EXAM #2

Lectures

What is included in prelingusitic communication?

What is included in prelingusitic communication?

• Prelingusitc Comm: occurs before the use of words

• EXAMPLES:

  • Eye Gaze

  • Shared Positive Affect

  • Sounds

  • Communicative non-word vocalizations

  • Gestures

Key Features of ASD

• Social Communication & Interaction

  • Social-emotional reciprocity

  • Nonverbal communicative behaviors

  • Understanding/ developing/ maintaining relationship.

• Restrictive Repetitive Behaviors (RRBs)

  • Stereotyped or repetitive movements, use of objects, or speech

  • Insistence on sameness

  • Highly Restricted interests abnormal in intensity or focus

  • Hyper-or Hypoacitvtiy to sensory stimuli

What behaviors are classified as social communication and which ones are restricted to repetitive behaviors

• Social Communication impairments

  • Reduced Joint Attention 

  • Reduced social communication (differences in frequency and rate of social communication) 

  • Deficits in eye contact 

  • Unshared affect/enjoyment 

  • Reduced gestures 

• Repetitive behaviors/play

  • Fixation on objects 

  • Repetitive vocalization 

  • Repetitive movements of the body 

  • Lack of pretend play; highly constructive play 

  • 'Sticky' attention

Communicative Functions: Intentions/ Intentional Communications

• Behavior regulation: indicating to adults that they want water by holding out the cup.

• Social interaction: waving hi and bye; initiating a social game; requesting comfort (e.g., playing with the cup)

• Joint attention: communicating to share interest on an object or event (e.g., showing adult that they have cup in their hand for the adult to notice – not really holding it out for adult to fill in it

Developmental Variability and diagnostic Stability

• The distinction between ASD and non- ASD D/LD can be blurred in toddlers.

  • Developmental Variability

  • Confounding conditions with some symptoms overlap

  • Differential diagnosis of ASD requires symptomatology beyond what can be accounted for by communication disorder

• Diagnostic stability improves with age

  • ASD and D/LD not often differentialized until a child is close to 3 

  • In children with ASD, without language delay, diagnosis below age 3 is rare 

• In the face of uncertainty, we can talk about the need for clinical monitoring and follow-up

T or F

It is common to have a diagnosis below the age of 3.

False, it is rare

T or F

Diagnostic Stability increases with age.

True

T or F

The average age of diagnosis for ASD is 3.

False, average age is 4

T or F

The distinction between ASD and non- ASD D/LD can be blurred in toddlers.

True

T or F

Screening equals diagnosis

False, it does NOT equal diagnosis

Screening Vs Diagnosis: SCREENING

• Screening does not equal diagnosis 

• Requires minimal training

• employs measures that are relatively easy to administer and score

• indicated a risk for a disorder on a cutoff score

Screening Vs Diagnosis: DIAGNOSIS

• Requires advanced clinical training and specialized experience

• Involves integration of information and evaluation of behavioral symptoms in the context of developmental history, family factors, and cognitive level 

T or F

SLP’s can diagnose Autism.

False; SLPs aren’t allowed to diagnose for autism, we can only provide screeners

Why “early” identifcation?

• For the child

  • Early years are an important time for active brain development and organization 

  • Brain development is influences by both genetics and experience 

  • Leads to specialized intervention 

• For the family

  • Alleviate uncertainty 

  • Provide access to resources, information, and support 

  • Provide strategies for promoting development 

• For science

  • Understanding cause 

  • Understanding developmental trajectories 

Early Identification

• What can be done to catch ASD as early as possible?

  • Developmental screening: a brief assessment designed to identify children who should receive more comprehensive evaluation

  • Broad developmental screeners vs. Autism specific screeners

    • Broad: autism is only 1 piece of the developmental puzzle

      • not specific to autism

    • Autism specific screeners: these are looking more at social communication and signs of autism.

T or F

Autism affects development and development affects autism.

True

What are Broad Developmental screeners that only doctors can do

• Parents Evaluation of Developmental Status (PEDS) (Glascoe) 

  • Birth-8 years of age 

• Ages and Stages Questionnaire (Squires and Bricker)

• CSBS-DP Infant Toddler Checklist (Wetherby and Prizant)

  • Normed for 6-24 months 

What is an early identification autism specific screener?

M-CHAT-R/F

M-CHAT

• Modified Checklist for Autism in Toddlers (M-CHAT) 

  • 16-30 months 

  • Modified parent report screening measure 

  • High false positive rate – refer to M-CHAT-R/F

M-CHAT-R/F

• Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) 

  • 16-30 months; parent report (with possible interview)

  • Strongly recommended; Autism-specific screening tool 

  • Goal: maximize sensitivity (detect as many cases of ASD as possible)

  • Revised tool which reduces the false positive rate and detects more ASD cases than the original M-CHAT when used during routine pediatric check-ups

  • Continues to have high false positive rate, so developed follow-up questions

    • Even so, many children who screen positive on M-CHAT-R will not be dx with ASD (but are at high risk for other DD)

  • If child screens positive based on parent completion of form, conduct follow-up interview

M-CHAT-R/F Scoring

• Low-Risk

  • Total score 0-2

  • If they are under 24 months, repeat after age 2

  • no further action is required

• Medium Risk

  • Total Score: 3-7

  • Administer the Follow-Up (second stage of M-CHAT-R/F) to get additional information about at-risk responses. If M-CHAT-R/F score remains at 2 or higher, the child has screened positive. Action required: refer child for diagnostic evaluation and eligibility evaluation for early intervention. If score on Follow-Up is 0-1, child has screened negative. No further action required unless surveillance indicates risk for ASD. Child should be rescreened at future well-child visits.

• High-Risk

  • total Score 8-20

  • It is acceptable to bypass the Follow-Up and refer immediately for diagnostic evaluation and eligibility evaluation for early intervention.

What do we need to do to improve screening?

• Evaluate high sensitivity (true positives) and low specificity of existing screening tools, and continue developing efficacious screening measures

  • high false positive rate

    • A measure is sensitive if it is picking up the children with ASD.  But a measure may be picking too many kids (low specificity). 

• Identify biological and/or behavioral markers to develop indices of risk for the development of autism in infants. 

• Develop feasible, sensitive autism screening method for young infants

How early is “early” for diagnosis?

• ASD still most often first diagnosed over age 3

• Studies have consistently found: Diagnostic stability is good in children over 2 (better in children over 3 years) 

• Can ASD be diagnosed younger than 2 years?

  • ASD can sometimes be reliably diagnosed as young as 2 years (younger in some children) 

    • children who have early symptom onset 

    • Assessment and diagnosis by experienced clinicians

  • Clinician experience critical, but not always enough

  • Home observation (in addition to comprehensive dx evaluation in clinic) increases clinician confidence in dx

• Overall, research supports the growing practice of making early clinical diagnoses when: 

  • Diagnostic presentations are clear (can defer if not)

  • Clinician is experienced in diagnosing ASD in young children

  • When home and clinical observations are included in the assessment process

Challenges in Diagnosing ASD under 3

• Increased behavioral variability and subtlety of symptoms in very young children

• Mild symptoms or absence of symptoms at ~18 months do not “rule out” a later ASD diagnosis

• Overlapping symptoms with other developmental delays/disorders

Diagnosis of ASD: SYMPTOMS

• Diagnosis comprised of symptoms (communication and behavioral) as defined by the DSM-5

• Symptom expression is variable across individuals, time, and settings

• Both positive (abnormal) and negative (absence of normal) behaviors are required to make diagnosis

  • Thus, developmental level can have a significant effect on diagnostic judgments 

Diagnosis of ASD: MEASURES

• No single measure is considered “the” one for diagnosing

• Various tools may be used

• But there is a “gold standard” 

Diagnosis of ASD: PERSONS

• No single person/professional is considered “the” one for diagnosing

• Often a psychologist, psychiatrist, physician (developmental pediatrician), but others (e.g., SLP) with adequate training may also diagnose

T or F

The gold standard diagnosis of ASD is only one assessment.

False; it is a combination of different assessments

Diagnosis of ASD: The Gold Standard

• Developmental/Cognitive Assessment 

• Adaptive Behavior Measure 

• Clinical Interview/ Developmental History 

  • Autism Diagnostic Interview-Revised  (ADI-R) 

• Direct Observation 

  • Autism Diagnostic Observation Schedule (ADOS-2)

  • Communication and Symbolic Behavior Scales (CSBS) Behavior Sample (for young Children) 

The Gold Standard: Developmental / Cognitive Assessment

• Knowing what to expect on social skills (behavioral/communication) -- distinguishing from other disorders such as ID 

• Social communication and social interaction skills, as well as Restricted, repetitive patterns of behavior, interests, or activities

The Gold Standard: Adaptive Behavior Measure

• "Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning..."

The Gold Standard: Clinical Interview/ developmental history

• Need to know if there were symptoms present from early on 

• May not see certain behaviors in the time of assessment --> parent report/developmental history is important to know what the individual does/has done beyond the clinician's time with them 

• Parent interview needed for history of early development, report on peer interactions, and report on repetitive behaviors

• Autism Diagnostic Interview-Revised  (ADI-R) 

  • Semi-structured, clinician administered interview for caregivers 

  • Used to obtain developmental history 

  • Originally developed as a research instrument, but clinically useful (although length makes clinical use difficult)

  • Intended for children and adults with a mental age above 2.0 years

  • Significant training needed for use

• Reports on pervasiveness of behaviors (in different settings)

  • Coded by trained raters

The gold Standard: direct Observation

• Autism Diagnostic Observation Schedule (ADOS-2)

  • Provides “natural” social environment with examiner 

  • Uses hierarchy of “presses” to rate responses

  • Tasks/modules (5 modules) differ according to language level (toys, interview questions)

  • Must be coded by trained/reliable raters 

  • Based on OBSERVABLE behaviors 

  • As with ADI-R, requires considerable  training and achieving reliability

• Communication and Symbolic Behavior Scales (CSBS) Behavior Sample (for young Children) 

  • The CSBS includes a sequence of 6 communication and play sampling opportunities while the child is interacting with the caregiver and clinician

What is included in the assessment process in the gold standard

• Vital information for parents...

• Characteristics of effective programming for young children with ASD

  • Info on child’s strengths and challenges 

  • Helping families locate services

  • Publicly funded services (early intervention or school-based services) 

  • Parent training

  • Parent support groups

What is not included in the assessment process in the gold standard

• Should not include a statement on child’s long-term prognosis

• No way of knowing how an individual child will respond to intervention 

Recommendations for Diagnosis of Possible ASD in Infants and Toddlers

• Diagnostic process led by expert clinician

• Information should be obtained by multiple sources (e.g., parent report, structured observation, standardized assessment of development, judgment of experience clinician along with multidisciplinary team)

• Treatment recommendations tied to specific symptoms/delays

• Provide parents with clear expectations about next steps (e.g., treatment options, monitoring, reevaluation)

• In the face of diagnostic uncertainty, the most critical issue is timely access to appropriate intervention services for  the child and supports for the family

Role of SLP in Diagnosis. only 1 question (select all that apply); just know the gist of it

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

• Ideally, the SLP is a key member of an interdisciplinary team with expertise in diagnosing ASD. 

• When there is no appropriate team available, an SLP—who has been trained in the clinical criteria for ASD and who is experienced in diagnosing developmental disorders—may be qualified to diagnose these disorders as an independent professional. (NOTE: this depends on your state)

• The SLP who has been trained in the clinical criteria for ASD, as well as in the use of reliable and valid diagnostic and assessment tools for individuals with ASD, and who is experienced in diagnosis of developmental disorders, may be qualified to diagnose these disorders as an independent professional.

• Make referrals to other professionals as necessary.

• providing information to individuals and groups known to be at risk for ASD, to their family members, and to individuals working with those at risk

• educating other professionals on the needs of persons with ASD and the role of SLPs in diagnosing and managing ASD

• screening individuals who present with language and communication difficulties and determining the need for further assessment and/or referral for other services

• conducting a culturally and linguistically relevant comprehensive assessment of language and communication, including social communication skills

• assessing the need and requirements for using augmentative and alternative communication (AAC) devices as a mode of communication

• assessing and treating feeding issues, if present (e.g., patterns of food acceptance or rejection based on food texture; consumption of a limited variety of foods)

• diagnosing the presence or absence of ASD (typically as part of a diagnostic team or in other interdisciplinary collaborations)

• referring to other professionals to rule out other conditions, determine etiology, and facilitate access to comprehensive services

• making decisions about the management of ASD

• participating as a member of the school planning team (e.g., a team whose members include teachers, special educators, counselors, psychologists) to determine appropriate educational services

Talking with families… (Screening /Assessment)

• When you have a concern

  • Offer screening to all families

  • Do not assume reticence is “denial”

  • Proceed on parents’ terms

  • Do not wait for diagnosis to address social communication needs

  • Avoid jargon

• When a parent/caregiver expresses concern

  • Parents often raise the first concern - take the concern seriously and provide prompt answers

  • Facilitate screening

  • Avoid suggesting ASD before diagnosis

Role of SLP in Assessment

• Screening individuals who present with language and communication difficulties and determining the need for further assessment and/or referral for other services​

• Conducting a culturally and linguistically relevant comprehensive assessment of language and communication, including social communication skills​

• Assessing the need and requirements for using augmentative and alternative communication (AAC) devices as a mode of communication​

• Assessing and treating feeding issues, if present (e.g., patterns of food acceptance or rejection based on food texture; consumption of a limited variety of foods)

• Diagnosing the presence or absence of ASD (typically as part of a diagnostic team or in other interdisciplinary collaborations) -- communication is a significant part of ASD diagnostic criteria 

• Participating as a member of the school planning team (e.g., a team whose members include teachers, special educators, counselors, psychologists) to determine appropriate educational services

• SLP's typically assess the speech, language, social communication/pragmatic, feeding skills of individuals with ASD

Play & ASD

• Play is…

  • Voluntary

  • Pleasurable

  • Intrinsically motivating

  • Requires active engagement

  • Flexible

  • Non-literal

Types of Play

• Solitary: Does not require sharing space, materials, or interaction 

• Parallel: Along others, may or may not involve observing 

• Cooperative: Share a common activity and work toward a common goal 

• Unstructured: Group activity that has no predictability 

• Pretend: Pretending an object is something else 

• Social : Involves social interaction in a group

T or F

Those with ASD prefer solitary play

True

Play, Language & Congition in ASD

• Symbolic/Pretend Play

  • Core deficit 

  • Central in diagnosis/intervention with ASD

• Play, Language, and Cognition 

  • Developmental sequence of play parallels language and cognitive development

  • Cognitive development = language development; means 

  • Play is associated with language development/language outcomes 

  • Play helps children recognize that objects have functions (other than those originally intended), which helps them learn to solve problems, imagine, and create. 

  • Children’s ability to solve problems, imagine, and create helps in problem solving and creative thinking and their ability to master abstract concepts

ASD: Challenges in Play

• May prefer to play alone, sensitive to intrusions 

• Children with ASD exhibit less functional and symbolic play with fewer actions 

• Constructive play stronger than imaginative play 

• Difficulty following themes introduced by others 

• Motivation in play may be dictated by repetitive actions/activities that do not require symbolic connections 

• Specific inflexible routines may be followed in play 

• Play themes kay focus on topics of specific or narrow interest 

• Lack of flexibility leading to stereotypic repetitive play behaviors

Assessment of Play

• Westby Play Scales

  • In 1980, Carol Westby created an assessment/scale that shows you what play skills children should have at certain ages as well as the language skills that should parallel them..

  • Cultural considerations in play assessment 

  • Can focus on play or play can be embedded into it

Prelinguistic Communication Characteristics include….

• Delay in/no use of communicative gestures 

• Reduced/no communicative intentions (joint attention, initiated social interaction)

• Minimal/lack of coordination of communicative means (coordinating eye gaze towards someone, pointing)

• Inconsistent eye contact 

• Minimal/no prelinguistic vocalizations

• Reduced age-appropriate play (e.g., infant social play) 

Language Characteristics in ASD

• Expressive/Receptive Language 

  • Language Delay (not specific or universal in ASD)

  • Comprehension (may be depressed relative to production) 

  • Tendency to use language for requests rather than commenting and generating novel messages 

• Differences in learning the meaning of words

• Differences in the Use of Language

  • May attain language skills but less able to use language to communicate

  • Echolalia 

Assessment of Speech and Language

• Culturally and linguistically appropriate assessment of communication skills 

• Standardized (formal) assessments (when appropriate)  

  • GFTA-3 

    • 2-60+ age

    • intelligibility (Language sample)

  • CELF-5

    • have more biases into it

    • not the best at capturing linguistic abilities

  • BESA (Bilingual English Spanish Assessment): Bilingual assessment

  • OWLS

    • expressive, receptive , reading, and writing

    • most expensive

    • children to adulthood

  • PLS

    • Preschool

  • Rosetti Infant-Toddler

    • Criterios Referenced

    • 3 and under ; early identification

• Non-Standardized (informal) assessments   

  • Language Sample 

  • Narrative Retel Tasks 

  • NWRT  

  • SLAM Cards 

  • Dynamic Assessments 

• AAC Evalution if needed 

• Fluency evaluation if needed

• Feeding/swallowing evaluation if needed

T or F

A good assessment tool is either standardized or non-standardized.

False, a good tool has both standardized or non standardized.

Conversation and Pragmatic Communication in ASD

• Difficulty turn-taking, topic, perspective-taking

• Routinized interactions

• Perseverative topics

• Self-directed conversation 

• Difficulty with reciprocal interaction

• Difficulty with flexible discourse

• Difficulty with shared conversation

Social-Emotional Development in ASD: Infancy

• Infancy

  • Lack of reciprocal eye contact

  • Infrequent or absent social smile

  • May receive less pleasure from physical contact or be less likely to reach for or seek physical comfort from parents

  • Attachments may develop more slowly

  • Lack of response to name

  • Reduced interest/attention to human faces

Social-Emotional Development in ASD: Early Childhood

• Early Childhood

  • Preference for objects over social interaction

  • Prefer solitary activities

  • Limited range of facial and body expressions

  • Difficulty with perspective taking

  • Less seeking to share enjoyment

  • Cooperative play uncommon

T or F

Looking at the ASHA social communication benchmarks is one way we can improve assessment.

True

Assessment of CLD Individuals with ASD

• Bilinguals with autism spectrum disorder (ASD) have difficulties in both languages compared to typically developing bilingual peers 

• No differences between bilinguals with developmental disabilities and monolinguals with  developmental  disabilities on measures of language performance 

• Bilingual children with ASD perform similarly to monolingual children with ASD on measures of vocabulary, receptive language, expressive language, and communication 

• Consistent evidence that bilingualism does not exacerbate symptoms of a (developmental) disorder nor limit treatment outcomes 

• Single-language recommendation (i.e., English-only) -- negative and long-lasting effects 

• Promoting evidence-based practice (EBP) and practicing cross-cultural competency to best support children and families 

• Per CDC data, over the years, more non-Hispanic white children are identified with ASD than non-Hispanic black or Hispanic children. 

• Some children with ASD may not be receiving the services they need to reach their full potential

• Previous studies have shown that potential barriers to identification of children with ASD, especially among Hispanic children, include

  • Stigma

  • Lack of access to healthcare services due to non-citizenship or low-income

  • Non-English primary language

Assessment of CLD Individuals with ASD: Why we have disparties

• Disparities in identification and diagnosis 

  • Interactions with healthcare providers 

  • Overdiagnosis/Underdiagnosis/Misdiagnosis 

• Disparities in research participation 

  • Scare body of literature with CLD clientele with and without ASD

• Disparities in prevalence rates, age of identification, and comorbidity of children with ASD across racial, ethnic, and socioeconomic status groups

  • Disparities in service provision for ASD

• Parental beliefs, awareness, & experiences 

• Further discussion in assessment and treatment units