The Rule Out Approach to Communications

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The Rule Out Approach to Communications
Learning Disorders

• Created by
• James J. Messina, Ph.D.

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ADHD, Learning Disabilities, Autism Related
Disorders

• To Identify, Assess, and Treat Communications and
  Learning Disorders

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Goals of Presentation

• Understand the scope of what constitutes a
  communications and learning disorder
• Establish the need for early identification and
  referral of children who show early warning signs
  of these disorders
• Identify the rule outs needed to make accurate
  diagnosis intervention of these disorders

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What are Communications and Learning Disorders?

• They involve
• lack of full gross fine motor coordination
• poor motor planning
• lack of age appropriate social interaction
• impaired healthy self-esteem
• speech language deficits
• impaired perceptual functioning

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What are Communications and Learning Disorders?

• They are often labeled as
• Attention Deficit Hyperactivity Disorder (ADHD)
  or Attention Deficit Disorder (ADD)
• Dyslexia or learning disabilities
• Autistic Spectrum Disorder (ASD), Autism,
  Aspergers Disorder, Multi-systems Disorder or
  Pervasive Developmental Delay
• Central Auditory Processing Disorder (CAPD)

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What is the Impact of these Disorders?

• 15 of Americans have learning disabilities with
  many going untreated due to lack of diagnosis
• 10 million children or approximately 1 in 5
  children in 1st through 9th grades (Cramer
  Ellis, 1996)
• 60 of adults with severe literacy problems have
  undetected/untreated LD
• (NALLDC, 1994)

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What is the Impact of these Disorders? (2)

• 35 of students with learning disabilities drop
  out of school
• 30 of adolescents with learning disabilities
  will be arrested 3 to 5 years out of High School
  (Wagner et al, 1993)
• Previously undetected learning disabilities have
  been found in 50 of juvenile delinquents. Once
  treated their recidivism drops to just 2
  (Lerner, 1997)

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What is the Impact of these Disorders? (3)

• About 3 of school-aged population has full ADHD
  symptoms and another 5-10 have partial ADHD
• Another 15-20 of school-aged population show
  transient behaviors suggestive of ADHD
• Boys are 3 times more likely than girls to have
  ADHD
• Symptoms decrease with age but 30-50 of children
  still manifest symptoms into Adulthood.

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What is the Impact of these Disorders? (4)

• Autistic Spectrum will affect 1 in every 500 new
  births (CDC, 1997)
• 1/2 million people in US have autistic spectrum
  disorder in some form
• California in last 11 years experienced 1,975
  increase in PDD-NOS reported and 272 of autism
  (Waltz, 1999)
• Autism is 4 times more prevalent in boys than
  girls

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What is the Impact of these Disorders? (5)

• Autism is considered the 3rd most common
  developmental disability
• Autism alone is estimated to cost 13.3 Billion
  in the USA
• These disorders know no racial, ethnic, or social
  boundaries
• Family income, lifestyle, or educational levels
  do not affect the chance of these disorders
  occurrence

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Rationale for Early Intervention of these
Disorders

• 0-3 Brain Research tells us
• brain development from pre-natal period to first
  three years of life is rapid extensive
• brain development is vulnerable to environmental
  influences and is long lasting
• environment affects both number of brain cells ,
  number of connections and ways these connections
  are wired
• negative impact of early stress on brain function

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Rationale for Early Intervention of these
Disorders (2)

• The period prior to 6 years of age is critical
  period in which brain develops vision, language,
  muscle control, emotional response, reasoning
  ability
• The brain is hungry for stimulation and with
  proper attention a disadvantaged childs IQ can
  be raised 30 points
• Denied proper stimulation, the brain atrophies
  neural connectons wither like dying leaves
  (Hotz,1997)

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Why Early Intervention?

• Recent Research Indicates children with
  communications and learning disorders who are
  identified earliest and receive subsequent
  treatment intervention may have the best
  prognosis
• Early intervention enhances growth of the
  developing cortex (neuropil) has greater effect
  given early in childs life (Greenspan Wieder
  1997) (McEachin, Smith Lovaas, 1997)

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What to Screen for in Children 18 month to 6
years of age

• Delays in
• receptive expressive language
• joint attention and enagagement
• two way communication skills
• imaginative play

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What to Screen for in Children 18 month to 6
years of age (2)

• Lack of childs ability for
• warm, joyful relating
• engaging in a continuous give take of emotional
  and gestural cues
• engaging caregivers in intentional, complex
  reciprocal interactions to solve problems

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Early Identification Screening Tools

• Available on www.coping.org
• Parent Developmental Questionnaire
• UCFs Warning Signs Questionnaire
• CHAT
• Complete Child Developmental History
• There are no cures but with appropriate
  structure early intervention functioning in
  later life can be enhanced (Howlin, 1997)

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Failure of Syndrome Approach

• Third party payers demand a label for
  reimbursement
• Research community, driven by NIH, is fixated on
  medical model Golden Bullet approach
• Parents often demand find comfort in label
• Lack of robust model to identify chart levels
  of behavior and their biological, environmental
  social determinants

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Replacement for Syndrome Approach

• Adopt broader functional descriptions of
  childrens needs
• Use broader eclectic intervention treatment
  options to accommodate for each childs needs
• Treat each child as a unique individual rather
  than a child with a diagnosis
• Fit treatment programs for children not fit
  children for these programs

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Rule Out Approach to Assessment Treatment

• Level 1 B - Biological State
• Level 2 O - Original Traits
• Level 3 L - Learned Behaviors
• Level 4 D - Derived Behaviors

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Purpose of Rule Out Approach

• Investigate, evaluate, and treat the 4 levels of
  structure in each child
• Identify underlying biological structure (level
  1)
• Each trait and behavior be placed at its
  appropriate level (levels 2, 3, or 4)
• Chart all significant relevant modifiers
• Identify behaviors which are modifiable and
  potential ways to modify them

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Level 1 Biological State

• DNA-basic genetic structure
• brain nervous system
• sensory motor organs
• immune system
• all other biological systems

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Level 1 Biological State Modifiers

• Womb environment-nutrition, stress, drug
  alcohol use, diseases, antibiotics
• Birthing process, pitocin, hypoxia
• Food, Drink, contaminants, additives
• Environment, air, water, noise pollution
• Medical interventions vaccines, antibiotics

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Biological Modifiers

• Researchers look at modifiers which may
  exacerbate developmental functioning of children
  with communications learning disorders
• antibiotics (Bolte, 1998)
• abnormal sleep pattern (Patzold et al, 1998)
• diet (Carlsson, 1998)
• medical illness (Volkmar, 1998)
• epilepsy (Kobayashi Murata, 1998)

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GENETICS

• Common belief communications and learning
  disorders are inherited it is challenging to
  find the genes involved (Folstein et al, 1998)
• Relatives with similar disorders have been
  identified (Bailey et al, 1998)
• Chromosome 15 and sex chromosome appear as
  promising markers (Gilberg, 1998)

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BRAIN STRUCTURE

• Autism found related to irregularities in
  cerebellar vermian lobules, parietal lobe,
  posterior regions of corpus callosum (Saitob
  Courchesne, 1998)
• Neurocortical dysfunction found present in autism
  (Minshew et al, 1999)

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BRAIN STRUCTURE

• In ADHD glucose metabolized more actively in
  frontal area of brain (Zametkin et al, 1990)
• PET show abnormalities related to language
  auditory perception (Muller et al, 1999)

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NEUROTRANMITTERS

• Levels of neurotransmitters such as serotonin
  beta-endorphin have been indicative of the
  presence of autism and other communications and
  learning disorders (Chugani et al, 1999
  Leboyer et al, 1999)

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AUTOIMMUNITY

• Association found between virus seriology and
  brain antibody in autism supporting hypothesis
  that a virus-induced autoimmune response may play
  a causal role in Autism (Sing, Lin Yang, 1998)

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AUTOIMMUNITY

• Comi et al (1999) Tested hypothesis autoimmune
  disease connection found
• mean number of autoimmune disorders greater in
  families with autism
• 46 had 2 or more family members with autoimmune
  disorders
• as number of members in family with autoimmune
  disorders increased fro 1 to 3 the risk of autism
  was greater with odds ratio that increased 1.9 to
  5.5 respectively

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AUTOIMMUNITY

• 46 of autistic group reported having relatives
  with rheumatoid diseases compared to 26 of the
  controls
• Most common autoimmune disorders in both groups
  were
• Type 1 diabetes
• adult rheumatoid arthritis
• hypothyroidism
• systemic lupus erythematosus

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AUTOIMMUNITY

• Connelly et al, 1999 found that children within
  the autistic spectrum disorders have a greater
  frequency of serum antibodies to brain
  endothelial cells which supports the possiblity
  that autoimmunity plays a role in the
  pathogenesis of language and social developmental
  abnormalities in a subset of children with these
  disorders

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BIOLOGICAL STATE

• All research to date comes to the prevailing view
  that many of these communications and learning
  disorders, especially autism, are caused by a
  pathophysiological process arising from the
  interaction of an early environmental insult and
  a genetic predisposition (Trottier, Srivastava,
  Walker, 1999)

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Level 2 Original Traits

• Functional, operating, core determinants of
  individual behavior
• biolgically based individual differences
• related to childs motor, sensory, reasoning, and
  affective patterns, etc.
• may or may not be modifiable depending on
  developmental biological life cycle
• earlier one intervenes the more likely to modify
  the original trait

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Level 2 Original Traits

• Visual acuity, visual/spatial processing
• auditory acuity, auditory processing
• sensory modulation
• motor planning sequencing
• kinesthetic processing
• affective processing
• cognitive functioning
• memory processing

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Level 2 Original Traits

• Level 2 Modifiers
• Parents, siblings, caregivers peers
• TV, radio, games, etc.
• tactile, auditory, visual, gustatory olfactory
  stimuli
• interactions with therapists teachers

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Level 3 Learned Behaviors

• Childs Developmental Level
• Normal coping behaviors
• Abnormal coping behaviors

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Level 3 Learned Behaviors

• Speech
• Language
• Reading
• Memory
• Attention
• Impulsivity
• Socialization
• Fine Motor Skills

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Level 3 Learned Behaviors

• Impaired Executive Functions
• Prolongation holding evaluating events in
  working memory
• Separation regulation of affect splitting
  facts from feeling
• Internalization of language reflection,
  self-control, will power
• Reconstitution break events into parts and
  reassemble into new ideas

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Level 3 Learned Behaviors

• Diminished executive functions leads to
• Deficient self-regulation of behavior, mood,
  response
• Impaired ability to organize/plan behavior over
  time
• Inability to direct behavior toward the future
• Diminished social effectiveness adaptability

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Level 3 Learned Behaviors

• Modifiers
• parents
• friends
• society in form of
• schools
• public places
• legal system
• community at large etc.

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Level 3 Learned Behaviors

• Inappropriate interventions at this level
• Sole use of drugs to control behavior
• isolating child in a self-contained or locked
  facility
• restricting child to a special needs environment
  and not including participation with typical
  children

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Level 4 Derived Behaviors

• Severe head banging, rocking, spinning
• constant self-stimulation
• physically attacking others by
• biting
• kicking
• head butting
• spitting

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Level 4 Derived Behaviors

• Yelling out inappropriately
• constant seeking attention by negative behaviors
• severe uncontrollable temper tantrums and anger
  flare ups
• complete social withdrawal and isolation
• lack of development of spoken language
• constantly in motion

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Rule Out Assessment Model

• Level 1 - Biological State - examine brain
  structure, lesions, seizures, metaboloic
  abnormalities, immune disorders, and modifiers
• Level 2 - Auditory, Visual Sensory
• Level 3 - Developmental Level of Functioning if
  adaptive or abnormal
• Level 4 - How social, familial, community and
  global environment impact

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Level 1 Biological State Medical Evaluation

• Good Family History
• Childs Developmental Medical History
• Physical neurological examination
• Referrals for

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Electroencephalography

• Rule out epileptiform activity and/or epilepsy
• Use sleep deprived prolonged overnight EEG study
  to obtain all four stages of sleep (Tuchman,
  1994, 1997 Volkmar Nelson, 1990 Tuchman et al
  1998 Chez et al, 1997)

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Metabolic Screening Tests

• Metabolic Lab tests are indicated with signs of
  metabolic disease e.g. lethargy, cyclic vomiting,
  failure to thrive, dysmorphic or coarse features,
  severe or profound mental retardation
• Use to rule out rare disorders that are difficult
  to detect occur in less than 5 of children
  with these disorders

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Metabolic Screening Tests

• Quantitative amino acids
• urine organic acids
• uric acid and calcium in a 24 hr urine
• thyroid studies
• lactate, pyruvate and carnitine levels
• lead levels

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Genetic Rule out Testing

• DNA Fragile X testing
• High resolution cytogenetic studies
• WARNING Parents need to be aware that absence of
  a positive genetic test does not exclude a
  genetic basis for these disorders. As ongoing
  research develops, other cytogenic tests may need
  to be included

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Structural Neuroimaging (Brain CT or MRI)

• To be used only if neurologic examination and EEG
  or other clinical indicators suggest a focal
  lesion (CAN 1998)

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Functional Neuroimaging

• The following have strong research potential but
  are not primary diagnostic evaluations of these
  disorders at this time
• SPECT single photo emission tomography
• PET magnetoencephalography
• MRS magnetic resonsance spectroscopy

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Other Rule out Laboratory Tests

• Otitis media
• altered immune parameters
• allergies
• gastrointestinal dysfunction
• All medical testing should be directed towards
  the detection and treatment of any disorder that
  may contribute to discomfort or behavioral
  dysfunction

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Level 2 Assessment

• Audiological - Pediatric Specialist
• behavioral in focus
• pure formal tone audiometry
• Brainstem auditory evoked potential if necessary
• rule out processing deficits
• rule out central nervous system abnormality

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Level 2 Assessment

• Opthalmological - Pediatric Specialist
• behavioral in focus
• pure formal visual screening
• rule out processing deficits
• rule out central nervous system abnormality

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Level 2 Assessment

• Cognitive, Speech Language, Motor, Sensory
  Motor Planning
• Pediatric Psychologist
• Speech Language Pathologist
• Occupational Therapist - sensory integration
• Physical Therapist

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Level 3 Assessments

• Functional Emotional Assessment Scale (FEAS)
  (Greenspan 1997)
• Developmental Functioning
• Observations of child with parent
• Observation of Family and siblings
• Observation of Child in school, natural
  environments and community
• Educational Achievement

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Level 4 Assessments

• Behavioral Analysis of abnormal behaviors
• Assessments of daily functioning in activities of
  daily living
• Behavioral ratings done at home, school and in
  the community

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Level 1 - Biological State Interventions

• Anti-seizure or mood stabilizer medications
• Immune suppression medications
• Nutrition therapy
• Hormonal or growth factors (e.g. steroids)
• Behavioral inhibiting medications
• Stimulant mediations
• Neurotransmitter (e.g., SSRIs)

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Level 2 - Original Trait Interventions

• Speech Language Therapy
• Sensory Integration OT
• Sensory Modulation
• Motor Planning Therapy
• Auditory Processing Therapy
• Processing amelioration
• Perceptual amelioration

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Level 3 - Learned Behaviors Interventions

• Discrete Trial Learning
• Applied Behavioral Analysis
• Floor Time
• Play Therapy
• Parent Training
• Child Behavioral Management
• Language Enhanced Classrooms
• Resource Rooms

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Level 4 - Derived Behaviors Intervention

• Social Skills Training
• Milieu Environment Therapy
• Study Skills Training
• Classroom Modifications
• One on One Assistants or Shadows
• Structured 24 hour residential programming

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Level 4 Derived Behavior Medical Interventions

• Use of medications to address
• obsessive/compulsive ritualized behaviors
• hyperactivity/inattention
• tics
• sleep disorders
• anxiety
• aggressive or self-injurious behaviors

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Conclusions drawn from Rule Out Approach

• Always rule out Biological State dysfunctions
  first
• Note all relevant Level 1 modifers
• Identify all relevant Level 2 Original traits and
  their modifers
• Monitor impact of interventions on all Level 1, 2
  3 traits and behaviors
• Recognize setbacks may be due to the presence of
  Biological/Physiological issues not identified yet

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Help Put a Dent in the Epidemic of these Disorders

• Do not put off referring for a Developmental
  Assessment when early signs occur
• Do not say Lets wait to see if the child will
  grow out of it or worse Lets wait to see if
  the child will grow into it
• Refer children immediately when they show even
  the slightest leanings so as to get early
  intervention as quickly as possible

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RULE OUT MODEL

• References at
• http//www.coping.org/intervention/ruleout/content
  .htm