CHAPTER III (continued)

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.

Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed

Recommendations

Importance of the developmental assessment

1. 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:

2. 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

3. 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:

Carrying out the developmental assessment

4. 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]
5. In order to assure quality and consistency, it is recommended that developmental assessments of young children:

6. 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]
7. It is important that the developmental assessment be individualized to the child by:

Considering the cultural context of the family

8. 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]
9. 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]

Considering the assessment setting

10. When assessing a young child with possible autism, it is important to consider the setting of the assessment including:

11. It is recommended that the assessment of the child occur in more than one session and in more than one setting because:

Using the findings of the developmental assessment

12. 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]

13. 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]
    
14. 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]

Communicating findings to parents and other professionals

15. 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:

16. 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]
17. 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]

Assessing Cognition

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

1. It is important to assess cognitive ability in children with possible autism because:

Methods for assessing cognition in children with possible autism

2. In attempting to assess cognition in children with possible autism, it is important to assess:

3. In determining the nonverbal cognitive level for a young child, it is useful to observe

4. 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:

Challenges in assessing cognition in children with autism

5. 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:

Diagnosing mental retardation in children with autism

6. 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]
7. 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]
8. It is also important that professionals not infer that the child has a higher cognitive level than can actually be observed and measured. [D2]

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

Memory: Short- and long-term memory

Information processing functions

Reasoning and concept formation

Response flexibility	Language
Concept formation	Perspective taking
Analogous reasoning	Social context and rules
Problem solving

How to Measure Cognition in Young Children

• Standardized testing designed to arrive at a developmental quotient (DQ)
• Criterion-referenced and curriculum-based assessments
• Direct observation

The following books deal in-depth with issues of cognition in children with autism:

• 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.

Adapted from: Romanczyk et al., 1998

Assessing Communication

Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed

Recommendations

Importance of assessing communication

1. 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]

2. Assessing communication in children with autism is also important because of these factors:

Components of the assessment of communication

3. In assessing communication in a young child with possible autism, it is important to evaluate the child's:

Definition of Communication: Communication is defined as nonverbal and verbal communication

• 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.

Components of Language: Language is the use of sounds, words, and phrases to verbally communicate between individuals. Language has the following five main elements:

• 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

Adapted from:

1. American Speech-Language-Hearing Association, 1993
2. New York Department of Health, Early Intervention Program, Communication Disorders Clinical Practice Guideline, 1999

Definition of Communication Disorders

• 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.

Types of Communication Disorders

Communication disorders in young children can be classified as hearing disorders, language disorders, or speech disorders.

• < 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