DMHAS

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Syndro erg Syndrom AspergerS Asp erge ome er The Learning Syndrom Clinic AspergerS Asp Treatment and Prevention of Dysfunctional Behavior in Adolescents Diagnosed within the Category of Pervasive Development Delay erge ome er

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 The Learning Clinic

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.

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. The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic, Inc.  

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

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.

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

Other Developmental Issues Deviation from normal development Do not “Outgrow” Developmental Deficits Stress Impairs Performance Co-Morbid Diagnosis Impairs Overall Functioning The Learning Clinic

Cognitive Functioning Medications Cognitive Functioning The Learning Clinic

Psychological Symptoms Age / Time Psychological Symptoms The Learning Clinic

Clinical Symptoms and Learning Disabilities Grade Clinical Symptoms and Learning Disabilities The Learning Clinic

Asperger Syndrome Pervasive Developmental Delay C O G N I T I O N Memory Higher Order Process Analysis, Synthesis, and Evaluation Organization Flexibility The Learning Clinic

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 The Learning Clinic

Asperger Syndrome Pervasive Developmental Delay L A N G U A G E Pragmatics Syntax Meaning: Connotative Denotative The Learning Clinic

Asperger Syndrome Pervasive Developmental Delay L A N G U A G E Processing Speed Expression Duration The Learning Clinic

Asperger Syndrome Pervasive Developmental Delay S P E E C H Prosody Pedantic Elocution Volume The Learning Clinic

Asperger Syndrome Pervasive Developmental Delay M O T O R Fine Control Gross Control Coordination Regulation The Learning Clinic

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 The Learning Clinic

Asperger Syndrome Pervasive Developmental Delay S O C I A L Cue Identification Responsive to others Isolate Rude Aggressive The Learning Clinic

Asperger Syndrome Pervasive Developmental Delay S O C I A L Boundary Acceptance Maintain Social Roles (e.g., student, son, daughter, friend) Self-Regulate The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

Education: Asperger Student Classroom Behavior 2. Responding Behavior Verbal Skills Pragmatic Language Skills Writing Ability Executive Function Ability Perseverance STM for Denotative Items The Learning Clinic

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 The Learning Clinic

Education: Asperger Student Classroom Behavior 4. Initiating Behavior Self - Initiate Classroom Routines Use CAI Prompts Start Task According to Direction The Learning Clinic

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 The Learning Clinic

Education: Asperger Student Classroom Behavior Completing Behavior Perform Tasks to Standards Return Completed Product to Supervisor The Learning Clinic

Education: Asperger Student Classroom Behavior 7. Transitioning Behavior Initiate Independent Steps between Tasks Use Prompts / Cues to Signal Move from One Task to Another The Learning Clinic

Education: Asperger Student Classroom Behavior 8. Cooperating Behavior Taking Turns Waiting Avoid Arguing Sharing Making Requests Before Acting The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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

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

Competing Clinical Behaviors / Continued Violation of Boundaries Cognitive Disorientation and Distortion The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

Optimal Classroom Behaviors / Continued Control Risk Minimize Transitions The Learning Clinic

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. The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

What are the Priorities of the Asperger Syndrome Student? The Learning Clinic The Learning Clinic

Priorities of the Asperger Student Rank December 2003 03/04 Group September 2004 04/05 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 The Learning Clinic

Priorities of the Asperger Student Rank December 2003 03/04 Group September 2004 04/05 Group 4. a. Social Activities b. Medication College Experience 5. Shared Living vs. Living Alone 6. Problem-Solving Living Alone The Learning Clinic

How Can We Assess Readiness for Independence? The Learning Clinic Pragmatic Skills Survey The Learning Clinic Transition & Independent Living Skills Assessment The Learning Clinic

Social Skills Training Effective Social Skills Training should include the following components: Comprehensive and Integrated approach Incorporate Changes in Development Tasks/Challenges The Learning Clinic

Social Skills Training Comprehensive & Integrated: Multiple Settings Clinical Therapy Groups Hands-on Role-plays Video Feedback Classroom Home/Residential House The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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

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 2004-05 T5 Sep Oct Nov Dec Jan Feb Mar Skills Showing Significant Improvement by Treatment vs. Non-Treatment Students Time - 5 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

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 The Learning Clinic

What Is on the Horizon for Asperger Students? Early Diagnosis Pediatric Training Teacher Training Psycho - Education Treatment Cognitive Behavioral Therapy The Learning Clinic

What Is on the Horizon for Asperger Students? Technology Distance Coaching (remote video monitoring) Computer Checklists and Prompting Computer Assisted Instruction (CAI) The Learning Clinic

What Is on the Horizon for Asperger Students? Technology / Continued Kurtzweil Dragon Naturally Speaking The Learning Clinic

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