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Treatment and Prevention of Dysfunctional Behavior in Adolescents Diagnosed within the Category of Pervasive Development Delay
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4. Hilton Garden Inn, Glastonbury, CT
Child & Family and DMHAS
Agency
A Scholar in Residence Workshop
Hilton Garden Inn, Glastonbury, CT
September 17, 2004
Presented by:
Raymond W. DuCharme, Ph.D.
Kathleen A. McGrady, Psy. D., ABDA
Pamela Ruff, Transition School Faculty
The Learning Clinic
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5. Introduction
What is a pervasive developmental delay? Is a diagnostic description of Pervasive Development Delay not otherwise specified, helpful to the individual, his family and those responsible to provide treatment?
The purpose of a diagnosis are to precisely describe a condition in need of treatment, and to determine from the described symptoms a preferred regimen of treatment. Further, the diagnosis should predict that if a treatment is provided then a forecast may be made of a prognosis.

6. Pervasive Development Disorder
Category of Diagnosis that includes Autism, Rett’s Disorder, Childhood Disintegrative Disorder, Asperger Syndrome, and PDD NOS. Historically, other diagnostic labels in this category have included Childhood Schizophrenia and Autistic Psychopathy.
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7. Asperger Syndrome Criteria
DSM-IV
ICD-10
Qualitative impairment in social interaction X
Restricted repetitive and stereotyped patterns of behavior, interests, and activities
No general language delay
No delay in cognitive development
Normal general intelligence (most)
Markedly clumsy (common)
No delay in development of:
age appropriate self-help skills
adaptive behavior (excluding social interaction)
curiosity about environment
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8. Differential Diagnosis Pervasive Developmental Disorders
Onset of Symptoms
Gender
Social Skills
Head Circumference
Language Skills
Cognitive Functioning
Motor Skills
Autism
Prior to age 3 years. Symptoms in infancy are subtle
Males (8 times greater than females)
Social skill deficits
Delay, or lack of development
75% have mental retardation
Repetitive and Stereotyped
Rett’s Disorder
Five months normal development; diagnosed between 5-48 months
Females
Loss of social interaction early; may develop later
Decelerates between 5-48 months
Expressive and receptive language problems
Severe to profound retardation
“Hand-Wringing” gait and truck coordination problems
Childhood Disintegrative Disorder
Two years normal development; diagnosed before age 10
Males – more common
Loss of social skills (after age 2 years)
Expressive or receptive (after age 2 years)
Severe mental retardation (usually)
Loss of motor skills after age 2 years
Asperger Syndrome
Recognition and diagnosis later (e.g., school age, between ages 7-11 years)
No general delay in language; but pragmatic language deficits. Theory of Mind-Subvocal Speech
Normal IQ Verbal Performance Deviation
Motor delays and clumsiness” Absence of research
PDD, NOS
Does no meet criteria for any of the above, but has some of the behaviors
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9. DSM-IV - ICD Diagnostic Criteria
Precise differential diagnosis of pervasive developmental delays evident in the symptom profile of an individual currently remain problematic. And the consequent ramifications are also evident.
Unclear diagnostic criteria result in error and misdiagnosis.
Misdiagnosis causes error in the selection of type and duration of treatment.
Treatment misapplications yield poor prognosis and little evidence of efficacy

10. DSM-IV - ICD Diagnostic Criteria
/ Continued
Gillberg’s six criteria (Elhers and Gillberg 1993) comprise social impairments, narrow interests, repetitive routines, speech and language peculiarities, non-verbal communication problems and motor clumsiness. Gillberg includes Szatmari’s (1989) criteria and Tantam’s (1988) five criteria. The ICD-10 and DSM-IV note an absence of any clinical delay in language and cognitive development in the first 3 years of life. The DSM-IV adds no delay in the development of self-help skills, adaptive behavior, and curiosity about the environment.

11. Asperger Syndrome Criteria
Pragmatic language skill deficits not part of DSM-IV or ICD-10 criteria but should be included for differential diagnosis.
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12. Other Developmental Issues
Deviation from normal development
Do not “Outgrow” Developmental Deficits
Stress Impairs Performance
Co-Morbid Diagnosis Impairs Overall Functioning
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13. Cognitive Functioning
Medications
Cognitive Functioning
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14. Psychological Symptoms
Age / Time
Psychological Symptoms
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15. Clinical Symptoms and Learning Disabilities
Grade
Clinical Symptoms and Learning Disabilities
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16. Asperger Syndrome Pervasive Developmental Delay
C O G N I T I O N
Memory
Higher Order Process Analysis,
Synthesis, and Evaluation
Organization
Flexibility
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17. Asperger Syndrome Pervasive Developmental Delas
C O G N I T I O N
Wide Band of Knowledge
Problem Solving
Verbal-Performance IQ
Attention Shift
Rule and Governing Behavior
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18. Asperger Syndrome Pervasive Developmental Delay
L A N G U A G E
Pragmatics
Syntax
Meaning: Connotative
Denotative
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19. Asperger Syndrome Pervasive Developmental Delay
L A N G U A G E
Processing Speed
Expression
Duration
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20. Asperger Syndrome Pervasive Developmental Delay
S P E E C H
Prosody
Pedantic
Elocution
Volume
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21. Asperger Syndrome Pervasive Developmental Delay
M O T O R
Fine Control
Gross Control
Coordination
Regulation
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22. Asperger Syndrome Pervasive Developmental Delay
S E N S O R Y P R E C E P T I O N
Visual Integration
Kinesthetic
Tactile Accuity
Gestalt
Integration of other Senses
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23. Asperger Syndrome Pervasive Developmental Delay
S O C I A L
Cue Identification
Responsive to others
Isolate
Rude
Aggressive
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24. Asperger Syndrome Pervasive Developmental Delay
S O C I A L
Boundary Acceptance
Maintain Social Roles
(e.g., student, son, daughter, friend)
Self-Regulate
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25. Developmental Tasks of Adolescence: Ages 12 - 18
Achieving new and more mature relations with age-mates of both sexes
Achieving a masculine or feminine social role
Accepting one’s physique and using the body effectively
Achieving emotional independence of parents and other adults
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26. Developmental Tasks of Adolescence: Ages 12 - 18
/ Continued
Preparing for marriage and family life
Preparing for an economic career
Acquiring a set of values and an ethical system as a guide to behavior; developing an ideology
Desiring and achieving socially responsible behavior
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27. Developmental Tasks of Early Adulthood
Selecting a mate
Achieving a masculine or feminine social role
Learning to live with a marriage partner
Starting a family
Rearing children
Managing a home
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28. Education: Asperger Student Classroom Behavior
1. Attending Behavior
Discern Task Expectations
Focus Attention on Relevant Stimuli
Shift Attention to Relevant Stimuli
Ignore Irrelevant Material
Perform Multi-Task Operations
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29. Education: Asperger Student Classroom Behavior
2. Responding Behavior
Verbal Skills
Pragmatic Language Skills
Writing Ability
Executive Function Ability
Perseverance
STM for Denotative Items
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30. Education: Asperger Student Classroom Behavior
3. Reinforcement Behavior
Provide Contingent Positive Social Reinforcement
Assert Negative Reinforcement in an Appropriate Way
Receive Positive Reinforcement
Ability to Respond to Positive Reinforcement
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31. Education: Asperger Student Classroom Behavior
4. Initiating Behavior
Self - Initiate Classroom Routines
Use CAI Prompts
Start Task According to Direction
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32. Education: Asperger Student Classroom Behavior
5. Comply / Demonstrate Rule - Governed Behavior
Accept Correction from Instructor
Accept Correction in Public Setting
Self - Correct Assignments to Pre - determined Standards
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33. Education: Asperger Student Classroom Behavior
Completing Behavior
Perform Tasks to Standards
Return Completed Product to
Supervisor
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34. Education: Asperger Student Classroom Behavior
7. Transitioning Behavior
Initiate Independent Steps between Tasks
Use Prompts / Cues to Signal Move
from One Task to Another
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35. Education: Asperger Student Classroom Behavior
8. Cooperating Behavior
Taking Turns
Waiting
Avoid Arguing
Sharing
Making Requests Before Acting
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36. Education: Asperger Student Classroom Behavior
9. Adapting Behavior
Adjust to Different Routines in Different Classrooms
Adjust to Alteration in Routine
Follow New Routine Required by a Situation
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37. Education: Asperger Student Classroom Behavior
10. Cooperate with Medication
Administration
Complete Homework
Attend School
Discern Task Expectations
Focus Attention on Relevant Stimuli
Shift Attention on Relevant Stimuli
Ignore Irrelevant Material
Perform Multi-Task Operations
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38. Competing Clinical Behaviors
Perseveration
Obsessive Thought
Rigid Cognitive Style
Inability to Shift from “Personal View”
to Data - Based Decision
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39. Competing Clinical Behaviors
/ Continued
Confabulation
Affirming False Information
“Stealing”
Sexually Inappropriate Actions and Statements
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40. Competing Clinical Behaviors
/ Continued
Violation of Boundaries
Cognitive Disorientation and
Distortion
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41. Optimal Classroom Behaviors
Closed Classroom
Applied Task - Oriented Setting
Standards are Limited, Precise and Based on Asperger Student’s Level of Ability to Self - Regulate
Class Size Under 10 - Over 3
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42. Optimal Classroom Behaviors
/ Continued
Cues and Prompts are Provided
Daily Plan / Organizer
Assigned Work Station
CAI Task Presentation
Clear System of Discipline Consistently Applied Setting Wide
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43. Optimal Classroom Behaviors
/ Continued
Classroom Mix Controlled
Interpersonal Style of Teacher:
Direct, Non-Judgmental, Organized
Task Analysis Reflects:
Backward Chaining
Performance Standards
Over - Learning Options
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44. Optimal Classroom Behaviors
/ Continued
Control Risk
Minimize Transitions
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45. Writing a News Story Hurricane Ivan Blasts Alabama, Kills 12
Associated Press
Hurricane Ivan Blasts Alabama, Kills 12
GULF SHORES, Ala. (AP) - Hurricane Ivan slammed into the Gulf Coast early Thursday with 130 mph wind, launching tornadoes, washing out a major bridge and hurling metal signs through the night. At least 12 U.S. deaths were blamed on the storm, but officials said the toll and the damage could have been even worse. Up to 15 inches of rain were expected as the storm moved inland. It weakened by late morning, but remained a Category 1 hurricane with wind of 75 mph eight hours after its 3 a.m. landfall.
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46. Writing a News Story Directions: Writing a News Story
Write a news story using what you consider the most relevant facts listed by numbered sentences.
First - read all the sentences and answer the question “What is the main point of the numbered sentences that are related
Second - arrange the sentences into a one paragraph news story
Third - be sure your first sentences is the main theme of the news story.
Fourth - place other sentences in order of story organization
Fifth - be prepared to explain why the sentences you did not use did not belong in the story
Sixth – read your story aloud and make any changes
Seventh – compare your story with one written by another student
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47. Writing a News Story Relevant and Irrelevant Information
Colorado experienced a severe winter storm today
Denver, Colorado international airport is located on a high mountain plateau
Low visibility and storms make a landing dangerous at the Colorado airport
A plane crashes in an attempt to land at Denver Colorado
Rescue efforts were started within minutes of the crash
Pilot training on simulators is important
Many people fear flying
The number of survivors in today's plane crash in Colorado is unknown
Colorado has many large ranches
People travel to Denver, Colorado by cars more than other types of transportation
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48. What are the Priorities of the Asperger Syndrome Student?
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49. Priorities of the Asperger Student
Rank
December /04 Group
September /05 Group 1.
Independence
Independence Work Experience 2.
Work Experience
Social Activities 3.
a. Shared Living vs.
b. Resources
a. Problem-Solving b. Resources
Living Alone
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50. Priorities of the Asperger Student
Rank
December /04 Group
September /05 Group 4.
a. Social Activities b. Medication
College Experience 5.
Shared Living vs. Living Alone 6.
Problem-Solving
Living Alone
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51. How Can We Assess Readiness for Independence?
The Learning Clinic Pragmatic Skills Survey
The Learning Clinic Transition & Independent Living Skills Assessment
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52. Social Skills Training
Effective Social Skills Training should
include the following components:
Comprehensive and Integrated approach
Incorporate Changes in Development Tasks/Challenges
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53. Social Skills Training
Comprehensive & Integrated:
Multiple Settings
Clinical Therapy Groups
Hands-on
Role-plays
Video Feedback
Classroom
Home/Residential House
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54. Social Skills Training
Comprehensive & Integrated:
Self-Regulation
Self-Restraint
Point/Level System
Extended School Day
Social Skills Goal
Community
Young Apprenticeship – Work Setting
Job Shadowing
/ Continued
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55. Social Skills Training
Social Skills and Developmental
Tasks/Challenges
Social Skill requirements change as the
Child goes through different
developmental stages
Social Skills learned at earlier developmental stage do not always generalize to challenges at next developmental stage
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56. Social Skills Training
Social Skills and Developmental
Tasks/Challenges
Mastery of skill at one developmental level does no ensure generalization to social challenges at next developmental level
/ Continued
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57. Social Skills Training
Social Skills and Developmental
Tasks/Challenges
Social challenges change
Childhood to Adolescence:
Childhood
casual friendships based on “unconditional acceptance
generally concrete communication
parallel interactions
/ Continued
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58. Social Skills Training
Social Skills and Developmental
Tasks/Challenges
Social challenges change
Childhood to Adolescence:
Adolescence
competition for social acceptance based on “popularity”
need to “read” nonverbal communication
/ Continued
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59. Social Skills Training
Social Skills and Developmental
Tasks/Challenges
Childhood to Adolescence:
Adolescence
must interpret increasingly abstract and complex communication
interactions include reciprocity and ability to “intuit” the feelings and thoughts of others
/ Continued
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60. Social Skills Training
Social Skills and Developmental
Tasks/Challenges
Adolescence to Young Adulthood
Adolescence
Parents are caretakers
Young Adulthood
Independent Living:
employment
driving
college
integration into community
accessing community services
/ Continued
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61. Social Skills Training
Social Skills and Developmental
Tasks/Challenges
Adolescence to Young Adulthood
Young Adulthood
Independent Living:
self-advocacy
finances
legal rights/responsibilities
health needs
maintaining an apartment
grocery shopping and meal preparation
/ Continued
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62. Which Asperger Symptoms Compete with Independence?
Age
Degree of Anosognosia
Over time, symptoms become egosyntonic
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63. Time Line for Data Collection 2004-05
Treatment and Non-treatment Students Skill Assessment T5
Housing Acquisitions & Leases Home Management Meal Planning & Preparation Dining Clean Up & Food Storage Budgeting & Taxes Banking & Credit Consuming Transportation Leisure Legal Awareness Health Time Management Maintain Personal Safety in House Maintain Personal Safety in Community Safety During Dating Relationships Personal Presentation Community Resources Community Service Career Planning Employment Post-Secondary Education Participation in Therapy Sessions
Time Line for Data Collection T5
Sep Oct Nov Dec Jan Feb Mar
Skills Showing Significant Improvement by Treatment vs. Non-Treatment Students
Time - 5
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64. Transition Program Independent Living Skills - Areas of Significant Progress
Housing Acquisitions & Leases Meal Planning & Preparation Dining Clean Up & Food Storage Consuming Transportation Legal Awareness Health Time Management Maintain Personal Safety in House Maintain Personal Safety In Community Safety During Dating Relationships Community Resources Community Service Career Planning Employment Post-Secondary Education Healthy Relationships
22%
Home Management Budgeting & Taxes Banking & Credit Leisure Personal Presentation
% of Skills (5 of 23) Significantly Increased from T1 – T4
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65. Transition Program Independent Living Skills - Areas of Significant Progress
Housing Acquisitions & Leases Budgeting & Taxes Banking & Credit Consuming Transportation Leisure Legal Awareness Time Management Maintain Personal Safety in Home Maintain Personal Safety in Community Safety During Dating Relationships Community Resources Community Services Career Planning Employment Post Secondary Education Health Post-Secondary Education Healthy Relationships
70% Significant Improvement
Home Management Leisure Personal Presentation Time Management
% of Skills (16 of 23) Significantly Increased T5 at 7 Months
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66. T1 Comparison:
Student Self-Assessment vs. Teacher Assessment Comparison
Skills Students Self-assessed higher
than Teachers Assessed
52%
Home Management Dining Clean UP & Food Storage
Nutrition Banking & Credit
Transportation
Legal Awareness
Health Time Management Safety During Dating Relationships
Personal Safety
Independent Living
Career Planning Employment Post-Secondary Education
22%
% of Skills (12 of 23) Students rated themselves significantly higher than Teachers at T1
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67. T5 Comparison:
Student Self-Assessment vs. Teacher Assessment Comparison
Skills Students Self-assessed higher
than Teachers Assessed
39%
22%
Clean UP & Food Storage
Leisure Health
Time Management
Safety During Dating Relationships
Personal Presentation
Career Planning Employment Healthy Relationships
% of Skills (9 of 23) Students rated themselves significantly higher than Teachers at T5
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68. What Is on the Horizon for Asperger Students?
Early Diagnosis
Pediatric Training
Teacher Training
Psycho - Education Treatment
Cognitive Behavioral Therapy
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69. What Is on the Horizon for Asperger Students?
Technology
Distance Coaching (remote
video monitoring)
Computer Checklists and Prompting
Computer Assisted Instruction (CAI)
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70. What Is on the Horizon for Asperger Students?
Technology / Continued
Kurtzweil
Dragon Naturally Speaking
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