Autism Spectrum Disorders Assessment and Diagnosis David A. Townsend, Ph.D.
What is Autism?• “According to the DSM-IV, autistic disorder is one of several pervasive developmental disorders (PDDs) that are caused by a dysfunction of the central nervous system leading to disordered development. All children with PDD are characterized by qualitative impairments in social interaction, imaginative activity, and both verbal and nonverbal communication skills” (Kabot et. al., 2003, p. 26) 2
Pervasive Developmental Disorders (PDD) – Most commonly diagnosed• Autism falls under the PDD umbrella of PDD – Impairs ability to communicate, form• Neurological disorder: relationships, and interact with others “severe and pervasive – Results in a range of impairment in multiple unusual and repetitive behaviors areas of development – Typically diagnosed by age 3 or 4 years – Frequently accompanied by mental retardation – Sometimes, uneven levels of intelligence (Masland, 2005)
Pervasive Developmental Disorders or ‘Autism Spectrum Disorders’ 1997-2004 ASD Aspergers (reported on IDEA) increased 471% in Kansas Autism RETTS RettsPDD CDDNOS CDD
History of Autism• Leo Kanner 1943• Isolated from environment• Cold, Aloof Parent• Definitional Parameters have been consistent: – Problems in Socialization – Problems in Language – Ritualistic Behavior and interests
Changes in Conceptualization • Biological Environmental• Developmental Psychiatric Disorder • Spectrum Specific Disorder • Early Late Detection
History of Autism• Changes in Definition:• DSM III Formally defined (1980)• DSM III R “Menu” of characteristics (8)• DSM IV PDD Spectrum (6 characteristics)
DSM-IV Criteria for Autistic DisorderDiagnostic and Statistical Manual of Mental Disorders, 4th edition,1994, Washington, DC: American Psychiatric Association, pp. 70-71.A. A total of at least six items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3): (1) Qualitative impairment in social interaction, as manifested by at least two of the following: (a) 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; (b) Failure to develop peer relationships appropriate to developmental level; (c) Markedly impaired expression of pleasure in other people’s happiness; (d) Lack of social or emotional reciprocity.
DSM-IV Criteria for Autistic Disorder (2) Qualitative impairments in communication as manifested by at least one of the following: (a) 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 gestures or mime); (b) In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others; (c) Stereotyped and repetitive use of language or idiosyncratic language; (d) Lack of varied spontaneous make-believe play or social imitative play appropriate to developmental level.
DSM-IV Criteria for Autistic Disorder (3) Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: (a) Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus; (b) Apparently compulsive adherence to specific nonfunctional routines or rituals; (c) Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements); (d) Persistent preoccupation with parts of objects.
DSM-IV Criteria for Autistic Disorder B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years; (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play. C. Not better accounted for by Rett’s Disorder of Childhood Disintegrative Disorder.
Defining Features• Qualitative Impairment in Communication• Qualitative Impairment in Social Interaction• Restricted, repetitive, and stereotyped Neurological disorders characterized by patterns of behavior "severe and pervasive impairment in several Imitation Deficit (DSM V?) areas of development
Rett’s Disorder• Is a genetic condition affecting only females in which normal brain development simply stops.• Its rare-affecting only 1 in every 15,000 children.• Growth & development appear normal until 5 mos. of age, when the head growth appears to slow through about 48 mos. of age.• Overall kids with Rett’s disorder have similar social & mental impairments of autistic disorder, but are much worse & more significantly impaired.
Childhood Disintegrative Disorder• A very rare PDD occurring in one in 100,000 children in which.• Is striking because it emerges after an extended period of typical development which often lasts for several years.• There is a marked regression in language skills, communication, social interactions, play, & motor behaviors.• Decline may occur over several weeks to several months.• In as many as 75% of the reported cases, the developmental deterioration was dramatic with little recovery of lost abilities.
Asperger’s Disorder • In 1944, Dr. Hans• *intense, but very narrow Asperger described a interests. group of 4 children ages 6-11 with typical• *speech that was unrelated communication & to the conversation’s topic cognitive skills, but who had significant problems• *interest in letters & number’s with social interactions. at a very young age. • Several symptoms were• *poor empathy. observed from these• *clumsiness children.• *difficulty controlling volume of voice when speaking• *trouble adjusting to school.
How is Asperger’s Disorder different from Autistic Disorder?• 1. Children with Asperger’s don’t have the same level of communication problems that kids with autistic disorder do. Nearly all kids with Asperger’s develop speech & language skills roughly when typical children do.• 2. Aren’t diagnosed until much later than kids with autistic disorder, since speech isn’t usually delayed.
How is Asperger’s Disorder different from Autistic Disorder? •3. Children with Asperger’s usually don’t score in range of mental retardation compared with many autistic kids who do.• 4. Kids with Asperger’s have verbal abilities (vocabulary, facts) that are generally better than their non-verbal abilities. This is the reverse for kids with Autistic Disorder.• 5. Socially, kids with Asperger’s have interest in other people, compared with the solitary existence of most kids with autistic disorder.
Symptoms of Asperger’s Disorder• *intense, but very narrow interests.• *speech that was unrelated to the conversation’s topic• *interest in letters & number’s at a very young age.• *poor empathy.• *clumsiness• *difficulty controlling volume of voice when speaking• *trouble adjusting to school.
PDD-NOS Pervasive Developmental Disorder –Not Otherwise Specified• Prevalence: 1 in 500 children• Is an autistic spectrum disorder in which some of Known as atypical the symptoms of autism are present, but not the autism four traditional required to fit into one of the other four categories (autistic disorder, Asperger’s Diagnosis given to disorder, Rett’s Disorder, Childhood children with some Disintegrative Disorder). symptoms of autism but who do• Fits children with a unique mixture of symptoms not meet specific that fall under the PDD umbrella, but don’t diagnostic criteria specifically fit into one of the four distinct diagnoses discussed above. In many cases, these children are later confirmed to have• The heterogeneity of symptoms among children an identifiable with PDD: NOS & its similarity to other PDD’s has disorder made it difficult for parents to get clear (Masland, 2005) information about their child’s condition or a diagnosis for their child.
Onset of disorder• Autism begins in infancy or early childhood. It is generally believed to be a lifelong disorder that a child is born with.• Although parents may get a firm diagnosis by 36 mos., it is usually common for such a diagnosis to occur later.
Autism Assessment Tools • Childhood Autism Rating Scale (CARS) • Autism Diagnostic Interview – Revised (ADI-R) • Autism Diagnostic Observation Schedule – Generic (ADOS-G) • Checklist for Autism in Toddlers (CHAT) • Screening Tool for Autism in Two-Year- Olds (STAT) • Autism Behavior Checklist (ABC) • E-1 and E-2 scales by Rimland • Detection of Autism by Infant Sociability Interview (DAISI) • Vineland Adaptive Behavior Scales (VABS)
Autism Behavior Checklist (ABC)• The Autism Behavior Checklist (ABC) is a list of questions about a childs behaviors.• The ABC was published in 1980 (Krug et al., 1980) and is part of a broader tool, the Autism Screening Instrument for Educational Planning (ASIEP) (Krug et al., 1978).• The ABC is designed to be completed independently by a parent or a teacher familiar with the child who then returns it to a trained professional for scoring and interpretation.• Although it is primarily designed to identify children with autism within a population of school-age children with severe disabilities, the ABC has been used with children as young as 3 years of age.
ABC• The ABC has 57 questions divided into five categories: (1) sensory, (2) relating, (3) body and object use, (4) language, and (5) social and self-help• The ABC appears to have limited usefulness in identifying children with autism who are under the age of 3. [A]• When used in conjunction with other diagnostic instruments and methods, the ABC may have some usefulness as a symptom inventory to be completed by parents or teachers. Clinicians could utilize this inventory in structuring their evaluation
Checklist for Autism in Toddlers (CHAT)• The Checklist for Autism in Toddlers (CHAT) is a brief screening instrument that is intended to detect possible autism in toddlers. Since it is a screening test, the CHAT provides a first level of evaluation leading to a yes/no decision that, at the current time, autism is either unlikely or is possible (and requires further evaluation). The CHAT was published in 1992 (Baron- Cohen, et. al., 1992).• The CHAT takes only about five to ten minutes to administer and score.• Specific training is not required, and it can be administered by a variety of individuals. The CHAT is designed to be used with toddlers as young as 18 months of age.• The CHAT consists of nine yes/no questions to be answered by the childs parent.• These questions ask if the child exhibits specific behaviors, including: social play, social interest in other children, pretend play, joint attention, pointing to ask for something, pointing to indicate interest in something, rough and tumble play, motor development, and functional play. The CHAT also includes observations of five brief interactions between the child and the examiner, which enable the clinician to compare the childs actual behavior with the parental reports.
CHAT• Checklist for Autism in Toddlers• “most well known screening test for identifying ASD in young children” (Kabot et. al., 2003, p. 28)• If CHAT suggests autism, an in-depth assessment is recommended; if it does not, further evaluations are recommended. (Kabot et. al., 2003)• “used to help identify the early signs of autism at 18 months by assessing the child’s attainment of developmental milestones” (Robins et. al., 2001, p. 133) 27
CHAT Checklist for Autism in Toddlers 18-month visit 9 Parent Questions/5 physician Observations 5 Key Items1. Parent: “Enjoy playing peek-a-boo?” - joint attention2. Parent: “Use his/her index finger to point, to ASK for something?) protoimperative pointing3. Physician : “Oh look (point), there’s a (toy).” - following a point4. Physician: “Can you pour a glass of water?”– pretending5. Physician: “Where’s the light?” - producing a point
M-CHAT• Modified Checklist for Autism in Toddlers• “a 23-item parent-report checklist, examining children’s developmental milestones” (Robins et. al., 2001, p. 140)• “a simple screen that can be given to all children during pediatric visits” (p.133)• “does not rely on the physician’s observation of the child, but on parents’ report of current skills and behaviors” (p. 133)• “solely for the purpose of initial screening” (p. 141) 30
STAT• Screening Tool for Autism in Two-Year-Olds• “designed for use by professionals involved in early identification and intervention”• “relatively brief interactive measure that can be used to identify children in need of more extensive follow-up” (p. 29)• “differs from the CHAT in that it was developed as a second-stage screening instrument to differentiate children with autism from children with other developmental disorders” 32
Diagnosing Autism• several tests have been developed that are now used in diagnosing autism – CARS rating system (Childhood Autism Rating Scale) – The Checklist for Autism in Toddlers (CHAT) – The Autism Screening Questionnaire – The Screening Test for Autism in Two-Year Olds 33
DiagnosisDiagnosis :• Out of 1,300 families surveyed: – The average age of diagnosis of autism was 6 years of age, despite the fact that most parents felt something was wrong by 18 months of age – Less than 10% of children were diagnosed at initial presentation – 10% were either told to return if their worries persisted, or that their child "would grow out of it" – The rest were referred to another professional (at a mean age of 40 months); of which: • 40% were given a formal diagnosis • 25% were told "not to worry" • 25% were referred to a third or fourth professional
Autism Diagnostic Observation Schedule (ADOS; ) Lord et al., 1989• The Autism Diagnostic Observation Schedule (ADOS; Lord et al., 1989)• consists of eight tasks, four focusing on social behaviors and four on communicative behaviors.• The test was intended primarily for older, higher- functioning, verbal autistic children.
ADOS• Purpose: Allows you to • Format: Standardized accurately assess and behavioral observation and diagnose autism and coding pervasive developmental • Score: Cutoff scores for disorder across ages, both a narrow diagnosis of developmental levels, and autism and a broader language skills diagnosis of pervasive• Ages / Grade: Toddlers to developmental disorder adults• Administration Time: 35 to 40 minutes
ADOS-G• Autism Diagnostic Observation Schedule- Generic• “semistructured assessment of play, interaction, and social communication” (Kabot et. al., 2003)• requires “extensive training of clinicians before it can be administered”• “four modules that match age and communication levels of individuals from childhood to adulthood” 37
The Pre-Lingusistic Autism Diagnostic Obesvation Schedule (PL-ADOS)• Semistructered assessment of: – Play – Interaction – Social Communication• Behaviors observed in a limited time period in a clinical setting• Less inclusive than CARS, ADI-R (Lord 95)
PL-ADOS• The Pre-Linguistic Autism The PL-ADOS may be useful Diagnostic Observation as part of a multidisciplinary Schedule (ADOS; Lord et al., intake assessment in 1989) is a semistructured diagnosing young children observation scale modified to with possible autism. [C] diagnose young children Since extensive training is (under the age of 6 years) who needed to learn how to are not yet using phrase administer the PL-ADOS, it speech and are suspected of may not be a practical having autism. The PL-ADOS assessment method in consists of eight tasks, four certain clinical situations. focusing on social behaviors and four on communicative behaviors. It takes approximately 30 minutes to administer and it is a semi- structured assessment of play, interaction, and social communication.
Childhood Autism Rating Scale (CARS)• The Childhood Autism Rating Scale (CARS) is the most widely used standardized instrument specifically designed to aid in the diagnosis of autism for use with children as young as 2 years of age.• Published in 1980 (Schopler et al., 1980), the CARS was originally correlated to the DSM-III and then to the DSM-III-R.• The CARS is intended to be a direct observational tool used by a trained clinician. It takes about 20-30 minutes to administer.
CARS • The CARS may be useful as part of the assessment• The 15 items of the CARS of children with possible autism in a variety of include: settings: early intervention programs, preschool developmental programs, and developmental• Relationships with People, Imitation, diagnostic centers. • Among the autism assessment instruments• Affect, Use of Body, reviewed, the CARS appears to possess an• Relation to Non-human Objects, acceptable combination of practicality and research support, despite the limited research on its use in• Adaptation to Environmental Change, children under 3 years of age.• Visual Responsiveness, • • It is very important that professionals using the• Auditory Responsiveness, CARS have experience in assessing children with• Near Receptor Responsiveness, autism and have adequate training in administering and interpreting the CARS. [D1]• Anxiety Reaction,• Verbal Communication, • An autism assessment instrument that is practical, is supported by research, and includes a severity• Nonverbal Communication, rating (such as the CARS) may be useful for collecting consistent information to assist with• Activity Level, Intellectual estimating the prevalence of autism and assess• Functioning, and the clinicians general functional outcomes (especially if tied to other information about interventions and service delivery) impression.
Autism Diagnostic Interview - Revised (ADI-R)• The Autism Diagnostic Interview-Revised (ADI-R) is a semi-structured interview for a clinician to use with the childs parent or principal caregiver.• The original version of this test, the Autism Diagnostic Interview (ADI) was published in 1989 (LeCouteur et al., 1989) and was correlated to the ICD-10 definition of autism.• The original ADI was intended primarily for research purposes, providing behavioral assessment for subjects with a chronological age of at least five years and a mental age of at least two years
ADI-R • The ADI-R may be useful as part• the ADI-R takes from 11/2 to 2 of a multidisciplinary intake hours to administer and can be assessment in diagnosing young used with children as young as children with possible autism. two years of age (with a mental • Because of the time needed to age greater than 18 months). administer the ADI-R, and the extensive training needed, this test may not be a practical• The ADI and the ADI-R focus assessment method in all clinical on getting maximal information situations. from the parent about the three • A structured parent interview, key areas defining autism: such as the ADI-R, is a method (1) reciprocal social interaction; that can help maximize parental – (2) communication and recall but is not a substitute for language; and direct observation of the child by a – (3) repetitive, stereotyped professional assessing the child. behaviors. Therefore, it is important to supplement structured parent interviews with direct observation of the child.
ADR-I• Purpose: Useful for • Administration Time: 1 diagnosing autism, 1/2 to 2 1/2 hours, planning treatment, and including scoring distinguishing autism from • Format: Standardized other developmental interview and response disorders coding• Ages / Grade: Children and adults with a mental age above 2.0 years
ADI-R• Autism Diagnostic Interview – Revised• “has demonstrated good sensitivity and specificity in validity testing” (Kabot et. al., 2003)• “require[s] extensive time and training to administer”• “may be most useful as part of a more in-depth assessment in children for whom screening tests suggest a fairly high level of concern for autism” 45
Social Communication Questionnaire (SCQ)• Purpose: Offers a quick, • Format: Parent easy, and inexpensive way questionnaire with 40 yes - to routinely screen for or n items. Current and - o autism spectrum disorders Lifetime Forms• Ages / Grade: Over 4.0 • Scores: Total score with years, with a mental age cutoff points over 2.0 years• Administration Time: Less than 10 minutes
Retrospective Video Analysis• “families in increasing numbers have home videos which inadvertently provide documentation of their children’s development” (Baranek)• “an excellent option for accessing very early periods in development – months or years before a child with autism is diagnosed” (• “methodological problems…(e.g. difficulty controlling variables such as the age of subjects and length, content, or structure of the video segments)” can be controlled 47
Features Distinguishing Autism Based on Home Videotapes at 12 months• Pointing• Showing• Looking at Others• Orienting to NameOnly the latter two distinguished children with autism from children with developmental delays. (Osterling & Dawson, 1994; 1999)
Who should diagnose autism?• Although educators, parents, and other health care professionals identify signs and symptoms characteristic of autism, a clinician experienced in the diagnosis and treatment of autism is usually necessary for accurate and appropriate diagnosis.• Clinicians must rely on their clinical judgment, aided by guides to diagnosis, such as DSM-IV and the Tenth Edition of the International Classification of Diseases (ICD-10), as well as by the results of various assessment instruments, rating scales, and checklists.• These instruments and criteria should be used by practitioners not as experienced in the diagnosis of autism.
PDD Behavior Inventory™ (PDDBI™) Ira L. Cohen, PhD, Vicki Sudhalter, PhD• Purpose: Assess responsiveness to intervention in children with a pervasive developmental disorder in ages 1.6-12.5 years• Age Range: Preschool Child Admin: Rating Forms completed by informant (e.g., parent, teacher, caregiver); Individual or groupTime:30-45 minutes for Extended Forms; 20-30 minutes for Standard Forms
Early Indicators: 0-6 mos.Typically Developing Child Autistic Child• Head turns when name • Does not respond to is called social cues without• Matches the direction of repeated prompting a mom’s head turn to • Displays minimal the visible target affective responses• Starts to develop joint • More passive, quieter attention • May lag behind in• Attends to affective motor skills displays of others (Zwaigenbaum, 2005; Dawson et. al., 2004; Werner et. al.,• Responds to emotions 2000) 53
Early Indicators: 7-12 mos.Typically Developing Child Autistic Child• Succeeds at joint • Greater incidence of attention unusual posturing• Seeks emotional • Needs more prompts to respond to name information from adult faces when presented • Mouthing of objects with uncertainty (social • Social touch aversion referencing) (Zwaigenbaum et. al., 2005; Dawson et. al., 2004; Werner et. al., 2000; Baranek, 1999) 55
Early Indicators: 7-12 mos. Typically Developing Autistic Child Child • Pays little attention to• Elementary vocal distress of others communication • Lacks of social smiling and appropriate facial• Early social imitation expressions skills • Unstable attention (Zwaigenbaum et. al., 2005; Dawson et. al., 2004; Werner et. al., 2000; Baranek, 1999) 56
The Transitivity of Preconditioned Infantile Memories During Deferred Imitation Deferred Imitation: Demonstration: • model a sequence of three target actions • 24-h imitation test: 1) remove the mitten 2) shake the mitten 3) attempt to replace the mitten
Deferred Imitation: 100 * 80 Latency (s) 60 40 20 0 C/A D/A A/C Demo/Test Group
Early Indicators: 13-24 mos. Typically Developing Autistic Child Child • Minimal responses to• Exhibits joint attention others (lack of empathy)• Engages in social • Does not exhibit relations pretend play (Dawson et. al., 2004; Kabot et. al., 2003; Robins et. al., 2001; Charman et. al., 1997) 59
Early Indicators: 13-24 mos. Typically Developing Autistic Child Child • Impaired joint• Communicates, both attention receptively and • Less gazing at people expressively • Absence of pre-• Shows greater linguistic functions (i.e. declarative incidences of pretend pointing, showing play objects) (Dawson et. al., 2004; Kabot et. 60 al., 2003; Robins et. al., 2001; Charman et. al., 1997)
Early Indicators: 13-24 mos. Red Flags: Significant differences between the ASD and Delayed Development (DD) groups and the ASD and Typical Development (TD) groups• Lack of showing• Unusual prosody• Repetitive movements or posturing of body, arms, hands, or fingers• Repetitive movements with objects (Wetherby et. al., 2004) 61
Early Indicators: 13-24 mos. Red Flags: Significant differences between the ASD and TD groups, not the ASD and DD groups• Lack of response to contextual cues• Lack of pointing• Lack of vocalizations with consonants• Lack of playing with a variety of toys conventionally (Wetherby et. al., 2004) 62
Early Indicators: 2-4 yrs. Typically Developing Autistic Child Child • EEG does not• Pro-social behaviors differentiate between are very developed mother’s and stranger’s• Face recognition face registers on EEG • Social orientation, joint• Socially appropriate attention, attention to contingent or others’ distress still synchronized gazing lacking (Dawson et. al., 2004; Kabot et.• Plays with a variety of al., 2003; Dawson et. al., 2002) 63 toys conventionally
Considerations for Assessing Autistic Children • Gross and fine motor impairments are common among children with autism (Blackwell, 2001). – Motor stereotypes are also common, such as hand flapping, finger mannerisms, body rocking, or unusual posturing. – The severity of motor deficits is inversely related to IQ. • Sensory impairments include preoccupation with the sensory features of an object, over or underresponsiveness to particular stimuli, or inconsistent responses to sensory stimuli overall. • Attention disorders are present in nearly all autistic children to some degree (Rapin, 2002). – The manifestations are variable, though. Some are highly distractible and hyperactive, while others can demonstrate long attention spans but only for a select few activities which they find highly interesting.
Social Joint AttentionInitiate Joint Attention – IJA Responds to Joint Attention (RJA) (emerges 6-9 months) (emerges 3-6 months)
General Indicators of Autism: Sensory Processing• Sensitive startle response• Avoidance of eye gaze• Under responsiveness to startle stimuli• Unusual sleep patterns• Unusual or exaggerated fears• Dropping oneself on the floor• Excessive seeking of movement (Audet, 2004) 66
Abnormal Responses to Sensory Stimulation• Unlike normal individuals, autistic children have difficulty filtering out extraneous stimuli from their environment (sounds, lights, and skin sensations may be overwhelming for them).• --kids may throw tantrums to sounds, or try to repeat sounds as if enthralled with them.• --certain tactile sensations may be perceived as painful or itchy to the skin (tactile aversions).• Young autistic children appear to use senses of smell & taste, more than auditory or visual modalities to explore their world.• --Pain thresholds will vary, being very insensitive one minute to vary sensitive the next.
General Indicators of Autism: Motor Skills• Low muscle tone• Limited oral exploration or play• Excessive drooling• Prone to choke or gag• Limited food tolerance• Delayed development in gross and fine motor skills (Audet, 2004) 68
Making an Autistic Disorder Diagnosis• Frequently used criteria to make a diagnosis are:• Absence or impairment of imaginative and social play• Impaired ability to make friends with peers• Impaired ability to initiate or sustain a conversation with others• Stereotyped, repetitive, or unusual use of language• Restricted patterns of interests that are abnormal in intensity or focus• Apparently inflexible adherence to specific routines or rituals• Preoccupation with parts of objects
Early Indicators: 0-6 mos.Typically Developing Child Autistic Child• Head turns when name • Does not respond to is called social cues without• Matches the direction of repeated prompting a mom’s head turn to • Displays minimal the visible target affective responses• Starts to develop joint • More passive, quieter attention • May lag behind in• Attends to affective motor skills displays of others (Zwaigenbaum, 2005; Dawson et. al., 2004; Werner et. al., 2000)• Responds to emotions 70
Early Indicators: 7-12 mos.Typically Developing Child Autistic Child• Succeeds at joint • Greater incidence of attention unusual posturing• Seeks emotional • Needs more prompts to respond to name information from adult faces when presented • Mouthing of objects with uncertainty (social • Social touch aversion referencing) (Zwaigenbaum et. al., 2005; Dawson et. al., 2004; Werner et. al., 2000; Baranek, 1999) 71
Early Indicators: 7-12 mos. Typically Developing Autistic Child Child • Pays little attention to• Elementary vocal distress of others communication • Lacks of social smiling and appropriate facial• Early social imitation expressions skills • Unstable attention (Zwaigenbaum et. al., 2005; Dawson et. al., 2004; Werner et. al., 2000; Baranek, 1999) 72
Early Indicators: 13-24 mos. Typically Developing Autistic Child Child • Minimal responses to• Exhibits joint attention others (lack of empathy)• Engages in social • Does not exhibit relations pretend play (Dawson et. al., 2004; Kabot et. al., 2003; Robins et. al., 2001; Charman et. al., 1997) 73
Early Indicators: 13-24 mos. Typically Developing Autistic Child Child • Impaired joint• Communicates, both attention receptively and • Less gazing at people expressively • Absence of pre-• Shows greater linguistic functions (i.e. declarative incidences of pretend pointing, showing play objects) (Dawson et. al., 2004; Kabot et. 74 al., 2003; Robins et. al., 2001; Charman et. al., 1997)
Early Indicators: 2-4 yrs. Typically Developing Autistic Child Child • EEG does not• Pro-social behaviors differentiate between are very developed mother’s and stranger’s• Face recognition face registers on EEG • Social orientation, joint• Socially appropriate attention, attention to contingent or others’ distress still synchronized gazing lacking (Dawson et. al., 2004; Kabot et.• Plays with a variety of al., 2003; Dawson et. al., 2002) 75 toys conventionally
Considerations for Assessing Autistic Children • Language is delayed, distorted, or absent altogether in children with autism (Kanner, 1997). – This makes it likely that IQ scores will be misleading, as many subtests of cognitive assessments are verbal, or require a solution that would be enhanced by a verbal strategy – Some preschool dysphasic autistic students who turn out to possess normal intelligence once they learn to speak, are mislabeled as mentally deficient when initially assessed with language-loaded tests. – Nonverbal assessments, such as the Universal Nonverbal Intelligence Test (UNIT) can be effective in measuring cognitive functioning in autistic children without the danger of misdiagnosis based on speech-language impairments.
Autism as a developmental disorder: What is manifested as autism changes with development Development is affected by having autism It is important that the developmental Considering the cultural and family contextassessment: A childs life is embedded within a cultural and family context. When assessing children with possible develop-mentalbe individualized for each child disorders, including autism, it is essential toutilize procedures that are reproducible by consider: the familys cultureother professionals parent priorities parenting styles family support systemsfocus on the childs presenting problems In evaluating a child with possible autism, it(such as suspected delays or deviations in is important to recognize that there may be cultural and familial differences indevelopment or behavioral problems) expectations about such things as eye contact, play and social interaction, and pragmatic use of language.define the childs strengths and/or If English is not the primary language of thecompensatory abilities family, it is important for professionals to look for ways to communicate effectively with the family and the child, includingmake use of parents observations of their finding professionals and/or translators who speak the childs familys language(s)childs skills and behaviors
• Both positive (abnormal) behaviors, and negative (the absence of normal) behaviors are required to make a diagnosis of ASD.• This means that developmental level and contextual effects (in what kind of circumstances does the child or adult function?) can both have significant effects on diagnostic judgments.
Surveillance and screening• In the United States, states must follow federal Public Law 105-17: the Individuals with Disabilities Education Act Amendments of 1997– IDEA’97, which mandates immediate referral for a free appropriate public education for eligible children with disabilities from the age of 36 months, and early intervention services for infants and toddlers with disabilities from birth through 35 months of age.
For all Autistic Infants and Children: Diagnoisis of autism• Requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speech–language pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators.• Reevaluation within 1 year of initial diagnosis and continued monitoring is an expected aspect of clinical practice because relatively small changes in the developmental level affect the impact of autism in the preschool years.
For all Autistic Infants and Children: Speech, language,and communication evaluation• A comprehensive speech–language– communication evaluation should be Recommendations: performed on all children who fail language developmental screening procedures by a speech–language pathologist with training and Receptive 1 expertise in evaluating children with (ROWPVT-r; Gardner 1990) developmental disabilities.• Comprehensive assessments of both preverbal and verbal individuals should REEL-R (Receptive, account for age, cognitive level, and expressive, emergent, lanquage socioemotional abilities, and should include scale; Bzoch 91) assessment of receptive language and communication, expressive language and communication, voice and speech production, Language and in verbal individuals, a collection and Pathologist analysis of spontaneous language samples to supplement scores on formal language tests.
For all Autistic Infants and Children: Cognitive and adaptive behavior evaluations• Cognitive evaluations should be Recommendation: performed in all children with autism by a Raven’s Progressive psychologist or other trained professional. Matrices (Motiron 2007)• Cognitive instruments should be appropriate for the mental and chronologic Vineland Adaptive age, provide a full range (in the lower Behavior Scales direction) of standard scores and current (Sparrow, et. Al; 85) norms independent of social ability, include independent measures of verbal Differential Ability and nonverbal abilities, and provide an Scales (Elliott, 1990) overall index of ability.
For all Autistic Infants and Children: Sensorimotor and occupational therapy evaluations• Evaluation of sensorimotor skills by a Recommendations: qualified experienced professional Analysis of Sensory (occupational therapist or physical therapist) Behavior Inventory should be considered, including assessment ( Morton and Wolford, 94) of gross and fine motor skills, praxis, sensory processing abilities, unusual or stereotyped Audiometric mannerisms, and the impact of these components on the autistic person’s life. assessment• An occupational therapy evaluation is indicated when deficits exist in functional skills or occupational performance in the Complete areas of play or leisure, self-maintenance Medical through activities of daily living, or productive school and work tasks. Examination
For all Autistic Infants and Children: Neuropsychological, behavioral, and academic assessments• These assessments should be performed Recomendations: as needed, to include social skills and relationships, educational functioning, Bayley Scales of problematic behaviors, learning style, Infant Development II motivation and reinforcement, sensory functioning, and self-regulation.• Assessment of family resources should be performed by appropriate psychologists or other qualified health care professionals and should include assessment of parents’ level of understanding of their child’s condition, family (parent and sibling) strengths, talents, stressors and adaptation, resources and supports, as well as offer appropriate counseling and education.
Bayley Scales of Infant Development II (BSID-II)• Type of Test A standardized assessment of infant development. Purpose The test is intended to measure a childs level of development in three domains, cognitive, motor and behavioral. Age Range One month to 42 months old• Test Components The BSID-II consists of three scales: mental, motor and behavior rating scales. The test contains items designed to identify young children at risk for developmental delay.• Testing and Scoring Procedures The examiner presents test materials to the child and observes the childs responses and behaviors. Performance results can be expressed as a developmental age or developmental quotient.• Time for Administering Test The administration time ranges from 30 minutes to 60 minutes.• Standardization/Norms BSID normative data reflects the U.S. population in terms of race/ethnicity, infant gender, education level of parents and demographic location of the infant. The Bayley was standardized on 1,700 infants, toddlers, and preschoolers between 1 and 42 months of age. Norms were established using samples that did not include disabled, premature, and other at-risk children. Corrected scores may be used for these higher risk groups, but their use is controversial
For all Autistic Infants and Children:• Autism Society of America (ASA) 7910 Woodmont Avenue Bethesda, MD 20814 Web Site: http://www.autism-society.org/