Autisms 01Autisms

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BEYOND CATEGORICAL ASSESSMENT
Dan Shapiro, M.D.
Developmental-Behavioral Pediatrician
Rockville, MD
drdanshapiro@gmail.com

Overview
 Categorical assessment: DSM5
 Beyond categorical assessment
 Etiologic assessment
 Functional assessment
 Transactional assessment
 Repercussions for management

Three Purposes of Assessment
1. Categorical diagnosis
2. Etiologic evaluation
3. Functional assessment

Putting it all together:
4. Transactional (multi-dimensional)
assessment

Categorical Diagnosis
 Establishes the diagnosis of an Autism Spectrum

Disorder, to:
 Gain eligibility for special services
 Justify insurance reimbursement
 Facilitate communication
 Demystify developmental difference

 Based on DSM
 ADOS, ADI, etc.

DSM5 criteria for ASDs
 Must meet criteria 1, 2, and 3:
 1. Clinically significant, persistent deficits in social communication and

interactions, as manifest by all of the following:
 a. Marked deficits in nonverbal and verbal communication used for social interaction:
 b. Lack of social reciprocity;
 c. Failure to develop and maintain peer relationships appropriate to developmental

level
 2. Restricted, repetitive patterns of behavior, interests, and activities, as

manifested by at least TWO of the following:
 a. Stereotyped motor or verbal behaviors, or unusual sensory behaviors
 b. Excessive adherence to routines and ritualized patterns of behavior

 c. Restricted, fixated interests
 3. Symptoms must be present in early childhood (but may not become fully

manifest until social demands exceed limited capacities)

Caution: screening vs. diagnosis
 Nonspecific Level I Screening: Identifies
children “at risk” for any disability from the
general population

 Autism-specific Level I Screening: Identifies
children specifically “at risk” for Autism from the
general population
 Level II screening/diagnosis: Differentiates
children with autism from those with other
developmental disorders

Differential diagnosis and
coexisting conditions
 Difficult temperament/ behavioral style
 ADHD
 Executive Dysfunctions (“ISIS”)

 Language-based Learning Disabilities
 Formal: phonology, semantics/ vocabulary, syntax,
language comprehension and expression
 Pragmatic, Non-Verbal, Social (non-literal,
interpersonal)
 Intellectual Disability (“MR”)

Differential diagnosis and
coexisting conditions (continued)
 Mood disorders: anxiety, OCD, depression, bipolar,
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severe emotional dysregulation
Thought disorders (schizophrenia)
Uneven sensory profile
Fine and gross motor disorders (CP, apraxias)
Movement disorders (chronic tics, Tourette’s)
Sleep disorders

Differential diagnosis and
coexisting conditions (continued)
 Severe environmental disadvantage
 Neglect
 Abuse
 Deprivation or adversity
 Lack of positive social role models and social teaching
 Parent psychopathology
 Family system pathology

Etiologic Evaluation
 Identifies specific underlying neurobiological, genetic,

metabolic or environmental causes, to:
 Subtype Autism Spectrum Disorders
 Promote research on prevention and management
 Possibly inform families regarding prognosis and

heritability

Etiologic Evaluation
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Fragile X Syndrome
Tuberous Sclerosis
Angelman Syndrome
Prader-Willi Syndrome
Williams Syndrome
Down Syndrome
Smith-McGuiness Syndrome
Velocardiofacial Syndrome (DiGeorge/ 22q11 deletion)
Duplication of 15 q 11-13
Metabolic disorders
Mitochondrial disorders
Seizure disorders (Landau-Kleffner Syndrome)
Fetal Alcohol Syndrome
And the list keeps growing

Etiologic Evaluation (continued)
 Hearing and vision assessment for every child
 Controversy: Genetic investigation for all? Or only if

global developmental delay/intellectual deficiency/
specific evidence of a syndrome?
 Microarray Comparative Genomic Hybridization

(mCGH)
 DNA for fragile X
 More specific studies only as indicated

 EEG, metabolic studies, fMRI only as indicated

Functional Assessment
 Determines overall and domain-specific functional

levels, to:
 Specify disparities between potential and real-life

capacities
 Establish baseline against which progress can be
measured
 Guide individualized management

Functional Assessment
 Cognitive/developmental potential
 Mullen
 Bayley
 Capute Scales
 WPPSI-III
 WISC-IV
 Leiter-R
 Differential Abilities Scales,
 etc.

Functional Assessment
 Achievement
 Assessment of Basic Language and Learning Skills
 VB-MAPP
 Woodcock-Johnson
 Vineland Adaptive Behavior Skills
 Adaptive Behavior Assessment System
 etc.

Functional Assessment (continued)
 Comprehensive speech-language assessment
includes formal aspects of linguistic skills
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Phonology
Vocabulary
Language comprehension and expression
Syntax

 But…

Functional Assessment (continued)
 Comprehensive speech-language assessment
should also include informal aspects:
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prosody (volume, pitch, rate, stress, phrasing)
pragmatics (social context, conversational rules, turntaking)
metalinguistics/ non-literal speech (metaphor, irony,
sarcasm, humor)
language of mental states (intentions, motivation,
beliefs, thoughts, feelings
narrative skills
early social skills (communicative intent, joint
attention, symbolic behaviors)

Functional Assessment (continued)
 Occupational/Sensorimotor assessment
 Functional Behavioral Assessment (FBA)
 Assessment of family functioning and

environmental stresses
 Strengths and interests

Transactional assessment
Mel Levine: “Dysfunction at the junction of the functions”
 Autism in DSM5 does require individual etiologic and

functional specifiers
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severity
current language functioning
intellectual level/disability
known genetic disorders
epilepsy (15-40%)

 4 types of “inattention”
 ADHD (distractible, impulsive)
 Autistic (perseveration, difficulty shifting)
 LD/ DD (secondary loss of attention due to task difficulty)
 Anxiety
 FBA and Family Systems Theory
 Closed/ liner vs. open/ intergenerational

Transactional assessment
Heraclitus: “No man ever steps in the same river twice,
for it's not the same river and he's not the same man.”
Over time…
 Changing profile
 mood disorder
 growing off the curve

 Changing social-cultural milieu
 school, family
 Changing medical / economic culture
 DSM IV to DSM5
 International, intra-national differences

Assessment reminders
 Nothing is more important than good ol’ history,

physical exam and observation.
 Autism assessment must include observation of peer
interaction.
 Assessment must take place across settings, across
people, and over time.

MANAGEMENT GOAL
 “To improve the overall functional status of the
child by promoting the development of
communication, social, adaptive, behavioral and
academic skills; lessening maladaptive and
repetitive behaviors; and helping the family
manage the stress associated with raising a child
with autism.”
 National Research Council, Educating Children with

Autism, National Academy of Sciences (2001)
 Also see National Standards Project, Phase 2, 2015
(www.nationalautismcenter.org)

Principles of Intervention
 Begin early
 Continue across the lifespan
 Insure sufficient intensity
 Provide sufficient structure
 Individualize plan based on functional assessment
 Remediate and accommodate
 Address weaknesses and strengths

More Principles of Intervention
 Be comprehensive
 Use multi-disciplinary team w/ case manager
 Empower the child and family
 Promote inclusion/mainstreaming

 Generalize and maintain learned skills
 Measure baseline and progress towards goals
 Modify the plan if insufficient progress

 “Keep it real-life” (Natural Environment Teaching)

The Great Debate: Which Model?
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Applied Behavior Analysis/ Discrete Trial Training (Lovaas)
Applied Verbal Behavior (Skinner/ Carbone)
DIR/ “floor-time” (Greenspan)
Relationship Development Intervention (Gutstein)
Pivotal Response Training (Koegel(s))
TEACCH (Chapel Hill, NC)
Hanen Program
The Early Start Denver Model (Rogers)
Etc.

“If you only have a hammer, all the world’s a nail.”

Non-evidence-based Treatments
 Nutritional supplements/ Elimination diets (CF/GF)
 Immunoglobulin therapy/ Steroid therapy
 Secretin/ Chelation
 Auditory integration training
 Developmental optometric training
 Interactive metronome/ Facilitated communication
 Sensory integration therapy

 Chiropractics/ acupuncture/ hyperbaric oxygen

Conventional Management
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Family/ parent/ sibling support
Speech-language therapy
Behavior management
Educational care
Social skills
Individual psychotherapy
Occupational therapy/ Physical therapy
Medication management
Transition planning
Nurture strengths and interests

Family/ parent/ sib support
 Education, counseling, training, coaching
 Disclosure/ dealing with others
 Genetics consultation
 Support groups
 Psychotherapy/psychiatric care as indicated

Speech-Language Therapy
 Top priority: ensure a system of communication,

usually emphasizing visuals
 Visual schedules, “if-then” boards
 Picture Exchange Communication System (PECS)

 Sign Language
 Augmentative and Alternative Communication (AAC)

technology (Proloquo-2-Go, Tango, etc.)
 Video/ computer-based learning

Behavior Management
 Neurodevelopmental approach
 Behavioral approach

Behavior Management (continued)
 Neurodevelopmental approach: What is it about the

child’s profile (specific skill deficits) that explains the
behavior?
 Language deficits

 Executive skills deficits
 Social-emotional skills deficits
 Motor deficits
 Etc.

 Accommodate and/ or remediate

Behavior Management (continued)
 Functional Behavioral Analysis approach: What is it

about the situation that explains the behavior?
 Positive reinforcement (reward)
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Social (attention, access to tangible materials)
Automatic (sensory stimulation)

 Negative reinforcement (relief)
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Social (escape from task demands)
Automatic (pain attenuation)

 Fix the situation

Educational Care
 Comprehensive assessment leads to…
 Comprehensive IEP in “least restrictive environment”
 Includes communication, social, emotional, and

adaptive life skills goals – not just academics!
 Leave No Child - with Autism - Behind!
 Under age 3, through State Early Intervention System
 Over age 3, through local school system

Social Choreography and Skill
Building
 Developmentally appropriate opportunities for social

success; facilitated, coached
 Training in social skills/ social thinking
 Individual or group
 Social Stories (Carol Gray)
 Interactive DVD
 Indirect learning: pets, books, etc.
 Classroom/ playground
 Peer-mediation/ social engineering

Individual Psychotherapy
 Child-led: DIR/ “floor time”/ play therapy
 Therapist-led: Cognitive-behavioral therapy

OT/ PT
 Specific adaptive skills
 Specific measurable goals
 Examples:
 Eating
 Toileting
 Dressing
 Writing/ keyboarding
 Participation in peer play/ games
 Executive skills: time management, transitions
 Assistive/ Augmentative/ Adaptive Technologies

(computers, blue-tooth, i-pad, MP3, DVD, etc.)

Medication Management
 Can not treat core deficits of autism
 Can treat symptoms that cause distress or impair
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availability for learning and socializing
Begin only on a trial basis and with specific outcome
measures
“Start low and go slow”
Continue only if significant improvement and no
significant side effects
25 -60% of children with ASD take psych meds; rates
and number of meds increase with age

Potential Medication Targets
 Anxiety (SSRIs, buspirone, propranolol)
 Depression or OCD (SSRIs)
 ADHD (stimulants, guanfacine, atomoxetine)
 Irritability/ aggression/ self-injury (neuroleptics)
 Mood instability (neuropletics, mood stabilizers)
 Sleep problems (melatonin, Benadryl, clonidine,

Remeron, Trazadone)
 Seizures (anticonvulsants)
 Specific medical conditions (allergy, GE reflux)

Transition Planning
 Disclosure and self-advocacy
 Life skills training
 Sex education
 Vocational planning and training
 College for Asperger-type ASD
 Life-span planning
 Group homes

 Financial planning

Nurture strengths and interests
 Leisure activities
 Sports
 Drama
 Music
 Art
 Technology
 Special interests/ relative strengths are the keys to

future success

References and Resources
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Temple Grandin, Thinking in Pictures
Mesibov, et. al The TEACCH Approach to Autism Spectrum Disorders
Carol Gray, Social Stories
Tony Attwood, The Complete Guide to Asperger Syndrome
Tony Atwood, Mind Reading, The Interactive Guide to Emotions (Jessica Kingsley Publishers-DVD)
Simon Baron-Cohen, The Essential Difference
Lynn Koegel, Overcoming Autism
Fred Volkmar et. al., Handbook of Autism and Pervasive Developmental Disorders
Catherine Faherty, What Does It Mean To Me? (Future Horizons)
Greenspan and Wieder, The Child with Social Needs, Engaging Autism
Daniel Goleman, Social Intelligence
Bryna Siegel, The World of the Autistic Child
Bondy and Fost, A Picture’s Worth, PECS and Other Visual Communication Strategies in Autism
McClannahan and Krantz, Activity Schedules for Children with Autism
National Research Council, Educating Children with Autism (2001), National Academy Press.
Michael Power, Children with Autism: A Parent’s Guide
Daniel Tammett, Born on a Blue Day
Roy Grinker, Unstrange Minds
www.autism-society.org
www.nas.org.uk
www.asperger.asn.au
Autism Speaks
First Signs



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Title                           : Autisms
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