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Guidelines • Diagnosis, Assessment, & Treatment of ASD 2006 / 1Guidelines

Guidelines for Speech-LanguagePathologists in Diagnosis, Assessment,and Treatment of Autism SpectrumDisorders Across the Life Span

Ad Hoc Committee on Autism Spectrum Disorders

Reference this material as American Speech-Language-Hearing Association. (2006). Guidelines for speech-lan-guage pathologists in diagnosis, assessment, and treatmentof autism spectrum disorders across the life span. Availablefrom http://www.asha.org/members/deskref-jour-nal/deskref/default

Index terms: autism, autism spectrum disorders, pervasivedevelopmental disorders, family roles, screening, diag-nosis, social communication, assessment, intervention

Document type: GuidelinesAssociated documents: Position statement, knowledge and

skills, and technical report

This guideline document is an official statement of theAmerican Speech-Language-Hearing Association(ASHA). It was developed by ASHA’s Ad Hoc Commit-tee on Autism Spectrum Disorders. Members of the com-mittee were Amy Wetherby (chair), Sylvia Diehl, EmilyRubin, Adriana Schuler, Linda Watson, Jane Wegner, andAnn-Mari Pierotti (ex officio). Celia Hooper, vice presidentfor professional practices in speech-language pathology,2003–2005, served as the monitoring officer. A completelist of committee members with their credentials and af-filiations as well as a declaration of competing interest isprovided at the end of this document. The ASHA Scope ofPractice in Speech-Language Pathology (ASHA, 2001)states that the practice of speech-language pathology in-cludes providing services for individuals with disorders ofpragmatics and social aspects of communication, whichwould include individuals with autism spectrum disorders.This also includes individuals with severe disabilities andlanguage disabilities in general. The ASHA (2004b) Pre-ferred Practice Patterns are statements that define univer-sally applicable characteristics of practice. The guidelineswithin this document fulfill the need for more specific pro-cedures and protocols for serving individuals with autismspectrum disorders across the life span. It is required that

individuals who practice independently in this area holdthe Certificate of Clinical Competence in Speech-LanguagePathology and abide by the ASHA (2003a) Code of Eth-ics, including Principle of Ethics II, Rule B, which statesthat “individuals shall engage in only those aspects of theprofessions that are within the scope of their competence,considering their level of education, training, and experi-ence.” This document was disseminated for select and wide-spread peer review to speech-language pathologists,speech-language-hearing scientists, and audiologists withexpertise in autism spectrum disorders, high-functioningadults with autism, family members of children and adultswith autism, graduate students in communication sciencesand disorders, and related professionals. The document(LC_SLP/SLS_2-2006) was approved by ASHA’s Speech-Language Pathology/Speech or Language Science Assem-bly of the Legislative Council on February 3, 2006. Theguidelines will be reviewed and considered for revision ona regular basis (within no more than 5 years from the dateof publication). Decisions about the need for revision willbe based on new research, trends, and clinical practicesrelated to autism spectrum disorders.

Executive SummaryThis document provides guidelines for imple-

menting the American Speech-Language-HearingAssociation (ASHA) policy document titled Roles andResponsibilities of Speech-Language Pathologists in Diag-nosis, Assessment, and Treatment of Autism SpectrumDisorders Across the Life Span: Position Statement(ASHA, 2006c). These guidelines summarize currentknowledge derived from available empirical researchthat provides a basis for understanding the socialcommunication characteristics and challenges of in-dividuals with autism spectrum disorders (ASD) andaddresses clinical questions about the critical role ofthe family; tools and strategies for screening, diagno-

American Speech-Language-Hearing Association2 / 2006

sis, and assessment for program planning; character-istics of empirically supported intervention ap-proaches and strategies; and decision making inselecting intervention strategies. The guidelines alsoaddress service delivery models and preparationneeded by speech-language pathologists (SLPs) towork effectively with this population. This documentincludes conclusions and recommendations derivedfrom available empirical evidence that were formedby consensus of the ASHA Ad Hoc Committee onAutism Spectrum Disorders through 2 face-to-facemeetings and 12 phone conferences over the courseof 1 year. However, SLPs recognize that in areas forwhich empirical evidence is lacking, extrapolationsfrom evidence with other populations and applica-tions of principles stemming from theoretical mod-els, societal norms, and government mandates andregulations also are relevant for decision making.Recommended practices are expected to change asnew evidence emerges. Within a collaborative con-text, SLPs should be able to articulate both the prin-ciples and the levels of evidence that undergird theirservice delivery practices. SLPs serve as an integralpart of a team, including individuals with ASD andtheir families, that is responsible for formulating andimplementing service delivery plans that meet theunique communication needs of the individuals withASD. The recommended knowledge and skillsneeded by SLPs serving individuals with ASD arepresented in a companion document (ASHA, 2006a).Further, a technical report providing background anda basis for understanding the social communicationcharacteristics and challenges of individuals withASD also was developed by the committee to providefurther information and guidance on the implemen-tation of the roles and responsibilities outlined in theposition statement (ASHA, 2006b).

Core Characteristicsand Challenges in ASD

The population of ASD presents with tremen-dous heterogeneity. However, there are commoncharacteristics and challenges that compromise thedevelopment of critical social communication skills.The core features of ASD include impairments in so-cial communication including aspects of joint atten-tion (e.g., social orienting, establishing sharedattention, monitoring emotional states, and consid-ering another’s intentions), social reciprocity (e.g.,initiating bids for interaction, maintaining interac-tions by taking turns, and providing contingent re-sponses to bids for interaction initiated by others),language and related cognitive skills (e.g., under-standing and using nonverbal and verbal communi-cation, symbolic play, literacy skills, and executive

functioning—the ability to problem solve and self-monitor future, goal-directed, behavior), and behav-ior and emotional regulation (e.g., effectivelyregulating one’s emotional state and behavior whilefocusing attention on salient aspects of the environ-ment and engaging in social interaction). More detailabout core characteristics and challenges with sup-porting references is provided in the technical report(ASHA, 2006b). By their very nature, disabilities witha social component are transactional, meaning thatthere is interaction back and forth between the indi-vidual with ASD and his or her communication part-ner (Wetherby & Prizant, 2000). The core socialcommunication deficits of individuals with ASD maycreate a transactional dynamic of limited social expe-rience or social exclusion, which may contribute toimpaired development and learning (Mundy &Burnette, 2005; Schuler & Wolfberg, 2000). When so-cial communication challenges are present, those whointeract with the individual also face significant chal-lenges in learning to modify their interactive style andthe environment in order to communicate success-fully. Thus, challenges are evident for both the indi-vidual with ASD and his or her communicationpartners.

Role of Familiesand Navigating Resources

Family members of individuals with autism ful-fill multiple roles beyond those inherent in being amember of any family (S. Cohen, 1998; National Re-search Council [NRC], 2001). Parents, in particular,often may find themselves becoming investigators asthey search for information on autism characteristics,causes, and especially interventions; advocates for theservices they believe their child needs and is entitledto receive; collaborators in assessment and diagnosisas they attempt to define their child’s symptoms;cotherapists involved in organized intervention pro-grams; service coordinators and managers of teamsof interventionists involved with their child and fam-ily; financiers of nonpublicly funded services; andlobbyists for changes in laws and policies to benefittheir own child as well as other individuals with ASD.Other family members, including grandparents andsiblings, also may find themselves assuming some ofthese roles.

The multiple roles create challenges for familieswho are attempting to access vast information andservices through a variety of systems that may focuson different aspects of the disability or offer an over-whelming plethora of intervention options. Sourcesof support may include teachers, other intervention-ists, formal support groups, informal networking

Guidelines • Diagnosis, Assessment, & Treatment of ASD 2006 / 3

with other caregivers of persons with ASD, and fami-lies, friends, and neighbors (NRC, 2001). Geographiclocation (R. L. Koegel, Symon, & Koegel, 2002) andlack of financial resources (NRC, 2001) can be con-straints on access. In a study of Medicaid-eligiblechildren with autism, for instance, Mandell, Literud,Levy, and Pinto-Martin (2002) found that AfricanAmerican children received diagnoses 1_ years laterthan Caucasian children, on average, with a mean ageof diagnosis of 7.9 years for the African Americanchildren with autism. Although this study did notinclude a comparison group of higher income chil-dren, the relatively late mean age of diagnosis for allthe Medicaid-eligible children included in theMandell et al. study suggests that few children in low-income families received services during their pre-school years, regardless of race.

Other cultural and linguistic factors may playroles in families’ access to or use of services (Dyches,Wilder, Sudweeks, Obiakor, & Algozzine, 2004;Wilder, Dyches, Obiakor, & Algozzine, 2004). Forexample, there is variability in the rate at which chil-dren from racial and ethnic minority groups areserved under the label of autism in the public schools(Dyches et al., 2004). This variability may be due tocomplex interactions between the values of familiesfrom different cultural backgrounds, and linguisticand cultural differences, which may contribute to anover- or underidentification of ASD among certaingroups. Ultimately, the diagnostic label of an indi-vidual will influence the information and resourcesthat will be offered to families or that the families willseek on their own. When a diagnosis of ASD is given,families will have different understandings of whatthe diagnosis means, views of etiology, attitudes to-ward the disability, and motivations regarding ac-cessing services. Families with limited Englishproficiency may face linguistic barriers to navigatinginformation and service systems in the United States.In addition, families of individuals with ASD maychoose alternative forms of treatment based on indi-vidual values or cultural background. For example,one study reported that Latino families were morelikely to access complementary and alternative medi-cal treatments for their children than were Caucasianor African American families (Levy, Mandell,Merhar, Ittenbach, & Pinto-Martin, 2003).

Special Demands on Families

Families of children with autism experiencemany special demands, including the increased inten-sity of caregiving required to meet the needs of thefamily member with ASD, the multiple roles familymembers may assume beyond those of caregiver,concerns about the impact of the disability on family

members other than the person with ASD, challengesin planning family events, and the responsibilities ofthe family as decision makers regarding services forthe member with ASD (NRC, 2001). They also mayface increased financial demands often combinedwith more limited income if a primary caregiver cutsback on or discontinues employment in order to carefor the individual with autism. Families often con-front problems related to obtaining an accurate diag-nosis, managing extremely challenging behaviors,dealing with limited understanding or tolerance ofbehaviors associated with ASD, reviewing claims andinformation regarding intervention effectiveness, andchoosing and implementing services for the indi-vidual with autism (D. E. Gray & Holden, 1992). Forsome families, demands are intensified by the par-ticular behavioral patterns of the child with ASD. Forexample, parents of children with autism, as a group,report more sleep problems in their children than doparents of children with other developmental dis-abilities (DD) or parents of typically developing chil-dren (Schreck & Mulick, 2000). Sleep problems of thechildren may lead to more daytime behavior prob-lems, a decrease in the effectiveness of interventionprograms, and disruption of the entire family’s sleep(Honomichl, Goodlin-Jones, Burnham, Gaylor, &Anders, 2002).

The nature of the demands and impacts on fami-lies of persons with ASD changes over time (Seltzer,Krauss, Orsmond, & Vestal, 2001). Families ofyounger children are more likely to experience stressrelated to obtaining a diagnosis and locating re-sources to meet their child’s needs; later, families maybecome more concerned with the development ofself-care skills in the child (Seltzer et al., 2001) or maybe concerned with issues related to their child’s iso-lation or experiences of bullying at school (D. E. Gray,2002). During adolescence, concerns may include re-strictions on family activities due to the challenge ofmanaging public behavior and coping with a realiza-tion that the child’s disability is permanent and willrequire an extension of the roles of family membersas caregivers (DeMyer & Goldberg, 1983). The lim-ited research available on families of adults with au-tism suggests that planning for future care is a majorissue (Seltzer et al., 2001).

Given the demands and problems confronted byfamilies of individuals with ASD, it is not surprisingthat a number of studies have found that parents ofchildren with autism, especially mothers, report morestress than parents of children with other disabilitiesas well as parents of typically developing children(e.g., Dumas, Wolf, Fisman, & Culligan, 1991; Fisman,Wolf, & Noh, 1989; Holroyd & McArthur, 1976;Rodrigue, Morgan, & Geffken, 1990). Parents of chil-


dren with autism may be at increased risk for depres-sion compared with parents of children with otherdisabilities (Gold, 1993; R. L. Koegel, Schreibman, etal., 1992). Genetic factors possibly contribute to thisfinding (Ghaziuddin, Ghaziuddin, & Greden, 2002),so that stress related to parenting a child with ASDmay not account completely for the increased inci-dence of depressive symptoms.

The individual with ASD is also at increased riskfor depression, anxiety disorders, and obsessive/compulsive behaviors (Ghaziuddin et al., 2002). Di-agnosis of depression is more common in older,higher functioning individuals with ASD than inyounger and lower functioning individuals, but thismay be related to the challenges of diagnosing de-pression in individuals with limited communicationskills. Depression may exacerbate behavior problems,leading to greater stresses on other members of thefamily.

More psychological problems have been reportedamong siblings of children with autism than in con-trol groups (Bagenholm & Gillberg, 1991; Fisman,Wolf, Ellison, & Freeman, 2000; Fisman et al., 1996;Gold, 1993; Rodrigue, Geffken, & Morgan, 1993;Roeyers & Mycke, 1995). Suggested moderators of theadjustment for siblings of children with ASD or otherDD include sibling gender, match of gender betweensibling and child with ASD or DD, whether sibling isolder or younger, age of sibling, and whether thechild with ASD or DD resides at home; however,these variables have not proven to have strong effectson sibling adjustment (Hastings, 2003).

As in parental depression, the increase in psycho-logical problems among siblings of children withASD may be related to shared genetic material andexpressions of the broader autism phenotype ratherthan being directly influenced by the presence of thechild with ASD. Nevertheless, the presence of devel-opmental or psychological problems among siblingsof children with ASD, or the presence of multiple fam-ily members with ASD, can add to the demands onfamilies and influence their ability to cope success-fully with those demands.

Despite the increased demands and risks forfamilies of individuals with ASD, many families copesuccessfully. In some cases, the activities involved inmeeting increased demands, such as learning inter-vention strategies or working with the child in anintervention program, are associated with reports ofdecreased stress by mothers of children with ASD(Bristol, Gallagher, & Holt, 1993; R. L. Koegel,Bimbela, & Schreibman, 1996). Stress also is alleviatedby perceived social support from both informal net-works and formal support systems (NRC, 2001).

Learning From Families

A philosophical mandate for family-centeredpractices has permeated both health care and educa-tional fields. This philosophy offers a foundation foreffective family–professional collaborations in assess-ment, diagnosis, and treatment of individuals withASD (Prelock, Beatson, Bitner, Broder, & Ducker,2003). Family-centered practices include careful atten-tion to family priorities and concerns in planning in-terventions (e.g., Marshall & Mirenda, 2002), as wellas to learning about the family system that includesan individual with autism, and developingcontextualized assessments and interventions thatrespect the family system and preferences(Hecimovic, Powell, & Christensen, 1999; Moes &Frea, 2000). Recognition that professionals have muchto learn from the families of individuals with ASD isreflected by the inclusion of family members as au-thors in various books and journal issues devoted toASD (e.g., Angell, 1993; Dominigue, Cutler, &McTarnaghan, 2000). Families of individuals withASD have assumed increasingly important roles inpromoting a broader-based awareness and under-standing of the disorders, and in the search for effec-tive treatments through their collaborations withprofessionals to set a national research agenda, ensurethe availability of research funding, and encourageparticipation in research (e.g., Anders, Gardner, &Gardner, 2003; Hollander, Robinson, & Compton,2004).

Teaching Families Needed Skills

Given the nature of autism and the needs of in-dividuals with ASD, families often become teachersand interventionists (NRC, 2001). Family involve-ment in teaching children with ASD has been docu-mented since the 1960s (Turnbull, Turnbull, Erwin,& Soodak, in press), though some families today placeless importance on their roles as teachers and insteadwant more information on varying topics (Turnbull,Blue-Banning, Turbiville, & Park, 1999). Most com-prehensive programs for individuals with autismoffer parents training (NRC, 2001). It is important toremember that teaching families skills is but one partof family-centered service provision (Dunlap & Fox,1999).

Families are consistent communication partnerswho should be provided with opportunities to giveinformation about their child, to learn new skills, andto receive information about available resources.How and what families are taught have been influ-enced by a shift from the “expert” model of parenteducation, in which the professional directs the par-ents, to a more collaborative model, in which familyindividuality is recognized and families define their


own needs and level of involvement (Becker-Contrill,McFarland, & Anderson, 2003; Turnbull et al., inpress). SLPs should establish partnerships with fami-lies to develop meaningful learning opportunities,provide information, teach strategies, and offer feed-back. Though the content and format of such teach-ing should be developed in partnership with families,teaching families interaction skills to support andmanage behavior and the development of communi-cation and language is important and should be on-going (Dunlap & Fox, 1999; NRC, 2001).

Supporting Families

Families of individuals with autism benefit fromsupport beyond the learning of new skills. They ben-efit from formal and informal supports as well (NRC,2001). Formal supports emerge from collaborativepartnerships between families and professionals,while informal supports include support groups, in-formal parent networks, and family members andfriends (NCR, 2001). Support for families is an ongo-ing process that takes different forms with differentfamilies based on their individual concerns, priorities,and interests (Blue-Banning, Summers, Frankland,Nelson, & Beegle, 2004; Dunlap & Fox, 1999; Sandall,Hemmeter, Smith, & McLean, 2005).

SLPs can support families by ensuring that fam-ily-centered, collaborative partnerships are estab-lished (Sperry, Whatley, Shaw, & Brame, 1999).Through this partnership, support may take differ-ent forms at different times, including coordinatingservices for the family, procuring resources and in-formation, teaching the family or other significantcommunication partners specific skills, and advocat-ing for or with the family.

Collaborative relationships with families are ap-propriately incorporated into the full range of rolesthat SLPs assume in providing services to individu-als with ASD (Diehl, 2003a). As diagnosticians, SLPs’roles include incorporating a family perspective intothe assessment of an individual, effectively elicitinginformation from families about their concerns, be-liefs, skills, and knowledge in relation to the indi-vidual being assessed. The SLP also should possessskills and personal qualities to convey information tofamilies clearly and empathetically, with an under-standing that the assessment and diagnosis processis likely to be stressful and emotion-laden for familymembers (Marcus, Kunce, & Schopler, 2005). The SLPalso should be sensitive to the fact that families pre-viously may have received information or arrived atconclusions about the family member of concern thatcreate conflict or confusion when juxtaposed with theinformation and conclusions provided by the SLP(Marcus et al., 2005).

As interventionists, SLPs’ roles with families in-clude incorporating family priorities for adaptationof the individual with ASD and/or of significant oth-ers who interact with the individual with ASD. Diehl(2003b) recommends the collaborative developmentof a family vision as the first step in the communica-tion assessment and intervention planning process.The family vision then drives the rest of the process.SLPs should be knowledgeable about interventionoptions and skillful in sharing with families the avail-able evidence on different options in an objectivemanner, while empowering the families to makechoices among those options that are most consistentwith the family vision. Ideally, the SLP and the fam-ily will arrive at a collaborative plan for interventiongoals and strategies. In cases where the SLP is unableto support intervention options that the family wantsto pursue, the clinician needs to explain the basis forhis or her disagreement without being coercive. Thisrequires that the SLP maintain current knowledgeabout the evidence base for different interventionsaimed at improving the social communication devel-opment and adaptation of individuals with ASD. In-dividuals with ASD seem to inspire more than theirshare of unproven but often highly promoted treat-ments (Diehl, 2003b), and thus the SLP working withfamilies of individuals with ASD frequently will en-counter families who want to pursue these ap-proaches.

The SLP should assist families in evaluating thelikely benefits and possible harms of different inter-vention approaches but also should recognize thelimitations in current empirical findings, which oftendo not provide a clear path for families and profes-sionals trying to make the best decisions for a particu-lar individual (cf. Marcus et al., 2005). Levy andHyman (2005) have provided a useful review of avail-able evidence on some complementary and alterna-tive medical therapies currently accessed bysubstantial numbers of parents with ASD. In addi-tion, Volkmar and Wiesner (2004) have written a bookfor caregivers of individuals with ASD to assist themin addressing health care needs, with a section de-voted to evaluating a variety of alternative treat-ments. The SLP can refer families to sources thatdiscuss controversial treatments (e.g., Volkmar &Wiesner, 2004); it is particularly important that theSLP alert parents to information about reportedharmful outcomes of treatments that they may beconsidering. In addition, as part of a multidisciplinaryteam, the SLP can assist families in developing a planto assess the effectiveness of different treatments theychoose for their family member with ASD. For ex-ample, if a family decides to try a dietary interven-tion for their child with ASD, the SLP can assist the


family in developing a plan for a trial period of hav-ing the child on the diet followed by a period off thediet, in conjunction with having some service pro-vider who sees the child regularly, but is unaware ofhis or her dietary status, complete behavior ratingsduring both time periods.

Marcus et al. (2005) outlined several differentstrategies that may be used in providing support tofamilies of individuals with ASD. All of these arepossible services and support activities that SLPs canincorporate into their work with families. These ap-proaches include (a) education, or providing informa-tion from the professional literature on topics such asASD, child development, learning principles, andintervention approaches to family members; (b)cotherapy, in which the professionals and familymembers play complementary roles in developingintervention goals and providing direct interventionto the person with ASD; (c) behavioral approaches,in which family members learn and apply specificbehavior-shaping strategies in intervention with theperson with ASD; (d) relationship enhancement, inwhich family members learn to attend to the interestsof the child with ASD and to incorporate child-di-rected intervention strategies into their interactions;(e) cognitive approaches, in which family membersdevelop such skills as problem solving, cognitive re-structuring, and setting realistic expectations; (f)emotional support, in which professionals provideempathetic listening and problem-solving strategiesfor family-identified concerns; (g) instrumental sup-port, in which professionals assist family members incase coordination and access to resources and ser-vices; and (h) advocacy training and support, inwhich professionals assist families in learning to ad-vocate for the services and system changes that theindividual with ASD requires to meet his or her needsacross the lifespan. Although research indicates thathaving families play a critical role in the interventionprocess is an important part of effective programs(NRC, 2001), research is not available yet to indicatewhich of these services and support strategies or whatcombination is most effective.

Summary of Recommendations

SLPs should form partnerships with families inassessment and intervention with individuals withASD, as effective programs have active family in-volvement. SLPs should consider how cultural, lin-guistic, and socioeconomic factors affect families’access to or use and selection of services. SLPs shouldprovide counseling, education and training, coordi-nation of services, and advocacy for families usingpractices that incorporate family preferences andaddress family priorities.

Screening and Diagnosis

The Important Role of the SLP

Given the importance of social communication inthe diagnosis of ASD, the SLP can play an importantrole in both screening and diagnosis. The Child Neu-rology Society and American Academy of Neurologyformed a multidisciplinary consensus panel to deter-mine practice parameters for screening and diagno-sis of ASD (Filipek et al., 1999). The panel includedrepresentatives from the disciplines of psychiatry,neurology, pediatrics, psychology, speech-languagepathology, audiology, and occupational therapy, aswell as from autism advocacy organizations, with li-aisons from the National Institutes of Health. Thepanel concluded that all professionals involved inearly health care, including SLPs, need to be able torecognize the symptoms of ASD and use autism-screening tools to make decisions about appropriatereferrals for further evaluations (Filipek et al., 1999).This panel emphasized the importance of interdisci-plinary collaboration in assessing and diagnosingASD, due to the complexity of these disorders, thevaried aspects of functioning affected, and the needto distinguish it from other disorders or medical con-ditions. Further, Filipek et al. stressed that profession-als involved in diagnosis of ASD must beknowledgeable and experienced in using guides suchas the Diagnostic and Statistical Manual of Mental Dis-orders, Fourth Edition (DSM–IV; American Psychiat-ric Association, 1994, 2000) along with results ofvarious diagnostic assessment tools to make clinicaljudgments about these types of disorders. A compre-hensive interdisciplinary assessment is important notonly for diagnosis but also for intervention planning.Thus, ideally the diagnostic role of the SLP would beas a key member of an interdisciplinary team with theappropriate individual and collective expertise inASD. In some cases, however, there may be no ap-propriate team accessible to a family. As Filipek et al.(1999) stated, “Language pathologists are indepen-dent health care providers who have responsibilitiesat the levels of screening (Level 1), diagnosis andevaluation (Level 2) of autism” (p. 461). The SLP whohas been trained in the clinical criteria for ASD, aswell as in the use of reliable and valid diagnostic andassessment tools for individuals with ASD, and whois experienced in diagnosis of developmental disor-ders, may be qualified to diagnose these disorders asan independent professional. It would be incumbentupon the SLP to ensure that diagnostic findings areinterpreted in relation to measures of nonverbal de-velopmental level or IQ and to make appropriate re-ferrals to other professionals to obtain a thoroughassessment of the individual’s needs and determina-


tion of any comorbid diagnoses that lie outside theexpertise of the SLP. The SLP plays a critical role inreferring children suspected of possible ASD to anaudiologist to confirm or rule out a hearing loss. Fur-thermore, the SLP should play a primary role in thediagnosis of speech and language impairments thatcan co-occur with ASD, including, but not limited to,features of specific language impairment, apraxia,and dysarthria. The SLP should be aware that somestate laws or regulations may restrict the scope ofpractice of licensees, however, and prohibit the SLPfrom providing such diagnoses.

Designation of a student with a disability withinschool settings must be made within the team deci-sion-making process as designated by the Individu-als with Disabilities Education Improvement Act of2004 (IDEA, 2004). Within a public school setting,eligibility for services under the disability categoryof autism is based on the definition provided in theIDEA, as provided below:

Autism means a developmental disabilitysignificantly affecting verbal and nonverbalcommunication and social interaction, gen-erally evident before age 3, which adverselyaffects a child’s educational performance.Other characteristics often associated withautism are engagement in repetitive activitiesand stereotyped movements, resistance toenvironmental change or change in dailyroutines, and unusual responses to sensoryexperiences. The term does not apply if achild’s educational performance is adverselyaffected primarily because the child has anemotional disturbance as defined by IDEAcriterion.

A child who manifests the characteristics of“autism” after age 3 could be diagnosed ashaving “autism” if the criteria in the preced-ing paragraph are met. (34 C.F.R. § 300.7 [c][1])

Individuals diagnosed with an ASD or pervasive de-velopmental disorder by means of other sources ofclinical criteria, such as the DSM–IV–TR (AmericanPsychiatric Association, 2000), are likely to be eligiblefor special education services under the category ofautism as defined above, due to the common chal-lenges and deficits in social communication function-ing across the various disorders on the autismspectrum.

Screening for ASD

Early indicators of ASD are observable by age 12months (Baranek, 1999; Osterling & Dawson, 1994,1999; Wetherby et al., 2004; Zwaigenbaum et al.,

2005), and ASD can be reliably diagnosed as early asage 24 months by experienced and knowledgeable di-agnosticians (Filipek et al., 1999). The main charac-teristics that differentiate ASD from otherdevelopmental disorders in young children includedifficulties in eye gaze, orienting to one’s name, point-ing to or showing objects of interest, pretend play,imitation, nonverbal communication, and languagedevelopment. It is important to consider cultural di-versity of social communication when examiningthese areas. In addition, loss of language or socialskills at any age should be considered grounds forscreening (Filipek et al., 1999). Because children withASD are often initially suspected of having a hearingproblem, audiologists are in a critical role to spotpossible signs of ASD in children whose hearing theyare testing and to make appropriate referrals forscreening and diagnosis of ASD.

Screening for ASD may utilize broadbandscreeners designed to detect developmental delays inthe general pediatric population or autism-specificscreening tools designed for either the general popu-lation or high-risk populations such as children re-ferred to the early intervention system. Any screeningtool should have strong psychometric features tosupport its accuracy in identifying at-risk childrenwho need further evaluation. The following propor-tions provide particularly important informationabout the accuracy of a screening tool:

• sensitivity, or true positives—the percent-age of children identified as at risk (i.e., re-ceiving a positive screen or evaluation result)who failed the follow-up testing or receiveda diagnosis of ASD. The percentage of truepositives added to the percentage of falsenegatives (i.e., the proportion of childrenidentified as no risk, by receiving a negativescreen or evaluation result, who failed thefollow-up testing or received a diagnosis ofASD) equals 100%. Thus, a lower false nega-tive rate means a higher true positive rate.

• specificity, or true negatives—the propor-tion of children identified as no risk (i.e., re-ceiving a negative screen or evaluationresult) who passed the follow-up testing orfor whom ASD was ruled out. The percent-age of true negatives added with the percent-age of false positives (i.e., the proportion ofchildren identified as at risk, by receiving apositive screen or evaluation result, whopassed the follow-up testing or for whomASD was ruled out) equals 100%. Thus, alower false positive rate means a higher truenegative rate.


• positive predictive value—the proportion ofchildren identified as at risk who fail the fol-low-up testing out of the total number of chil-dren identified as at risk.

• negative predictive value—the proportionof children identified as no risk who pass thefollow-up testing out of the total number ofchildren identified as no risk.

To be considered psychometrically sound, ascreening tool would minimally need to report sen-sitivity and specificity. Meisels (1989) recommendedthat cutoffs for both sensitivity and specificity be setat no less than 80% for developmental screening ofyoung children; however, he noted that a “75% sen-sitivity ratio is considerably less favorable than a 75%specificity proportion” (p. 579). It is also importantto consider the positive predictive value; however,this is related to the base rate of a disorder. That is,the higher the prevalence rate of the disorder, thegreater the probability that a positive result will becorrect and the higher the positive predictive value.In screening a general population for relatively lowincidence disorders such as ASD, even an instrumentwith a sensitivity and specificity of .80 will yield apoor positive predicative value. In other words, thelower the prevalence rate of a disorder, the lower theprobability that an individual has the disorder givena positive screen result. As Clark and Harrington(1999) point out, screening tools are intended to iden-tify individuals who may be at risk for a disorderrather than to serve as “gold standards” for determin-ing a diagnosis. Thus, professionals must not assumethat failing a screening means that an individual hasan ASD and must instead complete thorough assess-ments before providing a diagnosis.

There is currently very limited research on theaccuracy of broadband screeners to identify youngchildren at risk for ASD. The First Signs program(www.firstsigns.org), a national nonprofit organiza-tion whose goal is to improve early identification ofASD, has assembled a set of psychometrically soundbroadband screeners based on parent report that in-clude the Ages and Stages Questionnaire (Squires,Potter, & Bricker, 1999), the Parents’ Evaluation ofDevelopmental Status (Glascoe, 1997), and the Com-munication and Symbolic Behavior Scales Develop-mental Profile (CSBSDP) Infant Toddler Checklist(ITC; Wetherby & Prizant, 2002). All three of thesebroadband screeners have sensitivity and specificityat or near 80% for identifying children with develop-mental delays from a general pediatric population.The ITC is the only broadband screener that has pre-liminary validation data showing it has high sensi-tivity and specificity (both 88.9%) for catching

toddlers at risk for ASD and other developmentaldelays using a prospective sample of more than 3,000children (Wetherby et al., 2004).

Autism-specific screeners use parent report and/or interactive observational measures. Because of thechallenge of identifying very young children withASD, there is limited research on the accuracy of au-tism-specific screeners. Some of the tools have beenvalidated on children referred to health care or edu-cation agencies because autism was suspected orfrom children who already have been identified ashaving developmental delays or disabilities. How-ever, it is important also to validate autism-specificscreeners, either as an initial screener or follow-up toa broadband screener, on a general populationsample, since this is ultimately how they will be usedclinically. This is particularly critical for higher func-tioning children who may be more easily missed andnot be referred into the system. Following are autism-specific screening tools that have some publishedpsychometric information, including sensitivity andspecificity.

Checklist for Autism in Toddlers (CHAT; Baird etal., 2000; Baron-Cohen, Allen, & Gillberg, 1992; Baron-Cohen et al., 1996). The CHAT consists of 9 items re-ported by parents and 5 items observed by a healthprofessional at the 18-month developmental checkup.Baron-Cohen and colleagues screened more than16,000 children using the CHAT and identified 19children at 18 months who were later diagnosed withASD based on failure of the following 3 key items: (a)protodeclarative pointing, (b) pretend play, and (c)gaze monitoring. However, at follow-up at age 7years, 94 cases of ASD were identified. These findingsindicate that the CHAT has a specificity of 98% but asensitivity of 38% (Baird et al., 2000) and missed manychildren at 18 months who were later diagnosed withASD. While the validity of the CHAT is disappoint-ing, it indicates that some children with ASD can beidentified at 18 months and provides clues to earlyindicators of ASD, based on the children they wereable to identify early. The poor sensitivity indicatesthat it should not be relied on as an accurate screenerand likely does not merit the time in a pediatric prac-tice.

Modified Checklist for Autism in Toddlers (M-CHAT; Robins, Fein, Barton, & Green, 2001). The M-CHAT is an expanded version of the original CHAT.The M-CHAT has 23 questions using the original 9items from the CHAT as a basis. The M-CHAT iscurrently in its final stages of testing and validationand has not yet been validated for general populationscreening. Preliminary results, however, have sug-gested that it has improved sensitivity compared with


the CHAT. The M-CHAT has demonstrated validityin identifying the majority of children with ASD anddevelopmental delay from age 24 months in a studyin which most of the at-risk children had been re-ferred already to early intervention programs due todevelopmental concerns. Follow-up data for childrenwho were not found to be at risk on the M-CHAThave not been published yet; thus, the extent to whichthe M-CHAT may miss children who will later bediagnosed with ASD is still unknown. The M-CHATis available in both Spanish and English.

Social Communication Questionnaire (SCQ; Rutter,Bailey, Lord, & Berument, 2003). The SCQ is a 40-itemparent report screening tool for ASD and is a compo-nent of the Autism Diagnostic Interview, describedbelow. The SCQ is an autism-specific screening tool;that is, the intended use of the SCQ is for screeningindividuals previously identified with developmen-tal concerns. The SCQ yields a total score with 0 in-dicating no risk for ASD and 15 or higher indicatingrisk for ASD. The SCQ has been validated as a screen-ing tool for ASD in children age 4 and older, as wellas adults, and has good sensitivity and specificity.Preliminary research indicates that the specificity andsensitivity of the SCQ are slightly poorer for youngerchildren based on 112 children between age 2 and 5compared with 181 individuals over age 5 (Corsello,Cook, & Leventhal, 2003). Therefore, caution shouldbe taken in using this with younger children; how-ever, further research is needed on children under 4.

Pervasive Developmental Disorders Screening Test,Second Edition (PDDST–II; Siegel, 2004). Research onthe PDDST–II has been presented at several confer-ences but has not yet appeared in the peer-reviewedliterature. The PDDST–II is a clinically derived self-administered parent questionnaire divided into threestages. PDDST–II Stage 1 is intended for use in theprimary care setting with items ordered developmen-tally from birth to age 36 months. The cutoff score forStage 1 was derived by comparing results for 197 verylow birth-weight children with those for 380 childrenreferred due to concerns about possible ASD (someof whom were later diagnosed with ASD, and someof whom did not receive ASD diagnoses). The sensi-tivity and specificity were 85% and 71%, respectively,in identifying those children in need of further evalu-ation for possible ASD. The questionnaire has notbeen validated with a general population sample,however. The PDDST–II Stage 2 screener is intendedto aid in differentiating a possible diagnosis of ASDfrom other disorders such as developmental languagedelay, mental retardation, or ADHD. In a study in-volving 260 children with ASD and 120 children withother developmental disorders, different cutoff scoresyielded sensitivity ranging from 69% to 88% and

specificity ranging from 25% to 63%. The purpose ofthe PDDST–II Stage 3 is to assist in differentiatingchildren with autistic disorder from those with otherpervasive developmental disorders and to provideinformation on symptom severity. The author is con-tinuing research and development on this instrument,but the preliminary results suggest it has utility forscreening and diagnosing young children.

Screening Test for Autism in Two-Year-Olds (STAT;Stone, Coonrod, & Ousley, 2000; Stone, Coonrod,Turner, & Pozdol, 2004; Stone & Ousley, 1997). TheSTAT is a direct observational scale designed for chil-dren from age 24 to 35 months. The purpose of theSTAT is to serve as a Level 2 tool to screen for autismamong young children referred for developmentalconcerns. The 20-minute play interaction includes 12activities that sample 3 main developmental areas:play, motor imitation, and nonverbal communication.Stone et al. (2004) reported a sensitivity of 92% andspecificity of 85% for this instrument in identifyingchildren between the ages of 24 and 35 months withautistic disorder. The sensitivity of the instrument inscreening for other variants of ASD was lower. As theauthors point out, underidentification of childrenwith milder symptoms is an issue for other screen-ing tools and procedures as well. The authors alsoreported results indicating that the STAT has goodinterobserver and test–retest reliability, as well asconcurrent validity with clinical diagnoses of autis-tic disorder and results of independent assessment onthe Autism Diagnostic Observation Schedule (ADOS;Lord, Rutter, DiLavore, & Risi, 1999; see below).

Systematic Observation of Red Flags (SORF;Wetherby et al., 2004). The SORF consists of an ob-servational rating of 29 potential “red flags” for ASDthat can be scored from video of the CSBS DP Behav-ior Sample (Wetherby et al., 2004). The BehaviorSample uses a standard set of systematic proceduresdesigned to encourage spontaneous behaviors thatrange in degree of structure provided. Thirteen of theitems on the SORF have been shown to discriminatetoddlers who later are diagnosed with ASD from tod-dlers younger than age 2 with typical developmentand those with developmental delay in which ASDhad been ruled out, with an accuracy of 94.4%(Wetherby et al., 2004). This indicates strong sensitiv-ity and specificity on a preliminary sample of 18 chil-dren later diagnosed with ASD identified from ageneral population screen of about 3,000 children.The following red flags distinguished the childrenwith ASD from children who were developmentallydelayed in which ASD was ruled out and who weretypically developing in the second year of life: (a) lackof appropriate gaze; (b) lack of warm, joyful expres-sions with gaze; (c) lack of sharing enjoyment or in-


terest; (d) lack of response to name; (e) lack of coor-dination of gaze, facial expression, gesture, andsound; (f) lack of showing; (g) unusual prosody; (h)repetitive movements or posturing of body, arms,hands, or fingers; and (i) repetitive movements withobjects. The following red flags distinguished thechildren with ASD and developmental delay from thetypically developing children: (a) lack of response tocontextual cues; (b) lack of pointing; (c) lack of vocal-izations with consonants; and (d) lack of playing witha variety of toys conventionally.

Diagnosis of ASD

An early accurate diagnosis can assist in earlieraccess to needed services and appropriate treatment.Diagnosis also can provide a common languageacross multidisciplinary teams and can lead to somesense of relief for families and caregivers who areprovided with a framework within which to under-stand their child’s difficulties. Any diagnosis of ASD,particularly of young children, should be periodicallyreviewed, as diagnostic categories and conclusionsmay change as the child develops.

The following information should be gathered ina diagnostic evaluation of children at risk for ASD:(a) review of relevant background information toguide the diagnostic evaluation and the selection ofappropriate tools; (b) caregiver interview to gatherhealth, developmental, and behavioral history of thechild and medical and mental health history of thefamily; and (c) direct behavior observation. A medi-cal evaluation should be completed based on the rec-ommendations of the American Academy ofPediatrics on the role of the pediatrician in the diag-nosis and management of ASD (American Academyof Pediatrics, 2001a, 2001b). A medical evaluation fora child at risk for ASD should consist of a generalphysical and neurodevelopmental examination, in-cluding evaluations of vision and hearing. In addi-tion, if there is a family history of mental retardationor genetic conditions sometimes associated with ASD(e.g., fragile X, tuberous sclerosis), or if the child ex-hibits physical features suggestive of a possible ge-netic syndrome, then a recommendation for genetictesting would be appropriate. If the child exhibitssymptoms such as lethargy, cyclic vomiting, pica, orseizures, then selective metabolic testing may be ap-propriate (Filipek et al., 1999).

A diagnostic evaluation to confirm or rule out adiagnosis of autism or ASD should be performed onlyby professionals who have specific expertise in theevaluation and treatment of autism (Filipek et al.,1999; NRC, 2001). Diagnostic tools for ASD includeparent or caregiver report (i.e., interview or question-naire) as well as diagnostic observation instruments.

Following are diagnostic tools for ASD that havesome published psychometric information includingevidence of reliability and validity.

The ADOS (Lord et al., 2000) is a semistructuredobservational assessment in four modules that in-cludes activities designed to evaluate communica-tion, reciprocal social interaction, play, stereotypicbehavior, restricted interests, and other abnormalbehaviors in individuals with ASD across the agerange from preschool to adulthood and covering lan-guage skills from nonverbal to conversational. TheADOS consists of four modules developed for indi-viduals with varying levels of linguistic ability; eachmodule includes a set of activities that press for dif-ferent behaviors that contribute to a diagnosis of au-tism or ASD. Administration requires 30–45 minutes,thus making the ADOS a feasible diagnostic tool inmany clinical settings. As indicated in a recent reviewof autism diagnostic tools (Lord & Corsello, 2005),research has documented excellent interrater reliabil-ity for ADOS total scores (following substantial train-ing and practice) and excellent internal consistencyfor the two major domains of social communicationbehaviors and restricted-repetitive behaviors. TheADOS scores also have a high degree of accuracywhen compared with expert clinical diagnoses usingDSM–IV criteria. Lord et al. (2000) reported that thesensitivity of the four modules ranged from 90% to97%, and the specificity ranged from 87% to 93% inidentifying individuals with ASD versus individualswith other DD who were outside the autism spec-trum. The ADOS does not perform particularly wellin discriminating between individuals diagnosedwith autistic disorder versus pervasive developmen-tal disorders not otherwise specified (PDD-NOS),however. Lord and Corsello (2005) note that ADOSscores slightly overinclude young children with men-tal retardation in the autism spectrum and slightlyunderinclude older children and adults with milderimpairments and relatively high verbal skills.

The Childhood Autism Rating Scale (CARS;Schopler, Reichler, & Renner, 1988) is a 15-item struc-tured interview and observation instrument that issuitable for use with children above age 24 monthsonly. Each of the 15 items uses a 7-point rating scaleto indicate the degree to which the child’s behaviordeviates from an age-appropriate norm. It also dis-tinguishes between mild-to-moderate and severepresentations of ASD. The CARS is recognized widelyand used as a reliable instrument for the diagnosis ofASD (e.g., Morgan, 1988; Sevin, Matson, Coe, Fee, &Sevin, 1991). The examiner rates the child based onobservation of behaviors exhibited during other as-sessment activities. The CARS takes approximately15 minutes to complete but should be based on op-


portunities to observe the child across at least a 1-hourtime period and across a variety of types of activitiesand interactions. It can be used reliably with relativelylimited training and is available in a number of lan-guages other than English. In a recent review of di-agnostic instruments for autism, Lord and Corsello(2005) conclude that the evidence across several stud-ies indicates the CARS may overidentify children asfalling into the autism spectrum, particularly whenthe children have low verbal skills and/or low cog-nitive levels. For this reason, they do not recommendthe exclusive use of the CARS in identifying or clas-sifying participants for research purposes. Althoughthe CARS was originally developed to correspond tothe DSM, Third Edition (DSM–III; American Psychi-atric Association, 1980), a recent study reported 100%agreement between clinical diagnoses of autistic dis-order (vs. other disorders including Asperger’s andPDD-NOS) using DSM–IV criteria and a classificationthat was based on the CARS cutoff score (Rellini,Tortolani, Trillo, Carbone, & Montecchi, 2004), sug-gesting that the CARS continues to have clinical util-ity in identifying children with autistic disorder, butnot for diagnosing children with other ASD.

The Autism Diagnostic Interview—Revised (ADI–R; Rutter, LeCouteur, & Lord, 2003) is a comprehen-sive structured parent interview that probes forsymptoms of ASD in the areas of social relatedness,communication, and ritualistic or perseverative be-haviors. With this tool, information about the devel-opmental history of the individual is combined withinformation about current behaviors and used in ascoring algorithm to indicate whether the personmeets the DSM–IV criteria for autism or a relateddisorder. Administration takes approximately 2 to 3hours and requires specific training and validationprocedures. Due to the length of the ADI–R, it is usedrelatively infrequently in purely clinical settings. Inreviewing research on the instrument, Lord andCorsello (2005) noted that with training, highinterrater reliabilities have been achieved for each ofthe three subscales of the ADI–R (social reciprocity,communication, and restricted-repetitive behaviors).Internal consistency is also excellent within the threesubscale domains. The tool also has performed ex-tremely well in differentiating individuals with au-tism and those with other DD. Like some of the otherautism diagnostic instruments, the ADI–R tends toslightly overinclude individuals with mental ages lessthan or equal to 18 months. The evidence regardingindividuals who are high-functioning and verbal hasbeen inconsistent with respect to whether the tool isunder- or overinclusive.

The Parent Interview for Autism (PIA; Stone &Hogan, 1993) is a structured interview designed to

gather relevant diagnostic and symptom severity in-formation from parents of young children (under age6) suspected of having ASD. The PIA targets 11 rel-evant areas, including social behavior, communica-tion, repetitive activities, and sensory behaviors.Internal consistency and test–retest reliability areadequate, and concurrent validity with the DSM–III,Revised (American Psychiatric Association, 1987) andCARS (Schopler et al., 1988) was demonstrated; how-ever, concurrent validity examining clinical diag-noses or tools using current diagnostic criteria has notbeen published. More recently, Stone and colleagues(Stone, Coonrod, Pozdol, & Turner, 2003) have re-ported similar psychometric properties for a shorterclinical version of the PIA used with a sample of chil-dren under the age of 3.

The Gilliam Autism Rating Scale (GARS; Gilliam,1995) is a checklist designed to be used by parents,teachers, and professionals to help identify and esti-mate the severity of symptoms of ASD, but it is onlynormed from age 3. There is an optional subtest, how-ever, that describes development in the first 3 yearsof life. The tool provides a global rating of ASD symp-tomatology using 56 items that are grouped into foursubtests. The GARS has been standardized such thatthe total score yields an “autism quotient” with amean of 100 and a standard deviation of 10. In theauthor’s published research, quotients above 90 wereassociated with a high risk of autism, scores in the 70to 90 range were associated with a moderate risk, andscores below 70 with a limited risk for autism. Despitestrong psychometric properties reported in the initialresearch on the GARS, a recent independent studyfound that the GARS had a sensitivity of only 48% inidentifying children with autism who had been diag-nosed using DSM–IV criteria, with diagnoses verifiedusing the ADOS and the ADI–R (South et al., 2002).As noted above, underdiagnosis of the disorder is ofconsiderable concern in clinical settings. South andcolleagues noted that a revision of the GARS was inprogress at the time of their report.

A clinical diagnosis of one of the subcategoriesof PDD can be made using the DSM–IV criteria basedon information gathered from the diagnostic evalua-tion along with one or more ASD diagnostic tools. Thecurrent “gold standard” measures for the diagnosisof ASD in research protocols are the ADI–R and theADOS (Filipek et al., 1999; Lord & Corsello, 2005)because of their strong psychometric features. It isimportant for the team working with the child to con-tinue to provide information and support to parentsafter a diagnosis has been made. The goal of this sup-port is to help families understand the nature of thedisorder, where their child falls on the spectrum ofASD, how to access appropriate support and services,


and how to choose between the options available.Ongoing assessment also is important to monitor in-tervention effects on the changing needs of the childand possible changes in diagnosis.

Similar Diagnostic Categories andDifferential Diagnosis

Although there is general conceptual agreementregarding the core deficits of ASD, the variability seenin this spectrum of disorders presents a number ofchallenges to reliable diagnoses of ASD and otherdisorders that may overlap or be confused with ASD.For example, different diagnostic systems tend toconverge in specifying criteria for the diagnosis ofautistic disorder, but as Volkmar, Lord, Bailey,Schultz, and Klin (2004) pointed out, there are mul-tiple widely circulated definitions of Asperger’s dis-order. This situation undoubtedly contributes todivergent findings in research, stemming from thevarying diagnostic criteria used to select participants.Of particular relevance to the SLP, a primary differ-ence in criteria for Asperger’s disorder versus autis-tic disorder in the DSM–IV is the stipulation thatindividuals diagnosed with Asperger’s disorder willshow no clinically significant delay in language de-velopment (defined as having single words by age 2and phrase speech by age 3). But as Filipek et al. (1999)pointed out, the language in Asperger’s disorder “isclearly not typical or normal” (p. 447). Mayes,Calhoun, and Crites (2001) found that after groupingchildren with Asperger’s disorder and autistic disor-der who had normal intelligence based on a positiveor negative history of early language delay, thegroups were not different from each other on any of71 variables investigated. Thus, they questioned themeaningfulness of this criterion for differential diag-nosis. More recently, Howlin (2003) has reportedsimilar findings and further noted that both groupsexhibited low language scores as adults, calling intoquestion the assumption that language developmentin Asperger’s disorder (aside from pragmatic devel-opment) is essentially normal.

Despite existing criteria for differential diagnosesof Asperger’s disorder and autistic disorder,Macintosh and Dissanayake (2004) concluded fromtheir literature review that there is insufficient evi-dence that Asperger’s disorder is a syndrome distinctin meaningful ways from high-functioning autism.Some researchers have reported differing cognitiveprofiles between individuals with Asperger’s disor-der and those with high-functioning autism.Asperger’s disorder is more often associated with ahigher verbal IQ than performance IQ, contrastingwith the opposite pattern in high-functioning autism(e.g., Klin, Volkmar, Sparrow, Cicchetti, & Rourke,

1995; Volkmar et al., 2004). Thus, in these studies,individuals with Asperger’s disorder reportedlydemonstrated strengths in verbal language and ver-bal memory despite relative weaknesses in visuallybased tasks involving nonverbal concept formulation,the perception of visuospatial information, andmemory of visual images. The converse was reportedin individuals with high-functioning autism. Find-ings have been inconsistent, however. In two studiesusing DSM–IV criteria for differential diagnosis ofAsperger’s disorder and high-functioning autism,researchers found that as a group, the individualswith Asperger’s disorder had higher verbal IQs andfull-scale IQs than the individuals with high-function-ing autism (Ghaziuddin & Mountain-Kimchi, 2004;J. N. Miller & Ozonoff, 2000). At the individual level,however, varying cognitive profiles were found ineach group, and findings of normal language devel-opment histories, motor delays, and high verbal rela-tive to performance IQs were not specific to thegroups with Asperger’s disorder.

The question of whether individuals withAsperger’s disorder represent a distinct subgroupfrom individuals of normal intelligence with autisticdisorder continues to generate considerable interestand controversy. One possibility is that the currentdiagnostic criteria do not serve to reliably discrimi-nate between the two groups and that improvementsin identifying and operationalizing the key criteriawill yield meaningful subgroups (Klin, McPartland,& Volkmar, 2005), whereas another possibility is thatindividuals currently diagnosed with Asperger’s dis-order represent the highest IQ end of a continuousspectrum that cannot be subdivided meaningfully (J.N. Miller & Ozonoff, 2000). The existing researchserves to inform us clinically of the varying neurop-sychological and developmental profiles existingamong persons with ASD, and it reminds us of theimportance of careful individualized assessments forthe purposes of intervention planning.

Rett’s disorder offers a contrasting situation(Jellinger, 2003; A. M. Kerr, 2002; A. M. Kerr,Belichenko, Woodcock, & Woodcock, 2001). The dis-order is observed overwhelmingly in females, in con-trast to autism, Asperger’s disorder, childhooddisintegrative disorder, and PDD-NOS, all of whichoccur at higher rates in males. Rett’s disorder involvesregression in social, cognitive, and psychomotor de-velopment after an early period of development thatappears normal to caregivers (although retrospectiveanalyses of infant videotapes suggest there may besubtle indicators of the disorder during the first year,according to A. M. Kerr, 2002). The social regressionalong with the appearance of repetitive behaviors in-creases the chance of a misdiagnosis of autism early


on; across time, however, social interest and interac-tions develop that are consistent with the overall de-velopmental level of the children (although this isfrequently quite low). Identification of a commongenetic anomaly in the vast majority of children meet-ing the behavioral criteria for diagnoses of Rett’s dis-order in 1999 has led to opportunities for more refinedstudy of the developmental course of children witha known etiology for Rett’s disorder. Although mostof the diagnosed individuals present with severe de-velopmental delays across all areas, research since1999 has demonstrated a broad range of developmen-tal outcomes among girls with the characteristic ge-netic anomaly, with some individuals developingfunctional single word or phrase speech, and occa-sional individuals functioning within the normalrange (A. M. Kerr, 2002). The degree of impairmentappears to be related to the number of cells in whichthe mutated gene is active.

A number of diagnostic labels overlap with ASDto some extent, with the overlap and diagnostic un-certainty being the greatest for spectrum disordersother than autistic disorder itself (Volkmar et al.,2004). These diagnostic labels include semantic-prag-matic disorder (Bishop & Rosenberg, 1987; Rapin &Allen, 1983) or pragmatic language impairment(Bishop, 1998), nonverbal learning disorder (NLD;Volden, 2004), hyperlexia (Grigorenko, Klin, &Volkmar, 2003), sensory integration disorder/dys-function or sensory processing disorder (L. J. Miller,Cermak, Lane, Anzalone, & Koomar, 2004), and mul-tiple complex developmental disorders (Buitelaar &van der Gaag, 1998; D. J. Cohen, Paul, & Volkmar,1986). Widespread consensus does not exist on theexistence of, or criteria for, these disorders as repre-senting distinct diagnoses, which makes interpretingthe available literature more challenging. Fitzgerald(1999) argues that several of these categories repre-sent unnecessary “diagnostic splitting” resulting tosome extent from a lack of communication amongdifferent professional groups, such as SLPs and psy-chiatrists. Further, Fitzgerald suggests that familiesoften will be better served by receiving a diagnosisof ASD, at least in those situations in which the indi-vidual meets criteria for one of the disorders withinthe autism spectrum, in order to point to the need forand access to recognized services.

Botting and Conti-Ramsden (1999) maintain thatat least in Great Britain, the diagnosis of semantic-pragmatic disorder (or more recently, pragmatic lan-guage impairment) is used for children who do notmeet the criteria for a diagnosis of autism; however,they acknowledge an ongoing debate about whetherthese children are viewed more appropriately as rep-resenting a subgroup of children with language im-

pairments or a subgroup of children with PDD. Atleast 6 of the 10 children with pragmatic languageimpairment included in their study did not meet di-agnostic criteria for Asperger’s disorder or autisticdisorder. Thus, the only possibly appropriate ASDdiagnosis for these children would be PDD-NOS, andthe investigators questioned the benefit of that diag-nosis with respect to planning intervention or provid-ing families with access to services.

Nonverbal learning disorder or disability(Volden, 2004) is characterized by deficits in suchareas as arithmetic, tactile and visuospatial percep-tion, and motor coordination. Individuals with thisdisorder also have been described as having goodrote verbal memory and problems with social prag-matic skills (Myklebust, 1975; Rourke, 1989). AsVolden points out, the neuropsychological profile ofindividuals with NLD bears striking similarities tothat reported for many individuals with Asperger’sdisorder. There has been insufficient research to re-solve questions about overlap between these diag-noses, but it is likely at least some individuals withdiagnoses of NLD would be included appropriatelyon the autism spectrum.

Hyperlexia is another diagnostic term that hasbeen applied with varying criteria (Grigorenko et al.,2003) to refer to children with precocious printed lan-guage decoding abilities. In some definitions, hyper-lexia is identified based on a discrepancy betweenprint recognition and print comprehension abilities.Other proposals have identified hyperlexia based onprecocious print recognition in the context of signifi-cant language and/or cognitive impairments, andstill others have combined the criteria and specifiedthat hyperlexia involves a discrepancy between su-perior print recognition and both language or cogni-tive level and print comprehension abilities. Hyper-lexia has been reported among children with DDother than ASD, but particularly when the criteriaused for hyperlexia include the development of pre-cocious decoding skills relative to cognitive level,research demonstrates a high likelihood that childrenwith hyperlexia will meet criteria for an ASD diag-nosis (Grigorenko et al., 2002).

Sensory integration disorder or dysfunction andsensory processing disorder are diagnostic labelsstemming from Ayres’s (1975) work related to chil-dren with learning disabilities. Symptoms of sensoryintegration disorder include both oversensitivity andunderreactivity to various stimuli, distractibility, so-cial emotional problems, physical clumsiness, hyper-or hypoactivity, impulsiveness, and other difficultiesin self-regulation of arousal level, and concomitantdelays in speech, language, and motor skills and aca-


demic achievement (Anzalone & Williamson, 2000).Limited peer-reviewed research is available regard-ing differential diagnosis or characterization of thepopulation of individuals with sensory integrationdysfunction, but clinically it is common to encounterchildren with diagnosed or suspected ASD who alsohave been given a diagnosis of sensory integrationdisorder. Although few of the symptoms of sensoryintegration disorder appear among the diagnosticcriteria for ASD, these symptoms nevertheless arereported widely among children with ASD (Baranek,David, Poe, Stone, & Watson, in press; Piek & Dyck,2004). More detail about sensory and feeding issuesfor individuals with ASD with supporting referencesis provided in the companion technical report(ASHA, 2006b).

Multiple complex developmental disorders(Buitelaar & van der Gaag, 1998; D. J. Cohen et al.,1986) grew out of studies of children diagnosed withPDD-NOS and other severe developmental disorderswho did not meet the criteria for autistic disorder.Cluster analyses “identified a group of children char-acterized by social problems, bizarre and disorga-nized thinking, recurrent anxieties, inappropriateaffect, and mood lability” (Buitelaar & van der Gaag,1998, p. 912). Researchers have proposed that this isa distinct diagnostic subgroup that represents not amilder variant of autism, but rather a different groupwith different distinguishing diagnostic features.Compared with children with autism, these childrenshow more symptoms of aggression, more anxiety,and more psychotic thoughts and suspiciousness,whereas children with autism show more distur-bances in social interaction, communication, and ste-reotyped and rigid behaviors (van der Gaag et al.,1995). Unlike children with autism, children meetingthe criteria for multiple complex developmental dis-orders are at risk for developing schizophrenia inadulthood; they also show different biologicallybased responses to psychosocial stress, suggestingthat this subgroup may have a different biologicaletiology than children with autism (Jansen, Gispen-de Wied, van der Gaag, & van Engeland, 2003).

Determining Eligibility andthe Challenges of IdentifyingHigher Functioning Individuals

High-functioning individuals with ASD poseparticular challenges both for identification and fordetermining eligibility for services. By definition, in-dividuals with high-functioning autism or Asperger’sdisorder have either verbal or nonverbal measuredintelligence within normal limits. Many are not diag-nosed until later school age, adolescence, or evenadulthood (Howlin & Asgharian, 1999). One reason

for such late diagnosis is that they often appear tosucceed in some or most academic subjects, particu-larly in the early school years. This often masks thesignificant challenges faced by these students andthus may delay a referral for special education ser-vices. Long-term outcome research for individualswith high-functioning autism or Asperger’s disorder,however, has shown that social communication defi-cits significantly affect their ability to adjust to newsocial demands in later academic and communitysettings and, therefore, achieve vocational goals(Gilchrist et al., 2001; Mueller, Schuler, Burton, &Yates, 2003; Tsatsanis, Foley, & Donehower, 2004).These findings suggest that it is important to provideearly intervention to address the gap between cogni-tive potential and social adaptive functioning.

Although current research outcomes support theprovision of individualized educational program-ming, SLPs often find it challenging to demonstratethat a child or older individual with high-function-ing autism or Asperger’s disorder is eligible for ser-vices. The NRC has recognized this challenge and hasrecommended that all children with ASD, includingautistic disorder, Asperger’s disorder, and PDD-NOS, be deemed eligible for special education ser-vices under the category autistic spectrum disorders, asopposed to other educational categories often usedby school systems (e.g., other health-impaired, socialemotional disorder; NRC, 2001, p. 213). Nevertheless,it may be necessary to conduct a comprehensiveevaluation to demonstrate the expected gap betweenan individual’s cognitive potential and his or her so-cial adaptive functioning. Furthermore, school sys-tems need to make eligibility decisions through theteam process of the individualized educational pro-gram. The team should decide the optimal eligibilitydecision for the child. Formal testing may be usefulfor assessing the structure and form of language,whereas these evaluation tools may not provide anaccurate assessment of an individual’s use of lan-guage (i.e., pragmatics). Determining an individual’ssocial and communication competence, therefore,necessitates evaluation across a range of social set-tings and not just one-on-one structured formal test-ing sessions. A variety of strategies should be usedfor gathering information. These may include directstandardized assessments, naturalistic observationacross contexts, and caregiver/teacher interviews orquestionnaires. Standardized assessment tools suchas the Clinical Evaluation of Language Fundamentals,Fourth Edition (Wiig, Secord, & Semel, 2004) and theTest of Language Competence—Expanded Edition,Levels 1 and 2 (Wiig & Secord, 1989) should becomplemented with standardized measures of socialadaptive functioning such as the Vineland Adaptive


Behavior Scales—Expanded Edition (Sparrow, Balla,& Cicchetti, 1984) and the Vineland Adaptive Behav-ior Scales—Classroom Edition (Sparrow et al., 1984).Finally, measures that provide a means to assess anindividual’s spontaneous communicative bids withinnatural conversational exchanges such as the DamicoClinical Discourse Analysis (Damico, 1985), theChildren’s Communication Checklist (Bishop, 1998,2001), and the Pragmatic Rating Scale (Landa et al.,1992) also may be useful for documenting social com-munication deficits in higher functioning individu-als with ASD.


The SLP plays a critical role in screening and earlydetection of individuals at risk for ASD and makesreferrals to experienced professionals for diagnosisand intervention services. SLPs who acquire andmaintain the necessary knowledge and skills can di-agnose ASD, typically as part of a diagnostic team orin other multidisciplinary collaborations, and shouldmake appropriate referrals to rule out other condi-tions and facilitate access to comprehensive services.The SLP who has been trained in the reliable andvalid use of diagnostic and assessment tools as wellas in the clinical criteria for ASD may be qualified todiagnose these disorders as an independent profes-sional. Individuals with ASD may be eligible for ordemonstrate a need for speech-language pathologyservices due to the pervasive nature of the social com-munication impairment, regardless of age, cognitiveabilities, or performance on standardized testing offormal language skills.

As mandated by the IDEA (2004), SLPs shouldavoid applying a priori criteria (e.g., discrepanciesamong cognitive abilities and communication func-tioning, chronological age, or diagnosis) and makeindividualized decisions on eligibility for services.Further, in public school settings, a student’s diagno-sis and eligibility for services must be determined bya team rather than a single individual. Because for-mal assessment tools may not accurately detect prob-lems in the social use of language and com-munication, eligibility for special education servicesmay need to be based on clinical judgment and moreinformal, observational measures.

Characteristics of Effective Interventions

Framework for Consideringthe Evidence Base of Treatment

The NRC formed the Committee on EducationalInterventions for Children with Autism at the requestof the U.S. Department of Education, Office of Spe-cial Education Programs. The charge for the NRC

committee was to integrate the scientific, theoretical,and policy literature and create a framework forevaluating the scientific evidence concerning the ef-fectiveness of educational interventions for youngchildren with ASD. A report was published in Octo-ber of 2001 summarizing the findings and recommen-dations of this committee (NRC, 2001). The NRCreport delineated specific conclusions and recom-mendations about diagnosis and assessment, role offamilies, goals for educational services, characteris-tics of effective interventions based on empirical stud-ies, public policies, personnel preparation, andneeded research.

To achieve a systematic and rigorous assessmentof research studies, the NRC committee establishedguidelines for evaluating the quality of the scientificevidence based on the following three criteria (NRC,2001):

• internal validity or control for nonspecificfactors, such as maturation, expectancy, ex-perimenter bias

• external validity or control for selection bi-ases addressed in random assignment, ad-equate sample size, and well-definedpopulations

• generalization of treatment outcomes docu-mented in a natural setting outside of experi-mental intervention or with functionaloutcomes

The NRC committee rated each research study usinga 4-point scale for the level of rigor with respect tointernal validity, external validity, and generalizationwith 1 being the highest evidence and 4 being insuf-ficient design or no evidence (NRC, 2001, p. 15). TheNRC committee integrated this information with aneye toward convergence of evidence, particularlyfrom independent sources using different methodolo-gies in an effort to characterize features of appropri-ate, effective educational interventions for childrenwith ASD.

The ASHA Ad Hoc Committee on Autism Spec-trum Disorders used the NRC report and adopted theNRC guidelines to evaluate scientific evidence forthese guidelines and family of related documents onASD. The NRC report included a thorough literaturereview on children from birth to age 8, published inpeer-reviewed journals through 2000. The ASHAcommittee reviewed literature with an effort to iden-tify research published since the NRC report or thatwhich was not included in the NRC report. To assistthis committee, the ASHA National Center for Evi-dence-Based Practice in Communication Disordersconducted a literature search to identify empiricaltreatment studies on speech, language, and/or com-


munication in children with ASD that have been pub-lished since 2000, in adolescents or adults with ASDthat have been published over the past decade, andany studies pertaining to multicultural issues andASD. Studies were included in this review only if theywere published in English in peer-reviewed journalsand reached a Level 1, 2, or 3 rating on internal andexternal validity based on the NRC 4-point scale.Chapters in books were used only as resources forsummaries of findings based on peer-reviewed pub-lications.

Within the field of ASD, there is a wide varietyof approaches to intervention that vary with regardto availability of empirical evidence, longevity, popu-larity, and influence of marketing efforts. Because ofthe sheer number and variety of the approaches avail-able, criteria were established for the inclusion andexclusion of intervention information within theseguidelines. These criteria focused on available empiri-cal information and were based on criteria establishedby the NRC (2001). Intervention approaches werediscussed in these guidelines if

• empirical research published in a peer-re-viewed journal was available that includedindividuals with ASD;

• intervention outcomes were measured in re-lationship to the core challenges of ASD; and

• empirical research published in a peer-re-viewed journal was available for all or someof its methodological components.

Approaches that had no evidence were excluded.Approaches that had strong refuting evidence, suchas facilitated communication and auditory integra-tion training, were also excluded. Members are re-ferred to ASHA position statements for furtherinformation on these two methods (ASHA, 1994,2004a).

Treatment approaches were evaluated for inter-nal validity, external validity, and generalization ac-cording to guidelines described by the NRC (2001).Results are summarized in these guidelines in an ef-fort to characterize the strength of empirical evidencefor different intervention approaches considering thefindings of individual research publications, method-ological challenges in clinical studies, selection biases,and the difficulties in measuring meaningful, gener-alizable outcomes. Like the NRC committee, theASHA Ad Hoc Committee on ASD recognized thatwithin empirical research, there is a range of empha-ses and designs depending on the questions beinganswered, so no attempt was made to prioritize spe-cific interventions or programs. The goal was to in-tegrate intervention information in an effort toidentify points of convergence of findings and thus

to provide a framework to guide the clinician in mak-ing individual intervention decisions.

Active Ingredients of Effective Programs

Three major research conclusions emerge fromcurrent empirically supported intervention strategiesfor individuals with ASD and should form the basisfor clinical decision making. First, there is empiricalsupport demonstrating the effectiveness of a range ofapproaches for enhancing communication skills ofindividuals with ASD along a continuum from behav-ioral to developmental (Dawson & Osterling, 1997;NRC, 2001; Prizant & Wetherby, 1998; Rogers, 1998).Furthermore, there are no group design studies di-rectly comparing the effectiveness of different ap-proaches using randomly assigned, matched controlsamples with sufficient sample sizes and adequatestatistical power. Therefore, evidence that any oneapproach is more effective than another approach isnot available to date.

Second, intervention research is not yet availableto predict which specific intervention approaches orstrategies work best with which individuals withASD. No one approach is equally effective for all in-dividuals with ASD, and not all individuals in out-come studies have benefited to the same degree(NRC, 2001). Group design treatment studies areneeded to identify characteristics of individuals withASD that predict response to treatment (Yoder &Compton, 2004). For clinicians to determine whetheran individual with ASD is benefiting from a particu-lar treatment program or strategy, measurement ofthat individual’s progress using systematic methods,such as in single-subject research design, is recom-mended.

Third, knowledge about the effectiveness of treat-ment is limited by the outcome measures used in re-search. The most common reported outcomemeasures in comprehensive interventions for chil-dren with ASD are changes in IQ scores and post-intervention placement (NRC, 2001). The NRCconcluded that these measures may not be ecologi-cally valid, because they do not measure meaningfulchanges within natural learning environments, do notaddress the core deficits in ASD, and are particularlyproblematic for young children. The NRC (2001) rec-ognized the need for more meaningful outcome mea-sures and recommended measures that include (a)gains in initiation of spontaneous communication infunctional activities and (b) generalization of gainsacross activities, interactants, and environments. Thebroad impact of the social communication challengesand problems with generalization for individualswith ASD underscores the critical importance of eco-logically meaningful outcome measures. The NRC


concluded that learning in natural learning environ-ments appears to be the most effective interventionapproach. Not only do such environments invitehigher rates of initiation and generalization, they alsoenhance the ecological validity of the intervention be-cause the behaviors involved are more likely to trans-late into a better quality of life and increase socialacceptance.

Based on a systematic review of research on edu-cational interventions for children with ASD frombirth through age 8, the NRC concluded that there isa convergence of evidence that the following charac-teristics are essential active ingredients or compo-nents of effective interventions for children with ASD:

Entry into intervention programs as soon as ASD issuspected. Children who participate in intensive inter-vention beginning by age 3 have a significantly bet-ter outcome than those beginning after 5. Interventionbeginning before age 3 appears to have an evengreater impact. These intervention findings indicatethe pressing need to identify and provide interven-tion for children with ASD as early as possible (NRC,2001).

Active engagement in intensive instructional pro-gramming for a minimum of 5 hours per day, 5 days a week.Instruction is used broadly to refer to the structurethat supports learning and can occur in any environ-ment—the home, school, or community settings.Children with ASD need instructional strategies thatensure that they are actively engaged during activi-ties, and the intensity of programming needs to besufficient to provide 5 hours per day of active engage-ment (NRC, 2001). SLP direct services should contrib-ute to the 25 hours per week of active engagement butwould likely compose only a small portion of thesehours. SLP consultative services should be aimed athelping the communicative partner (i.e., teacher, par-ent, peer, or sibling) provide the supports and teach-ing strategies to enhance active engagement innatural learning environments.

Repeated, planned teaching opportunities. Instruc-tional opportunities should be organized in a seriesof brief time intervals and include sufficient amountof adult attention to meet individualized goals. Goalsand objectives should be targeted in systematicallyplanned, developmentally appropriate learning ac-tivities (NRC, 2001).

Inclusion of a family component, including parenttraining. Concerns, priorities and perspectives of thefamily need to actively shape educational planning.All of the comprehensive intervention programs withthe best treatment outcomes included a strong fam-ily component. Family members should be supportedto be effective members of the educational team and

provided with the opportunity to learn strategies forteaching their child new skills and reducing problembehaviors (NRC, 2001).

Low student:teacher ratios. A child must receivesufficient individualized attention on a daily basis sothat instructional strategies can be implemented ef-fectively. In order to accomplish this, a lowstudent:teacher ratio is needed, with no more thantwo young children with ASD per adult in the class-room as a guideline; however, this may vary depend-ing on the functioning level of the individuals withASD (NRC, 2001).

Mechanisms for ongoing assessment and programevaluation with corresponding adjustments in program-ming. An individual’s progress in meeting objectivesshould be measured on an ongoing basis to refine theinstructional program. Lack of documented progressover a 3-month period should be an indicator thatchanges in one or more aspects of programming needto be adjusted in some way, such as increasing inten-sity by adding instructional time or loweringstudent:teacher ratio, modifying the curricula or in-structional strategies, or targeting different objectives(NRC, 2001).

Six kinds of instruction should take priority for indi-viduals with ASD: (a) functional, spontaneous commu-nication; (b) social instruction in various settingsthroughout the day; (c) play skills with a focus onplay with peers and peer interaction; (d) new skillacquisition and generalization and maintenance innatural contexts; (e) functional assessment and posi-tive behavior support to address problem behaviors;and (f) functional academic skills when appropriate(NRC, 2001).

There are many different intervention ap-proaches and strategies that have been developed andimplemented for individuals with ASD. Programsdiffer in how goals are prioritized and the techniquesused to target goals. Some programs rely heavily onsingular strategies, while others are more comprehen-sive or eclectic. There are many “name brand” pro-grams; however, there can be much variation in theway these programs are implemented. More impor-tant than the name of the program is how the envi-ronment and instructional strategies supportindividualized goals and objectives for the individualwith ASD and his or her family and other communi-cation partners (NRC, 2001).

Application of Active Ingredientsto Decision Making for the SLP

It is challenging for SLPs to make informed deci-sions about intervention approaches and strategiesfor individuals with ASD, especially in light of the


wide variety of approaches to intervention within thefield of ASD and the variance in regard to availabil-ity of empirical evidence, longevity, popularity, andinfluence of marketing efforts. The following ques-tions should be considered by clinicians to aid thisdecision-making process based on efficacy researchand core characteristics of ASD:

1. Can the intervention approach harm thechild with ASD?

2. Is there empirical evidence to support or re-fute the intervention approach?

3. What is the impact of the intervention on thecaregiver?

4. How will you know the treatment is work-ing?

5. Does the intervention program match thefamily vision and the developmental leveland learning style of the individual withASD?

6. Does the intervention program include thefamily?

7. Does the intervention program support thedevelopment of spontaneous communica-tion?

8. Does the intervention program consistentlysupport social development, play, and inter-action with peers as appropriate?

9. Does the intervention program promote gen-eralization and maintenance in natural con-texts?

10. Does the intervention program incorporatefunctional assessment and positive behaviorsupport to address problem behaviors?

11. Does the intervention program provide suf-ficient intensity for meaningful progress?

12. Does the intervention program address func-tional academic skills, if appropriate?

13. Does the intervention program address self-advocacy skills and independence for activi-ties of daily living for adults with ASD?

The IDEA (2004) added a new provision that the in-dividualized education program should include astatement of the special education and related ser-vices, based on peer-reviewed research to the extentpossible (§1414(d)(1)(A)(i)(IV)). In public school set-tings, the SLP should play an active role as a teammember to stay abreast of peer-reviewed researchand incorporate strategies based on evidence-basedpractice into educational programs for students withASD.


Based on a review of empirical research on spe-cific intervention strategies and comprehensive inter-vention programs using a package of strategies, theNRC (2001) committee concluded that there are anumber of critical features that are the active ingre-dients in effective intervention programs for childrenwith ASD, delineated above. SLPs should be an ac-tive member of educational teams that workcollaboratively to incorporate these critical featuresinto educational programs of individuals with ASDas well as build the capacity within school districtsto incorporate these features systemwide.

Assessment for Program Planning

Assessment Goals and Strategies

Following screening, diagnosis, and eligibilityconsideration, ongoing assessment is critical to guideprogram planning. Assessment of an individual withASD should be an ongoing process for achieving anumber of essential goals. These include: (a) to deter-mine an individual’s current profile of social commu-nication skills, (b) to identify learning objectives thatare priorities within natural communication contexts,and (c) to examine the influence of the communica-tion partner and the learning environment on theindividual’s competence as a communicator (Meisels,1996). Dynamic assessment is a term used for assess-ment protocols in which support is systematicallyprovided to determine what factors influence and en-hance an individual’s current skills and ability tocomplete tasks that would otherwise be too difficultfor her or him to accomplish independently. Dynamicassessment procedures should be implemented, asthese procedures identify not only those skills that anindividual has achieved but also those skills that maybe emerging and what contextual supports enhancecommunication skills, such as augmentative and al-ternative communication (AAC) and modeling pro-vided by communication partners (Mirenda, 2003;Olswang, Bain, & Johnson, 1992; Schuler, 1989;Vygotsky, 1978).

With these assessment goals in mind, assessmentstrategies should not rely solely on standardized,norm-referenced tools, as information should be gath-ered across natural social contexts (Schuler, Prizant,& Wetherby, 1997). Additionally, primary caregiversand communication partners (e.g., family members,teachers, clinicians, and peers) should be incorpo-rated as active participants and informants in thisassessment process (Prizant & Bailey, 1992; Schuler,1989). Observing an individual in his or her naturalsocial contexts, gathering information from that


individual’s communication partners through ques-tionnaires and/or interviews, and staging communi-cation contexts that assess an individual’sspontaneous use of communication and languageprovide critical measures of an individual’s strengthsand functional needs across meaningful contexts(Schuler, 1989; Wetherby & Prizant, 1993).

Likewise, these assessment strategies provide ameans to examine the need to support communica-tion partners in their efforts to respond to theindividual’s subtle bids for communication, interpretthe functions of problem behavior, and modify theenvironment to foster social engagement. The idio-syncratic language used by individuals with ASDmakes it difficult for communication partners to beresponsive and adjust the quantity and quality oftheir language models. Consequently, language mod-eled for individuals with ASD is often too complexor too simple, limiting opportunities for communica-tion growth. Likewise, a communication partner maymisinterpret an individual’s subtle bids for commu-nication or the functions of problem behavior, a pat-tern that may limit the individual’s exposure tomodeling for coping and expressing intentions inmore socially appropriate ways.

Prioritizing Intervention Goals

Based on the ongoing assessment of anindividual’s strengths and needs as well as thestrengths and needs of his or her communication part-ners, intervention goals and strategies can be priori-tized. Developmental sequences and processes oflanguage development should provide a frameworkfor determining baselines and implications for inter-vention goals (Schuler et al., 1997). Family prioritiesalso should be considered paramount when selectingintervention goals, as meaningful outcomes arestrongly correlated with communication competenceacross functional social contexts (e.g., home, school,vocational, and community settings). An individualwith ASD will demonstrate greater social communi-cation competence when goals are prioritized to en-sure effective communication in meaningful contextsand across natural communication partners(Wetherby, Schuler, & Prizant, 1997).

The most critical domains for prioritizing inter-vention goals should be derived from the core fea-tures of ASD and the core challenges that affect socialadaptive functioning within the ever-changing socialcontexts of an individual’s natural routines. As out-lined previously in this document, core challenges arenoted in aspects of joint attention (e.g., social orient-ing, establishing shared attention, monitoring emo-tional states, and considering another’s intentions),social reciprocity (e.g., initiating bids for interaction,

maintaining interactions by taking turns, and provid-ing contingent responses to bids for interaction initi-ated by others), language and related cognitive skills(e.g., understanding and using nonverbal and verbalcommunication, symbolic play, literacy skills, andexecutive functioning), and behavior and emotionalregulation (e.g., effectively regulating one’s emotionalstate and behavior, maintaining social engagement,and attending to salient aspects of the social environ-ment). Thus, intervention goals should be prioritizedunder these domains following a developmentalframework.

These core challenges take different forms as anindividual matures and responds to intervention. Ap-plication of a developmental framework ensures thatappropriate goals are being addressed prior to theemergence of symbolic language, at emerging lan-guage stages, and at more advanced stages of conver-sational discourse (NRC, 2001; Prizant, Wetherby,Rubin, & Laurent, 2003). Table 1 provides sampleintervention goals for prelinguistic, emerging lan-guage, and more advanced language stages. Actualgoals for an individual should vary based on thoseaspects of development that are consistent with fam-ily priorities and an individual’s functional needswithin his or her current social contexts. Goals shouldincorporate the functional use of the individual’s fullcommunication abilities using a multimodal commu-nication system. Decisions about the integration ofmodes of communication (e.g., spoken language,gestures, sign language, picture communication,speech generating devices [SGDs], and/or writtenlanguage) should be individualized according to spe-cific capabilities and contexts of communication, aswell as cultural issues.


Integral to the diagnostic criteria, all individualswith ASD have core challenges in the area of socialcommunication. Therefore, problems in the use oflanguage and communication are overarching be-cause ASD is a primary social communication disabil-ity. These challenges result in far-reaching problemsincluding joint attention, shared enjoyment, socialreciprocity in nonverbal as well as verbal interactions,mutually satisfying play and peer interaction, com-prehension of others’ intentions, and emotional regu-lation. SLPs should conduct assessments andprioritize intervention goals and objectives in thoseaspects of development that are critical to the achieve-ment of social communication competence and thathonor and adapt to differences in families, cultures,languages, and resources. Embracing a broad view ofcommunication, SLPs should assess and enhance (a)the initiation of spontaneous communication in func-


Table 1. Sample intervention goals based on core challenges in ASD.

Joint attentionPrelinguistic stages• Orienting toward people in the social environment

• Responding to a caregiver’s voice

• Shifting gaze between people and objects

• Pairing communication gestures with gaze and/or physicalcontact when requesting and protesting as culturally appro-priate

• Directing another’s attention for the purposes of sharing aninteresting item or event

• Attending to emotional displays of distress or discomfort

• Sharing positive affect

• Initiating social routines

Emerging language stages• Expanding communication functions to seek specific emo-

tional responses from others (e.g., seeking comfort, greet-ing others, showing off)

• Commenting to share enjoyment and interests

• Recognizing and describing emotional states of self and oth-ers

Advanced language stages• Understanding what others are indicating with gaze and ges-

tures

• Determining causal factors for emotional states of self andothers

• Using emotions of others to guide behavior in social interac-tions (e.g., selecting topics based on another’s preferences,praising others, sharing empathy)

• Considering another’s intentions and knowledge (e.g., re-questing information from others, sharing information aboutpast and future events)

Social reciprocityPrelinguistic stages• Responding to the bids of others

• Initiating bids for interaction

• Increasing frequency of spontaneous bids for communica-tion

• Developing persistence in communication attempts

Emerging language stages• Increasing frequency of communication across social con-

texts and interactive partners

• Maintaining interactions by taking turns

• Providing contingent responses to bids for interaction initi-ated by others

• Recognizing and attempting to repair breakdowns in com-munication

Advanced language stages• Engaging in topic maintenance (e.g., providing expansion

comments)

• Maintaining conversational exchanges with a balance be-tween comments and requests for information

• Providing essential background information

• Initiating and maintaining conversations that are sensitive tothe social context and the interests of others

Language and related cognitive skillsPrelinguistic stages• Using a range of gestures to share intentions (e.g., giving,

showing, waving, pointing)

• Using effective strategies for protesting, exerting social con-trol, and emotional regulation in order to replace potentialproblem behaviors used for these functions

• Pairing vocalizations with gestures to share intentions

• Observing and imitating the functional use of objects

• Turning pages and pointing to pictures in books

Emerging language stages• Expanding word knowledge and use to include not only ob-

ject labels, but also action words, modifiers, and relationalwords

• Understanding and using more creative combinations ofwords

• Understanding and using more sophisticated grammar

• Engaging in representational play

• Understanding sequences of events in stories, attending tobeginning and rhyming sounds, and naming alphabet letters

• Producing a variety of speech sounds

Advanced language stages• Enacting social sequences in a representational manner by

incorporating themes or modifications introduced by others(e.g., role-playing and visualizing an event before it takesplace)

• Understanding and using nonverbal gestures, facial expres-sions, and gaze to express and follow subtle intentions (e.g.,sarcasm and other nonliteral meanings)

• Understanding and using intonation cues to express andfollow emotional states

• Understanding and using more sophisticated syntax to pro-vide background information for one’s listener

• Understanding and using more sophisticated syntax to showrelationships between sentences in conversational discourse

• Demonstrating story grammar knowledge, decoding, andletter–sound correspondence and expanding literacy skills(e.g., reading comprehension and written expression)

• Problem solving and self-monitoring future, goal-directed,behavior (i.e., executive functioning)

Behavior and emotional regulationPrelinguistic stages• Attending to salient aspects of the social environment

• Expanding the use of conventional behaviors to regulateone’s emotional state (e.g., covering one’s ears to block outnoise, carrying a preferred toy into an unfamiliar setting toassist in the transition, removing oneself from a situationwhen overwhelmed)

• Protesting undesired activities

Emerging language stages• Requesting a soothing activity when distressed

• Requesting a break from a given activity

• Requesting assistance from others

• Using language to maintain engagement within an activity(e.g., “first … then”)

• Using language to talk through transitions across activities

• Expressing one’s emotional state and the emotional stateof others

Advanced language stages• Preparing and planning for upcoming activities

• Perceiving one’s actions within social events and predictingsocial behavior in others in order to self-monitor

• Negotiating and collaborating within interactions with peers


tional activities across social partners and settings; (b)the comprehension of verbal and nonverbal discoursein social, academic, and community settings; (c) com-munication for a range of social functions that arereciprocal and promote the development of friend-ships and social networks; (d) verbal and nonverbalmeans of communication, including natural gestures,speech, signs, pictures, written words, as well as otherAAC systems; and (e) access to literacy and academicinstruction, as well as curricular, extracurricular, andvocational activities.

Intervention Approaches and StrategiesThe following sections contain a review of em-

pirical evidence of a variety of intervention ap-proaches and strategies for individuals with ASD.The framework for evaluating evidence and thesearch strategy were summarized above. The qualityof evidence with supporting references is providedin each of the following sections. The challenge forSLPs is matching intervention approaches and strat-egies with philosophical beliefs underlying best prac-tices as well as the core deficits of individuals withASD. Interventionists typically are guided by vary-ing beliefs about development, learning, the role ofsocial interactions, and attributions about the etiol-ogy of core deficits. The latter is most commonly at-tributed to factors intrinsic to the individual involved,and interventions typically target the remediation ofassessed deficits within the individual. By focusingon modification of the learning environment, ecologi-cal interventions take a different stance, as they ex-amine the context in which deficits are observed,targeting the contributing circumstances rather thanany intrinsic deficiencies. This approach is of particu-lar relevance to communicative interactions, which aredefined by situational context as well as by the inter-action style of the communication partner. If positivechanges are targeted solely within the behavior rep-ertoire of the least competent contributor to a success-ful communicative exchange, variables in the contextswhere those behaviors would be expected may notbe addressed and social communication challengesmay continue secondary to factors extrinsic to theindividual. Therefore, ecological interventions at-tempt to complement the latter by, for example, ex-plicitly training parents, siblings, and peers; coachingpartners to be less directive and to pause longer be-fore presenting next bids for interaction; or provid-ing more contextual supports, such as real-life objects,visual supports, and concrete physical activity.

Beliefs about learning and development under-lie the extent to which interventions are described asbehavioral, developmental, naturalistic, and affective

or “relationship based.” Behavioral interventionsderived from applied behavior analysis were the ear-liest to document their effectiveness in increasingrates of desirable and decreasing rates of undesirablebehaviors, but questions remain regarding the socialvalidity and generalization of some of the behaviorsthat were changed. In selecting appropriate interven-tions, it is important to discriminate between moretraditional applications of behavior modification,such as those relying primarily on massed discretetrial training approaches, and those that incorporatemore socially and cognitively mediated models oflearning, such as modeling, vicarious learning, andself-regulation␣ (cognitive behavior modification). Incontrast, developmental interventions generally at-tempt to carefully describe levels and/or stages ofdevelopment and to provide the corresponding strat-egies needed to proceed to the next developmentallevel.␣

Further differentiations need to be made betweenbehavioral interventions to the extent that they takeplace in natural learning environments␣ and use natu-ral, nonstigmatizing prompts or other supports andnatural consequences. These types of strategies em-bedded in natural settings are often described in thebehavioral intervention literature as incidental learn-ing and are aimed at promoting generalization andinclusion. This is consistent with the legal mandateto educate children with special needs in the leastrestrictive environment that can meet their educa-tional needs. The focus in some intervention pro-grams is primarily on positive behavior changes inthe individual with ASD without explicit regard tothe quality of interactions and relationships betweeninteraction partners. Other programs focus more ex-plicitly on the establishment of reciprocity and posi-tive affect in the context of developmentally pro-gressive interactions.

Although such different approaches to interven-tion may seem incongruent at first, they may be rec-onciled in intervention practices. For instance, thegrowing acceptance of functional assessment of be-havior may speak to the congruence of developmen-tal and behavioral perspectives, as the search for thefunctions of seemingly aberrant behaviors is congru-ent with a developmental perspective. Effective prac-titioners should combine a variety of interventionmethods and strategies, drawing from evidence-based practices rooted in varying conceptual models.In fact, overly strict applications of “developmentallogic” may backfire as individuals with ASD arenoted for their unique ways of learning and thinking.While much variation exists, individuals with ASDoften excel in tasks that require visuospatial skills tothe extent they may learn to “read,” or rather “de-


code,” before they learn to talk. Thus, learning stylesand developmental differences constitute an impor-tant consideration in designing effective interven-tions because they help determine best treatmentmodalities. Clinicians and educators need to deter-mine which different strategies are effective with stu-dents/clients presenting varying developmentallevels; social, linguistic, and cultural backgrounds;learning styles; behavior repertoires; and communi-cation needs; taking into consideration family re-sources and cultural values.

Many issues should be considered in order tomake informed decisions about specific instructionalstrategies. Clinicians need to ask themselves whetherthe interventions under consideration—

• focus on core characteristics and challengesas essential outcomes;

• incorporate empirically supported strategiesto support initiation and generalization;

• assess the link between behavior and com-munication and use of positive behavior sup-port;

• use strategies that support learning style,developmental framework, and self-determi-nation;

• incorporate AAC;• consider peer and peer-mediated learning as

a context.

Each of these considerations is discussed below inrelation to available evidence-based practice.

Focus on Core Characteristicsand Challenges as Essential Outcomes

Since positive long-term outcomes for individu-als with ASD are strongly correlated with the achieve-ment of social communication competence (L. K.Koegel, Koegel, Yoshen, & McNerney, 1999; NRC,2001; Venter, Lord, & Schopler, 1992), interventiongoals should be evaluated as to their relative impacton effective communication in meaningful contextsand across natural communication partners. An in-dividual with ASD will demonstrate greater socialcommunication competence when goals are priori-tized to address the core characteristics and chal-lenges of the disorder (NRC, 2001; Wetherby et al.,1997). Thus, efficacy of an intervention programshould not be judged by whether an individual hasbeen placed in a regular education environment or bywhether improvements have been made on IQ scores.Rather, essential outcomes in intervention should berelated to improvements in social communicationthat affect the ability to form relationships, functioneffectively, and actively participate in everyday life.

Longitudinal research has, in fact, shown that posi-tive outcomes in the hallmark features of the disor-der, including joint attention, social reciprocity,language and related cognitive skills, and behaviorand emotional regulation, are predictive of gains inlanguage acquisition, social adaptive functioning,and academic achievement (NRC, 2001). Refer toTable 1 for sample intervention goals that can guidethe development of essential and meaningful out-come measures.

Empirically Supported Strategiesto Promote Initiation and Generalization

The earliest research efforts at teaching speechand language to children with autism used masseddiscrete trial methods to teach verbal behavior. Amajor limitation of a discrete trial approach for lan-guage acquisition is the lack of spontaneity and gen-eralization. Lovaas (1977) stated that “the trainingregime . . . its use of ‘unnatural’ reinforcers, and thelike may have been responsible for producing thevery situation-specific, restricted verbal output whichwe observed in many of our children” (p. 170). In areview of research on discrete trial approaches, it wasnoted by L. K. Koegel (1995) that “not only did lan-guage fail to be exhibited or generalize to other envi-ronments, but most behaviors taught in this highlycontrolled environment also failed to generalize” (p.23).

There is now a large body of empirical supportfor more contemporary behavioral approaches usingnaturalistic teaching methods that demonstrate effi-cacy for teaching not only speech and language butalso communication. The following specific interven-tion strategies have been found to promote initiationand generalization: arrange the environment to pro-vide opportunities for communicating with preferredmaterials, encourage child initiations and follow thechild’s attentional focus and interest, intersperse pre-ferred and nonpreferred activities, use embeddedinstruction in the natural environment, offer choicesand encourage choice making, use natural reinforc-ers that follow what the child is trying to communi-cate, use time delay or waiting, use contingentimitation, and structure predictability and turn tak-ing into the activity. Some examples of comprehen-sive programs that incorporate some or many of thesenaturalistic behavioral techniques include naturallanguage paradigm (R. L. Koegel, O’Dell, & Koegel,1987), incidental teaching (Hart, 1985; McGee, Krantz,& McClannahan, 1985; McGee, Morrier, & Daly,1999), time delay and milieu intervention (Charlop,Schreibman, & Thibodeau, 1985; Charlop &Trasowech, 1991; Hwang & Hughes, 2000b; Kaiser,1993; Kaiser, Yoder, & Keetz, 1992), pivotal response


training (L. K. Koegel, 1995; R. L. Koegel, Camarata,Koegel, Ben-Tall, & Smith, 1998; Whalon &Schreibman, 2003), the Hanen Centre program forparents of children with ASD (Sussman, 1999), andthe Social Communication Emotional RegulationTransactional Supports comprehensive educationalmodel for children with ASD (Prizant, Wetherby,Rubin, Laurent, & Rydell, 2003, 2006).

There are only a few studies, all using single-sub-ject design, that have compared traditional discretetrial with naturalistic behavioral approaches. Thesestudies have reported that naturalistic approaches aremore effective at leading to generalization of lan-guage gains to natural contexts (R. L. Koegel et al.,1998; R. L. Koegel, Koegel, & Surratt, 1992; McGee etal., 1985). Although the empirical support for devel-opmental approaches is more limited than for behav-ioral approaches, there are a growing number ofresearch studies that provide support for using de-velopmental strategies (Aldred, Green, & Adams,2004; Hwang & Hughes, 2000b; Lewy & Dawson,1992; Mahoney & Perales, 2005; Rogers & DiLalla,1991; Rogers & Lewis, 1989), and there are many casestudies, with Greenspan and Wieder (1997) being thelargest case review. Furthermore, developmentalapproaches share many common active ingredientswith contemporary naturalistic behavioral ap-proaches and are compatible along most dimensions(Prizant & Wetherby, 1998).

Link Between Behavior and Communicationand Use of Positive Behavior Support

Positive, nonaversive approaches to address chal-lenging behaviors are the most effective, evidence-based practice for individuals with severe disabilities(see Horner, Albin, Sprague, & Todd, 2000). The ex-panded use of applied behavior analysis, improvedtechnology of functional assessment of problem behav-iors, and increased awareness of developmental con-structs such as emotional regulation have led to avariety of alternatives to the use of aversive proce-dures. These alternatives entail positive ways to sup-port individuals who demonstrate problem behavior(Carr et al., 1994; Fox, Dunlap, & Buschbacher, 2000;Horner et al., 2000; Prizant, Wetherby, Rubin,Laurent, & Rydell, 2003).

One of the most effective interventions derivedfrom a functional assessment has been to teach func-tional equivalents of the problem behaviors (Carr et al.,1994; Horner et al., 2000). For example, for behaviorsthat are determined to serve a communicative function(e.g., to request an object, to request assistance, toexpress frustration or boredom, to seek attention),teaching appropriate communicative forms to ex-press the function(s) served by the problem behav-

iors has been associated with a reduction in the prob-lem behavior (Carr et al., 1994; Durand, Berotti, &Weiner, 1993; Durand & Carr, 1991, 1992).

A process that uses the functional assessment ofproblem behaviors to directly target the relationshipbetween challenging behavior and communication iscalled positive behavior support. It integrates estab-lished scientific practices founded in applied behav-ior analysis with person-centered values, lifestylechanges, and comprehensive approaches to interven-tion (Buschbacher & Fox, 2003). Instead of conceptu-alizing intervention in narrowly defined settings andexpectations, positive behavior support focuses onintervention in the natural context. By broadening thefocus of behavioral intervention to include school,home, and community settings, positive behaviorsupport increases the quality and quantity of mean-ingful and positive interchanges. It is this comprehen-sive focus and the valuing of social and ecologicalvalidity that promote comprehensive lifestylechanges and sets positive behavior support apartfrom other methods (Carr et al., 2002).

Early research evidence of the effectiveness ofpositive behavior support for children with ASD canbe found in the literature on functional communica-tion training. Functional communication trainingprovided the underpinnings of positive behaviorsupport by generating the idea that challenging be-havior can serve one or more communication and/or regulatory functions and that teaching equivalentcommunication skills reduces the problem behavior(Durand et al., 1993; Durand & Carr, 1991, 1992;Horner, Day, Sprague, O’Brien, & Heathfield, 1991;Lalli, Casey, & Kates, 1995). A very robust researchbase for positive behavior support grew from thesebeginnings and continues to emerge. Carr et al. (1999)reviewed more than 100 single-subject studies from1985 to 1996. They concluded that 68% of the out-comes showed 80% or more reduction in the challeng-ing behaviors targeted. A review of single-subjectstudies for children with ASD published from 1996to 2000 supports these positive outcomes specificallyfor this population. A 94.6% average reduction ofinappropriate behavior for the participants was re-ported (Horner et al., 2000). The literature is unam-biguous in showing positive behavior support aseffective in reducing challenging behavior in childrenwith disabilities and more specifically in childrenwith ASD.

Positive behavior support includes the followingcomponents:

• Formulate Behavior Hypotheses—Deter-mine the purpose of the behavior or your bestguess about why the behavior occurs.


• Use Prevention Strategies—Implementways to make events and interactions thattrigger challenging behavior easier for theindividual to manage.

• Foster Replacement Skills—Enhance newskills throughout the day to replace the chal-lenging behavior and serve the same func-tion.

• Respond in a Positive Manner—Assist part-ners to identify and encourage the replace-ment skill and ensure that the challengingbehavior is not maintained.

With the appropriate experience with individualswith ASD and functional assessment, the SLP shouldplay a critical role in each of these components ofpositive behavior support. The SLP offers uniqueexpertise in social communication that should beused in the design of prevention strategies and re-placement skills. Positive Beginnings: Supporting YoungChildren with Challenging Behavior was a project ofnational significance funded by the U.S. Departmentof Education to develop training materials that in-clude video clips embedded within a PowerPointpresentation and extensive handouts to be used byprofessionals to train child care providers and para-professionals on positive behavior support. This re-source may be useful for clinicians and is availableat http://pbs.fsu.edu for a nominal fee.

Communication programming needs to be wellintegrated with the management of challenging be-havior in order to have an impact on the individual’slifestyle by enhancing meaningful progress in com-munication abilities. This will result in increased ac-cess to a variety of people, places, and events. Further-more, the use of AAC methods has positive effects onchildren with ASD, such as decreased rates of severeproblem behaviors (Bopp, Brown, & Mirenda, 2004;Frea, Arnold, & Vittimberga, 2001) and increasedrates of social interaction (Garrison-Harrell, Kamps,& Kravits, 1997). This makes the SLP’s unique exper-tise in social communication and AAC vital to thegoals of positive behavior support. Ultimately, it isthe individual’s competence in social interaction andcapacity to cope with stress using flexible communi-cation strategies that will determine the level of in-dependence that can be achieved in adulthood.

Strategies That Support LearningStyle, Developmental Framework,and Self-Determination

Not all intervention strategies are equally effec-tive with all individuals with whom they are imple-mented. Careful assessment of the needs, strengths,and preferences of an individual with ASD, along

with his or her family and other caregivers, may as-sist in determining strategies to promote better out-comes for the individual (Freeman, 1997; Quill, 1997;Rogers, 1998). Taking an individualized approachimplies that broader intervention programs should beconsidered in terms of their different components,both content and strategies, to evaluate the “goodnessof fit” between each component and the individual’sspecific developmental profile, interests, and learn-ing style, as well as family characteristics and prefer-ences (Rogers, 1998). This section will summarizeevidence-based strategies that capitalize on some ofthe relative strengths of many individuals with ASD,that compensate for relative weaknesses, and thathave demonstrated efficacy for promoting social com-munication; language, literacy, and related cognitivebehaviors; and behavioral and emotional regulation.The evidence for each of these strategies comes pri-marily from single-subject design studies; for each ofthe strategies included here, the efficacy has beensupported by the results of at least two empiricalstudies published in peer-reviewed journals using theNRC evaluation criteria.

Many individuals with ASD show relativestrengths in skills involving visuospatial processing(e.g., Harris, Handleman, & Burton, 1990; Lincoln,Courchesne, Kilman, Elmasian, & Allen, 1988;Minshew, Goldstein, & Siegel, 1997; Mitchell &Ropar, 2004). Other relative strengths include sus-tained attention; gestalt, simultaneous, and rule-based information processing; associative andrecognition memory, and cued recall; and graphicsymbol comprehension. Corresponding relativeweaknesses include shifting attention; sequential,analytical, and abstract information processing; com-plex encoding in memory and free recall frommemory; and oral language comprehension (Quill,1997). Other characteristics that have been consideredin the development and selection of interventionstrategies are the intense, sometimes idiosyncratic,interests that individuals with ASD may have in par-ticular objects or activities, coupled with a narrowerrange of interests than individuals without ASD typi-cally have. Individuals with ASD also face challengesin generalizing social communication and othernewly learned behaviors to other stimuli, settings,and partners who were not involved in the initialteaching.

The following strategies have been developed totake advantage of the relative strengths seen in manyindividuals with ASD and/or to compensate for rela-tive weaknesses:

• environmental arrangements and structure• picture schedules and other visual supports


• written scripts and social stories• video modeling• computerized instruction• previewing of learning context and activity• strategies to promote generalization• strategies to promote self-determination

Environmental arrangements and structure. Envi-ronmental arrangements to promote social commu-nication initiation and development have beenincluded as one component of a number of interven-tions, although these strategies have not been evalu-ated as separate intervention ingredients (Hwang &Hughes, 2000b). Several studies including environ-mental arrangements and structure have reportedpositive effects on social communication behaviorsduring both training phases as well as in generaliza-tion to other stimuli, partners, or situations (Charlopet al., 1985; Hwang & Hughes, 2000a; Matson, Sevin,Box, Frances, & Sevin, 1993; Matson, Sevin, Fridley,& Love, 1990). Environmental arrangements includestrategies such as using materials that are preferredby the individuals with ASD, placing preferred ma-terials out of reach, and creating unexpected “prob-lems” such as removing some essential, familiar partof the material. In addition, environmental arrange-ments can include designing spaces within class-rooms or other settings to provide visual clarityregarding the activity that occurs in that space(Panerai, Ferrante, & Zingale, 2002). Environmentalarrangements address the characteristics that indi-viduals with ASD often exhibit with respect to inter-ests and motivation, and thereby provide contexts forcommunication behaviors that will be meaningful tothe person with ASD (Hwang & Hughes, 2000a; R. L.Koegel, Koegel, & McNerney, 2001). In addition, theuse of visually structured spaces associated with spe-cific activities takes advantage of strengths in asso-ciative memory and cued recall (Rogers, 1998).

Picture schedules and other visual supports. Pictureschedules have been used successfully to promoteengagement and completion of activities for bothlower functioning (MacDuff, Krantz, & McClanahan,1993) and higher functioning (Bryan & Gast, 2000)individuals with ASD, with demonstrated generali-zation of picture schedule used for activities otherthan the ones originally trained. Picture sequencescan be used both to support an individual through adaily schedule of activities that may change some-what from day to day and to illustrate a sequence ofsteps that need to be completed within a single activ-ity. Visual cues also have been used to support indi-viduals with ASD in making choices, which isassociated with more engagement in activities; forinstance, Watanabe and Sturmey (2003) provided a

written list of possible activities to adults with autismand had them complete their own schedules for thedaily activities, whereas Reinhartsen, Garfinkle, andWolery (2002) provided toddlers with autism playchoices by visually presenting two toys. In addition,visual cues have been incorporated into interventionplans aimed at increasing social communication ini-tiations of individuals with ASD, with demonstratedefficacy. Visual cues also have been used to supportspecific social communication requests by childrenwith ASD to join in play with peers (Johnston, Nelson,Evans, & Palazolo, 2003). These types of visual cuesare consistent with a pattern of relative strengths invisuospatial, gestalt, and rule-based processing, cuedmemory recall, and comprehension of graphic sym-bols (e.g., Bryan & Gast, 2000; Charlop-Christy, Car-penter, Le, LeBlanc, & Kellet, 2002; Ganz & Simpson,2004; Johnston et al., 2003).

Written scripts and social stories. Written scriptshave been used to help readers with ASD initiate so-cial verbal communication and engage in conversa-tional exchanges with partners (Charlop-Christy &Kelso, 2003; Krantz & McClannahan, 1993, 1998;Sarokoff, Taylor, & Poulson, 2001). The participantsin these interventions were provided with cue cardsor more extensive written scripts and were promptedas needed to read the appropriate line of text. Acrossthe intervention studies, participants typicallylearned the scripts quickly and were then able to en-gage in the scripted behaviors without the writtencues. More importantly, the implementation of scriptinterventions was associated, in various studies, withan increase in unscripted comments, generalizationto new partners, settings, and topics, and mainte-nance of skills across time. As a “low-tech” strategy,the use of printed scripts for children with ASD whocan read can be adapted easily to the individualstudent’s interests and implemented in a variety ofsocial situations (Charlop-Christy & Kelso, 2003).

Social stories also have been used with individu-als with ASD to provide scripts for appropriate be-haviors and social skills. Beyond providing a scriptor directive statements about appropriate behaviors,however, social stories have other components aswell. These include descriptions of the setting andtypical characteristics of the setting to help the indi-vidual identify the relevance of the story to his or herexperiences, relevant cues that the individual canlearn to attend to in challenging situations, and state-ments describing the thoughts, feelings, and behav-iors of other people (C. A. Gray, 1995). As Barry andBurlew (2004) point out, the methods of using socialstories also are important as they involve empiricallysupported instructional components for individualswith ASD and other disabilities, including repetition,


priming, opportunities to practice, and correctivefeedback. Although the originator of social stories didnot specify the inclusion of pictures in the stories (C.A. Gray, 1995), in most of the available research,printed text was supplemented with picture icons orphotographs (e.g., Barry & Burlew, 2004; Ivey, Heflin,& Alberto, 2004). Social stories have demonstratedeffectiveness in decreasing inappropriate behaviorssuch as tantrums, aggression, and inappropriatesounds (e.g., Kuoch & Mirenda, 2003; Kuttler, Miles,& Carson, 1999) and in increasing prosocial behav-iors such as participation in novel events, indepen-dent choice making, and greater duration ofappropriate play (Barry & Burlew, 2004; Ivey et al.,2004).

A small body of research exists on the use ofthought bubbles with individuals with ASD. Thisoffshoot from social stories uses cartoon-type bubblesto represent the content of people’s minds as a strat-egy to help individuals with ASD compensate fortheir difficulties in understanding the thoughts andfeelings of others (C. A. Gray, 1998). Thought bubbleshave improved the performance of individuals withASD on false-belief and other related tasks involvingtheory of mind capabilities, including transfer ofimproved understanding to untrained tasks (S. Kerr& Durkin, 2004; Parsons & Mitchell, 1999; Wellmanet al., 2002). Thus far, however, evidence is not avail-able to document improvements in everyday socialinteraction skills following interventions withthought bubble cartoons.

Video modeling. Providing models via videotapehas been used successfully to promote conversationalskills; comments about play, play behaviors and so-cial initiations; and other individually targeted behav-iors (Charlop & Milstein, 1989; Charlop-Christy, Le,& Freeman, 2000; Nikopoulous & Keenan, 2004; Tay-lor, Levin, & Jasper, 1999). One study directly com-pared video modeling to live modeling and foundthat the video modeling resulted in faster improve-ments in the targeted behaviors across 5 differentchildren with ASD (Charlop-Christy et al., 2000). Inaddition, video modeling was associated with gen-eralization of skills, whereas the live modeling in theirstudy was not. The researchers of this study sug-gested that video modeling may be effective in help-ing to compensate for the tendency of individualswith ASD to overselect and attend to stimuli that arenot necessarily relevant for learning targeted instruc-tional behavior, because in video modeling the cam-era can zoom in on the critical aspects of the situation;in addition, the researchers suggest that watchingvideo models is intrinsically motivating for manyindividuals with ASD in a way that live models are

not, perhaps due to their ability to relate better toobjects than to people.

Computerized instruction. Computerized instruc-tion also has generated some research investigationsof its utility for improving language and social com-munication abilities of individuals with autism. It hasbeen beneficial in teaching sentence structure (withgeneralization of vocal and written responses to un-trained stimuli; Yamamoto & Miya, 1999), vocal imi-tation (Bernard-Opitz, Sriram, & Sapuan, 1999), socialproblem solving (Bernard-Opitz, Sriram, & Nakhoda-Sapuan, 2001), vocabulary (Bosseler & Massaro, 2003;Moore & Calvert, 2000), and increasing the use ofcommunication initiations and relevant speech(Hetzroni & Tannous, 2004). In investigations of vo-cabulary and increasing communication initiationand relevant speech, the computerized instructionwas found to carry over to naturalistic interactions(Bosseler & Massaro, 2003; Hetzroni & Tannous,2004). Moore and Calvert (2000) found that comput-erized instruction of vocabulary resulted in morerapid acquisition than teacher instruction, possiblydue to the nonsocial nature of the computer or to theability of computerized instruction to focus thestudent’s attention on the salient cues. A comparisonof personal instruction versus computerized instruc-tion to facilitate vocal imitation yielded similar results(Bernard-Opitz et al., 1999).

Previewing of learning context and activity. Anotherstrategy that is consistent with the learning styles ofmany individuals with ASD is the use of priming orpreviewing upcoming events or tasks. L. K. Koegel,Koegel, Frea, and Green-Hopkins (2003) investigatedthe efficacy of having a “primer” (the student’s par-ent or another individual outside of the classroom)spend approximately 1 hour previewing the subse-quent day’s academic lessons with 2 students withASD. Priming was associated with more appropriatebehavior and more correct behavior than when acomparable amount of time was spent outside of classon an assignment that was not a preview of the com-ing lesson. Other intervention strategies describedabove also have been used for priming, includingpicture or written schedules and social stories.

Strategies to promote generalization. A variety ofstrategies promotes better generalization of learning,language, and other social communication behaviorsto naturalistic settings (NRC, 2001; Schreibman, 2000).These include the involvement of parents and othercaregivers in intervention planning and implemen-tation, as well as the use of naturalistic approachesin teaching (e.g., natural settings, natural reinforcers,and capitalizing on child interests and child-initiatedbehaviors as the bases for intervention activities).


These strategies are important to help individualswith ASD compensate for relatively weak skills inanalytical and abstract information processing, whichlimit their ability to understand the application ofskills, particularly complex social communicationskills, in new situations.

Strategies to promote self-determination. Self-deter-mination is “living one’s life consistent with one’sown values, preferences, strengths, and needs”(Turnbull et al., in press). Self-determination is highlyvalued in our society. All persons, including indi-viduals with ASD, deserve the ability to have controlover their lives and to advocate for the quality of lifethey desire.

In children without disabilities, the school systemtacitly fosters self-determination through teachingprerequisite skills for technical careers or further edu-cation, providing increased opportunities for decisionmaking, and expecting students to assume more per-sonal responsibility as they grow older (Westling &Fox, 2000). Unfortunately, self-determination has tra-ditionally been overlooked for children with disabili-ties or postponed until adulthood (Bannerman,Sheldon, Sherman, & Harchik, 1990). It is now widelyrecognized that self-determination should be explic-itly addressed from an early age.

Regrettably, many individuals with ASD seem tohave been taught to depend on others (Wehmeyer &Shogren, in press). Wehmeyer and Shogren point outthat even when self-determination is addressed, be-cause of their differences in communication and so-cial interaction, individuals with ASD may be “at riskfor simply learning the component skills of self-de-termination, and practicing them in a rote manner,without fully understanding the application to theirlives.”

As self-determination emerges across the lifespan, SLPs can incorporate a variety of strategies tomake sure that choice and self-advocacy are inherentin the lives of persons with ASD. First and foremost,being able to make one’s own decisions is greatly af-fected by one’s ability to communicate with others(Baker, Horner, Sappington, & Ard, 2000). Teachingcommunication skills supports the development ofself-determination. In turn, strategies that lead to self-determination can be incorporated into communica-tion interventions, as well as daily activities across thelife span. Communication interventions that supportself-determination include (a) providing choices thatare meaningful and that honor preferences (Frea etal., 2001; Reinhartsen et al., 2002), (b) teaching andhonoring the ability to end and refuse activities, and(c) teaching social problem solving so that self-deter-

mination skills taught are not applied rotely(Wehmeyer & Shogren, in press).

AAC

A wide range of AAC approaches is often usedin order to improve the social and communicationcompetence of individuals with ASD. Unaided AACapproaches include, but are not limited to, the use ofgestures, sign language, and facial expressions. AidedAAC approaches include, but are not limited to, theuse of tools such as pictures, graphic symbols, orwritten cues and the use of tools such as SGDs. Arecent meta-analysis of studies examining the efficacyof AAC indicated that the majority of AAC interven-tions were either highly or fairly effective in terms ofbehavior change and generalization (Schlosser & Lee,2000), suggesting that a strong level of evidence ex-ists for these approaches (ASHA, 2004c, 2005;Mirenda, 2003). Nevertheless, the available literaturedoes not predict yet which forms of AAC will be mosteffective for a specific individual, particularly withrespect to individuals with ASD (NRC, 2001). Thus,clinical decisions about unaided AAC techniques andaided AAC techniques should be made on an indi-vidual basis by examining the quality and relevanceof evidence available and using principles of evi-dence-based practice. Considerations might includethe individual’s learning strengths and weaknesses,his or her developmental level of social communica-tion skills, and his or her motor abilities. In addition,the contexts in which AAC approaches might beembedded, potential communication partners, andfamily preferences should be considered, as the po-tential impact on quality of life should be of para-mount importance.

The use of both unaided and aided AAC ap-proaches with individuals with ASD has been asso-ciated with (a) improvements in behavior andemotional regulation (Frea et al., 2001); (b) improve-ments in speech, expressive language, and social com-munication (Garrison-Harrell et al., 1997; Light,Roberts, DiMarco, & Greiner, 1998; Mirenda, 2003;Schlosser, 2003); and (c) improvements in receptivelanguage development and comprehension (Brady,2000; Peterson, Bondy, Vincent, & Finnegan, 1995).Although consumers often raise concerns as towhether the implementation of AAC approaches in-terferes with or inhibits the development of speech,there is no evidence to support this notion (Mirenda,2001, 2003; NRC, 2001). Thus, AAC approaches canbe useful components of a comprehensive educa-tional program designed to promote social commu-nication, language, literacy, and related cognitivebehaviors, and behavior and emotional regulation(NRC, 2001). The following three sections summarize


evidence for the broad applications of AAC for indi-viduals with ASD.

The positive impact of AAC on behavior and emotionalregulation. Decreased rates of severe problem behav-iors are associated with the implementation of AAC(Frea et al., 2001; Wendt, Schlosser, & Lloyd, 2004).In addition to the use of gestures and manual signs,the use of symbol systems, particularly those withstatic visual representations such as picture and writ-ten communication supports, enhances the efficiencyof word recall and spontaneous communication(Ganz & Simpson, 2004). Therefore, when these sup-ports are available to serve the same function as aproblem behavior (e.g., aggression, crying, scream-ing), individuals with ASD have access to a simpleand efficient tool to communicate through more ap-propriate means (Mirenda, 1997; Wendt et al., 2004).Additionally, by capitalizing on the common learn-ing style preference for static visual information,many AAC approaches alleviate processing chal-lenges caused by information presented through theauditory modality, which is more “fleeting” in nature(e.g., oral directions, nonverbal social cues). Thesesupports may include the use of between-task sched-ules, within-task schedules, first/then boards, andsocial stories. When available, an individual withASD is likely to have more access to information thatdenotes the social expectations of a given activity andthe need for transitions between activities, allowingfor greater self-organization and emotional regula-tion (Shane & Simmons, 2001).

The positive impact of AAC on speech, expressive lan-guage, and social communication. Although there are asignificant number of children with ASD with limitedfunctional speech who are ideal candidates for AACsystems, AAC approaches also have shown utilitywith individuals who are developing speech, supple-menting existing speech, or using verbal language asa primary mode of communication. As noted earlier,there is no evidence that either unaided or aided AACapproaches interfere with speech and language de-velopment in individuals with ASD (Mirenda, 2003;NRC, 2001). In fact, the available evidence suggeststhat there is a range of AAC approaches that enhancethe use of speech, lead to improvements in expressivelanguage, and foster increased bids for social inter-action (Schlosser, 2003). Thus, consideration of the useof AAC, paired with systematic efforts to enhancespeech development, should be made on an individu-alized basis to support improvements in these areas.

With respect to unaided approaches such as theuse of speech paired with sign language (i.e., totalcommunication), research has indicated that thisAAC approach results in more efficient and broad

receptive and/or expressive vocabulary acquisitionthan targeting speech alone for many children withautism (Barrera, Lobatos-Barrera, & Sulzer-Azaroff,1980; Barrera & Sulzer-Azaroff, 1983; Layton, 1988;Yoder & Layton, 1988). The NRC (2001) summarizedthe literature on the efficacy of sign language andconcluded that (a) the use of manual signs enhancesthe use of speech for some children with ASD, (b)those children with good verbal imitation skills aremore likely to acquire speech (with or without thisAAC approach), and (c) those children who have dif-ficulty with speech imitation are ideal candidates forAAC, as they are likely to make poor progress inspeech acquisition without the use of AAC ap-proaches.

Although individuals with ASD may benefitfrom learning manual signs when acquiring speech,it is uncommon for individuals with ASD to use thismode of communication to create more sophisticatedand creative combinations of words and sentences(NRC, 2001). As a result of this limitation in treatmentoutcomes and the preference of individuals with ASDfor static visual information, the use of aided AACapproaches has received considerable attention.There is a growing body of research on the use of thePicture Exchange Communication System (PECS)with individuals with autism (Bondy & Frost, 1994;Charlop-Christy, Carpenter, Le, LeBlanc, & Kellet,2002; Ganz & Simpson, 2004; Kravits, Kamps,Kemmerer, & Potucek, 2002; Schwartz, Garfinkle, &Bauer, 1998; Tincani, 2004; Yoder & Stone, in press),demonstrating increased communication initiationsassociated with the PECS intervention. Furthermore,picture/graphic communication systems have beenused successfully to increase functional and sponta-neous requests in individuals with ASD (Mirenda &Santogrossi, 1985; Steibel, 1999), to increase requestsfor peer interaction (Johnston et al., 2003), and to en-gage in conversational exchanges with partners(Krantz & McClannahan, 1998). Although the use ofSGDs has not been studied systematically, prelimi-nary outcomes suggest that feedback through synthe-sized speech increases communication interactions(Schepis, Reid, Behrmann, & Sutton, 1998; Schlosser,2003; Wendt et al., 2004).

The positive impact of AAC on receptive languagedevelopment and comprehension. Individuals with ASDalso have benefited from the use of AAC to augmentlanguage input from others, as this instructional strat-egy fosters receptive language development of com-prehension (Brady, 2000; Light et al., 1998). Pre-senting more complex information such as the se-quence of activities, the components of tasks, and theindividual components of multiword utterances in astatic visual format may alleviate the processing chal-


lenges posed by orally presented verbal language. Be-tween-task schedules and within-task schedules,which were described above in relation to reducingproblem behaviors, provide an individual with ASDwith support in following symbolic representationsof tasks and task components more independently(Hall, McClannahan, & Krantz, 1995; Pierce &Schreibman, 1994), while aided language stimulation(i.e., pairing spoken language with visually depictedlanguage) and video-based instruction may fosterincreased utterance length and comprehension acrosssettings (Charlop & Milstein, 1989; NRC, 2001).

Play and Peer Mediation

While the pervasive social isolation often expe-rienced by individuals with ASD argues against thecontinued reliance on isolate settings in the provisionof treatment, ASHA survey data (2004c) suggest that“pull-out services” remain the most common modeof intervention in the schools. Nevertheless, inclusionof communication partners is essential in order tominimize social isolation and boost communicationcompetence. Peers are primary candidates for suchinclusion, particularly when children with ASD areserved in integrated or inclusive settings. Withoutintervention, children with ASD are even less likelyto initiate communication with peers than withadults. Moreover, since interactions with peers andparticipation in peer culture become more criticalover time (Hartup, 1979), children with ASD maybecome increasingly isolated without specific inter-ventions to counteract such developmental trends(for a more detailed overview, see Wolfberg &Schuler, in press).

The inclusion of communication partners in in-tervention efforts not only serves to decrease isola-tion, it also increases treatment intensity and, mostimportantly, makes the intervention more responsiveto the core features of ASD. The fact that the prevail-ing lack of reciprocal interaction may well be the mostdefining characteristic of individuals with ASD servesto underscore how important it is that the child’scommunication partners are included in interventionefforts. Finally, inclusion of peers and other commu-nication partners provides an antidote to the com-monly reported generalization problems. Oftencommunication gains made with a particular inter-ventionist are demonstrated only in the presence ofthat particular individual and only in the settingswhere training took place. Therefore, a model of ser-vice delivery that targets the communication respon-siveness and active engagement of communicationpartners is critical to success (for a further discussionof these issues, see the following section).

Despite the apparent benefits, the use of peers asintervention agents is not common practice. A num-ber of factors have hampered peer involvement. Firstof all, the common belief that so-called readiness skillsneed to be demonstrated prior to the provision of peeraccess means limited opportunities for peer interac-tions. But, as discussed by Strain (2001) and docu-mented by Strain and Kohler (1998) in their reviewof 80 case histories, accumulating evidence of success-ful peer interaction without the prior demonstrationof such readiness skills has contradicted such claims.

Another related obstacle to supported peer inter-actions lies in the common belief that the perspective-taking capabilities of young children limit their abilityto be successful communication partners. While theeffectiveness of such partners for children with ASDremains to be investigated systematically, evidencefrom various different peer-mediated interventionssuggests that the competencies of typically develop-ing peers exceed common expectations (Goldstein &Cisar, 1992; Guralnick, 1990, 1994; Guralnick &Neville, 1997; Strain & Kohler, 1998) when supportstructures are put in place (for a more extensive over-view and discussion of such evidence, see Wolfberg& Schuler, in press). Moreover, specific inquiry intothe perspective-taking skills of typically developingchildren has documented that they are able to adapttheir communication style and language use based ontheir perceptions of the linguistic and cognitive sta-tus of children with whom they are interacting (see,e.g., Goldstein, Kaczmarek, Pennington, & Schafer,1992).

The first accounts of the successful use of peersappeared in the late 1970s, documenting their useprimarily as trained tutors, role models, and initia-tors of interactions (Guralnick, 1976; Strain, 1977;Strain, Kerr, & Ragland, 1979). Odom and Strain(1984) further documented peer-mediated ap-proaches, with typically developing peers beingtrained, prompted, and reinforced by adults to in-crease the social initiations and responses of childrenwith autism. Although these early studies resulted inincreased frequency and duration of social interac-tion, critics pointed out that improvements did notgeneralize beyond the peer tutor (Lord & Hopkins,1986) and that interventions did not correspond tocontexts in which social behavior would naturallyoccur (Lord, 1984).

Besides providing specific reinforcement andmore general feedback, peers have proven to be ef-fective role models to boost communication and lan-guage skills through the use of incidental teaching,peer-based script training for language acquisition,and small-group individualized instruction. For in-


stance, Charlop and Milstein (1989) showed video-tapes of peers engaging in three turn conversationsto teach scripted interactions of varying length andcomplexity to children with ASD. Goldstein et al.(1992) successfully taught typically developing peersto comment and respond to peers with ASD in a playcontext. While the children with ASD demonstratedincreased social communication interactions, the in-teractions were reported to be mostly responsesrather than initiations, and the peers needed contin-ued prompting to act as facilitators, providing onlylimited evidence of generalization.

Extensions of these earlier approaches include adual focus on training the typical peers and the chil-dren with autism to increase interactive play (Haring& Lovinger, 1989; Oke & Schreibman, 1990). Self-monitoring has been used to increase play interac-tions between children with ASD and their typicallydeveloping peers (e.g., Sainato, Goldstein, & Strain,1992; Shearer, Kohler, Buchan, & McCullough, 1996).In vivo and video modeling has also been used toincrease play with peers and siblings (Taylor et al.,1999). Interventions are also more commonly beingcarried out in inclusive settings where play with typi-cally developing peers naturally occurs (e.g., pre-school settings; see, e.g., Pierce & Schreibman, 1997;Roeyers, 1996; Strain & Kohler, 1998). Further, thereis more of an emphasis on supporting the children inplay activities that are common among typically de-veloping children. For instance, Goldstein and Cisar(1992) used modeling, prompting, and reinforcementprocedures to train triads, consisting of 1 child withautism and 2 typically developing peers, to act outspecific turns in sociodramatic play scripts. Thiemannand Goldstein (2004) found that teaching typicallydeveloping peers to use specific social interactivestrategies led to better initiation and responding for4 of 5 elementary-age students with ASD. Interest-ingly, the addition of written cues prompting socialcommunicative behaviors for the students with ASDresulted in even further improvements in the commu-nicative functions expressed by the children withASD who had already shown positive changes dur-ing the peer training phase of the study and also re-sulted in improvements in social communicationbehaviors for the fifth child. Social validity data col-lected in conjunction with this study suggested thechanges in the children with ASD resulted in im-proved social skills in the classroom (as observed byteachers) and greater social acceptance and higherfriendship ratings among their classroom peers.

Although these types of adult-directed practicesinvolving peer-mediated play are documented to beeffective, it is well established that there is a heavy

reliance on explicit and precise adult control to effec-tively deliver the intervention (NRC, 2001). This typeof adult-imposed structure defies the inherent quali-ties of children’s play as intrinsically motivated, gov-erning a self-imposed structure. Drawing fromgeneral developmental knowledge and insights, anumber of investigators have reported the use ofnaturalistic approaches whereby children with ASDhad repeated exposure to familiar peers and theirplay activities with minimal adult support (e.g., Lord& Hopkins, 1986; McHale, 1983). These more child-centered interventions have yielded both quantitativeand qualitative improvements in the social interac-tion, language, and play of the children with ASD.Moreover, systematic comparisons of low versus highlevels of adult intrusion on children’s spontaneousplay (Meyer et al., 1987) have propelled a trend to-ward less adult-imposed structure consistent withmore child-centered practices. Subsequent effortshave included peers in a wider variety of roles andin a more reciprocal fashion, closer aligned with thecore challenges experienced by individuals with ASDand their communication partners. Moreover, a fur-ther examination of current literature, including be-havioral as well as developmental, affective, andecological sources, reveals some common themes andtrends (see Wolfberg & Schuler, in press). For in-stance, there is a growing recognition of the inherentvalue of more naturalistic approaches to support chil-dren with ASD in play.

Play interventions are increasingly taking placein natural settings with more involvement of typicallydeveloping peers. Many interventions share a focuson identifying and responding to what is intrinsicallymotivating for the child. Similarly, there is a greateracknowledgment of individual differences amongchildren, as early intervention programs incorporatestrategies that are tailored to each child’s develop-mental level and style of learning. Finally, moreblended approaches and practices are observed, asopposed to a strict adherence to a particular para-digm, method, or specific skill. To arrive at a broaderconceptual foundation that can incorporate comple-mentary perspectives and help guide practitioners indeciding which techniques and training contexts touse, a closer understanding is needed of the differ-ent layers and configurations of support that inviteplay. In doing so, it is important to realize that a solefocus on single contributions may not be productive;all these components may be better combined into amore powerful multidimensional approach. Thus, toprovide children with ASD sufficient and contextu-ally relevant support, all of the factors known to af-fect play (both from a developmental and socio-cultural perspective) must be carefully weighed and


considered when designing a comprehensive peerplay intervention.

While multilayered interventions have much in-tuitive appeal, as they seem to draw from all avail-able resources, they do complicate research effortsdesigned to compare the relative effectiveness of dif-ferent components and teaching methods (for a morein-depth discussion of such complications, seeGoldstein, 2002). Moreover, advances in play aremore difficult to operationalize and to quantify thanspecific interventions and outcomes, such as the typeand frequency of reinforcements provided to peers orthe physical proximity of the participating children.

By separating the social interactive componentsfrom the cognitive/representational dimensions ofplay, Wolfberg and Schuler (1993) managed tooperationalize play, documenting the positive impactof “integrated play” experiences quantitativelythrough a multiple-baseline design as well as quali-tatively through parent interviews. In an effort tohave children with ASD take turns in dramatic play,typically developing peers were taught to scaffoldplay. Coached by adults, peers learned to initiate playinteractions, model play behaviors, and even moreimportantly acknowledge even the most erratic playinitiations of their peers with ASD, learning to cueinto their often unusual forms of communication. Thewatchful layout of play space, the prudent structur-ing of and the ritualization of play events, and thecareful selection of toys and other play materials pro-vided additional levels of structure. While the pre-sented data clearly speak to the effectiveness of theintegrated playgroups, it is difficult to evaluate whichcomponents are most effective for whom, and whatadditional supports might have to be presented. Stud-ies such as the one carried out by Kok, Kong, andBernard-Opitz (2002) may be useful to investigatesuch questions. This study compared more tightlyadult-structured and looser facilitated peer play inchildren with ASD and found communication andplay increased with both techniques; however, thefacilitated approach was more effective in elicitingspontaneous communication and play in childrenwith more advanced skills.

Using combinations of quantitative and qualita-tive methods of inquiry, further positive impacts ofintegrated play on social communication, and morespecifically symbolic development, have been ex-plored and documented by Schuler and Wolfberg(2000), Wolfberg (1999), Yang, Wolfberg, Wu, andHwu (2003), and Zercher, Hunt, Schuler, and Webster(2001). Highlighting the inherent opportunities forjoint attention, affect, and action, the importance ofdramatic play to boost communication and symbolic

development was reviewed by Schuler (2003) and il-lustrated through case examples. More specifically,the latter served to demonstrate how participation inadult-mediated and peer-facilitated play helps theparticipating children to engage in longer interactioncycles, extending beyond mere instrumental lan-guage functions, such as requests and protests thattypically characterize the communicative interactionsof individuals with ASD. While supported peer playpromises to be a powerful tool to diversify commu-nication repertoires, more research is needed to inves-tigate such claims. The participation of SLPs in suchresearch efforts seems most important so that growthin social reciprocity and symbolic representation canbe carefully documented.


SLPs should recognize the guidelines and activecomponents of effective, evidence-based practice forindividuals with ASD. They should draw on empiri-cally supported approaches to meet specific needs ofchildren with ASD and their families, thereby incor-porating family preferences, cultural differences, andlearning styles. SLPs should assist communicationpartners in recognizing the potential communicativefunctions of challenging behavior and designing en-vironments to support positive behavior. SLPs shouldrecognize the importance of family involvement andworking with a variety of partners, the facilitation ofpeer-mediated learning, the continuity of servicesacross environments, and the importance of match-ing service delivery to meaningful outcomes.

Service Delivery Models andthe Collaborative Role of the SLP

There is little research on speech-language pa-thology service delivery models for individuals withASD. However, current recommended practice sug-gests a move from exclusive use of the traditionalmodel of individual pull-out services for individualswith ASD to a more flexible service delivery model(ASHA, 2003b; NRC, 2001). The search for more ef-fective treatment practices and service delivery op-tions along with the increased incidence of ASD maystimulate the examination of new models of servicedelivery that better address the specific challenges ofASD. The type of service delivery selected should beflexible and dynamic, adapting to changing needs,preferences, and priorities of the individual with ASDand his or her family. All service delivery optionsshould be sensitive to culture, language, and re-sources and reflect a partnership with families.

There are many variables involved in servicedelivery. First of all, interventions vary according to


whether the SLP directly works with the student oradult or serves them indirectly by collaborating withtheir communication partners. Second, interventionsvary according to their location, that is, whether theyare being delivered in home, clinic, school, or com-munity settings. Third, interventions vary as a reflec-tion of the extent to which the SLP or client operatesin social isolation. Fourth, interventions vary in theintensity or frequency of the services.

Direct service provision in a separate treatmentroom, the most prevalent model of service provision(ASHA, 1993, 1995, 1999, 2004c), includes individualor small-group face-to-face intervention sessions andevaluations as well as providing services to childrenin the classroom. The pull-out model of service de-livery continues to be the most used model for pre-school and school-age children (ASHA, 2004c;Paul-Brown & Caperton, 2001). This model focuseson the teaching of discrete skills with little contextualsupport. For individuals with ASD, exclusive provi-sion of services through pull-out services does notaddress the underlying challenge of social commu-nication inherent in the disorder, the issues of gener-alization, functional outcomes, or the importance ofcollaborating with significant communication part-ners.

Contextually referenced and ecologically basedservices are essential to support the communicationand social growth and development of persons withASD (Strain, 2001). Service delivery models that aremore contextually referenced and ecologically basedinclude home-, classroom-, or community-based ser-vices and collaborative consultation models (Paul-Brown & Caperton, 2001). These models focus onservices in natural learning environments and includeeducation and training of family members, teachers,peers, and other professionals. By augmenting orsupplanting pull-out services with services in every-day contexts, the SLP can involve important commu-nication partners to ensure understanding of thenature of communication in ASD and to provide theintensive intervention needed (NRC, 2001). Withinhome/classroom/community service deliverymodes, the SLP may provide direct service, designand maintain augmentative systems and/or othervisual supports, adapt curricular materials, and col-laborate with and train significant communicationpartners to support communication in all environ-ments (ASHA, 2003b). Recognizing the importance ofsupported social interactions, repeated, plannedteaching opportunities, and a focus on functionaloutcomes, service delivery models that provide rel-evant contextual support and include collaboration

with significant communication partners are impera-tive across the life span.

While services for children are often the focus ofSLPs, supports for adolescents, young adults, andtheir families in planning the transition to adulthoodare less available (Smith & Donnelly, 1998). Speech-language services for adolescents and young adultspreparing for adulthood are important to their suc-cess in functioning during activities of daily living.Community and home-based service delivery mod-els also are relevant for persons with ASDtransitioning to independent living and working.

Research on children with ASD suggests that thegreatest effects of any direct treatment are reflectedin the generalization of learning achieved by work-ing with parents and classroom personnel (NRC,2001). There is no evidence supporting the long-termeffectiveness of individual therapies implementedinfrequently (e.g., once or twice a week), unless thestrategies are taught to be used regularly by commu-nication partners in the natural environment. Skilldevelopment may begin in individual treatment, butthe intensity of treatment will affect outcomes, andgeneralization of gains must be planned and moni-tored. The impact of speech-language services on lan-guage outcomes for individuals with ASD has notbeen systematically investigated. However, Stoneand Yoder (2001) found a strong positive associationbetween the number of hours of speech therapy andthe participant’s language skills at age 4.


The broad impact of the social communicationchallenges and problems with generalization for in-dividuals with ASD necessitates service deliverymodels that contribute to intensive services and leadto increased active engagement in the natural envi-ronment. SLPs should provide services in naturallearning environments that are connected with func-tional and meaningful outcomes and only providepull-out services when repeated opportunities do notoccur in the natural environment or to work on func-tional skills in more focused environments. Becauseof the limited impact of pull-out services focused ondiscrete skills, SLPs should ensure that any pull-outservices are tied to meaningful, functional outcomesand incorporate activities that relate to the naturalenvironment. SLPs also play an important role asadvocates for individuals with ASD in promotingsocial communication skills that lead to greater inde-pendence in home, school, work, and community en-vironments and greater participation in socialnetworks.


Professional Developmentof SLPs to Work EffectivelyWith the Population of ASD

The recent NRC report (NRC, 2001) reviewedoverall needs related to personnel preparation towork with individuals with ASD. The conclusions ofthe NRC report are applicable to the preparation ofSLPs to work effectively with this population. TheNRC report emphasized the need to develop andsupport infrastructures for professionals workingwith this population, such that qualified service pro-viders continually flow into the system. Infrastruc-tures are needed to support direct service providersin the following ways: (a) to work as part of a sup-port system team; (b) to be part of a communicationnetwork that links them to other professionals whomay be encountering similar challenges; (c) to haveongoing access to technical support; and (d) to partici-pate in and benefit from applied research, programevaluation, organized data systems, and comprehen-sive planning for services to this population.

The U.S. Department of Education, Office of Spe-cial Education Programs, regularly provides grantsupport for personnel preparation for school settings(U.S. Department of Education, 2004). The fundedprojects have included a number that involve thepreparation of SLPs to work with children with ASD.The specific personnel preparation plan varies fromproject to project; however, the projects generallyinvolve a combination of academic course work re-lated to autism and specialized practicum experienceswith individuals with autism. Features of some of theprojects have included interdisciplinary training toprepare SLPs to work as part of a team, ongoing in-teractions with families of individuals with ASD,preparation in AAC strategies, recruitment fromunderrepresented groups, preparation to work withmulticultural populations, use of distance education,and the preparation and dissemination of evidence-based practice materials for in-service personnel de-velopment. To date, however, published descriptionsand program evaluations of these projects to prepareSLPs to work more effectively with individuals withASD are not available to help guide other programsinterested in improving the preparation of SLPs inthis area.


SLPs should collaborate with families, individu-als with ASD, other professionals, support personnel,peers, and other invested parties to identify prioritiesand build consensus on a service plan and functionaloutcomes. They should participate in preservice andcontinuing education designed to prepare and en-

hance the knowledge and skills of professionals whoprovide services for individuals with ASD. Further-more, they should be informed of current researchand/or participate in and advance the knowledgebase of the nature of the disability, screening, diag-nosis, prognostic indicators, assessment, treatment,and service delivery of individuals with ASD.

Consideration of Risks and Benefits ofIntervention for Individuals With ASD

Autism is a very challenging disability for fami-lies, schools, and society because it is often associatedwith severe communication and behavior problems.In this and previous generations, most individualswith ASD required special education at school age.The average annual cost for educating a child withASD, based on 2005 figures from the U.S. Govern-ment Accountability Office, is $18,800, comparedwith $12,500 for the average special education studentand $6,556 for the typical regular education student.Thus, the cost for educating a student with ASD is farmore than that of most students in special or regulareducation. Intensive, appropriate early interventionduring preschool has the potential to greatly reducethe cost of special education since about half of thechildren studied have been able to be included intoregular education at kindergarten (NRC, 2001). Fur-thermore, the number of hours of speech-languagetherapy in preschoolers with ASD was a significantpredictor of spoken language 2 years later (Stone &Yoder, 2001). The committee recognizes that there arepotential systemic, organizational, and financial bar-riers in implementing the recommendations made inthese guidelines. However, investing in improvedearly detection of ASD and early intervention serviceswill lead to cost savings later in life. Appropriate in-tervention services for school-age individuals withASD that lead to meaningful changes in social com-munication skills can enhance independence in adult-hood and impact on quality of life. Throughout thelife span of the individual with ASD, effective inter-ventions offer potential benefits to families by allevi-ating some of the stress family members experiencerelated to having a family member with ASD. Becausethe cost of individual speech-language therapy maybe prohibitive, the recommendations in these guide-lines emphasize targeting the communication partnerwithin the natural environment in order to maximizethe impact of services by building capacity of the fam-ily, classroom teacher, school system, and potentialjob placements and minimize the amount of profes-sional time.

Although there are no known risks associatedwith recommended practices for speech-language


pathology or other educational services for studentswith ASD that have been delineated in these guide-lines, lack of appropriate services may have graveconsequences on outcomes. The use of ineffectiveintervention practices or practices that have not beenvalidated or lack evidence can be very costly for fami-lies and institutional systems in terms of wasted timeand money. In addition, families’ emotional burdensmay be increased when the family member with ASDdoes not show improvement and has missed oppor-tunities to benefit from effective practices. Hence,time and/or money lost to ineffective or invalidatedpractices cannot be recouped, and the quality of lifefor the individual with ASD and the family and sur-rounding community members may be diminished.

The SLP’s role is critical as a team member insupporting the individual, the environment, and thecommunication partner to maximize opportunitiesfor interaction. This must be done to overcome bar-riers that would lead to ever decreasing opportuni-ties and social isolation if left unmitigated. SLPs alsoplay an important role in promoting social commu-nication skills that lead to greater independence inhome, school, work, and community environmentsand greater participation in social networks. Thus, thebenefits of appropriate, educational services, includ-ing speech-language pathology services, for individu-als with ASD may have a combination of benefits tothe quality of life of the individual and family as wellas cost savings for society.

Directions of Future Research Related toIndividuals With ASD

SLPs should seek to stay informed about currentresearch and/or participate in research to advance theknowledge base, enhancing the quality of profes-sional practice. Ongoing research should deepen ourunderstanding of the nature of ASD, of prognosticindicators, and long-term outcomes, and it shouldfine-tune procedures and protocols used for screen-ing, diagnosis, assessment, and treatment, as well asmodels of service delivery for the population of con-cern. The NRC (2001) made the following recommen-dations for future research to enhance our overallknowledge of ASD: (a) Funding agencies and journalsshould require minimum standards in design anddescription of participants and intervention pro-grams; (b) to improve child outcomes, better instru-ments for diagnosis and early screening of ASDshould be developed; and (c) to help educators makeinformed decisions about selecting appropriate treat-ment methods for particular children, treatment stud-ies should use more precise, ecologically validoutcome measures, define appropriate targets in-

formed by typical development, and measure the ef-fects of the interactions between family variables andchild factors on intervention outcomes as they per-tain to different treatment approaches.

Given that the core features of ASD revolvearound social communication and language use, thefield of speech-language pathology should take amore prominent role in future research of ASD. Manyquestions regarding speech production, auditoryperception, feeding issues, AAC, and language acqui-sition and loss in individuals with ASD remain un-answered. Future research should devote moreattention to the needs of culturally and linguisticallydiverse populations who have family members withASD. The expertise of SLPs with regard to early com-munication development and the overall acquisitionof language and literacy skills holds much promisein this regard. More precise documentation of thedevelopment of particular communication profilesover time in relation to particular interventions, edu-cational experiences, and home environments shouldhelp SLPs become more skilled in prognosis and theevaluation and fine-tuning of treatment variables.Investigations designed to compare the effectivenessof specific interventions aimed at promoting speechproduction with interventions targeting broader so-cial communication skills and to identify variablesthat predict response to treatment would help deter-mine whether particular children or subgroups ofchildren with ASD would benefit in different waysfrom different intervention strategies. By being moreknowledgeable and better informed, SLPs should bebetter equipped to help parents cope with the uncer-tainties and challenges of ASD and to guide and sup-port them in their decision making.

Ultimately, SLPs need to know at which point toimplement what type of intervention strategy, where,for how long, and by who, and, last but not least, howto evaluate outcomes and make treatment modifica-tions. No matter which interventions are recom-mended, designed, and/or implemented, a strongerresearch agenda is needed. Only careful observationand systematic analysis will lead to the level of pro-fessional sophistication, allowing SLPs to help findthe best matches between child and family character-istics, developmental levels, learning profiles, paren-tal believes, cultural values, treatment philosophies,and strategies, as well as suitable research methods.The heterogeneity of the population of concern aswell as its low incidence makes it particularly diffi-cult to conduct relevant and meaningful research. Todevelop measures that are sensitive to changes insocial communication and can be collected in a vari-ety of intervention settings that cannot be rigidly con-trolled, qualitative methodologies (Miles &


Huberman, 1994) may need to be combined withquantitative methods, as recommended by Greeneand Caracelli (1997) and described by Schwartz,Staub, Gallucci, and Peck (1995). Ultimately, the chal-lenges encountered in serving this population mayinspire practitioners to pose new pertinent clinicalquestions to be answered and develop alternativemethods of inquiry. Future research promises notonly to enhance the efficacy of speech-language pa-thology services but also to elucidate the enigma ofASD.

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Appendix

Ad Hoc Committee on Autism Spectrum Disorders

The following people served on the ASHA Ad Hoc Committee on Autism Spectrum Disorders. Creden-tials and affiliations are indicated for each committee member. Committee members were selected to serve onthe committee because of their expertise in the area of ASD.

Amy M. Wetherby, PhD, CCC-SLPCommittee ChairL. L. Schendel Professor of Communication DisordersFlorida State UniversityTallahassee, FL

Sylvia F. Diehl, PhD, CCC-SLPClinical Instructor, Department of Communication

Sciences and DisordersUniversity of South FloridaRiverview, FL

Emily B. Rubin, MS, CCC-SLPLecturer, Yale University School of MedicineDirector, Communication CrossroadsCarmel, CA

Adriana L. Schuler, PhD, CCC-SLPProfessor of Special Education and Communication

DisordersSan Francisco State UniversitySan Francisco, CA

Linda R. Watson, EdD, CCC-SLPAssociate ProfessorDivision of Speech and Hearing Sciences, Depart-

ment of Allied Health SciencesUniversity of North CarolinaChapel Hill, NC

Jane R. Wegner, PhD, CCC-SLPDirector of the Schiefelbush Speech Language Hear-

ing ClinicIntercampus Program in Communication DisordersUniversity of KansasLawrence, KS

Celia R. Hooper, PhD, CCC-SLPASHA Monitoring Vice PresidentUniversity of North Carolina at GreensboroGreensboro, NC

Ann-Mari Pierotti, MS, CCC-SLPASHA Ex OfficioAmerican Speech-Language-Hearing AssociationRockville, MD

Declaration of Competing Interest

All members of the Ad Hoc Committee on Autism Spectrum Dis-orders agreed to declare any interest or connections with any commer-cial programs or products discussed in the guidelines. No member hadany paid consultancy or any other conflict of interest with any of thecommercial programs or products described in this document.

guidelines for speech-language pathologists in diagnosis ......dren (schreck & mulick, 2000)....

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