Agenda AAP Screening Guidelines, 2007, 2010 Measuring social - PDF document

Early Communication Assessment How early? 9 ‐ 12 months… we attempt to make critical observations of younger sibs, capturing both home and clinic snapshots Early Social Communication Assessment: Models for Infant Siblings at Risk for ASD Moira Lewis M.S. CCC ‐ SLP Marcus Autism Center, Children’s Healthcare of Atlanta The presenters have no relevant financial/nonfinancial relationships to disclose Marcus Summer Symposium 2015 Agenda AAP Screening Guidelines, 2007, 2010 • Measuring social engagement in infancy • What are the earliest red flags to look for? • Engaging parents • Surveillance at every visit • Following early ASD diagnosis: What’s next? • Early Social Interaction project • Four risk factors for surveillance • Is this community viable? • Routine ASD screen at 18 months and 24 months Marcus Autism Center Marcus Autism Center AAP Guidelines, Cont’d Role of ALL early providers Surveillance factors 1. Sibling with ASD 2. Parent concern, inconsistent hearing, unusual ASD is presumably present at birth, with onset of symptoms responsiveness before 36 months 3. Other caregiver concern 4. Pediatrician concern Accurate diagnosis possible at 18 ‐ 24 months, latest baby sibling studies • suggest earlier If 2 or more, refer for EI, ASD Evaluation, and Audiology simultaneously. Average age of first concern: 15 months (Chawarska, Paul, Klin et al., 2007). • • If 1 and child at least 18 months old, use screening tool. • Parents note delays as early as 12 months, first voice concerns around 18 • When screen is positive, refer for EI, ASD Evaluation, and Audiology months, but diagnosis is typically not until 4 years or older • Huge potential benefits of early treatment • Marcus Autism Center Marcus Autism Center

DSM ‐ 5: Autism Spectrum Disorder Important to Consider SPEEC H ve rsus L ANG UAG E ve rsus D elays & deviance in the development of social communication skills, with the presence of restricted and/or repetitive COMMUNICAT ION behaviors, present in the early developmental period. Let ’ s talk about all 3! Aiming to build capacity to diagnose at a younger age • – Diagnosis can occur reliably by 18 months ‐ average closer to 4, SPEECH & LANGUAGE DEVELOPMENT is a primary area of delay in early • the numbers are worse for the state of Georgia autism symptomatology • Earlier intervention increases potential for better outcomes COMMUNICATION deficits are persistent in ASD throughout development • Assessment & intervention for a child with ASD should be ongoing • Marcus Autism Center Marcus Autism Center At ‐ risk Cohort: “Baby sibs” ASHA (2006a) Ad hoc Committee on Autism Spectrum Disorders defines appropriate UC ‐ Davis/Ozonoff et. al (2013) enrolled 294 infant sibs of children with ASD roles and responsibilities of SLP’s in dx, assessment and treatment of ASD across the and116 infant siblings of TD children. Time points of life span developmental/behavioral assessment at 6, 12, 18, 24 and 36 months. 1. SLPs play a critical role in screening, early detections of children at risk for ASD, Nearly Half Diagnosed with ASD or show related issues • and making referrals for dx and intervention 2. SLP’s who acquire and maintain the necessary knowledge and skills can By 36 months, 17 % of the baby sibs had been diagnosed with ASD. • diagnose ASD, typically within a multidisciplinary diagnostic team Another 28 % had related developmental issues including with communication delays and social vulnerabilities listed as extreme shyness, 3. SLP can make appropriate referrals to rule out other conditions and facilitate little eye contact or lack of pointing to share. access to services Screening & referral Also noteworthy: The baby siblings who showed early delays didn’t “catch • Assessment up” over time. This counters the traditional wait ‐ and ‐ see approach still common among many healthcare providers. Intervention American Speech ‐ Language ‐ Hearing Association. (2006). Roles and responsibilities of speech ‐ language pathologists in diagnosis, assessment, and treatment of autism spectrum disorders across the life span [Position Statement]. Available from www.asha.org/policy. Marcus Autism Center Marcus Autism Center Nonverbal capacity for communication Typical Developm ent Early Red Flags in Autism There were significant differences between the ASD & DD groups and the ASD & TD groups on the following 9 items: Eye gaze, gaze shifting Gaze aversion 1) lack of appropriate gaze 2) lack of warm, joyful expressions with gaze Response to name Lack of response to name 3) lack of sharing enjoyment or interest Orientation to speech Limited response to adult speech 4) lack of response to name 5) lack of coordination of gaze, facial expression, gesture, and sound Pointing Lack of Pointing 6) lack of showing 7) unusual prosody Affect sharing Object focused 8) repetitive movements or posturing of body, arms, hands, or fingers Caregiver referencing Lack of/ limited caregiver referencing 9) repetitive movements with objects Imitation Lack of imitation There were significant differences between the ASD & TD groups but not the ASD & DD groups on the following 6 items: Joint attention, response and initiation Lack of/ limited skills across these areas 1) lack of anticipatory posture or movement 2) lack of response to contextual cues Symbolic play Lack of symbolic play after 18 mos 3) lack of pointing 4) lack of vocalizations with consonants 5) lack of playing with a variety of toys conventionally Looking beyond typical speech milestones, there is a basis for social 6) difficulty calming when distressed. communication before words come along Marcus Autism Center

ACE Infant Sibling Testing Protocol : combining ‘ Socially deviant behaviors ’ experimental paradigm with direct assessment Assessment battery includes: • Can these be seen in toddlers? 1. 1 ‐ 9 months : • Important to understand the very early and Communication: SORF + • monthly eye tracking visits Communication and Symbolic emerging signs of social communication Behavior Scales (CSBS) that are deviant in autism 2. 9, 12, 15, 18, 24 months: 9, 12, 15, 18, 24 months eye tracking combined with • How are they expressed in toddlers? Social ‐ behavioral: ADOS ‐ Toddler • behavioral assessment Module • More importantly, 12, 15, 18, 24 months how can they be assessed? Early Development: Mullen Scales of • Early Learning 12, 18, 24 months Adaptive development: Vineland • Adaptive Behaviors Scales ‐ 2 24 months Marcus Autism Center Children’s Healthcare of Atlanta CSBS Development & Use of an ASD specific screener Communication and Symbolic Behavior Scales • The Systematic Observation of Red Flags (SORF) was Amy Wetherby, Barry Prizant, 2002 developed to directly observe symptoms in all three domains of ASD in very young children at risk for ASD Useful assessment tool for evaluating communication • in toddlers ages 12 months to 24 months • Based on a behavioral sample (vs. parent report) Effective way to assess early prelinguistic behaviors, • • Work completed via early ASD studies at FSU & Michigan and to examine social vulnerabilities as well • Tested and developed among 18 ‐ 24 month olds enrolled in the FSU First Words project (5,000 child broadband Only a portion of a global developmental assessment • population screener) Autism Diagnostic Observation Schedule ‐ Toddler Module – (ADOS ‐ T: Luyster et al., 2009) Mullen Scales of Early Learning – Marcus Autism Center Marcus Autism Center Quantifying RED FLAGS as early Screening Items & Symptoms as possible • Symptoms in all three core diagnostic domains were observed in a majority of children with ASD under 2 years Screening Tool; currently being tested among 9 ‐ 12 • The SORF and the ADOS detect symptoms that are highly month olds in ACE project diagnostic of ASD across the range of developmental functioning (e.g. language abilities) Currently being testing among 9 ‐ 24 month at ‐ risk infant siblings, plus low ‐ Ratings based on whether • risk controls at Marcus behavior exists, is delayed, or deviant Approaching year 3 of the longitudinal assessment process • Our team is testing cut ‐ offs for “enough” red flags at 12 months to enroll • into intervention Aligned with new DSM ‐ 5 criteria Marcus Autism Center 17

Marcus Autism Center Observing & Quantifying the earliest derailment of social attention “We’re measuring what babies see, but more importantly we’re measuring what they don’t see” – Warren Jones, Emory, Marcus Center . Baby’s Gaze May Signal Autism, a Study Finds, New York Times, Nov. 13, 2013 22 6 months 3 months Notice gaze to the adult, shared smiles, directed vocalizations, and attention to language Notice use of gaze shifts to the adult, shared smiles, reciprocity, and anticipation within a social routine Marcus Autism Center Marcus Autism Center