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Early Signs of Autism and Assessment in Identification of Autism Spectrum Disorders (ASD). Ann Levine, Psy.D. Neuropsychologist Texas Child Study Center Clinical Director of SHARE [email protected] Nuts and Bolts. Early signs of Autism Spectrum Disorders Gold Standards for Assessment

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early signs of autism and assessment in identification of autism spectrum disorders asd

Early Signs of Autism and Assessment in Identification of Autism Spectrum Disorders (ASD)

Ann Levine, Psy.D.


Texas Child Study Center

Clinical Director of SHARE

[email protected]

nuts and bolts
Nuts and Bolts
  • Early signs of Autism Spectrum Disorders
  • Gold Standards for Assessment
  • Neuropspychological Assessment
autism as a culture
Autism as a Culture
  • “Autism is of course not truly a culture; it is a developmental disability caused by neurological dysfunction. Autism too, however, affects the ways that individuals eat, dress, work, spend leisure time, understand their world, communicate, etc. Thus, in a sense, autism functions as a culture, in that it yields characteristic and predictable patterns of behavior in individuals with this condition…”
    • Gary Mesibov, Ph.D.
why talk about this why does it matter
Why Talk about this?Why does it matter
  • Rates of ASD are increasing
  • Early intervention has been shown to improve outcomes for children with ASD*
  • In order for children with ASD to receive intervention, first they need to be identified
  • To care for a person with autism without early intervention over his/her lifetime the estimated cost is $3.2 million.**

*Dawson, G. & Osterling, J.(1997). Early intervetnion in autism. In M.J. Guralnick (Ed.) The effectiveness of early intervention (pp. 307-326).Baltimore: Paul H. Brookes Publishing Co.

**Ganx, M., “The Costs of Autism,” Understanding Autism: From Basic Neuroscience to Treatment,S. Moldin, J.L.R. Rubenstein, eds., CRC Press, 2006, pg. 475-502. (As reported in the California Legislative Blue Ribbon Commission on Autism Report, Sept. 2007: An Opportunity to Achieve Real Change for California with Autism Spectrum Disorders.)

autism spectrum disorders asd
Autism Spectrum DisordersASD
  • Early emerging neuro-developmental disorders that have an impact on most domains of cognitive and adaptive functioning.
  • Developmental disorder involving life-long impairments in social interaction, communication, and narrow interests/repetitive behaviors
what is needed
What is needed
  • Coherent picture of early behavioral profiles and developmental trajectories that help distinguish very young children with ASD from typical developing children and from children with other developmental delays.
history of determining early signs of asd
History of Determining Early Signs of ASD
  • Retrospective studies
    • Limitations include
      • Recall bias
      • Possibility of isolated case reports representing atypical or most severe cases
currently determining early signs of asd
Currently Determining Early Signs of ASD
  • Prospective studies:
    • following infants that are at risk of developing ASD
    • Provides an opportunity to more accurately characterize the development of regression in ASD
possible areas of dysfunction in the 1st year
Possible Areas of Dysfunction in the 1st Year
  • 0-3 months
    • Preference for face like stimuli
    • Sensitivity to speech like sound
  • 3-6 months
    • Development of social interactions with others
  • 6-9 months
    • Response to name
    • Social games (peek-a-boo)
    • Recognize identity, affect, gender with face processing
  • 9-12 months
    • Joint attention
    • Social referencing
    • Social imitation and monitoring
results of following high risk infants
Results of following high risk infants
  • 9 infants followed prospectively starting at 6 months of age.
    • Symptoms not present at 6 months of age
    • All infants at 6 months demonstrated:
      • Interest in social interactions
      • Showed social smile
      • Sustained eye contact and affective responses to mother
      • Responsive to others

(Bryson, et.al 2006)

results of following high risk infants1
Results of following high risk infants
  • Symptoms developed for some infants by 12 months of age and for others by 18 months of age
  • 7 of the 9 children given diagnosis of ASD prior to 36 months of age
findings of a prospective study of 50 infants
Findings of a Prospective Study of 50 infants
  • No group differences at 6 months of age
  • Between 12 and 18 months for the group later diagnosed with ASD displayed loss of skills
    • Loss of social communication behaviors
      • Gaze to face, smile, vocalizations
      • (Ozonoff, et al 2010)
  • Changes in social communication development assessed through prospective research suggest a different picture of symptom onset from parents’ retrospective report.
common practice in assessment
Common Practice in Assessment
  • Gather information about symptom onset from parents, yet this practice may not be a valid assessment of slow decline in social communication that can be observed prospectively.
recent findings from prospective studies
Recent Findings from Prospective Studies
  • Signs of ASD emerge over the first year or so of life in many children with ASD rather than being present from close to birth
  • Pattern of having ASD expressed prior to 6 months may be less common than once thought
recent findings from prospective studies1
Recent Findings from Prospective Studies
  • Traditionally defined categories of early onset and regressive autism do not paint the picture of how symptoms develop
  • Social communicative behaviors decrease rather than fail to progress
recent findings from prospective studies2
Recent Findings from Prospective Studies
  • Deficits and delays in emerging joint attention
  • Decreased response to name
  • Decreased imitation
  • Delays in verbal and non-verbal communication
  • Motor delay
  • Elevated frequency of repetitive behaviors, e.g. hand waving
  • Atypical visuo-motor exploration of objects
  • Extremes of temperament
  • Bryson, S.E.et al.(2007), Landa, R. and Garrett-Mayer, E. (2006), Yoder, P.et al.(2009)
take home message about prospective studies
Take Home Message about Prospective Studies
  • Currently identification of autism may not be possible in the majority of affected children by 12 months of age
  • American Academy of Pediatrics recommendations for screening at both 18 and 24 months is essential and may even need to be supplemented by screens after age 2 years.
  • C. P. Johnson, et al, May 2007,
signs and symptoms
Signs and Symptoms
  • National Research Council in its 2001 report Educating Children with Autism remarked “the manifestation of autism vary considerably across children and within an individual child over time. There is no single behavior that is always typical of autism and no behavior that would automatically exclude an individual child from a diagnosis of autism, even though there are strong and consistent commonalities, especially relative to social deficit.”
  • National Research Council, Committee on Interventions for Children with Autism. Educating Children with Autism. Washington, DC: National Academies Press; 2001
differential diagnosis
Differential Diagnosis
  • ASD
  • Intellectual Disability
  • Language Disorders
  • Obsessive Compulsive Disorder
  • Schizophrenia
  • Reactive Attachment Disorder
making the diagnosis
Making the Diagnosis
  • Practice parameters published by the American Academy of Neurology and the American Academy of Child and Adolescent Psychiatry indicated children who fail ASD screeners should have a comprehensive diagnostic assessment by experienced clinicians.
  • Filipek, et al. 2000, Volkmar et al. 1999
comprehensive evaluation model
Comprehensive Evaluation Model
  • Interdisciplinary
  • Evaluates various areas of functioning
  • Gathers information across environments
  • Provides an integrated perspective
  • Communicates with schools and other providers
  • Provides recommendations
components of a comprehensive evaluation
Components of a Comprehensive Evaluation
  • Developmental history
  • Physical exam
  • Establishing cognitive and language baselines
  • Assessment of social, communication, play, and behavioral presentation
  • Assessment of motor skills and sensory functioning
components of a comprehensive evaluation1
Components of a Comprehensive Evaluation
  • Laboratory investigation to search for know etiology or coexisting condition(s)
  • Medical concerns and co-morbidity
  • Adaptive functioning
  • Neuropsychological, educational, and vocational assessments
  • Assessment of possible family/parent support needs
results of the assessment provides
Results of the Assessment Provides
  • Diagnostic clarification
  • Medical Findings
  • Profile of child’s strengths and challenges
  • Profile of child’s developmental level and adaptive functioning
  • Recommendations for evidenced-based developmental and educational interventions, as well as parent recommendations
variables neuropsychologists consider
Variables Neuropsychologists Consider
  • Information from multiple sources
  • Adaptive functioning
  • Social, communication, and behavioral problems
  • Family systems and needs
variables neuropsychologists consider1
Variables Neuropsychologists Consider
  • Intellectual ability
  • Problem solving and learning style
  • Academic Functioning
  • Neuropsychological profile
    • Memory
    • Language
    • Executive functions
    • Motor
    • Visual Spatial
typical referral questions
Typical Referral Questions
  • Diagnostic Clarification
  • Treatment Planning
  • Evaluation of Treatment Response
  • Eligibility for Services
the process of assessing autism
The process of assessing autism
  • No medical test
  • Behavioral diagnosis
  • General Impressions
  • Questionnaires/Screenings
  • “Gold-Standard”


assessment tools
Assessment tools
  • Autism Diagnostic Observation Scale-Generic (ADOS-G) Lord et al. 2000
  • Autism Diagnostic Interview (ADI-R)
    • Structured interview with parents Lord et al. 1994
  • ADOS and the ADI-R are considered the “gold standard” for diagnosis
  • These instruments may lead to provisional diagnoses from as early as 18 months of age but tend to be more reliable with increasing age of the child
  • Western Psychological Services
  • http://portal.wpspublish.com/portal/page?_pageid=53,70384&_dad=portal&_schema=PORTAL
autism diagnostic interview revised adi r
Autism Diagnostic Interview Revised (ADI-R)
  • Semi-structured based interview for caregivers
  • Interview may take between tow to three hours
  • This semi-structured assessment assesses toddlers to adults, from children with no speech to adults who are verbally fluent who may have ASD.
  • Western Psychological Services
  • http://portal.wpspublish.com/portal/page?_pageid=53,70384&_dad=portal&_schema=PORTAL
  • The ADOS consists of various activities; the clinician observes social and communication behaviors.
  • Look for target behaviors through specific use of toys, activities, and questions
  • Repetitive behaviors, sensory sensitivities, restricted interests observed and coded
  • The ADOS includes four modules, each requiring 35 to 40 minutes to administer. Modules based on communication level.
  • Western Psychological Services
  • http://portal.wpspublish.com/portal/page?_pageid=53,70384&_dad=portal&_schema=PORTAL
  • ADOS activities for a child who is nonverbal to single word utterances
  • Free play
  • Response to name
  • Joint Attention
  • Bubble Play
  • Anticipation of a Routine With Objects
  • Responsive Social Smile
  • Anticipation of Social Routine
  • Functional and Symbolic Imitation
  • Birthday Party
  • Snack
free play
Free play
  • Seek engagement with examiner or caregiver
  • Exploration of materials symbolic/functional
  • Length of time engaged in activity
bubble play
Bubble Play
  • Elicit eye contact and vocalization in coordination with pointing or reaching in order to direct the attention of parent or examiner
anticipation of a routine with objects
Anticipation of a routine with objects
  • Child’s affect
  • Initiation of joint attention
  • Shared enjoyment
  • Requesting
  • Motor behavior
anticipation of a social routine
Anticipation of a Social Routine
  • Assess the child’s anticipation of, request for, and participation in a social routine
cognitive developmental assessment
Cognitive/Developmental Assessment
  • Children with an ASD also have signs of intellectual disability, averaging 44% in 2004 and 41% in 2006
    • http://www.cdc.gov/ncbddd/features/counting-autism.html
  • Level of intellectual functioning is associated with severity of symptoms, ability to acquire skills, level of adaptive functioning, and outcome.
    • Filipek et al. 1999
intellectual assessment
Intellectual Assessment
  • Behaviors that interfere:
    • High distractibility
    • Off task behaviors
    • Social difficulties
    • Unusual use of language
    • Anxiety
training to help increase responsiveness to testing environment
Training to help increase responsiveness to testing environment
  • May need to teach the child how to sit in a chair for 5 minutes
  • May need to teach a child how to accept and trade toys
  • Addressing behavioral concerns
    • Enhance the child’s motivation
    • Conducted testing over multiple sessions
    • Frequent reinforcement breaks
intellectual assessment1
Intellectual Assessment
  • Intelligence tests for children with spoken language
    • Wechsler Scales(WPPS-III, WISC-IV, WASI, WAIS III)
    • Differential Ability Scales, 2nd edition
    • Stanford-Binet 5th edition
    • Kaufman Assessment Battery for Children, 2nd edition
intellectual assessment2
Intellectual Assessment
  • Nonverbal Children
    • Leiter International Performance Scale- Revised
developmental assessment
Developmental Assessment
  • Children under the age of five
    • Bayley Scales of Infant Development-II
      • Ages 1 to 42 months
    • Mullens Scales of Early Learning
      • Ages 1 to 60 months
predictive value of intellectual assessments
Predictive Value of Intellectual Assessments
  • Research has consistently documented that IQ at age 5 correlates with adult outcomes
  • It is unclear if IQ at 2 or 3 correlates with adult outcomes
attention with asd
Attention with ASD
  • Focusing
    • Tend to over focus on extraneous details (Fein et al., 1990)
    • Distracted by special interests
  • Sustaining
    • Children with ASD usually do not have a problem with sustained attention (Garretson, et al. 1990)
  • Shifting
attention with asd1
Attention with ASD
  • Continuous performance tests
    • TEA-Ch (Manly et al. 2001)
  • Assess attention and activity level across environments with questionnaires
    • CBCL (Achenbach, 1991)
    • BASC (Reynolds and Kamphaus, 1998)
    • BRIEF (Gerard A. Gioia, 2002)
executive functions
Executive Functions
  • Executive Functions include:
    • Planning
    • Inhibition
    • Organization
    • Self monitoring
    • Cognitive flexibility
    • Working memory
  • Deficits in executive functions common for children with ASD (Ozonoff and Jensen 1999, Russell 1997)
executive functions1
Executive Functions
  • Delis Kaplan Executive Function System (Delis et al. 2001)
    • Trailmaking
    • Verbal and Design Fluency
    • Color Word Interference
    • Tower
tower of hanoi
* Only one disk may be moved at a time.

* No disk may be placed on top of a smaller disk.

neuropsychological assessments
Neuropsychological Assessments
  • Results from neuropsychological evaluations may provide greater clarity of the child’s strengths and weaknesses which helps with planning for intervention
  • Neuropsychological testing is usually not warranted for nonverbal and intellectually deficit children.
brain based findings
Brain Based Findings
  • Atypical Visual Scanning and Recognition of Faces in 2 and 4-Year-Old Children with Autism Spectrum Disorder
brain based findings1
Brain Based Findings
  • Neural responses to faces
  • * Autistic children as young as 3 years of age exhibit atypical ERPs to faces and facial expressions but not to objects
  • Summary
  • * Children with ASD displayed a slow response to faces and larger response to objects compared to typical developing children
the objective
The Objective
  • “Don’t underestimate persons with autism, try to understand.”