+High Incidence Condition Presentation:

Autism Spectrum Disorders

Training School Psychologists to be Experts in Evidence Based Practices for Tertiary Students with Serious Emotional Disturbance/Behavior Disorders

US Office of Education 84.325K

H325K080308

Presented by Benjamin J. Springer

University of Utah

April 08, 2009

+Autism Spectrum Disorders Diagnostic Criteria

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)

299.00 Autistic Disorder falls under the category of Pervasive Developmental Disorders.

Diagnostic criteria are met for this disorder when a total of six (or more) items from:

(1) Qualitative Impairment in Social Interaction,

(2) Qualitative Impairments in Communication,

(3) Restricted Repetitive and Stereotyped Patterns of Behavior

The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder

+Autism Spectrum Disorders Diagnostic Criteria (cont’d)

DSM-IV-TR 299.80 Asperger’s Disorder Qualitative impairment in social interaction. Restricted repetitive and stereotyped patterns of

behavior. The disturbance causes clinically significant impairment

in social, occupational, or other important areas of functioning.

There is no clinically significant delay in language. There is no significant delay in cognitive development. Criteria are not met for another specific Pervasive

Developmental Disorder or Schizophrenia.

+Asperger’s & High Functioning Autism: Is there a difference?

Miller & Ozonoff, (1997) found that the four cases Hans Asperger originally described would be diagnosed, according to DSM criteria, as having autism, not Asperger’s syndrome.

Research suggests that the use of early language delay as a differential criterion between autism and Asperger’s is insufficient, (Eisenmajer, Prior, Leekam, Wing, Ong, Gould, and Welham, 1998).

Any differences in language ability that are apparent in the pre-school years between children with autism and Asperger’s has largely disappeared by early adolescence, (Eisenmajer, Prior, Leekam, Wing, Ong, Gould, and Welham, 1998; Ozonoff, South and Miller, 2000).

Some general agreement exiists that children with Asperger’s syndrome do not show conspicuous cognitive delays in early childhood, (Howlin and Asgharian, 1999).

+Autism Spectrum DisordersSpecial Education Eligibility

The Individuals with Disabilities Education Improvement Act of 2004, (IDEA-04) Regulatory Definitions of Disability Classifcations: 34 C. F. R. § 300.7(c)(2004).

Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child’s educational performance.

A child who manifests the characteristics of “autism” after age 3 could be diagnosed as having “autism” if the criteria stated above are satisfied.

An IDEA evaluation must use a variety of technically sound tools and strategies that assess the relative contribution of cognitive, behavioral, physical, and developmental factors.

No single measure is sufficient. The data generated must include relevant functional,

academic, and developmental information, including information provided by the parent.

+The History of Autism, in brief: Scattered reports of children who apparently had some type

of ASD in the 19th century (Maudsley, 1867)

“Wild Boy of Aveyron”, a feral child discovered by a young physician named Jean-Marc-Gaspard Itard (Itard, 1801/1962; Shattuck, 1994).

Formally identified by psychiatrist Leo Kanner in 1943, called it “early infantile autism.”

Asperger’s Syndrome named after the Austrian pediatrician Hans Asperger (1944). He called his patients, “little professors.”

In 1967, Bruno Bettleheim theorized that autism resulted from “a child’s defensive withdrawal from an intellectual, cold-hearted, and hostile parent.”

Zero support for Bettleheim’s theory (Rutter, 1999).

+Autism Now: Prevalence

There is not a full population count of all individuals with an ASD in the United States, however:

The Center for Disease Control and Prevention (CDC) and the Department of Health and Human Services provide data indicating approximately 1 in 150 children with an ASD in the U.S.

1 in 500 for autistic disorder (Baird et al. 2001; Bertrand et al. 2001; Chakbrabarti & Fombonne, 2001).

(Utah Autism Developmental Disabilities Monitoring (ADDM) Network Project in 2002 reported a total prevalence of ASDs as 7.5 per 1,000 children)

+Syndromal vs. Idiopathic Autism

Autism co-occurs with several syndromes at a high rate, thus the syndromes are considered “causally” related to autism:

Chromosomal Disorders, e.g., Fragile X, 15q duplication, Rett disorder, del22q11, Ring 20

Tuberous sclerosis; cytomegalovirus; in-utero thalidomide or valproic acid exposure; inherited metabolic disorders, and others.

When no such syndrome is present, the autism is considered idiopathic.

+Current Genetic Studies

Search for possible genetic markers Language impairments Psychiatric Comorbidity Broader Autism Phenotype (Sub-clinical ASD

characteristics that may run in families).

Utah Autism Research Program Hillary Coon, Ph. D., William McMahon, M.D., and Mark

Leppert, Ph. D. Utilizes Utah’s genealogy resources to create extended

pedigrees.

+Brain Studies

No clear pathology at a gross level

A possible pattern: Rapid early head growth, with abnormally slowed growth later on (Courchesne, 2001, 2003).

Location of more subtle pathology may be important Temporal lobe, limbic system (tubers or other neuron

abnormalities in these regions associated with autism, in other regions not associated, (Weidenheim et al., 2001; Bolton et al., 2002).

+Psychiatric Comorbidity

Core ASD symptoms may be exacerbated by comorbid disorders.

ADHD, Affective Disorders, are the most common.

Ghaziuddin et al., 1998 found that 23 of 35 individuals with ASD (65%) had symptoms of another psychiatric disorder.

Adolescents with mild ASD are particularly at-risk for anxiety and /or depression.

+Evidence Based Assessment

“Gold Standard” Measures Autism Diagnostic Interview-Revised, (ADI-R),

Western Psychological Services: Provides standardized developmental history.

-Excellent Diagnostic Validity Autism Diagnostic Observation Schedule (ADOS),

Western Psychological Services: Catherine Lord, Ph.D.

(1)Instrument used for direct child observation

(2)Assesses same areas as ADI-R

(3)Corresponds to DSM-IV

(4)Presses for behaviors critical to diagnosis

-Excellent Diagnostic Validity

+Evidence Based Assessment (cont’d)

Autism Checklists/Rating Scales

Make sure the measure is appropriate for the child’s cognitive level.

Autism Behavior Checklist (ABC) Krug et al., 1980 Childhood Autism Rating Scale (CARS) Gilliam Autism Rating Scale, second edition (GARS-2) Gilliam Asperger’s Disorder Scale(GADS) Asperger Syndrome Diagnostic Scale (ASDS) Australian Scale for Asperger’s Syndrome (Garnett & Attwood,

1994) Social Communication Questionnaire (Western Psychological

Services)

+Evidence Based Treatment of ASD Sally J. Rogers & Laurie A. Vismara of the M.I.N.D.

Institute, University of California Davis, 2008:EVIDENCE-BASED COMPREHENSIVE

TREATMENTS FOR EARLY AUTISM: Treatment of unwanted or challenging behaviors

should follow the principles and practices of POSITIVE BEHAVIOR SUPPORTS (Carr et al., 2002; Horner, Carr, Strain, Todd, & Reed, 2002, for review):

-Functional Analysis-Functional Behavioral Assessments-Instruction of Replacement Behaviors-Applied Behavioral Analysis (ABA)

Build spontaneous functional communication skills

+Evidence Based Treatment of ASD(cont’d)

Children with autism need to be engaged in meaningful (to the child as well as others), age-appropriate learning activities that are functional in multiple settings. “Naturalistic Teaching” approaches that begin with child choice and use intrinsic reinforcers.

Effective early intervention = Well defined and coherent set of teaching plans for developing functional skills, fitted to the child’s current developmental level. MUST BE DELIVERED AT A HIGH FREQUENCY THROUGHOUT THE DAY.

Peer Interactions are a crucial part of the intervention programs for children with autism. National reviews recommend that children with autism have frequent access to typical peers (NRC, 2001).

+Evidence Based Treatment of ASD(cont’d)

Assuring generalization of new skills and behaviors IS CRITICAL. Generalization is fostered when the skills that are taught are functional and ecologically valide in natural settings and daily routines.

Parents and family members need to be included in the intervention in a variety of ways, (e.g., setting goals, locating supports for themselves, and receiving training in effective ways, etc.)

+Overview of Intervention & Treatment Approaches for ASD Discrete Trial (Lovaas, 1973/1980, 1987)

Consists of Antecedent, Response, and Consequence Includes Detailed task analysis Is teacher directed Uses prompting, shaping, and chaining strategies Teaches verbalization through imitaiton of sounds, words,

sentences, questions, etc. Criticized for dependence on antecedents and consequences

Naturalistic Behavioral Interventions Pivitol Response Training (Koegel et al. 1998; Pierce &

Schreibman, 1997). Motivate the child to communicate by providing an enticing

environment.

+Overview of Intervention & Treatment Approaches for ASD(cont’d) University of Utah Meta-Analysis: Interventions

Targeting Reciprocal Social Interaction in Children and Young Adults with Autism (Miller et al., 2006).

Peer-mediated interventions significantly more effective than child-specific interventions.

Collateral skills interventions are at least equally effective (if not somewhat better) than child-specific interventions.

Picture Exchange Communication System PECS (Bondy & Frost, 1994).

Teaches the child to initiate a picture request and persist until the communicative partner responds.

+Overview of Intervention & Treatment Approaches for ASD(cont’d) Social Games

Teach specific dramatic play scripts (young children). (Goldstein et al., 1988).

Teach social game to group geared toward the child with ASD’s special interest (Baker et al., 1998).

Video Modeling Brief role-plays of social (or other) behavior Individual with ASD role-plays the behavior Several studies show it teaches a variety of skills, and

may be better than traditional role-play (Dorwick & Jesdale, 1991; Charlop-Christy et al., 2000).

+Fads and Non-Evidence Based Interventions

Scott O. Lilienfeld, Ph. D. “Scientifically Unsupported and Supported Interventions for Childhood Psychopathology: A Summary”, (2005).

Scientifically Questionable Treatments (SQT’s)are usually Somatic and/or Psychosocal:

Secretin Hormone Therapy Elimination Diets, (e.g., Gluten-Casein Free Diets,etc.) Vitamin B6 Therapy Facilitated Communication (FC) Sensory-Motor Integration (SMI)

+ Promising Developments:Increasing Social Engagement in Young Children with Autism Spectrum Disorders Using Video Self-Modeling.(Bellini S., J. Akullian, A. Hopf, (2007) School Psychology Review, Vol. 36, No. 1, pp. 80-90).

Assessment 2 preschool-aged students with ASD diagnosed by prior psychological

reports.

Design Multiple baseline design across participants.

Dependent Measures Unprompted social engagement with peers.

Steps to Intervention Video footage collected 2 weeks before collecting baseline data. Videos were edited to remove teacher prompting of pro-social behavior Children viewed one edited video clip per day. After watching the video, children participate in “free-play”

Data Analysis Calculation of non-overlapping data points and computation of effect

sizes (ES)

Results Student 1 yielded an ES of 8.38 Student 2 yielded an ES of 4.24

+Conclusions…

ASD’s present intriguing yet challenging sets of behaviors for school psychologists, teachers, and parents.

Evidence Based Treatments for Autism exist!

Increased public awareness of Autism presents unique challenges to school psychologists. Awareness of current research in the area is ESSENTIAL!

Advocacy for children and families struggling to find adequate treatment & resources is an important role for school psychologists.

Bridging the gap between research and practice has never been more salient, especially for school psychologists.