Red Flags and Screening for Autism

1. Red Flags and Screening for Autism Rose Iovannone, Ph.D., BCBA-D University of South Florida Tampa, FL 813-974-1696 iovannone@fmhi.usf.edu

2. Agenda • What do we know about autism? • Red flags • Screening • Strategies for after screening • Helpful resources

3. Objectives Participants attending the session will: • List key behavior markers that indicate a need for screening. • Describe various screening instruments that directly measure features unique to autism. • Cite appropriate actions to take when screening results indicate a need for further diagnostic evaluation.

4. What is autism?

5. First, A Quiz • A six month old child should smile or have other expressions of happiness • True or False • By nine months old, a child should have a. back and forth sharing of sounds b. facial expression c. both d. Neither • By one year, a child should be • Babbling • Pointing and showing • Reaching • Waving • All of the above • None of the above

6. Quiz 4. It is normal if a child has no words by 16 months • True or False 5. By two years, a child should have meaningful two-word phrases without simply imitating or repeating • True or False 6. A loss of speech or babbling or social skills is no cause for concern. • True or False

7. “If you’ve seen one child with Asperger’s Syndrome or autism, you have seen one child with Asperger’s Syndrome or autism.” Brenda Smith Myles November 14, 2000

8. Current Facts About Autism • 1% of child population (ages 3-17) have an autism spectrum disorder (ASD) • Current prevalence estimated at 1 per 100 births (CDC 2009) • Fastest growing developmental disability • Lifelong condition with no known cure • BUT—children with ASD can progress and learn new skills

9. Current Facts About Autism • Social-communicative disorder • Believed to have multiple etiological factors • All racial, ethnic, and social boundaries affected • Males to females—3-4:1 • Approximately 25-35% develop seizures • Behaviorally defined • No one specific assessment instrument/test sufficient for diagnosis

10. What We Know • Frequently occurs in association with other disabilities (MR, ADHD, fragile X syndrome, Turner’s syndrome, tuberous sclerosis, OCD, depression, anxiety) • Approximately 50% score within mentally retarded range • Approximately 10-15% score average to above average on IQ measures • Uneven development in skills/abilities • Prognosis improves with early identification and intensive intervention

11. Core Deficits • Spectrum disorder • Collection of symptoms that vary greatly among children • Diagnosis made on “cluster” of behaviors • Includes autism, Asperger syndrome, and PDD-not otherwise specified (PDD-NOS) • Triad for diagnosis • Reciprocal social interaction • Communication • Restrictive, repetitive behaviors or interests

12. Social Interaction Deficits • Deficit in use of Nonverbal Behaviors • Eye gaze • Typically do not use eye gaze to determine what others are viewing and to interact • Facial expression • Movement of fact to express emotions • Body posture • Posturing of body to relate with others • Gestures • Hand and head movements

13. Social Interaction: Nonverbal Behaviors http://www.firstsigns.org/asd_video_glossary/asdvg_about.htm Typical Child Red Flag

14. Social Interaction Deficits • Engaging in Interaction with Adults/Peers • Do not look at, smile, communicate verbally and nonverbally with others • Show more interest in objects than people

15. Social Interaction: Engagement Typical Child Red Flag

16. Social Interaction Deficits • Sharing or Joint Attention—Lack of: • Simultaneous enjoyment with another • Shifting gaze between object and person and back to object (also called “3 point gaze”) • Following gaze and points of others • Using gestures to draw attention of others

17. Social Interaction: Joint Attention • Red Flag • Typical

18. Social Interaction Deficits • Social Reciprocity Deficits: • Not showing interest in interacting with others (e.g., not exchanging smiles) • Not taking active role in social games • Preferring solitary activities • Using other person’s hand as tool or person as if they were a mechanical object • Not noticing other person’s distress or lack of interest or focus on conversational topic

19. Social Interaction: Social Reciprocity Typical Child Red Flag

20. Communication • Expressive and Receptive Language • Diverse range from no functional language (do not use words conventionally for communication) to very proficient vocabulary and sentence structure • Verbal—have odd intonation (flat, monotonous, stiff, “sing-songy” without emphasis on specific words) • May understand language but difficulty with non-literal interpretations and humor

22. Expressive/Receptive Language

23. Communication • Initiating and Sustaining Conversation • Difficulty following conversations • Difficulty initiating conversational topics of interest to others

24. Conversation

25. Communication • Repetitive Language • Echolalia (“movie talk”, “scripting”) • Immediate • Delayed • Does have communicative or regulatory function for child • Stereotypy • Abnormal or excessive repetition of action/phrase over time • Perseveration • Repeating or getting stuck carrying out a behavior (spinning wheels of car) when no longer appropriate • Idiosynchratic language • Language with private meanings

26. Communication Make Believe Play Typical Child • Become preoccupied with object/toy or parts of toy/object (wheels) rather than engaging in pretend play • May not imitate actions others make with toys/activities

27. Restricted Patterns of Interest Insistence on Sameness Red Flags • Rigid adherence to routine or activity carried out same way • React strongly to change in routines (distress, tantrums) • Repetitive movements with objects (lining up, collecting, or clutching similar objects)

28. Restricted Patterns of Interest Repetitive Motor Patterns Red Flag • Sterotyped, repetitive patterns of movement or body posturing • Hand flapping, finger flicking/twisting, rubbing or wringing hands • Pacing, rocking, swaying body • Odd posturing (toe walking) • May add sensory stimulation (“stimming”) or other functions (escape, attention)

29. Restricted Patterns of Interest • Preoccupation with Parts of Objects • Persistent, unusual interest or fixation with one aspect of an object • Flicking light switches, opening & closing doors • No functional use of objects

30. screening

31. One of the doctors we took Gary to told us, “Well if he’s autistic he could just snap out of it , like amnesia.” I thought to myself, “Don’t hold your breath.” Powers, M., 2000

32. Red Flags • No big smiles or other warm, joyful expressions by six months or thereafter • No back-and-forth sharing of sounds, smiles, or other facial expressions by nine months or thereafter • No babbling by 12 months • No back-and-forth gestures, such as pointing, showing, reaching, or waving by 12 months • No words by 16 months • No two-word meaningful phrases (without imitating or repeating) by 24 months • Any loss of speech or babbling or social skills at any age Behaviors warrant referral to pediatrician Source—First Signs and Center for Disease Control (CDC)

33. Absolute Indications for Immediate Evaluation • No babbling pointing or other gesture by 12 months • No single words by 16 months • No 2-word spontaneous (not echolalic) phrases by 24 months • ANY loss of ANY language or social skills at ANY age

34. Are We Missing The Boat? • Average age for diagnosis in United States is 3 to 4 years (Filipek, 1999). • Average age for screening/referral ranges from 24 to 40 months. • However, recommended age for referral by 18 months. • Most physicians rely on their clinical judgment, yet clinical judgment detects fewer than 30% of children who have developmental disabilities (Glascoe, 2000; Palfrey, 1994).

35. Early Screening:Why? Intensive early intervention before age 3 results in greater impact after age 5 (Wetherby et al., 2004). Presence of neurologic plasticity at younger ages Better school placement outcomes (general education vs. special education) (Harris & Handelman, 2000) Better chance of graduating from high school Greater developmental gains Higher likelihood to live independently Positive economic impact over a life-time with early intervention

36. General Developmental Screeners • Recommended General Screening Tools • Ages & Stages Questionnaires (ASQ) • Child Development Inventories (CDI) • Parents’ Evaluations of Developmental Status (PEDS) • Infant/Toddler Checklist for Communication and Language Development • Communication and Symbolic Behavior Developmental Profile (CSBSDP)

37. Ages and Stages Questionnaire (ASQ): • Relies on information from parents • Can be used in patients 4 months to 5 years • Screens for communication, gross and fine-motor, problem solving and personal adaptive skills • Pass/Fail • 30 items; Takes 10-15 minutes to complete • Separate 3-4 page form for each well-child visit (age-specific) • Available in English, Spanish, French, and Korean • Standardized scoring procedures • No cost associated with tool – can photocopy

38. Parent’s Evaluation of Developmental Status (PEDS): • Relies on information from parents • Can be used in patients birth to 8 years • Screens for both developmental and behavioral problems • 10 items (4th-5th grade reading level) • Can be used during well-child visits, while parents are waiting for appointments- takes about 2 to 10 minutes • Available in English, Spanish, and Vietnamese • Standardized scoring procedures • Total cost (including materials and administration) is $1.19 per patient

39. Autism Specific Screeners • Modified Checklist for Autism in toddlers (M-CHAT) (Robins, Fein, & Barton, 1999) • M-CHAT Follow-Up Interview

40. M-CHAT • Parent completed • Identifies children at-risk for autism • 23 items; 5-10 minutes • English, Spanish, Turkish, Chinese, and Japanese versions • Get from First Signs www.firstsigns.com • Can be completed online at http://www.forepath.org/ • Cost associated with it (PEDS done first)

43. Easy Road from Screening to Diagnosis • AAP recommends using a general developmental screening tool at all well-child visits • If pass, re-screen at next well-child visit • If fail, perform appropriate tests (e.g., hearing, lead levels, etc.) • If test results are normal then refer patient to subspecialist and/or early intervention programs

44. What to do after Screening

45. Working with Families • Family cost after diagnosis • Disbelief, fear, anger, grief, confusion • Earliest interactions with family: • Establish relationship of mutual respect • Willingness to listen and learn, problem-solve • Seek additional solutions, if necessary • Nobody is expected to have all the answers or energy to meet child’s needs (Guralnick, 2000) • Active family involvement key essential component to be included in every program

46. Early Intervention • More time spent in active, positive engagement results in better outcomes • Intensive supports—one to two hours a week may not be adequate for infants and toddlers • 15-20 hours a week active engagement (NRC) recommended for young children

47. www.nlconcepts.com