Early Identification of Autism – Part 1

Susan Hepburn, Ph.D. Author

04/20/2022 Added

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Tri State Webinar 2022

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[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.

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Early Identification of Autism – Part 1

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