Autism Classification: Integrating Assessment Sources

Julia Szarko, Ph.D. Rob Rosenthal, Ph.D. School Psychologist School PsychologistCentral Bucks School District Abington School Districtjszarko@cbsd.orgroserj@abington.k12.pa.us Autism Classification: Integrating Assessment Sources NASP 2012 Annual Convention Philadelphia, PA

Agenda • Review Autism Symptoms • Developmental Considerations • Review Best Practices in Evaluations • Guiding Principles in Making Decisions • Case Studies • No Brainers • Tricky One’s • You Decide

What to Look For • Neurodevelopmental Disorders with 3 Core Features (DSM): • 1 Impairments in Socialization • 2 Impairments in Verbal and Nonverbal Communication • 3 Restricted and Repetitive Patterns of Behavior or Interests

Impairment in Social Interaction • Nonverbal behaviors to regulate interactions • Few peer relationships; avoids contact • Lack of sharing enjoyment, interests or achievements • Lack of social/emotional reciprocity • Poor ToM; expects others to know their thoughts • Unaware of social codes of conduct

Impairment in Communication • Delay in spoken language • Impairment in initiating/sustaining conversations • Repetitive or idiosyncratic language • Delay in pretend/social/imitative play • Pedantic, pragmatic, literal, concrete • Issues with prosody

Patterns of Behavior • Preoccupations • Inflexible with routines or rituals • Repetitive motor mannerisms • Preoccupation with parts of objects • Abnormal memory • Rigid with changes

Developmental Considerations • Many 1 year-olds have significant differences • Pointing • Showing objects • Looking at the face of another • Orienting to their own names (Osterling and Dawson, 1994)

Diagnosing before age 3 years • Recent studies found measurable differences by 18 months of age: • Eye contact • Orienting to one’s name • Joint attention, • Underdeveloped pretend play and imitation skills • Problems with nonverbal communication • Problems with language development

Keys to Evaluation 1 • Evaluator should have experience with those with different developmental disabilities at different ages • Clinical judgment • Interdisciplinary approach • Speech/language therapist • Outside clinicians • You will be the coordinator of assessments

Keys to Evaluation 2 • Rely on numerous procedures • Must rule out medical, MR, thought disorders, mood disorders, ADHD • Must consider child development • There is a strong effort to assess the child’s social interaction capabilities, theory of mind skills, emotion regulation capabilities, language skills, sensitivity to sensory input, and play skills.

Rating Scales • Examples of instruments: • Emotional/Behavioral (Broad Band) • BASC-II CBCL Conners III • Social (Narrow Band) • Autism Spectrum Rating Scales (ASRS) • Childhood Autism Rating Scale – 2 (CARS2) • Gilliam Autism Rating Scale – 2 (GARS2) • Social Communication Questionnaire (SCQ) • Social Responsiveness Scale (SRS) • Social Skills Improvement System (SSIS)

Narrow Band Asperger’s • Australian Scale for Asperger’s Syndrome (ASAS) • Asperger Syndrome Diagnostic Scale • Sohn-Grayson Rating Scale • Asperger Syndrome Diagnostic Scale (Smith Myles) 5-18 yrs • Gilliam Asperger’s Disorder Scale (3yr+) • Test of Problem Solving (TOPS) • Functional Communication Profile (FCP-R)

Best Practices: Reviewing Records • Preschool age • Look for social indicators • Often misdiagnosis • All ages • Friendships • Cooperation and Group skills • Odd behaviors- flapping, mixes pronouns, obsessions • Anxiety problems

Best Practices: Interviews • ADI-R 1 ½ - 2 ½ hrs • Developmental Profile-3 (birth – 12yrs) • Personalized Caregiver Questionnaire • Must ask about functioning at 2-4 years of age • Joint Attention Skills • Difficulty when calling their name • Plays by self often

ADI-R • Semi-structured, standardized interview • For 18mos-adulthood • Linked to DSMIV and ICD-10 criteria • 1.5-2.5 hours • Effective in differential diagnosis • Results scored with Diagnostic Algorithm • 2.0-3.11 years form and 4.0 + years form • Also a Current Behavior Algorithm

Best Practices: Observation • Look for social interactions • Timing, prosody, pragmatics, reading other’s cues • Rigidity • Other’s reactions • Sensory experiences • Avoidance of others • Upset when other’s break rules • Not following social codes of conduct

Observations • Observations • In office: • Show boredom and other reactions to see if he “adjusts” • Make interesting statements/comments and see if he “bites” (presses) • In multiple, naturalistic environments (class, recess/lunch, home, camp): • Anecdotal • Structured and unstructured • If at home- see a playdate

For All Observations: • Pay particular attention to • a) all social attempts, quality of social interactions, peers reactions, reciprocity • b) communication skills, prosody, pragmatics, nonverbal communication skills • c) stereotypic behavior, odd behavior, emotional reactions

Autism Diagnostic Observation Schedule (ADOS) (Lord, Rutter, DiLavore, & Risi, 1999a, 1999b) • Considered to be part of the “gold standard” in the diagnosis of ASD. • Standardized, semi-structured interactive play assessment of social behavior. • Makes use of “planned social occasions” that facilitates observation of the social, communication, and play or imaginative use of material behaviors related to the diagnosis of ASD.

Autism Diagnostic Observation Schedule (ADOS)

Best Practices: NEPSY-II • Social Perception Area • Affect Recognition • CHD Classification: Gkn-BC • Measures ability to recognize emotions from pictures • Separate scores for each emotion • Theory of Mind • CHC Classification: Gkn-BC (Gc-LS; Gf-I) • Measures understanding another’s point of view, relating emotion to social context

Inconsistent Data • High Rating Scale Scores, Under cutoff on ADOS • Inconsistent Rating Scale Scores • No symptoms during any observation, high parent ratings • No signs in previous evaluations, high ADOS scores • Examples from audience??

Guiding Principles: Observations • Observe in other situations • Cafeteria, Specials, Transitions, Recess, Assemblies • Have Teacher do observation • Provide them with data form • Home-Schoolers/No Preschool • Go to home during play date

Guiding Principles: Interviews • Review rating scale responses with respondent • Review frequency definitions • Go item by item • Interview other staff-members • Review inconsistent parts of initial interview • Ask how they compare this child to other children the same age

Guiding Principles: Check Symptoms • Must have majority of symptoms • Many symptoms must present to a severe degree • Significantly interferes with social, emotional functioning and possibly academic functioning • Must be present in observations and at least one respondent • Symptoms present since preschool years or early schooling

Guiding Principles: Additional Tests • Emotional Assessment: Projectives • Sensory Profile (over 50% of ASD) • Facial Recognition (over 4yrs) • Figures of Speech from Atwood • Theory of Mind Skills from Atwood

Guiding Principles • Weigh observations more heavily- especially if you see something parent does not • Weigh ADOS more heavily • 1 piece of inconsistent data is ok- outliers exist • Go with majority of data • What does your instinct tell you?

Assumptions • Student has already been screened, and now needs a comprehensive evaluation • Rule out hearing issues and lead poisoning • Autistic Spectrum includes autism, autistic, PDDNOS, Asperger’s Disorder • Understanding of Spectrum • Range from severe to mild • May not have all symptoms

Case Study: No Brainer – Yes, ASD • 5 year old, in EI • Record Review: • Wrap-Around Eval- PDDNOS • Du Pont Eval- Autism Spectrum • Neurological Eva- Semantic/Pragmatic Deficit Syndrome • IU Eval- Developmental Delay • Observation • Followed Routine, no peer interactions, poor atten skills

Case Study: No Brainer – Yes, ASD • Rating Scales • SCQ parent 28 (cutoff 15) • Adaptive GAC 45 (very low) • Parent Report • Echolalic, poor response to questions, poor eye contact, no engagement with peers, avoids social contact, prosody issues, irrelevant comments, poor shifting attention, poor joint attention, tantrums, poor coping with change, odd hand mannerisms, narrow field of interest, abnormally good memory

Case Study: No Brainer – Yes, ASD • ADOS • Communication 5 (cutoff = 3) • Reciprocal Social Interaction 7 (cutoff=4) • IQ • FSIQ = 77, VIQ=66; NIQ=91 • Teacher Interview • Poor play skills, repetitive play schemes, no initiation of interaction with peers, language deficits

Case Study: No Brainer – No ASD • Male, age 7, 1st Grade • Parent request for evaluation • Previous Dx of PDD-NOS at 1 year, per parent report • Received EI – speech, OT, PT from age 2-3 • Observations during testing: engaged, talkative, interactive

Case Study: No Brainer – No ASD • Eval included: • RIAS CIX=124; VIX=112; NVIX=133 • PIAT-R Broad Reading=121, Math=134, Written Language=129 • Stage 1 Autism Assessment: BASC • Parent Clinically Significant: BSI, Internalizing, Adaptive • Somatization, Atypicality, Withdrawal, Attention Prbs, Social Skills • Teacher Clinically Significant: none (At-risk for withdrawal, adaptability)

Case Study: No Brainer – No ASD • Stage 3 Autism Assessment: ADOS, Module 3 • Communication=0 (Autism cut-off=3) • Social=1 (Autism cut-off=6) • Total=1 (Autism cut-off=10) • Stereotyped Behaviors and Restricted Interests=0 “Overall, Student presents as a social child without significant social and/or emotional difficulties in the school setting. He presents significant behavior difficulties in the home setting, based upon parent ratings. Since his attention skills and hyperactive behaviors are age-appropriate inside the school setting, an attention deficit disorder is ruled out. Formalized testing also rules out the presence of an Autism Spectrum Disorder, including PDD-NOS.”

Case Study: Tricky – Yes: ASD • Emotional Disturbance to Autism Spectrum Disorder: Male (10-3) • Identification Hx: OHI (ADHD)/SLI to ED/SLI • Previous Reevaluation (switch to ED/SLI) • 4/07 PIAT-R General Information SS=57, Reading Recognition SS=91, Reading Comprehension SS=91, Total Reading SS=90, Mathematics SS=92 • 5/07 Adaptive Behavior Assessment System-II (Teacher) GAC=74, Conceptual SS=63, Social SS=78, Practical SS=85 • 5/07 Gilliam Autism Rating Scales-2: Teacher SS=89 Probability of Autism "Very Likely"; Parent SS=126 Probability of Autism "Very Likely"

Case Study: Tricky – Yes: ASD TEST DATA: • Reynolds Intellectual Assessment Scales (RIAS) • Verbal=88, Nonverbal=108, Composite=96 • Peabody Individual Achievement Test-Revised (PIAT-R) • Written Language Composite=74 • Stage 1 Autism Assessment BASC: • Parent BASC: • Clinically significant: BSI, Atypicality, Hyperactivity, Functional Communication • At-Risk: Attention Problems, Conduct Problems, Depression, Withdrawal, Adaptive Skills • SPED Teacher BASC: • At-risk: Atypicality, Aggression, Adaptability, and Functional Communication

Case Study: Tricky – Yes: ASD ADOS Stage 3 Autism Assessment - ADOS Module 3 Summary • Total= 10 (Autism cut-off=10) Communication=3 (Autism cut-off=3) “Student's performance fell within the autism range due to communication characteristics including his fixation on certain topics (i.e., electricity, how things work) and his limited flexibility during conversation (i.e., difficulty conversing when not preferred topic; he initiated conversation to find answers to questions rather than engage in social chit-chat).”

Case Study: Tricky – Yes: ASD ADOS continued Reciprocal Social Interaction= 7 (Autism cut-off=10) “Reciprocal Social Interaction characteristics included his unusual eye contact, difficulty providing insight into the nature of social relationships (i.e., what is a friend?), and limited amount of reciprocal social communication.”

Case Study: Tricky – Yes: ASD ADOS continued Stereotyped Behaviors and Restricted Interests=5 “Additional characteristics observed included an unusual visual interest (i.e., prolonged and close visual examination of a spinning top), unusual hand and finger complex mannerisms (i.e., shook his arms back and forth quickly as he talked about trains), and his excessive interest in highly specific topics (i.e., numbers, electricity). Student did not display any aggressive or negative behavior throughout the assessment nor did he engage in echolalia (i.e., repeating what the examiner said).”

Case Study: Tricky – No ASD • 7 years old • Review Records • Psychiatric Eval- ADHD • Elwyn EI- S/L only • Spontaneously greets people • Asks for help • Gets attention from peers appropriately • Is Talkative • Variety of Interests • Good Imagination/pretend play

Case Study: Tricky – No ASD • Review Records cont. (Elwyn) • Changed moods abruptly; Defiance, SIB • Phil. S.D. Evaluation • FSIQ=114; PSI=131 • Spontaneous and relevant conversation • OHI- ADHD– 504 • Teacher Interview • Sensory processing issues • Refuses to share; tantrums

Case Study: Tricky- No ASD • Parent • Inconsistent reciprocal interactions • Infrequent chatting; eye contact • Poor coping with frustration • No narrow field/preoccupations or rituals • ADOS • Language/Comm 0 • Reciprocal Social Interaction 7 • Total over cutoff

Audience Participation • Case Studies – You make the call… • Questions and Comments

Autism Classification: Integrating Assessment Sources