability
2-5 years –
4-6 years
Early ASD diagnosis remained
stable
Eaves, 2004
Diagnostic
stability
49 with
characteristics
of Aut
2 years 9 mos –
4 years 11 mos
97% Aut retained ASD
77% PDD-NOS retained ASD
29 with Aut
Charman, 2005
Diagnostic
stability
2 years –
7 years
Standard measures at age 2
years did not predict outcomes
at 7 years, but measures at age
3 years were predictive
Diagnostic
stability
48 with Aut
3 years 11 mo –
19 years
96% retained diagnosis through
adolescence/early adulthood
McGovern,
2005
The Background
Yes, early diagnoses are
reliable and valid.
•80-90% of children id’d as toddlers or preschoolers
remain on “the spectrum” into school age years
•Many young children who have symptoms within
the profile of ASD but don’t meet full criteria also
end up with an ASD diagnosis
•Young children with milder presentations are
slightly more likely to change diagnosis from early
to later
The Background
How early is early identification?
3 years – no problem (except for especially
mild and complex cases)
24 months – most can be dxed by now
18 - 20 months – many can be
14-15 months – for some, strong risk can be
established
12 months – for a few, strong risk can be
established
There are different developmental
trajectories of ASD symptoms in children
Three major patterns of symptom emergence:
 Different from the start (never really develop
social linguistic skills)
 Plateau and fade (13 – 15 months)
 More clear regression (15-20 months, 20-35 %) in
second year
 Patterns in between
The Basics
• Current Terminology
• A Spectrum Disorder: The Issues
• The Diagnostic Criteria
• What Autism Isn’t
Current Terminology
The Basics
The Confusing Array :
Pervasive
PDD
Developmental
Infantile
Disorder
Autism
PDD-NOS
Asperger syndrome
Atypical Autism
CDD
Autism
Spectrum
Disorder
The Basics
Current Terminology
Professional
Autism
Spectrum
Disorder
Vs.
Diagnostic
The Pervasive
Developmental
Disorders
The Basics
Current Terminology
Manual for diagnosing all
mental health and
developmental disorders in
childhood and adulthood
Diagnostic and Statistical Manual
of Mental Disorders
The Basics
The Pervasive
Developmental Disorders
Autistic
Disorder
Asperger
Syndrome
PDD-NOS
Rett
Syndrome
Childhood
Disintegrative
Disorder
The Basics
The Pervasive Developmental Disorders
Autistic
Disorder
“Core Disorder”
Approx 50% of PDDs- wide
range of IQ
15% have some identifiable
genetic disorder, for
example FraX
30% have seizure disorder
PDD-NOS
Milder version
“Subthreshold”
Asperger
Syndrome
Aspergers - social
problems without
the same degree of
language
problems
Most have average to
above average IQ
The Basics
The issues with a “Spectrum Disorder”
1. A continuum of Severity
The Pervasive Developmental Disorders
Autistic
Disorder
More
severe
PDD-NOS
Asperger
Syndrome
More
Mild
The Basics
The issues with a “Spectrum Disorder”
2. The interface with cognitive delay
The Pervasive Developmental Disorders
Autistic
Disorder
More
severe
PDD-NOS
Asperger
Syndrome
More
Mild
The Basics
2. The interface of symptom severity with
cognitive delay
Low
Symptom
Cognitive
Functioning
High
Low
High
Severity
High
Low
Very Mild Autism/
PDD-NOS/
Aspergers
High
Functioning
Autism
Cognitive
Functioning
Symptom
Severity
Low
Functioning
Autism
ID (MR) with
Autistic-like
features
Low
High
The Basics
The issues with a “Spectrum Disorder”
3. Variable symptom presentation
The Pervasive Developmental Disorders
Autistic
Disorder
More
severe
PDD-NOS
Asperger
Syndrome
More
Mild
The Basics
Autism Spectrum Disorder:
The Three Symptom Domains
Social Interaction
Communication
Repetitive Behaviors
ASD Profile of Behaviors
The Basics
The Three DSM-IV Symptom Domains
Social Interaction
1.
2.
3.
4.
Impairment in
nonverbal
behaviors to
regulate social
interactions
Failure to
develop peer
relations
Lack of
spontaneous
sharing of
emotions
Lack of
reciprocity
Communication
1.
2.
3.
4.
Delay in
development of
spoken language
Lack of ability to
sustain
conversation
Atypical
language
features
Lack or reduced
social or pretend
play
Repetitive
Behaviors
1.
2.
3.
4.
Preoccupation
with unusual
pattern of
behavior
Inflexible
adherence to
routine
Stereotyped,
repetitive
mannerisms
Preoccupation
with parts of
objects
The issues with a “Spectrum Disorder”
Three Symptom Domains: Children can have
different degrees of symptoms across them
Social Interaction
severe
Communication
Repetitive Bhvrs
severe
mild
severe
mild
mild
The issues with a “Spectrum Disorder”
AUTISM SPECTRUM DISORDER
Communication
social language
difficulties
Social
Interaction
Repetitive
Behaviors
Restricted, repetitive
Difficulties initiating
and maintaining social play underdeveloped
for age
interaction
3. Variable symptom presentation
AUTISM SPECTRUM DISORDER
Communication
Social
Interaction
They may be better with highly familiar people in
very familiar routines or favorite activities
Great unevenness across people and settings is a
feature of ASD
The Behaviors
•Social Interaction
•Communication
•Repetitive Behaviors
Social Interaction Behaviors
What are the COMPONENTS?
1. Social Interest: How does a child show that they
are interested in and “tuned in” to other people?
2. Emotional Expression or Signaling: How does a
child share emotions and how “readable” are they?
3. Capacity for Interaction: How much “back and
forth” can they do?
The Social Interest Component: How do they show they are interested in
and tuned in to others?
Seeks Proximity: How “In the Mix” is the child?
Seeks Proximity: vs. Indifference or Avoidance
Stays physically close if
comfortable
The Social Interest Component
Seeks Proximity: How “In the Mix” is the child?
Indifference or Avoidance
Stays with
others but
does not
interact
Off by himself; may
take off when others
come near
The Social Interest Component
Eye Contact1: Gives frequent eye contact
Typical eye contact use vs. Avoidance of, reduced, or
impersonal eye contact
The Social Interest Component
Eye Contact2: Monitors partner’s
eyes & face for reactions
Monitors eyes and face vs. Does not monitor
of others
The Social Interest Component
Eye Contact2: Monitors partner’s
eyes for reactions
The Social Interest Component
Social Initiation: How does the child “get
something going” with another person?
Social Initiation
The Social Interest Component
Social Responding: How does the child react to
social bids from another person?
The Social Interest Component
Social Responding
The Social Interest Component
Social Responding
Social Interaction Behaviors
What are the COMPONENTS?
1. Social Interest: How does a child show that they are
interested in and “tuned in” to other people?
2. Emotional Expression or Signaling:
How does a child share emotions and
how “readable” are they?
3. Capacity for Interaction: How much “back and forth”
can they do?