Assessment of Autism: Differentiation Considerations for Speech-Language Pathologists
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Professional Background and Learning Outcomes
Angie Neal, MS, CCC-SLP, is the presenter for this course titled "Assessment of Autism: Differentiation Consideration." She serves as the SLP Contact and Policy Advisor for Speech-Language Services and Early Literacy at the South Carolina State Department of Education. Her professional roles include serving as a LETRS Facilitator, a board member with the State Education Agency Communication Disability Council, and a member of the ASHA School Issues Advisory Board. She is also a published author of two books. Regarding financial disclosures, Angie Neal was paid an honorarium for this presentation and receives profits from speech/language therapy materials she has authored and contributes to the TeachersPayTeachers online publication. Her non-financial disclosures include her role as a board member of the International Dyslexia Association (SC) and her positions on the State Education Agencies Communication Disabilities Council and ASHA’s School Issues Advisory Board. This course does not focus exclusively on any specific product and has no external sponsor. The specific learning outcomes for participants include the ability to list key questions supporting the accurate diagnosis or classification of Autism Spectrum Disorder (ASD), describe key differences between ASD and other conditions such as ADHD, emotional disabilities, intellectual disabilities, and speech-language impairments, and explain the critical data for an SLP to collect for diagnosis.
Core Features of Autism: Emotional Regulation and Central Coherence
According to Prizant (2015), difficulty staying well-regulated emotionally and physiologically should be considered a core, defining feature of autism, although focus is often placed on resulting behaviors rather than underlying causes. Emotional regulation is challenging for individuals with ASD due to difficulties in recognizing emotions based on internal body feedback or sensation, understanding which emotions are appropriate for specific contexts, labeling emotions correctly, expressing them appropriately, and using strategies to return to a neutral emotional state. Another critical concept is Central Coherence, often described as the inability to "see the forest for the trees." This refers to the ability to recognize invisible relationships between parts and understand the gist or main idea rather than focusing solely on isolated details. In conversation, poor central coherence manifests as an inability to get to the point or understand the shared gist of the exchange.
Theory of Mind and Developmental Milestones
Theory of Mind (ToM), as defined by Premack and Woodruff (1978), is the ability to attribute mental states such as beliefs, intent, desires, and knowledge to oneself and others, understanding that others have internal states different from one's own. Deficits in ToM result in a poor ability to consider interests outside of oneself, a lack of understanding that different situations have different expectations, and poor recognition of facial expressions or emotions. It can also lead to poor hygiene in older students, an unawareness of how behavior affects others, and an inability to identify a "future self." Precursors to ToM from birth through age include pretend play, joint attention, imitation, and metacognition (thinking about one's own thinking). This includes the use of verbs of cognition like "know," "think," or "remember," verbs of perception like "hear" or "see," and verbs of intention like "want" or "need." The first order of ToM typically develops between ages , enabling a child to tell a lie. The second order, occurring between ages , involves understanding that different contexts have different expectations. The third order, appearing between ages , allows for the understanding of figurative language and sarcasm.
Narrative Skills, Play, and Language Outcomes
Narration is vital for social competence and involves telling stories, describing events, and accounting for the thoughts and feelings of those involved. Bruner (1986, 1990) describes narrative discourse as a ubiquitous form of communication used to construct shared understanding. Narrative skills are a bridge between oral and written language, as noted by researchers like Westby (1985). Play and fiction share structures like setting and conflict; understanding temporal and cause-effect relationships in play builds a foundation for story comprehension. Research by the NICHD (2005) suggests that narrative skills at age contribute to reading comprehension at ages . Further studies by Babayigit and Shapiro (2020) show that skills at age contribute to reading success at ages and . In terms of development, social and joint attention, imitation, and play are significant variables for language outcomes (Watson and Flippin, 2008). Kasari, Paparella, and Freeman (2008) found that children in symbolic play interventions showed better expressive language than those in ABA services alone after one year.
Comprehensive SLP Assessment Domains
When assessing pragmatics, Timler et al. (2021) emphasize that standardized tests alone are insufficient. The SLP must determine when a behavior is appropriate based on context. A comprehensive report should cover five domains. Domain 1 is Social Interaction, which involves observing the student in varied settings like the classroom, lunchroom, and recess to document politeness rules, social reasoning, problem-solving, and conflict resolution. Domain 2 is Social Cognition, focusing on perspective-taking, ToM, inference, prediction, and the recognition of emotion based on context rather than pictures. Domain 3 is Verbal Communication, including prosody, figurative language, narrative skills, conversational turn-taking, and Grice’s Maxims (quantity, quality, relation, and manner). Domain 4 is Nonverbal Communication, capturing body language (e.g., shrugging, head tilting), gestures (deictic and representational), facial expressions, and joint attention. Domain 5 is Adverse Educational Impact, reviewing writing samples, curricular assessments for inference and figurative language, and the student's ability to use communication for self-advocacy and collaboration.
Differentiating ASD from Emotional Disturbance (ED)
Under IDEA (34 CFR 300.8(c)(1)(ii)), an autism classification is not applicable if the educational performance is adversely affected primarily by an emotional disturbance. While ASD involves restricted and repetitive patterns as a coping strategy to reduce anxiety and increase predictability, ED patterns are rarely used for self-soothing and may be more obsessive. In ASD, poor eye contact is often due to overstimulation, whereas in ED, it may result from shyness or a dislike of a person. Social-emotional reciprocity in ASD is often better when topics of interest are shared, while in ED, it is inconsistent and dependent on the individual's frame of mind. Individuals with ASD are capable of deep empathy but struggle to recognize cues; those with ED may have difficulty with empathy depending on their psychiatric impairment. Aggression in ASD is usually not intended to harm others, whereas in ED, there may be an intent to harm or clinical withdrawal. Furthermore, defiant behaviors in ASD often relate to a misunderstanding of the task, while in ED they relate to opposition or a dislike of the task.
ASD vs. ADHD and Intellectual Disability (ID)
In differentiating ASD from ADHD, ASD is defined by restricted, repetitive patterns that are absent in ADHD. Eye contact in ASD is overstimulating, while in ADHD it is often fleeting due to distraction. Emotional regulation issues in ASD stem from poor labeling of emotions, whereas in ADHD, they stem from impulsivity and poor inhibitory control. Students with ADHD usually know social expectations but forget them "in the moment," whereas students with ASD may not understand the cues at all. Regarding Intellectual Disability (ID), research by the AAP (2023) and Shenouda et al. (2023) shows significant bias; children in affluent areas are more likely to be identified with ASD without ID, while Black students are more likely to be labeled with ID than autism. In ID, eye contact and joint attention are typically appropriate for the developmental level, and language deficits are consistent with overall cognitive impairment. In contrast, ASD is characterized by a specific impairment in social communication and nonverbal language that is out of sync with other cognitive markers.
ASD vs. Speech-Language Impairment (SLI) and Eye Contact Nuances
Compared to Speech-Language Impairment (SLI), ASD involves restricted behaviors and overstimulating eye contact, both of which are typically absent in SLI. Students with SLI can communicate for various purposes and have social difficulties that are consistent across both peers and adults, whereas those with ASD may find it easier to interact with adults. Play in SLI is delayed but aligns with language development, while play in ASD is often limited to individual interests. SLI language difficulties commonly involve morphology, syntax, and phonological awareness across all three tiers of vocabulary, while ASD language difficulties are specific to pragmatics, figurative language, and discourse. Regarding eye contact across all conditions: in ADHD it is related to distraction; in ED it relates to psychiatric diagnoses; in ID it relates to medical diagnoses; in SLI there is typically no difficulty; and in ASD it is an issue of sensory overstimulation.
Ten Key Clinical Considerations for Diagnosis
The diagnostic team should consider ten specific questions. First, does the student break social rules they do not know (suggesting pragmatics) or rules they disagree with? Second, once a rule is learned, do they continue to break it? If they cannot stop, it suggests impulsivity; if they cannot comprehend consequences, it suggests ToM deficits. Third, is there performance inconsistency? True language impairment is present across all settings. Fourth, are interests abnormal in intensity and focus for their age? Fifth, is the student missing cues due to a lack of understanding or a lack of attention? Sixth, have they had opportunities to learn social rules, or has excessive digital device use (exceeding AAP recommendations) or trauma impacted development? Seventh, is there a deliberate intent to harm? This is not characteristic of ASD. Eighth, is the student manipulative? Manipulation requires advanced ToM, which is often a deficit in ASD. Ninth, are sensory behaviors impeding function? Sensitivity exists on a continuum and is only a disorder if it impacts daily life. Tenth, what is the evidence of adverse educational impact? IDEA requires a disability that impacts reading comprehension, problem-solving, or collaboration.