Autisms 01Autisms
User Manual: 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,
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
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
Phonology
Vocabulary
Language comprehension and expression
Syntax
But…
Functional Assessment (continued)
Comprehensive speech-language assessment
should also include informal aspects:
prosody (volume, pitch, rate, stress, phrasing)
pragmatics (social context, conversational rules, turn-
taking)
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
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?
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
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)
Social (attention, access to tangible materials)
Automatic (sensory stimulation)
Negative reinforcement (relief)
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
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
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
