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MDT EVALUATION MODEL FOR DETERMINING AUTISM IN STUDENTS WITH VI

Marnee Loftin, M.A,

School Psychologist, TSBVI

loftinm@tsbvi.edu

loftinm@att.net

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GOALS

• Acquire knowledge about DSM V criteria• Develop skills in Multidisciplinary Team

evaluation process• Develop skills in determining need for

evaluation• Acquire knowledge about specific instruments

and procedures used in evaluation• Develop skills in writing reports and

recommendation

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GOAL 1

GENERAL KNOWLEDGE OF THE

DIAGNOSTIC AND STATISTICAL MANUAL (DSM) FIFTH EDITION

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DSM: AN OVERVIEW

• Provides guidelines for diagnosis of psychological conditions

• Regular revisions• Significant changes in autism in

Fifth Version

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WHY DO I NEED TO UNDERSTAND THE DSM V?• Provides a common language

• Guides the diagnostic process

• Determines if an individual qualifies for the diagnosis

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CHANGES IN DSM CRITERIA

• Changes name of category from “Pervasive Developmental Disorder” to “Autism Spectrum Disorder

• Deletes different categories including Aspergers Disorder

• Simplifies criteria• Emphasizes levels of severity and

required support

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CRITERIA IN DSM-V

MAJOR CRITERIA ARE DEFICITS IN:• Social-Communication and Social

Interactions• Restricted, Repetitive Patterns of Behavior,

Interests, or ActivitiesAND THAT:• Are present in Early Childhood• Limit and Impair Everyday Functioning

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SOCIAL AND COMMUNICATION

Exhibits deficits in (all three)

1. Social-emotional reciprocity

2. Non-verbal communication

3. Developing and maintainingrelationships

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RESTRICTED, REPETITIVE PATTERNS OF BEHAVIOR, INTERESTS OR ACTIVITIES

Exhibits the following behaviors (at least two)

• Stereotyped speech, motor movements, echolalia, repetitive use of objects, idiosyncratic phrases

• Extreme adherence to routines, rituals, excessive resistance to change

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CONTINUED

• Restricted, fixated interests that are abnormal in intensity or focus

• Hyper- or hypo-activity to sensory input or unusual interest in sensory aspects

of environment

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IMPLEMENTATION OF NEW DSM V CRITERIA

• Scheduled to be implemented in May 2013

• Will be preceded by massive training

• Simple overview of current criteria

• Still considerable conflict over changes

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GOAL 2

The Multidisciplinary Team (MDT) Process

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ADVANTAGES OF MDT

• Gather large amounts of data

• From a variety of perspectives

• From experts with unique training

• Who often focus on particular aspects of person

• Allows data to be shared

• Shortens time for evaluation

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THE MDT PROCESS

• Decreases redundancy in gathering information

• Integrates different information obtained

• Synthesizes information for general conclusion

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PROBLEMS WITH MDT PROCESS

• Lack of time to implement

• Difficulty with synthesizing

• Handling disagreement

• Implementing consensus

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SOLVING THE PROBLEM

• Administrative support of membership

• Administrative support of time commitment

• Establishing procedure for leadership

• Developing format and procedure

• Developing standards for resolving conflicts and writing conclusions

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SPECIAL ISSUES WITH EVALUATION OF

STUDENTS WITH VI• Regulations usually require

Psychologist, SLP, Autism Specialist, and Parent

• OT is often added in clinical settings• Important that TVI must be included in

evaluation of student with VI• TVI is not typically included• Will have to advocate for this to occur

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ROLE OF THE TVI IN THE MDT PROCESS

• Provide information about developmental process for students with VI

• Summarize interventions attempted

• Facilitate appropriate test administration

• Assist with accommodations or modifications of test protocol

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GOAL 3

DETERMINING NEED FOR EVALUATION

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DEVELOPMENTAL PROCESS AND SIGHTED

CHILDREN• Emphasis has been on earlier diagnosis

• Process depends upon identifying early discrepancies from expected development

• Difficult to generalize these discrepancies separate from the visual impairment

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EARLY DIAGNOSIS WITH SIGHTED CHILDREN

• Poor eye contact

• Poor eye coordination with gestures or vocalization

• No pointing or showing of objects

• Inability to follow focus of another

• Less pre-verbal babbling

• No reciprocity in babbling

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EARLY DIAGNOSIS WITH STUDENTS WITH VI

• Are not supported by extensive research

• Should occur at an older age

• Should always consider developmental patterns

• Are based upon slightly different criteria

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BEHAVIORAL FEATURES AS PREDICTORS

• Unusual responses to environment

• Insistence on routines

• Stereotypic behaviors

• Special interests or abilities

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OTHER FACTORS FOR VI STUDENTS INCLUDE

• Failure to develop language

• Loss of skills that have been acquired

• Intense stereotypic behaviors

• Failure to respond to early interventions

• Specific etiologies associated with ASD

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WHY EVALUATE FOR ASD?

• Determine eligibility for programs

• Develop appropriate IEP

• Develop plan for transitions

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ETIOLOGIES FREQUENTLY ASSOCIATED WITH ASD

• Retinopathy of Prematurity

• Optic Nerve Hypoplasia

• Septo-optic Dysplasia

• CHARGE Syndrome

• Congenital Rubella

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THESE CONDITIONS ARE HIGH RISK AND OFTEN

ASSOCIATED WITH OTHER ISSUES. THE EVALUATOR

MUST BE CAREFUL TO ASSESS FOR CO-MORBID

CONDITIONS AS WELL.

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GOAL 4

Knowledge of specific evaluation procedures

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CAUTIONS

• Always consists of formal and informal data

• Requires MDT that is aware of and sensitive to needs of VI population

• Requires clinical skills rather than reliance on scores

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EVALUATION OF STUDENTS WITH VI

INCLUDES• Developmental History

• Observations and Interviews

• Evaluation of Communication, Sensory, Behavioral and Cognitive Functioning

• Synthesis of Results

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SPECIFIC EVALUATION PROCEDURES

Developmental History

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DEVELOPMENTAL HISTORY REQUIRES DATA ABOUT:

• Pregnancy and birth

• Perinatal experiences

• Medical history/medication

• Family history

• Previous evaluations and results

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PREDICTORS OF ASD IN DEVELOPMENTAL HISTORY• Family history of ASD or unusual

behaviors

• Pattern of early concerns of parent, particularly about hearing and language

• Early requests for intervention

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CONTINUED:

• Unusual interests on part of child

• Lack of responsiveness from their child

• Savant skills

• Self-abusive behaviors

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Specific Evaluation Procedures

Observation and Interviews

INFORMAL EVALUATION DATA

Informal survey of schools for blind indicate emphasis on these

data

Informal consists of behavioral observations and interviews

Content and extent depend upon age and functional level

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INFORMAL EVALUATION

• Informal survey of schools for blind indicate emphasis on informal evaluation data for determining ASD

• These data may consist of behavioral observations and/or interviews

• Content and extent depend upon age and functional level

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BEHAVIORAL OBSERVATIONS

Data should be gathered with concepts of:

• Definition of ASD

• Ways these behaviors are evidenced in student with VI

• Importance of observation in multiple environments

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SPECIFIC TYPES OF INFORMATION INCLUDE:

• Sensory

• Social-Communication

• Behavioral

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SPECIFIC OBSERVATIONS WILL VARY BASED UPON:

• Age and functional level of student

• Access to formal testing procedures

• Professional discipline that is observing

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INFORMATION GATHERED SHOULD REFLECT

• Current functioning in areas of Sensory, Communication, and Behavioral

• Strengths in these areas

• Difficulties and specific ways that they are exhibited

• Functional implications of these difficulties

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INFORMATION BEING GATHERED

• Can be gathered through actual observation or through video sources

• Is completed by different disciplines

• Is synthesized into a single summary

• Can be gathered through either formal or informal observation systems

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SENSORY ISSUES

• Individuals with ASD often exhibit a variety of sensory issues listed below

• Observation of sensory issues usually facilitated by OT and/or PT

• Type of issue will vary by age and functional level

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SENSORY ISSUES OFTEN IDENTIFIED

• Problems with motor control and development

• Gross and fine motor delays

• Abnormal muscle tone

• Sensory defensiveness

• Self regulation/modulation deficits

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PROBLEMS WITH SENSORY ISSUES MAY RESULT IN:

• Extreme responses to sound, touch, movement

• Excessive movement and repetitive behaviors

• Oversensitivity to textures

• Difficulty with modulation in areas of physical, emotional, and voice tone

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SOCIAL-COMMUNICATION ISSUES

Language has been removed as a specific criteria necessary for diagnosis of ASD in the DSM V

Communication remains an important aspect of Social-Communication and Social Interactions

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SOCIAL- COMMUNICATION ISSUES OFTEN OBSERVED• Maintaining echolalic patterns of

language• Lack of understanding of reciprocal

nature of communication• Difficulty with interpreting or expressing

emotions• Problems with gestures and non-verbal

cues

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PROBLEMS MAY MANIFEST AS DIFFICULTIES WITH:

• Responding to conversational cues

• Managing changes in conversations

• Inferring emotions from voice tones

• Maintaining appropriate prosody in expressive language

• Responding to non-verbal cues

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THESE PROBLEMS MAY RESULT IN:

• Difficulty in establishing and maintaining social relationships

• Problems with anticipating consequences of actions

• Difficulty in inferring emotions of others

• Problems with maintaining appropriate level of voice

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BEHAVIORAL

Although not specifically listed in the DSM criteria, behavioral

issues are often the most significant for education.

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BEHAVIORAL ISSUES OFTEN OBSERVED

• Perseveration on tasks

• Hypo- and hypersensitivity often result in high degrees of self-stimulatory behaviors

• Poor social skills

• Frequent behavioral outbursts

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PROBLEMS ARE OFTEN EVIDENCED BY

• Extreme resistance to change

• “Motor-driven” types of self-stimulatory behavior

• Social isolation

• Poor executive functioning

• Fixation on strange and unusual objects and/or interests

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SPECIFIC INSTRUMENTS: OBSERVATIONS AND

INTERVIEWS• Autism Diagnostic Observation

Schedule

• Autism Diagnostic Interview

• Childhood Autism Rating Scale

• Autism Behavior Checklist

• Gilliam Autism Rating Scale

• Social Relatedness Scale

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Specific Evaluation Procedures

Psychological: Cognitive, Adaptive Behavior, Emotional

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GENERAL INFORMATION ABOUT COGNITIVE SKILLS

Individuals may have intelligence that ranges from superior to profound intellectual disabilities. In about 75% of cases (with DSM IV criteria), intellectual disabilities were also present.

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PROFILES ON IQ TESTSFOR STUDENTS WITH VI

• Significant splinter skills on profile

• Short-term memory is a strength

• Vocabulary often is a strength for verbal students

• Social judgment is a weakness

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SPECIFIC INSTRUMENTS: COGNITIVE SKILLS

• Wechsler scales

• Woodcock Test of Cognitive Abilities

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REMEMBER!

IQ scores are NOT a good predictor of educational

performance or social judgment for children with ASD

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ADAPTIVE BEHAVIOR

• Adaptive behavior is a relative weakness for students with ASD

• The typical pattern is for areas involving Socialization and Communication to be lowest for students with ASD and VI

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SPECIFIC INSTRUMENTS:ADAPTIVE BEHAVIOR

• Vineland Adaptive Behavior Scale

• Woodcock-Johnson Scales of Independent Behavior (Short Form for Visually Impaired)

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EMOTIONAL-BEHAVIORAL

• Much information comes from observations and interview

• More is gathered through specific questionnaires and interviews

• Purpose is to explore/rule out other condition

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QUESTIONS TO BE ADDRESSED

• Other factors that are manifesting as social disconnect

• Extent to which student can adapt and focus in new situation

• Adjustment to vision loss

• Coping strategies in place

• Concerns of student

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OTHER HELPFUL INFORMATION

• Complete neuropsychological evaluations are seldom possible

• Portions of these types of evaluations should be considered

• This information will be helpful in planning instruction and remediation

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MEMORY

• Memory is often seen as significant strength

• Important to explore what is being remembered

• Often does not generalize to meaningful tasks

• Will be critical information to teach new skills

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EXECUTIVE FUNCTIONING

• Ability to plan, inhibit, consider an action and its consequence

• Significant problem in people with ASD

• Results in their becoming “stuck” in non-functional routines

• Will also be important in planning interventions

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SPECIFIC INSTRUMENTS

• California Verbal Learning Test

• Test of Problem Solving Skills

• Test of Executive Functioning

• Behavioral Assessment System for Children

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GOAL 5

WRITING REPORTS AND RECOMMENDATION

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SYNTHESIS OF RESULTS

• MDT process guarantees multiple results

• Goal is to summarize into a single report

• Report must reflect information from all

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INDIVIDUAL PROFILE AS BASIS OF REPORT

• Report should reflect the strengths and needs

• Situations in which each of these are demonstrated

• Extent to which these behaviors meet the criteria presented in the DSM for ASD

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RECOMMENDATIONS SHOULD

• Provide instruction to decrease need for supervision

• Increase level of independence

• Improve social-communication skills

• Decrease repetitive and restricted patterns of behaviors and interests

• Build upon strengths as well as needs

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THE EVALUATION PROCESS MUST ALWAYS

• Focus on a clear understanding of the visual condition and implications

• Consider the developmental level of student

• Provide opportunities for evaluation in multiple settings by multiple individuals

• Continually consider the most important caveat of evaluation

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CAVEAT OF EVALUATION

CONDITIONS ARE NOT DIAGNOSED BY TESTS BUT

RATHER BY KNOWLEDGEABLE AND CONCERNED

INDIVIDUALS