Early Screening of ASD & The Role of the SLP

Early Screening of ASD & The Role of the SLP

Objectives Identify reasons for early identification Identify screenings tools that aid in identification of ASD Define the role of the SLP in screening & assessment Identify early signs of ASD vs Typical Development

Rationale for Early Screening In 2018, the Centers for Disease Control and Prevention (CDC) released new data on the prevalence of autism in the US. Identified 1 in 59 children (1 in 37 boys and 1 in 151 girls) as having Autism Spectrum Disorder (ASD). Mean age for autism spectrum diagnosis is between 4 5 years of age Intervention for children on the spectrum has the greatest impact when begun prior to 3 ½ years of age Early, accurate diagnosis can help families access appropriate services and establish a framework for families and caregivers within which to understand their child s difficulties

Screening Guidelines Currently, there is no standardized screening approach for the early identification of autism. Screening provides a standardized process to ensure that children are systematically monitored for early signs of ASD to promote earlier diagnosis The AAP has recommended that ALL children be screened: At ages 18 and 24 months Utilizing an ASD-specific instrument during well-child visits In conjunction with ongoing developmental surveillance and broadband developmental screening (at every well check visit 9 30 months) regardless if concerns have been raised during the developmental surveillance process

Screening Tools Broadband developmental screener CSBS ITC (Communication and Symbolic Behavior Scales Infant Toddler Checklist) Standardized tool for screening of communication and symbolic abilities Ages 6 24 months 1-page, parent-completed screening tool Not specific for ASD (i.e., does not differentiate ASD from other communication disorders), A follow up evaluation by a developmental specialist (e.g., speech language pathologist, psychologist, developmental behavioral pediatrician) can help determine the need for ASD specific diagnostic assessment as well as identify other developmental delays in need of support and intervention.

Screening Tools (cont d) ASD Specific Screener Level 1: screening applies to all children regardless of their risk level for developmental disabilities (i.e., universal screening) Level 2: screening targets children already identified as being at increased risk for ASD (e.g., due to a positive family history, concerns raised by parents or clinicians, identification by a level 1 screener)

Screening Tools (cont d) Level 1: M-CHAT (Modified Checklist for Autism in Toddlers) Parent-completed questionnaire of 23-items, combined with a follow-up interview to help clarify items identified by parents on the initial screen Ages 16 30 months

Screening Tools (cont d) Level 2: STAT (Screening Tool for Autism in Toddlers & Young Children) An interactive screening tool consisting of 12 activities assessing play, communication Ages 24 36 months Requires a higher level of expertise to administer than parent questionnaires SORF (Systematic Observation of Red Flags of ASD) Observational screening measure designed to detect 22 red flags of ASD Ages 9 24 months

Screening Recommendations Children who screen positive on an ASD-specific screening tool should receive a follow up comprehensive diagnostic evaluation and referral to early intervention services as appropriate. Early screening will lead to improved outcomes as a result of earlier referral and earlier initiation of intervention Additional research is needed to address how to better engage families in the screening process to facilitate rapid follow-up, as well as to identify and characterize other potential barriers to early diagnosis and treatment related to system capacity or provider attitudes and practices

Challenges to Early Screening Lack of time, reimbursement, and resources Disruption of work flow Unfamiliarity and limited awareness of screening tools Concerns regarding quality of screening tools Difficulty with scoring Lack of referral tracking and follow up by providers

Solutions to Early Screenings Improve training of health care professionals in recognizing early ASD signs Improve use of specific screening tools Develop a specific referral protocol Ensure feedback to the referring offices

Early Screening Study The 1-Year Well-Baby Check-Up Approach - Dr. Karen Pierce and colleagues of the UCSD Autism Center of Excellence Developed standardized system of early screening for autism and other developmental delays as young as 12 months 130 Pediatricians within San Diego area were taught to administer and score CSBS ITC 10,479 babies were screened at 1 year of age over 3.5 years; failed screenings yielded referral for testing of language, social and cognitive abilities Of 184 babies who failed screening- 72% of those showed to have a delay, more specifically autism, language delay, global developmental delay or an associated condition

Early Screening Study (cont d) Study showed: Autism can be detected at age 1 year in some (but not all) toddlers Pediatricians are the first line of defense Early detection leads to early treatment Early detection and early treatment stand the greatest chance of positively impacting brain development Early detection may help scientists in the search for early biomarkers and causes

Role of the SLP in Screening As a result of the central role that communication plays in any autism spectrum diagnosis, the role of the SLP on autism screening and diagnostic teams is critical SLPs may be the first to encounter a child with communication difficulties, a subset of whom could have an autism spectrum disorders SLPs must have: Firm understanding of the signs of autism at different stages of language development Proficiency in administering, interpreting, and using autism screeners to make appropriate referrals

DSM-5 Criteria for Autism Spectrum Disorder: A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history: Deficits in social-emotional reciprocity (e.g., abnormal social approach and failure of normal back-and-forth conversation, reduced sharing of interests, emotions, or affect, failure to initiate or respond to social interactions) Deficits in nonverbal communicative behaviors used for social interaction (e.g., poorly integrated verbal and nonverbal communication, abnormalities in eye contact and body language, deficits in understanding and use of gestures, lack of facial expressions and nonverbal communication) Deficits in developing, maintaining, and understand relationships (e.g., difficulties adjusting behavior to suit various social contexts, difficulties in sharing imaginative play or in making friends, absence of interest in peers)

DSM-5 Criteria for ASD (cont d): B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases). Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

DSM-5 Criteria for ASD (cont d): C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

Typical Development of Social & Communication Milestones Major milestones which are problematic in 3-year-olds with autism develop in the typical child by 15 18 months 3-6 months: emergence of reciprocity 6-9 months: response to name 9-12 months: follow attention of others; social referencing prior to approaching novel stimuli; good communicators 12-15 months: initiate joint attention; verbal communication; functional play 15-18 months: early pretend play; developing vocabulary of words used with in different situations with more or less conventional meanings

Red Flags of Autism in the 2 nd Year of Life Impairment in Social Interaction Lack of appropriate gaze Lack of warm, joyful expressions Lack of sharing interest or enjoyment Lack of response to name Impairment in Communication Lack of showing Lack of coordination of nonverbal communication Unusual prosody Repetitive Behavior & Restricted Interests Repetitive movements with objects Repetitive movements or posturing of body

Role of the SLP in Assessment It is an SLPs responsibility to make the appropriate referral for further diagnostic evaluation based on screening and assessment results Interdisciplinary collaboration is important due to the complexity of the disorder, the varied aspects of functioning affected, and the need to distinguish ASD from other disorders or medical conditions Involvement with neurology, pediatrician, psychology, occupational therapy, social work, etc.

Components of an Assessment A thorough parent/caregiver interview to review historical and current information A structural language assessment is necessary (i.e., traditional receptive and expressive language developmental tests) Observations and assessment of social communication abilities or pragmatics Including areas within nonverbal and preverbal stages such as: use of eye contact affect sharing social referencing intentional communication gesture use (e.g., dyadic back-and-forth interactions between an adult and child and triadic interactions between an adult, child, and outside entity) joint attention communicative functions play skills

Signs at Non-verbal/Pre-verbal Stage Clinical signs of a possible autism spectrum disorder at the Non-Verbal/Pre-verbal stage

Signs at Phrase Speech to Complex Language Clinical signs of a possible autism spectrum disorder at the Phrase speech up to complex language usage stage

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