asd: evaluation & assessment in early intervention2/9/11 1 asd: evaluation & assessment in...
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ASD: Evaluation & Assessment in Early Intervention Teresa A. Cardon, PhD CCC-SLP
Introduction
Teresa A. Cardon, PhD CCC-SLP
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Teresa A. Cardon, PhD CCC-SLP
Note Taking . . . • A = AHA moment – these are the moments
when the light bulb goes off!
• D = Duh! You probably already new it – but a reminder won’t hurt!
• S = Say what?! New and useful information you REALLY don’t want to forget!
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Teresa A. Cardon, PhD CCC-SLP
Facts & Figures . . .
• 1.77 million cases of autism in the US (2006) • New case is diagnosed every 20 minutes • 1 in 110 children being diagnosed (2010) • Boys are 4x more likely than girls • Autism is the fastest growing developmental
disability in the US • Autism receives less than 5% of the research
funding of many less prevalent diseases!
Teresa A. Cardon,PhD CCC-SLP
What is Autism?
• A developmental disorder characterized by marked difficulty in communication and social relations and by the presence of atypical behaviors such as unusual responses to sensation, repetitive movements, and insistence on routine or sameness.
• The Autism Encyclopedia, 2005
Definition:
• DSM-IV – Autism Spectrum Disorder
• Marked impairment ▫ Social Interactions ▫ Communication
• Presence of ▫ Atypical or Repetitive
Behaviors
Teresa A. Cardon, PhD CCC-SLP
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What is Early Intervention (EI)?
• A collection of services provided by public and private agencies and designed by law to support eligible children and families in enhancing a child's potential for growth and development from birth to age three
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Autism & EI
• What have parents been told? ▫ The earlier the better ▫ Intensive intervention (what does this mean?) ▫ EI can help your child become indistinguishable
from their typical peers!
In other words: Parents have very high expectations of EI services!
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The path in EI
• Evaluation and Assessment
• Intervention Services
Transition to Part B
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Trivia Question:
Is there a difference between assessment and evaluation?
Evaluation vs. Assessment IDEA (2004) • Evaluation
The procedures used by appropriate qualified personnel to determine a child's initial and continuing eligibility for services under Part C.
• Assessment The ongoing procedures used by appropriate qualified personnel to identify the 1. child's unique strengths and needs and the services appropriate to meet those needs.
2. resources, priorities, and concerns of the family, 3. the supports and services necessary to enhance the family's
capacity to meet the developmental needs of their infant or toddler with a disability.
• Evaluation 1. Determines eligibility based on four eligibility criteria. 2. Once eligibility is established, further testing may be unnecessary. 3. More simply put, is the child in or out of early intervention?
4. Evaluation occurs for diagnostic purposes
Please note: Evaluation for eligibility does not provide information about what the family or child needs.
• Assessment 1. Drives intervention planning 2. IDEA requires a multidisciplinary assessment by two professionals from two different disciplines. 3. Assessment identifies child and family outcomes that are used in intervention planning. 4. Assessment for intervention planning often requires a process different from testing. 5. Assessment takes place for prescriptive purposes
Differences Between Evaluation and Assessment
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The Four Eligibility Criteria
1. Established disability or “condition” ▫ Autism may already be diagnosed
2. Developmental delay ▫ May indicate at risk for autism
3. Atypical development ▫ Again, may indicate at risk for autism
4. At risk for developmental delay due to biological and/or environmental factors
Formal Evaluation
Pros Cons
The Gold Standard in diagnosis
• Autism Diagnostic Interview – Revised (ADI-R) – an extensive interview with parents that looks at
the child’s developmental history and the pervasiveness of behaviors
• Autism Diagnostic Observation Schedule (ADOS) ▫ A series of presses that serve to observe diagnostic
behaviors
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Diagnosis should be:
• Multidisciplinary
• Administered by trained professionals ▫ Professionals who are also VERY familiar with
typical development and autism!
• Comprehensive
What does the ADOS do?
• Acts as part of a comprehensive autism eval. • Provides specific materials and procedures for
administering tasks • Provides rating scales to quantify behavior • Focuses on the stage of the child and not just the
age • Algorithm score is based on DSM-IV criteria • Results in a classification and NOT a diagnosis
What doesn’t the ADOS do?
• It DOES NOT diagnose autism on it’s own. • It is NOT a treatment measure on it’s own. • It does not adequately address low-functioning
or non verbal adolescents or adults because the materials are not appropriate
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ADOS Modules
• Choose the right module: ▫ Get a language sample (if possible) of at least
10-15 words ▫ Talk to caregiver briefly about how the child
make’s requests and asks for help ▫ Start with a lower module because you can always
add on more tasks if you find it neccessary
ADOS - Administration
The examiner needs to be sufficiently familiar with the ratings and the activities so that he/she can focus attention on observing the individual being assessed, rather than on administration of the tasks. This requires practice in administering the activities, scoring, and observation. Notes need to be sufficiently detailed to be interpretable but not so lengthy that they interfere with administration.
Module 1: Preverbal or single words 1. Free play 2. Response to name 3. Response to joint attention 4. Bubble play 5. Anticipation of routine with
objects
6. Responsive social smile 7. Anticipation of a social
routine 8. Functional and symbolic
imitation 9. Birthday party 10. Snack
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Module 2: Phrase Speech 1. Consturction task 2. Response to name 3. Make-Believe Play 4. Joint Interactive Play 5. Conversation 6. Response to Joint Attention 7. Demonstration Task
8. Description of a picture 9. Telling a story from a book 10. Free play 11. Birthday party 12. Snack 13. Anticiapton of a tourine with
objects 14. Bubble play
Module 3: Fluent Speech, Child/Adolescent 1. Construction Task 2. Make-believe play 3. Joint interactive play 4. Demonstration task 5. Description of a picture 6. Telling a story from a
book 7. Cartoons 8. Conversation/Reporting
9. Socioemotional Questions: Emotions
10. Socioemotional Questions: Social Difficulties/annoyance
11. Break 12. Socioemotional Questions:
friends/loneliness/marriage
13. Creating a Story
Module 4: Fluent Speech, Adolescent/Adult 1. Construction Task 2. Socioemotional
Questions: Work/school 3. Demonstration task 4. Description of a picture 5. Telling a story from a
book 6. Cartoons 7. Conversation/Reporting 8. Daily Living
10. Socioemotional Questions: Emotions
11. Socioemotional Questions: Social Difficulties/annoyance
12. Break 13. Socioemotional Questions:
friends/loneliness/marriage
14. Creating a Story 15. Plans & Dreams
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You are looking for
• The presence of Abnormal Behaviors
• The absence of Normal Behaviors
ADOS Scoring For each item, the clinician gives a score ranging from 0 to 3. A score of 0 is given when "behavior of the type specified in the coding is not present"; a score of 1 is given when “behavior of the type specified is present in an abnormal form, but not sufficiently severe or frequent to meet the criteria for a 2”; a score of 2 indicates "definite abnormal behavior” meeting the criteria specified; and a score of 3 is reserved for "extreme severity" of the specified behavior.
Scoring Considerations • You are supposed to score it right away! • You may only score behaviors you saw during
the assessment • Provide a detailed write up of every activity • Be conservative – if you are debating between
two numbers, go with the lower number • Cultural factors have not been addressed in the
ADOS as of yet!
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ADOS in action! ADOS CLIPS
How accurate is the ADOS?
• The ADOS is best at identifying kids who meet full DSM-IV criteria for autism
• The ADOS identifies kids who have autism from those who do not – but it is not good at separating children with Pervasive Developmental Disorders from Autism
ADI-R The Autism Diagnostic Interview-Revised (ADI-R) is a clinical diagnostic instrument for assessing autism in children and adults. The ADI-R provides a diagnostic algorithm for autism as described in both the ICD-10 and DSM-V. The instrument focuses on behavior in three main areas: qualities of reciprocal social interaction; communication and language; and restricted and repetitive, stereotyped interests and behaviors. The ADI-R is appropriate for children and adults with mental ages from about 18 months and above.
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ADI-R Description The ADI-R is a standardized, semi-structured clinical review for caregivers of children and adults. The interview contains 93 items and focuses on behaviors in three content areas or domains: quality of social interaction (e.g., emotional sharing, offering and seeking comfort, social smiling and responding to other children); communication and language (e.g., stereotyped utterances, pronoun reversal, social usage of language); and repetitive, restricted and stereotyped interests and behavior (e.g., unusual preoccupations, hand and finger mannerisms, unusual sensory interests). The measure also includes other items relevant for treatment planning, such as self-injury and over-activity.
ADI-R Format The interview starts with an introductory question followed by questions about the subject's early development. The next 41 questions cover verbal and nonverbal communication. Questions 50 through 66 ask about social development and play. The next 13 questions deal with interests and behaviors. The final 14 questions ask about "general behavior," including questions about memory skills, motor skills, over-activity and fainting.
ADI-R Format – cont.
This interviewer-based instrument requires substantial training in administration and scoring. A highly trained clinician can administer the ADI-R to the parent of a 3- or 4-year old suspected of autism in approximately 90 minutes. The interview may take somewhat longer (3 hours!) when administered to parents of older children or adults.
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ADI-R Scoring For each item, the clinician gives a score ranging from 0 to 3. A score of 0 is given when "behavior of the type specified in the coding is not present"; a score of 1 is given when “behavior of the type specified is present in an abnormal form, but not sufficiently severe or frequent to meet the criteria for a 2”; a score of 2 indicates "definite abnormal behavior” meeting the criteria specified; and a score of 3 is reserved for "extreme severity" of the specified behavior.
ADI-R Classifications • A classification of autism is given when scores in all
three content areas of communication, social interaction, and patterns of behavior meet or exceed the specified cutoffs, and onset of the disorder is evident by 36 months of age.
• Three versions containing minor modifications: 1) a life-time version; 2) a version based on current behavior; and 3) a version for use with children under the age of 4 years. The algorithm specifies a minimum score in each area to yield a diagnosis of autism as described in ICD-10 and DSM-IV.
How accurate are both tools combined? • ADI-R and ADOS combined have sensitivity and
specficity greater than 75-80% (2006)
• If you only use one instrument (either the ADOS OR the ADI-R), specifity is lost and falls to less than or equal to 50%
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Diagnosis of Autism
• Multidisciplinary – ▫ Who is on the team?
▫ Why not go solo as an SLP? Can you go solo?
SLP’s play a key role -
• We are the communication experts! ▫ Impairments in social interaction and
communication were found to be evident by 2 years, but restricted and repetitive activities and interests were not evident in some children until closer to 3 years of age.
ASHA Guidelines • Speech language pathologists who acquire and
maintain the necessary knowledge and skills can diagnose ASD, as part of a diagnostic team in schools or in other multidisciplinary collaborations, and should make appropriate referrals to rule out other conditions and facilitate access to comprehensive services. The speech language pathologist who has been trained in the reliable and valid use of diagnostic and assessment tools as well as in the clinical criteria for ASD may be qualified to diagnose these disorders as an independent professional.
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Screening Tools
• The Checklist for Autism in Toddlers (CHAT) ▫ Modified Checklist for Autism in Toddlers (M-
CHAT) • Autism Screening Questionnaire • Australian Scale for Asperger’s Syndrome • Childhood Autism Rating Scale (CARS)
Systematic Observation of Red Flags for ASD: Early Indicators (Wetherby et al. 2004)
• Difficulty with Reciprocal Social Interaction • Unconventional Gestures • Unconventional Sounds and Words • Repetitive Behaviors and Restricted Interests • Emotional Regulation
Red Flag Checklist
Comprehensive Eval Should Include:
• Developmental & Health History • Psychological Assessment • Communicative Assessment • Medical Evaluation • Consults regarding fine/gross motor skills • Other suspected areas of concern ▫ i.e. Neuropsychological
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Speech & Language Evals
• PLS – Preschool Language Scale • CELF – Preschool – Clinical Evaluation of
Language Fundamentals • CASL – Comprehensive assessment of Spoken
Language • PPVT – Peabody Picture Vocabulary Test • EVT – Expressive Vocabulary Test • MacArthur • Goldman Fristoe Test of Articluation
Preschool Language Scale
Clinical Evaluation of Language Fundamentals
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Comprehensive assessment of Spoken Language
Peabody Picture Vocabulary Test
Expressive Vocabulary Test
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MacArthur – Bates Communicative Development Inventory
Goldman Fristoe Test of Articulation
Don’t Forget!
• A secondary associated feature for autism:
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What to look for -
• Higher expressive than receptive • Echolalia • Oral motor difficulties • Communicative intent • Loss of language • First words ▫ Type and intent
Developmental Evals
• CSBS – Communication & Symbolic Behavior Scale
• Rossetti • Vineland • Mullen
CSBS - Communication & Symbolic Behavior Scale
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Rossetti
Vineland
Mullen Scales of Early Learning
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What to look for -
• Red Flags • Interaction • Communicative intent • Caregiver comfort • Delays
TECHNICAL ASSESSMENT OF FORMAL INSTRUMENTS:
Pros Cons
From Evaluation to Assessment
• Once eligibility is established, IDEA requires that the child’s current level of functioning be determined by a multidisciplinary assessment.
• Two or more professionals from at least two disciplines must participate in the multidisciplinary assessment to determine current level of functioning.
• The purpose of the multidisciplinary assessment is to identify the unique strengths and needs of the child.
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Upon arrival - look around: Informal Assessment
• Observation ▫ Attachment/interaction with caregiver ▫ The environment ▫ Interaction with the environment ▫ Play with toys/other objects ▫ Transitions ▫ Bids for attention ▫ Parent reactions to child
• Language Sample
Prescriptive Assessment • Goal: To produce a comprehensive survey of a child’s present level
of skill across and/or within developmental domains ▫ Multimeasure: Use of several measures, particularly several
different types of measures ▫ Multisource: Must rely on multiple sources of information (e.g.,
child, parent, own observations) ▫ Multidomain: Assessment must be comprehensive and include
multiple communication domains ▫ Multipurpose: Screening, identification, comprehensive
assessment with a link to intervention, programming, evaluation ▫ Multicontext: Assessments should capture a child’s authentic
behaviors in routine circumstances. (e.g., did the child get any sleep the night before?)
Prelinguistic Assessments for Infants
• Prelinguistic communication describes the use of facial expressions, gestures, and nonspeech vocalizations that typically precede the development of language.
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Prelinguistic Communication • Prelinguistic
communication begins in infancy
• Prelinguistic communication and social development are closely linked.
• Prelinguistic communication is tied to later language development.
What is prelinguistic communication?
• Non-Intentional/pre-intentional – ▫ Lack evidence of deliberate
communication BUT ▫ Often have an effect on the
adult ▫ Result in communication
because adult attributes meaning to child’s behavior
• Intentional ▫ Those produced by the child
with the intent to convey a message to the partner
▫ Non-verbal or vocalized behaviors become increasingly clear
Warning: the difference is not as easy to distinguish as you might think!
Nilla wafers
toss game (forward to 1 minute)
Transdisciplinary Play Based Assessment Vs. Traditional Assessment TPBA • Natural environment • Rapport with examiner and
accessibility to parent • Flexibility in testing • Holistic assessment • Every child is testable
Traditional • Unnatural environment • Unfamiliar examiner • Biased tests • Lack of functional assessment • Norm and criterion referenced
data not always appropriate for low functioning children
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Why use TPBA? • Transdisciplinary play-based assessment is a
natural, functional approach to assessment and intervention
• Parents are actively involved throughout the process • The model is less stressful for the child, less
intimidating to the family • Results in meaningful information that readily
translates into objectives and strategies for intervention
• Meets legislative and professional requirements while addressing the diverse needs of the children
Transdisciplinary Play-Based Assessment Includes: • Family Tailored Assessment • Curriculum-Based Assessment • Adaptive-to-Disability Assessment • Process (PR) Assessment • Norm-Based Assessment (NB) • Judgment-Based Assessment (JB) • Ecological/Environmental Assessment • Interactive Assessment (INT) • Direct Observation of Behavior (DOB)
Play based assessment/observation
• IJON – Developmental Play Assessment • TDEC – Developmental Play Assessment ▫ What is the child doing? Interacting with toys? Interacting with parent? ▫ What is the adult doing? Engaged with child? Comfortable with play?
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Families’ input about their priorities and concerns is required
when they are first referred to the program in preparation for evaluation or assessment for developing the priorities for the IFSP continually, to ensure that support is effective and
responsive to changing priorities and concerns
Family-Tailored Assessment (or . . . things to ask before you show up!)
• What questions or concerns do others have? (i.e., sitter, preschool, etc.)
• Are there other places where we should observe your child? (Get place, contact person, what to observe)
• How does you child do around other children? • Where would you like the assessment to take place? • What time of day? • Are there others who should be present in addition
to parents and staff? • What are your child’s favorite toys or activities that
will help him/her be comfortable, motivated, and become focused?
Family-Tailored Assessment (cont.)
• Which roles would you find most comfortable during assessment: ▫ sitting beside your child; offering comfort and
support to your child ▫ helping with activities ▫ exchanging ideas with the assessor ▫ carrying out activities to explore your child’s
abilities ▫ prefer for assessor to handle and carry out all
activities
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Families’ Concerns and Priorities • Assessment of a family’s resources, concerns,
and priorities should: 1. be voluntary on the part of the family. 2. be conducted by personnel using appropriate methods and procedures. 3. be based on information obtained in a personal interview with the family. 4. incorporate the family's description of its resources, priorities, and concerns regarding the child's development.
Questionnaires: Advantages and Disadvantages
▫ Questionnaires can be used to determine a family’s concerns and priorities ▫ Advantages Less time-consuming than interviews May be preferred by some fathers ▫ Disadvantages Not interactive No opportunity to discuss and expand responses
Interviews: Advantages and Disadvantages ▫ Interviews can be used to determine a family’s
concerns and priorities ▫ Advantages Interactive May be preferred by mothers ▫ Disadvantages Lack of structure Time-consuming
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Caregiver Assessment of Activities/Routines • Early intervention programs in all states require
some type of assessment of a child’s “natural environment” and the activities/routines in which a child is typically expected to participate. This might include: ▫ Caregiver assessment of a child’s performance within
an activity/routine ▫ Caregiver identification of activities/routines that are
of concern ▫ Caregiver satisfaction with a child’s participation in
activities/routines ▫ Extent to which a child’s performance in an activity/
routine might meet a caregiver’s expectations
Routine Problem (n=134) Count (%)
Bathing 111 (82.8)
Morning Routine 90 (67.2)
Evening Routine 69 (51.5)
Mealtime 86 (64.2)
Play 65 (48.5)
Leaving the House 40 (30.0)
Running Errands 33 (24.6)
Family Routines 43 (32.1)
Physical Activities 42 (31.3)
Family Outings 45 (33.5)
Caregiver’s of children with autism: Reports of problem routines
(Cardon & Wilcox, in press)
Information/Training Source Count (%)
Formal Workshops 31 (23.1)
Local Expos/Fairs 24 (17.9)
Local Lending Library 32 (23.9)
Program Specific Training 11 (8.2)
EI Personnel Provided Information 65 (48.5)
EI Personnel Referred to Resources 45 (33.6)
Help from another Caregiver 52 (38.8)
Other 0--
Caregiver support sources (for AT specifically)
(Cardon & Wilcox, in press)
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Learning about Activities/Routines and Caregivers’ Priorities and Concerns
• There are multiple methods and formats that may be used to gather information from caregivers – interview is most common
• Identify the following: ▫ Activities and routines that are not going well for the
caregiver and have been identified as high priority by the caregiver
▫ Activities and routines in which a child’s communication skills are a primary barrier to participation
▫ Activities and routines that are going well and can provide a context for learning new communication skills (i.e., embedding learning and practice opportunities)
12 Key Activities/Routines
1. Morning routine (getting up, getting dressed, etc.) 2. Bath time 3. Nighttime (getting ready for bed, going to bed, sleeping) 4. Mealtime (appetite, level of assistance) 5. Playtime (indoor play with family members, other caregivers, friends) 6. Story time 7. Outside play (riding a bike, playing outside, playing on playground
equipment, swimming) 8. Chores (cleaning, preparing meals, watching TV, caring for pets, etc.) 9. Leaving the house to go somewhere (e.g., getting ready to go) 10. Travel time (in the car) 11. Running errands (grocery store, mall/store shopping, banking, wash/
cleaners) 12. Community outings (visit a friend/relative, eat at a restaurant/fast food,
go to museums, amusement parks, zoo, etc.)
A Format for Caregiver Assessment
Caregiver Assessment/P. Campbell/6-2009REV/page 1 of 4 Thomas Jefferson University, Philadelphia
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Tips for Conducting the Interview
• Remember, it is a conversation • You may need more than one session to gather
all the information • You may need to talk to more than one caregiver,
particularly when young children are receiving care outside the home
• Be sure and get a rating of expectations and satisfaction, they are not the same concept!
Goals of Routines Based Assessment • Key areas of discussion with caregivers include ▫ Activities and routines that are not going well ▫ Activities and routines that are not going well and
communication appears to be the primary barrier for participation ▫ Activities and routines that are going well and can
serve and a context for learning new communication skills
• Goals of early communication interventions are to ▫ Enhance participation in activities/routines ▫ Embed learning opportunities for acquiring functional
skills within activities/routines ▫ Scaffold activities/routines to provide learning and
practice opportunities for more complex skills
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Practice a Caregiver Assessment
• Look over the form • Role play (caregiver, interventionist) • Remember to ask about the Satisfaction &
Expectations!
• How will this assessment guide your intervention? ▫ Write down three goals!
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Remember, it’s a TEAM approach!
T: Talk to the family not at them!
E: Everyone needs to be heard!
A: Assess what the most functional goals are for the family and the child!
M: Monitor progress and keep it motivating!
Why is early identification so important? • Symptoms are often measurable by 18 months of
age (Baird et al. 2000)
• Research indicates that intervention provided before age 3 years has a greater impact than that after age 5 (Fenske, Zalenski, Krantz, & McClannahan, 1985; Harris & Handleman, 2000).
Research suggests that earlier initiation of
services is associated with improved child outcomes.
Timely evaluation and
assessment
Identify family resources,
priorities, and concerns
Initial IFSP meeting
