Early Intervention for Toddlers with Autism Spectrum Disorders

Is It a Special Case?

Hannah Schertz, Ph.D.

Autism Spectrum Disorders (ASD)

Social communication disorder with repetitive or stereotypical behavior and/or fixed interests

Wide-ranging in severity4-5 times more prevalent in boys than girlsPrevalence in 8-year-olds is nearly 1:100

http://www.cdc.gov/ncbddd/autism/data.html#prevalence

Increase due to broader diagnostic criteria, awareness, improved screening and diagnosis

(Odom, Schertz, Wong, in press)

ASD in ToddlersAll

Difficulty with preverbal social communication◦ Looking at others’ faces◦ Reciprocal back-and-forth interaction with a

partner◦ Sharing attention about mutual interests

Some Fixed or repetitive interests and behaviors

(may not appear until later)Challenging behaviors related to

communication difficulties and/or fixed interests

(Boyd, Odom, Humphreys, & Sam, 2010)

Causes

Genetic influenceConnected to vaccines?

Disproved in multiple studiesBrain differences: Effect or cause?

Early Identification

Why is it important?◦Improved outcomes with early

intervention ◦Early support and education for

parents

Early Identification

How can early educators help? ◦Know red flags◦Listen and respond to parents’

concerns◦Provide prompt access to screening

and diagnostic evaluation ◦Be vigilant

Red flags for toddlers

Not “showing” objects or following points

No ‘pretend play’ by 18 monthsAvoiding looks to others’ facesRepeating actions over and over Difficulty adjusting to new routines

http://firstsigns.org/ http://firstwords.fsu.edu/ http://www.ddhealthinfo.org/documents/ASDquickguide.pdf

Communicating with FamiliesResponding to family suspicion of

ASDTake seriously: Parents often raise

first concern; want prompt answersFacilitate screeningRefer for diagnostic evaluation if

screen shows high riskAvoid suggesting ASD before

diagnosis

Communicating with Families

If you have concerns before the family does:Offer screening to all familiesAvoid using “autism” terminology Avoid writing off reticence as “denial”Keep in touch for support and follow-up Proceed on parents’ terms –when

ready.Do not wait for diagnosis to address

social communication needs

Screening

Modified Checklist for Autism in Toddlers (MCHAT; Robins, Fein, Barton, & Green,

2001): Free parent questionnaire & instructions

http://www2.gsu.edu/~psydlr/Diana_L._Robins,_Ph.D..html

Who can administer? ◦ Parent completed◦ Simple scoring procedures◦ Follow-up interview for greater

reliability

Evidence-based Intervention

Approaches reported for toddlers

with ASD

◦Traditional behavioral

◦Naturalistic behavioral

◦Developmental

Evidence-based Intervention

Consider each approach for:◦Intensity: Implications for each◦Effectiveness : The big picture, not

just narrow skills (Buysse & Wesley, 2006) ◦Outcomes: Socially grounded,

meaningful in everyday life, developmentally appropriate

◦Process : How it fits with principles of practice for toddlers and families’ values/priorities

Traditional BehavioralLovaas: Traditional Applied Behavioral

Analysis (ABA); Discrete Trial TrainingLearning theory: Modify what comes before

or after to elicit, change, eliminate behaviors

Adult directed (; prescribed learning tasks)Intensive (35-40 h/w)Prompting, reinforcement, fading, time-

delayResearch counters unqualified effectiveness

claimsIn widespread use

Naturalistic Behavioral

Similar to traditional behavioral view that children learn by modifying behaviors in response to environmental contingencies

Considers child interests & motives (more child centered); natural reinforcers

Gaining ground over traditional ABAExamples: Pivotal response treatment

(emphasizes behaviors important for broader learning); incidental teaching

DevelopmentalChild brings internal competency to learningAdults follow child’s lead to promote

spontaneity, initiative, & self-directed learning

Promotes internal motivation, natural consequences

Emphasizes social relationships, affect sharing

Examples: Developmental Social Pragmatic, Joint Attention Mediated Learning (JAML), Early Start Denver Model (hybrid)

Early Intervention: Core Principles

1. Family-centered and strengths-based

2. Natural and inclusive environments3. Developmentally sound4. Active and functional child

engagement5. Coordinated and systematic

Schertz, H. H. (in press)

Intervention for Toddlers with ASD

Observing practices for toddlers with ASD:How do current practices fit with

each principle?How can we reconcile differences

or make changes when there is not a fit?

Principle 1:

Family-centered & Strengths-basedFamily-centered

◦Incorporates family priorities◦Supports parent-child relationship

rather than replacing it with professional-child interaction

Strengths-based◦Views families as capable ◦Enables (rather than trains) families to

promote toddler social development

Principle 1:

Family-centered & Strengths-based

Which best promotes an active family role?

◦Child participates in prescribed, highly structured intervention

◦Train parents in specific behavioral strategies

◦Support families to use their knowledge of the child to embed learning throughout everyday activities

Principle 2:

Natural & Inclusive Environments

Part C requirementGroups mirror the general population in

proportion of children with disabilitiesBenefits

◦It is where most learning occurs◦Facilitates natural family role◦Embeds learning in natural everyday

activities with familiar people◦Naturally facilitates generalization of

learning

Principle 2:

Natural & Inclusive Environments

Which best promotes learning that is meaningful in the everyday world?

◦ Clinic-based or segregated settings◦Professionally implemented in natural

settings with expectation that learning will carry over

◦Natural settings with learning embedded into natural activities with familiar people

Principle 3:

Developmentally Sound Intervention

Follow natural developmental sequences◦Address preverbal social communication first◦Build on natural precursors

Motivate, prevent behavior challenges with:◦Developmentally appropriate activities◦Activities that match development &

interests◦Respect for child’s tolerance level

Principle 3:

Developmentally Sound Intervention

Which belief(s) about learning challenge the child just above current skill levels?◦Learning occurs by modifying behaviors◦Learning occurs by modifying behaviors

with consideration for child interests◦Learning builds on current competencies;

considers foundational competencies that can take child to a new level

Principle 4:

Active, Functional Child EngagementSocial communication is more than a collection of isolated skillsFollow child’s lead rather than

prescribing highly structured activities & materials

Encourage child initiative, not just responding

Avoid dependency on external rewardsPromoting foundational competencies

helps children learn on their own

Principle 4: Active, Functional Child Engagement

Which promote(s) meaningful engagement?◦Activities selected & directed by adults with

structured protocols; child engagement is maintained through reinforcers

◦Activities incorporate child interests, create opportunities for natural reinforcers

◦Activities follow child’s lead; goals promote meaningful social engagement in everyday interactions; passive responding is less valued

Principle 5:

Coordinated & SystematicTeam members provide systematic

background support rather than side-by-side services

Guidelines for developmental approaches: ◦ Intervene in the “zone of proximal development”◦ Embed learning within meaningful social contexts ◦ “Scaffold” learning ◦ Mediate learning (planfully) rather than “train”

Guidelines for behavioral approaches: ◦ Promote pivotal (foundational) learning◦ Use tested strategies; follow child interests◦ Avoid focus on narrow skills with limited

relevance to everyday life or to meaningful future goals

◦ Support generalization by working in natural environments

Principle 5:

Coordinated & Systematic

Which are coordinated & systematic?◦ Specialists organize services around areas of delay;

team defers decisions to specialists; may be intrusive, inefficient, and at cross purposes

◦ Team members (including parents) share expertise, encouraging others to consider their goals.

◦ Team members systematically support each other’s learning, fading support as expertise is gained

◦ Outcomes and intervention processes are planned and delivered systematically considering evidence of effectiveness and developmental research

Is toddler intervention in ASD a special case?

Yes

Focus on preverbal social

communication

No

◦Toddlers with ASD are children first

◦Principles of good early intervention

apply

Online ResourcesAssociation for Science in Autism Treatment http://

www.asatonline.org/ Autism Society of America

http://www.autism-society.org/site/PageServerAutism Speaks. http://www.autismspeaks.org/Centers for Disease Control: Autism Spectrum Disorders

(ASDs) http://www.cdc.gov/ncbddd/autism/index.htmlIndiana Resource Center for Autism (IRCA).

http://www.iidc.indiana.edu/irca/ National Early Childhood Technical Assistance Center

(NECTAC): Autism spectrum disorders. http://www.nectac.org/topics/autism/autism.asp

National Research Council (2001). Educating children with autism. http://www.nap.edu/openbook.php?isbn=0309072697

ReferencesBoyd, B. A., Odom, S. L., Humphrey, B. P., & Sam, A. M. (2010).

Infants and toddlers with autism spectrum disorder: Early identification and early intervention, Journal of Early Intervention, 32(2), 75-98.

Buysse, V., & Wesley, P. W. (Eds.; 2006). Evidence-based practice in the early childhood field. Washington, D.C.: Zero to Three.

Odom, S. L., Schertz, H. H., & Wong, C. (in press). Autism spectrum disorders in young children. In H. H. Schertz, C. Wong, & S. L. Odom (Eds.). Young Exceptional Children Monograph 12: Supporting Young Children with Autism and Their Families. Missoula, MT: Division for Early Childhood.

Robins, D. L., Fein, D., Barton, M.L., Green, J.A. (2001). The Modified Checklist for Autism in Toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31, 131-144.

Schertz, H. H. (in press). Principles of intervention for young children: Implications for toddlers and preschoolers with autism spectrum disorders. In H. H. Schertz, C. Wong, & S. L. Odom (Eds.). Young Exceptional Children Monograph 12: Supporting Young Children with Autism and Their Families. Missoula, MT: Division for Early Childhood.