Understanding the Social Deficits of Understanding the Social Deficits of Autism: Early Identification and Autism: Early Identification and

InterventionIntervention

Peter MundyPeter Mundy

M.I.N.D. Institute and School of Education

PROMISING PATHWAYS CONFERENCE, FGCU Research supported by NIH Grants HD 38052, MH 071273, Research supported by NIH Grants HD 38052, MH 071273,

the Marino Autism Research Institute (MARI) and the Lisa Capps the Marino Autism Research Institute (MARI) and the Lisa Capps endowment for research on neurodevelopmental disorders and education at endowment for research on neurodevelopmental disorders and education at

the M.I.N.D. Institute.the M.I.N.D. Institute.

OUTLINEOUTLINE

• Early Intervention:• Methods and Principles

• Understanding Early Intervention– Cognitive, Motivation & Neurodevelopmental Theory

• A Transactional and Discrete Trial Intervention for Joint Attention and Symbolic Play– Connie Kasari, Stephanny Freeman & Tanya Paparella,

– SRCD, 2007, Boston, MA., USA

Early InterventionEarly Intervention• Preschool: 0-months to 5-years

• Rogers (2006), Yoder & McDuffie (2006) • Social & Communication Development in Autism Spectrum

Disorders, Tony Charman & Wendy Stone (Eds.)

• First publications 40 years ago• Wolf, Risley & Mees (1964); Hewett (1965); Lovaas, Berberich,

Perloff & Schaffer (1966).

• Very few Randomized Control Trials (RCT)

• Few large scale or comparative studies

• Pharmacological & Alternative Communication

Early Intervention MethodsEarly Intervention Methods

• Discrete TrialDiscrete Trial– Adult Directed– Modeling of behavior

• Verbal & Physical Prompts

– Primary contingent reinforcement of successive approximations (shaping)

• Lovaas (1987)

• Skill Development

• DevelopmentalDevelopmental– Child attention directed– Imitation & shared experience– Multimodal social contingent

reinforcement of developmentally advanced behaviors

• (voice tone, affect & gesture)• Greenspan & Wiedner (2000)

• Learning Development

DiscreteTrial

Combined TransactionalDevelopmental

Responsive

Yoder & McDuffie (2006)

Interventions and Learning TheoryInterventions and Learning Theory• Behaviorism (Empiricism) – Discrete TrialBehaviorism (Empiricism) – Discrete Trial

– Define and manipulate external stimulus behavior response contingencies• Internal mental processes secondary or unnecessary (e.g. Skinner, 1952)

• Cognitive Revolution (Rationalism)Cognitive Revolution (Rationalism) - DevelopmentalDevelopmental– Internal mental & motivation processes affect learning

• Tolman (1932; Piaget, 1952; Chomsky, 1959)

• Pragmatics - DevelopmentalPragmatics - Developmental– Social functions provide a foundation for language

• Bates et al. (1975), Bruner (1975), Halliday (1975)

• Constructivism - DevelopmentalConstructivism - Developmental– The self-initiation of action, with time & experience is essential to

learning (e.g. Piaget, 1952)

MARKERS of AUTISMMARKERS of AUTISM

• Social BehaviorsSocial Behaviors– Social Orienting (e.g. responds to name)– Joint Attention (e.g. spontaneous seeking to share)Joint Attention (e.g. spontaneous seeking to share)– Imitation

• Cognitive BehaviorsCognitive Behaviors– Symbolic Play – Language– Social-Cognition

• Motivation & Self-InitiationsMotivation & Self-Initiations– Koegel, Carter & Koegel (2003)

Interventions Targeting Joint Interventions Targeting Joint AttentionAttention

• Developmental-Transactional child-parent intervention Developmental-Transactional child-parent intervention (Yoder & Stone, 2006)(Yoder & Stone, 2006)

• Programmatic Child Imitation (Lewy & Dawson,1992)Programmatic Child Imitation (Lewy & Dawson,1992)• Milieu Teaching Approach (Kasari, Freeman & Milieu Teaching Approach (Kasari, Freeman &

Paparella, 2006)Paparella, 2006)• Greenspan & Weidner (2000)Greenspan & Weidner (2000)• Transactional-Behavioral approach (Christina Whalen Transactional-Behavioral approach (Christina Whalen

& Laura Schriebman, 2001)& Laura Schriebman, 2001)• Parent based Relationship Development Intervention Parent based Relationship Development Intervention

(RDI, Guttstein & Sheilly, 2001)(RDI, Guttstein & Sheilly, 2001)

Understanding Early InterventionUnderstanding Early Intervention

Why Target Joint Attention?Why Target Joint Attention?

MAIN IDEAS

• Paying attention to what other people attend to is fundamental to human learning, communication, culture and social competence.

• A major developmental domain• A fulcrum for neuro-development • An axis of individual differences

• Early Development = Joint Attention

• Impairment Contributes to Autism

Social Joint Attention Social Joint Attention

Initiate Joint Attention – IJA (emerges 6-9 months)

Responds to Joint Attention (RJA)(emerges 3-6 months)

Dissociation of Initiating and Dissociation of Initiating and RespondingResponding

0

2

4

6

8

10

12

14

16

IJA LO MA IJA HI MA RJA LO MA RJA HI MA

AutismControls

Mundy, Sigman & Kasari (1994) also see Leekam (2000), Leekam & Moore (2000)

Lo MA = 8 to 22 months Hi MA = 23 to 39 months

****

**

INITIATING SHARING OF ATTENTION IS THE PROBLEMINITIATING SHARING OF ATTENTION IS THE PROBLEM

Individual Differences & Autism

RJA & IBR at 4years

N = 51

Sigman & Ruskin (1999)

ADOS IJAat 2 years

Penn InteractivePlay Scale at 9

N = 95

Lord, Floody, Anderson, & Pickles (2003)

Languageat 19 years

Social SymptomsN = 30

Mundy et al. (1994)

ESCS IJA at 4-5years

Sigman & McGovern (2005)

N = 48

Social Initiations inAdolescents

• Qualitative Impairment in Social Qualitative Impairment in Social InteractionInteraction

• A lack of spontaneous seeking to share A lack of spontaneous seeking to share enjoyment, interests or achievements with other enjoyment, interests or achievements with other people…people…

• Marked impairment in the use of multiple nonverbal Marked impairment in the use of multiple nonverbal behaviors such as eye-eye gaze, facial behaviors such as eye-eye gaze, facial expressions…expressions…

• Lack of social emotional reciprocityLack of social emotional reciprocity

• Failure to develop age appropriate peer relations

• Biological impairment of affective relatedness to Biological impairment of affective relatedness to others (Kanner, 1944)others (Kanner, 1944)

Joint Attention, DSM-IV & Diagnosis

Social-Cognitive ModelSocial-Cognitive Model(Carpenter, Nagell & Tomasello, 1998)(Carpenter, Nagell & Tomasello, 1998)

• Infants engage in JA when they Infants engage in JA when they understand others as intentional understand others as intentional agents. agents.

• 9-12 month developmental shift9-12 month developmental shift– Brooks and Meltzoff (2005)Brooks and Meltzoff (2005)

• All types of JA are simply different All types of JA are simply different manifestations of this underlying manifestations of this underlying understandingunderstanding

• Does not explain individual Does not explain individual differencesdifferences

From Gomez (1998)

Illustrations of Individual Differences in IJA-EC

0 10 20 30 40 50

IJA-EC at 9-Months

0

10

20

30

40

IJA

-EC

at

18-m

on

ths

0 10 20 30 40

IJA-EC at 18-months

-1.00

0.00

1.00

24 M

on

th L

ang

uag

e C

om

po

site

r = .35, p < .005 r = .32, p < .005

JOINT ATTENTION & JOINT ATTENTION & MOTIVATIONMOTIVATION

0

10

20

30

40

50

60

AUTISM MR

IJARequest

TYPICAL

Kasari et al. 1990Mundy et al. 1992Venezia et al. 2004

Dissociation of Joint Attention and Dissociation of Joint Attention and AttachmentAttachment

• Children with autism display attachment

• Attachment and IJA not related in autism or in typical development

• IJA motivated by reward value of sharing experience?

Self-organization and Social Learning

• Infants self-organize social information input via joint attention skills

• This facilitates learning in both structured and incidental social learning opportunities

• Constructivist Constructivist developmental accountdevelopmental account From Baldwin (1995)

Joint Attention Improves ProcessingJoint Attention Improves Processing

• 9-month olds process pictures more deeply when a passive partner also attend to the picture versus non-joint attention condition (Striano et al. 2006a,b)

• Duration of looking to target rather than frequency of looks during gaze-following predicts language (Brooks & Meltzoff, 2007).

Primordial Sharing SituationWerner & Kaplan (1963) Symbol Formation

Object

Mother Child

SymbolicDevelopment

Parallel Distributed Processing model of cognition suggests representations reflect “summaries” of experience that elicitsDistributed neural processing (e.g. McClelland & Rogers, 2003, Nature).

Joint Attention & InterconnectivityJoint Attention & Interconnectivity (Caplan et al. 1993; Henderson et al. 2004; Mundy, et al. 2000, 2002; Striano et al. 2006)

14-MonthEEG CoherenceEEG Coherence

Predicts 18-Month IJA

14 Month EEG Activity

18 MonthRJA

N = 32 InfantsWith Typical Development

IJA and EEG Coherence predict language development (Mundy, Fox & Card, 2002)

An fMRI study of the Experience of Joint Attention (Justin Williams et al. 2005)

Why Target IJA?Why Target IJA?

• Cardinal symptomCardinal symptom

• Motivation & InitiationsMotivation & Initiations

• Cognitive DevelopmentCognitive Development– Related to Symbolic DevelopmentRelated to Symbolic Development

• Self-Organizing PropertiesSelf-Organizing Properties– Constructivistic DevelopmentConstructivistic Development– Helps the child help themselves to learnHelps the child help themselves to learn

Developmental Intervention Developmental Intervention SequenceSequence

Child FocusConstructive

MOTIVATION

ImitationJoint AttentionJoint AttentionSymbolic Play

Social Cognition

Language

UCLA RCT on Play and Joint Attention

Connie Kasari, Stephanny Freeman & Tanya Paparella

SRCD

Boston, MassachusettsMarch 30, 2007

Study Design

Screen for Inclusion

Random Assignment

Intervention

3.5 years old

Joint Attention

Symbolic Play

Control

Pre-Tests

X

X

X

Follow up Tests

6-weeks 12-months

X N = 20 X

X N = 21 X

X N = 17 X

•Interventions for 30 minutes daily for 5-6 weeks30 minutes daily for 5-6 weeks

•5 minutes of priming skill--ABA discrete trial approach

•20-25 minutes of combined developmental and behavioral play targeting specific skill

•Child driven, following child’s interests

•Imitation of child and development of routines

•Criteria and mastery of skill before moving to next skill

–“Control” intervention considered “optimal”--6 hours per day, 5 days per week (Standard ABA program)

ASSESSMENTSASSESSMENTS

• Children assessed by Children assessed by independent examiners (pre & post)independent examiners (pre & post)– Joint attention--ESCS– Symbolic play--Structured Play Assessment– Developmental level--Mullens– Language level--Reynell Developmental Language Scales

• 4 year follow up--children on average 8.5 years old4 year follow up--children on average 8.5 years old– Differential Abilities Scale– PPVT– Expressive One-Word Test– ToM, Imitation, ADOS

Frequency of symbolic play types:Mother-child interaction

1

6

11

16

Time 1 Time 2 Time 3 Time 4

Joint AttnSym PlayControl*

Active Tx Follow Up Kasari, Freeman, & Paparella, 2006

Frequency of symbolic play types:Mother-child interaction

1

6

11

16

Time 1 Time 2 Time 3 Time 4

Joint AttnSym PlayControl

*

Active Tx Follow UpKasari, Paparella, Freeman & Jahromi, submitted

6 weeks

12 months

Initiated Joint Attention Skills:Composite ESCS & MCX

2

3

4

5

6

7

8

Time 1 Time 2

Joint AttnSym PlayControl

Active Tx Follow Up

*

Initiates Joint Attention Skills:Composite ESCS & MCX

2

3

4

5

6

7

8

Time 1 Time 2 Time 3 Time 4

Joint AttnSym PlayControl

Active Tx Follow Up

*

Expressive Language:Rate of Change

10

15

20

25

30

35

40

Time 1 Time 2 Time 3 Time 4

Joint AttnSym PlayControl

Active Tx Follow Up

Expressive Language:Rate of Change

15

20

25

30

35

40

Time 1 Time 2 Time 3 Time 4

Joint AttnSym PlayControl

*

*

Active Tx Follow UpKasari, Paparella, Freeman & Jahromi, submitted

4 year follow upChange in IQ

Intervention Group EntryAge 3.5 years

12 monthsAge 5 years

4 yearsAge 8.5 years

Change in IQ

# < 70 IQ

Time1--2--3

Play 59 (18) 69 (22) 76 (28) 15-- 9-- 5

Joint Attention 58 (17) 72 (21) 84 (33) 18--10--3

Control 52 (22) 59 (26) 73 (30) 12--11--8

Entry and 12 months--Mullens; 4 years--Developmental Abilities Scale

Predictors of OutcomePredictors of OutcomeConnie Kasari, Stephanny Freeman & Tanya Paparella (2007)

• Only Only InitiatingInitiating Joint Attention improvementJoint Attention improvement predicts to cognitive and language outcomes at predicts to cognitive and language outcomes at 4 year follow up4 year follow up

• Initiating Joint Attention improvement also Initiating Joint Attention improvement also predicts ADOS improvementpredicts ADOS improvement

Why Initiating Joint AttentionWhy Initiating Joint Attention

• Cardinal Symptom of Autism• Constructivist Development Theory

– Individual difference reflect motivation, self-organizing, information processing

• Interconnectivity Theory– Promoting IJA promotes cortical interconnectivity

which supports symbolic ability and central coherence

Pivotal Skill HypothesisPivotal Skill Hypothesis

• Change in one or two “pivotal” behaviors may Change in one or two “pivotal” behaviors may lead to changes in a broad range of problematic lead to changes in a broad range of problematic behaviors. (Koegel & Frea, 1993)behaviors. (Koegel & Frea, 1993)

• Is joint attention a pivotal skill?Is joint attention a pivotal skill?

• Change in JA as change in motivation to Change in JA as change in motivation to communicate?communicate?

• Is JA as a marker of readiness to learn?Is JA as a marker of readiness to learn?

RJA and Individual Differences in Treatment Response

• Bono, Daley & Sigman (2005)– 29 four-year-old children

• 6-53 hours intervention per weak (24 hours average)

• IJA and RJA predicted 1 year language gain– Intervention intensity did not predict

language gain directly

• Children with higher RJA showed positive effects of intervention intensity

» Joint attention, self -organization and learning

IJA and Intervention Response

• Yoder & Stone (2005, in press)• Randomized Control Trial

– 39 parent child ASD dyads

• Hanen Early Language Parent Program or Picture Exchange Communication System (PECS)

– Hanen parents learn to read and respond to children’s nonverbal communication and focus of visual attention lead.

– PECS parents learn to use pictures to facilitate communication with children.

• More IJA in Hanen than PECS (p < .001) if children displayed baseline evidence of IJA (at least 7 bids across two assessments)

Joint Attention and Pivotal Response Joint Attention and Pivotal Response TrainingTraining

• Christina Whalen (Dissertation 2001 with Christina Whalen (Dissertation 2001 with Schriebman)Schriebman) • Small sample Small sample • Behavior modification approach to RJA and PointingBehavior modification approach to RJA and Pointing• Multiple baselineMultiple baseline

– Positive effects on JAPositive effects on JA

– GeneralizationGeneralization

– Collateral changes in social initiations, positive affect and Collateral changes in social initiations, positive affect and language language

Interventions with RJAInterventions with RJA• Corkum and Moore Corkum and Moore

(1998)(1998)– 60 typical infants60 typical infants– Used operant training to Used operant training to

improve ability of 8 improve ability of 8 months olds to display months olds to display RJARJA

• Lewy & Dawson (1992)Lewy & Dawson (1992)– 20 children with autism vs 20 children with autism vs

DS (20) and non-DD DS (20) and non-DD children (20)children (20)

– Experimental play sessions Experimental play sessions where adult behavior where adult behavior followedfollowed and was and was contingentcontingent on child led to on child led to increase in RJA increase in RJA

RJA Intervention Paradigm

Caregiver-Child Interaction and Caregiver-Child Interaction and Development in AutismDevelopment in Autism

• Siller & Sigman (2002)– 25 children w/autism

– Caregiver behavior similar across groups

– Synchronized/”following” in predicts language gains over 10 to 16 years

• “Following in” with “undemanding vocalizations” best predictor

Relational Development InventoryRelational Development Inventory

• Steven Gutstein Rachelle Sheely– Clinically Developed– Focus on Experience Sharing or Joint Attention– Manual Based

• Detailed Intervention methods

• Detailed Assessment methods

– Parent/Family focus– No published research

Freeze GameFreeze Game

• Teaching Social Orienting/Referencing– Parents try to approach child without response– If they get close enough they take and action (tickle,

hat, lift)– Once child begins to track

• Parents Freeze

• Make face

• Turn activity into a game.

Phases of RDI

• Education• Demonstration

• Coaching• Independence

– Home work

• Generation (Parent)• Co-regulation

– Maintenance and modification by child

RDI Home Intervention

• 15 – 20 hours per week• Low stimulation room with been bag furniture• Reduce Complexity – Increase Predictability• Structured (Parents in Charge Initially)• Use amplified/exaggerated affect

– Nonverbal communication especially faces– Less Language

• Keep it Interesting • Gradual increase of demands on child

RDI Intervention with 34 Children

RDI Non-RDI

Age 60 mos60 mos.. 72 mos.72 mos.

Interval 15 mos.15 mos. 11 mos.11 mos.

Gender 94% boys 75.2 boys

IQ 87.487.4 75.275.2

RDI and Symptom Reduction

0

5

10

15

20

25

RDI-ADOS Con-ADOS

PrePost

Individual Variability and Predictors of Preschool Language Outcomes in

Autism

Sally Rogers, Ph.D.M.I.N.D. Institute, Univ. of California- Davis

Susan Hepburn, Ph.D. University of Colorado Health Sciences Center

Main Questions to be Answered

• Which early characteristics predict language development at age 4?

• Which early characteristics predict severity of autism at age 4?

• What role do environmental variables play in outcomes?

Participant Characteristics T1 Autism

(n = 31;6 girls)

DD

(n=18, 7 girls)

CA (months) 34 (4) 35 (8)

Mental Age 20 (6) 20 (5)

Ratio IQ 59 (20) 59 (10)

Vineland ABC 62 (7) 63(9)

SES 49.2 (12) 55.3 (7.5)

No group differences

Participant Characteristics T2 Autism

(n = 31;6 girls)

DD

(n=18, 7 girls)

CA (months) 57.5 (3.5) 59.3 (7.9)

Mental Age 34.8 (11.8) 33.5 (10.9)

Ratio IQ 61.2 (21.2) 57.5 (19.4)

Vineland ABC 61.2 (14.7) 58.9 (12.7)

No group differences

Neuropsych correlates with T2 ADOS z scores

Variables Children with Autism

Oral Imitation -.20

Affect -.52**

Responds JA

(%)

-.47**

Initiates JA -.53**

Sensory -.12

SummarySummary

• The ability to coordinate attention with other people The ability to coordinate attention with other people (joint attention) is vital to learning(joint attention) is vital to learning

• Measures of joint attention have improved our Measures of joint attention have improved our understand and early diagnosis of autism.understand and early diagnosis of autism.

• Interventions targeting joint attention show promise Interventions targeting joint attention show promise for longer term generalization of effects because for longer term generalization of effects because that teach children an important element of self that teach children an important element of self organization and learningorganization and learning.