early identification of infants and toddlers with autism and other developmental disabilities...
TRANSCRIPT
Early Identification of Infants and Toddlers With Autism and Other Developmental Disabilities
January 2012Albany, New York
Patricia Towle, Ph.D.Westchester Institute for Human
Development
Autism Spectrum Disorders in Young
Children: The Background, the
Basics, and the Behaviors
The Background
•Current prevalence estimates
•Current push for early identification
•The validity of early identification/diagnoses
•How early can we recognize or diagnose?
•Current prevalence estimates
The Background
• 1/150 children• 3-4 boys for every girl• this includes the broad spectrum from severe to mildSource: CDC--Morbidity and Mortality WeeklyDec 12, 2009
•Push for early intervention
The Background
• Early intervention works!• The earlier, the better• The closer to 2 years, the better
Early detection: Why is it so important?
Early intervention works!Supports development ->better foundation-
> supports higher levels of independence later
Starts caregivers with their advocacy training-the sooner, the betterUnderstanding needs, learning the system,
accessing resources, impacting on the system
• Pediatrician, family medicine and primary care provider in key role to refer parents for evaluations as early as possible
•Are early diagnoses reliable and valid?
The Background
Author, Date Goal Subjects Followed From – To
Results
Cox, 1999
Predictive validity of
ADI-R
45Compared
different ASD risk levels
20 mos – 42 mos
Diagnosis of ASD at 20 months is predicted to be highly sensitive and
stable
Stone, 1999
Diagnostic stability in children under 3 years
25 Aut, 12 PDD-NOS
31.4 mos – 45.0 mos
Stability seen in 92+%
Szatmari,
2000
Comparison of outcomes between Aut
and Asp
46 Aut20 Asp
4-6 years – 6-8 years
Diagnosis of Aut and Asp remained stable
Michelotti, 2002
Follow-up of children with ASD-
like symptoms
18 with language
delay and Aut features
4 years 4 mos –
8 years 7 mos
All were diagnosed with an ASD
(Aut, Atyp Aut, Atyp Aut with lang. delay)
Author, Date Goal Subjects Followed From – To
Results
Moore, 2003
Diagnostic stability
16 Aut3 Atyp Aut
1 Lang disorder
2 years 10 mos –
4 years 5 mos
All diagnosed with Aut or Atyp Aut retained ASD diagnosis
Freeman, 2003
Diagnostic stability
59 ASD 2-5 years – 4-6 years
Early ASD diagnosis remained stable
Eaves, 2004
Diagnostic stability
49 with characteristics
of Aut
2 years 9 mos – 4 years 11 mos
97% Aut retained ASD77% PDD-NOS retained ASD
Charman, 2005
Diagnostic stability
29 with Aut 2 years – 7 years
Standard measures at age 2 years did not predict outcomes at 7 years, but measures at age
3 years were predictive
McGovern,
2005
Diagnostic stability
48 with Aut 3 years 11 mo –
19 years
96% retained diagnosis through adolescence/early adulthood
•80-90% of children id’d as toddlers or preschoolers remain on “the spectrum” into school age years
•Many young children who have symptoms within the profile of ASD but don’t meet full criteria also end up with an ASD diagnosis
•Young children with milder presentations are slightly more likely to change diagnosis from early to later
Yes, early diagnoses are reliable and valid.
The Background
3 years – no problem (except for especially mild and complex cases)
24 months – most can be dxed by now
18 - 20 months – many can be
14-15 months – for some, strong risk can be established
12 months – for a few, strong risk can be established
How early is early identification?
The Background
There are different developmental trajectories of ASD symptoms in children
Three major patterns of symptom emergence:
Different from the start (never really develop social linguistic skills)
Plateau and fade (13 – 15 months)More clear regression (15-20 months, 20-35 %) in
second yearPatterns in between
The Basics
• Current Terminology
• A Spectrum Disorder: The Issues
• The Diagnostic Criteria
• What Autism Isn’t
The Confusing Array :
PDD-NOS
Atypical Autism
Asperger syndrome
PDD
Pervasive Developmental Disorder
Infantile
Autism
Autism Spectrum Disorder
CDD
The BasicsCurrent Terminology
Professional Vs. Diagnostic
Autism Spectrum Disorder
The Pervasive Developmental Disorders
The Basics
Current Terminology
Manual for diagnosing all mental health and developmental disorders in childhood and adulthood
Diagnostic and Statistical Manual of Mental Disorders
The Basics
Current Terminology
The Pervasive Developmental
Disorders
AutisticDisorder Asperger
Syndrome
PDD-NOS
RettSyndrome
ChildhoodDisintegrativeDisorder
The Basics
The Pervasive Developmental Disorders
AutisticDisorder
AspergerSyndrome
PDD-NOS
“Core Disorder”Approx 50% of PDDs- wide
range of IQ15% have some
identifiable genetic disorder, for example FraX
30% have seizure disorder
The Basics
Milder version“Subthreshold”
Aspergers - social problems without the same degree of language problems
Most have average to above average IQ
The Pervasive Developmental Disorders
AutisticDisorder
AspergerSyndrome
PDD-NOS
The Basics
The issues with a “Spectrum Disorder”1. A continuum of
Severity
More severe
MoreMild
The Pervasive Developmental Disorders
AutisticDisorder
AspergerSyndrome
PDD-NOS
The Basics
The issues with a “Spectrum Disorder”
2. The interface with cognitive delay
More severe
MoreMild
Cog
nit
ive
Fu
ncti
on
ing
HighLow
High
Low
Symptom Severity
The Basics2. The interface of symptom severity with
cognitive delay
CognitiveFunctioning
HighLow
High
Low
Symptom Severity
Low Functioning Autism
High Functioning Autism
ID (MR) with Autistic-like
features
Very Mild Autism/PDD-NOS/Aspergers
The Pervasive Developmental Disorders
AutisticDisorder
AspergerSyndrome
PDD-NOS
The Basics
The issues with a “Spectrum Disorder”
3. Variable symptom presentation
More severe
MoreMild
Autism Spectrum Disorder:The Three Symptom Domains
Social Interaction
Communication
Repetitive Behaviors
The Basics
ASD Profile of Behaviors
Social Interaction Communication Repetitive Behaviors
1. Impairment in nonverbal behaviors to regulate social interactions
2. Failure to develop peer relations
3. Lack of spontaneous sharing of emotions
4. Lack of reciprocity
1. Delay in development of spoken language
2. Lack of ability to sustain conversation
3. Atypical language features
4. Lack or reduced social or pretend play
1. Preoccupation with unusual pattern of behavior
2. Inflexible adherence to routine
3. Stereotyped, repetitive mannerisms
4. Preoccupation with parts of objects
The Three DSM-IV Symptom Domains
The Basics
Three Symptom Domains: Children can have different degrees of symptoms across
them
Social InteractionCommunication
Repetitive Bhvrs
severe
severe
severe
mild
mild
mild
The issues with a “Spectrum Disorder”
Communication Social Interaction
Repetitive Behaviors
AUTISM SPECTRUM DISORDER
social languagedifficulties
Difficulties initiating and maintaining social interaction
Restricted, repetitive play underdeveloped for age
The issues with a “Spectrum Disorder”
AUTISM SPECTRUM DISORDER
3. Variable symptom presentation
CommunicationSocial
Interaction
They may be better with highly familiar people in very familiar routines or favorite activities
Great unevenness across people and settings is a feature of ASD
The Behaviors
•Social Interaction
•Communication
•Repetitive Behaviors
Social Interaction Behaviors
What are the COMPONENTS?
1. Social Interest: How does a child show that they are interested in and “tuned in” to other people?
2. Emotional Expression or Signaling: How does a child share emotions and how “readable” are they?
3. Capacity for Interaction: How much “back and forth” can they do?
Seeks Proximity: vs. Indifference or Avoidance
The Social Interest Component: How do they show they are interested in and tuned in to others?
Stays physically close if comfortable
Indifference or Avoidance
The Social Interest Component
Off by himself; may take off when others come near
Stays with others but does not interact
Typical eye contact use vs. Avoidance of, reduced, or impersonal eye contact
The Social Interest Component
Monitors eyes and face vs. Does not monitorof others
The Social Interest Component
The Social Interest Component
The Social Interest Component
The Social Interest Component
The Social Interest Component
The Social Interest Component
Social Interaction Behaviors
What are the COMPONENTS?
1. Social Interest: How does a child show that they are interested in and “tuned in” to other people?
2. Emotional Expression or Signaling: How does a child share emotions and how “readable” are they?
3. Capacity for Interaction: How much “back and forth” can they do?