Introduction to Autism Spectrum DisordersReview, March 21, 2013

Agenda

1) Review of ASD and intro to communication disorders

2) Mini-lesson by students: Communication Disorders

3) Voicethread exercise (chapter 8)

1 in every 88 children in the U.S. OR11.3 per 1,000 1 in 88 children

See, for example: http://www.cnn.com/2012/03/29/health/autism

1 in every 54 boys is diagnosed with Autism Spectrum Disorder See, for example: http://www.autismspeaks.org/what-autism/facts-about-autism

Prevalence

Centers for Disease Control and Prevention

4 times more likely in boys than in girls1 in 54 boys1 in 252 girls

Occurs in all racial, ethnic, and socioeconomic groups

Autism Spectrum Disorder (ASD)

A complex neurological and developmental disorder that affects the normal functioning of the brain, social development and communication skills.

First signs appear by age 16 months

Children and adults with autism typically show varying degrees of difficulty with verbal and non-verbal communication, social interactions, and leisure or play activities.

(Smith, Polloway, Patton, & Dowdy, 2008)

- Asperger Syndrome

- Autistic disorder or Classic autism

-Rett Syndrome

-Childhood Disintegrative Disorder (CDD)

- Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS) or atypical autism.

Five Disorders (old definition)

Soon, to be, old definition of Autism Spectrum

http://www.nde.state.ne.us/autism/images/image002.jpg

Details of Prior Definitions of ASD on the next 6 slides

DSM IV

Asperger’s Syndromer• Qualitative Impairment in Social Interaction• Restricted Repetitive and Stereotyped patterns of

behavior• Causes clinically significant impairment in social,

occupational, or other important areas of functioning• NO clinically significant delay in language• NO clinically significant delay in cognitive development

or in adaptive behavior• Criteria are not met for another ASD or Schizophrenia

DSM IV

Pervasive Developmental Disorder Not Otherwise Specified

• Severe and pervasive impairment Reciprocal social interaction Impairment in either verbal or nonverbal communication Presence of stereotyped behavior, interests, and activities

• Criteria not met for other ASD, Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder

• Also includes “Atypical Autism”

DSM IV

Rett’s Disorder Onset of the following after the period of normal

development• Deceleration of head growth between 5 and 48 months• Loss of previously acquired purposeful hand skills

between 5 and 30 months• Loss of social engagement• Appearance of poorly coordinated gait or trunk

movements• Severe impairment of expressive and receptive

communication

Rett’s Disorder

Often misdiagnosed as autism or cerebral palsy or non-specific developmental delay

Occurs worldwide 1 of every 10,000 female births Caused by mutation on the X chromosome• Gene called MECP2• Blood test AND clinical evaluation are necessary for a

diagnosis

DSM IV

Childhood Disintegrative Disorder• Normal development for at least the first 2 years of life• Clinically significant loss of previously acquired skills

(before age 10) in at least two areas Expressive & receptive language Social skills and adaptive behavior Bowel or bladder control Play Motor skills

• Abnormalities in social interactions, communication, and stereotyped behaviors

DSM IV

Autistic Disorder• Qualitative Impairment in Social Interaction • Qualitative Impairments in Communication• Restricted Repetitive and Stereotyped patterns of

behavior, interests, and activities• Onset prior to age 3• The disturbance is not better accounted for by Rett’s

Disorder or Childhood Disintegrative Disorder

Recap of Old definition•Autistic Disorder•Asperger’s Disorder•Pervasive Developmental Disorder Not Otherwise Specified•Rett’s Disorder•Childhood Disintegrative Disorder

History: Schizophrenia & Autism

Dr. Eugene Bleuler Used term autistic in

1912 Referencing

schizophrenic patients

History

Autism• Greek for “autos”

meaning “self” Swiss Psychiatrist was

first to use the term to describe certain symptoms of schizophrenia

Leo Kanner• Child psychiatrist• John Hopkins

University

History: Leo Kanner

1943• “Autistic disturbances of affective contact” • Used to describe a group of 11 children• Provided a very detailed description of the 11 children

History: First Description of Autism

Kanner described children…• Having “extreme autistic aloneness” • Delay or failure to acquire speech• Repetitive play activities• Compulsive demand for the maintenance of sameness• Good memory for rote material• Lack of imagination

History: 1944 in Vienna

Hans Asperger • Austrian psychiatrist and pediatrician• Director of the University Children’s Clinic in Vienna• Published a paper in 1944 describing “autistic

psychopathy in childhood” Described the children…• Intelligence appeared normal• Lacked nonverbal communication• Clumsy• Called them “little professors”

The Formal Diagnosis of Autism in years past

New definition of Autism Spectrum Disorder

See: http://www.scientificamerican.com/article.cfm?id=autism-new-criteria

http://www.scientificamerican.com/article.cfm?id=autism-math-problem http://www.dnalc.org/view/876-Autism-Boundaries.html

DSM-V New Definition will define severity of 3 elements and identify levels of severity….

Severity Rating for Social Communication and Restricted Interests & Repetitive Behaviors • Level 1 – requires support

w/out support there are noticeable impairments & significant interference in functioning

• Level 2 – requires substantial support Marked deficits & RRB interfere with functioning in variety of

areas

• Level 3 – requires very substantial support Severe deficits and marked distress

DSM V

New Definition Scheduled to be published in May 2013• Change in diagnosis to Autism Spectrum Disorder• No longer discriminate between Asperger’s disorder,

autistic disorder, pervasive developmental disorder not otherwise specified, and childhood disintegrative disorder

At this point, Rett’s Disorder will not be included in the DSM-V

Commorbidity

The word above means that other conditions appear with autism

MR or Intellectual Disability

The CDC in 2009 reported 30-51% (average -41%) of children with an ASD also had an intellectual disability

IQ of 70 or below Impairments in adaptive functioning in two key

areas such as communication, self-care, social skills, etc.

Mild, Moderate, Severe, Profound

New Definition of Autism

Two key categories:• Impaired social interaction and communication

— Includes: delayed language development, avoiding

eye-contact and difficulty making friends—as well as restricted and repetitive behavior, such as repeatedly making the same sound or intense fascination with a particular toy.

Autism symptoms: http://www.dnalc.org/view/1267-Do-Autism-Symptoms-Cluster-Together-.html

http://www.dnalc.org/view/1267-Do-Autism-Symptoms-Cluster-Together-.html

Autism Consortium in Boston

What is autism? http://www.autismconsortium.org/families/understanding-autism-and-treatments/

Common Comorbid Conditions

Seizures • Estimated 11-39% of individuals with an ASD develop a

seizure disorder

Anxiety Depression ADHD****

Causes

(ABC News Photo Illustration)

Current Risk Factors

Section 2: Environmental Factors

                                                                                                

Section 2: Genetics, Family & Social History

                                                                                                

Section 2: Other Medical Conditions Associated With Autism

                                                                                                

National Institute of Health, 2005

Possible Genetic Link

Emerging research by consortium of scientists in Boston on Chromosome deletion or multiplication around Chromosome 16 (or de Novo) not directly inherited from either parent– opens up the possibility of determining risk of recurrence

Potential Causes under investigation

Inherited genetic conditions other medical problems Environmental factors

Behavioral Issues

Approximately 40% of children with an ASD do not speak. Another 25-30% have some words but lose them

Sleep Issues• Difficulty falling asleep• Early waking

Activity Level• Often diagnosed with ADHD

Behavioral Issues

Self-injurious Behavior Aggressive Behavior Food Selectivity Rigidity Gastrointestinal issue Difficulty Toilet Training Tantrum Behavior

Theories Impacting Development & Treatment of Autism

Psychoanalysis

Freud• Theory of development

Focus on early experiences

• Intrapsychic world • Drives and conflicts

Object Relations

Melanie Klein, Harry Stack Sullivan, Erich Fromm, etc.

Focus on interpersonal encounters External relationships become part of “we”• Internal objects

Distortions in the internalized self-structure may lead to problems later in life

Margaret Mahler

Pediatrician Worked with children with psychosis and autism Focused on importance of bonding and

interruptions in mother/child relationship Separation and differentiation theory

Bruno Bettleheim

The Empty Fortress: Infantile Autism and the Birth of Self (1967)

Cold and indifferent mothers results in autism • Kanner > “lack of maternal warmth”

University of Chicago Orthogenic School

Cognitive Psychology: Mirror Neurons

Mirror Neuron System (MNS)• Regions of the brain that respond to actions of self and

others

Primary function • Related to action interpretation

Cognitive Psychology: Mirror Neurons

Implicated in other social-cognitive processes• Imitation• Theory of mind

http://www.theglobeandmail.com/news/toronto/kindergarten/video-the-theory-of-mind-test/article605414/

• Language • Empathy

Lead to development of an unified neurocognitive theory of autism Broken Mirror Model http://www.pbs.org/wgbh/nova/body/mirror-

neurons.html

Cognitive Psychology: Mirror Neurons

http://www.youtube.com/watch?v=A0oCB5aTaBo

Cognitive Psychology: Mentalizing

http://www.youtube.com/watch?v=6bsvm7q3lWo

Biology

http://autismconsortium.org/research-symposium/2012-research-symposium/

Cognitive Psychology: Mentalizing

http://www.youtube.com/watch?v=6bsvm7q3lWo

Biology

http://autismconsortium.org/research-symposium/2012-research-symposium/

Behavioral Perspective

Behavior is determined ALL behavior is a result of • Current environment• Learning history • Physiological make up

Acknowledgement of “within the skin” events such as emotions • Not measurable

Behaviorally Oriented Clinicians

Focus on overt behavior Measurable goals/objectives Do not attribute behavior to “thoughts” but look for

function/purpose Make use of operant and respondent conditioning

Current status of genetic studies

Higher rates of autism • Monozygotic twins

If one has an ASD, the other will be affected 60-90% of the time

• Dizygotic twins If one has an ASD, the other will be affected 0-24% of the

time.

• One child in the family with an ASD results in a 2-8% chance of having a second child also affected

CDC

Genetics & Neurology

Estimated that 10% of children with an ASD have an identifiable genetic, neurologic or metabolic disorder such as Fragile X or Down Syndrome

Other Conditions

Fragile X• Approximately 2-6% of children with autism are

diagnostied with Fragile X• Genetic condition involving changes in part of the X

chromosome• A change in a gene called FMR1• Males and females can be affected

Other Conditions

Tuberous Sclerosis• Genetic disorder causing tumors to form in many

different organs including the brain, eyes, heart, kidney, skin, and lungs

• Approximately 1 in 6,000 births

Some Possible Red Flags for Autism

Delayed language development Tends not to follow direction (Child may even appear

deaf at times) Have violent tantrums Display odd movement patterns May not know how to play with toys May be overactive, uncooperative or resistant May not make eye contact or return a smile May prefer to play alone

Questions about Cause?

Breastfeeding And Risk Of Autism? Does Smoking Up Autism Risk In My Child? Household Items And Autism Risk? Can Lead Paint Increase Risk Of Autism? Could A Mother's Cold Up Autism Risk? Alcohol, Marijuana And Autism Risk? Do Vaccinations Cause Autism? … There are too many cases

with too many differences; not enough is know to draw any concrete conclusions about causes or therefore, cures.

Treatments for Children with ASD

No approved medications Behavior management therapy: Applied Behavior

Analysis). Different applications of ABA include• Positive Behavioral Intervention and Support

Plans• Pivotal Response Training• Incidental Teaching• Milieu Training• Verbal Behavior• Discrete Trial Training

Treatments

Evidence-based

Applied Behavior Analysis (ABA)

Early Intervention

Other treatments include…

Speech and language therapy Occupational therapy Physical therapy

Treatments

Aim to slow the loss of abilities, improve or preserve movement, and encourage communication and social contact.

Physical therapy to help patients improve or maintain mobility and balance and reduce misshapen back and limbs

Occupational therapy to help patients improve or maintain use of their hands and reduce stereotypic hand movements.

Speech-language therapy to help patients use non-verbal ways of communication and improve social interaction

Medication (such as for constipation or heart problems)

Surgery (to correct spine curvature or correct heart defects

Pervasive Developmental Disorders NOS

"Atypical Autism" for cases that meet some, but not all of the criteria for autism

Intellectual impairments Sensory Integration Disorder

http://abcnews.go.com/Health/AutismOverview/story?id=5387956

Childhood Disintegrative Disorder

Childhood disintegrative disorder- typical development until about three to four years or in some cases, older.

After that time, the child suffers a loss of many developmental skills that were previously acquired. Example: language, social skills, play, self-care, toileting and motor skills.

(Loveland, 2008)

Communicative Disorders

A preview

Communication

An active process by which individuals exchange information and communicate ideas (Owens, 1990)• Requires receiver who decodes, or comprehend the

message• Other aspects of communication that can enhance (or

distort) the linguistic code Paralinguistic cues, such as intonation patterns,

stress and speech rate – can signal attitude and emotions of the speaker

Non-linguistic cues: body movements, eye contact

Speech

One of the modes of communication• Oral, verbal• Involves precise coordination of

neuromuscular movements in order to produce sounds and linguistic units

Other modes of communication besides speech• Writing, drawing, manual signing,

augmentative communication systems

Language

Socially shared code, or conventional system, that represents ideas through the use of arbitrary symbols and rules that govern combinations of these symbols• Language exists because users agree on the

symbols and rules.• An individual’s implicit knowledge of the symbols

and rules is called linguistic competence• Oral language is the first language (foundation)

from which reading and writing develops

Forms of Language

Form• Phonology• Morphology• Syntax

Content Use

Connection between Spoken and Written Language

Receptive and expressive language

Spoken language is the foundation for the development of reading and writing.

Spoken language and written language have a reciprocal relationship, building on one another for the development of language competence.

Language in the Classroom

Receptive Language -Understanding Spoken LanguageIn the classroom: The ability to listening to a story & understand: the content, new vocabulary words, information that is implied, a problem, and a question asked about the story.

Expressive Language -Using Spoken LanguageIn the classroom: The ability to retell a story & use: age level words, grammar and sentence types and story line construction.

Social Language In the classroom: The ability to use and understand language in social situations such as taking turns, introducing a conversation topic, and classroom talk vs. home talk

Identifying Language Disorders in the Classroom

Recommend specialized services if…• Discrepancy between the child’s language age and

his/her mental age (Nelson, Silbar & Lockwood, 1981)• When scores on comparable tests (on two different

samples, and different times) differ• Recommendations.

Offer services during the lesson so that all children may benefit (Calculator & Jorgenson, 1991).

Encourage collaboration between SLP and classroom teacher. Conduct comprehensive interdisciplinary assessments.

Children with ASD and Language

Most individuals with ASD to learn appropriate social use of communication

The role of the SLP a. Screenings and/ or Assist with the diagnosisb. Provide language therapyc. Consult with Educators and caregiversd. Maximize opportunities for interaction to overcome barriers that lead to decreased educational opportunities and social isolation.

Writing Response: Select, read, and explain key ideas or issues from one of the articles on the front page of the link below:

At this link you will find instructions and the Autism Speaks website: http://hdp290.blogspot.com/

Discussion of Chapter 8: Communication Disorders

Kindly click on this link to complete the voicethread discussion. You must audio or videotape your response:

http://voicethread.com/share/4328776/

Key Resource

Ohio Center for Autism and Low Incidence:

http://www.ocali.org/

Contact: fcrawford@wheelock.edu