michael j. lucido, phd charlevoix center supervisor christine lennon, ma, lpc

M I C H A E L J . LU C I D O , P H DC H A R L E VO I X C E N T E R S U P E RV I S O R

C H R I S T I N E L E N N O N , M A , L P CD D C H I L D R E N ’ S B E H AV I O RA L S E RV I C E S

CHILD ABUSE COUNCIL SPRING CONFERENCESTRENGTHENING THE SOCIAL AND EMOTIONAL

HEALTH OF CHILDREN:

AUTISM SPECTRUM DISORDER OVERVIEW

A P R I L 2 6 , 2 0 1 3

Raise your hand if you personally know someone

impacted by autism or Asperger’s.

CDC (1985)1 per 2500

CDC (2007)1 per 150

CDC (2009) 1 per 110

CDC(2012)

1 per 88

PREVALENCE RATE

TAKING A LOOK AT AUTISM

STEPHEN WILTSHIRE’S STORY

Following 20 minute ride, he drew an 18 ft long drawing of New York city in exact detail

PERVASIVE DEVELOPMENTAL DISORDERSAutistic Disorder:

• Social impairment.• Communication impairment.• Restricted repetitive/stereotyped behaviors, interests, or activities.

Asperger’s disorder:• Higher functioning form of ASD.• Normal language with single words by 2-phrases by 3.

Rett’s Disorder:• Exclusively female genetic developmental disorder-progressive delays

throughout lifespan• Severe “apraxia”-inability to execute purposeful movements despite

physical capability.Childhood Disintegrative:

• “Heller’s Syndrome”- normal development from 2-10 years of age but then severe decline.

• Causes by lipid storage diseases, subacute sclerosing panencephalitis, tuberous sclerosis.

PDD Not otherwise specified:• Do not meet full criteria but have symptoms similar to the diagnoses

above.

DSM-V AUTISM SPECTRUM DISORDER (ASD)

DSM-V (2010) revised label & criteria: • Autism Spectrum Disorder under one label• Rett’s disorder is considered separate of

ASD• Reduced to two criterion• Require multiple observations• Provide qualifiers such as “with

intellectual disability” or “due to Fragile X syndrome”

Grandin wrote, •“As a child I remember Mother asking me time and again, ‘Temple, are you listening to me? Look at me.’ Sometimes I wanted to, but I couldn’t...”

AUTISM SPECTRUM DISORDER CRITERION

Socialization and Communication• Poor eye contact• Flat expressions• No peer relationships• Odd speech• Echolalia• Misinterpret emotion• Conversation issues

Repetitive and Obsessive Behaviors• Rocking• Hand wringing• Twisting fingers• Fixated interests• Intense focus• Set routines• Preoccupied parts• Sensory issues

ASD

BEHAVIORAL SIGNS AND SYMPTOMS

• Speech: monotone, rhythmic, nasally/high pitched (dysarthric), pedantic, repeating phrases (echolalic), and other idiosyncratic speech patterns.

• Eye contact: no, limited, or inappropriate eye contact- towards the ceiling, looking at the body, avoiding face/eyes.

• Gross and fine motor coordination: unable to balance on foot or tandem walk, or poor writing (dysgraphia).

• Stereotyped behaviors: hand-wringing or twisting, spinning in chair, complex whole body movement, hand-flapping, pacing.

SENSORY DISTURBANCES

• Behavior “meltdowns” are often sensory related• Grandin wrote,

• “But when I was in the world of people, I was extremely sensitive to noises..The pain that racked my head when the fog horn sounded was excruciating”. (hyperacusis-sensitivity)

• “Spinning was another favorite activity. I’d sit on the floor and twirl around. The self-stimulatory behavior made me feel powerful, in control of things…I realize that non-autistic children enjoy twirling around in a swing, too. The difference is that autistic child is obsessed with the act of spinning”.

UNDERSTANDING THE “BEHAVIORS”

• Common misnomers about behaviors:• He can control his meltdowns!• She is being oppositional!• He just wants it his way!• He can stop biting himself!

• It is an underlying neurological condition-first and foremost

• Most of the time is out of their control

• They struggle to be “normal”

WHAT CAUSES AUTISM?

IS IT THE PARENTS?

• Kanner said autism is a result of “genuine lack of maternal warmth”.

• Bruno Bettleheim said autism was caused by maternal coldness.

• Finally by 1960s, Bernard Rimland said it was a neurological disorder.

TEMPLE GRANDIN’S STORY

Graduated with a doctoral degree in animal science, wrote many books on autism and animal issues

A FEW THEORIES ON THE CAUSE OF ASD

•No single theory explains ASD

•Genetic and heredity•Abnormal development•Physical health issues•Autoimmune problems•Environmental toxins

HEREDITY & GENETIC ABNORMALITIES

• Monozygotic twins as high as 60-95% and siblings are 45-60 times greater to develop autism

• First degree relatives might have psychiatric issues like depression, OCD, anxiety disorders, etc

• X Chromosome as a factor?• Fragile , Turner’s syndrome, Klinefelter, Rett, Prader-

Willi, Timothy, Phenylketonuria, and Angelman syndromes.

• Reason for higher rates in males? (XY vs. XX in females)

DEVELOPMENTAL GROWTH

• 20-30% have seizures, up to 72% abnormal EEG

• 75% smaller head circumferences at birth, but rapid growth by first year in the 85th percentile

• 100-200g heavier brain weight in autism• Deficits in Emotion centers: amygdala, prefrontal cortex, temporal lobes, & thalamus

• Dysregulated neurochemicals like serotonin, dopamine, melatonin, and oxytocin

NEUROLOGICAL PATHWAYS FOR ASD

GASTROINTESTINAL PROBLEMS

• Gastrointestinal problems as high as 84%• Constipation, problems going to the bathroom, etc• These health issues impact moods, behaviors,

appetite• Interaction between the gut and the brain is

important to understanding ASD-serotonin?• Food allergies is strongest link to GI issues

• Food allergies have been attributed to conditions like celiac disease, which lead to the abdominal problems

AUTOIMMUNE RESPONSE

• Lowered immune response• High opioid activity

• High pain thresholds- high endorphin levels• Endocrine system related to thyroid

• Concerns regarding hypothyroidism or low thyroid will impact brain development

• Considered an iodine deficiency in prenatal and neonatal development

ENVIRONMENTAL TOXINS• Industrialization increased exposure to

neurotoxins• Heavy metals like mercury, lead, or cadmium• Pesticides such as cyanide.• Clothing, food, building materials, personal care

• New Jersey has highest rates for autism & asthma-has highest pollution levels in the nation

• Wakefield: vaccines link to autism retracted• 18 controlled epidemiological studies found no link

• No one factor accounts for autism

E V I D E N C E D B A S E D P RAC T I C E SDIAGNOSING AUTISM

WHAT IS EVIDENCED-BASED PRACTICE?

American Psychological Association (2006):• EBP: “integration of the best available

research with clinical expertise in the context of patient characteristics, culture, and preferences”.

• EBP is comprehensive with assessment, case formulation, therapeutic relationship, and specific decision-making process integrating research and intervention together.

A NEED FOR COMPREHENSIVE CARE

• Psychological evaluation• Behavioral, OT, and Speech Assessments• Psychiatric evaluation and medications• Dietary modifications and supplements• Behavioral interventions• Individual/group therapy• Parent Training• Case management• Employment assistance• Occupational therapy• Speech therapy• And many more!!!

EBP service

s:

HISTORY OF LACK OF FUNDING FOR SERVICES

Costs are $35 billion per year nationwideAverage costs:$29,000-$43,000 per yearHistory of disparity of Federal fundingPresident proposed $1 billion increase of

annual federal spending on autismMichigan Department of Community

Health expanded autism services

MDCH AUTISM SERVICES EXPANSION

• Created the 1915i State Plan Amendment and 1951b Mental Health Specialty Services and Support Waiver

• Started April 1, 2013 • Consist of early identification-average age of child being diagnosed with autism is age 8 in Michigan.

• Targeted18 months through age 5

ASD SCREENING AND DIAGNOSIS• Screening forms by parent and referred by

pediatrician • Modified Checklist for Autism in Toddlers (16-30 mo.)• Social Communication Questionnaire (ages 2 )

• Referred to Access Center for a more in depth diagnostic evaluation.

• Evaluation will consist of an in depth clinical interview, assessment, and other tests for behaviors, ability, language, etc as needed.• Diagnosis must be confirmed by a fully licensed

psychologist or physician/psychiatrist.

QUESTIONNAIRES ASSESSMENT

• Autism Diagnostic Interview-“Gold standard” (ADI)

• Autism Spectrum Rating Scales (ASRS)• Autism Treatment Evaluation Checklist (ATEC)• Modified Checklist for Autism in Toddlers

(MCHAT)• Asperger Syndrome Diagnostic Scale (ASDS)• Gilliam Autism Rating Scale: 2nd Edition (GARS2)• Childhood Autism Rating Scale (CARS)• Social Communication Questionnaire (SCQ)• Social Responsiveness Scale (SRS)

PSYCHOLOGICAL TESTING

Autism Diagnostic Observation Schedule

(ADOS)

“Gold standard” for assessing behaviors of

ASD

New versions of IQ testing

Profiles for individuals with

autism.

LOOKING BEYOND IQ

• University of Montreal found intelligence tests (WISC, WAIS) in ASD over-diagnosing ID

• None of the children scored in the high average range and a 1/3 scored in the ID range

• Nonverbal IQ test, a 1/3 scored in the high average range, and only 5% scored as ID

• Newer intelligence tests have profiles for ASD to explain such conflicting results

KIM PEEK’S STORY

• Inspired by movie Rain Man• Read two pages at once• Memorized 12,000 books• Low average IQ

NEUROPSYCHOLOGICAL TESTING

• Stroop• Continuous Performance• Trail Making• Shifting Attention• Symbol-digit coding• Finger Tapping• Verbal/Visual memory

Neuropsychological testing:

• Cognitive flexibility/switching• Organization, planning• Visual-working memory• Verbal fluency• Complex attention

Executive functioning deficits in ASD:

READING THE MIND’S EYE TEST

• Visual-perceptual processing

• Problems with facial recognition, and social-emotional processing.

• Social cognitive test for empathy or “Theory of Mind”.

• Best way to evaluate social issues is through observations.

OCCUPATIONAL/SPEECH ASSESSMENT

• Special education ASD evaluations include speech and occupational evaluations when identifying ASD.

• CMH provides contractual support for OT and Speech when physician has ordered interventions for ASD in the home.

NEED FOR MEDICAL EVALUATIONS• Gastroenterologist- problems with intestines

and stomach including issues like constipation• Neurologist- brain imaging like CT scans and

brain function with EEG• Immunologist/allergist- identify potential

environmental allergies influencing behaviors• Dietitian- identify health habits• Psychiatrist- medications for behavior and

mood

E V I D E N C E D -B A S E D P RAC T I C E S F O R A S D

AUTISM INTERVENTIONS

OPTIMIZING LIFE PURSUITS IN ASD

Grandin wrote, “I think the same principle applies to autistic children-work with them instead of against them. Discover their hidden talents and develop them”.

PERSON-CENTERED• Assist parents and individuals with ASD:

• Understanding procedures, aid in documents, ease transition in services, respect, be flexible.

• PC seeks collaboration with natural supports and community.

• Empathy, unconditional positive regard:• Individuals with autism are often on a one way street-walk with them for a while!

MDCH ASD BEHAVIORAL SERVICES

• Provided to age 18 months-5 y/o• Applied Behavior Analysis (ABA)

• Science of the principles of behavior• Two levels of service intensity for ABA

• Early Intensive Behavioral Intervention (EIBI)• Children with a diagnosis of autistic disorder• Average of 10-20 hours per week

• Applied Behavioral Intervention (ABI)• Children with a diagnosis of Aspergers, PDD, etc• Average of 5-15 hours per week

• Structured applied behavior analysis program that relies upon discrete trial training (DTT) methods and incidental teaching opportunities

• Administered in a child’s home or a clinic setting.

HOW SERVICES WILL BE CONDUCTED

DISCRETE TRIAL TRAINING• Comprehensive structured behavioral

intervention or discrete trial training (Lovaas, 1987)

• Operant conditioning (Skinner): rewarding specific behaviors to increase the likelihood of the behavior occurring again

• Learning environment is structured• Target behaviors are broken down into

discrete subskills• Initiated and selected by adult• Child’s response is prompted• Reinforcers are unrelated to the target

response (e.g. toy)• Rewards for correct response or successive

approximations

DIR FLOOR-TIME

• Developmental, Individual Difference, Relationship-Based (DIR) Floortime Model (Greenspan, 2000)

• Infants to preschoolers improve social-emotional cognition

• Motive, planning, and sequencing• http://www.youtube.com/watch?v=jrXGh9bT0Sw

PIVOTAL RESPONSE TRAINING• Pivotal response training: teaching core or

pivotal skills makes it easier for children with autism to learn basics (Koegel et al., 2001)

• Increasing motivation to engage in social communication• Motivation• Self-regulate behaviors• Initiate social interactions• Response to multiple social cues

COGNITIVE-BEHAVIORAL THERAPY•Social skills training•Anger management•Rethinking perspective•Regulate emotions•Social skills training•Social Autopsies•Social Stories

ASD PSYCHOPHARMACOLOGY IASD 2nd Generation

Neuroleptics:• FDA (2006) approved

risperidone as the first medication to treat irritability and aggression in children and adolescents with autism.

• Other medications like aripiprazole (second generation antipsychotics) are being approved for autism.

• Improve both dopamine and serotonin regulation.

• Decrease aggression, self-injuries, irritability, and improve mood stability.

ASD Antidepressants:• Research for 20 years

including clomipramine, desipramine, fluoxetine, citalopram, sertraline, and venlafaxine.• improve stereotypic and

obsessive behaviors.• Medscape (2010) SSRIs are not

recommended for just ASD because of limited research.

• Sertraline, fluoxetine, and fluvoxomine are approved for OCD, and fluoxetine and escitalopram approved for depression.

• Symptoms of anxiety and depression that are comorbid with ASD.

ASD PSYCHOPHARMACOLOGY II

• decrease hyperarousal, agitation, improve dental visitsAnxiolytic:

• decrease seizures and stabilize moodsAnticonvulsant:

• Decrease aggression1st generation neuroleptic:

• improve attention, concentration, and impulsivityNeurostimulant:

• improve sleep and attention and decrease aggressionAntihypertensive:

DIETARY AND VITAMINS

• Ketogenic diets (used in seizure disorders) and gluten-casein free diets (used in schizophrenia)

• Melatonin for initiating sleep• Fish Oil (EFA) improves cognition• Vitamin D to improve mood, sleep, cognition• Vitamin B6 and B12 to improve cognition• Oxytocin improve social affect and social cues• Recommendations come from physicians• Dietitians may provide nutrition consultation

OCCUPATIONAL THERAPY

• OT provides critical interventions that might offset need for medication or other therapy

• Assists in skills like in improving hand writing• Sensory diets regulate the environment and structure daily activities to prevent overload• Schedules are very important in ordering the

day’s sensory input!

SPEECH THERAPY

• Speech therapy teaches effective ways to communicate in areas like pragmatics

• Improve speech production such as voice modulation

• Picture Exchange Communication System (PEC)• PECS are helpful for improving

communication and schedule• Easily recognizable• Exchange the picture for a desired activity

or item

ABUSE IN CHILDREN WITH AUTISM

ABUSE IN CHILDREN WITH DD• A child with any type of developmental disability

was 4xs more likely to be sexually abused than a child without (Sullivan & Knutson, 2000).

• 50% of children with autism are nonverbal and unable to participate in usual means for verbal interviews that require reciprocal communication.

AT RISK

• Struggle with interpreting caution and picking up deceptive emotions in facial affect

• Perpetrators may target children with nonverbal autism because inability to disclose

• Issues with sequencing of events and misinterpreting them

• 50% of offenders of individuals with developmental disabilities had contact with them through their disability services

FORENSIC INTERVIEWING

• Need to provide multiple interviews in order to gain rapport and short sessions vs. long sessions

• “Referential communication” ability to know what another person is asking and refer to• Question: “Did John Doe touch you”• Answer: “No” (answering for today, but abuse

happened in past). • Children with autism struggle with responding

to questions appropriately or accurate information

SIGNS AND SYMPTOMS

• Often simply noticing change of behaviors is most important

• Increased self-stimulation

• Self-injurious behaviors• More meltdowns• New Behaviors not

present before

INTERVENTION

• Trauma focused therapies such as play therapy or cognitive therapies if verbal

• Sex education and education regarding appropriate and inappropriate touch

• Difference between public and private behaviors

• Providing social stories as a means of communication

JASON “J-MAC” MCELWAIN’S STORY

In his first-ever high school game, he scored 20 points and tied the school record with six 3-pointers in 4 minutes

In a book on autism, a mother describing her son and others with autism said,

“From their deep sense and connection to the universe and our planet they feel what a leaf feels, they can smell cold, they are truly in the moment. These special beings can teach us many things through their gifts that they have to offer.”

Thank you!!!

ANY THOUGHTS OR QUESTIONS?