Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social communication and social interaction in the presence of restricted, repetitive behaviors. Overall estimated ASD prevalence is 1 in 68 (14.7 per 1,000) in children age 8 years (Centers for Disease Control and Prevention, 2014). ASD and hearing impairment can occur in the same individual (Easterbrooks & Handley, 2005; Malandraki & Okalidou, 2007; Szymanski & Brice, 2008). The similarities in communication and socialization deficits between hearing impairment and ASD populations, along with the possibility of dual diagnosis, make early and differential diagnosis essential. Because most newborns are screened for hearing loss, it is often diagnosed first—which may sometimes delay the diagnosis of ASD.

Social communication deficits in ASD include impairments in aspects of joint attention (demonstration of shared interest or understanding); social reciprocity; and use of verbal and nonverbal communicative behaviors for social interaction.

On this page:

• Impact, Medical Necessity, and Benefit
• Role of the Audiologist
• Role of the Speech-Language Pathologist
• Evidence and Outcomes of Speech-Language Pathology Treatment
• Services Across the Lifespan
• Support Provided by SLPs for Individuals with ASD Transitioning in New Settings or Stages of Life
• Distinct Role of SLPs Compared with Applied Behavior Analysis (ABA) Therapists

Impact, Medical Necessity, and Benefit

In addition to enormous educational and societal impacts, ASD results in substantial health care expenditures:

• Compared to children without ASD, children with ASD incurred 2.5 times as much outpatient costs, 2.9 times as much inpatient costs, and 7.6 times as much medication costs (Croen, Najjar, Ray, Lotspeich, & Bernal, 2006).
• For young children with ASD, “higher rates of service use and thus costs are associated with more severe or pervasively impaired cases” (Barrett et al., 2011).

Determination of medical necessity considers whether the service is essential and appropriate to the diagnosis and/or treatment of an illness, injury, or medical condition. ASD is a medical condition and a disorder of body function where neurological substrates for audiology, speech, and language—including speech production, verbal expression, auditory processing, and social communication—are adversely affected. Audiology and speech-language pathology services are essential and appropriate in treating speech, language, and social communication disorders as well as feeding and swallowing disorders.

Audiologists and speech-language pathologists are specifically cited as integral to the evaluation of ASD in practice guidelines published by the following organizations (among others):

• American Academy of Neurology and the Child Neurology Society [PDF]
• American Academy of Pediatrics
• Missouri Foundation for Health [PDF]
• National Research Council of the National Academy of Sciences
• New Hampshire Department of Health and Human Services [PDF]
• New York State Department of Health [PDF]

Role of the Audiologist

Evaluation

Audiologists conduct audiologic evaluations when hearing loss and/or ASD are suspected. A complete audiologic evaluation typically includes a developmental screening to check that developmental milestones are being reached.

If ASD has not yet been identified, any red flags raised during developmental screening—particularly in communication and social domains—may warrant referral for further evaluation for ASD. Behavioral evaluation techniques are modified based on the individual’s developmental age and needs.

Treatment

Audiology services for individuals with hearing loss begin soon after a diagnosis is made. Services include audiologic habilitation/rehabilitation, which involves the selection, fitting, and evaluation of amplification technology (if selected by the individual/family as the treatment approach).

Individuals with both ASD and hearing loss may have sensory issues related to hearing aids, cochlear implants, or other hearing assistive technology. Audiologists can collaborate with early intervention, health care, and/or education teams to assist with improving compliance (e.g., gradual introduction of devices and increase of wear time) in the home or at school.

Role of the Speech-Language Pathologist

Evaluation

Speech-language pathologists (SLPs) are key members of interdisciplinary teams that diagnose ASD and determine an individual’s initial and continuing eligibility for habilitative and rehabilitative services and supports. Learn more about ASHA-certified SLPs and ASD [PDF].

Evaluation for individuals with ASD typically includes assessing the following:

• Verbal and nonverbal receptive language
• Verbal expressive language, including conversation skills such as topic management, turn-taking, and providing sufficient information in conversational contexts
• Nonverbal expressive language, including use of augmentative and alternative communication (AAC)
• Speech prosody
• Social communication skills in multiple contexts, including eye gaze, joint attention, initiation of communication, social reciprocity, play behaviors, and use of gestures and other body language
• Restricted, repetitive patterns of behaviors, interests, and activities such as (a) stereotyped use of speech and objects and (b) ritualized patterns of verbal and nonverbal behavior
• Sensory modality difficulties, including over-responsiveness, under-responsiveness, or mixed responsiveness patterns to environmental sounds, light, visual clutter, and social stimuli (e.g., social touch, proximity of others, and voices)
• Preference for nonsocial stimuli leading to intense interests with sensory aspects of objects and events
• Patterns of food acceptance or rejection based on manner of presentation or food texture

Continuing Assessment

In most cases, a confirmed diagnosis of ASD is possible before or around a child’s second birthday (Chawarska, Klin, Paul, Macri, & Volkmar, 2009). Any diagnosis of ASD, particularly of young children, is periodically reviewed because diagnostic categories and conclusions may change as the child develops. Ongoing assessment identifies the skills that an individual has achieved, the skills that are emerging, and the supports needed to enhance communication skills (e.g., AAC or modeling).

Continuing assessment can identify associated and secondary deficits, such as feeding and swallowing issues, including food sensitivities and aversions. A child with ASD is 5 times more likely to have a feeding problem compared with a child who does not have ASD (Sharp et al., 2013).

Comorbidities

Individuals with ASD often have comorbidities including mental disorders (e.g., anxiety and/or depression), gastrointestinal disorders, sleep disorders, and seizure disorders. These comorbid conditions are evaluated and treated by other medical professionals but may impact speech-language services.

Individuals with ASD who are experiencing restrictive and repetitive behaviors may exhibit avoidant/restrictive food intake disorder (ARFID)—avoidance of food due to texture, appearance, smell, brand, presentation, or a past negative experience. ARFID is a serious medical and mental health condition that can lead to malnutrition and other serious health conditions.

Treatment

SLPs play a central role in improving not only language impairments associated with ASD but also social communication and general functional communication related to personal and health care needs. SLPs contribute to the independence and productivity of individuals with ASD by ensuring effective functional communication systems or approaches (including AAC) that allow them to attain and maintain maximum levels of functional communication.

Treatment for individuals with ASD typically includes:

• Setting goals based on assessment data that target the core, associated, and secondary deficits in ASD (e.g., feeding and swallowing disorders);
• Focusing on initiating spontaneous communication in functional activities, engaging in reciprocal communication interactions, and generalizing gains across activities, environments, and communication partners;
• Using a multimodal communication system (e.g., spoken language, gestures, sign language, picture communication, speech-generating devices, and/or written language) that is personalized according to the individual’s abilities and the contexts of communication; and
• Measuring progress using systematic methods to determine whether an individual with ASD is benefiting from a treatment program or strategy.

Evidence and Outcomes of Speech-Language Pathology Treatment

According to data from ASHA’s National Outcomes Measurement System (NOMS), 76.6% of children with ASD receiving speech-language pathology services make clinically meaningful progress on spoken-language expression and/or comprehension.

In a 2013 systematic review, Wong et al. concluded that the following are considered to be evidence-based practices for the treatment of communication disorders in children, adolescents, and/or young adults with ASD:

• Visual support (children and young adults)
• Parent-mediated/implemented interventions (toddler to school age)
• Peer-mediated/implemented interventions (preschool to high school age)
• Pivotal response training (toddler to middle school age)
• Social skills training (children and young adults)
• Social narratives (preschool to high school age)
• Picture Exchange Communication System (PECS; Bondy & Frost, 2001) (pre-school to middle-school age)
• Technology-assisted instruction (including video modeling) and speech-generating devices (children and young adults)
• Modeling (children and young adults)
• Naturalistic intervention (toddler to elementary school age)
• Scripts (preschool to high school age)

Wong et al. (2013) also considered the following behavioral interventions, or components of behavioral interventions, to be evidence based:

• Antecedent-based intervention
• Reinforcement and differential reinforcement
• Discrete trial training
• Extinction
• Functional communication training
• Prompting
• Time delay

Services Across the Lifespan

The symptoms of ASD affect individuals throughout the lifespan, impacting them differently depending on the stage of life. Whereas (early) childhood services are critical, transitions from preschool to school age and from adolescence to young adulthood present particularly challenging communication issues for those with ASD.

ASD can affect success in postsecondary educational programs, employment, maintaining relationships, and acquiring the skills necessary for independent living (Howlin & Moss, 2012; Zager & Alpern, 2010). Youth with ASD need access to timely services that are community and evidence based. Communication services are a key support that can help youth with ASD achieve education, employment, independent living, and community integration goals as they transition to adulthood (Government Accountability Office, 2017).

The primary social communication impairments that accompany ASD continue into adulthood; these social communication deficits result in a greater tendency for adults with ASD to be overeducated for their jobs and have a lower employment rate. They are also more likely to live with their parents (Poon, 2017).

Support Provided by SLPs for Individuals with ASD Transitioning in New Settings or Stages of Life

A growing number of youth and young adults with ASD are leaving school with substantial service needs that will increase the demands on an already strained adult service system. These needs will continue to grow in the coming years, as young people who are identified with ASD in early childhood progress through school and into the adult services system.

Adults with ASD, including those with normal intellectual quotient (IQ), are significantly disadvantaged for employment, social relationships, physical and mental health, and quality of life (Howlin & Moss, 2012).

SLPs play a critical role in developing and assisting with medically necessary transition services and supports, including the following:

• Service provision for AAC devices (including updating an existing device) for the purpose of communicating health concerns/needs and functional expression of wants and needs, thereby enhancing life participation
• Social communication treatment when addressed for the purposes of obtaining employment and when an individual is in an employment setting
• Transition planning to help an individual adjust to a new living situation for the purpose of increasing independence, or when a parent or caregiver can no longer support them in an existing home environment
• Vocational support in employment programs to facilitate professional and social communication, job readiness, and independence skills

Distinct Role of SLPs Compared with Applied Behavior Analysis (ABA) Therapists

SLPs should be included in the comprehensive assessment for individuals with ASD in order to prioritize intervention objectives and coordinate planning for communicative success. Although ABA therapists may work on an individual’s behaviors, SLPs have the educational background that enables individuals to focus on the understanding and use of language, social communication, literacy, speech production, AAC, and feeding and swallowing.

SLPs’ training allows them to effectively identify the cause of the communication, feeding, and/or swallowing impairments and to develop treatment plans accordingly. Insurers should cover all medically necessary services for children with ASD.

Note: Individuals with ASD and their families must be provided with the full complement of services designed to meet their individual needs. Allowing individuals without the appropriate education and training to make assessment decisions about communication needs of individuals with ASD may result in an inaccurate assessment and inappropriate recommendations for services to the family.

The Centers for Medicare & Medicaid Services and the U.S. Department of Education have collaboratively issued guidance that supports the inclusion of all medically necessary services to meet the needs of individuals with ASD, including reference to the importance of speech-language pathology services.

Center for Medicare & Medicaid Services Autism Bulletin (2014)

Evidence from Systematic Reviews

“The [What Works Clearinghouse] found potentially positive effects [for ABA] on cognitive development for children with disabilities and no discernible effects on communication/language competencies, social-emotional development/behavior, and functional abilities” (U.S. Department of Education, Institute of Education Sciences, 2010).

“The meta-analyses of these studies showed that ABA did not result in significant improvement in cognitive, language, or adaptive behavioral outcomes compared with standard care . . . . Current evidence does not support [ABA] as a superior intervention for children with ASD” (Spreckley & Boyd, 2009).

Guideline

“Current best practices for interventions for children aged [less than] 3 years with suspected or confirmed ASD should include a combination of developmental and behavioral approaches and begin as early as possible . . . . Behavioral interventions are techniques based on behavioral analysis of antecedents and consequences of specific behaviors, and they use principles derived from experimental psychology research to systematically change behavior. Developmental models of intervention use developmental theory to design approaches to target ASD deficits. Developmental approaches often underlie community services, such as public school programs implemented by special education specialists and speech and language pathologists . . . . Our analysis supports the effectiveness of integrated developmental and behavioral interventions, outside of the laboratory setting, in improving developmental quotients, adaptive functioning, and language skills” (Zwaigenbaum, Bauman, et al., 2015).

Randomized Control Trial

“The results of this study . . . showed that the children who participated in the [pivotal response treatment] condition demonstrated greater gains in the targeted area (MLU) and in non-targeted verbal interaction, pragmatics, social relationships, and nonverbal skills, as well as showing greater decreases in disruptive behavior than the adult-directed ABA condition” (Mohammadzaheri, Koegel, Rezaei, & Bakhshi, 2015).

References

Barrett, D., Wilson, B., & Woollands, A. (2012). Care planning. Harlow, England: Pearson Education.Centers for Medicare & Medicaid Services Autism Bulletin. (2014). Retrieved from: https://www.medicaid.gov/federal-policy-guidance/downloads/cib-07-07-14.pdf 

Centers for Disease Control and Prevention. (2014). CDC estimates 1 in 68 children has been identified with autism spectrum disorder. Press Release, Retrieved from: https://www.cdc.gov/media/releases/2014/p0327-autism-spectrum-disorder.html 

Chawarska, K., Klin, A., Paul, R., Macari, S., & Volkmar, F. (2009). A prospective study of toddlers with ASD: short-term diagnostic and cognitive outcomes. Journal Of Child Psychology And Psychiatry, 50(10), 1235-1245. doi: 10.1111/j.1469-7610.2009.02101.x

Croen, L. A., Najjar, D. V., Ray G. T., Lotspeich, L., & Bernal, P. (2006). A comparison of health care utilization and costs of children with and without autism spectrum disorders in a large group-model health plan. Pediatrics, 118, e1203–1211. http://dx.doi.org/10.1542/peds.2006-0127 

Easterbrooks, S., & Handley, C. (2005). Behavior Change in a Student With a Dual Diagnosis of Deafness and Pervasive Developmental Disorder: A Case Study. American Annals of the Deaf, 150(5), 401-407. Retrieved from http://www.jstor.org/stable/26234748 

Howlin, P., & Moss, P. (2012). Adults with autism spectrum disorders. Canadian Journal of Psychiatry, 57, 275–283. http://dx.doi.org/10.1177/070674371205700502 

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. https://doi.org/10.1177/10883576070220010301

Mohammadzaheri, Fereshteh & Koegel, Lynn & Rezaei, Mohammad & Bakhshi, Enayatollah. (2015). A Randomized Clinical Trial Comparison Between Pivotal Response Treatment (PRT) and Adult-Driven Applied Behavior Analysis (ABA) Intervention on Disruptive Behaviors in Public School Children with Autism. Journal of autism and developmental disorders. 45. 10.1007/s10803-015-2451-4.

Poon, K., & Sidhu, D. (2017). Adults with autism spectrum disorders. Current Opinion In Psychiatry, 30(2), 77-84. doi: 10.1097/yco.0000000000000306

Sharp, W. G., Berry, R. C., McCracken, C., Nuhu, N. N., Marvel, E., Saulnier, C. A., . . . Jacques, D. C. (2013). Feeding problems and nutrient intake in children with autism disorders: A meta-analysis and comprehensive review of the literature. Journal of Autism and Developmental Disorders, 43,2159–2173. http://dx.doi.org/10.1007/s10803-013-1771-5 

Spreckley, M., & Boyd, R. (2009). Efficacy of Applied Behavioral Intervention in Preschool Children with Autism for Improving Cognitive, Language, and Adaptive Behavior: A Systematic Review and Meta-analysis. The Journal Of Pediatrics,154(3), 338-344. doi: 10.1016/j.jpeds.2008.09.012

Szymanski, C., & Brice, P. (2008). When autism and deafness coexist in children: What do we know now? Odyssey: New Directions in Deaf Education, 9(1), 10–15.U.S. Department of Education Autism Letter. (2015). Retrieved from: https://www2.ed.gov/policy/speced/guid/idea/memosdcltrs/dclspeechlanguageautism0706153q2015.pdf [PDF]

Wong, C., Odom, S. L., Hume, K. Cox, A. W., Fettig, A., Kucharczyk, S., … Schultz, T. R. (2013). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group.

Zager, D., & Alpern, C. (2010). College-Based Inclusion Programming for Transition-Age Students With Autism. Focus On Autism And Other Developmental Disabilities, 25(3), 151-157. doi: 10.1177/1088357610371331

Zwaigenbaum, L., Bauman, M., Choueiri, R., Kasari, C., Carter, A., & Granpeesheh, D. et al. (2015). Early Intervention for Children With Autism Spectrum Disorder Under 3 Years of Age: Recommendations for Practice and Research. PEDIATRICS, 136(Supplement), S60-S81. doi: 10.1542/peds.2014-3667e

Picture Exchange Communication System (PECS). Bondy, A., & Frost, L. (2001). The Picture Exchange Communication System. Behavior Modification, 25(5), 725–744. https://doi.org/10.1177/0145445501255004