Webinar: Autism in Preschool (Dr. Mike Assel)

Au#sm in the Pre-‐School Classroom

Dr. Mike Assel University of Texas Health Science Center at Houston

Associate Professor of Pediatrics May 17, 2012

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Today’s Speaker


Dr. Mike Assel Associate Professor,

University of Texas Health Science Center

Hatch Early Childhood Webinar May 17th, 2012

Mike A. Assel, Ph.D.

Autistic Spectrum Disorders within Early Childhood Educational Settings:

What a Teacher needs to know?

Why this topic? A simple question with an alarming answer? A US study completed in 2009 revealed that the average age of formal ASD

diagnosis was 5.7 years of age.

�  Shattuck, et al, (2009). Timing of identification among children with an autism spectrum disorder: findings from a population-based surveillance study.

Perspective from a teacher www.proteacher.net posted by dramacentral on 06-18-2006, at 04:38 AM �  “I found the job to be very rewarding and got lots of great experience, but it

was tiring. Sometimes the kids would appear to make progress and then suddenly "lose" the skills we'd taught them. It frustrated me very much when I couldn't get them to comply or when they engaged in behavior that was bizarre or hurtful to themselves or others. I developed a very close attachment to them, but it felt quite alien at first. You don't always get the typical feedback from them - you can't always tell by looking at them whether they are listening to you as you speak, or even if they know you are present. Some kids are very affectionate, but others may not show any signs that they like you or even recognize you from day to day. Some of my kids took a whole year just to learn to say my name - but when they did, it felt amazing. That is one of my proudest moments as a teacher”.

Teachers and Pediatricians �  Are on the front line in terms of early identification. �  Early identification is critically important due to the fact that

the there is a clear link between when children start treatment and their general developmental outcomes.

�  In short, kids who receive early intervention tend to have less severe presentations of the disorder.

What is an ASD? �  Current Classification: The autism spectrum or autistic

spectrum describes a range of conditions classified as pervasive developmental disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

�  Currently, the Pervasive Developmental Disorders include �  Autistic Disorder �  Asperger’s Disorder �  Pervasive Developmental Disorder, Not Otherwise Specified �  Childhood Disintegrative Disorder �  Rett Syndrome

�  The first three conditions are considered part of the Autistic Spectrum Disorders (and our talk today will focus on these areas).

Core Deficits

Social Deficits

Communication Deficits

Restricted and Repetitive Patterns of Behavior

Difficulties in Social Interactions �  Impairments in the use of multiple nonverbal behaviors

(e.g., eye gaze, facial expression, body posture, and gestures to regulate social interaction).

�  Failure to develop peer relationships appropriate to the developmental level.

�  Lack of spontaneous seeking to share enjoyment, interest, or achievements with others.

�  Lack of social or emotional reciprocity.

Qualitative Impairments in Communication �  Delay in, or total lack of, the development of spoken

language (without attempts to compensate through something like gestures).

�  Marked impairment in ability to initiate or sustain conversation.

�  Stereotyped and repetitive language �  Lack of varied spontaneous make believe play or social

imitative play.

Restricted and Repetitive Patterns of Behavior �  Preoccupation or obsessive interest in one or more stereotyped

behaviors. �  Inflexibly adhering to specific nonfunctional routines or rituals. �  Stereotyped and repetitive motor mannerisms

�  Hand flapping, finger flapping, complex whole body movements. �  Persistent preoccupation with parts of objects.

Other areas that MIGHT be impacted by ASD diagnoses.

�  Attention �  Anxiety �  Sensory-Integration �  Digestive Issues

Prevalence: Newsflash 3-29-12 �  The Centers for Disease Control and Prevention estimates

that 1 in 88 children in the United States has been identified as having an autism spectrum disorder (ASD), according to a new study released today that looked at data from 14 communities. Autism spectrum disorders are almost five times more common among boys than girls – with 1 in 54 boys identified.

Why the increase? �  Research has reported that as much as 40% of rise in ASD

diagnosis could be explained by broader diagnostic categories and heightened awareness.

�  BUT--- what about the other 60%. �  Honestly, we don’t know. However, suspicions have centered on

the following. �  Genetic changes �  Something in the environment �  Maternal or paternal age �  Multifactorial (combination of genetic and environmental factors). �  Mitochondrial Disorders �  Prior suspicions (Vaccines)

The teacher’s role in EC settings…. �  The 3 Rs……

�  Recognize… Teachers have a duty to know general developmental milestones (first). This will allow a classroom teacher to understand when a child is not meeting milestones and could potentially be at risk for some type of learning difference or ASD.

�  Report… If universal screening of language and/or social skills reveals that a

child is at risk, it is imperative that teachers take steps to initiate a more comprehensive evaluation. �  Centers and districts vary in terms of the processes that are used to make a

referral. �  Imperative that teachers know the procedures for referring children in their

particular setting. �  Respond… Teachers have a responsibility to assist the child through

implementation of any educational plans that might be put into place following the formal evaluation.

Recognition: NICHD Red Flags for Autism_Social

Social

The child does not respond to his/her name.

The child doesn’t point or wave “bye-‐bye.”

The child doesn’t know how to play with toys.

The child doesn’t smile when smiled at.

The child has poor eye contact.

The child seems to prefer to play alone.

The child gets things for him/herself only.

The child is very independent for his/her age.

The child seems to be in his/her “own world.”

The child seems to tune people out.

The child is not interested in other children.

Recognition: NICHD Red Flags for Autism_Langugae

Language

The child cannot explain what he/she wants.

The child’s language skills are slow to develop or speech is delayed.

The child doesn’t follow direc@ons.

At @mes, the child seems to be deaf.

The child seems to hear some@mes, but not other @mes.

The child used to say a few words or babble, but now he/she doesn’t.

Recognition: NICHD Red Flags for Autism_ Restrictive and Repetitive Patterns of Behavior Restric1ve and Repe11ve POB

The child throws intense or violent tantrums.

The child has odd movement paCerns.

The child is overly ac@ve, uncoopera@ve, or resistant.

The child gets “stuck” doing the same things over and over and can’t move on to other things.

The child does things “early” compared to other children.

The child walks on his/her toes.

The child shows unusual aCachments to toys, objects, or schedules (i.e., always holding a string or having to put socks on before pants).

Child spends a lot of @me lining things up or puHng things in a certain order.

Why is language such an important indicator of developmental progress…… �  The ability to use language makes us human. �  We are inherently social beings and from the dawn of time

humans have developed social systems that allow us to live better lives.

�  Language is also tangible (i.e., something that is fairly easy for parents to see and categorize). �  For instance, a child who has no language at age 3 is easy to pick

out in a crowded classroom of 12 other youngsters. In contrast, it is more difficult for parents to rate the quality of social gestures or eye gaze.

A Closer look at Language Development (American Speech- Language-Hearing Association)

One to 2 years of age

Hearing and Understanding Talking •  Understands differences in

meaning ("go-stop," "in-on," "big-little," "up-down").

•  Follows two requests ("Get the book and put it on the table").

•  Listens to and enjoys hearing stories for longer periods of time

•  Has a word for almost everything. •  Uses two- or three- words to talk

about and ask for things. •  Uses k, g, f, t, d, and n sounds. •  Speech is understood by familiar

listeners most of the time. •  Often asks for or directs attention

to objects by naming them.

2 to 3 years

Hearing and Understanding Talking •  Hears you when you call from

another room. •  Hears television or radio at the

same loudness level as other family members.

•  Answers simple "who?", "what?", "where?", and "why?" questions.

•  Talks about activities at school or at friends' homes.

•  People outside of the family usually understand child's speech.

•  Uses a lot of sentences that have 4 or more words.

•  Usually talks easily without repeating syllables or words.



4 to 5 years

Hearing and Understanding Talking •  Pays attention to a short story and

answers simple questions about them.

•  Hears and understands most of what is said at home and in school.

•  Uses sentences that give lots of details ("The biggest peach is mine").

•  Tells stories that stick to topic. •  Communicates easily with other

children and adults. •  Says most sounds correctly except a

few like l, s, r, v, z, ch, sh, th. •  Says rhyming words. •  Names some letters and numbers. •  Uses the same grammar as the rest

of the family.

Report (the 2nd R). �  Once symptoms have been recognized, we have a duty to assist

program directors, diagnosticians, or school psychologists complete an evaluation.

�  However, for many teachers, the first step is gathering information from parents surrounding behavioral concerns.

�  I have heard horror stories from parents surrounding how they have been told about behavioral concerns about their children. �  Some general guidelines.

�  Teachers are not diagnosticians and should not put themselves in a position to label a child.

�  One of the safest approaches is ask questions. Teachers can provide parents with some obvious information and then, provide a question (e.g., I have noticed that Jack has some trouble asking for help, what is his language like within the home?).

Report (the 2nd R) continued. �  Teachers might be asked to complete checklists, participate in

interviews, provide work samples, and describe the behaviors of concern surrounding a particular child.

�  An observation of the child within the classroom might be scheduled.

�  When completing checklists, specificity is critical. �  Vague comments are NOT helpful (e.g., Jimmy seems kind of odd). �  Comments that clearly describe the observed behaviors help diagnosticians

and school psychologists accurately assess children with ASDs (e.g., Jimmy rarely uses language in the classroom, he actively avoids other children, walks on his toes, covers his ears when the bell rings, and occasionally flaps his hands).

What happens after a referral has been made? �  The specific measures used within an evaluation vary by

community. However, there are some similarities. �  Cognitive Evaluation (IQ)

�  Wechsler (WISC-IV, WPPSI-3) �  Another measure of nonverbal behavior (e.g., Leiter International

Performance Scale-Revised, Comprehensive Test of Nonverbal Intelligence, Woodcock-Johnson Tests of Cognitive Abilities).

�  Evaluation of Adaptive Behavioral Functioning (e.g., Vineland Adaptive Behavior Scales, Adaptive Behavior Assessment System).

� Assessment of Language Functioning (e.g., CELF-Preschool-2, EOWPVT, PPVT).

� Assessment of symptoms related to ASDs (e.g., ADOS, ADI-R, CARS, etc).

� General behavior questionnaires (e.g., CBCL).

What is so important about an evaluation anyway? �  While it is true that many evaluations seem unnecessary, at

the minimum a FIE evaluation serves as a gate-keeping function (i.e., opens the door for specialized services).

�  However, a good evaluation provides the following… �  Accurate description of the developmental levels �  Provides insight into the types of strategies that work to

motivate a child with an ASD �  Provides the ARD committee with specific

recommendations surrounding the type of educational environment that would be ideal for the student.

Responding appropriately in the classroom: The third R. �  Needless to say, the way teachers respond to children with

ASDs is critical within the educational environment. �  Some teachers have spent their entire careers working to

perfect teaching strategies for children with ASDs (almost like a process of self-actualization where we continue to strive to make ourselves better).

�  In this section of the talk, we will talk about some general guidelines (and conclude with some more specific approaches).

You won’t be alone……hopefully. �  One of the benefits of the comprehensive evaluation is that it

opens up the door to a range of more specialized services. �  Speech Therapy � Occupational Therapy �  Social Skills Groups �  Behavioral support

Not all kids with ASD are the same �  The title on this slide is a no brainer. �  However, it is a serious issue.

� Children with ASDs run the gamut from being nonverbal and self-aggressive to quirky/unusual.

�  Important for all to remember the idea that it is spectrum of behavior in almost a literal sense.

�  In general, children with severe forms of the disorder that might include self aggression or significant behavior regulation difficulties are likely to be enrolled within a self-contained SPED classroom placement.

� However, that still leaves an incredible range of children who can be served within the regular classroom setting with differing levels of support.

Understanding ASDs from the child’s perspective…. �  One of the things that I have always try to do when assessing a child with an

ASD is to understand how they experience the environment. �  While certainly not an exact science, I take time to see if how a child……

�  Approaches others in social contexts �  Deals with environmental stimuli (e.g., aversion to lights, sounds, etc.). �  Responds to a touch (e.g., can they handle hand over hand demonstrations,

do they allow you to touch their chin to raise their chin for eye contact). �  How does a child comfort themselves when stressed �  What motivates the child (praise, tangible rewards, being left alone, ability

to engage in some form of self- soothing behavior). �  Even if you’re not an expert at some of the approaches used for children on

the spectrum, understanding how the child perceives the environment can help you be successful.

Take time to learn from members of the treatment team. �  Teachers will find that one of the best ways to learn how

to improve educational opportunities for children with ASDs is to learn from those with more experience.

�  I have been taught how to assess children with ASDs by other psychologists, speech pathologists, ABA staff, occupational therapists, moms, and siblings.

�  The one thing that is a given is that you will have to flexible due to the fact that the range of behavior for kids on the spectrum is so diverse.

Participate in all training opportunities offered by your center, district, or educational service center.

�  Learning to intervene is a process and as you move through your career you will be provided with training opportunities (e.g., today).

�  I can promise you that there is NO magic bullet training (i.e., one where you will leave and have the experience to work successfully with children with ASDs).

� However, you’ll take away things from most trainings that you can effectively implement in your classroom.

Take time to learn from the family of the child. � Never underestimate the power and knowledge of a

mother of child with Autism. �  Ask the mom about motivators, self-stimulatory

behaviors, methods used within the home to elicit compliance, and/or things to avoid.

General strategies for incorporating ASD children into the EC classroom �  Establish and maintain a consistent classroom routine.

� This is incredibly important as many children on the spectrum have difficulty adapting to change.

� Children with ASD will benefit from visual schedules which allow a tactile response (e.g., moving a stick or picture symbol with Velcro to the next scheduled activity).

Control the environment � Children with ASDs often struggle tolerating different

sensory input (i.e., called sensory integration difficulties/disorder). Therefore, teachers should make efforts to understand how environmental influences like (e.g., noise & light) impact children with ASDs.

�  Reasonable attempts to accommodate children’s sensory issues should be attempted.

Find the special interest and use it to motivate. � Children with ASDs often have some fairly specified

interests. �  In some instance, the heightened interest is described as

being an obsession. � However, children with milder presentations often

demonstrate appropriate interests in certain topics. Therefore, teachers need to determine what is an appropriate interest and find ways to get children to engage with peers surrounding that area (e.g., cars, trains, etc.).

Work diligently to keep children with ASD engaged. � One of the saddest stories that I hear from parents of

ASD children is when report that “the classroom teacher just seemed to let Jimmy wander around the room”.

�  Persistence, creativity, and appropriate reinforcement should be used to keep a child with ASD engaged in the classroom.

�  Teachers have to remember that their efforts might not be rewarded routinely.

Make requests that are clear and concise. � Concrete language should be used when making requests

to children with ASDs. �  Requests presented with pictorial supports have a better

chance of being followed. �  Lengthy instructions should be avoided (think Charlie

Brown’s teacher). � Use clear directives and avoid questions that could be

answered with “no” (e.g., OK, do we need to wash our hands now).

Make of habit of gently pulling for eye contact. �  Children with ASDs struggle establishing eye contact and joint

attention. �  Essentially, teachers have a responsibility to work to encourage eye

contact of children with ASDs. �  In my clinic, I will NOT provide instructions to children who do

not give me some indication that they are looking at me. �  They might not look at me the entire time that I am reading instructions for

tasks, but I encourage them to look at me to the best of their ability.

�  Looking at a speaker is typically a skill that comes naturally. Children with ASDs need to be taught to engage in this particular behavior.

Be a sponge and a squeaky wheel. �  Soak up knowledge from other service providers.

�  Ask the speech pathologist what types of activities you should be working on.

�  Ask the speech or occupational therapist whether or not they have found any specific techniques to motivate the student.

�  Actively seek out training opportunities. �  Push administrators to provide access to quality

training opportunities.

ABA, Floortime, and TEACH. � Historically, there are a number of well established

programs that have demonstrated success with children with ASDs.

� However, it is beyond the scope of a training like this to even provide a decent overview.

� However, let’s spend a minute or two on each one.

Applied Behavior Analysis �  Applied behavior analysis (ABA) is a science that involves using modern

behavioral learning theory to modify behaviors. Behavior analysts reject the use of hypothetical constructs[1] and focus on the observable relationship of behavior to the environment.

�  By functionally assessing the relationship between a targeted behavior and the environment, the methods of ABA can be used to change that behavior. Research in applied behavior analysis ranges from behavioral intervention methods to basic research which investigates the rules by which humans adapt and maintain behavior. \

�  Studies based upon the model proposed by Lovaas have demonstrated the effectiveness of ABA approaches.

�  Probably the best studied.

�  Downside for school settings: Intensity and cost (i.e., most models advocate for 25-40 hours of 1:1 intervention per week.

�  However, center based programs are gaining in popularity.

Floortime… For every action there is an equal and opposite reaction. • The Greenspan Floortime Approach is a system developed by the late Dr. Stanley Greenspan. Floortime meets children where they are and builds upon their strengths and abilities through creating a warm relationship and interacting. It challenges them to go further and to develop who they are rather than what their diagnosis says.

• In Floortime, parents spend time with their children in hopes of exiting their interests, increasing social skills, challenging children to be creative, curious, and spontaneous.

• Key Ideas • Follow the child’s lead • Challenge the child to be creative and spontaneous • Expand the interaction to cover most of the senses, motor skills, and emotions. (From the Floortime website).

Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH). TEACCH is a service, training, and research program for individuals of all ages and skill levels with autism spectrum disorders. Developed at the University of North Carolina in 1964 by Dr Eric Schopler and Dr Robert Reichler. Principles: • understanding the culture of autism • developing an individual person- and family-centered plan for each student • structuring the physical environment in a way that will assist students with autism to understand meaning • using visual supports to make the sequence of daily activities predictable and understandable • using visual supports to make individual tasks understandable.

• Additional information http://www.txautism.net/docs/Guide/Interventions/TEACCH.pdf

If educators know what works, why do parents complain about lack of quality services? �  In 2006 and 2007, there seemed to be a ground swell of public

interest in seriously working to provide quality treatment for ASD children.

�  At the time, we had special grant initiatives funded by the NICHD, private foundations were stepping up with resources, and you couldn’t turn on a television with a story on ASD.

�  However, around the same time we had the near collapse of the financial markets and there is much less talk.

�  We still have spikes in interest (e.g., when the 1 in 88 children number was introduced this spring). But, Texas suffered through a brutal budget cycle and it seemed that the focus on ASDs faded away with shrinking education budgets.

But there is hope…. �  Districts, parents, and professionals are taking the lead in

attempting to provide services that are of high quality. �  For instance, school districts are collaborating more with

private practitioners who are training teachers/staff to implement high quality programs.

�  Example… therapists who conduct social skills groups for children with high functioning ASDs in the private sector actually working for districts on a contract basis.

�  In addition, parents are becoming increasingly savvy. � A parent of one of the children I assessed retained the services

of a parent advocate and the child was eventually allowed to transition to a community based ABA program.

Hope…..continued �  As most of us understand, school districts are often an

incredibly large bureaucracy and change is difficult. �  I have a suspicion that the explosion in Charter Schools is

eventually going to have an impact on children with disabilities.

�  Finally, districts that figure out to work with partners are likely to have the most success.

Change is occurring….. �  In my short career in Houston, I have seen a huge increase in the

level and quality of services. �  16 years ago, when I started seeing patients in Houston, we

routinely counseled family of children with ASDs to contact Lovaas and colleagues at UCLA to arrange for ABA trainers to fly into Houston and train the family/staff.

�  At that time, most school districts, aggressive avoided implying that they might be able to provide some type of ABA program.

�  However, Houston currently has several center based ABA programs (of varying quality), individuals can arrange to work with practitioners who specialize in Floortime, and everyone is beginning to recognize that school districts need support.

Parents and technology…. �  I half jokingly state that “I learned more from mothers of

children with ASDs than most of the my graduate professors”.

�  Parents are driving forces behind the technology in AAC devices.

�  Augmentative and alternative communication (AAC) is an umbrella term that encompasses the communication methods used to supplement or replace speech or writing for those with impairments in the production or comprehension of spoken or written language.

AAC devices_continued �  Did you ever think you might hear someone mention that

Steve Jobs is a leader in the field of treatment for ASDs. �  The jury is still out, but I can tell you that parent interest is

driving product development. �  All you have to do is take a look at children, teens, and adults

to see how they are glued to their iphones, iPads, and laptops.

�  Many children with ASDs have the same level of heightened interest.

�  Yesterday cnn.com ran a story about a young child with an ASD

http://www.cnn.com/2012/05/14/tech/gaming-gadgets/ipad-autism/index.html?hpt=hp_bn11

�  Comments from a happy Dad. �  The dad reported, before the iPad, “the child’s only way of

communicating was crying. She was non-verbal and had no way of expressing what she wanted or how she was feeling.

�  "What the iPad has done has given her a sense of control that she never had before,“

�  "She knows when you touch it, something is supposed to happen. She knows she doesn't need to cry, she needs to point."

The research delay…. �  As I read stories about technology, I wonder whether or not

research studies are being conducted. �  We have consumers driving product development and little

data available to districts about whether or not the investment in technology is worthwhile.

�  This is due to the fact that the peer review takes a fairly long time.

�  Studies being done today are likely to be published in the next 2-3 years.

Applications to explore �  Proloque2go �  My Talk Tools �  iPrompts �  iCommunicate �  SpeechTree

�  In terms of positives, parents will not tolerate applications that are not intuitive and don’t work.

Is there a downside to AAC devices? �  The jury is still out. However, the popularity of these devices

makes me wonder about children with mild presentations who might become overly dependent on the machine versus learning to speak via more traditional means (e.g., speech therapy, social-language groups, etc).

�  However, it is hard to argue with some of the anecdotal evidence of parents who describe that it has literally allowed their children to express themselves for the first time.

Some final thoughts…. �  With AAC devices or intervention programs, I have

overarching rule for parents….. �  When it comes to Autism, if anyone tells you that it

is easy, run the other way…..fast. �  Parents, teachers, and children who make significant gains

work hard. In short, nothing comes easy.

Ques#ons


Dr. Mike Assel Associate Professor,

University of Texas Health Science Center


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