Autism: An Overview and Strategies for Learning in the Classroom Stewart H. Mostofsky, M.D.

1. Autism: An Overview and Strategies for Learning in the Classroom Stewart H. Mostofsky, M.D. Associate Professor, Neurology and PsychiatryKennedy Krieger InstituteJohns Hopkins University School of Medicine

2. Presentation Overview • Intro to High Functioning Autism (HFA) and Asperger Syndrome (AS) • Characteristics of population • Learning Style • Procedural (vs. declarative) learning • Studies of procedural learning and associated motor impairments • Interventions

3. What is Autism? • In 1943, Dr. Leo Kanner of the Johns Hopkins University Hospital studied a group of 11 children and introduced the label “early infantile autism” into the English language. • At the same time a German scientist, Dr. Hans Asperger, described a milder form of the disorder that became known as Asperger syndrome.

4. Social Interaction Communication Stereotyped / Repetitive Patterns of Behavior Core Deficits in Autism

5. Autism – Core Features • All children with autism demonstrate deficits in 1) reciprocal social interaction, 2) verbal and nonverbal communication, and 3) repetitive behaviors or excessive interests. • In addition, they will often have unusual responses to sensory experiences, such as certain sounds or the way objects look.

6. PDD Umbrella Pervasive Developmental Disorders Autism PDD-NOSCDD Asperger’s Syndrome Rett’s Syndrome PDD/NOS= pervasive developmental disorder, not otherwise specified CDD= childhood disintegrative disorder Autism Spectrum Disorder (ASD)

7. Diagnosis of Autistic Disorder • Qualitative Impairment in Social Interaction (2) • Impairment in use of nonverbal behaviors • Failure to develop peer relationships • Lack of spontaneous seeking to share interests • Lack of social/emotional reciprocity • Qualitative Impairments in Communication (1) • Delay in development of spoken language • Marked impairment in ability to initiate and sustain conversation • Stereotyped and repetitive use of language or idiosyncratic language • Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

8. Diagnosis of Autistic Disorder • Restrictive/Repetitive Stereotyped Patterns of Behavior or Interests (1) • Preoccupation with restricted or stereotyped patterns of interest • Inflexible adherence to routines and rituals • Repetitive motor mannerisms • Persistent preoccupation with parts of objects • Delays prior to 3 y.o. in social interaction, language for social communication, or symbolic or imaginative play

9. Diagnosis of Asperger Syndrome • Qualitative Impairment in Social Interaction (2) • Impairment in use of nonverbal behaviors • Failure to develop peer relationships • Lack of spontaneous seeking to share interests • Lack of social/emotional reciprocity • Restrictive/Repetitive Stereotyped Patterns of Behavior or Interests • Preoccupation • Inflexible adherence to routines and rituals • Repetitive motor mannerisms • Persistent preoccupation with parts of objects • No delay in language • No cognitive deficit

10. Social and Communication Skills • May have interest in others • One-sided dialogue • Lack of understanding when others are not interested • Lack of understanding when a topic is not appropriate • Comment on clothing • Concrete understanding of language • Spirit club • Difficulty with friendly teasing and sarcasm • Can be MASKED by advanced verbal skills

11. ASD – “Medical” Overview • Neurological Disorder • Heterogeneous (variability in skills and deficits) • No known cure • No medical tests • Early social development predictive of outcome

12. Possible causes of ASD • No consensus on current causes • Genetics • Little to no evidence: • Environmental causes • Immunizations – little to no evidence • Metabolic imbalances

13. Prevalence • Prevalence estimates are approximately 1 in 150 children (Center for disease Control and Prevention, 2007) • Fastest growing developmental disability • 90% of costs are in Adult Services • Cost of treatment can be reduced by 2/3 with early diagnosis and intervention • Early diagnosis is the key for treatment • Early intervention has dramatic impact on reducing symptoms and increasing child’s ability to learn new skills • Only 50 percent of children are diagnosed before kindergarten.

14. Learning Styles of Individuals with Autism Spectrum Disorders • Strengths: • Rote memory/ memorizing facts • Concrete information • Attention to detail • Needs-based interaction

15. Challenges: Poor attention: difficulty shifting attention from one activity to another Processing auditory information, specifically verbal information Organizing information and discriminating which information is relevant Processing multiple stimuli at one time Over or under reaction to sensory input (tantrum to not even noticing) Flexibility Reciprocal interaction Generalized learning Global processing Learning Styles (cont.)

16. Learning/Memory Procedural (“Unconscious” implicit learning of skills) Declarative (“Conscious” explicit learning of facts/events)

17. Declarative/Procedural Model Procedural Frontal/Parietal Basal Ganglia Cerebellum Declarative Medial Temporal (Cohen, 1984; Tulving, 1985; Squire, 1986 Mishkin, 1987; Saint-Cyr, 1988; Schacter, 1994)

18. Procedural Learning and Social Skills • Large component of social interaction involves the execution of a series of complex “learned” movements • HFA often report inability to “automatically” perform social gestures; compensate by using “declarative” scripts. • HFA= high functioning autism

19. Language: Declarative/Procedural Model Declarative Procedural Lexical/Semantic Grammar/Syntax Frontal/Basal Ganglia/ Cerebellum Medial Temporal

20. Autism, Language, and Procedural Learning • Difficulty with syntax and language “formulation” • Overly scripted language • Compensating using declarative learning (i.e., “memorization”)? • Children with ASD faster than TD children on object naming task for less frequent and less imageable words (Walenski et al., in press; JADD)

21. Background: Motor abnormalities in Autism • DSM feature: stereotypies • Other frequently reported motor findings: • Impaired basic motor control: gait, posture, balance, speed, coordination (e.g., Ghaziuddin, 1998; Jansiewicz, 2006; Noterdaeme, 2002; Rinehart, 2006) • Impaired skilled motor performance • Emphasis on motor imitation • Deficits also with pantomime and tool use on praxis testing highly robust and reproducible finding (e.g., Mostofsky, 2006; Dewey, 2007; Dziuk, 2007; Dowell, 2009) “developmental dyspraxia” in autism Donald Gray Triplett First person diagnosed as autistic

22. Social Interaction Communication Stereotyped Behaviors Why study motor function in autism? • Motor difficulties can have a substantial impact on schooling, socialization, and self-esteem. Motor Abnormalities

23. Handwriting and ASD • Good handwriting crucial for academic progress, social and communicative development, and self-esteem (Feder & Majnemer, 07) • Only study in ASD assessed letter size in adults (Beversdorf et al., 01) • No study had explored handwriting in children or adolescents with ASD • No study had assessed the multiple aspects of handwriting that may differentially contribute to impairments

24. Minnesota Handwriting Assessment • Scoring: legibility, form, alignment, size, spacing, rate • 14 ASD (10.2 ± 1.9 yrs) • 14 CTL (11.1 ± 1.3 yrs) (Fuentes, Mostofsky, & Bastian, 2009)

25. Children with ASD:worse overall and form quality p = 0.004 p = 0.017 (Fuentes, Mostofsky, & Bastian, 2009)

26. Social Interaction Communication Stereotyped Behaviors Why study motor function in autism? • Motor signs can serve as markers for deficits in parallel brain systems important for control of socialization and communication. The clearest predictor of optimal outcome in toddlers diagnosed with an autism spectrum disorder is motor skills at age 2 (Sutera et al., 2007 J Autism Dev Disord) Motor Abnormalities

27. “Dyspraxia” in Autism – Developmental Perspective • Adult lesion-based model (loss of skill after focal lesion) may not be appropriate • “Dyspraxia” in autism unlikely due to loss of already acquired skills • Consider lesion resulting in impaired acquisition (learning) of motor skills

28. Learning/Memory Procedural (“Unconscious” implicit learning of skills) Declarative (“Conscious” explicit learning of facts/events)

29. Social Interaction Communication Stereotyped Behaviors Why study motor function in autism? • Motor signs can serve as markers for deficits in parallel brain systems important for control of socialization and communication. • Procedural learning systems important for the acquisition of motor skills may also be critical to forming internal models of action necessary to engage in social and communicative skills. Motor Abnormalities

30. Feed-forward Hypothesis • The same internal models that are the basis of learning skilled movements are also the basis with which our brain understands the actions of others. • Impaired acquisition of skilled movements and gestures, including those important for social interaction, may therefore contribute to impaired development of “theory of mind.” • “Simulation Theory” (Carruthers and Smith, 1996) • Children come to read minds by “putting themselves in the others’ shoes” • Mentally (in their mind) act like other person, which is akin to imitation

31. Children with ASD show impaired ability to identify and recognize correct gestures in others Praxis (Motor Skill) Postural Knowledge

32. Children with ASD show impaired ability to identify and recognize correct gestures in others Praxis (Motor Skill) Postural Knowledge Social Skill Social Awareness

33. Treatment Implications: Teaching Skills to Children with Autism • Difficulty learning skills “naturally” – Both… • ability to perform motor, social, and communicative skills • ability to recognize and interpret the meaning of others motor, social, and communicative actions (“lack of social awareness”). • Often better with declarative learning • “Memorization”

34. Treatment Implications: Teaching Skills to Children with Autism • Two general approaches • 1) Work “around” the deficit • Teach social/communicative skills (eg, gestures, eye contact) using explicit “declarative” instruction • Applied Behavioral Analysis (ABA) and Discrete Trial Therapy (DTT) • Repeated explicit instruction with contingency

35. Applied Behavior Analysis • Applying behavioral laws to solve behavioral problems • Active attempts to change behaviors through chaining and shaping • Antecedent – Behavior – Consequence • Consequence determines whether or not behavior will occur again in the presence of an antecedent

36. Cognitive Behavior Therapy • More effective for high-functioning children • Focus on cognitive distortions and behavioral strategies • Anxiety and anger management

37. Discrete Trial Teaching (DTT) • Method for teaching new skills • Skills are broken into small parts called trials • Repeated practice is provided • Clear beginning and end • Reinforcement, prompts, shaping, etc., are all used within DTT

38. What Can Be Taught Using DTT • Imitation • Attending • Receptive language • Expressive language • Self help skills • Play skills • Social skills • Academic skills • Etc.

39. Treatment Implications: Teaching Skills to Children with Autism • Two general approaches • 1) Work “around” the deficit • Teach social/communicative skills (eg, gestures, eye contact) using explicit “declarative” instruction • Applied Behavioral Analysis (ABA) and Discrete Trial Therapy (DTT) • Repeated explicit instruction with contingency reinforcement • Problems • Teaching specific actions; lack of context • Poor generalizability

40. Treatment Implications: Teaching Skills to Children with Autism • Two general approaches • 2) Work “through” the deficit • Improve children with ASD’s ability to model others’ social/communicative actions • Floor Time (Greenspan)

41. Treatment Implications: Teaching Skills to Children with Autism • Two general approaches • 2) Work “through” the deficit • Improve children with ASD’s ability to model others’ social/communicative actions • Floor Time (Greenspan) • Problems • Not necessarily able to overcome the core impairment in learning these skills

42. School Difficulties • Hidden Curriculum • Academic Deficits • Reading Comprehension • Organization skills • Immature interests • Being rule-bound in a middle school

43. Difficulties with Peers • Trouble making friends • Odd interests • Deficits social skills and “social awareness” • Deficits in problem-solving • Going first in a game • Following directions in team games • At-risk for being teased and bullied

45. Changes through the Lifespan • Transition out of preschool • Fear of public school • Changes in curriculum • Loss of first therapists • Elementary school years • Academics more difficult • Social gap widens • Peers become more aware • Social events increase: birthday parties, etc. • Physical growth • Teasing and bullying

46. Changes through the lifespan • Middle School years • Social difficulties for everyone! • Puberty (!) • Behaviors no longer “cute” • Aggressive bursts • Increasing self-awareness • Socialization in groups – cliques • School change • Diploma track

47. Changes through the lifespan • High School years • Academically rigorous • Thoughts toward the future • Job training • College • Potential for greater isolation • At-risk for experimentation with rule-breaking behavior • Inappropriate comments result in harsher consequences • Feelings of sexuality develop • Driving

48. Changes through the lifespan • Post-high school • Increasing independence • Learning rules for workplace • Living situation • Group home vs. apt. vs. stay at home • Possibility of greater isolation

49. Scientific and Promising Practices (Simpson, 2005) • Applied behavior analysis • Discrete trial teaching • Pivotal response training • Milieu therapy • Incidental teaching • Structured teaching (e.g., TEACCH) • Picture Exchange Communication System • Augmentative alternative communication • Assistive technology • Joint action routines • Social stories

50. Treatment and Education of Autistic and related Communication-handicapped Children (TEACCH): Overall Focus • An individual’s skills • An individual’s interest • An individual’s needs • Centering on the individual • Adapting as appropriate • Intervention strategy built on existing skills and interests