Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social communication and social interaction and the presence of restricted, repetitive behaviors. Social communication deficits include impairments in aspects of joint attention and social reciprocity, as well as challenges in the use of verbal and nonverbal communicative behaviors for social interaction. Restricted, repetitive behaviors, interests, or activities are manifested by stereotyped, repetitive speech, motor movement, or use of objects; inflexible adherence to routines; restricted interests; and hyper- and/or hypo-sensitivity to sensory input.
This definition is consistent with the diagnostic criteria for ASD detailed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association, 2013). The criteria specified in the DSM-5 reflect a number of changes from those in the DSM-IV, the most notable of which are
- elimination of the Pervasive Developmental Disorders category that included diagnoses of Autistic Disorder, Asperger's Disorder, Childhood Disintegrative Disorder, Rett's Disorder, and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS). The DSM-5 criteria for ASD encompass the social and behavioral deficits typically associated with these populations (Note: The DSM-5 lists Rett syndrome as a separate diagnosis in which disruptions of social interaction may be observed during the regressive phase);
- omission of criteria related to delay in or lack of development of spoken language and, instead, allowance for the clinician to specify whether ASD occurs "with or without accompanying language impairment";
- change in age of onset from "prior to 3 years" to the presence of symptoms "in the early developmental period";
- recognition of unusual reactions to sensory input (e.g., hyper- or hypo-reactivity to sensory input, unusual interest in sensory aspects of environment).
According to the DSM-5, individuals who meet the specified criteria are given the diagnosis of "autism spectrum disorder (ASD)" with one of three levels of severity. Level of severity is defined in terms of the amount of support needed in the area of social communication and with restricted, repetitive behaviors, recognizing that severity may vary by context and fluctuate over time. Severity ratings are used for descriptive purposes only and not to diagnose or determine eligibility for services (American Psychiatric Association, 2013). See Paul (2013) for a more detailed discussion of DSM-5 changes and potential practice implications.
The scope of these pages includes ASD across the lifespan. For more detailed information and resources about social communication disorders in school-age children (5-21), including information about social communication deficits without repetitive behaviors, see the Social Communication Disorders Practice Portal page.
Impact of DSM-5 on Practice
There is some research to suggest that most individuals previously diagnosed with pervasive developmental delay (PDD) based on DSM-IV criteria would also receive a diagnosis of ASD using DSM-5 criteria (Huerta, Bishop, Duncan, Hus, & Lord, 2012). Additional research will be needed to evaluate the impact of the new DSM-5 criteria on the diagnosis of ASD.
It is important to differentiate between ASD and social communication disorders (i.e., difficulty with social communication skills—including pragmatic language—but without restricted or repetitive patterns of behavior). Speech-language pathologists (SLPs) will be instrumental in making this differential diagnosis and ensuring that individuals with ASD and those with social communication disorders gain access to services.
In addition, SLPs will need to advocate for inclusion of language intervention for individuals diagnosed with ASD and ensure that individuals with ASD also receive a diagnosis of language disorder (LD), when they meet the criteria. Regardless of the presence or absence of difficulties acquiring the form and content of language, all individuals with ASD are eligible for speech-language pathology services due to the pervasive nature of the social communication impairment.
Challenges Faced by the Communication Partner
At its core, communication is a social process; therefore, the social communication issues experienced by individuals with ASD also impact their communication partners. Family members, friends, teachers, SLPs, and other service providers who interact with someone with ASD are faced with the challenge of learning to respond to subtle bids for communication, interpreting the functions of problem behavior, and modifying the environment to foster active, social engagement. Peers often feel ineffective when engaged in social exchanges with an individual with ASD and may avoid that person and/or react in a negative way (e.g., teasing or bullying) to social overtures, which can have a negative impact on the development of appropriate social skills.
Given the challenges experienced by communication partners, treatment considers the whole range of service delivery models, including traditional pull-out; home-, classroom-, and community-based models; and collaborative consultation models. Service delivery focuses on natural learning environments and includes education and training of family members, teachers, peers, and other professionals.
The goal of family-centered practice is to create a partnership so that the family fully participates in all aspects of the individual's care. The participation of families in services aimed at addressing the needs of the individual with autism can serve to ameliorate the stress experienced by family members (National Research Council [NRC], 2001).
Cultural, linguistic, and socioeconomic factors affect families' access to and selection and usage of services. The range of services offered include counseling, education and training, coordination of services, and advocacy for practices that incorporate family preferences and address family priorities.
Through this partnership, support may take different forms at different times, including coordinating services for the family, procuring resources and information, teaching the family or other significant communication partners specific skills, and advocating for or with the family. It can also result in greater consistency in activities and routines across different contexts and communication partners. See family-centered practice.
Incidence and Prevalence
In 2010, overall estimated ASD prevalence was 14.7 per 1,000 (1 in 68) children age 8 years (U.S. Centers for Disease Control and Prevention [CDC], 2014).
Reported prevalence rates have been rising steadily since the 1960s, and it is not completely clear to what extent this is reflective of a true increase in prevalence or increased awareness of ASD and its diagnosis. For example, studies with access to both school and health records have found substantially higher rates than those with access to health records only. Some researchers believe that the increased prevalence of ASD may reflect changes in practices for diagnosing autism. For example, the likelihood of receiving a diagnosis of ASD increased as children with an earlier diagnosis of intellectual disability (ID) subsequently acquire the diagnosis of ASD (King & Bearman, 2009; Shattuck, 2006).
It has been established that prevalence varies by gender and race/ethnicity. The CDC study found that prevalence was 18.4 per 1,000 (1 in 54) among males and 4.0 per 1,000 (1 in 252) in females. Prevalence among non-Hispanic white children (12.0 per 1,000) was significantly greater than among non-Hispanic black children (10.2 per 1,000) and Hispanic children (7.9 per 1,000). Given that there are no clearly documented differences between these groups in terms of risk factors for ASD, disparities in prevalence estimates suggest under-identification among Hispanic and non-Hispanic black children. Insufficient data were available for children of Asian/Pacific Island descent.
Signs and Symptoms
The population of ASD presents with tremendous heterogeneity. Individuals can have abilities ranging from significant cognitive and language impairments (e.g., nonverbal) to superior cognitive and language abilities (e.g., college- and career-bound). However, regardless of these differences, the common characteristics and challenges associated with ASD impact the development of critical social communication skills.
The core features of ASD [PDF] include (a) impairments in social communication, language, and related cognitive skills and behavioral and emotional regulation and (b) the presence of restricted, repetitive behaviors. These core features are significantly influenced by an individual's developmental level of language acquisition (e.g., pre-symbolic, emerging language, and conversational language) and the level of severity of the disorder. In addition to these core features, sensory and feeding issues can also be present.
Awareness of individual and cultural differences is necessary to differentiate differences from disordered behaviors. For example, direct eye contact with an authority figure may be considered disrespectful due to cultural influences, and silence may be valued as a sign of respect. In a U.S. school system, these behaviors could easily be misinterpreted as socially inappropriate and a warning sign or symptom of a disorder such as ASD. When observing signs and symptoms, an SLP must be sure to account for cultural factors that influence social communication skills.
The following is a list of signs and symptoms common to ASD. Specific areas of deficit will vary; no one individual will have every sign and symptom.
Deficits in joint attention include
- difficulty orienting to people in a social environment,
- limited frequency of shared attention,
- impaired monitoring of emotional states,
- restricted range of communicative functions to seek engagement and comfort from others,
- limitations in considering another's intention and perspective.
Deficits in social reciprocity include
- difficulty initiating and responding to bids for interaction,
- limitations with maintaining turn-taking in interactions,
- problems with providing contingent responses to bids for interaction initiated by others.
Social cognition refers to the mental processes involved in perceiving, attending to, remembering, thinking about, and making sense of the people in our social world (Moskowitz, 2005).
Deficits in social cognition include
- deficits in social and emotional learning including difficulty
- managing emotions,
- appreciating the perspectives of others,
- developing prosocial goals,
- using interpersonal skills to handle developmentally appropriate tasks
(Payton et al., 2000);
- difficulty differentiating one's own feelings from the feelings of others (i.e., Theory of Mind);
- difficulty integrating diverse information to construct meaning in context (i.e., central coherence) (Frith & HappÈ, 1994).
Deficits in language and related cognitive skills include
- impaired acquisition of words, word combinations, and syntax—
- initial words are often nouns and attributes, while words representing social stimuli, such as people's names (i.e., subjects) and actions (i.e., verbs), are delayed;
- the child loses words previously acquired;
- use and understanding of nonverbal and verbal communication—
- facial expressions, body language, and gestures as forms of communication are delayed in the latter part of the first year of life and remain unconventional throughout development;
- unconventional gestures (e.g., pulling a caregiver's hand toward an item) emerge prior to more conventional gestures (e.g., giving, pointing, and head nods/headshakes);
- understanding of gaze shifting, distal gestures, facial expressions, and rules of proximity and body language is limited;
- receptive language appears more delayed than expressive;
- use of immediate echolalia and/or delayed echolalia (scripted language) is observed;
- vocal development deficits, including
- atypical response to caregiver's vocalizations,
- atypical vocal productions beyond the first year of life,
- abnormal prosody once speech emerges (speech may sound robotic);
- symbolic play deficits, including
- delayed acquisition of functional and conventional use of objects,
- repetitive, inflexible play,
- limited cooperative play in interactive situations;
- conversation deficits, including
- limitations in understanding and applying social norms of conversation (e.g., balancing turns, vocal volume, proximity, and conversational timing);
- provision of inappropriate and unnecessary information in conversational contexts;
- problems taking turns during conversation;
- difficulty initiating topics of shared interest;
- preference for topics of special interest;
- difficulties in recognizing the need for clarification;
- challenges adequately repairing miscommunications;
- problems understanding figurative language, including idioms, multiple meanings, and sarcasm;
- literacy deficits, including difficulty
- reading for meaning (functional use of books),
- understanding narratives and expository text genres that require multiple perspectives (e.g., persuasive and comparative/contrastive),
- getting the main idea and summarizing,
- providing sufficient information for the reader when writing;
- executive functioning deficits, including
- lacking/limited flexibility,
- poor problem solving,
- poor planning and organization,
- lack of inhibition.
Deficits in behavior and emotional regulation, including
- problems dealing with changes in routine and/or changing from one activity to the next;
- problems generalizing learned skills;
- using objects in unusual ways and uncommon attachments to objects;
- difficulty sleeping;
- crying, becoming angry, or laughing for no known reason or at inappropriate times;
- anxiety and/or social withdrawal (possibly due to factors such as misinterpretation of social events and failure to identify salient or irrelevant information);
- using early-developing and/or idiosyncratic strategies for self-regulation (e.g., chewing on clothing, rocking, hand flapping, vocal play);
- using unconventional behavioral strategies and emotional expressions (e.g., aggression, tantrums, bolting from situations);
- restricted, repetitive patterns of behavior, interests, or activities (e.g., immediate echolalia and scripted language);
- problems with self-management.
Sensory and feeding challenges, include
- sensory modality difficulties, including over-responsiveness, under-responsiveness, or mixed responsiveness patterns to environmental sounds, light, visual clutter, and social stimuli (e.g., social touch, proximity of others, voices);
- preference for nonsocial stimuli leading to intense interests with sensory aspects of objects and events;
- patterns of food acceptance or rejection based on manner of presentation or food texture;
- consumption of a smaller variety of foods than the variety consumed by other family members.
In addition to adults diagnosed with ASD as children, some live with undiagnosed or newly diagnosed ASD. Some of these individuals may seek out various supports and services (e.g., vocational/career counseling), particularly when they begin to experience problems in work and/or social settings. When a diagnosis of ASD is presented to a previously undiagnosed individual, it is essential that this be done with the utmost sensitivity.
For transitioning adolescents and adults with ASD, social communication is a particularly important skill area to consider. For example, social communication is important in the "peer arena," where adolescents explore different relationships and learn about friendship, loyalty, and individual differences (Seltzer, 2009). Communication rules in adolescent social interactions are often subtle and unspoken, and successful navigation within social settings requires awareness of these rules. In addition, the social, emotional, and critical thinking demands during adolescence are constantly evolving; managing these demands can be challenging for all adolescents, including students with social learning challenges such as ASD (Winner & Crooke, 2011). Similar social communication skills are important for young adults with ASD in workplace interactions with supervisors, coworkers, and the public. Other areas of importance include executive functioning and problem-solving skills needed to achieve greater independence in all settings.
Autism spectrum disorders (ASD) is typically diagnosed on the basis of behavioral symptoms, without reference to etiology. However, considerable research has been devoted to investigations of etiological factors. While no single cause has been identified, the available data suggest that autism results from different sets of causal factors—including genetic, neurobiological, and environmental—that manifest in characteristic behavioral symptoms.
It is largely agreed that ASD is the result of hereditable genetic differences and/or mutations, although not all children can be identified as having a genetic linkage or mutation that is obvious to family members. Findings in support of a genetic link include research results showing that ASD is more common in boys than girls—most likely due to genetic differences associated with the X chromosome (Chakrabarti & Fombonne, 2005)—and twin studies that show a 60% to 90% rate of concordance for identical twins compared with a 0% to 10% rate of concordance for fraternal twins (Bailey et al., 1995). In a study conducted by Ozonoff et al. (2011), almost 20% of infants with an older biological sibling with ASD also developed ASD; the risk for developing ASD was greater if there was more than one older affected sibling.
Given the current availability of rapid, precise gene-sequencing tools and the accessibility of large numbers of DNA samples, significant progress in identifying genetic factors associated with ASD has been made (Coe, Girirajan, & Eichler, 2012; lossifov et al., 2012; Neale et al., 2012; O'Roak et al., 2012; Sanders et al., 2012).
Abnormalities in the genetic code may result in abnormal mechanisms for brain development, leading in turn to structural and functional brain abnormalities, cognitive and neurobiological abnormalities, and symptomatic behaviors (Williams, 2012).
Neurobiological differences associated with a diagnosis of ASD include
- problems with genetic code development involving multiple brain regions, including frontal and anterior temporal lobes, caudate, and cerebellum (Abraham & Geschwind, 2010);
- structural and functional abnormalities of the brain, including
- increased gray matter in the frontal and temporal lobes (Carper & Courchesne, 2005; Hazlett, Poe, Gerig, Smith, & Piven, 2006; Palmen et al., 2005),
- decreased white matter compared with gray matter by adolescence (Volkmar, Lord, Bailey, Schultz, & Klin, 2004),
- anatomical and functional differences in the cerebellum and in the limbic system (Volkmar et al., 2004);
- differences in the brain's response to the environment, including
- decreased neural sensitivity to dynamic gaze shifts in infancy (Elsabbagh et al., 2012);
- preference for nonsocial versus social processing and hemispheric asymmetries in event-related potentials (ERPs; McCleery, Askchoomoff, Dobkins, & Carver, 2009);
- disruptions in normative patterns of social neurodevelopment that contribute to a diminished attention to social stimuli (Jones, Carr, & Klin, 2008).
Given the complexity of autism risk, researchers have begun to investigate how pre- and post-natal environmental factors (e.g., dietary factors, exposure to drugs and environmental toxicants) might interact with genetic susceptibility to ASD. A number of environmental exposures have been indentified for future study, including lead, polychlorinated biphenyls (PCBs), insecticides, automotive exhaust, hydrocarbons, and flame retardants (Landrigan, Lambertini, & Birnbaum, 2012; Shelton, Hertz-Picciotto, & Pessah, 2012). However, no specific environmental triggers have been identified at this time.
Research focused on the environmental risks involved with the development of ASD is quite complicated, as researchers must include how the environmental factors interact with individual genetic information.
Roles and Responsibilities
Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of persons with ASD. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (2007).
Appropriate roles for SLPs include
- providing information to individuals and groups known to be at risk for ASD, to their family members, and to individuals working with those at risk;
- educating other professionals on the needs of persons with ASD and the role of SLPs in diagnosing and managing ASD;
- screening individuals who present with language and communication difficulties and determining the need for further assessment and/or referral for other services;
- conducting a culturally and linguistically relevant comprehensive assessment of language and communication, including social communication skills;
- assessing for the need for and requirements for using augmentative and alternative communication (AAC) devices as a mode of communication;
- diagnosing the presence or absence of ASD ( typically as part of a diagnostic team or in other multidisciplinary collaborations);
- referring to other professionals to rule out other conditions, determine etiology, and facilitate access to comprehensive services;
- making decisions about the management of ASD;
- participating as a member of the school planning team (e.g., whose members include teachers, special educators, counselors, psychologists) to determine appropriate educational services;
- developing treatment plans for speech and language services, including social language goals and goals for literacy development and for assisting the student with self-regulatory and social interactive functions to allow him/her to participate in the mainstream curriculum to as great an extent as possible;
- providing treatment, documenting progress, and determining appropriate dismissal criteria;
- providing training in the use of AAC devices to persons with ASD, their families and caregivers, and educators;
- counseling persons with ASD and their families regarding communication-related issues and providing education aimed at preventing further complications related to ASD;
- consulting and collaborating with other professionals, family members, caregivers, and others to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate;
- partnering with families in assessment and intervention with individuals with ASD;
- remaining informed of research in the area of ASD and helping advance the knowledge base related to the nature and treatment of ASD;
- advocating for individuals with ASD and their families at the local, state, and national levels;
- serving as an integral member of an interdisciplinary team working with individuals with ASD and their families/caregivers and, when appropriate, considering transition planning;
- providing quality control and risk management.
There is great heterogeneity in the ASD population, evidenced by the broad range of cognitive, social, communication, motor, and adaptive abilities. Some individuals with ASD have intellectual disabilities, while others have intellectual functioning within the normal range. Individuals with ASD, regardless of intellectual functioning, have a developmental disability that affects social communication skills and can limit independence in home, school, work, and community environments and participation in social networks.
As indicated in the Code of Ethics (ASHA, 2010), SLPs who serve this population should be specifically educated and appropriately trained to do so.
Interdisciplinary collaboration in assessing and diagnosing ASD is important due to the complexity of the disorders, the varied aspects of functioning affected, and the need to distinguish ASD from other disorders or medical conditions. Ideally, the role of the SLP is as a key member of an interdisciplinary team whose members possess expertise in diagnosing ASD. In cases when there is no appropriate team available, an SLP, who has been trained in the clinical criteria for ASD and who is experienced in the diagnosis of developmental disorders, may be qualified to diagnose these disorders as an independent professional (Filipek et al., 1999).
Some state laws or regulations may restrict the scope of practice of licensees, however, and prohibit the SLP from providing such diagnoses. SLPs should check with their state licensure boards and/or departments of education for specific requirements.
In most cases, a stable diagnosis of ASD is possible before or around a child's second birthday (Chawarska, Klin, Paul, Macari, & Volkmar, 2009). An early, accurate diagnosis can help families access appropriate services, provide a common language across interdisciplinary teams, and establish a framework for families and caregivers within which to understand the child's difficulties. Any diagnosis of ASD, particularly of young children, is periodically reviewed, as diagnostic categories and conclusions may change as the child develops.
Interdisciplinary collaboration and family involvement are essential in assessing and diagnosing ASD; the SLP is a key member of a multidisciplinary team. In diagnosing ASD, it is important to have clinical experts agree that assessment results are consistent with the diagnostic characteristics of the disorder.
Assessment, intervention, and support for individuals receiving speech and language services are consistent with the World Health Organization's International Classification of Functioning, Disability, and Health (2001) framework. This framework considers impairments in body structures/functions, the individual's communication activities and participation, and contextual factors, including environmental barriers/facilitators and personal identity.
See the Assessment section of the autism evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
There is evidence to suggest that diagnostic features of ASD are evident in very young children. Most families/caregivers report observing symptoms within the first 2 years of life and typically express concern by 18 months of age. Studies of children with ASD have found
- parental reports of abnormalities in their children's language development and social relatedness were first noticed at about 14 months of age (Chawarska et al., 2007);
- displays of significantly fewer joint attention and communication behaviors at 1 year of age than shown by their typically developing same-age peers (Osterling & Dawson, 1994; Werner & Dawson, 2005);
- demonstrated atypical eye contact, passivity, decreased activity level, and delayed language by 12 months of age (Zwaigenbaum et al., 2005);
- subtle differences in sensory-motor and social behavior (Baranek, 1999) as well as differences in the use of communicative gestures (Watson et al., 2013) by 9 to 12 months of age;
- a decline (from normative levels) in eye fixation from 2 to 6 months of age not observed in infants who did not develop autism (Jones & Klin, 2013).
The identification of early behavioral indicators can help families obtain appropriate diagnostic referrals and access early intervention services, even before a definitive diagnosis is made (Woods & Wetherby, 2003). Furthermore, early intervention can improve long-term outcomes for many children (Dawson & Osterling, 1997; Harris & Handleman, 2000; Landa & Kalb, 2012).
There is research on the use of screening tools, including a broadband screener to identify communication delays (including ASD) in children from 9 to 24 months of age (Pierce et al., 2011; Wetherby, Brosnan-Maddox, Peace, & Newton, 2008) and questionnaire-based tools to screen for children at risk for ASD as early as 12 months of age (Turner-Brown, Baranek, Reznick, Watson, & Crais, 2012). There are also a number of algorithms and tools available to help physicians develop a strategy for early identification of children with ASD (Johnson & Myers, 2007).
Cultural and linguistic variables may contribute to challenges in identifying children with ASD and contribute to the disparity in the diagnosis of ASD among some racial/ethnic groups (Begeer, El Bouk, Boussaid, Terwogt, & Koot, 2009; Dyches, 2011). For example, Begeer et al. (2009) found that Dutch pediatricians might be inclined to attribute social and communication problems of non-European minority groups to their ethnic origin, while attributing these same characteristics to autistic disorders in children from majority groups.
While the core characteristics of ASD are common across cultures, parental response to the symptoms are not; these characteristics may be viewed through a cultural lens leading to under-, over-, or mis-diagnosis (Dyches, Wilder, & Obiakor, 2001). Signs and symptoms that are clearly "red flags" in the U.S. health care or educational system may not be viewed in the same way for someone from a culture that may not define the disorder.
One factor contributing to the inaccurate classification and diagnosis of students with autism is the "families' cultural and linguistic interpretation and reaction to receiving the diagnosis and to obtaining services" (Wilder, Dyches, Obiakor, & Algozzine, 2004, p. 106). Some cultures view disability in a negative light and feel that it is something that needs to be hidden from others, which may influence the type of care the family seeks. See cultural competence and the table of diverse perspectives on symptoms of autism [PDF] (Dyches, 2011).
Screening for ASD includes broadband screeners designed to detect developmental delays in the general pediatric population and autism-specific screening tools designed for either the general population or high-risk populations, such as children referred to the early intervention system. Any screening tool should have strong psychometric features to support its accuracy and be culturally and linguistically appropriate.
Screening typically includes
- norm-referenced parent and teacher report measures,
- competency-based tools, such as interviews and observations,
- hearing screening to rule out hearing loss as a contributing factor to communication and behavior difficulties.
Screening procedures evaluate the main characteristics that differentiate ASD from other developmental disorders, including difficulties in
- eye gaze,
- orienting to one's name,
- pointing to or showing objects of interest,
- pretend play,
- nonverbal communication,
- language development.
Social communication norms vary across cultures. When screening is conducted for non-linguistic aspects of communication, it is important to recognize when differences are related to cultural variances rather than secondary to a communication disorder. See cultural competence.
Loss of language or social skills at any age should be considered grounds for screening. In cases where children are being raised in a bilingual environment, consider whether language loss is attributable to language attrition. See bilingual service delivery.
Because children with ASD are often initially suspected of having a hearing problem, audiologists play a critical role in recognizing possible signs of ASD in children whose hearing they test and making appropriate referrals for screening and diagnosis of ASD.
- There are several tools currently being developed to screen children "at risk" for autism who are younger than 18 months; however, no tools are currently available for clinical use. Although many level 2 screening tools (i.e., tools that are used in developmental clinics and early intervention programs as opposed to primary care facilities) have been marketed for identification of older at-risk children, these tools require further comparative research before one can be recommended over another (Johnson & Myers, 2007, p. 1199).
- Researchers are encouraged to "develop and validate appropriate autism screening tools with adequate sensitivity and specificity in children younger than 1 year of age that could be used by a wide range of practitioners" (Filipek et al., 2000, p. 5).
Individuals suspected of having ASD based on screening results are referred to an SLP, and other professionals as needed, for a comprehensive assessment. Assessment of social communication skills should be culturally sensitive, functional, and sensitive to the wide range of acceptable social norms that exist within and across communities; and involve the collaborative efforts of families, caregivers, classroom teachers, SLPs, special educators, and psychologists as needed.
The SLP's role includes incorporating a family perspective into the assessment, effectively eliciting information from families about their concerns, beliefs, skills, and knowledge in relation to the individual being assessed. It is important to convey information to families clearly and empathetically, with an understanding that the assessment and diagnosis process is likely to be stressful and emotion-laden for family members (Marcus, Kunce, & Schopler, 2005).
The diagnostic evaluation for individuals at risk for ASD typically includes
- relevant case history, including information related to the child's health, developmental and behavioral history, and current medical status;
- a medical evaluation, including general physical and neurodevelopmental examination, as well as hearing and vision testing;
- medical and mental health history of the family;
- a comprehensive speech and language assessment.
In addition, diagnostic evaluation may include
- genetic testing, particularly if there is a family history of intellectual disability or genetic conditions associated with ASD (e.g., fragile X, tuberous sclerosis) or if the child exhibits physical features suggestive of a possible genetic syndrome;
- metabolic testing, if the child exhibits symptoms such as lethargy, cyclic vomiting, pica, or seizures.
Speech and Language Assessment
Depending on the individual's age and abilities, the SLP typically assesses
- receptive language;
- expressive language, including sound and word production and the frequency and function of verbal (vocalizations/verbalizations) and nonverbal (e.g., gestures) communication;
- literacy skills;
- social communication (See social communication disorders and social communication benchmarks [PDF]), including
- use of gaze,
- joint attention,
- initiation of communication,
- social reciprocity and the range of communicative functions,
- sharing affect,
- play behaviors,
- use of gestures;
- conversational skills, including
- topic management (initiating, maintaining, and terminating relevant, shared topics);
- providing appropriate amounts of information in conversational contexts;
- speech prosody.
Comprehensive assessment for ASD typically includes the following.
STANDARDIZED ASSESSMENT—an empirically developed evaluation tool with established reliability and validity. Formal testing may be useful for assessing the structure and form of language, but may not provide an accurate assessment of an individual's use of language (i.e., pragmatics). Standardized tests should be culturally and linguistically appropriate, and standard scores should not be determined if the norming sample is not representative of the individual assessed.
PARENT/TEACHER/SELF-REPORT MEASURES—rating scales, checklists, and/or inventories completed by the family member(s)/caregiver, teacher, and/or individual. Findings from multiple sources (e.g., family vs. teacher vs. self-report) may be compared to obtain a comprehensive profile of communication skills. When possible, parent checklists should be provided in their native language to obtain the most accurate information.
ETHNOGRAPHIC INTERVIEWING—an interview technique that uses open-ended questions, restatement, summarizing for clarification, and avoidance of leading questions and "why" questions in order to develop an understanding of the individual's and the family's perceptions, views, desires, and expectations. See cultural competence.
ANALOG TASK(S)—observation of the individual in simulated or staged communication contexts that mimic real-world events, including peer-group activities and simulated workplace interactions.
NATURALISTIC OBSERVATION—observation of the individual in everyday social settings with others. Criterion-referenced assessments may be used during naturalistic observations to document an individual's functional use of language across social situations.
DYNAMIC ASSESSMENT—a method that seeks to identify an individual's skills as well as his or her learning potential. Dynamic assessment is highly interactive and emphasizes the learning process over time. It can be used in conjunction with standardized assessments and for ongoing assessment following the diagnosis of ASD.
Assessment may result in
- data that contribute to the diagnosis of ASD;
- description of the characteristics and severity of communication-related symptoms;
- recommendations for intervention, priorities and goals, and supports;
- referral to other professionals for further testing if other disorders/conditions are suspected or for additional data to confirm the diagnosis of ASD.
- Evidence indicates that, for adults with autism, a comprehensive assessment for autism should occur if two or more of the following behaviors are present: difficulties in reciprocal social interaction, lack of responsiveness to others, little or no change in behavior in response to different social situations, limited social demonstration of empathy, rigid routines and resistance to change, and marked repetitive activities (National Collaborating Centre for Women's and Children's Health, 2011).
- "Assessment of social interaction and relationships includes evaluation of: social initiation (such as showing or giving objects to others for social purposes), social imitation (such as imitating actions of others), age-expected reciprocity (such as turn-taking during play), the child's attachment patterns in the presence of a caregiver (such as neutrality, excessive clinging, or avoidance of parent), the child's tendency for social isolation or preference to be alone, the child's use of people as tools to obtain desired ends (such as taking adult's hand to reach for a toy), and social interactions with familiar as well as unfamiliar adults and peers" (New York State Department of Health Early Intervention Program, 1999, p. III-72).
- "An initial framework of assessment should include communication strategies, social interaction and joint attention; learning potential and preferred learning style; readiness to engage, listen and attend, and play skills, as well as receptive and expressive competencies" (NIASA & Le Couteur, 2003, p. 36).
- "Assessments/evaluations should include information from the parent(s); data from previous interventions; criterion-referenced assessments; curriculum-based assessments; standardized, norm-referenced tests; structured interviews; and structured observations" (Autism Task Force, 2003, p. 24).
- "Healthcare professionals should consider using ASD-specific observational instruments, as a means of improving the reliability of ASD diagnosis" (Scottish Intercollegiate Guidelines Network, 2007, p. 12).
See the Assessment Areas section of the autism evidence map for pertinent scientific evidence, expert opinion, and client/patient perspective.
Need For Ongoing Assessment
Following a diagnosis of ASD, ongoing assessment focusing on the skills most essential for social and communication development is conducted to
- determine an individual's current profile of social communication skills,
- identify priority learning objectives within natural communication contexts,
- examine the influence of the communication partner and the environment on communication competence.
As part of the ongoing assessment process, dynamic assessment procedures can be used to identify the skills that an individual has achieved, those that may be emerging, and the contextual supports that enhance communication skills (e.g., AAC or modeling). See intervention goals associated with core challenges [PDF].
- Evidence indicates that "any treatment program must include a carefully designed assessment plan that includes a baseline assessment and periodic follow-up assessments measuring change in core deficits. Assessment should be done by using instruments with acceptable reliability and validity, as documented scientifically" (Maglione, Gans, Das, Timbie, & Kasari, 2012, p. S175).
See the Assessment: General Findings section of the autism evidence map for pertinent scientific evidence, expert opinion, and client/patient perspective.
Special Considerations: Audiologic Assessment
Individuals with hearing loss may present with symptoms similar to those of ASD, particularly within the communication and socialization domains. For example, in the case of children with significant hearing loss or deafness,
- when compared to peers with normal hearing, their speech may differ, and they may rely more heavily on gestures (Worley, Matson, & Kozlowski, 2011);
- the inability to hear may limit social interaction with peers and lead to the kind of deficits in social skills often seen in children with ASD.
It is also possible for an individual to have both ASD and hearing impairment (Easterbrooks & Handley, 2005; Malandraki & Okalidou, 2007; Szymanski & Brice, 2008). The similarities in communication and socialization symptoms between hearing impairment and ASD populations, along with the possibility of dual diagnosis, can present challenges for differential diagnosis. An audiologic assessment is conducted when hearing loss and/or ASD are suspected.
Some characteristic behaviors associated with ASD may make it challenging to obtain valid and reliable hearing assessment results. These include comfort with sameness and aversion to novel situations; hypersensitivity to sensory input and negative behavioral responses; and communication differences, such as receptive language deficits and unreliable pointing gestures (Davis & Stiegler, 2010). Suggestions for assessing hearing in individuals with these and other challenging behaviors include
- minimizing distractions in the test suite;
- using visual schedules to support audiological testing sequence;
- partnering with parents and the managing SLP, who are more familiar with the individual's behaviors, interests, and needs;
- using the individual's primary/preferred language form (e.g., spoken language, sign, AAC devices, or picture symbols);
- increasing the individual's familiarity with assessment procedures prior to testing, such as through the use of social stories (Gray, White, & McAndrew, 2002), a visual schedule, and/or practicing with a favorite doll or stuffed animal;
- allowing the individual to touch and explore earphones that will be used during testing to help him or her overcome tactile sensitivity and related anxiety;
- incorporating flexibility in the assessment situation (e.g., testing order or earphone type);
- practicing appropriate motor movements in response to test stimuli;
- knowing what is reinforcing to the individual (e.g., food, clips from favorite videos, playing with a favorite toy) and using these reinforcers to reward appropriate behavioral responses to test stimuli;
- considering the use of multiple sessions to obtain complete results;
- being aware of the individual's signs of distress and terminating testing before the situation escalates (Brueggeman, 2012; Davis & Stieger, 2010);
- considering the need for auditory brainstem response (ABR) testing when behavioral audiometry is not possible.
See the Assessment: Hearing section of the autism evidence map for pertinent scientific evidence, expert opinion, and client/patient perspective.
Special Considerations in the School Setting
Within a public school setting, eligibility for services under the disability category of autism is based on the definition provided in the Individuals with Disabilities Education Improvement Act of 2004 (IDEA, 2004):
Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, which adversely affects a child's educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The term does not apply if a child's educational performance is adversely affected primarily because the child has an emotional disturbance as defined by IDEA criteria.
A child who manifests the characteristics of "autism" after age 3 could be diagnosed as having "autism" if the criteria in the preceding paragraph are met.
34 C.F.R. ß 300.7(c)(1)
By their very nature, severe social communication challenges impinge on participation and progress in the general education curriculum, extracurricular settings, and other nonacademic settings, as specified as the basis for eligibility of services by IDEA. Therefore, the pervasive nature of the social communication challenges in individuals with ASD supports the decision-making process to determine eligibility for language services in the schools (IDEA, 2004).
Individuals diagnosed with an ASD by means of other sources of clinical criteria, such as the DSM-5 (American Psychiatric Association, 2013), are likely to be eligible for special education services under the category of autism as defined above, due to the common challenges and deficits in social communication functioning across the various severity levels on the autism spectrum.
As mandated by IDEA, a priori criteria should be avoided when making decisions regarding eligibility for services. Such criteria include the following.
- Cognitive referencing. This practice of comparing IQ scores and language scores to determine eligibility for speech-language intervention is based on the assumption that language functioning cannot surpass cognitive levels.
- Chronological age. Research has shown that infants, toddlers, and preschoolers with ASD do benefit from communication services and supports ( Garfinkle & Schwartz, 2002; Lawton & Kasari, 2012; Pierce et al., 2011). In addition, individuals with autism can continue to develop communication abilities across their lifespan (Hamilton & Snell, 1993; Pickett, Pullary, O'Grady, & Gordon, 2009; Watanabe & Sturmey, 2003).
- Diagnostic label. A diagnostic label on its own typically reveals very little about the individual's communication abilities; however, in the case of the autism spectrum, social communication impairment is encompassed in its very definition (Baron-Cohen, Allen, & Gillberg, 1992; DiLavore, Lord, & Rutter, 1995; Lord & Corsello, 2005). Therefore, the diagnosis of ASD indicates the inclusion of communication services and supports rather than the exclusion of services.
- Absence of cognitive or other prerequisite skills. Research has shown that individuals (including those with ASD) who do not demonstrate supposed prerequisites can benefit from appropriate communication services and supports (Amato, Barrow, & Domingo, 1999; Bondy & Frost, 1998; Moes & Frea, 2002);
- Failure to benefit from previous communication services. Lack of progress may be tied to issues other than factors associated with the individual, such as inappropriate goals, unsuitable intervention methods, failure to incorporate assistive technology, or insufficient methods in measuring outcomes (National Joint Committee, 2003). Access to communication services and supports should not be denied merely because an individual failed to progress as a function of prior therapy; rather, previous experiences should be examined in order to determine ways in which communication services and supports could be better tailored to meet the individual's unique communication needs.
- Lack of funding or adequately trained personnel. Lack of funding and expertise often fuels exclusionary practices. If trained personnel are not available, there is an obligation either to find trained personnel or to train existing personnel (Timothy W. v. Rochester, NH School District, 1989). Similarly, lack of funding does not constitute a reason for exclusion from communication services and supports. IDEA states that identified needs have to be met.
High-functioning individuals with ASD pose particular challenges both for identification and for determining eligibility for services. These individuals often have either verbal or nonverbal intelligence within normal limits and appear to succeed in some or most academic subjects, particularly in early school years. As a result, many are not diagnosed until later school age, adolescence, or even adulthood. Long-term outcomes research for these individuals has shown that social communication deficits significantly affect their ability to adjust to new social demands in later academic and community settings and to achieve vocational goals (Gilchrist et al., 2001; Mueller, Schuler, Burton, & Yates, 2003; Tsatsanis, Foley, & Donehower, 2004). These findings suggest that it is important to provide intervention to address the gap between cognitive potential and social adaptive functioning.
Determining an individual's eligibility for educational services necessitates the use of a variety of strategies for gathering information, including standardized measures of social adaptive functioning, naturalistic observation across a range of social settings, and caregiver/teacher interviews or questionnaires. However, regardless of the assessment measures or tools used, the clinician needs to be aware of any subtle signs and symptoms consistent with a diagnosis of ASD.
The goal of intervention is to improve social communication and other language impairments and modify behaviors to improve an individual's quality of life and increase social acceptance. Essential outcomes focus on improvements in social communication that affect the individual's ability to develop relationships, function effectively, and actively participate in everyday life. SLPs often collaborate with other professionals on the individual's team in designing and implementing effective treatment plans. See sample intervention goals associated with core challenges [PDF].
Given the nature of autism and the needs of individuals with ASD, families often become teachers and interventionists. Most comprehensive programs for individuals with autism offer parents/caregiver training. SLPs establish ongoing partnerships with families to develop meaningful learning opportunities, provide information, teach strategies, and offer feedback. Clinicians need to recognize and integrate goals that embrace the family's cultural and linguistic communication values and preferences. See family-centered practice.
Individuals with ASD have unique needs with respect to learning independence and self-advocacy due to their core challenges in social interaction and verbal and nonverbal communication. SLPs can contribute to the independence and self-advocacy of individuals with ASD by ensuring each individual has a functional communication system (including AAC) and by supporting communication in different social settings with a variety of partners to promote generalization of skills.
Treatment for individuals with ASD typically includes
- setting goals based on assessment data that target the core deficits in ASD and focus on initiating spontaneous communication in functional activities, engaging in reciprocal communication interactions, and generalizing gains across activities, environments, and communication partners;
- using a multimodal communication system (e.g., spoken language, gestures, sign language, picture communication, speech-generating devices [SGDs], and/or written language) that is individualized according to the individual's abilities and the contexts of communication;
- considering family priorities when selecting intervention goals—meaningful outcomes are strongly correlated with communication competence across functional social contexts (e.g., home, school, vocational, and community settings);
- incorporating cultural, linguistic, and personal values and attributes unique to each individual into therapeutic activities;
- using a range of approaches for enhancing communication skills along a continuum from behavioral to developmental;
- using developmental sequences and processes of language development to provide a framework for determining baselines and implications for intervention goals;
- measuring progress using systematic methods to determine whether an individual with ASD is benefiting from a particular treatment program or strategy.
Core challenges of ASD take different forms as an individual responds to intervention and progresses through developmental stages from prelinguistic to emerging language and advanced language stages. (See sample intervention goals associated with core challenges [PDF].) Actual goals will vary based on those aspects of development that are consistent with family priorities and with the individual's functional needs within his or her current social contexts.
A number of treatment modes/modalities and options are described below. When selecting a treatment mode/modality or option, the SLP matches the treatment with the intervention goals and priorities appropriate for the individual's developmental stage. For example, a treatment that is evidence-based for an individual at the emerging language stage may not be evidence-based for an individual at the prelinguistic stage.
- Evidence indicates that "when discussing and deciding on interventions with adults with autism, [health care professionals should] consider: their experience of, and response to, previous interventions; the nature and severity of their autism; the extent of any associated functional impairment arising from the autism, a learning disability or a mental or physical disorder; the presence of any social or personal factors that may have a role in the development or maintenance of any identified problem(s); the presence, nature, severity and duration of any coexisting disorders; and the identification of predisposing and possible precipitating factors that could lead to crises if not addressed" (National Collaborating Centre for Women's and Children's Health, 2011, p. 22).
- Individuals with ASD may benefit from the adaptation of the communicative, social, and physical environment (e.g., provision of visual prompts; reduction of requirements in social interactions; use of routine, time tables, and prompts; and reduction of sensory irritation; Scottish Intercollegiate Guidelines Network, 2007).
- "Instructional strategies should be based on individual learning styles and should take into consideration and capitalize upon the aspects of unique learning styles" (Autism Task Force, 2003, p. 23).
- "Factors associated with better outcomes include early identification resulting in early enrollment in appropriate intervention programs and successful inclusion in regular educational and community settings with typically developing peers" (Johnson & Myers, 2007, p. 1206).
See the Treatment section
of the autism evidence map for pertinent scientific evidence, expert opinion, and client/patient perspective.
Treatment modes and modalities are technologies or other support systems that can be used in conjunction with or in the implementation of various treatment options. For example, video-based instruction can be used in peer-mediated interventions to address social skills and other target behaviors.
Augmentative and Alternative Communication (AAC)
AAC involves supplementing or replacing natural speech and/or writing with aided (e.g., picture communication symbols [PECS], line drawings, Blissymbols, speech generating devices, and tangible objects) and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols. Whereas aided symbols require some type of transmission device, production of unaided symbols only requires body movements. For more information on speech-generating devices for children with autism, see van der Meer and Rispoli (2010).
- Evidence indicates that the use of aided AAC improves communication skills (Ganz et al., 2011).
Evidence indicates that
- PECS intervention is associated with gains in functional communication (Tien, 2008).
- PECS produce short-term improvements in word acquisition (Warren et al., 2011).
See the Treatment: AAC section
of the autism evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Activity Schedules/Visual Supports
Activity schedules/visual supports include objects, photographs, drawings, or written words that act as cues or prompts to help individuals complete a sequence of tasks/activities, attend to tasks, transition from one task to another, or behave appropriately in various settings. Written and/or visual prompts that initiate or sustain interaction are called scripts. Scripts are often used to promote social interaction, but can also be used in a classroom setting to facilitate academic interactions and promote academic engagement (Hart & Whalon, 2008).
- "Visual supports and technology should be available to support expressive and receptive communication and organization according to the child or young person's individual needs" (Ministries of Health and Education, 2008, p. 95).
Computer-based instruction involves the use of computer technology (e.g., iPADs) and/or computerized programs for teaching language skills, including vocabulary, social skills, social understanding, and social problem solving.
- Evidence indicates that "although [computer-based instruction] for communication skills of children with ASD should not yet be considered a researched-based approach, it does seem a promising practice that certainly warrants future research" (Ramdoss et al., 2011, p. 71).
See the Treatment: Computer-Based Instruction section
of the autism evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Facilitated communication is a technique by which a "facilitator" provides physical and other supports in an attempt to assist a person with a significant communication disability to point to pictures, objects, printed letters, and words or to a keyboard and thereby communicate. Supporters of this technique believe that its use can reveal previously undetected literacy and communication skills in persons with autism and other disabilities.
- Evidence indicates that facilitated communication should not be used with adults with autism (National Collaborating Centre for Mental Health, 2012).
- Facilitated communication may have negative consequences if it precludes the use of effective and appropriate treatment, supplants other forms of communication, and/or leads to false or unsubstantiated allegations of abuse or mistreatment. The scientific validity and reliability of facilitated communication have not been demonstrated to date; information obtained through or based on facilitated communication should not form the sole basis for making any diagnostic or treatment decisions (ASHA, 1995).
See the Treatment: Facilitated Communication section
of the autism evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.
Video-based instruction (also called video modeling) is an observational mode of teaching that uses video recordings to provide a model of the target behavior or skill. Video recordings of desired behaviors are observed and then imitated by the individual. The learner's self-modeling can be videotaped for later review.
- Evidence indicates that video modeling is an effective method for teaching social-communication skills (Delano, 2007; Reichow & Volkmar, 2010).
- Evidence indicates that different forms of video modeling (e.g., self as model, other as model, and peer as model) result in positive effects on target outcomes (Bellini & Akullian, 2007).
See the Treatment: Video Modeling section
of the autism evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
There are many different intervention approaches and strategies for individuals with ASD. Programs differ in the method used to address goals; approaches range from discrete trial, traditional behavioral therapies to social-pragmatic, developmental therapies (Prizant & Wetherby, 1998). Programs also differ in how goals are prioritized and addressed; focused interventions rely heavily on individual strategies, used alone or in combination, to target specific skills or behaviors (e.g., to increase verbalization), while comprehensive interventions involve multiple treatment strategies/treatment packages to target a broad range of skills or behaviors (e.g., to enhance learning).
SLPs and educators determine which methods and strategies are effective for a particular student/client by taking into consideration the individual's level of social and linguistic development, cultural background and values, personal preferences, family resources, learning style, behavior repertoire, and communication needs.
Below are brief descriptions of both general and specific treatments for addressing ASD. Some attempt has been made to organize treatment options into broader categories, recognizing that several approaches have components of more than one broader category (e.g., the Early Start Denver model combines developmental approaches with behavioral teaching strategies).
This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA. For a more comprehensive list of treatment options, see the autism evidence map.
Auditory/Sensory Integration Training
Broadly speaking, sensory integration therapies are used to treat integration dysfunction in one or more sensory systems. Treatments can include physical exercise, sensory/tactile stimulation, and auditory integration training. Auditory integration therapy (e.g., the Berard method) involves exercising the middle ear muscles and auditory nervous system to treat distortions/dysfunctions of the auditory system (Berard, 1993).
Behavioral interventions and techniques are designed to reduce problem behaviors and teach functional alternative behaviors using the basic principles of behavior change. These methods are based on behavioral/operant principles of learning; they involve examining the antecedents that elicit a certain behavior, along with the consequences that follow that behavior, and then making adjustments in this chain to increase desired behaviors and/or decrease inappropriate ones.
Behavioral interventions range from one-to-one discrete trial instruction to naturalistic approaches that focus only on communication, on communication as well as other aspects of educational programming, or on replacing maladaptive behaviors that are being used for communication.
Examples of behavioral interventions include the following:
APPLIED BEHAVIOR ANALYSIS (ABA)—a treatment approach that utilizes principles of learning theory to bring about meaningful and positive change in behavior. ABA techniques have been developed for individuals with autism to help build a variety of skills (e.g., communication, social skills, self-control, and self-monitoring) and help generalize these skills to other situations. The techniques can be used in both structured (e.g., classroom) and everyday (e.g., family dinnertime) settings and in one-on-one or group instruction.
Intervention is customized, based on the individual's needs, interests, and family situation. ABA techniques are often used in intensive, early intervention (below age 4 years) programs to address a full range of life skills. Intensive programs total from 25 to 40 hours per week for 1 to 3 years. Qualifications for providing ABA therapy to individuals with autism may vary by state; check with your state, as this may have an impact on reimbursement.
DISCRETE TRIAL TRAINING (DTT)—a one-to-one instructional approach utilizing behavioral methods to teach skills in small, incremental steps in a systematic, controlled fashion. The teaching opportunity is a discrete trial with a clearly identified antecedent and consequence (e.g., reinforcement in the form of praise or tangible rewards) for desired behaviors. DTT is most often used for skills that learners are not initiating on their own, have a clear, correct procedure, and can be taught in a one-to-one setting.
FUNCTIONAL COMMUNICATION TRAINING (FCT)—a behavioral intervention program that combines the assessment of the communicative functions of maladaptive behavior with ABA procedures to teach alternative responses. Problem behaviors can be eliminated through extinction and replaced with alternate, more appropriate forms of communicating needs or wants. FCT can be used with children with ASD across a range of ages and regardless of cognitive level or expressive communication abilities (Carr & Durand, 1985).]
INCIDENTAL TEACHING—a teaching technique that utilizes behavioral procedures; naturally occurring teaching opportunities are provided, based on the child's interests. Following the child's lead, attempts to communicate are reinforced as these attempts get closer to the desired communication behavior (McGee, Morrier, & Daly, 1999)
MILIEU THERAPY—a range of methods (including incidental teaching) that are integrated into a child's natural environment. It includes training in everyday environments and during activities that take place throughout the day, rather than only at "therapy time" (Kaiser, Yoder, & Keetz, 1992).
See the Milieu Treatment section
of the autism evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.
PIVOTAL RESPONSE TREATMENT (PRT)—a play-based, child-initiated behavioral treatment. Formerly referred to as Natural Language Paradigm (NLP), PRT has as its goals to teach language, decrease disruptive behaviors, and increase social, communication, and academic skills. Rather than target specific behaviors, PRT targets pivotal areas of development (response to multiple cues, motivation, self-regulation, and initiation of social interactions) that are central to—and result in improvements across—a wide range of skills (Koegel & Koegel, 2006). PRT emphasizes natural reinforcement (e.g., the child is rewarded with an item when a meaningful attempt is made to request that item).
POSITIVE BEHAVIOR SUPPORT (PBS)—uses functional assessment of problem behaviors to target the relationship between challenging behavior and communication. It integrates principles of applied behavior analysis with person-centered values to foster skills that replace challenging behaviors. The clinician carefully analyzes the functions of the behavior(s) and develops and implements prevention strategies (i.e., antecedent packages) to foster the client's successful use of replacement skills to produce positive response in social interactions. PBS can be used to support children and adults with autism who demonstrate problem behaviors (Carr et al., 2002).
- If a positive behavioral supports approach is selected then the individual's quality of life should be the focus; consideration should be given not only to the individual, but also to changes in the individual's support system; supports should be provided in the home and other natural environments; and adjustments to the plan may be required if results are not evident fairly soon after implementation (New Hampshire Task Force on Autism, 2001).
See the Treatment: Positive Behavioral Support section
of the autism evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
SELF-MANAGEMENT—an approach that involves interventions aimed at helping individuals learn to independently regulate their behaviors and behave appropriately in a variety of contexts. Individuals learn to tell the difference between appropriate and inappropriate behaviors, monitor and record their behaviors, and reward themselves for using appropriate behaviors. Self-management interventions can be used across a wide range of ages from early childhood through adulthood.
TIME DELAY—a behavioral method of teaching that fades the use of prompts during instruction. For example, the time delay between initial instruction and any additional instruction or prompting is gradually increased as the individual becomes more proficient at the skill being taught. Time delay can be used with individuals regardless of cognitive level or expressive communication abilities.
- Evidence indicates that constant time delay and progressive time delay have been effective in teaching children with autism spectrum disorder across settings, instructional arrangements, adult instructors, level of cognitive functioning, gender, and age (Walker, 2008).
See the Treatment: Time Delay section
of the autism evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy (CBT) is an intervention approach that combines cognitive and behavioral learning principles to shape and encourage desired behaviors. The underlying assumptions of CBT are that an individual's behavior is mediated by maladaptive patterns of thought or understanding and that change in thinking or cognitive patterns can lead to changes in behavior. CBT is used primarily to help individuals with ASD improve behavior by learning to regulate emotions and control impulses. Examples of programs/approaches that incorporate CBT principles include the following.
EXPLORING FEELINGS—a structured cognitive behavior therapy program designed to encourage the cognitive control of emotions (anxiety and anger). Sessions include activities to explore specific feelings (e.g., being happy, relaxed, anxious or angry). A follow-up implementation project is completed by the child prior to the next session. The Explore Feelings program was designed for small groups of children between the ages of 9 and 12, but it can be modified for use with only one child (Attwood, 2004).
RATIONAL EMOTIVE BEHAVIORAL THERAPY—a therapy approach that focuses on helping the individual acknowledge the problems that are upsetting him/her, accept emotional responsibility for these problems, and be empowered to change. The ultimate goal is to be able to lead a happier, more fulfilling life (Ellis & Dryden, 1997).
SOCIAL THINKING®—a cognitive-based treatment framework for preschool and school-age children and adults with social learning challenges (including ASD, social communication disorder, and other related diagnoses). It comprises strategies to target pragmatic language, social emotional learning, perspective taking, and social skills. The framework, based in CBT, teaches individuals to understand the "thinking" underlying the production (Lee et al., 2009; Winner & Crooke, 2009, 2011).
The Denver Model is a child-led, play-based treatment approach that focuses on the development of social communication skills through intensive one-on-one therapy, peer interactions in the school setting, and home-based teaching (Rogers & Dawson, 2009). The Early Start Denver Model for toddlers is an extension of the Denver Model; it combines developmental approaches with behavioral teaching strategies and can be delivered in a variety of settings (e.g., by the therapist and/or parents in group or individual sessions in the clinic or at home).
- Evidence indicates that use of the Early Start Denver Model is associated with positive effects on communication and social skills outcomes of children with ASD (Patterson et al., 2012).
See the Treatment: Denver Model section
of the autism evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.
Gentle Teaching is a framework for serving individuals with special needs that focuses on providing companionship and open, loving support and guidance. Gentle teaching uses the relationship between the individual and his/her caregiver as the foundation for teaching. The aim is to develop a safe and loving environment in which the individual can develop talents and reach his/her full potential. This approach eliminates punishment as a way to control behavior; it includes errorless learning, choice making, and fading prompts (Jones & McCaughey, 1992; McGee, 1990).
- Considerations for the implementation of Gentle Teaching include directly teaching and supervising caregivers, conducting observations over several months rather than days, and using self-assessment via video review for evaluation (New Hampshire Task Force on Autism, 2001).
See the Treatment: Gentle Teaching section
of the autism evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Literacy intervention approaches incorporate a variety of instructional strategies to improve word decoding, word identification, reading fluency, reading vocabulary, and reading comprehension across a variety of materials and in a number of contexts. Depending on the student's skill level, instructional strategies might include engaging in shared book reading, teaching literacy in natural contexts, labeling objects/pictures to promote sight word reading, reading and writing about personal experiences, promoting phonological awareness, and teaching the student how to monitor comprehension while reading. For a review of strategies for promoting literacy, see Lanter and Watson (2008).
- Evidence indicates that a massed trials approach featuring student response to a succession of items, systematic prompting, differential positive reinforcement, and use of visual supports (e.g., pictures, concrete objects) facilitates sight word instruction, whereas least intrusive prompting, adult-directed intervention, and modifying task characteristics are promising elements of sight word instruction (Spector, 2011).
See the Treatment: Literacy Interventions section
of the autism evidence map for pertinent scientific evidence, expert opinion, client/caregiver perspective.
Parent-mediated or implemented intervention consists of parents' using direct, individualized intervention practices with their child to increase positive learning opportunities and acquisition of skills.
MORE THAN WORDS—a Hanen Program® that offers a parent-directed approach focusing on day-to-day life, taking advantage of everyday activities to help the child improve communication and social skills (Sussman, 1999). This program is typically used for early language intervention with young children with ASD.
TALKABILITY™—a Hanen Program® for parents of verbal children with ASD. The program teaches parents practical ways to help their child learn people skills, such as "tuning in" to the feelings and thoughts of others by attending to nonverbal cues, such as body language, facial expressions, and tone of voice. The ability to consider the point of view of others and have empathy are considered essential for successful conversation and for making friends (Sussman, 2006).
SON-RISE—a child-centered, parent-directed, and relationship-based approach, based on the view that autism is a social connecting disorder (Kaufman, 1995). Parents and facilitators join in the child's repetitive behaviors until the child demonstrates a willingness to engage in play; more complex social interactions are then encouraged in a nonthreatening way. The Son-Rise program is used with children and adults with ASD and other developmental difficulties.
Peer-mediated or implemented treatment approaches incorporate peers as communication partners for children with ASD in an effort to minimize isolation, provide effective role models, and boost communication competence. Typically developing peers are taught strategies to facilitate play and social interactions; interventions are commonly carried out in inclusive settings where play with typically developing peers naturally occurs (e.g., preschool setting).
LEAP—a multi-faceted program for preschool children with ASD (Hoyson, Jamieson, & Strain, 1984). LEAP utilizes a variety of strategies and methods, including ABA, peer-mediated instruction, self-management training, prompting, and parent training. LEAP is implemented in a classroom setting consisting of children with ASD and typically developing peers and designed to support child-directed play.
CIRCLE OF FRIENDS—a treatment approach that uses the classroom peer group to improve the social acceptance of a classmate with special needs by setting up a special group or "circle" of friends. The focus is on building behaviors that are valued in everyday settings. The application of skills to new and appropriate situations is reinforced as naturally as possible as they occur (Whitaker, Barratt, Joy, Potter, & Thomas, 1998).
INTEGRATED PLAY GROUPS—a therapy model designed to support children of different ages and abilities with ASD in mutually enjoyed play experiences with typical peers and siblings. Small groups of children play together under the guidance of an adult facilitator. The focus is on maximizing the child's potential and his/her intrinsic desire to socialize with peers (Wolfberg & Schuler, 1993).
SCERTS—social communication (SC), emotional regulation (ER), and transactional support (TS)—is a comprehensive framework for targeting critical intervention goals relevant to the individual's stage of social, emotional, and communication development. The supports integrated into this framework fall under the transactional support process and are focused on enabling families, service providers, and members of the community to effectively implement evidenced-based teaching strategies in "real world" activities. The SCERTS Model is a comprehensive educational approach used with children of various ages, from preschool through school age (Prizant, Wetherby, Rubin, Laurent, & Rydell, 2006).
- For the SCERTS Model, it is recommended that adequate provision is made of the positive supports component of the model, adequate time is allotted to building relationships, those providing the intervention receive appropriate training, and assessment of the individual's strengths and weaknesses is conducted prior to intervention (New Hampshire Task Force on Autism, 2001, p. 36).
See the Training: SCERTS section
of the autism evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Social Communication Interventions
Social communication treatment approaches and frameworks are designed to increase social skills, using social group settings and other platforms to teach peer interaction skills and promote socially appropriate behaviors and communication. There continues to be research in the development of social communication treatment approaches (Adams et al., 2012). The following is not an exhaustive list; SLPs are encouraged to research additional social communication treatment programs and approaches.
JASPER (JOINT ATTENTION SYMBOLIC PLAY ENGAGEMENT REGULATION)—a treatment approach that combines developmental and behavioral principles. This approach targets the foundations of social communication (joint attention, imitation, play) and uses naturalistic strategies to increase the rate and complexity of social communication. The approach incorporates parents and teachers into implementation of intervention to promote generalization across settings and activities and to ensure maintenance over time (Kasari, Paparella, Freeman, & Jahromi, 2008).
SCORE SKILLS STRATEGY—a social skills program that takes place in a cooperative small group and focuses on five social skills: (S) share ideas, (C) compliment others, (O) offer help or encouragement, (R) recommend changes nicely, and (E) exercise self-control (Vernon, Schumaker, & Deshler, 1996).
SOCIAL SCRIPTS—a prompting strategy used to teach children to use a variety of language skills during social interactions. Scripted prompts (visual and or verbal) are gradually faded out as children use new language skills more spontaneously (Nelson, 1978).
SOCIAL SKILLS GROUPS—groups in which appropriate ways of interacting with typically developing peers are taught through direct instruction, role-playing, and feedback. Groups typically consist of two to eight individuals with social communication disorders and a teacher or adult facilitator.
SOCIAL STORIES™—a highly structured intervention that uses stories to explain social situations to children and to help them learn socially appropriate behaviors and responses (Gray et al., 2002).
- Evidence indicates efficacy of social communication interventions (Kasari & Patterson, 2012; Maglione et al., 2012; Rao, Beidel, & Murray, 2008; Wang, Parrila, & Cui, 2012; Warren et al., 2011). However, there is uncertainty about the effects in real life settings (Kasari & Patterson, 2012) and on core outcomes (Warren et al., 2011).
- Evidence indicates that "social learning programmes to improve social interaction should typically include: modeling, peer feedback (for group-based programmes) or individual feedback (for individually delivered programmes), discussion and decision-making, explicit rules, and suggested strategies for dealing with socially difficult situations" (NICE, 2012, p. 24).
- Evidence indicates that promising teaching strategies for social skills training include teaching social scripts, modeling and role-play, differential reinforcement, peer involvement, multiple trainers, parent involvement, practice in natural environments, fostering self-awareness, errorless teaching, and defining concrete social rules (Williams White, Keonig, & Scahill, 2007)
- Evidence indicates positive effects of social stories/social narratives/story-based interventions on social/interpersonal skills for individuals with autism (Ospina et al., 2008) and managing behavior (Karkhaneh et al., 2010).
See the Social Scripts
, Social Skills Groups
and Social Stories
sections of the autism evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Relationship-based practices in early intervention are aimed at supporting parent-child relationships (Edelman, 2004; Gutstein, Burgess, & Montfort, 2007).
GREENSPAN/DIR/FLOORTIME—a model that promotes development by encouraging children to interact with parents and others through play. The model focuses on following the child's lead; challenging the child to be creative and spontaneous; and involving the child's senses, motor skills, and emotions (Greenspan, Weider, & Simons, 1998).
PROJECT DATA (DEVELOPMENTALLY APPROPRIATE TREATMENT FOR AUTISM)—a model for developing, implementing, evaluating, and disseminating a program for young children with autism and their families. The project emphasizes best practice from early childhood special education combined with applied behavioral analysis to develop intervention strategies for the classroom and community settings (Center on Human Development and Disability, n.d.).
RELATIONSHIP DEVELOPMENT INTERVENTION® (RDI)—a family-based, behavioral treatment designed to address the core symptoms of autism. It is based on the theory that dynamic intelligence (the ability to think flexibly) is the key to improving the quality of life for individuals with ASD. RDI helps individuals form personal relationships by strengthening the building blocks of social connections, including the ability to form emotional bonds and share experiences. Parents, teachers, and other caregivers can be involved in the implementation of RDI (Gutstein & Gutstein, 2009).
TEACCH (Treatment and Education of Autistic and Related Communication Handicapped Children) is a university-based system of community regional centers that provides clinical services, such as diagnostic evaluations, parent training and parent support groups, social play and recreation groups, individual counseling, and supported employment (Mesibov, Shea, & Schopler, 2007). TEACCH combines developmentally appropriate practice with behavioral techniques (e.g., environmental control/structure) and family collaboration and involvement.
- TEACCH has been found to have positive effects on cognitive outcomes, social behaviors, and communication (Ospina et al., 2008).
See the Treatment: TEACCH section
of the autism evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
The transition from adolescence to young adulthood can be challenging for individuals with or without disabilities. The core challenges associated with ASD can present added challenges to success in post-secondary educational programs, employment,maintaining relationships, and acquiring the skills necessary for independent living (Howlin & Moss, 2012; Zager & Alpern, 2010). These findings highlight the need for continued support to facilitate a successful transition to adulthood. SLPs are involved in transition planning and may be involved to varying degrees in other support services beyond high school.
Support for transitioning individuals with ASD includes, but is not limited to, the following.
TRANSITION PLANNING—the development of a formal plan during the transition year of high school that includes identifying career goals and educational needs; providing career counseling and opportunities for work experiences; and providing training in communication skills unique to academic, employment, and community settings. Effective transition planning involves the student as an active, respected participant of the team (Wehman, 2006) as well as his/her family, who can provide valuable information about the student's needs.
DISABILITY SUPPORT SERVICES—individualized support for college-level students that can include academic accommodations if needed and social communication supports (e.g., counseling, support groups).
VOCATIONAL SUPPORT SERVICES—including assessments to identify vocational strengths, career counseling, training in social skills for the workplace, vocational training, résumé preparation, interview practice, job search and job placement, and on-the-job supports such as reasonable workplace modifications and job coaching (Hendricks, 2010; Van Bourgondien & Woods, 1992)
HOUSING—including transition from the family home to a group home, semi-independent residence, or independent living environment (Lawrence, Alleckson, & Bjorklund, 2010). Residential settings are often small, community-based settings designed to support independence, community living skills, and continued collaboration between persons with autism and their family members, residential staff, case managers, SLPs, job coaches, etc.
COMMUNITY INTEGRATION—providing opportunities for social involvement and the development of friendships. A peer mentor can serve as a role model and source of social skills information and feedback in these settings (Lawrence, Alleckson, & Bjorklund, 2010).
In addition to determining the type of speech and language treatment that is optimal for children with social communication disorders, SLPs consider other service delivery variables—including format, provider, dosage, and timing—that may impact treatment outcomes.
- Format: whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group
- Provider: the person providing treatment (e.g., SLP, trained volunteer, caregiver)
- Dosage: the frequency, intensity, and duration of service
- Timing: the timing of intervention relative to the diagnosis
- Setting: the location of treatment (e.g., home, community-based, school)
Learning in natural learning environments appears to be the most effective intervention approach. Not only do such environments invite higher rates of initiation and generalization, they also enhance the ecological validity of the intervention (NRC, 2001).
- Evidence indicates that the following should be considered for adults with autism without a learning disability or with a mild to moderate learning disability, who have identified problems with social interaction: a group-based social learning program focused on improving social interaction or an individually delivered social learning program for people who find group-based activities difficult (NICE, 2012).
- As indicated in the evidence, parents of adolescents and young adults with ASD have reported improvements in a variety of social skills that involved individual or group-based interventions (Lounds et al., 2012).
- Evidence indicates that "in all settings, [you should] take into account the physical environment in which adults with autism are assessed, supported and cared for, including any factors that may trigger challenging behaviour. If necessary make adjustments or adaptations to the amount of personal space given (at least an arm's length), using visual supports (for example, use labels with words or symbols to provide visual cues about expected behaviour), colour of walls and furnishings (avoid patterns and use low-arousal colours such as cream), lighting (reduce fluorescent lighting, use blackout curtains or advise use of dark glasses or increase natural light), and noise levels (reduce external sounds or advise use of earplugs or ear defenders)" (NICE, 2012, p. 12).
See the Service Delivery
section of the autism evidence map for pertinent scientific evidence, expert opinions, and client/caregiver perspectives.
ASHA'S Resources on Cognitive Referencing
ASHA Store Resources on Autism
Consumer Information: Autism
DSM-5 Changes May Cause Billing Headaches
A Quick Guide to DSM-5
State Insurance Mandates for Autism Spectrum Disorder
American Academy of Pediatrics' Autism Resources
Bilingual Autism Guide
Birth to 5: Watch Me Thrive
Center on Secondary Education for Students with Autism Spectrum Disorder
Centers for Disease Control and Prevention (CDC): Learn the Signs. Act Early
Easter Seals: Autism Services
Evidence-Based Practices for Children, Youth, and Young Adults With Autism Spectrum Disorder [PDF]
First Words Project-The Florida State University College of Medicine: Autism Institute
Interactive Autism Network
Interagency Autism Coordinating Committee Strategic Plan for Autism Spectrum Disorders-2012 Update
Marcus, L. M., Kunce, L. J., & Schopler, E. (2005). Working with families. In F. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.). Handbook of autism and pervasive developmental disorders (3rd ed., pp. 1055-1086). Hoboken, NJ: Wiley.
National Autism Association
National Joint Committee for the Communication Needs of Persons with Severe Disabilities
Rubin, E. (2012). Neurodevelopment of social competence; produced as a free webinar by the National Autistic Society .
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