Transcript Slide 1

USING THE BEST AVAILABLE
EVIDENCE TO IDENTIFY INFANTS
AND TODDLERS WITH (OR AT RISK
FOR) COMMUNICATION DEFICITS
Elizabeth Crais
The University of North
Carolina at Chapel Hill
TelAbility/WATCH Project
January 11, 2008
Where We Are Now?
• Clear evidence that early intervention works
• Growing evidence across a variety of disabilities
supports maxim “earlier ID is better”
• 10-12% of school-age population receiving special
education services
• 12-16% of children have developmental or
behavioral disabilities (Comm. on Child with Dis,
2001)
• 7-24% of 2-3 year olds have social-emotional or
behavioral deficits (Briggs-Gowan et al, 2001)
• How early are we identifying these children?
Percentage of Children Identified
For EI By Age Range
• 1.6 % Birth to 2 years
• 4.9% 3-5 years
• 11% 6-18 years (U.S. Department of Education,
2005)
• Even among those identified early 0 - 3:
14% 0-1 years
32% 1-2 years
54% 2-3 years
(Part C Update, 2004)
• Most commonly identified early concerns are
related to motor or language delays
Are We Using the Best Predictors?
• One of best predictors of child’s future
language is child’s current
communication performance (Brady,
Marquis, Fleming, & McLean, 2004;
Facon, Facon-Bollengier, & Gruber,
2002).
• Language skills are a strong predictor
of cognitive skills (Brady et al, 2004).
Current Evidence Based
Predictors
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Vocal Behaviors
Vocabulary Comprehension
Prelinguistic communication
Gesture Use
Symbolic Play
Vocal Behaviors Predictive of
Later Language
– More vocalizations
– More consonant-vowel syllables
– Rate of vocalization
– Rate of vocalizations with
consonants
– Rate of vocalizations in interaction
with others (***). (McCathern,
Yoder, & Warren, 1999).
– Ability to use sounds is strongest
predictor of language skills one
year later (First Words)
Prelinguistic Communication
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Rate of prelinguistic communication
Rate of symbol use (especially gestures)
Rate of different symbol use
Significantly correlated with later language
outcomes 12 months later
• Amount of prelinguistic communication
predictive of later symbolic communication
(Calandrella & Wilcox, 2000).
• Frequency of nonverbal communication in
preschoolers with ASD predicts language 1 ye
later (Sigman & Ruskin, 1999)
Motivation for Our Research in
Autism
• Diagnosis of children with autism typically
occurs between 2 - 3 years of age
• Diagnosis is rare before two years of age
• Yet the literature shows enhanced
outcomes with early identification and
intervention
• Thus, our ultimate goal is to identify
children with autism even earlier
• But what are the barriers to earlier
identification?
Barriers To Early ID Include
• Difficulty identifying behaviors that could be
markers for group differences
• Need to look for both presence of atypical
behaviors and absence of typical behaviors
• Limited knowledge of developmental course
of behaviors that may be common in young
children (e.g., repetitive movements,
mouthing)
• Therefore, relatively “late” identification
makes it difficult to know the course of early
development in these children
Retrospective Video Analysis
• Ecologically valid methodological tool for
earlier identification of children at very early
periods in development (prior to diagnosis)
• Several retrospective video studies of
autism suggested young children with
autism can be distinguished from typically
developing children (Adrien et al., 1993;
Baranek, 1999; Osterling and Dawson,
1994)
Retrospective Video Analysis
• UNC researchers have used footage that
families provided of their child under two
years of age (well before diagnosis).
• Footage representative of a wide range of
family play situations.
• Videotapes edited for randomly selected
cross-section of situations and events.
• Studies include typically developing infants,
infants later diagnosed with autism, and
infants diagnosed with developmental delays
at 9-12 and 15-18 months of age.
(Baranek, 1999; Watson, Crais, Baranek, Roy, & Dykstra, 2004;
Lanter, Colgan, McComish, Watson, Baranek, & Crais,
submitted).
Possible Behaviors of Interest
• Increasing interest and research in
early prelinguistic behaviors in children
developing typically and with autism
• Areas of promise targeted today are
gesture use, play development, and
relationship between play behaviors
and gesture use
• Helpful to first be familiar with typical
development in these areas
Development of Gestures: Why
Are They Important?
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Early means to communicate
One of the first signs of intentionality
Can be used in profiling skills
Can be helpful in identifying delays
Important to intervention planning
Gesture Development and Use
• Amount of gesture use can help
distinguish between “late talkers” and
children with true language deficits (Thal
& Tobias, 1992; 1994).
• Early onset of pointing predictive of
advanced language skills (Butterworth &
Morisette, 1996).
• Use of distal (e.g., show, give, point)
gestures predictive of higher rate of
communication (McLean, McLean,
Brady, & Etter, 1991).
What Are Gestures?
• Gestures are actions produced with the
intent to communicate and are typically
expressed using the fingers, hands,
and arms, but can also include facial
features (e.g., lip smacking for "eating")
and body motions (e.g., bouncing for
“horsie")
• (Iverson & Thal, 1998)
Age Ranges of
Emergence of Common
Gestures
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Reaching
Giving
Showing
Pointing
6-9 months
8-11 months
8-13 months
9-14 months
(Bates et al., 1975; Carpenter, Nagell, Tomasello,
1998; Crais, Douglas, & Campbell, 2004;
Masur, 1983)
Functions of Gestures
• Social interaction: initiating or sustaining
a social game or routine, providing
comfort, teasing, showing off
• Behavior regulation: regulate behavior of
others to obtain an object, get them to
carry out action, or stop someone from
doing something
• Joint attention: direct other’s attention in
order to comment on an object or event,
provide information on an object or event,
or acknowledge shared attention to an
object or event
Age of Emergence of
Functional Categories
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Protests
Requests for actions
Requests for objects
Comments
Answering
6-8 months
6-10 months
6-10 months
8-11 months
13-16 months
(Carpenter, Mastergeorge, & Coggins, 1983;
Crais et al, 2004)
Array of Gestures Seen in 9-12
Month Old Children (Crais et al, 2004)
Behavior Regulation
• Protest (use body, push away object with hand/s)
• Request Objects (reach for object, pull on adult’s hand with
object, point to obtain object)
• Request Actions (reach to be picked up, do the action)
Social Interaction:
• Seek Attention (body movement, grab hand, bang object)
• Social Games (participate by imitating, initiate games)
• Representational Gestures (“bye bye”, imitation clapping,
show functions of objects)
Joint Attention:
• Comment (show object, give object)
Array of Additional Gestures Seen
in 15-18 Month Old Children
Behavior Regulation:
• Protests (shake head “no”)
• Request Objects (reach while opening & closing hand)
• Request Actions (point, take hand of adult, give object)
Joint Attention:
• Comment (point to object, point to object by request)
Social Interaction:
• Seek Attention (show off)
• Representational Gestures (hug objects, smack lips, clap
for excitement/accomplishment),
(Crais et al, 2004)
Results: Comparing Group Means for
Gesture Functions at Time 1 (9-12 m)
4
3.5
3
2.5
ASD
DD
TYP
2
1.5
totgest_1
1
0.5
0
BR@1
ASD<TYP
SI@1
JA@1
ASD < TYP
DD < TYP
(ASD n=24, DD n=14, TYP n=22)
Gesture Use In Infants &
Toddlers
• Results indicate differences in gesture
use between 9-12 month old infants later
diagnosed with autism or developmental
disabilities and children with typical
development.
• Total number of gestures (differences
between children with ASD & TYP, DD &
TYP)
• Group differences on behavior regulation
& joint attention gestures, but not social
interaction (9-12 & 15-18 months)
Gestures Seen in Sample
Autism Group (n=9)
Total
Type of Gesture (# of
each)
Typical Group (n=10)
Total Type of Gesture (# of each)
9
wave (3), so big (2), kiss (3),
shake head (1)
12
so big (11), wave (1)
5
peek-a-boo (4), wiggle (1)
6
clap (2), reach (2), wave (2)
5
peek-a-boo (5),
5
4
clap (2), peek-a-boo (1),
wave (1)
clap (2), dancing (1),
peek-a-boo (2)
5
kiss (1), “oh-my” (1), so big (3)
3
wave (2), clap (1)
4
dancing/ waves arms (4)
2
shake head no (2)
3
clap (1), wave (2)
2
wave (2)
3
hop in chair (1), peek-a-boo (2)
1
wave (1)
2
claps (1), reaches (1),
1
dancing (1)
1
shake head no (1)
1
so big (1)
Levels of Play Development
Level 0 = No object play
Exploratory = the way infant examines the
environment in order to gain information from
objects or toys (e.g., mouthing, banging,
shaking, poking): Level I (indiscriminate
actions), Level 2 (simple manipulations of
single objects)
Relational = two or more objects used in
combination with one another, without regard to
attributes or functions of objects (e.g., objects
pushed, stacked, nested, piled): Level 3 (taking
objects apart), Level 4 (general combinations)
Levels of Play Development
Functional = influenced by social or cultural
properties of objects (e.g., pretend actions,
spoon to doll’s mouth): Level 5 (directed
toward object), Level 6 (toward self), Level 7
(toward doll), Level 8 (toward other person)
Symbolic = items, attributes not actually
present, or substitution of objects: Level 9
(object substitution), Level 10 (agent play),
Level 11 (imaginary play)
(Baranek, Barnett, Adams, Wolcott, Watson, & Crais,
2005; Belsky & Most, 1981; Casby, 1991, Knox, 1997;
Libby, Powell, Messer, & Jordan, 1998; Lifter, SulzerAzaroff, Anderson, & Cowdery, 1993)
Age Ranges of Play Levels
Exploratory
• Level 1 (indiscriminate actions)
• Level 2 (simple manipulations)
Relational
• Level 3 (Takes objects apart)
• Level 4 (General combinations)
Functional
• Level 5 (object directed)
2 - 10 months
2 - 10 months
10 - 18 months
10 - 18 months
12 –18 months
Age Ranges of Play Levels
Functional
• Level 6 (self directed)
• Level 7 (doll directed)
• Level 8 (other directed)
Symbolic
• Level 9 (object substitution)
• Level 10 (agent play)
• Level 11 (imaginary play)
12 – 18 months
12 - 18 months
12 - 18 months
18 – 30 months
18 – 30 months
18 – 30 months
Concurrent Language/Play
Associations
13 - 20 months
• First words appear along with more
consistent communicative gestures and
single play schemes (e.g., child feeds self
with spoon)
20 - 24 months
• Word combinations appear along with single
play schemes combined (e.g., child feeds
self with spoon, then drinks from cup).
• (Kennedy, Sheridan, Radlinski, & Beeghly, 1991)
Predictive Language/Play
Associations
• Early skill with communicative gestures predicts
later language levels (Mundy & Gomes, 1998; Thal,
Bates, Goodman, & Jahn-Samilo, 1997)
• Early functional object play has been associated
with later language ability (Lyytinen et al., 1999;
Ungerer & Sigman, 1984)
• Level of symbolic play exhibited is predictive of later
language skills (Lyytinen, Laakso, Poikkeus, Rita,
1999; Lyytinen, Poikkeus, Laakso, Eklund, &
Lyytinen, 2001).
Longitudinal Relations
between Play and Gesture
Behaviors in Infants with
Autism (Watson, Crais, Baranek, Roy,
& Dykstra, 2004)
Examined predictive relations
within and across the domains
of play and gesture from 9-12 to
15-18 months
Subjects
(Watson, Crais, Baranek, Roy, & Dykstra,
2004)
• 27 children in three groups
– Autism spectrum disorder (n = 15);
DSM-IV criteria, verified by CARS
scores, and for 10 of 15 by ADI-R
– DD (n =4); nonspecific, mixed
diagnoses
– Typical (n = 8)
T1 to T2 Gesture Use
(Watson et al. 2004)
Figure 1: Mean Frequency of Gestures for Total Sample (p=.08)
5
4
Ges T 1
3
N o Ges
T1
2
1
0
T ime 1
T ime 2
T1 to T2 Gesture Use
(Watson et al., 2004)
Figure 2: Mean Frequency of Gestures for ASD Sample
4
3
Ge s T 1
2
N o Ge s
T1
1
0
Ti me 1
Ti me 2
T1 to T2 Higher Level Play
(Relational Play+)
(Watson et al., 2004)
Figure 3: Mean Second in Higher Level Play for Total Sample
30
25
H i pl a y
T1
20
15
Lo pl a y
T1
10
5
0
Ti me 1
Ti me 2
T1 to T2 Higher Level Play
(Relational Play+)
(Watson et al., 2004)
Figure 4: Mean Seconds in Higher Level Play for ASD Sample
20
15
Hi P lay
T1
10
Lo P l a y
T1
5
0
Ti me 1
Ti me 2
Clinical Implications
• Preliminary guidelines for clinicians seeking
developmental models for both the range of
expected ages of emergence of targeted
gestures and play behaviors and their
hierarchy in typically developing children.
• Clinicians can assess the depth and
breadth of gestures and play behaviors
used by children demonstrating
communication delays
• Hierarchy of gesture and play development
can be used in determining potential
developmental targets for intervention.
Red Flags Approach: Social Development
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Be concerned if the child is not:
By:
Responding to familiar adults with a social smile
3 months
“Talking” back by vocalizing to familiar adults who talk to child
8 months
Attentive to social games played by familiar adults (e.g., Peek-a-Boo)
8 months
Participating in social games (e.g., hands up for “Pat-a-Cake”)
12 months
Showing and/or giving objects to familiar adults
15 months
Pointing to objects to indicate interest in them
18 months
Seeking adult interaction to play with toys/look at books
18 months
Pointing either spontaneously or by request to pictures in books
24 months
*** General Social Concerns = inattentiveness to people, lack of eye contact or shared mutual
gaze with familiar adults by 12 months; preferring to play alone at 18 months or older; social play
is limited to “chase” or “tickle” games at 24 months.
Intentionality
Be concerned if the child is not:
Showing any type of intentional behavior (e.g. requests, protests)
Communicating for a variety of reasons (e.g., protesting, requesting,
seeking social interaction, commenting)
Using a variety of means (e.g., gestures, vocalizations, eye gaze)
By:
10 months
18 months
18 months
*** General Intentionality Concerns = children who primarily regulate others behavior
(e.g., putting someone’s hand on toy to operate it, leading adult to door to open it),
but do not display more social forms of communicating (e.g., giving book to another
to read, pointing to objects of interest, drawing attention to self for social reasons).
Play Skills
Be concerned if the child is not:
By:
Mouthing, banging, shaking, and/or manipulating objects
Throwing, dropping toys especially for others to get
Participating in social games (e.g., looks for Mom during “Peek-a-Boo”).
Giving or showing toys to adults
Pushing, pulling, turning on, putting in, and taking out objects
Showing knowledge of how to use toys functionally (e.g., push toy car)
Stacking cups or rings on a toy stand (not necessarily correct)
Performing some pretend play behaviors (e.g., drinking from empty cup)
Combining play acts (e.g., rocks baby and puts down for nap)
Playing with familiar children some of the time when in close proximity36 months
Taking turns in constructive or pretend play with familiar children
8 months
12 months
12 months
15 months
18 months
18 months
24 months
24 months
30 months
48 months
*** General Play Concerns = children who primarily perform play behaviors representative of younger
children; have limited play behaviors (e.g., play with only one type of toy, play very briefly with
toys); seem averse to playing with others (including caregivers); play alone for longer periods of
time than would be expected at their developmental age; have stereotypic play behaviors (e.g.,
repeatedly open and close drawers, line up their toys and become upset if others change the
order); or display unusual play behaviors (e.g., rub plastic stacking rings over their hands or face,
lick and smell toys).
Comprehension Skills
Be concerned if the child is not:
By:
Looking at objects looked at by others
Acting on objects that are noticed
Imitating ongoing actions
Responding to own name
Attending to an object mentioned
Doing what is usually done in a situation (e.g., child puts on coat
when others do)
Using conventional behaviors (e.g., combing hair with comb)
Acting on objects as the agent (e.g., child brushes own teeth
when asked to “Brush the baby’s teeth”)
Responding to many object names
Retrieving a familiar object out of sight
12 months
12 months
12 months
15 months
15 months
18 months
18 months
24 months
24 months
24 months
Sound Production
Be concerned if the child is not:
By:
Producing cooing and gooing sounds
Babbling in repeated sequences of sounds (e.g., baba, gaga)
Producing 3 different consonant sounds (e.g., b, p, m, n, d, k, t, g, w) 18 months
Imitating any non-speech sounds (e.g., truck sound, animal sounds)
Using sound sequences that sound like talking
Producing (VC) syllables (e.g., up), (CVC) syllables with a single
consonant (e.g., cake), and some vocalizations or words
with two or more different consonants (e.g., pat, tummy)
Producing 6 different consonants
Producing initial consonants in most words (says “at” for pat, “ot” for boat)
Producing 10 different consonants
Producing any final sounds (“bo” for “boat”, “e” for “eat”)
6 months
11 months
18 months
24 months
24 months
24 months
36 months
36 months
36 months
Word Productions and Word Combinations
Be concerned if the child is not:
Producing any words or word approximations
Producing 50+ words or word approximations
Producing 100+ words
Combining words
By:
18 months
28 months
30 months
28 months
E. Crais. (2001). Identifying communication and related developmental disabilities in
young children. In J. Roush (Ed.), Screening for hearing loss and otitis media in
children. San Diego, CA: Singular
Questions?