Posts Tagged ‘autism spectrum disorder’

Early Signs of Autism Spectrum Disorder

Wednesday, June 8th, 2016

by Nancy Volkers
Reprinted from The ASHA Leader, April 2016, Vol. 21, 44-49.

Fifteen-month-old Charlie is watching his mother blow bubbles. He points at the bubbles, laughs and looks at the adults sitting at the table with him. When given the bottle of bubble liquid, Charlie tries to open it; he grunts and says “stuck,” then offers it to an adult for help.

Luke, who is 16 months old, focuses only on the bubbles, even when the adults call his name. With one hand, he half-heartedly twists the bottle back and forth on the table. Finally, he offers it to an adult. He never makes a sound or changes expression.

Charlie and Luke are being evaluated with an assessment called the Communication and Symbolic Behavior Scales Developmental Profile (CSBS-DP). Developed by Florida State University’s Amy Wetherby (a distinguished research professor there) and Brown University’s Barry Prizant, the assessment helps to identify children younger than 2 who are at risk for a communication impairment.

The two toddlers, and at least a dozen others, are featured in the video library of Autism Navigator’s “About Autism in Toddlers” module. Created at Florida State University by Wetherby and colleagues, Autism Navigator is a collection of Web-based tools and resources that uses extensive video footage to help providers and parents bridge the gap between science and community practice.

Many toddlers diagnosed with ASD who receive early intervention can attend regular kindergarten, cutting annual education costs by $10,000 per child, according to Autism Navigator. The Autism Society of the United States says that early intervention can reduce the lifetime cost of care by 67 percent.

The “About Autism in Toddlers” module is designed to show some of the early behaviors that may indicate autism spectrum disorder (ASD). A child diagnosed with ASD before age 3 has access to early-intervention services provided by speech-language pathologists and others, as specified in the Individuals With Disabilities Education Act. Compared with treatments offered later in life, early intervention for ASD appears to carry a greater chance for academic, vocational/career and social success and potentially lower education costs. But today, only 20 percent of U.S. children are diagnosed before age 3; the average age at diagnosis falls somewhere between 4 and 5 years old.

Autism Navigator’s developers hope that it and other tools will aid SLPs and other professionals in earlier diagnosis of children with ASD. Even in areas where early intervention services aren’t widely available, earlier identification of ASD will likely prompt their growth, says Elizabeth Crais, professor of speech and hearing sciences at the University of North Carolina (UNC), Chapel Hill. “School districts and early intervention programs are beginning to respond because they know they have to provide services,” she notes, adding that some states also have made changes mandating insurance coverage for ASD services—not the case in the past.

SLPs’ crucial role

Many toddlers diagnosed with ASD who receive early intervention can attend regular kindergarten, cutting annual education costs by $10,000 per child, according to Autism Navigator. The Autism Society of the United States says thatearly intervention can reduce the lifetime cost of care by 67 percent.

SLPs can and should be an integral part of early diagnosis, according to Stephen Camarata, professor of hearing and speech sciences at Vanderbilt University School of Medicine. “One of the primary reasons, if not the primary reason, to refer a child for an autism assessment is because the child is not speaking,” he said. Because concerns about speech development can occur as early as age 2, this is one opportunity to identify children with ASD. “It’s vitally important that an SLP be involved [in these cases],” said Camarata. “If a child is not speaking, it could be autism, but it also could be hearing loss, an intellectual disability or a language disorder.”

The Diagnostic and Statistical Manual, Fifth Edition (DSM-5), provides criteria to diagnose ASD. The two sets of criteria involved are related to social communication deficits and restricted, repetitive patterns of behavior, interests or activities (see “ASD Diagnosis Criteria,” below). Multiple assessment tools have been tailored for use with younger children (see “Diagnosis Tools” online).

Crais agrees that an SLP often will be the first professional to raise the autism question. “It is within the scope of practice [to diagnose ASD], if you have the skills and knowledge and your state allows it,” she says.

Camarata recommends that SLPs check with their state licensing board or with ASHA to determine if they can provide a primary ASD diagnosis. “Even if [the SLP] isn’t involved at the time of diagnosis, they definitely should be part of a clinical team,” he says.

“If a child is not speaking, it could be autism, but it also could be hearing loss, an intellectual disability, or a language disorder.”

SLPs always can be important advocates for parents who have concerns about their young children, says Linda Watson, professor of speech and hearing sciences at UNC-Chapel Hill.

“Some SLPs may be told not to mention ‘the A word’ to parents,” she says. “But a knowledgeable clinician should raise concerns with families. We shouldn’t tie people’s hands by telling them not to talk about it.”

Identifying at-risk infants

As clinicians work toward more early diagnosis in toddlers, researchers are looking for ways to diagnose children even earlier—as babies.

“Recent reports are showing that even in the first year of life, and certainly during the second year, there are characteristics that can be seen,” Crais says. “And if clinicians, parents and speech-language pathologists know what to look for, the result is getting services for more children.”

During the first year, eye gaze, babbling and feeding issues all have been identified as possible risk indicators. For example, research by Warren R. Jones and Ami Klin published in Nature found that children later diagnosed with ASD tended to make less eye contact with their mother or caregiver as infants (2 to 6 months), compared with children who developed normally.

Although a 3-month-old who doesn’t make much eye contact may not seem alarming, it can disrupt natural parent-child interactions, says Crais. “The first year of life is when babies should be looking at other people and learning,” she says. “If the child isn’t interacting, the parent may be giving less input to the child.”

Like Jones and Klin, Crais and Watson have used retrospective video analysis in their research, collecting early home videos from families who have children later diagnosed with ASD. Crais and Watson have found several distinctions between these children and those who develop in a typical way, as well as those with other developmental delays.

“The first year of life is when babies should be looking at other people and learning. If the child isn’t interacting, the parent may be giving less input to the child.”

For example, when children with ASD are very young, they don’t babble at all or as much as other babies. “They may not say ‘ba-ba-ba’ or ‘ga-ga-ga,’” Watson says. And that affects how parents interact. “When infants start using those sounds, parents’ responses become more ‘language-like’—and that’s better for language-learning. So if a baby is not babbling, you may be eliciting fewer language-learning opportunities.”

Feeding issues may send infants to SLPs long before there are concerns about language delays, says Watson. This is an opportunity to use a screener tool, in concert with observation. The SLP, she says, “can observe whether the infant is developing the expected prelinguistic communication, as well as using varied gestures for varied purposes”—such as requesting things, refusing things, showing objects to others and playing social games.

Awareness and intervention

Early identification, then, could help parents learn to plan and initiate some otherwise spontaneous interactions with their children, possibly improving outcomes. Autism Navigator illustrates this concept in multiple videos that show parents taking advantage of “teachable moments.” This type of effort, combined with sustained professional intervention, can help children with ASD.

However, it may be difficult to run controlled trials that can show the effects of early intervention, because families randomized to the control group are still aware that they have a child at risk for ASD.

Watson sees the positive side of this caveat. “In our study, equal numbers of families in both groups [intervention and control] sought community services for their 1-year-olds,” she says. “If they weren’t in the study, they probably wouldn’t even be aware of the risk. So just making parents aware also makes them better advocates.”

Crais agrees. “More studies, including ours, have shown that parents learn more about their children and are more proactive and responsive.”

ASD Diagnosis Criteria

To be diagnosed with ASD, a child must show three types of impairments in social communication and interaction, according to DSM-5:

  • Deficits in social-emotional reciprocity—difficulty having back-and-forth conversation; reduced sharing of interests or emotions; failure to initiate or respond to social interactions.
  • Deficits in nonverbal communication—trouble integrating gestures and language; poor or no eye contact/body language; little or no change in facial expression.
  • Deficits in developing, maintaining and understanding relationships—difficulty adjusting behavior to different contexts; problems sharing in imaginative play; difficulty making friends; lack of interest in peers.

The child also must show at least two of the following four types of restrictive or repetitive patterns of behavior:

  • Repetitive movements, speech or use of objects—hand-flapping or other repetitive body movements; repeating the same phrase; lining up toys or flipping objects.

  • Insistence on sameness (inflexible routines), or ritualized patterns of verbal or nonverbal behavior—extreme distress at small changes in routine; difficulty with transitions; need to travel the same route or eat the same food every day.

  • Highly restricted, fixated interests that are abnormal in focus/intensity—the child likes trains, for example, and is focused on collecting, building, playing with, and talking about trains at the expense of all other toys or topics of conversation.

  • Over-reaction or under-reaction to sensory input, or unusual sensory interest—indifference to pain or temperature; adverse response to certain sounds or textures; fascination with certain lights or movements; fixation on smelling or touching objects.

Finally, the impairments must:

  • Be present in early development.

  • Cause impairment in social, occupational or other areas of functioning.

  • Not be better explained by intellectual disability or global developmental delay.

Note that there is no longer a criterion for language delay. People with an earlier (DSM-IV or previous) diagnosis of autistic disorder, Asperger syndrome or PDD-NOS should now be given a diagnosis of ASD.


Diagnosis Tools

Several tools and assessments are available to aid in diagnosis of children under 4. They include:

M-CHAT (Modified Checklist for Autism in Toddlers). This is the most popular tool, according to Elizabeth Crais of the University of North Carolina.Designed for children 16–30 months, the questionnaire can be administered during a well-child physician visit or completed online by a parent. High scores initiate recommendations for follow-up. The latest version, M-CHAT-R/F, has a reduced false-positive rate, compared with the original M-CHAT. A 2013 study by Diana L. Robins and colleagues in Pediatrics found that 2 percent of 16,000 toddlers screened at well-child visits with M-CHAT-R/F required a full evaluation by a specialist. Of those, 95 percent were diagnosed with ASD.

CSBS-DP (Communication and Symbolic Behavior Scales Developmental Profile). The CSBS-DP is used with children 6 months to 6 years who have a functional age of 6–24 months. It can help to identify those at risk for communication impairment, and to monitor changes over time. The tool consists of a 24-item checklist, a four-page caregiver questionnaire and a behavior sampling taken with a parent present.

ADOS-2 (Autism Diagnostic Observation Schedule, newest version). Although ADOS is considered the “gold standard” for ASD diagnosis, it is not as helpful in younger children. Its toddler module, for assessing children 12–30 months, consists of 30 to 45 minutes of observation and focuses on communication, reciprocal social interaction, object use and play skills.

STAT (Screening Tool for Autism in Toddlers). This assessment, for children 24–36 months, consists of 12 items and takes about 20 minutes to administer.

Autism Navigator. This website includes family resources and a module, “About Autism in Toddlers,” that uses extensive video footage to illustrate the differences between young children with ASD and those developing normally. The site plans to soon launch professional development courses, online courses for families and social development growth charts.


Federal Panel Rejects Establishing Universal Early ASD Screening, Pending More Research

A government panel, despite finding adequate evidence that “currently available screening tests can detect ASD among children aged 18 to 30 months,” does not recommend universal screening of young children for autism spectrum disorder, saying more evidence is needed to make a recommendation on its benefits and harms.

The U.S. Preventative Services Task Force (USPSTF) released a draft proposal on ASD screening in 2015 with the same recommendations. In its comments on the draft, ASHA took exception with the recommendation, which conflict with American Academy of Pediatrics guidelines recommending screening for all children at ages 18 and 24 months. The task force did not accept ASHA’s suggested additional wording about the efficacy of ASD tests and that early identification and intervention is critical.

The final recommendation states that for children 18–30 months, “The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for autism spectrum disorder (ASD) in young children for whom no concerns of ASD have been raised by their parents or a clinician.”

Supporting information for the recommendation, however, clearly states that the task force is not recommending against universal screening, but calling for more research about its impact. Until the research is available, it advises health care providers to use their clinical judgment in deciding who and when to screen.

The 16-member task force of mostly health care epidemiologists and clinical scientists was assembled by the Agency for Healthcare Research and Quality, a division of the U.S. Department of Health and Human Services. Its recommendations often have widespread implications in driving practices and determining reimbursement policies.

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Event: Autism Friendly Spaces and The New Victory Theater

Tuesday, October 7th, 2014

Autism Friendly Spaces (AFS) is partnering with The New Victory Theater to present an autism‐friendly performance on Saturday October 18th and on Friday December 12th 2014

This performance will be modified to accommodate and support the sensory, social, and emotional needs of individuals with autism spectrum disorder. Throughout the event, the Autism Friendly Spaces (AFS) team will be on site and ready to welcome families into a judgment-free and accommodating environment, complete with:

  • Trained Autism Support Specialists to help facilitate activities, and assist families throughout the performance
  • An array of visual supports and fidget tools
  • A Calming Corner & Activity Area, stocked with a variety of tools for anyone needing a break
  • Downloadable social narratives will be designed exclusively for the New Victory Theater, and will be made available online at the New Victory Theater’s website:

    Download a flyer here: AFS Flier

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    Park Slope Speech Language Therapy for Children

    Thursday, August 28th, 2014

    Park Slope Speech Therapy

    Park Slope, Brooklyn speech therapy services in the convenience of your home or come to one of our offices!

    Speech language services include:

    Pronunciation (all ages)
    Early Childhood Expressive Language
    School Age Expressive Language
    Tongue Thrust Therapy
    Autism Spectrum Disorder (PDD, Aspergers, etc.)
    Social Skills
    Listening Difficulties (auditory and language processing)
    Picky Eaters and Early Childhood Feeding Delays
    Voice (Dysphonia) Therapy
    Augmentative and Alternative Therapy (AAC)
    Adult Speech Therapy

    Our Licensed Speech & Language Therapists’ qualifications include: – Master’s degree in speech language pathology – New York State and national certification – PROMPT training – We offer bilingual services (Spanish, French, Hebrew, or Hungarian).

    Here’s our team.

    Speech, Language, Feeding Therapy

    We are experienced to treat babies to adolescents (we are now offering adult speech language therapy!) with a variety of speech language difficulties, including articulation/enunciation difficulties (e.g lisp, tongue thrust, and/or difficulty saying sounds, and more), speech delay (including apraxia, oral motor difficulties, cleft palate), late talkers/expressive and receptive language delay (including multilingual homes), autism spectrum, e.g. Asperger’s, pervasive developmental disorder (PDD-NOS), social language delays, disfluency (stuttering), and feeding delays (including picky eaters, oral motor delays, medically fragile).

    Contact Craig for more information at

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    Finding the Right Social Skills Group for Your Child

    Thursday, October 24th, 2013

    Social skills refer to the set of unwritten rules that facilitate effective interaction with others at home and in the community. These skills impact appropriate classroom behavior, study skills, and the ability to sustain age appropriate friendships.

    In Autism Spectrum Disorder (ASD), deficits in social-communication skills can have a profound effect on functioning and well-being. ADHD, mood disorders, and anxiety disorders are associated with social skills difficulties as well. In addition, one may present with social skills deficits without meeting criteria for a disorder.

    One intervention for improving social skills is involvement in a social skills group. However, it is important that the group be carefully selected to ensure that it is an appropriate match for the participant. In this article, I plan to outline the features that I have found make for a successful social skills group. Please keep in mind that these characteristics are based on impressions from my experience.

    1. A group should consist of children around the same age and verbal ability:
    Ensuring that the other participants are of about the same age and verbal ability will maximize opportunities for socialization.

    2. Look for a small-sized group, or a group with more than one leader:
    To my knowledge, there is no magic number for how many children should be in a social skills group. I can say from experience, however, that smaller groups allow leaders to provide more individualized training to group participants, as well as the opportunity to offer more intensive behavioral support. Social skills dyads (groups consisting of 2 children) can be very effective if the children are well matched. However, the downside may be less consistent treatment, as the group will be canceled if one participant is unavailable.

    3. Parent Involvement:
    Parent involvement is very important for skill generalization. Some research has shown that while participants are able to acquire skills within the social skills group, they may not show these skills in other settings, such as home, school, and community.

    I recommend that parents share their concerns with the group leader prior to the date when their child will begin attending group. Supporting documentation, such as previous evaluations, letters from teachers, etc. are also informative for group leaders. I also suggest that parents ask to review the group curriculum. The curriculum should reflect at least some of the skills on which your child is working to improve.

    Once group attendance has begun, regular communication between parents and leaders is important for gauging progress across settings. In addition, if homework assignments are not being given, parents should ask the leaders what exercises they can do at home to practice the skill and provide regular feedback on how their child responds to these exercises.

    In addition, play dates can serve as an excellent venue for facilitating effective social interaction. Ask the group leader for suggestions about games that one can organize during a play date that promote social-communication, as well as strategies for managing social-interaction during a play date.

    In summary, social skills are required of us every day and in various settings. Improving social skills requires consistent practice across these settings. Social skills groups can be very helpful when they are focused on specific goals. Groups should facilitate interaction in a way that mirrors real life situations and demands, and that encourages participants to expand their social behavioral repertoire.

    Jennifer (Rodman) Keluskar, Ph.D. is a licensed clinical psychologist whose areas of specialization include Autism Spectrum Disorder and other developmental disabilities, behavior management, and anxiety disorders. She can be contacted at or (347) 974-1106.

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    The Value of Schedules for Individuals with Autism Spectrum Disorders by Carolyn Kessler, Ph.D.

    Wednesday, January 16th, 2013

    Visual supports are often recommended for individuals with autism spectrum disorders, but the many reasons for this are often misunderstood. One commonly used visual support are visual schedules, which can be based on objects, pictures, and/or words. There are several advantages to the use of schedules, whether the individual knows the general daily routine or not.

    Schedules teach independence. Instead of a parent, teacher, or other professional transitioning the individual with ASD, they can reference their schedule. Rather than an adult answering “what’s next” questions, the schedule provides this information.

    Schedules create predictability and organization. They let the individual with ASD know what is going to happen, when it will happen, and where. Individuals with ASD are prone to anxiety, particularly when their world is unpredictable, therefore, schedules can reduce this anxiety by increasing predictability.

    Many individuals with ASD have verbal/language delays. This makes it difficult for them to fully understand transitions that are presented verbally. A visual schedule, which can be used in conjunction with verbal input, capitalizes on visual strengths to shore up the verbal difficulties.

    Schedules can be used to ration the repetitive behaviors and special interests that so often are part of ASD. For a child who wants to talk about superheroes all day long, a schedule can show them when it’s ok to do this. By scheduling the special interest activity, the child still has access to it, but it doesn’t interfere to such a significant degree in other aspects of their day.

    Schedules can be used to teach flexibility because they can constantly change. For individuals with ASD, who typically crave routine, the routine of checking a schedule can be the inflexible part of the system, but what is on the schedule can be flexible. This means they can change from day to day, as well as change within the day, even after it’s already been presented to the child. To do this successfully, it’s best to use a visual to indicate that a change in schedule is happening.

    Carolyn Kessler, Ph.D. is a child psychologist with more than 10 years of experience working with children, adolescents, and their families on issues related to behavior management and parenting, anxiety disorders, mood disorders, developmental disabilities, and ADHD. She is a graduate of the University at Albany doctoral program in clinical psychology and completed her internship and postdoctoral training at the University of North Carolina School of Medicine. She can be reached at or (919) 280-2151.

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