Autism Spectrum Disorder: Best Practices and Strategies in ......Autism Spectrum Disorder – DSM-V ´ A. Persistent deficits in social communication and social interaction across

Autism Spectrum Disorder: Best Practices and Strategies

in the Classroom Setting

Brittany Lyman, PsyD

Autism Spectrum Diagnostics & Consulting

November 10, 2017

Copyright 2017. Brittany Lyman, PsyD. Autism Spectrum Diagnostics and Consulting.

Learning Objectives

´  Identify the core deficits in individuals with ASD

´  Identify common comorbid conditions and disorders seen in children and adolescents with ASD

´  Explain how and by whom comorbid conditions are assessed in the school setting

´  Distinguish appropriate and effective accommodations and services to

be implemented in a 504 Plan, IEP, or classroom to address co-occurring conditions.

´  Recognize the importance of a whole-child approach and

collaboration across specialists in addressing a child’s challenges and facilitating progress


What is Autism Spectrum Disorder (ASD)?


Rise in Prevalence Rates



Etiology ´  Research indicates:

´  No single cause

´  Most cases a gene-environment interaction

´  Identified risk factors

´ Genetic and physiological

´ Heritability

´ Gene mutations

´ Brain structure abnormalities

´ Broader Autism Phenotype

´ Environmental

´ Advanced parental age (both parents)

´ Exposure to valproate

´ Prematurity with low birth weight

´ Oxygen deprivation at birth

(http://www.cdc.gov/ncbddd/autism/facts.html; Campbell, Chang, & Chawarska, 2014) Copyright 2017. Brittany Lyman, PsyD. Autism Spectrum Diagnostics and Consulting.

Autism Spectrum Disorder – DSM-V

Social Interaction Social Communication

Restricted, Repetitive Behaviors


Autism Spectrum Disorder – DSM-V

´ A. Persistent deficits in social communication and social interaction across contexts

´ Not accounted for by general developmental delays

´ Needs 3 out of 3 symptoms

´ B. Restricted, repetitive patterns of behavior, interests or activities

´ As manifested by 2 of 4 symptoms

´ C. Symptoms present in early childhood

´ D. Symptoms limit and impair every day functioning. Copyright 2017. Brittany Lyman, PsyD. Autism Spectrum Diagnostics and Consulting.

Autism Spectrum Disorders – DSM-V: Criteria A

Persistent deficits in social communication and social interaction across contexts

Impaired social communication

Social-emotional reciprocity

Non-verbal communication

Developing and

maintaining relationships


A1- Social Initiation and Response

´  Unusual social approach

´ Intrusive touching, licking

´ Use of others as a tool

´  Failure of to and fro conversation

´  Reduced sharing of interest

´  Reduced sharing of emotions

´ Social smile, response to praise, showing pleasure from social interaction, no offer of comfort

´  Lack of initiation of social interaction

´  Poor social imitation

Impaired social communication



Developing and maintaining relationships


A2 - Nonverbal Communication

´  Impairments in eye contact

´  Use of body postures

´  Use and understanding of gestures

´ Abnormal volume, pitch, intonation, rate, rhythm stress or volume of speech

´ Abnormalities in use and understanding of affect

´  Lack of coordinated verbal and nonverbal communication

´  Lack of coordinated nonverbal communication

Impaired social communicatio

n



Developing and



A3 - Social Awareness and Insight as Well as Broader Concepts of Social Relationships

´ Deficits in developing and maintaining relationships appropriate to developmental level

´ Lack of Theory of mind (>4yo)

´ Difficulties adjusting behavior to suit social contexts

´ Difficulties in sharing imaginative play

´ Difficulties in making friends

´ Absence of interest in others

Impaired social communicatio

n



Developing and



Restricted, Repetitive Patterns of Behavior, Interests or Activities (2 out of 4 Symptoms)

Repetitive/Restricted patterns of behavior

Stereotyped repetitive speech/

movement/ play

Excessive adherence to

routines

Restricted and fixated interests

Hyper or hypoactivity to sensory input


B1 - Atypical Speech, Movements and Play ´  Stereotyped or repetitive speech

´  Stereotyped or repetitive motor movements

´ Hand movements, rocking, body tensing

´  Stereotyped or repetitive use of objects

´ Lining up, dropping, waving



movement/ play


routines

Restricted and fixated

interests

Hyper or hypoactivity

to sensory input


B2 - Rituals and Resistance to Change ´ Adherence to routine

´ Unusual multi-step routines

´ Insistence on rigid routines (except bed time)

´  Ritualized patterns of verbal and nonverbal behavior

´  Excessive resistance to change

´  Rigid thinking

´ No humor, irony. Rule bound behaviors or thoughts.



movement/ play


routines

Restricted and fixated

interests

Hyper or hypoactivity

to sensory input


B3 - Preoccupations with Objects or Topics

´  Preoccupations, obsessions

´ Abnormally intense interests

´ Narrow range of interests

´  Preoccupation with numbers/letters/symbols

´ Attachment to unusual inanimate object

´ Having to carry around an object

´  Unusual fears Repetitive/

Restricted patterns of behavior


movement/ play


routines Restricted and fixated interests



B4 - Atypical Sensory Behaviors

´  Pain tolerance

´  Preoccupation with texture or touch

´  Unusual visual exploration

´ Odd response to sensory stimuli (all domains)

´ Touch, smell, taste, vestibular, visual

´  Unusual sensory exploration

´ Lick, touch, smell, (not part of a ritual)



movement/ play


routines Restricted and fixated interests



Severity Levels for ASD


Gender Differences in Symptom Presentation

´  Diagnostic criteria based on behavioral symptoms of boys with ASD

´  Girls are often misdiagnosed

´ ADHD, OCD, Bipolar Disorder, Anorexia

´  Differences in brain studies

´  Girls

´  Better social awareness and imitation of others

´  Restricted interests more “typical”

´  Reading, fantasy, animals, dolls

´  Better at pretend play

´  Trouble with social hierarchies and social chit-chat


Strengths of Children with ASD ´  Unique and special talents

´ Detail oriented

´  Thrive in routine and structure

´ Often rule-abiding

´ Genuine

´  Passionate

´ Caring and involved families


Associated Features

´  Pragmatic language deficits

´ Adaptive skill deficits

´  Sleep difficulties

´ Gastrointestinal Symptoms

´  Seizures

´ Hyperactivity/Impulsivity

´ Aggression

´  Self-injurious behavior

´  Inattention

´  Elopement Copyright 2017. Brittany Lyman, PsyD. Autism Spectrum Diagnostics and Consulting.

Intellectual Disability

´ Most common co-occurring disorder with ASD

´  Strong predictor of prognosis

´ Comorbidity rate of about 31% with ASD

´ Higher rates in girls with ASD


Comorbidity of ASD and Other Psychopathology

´  Simonoff and colleagues (2008) found that ~71% of children with ASD met criteria for at least one comorbid psychiatric dx

´  41% with ≥2 comorbid dx

´  24% had 3 or more diagnoses

´  Anxiety and Depression are very common in teens

´  Thought to be higher in those with average to above average IQ

´  ADHD

´  1 in 3 children with ASD also diagnosed with ADHD


Prognostic Factors

´  Early identification/diagnosis

´ Cognitive Ability

´  Early Treatment

´ Intensity and quality of treatment

´  Language Abilities

´  Severity of behaviors

´ Comorbid conditions

´  Parent involvement


Evidenced-Based Treatment National Standards Project – Phase 2 (National Autism Center, 2015) ´  Update from the original NSP in 2009 ´  Identify the strength of evidence supporting educational and behavioral treatments

for individuals with ASD across the lifespan

´ Ratings: ´ Established

´ Emerging

´ Unestablished

´ Ineffective/Harmful

´  Show the strength of evidence based on treatment name, focus of treatment, age, and diagnostic classification

http://www.nationalautismcenter.org/national-standards-project/phase-2/)

(


14 Established Treatments for Individuals Under Age 22

´  Behavioral Interventions

´  CBT Intervention Package

´  Comprehensive Behavioral Treatment for Young Children

´  Language Training

´  Modeling

´  Naturalistic Teaching Strategies

´  Parent Training Package

´  Peer Training Package

´  Pivotal Response Treatment

´  Schedules

´  Scripting

´  Self-Management

´  Social Skills Package

´  Story-Based Intervention Package


Impact of Comorbid Symptoms in the School Setting

Assessment of Comorbid Symptoms


Factors That Impact School Performance

´  Learning Style

´ Communication Skills

´  Social Skills

´  Executive Functioning

´  Behavioral Challenges (e.g., anxiety, emotion dsyregulation)

´  Sensory Processing Difficulties

´  Transition to Adulthood


Identifying the Appropriate Educational Plan

´  Presence of comorbid conditions will impact the type of plan and services the child requires

´ Ex. Child with a speech and/or language disorder will require special education services in the school setting

´ Question to ask:

´ Are the child’s comorbid conditions and/or challenges impacting their ability to learn and access the curriculum?


Who Should be Involved in the Evaluation? ´  Speech and Language

Pathologist ´ Assessing the child’s receptive,

expressive, and pragmatic language skills

´  Occupational Therapist ´ Assessing the impact of sensory

processing on the child’s ability to learn

´  School Psychologist ´  Learning difficulties

´ Assessing the child’s cognitive and academic skills

´  Emotional and behavioral assessment


Who Should be Involved in the Evaluation?

´  School Counselor

´  Providing counseling and support related to symptoms of anxiety and other behaviors

´  Facilitating social skills and/or friendship groups

´  Behavior Specialist

´  Involved in assessment and treatment of behavioral challenges

´  Functional Behavioral Assessment


Role of Educational Staff

´  Thorough understanding of the child and ASD presentation

´  Individualized recommendations

´ Ensure that the strategies used across services and environments are in line with the child’s current level of communication and social skills

´  Facilitation of accommodations and services

´  Collaboration across team members to ensure generalization of skills

´ Ex. OT sharing strategies with the classroom teacher

´  Communication and collaboration with the child’s family


Appropriate accommodations and supports to be implemented in a 504 plan, IEP, or classroom

Impact of Comorbid Symptoms in the School Setting


Classroom Management Strategies

´  Use of Visual Supports

´  Provide Daily Schedules

´  Routines & Structure

´  Transition Warnings

´ Give the Child Choices and Control

´  Provide Clear Rules & Expectations

´  Use of First, Then Statements


Differences in Learning Style

´ Language-Based Learning Difficulty Supports: ´ Provide important information/directions in both a written and

oral format

´ Multi-sensory instruction (i.e., visual, auditory, and tactile)

´ Read aloud when writing on the board

´ Keep instructions brief and uncomplicated

´ Provide study guides or review sheets

´ Multiple methods for class/course assessments ´ Exam/write a paper, work alone or in a group, deliver an oral,

written, or videotaped project presentation

´ Use captioned videos Copyright 2017. Brittany Lyman, PsyD. Autism Spectrum Diagnostics and Consulting.

Differences in Learning Style

´ Nonverbal Learning Difficulty Supports: ´ Pairing verbal instructions with all visual materials to ensure comprehension of

material. ´ Reviewing past information before presenting new concepts, and using

language and discussion to connect new situations to previous learning.

´ Breaking down visual information into smaller, more manageable steps to increase comprehension and decrease frustration.

´ Methodically discussing the cause-and-effect relationships of events and situations

´ Reducing the number of visual displays involving manipulatives, drawings, and diagrams during instruction, and replacing them with clear verbal instruction.

´ Replacing copying of information from the board with providing copies of the notes or assignments.

´ Providing math exercises on worksheets with only a few questions and plenty of white space to reduce anxiety and impulsive responding. Copyright 2017. Brittany Lyman, PsyD. Autism Spectrum Diagnostics and Consulting.

Impairments in Communication

´  Motivation to communicate

´  Greeting others

´  Commenting

´  Asking Questions

´  Initiating & Maintaining Conversations

´  Sharing Feelings & Opinions

´  Answering Questions

´  Tone of Voice

´  Receptive Language


Communication

Impairments

Individual Therapy Group Therapy

Use of Visuals Throughout Instruction

Multisensory Instruction

Assistive Technology (e.g., Monitoring Volume)

Include the Child’s Interests/ Boundaries Related to Discussion of Interests

Avoid Complex Verbal Instructions/Information

Allow “Wait-Time”


Social Skills Deficits

´  Nonverbal communication

´  Joint Attention

´  Reciprocity

´  Relationships

´  Group Participation/Projects

´  Perspective Taking/Theory of Mind


Social Skills Deficits

Define Student’s Role During Group Activities & Projects

Include Familiar Peers/Buddies

Friendship Group/Lunch Bunch/ Facilitated Recess

Practicing Skills Across Settings

And Environments

Peer Feedback & Modeling

Behavioral Goals & Experiments

Self-Monitoring (e.g., Talking About

Interests)

Feedback in Real Time

Social Stories


Executive Functioning

´  Planning & Organization

´ Difficulty starting/completing tasks

´ Distracted

´  Losing items/assignments

´  Problem solving

´ Monitoring their behavior


Executive Dysfunction

Redirection

Allowing Extended Time To Complete Tasks And During Tests

Separate Location For Testing

Preferential Seating

Movement Breaks

Breaking Down Larger Tasks

Behavior Plan/ Use of Rewards

Use of Technology

Two Sets of Books

Time Management Skills/Binders/ Checklists


Behavioral Challenges

´ Anxiety

´  Emotion Dysregulation

´  Irritability

´  Tantruming

´ Non-Compliance


Behavioral Challenges

Go-To Person – Guidance Counselor/

Safe Place

Parent/Child Written Description Understanding Function of Behavior

Emotion Identification

Coping Skills

Preparation/Warnings

Behavior Plan/Reward System

Clear Directives

Use of Social Stories


Sensory Processing Difficulties

´  Sensitivities to:

´ Noises

´  Smells

´  Textures

´  Sights

´  Can lead to:

´  Shutting down

´  Fidgeting

´  Emotion dysregulation


Sensory Sensitivities

Occupational Therapy

Sensory Diet

Movement Breaks

Headphones

Anticipate Challenges (e.g., Fire Drill)

Self-Monitoring of Arousal States


Transition to Adulthood

´  Hygiene

´  Daily Living Skills

´  Vocational

´  Self-Advocacy

´  Sexuality Education

´  Interpersonal Skills

´  Skills Necessary for College


Transition To

Adulthood

Job Sampling Self-Advocacy Training

Understanding ASD Diagnosis

Customizable Employment Interviewing Skills

Money Management Time Management

Sexuality Training

Appropriate Use of Technology


Summary

´  Individuals with ASD vary in their presentation and needs

´  Individuals with ASD have many strengths and talents

´  Many children with ASD experience comorbid disorders and symptoms that impact their ability to learn

´  Specific interventions and accommodations are necessary in order to address the comorbid conditions

´  Collaboration and a team approach is critical in order to ensure that the child with ASD’s needs are met



My Contact Information

Dr. Brittany Lyman Autism Spectrum Diagnostics & Consulting

Doylestown, PA www.autismdiagnostics.com

[email protected]

215-230-3616


Autism Spectrum Disorder: Best Practices and Strategies in ......Autism Spectrum Disorder – DSM-V ´ A. Persistent deficits in social communication and social interaction across

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