Most children affected by autism spectrum disorder (ASD) are not diagnosed or treated until preschool or early school age, though the first symptoms appear in the first or second year of life (Chawarska, Klin, & Volkmar, 2008). This discrepancy between the first signs of symptoms and diagnosis is dispiriting for both practitioners and parents alike. Fortunately, advances in research on diagnosis and treatment have been made over the past decade. It has become evident that early identification is relatively stable and that expedient initiation of services and treatment leads to improved outcomes for these children in terms of cognition, social skills, language and communication, and adaptive functioning. This paper attempts to integrate the most current knowledge regarding early manifestation of autism spectrum disorder, while highlighting the areas of clinical practice and research that remain unclear. It will also discuss some of the current issues related to classification, diagnosis, assessment and treatment of autism spectrum disorder young children, as well as some intervention that have gained empirical support for being effective.
Precipitated Parental Concern
A vast majority of parents of children with ASD first noticed behavioral oddities during the course of the first two years of their child’s life (Baghdadli, Picot, Pascal, Pry, & Aussilloux, 2003), with approximately 30% to 50% of parents noticing issues in the first year or the child’s life and about 80-90% noticing by the second year (Baghdadli et al., 2003). A parent’s first signs of concern typically appear when they notice speech and language delays. Atypical social receptivity and general difficulties related to attention, eating, and sleeping are among other most common first noted concerns (Chawarska et al., 2007). Parental distress may also surface in response to abnormal variations in development, such as noticeable slowing of development or regression of skills (Siperstein & Volkmar, 2004), either in speech or in social skills, imitation, or play skills (Davidovitch et al., 2000). The presence of concurrent cognitive delays, motor delays (DeGiacomo & Fombonne,1998), prenatal complications, or sensory deficits (Baghdadli et al., 2003) have also been associated with precipitated parental concern. When parents first approach the school for advice on how to handle their suspicions, it is important to investigate what parents have noticed thus far to get a sense of symptom severity and start brainstorming about how to best address their concerns and plan a fitting assessment.
Assessment of ASD in Preschool Children
As is the case with all assessments, accurate evaluations include multiple sources of data and informants. When assessing for childhood disorders, it is crucial to have a clear understanding of what constitutes typical behavior in a child of the same developmental level. Beyond those ground rules, assessing preschoolers for ASD looks much like any other assessment.
Developmental and Medical History
Common practice among practitioners is to send home a health and development survey to gain important information about the child under evaluation. This survey is vital because it aggregates information about language milestones, social behaviors, temperament, behaviors in the household, and motor skills. In order to make use of this information, an understanding of what is typical is necessary to glean important information from these questionnaires. For instance, a practitioner should know that language development during preschool years is moving at an alarming rate in typical children. Preschoolers are starting to build complex, informative sentences that link ideas, events, or pieces of information, that are usually about three to five words in length (Fields & Brown, 2007). They can categorize concrete concepts (Severe, 2002). They are able to use pronouns and have anywhere from 500 to 1000 words in their vocabulary (Fields & Brown, 2007). They also begin to develop an awareness of time and sequence, and begin using words such as “before” and “after,” and can understand words like, “in,” or “under.” Typically, they can recognize some letters of the alphabet (Fields & Brown, 2007). Preschoolers continually practice their language skills during social interaction, and begin to facilitate ideas like taking turns and judging the effects of their words on others (Thompson, Goodvin, & Meyer, 2006). Socially, they typically are able to engage in symbolic play, parallel play, and symbolic play. They can read basic body language like someone shaking their head, “no” (Field & Brown, 2007). A preschooler has also begun to conceptualize cause and effect, and the fact that external events can lead to emotions that produce specific behaviors (Thompson, Goodvin, & Meyer, 2006). Gross motor skills of a preschooler include, but are not limited to, the ability to kick a ball, throw a ball overhand, jump, balance on one foot, and ride a tricycle. Fine motor skills include demonstrating some sort of hand preference when writing and drawing people with about three to six body parts (Field & Brown, 2007). For more formal information about a child’s development, tools like the Bayley Scale of Infant and Toddler Development, Third Edition (Bayley-III; Bayley, 2006) and the Mullen Scales of Early Learning (Mullen Scales; Mullen, 1995) are widely used (Chawarska & Bearss, 2008). The Bayley-III has been designed for infants between 1 and 42 months of age, and consists of a cognitive, language, motor, social-emotional, and adaptive behavior scale. Normative data from 2004 included about 1,7000 children and results indicate strong validity and reliability (Chawarska & Bearss, 2008). The Mullen Scales are discussed in further detail later.
When looking at a potential case of ASD in a toddler, adult reports, particularly from the parent are very important. Parents, or guardians, usually have the most information to offer because of the extensive amount of time they spend with their preschoolers. Semi-structured interviews are good to use when assessing for ASD because the more structured format ensures that all of the necessary information is obtained. Since semi-structured interviews have a more conversational element to them, an evaluator can use this tool for the dual purposes of building rapport with a client and asking additional questions when parents offer extraordinary information during the questioning (Bishop & Lord, 2006). The Autism Diagnostic Interview-Revised (ADI-R; Le Couteur, Lord, & Rutter, 2003) and the Diagnostic Interview for Social and Communication Disorders (DISCO; Wing, Leekam, Libby, Gould, & Larcombe, 2002) are two widely used and well-established semi-structured interview tools for assessing toddlers for ASD. The ADI-R offers scores on communication, social reciprocity, and restricted/repetitive behaviors, and contains different calculations for verbal and nonverbal children. A downside to the ADI-R, however, is it takes about two to three hours to administer and tends to over-diagnose ASD in children with nonverbal mental ages under two. The DISCO is broader in scope, as it can be used to diagnose other developmental disorders aside from ASD, but it takes about the same amount of time to administer and has weaker psychometrics.
A new computer-based semi-structured tool is the Development, Diagnostic, and Dimensional Interview (3di; Skuse et al., 2004). The 3di is intended to assess autism severity and syndromes of comorbid conditions, so it is broader in scope than the ADI-R. Though it has high validity and reliability estimates, the original sample used to test the 3di had few preschool, nonverbal, and mentally retarded children. Therefore, Bishop and Lord (2006) suggest that the 3di be used in conjunction with a child observational assessment tool, like the Autism Diagnostic Observation Schedule (ADOS; Skuse et al., 2004).
An assessment for suspected ASD should not be decided upon before a child observation is made within a variety of social contexts (Bishop, Luyster, Richler, & Lord, 2008). Since the presence or absence of certain stimuli may or may not trigger the behaviors or reactions an assessor is looking for, setting up scenarios to elicit behaviors associated with ASD can provide information not available in other ways. The previously mentioned Autism Diagnostic Observation System (ADOS; Lord, Rutter, DiLavore, & Risi, 1999) is one practitioner-administered observation measure that assesses a number of areas in young children’s behavior (Bishop & Lord, 2006). The activities are play-based, so they reveal a lot about behavior when the child is happy and engaged. Aside from play behavior, the ADOS consists of various activities that allow you to observe communication behaviors related to the diagnosis of ASD. These activities can be completed in as little time as 35 to 40 minutes, but yield a great deal of information.
Questionnaires and Checklists
Social and communication impairments are also measureable through questionnaires and checklists (Bishop & Lord, 2006). These two can be used in conjunction with, or in place of, interviews when time is limited and access to interviewees is difficult. Some examples of questionnaires are the Childhood Autism Rating Scale (CARS; Schopler, Reichler, & Ro; 1980), the Gilliam Autism Rating Scale, Second Edition (GARS-2; Gilliam, 2006), the Autism Behavior Checklist in the Autism Screening Instrument for Educational Planning — Third Edition (ABC; Krug, Arick, & Almond, 2008), and the Children’s Communication Checklist, Second Edition (CCC-2; Bishop, 2003). The CARS is a diagnostic measure that was initially completed through practitioner observation, but is now often used as a parent checklist also. Brief, convenient, and suitable for use with any child over two years of age, the CARS was developed over a 15-year period with a normative sample of about 1,500 people. The ABC provides a checklist of 47 behaviors typical of autistic individuals for use during the initial screening process. This revised edition covers normed data for individuals between the ages of two through 13 years and 11 months. The GARS-2 assists practitioners in identifying autistic-like behaviors in individuals preschoolers through young adults. It also helps estimate the severity of the child's disorder. Items on the GARS-2 are based on the definitions of autism adopted by the Autism Society of America and the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition-Text Revision (DSM-IV-TR). GARS-2 was normed on a representative sample of over one thousand people with autism from 48 states within the United States, and has strong psychometric characteristics that were confirmed through studies of the test's reliability and validity. The CCC-2 allows one to screen for language impairments and verbal pragmatic impairments in children. The 70-item questionnaire screens for communication problems in children ages four to sixteen. The one major disclaimer about this measure is that it was normed in the United Kingdom.
Gathering data about a child’s language level is critical to assessing for ASD. Language ability can have important implications for both intervention and outcome in children with ASD. Language measures like the Reynell Developmental Language Scales (Reynell & Huntley, 1987), the Preschool Language Scales, Fourth Edition (PLS-4; Zimmerman, Steiner, & Pond, 2002), the Clinical Evaluation of Language Fundamentals – Preschool Edition (CELF-P; Wiig, Secord, & Semel, 1992) are all suitable for assessing a preschooler’s expressive and receptive language ability.
The Mullen Scales of Early Learning (Mullen, 1995) or the Differential Ability Scales (DAS, Elliott, 1990) are two assessment tools that yield nonverbal IQ scores that are not overly influenced by a child’s verbal abilities and are more appropriate for measuring intelligence in children with potentially severe language delays (Bishop & Lord, 2006). Using more traditional measures like the Wechsler Preschool and Primary Scales of Intelligence, Third Edition (WPPSI-III; Wechsler, 2002) is less appropriate because it does not take into account potential splinter skills in expressive and receptive language abilities. If the WPPSI-III is administered, additional language measurements may be need to be given as well to construct an accurate profile of verbal intelligence (Bishop & Lord, 2006).
Issues to Consider for Standardized Measures
Assessment tools presuppose a repertoire of abilities in their test taking populations, including comprehension of simple spoken language, which is not always characteristic of children with ASD. Moreover, some of the skills necessary for successful test taking are skills that many preschoolers with ASD have not yet developed. For example, even tests designed for very young children require the child to point to an object or picture to indicate a response choice, but many preschooler with ASD do not understand pointing or use it as a mode of communication. Another challenge of testing preschoolers with suspected ASD is that they are often quite difficult to engage, thus it is not always easy to distinguish the child’s lack of ability from the practitioner’s inability to engage the child in an activity (Bishop & Lord, 2006).
To increase the chance of a valid assessment, practitioners should create a testing environment in which the child is most likely to perform best. This can be accomplished by allowing sufficient time for the assessment, having a parent available for the child if needed, and not introducing too many new adults during the assessment. It is also useful to organize an assessment such that work is interspersed with play (Bishop & Lord, 2006).
Play assessment has been specifically mentioned as an appropriate way to evaluate the needs of young children by the National Association of School Psychologists. It has become increasingly popular because of the paradigm shift toward ecologically valid assessment, context based interventions, and progress monitoring (Kelly-Vance & Ryalls, 2008). Further, it is seen as a culturally sensitive practice. Though there are three types of play assessments mentioned by NASP, only one approach has been empirically tested to an acceptable degree. The Play in Early Childhood Evaluation System (PIECES; Fiscus, 2006). There are many consideration to account for before holding a play session. Settings like the child’s classroom or daycare are preferred, and the toys selected must match the gender, expected developmental level, and age of the child (Kelly-Vance & Ryalls, 2008). Toys should be visible and grouped together to encourage thematic play (Kelly-Vance & Ryalls, 2008). NASP endorses non-facilitated play, or free play with minimal direction because research shows that facilitated play sessions impacts standardization and often has no effect or a negative effect on the child’s play. Thus, child-centered play and verbal praise is preferred. In the PIECES assessment, children engage in free play for about 30-45 minutes while being videotaped, if possible. It yields a core subdomain, Exploratory/Pretend play, as well as many supplemental domains like problem-solving skills and planning, categorization, and quantitative skills. The information obtained from a coding procedure is then compared to norms of typically developing children, whereafter cognitive functioning estimates are produced and discrepancies are noted (Kelly-Vance & Ryalls, 2008).
Evidence Based Interventions
After a child has been diagnosed with ASD and data about his or her intelligence, language level, social skills, and associated psychological and medical conditions have been gathered, recommendations should be made to the child’s family about appropriate services, useful strategies, and relevant goals. Since symptoms are so variable, there is no single intervention or combination of interventions that will be best for every child with ASD. Thus the child’s individual profile, rather than the diagnosis of ASD itself, should be the basis for design and implementation of intervention.
Despite limited research comparing the effectiveness of different interventions for children with ASD, there is no shortage of treatments claiming to be effective. Whereas some of these interventions are based on widely accepted theories about the core deficits of ASD, others have little or no scientific basis and are viewed as generally ineffective (Dawson & Watling, 2000). The most consistent findings in the treatment literature suggest applied behavioral analysis is the most dependable approach (Faja & Dawson, 2006). Naturalistic ABA approaches have been gaining popularity, especially since the infamous Discrete Trial Training (DTT) approach has been criticized as not being generalizable. Incidental teaching has emerged from this criticism. Incidental teaching tries to create controlled, yet comfortable and natural environments for the child in which learning can occur by expanding the child’s spontaneous behaviors within more developmentally appropriate behaviors (Faja & Dawson, 2006). Practitioners try to prompt an elaboration of the initial behavior done by the child, for which the child gains contingent access to a desired item or activity and receives praise. The Walden model incorporates these practices in the classroom and home environments. The Walden Toddler Model at Emory University (McGee et al., 1999) is designed for very young children with autism, and research is indicating this intervention model is effective in increasing langue and social functioning (Faja & Dawson, 2006), especially when used with other ABA techniques like DTT.
Empirical support has also been derived for the Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH) model. This program typically takes place in a classroom setting that is engineered to use the strengths and compensate for the weaknesses associated with autism (Faja & Dawson, 2006). Predictability and routine are used to create a structured environment to promote self-reliance. For example, one structured piece of this program is student location. The TEACCH classroom makes use of the seating of students and may begin by placing children in individual carrels, to help eliminate distraction. Gradually, the child may get moved to a table with dividers, and eventually to an open table with other students. Parents are heavily engaged in the process, directed to trainings which offer psychoeducation (Faja & Dawson, 2006). Research has shown that this method combined with DTT and other Lovaas-based day treatments resulted in significantly better school functioning (Ozonoff & Cathcart, 1998) in preschoolers with autism.
Child’s Talk is a third approach to intervention with children with ASD. Child’s Talk focuses on core social and communication deficits in autism, and is predominantly designed for use with children with lower language functioning. A major difference in Child’s Talk is that parents are the key therapists. This model perceives parents as the ones with the most investment in, and resources for, the child and targets them in treatment through the use of video feedback. Recordings of parent-child interactions are reviewed and scanned for specific dyadic patterns. These patterns are then examined, and strategies are developed to improve specific aspects of the parent-child communication system that seem faulty. This method not only invests more in the parents, which increases the likelihood the child receives consistent therapy, but it informs the parents on how to adjust their communication and interaction patterns as their child develops and matures. Shared attention, modeling, adapted communication, and parental sensitivity and responsiveness are emphasized. Treatment starts with psychoeducation for the child’s parents, followed by regular consultation. Child’s Talk may be used to complement other treatments, but research shows it is responsible for significant improvements in symptom severity, expressive language, opening circles of communication, and parent-child interaction (Faja & Dawson, 2006).
Other intervention practices which have had some positive effect on children with ASD include speech therapy, occupational therapy, music therapy, social skills training, and Floor Time. Current research suggests that children with ASD should be aggressively enrolled in special therapy for at least 20-25 hours a week (National Research Council, 2001). Rather than selecting a single type of therapy, many experts suggest finding a good combination of practices to tailor an intervention to fit the individual needs of the preschooler. Taking that multidisciplinary and multi-method approach, parents of children with ASD should enroll their children in a number of different treatments or educational program, in addition to regular preschool (Bishop & Lord, 2006).
As evident by the myriad of assessment procedures and intervention practices that have psychometric support and empirical research backing their value, the autism spectrum disorder has been a major focus of the psychoeducational profession for quite some time. The good news is that children are receiving early intervention at a younger age than ever before, and positive outcomes are increasing. Hopefully, with the same rate of research and support, the disorder will no longer plague our population, and children will no longer have to suffer though language impairments, behavioral oddities, and social rejection. The future looks bright for those with autism spectrum disorder.
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