Although autism is a disorder of infancy, it is not usually diagnosed until between 3 and 4 years. In a recent consortium study, 664 infants who were sibs of ASD children were followed monthly from 6 mos. to 36 mos., when they were assessed for ASD (Ozonoff et al, 2011). There were no concerns at 6 mos. At 9 mos., 6 of the 26 children who ended up with the diagnosis of autism raised some concerns. At 12 mos., half raised concerns, but one raised concerns about autism. At 18 mos. only half of the children showed signs of autism. At 24 mos., there were more, but only by 36 mos. do all the children look autistic. Early symptoms in a 12-month old: (1) Problems with imitation;(2) Repetitive behavior; (3) Abnormal play patterns; (4) Communication disorders; (5) Problems with social orienting, attention, engagement, and initiation.Dr. Rogers showed a video to demonstrate the core diagnostic symptoms. In the video the little girl showed no gaze shifting; she was locked into stimuli. She was tracking well, transferring well from one hand to the next, and her fine motor skills seemed normal for age, but she had little finger movements that looked like repetitive movements. She shifted her gaze nicely from one toy to another but not to the person, the researcher. When she was offered a baby doll, she inspected it, moves it in space, but did not mouth it. When the researcher called her name, she did not look at her. Instead, she watched the lights and shadows. The researcher tried to play peek a boo with her and although the child first looked up at her, the child quickly shifted her gaze to the light, and then started to cry. Her parents worked very hard with her and she received intensive therapy. She is now at normal levels in speech and everything else including pretend play and initiation, except for gross motor, at 2 years.What are the Underlying Neurological Problems in ASD? The social brain networks are different in children with ASD (Dawson et al, 2004, 2005). Impairment in the neural social reward circuitry leads to a lack of salience to social rewards, creating a deficit in social approach and orientation. Because these children are biologically not getting as much reward back from social engagement, they do not discriminate and look for it, and the baby provides fewer attentive moments to parents in that way affecting the caregiving relationship. So the child does not adequately engage in social learning and experiences social deprivation, which alters the future course of neural and psychological development. Parents adapt both by protecting the child and also by not intruding in a way that the infant finds aversive. The are “reading the baby’s cues. Rogers says that autism functions like a “Gardol Shield”, an invisible protective shield that protects the child from distressing intrusion but also continues the social deprivation. In effect, by not intervening early and helping parents change the way they behave with their children, we may be contributing to the creation of brain differences. The data is clear that autistic people are good learners throughout their lifetime when provided with educational experiences, but the early social learning in the infant and toddler period is critical.Language development shows a huge difference between normal and autistic children groups. At 12 months the scores already begin to plummet, although they are not yet outside the normal range and at 18 months it is much worse. There is no regression; it is a deceleration of the developmental rate when the language development runs into the need for social learning to bootstrap the language learning. However that is not all. Motor development is similar. The number of gazes, smiles per minute starts to decrease in the autistic group, as well as directed vocalization. Things are dropping off long before the clinicians are aware of it.The most important brain difference between ASD and neuro-typical children found on autopsy is that of abnormal connectivity, in that long-range connectivity is decreased and short range increased. Courschesne et al speculate, “Excess neuron numbers may be one possible cause of early brain overgrowth and produce defects in neural patterning and exuberant local and short-distance cortical interactions impeding the function of large distance interactions between brain regions. Because large-scale networks underlie social communication functions, such alterations in brain architecture could relate to the manifestations of autism” (Courschesne et al, 2007). What do we do for the infant whose development is decelerating? We must address the cascading effects of the early brain differences on development. The goal of infant learning is to establish neural circuits.There are many established interventions for autism, though fewer of them are supported by empirical studies. Rogers has developed an ABA-based intervention, the ESDM. She was quick to explain that ABA (applied behavior analysis) is not all DTT (discrete trial training). Elements of approaches based on ABA include: (1) Focus on behavior – excesses and deficits; (2) Built from Skinnerian principles of operant learning; (3) Address deficits through careful attention to antecedents, elicitation of behavior and positive consequences in multiple repetitions; (4) Decrease excesses through antecedent-behavior-consequence manipulations: extinction, punishment, or reinforcement of alternative behaviors; (5) Task analysis breaks complex behaviors into smaller component parts; (6) Use prompting, shaping, fading, and chaining procedures to elicit and shape the behavior.In some cases DTT is helpful, especially in children with severe behavior problems or lack of self help skills, but since the learning tasks are adult designed and initiated and since it does not emphasize affect or the relationship, many researchers and clinicians prefer more developmentally oriented models. It is also difficult to generalize the tasks learned in DTT.ESDM Elements: Parents at the Helm.Rogers says it should be 70 hours a week. How are we going to get interventions into every part of his day without the parents? It uses (1) Prompting: fading, shaping, chaining; (2) Management of motivation and attention; and (3) Defined antecedent-behavior. The ESDM Model is designed to bring the child back into the social loop, teach the building blocks of social life (imitation, emotional communication, sharing experience, social and symbolic play, and language), and fill in the learning gaps that have accumulated. In every session, they want a joint activity structure of a piece of play that has a beginning, some elaboration, and a conclusion.Video of a 24-mo who is passive, low energy, low initiative girl. Her parents say she echoes a little bit, doesn’t speak, and is still fed. The child goes into the room and looks at some blocks. The therapist picks them out and sits down with them, narrates her sitting down with the blocks, but the child does not follow. Instead, she moves to a drum. The therapist goes over to the child and hits the drum, which the girl does too. The therapist introduces a stop and go rhythm into the drumming, ramping up the excitement. “Stop!” “Go!” The child whispers, “Go.” The therapist manages arousal in the moment with the rhythm of stop and go and by matching the child’s rhythm. When the therapist stops and lets the drum go, the child picks it up and gives it to her to continue. There is a variation in the up, down, fast, slow, and an attempt to do peek a boo in the drum play.Theoretically, the intervention emphasizes the developmental feature of the relationship; the child and therapist are “play partners”, co-constructing activities. Technically, they support the child’s initiative by setting up a rhythm and then stopping, offering the child a turn to initiate. The therapist establishes attunement by imitating the child, setting up synchrony. The therapist tries to maintain a topic and to negotiate the change in topic with the child. They teach the therapist to get in front of the child and to manage affect. The therapist models the words that fit the actions of the child and marks the child’s affects. She uses one-word utterances - the “one word up” rule. Your words should not be more than one word up from the child’s. Reduce the syntax. Set up the routine and then put the language with it. Talk about what the child is doing in sentence length that the child can handle. The researcher uses a kind of “motherese”. The structure of the joint activity is – set up, theme, variations (up and down, stop and go, peekaboo), and then a clear ending and transition so that there is no down time. How frequently does the child have a chance to learn something from therapist - every 10 seconds in work with skilled teachers. They expect to see skills learned inside the hour. The re-enforcer in this activity – she wants the adult to bang a drum. The adult identifies the child’s intention and gives that as a reward. What skills is the therapist teaching? Motor and verbal imitation; joint attention; turn taking; vocabulary – expressive and receptive play – object play with a person; initiation (verbally requests, puts object in her hand, gaze. Their goals are always to teach language and at least one other domain.They showed very good results. IQ changes, though the children with most severe autism gain less. They have followed the kids to age 6 and they all the kids are out of the intellectual disability area. Social affect, social responsivity scale, irritability, and other domains are better. (Dawson et al, 2012, NIMH STAART Center). Also, the response of theta and alpha waves of ASD children after the treatment are same as normal, and this is shown to be associated with social capacity. The predictors of positive child change include the number of intervention hours, the IQ, the child’s vocabulary comprehension, and the younger child’s age. They believe that therapy works by altering the structure and function of the brain.What they teach parents is the interactive procedures. They developed a set of lessons in a book for parents in early intervention. It is broken down into little steps and makes it fun. The first lesson is to find a smile. (1) Step into the spotlight (the child’s attention); Where is the spotlight? (2) Find the smile; (3) Imitate children. Put something out there; (4) Joining – joint activity, elaboration and closing; (5) Vocal response on what to say, how much to say, and gestures; (6) Step on the stage – where do you find the stage when you are at the table, on the playground, etc.They think that one on one is very important. These children need repetition. They keep trying to get one or two interactions every minute. Bath and bedtime routines are good times for one on one. Mealtime is another good time - how to give food to elicit more interaction. Trying to find ways to change your own behavior to accomplish more one on one moments with your child. Older sibs can learn to sit in front and roll a ball to him, not to give it to him, but get him to ask for it. They always think of expanding the child’s repertoire.The main differences between ESDM and other models are that they take data, it is a comprehensive curriculum, and they don’t refer children to OT and do not have the children see multiple therapists. They think that children progress better if they have a coherent program than with multiple therapists. What they are really doing is asking parents to change their behavior in order to get their child to change.References Courschesne K, Schumann C, Redcay E, Buchwalter J, Kennedy D, & Morgan J, Mapping early brain development in autism, Neuron, 56:399- 413.
Dawson G, Webb S, Carver L, Panagiotides, McPartland (2004) Young children with autism show atypical brain responses to fearful versus neutral facial expressions of emotion, Developmental Science, 7(3):340-359.Dawson G, Rogers S, Munson J, Smith M, Winter J, Greenson J, Donaldons, Varley J, (2010). Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model, Pediatrics, 125(1).Ozonoff S, Young, G, Carter, A, Messinger D, Yirmiya N, Zwaigenbaum L, Bryson S, Carver L, Constantino K, Dobkins T, Iverson J, Landa R, Rogers S, Sigman M, and Stone W (2011). Recurrence risk for autism spectrum disorders: A baby siblings research consortium study, Pediatrics, 2010-2825.Rogers S, Dawson G, Vismara L (2012). An Early Start for Your Child with Autism, Using Everyday Activities to Help Kids Connect, Communicate, and Learn, Guilford Press.
Photograph by Ginger Gregory
