PA-IMH breakfast 1-8-16
At the January 8, 2016, infant mental health breakfast, Una Majmudar and Nina Mendez of the Health Federation of Philadelphia presented on the clinical implementation of Child-Parent Psychotherapy (CPP) in the Child Parent Project. Una is the program manager and Nina a family therapist in the program. Children being treated as part of this project are involved with the child protective system, with possible issues including problems of the custodial parent, the other parent, substance abuse, and so on. CPP is carried out dyadically with the child and caregiver.
CPP is an evidence-based trauma intervention developed under the auspices of Alicia Lieberman. It is unique in that the “client” is seen as the relationship between adult and child, not as either individual. The treatment lasts from 9 to 12 months and involves weekly hour-long sessions. Unlike many manualized treatments, CPP does not prescribe the focus of each of a series of meetings, but instead assesses at every session how the relationship looks through the “lens” of safety, of attachment, of developmental progress, of “ghosts in the nursery”, and of “angels in the nursery”. CPP asks how a parent and child can move past a traumatic event, but also considers concrete needs like housing.
Nina Mendez presented a case being treated with CPP. A 4-year-old girl who had been removed from her mother because of inadequate housing and other issues like the mother’s incarceration and drug and alcohol use was seen along with her mother. She had lived briefly with her biological father, whom she had never met before, but now was with a grandmother. The mother’s strengths were seen as her willingness to attend drug and alcohol treatment and to plan for their future, and her real dedication and longing for her daughter to feel safe and protected. The little girl had been described as hyperactive and defiant, but was also smart, talkative, playful, and imaginative. She responded enthusiastically to interesting activities like nail-painting that she could do with her mother and Nina. Using a CPP method, these were regulated by a “time timer” giving 15 minutes for each. The timer was set by the child, who responded with increased calmness to this structure.
The daughter’s aggressive behaviors had been ignored by the mother in the past rather than interpreted. CPP helped them discuss past events of domestic violence, to distinguish between “then and now”, and to establish safety plans for the future. As part of CPP, the program also worked to help the child attend the same school as her older brother, supporting her feeling of safety and security.
When events connected with this dyad made the therapist very frustrated and angry on their behalf, the reflective supervision aspect of CPP came into play. Reflective supervision allowed the therapist to have a safe space in which she could examine her thoughts and feelings in a trauma-informed way, in a parallel process to what the mother and child were doing. She could then self-regulate and be available to help the mother create a safe space for the child.
A lengthy discussion of audience questions followed the case presentation. One attendee asked about doing CPP with preverbal children. Una commented that this could work well, providing timely interactions as mother cares for a younger child. Discussion of “ghosts in the nursery” can be done, and this approach can be helpful for depressed mothers. A second question was about the use of CPP for children older than 5 or 6; the intervention was not developed for those children, who are developmentally ready to work with the therapist themselves rather than in the dyadic setting. An audience member asked about a research component of the 5-year Child Parent Project grant; this is in place and focuses on efficacy and reunification as well as on a cost analysis. A final question addressed training in CPP. This is not available for individuals, but is done through a network of learning collaboratives and is available only to people with master’s or doctoral level training. Further information is available at www.nctsn.org.
PA-AIMH breakfast 12-04-15
The December 2015 infant mental health breakfast featured a lively resource fair with presentations and materials from five organizations, followed by much discussion and commentary.
Karen Krivit from Elwyn SEEDS showed a remarkable autism education video, made by herself, and directed toward assuring parents that they are not alone in dealing with autistic children. Karen has created videos for a range of languages and cultural backgrounds. The one she showed us was in Spanish and English, with the innovative feature of alternating languages for spoken words and subtitles-- sometimes English with a Spanish subtitle, sometimes the other way around. The audience was fascinated and impressed, and we could easily have spent the whole meeting discussing the video and how it was made and is used.
Brenda Golden and Marilyn Edmond of ChildLink discussed the provision of early intervention services to children 3 years old and under, and brought materials about infant-toddler and preschool intervention. They brought up an issue that became a general theme of this breakfast: how do we communicate with families in need of services? What happens if the family moves to a different area of the city? What happens if they become homeless? And what happens if one child problem is successfully addressed, but a different one emerges with age? These questions can be particularly important for issues like hearing impairment, where problems change or appear to be “solved” as development progresses. The presenters also pointed out that a stumbling block for provision of services is difficulty in recognizing early signs of trouble; another problem is keeping a positive approach so parents are not scared.
Sharon McClafferty of Southeast Regional Key sent information about Keystone STARS, and infant-toddler specialists Sarita Brown and Lizbeth Ramos presented. STARS is a statewide program of the Pennsylvania Office of Child Development and Early Learning which supports childcare programs, with an emphasis on staffing. Programs approved by STARS at the Star 1 level have a parent handbook, an annual plan to continue professional development, and a practice of meeting with parents when a child enrolls. In Star 2 programs, at least half of the group supervisors have associate’s degrees in early childhood education, parents get daily updates on classroom activities, and teachers observe children’s development when they enroll. In Star 3 programs, group supervisors have at least associate’s degrees in early childhood education, there are at least two teacher conferences each year, and there are independent evaluations of classroom arrangements and learning activities. At the Star 4 level, at least half of the group supervisors have bachelor’s degrees in early childhood education and programs have strategic plans to ensure continuing quality improvement. Infant-toddler specialists, child care health consultants, and early childhood mental health consultants are available for needed assistance.
Elaine Frank and Denise Rowe of Parenting Services for Families described their organization’s services for both adoptive and non-adoptive families. These include assessment of family relationships, child behavior, and parenting concerns and parent-child counseling and therapy. Adoptive families may also need help with children’s adjustment to the new family, developmental delays, attachment problems, or the consequences of coming to the family from other countries, orphanages, or foster care. Parent-child counseling and therapy are available for children under three as well as for older ones. Parent coaching and developmental guidance is another service offered.
Icylee Basketbill of Health Federation of Philadelphia discussed home visitation and a recruitment program, and mentioned the importance of working with both fathers and mothers. In addition, Icylee was mentioned as one of the “stars” of one of Karen Krivit’s autism education programs!
The group discussion was enlivened by the presence of Stephanie Bey, program analyst for early intervention for the city of Philadelphia, who joined with the rest of us in the discussion of issues of collaboration and communication.
A large and enthusiastic audience welcomed the infant mental health breakfast seminar presentation by Dr. Nathan Blum on Nov. 6, 2015. Dr. Blum is Chief of the Division of Developmental and Behavioral Pediatrics at Children’s Hospital of Philadelphia. He spoke on behavioral management of children’s oppositional behavior.
A basic theme of Dr. Blum’s presentation was that oppositional behavior has generally been learned in the course of a child’s interactions with parents, and if the nature of the interactions is changed, more compliant behavior can be learned and can take the place of opposition. To accomplish this, parents need to understand the role of reward/reinforcement of desirable behavior and the withholding of rewards for unwanted oppositional behavior (for example, by the use of time-outs).
Children who become oppositional may lack flexibility and adaptability to begin with, but a problematic social environment operates to bring about consistent noncompliance. Dr. Blum mentioned as features of this environment the following: unclear rules; inappropriate expectations about behavior; lack of parental attention for desirable behavior; parental failure to recognize a child’s efforts when they do not have a perfect outcome; the child’s experience of escaping from demands by inappropriate behavior; “bribing” by allowing the child a reward following undesirable behavior; and the existence of excessive environmental stressors.
As children become more oppositional, parent-child interactions move toward a more coercive pattern, said Dr. Blum. The child learns not to listen; the parent learns to repeat commands; the parent learns that only the statement of a threat will bring compliance; and the child learns that it is not necessary to listen until the threat appears. Parents who have learned to use threats begin to threaten or yell at the slightest problem event, and the child learns to engage the parents’ attention in this way.
Dr. Blum mentioned a number of evidence-based treatments (EBTs) designed to correct oppositional behavior. These all share certain components that are taught to parents: the use of praise, time-outs that withhold attention and rewards following unwanted behavior, the use of tangible rewards, the use of clear commands, problem-solving to eliminate obstacles like stress, and the use of differential reinforcement with high contrast between reinforcing and non-reinforcing conditions. Dr. Blum also recommended the “1, 2, 3, magic” approach, in which clear, brief, and precise commands – statements, not questions—are not followed by parent commentary or discussion; the parent counts to 3 instead of continuing to talk.
Dr. Blum suggested that when a new behavior is to be learned, its difficulty should be managed so that the child can be successful and be reinforced on 7 or 8 occasions out of every 10 attempts. When the behavior has become well established, reinforcement can become intermittent, but frequent reinforcement is needed early on. If this reward system does not seem to be working, there may be one or more of several problems that need to be corrected. The behavior being demanded may be too difficult for the child at this point in development. The reward chosen may be wrong-- not of interest or value to the child. (Parental attention is often the most valuable reward.) Or, high levels of stress in the environment and the parent-child relationship may interfere with the child’s ability to comply.
Some problems with which parents may need help are inconsistency and the wish to try to change too many behaviors at the same time. Rules and commands need to be limited. Parents need to be counseled to ignore behaviors that are simply mildly to moderately annoying, and to select 2 or 3 positive behaviors that can be worked on consistently and attentively; once these are established, 2 or 3 more may be chosen. Dangerous behaviors should always be punished by methods like time-out. In answer to an audience question, Dr. Blum suggested that parents who are unduly concerned with “defiance” and triggered emotionally by child opposition may need more basic work before they are able to use behavior management methods.
PA-AIMH breakfast 9/11/2015
The PA-IMH breakfast seminar on Sept. 11, 2015, featured Dr. Wanjiku Njoroge presenting on the topic “What are young children watching? Exploring the cultural determinants of early childhood viewing practices”. The presentation included Dr. Njoroge’s own research as well as a review of much other work on the subject of young children’s use of television and DVDs.
Dr. Njoroge began with a critical point: yes, television is educational; the question is, what does it teach? From this, she continued to the basic question of her research: how do cultural attitudes influence the television experiences that parents mediate for their young children? What are the beliefs and goals that lead parents of color to permit or encourage more use of television for their young children than is the case for non-Hispanic white parents? Given that television and other screen experiences are not going to go away, how can we shape children’s use of television in a beneficial way while working within the parameters established by parents’ beliefs and wishes?
The American Academy of Pediatrics in 1999 and again in 2011 advised against television viewing for children under the age of two, and minimal viewing for preschool children. But, Dr. Njoroge, asked, how did that advice work in the context of parents’ beliefs and goals for their children? There is no question that there are risks connected with extensive television use in early childhood; these risks include compromised executive functioning, increased aggression and disruptive behavior, and delayed language and reading skills. But are there also benefits that parents are seeking? Yes, there is evidence of early learning and the development of prosocial behaviors as modeled in appropriate television programming. When parents mediate by watching with children and interacting with them about what they see, developmentally-appropriate, educational, prosocially-oriented programs can lead to those benefits. It’s the type of program and the context that makes the difference, not just the amount of viewing time. Guidance to parents needs to stress these issues, not just to prohibit television use for young children.
Many Hispanic parents are reported to see television and other communication technology as beneficial for their preschool children’s reading skills. Lower-income families in general are more likely than high SES parents to turn to television as a way to enrich and supplement their children’s early learning, with a view to helping them prepare for school success.
Research done in Seattle suggests that in fact family income is a more significant factor in determining young children’s television use than race is. Children in the Seattle study watched more educational television when their parents believed there were positive effects of watching. African-American and Asian-American parents were more likely than non-Hispanic whites to think that television can encourage prosocial behavior in preschool children.
Recommending that parents co-view television with their children, and intervening to help parents learn to interact with the children over material viewed, seem to be ways to help reduce the risks and increase the benefits associated with television-watching by young children. These approaches may be more effective than attempting to get all parents to minimize television use, when we know that the parents may believe that television benefits their children. In addition, parents may be helped to identify good television for children by groups such as the Fred Rogers Institute and commonsensemedia.org.
The April 2015 infant mental health breakfast featured a presentation by Carmen Marcet, an early childhood education teacher and early intervention supervisor, on the subject “Cultural awareness and interpretation services: Working with immigrant families”. Ms. Marcet started her presentation by greeting each arriving person in Spanish, effectively showing many of us how it feels to be spoken to in a language we do not understand. She emphasized language differences as the foundation of cultural differences and the importance of good use of interpreters as part of culturally competent services for families with young children.
Ms. Marcet described the fact of levels of cultural awareness that help or hinder work with families. The simplest level is one where the service provider thinks that her culturally-sanctioned ways of doing things are the only way to do them, thus setting the stage for conflict with immigrant families. A second step is the thought that although the service provider knows “their” way, her way is actually better. At the third level, the provider recognizes that of “their” way and her way, one is sometimes better than the other. At the highest level of cultural awareness, the provider can focus on sharing meanings and creating new and effective rules while working with a specific family.
Ms. Marcet went on to address the problem of bridging cultures and used the example of an immigrant family who are offered services for their children but do not return calls or respond to a welcome letter. She listed a number of reasons for this response-- none of which mean that the family does not want the services. A family may be fearful of agency contact because they are undocumented or because they have had distressing experiences with “officials” in the past. The calls and the letter are likely to have been in English, and the family may not have understood them, or may be reluctant to be expected to communicate in English rather than their home language. In addition, immigrant families often do not understand the concept of early intervention or the meaning of different kinds of services, and their fear and distrust of strangers make it difficult for them to seek any explanation. All of these problems could be helped by identifying the family’s language and using a culturally-aware interpreter to facilitate communication with them.
Ms. Marcet discussed several cases where a young child’s unfamiliarity with English and with some American ways made a service or experience problematic rather than helpful. For example, a two-year-old with limited communication skills (“no”, pointing) was in child care. He would eat grapes and crackers at snack time but would not touch other food at meals. The teacher was not allowed to feed him, and threw away the untouched food after a while. She assumed that the child was not hungry and would eat at another time (although he was at the center for many hours at a time). One problem here was that the child did not understand what was said to him; in addition, he was accustomed to having his mother feed him, as was appropriate for the family’s culture. Ms. Marcet pointed out the need for flexibility of rules as children go through a transition into day care. In addition, with the help of an interpreter, it would have been possible for family routines to have been explored before the child began attending day care, so that teachers would have been aware of activities that were familiar or unfamiliar to the child, and would have been able to lessen the cultural shock he experienced.
Ms. Marcet mentioned a number of facts about an immigrant family that need to be established before they can be expected to benefit from early intervention services. Where do they go to shop or seek health care? Do they know how to take a bus or train to get to services that have been recommended? Do they know how to use services like a library? Do they know how to get an interpreter if they need one? Do they know other people in the community? Does only one family member deal with all community interactions? The answers to these questions help establish what guidance the family will need in obtaining and using early intervention services for a child.
Among other points Ms. Marcet discussed, she elaborated on the need for interpreters. These are ideally not just people who speak a language other than English, but need to be carefully trained and to be bicultural as well as bilingual. Interpreters need to understand the topics being discussed with the family and need to know the purpose of an interview; they also need to understand and be able to translate the “jargon” a service provider may use, including the term “early intervention”. An interpreter needs to be able to provide interpretation for the child as well as the adults in the family.
Ms Marcet’s presentation was followed by much enthusiastic discussion and many practical questions from the audience.
PA-IMH Breakfast February 6, 2015
The PA-IMH breakfast seminar on Feb. 6, 2015 featured a presentation by Dr. Daniel Hart of the Institute for Effective Education. Rutgers-Camden, on “Quality Early Childhood Education: Why Does It Matter? What Does It Look Like?”. Dr. Hart’s presentation returned several times to the theme sounded by President Obama not long ago: “Tonight, I propose working with states to make high quality preschool available to every child in America. Every dollar we invest in high quality early education can save more than seven dollars later on.”
But is this claim correct? Are we even in a position to define high quality early education and to identify factors in preschool that cause improved academic and behavioral performance later on?
Research on some programs shows great overall benefit from high quality preschool education. For example, results of the Perry Preschool program included a reduction in the number of children needing special education, an increased number graduating from high school, increased earnings and increased home ownership. A study of the outcome of a weekly stimulating play group in Jamaica showed increased earnings 20 years later. However, while some research on Head Start shows short-term gains for the children, by the end of third grade these were no longer apparent.
Is it a problem that research on preschool education may sometimes be poorly designed, in addition to having a focus on factors that are actually not very important? Research on the Abecedarian Project in the 1979s was described as using a randomized controlled design, but in fact did not entirely conform to the rules about designs of this kind.
What about the factors that need to be studied? Dr. Hart discussed the adoption of Quality Rating and Improvement Systems (QRISs) by states. Started by the U.S. Department of Health and Human Services in the 1990s, QRISs are a method for encouraging the use of high quality preschool practices. But, according to an article cited by Dr. Hart and written by T.J. Sabol et al (“Can rating pre-K programs predict children’s learning? Science, 341, 23 August 2013, 845-846), QRISs on the whole have not looked at child outcomes in ways that can tell us whether programs we call “high quality” are actually facilitating learning and fostering children’s good development. Most QRISs have been based on local professionals’ judgments about the selection of practices that indicate high quality, their decisions about how to determine levels of quality, and suggested methods for creating composite ratings for programs. Rather than looking at what teachers actually do, QRISs have tended to look at easily-determined information like the teachers’ academic qualifications. Acccording to Sabol and colleagues, when child outcomes are measured, high quality programs do not give better results on most outcomes than programs that are rated lower in quality. In their research, a measure of the quality of child-teacher interaction—not usually included in QRISs-- was the best predictor of good learning outcomes.
There are many reasons to encourage early childhood education and to fund it adequately, but there continue to be many unanswered questions about how we assess high quality programs and assure the public that funds are well-spent.
PA-IMH Breakfast 1-7-15 Powerpoint Slides Provided click here
The PA-IMH breakfast seminar audience on Jan. 7, 2015, heard a presentation by Nathan Blum, M.D., Professor of Pediatrics at CHOP, on aspects of Attention Deficit/Hyperactivity Disorder (ADHD) in preschool children. Dr. Blum addressed questions of both theoretical and practical importance: 1) at what age is it possible to diagnose ADHD?, 2) when preschool children are diagnosed with ADHD, is the diagnosis associated with impairment?, 3) how do the symptoms and diagnosis change with age?, and 4) when ADHD has been diagnosed in young children, how should we treat the disorder? As Dr. Blum noted, the answers to these questions are not necessarily the same for preschoolers as they are for school-age children. The nature of the answers is also complicated by differences between the criteria for diagnosis given by DSM-IV and DSM-5, and by the fact of subtypes of ADHD.
DSM-IV offered mixed messages about early diagnosis of ADHD, sometimes suggesting that age 4 or 5 years was the youngest period at which an ADHD diagnosis could be made, but at other times referring to the attentional capacities of toddlers. DSM-5 commented that although parents may observe excessive motor activity in toddlers, there is so much normal variability in attention and impulsiveness that other symptoms may not be able to be distinguished until age 4. In line with this observation, the American Academy of Pediatrics now recommends that children with symptoms of ADHD be evaluated from age 4 onward. At age 3, 3% of boys and less than 1% of girls have already been diagnosed with ADHD.
Do these symptomatic children show other impairments? What happens to them as they get older? Younger children diagnosed with ADHD were also seen to have problems of slowed language development, and as they moved into the school years they had lower reading scores than others, but their math scores were not different from those of non-ADHD children. By age 11, about 50% in one study no longer met criteria for attention disorders of for other mental health problems.
Which were the children who, after being diagnosed with ADHD at age 3, later did not show symptoms of the disorder? Dr. Blum pointed out that although it is possible to describe differences between groups who were more or less likely to continue to show symptoms, there is no way to identify an individual who will “grow out” of ADHD symptoms. The period between 3 and 4 years is the time when “growing out” is likely to occur if it is going to do so, with about 50% of symptomatic 3-year-olds improving by age 4.
For preschool children who persisted with symptoms of ADHD, a number of factors were associated with the persistence, but no single factor or pattern predicted what would happen to an individual. Children with persisting ADHD were more likely to have had sleep problems at 24 and 36 months and to have lower language ability. They had more negative behaviors even in infancy, and more negative parenting behaviors were likely to be present. There were more externalizing, disruptive behaviors, and also more internalizing behaviors such as anxiety and negative moods. Family incomes and parental educational levels were lower among children with persistent ADHD. Those children also were more likely to be exposed to parental psychopathology, and 25% of parents of ADHD children have ADHD themselves.
Dr. Blum also discussed some issues about treatment of ADHD in preschool children. He pointed out that of the available treatments, behavior therapy and methylphenidate (Ritalin), neither treatment is specific to ADHD, but is instead directed at symptoms that cause problems. The American Academy of Pediatrics has recommended that the first choice of treatment is evidence-based behavioral therapy. If this is not sufficient, or if behavioral therapy is not available where the family lives, or acceptable to the family, methylphenidate may be used after weighing the risks of starting the medicine at an early age versus delaying treatment.
The side effects of methylphenidate in preschoolers with ADHD are more worrisome than they are in school-age children. In one study, 11% stopped the medication because of side effects, more than half of these being irritability and emotionality, and others being decreased appetite, tics, insomnia, and occasionally other problems. In the same study, preschool children grew an average of 1.38 centimeters a year less than expected; in another study, the growth lag in school-age children was only 0.86 cm. In addition to these problems, it was notable that while 22% of children on methylphenidate met the criteria for a significant improvement, 13% of those on a placebo also met the criteria, leaving a relatively small difference to be attributed to the medication.
Parent training has also resulted in some improvements in preschool ADHD symptoms, but these do not occur in all children or by all measures. For example, in a study of the New Forest Parenting Program, parent ratings of children’s behavior improved, but observational measures did not change. This program’s positive effects occurred when training was provided by home visitors with a mental health background, but not when it was done by medically-trained visitors who had been trained in the parenting program.
In conclusion, Dr. Blum offered the following summary statements: Preschoolers with ADHD have significant functional impairments; behavioral treatments and medication can both cause improvement, but less than half the children are excellent responders; and methylphenidate side effects may be more significant in preschoolers than in school-age children.
The PA-IMH breakfast seminar presentation for November, 2014 was given by Judith Silver, Ph.D., of CHOP, and focused on the special needs of children between birth and three years who are involved with the child welfare system. Because Pennsylvania state laws will soon change to lower the bar for investigation of abuse and neglect cases, it will become increasingly important to be able to make an accurate assessment of the needs of vulnerable young children. Infants and toddlers are especially vulnerable to neglect, they are the largest cohort of victims of substantiated abuse and neglect, they make up half of all substantiated medical neglect cases, they account for 70% of all child deaths, and they are often without contact with mandated reporters of abuse and neglect. Unfortunately, few states treat the needs of infants and toddlers as different from the needs of older children, and few have put to work some of the promising approaches for meeting young children’s developmental needs. The Family Advocacy & Support Tool (FAST 0-5 module) offers a way to help caseworkers plan effective interventions and provides a rating system that identifies specific problems as “actionable”. The FAST approach includes items that have to do with risk for death and injury and medical neglect or developmental disabilities. Failure to thrive is one focus, and includes concerns about babies receiving insufficient calories because of inappropriate formula preparation, failed breast feeding, or food insecurity, all possibly associated with parents’ intellectual disability or with medical causes such as lead exposure or HIV. Another serious concern has to do with the development of early vision and hearing problems, which must be resolved in the first year or less in order to prevent long-term effects on language development or blindness.
For most breakfast seminar attendees, an important aspect of FAST was the setting of standards to use in assessing behavioral and emotional concerns such as sleep practices, self-regulation issues like crying and tantrums, and the progress of eye contact and social engagement. Most of the FAST items of this kind are not only focused on birth to age three, but provide information on developmental sub-periods, as sleep practices or concerns with crying are very different for young infants than they are for toddlers. For example, with respect to sleep issues, one item is specifically designed for babies from birth to four months of age, the period when death from SIDS is by far the most likely. During this age period, babies’ sleep situations may be evaluated as having 0 or 1 concerns, in which no changes are needed, or they may be ranked as having moderate or significant concerns, and therefore needing to have this issue included in the individual family plan.
Concerns about crying in young babies and tantrums in toddlers are carefully defined in the FAST approach. If infants aged 1 to 5 months are moderately easily soothed, this concern is a minor one, but there is much more concern if a baby cries for extended periods and does not soothe, especially if the caregiver gets no breaks from responsibility. The concern with tantrums focuses on children from about 12 months to 5 years of age. No problem is indicated if these are brief outbursts that are resolved in 10 minutes or so, and if they are triggered by age-appropriate issues like power struggles or crankiness. There is slight concern if tantrums occur more than 5 times a day and if they resolve in 10 to 15 minutes. Moderately concerning tantrum behavior involves tantrums more than five times a day, lasting more than 20 minutes, or involving aggression or head-banging on soft surfaces. Significant reason for concern exists if tantrums are intense and the child hysterical and inconsolable for long periods, and where there is abrupt head-banging on hard surfaces. In the last case, planning should include investigation of developmental disorders like language delays, or reminders of past trauma as reasons for significant tantrums.
The FAST birth-to-five module presents an extremely useful definition/checklist approach that should be of great value to professionals doing individual family plans.
On Sept. 5, 2014, Judith Miller,Ph.D. of the Center for Autism Research at Children’s Hospitalof Philadelphia, presented on “DSM-5: Changes to Autism Spectrum Disorder and Intellectual Disabilities” This topic drew a large and interested audience because of ongoing changes in the use of the new criteria for these diagnoses, and their implications for services children may receive.
Dr.Miller noted the history of changes in DSM descriptions and criteria for autism and similar disorders. From 1980 on, there have been alterations in DSM views of autistic disorders and pervasive developmental disorders, with the addition of Rett’s disorder, childhood disintegrative disorder, and Asperger’s disorder in 2000. DSM-5 omits some of these categories and places individuals on an autism spectrum disorder continuum, with narrative descriptions of specific criterion skills and behaviors, and assessment of the severity of each problem in terms of services needed.
Comparing the DSM-IV-Tr criteria for autism to the DSM-5 criteria for ASD, Dr. Miller pointed out that the delayed language criterion, at one time such a focus for assessment of autism, has now been removed from the DSM-5 list. The reason for this was that this problem is not unique to autism, and in fact with increased access to speech interventions is less likely than it once was. Language problems are still of interest in the DSM-5 approach, but are considered as aspects of social-emotional reciprocity and of stereotyping.
Like DSM-IV-Tr, DSM-5 looks at a category of nonverbal communication. There is a concern with difficulties with relationships in general, not just with the peer relationships of concern to DSM-IV-Tr; the old criterion of delayed pretend play is also included in the relationship category. The old categories of lack of emotional reciprocity and impaired conversations are included as aspects of social-emotional reciprocity. Circumscribed interests continue to be a criterion, as do routines and resistance to change. Stereotyped movements, speech, and object use now takes the place of stereotyped language and stereotyped movements. The earlier “preoccupation with parts” criterion is now expanded to unusual sensory reactivity or interest, although Dr.Miller pointed out that not all ASD children have these and that the evidence for Sensory Integration Disorder is weak. Finally, the old criterion of onset before 30 months is now broadened to onset in early developmental period. Each of these criteria is considered in terms of its severity and the level of support the child needs.
The narrative description required by DSM-5, which no longer uses the “axis” approach, is intended to focus on a child’s individual pattern of strengths and weaknesses and to avoid the “diagnostic overshadowing” that suggests that all children with a diagnosis are alike. Children who have deficits in social communication but do not meet other criteria for ASD should be evaluated for social communication disorder. Dr. Miller also stressed the fact that autism is simultaneously heterogeneous and often coupled with co-occurring diagnoses.
Problems that have known medical or genetic foundations, like Rett’s disorder or Fragile X, are no longer included in this diagnostic category. However, children who were previously diagnosed as autistic under DSM-IV-Tr will be “grandfathered” into the new diagnostic category with respect to the availability of services.
Audience questions included a number of inquiries about how these changes affect the services children get. Dr. Miller noted that the States interpret Federal criteria in different ways, but that school districts also develop their own cultures that help to determine how services are provided. One audience member referred to her experience that parents are quick to accept the idea that a child is autistic without waiting for a full assessment. This question led to a discussion of which professionals can diagnose ASD, with the conclusion that although people should be working within the scope of their expertise, state laws differ with respect to the role of social workers in ASD diagnosis.
The interest of the audience in ASD limited the time that Dr. Miller was able to give to the new DSM-5 diagnosis of Intellectual Disability Disorder, now replacing the term “mental retardation”. However, she noted the DSM-5 emphasis on adaptive impairments in various areas, and pointed out that IQ scores are more problematic at the low end of the range.