panel: assessment and intervention for individuals with

Autism Diagnostic Center

Department of Communication Disorders

Department of Counseling and Educational Psychology

Joan Esse Wilson, PhD, CCC-SLP; Heike Lehnert-LeHouillier, PhD, CCC-SLP; Lisa Peterson, PhD, NCSP; MacKenzie Sidwell, PhD, NCSP;

Victoria Alamaguer, MA, CCC-SLP; Kali Hall, MA, LCSW

ASD Diagnosis GENERAL CONSIDERATIONS AND USE

OF TELEHEALTH MODELSVictoria Almaguer, M.A. CCC-SLP,

Heike Lehnert-LeHouillier, Ph.D. CCC-SLP

Autism Diagnostic Center Department of Communication Disorders

Medical versus Educational Diagnosis

A. Persistent deficits in social communication and social interaction (social-emotional reciprocity, nonverbal communication, relationship building and maintenance)

B. Restricted, repetitive patterns of behavior, interest, or activities (repetitive motor movements, inflexible routines, restricted interests, sensory deficits)

Severity is based on social communication impairments and restricted, repetitive behaviors.

DSM-V Diagnostic Criteria

Medical and/or Educational Diagnosis

Medical or Educational Diagnosis Why does it matter?

Recognized by insurancesAllows families to obtain services (ABA, SLP, OT, etc.) covered by insurancesUses DSM-V as diagnostic criteriaDoes not automatically qualify child for educational support services (Special Education, SLP, OT, etc.)

Recognized by the school districtsQualifies child for educational support services (Special Education, SLP, OT, Counseling, etc.)Educational impact must be present for educational diagnosisDoes not qualify families to obtain services covered by insurances (ABA, SLP, OT, etc.)

While an interdisciplinary assessment team is best practice (Gerdts et al., 2018), insurances will accept an ASD diagnosis made by a licensed psychologist, board certified child/adolescent psychiatrist, or pediatrician with expertise in ASD (Stage 1 ABA provider).

However, interdisciplinary or multidisciplinary assessment teams are best suited to develop a comprehensive treatment plan.

Diagnostic Team - Who can diagnose ASD?

PsychologistChild/Adolescent PsychiatristDevelopmental PediatricianSpeech-Language PathologistOccupational TherapistSocial WorkerNeurologist

Diagnostic Team - medical

School PsychologistDiagnosticianSpeech-Language PathologistGeneral Education TeachersSpecial Education Teacher / Case ManagerParents/Caregivers

Diagnostic Team -educational

Diagnosing ASD Using a Telehealth

Model

Telehealth options have been more widely used during pandemic, but would also be beneficial for many families living far away from providers offering ASD assessments.

Is telehealth a good option for ASD assessment that should be used in the future?

Is telehealth a good option for ASD diagnostic services?

Research suggests (Mathews et al., 2021):

A diagnostic determination can be made for a high percentage of clients see (90%).A majority of parents find the telehealth model acceptable (60%) parents of girls found telehealth assessment more acceptable than parents of boys.Diagnosing psychologists found telehealth acceptable in general, but felt it was easier to use telehealth assessments with younger children.

Telehealth for ASD Assessment

The take-home message seems to be (so far):

Yes, telehealth is a good option for most clients.

Younger children seem to be better candidates for telehealth ASD assessment, but older children can also be assessed via telehealth

Telehealth for ASD Assessment

Some Considerations for SLPs on the ASD

Diagnostic Team

Comprehensive language skillsAge-appropriate pragmatic skills

Communicating to establish social relationshipsRelationship buildingReciprocal communicationCommunicating within a social context

Other:Echolalia, odd prosody

What to look for?

Most recent evaluationTreatment plan (IEP, IFSP, etc.)Autism Screening

Modified Checklist for Autism in Toddlers, Revised with Follow-Up; M-CHAT-R/FSocial Communication Questionnaire; SCQ

What to include in a referral?

Comprehensive language evaluationPLS, CELF, TOLD, etc.

Social CommunicationRosetti Infant-Toddler Language ScalePragmatic Language Observation Scale (PLOS)Communication and Symbolic Behavior Scales (CSBS)

-2)General Communication Composite ScoreSocial Interaction Deviance Composite

What assessments to use?

Contact Information

Victoria Almaguer, MA, CCC-SLPCollege of Health, Education and Social Transformation

Autism Diagnostic Center

cd.nmsu.edu/autism/autism-diagnostic-center

(575) 646-3177

[email protected]

Contact Information

Heike Lehnert-LeHouillier, Ph.D., CCC-SLPCollege of Health, Education, and Social TransformationAutism diagnostic Center/Communication [email protected]

Assessment of Autism Continued

BEHAVIORAL FEATURES AND DIAGNOSTIC CONSIDERATIONS

Lisa Peterson, Ph.D., NCSP, LP & MacKenzie Sidwell, Ph.D., NCSP

DSM-5Diagnostic Criteria

AUTISM SPECTRUM DISORDERS

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

2. 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).

Domain B: Restricted, repetitive patterns of behavior, interests, or activities, as manifested at least two of the following, currently or by history:

3. 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).

4. 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).

Domain B: Restricted, repetitive patterns of behavior, interests, or activities, as manifested at least two of the following, currently or by history:

ASD Criteria ContinuedSpecify current severity: requiring very substantial support, requiring substantial support, requiring support

Severity is based on social communication impairments and restricted, repetitive patterns of behavior

ASD Criteria ContinuedC. Symptoms must be present in the early developmental

period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder (or global developmental delay). Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

ASD Criteria Continued

Specify if:With or without accompanying intellectual impairmentWith or without accompanying language impairmentAssociated with a known medical or genetic condition or environmental factorAssociated with another neurodevelopmental, mental or behavioral disorderWith catatonia

Assessment of Autism Spectrum Disorders

Comprehensive Assessment of Autism

Benefits of interdisciplinary assessmentAll assessment should be multi-faceted Types of assessment:

Records reviewObservations across multiple settingsInterviews with teacher and parent

traditional measures with nonverbal measures OR measures

Adaptive Functioning: assessment of daily living/communication/self help skillsAcademic Abilities: required in schools to determine the educational impact and need for special education services

Comprehensive Assessment of Autism

Social/Emotional/Behavioral AssessmentRating scales: Broad to narrow band measures

Broad: Behavior Assessment System for Children, Third Edition (BASC-3), Child Behavior Checklist (CBCL), Conners Comprehensive Behavioral Ratings Scales (CBRS)Narrow: Autism Spectrum Rating Scales (ASRS), Social Responsiveness Scale, Second Edition (SRS-2)

Direct AssessmentAutism Diagnostic Observation Schedule, second Edition (ADOS-2)Monteiro Interview Guidelines for Diagnosing the Autism Spectrum, Second Edition (MIGDAS-2)

Interviews: Autism Diagnostic Interview, Revised (ADI-R)Functional Behavioral Assessment (FBA)

Other areas (depending on referral concern/differential diagnosis)

ASD Diagnostic Considerations:Gender-Related Factors

4:1 male: femaleAutism masking

What behaviors might be used to survive social situations?Why would someone mask their autism?

ASD Diagnostic Considerations: Cultural Factors

Use of eye contactSocial skill developmentVariations in playExposure to school and other structured environments

ASD Diagnostic Considerations: Differential Diagnosis

Intellectual disabilityAttention-deficit/hyperactivity disorder (ADHD) Rett syndrome Selective mutism Language disorders Stereotypic movement disorder Schizophrenia

ASD Diagnostic Considerations: Comorbidities

Intellectual disabilityADHDSpecific learning disabilityGeneralized anxiety disorder

ASD Assessment Considerations:Impact of COVID-19

Access to education/social environmentsSkill development in structured settings (school, day care)Peer interaction in unstructured settings (play with friends and relatives)

Impact on mental healthLack of routinesReduced social interactions and time spent in uncomfortable or unpleasant situations

Contact Information

Lisa S. Peterson, [email protected]

MacKenzie Sidwell, [email protected]

Social Communication Interventions for

Individuals with ASDEVIDENCE-BASED PRACTICES AND

RESOURCESJoan Esse Wilson, Ph.D., CCC-SLP

Autism Diagnostic Center Department of Communication Disorders

What is Considered Evidence-Based?

Three components are necessary for EBP:

1. Client Perspective What are the opinions of the client, family, or caregiver? Does intervention fit with their culture? Does intervention address something that is important to them?

2. Clinical Expertise Our theoretical knowledge, clinical training, and expertise

3. Scientific Evidence Peer-reviewed research, ASHA evidence-maps

Evidence-Based Practice (EBP) Evidence-Based Practice (EBP)

ASHA Evidence maps an overviewhttps://www.youtube.com/watch?v=MaWbhOukyGY

Evidence Maps Series Episode 1: What You Find in the Evidence Mapshttps://www.youtube.com/watch?v=NYMlr98CJZ8

Evidence Maps Series Episode 2: Searching the Evidence Mapshttps://www.youtube.com/watch?v=CGEnCjkcttM

Institute of Education Sciences U.S. Department of Education What Works Clearinghousehttps://ies.ed.gov/ncee/wwc/

RESOURCES

Interventions

Overview -> Specific Interventions with Resources

Infants/Toddlers

Majority of Interventions are Parent Implemented

Things learned at home with objects in the houseLearning through everyday routines with the people who care for them

Infants/Toddlers

Naturalistic Techniques

This type of intervention looks more like everyday play with children, not like clinician-directed therapy

and goals there is where the professional comes in for providing intervention

Infants/ToddlersCommunication that enhances development should be enriching and responsive:

EnrichingUtilize visual, auditory, tactile, and novel features

With a Focus on RespondingMake responses contingent on what the baby is doing.

attention or interaction Reinforce with family that responding to these signals is correct Being consistently responsive is key

Infants/Toddlers

Provide instructions and modeling of adult-infant communication

Pick up baby and talk using infant-directed -

make eye contact, talk, sing, show them thingsLet parents/caregivers know to continue even

Help parents/caregivers develop self-monitoring skills so that they can modify their own performance

Infants/Toddlers

Remind parents that the child cannot choose how they interact they are not choosing to be difficult or to reject the parentTell parents the most important thing they can do

Anything they both enjoy is an ideal interactive context. This is also true with sibling interactions with the baby.

Infants/Toddlers

SLPs model interactive behaviors for parents/caregivers:

Turn Taking taking turns talking, handing a ball back and forth with siblings, playing games with turnsImitation adult imitates the babyDeveloping Interactive, Anticipatory Games peek-a-boo, jack-in-the-boxEstablishing Joint Attention coordinating attention for purpose of sharing

Infants/ToddlersJASPER (for ages 1-8 years)

Joint Attention: The coordination of attention between objects and people for the purpose of sharing;

the child looks

Symbolic Play: The modeling of appropriate, flexible, and diverse types of play and play routines

Example: Using a cardboard box as a car, spaceship, etc.

Engagement: The expression of interest and undivided attention.

Regulation: Referring to the regulation of emotion and behavior that may be inhibiting social growth.

Infants/Toddlers

http://www.kasarilab.org/treatments/jasper/

JASPER has been found to be equally effective across low-and high-resource communities, as well as when through telehealth or in-person (Kasari, Lawton, Shih, Barker, Landa, Lord, et al. 2014; Shire, Worthman, Shih & Kasari, 2020)

JASPER video Connie Kasari, Ph.D.RESOURCE

Infants/Toddlers

https://www.youtube.com/watch?v=5m_cJQQVieU

Early Start Denver Model (ESDM) (for ages 1-4 years)

Goals are for developmental change, adaptive behavior, and language.

A low-cost intervention with options for lower hours of intervention, parent-implemented, hybrid clinic and home visit etc.

1. Therapist and parent training2. Several focused therapies in one program

Sally Rogers, Ph.D., on ESDMRESOURCE

School-Aged /Young Adults

We move from Parent Implemented Intervention to Mediated Interventions (Laugeson, Ellingsen, Sanderson, Tucci, & Bates, 2014)

Mediated interventions occur when either a peer, parent/caregiver or teacher interacts with or supports an individual with ASD to acquire new skills and learning (Wong et al., 2015)

(Bellini & Akullian, 2013; Laugeson & Ellingsen, 2014; Reichow & Volkmar, 2010)

Mediated Interventions

Often implemented during social skills groupsMediators are trained to assist with interventions and may utilize:

Visual or verbal promptingPositive reinforcementDeveloping scripts and social storiesRole playingVideo models


The UCLA Program for the Education and Enrichment of Relational Skills (PEERS®)

Focus is on developing social skillsPreschool young adultsIncludes topics such as careers, dating, bullying, and having conversations


https://www.semel.ucla.edu/peersRESOURCE

Link to the PEERS website:

The UCLA Program for the Education and Enrichment of Relational Skills (PEERS®)


Most social skills trainings are based on what people think others should do sociallyInstead, PEERS® focuses on teaching Ecologically Valid Social Skills which are what socially successful people are actually doing

Scripting and Video Modeling:


Scripting allows us to practice for specific social situations

Allows us to provide a visual model of a targeted behavior or skill

Example video model from The Science of Making Friends (Laugeson, 2013):

(Reichow & Volkmar, 2010)

Social Stories:


Explain difficult social situations and concepts in simple words with practical, tangible social information

Not intended to be a tool for behavior change, but to improve in targeted behaviors and social functioning

(Gray, 2015; Karal & Wolfe, 2018)

https://carolgraysocialstories.com/

Note: she includes several Covid social stories.RESOURCE

Narrative Story Telling


(Westby & Culatta, 2016)

thoughts and emotions about experienced events

Individuals with ASD frequently display difficulty producing narratives when compared to neurotypical individuals

Narrative Story Telling



Arranging for interesting things for the child to tell (e.g., field trip, activities)

Model telling your own interesting story and asking child to talk about something similar that happened to them

Narrative Story TellingSchool-Aged /Young Adults


Encourage Reminiscing

This should not be a question-asking and question-answering task, however, but rather a collaboration in rememberingReminisce about therapy activities you did together session-to-sessionUse photos or videos to help with reminiscingCRITICAL: Include discussion of / connection to emotions and core memories

https://www.youtube.com/watch?v=5n9vlBtbji8&t=33s

Pivotal Response Treatment (ages 2 and up)

1. Naturalistic Developmental Behavioral Intervention 2. Family Involvement3. Play-Based4. Coordination Across All Environments5. Treatment of Pivotal Areas, Including Social Communication

Goals

Lynn Koegel, Ph.D., CCC-SLP on PRT:

RESOURCE


Social Skills Study:Individuals with ASD or with high ASD traitsAges 15-30 yearsParticipants receive $200-$300 for their time

SLPs or Graduate Student Clinicians:$30 Amazon gift card for eachteletherapy session uploaded

Recruiting for Research Studies

Contact InformationJoan Esse Wilson, Ph.D., CCC-SLPCollege of Health, Education, and Social TransformationAutism Diagnostic Center / Department of Communication [email protected]

Behavioral Supports for Autistic

Individuals & Families

KALI HALL, M.A., LCSW & MACKENZIESIDWELL, PH.D., NCSP

Applied Behavioral Analysis (ABA) is based in Behavioral Learning Theory

Environmental ResponseReinforcement increases the likelihood a behavior will be repeated.

It can be positive (++) or negative (--). Punishment decreased the likelihood a behavior will be repeated.

It can be positive (+-) or negative (-+) To build skills use Reinforcers, not Punisher.

Overview of Behavioral Learning Theory

Access to attentionAccess to tangibles (edibles, & activities)Escape/avoidance from demandsSensory stimulation

Functions of Behavior

A Antecedent B Behavior C Consequence

*Their current behavior is the most efficient way for the environment to produce the desired function. The goal is not eliminating undesired behavior. Always work toward replacing the undesired behavior with an appropriate replacement skill.

Ask yourself:How much does the behavior interfere with their daily living?

them to better access education, meaningful relationships, etc. What behavior does the family prioritize?

Identifying Target Behaviors

Interventions that Address Core SymptomsSocial communication, imitation, play, etc.Examples:

Joint Attention Symbolic Play (JASPER; Kasari, et al., 2014)Early Start Denver Model (ESDM; Dawson, et al., 2010)

Interventions that Address Maladaptive BehaviorDisruptive behavior, feeding, toileting, sleeping, etc.Examples:

The Incredible Years Autism Spectrum & Language Delays (Webster-Stratton)Research Units in Behavioral Intervention (RUBI) Autism Network Parent Training for Disruptive Behavior (Bearss et al.)

Referral Supports

Bearss, et al (2015)

Mental Health Considerations

70-85% of youth on the autism spectrum have a co-occurring mental health diagnosis.40%+ of those are anxiety related.ADHD is the next highest overlap.Co-occurring diagnosis can also be depression, OCD, mood disorders, and rarely psychotic disorders.

Mental Health ConsiderationsAnxiety and Covid-19.

CBT and Medication Management

Encourage families to add a mental health professional/medication prescriber to their care team if needed.

Mental Health Considerations

ResourcesIris Center https://iris.peabody.vanderbilt.eduIntervention Central https://www.interventioncentral.org/behavioral-intervention-modificationAssociation for Science in Autism Treatment https://asatonline.org/for-educators/Colleagues!

Child Focused Behavioral Supports Supports for adults

working with high behavior children.UNDERSTANDING STAGES OF ESCALATION

AND STRATEGIES FOR DE-ESCALATION

Heart Space Unusual Behavior?

Interfering Behavior?

Dysregulation?

Crisis Situation?

Crisis Interventions for Professionals

Dysregulation does not get them out of treatment.

Follow through with the original demand that was asked of them before they dysregulated.

Modify the demand if necessary.

Returning to treatment

References

JASPER; Kasari, et al., 2014ESDM; Dawson, et al., 2010https://qbs.com/safety-care/Parent Training for Disruptive Behavior. The RUBI Autism Network, Bearss, et, all 2015An update on anxiety in youth with autism spectrum disorder, Vasa and Mazurek, 2015

Contact Information

Kali Hall, LCSW & MacKenzie Sidwell, Ph.D.Health Education and Social TransformationCommunication [email protected]

Case Studies for Discussion

Case Study #1

Amber is 5 years old and in kindergarten. She is very interested in PAW Patrol and will talk about the show and movie constantly. She shows interest in her peers but tends to play alongside them instead of with them. She has trouble expressing her needs to her teacher and seems to be falling behind. Her parents are interested in an autism evaluation.

evaluation consist of?What would the behavior and social/emotional component of her evaluation consist of?What else would you consider when evaluating her?

Case Study #2

Riley is a 3 year old who has been referred to your clinic due to a speech delay. He has other behaviors of note, including difficulty adjusting to changes in his routine and a perceived disinterest in playing with the children at his daycare. During the first year of the pandemic his mother, who is a nurse, kept them at home, and he had limited opportunities to interact with others outside of his immediate family.

behavioral concerns?What interventions would you recommend to his mother and daycare providers?

Case Study #3

Gabriela, age 9, has returned to school this year after spending the end of 2nd grade and all of 3rd grade in a virtual learning environment. Her inability to connect with her peers has always been present; she will attempt to join a social group during recess and free time, but when given the choice will sit on her own and draw. She does not seem to

she takes something too literally. Her second grade teacher noticed these problems, but felt that overall she was

How might Gabriela have fallen under the radar when she was younger?What assessments might she need? How would you decide if and when to evaluate her?What interventions might be helpful for her?

panel: assessment and intervention for individuals with

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