Assessment of the efficacy of a program to improve the social communication and behavior of young children with autism spectrum disorders

Disponible on-line en: http://revistalogopedia.uclm.es Revista de Investigación en Logopedia 2 (2015) 167-185. ISSN-2174-5218 Assessment of the efficacy of a program to improve the social communication and behavior of young children with autism spectrum disorders María del Sol Fortea, María Olga Escandell y José Juan Castro Universidad de las Palmas de Gran Canaria, España Abstract Numerous studies reveal the benefits of early intervention for the adequate development of children with autism spectrum disorders (ASD). Most of the interventions designed for people with ASD focus exclusively on a sole methodology. This study proposes a Combined Early Intervention Program (hereafter CEIP) using different methodologies with scientific evidence: Early Intensive Behavioral Interventions (EIBI), Early Start Denver Model (DENVER), spatial-temporal organization (TEACCH), augmentative communication systems (the Picture Exchange Communication System—PECS—, Total Communication Program, Picture Communication Symbols—PCS), behavioral strategies, and training of the parents. This CEIP contemplates intervention in areas that are typically affected in ASD: socialization, communication, symbolization, and behavioral flexibility, producing considerable improvement in the children's behavior, decreasing problem behaviors and improving social communication. Keywords: Applied behavioral analysis; Augmentative communication systems; Denver model; Early intervention; Intervention program; TEACCH methodology. Evaluación de la eficacia de un programa para mejorar la comunicación social y el comportamiento en jóvenes con trastornos del espectro autista Resumen Numerosos estudios ponen de manifiesto los beneficios de la atención temprana para la buena evolución de los niños con trastornos del espectro autista (TEA). La mayoría de las intervenciones diseñadas para personas con TEA se centran en una única metodología exclusivamente. Este estudio plantea un Programa de Intervención Temprana Combinando (en adelante CEIP) empleando diferentes metodologías con evidencia científica: Early Intensive Behavioral Interventions (EIBI), Early Start Denver Model (DENVER), organización espaciotemporal (TEACCH), sistemas aumentativos de comunicación (PECS, Comunicación Total, SPC), estrategias conductuales y entrenamiento a padres. Este CEIP contempla la intervención sobre las áreas típicamente afectadas en TEA: socialización, comunicación, simbolización y flexibilidad comportamental, repercutiendo en una mejora significativa del comportamiento de los niños, reduciendo las conductas problema y mejorando la comunicación social. Palabras clave: Análisis de conducta aplicado; Atención temprana; Metodología TEACCH; Modelo Denver; Programa de intervención; Sistemas aumentativos de comunicación. __________________________________________________________________________________________ Correspondencia con los autores: [email protected] Recibido 25 de Junio de 2015. Revisado 15 de Julio de 2015. Aceptado 17 de Julio de 2015. Agradecimiento: A las familias del Centro de Psicología Infantil FOR.TE.A. por su participación y colaboración en este estudio. A todas las personas con trastornos del espectro autista. Escandell et al., Revista de Investigación en Logopedia 2 (2015) 167-185 168 Introduction People with autism present very varied functioning profiles despite sharing common alterations in typically disturbed development areas (reciprocal social interaction, language and communication, symbolization and behavior). These alterations have very diverse phenotypes in each person with ASD (Nazeer & Ghaziuddin, 2012), varying as a function of age, intellectual capacity, associated pathologies, the effects of received treatment, the person's social environment, family involvement, etc. Therefore, many factors will determine how the symptoms manifest in each person with ASD. The important aspect is that early detection of these symptoms is decisive for their improvement (Crosland, Clarke, & Dunlap, 2012; Granpeesheh, Dixon, Tarbox, Kaplan, & Wilke, 2009) because thereby, disruptive behaviors decrease and functional skills improve (Rogers & Vismara, 2008). However, there is an obvious increase of ASD in young children (Fortea, Escandell, & Castro, 2013a; Nygren et al., 2012), which confirms earlier tendencies in countries like the United States (Centers for Disease Control and Prevention, 2009), Canada (Baird et al., 2006) or Norway (Kogan et al., 2009). These high prevalences directly affect the need for early intervention (ET) and the design of effective programs (Fombonne, 2009) because of the direct correlation between ET and a positive prognosis (Schertz, Baker, Hurwitz, & Benner, 2011). The last authors also indicate the need to intervene in natural and inclusive settings and to focus on pre-verbal behaviors, which are the basis for the development of higher competences. It has also been confirmed that intellectual capacity improves in cases where ET was implemented (Campbell & Figueroa, 2001; Canal et al., 2006; Ramey & Ramey, 1998; Ruiz & Martin, 2009). Other ET programs achieve improvements in adaptive behavioral functioning and language, as well as decreases in the parents' stress and improvement of their perceptions of their own abilities (Reed et al., 2013). When parents receive the diagnosis of their child's autism, they must not only face this fact, they must also choose a treatment from the large variety of existing methods (Miller, Schreck, Mulick, & Butter, 2012), with or without underlying scientific support. Despite the fact that there are scientifically supported methods, parents continue to resort to methods with scarce validity, without the guarantee of research, and involving expensive, long, and in many cases, dangerous interventions (Matson, Adams, Williams, & Rieske, 2013). The factors influencing the parents' decision about what method to follow are usually the recommendations of others, practical issues (availability, accessibility, cost, time required, the child's needs, and compatibility with other activities…), effectiveness of the intervention, Escandell et al., Revista de Investigación en Logopedia 2 (2015) 167-185 169 and proven scientific evidence (Carlon, Carter, & Stephenson, 2013). There is currently no agreement among researchers to defend a specific early intervention model versus another model, due to the heterogeneity of children with autism and their families (Howlin, Magiati, & Charman, 2009; Ospina et al., 2008). However, they do agree that these children should receive treatment, the sooner, the better. In this study, we propose an intervention based on the following methodologies: Early Intensive Behavioral Interventions (EIBI), the Early Start Denver Model (DENVER; Dawson et al., 2010), TEACCH (Mesibov, Shea, & Schopler, 2005), and interventions focusing on communication, such as the Picture Exchange Communication System (PECS, Bondy & Frost, 1994), the Total Communication Program (Schaeffer, Musil, & Kollinzas, 1980), the Picture Communication System (PCS; Johnson, 1981), as well as training the parents. All these intervention models have shown their efficacy and will be described below. As with the applied behavioral analysis (ABA) methodology (Lovaas, 1993), many investigations support the efficacy of EIBI (Eldevik et al., 2009) and recommend its application (Hayward, Eikeseth, Gale, & Morgan, 2009) because it improves the intelligence quotient, adaptive behavior (Peters-Scheffer, Didden, Korzilius, & Sturmey, 2011) and global functioning in small children (Eikeseth, 2009). The Denver model (Rogers & Dawson, 2010) is an ET model that integrates ABA with a relational-based approach. In this model, the children play an active role in the construction of their mental world, with a great impact on their interpersonal, affective, motor, and sensory relations. This is an efficacious intervention model because it improves cognitive and adaptive behavioral capacities and reduces the severity of the ASD diagnosis, while underlining the importance of early detection and intervention in autism (Dawson et al., 2010). TEACCH (Mesibov et al., 2005) is based on the spatial-temporal organization of different settings to make them more comprehensible and predictable, capitalizing on the strong points and interests of children with ASD and endorsing the use of spontaneous and functional communication. Various investigations confirm an increase in fine motor and visual skills, personal autonomy, improvement of adaptive behavior, and a decrease in parents' anxiousness (Mesibov & Shea, 2010; Welterlin, Turner-Brown, Harris, Mesibov, & Delmolino, 2012). An early intervention program based on the TEACCH methodology reported a statistically significant decrease in parents' stress as well as an increase in the children's expressive and receptive language (Braiden, McDaniel, McCrudden, Janes, & Crozier, 2012). Escandell et al., Revista de Investigación en Logopedia 2 (2015) 167-185 170 The prioritization of the development of spontaneous and functional communicative skills should be inherent in every intervention program, as well as inviting the parents to participate in the setting of goals (Lord & Bishop, 2010; Rogers & Vismara, 2008). Hence, and taking into account that people with ASD prefer the visual information processing channel, we decided to use augmentative communication systems that combine spoken words with visual support (signs, pictograms, and photographs), like the Total Communication Program (Schaeffer et al., 1980), the PCS (Johnson, 1981), and the PECS (Bondy & Frost, 1994). With regard to family participation in the intervention, various studies show that when parents take on their educational responsibility in the program, they are capable of promoting many positive changes at home and in their lives, fostering children's learning and development (Panerai et al., 2009) as well as expressing a high level of satisfaction with the program (Braiden et al., 2012). Therefore, we contemplate family participation throughout the entire CEIP. Despite that the effects of EIBI seem strong and robust, no treatment, including this one, has been efficacious for all children with ASD (Reichow, 2012). Moreover, there seems to be a tendency to use not one, but various different models as a function of the characteristics and needs of children with ASD (Eldevik et al., 2009). Thus, the study of Callahan, Shukla-Mehta, Magee, and Wie (2010) reports that special education teachers, parents, and therapists observe that the combination of ABA and TEACCH favors the development of people with ASD. Method Participants The sample (Table 1) is made up of 26 boys and 2 girls, aged between 17 and 74 months; 93% of them were 38 months old or younger at the time of diagnosis and initiation of treatment. All are residents of Gran Canaria (Spain). The rest of them—two participants— were 44 and 74 months old, respectively, at initiation of treatment. The former child has Down's syndrome and ASD, and the latter has intellectual disability associated with ASD. None of them had received medication for the central symptoms of ASD. Escandell et al., Revista de Investigación en Logopedia 2 (2015) 167-185 171 Table 1. Frequency of Children's Age (in Months) at Treatment Initiation Age Frequency Percentage Valid percentage Accumulated percentage 17 2 7.1 7.1 7.1 18 2 7.1 7.1 14.3 19 1 3.6 3.6 17.9 20 1 3.6 3.6 21.4 21 1 3.6 3.6 25.0 23 2 7.1 7.1 32.1 24 1 3.6 3.6 35.7 26 1 3.6 3.6 39.3 27 2 7.1 7.1 46.4 28 3 10.7 10.7 57.1 29 1 3.6 3.6 60.7 30 1 3.6 3.6 64.3 31 4 14.3 14.3 78.6 33 1 3.6 3.6 82.1 35 1 3.6 3.6 85.7 38 2 7.1 7.1 92.9 44 1 3.6 3.6 96.4 74 1 3.6 3.6 100.0 Total 28 100.0 100.0 They came to the Child Psychology Center, specialized in the diagnosis and treatment of ASD and behavioral disorders, because they did not speak or they had difficulties communicating, according to their parents' reports. Most of them were referred from pediatric consultations where the validated Spanish version of Canal et al. (2010) of the Modified Checklist for Autism in Toddlers (Robins, Fein, Barton, & Green, 2001) was administered and the suspicion of ASD was proposed. They all underwent a process of diagnosis and were classified as autistic (according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders-IV-TR, American Psychiatric Association, 2000). The Autism Diagnostic Interview-Revised (ADIR; Rutter, Le Couteur, & Lord, 1994) and the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 2000) were employed, administered by experts accredited in their use. Instruments To measure the efficacy of the CEIP, we created an ad hoc survey (Annex 1) that the parents completed in two stages: before and three months after initiating the intervention program. This survey is taken from a prior study (Fortea, Escandell, & Castro, 2013b) that used the “Cuestionario para familias de personas con autismo” [Questionnaire for families of autistic Escandell et al., Revista de Investigación en Logopedia 2 (2015) 167-185 172 people]. It is made up of 43 questions, the same as those used for the surveys carried out with relatives of people with autism in Spain, designed and assessed by the “Grupo de Estudio de los Trastornos del Espectro Autista” [Study Group of Autism Spectrum Disorders] (2003). It collects data about the needs of people with autism and their families with regard to diagnosis, care, and orientation in order to improve their quality of life. One of the open questions requested the families to name the first behaviors that made them suspect that something was wrong with their child's development and that led them to consult with professionals for a diagnosis. These behaviors are independently categorized by three expert observers according to the development areas that are altered in ASD (reciprocal social interaction, communication, and behavior) and which are tapped by the diagnostic instruments employed. Lastly, the questions were reduced to 10 items that make up the survey. Parents score the extent to which a behavior is present in their child on a 4-level frequency scale: never, sometimes, frequently, and always. Procedure After completing the diagnostic process, the children initiated the CEIP (Escandell & Fortea, 2013) at the Child Psychology Center. The CEIP proposes individualized goals in four developmental areas: a) basic behavior and skills (with goals like increasing waiting times, focusing and maintaining attention on an activity, responding to simple and contextualized orders, extinguishing inadequate behaviors, increasing variety in food ingestion…), b) cognition and symbolization (developing the first functional and symbolic games, imitating simple motor models, performing hand-eye coordination games in an orderly and sequenced fashion, recognizing body schema…), c) language and communication (concurrently pointing and vocalizing, imitating sounds and syllables, receptive and expressive discrimination of yes-no with a function of acceptance-rejection using gestural and verbal modalities, promoting imitation of sounds and words, favoring the development of spontaneous oral speech…); and d) socio-emotional (developing circular games of reciprocal social interaction, fostering gestures of greeting, leave-taking, social kiss or smile, developing reference capacities, recognizing basic emotions in self and others, favoring the skills of social peer interaction, either self-initiated or in response to actions initiated by others…). The application frequency of the CEIP varied from three to five 45-minute weekly sessions carried out by professional experts in ASD. In addition, the families attended a weekly 2-hour family school session so that the parents would understand the psychological functioning of their children, while learning adequate action strategies. Before initiating the Escandell et al., Revista de Investigación en Logopedia 2 (2015) 167-185 173 program, the parents completed the first part of the survey (S1) and three months after initiating the CEIP, they completed the second part (S2) (Annex 1). Results The results revealed significant differences in all the items before and after the intervention. All the behaviors observed were sensitive to treatment, and significant improvements were obtained in all of them after the intervention (Table 2). With regard to the relationships between the improvements found in the different areas assessed, strong positive correlations were observed (Table 3) between improvement in communication and improvement in expressive and receptive language; improvement in expressive language correlated with improvement in receptive language; improvement in social interaction correlated with improvement in emotional lability and play; improvement in play correlated with improvement in emotional lability and motor behavior and with a decrease in self-injury. Table 2. Differences in pre-posttreatment means of the different behaviors assessed by parents Related differences T df p (twotailed) M SD SEM Upper Lower Altered social interaction 1.286 .854 .161 .954 1.617 7.962 27 .000 Altered gaze 1.107 .685 .130 .841 1.373 8.549 27 .000 Altered communication 1.643 .951 .180 1.274 2.012 9.139 27 .000 Altered expressive language 1.321 .819 .155 1.004 1.639 8.538 27 .000 Altered receptive language 1.250 .887 .168 .906 1.594 7.456 27 .000 Emotional lability 1.107 .786 .149 .802 1.412 7.454 27 .000 Altered motor behavior .750 .799 .151 .440 1.060 4.965 27 .000 Altered play 1.214 .917 .173 .859 1.570 7.005 27 .000 Self-injuries .429 .790 .149 .122 .735 2.870 27 .008 Sensitivity to sensory stimuli .714 .713 .135 .438 .991 5.303 27 .000 95% Confidence interval of the difference Escandell et al., Revista de Investigación en Logopedia 2 (2015) 167-185 174 In view of these results, which confirmed significant improvements in all the areas assessed and the relationships between these improvements, we proposed to determine which items from the different diagnostic tests previously applied (before treatment) predict or are related either to more extensive improvement or to greater resistance to change after treatment. Table 3. Correlations of the Posttreatment Improvements in the different Behaviors assessed by Parents Social interaction Communication Expressive language Emotional lability Motor behavior Play Expressive language .676** Receptive language .636** .650** Emotional lability .449* Play .392* .378* .379* Decrease of selfinjuries .494** *p = .05 (bilateral). **p = .01 (bilateral). Table 4 presents the correlations between improvement of the different behaviors observed and the partial scores of the diagnostic tests ADOS and ADIR. As can be observed, the greatest resistance to improvement in communication (Item 3) occurs in children with high scores in the “use of another person's body to communicate,” with marked qualitative alteration in “reciprocal social interaction” in general, specifically, in “lack of shared enjoyment or pleasure” or altered behavior “nodding head for yes.” Altered expressive language (Item 4) is an objective behavior that is more difficult to improve in children with high scores in “lack of shared enjoyment or pleasure” or with few behaviors of “seeking to share their delight or enjoyment with others.” It is difficult to improve receptive language (Item 5) in children with “altered social smile, lack of “imaginative play with their peers,” or lack of “friends,” “lack of shared enjoyment or pleasure,” few behaviors of “seeking to share their delight or pleasure with others,” or presence of “limited interests.” Emotional lability (Item 6) barely improves in children with difficulties making “friends.” Escandell et al., Revista de Investigación en Logopedia 2 (2015) 167-185 175 Motor behaviors are especially prone to improvement (Item 7) in children with marked alterations in “play” in general and in “functional play with objects” in particular, in the “quality of social approaches,” or who are “preoccupied with parts of objects or nonfunctional elements of materials.” In contrast, children with high scores in “relative inability to initiate or maintain a conversation” in general, “verbalization social/talk,” “reciprocal conversation,” or who use “inverted pronouns” are especially resistant to change. Play (Item 8) improves especially in children with high scores in “unusual visual contact.” In contrast, it is more resistant to change in children with high scores in difficulties making “friends” or “nodding head for yes.” Sensitivity to sensory stimuli (Item 10) improves especially in children with high scores in “apparently compulsive adherence to routines or non-functional rituals” or in “verbal rituals.” In contrast, this behavior change is reduced in children with altered behavior “Shaking head for no.” We did not take into account the correlations obtained among the improvements in the assessment survey items and the scores concerning age at the onset of the development alterations (section D of the ADIR) because many of these children were not yet 24 months old (35.7%), and most of them were not even 33 months old (82.1%). Escandell et al., Revista de Investigación en Logopedia 2 (2015) 167-185 182 Matson, J. L., Tureck, K., Turygin, N., Beighley, J., & Rieske, R. (2012). Trends and topics in early intensive behavioral interventions for toddlers with autism. Research in Autism Spectrum Disorders, 6, 1412–1417. McGarrell, M., Healy, O., Leader, G., O’Connor, J., & Kenny, N. (2009). Six reports of children with autism spectrum disorder following intensive behavioral intervention using the Preschool Inventory of Repertoires for Kindergarten (PIRK). Research in Autism Spectrum Disorders, 3, 767–782. Mesibov, G. B., & Shea, V. (2010). The TEACCH Program in the era of evidence-based practice. Journal of Autism and Developmental Disorders, 40, 570-579. Mesibov, G. B., Shea, V., & Schopler, E. (Eds.). (2005). The TEACCH approach to autism spectrum disorders. New York: Springer. Miller, V. A., Schreck, K. A. Mulick, J. A., & Butter, E. (2012). Factors related to parents’ choices of treatments for their children with autism spectrum disorders. Research in Autism Spectrum Disorders, 6, 87-95. Nazeer A., & Ghaziuddin M. (2012). Autism spectrum disorders: Clinical features and diagnosis. Pediatric Clinics of North America, 59 (1), 19-25. Nygren, G., Sandberg, E., Gillstedt, F., Ekeroth, F., Arvidsson, T., & Gillberg, C. (2012). A new screening programme for autism in a general population of Swedish toddlers. Research in Developmental Disabilities, 33, 1200-1210. Osborne, L. A., McHugh, L., Saunders, J., & Reed, P. (2008). The effect of parenting behaviors on subsequent child behavior problems in austictic spectrum condition. Research in Autism Spectrum Disorders, 2, 249-263. Ospina, M. B., Seida, J. K., Clark, B., Karkhaneh, M., Hartling, L., Tjosvold, L.,… Smith, V. (2008). Behavioural and developmental interventions for autism spectrum disorder: A clinical systematic review. PLoS ONE, 3, 1–32. Panerai, S., Zingale, M., Trubia, G., Finocchiaro, M., Zuccarello, R., Ferri, R., & Elia, M. (2009). Special education versus inclusive education: The role of the TEACCH program. Journal of Autism and Developmental Disorders, 39, 874–882. Peters-Scheffer, N., Didden, R., Korzilius, H., & Sturmey, P. (2011). A meta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with autism spectrum disorders. Research in Autism Spectrum Disorders, 5, 60–69. Ramey, C. T., & Ramey, S. L. (1998). Early intervention and early experience. American Psychologist, 53, 109-120. Escandell et al., Revista de Investigación en Logopedia 2 (2015) 167-185 183 Reed, P., Osborne, L. A., Makrygianni, M., Waddington, E., Etherington, A., & Gainsborough, J. (2013). Evaluation of the Barnet Early Autism Model (BEAM) teaching intervention programme in a ‘real world’ setting. Research in Autism Spectrum Disorders, 7, 631–638. Reichow, B. (2012). Overview of meta-analyses on early intensive behavioral intervention for young children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 512-520. Roberts, J., Williams, K., Carter, M., Evans, D., Parmenter, T., Silove, N., …Warren, A. (2011). A randomised controlled trial of two early intervention programs for young children with autism: Centre-based with parent program and home-based. Research in Autism Spectrum Disorders, 5, 1553–1566. Robins, D.L., Fein, D., Barton, M.L., & Green, J.A. (2001). The modified checklist for autism in toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31, 131–144. Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism. Promoting language, learning and engagement. New York: Guilford Press. Rogers S. J., & Vismara, L. A (2008). Evidence-based comprehensive treatments for early autism. Journal of Clinical Child & Adolescent Psychology, 37, 8-38. Rutter, M., Le Couteur, A., & Lord, C. (1994). Autism Diagnostic Interview-Revised: A revised version of a diagnostic interview for caregivers of individuals with posible pervasive developmental disorders. Journal of Autism and Developmental Disorders, 24(3), 659-685. Ruiz, J., & Martin, P. (2009). La prevalencia de los trastornos del espectro autista no ha aumentado pero su diagnóstico se realiza en edades más precoces. Evidencias en Pediatría, 5, 1-14. Schaeffer, B., Kollinzas, G., Musil, A. & McDowell, P. (1977). Spontaneous verbal language for autistic children through signed speech. Sign Language Studies, 17, 287-328. Schaeffer, B., Musil, A., & Kollinzas, G. (1980). Total Communication: A signed speech program for non-verbal children. Champaign, IL: Research Press. Schertz, H. H., Baker, C., Hurwitz, S., & Benner, L. (2011). Principles of early intervention reflected in toddler research in autism spectrum disorders. Topics in Early Childhood Special Education, 31, 3-21. Escandell et al., Revista de Investigación en Logopedia 2 (2015) 167-185 184 Solomon, R., Necheles, J., Ferch, C., & Bruckman, D. (2007). Pilot study of a parent training program for young children with autism: The PLAY Project Home Consultation program. Autism, 11(3) 205-224. Tonge1, B., Brereton, A., Kiomal, M., Mackinnon, A., & Rinehart, N. J. (2014). A randomised group comparison controlled trial of ‘preschoolers with autism’: A parent education and skills training intervention for young children with autistic disorder. Autism, 18(2) 166-177. Virués-Ortega, J., Julio, F. M. & Pastor-Barriuso, R. (2013). The TEACCH program for children and adults with autism: A meta-analysis of intervention studies. Clinical Psychology Review, 33, 940-1417. Welterlin, A., Turner-Brown, L. M., Harris, S., Mesibov, G., & Delmolino, L. (2012). The home TEACCHing program for toddlers with autism. Journal of Autism and Developmental Disorders, 42, 1827–1835. Annex 1. Preand Posttreatment Assessment Survey to be completed by the Parents BEHAVIORS ASSESSED NEVER SOMETIMES FREQUENTLY ALWAYS 1. Altered social interaction: distracted, absent, in his/her own world, not interested in other children, does not give kisses, does not smile, withdrawn, solitary, independent, plays alone 2. Altered gaze: Does not maintain gaze 3. Altered communication: scarce communication, does not point, does not ask, does not request, does not gesture, indicates needs by taking you by the hand 4. Altered expressive language: loss or lack of language, little vocabulary, echolalia 5. Altered receptive language: Low comprehension: does not respond to orders, does not respond when called, does not respond to his/her name, pays no attention, seems deaf 6. Emotional lability: crying intensely, unmotivated tantrums, excessive crying, fears, hesitations, laughs for no reason 7. Altered motor behavior: Stereotyped movements, flapping, mannerisms, rocking, tiptoeing, motor clumsiness, racing, jumping, low/high muscle tone, too quiet or excessive activity 8. Altered play: Inappropriate use of toys (rotates them, lines them up, throws them, tears papers...), fixations, arranging, collecting things 9. Self-injuries: hits self on head, bites self 10. Sensitivity to sensory stimuli: Very sensitive to sounds, smells, textures, rejects physical contact