www.mghcme.org

Neuropsychological Findings and Managing Educational Needs in

ASD

Ronna Fried, Ed.D

Director of Neuropsychology

Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD

Bressler Program for Autism Spectrum Disorders

Massachusetts General Hospital

Assistant Professor of Psychology

Harvard Medical School

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Disclosures

I have the following relevant financial relationship with a commercial interest to disclose:

– receive grant support from the FDA ; Lundbeck

– In the past, I have received grant support from NIH and Shire.

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Benefits of a Neuropsychological Evaluations

• Confirm or clarify a diagnosis (ASD and/or ADHD)

• Provide profile of strengths and weaknesses for educational, vocational, or other services

• Document changes in functioning since prior examinations, including effects of treatment

• Clarify what compensatory strategies would help

• Result in referrals to other specialists

• Documents LD

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Motor,Skills

Communication Non-verbal Verbal

Measured I.Q.

Neuropsych

Deficits

Social-

Emotional

Interaction

Sensory

Awkward Agile

Severe Gifted

Significant Mild

Aloof Passive Active but Odd

Hypo Hyper

Autism Impairments

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Three Areas now Documented

• Theory of Mind (ToM)

• Central Coherence (CC)

• Executive Functions (EF)

AND COMORBIDITY CRITICAL TO TREATMENT

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Theory of Mind (ToM)

• Intuitively understand by age 4 that people have beliefs, wishes, desires, and opinions about the world which determine how they behave, rather than the actual physical world.

So:

*people can believe untrue things

*different people can believe different

things about the same affairs

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• Unseen Displacement (Sally-Anne, Maxi Task)

• Unexpected Contents (Smarties)

• Ice-Cream Man (Baron-Cohen, 1989) Prelock, P. (2011). Innovations in theory of mind assessment and intervention for children with ASD. www.theoryofmindinventory.com

Theory of Mind

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Unseen Displacement: Sally-Anne

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Effects of Impaired Theory of Mind (ToM)

• Difficulty taking into account what other people know or can be expected to know.

• Inability to read and react to the listener’s level of interest in what is being said.

• Inability to anticipate what others might think of one’s actions

• Inability to deceive or to understand deception: (Don’t tattle tale)

• Difficulty distinguishing between deliberate and accidental actions of another person (paranoia)

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Theory of Mind (ToM) in Testing

• Comprehension: own point of view e.g. why is news form newspaper better? “It is bad for brain to watch TV…reading good for you”

• Reading Comp questions about readers message : What he meant by…. “he did not mean that”

• What is alike : “there is nothing alike about those” (pedantic voice)

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Central Coherence

• Neurological impairments in those parts of the CNS that bring together perceptions, stimuli, experiences, memory, & relevance in order to synthesize appropriate contingent meaning for a particular point in time.

• fMRI indicates less connectivity between areas of brain needed for this function

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Effects of Impaired CC

• Reduced attention (focus) to the ‘big picture’ along with preference for details leads to:

– Egocentric behavior: Imposition of own perspective, preference for the known

– Difficulty choosing and prioritizing

– Difficulty seeing connections

• rule-bound behavior

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Testing and Central Coherence

• Reading Comp scores usually lower than Word Reading for inferential Questions

– Similarities- Cat and Mouse alike due to whiskers, tails, NOT stating animals

– Picture Concepts : gets stuck when 2 Alike in first two rows and cannot get third item

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• To use data from the MGH Bressler Clinic to assess neuropsychological profile of ASD

• To compare neuropsychological deficits of ASD with ADHD and healthy controls in both children to adults

• To focus on individuals with ASD who have IQ scores > 80

Current Study Objectives

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Neuropsychological Battery

• WASI

– Vocab

– Matrix

• WISC/WAIS

– Arithmetic

– Digit Span

– Letter Number

– Digit Symbol/Coding

– Symbol Search

• WRAT

– Arithmetic

• D-KEFS

– Color Word

– Trail Making

• TOWRE

– Sight Word

– Phonemic Decoding

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Children

ASD N=49

ADHD N=147

Controls N=32

FS IQ 104±12 103±11 106±13

Age 12.0 14.3 14.0

Sex(Male) 44 (90%) 110 (75%) 18 (56%)

SES 1.85 1.97 1.74

Adults ASD N=26

ADHD N=89

Controls N=138

FS IQ 109±12 108±14 112±11

Age 27.5 24.6 24.2

Sex(Male) 20 (77%) 45 (51%) 53 (38%)

SES 2.12 2.07 1.87

Demographics

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Full Scale IQ

ap<0.05 versus controls

bp<0.05 versus ADHD

a

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WASI Vocab

ap<0.05 versus controls

bp<0.05 versus ADHD

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WASI Matrix

ab

a

ap<0.05 versus controls

bp<0.05 versus ADHD

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• Executive functions (EFs) are mental operations involved in goal directed behavior and self regulation

– Set Shifting, Planning/Organizing, Working Memory, Inhibition, Attention, Self-Monitoring, Initiating, Emotional Control

• ASD is associated with neuropsychological deficits, including executive functioning deficits (EFDs)

Executive Functions

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Executive Functions

• Executive Functions (EF) are mental operations

involved in goal directed behavior and self-regulation

- Set Shifting

- Planning

- Working Memory

- Inhibition

- Attention

- Organization

- Emotional Dysregulation

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• ASD children compared to typical children – Problems with organizational skills (81%) – Handwriting (73%) – Explaining thoughts into words (77%) – Planning problems (78%) – Time management (80%) – One track mind

• The last to know and seek help if on the wrong track • Distressed if there is a schedule change • Does not have an‘inner’conversation to solve problems

Tony Attwood, 2007

Executive Functions

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Executive Function Deficits

• 2 or more tests < 25th percentile

– Processing Speed Index

– WISC/WAIS

• Digit Span, Letter Number, Arithmetic, Coding

– D-KEFS Color Word

• Inhibition, Switching

– D-KEFS Trail Making

• Contrast Measure, Number Letter

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Prior Study of EFDs (>2 tests)

• In children, ADHD with EFDs was associated with an increased risk for grade retention and a decrease in academic achievement, relative to ADHD alone.

• Adults with ADHD and EFDs had significantly lower levels of education, occupation, and overall socioeconomic status

• Adults with ADHD and EFDs had significantly more impaired interpersonal functioning

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Executive Function Deficits

ap<0.05 versus controls

bp<0.05 versus ADHD

a

ab a

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Working Memory Index

a

ap<0.05 versus controls

bp<0.05 versus ADHD

ab a

a

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• Tendency to lose track of what they’re doing while working on a problem (multi-step math)

• Forgetting one task while working on another part (reading comprehension)

• Inadequate space to hold ideas, facts or parts of procedures while working with them

Insufficient Working Memory

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• Is likely to be episodic

• Events are not stored in the context in which they occurred

• Lists of facts may be stored without a meaningful framework to link them

But Memory is Great

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Processing Speed Index

ap<0.05 versus controls

bp<0.05 versus ADHD

a

a a

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WISC/WAIS Coding

ap<0.05 versus controls

bp<0.05 versus ADHD

a

ab ab

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Set Shifting

• Ability to move from one situation, activity, or part of a problem to another as the condition demands

• Test

– Trails Making (D-KEFS)

– Intra-Extra Dimensional Shift Set (CANTAB),

• BRIEF examples

– Tries the same approach even when it does not work

– Has trouble moving from activity to activity

– Resists accepting a different solution

– Experiences anxiety, or extreme anger when things change

Roth, R.M., Isquith, P.K., & Gioia, G.A. (2005). Behavior rating inventory of executive function-adult version: Professional manual. Lutz, FL: PAR Psychological Assessment Resources, Inc.

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Trails Making

• Switch between connecting the numbers and letters

• Begin at number 1 and draw a line from 1 to A, A to 2, 2 to B, B to 3 and so on until you reach the end

G H I B C

10 2 4

7 8 9 J 1 3 D

6 A

F E

5

Start End

Delis, D.C., Kaplan, E., & Kramer, J.H. (2001). Delis-kaplan executive function system (d-kefs). San Antonio, TX: Pearson Education.

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D-KEFS Trail Making Number Sequencing

ap<0.05 versus controls

bp<0.05 versus ADHD

ab

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D-KEFS Trail Making Number Letter

ap<0.05 versus controls

bp<0.05 versus ADHD

a a

a

ab

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Color Word

red blue red

green red blue

red blue green

blue green red

Delis, D.C., Kaplan, E., & Kramer, J.H. (2001). Delis-kaplan executive function system (d-kefs). San Antonio, TX: Pearson Education.

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D-KEFS Color Word Inhibition SS

ap<0.05 versus controls

bp<0.05 versus ADHD

a a

a ab

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D-KEFS Color Word Switching SS

ap<0.05 versus controls

bp<0.05 versus ADHD

a

ab

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WRAT Arithmetic

ap<0.05 versus controls

bp<0.05 versus ADHD

a a

a

ab

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TOWRE Sight Word

ap<0.05 versus controls

bp<0.05 versus ADHD

a

ab

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TOWRE Phonemic Decoding

ap<0.05 versus controls

bp<0.05 versus ADHD

a a

a

a

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Shifting Deficits

• May learn a set of responses for a set situation

• May have a set of strategies, but not be aware they possess them or are unable to select a strategy for a new situation

Academic Example:

48 Tim has 48 stamps

23 48 23 71 and gets 23 more.

71 How many does he have now?

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ASD: Successful Classroom

• Clear, Consistent Routines (Daily Schedule)

• Flexibility in Programming-e.g. recess—specials, class choices

• Academics Limiting Integration (Journal

Writing; Metaphoric Literature)

• Less Stimulating Environments

• Teachers Highly Trained in ASD

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Interventions for EFD

• Scaffolding for planning

www.mapthemind.com

• Tasks Broken Down for working memory

• Sheet with Lecture Bullets for attention

• Extra time for processing speed

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Stages of Intervention

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ASD: Elementary School Years

• Observations: – Difficulty making connections – Overwhelmed by settings (e.g. recess, field trips,

assemblies) – Mounting anxiety, esp. at transitions – Hard to explain behaviors (may be considered atypical)

• Interventions: – Mainstreaming usually works OK – Kids are tolerant in early grades – May require special classroom aide in specials and field

trips – Breaks or sensory input in class-limit fine motor

**Personality of teacher crucial **Always better with adults than peers

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Later Elementary Years

• 3rd graders are xenophobic

• Teasing, cruelty, more social isolation

• Retreat into special interests

• Perseverations and rituals developing

• Medications often started for “ADHD”

WORST CLASSES: School bus

Gym Recess Lunch Music

Field trips Snow days

Hate substitute teachers

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Classroom: Social Supports

• ASD child is not antisocial, but rather, asocial. – At times, he wants to be socially a part of the

classroom, but doesn’t know how to enter it. – Social skills are not learned incidentally, they need

to be specifically taught (just like reading).

• Socially facilitate cooperative learning: – Create small groups – Select members – Work toward integrating student into larger

groups

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Support for Shifting Deficits

• Use prediction, routine and repetition to support behavior – Make schedule clear and public

– Forewarn of any changes in schedule

– Give 2 minute warnings of time to change

– Make changes from one task to the next, or one topic to the next, clear and explicit

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ASD: Middle School Years

Perhaps the hardest transition of all:

• More distant teachers

• Multiple classrooms

• Busy hallways, huge peer group, noisy, overwhelming cafeteria

• Oppositionality

• Often refuse or hate homework

• Power struggles

• Parents and teachers punitive

• Misinterpret social cues (paranoid flavor)

• Remarkable rudeness, obscenities, antisocial behavior

Observations: • Starts to Dislike Going to School

• Grades Fall

• Pattern of Wanting to Stay Home (specific classes like PE)

Interventions: • Coach at School (daily check-in)

• Teachers Adapt Output Expectations

• Find Peer Group with Perseverative Interest

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Classroom Accommodations

• For larger assignments:

– Break down tasks into clearly identifiable steps

– Use ‘backward planning’

• Develop hierarchy of subgoals (checklist)

• Skills to consolidate and apply information:

– Identify main idea in new information

– Draw associations between old and new info.

– Continually cue student to see the whole picture

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Allowing for Interests & Obsessions

• If student has an obsession, do not ignore it but make it possible to use it. - Identified time: At breaks, projects, lunchtimes, during

transitions

- Identified Activity: Writing in area of Interest

• Presentation to Class

• Allowable in Outside Reading

- Identified number: Same question no more than three times, or the special topic for 5-minutes then change topic.

Cumine, Leach & Stevenson, 1998

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ASD: High School Years

Observations:

• Often easier: Individual differences are more accepted

• Eccentricity is better accepted

• Growing possibilities for special interests: computers, chess club, video games, Star Trek, D.&D.

• More self conscious and aware of deficiencies

• School refusal

• Missing Assignments/Procrastination

• Poor Test Grades

• Social Isolation

Interventions:

• Increase participation in special interests computers, chess club, video games, Star Trek

• Provide Coaching on Daily Basis

• Have Notes Provided

• Technology Use for Assignments/Test Reminders

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Academic Accommodations Writing Programs

• Strategies that teaching expository writing via EF:

e.g., Landmark Program: Framing Your Thoughts

• Draft Builder: Soft-ware

www.draftbuilder.com

• Typing & Word processing

– Dragon Naturally Speaking

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Academic Accommodations: Note Taking

Teach Note Taking

Step 1: Teacher-developed outline that includes the main ideas and supporting details

Step 2: Skeletal outlines that includes main ideas but provide spaces for details

Step 3: Template but no information

Step 4: Computer software that allows student to take notes on main idea and details

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ASD in Adulthood and Later Life

• Transition planning and training should start in middle school

• College

- Field of interest (engineering, game design)

- Careful dormitory planning

- Coach

• Work

- Careful supervisor match

- Field of interest

• Careers

- Difficulty in marketplace - Promotions - Changes - Exploitation - Family

• Mental Health System - Misdiagnosis

• Residential Placement - Group homes, apts.,

sheltered living • Late Life and Retirement

- Triumph of routine

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In Summary

• There is no simple test, marker, checklist which will give prescription for services

• ASD is presently diagnosed by a pattern of clinical behaviors defined by DSM-V

• Symptoms vary in severity and specificity

• Significant Overlap of ASD with other conditions

• Some clear areas emerging (Working Memory/Shifting/Processing Speed)