Foundations of Autism(Autism Spectrum Disorder)

Steven M. Graff, Ph.D.Director of Clinical ServicesTri-Counties Regional Center

&Laura D. Valdez, M.S.

Camarillo Academy for ExcellenceNovember 3, 2012

Clinical Definitions

Diagnostic and Statistical Manual (DSM-IV-TR): Autism, Asperger syndrome, and Pervasive developmental disorder NOS

are discrete disordersThey will be combined and called ASD with level of

severity specified in the new DSM-5.

.Federal Educational Code

A wide variety of problems can earn the same eligibility: autistic/autistic-like

Presentations of Classic Autism

Birth to 24 months: feeding problems; failure to thrive; poor latch and suck; arching back; colic; problems sleeping; poor eye contact; not

responding to name; loss of previously acquired language.

Why does this get missed? (Subtle oddities; first child; families moving away from grandparents & family?)

Presentations of Late Onset

3 to 5 years old:Jargon, echolalia, scripted language; lack of imaginative play, fascination with cause-and-effect toys, lights, mirrors or fans; odd or perseverative interests; lack of interest in others, especially children (no parallel or

interactive play); severe tantrums (>60’)

Other Disorders That Are Commonly Mistaken For Autism

Fragile X syndromeTuberous SclerosisBipolar DisorderLandau-Kleffner Syn.Tourette’s Syn.Fetal Alcohol Syn. (FAS)Epileptic aphasiaAsperger Syn.Pervasive developmental disorder NOS

Communication DisordersNeurofibromatosisIntellectual Disability (Mental Retardation)Severe Abuse or NeglectADHDObsessive Compulsive DisorderSocial communication disorderChildhood disintegrative disorderRhett’s disorder

Myths of Persons with Autism

Do not care about othersDo not feel emotionsDo not feel painDo not want relationshipsAll are savant geniuses

Epigenetics: interaction between environmental exposure and genetic

material

Genetic predisposition EXTREMELY LIKELY[over 60 genes identified so far and increasing] +Environmental exposure: pesticides heavy metal

pollutants; air pollutants; bisphenyl A [plastics], flame retardants; and viruses

Vaccinations are not a cause according to most scientific research

Theory of mind and Mirror Neurons

Ever wondered how some people can “put themselves into another person's shoes” and some people cannot? Our ability to empathize with others seems to depend on the action of "mirror neurons" in the brain, Mirror neurons activate when an action is observed, and also when it is performed. Research reveals that there are mirror neurons in humans that fire when sounds are heard. In other words, if you hear the noise of someone eating an apple, some of the same neurons fire as when you eat the apple yourself. Subjects in the study who scored higher in empathy tests also showed higher levels of mirror neuron activation. (Gazzola, 2006)

Persons with autism seem to lack this Mirror system.

More thoughts on symptom causation: Reticular activating system (the brain’s “alarm clock” is often hyper developed, leading to sleep disorders which can lead to behavior problems!

Higher incidence of allergies and sensitivities, leading to sinus headaches and diarrhea, which lead to behavior problems!

Left supra orbital frontal cortex (social awareness center) is underdeveloped-no Theory of Mind (T.O.M.) which leads to social problems

Dopaminergic pathways tend to be underdeveloped, leading to emotional dysregulation which leads to behavior problems!

Brain

Structure and organization of the brain is often different than control studies.

Often see microcephaly at birth; yet macrocephaly at first year check up (too rapid brain growth without apoptosis, or normal death of unneeded cells).

Cerebellum: Punkinje (nourishment) cells-decreased number.

Limbic System and Cortex-decreased neuron density.

Dendridic interconnectivity odd everywhere.

Embryology

Autism starts in the first trimester [Thalidomide; viral infection history] in the gastrula stage, when the neural plate is forming the neural tube. Normal axon migration is disrupted-cells going in the wrong direction, with too few/too many cells in nerve tracts, and poor connectivity of synapses

“Red Flag” Indicators

NO babbling by 12 monthsLack of response to name at 12 monthsNO back and forth gestures such as pointing, showing, reaching, or wavingNO meaningful words by 16 monthsNO 2-way meaningful phrases by 24 months of age (excluding imitation)ANY loss of speech, babbling, or social skills at ANY age (but remember, new siblings often bring loss of adaptive skills for a while in typical kids)

How do we diagnosis Autism?

Interdisciplinary Team [IDT] is Best Practice

An IDT approach allows you to evaluate and integrate the effects of ASD on multiple areas of the child’s development and provide a comprehensive profile of the child

Domains of Observation

Reciprocal turn – takingSocial reciprocitySustained interactionSpontaneous giving/showingImitation of novel acts

Shared attentionPretend PlayGaze aversionAbility to have examiner direct attentionUse of toys and objects

Cognitive Assessment

A careful examination of cognitive functioning is needed to plan meaningful interventionsCognitive functioning is measured more accurately using a combination of formal and informal observational methods.The assessment of young children with suspected ASD requires knowledge of both normal child development as well as the developmental issues of persons with autism.

Adaptive Functioning

Adaptive functioning refers to the child’s ability to use acquired skills and abilities to cope with the demands of daily living.

Measures of adaptive functioning are required to render a formal diagnosis of mental retardation concomitant with ASD as well as determine a baseline of acquired skills for ASD or other differential diagnosis.

Children with ASD often display discrepancies in certain facets of cognitive abilities and adaptive functioning levels.

Social Deficits

Deficits of interactivityPoor eye contactFlat/inappropriate facial expressionPoor non-verbal social skills

Lack of empathy or blunted emotional responsesDelayed or absent peer relationshipsDelayed or absent interest in others

Socialization Styles

Aloof-often described as “being in his own world”

Passive-which can be ignored if not a problem in the classroom

Interactive but odd

Communication

Severe delay or absence of useful speech/nonverbal communication.Receptive language skill level often different than expressive skill level.Use of evasive language is common.Parent anticipation of communicative intent/ using parents as tools

Communication Cont.

Echolalia, delayed echolaliaJargon, idiosyncratic wordsScripted speech [TV, movies]Prosody/pragmatics of speech Pronoun reversal

Behavior

Stereotypic motor movements and perseverations

Hand flapping, spinning, finger play, fixation on themes, colors, numbers, people, objects. [must differentiate between “party behavior” vs. true oddities]-not toe walking-very common in all children.

Behavior Cont.

Difficulty with transitions Routines, rituals, difficulties when they

are disrupted even from highly non-preferred activities

Need for task completion or closure

Fixation with parts (wheels) versus whole (car)

Sensory Differences

“It is likely there is a continuum of visual and auditory processing problems for most people with autism, which goes from fractured, disjointed images at one end to a slight abnormality at the other end.”

Temple Grandin, Thinking in Pictures

Hyper/Hypo-sensitivities (increased/decreased)

Sound

Touch

Light

Smell

Taste

Movement

Texture

Hyper/Hypo-sensitivities

They can co-exist:“How come his pain tolerance is so high yet he can’t stand to be touched?”“Why does he act like he’s deaf, yet is bothered by the buzzing of the lights in the classroom?”

Learning and Thinking in Autism

Visual Learners mostly, but not always.

Auditory learning with comprehension is not usually a strength (but mimicry is)

Often Kinesthetic learners (need motoring through; can’t be told how to do it)

Concrete thinkers, not abstract

A child with autism may look like…..

Uneven pattern of development

Rote memory a relative strength, but analysis and inference are weaknesses

Visual procession of information a relative strength

Communication/social interactions highly problematic

A child with autism may also look like…

Generalization of knowledge/skills is difficultSkills available spontaneously, but not on requestResistance to change/desire for sameness can be problematicAttention difficultiesSensory differences

Three Mainstream Treatment Approaches

Intensive Behavioral Interventions-IBIDiscrete Trial Training (DTT), Applied Behavioral Analysis (ABA), Lovaas and Pivotal Response Therapy (PRT)

Treatment & Education of Autistic & Communicationally Handicapped Children (TEACCH)

Developmental: Greenspan/Floor time, DIR-individual difference, relationship-based model

Individuals with Disabilities Education Act

The IDEA mandates that all children with disabilities receive a free, appropriate public education in the least restrictive environment, tailored to each child’s individual needs.

Educational Needs of Persons with Autism

1. Preschool AgeCommunication therapies in the classroom and at home. (group and individual)Parent participation and training1:1 as well as small group instructionChild engaged in a variety of developmentally appropriate activities

Educational Needs of Persons With Autism

2. School Age ChildrenA variety of options with autism specific servicesCurriculum that focuses on developing independence

Common School Age Children Curriculum Areas:

Communication

Social

Community

Domestic

Functional academics

Mobility

Self Help

Recreation/Leisure

Vocational

Educational Needs of Persons with Autism

3. High School AgeSame as school age but with increased emphasis on vocational and community based instruction.

Educational Needs of Persons with Autism

4. AdultCollege vs. vocational trainingNeed for appropriate housing (ranging from living with family, group home, or own apartment)Independent living skills trainingSocial/recreational/dating support

National Autism Center- National Standards Report

Includes the identification of “Established, Emerging, and Unestablished” treatments for children with autism. [The report focuses on ages 0-22 and not on adults].The report on can be found at the following link:http://www.nationalautismcenter.org/affiliates/reports.php

Established treatment

“Established” Treatments: treatments that produce beneficial outcomes and are known to be effective for individuals on the autism spectrum. The report identified 11 Established Treatments; the majority of these are based on the behavior therapy literature, and include: Applied Behavior Analysis (ABA), Discrete Trial Training (DTT), and Pivotal Response Therapy (PRT).

Some non-Established Autism “Therapies”

Auditory Integration Therapy/Tomatis methodSwimming with DolphinsEquestrian TherapyMusic TherapySpeech therapySocial SkillsRDI

Sensory Integration TherapyFacilitated CommunicationHyperbaric Oxygen Therapy (HBOT)Surfing TherapyMegavitaminsVision/Irlen lensesPsychosurgery

The Established therapies:

Behavior therapyMedication to address symptoms

Choosing a Therapy

There are lots of “therapies” which purport to cure, alleviate, or improve autism. Beware of poor research. Parents may believe that one, or even 1000 hopeful anecdotes outweigh negative research. [No, it doesn’t].

Medications don’t “cure” autism, but the symptoms may be treatable

CNS Stimulants (attention/hyperactivity)Anti-Depressants (for agitation/mood)Anti-Convulsants (mood stabilization)Anti-Psychotics (impulsivity/agitation)Anti-Opiates (“Stimming” or Self-Injurious

BehaviorAnxiolytics (anxiety)

Guidelines for Evaluating Approaches

Be skeptical of any treatment that provides a “magic” cure or any program that represents only one optionIndividualize programs are bestGoals should be to increase independence/ functional skillsPrograms should be structured and geared toward developmental level

Number one rule of intervention should be…

Focusing on the acquisition of skills as well as the generalization of functional, adaptive behaviors.

The End

Questions?