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Assessment of Autism: Differentiation Considerations

Assessment of Autism: Differentiation Considerations
Angie Neal, MS, CCC-SLP
July 9, 2024

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Editor's Note: This text is an edited transcript of the course Assessment of Autism: Differentiation Considerations presented by Angie Neal, MS, CCC-SLP.

Learning Outcomes

After this course, participants will be able to:

  • List key questions to support accurate diagnosis or classification of ASD
  • Describe key differences between ASD and ADHD, emotional disabilities, intellectual disabilities, and speech-language impairments
  • Explain critical data for the SLP to collect in order to determine accurate diagnosis or classification

Highlights From: What Do The Words Mean and Why That’s Important

Thank you for joining me today for what is essentially part two of our assessment of autism. Today, we'll dive into SLP assessment tools and the critical data we need to gather, as well as considerations for differentiation.

We'll start with some highlights by revisiting questions from the end of part one. Most of them focused on neurodiversity and goals that may lend themselves to an ableist view. For example, one question addressed tone of voice and asked what to do if a student responds in a certain tone. This is different from trying to change someone's tone of voice to "fit with the rest of the world."

For instance, I have a very animated voice, and it would not be appropriate to teach me to be less animated. Similarly, if someone doesn't have an animated voice, it is not appropriate to make them sound more animated just to fit in.

Another question was about prosody, which relates to reading comprehension due to the prosodic elements that convey meaning. For example, consider the sentence, "He broke the window." The way it is read can imply different meanings: 

  • "He broke the window" suggests a male did it, as opposed to a female.
  • "He broke the window" raises a question about whether it was broken or cracked.
  • "He broke the window" questions if it was actually a window or perhaps a glass storm door.

These examples illustrate ableist views and goals from a general perspective. However, it's crucial to always consider individual student data and what each student needs.

Going back to a few key highlights, understanding key terms is crucial for accurate classification and diagnosis. We discussed how emotional regulation is a core defining feature of autism spectrum disorder, according to Dr. Barry Prizant. We also explored why this is important, including the need to appreciate that those on the autism spectrum often aren't taught or exposed to opportunities to learn emotional regulation.

Individuals on the autism spectrum tend to have more difficulties recognizing emotions within their own bodies. This struggle is partly due to challenges in getting feedback from their bodies based on internal sensations, understanding what these sensations mean, and knowing how to interpret them. Similarly, there is often a poor understanding of emotions, including labeling them, because emotions are abstract concepts. Students on the autism spectrum typically struggle with abstract thoughts and are better with concrete thoughts. We will delve into this further.

Understanding how emotions relate to context is another area of difficulty. For instance, funerals are typically sad events, while football games can be either very happy or very sad/frustrating, depending on which team you support. Additionally, there is often limited knowledge of how to express emotions appropriately.

Having knowledge of these concepts is different from acting on them and choosing to apply what one knows. There's also limited knowledge about strategies to help students return to a neutral emotional state.

Another key highlight is the distinction between social skills and social communication. For example, we discussed ordering food at Subway versus Applebee's. It's the same skill of ordering food, but different contexts have different expectations. This illustrates what social communication is: knowing the skill and how to apply it across different contexts and why this understanding is so important.

We also talked about adverse educational impact, which is critical in the school setting and from an outpatient standpoint. It's important to address skills that will help students be successful in their academic pursuits.

In this course, we'll touch on a few more of these aspects. In part one, we discussed figurative language, making inferences, prediction, and cause and effect. We also talked about using verbal skills for collaboration, self-advocacy, and personal safety.  We talked about writing, written expression, and writing for an audience, including presupposing what the reader knows or will bring to the passage. We also discussed nonverbal communication and gestures in great detail. If you missed that session, I highly recommend revisiting it because these are some of the core distinguishing features of autism that we can identify at a very early age, though they are often poorly assessed, if assessed at all.

We also covered stereotyped and repetitive motor movements, exploring what is truly atypical, the function or functional impact of these movements, and their underlying causes. Understanding this information can help us provide better support. The same goes for highly restricted and fixated interests: identifying what is atypical and understanding the functional impact.

Additionally, we discussed hyper- and hyposensitivity, examining what is atypical. Since most of us have some kind of dislike or aversion to something, it's essential to understand the functional impact of these sensitivities in individuals on the autism spectrum.

Play

Now, we're going to dive into areas that are uniquely specific to the training and expertise of SLPs, starting with play. If you've ever followed the work of Carol Westby, you're likely familiar with the importance of play. If not, I'll fill you in.

One of the research-based tools that Carol Westby created is the Westby Play Scale. This scale follows the continuum of narrative development, which is crucial for understanding a child's progression. I have a handout that includes all this information in one document. It covers the Westby Play Scale, the continuum of narrative development, the continuum for gestures by age range, as well as theory of mind and central coherence. This document is available on my Teachers Pay Teachers page.

We'll go over these elements, so there's no need to get the document unless you want to. The reasons to assess play are numerous and extend far beyond what I can cover in this single presentation.

It really deserves its own presentation, but the key takeaway about play is that it is a language-rich experience. Play is where children learn and apply language. For instance, I had a second-grade student on the autism spectrum who was new to me. I started therapy at the level of play because without that foundation, the language would not be meaningful or applicable.

Let's also discuss formal psychometric assessments. These assessments are just estimates of some skills and are not definitive tools for assessing cognitive, representational thinking skills, and other necessary components for language and communicative purposes. To ensure therapy leads to effective communication, we must consider the level of play and intervene accordingly.

Research supports that social and joint attention, imitation, and play are significantly related to language outcomes. Children who participated in joint attention or symbolic play interventions demonstrated better expressive language skills compared to those who only did ABA (Applied Behavior Analysis). This highlights the importance of incorporating play into therapy to improve outcomes.

Central Coherence

How many of you are familiar with the term "central coherence"? I believe central coherence is one of the most underrated and important skills, truly a hallmark of autism. To Doctor Barry Prasant's core feature of autism being emotional regulation, I would add central coherence.

So, what is central coherence? It is a focus on details. In other words, those with autism often focus so intensely on details that they can't see the whole or the bigger picture. You've likely heard the phrase, "they can't see the forest for the trees." An autistic person, when looking at a bunch of trees, doesn't see a forest. They see an oak, a maple, a pine tree, and a fallen stump. They notice all these details at a level most people don't, but they miss the bigger picture and the invisible relationships between these details.

What does this look like in real life? In conversation, these individuals struggle to get to the point. They share detail after detail without connections or a clear end result. Academically, these students excel in short-term recall questions but struggle with main ideas, inference, or prediction. For instance, on a social studies test, they might tell you the names of Christopher Columbus's ships but not why he was sailing them unless explicitly stated.

To me, central coherence—this ability to see things in incredibly detailed ways—is our calling. I am convinced that students who can perceive this level of detail, which others cannot, are the ones who might find cures for diseases like cancer. They see details that most can't even begin to fathom. However, if we, as a collective team, don't teach them collaboration and communication skills, we won't get the answers we're seeking.

Theory of Mind

Now, let's talk about theory of mind. In a nutshell, it means perspective-taking—the ability to understand that other people have beliefs, desires, and intentions that are different from our own.

How can you tell if a student has difficulty with theory of mind? One sign is a poor ability to consider that others have interests outside of their own. For example, not everyone shares an intense interest in manhole covers and car emblems. Students with theory of mind difficulties also struggle to understand that different people, situations, settings, or locations have different expectations. This highlights the importance of teaching not just the skill but also the context, which ties into the differences between social skills and social communication.

Poor hygiene is another example, especially among older elementary, middle, and high school students. If a student doesn't think they smell bad, they might not understand why anyone else would think so. Similarly, they might not realize that dressing poorly or having messy hair impacts how others perceive them. This lack of understanding about how one's appearance affects others' opinions is a key aspect of theory of mind and perspective-taking.

Also, students with theory of mind difficulties often have poor recognition of facial expressions and understanding of emotions. As mentioned in part one, facial expressions convey emotions, and recognizing them requires appreciating that others have different thoughts, feelings, beliefs, intents, and desires. Additionally, these students may be unaware that their current behavior impacts how others think about and perceive them.

In a moment, we'll discuss how this is critical for differentiating an emotional disability. It's one thing not to know how your behavior impacts others' thoughts and feelings about you. It's quite another to know that your behavior will impact others but to proceed with your actions, even with a deliberate intent to harm.

Finally, an inability to identify your future self is another critical aspect. This ability is essential because it relates to considering the consequences of your actions before you take them. Your future self is essentially another perspective—yourself in five minutes, a year, or ten years from now.

Theory of mind has a continuum of development, and it's crucial to understand and address this in our teaching and support strategies. So, I hope you start incorporating this into your assessments.

We need to evaluate what students are learning at young ages and identify what we need to teach to help them reach advanced levels of theory of mind. Theory of mind begins with play, particularly pretend play, which is essential. It also includes verbal and nonverbal language, joint attention, early narrative skills, early cognitive skills, and the ability to initiate and imitate actions.

The development of theory of mind truly begins when children start thinking about their own thinking—metacognition. Look and listen for signs that they are using verbs of cognition that reflect this awareness. Phrases like "I know," "I don't know," "I remember," "I think," "I believe," "I guess," and "I forgot" are examples of cognition verbs paired with the pronoun "I." Similarly, verbs of perception such as "I hear," "I see," "I smell," "I taste," and "I feel" indicate they are reflecting on their own sensory experiences.

Additionally, verbs of intention such as "I want," "I need," "I like," and "I don't like" are crucial indicators that a child is developing theory of mind by thinking about their desires and preferences.

Then we move into the more advanced levels of theory of mind, where we begin to think about what other people are thinking. Remember, you don't just jump to this level; you must first establish all the foundational skills. Advanced theory of mind involves considering not only what others are thinking but also what others think about other people's thoughts, and so on.

Adults can reach up to the fifth-order theory of mind, which involves complex layers of thought like, "I think that you think about how they think about another person and that other person's thinking." It gets quite intricate and challenging to verbalize.

Looking at theory of mind provides valuable insights. One of my favorite diagnostic tools for assessing theory of mind is asking if a student tells little white lies or lies about anything. Why is this important? Because to tell a lie, you must consider the other person's perspective and what they would believe as a plausible explanation. This ability to lie or be purposefully manipulative or deceitful is a strong indicator of first-order theory of mind. Not being able to lie suggests difficulty with perspective-taking.

Let me share my favorite story about lying and autism spectrum. I had a little boy in second grade, and one day during car line dismissal at 2:20, the fire alarm went off. We assumed it wasn't a drill because why would we have a fire drill during dismissal? While we were all outside, the fire trucks arrived, and it seemed like a real emergency. Then, I saw my buddy Dawson running out of the building, yelling, "I did it! I was just curious. I just wanted to see what would happen." In other words, he was incapable of telling a lie. This story perfectly illustrates theory of mind and the ability (or inability) to lie.

As mentioned in theory of mind, the second order involves understanding that different contexts have different expectations. The third order is where we can truly grasp figurative language. Figurative language involves words saying one thing but meaning another, requiring us to step out of our own thinking and consider the context in which the figurative language is used.

A side note on figurative language: I love teaching it, but if you've taught one idiom, you've only taught one idiom. For example, "under the weather" does not generalize to "raining cats and dogs." To effectively teach figurative language, organize idioms into categories such as color, sports, and weather. Teach the etymology of each idiom because humans are innately wired for stories. This approach helps with retention.

For example, "under the weather" is a sailing term. When sailors were sick, they went below deck, hence they were "under the weather." You'll never forget that now. Another example is "skeletons in the closet," which comes from a time when grave robbing was illegal. Doctors would hide the bodies in their closets until they could study them.

Lastly, regarding figurative language, please avoid using pictures that reinforce the literal meaning. For instance, don’t use images of a man holding an umbrella with cats and dogs falling down for "raining cats and dogs." This reinforces the literal interpretation, which is not helpful at all.

Narrative Skills

Narrative skills are often overlooked in language studies, but they are crucial. Discourse and narrative, which involve using and understanding language beyond single sentences, are fundamental components of language. Humans are innately wired for storytelling, making narratives essential for communication. When you share with others, you're not just exchanging facts; you're sharing a story. For instance, after this course, you might call a friend and say, "I heard a talk about autism today," and then narrate your experience.

Narratives are critical for connecting with other humans. A citation I love states, "Narrative discourse, or storytelling, is a ubiquitous form of communication used to derive meaning from experiences and construct shared understanding of events." This ranges from discussing a test to recalling where you were during significant events like the fall of the Twin Towers. Our stories connect us in a deeply human way.

Moreover, narratives are part of the English Language Arts standards in every state, requiring students to read and write stories. This has specific implications for educational impact. We need to assess narrative knowledge: Can students identify and discuss settings, characters, conflicts, and resolutions? Do they understand transition words and cause-and-effect relationships? This foundational narrative knowledge is built through play and bridges oral and written language, as we are wired to tell, read, and write stories.

Research highlights the importance of narrative skills. For instance, narrative skills at age three contribute to reading comprehension at ages eight and nine. At age five, these skills independently contribute to reading comprehension at age ten and reading achievement at age fourteen. This underscores the need to assess narrative abilities.

Include conversational sample analysis in your assessments to look at narrative skills. Check if your student has abrupt topic shifts, perseverates on topics, or struggles to notice nonverbal cues from the listener. Pay special attention to the use of causal links, as this demonstrates the organization of language and narratives.

SLP's Assessment of Pragmatics

The most frequently asked question I receive about autism assessment is, "What test should I give?" This is an important question because test accuracy is critical when the purpose of testing is to make a diagnostic decision about whether a person has an impairment, whether it is autism or just a pragmatic issue.

However, I'm here to tell you that it's not about a specific test or even the idea of a test. The Individuals with Disabilities Education Act (IDEA) is very clear on this. One of the requirements of IDEA is that eligibility cannot be determined based on a single score alone. Moreover, IDEA does not require standardized assessments. The limitations of standardized assessments are extensive and more than we can cover here.

What I will highlight is that out of six different standardized language tests that assess pragmatics, their range of cut scores falls between 85 and 92. Only two out of these six tests have solid diagnostic accuracy.

The Clinical Assessment of Pragmatics (CAPS) has 100% sensitivity and 85% specificity. The CELF-5 Metalinguistic has 96% sensitivity and 78% specificity. Remember, the goal is 80% sensitivity and specificity, as even at 80%, there is still a 20% chance of misdiagnosis. The Social-Emotional Evaluation boasts 100% sensitivity and specificity, making it another reliable option.

The Social Language Development Test - Adolescents shows 75% sensitivity and 94% specificity for students on the autism spectrum. For those not already diagnosed with autism, it has 57% sensitivity and 83% specificity.

The Social Language Development Test - Elementary has 85% sensitivity and 84% specificity for autism spectrum diagnoses. However, for those with Speech-Language Impairments (SLI) but not on the autism spectrum, the test has 61% sensitivity and 80% specificity.

Again, only two out of six standardized tests have solid diagnostic accuracy. What I really hope you take away from this is that standardized assessment for pragmatics is the worst way to assess language use. A standardized assessment requires a single correct answer, which is not the case for social communication and contexts, as I illustrated in part one.

The bottom line is that a comprehensive assessment of pragmatics and social communication must include more than just standardized tests—or better yet, avoid standardized tests unless they have proven diagnostic accuracy. When we, as SLPs, are assessing pragmatics, it's less important to ask if a certain social skill is present or appropriate. Instead, we should ask when and in what context it is demonstrated appropriately.

To do this, we must examine the context in which these behaviors occur, looking for more than just rote responses of yes or no. Let me give you an example. Consider the question, "Is it appropriate to touch someone's hair?" The answer is generally no, unless you are a hairdresser. Or take the question, "What's a perfect gift for a friend?" There is no single perfect answer; it depends on the context.

The SLP Report Should Include Information from All Five Domains

So, we must consider social communication across a variety of contexts. Today, I'm advocating for including information from these five domains in the SLP report: social communication, social cognition, verbal communication, nonverbal communication, and adverse educational impact. These domains are essential even if you are not in a school setting.

Where did I come up with these five domains? They are derived from ASHA's components of social communication, which you can find on the ASHA website.

Domain 1: Social Interaction

Let's delve into the data we should be looking for in terms of social interaction, particularly through observation across multiple contexts. Our goal is to observe the student in a variety of settings and types of interactions, and with different people. For example, observe their interaction in the classroom during instruction, independent work, recess, lunchroom, PE, and so on.

We also want to assess their knowledge of accepted or taught rules, including classroom rules. Consider how this might vary based on region, culture, or age. As mentioned in part one, ask them what they know about these rules.

This is the same for understanding classroom rules. If students are breaking these rules, we need to ask them why. Do they know the rule? If so, why are they breaking it?

We need to examine social reasoning, which involves understanding cause-and-effect relationships. For example, "If you do this, then this will happen." Problem-solving abilities should also be observed. Gather observations from teachers about their students' problem-solving abilities.

For instance, I once knew a first-grade teacher whose student asked for help opening a carton of milk. The teacher encouraged the student to try first, but the student gave up and threw the milk away, demonstrating a lack of problem-solving skills. Teacher data is important for understanding these behaviors.

The same goes for conflict resolution. You won't always see conflict during your evaluation, so gather data from teachers and parents. Additionally, assess initiation and response to social interaction and play, not just for preschoolers but also for elementary-aged students. This can help target interventions more effectively across various contexts.

Domain 2: Social Cognition

Look at perspective-taking. You can gather excellent data on this from their reading comprehension questions. Theory of mind is also essential. Recall what I described earlier about using pronouns and the verbs of cognition, perception, and intention. Reading tests often illustrate this well with questions like "Why do you think...?" or "What might happen next?" This data is crucial and can be derived from reading comprehension information and classroom-based assessments.

Labeling and recognizing emotions in oneself and others is another critical area. Gather this observationally across multiple contexts. Avoid using methods like showing an emoji and asking for the emotion, as this is not effective.

Metacognition is another key area. Ask questions that prompt students to think about their own thinking. These questions could relate to a specific topic, conflict resolution, or problem-solving. It doesn't have to be solely about themselves; it could be their thoughts on various subjects, even historical figures like Christopher Columbus.

Domain 3: Verbal Communication

In terms of verbal communication, what data and documentation are we really looking for? Let's start with prosody. Oral reading fluency data can be very helpful for documenting prosody, and you can obtain this from classroom teachers.

Next is vocabulary, particularly figurative language and labeling of emotions, as labeling emotions is part of vocabulary. Narrative skills are also important—what do these look like along the developmental continuum?

Conversational turn-taking is another important aspect. Does it vary based on the topic? How does it vary across different contexts, people, and settings? Consider how they express their needs and wants. Do they need a lot of prompting? Are there accommodations in place? Can they pinpoint and label what they need, or do they rely on giving the paper to the teacher and saying, "Here's your accommodations"? Examine this across different classrooms and curricular subjects.

Then we have Grice's maxims of conversation. How does their communication compare to same-age peers? Consider:

  • Quantity: Do they talk more or less compared to their peers?
  • Quality: Are they more or less effective in communicating information compared to their peers?
  • Relation and Relevance: How well do they relate their communication to the context? For instance, do they bring up manhole covers in a class discussion about the life cycle of frogs, which would be unrelated?
  • Manner: Is the manner in which they communicate more or less effective than their peers?

Lastly, as mentioned earlier, consider central coherence. Collecting data and observations in these areas will provide a comprehensive understanding of their verbal communication skills.

Domain 4: Nonverbal Communication

In terms of nonverbal communication, it's not very helpful to ask vague questions like, "Does your child use gestures?" Most non-SLP individuals, such as parents, might not understand what that means. Instead, we should provide a list of specific body language and facial expressions and ask them to check off which ones they have observed the child demonstrating. The same approach applies to teachers.

For example, the list could include actions like:

  • Shrugging shoulders for "I don't know"
  • Nodding head
  • Crossing arms like they're upset
  • Tilting head in confusion
  • Putting a hand on their cheek
  • Putting hands on hips

Providing a list of body language and facial expressions helps parents and teachers identify specific behaviors. Also, include questions about the context in which these gestures occur.

Joint attention is another crucial aspect to assess. Observe what joint attention looks like in different contexts, not just when the child is interested in something. It's important to see how their attention varies across all contexts.

Domain 5: Adverse Educational Impact

And then finally, let's consider the educational impact. For this, we must rely heavily on data from regular education classroom teachers. This data should reflect difficulties the student has in accessing and progressing toward the educational standards that apply to all students. This is the whole purpose of specially designed instruction or special education.

Look for difficulties such as asking for help. Review work samples for signs of struggle, such as those involving figurative language and inference, as previously mentioned. Examine their curricular assessments for these same elements.

Observe their use of verbal communication within the curriculum and classroom settings. What do your observations reveal about their ability to communicate effectively in these contexts? How well do they use verbal communication to engage with the curriculum and participate in classroom activities?

Social Communication Areas More Closely Aligned with the Unique Skills and Expertise of an SLP That Also Have Adverse Educational Impacts.  The skills we've discussed are closely aligned with language and fall within our area of expertise. These skills are critical for us to contribute to an autism diagnosis relative to pragmatics. We should focus on central coherence, narrative skills, figurative language, theory of mind, play, gestures, other nonverbal language, self-advocacy, cause and effect, overall communication of ideas, wants and needs, syntax and morphology, social problem-solving skills, Grice's maxims, and joint attention.

Social communication happens every day throughout the day. While these areas fall specifically under the umbrella of language and our unique skills and expertise, I highly encourage writing collaborative goals where both the SLP and the special education teacher target these skills from different perspectives. The goal is to provide parallel instruction, ensuring these skills are reinforced across all environments and not just in the speech room.

There is nothing in IDEA that prohibits collaborative IEPs. In fact, IDEA strongly supports a team-based approach. The benefits of receiving services in a school include having all these experts in the building who can and should collaborate while the student is present.

ASD Assessment Critical Data Checklist

Before we get into differentiation, based on everything you've heard in part one and this part two course, let's discuss some of the most critical data for considering autism. If I had to boil it down, the most crucial data for helping with differentiation and documenting adverse educational impact includes:

  • Theory of Mind: Assess where they fall in the orders of theory of mind.
  • Narrative Skills: Examine these along the developmental continuum.
  • Play: Look at the play developmental continuum.
  • Gestures: Identify the types of gestures and where they fall on the developmental continuum.
  • Figurative Language: Evaluate their understanding and use of figurative language.

These areas are essential for making informed decisions about autism diagnosis and understanding the educational impact on the student.

IDEA Definition of Autism (34 CFR 300.8(c)(1)(ii)

It's important to note, though rarely discussed that IDEA specifically states that autism does not apply if the child's educational performance is adversely affected primarily because of an emotional disturbance. When there is overlap, which often happens, the team needs to consider which difficulty is primary or has the greatest impact. The concern here is that when you conduct an evaluation for autism, you're often focused solely on autism. Instead, the approach should be to conduct an evaluation and see where the data leads.

This is why it's so important to understand the aspects I'm about to cover in terms of differentiation. Knowing these will help direct the data we gather during the evaluation. 

Empathy

The first differentiation we will discuss is emotional disability. To understand and differentiate it from autism, we need to talk about empathy. Empathy means feeling with people.

If someone lacks empathy, it becomes easy to hurt another person because they're not feeling with others. Empathy requires recognizing emotions and nonverbal cues. For example, if someone is struggling to get through a door with packages, you recognize the nonverbal cue and respond appropriately by holding the door open. Empathy can be affected by various external factors, such as trauma, but it's important to know that autistic individuals are capable of great depths of empathy. What they often struggle with is recognizing emotions in others and knowing the appropriate response.

ASD versus Emotional Disability

With that in mind, let's look at some of the differentiation considerations. First, we're going to look across these different areas:

Restricted, repetitive, stereotypical, atypical patterns of behavior, activities, and interests: These are typically seen in autism but not in someone with an emotional disability.

Sensitivities: These are common in autism but are not typically seen in emotional disabilities unless they are having a functional impact.

Insistence on sameness: This is common in autism spectrum disorder. However, in emotional disability, insistence on sameness may be more related to obsessive-compulsive concerns, which will impact their function. The key differentiation is that obsessive-compulsive behaviors rarely make the person feel better, allowing you to distinguish between the two conditions.

Considering eye contact with emotional disability and autism: Eye contact in someone with an emotional disability is more related to dislike of a person, extreme shyness, or anxiety. In contrast, difficulty with eye contact in autism is because it's overstimulating and can be painful.

Now, let's consider social-emotional reciprocity and social interactions. This is a core feature of autism, where difficulty with social-emotional reciprocity and social interaction is consistent. Individuals with autism struggle with these interactions all the time. However, in emotional disability, social-emotional reciprocity is likely inconsistent. There are times when individuals with an emotional disability may have great social-emotional reciprocity and interactions, but this will vary based on their frame of mind and how they feel at the moment.

As far as anxiety or depression, this is a significant factor to consider. Think back to our discussion about theory of mind and thinking about your own thinking and future self. If someone struggles with thinking about their future self, they may also struggle with anxiety about what might happen. Anxiety is closely linked to worries about future events. Depression, on the other hand, involves worry or frustration about things that have already happened. This distinction can serve as a good differentiator. While there can be overlap between anxiety and depression, with an underlying emotional disability, you typically see more depressive characteristics than anxiety. However, it's important to note that these are general considerations and there can be exceptions.

Next, let's talk about empathy. Depending on the underlying emotional disability, you will see difficulties with empathy, with feeling with people. However, individuals on the autism spectrum, while capable of great depths of empathy, struggle with knowing and recognizing nonverbal cues. 

Now let's consider emotional regulation. Dr. Barry Prizant identifies this as a core feature. Both individuals with autism and those with an emotional disability benefit from emotional regulation strategies and the ability to label and recognize emotions. This need for emotional regulation strategies is consistent across both groups.

As far as building and maintaining relationships, the differences between autism and emotional disability are driven by different reasons. A person on the autism spectrum may struggle to build and maintain interpersonal relationships with people who do not share similar interests. In contrast, for those with an emotional disability, interpersonal relationships may be interrupted because the child may be unpredictable, emotionally dysregulated, or withdrawn. They might exhibit overly intense or inappropriate behaviors or feelings in typical circumstances, or they may be pervasively unhappy.

Then the last consideration, as it relates to autism versus emotional disability, is the potential for underlying psychiatric impairments. There can certainly be overlap, but remember that IDEA specifies if the primary disturbance, the issue causing the greatest difficulty, is an underlying emotional disturbance, it is not autism and should not be labeled as such. This distinction is crucial in ensuring accurate diagnoses and appropriate support for the individual.

I'll give you an example. I was working with a school psychologist on an autism evaluation, and she mentioned that the child had reactive attachment disorder. Reactive attachment disorder is an emotional disability. In the data I collected, there was nothing indicating that the child's pragmatic difficulties stemmed from a lack of knowledge. So, we revisited the characteristics of emotional disability to see if they were more appropriate.

Regarding aggressive behaviors, when a student on the autism spectrum becomes upset or aggressive, there is typically a purpose behind it, such as trying to retrieve something or communicate a need. There is generally no intent to harm. In contrast, with an emotional disability, you often see an intent to harm. Additionally, emotional disabilities might manifest as self-injurious behaviors, or the student might display more immature or withdrawn behaviors.

There's another important distinction regarding emotional disability. When we talk about defiant behaviors in students with autism spectrum disorder, it's often because they don't understand what they're being asked to do. In contrast, for an emotional disability, defiance is typically opposition to the task itself. It might be, "I don't want to do this task," or "This is too hard for me," leading to a complete shutdown. This is where their frame of mind comes into play. If they're thinking, "No, I'm not doing it," their ability to comply is significantly impacted. Word to the wise: don't get into a power struggle, as their frame of mind heavily influences their compliance.

As far as language is concerned, it can be disordered in both autism and emotional disabilities. This disorder can affect overall language skills, not just specific aspects.

When it comes to reading, both groups can have difficulties, but the reasons behind these difficulties differ. For a student with autism spectrum disorder, if we consider hyperlexia, they may be excellent decoders but struggle with reading comprehension. On the other hand, students with an emotional disability are likely to have difficulties with both decoding and comprehension. Their challenges with decoding could stem from missed learning opportunities or difficulties with learning letter-sound correspondence and phonics patterns. These issues could also be related to a true underlying disability.

ASD versus ADHD

Typically in ADHD, you don't see repetitive, restrictive movements. However, it's important to understand the function and impact of these behaviors. For example, I had a principal who would cross his leg and shake it continuously during meetings. This wasn't inattention; it was an effort to stay awake. So, we need to consider the purpose and impact of these behaviors.

In terms of eye contact, individuals with ADHD might have fleeting eye contact or difficulty maintaining it, but this can be due to distractions. Emotional regulation is another area of difficulty, primarily related to impulsivity and an inability to inhibit immediate desires. They often struggle with considering consequences before acting, embodying a "fire, aim, ready" approach.

Regarding social emotional reciprocity, individuals with ADHD know social expectations but might forget them in the moment. They have the knowledge but may not always apply it. Social relationships can be challenging, often because they fail to pay attention to nonverbal cues from their peers, have difficulty understanding contextual expectations, and struggle with planning and follow-through.

Both ADHD and autism can involve difficulties with task completion, but for different reasons. In ADHD, this is often due to rushing through tasks, being distracted, or hyper-focusing on certain details.

In terms of language, individuals with ADHD may or may not have impacted language development. Their reading difficulties might stem from challenges in monitoring their reading comprehension due to working memory issues. They might skip words or lines of text and struggle to make meaning as they decode.

Bias and Intellectual Disability Classifications

Now, let's talk about intellectual disability. This topic is super important, which is why I included this extensive data before we get into differentiation considerations. There's some fascinating research on this. Researchers examined autism spectrum disorder in eight-year-olds in the New York and New Jersey area from about 2000 to 2016.

What they found is quite interesting: the diagnosis of children with autism spectrum disorder without intellectual disability increased by 500%. Moreover, only one in three children with autism spectrum disorder had an intellectual disability. They also discovered that children residing in affluent areas were 80% more likely to be identified as ASD without intellectual disability compared to those in underserved areas. Additionally, black students were more likely to be identified with an intellectual disability rather than autism.

This is crucial to highlight, especially for those working in schools, because of the term "significant disproportionality." The Office of Special Education Programs at the US Department of Education collects data on the frequency of reported disabilities. The data shows a dramatic increase in autism spectrum disorder diagnoses while the number of students with intellectual disabilities has significantly decreased. This calls for a need to check our biases at the door.

ASD versus ID

But here are some considerations in terms of what we need to be looking at and considering:

If there are atypical movements in those with an intellectual disability, it may be related to an underlying medical concern or the effect of medication. Regarding eye contact, you don't typically see difficulties with eye contact in someone with an intellectual disability unless there's an underlying medical condition.

For sure, you'll see impaired language and cognition in individuals with intellectual disabilities, along with challenges in adaptive skills. These adaptive skills result from difficulties with language and cognition, and they are not easy to modify or teach, with only limited improvement.

Emotional regulation issues can be present in both autism and intellectual disability. In terms of social-emotional reciprocity, individuals with intellectual disabilities often have great capacity for joint attention, redirecting attention, maintaining good eye gaze, and engaging with conversational partners.

Their capability in building and maintaining relationships will be relative to their cognition and language skills.

Regarding safety concerns, those with autism spectrum disorder might have more issues related to wandering or escaping due to limited understanding of different contexts. For intellectual disability, safety concerns are more likely tied to medical concerns.

As for reading, individuals with both autism and intellectual disabilities are likely to have difficulties, but the reasons and specifics of these challenges may differ based on the underlying conditions.

ASD versus SLI

With speech language impairment, you're not going to see restrictive, repetitive behaviors and interests that are atypical. For example, a fascination with Minecraft in an eight-year-old boy is not atypical. You are also not likely to see difficulty with eye contact. These individuals can communicate for a variety of purposes with different people, and any social difficulties will be consistent across interactions with peers and adults.

Language development might be delayed, but this delay will align with their overall language development. Emotional regulation is typically appropriate, though you must consider their exposure and opportunities to learn these skills. Gestures are likely not impacted, but narrative skills and vocabulary—particularly tier-one vocabulary—will be affected. In contrast, on the autism spectrum, you might see an extensive knowledge of tier-three vocabulary specific to their interests.

All areas of language, including morphology, will be impacted, which in turn affects both decoding and encoding abilities.

Returning to eye contact, this is a frequent point of discussion. Difficulties with eye contact can be influenced by various factors. In the case of attention deficit and hyperactivity, fleeting eye contact may be due to distractions. For emotional disabilities, it could be related to an underlying psychiatric diagnosis. In intellectual disabilities, it might be connected to an underlying medical condition. However, in speech language impairment, eye contact issues are less likely to be present.

10 Key Considerations

I'm not going to go through all of these in detail, but here are ten key questions that I think are ideal for the team to ask. These questions help tease apart different aspects and provide clarity.

For example, does the student appear to break social rules or expectations because they don't like them (emotional disability), don't agree with them (emotional disability), or don't know them? Our job in specially designed instruction is to help teach what they don't know.

Once the student breaks a social rule or expectation, do they continue to break it? If so, why? Is it because they don't like it, or are they too impulsive to stop themselves? Is their performance inconsistent?

Are the interests abnormal for their age? Are they not paying attention to social cues or their environment? Have they missed opportunities to learn these skills, or are there trauma-related issues that need consideration?

Additionally, ask questions about empathy, lies or being manipulative or purposely deceitful, sensory issues, and what is the evidence of adverse educational impact.

References

*See additional handout for references

Citation

Neal, A. (2024). Assessment of autism: differential considerations. SpeechPathology.com. Article 20680. Available at www.speechpathology.com

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angie neal

Angie Neal, MS, CCC-SLP

Angie Neal is the SLP Contact and Policy Advisor for Speech-Language Services and Early Literacy at the SC State Department of Education. She stays busy as LETRS Facilitator, a board member with the State Education Agency Communication Disability Council, and as a member of the ASHA School Issues Advisory Board. She is a published author of two books and presents on a wide variety of topics all across the United States.



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