A Proposal for Early Screening practices for ASD

1
A Proposal for Early Screening practices for ASD

• Rebecca Landa, Ph.D., CCC-SLP
• Katherine Holman, Ph.D., CCC-SLP
• KKI Center for Autism and Related Disorders
• Landa_at_kennedykrieger.org
• Holmank_at_kennedykrieger.org

2
Outline for Presentation

• The importance of studying early symptoms of ASD
• Early symptoms associated with a diagnosis of ASD
• Common screening tools for ASDs
• Suggested steps for EHS programs to implement a
  screening process for young children with ASDs
  while strengthening collaborative relationships
  with EI providers in the community

3
ASD Umbrella

• Autism Spectrum Disorders
• Autism
• PDD-NOS
  CDD
• Aspergers Syndrome
  Retts Syndrome

4
Facts about Autism

• Autism is a brain-based disorder, onset prenatal
• Involves abnormalities in
• Qualitative aspects of social development
• Qualitative aspects of communication development
• Repetitive, stereotyped patterns of behavior
  interests
• Affects 4 males to 1 female
• Prevalence for autism is 1/500 prevalence for
  ASD is 1/250

5
Facts about Autism

• Onset lt36 months
• Some have regression before 24 m.
• Diagnosed based on presence of symptoms (no
  medical test, no medical cure)
• Numerous comorbid disorders (mood, anxiety,
  attention, OC, MR)
• Educational/behavioral tx leads to improvement,
  sometimes enormous effects
• Pharmacologic tx helps with some sxs

6
Facts about Autism

• Most cases have no known cause
• Most cases probably heritable
• If have a child with autism, 8 risk for autism
  in later-born children
• 20-40 of siblings of a child with autism have
  language and/or social deficits

7
Rationale for Studying Early Markers for Autism

• Parents report first concerns around 18 m.
• Parents often say babies not normal even before
  first concern
• Retrospective studies indicate abnormalities
  present by 12 months of age in some cases
• Brain abnormality as early as prenatal life
• Early intervention may have great benefit
• 86 of 2 year olds with ASD are on the spectrum
  at 9 years of age
• Most cases are diagnosed after 3 years of age

8
Challenges to Early Identification

• Absence of standardized diagnostic tools for
  children under 24 months
• Absence of diagnostic criteria for children under
  24 months
• Physician time with child is brief
• Children often have normal appearance
• Physicians not trained in infant development
  (wait see)

9
Our Program

• Early Detection of ASD Research
• Early markers
• Differentiate from LI
• Efficacy of screening instruments
• Training of professionals
• Monitor through period of regressions, vaccines,
  sensitive periods for brain development of
  certain regions

10
Our Program (Continued)

• Early Intervention for ASD Research
• Classroom for toddlers with ASD
• Parent training
• Parent sharing
• Early Detection and Early Intervention Network
• Clinical assessment and intervention

11
Infants without autism

• Come into the world with certain abilities (face
  preference, imitation, motor synchrony,
  informative cries, regularities in biological
  functioning)
• Change in predictable ways over the first year of
  life
• Are communicative before they are intentional
• Social in nature

12
Insights into the Early Manifestation of ASD

• Interpersonal synchrony
• Monitoring the attention of others
• Motivated to initiate social engagement (except
  around special interests)
• Social interaction hard to sustain
• Ability to integrate
• Special interests
• Babbling
• First words
• may see before first birthday

13
Early Manifestation of ASD

• Play imagination
• Poor integration of gaze, smile, communication
• Impoverished gesture repertoire
• Limited range of facial expression
• Repetitive behavior, sensory interests
• Possible atypical motor features at 6 m

14
Development of ASD in infants

• Looks different from child to child (cog)
• Social is always impaired
• Social, language, motor change or slowing between
  14 and 24 months for many of the children
• Implications of delays at 14 months of age
• Implications of ASD symptoms at 14 months with
  intact IQ

15
Characterization of Early ASD

• Strengths are present
• Low rate of occurrence of expected skills
  (social, language)
• Presence of atypical features

16
Strengths at 14-24 Months

• Play with toys
• Initiation of communication
• Some imitation, oddly manifested
• May follow pointing gestures, but not know what
  to do when get to the object
• Positive affect in solitary play
• Attachment
• Some intact social smiling

17
Strengths

• May give eye contact during requests for objects,
  not much eye contact during interactions
• Enjoy rough and tumble play

18
Predictors of outcome

• IQ
• Social (more imitative, better joint attention)
• Verbal ability
• Severity and number of Autism symptoms

19
Developmental Trajectory Different for ASD

• Motor
• Language

20
Tools

• M-CHAT, CHAT
• Pervasive Developmental Disorder Screening Test
• CSBS Caregiver Questionnaire
• Screening Tool for Autism in Two-Year-Olds (STAT)
  
• Autism Behavior Checklist
• Autism Behavior Checklist (ABC)

21
Our Proposed Practice Three Components

• Training of Early Head Start Staff on the early
  signs of ASD and the importance of Early
  Intervention
• EHS providers give the MCHAT to all children from
  18 to 36 months of age
• Develop a stronger collaborative network between
  EHS staff and EI providers

22
Target I Training of Early Head Start Staff

• Potential Training Targets (3)
• 1) What are autism spectrum disorders (ASD)
• 2) Early Screening and Diagnosis of ASDs, Sharing
  information with families, and How to make a
  referral
• 3) Basic strategies for working with a child with
  an ASD in your classroom

23
Training of Early Head Start Staff

• What are autism spectrum disorders (ASD)
• What is autism what are the causes and the
  different symptoms associated with the diagnosis
• What does autism look like in children under 3
  years of age early signs and symptoms
• How is autism similar and different from other
  developmental disorders

24
Training of Early Head Start Staff

• Early Screening and Diagnosis of ASDs
• What are the early signs of ASD
• Why is early diagnosis important
• How to screen for autism at an early age
  appropriate screeners (MCHAT)
• Effective ways to collaborate and share
  information with families about the screening,
  possible need for referral, and benefits of
  beginning intervention early
• How to make an appropriate referral for a child
  who fails a screening

25
Training of Early Head Start Staff

• Basic strategies for working with a child with an
  ASD in your classroom
• -How to structure the environment to increase
  learning success in young children with ASD
• -Functional ways to facilitate play, language,
  and social development
• -How to collaborate with caregivers, daycare
  providers and other EI providers to develop
  consistent and effective daily routines and
  strategies across environments

26
Target II Screening of ASDs for all children
18-30 months

• Give MCHAT to all children in EHS who are between
  18-30 mos
• Talk with caregivers about the screening process,
  the results of the screening, and the next
  stepsthe importance of following up with an
  autism expert from EI for a full developmental
  evaluation and possibly early intervention
• Work closely with EI and caregivers to develop an
  effective plan of action for the child

27
Screening Tools vs. Diagnostic Instruments

• Screening by itself does not provide a diagnosis,
  but is the first key step in the diagnostic
  process.  Therefore, it is important for health
  care providers to immediately refer those flagged
  as "at risk" during screening to diagnostic
  specialists for more extensive diagnostic
  evaluation and referral for appropriate
  intervention. 

28
Target II Steps in screening process

• EHS staff gives MCHAT to children between 18-30
  months
• EI provider from local program scores MCHAT and
  discusses results with EHS staff
• EHS (and possibly) EI staff arrange meeting with
  caregiver to discuss results and make appointment
  for dev. evaluations
• EHS and EI staff work together with family to
  develop early intervention plan for child who is
  showing ASD symptoms

29
Importance of Early Screening

• Increase in prevalence of ASDs
• Emerging ability to recognize ASD symptoms in
  toddlers
• Increasing evidence that early, intensive
  treatment for children with autism has a
  significant impact on outcome
• Answers questions and provides potential
  solutions to challenges staff and family may have
  had with the child

30
Target III Improve collaborative relationship
EHS and Local EI providers

• -Information is the key information sharing
  meetings of how each organization works to serve
  young children and their families in the
  community
• -Develop an effective referral process and
  ongoing communication opportunities
• -Develop collaborative ways to mutually support
  the family and work with the child with an ASD

31
Impact on Families

• If the child is provisionally identified as
  having characteristics of ASD
• EHS staff who are trained in this model can help
  families to
• Understand their child
• Improve their ability to understand their childs
  behavior
• Give them more effective ways of interacting and
  relating to their child
• Help with behavioral management issues

32
Barriers and proposed supports

• Families with lower SES backgrounds gaining
  access to local EI services
• Families who are already connected with EHS
• EHS will screen children for possible ASDs (and)
  other developmental disorders
• EHS staff, who knows child and family well, will
  coordinate and collaborate with EI service
  providers to maximize potential EI opportunities

33
Barriers and proposed supports

• Time and cost of training EHS staff and
  collaborating with EI providers
• Mandated under Childrens Health Act of 2000 to
  screen earlier
• Overall time and cost from the outset will
  definitely outweigh risks associated with
  children not being identified and therefore not
  receiving appropriate EI services
• Classroom disruption, family/caregiver and
  teachers frustration, childs declining
  behaviors and skills, etc.

34
Need for Early Intervention

• Critical periods of brain development
• Capitalize on neuroplasticity
• Basic social impairments may result in quite
  different kinds and amounts of social experience
  for autistic people starting early in childhood.
  The lack of this 'expected' input may play a role
  in brain organization.

35
Benefit of EI Evidence

• Mostly from children gt3 years of age
• Early intensive intervention improve IQ by
  average of 20 points
• Children who start tx earlier tend to fare better
• EI associated with reduced need later for special
  education services
• More children are acquiring language

36
Early Intervention

• Beginning by 24 months is critical
• Parent training
• Systematic instruction in the home and in an
  educational setting
• 11 as well as group work necessary
• Reconsider least restrictive environment
  cannot consider classroom as restrictive if it
  leads to gains in language, social, self reg

37
EI

• Goals play (object knowledge, social, scripts,
  language, symbol) functional communication
  social (face recognition, imitation, joint
  attention) cognitive self regulation
• Methods continuum of structure environmental
  engineering visual assists
• Developmental considerations
• Family and community training/involvement
• Setting home, community (parent-child groups
  with typical children), educational

38
Research on EI

• Very little on kids under 3 yo.
• What to teach/how to teach
• No focus on individual differences
• Small ns, single subject design
• Different approaches show benefit to children
• All approaches have non-responders

39
Our To Do List

• Develop better screeners for ASD
• Increase awareness of primary care providers
• Increase detection knowledge of EI staff
• More research on early markers
• Treatment research (what to teach, how to teach,
  individual differences)
• Increase EI programs

40
Conclusions

• Use what we have now to start screening
• If parent is concerned, refer
• If initial assessment suggests hint of ASD, refer
  to autism infant expert
• Monitor development of all children with social
  or language delays
• Monitor development of all sibs of autism
• We know enough to get started now

41
FYI

• Early Detection and Early Intervention Conference
  June 7-9 Baltimore
• To refer children with few words before 24
  months, toddlers with ASD, babies with no family
  history of autism, babies having a sibling with
  autism, call toll free 1-877-850-3372
  reach_at_kennedykrieger.org

42
Thank you

• NIMH
• NAAR
• CAN, Coalition for Autism
• Pathfinders for Autism
• Families of participants
• Research team Julie Cleary, Kate Brooks, Kathryn
  Gleeson, Kirsten McGowan, Erica Gee, Andrea
  Schanbacher, Michelle Sullivan, Cornelia Taylor,
  Andrea Gollogher, Kay Holman, Sharon Loza, Kelley
  Duff, Juhi Pandey, Rachel Pletcher