If a child under age 6 has a new diagnosis of ASD, a referral to a Neurologist should be seriously considered. The parents may wish to have a full neurologic workup to assess for genetic abnormalities, seizures, and/or neurophysiological problems although many would feel a neurological consult is not critical since it is not necessary for the diagnosis. When the client has any of the following additional conditions or symptoms, however, a referral to a Neurologist is recommended:

If a client has any of the following conditions, a referral to a psychiatrist is in order:

Whenever the client presents with moderate to severe behavior problems, and especially when those behaviors are self-injurious or threaten the safety of others, it is essential to refer or consult regularly with a Board Certified Behavior Analyst (BCBA ) for either an analytical Functional Behavior Analysis (FBA ) or for intervention services as discussed further under School or Home below.

Unfortunately, many people are not fully aware of the importance of involving a BCBA in the treatment of moderate to severe behavior problems and such an omission readily results in delay or ultimate failure of effective behavioral management. It is truly sad when professionals who are incompetent in the treatment of moderate to severe problem behaviors foolishly embark on unsound and even harmful strategies when their professional training and credentials are actually in a completely different discipline.

In general, although some alternative treatments have their place, therapies without a clear research base should not be used. Methods such as simple dietary restrictions, “neurological massage,” and isolated sensory treatments that are promised to families as an alteration or cure for behavior problems are misleading at the least. These “therapies” may not directly harm their clients; however, indirect harm is done when families waste time and money that could be spent on therapies that work. “Treatments” such as hyperbaric chambers, chelation, unsupervised supplements and off-label medications, and punitive behavior measures can be extremely harmful, abusive, or potentially fatal. Frankly, the world will be a happier place for individuals with ASD and their families when professionals who are unqualified to treat problem behaviors, and erroneously lead the family toward a harmful treatment, rightly face severe disciplinary consequences including but not limited to legal and professional sanctions as a result of the behavioral and psychological harm inflicted on clients and their families when such professionals practice beyond their domain of competency. Many times clients have suffered significantly, even developing symptoms of Post-Traumatic Stress Disorder, through the needless and ignorant practice of professions unqualified to treat problem behaviors. Such practice has to stop.

An analytical FBA is a series of experimental procedures designed to validly determine the cause of problem behavior(s) whereby a behavior is maintained by either positive (tangible, social, or internal/automatic) reinforcement or negative (escape or avoidance of something undesirable) reinforcement (Iwata, Vollmer, & Zarcone, 1990; Iwata et al., 1994). Since reinforcement is defined as a consequence that increases the probability of the preceding behavior reoccurring, a problem behavior is being reinforced by something and a necessary step in treating the problem behavior is validly determining that causal variable(s). Note that reinforcement is not the same as a reward or prize and this ABA definition of reinforcement is objectively based purely on mathematical principles of probability. If a behavior persists or increases, it is being reinforced. Once the reinforcing consequences are identified, effective steps can be taken to reduce or eliminate those problem behaviors and cultivate more adaptive responses for the benefit of the individual and their loved ones.

Like ABA in general, the concept of reinforcement is widely misunderstood. For example, many people mistakenly believe negative reinforcement refers to providing attention for undesirable behaviors. In fact, negative reinforcement refers to the removal of something aversive such as turning off a loud air conditioner and observing an individual to be more productive as a result.

Most FBAs are only descriptive in nature. In a descriptive or correlational FBA, the observer notes events or situations co-occurring with problem behaviors and presumes that some combination of these co-occurring variables is also causing the behavior problems. Significant research has proven that descriptive FBAs are not valid for determining the cause of such problems. In addition, substantial time can easily be lost in haphazardly attempting to change parameters in the classroom or work environment only to discover no improvement or even worsening of the problem behavior. In an analytical FBA, careful experiments are set up to determine definitively what variables are causing the problem behaviors, so effective intervention can be planned from the FBA results. While this is not a book on intervention, nonetheless the critical nature of promptly remediating moderate to severe problem behaviors warrants this limited dialogue on the importance of referring the client to persons competent in performing an analytical FBA. In many cases, when even moderate problem behaviors are not treated promptly, they readily worsen only to subsequently require the individual to be placed in more restricted home and school settings; sometimes including possibly having to change schools, or even placement in residential care facilities. In the worst cases, client can suffer permanent disfigurement from severe self-injury. Every effort should be made to refer the client to a BCBA competent in performing an analytical FBA or treating the problem behaviors as discussed further below.

Evidence exists to support the co-occurrence of compromised mitochondrial functioning and ASD (Weissman, Kelley et al., 2008). Mitochondria are responsible for the storage and maintenance of energy (among other functions), and persons with primary or secondary mitochondrial disorders often manifest with widely fluctuating energy levels. In addition, there are numerous cases of individuals with ASD who experience marked cognitive decline both before and after an illness. Such individuals may exhibit substantial cognitive regression for days before an illnesses and even weeks after an illness. In some rare cases, patients with ASD have even been hospitalized for notable cognitive degeneration, including loss of speech and motor skills, co-occurring with an illness. When parents or clients report such events in their history, it is prudent to refer them to a physician who specializes in mitochondrial disorders for further assessment of these symptoms.

If a client exhibits gross or fine motor impairments or complains of significant sensory sensitivities, it is helpful to refer them to an occupational therapist for further evaluation. When the evaluation team includes a neuropsychologist, physical therapist, or occupational therapist, assessment of motor skills is typically included and determination of the degree of weakness or impairment in this area is possible. Most young clients with ASD will benefit from occupational therapy to assist them in strengthening play skills and learning adaptive behaviors (tying shoes, cutting meat, and brushing teeth for example). Referral to an occupational therapist is reiterated under Home recommendations discussed below. In the USA, Occupational therapy is available for qualified children through the use of public funds under the Individuals with Disabilities in Education Act (IDEA).

A statement about class placement should be included under school recommendations. This determination comes largely from the results of assessment of Intellectual Ability (discussed above). In addition to noting the Full Scale IQ, General Cognitive Ability or General Cognitive Index, for example, particular emphasis should be placed on review of the client’s verbal abilities because most regular education classrooms rely heavily on verbal means of instruction including oral lecture, group discussion, and reading of verbal information. If a client’s verbal abilities or language skills are weak or deficient, placement in small group instruction or self-contained classroom, respectively, may be warranted. Note that all regular and Gifted and Talented (G/T) classroom placements are typically contingent upon the limited or absent problem behaviors including but not limited to any aggression toward self, others or property, as well as unmanaged elopement. Hence, the critical importance of effective evaluation and treatment of such moderate to severe problem behaviors cannot be overstated. In addition, any relevant modification and accommodations as outlined in Tables 15.1 and 15.2 below must also be appropriately provided for the student’s success. This table also outlines guidelines for class placement:

Behavioral and educational interventions are currently the main treatments for individuals with ASD. Of these interventions, approaches based on applied behavior analysis (ABA) have received the most extensive research. ABA can be described as a science devoted to the acquisition of socially relevant skills and/or remediation of problem behaviors (www.​abainternational​.​org). Goals for which ABA should be recommended include, but are not limited to, improved learning in the wake of intellectual deficits, improving communication and social skills, reducing repetitive behaviors, and reduction or elimination of behavior problems. Additionally, it is highly effective for expediting learning in general especially for persons with ASD (www.​asatonline.​org). Because it is a science requiring the acquisition and analysis of valid data taken on target behaviors, it readily reveals how successful or useless any particular intervention is; even treatments not based on ABA principles can be evaluated with ABA techniques.

Almost all expert reviewers conclude that early intensive behavioral intervention (sometimes called EIBI), based on ABA, is shown to be effective in increasing IQ and/or adaptive behavior. While the core characteristics of ASD are neither IQ nor behavioral deficits per se, it is not possible for individuals with ASD to independently access either regular education classes or most opportunities in the community if they have intellectual deficits or significant impairment in adaptive behavior. Additionally, language skills have been shown to account for a significant amount of the variance in IQ (Huckabee, 2003), and communication challenges are a core characteristic of ASD. In other words, it is very difficult for a person with ASD to learn to effectively communicate and socially interact with others as long as IQ or adaptive behavior remains impaired. Because of these issues, ABA should be included as a recommendation for all young children with ASD as well as any person with an intellectual disability or problematic behaviors.

While ABA is arguably one of the most effective interventions for individuals with ASD, the truth is that many individuals and school districts provide the so-called ABA services by unqualified or inadequately trained or supervised staff. If a school-based clinician finds himself or herself in the position of managing challenging behaviors without adequate training or support, it is generally possible to obtain consultation from a qualified BCBA for minimal cost. When school staff or clinicians do not receive support and training on how to assess and manage behavior, results are inevitably diluted or ineffective. Many times, children have acquired very bad habits such as irritatingly echoing instructions completely out of context, sitting docilely without ever using their skills because they are dependent on being told what to do, or even acquiring self-injurious behaviors. Sometimes, school districts will profess to provide effective ABA services for students; however, minimal standards of staff supervision are barely maintained. In many instances, paraprofessional aides are left desperately attempting to teach skills or manage severe behavior problems without remotely having the knowledge and skills to be successful. Such conditions are woefully inadequate. Parents or professionals who are seeking to identify qualified ABA services should first locate a BCBA or Board Certified Associate Behavior Analyst (BCABA) through the Behavior Analyst Certification Board (www.​BACB.​org) who can properly supervise the intervention. The BACB does an excellent job of ensuring minimal standards are achieved by Board Certified personnel. When including a recommendation for ABA intervention, the evaluating clinician can apprise the parents or guardians of these important teaching parameters and strive to ensure referrals are appropriate.

Questions about the amount of ABA services and whether it should be in individual or group format are relevant. While there are countless peer-reviewed studies on the effectiveness of ABA for teaching a plethora of skills documented in the Journal for Applied Behavioral Analysis (JABA) and other scientific publications, there are few parametric studies precisely outlining the amount and format of ABA necessary to achieve optimal results covaried for age, ASD severity, and skill profile. Compelling research was presented which outlined the amount of time students with ASD were engaged in the classroom as a function of class size (Dykstra, 2014). These results showed a loss of coordinated joint engagement with each additional peer in the class. One can generally assume that individual or small group (3–6 students) settings will be more effective for teaching new communication or other social skills while emphasis on generalization (using skills in more complex settings, etc.) and maintenance of existing skills can be targeted in larger groups or a full class of 20 or more students. Most problem behaviors need to be addressed through individual instruction until at least low levels of intensity or frequency are achieved. Again, if individualized instruction is provided by a paraprofessional or teaching assistant, such a staff member must be properly trained and supervised to achieve successful results.

Speech therapy is recommended whenever the individual has significant weaknesses or impairments in intelligibility such as problems with sound production, substitutions, or omissions. Other speech problems which frequently occur in ASD including problems with prosody (speech rhythm) or volume may also be addressed with a recommendation for speech therapy. Some speech pathologists can also assist with expressive and receptive language weaknesses for persons with ASD such as deficits in comprehension, vocabulary, syntax, grammar, and sentence formulation. It should be remembered, however, that many people with ASD also have problems sustaining attention and motivation to learn from others thereby requiring that the referred speech therapist be competent at addressing both these issues if necessary.

Speech therapy can be appropriately recommended, as discussed above, in both the school and/or home settings. Speech therapy in the school will be provided based on “academic necessity” which is a fancy way of saying such therapy will address skills necessary for school success. School success is only a fraction of the scope of skills necessary for success in life and therefore private speech therapy may be recommended as well. When it is determined that a student qualifies for speech therapy services in the school, such services are provided free of charge and range in frequency from about 1 h per month to 2 h per week depending on the severity of the need. It is recommended that the evaluating clinician specify the amount of speech therapy required, based on severity of speech and language deficits. Speech therapy services and/or consultation provided by the school needs to be included in the student’s IEP discussed above.

Occupational therapy should be recommended specifically when clients have problems including fine or gross motor coordination weaknesses, hand writing problems, or marked sensory sensitivities such as tactile defensiveness. These motor and sensory challenges are not part of the core characteristics of ASD but frequently co-occur with ASD. Many students with ASD enjoy and may benefit from “sensory breaks” or a sensory rich diet, including regular opportunities to access a variety of proprioceptive activities like swinging or bouncing, weight bearing activities as well as activities that stimulate light touch and deep pressure sensors such as playing in a sand tray or crawling through a tight lycra tunnel, respectively. These sensory activities are often professed to indirectly assist the student to subsequently sustain attention, sit quietly, concentrate, or decrease response latency, for example. It should be noted that these skills are foundational prerequisites to learning rather than academic or intellectual outcomes reflected in grades. For these reasons, and because each individual with ASD is highly unique, it is valuable to empirically assess through the acquisition of ABA or other empirical data, the degree to which sensory breaks are benefitting the student versus simply representing a fun break from academic instruction. It is imperative to ensure that any sensory breaks are provided proactively so they don’t inadvertently serve to reinforce off-task or otherwise disruptive classroom behaviors by reactively taking the student for a fun sensory break in response to inappropriate behavior. Occupational therapy services and/or consultation provided by the school needs to be included in the student’s IEP discussed above.

Physical therapy services or consultation should be recommended for clients who present with motor weaknesses or other related challenges. Unless a neuropsychologist, physical or occupational therapist is included on the assessment team, direct assessment of muscle strength is probably not included in the assessment. Motor weaknesses can be suspected, however, if the client physically appears to have low muscle tone as evidenced by small muscle mass, the client is clumsy and/or motor speed or dexterity is poor (see Chap. 10: Assessing for Visual Spatial and Motor). Motor weaknesses are not part of the core characteristics of ASD but frequently co-occur with ASD. When in doubt, it is best to refer at least for a physical therapy consult. If the physical therapist determines services are not necessary, at least the client has received thorough evaluation in this area. Physical therapy services and/or consultation provided by the school needs to be included in the student’s IEP discussed above.