CHAPTER III (continued)

This section provides recommendations on the general approach for identifying children with developmental problems, particularly autism, at an early stage. This section also includes suggestions on the ways that various parts of the assessment process fit together. The other sections contain more recommendations for in-depth evaluation and recommendations about specific parts of the assessment process.

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

Recommendations

Importance of early identification of autism

1. It is important to identify children with autism and begin appropriate interventions as soon as possible since early intervention may help speed the child's overall development, reduce inappropriate behaviors, and lead to better long-term functional outcomes. It is often possible to recognize autism within the first 3 years of life. [A]

Identifying initial concerns about possible autism

2. It is important for professionals and parents to recognize that there are several ways children with autism are first identified. These ways include:

Developmental surveillance

3. Developmental surveillance done routinely at specific age points is important for all young children. Health care providers or other professionals can provide such surveillance and can facilitate the identification of developmental problems as early as possible. [D2]
4. The periodic exams at 15, 18, and 24 months are particularly useful in providing information about possible autism, since this condition can often be identified within the first 3 years of life. [D2]

A practical approach for identifying young children with possible autism

5. Studies suggest there are approximately one to two children with autism for every 1,000 children in the general population. Since autism is relatively rare, it is usually not practical to screen the general population of young children for autism using any specific screening test for autism. [D2]
6. A more useful approach for identifying children with possible autism is to:

Recommendations

Using autism assessment instruments to help make a diagnosis

1. Instruments specifically designed to assess autism in younger children (referred to here as "autism assessment instruments" and described in the section on assessment instruments) can be useful in assisting with the diagnosis of children suspected of having autism. [A]
2. It is recommended that no single autism assessment instrument be used as the sole basis for diagnosing autism because:

3. It is important to use multiple sources of information in assessing children suspected of having autism; it is especially important to include direct observation of the child. [A]

Making a specific diagnosis of autism

4. Based on the practice acts of New York State, licensed psychologists and physicians are the only individuals qualified to diagnose autism. [D2]
5. 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.[D2]
6. It is recommended that the diagnosis of autism be based on the criteria in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), or the most current edition of this manual (see Tables III-1 and III-2). [D2]

General Approach for Developmental Assessment of Children with Possible Autism

Recommendations

Importance of the developmental assessment

1. It is important that all children with suspected developmental problems have an age-appropriate developmental assessment. This may include evaluation of such areas as cognition, communication (including an objective test of hearing), behavior, social interaction, motor and sensory abilities, and adaptive skills. [D2]

2. It is important to carry out developmental assessments for children with possible disabilities because such assessments can:

Carrying out the developmental assessment

3. It is important that the developmental assessment not be viewed as a single event, but as an ongoing process that follows the child over time. [D2]
4. Developmental assessments can be performed by a variety of professionals in a number of settings. Since 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 such young children with autism. [D2]
5. It is important that the developmental assessment:

Using the findings of the developmental assessment

6. It is important to follow up on abnormal findings in the assessment by adding elements to the assessment and/or referring the child to other professionals for more detailed evaluation and specific diagnosis. [D2]
7. It is important that the findings of the developmental assessment be used in developing any intervention programs for the child. [D2]
8. For children with autism and other developmental disabilities, it is important to do both a diagnostic evaluation (to determine the specific diagnosis) and a functional assessment (to evaluate the child's strengths and needs in various developmental domains). [D2]
9. It is important to recognize that the order in which the diagnostic evaluation and general developmental assessment are done may vary for children with autism. These assessment processes may occur in several phases and may involve multiple professionals as well as the child's parents. [D2]

Recommendations

Importance of the health evaluation for young children with possible autism

1. It is important that all children with suspected developmental problems, including possible autism, have a comprehensive health evaluation. [D2]

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2. The need for a comprehensive health evaluation may be triggered by findings of the general developmental surveillance, or because of concerns by parents or professionals that a developmental problem may exist. [D2]
3. It is important to recognize that the diagnosis of autism is made based on historical information about and direct observation of a child's behavior (in terms of communication, social interactions and maladaptive behaviors). There are no specific laboratory, imaging, electrophysiological or other medical tests that can be used to establish the diagnosis of autism. [D1]
4. It is important that children with possible autism have a thorough health evaluation in order to identify and assess:

Assessing general health problems in children with autism

5. It is important to recognize that children with autism are susceptible to all the same health problems as children without autism. (Note: Assessment and intervention for these general medical conditions is outside the scope of this guideline and, therefore, not addressed in this document. [D2]
   
6. It is important to recognize that assessment and intervention for medical problems for children with autism may present special challenges for health care providers and parents. [D2]

Recommendations

Considering the cultural and family context

1. A child's life is embedded within a cultural and family context. When assessing children with possible develop-mental disorders, including autism, it is essential to consider:

2. In evaluating a child with possible autism, it is important to recognize that there may be cultural and familial differences in expectations about such things as eye contact, play and social interaction, and pragmatic use of language.[D2]

3. 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 and the child, including finding professionals and/or translators who speak the child's family's language(s). [D2]

Considering the assessment setting

4. When assessing a young child with possible autism, it is important to consider the setting of the assessment. Some important factors to consider include:

5. It is sometimes useful to assess the child in different environments and on multiple occasions because:

Communicating findings to parents and other professionals

6. It is important that professionals assessing children with possible autism explain to parents the procedures and findings of the assessment in terms that are easily understood. This would include a full explanation of:

7. It is always good clinical practice for professionals to explain the results of their assessments to the child's parents. Such an explanation is particularly important for children with autism because their characteristically uneven developmental profile can be confusing. For example, a child may have age-level nonverbal skills and severely impaired communication skills.[D2]
8. It is important for all professionals involved in the assessment of a child with possible autism to communicate with each other regarding their findings and recommendations. [D2]
9. It may be useful to provide parents with recommendations about credible sources where they can obtain further information about autism. [D2]