Autism Spectrum Disorders: Diagnosis and Treatment .
Autism Spectrum Disorders: Diagnosis and Treatment Sharifa Yateem, MS. ABA. New England Center for Children Abu Dhabi © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Outline of the presentation • How is Autism Diagnosed ? o What is Autism? o DSM-V Diagnostic Criteria • • • • • Severity of Autism and SCD What causes Autism ? Autism Treatments What is ABA ? Summary © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. How is Autism Diagnosed? © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Autism Diagnosis • No medical diagnostic test – No prenatal test – No definitive genetic test (yet) • Diagnosis should include – Detailed developmental history – Direct observation and assessment of child’s behavior • Diagnosis by a practitioner experienced in childhood developmental disorders © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Autism Diagnosis “Red Flags” No big smiles or other warm, joyful expressions by 6 months No back- and- forth sharing of sounds, smiles or other facial expressions by 9 months No babbling by 12 months © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Autism Diagnosis “Red Flags” No words by 16 months No meaningful, two-word phrases ( not including imitating or repeating) by 24 months Any loss of speech, babbling or social skills at any age © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Diagnostic Criteria • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association (2013; DSM-V) :Autism spectrum disorder (ASD) and the related diagnosis of social communication disorder (SCD) • Symptoms must begin before the child reaches 3 year old. © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Autism Spectrum Disorders All Autism Spectrum Disorders (ASD) include one or more of these … – Impairments in Communication skills – Impairments in Social skills and interactions – Occurrence of Stereotyped (repetitive) behavior or highly restricted interests © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Impairments in Communication Examples of impairments: a. delay in, or total lack of, the development of spoken language b. impairment in the ability to initiate or sustain a conversation with others c. stereotyped and repetitive use of language or idiosyncratic language a. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Impairments in Social Interaction Examples of Impairments: a. impairment in the use of nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction b. failure to develop peer relationships appropriate to developmental level c. lack of spontaneous seeking to share enjoyment, interests, or achievements with other people, lack of joint attention (e.g., by a lack of showing, bringing, or pointing out objects of interest) d. lack of social or emotional exchanges © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Restricted, repetitive patterns of behavior Examples of impairments: a. preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus b. inflexible adherence to specific, nonfunctional routines or rituals c. stereotyped and repetitive motor mannerisms (e.g., hand flapping, rocking, repetitive vocalizations) d. persistent preoccupation with parts of objects © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Severity levels of Autism © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Severity Levels of Autism Level 3 “Requiring very substantial support” Level 2 “Requiring substantial support” Level 1 “Requiring support” © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Level 3 Social Communication • Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, • very limited initiation of social interactions • minimal response to social overtures from others. • rarely initiates interaction • makes unusual approaches to meet needs only and responds to very direct social approaches © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Level 2 Social Communication • Marked deficits in verbal and nonverbal social communication skills • social impairments apparent even with supports in place • limited initiation of social interactions • reduced or abnormal responses to social overtures from others. • For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and who has markedly odd nonverbal communication. © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Level 1 Social Communication • Without supports in place • deficits in social communication cause noticeable impairments. • Difficulty initiating social interactions, and clear examples of atypical or unsuccessful response to social overtures of others. • May appear to have decreased interest in social interactions. • For example, a person who is able to speak in full sentences and engages in communication but whose to- and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful. © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Level 3 Restricted, repetitive behaviors • Inflexibility of behavior • Extreme difficulty coping with change • Other restricted/repetitive behaviors markedly interfere with functioning in all spheres. • Great distress/difficulty changing focus or action. © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Level 2 Restricted, repetitive behaviors • Inflexibility of behavior • Difficulty coping with change • Other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. • Distress and/or difficulty changing focus or action. © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Level 1 Restricted, repetitive behaviors • Inflexibility of behavior causes significant interference with functioning in one or more contexts. • Difficulty switching between activities. • Problems of organization and planning hamper independence © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Social Communication Disorder (SCD) • SCD is a new diagnosis in the DSM-V • Disabilities in the area of social communication without repetitive behaviors and/or restricted interests • Struggle with rules of conversation such as taking turns • Problems understanding the underlying meaning conveyed by tone © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Main difference between ASD and SCD Clearly, many individuals with autism share these difficulties. But to receive a diagnosis of ASD under DSM-5, one must also have the repetitive behaviors and/or restricted interests typical of autism © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. What causes Autism? © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. What causes autism? • Research from various disciplines support the concept that autism is a biological, geneticallybased disorder of brain development • There is no single known cause at this time. Why? – Diagnostic inconsistency – Heterogeneous population © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Prevalence of Autism Spectrum Disorders All ASDs • 1994 DSM-IV: 2–5 cases in 10,000 • 1999 NYS Clinical Practice Guidelines: 10-15 per 10,000 • 2003 US Center for Disease Control: 20-60 per 10,000 • 2006 US Department of Education: 40-45 per 10,000 • 2007 US Center for Disease Control: 1 in 150 individuals • 2012 US Center for Disease Control: 1 in 88 individuals © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Why the increase? Apparent increases in prevalence may be due to… 1. Changes in diagnostic criteria and reporting requirements over time (in US; “diagnostic substitution”) 2. Differences in methods across studies 3. Increased public awareness 4. Real increase?? (Wing & Potter, 2002) © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Autism Spectrum Disorders • Early diagnosis and intervention greatly improves the prognosis, and • Substantially reduces cost of care over the lifespan (Jacobson et al., 1998) © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Autism Treatment: Early Intensive Behavioral Intervention (EIBI) © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Autism Treatment The GOOD news: • Effective treatment is available The BAD news: • It is hard work, expensive to deliver, and takes time • There are not enough well-trained practitioners © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. EIBI Autism Treatments The most reliable treatments are those that • use quantitative outcome measures to • demonstrate socially-meaningful and durable changes in • key behaviors that increase independent functioning © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. EIBI Autism Treatments Evidence-based treatments will include… – Evaluation before, during, and after treatment – Measurable change in skills and behaviors – Replication of effects across many individuals © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. When considering a treatment… • How has the treatment been evaluated? • Are specific skills targeted, that is, are there specific goals for increasing functioning? • How is progress monitored? Objective, quantitative data? • Has the treatment been demonstrated effective with many children with ASD? • Does it interfere with other treatments? © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Autism Treatments There currently is no sound scientific support for the use of these as primary treatments for ASD: • • • • • • Hormone medications Chelation therapy Hyperbaric chamber Gluten free - casein free diet (GFCF diet) Immunological medications Mega- vitamin doses © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Psychopharmacological Interventions Medication is sometimes used to treat problem behaviors seen in ASD including… • • • • “Irritability” and acting out Hyperactivity, inattention, and impulsivity Preoccupations, rituals, and compulsions Anxiety © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. What is ABA ? © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. • Common Elements of Effective EIBI/ABA Programs Curriculum focus in major ASD deficit areas (videos) • Communication • Social interaction • Imitation • Play skills • Program for skill generalization Ref: New York State (US) Early Intervention Practice Guidelines (1999) © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Common Elements of Effective EIBI/ABA Programs continued… • Function-based approach to problem behaviors • Teach appropriate replacement behavior • Transition to typical setting • Critical importance of family involvement Ref: New York State (US) Early Intervention Practice Guidelines (1999) © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. EIBI/ABA at NECC-Abu Dhabi • • • Services delivered at school and home Curriculum emphasizes: eye contact and attending, imitation, play, discrimination skills, communication, motor, self-help, and preacademics Combination of techniques used across multiple environments: individual and small-group instruction, community and social integration, etc. © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. EIBI Treatment Outcomes “In any group of children with ASD who receive competently delivered EIBI, between 20% and 50% will achieve normal functioning; about 40% will achieve meaningful but moderate gains; and about 10% will continue to require intensive special education and adult services” (Jacobson et al., 1998) © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. ABA/ EIBI parameters How many hours ? Who should deliver service ? Certified BACB www.bacb.com How it should be supervised ? © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Summary • Early diagnosis is critical – look for – Communication deficits – Social skills deficits – Unusual habits or behaviors • Effective treatment is available – Earlier intervention is associated with better prognosis – Treatment should be based on sound scientific principles and research © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. New England Center for Children - Abu Dhabi Sharifa Yateem, MSc. P.O. Box 112923 Abu Dhabi, UAE syateem@NECCUAE.org www.NECCABUDHABI.org www.bcba.org © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. Want more information about ABA ? Join UAE Association for Behavior Analysis uaeaba@gmail.com Facebook group: ABA Middle East © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC. DSM 4 vs DSM 5 Individuals with a well-established DSM-IV diagnosis of Autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified (PDD-NOS) should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder. © 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
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