Drexel University Online - March and May

The Early Identification of Young Children with ASD

In developed countries, a child’s initial assessment for ASD typically takes place before they enter elementary school. Usually the question asked at that point is whether or not the child suffers from Autism and what can be done as the child prepares to enter an organized school setting. Typically parents of such children seek assessment after having observed another child with ASD or been told by others that their child’s pattern of behavior and development may in fact meet one of the ASD diagnostic criteria.

It is still the case that many parents are upset and significantly impacted to learn their child has ASD. In particular, the outcome data of children with ASD grown-up has failed to demonstrate the significant success of educational programs in preparing these children for normal adult life. However, there is reason for optimism as an increasing body of scientific evidence has demonstrated that early identification and comprehensive intervention appears to have a positive dramatic impact on the social and related behavior of children with ASD.

The study of any psychological disorder is dependent upon the tools that are used as these tools directly influence what is learned about the subject in research as well as clinical practice. As in all areas of science, what is discovered depends upon the quality of the instruments used and the information they provide. Well-developed assessment instruments yield more accurate and reliable information. Instruments that uncover more information relevant to the subject being examined will have better validity and ultimately will more completely inform researchers, clinicians and treatment providers. The tools used for diagnosis of a condition such as ASD will have a substantial impact on the reliability and validity of the information obtained and the decisions made. Simply put, the better the tool the more valid and reliable the decisions, the more useful the information obtained and the better the services that are eventually provided.

As our understanding of ASD is evolving emerging research has demonstrated that the key to successful intervention requires not only an evidence-based treatment program delivered with fidelity but also delivered early in a child’s development. In order for children to be appropriately identified and determined to be eligible candidates for effective programs, research proven assessment tools are needed. The Autism Spectrum Rating Scales (ASRS) were designed to measure behaviors of youth aged two through eighteen years reported by parents and/or teachers associated with ASD. As such, the ASRS helps guide diagnostic decisions and can be used during treatment planning, ongoing monitoring of response to intervention and program evaluation. The ASRS includes items related to Autistic Disorder, Asperger’s Disorder and Pervasive Developmental Disorder – Not Otherwise as specified under the current DSM-IV-TR. The symptom items included in the ASRS are also generally inclusive of the proposed items for the next diagnostic guidelines contained in the DSM-V to be published sometime in 2013 or 2014.

The ASRS can be used as an aid in the diagnostic process. Standardized scores from the ASRS allow clinicians to effectively compare children to a normative group in an objective and reliable manner. Scores can be integrated with other information to form a complete understanding of the child. When used in combination with other assessment information, results from the ASRS helps guide diagnostic decisions, treatment planning and ongoing monitoring of response to intervention. The ASRS can also be used to evaluate the effectiveness of a treatment plan for a young child with ASD.

A separate version of the ASRS has been created for preschool children, age two to five years. A comprehensive review of current theory and literature on the assessment of ASD is the DSM-IV and the ICD-10 diagnostic criteria as well as the authors’ clinical and research experiences were used to determine the preliminary content structure. This structure guided item generalization and multiple items were developed to capture key components of each construct. For young children, key content areas included socialization (with children and adults), stereotypes, behavioral rigidity, sensory sensitivity, language and attention. In the normative standardization, 640 two to five-year-old normal children were rated by parents and teacher/child care providers. These samples included ratings of forty males and forty females at each age and are representative of the U.S. population across several demographic variables. Clinical samples included nearly 700 ratings of youth diagnosed with ASD and over 500 ratings of youth diagnosed with other clinical disorders, including delayed cognitive development, delayed communication and language development, ADHD, anxiety disorders, and depression.

In order to exam the underlying factor structure of the ASRS items, data from both normative and clinical samples were used in exploratory factor analyses. Results of these analyses suggested that a two-factor model was most suitable for parent and teacher ASRS forms for two to five-year-olds, whereas a three factor model was most suitable for the parent and teacher ASRS for older children. These factor-derived scales were labeled the ASRS Scales and for young children included Social/Communication and Unusual Behaviors. The accuracy of the ASRS to identify young children with ASD is over 90% with a very low false positive rate.

The ASRS is designed such that once the instrument is scored, a profile of strengths and weaknesses can be generated, leading to the development of treatment plans in clinical settings and Individualized Education Plans as per the Individuals with Disabilities Education Improvement Act and/or 504 Plans under the Americans for Disabilities Act. The ASRS has been constructed and designed to allow treating providers to evaluate specific behaviors over multiple periods of time in an effort to determine if treatment has yielded clinically significant results.

The assessment of ASD, especially in young children, is complex, requiring a reasoned and reasonable appreciation of diagnostic criteria, assessment tools and comorbid problems. As an increasing body of the literature is demonstrating the critical importance of identification of ASD at young ages, the tools used in this identification and diagnostic process become increasingly important. A brief historical review reveals that autistic qualities are not simply manifestations of twentieth or twenty-first century culture but have probably presented challenges for individuals throughout human history. It is very positive to note that in the last ten years the emergence of good science relative to the assessment and effective evidence-based treatment of ASD has greatly accelerated and should continue to do so into the near future.

 

Sam Goldstein, PhD is a Clinical Assistant Professor of Psychiatry at the University of Utah School of Medicine. He can be contacted at info@samgoldstein.com. Jack Naglieri, PhD is Research Professor at the University of Virginia. He can be contacted at jnaglieri@gmail.com.

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