School Neuropsychological Assessment Of Children with Autism Spectrum Disorders
Rienzi K. Haytasingh – Brandman University
Autism is now widely considered a disorder of brain development and-, hence-, one of neurological origin, (Minshew, et. al., 2005). When assessing students with autism spectrum disorders(ASD), an important goal of assessment is to move away from global neuropsychological descriptions to a more refined, precise documentation of an individual’s functioning in various neuropsychological domains (Volkmar, 2005). School neuropsychological assessments typically measure a wider variety of neurocognitive constructs such as sensory-motor functions, attentional processes, visual-spatial processes, language processes, memory and learning, executive functions, speed and efficiency of cognitive processing, general intellectual ability, academic achievement, and social functioning (Miller, 2010). The purpose of neuropsychological assessments can be to identify strengths and weaknesses, establish baseline functioning, document performance status and changes in performance, and help guide educational treatments and outcomes (Corbett, Carmean, & Fein, 2009). Today there is an increased interest in evidenced based school europsychological assessment and how the assessment itself can help students with ASD learn.
School neuropsychology continues to be described as an “emerging specialization” among the practice of school psychology (Miller, 2010). The interest in the biological basis of human behavior is not new to the school psychology profession; however it has been applied more recently in schools through assessment and intervention (Miller, 2010). The proper understanding of brain behavior relationships allows educators to select the appropriate research ased interventions. School neuropsychological evaluation systematically assesses all the domains that effect school performance, while also considering ow these domains interact with each other. The domains include: cognitive ability, attention, learning and memory, language, visual spatial ability, sensory motor ability, executive functioning, and adaptive skills. In addition to these domains, there is a great deal of value in conducting a thorough history of the child in the school neuropsychological assessment model. It is widely known that there are instances of children with ASD receiving several misdiagnoses before being correctly diagnosed. In addition to specific measures of these neuropsychological domains, there is a great deal of consideration about how the constructs are measured.
When discussing assessment and treatment for students with ASD, one of the biggest challenges is the heterogeneous phenotype of behaviors. Many variables such as developmental levels, chronological age, and cognitive skills must be considered when developing the evaluation approach. Lang (2010) emphasizes the consideration of individual differences in presentation that occur when evaluating children with ASD. To date, there is no lab test or medical test to diagnose autism;there exists no MRI test or genetic test to diagnose ASD. Instead the diagnosis is based on observable behaviors. In the School neuropsychological assessment model, attention and appreciation is given to the neurological underpinnings of the observable behaviors. The process of investigating the symptoms in connection with the overall functional capacity of the child and then breaking down the behaviors to neurocognitive issues that affect behavior must be considered (Lang, 2010). In addition to over neuropsychological functioning, there are three main areas that require attention when assessing ASD, reciprocal social interaction, communication, and behavior.
The first core deficit among children with ASD is reciprocal social interaction. Although research reflects considerable heterogeneity among children with ASD in the presentation of their social behavior, some generalizations can be made which can be useful for both evaluative and treatment purposes (Loveland &Tunali-Kotishi, 2005). Specifically, when evaluating reciprocal social interactions a school neuropsychological assessment includes both qualitative and quantitative information about the nature and severity social interaction difference. Structured interview systems like the Autism Diagnostic Observational Schedule (ADOS) can be used to evaluate the quality of reciprocal social interaction in a clinical setting (Lord et al.2005). They can be very useful in pressing for specific behaviors. Outside the testing environment, direct observations by the examiner will identify how the child applies or uses reciprocal social interaction. The application of skills in a natural setting is important in the assessment process, particularly in the area of everyday peer relations (Gamliel&Yirmiya, 2009). Students with ASD have difficulty applying previously learned skills because of the large array of variables in a natural environment (Volkmar, 2005). In evaluating the application of knowledge and skills, adaptive skill rating scales are important tools for quantifying the application of these skills in multiple settings. The gap in adaptive behavior will be observed when conducting the ecological or naturalistic aspect of the assessment, and will be very helpful for structuring the interventions. Much research has focused on the social problem-solving ability, considered to be associated with the social difficulties of individuals with autism (Gamliel&Yirmiya, 2009). Being deficient a solving social problems is one of the biggest reasons young adults with ASD do not sustain jobs. Assessment of “how” the child with ASD navigates through social situations is an important aspect of the evaluation.
The second domain that must be evaluated is communication because communication is among the core symptoms of ASD. The characterization of communication skills is an essential task inevaluation (Paul, 2005). Communication includes not only the ability to speak and understand language, but also the ability to send and receive messages through nonverbal channels (Paul, 2005). Because of the wide range of differences in communication skills among students with ASD the examiner must first consider the appropriateness of the assessment method. Users of diagnostic instruments should be aware of the needs of their particular situation and population in order to make the most informed choice of instruments. In a school neuropsychological assessment, both verbal and nonverbal communication skills should be evaluated qualitatively and quantitatively (Lang, 2010). The careful evaluation of communication strengths and limitations can provide direction and guidance to evidence based instruction and treatment.
When assessing language and communication in children with ASD, bothqualitative and quantitative aspects of language expression and comprehension are evaluated (Tsatsanis, Saulnier, Sparrow, &Cicchetti, 2011).For example, atypical features such as echolalia, pronoun reversal, and scripted language can be observed during the assessment. Other aspects of language assessment include prosody, inflection, volume, and register. Nonverbal forms of communication such as gestures, eye contact, and the use of language for social communication should be identified during the evaluation. Additionally, understanding children’s social perception skills is an important variable to evaluate. Social perception can be defined as the initial stages of processing that allow a child to accurately figure out or diagnose another person’s intentions on the basis of their actions (Volkmar, 2005). When obtaining historical and developmental information, the evaluation should include an interview with the parent. The use of the Autism Diagnostic Interview (ADI) is a thorough means to obtaining complete historical accounts of development and behavior (Lord, C., &Corselo, C., 2005). The interview or semi-structured observation of the student is a critical piece in a neuropsychological evaluation.
The third domain of importance is behavior. Restricted and repetitive behaviors can dramatically impact individuals with ASD, especially in daily living. These behaviors can present with different degrees of severity and consequently impact the ability of the child to benefit from instruction. While repetitive behaviors are often observed in younger children with ASD, stereotyped or ritualistic behaviors are present in older or more developed children (Loveland &Tunali-Kotishi, 2005). In a school neuropsychological assessment, consideration is given to the severity of these behaviors, which may change the course of or the procedures usedin the evaluation. Although repetitive and ritualistic behaviors are not unique to ASD, they are among the most troubling features of the syndrome from the standpoint of parents, teachers, and peers (Loveland &Tunali-Kotishi, 2005). These behaviors can also include fascination with a particular object, motor mannerisms, or ongoing preoccupation with parts of objects or toys. These fascinations can cause attention to be restricted thereby causing children to miss important information in their environment. In the school neuropsychological assessment, rating scales can be meaningful for assessment of the presence and degree of the behaviors in multiple environments. Evaluation of the environment and how the child interacts in that environment will yield important education considerations, especially for reducing or management of the impeding behaviors. There are a number of different features within each domain that differ from child to child in severity and frequency. Diagnosis is only one part of the assessment process. In other words, we should always be careful when describing the features of the diagnosis in that those features are only part of the individual with ASD. The diagnosis is meant to capture features of the child not the entire child.
There is a significant amount of variability in cognitive skills among children with ASD, and thiswarrants a more comprehensive approach tointerpret the results (Tsatsanis et al, 2011). There are three important considerations when interpreting cognitive measures for children with ASD because of the variability in skills (Tsatsanis et al. 2011). First, when describing a “global score,” extreme caution must be used because of the variability in skills. Second, the examiner must consider that while there are many tests that measure similar cognitive skills, it is the way in which these skills are measured that varies. For example, there are differences in the level of language skills required, level of structure, degree of complexity, extent of social demands, use of timed task, and level of motor involvement (Tsatsanis, et.al., 2011). Third, the variables that children with ASD demonstrate may optimize or diminish performance on standardized measures.
When evaluating cognitive ability in students with ASD, it is important to consider the variety of different cognitive skills that go into the overall cognitive functioning. Today it is generally accepted that the construct of cognitive functioning is not a unitary construct. This gives way to the importance of a school neuropsychological approach where the examiner looks at all the construct both independently and interdependently At present approximately 45% of individuals with ASD reflect cognitive functioning in the expected range for age, while 70-75% of individuals with ASD fall in the below expected range (Tsatsanis, et. al., 2011). This large variability in cognitive functioning among individuals with ASD requires a very careful approach when measuring these functions, and identifying strengths and weaknesses.
Although described as “emerging,” school neuropsychological assessment can be a very meaningful approach to the assessment of students with ASD. The idea of ascertaining information about a child for both diagnostic and treatment purposes should not seem unattainable. ASD is a prevalent disorder that affects individuals, families, communities, and society (Lang, 2010). The approach of a school neuropsychological assessment is both qualitative and quantitative, and can lead to evidenced based treatments (Miller, 2010). With the increased evidence in support of neuropsychological correlates in children with ASD, an assessment approach that is based on the interaction between brain and behavior relationships seems essential. The fundamental approach of school neuropsychological assessment for students with ASD should be to describe the functional nature of neuropsychological characteristics. Ultimately the school neuropsychological assessment is a process, not a product.
ReferencesCorbett, B.A., Carmean, V., & Fein, D. (2009).Assessment of neuropsychological functioning in autism spectrum disorders.In S. Goldstein, J.A., Naglieri, & S. Ozonoff (Eds.). Assessment of autism spectrum disorders (pp. 253-289). New York: Guilford Press.
Gamliel, I. &Yirmiya, N. (2009).Assessment of social behavior in autism spectrum disorders. In S. Goldstein, J. A. Naglieri, & S. Ozonoff (Eds.), Assessment of autism spectrum disorders (pp.138-170). New York, NY: The Guilford Press.
Lang, M. J. (2010). Assessing and Intervening with Children with Autism Spectrum Disorders. In D. Miller (Ed.), Best practices in school neuropsychology (pp. 3-18). Hoboken, NJ: Wiley & Sons.
Lord, C., and Corselo, C. (2005). Diagnostic instruments in autistic spectrum disorders. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders (3rd ed., Vol. 2, pp. 730-771). Hoboken, NJ: Wiley & Sons.
Lord, C., Rutter, M., Goode, S., Heemsbergen, J., Jordan, H., Mawhood, L., &Schopler, E. (1989). Autism diagnostic observation schedule: A standardized observation of communicative and social behavior. Journal of Autism and Developmental Disorders,19(2), 185–212.
Loveland, K. A., and Tunali-Kotoski, B. (2005).The school-age child with an autistic spectrum disorder. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders (3rd ed., Vol. 2, pp. 247-287). Hoboken, NJ: Wiley & Sons.
Miller, D. (2010). School psychology, an emerging specialization. In D. Miller (Ed.), Best practices in school neuropsychology (pp. 3-18). Hoboken, NJ: Wiley & Sons.
Minshew, N.J., Sweeney, J. A., Bauman, M. L., & Webb, S.J.(2005). Neurologic Aspects of Autism. In F.R. Volkmar, R.Paul, A.Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders (3rd ed., Vol. 2, pp. 473-514). Hoboken, NJ: Wiley & Sons.
Paul, R. (2005). Assessing communication. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders (3rd ed., Vol. 2, pp. 799-816). Hoboken, NJ: Wiley & Sons.
Tsatsanis, K. D., Saulnier, C., Sparrow, S. S. &Cicchetti, D. V. (2011). The role of adaptive behavior in evidence based-practices for ASD: Translating intervention into functional success. In Reichow, B., Doehring, P., Cicchetti, D. V, Volkmar, F. R. (Eds.), Evidence-based practices and treatments for children with autism (pp. 297-309). New York, NY: Springer.
Volkmar, F. R., (2005). Assessment of the school-age child with an autistic spectrum disorder. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders (3rd ed., Vol. 2, pp. 705-706). Hoboken, NJ: Wiley & Sons.
