Early Identification of Autism Spectrum Disorder: Part II

Susan Hepburn, Ph.D. Author

04/20/2022 Added

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Tri State Webinar 2022

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[00:00:11.960]Hello everyone.
[00:00:13.470]My name is Susan Hepburn
[00:00:15.150]and I'm a professor in the Department of Human Development
[00:00:17.720]and Family Studies at Colorado State University.
[00:00:20.460]And I'm also trained as a licensed clinical psychologist,
[00:00:23.700]and I've been working in the area
[00:00:25.230]of educational identification of autism
[00:00:27.870]for approximately 20 years.
[00:00:30.290]So I'm really pleased to be here today
[00:00:32.030]to present the second part of our webinar
[00:00:34.660]on the early identification of autism spectrum disorder.
[00:00:39.660]I'd also like to thank Brooke Carson, Rhonda Daniels,
[00:00:43.670]and the Educational Identification Autism Team
[00:00:47.120]at the Colorado Department of Education
[00:00:49.810]for access to some of the materials
[00:00:51.620]from their educational identification trainings.
[00:00:54.560]I'm also grateful to my mentors,
[00:00:56.550]Wendy Stone and Sally Rogers,
[00:00:58.710]who gave me a lot of learning opportunities
[00:01:00.960]and taught me a great deal about early identification
[00:01:03.730]and intervention.
[00:01:04.880]Many of their ideas are reflected in this presentation.
[00:01:08.000]And I'm also grateful to all the children and families
[00:01:11.150]that I've had the opportunity to work with over the years,
[00:01:13.820]as they've taught me a lot about
[00:01:15.910]what autism looks like in young children,
[00:01:18.440]as well as the experience of growing up with a young child
[00:01:21.520]who has some features of an autism spectrum disorder.
[00:01:24.670]And I also really appreciate as a psychologist,
[00:01:27.970]the ongoing collaborations I've had
[00:01:30.350]with many speech language therapists
[00:01:32.460]and occupational therapists, as well as special educators
[00:01:35.640]who've taught me a lot about this field.
[00:01:39.580]It is my hope that by the end of this presentation,
[00:01:42.800]people who are participating
[00:01:44.260]would be able to describe five key elements of an evaluation
[00:01:47.970]for autism spectrum disorder in young children,
[00:01:50.770]to be able to think about at least
[00:01:52.520]three evidence-based tools
[00:01:54.110]and describe some strengths
[00:01:55.400]and relative weaknesses of those,
[00:01:57.640]to recognize a few things about how family culture
[00:02:00.080]and language can impact the evaluation process,
[00:02:02.960]and I would add, to have a few resources on hand
[00:02:06.400]to be able to explore those topics.
[00:02:08.660]And finally, to think about things
[00:02:10.980]that will help when you're differentiating between
[00:02:13.450]an autism spectrum disorder, a lack of social experience
[00:02:17.030]and possibly trauma in a young child.
[00:02:21.960]So, as I mentioned, this is part two of a two-part webinar.
[00:02:25.250]And previously in part one,
[00:02:27.500]we covered some of the things to look for
[00:02:30.290]in an autism evaluation when looking at young children.
[00:02:33.560]So early emerging social behaviors, communication behaviors,
[00:02:37.500]the range and flexibility of interests and play skills,
[00:02:40.960]how a child uses his or her body
[00:02:43.230]and their overall responses to the environment.
[00:02:46.540]Now, today, we're gonna look at what you'd actually do
[00:02:49.960]in your evaluation when trying to decide if a young child
[00:02:54.240]is presenting with an autism spectrum disorder.
[00:02:57.450]So I've organized this talk into five parts,
[00:03:00.400]which I think of as critical elements
[00:03:02.850]for any evaluation for a young child.
[00:03:05.560]And those elements are described here.
[00:03:08.070]We're gonna talk about
[00:03:09.470]the importance of interviewing the parent
[00:03:11.410]to learn about the child's developmental history,
[00:03:13.900]as well as the family's current concerns,
[00:03:16.690]the importance of integrating reports from multiple people
[00:03:19.890]who know the child well.
[00:03:21.540]Could be parents, family members, childcare providers,
[00:03:24.350]preschool teachers, early interventionists.
[00:03:26.590]And we're gonna talk about well-validated ASD checklists
[00:03:30.170]or screening tools that can be given to those individuals.
[00:03:33.820]Third, it's really important to observe the child,
[00:03:36.630]in a variety, if possible,
[00:03:38.450]of unstructured social interactions.
[00:03:40.970]So kind of a free play situation
[00:03:43.280]where there aren't any formal interventions or structures.
[00:03:46.540]This will allow us to really see
[00:03:48.350]what the child naturally does in various social contexts.
[00:03:53.350]Fourth, we need to have direct observation of the child
[00:03:56.150]in daily routines, things such as mealtime, dressing,
[00:03:59.690]toothbrushing, or reading together.
[00:04:01.970]Things that parents and children do on a daily basis.
[00:04:05.150]And then lastly,
[00:04:06.140]it's very helpful to have some direct intervention,
[00:04:09.980]or direct interaction, I should say, between the assessor,
[00:04:13.320]who's a professional in child development,
[00:04:15.800]through playful activities
[00:04:17.300]that will allow you to see
[00:04:18.690]some somewhat subtle communication
[00:04:21.210]and social behaviors
[00:04:22.310]that you may not get a chance to experience directly
[00:04:25.360]when you're just observing.
[00:04:26.790]And today we'll talk about some of the formal measures
[00:04:29.200]that help you do that,
[00:04:30.380]as well as giving you ideas
[00:04:31.980]about how you could construct your own interaction.
[00:04:37.100]So let's begin with the parent interview,
[00:04:39.430]which should really focus on
[00:04:40.840]the child's developmental history.
[00:04:42.670]What might have been going on medically.
[00:04:44.750]Any significant events in the past,
[00:04:47.090]as well as beginning to identify
[00:04:49.240]the parent's current concerns.
[00:04:51.530]Now there are several public domain tools
[00:04:53.800]that you can access
[00:04:55.140]to guide a developmental assessment interview.
[00:04:58.350]Some people prefer to send a written form
[00:05:02.040]and ask the parent to fill it out.
[00:05:03.840]I find it can be a really good way
[00:05:06.330]to structure the initial conversation,
[00:05:09.130]either through telephone, video conference or a home visit.
[00:05:13.580]There are also several autism assessment tools
[00:05:16.640]that will give you either ideas
[00:05:18.640]for creating your own developmental history section
[00:05:21.490]or provide you with important questions.
[00:05:23.950]I'm gonna walk you through some of the highlighted elements
[00:05:26.520]I'd like to see on a developmental history
[00:05:28.640]when I'm considering if autism
[00:05:30.290]is relevant for a young child,
[00:05:32.030]and I'm referring by a tool that is available
[00:05:34.880]through the Autism Team at Colorado Department of Education.
[00:05:40.500]Within this developmental history form,
[00:05:43.480]you see some examples of what can be important information
[00:05:47.840]to know about early emerging development.
[00:05:51.270]So one of the first sections I look for
[00:05:53.570]is understanding the milestones.
[00:05:56.130]What happened in the area of motor skills?
[00:05:58.900]What happened in language development for this child
[00:06:01.860]at a young age?
[00:06:03.330]We also know that if a child has had an uneven history
[00:06:07.960]of language development,
[00:06:09.840]for example, used words spontaneously for a time
[00:06:13.330]and then stopped using those words
[00:06:15.440]and kind of plateaued
[00:06:16.790]or held steady in their language development
[00:06:19.230]without adding new skills,
[00:06:21.150]understanding that aspect
[00:06:23.530]of an early developmental trajectory
[00:06:25.580]can be very informative,
[00:06:27.060]'cause it's quite unusual for a child to go through
[00:06:29.730]even a brief loss of language skills,
[00:06:32.130]unless that child has a condition
[00:06:34.400]such as an autism spectrum disorder.
[00:06:36.930]So getting information
[00:06:39.370]about the child's developmental milestones
[00:06:42.020]is a really important start.
[00:06:45.300]I also think it's helpful
[00:06:46.730]if you have a sense of the child's health history.
[00:06:49.580]Understanding if a variety of conditions
[00:06:52.650]have been a part of that child's experience,
[00:06:54.900]and this is just an excerpt here of a much longer list.
[00:06:59.930]It's also important
[00:07:01.250]to get a sense of any current medical conditions,
[00:07:04.210]medications, or treatments that the child may be needing.
[00:07:09.170]And in this particular developmental questionnaire,
[00:07:11.770]the team also brought in a couple of items
[00:07:14.390]from a general developmental screener that gives us a sense
[00:07:18.100]of the child's current social and play behaviors.
[00:07:21.420]Just trying to kind of build up a mental image
[00:07:23.930]of how the child interacts and behaves.
[00:07:27.900]It's good if this developmental interview
[00:07:30.340]also includes the child's preferences,
[00:07:33.110]games and activities he or she really seeks out,
[00:07:36.060]and a more strength based approach
[00:07:37.930]can be quite helpful in building rapport.
[00:07:40.200]And it's a good opportunity to open up the conversation
[00:07:44.110]regarding significant concerns about behavior
[00:07:47.750]or any traumatic events that may or may not have happened
[00:07:50.550]to the child in the past.
[00:07:54.360]It's also important
[00:07:55.440]to get a sense of any existing evaluations
[00:07:58.630]and it's a good chance to ask the family
[00:08:00.690]if you could see those records,
[00:08:02.360]as you're trying to develop
[00:08:03.610]a deeper understanding of the child.
[00:08:06.320]It's also good to understand
[00:08:08.720]if there are current interventions underway.
[00:08:11.970]For example, if the child is already enrolled
[00:08:13.990]in speech language therapy,
[00:08:15.420]to know when that started
[00:08:16.770]and how intensive those services can be.
[00:08:19.630]So once you have this sort of general structure,
[00:08:22.600]you may find that if you're doing an interview,
[00:08:24.970]the parent can give you a lot of examples
[00:08:27.210]and go into more detail
[00:08:28.730]and really help you to understand
[00:08:30.680]what a typical day is like for the family.
[00:08:33.050]What parts of the day might be problematic.
[00:08:36.100]In any case, opening up with this parent input piece
[00:08:40.700]is a really important part
[00:08:42.290]of the early identification process.
[00:08:46.660]Then we move on to the second element,
[00:08:48.930]which is where you want to gather reports,
[00:08:52.030]specific reports about specific kinds of behaviors
[00:08:55.690]from multiple people who know the child well.
[00:08:59.480]It's really important to choose
[00:09:00.820]an evidence based screening tool
[00:09:02.640]for autism spectrum disorders,
[00:09:04.550]which has been normed, or validated,
[00:09:06.970]and had scoring developed for children who may be
[00:09:11.350]between the ages of 18 months and beyond.
[00:09:13.210]But basically, you need to make sure
[00:09:14.890]it's developmentally sensitive for use in young children.
[00:09:19.010]So definitely look for the ages
[00:09:21.810]that the tool has been validated for.
[00:09:24.580]There are some tools
[00:09:26.030]that have versions for both parents and interventionists.
[00:09:29.680]Others do not,
[00:09:30.810]and it's important to choose the right tool
[00:09:33.580]for the right person who's giving the information.
[00:09:36.940]It's also helpful if the tool you choose
[00:09:39.400]provides a scoring method that can assess risk.
[00:09:43.330]So as we're gathering this information from parents,
[00:09:46.630]teachers, childcare providers,
[00:09:48.700]we are looking at it as informing a bigger picture.
[00:09:51.460]It's kind of like building a mosaic
[00:09:53.290]and this is giving us a sense
[00:09:54.820]of how the child is perceived in different settings.
[00:09:58.810]At this stage,
[00:09:59.950]you would never let the results of one tool
[00:10:02.990]tell you if it looks like autism or not.
[00:10:05.720]You're gathering multiple reports
[00:10:08.620]in order to paint a picture.
[00:10:10.560]So we are using these tools
[00:10:12.190]to think about assessing risk for autism,
[00:10:15.200]helping us understand what behaviors of concern
[00:10:18.980]are presented across settings.
[00:10:21.920]Now there are many different tools
[00:10:23.250]that you could choose from.
[00:10:24.480]And some of you may work for agencies or school districts
[00:10:27.970]that have a set of tools that they prefer to use.
[00:10:31.380]That's great.
[00:10:32.300]We're gonna highlight a couple of tools
[00:10:34.380]and try to talk about some of the characteristic to look for
[00:10:38.100]when you're seeking out an appropriate tool.
[00:10:40.380]Also like to refer you to the resource section
[00:10:42.840]of this presentation.
[00:10:44.110]For every tool we'll talk about,
[00:10:45.780]we will let you know who the publisher is
[00:10:47.540]or how you could get your hands on it.
[00:10:50.610]Some of the tools that I'll describe to you are free,
[00:10:53.460]but most would require an initial expense
[00:10:56.680]to buy the test kit.
[00:10:58.040]And as we'll discuss,
[00:10:59.730]most of them have a training criteria
[00:11:02.490]for the person who is administering the tool
[00:11:05.490]and interpreting it.
[00:11:06.900]So I will try to identify those things
[00:11:08.980]as we move through these tools.
[00:11:11.310]So the first is the Childhood Autism Rating Scale,
[00:11:14.260]the 2nd Edition.
[00:11:15.810]This is a set of behavior checklists
[00:11:18.810]that can be used by multiple raters
[00:11:21.720]to give their impressions of the child
[00:11:23.400]in multiple situations.
[00:11:25.160]It does begin at approximately age two.
[00:11:28.290]So it could be used in the second year of life
[00:11:31.580]within the Child Find system, for birth to three, I mean,
[00:11:35.330]but most likely it will be used in a preschool situation.
[00:11:39.170]There are two versions of the tool.
[00:11:41.050]One for when the child has a significant delay
[00:11:43.840]in language development,
[00:11:45.400]which they refer to as the standard version
[00:11:47.850]and the other, where the child is described as
[00:11:51.080]meeting language milestones on time
[00:11:53.290]and solving problems well within the average range.
[00:11:56.980]The CARS is useful, as I mentioned,
[00:11:59.400]for bringing together multiple viewpoints.
[00:12:01.650]It allows you to observe in natural settings
[00:12:03.960]as well as interview.
[00:12:05.240]And it comes up with a score
[00:12:06.970]that's assigned to a severity rating.
[00:12:09.310]Can also be used as you begin intervention
[00:12:12.350]and you want to see if a child's symptoms of autism
[00:12:16.610]may be changing over time.
[00:12:20.080]The Autism Spectrum Rating Scales
[00:12:22.650]is also a tool that is commonly used
[00:12:24.960]in two to five year old children
[00:12:26.630]with autism spectrum disorders.
[00:12:29.080]It has subscales that reflect the aspects of autism
[00:12:33.540]that impact a preschool or a school environment.
[00:12:37.860]Some of the items are sensitive for the home environment,
[00:12:41.610]but one of the advantages
[00:12:43.270]has been for use in educational contexts.
[00:12:46.690]One of the disadvantages
[00:12:48.260]is not being as heavily influenced by parent perceptions
[00:12:52.660]in less structured settings,
[00:12:54.430]but it does have a parent caregiver version,
[00:12:58.240]which is well validated.
[00:13:00.680]Both the Autism Rating Scales
[00:13:02.600]and the CARS would need to be implemented
[00:13:05.700]by either a school psychologist,
[00:13:08.272]a speech language pathologist, an occupational therapist,
[00:13:12.570]or someone who has been trained
[00:13:14.590]in how to interpret behavior checklists
[00:13:17.590]with standardized norms.
[00:13:20.980]Similarly, the Social Responsiveness Scale 2nd Edition
[00:13:24.980]is a really good set of tools where you have teacher
[00:13:28.700]and caregiver or parent versions.
[00:13:31.627]But the age to start this would be a little bit later
[00:13:34.860]from approximately 2 and 1/2 years
[00:13:36.850]throughout the lifespan.
[00:13:39.020]So the SRS-2 is often a choice of tools
[00:13:42.530]when you're working with elementary school age children
[00:13:45.620]with autism spectrum disorder,
[00:13:47.370]or even those in the secondary school years.
[00:13:50.380]It can be helpful
[00:13:51.213]because it has different norms
[00:13:53.110]for the biological sex of the child.
[00:13:55.340]And the developers are working towards more diverse norms
[00:13:58.870]to be able to compare their tools to.
[00:14:03.640]So the advantages of this tool
[00:14:06.400]seem to come through when children are a bit older,
[00:14:09.660]but continued validation efforts of the preschool version
[00:14:12.530]are demonstrating that it does have potential,
[00:14:14.910]particularly after the age of three
[00:14:17.190]and before the age of six.
[00:14:20.600]You may have also heard of a tool called the M-CHAT,
[00:14:23.600]which is commonly used, we hope, in pediatric practices.
[00:14:27.670]In fact, it's recommended
[00:14:29.030]by the American Academy of Pediatrics
[00:14:31.410]for the M-CHAT to be implemented at 18 months and 24 months,
[00:14:35.970]those well-child visits.
[00:14:37.900]It's also being used more and more by Child Find teams
[00:14:41.520]and individuals working throughout
[00:14:43.080]the early intervention system.
[00:14:45.670]There's a new version which has been demonstrated
[00:14:48.830]to have some improved specificity.
[00:14:51.740]In other words,
[00:14:52.573]its ability to tell the difference
[00:14:54.130]between children at risk for autism
[00:14:56.300]versus having any developmental problem.
[00:14:59.210]So this new version is called
[00:15:00.580]the M-CHAT Revised with Follow-Up
[00:15:02.750]and it's available for free, I believe,
[00:15:05.520]through a public domain website,
[00:15:06.950]which we've attached in the resource section.
[00:15:09.570]It includes 20 items.
[00:15:11.260]The caregiver can complete it independently,
[00:15:14.390]or it can be done by an early interventionist
[00:15:17.730]with some interviewing.
[00:15:19.340]While it was developed for use in pediatric visits,
[00:15:22.650]it's also been studied internationally
[00:15:25.170]and it's available in multiple languages.
[00:15:27.610]So when you go to the website,
[00:15:29.470]take a look at the various translations.
[00:15:31.440]If you're working with families from
[00:15:33.230]other parts of the world, this may be your best tool.
[00:15:37.340]It's very strong in identifying any developmental condition
[00:15:41.500]in young children as compared to
[00:15:44.100]a child who doesn't have any developmental concerns.
[00:15:46.850]And as I mentioned, this new version is getting better
[00:15:50.390]at being more ASD-specific.
[00:15:52.600]And this is primarily because
[00:15:54.260]it provides a scoring algorithm
[00:15:56.530]that has three different risk ranges,
[00:15:58.940]and then what you're supposed to do as the assessor
[00:16:02.190]differs based on the risk level of the child.
[00:16:06.270]So if the child is identified as being low risk,
[00:16:10.120]in other words, the parent endorsed three or fewer items,
[00:16:13.750]there's no follow up needed,
[00:16:15.570]and you can basically rule out autism
[00:16:18.640]according to this screener for this child.
[00:16:21.950]If the parent endorses between three and seven items,
[00:16:25.660]you're now in the medium risk territory
[00:16:28.260]and this requires a brief follow up interview
[00:16:31.570]where the developmental specialist contacts the parent
[00:16:34.820]and goes through each of the items that were endorsed,
[00:16:37.770]asking for information.
[00:16:39.690]If at the end of that brief interview,
[00:16:41.550]about 10 minutes actually,
[00:16:43.230]two or more items continue to be endorsed,
[00:16:45.950]then the child is referred for a full autism evaluation.
[00:16:51.030]In the high risk group,
[00:16:52.780]if a child receives endorsements on eight items or more,
[00:16:57.150]then the flow was to refer that child for full evaluation.
[00:17:02.730]In other words, quite likely that autism is there
[00:17:05.290]and we need to understand better
[00:17:08.730]how this child is presenting, excuse me.
[00:17:12.560]So the M-CHAT could be considered a level one screener,
[00:17:16.070]meaning that it helps you pick out the kids
[00:17:18.700]who may be at risk for a developmental problem,
[00:17:21.530]possibly of the autism variety,
[00:17:23.380]as compared to those who are developing typically.
[00:17:26.430]With a level one screener,
[00:17:27.880]you often need to do an additional tool
[00:17:30.440]to make sure that you're understanding of autism
[00:17:32.590]is actually the driver of the developmental problems
[00:17:35.590]that you're observing.
[00:17:37.120]So another tool that kind of straddles this line
[00:17:41.210]between a level one screener,
[00:17:43.650]finding autism within the general population,
[00:17:45.890]and a level two screener,
[00:17:47.690]getting more specific about autism
[00:17:50.010]from a developmental language delay, for example.
[00:17:52.840]Another example of a tool like that
[00:17:54.770]is the Infant Toddler Checklist, which is part of
[00:17:57.770]the Communication and Symbolic Behavior Scales Program,
[00:18:01.420]which was developed at Florida State by Amy Weatherby
[00:18:04.280]and Barry Prizant over the past 25 years or so.
[00:18:08.320]Recent reviews of screening tools
[00:18:10.370]in autism spectrum disorders suggest
[00:18:12.730]that the CSBS and specifically,
[00:18:14.780]the Infant Toddler Checklist,
[00:18:16.760]is a really promising tool
[00:18:18.650]for nine to 20 month old infants and toddlers.
[00:18:22.220]It's not recommended for use below the age of nine months,
[00:18:25.830]and you would need to use a different version of the tool
[00:18:28.670]if you're looking at a child who is older than 24 months.
[00:18:32.850]So on a positive note,
[00:18:34.710]the CSBS gives you a combination of parent report
[00:18:38.040]and observation tools
[00:18:39.830]that are really developmentally sensitive.
[00:18:42.930]Some of the data on the Infant Toddler Checklist
[00:18:46.730]suggests that it has strong sensitivity.
[00:18:49.670]In other words, if autism spectrum disorder is out there,
[00:18:53.270]it's likely to find it.
[00:18:55.070]And it's actually doing pretty well in specificity
[00:18:58.630]in a recent study of their revision,
[00:19:00.760]but like other screening tools,
[00:19:02.870]scores that go above the risk cut off
[00:19:05.340]on the Infant Toddler Checklist
[00:19:07.790]mean that the child has
[00:19:09.310]a developmental disability of some kind.
[00:19:12.420]Further inquiry is often needed
[00:19:14.830]to determine if it is because of autism
[00:19:17.830]or another developmental condition.
[00:19:21.850]Now, if you're using multiple screening tools
[00:19:24.360]and gathering information from multiple people,
[00:19:27.330]it's going to be important to have a way
[00:19:29.350]to track what it is that you're learning.
[00:19:32.100]So this is an example of a tool
[00:19:34.090]that I've used on school consult services
[00:19:36.550]where we just keep a running list of the tools
[00:19:39.290]and pull out the possible behaviors that are reported
[00:19:42.750]that could be consistent with ASD
[00:19:45.290]as well as a list of behaviors that do not signal ASD,
[00:19:50.330]but are probably associated with something else.
[00:19:53.350]And then a quick way to just keep your own records,
[00:19:56.760]noting whether or not the child obtained a score
[00:19:59.620]above the risk cutoff.
[00:20:02.250]I believe that what I'm about to say
[00:20:03.950]is true for all developmental evaluations,
[00:20:06.750]but definitely when you're evaluating a young child,
[00:20:09.510]it is never about the scores in my experience.
[00:20:12.410]It's not about the numbers.
[00:20:13.790]It's about the qualitative information that you're gaining,
[00:20:17.590]the things that parents are reporting,
[00:20:19.640]the things you're observing
[00:20:21.040]and the exact sort of behavioral examples
[00:20:23.990]you have to work with.
[00:20:26.890]So in addition to collecting multiple informant reports
[00:20:31.550]about the child's behavior in different contexts,
[00:20:34.500]it's also really helpful to observe the child
[00:20:38.360]in unstructured social interactions.
[00:20:41.370]And I realize this is gonna differ
[00:20:43.820]depending on where it is that you practice.
[00:20:46.760]If you have the opportunity
[00:20:48.560]to watch the child in unstructured free play with a sibling
[00:20:52.780]or a cousin or a neighbor child,
[00:20:55.050]that can be very informative.
[00:20:57.410]It can happen outside or inside, with or without objects.
[00:21:00.710]You just want the parents or the adults
[00:21:03.020]to do as little facilitation as possible
[00:21:05.520]so that you can observe the child's
[00:21:07.450]natural social engagements.
[00:21:10.460]It's also important to make sure
[00:21:12.440]that you're at least observing for 15 to 20 minutes,
[00:21:16.110]because you need to see how much time it will take
[00:21:18.500]before initiations and responses can occur.
[00:21:21.400]This will allow you to, even at the very beginning,
[00:21:24.290]be able to differentiate from temperament and ASD.
[00:21:29.390]Sometimes you can just do these observations
[00:21:31.520]in an unstructured way,
[00:21:32.720]keeping a running list of what it is you see,
[00:21:35.360]or you could use a tool to guide those observations.
[00:21:38.410]And I've listed some of the measures
[00:21:40.650]that would give you some ideas for what to look for
[00:21:44.510]as you're watching a social interaction.
[00:21:47.470]Let's take a look, for example,
[00:21:50.190]at the Functions and Forms Checklists
[00:21:52.300]from the Colorado Department of Education trainings.
[00:21:55.610]This is something that our speech language colleagues
[00:21:58.490]would be very familiar with.
[00:22:00.150]It's basically a list of reasons why a child communicates.
[00:22:04.460]Those are referred to as communicative functions.
[00:22:07.240]Things like requesting an object, requesting help,
[00:22:10.950]requesting attention.
[00:22:12.350]And then it also gives you a list of communicative forms.
[00:22:16.580]What does the child do to meet this communicative function?
[00:22:21.240]And that could be a variety of things, such as using sounds,
[00:22:24.930]words, eye gaze, gesture, or even a tantrum-like behavior.
[00:22:30.980]And then to see if you get integration
[00:22:32.860]of more than one or just one.
[00:22:36.666]So as you're observing a child,
[00:22:38.040]you may be looking for specific social and play behaviors.
[00:22:41.170]And you're probably also looking for
[00:22:43.830]is the child sending and receiving messages
[00:22:47.180]in a way that fits the context?
[00:22:48.673]In a other words, what is their social communication like?
[00:22:51.740]And a Functions and Forms Checklist
[00:22:54.050]can really help you gather this information in a clear way.
[00:22:59.670]Just as you want to watch the child's behavior
[00:23:02.140]in an unstructured situation,
[00:23:04.350]it is important to watch the child within daily routines
[00:23:08.600]to see how the child interacts with a parent
[00:23:11.740]when they're doing things
[00:23:12.820]that give them a variety of sensory inputs
[00:23:15.870]when there are a variety of challenges
[00:23:17.820]or new skills to try or to integrate.
[00:23:20.650]You can also get a sense of communication
[00:23:22.750]and social interaction within these daily routines.
[00:23:28.020]And then the fifth and final element
[00:23:29.990]that I wanna mention today
[00:23:31.580]on your methods for early identification
[00:23:35.050]is to make sure that you spend some time
[00:23:37.300]in direct interaction with the child.
[00:23:40.130]As somebody who has a lot of training
[00:23:42.140]in typical development,
[00:23:43.520]and many of you have a lot of expertise
[00:23:45.400]in training in atypical development.
[00:23:48.500]It probably requires you being in those interactions
[00:23:52.420]with the child to get a feel for the child's strengths
[00:23:56.210]and relative weaknesses when it comes to interaction.
[00:24:00.080]It's something that we can watch,
[00:24:01.800]but when you're in there playing with the child,
[00:24:03.940]you can really feel what that transaction is like.
[00:24:07.000]And you may find
[00:24:08.570]that this is something you wanna do multiple times
[00:24:11.180]for short periods of time,
[00:24:13.250]particularly for a young child
[00:24:15.650]who doesn't have a lot of social experience
[00:24:18.000]or who may be a bit shy temperamentally.
[00:24:21.480]So during these direct interaction moments,
[00:24:24.790]it's a good idea to take notes during these times,
[00:24:29.010]or with parent permission, have a videotape recording
[00:24:32.460]so that you can also document
[00:24:34.830]some of the more subtle things that may emerge.
[00:24:37.940]You wanna choose play activities that are gonna help you
[00:24:41.110]elicit the things I have listed here.
[00:24:43.920]You wanna make sure you have a handle
[00:24:45.880]on the child's overall ability to orient to others
[00:24:49.550]and to see what they do to initiate interactions,
[00:24:52.940]as well as to respond
[00:24:54.240]when somebody else starts an interaction.
[00:24:57.700]You need to have opportunities where you get to witness
[00:25:00.620]what the child does to intentionally send
[00:25:04.110]and receive a message.
[00:25:05.660]So you need to know what they do,
[00:25:07.670]verbally or with non-verbal behaviors,
[00:25:10.500]to request a toy they really like,
[00:25:12.580]or to reject an activity that they don't enjoy.
[00:25:16.660]It's important to create opportunities,
[00:25:19.010]to look at how a child shares their affect
[00:25:21.790]or their emotions with you.
[00:25:23.430]And that could include everything from enjoying something
[00:25:26.510]to being frustrated by something.
[00:25:28.580]It's just really important to see a variety of affects
[00:25:31.370]and whether or not there's a social piece
[00:25:33.670]to sharing that emotion with others.
[00:25:36.210]Similarly, we need opportunities to watch
[00:25:39.360]if the child tries to direct our attention to things
[00:25:43.170]that are of interest to them,
[00:25:44.920]or we also, I shouldn't say, or,
[00:25:47.050]and we need to see what the child does
[00:25:49.230]when we try to get the child to attend
[00:25:51.530]to the same thing we're interested in.
[00:25:54.030]In addition to these opportunities
[00:25:55.740]to observe sharing affect, sharing attention,
[00:25:58.290]we also need to see if the child will initiate communication
[00:26:02.770]and communicate for just purely social purposes.
[00:26:05.870]In order to do that,
[00:26:07.150]you do have to become a familiar enough person
[00:26:10.100]in that child's play.
[00:26:12.630]In addition, we're always observing
[00:26:14.730]for the child's spontaneous and responsive acts with toys.
[00:26:19.610]We wanna see what their functional play skills are like.
[00:26:22.750]Particularly given that what a child does with toys
[00:26:26.700]can be a really good reflection
[00:26:29.120]of the inner sophistication of their language.
[00:26:32.630]So functional play,
[00:26:33.950]as well as imaginative play are both important.
[00:26:37.480]And one of the behaviors that tends to differentiate
[00:26:41.360]young children with autism
[00:26:43.040]from children with other developmental conditions
[00:26:45.660]is the ability to play symbolically with a doll.
[00:26:49.180]So simple acts such as feeding a baby,
[00:26:51.750]putting a baby to bed, or longer playing schemes
[00:26:54.510]are less common in young children
[00:26:57.020]who turn out to have autism.
[00:26:58.740]So you'd want to have those play activities available,
[00:27:01.540]and you may need to introduce them repeatedly
[00:27:04.100]if they're not familiar to the child
[00:27:06.180]so that you can observe what they can do with them.
[00:27:09.420]You also wanna look for spontaneous imitation.
[00:27:12.840]Under the age of three, spontaneously imitating
[00:27:16.930]the relevant actions of another person
[00:27:19.470]is less common in autism than in other conditions.
[00:27:22.690]So look for spontaneous imitation.
[00:27:25.330]Look for whether or not the child learns readily by watching
[00:27:29.240]and repeating the actions of others,
[00:27:31.210]because that tends to not be
[00:27:33.200]the best way for young children with autism
[00:27:35.340]to learn new things.
[00:27:36.780]And in final, we're also always looking at flexibility.
[00:27:41.210]Is the child able to pivot
[00:27:43.410]and use a toy in an unexpected way?
[00:27:45.740]Can they switch activities?
[00:27:47.310]What happens if you interrupt a routine?
[00:27:49.720]So these direct interactions through playful activities
[00:27:52.880]give you a lot of opportunities
[00:27:55.550]to observe some pretty important things.
[00:27:58.470]Now, obviously,
[00:28:00.060]since research has helped us understand what to look for,
[00:28:02.790]it's also helped us identify tools
[00:28:05.640]that are designed specifically
[00:28:08.110]to provide these kinds of opportunities.
[00:28:10.350]So you can create your own,
[00:28:12.490]or you can check out one of the two tools
[00:28:15.470]that I'm about to mention to you.
[00:28:17.750]And I should let you know that there are additional tools
[00:28:20.880]that are in the process of being validated
[00:28:23.660]with larger and larger samples
[00:28:25.710]that we should learn more about
[00:28:27.620]in literature and practice in the upcoming years.
[00:28:30.470]But for today, I wanna focus on one tool called the STAT,
[00:28:34.570]the Screening Tool for Autism in Toddlers
[00:28:37.700]and Young Children.
[00:28:39.380]This was developed by my mentor at Vanderbilt.
[00:28:42.340]So I must admit, there is a little bit of bias there.
[00:28:45.430]I got to observe the development process
[00:28:47.520]and see just how careful the team was
[00:28:49.700]as they tried to put this together.
[00:28:51.250]And Dr. Stone based all of the items
[00:28:54.140]on her previous research
[00:28:55.930]on the symptoms of autism in two year olds.
[00:28:58.540]So this is an evidence-based 20 minute interactive tool
[00:29:03.030]that a developmentalist does with a child
[00:29:05.670]with the parent present.
[00:29:07.140]And you also have some questions
[00:29:08.950]within the tool to ask the parent.
[00:29:11.260]The play opportunities are focused on imitation,
[00:29:14.650]communication, actions with objects.
[00:29:17.800]Toddlers don't feel like they're being assessed
[00:29:20.470]during this brief play-based interaction.
[00:29:23.950]And you can seek the training that you need
[00:29:27.540]through a web-based module
[00:29:29.120]that's available through Vanderbilt University.
[00:29:32.110]You do need to purchase the kit,
[00:29:33.900]which a district or a practice could purchase.
[00:29:36.750]I believe it's approximately $500
[00:29:39.260]from Vanderbilt University.
[00:29:40.800]It comes with all the scoring forms that you need
[00:29:43.140]and with the training.
[00:29:44.750]And once you accomplish the exercises
[00:29:47.070]in scoring the tool appropriately, you're now certified
[00:29:50.410]and allowed to embed this in your practice.
[00:29:53.310]So the STAT was developed specifically for Child Find teams
[00:29:57.120]and has terrific norms for two year olds.
[00:30:00.080]So in other was 24 months up to 34 months.
[00:30:03.580]They are also working on extending those norms
[00:30:06.470]into the preschool and below.
[00:30:10.150]The advantage of the STAT is that the training
[00:30:12.600]is relatively less
[00:30:15.180]than the other tool that we have in our toolbox as a field.
[00:30:18.180]And that's the Autism Diagnostic Observation Schedule.
[00:30:21.260]It's been revised, the 2nd Edition.
[00:30:23.310]So many of you are probably quite familiar with this tool.
[00:30:26.220]It is thought of as the best practice tool that we have
[00:30:29.620]in autism assessment in the clinical or medical world
[00:30:33.030]and it is sometimes adopted
[00:30:35.130]in the educational identification realm.
[00:30:37.760]But because of the intensive training requirements
[00:30:41.050]and the need to stay practiced,
[00:30:43.000]doing approximately two to four autism evaluations per week,
[00:30:46.540]is thought to help maintain good reliability in scoring.
[00:30:49.760]It's not commonly used in schools,
[00:30:53.200]but when it is used,
[00:30:54.970]you could use the toddler module for young children.
[00:30:58.350]So this is a set of play-based activities
[00:31:01.270]that were designed specifically for children
[00:31:03.700]between one year and 30 months
[00:31:06.270]who are not consistently yet using spontaneous phrases.
[00:31:10.780]If you were working with a child outside of that age range
[00:31:14.190]or somebody in that age range,
[00:31:15.870]but who has better language,
[00:31:17.340]you would choose a different module,
[00:31:20.290]which reflects their language competence.
[00:31:23.600]So the ADOS is a very strong tool,
[00:31:26.080]but it requires more training
[00:31:28.040]and more investment than the STAT
[00:31:30.480]when it comes to direct observation.
[00:31:33.560]So given that you have five elements
[00:31:36.200]of an early identification process to consider,
[00:31:40.050]everything from multiple reports,
[00:31:42.650]direct observation in a couple of different settings,
[00:31:45.230]and then direct engagement,
[00:31:47.140]all in the context of a developmental interview,
[00:31:50.090]it's also critical that we consider
[00:31:53.010]what we're now learning are some limitations
[00:31:55.600]in the cultural sensitivity of our autism assessment tools.
[00:32:00.330]So here, I just wanna shine a light on this topic
[00:32:03.370]and share some resources
[00:32:05.060]and remind you that there are probably some webinars posted
[00:32:08.580]in the tri-state that are particularly relevant
[00:32:11.640]to cultural competence in evaluation.
[00:32:14.830]And I encourage you to seek those out.
[00:32:17.400]So a couple of things to think about.
[00:32:19.650]We now recognize that understanding
[00:32:22.100]the culture of the family
[00:32:23.740]is really important in this process.
[00:32:26.000]We have to understand what the parents value
[00:32:28.920]and expect about child development,
[00:32:31.770]what their attitudes are towards a developmental delay
[00:32:35.580]or unexpected development.
[00:32:37.790]We also need to understand how they feel about an outsider,
[00:32:41.150]somebody who might be an expert in development,
[00:32:43.900]but isn't obviously an expert in their child,
[00:32:46.180]coming into their home
[00:32:47.180]and talking with them
[00:32:48.540]about the characteristics of their child.
[00:32:50.373]That can be very sensitive in some cultures.
[00:32:53.520]And it's important to understand
[00:32:55.410]the social conventions of a culture.
[00:32:58.110]So say for example,
[00:33:00.340]I was working for a while in Alaska
[00:33:02.190]and we would visit some Native people
[00:33:05.760]for whom if a young child made direct eye contact
[00:33:09.560]with a new adult
[00:33:11.010]that would be considered a sign of disrespect.
[00:33:13.640]So therefore, everything that I had learned
[00:33:15.900]as an autism specialist about eye contact
[00:33:18.840]being an important marker of autism, I needed to disregard
[00:33:22.900]because in this culture,
[00:33:24.470]children were intentionally taught
[00:33:28.080]not to look directly at adults
[00:33:30.550]in certain communicative exchanges.
[00:33:32.920]So the more we understand about the culture, the better.
[00:33:36.290]And ideally, it is best if examiners share a common culture
[00:33:40.670]with the families they serve.
[00:33:42.560]So there's a real need in our field
[00:33:44.850]to bring in more individuals
[00:33:47.220]who represent other cultural backgrounds
[00:33:50.040]into this work that we do.
[00:33:53.010]Now, many tools that we have that we rely on,
[00:33:55.550]that have good psychometrics,
[00:33:57.150]have been developed with items that came out of science
[00:34:01.220]that was conducted on primarily Caucasian,
[00:34:04.130]primarily middle class individuals
[00:34:06.800]who are predominantly male.
[00:34:08.990]So it's just important to know that going in.
[00:34:11.760]And we are now finding out that there are different ways
[00:34:16.070]that symptoms of autism might be expressed
[00:34:18.790]in females versus males, particularly at different ages.
[00:34:22.720]And that there could be differences
[00:34:24.650]by racial or ethnic group,
[00:34:26.840]depending on the cultural norms around particular behaviors.
[00:34:32.420]So when using the tools that you've chosen,
[00:34:36.150]be sure that you understand
[00:34:37.820]the strengths or limitations of its psychometrics,
[00:34:40.700]and just be ready to put a line in your report
[00:34:43.390]that clarifies what those strengths or limitations might be.
[00:34:48.100]Transparency is probably the best we can do right now.
[00:34:51.220]And as publishers are getting better
[00:34:53.800]at seeking more representative normative samples,
[00:34:57.800]you may find that you need to check
[00:35:00.240]not only the publisher manual of the tools you use,
[00:35:03.020]but look at their websites in a pretty regular way
[00:35:06.330]for updated norms tables.
[00:35:08.670]So as a field, we have a way to go
[00:35:10.920]to improve our culturally sensitive practices
[00:35:13.640]in autism evaluation,
[00:35:15.520]but a couple of resources I wanted to share with you
[00:35:18.760]that could be helpful
[00:35:20.450]in your career development in this area.
[00:35:23.740]One is that the Association of University Centers
[00:35:27.250]on Disability in collaboration with ITAC,
[00:35:30.690]Technical Assistance Centers,
[00:35:32.520]have developed a collection of recommended resources
[00:35:36.210]that are specifically helpful for culture.
[00:35:40.180]For example, CDC's website, Learn the Signs, Act Early,
[00:35:44.510]provides materials in different languages,
[00:35:47.955]and also gives you links to specific ways
[00:35:51.470]that different cultures think about autism.
[00:35:55.120]We also find in that same Autism Cares document,
[00:35:59.160]some resources specific to
[00:36:02.670]working with people whose primary language is not English
[00:36:05.650]coming from a team out of the state of Massachusetts.
[00:36:09.390]There are also toolkits for Spanish speaking families
[00:36:12.730]available through Autism Speaks.
[00:36:15.090]So while this is just the very, very beginning of resources
[00:36:18.610]you may find to be useful,
[00:36:20.130]it's just essential to always be thinking about
[00:36:22.770]the culture of the family
[00:36:24.300]as you're embarking on these educational evaluations.
[00:36:28.890]And now as our final topic for tonight,
[00:36:31.330]I just wanna touch on a couple of considerations
[00:36:34.280]if you're trying to differentiate
[00:36:35.890]between an autism spectrum disorder,
[00:36:38.030]lack of social experience or possible trauma.
[00:36:41.090]This has come up quite a lot in the trainings we're doing
[00:36:43.950]in Colorado on educational identification.
[00:36:46.910]And we're gonna offer a webinar specifically on this topic
[00:36:50.710]in about a month from now.
[00:36:53.990]So many times in our practice, we run into families
[00:36:58.220]and children who face multiple challenges,
[00:37:01.300]and these challenges can be complex and deep.
[00:37:04.480]Oftentimes our jobs are to identify those challenges
[00:37:07.890]and narrate them and hopefully select interventions
[00:37:11.830]that fit well with those challenges.
[00:37:14.980]And sometimes when you're beginning to work with a family,
[00:37:17.970]you'll start with one conceptualization,
[00:37:20.030]such as seeing a child's behaviors
[00:37:22.150]under a developmental lens,
[00:37:23.610]and then the more experience you have with the child,
[00:37:26.800]it becomes apparent
[00:37:27.930]that you may need to alter that conceptualization.
[00:37:30.970]I wanna narrate this dynamic part of this process
[00:37:34.410]because if a child has experienced trauma,
[00:37:37.920]even if we suspect that they have,
[00:37:39.580]but we don't know for sure,
[00:37:41.570]ongoing assessment of that child is going to be necessary.
[00:37:46.320]Interventions that you select
[00:37:48.700]are going to probably be a blend between
[00:37:51.470]developmental interventions and trauma-informed care.
[00:37:55.551]But I find when cases are really complex like this,
[00:38:01.030]it is a question that continues
[00:38:03.260]to be addressed across the child's lifetime.
[00:38:07.060]Our field is not precise enough
[00:38:09.520]to be able to give us the tools to not only identify
[00:38:13.460]a set of things in a child to be concerned about,
[00:38:16.420]and then to understand exactly where they came from.
[00:38:20.110]So sometimes what we're trying to do
[00:38:22.550]is put a name to what we see
[00:38:25.910]that is interfering with the child's ability to learn
[00:38:30.140]and engage socially and communicatively with others.
[00:38:34.240]Over time as we understand the child,
[00:38:36.920]we may understand the etiology
[00:38:39.270]or the factors that contribute
[00:38:41.210]to the onset of this developmental problem.
[00:38:44.290]But in many ways, the question of is it autism,
[00:38:48.140]or is it a lack of experience?
[00:38:49.980]Is it autism or is it trauma,
[00:38:52.410]may at some point not be the most important question.
[00:38:56.690]The most important question might be, is there trauma?
[00:39:00.870]Has there been enough social experience
[00:39:04.130]and do I see symptoms of autism spectrum disorder
[00:39:07.680]in this child?
[00:39:09.090]So in my mind,
[00:39:10.980]those three things may be co-occurring
[00:39:13.950]more often then when one is a better explanation of another.
[00:39:18.490]And so, particularly as you're starting
[00:39:21.010]your information gathering process,
[00:39:23.330]you wanna keep an eye out for narrating
[00:39:25.940]all three of those things if they are present for a child.
[00:39:29.590]And then as the body of evidence comes in
[00:39:32.490]and you learn about the child's behavior
[00:39:34.780]and functioning in different context,
[00:39:36.890]you and others can come to a determination to describe
[00:39:41.220]what seems to be the primary driver
[00:39:44.220]of the child's challenges.
[00:39:45.990]And if there is a second thing going on,
[00:39:49.320]we'd wanna have that narrated too.
[00:39:51.560]So I just wanted to lay out
[00:39:52.830]that sometimes our desire to put things neatly in a category
[00:39:56.940]is not the best way to go
[00:39:58.770]when it comes to really complex cases.
[00:40:01.650]And that our question may not so much be,
[00:40:06.820]the relevant question may not be, is it autism or this,
[00:40:10.340]sometimes it's, is it autism and this?
[00:40:14.500]But when we are trying to figure out
[00:40:16.040]if autism spectrum disorder is relevant
[00:40:18.260]or meaningful for a particular child,
[00:40:20.780]we might have a competing hypothesis,
[00:40:22.640]that hey, maybe this child
[00:40:24.360]is neurologically built just fine.
[00:40:27.120]There's no underlying
[00:40:28.310]neurodevelopmental disorder here perhaps.
[00:40:30.550]Maybe the child's presenting differently
[00:40:33.390]because she lacks social experience.
[00:40:35.560]And this becomes particularly important to consider
[00:40:38.300]with COVID having just taken two years
[00:40:41.610]of a child's social experience and really messed with it.
[00:40:44.960]So in order to kind of tackle this differentiation,
[00:40:48.590]I think the very first thing is to narrate it.
[00:40:51.450]If you are starting to see concerns
[00:40:53.550]about a child's social communication behavior
[00:40:56.300]and they have been through COVID as a young child,
[00:40:59.840]for example, you'd wanna say to the parent upfront,
[00:41:03.590]we always wanna remember,
[00:41:05.130]your child has not had typical social experiences
[00:41:08.320]with other children.
[00:41:09.770]So we are going to get to know your child,
[00:41:12.710]work with your child,
[00:41:13.800]see your child in interactions with you, the parent,
[00:41:16.590]but over time,
[00:41:17.670]we really do need to see
[00:41:19.640]your child have some more experiences with other children,
[00:41:22.140]and we can watch how those behaviors grow and develop.
[00:41:26.100]So you're always gonna gather information
[00:41:28.030]about the child's social experiences
[00:41:29.920]so you can describe them in your written report.
[00:41:32.490]And you do wanna plan these ongoing assessments
[00:41:35.540]so that as the child gains social experience,
[00:41:38.600]you can see what sorts of
[00:41:39.850]qualitative changes occur over time.
[00:41:43.100]If the child truly has autism,
[00:41:45.230]it will take a lot of repetition
[00:41:48.080]to be able to learn new skills with new social experience.
[00:41:51.470]If the child doesn't have
[00:41:53.580]an underlying autism spectrum disorder,
[00:41:55.970]one would expect the social gains to occur more quickly
[00:41:59.970]with the access to peers increasing.
[00:42:03.490]It's really important in my opinion,
[00:42:05.630]and this is not based on the research,
[00:42:07.310]based on my opinion of trying to do these assessments,
[00:42:09.900]to spend time observing
[00:42:12.450]and reporting on the integration of the pragmatics
[00:42:15.710]or the communication domain
[00:42:18.010]so that you're really looking hard at whether or not
[00:42:20.420]these verbal and nonverbal communication behaviors,
[00:42:23.210]such as eye gaze, gestures, facial expressions
[00:42:26.850]are integrated in a smooth and reciprocal fashion.
[00:42:30.310]The reason I like to look at those
[00:42:32.080]is that they are things
[00:42:33.440]that appear to be more neurologically based
[00:42:36.380]as a part of the connectivity problems
[00:42:38.500]associated with autism.
[00:42:40.690]So seeing the integration of complex communication behaviors
[00:42:45.530]may help you see kind of the core
[00:42:48.310]of an autism spectrum disorder
[00:42:50.180]relative to something happening outside the person,
[00:42:53.810]a lack of social experience.
[00:42:56.450]In young children who do have autism,
[00:42:59.770]they tend to share affect really well with their parents.
[00:43:02.880]They share attention, they imitate.
[00:43:05.150]So a lack of experience with peers,
[00:43:08.070]shouldn't compromise
[00:43:09.530]the quality of a child's social behavior
[00:43:11.760]with his or her parents.
[00:43:13.360]So I would look carefully at those things.
[00:43:15.900]You'd also wanna look at
[00:43:17.250]the range of play skills used with parents
[00:43:19.870]and whether or not the parents can work with the child
[00:43:22.310]to shift what they do with objects and be flexible.
[00:43:26.800]So for a child who I'm thinking
[00:43:29.160]has lacked exposure to peers,
[00:43:31.700]I would wanna make sure
[00:43:33.190]that my evaluation covers those things on the bullet points.
[00:43:37.140]There are some behaviors that are thought to be
[00:43:41.030]much more specific to autism
[00:43:42.980]than even to other developmental disorders.
[00:43:45.760]So one of those to look for,
[00:43:47.620]which is more consistent with autism,
[00:43:49.890]is when a child who's not yet learned
[00:43:51.750]how to use language flexibly,
[00:43:53.710]takes his hand, puts it on the hand of an adult,
[00:43:56.850]and then uses that adult's hand as a tool,
[00:43:59.810]like to operate a toy or to put something somewhere.
[00:44:03.080]When a child manipulates an adult's hand like this
[00:44:06.340]without coordinated eye contact,
[00:44:09.410]the research tells us that is much more likely
[00:44:13.290]to be consistent with autism
[00:44:14.890]than another development condition.
[00:44:17.810]So when trying to differentiate ASD
[00:44:20.060]from a lack of social experience,
[00:44:22.150]I would recommend looking at these behaviors
[00:44:24.790]that are more neurologically functioning.
[00:44:28.030]Including the last one, sensitivities to the environment.
[00:44:31.440]So things that don't have to do with peer interaction,
[00:44:34.220]but have to do with adapting to the outside world
[00:44:37.200]could be most helpful in those evaluations.
[00:44:42.380]Now, when you're trying to understand
[00:44:44.400]if a child is presenting with true autism spectrum disorder,
[00:44:49.180]which is a neurobiological condition,
[00:44:52.650]or if the child is behaving in a limited social
[00:44:57.120]and emotional way, because of experiences with trauma,
[00:45:01.190]that's when we are often treading on really tricky territory
[00:45:04.800]and the research on best practice is still developing
[00:45:08.520]and we don't yet have a lot of evidence to rely upon
[00:45:12.470]to guide our practices.
[00:45:14.440]So what I'm about to share with you
[00:45:16.260]comes from consulting the research
[00:45:19.890]and in hopefully I guess you would say,
[00:45:22.090]informed by clinical practice.
[00:45:23.970]Hopefully we will learn more as this field evolves.
[00:45:28.120]If you're trying to understand if a child's presenting
[00:45:30.730]in a certain way, because of autism versus trauma,
[00:45:33.360]one of the first things I'd recommend
[00:45:35.140]is make sure you get as thorough
[00:45:37.190]a developmental history as you can.
[00:45:39.590]It's important to understand the timing of things.
[00:45:42.640]When did the trauma occur?
[00:45:44.840]And it would be helpful to understand
[00:45:47.250]if it occurred for a long period of time
[00:45:49.020]or was a one time situation.
[00:45:51.910]You also wanna understand the timing of concerns
[00:45:55.080]about the child's social and communication development.
[00:45:58.240]So clearly if there were concerns about development
[00:46:01.100]prior to the trauma,
[00:46:03.060]it could be an indicator that the behaviors you're seeing
[00:46:06.170]are influenced by an underlying developmental condition.
[00:46:09.630]If the child appeared to be developing typically
[00:46:13.110]until the age of the trauma
[00:46:15.180]and that age was, let's say,
[00:46:17.210]old enough to allow for observation
[00:46:21.910]of communication and language development,
[00:46:24.330]so I would say after about 18 months,
[00:46:28.000]then one could suggest that
[00:46:30.680]typical development prior to 18 months
[00:46:32.980]is usually followed by typical development after 18 months.
[00:46:36.430]So if the trauma happened and then things changed,
[00:46:39.500]then you are probably more likely
[00:46:41.760]dealing with the behavioral aftermath of a trauma.
[00:46:46.510]It's also important to recognize that sometimes this timing
[00:46:49.560]is going to be mixed or you won't have enough information.
[00:46:52.860]So it's something you wanna do,
[00:46:54.920]and you hope will add to your evidence,
[00:46:56.930]but you'll need to see how it all works out
[00:46:59.210]with each individual case.
[00:47:01.460]In cases I've been involved with,
[00:47:03.220]we didn't understand the roots of the trauma
[00:47:05.460]until many years later.
[00:47:08.920]It may also be helpful to think about how
[00:47:11.580]an autism spectrum disorder
[00:47:13.430]is thought to be neurologically based.
[00:47:16.270]So it's characterized by some consistent
[00:47:18.970]and persistent problems
[00:47:20.890]in the integration of social communication
[00:47:23.820]and sensory adaptations to the environment.
[00:47:27.030]So you should see that there is functional impairment
[00:47:31.900]across different contexts,
[00:47:34.280]that there isn't one situation
[00:47:36.910]where the child is just flourishing with rich
[00:47:40.270]and reciprocal well integrated social, emotional,
[00:47:43.380]and communication behaviors.
[00:47:45.070]That just doesn't happen in a young child
[00:47:48.170]with significant autism symptoms.
[00:47:50.510]You may see a child who behaves better
[00:47:52.720]with a particular person
[00:47:54.560]or who when they are with a familiar parent
[00:47:57.560]can be more affectionate and socially available,
[00:48:00.690]is really at their best,
[00:48:02.460]but those biologically-based aspects of autism,
[00:48:07.420]self-regulation problems,
[00:48:09.260]integrating verbal and nonverbal behaviors,
[00:48:12.950]managing repetitive activities and interests.
[00:48:15.910]Those things are not going to vary
[00:48:19.360]across context significantly.
[00:48:22.420]So if a child functions beautifully
[00:48:25.700]with well integrated rich
[00:48:27.230]and reciprocal social behavior with one person,
[00:48:29.970]but then shuts down with another person,
[00:48:32.620]that to me is not an autism spectrum presentation.
[00:48:36.550]That makes me think there's something going on
[00:48:38.830]more in the emotional domain that is perhaps trauma related.
[00:48:43.850]Another thing I wanna mention that we said in the intro
[00:48:46.610]is that co-occurrence of these two things is quite possible.
[00:48:50.900]So we don't wanna rule anything out.
[00:48:53.570]It may be less a question of is it this or that,
[00:48:57.390]or have both of these things exerted some influence
[00:49:02.530]on the child's development?
[00:49:04.530]And if so, let's identify them both
[00:49:08.100]and figure out how interventions taken from both worlds
[00:49:12.100]can contribute to helping this child.
[00:49:15.050]So, I would say that the true differentiation
[00:49:18.620]between these two things
[00:49:20.500]is going to have to do with not only
[00:49:23.040]finding really sophisticated markers
[00:49:25.230]of what's different on the surface,
[00:49:26.710]but understanding the etiology
[00:49:28.670]or how these developmental challenges came to be.
[00:49:31.920]And that differentiation
[00:49:33.590]often requires a comprehensive multidisciplinary evaluation
[00:49:37.870]that would include a combination of medical, clinical,
[00:49:40.930]and educational professionals.
[00:49:43.080]So depending on where you practice,
[00:49:45.810]it may be most important to determine
[00:49:48.640]is autism relevant for this child?
[00:49:51.480]Is trauma relevant for this child?
[00:49:54.410]And to document both.
[00:49:56.770]Now, sometimes a child will present
[00:49:58.700]with an autism-like presentation,
[00:50:01.090]but there's a different qualitative feel to it.
[00:50:03.800]So maybe there is social withdrawal,
[00:50:06.750]but you're seeing other aspects of strengths
[00:50:09.540]and integration of communication for example.
[00:50:13.040]It can be that when you begin
[00:50:16.300]with interventions that are developmentally sensitive
[00:50:19.820]and are trauma informed
[00:50:21.670]and perhaps are focused on a parent-child interaction
[00:50:25.130]or targeting social relatedness or emotional understanding,
[00:50:29.970]if the child doesn't have neurologically-based autism,
[00:50:33.930]but rather has an autism-like presentation,
[00:50:37.240]literature suggests that progress
[00:50:39.520]on these core social relatedness features
[00:50:42.500]tends to be faster for a child that has a trauma history
[00:50:48.040]as opposed to neurologically-based autism.
[00:50:51.150]And so in this way,
[00:50:52.490]you can see how sometimes you begin the interventions
[00:50:55.380]while continually assessing,
[00:50:57.370]and it may not be until you can see the response
[00:51:00.130]to the intervention that you or the family feels clearer
[00:51:04.290]about how best to describe
[00:51:06.170]the origin of the child's social difficulties.
[00:51:09.650]So even with a trauma history,
[00:51:11.910]if the child is showing qualitative differences
[00:51:14.520]in reciprocity, nonverbal communication, and flexibility,
[00:51:18.520]identifying autism is appropriate.
[00:51:20.950]You actually don't have to understand how problems arose,
[00:51:25.460]what their history is, as much as you need to know,
[00:51:29.430]is the child presenting with a set of behaviors or features
[00:51:33.390]that meet the educational criteria
[00:51:36.320]for an autism spectrum disorder
[00:51:38.140]if you're working in the school system.
[00:51:40.510]It could be that you think trauma may be driving this,
[00:51:44.740]but the child is meeting criteria for autism.
[00:51:47.980]It could be that the behaviors
[00:51:51.270]that are associated with autism
[00:51:53.300]are the things that are getting in the way
[00:51:55.330]of accessing an appropriate education.
[00:51:58.200]So particularly in the school system,
[00:52:00.650]your job is often to
[00:52:03.070]identify what the developmental concerns are
[00:52:06.000]and then reflect those
[00:52:07.630]in the educational eligibility categories that you choose.
[00:52:11.110]And it is most important to document both
[00:52:14.950]if both seem to be present.
[00:52:17.530]You just don't want to not include the information,
[00:52:20.530]because it will give you ideas about how to program,
[00:52:23.940]depending on whether or not autism
[00:52:26.200]or trauma is in the child's background.
[00:52:29.090]So we will cover this topic more in a future webinar.
[00:52:32.650]For now, I just wanted to introduce that topic
[00:52:35.810]and help you get thinking
[00:52:37.900]about our role in early identification,
[00:52:40.400]is identifying people who are at risk for autism.
[00:52:43.490]We don't have to expect that we're gonna go down the road
[00:52:46.750]of a lifelong diagnosis
[00:52:48.450]or even tease apart the etiology of these difficulties.
[00:52:52.520]Our role has more to do with a functional identification
[00:52:56.940]that will allow intervention to begin
[00:52:59.160]and will inform the interventions that we select.
[00:53:02.310]And so today I wanted to try to share some of the tools
[00:53:04.930]that we have that are useful
[00:53:06.800]in identifying young children at risk for autism.
[00:53:10.710]Also hope that you'll take away the message
[00:53:13.180]that it's really important
[00:53:15.070]to address this evaluation in a comprehensive way.
[00:53:18.830]And we outlined five elements
[00:53:20.770]of that evaluation process today.
[00:53:23.150]Developmental history,
[00:53:24.610]reports from multiple people using well validated measures,
[00:53:28.240]observing the child in structured and unstructured context,
[00:53:31.520]and directly interacting with the child
[00:53:33.880]to look at reciprocity, pragmatics, and flexibility.
[00:53:38.570]Now, before I leave you,
[00:53:39.470]I wanna let you know about a couple of resources
[00:53:42.390]that we have posted in this particular slideshow.
[00:53:45.520]Links that will help you to assess autism
[00:53:50.250]as well as communicate with parents
[00:53:52.090]when you're sharing results.
[00:53:53.950]So we also have included information
[00:53:57.300]about how to seek training
[00:53:58.860]in some of the screeners that we recommended today.
[00:54:02.230]And we always recommend
[00:54:03.650]checking out the professional development opportunities
[00:54:06.350]that are available through the archived webinars
[00:54:08.900]from the Tri-State Autism Network,
[00:54:11.090]of which this webinar is a part.
[00:54:13.100]And then finally, as I mentioned,
[00:54:15.670]we do wanna make sure that you could locate
[00:54:17.680]the measures we talked about here.
[00:54:19.320]And one more qualifying comment,
[00:54:21.750]that there are other measures
[00:54:23.430]with strong psychometric characteristics
[00:54:26.320]that you or your colleagues may opt to use.
[00:54:29.710]We only had time today to focus on some of them.
[00:54:33.560]So these are some of our favorites
[00:54:35.010]based on their psychometrics,
[00:54:36.400]but there are other tools out there
[00:54:38.000]and being developed all the time.
[00:54:40.010]And then lastly,
[00:54:41.270]I just wanna leave you with the reference list.
[00:54:43.950]We can make these things available to you
[00:54:46.190]if you prefer to get them in a Word document.
[00:54:49.510]So thank you for all of your time and attention.
[00:54:52.760]Appreciate that you're working in this important field
[00:54:55.330]of early identification,
[00:54:57.050]and we'd be happy to stick around
[00:54:59.010]and answer any of your questions.
[00:55:01.050]So thanks.

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Early Identification of Autism Spectrum Disorder: Part II

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