Autism Spectrum Disorders:
Diagnosis and Treatment
Sharifa Yateem, MS. ABA.
New England Center for Children Abu Dhabi
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Outline of the presentation
• How is Autism Diagnosed ?
o What is Autism?
o DSM-V Diagnostic Criteria
•
•
•
•
•
Severity of Autism and SCD
What causes Autism ?
Autism Treatments
What is ABA ?
Summary
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
How is Autism Diagnosed?
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Autism Diagnosis
• No medical diagnostic test
– No prenatal test
– No definitive genetic test (yet)
• Diagnosis should include
– Detailed developmental history
– Direct observation and assessment of child’s
behavior
• Diagnosis by a practitioner experienced in
childhood developmental disorders
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Autism Diagnosis
“Red Flags”
 No big smiles or other warm,
joyful expressions by 6 months
 No back- and- forth sharing of
sounds, smiles or other facial
expressions by 9 months
 No babbling by 12 months
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Autism Diagnosis
“Red Flags”
 No words by 16 months
 No meaningful, two-word phrases
( not including imitating or
repeating) by 24 months
 Any loss of speech, babbling or
social skills at any age
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Diagnostic Criteria
• Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, American Psychiatric
Association (2013; DSM-V) :Autism spectrum disorder
(ASD) and the related diagnosis of social communication disorder (SCD)
• Symptoms must begin before the child reaches
3 year old.
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Autism Spectrum
Disorders
All Autism Spectrum Disorders (ASD) include
one or more of these …
– Impairments in Communication skills
– Impairments in Social skills and interactions
– Occurrence of Stereotyped (repetitive) behavior
or highly restricted interests
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Impairments in
Communication
Examples of impairments:
a. delay in, or total lack of, the development of
spoken language
b. impairment in the ability to initiate or sustain a
conversation with others
c. stereotyped and repetitive use of language or
idiosyncratic language
a. lack of varied, spontaneous make-believe play or
social imitative play appropriate to developmental
level
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Impairments in
Social Interaction
Examples of Impairments:
a. impairment in the use of nonverbal behaviors
such as eye-to-eye gaze, facial expression, body
postures, and gestures to regulate social interaction
b. failure to develop peer relationships appropriate
to developmental level
c.
lack of spontaneous seeking to share enjoyment,
interests, or achievements with other people, lack
of joint attention (e.g., by a lack of showing,
bringing, or pointing out objects of interest)
d. lack of social or emotional exchanges
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Restricted, repetitive
patterns of behavior
Examples of impairments:
a. preoccupation with one or more stereotyped and
restricted patterns of interest that is abnormal either
in intensity or focus
b. inflexible adherence to specific, nonfunctional
routines or rituals
c. stereotyped and repetitive motor mannerisms (e.g.,
hand flapping, rocking, repetitive vocalizations)
d. persistent preoccupation with parts of objects
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Severity levels of Autism
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Severity Levels
of Autism
Level 3
“Requiring very
substantial support”
Level 2
“Requiring substantial
support”
Level 1
“Requiring support”
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Level 3
Social Communication
• Severe deficits in verbal and nonverbal social
communication skills cause severe impairments
in functioning,
• very limited initiation of social interactions
• minimal response to social overtures from
others.
• rarely initiates interaction
• makes unusual approaches to meet needs only
and responds to very direct social approaches
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Level 2
Social Communication
• Marked deficits in verbal and nonverbal social
communication skills
• social impairments apparent even with supports
in place
• limited initiation of social interactions
• reduced or abnormal responses to social
overtures from others.
•
For example, a person who speaks simple sentences,
whose interaction is limited to narrow special interests,
and who has markedly odd nonverbal communication.
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Level 1
Social Communication
• Without supports in place
• deficits in social communication cause noticeable
impairments.
• Difficulty initiating social interactions, and clear
examples of atypical or unsuccessful response to
social overtures of others.
• May appear to have decreased interest in social
interactions.
•
For example, a person who is able to speak in full sentences and engages in
communication but whose to- and-fro conversation with others fails, and
whose attempts to make friends are odd and typically unsuccessful.
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Level 3
Restricted, repetitive behaviors
• Inflexibility of behavior
• Extreme difficulty coping with change
• Other restricted/repetitive behaviors
markedly interfere with functioning in all
spheres.
• Great distress/difficulty changing focus or
action.
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Level 2
Restricted, repetitive behaviors
• Inflexibility of behavior
• Difficulty coping with change
• Other restricted/repetitive behaviors appear
frequently enough to be obvious to the casual
observer and interfere with functioning in a
variety of contexts.
• Distress and/or difficulty changing focus or
action.
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Level 1
Restricted, repetitive behaviors
• Inflexibility of behavior causes significant
interference with functioning in one or more
contexts.
• Difficulty switching between activities.
• Problems of organization and planning
hamper independence
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Social
Communication
Disorder (SCD)
• SCD is a new diagnosis in the DSM-V
• Disabilities in the area of social
communication without repetitive behaviors
and/or restricted interests
• Struggle with rules of conversation such as
taking turns
• Problems understanding the underlying
meaning conveyed by tone
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Main difference between ASD
and SCD
Clearly, many individuals with autism
share these difficulties. But to receive a
diagnosis of ASD under DSM-5, one must
also have the repetitive behaviors and/or
restricted interests typical of autism
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
What causes Autism?
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
What causes
autism?
• Research from various disciplines support the
concept that autism is a biological, geneticallybased disorder of brain development
• There is no single known cause at this time.
Why?
– Diagnostic inconsistency
– Heterogeneous population
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Prevalence of
Autism Spectrum
Disorders
All ASDs
• 1994 DSM-IV: 2–5 cases in 10,000
• 1999 NYS Clinical Practice Guidelines: 10-15 per 10,000
• 2003 US Center for Disease Control: 20-60 per 10,000
• 2006 US Department of Education: 40-45 per 10,000
• 2007 US Center for Disease Control: 1 in 150 individuals
• 2012 US Center for Disease Control: 1 in 88 individuals
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Why the increase?
Apparent increases in prevalence may be due
to…
1. Changes in diagnostic criteria and reporting
requirements over time (in US; “diagnostic
substitution”)
2. Differences in methods across studies
3. Increased public awareness
4. Real increase??
(Wing & Potter, 2002)
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Autism Spectrum
Disorders
• Early diagnosis and intervention greatly
improves the prognosis, and
• Substantially reduces cost of care over the
lifespan (Jacobson et al., 1998)
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Autism Treatment:
Early Intensive Behavioral
Intervention (EIBI)
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Autism Treatment
The GOOD news:
• Effective treatment is available
The BAD news:
• It is hard work, expensive to deliver, and takes
time
• There are not enough well-trained practitioners
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
EIBI Autism
Treatments
The most reliable treatments are those that
• use quantitative outcome measures to
• demonstrate socially-meaningful and durable
changes in
• key behaviors that increase independent
functioning
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
EIBI Autism
Treatments
Evidence-based treatments will include…
– Evaluation before, during, and after
treatment
– Measurable change in skills and behaviors
– Replication of effects across many
individuals
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
When considering
a treatment…
• How has the treatment been evaluated?
• Are specific skills targeted, that is, are there
specific goals for increasing functioning?
• How is progress monitored? Objective,
quantitative data?
• Has the treatment been demonstrated
effective with many children with ASD?
• Does it interfere with other treatments?
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Autism Treatments
There currently is no sound scientific support for
the use of these as primary treatments for ASD:
•
•
•
•
•
•
Hormone medications
Chelation therapy
Hyperbaric chamber
Gluten free - casein free diet (GFCF diet)
Immunological medications
Mega- vitamin doses
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Psychopharmacological
Interventions
Medication is sometimes used to treat problem
behaviors seen in ASD including…
•
•
•
•
“Irritability” and acting out
Hyperactivity, inattention, and impulsivity
Preoccupations, rituals, and compulsions
Anxiety
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
What is ABA ?
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
•
Common Elements of
Effective EIBI/ABA
Programs
Curriculum focus in major ASD deficit areas
(videos)
• Communication
• Social interaction
• Imitation
• Play skills
• Program for skill generalization
Ref: New York State (US) Early Intervention Practice Guidelines (1999)
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Common Elements of
Effective EIBI/ABA
Programs
continued…
• Function-based approach to problem behaviors
• Teach appropriate replacement behavior
• Transition to typical setting
• Critical importance of family involvement
Ref: New York State (US) Early Intervention Practice Guidelines (1999)
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
EIBI/ABA at
NECC-Abu Dhabi
•
•
•
Services delivered at school and home
Curriculum emphasizes: eye contact and
attending, imitation, play, discrimination skills,
communication, motor, self-help, and preacademics
Combination of techniques used across multiple
environments: individual and small-group
instruction, community and social integration, etc.
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
EIBI Treatment
Outcomes
“In any group of children with ASD who receive
competently delivered EIBI, between 20% and
50% will achieve normal functioning;
about 40% will achieve meaningful but
moderate gains;
and about 10% will continue to require
intensive special education and adult services”
(Jacobson et al., 1998)
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
ABA/ EIBI parameters
How many hours ?
Who should deliver service ?
Certified BACB www.bacb.com
How it should be supervised ?
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Summary
• Early diagnosis is critical – look for
– Communication deficits
– Social skills deficits
– Unusual habits or behaviors
• Effective treatment is available
– Earlier intervention is associated with better
prognosis
– Treatment should be based on sound scientific
principles and research
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
New England Center for Children - Abu Dhabi
Sharifa Yateem, MSc.
P.O. Box 112923
Abu Dhabi, UAE
[email protected]
www.NECCABUDHABI.org
www.bcba.org
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Want more information about
ABA ?
Join UAE Association for Behavior
Analysis
[email protected]
Facebook group: ABA Middle East
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
DSM 4 vs DSM 5
Individuals with a well-established DSM-IV
diagnosis of Autistic disorder, Asperger’s
disorder, or pervasive developmental disorder
not otherwise specified (PDD-NOS) should be
given the diagnosis of autism spectrum disorder.
Individuals who have marked deficits in social
communication, but whose symptoms do not
otherwise meet criteria for autism spectrum
disorder, should be evaluated for social
(pragmatic) communication disorder.
© 2007 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.