Skyrocketing Autism Numbers a Call to Action for SLPs

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Last week the child-development community got a jolt from news of a jump in numbers of children diagnosed with autism spectrum disorder: an increase of 30 percent in just two years. One in 68 children had ASD in 2010, up from one in 88 children in 2008, according to data from the U.S. Centers for Disease Control and Prevention.

And that’s raised many questions among speech-language pathologists and other developmental experts. For one thing, what’s driving the increase? And what does it mean for ASD diagnosis and treatment? There are no clear answers or absolutes. But developmental expert Stephen Camarata is willing to speculate. We talked with the Vanderbilt University hearing and speech sciences professor about his take.

What is behind this increase? Is it really just an increase in identification?

There are three main factors. One is a real increase in incidence. Our technological ability to take preemies weighing less than a pound and have them survive has changed, and it’s not surprising that more of these kids might have challenges.
Second, there’s increased awareness, so more people are looking for ASD in kids. And third there’s the expansion of the definition of spectrum. The numbers of kids identified as high functioning and as having Asperger syndrome has skyrocketed.

What do the higher numbers mean for SLPs?

We’re the speaking profession, so we have a central role in assessing and treating these kids. Based on this, we’re obviously seeing a big increase in caseload, which as a field we need to develop ways to handle. But more basically than that, we need to figure out how to differentially diagnose these young kids, these 2-year-olds, distinguishing between ASD and the new DSM-5 [Diagnostic and Statistical Manual of Mental Disorders] category of social communication disorder.

We are the main profession driving identification and treatment of SCD, and we need to develop assessments and interventions in this area. It’s a huge opportunity and a huge challenge—and we need to be prepared to handle this demand.

The study suggests that there is a lag in identification, with most kids diagnosed at 4 and older when they could be diagnosed as early as age 2. What can SLPs do to help get these kids diagnosed earlier?

First I should point out that when the kids in this study were toddlers, in 2004 and 2005, we weren’t yet able to accurately diagnose autism at those young ages. Now, with the toddler module of the Autism Diagnostic Observation Schedule, we can. And given that with ASD comes late onset of speaking, SLPs are often doing the earliest assessments. Right now, we may be less inclined to put a late-speaker in the SCD category because we want to get these kids services but don’t yet have appropriate assessments, treatments or reimbursement for SCD. Our charge is to develop these. And it’s also to it’s also to continue to develop continuing education for our practitioners to diagnose autism, which we can do, typically as part of a team.

The study suggests that kids who are African American and Hispanic are being underdiagnosed relative to white kids—again, what can SLPs be doing to help close this gap?

It should be noted that, if you look at the report, there actually has been a dramatic increase in diagnosis in both those communities. But yes, the rates still lag behind those in white children a great deal, so there’s a need to close this gap. Part of this is an issue of cultural difference, but it’s also the well-known health-disparities story of lack of access to services. So we need to do more outreach and education in the African American and Hispanic communities about early intervention and their entitlement to public services.

What are the implications of these findings for the services SLPs provide to children on the spectrum?

This is my sense: Some SLPs feel like they’re not necessarily the primary interventionists in cases of autism but if a kid’s primary weakness is in the speech and language domain—which is the case in ASD, along with behavior—then they really have the role. Improved speech improves behavior. And parents want their kids to talk, so we are and should be primary clinicians involved in diagnosing and treating ASD.

As we go forward, we need to work on distinguishing SCD from autism. We need to own this, but to do that we need to provide data that make a difference and train others on what we know.

 Learn more about social communication disorders  and autism spectrum disorder on ASHA’s website. More information on both categories is available from ASHA—e-mail Diane Paul, ASHA director of clinical issues in speech-language pathology, at dpaul@asha.org.

Stephen Camarata, PhD, CCC-SLP, is a professor of hearing and speech sciences at the Bill Wilkerson Center at the Vanderbilt University School of Medicine. He is an affiliate of Special Interest Group 1, Language Learning and Education. Contact him at stephen.m.camarata@vanderbilt.edu.

Coaching Parents to Foster Their Child’s Expressive Language Skills

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I recently had the opportunity to provide tele-speech-language services to a toddler with autism spectrum disorder. I knew it would be difficult to have him sit in front of a computer for long periods, so I decided that I would employ a “parent coaching” approach, empowering his parents to more effectively help their son.

I started by having the parents videotape their daily interactions with him, which revealed that they were aware of their son’s difficulties and in-tune with his communication needs. However, even though this little boy appeared quite bright, it was difficult to distinguish when he was answering a question from what he had learned, or if it was a rote response. The parents had specific goals they wanted their son to achieve, so how was I going to help them?

I provided the boy’s parents with information about expressive language development and explained that their expectations appeared to be beyond this child’s current capabilities (determined by the boy’s age, as well as his disability). Next I took the language and vocabulary skills the parents wanted their son to learn—such as labeling an apple—and broke them out into smaller steps. These are the types of activities I suggest parents use to help a child grasp a language concept:

  • Present the child with several apples, preferably of different colors.
  • Talk about the outside of the apples: color, shape, size, smell, taste and texture.
  • Cut open the apples (“What do you see?”) , and eat some of each, talking about how it sounds and tastes as you bite into each piece.
  • Cut an apple in half horizontally and use washable tempera paints to make apple prints on paper using the different colors apples can be.
  • Find a simple recipe to make applesauce or another food from apples.
  • Eat apple slices with peanut butter and talk about how it tastes, and about the messiness and stickiness.
  • Make a pretend apple out of PlayDoh.
  • Compare the “fake” apple with the real one, explaining that you can eat a “real” apple but not the “pretend.” This models analytical thinking.
  • Bring in another fruit, such as an orange, and do the same steps.
  • Try making and drinking homemade orange juice.
  • Compare an apple to an orange.
  • Show video clips of people picking apples and oranges, showing how both grow on a tree.
  • Add bananas, doing the first seven steps (tastes great with peanut butter).
  • Roll the items across the floor and talk about how they roll. Compare.
  • Use this method to teach about common fruits you either purchase or see in the market.

Of course, just relating these steps to parents isn’t enough, because they have a tendency to take over for their child if they see the child struggling. For example, it’s tempting for them to place the child’s hands on the paper to make the apple prints, which removes the child from the process and leads to a loss of interest. To help parents avoid this, I explain that learning involves making mistakes. Other suggestions I provide include:

  • When speaking to your child, keep your sentences simple and to the point (approximately three to four words per utterance: “Are you hungry?” versus “Are you ready to go have some sandwiches for lunch?” Expanding utterances will come along a bit later!
  • Speak slowly because it may take the child additional time to process the information.
  • Do not require the child to look you in the eye when you are speaking to him. A glance at your face, especially at this age, should suffice. Toddlers are busy-bodies and need to keep moving and exploring.
  • If you ask a child a comprehension question, he or she may provide a quick or rote answer to be able to do what he wants to do.
  • Allow time to just play with your child. Let the child direct the play. Have a few toys out to choose from and follow his or her lead.
  • Make simple remarks about what is going on, but avoid asking questions to probe for an answer: “What color is your truck? How about that car? What is this part of the car called?” This is play time, not teaching time.
  • Model out loud how to think about items: “You have a big, blue truck! Wow! Mine is small. I have a small, yellow truck. “
  • Model out loud how to problem-solve (over-and-over-and-over again): “Oops! The wheel came off my truck. Hmmm. How can I fix it? {looking over the whole truck while thinking….} If I get something to help the wheel stay on, I should be able to fix it. If I use glue, the wheel may not spin.”
  • Allow some “quiet” play time as well and let your child do the talking (or not if he so chooses). This is a great opportunity to just sit and listen to what your child is saying (to you and/or the toys).

I have parents send me some YouTube video of them performing some of these activities with their child. In subsequent sessions, we discuss what works well (and not so well) with the child, and I share more activity ideas and literature with them.

Tracy Sippl, MS, CCC-SLP, is a Seymour, Wisc.-based speech-language pathologist and tele-therapist with Cumberland Therapy Services. She is an affiliate of ASHA Special Interest Group 18, Telepractice. This post was adapted from a post on the Cumberland Therapy blog,  Right Therapy–Right Results–Right Now.

Yes, DSM-5 Changes SLP-Relevant Disorder Categories: What You Need to Know

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The speech-language pathology community has been abuzz for months about the pending release of the new Diagnostic and Statistical Manual of Mental Disorders because of expected changes to autism spectrum disorder and other communication disorders involving SLPs.

And indeed, the fifth edition, issued by the American Psychiatric Association last month, significantly changes ASD and several other SLP-relevant categories—and also unveils the new social (pragmatic) communication disorder.

As most SLPs well know, DSM is the standard classification of mental disorders used in clinical and community settings in the United States and other countries. The new edition is available first in print, with an electronic version to be offered later this year. See highlights of the changes to DSM-5 on the American Psychiatric Association’s website.

Here are some of the major changes in the category of Neurodevelopmental Disorders that are relevant to the work of speech-language pathologists:

 Intellectual disability (Intellectual developmental disorder)

  • Replaces the term “mental retardation” with “Intellectual disability (Intellectual developmental disorder).”
  • Relies more on adaptive functioning rather than on specific IQ scores.

Communication Disorders

Changed from expressive and mixed receptive-expressive language disorders to include:

  • language disorder
  • speech sound disorder
  • childhood-onset fluency disorder
  • social(pragmatic) communication disorder

Autism spectrum disorder (ASD)

  • Eliminates pervasive developmental disorder and its subcategories (autistic disorder, Rett’s disorder, childhood disintegrative disorder, Asperger’s disorder, pervasive developmental disorder-not otherwise specified). Instead, children meeting the criteria will be given a diagnosis of “autism spectrum disorder” with varying degrees of severity.
  • Omits criterion related to the development of spoken language.

 Specific Learning Disorder

  • Combines diagnoses of reading disorder, disorder of written expression, mathematics disorders, and learning disorder not otherwise specified.
  • Recognizes the need to use a variety of culturally and linguistically appropriate assessment tools and strategies and does not require use of a standardized measure.
  • Does not include oral language.
  • No reference to modalities of language.


Changes in the section on Neurocognitive Disorders pertinent to the speech-language pathology field include the following:

  • Dementia is considered a major neurocognitive disorder.
  • A less severe cognitive impairment is considered a mild neurocognitive disorder.

We were fortunate to have SLPs involved in developing some of the diagnostic criteria in DSM-5. Amy Wetherby was a member of the DSM-5 neurodevelopmental workgroup and chaired a subgroup on communication disorders. Mabel Rice, Nickola Nelson and I worked on this group. ASHA responded during the three public comment periods.

Now that the new edition is out, ASHA has assembled a DSM-5 response team coordinated by me and composed of Janet McCarty, Andrea (Dee Dee) Moxley, Froma Roth and Monica Sampson. We are developing resources to guide members and consumers on the changes, including at least three articles in upcoming issues of The ASHA Leader. The articles will include:

  • A comparative analysis of what ASHA recommended and what DSM-5 includes, with clinical implications for SLPs.
  • Coding implications for reimbursement.
  • Case studies to demonstrate how the changes will affect people with speech, language, communication and cognitive disorders.

ASHA also will communicate with consumers about what the DSM-5 might mean to them through podcasts, media interviews and other dissemination vehicles. A critical message we want to convey is that SLPs will continue to provide needed services, which are based on assessment of communication strengths and needs, and not on specific DSM-5 diagnostic labels.

ASHA would like to know how you think the changes in DSM-5 will affect your clinical practice. We also are seeking case studies that demonstrate impacts of the changes for a future Leader article. Please contact Diane Paul at dpaul@asha.org.

Diane Paul, PhD, CCC-SLP, is ASHA’s director of clinical issues in speech-language pathology.