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 present in various ways and can include impairments in joint attention and social reciprocity as well as challenges using verbal and nonverbal communication 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 described in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5; American Psychiatric Association [APA], 2013).
The criteria specified in the DSM-5 reflect a number of changes from those in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (Text Revision; DSM-IV-TR [APA, 2000]), the most notable of which are the following:
Elimination of the Pervasive Developmental Disorder (PDD) 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 (the term used in place of PDD) encompass the social and behavioral deficits typically associated with these populations but no longer specify subtypes. (Note: The DSM-5 lists Rett syndrome, a genetic disorder, 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 severity levels. Each severity level specifies the amount of support needed to function in the general community, given the individual's social communication skills and degree of restricted, repetitive behaviors. Severity may vary by context and may fluctuate over time. Severity ratings are used for descriptive purposes only and not to diagnose or determine eligibility for services (APA, 2013). See Paul (2013) for a more detailed discussion of DSM-5 changes and potential practice implications.
Although subtypes are no longer specified, the DSM-5 notes, "Individuals with a well-established DSM-IV TR diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder" (APA, 2013, p. 51).
Between 50% and 75% of individuals diagnosed with PDD under the DSM-IV-TR will maintain a diagnosis of ASD using DSM-5 criteria (see Smith et al.  for a review of relevant studies). The greatest decreases in diagnosis were among individuals with intelligence quotients (IQs) over 70 and those with a previous diagnosis of PDD-NOS or Asperger's Disorder (Maenner et al., 2014; Smith et al., 2015).
However, although ASD prevalence is likely to be lower under DSM-5 than under DSM-IV-TR, this trend may be offset by (a) increased awareness of ASD and the DSM-5 criteria; (b) more detailed description and documentation of behaviors that meet the new ASD criteria; and (c) adaptation of policies and tools for determining eligibility in response to DSM-5 changes (Maenner et al., 2014).
Some children who do not meet the criteria for ASD under DSM-5 may meet the criteria for social communication disorder. According to the DSM-5, "Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder" (APA, 2013, p. 51).
It is important to differentiate between ASD and social communication disorder (Rosin, 2016). Speech-language pathologists (SLPs) are instrumental in making this differential diagnosis and ensuring that individuals with ASD and those with social communication disorder gain access to services. See ASHA's Practice Portal page on Social Communication Disorder.
Regardless of the presence or absence of difficulties acquiring the form and content of language, all individuals with ASD are eligible for speech-language services due to the pervasive nature of the social communication impairment. Therefore, SLPs 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. See ASHA's Practice Portal pages on Spoken Language Disorder and Written Language Disorder.
At its core, communication is a social process. The social communication issues experienced by individuals with ASD also affect their communication partners. Family members, friends, teachers, and coworkers face the challenge of learning to recognize and respond to subtle bids for communication and to interpret the communication functions of challenging behaviors.
Individuals with ASD report a desire to have friendships and relationships, despite their social communication challenges. However, peers often feel ineffective in social exchanges with an individual with ASD and may avoid that person or react to social overtures in a negative way (e.g., by teasing or bullying). This lack of appropriate engagement and bullying can have a negative impact on the development of social skills.
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).
The core features of ASD include
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 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
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
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:
Impairments in language and related cognitive skills include deficits in the following 7 areas:
Behavioral and emotional challenges include
Sensory and feeding challenges include
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:
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
Boys with ASD
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).
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
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
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.
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:
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.
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
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
Pinpointing the pathological nature of ASD and understanding the relationship between genetic mutations and neurobiological outcomes is complicated by several factors, including the
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, 2016b).
Appropriate roles for SLPs include the following:
As indicated in the Code of Ethics (ASHA, 2016a), 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 disorder, the varied aspects of functioning affected, and the need to distinguish ASD from other disorders or medical conditions.
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 (Filipek et al., 1999).
Some state laws or regulations may restrict a licensee's scope of practice and may prohibit the SLP from providing such diagnoses. SLPs should check with their state licensure boards and/or state departments of education for specific requirements.
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, 2016a; WHO, 2001), assessment is conducted to identify and describe
See ASHA's resource on the International Classification of Functioning, Disability and Health (ICF) for examples of ICF handouts specific to selected disorders.
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).
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 Competence. See also Taylor Dyches (2011) for a discussion of diverse perspectives on symptoms of autism.
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
Screening procedures evaluate the main characteristics that differentiate ASD from other developmental disorders, including difficulties in
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 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 ASHA's Practice Portal page on 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.
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:
The comprehensive assessment may also include
The comprehensive assessment may result in
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.
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:
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
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].
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,
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
See Scope of Practice in Audiology (ASHA, 2018c).
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.
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.
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.
Determining eligibility for educational services requires using a variety of strategies for gathering information, including
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.
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.
See the Treatment section of the Autism Spectrum Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Consistent with the WHO (2001) framework, treatment is designed to
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
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.
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.
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 Competence.
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 Bilingual Service Delivery and Collaborating With Interpreters, Transliterators, and Translators.
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.
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 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 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 (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 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.
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 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) 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).
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 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 or 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 or her 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 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.
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 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 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 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 his or her intrinsic desire to socialize with peers (Wolfberg & Schuler, 1993).
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 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 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).
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.
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 (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 (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).
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 her 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).
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
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 transitioning youth.
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).
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.
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).
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.
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
Adams, C., Lockton, E., Freed, J., Gaile, J., Earl, G., McBean, K., Green, J., Vail, A., & Law, J. (2012). The Social Communication Intervention Project: A randomized controlled trial of the effectiveness of speech and language therapy for school-age children who have pragmatic and social communication problems with or without autism spectrum disorder. International Journal of Language and Communication Disorders, 47(3), 233–244.
Amato, J., Barrow, M., & Domingo, R. (1999). Symbolic play behavior in very young verbal and nonverbal children with autism. Infant–Toddler Intervention: The Transdisciplinary Journal, 9(2), 185–194.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
American Speech-Language-Hearing Association. (2004). Auditory integration training [Position statement]. www.asha.org/policy/
American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. www.asha.org/policy/
American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of Practice]. www.asha.org/policy/
American Speech-Language-Hearing Association. (2018a). Facilitated communication [Position Statement]. www.asha.org/policy/
American Speech-Language-Hearing Association. (2018b). Rapid prompting method [Position Statement]. www.asha.org/policy/
American Speech-Language-Hearing Association. (2018c). Scope of practice in audiology [Scope of Practice]. www.asha.org/policy/
Attwood, T. (2004). Exploring feelings: Cognitive behavior therapy to manage anxiety. Future Horizons.
Bailey, A., Le Couteur, A., Gottesman, I., Bolton, P., Simonoff, E., Yuzda, E., & Rutter, M. (1995). Autism as a strongly genetic disorder: Evidence from a British twin study. Psychological Medicine, 25(1), 63–77. https://doi.org/10.1017/s0033291700028099
Baio, J., Wiggins, L., Christensen, D. L., Maenner, M. J., Daniels, J., Warren, Z., Kurzius-Spencer, M., Zahorodny, W., Robinson Rosenberg, C., White, T., Durkin, M. S., Imm, P., Nikolaou, L., Yeargin-Allsopp, M., Lee, L.-C., Harrington, R., Lopez, M., Fitzgerald, R. T., Hewitt, A., . . . Dowling, N. F. (2018). Prevalence of autism spectrum disorder among children aged 8 years — Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2014. MMWR Surveillance Summaries, 67(SS-6), 1–23. https://doi.org/10.15585/mmwr.ss6706a1
Baranek, G. T. (1999). Autism during infancy: A retrospective video analysis of sensory-motor and social behaviors at 9–12 months of age. Journal of Autism and Developmental Disorders, 29(3), 213–224.
Baron-Cohen, S., Allen, J., & Gillberg, C. (1992). Can autism be detected at 18 months? The needle, the haystack, and the CHAT. British Journal of Psychiatry, 161(6), 839–843.
Begeer, S., El Bouk, S., Boussaid, W., Terwogt, M. M., & Koot, H. M. (2009). Underdiagnosis and referral bias of autism in ethnic minorities. Journal of Autism and Developmental Disorders, 39(1), 142–148. https://doi.org/10.1007/s10803-008-0611-5
Berard, G. (1993). Hearing equals behavior. Keats.
Blanc, M. (2012). Natural language acquisition on the autism spectrum: The journey from echolalia to self-generated language. Communication Development Center.
Bondy, A. S., & Frost, L. A. (1998). Picture Exchange Communication System. Topics in Language Disorders, 19(4), 373–390. https://doi.org/10.1055/s-2008-1064055
Bourgeron, T. (2016). Current knowledge on the genetics of autism and propositions for future research. Comptes Rendus Biologies, 339(7–8), 300–307. https://doi.org/10.1016/j.crvi.2016.05.004
Bradshaw, J., Steiner, A. M., Gengoux, G., & Koegel, L. K. (2015). Feasibility and effectiveness of very early intervention for infants at-risk for autism spectrum disorder: A systematic review. Journal of Autism and Developmental Disorders, 45(3), 778–794. https://doi.org/10.1007/s10803-014-2235-2
Brueggeman, P. M. (2012). 10 tips for testing hearing in children with autism. The ASHA Leader, 17(1), 5–7. https://doi.org/10.1044/leader.FTR3.17012012.5
Brugha, T. S., McManus, S., Bankart, J., Scott, F., Purdon, S., Smith, J., Bebbington, P., Jenkins, R., & Meltzer H. (2011). Epidemiology of autism spectrum disorders in adults in the community in England. Archives of General Psychiatry, 68(5), 459–465. https://doi.org/10.1001/archgenpsychiatry.2011.38
Bryson, S. E., Zwaigenbaum, L., McDermott, C., Rombough, V., & Brian, J. (2008). The Autism Observation Scale for Infants: Scale development and reliability data. Journal of Autism and Developmental Disorders, 38(4), 731–738. https://doi.org/10.1007/s10803-007-0440-y
Carper, R. A., & Courchesne, E. (2005). Localized enlargement of the frontal cortex in early autism. Biological Psychiatry, 57(2), 126–133. https://doi.org/10.1016/j.biopsych.2004.11.005
Carr, E. G., Dunlap, G., Horner, R. H., Koegel, R. L., Turnbull, A. P., Sailor, W., Anderson, J. L., Albin, R. W., Koegel, L. K., & Fox, L. (2002). Positive behavior support: Evolution of an applied science. Journal of Positive Behavior Interventions,4(1), 4–16. https://doi.org/10.1177/109830070200400102
Carr, E. G., & Durand, V. M. (1985). Reducing behavior problems through functional communication training. Journal of Applied Behavioral Analysis, 18(2), 111–126. https://doi.org/10.1901/jaba.1985.18-111
Chakrabarti, S., & Fombonne, E. (2005). Pervasive developmental disorders in preschool children: Confirmation of high prevalence. American Journal of Psychiatry, 162(6), 1133–1141. https://doi.org/10.1176/appi.ajp.162.6.1133
Chawarska, K., Paul, R., Klin, A., Hannigen, S., Dichtel, L. E., & Volkmar, F. (2007). Parental recognition of developmental problems in toddlers with autism spectrum disorders. Journal of Autism and Developmental Disorders, 37(1), 62–72. https://doi.org/10.1007/s10803-006-0330-8
Coe, B. P., Girirajan, S., & Eichler, E. E. (2012, May). The genetic variability and commonality of neurodevelopmental disease. American Journal of Medical Genetics. Part C, Seminars in Medical Genetics, 160C (2), 118–129. https://doi.org/10.1002/ajmg.c.31327
Cole, K. N., Dale, P. S., & Mills, P. E. (1990). Defining language delay in young children by cognitive referencing: Are we saying more than we know? Applied Psycholinguistics, 11(3), 291–302. https://doi.org/10.1017/S0142716400008900
Colvert, E., Tick, B., McEwen, F., Stewart, C., Curran, S. R., Woodhouse, E., Gillan, N., Hallett, V., Lietz, S., Garnett, T., Ronald, A., Plomin, R., Rijsdijk, F., Happé, F., & Bolton, P. (2015). Heritability of autism spectrum disorder in a UK population-based twin sample. JAMA Psychiatry, 72(5), 415–423.
Crooke, P. J., Hendrix, R. E., & Rachman, J. Y. (2008). Brief Report: Measuring the effectiveness of teaching social thinking to children with Asperger syndrome and high-functioning autism. Journal of Autism and Developmental Disorders, 38(3), 581–591. https://doi.org/10.1007/s10803-007-0466-1
Davis, R., & Stiegler, L. N. (2005). Toward more effective audiological assessment of children with autism spectrum disorders. Seminars in Hearing, 26(4), 241–252. https://doi.org/10.1055/s-2005-922446
Dawson, G., & Osterling, J. (1997). Early intervention in autism. In M. Guralnick (Ed.), The effectiveness of early intervention (pp. 307–326). Brookes.
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., & Varley, J. (2010). Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model. Pediatrics, 125(1), e17–e23. https://doi.org/10.1542/peds.2009-0958
Dean, M., Harwood, R., & Kasari, C. (2017). The art of camouflage: Gender differences in the social behaviors of girls and boys with autism spectrum disorder. Autism, 21(6), 678–689. https://doi.org/10.1177/1362361316671845
De Rubeis, S., He, X., Goldberg, A. P., Poultney, C. S., Samocha, K., Ercument Cicek, Kou, Y., Liu, L., Fromer, M., Walker, S., Singh, T., Klei, L., Kosmicki, J., Fu, S.-C., Aleksic, B., Biscaldi, M., Bolton, P. F., Brownfeld, J. M., Cai, J. . . . Buxbaum, J. D. (2014, October 24). Synaptic, transcriptional and chromatin genes disrupted in autism. Nature, 515(7526), 209–215. https://doi.org/10.1038/nature13772
DiLavore, P., Lord, C., & Rutter, M. (1995). The Prelinguistic Autism Diagnostic Observation Schedule. Journal of Autism and Developmental Disorders, 25(4), 355–379. https://doi.org/10.1007/bf02179373
Drysdale, H., van der Meer, L., & Kagohara, D. (2015). Children with autism spectrum disorder from bilingual families: A systematic review. Review Journal of Autism and Developmental Disorders, 2, 26–38. https://doi.org/10.1007/s40489-014-0032-7
Dworzynski, K., Ronald, A., Bolton, P., & Happé, F. (2012). How different are girls and boys above and below the diagnostic threshold for autism spectrum disorders? Journal of the American Academy of Child and Adolescent Psychiatry, 51(8), 788–797. https://doi.org/10.1016/j.jaac.2012.05.018
Easterbrooks, S. R., & Handley, C. M. (2005). Behavior change in a student with a dual diagnosis of deafness and pervasive development disorder: A case study. American Annals of the Deaf, 150(5), 401–407. https://doi.org/10.1353/aad.2006.0001
Ecker C., Spooren, W., & Murphy D. G. (2013). Translational approaches to the biology of Autism: False dawn or a new era? Molecular Psychiatry, 18(4), 435–442. https://doi.org/10.1038/mp.2012.102
Edelman, L. (2004). A relationship-based approach to early intervention. Resources and Connections, 3(2), 2–10.
Ellis, A., & Dryden, W. (1997). The practice of rational emotive behavior therapy. Springer.
Ellison, M., Clark, J., Cunningham, M., & Hansen, R. (2013, September). Academic and campus accommodations that foster success for college students with Asperger's disorder: Academic and campus accommodations necessary for an effective college experience. In F. Kochan, L. Searby, & M. Barakat (Eds.), Southern Regional Council on Educational Administration 2013 Yearbook: Jazzing It Up (pp. 65–76). Auburn University College of Education.
Elsabbagh, M., Mercure, E., Hudry, K., Chandler, S., Pasco, G., Charman, T., Pickles, A., Baron-Cohen, S., Bolton, P., & Johnson, M. H. (2012). Infant neural sensitivity to dynamic eye gaze is associated with later emerging autism. Current Biology, 22(4), 338–342. https://doi.org/10.1016/j.cub.2011.12.056
Filipek, P. A., Accardo, P. J., Baranek, G. T., Cook, E. H., Jr., Dawson, G., Gordon, B., Gravel, J. S., Johnson, C. P., Kallen, R. J., Levy, S. E., Minshew, N. J., Ozonoff, S., Prizant, B. M., Rapin, I., Rogers, S. J., Stone, W. L., Teplin, S., Tuchman, R. F., & Volkmar, F. R. (1999). The screening and diagnosis of autistic spectrum disorders. Journal of Autism and Developmental Disorders, 29(6), 439–484. https://doi.org/10.1023/a:1021943802493
Frith, U., & Happé, F. (1994). Autism: Beyond “theory of mind.” Cognition, 50(1–3), 115–132. https://doi.org/10.1016/0010-0277(94)90024-8
Garcia Winner, M., & Crooke, P. J. (2009). Social thinking: A training paradigm for professionals and treatment approach for individuals with social learning/social pragmatic challenges. Perspectives on Language Learning and Education, 16(2), 62–69. https://doi.org/10.1044/lle16.2.62
Garcia Winner, M., & Crooke, P. J. (2011, January 18). Social communication strategies for adolescents with autism. The ASHA Leader 16(1), 8–11. https://doi.org/10.1044/leader.FTR1.16012011.8
Garfinkle, A. N., & Schwartz, I. S. (2002). Peer imitation: Increasing social interactions in children with autism and other developmental disabilities in inclusive preschool classrooms. Topics in Early Childhood Special Education, 22(1), 26–38. https://doi.org/10.1177/027112140202200103
Geurts, H. M., & Jansen, M. D. (2012). A retrospective chart study: The pathway to a diagnosis for adults referred for ASD assessment. Autism, 16(3), 299–305. https://doi.org/10.1177/1362361311421775
Gilchrist, A., Green, J., Cox, A., Burton, D., Rutter, M., & Le Couteur, A. (2001). Development and current functioning in adolescents with Asperger syndrome: A comparative study. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 42(2), 227–240. https://doi.org/10.1017/S0021963001006631
Gray, C., White, A. L., & McAndrew, S. (2002). My social stories book. Jessica Kingsley Publishers.
Greenspan, S. I., & Wieder, S. (2007). The developmental individual-difference, relationship-based (DIR/Floortime) model approach to autism spectrum disorders. In E. Hollander & E. Anagnostou (Eds.), Clinical manual for the treatment of autism (p. 179–209). American Psychiatric Publishing.
Gutstein, S. E., & Gutstein, H. R. (2009). The RDI book: Forging new pathways for autism, Asperger's and PDD with the relationship development intervention program. Connections Center Publications.
Gutstein, S. E., Burgess, A. F., & Montfort, K. (2007). Evaluation of the Relationship Development Intervention program. Autism, 11(5), 397–411. https://doi.org/10.1177/1362361307079603
Ha, S., Sohn, I. J., Kim, N., Sim, H. J., & Cheon, K. A. (2015). Characteristics of brains in autism spectrum disorder: Structure, function and connectivity across the lifespan. Experimental Neurobiology, 24(4), 273–284. https://doi.org/10.5607/en.2015.24.4.273
Hambly, C., & Fombonne, E. (2012). The impact of bilingual environments on language development in children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42(7), 1342–1352. https://doi.org/10.1007/s10803-011-1365-z
Hamilton, B., & Snell, M. (1993). Using the milieu approach to increase spontaneous communication book use across environments by an adolescent with autism. Augmentative and Alternative Communication, 9(4), 259–272. https://doi.org/10.1080/07434619312331276681
Harris, S. L., & Handleman, J. S. (2000). Age and IQ at intake as predictors of placement for young children with autism: A four- to six-year follow-up. Journal of Autism and Developmental Disorders, 30(2), 137–142. https://doi.org/10.1023/a:1005459606120
Hart, J. E., & Whalon, K. J. (2008). Promote academic engagement and communication of students with autism spectrum disorder in inclusive settings. Intervention in School and Clinic, 44(2), 116–120. https://doi.org/10.1177/1053451207310346
Hazlett, H. C., Poe, M. D., Gerig, G., Gimpel Smith, R., & Piven, J. (2006). Cortical gray and white brain tissue volume in adolescents and adults with autism. Biological Psychiatry, 59(1), 1–6. https://doi.org/10.1016/j.biopsych.2005.06.015
Helping Autism Through Learning and Outreach (HALO). (n.d). RPM: A new way of looking at autism. http://www.halo-soma.org/
Hendricks, D. (2010). Employment and adults with autism spectrum disorders: Challenges and strategies for success. Journal of Vocational Rehabilitation, 32(2), 125–134. https://doi.org/10.3233/JVR-2010-0502
Howlin, P., & Moss, P. (2012). Adults with autism spectrum disorders. Canadian Journal of Psychiatry, 57(5), 275–283. https://doi.org/10.1177/070674371205700502
Hoyson, M., Jamieson, B., & Strain, P. S. (1984). Individualized group instruction of normally developing and autistic-like children: The LEAP curriculum model. Journal of Early Intervention, 8(2), 157–172. https://doi.org/10.1177/105381518400800209
Individuals with Disabilities Education Improvement Act of 2004. P.L. 108-446, 20 U.S.C. §§ 1501et seq. (2004). https://www.congress.gov/bill/108th-congress/house-bill/1350
Interagency Autism Coordinating Committee (IACC). (2017, October). 2016–2017 Interagency Autism Coordinating Committee strategic plan for autism spectrum disorder. https://iacc.hhs.gov/publications/strategic-plan/2017/
Iossifov, I., Ronemus, M., Levy, D., Wang, Z., Hakker, I., Rosenbaum, J., Yamrom, B., Lee, Y.-H., Narzisi, G., Leotta, A., Kendall, J., Grabowska, E., Ma, B., Marks, S., Rodgers, L., Stepansky, A., Troge, J., Andrews, P., Bekritsky, M., . . . Wigler, M. (2012). De novo gene disruptions in children on the autistic spectrum. Neuron, 74(2), 285–299. https://doi.org/10.1016/j.neuron.2012.04.009
Iversen, P. (2007, November 11). The informative pointing method. https://www.strangeson.com/files/Informative_Pointing_Method.pdf
Jones, W., Carr, K., & Klin, A. (2008). Absence of preferential looking to the eyes of approaching adults predicts level of social disability in 2-year-old toddlers with autism spectrum disorder. Archives of General Psychiatry, 65(8), 946–954. https://doi.org/10.1001/archpsyc.65.8.946
Jones, W., & Klin, A. (2013, December 19). Attention to eyes is present but in decline in 2–6-month-old infants later diagnosed with autism. Nature, 504(7480), 427–431. https://doi.org/10.1038/nature12715
Kaiser, A. P., Yoder, P. J., & Keetz, A. (1992). Evaluating milieu teaching. In S. F. Warren & J. Reichle (Eds.), Causes and effects in communication and language intervention (pp. 9–47). Brookes.
Kasari, C., Paparella, T., Freeman, S., & Jahromi, L. B. (2008). Language outcome in autism: Randomized comparison of joint attention and play interventions. Journal of Consulting and Clinical Psychology, 76(1), 125–137.
Khowaja, K., & Salim, S. S. (2013). A systematic review of strategies and computer-based intervention (CBI) for reading comprehension of children with autism. Research in Autism Spectrum Disorders, 7(9), 1111–1121. https://doi.org/10.1016/j.rasd.2013.05.009
Koegel, L. K., Ashbaugh, K., Koegel, R. L., Detar, W. J., & Regester, A. (2013). Increasing socialization in adults with Asperger's syndrome. Psychology in the Schools, 50(9), 899–909. https://doi.org/10.1002/pits.21715
Koegel, L. K., Ashbaugh, K., Navab, A., & Koegel, R. L. (2016). Improving empathic communication skills in adults with autism spectrum disorder. Journal of Autism and Developmental Disorders, 46(3), 921–923. https://doi.org/10.1007/s10803-015-2633-0
Koegel, R. L., & Koegel, L. K. (2019). Pivotal response treatment for autism spectrum disorders. Brookes.
Koegel, L. K., Navab, A., Ashbaugh, K., & Koegel, R. L. (2015). Using reframing to reduce negative statements in social conversation for adults with autism spectrum disorder. Journal of Positive Behavior Interventions, 18(3), 133–144. https://doi.org/10.1177/1098300715596136
Koegel, L. K., Singh, A. K., Koegel, R. L., Hollingsworth, J. R., & Bradshaw, J. (2014). Assessing and improving early social engagement in infants. Journal of Positive Behavior Interventions, 16(2), 69–80. https://doi.org/10.1177/1098300713482977
Kogan, M. D., Vladutiu, C. J., Schieve, L. A., Ghandour, R. M, Blumberg, S. J., Zablotsky, B., Perrin, J. M., Shattuck, P., Kuhlthau, K. A., Harwood R. L., & Lu, M. C. (2018). The prevalence of parent-reported autism spectrum disorder among U.S. children. Pediatrics, 142(6), Article e20174161. https://doi.org/10.1542/peds.2017-4161
Krieger, B., Piškur, B., Schulze, C., Jakobs, U., Beurskens, A., & Moser, A. (2018). Supporting and hindering environments for participation of adolescents diagnosed with autism spectrum disorder: A scoping review. PLOS ONE, 13(8), Article e0202071. https://doi.org/10.1371/journal.pone.0202071
Landa, R. J., & Kalb, L. G. (2012). Long-term outcomes of toddlers with autism spectrum disorders exposed to short-term intervention. Pediatrics, 130(Suppl. 2), S186–S190. https://doi.org/10.1542/peds.2012-0900Q
Landrigan, P. J., Lambertini, L., & Birnbaum, L. S. (2012). A research strategy to discover the environmental causes of autism and neurodevelopmental disabilities. Environmental Health Perspectives, 120(7), a258–a260. https://doi.org/10.1289/ehp.1104285
Lanter, E., & Watson, L. R. (2008). Promoting literacy in students with ASD: The basics for the SLP. Language, Speech, and Hearing Services in Schools, 39(1), 33–43. https://doi.org/10.1044/0161-1461(2008/004)
Lawton, K., & Kasari, C. (2012). Teacher-implemented joint attention intervention: Pilot randomized controlled study for preschoolers with autism. Journal of Consulting and Clinical Psychology, 80(4), 687–693.
Lounds Taylor, J., Adams, R. A., & Bishop, S. L. (2017). Social participation and its relation to internalizing symptoms among youth with autism spectrum disorder as they transition from high school. Autism Research, 10(4), 663–672. https://doi.org/10.1002/aur.1709
Lounds Taylor, J., Henninger, N. A., & Mailick, M. R. (2015). Longitudinal patterns of employment and postsecondary education for adults with autism and average-range IQ. Autism, 19(7), 785–793. https://doi.org/10.1177/1362361315585643
Lounds Taylor, J. L., & Seltzer, M. M. (2011). Employment and post-secondary educational activities for young adults with autism spectrum disorders during the transition to adulthood. Journal of Autism and Developmental Disorders, 41(5), 566–574. https://doi.org/10.1007/s10803-010-1070-3
Lord, C., & Corsello, C. (2005). Diagnostic instruments in autistic spectrum disorders. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders: Volume 2: Assessment, interventions, and policy (pp. 730–771). Wiley.
Maenner, M. J., Rice, C. E., Arneson, C. L., Cunniff, C., Schieve, L. A., Carpenter, L. A., Van Naarden Braun, K., Kirby, R. S., Bakian, A. V., & Durkin, M. S. (2014). Potential impact of DSM-5 criteria on autism spectrum disorder prevalence estimates. JAMA Psychiatry, 71(3), 292–300. https://doi.org/10.1001/jamapsychiatry.2013.3893
Malandraki, G. A., & Okalidou, A. (2007). The application of PECS in a deaf child with autism: A case study. Focus on Autism and Other Developmental Disabilities, 22(1), 23–32.
Mandy, W., Chilvers, R., Chowdhury, U., Salter, G., Seigal, A., & Skuse, D. (2012). Sex differences in autism spectrum disorder: Evidence from a large sample of children and adolescents. Journal of Autism and Developmental Disorders, 42(7), 1304–1313. https://doi: 10.1007/s10803-011-1356-0
Marcus, L. M., Kunce, L. J., & Schopler, E. (2005). Working with families. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders: Volume 1: Diagnosis, development, neurobiology, and behavior (pp. 1055–1086). Wiley.
McCleery, J. P., Akshoomoff, N., Dobkins, K. R., & Carver, L. J. (2009). Atypical face versus object processing and hemispheric asymmetries in 10-month-old infants at risk for autism. Biological Psychiatry, 66(10), 950–957. https://doi.org/10.1016/j.biopsych.2009.07.031
McGee, G. G., Morrier, M. J., & Daly, T. (1999). An incidental teaching approach to early intervention for toddlers with autism. Journal of the Association for Persons With Severe Handicaps, 24, 133–146. https://doi.org/10.2511/rpsd.24.3.133
McGee, J. J. (1990). Mental handicap nursing. Gentle teaching: The basic tenet. Nursing Times, 86(32), 68–72.
Mesibov, G. B., Shea, V., & Schopler, E. (2007). The TEACCH approach to autism spectrum disorders. Springer.
Miller, J., & Chapman, R. (1980). Analyzing language and communication in the child. In R. Schiefelbusch (Ed.), Nonspeech language, and communication: Acquisition and intervention (pp. 159–196). University Park Press.
Mirenda, P., Wilk, D., & Carson, P. (2000). A retrospective analysis of technology use patterns of students with autism over a five-year period. Journal of Special Education Technology, 15(3), 5–16. https://doi.org/10.1177/016264340001500301
Moes, D. R., & Frea, W. D. (2002). Contextualized behavioral support in early intervention for children with autism and their families. Journal of Autism and Developmental Disorders, 32(6), 519–533. https://doi.org/10.1023/A:1021298729297
Morgan, L., Leatzow, A., Clark, S., & Siller, M. (2014). Interview skills for adults with autism spectrum disorder: A pilot randomized controlled trial. Journal of Autism and Developmental Disorders, 44(9), 2290–2300. https://doi.org/10.1007/s10803-014-2100-3
Moskowitz, G. B. (2005). Social cognition: Understanding self and others. Guilford.
Mueller, E., Schuler, A. L., Burton, B., & Yates, G. (2003). Meeting the vocational support needs of individuals with Asperger's syndrome, and other autism spectrum disabilities. Journal of Vocational Rehabilitation, 18(3), 163–176.
Mukhopadhyay, S. (2008). Understanding autism through rapid prompting method. Outskirts.
Mukhopadhyay, S. (2011). Curriculum guide for autism using rapid prompting method: With lesson plan suggestions. Outskirts.
Mulvihill B, Wingate M, Kirby RS, Pettygrove S, Cunniff C, Meaney FJ, Miller L, Robinson C, Quintana G, Kaiser MY, Lee LC, Landa R, Newschaffer C, Constantino J, Fitzgerald R, Daniels J, Giarelli E, Pinto-Martin J, Levy SE, . . . Doernberg N. (2009). Prevalence of autism spectrum disorders – Autism and Developmental Disabilities Monitoring Network, United States, 2006. MMWR Surveillance Summaries, 58(10), 1–20.
Myers, E., Davis, B. E., Stobbe, G., & Bjornson, K. (2015). Community and social participation among individuals with autism spectrum disorder transitioning to adulthood. Journal of Autism and Developmental Disorders, 45(8), 2373–2381. https://doi.org/10.1007/s10803-015-2403-z
National Joint Committee for the Communication Needs of Persons With Severe Disabilities. (2003). Position statement on access to communication services and supports: Concerns regarding the application of restrictive "eligibility" policies [Position statement]. www.asha.org/policy/
National Research Council. (2001). Educating children with autism. National Academy Press.
Neale, B. M., Kou, Y., Liu, L., Ma'ayan, A., Samocha, K. E., Sabo, A., Lin, C. F., Stevens, C., Wang, L. S., Makarov, V., Polak, P., Yoon, S., Maguire, J., Crawford, E. L., Campbell, N. G., Geller, E. T., Valladares, O., Schafer, C., Liu, H., , . . . Daly, M. J. (2012, April 4). Patterns and rates of exonic de novo mutations in autism spectrum disorders. Nature, 485(7397), 242–245. https://doi.org/10.1038/nature11011
Nelson, K. (1978). How children represent knowledge of their world in and out of language: A preliminary report. In Robert S. Siegler (Ed.), Children's thinking: What develops? (pp. 255–273). Erlbaum.
O'Neill, T., Light, J., & McNaughton, D. (2017). 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. Perspectives on Augmentative and Alternative Communication, 2(12), 55–69. https://pubs.asha.org/doi/full/10.1044/persp2.SIG12.55
O'Roak, B. J., Vives, L., Fu, W., Egertson, J. D., Stanaway, I. B., Phelps, I. G., Carvill, G., Kumar, A., Lee, C., Ankenman, K., Munson, J., Hiatt, J. B., Turner, E. H., Levy, R., O'Day, D. R., Krumm, N., Coe, B. P., Martin, B. K., Borenstein, E., . . . Shendure, J. (2012, December 21). Multiplex targeted sequencing identifies recurrently mutated genes in autism spectrum disorders. Science, 338(6114), 1619–1622. https://doi.org/10.1126/science.1227764
Orsmond, G. I., Shattuck, P. T., Cooper, B. P., Sterzing, P. R., & Anderson, K. A. (2013). Social participation among young adults with an autism spectrum disorder. Journal of Autism and Developmental Disorders, 43(11), 2710–2719. https://doi.org/10.1007/s10803-013-1833-8
Ozonoff, S., Young, G. S., Carter, A., Messinger, D., Yirmiya, N., Zwaigenbaum, L., Bryson, S., Carver, L. J., Constantino, J. N., Dobkins, K., Hutman, T., Iverson, J. M., Landa, R., Rogers, S. J., Sigman, M., . . . Stone, W. L. (2011). Recurrence risk for autism spectrum disorders: A Baby Siblings Research Consortium study. Pediatrics, 128(3), e448–e495. https://doi.org/10.1542/peds.2010-2825
Palmen, S. J., Hulshoff Pol, H. E., Kemner, C., Schnack, H. G., Durston, S., Lahuis, B. E., Kahn, R. S., & Van Engeland, H. (2005). Increased gray-matter volume in medication-naive high-functioning children with autism spectrum disorder. Psychological Medicine, 35(4), 561–570.
Patten, E., Belardi, K., Baranek, G. T., Watson, L. R., Labban, J. D., & Oller, D. K. (2014). Vocal patterns in infants with autism spectrum disorder: Canonical babbling status and vocalization frequency. Journal of Autism and Developmental Disorders, 44(10), 2413–2428.
Paul, D. (2013). A quick guide to DSM-5. The ASHA Leader, 18(8), 52–54. https://doi.org/10.1044/leader.FTR4.18082013.np
Payton, J. W., Wardlaw, D. M., Graczyk, P. A., Bloodworth, M. R., Tompsett, C. J., & Weissberg, R. P. (2000). Social and emotional learning: A framework for promoting mental health and reducing risk behavior in children and youth. Journal of School Health, 70(5), 179–185.
Pea, E. D. (1996). Dynamic assessment: The model and its language applications. In K. N. Cole, P. S. Dale, & D. J. Thal (Eds.), Communication and language intervention series: Vol. 6. Advances in assessment of communication and language (pp. 281–307). Brookes.
Pickett, E., Pullara, O., O'Grady, J., & Gordon, B. (2009). Speech acquisition in older nonverbal individuals with autism: A review of features, methods, and prognosis. Cognitive and Behavioral Neurology, 22(1), 1–21.
Pierce, K., Carter, C., Weinfeld, M., Desmond, J., Hazin, R., Bjork, R., & Gallagher, N. (2011). Detecting, studying, and treating autism early: The one-year well-baby check-up approach. The Journal of Pediatrics, 159(3), 458–465.
Plauché Johnson, C., & Myers, S. M. (2007). Identification and evaluation of children with autism spectrum disorders. Pediatrics, 120(5), 1183–1215. https://doi.org/10.1542/peds.2007-2361
Plumb, A. M., & Wetherby, A. M. (2013). Vocalization development in toddlers with autism spectrum disorder. Journal of Speech, Language, and Hearing Research, 56(2), 721–734. https://doi.org/10.1044/1092-4388(2012/11-0104)
Polirstok, S. R., Dana, L., Buono, S., Mongelli, V., & Trubia, G. (2003). Improving functional communication skills in adolescents and young adults with severe autism using gentle teaching and positive approaches. Topics in Language Disorders, 23(2), 146–153.
Prizant, B. M., & Wetherby, A. M. (1998). Understanding the continuum of discrete-trial traditional behavioral to social-pragmatic developmental approaches in communication enhancement for young children with autism/PDD. Seminars in Speech and Language, 19(4), 329–353. https://doi.org/10.1055/s-2008-1064053
Prizant, B. M., Wetherby, A. M., Rubin, E., Laurent, A. C., & Rydell, P. J. (2006). The SCERTS Model: Comprehensive educational approach for children with autism spectrum disorders. Brookes.
Rogers, S. J., & Dawson, G. (2009). Play and engagement in early autism: The Early Start Denver Model. Volume I: The Treatment. Guilford.
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Promoting language, learning, and engagement. Guilford.
Sanders, S. J., Murtha, M. T., Gupta, A. R., Murdoch, J. D., Raubeson, M. J., Willsey, A. J., Gulhan Ercan-Sencicek, A., DiLullo, N. M., Parikshak, N. N., Stein, J. L., Walker, M. F., Ober, G. T., Teran, N. A., Song, Y., El-Fishawy, P., Murtha, R. C., Choi, M., Overton, J. D., Bjornson, R. D., . . . State, M. W. (2012, April 4). De novo mutations revealed by whole-exome sequencing are strongly associated with autism. Nature, 485(7397), 237–241. https://doi.org/10.1038/nature10945
Scarpa, A., & Reyes, N. M. (2011). Improving emotion regulation with CBT in young children with high functioning autism spectrum disorders: A pilot study. Behavioural and Cognitive Psychotherapy, 39(4), 495–500. https://doi.org/10.1017/S1352465811000063
Schmidt, R. J., Lyall, K., & Hertz-Picciotto, I. (2014). Environment and autism: Current state of the science. Cutting Edge Psychiatry in Practice, 1(4), 21–38.
Shane, H. C., & Bashir, A. S. (1980). Election criteria for the adoption of an augmentative communication system: Preliminary considerations. Journal of Speech and Hearing Disorders, 45(3), 408–414. https://doi.org/10.1044/jshd.4503.408
Shattuck, P. T., Carter Narendorf, S., Cooper, B., Sterzing, P. R., Wagner, M., & Lounds Taylor, J. (2012). Postsecondary education and employment among youth with an autism spectrum disorder. Pediatrics, 129(6), 1042–1049. https://doi.org/10.1542/peds.2011-2864
Shelton, J. F., Hertz-Picciotto, I., & Pessah, I. N. (2012). Tipping the balance of autism risk: Potential mechanisms linking pesticides and autism. Environmental Health Perspectives, 120(7), 944–951. https://doi.org/10.1289/ehp.1104553
Smith, I. C., Reichow, B., & Volkmar, F. R. (2015). The effects of DSM-5 criteria on number of individuals diagnosed with autism spectrum disorder: A systematic review. Journal of Autism and Developmental Disorders, 45(8), 2541–2552. https://doi.org/10.1007/s10803-015-2423-8
Smith, M. J., Ginger, E. J., Wright, K., Wright, M. A., Lounds Taylor, J., Humm, L. B., Olsen, D. E., Bell, M. D., & Fleming, M. F. (2014). Virtual reality job interview training in adults with autism spectrum disorder. Journal of Autism and Developmental Disorders, 44(10), 2450–2463. https://doi.org/10.1007/s10803-014-2113-y
Snell, M. E. (2002). Using dynamic assessment with learners who communicate nonsymbolically. Augmentative and Alternative Communication, 18(3), 163–176. https://doi.org/10.1080/07434610212331281251
Stiegler, L. N., & Davis, R. (2010). Understanding sound sensitivity in individuals with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 25(2), 67–75. https://doi.org/10.1177/1088357610364530
Sussman, F. (1999). More than words: Helping parents promote communication and social skills in children with autism spectrum disorder. The Hanen Centre.
Sussman, F. (2006). TalkAbility: People skills for verbal children on the autism spectrum: A guide for parents. The Hanen Centre.
Szymanski, C., & Brice, P. J. (2008). When autism and deafness coexist in children: What we know now. Odyssey: New Directions in Deaf Education, 9(1), 10–15.
Taylor Dyches, T. T. (2011). Assessing diverse students with autism spectrum disorders. The ASHA Leader, 16(1), 12–15. https://doi.org/10.1044/leader.FTR2.16012011.12
Taylor Dyches, T., Wilder, L., & Obiakor, F. (2001). Autism: Multicultural perspectives. In T. Wahlberg, F. Obiakor, S. Burkhardt, & A. F. Rotatori (Eds.), Autistic spectrum disorders: Educational and clinical interventions: Vol. 14. Advances in Special Education (pp. 151–177). Emerald Group Publishing. https://doi.org/10.1016/S0270-4013(01)80012-X
Tek, S., & Landa, R. J. (2012). Differences in autism symptoms between minority and non-minority toddlers. Journal of Autism and Developmental Disorders, 42(9), 1967–1973. https://doi.org/10.1007/s10803-012-1445-8
Tierney, S., Burns, J., & Kilbey, E. (2016). Looking behind the mask: Social coping strategies of girls on the autistic spectrum. Research in Autism Spectrum Disorders, 23, 73–83. https://doi.org/10.1016/j.rasd.2015.11.013
Tierney, C., Mayes, S., Lohs, S. R., Black, A., Gisin, E., & Veglia, M. (2015). How valid is the checklist for autism spectrum disorder when a child has apraxia of speech? Journal of Developmental and Behavioral Pediatrics, 36(8), 569–574.
Timothy W. v. Rochester, New Hampshire School District, 875 F.2d 954 (1st Cir.) cert. denied, 493 U.S. 983 (1989).
Tsatsanis, K. D., Foley, C., & Donehower, C. (2004). Contemporary outcome research and programming guidelines for Asperger syndrome and high-functioning autism. Topics in Language Disorders, 24(4), 249–259.
Turner-Brown, L. M., Baranek, G. T., Reznick, J. S., Watson, L. R., & Crais, E. R. (2012). The First Year Inventory: A longitudinal follow-up of 12-month-old to 3-year-old children. Autism, 17(5), 527–540. https://doi.org/10.1177/1362361312439633
Van Bourgondien, M. E., & Woods, A. V. (1992). Vocational possibilities for high-functioning adults with autism. In E. Schopler & G. B. Mesibov (Eds.), High-functioning individuals with autism (pp. 227–239). Plenum.
van der Meer, L. A. J., & Rispoli, M. (2010). Communication interventions involving speech-generating devices for children with autism: A review of the literature. Developmental Neurorehabilitation, 13(4), 294–306. https://doi.org/10.3109/17518421003671494
Volkmar, F. R., Lord, C., Bailey, A., Schultz, R. T., & Klin, A. (2004). Autism and pervasive developmental disorders. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 45(1), 145–170. https://doi.org/10.1046/j.0021-9630.2003.00317.x
Watanabe, M., & Sturmey, P. (2003). The effect of choice-making opportunities during activity schedules on task engagement of adults with autism. Journal of Autism and Developmental Disorders, 33(5), 535–538. https://doi.org/10.1023/a:1025835729718
Watson, L. R., Crais, E. R., Baranek, G. T., Dykstra, J. R., Wilson, K. P., Hammer, C. S., & Woods, J. (2013). Communicative gesture use in infants with and without autism: A retrospective home video study. American Journal of Speech-Language Pathology, 22(1), 25–39. https://doi.org/10.1044/1058-0360(2012/11-0145)
Wehman, P. (2006). Individualized transition planning: Putting self-determination into action. In P. Wehman (Ed.), Life beyond the classroom: Transition strategies for young people with disabilities (pp. 71–96). Brookes.
Wehman, P., Brooke, V., Brooke, A. M., Ham, W., Schall, C., McDonough, J., . . . Avellone, L. (2016). Employment for adults with autism spectrum disorders: A retrospective review of a customized employment approach. Research in Developmental Disabilities, 53–54, 61–72. https://doi.org/10.1016/j.ridd.2016.01.015
Wei, X., Wagner, M., Hudson, L., Yu, J. W., & Shattuck, P. (2015). Transition to adulthood: Employment, education, and disengagement in individuals with autism spectrum disorder. Emerging Adulthood, 3(1), 37–45. https://doi.org/10.1177/2167696814534417
Weng, P. L., Maeda, Y., & Bouck, E. C. (2014). Effectiveness of cognitive skills-based computer-assisted instruction for students with disabilities: A synthesis. Remedial and Special Education, 35(3), 167–180. https://doi.org/10.1177/0741932513514858
Werner, E., & Dawson, G. (2005). Validation of the phenomenon of autistic regression using home videotapes. Archives of General Psychiatry, 62(8), 889–895. https://doi.org/10.1001/archpsyc.62.8.889
Wetherby, A. M., Brosnan-Maddox, S., Peace, V., & Newton, L. (2008). Validation of the Infant–Toddler Checklist as a broadband screener for autism spectrum disorders from 9 to 24 months of age. Autism, 12(5), 487–511. https://doi.org/10.1177/1362361308094501
Wetherby, A. M., Prizant, B. M., & Schuler, A. L. (2000). Understanding the nature of communication and language impairments. In A. M. Wetherby & B. M. Prizant (Eds.), Autism spectrum disorders: A transactional developmental perspective: Vol. 9 (pp. 109–141). Brookes.
Whitaker, P., Barratt, P., Joy, H., Potter, M., & Thomas, G. (1998). Children with autism and peer group support: Using “circles of friends.” British Journal of Special Education, 25(2), 60–64. https://doi.org/10.1111/1467-8527.t01-1-00058
Wilder, L. K., Taylor Dyches, T. T., Obiakor, F. E., & Algozzine, B. (2004). Multicultural perspectives on teaching students with autism. Focus on Autism and Other Developmental Disabilities, 19(2), 105–113. https://doi.org/10.1177/10883576040190020601
Williams, D. (2012, March). Neurological basis for autism: Implications for speech-language pathologists. Mini-seminar presented at the Ohio Speech-Language-Hearing Association, Columbus, OH.
Willsey, A. J., & State, M. W. (2015). Autism spectrum disorders: From genes to neurobiology. Current Opinion in Neurobiology, 30,92–99. https://doi.org/10.1016/j.conb.2014.10.015
Wolfberg, P. J., & Schuler, A. L. (1993). Integrated play groups: A model for promoting the social and cognitive dimensions of play in children with autism. Journal of Autism and Developmental Disorders, 23(3), 467–489. https://doi.org/10.1007/BF01046051
Wood, J. J., Drahota, A., Sze, K., Van Dyke, M., Decker, K., Fujii, C., Bahng, C., Renno, P., Hwang, W.-C., & Spiker, M. (2009). Brief report: Effects of cognitive behavioral therapy on parent-reported autism symptoms in school-age children with high-functioning autism. Journal of Autism and Developmental Disorders, 39(11), 1608–1612. https://doi.org/10.1007/s10803-009-0791-7
Woods, J. J., & Wetherby, A. M. (2003). Early identification of and intervention for infants and toddlers who are at risk for autism spectrum disorder. Language, Speech, and Hearing Services in Schools, 34(3), 180–193. https://doi.org/10.1044/0161-1461(2003/015)
World Health Organization. (2001). International classification of functioning, disability and health.
Worley, J. A., Matson, J. L., & Kozlowski, A. M. (2011). The effects of hearing impairment on symptoms of autism in toddlers. Developmental Neurorehabilitation, 14(3), 171–176. https://doi.org/10.3109/17518423.2011.564600
Yu, B. (2013). Issues in bilingualism and heritage language maintenance: Perspectives of minority-language mothers of children with autism spectrum disorders. American Journal of Speech-Language Pathology, 22(1), 10–24. https://doi.org/10.1044/1058-0360(2012/10-0078)
Zager, D., & Alpern, C. S. (2010). College-based inclusion programming for transition-age students with autism. Focus on Autism and Other Developmental Disabilities, 25(3), 151–157. https://doi.org/10.1177/1088357610371331
Zwaigenbaum, L., Bryson, S., Rogers, T., Roberts, W., Brian, J., & Szatmari, P. (2005). Behavioral manifestations of autism in the first year of life. International Journal of Developmental Neuroscience, 23(2–3), 143–152. https://doi.org/10.1016/j.ijdevneu.2004.05.001
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.
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.
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/.