Presentation on theme: "Autism Spectrum Disorder:"— Presentation transcript:
1 Autism Spectrum Disorder: A Personalized Assessment and Treatment Model for Individuals with a Diagnosis of anAutism Spectrum Disorder:Asperger SyndromeJanuary 24 and 25, 2013Raymond W. DuCharme, PhD
2 phrenia. Rigorous definition in psychiatric manuals began in 1980 but Broader Definition, Autism Cases per 10,000 U.S. childrenMore CasesFor decades autism was considered rare, perhaps a form of schizophrenia. Rigorous definition in psychiatric manuals began in 1980 butbroadened to “autism spectrum disorder” by As a result, moreandmore U.S. children were diagnosed, prompting schools to offerspecial education, parents to call for better treatments and practitionersto offer an increasingly array of unapproved therapies.| o | | | | o | o | || | |1943 Autism Autism first Category changed to Autism first tracked Autistic disorder, popularlydefined 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 toin 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 DiagnosisOnset of SymptomsGenderSocial SkillsHead CircumferenceLanguage SkillsCognitive FunctioningMotor SkillsAutismPrior to age 3 years. Symptoms in infancy are subtleMales (8 times greater than females)Social skill deficitsDelay, or lack of development75% have mental retardationRepetitive and StereotypedRett’s DisorderFive months normal development; diagnosed between 5-48 monthsFemalesLoss of social interaction early; may develop laterDecelerates between 5-48 monthsExpressive and receptive language problemsSevere to profound retardation“Hand-Wringing” gait and truck coordination problemsChildhood Disintegrative DisorderTwo years normal development; diagnosed before age 10Males – more commonLoss 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 yearsAsperger SyndromeRecognition 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 SpeechNormal IQ Verbal Performance DeviationMotor delays and clumsiness” Absence of researchPDD, NOSDoes no meet criteria for any of the above, but has some of the behaviors
4 Asperger Syndrome Criteria DSM-IVICD-10Qualitative impairment in social interactionXRestricted repetitive and stereotyped patterns of behavior, interests, and activitiesNo general language delayNo delay in cognitive developmentNormal general intelligence (most)Markedly clumsy (common)No delay in development of:age appropriate self-help skillsadaptive 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 eachsubtype needs to be separated for reliable interpretation of researchoutcomes.Most of the 2012 studies I reviewed failed to distinguish betweensubtypes. The studies bifurcated individuals into two groups HighFunctioning 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 smallsub-samples of age, sex, and undifferentiated diagnoses.These threats to validity yield concern about the application of findingsin treatment.
7 Key question that needs to be resolved prior to treatment planning: Is Autism Spectrum Disorder(ASD) a Phenotype or a Dimensional Structure ofSymptoms?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 basicquestions at this time.The current trend in the literature is toward the acceptance ofthe concept of an Autism continuum without empirical supportfor the concept.
8 Some generalizations may be drawn however: ASD cluster scores in research studies indicate that a diagnosis of ASDand low IQ (< 75) scores will reveal problematic performance on:Theory of Mind (ToM)Attribution TasksDivided AttentionSocial 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, thebetter the scores by individuals on such tasks.Scores for the cluster of ASD did differentiate ASD from other clinicaldiagnoses, but did not differentiate quantitatively distinct phenotypes:Autism, HFA, PDD-NOS, or Asperger Syndrome.
9 Differential Diagnosis Asperger Syndrome vs. Autism – 75% IQ below 75Verbal IQ – normal or above Developmental skills delayedLater onset of symptoms throughout developmentAcademic competencies < LD Avoids social contactsspecifically Math Early onset of developmentalWants relationships with peers delaysLack of social reciprocity Impaired social judgmentNarrow focus of interest Early delayed languagePerceived as bright, even developmentgifted early Long-term support usuallyPrognosis is positive for IL requiredCo occuring Diagnoses:Anxiety D/ODeppressionOppositional – DefiantD/OLD
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 actionhold information in a fixed position in the mindin order to compare and contrast datainsight into consequences of actionsresponse 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 affectivesignalsImpaired 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 persistenceability to perform two motor acts simultaneously . . .
16 Differential Diagnosis Asperger SyndromeChildhood onset of symptomsImpaired social judgmentPoor peer relationshipsLack of social reciprocityMultiple psychiatric diagnosesPoor response to psychotropictreatmentsSomatic complaintsDiscrepancy between verbal andperformance IQ (verbal high score)Preferred, more successfulrelationship with older peopleRepetitive ideationSchizo-Affective DisorderSchizophreniaLack of cause & effect reasoningPsychotic presentation manifested by delusion and/or hallucinationStabilized by psychotropicmedicationsAffect inappropriate to contextExecutive Function DeficitsIsolative
17 Chart of Comparative Symptoms ClassicalAutismAspergerSyndromeCognitive Traits ObservedIQ < 75Intelligence quotient is the product of measurements of a series of subtests in both verbal and nonverbal competencies compared to a norm based group5Perceptual DifficultiesMeasurements of abilities to perform subtest tasks that assess visual, tactile, auditory, motor developmental level performance.2Executive FunctionCognitive 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.13ProprioceptionKnowledge 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 ClassicalAutismAspergerSyndromeCognitive RigidityConcrete 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.52Sensory SensitivityDeficits 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.3Apprehension of Context or CuesAwareness 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.1Connotative and Denotative Language DeficitsDenotative 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 ClassicalAutismAspergerSyndromeCommunication DisorderA 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.53Meta Cognitive Deficits: Analysis, Synthesis, Evaluation; Social PragmaticsAnalysis 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 ClassicalAutismAspergerSyndromeSocial 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.2Expressive –Receptive Language DeficitsExpressive 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.53Receptive Language Deficits – difficulty understanding words, sentences, or specific types of words.Developmental Delays – Source MemoryDevelopmental 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.4Source 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 ClassicalAutismAspergerSyndromeSocial SkillsProspective PlanningAbility to develop future plans, e.g., appointments, and actions.13Self-RegulationThe ability to exercise self-control, and includes the skills of planning, self-monitoring, other awareness, delayed gratification and goal setting.Social Judgment ImpairmentsThe ability to choose a socially appropriate behavior in response to a social interactionReciprocity ImpairmentsTurn taking in communication and other interactions. Providing others with an opportunity to respond and/or provide input during a conversation or social interaction.Structure DependentDependence on pre-planned schedules, routines, advance rehearsal.54Resiliency DifficultiesThe ability to recover readily from disappointments, adversity, performance errors, embarrassment2
22 ClassicalAutismAspergerSyndromeLimited InterestsRestricted range of interests. Narrow band of activities or hobbies in which the person engages.54Delayed Gratification DifficultiesThe ability to postpone pursuit or attainment of a desired activity or object.1RedirectionVerbal direction to return to behavior that is task relevantPromptVerbal, ideagram or diagram that provides assistance to stay on task.3Social & Tangible Reinforcements Unreliable Inconsistent response to the availability of social or concrete/physical rewards and ratio of positive reinforcement2Social Development DelaysA 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 ClassicalAutismAspergerSyndromePhysical BehaviorsSelf-HarmDemonstration of self-injurious behaviors.42Self-Stimulation DependentStereotyped, functionally autonomous behaviors. Repetitive body movements or repetitive movement of objects used solely to simulate one’s own senses.1Physical Development DelaysA delay in the physical development of children. The child lags behind the normative schedule for biological milestones.53Emotional DysregulationAnxietyA 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.AggressionA 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 ClassicalAutismAspergerSyndromeNaïveLack of experience or knowledge: lacking in worldly wisdom or informed judgment.53IsolativeTendency or desire to seek solitude; avoids social contact.ImpulsiveTendency to behave without forethought, and without considering the consequences of one’s actions. To act suddenly without careful thought.GoalsResponsivity to non-verbal ideogramsAbility to demonstrate a physical or verbal response in a presence of symbolic language, such as icons, pictures, that illustrate concepts or actions.4Supported Living During High SchoolProvision of the necessary support, training, and assistance to students with developmental disabilities during high school years.
25 ClassicalAutismAspergerSyndromeSupported Living Post High SchoolProvision of the necessary support, training, and assistance to students with developmental disabilities during post high school years.53In Home ServicesServices to provide functional analysis of child-parent-sibling interaction. Intervention protocols are provided by professional and paraprofessional staff at the child’s residence.2Independent LivingAdolescents over 18 and young adults provided residential living within the community. Support services are typically provided and monitored.Supported EmploymentEmployment provided in conjunction with agency advocacy, training, job coaching and monitoring1Modified EmploymentStudent 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 ClassicalAutismAspergerSyndromeCompetitive EmploymentStudent sixteen or older; self-initiated contact with employer for interview and paid employment.3High School Applied Instruction and Experiential Training High school instruction is modified to provide employer required skill sets, and applied onsite training.15Post Diploma Training or EducationAchievement 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 LEGEND0 = no behavior observed(0 out of 10 times)Behavior is never observed1 = 1-20% of the time(1-2 out of 10 times)Behavior is rarely observed2 = 21-40% of the time(3-4 out of 10 times)Behavior is sometimes observed3 = 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 behavior5 = % of the time(9-10 out of 10 times)Demonstrated consistensy in all settingsThe Learning Clinic January 2013
30 Psychological Symptoms Age / TimePsychological Symptoms
31 Clinical Symptoms and Learning Disabilities GradeClinical Symptoms and Learning Disabilities
32 Which Asperger Symptoms Compete with Independence? AgeDegree of AnosognosiaOver time, symptoms become egosyntonic
33 Personalized Treatment Model (PTM) requires identifying idiosyncrasies in each person’s general diagnosis that is relevant topredicted treatment outcomes.This PTM approach to treatment indicates the following three part focusfor treatment:I. Psychopharmacological Management:Genotyping to identify open or deficient pathways to drug metabolism and given medication optionsCo-occurring conditions require treatment triage to maximize generalizations.Number of discontinued medication trialsHistorical polypharmacyDose changes through and over timeMedication synergiesUnintended outcomes from particular prescriptive drug use – weight gain, cognitive function interference
34 Percentage of Medication Metabolized thru 2D6 66.7%Stimulant76.9%Antidepressants86.7%Neuroleptics
35 Short-term objectives focus: GoalsShort-term objectives focus:self-regulationresiliencyIntermediate functional social judgmentdisclosureinterpersonal communicationLong-term family separation and individuation
36 Other Developmental Issues Deviation from normal developmentDo not “Outgrow” Developmental DeficitsStress Impairs PerformanceCo-Morbid Diagnoses Impairs Overall Functioning
37 Competing Clinical Behaviors PerseverationObsessive ThoughtRigid Cognitive StyleInability to Shift from “Personal View”to Data - Based Decision
39 Competing Clinical Behaviors / ContinuedViolation of BoundariesCognitive Disorientation andDistortion
40 II. Therapeutic Needs for Management: Social/Developmental atypicalitiesSpecific developmental strengths and deficitsFamily history of DSM diagnosesClinical service history: individual, group, family, extended family therapy, partial hospital care, hospitalizationSpecific family stressorsTreatment methods used and outcomes: CBT, Family Systems, Child-Parent Interactive Therapy, etc.Fit of treatment approaches to clinical diagnoses, as perceived by family and childGAF and PrognosisGenetic markers associated with current diagnoses
41 III. Special Education Services A. Student Role Performance Assessment through time and over timeReliability of observations (in-vivo) teacher, mother, father, selfTargeted performance over time minus baseline data = treatment benefitB. Level of intervention for in-school services through time andover time,e.g., full inclusion, partial special classroom, shadow monitor, fullspecial class, in-home supports, day outplacement, residentialplacementC. Evidence-based outcomes plus unintended outcomesD. Evidence of communication with parentsE. 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 requirementsG. 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 ofaccountability 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 performance2. Measures of retained academic skills3. Measured ability to apply knowledge to real world problems4. Self-regulation and classroom performance commensuratewith the individual’s developmental age5. IEP fit with assessed transition to post-high school plan, e.g.,social judgment, pragmatic language skills, self-regulation,college experience, vocational experience, independentliving 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) onmeasures of object exploration, diversity of play, and turn-takingtasks in young children.Criteria for Comprehensive Treatment Models for Individuals withASD (J. Autism and Dev Disorders (2010) ODOM, et al) describean evaluation system endorsed by the American EvaluationAssociation (2008).
45 Six Features of a Comprehensive Treatment Operationalized Practices: Manuals illustrate what to do andhow to do it.2. Practices must be replicated.3. Demonstrate types of empirical evidence, e.g. articles, book chapters, books.4. Quality of Methodology5. Use of complementary evidence6. Evaluation rating scales applied to practice
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