Early Identification of Autism – Part 1

Susan Hepburn, Ph.D. Author

04/20/2022 Added

199 Plays

Description

Tri State Webinar 2022

Searchable Transcript

Search:

[00:00:13.440]Good afternoon, everyone.
[00:00:15.260]My name is Susan Hepburn,
[00:00:16.800]and I'm really pleased to be providing this webinar today
[00:00:19.760]on early identification of autism spectrum disorders.
[00:00:23.600]I'm trained in child clinical psychology,
[00:00:26.380]and I've been specializing
[00:00:28.120]in the identification of autism spectrum orders for, gosh,
[00:00:32.070]I guess a little over two decades now.
[00:00:35.380]After working at JFK Partners
[00:00:37.500]at the University of Colorado Medical School
[00:00:40.410]for about 18 years,
[00:00:42.130]I took a position as a professor
[00:00:44.780]at Colorado State University,
[00:00:46.430]where I currently am working with students,
[00:00:48.800]and running some research projects.
[00:00:52.740]So today, I'm gonna present to you part one
[00:00:56.110]of a two-part webinar on early identification
[00:00:58.970]of autism spectrum disorders.
[00:01:00.990]I would consider this particular part
[00:01:03.910]to be a beginning orientation to early identification,
[00:01:08.400]and is probably most appropriate for people
[00:01:11.380]who do not have extensive experience
[00:01:14.910]in early identification.
[00:01:17.070]My goals in part one are to explain why it's important
[00:01:21.260]to identify autism symptoms in early childhood,
[00:01:24.520]to talk with you about specific early emerging symptoms
[00:01:28.010]to look for between birth to three,
[00:01:32.140]that signal possible autism spectrum disorder
[00:01:35.000]in young boys and girls.
[00:01:36.910]And then, to talk very briefly about considerations
[00:01:40.510]when you're trying to differentiate
[00:01:42.150]between an autism spectrum disorder,
[00:01:44.230]a global developmental delay, or intellectual disability,
[00:01:47.630]and a speech-language impairment in young children.
[00:01:51.900]In part two, we're gonna cover more practical skills
[00:01:55.350]regarding the tools that are out there that you can use,
[00:01:58.090]and some of the ways that you can approach
[00:02:01.860]the early identification of autism.
[00:02:04.170]So first, very briefly,
[00:02:05.890]let's talk a little bit about why we're here.
[00:02:08.620]So why should we identify autism spectrum disorder early,
[00:02:13.010]versus taking what some might call, a wait and see approach?
[00:02:18.630]Well, I think it really begins with thinking about
[00:02:21.730]how we think about autism.
[00:02:24.340]So if you see autism spectrum disorder as devastating,
[00:02:29.210]impossible, really hard to adjust to and manage,
[00:02:33.260]then you are probably feeling
[00:02:35.680]a lot of hesitation and concern about using that word
[00:02:39.410]to describe the behaviors that you're observing
[00:02:41.750]in a young child,
[00:02:43.060]As we all know, behavior and development is really dynamic
[00:02:47.410]in the early childhood years.
[00:02:48.940]And we can be hesitant to put a word on a child
[00:02:52.690]if we're thinking that could experience a lot of changes,
[00:02:56.570]and that word would no longer apply.
[00:02:59.560]Well, I would actually consider taking a step back.
[00:03:02.640]And if you think about autism spectrum disorder
[00:03:05.740]in a more hopeful way,
[00:03:07.340]where the idea is that if we can identify children at risk,
[00:03:11.010]we can then help parents understand
[00:03:14.040]why their children are behaving as they do.
[00:03:16.730]And we can get in their early and provide interventions
[00:03:21.260]that hopefully, can actually change
[00:03:24.020]the developmental trajectory of autism in children.
[00:03:27.580]So to me, thinking about autism spectrum disorder
[00:03:31.070]as a condition that is responsive to intervention,
[00:03:34.870]where there's a lot of hope there
[00:03:36.490]for what we can do about it,
[00:03:37.990]is an important way to approach it.
[00:03:42.800]How we think about our role with families also matters.
[00:03:46.560]If we adopt an approach that we are to be the gatekeepers
[00:03:51.430]or the people to take care of parents and protect them
[00:03:54.530]from things that are hard,
[00:03:56.220]that care taking role would then have us thinking about
[00:03:59.730]ways to not necessarily share all the information,
[00:04:03.370]because we feel that we're responsible
[00:04:05.930]for a family's wellbeing, and we're trying to prevent them
[00:04:09.840]from feeling the emotional distress and sadness
[00:04:12.380]they may feel when they first hear
[00:04:14.930]about their child's developmental progress.
[00:04:18.700]On the other hand,
[00:04:19.900]one could argue that that kind of posture,
[00:04:22.770]where you're in the role of caretaker
[00:04:24.930]is kind of paternalistic, even condescending,
[00:04:28.250]and doesn't really honor the dignity that families have,
[00:04:32.270]that they deserve to know
[00:04:34.380]what professionals in child development are thinking
[00:04:37.480]about their son or daughter.
[00:04:38.910]And if we adopt a posture that our role
[00:04:41.210]is to collaborate with families,
[00:04:43.400]then we are not specifically there
[00:04:46.210]to make decisions for them,
[00:04:47.910]or to edit the information we share,
[00:04:50.330]but rather to think really hard
[00:04:52.120]about how we can be sensitive and careful,
[00:04:55.460]and somewhat tentative at times,
[00:04:58.080]but truthful and candid as we express our observations
[00:05:02.660]about a child's development.
[00:05:04.980]So to me,
[00:05:06.270]if we have a hopeful idea about young children
[00:05:09.120]who are showing some delays
[00:05:10.770]and we adopt a collaborative model,
[00:05:13.410]then, early identification of young children
[00:05:16.200]at risk for autism seems a pretty important thing to do.
[00:05:21.390]In fact, I might argue that there are three specific reasons
[00:05:27.000]why we would want to identify autism as early as possible.
[00:05:31.530]And I'm gonna spend a moment or two,
[00:05:33.190]talking about each of these three things.
[00:05:35.490]The cognitive coping perspective,
[00:05:37.580]which has to do with how parents learn to think about,
[00:05:41.400]and adjust to the reality of having a person
[00:05:44.170]with autism in their family.
[00:05:46.030]We'll also talk about the prevention science approach
[00:05:48.630]to early identification.
[00:05:50.360]The idea that if you can identify children at risk
[00:05:54.710]for developing problems in certain areas,
[00:05:57.580]you have a lot more leverage for encouraging that
[00:06:00.440]developmental trajectory to go on a positive bent.
[00:06:02.058]And then, we'll also talk about the practical aspects,
[00:06:07.590]that just because we think it's important,
[00:06:09.630]doesn't mean it can happen automatically.
[00:06:11.830]We have to be really careful and thoughtful
[00:06:14.290]about how we're supporting our child care professionals,
[00:06:17.840]out there in the world,
[00:06:18.860]who are endeavoring to screen and identify
[00:06:21.380]people with autism.
[00:06:24.950]So let's look at the coping perspective.
[00:06:28.160]This is a set of theories that has to do
[00:06:33.260]with the importance of supporting
[00:06:35.580]how somebody thinks about a condition,
[00:06:38.830]in order to cope with it well and adjust to it,
[00:06:42.810]and move towards really thriving.
[00:06:46.310]So a cognitive coping perspective would suggest
[00:06:49.500]that how a parent thinks about autism
[00:06:52.690]is going to have a lot to do
[00:06:54.190]with how actively they seek intervention, or alternatively,
[00:06:58.330]how helpless they may feel and how it may be difficult
[00:07:01.610]to seek help or collaborate with providers.
[00:07:05.750]The important part of adjusting
[00:07:08.100]to having a family member with an autism spectrum disorder
[00:07:11.650]is being able to have the information that you need
[00:07:14.930]about your specific son or daughter,
[00:07:17.230]in order to make good decisions.
[00:07:19.540]Good decisions, not only about
[00:07:21.160]what will happen in school programming,
[00:07:23.500]but good decisions about the rules
[00:07:25.560]that your family will have.
[00:07:27.090]What behaviors you're going to actively teach,
[00:07:30.590]and which ones you're going to discipline,
[00:07:33.090]and which ones you're gonna see as skilled deficits,
[00:07:35.840]and which ones as inappropriate behaviors
[00:07:38.260]that need some kind of consequence.
[00:07:40.720]So in a cognitive coping perspective,
[00:07:42.970]the professional's role is to encourage
[00:07:45.850]that parents are making accurate appraisals
[00:07:49.360]of their children's behavior,
[00:07:51.820]and that they are noticing progress,
[00:07:54.000]and being able to have a realistic idea
[00:07:57.140]of what they might be able to expect in the future.
[00:08:01.060]In a cognitive coping perspective,
[00:08:03.700]there's a strong value then for family autonomy,
[00:08:06.920]that they're the decision makers, and professionals
[00:08:09.450]are the one to provide our expertise and information,
[00:08:12.550]but families get to make the decisions about their children.
[00:08:16.040]A cognitive coping perspective also values transparency,
[00:08:20.270]where the professional takes on the role of observing,
[00:08:23.750]narrating, but not judging, not withholding information,
[00:08:28.270]and not editing things out.
[00:08:30.530]Now, transparent communication is very difficult to do.
[00:08:33.640]These are challenging conversations,
[00:08:35.630]and that I can't think of too many things
[00:08:37.430]that are more sensitive or difficult to communicate
[00:08:40.670]than news that a child is not thriving in his current state.
[00:08:46.230]So while we are wanting to value transparency,
[00:08:49.440]we wanna do it in a kind way, a compassionate way,
[00:08:52.590]and really be thoughtful about our communications.
[00:08:57.560]Oftentimes, as we do talk to parents
[00:09:00.130]about autism signs and symptoms in their son or daughter,
[00:09:04.070]we will have multiple conversations about this.
[00:09:06.940]And it's really important to build trust with families
[00:09:10.140]through this identification process,
[00:09:12.320]as that's quite likely to set the tone
[00:09:14.660]for future homeschool collaborations.
[00:09:17.180]And we know from the research in special education,
[00:09:19.960]that when families and school teams are on the same page
[00:09:23.070]for a particular student, we tend to see better outcomes.
[00:09:26.730]So there are lots of good reasons
[00:09:29.190]for trying to build that trust,
[00:09:31.310]share what we are seeing, as child development experts,
[00:09:34.790]and support the parents to manage and adjust
[00:09:38.530]to what might be difficult news,
[00:09:40.510]but not to protect them from it.
[00:09:44.490]A couple of important assumptions
[00:09:46.700]underlying the cognitive coping perspective
[00:09:49.440]actually come from parent advocates,
[00:09:52.100]leaders in the field, like the Turnbulls from Kansas.
[00:09:55.630]What they would suggest is that not naming,
[00:09:58.910]or identifying the autism doesn't mean it doesn't exist.
[00:10:03.420]Children are probably noticing some differences
[00:10:06.370]in a child's behavior
[00:10:07.420]when that child is showing signs of autism.
[00:10:09.720]Other adults can see some of those behavioral differences.
[00:10:13.180]And by naming it, you're beginning to an explanatory model
[00:10:18.190]that we can seek more information about,
[00:10:20.800]and then really have a sense of where to go next.
[00:10:24.680]A lot of the literature on parent coping and adjustment
[00:10:27.710]in developmental disabilities, more broadly,
[00:10:30.520]suggests that the experience of uncertainty
[00:10:33.740]is the hardest part of adjusting
[00:10:36.280]to have being a child with special needs.
[00:10:38.780]Not knowing what's going on,
[00:10:41.180]wondering if your own kind of observations or concerns
[00:10:45.880]are reasonable, or if you're off base,
[00:10:48.910]that's a really, really difficult place to be in.
[00:10:51.820]And if all of the professionals around a parent,
[00:10:54.870]take a wait and see approach,
[00:10:56.950]but the parent is experiencing
[00:10:59.700]a sense of a lack of social connectedness,
[00:11:02.590]or some concern about a child's behavioral
[00:11:05.380]or communication development,
[00:11:07.450]being told to just wait and see
[00:11:09.860]can actually increase anxiety in a sense of uncertainty.
[00:11:14.150]And some parents may begin to doubt themselves
[00:11:17.610]if they're the only voice at the table
[00:11:19.740]that is wondering about autism.
[00:11:22.900]Now some may say, "Well, a lot of times we talk to a parent,
[00:11:26.210]who's never thought about autism,
[00:11:28.080]who doesn't have a lot of experience with children maybe,
[00:11:31.150]or who just, it never occurred to them.
[00:11:34.120]Are we within our rights, or is it the right thing to do
[00:11:37.600]to talk to them about autism early?
[00:11:40.290]Or should we allow them to explore, get to know this world,
[00:11:43.980]and then we'll tell them?"
[00:11:46.010]Well, of course, it's going to be different
[00:11:47.580]for every family that you work with.
[00:11:49.620]But in general, as a professional,
[00:11:51.840]you just wanna keep in mind,
[00:11:53.390]that part of what you are bringing to your work
[00:11:56.290]is a lot of knowledge and experience
[00:11:58.990]about child development.
[00:12:00.680]Most of you have worked with children for many, many years,
[00:12:04.020]and you understand how dynamic and amazing
[00:12:06.720]child development can be.
[00:12:08.530]You also probably recognize different in development
[00:12:13.610]when you see them.
[00:12:15.290]And parents can rely, need to rely on professionals,
[00:12:20.210]in the field, to be able to give them the information
[00:12:23.390]about whether or not their child
[00:12:24.810]is on track developmentally, or perhaps,
[00:12:27.440]could use some additional intervention and support.
[00:12:33.160]So while getting the information early,
[00:12:35.930]delivered sensitively, has been demonstrated
[00:12:38.530]to be associated with positive outcomes for parents,
[00:12:42.070]we also can consider a prevention science approach
[00:12:45.260]to why it's important to identify early.
[00:12:48.010]In prevention science,
[00:12:49.320]you're often asking yourself a question,
[00:12:51.880]what is worse when trying to identify a condition?
[00:12:55.530]If I make a mistake and have a false positive,
[00:12:59.520]in other words, is it more harmful?
[00:13:01.690]If I think I see autism in a child,
[00:13:04.300]and he doesn't actually have it?
[00:13:06.640]Or is it worse to have a false negative approach,
[00:13:11.060]where I'm failing to identify
[00:13:14.380]the autism spectrum disorder and a child
[00:13:16.390]when it's actually there.
[00:13:18.860]Prevention science would say
[00:13:21.100]that if you're thinking on a systems level,
[00:13:23.480]if you're thinking about resources,
[00:13:25.540]and providing intervention,
[00:13:27.630]then you probably have a pretty low tolerance
[00:13:30.170]for false positives.
[00:13:31.920]You don't want your system to be overburdened
[00:13:35.040]by having to give intervention to people,
[00:13:37.680]who would've developed OK, without it.
[00:13:41.120]If however, you're thinking about an individual child,
[00:13:44.370]then you probably have a low tolerance for false negatives.
[00:13:49.010]In other words,
[00:13:49.990]you can't afford to miss a child who does require
[00:13:54.860]the early intervention and help,
[00:13:56.760]because if he doesn't get that help,
[00:13:58.660]you might expect that growth and development
[00:14:00.740]won't happen as quickly.
[00:14:03.030]Either way, whether you're thinking on a systems level
[00:14:05.950]or an individual level,
[00:14:07.760]we need an evidence-based approach to screening,
[00:14:11.360]to identifying children at risk.
[00:14:13.960]And that approach need to include tools
[00:14:17.040]that have what we would call strong predictive power.
[00:14:19.930]That basically means,
[00:14:21.270]these tools are built and studied in young children,
[00:14:24.610]and they don't have too many false positives
[00:14:27.260]and they don't have too many false negatives.
[00:14:29.620]Therefore, you can trust that your results
[00:14:32.620]are more likely to be accurate.
[00:14:36.330]So whether you think on a systems or an individual level,
[00:14:39.540]we need this evidence based approach.
[00:14:41.950]And many times in prevention science,
[00:14:44.130]what we value most is identifying risk
[00:14:47.420]and protective factors early on,
[00:14:50.090]that are associated with outcomes later.
[00:14:52.640]And then we do whatever we can in professional practice
[00:14:56.160]to decrease risk factors for bad outcomes later,
[00:15:00.150]and increase protective factors or the good things
[00:15:03.530]that will promote positive outcomes.
[00:15:06.090]And we have a whole body of research
[00:15:08.060]that suggests delayed identification,
[00:15:11.080]after the age of three or four is associated
[00:15:15.570]with delayed access to intervention,
[00:15:18.200]which is associated with pervasive ongoing problems,
[00:15:22.150]communicating and interacting socially with others.
[00:15:25.760]We also see that children with autism
[00:15:27.770]who are not identified early are at greater risk
[00:15:31.160]of not developing functional communication,
[00:15:34.040]verbal or otherwise.
[00:15:35.760]And the longer they go without being identified,
[00:15:39.160]the longer people have to make attribution or judgements
[00:15:44.110]about problem behaviors or things that are interfering.
[00:15:47.320]And if you don't understand that a child's autism
[00:15:50.690]is part of what's driving some inappropriate behaviors,
[00:15:55.470]you may take an inappropriate parenting discipline
[00:16:00.010]or intervention approach.
[00:16:02.030]So as we consider risk and protective factors,
[00:16:05.280]a protective factor for children with autism,
[00:16:08.480]that's associated with better outcomes in life later
[00:16:12.110]is timely identification.
[00:16:14.530]Usually meaning before the age of three.
[00:16:17.740]Timely access to intervention in order to have
[00:16:22.190]access to what you need to develop
[00:16:26.030]in positive ways over time.
[00:16:29.770]Now finally, there's also a practical aspect
[00:16:32.600]to encouraging early identification of autism.
[00:16:35.700]This is not a simple thing, and even school professionals
[00:16:39.000]with a lot of experience working with young children
[00:16:42.100]may not feel competent in identifying those
[00:16:44.940]who may be at risk for autism spectrum disorder.
[00:16:47.960]As many of you know, there's a lot of variability
[00:16:50.780]in how children will present.
[00:16:52.530]Some children may be relatively easier
[00:16:55.280]to identify than others.
[00:16:57.140]And school personnel and early childhood professionals
[00:17:00.730]may not feel competent to identify children
[00:17:04.150]with mild presentations,
[00:17:05.770]or when they are intellectually competent.
[00:17:08.230]And it's completely appropriate for a professional to say,
[00:17:11.847]"Ethically, I can't take on,
[00:17:14.210]because I don't think I have the skillset
[00:17:16.290]or the experience to do it."
[00:17:18.520]That is very reasonable,
[00:17:20.040]and I applaud people who are approaching it that way.
[00:17:22.950]I also am really pleased that you've shown up today
[00:17:25.890]for this training,
[00:17:26.970]because hopefully, this kind of interaction,
[00:17:30.530]seeking out didactic kinds of webinars,
[00:17:33.290]in combination with ongoing coaching and consultation,
[00:17:37.720]can really help a school or early childhood professional
[00:17:41.330]to gain a sense of self-efficacy and competency
[00:17:43.709]in identifying children who are at risk.
[00:17:48.640]I think it's also helpful and important
[00:17:51.270]to remember that the task for early childhood professionals
[00:17:55.560]is not to make a medical diagnosis,
[00:17:59.100]which would be thought of as a lifelong conceptualization.
[00:18:04.470]But rather,
[00:18:05.310]we're asking our early childhood professionals
[00:18:07.900]to identify young children who are at risk
[00:18:12.010]for developing an autism spectrum disorder,
[00:18:14.490]who are showing signs and symptoms
[00:18:17.720]that could be associated with autism.
[00:18:20.460]And if not autism,
[00:18:21.830]are probably associated with a delay in development,
[00:18:25.470]or possibly a speech-language issue.
[00:18:28.580]So if we think about the task of early identification
[00:18:31.720]as more of a screening opportunity
[00:18:34.710]and not a diagnostic opportunity,
[00:18:37.490]I hope that that might allay some of the fears
[00:18:40.250]about the expectations that we have
[00:18:42.400]of early childhood professionals.
[00:18:45.100]We also know that if somebody working with the child
[00:18:49.380]in the birth to three system, brings up the idea
[00:18:53.730]that the child is showing some signs
[00:18:56.270]of an autism spectrum disorder,
[00:18:58.550]that increases the likelihood
[00:19:00.780]that the child will get the interventions later,
[00:19:03.560]that meet their needs.
[00:19:05.060]We really need to signal to pediatricians,
[00:19:07.890]and later to preschool teams and school teams,
[00:19:10.687]if we see things that we're concerned about.
[00:19:14.750]Not naming it or describing it to a parent
[00:19:18.260]can delay access to intervention,
[00:19:20.830]and we may miss an important window
[00:19:23.270]when the brain and nervous system is particularly primed
[00:19:26.720]to learn new ways to communicate and interact socially.
[00:19:30.340]And then finally, if an early childhood professional
[00:19:33.980]doesn't say autism out loud to a parent, even as a concern,
[00:19:38.860]what we find is that many times,
[00:19:41.140]there can be gaps in the system.
[00:19:43.030]And when other professionals work with that family,
[00:19:45.870]and see a paper trail where nobody has called it out,
[00:19:49.120]it becomes increasingly hard to be the team
[00:19:52.650]that does put words to it.
[00:19:55.410]So all of that to say, I view it as really important
[00:19:59.400]to try to identify autism in young children.
[00:20:02.930]And we have now heard from parents,
[00:20:05.140]when they talk about their experiences early on.
[00:20:08.140]As a whole, parents are more concerned and more upset
[00:20:13.080]when developmental professionals don't share their concerns
[00:20:17.320]than they are when they report that they went for years,
[00:20:20.470]that other people had concerns about autism,
[00:20:23.230]but didn't raise them with the parents.
[00:20:25.730]So just wanna encourage those of you that are wondering
[00:20:29.520]if it really should be your role
[00:20:31.430]to consider the specific training
[00:20:33.900]that you feel like you need
[00:20:35.290]to be able to function well in this role
[00:20:37.510]and to consider working in teams
[00:20:39.300]that can support each other,
[00:20:40.940]so that this becomes a helpful way
[00:20:43.600]of getting a family and a child,
[00:20:45.500]the appropriate services that they need.
[00:20:48.590]Well now, let's go ahead and talk about
[00:20:50.220]what you should be looking for?
[00:20:51.730]What are the early emerging symptoms
[00:20:53.890]of autism spectrum disorder?
[00:20:55.410]And I'm gonna focus primarily
[00:20:57.100]on the birth to three time period.
[00:21:00.860]In general, a main idea to hold onto
[00:21:03.500]is that early symptoms of autism
[00:21:05.980]are not characterized as unusual behaviors
[00:21:09.780]that you can readily see on the surface.
[00:21:12.540]Early symptoms of autism
[00:21:14.260]are more likely to be the absence of rich development
[00:21:19.760]of early emerging social and communication skills.
[00:21:24.740]So early symptoms of autism
[00:21:26.400]could be thought of as negative symptoms,
[00:21:28.750]meaning you expect to see a child develop in a certain way,
[00:21:33.090]and this child isn't showing that development.
[00:21:36.960]In this way, early identification is challenging
[00:21:39.910]because you're focused on what isn't there, but should be.
[00:21:44.830]And in general, it's a whole lot easier to I things
[00:21:48.320]that you might think of as positive symptoms,
[00:21:50.070]they're right in front of you.
[00:21:51.610]But those things, like unusual behaviors you could observe
[00:21:54.770]such as hand flapping or pacing in a circle,
[00:21:58.300]those things don't usually emerge until later in childhood.
[00:22:01.860]So in the early years,
[00:22:03.460]you're really looking for
[00:22:04.760]a lack of normal language development,
[00:22:07.760]or a different trajectory,
[00:22:10.030]or way of learning how to communicate.
[00:22:13.050]You're looking for a lack of,
[00:22:14.880]or a loss or some limited social interest.
[00:22:18.500]That's often demonstrated by orienting to others
[00:22:21.440]by the baby or the toddler, looking toward people,
[00:22:24.730]sharing their facial expressions with others,
[00:22:27.500]and then also catching the emotional expressions
[00:22:30.640]that others give.
[00:22:32.620]During the early childhood years, we also tend to see
[00:22:35.540]a lack of functional communication and imitation.
[00:22:38.377]So you don't see as much imitation with objects,
[00:22:42.690]or imitation with sounds.
[00:22:44.960]Although, as we'll talk in a moment,
[00:22:46.910]we now have some data that suggests two year old girls
[00:22:50.690]are much more likely to imitate,
[00:22:53.940]even when we later find out
[00:22:56.070]they have an autism spectrum disorder
[00:22:57.960]than their male counterparts.
[00:22:59.690]So girls may show some strengths
[00:23:01.860]in early imitation and yet, still present
[00:23:05.240]with full autism spectrum disorder later on.
[00:23:08.630]In the early childhood years,
[00:23:10.280]there's usually a lack of typical play development,
[00:23:13.470]some difficulties putting together complex play schemes,
[00:23:18.110]and a tendency to have limited or absent pretend play.
[00:23:22.590]And as we mentioned,
[00:23:23.870]the positive symptoms tend to come later.
[00:23:27.490]So let's look at each year of these first years of life,
[00:23:30.730]and see what the research can tell us.
[00:23:33.390]The first year of life is a very difficult time
[00:23:36.950]to identify a person who's at risk for autism.
[00:23:40.150]There are some clinicians out there
[00:23:42.140]with a ton of experience in infants
[00:23:44.560]who can pick up on some of the subtler signs,
[00:23:48.240]but most of our studies suggest that it's pretty rare
[00:23:52.210]to be able to identify behaviors associated with autism,
[00:23:55.840]under the age of 12 months.
[00:23:57.700]At about nine to 12 months and beyond,
[00:24:00.600]we can begin to see certain social
[00:24:03.480]and communicative milestones
[00:24:05.200]that typically developing children naturally go through,
[00:24:09.360]that many children with autism do not demonstrate.
[00:24:13.550]However, we are very, very cautious
[00:24:16.480]in our first year assessments.
[00:24:19.010]And if we see difficulties in say, parent-child synchrony,
[00:24:23.070]we'll intervene on the back and forth
[00:24:25.910]face to face interventions,
[00:24:27.630]but are probably not able yet
[00:24:30.210]without really, really strong data
[00:24:32.250]or a sense of a strong genetic background
[00:24:35.610]to make the call, under the first year of life.
[00:24:38.780]So what parents tell us, and what we see in the studies
[00:24:41.630]is we have overall delays for many children,
[00:24:44.520]who turn out to have ASD
[00:24:46.140]in their sensory motor functioning.
[00:24:48.020]And that includes the timelines for when they let go
[00:24:51.230]of primitive reflexes, how they explore their environments.
[00:24:55.520]We often see reduced gaze fixation at six months,
[00:24:59.920]meaning they don't look at things quite as long.
[00:25:02.890]And one of the findings
[00:25:04.220]that has been replicated most strongly,
[00:25:06.590]is that parents and early interventionists have identified
[00:25:09.900]a limited range of the vocal play in the first year of life.
[00:25:15.040]Not necessarily for all infants,
[00:25:17.140]but when there's a restricted range
[00:25:18.970]of those sound qualities,
[00:25:20.830]it could be a sign of early emerging autism.
[00:25:26.260]In general, within the first year of life, you may see
[00:25:29.360]some limited dyadic social interaction behaviors.
[00:25:34.000]What we mean by that is face to face kinds of interactions
[00:25:37.880]that adults often do with babies.
[00:25:39.960]When you make noises and they make noises back,
[00:25:42.760]or you make faces and they copy them.
[00:25:45.600]We tend to see diminished social smiles, restricted range,
[00:25:49.910]or used less frequently, in children who later on,
[00:25:53.510]we identify with autism.
[00:25:55.210]And there tends to be pretty strong predictor here,
[00:25:58.810]a delayed response to name that emerges
[00:26:01.460]after about the age of nine months,
[00:26:03.510]when most typically developing children
[00:26:05.870]are orienting to \the sound of their names.
[00:26:09.490]Unusual affect can be presented by some infants
[00:26:12.540]who have autism.
[00:26:13.850]You may see a serious or flat facial expression,
[00:26:17.990]or a facial expression that doesn't really fit
[00:26:20.130]what's going on around the child.
[00:26:22.070]And that back and forth imitative, emotional play,
[00:26:26.350]might feel somewhat constricted or limited
[00:26:29.880]from the parents' perspective.
[00:26:33.720]As we move into the second year of life,
[00:26:36.180]so this is basically from about 12 to 13 months,
[00:26:40.340]to about 24 months.
[00:26:42.260]That's when the symptoms of autism
[00:26:44.170]usually become increasingly clear.
[00:26:47.440]So we now have measures that I'll talk about next time
[00:26:50.130]that are specifically designed to identify autism
[00:26:53.420]in two year olds.
[00:26:54.580]And those measures are very developmentally sensitive,
[00:26:57.030]and can help us differentiate autism
[00:27:00.100]from developmental delay or a speech-language impairment
[00:27:04.150]without the social difficulties that characterize autism.
[00:27:08.620]So in the second year of life,
[00:27:10.200]we have a strong body of research that suggests
[00:27:12.760]you'll see developmental delays in social communication,
[00:27:15.860]such as initiating joint attention.
[00:27:18.180]That's when a child points to something
[00:27:20.450]that they're interested in, and then looks to the parent,
[00:27:23.040]and looks back at what they're interested in.
[00:27:25.270]That ability to recruit somebody
[00:27:27.870]to look at what you are interested in looking at
[00:27:30.530]is an important hallmark of early autism,
[00:27:33.590]because many children on the spectrum,
[00:27:35.710]tend to not share attention with others very easily.
[00:27:40.110]And initiating that attention share is a particular problem
[00:27:43.890]for most two year olds who have autism.
[00:27:46.900]There also can be significant delays
[00:27:48.910]in language understanding,
[00:27:50.630]and often find motor skills with a relative strength
[00:27:54.650]in doing puzzles or solving problems
[00:27:57.240]that don't require words.
[00:27:59.680]You probably will notice
[00:28:00.940]some atypical modulation of eye contact,
[00:28:03.910]either looking too long,
[00:28:05.580]or not sharing or modulating an eye gaze
[00:28:08.890]between people and objects
[00:28:10.640]as flexibly as a typically developing child would do.
[00:28:15.140]There are many reports of poor visual tracking skills
[00:28:18.880]in children who grew up to have autism,
[00:28:21.230]in the thought that the nervous system
[00:28:22.920]hasn't yet figured out how coordinate
[00:28:25.990]these smooth kinds of eye movements with social interaction.
[00:28:31.430]There can be a difficulty in the age of two
[00:28:34.260]of actually disengaging or shifting attention
[00:28:37.550]away from something that is distressing.
[00:28:40.620]This speaks to the relative immaturity
[00:28:43.640]that we may have in the frontal lobes of the brain
[00:28:46.150]for a person with autism.
[00:28:47.790]That's the part of the brain that helps you regulate
[00:28:50.160]and coordinate attention.
[00:28:51.890]And if it's not clearly connected to the rest of the brain,
[00:28:55.900]you may see a child who has a hard time shifting
[00:28:59.340]from one activity to another,
[00:29:01.440]later on, from one topic or idea, to another.
[00:29:04.770]If you can't away from something that's upsetting you,
[00:29:08.890]it can also lend to tantrums that can persist
[00:29:12.170]longer than they might.
[00:29:13.420]If a typically developing child has the instinct
[00:29:16.100]to look away from what's distressing,
[00:29:18.190]you may see those maladaptive behavioral episodes,
[00:29:20.830]be a bit shorter.
[00:29:22.240]And then lastly, in the second year of life,
[00:29:24.710]we continue to see an consistent response
[00:29:28.470]to their name being called.
[00:29:31.710]Other markers to look for,
[00:29:34.050]less frequent looking at the caregiver's face,
[00:29:37.160]especially to get information
[00:29:38.880]about how I'm supposed to feel about this,
[00:29:41.620]or what's going on.
[00:29:42.930]So there's a lack of co-regulation or relying on the parent
[00:29:47.702]for young children with autism.
[00:29:50.840]There's less monitoring of what other people are looking at,
[00:29:54.040]less imitation of how they behave and act in their social
[00:29:59.510]and emotional affects.
[00:30:01.370]There's less sharing of emotion.
[00:30:03.440]So a child with autism may show a variety of emotions,
[00:30:07.610]angry, sad, fearful, happy.
[00:30:09.950]What we're looking at here is are they taking the time,
[00:30:14.250]and is it instinctive and easy to hold their face up
[00:30:18.390]to the caregiver, send that facial expression to them.
[00:30:21.840]In other words, share that feeling,
[00:30:23.630]so that the caregiver can then respond.
[00:30:25.790]Many kids with autism will have the feelings,
[00:30:28.130]but they're not sharing those feelings with others.
[00:30:30.980]And then as I mentioned,
[00:30:32.230]we get less frequent joint attention behaviors
[00:30:34.970]in the second year of life.
[00:30:37.990]By about two and a half years of age,
[00:30:40.930]many children with autism
[00:30:42.920]have gained important social and communication skills
[00:30:47.040]that are important to recognize.
[00:30:49.200]So if you are looking at a child who's 30 to 36 months,
[00:30:53.690]you may find that they can follow
[00:30:56.720]an adult's attention, pretty well.
[00:30:58.800]Now, maybe they were somewhat delayed
[00:31:00.830]in their acquisition of this behavior,
[00:31:03.310]but many children who do have autism can actually respond
[00:31:06.827]to an adult pointing and saying, "Look at this,"
[00:31:10.337]after the age of 30 months.
[00:31:12.610]So having responsive joint attention
[00:31:15.210]after the age of 2 1/2,
[00:31:17.071]does not mean the child doesn't have autism.
[00:31:20.020]The more important behavior to look for
[00:31:21.900]in the joint attention realm for 2 1/2 year olds,
[00:31:24.880]is whether or not they initiate that joint attention.
[00:31:29.040]By the age of 2 1/2, especially if they've had intervention,
[00:31:32.470]many children with autism can indicate a simple request,
[00:31:36.180]oftentimes, without a coordinated eye gaze,
[00:31:38.930]and requesting often a improves by the age of three.
[00:31:43.140]So in the early twos,
[00:31:44.960]you may have a lack of intentional attempts to communicate,
[00:31:48.470]that could improve over time with experience in teaching,
[00:31:51.612]but just because requesting is kicking in,
[00:31:54.760]we don't wanna preemptively rule out autism.
[00:31:57.730]Many kids at 2 1/2 with autism,
[00:32:00.780]who are intellectually doing okay,
[00:32:02.950]we'll learn how to do some simple requesting
[00:32:05.410]to get their needs met.
[00:32:08.040]We do find that that requesting behavior is not as complex,
[00:32:12.290]or as well integrated, or as fluid,
[00:32:14.930]as you'll notice with children who are developing typically.
[00:32:18.840]The other thing to look for at about 2 1/2 to three years
[00:32:22.680]is that some young children with autism
[00:32:25.520]will use a communication behavior
[00:32:27.600]that is kind of unique to autism.
[00:32:29.800]And that's when they take their hand,
[00:32:31.830]and they put it on an adult's hand,
[00:32:33.850]almost like they're using the adults' hand as a tool,
[00:32:36.900]to either get something for them or send a message.
[00:32:39.730]So if a child is requesting,
[00:32:41.850]by putting their hand on somebody else's hand
[00:32:43.870]and moving it toward what they want,
[00:32:45.670]while not looking at the adult,
[00:32:47.980]that is an early sign of autism
[00:32:49.860]we wanna take very seriously.
[00:32:53.700]When we look at the variety of early screeners
[00:32:57.330]that we now have in the field,
[00:32:58.880]many of which will talk in part two of this presentation,
[00:33:02.160]we see some pretty common items
[00:33:04.430]that help us differentiate autism
[00:33:06.920]from other developmental conditions in the early years.
[00:33:10.430]In general, those measures tend to emphasize
[00:33:14.280]different things for toddlers than for preschoolers.
[00:33:17.730]As you can see here,
[00:33:19.290]for toddlers in that 18 to 36 month range,
[00:33:22.750]we're looking at not responding to a name,
[00:33:25.150]failing to follow a point,
[00:33:27.510]rarely directing other people's attention,
[00:33:29.890]having poor back and forth, emotional sharing,
[00:33:33.260]and not playing very often with a doll, in a functional way.
[00:33:37.700]In the preschool years, we want to be particularly attentive
[00:33:41.040]to the child's pretend play skills,
[00:33:43.020]as many children with autism are not developing
[00:33:46.080]or creating original schemes.
[00:33:48.640]There's usually a lack of gesture use
[00:33:51.560]that is combined with other methods to communicate.
[00:33:55.100]You often can see holding onto a doll or hugging it,
[00:33:59.610]but specific actions with the doll,
[00:34:02.080]where the doll is being treated
[00:34:03.610]as if it's a person doing things.
[00:34:06.220]So you may have passive play with the doll,
[00:34:08.360]but not active or agency play with the doll.
[00:34:12.000]Communicative efforts are often poorly
[00:34:14.040]integrated in preschool.
[00:34:15.710]So voice, eye gaze, and gesture
[00:34:17.930]may not be occurring together or may be off time.
[00:34:21.670]And imitation skills
[00:34:23.380]continue to be a concern for many children.
[00:34:27.970]There are some impairments that tend to persist
[00:34:30.890]across early childhood.
[00:34:32.830]Coordinating eye gaze and gesture,
[00:34:35.040]initiating gestures that are appropriate
[00:34:37.370]in range and function,
[00:34:38.900]and this idea of initiating joint attention.
[00:34:42.130]So while there are developmental changes
[00:34:45.200]within this time period to be aware of,
[00:34:47.630]these are three specific behaviors
[00:34:50.160]that the research suggests
[00:34:52.120]that you can continue to look for
[00:34:54.170]across birth to five, or age two to five, I should say.
[00:34:59.910]Similarly, the research suggests
[00:35:02.120]that there are some symptoms of autism
[00:35:04.320]that emerge later than the early childhood period,
[00:35:07.760]so don't be surprised if you don't see them.
[00:35:11.070]As you might imagine, the majority of toddlers
[00:35:14.520]do not show impaired conversational skills.
[00:35:18.560]Their communication needs
[00:35:19.830]usually have to do with intentionality,
[00:35:23.140]or knowing how to use their communication, socially.
[00:35:26.650]We usually don't see young children with autism,
[00:35:29.680]having difficulties being overly reliant on routines.
[00:35:34.310]That sort of flexibility problem tends to emerge later.
[00:35:39.470]And that's because you have to have the cognitive skills
[00:35:42.890]to anticipate what's coming next,
[00:35:45.510]and then be able to see that what's happening
[00:35:47.870]isn't what you expected.
[00:35:49.840]So that's a higher level cognitive function
[00:35:52.590]than many young children that you see,
[00:35:54.936]will have in their repertoire.
[00:35:56.930]So we tend to pay less attention
[00:35:59.940]to an over-reliance on routine in this particular age group.
[00:36:04.780]It doesn't mean that no one with autism will ever do this,
[00:36:07.430]but it's just less common.
[00:36:09.500]Stereotype language where they're repeating certain phrases
[00:36:13.040]or using echolalia,
[00:36:15.010]is not as common in young children as older children.
[00:36:18.140]And we don't get reports of restricted interests
[00:36:21.590]as much as we might get a child
[00:36:23.850]who wants to carry an object everywhere.
[00:36:26.310]So you're more likely to see preoccupation
[00:36:29.130]with parts of objects, carrying an object everywhere,
[00:36:32.810]or repetitive body movements than you are,
[00:36:35.840]some of those higher level repetitive
[00:36:38.750]and restricted interests.
[00:36:41.740]Sometimes, parents of young children
[00:36:44.440]will report overall problems behaving well in situations.
[00:36:49.140]Very rarely do parents come
[00:36:51.570]to an early childhood professional
[00:36:53.300]with a specific concern about imitation,
[00:36:56.250]joint attention, or play.
[00:36:58.330]That's often not in the repertoire of most parents,
[00:37:01.330]as they're monitoring their children's development.
[00:37:04.150]They do notice delays in becoming functional communicators,
[00:37:08.820]and they notice delays in first words and phrases.
[00:37:12.380]Parents also tend to report unusual responses to sensation.
[00:37:16.960]A child who maybe does and like loud noises
[00:37:19.740]and covers his ears, for example.
[00:37:22.130]So parents tend to be better reporters of positive symptoms,
[00:37:26.360]right at a time when we as professionals
[00:37:28.730]know we need to pay a lot more attention
[00:37:31.090]to the negative symptoms, what isn't there that should be,
[00:37:34.180]and that can make early identification a bit tricky.
[00:37:37.470]It's also important to know
[00:37:39.240]that within the first two years of life,
[00:37:42.310]approximately 15 to 30% of children,
[00:37:45.920]who we identify with autism,
[00:37:48.370]go through a time period
[00:37:50.000]where they show a loss of language skills.
[00:37:53.040]Maybe they had five to 10 words in their vocabulary,
[00:37:56.400]and at about 22 months have stopped using those words.
[00:38:01.960]That is not uncommon in children who have autism.
[00:38:05.810]And it's a phenomena that's continued to be studied.
[00:38:08.850]Some recent data suggest that the majority of children
[00:38:12.810]get past this plateau or this period,
[00:38:15.640]where they aren't showing the growth
[00:38:16.990]they used to show in communication.
[00:38:19.110]Particularly with the help of a speech-language therapist,
[00:38:22.030]and some really good responsive parenting,
[00:38:24.370]the majority of children with autism,
[00:38:26.230]who've had a loss regain those skills
[00:38:29.200]and move on to not have any worse impairment
[00:38:33.000]in their social or communication
[00:38:34.970]than children with autism who didn't show
[00:38:37.370]a period where they lost skills.
[00:38:40.020]The reason I'm bringing up here is sometimes,
[00:38:42.560]it's that plateau or that loss of development
[00:38:46.160]in communication that is the first sign
[00:38:48.770]that a child requires a developmental evaluation.
[00:38:51.530]And if you hear a parent describing that,
[00:38:54.479]an evaluation should absolutely occur.
[00:38:57.720]One of the reasons for that is that sometimes,
[00:39:00.450]very, very rarely, but sometimes,
[00:39:02.420]a regression and communication skills
[00:39:04.570]is not a part of autism,
[00:39:06.310]but could signal a seizure disorder,
[00:39:09.360]or an underlying neurological problem
[00:39:11.770]that ought to be looked at medically.
[00:39:13.790]But if the child does have autism,
[00:39:15.700]you can encourage the parents to recognize
[00:39:18.290]this happens in almost a third of children,
[00:39:20.780]and with consistency and ongoing intervention,
[00:39:24.080]they're quite likely to regain those skills,
[00:39:26.800]and keep moving forward.
[00:39:29.880]So the American Academy of Pediatrics,
[00:39:32.060]as well as the Learn the Signs campaign from the CDC,
[00:39:35.760]have indicated specific things to look for
[00:39:39.080]across a young child's development
[00:39:40.910]that would signal the need for a developmental evaluation.
[00:39:44.270]And many of you are probably familiar with these,
[00:39:46.250]but I wanted to make sure that you had them.
[00:39:48.410]So if a child is not babbling,
[00:39:50.300]engaging in vocal play by 12 months,
[00:39:52.480]we want to screen their overall development.
[00:39:54.920]If we don't see gesture use,
[00:39:56.680]such as holding up arms to be picked up, waving, pointing,
[00:40:01.500]by 12 months, we'd like to evaluate.
[00:40:03.840]If you don't see single words emerging spontaneously
[00:40:06.850]by 16 months, let's get in there,
[00:40:09.110]and see where the child is,
[00:40:11.750]see how the child's doing communicatively.
[00:40:13.960]Similarly, if a child does not have
[00:40:16.330]spontaneous, flexible two word phrases by two years,
[00:40:20.280]that's another good time to signal
[00:40:22.360]a developmental evaluation.
[00:40:24.220]And as we said,
[00:40:25.220]any loss of skills should trigger an evaluation.
[00:40:30.080]So in summary,
[00:40:31.380]what we know is that in the first three years of life,
[00:40:34.700]the most important thing is to look for the absence,
[00:40:37.970]or the lack of well integrated skills
[00:40:41.450]that are used consistently.
[00:40:43.930]Many times, what infants and toddlers are showing
[00:40:46.830]are subtle and qualitative signs of autism.
[00:40:49.930]So you may have a child who is doing the behaviors
[00:40:52.670]that you're looking for,
[00:40:53.650]but they don't seem as rich as well integrated,
[00:40:56.774]or is in embedded in the context in an appropriate way.
[00:41:02.450]It's important to keep in mind
[00:41:04.270]that a child's overall developmental functioning
[00:41:07.530]is really going to be important to consider
[00:41:10.730]when you're evaluating
[00:41:12.660]a child for an autism spectrum disorder.
[00:41:15.320]So if you are working with a child
[00:41:17.460]who is 33 months chronologically,
[00:41:21.670]but their overall developmental level from your assessment
[00:41:24.900]is that they're at about 18 months,
[00:41:27.430]then you would expect to see
[00:41:29.230]social and communication behaviors at the 18 month level.
[00:41:33.950]If that child is not initiating joint attention,
[00:41:37.320]isn't responding to joint attention,
[00:41:39.400]isn't attempting to communicate
[00:41:41.650]when given a communicative temptation,
[00:41:44.610]those are social and communication behaviors
[00:41:46.550]that you should see kick in before the age of 18 months.
[00:41:50.710]So in a child whose develop 18 months,
[00:41:54.090]if their social communication skills are more impaired,
[00:41:59.100]are less well developed
[00:42:00.890]than their overall developmental level,
[00:42:03.200]then, autism is still on the table.
[00:42:06.590]A child with a developmental delay
[00:42:09.820]is more likely to have social and communication skills
[00:42:13.660]that are on par, or relatively even
[00:42:16.960]with the rest of their skills.
[00:42:19.970]In autism, social and communication skills
[00:42:23.190]are selectively impaired, above and beyond,
[00:42:27.150]over developmental level.
[00:42:29.070]So you're gonna be looking for those relative weaknesses,
[00:42:33.210]even if the child has developmental delays,
[00:42:36.320]in order for them to have developmental delays plus autism.
[00:42:41.040]You would need to have evidence
[00:42:42.580]that their social and communication skills
[00:42:44.960]are lower than expected
[00:42:46.770]for their overall developmental level.
[00:42:49.250]And oftentimes, when we're looking at young kids,
[00:42:51.910]sometimes, they will do appropriate pro-social behaviors
[00:42:55.690]we're looking for.
[00:42:56.950]So in a sense, don't be fooled if you see a good example
[00:43:01.010]here or there of good social behavior.
[00:43:02.730]That's a great thing, we wanna see more of it.
[00:43:05.470]But young children who have autism may show
[00:43:09.030]some of those things, some of the time,
[00:43:11.160]but there are difficulties in consistency
[00:43:14.060]and quality are what we're really paying attention to.
[00:43:18.140]So you're looking for the presence of intact behavior
[00:43:21.760]with quality, consistently.
[00:43:23.870]And as you know, the more time you spend
[00:43:26.050]with typically developing children,
[00:43:27.840]there are pro-social behaviors happening constantly
[00:43:30.750]within a couple of minutes of interaction.
[00:43:33.950]So while we're excited it to see
[00:43:35.940]a really nice social behavior from a child,
[00:43:38.660]we're wondering if she has autism,
[00:43:41.000]we don't want to give too much credit,
[00:43:43.840]I guess you would say,
[00:43:44.800]and let a couple of good social behaviors
[00:43:47.570]obscure some of the underlying difficulties
[00:43:50.380]that might still be there.
[00:43:53.650]So now that we've talked through
[00:43:55.060]what you've can expect to look for in a child under three,
[00:43:58.600]I wanna very briefly go over some of the things
[00:44:01.880]we've learned about how young girls can present differently
[00:44:05.910]than boys.
[00:44:07.050]And this is a growing body of research in the field.
[00:44:09.810]And I think you'll find some other webinars
[00:44:12.360]that are posted within the Tri-State Webinar Series,
[00:44:15.550]as well as of professional development websites
[00:44:18.130]of your various states.
[00:44:19.610]That will go into the topic of what to look for in girls,
[00:44:24.100]when you're concerned about an autism spectrum disorder.
[00:44:27.060]For today, I just wanna give you a couple of things
[00:44:29.270]to think about
[00:44:30.820]First, we are still identifying boys
[00:44:33.360]about four times more often than girls,
[00:44:35.850]and this could be for appropriate scientific reasons.
[00:44:40.670]It could be that autism is more common in males,
[00:44:45.150]if neurologically, as scientists are wondering,
[00:44:48.520]females could have some sparing or some strengths
[00:44:52.910]in core social relatedness,
[00:44:54.630]within their neurological system,
[00:44:56.610]that help them to function in a better way at young ages.
[00:45:01.430]So we don't know just how much autism truly is different
[00:45:07.960]in biological males and females, or if as a culture,
[00:45:12.630]we've developed all of our measures around boys,
[00:45:16.050]and we haven't yet figured out how to identify the girls
[00:45:19.850]who are there, but they're presenting
[00:45:22.330]with a different profile, so we miss them at young ages.
[00:45:26.060]So it's still an open question.
[00:45:27.830]And tools are being developed and now normed separately
[00:45:31.290]for girls versus boys,
[00:45:32.800]as we try to get a handle on this in our field.
[00:45:36.090]Overall, in prevalence estimates from studies
[00:45:38.610]that the CDC has done in educational identification
[00:45:42.260]and community-based diagnoses around the country,
[00:45:45.180]we find that approximately 1 in 42 males
[00:45:48.070]is identified as at risk for autism,
[00:45:50.710]whereas 1 in 189 females are identified.
[00:45:54.540]And that's based on children being the age of eight,
[00:45:57.690]so it does seem as though we have a way to go
[00:46:00.820]to figure out how to identify girls earlier
[00:46:03.970]than we currently do.
[00:46:05.640]So whereas the average age of identification
[00:46:07.840]for males around the country is between three to four years,
[00:46:11.660]girls are usually developed closer
[00:46:13.870]to eight to 10 years of age,
[00:46:15.990]which tells us that we have to begin to
[00:46:18.630]be sensitive to how early emerging profiles
[00:46:22.710]could exist for females.
[00:46:25.410]It turns out as a field,
[00:46:27.320]we're pretty good at identifying females
[00:46:30.780]who have cognitive delays with autism.
[00:46:34.840]Where we really struggle is in identifying girls
[00:46:38.360]who have average or above intellectual capacity.
[00:46:42.230]Those tend to be missed during early childhood,
[00:46:45.390]and aren't identified until the third to fifth grade.
[00:46:48.630]And there's a lot of different reasons for this.
[00:46:51.170]It's possible that there's some core social relatedness
[00:46:54.600]and some strengths that young girls can bring to the table,
[00:46:57.670]that really help them to present well.
[00:47:00.520]But at around the ages of eight to 10,
[00:47:03.160]when the social world gets much more complex,
[00:47:05.660]and more is expected of them,
[00:47:07.730]that to in the moment, in a dynamic way,
[00:47:10.490]that's when some of their social impairments may emerge.
[00:47:15.360]So it's very important to consider,
[00:47:17.970]if you're evaluating a girl,
[00:47:19.620]that you could be looking at a slightly different set
[00:47:24.280]of behavioral markers.
[00:47:26.540]For example, female infants tended to look at faces
[00:47:32.670]longer than their male counterparts,
[00:47:35.410]and actually longer than girls who weren't at risk for ASD.
[00:47:40.320]So this has led to a thought that perhaps,
[00:47:43.210]females who are at risk for having autism,
[00:47:46.550]have a difficult time shift away from social information.
[00:47:51.450]So this would mean that they do pay attention
[00:47:55.010]to people's faces, their eyes and their expressions,
[00:47:57.670]so they will learn
[00:47:59.130]some more core social relatedness skills earlier,
[00:48:02.370]which is a good thing.
[00:48:03.780]However, it could also be associated
[00:48:06.300]with the advent of social anxiety later,
[00:48:09.190]because there's this hyper-vigilance,
[00:48:11.240]to pick up on the cues in front of you
[00:48:13.340]that can tend to be associated with anxiety
[00:48:16.810]in social situations,
[00:48:18.270]which we see commonly reported in school-aged girls,
[00:48:21.750]adolescents, and women, who we later find out have autism.
[00:48:27.310]During the toddler years, two year old girls
[00:48:29.820]are likely to show fewer repetitive behaviors,
[00:48:33.130]both with objects and with their bodies
[00:48:35.100]than their male counterparts.
[00:48:36.770]So you'll have less spinning of objects,
[00:48:39.000]less carrying around of objects,
[00:48:40.660]and less unusual body use.
[00:48:43.950]Relative to young boys, young girls are more likely to show
[00:48:47.630]significant difficulties in how they manage emotion.
[00:48:51.730]And in the school years, and even in adolescents and beyond,
[00:48:55.680]females with autism report emotional regulation
[00:49:00.120]as one of their greatest areas of need for intervention.
[00:49:03.700]And it's possible that we could begin to see markers
[00:49:07.120]of this sensitivity in the second and third years of life.
[00:49:11.060]So we often see females show less affect sharing,
[00:49:16.030]have a really difficult time regulating
[00:49:18.650]very intense emotions, either happiness
[00:49:20.810]or a more negative affect state like sadness,
[00:49:23.240]so harder to console.
[00:49:25.330]And there are some studies that suggest
[00:49:27.330]that it is harder for young girls
[00:49:30.170]to show an empathic response,
[00:49:32.730]like comfort somebody who's been hurt,
[00:49:34.830]than their male counterparts, when both have autism.
[00:49:39.760]We also know that there are differences in how girls present
[00:49:43.840]based on their cognitive functioning,
[00:49:46.630]when you're assessing them.
[00:49:48.330]So a two year old girl who would turn out
[00:49:51.920]to have an autism spectrum disorder,
[00:49:53.630]but doesn't have a cognitive delay,
[00:49:56.150]tends to show the following symptoms relative to a child,
[00:50:00.110]to a female child with a delay.
[00:50:02.150]So a girl without a cognitive delay
[00:50:05.320]probably shows more overreactions to sounds,
[00:50:08.320]motoric clumsiness, more problems with personal space,
[00:50:12.270]and that's the case compared to males
[00:50:14.920]without a cognitive delay,
[00:50:16.350]as well as females with a cognitive delay.
[00:50:19.560]Girls also tend to show fewer problems with imitation,
[00:50:22.360]preoccupation with parts,
[00:50:23.830]and being completely visually fascinated
[00:50:28.070]by things like fans or spinning objects.
[00:50:31.710]Two year old girls with ASD and cognitive delays
[00:50:35.300]compared to boys with cognitive delays,
[00:50:37.990]show more problems with appropriate gesture use.
[00:50:40.690]They have a more limited range of facial expression.
[00:50:43.100]They don't tend to explore their toys or environment
[00:50:45.990]as much as boys.
[00:50:47.470]They also reported as having fewer problems
[00:50:50.160]attempting to communicate,
[00:50:51.780]and will interact purely for social purposes,
[00:50:55.150]more than their male counterparts.
[00:50:57.290]So I hope I didn't misstate that.
[00:50:59.030]We're really looking at comparing
[00:51:00.880]two year old girls with boys,
[00:51:03.650]but considering their cognitive functioning.
[00:51:06.420]So what you see on this slide are some things
[00:51:08.620]to think about, if you're working with young females.
[00:51:14.390]So now in this final part,
[00:51:16.210]I'd like to just very briefly go over some of the ways
[00:51:20.500]that you can tell the difference
[00:51:22.590]between an autism spectrum disorder
[00:51:24.870]and two other developmental conditions.
[00:51:27.550]A global developmental delay,
[00:51:29.310]where skills are evenly behind,
[00:51:31.730]or a speech-language impairment.
[00:51:33.830]And this will be very brief,
[00:51:35.310]but we'll touch on it more when we get to part two,
[00:51:37.720]and discuss the different tools that will help us
[00:51:40.100]with this differentiation.
[00:51:43.090]So if your task is to try to tell the difference
[00:51:45.740]between an autism spectrum disorder
[00:51:47.470]or a developmental delay in a child under three,
[00:51:51.180]here are some of the things we think you ought to look for.
[00:51:54.940]If the child has ASD,
[00:51:56.940]you'll notice that social communication skills
[00:51:59.060]are gonna be less well developed
[00:52:00.990]than their overall developmental level.
[00:52:03.980]As opposed to if the child has a developmental delay,
[00:52:07.000]those social and communication and skills
[00:52:09.080]are more likely to be on the same level
[00:52:11.570]as the other skills that are delayed.
[00:52:14.400]So in ASD,
[00:52:15.880]development tends to be more uneven across domains,
[00:52:20.320]whereas in a global developmental delay situation,
[00:52:23.460]development is usually
[00:52:25.480]relatively evenly delayed across domains.
[00:52:30.090]In autism, problems in social orienting, imitation, play,
[00:52:35.640]and non-verbal communication skills,
[00:52:38.010]tend to be weaknesses within the profile.
[00:52:41.310]If the child has a developmental delay,
[00:52:43.590]those very same skills could be relative strengths,
[00:52:47.180]or would at least be as strong as other skills
[00:52:50.800]in their overall developmental functioning.
[00:52:54.600]And in ASD, the paying attention to affect and emotion
[00:52:58.570]is really important.
[00:53:00.000]So you may see a lack of consistent quality
[00:53:03.370]in sharing affect and in feeling connected to the child,
[00:53:06.790]when you're in face to face play, without objects.
[00:53:09.760]Whereas if the child has a global developmental delay,
[00:53:12.540]it's more likely that early social relatedness is present,
[00:53:16.360]and there's some good social quality
[00:53:18.650]at the developmental level that the child is functioning at.
[00:53:23.990]Now, when we look at trying to figure out
[00:53:25.770]the difference between ASD versus a speech-language delay,
[00:53:30.340]or impairment in a young child, it's a similar picture.
[00:53:34.440]In autism, the impairment is not so much
[00:53:38.750]about the production of verbal speech,
[00:53:41.270]although that often signals that we need to come in
[00:53:43.710]and do an evaluation.
[00:53:45.560]In autism, the impairment is in understanding
[00:53:50.060]the process of communication,
[00:53:52.040]understanding that there are two people
[00:53:55.540]that can do things with their bodies and their mouths,
[00:53:58.750]in order to regulate each other's behavior
[00:54:01.591]or connect with the other person.
[00:54:04.520]So in ASD, the problem has to do
[00:54:07.100]with learning about the process of communication.
[00:54:10.530]Whereas in a speech-language delay,
[00:54:12.790]the impairment could be in the cognitive aspects
[00:54:15.610]of sorting and categorizing and learning words,
[00:54:19.200]or it could be in the motoric aspects of producing speech.
[00:54:23.180]But usually,
[00:54:24.094]for a child who has a developmental delay in language,
[00:54:28.500]but doesn't have autism,
[00:54:30.310]the process of communication is clear.
[00:54:34.160]Many young children with autism
[00:54:35.930]will show a limited range of reasons why they communicate,
[00:54:39.950]we refer to these as functions.
[00:54:41.970]So they may just attempt to communicate,
[00:54:44.810]to request or to reject.
[00:54:46.780]Whereas a child with a speech-language impairment
[00:54:49.550]is more likely to use non-verbal communication.
[00:54:52.590]Gestures, eye gaze, vocalizations of all kinds,
[00:54:56.360]for many different purposes,
[00:54:58.460]to make connections with people, to request, to reject,
[00:55:01.790]to share effect, to share comments.
[00:55:05.210]In autism, there's often a limited form of communication.
[00:55:08.960]So there might be a very small repertoire of behaviors
[00:55:11.880]that are used to send a message, maybe just a few gestures,
[00:55:15.610]or just one way of communicating.
[00:55:18.410]Whereas, in a developmental delay of language development,
[00:55:21.960]we often see that the child has multiple ways
[00:55:24.740]of delivering messages.
[00:55:26.190]They show a clear intention
[00:55:27.690]that they're trying to communicate.
[00:55:29.330]And if their non-verbal strategy doesn't work,
[00:55:32.470]they have others in their toolbox
[00:55:33.950]that they'll pull out and try.
[00:55:35.400]So you see more persistence in trying new strategies,
[00:55:38.630]and you see this integration
[00:55:40.430]of verbal and non-verbal aspects of communication
[00:55:43.640]that happens more seamlessly.
[00:55:45.850]Whereas in autism,
[00:55:47.150]there are off been limited attempts to repair
[00:55:49.700]when their message has not been received.
[00:55:51.810]They tend to not have a flexible way
[00:55:54.230]of continuing to express their intention.
[00:55:58.600]So in conclusion,
[00:56:00.540]I'm hoping that we can look at early identification
[00:56:03.610]as really focusing on identifying children
[00:56:06.250]who are at risk for an autism spec term disorder,
[00:56:09.080]as this is very important for child and family outcomes.
[00:56:13.290]We also know that early childhood professionals
[00:56:16.570]deserves support training and ongoing consultation,
[00:56:19.550]as they gain proficiency in identifying these signs,
[00:56:23.280]it's also important to help professionals
[00:56:26.840]learn how to communicate
[00:56:28.620]what can be difficult news for families.
[00:56:30.810]So all of those support and training things
[00:56:33.610]need to be there, in order for us to ask professionals
[00:56:37.620]to do this difficult work.
[00:56:39.540]And I'd like to say that we wanna remember
[00:56:41.970]that the expert isn't to diagnose,
[00:56:45.180]but to signal to the parent that you have some concerns
[00:56:48.150]in particular areas,
[00:56:50.090]which lead you to think that the child
[00:56:52.070]may be at risk for this condition.
[00:56:54.350]And thus, your role is to provide parents
[00:56:56.940]with objective, evidence based, thoughtful,
[00:57:00.670]developmentally sensitive information
[00:57:03.550]about the child's developmental profile,
[00:57:05.910]where the strengths are and where the needs are.
[00:57:08.070]And if their profile looks like it could be leading
[00:57:12.500]to an autism spectrum disorder manifestation,
[00:57:15.820]I would suggest that it's really important to narrate that.
[00:57:19.560]Not in a definitive way, we're absolutely sure,
[00:57:22.930]but in a, I'm concerned that this pattern is consistent
[00:57:28.070]with what we're learning about how autism
[00:57:30.240]can present in young children,
[00:57:31.720]and I think we ought to assess it further.
[00:57:34.620]And then lastly, I can't say enough how important it is
[00:57:38.900]to have a lot of knowledge and experience
[00:57:41.840]in typical development,
[00:57:43.190]if you are to trying to identify young children,
[00:57:46.190]who may have an autism spectrum disorder.
[00:57:48.180]And that's because the more experience you have,
[00:57:51.060]seeing how rich, how frequent, how consistent,
[00:57:54.340]early social and emotional behaviors are
[00:57:57.130]in typically developing infants and toddlers,
[00:57:59.600]the better prepared you'll feel to identify
[00:58:03.240]or look for autism in those children.
[00:58:07.370]As I mentioned, next time,
[00:58:08.670]we will talk about the tools that are at our disposal.
[00:58:11.730]To try to understand a child's developmental profile.
[00:58:14.890]And we will, in the future,
[00:58:16.300]also talk about some different ways
[00:58:18.750]to share your observations with parents
[00:58:21.710]that is empathic, realistic, and encourages collaboration,
[00:58:26.130]and a sense of hope.
[00:58:28.110]As hard as it is, and it is very, very difficult.
[00:58:31.070]I don't mean in any way to be callous
[00:58:34.580]or insensitive about it.
[00:58:36.210]We know, it can be really, really hard for a parent
[00:58:39.630]to hear that their son or daughter
[00:58:41.640]is not developing as expected,
[00:58:44.010]especially in these important areas
[00:58:46.130]of social communication functioning.
[00:58:48.380]I can't imagine anything harder
[00:58:51.070]than maybe learning about a physical health condition
[00:58:54.330]that really puts a child at risk.
[00:58:56.820]So we know those feelings are there,
[00:59:00.060]and there's going to be a grief process for a parent.
[00:59:04.960]But that grief process starts when the parent notices
[00:59:09.010]that skills are not developing on time.
[00:59:11.620]The grief process doesn't start when a professional
[00:59:14.470]puts words to those problems.
[00:59:16.360]It starts when the parent is aware of the problems.
[00:59:19.860]So while we can't prevent or subvert
[00:59:22.990]the emotional difficulties a parent may experience
[00:59:26.630]when we deliver this hard news,
[00:59:28.900]if we avoid having those conversations,
[00:59:32.400]we may unintentionally,
[00:59:35.070]actually make things harder for those parents
[00:59:38.340]in their own cognitive coping, and harder for the children,
[00:59:42.110]because they won't have had the access
[00:59:44.300]to an explanatory model that helps us make sense
[00:59:47.330]of their behaviors.
[00:59:48.340]And parents and teachers might discipline things,
[00:59:50.900]instead of teach them actively, for example.
[00:59:53.850]But most importantly,
[00:59:54.920]we know that if we don't have this conversation,
[00:59:58.610]and parents don't hear it
[01:00:00.120]from early childhood professionals,
[01:00:02.230]they may not ask their pediatrician about it.
[01:00:05.150]They may not bring it up
[01:00:06.430]when their child goes into kindergarten,
[01:00:08.210]and we could have lost an important time
[01:00:11.610]for early intervention in social and communication skills.
[01:00:16.780]So if this is a topic that you'd like to learn more about,
[01:00:19.860]or if you feel pretty competent in it,
[01:00:21.980]but you wanna have resources to share with others,
[01:00:24.720]I wanna offer some of these web-based research resources.
[01:00:28.810]So first of all,
[01:00:29.643]the Autism Navigator is a free service
[01:00:32.500]that parents or professionals can log in for free
[01:00:35.440]and have total access to it.
[01:00:37.090]And it has a product that's referred to as a video glossary.
[01:00:41.080]It's basically as set of short videos
[01:00:43.780]that illustrate what autism looks like in young children,
[01:00:47.870]and co compares and contrasts presentations
[01:00:50.500]of young children with autism,
[01:00:52.000]and those who are developing typically.
[01:00:55.000]I have pulled up the Autism Navigator
[01:00:57.290]to show these video clips to parents
[01:00:59.490]when I'm trying to describe what autism is,
[01:01:02.580]and how it can present itself.
[01:01:04.510]So they can be very useful tools for parents
[01:01:07.430]to explore on their own, or for you to use,
[01:01:10.270]when you're trying to describe the behaviors
[01:01:12.160]that you are concerned about.
[01:01:15.610]Similarly, there's a wealth of information available to you
[01:01:20.520]on the CDCs, Learn the Signs/Act Early website.
[01:01:24.800]A lot of toolkits, a lot of videos,
[01:01:27.010]a lot of things for parents, a lot of one pager fact sheets
[01:01:30.630]on things like why vaccinations don't cause autism,
[01:01:34.070]and other sorts of myths about the condition.
[01:01:37.240]I also very much like this video
[01:01:39.770]from the Kennedy Krieger Institute,
[01:01:41.960]done by Dr. Rebecca Landa,
[01:01:44.130]who's a Speech-Language Pathologist.
[01:01:46.120]It does a nice job of in eight to 12 minutes,
[01:01:49.050]showing different samples
[01:01:51.150]of what autism can look like in young children.
[01:01:54.000]And then lastly,
[01:01:55.010]I encourage you to take a look
[01:01:57.090]at the Department of Education websites in your state.
[01:02:01.880]So in Colorado, Kansas, and Nebraska,
[01:02:03.910]I've put some of those links up there.
[01:02:05.890]All members of the Tri-State Autism Network,
[01:02:08.730]and I think you'll find a lot of webinars and products
[01:02:12.620]that could be very useful as you learn more in this area.
[01:02:16.740]So I have attached all of the references
[01:02:19.370]that I used in this particular presentation.
[01:02:22.430]There's quite a few of them, but they're there.
[01:02:25.270]If you are interested in seeing
[01:02:26.880]where we found the information that we're providing.
[01:02:30.960]Research in this area continues to grow and develop.
[01:02:34.290]It's a very active and dynamic field.
[01:02:36.970]And we're learning more and more
[01:02:38.690]about what we can do to support parents,
[01:02:41.400]who have young children,
[01:02:42.740]who are developing differently in the area
[01:02:45.120]of social and communicative functioning.
[01:02:47.400]It definitely takes a village.
[01:02:49.090]So I hope that you'll continue
[01:02:50.690]to seek consultation and input,
[01:02:53.250]and encourage you
[01:02:55.460]to keep building those strong relationships
[01:02:57.570]with children and families.
[01:02:59.000]'Cause no matter what your skill area,
[01:03:01.210]in autism specifically, being a trusted provider,
[01:03:05.910]who can support a family as they're adjusting to this news,
[01:03:10.090]is also a really critical role.
[01:03:12.930]So thank you for your time and attention.
[01:03:15.730]And feel free to email if you have any questions.

The screen size you are trying to search captions on is too small!

You can always jump over to MediaHub and check it out there.

Comments

0 Comments

Early Identification of Autism – Part 1

Description

Searchable Transcript

Comments icon comment

Related Channels

Comments