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COULD THIS BEHAVIOR BE AUTISM SPECTRUM DISORDER

Regina A. Gargus, MD, FAAPMedical Director , Siskin Children’s Institute and Center for Developmental Pediatrics

Chief, Division of Developmental Pediatrics, Children’s Hospital of Erlanger

Associate Professor of Pediatrics, Univ Tenn College of Medicine-Chattanooga

Disclosure

• I have no financial conflicts of interest to disclose.

• There will not be any off label use of medications discussed in this presentation.

AGENDA

• Review DSM-5of Autism Spectrum Criteria

• First Signs: Developmental Challenges in ASD

• Social Awareness for Engagement

• Unique learning style and communication in ASD

• Importance of sensory integration on behavior

• Medical setting challenges for children with ASD

• Techniques to comfort children with ASD

• Sharing Ideas and Questions

Birth to KindergartenGross Motor

Fine Motor

Balance

Visual Motor

Language

Sensory

Vision

Hearing

SocialEmotional

Self Care

Play

3 mo 7mo 12mo 24mo 36mo 48mo 60mo

QUALITY

Which child has ASD?

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Key Impairments in Children with ASD

• Facial Recognition

• Understanding Peer Play• Empathy

• Emotions and Feelings

• Engaging with Others• Communication

• Sensory Integration

• Theory of Mind• Rigid Thought Processes

• Reading Social Cues• Gestures and Body

Language

• Language Processing• Motor Planning

DSM-V Criteria• Persistent deficits in social communication and social

interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text):

• Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

• Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

• Deficits in developing, maintaining, and understand relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

• Specify current severity: degree of impairment/need for support requires: [1] support; [2]substantial support; [3] very substantial

DSM-V Criteria

• Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

• Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

• Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).

• Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).

• Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

• Specify current severity:

DSM-V Criteria• With or without accompanying intellectual impairment

• With or without accompanying language impairment

• Associated with a known medical or genetic condition or environmental factor

• (Coding note: Use additional code to identify the associated medical or genetic condition.)

• Associated with another neurodevelopmental, mental, or behavioral disorder

• (Coding note: Use additional code[s] to identify the associated neurodevelopmental, mental, or behavioral disorder[s].

PossibleRed Flags for AutismRESEARCH AT THE NICHD

• Lack of response to name.

• Cannot explain what he/she wants.

• Language skills are slow to develop or speech is delayed.

• Doesn’t follow directions.

• The child seems to be deaf.

• Seems to hear sometimes, but not other times.

• Doesn’t point or wave “bye-bye.”

• Used to say a few words or babble, but now he/she doesn’t.

• Throws intense or violent tantrums.

• Has odd movement patterns.

• Overly active, uncooperative, or resistant.

• Doesn’t know how to play with toys.

• Doesn’t smile when smiled at.

• Lacks imaginary play

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Possible Red Flags for AutismRESEARCH AT THE NICHD

• Has poor eye contact. • Gets “stuck” doing the same things over and over and can’t move on to other

things. • Prefers to play alone. • Gets things for him/herself only. • Very independent for his/her age. • Does things “early” compared to other children. • In his/her “own world.” • Tunes people out. • Lack of interest in other children. • May walk on his/her toes. • Shows unusual attachments to toys, objects, or schedules (i.e., always holding

a string, has to put socks on before pants, flicks hanger as play). • Has unusual play: lining things up or putting things in a certain order.

First Signs

Impairment in Social Interaction:• Lack of appropriate eye gaze

• Lack of warm, joyful expressions

• Lack of sharing interest or enjoyment

• Lack of response to name

Repetitive Behaviors & Restricted Interests:• Repetitive movements with objects

• Repetitive movements or posturing of body, arms, hands, or fingers

Impairment in Communication:• Lack of showing gestures

• Lack of coordination of nonverbal communication

• Unusual prosody (little variation in pitch, odd intonation, irregular rhythm,unusual voice quality)

"The dreams that you once had for your child's future are going to be different.

But you are going to be able to build dreams for your child.“

Nancy D. WisemanFounder and president of First Signs Inc , Mother of a 12-year-old daughter diagnosed with autism at age 2.

"Your life is going to be different“ What Defines the Child with an Autism Spectrum Diagnosis

• Cognitive [Language] Ability• Ability can be modified by comorbid conditions:

• Anxiety, ADHD, Aggression, Sleep issues, Feeding Issues, Sensory Integration Issues

Different ABILITY

Play

Communication

Behavior

Sleep

Feeding

CHILDWithASD

Regulation

JointAttention

Theory Of

Mind

Comprehension

Imitation

SensoryIntegration

Motor Planning

Flexibility

Social

Engagement

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First

I

AM

A

CHILD

Recognizable Social Deficits

• Non-verbal behaviors• Eye to eye gaze; facial expression; body postures; gestures

• Often prefer solo activities • [alone rather than in group]

• Uninterested in competitive activities • Sports or academics

• Inappropriate responses• Poor to no appreciation of social cues• Inability to interact with peers

• Uninterested in others conversation• “In their own world”

• Do not question or ask others opinion

• Not be influenced by peer pressure, trends or fads

Recognizable Social Deficits

• Lack of spontaneous seeking to share enjoyment• Lack of showing; bringing or pointing out

objects

• Expressing own emotions• Limited facial expressions• Make limited eye contact

• Recognizing emotions in others• Unaware of behavior/comments or affect on others• Cannot read facial expressions or body language

• Taking another person’s perspective• Theory of Mind

• Shifting attention• Easily distracted

• Impulse control• Limited coping skills

• Understanding rules• Rule followers / inflexibility of thought• Cross boundaries and personal space of others

Sheer JOY

Language and Communication

• Timing for language acquisition

• Concrete: Take everything literally

• Pragmatics: does not understand figures of speech

• Prosody: Has an unusual tone of voice; odd rhythm to voice; peculiar voice characteristics.

• Pedantry: Overly formal with advanced vocabulary

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Atypical Communication in Children with ASD

• Jargoning

• Echolalia

• Scripted Speech

• Rote Phrases

• Lack of conversation

• Lack of questions

• Lack of interest in others ideas

• Lack of imagination

• Concrete thought

• Inflexibility

• Reversal of pronouns

Communication Supports

• Obtain attention before message is given

• Never assume information is already known or understood

• Use visual strategies, even when cognitive and verbal skills are good

Reduce the Guessing Game

• COMMUNICATION

• COMMUNICATION

• COMMUNICATION

•Develop a daily routine that is very structured

•Use visual cues to help child know what comes next

Communication+ Sensory Integration Recipe for Success

• Follow child’s lead

• Increase complexity of task gradually

• Be excited

• Reconfirm understanding

• Visual reinforcement

• Redirect

Communication in a Concrete World

• Use slow quiet voice [Use your Inside Voice]

• Facial Expression to match situation

• If you give a choice be ready for “no”

Can you pick up your shoes? Instead might say:

• Make direct and simple requests

Pick up your shoes and put them in the closet…

• Show child how to respond [hand over hand]

• Use enthusiasm /excitement/clap

Thank you for putting your shoes in the closet

• If nonverbal, use single word label or picture

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Repetitive Routines Behaviors and Movements

• Sticks to rigid routine

• Difficulty being flexible

• Imposes routine on others [play by my rules]

• Upset by change in routine

• Needs excessive reassurance when changes take place

• Repetitive senseless body movements

• Body movements may have pattern

Emotions:Challenge to Regulate Challenge to Read

• Lack of Empathy

• Do not understand feelings of others

• Extreme reactions to minor upsets

• Feelings are All or None

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Thinking Patterns in Children with ASD

• Facts, m’am only the facts

• Obsessed with one or two topics

• Expects others to understand what they are thinking without telling them

• Does not ask for clarification when confused

• Cannot imagine what others are thinking about [Theory of Mind]

• Cannot interpret others intensions

• Always right

• [perceived argumentativeness]

• Impressive long term memory

Playing is important for all children

• A time to engage with parent and siblings.

• A time to learn lots of different ways to play and build learning skills.

• Mastery of skills need practice. Play alone and with others gives these opportunities

• Children need play ideas and games

• Play improves coordination in all developmental domains

• It also helps your child:• build confidence • feel loved, happy and safe • develop social skills,

language and communication

• encourages sharing• learn about caring for

others and the environment

• develop physical skills • connect and refine

pathways in her brain.

Play in children with ASDcan be CHALLENGING

• Offers to play alone rather than with peers

• Uses playmates as objects sometimes

• Seems to not understand how to play

• Does not know the unspoken rules of play

• Intense reaction if does not get his own way

• Difficulty sharing toys

• Needs to be rule-maker [little policeman]

• Lack of or limited imaginative play

Intense Preoccupation with One or Two Topics [ can change over time]

• Almost fanatical about interest

• Obsessed, talks incessantly about interest

• Little interest in other topics

• Pursues advanced knowledge in area of interest

• Gives knowledge in almost an encyclopedic manner

• Carries object everywhere [Ball, Blanket, String, Toy]

Stereotypic Play

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Preparing for and dealing withMelt Downs

• Understand triggers

• Prepare child for change

• Read child’s reaction

• Abort scene

• Build skills

• Calm-down Place

Engage the Self Directed Child

• Entry into child’s world

• Gain Attention

• Support Activity and Prompt Imitation

• Interpret Activity

• Motivate

• Expand experiences

• Be Flexible

Do not rely on TV Video Game, Computer,

Puzzles, etc to teach skills

Do not give up: Try -TRY- TRY Again

Self- Injury

Limited Verbal AbilityCognitive ImpairmentFrustrated /AngrySensory/Repetitive Behavior

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Adapting these challenges to the Acute care setting-Urgent/Emergent

• Know when time allows learning the child first

• When time does not permit care delay, consider sedation

• Address sensory issues

• Work with families to have or to bring appropriate comfort items

• Spend time with child relating when urgency resolved.

Life is a journey [interfacing with health care] not a destination [single acute care visit]….

• Appreciation of our medical environments from the eyes of a child.

• Understanding of the challenges faced by a child with an ASD.

• How adaptations might improve current and future behavior when interfacing within our acute care settings

• What you need to know about every child with an ASD to improve experiences in the acute care setting

Sharing Ideas and Questions