Autism: An Overview and Strategies for Learning in the Classroom

1
Autism An Overview and Strategies for Learning
in the Classroom Stewart H. Mostofsky,
M.D. Associate Professor, Neurology and
PsychiatryKennedy Krieger InstituteJohns
Hopkins University School of Medicine
2
Presentation Overview

• Intro to High Functioning Autism (HFA) and
  Asperger Syndrome (AS)
• Characteristics of population
• Learning Style
• Procedural (vs. declarative) learning
• Studies of procedural learning and associated
  motor impairments
• Interventions

3
What is Autism?

• In 1943, Dr. Leo Kanner of the Johns Hopkins
  University Hospital studied a group of 11
  children and introduced the label early
  infantile autism into the English language.
• At the same time a German scientist, Dr. Hans
  Asperger, described a milder form of the disorder
  that became known as Asperger syndrome.

4
Core Deficits in Autism
5
Autism Core Features

• All children with autism demonstrate deficits in
• 1) reciprocal social interaction,
• 2) verbal and nonverbal communication, and
• 3) repetitive behaviors or excessive interests.
• In addition, they will often have unusual
  responses to sensory experiences, such as certain
  sounds or the way objects look.

6
PDD Umbrella
Pervasive Developmental Disorders
Autism PDD-NOS
CDD Aspergers
Syndrome
Retts Syndrome PDD/NOS pervasive developmental
disorder, not otherwise specified CDD childhood
disintegrative disorder
Autism Spectrum Disorder (ASD)
7
Diagnosis of Autistic Disorder

• Qualitative Impairment in Social Interaction (2)
• Impairment in use of nonverbal behaviors
• Failure to develop peer relationships
• Lack of spontaneous seeking to share interests
• Lack of social/emotional reciprocity
• Qualitative Impairments in Communication (1)
• Delay in development of spoken language
• Marked impairment in ability to initiate and
  sustain conversation
• Stereotyped and repetitive use of language or
  idiosyncratic language
• Lack of varied, spontaneous make-believe play or
  social imitative play appropriate to
  developmental level

8
Diagnosis of Autistic Disorder

• Restrictive/Repetitive Stereotyped Patterns of
  Behavior or Interests (1)
• Preoccupation with restricted or stereotyped
  patterns of interest
• Inflexible adherence to routines and rituals
• Repetitive motor mannerisms
• Persistent preoccupation with parts of objects
• Delays prior to 3 y.o. in social interaction,
  language for social communication, or symbolic or
  imaginative play

9
Diagnosis of Asperger Syndrome

• Qualitative Impairment in Social Interaction (2)
• Impairment in use of nonverbal behaviors
• Failure to develop peer relationships
• Lack of spontaneous seeking to share interests
• Lack of social/emotional reciprocity
• Restrictive/Repetitive Stereotyped Patterns of
  Behavior or Interests
• Preoccupation
• Inflexible adherence to routines and rituals
• Repetitive motor mannerisms
• Persistent preoccupation with parts of objects
• No delay in language
• No cognitive deficit

10
Social and Communication Skills

• May have interest in others
• One-sided dialogue
• Lack of understanding when others are not
  interested
• Lack of understanding when a topic is not
  appropriate
• Comment on clothing
• Concrete understanding of language
• Spirit club
• Difficulty with friendly teasing and sarcasm
• Can be MASKED by advanced verbal skills

11
ASD Medical Overview

• Neurological Disorder
• Heterogeneous (variability in skills and
  deficits)
• No known cure
• No medical tests
• Early social development predictive of outcome

12
Possible causes of ASD

• No consensus on current causes
• Genetics
• Little to no evidence
• Environmental causes
• Immunizations little to no evidence
• Metabolic imbalances

13
Prevalence

• Prevalence estimates are approximately 1 in 150
  children (Center for disease Control and
  Prevention, 2007)
• Fastest growing developmental disability
• 90 of costs are in Adult Services
• Cost of treatment can be reduced by 2/3 with
  early diagnosis and intervention
• Early diagnosis is the key for treatment
• Early intervention has dramatic impact on
  reducing symptoms and increasing childs ability
  to learn new skills
• Only 50 percent of children are diagnosed before
  kindergarten.

14
Learning Styles of Individuals with Autism
Spectrum Disorders

• Strengths
• Rote memory/ memorizing facts
• Concrete information
• Attention to detail
• Needs-based interaction

15
Learning Styles (cont.)

• Challenges
• Poor attention difficulty shifting attention
  from one activity to another
• Processing auditory information, specifically
  verbal information
• Organizing information and discriminating which
  information is relevant
• Processing multiple stimuli at one time

• Over or under reaction to sensory input (tantrum
  to not even noticing)
• Flexibility
• Reciprocal interaction
• Generalized learning
• Global processing

16
Learning/Memory

Procedural (Unconscious implicit learning of
skills)
Declarative (Conscious explicit learning of
facts/events)
17
Declarative/Procedural Model
Procedural Frontal/Parietal Basal
Ganglia Cerebellum
Declarative Medial Temporal
(Cohen, 1984 Tulving, 1985 Squire,
1986 Mishkin, 1987 Saint-Cyr, 1988 Schacter,
1994)
18
Procedural Learning and Social Skills

• Large component of social interaction involves
  the execution of a series of complex learned
  movements
• HFA often report inability to automatically
  perform social gestures compensate by using
  declarative scripts.
• HFA high functioning autism

19
Lexical/Semantic
Grammar/Syntax
Frontal/Basal Ganglia/ Cerebellum
Medial Temporal
20
Autism, Language, and Procedural Learning

• Difficulty with syntax and language formulation
• Overly scripted language
• Compensating using declarative learning (i.e.,
  memorization)?
• Children with ASD faster than TD children on
  object naming task for less frequent and less
  imageable words (Walenski et al., in press JADD)

21
Background Motor abnormalities in Autism

• DSM feature stereotypies
• Other frequently reported motor findings
• Impaired basic motor control gait, posture,
  balance, speed, coordination (e.g., Ghaziuddin,
  1998 Jansiewicz, 2006 Noterdaeme, 2002
  Rinehart, 2006)
• Impaired skilled motor performance
• Emphasis on motor imitation
• Deficits also with pantomime and tool use on
  praxis testing
• highly robust and reproducible finding (e.g.,
  Mostofsky, 2006 Dewey, 2007 Dziuk, 2007
  Dowell, 2009)
• developmental dyspraxia in autism

Donald Gray Triplett First person diagnosed as
autistic
22
Why study motor function in autism?

• Motor difficulties can have a substantial impact
  on schooling, socialization, and self-esteem.

Motor Abnormalities
23
Handwriting and ASD

• Good handwriting crucial for academic progress,
  social and communicative development, and
  self-esteem (Feder Majnemer, 07)
• Only study in ASD assessed letter size in adults
  (Beversdorf et al., 01)
• No study had explored handwriting in children or
  adolescents with ASD
• No study had assessed the multiple aspects of
  handwriting that may differentially contribute to
  impairments

24
Minnesota Handwriting Assessment

• Scoring legibility, form, alignment, size,
  spacing, rate
• 14 ASD (10.2 1.9 yrs)
• 14 CTL (11.1 1.3 yrs)

(Fuentes, Mostofsky, Bastian, 2009)
25
Children with ASDworse overall and form quality
p 0.004
p 0.017
(Fuentes, Mostofsky, Bastian, 2009)
26
Why study motor function in autism?

• Motor signs can serve as markers for deficits in
  parallel brain systems important for control of
  socialization and communication.

The clearest predictor of optimal outcome in
toddlers diagnosed with an autism spectrum
disorder is motor skills at age 2 (Sutera et
al., 2007 J Autism Dev Disord)
Motor Abnormalities
27
Dyspraxia in Autism Developmental Perspective

• Adult lesion-based model (loss of skill after
  focal lesion) may not be appropriate
• Dyspraxia in autism unlikely due to loss of
  already acquired skills
• Consider lesion resulting in impaired acquisition
  (learning) of motor skills

28
Learning/Memory

Procedural (Unconscious implicit learning of
skills)
Declarative (Conscious explicit learning of
facts/events)
29
Why study motor function in autism?

• Motor signs can serve as markers for deficits in
  parallel brain systems important for control of
  socialization and communication.

Procedural learning systems important for the
acquisition of motor skills may also be critical
to forming internal models of action necessary to
engage in social and communicative skills.
Motor Abnormalities
30
Feed-forward Hypothesis

• The same internal models that are the basis of
  learning skilled movements are also the basis
  with which our brain understands the actions of
  others.
• Impaired acquisition of skilled movements and
  gestures, including those important for social
  interaction, may therefore contribute to impaired
  development of theory of mind.
• Simulation Theory (Carruthers and Smith, 1996)
• Children come to read minds by putting
  themselves in the others shoes
• Mentally (in their mind) act like other person,
  which is akin to imitation

31
Children with ASD show impaired ability to
identify and recognize correct gestures in others

Postural Knowledge
32
Children with ASD show impaired ability to
identify and recognize correct gestures in others

Praxis (Motor Skill)
Postural Knowledge
33
Treatment Implications Teaching Skills to
Children with Autism

• Difficulty learning skills naturally Both
• ability to perform motor, social, and
  communicative skills
• ability to recognize and interpret the meaning of
  others motor, social, and communicative actions
  (lack of social awareness).
• Often better with declarative learning
• Memorization

34
Treatment Implications Teaching Skills to
Children with Autism

• Two general approaches
• 1) Work around the deficit
• Teach social/communicative skills (eg, gestures,
  eye contact) using explicit declarative
  instruction
• Applied Behavioral Analysis (ABA) and Discrete
  Trial Therapy (DTT)
• Repeated explicit instruction with contingency

35
Applied Behavior Analysis

• Applying behavioral laws to solve behavioral
  problems
• Active attempts to change behaviors through
  chaining and shaping
• Antecedent Behavior Consequence
• Consequence determines whether or not behavior
  will occur again in the presence of an antecedent

36
Cognitive Behavior Therapy

• More effective for high-functioning children
• Focus on cognitive distortions and behavioral
  strategies
• Anxiety and anger management

37
Discrete Trial Teaching (DTT)

• Method for teaching new skills
• Skills are broken into small parts called trials
• Repeated practice is provided
• Clear beginning and end
• Reinforcement, prompts, shaping, etc., are all
  used within DTT

38
What Can Be Taught Using DTT

• Imitation
• Attending
• Receptive language
• Expressive language
• Self help skills
• Play skills
• Social skills
• Academic skills
• Etc.

39
Treatment Implications Teaching Skills to
Children with Autism

• Two general approaches
• 1) Work around the deficit
• Teach social/communicative skills (eg, gestures,
  eye contact) using explicit declarative
  instruction
• Applied Behavioral Analysis (ABA) and Discrete
  Trial Therapy (DTT)
• Repeated explicit instruction with contingency
  reinforcement
• Problems
• Teaching specific actions lack of context
• Poor generalizability

40
Treatment Implications Teaching Skills to
Children with Autism

• Two general approaches
• 2) Work through the deficit
• Improve children with ASDs ability to model
  others social/communicative actions
• Floor Time (Greenspan)

41
Treatment Implications Teaching Skills to
Children with Autism

• Two general approaches
• 2) Work through the deficit
• Improve children with ASDs ability to model
  others social/communicative actions
• Floor Time (Greenspan)
• Problems
• Not necessarily able to overcome the core
  impairment in learning these skills

42
School Difficulties

• Hidden Curriculum
• Academic Deficits
• Reading Comprehension
• Organization skills
• Immature interests
• Being rule-bound in a middle school

43
Difficulties with Peers

• Trouble making friends
• Odd interests
• Deficits social skills and social awareness
• Deficits in problem-solving
• Going first in a game
• Following directions in team games
• At-risk for being teased and bullied

44
(No Transcript)
45
Changes through the Lifespan

• Transition out of preschool
• Fear of public school
• Changes in curriculum
• Loss of first therapists
• Elementary school years
• Academics more difficult
• Social gap widens
• Peers become more aware
• Social events increase birthday parties, etc.
• Physical growth
• Teasing and bullying

46
Changes through the lifespan

• Middle School years
• Social difficulties for everyone!
• Puberty (!)
• Behaviors no longer cute
• Aggressive bursts
• Increasing self-awareness
• Socialization in groups cliques
• School change
• Diploma track

47
Changes through the lifespan

• High School years
• Academically rigorous
• Thoughts toward the future
• Job training
• College
• Potential for greater isolation
• At-risk for experimentation with rule-breaking
  behavior
• Inappropriate comments result in harsher
  consequences
• Feelings of sexuality develop
• Driving

48
Changes through the lifespan

• Post-high school
• Increasing independence
• Learning rules for workplace
• Living situation
• Group home vs. apt. vs. stay at home
• Possibility of greater isolation

49
Scientific and Promising Practices (Simpson, 2005)

• Applied behavior analysis
• Discrete trial teaching
• Pivotal response training
• Milieu therapy
• Incidental teaching
• Structured teaching (e.g., TEACCH)
• Picture Exchange Communication System
• Augmentative alternative communication
• Assistive technology
• Joint action routines
• Social stories

50
Treatment and Education of Autistic and related
Communication-handicapped Children (TEACCH)
Overall Focus

• An individuals skills
• An individuals interest
• An individuals needs
• Centering on the individual
• Adapting as appropriate
• Intervention strategy built on existing skills
  and interests

51
Structured Teaching An important priority of
TEACCH

• Organizing the physical environment
• Developing schedules
• Developing independent work stations
• Using skills independently of adult cueing and
  prompting

52
TEACCH

• Physical organization of the classroom
• Consistent, visually clear boundaries for
  specific activities
• Specific transition area
• Schedules
• reduces anxiety about time and organization
• Compensate for language impairment
• Foster independence

53
Modifications and AccommodationsPhysical
Arrangement

• Environmental Engineering
• Visual arrangement of teaching environment
• Both home and classroom
• Consistent area for only one activity

54
Arrangement of Different Teaching Areas

• Play, circle, snack, and table time
• Clear divisions of different areas by
• Furniture
• picture schedule
• Materials
• expectations

55
Modifications and AccommodationsVisual
Arrangement

• Predictability
• Visual supports/ Visually augmenting language
• Picture schedules
• Picture symbols
• Picture communication
• Scripts/social stories

56
Increasing Predictability

• Visual
• Visual information is often used to add to
  information that is provided verbally
• Visual supports provide an ongoing, stable cue as
  to what is coming next and helps children
  understand
• Visual supports can also help children express
  their ideas better and to understand language

57
Increasing Predictability

• Timers can help children know exactly how long
  they have for a given task
• Egg timers
• Time Timer
• Using the same exact phrase (all done), or
  sound ( a bell, a simple song) at the end of a
  task helps children know it is time to end
• Sometimes it helps to have an object the child
  likes, given to him/her consistently for a short
  time between events/activities
• Ex A favorite toy that is only given during
  transitions

58
Language skills in Autism- What we know.

• Extensive challenges using language to express
  themselves
• 80 of children with autism entering the public
  school 5 years and younger, do not display useful
  speech (Bondy Frost,1992)
• 50 of children with autism remain mute past the
  age of five (Charlop Haymes, 1994)
• Initiation of interactions with others is
  primarily needs based

59
High Technology Augmentative Communication

• Voice output devices (range of complexity)
• Advantages
• Others hear message (social participation)
• Student hears exact repetition of speech
• Grammar/syntax teaching with visual language that
  is static
• Disadvantages
• Can be distracting
• Abstract thinking for advanced devices
• Portability

60
Low Technology Augmentative Communication

• Communication through use of objects, photos, or
  symbols
• Provides verbal children with visual cues or
  representation to support language and initiation

61
Low-Technology Systems Features and Benefits

• Picture-based (symbol or photo)
• Expanding communicative intent
• Building syntax
• Emphasizing reciprocity and active participation
• Providing language foundation for speech
• PECS is the most common form
• PECS picture exchange communication system

62
What is PECS

• A pictoral system developed for children with
  social communication deficits by Frost Bondy
• Using PECS, children are taught to approach and
  give a picture of a desired item to a
  communicative partner in exchange for that item
• Helps children develop a functional communication
  system quickly
• Pictures can be used to make requests, comment
  and answer questions

63
Benefits of Using Visuals to aid Communication

• Provides child with a means to initiate
  communication
• Aids comprehension
• Provides a static and concrete reminder of
  verbalization
• Helps to establish and maintain attention
• Helps others to understand what child is trying
  to say
• Information provided that can be quickly and more
  easily interpreted

64
Social Skill Interventions

• Primarily clinic-based or pull-out services in
  schools
• Less than 30 hours of intervention typically does
  not yield significant results (Gresham et al.,
  2001)
• Higher intervention, maintenance, and
  generalization effects in naturalistic settings
  (Bellini et al., 2007)

65
Social Skills Intervention

• Preschool to Early Elementary Age
• Eye contact and integration of eye contact with
  other communication
• Sharing enjoyment with others
• Giving and showing for getting help or sharing
• Initiating joint attention to items
• Responding to joint attention attempts of others
• Turn-taking with peers

• Late Elementary and Adolescent/Adult
• Reciprocal social communication and conversation
  with peers
• Eye contact
• Comprehension and expression of emotions
• Nonverbal communication use and understanding
• Empathy , insight, and perspective-taking

66
Quality of Relationships

• Social abilities generalized into higher quality
  relationships
• Understanding age appropriate communication
• Age appropriate interaction and activities
• Meaningful experiences with family and peers
• Meaningful experiences in the community

67
Homework Example
68
Feelings Chart
69
(No Transcript)
70
Social Stories

• One of the best mechanisms for teaching
  appropriate social behavior is the use of social
  stories, a special kind of storytelling
  originally developed by educator Carol Gray in
  1991.
• They provide the child with a narrative of events
• Are short and easy to remember
• Can be told over and over to help the child
  internalize what's expected

Taken from The Social Story Guidelines, by Carol
Gray
71
Things to consider

1. Identify your goal or target behavior before
   writing the story.
2. Be sure your Social Story has an introduction,
   body and conclusion.
3. Start out with general sentences such as
   Everyone eats dinner. End with your reinforcer
   and feelings sentences such as When I eat my
   dinner I will probably get ice cream. This makes
   me happy.

72
Things to consider (cont.)

1. Keep it positive! Use extreme caution with
   directive sentences. Positively state desired
   behaviors. Avoid statements using no and I
   wont.. Instead use I will try.. and focus on
   the desired behavior. (i.e., for no hitting use
   I will try to keep my hands to myself. )
2. Write at or below a childs reading comprehension
   level. For preschoolers and not-yet readers,
   keep the story and statements short and to the
   point.

73
Things to consider (cont.)

1. Provide assistance recognizing and interpreting
   social cues, describe who, what, when, when its
   over, why and where.
2. Illustrations can enhance comprehension of the
   story concept. Use caution with illustrations
   though. Be careful of extraneous information
   that may be contained in photos or drawings.
3. Functionally or visually define ambiguous terms.
   Translate abstract concepts into more easily
   understood formats. Always try to describe a
   desired behavior and what you mean by a
   particular term. (i.e. sit nicelydefine what
   nicely looks like).

74
Things to consider (cont.)

1. Carefully write from a first person perspective
   as though the child is describing the event.
2. Write in reality. Mention variations in routine.
   Ensure a story is accurate if interpreted
   literally.

75
Acknowledgments
Laboratory for Neurocognitive and Imaging
Research (LNIR) / KKI Anita Barber Mary Beth
Nebel Jennifer Gidley-Larson Lauren Dowell
Marcy Adler Lindsay Koenig Marin Ranta Deana
Crocetti Lindsey MacNeil Michelle Talley
Jessica Foster Martha Denckla
Ctr for Autism and Related Disorders Rebecca
Landa Klaus Libertus
KKI Motion Analysis Laboratory Amy Bastian
Christina Fuentes Pablo Celnik
JHU Lab for Computational Motor Control Reza
Shadmehr, Jun Izawa, Courtney Haswell, Mollie
Marko, Sarah Pekny
Support Autism Speaks Foundation, NIH (NINDS)
R01 NS048527, K02 NS044850, JHU Institute for
Clinical and Translational Research (UL1 RR025005)