Infants and
Toddlers with or at
Risk for ASD: Early
Identification and
Evidence-based
Practices.
Cox, A, & Shaw, E. (2011). Infants and toddlers with or at risk for ASD:
Early identification and evidence-based practices. Presentation at
the annual Smart Start Conference. Greensboro, NC, May 3, 2011.
National Professional Development Center on Autism Spectrum
Disorders, FPG Child Development Institute, The University of North
Carolina at Chapel Hill.
National Professional Development
Center on Autism Spectrum
Disorders
A multi-university
center to promote
use of evidencebased practice for
children and
adolescents with
autism spectrum
disorders
FPG Child Development Institute, University of North Carolina at Chapel
Hill; M.I.N.D. Institute, University of California at Davis Medical Center;
Waisman Center, University of Wisconsin at Madison
Goals of the National Center
• Promote development, learning, and
•
•
achievement of children with ASD and support
families through use of evidence-based
practices
Increase state capacity to implement evidencebased practices
Increase the number of highly qualified
personnel serving children with ASD
What do we do?
Bridge the Gap
Replicable
practices in
programs and
classrooms
Researchbased
practices
Topics of this Presentation
• Characteristics of autism in infants
and toddlers
• Early screening and diagnosis
• Evidence-based practices for toddlers
with ASD
Part I
Characteristics of Autism in
Infants and Toddlers
Autism Spectrum Disorders
•
•
•
•
Are developmental disorders
Symptoms evolve and change with development
“spectrum disorder”
Consists of the following primary diagnoses:
 PDD-NOS
 Autism
 Asperger ‘s syndrome
Core Triad of Characteristics
• Impairments in Social Interaction
• Impairments in Communication/Language
• Restricted, Repetitive, and Stereotyped
Patterns of Behavior, Interests, and
Activities
DSM-IV Symptoms of Autism
• Qualitative impairment in social
interaction
 decreased/absent nonverbal behaviors to
regulate interactions
 lack of spontaneous sharing
 lack of social reciprocity
 failure to develop peer relations
DSM-IV symptoms of autism
• Qualitative impairments in
communication




delay in communication/speech development
lack of appropriate imitative or pretend play
lack of initiating and sustaining conversation
stereotyped, repetitive language
DSM-IV symptoms of autism
• Repetitive, restricted patterns of behavior,
interests, and activities




preoccupation with parts of objects
repetitive motor movements
abnormally preoccupied with interests
rigid adherence to nonfunctional rituals,
routines rarely endorsed
Not all DSM-IV criteria for autism
applicable for young children
(Stone 1999)
How early do symptoms or
characteristics of ASD emerge?
Characteristic developmental
problems in 24 month olds with
ASD
In virtually all children
• Problems with imitation
• Joint attention deficits
• Receptive and expressive language delays and
deviance
• Immature functional and symbolic play
• Lack of typical emotional expressiveness and
communication
Developmental problems in
18-24 month olds with ASD
In many children
• Increased repetitive behaviors
• Increased parental reports of sensory
•
responsivity
Sleep, eating, and behavior problems
Imitation
• Imitation
 Imitation is used by typically developing
children to acquire communication, social,
and motor skills
 Imitation skills of children with ASD tend to be
poor
 Impairments in imitation often persist
throughout life in individuals with ASD
Problems imitating other
people’s actions (Rogers et al., 2004)
Autism specific problems with all types of
imitation
8
7
6
5
*
*
autism
DD
typical
4
3
2
1
0
manual
oral
object
Deficits in play
• Symbolic play underdeveloped
• Functional object use infrequent
• Sensorimotor play – less novelty and more
•
repetition
Fewer advanced play
schemes
Repetitive and Exploratory Play
(Ozonoff et al., 2008)
Atypical Uses of Objects
•Spins (frequency)
•Rolls (frequency)
•Rotates (duration)
•Unusual Visual (duration)
10
70
9
Frequency
7
6
Autism/ASD
5
Other Delays
4
No Concerns
3
2
Duration (seconds)
60
8
50
Autism/ASD
40
Other Delays
30
No Concerns
20
10
1
0
***
0
Spins
** **
Rolls
Rotates
*
*
Unusual Visual
***
Sample – 12 month olds, 9 ASD, 10 DD, 47 TYP
Additional Learning
Characteristics and Needs
• Sensory issues: Heightened or decreased
experience of sounds, lights, movement,
touch, smell or taste, or fascination with
sensory experiences
 Contribute to distractibility, difficulty in shifting
attention
 May lead to avoidance behaviors
 May lead to sensory seeking behavior
 May impact learning, social interactions,
behavior
Sensory/repetitive behavior
(Rogers et al 2003)
Total sensory scores of
2 year olds on Dunn’s Sensory Profile
60
14
50
40
Total repetitive behavior scores on
ADI
*
*
*
12
10
8
30
*
6
20
4
10
2
0
autism
FXS
DD
typical
0
ADI total
autism
FXS
DD
typical
Developmental rates from 6-24
months: Language development
9 children with ASD; 27 with typical development
p<.001 at all ages except 6 months
30
27
24
dev.age
21
ASD RL
TYP RL
TYP EL
ASD EL
18
15
12
9
6
3
6
12
18
Months
24
Developmental rates from 6-24
months: Motor development
9 children with ASD; 27 with typical development
p<.001 at all ages except 6 months
30
27
24
dev. age
21
ASD VR
ASD FM
TYP FM
TYP VR
18
15
12
9
6
6
12
18
Months
24
Prototypic “early autism profile”
25
20
15
10
TYP
AUT
5
0
TYP
LANG
SOC
COG
SC
FM
GM
Prototype of 24 month old profile
Take home messages
• Onset of ASD symptoms more of a continuum
•
•
•
•
than a dichotomy.
Onset of ASD symptoms typically occurs
between ages 1-3.
Deceleration of development occurs in the
majority of children.
Different routes to full symptom expression may
represent individual differences.
Children on the spectrum have different early
developmental characteristics than typically
developing children.
Part II: Early Screening and
Diagnosis
Value of Early Identification
• Mean age of autism diagnosis
•
Years
•
= 34 – 61 months
Mean age of first parental
concern = 18 – 19 months
Gap means 1-2 years
before diagnosis made
 Treatment thus delayed
Intensive early
intervention = better outcomes
Earlier identification  earlier
intervention
•
•
Mandell et al., 2005
8
6
4
2
0
First
concerns
Autism
Dx
PDDNOS
Dx
n = 965
Asperger
Dx
What are the Red flags
of ASD?
Red flags of autism in infants
Impairment in Social Interaction
• Lack of appropriate eye gaze
• Lack of warm, joyful expressions
• Lack of sharing interest or enjoyment
• Lack of response to name
Impairment in Communication
• Lack of showing gestures
• Lack of coordination of nonverbal communication
• Unusual prosody (little variation in pitch, odd intonation,
irregular rhythm, unusual voice quality)
Repetitive Behaviors and Restricted Interests
• Repetitive movements with objects
• Repetitive movements or posturing of body, arms, hands,
fingers
IDEA Early Identification
Efforts
 Early ID is federally mandated



through Part C of IDEA.
Are the processes for early ID
similarly mandated? No!
There is currently no standard for
ID of children under 2 years.
There is no national data of
number of infants/toddlers with or
at risk for ASD.
NECTAC/NPDC on ASD On Line
Survey
2009
40 respondents in 30 states/jurisdictions
scattered throughout the US and Pacific.
 Part C program = 18
 Section 619 program = 13
 Represented both programs = 9
Survey Question: Screening
Which screening measures or tools are used to
screen young children for ASD?
States could select “all that applied” from a list of
typically used measures.
Screening Tools
Screening tools most often used out of 10 screening tools
identified. Most respondents indicated that more than one
screening tool is being used (N=36, 90%).
Measure
States/Jurisdictions
(N=40)
% of Participating
State/Jurisdictions
ASQ-SE
33
83%
MCHAT
29
73%
CHAT
14
35%
Survey Question: Diagnostic
Procedures/Instruments
Identify the instruments/procedures used to
diagnose ASD in children under five years of
age.
States could select “all that applied” from a list of
typically used instruments or procedures.
Diagnostic Instruments/Procedures
Most frequently identified diagnostic instrument/procedures
used in states. Most respondents indicated that multiple
measures were being used (N= 29, 81%)
Measure
States/Jurisdictions
(N=36)
% of Participating
State/Jurisdictions
CARS
25
69 %
ADOS
22
61%
DSM-IV
18
50%
3
8%
No diagnoses made
Current Trends: Age of Earliest
Diagnosis
87.5% of Part C and Section 619 coordinators
indicated a trend in diagnoses before age 3
<18 months = 3 (7.5%)*
Between 18 and 23 months = 17 (42.5%)
Between 24 and 35 months = 15 (37.5%)
Between 36 and 47 months = 4 (10%)**
Between 48 and 59 months = 1 (2.5%)***
*Part C only; ** 3 of 4 Section 619; *** Part C
Stability of 18 month Diagnoses
 Stable when clinically referred


and diagnosed by experts
Stable following multiple stage
screening and diagnosis (Cox et
al., 1999)
Validated diagnostic
instruments: AOSI
and Toddler ADOS (2011) are
coming
Conclusions
 Trend toward earlier ID.
 Two primary screening tools &


diagnostic measures used most often.
Majority of states use multiple tools and
diagnostic measures.
Use of multiple tools/procedures for screening &
diagnosis of ASD may lead to inconsistencies
within states.
Conclusions
 No national data is collected on number of
young children with ASD under the age of
three.
 National data may under-represent number of
3-5 year olds with ASD due to states’ use of
developmental delay category.
National Efforts
• Priority for multiple federal agencies (Health and
•
Human Services, the Centers for Disease
Control (CDC) and the U.S. Department of
Education).
Since 2007, CDC, Maternal and Child Health
and the Association of University Centers on
Disabilities (AUCD) have convened states to
improve Early ID: Act Early Regional Summits.
http://www.aucd.org/template/page.cfm?id=547
National Early Identification
Efforts
Learn the Signs, Act Early – Centers for Disease
Control, National Center on Birth Defects and
Developmental Disabilities
(http://www.cdc.gov/ncbddd/actearly/index.html)
 Free materials for multiple audiences
 Developmental Milestones Fact Sheets,
interactive tools and videos
 Developmental Screening Fact Sheets
 Fact Sheets on ASD and other developmental
disabilities
Recommended Screening
Approaches
• Level 1: Screen for general developmental
delays
• Level 2: Screen all children for ASD and
Identify (Chakrabarti et al., 2006)
 Rationale: tools are much better
 Most young children with ASD have delays
American Academy of Pediatrics
Recommends primary care providers should:
 Be aware of early signs of ASD;
 Ask all parents about developmental milestones
and behavior at each visit;
 If concerns are identified by parents/professionals:
 Administer an autism-specific screener and/or refer child
immediately for a diagnostic evaluation
 Screen all children, using an autism-specific
screener, at 18 and 24 months of age.
Modified Checklist for Autism in
Toddlers M-CHAT – Robins, 1999
•
•
•
•
•
•
For 18 months and up
Published and available online
23 yes/no parent questionnaire for ASD
Built from CHAT items
Screening positive for ASD = failing any 3 items,
OR, failing 2 of 6 critical items
For positive screens, failures are followed up
with phone call
M-CHAT Key Items
Robins et al., 1999
2. Does your child take an interest in other children?
7. Does your child ever use his/her index finger to point, to
indicate interest in something?
9. Does your child ever bring objects over to you (parent)
to show you something?
13. Does your child imitate you? (e.g., you make a face-wil
your child imitate it?)
14. Does your child respond to his/her name when you call?
15. If you point at a toy across the room, does your child
look at it?
Clinical Diagnosis of Autism
Requires:
• detailed history of early development,
• parental descriptions of current behavior at
home,
• direct clinical interactions with child by
experienced practitioner, and
• follow up until 3 years.
Screening must occur across
the first five years
Screen 18 months
and yearly til
5
Re-assess
at 36 and 60 mos
at least
Evaluate those
who fail
screens
Provide intervention
for atypical
development
Part III: Evidence-Based
Practices (EBPs) for Toddlers
with ASD
What are EBPs?
National Professional Development Center on ASD
Focused interventions that:
• Produce specific behavioral/developmental
•
•
outcomes for a child
Have been demonstrated as effective in applied
research literature
Can be successfully implemented in educational
settings
(Odom, Boyd, Hall, & Hume, 2009)
What Counts As Evidence?
57
What Counts As Evidence?
• Peer-reviewed, refereed journal articles
•
 Report research
 Clearly identified children with ASD and/or
families as participants
High quality methodologies
 Experimental group designs
 Quasi experimental designs
 Single subject designs
58
National Professional
Development Center on ASD
• Began in 2007 to promote the use of evidence•
•
•
based practices in programs for children and
youth with ASD and their families.
Had to identify evidence-based practices.
Conducted literature review of focused
interventions (as compared to comprehensive
treatment models).
Formulated a set of criteria for the type and
amount of evidence needed to support efficacy.
EBP for Learners
Younger than 36 Months
• Antecedent-based interventions
• Differential reinforcement
• Discrete trial training
• Extinction
• Functional behavior assessment
• Functional communication training
• Naturalistic interventions
• Parent-implemented intervention
• Peer-mediated instruction/intervention
• Picture Exchange
Communication System
• Pivotal response training
• Prompting
• Reinforcement
•
•
•
•
•
Response interruption/redirection
Self-management
Social narratives
Social skills training groups
Speech generating devices
• Structured work systems
• Task analysis
• Time delay
• Video modeling
• Visual supports
Evidence-Based Practices Birth – 2
What We Know
• Research literature involving infant and toddler
•
participants with ASD is limited but growing.
Some defensible practices for early intervention:
 Parent-implemented interventions
 Naturalistic interventions employed in the
home (milieu, activity-based, incidental)
 Current work on joint attention & prelinguistic
communication
 Discrete trial training for older 2 year olds
Evidence-Based Practices Birth– 2
What We Know
• Focused interventions with promise
 Picture Exchange Communication System
 Pivotal Response Training
 Behavioral strategies: prompting, time delay,
task analysis, reinforcement
 Practices used to decrease challenging
behaviors: FBA, FCT, RIR, extinction
 Visual supports
 Structured work systems
Boyd, Odom, Humphreys & Sam (2010)
Summary
• A few focused interventions for infants and
•
•
toddlers with ASD have established efficacy
through research.
Some comprehensive treatment models exist;
one has been shown to be efficacious through
randomized control trial study (Early Start
Denver Model).
Toddler Treatment Network * – 8 projects
focusing on infants/toddler intervention models
underway.
*Funded by Autism Speaks
Conclusions
• Intervention in the first three years of life
may have powerfully positive effects for
infants and toddlers with ASD.
• A research literature on effective early
intervention is emerging.
• Practice may be guided by current
emerging literature and existing research
with preschool children with ASD.
64
Prompting
• Prompting procedures include help given to
learners to assist them in using a specific skill.
• Prompting procedures that have been shown to
be effective with learners with ASD include leastto-most-prompts, simultaneous prompting, and
graduated guidance and can include verbal,
gestural, and model prompts.
Reinforcement
• An association between learner behavior and a
•
•
•
consequence that follows the behavior.
If a consequence increases the probability that a
behavior will occur again, it can be said to be a
reinforcer.
Positive reinforcement involves offering
incentives to reward behavior (token economy).
Negative reinforcement involves removing an
aversive stimulus to reward behavior so that
learners will use the targeted skill or will not
engage in interfering behaviors.
Time Delay
• Time delay focuses on fading the use of prompts
•
•
during instructional activities.
Progressive time delay involves gradually
increase the waiting time between an instruction
and any prompts that might be used to elicit a
response.
Constant time delay, a fixed amount of time is
always used between the instruction and the
prompt as learners become more proficient at
using the new skill.
Discrete Trial Training
• Discrete trial training (DTT) is
•
•
•
 a one-to-one instructional approach that teaches
skills in a planned, controlled, systematic
manner.
 used when a skill can be taught in small repeated
steps.
Each trial has a definite beginning and end.
Antecedents and consequences are carefully
planned and implemented.
Positive praise and tangible rewards are used to
reinforce desired skills or behaviors.
Functional Communication
Training (FCT)
• FCT is a systematic practice to replace inappropriate
•
•
or interfering behaviors serving a communicative
function with more effective behaviors.
The targeted behavior is analyzed to identify its
communicative function using a functional behavior
assessment (FBA).
An alternative and appropriate communicative
behavior is taught to replace the interfering behavior.
Naturalistic Intervention
• Naturalistic intervention is a collection of
•
practices including environmental arrangement,
interaction techniques, and behavioral strategies
that are used to promote appropriate
communication and social skills.
The practices encourage specific target
behaviors based on learner’s interests and build
more elaborate learner behaviors that are
naturally reinforcing and appropriate to the
interaction.
Parent-Implemented
Intervention
• Parents are taught to provide individualized
•
intervention to their child to improve/increase a
wide variety of skills and/or to reduce interfering
behaviors.
Parents learn to implement practices in their
home and/or community through a structured
parent training program.
Picture Exchange
Communication System (PECS)
• PECS helps children communicate and promotes
•
speech development and production.
There are six phases of PECS instruction, with each
phase building on the previous.
1. Teaching the physically assisted exchange
2. Expanding spontaneity
3. Simultaneous discrimination of pictures
4. Building sentence structure
5. Responding to, “What do you want?”
6. Commenting in response to a question
Pivotal Response Training (PRT)
• Teaches children to respond to naturally occurring
•
•
•
learning opportunities and to seek out such
opportunities.
Builds on children’s initiative and their own
interests.
Particularly effective for developing communication,
language, play, and social behaviors.
Intervention enhances four pivotal learning
variables: motivation, responsivity to multiple cues,
social initiations, and self regulation.
Visual Supports
• Enable learners to independently track events
•
and activities.
Include the use of pictures, written words,
gestures, objects within the environment,
arrangement of the environment or visual
boundaries, schedules, maps, labels,
organization systems, timelines, and scripts.
EBP Learning Resources
• Evidence-based practices briefs (available
on NPDC website:
http://autismpdc.fpg.unc.edu
 Overview of the practice
 Steps for Implementing practice
 Implementation Checklist
 Evidence-base for practice
• Online modules on evidence-based
practices (www.autisminternetmodules.org)