PSY of autism ch 7

• Early diagnosis


  Emphasized but more likely to be inaccurate
• Hypotheses that impact developmental trajectory

  • Several social and non-social hypotheses
• Theory


  Impacts intervention
• Types of intervention


  • Behavioral
  • Relational
• Goals of therapy


  Parent-infant interactions/relationship has an effect
• Parents act differently toward an infant who doesn't smile/cuddle/play socially
• Lack of early interactional synchrony shapes child's developmental path
• Factors that shape developmental pathways

  • Genetic and epigenetic features or vulnerabilities
  • Environmental factors after birth
  • Epigenetic changes
  • Social experiences (positive or negative)
  • Age of diagnosis
  • Effects of early interventions
• Assessments


  Should be conducted over time in many contexts by a multidisciplinary team of professionals
• No reliable way to diagnose before 12 months
• Diagnosis before 3 years is not always stable - misdiagnosis is more likely
• Females with better language skills get diagnosed later
• Factors affecting diagnostic access and motivation

  • Race
  • Culture
  • Socioeconomic status
• Black and Latino children get diagnosed later than white children
• Low income families have less access to proper assessments
• Culture shapes how parents interpret typical/atypical child behavior
• Minority parents may not trust professionals
• Early red flags


  • Following a point
  • Reduced smiling (around 12 months)
  • Responding when name is called (around 12 months)
  • Spinning or lining up objects
  • More interest in objects than people (ceiling fans, lights, screens, toys, etc.)
  • Reduced eye contact
  • Not wanting to be held
  • Rocking/flapping/head banging/tip toe walking/ awkward or slower gait
• Older studies were retrospective- parent interviews and family videos
• Studies focus on younger siblings in families that already have a child diagnosed with autism
• Newer studies focus on children who have autistic mothers/ premature infants
• Currently, not enough longitudinal studies on large enough samples to be conclusive
• To date, no single behavioral marker in early childhood can reliably predict later autism diagnosis
• Social Orienting


  Innate lack of orienting/paying attention to social content (faces & voices)
• Social Motivation


  Innate - Social interaction isn't pleasant or rewarding
• Intersubjectivity


  Innate differences in ability to perceive/respond to affective expressions of others lead to atypical social experiences which later influence social understanding (mentalization)
• Attention Shifting (Executive Function)


  Gap overlap task- infants must switch attention (looking) between a central target to a peripheral target- disengagement and switching- autistic infants take longer to switch between targets
• Gross and Fine Motor Development

  • Bouncy or slow gait, tip toe walking
  • Hand flapping, finger twiddling
  • Dyspraxia=Developmental Coordination Disorder=motor planning=difficulty forming mouth muscles to form speech sounds, handwriting/ bike riding/buttoning, etc.
• Interactional Synchrony


  • Coordinating gaze and movements between infant and parent
  • Leads to serve & return interactions with joint attention (pointing)
  • Leads to emotional referencing- using nonverbal signals of parents to learn about the world- what is safe/non safe, mutually pleasurable
  • These are absent or reduced in most or all autistic infants/young children
• Serve and return as intervention


  If we accept that non autistic children need serve and return for optimal brain development and social/emotional learning then can we use serve and return interactions between parents and children as an intervention?
• Early interactions between infants and parents require both social and non social skills
• A strategy to mitigate developmental risks and modify prodromal (early) symptom trajectories could create an optimal early environment allowing autistic children to achieve greater autonomy but this won't eliminate autism (paraphrased from pg. 113)
• Relational Interventions


  Most programs seek to teach parents how to change their interactions with their infants/young children to make them more pleasurable and successful for both child and parent
• What parents usually need to do

  • Slow down, talk less, follow the child's lead/interests, moderate sensory stimuli, exaggerate facial expressions, wait longer for child to respond, accommodate motor difficulties, etc.
• Typical Developmental Sequence


  • 0-6 months: Attention to people

  1. 12 months: Joint Attention

  12-18 months: Initiate joint attention (pointing to show)

  18-36 months: Recognize Emotions, Desire based reasoning

  36-60 months: Implicit Mentalizing, Theory of Mind, Deception, False Belief, Humor, Pretend Play
• Relational/Developmental Intervention Programs


  • DIR/Floortime - "Developmental Individual Difference and Relationship Based Model"

  2. RDI - "Relationship Development Intervention"
• Benefits of Relational Programs

  • Professional coaches parent to provide the therapy- usually at home

  Parents are most consistent and important relationships in a child's life- therapists will come and go over time

  Takes place during small chunks of time spread throughout everyday

  Dynamic not static interactions-predictable but not robotic

  Focus on developmental age NOT chronological age

  Follows developmental order of social skills (ex. Babbling before speaking)

  Provide opportunities for child to discover that social interactions are pleasant and meaningful and that they can influence others' behavior

  Child discovers that looking, pointing, smiling, taking turns, etc. is useful to initiate, maintain or repair an interaction, receive valuable information about the world ("opening and closing circles of communication"=serve and return)

  NEVER forced- focus on intrinsic motivation with consent

  The quality of the relationship/trust is always more important than the behavior

  Improves emotional connection/trust/communication between parent and child (extended family members may also be involved)

  Over time children become more socially engaged, flexible, playful and open to guidance from parents

  Relieves stress for the entire family system, promotes bonding between family members
• Costs of Relational Programs

  • Not covered by insurance- families pay out of pocket

  Parents must devote a lot of time/energy to working with child and changing their expectations, style of interacting

  May take longer to see initial improvement (than ABA)

  Fewer research studies proving effectiveness- harder to study (than ABA)

  Less public/professional knowledge/access- harder to find trained professionals/support

  Harder to train parents/professionals in this modality- not formulaic and requires extensive knowledge of typical development

  Rarely provided in school/group settings- a few private schools do exist
• Benefits of ABA or Behavioral Interventions

  • Covered by insurance

  Widely available in public/private schools/programs

  More professional knowledge/support (just google "autism therapy")

  Often presented as the only or best "evidence based" intervention (despite many flaws in research designs)

  Doesn't require intensive parent involvement- delivered by professional RBT's- in home or group settings

  Usually results in a faster increase in desired behaviors and decrease in undesired behaviors=compliance

  Easier to train people to do therapy- very formulaic, doesn't require any understanding of typical development
• Costs of ABA or Behavioral Interventions

  • Intensive and stressful for children (20-40 hrs week)

  Compliance is often demanded- no consent

  Behaviors are taught through repetition and reward (operant conditioning) foods, toys, praise)- extrinsic motivation

  May focus more on chronological age appropriate behaviors (regardless of developmental age)

  Self stimming is often discouraged

  Skills don't generalize easily from one context to another

  Can often result in learning scripts (static not dynamic interactions)- reduces flexibility

  Prompt dependence- behavior is only performed when prompted to do so and/or rewarded, lack of intrinsic motivation/initiation

  Autistic adults frequently report being traumatized

  Social Interactions are transactional

  Frequent changes in therapists can lead to more relationship avoidance over time