Can ASD be Identified in Children Under Two

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Can ASD be Identified in Children Under Two?
Rhea Paul, Ph.D., CCC-SLP Prof., Yale Child
Study Center Director, Communication Disorders
Section Rhea.paul_at_yale.edu
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Preparation of this Presentation was supported by

• Research Grant P01-03008 funded by the National
  Institute of Mental Health (NIMH)
• Research Grant R01 DC07129 funded by National
  Institute on Deafness and Other Communication
  Disorders (NIDCD),
• STAART Center Grant U54 MH66494 funded by the
  the National Institute of Environmental Health
  Sciences (NIEHS), the National Institute of Child
  Health and Human Development (NICHD), the
  National Institute of Neurological Disorders and
  Stroke (NINDS),
• MidCareer Development K24 HD045576 funded by
  National Institute of Deafness and Other
  Communication Disorders
• National Alliance for Autism Research
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Acknowledgements Collaborators
Kasia Chawarska, Ph.D. Ami Klin,
Ph.D. Fred Volkmar, M.D. Carol
Fowler, Ph.D. Peter Jusczyk, Ph.D.
Anne Marie Jusczyk Sophie Scott, Ph. D.
Donald Cohen, M.D.    
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Acknowledgements Stimulus Prepararion, Data
Collection and Coding

Jeff Weihing Brooke Swainson Carolyn
Gosse Hillary Chuba Liz Schoen Kate
Elliot Stephanie Miles Lauren Herzog Moira
Lewis Lauren Berkovits Allison Lee
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Report on Data from

• Klin, A., Chawarska, K., Paul, R., Rubin, E.,
  Morgan, T., Weisner, L., Volkmar, F. (2004).
  Autism in a 15 month old child. American Journal
  of Psychiatry, 161, 1981-1988.
• Paul, R., Chawarska, K., Fowler, C., Klin, A.,
  Cicchetti, D., Volkmar, F. (2007) Listen my
  children and you shall hear Auditory preferences
  in toddlers with autism spectrum disorders.
  Journal of Speech, Language and Hearing Research,
  50, 1350-64.
• Chawarska, K. Klin, A. Paul, R. Volkmar, F.
  (2007). Autism spectrum disorder in the second
  year Stability and change in syndrome
  expression. Journal of Child Psychology and
  Psychiatry, 48, 128-138.
• Paul, R., Chawarska, K., Klin, A., Volkmar, F.
  (2008). Language outcomes in toddlers with ASD A
  2 year follow-up. Autism Research, 1, 97-107.

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Klin, Chawarska, Paul, Rubin, Morgan, Weisner,
Volkmar, 2004

• Helen 15 mo.
• Series of ear infections at 12 mo.
• Stopped vocalizing and approximating words at 12
  mo.
• Decreased social interaction
• Aversion to bright lights and loud noises
• Brother 22 mo. older w/ ASD

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Helen at 15 mo.
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Klin, Chawarska, Paul, Rubin, Morgan, Weisner,
Volkmar, 2004

• At 15 mo., Helen
• Met ADOS criteria for autism
• Met clinical criteria for autism
• Met DSM-IV criteria for autism
• EI program developed
• To increase rate of communication
• Increase ability to make requests
• Increase frequency of joint attentional
  interactions
• Increase repertoire of gestural communication
• Introduce a picture communication system
• Increase language comprehension

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Helen Assessment Data MullenThree time points

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Helen Assessment Data VinelandThree time
points

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Helen at age Four Video

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Making Early Diagnoses Group Data (Chawarska et
al., 2007 Paul et al., 2008)

• Subjects (n37)
• 15-24 mo.
• Referred for suspicion of ASD or TD
• Normal vision and hearing
• Extensive evaluation including
• Mullen
• CSBS
• Vineland
• ADOS
• Met clinical and ADOS criteria for ASD
• 77 males
• Seen at 2 and 4 years

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Making Early Diagnoses Use of Communicative
Behaviors (Chawarska et al., 2007 Paul et al.,
2008)
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Language and Cognitive Scores Time 1
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Profiles of Communication Skills Time 1
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Observations

• Language lags behind CA and NV MA
• Language production in advance of language
  comprehension
• Speech sound production at near-normal to mildly
  delayed levels
• Expressive language less advanced than speech
• Receptive skills moderately to severely affected

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Data on Communication show

• Below average response to others speech
• Less ability to tune in to speech signals
  relevant to their stage of language learning
  (Paul et al., 2007)
• Use of gestures and manage affect, gaze and
  reciprocity
• Low rate of expression of communicative function
• Little symbolic play
• Relative strengths
• Nonverbal cognitive measures,
• Production of sounds and words

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Other Behaviors in Children with Autism Under Age
2 ADOS scores (Chawarska et al., 2007)
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Other Behaviors in Children with Autism Under Age
2 ADOS scores
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Other Behaviors in Children with Autism Under Age
2 ADOS scores
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Other Behaviors Summary

• Even before age 2, children who meet clinical
  criteria for ASD show the triad of symptoms
• Even before verbal skills emerge, ADOS assessment
  showed
• Lack of response to name
• Poor eye contact
• Limited response to joint attention bids
• Lack of pointing
• Delays in functional and symbolic play

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Changes in Syndrome Expression over Time

• 90 of children diagnosed as autism before age 2
  retained the diagnosis by age 3-4 ALL diagnoses
  as ASD (autism PDD-NOS) retained the diagnosis
  by age 3-4
• There were changes in patterns of syndrome
  expression

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Change in Patterns of Response Over Time
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Changes in Other Behaviors in Children with
Autism Under Age 2 Over Time ADOS scores
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What Predicts Language Outcomes?(Paul et al.,
2008)

• Examined outcomes for those children who did and
  did not achieve spoken language by age 4.
• Defined as Adaptive Communication w/in 2 s.d. of
  mean on Vineland
• 54 of sample achieved this standard
• Those more likely to end up in the better
  language outcome group had
• Higher nonverbal cognitive score before age 2
• Fewer stereotyped and repetitive behaviors before
  age 2 Better comprehension before age 2
• More sounds in the inventory before age 2
• More response to joint attention before 2
• Some symbolic play before 2

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What Predicts Language Outcomes?(Paul et al.,
2008)

• Regression analysis showed the BEST predictors
  before age 2 of language outcome at age 4 were
• Receptive language level
• Absence of stereotypic and repetitive behaviors

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Auditory Preference Study (Paul et al., 2007)

• Children with ASD show a reduced preference for
  speech relative to TD
• Children with TD show preferences for prosodic
  cues that are tuned to the language they are
  mastering
• Children with ASD fail to show these tuned
  preferences
• In ASD, degree of preference for speech is
  correlated w/
• Concurrent language skill
• Level of language one year later

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Summary ASD in Children Under 2

• ASD can be identified by experienced clinicians
  using multiple assessment instruments before age
  2
• Diagnoses made this way are relatively stable.
• Behaviors that identify ASD before 2 are
• Similar to symptoms in older toddlers and
  preschoolers
• Poor response to name and language
• receptive deficits are especially likely to be
  seen
• so is poor response to joint attention bids
• Reduced use of gestures,
• Reduced rate of expression of communication
• Poor eye contact lack of coordination of gaze
  and gestures and vocalizations
• Reduced functional and symbolic play
• Presence of stereotypic and repetitive behaviors
  at this early age is associated with poorer
  language outcome

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Predicting Language Outcomes

• Children under 2 with symptoms of ASD are more
  likely to show better language outcomes by
  preschool age if they
• Perform better on non-verbal cognitive tests
• Have better response to name, language, and
  gesture (RJA)
• Have higher receptive language performance
• Produce more sounds
• Show some symbolic play
• DO NOT show stereotyped and repetitive behaviors

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Guidelines and Evidence-Based Practices for
Improving Communication Skills in Children with
ASD Under Age 2
Rhea Paul, Ph.D., CCC-SLP Prof., Yale Child
Study Center Director, Communication Disorders
Section Rhea.paul_at_yale.edu
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Implications Studies of Early Communication
Development

• Attention to speech is reduced
• Developmental tuning of attention to speech does
  not proceed in typical fashion.
• Response to nonverbal bids for communication is
  reduced.
• These all affect the development of the
  understanding of language which, in turn,
  affects expressive language.
• Also characteristic are failures to
• use and respond to gestures,
• respond to and initiate joint attention,
• develop play skills are
• Basic motor skills that support speech do appear
  to proceed relatively normally we see relative
  strengths in sound production

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Intervention for Suggestions for
Social-Communicative Deficits in Young Children

• Increase frequency of communication w/
  prompt-free elicitations and communicative
  temptations
• Increase repertoire of social interaction and
  play routines
• Increase use of conventional gestures and
  speech-like vocalizations
• Increase receptive language through focused
  stimulation
• Focus on prelinguistic skills known to be related
  to language development
• Joint attention
• Play
• Imitation

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Joint Attention(Kasari, Sigman, Mundy,
Yirmiya, 1990 Yoder McDuffie, 2006)

• Supported joint attention
• Adult manipulates object to get child attention
• Adult comments on object child is focused on
• Provides linguistic mapping for objects and
  activities child shows interest in
• Found to support the development of vocabulary
  (Siller Sigman, 2002)
• Associated with language development after age 2
  (Paul et al., 2008 Wetherby et al., 2007)

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Symbolic Play (Toth, K., Munson, Meltzoff,
Dawson, 2006)

• Play behaviors taught by
• Discrete trial imitation
• Physical guidance
• Modeling and practice in
• using objects representa-tionally,
• Referring to absent objects
• Attributing propertiesto objects (hot!)
• Evidence shows these can be taught
• Evidence also shows children with more play
  skills do better in other interventions for
  communication

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Imitation (Ingersoll Gergans, 2007)

• Case study w/ 3 2 year olds with ASD
• Parents were trained to deliver treatment
• Taught first to imitate childs actions with
  toys, gestures, and vocalization
• Next taught to model an action with a toy related
  to what the child was doing, combined w/ verbal
  label
• Physical guidance used if needed
• Training provided 2 days/week for 10 weeks
• Results
• Parents implemented the strategies
• Children showed increased imitation

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Some Guiding Principles for Communication
Programming for Children Under 2

• Treat behavior as if it were communicative match
  child where s/he is accept any communicative
  behavior then up the ante
• Focus on skills underlying communication
• Joint attention
• Play
• Imitation
• Utilize the childs preferred strategies,
  materials, and modalities
• Use simple, minimal labels and short, grammatical
  remarks
• Provide language for what is on the childs mind
  Use unconventional behaviors as a starting point
  for communication
• Start by following child interests Later provide
  models of more adaptive, conventional behaviors
• Provide concentrated, repeated opportunities
• Teach both initiation and responsive behaviors
• Embed in natural interactions (play, routines)