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Autism Spectrum Disorder:

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1 Autism Spectrum Disorder:
A Personalized Assessment and Treatment Model for Individuals with a Diagnosis of an Autism Spectrum Disorder: Asperger Syndrome January 24 and 25, 2013 Raymond W. DuCharme, PhD

2 phrenia. Rigorous definition in psychiatric manuals began in 1980 but
Broader Definition, Autism Cases per 10,000 U.S. children More Cases For decades autism was considered rare, perhaps a form of schizo phrenia. Rigorous definition in psychiatric manuals began in 1980 but broadened to “autism spectrum disorder” by As a result, more andmore U.S. children were diagnosed, prompting schools to offer special education, parents to call for better treatments and practitioners to offer an increasingly array of unapproved therapies. | o | | | | o | o | | | | | 1943 Autism Autism first Category changed to Autism first tracked Autistic disorder, popularly defined designated as its own “autistic disorder” in revised under the Individuals with known as Autism spectrum disorder, category, infantile autism, DSM-III; eight of 16 criteria Disabilities Education Act, is defined more broadly in DSM-IV to in DSM-III (Diagnostic and had to be met for a diagnosis. indicating need for special include syndromes such as Asperger’s; Statistical Manual of Mental education only six diagnostic criteria had to be met. Disorders, third edition).

3 Cognitive Functioning Motor Skills
Diagnosis 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

4 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

5 Asperger Syndrome Criteria
Pragmatic language skill deficits not part of DSM-IV or ICD-10 criteria but should be included for differential diagnosis.

6 The lack of a well-defined diagnostic nosology results in questionable
validity for research. If there is a continuum of degrees of impairment, developmental delays, and problematic self-regulation for each subtype of Autism, then each subtype needs to be separated for reliable interpretation of research outcomes. Most of the 2012 studies I reviewed failed to distinguish between subtypes. The studies bifurcated individuals into two groups High Functioning Autism (HFA) and Low Functioning Autism (LFA) or “blended” individuals into one group with a “typical developing group” for comparison. In most cases studies relied on small samples or large groups with small sub-samples of age, sex, and undifferentiated diagnoses. These threats to validity yield concern about the application of findings in treatment.

7 Key question that needs to be resolved prior to
treatment planning: Is Autism Spectrum Disorder (ASD) a Phenotype or a Dimensional Structure of Symptoms? Corollary Questions: What is the validity of the separate nosologic types of ASD? (Autism vs. High Functioning Autism vs. PDD-NOS vs. Asperger Syndrome) Are the subtype diagnoses Quantitatively distinct (phenotypes) or Qualitative manifestations of the same disorder? There is no clear empirical data to answer these basic questions at this time. The current trend in the literature is toward the acceptance of the concept of an Autism continuum without empirical support for the concept.

8 Some generalizations may be drawn however:
ASD cluster scores in research studies indicate that a diagnosis of ASD and low IQ (< 75) scores will reveal problematic performance on: Theory of Mind (ToM) Attribution Tasks Divided Attention Social Skills and Adaptive Behavior composite scores are down by 2 sd (SD=16.9) for this LFA group. The stronger the “cognitive make-up” measured high IQ scores, the better the scores by individuals on such tasks. Scores for the cluster of ASD did differentiate ASD from other clinical diagnoses, but did not differentiate quantitatively distinct phenotypes: Autism, HFA, PDD-NOS, or Asperger Syndrome.

9 Differential Diagnosis
Asperger Syndrome vs. Autism – 75% IQ below 75 Verbal IQ – normal or above Developmental skills delayed Later onset of symptoms throughout development Academic competencies < LD Avoids social contacts specifically Math Early onset of developmental Wants relationships with peers delays Lack of social reciprocity Impaired social judgment Narrow focus of interest Early delayed language Perceived as bright, even development gifted early Long-term support usually Prognosis is positive for IL required Co occuring Diagnoses: Anxiety D/O Deppression Oppositional – Defiant D/O LD

10 Neuroatypical Learners
What interferes with the student development of educational competencies and cause special needs classification? Neuroatypical factors specifically associated with LD and Autism Spectrum Disorders are discussed in Neurology of Cognitive and Behavior Disorders by Devinsky and D’Espisito (2004).

11 Functional brain imaging and electrophysiological studies indicate right brain hemisphere dominance over critical factors that influence how we experience “self” and therefore how we present to others, learn social skills and behavioral expectations. Right hemisphere dominance controls: self-recognition of one’s own face, ability to identify and describe feelings, our level of depersonalization, lack of sense of self, fear, grief, crying, morbid thoughts, ecstatic feelings

12 . . . and the . . . ability to connect relationships between past and current experience. (source memory) tangential thought, rambling, vague, loquacious speech

13 Volition (will) is modulated by right hemisphere function as is:
the ability to select and decide to take action hold information in a fixed position in the mind in order to compare and contrast data insight into consequences of actions response to information directed at others versus self

14 The right hemisphere disorders can impair social awareness and behavior i.e. inability to comprehend emotional and social cues. Such impairment can cause lack of social greeting, eye contact and facial expression. A person may have a normal to high IQ but lack the social pragmatic skills needed for social interactions, friendship and close personal relationships and motivation for social acceptance. Impaired verbal communication of nonverbal affective signals Impaired higher level inferential reasoning (figures of speech, sarcasm)

15 The lack of prosodic communication and impoverished gestural behavior are also evident. Flat affect, impaired awareness and responsiveness to social context is evident. Poor arithmetic and visuo-spatial skills are also evident with impaired right hemisphere function. demonstrate motor persistence ability to perform two motor acts simultaneously . . .

16 Differential Diagnosis
Asperger Syndrome Childhood onset of symptoms Impaired social judgment Poor peer relationships Lack of social reciprocity Multiple psychiatric diagnoses Poor response to psychotropic treatments Somatic complaints Discrepancy between verbal and performance IQ (verbal high score) Preferred, more successful relationship with older people Repetitive ideation Schizo-Affective Disorder Schizophrenia Lack of cause & effect reasoning Psychotic presentation manifested by delusion and/or hallucination Stabilized by psychotropic medications Affect inappropriate to context Executive Function Deficits Isolative

17 Chart of Comparative Symptoms
Classical Autism Asperger Syndrome Cognitive Traits Observed IQ < 75 Intelligence quotient is the product of measurements of a series of subtests in both verbal and nonverbal competencies compared to a norm based group 5 Perceptual Difficulties Measurements of abilities to perform subtest tasks that assess visual, tactile, auditory, motor developmental level performance. 2 Executive Function Cognitive abilities necessary for complex goal-directed behavior and adaptation to a range of environmental changes and demands. Executive function includes the ability to plan and anticipate outcomes (cognitive flexibility) and to direct attentional resources to meet the demands of non-routine events. 1 3 Proprioception Knowledge about the position of one’s body in space that is based on sensory information from receptors in the muscles, tendons, and viscera. 4

18 Classical Autism Asperger Syndrome Cognitive Rigidity Concrete thinking often associated with inability to transfer attention away from one stimulus to another, or to pay attention to more than one stimulus at a time. Impedes ability to benefit from verbal self-regulation and even verbal instructions received. Often manifests as an inability to modify behavior according to feedback or responses from others. 5 2 Sensory Sensitivity Deficits in sensory sensitivity manifest as either over (hyper) and under (hypo) responsive to sensory stimuli. Perceived intensity of the sensory stimuli is can be either high or low. 3 Apprehension of Context or Cues Awareness and understanding the setting or circumstances in which an event occurs. Also awareness and understanding of verbal or nonverbal behavior that serves as prompts for a response. 1 Connotative and Denotative Language Deficits Denotative meaning of a word is its literal meaning; Connotative meaning of a word is its figurative meaning, associations related to the word. These associations can be personal or general to one’s culture. 4

19 Classical Autism Asperger Syndrome Communication Disorder A speech or language disorder which refers to problems in communication and in related areas such as oral motor function. Can manifest as saying sounds incorrectly to being completely unable to speak. The inability to demonstrate the social pragmatics of reciprocal communication. 5 3 Meta Cognitive Deficits: Analysis, Synthesis, Evaluation; Social Pragmatics Analysis and Synthesis are prerequisites for Evaluation. Analysis – is the process of breaking a complex topic into smaller parts to gain a better understanding. Closely examining something to understand its parts and the ways they work together. Synthesis – to combine separate elements or components in order to form a coherent whole. Bringing together information from several sources to make a new point. Evaluation - the systematic determination of merit, worth and significance of something using criteria against a set of standards. Your informed judgment.

20 Classical Autism Asperger Syndrome Social Pragmatics - social language involving learning rules for interacting with others in socially acceptable behaviors. Includes language development of vocabulary and grammar into meaningful speech patterns for communication. 2 Expressive –Receptive Language Deficits Expressive Language Deficits – distinctly limited vocabulary, errors in tense, difficulty recalling words or producing sentences with developmentally appropriate length or complexity, and general difficulty expressing ideas. 5 3 Receptive Language Deficits – difficulty understanding words, sentences, or specific types of words. Developmental Delays – Source Memory Developmental Delay – Any significant delay in a child’s physical, cognitive, behavioral, emotional or social development in comparison with established norms for the child’s age. 4 Source Memory – Memory for the circumstances in which an episodic memory is formed. Episodic memory is context specific, and often personal, preserving the time and space aspects of past events. 1

21 Classical Autism Asperger Syndrome Social Skills Prospective Planning Ability to develop future plans, e.g., appointments, and actions. 1 3 Self-Regulation The ability to exercise self-control, and includes the skills of planning, self-monitoring, other awareness, delayed gratification and goal setting. Social Judgment Impairments The ability to choose a socially appropriate behavior in response to a social interaction Reciprocity Impairments Turn taking in communication and other interactions. Providing others with an opportunity to respond and/or provide input during a conversation or social interaction. Structure Dependent Dependence on pre-planned schedules, routines, advance rehearsal. 5 4 Resiliency Difficulties The ability to recover readily from disappointments, adversity, performance errors, embarrassment 2

22 Classical Autism Asperger Syndrome Limited Interests Restricted range of interests. Narrow band of activities or hobbies in which the person engages. 5 4 Delayed Gratification Difficulties The ability to postpone pursuit or attainment of a desired activity or object. 1 Redirection Verbal direction to return to behavior that is task relevant Prompt Verbal, ideagram or diagram that provides assistance to stay on task. 3 Social & Tangible Reinforcements Unreliable Inconsistent response to the availability of social or concrete/physical rewards and ratio of positive reinforcement 2 Social Development Delays A delay in the development of social interaction skills and social competence in children. The child lags behind the normative schedule for acquiring social skills.

23 Classical Autism Asperger Syndrome Physical Behaviors Self-Harm Demonstration of self-injurious behaviors. 4 2 Self-Stimulation Dependent Stereotyped, functionally autonomous behaviors. Repetitive body movements or repetitive movement of objects used solely to simulate one’s own senses. 1 Physical Development Delays A delay in the physical development of children. The child lags behind the normative schedule for biological milestones. 5 3 Emotional Dysregulation Anxiety A dysregulated psychological or physiological state in response to a perceived stressor; a state characterized by somatic, emotional, cognitive and behavioral components, such as fear or nervousness about what might happen (anticipation), worry. Aggression A forceful act or procedure, intended to dominate or master. Behavior aimed at causing harm or pain, psychological harm, or personal injury or physical distraction.

24 Classical Autism Asperger Syndrome Naïve Lack of experience or knowledge: lacking in worldly wisdom or informed judgment. 5 3 Isolative Tendency or desire to seek solitude; avoids social contact. Impulsive Tendency to behave without forethought, and without considering the consequences of one’s actions. To act suddenly without careful thought. Goals Responsivity to non-verbal ideograms Ability to demonstrate a physical or verbal response in a presence of symbolic language, such as icons, pictures, that illustrate concepts or actions. 4 Supported Living During High School Provision of the necessary support, training, and assistance to students with developmental disabilities during high school years.

25 Classical Autism Asperger Syndrome Supported Living Post High School Provision of the necessary support, training, and assistance to students with developmental disabilities during post high school years. 5 3 In Home Services Services to provide functional analysis of child-parent-sibling interaction. Intervention protocols are provided by professional and paraprofessional staff at the child’s residence. 2 Independent Living Adolescents over 18 and young adults provided residential living within the community. Support services are typically provided and monitored. Supported Employment Employment provided in conjunction with agency advocacy, training, job coaching and monitoring 1 Modified Employment Student or young adult is able to have the employment expectations modified to suit their needs; level of supervision, specific challenges and schedule by their employer.

26 Classical Autism Asperger Syndrome Competitive Employment Student sixteen or older; self-initiated contact with employer for interview and paid employment. 3 High School Applied Instruction and Experiential Training High school instruction is modified to provide employer required skill sets, and applied onsite training. 1 5 Post Diploma Training or Education Achievement of academic requirements is met and diploma deferred until transition to work or college skills are met by demonstration and application.

27 The Learning Clinic January 2013
LEGEND 0 = no behavior observed (0 out of 10 times) Behavior is never observed 1 = 1-20% of the time (1-2 out of 10 times) Behavior is rarely observed 2 = 21-40% of the time (3-4 out of 10 times) Behavior is sometimes observed 3 = 41-60% of the time (5-6 out of 10 times) Behavior is evident in many settings, performance is inadequate and inconsistent; Skill still dependent on external prompts. 4 = 61-80% of the time (7-8 out of 10 times) Demonstrated in most settings; Evidence of a level of persistent behavior 5 = % of the time (9-10 out of 10 times) Demonstrated consistensy in all settings The Learning Clinic January 2013

28 Diagnostic Characteristics
Autism High Functioning Autism PDD NOS Developmental Anomalies Asperger Syndrome

29 Cognitive Functioning
Medications Cognitive Functioning

30 Psychological Symptoms
Age / Time Psychological Symptoms

31 Clinical Symptoms and Learning Disabilities
Grade Clinical Symptoms and Learning Disabilities

32 Which Asperger Symptoms Compete with Independence?
Age Degree of Anosognosia Over time, symptoms become egosyntonic

33 Personalized Treatment Model (PTM) requires identifying
idiosyncrasies in each person’s general diagnosis that is relevant to predicted treatment outcomes. This PTM approach to treatment indicates the following three part focus for treatment: I. Psychopharmacological Management: Genotyping to identify open or deficient pathways to drug metabolism and given medication options Co-occurring conditions require treatment triage to maximize generalizations. Number of discontinued medication trials Historical polypharmacy Dose changes through and over time Medication synergies Unintended outcomes from particular prescriptive drug use – weight gain, cognitive function interference

34 Percentage of Medication Metabolized thru 2D6
66.7% Stimulant 76.9% Antidepressants 86.7% Neuroleptics

35 Short-term objectives focus:
Goals Short-term objectives focus: self-regulation resiliency Intermediate functional social judgment disclosure interpersonal communication Long-term family separation and individuation

36 Other Developmental Issues
Deviation from normal development Do not “Outgrow” Developmental Deficits Stress Impairs Performance Co-Morbid Diagnoses Impairs Overall Functioning

37 Competing Clinical Behaviors
Perseveration Obsessive Thought Rigid Cognitive Style Inability to Shift from “Personal View” to Data - Based Decision

38 Competing Clinical Behaviors
/ Continued Confabulation Affirming False Information “Stealing” Sexually Inappropriate Actions and Statements

39 Competing Clinical Behaviors
/ Continued Violation of Boundaries Cognitive Disorientation and Distortion

40 II. Therapeutic Needs for Management:
Social/Developmental atypicalities Specific developmental strengths and deficits Family history of DSM diagnoses Clinical service history: individual, group, family, extended family therapy, partial hospital care, hospitalization Specific family stressors Treatment methods used and outcomes: CBT, Family Systems, Child-Parent Interactive Therapy, etc. Fit of treatment approaches to clinical diagnoses, as perceived by family and child GAF and Prognosis Genetic markers associated with current diagnoses

41 III. Special Education Services A. Student Role Performance
Assessment through time and over time Reliability of observations (in-vivo) teacher, mother, father, self Targeted performance over time minus baseline data = treatment benefit B. Level of intervention for in-school services through time and over time, e.g., full inclusion, partial special classroom, shadow monitor, full special class, in-home supports, day outplacement, residential placement C. Evidence-based outcomes plus unintended outcomes D. Evidence of communication with parents E. Evidence of collaboration among professional disciplines: pediatrician, psychiatrist, developmental specialist, special educator, speech and language specialist, other . . .

42 F. Evidence of cohesive treatment and integrated services particular to an ASD individual’s requirements G. Academic modifications: evidence-based procedures such as teacher verbal or visual demonstration, rehearsal, prompting, redirection strategies, backwards chaining for sequential instruction, active learning instructional methods, Virtual Lab and CAI instruction. H. School and classroom ecology designed to structure support and elicit student role behaviors for individuals with ASD diagnoses. I. Safe school orientation operationalized to provide standards of accountability for staff and students regarding bullying, victimization, mutual respect and peer support

43 J. IEP written with personalized strategies to accommodate
idiosyncrasies in student strengths and deficiencies with related assessment protocols: 1. Student role performance 2. Measures of retained academic skills 3. Measured ability to apply knowledge to real world problems 4. Self-regulation and classroom performance commensurate with the individual’s developmental age 5. IEP fit with assessed transition to post-high school plan, e.g., social judgment, pragmatic language skills, self-regulation, college experience, vocational experience, independent living skills, and experience with competitive employment (TILSA)

44 And IQ scores in another study accounted for more differences
between groups than diagnoses (Rodman, J.L. et al, 2010) on measures of object exploration, diversity of play, and turn-taking tasks in young children. Criteria for Comprehensive Treatment Models for Individuals with ASD (J. Autism and Dev Disorders (2010) ODOM, et al) describe an evaluation system endorsed by the American Evaluation Association (2008).

45 Six Features of a Comprehensive Treatment
Operationalized Practices: Manuals illustrate what to do and how to do it. 2. Practices must be replicated. 3. Demonstrate types of empirical evidence, e.g. articles, book chapters, books. 4. Quality of Methodology 5. Use of complementary evidence 6. Evaluation rating scales applied to practice

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