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Hi, my name is Dr. Debbie Mood.
I'm a licensed psychologist.
Today I'm here to talk to you about assessment
of autism spectrum disorder with children,
who are deaf and hard of hearing.
To give you a little bit of information about
my background. I am a psychologist,
and I have specialized training in working
with children, who are deaf and hard of hearing,
with a degree in school psychology from Gallaudet University.
Then I later pursued a PhD in school psychology, as well.
In my current work capacity,
I work at a local Children's Hospital,
where I work with children, who have a wide variety
of developmental disabilities including autism, as well as, with children, who are deaf and hard of hearing.
Today what I hope to talk about is: What are the symptoms of autism
and how do they present specifically among children,
who are deaf and hard of hearing?
Today we'll be talking about symptoms as they might
present in children who have reduced hearing,
who use an auditory verbal approach, as well as,
in children, who use a sign communication modality,
and how the symptoms of autism can present both
similarly and differently among children, who are deaf and hard of hearing.
We're also going to talk a little bit about how do we assess for autism with children,
who are deaf and hard of hearing.
Many of you may have already seen the broadcast
by Dr. Angie Lawson, where she reviewed the criteria
for a diagnosis of autism, and I'll refer you
to that presentation for more in-depth information
about the specific criteria in general
and for information about how medical diagnosis of autism
differs from an educational classification of autism.
Just to briefly review those diagnostic criteria, that physicians and psychologists use
for diagnosing an autism spectrum disorder.
We use a manual called the DSM-5,
the Diagnostic Statistical Manual, Fifth edition.
The criteria that's outlined in that DSM-5 manual
indicates that for an individual to be given a diagnosis of autism, they have to meet specific criteria.
They have to have difficulties with social communication
and social interaction across several contexts that are
not just explained by either a sensory difference,
like a vision or hearing difference,
or by a general developmental delay.
The criteria also indicates that those areas of social communication, that we're looking for,
that might be different for children, who have an autism spectrum disorder are specifically
difficulties with social emotional reciprocity,
difficulties with nonverbal communicative behaviors,
and difficulties developing and maintaining
developmentally appropriate relationships,
so relative to their developmental age rather than
their chronological age in the situation,
where you have children, who have some kind
of developmental delay.
We're going to talk more specifically about what those symptoms look like in hearing children with autism.
How they might present in children, who are deaf and hard of hearing, and how that differs
from symptoms that might appear to be related to the child's reduced hearing.
The next DSM-5 criteria that has to be met is at least two of the following have to be met,
two difficulties with restricted or repetitive
patterns of behavior have to be met.
The potential options there would be: stereotyped or repetitive speech,
repetitive motor movements (we'll talk more about
what stereotyped language means), excessive adherence
to routines or ritualized patterns of behavior,
highly restricted, fixated interests or interests
that seem abnormal in terms of the intensity or things
that seem unusual for the child's age.
A newer criteria that was added with this revision of the DSM-5
are hyper- or hypo- reactivity to sensory inputs.
We'll talk more about what those mean in a minute.
The other stipulation in the guidelines in the DSM-5
are that the symptoms have to be present from early childhood, however, they may not become
readily apparent to everybody in some situations until the child is in a social context,
where their abilities to manage the social demands are unable to meet the expectations in that context.
The other criteria is that the symptoms have to have a functional impact for the child.
That's the diagnostic criteria, that we use for assessing for an autism spectrum disorder,
but the criteria itself is kind of vague and ambiguous unless you really understand
what those symptoms mean. I also want to provide a broader context for understanding autism.
When we talk about autism, those DSM-5 criteria are what we consider the core difficulties,
however, how autism can present varies very much across children.
So we often say, "If you've met one child with autism, you've met one child with autism."
Because children can meet the diagnostic criteria for autism in a variety of different ways
as long as they have those core difficulties.
Some of the things that contribute to how children with autism might look differently
are what we call moderating features,
features that impact how those symptoms present.
An example of that would be how a child, who was
minimally verbal or had minimal communication in any modality, whether that's sign language
or spoken language, might look compared to a child, who had very good communication skills.
Another example of a moderator would be their cognitive abilities.
A child who had an intellectual disability, in addition to autism, might look very different than a child,
who had average to an above-average IQ in terms of how the specific symptoms present.
Then we'll talk about also some of the things that could really impact a child with autism
or some of these associated features. If we pull out, and we look at the broad concept
and the big picture of what an autism spectrum disorder, how it might present.
Again we have those core difficulties with social difficulties, the social communication difficulties,
and those repetitive behaviors, but among children with autism we often see patterns of children,
who are more likely to have associated difficulties.
Those can include medical, specific medical issues such as GI issues, gastrointestinal dysfunction,
feeding difficulties, sensitivities to particular types of food.
We also often see children, who have sleep difficulties,
and as we all know, if children are not sleeping well,
or if any of us are not sleeping well,
that can have a huge impact on the child's behavior.
Some of the other things that can manifest later
or can be present with an autism spectrum disorder
are the presence of other neurological concerns
such as, seizures and seizures can have
a definite impact on the child's functioning.
Even though we talk about the core features that we look for in diagnosing autism,
all these other things are really important to look at, too,
because they have an impact on the child's quality of life, and how they function.
Oftentimes when teachers or parents are concerned about behaviors, sometimes we can approach
that from a behavioral standpoint, but often we also need to approach it from a medical standpoint
to really have success in managing that behavior.
Another associated difficulty that we sometimes see, especially as children with an autism spectrum disorder
approach adolescence, is the onset of an anxiety disorder, and sometimes a mood disorder.
Again those are things that are also important to screen for and to consider in your diagnosis,
because they have a big impact on the child's quality of life and their functioning.
Any assessment or diagnosis of autism should also include a developmental interview
and clinical interview that looks at those related areas of difficulty.
Why is it so important to understand how autism presents in children, who are deaf and hard of hearing?
We have some information that suggests, that there might be a higher rates of an autism spectrum disorder
among children, who are deaf and hard of hearing.
In Dr. Angie Lawson's presentation, she discusses that quite a bit.
I'll leave that topic for today, but one of the things that we do know is that children,
who are deaf and hard hearing tend to be diagnosed later
than hearing children with an autism spectrum disorder,
and particularly when we're talking about autism,
we know that earlier intervention is so critical
in contributing to better outcomes and so it's really
important to understand how autism looks and presents
in children, who are deaf and hard of hearing, so that we can make sure that if they have additional needs
that are related to autism, that we can intervene early and change those developmental outcomes.
Now I'm going to talk about the symptoms of autism, how they present in hearing children who have autism,
and we'll talk about how some of these behaviors might be confused as being symptoms of autism
among children, who are actually typically developing children with reduced hearing, and then we'll talk
about how they specifically look in children, who are deaf and hard of hearing who also have autism.
How do we distinguish that?
For example, when we talk about difficulties in communication, hearing children with autism
often have very specific communication difficulties.
They often have difficulty integrating their eye contact with their spoken or signed communication,
if they're using sign communication. They have differences in how they use eye contact.
They also have difficulty integrating their spoken communication with gestures.
Most of the time when we talk, we support our communication with gestures and especially
in early childhood. That's a skill that young children rely on quite a bit to make their communication
understood and children with autism, who are hearing have difficulty with this.
They also often have difficulty regulating how they use other nonverbal aspects of communication.
Their facial expressions may not match the situation. This can be confusing to people,
because if we see a child who laughs when someone gets hurt, we get upset, that they're laughing,
when someone's hurt. But for a child with autism, they may have difficulty using those facial expressions
and matching the situation. Oftentimes, you'll see hearing children with autism have difficulty
understanding their peers nonverbal cues. What that can look like is children, who don't recognize
when their peers are making a face or gesture that they don't want to play with them,
or that the child is doing a behavior that's upsetting to the other child and so those children with autism
will sometimes persist in doing that behavior that the child is trying to non-verbally communicate,
and that they don't like. In typically developing children who are deaf and hard of hearing,
a lot of those difficulties are not the norm. Right?
Children, who are typically developing, who are deaf and hard of hearing, generally have appropriate eye contact.
You'll sometimes see children, who are typically developing, who are deaf and hard of hearing,
who might purposely avoid eye contact, especially if that's their primary means of communication.
But otherwise especially when they're making requests themselves for something
they usually direct their eye contact with the persons that are trying to communicate.
Even for children, who use sign language to communicate, we know that they use both formal signs
that are the signs that are used in their environment, that are formerly shared among the community
for communicating, but they also use descriptive gestures that might be spontaneous ways
of using those ASL classifiers, in the case of children, who are signing using American Sign Language.
Children, who are deaf and hard of hearing often use a wide range of facial expressions
in the absence of an autism spectrum disorder. In fact facial expressions are part of some of the grammatical
features of American Sign Language, and so they're necessary for children learning the language
and using the language to use them appropriately. Having said that children, who are deaf
and hard of hearing sometimes have difficulty acquiring English and spoken English in very specific ways.
There are specific difficulties that we know children with reduced hearing might have in terms
of vocabulary, grammar, depending on their degree of hearing loss. They might miss particular morphemes
in the spoken language. Children, who are deaf and hard of hearing may misunderstand or not fully
understand idiomatic expressions that we use if they haven't been exposed to those.
Those are differences in their language that we might see even among children, who are typically developing,
who are deaf and hard of hearing, but with intervention those skills typically improve.
Generally speaking, the language progression in children, who are deaf and hard of hearing,
who are typically developing, is one that follows an expected pattern.
There might be those differences in how they acquire a language depending on the modality
of their communication, that I just described, but generally with intervention,
they make progress and use that language spontaneously across a variety of contexts.
Whereas in autism the trajectory of how the child learns language can differ in very specific ways.
For children, who are deaf and hard of hearing, who have an autism spectrum disorder,
the way that they acquire language might differ in ways that are more similar to children
with autism than to children who are deaf and hard of hearing. Typically developing children,
who are deaf and hard of hearing before they establish the ability to use spoken words,
if that's their communication modality or signs if that's their communication modality,
tend to communicate by using eye contact and gestures. In typical development for children,
who are deaf and hard of hearing, those things are not really impacted by their reduced hearing
but for children, who are deaf and hard of hearing,
who have autism, we often see that those children
have difficulty again making eye contact.
They have difficulty using gestures.
Some common early gestures that might be
an example of that are pointing. Pointing is a really
important skill, that it comes in pretty early,
usually by 12 to 18 months, we expect children
to be pointing, and pointing not just to request
something like pointing to something over there that
they want and vocalizing or signing [Laugh]
that they want it, but pointing to things
that they want and looking back to the person
that they're trying to communicate.
Also not just pointing for things that they want [Laugh],
because sometimes kids have been reinforced to do
that, but also pointing for the purpose,
the very social purpose, of sharing interest in something,
pointing when they see something new in the sky,
like a hot-air balloon or an airplane,
pointing when anything stands out to them as being
interesting and again directing that and looking
at the person that they're with, whether that's a caregiver or teacher or friend.
Children, who are deaf and hard of hearing, who have an autism spectrum disorder, sometimes fail
to use those early communicative gestures, in addition to pointing.
One of my favorite ones for young kids is this one for, "Where is it?" [Laugh]
Or the other ones that we see like "Up" or
"Come here."
Those are some early gestures that we expect
to come in definitely by the first and second year of life,
if the child is mobile. Some other ways that we see language look differently for children, who are deaf
and hard of hearing, who have autism is differences in how they use their speech.
What we call the prosody of their speech. If they're using spoken communication or their sign.
You might see children, who are deaf and hard of hearing, who have autism, who are not using
the correct signing space, the culturally appropriate signing space.
Sometimes they're signing down here to themselves, but they're not orienting the signing for the purposes
of communicating with other people. If they're using speech, you might see children,
who have kind of a monotone intonation in their speech. Again even for children, who have some kind
of reduced hearing, that can have an impact on the quality of their speech sometimes
or the way that they produce sounds, and sometimes it has a variable impact in how they're speaking.
But generally they're still able to recognize and understand how others in their environment
are shifting their spoken language to ask a question, for example, with a rising intonation at the end,
rather than having a monotone tone of voice in asking a question or expressing excitement.
One of the big red flags, that we look at, is as children are acquiring language are they starting
to use it spontaneously? That is, do they only use it in the situations where you've taught them to ask for more,
like more food, because you worked very hard at teaching them the sign for "More" at the dinner table
or during snack time? But then do they have difficulty using that same sign "More" to ask for more
of an activity [ Laugh] or more of a social interaction, that they want. Sometimes we see children,
who are deaf and hard of hearing, who have autism, who have difficulty generalizing the language
as they're learning it across different contexts and across different people.
Whereas, for typically developing children, who are deaf and hard of hearing, they're generally able to do that.
For older children, who are deaf and hard of hearing,
some of the ways that we see differences
in their communication behavior present might be
difficulty understanding what we call the pragmatics
of communication, the social use of language.
They might have difficulty understanding how to enter
a conversation with other people, who are signing,
or how to leave a conversation with other people,
who are signing or how to appropriately get someone's
attention in ways that are consistent with deaf
cultural norms for that.
I'm going to talk quite a bit about this aspect of how language might look differently
for children, who are deaf and hard of hearing, who have autism. It's one of the few areas where we do have
a little bit of emerging research in this area. And there are differences in how these communication features
can present in a spoken language versus a signed language, that I think are important.
One thing that I do want to emphasize in relation to this point, that children, who are deaf and hard of hearing,
who might have an autism spectrum disorder, sometimes have differences in how
they're communicating, is that we should never assume
that a child, who's having difficulty acquiring a language
in whatever modality that is, whether it's through spoken
or sign language is having that difficulty just because
of the modality itself, or because they may not have
as much exposure for example to sign language
in their home environment with parents,
who are learning sign language.
If a child is having difficulty acquiring language
at the rate that we, as professionals in deafness,
would expect. Then we should look further and consider
whether there might be something like an autism
spectrum disorder or another developmental difference
that might be contributing to that.
I also want to emphasize that although language deficits or delays are not one of the core symptoms
that we described in terms of the diagnostic criteria
for autism. So that is that a child can have a diagnosis
of autism and they're receptive and expressive language
can actually be age-appropriate, but their social use
of language can be very different.
Having said that, even though it's not a core deficit
associated with autism, language delays are
very commonly found among children,
who have an autism spectrum disorder.
In Dr. Aaron Shield's study of children, who are deaf
with deaf parents, who have an additional diagnosis
of an autism spectrum disorder, even though
those children had exposure to native language models
of ASL, about 1/3 of those children who had a diagnosis
of autism had limited language in sign language.
On average their receptive ASL skills also were
significantly below their typically developing deaf
and hard of hearing peers.
That suggests, that even though we use sign language, sometimes as an intervention
with hearing children, who are minimally verbal,
even though, we could expect them to have auditory access to spoken communication,
exposure to sign language itself is unlikely to be enough
of an intervention in and of itself, to be a "silver bullet",
that's going to remediate the child's communication difficulties.
Instead we need to think about incorporating very
specific strategies, to teach the social aspects
of communication for children, who we suspect
might have an autism spectrum disorder. In some cases
this means that we need a different approach,
such as using assistive communication devices.
I'm going to talk about how the communication features of autism can present both similarly
and slightly differently in spoken and sign modalities.
Some of the things, that we see, that are the same are that in both spoken speech and sign language,
we see something called echolalia,
which is a common symptom of autism.
Echolalia refers to children, who repeat back
what is signed or spoken to them.
Both clinically and in the literature, we see evidence
of that in hearing children with autism, who use spoken
communication, and children, who are deaf and
hard of hearing, who communicate using
spoken language and also in children,
who communicate using a sign modality.
These are the children, who might be repeating back
in sign or spoken language what you say to them
in a way that feels odd.
Repeating what you say might be in early stages
of acquiring language more common, because it can be
a mechanism for that child to learn how to produce
the new word or the new sign.
But as children acquire and have combined words
and signs, we would expect echolalia to disappear,
as they acquire more language.
Another thing that we can see in spoken language and sign language
is something called idiosyncratic language.
That's a big fancy way of referring to children,
who use words in ways that are unique to them.
In spoken language this can be a variety
of different things. It could be children, who refer
to somebody by their age or by where they met them
or by the car that they drive.
I've worked with children, who called me
"Miss Debbie Toyota Camry 1999" [Laugh]
back when I was driving that car.
I've also seen this in sign language.
Sometimes, I've seen some children, who refer
to their grandparents or a grandparent,
by the sign for McDonald's, because they associate
their grandfather as taking them to McDonald's.
You might also see this in sign language as a persistent
use of a particular gesture, even though it's not
the formal sign that's being taught or used with the child.
A child, who persists in signing, "Red" for ketchup
even though everybody around them is signing
"Ketchup" or something different, depending
on your regional sign for that.
But again it's that idea of when presented with a formal
sign for that, the child is still persisting and using
this gesture or sign or word that they've associated
with a particular situation or person.
We know that children with an autism spectrum disorder
sometimes have something called Pronoun Confusion,
where they can specifically confuse the pronouns
you and I. So confusing he and she, and things like that
is part of a typical developmental trajectory,
but specifically confusing you and I is very unique
for children, who are deaf and hard of hearing,
who are communicating in a spoken modality
in the absence of an additional vision impairment.
I should clarify that much of what we're talking about today actually is very specific to children,
who are deaf and hard of hearing, who don't have an additional vision impairment, because their
developmental trajectory in the acquisition of these early social communication skills is different.
For children, who communicate using spoken language, an example of you and I pronoun confusion
might be, you might say to the child, "Do you want a cookie?" and they repeat back,
"You want cookie?", instead of "I want cookie."
This involves a difference in perspective taking that's necessary in order to switch the pronoun's use correctly.
Dr. Aaron Shield is a linguist, who has looked at language features of children with autism,
who are deaf and hard of hearing, and in his sample of these children,
he's seen something called Pronoun Avoidance.
Rather than using what we would use in sign language,
which would be pointing to refer to the person.
Children often avoid using that point to reference
a person. He showed them a picture of himself
and he asked them, "Who is this?" and children,
who had autism were far more likely
to sign "Boy" or "Man" or fingerspell his name
rather than pointing to him, when he was in the room
showing them the picture.
Children, who communicate using a sign modality,
might be likely to avoid using pronouns.
One of the other things that Dr. Shields saw in his sample of children, who had autism,
who are native ASL users, was a tendency to reverse their palms in their signing.
Where you might sign the alphabet outward, the children were reversing their palms and signing it to themselves,
reflecting difficulty understanding that they had to orient
that outward for somebody else's perspective
and instead signing it to themselves the way that
they perceived it. There are several theories
about why that might be, but one of them is
that again it reflects this difference with their ability
to shift perspective taking, to take on an understanding
of the other person's perspective, and we can see how
that could impact their acquisition of sign language.
This is something that we also see in hearing children
with autism. You might see early on children,
who wave this way, when we're working on teaching
them to wave, again reflecting that difficulty with perspective taking perhaps.
Some of the other differences, that we might see in language features in sign language,
are difficulties in the deaf child's use of facial grammar for ASL
This is something that is still being researched.
Tanya Denmark in Great Britain has been looking at this,
and we're not sure yet whether difficulty
in understanding nonverbal aspects of communication
will impact a deaf child with autism's ability to acquire
those ASL grammatical facial features.