1 Education-Based Evaluations for ASD

2 Stephanie Dyer Kelly Dunlap

3 Establish Our Learning Principles

4 AGENDA New Reality in ASD EvaluationsFoundations in CET (Centralized Evaluation Team) MARSE Eligibility Criteria for ASD Essential Evaluation Components Early Childhood Considerations Differential Eligibility

5 New Reality: MORE KIDS

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7 New Reality: Players at the TableArea Special Ed Autism Insurance Benefit (AIB) Private Insurance Medicaid / MIChild Criteria ASD / MARSE ASD = Autistic Disorder, AS, PDD-NOS (DSM IV) Plan for Evaluation REED / Timeline Who Evaluates Psych, SSW, SLP Licensed Psych or Physician CMHP Using What Tools Prescriptive for Child / Purpose Must include an “Autism Diagnostic Observation Schedule” (e.g. ADOS-2) Must include ADOS-2 and Developmental Family History (e.g. ADI-R) Determination of Impairment / Diagnosis IFSP / IEP Team Determines Impairment Diagnosis of Condition Eligibility for Services IFSP / IEP Team determines adverse impact Treatment prescribed or ordered by evaluator CMHP + Medicaid Agency final approval Service Plan IFSP / IEP Treatment Plan developed by board certified or licensed provider IPOS developed through PCP process Types of Services IFSP=Early Intervention services; IEP=SE, RS, and SAS Behavioral Health, Pharmacy, Psychiatric, Psychological, Therapeutic ABA (EIBI and ABI) Outcomes: High Quality evaluations…this is what all of this is leading to

8 Persistent Deficits in Social Communication & Social InteractionDSM-V Change: ASD Restricted & Repetitive Patterns of Behavior Persistent Deficits in Social Communication & Social Interaction SEVERITY RATING LEVELS 1-3: 3 = Requiring very substantial support 1 = Requiring support

9 Qualitative Impairments Qualitative ImpairmentsMARSE ASD Triad Qualitative Impairments in Reciprocal Social Interaction Qualitative Impairments In Communication ASD SOCIALIZATION DIFFERENCES: 1. Marked impairment in the use of nonverbal behaviors to regulate social interaction: eye to eye gaze, facial expression, body postures and gestures 2. Failure to achieve developmentally appropriate peer relations 3. A lack of spontaneous seeking to share enjoyment, interest, or achievements with other people: Lack of showing, bringing, or pointing to objects of interest 4. Lack of social or emotional reciprocity: Identifying and responding appropriately to other’s emotional states (e.g., comfort a crying person) 5. Impaired perspective taking: Viewing situations from another’s point of view and predict other’s behavior (e.g., if I take his toy he will be mad at me and won’t want to play) COMMUNICATION DIFFERENCES: 1. Delay in or total lack of, the development of spoken language (with no attempt to compensate) 2. Individuals with adequate speech: impairment in ability to initiate and sustain conversation: Stereotyped and repetitive use of language or idiosyncratic language: echolalia; pronominal reversal; dysrhythmic speech 3. Lack of varied, developmentally appropriate, spontaneous, make believe play or social imitative play: lining up blocks, spinning tires, building the same lego figure over and over REPETITIVE BEHAVIOR DIFFERENCES: 1. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest, abnormal in intensity or focus (i.e, food preferences,video interest) 2. Apparently inflexible adherence to specific nonfunctional routines or rituals: Dressing rituals, driving rituals; Distress at any change 3. Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex-whole body movements) 4. Persistent preoccupation with parts of objects (i.e., taking wheel off toy car and repeatedly spinning it) Restrictive, Repetitive & Stereotyped Behavior

10 Acronym Deciphering ToolAIB = Autism Insurance Benefit DSM = Diagnostic and Statistical Manual of Mental Disorders PDD-NOS = Pervasive Developmental Disorder – Not Otherwise Specified ADOS = Autism Diagnostic Observation Schedule ADI = Autism Diagnostic Interview CMHP = Child Mental Health Professional PCP = Person-Centered Plan IPOS = Individual Plan of Service ABA = Applied Behavioral Analysis EIBI = Early Intensive Behavioral Intervention ABI = Applied Behavioral Intervention ABLLS = Assessment of Basic Language and Learning Skills VB-MAPP = Verbal Behavioral Milestones Assessment and Placement Program SE = Special Education ASD = Autism Spectrum Disorder MARSE = Michigan Administrative Rules for Special Education REED = Review of Existing Evaluation Data MET = Multidisciplinary Evaluation Team IFSP = Individual Family Service Plan IEP = Individualized Educational Program SAS = Supplementary Aids and Services P&S = Programs & Services FAPE = Free and Appropriate Public Education LRE = Least Restrictive Environment

11 New Reality in Evaluations for ASDPotential increase in referrals Potential increase in pressure to accept clinical diagnoses Increased need for collaboration across systems Can this slide be covered during the grid slide?

12 New Reality: More ComplexityCommon Comorbid Conditions: Seizures and epilepsy Anxiety Depression Attention difficulties Bipolar Disorder Obsessive Compulsive Some comorbid conditions are characteristics of ASD; Some cannot be primary for eligibility under ASD

13 FIRST STEP: Improve OUR ProcessAll staff need to be competent at ASD screening / evaluation Current Issues: Not recognizing there are THREE required eligibility areas Not recognizing that “educational impact” can be in one of THREE areas (e.g. academic, behavior, social) Use of tools with no observational data Not understanding terms: Pervasive Marked Qualitative Adverse Impact

14 Goals for Evaluation TeamsConfident and Competent Strength in Process Defendable Consistent

15 Screening and Assessment / ASD Eligibility DeterminationAutism Council SUBCOMITTEES Early Intervention Adult Services Education Workgroups Screening and Assessment / ASD Eligibility Determination

16 Autism Council START

17 Foundations in CET (Centralized Evaluation Team)Educational Eligibility vs. Medical Diagnosis Parent and Family Engagement Focus on Qualitative using Quadrants Combined Report Writing Use of Meeting Mechanics OBJECTIVE Team

18 Eligibility vs Diagnosis

19 Foundations in CET (Centralized Evaluation Team)Educational Eligibility vs. Medical Diagnosis Parent and Family Engagement Focus on Qualitative using Quadrants Combined Report Writing Use of Meeting Mechanics OBJECTIVE Team

20 Initial ASD Evaluation Team for Building AObjective Team Team B Building B Team A Building A Team C Initial ASD Evaluation Team for Building A Psych Team B SSW Team B SLP Team C Building C

21 TEAM CONFIGURATIONS (Pg 30)Which best represents your current configuration? Considerations for Changes?

22 TEAM Evaluation Collaboration One voice One contact One reportStrategic assignment of teams

23 The Three Prongs of EligibilityCRITERIA IMPACT NEED

24 MARSE Criteria Autism Spectrum Disorder (ASD)(a) Academic MARSE Criteria Autism Spectrum Disorder (ASD) Considered a lifelong developmental disability that adversely affects a student’s educational performance in 1 or more of the following areas: (Establishes IMPACT and NEED for SPECIAL EDUCATION) a) Academic (e.g. ability to meaningfully participate and progress in the general curriculum including lack of initiation, impaired quality of participation, low grades, etc.) (b) Behavioral (e.g. disruption, aggression, lack of appropriate engagement, eloping, tantrums, etc.) (c) Social (e.g. ability to develop and maintain relationships/friendships, responses to social situations that alienates others and diminishes acceptance, etc.)

25 Purpose of “LIFELONG” Definition of ASDIncreases threshold for decisions Reduces need to re-evaluate for evidence of ASD

26 MARSE Criteria ASD Age of EligibilityAutism spectrum disorder is typically manifested before 36 months of age. A child who first manifests the characteristics after age 3 may also meet criteria. Autism spectrum disorder is characterized by qualitative impairments in reciprocal social interactions, qualitative impairments in communication, and restricted range of interests/repetitive behavior.

27 National Research Council“There is no single behavior that is always typical of Autism and no behavior that would automatically exclude an individual child from a diagnosis of Autism.”

28 MARSE Criteria for Autism Spectrum Disorder (ASD)Characterized by : Qualitative Impairment in Reciprocal Social Interactions Qualitative Impairment in Communication Restricted, Repetitive, and Stereotyped Behaviors

29 “Qualitative” AtypicalSignificantly different from other students at the same age and developmental level Outside the typical sequence of development Across all environments. Presence and Absence Unique to each Student

30 MARSE Definition Socialization(a) Qualitative impairments in reciprocal social interactions including at least 2 of the following areas: (i) Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction. (ii) Failure to develop peer relationships appropriate to developmental level. (iii) Marked impairment in spontaneous seeking to share enjoyment, interests, or achievements with other people, for example, by a lack of showing, bringing, or pointing out objects of interest. (iv) Marked impairment in the areas of social or emotional reciprocity.

31 Reciprocal Social InteractionA mutual exchange (e.g. of words, actions, or feelings).

32 Reciprocal Social Interaction At least 2 of the 4(i) Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction. Marked = Substantial & Sustained; Clearly Evident; Distinctive and noticeably different from same-aged peers PURPOSE / FUNCTION of Nonverbal Behavior EXAMPLES: Seems to look “through” a person, lacks eye contact to initiate or sustain interaction, has fleeting or inconsistent eye contact Lacks emotion or appropriate facial affect for the social situation, lacks accurate facial expression to reflect internal feelings, facial expressions seem rehearsed or mechanical Difficulty maintaining appropriate body space, awkward/stiff response or movement, gait challenges Lacks understanding of the use of nonverbal cues (e.g. pointing, head nod, waving), does not respond to communication partner signals to start or end a conversation

33 Reciprocal Social Interaction At least 2 of the 4(ii) Failure to develop peer relationships appropriate to developmental level. Impaired perspective taking: viewing situations from another’s point of view / emotional state; predicting other’s behavior (THEORY OF MIND) Anthropomorphic Examples: not understanding humor / jokes, disrupting activities (play), rarely initiates or sustains interaction, tolerates peers but not engaged in interaction

34 Reciprocal Social Interaction At least 2 of the 4(iii) Marked impairment in spontaneous (i.e. without prompting) seeking to share enjoyment, interests, or achievements with other people, for example, by a lack of showing, bringing, or pointing out objects of interest. (i.e. Joint / Shared Attention) Examples: Deficits in the use of pointing to orient another to an object or event Bringing objects or items to others for the purposes of getting needs met, but not for a shared experience Shifting conversations to one’s own interest rather than responding to the interests of others

35 Developmental Trajectories TheoriesExperts on People Typical Birth ASD Key Concepts: Neurobiological differences put children on different developmental trajectories. Typically developing children become experts on people, while children with ASD become experts on things. The Yale study shown on the 20/20 clip previously shown indicates functional brain differences (areas in the brain intended for processing objects light up when child with AS looked at pictures of facial expressions). Considerations: Slide was shared courtesy of Peter Mundy at the NPDC Summer Institute 2009. Application: Experts on Things

36 Reciprocal Social Interaction At least 2 of the 4(iv) Marked impairment in the areas of social or emotional reciprocity (i.e. Identifying and responding appropriately to other’s emotional states (e.g., comfort a crying person)) EXAMPLES: Lack of social smiling; Lack of interest in the ideas of others Aloofness and indifference toward others Seemingly rude statements to others without filter or negative intent Difficulty explaining their own behaviors in context of impact on others Difficulty predicting how others feel or think Problems inferring the intentions or feelings of others Failure to understand how their behavior impacts how others think or feel Problems with social conventions (e.g. turn-taking / personal space) Lack of appropriate responding to someone else’s pain or distress Creating arbitrary social rules to make sense of ambiguous social norms

37 MARSE Criteria: Communication(b) Qualitative impairments in communication including at least 1 of the following: (i) Delay in, or total lack of, the development of spoken language not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime. (ii) Marked impairment in pragmatics or in the ability to initiate, sustain, or engage in reciprocal conversation with others. (iii) Stereotyped and repetitive use of language or idiosyncratic language. (iv) Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.

38 MARSE Criteria: Communication At least 1 of the following 4(i) Delay in, or total lack of, the development of spoken language not accompanied by an attempt to compensate Failure to understand that words have communicative intent Some students with an ASD do not talk at all; Some students with ASD have words at 12 to 18 months of age and then lose them; Some students with ASD speak, but sometimes not until later in childhood and/or use non-functional / atypical speech.

39 Communication (ii) Impairment in Pragmatics: The ability to initiate, sustain, or engage in reciprocal conversation with others Using language for varying purposes (e.g. greeting, informing, promising, requesting, etc.) Changing language according to the needs of the listener or situation (e.g., giving background information to an unfamiliar listener, speaking differently in a classroom than on a playground) Following rules of conversations and storytelling (e.g., taking turns in conversation, staying on topic, rephrasing when misunderstood, proximity, use of eye contact EXAMPLES: Difficulty with the social aspects of language (e.g. understanding non-literal language used in conversation) Issues with prosody (e.g. flat and emotionless or high and pitchy with atypical rhythm or rate) Difficulty initiating, sustaining, or ending conversations with others Difficulty using repair strategies when communication breaks down Talking for extended periods of time about a subject of the student’s liking, regardless of the listener’s interest Talking at someone in a monologue rather than conversing

40 RECEPTIVE & EXPRESSIVE LANGUAGE are not equalI didn’t say she stole my money.

41 Communication (iii) Stereotyped / repetitive use of language / idiosyncratic Idiosyncratic = contextually irrelevant or not understandable to the listener; may have private meaning / be understood by the speaker or to those familiar to the situation (e.g. movie lines) Can include: Echolalia Repeat videos / scripts Nonsense language Verbal Fascinations

42 (iv) Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level. Compared to Developmental Level (Pg 26) Play Scheme vs. Directive Repetitive Play

43 MARSE Criteria: Restricted, Repetitive, Stereotyped Behaviors At least 1 of the following 4(i) Encompassing preoccupation with 1 or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus. DISTRESS OVER DISRUPTION (ii) Apparently inflexible adherence to specific, nonfunctional (e.g. no purpose) routines or rituals. (iii) Stereotyped and repetitive motor mannerisms, for example, hand or finger flapping or twisting, or complex whole-body movements. (iv) Persistent preoccupation with parts of objects.

44 MARSE Criteria – Sensory(3) Determination may include unusual or inconsistent response to sensory stimuli, in combination with subdivisions (a), (b), and (c) of subrule 2 of this rule.

45 Michigan Definition Cont’d Other Considerations(4) While autism spectrum disorder may exist concurrently with other diagnoses or areas of disability, to be eligible under this rule, there shall not be a primary diagnosis of schizophrenia or emotional impairment. (5) A determination of impairment shall be based upon a comprehensive evaluation by a multidisciplinary evaluation team including, at a minimum, a psychologist or psychiatrist, an authorized provider of speech and language under R (d), a school social worker.

46 AGENDA New Reality in ASD EvaluationsFoundations in CET (Centralized Evaluation Team) MARSE Eligibility Criteria for ASD Essential Evaluation Components Early Childhood Considerations Differential Eligibility

47 REED (Review of Existing Evaluation Data)Required at re-evaluations and at termination of eligibility. Recommended at initial evaluation, especially if evaluation data from outside sources is available (e.g. diagnostic reports from a private clinic). (NOTE: COLLABORATION OPPORTUNITY) Purpose of the REED is to: Review available information and assessment data (e.g. ADOS, developmental history, rating scale results); Determine if the information is sufficient to make a determination of eligibility (i.e. meets eligibility criteria that impacts academic, behavioral, or social progress in school that necessitates special education); If not, determine what else is needed to make a determination of eligibility (e.g. observations to determine impact on educational performance); Establish a plan for gathering the additional information.

48 Other Considerations Consideration of ALL potential disabilitiesInformation to assist in differential eligibility Gather information to assist in developing the IEP Communication needs of the student including assistive technology The student’s social needs including peer to peer support The student’s behavioral needs including the need for a functional behavioral assessment, positive behavioral support plan, or an emergency crisis plan Academic needs of the student (i.e. accommodations and differentiation)

49 ESSENTIAL EVALUATION COMPONENTSTeacher / Staff Interviews / Surveys Parent / Family Interviews & Home Visit DIRECT OBSERVATION Standardized Test Considerations

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51 Evaluation Checklist MeetingAttended by MET members (Psych, SSW, SLP) Critical for coordination of scheduling (ie. IEP, RRM, observations…) Discussion and assignments of evaluation components (evaluation checklist) Allows time for training, questions, case study, problem solving

52 Evaluation Tasks Teacher interview Parent interview / home visitObservations CA-60 review ADOS Diagnostic Testing Report Writing Results Review Mtg Need / Impact Determination Schedule IEP Feedback to building team/coach/sped rep Parent interp IEP attendees

53 Evaluation Plan Checklist

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55 ESSENTIAL EVALUATION COMPONENTSTeacher / Staff Interviews / Surveys Parent / Family Interviews & Home Visit DIRECT OBSERVATION Standardized Test Considerations

56 Documentation Form Record Reviews Observations Interviews Meetings

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58 Survey Questions Talking Points vs. Questions AREAS TO CONSIDERChallenges with published tools: Don’t match MARSE criteria Don’t focus on impact and need May not facilitate robust discussion AREAS TO CONSIDER Reciprocal Social Interaction Communication Restrictive / Repetitive Behavior Differential Eligibility: Developmental History Medical History Cognitive / Adaptive Skills Educational Skills

59 FACILITATED MEETING Referring TeamSocial Interaction Communication OTHER (e.g. academic, cognitive functioning) Behaviors Sensory

60 Teacher Interview Allow at least 45 minutesPreferably two evaluation team members Guided interview Biggest concern Describe interview process Go through “teacher interview” questions Academics Explain rating scale if using one & set up return process

61 ESSENTIAL EVALUATION COMPONENTSTeacher / Staff Interviews / Surveys Parent / Family Interviews & Home Visit DIRECT OBSERVATION Standardized Test Considerations

62 What does your child do that makes you wonder ASD?Home Visit Build Relationship Pervasiveness of Characteristics Describe Behaviors from Varying Perspectives (Report) What does your child do that makes you wonder ASD?

63 Parent / Family InterviewDuring home visit At least two evaluation team members Guided Interview Biggest concern Describe interview process Birth, developmental, medical history Go through questions Visit child’s room if possible

64 ESSENTIAL EVALUATION COMPONENTSTeacher / Staff Interviews / Surveys Parent / Family Interviews / Surveys DIRECT OBSERVATION Standardized Test Considerations

65 OBSERVATION FORMAT Sensory Qualitative Impairment in CommunicationDelay or Lack of Development Pragmatics Stereotypical or Repetitive Creative Pretend Play Qualitative Impairment in Reciprocal Social Interaction Non-Verbal Behavior Peer Relationships Showing and Sharing Social/Emotional Reciprocity Restrictive, Repetitive and Stereotyped Behaviors Restricted Interests Nonfunctional Routines Motor Mannerisms Parts of Objects Sensory

66 Char-Em Eligibility Guidelines

67 Observations (pg 33 – 35) “Eyes on Kid”All Team Members All Settings & Times Capture Presence / Absence of Behaviors Examples / non-examples but NOT interpretation—that meeting is later Is ASD dominating student’s thinking / interaction with environment Integrated Observations: Participate to get more detailed information Investigate – dig down below the surface Conduct mini experiments to see the impact or response Consider context and FUNCTION

68 Observations in Context INTEGRATED OBSERVATIONS The Tip of the Iceberg AnalogyThe tip is the observable behavior; The context cues us into what underlies the behavior (e.g. motivation, intent, function) Function = Differential Eligibility

69 Caution Fundamental Attribution ErrorBEHAVIOR Key Concepts: The attribution errors that we make can dramatically affect the outcomes for the students. We need to be aware of the link between our attributions and outcomes. Our attribution errors have consequences. Considerations: Application: Share the behaviors of concern that resulted from Jared’s lack of understanding of social communication. He told the teacher that he really liked her moustache. Ask “If we view Jarod’s behavior through the lens of Aspergers and its neurobiology, what are the likely outcomes for Jarod? What if we view his behavior as being a reflection of who he is (rude, disrespectful)? What are the outcomes then?” ASD EI / SM EXPLAIN BEHAVIOR EXPLAIN BEHAVIOR?

70 Possible Function? When peers try to talk to her, Mariah turns away, does not respond verbally, and pulls her sweater over her head; peers move away. When the teacher gives her corrective feedback about her work, Mariah turns away, does not respond verbally, and pulls her sweater over head; the teacher sits next to her, rubs her shoulders and says comforting words. Key Concepts: We have to carefully look at situations and context in order to reduce our changes of making a fundamental attribution error. Considerations: The behavior in red is the same behavior. The difference is the situation or context. Application: Ask the group to identify the function of the behavior in each context (Suggestion: first one is avoiding peers; second one is seeking adult attention) Point out the importance of determining the function, rather than just focusing on the behavior Ask, “Wouldn’t we implement different supports or teach different skills in each scenario?” Make sure the group sees the importance of the context/situation and the importance to determining function of behavior. This drives the type of strategies that should be implemented.

71 Marci was observed grabbing toys and objects from others and appeared unaware that the other child was using or playing with the object. Marci was observed tickling peers under the chin while giggling, moving from one peer to the next. None of the children appeared to be enjoying this, but Marci did not seem to recognize their displeasure. Marci was observed pulling at girls’ ponytails and accessories; Marci has not been noted to pull hair other than in pony/pigtails or when there are accessories present. Marci was noted to state, “I want to poke her in the eye” and “I want to kick her” in a very unemotional manner not directed at anyone. Despite her statement, Marci has not attempted to do the things that she says. Key Concepts: We have to carefully look at situations and context in order to reduce our changes of making a fundamental attribution error. Considerations: This slide is the first of two that work together. Once you complete the first part of this activity, then click the mouse and the rest of the words will fill into the slide. Application: Ask a volunteer to read this slide. Ask participants to talk with a partner for a minute about what their response to this behavior would be? What do they think of Marci’s behavior? Is it intentional? Is she mean and aggressive? Take a few report outs

72 Marci was observed grabbing toys and objects from others and appeared unaware that the other child was using or playing with the object. Marci was observed tickling peers under the chin while giggling, moving from one peer to the next. None of the children appeared to be enjoying this, but Marci did not seem to recognize their displeasure. Marci was observed pulling at girls’ ponytails and accessories; Marci has not been noted to pull hair other than in pony/pigtails or when there are accessories present. Marci was noted to state, “I want to poke her in the eye” and “I want to kick her” in a very unemotional manner not directed at anyone. Despite her statement, Marci has not attempted to do the things that she says. Key Concepts: We have to carefully look at situations and context in order to reduce our changes of making a fundamental attribution error. Looking at context makes a huge difference. Considerations: Marci is a real 4 year old with AS. Now, with context available, we are better able to see her behaviors through the lens of AS. Remind participants that now we are able to respond via Path A, which will result in understanding, teaching, and support for Marci, as opposed to Path B, with getting kicked out of this preschool. Powerful, powerful stuff!! Application: Ask a volunteer to read this slide again with the new information included. Ask participants to talk with a partner for a minute about what their response to this behavior would be? What do they think of Marci’s behavior now? Is it intentional? Is she mean and aggressive? Have their opinions and assumptions changed? Why? Take a few report outs

73 Marci was observed grabbing toys and objects from others, while yelling, “I had it first!” and pushing peers away. Marci was observed tickling peers under the chin while giggling, moving from one peer to the next. None of the children appeared to be enjoying this, but Marci kept saying, “Am I bugging you yet?” and “Isn’t this so funny?” Marci was observed pulling at girls’ ponytails and accessories; she will say, “I don’t like your hair like that-it looks stupid.” Marci was noted to state, “I want to poke her in the eye” and “I want to kick her” while being redirected from an argument with a peer. Marci has previously shoved, kicked and poked this girl when she doesn’t do what Marci wants her to do. Key Concepts: We have to carefully look at situations and context in order to reduce our changes of making a fundamental attribution error. Looking at context makes a huge difference. Considerations: Now, we have superimposed behaviors of a preschool girl with a behavior disorder. Even though we aren’t dealing with AS, we still have the responsibility to implement positive behavior supports. Emphasize how important the context is. You may have to do repeated observations. Remind participants that now we are able to respond via Path A, which will result in understanding, teaching, and support for Marci, as opposed to Path B, with getting kicked out of this preschool. Powerful, powerful stuff!! Application: Ask a volunteer to read this slide again with the new information included. Ask participants to talk with a partner for a minute about what their response to this behavior would be? What do they think of Marci’s behavior now? Is it intentional? Is she mean and aggressive? Have their opinions and assumptions changed? Why? Take a few report outs

74 Data to Support Impact / Need

75 Supporting Evidence Checklists Interview Forms Direct Assessment Tools

76 Be Intentional with Standardized ToolsRemember: Tools were not designed to align with the MARSE criteria or measure impact / need. ASD characteristics that may negate results: Difficulty establishing rapport Lack of motivation to please Challenges with attention, engagement, and persistence in task demands Difficulty transitioning Language deficits Interfering and challenging behaviors Tools are only as good as their technical adequacy

77 Technical Adequacy Sample Reliability Validity EXAMPLE: ADOS-2:Test / Re-test Reliability—2 Weeks: Classification changed for 9 of the 39 children (23%)

78 ASIEP-3 (Autism Screening instrument for educational planning)Consists of 5 Separate Measures The Autism Behavior Checklist (ABC) = 47 item checklist Results indicate the probability of the student having ASD Content Validity: Items were developed based on an extensive review of the literature describing the characteristics of autism “The ability of the ABC to discriminate among different diagnostic groups needs to be examined further”

79 Assessment Tools Central Assessment Lending Library (CALL) https://wwwGADS: Gilliam Asperger Disorder Scale KADI: Krug Asperger Disorder Index PEP-3: Psycho-Educational Profile ABLLS-R: Assessment of Basic Language and Learning Skills VB-MAPP: Verbal Behavior – Milestones Assessment and Placement Program ASIEP-3: Autism Screening Instrument for Educational Planning ADOS-2 (Autism Diagnostic Observation Schedule) ADI-R: Autism Diagnostic Interview CARS-2: Childhood Autism Rating Scale GARS-2: Gilliam Autism Rating Scale

80 Questions to Guide the Use of Standardized ToolsDoes the tool have adequate technical adequacy? What is the purpose or intended outcomes? What questions are you attempting to answer and will the tool provide that information? What are the language requirements and do they match the ability level and communication modality of the student? Given the student’s behavioral challenges, will the tool likely produce reliable and valid results? How current is the tool (e.g. when was it published and standardized)? What are the potential challenges in using the tool (e.g. results are not consistent with other information)?

81 Creative Uses of Standardized Tools “Breaking Standardization”Observe performance under various conditions (e.g. use of visuals supports) Create conditions not easily observed in natural settings. NOTE: Such expansions can be beneficial in capturing rich information on the student’s learning needs, strengths, and challenges, but invalidates obtained scores. Avoid by first administering under standardized conditions. Some options for breaking standardization include the following: Administer subscales or items within subscales in a different order so highly preferred tasks can follow less preferred ones to increase motivation; Start at the beginning of a particular subscale (easiest item) rather than the age-suggested starting point to create behavioral momentum; Take frequent breaks; Use tangible reinforcers; Use a multiple-choice or fill-in-the-blank formats rather than an open-ended; Paraphrase instructions and/or simplify language to match child’s level; Use terms and phrases that are familiar to the child (e.g., “match” vs. “find me another one just like this”); 

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83 Determining Eligibility Results Review MeetingFormal Meeting w/ MET Use Meeting Mechanics / Quadrants / Board Review documentation from all sources (color-code) Integrate quantitative & qualitative information Focus on the child and spectrum, not just individual characteristics “Preponderance of the Evidence”

84 Preponderance of EvidenceThe Results Review Meeting Social Communication OTHER Behavior Sensory IMPACT / NEED

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87 TAKE NOTES

88 Foundation for Impact and Need StatementOf primary concern is Johnny’s level of independence. Due to difficulties in pragmatic language and communication, sensory modulation, and socialization, Johnny’s independence is limited. In order to participate with the routines and activities of the classroom, Johnny currently requires considerable physical and verbal prompting from adults. His independence is significantly impacted in the following areas: • Transition (task to task and place to place) • Group participation • Direction following • Self care • Interactions with peers • Outside play • Inside play with free choice time • Spontaneous conversation

89 The Impact and Need Statement FoundationHow does the ASD impact access and progress in general education curriculum and environments? Independence: Due to Sean’s lack of reciprocity and engagement and his restricted range of interests, he does not independently navigate the daily schedule and requires 6-7 verbal and visual prompts by adults before following simple tasks. He also does not independently get materials he needs to complete classroom activities and tasks, and requires up to 10 adult prompts to complete his classroom work. Independence is also impacted in the following areas: Group participation Direction following Self care Behavior / Instruction: As many as 6 times an hour, Sean attempts to leave the classroom to seek out his preferred activity (basketball) and as a result, he misses instruction 3-4 times per day for 5-10 minutes. Key Concepts: Perfect PLAAFP statements are not provided as it is human nature to get the “cut and paste” effect. Guided practice allows participants to really problem solve the information and consider alternative ways to provide or gather it. Such practice increases implementation fidelity of the process. Words in red are “wiggle” words (i.e. words that are loosely defined and can easily be misinterpreted). Have participants discuss what data they might need to change the wiggle word into actual data. It is not by accident that socialization and independent skills were used for guided practice. Read each statement and allow for discussion / practice. Considerations: Application:

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92 Organization of ReportCOMBINED: Three Evaluators - ONE Report Outline Details from the ASD Eligibility Criteria RELEVANT History MARSE ASD Criteria Evaluation Results: Reciprocal Social Interaction Communication Restrictive / Repetitive Patterns of Behavior EXPLAIN what does NOT align with conclusions – PERSUASIVE WRITING

93 Report Template Example

94 Report Template Example

95 Report Template Example

96 Process and Application Activity “NO WAY” No Report Considerations

97 AGENDA New Reality in ASD EvaluationsFoundations in CET (Centralized Evaluation Team) MARSE Eligibility Criteria for ASD Essential Evaluation Components Early Childhood Considerations Differential Eligibility

98 Key Early Indicators of ASD http://www. cdc. gov/ncbddd/autism/indexLack of: Reciprocal social smiling by 6 months Response/Orientation to name by 12 months Reciprocal gestures by 14 months (showing objects, pointing, reaching, waving) Avoids eye contact / wants to be or play alone No words by 16 months (and meaningful 2-word phrases by 24 months) Not play “pretend” games (feed a doll) by 18 months Plays with parts of objects (e.g. wheels) More Info at: (www.autisminternetmodules.org) Dashboard: Recognizing ASD—What Early Interventionists Should Know (What are some of the red flags you might see during the first three years of the child's life?)

99 EARLY CHILDHOOD CONSIDERATIONS Identify or Not?Retrospective studies (e.g., looking at home videos) Prospective studies (following the development of children at low and high risk for autism) Signs of autism are often present in the first year of life, and especially by the first birthday (Landa, Holman, & Garrett-Mayer, 2007). If pay close attention to red flags, experts suggest that many children could be diagnosed by age 2 (Plauché Johnson, 2008), and perhaps up to 50% of children with autism could be diagnosed reliably as early as 14 months of age (Landa, 2007).

100 MCHAT Failed Screening = 2 or more failed critical items OR failed three items or more. (Yes/No converted to Pass/Fail) Bold capitalized are CRITICAL 1. No NO No No No No NO No NO No Yes No 13. NO NO NO 16. No No Yes 19. No Yes No 22. Yes No

101 Common Misrules No ASD until age 5, age 8, kindergarten; Just use ECDD for now, parents aren’t ready to hear the A word; ECDD classroom is successful so can’t be eligible ASD; Hasn’t been in daycare or preschool (programming), so can’t consider ASD

102 R 340.1711 “Early childhood developmental delay” defined; determination. Rule 11.means a child through 7 years of age whose primary delay cannot be differentiated through existing criteria within R to R or R to R and who manifests a delay in 1 or more areas of development equal to or greater than 1/2 of the expected development. This definition does not preclude identification of a child through existing criteria within R to R or R to R

103 …..it is not appropriate to recommend eligibility in another category to prolong or avoid the ASD eligibility. If, after careful and comprehensive assessment, the child fully meets the criteria for eligibility under ASD, the multidisciplinary evaluation team must provide the recommendation of ASD eligibility to the IEP team. The regular practice of finding a child eligible in the categories of R (“Speech and language impairment” defined; determination) or R (“Early childhood developmental delay” defined; determination) to “wait and see” if it is ASD should be discontinued. According to MARSE, the early childhood developmental delay eligibility category should be used only when “primary delays cannot be differentiated through existing criteria within [other eligibility categories].” In addition, policies that indicate age cutoffs for finding a student eligible under the ASD classification should also be eliminated.

104 Early Eligibility DeterminationKNOW typical development KNOW developmental issues that can mirror ASD Higher threshold given developmental changes / environmental impact

105 AGENDA New Reality in ASD EvaluationsFoundations in CET (Centralized Evaluation Team) MARSE Eligibility Criteria for ASD Essential Evaluation Components Early Childhood Considerations Differential Eligibility

106 Differential EligibilityDo you think its ______________________? ASD or CI? EI?

107

108 Preponderance of Evidence Compare & ContrastThe Results Review Meeting Social Communication OTHER Behavior Sensory

109 Preponderance of Evidence Compare & Contrast Characteristics Developmental History History of Interventions

110 MARSE Criteria Cognitive ImpairmentDevelopment at a rate at or below approximately 2 standard deviations below the mean as determined through intellectual assessment. Scores approximately within the lowest 6 percentiles on a standardized test in reading and arithmetic. This requirement will not apply if the student is not of an age, grade, or mental age appropriate for formal or standardized achievement tests. Lack of development primarily in the cognitive domain. Impairment of adaptive behavior.

111 MARSE ASD Eligibility Reciprocal Social Interaction (2)Non-verbal behavior Peer relationships Show and share Social / emotional reciprocity Communication Delay without compensation Pragmatics Stereotyped / repetitive Make-believe Restrictive / Repetitive Behavior Restricted Interests Inflexible routines Motor mannerisms Parts of objects

112 AREA ASD Cognitive ImpairmentDevelopmental Rate Range of Ability Output (Theory of Mind) 2 SD below mean Even Profile Academic Achievement Interest Areas Below 6th %til rdg / math Adaptive Behavior Deficits can be present in both; ASD may have more uneven profile Communication Impaired joint communication and/or pragmatics Integrating gaze with gestures is present at developmental level Reciprocal Social Impaired joint attention, gesture use, social awareness and understanding, and/or reciprocity Joint attention, (sharing/showing), gesture use, social awareness, reciprocity commensurate with development Restricted Behaviors Can be present in both

113 EI (Emotional Impairment) CriteriaThe problems result in behaviors manifested by 1 or more of the following characteristics: Inability to build or maintain satisfactory interpersonal relationships within the school environment. Interpersonal relationships refer to developmentally appropriate actions and reactions to peers and adults. To meet this criteria, a student should demonstrate pervasive (generally all teachers and peers) aberrant behaviors that occur at a greater frequency, intensity and duration for others at that developmental level. Inappropriate types of behavior or feelings under normal circumstances. This criterion implies atypical behaviors for which no observable reason exists. Mere misconduct or refusal to comply does not qualify a student in this category. The pervasiveness and frequency, intensity, and duration should also be considered.

114 EI (Emotional Impairment) Criteria, cont.c. General pervasive mood of unhappiness or depression. This criterion means a student must exhibit depressive symptomatology which typically involves changes in all four major areas: (1) affective (emotions), (2) motivation (loss of interest), (3) physical/motor functioning (e.g. weight / appearance), and (4) cognition. Pervasiveness implies impact in almost all aspects of a person’s life. NOTE: Aggression and non-compliance can mask depression. d. Tendency to develop physical symptoms or fears associated with personal or school problems. First consider a student’s medical condition before considering eligibility under this criterion. This criterion is related to conditions like school phobia and other intense anxiety disorders that result in physical symptomology and somatic complaints (e.g. headache, tics, stomachache).

115 Example EI CharacteristicsInability to Maintain Relationships Inappropriate Behaviors or Feelings Unhappiness or Depression Physical Symptoms / Fears In ability to maintain relationships due to: Responding aggressively toward others Short temper Starts fights Withdrawn Has intense emotional responses to typical peer disagreements Demonstrates inappropriate sexual behaviors Seeks excessive approval from others Over-reacts to everyday occurrences (i.e. rage, excessive laughter, hysterics) Exhibits catastrophic or panic reactions to everyday occurrences Demonstrates flat, distorted or excessive affect Exhibits self-abusive behaviors Exhibits delusions and/or hallucinations or thought disorders Demonstrates extreme mood swings Decreased interest / pleasure in previously enjoyed activities Excessive guilt and/or self-criticism Expresses feelings of extreme sadness Predicts failure or refuses to attempt tasks (projects hopelessness) Demonstrates agitation or lethargy Difficulty concentrating and/or making decisions Chronic Somatic complaints (i.e. headaches, stomach aches) Intense anxiety not associates with a specific stimuli Extreme fear in response to a specific stimuli Panic reactions to everyday occurrences

116 MARSE ASD Eligibility Reciprocal Social Interaction (2)Non-verbal behavior Peer relationships Show and share Social / emotional reciprocity Communication Delay without compensation Pragmatics Stereotyped / repetitive Make-believe Restrictive / Repetitive Behavior Restricted Interests Inflexible routines Motor mannerisms Parts of objects

117 EI (Emotional Impairment) Criteria, cont.(2) Emotional impairment also includes students who, in addition to the characteristics specified in subrule (1) of this rule, exhibit maladaptive behaviors related to schizophrenia or similar disorders. The term “emotional impairment” does not include persons who are socially maladjusted, unless it is determined that the persons have an emotional impairment. What is Social Maladjustment? Not defined by federal or state departments or clinical literature Understanding is derived from the educational literature and practice, administrative decisions and court interpretations Often associated with clinical Dx of CD, ODD, or Antisocial Definition Components: Pervasive intentional behaviors that violate socially acceptable rules and norms Accepting no responsibility for actions Demonstrating little to no remorse Blame and intimidate / charm others while manipulating the situation to meet own needs

118 ASD vs. EI / SM BEHAVIORS: DISTINGUISH BETWEEN:Refusal to do academic work Not following school expectations / rules Aggression toward peers DISTINGUISH BETWEEN: I don’t care about your rule vs. I don’t understand the rules and the rules frequently change; ODD vs. I already know how to do this and if I know, then you should know; I don’t care about your thoughts or feelings vs. I don’t understand you have different thoughts or feelings from me. Key Concepts: We have to carefully look at situations and context in order to reduce our changes of making a fundamental attribution error. Considerations: The behavior in red is the same behavior. The difference is the situation or context. Application: Ask the group to identify the function of the behavior in each context (Suggestion: first one is avoiding peers; second one is seeking adult attention) Point out the importance of determining the function, rather than just focusing on the behavior Ask, “Wouldn’t we implement different supports or teach different skills in each scenario?” Make sure the group sees the importance of the context/situation and the importance to determining function of behavior. This drives the type of strategies that should be implemented.

119 Making a Final DecisionPreponderance of Evidence No one behavior includes or excludes any specific eligibility area: There are always going to be instances that don’t fit the criteria!! MUST explain what does not align MUST build a case for your conclusion However & Despite Intelligent People can Disagree!!

120 What if there is Disagreement?(e.g. Medical says “YES” and School says “NO”) Different purposes (diagnosis versus special education eligibility and IEP development) Adherence to strong evaluation process & report is defendable Commitment to Communication Focus on Student Needs

121 What if there is Internal Disagreement?Keep true to the process (run the board) Presume Positive Intent Ask questions to obtain a deeper understanding of the disagreement -- PPP Is there a misunderstanding of ASD? Is there a focus on singular behaviors rather than preponderance of evidence? Is there an agenda or pressure to land on one decision vs. another Gather additional information/data Add another evaluator / team Write a dissenting report

122 WRAP UP the C’s Concepts Changes Capacity

123 Selected References MARSE RulesISD Guidelines for Determining Eligibility of Emotional Impairment Macomb Char-Em Ottawa OCALI Online Identification Module Other State Guidelines NATTAP (Network of Autism Training and Technical Assistance Providers) 2008 Conference Session “Compare and Contrast EBD & ASD”—Columbus, OH Trammell, B., et.al. (2013) Assessment and Differential Diagnosis of Comorbid Conditions in Adolescents and Adults with ASD. Psychology in the Schools, 5 (9).