The incidence of autism spectrum disorder (ASD) refers to the number of new cases identified in a specified time period. The prevalence of ASD refers to the number of individuals who are living with ASD in a given time period.

Completely accurate numbers are difficult to obtain due to possible under- or overidentification, lack of a biological marker, variations in the quality and quantity of behavioral information in records, and other factors (Mulvihill et al., 2009).

In 2014, estimated ASD prevalence was 16.8 per 1,000 (1 in 59) children 8 years of age (Baio et al., 2018). The 2016 National Survey of Children's Health (NSCH) estimated parent-reported ASD prevalence to be 1 in 40 (2.5%) children aged 3–17 years (Kogan et al., 2018). Variance in prevalence estimate systems could be partially due to regional and policy differences in the accessibility of evaluation and diagnostic services for children (Baio et al., 2018).

According to data from the CDC, ASD prevalence was significantly higher in boys (26.6 per 1,000) than in girls (6.6 per 1,000). The estimated ASD prevalence for White children (17.2 per 1,000) was 7% greater than that for Black children (16.0 per 1,000) and was 22% greater than the estimated rates for Hispanic children (14.0 per 1,000). The overall estimated ASD prevalence for Asian/Pacific Islander children was 13.5 per 1,000 (Baio et al., 2018).

Common Signs and Symptoms

The core features of ASD include

• impairments in social communication,
• impairments in language and related cognitive skills, and
• behavioral and emotional challenges.

These core features are significantly influenced by developmental level of language acquisition (e.g., pre-symbolic, emerging language, and conversational language) and the severity level of the disorder. In addition to these core features, sensory and feeding challenges may also be present.

The population of individuals with ASD is heterogeneous. Individuals can have abilities ranging from significant cognitive and language impairments to above-average cognitive and language abilities (e.g., college- and career-bound). However, regardless of these differences, the core characteristics and challenges associated with ASD will have an impact on the development of critical social communication skills.

Following are signs and symptoms common to ASD. Specific areas of deficit will vary; no one individual will have every sign and symptom.

Impairments in Social Communication

Impairments in social communication include deficits in joint attention, social reciprocity, and social cognition.

Joint attention is the shared focus of two or more individuals on the same object or event.

Deficits in joint attention include

• difficulty orienting toward people in a social environment;
• limited frequency of directing another's attention to share an item or event;
• restricted range of communicative functions to seek engagement and comfort from others;
• limitations in recognizing and describing another's emotional state, intention, and perspective; and
• difficulty determining causal factors for emotional states of self and others.

Social reciprocity is the back-and-forth interaction between people, during which the behavior of each person influences the behavior of the other person.

Deficits in social reciprocity include

• difficulty initiating bids for interaction,
• problems responding to bids for interaction initiated by others,
• difficulty initiating and maintaining conversations that are sensitive to social context and the interests of others,
• limitations with maintaining turn-taking in interactions, and
• difficulty recognizing and repairing breakdowns in communication.

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 the following:

• Challenges in social and emotional learning, including difficulty
  • understanding and regulating emotions,
  • appreciating the perspective of others,
  • developing prosocial goals, and
  • using interpersonal skills to handle developmentally appropriate tasks
    (Payton et al., 2000).
• Difficulty differentiating one's own feelings from the feelings of others, taking the perspective another person, and modifying language accordingly (i.e., theory of mind).
• Difficulty integrating diverse information to construct meaning in context (i.e., central coherence; Frith & Happé, 1994).

Impairments In Language and Related Cognitive Skills

Impairments in language and related cognitive skills include deficits in the following 7 areas:

1. Delayed or impaired acquisition of words, word combinations, and syntax, including
   • loss of earlier learned words,
   • delayed acquisition of words representing social stimuli such as actions and people's names (initial words are often nouns and attributes), and
   • use of echolalia (i.e., repetition of utterances produced by others; see ASHA's resource on echolalia and its role in gestalt language acquisition).
2. Deficits in use and understanding of nonverbal and verbal communication, including
   • delayed use of facial expressions, body language, and gestures as forms of communication in the latter part of the first year of life, remaining unconventional throughout development;
   • use of unconventional gestures (e.g., pulling a caregiver's hand toward an item) emerge prior to or in place of more conventional gestures (e.g., giving, pointing, and head nods/headshakes);
   • limited understanding of gaze shifting, distal gestures, facial expressions, and rules of proximity and body language; and
   • more delayed receptive language than expressive language.
3. Vocal development deficits, including
   • atypical response to caregiver's vocalizations,
   • atypical vocal productions, and
   • abnormal prosody once speech emerges (speech may sound robotic).
4. Symbolic play deficits, including
   • delayed acquisition of functional and conventional use of objects,
   • repetitive, inflexible, and less sophisticated and inventive play, and
   • limited cooperative play in interactive situations.
5. Conversation deficits, including
   • limitations in understanding and applying social norms of conversation (e.g., balanced turn-taking, vocal volume, proximity, prosody, and conversational timing;
   • provision of inappropriate and unnecessary information in conversation;
   • provision of too little detail in conversation;
   • 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 in adequately repairing miscommunications;
   • problems understanding figurative language, including idioms, multiple meanings, and sarcasm; and
   • lack of or limited question asking in conversation.
6. 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, and
   • providing sufficient information for the reader when writing.
7. Executive functioning deficits, including
   • lack of or limited flexibility,
   • poor problem solving,
   • poor planning and organization, and
   • lack of inhibition.

Behavioral and Emotional Challenges

Behavioral and emotional challenges include

• 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 reason that are difficult to determine or at seemingly inappropriate times;
• anxiety and/or social withdrawal (possibly due to factors such as misinterpretation of social events, failure to identify salient or irrelevant information, and challenges with socialization);
• depression (possibly due to challenges with socialization);
• 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; and
• problems with self-management.

Sensory and Feeding Challenges

Sensory and feeding challenges include

• sensory modality difficulties, including over-responsiveness, under-responsiveness, or mixed responsiveness patterns to environmental sounds, smells, light, tactile stimulation, movement, 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; and
• consumption of a smaller variety of foods than the variety consumed by other family members.

Early Signs and Symptoms

Diagnostic features of ASD are present in very young children. Most families and caregivers report observing symptoms within the first 2 years of life and typically express concern by the time the child reaches 18 months of age.

Studies of children with ASD found the following:

• Parents of children with ASD reported first noticing abnormalities in their children's development—particularly in language development and social relatedness—at about 14 months of age on average (Chawarska et al., 2007).
• Infants at risk for—and later diagnosed with—ASD showed a decline (from previous normative levels) in eye fixation within the first 2–6 months of age. This pattern was not observed in typically developing infants (Jones & Klin, 2013).
• By 12 months of age, infants at risk for—and later diagnosed with—ASD demonstrated atypical eye gaze, social smiling passivity, decreased positive affect, and delayed language (Zwaigenbaum et al., 2005).
• Children with autism used fewer joint attention gestures and behaviors as infants and toddlers (based on early home videos) than did age-matched peers who were typically developing (Watson, et al., 2013; Werner & Dawson, 2005).
• Children with autism showed subtle differences in sensory–motor and social behavior at 9 to 12 months of age (based on early home videos) when compared with typically developing peers (Baranek, 1999).
• Children with autism showed lower rates of canonical babbling and fewer speech-like vocalizations across the 6- to 24-month age range (based on early home videos) than did typically developing peers (Patten et al., 2014).
• Infants at risk for—and later diagnosed with—ASD used significantly more distress vocalizations (e.g., cries, whines, screams, and squeals) than did children who were typically developing and children who were developmentally delayed; this may reflect the difficulties that children with ASD have with emotional regulation (Plumb & Wetherby, 2013).

Signs in Girls vs. Boys

It is well documented that more boys than girls are diagnosed with ASD (e.g., Baio et al., 2018). Girls who do meet the diagnostic criteria for ASD during early childhood tend to have additional problems (lower cognitive ability and/or additional behavioral problems). This is not the case for boys (e.g., Dworzynski et al., 2012; Lord & Schopler, 1985).

One reason for the discrepancy in diagnosis may be that ASD traits "look different" in girls than in boys. A diagnostic bias toward characteristic ASD traits as they present in boys makes it easy to miss ASD traits as they present in girls (Dworzynski et al., 2012). In addition, girls also tend to have fewer and less unusual repetitive stereotyped behaviors than boys (Mandy et al., 2012).

The following are differences in the playground behaviors of girls and boys with ASD (Dean, Harwood, & Kasari, 2017):

Girls with ASD

• stay in closer proximity to their peers and are better able to capitalize on social opportunity,
• spend more time in joint engagement,
• spend more time talking as a primary activity, and
• appear to use compensatory behaviors to gain access into peer groups (e.g., swinging a jump rope near girls playing jump rope).

Boys with ASD

• tend to play alone rather than participating in organized games,
• spend more time alone, and
• spend more time wandering as a primary activity.

A second explanation for the discrepancy in diagnosis might be that girls without additional problems are better able to cope with similar levels of ASD traits. They may mask their social challenges by using various compensatory behaviors (Dworzynski et al., 2012; Tierney et al., 2016).

Differences in the social landscape of girls may make it easier for them to camouflage or mask their social differences. For example, the social groups that girls form on the playground are "fluid." Girls with ASD stay in close proximity to peer groups and, to an observer, look similar to typically developing girls. Most boys, on the other hand, play structured games on the playground. Boys with ASD tend to spend more time wandering and, therefore, do not appear similar to their typically developing peers (Dean et al., 2017).

Co-Occurring Conditions

There are a number of co-occurring conditions frequently identified in individuals with autism. They are not necessarily present in every person.

These co-occurring conditions include

• gastrointestinal conditions,
• epilepsy,
• sleep disorders,
• neurodevelopmental disorders such as attention deficit hyperactivity disorder (ADHD),
• psychiatric disorders, and
• immune/metabolic conditions.

For a better understanding of these conditions and the impact they have on individuals with ASD, see Interagency Autism Coordinating Committee (IACC; 2017).

Speech and language disorders can also co-occur with ASD. These include

• spoken language disorders,
• written language disorders, and
• speech sound disorders (including motor speech disorders).

Autism spectrum disorder (ASD) is typically diagnosed on the basis of behavioral symptoms, without reference to etiology. However, researchers have devoted considerable efforts to investigating etiological factors. Although no single cause has been identified, the available data suggest that autism results from different sets of causal factors, including genetic, neurobiological, and environmental factors.

Genetic Risk Factors

Researchers largely agree that ASD is the result of hereditable genetic differences and/or mutations. Findings that support a genetic link include research results showing the following:

• ASD is more common in boys than in girls—it is most likely linked to genetic differences associated with the X chromosome (Chakrabarti & Fombonne, 2005).
• The rate of concordance for identical twins is higher compared with the concordance rate in fraternal twins (Bailey et al., 1995; Colvert et al., 2015).
• 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 (Ozonoff et al., 2011).

Given the current availability of rapid, precise gene-sequencing tools and the accessibility of large numbers of DNA samples, researchers have made some progress in identifying genetic factors associated with ASD (Coe et al., 2012; De Rubeis et el., 2014; lossifov et al., 2012; Neale et al., 2012; O'Roak et al., 2012; Sanders et al., 2012).

See Bourgeron (2016) for a summary of research on the genetics of autism.

Neurobiological Factors

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).

Structural and functional abnormalities in the developing brain include

• increased gray matter in the frontal and temporal lobes (Carper & Courchesne, 2005; Hazlett et al., 2006; Palmen et al., 2005);
• decreased white matter compared with gray matter by adolescence (Volkmar et al., 2004);
• anatomical and functional differences in the cerebellum and in the limbic system (Volkmar et al., 2004); and
• synaptic deficits that affect anatomical structures and neuronal circuitry (Ecker et al., 2013).

See also Ha et al. (2015) for a review of brain characteristics in ASD.

Differences in the brain's response to the environment may result in symptomatic behaviors that include

• 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 et al., 2009); and
• disruptions in normative patterns of social neurodevelopment that contribute to diminished attention to social stimuli (Jones et al., 2008).

Pinpointing the pathological nature of ASD and understanding the relationship between genetic mutations and neurobiological outcomes is complicated by several factors, including the

• genetic heterogeneity underlying ASD,
• biological pleiotropy of risk genes (single genes affecting multiple traits),
• challenges differentiating primary from secondary effects in developmental syndromes, and
• dynamic nature of brain development (Willsey & State, 2015).

Environmental Factors

Researchers have begun to investigate how pre- and postnatal environmental factors (e.g., dietary factors, exposure to drugs and to environmental toxicants) might interact with genetic susceptibility to ASD.

Researchers have identified a number of environmental exposures for future study, including lead, polychlorinated biphenyls (PCBs), insecticides, automotive exhaust, hydrocarbons, and flame retardants (Landrigan et al., 2012; Schmidt et al., 2014; Shelton et al., 2012). However, no specific environmental triggers have been identified at this time.

For more information on the causes of ASD, see IACC (2017).

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 (ASHA, 2016).

Appropriate roles for SLPs include the following:

• 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 the need and requirements for using augmentative and alternative communication (AAC) devices as a mode of communication
• assessing and treating feeding issues, if present (e.g., patterns of food acceptance or rejection based on food texture; consumption of a limited variety of foods)
• diagnosing the presence or absence of ASD (typically as part of a diagnostic team or in other interdisciplinary 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., a team whose members include teachers, special educators, counselors, psychologists) to determine appropriate educational services
• developing speech and language goals focused on social language and literacy, and assisting the student with self-regulatory and social interactive functions so that they can participate in the mainstream curriculum as much as possible
• providing treatment, documenting progress, and determining appropriate dismissal criteria
• providing training in the use of AAC devices to persons with ASD as well as their families, 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 (see ASHA's Practice Portal page on Counseling for Professional Service Delivery)
• 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 (see ASHA's resources on interprofessional education/interprofessional practice [IPE/IPP], collaboration and teaming, and person- and family-centered care)
• partnering with families in assessment and intervention with individuals who have ASD (see ASHA's resource on person- and family-centered care)
• providing parent education so that families may continue to provide intervention beyond the sessions
• 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 and, when appropriate, considering transition planning (see ASHA's resources on interprofessional education/interprofessional practice [IPE/IPP] and collaboration and teaming)
• providing quality control and risk management

As indicated in the Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.

Role of the SLP In Diagnosis

Interdisciplinary collaboration in assessing and diagnosing ASD is important due to the complexity of the disorder, the varied aspects of functioning affected, and the need to distinguish ASD from other disorders or medical conditions. (Hyman, et al., 2020)

Ideally, the SLP is a key member of an interdisciplinary team with expertise in diagnosing ASD. When there is no appropriate team available, an SLP—who has been trained in the clinical criteria for ASD and who is experienced in diagnosing developmental disorders—may be qualified to diagnose these disorders as an independent professional.

Additional Considerations

State speech-language pathology licensing boards do not always specify whether the diagnosis of ASD and other conditions are expressly within a licensee's scope of practice. Moreover, licensing agencies for other health professions, such as a state medical board, may set rules that prohibit SLPs from diagnosing ASD independently. School districts and employers in other settings may also have policies regarding the professionals who can establish the diagnosis. In addition, payers (Medicare, Medicaid, commercial, or private insurers) typically require a diagnosis by a physician, psychiatrist, or other medical professional for coverage of services. SLPs are responsible for understanding the requirements in place in their state, setting, and by payer so that appropriate services are not delayed. Please see ASHA’s state-by-state resources for state licensing requirements and contact information. ASHA also provides tracking of state insurance mandates for ASD. For questions regarding specific payer requirements, please contact reimbursement@asha.org.

Interdisciplinary collaboration and family involvement are essential in assessing and diagnosing ASD. The SLP is a key member of an interdisciplinary team that includes the child's pediatrician, a pediatric neurologist, and a developmental pediatrician. There are a number of available algorithms and tools to help physicians develop a strategy for early identification of children with ASD (Plauché Johnson & Myers, 2007).

Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability, and Health framework (ASHA, 2023; WHO, 2001), assessment is conducted to identify and describe

• impairments in body structure and function, including underlying strengths and weaknesses related to ASD that affect communication performance;
• co-morbid deficits or conditions, such as developmental disability, genetic syndromes, or hearing loss;
• limitations in activity and participation, including functional communication in everyday communication contexts;
• contextual (environmental and personal) factors that serve as barriers to or facilitators of successful communication and life participation; and
• the impact of communication impairments on the individual's quality of life.

See ASHA's resource on the International Classification of Functioning, Disability and Health (ICF) for examples of ICF handouts specific to selected disorders.

Benefits of Early, Accurate Diagnosis

An early, accurate diagnosis of ASD can (a) help families and caregivers access appropriate services, (b) provide a common language across interdisciplinary teams, and (c) establish a framework to help families and caregivers understand the child's difficulties. Any diagnosis of ASD—particularly of young children—is periodically reviewed by members of the interdisciplinary team because diagnostic categories and conclusions may change as the child develops.

The identification of early behavioral indicators can help families and caregivers 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; Dawson et al., 2010; Harris & Handleman, 2000; Landa & Kalb, 2012). A number of researchers have been reporting the benefits of providing intervention to at-risk infants that targets pre-linguistic communication (Bradshaw et al., 2015; Koegel et al., 2014).

Cultural and Linguistic Considerations

Awareness of individual and cultural differences is essential for accurate diagnosis. For example, direct eye contact with an authority figure may be considered disrespectful in some cultures, 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.

The core characteristics of ASD may be viewed through a cultural lens leading to under-, over-, or misdiagnosis (Taylor Dyches et al., 2001; Tek & Landa, 2012). 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 by someone from a culture that does not formally define the disorder.

Cultural and linguistic variables may contribute to the disparity in the diagnosis of ASD among some racial/ethnic groups (Begeer et al., 2009; Taylor 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.

Cultural and linguistic factors can affect the family's reaction to an ASD diagnosis and their decisions regarding services (Wilder et al., 2004). For example, some cultures view disability in a negative light and feel that it needs to be hidden from others; this, in turn, may influence the type of care that the family seeks. See ASHA's Practice Portal page on Cultural Responsiveness. See also Taylor Dyches (2011) for a discussion of diverse perspectives on symptoms of autism.

Screening

The goal of screening is to detect developmental delays that might signal ASD in high-risk populations, such as children referred to the early intervention system or younger siblings of children with autism. See ASHA's Practice Portal page on Early Intervention.

Screening tools for early identification are available, including one that can be used to identify pre-linguistic behavioral vulnerabilities in infants from 6 to 18 months of age (Bryson et al., 2008) and a broadband screener to identify communication delays (including ASD) in children from 9 to 24 months of age (Pierce et al., 2011; Wetherby et al., 2008). Questionnaire-based tools to screen children at risk for ASD as early as 12 months of age are also available (Turner-Brown et al., 2012). Any screening tool should be culturally and linguistically appropriate and have strong psychometric features to support its accuracy.

Screening typically includes

• norm-referenced parent and teacher report measures,
• competency-based tools, such as interviews and observations, and
• 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,
• imitation,
• nonverbal communication, and
• language development.

Social communication norms vary across cultures. When screening is conducted for nonlinguistic aspects of communication, it is important to recognize when differences are related to cultural variances rather than to a communication disorder. See ASHA's Practice Portal page on Cultural Responsiveness.

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 ASHA's Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology.

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.

Comprehensive Assessment

Individuals suspected of having ASD on the basis of screening results are referred to an SLP and other professionals, as needed, for a comprehensive assessment. Assessment should be functional and sensitive to the wide range of acceptable social norms within and across communities and cultures. It should involve the collaborative efforts of families, caregivers, classroom teachers, SLPs, special educators, and psychologists, as needed.

The SLP incorporates the family's perspective into the assessment and effectively elicits information about their beliefs and concerns. It is important to convey information to families clearly and empathetically, as the assessment and diagnosis process is likely to be stressful and emotional (Marcus et al., 2005).

The comprehensive assessment for individuals suspected of having ASD typically includes the following:

• Relevant case history, including information related to the child's health, developmental and behavioral history, and current medical status.
• Medical and mental health history of the family, including history of siblings with ASD.
• Medical evaluations, including general physical and neurodevelopmental examination and vision testing.
• Formal and informal assessments by an SLP, including
  • language assessment
  • speech assessment, including assessment of motor speech abilities,
  • feeding and swallowing assessment, as needed, and
  • AAC assessment (as needed) to determine the potential benefits for improving functional communication.
• Audiologic assessment by an audiologist.

The comprehensive assessment may also 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 that suggest a possible genetic syndrome; and
• metabolic testing—if the child exhibits symptoms such as lethargy, cyclic vomiting, pica, or seizures.

The comprehensive assessment may result in

• a diagnosis of ASD;
• a description of the characteristics and severity of communication-related symptoms;
• recommendations for intervention, goals, and supports;
• a referral for AAC assessment, if not completed as part of the comprehensive assessment; and/or
• referral to other professionals for additional data to confirm a diagnosis of ASD or for further testing if other disorders/conditions are suspected.

Whenever a diagnosis of ASD is given, it is essential that this be done with the utmost sensitivity. See ASHA's Practice Portal page on Counseling for Professional Service Delivery.

Speech-Language Assessment

The SLP can use both formal and informal assessment approaches. Formal testing may be required if a diagnosis or eligibility for services has yet to be determined. Informal testing may be most useful in determining whether specific communication milestones have been met or for assessing communication skills in everyday settings. See ASHA's resource on assessment tools, techniques, and data sources that may be used in a comprehensive communication assessment. Dynamic assessment may be used to identify nonsymbolic and symbolic communication behaviors and to evaluate individual learning potential (Pea, 1996; Snell, 2002).

A comprehensive speech-language assessment includes testing of skills in language, speech, feeding and swallowing, and augmentative and alternative communication (AAC).

Language. Depending on the individual's age and abilities, the SLP assesses the following language skills:

• Spoken language—this includes language expression and language comprehension (see ASHA's Practice Portal page on Spoken Language Disorders). All means of expressive language—verbal (including echolalia) and nonverbal (including gestures)—should be assessed for communicative function and intent (see, e.g., Stiegler, 2007). See ASHA's resource on echolalia and its role in gestalt language acquisition.
• Written language—this includes reading decoding, reading comprehension, written expression, and writing for varied audiences (see ASHA's Practice Portal page on Written Language Disorders).
• Social Communication—this includes
  • use of gaze;
  • joint attention;
  • sharing affect;
  • initiation of communication;
  • social reciprocity and the range of communicative functions;
  • play behaviors;
  • understanding and use of facial expressions;
  • use of gestures;
  • speech prosody (using stress and intonation to effectively convey meaning); and
  • conversational skills, including
    • topic management (initiating, maintaining, and terminating relevant, shared topics);
    • turn-taking; and
    • providing appropriate amounts of information in conversational contexts.

(See ASHA's Practice Portal page on Social Communication Disorders and ASHA's resource on social communication benchmarks.)

Speech. A speech assessment is important for determining the presence or absence of a speech sound disorder (including a motor speech disorder). See ASHA's Practice Portal pages on Speech Sound Disorders: Articulation and Phonology and Childhood Apraxia of Speech.

A speech sound disorder can result in a person having significant difficulty producing speech—or, possibly, an inability to speak. Without an accurate diagnosis, significant speech difficulties might be attributed mistakenly to language and communication problems associated with ASD. For example, when a speech sound disorder results in lack of speech or highly unintelligible speech, someone might assume that the individual is nonverbal—when, in fact, they have average to above-average language and communication abilities (see, e.g., Tierney et al., 2015). Therefore, it is important to accurately diagnose and address co-morbid speech sound disorders, in addition to addressing the language and communication difficulties associated with ASD.

Feeding and swallowing. See ASHA's Practice Portal page on Pediatric Feeding and Swallowing.

Augmentative and alternative communication (AAC). See ASHA's Practice Portal page on Augmentative and Alternative Communication.

Following a diagnosis of ASD, ongoing assessment is conducted to

• determine an individual's current profile of social communication skills,
• identify high-priority learning objectives within natural communication contexts, and
• examine the influence of the communication partner and the environment on communication competence.

As part of the ongoing assessment process, clinicians can use dynamic assessment procedures to identify 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 ASHA's resource on intervention goals associated with core challenges in ASD [PDF].

Audiologic Assessment

Individuals with hearing loss may present with symptoms similar to those of ASD, particularly in the areas of communication and socialization. For example, in the case of children with significant hearing loss or deafness,

• the inability to hear may limit social interaction with peers and may lead to the kinds of social skills deficits often seen in children with ASD, and
• when compared to peers with normal hearing, the speech of children with hearing loss or deafness may be different, and they may rely more heavily on gestures (Worley et al., 2011).

It is also possible for an individual to have both ASD and hearing impairment (Easterbrooks & Handley, 2005; Malandraki & Okalidou, 2007; Szymanski & Brice, 2008). The potential similarities in symptoms between hearing impairment and ASD, and the possibility that both might be present, can make diagnosis challenging.

Also, some characteristic behaviors associated with ASD can make it challenging to obtain valid and reliable hearing assessment results. These include (a) comfort with sameness and aversion to novel situations; (b) hypersensitivity and negative responses to sensory input; and (c) communication differences, such as receptive language deficits and unreliable pointing gestures (Davis & Stiegler, 2005; Stiegler & Davis, 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, all of whom 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 et al., 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 them 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 & Stiegler & Davis, 2010);
• considering the use of alternative behavioral stimuli, such as the child's favorite sounds (e.g., unwrapping a candy wrapper outside of the child's vision); and
• considering the need for auditory brainstem response (ABR) testing when behavioral audiometry is not possible.

See Scope of Practice in Audiology (ASHA, 2018c).

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)

Social communication challenges affect participation and progress in the general education curriculum. The pervasive nature of these challenges in individuals with ASD supports the criteria for eligibility for services in the schools (IDEA, 2004).

Individuals diagnosed with ASD using other sources of clinical criteria, such as the DSM-5 (APA, 2013), are likely to be eligible for special education services under the autism category, as defined above, due to deficits in social communication functioning across severity levels.

Inappropriate Exclusion of Services

IDEA (2004) mandates that "a priori" criteria should be avoided when making decisions about eligibility for services. These criteria are listed below, with reference to ASD as relevant.

Cognitive referencing. This practice of comparing IQ scores and language scores to determine eligibility for speech-language intervention assumes that language functioning cannot surpass cognitive levels. Consequently, if language functioning is commensurate or consistent with cognitive skills, no further gains can be made through intervention. Research had demonstrated that children with disabilities whose language and cognitive levels were commensurate nonetheless benefit from language intervention (Cole et al., 1990).

Chronological age. This argument suggests that individuals with disabilities are either "too young" or "too old" to benefit from communication services. However, research shows that infants, toddlers, and preschoolers with ASD do benefit from communication services and supports (Garfinkle & Schwartz, 2002; Koegel et al., 2014; Lawton & Kasari, 2012; Pierce et al., 2011). In addition, individuals with ASD can continue to develop communication abilities across their lifespan (Hamilton & Snell, 1993; Pickett et al., 2009; Watanabe & Sturmey, 2003).

Diagnostic label. The term "severe disability" is used to describe a variety of diagnostic labels that result in significant communication impairment. However, research shows that individuals with severe disabilities—regardless of the underlying diagnosis—can learn to communicate effectively. In the case of ASD, social communication impairment is a core feature (Baron-Cohen et al., 1992; DiLavore et al., 1995; Lord & Corsello, 2005). Therefore, a diagnosis of ASD indicates the inclusion of communication services. Research has indeed demonstrated the benefits of instruction and support for individuals with ASD (Hamilton & Snell, 1993; Mirenda et al., 2000; Wetherby et al., 2000).

Absence of cognitive or other prerequisite skills. This practice posits that certain skills and performance criteria are necessary to benefit from communication services and supports, based on an interpretation of some research findings (Miller & Chapman, 1980; Shane & Bashir, 1980). However, subsequent research shows that individuals (including those with ASD) who do not demonstrate supposed prerequisites can benefit from appropriate communication services and supports (Amato et al., 1999; Bondy & Frost, 1998; Moes & Frea, 2002).

Failure to benefit from previous communication services. Lack of progress in therapy is often attributed to a lack of "potential" to benefit from services. But lack of progress can be tied to other factors, including inappropriate goals, unsuitable intervention methods, failure to incorporate assistive technology, or insufficient methods in measuring outcomes (National Joint Committee for the Communication Needs of Persons with Severe Disabilities, 2003). Access to communication services and supports should not be denied because of failure to progress as a function of these other factors. Rather, previously unsuccessful therapy experiences should be examined to help determine ways in which communication services and supports can better be 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, then there is an obligation either to find trained personnel or to train existing personnel (Timothy W. v. Rochester, New Hampshire School District, 1989). Similarly, lack of funding does not constitute a reason for exclusion from communication services and supports. IDEA (2004) mandates that identified needs must be met.

Challenges of Identifying High-Functioning Individuals

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 or above the average range 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 for these individuals show that challenges with social engagement and social communication can significantly affect their ability to adjust to social demands in later academic and community settings and in the workplace (Gilchrist et al., 2001; Mueller et al., 2003; Tsatsanis et al., 2004). These findings suggest the importance of providing intervention to address the gap between cognitive potential and social adaptive functioning.

School-age Children

Determining eligibility for educational services requires using a variety of strategies for gathering information, including

• standardized measures of social adaptive functioning,
• naturalistic observation across a range of settings, and
• caregiver/teacher interviews or questionnaires.

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.

Adult Diagnosis

Some adults are diagnosed with ASD as children. Others have lived with undiagnosed ASD and seek services only when they start experiencing challenges at work, in social relationships, or in academic settings (Brugha et al., 2011). Some individuals may find a diagnosis of ASD in adulthood a relief. But for many, it can come as a surprise and may be difficult to accept, even if it helps explain some of the challenges they have been experiencing. Therefore, it is essential to give the diagnosis with the utmost sensitivity. See ASHA's Practice Portal page on Counseling for Professional Service Delivery.

Adult diagnosis is complicated by the fact that there is limited information about how the core characteristics of ASD manifest in adults, and there are no standard screening and diagnostic tools for ASD in adults (IACC, 2017). The importance of involving professionals from multiple disciplines cannot be overstated, especially because many adults receiving an ASD diagnosis for the first time can have other related concerns (e.g., mental health; Geurts & Jansen, 2012). SLPs with expertise in assessing social communication, higher-level language, conversation, and discourse are integral members of this team.

For a comprehensive discussion of individuals with ASD as they transition into and through adulthood, see IACC, 2017.

Consistent with the WHO (2001) framework, treatment is designed to

• capitalize on strengths and address weaknesses related to the core features of ASD;
• facilitate activities and participation by helping the individual acquire new communication skills and strategies or modify existing skills; and
• modify contextual factors to reduce barriers and enhance facilitators of successful communication and participation, including identification and use of appropriate accommodations.

See ASHA's resource on the International Classification of Functioning, Disability and Health (ICF) for examples of ICF handouts specific to selected disorders.

The goal of treatment is to improve social communication and other language skills and to modify behaviors so that the individual is better able to develop relationships, function effectively in social settings, and actively participate in everyday life. SLPs often collaborate with other professionals to design and implement effective treatment plans.

Goals target core challenges of ASD and focus on

• initiating spontaneous communication in functional activities;
• engaging in reciprocal communication interactions; and
• generalizing skills across activities, environments, and communication partners.

Developmental sequences and processes of language development provide a framework for determining treatment baselines, adjusting goals, and tracking progress. 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].)

The mode of communication used during treatment (e.g., spoken language, gestures, sign language, picture communication, speech-generating devices [SGDs], and/or written language) can vary, and more than one mode can be used. Multimodal communication systems are individualized according to the person's abilities and the context of communication.

Family-Centered Practice

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. Participation of families in services for the individual with autism can help reduce the stress experienced by family members (National Research Council [NRC], 2001).

Support may take different forms at different times and may include coordinating services for the family, procuring resources and information, teaching the family or other significant communication partners specific skills and strategies, providing learning opportunities, and advocating for or with the family. See ASHA's resources on family-centered practice and person- and family-centered care.

Cultural and Linguistic Considerations

It is important that goals embrace the priorities and preferences of the individual and family. Cultural, linguistic, and personal values should be incorporated into therapeutic activities. Clinicians also need to recognize that cultural, linguistic, and socioeconomic factors can affect a family's access to—as well as selection and use of—services (Yu, 2013). See ASHA's Practice Portal page on Cultural Responsiveness.

Advancements have been made in research on bilingual individuals with ASD. Research indicates that children with ASD who are being raised in bilingual language environments are not more likely to have language delays than their monolingual counterparts (Drysdale et al., 2015; Hambly & Fombonne, 2012). In fact, there is no evidence to show that bilingualism has a negative impact on language development in children with ASD.

When determining the language of treatment for a child with ASD, SLPs should carefully consider the child's linguistic environments. Treatment is provided either by a bilingual SLP or through the use of trained interpreters, when necessary. See ASHA's Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Collaborating With Interpreters, Transliterators, and Translators.

Treatment Modes and Modalities

Treatment modes and modalities are technologies or other support systems that the SLP can use in conjunction with, or during implementation of, various treatments. For example, the SLP can use video-based instruction in peer-mediated interventions to address social skills and other target behaviors.

A number of treatment modes and modalities are described below. When selecting a mode or modality, the SLP considers the intervention goal and the individual's developmental stage. For example, a mode or modality that is appropriate for an individual who is at the emerging language stage may not be appropriate for an individual who is at the prelinguistic stage. The list below is not exhaustive, and inclusion does not imply an endorsement from ASHA.

Augmentative and Alternative Communication (AAC)

An AAC system is an integrated group of components—including symbols, selection techniques, and strategies—used to enhance communication. AAC uses a variety of techniques and tools—including picture communication systems, line drawings, photographs, video clips, speech-generating devices (SGDs), tangible objects, manual signs, gestures, and finger spelling—to help the individual express thoughts, ideas, wants, needs, and feelings. AAC can be used to supplement existing expressive verbal communication or with individuals who are unsuccessful at learning expressive verbal communication.

For more information on SGDs for children with ASD, see van der Meer and Rispoli (2010). For more information about AAC, see ASHA's Practice Portal page on Augmentative and Alternative Communication.

Activity Schedule and Visual Supports

Activity schedules and visual supports include objects, photographs, drawings, or written words that act as cues or prompts to help individuals complete a sequence of tasks or activities, attend to tasks, transition from one task to another, or maintain emotional regulation 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 to promote academic engagement (Hart & Whalon, 2008).

Computer-Based Instruction

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 (see, e.g., Khowaja & Salim, 2013; Weng et al., 2014).

Video-Based Instruction

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. The individual observes and then imitates video recordings of desired behaviors. Video modeling procedures can be implemented in three ways: (a) using a video of the behavior to be targeted with another person as a model, (b) using a video of the behavior to be targeted without a model (usually called "point of view modeling"), or (c) using videos of the learner as a model (known as "self-modeling"). In all cases, the SLP works with the learner to provide practice and feedback. As recording devices become more portable and easier to use, video-based techniques are more frequently being used in treatment (see, e.g., Wilson, 2013). Videos with integrated AAC visual scene displays may enhance participate in community and vocational settings for individuals with ASD (O'Neill, Light, McNaughton, 2017).

Treatment Approaches

Treatment approaches differ in the method used to address goals—they range from discrete trial, traditional behavioral approaches to social-pragmatic, developmental approaches (Prizant & Wetherby, 1998).

Approaches 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). Comprehensive interventions use multiple strategies to target a broad range of skills or behaviors (e.g., to enhance learning).

The selection of specific approaches takes into consideration the level of social and linguistic development, cultural background and values, personal preferences, family resources, learning style, behavior repertoire, and communication needs.

Treatment Options

Below are brief descriptions of general and specific treatment options for addressing ASD. Some attempt has been made to organize them into broader categories, recognizing that some approaches have components of more than one broad category (e.g., the Early Start Denver model [Rogers & Dawson, 2010] 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 Treatment section of the Autism Spectrum Disorders Evidence Map.

Behavioral Interventions and Techniques

Behavioral interventions and techniques are designed to reduce challenging 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 for ASD range from one-on-one discrete trial instruction to naturalistic approaches that focus on communication, on communication and other aspects of educational programming, or on modifying ineffective communication behaviors.

Examples include the following:

Applied Behavior Analysis (ABA)—a behavioral intervention that focuses on bringing 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 to 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 on the basis of 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 25–40 hours per week for 1–3 years. Qualifications for providing ABA therapy to individuals with autism may vary by state; check with your state, as this may affect reimbursement.

Discrete Trial Training (DTT)—a one-on-one instructional approach using behavioral methods to teach skills in small, incremental steps in a systematic, controlled fashion. The teaching opportunity is a discrete trial consisting of an antecedent (such as an instruction from the teacher), a response from the learner, and a consequence or feedback regarding the response. DTT is most often used for skills that (a) learners are not initiating on their own; (b) have a clear, correct procedure; and (c) 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 the use of ABA procedures to teach alternative responses. Problem behaviors can be eliminated through extinction and replaced with alternate, more appropriate ways 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 uses behavioral procedures. The clinician provides naturally occurring teaching opportunities that are based on the child's interests. The clinician follows the child's lead and reinforces communication attempts as these attempts get closer to the desired communication behavior (McGee et al., 1999).

Milieu Therapy—a range of methods (including incidental teaching) that are integrated into a child's natural environment. Milieu therapy includes training in everyday environments and during activities that take place throughout the day rather than only at "therapy time" (Kaiser et al., 1992).

Pivotal Response Treatment (PRT)—a play-based, child-initiated behavioral treatment. Formerly referred to as "Natural Language Paradigm (NLP)," PRT's goals are to (a) teach speech sounds, first words, and language; (b) decrease disruptive behaviors; and (c) increase social, communication, and academic skills. Rather than target specific behaviors, PRT targets pivotal areas of development (response to multiple cues, motivation, self-regulation, initiation of social interactions, and empathy) that are central to a wide range of skills (Koegel & Koegel, 2019). PRT emphasizes natural reinforcement (e.g., the child is rewarded with an item when they make a meaningful attempt to request that item).

Positive Behavior Support (PBS)—an approach that uses positive (nonpunitive) interventions for decreasing challenging behaviors. A commonly used strategy involves (a) functionally assessing challenging behaviors to identify the relationship between these behaviors and communication and (b) replacing the challenging behaviors with appropriate functionally equivalent replacement behaviors (FERBs). Multicomponent intervention plans often include prevention strategies (i.e., antecedent packages). PBS integrates principles of behavioral analysis with person-centered values to foster skills that replace challenging behaviors. PBS can be used to support children and adults with autism who demonstrate problem behaviors (Carr et al., 2002).

Self-Management—an approach aimed at helping individuals learn to independently regulate their behaviors and behave appropriately in a variety of contexts. Individuals are taught to discriminate the difference between appropriate and inappropriate behaviors, evaluate and record their behaviors, and (when possible and appropriate) reward themselves for using appropriate behaviors. Self-management interventions can be used across a wide range of ages from early childhood through adulthood.

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 changes 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.

The most effective CBT programs for ASD tend to include a parent education component (Scarpa & Reyes, 2011). Effective interventions often include intervention in natural settings (school, home, community; Wood et. al., 2009). Because the intervention generally involves developing hierarchies and training individuals to change thought processes, the procedures are generally used with individuals who have verbal skills and who are mildly affected by core ASD symptoms. For more information about cognitive-behavioral theory, see ASHA's Practice Portal page on Counseling for Professional Service Delivery.

Examples include the following:

Exploring Feelings—a structured CBT 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). The child completes a follow-up implementation project prior to the next session. The Explore Feelings program was designed for small groups of children between the ages of 9 and 12 years, 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 them, 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 teaches individuals to understand the "thinking" that underlies the production (Crooke et al., 2008; Garcia Winner & Crooke, 2009, 2011).

Denver Model

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 (Rogers & Dawson, 2010) 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).

Gentle Teaching

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 thier 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 thier full potential. This approach eliminates punishment as a way to control behavior; it includes errorless learning, choice making, and fading prompts (McGee, 1990; Polirstok et al., 2003).

Literacy (Written Language) Intervention

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. Older children with ASD may also have difficulty with higher-level literacy skills that require theory of mind.

Depending on the student's skill level, instructional strategies might include engaging in shared book reading, teaching literacy in natural contexts, labeling objects or 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). See also ASHA's Practice Portal page on Written Language Disorders.

Spoken Language Intervention

The goal of spoken language intervention is to facilitate overall language development and functional, everyday communication. The selection of treatment options and approaches are based on the individual's current level of language functioning and may reflect views on language acquisition patterns in children with ASD and the role of echolalia (see, e.g., Blanc, 2012). See also ASHA's Practice Portal pages on Spoken Language Disorders for descriptions of various treatment options and approaches.

Speech Sound Intervention

Speech sound intervention addresses functional disorders such as articulation and phonology and motor speech disorders such as apraxia of speech and dysarthria. See ASHA's Practice Portal pages on Speech Sound Disorders: Articulation and Phonology and Childhood Apraxia of Speech for relevant treatment options.

Parent-Mediated or Parent-Implemented Intervention

Parent-mediated or parent-implemented intervention consists of parents' using direct, individualized intervention practices with their child to increase positive learning opportunities and acquisition of skills.

Examples include the following:

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 others' feelings and thoughts by attending to nonverbal cues, such as body language, facial expressions, and tone of voice. The ability to consider others' point of view and to empathize are considered essential for successful conversation and for making friends (Sussman, 2006).

Peer-Mediated or Peer-Implemented Treatment

Peer-mediated or peer-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).

Examples include the following:

LEAP—a multifaceted program for preschool children with ASD (Hoyson et al., 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 is 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 et al., 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 their intrinsic desire to socialize with peers (Wolfberg & Schuler, 1993).

SCERTS

SCERTS—which stands for 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 focus on enabling families, service providers, and community members 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 et al., 2006).

Social Communication Intervention

Social communication intervention approaches and frameworks are designed to increase social skills, using social group settings and other platforms to teach peer interaction skills and promote effective communication. See ASHA's Practice Portal page on Social Communication Disorder.

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.

Examples include the following:

Joint Attention Symbolic Play Engagement Regulation (JASPER)—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 et al., 2008).

Social Scripts—a prompting strategy that teaches 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 customized and carefully constructed stories to explain social situations to children and to help them learn socially appropriate behaviors and responses (Gray et al., 2002).

Relationship-Based Interventions

Relationship-based interventions are aimed at supporting parent–child relationships (Edelman, 2004; Gutstein et al., 2007).

Examples include the following:

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 & Wieder, 2007).

Relationship Development Intervention® (RDI)—a family-based, behavioral treatment designed to address the core symptoms of ASD. 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 (TEACCH) 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 et al., 2007). TEACCH combines developmentally appropriate practice with behavioral techniques (e.g., environmental control/structure) and family collaboration and involvement.

Treatment Considerations: ASHA's Position

Several treatment options and approaches lack scientific evidence of validity and are not endorsed by ASHA. They are Auditory Integration Training (AIT), Facilitated Communication (FC), and Rapid Prompting Method (RPM). Below are brief descriptions of these treatments, along with ASHA's position on each. Click on the hyperlinks provided to read ASHA's full position statements.

Auditory Integration Training

Auditory Integration Training (e.g., the Berard method; Berard, 1993) is a type of sensory integration treatment that involves exercising the middle ear muscles and auditory nervous system to treat a variety of auditory and nonauditory disorders, including auditory processing problems, dyslexia, learning disabilities, attention-deficit disorders, and ASD. The treatment typically involves listening to specially filtered and modulated music for two 30-minute sessions per day for 10 consecutive days. The objective is to reduce distortions in hearing and hypersensitivity to specific frequencies so that the individual will be able to perceive sounds—including speech—in a normal fashion.

According to ASHA's position statement titled, Auditory Integration Training, "The 2002 ASHA Work Group on AIT, after reviewing empirical research in the area to date, concludes that AIT has not met scientific standards for efficacy that would justify its practice by audiologists and speech-language pathologists" (ASHA, 2004, para. 1).

Facilitated Communication

Facilitated Communication (FC)—also referred to as "Assisted Typing," "Facilitated Communication Training," and "Supported Typing"—is a technique that involves a person with a disability pointing to letters, pictures, or objects on a keyboard or on a communication board, typically with physical support from a "facilitator." This physical support usually occurs on the hand, wrist, elbow, or shoulder (Biklen et al., 1992) or on other parts of the body.

According to ASHA's position statement titled Facilitated Communication, "It is the position of the American Speech-Language-Hearing Association (ASHA) that Facilitated Communication (FC) is a discredited technique that should not be used. There is no scientific evidence of the validity of FC, and there is extensive scientific evidence—produced over several decades and across several countries—that messages are authored by the ‘facilitator' rather than the person with a disability. Furthermore, there is extensive evidence of harms related to the use of FC. Information obtained through the use of FC should not be considered as the communication of the person with a disability" (ASHA 2018a, para.1).

Rapid Prompting Method (RPM)

The Rapid Prompting Method (RPM) is described on the home page of the Helping Autism Through Learning and Outreach (HALO) website (HALO, n.d.) as a teaching method "leading towards communication for persons with autism" (Mukhopadhyay, 2008). Information about RPM is available primarily through the HALO website and in books by Soma Mukhopadhyay (see, e.g., Mukhopadhyay, 2008, 2011), who developed RPM for their son. According to the HALO website (HALO, n.d.), RPM involves pointing to letters "to form words on a letter board, typing device, and/or by handwriting." Untested assertions are that RPM assists with motor planning and that "prompting is necessary in order for the student to initiate a response" (Mukhopadhyay, 2008, p. 139).

Although RPM—also known as Soma® RPM—is primarily associated with HALO-Soma and Soma Mukhopadhyay, foundationally and procedurally similar alternative forms have appeared, such as "Informative Pointing" (Iversen, 2007), "letterboarding," and "Spelling to Communicate." This position statement is applicable regardless of the name used for the technique.

According to ASHA's position statement titled Rapid Prompting Method, "use of the Rapid Prompting Method (RPM) is not recommended because of prompt dependency and the lack of scientific validity. Furthermore, information obtained through the use of RPM should not be assumed to be the communication of the person with a disability" (ASHA, 2018b, para. 1).

Treatment Considerations: Transitioning Youth and Adults

The core challenges associated with ASD can have an impact on the ability to succeed in postsecondary educational programs, employment, and social relationships, and to acquire the skills needed to live independently (Howlin & Moss, 2012; Zager & Alpern, 2010).

Individuals with ASD who are transitioning to young adulthood experience high rates of unemployment and underemployment (Lounds Taylor & Seltzer, 2011; Shattuck et al., 2012) and may have difficulty maintaining employment once secured (Lounds Taylor et al., 2015; Wei et al., 2015). Socially, they may discontinue friendships, participate in fewer social activities (Orsmond et al., 2013), and experience social isolation (Lounds Taylor et al., 2017; Myers et al., 2015).

These findings highlight the need for continued support to facilitate a successful transition to adulthood. SLPs are involved in transition planning in high school and may be involved, to varying degrees, in other support services beyond high school.

Transition planning for individuals with ASD may include

• determining the need for continued therapy, if appropriate;
• identifying career goals and educational needs;
• providing academic or career counseling;
• providing opportunities for work experience;
• discussing housing options; and
• facilitating community networking (see, e.g., Hendricks, 2010; Van Bourgondien & Woods, 1992; Lawrence et al., 2010).

Effective transition planning involves the student as an active and respected member of the team (Wehman, 2006) as well as their family, who can provide valuable information about the student's needs. See ASHA's resource on Postsecondary Transition Planning.

Individuals with ASD who pursue postsecondary education will benefit from disability support services. However, they may need supports that are not typically provided; these include supports to help them live independently, to self-advocate, and to communicate effectively inside and outside the classroom (Ellison et al., 2013).

Those who pursue employment following high school will benefit from job-related supports such as training to improve interview skills (Morgan et al., 2014; Smith et al., 2014), interventions to improve social communication (Koegel et al., 2013, 2015, 2016), and customized employment that incorporates career assessment, job search, on-site training, and teaching job retention techniques (Wehman et al., 2016).

For a comprehensive discussion of individuals with ASD as they transition into and through adulthood, see IACC (2017). For a review and discussion of research on environmental supports and barriers to participation in adolescents with ASD, see Krieger et al. (2018).

Service Delivery Options

See the Service Delivery section of the Autism Spectrum Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

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)

Given the challenges experienced by communication partners, treatment considers a 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. Learning in natural learning environments invite higher rates of initiation and generalization and enhance the ecological validity of the intervention (NRC, 2001).

Service Delivery: Adults

Access to state-funded ASD programs may be limited for adults who are newly diagnosed because documentation of a developmental disability prior to the age of 22 years is typically required. However, some funding for services may be available; services include counseling, vocational supports, and speech-language services to address core social communication challenges. Community support programs and various online support groups are also available.

For a discussion of service delivery for adults with ASD, see IACC (2017).

ASHA Resources

• ASHA Resources on Cognitive Referencing
• ASHA Store Resources on Autism
• Case Studies: Autism Spectrum Disorder or Social Communication Disorder? Video
• Communication About Autism: Considerations for ASHA Members
• Consumer Information: Autism
• DSM-5 Changes May Cause Billing Headaches
• A Quick Guide to DSM-5
• State Insurance Mandates for Autism Spectrum Disorder
• Videos With Integrated AAC Visual Scene Displays to Enhance Participation in Community and Vocational Activities: Pilot Case Study With an Adolescent With Autism Spectrum Disorder (O'Neill et al., 2017)

Organizations and Related Content

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

Across the Lifespan

• Easter Seals: Autism Services
• Evidence-Based Practices for Children, Youth, and Young Adults With Autism Spectrum Disorder [PDF]

Adults

• Job Accommodation Network (JAN)
• National Autism Indicators Report 2017: Developmental Disability Services and Outcomes in Adulthood

Children

• Birth to 5: Watch Me Thrive
• Autism Navigator
• Center on Secondary Education for Students With Autism Spectrum Disorder
• Centers for Disease Control and Prevention (CDC): Learn the Signs. Act Early.
• First Words Project-The Florida State University College of Medicine: Autism Institute
• Family Guided Routines Based Intervention: Key Indicators Manual (Copyright ©2017 by Juliann Woods) [PDF]

General Resources

• Autism Now
• Autism Self Advocacy Network
• Autism Speaks
• Bilingual Autism Guide
• Interactive Autism Network
• Interagency Autism Coordinating Committee
• National Autism Association
• National Joint Committee for the Communication Needs of Persons With Severe Disabilities
• Report to Congress 2017: Young Adults and Transitioning Youth With Autism Spectrum Disorder
• Neurodevelopment of social competence (Rubin, 2012). National Autistic Society free webinar
• Screening and Diagnosis of Autism: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society [PDF]
• The National Professional Development Center on Autism Spectrum Disorder

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Acknowledgments

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Autism page.

• Pamela J. Crooke, PhD, CCC-SLP
• Elizabeth R. Crais, PhD, CCC-SLP
• Sylvia F. Diehl, PhD, CCC-SLP
• Lynn Kern Koegel, PhD, CCC-SLP
• Rhea Paul, PhD, CCC-SLP
• Patricia A. Prelock, PhD, CCC-SLP
• Emily B. Rubin, MS, CCC-SLP
• Carrie D. Slaymaker, MA, CCC-SLP
• Lillian N. Stiegler, PhD, CCC-SLP
• Linda R. Watson, EdD, CCC-SLP
• Jane R. Wegner, PhD, CCC-SLP
• Michelle Garcia Winner, MA, CCC-SLP

In addition, ASHA thanks the members of the Ad Hoc Committee on Autism Spectrum Disorders whose work was foundational to the development of this content. Members of the committee were Amy Wetherby (chair), Sylvia Diehl, Emily Rubin, Adriana Schuler, Linda Watson, Jane Wegner, and Ann-Mari Pierotti (ex officio).  Celia Hooper, vice president for professional practices in speech-language pathology, 2003-2005, served as monitoring officer.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association (n.d.). Autism (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Autism/.