Identification, Diagnosis, and Treatment of Early Identifying Characteristics (EIC) in Toddlers with ASD A Preliminary Study

Identification, Diagnosis, and Treatment of Early Identifying Characteristics (EIC) in Toddlers with ASD: A Preliminary Study

Kelly J. Bryant

Loma Linda University

Abstract

Purpose: Autism spectrum disorder (ASD) is a term used to describe neurological differences affecting almost one percent of people worldwide. Diagnosis of ASD is not typical until age three. Until then, the toddler exhibits “autistic-like” symptoms but no diagnosis of ASD, resulting in possible delays in accessing therapies that treat the characteristics specific to ASD. Two of these interventions are behavioral and relationship-based treatment. This study sought to 1) recognize how early signs of autism manifest and 2) report on caregiver education and support regarding behavioral intervention and relationship-based services.

Method: This retroactive study involves file review with a qualitative parent interview portion.

Results:

Discussion:

Key Words: early intervention, autism, autism diagnosis, treatment for autism, autism spectrum disorders, DIR Floor-time, relationship-based intervention, behavioral intervention, parent involvement, parent training,

Autism spectrum disorder (ASD) is a diverse collection of neurodevelopmental differences impacting nearly one percent of the world’s population (Abruzzo et al., 2015; Lord et al., 2020). ASD refers to phenomena in the brain that causes an individual to experience the world differently, resulting in trouble interacting with people and their environment. ASD is a “neuro-difference” associated with brain development, resulting in difficulty with socializing and interacting. With the condition’s etiology largely unknown (Elder et al., 2017) as the underlying challenge in autism is facilitating brain connectivity to specific cerebral areas (Bradshaw et al., 2015; Jagan & Sathiyaseelan, 2016).

Leo Kanner made the first clinical description in 1943, recognizing diagnostic heterogeneity, and noting that the children did not easily fall into clear-cut categories (Harris, 2018). About one in 100 children has autism (World Health Organization, 2022), and more than 3.5 million Americans have ASD. Prevalence in the United States is 1 in 54 births (CDC, 2020). In children, the prevalence of autism in the U.S. increased by 119.4 percent from 2000 (1 in 150) to 2010 (1 in 68) (CDC, 2014). Prevalence has increased by 6-15 percent each year from 2002 to 2010, making autism the fastest-growing developmental disability (CDC, 2020). The cost of treatment over the lifespan can be 1.4-2.4 million dollars depending on the severity of symptoms (Beuscher et al., 2014). Currently, there is no cure, but treatment and medication can decrease some symptoms (Bradshaw et al., 2015; National Conference of State Legislature, 2018; Salari, et al; 2022).

Early detection can assist in remediating symptoms and is crucial for facilitating access to treatment (Clark et al., 2018, 2014; Mazurek et al., 2019). It is difficult, however, to diagnose ASD with certainty before two years of age (e.g., Bölte et al., 2013; Eriksson et al., 2013; Germani et al., 2014; Grant & Nozyce, 2013; Lord et al., 2020) as the behavioral characteristics which form the basis of ASD diagnosis are difficult to assess in young children (Barton et al., 2013).

Neurodiversity—-make if flow in order to make statement in discussion

Early Identifying Characteristics

Identifying toddlers presenting with ASD involves observation of key developmental behaviors. Early identifying characteristics (EICs) are less obvious as they involve the underlying skills of affect, eye gaze, joint attention and social referencing, comprehension of spoken words, and play skills.

Eye gaze is a consistent indicator of engagement/interest particularly in toddlers who exhibit non/low verbal skills. Grynszpan et al., (2012) define “social gaze” as a form of non-verbal interaction characterized by friendly eye contact in which one’s eyes move around an imaginary inverted triangle on someone’s face (between the two eyes down to the mouth). A toddler’s gaze is often motivated by a caregiver’s affect (i.e., feelings or interests). This motivation is needed to facilitate the engagement necessary to mirror caregivers’ affective behaviors to establish social connections needed for relationships to grow. Social gazing and affect are precursors for establishing engagement; the lack thereof is one of the hallmark features of ASD. Mastering social gaze and affect prepares the toddler to participate in the “dance” of interaction; facilitating social reciprocation.

An integral part of human development (a developmental milestone), play is “work” for children. A spontaneous and enjoyable activity for self-amusement, play offers behavioral, social, and psychomotor rewards critical for social and linguistic interaction and is a significant childhood developmental milestone. Social play allows the toddler to begin and maintain interactions with others through experiences (Ginsburg, 2007).

Exploration and manipulation of the environment is essential to healthy development in toddlers. Physically interacting with the world around them requires the ability to navigate and process environmental stimuli. Sensory/Movement skills are essential for toddlers to establish connections between their surroundings and others.

Joint attention is an early developmental milestone that leads to social engagement, the experience of being”locked in” and enjoying the same experience and this then leads to social attachment. This milestone is necessary to establish the intrinsic motivation to seek, establish, and maintain relationships (Kasari et al., 2006).

In young toddlers, it can be challenging to discern if the child is not responding because he cannot understand or cannot hear. (e.g., Bölte et al. 2013; CDC, 2020; 2013; Eriksson et al., 2013; Germani et al., 2014; Grant & Nozyce, 2013; Lord et al., 2020; Robins et al., 2014).

Early Diagnosis of Autism

Early Intervention (EI) is the term applied to a community-based treatment program for toddlers from nine months to three years of age and offers interventions for many different developmental delays, including ASD (Anderson et al., 2014; Landa, 2018; Rollins et al., 2016). Types of services offered in EI programs include infant stimulation, occupational therapy, speech-language therapy, and psychological therapy (Anderson et al., 2014; Braddock & Twyman, 2014; Individuals with Disabilities Act; Ketcheson et al., 2017; Volkmar, 2014). Communication, cognitive, social, and adaptive skills are extremely inter-reliant; therefore, impairment in one area impacts other skill areas (Wilcox & Woods, 2011).

Diagnosis of autism generally occurs between 3 and 4 years of age (Anderson et al., 2014; Hyman et al., 2020; Jeans et al., 2013; Landa, 2018; Sheldrick et al., 2017). Some toddlers, however, may not receive diagnoses until they turn three, missing out on intervention in their early years (Daniels & Mandell, 2014; Taylor et al., 2016). This delay in intervention could significantly impact their development as consistent EI services can remap neurological pathways, taking advantage of the high brain plasticity in toddlers (Braddock & Twyman, 2014; Jagan & Sathiyaseelan, 2016).

A delay in diagnosis of ASD may be due to a multitude of factors such as the lack of genetic markers or co-occurrence with other disabilities, as 18% of ASD diagnoses tend to co-exist with other medical conditions (Abruzzo et al., 2015; Eriksson et al., 2013). Other confounding diagnostic factors include maturation, limited diagnostic tools, lack of knowledge among professionals, and the negative stigma attached to the diagnosis (Jagan & Sathiyaseelan, 2016; Klintwall et al., 2015; Ning et al., 2019). There is currently no “gold standard” for diagnosis (Fletcher-Watson & McConachie, 2017), resulting in the possibility of delayed intervention if not diagnosed by a certain age (Anderson, 2014; Bradshaw et al., 2015; Landa, 2018).

As a recompense for an actual diagnosis of autism, early intervention programs use screenings to identify traits for toddlers “at risk” for ASD before age three. The Modified Checklist for Autism in Toddlers-Revised (MCHAT-R™) is one early autism identification tool for toddlers experiencing atypical development (Robins et al., 2014). Screening for ASD often occurs between 18-24 months, although EICs may occur earlier (Cangialose & Allen, 2014; Rotholz et al., 2017). Early diagnosis of ASD is the best practice approach as research has shown that the cognitive and behavioral results achieved after participating in Early Intervention (EI) improved verbal skills and overall cognition upon reaching school age as compared to those who did not receive EI (Eriksson et al., 2013; Fletcher-Watson & McConachie, 2017; Lord et al., 2020; Jagan & Sathiyaseelan, 2016). Participating in EI also increased the prospect of mainstreaming in school while decreasing their need for support (Abruzzo et al., 2015; Clark et al., 2018; Towle et al., 2014).

Once diagnosed, the process of assigning a treatment that focuses on the symptoms associated with autism can begin. Bradshaw et al. (2015) suggested by completing a reliable screening by one year old, a diagnosis can be given as early as 12 to 14 months of age (by a developmental pediatrician, child psychologist, or child psychiatrist). It is favorable to diagnose as early as one year old, so that the child can have two years of intervention before the age of 3 as opposed to having one.

. (Peirce et al., 2019; Rotholz et al. 2017) conducted a study showing that early identification and intervention improvements are achievable with policy change. The South Carolina Act Early Team (SCAET), an early intervention program, worked to use existing tools and approaches in different ways to improve the early identification of toddlers with ASD, resulting in increased effects of treatment (Anderson et al., 2014; Bradshaw et al., 2015).

There are two popular treatments for the behavior characteristics of ASD in toddlers; behavioral intervention and relationship-based treatments (Parsons et al., 2017). Although they are used to treat the same disorder, they represent contrasting philosophies. Both address behaviors specific to ASD, but there is some debate among professionals and governing bodies as to which treatment is most effective (Anderson et al., 2014; Hyman et al., 2020; Jeans et al., 2013; Landa, 2018; Sheldrick et al., 2017). A well-established behavioral intervention method is Applied Behavior Analysis (ABA) (Lovaas, 1987). The most commonly used relationship-based treatment is DIR Floortime™ (Greenspan & Weider, 2009; Hess, 2013).

Applied Behavioral Analysis (ABA)

B.F. Skinner believed that learning is a function of change in overt behavior and that changes in one’s behavior are secondary to an individual’s response to stimuli (Goddard, 2014). Therefore, one can shape or replace behavior in an individual with step-by-step instruction, data collection, and repetition of the desired behavior until the desired behavior is practiced and becomes automatic. The goal of ABA, initially developed by Ivar Lovaas, is to “make the autistic child indistinguishable from his non-autistic peers.” (Lovas, 1987). Traditionally, ABA treatment deals with the management of “non-compliant,” “aggressive,” “destructive,” “self-injurious,” and “stereotypical” behaviors frequently exhibited by children presenting with ASD into behaviors that are more aligned with social norms (Leblanc, 2012; Leaf, 2021). Success with ABA depends on the professional use of positive reinforcement (e.g. favorite foods or drinks, movies/shows, video games, or toys), in combination with socially motivating interactions, to encourage independent skills. ABA utilizes parent training, instructing caregivers in critical components. The family works with the provider to identify reinforcers for their child’s program and implement techniques learned during sessions into daily living. ABA has been effective in altering the symptoms of autism (e.g., LeBlanc, 2012; Leaf, 2021; Lovaas,1987; Schreibman et al., 2015). 

DIR Floortime ™

The relationship-based approach highlighted in this study, the Developmental, Individual, and Relationship (DIR) Floortime ™ model (Greenspan, 2009), founded by Stanley Greenspan, operates using an individual’s intrinsic interest as motivation to facilitate mutual interest in others, while taking into account the neurological differences that may hinder neurotypical development. This approach also employs predetermined milestones to determine current skill levels as practitioners work closely with a child and their parents. Recognizing how the many interrelated relationships coincide with early intervention, through play (how children learn) and parents taking an interest in their child’s interests, children can participate, learn, and develop in the context of their everyday routines, activities, places, and relationships, understanding that each relationship they have can affect the others (Hess, 2013). This method works through a lens that offers insight in facilitating relationships and engagement, necessary for intrinsic motivation to shape behavior.

The “DIR” in DIR Floortime ™ is an acronym for D-Developmental Milestones, I- Individual Differences, and R-Relationships. “Floortime ” is the specific treatment used in EI that involves a practitioner facilitating child-directed play scenarios. The D-Developmental in DIR involves the following six stages or “milestones” called “developmental milestones” utilized to establish a focus for treatment: 1) attending and regulation/homeostasis; 2) engaging and relating to others; 3) two-way communication or reciprocation 4) shared problem-solving; 5) creative/symbolic play and 6) building bridges between ideas. Once the developmental milestone levels are determined, they inform the starting point and goals for treatment. Per parent interview, a review of medical history and personal background information specific to their child offers information that fulfills the “I” in “Individual Differences”. The interview with the parents and observation of the child and parent/caregiver interaction also offer insight into the R-Relationship component, an essential aspect of this intervention. Combining all three DIR components dictates the focus of treatment (Greenspan, 2009).

ABA and DIR Floortime™

DIR Floortime™ and ABA treatments have similarities and differences in their approach. One similarity is that they both address the specific traits exhibited in autistic toddlers. Additionally, they offer parental involvement and training. In both interventions, parents are encouraged to participate and use techniques learned in their homes and surrounding communities (Rivard et al., 2017; Schreibman et al., 2015).

These treatments, however, also possess notable differences regarding style and manner of treatment. One such difference is the “lens” or perspective from which the individual is viewed. To summarize, behavior intervention pursues shaping an individual’s behavioral responses by collecting data on observable, “outward” bodily responses to environmental stimuli to assist with creating a plan of action for replacing those behaviors (LeBlanc, 2012). In contrast, relationship-based treatments look “inward,” seeking to understand the individual’s relationship dynamics to intrinsically motivate their affect and behavior (Greenspan, 2009; Hess, 2013).

Another difference is that ABA is a stand-alone profession in and of itself, and completion of a specialized education program is required to practice. Relationship-based program practitioners can practice solely, but generally are professionals in other therapeutic fields (e.g., music therapy, speech therapy, or occupational therapy) that use relationship based techniques to enhance their skill base (Leaf, 2021; Greenspan, 2009). ABA also receives more funding as it has more research evidence of its effectiveness (e.g., Yu et al., 2020; Klintwall et al., 2015; Kodak, 2020). Although research supports relationship-based treatments (e.g., Hess, 2013; Yu et al., 2020), DIR Floortime™ treatment is often not funded by community-based programs (Leblanc, 2012).

Most EI programs recognize a child’s relationship with their parents, caregivers, and other family members as critical for development while emphasizing the significance of relationships between practitioners and parents. Similarly, ABA and DIR Floortime ™ programs both have parent and family involvement. ABA emphasizes consistency and data collection for parents to shape more socially acceptable behaviors successfully. The aim of DIR Floortime ™ practices in EI is to foster parent-child relationships, along with other significant relationships (e.g., practitioner-parent, practitioner-child, practitioner-family members, and supervisor-practitioner) and promote successful delivery of support services for toddlers and their families. (Zaidman-Zait et al., 2014). From this foundation, a support network for children, their families can emerge and thrive (Jagan & Sathiyaseelan, 2016; Landa, 2018).

Parent Education

Outcomes of intervention for EI increased with consistent caregiver involvement. However, receiving the diagnosis of ASD for their child can be disorienting and hinder the ability of parents to make decisions (Hampton & Kaiser, 2016; Keenan et al., 2016 ). Families experience stress and confusion related to difficulties in identifying, acknowledging, and understanding their toddler’s problem. In this study, Edwards et al. (2017) concluded that parents were keenly mindful of the importance of EI (Rivard et al., 2017). Once the shock and guilt wears away, the parents are left responsible for making tough decisions (Ho et al., 2018; Lord et al., 2020; Zaidman-Zait et al., 2014;). The stress of not knowing what to do regarding intervention can be eased with training and education, (Suma et al., 2016) while simultaneously enhancing parent-toddler relationships (Fletcher-Watson & McConachie, 2017). Grant et al. (2016) revealed that the parent’s “journey” after diagnosis involves being overwhelmed by how much information is available (Jagan & Sathiyaseelan, 2016). Uninformed parents tend to employ a “trial and error” method when deciding on ASD interventions, highlighting the importance of parent training and assistance (Grant et al., 2016). Knowledgeable professionals can empower parents of toddlers with ASD to be strong advocates for their child while also setting a positive tone for future intervention (Park et al., 2018; Wang et al., 2016).

Benefits and Barriers to Early Detection

Even though behavioral characteristics for toddlers with ASD start at a young age, in the United States, diagnosis typically does not occur until 3 to 4 years old (Daniels & Mandell, 2014; Landa, 2018; Wang et al., 2016). Generally, however, caregivers notice symptoms before two years of age and initially voice concerns to their pediatrician by 18 months (Mazurek et al., 2019). Wetherby et al., (2004) revealed that for 80% of the children studied, a reliable, professional diagnosis was obtained as early as 24 months of age, demonstrating a significant connection to early indicators of ASD. EI providers, other than caregivers, are generally the first to witness behaviors that may signal that the toddler may present on the spectrum (Jeans et al., 2013). Symptoms commonly associated with ASD involve impaired social interaction, difficulty with verbal and nonverbal communication, repetitive movements, stereotypical behavior, and hyper involvement with personal interests (Autism Society, 2022; CDC, 2020). Symptoms in young toddlers involve difficulties with eye gaze, facial affect, joint-attention, and manipulating their environment (Daniels & Mandell, 2014).

Other factors preventing initial detection of early identifiers include the inconsistency of behavior in young children, the absence of suitable referrals by primary doctors (to whom parents often consult with concern), and the family’s decreased knowledge of services or how to access them (Keenan et al., 2016 ). An initial referral is most probable when biological risk factors, such as low birth weight, prenatal complications, or communication and language delays, coincide with substantial physical, sensory, or cognitive debilities (Celia & Frye, 2016; Gulsrud et al., 2016). Service providers that observe the early signs of autism may also hesitate to discuss traits with parents, even when symptoms are evident, to avoid uncomfortable conversations (Jagan & Sathiyaseelan, 2016; Sheldrick et al., 2017).

Purpose of Study

Early diagnostic characteristics observed in toddlers with ASD differ from skills that naturally develop in the first years of life. Symptoms of ASD are difficult to pinpoint, resulting in lost time in intervention. Thus, observation of early indicators by treatment providers and parents is vital. Determining what the possible markers or early characteristics are and if they are present at a young age can increase the probability of receiving early treatment, it is crucial for the toddler to learn foundational skills to establish support for later development. Diagnosis serves as the conduit to access services. More specifically, there is no funding for services without a diagnosis or eligibility to justify treatment (Braddock & Twyman, 2014: Yingling et al., 2018). This study sought to answer the following questions:

What is the distribution of EICs based on the MCHAT entrance?

What is the distribution of EICs based on the Psych exit?

What are parents’ opinions about the treatment their children receive?

Methods

Participants

Retrospective

Six subject families with toddlers between the ages of 18 to 36 months were consecutively selected from a randomized system for participation in this study; three received Behavioral Intervention (BI), and three received DIR Floortime ™ (DIR FT ™) services in the central Los Angeles area, between the years 2016 and 2021. If the information within the subjects’ file indicated a hearing impairment or other previously identified developmental disabilities such as Down’s syndrome, Prader-Willie, or Dup-15q, they were excluded. The average age of the toddlers admitted into the EI The program was 20.8 months long. The average time spent in EI services for toddlers was approximately 16 months.

Qualitative

Parents of individuals who have recently received treatment through a community-based regional center EI programs in the central Los Angeles area participated. Six consecutively chosen parents, three whose children received BI and three whose children received DIR Floortime™, completed a seven-question questionnaire regarding their child’s intervention. This questionnaire also contains a narrative portion where parents could type in their own words.

Instrumentation and Materials

Entrance

Revised in 2013, The Modified Checklist for Autism in Toddlers-Revised (M-CHAT-R/F™) (Robins et al., 2014) is a validated screening tool for assessing risk for ASD in children between 16 and 30 months of age as part of the intake process for EI program used in this study. The MCHAT-R/F ™ consists of an initial screening assessment and, depending on the score on that measure, a follow-up (Robins et al., 2014). The MCHAT-R/F ™ requires that parents respond “yes” or “no” to a series of 20 questions to determine if the toddler is “at risk” for a diagnosis of ASD at the age of three years. The MCHAT-R/F ™ offers detailed information regarding the Early Identifying Characteristics (EIC) exhibited during the first screening and represents the data used as the pre-test criteria in this study (Appendix 1 ). The interviewer administering the MCHAT-R/F ™ screening follows a flowchart design or script which matches up to each question asked on the MCHAT-R/F ™ and renders a “pass” or “fail” for each item scored. For all items except 2, 5, and 12, if the parents respond, “no” indicates risk, while for items 2, 5, and 12, a “yes” response indicates risk.

The MCHAT-R/F ™ has a scoring rubric representing toddlers performance on the measure. Low Risk is when the total score is zero to two (0-2). If the toddler is younger than 24 months, a re-screening would be warranted when the toddler turns two years old, Medium risk is represented by a total score of three to seven (3-7). With this score, the MCHAT-R/F ™ was used to obtain more information regarding the “at risk” responses. If the toddler scores a two or higher, then action is required, and the suggestion is to conduct an evaluation to receive EI services. The MCHAT-R/F ™ has a follow-up with different questions. High Risk is when the total score is eight to twenty (8-20). If the toddler scores within this range, it would be acceptable to bypass the follow-up and refer for diagnostic evaluation for EI services.

Data collected was recorded in a document that provided a setting for each variable (i.e., subjects’ age, treatment received, EICs, the total number of EICs professionally observed, and the resulting diagnosis) (Appendix 2). For later analysis, a digital device was used to record parents’ narrative responses

Early Identifying Characteristics

The early identifying characteristics (EIC) categories represented traits derived from the questions on the MCHAT-R/F ™ and grouped via professional judgment into five categories. The MCHAT-R/F ™ is a screening measure designed to target the signs of autism in toddlers. Hence, questions on the screening pertain to characteristics that should be in place during early childhood.

Early Identifying Characteristics

Identifying toddlers presenting with ASD involves observation of key developmental behaviors. Early identifying characteristics (EICs) are less evident as they involve the underlying skills of affect, eye gaze, joint attention and social referencing comprehension of spoken words, and play skills. Questions from the MCHAT-R/F ™ that represented “Social Gaze and Affect- EIC-1” (i.e., 10, 11*14, 15, 19) corresponded to eye contact related to social, affective responses. “Play-EIC-2” comprises MCHAT-R/F ™ items (e.g., 3, 8, 9, 17) involving play and complementary skills of initiation and interest in others. The questions involving Sensory/Movement-EIC-3 (e.g., 4, 5, 12, 13 20) dealt with processing environmental stimuli and physical movement. Questions for “Joint Attention- EIC-4” (e.g., 1, 6, 7, 16) involved engagement with others in mutual awareness of shared interests. Questions selected (e.g., 2,18) for “Comprehension- EIC-5” involved the toddler’s hearing ability (the physical process of vibration reaching the ear outer and inner ear), listening aptitude (the auditory ability to perceive and interpret messages), and how they affect comprehension (an act or demonstration of knowledge gained) skills. There was also a question in EIC 1-Social Gaze Affect (i.e., 11*), indicating hearing issues or decreased ability to comprehend spoken words (see Table 1).

Collection of Exit Data

The MCHAT-R/F ™ was used to establish entrance/intake data. Exit data obtained via a diagnostic report written by a psychologist determined whether or not the child presented with ASD by age three. Clinical judgment matched each EIC to the corresponding characteristic detailed in the diagnostic report. An interrater was employed to ensure consistency with the interpretation of the intake versus exit data. (SEE WHAT ELSE YOU CAN SAY ABOUT IT OR WHERE YOU CAN MOVE IT)

Parent Questionnaire

A seven-item questionnaire was employed to obtain qualitative information regarding the parents’ perspectives concerning their therapeutic experience with either BI or DIR Floortime ™. Five of the questions followed a 5-point Likert scale format: 1) strongly disagree, 2) disagree, 3) neutral, 4) agree, and 5) strongly agree. In addition, two questions were open-ended and required narrative responses from the parents (Appendix A). Questions sought to understand parents’ overall satisfaction with therapeutic outcomes, training in techniques, and quality of intervention received while participating in sessions.

The construction of the parent questionnaire aimed to be as simple for the parent to understand while simultaneously being as comprehensive as possible. Questions dealt with how the parents felt their intervention treated their toddler’s autistic symptoms, if they were trained in the techniques, if they could use them outside of the session, and their overall opinion of the treatment in general. The purpose was to understand better a vital aspect of early intervention; parent involvement and training.

NO RATIONALE… JU Number of question s what kinds of questions,,, give example,,, what kind of responses do they make. (see appendix 1)

(DESCRIBE THE INSTRUMENT; WHAT IS IN IT? WHAT KIND OF QUESTIONS DO YOU ASK; WHAT IS THE PURPOSE?)

Procedures

This cross-sectional study collected data from an EI program in Los Angeles. The MCHAT-R/F ™ screening tool was used to screen toddlers from nine months to three years old upon entry into the EI program to determine if the child was “at risk” for ASD. Before exiting the program, each toddler underwent a psychological evaluation conducted by a certified psychologist.

From the behavioral observations portion of the psychological report, researchers discerned whether an early identifying characteristic (EIC) was present, then rendered a professional determination regarding the correlation between entrance and exit skill level skills. In other words, the MCHAT-R/F ™ scores were not compared to another standardized measure; instead, behavioral observations involving professional opinion were employed to connect with entrance and exit information.

An occupational therapist with over twenty years of experience working with “at-risk” toddlers in early intervention was interrater when correlating the entrance and exit information. The interrater and researcher reconciled any discrepancies in scores to make a final determination. From that determination, a quantifier/score to represent levels of functioning was achieved.

Data for the entrance/intake portion was obtained through file review.

Table 1.

MCHAT-R/F ™ Items which Represent Early Identifying Characteristics (EICs) 1-5

EIC 1 Social Gaze/Affect EIC 2 Play EIC 3 Physical/Sensory/Movement EIC 4 Joint Attention EIC 5 Comprehension

10 3 4 1 2

11 8 5 6 18

14 9 12 7 15 17 13 16 19 20 Data concerning the reconciled psychological determinations were placed into three descriptive categories involving “No,” “Partially,” and “Yes .” The description “No” signified that the “EIC not achieved/Characteristic mainstream norms not observed,” “Partial” denoted some improvement in that there was some progress noted towards mainstream norms, and “Yes” represented achievement of characteristics to mainstream norms.

This study is a quasi-experiment. Although we were interested in comparing some of the variables, the small sample size precluded the use of inferential statistical analyses. We instead used visual analyses to determine trends and proportions within and between data. An interrater reviewed the EICs and compared them to observations from the psychological report to offer another professional judgment regarding the presence or absence of the