1. When you see tell tale signs of autism: Early Identification and Intervention Dr. Deepali Mankad Developmental Paediatrician, The Scarborough-Rouge Hospital Jordana Caruso Occupational Therapist, The Scarborough-Rouge Hospital

2. Conflict of Interest No conflict of Interest
No funding or grant received

3. Objectives Discuss the differences between DSM-IV and DSM-5
Early intervention- research and impact
Toddler behaviors that may be tell-tale
Role of primary caregivers
Resources for professionals and families working with children with autism
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4. DSM criteria

5. DSM IV vs DSM 5

6. Early Intervention – Impact and Research

7. Early Intervention Hanen Program- More than words, Talkability
Developmental, Individual Difference, Relationship based model (DIR)- Greenspan Model
Early Start Denver Model-ESDM
Therapy mediated
Social ABCs
Caregiver mediated

8. ESDM Dawson G et al, 2010 RCT to evaluate efficacy
Forty-eight children m old with ASD
2 groups, ESDM (developmental and applied behavioural analytic principles) or community intervention
Significant improvements in IQ, adaptive behavior, and autism symptoms

9. ESDM-Brain activity Dawson G et al, 2012
Forty-eight m old randomized
ESDM vs Community based intervention
After 2 years of intervention EEG activity was measured
Age matched typical children also assessed
ESDM and typical group showed
Increase cortical activity when shown faces in typical children and ESDM group

10. ESDM- Follow-Up study in 6-year-olds
Estes. A et al, 2015
39 children followed prospectively
18-30 months early participation
Intensive 2 year in-home therapy
Followed at 6 years of age, 2 years after intervention ended
Compared to children who received community-intervention
No group differences in the core autism symptoms immediately after but were present 2 years later
No differences in intellectual functioning

11. ESDM-Parent Intervention
Rogers. S et al, 2012
To examine efficacy of a 12m low-intensity parent delivered intervention for toddlers 14-24m
RCT, 98 children
P-ESDM
No effect
Parent implemented not as effective as intensive intervention

12. Social ABCs Brian et al 2017 RCT 63 parent-toddler dyads, 16-30 m
Confirmed or suspected ASD
Increase in parent smiling predicted increase in child smiling and social orienting
‘Enabling model’

13. Social ABCs Ongoing projects
Behavioural Intervention
Social ABCs Training for Early Childhood Educators at Humber College
Social ABCs for Toddlers with Suspected Autism: Evaluation of a Parent-Mediated Intervention

14. Early Identification is key!

15. Tell Tale Signs

16. Social Communication and Behaviours
Possible Early Signs
Social Communication
Non Verbal Communication
Receptive and Expressive Language
Play and Behaviours

17. Behaviors Difficulty with transitions Need for sameness
Communication &
Social skills
Behaviors
Difficulty with transitions
Need for sameness
Repetitive play/interests
Insists on certain routines and rituals
‘my way or high way’
Frequent and Prolonged temper tantrums
Motor mannerisms
Lack of attention
own name
comments
instructions
interactions
Language delay/difficulty using language skills for functional communication
Social Behaviour
inconsistent eye contact
difficulty with shift of gaze
initiating social overture/play
sharing, turn taking is hard
atypical social skills eg overfriendly with strangers, personal space

18. Motor and Sensory Possible Early Signs Sensory Processing Motor Skills
Feeding issues
Self Regulation

19. Sensory
Sensory seeking – jumping, spinning, touching, crashing, throwing
Sensory defensive- bothered by loud noise, movement, tactile,
Motor
Oral motor difficulties – difficulty with solid food, speech production, gagging, swallowing
Toe walking
Motor planning
Motor mannerisms
Low muscle tone
Feeding
Texture specificity- sensory related
Selectivity- behavioural
Chewing, swallowing – motor related
Self Regulation
Emotional distress
Self injury and aggressiveness
Atypical arousal

20. Role of Primary Care Physicians
Recommend
Refer
Early intervention (Centennial Infant and Child Centre, HBKR Nursery schools)
Gross Motor Programming in the community
EarlyON
Developmental assessments through Child Development Programs (e.g. SRH, HBKR)
Central East LHIN (OT,PT)
Early Abilities

22. Does one need a specialist to diagnose children with suspected autism?

23. Educational Resources

24. Educational…. ECHO Ontario Autism Program
Ability to screen, diagnose, and manage children and youth with autism spectrum disorder (ASD) in Ontario
The Extension of Community Healthcare Outcomes(ECHO) model
Erase barriers between specialty and primary care
Participate in biweekly teleECHO clinics didactics, mentoring, patient case discussions
ECHO program registration is open

25. Conclusion Early identification is the way to go!
Primary care physicians play a crucial role!

26. References
ESDM
Dawson, G., Rogers, S., Munson, J., Smith, M., Jamie, W., Greenson, J., et al. Randomized controlled trial of the Early Start Denver Model: A developmental behavioral intervention for toddlers with autism: Effects on IQ, adaptive behavior, and autism diagnosis. Pediatrics doi/ /peds
Rogers, S.J., Estes, A., Lord, C., Vismara, L., Winter, J., Fitzpatrick, A., Guo, M., & Dawson, G. Effects of a brief early start denver model (ESDM)-based parent intervention on toddlers at risk for autism spectrum disorders: A randomized controlled trial. J of the Am Acad of Child & Adolescent Psychiatry. 2012;51(10),
Dawson, G., Jones, E.J.H., Merkle, K., Venema, K., Lowy, R., Faja, S., Kamara, D., Murias, M., Greenson, J., Winter, J., Smith, M., Rogers, S.J., & Webb, S.J. Early behavioral intervention is associated with normalized brain activity in young children with autism. J of the Am Acad of Child and Adolescent Psychiatry. 2012;51(11),
Estes, A., Munson, J., Rogers, S.J., Greenson, J., Winter, J., & Dawson, G. Long-term outcomes of early intervention in 6-year-old children with autism spectrum disorder.  J of Autism and Developmental Disabilities. 2015;54(7),
Social ABCs
Brian JA, Smith IM, Zwaigenbaum L, Bryson SE. (2017). Cross-site randomized control trial of the Social ABCs caregiver-mediated intervention for toddlers with autism spectrum disorder. Autism Research (June 2). Epub ahead of print.
L.R. Sacrey, S. Bryson, L. Zwaigenbaum, JA. Brian, I.M. Smith, W. Roberts, P. Szatmari, T.Vaillancourt,C. Roncadin, and N.Garon. (2016). The Autism Parent Screen for Infants: Predicting Risk of ASD based on Parent-Reported Behaviour Observed at 6 to 24 months of Age.Autism (Dec.21).
Brian J, Bernardi K, Dowds E, Easterbrook R, MacWilliam S, Bryson S. (2017). Feasibility of Training Early Childhood Educators in a Community Child Care Setting Using a Caregiver-mediated intervention for toddlers with Autism Spectrum Disorder. Journal of Education and Training Studies (May). 5(5):

27. Thank you!