Diagnosis and Eligibility
Assessment in the public schools is conducted for the purposes of identification or establishing eligibility for special education services and to assist in planning an individualized education program (IEP). In Texas, assessment for identification requires that a licensed or certified specialist, such as a licensed specialist in school psychology or a speech/language pathologist, be involved in the assessment. Evaluation for programming, on the other hand, can be conducted by educational professionals. It is the responsibility of the public schools to provide an assessment when a student demonstrates characteristics consistent with an autism eligibility at no expense to the family.
The contrast between diagnosis and eligibility is subtle. The term “diagnosis” is used most often in assessments conducted in the private sector. In the United States, diagnosis is based on the current edition of the Diagnostic and Statistical Manual of Mental Disorders –Fifth Edition (DSM‐5), (American Psychiatric Association, 2013). In other countries, the International Classification of Diseases‐Tenth Revision (ICD‐10) (World Health Organization, 2014) serves as the diagnostic guide.
There are several specific differences between a medical diagnosis and an eligibility determination for receiving special education services. First, there is not a conclusive medical test for ASD. A diagnosis of autism is based on observing and interacting with the child. A medical diagnosis of autism is usually made by a physician, or medically-trained person, based on limited observations in the office setting (Finke, Drager & Ash, 2010). In contrast, an eligibility determination for autism in a school setting is completed by a trained team and they often have the opportunity to observe the child over a period of time, and in a variety of settings (Noland & Gabriels, 2004). A child may receive a diagnosis of autism from a physician or other professional in the public sector (i.e., psychologist), and this diagnosis may not be equivalent to eligibility for that child to receive special education services in the public school system. This situation can be particularly confusing for parents. In order for a child to be eligible for special education supports and services, his or her disability must have an adverse effect on the student’s education.
Unfortunately, school evaluation teams sometimes fail to consider educational factors beyond traditional academics. As a result, academically capable students with autism spectrum disorders who display deficits in socialization and communication that impact educational progress often are not served.
This practice conflicts with the very purpose of special education. According to federal law (IDEA), the purpose of special education is “to ensure that all children with disabilities have available to them a free appropriate public education that emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living” (Individuals with Disabilities Education Act, 2004, §300.1; emphasis added). In light of this purpose, it is evident that the social and communication deficits displayed by students with autism must be included in the evaluation of educational need. In order to properly prepare students in these areas, the curriculum must include interventions beyond traditional academics.
Diagnosis versus Eligibility
Based on a set of criteria (e.g., DSM‐5, ICD‐10)
Based on federal law (IDEA)
Refers to a single diagnosis dimension: autism spectrum disorder (ASD)
Refers to a broad disability category
Used in private settings
Used only in public school system
May be determined by an individual or team
Must be determined by a team
Educational need may include:
Autism is defined by the Diagnostic and Statistical Manual – 5th Edition (DSM-5) (APA, 2013) using a two-domain model which includes social-communication deficits and repetitive interests/behaviors (RRB). With the updating of the DSM IV to DSM 5, a primary goal of refining the definition of autism was to increase specificity. Specifiers are important to assure validity across a variety of settings, so children with autism are correctly identified as having ASD, and other children who do not have autism do not incorrectly receive an ASD diagnosis. The DSM-5 exemplifies a dimensional approach to describing the variability of behaviors that are seen in individuals with autism. These complex behaviors are described based on the quality and quantity of the specific social-communication deficits and specific RRBs that are represented in the ASD diagnosis. It also allows for the fact that many features may be found in individuals with ASD, however, are not exclusively specific to individuals with ASD. (Grzadzinski, Huerta & Lord, 2013).
If a student who is eligible for special education under the category of Autism has an additional eligibility, the student should be served under both categories. One exception to this is if the child meets diagnostic criteria as a student with an emotional disorder. IDEA stipulates “Autism does not apply if a child’s educational performance is adversely affected primarily because the child has an emotional disturbance” (IDEA, 2004, §300.8, (c)(1)(ii)). In the vast majority of cases, Autism is appropriately considered the primary eligibility area. For example, when disorders such as depression or anxiety are observed, autism is most likely the underlying or “primary” disorder. Based on IDEA 2004, behaviors related to a diagnosis of autism may be manifested after three years old, however, these behaviors must adversely impact the child’s educational performance (IDEA, 2004). §300.8, (c)(1)(iii).
Since symptoms of autism are generally evident before the age of three, it is difficult to imagine a scenario where symptoms of anxiety or depression precede the autism. Applying the DSM-5 diagnostic criteria for autism, the behaviors may be manifested currently or the family may report that these behaviors occurred in the past.
A variety of developmental, psychiatric and medical conditions are identified that may co-occur with ASD. The most prevalent conditions include the following: (a) developmental – language disorder, ADHD, intellectual disability, sensory integration, learning disorder; (b) psychiatric diagnoses – oppositional defiant disorder, anxiety disorder, emotional disorder, mood disorder [including OCD, depression, bipolar disorder, mutism, psychosis]; and (c) neurologic diagnoses – epilepsy, encephalopathy, hearing loss, cerebral palsy, and visual impairments. When the range of these varying conditions is taken into consideration, it highlights the need for clinicians to remember that the features associated with these co-occurring conditions could mask or obscure the core symptoms of ASD (Levy, et.al. (2010).
Evaluation measures include the following evaluation categories: Academic Achievement, Adaptive Behavior, Autism Screening, Cognition, Developmental, Emotional and Behavioral, Functional Behavioral, Motor, Sensory, Social Relationship, Speech language, Transition Vocational, Other. For each category, there is an introduction that includes a brief description of the assessment category, as well as the information it can yield for eligibility and/or programming. The category introduction also includes a table of misconceptions and highlights commonly held myths and realities about a given assessment category. All sources cited in the introduction are listed among the references.
Within each category, each assessment includes an overview of the specific assessment, a summary table describing the assessment, autism-related research, and references. The summary table offers the following information: (a) name of tool/ author (year), (b) age range (in years), (c) method of administration/format, (d) approximate time to administer, (e) subscales, and (f) availability.
Autism is a developmental disability where the hallmark characteristics are social-communication deficits and repetitive interests/behaviors (RRB). For a student to receive educational services in Texas, these behaviors must significantly affect a child’s educational performance. The following federal and state regulations provide guidance for educational assessment teams when identifying students with autism:
(c) Definitions of disability terms
The terms used in this definition of a child with a disability are defined as follows:
(i) Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age three, that adversely affects a child’s educational performance. Other characteristics often associated with autism include engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences.
(ii) Autism does not apply if a child’s educational performance is adversely affected primarily because the child has an emotional disturbance, as defined in paragraph (c)(4) of this section.
(iii) A child who manifests the characteristics of autism after age three could be identified as having autism if the criteria in paragraph (c)(1)(i) of this section are satisfied. (34 CFR §300.8(c)(1)
Texas Commissioner’s Rules Concerning Special Education
(1) Autism. A student with autism is one who has been determined to meet the criteria for autism as stated in 34 CFR, §300.8(c)(1). Students with pervasive developmental disorders are included under this category. The team's written report of evaluation must include specific recommendations for behavioral interventions and strategies. (19TAC, §89.1040(c)(1)
Identifying and implementing appropriate evidence-based practices (EBP) are important priorities for persons working with individuals with ASD. The National Professional Development Center on Autism Spectrum Disorders (NPDC on ASD, 2014), the National Autism Center (NAC, 2009), and the Centers for Medicare and Medicaid Services (CMS, 2010) have all published systematic reviews of intervention practices for children and youth on the spectrum. The Texas Autism Resource Guide for Effective Teaching (TARGET) uses the criteria most closely aligned with NPDC. The NPDC was funded by the U.S. Department of Education, Office of Special Education Programs, with the twofold goal of conducting systematic reviews using rigorous criteria, examining focused practices (Odom, Collet-Klingenberg, Rogers, & Hatton, 2010) and translating practices with sufficient scientific evidence into usable resources for service providers (NPDC, n.d.). To date, the NPDC has identified 27 focused interventions as meeting the criteria for appropriate scientific evidence. Focused interventions are practices that are used to promote a specific skill or outcome, such as behavior, language, social skills, or academics (Odom et al., 2010).
According to the NPDC, scientific evidence must be established for each age group and outcome separately. For an intervention to meet the criteria for appropriate scientific evidence, sufficient research must be reported in peer-reviewed journals. Specifically, there must be (a) at least two experimental or quasi-experimental group design studies carried out by independent investigators; (b) at least five single-case design studies from at least three independent investigators; or (c) a combination of at least one experimental/quasi-experimental study and three single-case design studies from independent investigators. It is important to note that not all focused practices have been found to be effective for all skills or all grade levels.
Often, focused treatments are the building blocks for comprehensive treatment models. A comprehensive treatment model “… consists of a set of practices designed to achieve a broader learning or developmental impact on the core deficits of ASD” (Odom, Boyd, Hall, & Hume, 2009, p. 426). Scientific evidence has been harder for researchers to establish with comprehensive treatment models, and have been evaluated based on “quality of the procedures and implementation, the number of replications of the model, and the associated evidence generated by the efficacy of focused interventions that are components of the models” (Odom et al., 2009, p. 432).
Scientific evidence is just one component of EBP. True EBP requires that scientific evidence be viewed through the lens of professional expertise/experience and child/caregiver characteristics (Dollaghan, 2007; Odom et al., 2010). As such, EBP will not be successful if support for the intervention is not available within the school and community (Odom, 2009). School support is an especially important consideration when children with ASD are integrated into general education classrooms.
The TARGET project reviews focused on interventions that meet the criteria for EBP. In addition, comprehensive packages and practices with some support or little support have been included.
Individual Intervention programs/models are described in this section of the guide. Each intervention contains the following elements:
- Brief Introduction. This section provides background information, such as definitions of terms, or how an intervention may be used with individuals with ASD. A matrix for each intervention represents the age group in which the intervention is the most effective, and the multiple developmental and developmental skill areas where the intervention had the most significant impact.
- Description. The description includes a narrative of the intervention.
- NPDC Matrix. This matrix represents the intervention results categorized by the outcome, and the age (in years) of individuals for whom this intervention is most effective.
- Research Summary. This chart is a quick summary of all of the research available and includes information on the age, skills/intervention goals, settings, and outcome. The outcome summary allows the reader to quickly identify if the intervention is one that is considered evidence-based or if it has some scientific evidence or no evidence supporting its use. The outcome will also indicate if the intervention was identified as an evidence-based practice by the NPCD and/or NAC.
- Selective Research. Research meeting the NPDC’s criteria for scientific evidence prior to 2013 is grouped based on applicability for age groups, as well as general references. Additional research conducted since 2013 is provided in the reference list and summary chart, which includes the following information: (a) article authors and publication date, (b) number of subjects, (c) ages of subjects, (d) severity level of subjects, (e) intervention/setting, (f) interaction partners, and (g) results.
- Steps. The intervention steps are identified and described.
- Variations for these steps. If applicable, a description of possible variations for the intervention steps is provided.