Early Childhood

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Introduction

While ASD can  be detected as early as 18 months or younger, diagnosis is considered very reliable by the age of 2 (Lord et al, 2006). However, many children fail to receive a diagnosis until much later, which may prevent them from getting the help they need right away.

Learn about the “red flags” by CDC.

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What Can Parents Do?

As a parent, you know your child and can spot warning signs of autism early on.

  • Monitor the development of your child. Keep an eye on how your child is developing socially, emotionally, and cognitively. While developmental delays do not equate to autism, they can indicate a risk.
  • If you are concerned, take actions. If you have any concerns or have questions, talk to your doctor right away.
  • Trust your instincts. 

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ASD Screening Poster by HANDS in Autism®

Download a screening poster and a checklist from the HANDS in Autism® Website

ScreeningPoster_English_LETTER

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More Resources

Resources for childcare providers

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Looking for More Information?

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There are many reputable resources that can help you explore autism spectrum disorder (ASD). Here are some of them:

Autism Internet Modules (AIM) Project

Autism Society of America

Centers for Disease Control and Prevention

First Signs

HealthyChildren.org (American Academy of Pediatrics)

National Institutes of Health (NIH) – MedlinePlus

National Institute of Mental Health (NIMH)

National Institute of Child Health & Human Development

National Institute on Deafness & Other Communication Disorders

National Professional Development Center on Autism Spectrum Disorders

Organization for Autism Research (OAR)

WebMD

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Diagnosis Across Lifespan


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Introduction

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder that impacts individuals across the lifespan. Therefore, to support individuals across lifespan stages, it is important to regular monitor and re-evaluate individual’s progress throughout his or her life.

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School-Age Children

Autism symptoms are often easier to identify in school-age children due to the gap between age and social challenges is bigger.

Evaluations involve assessment of a child’s:

  • speech
  • language
  • communication
  • social skills
  • intellectual functioning
  • behaviors
  • adaptive function.

Assessment is done through direct testing and developmental and educational history.

While at school, children may exhibit an increase in:

  • learning, particularly when moving from concrete to abstract topics and concepts
  • behavioral challenges, including aggression, tantrums, melt-downs, and self-injury
  • emotions, particularly anxiety due to the need to navigate social complexities, as well as atypical reactions to the environment, like fears and phobias, and obsessive compulsive behaviors.

Research has also shown that up to 60% of indivdiuals show a range of behaviors that may be:

  • self-injurious
  • aggressive
  • oppositional
  • disruptive, or
  • destructive.

Additionally, some may show behaviros that are of more serious safety concern, like:

  • elopment
  • self-injury
  • pica (eating non-food items, like clay or soil).

Children may also exhibit symptoms of inattention, impulsivity, and/or hyperactivity beyond what would be expected for ASD. As a result, they may be diagnosed with ADHD as well.

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Adolescents and Adults

While symptoms of ASD may be identified in the first few years of life, many adults, like the woman on the video at the top of the page, remain unidentified or misidentified with another disorder. Often requests for evaluations at this age are due to a specific need, like transition to adulthood, planning for college, eligibility for state services, and others.

The majority of individuals with ASD have above-average intellectual abilities, and have the capacity to be independent adults. Yet, over half of the adult population with ASD are unable to find employment, live independently, self-care, or establish meaning social relationships.

Similarly to school-age children, adults often have high rates of co-morbid conditions, including:

  • anxiety disorders
  • depressive disorders
  • ADHD.

For more information on adults with ASD, go to Adult page.

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Additional Resources

Klaiman, C., et al. (2015). Assessment of autism across the lifespan: A way forward. Current Developmental Disorders Report, 2(1), 84-92

Murphy et al. (2016). Autism spectrum disorder in adults: Diagnosis, management, and health services development. Neuropsychiatric Disease and Treatment, 12, 1669-1686

References

Klaiman, C., et al. (2015). Assessment of autism across the lifespan: A way forward. Current Developmental Disorders Report, 2(1), 84-92

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About the Diagnosis

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Introduction

As children develop, parents, teachers, or medical professionals may begin to notice signs or indicators of ASD. It is important to discuss these concerns with a medical professional in order to screen for the disorder and obtain a diagnosis, if appropriate, so that the individual may start receiving services and accessing necessary treatment options as soon as possible. The information below outlines general characteristics of ASD, the steps for pursuing an ASD diagnosis, and the differences between diagnoses within the medical versus educational setting.

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What are the General Symptoms of ASD?

As specified within the current diagnostic criteria (DSM-5), ASD is characterized as affecting individuals across their lifespan in two functional areas:

  1. challenges related to social communication and social interactions and
  2. restricted repetitive behaviors, interests, or activities.

These characteristics related to ASD do not suggest that individuals with ASD do not engage communicatively, socially, or otherwise. Rather, their behavior in these core areas are different from those observed in children of the same developmental age.

ScreeningPoster_English_LETTER

The resource is provided by the HANDS in Autism Interdisciplinary Training and Resource Center. For more information about this and other resources, go to www.HANDSinAutism.iupui.edu

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Challenges Related to Social Communication and Social Interactions

Communication challenges vary amongst individuals with ASD, as some individuals may be completely nonverbal while others may speak but struggle to use language to communicate effectively with others. Similarly, social challenges among individuals with ASD can vary greatly, but individuals frequently experience difficulty in using and recognizing nonverbal cues such as

  • eye contact,
  • facial expressions,
  • body posture, and
  • gestures.

Many individuals also have trouble understanding social cues and rules, which can make social situations uncomfortable and lead to anxiety and challenging behaviors.

Children with ASD may also experience a delay in the development of language, or even the absence of language entirely. When language is used, individuals may demonstrate echolalia, or the repetition of words or phrases without meaning to the context of the social interaction.

For instance, an individual may repeat phrases he or she has just heard or heard previously within a movie or conversation.

They may also have difficulty starting or maintaining a conversation, hold one-sided conversations, or choose to only talk about their own interests when interacting with others.

Individuals with ASD may sometimes:

  • avoid eye contact
  • refrain from making certain nonverbal gestures or facial expressions
  • struggle with engaging in make-believe play
  • prefer to play by themselves than with other children, sometimes demonstrating a limited desire to share toys or other items when interacting with others.

An additional social-communication challenge for individuals with ASD includes difficulty recognizing social rules and expectations, leading to increased anxiety and limited success with socially situations.

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Restricted Repetitive Behaviors, Interests, or Activities

Some individuals with ASD may also demonstrate unusual interests and repetitive behaviors.

For instance, an individual may be intensely focused on a particular cartoon character, historical event, toy, or animal to the extent that the interest interferes with his or her ability to socialize or engage in other activities.

In addition, some individuals with ASD engage in:

  • repetitive motor movements,
  • use of objects, or
  • speech (repeating certain words or phrases).

Examples of repetitive motor movements may include flicking fingers, walking on toes, holding fingers in odd postures, unusual facial grimacing, or even self-injurious behavior. Individuals with ASD may also engage in repetitive play with certain toys or objects, such as arranging toy cars in a certain order, turning lights on and off repeatedly, or re-watching the same segment of a television show multiple times in a row.

Those with ASD also tend to seek out routines and sameness and may experience behaviors when typical routines or their environment are changed.

For example, an individual may get upset when a minor change is made to his or her bus route or when a classroom seating arrangement is adjusted.

Additionally, individuals with ASD may be overly or under reactive to certain sensory experiences (such as the way things feel, taste, look, smell, or sound) within their environment, and as a result they may seek out certain sensory experiences or withdraw from them altogether.

For instance, some individuals may choose to smell or lick their toys or other objects before using them, while others may be extremely sensitive to the volume of a movie or the feel of the fabric on their clothes, becoming upset or anxious from this sensory stimuli.

Because ASD is a spectrum disorder, the presence and intensity of any of these characteristics vary greatly from individual to individual, and some individuals may experience challenges and symptoms not listed above.

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How Early Can ASD be Diagnosed?

Typically, concerns regarding the presence of ASD arise in the early years. However, because ASD is a spectrum disorder, the early indicators of ASD may be more or less present at different ages among different children.

For some, delays or abnormal behaviors are observed early in infancy or toddlerhood, while others appear to be developing on track until around 18-24 months when a perceived regression or loss of skills may occur. For most children, the symptoms or indicators are exhibited and noted in the early developmental period. However, given the overlap of symptoms with other communication and/or neurodevelopmental disorders, the diagnosis many not be received until later; it can be achieved at any age.

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What are the Early Indicators of ASD?

The challenges related to social communication and repetitive behaviors listed above are generally present early in a child’s development (even when a child is less than two years old). In children under two years of age, early indicators of ASD may include:

  • a child being limp or floppy when not seated upright or when being held,
  • rarely crying in environments that would typically induce crying (such as pain, hunger, or discomfort),
  • being difficult to comfort (or being comforted only by motion), and
  • a limited understanding or use of specific gestures or other communication methods.
  • a lack of babbling, pointing, or gesturing by 12 months of age,
  • complete lack of speech by 16 months of age, and
  • an inability to combine words by 2 years of age.
  • limited eye contact or
  • social smiling (smiling in responses to parents/caregivers),
  • limited interest in or awareness of others in the environment, and
  • unusual (high or low) sensitivity to the sensory features of an object or environment (sight, sound, smell, taste, feel).

Possible indicators of ASD in children over the age of two may have difficulty:

  • expressing wants or needs and
  • have limited conversation skills or even loss of expressive language
  • high levels of stress related to minor changes within their environment, such as their favorite toy being put away in a different spot,
  • spend a significant amount of time seeking sensory input (such as spinning in circles or wedging themselves into tight spaces).

In addition, children with ASD often:

  • engage in repetitive motor movements such as flapping their hands or even hurting themselves
  • oftentimes have a lowered sensitivity to pain.

Sometimes, children with ASD have difficulty with imaginative play and the social rules or interactions of playtime, leading them to interact with others only to meet a particular need, such as asking a parent to fix a toy they were playing with alone or rewind their favorite scene from a movie repeatedly.

Children over two years old are generally strong visual learners and react well to visual cues and routines.

Other possible early indicators of ASD in younger children may include:

  • a child not responding to his or her name,
  • becoming attached to a particular toy or object,
  • limited smiling,
  • lack of attending to what others are attending to (i.e., joint attention), and
  • a habit of playing with toys or objects in a different manner from typical peers.

Although the presence of these or any early indicators does not necessarily mean that a child has ASD, it may suggest that a child should be screened for ASD or other possible developmental delays by a medical professional.

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Who Can Provide a Diagnosis of ASD?

Psychiatrists, developmental pediatricians, pediatric neurologists, and psychologists with expertise in childhood onset disorders and ASD can typically provide a medical diagnosis of ASD. Other disciplines, such as therapists social workers may screen and suggest further referral for ASD evaluation but are not qualified to make formal medical diagnoses.

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 How is ASD Identified and Diagnosed?

For some children, signs and early indicators of ASD are apparent during infancy, with diagnoses occurring as early as 12 months. However, for others, the impact or appearance of symptoms may not be evident until later in their development when the challenges of social demands exceed the individual’s social abilities and capacities. The timeline of identification and diagnosis depend on the individual. There is no medical or biological test for ASD, so screenings and evaluations are important aspects of medical diagnosis process.

Once signs and indicators of ASD have become apparent, individuals may undergo a general developmental screening, hearing assessment, and, if needed, additional medical testing specific to parent and/or physician concerns. Following the assessment and testing, if concerns regarding the presence of ASD remain, the physician or pediatrician would recommend a comprehensive evaluation by a multidisciplinary team to administer specific ASD diagnostic screening tools and possibly a referral to other specialists. Psychiatrists, developmental pediatricians, pediatric neurologists, and psychologists with expertise in childhood onset disorders and ASD can typically provide a medical diagnosis of ASD. Other disciplines, such as therapists or social workers may screen and suggest further referral for ASD evaluation but are not qualified to make formal medical diagnoses.

During the comprehensive evaluation, one or more of the providers noted above would observe a child’s:

  • social skills and communication,
  • cognitive ability (IQ),
  • play skills, and
  • everyday skills such as feeding and dressing

to determine if the characteristics of ASD are apparent.

In addition, the provider may:

  • conduct interviews with the child’s parents
  • review information from other caregivers (such as teachers and therapists) or providers

to learn about how the child behaves and interacts across settings and to obtain information about the child’s developmental, social, family, and behavioral histories.

Additional testing may be undertaken to rule out other medical, mental health, and/or neurodevelopmental disorders. The medical professional may also utilize standardized diagnostic tools, such as the Autism Diagnostic Interview – Revised (ADI-R) or the Autism Diagnostic Observation Schedule – Generic (ADOS-G). A medical diagnosis of ASD is made according to diagnostic criteria as described in the current version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013).

In addition to a medical diagnosis, a student may receive an educational classification of ASD within the school setting. A medical diagnosis differs from an educational diagnosis, as explained in more detail below.

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What is the Difference Between a Medical Diagnosis of ASD and an Educational Classification?

Obtaining a medical diagnosis of ASD, as outlined above, is an important step in identifying services that are determined by a provider to be a “medical necessity” for a child with ASD. The medical evaluation serves to look at the “whole child” to assess overall functioning and need for services. These services may be covered by certain insurance providers and are related to the overall health of the child across settings.

By contrast, within the school setting, a child may be eligible for special education services under ASD eligibility if the child meets diagnostic criteria for ASD as outlined within the current edition of the DSM-5 and if such symptoms or challenges result in a consistent and negative impact upon the child’s academic achievement and/or functioning performance as specified within the Individuals with Disabilities Education Improvement Act (IDEA) and the Indiana Department of Education Article 7.

In order to determine special education eligibility, a multidisciplinary team comprised of qualified professionals (including school psychologists, speech-language pathologists, occupational therapists, and special education teachers, among others depending on the student’s unique needs) will conduct an educational evaluation of the student’s:

  • academic achievement,
  • functional skills across settings,
  • communication skills,
  • motor and sensory responses, and
  • developmental history.

Following and based upon this evaluation, a case conference committee (CCC) comprised of various school professionals and the student’s parents will decide whether the student’s ASD symptoms result in a consistent and significant negative impact on his or her academic achievement or functional performance; if the CCC concludes that the student’s ASD does negatively interfere with learning, he or she would be determined to be eligible for special education services within the school setting.

A medical diagnosis of ASD may be used in consideration of eligibility decisions but is not necessary or sufficient to make the educational classification.  As such a medical diagnosis is not equivalent to a special education eligibility of ASD and vice versa. For more information about how medical diagnosis and educational determinations differ, refer to this guide by the Indiana Department of Education (IDOE).

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Additional Resources

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State Resources:

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Intervention Services

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Introduction

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Upon receiving an ASD diagnosis, families may begin to consider options for treatment and intervention. A number of different types of treatment exist, so it is important to choose what is best for the individual and the family as a whole. Below is information about best practices within the medical and educational settings, research-based interventions, and how to determine which option or options may be best for your family. This not a complete list of all available treatments, nor is it a list of suggested treatments; rather, the information below is designed to help provide families with general ideas related to the various treatments available for individuals with ASD. Before making any decisions about any treatment, the providers and family involved in an individual’s care should work together to determine the most appropriate intervention for the individual and family.

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Is ASD a Curable Disorder?

There is no cure for ASD, but the use of evidence-based strategies and interventions can help reduce common symptoms and challenges associated with the disorder.

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What are Evidence-Based Practices?

“Evidence-based” means that the scientific community has found evidence that establishes the effectiveness of a treatment or intervention through rigorous evaluation and scientific research as demonstrated in repeated studies. The National Autism Center’s National Standards Project (2007) categorizes various treatment options based on the level of scientific evidence that supports each and is a useful tool to reference when considering which treatment option may be best for different individuals.

Learn more about evidence-based practices on the page What is Evidence-Based?

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What Treatment is Available for Individuals with ASD?

There are many interventions and services available for individuals with ASD, with the effectiveness or appropriateness of each treatment varying among and between individuals. Some interventions have been studied more than others and, if noted repeatedly to be effective, are considered to be evidence-based practices (EBPs).  Those that have not yet been studied or adequately studied may someday be found to be evidence-based. Common, EBPs are briefly described below. The Centers for Disease Control and Prevention (CDC) also offers a helpful list of treatment options backed by scientific research and provides information about additional interventions not listed below.

Applied Behavior Analysis (ABA)

Applied Behavior Analysis, or ABA, is a research-based philosophy of working with individuals of different abilities, not just individuals with ASD. ABA encompasses a range of strategies and methods based on standard behavioral principles designed to address reduction of behaviors by encouraging positive or desired behaviors and discouraging negative or unwanted behaviors in order to improve a variety of skills. Behaviors are considered to be a form of communication that can be addressed by teaching appropriate skills to support the reduction of undesired behaviors across settings. Examples of ABA methods include, but are not limited to:

Discrete Trial Training: Teaching an individual one particular skill through repeated trials
Incidental Teaching: Creating a learning environment based on an individual’s interests or motivations
Pivotal Response Training: Focusing on positive changes in key behaviors to positively affect other behaviors
Social Stories™: Using words and/or pictures to describe what to do in various situations that may challenge or provoke anxiety within an individual (developed by Carol Gray)

Learn more about ABA on the ABA page

Structured Teaching (TEACCH; Schopler)

Structured teaching involves setting up an individual’s environment for success by using structure (e.g., physical structure, visual structure, visual schedules, work systems) to lend organization, predictability and understanding of expectations.  The structured teaching method is designed to capitalize on strengths of individuals with ASD, minimize their challenges and support independence. Structured teaching originated at the TEACCH Program at the University of North Carolina. Learn more on the EBP page.

Picture Exchange Communication Systems (PECS; Bondy and Frost)

The Picture Exchange Communication System, or PECS, is designed to improve an individual’s ability to expressively communicate through the use of pictures representing language or concepts. The individual is systematically and gradually taught the expectation for exchange of a picture to communicate and interact with others.  As the system is utilized, additional picture cards are added as appropriate and the complexity of the communications can be increased.  This low tech communication system can be utilized to promote functional communication as an alternative to negative behaviors and in combination with and/or to promote verbal or other communications as well.  Learn more on the EBP page

Verbal Behavior Analysis (VBA; Skinner)

Verbal Behavior Analysis utilizes DTT methods to specifically focus on and teach verbal skills. Individuals are taught to use appropriate words when motivated to make it clear to the individual that communication has a function and to help individuals learn the right words to use within a given context.  Learn more on the EBP page

Unestablished treatment options also exist and may be explored in more detail using credible resources such as the Centers for Disease Control and Preventionthe National Autism Center’s National Standards ProjectNational Institute of Health, and medical providers in your area.

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What is Early Intervention?

Early intervention is offered to children with developmental delays or challenges ages birth until their third birthday.  This group of infants and toddlers have access to early intervention services inclusive of speech, occupational, physical and developmental therapies often conducted within the family’s home through Indiana’s First Steps program.  For more information about referrals or to contact your local First Steps agency, refer to the DDRS First Steps map

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What is the Best Intervention for ASD?

The scientific literature on treatments for ASD continues to grow, with few guidelines for selecting the best treatment or intervention. Because ASD is a spectrum disorder, no two individuals with ASD will have the exact same behaviors, challenges, or skills–so, treatments and interventions should be individualized according to specific strengths and challenges. No single intervention is best for all individuals, and, oftentimes, the best approach involves a blending of strategies. ABA-based interventions with or without medication management have received the most empirical support in the literature. When considering treatment options, it is important to distinguish between those with empirical support and those without, and it is also helpful to follow certain steps throughout the treatment decision-making process:

  1. Conduct an assessment of the individual’s skills and behaviors before attempting to teach any new skills or implement certain interventions. Assessments may be completed by professionals such as psychiatrists, developmental pediatricians, pediatric neurologists, and licensed psychologists with expertise in childhood onset disorders and ASD.
  2. Select an intervention based on the assessment that focuses on the individual’s particular strengths and challenges
  3. Monitor and continually reevaluate the intervention program, making adjustments as necessary based on the individual’s progress toward established goals
  4. Ensure the staff providing the intervention is competently trained by asking questions about staff members’ background, experience, and credentials.
  5. Implement interventions one at a time to accurately track which has an effect on the individual and the extent to which the intervention is or is not successful.

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How do I find a provider who works with individuals with ASD?

Often parents find it helpful to contact your school district as well as to talk with other parents in your area.  However, there are also a number of statewide organizations that can lend some assistance in finding a provider in your area.  A couple are noted below and in the resource section of the website.

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What questions should I ask a provider about intervention services?

When discussing intervention services with a provider it’s important to ask questions that pertain to specific concerns regarding your child and their diagnosis or identified developmental delays. A provider should be more than willing to listen to your concerns and answer any questions you have. Listed below are a few suggested questions but certainly aren’t an exhaustive list as your questions should be tailored to your child’s and family’s needs:

  • What training have you received to provide intervention services?
  • What are your intervention goals for my child? Do the goals align with his/her current level of development?
  • How will your intervention sessions be tailored to meet the individual needs of my child?
  • How will you track my child’s progress?
  • How will you determine if my child is meeting his/her goals?
  • What will you do if my child is not making progress?
  • How do you plan to communicate about my child’s progress?
  • How can I be involved in sessions so we work together as a team?

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Available Resources

References

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