Screening for Autism in the Early Childhood Education Environment

okay so good morning and welcome everybody I want to introduce myself first my name is dr. Mohan Krishna the director of children services at hook networks botanical services and i’m here today to talk to you about autism uh I want to first of all thank you all for coming out I know it’s early on a Saturday morning and I’m sure that I’ve got me you’d rather be out walking your dogs or having a light breakfast or something like that but I’m right excited that you take it at a time this morning to come learn and I hope that we can have a good time learning about autism this morning I there are a lot of really exciting topics through the rest of the morning in the afternoon I’m couple of quick reminders it is a really cramped room and it’s also quite warm so take those two things into consideration if you need to step out anytime I will not be offended for a drink of water or something like that so please just bear with us in terms of their cramped spaces hope I get to know your neighbor a little bit this lecture will go for the full 60 minutes and i do have stickers for your cv certificates at the end and i think that’s the only thing that I need to tell you there are bathrooms around the corner adding the main hall whenever you need them and the only time for questions or play at the end as well but if you’re not understanding something along the way it’s fine to interrupt as well please so I want to start by asking for a quick show of hands here because I’ve actually never been to this conference before how many people here are preschool teachers okay so that’s a lot of people has anyone a school teacher k through 12 okay so a couple is anyone a new school therapist to social worker or occupation they’re just speech and language pathology is anyone in school any other in school service at parapro like that is anyone a clinician or from the health care environment any parents have kids with special needs a couple of those okay anyone i missed home buddy came to our home daycare providers Oh excellent welcome all right well I think that hopefully I’ve got the right information for this audience and welcome to make yourself comfortable initiative here ah so I’m going to emphasize today talking about screening in the early childhood environment and particularly talking about a basic underground basic background of what autism is because of you who may more be more or less familiar with how it’s diagnosed and treated understanding signs and symptoms to suggest an increased likelihood of autism particularly in kids are in the preschool age range and then understand some formal tools that can be used for screening purposes and learning mechanisms for clinical follow-up especially I’m sure that you all do more that about academic follow-up than I do Paul mentioned that briefly as well but you’ve really already more than expert on that than I am so those are things I’d like to try to accomplish today briefly about me I chill used to be an engineer and I studied the University of Michigan I did my psychology training at University of Florida and then the University of Chicago’s Medical Center I fell over here at Mary free bed downtown and I’ve been with hope network ever since I am currently responsible thank you so much and those include an outpatient autism program focusing especially on early interventions but also i love spent services and then i would you also coordinate residential services for kids and developmental issues so that’s what i do to find a job the Center for autism pretty clear about network we were created in the 60s I we used to be the rehabilitation arm of I dressed research over the neuro developmental issues autism as well as kids with global intellectual disability or other concerns book FAS women serving them since about two thousand and four in crime methods in the boat outpatient and residential capacities but in 2010 we bought the Center for autism to really emphasize that I needs of this underserved population because kids with autism remain at that time you were in particular had relatively little access to clinical services that continues to be a major issue and so we wanted to really focus on something that would serve this population our emphasis clinically is on early diagnosis and comprehensive treatment planning I replaced a special emphasis on early intensive behavioral interventions this is a service provide by provided by an applied behavior analyst so if you’ve heard of the phrase ABA and the context of autism that’s this we’ll talk about this brief stay with that is we also provide a variety of ancillary clinical services additional speech and

occupational therapy on occasion more speech than OT as a booster for services being provided in the school there particularly it also psychotherapy for things like helping families it’s to make develop maintain friendships and if I will be provide a horrible social supports we have a vertical puzzle partners which is a really exciting program for teens and young adults that emphasizes a social integration of the community adapting activities to make them more accessible to people with autism so this includes things like I went geocaching with some of our boys to summer downtown we’ve done our prize with adaptations to make it a more successful experience for kids are trouble and big crowds we do a write a game that sometimes like that as well and then finally we do educational programming once a month we provide a professional education here in Grand Rapids it’s a first friday at noon it’s called Grand Rounds the wheels are starting just this month family rounds which is a education program and directed more at parents and that is a day that happens once a month on a Wednesday night starting on the twenty-third yes so in order to participate in anything we could just describe what you have to get qualified aha so that’s a good question in terms of our clinical services they’re generally insurance bill clinical services and we provide diagnosis as the front end to that but the diagnosis is going to guide service availability so for instance a VA is available to kids of autism increasingly but it’s not available for other kinds of diagnosis other things like social social supports also partners is actually much more informal it doesn’t require our formal clinical diagnosis it’s not a health care service and so it’s much more flexible basically we look at kids in terms of currently we’re serving kids and young adults who are able to have conversations and don’t have major issues like aggression kids are basically being able to function in a group kind of setting we do say screening to make sure they’re appropriate we can work with parents to determine that but that’s much more of a kind of way you can sort of thing typically sessions with puzzle partners cost $15 we have some scholarships available for that tooth that’s really accessible and the final the educational programming is of course created open to the public you just can’t come here in so currently our clinic is only here in Grand Rapids we serve a large catchment area we have kids come from routinely from two to four hours away for diagnosis who are not providing on-site treatment attic run outside of Grand Rapids at this time we’re working on that isn’ta something that definitely needs has and more when you look at things like a be a really high quality in clinic in VA is available in Michigan in the Detroit suburbs in Kalamazoo and Brent Rapids and that’s it even Lansing doesn’t have access to this kind of care and certainly northern Michigan and that’s some that’s we talked about it a daily basis how to address that need I’m gonna get to that good we can see these so really briefly I want to mention that for knierim I don’t want to mention that you have a crucial role as educators studies this is a kind of dated studies about 10 years old now suggest thing the vast majority of kids who are diagnosed with autism are identified with autism are diagnosed through through support of the schools and in two thousand doing the study found that only three percent of kids received an autism diagnosis with no school involvement the other ninety seven percent came to clinical attention through you that may be a combination of school and clinic so it may be a situation where a said there’s something not right here and sent them back to their pediatrician it may be by school alone and their continued to a lot of kids who receive academic ASD qualification services but who don’t forget any clinical services part of that is because of insurance coverage and that changed last year and is still in the process of changing but it’s certainly something that we can’t do without you and I want to really emphasize that so your crucial to the screening process what makes you particularly crucial also is that a lot of you spend a lot of time observing the plane interaction of young kids and so you’re going to be you’re going to be really uniquely able to do that as a professional and as an outsider not as apparent to identify kids whose development is unusual you know as opposed to a pediatrician who might have 15 minute contact once every three six months with a child so children with autism can also be frequently mainstreamed into into general education that’s increasingly happening and some of the clinical services we provide are really designed to increase the likelihood of that and so that’s something that we obviously have to collaborate on because we want kids to be learning in school so we really cannot do this unless we work together and the teachers are really crucial educators of all prices will be crucial in making this house so I want to spend

some time I don’t want to go into this into too much detail but always with some time talking about a perspective reference okay before I understand between how we do things in a health care clinic and how we do things in a school we do approaches from somewhat different ranges so they’re different turns you to inscribe things and some of these terms are used in an overlapping fashion but some of these differences are important to understand on the ground floor because they do inform the way we do things in a clinical setting getting back to your question and how they may be the same or different than how you do things in this school so first of all I talk about academic service qualifications and you probably are all much more of experts on this topic than i am but children make qualify as you know from mecca for special services in school under one or more mechanisms but in particular ide a and 504 plan kinds of mechanisms so for kids who have IE services generally speaking you have an IEP meeting I’m not initiated in one of multiple situations you’re based on parent concern based on educator concern or based on certain kinds of critical incidents that tell you that a child isn’t it was objectively not achieving what you’re expecting to understand correctly and so at that point when you do that process you evaluate children’s in purpose determining if they’re eligible for services right and that’s really the core outcome of that first part of the IEP process and they may be eligible under one or more criteria and as a jig educators you may decide as a team what criteria best describe the child you may provide a blend of services for multiple criteria and so the plan is customized although since assembly center services are also going to be driven by the classification the child receives and the chocolate he’ll be eligible for criteria and may not match how the family thanks to much available right so you may have a child whose family thinks of them as an autism thur very high-functioning and you really only see eligibility under an LD criteria or a speech criteria you might in contrast have a family believes their child is perfectly normal but is eligible for fairly substantial services because their development is different than what you would expect and then it shall be also be ineligible for accommodations or modifications even if they have a clinical diagnosis that a doctor would give them right I mean there are lots of examples of people with autism for instance who were very very high functioning and don’t need any kind of help so if temple grandin were in your classroom she may not at this point mean any services right so there are also people who may have a diagnosable condition that they don’t need services because they’re learning to sign for their bday making much more subtle surfaces and autism is a particularly important area where this kind of thing happens because some people with autism may need really substantial modifications to their education and some people might just be a little bit of help around the edges essentially so the purpose of this process is what I would argue is not necessarily a treat or cure a disorder but to a deaf be educational process to maximize the outcome meaning your point is to make sure that these kids are learning effectively building up the scope they’ll need to succeed in subsequent education and then also in the real world but there’s a lot of overlap between what I might call treating a disorder of what you might call maximizing education so this is the 3 40 41 715 the autism spectrum classification for Michigan and it goes through criteria and some of these criteria have to do with basically math essentially quite margarita I’m sorry and there’s no screen it’s a little harder yet you can buy these online pretty readily and I’m sure that you prolly already have a copy uh but basically somebody’s Ridge area map onto the psychiatric TSM for language for diagnosing autism but then there also some criteria that have to do with how you go about doing the evaluation so for instance it requires certain kinds of professionals in the academic setting it requires the in front of a psychologist or psychiatrist of course he is a social worker in quietly requires day in front of the speech and language pathologists and then there has to be evidence of disturbance in a number of areas the greater sequence of cognitive affective psychomotor or language speech development disturbance in the capacity to relate appropriately appears and a number of other things and then I describe these in more detail these get to the definition of autism so I’ve got a slide where it’s a little bit more legible a little bit here but the point is if these eligibility criteria basically defined a set of conditions in which the school credibly finds that a child fits into a category in which you can make modifications or accommodations to a patient likely to succeed and are likely to be necessary and importantly successes is less likely if these accommodations and modifications are not put in place is it

is that pretty reasonable okay again I’m naughty teacher and so when emphasize that this that’s not the way I understand it um clinical diagnosis has a lot of overlap but there are some important differences the predication of clinical diagnosis is essentially a philosophy that when people come to a doctor and complain about something we believe there’s something wrong and our job is to figure out what that is and the technical term for that is differential diagnosis is of most of diagnosis meaning among those little possibilities that explain the complaint of the patient I’m looking for the one that’s the best match for their their problems that may be autism or maybe something else in this case but what’s important about this is generally speaking when you go to a doctor with a complaint you don’t go home without a diagnosis you’re that process the way that most is supposed to work is you’re supposed to come out of that process from some kind of diagnosis that address is how we’re going to address that problem much more rarely there’s no diagnosis at all and it’s an educational issue the child’s normally developing there’s nothing wrong with them essentially but usually people who come to the clinic it’s more a matter of is this autism versus it a speech delay or an intellectual delay is it an anxiety disorder that happens in childhood is it something else so it’s more going to be a differential between these multiple options in the goals of my new best explanation and the purpose of diagnosis is really to guide treatment planning whether that be medication or get further diagnostics like brain imaging or EG or something like that genetic testing whether it be behavioral therapy is like in clinic services like early intensive behavioral intervention and also to determine what the prognosis is meaning what the parents should expect about the child in this case at this point are we seeing evidence that visited child was likely have a very high-functioning projectory is do we see evidence this is a child who is going to continue to struggle in the ongoing basis we see evidence that’s inconclusive depending on how they respond to treatment for it stands and so really the purpose is to guide treatment planning and help identity something about the public that they come to us with but like I you keep lighting Sunday aspects of which there may be treated on a case-by-case basis so we might treat emotional symptoms under an autism diagnosis because there are emotional symptoms that really have to do with the autism but we would treat them much the way we were treated Marshall symptoms in congedo net watches like we were treated and anxiety and a high-functioning child with autism much like anxiety and a high-functioning child without autism so there is some empirical components to this you’re very similarly a lot of medications hardly any medications are approved by the FDA for autism most of them are approved for other disorders where there’s symptom overlap with autism and server instance there are depression and anxiety medications that are approved for depression anxiety and they do work in autism there are some exceptions to that but a lot of the medical science of treating autism with medications is is a isn’t working processes and I’m a psychologist and I don’t prescribe medications but I do make recommendations on that and coordinate them with physicians so the perspective difference is that a low vision or electric terminology there’s a distinction between the clinical diagnosis which is intended to identify a medical diagnosis that is the most consistent match for all the symptoms and the educational classification which is meant to essentially identify the educational process that is most likely to educate the child successfully so there is a full overlap for that it is important to emphasize that there may be children who are eligible for ASD services appropriately but they actually have a different diagnosis order in the eyes of a healthcare medical professional they may have a specific genetic syndrome that we consider similar to autism but not be me overlapping with autism they may have another kind of diagnosis as well and then by sources some children of clinical launches and diagnosis don’t qualify for IEP services because they’re learning just fine because although their friendships aren’t perfect they’re workable they’re able to socially interact with the level that they need to be able to so that’s where there’s an incomplete overlap between the clinical medical kind of approach in the educational approach so when that system works this actually perfectly okay there doesn’t need to be complete overlap between the way a clinic does things in the way of school those things we all share the goal of leveraging our tools to healthy skits drive and we each child may need a different set of tools both from the school and possibly from a clinic and some children may not need one of these like some children may be able to take a medication and stay against your classroom some children may be able to progress so well in early childhood academic interventions that in clinic services are necessary and that’s fine

however when the system goes wrong what’s going to happen well one is we may miss children altogether we may have a diffusion of responsibility and you may think I’m looking for them and I think you’re looking for them and nobody’s looking for and the child doesn’t get it i defied and they don’t get any of the services from either of us another possibilities we could spend their time arguing about who’s right who’s wrong noindex this kid doesn’t have autism yes this kid does have autism know if it doesn’t have office and that’s a waste of time right so if we fail to coordinate our services it’s become significantly less likely than our kids will thrive there’s that you’re here and there to kidding sorry it’s a very high relative so that’s my motivation for saying we want to try to work together if at all possible um so and I keep looking back I’m sorry I have a screen here which doesn’t show me the right slides for some reason so this is a bit of an eye chart also i don’t know if it’s lunchable on the head up to not this is the dsm-4 criteria for autism I want to walk you through it I don’t want to walk you through every piece of it but I want to give you a give an overview of how it works this is actually changing as many of you may know we go through a revision process clinical diagnosis and standards that happens about once every six to ten years and the criteria has essentially been locked down over the past couple months and at this point we’re just kind of in a roll out process for the new criteria it’s a very complicated system because the DSM the Diagnostic and Statistical Manual is the generally recognized tool worldwide for diagnosis psychiatric diseases however there’s another tool the ICD the International classification of disorders as the worldwide recognized tool for classifying all medical disorders and psychiatric problems are considered medical disorders now the problem is that when the DSM changes and the ICD changes they don’t change at the same time so now we have some new problems that are introduced because the new DSM doesn’t match the old ICD will have to work all of that out amazingly this kind of system has been working for quite a while the dsm-4 isn’t fifth major revision this year the ICD is actually in its 10th major revision somehow it works sometimes it kind of shocks me that it does but it does these are the dsm-4 criteria essentially the outgoing criteria and what they talk about is this in essence three major areas of problems for people who have an autism or an autistic disorder diagnosis and those three areas are essentially deficits in functional verbal communication functional nonverbal communication and restricted rip or repetitive or stereotyped behaviors or areas of interest the first serie a functional verbal communication essentially means that these kids have trouble either learning to talk or more particularly learning to talk in a way that it’s used for communication and so there’s a mage it’s a spectrum on the severe and kids may have little or no language output and in particular if they do have language output that language output may be more self stimulatory or what we call stimming it may be there more to sort of amuse the child themselves rather than communicate so the child may sing songs that they hear on TV but they won’t ask for things with words that’s functional communication they won’t tell you what they need or what they want you to do if they want you to do something they may use some other means like pulling your hand to the refrigerator door or they may just cry and let you figure it out then on the nonverbal side the same kind of concept body language gesturing pointing eye contact these are all forms of communication as well and the point again is that these are used to communicate so kids are looking at you for the purpose of getting your attention and we’ll talk about this idea of joint attention which is a really important concept in understanding autism kids are pointing to get your attention and draw to something like I want that one or why don’t you go in the kitchen and make me a drink right there waiting or nodding these are all forms of communication using the body again it’s a spectrum of the severe end these may be completely absent and the mild ending just may not be well it degraded or modulated meaning they’re used awkwardly they’ll use one at a time whereas if I want you to do something I might look at you if I think I do in the back row i might say can you close the door please i’ll look at you a look at the door i look back at you to see if you looked at the door i’ll point at the door that’s integration of multiple means of functional verbal and nonverbal communication I’m talking to you I’m looking at you and pointing and monitoring you with my with my vision right so those that’s what i mean by integration we’ll talk a little bit more about that in a curly slide but that’s a

second piece so we’re not only asking is it present but isn’t well integrated and then the restricted or repetitive behaviors in lower functioning kids is maybe rocking and flapping and things like that in higher functioning kids is going to be specific here as an interest until you get a usual pattern of interest experienced clinicians tend to think in exemplars meaning i think a specific kids who fit these criteria so well than to help me remember what it is that i’m trying to remember so if i give you a couple examples from keith i see so an example of an unusual interest area in a younger kid we had a kid in Florida who was really interested in years and air conditioners and things like that see we draw them all the time if you brought him over your house and there was one of those outside you could he’d be standing over by and looking at it um if you ask him to rocket or a person you draw a body with a radiator forehead right so that’s an unusual pattern of interest even in someone who works courage as a job you know if their job we’re creating radiators that still be estrangement interest right another example is um when I was in Chicago I saw a child who was was older and he was rewritten sounds pretty normal right but this kids interest in football was that he could draw every NFL helmet for you and you get to give you some statistics and things he asked him how you play football and why football is fun he would look at you kind of blankly and wouldn’t be able answer those kinds of questions and he didn’t play football you do like particularly like watching football and so it’s an unusual pattern of interest compared to other little boys who like football until you may see one or both of those things those restricted here interest can be very consistent over a lifetime they can also change over mine and then you’re looking for some rule outs and so for instance some of these repetitive behaviors happen in many kids who have intellectual delays MRDD kinds of kids and so for instance those kids lots of those kids rock and flatbed spend and so if you’re seeing that in the context of globally low functioning then that’s not that’s less likely to be autism that’s to be disproportionate here similarly if you’re seeing delays in speech development but as the kid is learning to talk they’re using all that language functionally that’s much less likely to be autism as much way to be a language delay and you want to look out for some specific medical reasons for these kinds of problems that’s actually kind of an area of controversy within the field there are more and more genetic syndromes that feature things like autism if you look at them closely each one of them most of them don’t look exactly like traditional autism but then again traditional kids with autism don’t look one like the other a high functioning person who is a friend of mine the way he said it is if you met one person with autism you’ve met one person with autism they’re all very different one over the other and so that’s actually there controversy like are their genetic syndromes that are close to autism but they’re not autism and for instance can you have autism secondary to these genetic syndromes then the reason that’s a controversy is it affects service eligibility on our side to a VA for instance is only approved for autism and related disorders and so if it’s not an autism spectrum disorder it’s another genetic condition that causes unusual development in social interactions it’s not eligible for the clinical service that’s I so that’s a bone of a contention that we’re still figuring out together the real answer on our side is going to be very similar the real answer on your side the question would ask is one of these other kids do they benefit from the same therapies if they do that’s a good argument that these are autism spectrum issues if they don’t it’s a good argument that there’s something different about them having the same problems so I wonder briefly mentioned some other technical terms that are currently used Asperger’s disorder your public or donut or Asperger’s syndrome and then some people say syndrome in particular because this one has a real range these kids are all by definition cognitively normal with some very rare exceptions meaning they have a normal IQ they met their basic milestones on time to have the autistic disorder diagnosis you have have the late milestones these kids have to have untied milestones they have to learn to walk and talk on but they still have all the same symptoms we just talked about they have difficulties using language to communicate it’s going to be subtle especially if you’re older kids what you’re gonna find is that it’s it’s that they don’t use the subtle aspects of language they don’t understand jokes as well they donors and understand slang or not literal language or ambiguous language they don’t understand how to use language for things like small talk small talk is what they will call a particularly neurotypical activity and they have conversations amongst themselves about why we do stuff like that so in the restricted behaviors and patterns yawns

are inviting the nonverbal behaviors very similar again it’s going to be poorly modulated eye contact they’re going to be able to typically point and wave and things like that they may not use these things as often as other people they may not be able to integrate them together as often they may have to put a lot of effort into them a lot of people who have functioning eyegasms back from wooden things like Asperger’s disorder will tell me that they put a lot of work into this like they learn act essentially and when they’re trying it can appear much more like us neurotypicals with expected socially but when I’m not trying would they let it go it’s a little bit more obvious so in other respects then finally with the restricted interest sorry to see special areas of interest mostly missing less repetitive behaviors you may see some of those and they should still interfere but in the highest functioning end of this range a lot of these kids are the ones that go on to do relatively specific areas these kids are more likely to thrive in an esoteric kind of feel like the running joke is that there are lots of college professors who have ultimate I’ve asked because you’re allowed to send all your time being interested in something that ninety-nine point nine percent of the population doesn’t really care about right that’s what it’s like but but I do want to emphasize that not everyone in Asperger’s has an exceptionally high IQ it’s arranged so they’re going to similarly do well with very specific areas but you’d be surprised some of them thrive in areas where you wouldn’t expect more than a few of our Asperger’s kids really love theatre because they take it on as a challenge to figure out how to act like other people expect them to act and we have in Michigan there’s a famous basketball player who helped lead Michigan State to a world championship he actually has high-functioning autism and Asperger’s but similarly you know not exactly a place where you expect to find someone on the autism spectrum they are more and more thriving all over the place doing all kinds of things so briefly speaking directly there is another specific diagnosis pervasive developmental disorder not otherwise specified or Nos isn’t this is a catch-all for people around the autism spectrum that they don’t fit into a specific area there are a couple of other diagnoses of childhood disintegrative disorder and rest disorder that are the dsm-4 that I’m not going to go into at the moment and then more and more their genetic syndromes associated with autism that are being identified energy hypoid shipping autism is attorney should know what high-functioning autism means is a little bit inconsistent depending who is using it um generally it’s taken by professionals in the autism community to need children have an autistic disorder diagnosis but who over time improve said that the IQ is normal so that they have most of the and behavioral skills that their peers have so kids who can do flexible communication in a complex way names and sentences kids who have a normal IQ although in a previous time they had languished away sometimes kids who are pdd-nos are also referred to as high functioning autism and that’s where the confusion lies the difference is going to be the kids who have the pervasive developmental disorder not otherwise specified are not going to meet all of the clinical criteria as clearly whereas the high functioning autism where autistic disorder but there was improvement over time these kids are still going to meet all the criteria it’s just going to be more subtle than they were a younger age um and in fact he’s keen to have high functioning autism as I’m defining it meaning autistic disorder with improvement these kids are actually indistinguishable at school age from Asperger’s karen’s that’s important to know because their IQ is normal just like you asked workers kids what’s different about them is that in their clinical history they have a language delay and we’re still understanding that like is this two different pieces is language delay one piece and the rest of the Asperger’s autism symptoms and other piece or is there a reason why some kids have a delay in some kids don’t but if you look at these kids with their 10 or 11 they’re going to be very hard to distinguish clinically and most professionals would say impossible to distinguish except by their history may be back we wouldn’t treat them very differently so um briefly then people say autism spectrum in the current technical terminology offensive starts informal term it synonymous with pervasive developmental disorder and then you somewhat interchangeably they both want James umbrella terms to describe a wider range of kids all of them have these same issues problems with functional verbal and number communication and either repetitive or restricted behavioral patterns but it’s an umbrella term some of them make the specific criteria like autistic disorder in son bill and most of the diagnostic disagreement some stems from the kids

who need the nos criteria not otherwise specified criteria mostly if it’s autistic disorder everyone’s going to agree that it’s autistic disorder so you can supply has basically been finalized and it is coming out and going to happen it’s way to change things some of those things are well understood some of those changes can tell you exactly how they’re going to work and we’re going to have to wait and see together but in the new language that psychiatry and psychology are using autism moves to a new category and neurodevelopmental disorders which makes sense it’s going to continue to be alongside things like ADHD but it’s not going to continue to be alone said things like say separation anxiety there’s more of an emotional disturbance of childhood in a normally developing child so the new term is autism spectrum disorder and that’s now the formal term in the new DSM as opposed to pervasive developmental disorder and this term have been used informally and actually does the ugly diagnosis and so Asperger’s disorder is being eliminated from the dsm-5 which is a source of significant controversy especially because there’s a large group of people who identify themselves this way you are who you are right and ask for a ger contest burger and the story of how this term aspartame to be is no less relevant tomorrow than it is today but however technically then people who dad qualify for Aspergers an autistic disorder diagnosis would both receive the autism spectrum disorder diagnosis and the new definition requires both social communication deficits or restricted behavioral patterns and they modified the way that we defined behavioral patterns slightly and these changes were spread by a lack of clear clinical in between these subtypes just like I said you can’t really tell people who have high functioning autism apart from people with Asperger’s after the language delays it’s not really clear that they be in separate diagnosis although this is still a work in progress so this is an eye chart again the dsm-5 language is available online what I want to briefly mention is back there are two areas now social communication and behavioral a bird’s the first area encompasses the old first two areas when I say social communication now we’re talking about a pattern of functional verbal and nonverbal communication problems just like we were before is now considered all in one area and what we talked about restricted and repetitive behaviors that’s essentially the old criteria just like they were except they have added a new thing which is for a long time we’ve known that their sensory abnormalities in kids with autism and there’s actually evidence that some kids at abnormal pain receptor density of their skin so there’s a solid reason to believe that there are there are sensory motor and two differences gave autism this last area includes things like at usual responses to light sound temperature texture in those kinds of things and it includes these non-functional sensory play activates kids you play by licking toys or stacking them or banking them repeatedly a lot of that is stuff that we already knew was happening in autism it’s just been promoted into this behavioral pattern area because in the old criteria it wasn’t it wasn’t so it has his three become to the old functional verbal and nonverbal communication become dysfunctional so for social communication and behavioral patterns continues but there’s a slight modification so when a peasant studies looking a comparison of these but what I will emphasize is that is an area controversy among the people I respect many of them say is not a big deal and then a few of them say it is a big deal and the biggest deal seems to be over kids you have the pdd-nos criteria who have the symptoms there’s something there but they don’t fully meet the criteria for autism or Asperger’s those are the kids where there’s a big distinct there’s there’s possibility of distinction between the new and old definition and what we have to work out is whether that changes because these kids didn’t have lots of them all along or because the new criteria aren’t good want to figure that I remember there is a lot of unintended consequences right whenever we make a medical change it has all kinds of impacts on lots of other things including the educational system and you know that’s something we can only find out over time together I don’t know what will happen our emphasis is going to continue to be on serving these kids we’re going to continue to learn how best to identify and serve them and the diagnostic criteria are going to change over time but we need to make sure that it works if it leaves kids in the cracks in summary I’m just wondering the sensory motor do you see is that something that you see in Asperger’s or is that more the high functioning he won’t even ask burgers yeah and it’s going to be more subtle but it can be

there and and you a can be things like gosh there are lots of Asperger kids who do have things like restricted food pallets pellets because the tactile issues with there are kids who are less pain sensitive it consultant trouble you said to see more of it in autism and you see less of an ass burgers but also importantly you see more of it an autism at a young age and then it gets better over time and so if you’re looking at Asperger’s kids you want to look at the mini young age as well where it’s going to be more noticeable you may become very subtle over time and often times we talk about essentially taking these things in rather than over diagnosing or pathologizing them as much as possible later for these kids we want them to be just stuff you manage you know like if you sitting at a desk all day your back can start to hurt right you could diagnose that as a sensory motor abnormality or you could just say I need to get up and stretch if you can solve your problem by getting up and stretch to move you probably don’t need a diagnosis and so we try not to use a document that i noticed becomes a stumbling block Kotick it and that’s a problem right but yeah you can’t see these things in Asperger’s didn’t we do that I didn’t use that 16 and she was was diagnosed with Asperger’s and now they’ve changed that and she’s flying twenty you know anxiety disorders and Elvis and she had in a real problem with school I just spend a vacation with herself and I’ve been in Italy chocolate for a lot of time and work with with older autism like when there was only one in a group of individuals way back in the important thing to understand is that generally speaking if you have Asperger you have Asperger’s there are some kids who improved so much that they don’t need criteria anymore those Asian in the days over the last week but generally speaking even attempted to come subtle we’re going to look and see if there’s still the kind of things that were problems before it ourselves that hurt her anxiety seemed to go up a lot more as she’s gotten older see more aware of what other people think out for odd behavior so yeah now i got is mass yeah I’d be glad to talk to you more about that after good I can tell you a little bit about what we would do in our clinic or the kinds of approaches reviews yeah but then seven way something that we work on a lot and we can make significant progress well that way it would like to kind of make sure that we stand Sakura about 20 minutes left really briefly in a clinical setting there’s no blood test or definitive test fit gives you a totally objective answer for diagnosing autism however the behavioral tests have been probably validated meaning that multiple people who have the same training we use the same instruments arrived at the same answers and so they are objective in the sensitive provide consistent answers even though they’re not like a blood test that gives you an air to be or me and it’s actually also important to remember that even these supposedly objective biological tests have false positive error rates and things what I want to emphasize here is that there is a pretty well approved approach that provides consistent cancers that are reliable and valid in clinical setting even though it involves things like interviews and play observations yes everybody during you able seems a good question um kids who are on the more severe and can be pretty reliably diagnosed with after 18 months and we’ll see kids at 18 months we’re working on pushing that back but really the problem is that the kids are three they don’t get put in treatment right now that’s a bigger problem than the fact that they weren’t identified to but we can reliably diagnosed kids in there two sentries um so if they’re not aid what what do you do with them today that’s it ever oh yeah so we actually went through a process this last month last year we don’t have a state plan in Michigan for autism and something that we need to develop then there’s a council that was established last year to do that and I was part of a working group to define how we diagnose autism in clinical settings and I helped write the working paper for this and we’re currently submitting that to our council to try to embed it in our state plan it was actually a really good process and we all pretty much agree this was between eight or nine large autism practices in Grand Rapids in Kalamazoo and in the trim etro area including the University of Michigan but you need a thorough diagnostic interview and so you should really ask you to ask about a wide variety of things ranging from the gestational and early infancy history to the development industry after that unusual development of the body like like unusual development of the face the fingers the feet are really coming areas that would make us think more about specific genetic issues early attachment and temperament like this child like being held to comfort them language in motor milestones where to

look at both of those because kids with other kinds of issues to have language delays major illness is a childhood it changes and functioning over time they’re socializing their language abilities now their motor and behavior function your areas of interest he saw harm their education of the interventions have been done today and there are some specific tools I’m going to spend a little less time talking about these as you’ve been spending a lot of time talking about diagnosis and I want to get to screening um there’s a structured clinical interview a dir it’s used more in research settings although some schools also use it you’re not actually using our clinical setting because it takes up a lot of time and that we take the ticks away from our addressing what we do with the kids or don’t have autism and we can get a reasonably reliable at or without it gave us our autism diagnostic observation schedule is basically a set of play and conversation situations that make autism behaviours more evidence to the mission TM to understand autism to making use of the 80 s it’s not going to be effective unless you do but what it does is it makes these things much more readily apparent and these precedents are designed so that kids who are not on the autism spectrum will behave one way into are on the autism spectrum will behave it other way so those include things like specific situations that are structures and then kids will have social interaction like very specific ways of giving a kid a chance to show interest in something i’m talking about rather than something here she is talking about really specific ways for to see whether or not they respond to the interest I show and their topics that’s another thing where kids with autism they may talk there is very extensively about topic of personal interest and even when you try to talk to them about their issue it’s really hard to engage them so one of the kids I’ve been here caching with this summer was going was talking extensively about GPS satellites and how he had a GPS that could access the Russians have lights and the American tablet and I used to be an engineer actually know what he’s talking about but I couldn’t even engage him in a conversation about that topic of his interest so looking at seeing whether kids can engage you in their interest as well as you whether you can get your interest looking for things like whether you can get them to play imaginatively whether you can change the play situation to have them follow your lead those kinds of things happen to be a toss it’s adapted for different age ranges so it starts at about 18 months but then it goes all the way up to adulthood the situations are going to be different yeah dog versions for the high functioning people more focused on asking questions they might be questioned like hi what’s the difference between a teacher and your mother or what’s the difference between a friend and a classmate then might be questions like you know you can think of something that made you feel sad but what’s it like tickets now can you describe that feeling of sadness we’ve had examples were young or prasad for the younger kids is going to be things like if i say hey look will you look where I’m pointing can I get you to ask me for things by pointing can I get you to play with toys and imagine in fashion I do you understand cause an effect like it do you understand that if I spin a jack in the box to the bottom of the thing will pop out and then want to do it again will you expect it to happen the next time like if I stop in the middle of that social routine we look at me and laugh or say hey why did you stop or will you just walk away and do something those kinds of things are going to be more and the young kids oh yeah and then there are some things that elicit stereotypic behaviors more and different kinds of things but they’re going to be adapted to any kinds of things up to 34 year olds do so they’re very plentiful young kids and the way it works is essentially a lot of different toys and this is the old a toss but the toys are designed so that we give kids multiple opportunities to do each kind of skill we provide them varying levels of support to see if they’ll do it independently and then with some additional help so for instance if it kid doesn’t smile when you say something funny will they smile when you do a funny act you know we can chase them around or will they smile when you tickle them and then some of the kids won’t smile even put on so you’re looking at different levels of response like between what I’m normally functioning normally developing childhood do a childhood severe autism won’t do so covance of these tools these tools are really designed for specialists the is really like a microscope or a stethoscope so I said this group is not going to allow you to diagnose heart disease unless you already know what heart disease looks like right microscope is not gonna allow you to tell the difference between bacteria unless you’re a biologist you need to understand autism to use the aid us doesn’t mean you have to be specific attending physician or psychologist or whatever but you do need to understand which is a civic sense of the Agha’s interpreter is what I do evaluations I

might use an assistant for a lot of things but I do I personally did a toss hands-on for the most part because I want to see it that’s the whole point um so the more you understand how it isn’t the better a tool like da das is going to work for you and help you’ll be morning at present get to do it don’t purposely there are other components evaluation it’s really important to look at the cognitive functioning we use those as progress metrics in our clinic I’ll show you an example of that we’re looking at things like self-care skills lots of kids with autism don’t find it reinforcing to learn how to toilet for instance just like they didn’t find a reinforcing to talk and in our approach and fundamental is that when we make the diagnosis we use it to inform actual what I do an evaluation I make recommendations for medicine or Diagnostics whomever in the nation’s main clinic therapies they make recommendations for school to get ready you guys have helped make recommendations for the community of a child is ready to do sports or martial arts or top tumbling talk to inner class or playdates and make recommendations for complementary alternative medicine supplements or other things that may help the child and get a home remedies essentially and me this is an iterative process the kids come back on a yearly basis for these full evaluations come back on a quarterly basis in our clinic for ongoing progress checks we’re building that to work more and more like what you do in essence where kids get a progress part of a report card and we really emphasize early intensive behavioral intervention which is then one-on-one high intensity often 10 to 12 hours sometimes 20 30 40 hours a week of therapy one-on-one with a tutor working for behavior analyst they tell you one story about this is a kid in our clinic was in it if I’ve been in school for than three years old and the first couple years he received only academic interventions which are great but they weren’t one-on-one and then for a year he actually received clinical interventions with us primarily ot and speech and after that had an IQ a 54 and if you know I cute measures that’s not so good that puts you in the MRA the mild I mark underage and if your IQ is it 54 when you’re an adult you’re going to need like lifelong support although it may be he was in our early intensive behavioral intervention clinic for 16 months on average probably eight to ten hours a week as like you a few weeks ago was 84 and so that’s within the normal range at that level you can understand school you can participate in normal daily life activities and an adult hood if your IQ is at that level you’re likely to live independently at work so he isn’t mainstream kindergarten which is one of the major success stories the biggest one probably more fun he you know he’s starting to make friends he reads bedtime stories to his little sister which is really cute he’s trying to we’re trying to get about a t-ball team in this summer these kinds of things are going to be much more successful ones kids have a verbal level that we estimated about a five year olds verbal level because the kids were 12 schooling is designed to start there and so they’re going to be able to handle the verbal challenges at school five-year-olds if you think about them also when you’re five or six you started to have deep and meaningful friendships even normally developing kids in three or four don’t really have a fully developed friendship like you would think about older kids happy and so when you reach at five your verbal level rules in the clinic is the kids will start to ask you know like hey is Billy going to be here today or I hope that when the next time I come amy is here you know they’ll start to do things like that or they’ll start to fight over which therapist works really well and you don’t see that when they’re either Bowl level is three is it a three or three or although you see that when it’s more like a four or five year old so those kinds of things become more and more possible and in this particular case this was a case of a kid we’re just an early academic intervention wasn’t successful for him but the coordination of the two has been great we work really closely with this school we’re really excited that he’s in nature of Education we’re really what we think about there is we want to be able to kids who can learn to the cajun through 12 system which is the point of early education is devil so our next challenge is to make this happen more consistent man for markets because he’s just one kid and we have 10 kids in our early intervention program and that’s because this legislation from last year is just ramping in will probably be from the 20 to 30 range by the end of this year but that’s a small number the kids just in Grand Rapids that hit this kind of help and their kids akalin and the spigen given and be honest kind of helpless like so let me talk about screening so screaming is a crucial part of the process and these specific services like applied behavior analysis are going to really make large gains but only in kids with autism so we need to know who those kids are you can’t just apply them to the mall and besides these interventions

cost ten twenty thirty forty thousand dollars a year it’s not feasible to apply them to every child so these services work fast at young ages I nearly below six and the younger the better an average diagnosis age though still hovers around four and a half or five and so you get diagnosed at five and there’s a waiting list you might not get into the clinic until you’re five and a half you’re almost six already we need to we do need to push that back so the autism specialist doesn’t see every child we don’t think it’s unless there’s a problem in schools and pediatricians in particular take care as well play a Kosho role because you all have access to kids long before early enough that you be able to get them into this kind of process will that be nominated clinically so the American Association of Pediatrics has an acronym alarm autism is prevalent listen to parents act early refer to specialists and monitor over time that’s what the Association tells pediatricians to do and their decision matrix that you can get online basically it because it’s really very simple the alarm that’s hot boxing and I was able to read are essentially you’re looking for kids who have siblings with autism that’s a risk factor you’re looking at kids who have where the character concerned where another caregiver or an educators about that is concern or where the pediatrician and him or herself is concerned if you have one or more of those things the pediatrician should take a closer look at development you have two of those things the pediatrician should still do that but they should also go immediately to getting the child into early interventions in a clinic into early interventions in an academic setting and medical diagnostic services as well so if you have two of those things like if multiple people are concerned about the child or one burst is concerned about a child whose brother or sister has autism you should you should fastrack um and there are some concrete milestones that the Academy of Neurology proposes so kids aren’t babbling by 12 months it’s a major risk factor um cage or gesturing ludum pointer wave like I by or hello or I want that by someone’s it’s another major risk factor kids you don’t have single words by 16 months that’s unusual if they happen for multiple reasons kids dinner and have spontaneous phrases or particularly looking for noun and verb pairings by 24 months so go home or go outside or wear this or I eat pizza like those are you might have more words lunchtime to that but you want to look for those flexible Frances you don’t want to just look for I don’t want to is it is technically afraid it’s sentence it’s not a very good one if that’s all you can do you want to look for flexible sentences using several different verbs and nouns appropriate anytime to kid is a loss of language or social skills at any age is also in their morning so I not necessarily for autism but for evaluation for the regatta fish there are some specific tools but i want to mention there a few minutes left some key concepts we’ve already talked everything a little bit to developmental disorder so first of all it gets better generally over five of anything although if their specific stressors that contemporarily outdoors there is regression and autism regression it will happen to cox is among skills get worse over time it’s typically going to happen to train about to fall between four months if it happens at a different time here in the night it’s usually further on there is innocent and the new problems occur newsreader forum later and usually for a different reason but they’re still indicative of a clinical mayan specialists i can try to join attention or particularly important you’re a look for whether kids will look at you spontaneously when they look at you to get you to do something if you say like with a baby if you’re rattling you wave it will they look at the rattle when you look at the rattle will they look at the door when you look at the door if they want something well they look at that thing and then look back at you to see if they’re you’re looking to that’s join attention um any integration is specially modulation in deliberations you’re looking for eye contact that’s flexible look what I’m talking to you I’m making eye contact with a lot of you but it’s bleeding I may look in another direction when I’m talking or thinking and they not look at you at all that’s normal i contacted it recursion arrange some of you may make a lot of its of a numerical limit I’m just staring at you kind of lengthly you know whether or not I’m talking to you that’s abnormal eye contact even even though I’m looking at you so that’s not well modulated integration would be like when I’m talking to you I don’t look at you or I only look at you and I don’t talk to you so you want to use multiple games together and to join detention is using this for both in both directions for me to get to get for me to get you to pay attention to what I’m paying attention to and for you to get me to pay attention to what you’re paying attention to and gift should be able to do these things starting in those

toddler years and in a simple level in infancy so again we talked a lot about this the communication should be functional maybe it should be you should be seeing communication that’s for a purpose for asking for things for telling you about things you think about that language is naturally reinforcing babies who learn to talk and tell you they’re thirsty and so you’re drinking giving them a drink instead of changing them they can tell you they’re hungry so you’re giving them food instead of a nap right and so they get what they want that’s a area that’s what falls off track with autism and so if you’re not seeing language used to obtain pens for functional purposes that’s does a clear indicator thing you should be thinking about us a couple more things that sorry we’re running a little late here oh I want to mention briefly obvious get over some differentials between different kinds of delays how image do you want to mention these things however verse 16 to 30 months is a great tool called the modified checklist for autism puddlers it’s available for free online at this website it takes a couple minutes to allowed is 23 questions and there are some questions that are low risk and some questions are high risk and there’s some key items parents can fill this out two or three minutes is well understood by most clinicians and this will tell you if a child needs further evaluation by a specialist um so it’s available online you can actually fill it out by clicking the boxes and gifts for anyway the university of northern North Carolina actually developing a tool that is useful for for 18 months it’s not being used critically yet there are some tools for older kids the gads and the gars gilliam autism rating scale and Asperger’s disorder scale goes started three so those are good options there’s the odd social communication questionnaire that starts at four I’m send our number of options to scream older kids in a lot of these I think are already in use the educational system and so your IEP team may well be using something like the gars or gas possible as in the AP model what you should do is use these simple early screening tools first and then if you’re seeing problems simultaneously refer get the kid into their pediatrician so that they can see if they need to go specialist and then also struck the IEP process you want to make false positive errors it’s okay if some of these kids turn out not to have autism because there are multiple layers in this system that will identify that and get them into the right kind of services at the screening level you would rather do that that how they should go without is an important consideration it so just briefly what to do next you the big thing for clinical services is start start with a pediatrician and then needs to be closely involved in this process they’ll determine if the specialty evaluation but someone like me is appropriate if they don’t have a pediatrician may be one and then depending on the agenda you can do the specialist depending on the insurance plan nobody’s approvals to how that works particularly for Blue Cross and priority health insurance plan they have centers of excellence in some places are one and up the other for instance spectrums of Blue Cross Center and not a priority health center where a party health center but not blue cross under will work out all that with you we have a practice manager and most these other clinics do specifically to help figure out like you feel with all that most of us have limited scholarship programs for kindergarten access to care in fact the kid in the example it was being seen through scholarship and the rules are medicator still being finalized and so that’s thirty or forty percent of kids or so bigger now that works it’s supposed to happen starting around April so there’s some information about how to get ahold of us we do videotape a lot of things especially to see if a round website as there’s lots in educational resources available to you there as part of the community we’re really deeply motivated to work with all of you to help put you in the best effort to start them on a little long as I back up I’m happy to answer questions make sure you get one of these