Assessment of the Core Features of ASD

Behaviors between birth and 1 year of age

Behaviors from 1 to 3 years of age

Limited ability to anticipate being picked up

Abnormal eye contact

Low frequency of looking at people

Limited range of facial expressions

Little interest in interactive games

Limited social referencing

Little affection towards familiar people

Limited sharing of affect/enjoyment

Content to be alone

Limited interest in other children

Little interest in interactive games

Limited social smile

Limited functional play; no pretend play

Low frequency of looking at people

Limited motor imitation

Many instruments are now available for the assessment of ASD in young children and will be highlighted in the instruments listed below .

Observational methods

One of the most commonly used observational measures in the assessment and diagnosis of ASD is the Autism Diagnostic Observation Schedule (ADOS; Lord et al. 1999). The ADOS is a semi-structured standardized assessment instrument that creates many opportunities for an examiner to observe any social difficulties through the use of play and activities designed to foster social communication with a child such as blowing bubbles, looking at pictures, and reading stories. The ADOS comprises four different modules, which have been carefully designed to match the language ability and developmental level of the child, ranging from preverbal/single words to fluent speech. A toddler version of the ADOS (ADOS-T; Luyster et al. 2009) has been developed to ascertain deficits in children under 24 months . All versions of the ADOS can be administered in 30–45 min. For younger, more cognitively and verbally impaired children, key social behaviors assessed include showing, pointing, coordination of gaze, frequency of vocalizations directed to others, and joint attention. For older children with fewer to no verbal or cognitive limitations, key social behaviors assessed include insight into the nature of interpersonal relationships, the amount of reciprocal social communication, and quality of social response. All individuals, no matter their age, verbal, or developmental level are also assessed in the following social skill areas: unusual eye contact, facial expressions directed to others, gestures, shared enjoyment in interaction, quality of social overtures, and overall quality of rapport.

The Childhood Autism Rating Scale, Second Edition (CARS2; Schopler et al. 1988; Schopler et al. 2010) is an observational rating scale that is used to assess behaviors associated with ASD in children 2 years and older. The CARS2 consists of 15 items on which the child is rated by a trained clinician using a 4-point scale based on their interactions with and observations of the child . The ratings take into consideration the frequency, intensity, peculiarity, and duration of the behavior. There are three forms included in the CARS2: the Standard Version Rating Booklet (CARS2-ST) appropriate for children under 6 years of age, the High-Functioning Version Rating Booklet (CARS2-HF) appropriate for children over 6 years of age, and the Questionnaire for Parents or Caregivers (CARS2-QPC) which aids in scoring both the ST and HF versions. Specific social skills assessed using the CARS2 include interpersonal relationships, emotional responses, and imitation .

The Early Social Communication Scales (ESCS; Mundy et al. 2003) is an observational measure designed to assess nonverbal social-communication skills. The three main behaviors of interest are joint attention behaviors (i.e., does the child use nonverbal behaviors to share their experiences pertaining to objects and events), behavioral requests (i.e., does the child use nonverbal behaviors to request help during events or to obtain objects), and social interaction behaviors (e.g., does the child engage in turn-taking interactions with others). The assessment also differentiates whether the behaviors are child-initiated versus responses to the examiner’s bids .

The Communication and Symbolic Behavior Scales Developmental Profile (CSBS DP; Wetherby and Prizant 2002) is a screening tool administered by a trained professional that utilizes direct observation to assess social communication skills in young children. The social domain is divided into three major sections that assess specific behaviors: (1) emotion and eye gaze (gaze shifts, shared positive affect, gaze/point following), (2) communication (rate of communicating, behavior regulation, social interaction, and joint attention), and (3) gestures (conventional gestures, distal gestures) .

Other standardized, normed assessments of related social abilities include measurements of face recognition (NEPSY-II, Korkman et al. 2007) and face memory (Children’s Memory Scales: Face Memory Subscales; Cohen 1997) .

Interview formats

The Autism Diagnostic Interview-Revised (ADI-R; Lord et al. 1994) is an extended parent interview used in the assessment of ASD that typically takes 1.5 to 2.5 h to administer by a trained professional. The ADI-R consists of 93 items, 17 of which are grouped into the “social development and play” category. Specific items from this category are then chosen for the ADI-R diagnostic algorithm, which mirrors DSM-IV-TR criteria in the social domain for Autistic Disorder and Asperger’s Disorder. Thus, DSM-IV-TR criterion (a) “marked impairment in the use of multiple nonverbal behaviors” is assessed by questions probing for a child’s use of direct gaze, social smiling, and range of facial expression; criterion (b) “failure to develop peer relations” is assessed by questions which ask about the child’s interest in and response to other children, group play with peers, and friendships; criterion (c) “lack of spontaneous seeking to share enjoyment” is assessed by questions which probe whether a child is actively showing things of interest, offering to share things with others, or seeking to share his/her own enjoyment with others; criterion (d) “lack of social emotional reciprocity” is assessed by questions which probe for quality of social overtures, inappropriate facial expressions (i.e., those that are incongruent to the situation and indicate a lack of understanding of others’ affective states), appropriateness of social response, and the act of offering comfort when others when are hurt or ill .

The Vineland Adaptive Behavior Scales, Second Edition (VABS-II; Sparrow et al. 2005) is a 30–45 min parent interview that assesses a child’s adaptive functioning in the domains of communication, daily living skills, socialization, motor skills, and maladaptive behaviors. The VABS-II is used frequently with children suspected of ASD, intellectual disability, and developmental delay. Within the socialization domain, children are assessed in the areas of interpersonal relationships, play and leisure time, and coping skills .

Questionnaires

Questionnaires that assess social functioning can be very useful in assessing the social domain. The Social Communication Questionnaire (SCQ; Berument et al. 1999; Rutter et al. 2003a) is a 40-item “yes/no” questionnaire that can be completed by a parent or caregiver in about 10 min. The questions directly mirror those of the ADI-R and provide evidence of social deficits as well as challenges in communication and behavior. The SCQ has both Lifetime and Current forms which can be used to focus on a child’s developmental history or present functioning, respectively, in the three core domains of impairment in ASD.

The Social Responsiveness Scale (SRS; Constantino 2002) is a 65-item scale that assesses the severity of symptoms associated with ASD, has both parent and teacher report forms, and can be completed in about 15 min. Behaviors are divided into the following five subscales: receptive, cognitive, expressive, and motivational aspects of social behavior, as well as autistic preoccupations. Besides subscale scores, the SRS generates a total score indicative of overall social impairment .

The PDD Behavior Inventory (PDDBI; Cohen et al. 2003) is a parent/teacher rating scale that was designed to aid professionals in evaluating the treatment progress of children with ASD and related disorders. The PDDBI comes in a standard form (124 items; 20–30 min) and extended form (180–188 items; 30–45 min), depending on the needs of the assessor. The standard form focuses on behaviors specific to ASD in the three core domains and the extended form includes behaviors that are not solely related to ASD, such as aggression and specific fears . Key social skills assessed include social pragmatics and social approach .

The Infant/Toddler Social Emotional Assessment (ITSEA; Carter and Briggs-Gowan 2000) is a 166-item parent/caregiver scale used to assess developmental strengths and weaknesses in young children. It may be completed by a parent/caregiver or administered as a structured interview. The ITSEA comprises four broad domains: externalizing, internalizing, dysregulation, and competence. The competence domain includes the social skills of compliance, attention, imitation/play, mastery motivation, empathy, and pro-social peer relations. Elevated scores in any subdomain are classified as “Of Concern” and may indicate the need for early intervention services.

The Social Skills Improvement System Rating Scales (SSIS; Gresham and Elliott 2008) measures social skills, problem behaviors, and academic competence in children ages 3–18. It may be completed by a parent, caregiver, or by the student. The social skills of communication, cooperation, assertion, responsibility, empathy, engagement, and self-control are assessed. An “Autism Spectrum” subscale was added to the newest published version .

Experimental approaches

A wide variety of experimental measures have been employed to quantify the social functioning of children in ASD. A description of all the behavioral, psychophysiological, and imaging paradigms used to characterize the social challenges noted in ASD is beyond the scope of this chapter, but a few experimental measures will be briefly described to provide the reader with some insight into the tools available to scientists .

Atypical eye gaze is one of the primary features noted in ASD. Eye-tracking technology has elucidated significant differences between the use of gaze in children with ASD and matched controls. Many studies indicate that while typically developing children focus on the eyes of others, children with ASD tend to focus instead on the mouth, body, or even objects (Klin et al. 2002). Findings using this technological approach have indicated the utility of eye-tracking paradigms to assess social impairments in ASD and suggest that a toddler’s failure to orient to a caregiver’s gaze is an early disruptor of socialization and language acquisition (Jones et al. 2008).

As described above, children with ASD show reduced attention to information in the social world. Dawson et al. (1998) illustrated this key deficit in a novel experiment in which children with autism were compared to children with Down syndrome and typical development in their ability to orient towards auditory social stimuli and nonsocial stimuli. Results indicated that children with autism were significantly more impaired than the other children in responding to both types of stimuli, and their lack of response to social stimuli was even more pronounced. In this social orienting assessment a child sits across from an experimenter and is presented with auditory stimuli. From four locations around the room, a second experimenter delivers social (e.g., calling child’s name, clapping hands) and nonsocial (e.g., car horn honking, kitchen timer) sounds. Each sound is presented for approximately 6 s, at the same decibel level, and once in the child’s left and right visual field and once 30 degrees behind the child to the left or right. The number of times the child orients to the sound is summed .

Since DeMeyer and colleagues’ first report of imitation deficits in ASD (DeMeyer et al. 1972), a number of experimental tools have been developed to assess imitation abilities in young children with ASD (Smith et al. 2006). Of the experimental measures, the Motor Imitation Scale (MIS; Stone et al. 1997), a 16-item scale based on Piaget’s developmental sequence, shows good psychometric properties . Several studies with ASD have also utilized the gestural imitation battery from Uzgiris and Hunt’s sensorimotor scales (Uzgiris and Hunt 1975) .

The assessment of empathy has been assessed experimentally using the response to distress task (Sigman et al. 1992). In this paradigm, while seated across from a child, the experimenter pretends to bang a finger with a toy hammer and then proceeds to cry for a short period of time. The amount of time the child spends attending to the crying experimenter is tallied offline by coders blind to child group status. Children with ASD have been found to attend less to crying experimenters than their typically developing peers (Sigman et al. 1992).

The use of facial expressions in ASD has been assessed with the Maximally Discriminative Facial Movement Coding System (MAX; Izard 1979). Results from the use of this assessment instrument indicated children with ASD were more neutral in their facial expressions and displayed more ambiguous expressions than comparison children (Yirmiya et al. 1989) .

Several experimental measures have been developed to assess “theory of mind” abilities in young children with ASD. In the Sally and Anne task (Baron-Cohen 1985) the child observes a model put an object in one location and then watches the object be moved by another without the model being aware of the move. The child must then identify where the model would look for the object. The Smarties task (Perner et al. 1989) calls one’s own experience into the scenario. A child is shown a Smarties box that contains another object and then asked what others would think would be in the box. The Charlie Test (Baron-Cohen et al. 1995) utilizes a nonverbal approach in which a child looks at a picture of Charlie looking at one of four tasty treats. The child must infer from Charlie’s gaze which sweet Charlie likes the most. Children with ASD show impairments in these three theory of mind tasks .

Face processing impairments have been described using electrophysiological paradigms. Electrophysiological studies require only passive viewing, rendering language and behavioral responses unnecessary, and making these paradigms appropriate for young children of all functioning levels. The presentation of faces elicits a well-described pattern of activation in the brain, or event related potential (ERP). The latency and amplitude of select ERP components, such as the face specific, negative going wave that is observed approximately 170 ms after viewing a face can then be analyzed as a measure of face processing brain activation. Findings from studies employing these paradigms indicate individuals with ASD show atypical activation to neutral and fearful faces (Dawson et al. 2004; Webb et al. 2006) and upright and inverted faces (McPartland et al. 2004) .

There are many options available for clinicians and scientists to utilize in the assessment of social abilities in young children with ASD. These measures range from standardized questionnaires with good psychometric properties to experimental, psychophysiological paradigms conducted with small samples and limited control groups. Given the heterogeneity in presentation of children with ASD, broad-based measures as well as assessments focused on specific aspects of social cognition are all needed to contribute to the understanding of the social deficits in ASD .

Communication Domain

Definition

A second core domain of ASD is communication. Communication is a broad term that refers to the giving and receiving of information through spoken language and sounds, written language, gestures, sign language, and body language (Paul and Wilson 2009). It is important to consider the different components of communication as the evaluation of communication, language, and speech overlap and can involve their own processes and assessment measures.

Impairment in communication can range from total lack of language, or an absence of an apparent desire to communicate, to excessive or formal speech with poor reciprocal conversation abilities. The DSM-IV-TR (APA 2000) diagnostic criteria for the communication impairment component of Autistic Disorder requires at least one of the following: (a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime); (b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others; (c) stereotyped and repetitive use of language or idiosyncratic language; and (d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.

Key features in the communication domain

The communication domain encompasses a large variety of speech, language, communication, and play-related deficits. Speech delays or language deficits, particularly difficulties with expressive language, are the most common concerns shared by parents about children between age 1 and 5 years (Filipek et al. 1999). Other common communication concerns that parents report include: difficulties with sharing needs, not pointing or using other common gestures such as waving, and regression in the use of words (Filipek et al. 1999). Early communication deficits also include accompanying behaviors or difficulties with pragmatics such as lack of appropriate gaze integrated with communication, lack of reciprocal (alternating to-and-fro pattern) vocalizations between child and caregiver, lack of or decreased use of gestures to communicate wants and needs, and delayed babbling after 9 months of age (Johnson et al. 2007). Table 4.2 lists several communication-based red flags that warrant immediate evaluation for possible ASD as identified by the American Academy of Neurology and Child Neurology Society (Filipek et al. 2000b).

Table 4.2

Red flags in the communication domain

Red flags
No babbling, pointing, or other gesture by 12 months
No single words by 16 months
No two-word spontaneous (non-echolalic) phrases by 24 months
Loss of language or social skills at any age

In addition to the early signs of communication deficits, there are several other communication, language, or speech difficulties observed in ASD. For example, some children use spoken language, but demonstrate atypical use of language, such as employing more formal or articulated speech, echolalia (immediate or delayed repetition of others’ speech), or atypical tonal or rhythm qualities. Some children also have difficulties with using correct pronouns or may use neologisms (a made up word) or literal idiosyncratic phrases. Children who have adequate speech may show communication deficits through impairment in initiating or sustaining conversations with others or staying on topic of mutual interest (Filipek et al. 1999; Johnson et al. 2007).

Regression of language, speech, or communication is another significant indicator of ASD. It is estimated that 25 to 30 % of children with ASD have exhibited language for some period of time but then stop, typically between 15 and 24 months of age (Tuchma and Rapin 1997; Turner et al. 2006). Regression can be sudden or gradual and can be accompanied by other losses such adaptive functioning abilities, loss of communicative gestures (e.g., pointing), or loss of social skills such as eye contact (Rogers 2004).

Play skills are also captured under the communication domain of ASD. Some children with ASD may play with toys, miniature objects, or dolls in a repetitive and mechanical way and demonstrate less flexible use or representation of objects. Other children may use toys or objects appropriately in a functional manner, but struggle with engaging in creative and imaginative play such as having dolls or action figures interact as agents or pretending that a block is a cup. Very verbal children may create fantasy worlds where certain topics become the center of their play and they struggle to play anything else (Filipek et al. 1999).

To capture the wide variety of possible communication deficits in ASD, multiple assessment procedures including observations, parent report, questionnaires, standardized language assessments, and experimental methods can be utilized. The following is a brief summary of assessment tools that are available to evaluate a child’s overall communication abilities, specific communication and language-related strengths and weaknesses, and possible red flags and indicators of ASD.

Assessment of the communication domain

As stressed previously, the evaluation of communication skills and deficits should ideally include a comprehensive, multidisciplinary assessment that involves behavioral observations, parent report and interview, questionnaires completed by individuals familiar with the child, and standardized instruments to assess abilities. Additionally, if there are red flags within the domain of communication, it is especially important for the child to be evaluated by a speech and language therapist or pathologist and to undergo an audiological evaluation if indicated, as these professions are highly specialized in the assessment of hearing, communication, language, and speech. Next is a review of possible tools that can be used for the assessment of the communication domain of ASDs.

Observational methods

Structured behavioral observations and standardized measures of behavior provide specific opportunities for children to demonstrate their communication, speech, language, sign and gesture abilities. More specifically, observations allow clinicians to look for the presence or absence of a variety of communication skills by creating opportunities for conversation, social interaction, play or other scenarios (in clinical or laboratory settings) where communication of some sort would typically be present. There are very few standardized observational measures designed specifically for the assessment of the communication domain of ASD. Below is summary of the most well-known measures to date.

As described above in the social domain, the ADOS examines components of communication in addition to the social and behavioral domains. Language and communication use, speech, pragmatics, and play are all coded after careful administration of the instrument. First, the ADOS provides opportunity to assess a child’s overall level of language (i.e., does he/she use mostly single words, no words, two-three word phrases, or phrase speech), the amount of verbal social overtures and verbal maintenance of the examiner’s attention, and whether echolalia is present (the immediate or delayed repetition of the last statement or series of statements heard). Conversation ability is also assessed by focusing on whether the child verbally shares information, asks questions, engages in social chat, and how well he/she is able to build and carry on to-and-fro conversations. Second, the ADOS allows the examiner to listen to aspects of speech patterns and abnormalities that are associated with ASD such as flat or exaggerated intonation, little variation in tone or pitch, unusual volume, or a slow or quick rate of speech. Additionally, the examiner evaluates the presence of highly repetitive utterances with consistent intonation patterns (stereotyped or idiosyncratic use of words). Third, the ADOS assesses for pragmatic aspects of communication. The use of gestures such as pointing, as well as descriptive (holding arms out to indicate size), conventional (clapping for “well done”), instrumental, or informational gestures (shrugging, head nodding, or head shaking) are observed. Fourth, functional and imaginative/creative play are also assessed through observations and interactions during the ADOS. The examiner looks for whether the child spontaneously plays with a variety of toys, how the child plays with the toys (i.e., uses the toys in a cause-and-effect or functional manner, imitates use of toys, or uses figures as agents of action), and how flexible and creative is the use of toys. Overall, the ADOS is considered to be a “gold standard” for the observational and interactive assessment of ASD and provides an opportunity to obtain a snapshot of a child’s overall communication skills.

As described above, The Childhood Autism Rating Scale, Second Edition (CARS2) provides observational information regarding ASD. In regard to the communication domain the CARS2 provides a measure of both verbal and nonverbal communication skills including functional speech, echolalia, pronoun reversal, peculiar words or jargon, and gestures such as pointing. Similarly, as described above, The Early Social Communication Scales (ESCS) is a structured observation-based measure designed to assess nonverbal social communication skills in young children while The Communication and Symbolic Behavior Scales (CSBS) uses direct observation and parent interview to assess for communication impairments and delays in addition to examining social communication skills. The CSBS has 18 subscales that measure various aspects of communication including communicative functions, use of gestures and vocals, gaze shifts, affect, and reciprocity, as well as four scales that measure symbolic development such as constructive and symbolic play. The Developmental Play Assessment Instrument (Lifter 2000) taps into the play skills component of the communication domain of ASD by investigating a child’s level of pretend play and the frequency of a variety of play activities. The Play Assessment Scale (Fewell 1986) is a play-based measure that can be administered by a teacher, parent, researcher or another adult familiar with the child and the measure. It consists of two conditions: one involves examining the child’s spontaneous play with one set of toys, while the other entails eliciting “a higher level” of play behavior in response to verbal prompts (e.g., will the child offer a fork in response to an “I’m hungry” prompt).

There are also several standardized assessment options that offer direct assessment of communication and language and can provide valuable information about a child’s current abilities and weaknesses. These measures are typically administered in a clinical or research setting and are administered by trained psychologists, school psychologists, or speech and language professionals. The following is a brief summary of a small selection of the many communication and language assessment measures that are commonly used in the assessment of communicative abilities in ASD. The Comprehensive Assessment of Spoken Language (CASL; Carrow-Woolfolk 1999) is an oral assessment of language for ages 3 to 21 that measures lexical/semantic language, syntax, supralingustic abilities, and pragmatics. The Clinical Evaluation of Language Fundamentals—Preschool, 2nd Edition (CELF-P2; Semel et al. 2003) and The Preschool Language Scales, 5th Edition (PLS-5; Zimmerman et al. 2011) also assess a broad range of language skills for preschool children. The Peabody Picture Vocabulary Test—Fourth Edition (PPVT-4; Dunn and Dunn 1997) assesses receptive language skills through the use of a variety of pictures while its co-normed companion, The Expressive Vocabulary Test, Second Edition (EVT-2; Williams 2007) tests expressive vocabulary and word retrieval. The Test of Early Language Development—Primary: Third Edition (Newcomer and Hammill 1997) also measures receptive and expressive language and yields an overall spoken language score.

Interview format

Parents are often the first to identify problems with speech or language and parents are the best resource for information about their child’s language milestones, current abilities, any language loss, as well as social communication and pragmatic skills. The ADI-R, described above in social assessments, dedicates 21 items to investigating language and communication skills and deficits. Clinicians using the ADI-R assess a child’s overall level of language by asking questions about the child’s comprehension of spoken and overall language ability. Items on the ADI-R address the presence of abnormal language such as stereotyped and repetitive patterns of verbal and nonverbal language (e.g., neologisms, idiosyncratic language, verbal rituals) . The ADI-R interviewer also asks parents to describe their child’s speech and various deficits that could be present (e.g., articulation/pronunciation difficulties, intonation/rate/tone volume of speech, pronominal reversal). Social aspects of communication such as the frequency and quality of social chat, reciprocal conversation, and inappropriate statements are investigated. Clinicians using the ADI-R also gather information about nonverbal aspects of communication. For example, parents are asked whether their child uses another’s body to communicate (e.g., using another person’s hand to perform some sort of task like opening a door). The frequency and quality of gestures such as pointing to express interests, nodding and head shaking, and conventional and instrumental gestures (e.g., blowing a kiss, clapping, finger to lips) are also discussed.

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