CLINICAL PRACTICE GUIDELINES Quick Reference Guide · There are three versions of each clinical...

GUIDELINE VERSIONSThere are three versions of each clinical practice guideline published by the Department of Health. All versions of the guideline contain the same basic recommendations specific to the assessment and intervention methods evaluated by the guideline panel, but with different levels of detail describing the methods, and the evidence that supports the recommendations.

The three versions are:

The Clinical Practice Guideline:Report of the Recommendations full text of all the recommendations background information summary of the supporting evidence

Quick Reference Guide summary of major recommendations summary of background information

The Guideline Technical Report full text of all the recommendations background information full report of the research process and

the evidence

For more information contact:

New York State Department of HealthEarly Intervention Program

Corning Tower Building, Room 287Albany, New York 12237-0618

(518) 473-7016

http://www.health.state.ny.us/nysdoh/eip/[email protected]

SECOND PRINTING4216 10/11

Quick R

eference Guide

A

utism/Pervasive D

evelopmental D

isorders

CLINICAL PRACTICE GUIDELINES

Quick Reference Guide

for Parents and Professionals

AUTISM/

PERVASIVE DEVELOPMENTAL

DISORDERS

ASSESSMENT AND INTERVENTION FOR

YOUNG CHILDREN (AGE 0-3 YEARS)

SPONSORED BY NEW YORK STATE DEPARTMENT OF HEALTH

EARLY INTERVENTION PROGRAM

CLINICAL PRACTICE GUIDELINE

Quick Reference Guidefor Parents and Professionals

AUTISM /


DISORDERS



SPONSORED BY NEW YORK STATE DEPARTMENT OF HEALTH

DIVISION OF FAMILY HEALTH BUREAU OF EARLY INTERVENTION

This guideline was developed by an independent panel of professionals and parents sponsored by the New York State Department of Health. The recommendations presented in this document have been developed by the

panel, and do not necessarily represent the position of the Department of Health.

GUIDELINE ORDERING INFORMATION Ordering information for New York State residents: The guidelinepublications are available free of charge to New York State residents.

To order, contact:Publications New York State Department of Health

P.O. Box 2000 Albany, New York 12220 Fax: (518) 486-2361

Ordering information for non-New York State residents: A small fee will be charged to cover printing and administrative costs for orders placed by non-New York State residents.

To order, contact: Health Education Services P.O. Box 7126 Albany, New York 12224 healthresearch.org/store

MasterCard and Visa accepted via telephone: (518) 439-7286. 1. Clinical Practice Guideline: Report of the Recommendations.

Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children (Age 0-3 Years). 5 1/2 x 8 1/2, 322 pages, 1999. Publication No. 4215.

2. Clinical Practice Guideline: Quick Reference Guide. Autism/PervasiveDevelopmental Disorders, Assessment and Intervention for Young Children (Age 0-3 Years). 5 1/2 x 8 1/2, 108 pages, 1999. Publication No. 4216. Reprinted 2006, 2008, 2009.

3. Clinical Practice Guideline: The Guideline Technical Report. Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children (Age 0-3 Years). 8 1/2 x 11, 434 pages, 1999. Publication No. 4217.

For permission to reprint or use any of the contents of this guideline, or formore information about the NYS Early Intervention Program, contact:

NYS Department of Health,

Bureau of Early Intervention

Corning Tower Building, Room 287

Empire State Plaza

Albany, New York 12237-0660 (518) 473-7016 [email protected]

http://wwwhealthQ\.gov/community/infants_ children/early_ intervention/

http://wwwhealthQ\.gov/community/infantsmailto:[email protected]

The New York State Department of Health gratefully acknowledgesthe contributions of individuals who have participated as consensuspanel members and peer reviewers for the development of thisclinical practice guideline. Their insights and expertise have beenessential to the development and credibility of the guidelinerecommendations. The New York State Department of Health especially appreciates theadvice and assistance of the New York State Early InterventionCoordinating Council and the Clinical Practice Guidelines ProjectSteering Committee on all aspects of this important effort to improvethe quality of early intervention services for young children withautism/pervasive developmental disorders and their families.

The contents of the guideline were developed under a grant from the U.S. Department ofEducation. However, the contents do not necessarily represent the policy of the Departmentof Education, and endorsement by the federal government should not be assumed.

TABLE OF CONTENTS

AUTISM/PERVASIVE DEVELOPMENTAL DISORDERS ASSESSMENT AND INTERVENTION

FOR YOUNG CHILDREN (AGE 0-3 YEARS)

PREFACE: WHY THE EARLY INTERVENTION PROGRAM IS DEVELOPING CLINICAL PRACTICE GUIDELINES

INTRODUCTION .............................................................. 1 Scope of the Guideline...................................... 2 Definitions of Other Terms ............................... 3 Why the Guideline Was Developed .................. 4 How the Guideline Was Developed .................. 5 Guideline Versions ........................................... 6 Where Can I Get More Information? ................ 6

BACKGROUND: UNDERSTANDING AUTISM .................... 7 ASSESSMENT METHODS............................................... 11

Early Identification of Possible Autism .......... 13 Screening Tests and Assessment Instruments . 17 The Developmental Assessment ..................... 20 The Health Evaluation .................................... 24

INTERVENTION METHODS ........................................... 30 Behavioral and Educational Approaches......... 33 Other Experiential Approaches ....................... 38 Medication and Diet Therapies ....................... 44

APPENDICES A. ARTICLES THAT MEET CRITERIA FOR EVIDENCE ....... 53 B. NEW YORK STATE EARLY INTERVENTION PROGRAM..63

Relevant Policy Information ........................... 65 Description ..................................................... 73 Program Definitions........................................ 81 Telephone Numbers of Municipal Early

Intervention Programs..................................... 85 C. ADDITIONAL RESOURCES.......................................... 87 SUBJECT INDEX............................................................ 91

AUTISM /

PERVASIVE DEVELOPMENTAL DISORDERS

CLINICAL PRACTICE GUIDELINE DEVELOPMENT PANEL Harold Alan Kanthor, MD Guideline Panel Chairman Pediatrician Rochester, New York Stephen Anderson, PhD Language Development Program Tonawanda, New York Stephen Bauer, MD Developmental Unit The Genesee Hospital Rochester, New York Mary P. Bergin, CCC-SLP Monroe #1 BOCES Fairport, New York Marlene Breitenbach, MS Ed Intensive Learning Program The Childrens Annex Kingston, New York Patricia Calandra Wading River, New York Christine Clarke, MS Just Kids Learning Center Middle Island, New York Ira L. Cohen, PhD, FAPS Department of Psychology NYS Institute for Basic Research Staten Island, New York Carroll J. Grant, PhD Margaret L. Williams Developmental Evaluation Center Syracuse, New York

Margaret Kuhn Lowville, New York Gloria Lucker, MS, OTR/L, FAOTA Optimal Therapy Associates Buffalo, New York Margaret Oldendorf Schenectady, New York Michael Palone III, RPh Ambulatory Pharmacy Manager Strong Memorial Hospital Rochester, New York Richard Perry, MD NYU Medical Center and Bellevue Hospital New York, New York Christine Radziewicz, DA, CCC-SLP School for Language and

Communication Development North Bellmore, New York Raymond G. Romanczyk, PhD Institute for Child Development SUNY Binghamton Binghamton, New York Ellen Woodward, CSW Early Childhood Division Developmental Disabilities

Institute Huntington, New York

AUTISM /

PERVASIVE DEVELOPMENTAL DISORDERS

PROJECT STAFF Project Director

Demie Lyons, RN, PNPPharMark CorporationLincoln, Massachusetts

Director of Research/Methodologist

John P. Holland, MD, MPHSeattle, Washington

Senior Research Associate Mary M. Webster, MA, CPhilSeattle, Washington

Research Associates PharMark Corporation

Beth Martin, MLISCeleste Nolan, MS

Seattle, WashingtonCarole Holland, BA

SUNY Binghamton Tamara Weiner, MAMeredith Cochran, BA

Topic AdvisorMichael Guralnick, PhDUniversity of WashingtonSeattle, Washington

Writers/Copy EditorsPatricia Sollner, PhDWinchester, Massachusetts Diane Forti, MADedham, Massachusetts

Meeting FacilitatorAngela Faherty, PhDPortland, Maine

NEW YORK STATE DEPARTMENT OF HEALTH CONTRIBUTING STAFF

Guideline Project Director Donna M. Noyes, PhDDirector, Policy and Clinical Services

PREFACE: WHY THE EARLY INTERVENTION PROGRAM IS DEVELOPING CLINICAL PRACTICE GUIDELINES In 1996, the New York State Department of Health (NYSDOH) initiated amultiyear effort to develop clinical practice guidelines to support the effortsof the statewide Early Intervention Program. As lead agency for the EarlyIntervention Program in New York State, the NYSDOH is committed toensuring that the Early Intervention Program provides consistent, highquality, cost-effective, and appropriate early intervention services that resultin measurable outcomes for eligible children and their families. The guidelines are not standards nor are they policies. The guidelines aretools to help ensure that infants and young children with disabilities receive early intervention services consistent with their individual needs and consistent with the resources, priorities, and concerns of their families. The guidelines are intended to help families, service providers, and publicofficials make informed choices about early intervention services by offeringrecommendations based on scientific evidence and expert clinical opinion oneffective practices. The impact of clinical practice guidelines for the Early Intervention Programwill depend on their credibility with families, service providers, and publicofficials. To ensure a credible product, the NYSDOH elected to use anevidence-based, multidisciplinary consensus panel approach. Themethodology used for this guideline was established by the Agency forHealth Care Policy and Research (AHCPR), and was selected for this effortbecause it is an effective, scientific, and well-tested approach to guideline development. The NYSDOH has worked closely with the State Early InterventionCoordinating Council throughout the guideline development process. A state-level steering committee comprised of early intervention officials,representatives of service providers, and parents was also established toadvise the department regarding this initiative. A national advisory group ofexperts in early intervention has been available to the department to reviewand to provide feedback on the methodology and the guideline. Their effortshave been crucial to the successful development of this guideline.

WhWheenn tthhiiss ssyyymmbbooll aappppeeaarrss,, iitt iinnddiiccaatteess tthhhaatt tthheerree iiss infoinf tion in ppe dix out levant Ea ly nte vennttiioonn PrProoggrraamm ((EEIIPP))nfforrormmaation in AAppenndix BB aaabbout rreelevant Earrly IInterrvention ppolicpolicy.y.

IItt iiss iintnntteendende ha he DDDOOHH cclliininiccaall praaccttiiccee guide nedd tthatt tthe NNYYSS pr guiguidelliiness ffforor deve opm nteopmopmopmopmee aantntalll disabillbiasdidi lbias iiitttiiieeesss iii hi dr om bi ooooo aaa 33gege 3 be dynammdynabebe mdyna iiicccllvedede lve nnnnn ccc llhihil eedrdrennn fffrrr rrbiomom rbi ttthhh ttt ge docum nts thaeumuments thatt aarree updaupdatteedd pe od ne ccciieentiifffiiicc iinfnffooorrmmaattiioonndoc perriiodiiccaallllyy aass neww ss nt be ombecc va bl . Thi guide ne fl he tttee of knowof knowlleedgedge aatt tthhee ttiimmeeeomomess aavaiillaablee. Thiss guidelliine rreefflleeccttss tthe ssttaa ofof dedeveve .. HHow veoweeverr,, give he nevi bl volut on ofvellopmopmeentnt givenn tthe iinevittaablee ee ntvolvolutiion of sscciieentiifffiiicc

he nt nt on of hettthe NNYYSSDDOOHH tthatt perr diiinfonfforrormmmaattiionon aandnd tteecchnology,hnol iogy,ogy, itt iiss tthe iinteentiion of ha pe iiioodicc vi www,, upda ng,updattiing, aandnd rreevissiion be ncorpor dd iintntoo aann ongoinnggrreeviee vi on wwiillll be iincorporaattee ongoi

guide ne deve opllliine devellopmmeent procent proc sss.guide e s.

ThThee NeNeww Yorrkk SSttaattee EEaarrllyy IInntteerrvveennnttiioonn PPrrooggrraamm ddooeess nnoott ddiissccrriiimmiinnaattee oonn tthhee bbaassiiss ooff hhaannddYo iiccaapp iinn ad iiioonn,, oorr accesaccesss ttoo,, oorr ttrereatatmmen em en ramram andd aactctiivviittiies..admmiissss tenent oorr emppllooyymmentt iinn iittss ppro ram anrogg es IfIf yyoouu fffeeleel yyoouu hhavee bbeeneen ddiissccrimmii ated agai ad ooav ri nnnated againnsstt iinn admmiissssiioonn,, rrr aacccceessss ttoo,, oorr ttrreeaattmmeenntt oorr ememppllooyymmenentt iinn tthhee NNeeww YYoork SSttatatee arl In erven ro rammm,, yyoouu mmayay,, iinn adddiittiioonn ttoo alalll ootthherrk EEarlyy Intterventtiioonn PProggra ad er ri andanand remmed es coediies,, connttact DDiirectrect reau rl erventttiioonn,, NNeeww YYoorkrk SSttatee DDepartep martartmenttrigghhttss re act ooorr,, BBuureau ooff EEaarlyy IInntterven at en of lth, o 287 orning eeerr BBuilding, Empir tate lllaaazzaa,, AAlbany NY 12237lbany,, NY 12237 0660.0660.of HHeeaa Rlth,lth, Rooomm 287 CCorning TTooww uilding, Empiree SState PP --0660.

CLINICAL PRACTICE GUIDELINE

Quick Reference Guidefor Parents and Professionals

AUTISM /


DISORDERS



This Quick Reference Guide provides only summary information. For the full text of the recommendations and a summary of theevidence supporting the recommendations, see Clinical Practice Guideline: Report of the Recommendations.

QUICK REFERENCE GUIDE

INTRODUCTION

The guideline recommendations

suggest best practices,

not policy or regulation

The Clinical Practice Guideline on which this Quick Reference Guide is based was developed by a multidisciplinary panel of clinicians and parents. The development of guidelines for the Early Intervention Program was sponsored by the New York State Department of Health as a part of its mission to make a positive contribution to the quality of care for children with disabilities. The guideline is intended to provide parents, professionals, and others with recommendations based on the best scientific evidence available about best practices for assessment and intervention for young children with autism/pervasive developmental disorders.

The guideline is not a required standard of practice for the Early Intervention Program administered by the State of New York.

This guideline document is a tool to help providers and families make informed decisions.

Providers and families are encouraged to use this guideline, recognizing that the care provided should always be tailored to the individual. The decision to follow any particular recommendations should be made by the provider and the family based on the circumstances presented by individual children and their families.

1

EI

AAUTUTISISMMM/P/PERERVVAASSIIVVEE DD EL ENEVEVELOOPPMMMENTATALL DDISISOORRDEDERRSS

SCOPE OF THE GUIDELINESCO EHTFOEPCO G NEILEDUI NE

oc sss ofof ttthhhee GGuuiidellliiinneeFFocuu de he us of he guide ne onononTThe fffooccoocus of tthe guidelliine

ui eefffeeerreencee uidewwhihicchhh tthihiss QQuicckk RRef nc GGuide ba eeedd iiss aasssseessssmmeentnt aandiiss bass nd

iinteerr o yont vent onveventiion ffforror youunngg cchhiilldddrreenn wwiitthh au pr yyy fffoccocustauautiissmm,, wwiitthh aa priimmaarr o us

unde of geonon cchi drlhihildreenn underr 33 yeyeaarrss aofof age.. ow ve , ageeeeverr, age 33 iiss notnot aann aabsbsoluteeHHow bsolut

uto fff,, aandnd mmaany of ttheccutoffff ny of he rreeccommomommeenda onsndattiions iinn tthe guidelliinehe guide ne

ppl bl om wwwwwhatthahataaarrreee aaalllsssssooo aaa iipplpplicccaaa eeblble iiinnn sss eeomome oldeolderr hi dr n.ccchilldreen.

DDeeeffffiiinniinnggg auauttiissmm asas iitt iiss uusseeedd iinn gu dettthhiiss guii ldedelliiinnee

TThe dehe defffini on of autautiissmm usiiinittiion of aass useeedd iinn thi ui eeffffeeerreencee GGGuide ideuiui ide issshitt shi QQQ cuiuickkk RRRef nc ba on he di gnos aabasseedd tonon the diaagnosttiicc ccrriitteerrii ha de ne pr sent ddd iinntthatt defffi ut smiiine aautiism aass preesentee

tthehe AAmm ychieeerriiccaann PPssychiaattrriicc As oc on DDiiagnosttiicc andandAsssociiaattiionss agnos

al Mannuuaalla alStStatatiissttiiccal MManual ofof MMMeeennttal sorde s, 4t di on, comcommmoonlyyDDiisorderrs, 4thh EEdittiion, nl

rreefffeeerrrreedd he IVIV..ttoo aass tthe DSDSMM--

P 11P

Opeep rra onalat eefffiiinniitttiionOOperattttiional DDef on IInn tthihiss QQuiuicckk RRef nc uide, the thehe teerrmm perrvassiive devell di ordeeefffeeerreencee GGuide, t pe va ve deve opm nteopmopmentaall dissorderr

ut bbr vi hrhrhroughoutoughout aass aaututiissmm. W ehheerr he eefffeeerreenncccee ttoo((PPDDDD))///aautiissmm iiss aabbreeviaatteedd tt . WhWh eevveerr ttherree iiss aa rref aut , i nt nde an bothbotboth PPDDDD and autiissttiicc di ordedissororderr..autiissmm,, itt iiss iinteendedd ttoo mmeean and aut

22

E

QQUICUICKK RREFEFEERREENNCCEE GGGUIUIDDEE

DEFINITIONS OF OTHER TERMSD NIEF OFSONITIN O ERTH TER SMER

DDeefffiiini ons give be ow ffforor ssomee mmajor he us shihistninitiions aarree givenn bellow om aajjor tteerrmmsss aass ttheyy aarree useedd iinn tthi ui eefffeeerreencncee GGuide..QQuicckkk RRef uide

Assessmesmentnt TThehe eentiirr proc ttthe cchilld, iinclluding ttheAssess nt eee proceessss ofof eeva ua ng hevalluattiing hi d, nc uding he activities aand oolnd ttoolss ususeedd ttoo mmeeaassuurr ve of nc oning,activities uree lleevell of fffuuuncttiioning, eessttaablbliisshh gibi or vi tdedeteerrmmiinene aa diaagnosiiss,, pleelliigibilliittyy ffforor sseerrvicceess, de, di gnos aplplann nt vent on, nd eent out omnt outccomeess..iinteerrvent uriiion, aand mmeeaassuree ttrreeaattmm

FamilyFamillyyy he hi ddss pr give wwwhicchh mmiightght iinncclludepriimmaarryy ccaarreegiverrss,, hi ude one orTThe cchilld oneone or bot pa eeentss,, ssiibl ngs gr ndpabliings,, graandparreent , fos ororbothh parr nt sntnts, ffosostteerr ccaarree paparreent , orntss, othe usua eee eenvi onm ntnvirronmeent((ss))..otherrss us he hi d homluaualllyy iinn tthe cchilldss hom

Parentsntnts he pr aarryy ccaarreegiverr((ss)) or otheor othe pe on( have)veve)TThe priimm give ho haPare rrr perrsson(ss)) wwho hass ((ha ssiignifffiiccaant pons bi yyy ffforor tthe of he hi d.ngnigni ntt rreess iiponspons billiitt or he wwweellfffaaarree of tthe cchilld.

Professionalsssional ny provideovioviderr of profof proffeeessssiionall sseerrvi ua oooAAny pr ona hoProffee cviviceess wwho iiss qqualliifffiiieedd tt provide he nt nde vi luaualiifffiiiccaattiions geneons generraallllyy ii lncncludeprovide tt ihehe inteendedd sseerrviccee. Qua. Q nc ude ttrraaiining,ning, xpe nc nd/or otheeeexperriieencee,, lliicceensuree,, aansur nd/nd/or otherr ssttaattee

he dededd ttoo iimmplyy aany sspeccciifffiiiccrreequiquirreemmeeentntss.. TThe tteerrmm iiss not ntnot iinteenn pl ny pe prof ona degr or qua ons otheons otherr tthann aapproprppropriiaaatteeproffeeessssii lonaonal degreeee or qualliifffiiiccaattii ha

ning nd dent . ( beyond hetyondyond the ssccope of tthissttrraaiining aaand ccrreedentiiaallss. (IItt iiss be ope of hi guide ne tnene too aaddrddreessss profffeessssiiona pronall praaccttiiccee iissssuess..))guidellii pro ue

Screeningngng TThehe eeaarrllyyyyy ssttaa ssgege of tthe aasssseessssmmeent proc rreeeeningngScreenini ge of he nntt prproceessss.. SScc ning mmaaayyy rpapareent iinteerrvieewwss or que va on ofiinc ude pancllude nt nt vi or quesssttiionnaonnaiirreess,, obsobseerrvattiion of

he hi d, or usor usee of peof sspecciifffiicc ssccrreeeening ning ususeeddtthe cchilld, ning tteessttss.. SSccrreeeening iiss ttoo iidentdentiifffyyyy cchi drhilldreenn wwho neeedd mmor --deptho ne oorree iinn uadepthh eevvaalluattiioonn..

TargetTar Att A ssttudy groupudy grgroup sseelleecctteedd aaccccording pe ha ririsstt cs.Targe ordinngg ttoo sspecciifffiiicc ccharraaccttee stiics. Population or hi guide neguiguidelliine,, tthe ttargett populpopulatiion hi drPopulatation FFor tthiss he arge populat on iiss cchilldreenn wwiitthh

pos bl ut om bi ge 3gege 3 yeaarrss.. TThr ughout hihrooughout tt shihisposssiiblee aaautiissmm fffrrrom birrtthh ttoo aa ye docum nt, thentnt, the tteerrmm oung hi dreenn us be hishihisdocumee yyoung cchilldr iiss useedd ttoo ddeessccrriibe tt ttaarrgegett aage group.gege group.

YoungYoung us hi guide ne ddee ge groupoupoupYoung TTeerrmm useeedd iinn tthiss guidelliine ttoo be hedessccrriibe tthe ttaarrggeett aage grCC drhildredrenn ((cchi drhilldreenn om bi ge ye rrrss..)) AAlltthough hi drhough cchilldreenn fffromhil fffrrom birrtthh ttoo aage 33 yeaa rrrom

bi ge 3gege 3 iiss tthehe nt ndeiinteendedd fffococus of he guide neocusus of tthe guidelliine,, tthebirrtthh ttoo aa he ttteerrmm young hi dr nc ude ssomeewwha oldehatt olderr cchilldreeen.young cc lhihildreenn mmaayy aallssoo iincllude om hi dr n.

IIE 2,PPP 2, 33

33

AUTISM/PERVASIVE DEVELOPMENTAL DISORDERS

WHY THE GUIDELINE WAS DEVELOPED

THE IMPORTANCE OF USING SCIENTIFIC EVIDENCE TO HELP SHAPE CLINICAL PRACTICE

Every professional discipline today is being called upon to document its effectiveness. Current questions often asked of professionals are: How do we know if current

professional practices are effective in bringing about the desired results?

Are there other approaches, or modifications of existing approaches, that might produce better results or similar outcomes at less cost?

The difficulty in answering these questions is that many times the methods used in current professional practice have not been studied extensively or rigorously.

Evidence-based clinical practice guidelines are intended to help professionals, parents, and others learn what scientific evidence exists about the effectiveness of specific clinical methods. This information can be used as the basis for informed decisions. This guideline represents the panels attempt to interpret the available scientific evidence in a systematic and unbiased fashion and to use this interpretation as the basis for developing guideline recommendations. It is hoped that by this process, the guideline offers a set of recommendations that reflects current best practices and will lead to the best results for children with developmental problems.

4


HOW THE GUIDELINE WAS DEVELOPED

This guideline was developedusing standard research methods for evidence-based guidelines. Theprocess involved establishingspecific criteria for acceptableevidence and reviewing thescientific literature to find such evidence. Relatively rigorous criteria were used to select studies that would provide adequateevidence about the effectiveness of assessment and intervention methods of interest. Studies meeting these criteria forevidence were then used as the primary basis for developing therecommendations. In addition, there were numerous articles in the scientific literature that did not meet the evidence criteria, yet stillcontained information that may beuseful in clinical practice. In manycases, information from these otherarticles and studies was also used by the panel, but was not given as much weight in making the guideline recommendations.

When no studies were found that focused on children in the targetage group (from birth to age 3), generalizations were made fromevidence found in the studies of somewhat older children. In the full-text versions of this guideline, each recommendation isfollowed by a strength ofevidence rating indicating theamount, general quality, andclinical applicability (to theguideline topic) of the evidencethat was used as the basis for the recommendation.

For more information about the process used to develop theguideline recommendations, as wellas a summary of the evidence thatsupports them, see Clinical Practice Guideline: Report of theRecommendations. A full description of themethodology, the recommendations, and the supporting evidence can be found in Clinical Practice Guideline: The Technical Report.

5


GUIDELINE WHERE CAN I GET MORE VERSIONS INFORMATION

There are three versions of this clinical practice guideline published by the Department of Health. The versions differ in their length and level of detail in describing the methods and the evidence that support the recommendations. The Report of the Recommendations full text of all the

recommendations background information summary of the supporting

evidence The Quick Reference Guide summary of major

recommendations summary of background

information The Technical Report full text of all the

recommendations background information full report of the research

process and the evidence reviewed

There are many ways to learnmore about autism and pervasivedevelopmental disorders. Severalresources are listed in the back of this booklet. When reviewing thislist of resources, families andprofessionals should be aware thatthe information provided by theseresources has not been specificallyreviewed by the guideline panel.

Caution is advised when considering assessment or treatment options that have notbeen studied using a goodscientific research methodology.

It is important to considerwhether or not there is goodscientific evidence that the approach being considered is effective for young childrenwith autism/PDD.

6


BACKGROUND: UNDERSTANDING AUTISM

Since the 1980s, we have gained abetter understanding of the broaddiagnostic category that includes autism and autism-like disorders. Autistic Disorder (autism) is nowbelieved to represent only one partof a clinical spectrum or group ofdisorders termed pervasivedevelopmental disorders. What is autism? Autism is a neuro-behavioral syndrome caused by problems inthe central nervous system thataffect the childs development. The onset of autistic symptoms occurs within the first 3 years oflife and includes three generalcategories of behavioralimpairment common to all persons who have autism: 1. Qualitative impairments in

social interaction 2. Qualitative impairments in

communication 3. Restricted, repetitive, and

stereotyped patterns ofbehavior, interest, andactivities

Qualitative impairments in socialinteraction Sometimes this deficit in social relatedness is noticeable during thefirst months of life; parents mayreport that their child has poor eyecontact, lacks interest in beingheld, or stiffens when held. Youngchildren who have autism often do not initiate or sustain play withtheir peers and often do not takepart in groups. They may lack theability to judge appropriate reactions in social situations; theymay not feel anxiety aroundstrangers, or not be aware of howclose to stand to someone. Qualitative impairments incommunication When language is present in theyounger child with autism, it tends to be rote, repetitive, and lackingin apparent communicative intent.

7


Restricted, repetitive, andstereotyped patterns of behavior,interest, and activities Most young children who have autism will demonstrate repetitive motor or verbal actions. Children may, for example, flap their hands, bang their heads, rock, pace, spin on their feet, or use repetitive finger movements. In some children, these stereotyped behaviors tend to occur primarily when the child is excited, stressed, or upset. Children with autism also have a tendency to be preoccupied with a small number of activities, interests, or objects. The nature of their play tends to be restricted or repetitive. Several other common findings in children who are autistic do not fit easily into the symptoms described above. Those findings may include the following: Unusual responses to sensory

stimuli Behavior disturbances Cognitive characteristics

How common is autism? Autism may be more common than previously thought, particularly if defined as a spectrum disorder. Earlier studies suggest that about 3 to 4 children in 10,000 have autism. More recent studies suggest as many as 20 or more children in 10,000 have autism. A range of 10 to 15 children per 10,000 is a commonly accepted middle range estimate.

Who can make a diagnosis ofautism? Based on the medical practice acts of New York State, licensed psychologists and physicians are the only individuals qualified to make a diagnosis of autism. Since making an accurate diagnosis of autism is complex, particularly in children under 3 years of age, it is important that physicians and psychologists who make the diagnosis have experience and expertise in assessing young children with autism.

8


What causes autism? Many different types of researchsupport the concept that autism is abiologically based developmentaldisorder. However, no specificcause has yet been identified. Is there a cure? Given that autism is a spectrumdisorder with a wide range ofpresentations and no knownspecific cause, it seems unlikelythat any single cure will be found. Although there is no known cure,there are interventions that show promise for treating some of the symptoms of autism.

What is the prognosis for childrenwith autism? The prognosis for children with autism varies considerably.Traditional estimates suggest thatabout two-thirds of cases have an overall poor outcome (as definedby social adjustment), ability towork, and ability to functionindependently. The more recent, broaderdefinitions of autism and PDD include many children with mildersymptoms for whom the long-term prognosis may be better. Currently, the majority of childrenwith autism can be expected tocontinue to need some degree ofassistance as adults. A much smaller group, perhaps 10% ofcases, may actually seem tooutgrow their autism and returnto near normal functioning.Some data suggest that recentbehavioral approaches, appliedearly and intensively, maysignificantly improve the outcomefor at least some children with autism.

9


WHAT ARE SOME COMMON MISCONCEPTIONS ABOUT AUTISM?

Although much has been learned about autism in recent years, there are stillsome commonly held misconceptions. Common misconceptions may include the following:

Misconception: Autism is a mental illness. Fact: Autism is a neurologically based disorder of development. It is not

considered a mental illness.

Misconception: Children with autism are mentally retarded. Fact: Although mental retardation may frequently coexist with autism, not

all children with autism are mentally retarded. The intelligencequotients of children with autism span a range from very low to veryhigh.

Misconception: Children with autism are unruly kids who choose not tobehave.

Fact: Certain aggressive behaviors may be symptoms associated withautism. There may be many reasons why certain children with autismsometimes demonstrate disruptive or aggressive behaviors (confusiondue to language deficits, sensory sensitivities, high anxiety, and lowtolerance for change, to name a few). However, these behaviors are generally not chosen by the child.

Misconception: Bad parenting causes autism. Fact: There is no credible evidence that autism can be caused by deficient

or improper parenting, contrary to what may have been believed in thepast.

10

E

li


ASASSSEEESSSSMMEENTNT MMEETTHHOODSDS

por nt de hi drlhihildreennIItt iiss iimmmporttaant ttoo iidennttiifffyyy cc ut sm s possibliblee.. IIttwwiitthh aaautiism aass eeaarrllyy aas poss

s ooffftt possibl zzzeeiis ognieeenn possiblee ttoo rreeccognihe ofaaututiissmmm wwiitthihinn tthe fffiiirrsstt 33 yeyeaaarrss of

fliflifffeee..

IPI 4, 5,PP 4, 5, 66

ngl utTTheherree iiss nono ssiinglee wwaayy tthahatt aaautiissmm dent youngiiss fffiiirrssttt iidentiiffiieedd iinn young

chi dreneen he sequenc of hechilldr .. TThe sequencee of tthhee aasssseess nt proc varrryy fffrrromsssmmeent proceessss mmaayy va om

he next ooneone cchilhihildd ttoo tthe next.. TTheherreefffforroree,,he orde of he nttthe or rdeder of tthe aasssseessssmmeent

ccomponents pr sentomponeponents preesenteedd iinn tthishihis ui kkk RRef nc iiss notQQuicc uide notnoteefffeeerreencee GGuide

ne ssassarriillyy tthe orderr iinn wwhihiccchh ttheneccees he orde he nt proc oc ur our ffforror aaaasssseesssssmmeent proceessss wwiillll occc

uu aallarrr ccchi d. R ga dlllhihil eeRd.d. eR rrgagar eedldlessssss of hepapaparrrtttiiicccululul ttofof thehe orde hi oc urcococcurss,,orderr he prociinn wwhicchh tthe proceessss aallll tthe gene nt of hehehe generraall eelleemmeentss of tthehe aasssseesssssmmeent procnt proceessss aarree iimmpor nttporportaant or pr ona ntss ttoofffor pr nd paooofffeeessssiionallss aand parreent ons derdeder wwhehenn aasssseessssiing youngyoungcconsii ng young

cchi drhilldreeenn wwiitthh posposssiiblblee aautiissut mmm..

FFrreequent y, theque ndi oonn tthalntntly, the fffiiirrsstt iindiccaattiion hatt he aaayy bebe aa probleemm iiss aattherree mm probl

pa nt onc ha om pecpepecttparreentss cconceerrnn tthatt ssomee aass of he hi ds deve opmof tthe cc lhihilds devellopmeenntt iiss delldedelaaayeddyeyed or ha om hingttoror t tthahat sss eeomomettt iinghihi ing sss aabnorbnormm bout he hiaaall aabout tthe cchillddss behaviorbehavi he be.oror. TThe cconceerrnn mmaayy aallonc sssoo be dent eeedd byby aa heaalltthchcaarree provioviderriidentiifffiii he provide

or othe pror otherr ona ofproofffeessssiionall aatt tthe ttiihe mmmee of gul he xa or hennn ttheheaa rreegulaarr heaalltthh eexamm or wwhe

hi s be ng o someomomecchilldd iis va uabeiing eevalluatteedd ffforror s otheotherr he onc orahehealltthh cconceerrnn or deve opm nt obldevell eopmopmentaall pprrobleemm.. SSiincncee aaut sm s riututism iis reellaattiivellyy rraarreeve ,, iitt iiss not pr he generneneraallnot praacccttiiccaall ttoo ssccrreeeenn tthe ge popul on ffffororpopulaatt young hiiiion ooff young cchillddrreenn aaututiissmm us ng pe inngiususing aa sspecciifffiiicc ssccrreeeeninni gtteestst.. AA or use u pproa fffforrormmmoree usefffullul aapproacchh o iidentdentiifffyyiiing hing cchillddrreenn wwiitthh posssiibleepos bl aautiiututissmm iii ook oss tttoo lll ffookook fforror cceerrtttaaiiinn iinappropnappr behavi ofropopriiaattee behavioorrss or llaaccor kk of cceerrttaaiinn aaa -ge- ppr pr behavioorrssge aapproopriiaattee behavvii

ni oftthahatt mmaayyy bebe cclliiniccaall ccllueuess aofof a pos bl probleee probleemm.. TThehessee cclliinicccaallposssiibl ni

ues a eee iidentdentiifffiiieedd iinn TTABABLELE 2.2.ccllues arr 2.

1111

E


a lllliiisshhiinngg aa SpeepEEsstttabbab SSpecciiiffffiiicc DDiiagnos ofagnagnosiiss of AAuutttiiissmm WWhihilleee tteessttss sspepecciifffiiiccaallllyy dessiiigneddde gne

ut youngettoo aasssseeessss aautiissmm iinn youngerr hi dr be us sssiissttiingngcchilldr ueeenn ccaann be useefffullul iinn aass

hehe diaagnosiiss,, no ssiinglwwiitthh tthe di gnos no ngleee tteesstt providesdedes eenoughnough iinnffformmaattiion tonon too beprovi or be use aaass tthe sol bahe solee bassiiss fffor ttheheusedd or he di gnosdiaa of utignosgnosiss of aautiissmm..

om nde ha heIItt iiss rreeeccommmeendedd tthatt tthe di gnosignosgnosiss ofof aautiissmm be babe basseeddd ondiaa ut on tthehe ccrr heiiitteerriiaa iinn tthe AAmmeerriiccaann PPsychisyc soc onahihiattrriicc AAsssociiaattiionss DDDiiiagnostagnosagnostiiicc and StatStandand Statiiissttiiiccalal a ualal MMMMManualualMann of MMeental 4thh EEddii onof Me sorders 4t dittiionnnttal DDiisorders,,(DSM-SMSM-IVIV)),, or he os ur eeenntt(D V) or tthe mmostt ccurrr di on of hi nuaeedittiionon of tthiss mmaanuall..

DSMM-IIIVV vs.. OOtthheerr CCrriitteerriiaaDS - vs

IIVV ccrriitteerriiaa wweerree detteerr neTThehe DDSSSMM-- de mmmiinedd ttthroughhrhr xt ns ve proc ofaoughoughoughough aannn eee eextxte iinsnsi eeocprveve eocpr ssssss ofof ons nsunsnsuss bui dingbuillding aandnd ffiieelldd tteesstttiing,cconsee ng, nd heyhehey rreeprpreesseent tthe mmosostt wwii ldedelyyaand tt nt he de

pt nd ut didiaagnosgnosttiiccaacccceepteeedd aand utiilliizzeedd ode aaccrrososss tthe ccountrry. AAnnmmodell he ount y.

aalltteerrna ve di gnosna ode ha bettiive diaagnosttiicc mmodell hass beeenn propospropos by EERO H EEEE NNaa onaleedd by ZZZERO TTOO :: NattTTTHRHREE atiional CCeentnteerr ffforroor IIInffnffanntt , ToToddleerrss,n aanttsss, Toddddll , andandand FamFamiilliieeess.. ow ve da , thaHHoweeverr,, ttoo dattee, thatt

ode ks basbabababasseeemmm llodeodel orlllaaaccc aaksks a fff mmorormaaalll rrreeessseeeaaarrrccchhh

nd ha not ye ga ne oaaand hasss not yett gaiinedd bbrroadd

acceptanceaance ong deve opm ntaaallaccept aammong devellopmeent pe . Thus, i bebesspecciiaall noiissttss. Thus, itt iiss nott ffeelltt ttoo

aapproprppr ba or heiopropriaattee aass aa bassiiss ffor tthe di gnos of hidiaa utignosgnosiss of aautiissmm aatt tthiss ttiimmee..

CuCullltttuurraaal Con de a onrratiionssal Conssiideratt va ua ngtuauatiing aa cchihilldd wwiitthh posssibleeIInn eevall possibl

aaututiissmm,, s i por nt oo rreeccooggnniiiitt iis immporttaant tt ognizzee tthahatt tthehe be ul ur ndrrree mmaayy be ccultturaall aand

di nc xpe aaattiionsonsfffaammiilliiaall difffffffeeerreenceess iinn eexpecctt bout suchucuch tthingshings aas eyes eye ccontaaacctt,,aabout s ont

pl nd soc on, ndndndplaayy aa ntndnd sociiaall iinteerraaccttiion, aa pr gmpraagmaa us of nguagetttiicc usee of llaanguage.. IIff EEngngllii not he prssshh iiss not tthe priimmaarryy

nguage of he y, illaanguagege of tthe fffaaammiilly, itt iiss por nt ofntnt fforror pprrofoffeeessssiiona s t llookiimmporttaa onalls too ook

ffforor wwaays om unitysys too ccommmuniccaattee eeccttiive he tndnd theeefffffffe lvevelyy wwiitthh tthe fffaammiillyy aand he

hi nc udillncncl nudiudingg fffiififii nndindinggcc llhihilddd iii ndi nd/or orprofproffeeessssiionalonaonalss aand/or ttrraansnsllaatt sorors

ho peapepeakk tthehe cchi dhilldss fffaammiillyssswwho ss y languagelangua (gege(ss))..

IIPP 77

1212


EARLY IDENTIFICATION OF POSSIBLE AUTISM

Developmental surveillance is the term that most accurately describesthe approach currently practicedby many healthcare providers andother professionals for the earlydetection of developmentalproblems. Developmental surveillance is a flexible, continuous process inwhich knowledgeableprofessionals monitor a childs developmental status during theprovision of health care services.

Developmental surveillance atspecific ages is important forall young children. Theperiodic exams at 15, 18, and24 months are particularlyuseful in evaluating concerns about possible autism.

Developmental surveillance maybe done using either parentquestionnaires and/or formalscreening tests of generaldevelopment. The informationgathered is then reviewed byprofessionals and discussed withthe childs parents. During the course of surveillance,the professionals may note certainbehavioral characteristics that increase concerns that the child may have a specific developmentalproblem. These concerns may bebased on observations made duringthe exam, information about riskfactors, and/or parental concerns. One method of developmentalsurveillance is for the professionalto look for certain age-specificdevelopmental milestones. Normaldevelopmental milestones in the social and communicative behavior that may provide clinicalclues about possible autism arelisted in TABLE 1.

13


This table lists developmental milestones for communication and social skills, two ofthe developmental areas that define autism. The items listed are developmentalmilestones that children following a typical developmental sequence should exhibitby the time they reach the specified age. Failure to achieve a developmentalmilestone is a clinical clue that raises concerns that the child may have autism orsome other developmental delay or disorder.

TABLE 1

DEVELOPMENTAL MILESTONES FOR COMMUNICATION AND SOCIAL SKILLS

15-month developmental milestones Makes eye contact when spoken to Reaches to anticipate being picked up Shows joint attention (shared interest in object or activity) Displays social imitation (e.g., reciprocal smile) Waves bye-bye Responds to spoken name consistently Responds to simple verbal request Says Mama, Dada, 18-month developmental milestones(All of the above, plus the following) Points to body parts Speaks some words Has pretend play (e.g., symbolic play with doll or telephone) Points out objects Responds when examiner points out object 24-month developmental milestones(All of the above, plus the following) Uses two-word phrases Imitates household work Shows interest in other children

Adapted from Siegel (1991) and from Table III-5 in Clinical Practice Guideline: The Technical Report.

14

Identifying Clinical Clues andParental/Caregiver Concerns ofPossible Autism Clinical clues, sometimes referredto as red flags, are historical facts and current observations which, if present, increase concernabout possible autism in a youngchild. Clinical clues may benoticed by the parents, othersfamiliar with the child, or aprofessional as part of routinedevelopment surveillance or during health care visits for someother reason. Clinical clues of autism can include historical information about the child obtained from the parents (for example, the child hasno peer friends) or currentobservations made by theprofessional at the time of evaluation (for example, unusualrepetitive hand movements). Clinical clues of possible autismare listed in TABLE 2.


The clinical clues listed in TABLE 2 represent delayed or abnormalbehaviors that are seen in children with autism (although some of these findings may also be seen inchildren who have a developmental delay or a disorderother than autism). If clinical clues of possible autismare identified by either parents orprofessionals, it is important tofollow up with appropriatescreening tests. For children withsuspected autism, it is important todo both a diagnostic evaluation (todetermine the specific diagnosis)and a functional assessment (toevaluate the childs strengths andneeds in various developmentaldomains).

15


The clinical clues listed below represent delayed or abnormal behaviors that areseen in children with autism (although some of these findings may also be seen inchildren who have a developmental delay or disorder other than autism). If any ofthese clinical clues are present, further assessment may be needed to evaluate thepossibility of autism or other developmental disorder.

TABLE 2

CLINICAL CLUES OF POSSIBLE AUTISM

Delay or absence of spoken language Looks through people; not aware of others Not responsive to other peoples facial expressions/feelings Lack of pretend play; little or no imagination Does not show typical interest in or play near peers purposefully Lack of turn-taking Unable to share pleasure Qualitative impairment in nonverbal communication Does not point at an object to direct another person to look at it Lack of gaze monitoring Lack of initiation of activity or social play Unusual or repetitive hand and finger mannerisms Unusual reactions or lack of reaction to sensory stimuli

Source: This table is derived from Table III-5 in Clinical Practice Guideline: The Technical Report.

16


SCREENING TESTS AND ASSESSMENT INSTRUMENTS

Screening Tests for Autism Screening tests for autism are often used if there is an increased concern about possible autism orthe childs development. Screeningfor autism is a preliminaryassessment method intended to lead to a decision that autism either is unlikely, or is possibleand requires further evaluation. Most screening tests are designedto be brief and easy to administer. Many simple screening tests forautism are available to the publicthrough a variety of sources andclaim to be useful in identifyingchildren with autism. Most of these tests have not been evaluated using standard research methods. Only one screening test for autismin young children, the Checklistfor Autism in Toddlers (CHAT), was evaluated in research studies meeting criteria for adequateevidence about effectiveness.

The CHAT takes only about 5 to10 minutes to administer and score. The examiner does not need specific training, and the test canbe administered by a variety ofindividuals. The CHAT is designed to be used with toddlersas young as 18 months of age. The CHAT consists of nine yes/no questions to be answeredby the childs parent. The CHATincludes questions about whetherthe child exhibits specificbehaviors such as social play,social interest in other children, pretend play, pointing to ask for something, pointing to indicateinterest in something, rough andtumble play, motor development,and functional play. The CHATalso includes observations of five brief interactions between the child and the examiner.

The CHAT is a useful first-level screening method forchildren 18 to 36 months of age in whom there is any levelof concern about possibleautism.

17

E


he ning uggesuggeuggesttssIIff tthe CCHHAATT ssccrreeeening ss pos bleblble aaututiissmm,, fffurrurttheherr aasssseeessssmmeentposssii u nt iis ne des neee de di gnosis.ddeded ttoo detteerrmmiine aa dine aaagnosis.

he ning uggesuggeuggesttssIIff tthe CCHHAATT ssccrreeeening ss ut mmm iiss unl ke y,unliikelly, iitt iis stiillllaautiiss s st

iimmpor nt otporportaant ttoo aassss eessss tthe cchillhe hi ddd ffforror othe deve opmdededede llvevel eeopmopmennntttaaalll or mmoror meee cdidididiccaaalllrrheotot rhe di probleeemmss tthahatt mmaayy have iinitttiiaatteeddprobl have ni he onc ont nuenuenuetthe cc n, ndeonconcerrn, aand ttoo ccontii

gul pe odi nceee fffooorrrreegul urveaaarr perriiodicc ssurveiillllaanc probl ha ddd ttoo ttheheprobl beeeemmss tthatt mmaayy be rreellaattee ni cconconceerrn.iinittiiaall n.

IIIPPP 888

Itt iis i nt rbeberI s immporporttaant ttoo rreemmeemmbe ha not hi drtthatt not aallll cchilldreenn wwiitthh

aaututiissmm ccaann be dentbe iidentiifffiiieedd eeaarrlly.y. us he of ons ttt aandndBBeecccaausee tthe ttiimmee of onsee

sseeverveveriittyy of ymptof ssymptoommss varr iy,y, ittva y,

iiss rr om nde haeeeccommmeendedd tthatt

nings be pessccrreeeeenings be rreepeaatteedd aatt va ous ge he onc rrrnsnsvarriiious aagess wwhenn cconcee or aaaututiissmm perrssiisstt..fffor pe

AuAutttiissmm AAssAssseessssmmeent ns um ntnt IInstttrrrumeenttsss ve st nda di ndndndSSeeverraall staandarrdizzeedd tteeststss aa

he kl sssttss have behave beeenn devell dopeoped ttooccheccklii deve ope hehellpp aassss he behavior ofeessss tthe behavior of hi dr nnn wwiitthh posposssiiblblee aautiissmm..cchilldree ut he nt nde ooTThessee tteeessttss aarree aallssoo iinteendedd tt

u he eeevalluattee cchi drhilldreenn iinn ww mhohomfffurrurttherr va ua ho aaututiissmm ii onsiidederreedd possiblee duess ccons possibl ((due

pa nt cntnt conceerrns, c nins, clliiniccaall ccll sueues,,ttoo parree onc ue aand/or posnd/or ve ningiposposittiive ssccrreeeening tteesstt re ulressulttss))..

he nt ns um nt ccaannTThessee aassssseessssmmeent iinsttrrumeentss be use iinn vavarriious waays innbe usedd ous w ys iaasssseessssiiing hi dr pos blcngng c llhihil edrdrenn wwiiitthhh posssiii eblblblble ut SSomomeettiimmeess tthesseeaautiissmm.. he ns um nteeentss ccaann be useedd ttooiinsttrrum be us

dedetteerrmmiinneene iiff ut ke haaautiissmm iiss lliikellyy ssooo tthatt de on de kkk aaaa decciissii beconon caann be mmaade ttoo sseeee

pe di gnosdiaagnosiiss.. AAtt otherr ttiimmmeess,,sspecciifffiiicc othe tthesehese aasssesessssmmeent iinstrrumeents ammayynt nst um nts m be usbe useedd aass pa of he orrpapa tt of tthe ffforrormmaall di gnosdiaagnos proctttiicc proceessss..

om of he ns bebeSSomee nttofof the iinsttrruummeentss mmaayy ususeedd ttoo he ve ofrrraattee tthe sseeverriittyy of ssymptom be use uymptoommss,, wwhihicchh mmaayy be useffffullul iinn de ng nt ons, perrriiodiodiccdetteerrmmii vennniing iinteerrvennttiions, pe

oni iiing of heng of tthe cchihillddss pr eogrogressss,,mmonittoorr progr aandnd aassss ng out omeeessssiing outccomeess..

1818


The autism assessment instruments reviewed in the full text of the guidelineinclude the following:

The Autism Behavior Checklist (ABC): a behavior checklist completed by a parent. Theaccuracy of the ABC foridentifying children with autism isrelatively low when compared toother autism assessment instruments. In addition, thecontent of the test items appearsmore appropriate to children over age 3. Therefore, the ABC isconsidered to be of limited usefulness in identifying youngchildren with autism.

The Autism Diagnostic Interview-Revised (ADI-R): a structuredinterview. The ADI-R is a relatively new test that hasdemonstrated good accuracy inidentifying young children withautism. However, because theADI-R requires extensive time andtraining to administer, it may bemost useful as part of a more in-depth assessment of children forwhom there is a fairly high level ofconcern for possible autism. The Childhood Autism RatingScale (CARS): a test combiningparent reports and directobservation by the professional. Among the autism assessmentinstruments reviewed, the CARSappears to possess an acceptable

combination of practicality and research support. The CARS maybe useful as part of the assessmentof children with possible autism ina variety of settings, includingearly intervention programs,preschool developmentalprograms, and developmentaldiagnostic centers. Because itgives a symptom severity rating,the CARS may be useful forperiodic monitoring of childrenwith autism and for assessing long-term outcomes. It is very importantthat professionals using the CARShave adequate training inadministering and interpreting theCARS. The Pre-Linguistic AutismDiagnostic Observation Schedule(PL-ADOS): a test using directobservation of the childs behavior as elicited by the examiner. ThePL-ADOS has adequate accuracyin identifying children with autism.Since extensive training is needed to learn how to administer the PL-ADOS, it may not be a practicalassessment method in certain clinical situations. However, thePL-ADOS may be useful as part ofa multi-disciplinary intakeassessment in diagnosing youngchildren with autism.

19

E


THE DEVELOPMENTAL ASSESSMENTTHE DEV LTAENMLOPEEV A ESSSS TNEMESS

hennn ttheherree iis suffffffiiicciieentnt eevidedenceeWWhe s suf videnc suggest he poss bi ofttoo suggeuggest tthe possiibilliittyy of

por doaaututiissmmm,, iitt iis ves verryy iimmporttaantnt tttoo do aa gene aaall aasssessm nt of hesessmeent of tthe cc lhihildssgenerr hi d deve opm nteopmopmopmopmee ((ntnt (iiifff ttthisshihis notsha notnothas notllvedede lve has not

dy be doneaallrreeaadydy beeenn done)).. AA dedeve opmmeentaall aasssseessssmmeenntt ovveellop nt nt ffforror hi dr unde ttttteemmptptcchilldr geeenn underr aage 33 iiss aann aa

ttoo aassss va ous pe of hettheeeessss varriious aasspeccttss of cchi dhilldss fffunnccuuncttiioning, iinclludingngoning, nc uding aarreeaas sucs s com on,suchh aas commmuniccaattiiuni on,on, behaviorvivior,,, ssocociiaall iinteerraaccttiion, mmotoorrbeha nt on,on, ot ki nsor dapt veiptptivesskillllss,, bisseensoryy aabilliittiieess,, aada

ogni ntsskikillllss,, aandnd ccognittiion.on. AAsssseesssssmmeent of heof tthe fffaaammiillyy aand hend tthe cchillddhi sss eenvi onnvirr nt providemononmeent aallssoo providess iimmpor nt nf on.tporportaant iinffooorrmmaattiion.

IP 9, 10, 11IP 9,9,9, 10,10, 11

AAnn aage pprop ---gege- deve opaapproprriiaattee devellop ntaaall aasssseessssmmeentnt mmaayy iinclludemmeent nc ude

eeva uavall on of suc s atuauatiion of suchh aarreeaas ass ccogniogni on, com ni on,tttiion, commmuuniccaattiion, behavior oc nt on, mmotoorrbehavivior,, ssociiaall iinteerraaccttiion, ot nd nsoryyy aabilliittiieess,, aandnd aaddaadaptpteeensor bi pt veaand ss iive

ski s.skilllls.

IItt iiss iimmpor nt ha hetporportaant tthatt tthe deve opm nt nt bedevell eopmopmentaall aasssseessssmmeent be iindividuandivi he by us nglduadualiizzeedd ttoo tthe cchilldd byhi usiing agea - pppprr-aa op ng nd oriingge pproprriiaattee tteessttiing aand ssccor ng mmmeeettthods, and o us ng on hehodshodshodshods, ffndaa fnd cfofocc iiusococ ius ttonngng ton hehe hi d pr . AnAAncchilldss nt ng probleprpresseentiing probleemmss.

aasssseessssmmmeent of hent of tthe cchi dhilldss sspepeccciifffiiicc of ngt nd kne ss iissaarreeaass sofof sttrreengthh aand wweeaakness

so portporportaant..aallso iimm nt IImmpoporrttaant omponent ofcntnt componentss of aa deve opm ntdevell nt nc udeeopmopmentaall aasssseessssmmeent ii lncnclude tthehe fffolloolll iowowing:ng:ow ng:

an objeobjobjeccttiivvee tteesstt of hear ngof heariingng an (((sssttandardiandarandardizzeedd tteessttiingng mmay bebeay be lleessss rrreelliiablablee iinn cchi drhilldreenn underundeunder tttheehhe age of 2)ageage of 2) standardizest st ng of andarandardizedd tteestiing of - cco- oggnnii abiognittiivvee abilliitttyyy - cocommmuniccatiioonn- omm uni at -- motor por///phhyyphyssiiccal sskkiilllllsssmmot r/ al - aadaptiivvee skiilllllsss- addaapptt sk - sso ot onal and- occ al, eociial, emmotiional,, and

behav oral u on ngbebehaviioral fffunnccuncttiioniing se sorsenns ry proc ngyorory proceessssiing cu ulum--base eeenttssscurrrriiicculum assessm ntbasedd assessm

obs rrrvvat on of hatiion of tttheehe cchihilldd atat obsee nfo al or play,ayay,iinfforr uc urmorormal or ssttrructtureedd pl

and ofand ofoff ppparareentnt-- hi nt raacttiionscchilldd iinteeracc ons

2020

E


par ntal nt ccciitt tttheehheiirr eparparental iinteerrvviieeww ttoo eellii onc rns, obtaieonconcerns, obtainn aa hihissttorry ofofcc oryry h chehe chi dhilldss eearllyyy dedevveell eopmopment,,ttthee arl opm nt

and gathgattheeherr iinfonfforrormmatiion aboaboutandand at on about tttheeh hi d ofchehe chilldss ccurrent lleevveellurrent ofof ffufunnccun tioningunctioning

vvviieeww tofof tthee chehe c llhihil sdds rreecc ds rree of h hi d ooorrdsds hheeeal halttth,,h, eeducat on,ducatiion, dddayay ar(((hhe ay cccaree,,

eett di al hiccc.) and.) and fffammaamiilllyyy mmeediccal hissttororryyy IInn soms deve opm nteomome ccaasseess,, aa devellopmeentaall aasssseesssssmmeentnt ttoo eeva uavalluattee aa ssuspeususpecctteedd deve opm ntdevell obleopmopmentaall pprrobleemm mmaayyy provide prdede proofffeeessssiionaonallss wwiitthh tthe fffiiirrssttprovi he

ha haveiiindiccndindicaaaaatttiiion ttonon t tthahat aaa ccchillhihilddd mmmaaayyy hahahahaveve aut mmm..autiiss

por nt o ow up onononIItt iiss iimmmporttaant ttoo fffollolllow up quequessttiionaonabbllee aabnorbnormmaall fffiiindingsndindings iinn tthe deve opm nthe dedevellopmeentaall aasssseessssmm nt ofeeent of aany youngny hi d. ghtcyoungyoung chilld. TThiss mmiihi ghtght iinc udencll dding heaudeude adding eelleemmeentss ttoont ttthe deve opm ntllvedede lve sse nd/oreopmopmopmopmee aantntalll aaa ssssesss sses mmmeeentntnt aaaaa ornd/nd/or rreefffeeerrrr ng he hi otheiiing tthe cchilldd ttoo otherr prof sssssiionaonallss ffforror mmororee dettaaiiilleeddproffeee o de va uatuauatiionon aand sspepecciifffiiicc diaa ignosgnosiss..eevall nd di gnos

IItt iiss ii por nt ha ndings ofmmmporttaant tthatt tthehe fffiiindinnggss of tthe deve opm nthe dedevellopmeentaall aasssseessssmm nt beeeent be us nn deve opingdevelloping aanyuseedd ii ny nt vent on pl nsveventiion plpl nd oiinteerr aans aand ffforror oni ng he progreogrogressss..mmonitt hioorriing tthe cchillddss pr

ogn onAAsssseessssiinnngg CCogniitttiiion IItt iiss iimmpor nt vetporportaant ttoo aasssseessss ccogniognitttiive bi nnn cchihillddrreenn wwiitthh posssiiblaabilliittyy ii pos blblee ut HHHow veoweeverr,, aaccccuraatteeaautiissmm.. ur sse nt offttteenn didifffffffiiiccultt iinnnaassessssmmmeent iiss of ul

be ofcchi drhilldreennn wwiitthh aaututiissmm beccaaususee ofof he uneve ve of ki ndndndttheiirr uneunevenn lleevellss of sskillllss aa

lliimmiitteedd lllaanguagenguage.. YYoungoung cchillhi dddrreenn wwiitthh aaut smiututism mmaayy have dihave difffffffiiiccululttyy pa pa ng ssessm ntntntparrttiiccii hetpapatiing iinn tthe aassessmee procproceessss.. ve he s,NNeeverrtthelleesss, iitt iiss

por nt ttoo aasssseessss aass aaccccururaatteeellyy aassiimmporttaanntt pos bl he hi d ve ba ndndndposssiibleee tthe cchilldss verrball aa nonve balbabababall cccognittogniognitiii ssveve skillkikillllsss aaa ews es wwew llllllrrnonvenonver ve s w

he hi d ve ydayydaydayaass tthe cc kilhihildss sskillllss iinn eeverr envi onenvirron ntmmmeentss..

12IIPP 12

AAlltthough da ndmhoughhough meennttaall rreettaarrdattiionon aaand

ut cccomommmonlyy ccoexioexisstt, itt iisssaautiissmm onl , i

por nt notntnt not ttoo preemmaatturureellyy llaabbiimmporttaa pr l elel tthehe cchihill s having ntddd aas having mmeentaall

da iiioonn untuntiill aappropriiaatteerreettaarrdatt ppropr nda dizdidizeedd aand nonsnd nonsttaandarr zdidizeeddssttaandarr nda di

tteessttiing ofng ogni ha donecofof cognittiioonn hass beeennbe .donedone. por nt haIIIttt iiisss aaalllsssooooo iiimmm ttporportaaa ttntnt t tthahat

prof ssionaproffeeessi not nf heonallss not iinffeeerr tthatt ttha hehe hi ha highe ogni ve eeevevellcchilldd hass aa higherr ccognittiive ll

be obs ndtthahann ccaannn aaccttuauallllyy be obseerrvevedd aand me ur d.meaassureeed.

2121

E


AAsssseesssssiinngg CComommmuunniiccaatttiioonn om uni s one of heheheCCom onmmmuniccaattiion iis one of tt

ccrriittiiccaaall cclliininiccaall ccllueuess iinn iide intntifffyiiyingdent y ng por va uaaaututiissmmm.. IItt iis is immporttaantnt ttoo ee lvavaluattee

om onbotbothh nonve barnonvenonverball ccommmuniuniccaatttiion uc ge nd ve balbabal((ssuchh uraass gessttureess)) aand verr

aaspespecc s of om uni iion ((spettts of ccommmuniccaatt on sspeeecchh aandnd ll nguageaaanguage))..

II 13PP 13

ng om uni on nnnAAsssseessssiing ccommmuniccaattiion ii ccchi drllhihildrdr uteeennn wwwiiittthhh aaa iiututisssmmm iiisss aaalllsssooo iimmpor nt be use of s i pa ontporportaant beccaause of iitts imm cpapactt on nt vent on deveventiion decciissiions and iitttssiinteerr ons and

pl ns out om tttiimmplii occcaattiioons ffforror outccomee.. II provideprovi ba ne o oni ngsdedes aa basseelliine ffforror mm tonionitoorriing progreeessss.. IItt iiss iimmporporttaant ttooprogr nt

o g:evalevaluuaaattee aallll of heof tthe fffollolllowowiinng:g: hheearing statusararing status

abi us nonv bal labiabiliitttyyy ttoo usee nonveerrbal om uni at at gieeess (((sssucuchhcc momommuniccatiioonn ssttrrateegi

as point ngpoipointiing ttoo show orshow or rreeequessttas que anan mm))iitteem) at pypii al or de ay enonvnonverbal attyyyypiccal or dellayeedd nonv rbal om uni at behav orss (((sssucuchhcc momommuniccatiivvee behaviior

as atyyypp al eeyyyee eegazgaz andas attypiccal ey gaziypypii andand

gege ss))sssttururees)

uuncttiionaonall uuse of spspookkfffunnccun se of spokeenn llanguage (anguageanguage ((hoowwhhow cchi drhilldreenn useususe wwords and ounds hatorords and ssounds ttoo gettge wwhat ttthheheyeeeyy wwantantt))) signignigniiffffiiiccant de ayant dellayss iinn ons teet ofof si onseposspo anguage or loss ofofofspspspoookkkeepokpokennn lll sosloranguageanguage soslor

languagelanguageanguage

at pattyyyypii al om uni oncpipical ccommmuniccaattiion uc ntpatpattteeerrnsns (((sssuchh as peas perrssiisstteentnt

rrepeep tttiittiion ofon of wwords and us ofeepe ords and useee of wworords h om unic tiicaatddss wwiittthoouutthout ccommmun ativvee intentintentntt)))

nnngg SSoc alociial IInnttteerrraccaactttiiion anAAsssseessssii onsss andd Rela on pRellatttatii sononshhiiipssps

nt of oc nt onsonsonsAAsssseessssmmmeent of ssociiaall iinteerraaccttii nd ttiionshipsonships iiss iimmporttaannttaand rreellaa por

he nabi ocbebeccaaususee tthe iinabilliittyy ttoo ffforroormm sssociiaall rreellaattiionships one of heonsonships iiss one of tthe chacharraacctt of uteeerriissttiiccss of aautiissmm..

nt of oc nt onsonsonsAAsssseessssmmmeent of ssociiaall iinteerraaccttii nd ttiiionshipsonshihips iiinc udenclll sudeudes ttheheaa rndnd reelllaa he

ow ng:ffofollolllowiing:ng: soc al ialal ininittiiat onatiion (((ssucsuchh associi as

sshow ng or giihowhowing or givviing objng objeecctttsss tttoo oth rrrss ffforroor ssociial ss))ottheehe oc al purppurrpoossposees) ssoc alocii at uc as ialal immiittatiioonn (((sssuchh as iimmiittatiatatinngg acacttiions of ottheeherrs)ons of oth ss)))

ageage--exp p oc ttturnn--xpecctteedd rreecciiiprrprociitttyyy (((tureexpee

ttaakkiing during playngng during playy))) tttheehhe cchi dhilldss atttachmeent pat rns at achm nt patttteerns

hhehe prepresseencee ofof aa ccaregivveerriinn ttthee nc aregi (((sssucuchhh as neut alas neutrraliitttyyy, exxcceessss, e iiivvee cclliinging, or avoidanc ofnginging, or avoidancee of parpareentntntt)))

ndencncyy ffforror ssoc al tttheehhe cchi dhilldss tteende cy o iococial iatation or pref beiisolat on or prsol eefffeeerencrencee ttoo bebe

alaloneoneone

2222

E

hehe hi d us ofof p oplf peepeoplee as tththee cchilldss usee as ttoolool obtai ndsollsss ttoo obtainn desiredd eedesire ndsnds

uc as ak ng an adul ss handhand(((sss hucuch as ttakiing an adultt ttoo rreeacachh ffforroor aa ttoyy)oy))

ssoc al nt ac onsiococial iinteerracttiions wwiittthhh a iamamilliiar asar as wweellll as unffamm arfffamm as unfa iamamilliiar

adul and petaduladulttsss and peeerrss

AAsssseess av or ansssiinngg BBeehhaviior andd

ponses too ttthhee EEnnvviironRReessspoonnppo ses t ronmmmeenntt

AAsssseess ng hi d behavior aoror andndssiing aa cchilldss behavi rreessponseponsponsess ttoo tthehe eenvirronmee intnt issnvi onm nt

use oriimmportporportaant bent beccaause tthesehese fffaaacctttorss eecctt iinteerrvennttiion decc onsmmaayyy aaafffffffe nt ve on de iiissiions

aand provide band ne oprprovide basseelliiness ffforror mmonionitt ng progroorriing progreessss.. AAsssseessssmmeent ofnt of aa cchi dhilldss behahaviorbehavior papatttteerrnnss ve st ngths, ndns,, rreellaattiive strreengths, aaand probl nc ude::probleeemm aarreeaass mmaayy iincllude bbeehav or pat rns and problprprobleemmihavhavior pattteerns and

bebehavhavhaviiororss sponsess ttoo sseenso unusual reunusunusual respspoonnsse nsnsorryryy

exper encesxpexpeperiiences mmotor skototor skiilllllsss

play sk playay skiilllllsss adapt behav ors iadaptadaptivvee behaviiors sesesellllflflflfff-fff-f---he sk llhehelpplplpp iikss ik llllllsslslss


am an eeeAAsssseessssiinnngg ttthhhee FFamiilllyyy andd ttthhh d onmemennttCChhiilllddss EEnnvviirron

o ofIItt iiss iimmportporportaantnt ffforror tthehe fffaaammiillyy aofof a young hihilldd wwiitthh aautiissmm ttooyoung cc ut pa patpapatee iinn aa fffaaammiillyy aasssseessssmmmeentparrttiiccii nt be us fffaaaccttororss rreellaattiingng ttoo tthebeccaausee he

eecctt iinteerrventiioonn ndfffaaammiillyy cccaann aafffffffe nt vent aand nage nt de nd mmmaayymmaanage onsmmmeent decciissiions,, aand

have pl out omeeess..have iimm onspliiccaattiions fffooorr outccom

14IIPP 14

AAAsssssseeessssssmmmmmeeent of hettofntnt tof sshehe stttrrreeengths aahsngtngt ahs ndndndndnd ons of he nd hehehelliimmiittaattiionsons of tthe fffaaammiillyy aand tt

hi d nvi on nc udeudeudecchilldss nteeenvirronmmeent mmaayy iincll tttiion aand/ ofobobsseerrvava on nd/oorr discussidiscussioonn of::

h a st ssors rranceetttheehe ol rancfff mfafammamiilllyyyss strreessors,, ttolee or strttreessss,, andand ccopingffforor s oping

me hani msmecc shanihanisms h fffff mfamfafafammma amam ur nt tupporupporupporupportt ttt eththee ihehe iilllyylylyy sss ccc rrururreee ssntnt suppor

sysyststeeemmss eeducat onduc xxp ri ncperieenceess off ffffaammaatiion eexpee of amiilllyyy

mememmbeberrss a llllyyy ccompmpoossfffammamii on,omposiittiion,

dedemmographiogrographiccss,, and speepand sspecciiiffffiiiccc ci cum ancescirrc sumumsttances

a nt rac on and patttteernsfffammamiillllyyy iinteeracttiion and pat rns of disc p neof dissciiipllpliine

eemmot onal pression of iamamilllyyyoff ffffammiototional eexxxprpression a mememmbeberrss

regi ng sk and sharinngg ofccaare vgigiviing skiilllllsss and sharing of aregi ng responsibilliittiieessccare vgigiviing respspoonnssibi

kkkn dge about aut smoknknoowwwlnownownownowlleee iiautaboutdgedge iautabout mssm

2323

E


THE HEALTH EVALUATIONTHEHE H HLTEA E OIUATLVA NO

por nt ha hi dredrdrennIItt iiss iimmmporttaant tthatt aallll cchill suspe deve opm ntantntallwwiitthh ssuspecctteedd devellopmee

probleeemms, nc udis, iinclludinngg possibleeeprobl possibl ut have heaaalltthhaautiiss omplmmm,, have aa ccompleettee he

evaluat on.ualvae uauae lva ua iittion.on.

II 15, 66PPP 15, 11

he aarree tthrhreeee iimmporrttaantnt rreeeaassonsTTherree po ons fffor doing heor va ua onsdoidoing heaalltthh eevalluattii ionsons inn cchi drllhihildrdr uteeenn wwiiitthhh aautiiissmm:: 1. provide sssssmmeentnt1. ttoo geneprprovide aa generraall aassssee

of heof hi ds he ustthe cchillds heaalltthh ssttaattusus 2. iiidentdentiifffyyy otherr ccondiondittiiooons tthatt2. ttoo othe ns ha

mmaaayy bebe cconfuse ut smiututismonffususedd wwiitthh aa 3.3. ttoo iident nd iccaldedentiifffyyy aand aasssseessss mmeediddi al

cccondi ons or genetondiondiondiondittiii ttnegeoronsons tnegeor iiiccc ssyndromyndryndromeess tthahatt aarree ssomomeeettiimmeess ssoc ut smaasssociiaatteedd wwiitthh aautiism

por nt be tthahattIItt iiss iimmmporttaant ttoo rreemmeemmberr cchi drhilldr uteeenn wwiitthh aautiissmm aarree us pt bl heahehealltthhssusccee heiptptiblee ttoo aallll tthe ssaammee

probleeemmss aass cchi drhilldreenn wwiitt thouhoutprobl hou ut he probleobloblemmss iinnaautiiss dimmm.. TThessee mmeediccaall pr

cchilldr nthi dreeenn wwiitthh aaututiissmm mmaayy pprrreesseent spe aaall cchahalllleengess ffforro heor heaalltt ahchcarreespeccii nge hc provideprovi nd pa ntrdederss aand parreentss..

AAlltthough ihoughhough itt iis genes generraallllyy aacccceepteptptedd ha utiiissmm iiss aa biologiccaallllyy batthatt aaut biologi sbabaseedd

ccondi onondittii ng he ntaonon afffffffeeeccttiing tthe cceentrraall ne vous ssysystteemm,, eexteensiivenerrvous xt ns ve biologi ha not yetttttccogiolbibi ccogiol caaalll rrreeessseeeaaarrrccchhh sshahas yenotnot yeiidentdentiifffiii ny spe tommicnatoomicaalleeedd aany specciifffiiicc aanaor biocheor bioc ndings onsidemhehemiiccaall fffiiindings cconsi rdedereedd ttoo ccaausus ut smeee aautiism..

he no di tteessttssTTherree aa perrree no sspecciifffiiicc mmeediccaall ha be use hehehetthatt ccaann blbe usedd ttoo eessttaabliisshh tt

di gnosiiiss ofof aautiissmm.. RRaattheherr,, tthehediaagnos ut he di gnosiignosgnosiss iiss mmaade bade basseedd ondiaa on

or alal iinnffforroro mmat onatiion aand dididirreecctthhiissttoriicc ndvatvatvatiioonn of hi dobobsseerr of aa cchilldss

be or spespecciifffiiiccaalllly,behahavivioror y, om unicuniunicaattiion, sociiaallccommm on, soc

iintnteerraacctt ons nd dapt veiiions,, aand mmaallaadaptiive bebehahaviviorororss..

he mmmororee ccontrroverrsiaallOOttherr ont ove si nt hodsaasssseessssmmmeent mmeetthods aarree aallssoo

om propos d, ttthehessomeettii ucmmmeess proposeed, ssuchh aass us of pe gi , orcgigic, orusee of ss unecpepeciifffiiicc iimmmmune,, aalllleerr

bol sts. sons formmeettaabol heiicc tteests. TThe rreeaasons ffoorro sucsuchh tteest ngs ba eedd on vaon varriioouusstiing aarree bass ous ont ove siroveoversiaall ttheheoorriiees about ttheheccontrr s about he us of aofof autiissmm..ccaausee ut

2424

E


ttthhee alGGeenneerarallrral SStttrrat giratateeegieess ffforroor HHHeealltttthhh Eval aEvaluuuatttiioonn IItt iiss iimmmporporttaant hant tthatt aallll cchill edrdrennhi dr

suspe deve opm ntantntallwwiitthh ssuspecctteedd devellopmee eeemms have ompr he siveprpr nsiveprprproblobl s have aa ccom eehenns

heheaalltt va ua on nd hahhh eevalluattiion aand tthatt iitt iinc udencll st he ow ng:audeude att lleeaast tthe fffollolllowiio ng:ng: aasss sm nt of hearing andessesssmeent of hearing andand

vivi onsssiion aa neurologi alneneurologiccal eevvaluataluatiioonnn aa am o gns ofssskkiinn eexxam (((fffforror ssiigns ofof

ccondi ons uc as ube ousttondiondionditiiions ssuchhh as ttt rubeuberousous scsc ros s or neurof bromatos s)llleerosiis or neuroffiiibromatosiis)s)

aa ar o di alssseearcchh ffforror mmeediccal onditondionditiions, geneons, genettiicc ssysyyndrom s,cc ndrndromees,

or othor de opm ntalottheeherr devveellopmeental probleobloblemms ths tthaatthat are someettiiimmeesspr are som as oc at autassssociiateedd wwiittthhh autiissmm ass sm nt of oottthehththeeherr ccurrentnt as essesssmee ofntnt of urrent heal problhe talaltthhh probleemmss

eell nts of rout neeeemmeenttss of routiine dedevvveellopm ntalopmeental ssurvveeiillllancur andeancance and general healge ningneneral healttthh ssccrreeeeningng appropr at o h hilldapprappropriiatee ffforror tttheehe cchi agesdds age

addr ng any oth talaltthhhottheeherr heeaddraddressssiing any heal onceonconcerrnsns eexxxprrpreesssseedd byby ttthheehcc p he

parparpareentnttss

r ReRRelllatttaateedd ssesssmeenntttsssOOttthheer AAsse sm IItt iiss rreeccom nde hamomommeendedd tthatt profproffeeessssiionaonallss aasssseessssiing tthe heng he heaalltthh ssttaattus ofus hi dr utcofof chilldreenn wwiitthh aautiissmm

ve yyy ook aassssocociiaatteedd hheeaaccttiivell o heaalltthhllook ffforror ondi ons sonsons seeeenn mmoree ccomommm lononlyy iinnccondittii or on hi dr nnn wwiitthh aaututiissmm tthann iinncchilldree ha ypi yyy deve opingdevelloping cchilldreen.ttypiccaallll hi dr n.

IItt iiss eext po ntrxtxtreemmeellyy iimmporrttaant ttoo bl he hheeariinngg statstatuusss iinneessttaabliisshh tthe ar

hi ddddd wwwiiittthhh sssuspeccpeusus cpe ttteeeddd ororaaa ccc llhihil or di gnosediaa ut sm outgnosgnosedd aautiism ttoo rruleeul outout he pa nt ctorctorheaarriingnngg iimmpaiirrmmeent aass aa fffaaa

he cchi ds comhillds commmuniuniccaattiiononiinn tthe onprproblobleeemmss..

II 17PPP 17

he ny ndi ha aaaIIff ttherree oniiiss aany iindiccaattiion tthatt hi ha ng probl ttt iisscchilldd ha hess aa heaarriing probleemm,, ii

iimmporporttaant tntnt too rreefffeeerr tthe cchihilldd ffforrhe o aoror a heheaarriingng va ua on byeevalluattiion by aann

udiologistogiogist ((iinc udinclludinngg tthe use ofaaudiol he use of

br nst mmm eevokedd rreesponsesponse tteestibraaiinstee voke sts nggin ppropiiff aappr ropopriiaattee))..

os hi dr eeedd ororIInn mmostt uspecchilldreenn wwiitthh ssuspecctt di gnos ut , i us u tttoo dododiaagnoseeedd aautiissmm, itt iiss useefffullul aann aapproprppr bo or stiopropriaattee llaaborraattoryy tteest fffooorr FrFrragi Syndrom aaa ttnegege tne iiicccccFFF llagirr lagi eee XXXXX eeomndrSySy eomndr ,, gene ondi on fonon ffouunnddound iinn ssomomee cchill edrdrennccondittii o hi dr

wwiitthh aaut smiututism..

2525


When there is an increased likelihood or suspicion of possibleseizures in a child with suspectedor diagnosed autism, electroencephalograms (EEGs),including possibly a sleep EEG, may be useful. Magnetic Resonance Imaging(MRI) MRI scans provide detailed cross-sectional computerized images ofthe head and brain. MRI scans do not involve the use of radiation. MRI scans are generally used todetect abnormal anatomical structures, tumors, infections,traumatic injuries, and otherchanges in the brain. MRI scans may provide usefulinformation in certain clinical situations when there is heightenedconcern about specificneurological problems, such asseizures.

MRI scans may also be useful inassessing some children at risk forcertain neurological problems,such as children with a history ofperinatal problems (medicalproblems that occurred around thetime of birth). MRI scans are not useful in diagnosing autism and they are notgenerally used in the routineassessment of children with possible autism. There are minimal risks associated with the use of MRI scans exceptfor those related to sedation for the procedure.

26


Single Photon EmissionComputerized Tomography(SPECT) Single photon emissioncomputerized tomography(SPECT) is a nuclear medicinetechnique that has been used toevaluate regional blood flowwithin the brain. SPECT involves the use of a small amount of radioactive tracer materials (radioisotopes). These may beeither injected or inhaled. The radioisotopes travel via thebloodstream to the brain, andimages of cerebral blood flow areobtained using a special camerathat measures photon emissions from the radioisotopes. Subjectsmust remain still for 4 to 5 minutes while images are being recorded, so sedation is often needed to perform SPECT in youngerchildren and uncooperativesubjects.

No adequate evidence hasbeen found to support the useof SPECT scans in the assessment of children with autism. Therefore, the use of SPECT scans is not recommended.

Assessment of Immune Status A major function of the immunesystem is to identify foreignmaterials in the body that might beharmful (such as viruses orbacteria) and to defend the bodyagainst these foreign elements. One controversial theory suggests that autism may be caused oraggravated by immune reactions either to foreign elements in thebody (such as viruses) or to apersons own tissues (known as anautoimmune response). No studies were found that produced adequate evidence thatautism is caused or otherwise related to the immune system.

No adequate evidence hasbeen found indicating thatimmunologic testing is usefulin any way for helping todiagnose autism, for planningtreatment, or for assessingoutcomes of interventions. Therefore, the use ofimmunologic testing is not recommended for the routine assessment of young childrenwith possible autism.

27


Food Allergy and DietAssessment Testing for allergies is sometimes proposed for children with autism. An allergy is a reaction of theimmune system to specific foreignmaterial in the environment. Allergies are not inherited but are acquired. Upon exposure to certainmaterials, a person can becomesensitized and then later developallergic reactions when re-exposed to that substance. The most common types ofallergic conditions are allergicrhinitis (hay fever) and allergicasthma. Allergic reactions can alsooccur to a variety of foods. However, in young children, foodallergies are much less commonthan hay fever or allergic asthma. Elimination diets are sometimes proposed as a method for detectingfood allergies. These involveeliminating certain foods from thediet that are suspected of possiblycausing allergic problems. After

these foods have been eliminated for several weeks, each of theeliminated foods is added back into the diet one at a time (referredto as a food challenge). Testing for food allergies may beuseful in some children if there is an increased concern about allergies. However, there is noclear evidence that children with autism are any more likely to havefood or other allergies thanchildren without autism.

No adequate evidence hasbeen found indicating thatautism is either caused or made worse by allergies orany specific foods, such asmilk lactose or wheat gluten.Therefore, testing for foodallergies is not recommended in the routine assessment of children with possible autism.

It is recommended that children with possible autism be treated nodifferently than other children inthe assessment of food allergies.

28


Assessment of Organic AcidMetabolites (Yeast) This assessment method involves laboratory analysis of a urinespecimen for specific organicacids. The proposed rationale forsuch testing is based on thecontroversial theory that in somepersons an overgrowth of yeast inthe intestinal tract can cause or aggravate autism. Proponentssuggest that in these individuals,anti-fungal therapy may bringabout an improvement in autism.

No adequate evidence hasbeen found to support thetheory that an overgrowth ofyeast in the intestinal tract can either cause or aggravateautism. Therefore, testing forspecific organic acids in theurine (or any other testclaiming to identify anovergrowth of yeast in theintestinal tract) is not recommended as part of theroutine assessment of children with possible autism.

29

EI


INT RV NTINTEE DSERVRVENTIIOONN MMEETTHHHOODS

hi dredrdrenn wwiitthh aaututiissmm mmaayy hahave aaCChill have gr hanc uc ulgreeaatt oeeerr cchancee ffforror ssuccceessssfffuullu out om s ioutcc nt ve ons aeomomes iff iinteerrvennttiions arrree ssttaarrttee geddd aatt aann eeaarrllyy aage..

18, 19,, 2200,, 21PP 18, 19 20, 21

In ons tLLiinnkkiinnngg Inttteerrvveenntttiiions too AAAsse eessmssmennnttt ofssssssessessmmm ttofof thhththheee CCChhhiiilllddldldd

por nt ::IItt iiss iimmmporttaant ttoo iidentdedentiifffyyy cchi drhilldreenn wwiitthh aautiututissmm

nd begi ppropraandnd beginn aappropriiaattee nteerrvent ons aventiions ass soon aassiint soon

pos bl ncspospossiiblee ssiincee eeaarrllyy iintnteerrvent onventiion mmaayy hellpp sspehe heepepeedd tthe hi d ove deve opmmmmmeeent,ntnt,ccc lhihihihill ssdds rroveoveraaallllll llvedede lve opop

reducre educduce iinappropnapproprriiaattee behahavioorrss,,behavinndd lleeaadd ttoo bebetttteerr llongong--teaand teterrmm u ona omfffunnccun ouuncttiionall outtccomeess

iindividuandindividualliizzee iintnteerrventiionsonsvent ons babassseedd onon aann aasssseessssmmeent tofof thent of he sspecpepeciifffiiicc ssttrreengthsngths aand neeeds ofnd ne ds of ttthe hi ndchehehehe cc llhihilddd aaa ffndnd faafafaammmiiilllyyy

iinteerrventiions ttoo ongoing ttiiee nt vent ons ongoiongoing mmonitonionitoorriing of heng of tthe cchillddhi sss prprogrogrogreessss

rra Calal Cononssiiderrataat ontiiionss ffforrorGGeenneerall de o Impmplleeemm InImpll eeenntttiinngg Inttteeerrvveenntttiiioonnss IInn seselleecc ng nt vent ons otttiing iinteerrventiions ffforror hi dr nnn wwiitthh aaututiissmm, twwoocchilldree , t

iimmporporttaannttnt ccons deonsiiderraattiioons aarreens :: scsciieent videnc ha heintntifffiiicc eevidencee tthatt tthe

iinntteerrvent on iviveevveentiion iiss eefffffffeeeccttvidencdedencee tthahatt tthe iinteerrventventiiioonn iiss eevi he nt

sasafffeee

ol of ttthhhee PParre amiiilllyyy iinnRRolleee of an FFamareenntttsss andd InttnII tn eeteteerrrvvveee onnnnnntttiititii ssonons IItt iiss iimmpor nt ha pa nt betporportaant tthatt parreentss be

ve nvolve s ofs ofaaccttiivellyy speiinvolvedd iinn aallll aaspecctt tthehe cchi dhill nt ndsdds aasssseessssmmeent aand interrvevenntt on proc he xt ntextxtentinte ntiion proceessss ttoo tthe ee of he nt ndndndof ttheiirr ouriiinteerreessttss,, rreessourcceess,, aa abi esabilliittiies..

ng ssshhh iiiss not henot tt ffhehe ffaaammiiilll syysIIfff EEngllliii y pr nguage aaantntpriimmaarryy porllaanguage,, iitt iiss iimmportt o pr nd yyy ttooffforror proofffe onaeeessssiionallss ttoo fffiiind aa wwaa om uni ttheheccommm vecuniunicaattee eefffffffeeeccttiivellyy wwiitthh

fffaaammiilly.y. IIItt mmaayy be he pfbe hellpffuuull ttoo eususeus tr nslatotraanslator fffaaammiilliiaarr wwiitthh tthehe ccuullorrss ulttuurree nd nguage of henguanguage of tthe fffaaammiilly.aand llaa y.

3030


PARENT INTERVENTION GUIDE: QUESTIONS TO ASK PROVIDERS

The following are questions that may be helpful to parents wheninterviewing potential intervention providers. 1. What kinds of intervention, therapy, and services do you provide? 2. Do you have a particular philosophy for working with children with

autism/PDD? 3. How many hours per week do these services require, and how much of

this is one-on-one time with the child? 4. How would you describe a typical day or session? 5. What experience do the teachers and/or therapists have in working with

children with autism? 6. What experience does the person who supervises the program have?

How closely does the program supervisor work with the therapists,teachers, and parents?

7. What kinds of ongoing training do your full and part time staffsparticipate in?

8. Are parents involved with planning as part of the intervention team? 9. Do you provide a parent training program? 10. How much and what kinds of involvement are expected of parents and

family members? 11. Are parents welcome to participate in or observe therapy and/or group

sessions? 12. What techniques do you use to manage difficult behaviors? 13. Do you ever use physical aversive techniques or any physically

intrusive procedures? If yes, please describe them. 14. Please describe your program for communication and language

development. Do you use a picture communication system, signlanguage, other kinds of communication systems, or all of these?

15. Are there opportunities for integration with typical and/or higherfunctioning children?

16. How do you evaluate the childs progress, and how often? 17. How do you keep parents informed of the childs progress?

31


Common Elements of Effective Interventions Over the last 25 years, a smallnumber of programs have workedintensively on researchinginterventions for young childrenwith autism and their families. Although these programs vary intheir philosophical approach andstrategies, they include severalcommon elements. Dawson and Osterling (1997)recently reviewed eight modelearly intervention programs forchildren with autism and described the following six elements thatseemed to be common to effective intervention programs. (1) A curriculum content

emphasizing five basic skills: toattend to elements of the environment that are essential for learning; to imitate others;to understand and use language;to play appropriately with toys;and to interact socially.

(2) A supportive and structured environment that includes strategies for generalization to more complex, naturalenvironments.

(3) Predictability and routine to assist the child with transitions from one activity to another.

(4) A functional approach to problem behaviors that includesrecording the behavior, developing a hypothesis aboutthe function of the behavior for the child, changing theenvironment to supportappropriate behavior, andteaching appropriate behaviorsto replace problem behaviors.

(5) Plans for transition from preschool classroom byteaching survival skills thatchildren will need later.

(6) Family involvement as a critical component in theoverall program.

32


BEHAVIORAL AND EDUCATIONAL APPROACHES

Behavioral and educational interventions have become the dominant approach for treatingchildren and adults with autism. In recent years, several intensive intervention programs for childrenwith autism have been developedusing a systematic behavioralapproach, often referred to asapplied behavioral analysis(ABA). Many of the current formsof speech and language therapyand many other educationalinterventions for young childrenwith autism are based uponsomewhat similar behavioral principles.

It is recommended that principles of applied behavioranalysis (ABA) and behaviorintervention strategies beincluded as importantelements in any interventionprogram for young childrenwith autism.

Basic Principles of Behavioraland Educational Intervention Approaches Behavioral techniques include specific approaches to helpindividuals acquire or changebehaviors. Behavioral therapies aresometimes called behavioral modification methods. As used here, the term behavioral techniques refers to specificprocedures aimed at teaching newskills and behavior. Intensive behavioral intervention programs use an array of behavioraltechniques that change over timeas the child progresses and asdifferent skill areas are addressed. Behavioral and educational interventions can be divided into three general approaches: (1) operant conditioning (2) respondent (Pavlovian)

conditioning (3) cognitive approaches

33

E


OOpeperraaantnt ccondittiioning aappr coaoachessondi oning pproa he aarree ttypicypiypicaallllyy useusedd iinn ttrreeaattiingngng cchi drhilldreenn wwiitthh aaututiissmm. Att tthe. A osmhehe mostt basi llleevevell,, operraantnt ccondittiionioningbasicc ope ondi oning

olvvee ststtiiimmuu andinvinvolves pr sent ngs preesentiing aa lllluuss and tthenn con equencehe providingprproviding aa conssequennce ba on hi d eponsponsponsponsee.. FFForororssbabaseeeddd ttonon the cchehe c llhihil ssdds rrreeessspons xa pl pi sghtght showhoweexamm eplple,, tthehe ttheherraapisstt mmiight

pi his woultthehe cchilhihildd tteenn picctturureess ((tthis wwouldd bebe tthe ulus giveshehe sttiimmulus)) aand tthenn gind he aveve a

nf rrcciingng cconseequencee eeaaccchh ttiimmeerreeiinffooo ons quenc tthehe cchi ponds or ctctllyy..hhiilldd rreessponds ccorrree y.

re nforc iiss aa cconsequenconsequequencee AA rreiinffororceerr ttha nc oba lbibiliittyyy ofses the probabithahat iincrreeaa

Date post:	19-Apr-2018
Category:	Documents
Upload:	duongkhanh
View:	235 times
Download:	9 times

CLINICAL PRACTICE GUIDELINES Quick Reference Guide · There are three versions of each clinical...

Documents