Autism Workshop-SPARKS- April 2012

(1)

Kristie Ford, MS., CCC-SLP Mindy Nelson, MS., CCC-SLP

Speech-Language Pathologists UAB Civitan-Sparks Clinics

An Introduction

to Autism Spectrum Disorders

(2)

Autism Spectrum Disorders

(Pervasive Developmental Disorders)

Autism

Asperger’s Syndrome

PDD-NOS Rett’s Disorder

Childhood Disintegrative Disorder

UAB Civitan-Sparks Clinics Autism Clinic Team 2012

(3)

Prevalence of ASD

(CDC, March 2012)

 11.3 per 1,000 children, or 1 in 88 children.

 Average increase of 23% since 2009 and increase of

78% since 2007

 1/54 for boys, 1/252 for girls

 ASD prevalence was 4 to 5 times higher for boys

than for girls

 Largest increase across this time was among

(4)

The Autism “Triad”

Impairments in Social Interaction

Restricted Range of Behaviors & Interests Communication Deficits

ASD

(Onset prior to 36 months)

(5)

Impaired

Communication Skills

 Delayed Language Development

 Stereotyped, Repetitive, Idiosyncratic Language  Echolalia, jargon, pronoun reversal, unusual pitch  Difficulty Initiating and Sustaining Conversation  Monologues, inability to answer questions

(6)

Impairments in Social Interaction

 Impairments in Non-Verbal Behaviors

 Lack of Reciprocal Social Interactions  Failure to Develop Peer Relationships

 Lack of Seeking to Share Enjoyment & Interests

(7)

Restricted and Repetitive

Behaviors or Interests

 Stereotyped and Repetitive Motor Mannerisms

 Preoccupation with Parts of Objects

 Preoccupation with Particular Activity or Topic  Inflexible Adherence to Routines or Rituals

(8)

Common ASD evaluations

 Modified Checklist for Autism in Toddlers (M-CHAT)  Gilliam Autism Rating Scale 2nd Ed. (GARS-2)

 Childhood Autism Rating Scale (CARS)

 These scales/checklists are typically used in doctor’s offices

to determine warning signs and refer for further evaluation

 Autism Diagnostic Observation Schedule (ADOS)

 _{Considered the “gold standard” of diagnostic tools}

 Autism Diagnostic Interview (ADI)

 Used presently at Sparks to determine diagnosis

(9)

Who diagnoses ASD?



NOT US!!! But, we are a piece of the puzzle



Determined by a specialist: Developmental

Pediatrician, Pediatric Neurologist, Child

Psychologist



In conjunction with a multidisciplinary team:

(10)

Types of ASD diagnoses



Medical Diagnosis

 _{Made by a physician or medical professional based on}

symptoms according to the DSM-IV and diagnostic testing

 _{Allows families/individuals to receive financial assistance}

throughout their lifespan (SSI, Disability, etc.)



Educational Determination

 Made by a multidisciplinary evaluation team consisting of

various school professionals.

 _{IDEA – Individuals with Disabilities Education Act}

 _{Must further determine if the disability affects progress and/}

or participation in the classroom

(11)

S/L Diagnostic Tools



Birth-3

 PLS-4 & -5; Rossetti; REEL



Ages 3-7

 PLS-5; CELF P-2



Older kids

 OWLS; CELF-4; TOPL



Note: A question of ASD does not change

(12)

Areas SLPs Assess



Receptive Language



Expressive Language



Social Language (Pragmatics)

(13)

Receptive Language



Identifying

– Objects, pictures, body parts, clothing items,

actions, etc.

– Basic concepts (spatial, qualitative, quantity,

descriptive, etc.)

– Educational concepts (colors, shapes, letters,

etc.)

(14)

Expressive Language

 Gestures

– Includes reaching, pointing, pushing and pulling behaviors,

sign language, etc.

 Babbling

– Things to consider: variety of consonant and vowel sounds,

jargon, intent, and inflection?

 Words

– Using words for a variety of purpose?

– Label? Request? Gain attention? Answer questions?

(15)

Is Speech Functional?



Phrases and/or sentences



Things to consider:

– Echolalia (immediate or delayed) – Rote phrases only

– Random speech at inappropriate times

– Using speech to respond to questions

appropriately

(16)

Social Language (Pragmatics)



Play skills

– Parallel play versus joint play – Functional Play

– Relational Play

– Symbolic Play

– Pretend Play

(17)

Social Language (cont.)



Other factors to consider:

– Eye contact

– Responds when name is called

– Seeks out attention – Initiates play routines – Joint attention

(18)

Challenges during testing



Sensory Issues

 Touch, visual, hearing



Engaging/Joint attention

 Difficult to do with children on the spectrum



Behavior

 Aggressive behaviors (hitting, spitting, etc.)  Avoidance behaviors (turning away,

perseverating, etc.)

(19)

Comorbid Disorders

 _{Seizure Disorder}

 _{Mental Retardation}

 _{Sensory Impairment (blindness or deafness)}

 _{Fragile X}

 _{Tuberous Sclerosis}

 _{Other Genetic Disorders}

 _Depression

(20)



Evidence that intervention does cause

change in symptoms and behaviors



Not enough rigorous research

 Few cross-program comparisons

 Many programs/packages have many elements



A great deal of research currently filling

this gap

Current Evidence Base for

Intervention with ASD

(21)



Implementation as soon as an ASD diagnosis

is seriously considered



Implementation by highly trained staff who

 have an understanding of the features of ASD

 have training and background in ASD-specific

techniques of intervention



Active engagement in planned programming

for more than 25 hours per week, 12 months

per year

Critical Elements of Effective

Intervention

(22)



Working toward specific individualized goals

and objectives



Ongoing assessment of progress (i.e., at least

every 3 months) and adaptation of

programming if adequate progress is not

being attained



Individualized attention provided in frequent

intervals

Critical Elements of Effective

Intervention

(23)

 Inclusion with peers with typical development as

appropriate

 Highly structured and supportive environment and

routine

 Generalization of skills across environments and

working in the natural environment

 Family involvement and parent education

 Problem behaviors should be addressed in a positive

manner and in context, with a focus on developing replacement behaviors

Critical Elements of Effective

Intervention

(24)



Functional, spontaneous communication



Receptive language



Attention to the environment and response

to appropriate motivators



Social and Play Skills (age appropriate)

 Imitation

 Joint attention  Turn-taking  Pretend play

 Peer Interaction

Target Areas for Interventions

(25)



Independent organization skills



Cognitive and functional academic skills

taught in context



Fine and gross motor



Self-help and adaptive skills



Positive behavioral supports in context of

problem behavior

(26)



Remediation of skill deficits in ASD



Alter the child’s spontaneous interactions

with their environment to support

learning



Accommodations for ASD



Visual supports



Alter the environment to support learning



Teach to compensate for learning

difficulties

Categories of Treatment

(27)

Visual Supports



Picture symbols

– Many children on the autism spectrum are

nonverbal and need alternative means to communicate their wants and needs

– Does not hinder language development

– Decreases frustration

– Promotes positive behavior and decreases

(28)

Visual Supports (cont.)



Who is a good candidate for picture

symbols?

– Difficulty communicating basic needs and wants – Difficulty understanding verbal speech

– Difficulty initiating communication spontaneously – Limited vocabulary or functional speech

– Difficult to understand

(29)

Levels of Visual Support



Actual Object



Photographs



Pictures/Line drawing



Words

(30)

Visual Supports (cont.)



Where to begin with picture symbols?

– Use picture symbols to request highly desirable

items (e.g. food, toys, activities)

– Trouble identifying motivating items

 _{Spend a free day with your child and make a list of what}

interest him/her

 _{Items do not have to be functional initially}

(31)

Visual Supports (cont.)



Using picture symbols to request

– Teach skill during a motivating activity (e.g. snack

time)

– Skill is best taught with two people present

– One person stands behind the child to prompt

him/her to exchange the picture to receive desired item

(32)

Visual Supports (cont.)



Always pair picture symbols with verbal

language



Teaching a child to use picture symbols is a

challenging task!



Once your child can discriminate a variety of

pictures consider placing picture symbols in a

communication notebook



Do not bombard child with too many pictures



Picture exchange versus PECS

(33)

First-Then Boards

First-Then boards often pair a non-preferred activity, (e.g.,

brushing their teeth) with a preferred activity (e.g., watching TV) Boards can be used in a variety of ways:

 Assisting with transitioning from one activity to another.  Breaking a large schedule into smaller steps.

 Assisting in completing an undesired task. (e.g. chores,

(34)

Visual Schedule

 Used to organize and structure a child’s daily routines.

 Schedules increase a child’s ability to understand rules and

steps that apply to specific routines.

 Used in a variety of situations:

 Sequencing a child’s entire day.  Sequencing routines at school.

 _{Sequencing steps to complete an activity (e.g. brushing your teeth,}

using the restroom)

 Preparing a child for a change in his/her daily routine (e.g. doctor’s

appointment)

 Preparing your child for a stressful event. High-stress situations

require a more detailed breakdown using sequential pictures.

(35)

(36)

(37)

Other uses of pictures



Choice boards



Labeling a home or classroom



Behavior cues

(38)

Examples of Picture

Communication

(39)

(40)

Social Stories (Carol Gray)

 Translate the “secrets” of social interaction and

daily situations into practical, tangible social information for students with ASD

 Helps insure that the student is not

misperceiving or missing important social information

 Relevant information (who, where, when, why)

is provided in a concrete manner

(41)

Social Story Example

When I am on the playground I might want to

play with other kids. This is a good thing to

do. If I pull a kid’s hair, their head will hurt

and this will make them mad. They will not

want to play with me. Instead, I should walk

over to the other kids, keep my hands to

myself and ask, “Can I play, too?” Then the

kids might say, “yes,” and we might have fun

(42)

Comic Strips Conversation (Gray)

 Depicts a conversation between two or more people

in a comic strip format

 Can be used to convey info, to problem-solve, learn

social skills, follow rules, or communicate thoughts/feeling

 Uses thought bubbles and conversation bubbles

 Colors can be used to further express feelings (e.g.,

green=happy; red=angry)

(43)

(44)

Video Self-Modeling

 Used to teach children a specific skill (e.g.,

conversation, play, requesting)

 Video the child performing the skill in the preferred

manner, using prompts if necessary

 Edit out the prompts and have the child view

themselves in the video

 Overall, the use of videos was found to be effective

for teaching and generalizing skills

(45)



Provide opportunities for adult-guided social

interactions



Teach specific social skills

 Conversation skills

 How to read others’ social cues  Choosing appropriate friends

 Responding to negative feedback

(46)

 Initial concern regarding development of the child  Seeking a diagnosis

 Adjusting to the diagnosis  Lifelong impact

 Parents and siblings of individuals with ASD experience significant levels of stress

 _Caregiving

 Participation in interventions  Divorce and family functioning

 Financial difficulties

 Cost of assessments and interventions  _{Caregiving versus employment}

Impact of ASD on the Family

(47)

Although autism is typically

diagnosed in early childhood,

impairments associated with

autism last a lifetime.

(48)

Characteristics of High-Functioning

ASD: Social Communication

 Awkward communication despite strong vocabulary and

grammar

 Trouble understanding and using nonverbal behaviors

 Difficulty choosing appropriate behaviors to fit the

situation

 Difficulties with perspective-taking/theory of mind  Difficulties with self-reflection

 Difficulties understanding and interpreting “unspoken”

rules (e.g., manners, social norms)

UAB Civitan-Sparks Clinics Autism Clinic Team 2012

(49)

Characteristics of High Functioning ASD:

Intense Interests & Sensory Behaviors

 A tendency towards specific and intense interests

 Rule-based behaviors and beliefs

 A preference for predictability

(50)

Strengths Associated with High

Functioning ASD

 Not as preoccupied with social norms, conventions, or

manners.

 Enhanced perception allows for focus on details and

unique views.

 Intense interests may lead to productivity and

creativity in these areas.

 Preference for predictability may lead to individual

being a model employee and student.

UAB Civitan-Sparks Clinics Autism Clinic Team 2012

(51)

ASD in Adolescents & Adults

 Symptom profile changes across lifespan

 Behaviors absent in children may develop by

adulthood, but maybe not appropriately

 Treatments are different from childhood

 Subtypes become less important

 Structured & repetitive jobs and activities  Independent living

(52)

Personal Perspectives on ASD

 The Way I See It: A Personal Look at Autism and Asperger's

Temple Grandin

 Look me in the Eye: My Life with Asperger’s

John Elder Robison

 _{The Unwritten Rules of Social Relationships}

Temple Grandin, Sean Barron

 _{There’s A Boy in Here}

Judy Barron, Sean Barron

 _{Thinking in Pictures: My Life with Autism}

(54)

Websites for more Information



Autism Speaks:

_{www.autismspeaks.org}



Alabama Autism Society:

_{www.autism-alabama.org}



Autism Society of America:

_{www.autism-society.org}

 http://isnt.autistics.org/index.html  http://templegrandin.com

 http://www.tonyattwood.com.au/index.html

(55)

Questions?

(56)

*Adapted from presentation by Sarah O’Kelley, Ph.D.

Clinical Child Psychologist UAB Civitan-Sparks Clinics Autism Clinic Team

[email protected]

An Introduction

(57)

Sparks Clinics

 _{Interdisciplinary clinic that serves primarily as a pediatric diagnostic}

clinic.

 _{Clinics can consist of the following professionals:} – Social worker – Speech pathologist – Occupational therapist – Audiologist – Psychologist – Nutritionist – Physical therapist – Optometrist

(58)

Sparks Clinics

 Clinics

– Infant Toddler Clinic (ITC)

– Child Development Clinic (CDC)

– Pediatric Communication Clinic (PCC) – Psychoeducational Clinic (PEC)

– Multi-Disability Clinic (MDC) – Speech and Language Clinic – Screening Clinic

– Adult Down Syndrome Clinic

(59)

Sparks Clinics

 Children come locally and from all over the state.

 Appointments are usually spread over 2-3 days.

 Staffings are held weekly to determine appropriate

diagnoses and recommendations.

 Typical diagnoses: Mixed Developmental Delay,

Mental Retardation, Autism, and psychological disorders.

 Last appointment is a parent conference. The family

(60)

Sparks Clinics



Primary caseload consists of children 3-8

years old.



See a variety of children

– Autism Spectrum Disorders

– Genetic Syndromes

– Nonverbal

– Behavioral

(61)

Opportunities at Sparks Clinics

 _{Sparks Clinics except graduate students completing off-site practicums and}

clinical fellows

 _{Positives to working at Sparks!}

– Opportunity to learn from other disciplines

 _{Trainee Office}

 _{New to professionals with years of experience}

– Audiologist in house

– Cognitive scores help make better recommendations

– Great resume builder and experience to start your career

– Connections throughout the state

– Observation opportunities

– Core lectures