Chapter 02, The Behavioral Manifestations of Autism Spectrum Disorders

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High sensitivity and specificity of the instrument were found in a sample of high-risk infants. At present, there are no clinical instruments available for use in the first year of life. This may be appropriate, as to date, the infant sibling studies have not revealed consistent markers for ASD before 12 months of age.

In addition to the ADOS-T, the AOSI, a semistructured, play-based assessment was developed to identify early signs of autism in infants at high-risk, which has been defined as infants with older siblings diagnosed with ASD. However, a diagnosis alone is insufficient to make treatment recommendations. At a minimum, a comprehensive assessment must include a detailed developmental history, including the range of settings and caregivers that the child has experienced, as well as standardized assessments of language and communication, intellectual functioning, adaptive functioning, and co-occurring social-emotional eg, anxiety , behavioral eg, aggression , and regulatory problems eg, sleep and eating problems that are not specific to ASD.

Although it is beyond the scope of this paper to review specific assessment tools in these relevant domains, Goldstein and colleagues 87 present a comprehensive review of assessment instruments that are uniquely suited for the assessment of individuals with ASD, with detailed recommendations for young children. All young children are embedded in family relationships. When a child is diagnosed with ASD, families are affected in different ways. Elevated parenting stress and depressive symptom scores have often been reported among parents raising children with ASD, whether they are compared with parents raising typically developing children or to parents of children with other developmental delays.

There are several stressors that families of young children with ASD may confront that affect their psychological adjustment. Parental stress is particularly high when there is no confirmed diagnosis, but either parents, early intervention, or health care providers suspect that an ASD diagnosis may be present. Parents report being less satisfied and more frustrated when delays are long and the diagnosis less clear.

It could be challenging for parents to follow a period of little developmental variation or regression that was preceded by an apparently normal period of early development. Certain delays eg, language, imitation, and play can be overlooked due to perceived strengths in other developmental areas eg, visual spatial skills and motor skills or due to expectations that deficits are developmental lags, which are temporary.

Indeed, this is particularly challenging for parents and professionals, as there are no biological or behavioral markers to predict who will respond to early intensive interventions. When a child is diagnosed with ASD, parents might experience stress as a result of a feeling of losing the life they expected for their children, for themselves as parents, and for their family. Efforts for coordinating, advocating for, and making decisions related to treatment, as well as acquiring skills to foster their child's development, are only a few examples of challenges parents of children diagnosed with ASD face.

Some parents spend additional money for treatments beyond those provided by the state-financed programs eg, more hours of same treatment or other treatments. When parents stop working, their previous expectations, identities, and desires of pursuing their own careers are also affected.

Parents of young, newly diagnosed children also report elevated parenting stress associated with behavior difficulty and severity of deficits and delays in children's social relatedness. They question whether their child cannot, does not want to, or will not be able to carry out certain actions. Child-related stress in parents is also reported with regard to 1 children's lack of reciprocity to their parents 97 and 2 children's disruptive or embarrassing acts, especially in public places. These behaviors could also place restrictions on family activities and interactions with others.

Child behaviors have been shown to differentially impact parenting stress depending on the parent's gender. Maternal stress shows stronger relation to child regulatory problems, whereas paternal stress is more related to child externalizing behaviors.

A more systemic assessment approach has been helpful to understand family functioning variables and interrelations within families with children with ASD. From a systems analysis standpoint, maternal stress is not only predicted by the severity of the preschool child's behavioral symptoms but also by the partner's depressive symptoms, whereas paternal stress was found to be predicted only by maternal depressive symptoms.

Several studies have suggested that characteristics of parent-child relationships are associated with gains in language for children with ASD. Such models exist, as several intervention approaches include parents as co-therapist for their children. Increases in parent confidence and self-efficacy due to learning techniques have been observed to decrease parent stress levels.

In concert with efforts to enhance earlier detection of ASD, there has been a great deal of work to improve early interventions for young children with ASD. This work has been informed by our deepening understanding of the earliest signs and relationships between deficits in joint attention, play, social communication, and language. Specifically, few completed studies provide evidence regarding the efficacy of different treatment interventions that young children with ASD receive, particularly for children under the age of 2 years.

In addition, even for treatments for which evidence exists, there is limited empirical information available to guide decisions regarding treatment intensity, intervention settings, integration of parents and other caregivers, and different intervention approaches. Further, critical outcome variables and individual responses to interventions still need to be addressed.

Interventions for young children with ASD that are designed to provide optimal learning opportunities must be individualized to meet the child's current learning and developmental characteristics. For example, for to month-olds, social interaction contexts must almost always give priority to caregiving rather than peer interactions; communication patterns require a focus on nonverbal communication, gestures, and joint attention; and learning approaches need to address exploration of objects and developing imitation and play skills in a manner that is quite distinct from the approaches that are appropriate for older children.

The purpose of discussing several interventions for young children with ASD is to provide a brief review that does not intend to be exhaustive or conclusive about best intervention approaches. First, examples of home-based and school-based intervention programs are described, followed by a review of several interventions that teach specific skills relevant to children with ASD eg, language interventions. It should be noted that for children under 2 years of age, ASD-specific interventions might not be widely available. Yet families and their children could benefit from other early intervention services such as speech-language therapy, and providers should seek opportunities for further training.

ABA has a body of data that supports it. Skills include responding to more than one cue, initiating behaviors such as help seeking and requesting, and responding to prompts. School-based programs intend to provide services to preschoolers within the traditional school context as opposed to specialized schools or the home-based services that are more typical before 3 years of age. The Treatment and Education of Autistic and Related Communication Handicapped Children TEACCH is a school-based program developed at the University of North Carolina, which focuses on structured teaching, visual spatial understanding, and object manipulation, all of which seem to be relevant learning principals for children with ASD.

The program also emphasizes development of communication skills through incidental teaching, and use of alternative communicative technique. Parent-delivered TEACCH intervention for preschoolers was found to be effective for improving developmental areas, such as cognition and nonverbal perception, when compared with a behavioral-education-only control group.

A second school-based program is the Denver Model, developed at the University of Colorado.

Autism Spectrum Disorder Updates – Relevant Information for Early Interventionists to Consider

The Denver Model is based on a developmental model of ASD that emphasizes the development of play skills, positive affect, interpersonal relationships, and language development. The Early Start Denver Model is the early intervention component of this model, which targets parents of children from 14 months to 3 years of age. For example, certain interventions target behaviors such as joint attention eg, Joint Attention [JA]. In a randomized, controlled trial that compared PECS and RPMT, 1 PECS was found to facilitate more generalized requests in children with little initiating joint attention, whereas 2 RPMT was found to facilitate turn taking and initiating joint attention for children with some initiating joint attention before the intervention.

These results suggest that certain interventions might be more appropriate for specific individuals at specific stages of development or based on a specific level of skill acquisition. To date, little research has been conducted to address which specific intervention will best meet the needs of specific children.

In light of the heterogeneity of symptom presentation and strengths and weaknesses observed among young children with ASD, research that informs how to tailor treatments to individual children is greatly needed. There is now clear evidence that the first signs and symptoms of ASD are evident for most children by 12 to 18 months of age. This knowledge, coupled with emerging evidence that early intervention that targets social-communicative behaviors improves long-term outcomes, has led to increased early detection efforts. Families who are confronted with a diagnosis of ASD often experience significant parenting stress and strain as they must navigate complex intervention decisions and learn to adapt to their child's unique set of challenges.

The severity of social and communication deficits, along with sensory sensitivities and behavioral difficulties, appears to exacerbate parenting stress. Helping parents of very young children learn how to facilitate their children's social and communicative behaviors is the goal of several relatively new interventions for young children eg, Early Denver Model, Floortime.

Such approaches, which show great promise for children's long-term adaptation, are also likely to increase parenting efficacy and reduce stress. Earlier detection and intervention efforts are improving the long-term functioning of children with ASD. This is an extremely exciting moment for research on young children with ASD. In addition to many novel experimental approaches, important questions regarding intervention are being studied, including dismantling studies that illuminate which intervention may be most efficacious for which children and families.

National Center for Biotechnology Information , U. Author manuscript; available in PMC Sep 4. Author information Article notes Copyright and License information Disclaimer. Autism, Young children, Early diagnosis, Early intervention, Family. See other articles in PMC that cite the published article. Qualitative impairment in social interaction as manifested by two of the following: Qualitative impairment in communication in at least one of the following areas: Restricted repetitive and stereotyped patterns of behaviors, interests, and activities as manifested by preoccupation with one or more restricted patterns of interests, inflexible adherence to nonfunctional routines or rituals, repetitive motor mannerisms, or preoccupation with parts of objects.

Table 1 Diagnostic criteria for autistic disorder. Domains Involved in ASD Symptomatology Related Areas Impaired or Delayed Social interaction Nonverbal behaviors Peer relationships Sharing of enjoyment Social and emotional reciprocity Communication Spoken language Conversation abilities Spontaneous play Restricted and repetitive behaviors Preoccupation with restricted interests Motor mannerisms Preoccupation with parts of objects Nonfunctional routines and rituals.

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Autism Spectrum Disorders in Young Children

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SIGNS OF ASD IN YOUNG CHILDREN

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