Chapter 7 Autism Spectrum Disorders

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Chapter 7Autism Spectrum Disorders
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DSM-IV Definitions

• Autistic Disorder - marked by three defining
  features, with onset before age 1) impaired
  social interaction, 2) impaired communication,
  and 3) restricted, repetitive, and stereotyped
  patterns of behavior, interests, and activities
• Asperger Syndrome - impairments in all social
  areas, particularly an inability to understand
  how to interact socially
• Rhetts Syndrome - a distinct neurological
  condition that begins between 5 and 30 months of
  age, marked by a slowing of head growth,
  stereotypic hand movements, and severe
  impairments in language and coognitive abilities
• Childhood disintegrative disorder - shares
  characteristics with autistic disorder, but
  doesnt begin until after the age of 2 and
  sometimes not until age 10
• Pervasive Developmental Disorder - Not Otherwise
  Specified (PDD-NOS) - diagnosis given to children
  who meet some, but not all, of the criteria for
  autistic disorder.

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IDEA Definition

• Autism is a developmental disability affecting
  verbal and nonverbal communication and social
  interaction, generally before age 3, that
  adversely affects a childs performance.

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Characteristics

• Impaired social relationships
• Many children with autism do not speak.
  Echolalia is common among those who do talk
• Varying levels of intellectual functioning,
  uneven skill development
• Unusual responsiveness to sensory stimuli
• Insistence on sameness
• Ritualistic and stereotypic behavior
• Aggressive or self-injurious behavior

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Screening

• Early diagnosis is highly correlated with
  dramatically better outcomes
• Autism can be reliably diagnosed at 18 months of
  age
• Checklist for Autism in Toddlers (CHAT)
• Modified Checklist for Autism in Toddlers
  (M-CHAT)

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Diagnosis

• Childhood Autism Rating Scale (CARS)
• Autism Diagnostic InterviewRevised
• Gilliam Autism Rating Scale (GARS)
• Asperger Syndrome Diagnostic Scale (ASDS)
• It is largely based on clinical judgment

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Prevalence and Causes

• Prevalence
• Recent estimates - Autism occurs in as many as 1
  in 150 children (CDC, 2007)
• Boys are affected about 4 times more often than
  girls
• Autism is the fastest-growing category in
  special education (autism epidemic)

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Prevalence and Causes

• Causes
• The cause of autism is unknown
• Controversial theories
• MMR vaccine
• Mercury (thimerosal)
• No evidence of childhood vaccinations causing
  autism
• There is a clear biological origin of autism in
  the form of abnormal brain development,
  structure, and/or neurochemistry
• Genes may be responsible for the abnormality
• Environmental factors may trigger the disorder

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• What is a science-based approach?
• and how is it different from pseudo-science?

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Science

• reliable and valid measurements
• pre- post measures
• control/comparison group(s)
• blind or independent evaluators
• replication
• published in peer reviewed journals

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Pseudoscience

• No scientifically valid evidence
• (no) controlled studies
• (in)consistent findings
• (not) published in peer reviewed journals
• Use numbers and graphs
• Ph.D.s and M.D.s Institutes
• www.quackwatch.org

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• What does body of scientific research conclude
  about interventions with children with ASD?

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Current unproven or disproven medical
interventions

• Secretin
• peptide hormone that stimulates the secretion of
  digestive fluids, no benefits in 3 controlled
  studies
• Gluten Free/Casein Free Diet
• food allergies cause or contribute to autism has
  no sound scientific evidence supporting
• Hyperbaric oxygen
• The logic for using hyperbaric oxygen treatment
  for developmental disorders relates to the
  auto-immune and/or viral theory of these
  conditions. Encephalitis, in this theory, is
  thought to be part of developmental disorders. No
  data on the use of hyperbaric oxygen for
  developmental disorders

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Current unproven or disproven medical
interventions

• Vitamin B6 and magnesium
• Dimethylglycine (DMG) (Vitamin B 15)
• AZT (Terovir)
• Steroids
• Antibiotics
• Antifungal medications
• Behavioral Optometry
• Craniosacral therapy
• The emphasis in Biodynamic Craniosacral Therapy
  is to help resolve the trapped forces that
  underlie and govern patterns of disease and
  fragmentation in both body and mind. This
  involves the practitioner "listening through the
  hands" to the body's subtle rhythms and any
  patterns of inertia or congestion.

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Current not yet validated or disproven nonmedical
interventions

• DIR (Greenspans Floortime)
• Floortime is your childs practice time. Each
  time you get down on the floor and
  interactspontaneously, joyfully, following your
  childs interests and motivationsyou help him
  build that link between emotion and behavior, and
  eventually words, and in doing so move forward on
  his journey up the developmental ladder
• Sensory Integration
• is a complex disorder of the brain that affects
  developing children. Children with SPD
  misinterpret everyday sensory information, such
  as touch, sound, and movement.
• RDI (Guttstein)
• Higashi Method
• Music Therapy
• AIT (Auditory Integration Training)
• Hippotherapy/Dolphin therapy
• Occupational Therapy

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Found harmful in scientific studies

• Facilitated Communication
• Auditory integration training
• Intravenous immune globulin
• withholding vaccinations

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Evidence-Based Treatment

• Applied Behavior Analysis is the only treatment
  approach that has been documented to produce
  significant gains (comprehensive and
  long-lasting) for children with ASD
• U.S. Surgeon Generals Report
• New York State Department of Early Intervention
  Task Force
• 12 well-designed, peer-reviewed comparison
  studies (with over 342 subjects)
• Hundreds of peer-reviewed studies documenting
  specific ABA procedures

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Why Science?

• Basing decisions about interventions mainly on
  preconceptions, opinions, speculations,
  subjective impressions, and badly done studies
  has many risks
• Wasted money, time, energy
• Exploitation of vulnerable people
• Physical and emotional injuries
• Lost opportunities to make real advances
• Reinforcement and perpetuation of practices that
  impede progress
• The most tried-and-true way to reduce those risks
  is to rely on careful scientific evaluation to
  separate opinions and beliefs from verifiable
  facts.

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Educational Approaches

• Applied Behavior Analysis (ABA)
• Discrete Trial Training
• Picture Exchange Communication System (PECS)
• Peer-mediated interventions
• Errorless discrimination learning
• Generalization
• Functional assessment of challenging behavior
• Pivotal response intervention
• Naturalistic language strategies

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Educational Approaches (continued)

• Social stories
• Picture activity schedules
• Educational Placement Alternatives
• Regular Classroom
• Resource Room

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Where do we start?

• Imitation
• Attending to environment
• Visual auditory
• Eye contact
• Joint Referencing
• Exploratory behavior
• Shared attention

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Howard, Sparkman, Cohen, Green, Stanislaw (2005)

• Generic Early Intervention
• Autism Programs
• Intensive ABA
• parental preference most significant factor in
  placement

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Children in the study

• lt48 months of age
• Dx
• Autism or PDDNOS
• qualified, independent examiners
• Intervention
• No secondary medical condition
• English primary language
• No IQ cut off

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Generic Early Intervention Programs
?16 staffing ratio ?15 - 17 hours per week ?gt50
individual or group Speech Tx ?Curriculum ?develop
mentally appropriate ?language rich
environments ?typical preschool activities
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Autism Preschool Programs
11 or 12 staffing ratio 26 - 30 hours per
week Behavioral consultant 50 individual or
group Speech Tx Curriculum Discrete trial
component PECs TEACCH typical preschool
activities
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Intensive ABA

• 11 staffing
• 35 hours per week
• errorless learning
• gt800 trials/structured opportunities per day
• Joint attention, imitation, and initiation
• Speech Pathologist consultant

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Procedure

• Re-contacted 1 year after baseline
• Independent follow-up testers
• IEP and file review
• educational placement
• hours and services

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Participants at Baseline
Generic EI (16) Autism (16) Intensive ABA (29)
Age (mos) 35 39 31
IQ (SS) 60 54 59
Language (mos) 17 15 14
Autism Dx 72 81 82
Mother Ed (yrs) 13 13 14
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Cognitive Functioning
Standard Scores
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Receptive Language
Standard Scores