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Preschool Assessment for Autism

Written by Pam MS, NCSP | Fact checked by Psychology Dictionary staff

prekautismMost 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 childs life (Baghdadli, Picot, Pascal,
Pry, & Aussilloux, 2003), with approximately 30% to 50% of parents noticing
issues in the first year or the childs life and about 80-90% noticing by the second
year (Baghdadli et al., 2003). A parents 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 childs
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.

Parent Interviews

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 semistructured 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).

Observations

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 childrens 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 Childrens 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.

Language Testing

Gathering data about a childs 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 preschoolers expressive and receptive
language ability.

Cognitive Testing

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 childs 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 childs lack of ability from the practitioners 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

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 (KellyVance & 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 childs 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 childs 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 (KellyVance & 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 childs 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 childs 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 childs 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.

Childs Talk is a third approach to intervention with children with ASD. Childs
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 Childs 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
childs parents, followed by regular consultation. Childs 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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Preschool Assessment for Autism