How stable is an early ASD diagnosis?

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Turns out, pretty stable. While available diagnostic tools may not be the best for very early diagnoses (<12 months), this study on over 1000 toddlers sampled from the general population found a diagnosis of ASD made at 18 months by a clinician with expertise in ASD was more stable than diagnoses of language delay or typical development. 84% of children who received an early diagnosis of ASD still qualified for that diagnosis at 3–4 years of age. Other relevant takeaways include:

  • The most common diagnostic transition: ASD at first visit to ASD features at last visit (i.e., children no longer met full criteria for ASD on DSM-V, but still had some characteristics of ASD)

  • Only 1.8% of toddlers went from an initial diagnosis of ASD to typical development

  • ASD was missed in almost 1/4 of first evaluations; many of these later-diagnosed children (~43%) were initially suspected to have a language delay instead

We still need more research to figure out the best treatments and courses of action, so the intervention piece is still business-as-usual; but for now we can trust that early diagnosis of ASD is not only possible, it’s pretty reliable.

 

Pierce, K., Gazestani, V. H., Bacon, E., Carter Barnes, C., Cha, D., Nalabolu, S., …, & Courchesne, E. (2019). Evaluation of the diagnostic stability of the early autism spectrum disorder phenotype in the general population starting at 12 months. JAMA Pediatrics. doi:10.1001/ jamapediatrics.2019.0624.

Teaching parents language strategies during shared book reading

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As early intervention SLPs, we know the importance of teaching parents to use language facilitation strategies (see the Heidlage & Roberts meta-analyses we discuss in the last bullet point, here). We also know the value of shared book reading as a context for language learning. These researchers decided to take a close look at the process of teaching parents to use naturalistic language strategies during book reading. To do this, they taught two mothers, one with a three-year-old with ASD and one with a 5-year-old with cerebral palsy, two sets of strategies.

The first set of strategies was engagement strategies for parents to use before, during, and after reading books.

  • Before book reading:

    • Say the title and author (e.g. “This book is called ____ and is written by ____.”)

    • Ask a question to build interest (e.g. “What do you think this book is about?”)

  • During book reading:

    • Make encouraging statements (e.g. “I like how you’re sitting so nicely with me!” “Good job turning the page.”)

    • Use nonverbal and verbal means to focus the child’s attention (e.g. point to a picture and say, “Look! It’s a gorilla!”)

  • After book reading:

    • Ask a closing question to maintain interest, or relate the book to the child’s life (e.g. “Which animal makes a funny sound, a cow or a sheep? Why? What sound does our dog make?”)

The second set of strategies was components of the intervention program Parent-Implemented Communication Strategies (PiCS) (Meadan et al. 2014).

  • Modeling: demonstrate a word, phrase, or gesture with the expectation that the child will imitate (e.g. “Turn the page”)

  • Mand–model: in addition to the model, use a verbal prompt in the form of a question (e.g. “What do you want?”), a choice (e.g. “Should we read the cat book or the tractor book?”), or a command (e.g. “Say ‘turn the page”).

  • Time delay: pause within an established routine to give the child an opportunity to initiate communication (e.g. label all of the pictures on a page except for one, point to the last picture, and look expectantly at the child for five seconds).

They taught parents these strategies via two initial teaching sessions followed by 12 weeks of twice-a-week coaching sessions. The two initial teaching sessions included reviewing the material, watching example videos, role-playing, and feedback. The coaching sessions used the following format:

  • The researcher reviewed the target strategy

  • The researcher provided feedback on the previous session using a video clip, giving direct positive and constructive feedback

  • The mother and child engaged together in shared storybook reading while the researcher observed

  • The mother reflected on her own use of the strategies, and the researcher provided suggestions and feedback. Together, they problem-solved any concerns or issues

The researchers found a connection between the mothers’ use of the PiCS strategies and the child’s communication, providing support for teaching parents to use the PiCS strategies during shared book reading. They also found that the hands-on practice/coaching component was key for the mothers to use the PiCS strategies successfully. Because we EI SLPs are already familiar with the strategies that were taught to the parents in this study, this is definitely something we can use in our sessions!

 

Akamoglu, Y., & Meadan, H. (2019). Parent-implemented communication strategies during storybook reading. Journal of Early Intervention. doi: 10.1177/1053815119855007.

Let’s hear it for the verbs! Parents’ early verb use predicts children with ASD’s later verb vocabulary

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Verbs are important for early language development; they are the building blocks for early sentences and help kids tell us about the things that are happening around them. But as we know, many of our children with ASD struggle to learn and use them flexibly. We know from the literature that for typically developing children, parents’ verb use can predict their later verb vocabulary. These researchers wanted to know if the same was true for children with ASD.

To do this, they measured the verbs that parents of children with ASD used during “follow-in utterances.” Follow-in utterances are comments that parents make during moments when they and their child are both focused on the same thing. So if a child knocked down a tower of blocks and looked up at his mom, her saying, “The tower crashed!” would be a follow-in utterance. The researchers looked at three aspects of parent verb use during follow-in utterances:

  1. The quantity of verb input, i.e., how often parents said verbs

  2. The diversity of verb input, i.e. how many different verbs parents said

  3. The grammatical informativeness of verb input, i.e. how much rich morphological information surrounded the verb. For example, “We’re jumping” would be more grammatically informative than “jump.” (See the article’s appendix for additional definitions and examples.)

They found that together, these three aspects of parent verb use during follow-in utterances predicted children with ASD’s later verb vocabulary. Because this is a correlational study (and doesn’t tell us what causes what), we’ll need further research to tell us if teaching parents to increase their quantity and quality of verb use will improve their children’s verb vocabulary. That being said, here are some ways authors describe that this line of research may impact what we teach parents:

  • We could teach parents to expand what their child says by adding a verb. For example, if the child says, “baby,” we could teach the parent to respond with, “the baby is sleeping,” rather than adding on to the noun phrase (e.g. “little baby”).

  • We could encourage parents to use diverse verbs during follow-in utterances, rather than over-relying on a small number of verbs and verb forms (such as “I want _____,” or “I need ______”).

  • We could teach parents to use grammatical language, rather than telegraphic. Because including grammatical morphemes seems to support children’s learning of verbs, we could teach parents to model fully grammatical language. For more research about using grammatical vs telegraphic language, see our previous review here.

 

Crandall, M.C., McDaniel, J., Watson, L.R., Yoder, P.J. (2019). The relation between early parent verb input and later expressive verb vocabulary in children with autism spectrum disorder. Journal of Speech, Language, and Hearing Research. doi:10.1044/2019_JSLHR-L-18-0081.

Perspectives & Tutorials

Providing supportive hospital environments to promote the language development of infants and children born prematurely: insights from neuroscience

 This article is an excellent intro (or reminder) of the basics of best-practice for developmental care in the NICU, with an emphasis on language development and tips for training parents and hospital caregivers on how to support these babies.

 

How meaningful is more? Considerations regarding intensity in early intensive behavioral intervention

Most SLPs who work with young children with autism are well-aware of the 10–40 hours per week of EIBI (Early Intensive Behavioral Intervention) that’s often recommended by private practices, centers, and the Behavior Analyst Certification Board (BACB). This editorial turns those recommendations upside down, pointing out that:

  • There is no strong evidence to show that a high level of EIBI is necessary or appropriate for all children with autism.

  • There is no strong evidence to show that increasing the hours of EIBI leads to better child outcomes. There simply aren’t many studies on treatment dose.

  • Recommending high levels of EIBI ends up excluding other educational opportunities and services the child may need (like speech­–language therapy) which can be detrimental.

  • Overall, this editorial doesn’t advise against a high dose of ABA treatment; rather, they’re saying that recommending high doses across the board, for all children with autism, isn’t backed by the science.

Measuring the earliest forms of communication

As you may have realized (with frustration!) by now, we have limited options for evaluating the expressive communication skills of children who are minimally verbal. Enter: the Communication Complexity Scale (CCS), designed to measure just that. Prior papers have described the development of the CCS and determined its validity and reliability, but in this study, we get to see it in action with a peer-mediated intervention.

First, a little bit about the tool. It’s a coding scale—not a standardized assessment—that can be used during observations. Because prelinguistic communication skills often take time to develop with this population, this tool helps us think about all the incremental steps along the way and accounts for the variety of communicative modes the children might use. It’s a 12-point scale following this pattern:

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The researchers found that the CCS could measure improvement in overall communication complexity and behavior regulation for preschoolers with autism after a peer-mediated intervention (the same one we reviewed here!).

So far in the research, the CCS has only been used during structured tasks meant to elicit communicative responses (see the supplemental material), such as holding a clear bag with toys where the child can see it, but can’t access it independently. We know it's crucial to observe our students in natural communication opportunities, though, so we'd have to be a little flexible in using the CCS during unstructured observations. The scale could definitely be useful when describing communication behaviors during evaluations or when monitoring progress. Wouldn’t it be much more helpful to say “The child consistently stopped moving (i.e. changed her behavior) in response to the wind-up toy stopping” instead of “The child was not observed to demonstrate joint attention”? Using the CCS, we have new ways of describing those “small” behaviors that really aren’t small at all!

NOTE: This study crosses over our Early Intervention vs. Preschool cut-offs, with kids from 2 to 5 years old. So is published in our School-Age section, too!

Find links to the scale and score sheets, here.


Thiemann-Bourque, K. S., Brady, N., & Hoffman, L. (2018). Application of the communication complexity scale in peer and adult assessment contexts for preschoolers with autism spectrum disorders. American Journal of Speech-Language Pathology. doi:10.1044/2018_AJSLP-18-0054