Understanding Autism Spectrum Disorders: The Role of Speech-Language Pathologists and Audiologists in Service Delivery It is a hopeful time for families and children affected by autism spectrum disorders (ASD). It is also a critical time for speech-language pathologists and audiologists to increase their knowledge and skill in the delivery of services for this special population. Although SLPs and audiologists don’t typically diagnose autism, many ... Features
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Features  |   September 01, 2001
Understanding Autism Spectrum Disorders: The Role of Speech-Language Pathologists and Audiologists in Service Delivery
Author Notes
  • Patricia Prelock, is an ASHA Fellow and professor at the University of Vermont. As project director for the Vermont Rural Autism Project, she prepares SLPs and early childhood providers to serve children with autism and their families. She is also training director for an MCHB interdisciplinary leadership training program and project director of Vermont’s State Improvement Grant initiative to increase the number and quality of school-based SLPs. Contact her by email at pprelock@zoo.uvm.edu.
    Patricia Prelock, is an ASHA Fellow and professor at the University of Vermont. As project director for the Vermont Rural Autism Project, she prepares SLPs and early childhood providers to serve children with autism and their families. She is also training director for an MCHB interdisciplinary leadership training program and project director of Vermont’s State Improvement Grant initiative to increase the number and quality of school-based SLPs. Contact her by email at pprelock@zoo.uvm.edu.×
Article Information
Special Populations / Autism Spectrum / Features
Features   |   September 01, 2001
Understanding Autism Spectrum Disorders: The Role of Speech-Language Pathologists and Audiologists in Service Delivery
The ASHA Leader, September 2001, Vol. 6, 4-7. doi:10.1044/leader.FTR1.06172001.4
The ASHA Leader, September 2001, Vol. 6, 4-7. doi:10.1044/leader.FTR1.06172001.4
It is a hopeful time for families and children affected by autism spectrum disorders (ASD). It is also a critical time for speech-language pathologists and audiologists to increase their knowledge and skill in the delivery of services for this special population.
Although SLPs and audiologists don’t typically diagnose autism, many practitioners are involved in interdisciplinary teams that do. Further, SLPs and audiologists play a significant role in describing and defining the communication and social interaction skills so often impaired in children with ASD. They also offer insight into differential diagnosis, helping to determine when there is more than just a communication problem.
Affecting approximately one in 500 children, autism is currently seen as a common childhood disorder with core deficits in communication, socialization, play, and behavior. There is, however, considerable variation in the manifestations of autism, both across individuals and within individuals over time. Variability in symptom expression and in assessment expertise has increased the complexity of diagnosis. Yet, in spite of these evaluation challenges, assessment practices are receiving growing amounts of attention both nationally and internationally. Those moved by the challenge and intriguing nature of ASD are seeking better ways to understand and meet the needs of those affected by the disorders. At the same time, families and professionals are pursuing effective intervention practices to address the lifelong learning needs of children with ASD.
Early Indicators of ASD
Over the last 10 years, researchers have identified several red flags to consider in the early diagnosis of autism. Some research is based on retrospective video analysis of social, communication, and play behaviors in the first two years of life for those children later receiving a diagnosis of autism. Other research uses screening methods of children at risk with follow-up over time to determine if the diagnosis is maintained and what might be predictive at 18, 24, and 36 months of age.
We have learned that there are key factors alerting families and providers to the possibility of autism. These include:
  • absence of or delay in pointing to express interest

  • hand leading or using another’s body to communicate, often replacing pointing

  • failure to show interest in or joint attention to games for pleasure or connection with another

  • failure to “show” objects

  • failure to look at others

  • failure to show an interest in other children

  • failure to orient to name or delayed response to name; lack of attention to voice, particularly neutral voice

  • no meaningful words or fewer than five meaningful words at 24 months, or cessation of talking after saying three or more meaningful words

  • no understanding of words out of context

  • failure to demonstrate symbolic play

  • aversions to social touch, poor nonsocial visual orientation/attention, excessive mouthing of objects

  • unusual mannerisms involving the hands and/or fingers

Making an early diagnosis, however, has its challenges. Lord and Risi report that diagnosis at 2 and 3 years is very different from diagnosis at 5 and 6 years. For example, children following a typical course of development are variable in establishing joint attention, saying their first word, and initiating social interaction. This variability requires SLPs and audiologists to be cognizant of subtle developmental differences in young children with and without autism. It also suggests the need to actively involve family members in the screening process.
Clinicians must make a commitment to careful observation of the social interaction, communication, play, and behavior in young children. Many of the clearest discriminators at age 24 months (i.e., joint attention and attention to voice) and at age 36 months (i.e., absence of pointing, hand leading, unusual mannerisms, no meaningful words) can be observed during early intervention and preschool screening.
Assessment Guidelines
Recognizing early indicators is just the first step in the assessment process. Currently, there are efforts in both child neurology and pediatrics to more clearly specify practice parameters for screening and diagnosing children suspected of ASD.
The Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society (with Barry Prizant as the ASHA representative and Judy Gravel as the American Academy of Audiology representative) have issued a report with practice parameters for both the screening and diagnosis of ASD (Filipek et al., 2000). The screening parameters for which SLPs and audiologists play a critical role include:
  • formal hearing testing

  • further evaluation if there is no babbling or gesturing by 12 months, a loss of language or social skills, no single words at 16 months, or no two-word phrases by 24 months

  • monitoring siblings for social, communication, and play skills because of the potential genetic link

The diagnostic parameters that are particularly relevant to SLPs and audiologists include:
  • examination of family prevalence and patterns of decreased cognitive skills, specifically verbal and adaptive function

  • observation of verbal and nonverbal communication, and specific deficits in speech and language

The American Academy of Pediatrics (AAP, 2001) has also issued a technical report on the pediatrician’s role in the diagnosis and management of ASD in children. Because pediatricians share the challenge of making an accurate and early diagnosis and implementing a timely intervention program, collaboration with pediatricians and the families they serve is essential. The AAP provided 12 key recommendations in their report. Four of these have important implications for consultation with pediatricians. They include:
  • monitoring all development at well child visits, specifically language and social skill development

  • referral for audiologic and speech and language evaluations for children with language delays

  • seeking opportunities for enrollment in early intervention or school programs for children with suspected delay or symptoms of ASD

  • provision of care coordination among interprofessional services

Screening tools for autism are currently being investigated and refined. Diagnostic tools also are available for assessing autism in children. Ultimately, the goal of assessment is to devise an educational program that addresses a child’s needs in the areas of social interaction, communication, play, behavior, and overall learning. Recognizing autism as a spectrum of symptoms allows researchers, families, and service providers to understand and address the specific strengths and challenges of individual children over time.
Intervention Decision Making
There is general consensus that children with a diagnosis of ASD need early intervention, intensive instruction, planned teaching opportunities, and adult support. There are, however, differences in philosophies and approaches to intervention that have led to confusion and frustration for families and service providers. To effectively engage in a discussion of intervention practices, SLPs and audiologists must understand the available approaches, be able to evaluate claims of effectiveness, and recognize principles of best practice. (See ASHA’s Web site for a list of questions formulated to help clinicians evaluate therapeutic procedures.)
Intervention approaches.
Several clinical researchers have attempted to provide a framework in which to view interventions for children with ASD. Heflin and Simpson identify three basic approaches: relationship-based--interventions attempting to facilitate a child’s attachment, affect, or relatedness (e.g., floor time); skill-based--interventions supporting the development of specific skills (e.g., Picture Exchange Communication System, social stories, discreet trial learning); and physiologically oriented--interventions attempting to change how information is received and processed by the brain (e.g., sensory and auditory integration, psychopharmacologic and dietary treatments).
Rogers divides interventions into two categories--focal treatments and comprehensive programs. Focal treatments are similar to skill-based interventions, in that specific learning needs are addressed (e.g., increasing social interaction). In contrast, comprehensive programs are designed to reduce impairment across ability areas and improve long-term outcomes (e.g., TEACCH; see Watson, Lord, Schaffer, & Schopler, 1989). Rogers also places the work of Lovaas (1987) in this category because of the intensity of intervention provided.
A third approach to defining interventions is offered by Prizant and Wetherby. They describe a continuum of traditional behavioral to social-pragmatic developmental approaches. At one end of the continuum is discreet trial learning with a highly prescribed teaching structure focusing on skill learning during individual instruction with predetermined criteria for correct responses. On the other end of the continuum are developmental approaches (e.g., floor time) emphasizing initiation, spontaneity, following a child’s lead, and using natural contexts to support development. Prizant and Wetherby describe a “middle ground” in practice, believing that more contemporary behavioral approaches offer children choices, share control of teaching opportunities, and use child-preferred activities and materials. Differences remain, however, in the integration of developmental research, the emphasis on eliciting specific behaviors, the type of data collected, and the recognition of interrelationships between social-emotional and communication development.
Intervention effectiveness.
Discrepancies exist between what is known and what is practiced. Prizant and Rubin (1999) challenge practitioners to consider the following when evaluating interventions:
  • the literature reports a range of effective approaches

  • approaches have not been compared to determine effectiveness

  • benefits vary for individual children

  • design problems plague intervention research

  • child outcome has been the sole focus

  • treatment intensity has not been defined

  • overlap of approaches exists

  • treatment fidelity has not been evaluated

  • effects of other variables have not been addressed

Prizant and Rubin go on to suggest that outcome measures should consider the valued outcomes of families and include measures of social-emotional and communicative development in natural contexts.
Preferred best practice.
Educational services for children suspected of ASD should be immediate. The Committee on Educational Interventions for Children With Autism (with Amy Wetherby representing speech-language pathology) has suggested that, minimally, services should be 25 hours weekly, 12 months a year, in which a child is engaged in developmentally appropriate, systematically planned, and individually defined activities that are responsive to identified goals (National Research Council, 2001). Prizant and Rubin (1999) pose five principles of best practice:
  1. match individual needs with developmental level

  2. consider what is known about child development

  3. ensure the intervention addresses core deficits in autism

  4. evaluate consistency between valued outcomes and the process to achieve those outcomes

  5. understand the derivations of interventions (e.g., theory-based, data-based, knowledge of best practice, etc.)

In addition to these tenets, the following guidelines (adapted from Freeman, 1997) support effective intervention decision-making:
  • approach treatments with a clear, pragmatic perspective

  • select treatments that support quality of life and do no harm

  • consider the cultural values and priorities of the family

  • have a method for assessing intervention effectiveness

  • be aware of your own philosophical bias

In a pilot study examining parent perspectives on the impact of a strengths-based and family-centered assessment process guided by professionals specifically trained in ASD, parents perceived a shift in the professionals’ attitudes toward their children with ASD (Beatson & Prelock, in press). Parents reported a renewed professional commitment to understanding and accommodating their children and to seeing their children as capable of learning and participating as part of their educational and social community.
This renewal in professional commitment was the result of increased knowledge and training of these school-based providers in collaboration with families affected by ASD. As one parent so aptly said, “We felt that, while there weren’t answers, there were a lot of people out there who could give us ideas.”
It is our responsibility as providers to this population to pursue the knowledge we need, remain current in our understanding of the issues, and share the ideas we have.
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September 2001
Volume 6, Issue 17