Comparing toddler communication
assessments within early ASD diagnosis
Kelly Caravella, BS, Yael Stern, BS & Moira Lewis, MS CCC-SLP
Marcus Autism Center
Children’s Healthcare of Atlanta
Division of Autism & Related Disorders
Department of Pediatrics
Emory University School of Medicine
Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
ASHA Convention 2012, Atlanta, GA
Disclosure
We have the following relevant nonfinancial relationship(s) in the data
described and reviewed in this presentation:
These studies were supported by grant funding from the following
organizations: NIMH & The Marcus Foundation.
We have no relevant financial relationships to disclose.
2
Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Early ASD Diagnosis
• Majority of parents express their concerns prior to
their child’s 2nd birthday (Young et al., 2003; Chawarska et al.,
2007; Zwaigenbaum et al., 2009)
• High stability (80-90%) of ASD diagnosis made at
18-24 months when diagnosis is made by
experienced clinicians (Chawarska et al., 2007; 2009; Lord et
al., 2006)
• With high autism prevalence rates, 1 in 88, the
importance of state providers (SLPs) to be aware
of ASD red flags is paramount. (CDC, 2012)
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Front Lines of Assessment and Diagnosis in
Georgia
 In Georgia, children suspected of developmental
delays before the age of 3 are referred to Babies
Can’t Wait (BCW).
 BCW evaluation teams are comprised of a
multidisciplinary team with at least two of the
following: speech therapist, early interventionist,
occupational therapist or physical therapist
 In 2011, 5858 children statewide were receiving
intervention services through BCW.
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Roles and Responsibilities of Speech-Language Pathologists in Diagnosis,
Assessment, and Treatment of Autism Spectrum Disorders Across the Life
Span, Ad Hoc Committee on Autism Spectrum Disorders; 2006
 Screening: SLPs play a critical role in screening and early detection of
individuals at risk for ASD and makes referrals to experienced professionals
for diagnosis and intervention services.
 Diagnosis: SLPs who acquire and maintain the necessary knowledge and
skills can diagnose ASD, typically as part of a diagnostic team or in other
multidisciplinary collaborations, and the process of diagnosis should include
appropriate referrals to rule out other conditions and facilitate access to
comprehensive services.

Assessment and Intervention: SLPs should prioritize assessment and intervention in those aspects of
development that are critical to the achievement of social communication competence and that honor
and adapt to differences in families, cultures, languages, and resources. Speech-language pathologists
should recognize the guidelines and active components of effective, evidence-based practice for
individuals with ASD….. (cont’d)
American Speech-Language-Hearing Association. (2006). Roles and responsibilities of speech-language
pathologists in diagnosis, assessment, and treatment of autism spectrum disorders across the life span
[Position Statement]. Available from www.asha.org/policy.
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Diagnostic & Screening Tools for Toddlers
Autism Diagnostic Observation
Schedule-Toddler Module
Communication and Symbolic Behavior
Scales- Developmental Profile
Amy Wetherby, Barry Prizant, 2002
 Useful standardized assessment tool for
screening and evaluating communication in
toddlers ages 12-24 months
 Effective way to assess early prelinguistic
behaviors, and to examine social
vulnerabilities
 Effective way to differentiate among early
ASD behaviors and solely communication
delays
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ADOS-T: Luyster et al., 2009
•
•
Offers new and modified ADOS activities and
algorithms appropriate for children under 30
months of age who have minimal speech
(ranging from no spoken words to simple
two-word phrases), have a nonverbal age
equivalent of at least 12 months and are
walking independently
Similar procedures as ADOS module 1, with
added probes to examine early symbolic play
behavior, response to social initiation and
age-appropriate materials/toys
The average age of parental concern is between 15 and 18 months (Chawarska, Paul et al., 2007; DeGiacomo & Fombonne, 1998)
Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Communication and Symbolic Behavior Scales-Developmental Profile
(Wetherby & Prizant, 2002)
Examines 3 areas of early communication skills in toddlers:
1. SOCIAL COMPOSITE
Early social behavior:
Gaze shifts, shared positive affect, gaze and point following
Communication:
Rate of communication
Functions of communicating- requests, social interaction, joint attention
Gesture Use:
Inventory of gestures
2. SPEECH COMPOSITE
Inventory of sounds & words
3. SYMBOLIC COMPOSITE
Understanding of words, early commands
Inventory of play actions
Constructive play (stacking blocks)
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Social Communication Deficits in ASD
 Communication deficits are one of the most frequent reasons for referral
among children who are later dx with ASD (Tager-Flusberg, Paul & Lord, 2005).
 At 12 months, risk factors for ASD diagnosis at 24 months included less
frequent use of eye contact, social smiling, and low levels of social interest
(Zwaigenbaum, Bryson, Rogers, Roberts, Brian & Szatmari, 2005).
 Deficits in joint attention skills specific to group of 3-4 year olds diagnosed
with ASD (Carpenter, Pennington & Rogers, 2002).
• use of declarative gestures
• gaze following
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Typical Development of Communication
 Between 9-15 months, typically developing infants transition from following
attention to directing attention (Carpenter, Nagell & Tomasello, 1998).
 By age 2, typically developing children use gestures for many purposes: behavior
regulation, joint attention, social interaction (Crais, Douglas & Campbell, 2004).
 Toddlers at 18 months produce an average of 2 communicative acts per minute to
express intention; at 24 months, a child produces an average of 5 acts per minute
(Wetherby, Can & Walker, 1988; Paul and Shiffner, 1991).
 In a group of typically developing children, performance on CSBS near 2nd birthday
was predictive of language profile at age 3 (Watt, Wetherby and Shumway, 2006)
• Receptive Language: Gesture Inventory
• Expressive Language: Acts for joint attention
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Typical Development of Communication
Non-verbal capacity for communication
Looking beyond typical speech milestones:
• Eye gaze, gaze shifting
• Orientation to speech
• Response to name
• Affect sharing
• Caregiver referencing
• Joint attention, response and initiation
• Pointing
• Imitation
• Symbolic play
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
9 Month Old Infant, Typically Developing
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Atypical communication development
Early Red Flags for ASD:
• Gaze aversion
• Limited response to adult speech
• Difficult to comfort
• Object focused
• Attention disengagement
• Lack of imitation
• Lack of pointing
• Hand over hand gestures
Summarized in Chawarska & Volkmar, 2005
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
23 month old, Autism Spectrum Disorder
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
24 month old, Autistic Disorder
14
Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Compensating for Limited Language
with Non-verbal Acts
Common in non-ASD Developmentally Delayed Toddlers
Compensatory Non-verbal
Communicative Acts
• Eye gaze, gaze shifting
• Response to name
• Orientation to speech
• Pointing
• Affect sharing
• Caregiver referencing
• Imitation
• Joint attention, response
and initiation
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
Absence of ASD Red Flags:
• Gaze aversion
• Limited response to adult
speech
• Difficult to comfort
• Object focused
• Attention disengagement
• Lack of imitation
• Lack of pointing
• Hand over hand gestures
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
24 month old, Mixed Expressive/Receptive Language Delay
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Current Study
Participants
•
46 toddlers, 28 ASD, 18 DD
•
36 males
•
12 females
Participants
•
Clinically referred sample, study eligibility based on parent concern of
broad band developmental delays or autism.
•
Some participants have a language delay or global delay dx, at
enrollment, none with ASD.
Diagnostic Measures
•
Mullen Scales of Early Learning (Mullen, 1995)
•
Autism Diagnostic Observation Schedule, Toddler Module (ADOS-T;
Luyster al., 2009)
•
Vineland Adaptive Behavior Scales II, Survey Form (Sparrow, Cicchetti and
Balla, 2005)
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•
Communication and Symbolic Behavior Scales (Wetherby and Prizant, 2002)
Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
ADOS-T vs. CSBS
ADOS –T
Format
Unstructured, free to roam
room
Semi-structured, child seated at a
table
Type of
Clinician
Typically Psychologist
Typically SLP
Time to
administer
30-45 minutes
~20 minutes
Social behavior
examined
•
•
Shared positive affect
•
•
•
•
Requesting
Point following
Joint attention
Gestures (including, giving,
showing and pointing)
•
•
•
Gaze shifts
Rate of communication
Social Interaction
•
•
•
•
•
•
•
•
•
18
CSBS
Shared positive
affect/directed facial
expressions
Requesting
Point following
Joint attention
Gestures
Giving
Showing
Gaze Integration
Frequency of directed
vocalizations
Response to name
Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Characterization Table
** p<.01, * p<.05
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Comparing Language Scores
50
45
40
35
30
25
20
μ = 50
σ = 10
Mullen:
Expressive
ASD
DD
Mullen:
Receptive
100
90
μ = 100
σ = 15
80
70
60
Vineland: Communciation
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Correlations: ADOS-T and CSBS Social Scales
r = - .663
(p<.01)
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
CSBS - Social and Speech Domains
μ = 10
σ=3
** [F(1,44)=31.04, p<.01
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Future Directions
• Important for SLPs to choose an instrument within their clinical
toolbox that looks beyond requesting and early sound inventories in
toddlers
• With the increasing literature supporting red flags of autism as early
as 12 months, it would be interesting to see if we can replicate these
findings in toddlers at risk between 9-12 months.
• Although we have significant findings with our current sample size,
we would be interested to replicate these findings with a larger
sample.
• Clinical utility of an instrument such as the CSBS in a non-research
setting; versus the ADOS which may not be in line with
billing/time/training/discipline constraints
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Acknowledgements
Many thanks to all the incredible clinical staff, research
assistants, fellows, students, & trainees on this toddler
longitudinal study.
And of course, eternal thanks to the children and families for
their participation in and support for research.
Special thank you to the following staff at Marcus Autism Center:
Christy Hall, Ph.D.
Sara Hoffenberg, Psy.D.
Cheryl Klaiman, Ph.D.
Opal Ousley, Ph.D.
Celine Saulnier, Ph.D.
Ami Klin, Ph.D.
Gordon Ramsay, Ph.D.
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Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta.
©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.