CHILD ABUSE COUNCIL SPRING CONFERENCE STRENGTHENING THE SOCIAL AND EMOTIONAL HEALTH OF CHILDREN: AUTISM SPECTRUM DISORDER OVERVIEW MICHAEL J. LUCIDO, PHD CHARLEVOIX CENTER SUPERVISOR CHRISTINE LENNON, MA, LPC DD CHILDREN’S BEHAVIORAL SERVICES APRIL 26, 2013 Raise your hand if you personally know someone impacted by autism or Asperger’s. PREVALENCE RATE TAKING A LOOK AT AUTISM STEPHEN WILTSHIRE’S STORY Following 20 minute ride, he drew an 18 ft long drawing of New York city in exact detail PERVASIVE DEVELOPMENTAL DISORDERS Autistic Disorder: • Social impairment. • Communication impairment. • Restricted repetitive/stereotyped behaviors, interests, or activities. Asperger’s disorder: • Higher functioning form of ASD. • Normal language with single words by 2-phrases by 3. Rett’s Disorder: • Exclusively female genetic developmental disorder-progressive delays throughout lifespan • Severe “apraxia”-inability to execute purposeful movements despite physical capability. Childhood Disintegrative: • “Heller’s Syndrome”- normal development from 2-10 years of age but then severe decline. • Causes by lipid storage diseases, subacute sclerosing panencephalitis, tuberous sclerosis. PDD Not otherwise specified: • Do not meet full criteria but have symptoms similar to the diagnoses above. DSM-V AUTISM SPECTRUM DISORDER (ASD) DSM-V (2010) revised label & criteria: • Autism Spectrum Disorder under one label • Rett’s disorder is considered separate of ASD • Reduced to two criterion • Require multiple observations • Provide qualifiers such as “with intellectual disability” or “due to Fragile X syndrome” Grandin wrote, • “As a child I remember Mother asking me time and again, ‘Temple, are you listening to me? Look at me.’ Sometimes I wanted to, but I couldn’t...” AUTISM SPECTRUM DISORDER CRITERION Repetitive and Obsessive Behaviors Socialization and Communication • Poor eye contact • Flat expressions • No peer relationships • Odd speech ASD • Echolalia • Misinterpret emotion • Conversation issues • Rocking • Hand wringing • Twisting fingers • Fixated interests • Intense focus • Set routines • Preoccupied parts • Sensory issues BEHAVIORAL SIGNS AND SYMPTOMS • Speech: monotone, rhythmic, nasally/high pitched (dysarthric), pedantic, repeating phrases (echolalic), and other idiosyncratic speech patterns. • Eye contact: no, limited, or inappropriate eye contact- towards the ceiling, looking at the body, avoiding face/eyes. • Gross and fine motor coordination: unable to balance on foot or tandem walk, or poor writing (dysgraphia). • Stereotyped behaviors: hand-wringing or twisting, spinning in chair, complex whole body movement, hand-flapping, pacing. SENSORY DISTURBANCES • Behavior “meltdowns” are often sensory related • Grandin wrote, • “But when I was in the world of people, I was extremely sensitive to noises..The pain that racked my head when the fog horn sounded was excruciating”. (hyperacusis-sensitivity) • “Spinning was another favorite activity. I’d sit on the floor and twirl around. The self-stimulatory behavior made me feel powerful, in control of things…I realize that non-autistic children enjoy twirling around in a swing, too. The difference is that autistic child is obsessed with the act of spinning”. UNDERSTANDING THE “BEHAVIORS” • Common misnomers about behaviors: • • • • He can control his meltdowns! She is being oppositional! He just wants it his way! He can stop biting himself! • It is an underlying neurological condition-first and foremost • Most of the time is out of their control • They struggle to be “normal” WHAT CAUSES AUTISM? IS IT THE PARENTS? • Kanner said autism is a result of “genuine lack of maternal warmth”. • Bruno Bettleheim said autism was caused by maternal coldness. • Finally by 1960s, Bernard Rimland said it was a neurological disorder. TEMPLE GRANDIN’S STORY Graduated with a doctoral degree in animal science, wrote many books on autism and animal issues A FEW THEORIES ON THE CAUSE OF ASD • No single theory explains ASD • Genetic and heredity • Abnormal development • Physical health issues • Autoimmune problems • Environmental toxins HEREDITY & GENETIC ABNORMALITIES • Monozygotic twins as high as 60-95% and siblings are 45-60 times greater to develop autism • First degree relatives might have psychiatric issues like depression, OCD, anxiety disorders, etc • X Chromosome as a factor? • Fragile , Turner’s syndrome, Klinefelter, Rett, Prader-Willi, Timothy, Phenylketonuria, and Angelman syndromes. • Reason for higher rates in males? (XY vs. XX in females) DEVELOPMENTAL GROWTH • 20-30% have seizures, up to 72% abnormal EEG • 75% smaller head circumferences at birth, but rapid growth by first year in the 85th percentile • 100-200g heavier brain weight in autism • Deficits in Emotion centers: amygdala, prefrontal cortex, temporal lobes, & thalamus • Dysregulated neurochemicals like serotonin, dopamine, melatonin, and oxytocin NEUROLOGICAL PATHWAYS FOR ASD GASTROINTESTINAL PROBLEMS • Gastrointestinal problems as high as 84% • Constipation, problems going to the bathroom, etc • These health issues impact moods, behaviors, appetite • Interaction between the gut and the brain is important to understanding ASD-serotonin? • Food allergies is strongest link to GI issues • Food allergies have been attributed to conditions like celiac disease, which lead to the abdominal problems AUTOIMMUNE RESPONSE • Lowered immune response • High opioid activity • High pain thresholds- high endorphin levels • Endocrine system related to thyroid • Concerns regarding hypothyroidism or low thyroid will impact brain development • Considered an iodine deficiency in prenatal and neonatal development ENVIRONMENTAL TOXINS • Industrialization increased exposure to neurotoxins • Heavy metals like mercury, lead, or cadmium • Pesticides such as cyanide. • Clothing, food, building materials, personal care • New Jersey has highest rates for autism & asthmahas highest pollution levels in the nation • Wakefield: vaccines link to autism retracted • 18 controlled epidemiological studies found no link • No one factor accounts for autism DIAGNOSING AUTISM EVIDENCED BASED PRACTICES WHAT IS EVIDENCED-BASED PRACTICE? American Psychological Association (2006): • EBP: “integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences”. • EBP is comprehensive with assessment, case formulation, therapeutic relationship, and specific decision-making process integrating research and intervention together. A NEED FOR COMPREHENSIVE CARE EBP services: • Psychological evaluation • Behavioral, OT, and Speech Assessments • Psychiatric evaluation and medications • Dietary modifications and supplements • Behavioral interventions • Individual/group therapy • Parent Training • Case management • Employment assistance • Occupational therapy • Speech therapy • And many more!!! HISTORY OF LACK OF FUNDING FOR SERVICES Costs are $35 billion per year nationwide Average costs:$29,000-$43,000 per year History of disparity of Federal funding President proposed $1 billion increase of annual federal spending on autism Michigan Department of Community Health expanded autism services MDCH AUTISM SERVICES EXPANSION • Created the 1915i State Plan Amendment and 1951b Mental Health Specialty Services and Support Waiver • Started April 1, 2013 • Consist of early identification-average age of child being diagnosed with autism is age 8 in Michigan. • Targeted18 months through age 5 ASD SCREENING AND DIAGNOSIS • Screening forms by parent and referred by pediatrician • Modified Checklist for Autism in Toddlers (16-30 mo.) • Social Communication Questionnaire (ages 2 ) • Referred to Access Center for a more in depth diagnostic evaluation. • Evaluation will consist of an in depth clinical interview, assessment, and other tests for behaviors, ability, language, etc as needed. • Diagnosis must be confirmed by a fully licensed psychologist or physician/psychiatrist. QUESTIONNAIRES ASSESSMENT • Autism Diagnostic Interview-“Gold standard” (ADI) • Autism Spectrum Rating Scales (ASRS) • Autism Treatment Evaluation Checklist (ATEC) • Modified Checklist for Autism in Toddlers (MCHAT) • Asperger Syndrome Diagnostic Scale (ASDS) • Gilliam Autism Rating Scale: 2nd Edition (GARS2) • Childhood Autism Rating Scale (CARS) • Social Communication Questionnaire (SCQ) • Social Responsiveness Scale (SRS) PSYCHOLOGICAL TESTING Autism Diagnostic Observation Schedule (ADOS) “Gold standard” for assessing behaviors of ASD New versions of IQ testing Profiles for individuals with autism. LOOKING BEYOND IQ • University of Montreal found intelligence tests (WISC, WAIS) in ASD over-diagnosing ID • None of the children scored in the high average range and a 1/3 scored in the ID range • Nonverbal IQ test, a 1/3 scored in the high average range, and only 5% scored as ID • Newer intelligence tests have profiles for ASD to explain such conflicting results KIM PEEK’S STORY • • • • Inspired by movie Rain Man Read two pages at once Memorized 12,000 books Low average IQ NEUROPSYCHOLOGICAL TESTING Neuropsychological testing: • Stroop • Continuous Performance • Trail Making • Shifting Attention • Symbol-digit coding • Finger Tapping • Verbal/Visual memory Executive functioning deficits in ASD: • Cognitive flexibility/switching • Organization, planning • Visual-working memory • Verbal fluency • Complex attention READING THE MIND’S EYE TEST • Visual-perceptual processing • Problems with facial recognition, and socialemotional processing. • Social cognitive test for empathy or “Theory of Mind”. • Best way to evaluate social issues is through observations. OCCUPATIONAL/SPEECH ASSESSMENT • Special education ASD evaluations include speech and occupational evaluations when identifying ASD. • CMH provides contractual support for OT and Speech when physician has ordered interventions for ASD in the home. NEED FOR MEDICAL EVALUATIONS • Gastroenterologist- problems with intestines and stomach including issues like constipation • Neurologist- brain imaging like CT scans and brain function with EEG • Immunologist/allergist- identify potential environmental allergies influencing behaviors • Dietitian- identify health habits • Psychiatrist- medications for behavior and mood EVIDENCED-BASED PRACTICES FOR ASD AUTISM INTERVENTIONS OPTIMIZING LIFE PURSUITS IN ASD Grandin wrote, “I think the same principle applies to autistic childrenwork with them instead of against them. Discover their hidden talents and develop them”. PERSON-CENTERED • Assist parents and individuals with ASD: • Understanding procedures, aid in documents, ease transition in services, respect, be flexible. • PC seeks collaboration with natural supports and community. • Empathy, unconditional positive regard: • Individuals with autism are often on a one way street-walk with them for a while! MDCH ASD BEHAVIORAL SERVICES • Provided to age 18 months-5 y/o • Applied Behavior Analysis (ABA) • Science of the principles of behavior • Two levels of service intensity for ABA • Early Intensive Behavioral Intervention (EIBI) • Children with a diagnosis of autistic disorder • Average of 10-20 hours per week • Applied Behavioral Intervention (ABI) • Children with a diagnosis of Aspergers, PDD, etc • Average of 5-15 hours per week HOW SERVICES WILL BE CONDUCTED • Structured applied behavior analysis program that relies upon discrete trial training (DTT) methods and incidental teaching opportunities • Administered in a child’s home or a clinic setting. DISCRETE TRIAL TRAINING • Comprehensive structured behavioral intervention or discrete trial training (Lovaas, 1987) • Operant conditioning (Skinner): rewarding specific behaviors to increase the likelihood of the behavior occurring again • Learning environment is structured • Target behaviors are broken down into discrete subskills • Initiated and selected by adult • Child’s response is prompted • Reinforcers are unrelated to the target response (e.g. toy) • Rewards for correct response or successive approximations DIR FLOOR-TIME • Developmental, Individual Difference, Relationship-Based (DIR) Floortime Model (Greenspan, 2000) • Infants to preschoolers improve socialemotional cognition • Motive, planning, and sequencing • http://www.youtube.com/watch?v=jrXGh9bT0Sw PIVOTAL RESPONSE TRAINING • Pivotal response training: teaching core or pivotal skills makes it easier for children with autism to learn basics (Koegel et al., 2001) • Increasing motivation to engage in social communication • • • • Motivation Self-regulate behaviors Initiate social interactions Response to multiple social cues COGNITIVE-BEHAVIORAL THERAPY •Social skills training •Anger management •Rethinking perspective •Regulate emotions •Social skills training •Social Autopsies •Social Stories ASD PSYCHOPHARMACOLOGY I ASD 2nd Generation Neuroleptics: • FDA (2006) approved risperidone as the first medication to treat irritability and aggression in children and adolescents with autism. • Other medications like aripiprazole (second generation antipsychotics) are being approved for autism. • Improve both dopamine and serotonin regulation. • Decrease aggression, selfinjuries, irritability, and improve mood stability. ASD Antidepressants: • Research for 20 years including clomipramine, desipramine, fluoxetine, citalopram, sertraline, and venlafaxine. • improve stereotypic and obsessive behaviors. • Medscape (2010) SSRIs are not recommended for just ASD because of limited research. • Sertraline, fluoxetine, and fluvoxomine are approved for OCD, and fluoxetine and escitalopram approved for depression. • Symptoms of anxiety and depression that are comorbid with ASD. ASD PSYCHOPHARMACOLOGY II Anxiolytic: Anticonvulsant: 1st generation neuroleptic: Neurostimulant: Antihypertensive: • decrease hyperarousal, agitation, improve dental visits • decrease seizures and stabilize moods • Decrease aggression • improve attention, concentration, and impulsivity • improve sleep and attention and decrease aggression DIETARY AND VITAMINS • Ketogenic diets (used in seizure disorders) and gluten-casein free diets (used in schizophrenia) • Melatonin for initiating sleep • Fish Oil (EFA) improves cognition • Vitamin D to improve mood, sleep, cognition • Vitamin B6 and B12 to improve cognition • Oxytocin improve social affect and social cues • Recommendations come from physicians • Dietitians may provide nutrition consultation OCCUPATIONAL THERAPY • OT provides critical interventions that might offset need for medication or other therapy • Assists in skills like in improving hand writing • Sensory diets regulate the environment and structure daily activities to prevent overload • Schedules are very important in ordering the day’s sensory input! SPEECH THERAPY • Speech therapy teaches effective ways to communicate in areas like pragmatics • Improve speech production such as voice modulation • Picture Exchange Communication System (PEC) • PECS are helpful for improving communication and schedule • Easily recognizable • Exchange the picture for a desired activity or item ABUSE IN CHILDREN WITH AUTISM ABUSE IN CHILDREN WITH DD • A child with any type of developmental disability was 4xs more likely to be sexually abused than a child without (Sullivan & Knutson, 2000). • 50% of children with autism are nonverbal and unable to participate in usual means for verbal interviews that require reciprocal communication. AT RISK • Struggle with interpreting caution and picking up deceptive emotions in facial affect • Perpetrators may target children with nonverbal autism because inability to disclose • Issues with sequencing of events and misinterpreting them • 50% of offenders of individuals with developmental disabilities had contact with them through their disability services FORENSIC INTERVIEWING • Need to provide multiple interviews in order to gain rapport and short sessions vs. long sessions • “Referential communication” ability to know what another person is asking and refer to • Question: “Did John Doe touch you” • Answer: “No” (answering for today, but abuse happened in past). • Children with autism struggle with responding to questions appropriately or accurate information SIGNS AND SYMPTOMS • Often simply noticing change of behaviors is most important • Increased selfstimulation • Self-injurious behaviors • More meltdowns • New Behaviors not present before INTERVENTION • Trauma focused therapies such as play therapy or cognitive therapies if verbal • Sex education and education regarding appropriate and inappropriate touch • Difference between public and private behaviors • Providing social stories as a means of communication JASON “J-MAC” MCELWAIN’S STORY In his first-ever high school game, he scored 20 points and tied the school record with six 3-pointers in 4 minutes In a book on autism, a mother describing her son and others with autism said, “From their deep sense and connection to the universe and our planet they feel what a leaf feels, they can smell cold, they are truly in the moment. These special beings can teach us many things through their gifts that they have to offer.” ANY THOUGHTS OR QUESTIONS? Thank you!!!