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Autism Spectrum Disorder Archive 2012

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Ann England, M.A. CCC-SLP-L
Speech-Language Pathologist
Assistant Director Diagnostic Center, Northern California

Ann has 27 years of special education experience and has extensive training and certification in the assessment and teaching of students with an Autism Spectrum Disorder (e.g., TEACCH, PECS, ADOS, etc.) She participates on a multidisciplinary assessment team at the Diagnostic Center to determine if students have an Autism Spectrum Disorder. She also provides the all day training “Teaching Students with an Autism Spectrum Disorder” to school staff throughout northern California. Additionally, she provides onsite consultation and mentoring to school district administrators and teaching teams to assist in the development and implementation of evidence-based public school programs for students with an Autism Spectrum Disorder. Ann has served on several California Department of Education committees related to Autism Spectrum Disorders and most recently was invited to participate on the Task Force on Education and Professional Development of The Legislative Blue Ribbon Commission on Autism.

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  • If a child with ASD isn’t speaking by age 4 will he ever speak?

Question:

Hi Ann,

I’ve heard that if a child with autism isn’t speaking by age 4 or 5, he/she isn’t likely to ever do so. Is this true? Is this what I should be telling the parent(s) of the children on my caseload?

Just Wondering in San Mateo


Answer:

Dear Just Wondering in San Mateo,

Thank you so much for your question and do know it is one that I’ve been asked a lot. First, I would advise against making a sweeping generalized statement about the outcome expectations of any child. As you know, each child with an ASD is a unique individual with a unique profile and unique history, etc. and there are a myriad of factors to consider when a professional dares to predict outcomes for their clients but more about that later!

New Research!

There is a lot of research going on in the field of autism and in early March 2013, a study was published in the journal Pediatrics. Researchers at the Center for Autism and Related Disorders, in Baltimore, looked at information on 535 children, ages 8 to 17, diagnosed with autism who, at age 4, had language delays ranging from not speaking at all to using single words or phrases without verbs.

The researchers found a total of 372 children (70%) attained phrase speech and 253 children (47%) attained fluent speech at or after age 4. The researchers also wanted to see what factors might predict whether a severely language-delayed child with autism would eventually develop speech. They found that most of the children who did develop speech had higher nonverbal IQs (assessed with nonverbal tests) and lower social impairment. Interestingly, the researchers found that a child’s level of repetitive behaviors and restricted interests did not affect the likelihood of language development.

The researchers concluded that their data also implicates the importance of evaluating and considering nonverbal skills, both cognitive and social, when developing interventions and setting goals for language development.

Think about it this way:

Even though there is evidence that provides findings related to predicting communication outcomes in children with autism, research cannot really provide precise answers to parents/caregivers who ask, "When will my child talk?" Particularly in working with young children, I would recommend that we don’t simply use this evidence to try to predict whether or when a young child will talk, but do use this information to focus our assessments and interventions on those areas that will increase the likelihood of good language and communication outcomes.

We know research reveals that appropriate early intervention does improve the outcomes of children with ASD. In the ASHA article, Language Outcomes for Young Children with Autism Spectrum Disorders, Watson et.al. state, “Early intervention targeting joint attention, imitation, and play abilities appears to have cascading benefits for the language and social development of children with ASD. Thus, SLPs and other service providers should target these abilities, and use assessment information about specific child characteristics and family needs to select and administer effective intervention approaches.”

And, thank goodness, now more than any other time, we have evidence and research-based strategies from which to choose that increase the chances of improving communication outcomes for our clients with an ASD. That is, these evidence and research-based treatments described in publications by the National Professional Development Center on ASD and the National Autism Center National Standards Report(s) have sufficient evidence to show that they can produce beneficial treatment effects. Still, treatment selection isn’t an easy task and even with careful professional judgment for selection and tremendous implementation effort, we know that a strategy that may have worked well with one child may not work with another. In order to be certain than an intervention is effective, it will be necessary to collect data. And, again, using professional judgment, the SLP needs to analyze the data to quickly make changes if that intervention isn’t producing desired positive improvement. For sure, treatment selection is complicated and should be made by a team of individuals (including the family/caregivers) who can incorporate the unique history and needs of the child.

I would like to suggest that rather that focusing on whether or not you can predict if or when a child will talk, focus on believing that every person with ASD can learn to communicate; however, it may not always be through spoken language. As Autism Speaks, Geraldine Dawson says, “We know that nonverbal individuals with autism also have much to contribute to society and can live fulfilling lives with the help of visual supports and assistive technologies.”

Hope this helps!

Ann

REFERENCES:

  • American Speech Language Hearing Association Leader: Language Outcomes for Young Children with Autism Spectrum Disorders (2008) http://www.asha.org
  • Autism Speaks, Seven Ways to Help Your Nonverbal Child to Speak, Geraldine Dawson, et.al. (March 2013) http://www.autismspeaks.org
  • National Autism Center, National Standards Report: The National Standards Project Report, Addressing the Need for Evidence-based Practice Guidelines for ASD (2009) http://www.nationalautismcenter.org
  • National Professional Development Center on Autism Spectrum Disorders: 24 Evidence Based Practices, http://autismpdc.fpg.unc.edu/
  • Pediatrics Journal of the American Academy of Pediatrics, Predictors of Phrase and Fluent Speech in Children With Autism and Severe Language Delay, Ericka L. Wodka, et.al., March 2013

  • New Resource: CAPTAIN (California Autism Professional Training and Information Network)

Question:

When is California going to do something like the other states to make sure teachers know how to teach students with an ASD?  I noticed states like Missouri, Texas, Maine and others have developed and posted their state’s guidelines for serving individuals with ASD.  Thanks, I’m looking for some guidance!

Curious in California


Answer:

Hi “Curious in California”! Yes, we have all been waiting for the ASD Guidelines for California to be released but they are not forthcoming as far as I know. However, there is something very exciting going on in California of which I’m a part; it’s called CAPTAIN (California Autism Professional Training and Information Network).

CAPTAIN is a cross agency network developed to support the understanding and use of evidence based practices (EBPs) for individuals affected by Autism Spectrum Disorder (ASD) across the state of California.

CAPTAIN LEADERSHIP TEAM:
The leadership team is made up of professionals from the California Department of Education, Diagnostic Centers, University Centers for Excellence in Developmental Disabilities (UCEDDS), Regional Centers, SELPAs, Family Resource Centers, and County Offices of Education. Most of these professionals participated as trainers in the National Professional Development Center for Autism Spectrum Disorders (NPDC-ASD) statewide training project for the past few years; as a part of the dissemination efforts of the NPDC-ASD, we have established CAPTAIN to support the implementation of EBPs.

CAPTAIN CADRE MEMBERS:
CAPTAIN cadre members will receive training as trainers so that they can provide local trainings, cross agency collaboration and dissemination of the EBPs. They will gain access to all of the NPDC-ASD, National Standards Project and CAPTAIN training materials and resources and will assist with the statewide distribution of the EBPs.

Cadre members were nominated from SELPAs, Regional Centers and Family Resource Centers/Family Empowerment Centers throughout the state in January 2013. The number of cadre slots per agency was determined using a formula developed by the CAPTAIN leadership team based on the capacity for the annual summits and enrollments in the Foundations of Autism class that is required for each cadre member.

CAPTAIN SUMMITS:
There will be two Summits for the invited cadre; one in Northern California and one in Southern California:

  • October 3-4, 2013:               Located at Riverside County Office of Education
  • October 17-18, 2013:           Located at San Joaquin County Office of Education

We have been planning these CAPTAIN Summits for the past year and are looking forward to next October 2013 when we meet with the invited CAPTAIN Cadre from across the state to teach them all about Evidence-Based Practices for students with an ASD.

Thanks for being “Curious in California”. Soon you will be able to visit our website once the final touches are completed where you can learn all about the EBPs and the goings on with CAPTAIN!
Ann


  • DSM-V revisions regarding ASD

Dear Friends of Ask A Specialist-ASD,

As you know, I’ve been keeping you aware of the planned revisions to the definition of ASD in the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) due to be released in May 2013.

The latest findings from the field trials using the proposed new DSM-V diagnostic criteria for ASD suggest that it does not appear to reduce the number of individuals who receive an ASD diagnosis; the majority of children who had been diagnosed with ASD using the DSM-IV kept their diagnosis under the new proposed DSM-V criteria. That is, approximately 5-10 percent received a different diagnosis such as Attention Deficit/Hyperactivity Disorder (AD/HD) or the new diagnosis of Social Communication Disorder. Interestingly, the proposed DSM-V also identified children who did not previously meet the definition of autism using the DSM-IV criteria.

These field trial preliminary findings released in early May 2012 do not support the idea that the proposed changes will exclude high-functioning individuals with autism or reduce the number of children who receive a diagnosis of ASD.

However, please note that the DSM-V presented by the APA on their website is still a draft. The final commenting period on the draft fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) closed as of June 15, 2012. All comments will be reviewed by the DSM-V Work Groups, before producing the final DSM-V text. Although each disorder area drew a wide range of comments, the two Work Groups with the highest number were the Neurodevelopmental Work Group (ASD is in this group) with 397 comments and the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic Stress and Dissociative Disorders Work Group with 545 comments.

After the Work Groups make their last revisions to the draft diagnostic criteria, the proposals will receive multi-level reviews by the entire DSM-5 Task Force, a separate Scientific Review Committee and a Clinical and Public Health Committee. The latter two committees will be working to evaluate the strength of scientific evidence supporting significant changes and to assess the impact of changes for clinicians and public health.

The Task Force will make recommendations to the APA Board of Trustees for its final decisions on the manual’s fifth edition which is still planned to be released during the APA’s May 18-22, 2013 Annual Meeting in San Francisco, CA.

REFERENCES:

American Psychiatric Association (APA) http://www.psych.org

DSM-V Development American Psychiatric Association http://www.dsm5.org

Autism Speaks http://www.autismspeaks.org


  • Bullying and Students with Special Needs

Dear Ask A Specialist Readers,

Did you know that children with disabilities are at an increased risk of being bullied?  Any number of factors:  physical vulnerability, social skill challenges, or intolerant environments, may increase the risk. Research suggests that some children with disabilities may even bully others as well.

On April 3, 2012 the U.S. Education Secretary, Arne Duncan, and Health and Human Services (HHS) Secretary, Kathleen Sebelius, unveiled the revitalized Stop Bullying website: www.stopbullying.gov.

The Stop Bullying Website:

“The site encourages children, parents, educators, and communities to take action to stop and prevent bullying, and provides a map with detailed information on state laws and policies, interactive webisodes and videos for young people, practical strategies for schools and communities to ensure safe environments, and suggestions on how parents can talk about this sensitive subject with their children. The site also explores the dangers of cyberbullying and steps youngsters and parents can take to fight it.”

Special Resources to Help Children with Disabilities:

This website also provides special resources to help children with disabilities who are bullied or who bully others. The website illustrates how IEPs or Section 504 plans can be useful in designing specialized approaches for preventing and responding to bullying.  Additionally, the website discusses how civil rights laws protect students with disabilities against harassment. That is, when bullying is directed at a child because of his or her disability and it creates a hostile environment at school, bullying behavior may cross the line and become “disability harassment.”  Under Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act of 1990, the school must address the harassment.

Act Now!

We know that bullying can negatively impact a student’s ability to learn and threaten their physical and emotional safety at school. We know, too, that the best way to address bullying is to stop it before it starts. The Stop Bullying website and the other websites listed in the Resources provide a number of actions school staff can take to make schools safer and prevent bullying.

We here at Ask A Specialist encourage you to do your part to help all students be safe at school.

Submitted by Ann England, Assistant Director, Diagnostic Center, Northern California on behalf of all the Ask A Specialist Contributors

RESOURCES:

  • Positive Behavioral Interventions and Supports

  • Do you have any ideas on how I can help my 7 year old child with Autism sleep better?

Question:

Dear Ann,

Do you have any ideas on how I can help my 7 year old child with Autism sleep better? Any suggestions would be very much appreciated.

Sleepless in Burlingame!


Answer:

Dear Sleepless in Burlingame,

I’m sure you already know that sleep problems such as trouble falling asleep, staying asleep or early morning waking, are common in children with ASD.

The Autism Treatment Network, a funded program of Autism Speaks, has developed a free downloadable informational booklet designed to provide parents with strategies to improve sleep patterns in their child with ASD: Strategies to Improve Sleep in Children with Autism Spectrum Disorders-A Parent’s Guide. The suggestions in this booklet are based on both research and clinical experience of sleep experts and may help your child get a better night’s sleep and improve his or her sleep/wake schedule.

Strategies to Improve Sleep in Children with Autism Spectrum Disorders - Cover

Also suggested in this booklet is for you to talk to your child’s doctor to explore any medical reasons as to why your child is not sleeping well. For example, some symptoms such as snoring, gasping for breath while sleeping, and/or bedwetting at night, may need further evaluation and treatment from a sleep specialist. Sometimes there may be medications prescribed by your child’s medical specialist that may help your child sleep better. However, many parents may be able to help their children develop better sleep patterns by trying the suggestions described in this booklet. The booklet includes information such as how to:

  • Provide a comfortable sleep setting
  • Establish a regular bedtime routine
  • Tips to keep a regular schedule
  • Teach your child to fall asleep alone
  • Promote daytime behaviors

The booklet also includes information about how to use visual supports (an evidence-base practice) such as a mini-task card to increase the structure and predictability of getting ready for bed:

Example Bedtime Routine and Visual Schedule

Another suggestion is to consider using the “Bedtime Pass” strategy which is a positive behavioral strategy (an evidence-base practice):

Bedtime Pass

“A Bedtime Pass is a card (or other object) that your child can present to you if he/she wakes at night. Your child may use it to trade for something brief, such as a quick hug or a drink of water.
Your child should be taught that they may only use the pass one time during the night, and that once the pass is used, it will be given to you. You will return the pass to the child the following night to use again.
Teach your child that if the pass is not used all night, it can be traded for a morning present. You can also set up a reward system. For example, for every night the child does not use the pass, he/she gets a sticker. If your child collects a certain number of stickers (e.g. five) they receive a special gift. The presents can be dollar store items or a special outing with you.”

I’m pretty sure you’ll find this booklet helpful and easy to understand, however, I do know that it is definitely easier said than done!!!! As you review the suggestions in the booklet try one small change when you have the time and energy and life is relatively calm in your household! The experts say that it can take upwards of two weeks to see a change so be patient and hang in there.

I’m wishing you success and a good night’s sleep for everyone!

Ann

Resources:

Autism Speaks Treatment Network:
Strategies to Improve Sleep in Children with Autism Spectrum Disorders-A Parent’s Guide free download available at:
http://www.autismspeaks.org/science/resources-programs/autism-treatment-network


  • I’ve been hearing all over the news recently that the new DSM-5 will make changes in diagnosing Autism

Question:

Dear Ann,

I’ve been hearing all over the news recently that the new DSM-5 will make changes in diagnosing Autism. I’m very concerned because I wonder if my son would even qualify because he is high functioning. He gets services that are helping him and we are worried he won’t get them anymore. What can you tell me about this?

A Concerned Mother


Answer:

Yes, you are right that there was a recent media blitz about the new DSM-V. Also in the media were different reactions to the information.

First, let me provide some background: the American Psychiatric Association (APA) is currently completing the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which will be published in 2013. The DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders and it influences availability of treatments as well as insurance coverage.

The changes in the new version of the DSM propose a change in the current definition of autism in part because of shortcomings in how it is currently used for diagnosis. The proposal by the APA DSM-5 Neurodevelopmental Work Group recommends a new category called Autism Spectrum Disorder (ASD) which would incorporate several previously separate diagnoses, including Autistic Disorder (“classic autism”), Asperger’s Disorder, Childhood Disintegrative Disorder and Pervasive Developmental Disorder- Not Otherwise Specified (PDD-NOS). It would also change the criteria for diagnosing ASD.

Under the current definition, a person can qualify for an Autistic Disorder diagnosis by exhibiting at least 6 of 12 behaviors that include deficits in social interaction, communication or repetitive behaviors. Under the proposed definition, the individual would have to exhibit three persistent deficits in social communication and social interaction across contexts and at least two restricted, repetitive patterns of behavior, interests, or activities for a diagnosis of ASD. The APA has also proposed that a new category be added to the DSM-5: Social Communication Disorder. This would allow for a diagnosis of disability in social communication without the presence of repetitive behavior.

Some believe that many individuals who currently meet the criteria for an ASD, especially those who are more cognitively capable, would no longer meet criteria for ASD using this new version. However, the APA January 20, 2012 news release stated, “Proposed DSM-5 criteria are being tested in real-life clinical settings known as field trials. Field testing of the proposed criteria for autism spectrum disorder does not indicate that there will be any change in the number of patients receiving care for autism spectrum disorders in treatment centers--just more accurate diagnoses that can lead to more focused treatment.”

The final decisions about the DSM-V are still months away and disagreement about the effect of the new definition will almost certainly increase scrutiny of the finer points of the APA’s changes to the manual. Criteria proposed for the DSM-5 are posted on the DSM-5 website and will be re-opened for additional public comment this spring 2012.

I hope this information helps.

Ann

REFERENCES:

  1. American Psychiatric Association (APA)
    http://www.psych.org

  2. DSM-V Development American Psychiatric Association
    http://www.dsm5.org

  3. DSM-V January 20, 2012 News Release: DSM-5 Proposed Criteria for Autism Spectrum Disorder Designed to Provide More Accurate Diagnosis and Treatment”
    http://www.psych.org/MainMenu/Newsroom/NewsReleases/2012-News-Releases/DSM-5-Proposed-Criteria-for-Autism-Spectrum-Disorder-Designed.aspx?FT=.pdf

  • What can I do, I am expected to evaluate a child who entered our school with a prior diagnosis of Autism. Now it is time to plan for his assessment but the parent is refusing to allow me to use the ADOS among other tools. Are there other instruments I can use?

Question:

Hello Ann,

I am currently evaluating a child who was evaluated prior to entering school, and was diagnosed with Autism through a private clinical psychologist through our Regional Center when he was 4.6 – he is almost 8 now. We have worked with this student for two plus years – and in planning for the assessment, I added the ADOS among other tools. The parent would not allow us to re-evaluate him with this instrument. I have completed a couple of NEPSY subtests (Theory of Mind and Facial Affect Recognition) – his aide has completed the Social Responsiveness Scale (he did extremely well on these scales showing social cognition). I have also provided the teacher with adaptive behavior, Burks Behavior Rating Scale, BASC-2, SCALES. I honestly do not see the Autism and instead see severe AD/HD symptoms, and a lack of age appropriate socialization opportunities as his key barriers at school and with learning. Also, his parent is very attached to the Autism DX – he is currently under S/L and she expects the Autism designation as well. Other than my clinical judgment – are there other instruments I can use to address the behavioral portion of this assessment? I have done a fair amount of observation in and out of the classroom – rating scales are so poorly designed and subjective (GARS, CARS) – as there are overlapping symptoms in this case diagnostically speaking.

Thank you,
Vickie


Answer:

Vickie,

Thank you, Vickie, for your question. I have asked the Diagnostic Center school psychologist who has expertise in ASD to answer your question. Mirit Friedland provides our trainings in best practices for assessing individuals with an ASD and I’m certain you will find her response helpful and informative.

Ann


Hi Vickie,

You bring up a lot of key issues related to differential diagnosis for autism assessment. School professionals in the district level have responsibilities and expertise in both determining autism characteristics, eligibility for special education services, and designing individualized interventions for the student based on his learning and social-emotional needs in the school environment. It sounds like you have already gathered a lot of key information to address these three areas. I suggest that you use an interdisciplinary model with your team to collect, analyze and integrate your assessment data using the RIOT (Review Interview Observe Test).

Review:

Include a review of your student’s development and educational history. It is important to determine the initial concerns by the parents and educators, both the specifics and when they occurred. Individuals with autism (except those with Asperger’s) have a significant history of language delays, in additional to delays in nonverbal communication skills. Determine if there was a regression of language development or milestones, as approximately 25 to 30% of individuals with autism have a history loss of language skills. Review for history of deficits in social interactions and restricted behaviors, activities and interests as outlined in the DSM-IV. You have the benefit of having worked with this student for more than two years, so also provide details about past concerns, areas of progress, and interventions which have been associated with his progress.

Interview:

Interview the student’s parents, teachers, speech pathologist and other service providers for clarification regarding history, including consistencies and inconsistencies, current concerns, and diagnostic symptoms of both ASD as well as competing diagnoses (i.e. AD/HD or other disabilities accounting for his challenges). Collect specific information about the child’s friendships, what he enjoys doing with friends, sensitivity towards others, and activities/interests using a combination of interviews and observations. Since several rating scales have been completed by the parents and teachers, I would recommend that you interview the parents by asking them open-ended questions and for clarification of information. If you feel more comfortable with a structured interview, consider having the parents first fill out CARS2 –QPC questionnaire for parents (QPC), so that they indicate the specific concerns and past concerns and their level of concern or perceived severity. The CARS2-QPC does not provide a specific score; rather review of the parent responses will provide you structure or specific areas for further interview with the parents.

Observe:

You and your school team have rich opportunities to collect observational data. You have daily opportunities to observe the child in his natural social environments, and to compare his functioning to typically developing students/children. In addition to your observations during his direct contact with you, observe your student during both structured and structured tasks, high and low interest activities, individual, small and large group, novel and familiar activities, transitions and interacts with peers, adults and family members. Specifically observe for social interaction skills including initiation, response, reciprocity, giving and showing, play, functional communication as well as specific autism characteristics outlined in the DSM-IV-TR related to communication and behaviors and activities (as is done by the ADOS). Observe for potential social strengths, difficulties and challenges and note these so you can specifically ask the student about his perspective.

Test:

It sounds like you have already administered a variety of tests. As part of this student’s triennial, you and the Speech-Language Pathologist should include assessments and descriptions of the student’s cognitive, language and communication, and processing skills. Assess for processing speed, including visual motor processing and auditory processing, areas that tend to be weaknesses for both those with ASD and AD/HD. Retrieval fluency or the rate of accessing information from long term memory is also a common area of weakness. Additional processing areas I recommend to assess include executive processing, including shifting, planning, sustained attention, and working memory. The WJ-III and the NEPSY-II have subtests that tap into these areas. Social cognition and perspective taking are best examined by observations, projective testing, and direct interviews or interactions with the student. For example, specifically ask the student about social challenges you observe or that have been shared with you to determine their awareness of the situation, the other person’s perspective, and consequences of certain actions. Collaborate with your Speech-Language Pathologist, who will be providing a comprehensive assessment of language and communication (i.e., articulation, phonological process, oral-motor, syntax/morphology, semantic abilities, language literacy, language processing, social communication, verbal formulation, fluency, prosody, voice and any AAC needs) in addition to evaluating specific language weaknesses associated with ASD (e.g., topic management, conversational skills, language flexibility, nonverbal communication, prosody, and stereotyped or perseverative language.) Projective testing is also another method to collect information on the student’s ability to read and understanding emotions, social situations, perspective taking, as well as language samples.

Differential Diagnosis: if the student’s difficulties appear to be better explained by another disability, such as AD/HD and/or a learning disability, ensure that you have clearly outlined these challenges related to the diagnostic criteria and how they impact the student’s learning. For example, if you determine that the student has AD/HD and it significantly impacts his work performance, production, and progress, indicate this relationship and point out what interventions would be most effective. When making a differential diagnosis with AD/HD, highlight the differences that would distinguish this child from having ASD. Explain how the student’s impairments associated with AD/HD (i.e. social motivation, response to novelty, making an emotional connection) contribute to emotional and behavioral challenges, and also offer diagnostic impressions and interventions to address these. For example, a high percentage of individuals with AD/HD have anxiety disorders and significant social challenges.

I hope this response is helpful. If you would like additional guidance in best practices for ASD assessment, please attend my training, “Best Practices for ASD Assessment-Advanced”; you can learn more information about this when and where this training is offered by visiting the Diagnostic Center North website and click on the Professional Development link.

Best of luck to you!
Mirit