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The ASD Evaluation from the Psychological Perspective

The ASD Evaluation from the Psychological Perspective. Kathrin Hartmann, Ph.D. Clinical Psychologist / Associate Professor Department of Psychiatry Eastern Virginia Medical School.

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The ASD Evaluation from the Psychological Perspective

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  1. The ASD Evaluation from the Psychological Perspective Kathrin Hartmann, Ph.D. Clinical Psychologist / Associate Professor Department of Psychiatry Eastern Virginia Medical School

  2. Difficulty in Early Identification [Landa, R. & Garrett-Mayer, E. (2006). Development in infants with autism specturm disorders: A prospective stuey. Journal of Child Psychology and Psychiatry 47 (6), 629-638.] Overlap with other developmental disabilities (e.g. speech and language delay) Presence of clearly abnormal behaviors is easier to detect than absences of behaviors Variability of child behaviors as seen in the home by family Each family has a unique interpretation of their child’s development

  3. ASD Clinical Database – Participants and Procedures Retrospective clinical chart review (2005-2008) • Demographic data • Pregnancy and birth complications • Maternal/infant characteristics • Family History of psychiatric disorders and stressors • Developmental history and educational information • Behavioral observations by the clinician • Parent report of ASD characteristics • Standardized test scores for intellectual, behavioral, and adaptive functioning • Referral and recommendation information

  4. Proportion of males to females (4:1) matched national prevalence data (CDC, 2010) ASD Database – Preliminary Data Analysis Figure 1. Gender Distribution of Participants

  5. Most participants were preschool-aged children. CDC (2010) reports that the median age of diagnosis is 4.5 to 5.5 years old. ASD Database – Preliminary Data Analysis Figure 2. Age Distribution of Participants.

  6. Full-Scale IQ was assessed for 48 of the participants using either the WISC-IV or the WPSSI-III. Only 21% had an IQ of 70 or below, as compared to the national prevalence estimate of 30-51% possessing an Intellectual Disability (CDC, 2009). ASD Database – Preliminary Data Analysis Figure 3. Distribution of Participant IQ Scores

  7. ADHD was the most common primary diagnosis for ASD rule-out participants. ASD Database – Preliminary Data Analysis Figure 4. Percentage of Primary vs. Rule-Out PDD Diagnoses

  8. Eating and sleeping difficulties were reported in approximately half of the participants. Developmental delays and a history of speech-language and/or occupational therapy were present the majority of participants. ASD Database – Preliminary Data Analysis Figure 6. Developmental Variables

  9. ASD Database Qualitative Observations • Birth of a sibling frequently reported as a significant family stressor. • Feeding problems (most notably reflux), frequent ear infections, and sleep apnea most commonly reported health problems in infancy. • Asthma, eczema, environmental allergies, and seizures most commonly reported ongoing health problems. • Use of prescribed stimulants (e.g., Adderall, Concerta, Ritalin) frequently reported. • Developmental delays present in large majority of cases. • Social difficulties and speech irregularities present in large majority of cases. • First relationship in infancy between primary care-giver and child reported as “good” or “great” in majority of cases.

  10. Screening versus Testing versus Assessment Screening: Use of initial clinical questions about a problem, either in an interview format or with screening measures that include questions and/or direct observations Testing: Use of one or more psychological tests by the clinician to assess specific or global areas of functioning (e.g. administration of an IQ test) Assessment: Sophisticated integration of information derived from a flexible multimethod assessment battery

  11. Purpose of Psychological Assessment Answers the referral question Provides a frame of reference for the individual child, e.g. their strengths and weaknesses Helps narrow down diagnostic possibilities Provides a basis for what treatment strategies should be used Documentation of functioning may provide access to further services as needed

  12. ASD Evaluation: Part of an Interdisciplinary Approach • Parents/Caregivers/Family/Friends • Pediatricians, pediatric specialties, and other health care providers • Speech and language therapists • Occupational therapists • Physical therapists • Special education professionals and guidance counselors and other school professionals

  13. Essential Elementsof the ASD Evaluation Diagnostic work-up (health, behavioral, educational, and intervention history; current symptoms and behaviors, family vulnerability) Developmental or intellectual assessment Adaptive functioning assessment Speech, language, and communication assessment Fine and gross motor assessment Additional assessment (e.g. clinical genetics; neurological status, and sensory/motor functioning)

  14. ASD Cognitive and Social-Adaptive Testing[Klin, A., Saulnier, C., Tsatsabusm, J. & Volkmar, F.R. (2005). Clinical evaluation in autism spectrum disorders: Psychological assessment within a trandisciplinary framework. In: F.R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders (3rd Ed., pp. 772-798). New Yorlk: Wiley.] Examples Bayley Scales of Infant Development (2003) Mullen Scales of Early Learning (1995) Wechsler Primary and Preschool Scale of Intelligence - Third Edition (2002) Vineland Adaptive Behavior Scales - Second Edition (2005) and many others

  15. ASD Specific Screening MeasuresCompleted by ProfessionalAAP Clinical Report on Children With Autism Spectrum Disorders (ASD)[Plauché Johnson, C., Myers, S.M, and the Council on Children with Disabilities (2007). Identification and Evaluation of Children with Autism Spectrum Disorder. Pediatrics, 120 (5), 1183-1215.] Checklist for Autism in Toddlers (CHAT); 18 m+ Interview and Interaction Childhood Autism Rating Scale (CARS); 2 y+ Gilliam Autism Rating Scale (GARS); 3-22 y Screening for Autism in 2- Year-Olds (STAT); 24-36m Autism Behavior Checklist (ABC);18 months+

  16. ASD Specific Screening Measures Completed by Parents/CaregiversAAP Clinical Report on Children With Autism Spectrum Disorders (ASD)[Plauché Johnson, C., Myers, S.M, and the Council on Children with Disabilities (2007). Identification and Evaluation of Children with Autism Spectrum Disorder. Pediatrics, 120 (5), 1183-1215.] Modified Checklist for Autism in Toddlers (M-CHAT); 18 m + Pervasive Developmental Disorders Screening Test (PDDST); 18-48 m Autism Screening Questionnaire/Social Communication Questionnaire (ASQ/SCQ); 4 y +

  17. ASD-Specific Diagnostic Measurescompleted by Clinician Autism Diagnostic Interview - Revised (ADI-R) Autism Diagnostic Observation Schedule (ADOS) ADI-R and ADOS are effective ways of qualifying subjects and superior to screening instruments ADOS with young children (below 6 years) includes the parents in the assessment process

  18. Autism Diagnostic Observation Schedule (ADOS)Catherine Lord, Ph.D., Michael Rutter, M.D., FRS, Pamela C. DiLavore, Ph.D., and Susan Risi, Ph.D. Social Behavior Use of Vocalizations and Speech and Gesture in Social Situations Play and Interests For more ADOS information see: http://www.wpspublish.com

  19. ADOS Triggers for Language and Communication Greeting and small talk Tell me about your school/job Tell me about your friends What makes you feel …. Tell a story from a wordless picture book Describe the action in a comic strip Tell me about your ideas for your future

  20. Scoring Language and Communication Frequency of Vocalizations Directed at Others Stereotyped or Idiosyncratic Use of Words or Phrases Use of Others’ Body to Communicate Pointing Gestures Reporting of Events Conversation

  21. ADOS Triggers forReciprocal Social Interaction Providing inviting activities that typically pull for enjoyment (e.g. bubble or balloon play) Providing play materials that lend themselves to sharing or showing Activities the participants do on their own to provide for ample observation time Engaging the participant in conversations about the nature of social relationships and their current experiences

  22. Scoring Reciprocal Social Interactions Unusual Eye Contact Facial Expressions Directed to Others Sharing Enjoyment in Interaction Showing Objects to Others Spontaneous Initiation of Joint Attention Response to Joint Attention Quality of Social Overtures Insight Amount of Reciprocal Social Communication

  23. ADOS Triggers for Restricted and Repetitive Behaviors Inviting the participant to engage in an open-ended conversation for social purpose only to elicit further observations of participant’s interests in topics or objects or behaviors Time/Space for general observations of participant’s unusual sensory interests or compulsions or rituals or hand and finger or other mannerisms or self-injurious behaviors

  24. Scoring Restricted & Repetitive Behaviors Intonation of Vocalizations of Verbalizations Stereotyped/Idiosyncratic Use of Words or Phrases Unusual Sensory Interest in Play Material/Person Hand and Finger and Other Complex Mannerism Unusually Repetitive Interests or Stereotyped Behaviors Excessive Interest in or Reference to Highly Specific Topics

  25. ADOS Summary Algorithm - What Does the ADOS Score Mean? Originally based on 2 Domains: Communication Reciprocal Social Interactions Now based on 3 Domains: Communication Reciprocal Social Interactions Restricted and Repetitive Behaviors Provides Cut-Offs for Autism and Autism Spectrum

  26. Need for the Testing Feedback Session with the Parents/CaregiversEisman, E.J. et al. (2000). Problems and limitations in using psychological assessment in the contemporary health care delivery system. Professional Psychology: Research and Practice, 31, ( 2), 131-140. Feedback is necessary overall for the sucessful treatment process (Finn & Tonsager, 1992, 1997; Newman & Greenway, 1997; Pollak, 1988). Increases hope Decreases parental distress Helps the family understand their child’s functioning Alleviates symptomatic distress Affects the course of treatment Educates about treatment options and resources May open access to services

  27. After the ASD Identification: Essential Elements of Successful Intervention Methods(Dawson & Osterling, 1997; Lord & McGee, 2001] • Intervention begins early and is intensive in hours • Families are active participants in their child’s intervention • Staff are well-trained and knowledgeable about autism • There is objective evaluation of the child’s progress • The curricula is highly structured with predictable routine and focus on developing communication and other skills • Teaching procedures emphasize generalization and maintenance of skills • Transitions to school and between schools are carefully planned and well supported

  28. Testing and Assessment Websites American Academy of Pediatrics, see specific Policies and Guidelines: http://www.aap.org General Psychological Testing: American Psychological Association http://www.apa.org/science/faq-findtests.html Test Reviews: Tests in Print. The Buros Institute for Mental Measurements www.unl.edu/buros Test Locator for Internet Searches http://ericae.net; http://buros.unl.edu/buros/jsp/search.jsp; http://www.ets.org/testcoll Specific Test see Test Publishers, e.g. Western Psychological Services Publishers and Distributors www.wpspublish.com or Pro-Ed www.proedinc.com or PsychCorp/HarcourtAssessmentwww.harcourtassessment.com

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