With efforts to increase the inclusion of special education students in classrooms, teachers and daycare providers are often the first to raise developmental concerns about a child in their care. With no biological marker for autism, and in tandem with heightened awareness about the disorder, families and caregivers have options for early intervention that starts with by both health care and education teams to determine a diagnosis.
Colleen Forbes, an Early Intervention/Early Childhood Special Education teacher with Portland Public Schools, said that state eligibility requirements dictate how a public school student is made eligible for services. State eligibility requirements for an education diagnosis of Autism Spectrum Disorder (ASD) is broad and doesn’t differentiate “low” and “high functioning.” It does include, however, include “sensory” behaviors and if there are discrepancies in development, she said.
“The eligibility needs to address impact in behavior, sensory, social and communication,” Forbes added. “It needs to show an impact in the ability to perform adequately in a school setting. We also need to document that concerns and behaviors have continued over a period of time.”
Additionally, students that have a medical diagnosis are not automatically eligible for special education services, according to the Individuals with Disabilities Education Act (IDEA). Educational eligibility and subsequent services are determined by conducting assessments and testing performed by a school’s multidisciplinary team and not that of medical diagnostic tests. These can include observations, history, developmental information, behavior information and a documented prevalence over a period of time.
The school’s team works with families as a team to determine eligibility and services available under IDEA.
According to the Oregon Administrative Rules (OAR) for Special Education, the 11 categories for IEP eligibility include:
- Autism Spectrum Disorder
- Communications Disorder
- Emotional Disturbance
- Hearing Impairment
- Mental Retardation
- Orthopedic Impairment
- Other Health Impairment
- Specific Learning Disability
- Traumatic Brain Injury
- Vision Impairment
To meet OAR’s eligibility criteria for ASD, the rules state that a student must undergo evaluations including a developmental profile describing autism-related characteristics; at least three observations of behavior, one including direct interactions with a child in a play-based fashion; assessments of communication; a medical or health assessment including whether physical factors may affect the child’s educational performance; and a behavior rating.
Once a student receives eligibility under the ASD diagnosis, it sets the stage for the development of an Individualized Education Program (IEP) that can implement specific accommodations in the school setting, Forbes said. These supports help meet the federal standards for keeping special education students in their “least restrictive environment,” the classroom, for 80 percent of their day, according to Oregon Department of Education (ODE) criteria.
“Once you have an eligibility you start the education plan,” Forbes said. “Look at the learning styles of your child and if there are accommodations that a classroom can make.”
Washington and Oregon state law dictates that the only professionals who can medically diagnose ASD include: board eligible neurologists, board eligible psychiatrists, licensed psychologists, board certified developmental and behavioral pediatricians. Health professionals typically use The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) to diagnose a child, combined with a battery of assessments to support and verify a diagnosis.
“Educators cannot give a diagnosis and it may sound like semantics, but legally we teachers are not allowed to diagnose, so this is an important distinction,” Forbes said.
From birth to age 5, county education service districts and preschools or daycares are involved in creating an Individualized Family Service Plan (IFSP). An IFSP defines clear goals that support and can be implemented in a child’s natural setting, whether it be at home or in a daycare setting, combining a team of professionals to provide intervention services such as speech therapy, sensory supports and psychological care.
Children that obtain an educational diagnosis may or may not also have a medical diagnosis of ASD. Although attempts are in process to create more uniformity across education and medical fields, the process currently for assessments between systems can often differ, said Dr. Sherri Alderman, medical director and developmental behavioral pediatrician with the Children’s Developmental Health Institute.
“There are efforts to build conformity across educational systems in Oregon and standards for both medical and education that will bring both into closer alignment,” Alderman said. “The Oregon Autism Commission has been doing this very important work.”
Medical evaluations should include autism-specific standardized testing while educational assessments will often include non-standardized parent interviews, cognitive and autism-specific testing tools that can vary from school district to school district.
If there are concerns that a child shows markers of ASD, health care specialists such as psychologists, developmental-behavior pediatricians, child psychiatrists and pediatric neurologists will often work collaboratively with a multidisciplinary team to diagnose and treat those with ASD, said Dr. Fulgencio del Castillo, developmental behavioral pediatrician with the Providence Neurodevelopmental Center for Children.
“For families, the mere suspicion that a child might be autistic is life-changing,” del Castillo said. “There are numerous sources of information, many ways in which autism can affect a person’s ability to function and the observation that no two children have exactly the same symptoms,” he continued. “Combined with the differences in the number and severity of symptoms a person may have, a diagnosis of autism means different things to different people.”
Special Educational Services for Children with Autism
Birth through age 5 of a child is a crucial time for learning. Neuron connections made in early childhood will be maintained throughout the lifetime. Children have “developmental plasticity” and neurons will adapt to changing demands, said Mary Bridget Barniskis, inclusion specialist for the Helen Gordon Child Care Center at Portland State University.
“Early Intervention and Early Childhood Special Education is not just about the child,” Barniskis said. “The idea behind Early Intervention (EI) is to support children through empowering families. Children are most at ease and comfortable with family so it makes sense that they will learn the most with them.”
After the evaluation process, interviews and determining what motivates children, the Early Interventionists’ role is to help families see their own strengths and resources, Barniskis said. EI can help families develop new routines, tweak others and provide support to help them feel empowered.
The ODE states that those with the educational classification of Autism Spectrum Disorder may be eligible for special educational services if the child meets multiple criteria:
- Has documented evidence by the school team that there are impairments in communication; impairments in social interaction; patterns of behavior that are repetitive, restricted or stereotypic; and unusual responses to sensory experiences
- Has impairments inconsistent with his or her development in other areas
- Has these impairments documented over time and/or intensity
The school team must also determine and document that:
- The disability adversely affects the student’s ability to learn
- The student needs special education services as a result of the disability
The medical diagnosis and educational eligibility rely on similar criteria; however, the results of each do not necessarily impact the other:
- Physicians use standardized tools to make the medical diagnosis based on autism diagnostic criteria. School personnel use observational data occurring in multiple environments on at least two different days.
- The medical evaluation helps determine the child’s overall level of functioning. The educational evaluation helps determine the impact of autism characteristics on the child’s development and educational performance and, therefore, his or her need for specially designed instruction.
Diagnosing Autism Spectrum Disorders
Since there is no medical test to diagnose ASD, primary care providers, such as pediatricians, family physicians, and pediatric or family nurse practitioners, use standardized tools at specific intervals to screen or identify patients.
“Many families who do seek the autism-specific medical evaluation and receive the diagnosis often experience a sense of validation and reduced self-blame,” Alderman explained. “It also connects them with other families with a child with autism with similar experiences and begins a process of social networking that can be very supportive for the family and give them direction and purpose.”
According the to Autism Society of America, an initial medical assessment typically includes:
- Medical history of the mother’s pregnancy
- Review of developmental milestones
- Eating and sleeping habits
- Stomach and bowel functioning
- Sensory challenges
- Medical illnesses, including ear infections, seizures
- Any family history of developmental disorders
- Any family history of genetic and metabolic disorders
- Parents’ and child’s exposure to environmental toxins
- A thorough physical exam
- Routine lab tests
The results of those screenings may lead some to undergo subsequent, more targeted evaluations. In some children, a diagnosis of autism may be quite obvious, del Castillo adds.
“On the other hand, diagnosing autism may be quite challenging if the child has other behavioral symptoms or coexisting disorders. Ideally a team of specialists with expertise in autism will work together to make the definitive diagnosis.”
School personnel indicate in their IEP documentation that they are not ascribing a medical diagnosis to a student, del Castillo added. Professionals are also aware that characteristics taken into account when making medical diagnoses may not always impact function in the school setting.
“From a medical perspective, the medical diagnosis of autism sometimes suggests other studies that may reveal other associated conditions such as a genetic abnormality that can lead to even better medical management of the child,” Alderman said. “With the medical diagnosis of autism, the parents can be better informed of the increased risk to future and present children in the family as well.”
Overall, there are more similarities than differences in making a medical diagnosis of autism and in determining educational eligibility, del Castillo concluded.
“The most important factor in both processes is the goal of maximizing each child’s potential.”