Foundations of Autism (Autism Spectrum Disorder)

1. Foundations of Autism(Autism Spectrum Disorder) Steven M. Graff, Ph.D. Director of Clinical Services Tri-Counties Regional Center & Laura D. Valdez, M.S. Camarillo Academy for Excellence November 3, 2012

2. Clinical Definitions Diagnostic and Statistical Manual (DSM-IV-TR): Autism, Asperger syndrome, and Pervasive developmental disorder NOS are discrete disorders They will be combined and called ASD with level of severity specified in the new DSM-5. . Federal Educational Code A wide variety of problems can earn the same eligibility: autistic/autistic-like

3. Presentations of Classic Autism Birth to 24 months: feeding problems; failure to thrive; poor latch and suck; arching back; colic; problems sleeping; poor eye contact; not responding to name; loss of previously acquired language. Why does this get missed? (Subtle oddities; first child; families moving away from grandparents & family?)

4. Presentations of Late Onset 3 to 5 years old: Jargon, echolalia, scripted language; lack of imaginative play, fascination with cause-and-effect toys, lights, mirrors or fans; odd or perseverative interests; lack of interest in others, especially children (no parallel or interactive play); severe tantrums (>60’)

5. Fragile X syndrome Tuberous Sclerosis Bipolar Disorder Landau-Kleffner Syn. Tourette’s Syn. Fetal Alcohol Syn. (FAS) Epileptic aphasia Asperger Syn. Pervasive developmental disorder NOS Communication Disorders Neurofibromatosis Intellectual Disability (Mental Retardation) Severe Abuse or Neglect ADHD Obsessive Compulsive Disorder Social communication disorder Childhood disintegrative disorder Rhett’s disorder Other Disorders That Are Commonly Mistaken For Autism

6. Myths of Persons with Autism • Do not care about others • Do not feel emotions • Do not feel pain • Do not want relationships • All are savant geniuses

7. Epigenetics: interaction between environmental exposure and genetic material Genetic predisposition EXTREMELY LIKELY [over 60 genes identified so far and increasing] + Environmental exposure: pesticides heavy metal pollutants; air pollutants; bisphenyl A [plastics], flame retardants; and viruses Vaccinations are not a cause according to most scientific research

8. Theory of mind and Mirror Neurons Ever wondered how somepeople can “put themselves into another person's shoes” and some people cannot? Our ability to empathize with others seems to depend on the action of "mirror neurons" in the brain, Mirror neurons activate when an action is observed, and also when it is performed. Research reveals that there are mirror neurons in humans that fire when sounds are heard. In other words, if you hear the noise of someone eating an apple, some of the same neurons fire as when you eat the apple yourself. Subjects in the study who scored higher in empathy tests also showed higher levels of mirror neuron activation. (Gazzola, 2006) Persons with autism seem to lack this Mirror system.

9. More thoughts on symptom causation: Reticular activating system (the brain’s “alarm clock” is often hyper developed, leading to sleep disorders which can lead to behavior problems! Higher incidence of allergies and sensitivities, leading to sinus headaches and diarrhea, which lead to behavior problems! Left supra orbital frontal cortex (social awareness center) is underdeveloped-no Theory of Mind (T.O.M.) which leads to social problems Dopaminergic pathways tend to be underdeveloped, leading to emotional dysregulation which leads to behavior problems!

10. Brain Structure and organization of the brain is often different than control studies. Often see microcephaly at birth; yet macrocephaly at first year check up (too rapid brain growth without apoptosis, or normal death of unneeded cells). Cerebellum: Punkinje (nourishment) cells-decreased number. Limbic System and Cortex-decreased neuron density. Dendridic interconnectivity odd everywhere.

11. Embryology • Autism starts in the first trimester [Thalidomide; viral infection history] in the gastrula stage, when the neural plate is forming the neural tube. • Normal axon migration is disrupted-cells going in the wrong direction, with too few/too many cells in nerve tracts, and poor connectivity of synapses

12. “Red Flag” Indicators • NO babbling by 12 months • Lack of response to name at 12 months • NO back and forth gestures such as pointing, showing, reaching, or waving • NO meaningful words by 16 months • NO 2-way meaningful phrases by 24 months of age (excluding imitation) • ANY loss of speech, babbling, or social skills at ANY age (but remember, new siblings often bring loss of adaptive skills for a while in typical kids)

13. How do we diagnosis Autism?

14. Interdisciplinary Team [IDT] is Best Practice An IDT approach allows you to evaluate and integrate the effects of ASD on multiple areas of the child’s development and provide a comprehensive profile of the child

15. Reciprocal turn – taking Social reciprocity Sustained interaction Spontaneous giving/showing Imitation of novel acts Shared attention Pretend Play Gaze aversion Ability to have examiner direct attention Use of toys and objects Domains of Observation

16. Cognitive Assessment • A careful examination of cognitive functioning is needed to plan meaningful interventions • Cognitive functioning is measured more accurately using a combination of formal and informal observational methods. • The assessment of young children with suspected ASD requires knowledge of both normal child development as well as the developmental issues of persons with autism.

17. Adaptive Functioning Adaptive functioning refers to the child’s ability to use acquired skills and abilities to cope with the demands of daily living. • Measures of adaptive functioning are required to render a formal diagnosis of mental retardation concomitant with ASD as well as determine a baseline of acquired skills for ASD or other differential diagnosis. • Children with ASD often display discrepancies in certain facets of cognitive abilities and adaptive functioning levels.

18. Deficits of interactivity Poor eye contact Flat/inappropriate facial expression Poor non-verbal social skills Lack of empathy or blunted emotional responses Delayed or absent peer relationships Delayed or absent interest in others Social Deficits

19. Socialization Styles • Aloof-often described as “being in his own world” • Passive-which can be ignored if not a problem in the classroom • Interactive but odd

20. Communication • Severe delay or absence of useful speech/nonverbal communication. • Receptive language skill level often different than expressive skill level. • Use of evasive language is common. • Parent anticipation of communicative intent/ using parents as tools

21. Communication Cont. • Echolalia, delayed echolalia • Jargon, idiosyncratic words • Scripted speech [TV, movies] • Prosody/pragmatics of speech • Pronoun reversal

22. Behavior Stereotypic motor movements and perseverations Hand flapping, spinning, finger play, fixation on themes, colors, numbers, people, objects. [must differentiate between “party behavior” vs. true oddities]-not toe walking-very common in all children.

23. Behavior Cont. Difficulty with transitions Routines, rituals, difficulties when they are disrupted even from highly non-preferred activities Need for task completion or closure Fixation with parts (wheels) versus whole (car)

24. Sensory Differences “It is likely there is a continuum of visual and auditory processing problems for most people with autism, which goes from fractured, disjointed images at one end to a slight abnormality at the other end.” Temple Grandin, Thinking in Pictures

25. Sound Touch Light Smell Taste Movement Texture Hyper/Hypo-sensitivities (increased/decreased)

26. Hyper/Hypo-sensitivities • They can co-exist: • “How come his pain tolerance is so high yet he can’t stand to be touched?” • “Why does he act like he’s deaf, yet is bothered by the buzzing of the lights in the classroom?”

27. Learning and Thinking in Autism • Visual Learners mostly, but not always. • Auditory learning with comprehension is not usually a strength (but mimicry is) • Often Kinesthetic learners (need motoring through; can’t be told how to do it) • Concrete thinkers, not abstract

28. A child with autism may look like….. • Uneven pattern of development • Rote memory a relative strength, but analysis and inference are weaknesses • Visual procession of information a relative strength • Communication/social interactions highly problematic

29. A child with autism may also look like… • Generalization of knowledge/skills is difficult • Skills available spontaneously, but not on request • Resistance to change/desire for sameness can be problematic • Attention difficulties • Sensory differences

30. Three Mainstream Treatment Approaches Intensive Behavioral Interventions-IBI Discrete Trial Training (DTT), Applied Behavioral Analysis (ABA), Lovaas and Pivotal Response Therapy (PRT) Treatment & Education of Autistic & Communicationally Handicapped Children (TEACCH) Developmental: Greenspan/Floor time, DIR-individual difference, relationship-based model

31. Individuals with Disabilities Education Act The IDEA mandates that all children with disabilities receive a free, appropriate public education in the least restrictive environment, tailored to each child’s individual needs.

32. Educational Needs of Persons with Autism • Preschool Age • Communication therapies in the classroom and at home. (group and individual) • Parent participation and training • 1:1 as well as small group instruction • Child engaged in a variety of developmentally appropriate activities

33. Educational Needs of Persons With Autism • School Age Children • A variety of options with autism specific services • Curriculum that focuses on developing independence

34. Communication Social Community Domestic Functional academics Mobility Self Help Recreation/Leisure Vocational Common School Age Children Curriculum Areas:

35. Educational Needs of Persons with Autism • High School Age • Same as school age but with increased emphasis on vocational and community based instruction.

36. Educational Needs of Persons with Autism • Adult • College vs. vocational training • Need for appropriate housing (ranging from living with family, group home, or own apartment) • Independent living skills training • Social/recreational/dating support

37. National Autism Center- National Standards Report • Includes the identification of “Established, Emerging, and Unestablished” treatments for children with autism. [The report focuses on ages 0-22 and not on adults]. • The report on can be found at the following link: • http://www.nationalautismcenter.org/affiliates/reports.php

38. Established treatment • “Established” Treatments: treatments that produce beneficial outcomes and are known to be effective for individuals on the autism spectrum. The report identified 11 Established Treatments; the majority of these are based on the behavior therapy literature, and include: Applied Behavior Analysis (ABA), Discrete Trial Training (DTT), and Pivotal Response Therapy (PRT).

39. Some non-Established Autism “Therapies” • Auditory Integration Therapy/Tomatis method • Swimming with Dolphins • Equestrian Therapy • Music Therapy • Speech therapy • Social Skills • RDI • Sensory Integration Therapy • Facilitated Communication • Hyperbaric Oxygen Therapy (HBOT) • Surfing Therapy • Megavitamins • Vision/Irlen lenses • Psychosurgery

40. The Established therapies: • Behavior therapy • Medication to address symptoms

41. Choosing a Therapy • There are lots of “therapies” which purport to cure, alleviate, or improve autism. Beware of poor research. Parents may believe that one, or even 1000 hopeful anecdotes outweigh negative research. [No, it doesn’t].

42. Medications don’t “cure” autism, but the symptoms may be treatable CNS Stimulants (attention/hyperactivity) Anti-Depressants (for agitation/mood) Anti-Convulsants (mood stabilization) Anti-Psychotics (impulsivity/agitation) Anti-Opiates (“Stimming” or Self-Injurious Behavior Anxiolytics (anxiety)

43. Guidelines for Evaluating Approaches • Be skeptical of any treatment that provides a “magic” cure or any program that represents only one option • Individualize programs are best • Goals should be to increase independence/ functional skills • Programs should be structured and geared toward developmental level

44. Number one rule of intervention should be… Focusing on the acquisition of skills as well as the generalization of functional, adaptive behaviors.

45. The End Questions?