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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2012
Hatch
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Today’s
Speaker

Dr.
Mike
Assel

Associate
Professor,

University
of
Texas
Health

Science
Center

Early
Learning
Technology

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#HatchExperts|

Copyright
2012
Hatch
Inc.
All
Rights
Reserved.

Autistic Spectrum Disorders within Early Childhood
Educational Settings:
What a Teacher needs to know?
Hatch Early Childhood Webinar
May 17th, 2012
Mike A. Assel, Ph.D.

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

Restricted and
Communication Repetitive Patterns
Deficits
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 •  Has a word for almost everything.

meaning ("go-stop," "in-on," "big-
Uses two- or three- words to talk
little," "up-down").

• 
about and ask for things.

•  Follows two requests ("Get the
Uses k, g, f, t, d, and n sounds.

book and put it on the table").

• 

•  Speech is understood by familiar
•  Listens to and enjoys hearing
listeners most of the time.

stories for longer periods of time

•  Often asks for or directs attention
to objects by naming them.

2 to 3 years

Talking

•  Hears you when you call from •  Talks about activities at school
another room.
or at friends' homes.

•  Hears television or radio at the •  People outside of the family
same loudness level as other usually understand child's
family members.
speech.

•  Answers simple "who?", "what?",•  Uses a lot of sentences that
"where?", and "why?" questions.
have 4 or more words.

•  Usually talks easily without
repeating syllables or words.

4 to 5 years

Talking

•  Pays attention to a short story and •  Uses sentences that give lots of
answers simple questions about details ("The biggest peach is mine").

them.

•  Tells stories that stick to topic.

•  Hears and understands most of what
Communicates easily with other
is said at home and in school.

• 
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.

NEXT
SESSION:
June
7,
2012
@
2PM
EST

Online
Professional
Development
for
Early

Childhood
Leaders

Kara
Lehnhardt

McCormick
Center
for
Early
Childhood
Leadership

Early
Learning
Technology

|

#hatchinars

|

Copyright
2011
Hatch
Inc.
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Rights
Reserved.

Webinar: Autism in Preschool (Dr. Mike Assel)

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