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

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 Marcus Summer Symposium 2015

The presenters have no relevant financial/nonfinancial relationships to disclose

Early Communication Assessment How early? 9 ‐12 months… we attempt to make critical

• bservations of younger sibs, capturing

both home and clinic snapshots

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Agenda

• Measuring social engagement in infancy
• What are the earliest red flags to look for?
• Engaging parents
• Following early ASD diagnosis: What’s next?
• Early Social Interaction project
• Is this community viable?

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AAP Screening Guidelines, 2007, 2010

• Surveillance at every visit
• Four risk factors for surveillance
• Routine ASD screen at 18 months and 24 months

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AAP Guidelines, Cont’d

Surveillance factors

• 1. Sibling with ASD
• 2. Parent concern, inconsistent hearing, unusual

responsiveness

• 3. Other caregiver concern
• 4. Pediatrician concern
• If 2 or more, refer for EI, ASD Evaluation, and Audiology simultaneously.
• If 1 and child at least 18 months old, use screening tool.
• When screen is positive, refer for EI, ASD Evaluation, and Audiology

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Role of ALL early providers

ASD is presumably present at birth, with onset of symptoms before 36 months

• Accurate diagnosis possible at 18‐24 months, latest baby sibling studies

suggest earlier

• Average age of first concern: 15 months (Chawarska, Paul, Klin et al., 2007).
• Parents note delays as early as 12 months, first voice concerns around 18

months, but diagnosis is typically not until 4 years or older

• Huge potential benefits of early treatment

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DSM‐5: Autism Spectrum Disorder

Delays & deviance in the development of social communication skills, with the presence of restricted and/or repetitive behaviors, present in the early developmental period.

• Aiming to build capacity to diagnose at a younger age

– Diagnosis can occur reliably by 18 months‐ average closer to 4, the numbers are worse for the state of Georgia

• Earlier intervention increases potential for better outcomes

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Important to Consider

SPEEC H ve rsus L ANG UAG E ve rsus

COMMUNICAT ION

Let’s talk about all 3!

• SPEECH & LANGUAGE DEVELOPMENT is a primary area of delay in early

autism symptomatology

• COMMUNICATION deficits are persistent in ASD throughout development
• Assessment & intervention for a child with ASD should be ongoing

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ASHA (2006a) Ad hoc Committee on Autism Spectrum Disorders defines appropriate roles and responsibilities of SLP’s in dx, assessment and treatment of ASD across the life span 1. SLPs play a critical role in screening, early detections of children at risk for ASD, and making referrals for dx and intervention 2. SLP’s who acquire and maintain the necessary knowledge and skills can diagnose ASD, typically within a multidisciplinary diagnostic team 3. SLP can make appropriate referrals to rule out other conditions and facilitate access to services

Screening & referral Assessment 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.

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At‐risk Cohort: “Baby sibs”

UC‐Davis/Ozonoff et. al (2013) enrolled 294 infant sibs of children with ASD and116 infant siblings of TD children. Time points of developmental/behavioral assessment at 6, 12, 18, 24 and 36 months.

• Nearly Half Diagnosed with ASD or show related issues
• By 36 months, 17 % of the baby sibs had been diagnosed with ASD.

Another 28 % had related developmental issues including with communication delays and social vulnerabilities listed as extreme shyness, little eye contact or lack of pointing to share.

• Also noteworthy: The baby siblings who showed early delays didn’t “catch

up” over time. This counters the traditional wait‐and‐see approach still common among many healthcare providers.

Marcus Autism Center There were significant differences between the ASD & DD groups and the ASD & TD groups on the following 9 items: 1) lack of appropriate gaze 2) lack of warm, joyful expressions with gaze 3) lack of sharing enjoyment or interest 4) lack of response to name 5) lack of coordination of gaze, facial expression, gesture, and sound 6) lack of showing 7) unusual prosody 8) repetitive movements or posturing of body, arms, hands, or fingers 9) repetitive movements with objects There were significant differences between the ASD & TD groups but not the ASD & DD groups on the following 6 items: 1) lack of anticipatory posture or movement 2) lack of response to contextual cues 3) lack of pointing 4) lack of vocalizations with consonants 5) lack of playing with a variety of toys conventionally 6) difficulty calming when distressed.

Nonverbal capacity for communication

Typical Developm ent Early Red Flags in Autism Eye gaze, gaze shifting Gaze aversion Response to name Lack of response to name Orientation to speech Limited response to adult speech Pointing Lack of Pointing Affect sharing Object focused Caregiver referencing Lack of/ limited caregiver referencing Imitation Lack of imitation Joint attention, response and initiation Lack of/ limited skills across these areas Symbolic play Lack of symbolic play after 18 mos

Looking beyond typical speech milestones, there is a basis for social communication before words come along

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‘Socially deviant behaviors’

• Can these be seen in toddlers?
• Important to understand the very early and

emerging signs of social communication that are deviant in autism

• How are they expressed in toddlers?
• More importantly,

how can they be assessed?

Children’s Healthcare of Atlanta

ACE Infant Sibling Testing Protocol: combining experimental paradigm with direct assessment

1. 1‐9 months:

monthly eye tracking visits

2. 9, 12, 15, 18, 24 months: eye tracking combined with

behavioral assessment Assessment battery includes:

• Communication: SORF +

Communication and Symbolic Behavior Scales (CSBS) 9, 12, 15, 18, 24 months

• Social‐behavioral: ADOS‐ Toddler

Module 12, 15, 18, 24 months

• Early Development: Mullen Scales of

Early Learning 12, 18, 24 months

• Adaptive development: Vineland

Adaptive Behaviors Scales‐ 2 24 months

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CSBS

Communication and Symbolic Behavior Scales

Amy Wetherby, Barry Prizant, 2002

• Useful assessment tool for evaluating communication

in toddlers ages 12 months to 24 months

• Effective way to assess early prelinguistic behaviors,

and to examine social vulnerabilities as well

• Only a portion of a global developmental assessment

– Autism Diagnostic Observation Schedule‐ Toddler Module

(ADOS‐T: Luyster et al., 2009)

– Mullen Scales of Early Learning Marcus Autism Center

Development & Use of an ASD specific screener

• The Systematic Observation of Red Flags (SORF) was

developed to directly observe symptoms in all three domains of ASD in very young children at risk for ASD

• Based on a behavioral sample (vs. parent report)
• Work completed via early ASD studies at FSU & Michigan
• Tested and developed among 18‐24 month olds enrolled in

the FSU First Words project (5,000 child broadband population screener)

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Screening Items & Symptoms

• Symptoms in all three core diagnostic domains were observed

in a majority of children with ASD under 2 years

• The SORF and the ADOS detect symptoms that are highly

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‐

risk controls at Marcus

• 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

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Aligned with new DSM‐5 criteria Screening Tool; currently being tested among 9‐12 month olds in ACE project

Ratings based on whether behavior exists, is delayed,

• r deviant

Quantifying RED FLAGS as early as possible

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Observing & Quantifying the earliest derailment of social attention

Baby’s Gaze May Signal Autism, a Study Finds, New York Times, Nov. 13, 2013

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“We’re measuring what babies see, but more importantly we’re measuring what they don’t see” – Warren Jones, Emory, Marcus Center.

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3 months

Notice gaze to the adult, shared smiles, directed vocalizations, and attention to language

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6 months

Notice use of gaze shifts to the adult, shared smiles, reciprocity, and anticipation within a social routine

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Baby & Toddler communication

Many areas develop together from infancy through toddlerhood:

Communication milestones include: Communication milestones include:

Early social engagement Early social engagement Early understanding

• f language

Early understanding

• f language

Sound development Sound development Gesture use Gesture use Marcus Autism Center

2 step process in order to collect information regarding communication skills at home:

• 1. CSBS Infant‐Toddler Checklist
• Completed by parent at home/in a doctor’s office/childcare facility or

during intake process, prior to speech evaluation

• Considered a 1st step screener, Normed at 9‐24 months
• Available free online in 8 languages, Brookes Publishing
• 2. CSBS Behavior Sample
• Assessment completed by clinician, parent in the

room.

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What are we examining? Functions of Communication

3 basic functions of communication to look for in toddler

development:

• 1. regulatory functions, used to get others to do or

not do things; (REQUESTS)

• 2. social interaction functions, used to greet, call

attention to oneself or one’s actions or to ‘show off’

• 3. joint attention functions, used to direct an adult’s

attention to objects or events for the purpose of sharing focus.

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Toddler with ASD: Notice

lack of eye gaze, sounds, and communication attempts

9 months old, typically developing: Notice eye gaze,

smiles, and communication attempts

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13 months:

Behavior regulation: Observe use of eye gaze, sounds, and engagement with an adult

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Joint Attention is the process of sharing

• ne’s experience of observing an object
• r event, by using gaze shifts and/or

pointing gestures. It is critical for social development, language acquisition & cognitive development…

In other words: Joint attention is a child’s way of pointing something out for the purpose of sharing.

This is NOT requesting, and is purely a social behavior.

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12 month old:

Social interaction & joint attention

Play Development: a window into language (13 months)

Children’s Healthcare of Atlanta

Case Study: 15 month old female A.E., ‘baby sibling’

‐ older brother diagnosed at Marcus Center 22 months

Absence of: gaze shifts, response to name, response to giving gesture, directed sounds Presence of: repetitive arm movements, slight visual peering

Children’s Healthcare of Atlanta

Case Study: 15 month old female A.E., ‘baby sibling’

‐ older brother diagnosed at Marcus Center 22 months

Absence of: gaze shifts, response to language, symbolic play, directed sounds, directed facial expressions Presence of: clutching objects, sticky attention, repetitive arm movements, slight visual peering

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Stability of Early Clinical Diagnosis

• Short term stability (2nd year to 4 years) (Chawarska et al.,

2007; 2009) – Very good for ASD diagnosis (80‐90%) – Changes expected within spectrum due to shifts in number

• f symptoms and intensity
• Long term stability (2 to 4 to 9 years) (Lord et al., 2006)

– High stability of ASD diagnosis (90%) – Shift from PDD‐NOS to Autism Dx: ~20% – Shift from Autism to PDD‐NOS: ~10%

We’ve completed our assessment… We’ve identified “enough” red flags at 12 months, we present this information to families…

NOW WHAT?

Questions?