Download Autism Spectrum Disorder… beyond the Red Flags AHEC School Nurse Grand Rounds

Autism Spectrum Disorder…
beyond the Red Flags
AHEC School Nurse Grand Rounds
March 18, 2014
Presented by Dr. Johana “Jody” Brakeley
[email protected]
Disclosures
• I have nothing to disclose
– No financial relationships
– Will not discuss commercial products
Today’s Objectives
The primary focus
• The history of ASD
• The “nuts and bolts” of ASD (prevalence,
etiology, conditions that imitate or coexist with
ASD)
• The DSM-5 criteria with examples
A brief look at
– Treatment recommendations
– Suggestions for the evaluation process
– Resources
Red Flags for Autism
The following "red flags" may indicate your child is at risk for an Autism
Spectrum Disorder
• No big smiles or other warm, joyful expressions by six
months or thereafter
• No back-and-forth sharing of sounds, smiles, or other
facial expressions by nine months
• No back-and-forth gestures such as pointing, showing,
reaching, or waving by 12 months
• No babbling by 12 months
• No words by 16 months
• No meaningful two-word phrases (not including imitating
or repeating) by 24 months
• Any loss of speech, babbling, or social skills at any age
From Autism Speaks website
Autism Spectrum Disorder (ASD)
• ASD is a complex neurodevelopmental (brain
development) disorder present from infancy
or early childhood.
• ASD is characterized by difficulties with social
communication and social interaction and by
restricted, repetitive patterns of behavior,
interests, or activities.
• ASD may not be detected until later when
there are more social demands and less
support from parents / caregivers.
Brief History of Autism
• The word “autism” comes from the Greek word
autos meaning self.
• 1911 Eugen Bleuler, Swiss psychiatrist, coined the
term autism/autistic to describe when a person
with schizophrenia withdraws into him/herself
from the outside world.
• 1943 Leo Kanner, American psychiatrist,
published an article about 11 children with
characteristics similar to what we know as
Autism.
Brief History of Autism cont’d
• 1943 Hans Asperger, Austrian pediatrician,
described 4 boys with characteristics similar to
what has been known as Asperger’s Disorder.
• Late 1940’s Bruno Bettelheim described
“refrigerator mothers” (cold, unfeeling parents)
as the cause of Autism. This notion was widely
accepted for 20 years and continues to color
some individuals’ understanding.
Brief History of Autism cont’d
• 1960 Bernard Rimland, psychologist and parent
of a child with Autism, suggested that Autism was
a biological disorder, not an emotional condition
caused by refrigerator mothers.
• Rimland founded of the Autism Society of
America (www.autism-society.org).
• In 1980, Autism made its debut in the DSM-III.
Diagnostic and Statistical Manual(s) of
Mental Disorders
1968
1980
1987
1994
2000
2013
Brief History of Autism cont’d
• In 1994, the DSM-IV included Asperger’s Disorder
and Pervasive Developmental Disorder- Not
Otherwise Specified (PDD-NOS).
• The 2000 version (DSM-IV-TR) included 5
subcategories of Pervasive Developmental
Disorder (PDD):
–
–
–
–
–
Autistic Disorder
Asperger’s Disorder
PDD-NOS
Rett’s Disorder
Childhood Disintegrative Disorder
How Common is ASD?
• In 2013, Autism was thought to occur in 1 in
88 to 1 in 50 children.
• Traditionally, boys were diagnosed with ASD 45 times as often as girls. Some studies are now
showing less of a difference.
• Worldwide numbers vary due to a number of
factors.
Autism by the Numbers
See also, Autism Speaks at
www.AutismSpeaks.org
2010 prevalence of
ASD in 8-year-old
Vermont children
was 1 in 104 (tied for
9th in the country)
“Cost of Autism
Study” funded by
Autism Speaks
and Goldman
Sachs 2012
Proposed Theories for
Increasing Rates of ASD
• Change in the diagnostic criteria
• PDD/ASD category is more inclusive (PDD-NOS,
Asperger’s)
• Greater awareness
– Strong emphasis for clinicians to screen, diagnose,
and refer as soon as suspected
– Better standardized tools for screening and
diagnosis
• However, this does not fully explain the
increasing numbers
What Causes Autism?
• ASD is not a single disorder; rather, it is a group of disorders
with many different causes.
• Combination of genetic risk factors that interact with
environmental conditions, e.g., pollutants in water, soil, air,
food, and more (polygenic, multifactorial, epigenetic).
– Autism susceptibility genes, e.g., Fragile X Syndrome, Tuberous
Sclerosis, Angelman Syndrome and many more.
• Estimates are that a precise genetic cause is detected in only
10-15 percent of individuals.
• In the vast majority of cases, no underlying disorder found.
Some Children are at Higher Risk to
Develop ASD
• Siblings of children with ASD 7-10 times
increased risk
• Premature infants
• Co-morbid genetic syndromes
• Prenatal exposures. e.g., valproic acid,
maternal alcohol
What Does Not Cause Autism?
• “Refrigerator” mothers / poor parenting
• Vaccinations: In particular MMR (measles,
mumps, rubella)
• 1998 study published in The Lancet by Andrew
Wakefield and 11 other co-authors has been
fully retracted
• Mercury
• Secretin
• Gluten / Casein
“If it’s not ASD, what is it?”
What is the Differential Diagnosis?
• Intellectual Disability / low cognitive skills /
specific learning disorder
• Speech-language delays
• Attention regulation issues (e.g., ADHD)
• Executive skills immaturity
• Anxiety disorders / Mood disorders
• Developmental trauma
• Obsessive-Compulsive Disorder
• Hearing-vision impairments
Conditions that
can imitate,
masquerade as,
exacerbate, or
coexist with
Autism
Spectrum
Disorders
Physical and Medical Issues
That May Accompany ASD
• Seizure disorders
• Genetic conditions
• Gastrointestinal disorders
– Diarrhea, constipation, bloating, abdominal pain
• Feeding behaviors
– Aversion re: taste, texture, appearance
• Sleep dysfunction
– Delayed sleep onset, night awakening
• Sensory issues
Diagnostic and Statistical Manual of
Mental Disorders - Fifth Edition
DSM-5 (published May 2013; note the Arabic
numeral 5, not Roman numeral V)
A. Persistent deficits in social communication and
social interaction across multiple contexts, as
manifested by all three of the following, currently
or by history (examples are illustrative, not
exhaustive):
B. Restricted, repetitive patterns of behavior,
interests, or activities, as manifested by at least two
[of four] of the following, currently or by history
(examples are illustrative, not exhaustive):
•
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
DSM-5 Criteria for ASD “Outline”
• A. (need all three)
–1
–2
–3
• Current level of severity
• B. (need two of four)
–
–
–
–
1
2
3
4
• Current level of severity
• C.
• D.
• E.
• Specifiers:
A. Persistent deficits in social communication and
social interaction across multiple contexts, as
manifested by all three of the following,
currently or by history:
1. Deficits in social-emotional reciprocity,
ranging, for example, from abnormal social
approach and failure of normal back-and-forth
conversation; to reduced sharing of interests,
emotions, or affect; to failure to initiate or
respond to social interactions.
A.1 REFLECTS PROBLEMS WITH SOCIAL
INITIATION AND RESPONSE
A.1 Problems with Social Initiation and
Response examples
• Impaired joint attention
• Failure to follow another person’s point
• Lack of pointing, showing, or bringing objects to share
interest / enjoyment with others
• Failure to respond to own name
• Lack of response to social smile
• Failure to engage in simple social games
• Failure to respond to praise
• Failure to offer comfort to others
• Failure to initiate conversation; monologue speech
• Intrusive touching or licking others
A.1 Tips, Traps, and Pitfalls
• Seeking to share enjoyment
– Even children who are developmentally delayed,
deaf, or blind try to share their interests and
interact. Presence of this characteristic is truly a
red flag
A.1 Tips, Traps, and Pitfalls cont’d
• Delayed conversation skills / speech delay
– Children with expressive language problems may have good
“spontaneous speech” when discussing topics of interest or
areas of expertise but have difficulty in other contexts.
– This interferes with social interactions, is frustrating, and may
result in behavior problems.
– Anxious, shy, behaviorally inhibited children are not very
outgoing and may not engage, talk, or smile back.
– Ask yourself, “Does this child want to communicate, and if so,
how?”
A.1 Tips, Traps, and Pitfalls cont’d
• Response to name
– Make sure the child is not hearing impaired. Obtain
evaluation by a specialist who is knowledgeable,
experienced, and skillful, and who likes children with
developmental differences.
• Offering comfort
– Some children are not developmentally ready to offer
comfort, or it is not a custom in their family
– Children with ADHD might not pay attention long
enough to “notice.”
A. Persistent deficits in social communication and
social interaction across multiple contexts, as
manifested by all three of the following, currently or
by history:
2. Deficits in nonverbal communicative behaviors used for
social interaction, ranging, for example, from poorly
integrated verbal and nonverbal communication; to
abnormalities in eye contact and body language or
deficits in understanding and use of gestures; to a total
lack of facial expressions and nonverbal communication.
A.2 INVOLVES PROBLEMS WITH NONVERBAL
COMMUNICATION
A.2 Problems with Nonverbal
Communication examples
• Impairments in social eye contact
• Impairments in use and understanding of
gestures or use of facial expressions
• Inability to coordinate eye contact or body
language with words or gestures
• Inability to convey a range of emotions via
words, expressions, tone of voice, or gestures
• Abnormal volume, pitch, intonation, rate,
rhythm, stress, or prosody in speech
A.2 Tips, Traps, and Pitfalls
• Poor eye contact
– Children with ADHD often have fleeting eye gaze
as they scan the environment. They bump into
people or objects, may fail to notice themselves in
relationship to their environment, or may be so
impulsive that they act without thinking things
through.
– Children with anxiety traits often avoid eye-to-eye
contact and social interaction until they are feeling
comfortable.
A.2 Tips, Traps, and Pitfalls cont’d
• Voice characteristics, facial expression
– Children with ASD often have speech that is
monotone/flat or voice characteristics that are not
typical.
– Consider the social environment at home. Some
adult models use little intonation or facial
expression (especially if they are depressed).
– Keep in mind that 60-90% of communication is
nonverbal (words, pragmatics, gestures).
A. Persistent deficits in social communication and
social interaction across multiple contexts, as
manifested by all three of the following, currently or
by history:
3. Deficits in developing, maintaining, and
understanding relationships, ranging, for example,
from difficulties adjusting behavior to suit various
social contexts; to difficulties in sharing imaginative
play or in making friends; to absence of interest in
peers.
A.3 REFLECTS PROBLEMS WITH SOCIAL
AWARENESS AND INSIGHT, AS WELL AS WITH THE
BROADER CONCEPT OF SOCIAL RELATIONSHIPS
A.3 Problems with Social Awareness,
Insight, and Social Relationships examples
•
•
•
•
•
•
•
•
•
Lack of theory of mind
Inability to take another person’s perspective
Laughing / smiling out of context
Asking socially inappropriate questions or making
inappropriate statements
Lack of noticing another’s distress
Lack of interest in peers
Obliviousness, “aloofness,” or lack of awareness of
children or adults
Lack of imaginative play with peers, including social
role playing
Lack of trying to establish friendships
A.3 Tips, Traps, and Pitfalls
• Peer relationships
– Intellectual Disability (ID): A child who is 5 years old
chronologically but developmentally at a 2½-year level will
have the social skills of a toddler.
– Children with ADHD often have difficulty interacting
socially. They can be highly active, impulsive /
unpredictable, unable to follow what the other kids are
doing or saying, and may be “in their own world.” Some
have a rambunctious, rough style of play.
– Children with anxiety traits may be too shy to enter play
with others.
– Children with language disorders may not understand the
rules of a game or may not produce quick, accurate
responses.
A.3 Tips, traps and pitfalls cont’d
• Pretend, imaginative play
– Playing and imitation are crucial to learning. It is
important to consider the child’s developmental level
and language skills when assessing this.
– It takes a certain amount of language to pretend
“school,” “fireman,” “grocery store” or “restaurant.”
– However, you don’t need much language to pretend a
banana is a telephone or wear a pot on your head like
a hat.
B. Restricted, repetitive patterns of behavior,
interests, or activities, as manifested by at least
two of the following, currently or by history:
1. Stereotyped or repetitive motor movements,
use of objects, or speech (e.g., simple motor
stereotypies, lining up toys or flipping objects,
echolalia, idiosyncratic phrases).
B.1 INCLUDES ATYPICAL MOVEMENTS, PLAY,
AND SPEECH
B.1 Atypical Movements, Play, and
Speech examples
•
•
•
•
•
•
•
•
•
Hand-clapping, finger-flicking, flapping
Body twisting, rocking, dipping, spinning, swaying
Repetitively dropping items
Lining up toys / objects
Repetitively opening / closing doors; repetitively
turning lights on / off
Repetition of words, phrases, songs, or dialogue
Use of “rote” language
Pronoun reversal (“You” for “I” or third person rather
than “I”)
Repetitive unusual vocalizations (e.g., guttural sounds,
screeching, humming, “diggy-diggy-diggy”).
B.1 Tips, Traps and Pitfalls
• Repetitive motor movements / mannerisms
– Sometimes hand flapping, fisting, or shaking can
be merely an “overflow”, happy activity.
– Children with Autism have behaviors that appear
self-stimulatory and self-soothing.
– These behaviors can be so pervasive that they
interfere with daily activities.
B.1 Tips, Traps, and Pitfalls cont’d
• Stereotyped language, echolalia, repetition
– It is normal for children to imitate favorite books,
movies, commercials, etc.
– Repeating others is often a stair-step to fluent
speech.
– It is unusual to use this type of language as a
primary form of communication.
– Look for spontaneity, novelty, varied intonation,
interest in others (“wh” questions: what, where,
when, why, who, how), back-and-forth
conversation.
B. Restricted, repetitive patterns of behavior,
interests, or activities, as manifested by at least
two of the following, currently or by history:
2. Insistence on sameness, inflexible adherence to
routines, or ritualized patterns of verbal or nonverbal
behavior (e.g., extreme distress at small changes,
difficulties with transitions, rigid thinking patterns,
greeting rituals, need to take same route or eat same
food every day).
B.2 INCLUDES RITUALS AND RESISTANCE TO
CHANGE
B.2 Rituals and Resistance To Change
examples
• Nonfunctional routines or rituals; specific,
unusual multi-step sequences of behavior
• Repetitive questioning about a particular topic
• Verbal rituals (has to say one or more things in a
specific way or insists others say or answer in a
specific way)
• Compulsions (e.g., insistence on turning three
times before entering a room)
• Excessive rigidity
• Inflexibility or rule-bound in behavior or thought
B.2 Tips, Traps, and Pitfalls
• Inflexible, poorly adaptable, need for
sameness
– Children with anxiety traits and challenging
temperamental traits for low adaptability, and
“slow to warm up” are more comfortable when
things are the same.
– Individuals with immaturely developed executive
skills may struggle with transitions and change.
B. Restricted, repetitive patterns of behavior,
interests, or activities, as manifested by at least
two of the following, currently or by history:
3. Highly restricted, fixated interests that are
abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual
objects, excessively circumscribed or
perseverative interests).
B.3 INCLUDES PREOCCUPATIONS WITH OBJECTS
OR TOPICS
B.3 Preoccupations with Objects or
Topics examples
• All-encompassing, overwhelming interest(s)
• Preoccupation with numbers, letters, or symbols
• Excessive interest in non-relevant or nonfunctional parts of objects
• Preoccupations (e.g., color, timetables, historical
events)
• Need to carry or hold specific unusual objects
(not a blanket or stuffed animal)
• Unusual fear (e.g., afraid of people wearing
earrings)
B.3 Tips, Traps and Pitfalls
• Intense, all-encompassing interests
– It is normal for children to go through phases of
intense interest, e.g., trains, dinosaurs,
superheroes, Legos, etc., but typically these
interests are not “all-encompassing.”
– Autistic children know much more about their
topic than expected for their age. For instance,
they may know all the dimensions of the Titanic,
the names of all the passengers, etc.
– Special interests may not emerge until a slightly
older age.
B. Restricted, repetitive patterns of behavior,
interests, or activities, as manifested by at least
two of the following, currently or by history:
4. Hyper- or hyporeactivity to sensory input or
unusual interest in sensory aspects of the
environment (e.g., apparent indifference to
pain/temperature, adverse response to specific
sounds or textures, excessive smelling or touching of
objects, visual fascination with lights or movement).
B.4 INCLUDES ATYPICAL SENSORY BEHAVIORS
B.4 Atypical Sensory Behaviors examples
• Unusual response to sensory stimuli: feel / touch, taste,
smell, sounds, look / appearance
– Particular about foods, tastes, textures, colors
– Smells or licks everything including people
– Certain sounds spark tantrums (e.g., toilets flushing, vacuum,
dogs, fire alarms)
– Does not like the feel of certain objects, textures, or people
• Close visual inspection of objects for no apparent reason
– (e.g., holding things at usual angles)
– Looking at objects / people out of the corner of eye, unusual
squinting of eyes
• Extreme sensory interest / fascination with watching
spinning wheels, opening and closing doors, electric fans
B.4 Tips, Traps, and Pitfalls
• Sensory issues
– May be part of a child’s inborn temperamental
characteristics
– Often coexist with shy, withdrawn, anxious traits
– “Sensory over-responsiveness” often coexists with
other psychiatric diagnoses (e.g., ADHD, anxiety,
depression)
– Can be an enormous challenge even when not
part of an ASD picture
B.4 Tips, Traps, and Pitfalls cont’d
• Preoccupations with parts of objects, licking,
looking
– Babies and toddlers exhibit many of these behaviors
as they examine and learn about the world.
– Children with developmental delays / intellectual
disabilities may appear odd if expectations are not
gauged to the child’s cognitive or developmental level.
– Children with pica (mouthing or eating non-food
substances) should have lead levels and blood counts
tested to assess lead toxicity and or anemia.
DSM-5 Additional Components
C. Symptoms must be present in the early developmental
period (but may not become fully manifest until social
demands exceed limited capacities, or may be masked by
learned strategies in later life).
D. Symptoms cause clinically significant impairment in
social, occupational, or other important areas of current
functioning.
E. These disturbances are not better explained by
intellectual disability (intellectual developmental
disorder) or global developmental delay.
DSM-5 Specifiers
• Current Severity Level for A. and B.
Level 1  “Requiring support”
Level 2  “Requiring substantial support”
Level 3  “Requiring very substantial support”
• With or without accompanying intellectual
impairment
• With or without accompanying language impairment
(e.g., no intelligible speech, single words only, phrase
speech) - consider receptive and expressive language
separately
DSM-5 Specifiers cont’d
• Associated with known medical or genetic condition or
environmental factor (e.g., Rett syndrome, Fragile X
syndrome, Down syndrome, epilepsy, exposure to
valproate, fetal alcohol syndrome, very low birth
weight)
• Associated with another neurodevelopmental, mental,
or behavioral disorder (e.g., ADHD; developmental
coordination disorder; disruptive, impulse-control, or
conduct disorders; anxiety disorders; depressive or
bipolar disorders; tic disorders; self-injury; feeding,
elimination, or sleep disorders)
Tips to Keep in Mind About ASD
• ASD implies that there exists a range of symptoms,
behaviors, and characteristics typical of this condition.
Symptoms can vary from mild to severe and few to
many. Thus the “spectrum” designation.
• To meet the DSM-5 criteria, an individual must meet all
three criteria in category A. If s/he has 30 sensitivities
but is socially engaged and interactive, ASD criteria are
not met.
• There is a “spectrum” inherent in each of the criteria.
ASD Tips cont’d
• The symptoms must be developmentally
inappropriate, which takes into consideration an
individual’s cognitive and physical abilities.
• The symptoms must be of sufficient intensity and
frequency to cause significant impairment in the
individual’s function in activities of daily living.
• At least some of the symptoms must present in
the early years.
DSM-5 Criteria for ASD “Outline”
• A. (need all three)
– 1 Reflects problems with social initiation and response
– 2 Involves problems with nonverbal communication
– 3 Reflects problems with social awareness and insight,
and the broader concept of social relationships
• B. (need two of four)
–
–
–
–
1 Includes atypical movements, play, and speech
2 Includes rituals and resistance to change
3 Includes preoccupations with objects or topics
4 Includes atypical sensory behaviors
ASD Tips cont’d
• Each of us at any particular moment has certain
personal traits that are similar to those described in
the DSM-5.
• It is impossible to make a diagnosis based upon the
results of a single instrument.
Autism Speaks Video Glossary
• Videos of children with ASD compared to
children with typical development
• http://www.autismspeaks.org/whatautism/video-glossary
AAP Bright Futures
Recommendation for Autism Screening
• “… [R]ecommends surveillance for developmental
problems at all well-child preventative care visits with a
general screening tool at the 9, 18, and 30 month visits,
plus screening with an autism-specific tool at the age
of 18 months.
• Screening with an autism-specific tool should be
repeated at 24 months or at any encounter when a
parent raises concern.
• Citation: Gupta VB, Hyman SL, Johnson CP et al.
Identifying children with autism early? Pediatrics.
2007; 119:152-153”
Excerpt from AAP Bright Futures Third edition page 226
The Modified Checklist for Autism in Toddlers-Revised
with Follow-Up (M-CHAT-R/F)
Robins, Fein, & Barton, 1999
Available for free download
• http://www2.gsu.edu/~psydlr/M-CHAT/Official_MCHAT_Website.html
• Google MCHAT-R/F
• Validation of the Modified Checklist for Autism in
Toddlers, Revised With Follow-up (M-CHAT-R/F)
Diana L. Robins, et al. Pediatrics; originally published
online December 23, 2013
Recommendations for ASD Evaluation
• Evaluations should be performed by individuals
who are trained and experienced in ASDs.
• Evaluations are performed by a team (or virtual
team) of said experts. This requires collaboration.
• Evaluation considers numerous aspects from
prenatal life to the present and include:
For more: see Vermont Best Practice Guidelines for Evaluation of PDD 2009 (Department of
Disabilities, Aging and Independent Living (DAIL) *currently in revision
ASD Evaluation Recommendations
cont’d
• Pertinent family history
– Parents’ genetic traits, education, work experiences, maternal
health and welfare, pregnancy, labor, delivery, early
developmental milestones (MCHAT, ASQ, PEDS)
• When did concerns and differences emerge and what
were they?
– What other factors were going on at that time? (e.g., family
discord, stresses, homelessness, household moves)
• A detailed review of all challenges, keeping in mind the
full differential diagnosis for ASD
• Information from parents/relatives and caregivers,
educational and medical professionals
• Use of standardized, validated instruments such as the
Achenbach CBCL, ADOS-2, ADIR, SCQ
ASD Evaluation Recommendations
cont’d
• Direct observations and interaction with the
child
• Summary that includes pertinent positive and
negative information
• If there is/are conflicting information or
findings, there should be a reasonable
attempt to address these
Therapies
Behavior and
Development
Programs
Medications
Education and
Learning
Programs
Other Treatments
and Therapies
From website of Agency for Healthcare Research and Quality
From Vermont Family Network
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Applied Behavior Analysis
APPS for Autism
Augmentative Communication
Biomedical
Complementary and Alternative
Medicine Therapy
Dietary Interventions
Lovaas and Discrete Trial
Evidence based Interventions
Facilitated Communication
Floortime
Hippotherapy/Therapeutic Riding
ILaugh Program
LEAP Program
Music Therapy
Peer Mediated Intervention Strategy
Pivotal Response Therapy
•
•
•
•
•
•
•
•
•
Relationship Development Intervention
or RDI
Sensory Integration Therapy
Sensory Processing Intervention
Social Communication/ Emotional
Regulation/ Transactional Support
(SCERTS)
Social Stories
Social Thinking
The Son-Rise Program
TEACCH
Verbal Therapy
See: Vermont Family Network
http://www.vermontfamilynetwork.org/
Medications for Coexisting Conditions
• Inattention, impulsivity, hyperactivity
• Anxiety
• Depression
• Obsessive-compulsive symptoms
• Disruptive, irritable, or aggressive behavior
• Self-injurious behavior
• Tics
• Sleep disruption
Evidence-Based Practices for Children,
Youth, and Young Adults
with Autism Spectrum Disorder
• This report is available online at
http://autismpdc.fpg.unc.edu/sites/autismpdc
.fpg.unc.edu/files/2014-EBP-Report.pdf
From: Autism Evidence-Based Practice Review Group Frank Porter Graham Child
Development Institute University of North Carolina at Chapel Hill ©2014 Samuel L
Odom
Evidence-Based Practices for Children,
Youth, and Young Adults with
Autism Spectrum Disorder (list)
•
•
•
•
•
•
•
•
•
•
•
•
•
Antecedent-Based Interventions
Discreet Trial Teaching
Cognitive Behavioral Therapy
Exercise
Extinction
Functional Behavioral Assessment
Functional Communication
Training
Modeling
Naturalistic Intervention
Parent-Implemented Intervention
Peer Mediated Instruction and
Intervention
Picture Exchange Communication
System
Pivotal Response Training
• Prompting
• Reinforcement
• Response
Interruption/redirection
• Scripting
• Self-Management
• Social Narrative
• Social Skills Training
• Structured Play Groups
• Task Analysis
• Technology-Aided Instruction &
Intervention
• Time Delay
• Video Modeling
• Visual Supports
Predictors of Better Outcome
•
•
•
•
Earlier age of diagnosis and treatment
No cognitive impairment
Early language and nonverbal skills
More easily acquired social skills
Summary of ASD
• ASD is a neurodevelopmental disorder characterized by
difficulties with social communication and social interaction and
by restricted, repetitive patterns of behavior, interests, or
activities
• Prevalence is 1 in 50-88 and is increasing for reasons that are
currently unclear; genetic and environment interaction is likely
• DSM-5 criteria with examples
• Differential diagnosis
• Assess the impact of symptoms on daily life
• Tips, traps, and pitfalls in ASD diagnosis
• Resources list for the Evaluation process and Therapies
Resources
• Agency for Healthcare Research and Quality (Therapies):
http://effectivehealthcare.ahrq.gov/search-for-guides-reviewsand-reports/?pageaction=displayproduct&productID=709
• Autism Speaks: www.autismspeaks.org
• Autism Society of America: www.autism-society.org
• Bright Futures: www.brightfutures.aap.org
• Center for Disease Control and Prevention:
http://www.cdc.gov/ncbddd/autism/screening.html
• First Signs (CDC): www.firstsigns.org
• Vermont Family Network:
http://www.vermontfamilynetwork.org/
• Vermont Department of Disabilities, Aging and Independent
Living (DAIL): http://ddas.vermont.gov/ddas-programs/programsautism-default-page#publications
• http://www.ellennotbohm.com/article-archive/ten-things-yourstudent-with-autism-wishes-you-knew/
Contact Information
Johana “Jody” Kashiwa Brakeley, M.D., F.A.A.P.
Developmental & Behavioral Pediatrics
5 South Street Middlebury, Vermont 05753
Office telephone: 802-989-7332
e-mail: [email protected]
Vermont Department of Health
Child Development Clinic
Telephone: 802-863-7338