Read KidsMatter’s interview with Michelle Savage, a psychologist and registered teacher, who regularly works with children who have ASD.
Why is early detection of Autism Spectrum Disorder important?
Research has demonstrated that appropriate early intervention can make significant differences to outcomes for individuals with Autism Spectrum Disorder. The earlier ASD is detected and diagnosed, the earlier intervention can begin, in areas such as social interaction, communication and daily living skills. The diagnostic process itself provides an opportunity to gain comprehensive information on the way a child understands and interacts with the world, and ensures the most appropriate intervention can be implemented based on that child’s specific needs. Early intervention can mean more time to teach skills that will support a child to reach their full potential.
What are some of the recent changes in criteria for diagnosing Autism Spectrum Disorder?
The diagnostic criteria for ASD used by the vast majority of health care professionals in Australia and internationally is contained in the Diagnostic and Statistical Manual of Mental Disorders (DSM). In 2013, the 5th Edition of this manual was released within it new criteria that have resulted in changes to the way clinicians refer to ASD. The DSM 5 now contains a single diagnosis of Autism Spectrum Disorder. Other labels such as Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder – Not Otherwise Specified, are no longer present and are now subsumed under the broader ASD category.
Now, a diagnosis of ASD is based on difficulties in two key areas:
- Social communication and social interaction
Difficulties with social communication include deficits in emotional and social reciprocity, body language and verbal communication, and reciprocal conversation.
- Restricted and repetitive patterns of behaviour or interests
Restricted and repetitive patterns of behaviour or interests may manifest as rigidity around routines, repetitive motor or play behaviours, rituals, or inflexibility. This may also include hypo- or hypersensitivity to sensory input, which has not been mentioned in previous DSM.
The DSM 5 also specifies that the symptoms must be present from an early age and manifest across multiple contexts.
A further addition to the new DSM criteria is that clinicians are required to specify the severity level for that individual on each of the two criteria. Specifiers are provided for each of the three severity levels:
requires substantial support
requires very substantial support.
Descriptive examples are also provided to aid in this process.
These changes to DSM criteria have resulted in the loss of other well-known labels, such as Asperger Syndrome (AS) and Pervasive Developmental Disorder – Not Other Specified (PDD-NOS). This led to concern over the effects on an individual’s diagnosis, treatment and funding, for those who received diagnosis under DSM IV. Now, three years after the introduction of DSM 5, research indicates that most children who were diagnosed previously are still eligible for an ASD diagnosis under the new criteria. There were also suggestions that the new criteria would result in reduced ASD prevalence rates, however the opposite appears to be true. In contrast to expectations, the new criteria are believed to be more sensitive in diagnosing females, those with less severe symptoms, and children at a younger age.
What evidence-based assessment tools are used for diagnosing children with Autism Spectrum Disorder?
Across Australia, there are different state-wide standards and requirements for the assessment of ASD. This means that there is currently no consistent standard for diagnosis, which creates a confusing landscape for parents and families as they seek assessment for their child. A recent study conducted by the Cooperative Research Centre for Living with Autism (Autism CRC Ltd, 2016) examined the assessment processes and tools used by practitioners around Australia, and certainly found significant variation in the assessment of ASD.
However, despite lack of consistency, there are best-practice guidelines that set out the ‘gold standard’ for assessment. According to these guidelines, assessment should include developmental, cognitive and language assessments, which gather information across more than one setting, and from more than one source. Diagnosis of Autism Spectrum Disorder is a complex process that should be carried out by professionals who are qualified and experienced in this area. Typically, assessment is conducted by a multidisciplinary team, which most often includes a paediatrician, psychologist and speech pathologist.
Diagnosis must consider both current development and developmental history. Obtaining information regarding current functioning involves observing the child to determine how they play and interact with others. Developmental history is typically obtained through interviewing parents and reviewing previous assessments and reports. There is no single test that adequately gathers all of the information needed to make an accurate diagnosis of Autism Spectrum Disorder. Instead, professionals use a range of standardised tools, with the Autism Diagnostic Interview (ADI-R) and Autism Diagnostic Observation Schedule (ADOS 2) considered ‘gold standard’. In addition, a cognitive assessment (IQ test) may be used to identify developmental strengths and weaknesses, and to rule out a differential diagnosis of intellectual disability.
What age can children be diagnosed with Autism Spectrum Disorder?
Currently, the average age of diagnosis for children is around four years. However, there are many children who are not formally diagnosed until much later – primary school or beyond. This is particularly true for those children considered to be ‘higher-functioning’ who are less likely to be diagnosed at an early age due to their higher cognitive abilities and language skills. Also, girls are typically diagnosed later than their male peers, possibly due to their ability to mask social difficulties in younger years. This is an area currently undergoing considerable research to determine the mechanisms underlying these gender differences in presentation.
There is a growing body of research, however, which has indicated that delays in communication, social skills and motor skills can be recognised as early as 12 months of age. For example, The Olga Tennison Research Centre (OTARC, Latrobe University) have developed screening tools that are purported to be able to identify children younger than two years of age.
What are the main evidence-based interventions frameworks used by professionals working with children with Autism Spectrum Disorder?
Despite the large number of interventions available, there are relatively few that have strong evidence for their efficacy and effectiveness. There are guidelines available that provide valuable information on those that meet strict parameters to be considered evidence-based (see Prior and Roberts, 2012). The strongest evidence for effective treatment for ASD is for behavioural intervention therapy, namely ABA (Applied Behavioural Analysis). There is also a range of therapies that are considered evidence-based, due to emerging evidence, including ESDM (Early Start Denver Model) and Triple P Parenting Programs. Other widely-used therapies are considered ‘best practice approaches’ but currently lack evidence, including teacher training, the Alert Program, and other developmental programs. Beyond these, there are countless other therapies including complementary and alternative medicine and medication treatments for ASD that are more controversial and are not as strongly supported by scientific studies.
There is no ‘one-size-fits-all’ approach to intervention and factors such as cost, time, and availability are important considerations. The best outcomes will come from interventions that include individualised plans that are derived from comprehensive assessment. These plans must be reviewed and modified, as needed, on a regular basis. They should also involve multi-disciplinary collaboration, and be based within a family-centred framework.
How can health professionals assist early childhood services and schools to support children with Autism Spectrum Disorder?
For many children with ASD, the transition to early childhood education and school settings can be challenging and requires careful planning and support. Health and community professionals are well placed to provide information, assist with planning and give ongoing support to ensure the success in these settings.
The success of the initial transition in to educational settings depends enormously on the relationship between the school, family and professionals involved. An open and collaborative relationship will ensure that information is shared in a timely and accurate manner. Early planning for this transition is key as it allows for time to gather relevant information such as previous assessment and therapist reports. It also ensures time for comprehensive orientation for the child at the new setting. A ‘transition plan’ is a useful tool to support this process to focus on gaining a shared understanding of a child’s needs by all involved. This is critical, given that the transition to early childhood or school settings is one of many transitions that a child will experience, as they move through the education system. Health and community professionals can contribute to this process by helping to identify the child’s strengths and specific support needs, as well as provide advice around curriculum planning, environmental supports and maximizing engagement.
The support provided by health and community professionals is also vital beyond the initial transition to facilitate awareness and understanding. This includes providing early childhood and school staff with information about Autism Spectrum Disorders in general, as well as specific information pertaining to that individual child. It is essential that all staff, not just those working directly with that child, receive this information. This ensures a whole-school approach to supporting that child, and ultimately improves outcomes.
On a day-to-day basis, early childhood and school staff require practical information and strategies that will be of benefit to within the classroom with that child. This may include general strategies such as ensuring consistency and predictability in timetabling, with sufficient warning of changes to minimize stress and anxiety in the child. It is also helpful if information is presented so the student can learn by seeing as well as hearing (eg. using visual displays to support verbal information). In addition to these general strategies, the health and community professional can provide valuable information about specific strategies that are beneficial for an individual child.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Australian Advisory Board on Autism Spectrum Disorders. (2007, July 29). Position paper on the diagnosis and assessment of Autism Spectrum Disorders in Australia.
Prior, M., Roberts, J. M. A., Rodger, S., & Williams, K. (2011). A review of the research to identify the most effective models of practice in early intervention for children with autism spectrum disorders. Australian Government Department of Families, Housing, Community Services and Indigenous Affairs, Australia.
Roberts, J. M. A., & Prior, M. (2006). A review of the research to identify the most effective models of practice in early intervention of children with autism spectrum disorders. Australian Government Department of Health and Ageing, Australia.
Latrobe University (2013). Latrobe discovers early signs of Autism.