New York State Department of Health Clinical Practice Guideline on Assessment and Intervention Services for Young Children (Age 0-3) With Autism Spectrum Disorders (ASD): 2017 Update. Report of the Recommendations
NYS Department of Health. (2017).
Albany (NY): NYS Department of Health.
This guideline provides recommendations for the screening, assessment, and treatment of children on the autism spectrum under three years of age. The target audience for this guideline is families, service providers, and public officials.
New York State Department of Health
<p>This guideline was reviewed with the following supplemental documents:</p>
<ul>
<li>New York State Department of Health. (2017). <i>Clinical Practice Guideline on Assessment and Intervention Services for Young Children with Autism Spectrum Disorders (ASD): 2017 Update. Quick Reference Guide for Parents and Professionals</i>. Albany (NY): New York State Department of Health.</li>
<li>NYS Department of Health. (2017). New York State Clinical Practice Guideline on Assessment and Intervention Services for Young Children (Ages 0-3) With Autism Spectrum Disorders: Update – 2017.<i> Report of the Research of Evidence. A. Screening for Autism Spectrum Disorders in Young Children.</i> Retrieved from <a href="https://www.health.ny.gov/community/infants_children/early_intervention/disorders/autism/">https://www.health.ny.gov/community/infants_children/early_intervention/disorders/autism/</a></li>
<li>NYS Department of Health. (2017). New York State Clinical Practice Guideline on Assessment and Intervention Services for Young Children (Ages 0-3) With Autism Spectrum Disorders: Update – 2017. <i>Report of the Research of Evidence. B. Assessment for Autism Spectrum Disorders in Young Children.</i> Retrieved from <a href="https://www.health.ny.gov/community/infants_children/early_intervention/disorders/autism/">https://www.health.ny.gov/community/infants_children/early_intervention/disorders/autism/</a></li>
<li>NYS Department of Health. (2017). New York State Clinical Practice Guideline on Assessment and Intervention Services for Young Children (Ages 0-3) With Autism Spectrum Disorders: Update – 2017. <i>Report of the Research of Evidence. C. Review of Empirical Literature of Behavioral Interventions for Children with Autism Spectrum Disorders: Years 2000-2011.</i> Retrieved from <a href="https://www.health.ny.gov/community/infants_children/early_intervention/disorders/autism/">https://www.health.ny.gov/community/infants_children/early_intervention/disorders/autism/</a></li>
<li>NYS Department of Health. (2017). New York State Clinical Practice Guideline on Assessment and Intervention Services for Young Children (Ages 0-3) With Autism Spectrum Disorders: Update – 2017. <i>Report of the Research of Evidence. D. An Analysis of Published Research Evaluating Outcomes Associated with Parent-Mediated Interventions for Young Children with ASD: Years 1999-2013.</i> Retrieved from <a href="https://www.health.ny.gov/community/infants_children/early_intervention/disorders/autism/" class="ApplyClass">https://www.health.ny.gov/community/infants_children/early_intervention/disorders/autism/</a></li>
</ul>
The Screening Test for ASD in Toddlers (STAT) and the ASD Detection in Early Childhood (ADEC) are designed to identify children on the autism spectrum, particularly those children with more characteristics of autism and fewer developmentally expected abilities ( E Rating; p. 37).
"To track progress regarding children’s individualized treatment goals, it is recommended that measurable criteria for mastery are established and progress is evaluated through ongoing measurement. This may include curriculum-based assessments to examine progress at specific time periods (for example, monthly or quarterly)" (E Rating; p. 58).
The ASD Detection in Early Childhood (ADEC) "may be a useful tool for children 12 to 36 months of age by a variety of qualified<br />professionals across a range of settings" (E Rating; p. 37).
"The [Modified Checklist for ASD in Toddlers-Revised with Follow-Up] M-CHAT-R/F also has risk ranges. If the child scores positive ..., the Follow-up Parent Interview [should] be administered. However, if the child scores ... 8 or more, then it is recommended to bypass the Follow-up Interview with the parent and to refer the child immediately for a diagnostic evaluation for ASD" (E Rating; p. 36).
"The [Childhood Autism Rating Scale-2 (CARS-2)] is a clinician-judgment/clinician-rated instrument that can be useful for evaluation of young children. The research applicable to its utility and predictive validity has yielded the following guidelines:
<ul>
<li>It is recommended that a cutoff score of 25.5 be used rather than 30, as designated in the manual, especially to include children with [more skills and abilities within developmental expectations].</li>
<li>The CARS-2 has been shown to better detect children [on the autism spectrum] ... who have more cognitive delay compared to those [without cognitive delay].</li>
<li>Additional research will be important for use of the CARS-2 with children under 3 years old" (E Rating; p. 49).</li>
</ul>
"The [physician] should be proactive in addressing feeding problems. The first intervention should be behavioral suggestions and assessment of nutritional status. Counseling about nutrition and correcting nutritional deficits should take place in primary care.... Referral for behavioral or oral motor feeding support should be considered if feeding problems persist" (E Rating; p. 78).
"It is important to identify children [who are on the autism spectrum] ... and begin appropriate interventions as soon as possible. Early intervention may help through advancing the child's overall development, accomplishing immediate goals, and increasing appropriate behaviors, and may lead to better long-term functional outcomes" (E Rating; p. 53).
The Parent Observation of Early Milestones (POEMS) "is a useful second-level screening instrument [i.e., an instrument used to screen those referred from a general population screening] for children from 12 [to] 24 months of age" (E Rating; p. 38).
When selecting the intensity and duration of support services for young children on the autism spectrum, "it is important to recognize that based on available scientific evidence, it is not possible to accurately predict the optimal intensity that will be effective for any given child and family. However, it is recommended that behavioral programs include a minimum of approximately 20 hours per week of individualized intervention" (E Rating; p. 62).
"It is recommended that children with [a greater likelihood for being on the autism spectrum] ... (have an older biologic sibling or twin diagnosed with [autism spectrum disorder] ASD, were born preterm, or have certain genetic conditions) be screened earlier and more frequently, even starting at 12 months with valid and reliable screeners for their age" (PO Rating; p. 35).
"It is recommended that intensive early intervention approaches be used to address a range of child outcomes including improvements in cognitive abilities, adaptive behaviors, language and communication, and social skills/social behavior .... The early intervention approach [should] be guided by scientific evidence on the effectiveness of the intervention strategy, including child outcomes, parental resources, priorities, and concerns and values, and provider training and available training resources" (E Rating; p. 63).
Comprehensive parent-mediated interventions should be conducted in the child's typical environment (e.g., home, daycare) and be of the intensity, duration, and context that reflect the child's schedule and family time constraints (PO Rating).
Parent-mediated interventions should provide parents with necessary information to meet their child's needs and promote learning. These approaches should be based on scientific evidence, parental priorities and resources, and available trainer resources (PO Rating).
"It is recommended that parent-mediated intervention approaches be used to target a range of child outcomes including communication and language, adaptive behaviors, ..., joint attention, play skills, social behaviors, and sensory-regulation" (E Rating; p. 66).
"In addition to ongoing monitoring, it is recommended that periodic, formal appropriate reassessment of the child's progress and developmental status be done at least once every 6 to 12 months, and, as appropriate, compare the child’s progress and functional level with age-expected levels of development and functioning" (PO Rating; p. 59).
It is recommended that parent training and education consider how to include siblings and other key family members. Parent training and education should "be included as an important component of comprehensive intervention programs for children [on the autism spectrum] .... Parent training programs may be useful because they:
<ul>
<li>help support the family in caring for the child;</li>
<li>involve the parents in choosing intervention outcomes, goals, and strategies important to the family;</li>
<li>help the family incorporate the intervention strategies into the daily routines of the child and family;</li>
<li>help to ensure consistency in strategies used by interventionists and parents;</li>
<li>improve the interaction between the parents and their child;</li>
<li>increase parent satisfaction and reducing [sic.] parent stress; [and]</li>
<li>promote reinforcement to enhance the occurrence and generalization of desired behaviors" (E Rating; p. 64).</li>
</ul>
The Modified Checklist for ASD in Toddlers-Revised with Follow-Up (M-CHAT-R/F) is a useful instrument for screening children from the general population instead of those who may be on the autism spectrum. "This is the most recent revision. It is recommended that it be used instead of the M-CHAT because research shows it has improved ability for detection of ASD and other developmental disabilities" (E Rating; p. 36).<br /><br />"The [Modified Checklist for ASD in Toddlers-Revised with Follow-Up] M-CHAT-R/F is a two-stage screening instrument, and it is very important to use both parts. The first part is a 20-item parent checklist. If the child scores positive ... then the Follow-up Interview with the parent is to be given. By continuing to score positive on the Follow-up Interview, a referral for diagnostic evaluation for ASD is indicated" (E Rating; p. 36).
It is recommended that skills generalization be promoted during intervention and that, when appropriate, learning opportunities be included in child-directed play or familiar daily routines (PO Rating).
The Infant-Toddler Checklist (ITC) is a useful instrument for screening children from the general population between 12 and 24 months of age (E Rating; p. 36).
"It is recommended that the child’s progress be monitored on an ongoing basis by the provider(s) delivering early intervention services and that intervention techniques be modified as appropriate based on the child’s progress. This should include collection of data on the child’s skill acquisition that can be used on an ongoing basis to guide decisions about intervention. It is recommended that clinicians use standardized assessments with established reliability and validity, observations, and developmental checklists to guide the development and selection of individualized intervention goals" (PO Rating; p. 58).
For Level 2 screening (i.e., screenings administered to children already identified by a general population screening), the Screening Test for ASD in Toddlers (STAT) is useful for screening children between 24 and 36 months of age by different qualified professionals across a variety of settings (E Rating; p. 37). "The [Screening Test for ASD in Toddlers] can be used with children 12-24 months, but within this age range has best prediction between 14 and 24 months" (E Rating; p. 37).
"It is recommended that interventions incorporate (but not be limited to) strategies to increase the child’s motivation such as following the child’s lead, giving the child choices about the intervention activities and materials, shared turn-taking within object or social play routines, or adult imitation of the child’s language, play, or body movements" (E Rating; p. 56).
The Parent Observation of Social Interaction (POSI) "is a promising Level 1 screening instrument [screening within the general population] for potential use in a variety of clinical settings to screen children from 16-35 months of age .... However, further research validation is necessary to recommend its use" (E Rating; p. 37).
"The Autism Diagnostic Interview-Revised (ADI-R) may be useful in assessments for young children [on the autism spectrum] .... It is an evidence- based parent interview instrument for children starting at 30 months and up through adulthood. It collects information in detail about the child’s development, emergence of [characteristics] ..., and current symptoms across all symptom domains" (E Rating; p. 49).
The Infant-Toddler Checklist (ITC) "is a 'broadband' screening instrument, meaning that while it has been shown to detect with acceptable accuracy children with developmental disability, including [autism spectrum disorder] ASD, it is not accurate in distinguishing possible ASD from other developmental delays" (E Rating; p. 36).
"In evaluating a child [who may be on the autism spectrum] ..., it is important to recognize that there may be cultural and familial differences in expectations about such things as eye contact, play and social interaction, and pragmatic use of language" (PO Rating; p. 46).
For children who do not demonstrate an increased likelihood of being on the autism spectrum, "universal screening with an [autism spectrum disorder] ASD-specific instrument at 18 and 24 to 30 months is recommended" (PO Rating; p. 34).
"It is recommended that parents and professionals consider modification of an intervention when:
<ul>
<li>the child has progressed and target objectives have been achieved;</li>
<li>the therapist-child/family match is not an effective working partnership;</li>
<li>progress is not observed after an appropriate trial period;</li>
<li>the child has shown some progress but target objectives have not been achieved after an appropriate trial period;</li>
<li>there is an unexpected change in a child's behavior or health status;</li>
<li>there is a change in the intervention setting (for example, moving from the home to a preschool setting); [and/or]</li>
<li>there is a change in family priorities" (PO Rating; p. 58).</li>
</ul>
The Parent Observation of Early Milestones (POEMS) "is a screening instrument intended for ... younger siblings of children diagnosed with [autism spectrum disorder] ASD [who are more likely to also be on the autism spectrum]. It is recommended that parents fill it out every few months" to identify areas needing support as soon as possible (E Rating; p. 38).
"It is recommended that developmentally appropriate practice is incorporated into intervention strategies .... Developmentally appropriate practices:
<ul>
<li>are based on research on how young children develop and learn;</li>
<li>recognize and incorporate individual characteristics of the child when intervening; [and]</li>
<li>recognize and incorporate the values, expectations and factors that shape the child’s home and family environment" (E Rating; p. 56).</li>
</ul>
For children with an increased likelihood of being on the autism spectrum or who demonstrate characteristics of autism, "screening every three months beginning at 12 months with the [Infant-Toddler Checklist] ITC may be useful" (E Rating; p. 36).
"It is important to include parents as active participants in the intervention team to the extent of their interests, resources, and abilities. Parental involvement is important to ensure that the behavioral and developmental outcomes, goals, and strategies most important to the family are incorporated in the intervention, and to promote generalization of new skills" (E Rating; pp. 54-55).
If a child who is on the autism spectrum, or who may be on the autism spectrum, demonstrates hearing difficulties, "it is important to refer the child for a hearing evaluation by an audiologist (including brain stem evoked response testing if appropriate)" (PO Rating; p. 74).
"The [Modified Checklist for ASD in Toddlers-Revised with Follow-Up] M-CHAT-R/F is a two-stage screening instrument, and it is very important to use both parts. The first part is a 20-item parent checklist. If the child scores positive (for possible [autism spectrum disorder] ASD) then the Follow-up Interview with the parent is to be given. By continuing to score positive on the Follow-up Interview, a referral for diagnostic evaluation for ASD is indicated" (E Rating; p. 36).
"It is recommended that a lack of objectively documentable progress over a three-month period be taken to indicate a need to revise the intervention approach, increase individualized attention or programming time, reformulate the learning targets, or provide additional training and consultation. For very young toddlers, parents and interventionists may want to consider [that] lack of progress in a two-month period suggests the need to revise the intervention approach" (PO Rating; p. 58).
"It is recommended that intervention approaches be tailored to the child's learning style. Some children learn more quickly using a more structured teaching approach where skills are broken down into small steps for learning and each step is taught very systematically, typically in a highly structured situation (e.g., Discrete Trial Training), while other children improve with approaches that emphasize less structured natural situations that focus on the child’s interest and natural consequences (e.g., Incidental Teaching, Pivotal Response Training)" (PO Rating; p. 63).
The diagnostic and developmental assessment is an ongoing process that should be individualized for each child (PO Rating).
"The [Autism Spectrum Disorder Diagnostic Observation Scale-2] is a useful clinician interaction/observation instrument that can be used with young children 15 months of age and above, and with a mental age of 12 months and above as part of a diagnostic assessment for [autism spectrum disorder] ASD. As with all other ASD measurement tools, it is to be used in conjunction with other information-gathering strategies and clinical judgment for a thorough assessment.
<ul>
<li>The Toddler Module and Module 1 are appropriate for assessment of children under 36 months. Very occasionally Module 2 may be used.</li>
<li>The use of Calibrated Severity Scores (CSS) will aide in comparing a child’s current [characteristics] ... to others who [are also on the spectrum] ..., and in tracking the child’s progress over time" (E Rating; pp. 48-49).</li>
</ul>
"It is recommended that early behavioral and developmental interventions based on principles of [applied behavior analysis] ABA be incorporated as an important element of any intervention approach for young children" (E Rating; p. 62).
The hearing status of a child who may be on the autism spectrum should be evaluated to rule out hearing loss as a contributing factor to any of the child's communication differences (E Rating; p. 74).
Based on recent studies, effective applied behavior analysis (ABA)-based interventions ranged in intensity from 14-28 hours per week and extended over a period of eight months to two years. "It is recommended that the precise number of hours and duration of behavioral intervention be determined based on a range of child and family characteristics, including [the child's skills and abilities]..., rate of progress, health considerations, the child’s tolerance for the intervention, and family participation" (E Rating; pp. 62-63).
As part of a comprehensive early intervention plan for young children on the autism spectrum, it is recommended that parent-mediated interventions be offered to families and implemented "with sufficient duration and intensity to effectively increase children’s learning opportunities during a broad range of familiar daily life routine" (E Rating; p. 65).
"It is recommended that intervention outcomes for each child be clearly identified, appropriate for the child’s age and developmental status, and include criteria for intervention outcomes that are measurable. Depending on the specific outcomes that are targeted (e.g., social, communication, behavior, joint attention, play, cognitive, school readiness, academic, motor, adaptive), it is recommended that a range of evidence-based practices be used" (E Rating; p. 54).
"In conducting the periodic re-assessment, it is important for professionals to use good clinical judgment and current best practice, and individualize the assessment to the child. As appropriate, the re-assessment may include:
<ul>
<li>a curriculum-based assessment;</li>
<li>a functional behavioral assessment if interfering behaviors continue;</li>
<li>assessment of social (pragmatic) communication and expressive and receptive language;</li>
<li>standardized testing to help assess the child's progress; [and/or]</li>
<li>diagnostic testing to assess the child’s status" (E Rating; p. 59).</li>
</ul>
