The Developmental Assessment for Young Children With Possible Autism
A developmental assessment for children under age 3 is an attempt to assess various aspects of the child's functioning, including areas such as cognition, communication, behavior, social interaction, motor and sensory abilities, and adaptive skills. Assessment of the family and the child's environment also provides important contextual information.
Topics covered in this section
This section covers the basic aspects of the general developmental assessment for young children with suspected developmental problems including possible autism. This section focuses on the general approach to the developmental assessment, including some specific components of such an assessment, but does not review information on specific autism assessment instruments.
Basis for guideline recommendations about the general developmental assessment
In the previous section on the use of autism assessment instruments, the guideline recommendations are based on the panel's interpretation of an extensive and systematic review of the scientific literature. The panel did not attempt to systematically evaluate the research evidence on effectiveness of the general developmental assessment methods discussed in this section as this was considered outside the specific scope of the guideline. Therefore, guideline recommendations in this section are based on the consensus opinion of the panel, using its collective knowledge and experience in assessing children with autism. In the panel's opinion, these recommendations reflect appropriate practices for assessing children with possible autism and are generally consistent with the scientific knowledge in this field.
General Strategies for the Developmental Assessment of Children with Possible Autism| Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed |
Recommendations
Importance of the developmental assessment
- Developmental assessments are usually done because of a concern that the child may have a developmental delay or disorder. It is important to include a developmental assessment when evaluating children with possible developmental problems because such assessments can:
- help identify possible developmental problems and the need for further diagnostic evaluation
- provide an objective description of the child's abilities and deficits (a functional assessment)
- determine eligibility for programs (such as early intervention programs)
- aid in planning for appropriate interventions. [D2]
- In children who are diagnosed with autism, or in whom there is sufficient evidence to suggest a diagnosis of autism, it is very important to do a general assessment of all developmental domains. Because children with autism may demonstrate different patterns of strengths and weaknesses, it is important to individualize the specific components of a developmental assessment. [D2]
Components of the developmental assessment
- It is recommended that a developmental assessment for a young child provide an adequate functional evaluation of all developmental domains. Important components of a developmental assessment include the following:
- an objective test of hearing (standardized testing may be less reliable in children under the age of two)
- standardized testing of:
- cognitive ability
- communication
- motor/physical skills
- adaptive skills
- social, emotional, and behavioral functioning
- sensory processing
- curriculum-based assessments
- observation of the child at informal or structured play and of parent-child interactions
- parental interview to elicit their concerns, obtain a history of the child's early development, and gather information about the child's current level of functioning
- review of the child's records (health, education and daycare, etc.) and family medical history [D2]
- Developmental assessments can be performed by a variety of professionals in a number of settings and for a number of reasons. Insofar as assessing children with autism is complex, particularly in children under 3 years of age, it is important that professionals participating in the developmental assessment have experience and expertise in assessing young children with autism. [D2]
- In order to assure quality and consistency, it is recommended that developmental assessments of young children:
- be performed by professionals with experience assessing young children
- utilize procedures that are reproducible by other professionals
- use age-appropriate testing and scoring methods [D2]
- It is important the developmental assessment be viewed as an ongoing process that follows the child over time rather than as a single event. [D2]
- It is important that the developmental assessment be individualized to the child by:
- using age-appropriate testing and scoring methods
- focusing on the child's presenting problems (such as suspected delays or deviations in development or behavioral problems)
- assessing specific areas of strength and weakness, including specific discrepancies in functioning across and within developmental domains [D2]
- A child's life is embedded within a cultural context. It is essential to consider and respect the family's culture when assessing children with possible developmental disorders, including autism. [D2]
- If English is not the primary language of the family, it is important for professionals to look for ways to communicate effectively with the family, including the use of professionals and/or translators who speak the child's language. [D2]
- When assessing a young child with possible autism, it is important to consider the setting of the assessment including:
- the presence of parents and the resulting effects on the child's behavior
- the child's familiarity with the environment
- aspects of the test environment that are distracting [D2]
- It is recommended that the assessment of the child occur in more than one session and in more than one setting because:
- the child's behaviors may vary depending on familiarity with the testing environment and examiner
- the child's comfort level with the examiner may increase over time
- a child's behavior can vary from day to day [D2]
- In some cases a developmental assessment to evaluate a suspected developmental problem may provide professionals with the first indication that a child may have autism. When this occurs, it is recommended that further evaluation of possible autism be carried out. [D2]
- It is important to follow up on
questionable abnormal findings in the developmental assessment of
any young child. This might include adding elements to the
developmental assessment and/or referring the child to other
professionals for more detailed evaluation and specific
diagnosis. [D2]
- It is important that the findings of the developmental assessment be used in developing any intervention plans for the child. The developmental assessment also provides useful objective anchor points for monitoring the progress of the child and assessing the outcomes of interventions. [D2]
- It is important for professionals assessing children with possible autism to explain the procedures and findings of the assessment to the parents in terms that are easy to understand. This would include a full explanation of:
- important terms and concepts used in reports
- the results and implications of the assessment
- a comparison of the child's performance to developmental norms [D2]
- Explaining assessment results to parents whose children have autism is particularly important because the characteristically uneven developmental profile can be confusing. For example, a child may have age-level nonverbal skills and severely impaired communication skills. [D2]
- It is important that all professionals involved with the assessment of a child with possible autism communicate with each other regarding their findings and recommendations. [D2]
- It is important to assess cognitive ability in children with possible autism because:
- information about the child's cognitive ability is useful in the diagnostic process, specifically in differentiating children with autism alone, children with mental retardation alone, and children who have both autism and mental retardation
- the child's cognitive ability has implications for intervention decisions and has possible implications for outcome [D2]
- In attempting to assess cognition in children with possible autism, it is important to assess:
- verbal and nonverbal cognitive skills as accurately as possible
- the child's ability to use skills and information in everyday environments [D2]
- In determining the nonverbal cognitive level for a young child, it is useful to observe
- the child's behaviors during structured and free play
- the child's other interactions with people and objects in the immediate environment [D2]
- It is important to remember that levels of cognitive skills in young children are sometimes estimated using a standardized test to derive one of the following measures:
- developmental quotient (DQ); used mainly for children under 3 years old
- mental developmental index (MDI); also used for younger children
- intelligence quotient (IQ); used mainly for older or for more verbal younger children [D2]
- It is important to recognize that it is often difficult for professionals to accurately assess the cognitive level of a child with autism. Children with autism often:
- display uneven levels of skills between different developmental domains
- have limited language
- participate in a very limited way in the assessment process [D2]
- Although mental retardation and autism commonly coexist, it is important that professionals exercise caution in making the diagnosis of mental retardation in young children with possible autism. [D2]
- It is important that professionals not prematurely label the child as having mental retardation until appropriate standardized and non-standardized testing of cognition has been done. [D2]
- It is also important that professionals not infer that the child has a higher cognitive level than can actually be observed and measured. [D2]
- Standardized testing designed to arrive at a developmental quotient (DQ)
- Criterion-referenced and curriculum-based assessments
- Direct observation
- Berkell D (ed.). Autism: Identification, Education, and Treatment. Hillsdale, NJ: Lawrence Erlbaum Associates, 1992.
- Matson JL (ed.). Autism in Children and Adults: Etiology, Assessment, and Intervention. Pacific Grove, CA: Brooks / Cole, 1994.
- Rutter J, Tuma AH, Lann IS (eds.).
Assessment and Diagnosis in Child Psychopathology. New York,
NY: Guilford Press, 1998.
- Schopler E. Mesibov GB (eds.) Learning and Cognition in Autism. New York, NY: Plenum Press, 1995.
- It is important to adequately assess communication in children with possible autism because delayed and/or atypical communication is one of the critical clinical clues in identifying autism. [D2]
- Assessing communication in children with autism is also important because of these factors:
- its impact on intervention decisions
- it provides a baseline for monitoring progress
- its implications for outcome [D2]
- In assessing communication in a young child with possible autism, it is important to evaluate the child's:
- hearing status
- ability to use nonverbal communication strategies (such as, pointing to request or show an item)
- atypical or delayed nonverbal communicative behaviors (such as, atypical eye gaze and gestures)
- functional use of spoken language (how children use words and sounds to get what they want)
- significant delays in onset of spoken language or loss of language
- atypical communication patterns (such as echolalia, perseveration, and use of words without apparent communicative intent) [D2]
- Nonverbal communication
involves all aspects of communication between the child and others
except for spoken language. In young children this may include the
use of such things as facial expressions, pointing, and gesturing
to communicate with others. In older children this may include the
use of symbol systems.
- Verbal communication is the use of spoken language or other verbal utterances to communicate.
- Phonology is the sound system of spoken language
- Morphology is the system that governs the structure of words and construction of word forms
- Syntax is the system governing the order and combination of words to form phrases or sentences
- Semantics is the system that governs the meaning of words and sentences
- Pragmatics is the system that combines all other language components in functional use of language
- American Speech-Language-Hearing Association, 1993
- New York Department of Health, Early Intervention Program, Communication Disorders Clinical Practice Guideline, 1999
- Communication disorder is a broad term that encompasses any impairment in the ability to receive, send, process, and comprehend concepts, or verbal, nonverbal and graphic symbol systems. A communication disorder may involve hearing, language, or speech. Communication disorders may range in severity from mild to profound.
- Communication delay refers to a quantitative delay in meeting certain age-specific developmental milestones for communication (the normal language milestones). Language delay is sometimes determined by test scores for a particular language development measure (such as vocabulary size) that are significantly below the mean for typically developing children of that age.
- < Hearing disorders
- articulation disorders, which involve the atypical production of speech sounds (such as problems with pronunciation)
- fluency disorders, which involve an interruption in the flow of speech, including abnormal rate and rhythm, and unintentional repeating of sounds as in stuttering
- voice disorders, which involve the abnormal production of vocal quality, pitch loudness, or resonance
- Methods to assess
hearing disorders in young children include:
- audiometry
- brainstem evoked-response testing
- Methods to assess speech and language disorders include:
- standardized testing designed to assess speech and language development
- direct observation of the child, especially when interacting with parents, other children, or professionals
- Assessing social interactions and relationships is important in young children with possible autism because an inability to form social relationships is one of the primary characteristics of autism. [D2]
- Assessment of social interactions and relationships includes evaluation of:
- social initiation (showing or giving objects to others for social purposes)
- social imitation (imitating actions of others)
- age-expected reciprocity (turn-taking during play)
- the child's attachment patterns in the presence of a caregiver (neutrality, excessive clinging, or avoidance of parent)
- the child's tendency for social isolation or preference to be alone
- the child's use of people as tools to obtain desired ends (taking adult's hand to reach for a toy)
- social interactions with familiar as well as unfamiliar adults and peers [D2]
- When assessing young children with autism, it is important to assess their behavior and responses to the environment because these factors may impact intervention decisions and provide baselines for monitoring progress. [D2]
- In assessing a child with possible autism, it is important to identify behavior patterns, relative strengths, and problem areas. [D2]
- Assessment of a child's behavior and responses to the environment may include evaluation of:
- behavior patterns and problem behaviors
- unusual responses to sensory experiences
- motor skills
- play skills
- adaptive behaviors
- self-help skills [D2]
- It is important for the family of a young child with autism to participate in a family assessment because factors relating to the family can impact intervention and management decisions and may have implications for outcomes. [D2]
- Assessment of the strengths and limitations of the family and the child's environment may include observation and/or discussion of:
- the family's stressors, tolerance for stress, and coping mechanisms and styles
- the family's current support systems
- education experiences of family members
- family composition, demographics, and specific circumstances
- family interaction and patterns of discipline
- emotional expression of family members
- caregiving skills and sharing of caregiving responsibilities
- knowledge about autism [D2]
Carrying out the developmental assessment
Considering the cultural context
of the family
Considering the assessment setting
Using the findings of the developmental assessment
Communicating findings to parents and other professionals
| Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed |
Recommendations
Importance of assessing cognition in children with possible autism
Methods for assessing cognition in children with possible autism
Challenges in assessing cognition in children with autism
Diagnosing mental retardation in children with autism
Table III-6
Assessing Cognition in Young Children
Definition of Cognition: Cognition includes the processes of the brain that allow us to experience the environment, remember, think, act, and feel emotions. Cognitive processes are complex, diverse, and highly inter-related.
Components of Cognition: The components of cognition listed below are particularly important with respect to autism:
Arousal, orientation, attention, and executive function
| Arousal | Distributed attention |
| Orienting | Shared attention |
| Perception | Exploration - stimulus seeking |
| Selective attention | Executive functions |
| Sustained attention |
Memory: Short- and long-term memory
Information processing functions
Facial/emotion recognition
Processing emotional content
Imitation
Cause and effect association
Deducing rules for responding
Cross-sensory modality information exchange
Processing multiple sources of information simultaneously
Reasoning and concept formation
| Response flexibility | Language |
| Concept formation | Perspective taking |
| Analogous reasoning | Social context and rules |
| Problem solving |
The following books deal in-depth with issues of cognition in children with autism:
Adapted from: Romanczyk et al., 1998
| Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed |
Recommendations
Importance of assessing communication
Components of the assessment of communication
Table III-7
Assessing Communication in Young Children
Definition of Communication: Communication is defined as nonverbal and verbal communication
Components of Language: Language is the use of sounds, words, and phrases to verbally communicate between individuals. Language has the following five main elements:
Adapted from:
Definition of Communication Disorders
Types of Communication Disorders
Communication disorders in young children can be classified as hearing disorders, language disorders, or speech disorders.
How to Measure Communication in Young Children
Assessment of hearing is covered
in the health evaluation section.
Assessing Social Interactions and Relationships
| Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed |
Recommendations
Importance of assessing social interactions and relationships
Components of the assessment of social interactions and relationships
Assessing Behavior and Responses to the Environment
Recommendations
Importance of assessing behavior and responses to the environment
Components of the assessment of behavior and responses to the environment
Assessing the Family and the Child's Environment
| Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed |
Recommendations
Importance of assessing the family and the child's environment
Components of an assessment of the family and the child's environment
