Chapter 10

Assessment Related to Developmental

Disabilities and Psychological Disorders
During Early Childhood

Kirsten M. Ellingsen, Dianna Boone and Lacy Chavis

Abstract This chapter focuses on the identification and assessment of suspected

developmental disabilities and externalizing disorders during early childhood. It
begins with a literature review and general background of developmental disabil-
ities in young children and then describes general considerations for conducting
psychological evaluations in this domain. Next, three of the most common devel-
opmental disabilities [e.g., Autism Spectrum Disorder (ASD), Attention Deficit
Hyperactivity Disorder (ADHD), and Oppositional Defiant Disorder (ODD)] are
described with respect to their presentation in young children. This is followed by
an outline of general assessment guidelines and specific instruments and methods
for the identification and diagnosis of these developmental disabilities. The chapter
concludes with examples of young children who represent common referral con-
cerns for case study discussion and assessment planning.

Keywords Early childhood developmental disabilities Early assessment of aut-



ism spectrum disorder Preschool ADHD Early childhood oppositional defiant



disorder Autism screening measures BASC-3 preschool CBCL-preschool

K.M. Ellingsen (&)

University of South Florida, Tampa, USA
e-mail: [email protected]
D. Boone
Doctoral Candidate in Clinical Psychology, Texas Tech University,
Lubbock, USA
e-mail: [email protected]
L. Chavis
Licensed Psychologist, All Children’s Hospital, Johns Hopkins Medicine,
St. Petersburg, USA
e-mail: [email protected]

© Springer Science+Business Media New York 2016 203

A. Garro (ed.), Early Childhood Assessment in School
and Clinical Child Psychology, DOI 10.1007/978-1-4939-6349-2_10
204 K.M. Ellingsen et al.

Introduction

Young children exhibit aggression, disruptive behavior, hyperactivity, and impaired

social interactions for different reasons. Children under six years of age can be
expected to display these behaviors to some extent, particularly when under duress,
tired, sick, scared, or when learning how to express frustration and assert indepen-
dence. However, when young children experience more sustained difficulties
managing their emotions or behavior, the quality of their relationships with care-
givers or peers may suffer, and these difficulties might limit the ability to success-
fully engage in educational settings. Early identification and accurate assessment of
developmental disabilities is critical so that targeted support and evidence-based
interventions can be accessed to facilitate optimal development and functioning.
While psychologists can consult with parents and caregivers about evidence-based
strategies to support healthy social-emotional development and positive early rela-
tionships for any child who demonstrates challenging behaviors, a critical role for
early childhood psychologists is to understand when these behaviors suggest a
potential underlying disability and how to conduct accurate diagnostic assessments.
This chapter focuses on the identification and assessment of suspected devel-
opmental disabilities and externalizing disorders during early childhood. It begins
with a description of general considerations for psychological evaluations of young
children who demonstrate significant behavioral and social-emotional problems.
Next, three of the most common developmental disabilities in early childhood [i.e.,
Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder
(ADHD) and Oppositional Defiant Disorder (ODD)] are described. This is followed
by an outline of general assessment guidelines and specific instruments and
methods for the identification and diagnosis of these developmental disabilities. The
chapter concludes with examples of young children who represent common referral
concerns for case study discussion and assessment planning.

Literature Review

Background Related to Developmental Disabilities in Early

Childhood

All young children demonstrate behaviors that might be of concern to parents at

some point, including heightened emotionality and temper tantrums, aggression,
defiance, and high levels of activity. However, an underlying disability or neu-
rodevelopmental disorder might be present when the behaviors are more frequent,
intense, sustained or persistent, or when they markedly interfere with a child’s ability
to engage in daily activities and appropriate social interactions. Psychologists who
work with children under six years of age need to have a solid working knowledge of
typical development and how to address parent concerns about social-emotional
10 Assessment Related to Developmental Disabilities … 205

development and challenging behaviors, including how to screen for developmental

disabilities and externalizing disorders and how to conduct accurate diagnostic
assessments when indicated. Children with developmental disabilities and those
with disruptive or externalizing disorders are at increased risk for long-term social
and academic difficulties (American Academy of Pediatrics, 2011). Early identifi-
cation and participation in evidence-based interventions are key strategies to reduce
and prevent problems, as well as to promote better health and functional outcomes
for children with developmental disabilities. Obtaining an accurate diagnosis in a
timely manner is important for treatment planning and can benefit children by
allowing access to early intervention services and special education resources.
The Centers for Disease Control and Prevention (CDC) define developmental
disabilities as a “group of conditions due to impairments in physical, learning,
language, or behavior areas”. Recent estimates suggest one in six children between
the ages of 3 and 17 (15 %) has a developmental disability (CDC 2015a). National
prevalence rates collected between 1997 and 2008 showed a 17 % overall increase
in developmental disability rates reported by parents and documented “significant
and successive” increases in both ASDs and ADHD, with those two diagnoses
accounting for most of the change in rates (Boyle et al., 2011).
Behavioral manifestations of different developmental disabilities during early
childhood can look similar. Not only are there shared behavioral concerns and
common indicators among diagnoses, there is heterogeneity of the combinations of
symptoms within each disability category. For example, aggressive, disruptive, and
oppositional behaviors are frequently reported for young children with an ASD,
ADHD, or ODD diagnosis. Within these disabilities, there are also overlapping
symptoms that are present with anxiety, learning disorders, and intellectual dis-
ability. To further complicate accurate diagnosis, children might meet criteria for
multiple diagnoses among developmental disabilities and psychological disorders.
Problematic behaviors prompting an assessment referral might also be due to other
factors including exposure to trauma, communication difficulties or other devel-
opmental delays. Child functioning is influenced by general health, temperament,
disciplinary practices and other aspects of the family environment (e.g., family
conflict, parent mental health status, etc.). Therefore, depending on the referral
concerns presented, initial case conceptualization should consider differential
diagnosis and dual diagnosis, as well as attempt to rule out other causes for
behaviors such as trauma exposure and heightened family or situational stressors.

General Considerations for a Diagnostic Assessment

of a Developmental Disability

Diagnosis is a complex process. Accurately identifying a developmental disorder in

early childhood requires clinical judgment and the use of multiple measures and
sources of information that consider history, context, and current functioning across
206 K.M. Ellingsen et al.

settings and over time. The cause of developmental disabilities, including autism
and ADHD, is generally considered to be a combination of complex variables,
some of which begin prenatally, including genetic factors, exposure to toxins,
infection, and injury. For each of the disorders considered in this chapter, there is no
known definitive cause, biological marker, or single test that can be used to diag-
nose a child. Further, there is heterogeneity of symptoms for each child who meets
diagnostic criteria, as all children have a unique constellation of resources, family
support, and individual strengths and limitations that influence functioning and
ongoing development.
A comprehensive psychological evaluation begins with timely screening for
common risk factors. Selecting and administering reliable and valid screening mea-
sures and collecting adequate background information from parents is often a first step
to determine when a referral for an evaluation or diagnostic assessment should be
made. While early childhood psychologists’ roles in an initial developmental screening
might vary, they should be able to understand and interpret screening measures and
assessment methods for developmental disabilities. Once a referral for a diagnostic
assessment is made, psychologists might be required to conduct the evaluation inde-
pendently or as part of a multidisciplinary team. They will need to know both typical
and atypical behavior during early childhood from infancy to school entry.
Understanding typical development in early childhood will help to appropriately frame
parent or caregiver concerns. It is also important for diagnostic decisions, as behaviors
that indicate a developmental disability need to be markedly inconsistent with a child’s
age and developmental level. Psychologists need to know established diagnostic and
differential diagnosis criteria; best practices in assessment, including selection of valid
measures; and how to interpret results within a biopsychosocial framework that
informs treatment planning and takes into account cultural background and environ-
mental facilitators and barriers. For example, maternal psychosocial adversity has been
associated with poorer emotion regulation for infants to children 5 years of age
(Halligan et al., 2013).
There are a variety of standardized measures that are commonly employed as
part of screening or diagnostic evaluations in young children. A number of these
measures are broad-band, meaning that they cover a wide range of symptoms and
problematic behaviors. Many of these are parent-report instruments, which pose
both strengths and limitations as part of the evaluation process. Parental input is
necessary and valuable to provide a comprehensive picture of the child’s func-
tioning, though parents might present a biased perspective. A sample of these
measures is summarized in Table 10.1.

Autism Spectrum Disorders (ASDs)

ASDs are a group of neurodevelopmental disabilities characterized by pervasive and

sustained impairments in social interaction, communication, and behavior. More
specifically, symptoms involve problems in reciprocal communication and initiating
10 Assessment Related to Developmental Disabilities … 207

Table 10.1 General Measures of Social-Emotional and Behavioral Functioning in Young Children
Screening Measures
Ages and Stages Questionnaires: • Parents complete this measure to identify
Social-Emotional, Second Edition (ASQ: social—emotional difficulties for children
SE-2) (Squires et al., 2015) ages 1–72 months of age
• 9 different age questionnaires, 30 items per
questionnaire
• Administration time 10–15 min
Brief Infant Toddler Social Emotional • The BITSEA scales and newly calculated
Assessment (BITSEA) (Briggs-Gowan & BITSEA Autism score have good
Carter, 2006b) discriminative power to differentiate children
with and without ASD (Kruizinga et al.,
2014)
• For children 12–36 months of age
• Parent report, total problems score,
competence score, autism composite
• 7–10 min to complete
• 12–36 month
The Devereux Early Childhood Assessment DECA-P2
Preschool 2nd Edition (DECA-P2) (LeBuffe (DECA-I/T)
& Naglieri, 2012) • Both are strengths based, standardized norm
The Devereux Early Childhood Assessment referenced behavior rating scales
for Infants and Toddlers (DECA-I/T) • Both have three key protective factors related
(Mackrain, LeBuffe, & Powell, 2007) to resilience: initiative, self-regulation and
attachment/relationships both yield a total
protective factors score
• DECA-P2 is the parent report measure for
children ages 3–5 years
• DECA-P2 includes a behavior concerns
screener score
• DECA-I/T is for children ages 1 month–
2 years
Strengths and Difficulty Questionnaire • Parent or teacher completed questionnaire as
(SDQ)(Goodman, 2007) a general psychosocial screening
• 10 min to complete
• For children ages 3–17
• 25 items; 5 scales (extended versions include
items about impact)
• Scales include: Emotional Symptoms,
Conduct Problems,
Hyperactivity/Inattention, Peer Relationship
Problems and Prosocial Behavior
Available for free at: http://www.sdqinfo.com/
a0.html
Diagnostic Assessment Measures
Behavior Assessment System for Children • Norm referenced, standardized rating scale
Third Edition (BASC-3) (Reynolds & that assesses current level of social and
Kamphaus, 2015) emotional functioning. It assesses a wide
range of child behavior problems and
psychopathology, including attention
(continued)
208 K.M. Ellingsen et al.

Table 10.1 (continued)

problems, hyperactivity, and aggression. The
behavioral ratings are categorized as average
(normal for age), at-risk, or clinically
significant
• The instrument includes several composite
and scale scores including the Behavioral
Symptoms Index (BSI), which is a
Composite score suggesting overall level of
behavioral problems
• Describes the child’s current behavior or
behavior evidenced within the past six
months
• Ages 2–5 years (preschool); child (6–
12 years)
• Administration time 10–20 min
The Child Behavior Checklist (CBCL) 1.5-5 1.5-5
(Achenbach & Rescorla, 2001) • Part of the Achenbach System of Empirically
Based Assessment (ASEBA) system
• Children ages 1½–5 years
• 99 items rated by parents and a
teacher’s/caregiver’s form
(Caregiver-Teacher Report Form, C-TRF);
Language Development items for children
18–34 months of age
• Assesses internalizing problems
externalizing problems and sleep problems.
15–20 min for administration
• There is also multicultural supplement to
manual which describes development of
multicultural norms and illustrates
multicultural scoring
The Devereux Early Childhood Assessment Supports early intervention to reduce or
Clinical (DECA-C) (LeBuffe & Naglieri, eliminate behavioral or social-emotional
2003) problems
• Used for children already showing
social-emotional concerns
• For children 2–5 years
• Standardized, norm referenced behavior
rating scale. Contains all of the resiliency
and strength-based items found on regular
DECA-P
• Also contains four scales to assess problem
areas including: Aggression, Attention
Problems, Emotional Control Problems, and
Withdrawal/Depression
• Can be completed by parents or teachers
Infant Toddler Social Emotional • For young children ages 12–36 months
Assessment (ITSEA) (Briggs-Gowan & • Administration time 25–30 min
Carter, 2006a) • Yields T scores for four broad domains, 17
specific subscales, and three index scores
10 Assessment Related to Developmental Disabilities … 209

and carrying out age-appropriate social interactions as well as behavioral patterns,

and interests or activities that are restricted and/or repetitive. The primary symptom
of an ASD is impaired social interaction (APA, 2013c). Symptoms are initially
present in early childhood and profoundly impact daily functioning for a child.
During the last 20 years, the number of children diagnosed with an ASD has
dramatically increased. In the 1980s, children were diagnosed at a rate of two to five in
10,000 (Kogan et al., 2009). Autism was once considered rare but has become one of
the most common childhood disorders (Fombonne, 2008). According to the CDC,
current rates of autism in the United States are now estimated at 1 in 68 children, with
rates higher for boys (i.e., 1 in 42) as compared to girls (i.e., 1 in 189) (CDC, 2010).
National estimates were derived from health and special education records in 2010
gathered from 11 states for children who were 8 years of age. These rates represent an
almost 60 % rise as compared to 2006 and an almost 120 % rise since 2002.
Prevalence of ASD is a highly controversial topic. More specifically, controversy
exists about the reason(s) for the increasing rates. Matson and Kozlowski (2011)
identified several possible hypotheses, including true increases in prevalence, which
might be attributable to a variety of factors; different research methodologies used to
establish prevalence rates; new assessment instruments; inaccurate diagnosis;
changing diagnostic criteria; diagnosis at earlier ages; and increased awareness and
acceptance of ASD. One of the most significant recent changes in diagnostic pro-
tocols involves revision of the DSM. More specifically, in 2013, the fifth edition of
the DSM collapsed four separate diagnoses (i.e., Autistic Disorder, Asperger’s
Disorder, Childhood Disintegrative Disorder and Pervasive Developmental
Disorder, Not Otherwise Specified, also known as PDD-NOS) into one general ASD
diagnosis with ratings for severity of symptoms. The DSM-5 diagnosis of ASD now
includes two main behavior categories instead of three, since problems related to
social interaction and communication are now grouped under one umbrella instead
of two. The second main behavior category still involves restrictive, repetitive
behaviors. The change from DSM-IV to DSM-5 was prompted by research indi-
cating that the separate diagnoses, particularly Autistic Disorder and Asperger’s
Disorder, could not be reliably differentiated from each other as well as research
demonstrating low validity for the separate diagnoses (see Frazier et al., 2012; Lord
et al., 2012; Miller & Ozonoff, 2000; Macintosh & Dissanayake, 2004).
Children with ASD are also being diagnosed at earlier ages (Guthrie et al.,
2013). Earlier diagnosis is occurring for a variety of reasons. There has been a
decrease in average age of first diagnosis, as parents and professionals become more
familiar with manifestations of early symptoms and where to receive professional
help (Shattuck et al., 2009). Increased public awareness has been important in
facilitating diagnosis, as national government and nonprofit organizations have led
public campaigns, initiated advocacy efforts for early and universal screening, and
provided information about signs and behavioral indicators during infancy and
early childhood. In addition, research conducted over the past decade, from both
retrospective and prospective studies, has begun to document discriminating
behaviors in infancy, altogether indicating an increased need for diagnostic
assessment of children early in life (Zwaigenbaum et al., 2009). The importance of
210 K.M. Ellingsen et al.

an early ASD diagnosis is highlighted by accumulating evidence demonstrating the

effectiveness of early childhood intervention programs (e.g., Reichow, 2012).
Further, the earlier the diagnosis of ASD, the more time for participation in
interventions and services that can positively influence the functioning and devel-
opmental trajectory of affected children and provide supports for their families.
Although diagnosis is occurring earlier in life for many children with ASD, the
average age of diagnosis is still not until almost 4 years of age. In 2010, the Autism
and Developmental Disabilities Monitoring (ADDM) Network examined preva-
lence of ASD across 11 US states and found that the average age of participation in
a comprehensive evaluation was 44 months. However, 36 % of children did not
have a comprehensive evaluation until after 4 years of age even though the majority
of families (i.e., 89 %) had developmental concerns before their children were three
years of age (Baio, 2014). Despite the call and sound rationale for earlier diagnosis,
early detection continues to present a number of challenges, especially in children
younger than three. This is due to the fact that characteristic behaviors might be
hard to identify until they become more prominent and distinctive from general
developmental delay (Sunita & Bitszta, 2013).
Several researchers have examined diagnosis of autism in children as young as
two (e.g., Kleinman et al., 2008; Zwaigenbaum et al., 2009). Early signs may be
noted as early as 12 months, and are typically recognized by 24 months with
appropriate screening and/or assessment. Signs that might be reported by parents at
these young ages include a child’s apparent inability to hear or lack of response to
others, delays in language development, and low or diminished interest in social
interactions. Parents may be concerned that a child loses communication skills or
stops acquiring expressive language. According to the CDC 2015b, 40 % of chil-
dren with autism will be nonverbal or have no expressive language and 25–30 %
will have some words in infancy and lose them after 18 months. Below is a list of
very early indicators or possible “red flags” that require evaluation by an expert.
• No babbling or pointing by age 1
• No single words by 16 months or two-word phrases by age 2
• Not responding to name by 12 months of age
• Not pointing at objects to show interest (e.g., pointing at an airplane flying over)
by 14 months
• Loss of language or social skills
• Poor eye contact
• Excessive lining up of toys or objects
• No smiling or social responsiveness
• Not engaging in “pretend” games/activities (e.g., pretend to “feed” a doll) by
18 months
Behavioral indicators during toddlerhood include:
• Limited interest in social and reciprocal face-to-face interactions (unless inter-
actions are also physical such as rocking, tickling, tossing in the air)
• Seeking physical comfort from parents infrequently
10 Assessment Related to Developmental Disabilities … 211

• Limited response to name

• Fleeting eye contact or eye contact that is not consistent with social interactions
• Communication that is scripted, repetitive, or with unusual pitch and intonation
• Limited creativity or pretend in play
• Uses few or no gestures
• Moving quickly between toys and objects, stereotypical play, or unusual sensory
interest in exploring objects (e.g., licking toy, sniffing objects, rubbing toy on
face)
• Motor mannerisms such as hand flapping, toe walking, repeatedly opening and
closing doors
• Flat or inappropriate facial expressions
Later early childhood behavioral indicators include:
• Avoiding eye contact and wanting to be alone
• Having trouble understanding other people’s feelings or talking about their own
feelings
• Impaired ability to make friends or develop relationships with peers
• Impaired ability to initiate or sustain conversations with others
• Does not share interests with others
• Absence or impairment of imaginative and social play
• Stereotyped, repetitive, or unusual use of language
• Excessive use of repetitive words or phrases (echolalia)
• Giving unrelated answers to questions
• Restricted patterns of interest that are abnormal in intensity or focus
• Preoccupation with certain objects or topics
• Getting upset by minor changes
• Delayed speech and language skills
• Inflexible adherence to specific routines or rituals
• Having obsessive interests
• Does not understand jokes, sarcasm, or teasing
There are other common behavioral symptoms including temper tantrums,
hyperactivity, aggression, unusual sleeping and eating patterns, sensory sensitivity,
and either heightened fear or lack of fear in situations (CDC 2015b; Steiner et al.,
2012). ASD is frequently associated with impairments in intellectual functioning
and structural language disorder. The co-occurrence rate for ASD with other
developmental, chromosomal, genetic, and psychiatric disorders is approximately
83 % (Levy et al., 2010). While anxiety is not a defining characteristic of ASD,
prevalence rates for comorbid anxiety disorders and ASD range from 11 to 84 %,
averaging around 40–50 % (White, Oswald, Ollendick, & Scahill, 2009).
Assessment guidelines and recommendations. A diagnosis of ASD often begins
with a developmental screening at a pediatrician’s office or early intervention
center. According to recommendations of the American Academy of Pediatrics, all
18- and 24-month-old children should be screened for ASD (Zwaigenbaum et al.,
2009). Early and accurate diagnosis of an ASD enables families to learn about their
212 K.M. Ellingsen et al.

child’s developmental challenges, cope with caregiving demands, seek appropriate

services, and obtain generic counseling (Shattuck et al., 2009). The American
Academy of Pediatrics also recommends rescreening for children who are younger
than 24 months of age. Children who are found to be at-risk on screening measures
should be referred for comprehensive diagnostic evaluations consisting of multiple
measures and methods. Referrals for genetic testing should be made if warranted.
Various screening instruments have been developed to help identify young
children at risk for autism in primary care settings (Sunita & Bitszta, 2013).
Table 10.2 provides a description of commonly used ASD screening measures. The
most common ASD-specific screening tool used in primary care is the
Modified-Checklist for Autism in Toddlers (M-CHAT; Robins, Fein, & Barton,
2009). It is available for free online: http://www.firstsigns.org/downloads/m-chat.
PDF and in an electronic format (https://www.mchatscreen.com; https://www.
autismspeaks.org/). The M-CHAT was modified from the Checklist for Autism in

Table 10.2 ASD Screening Measures

Modified Checklist for Autism in Toddlers • Parents answer 23 yes/no questions to
(M-CHAT) (Robins, Fein, Barton, & Green, screen for autism spectrum disorder (ASD)
2001) • For children ages 16–30 months
• A follow-up interview is warranted if child
“fails” the screen before referral to
comprehensive autism evaluation (2 critical
items or 3+ non-critical items)
Screening Tool for Autism in Toddlers and • The STAT is “level 2 screen” a play-based
Young Children (STAT)TM interactive assessment designed to identify
signs of ASDs in referred or at-risk children
• 12 items; about 20 min to administer
• For children between 24 and 36 months of
age
• Screening tool for autism in two-year-olds
(STAT)
• http://vkc.mc.vanderbilt.edu/vkc/triad/
training/stat/
• http://stat.vueinnovations.com/about
The Modified Checklist for Autism in • Simplifies wording of the original M-CHAT
Toddlers, Revised with follow-up • Two-stage screener with follow-up parental
(M-CHAT-R/F) (Robins et al., 2009) interview for positive screens
• Available for free at: www.mchatscreen.
com
Brief Infant Toddler Social Emotional • The BITSEA scales and newly calculated
Assessment (BITSEA) (Briggs-Gowan & Autism score have good discriminative
Carter, 2006) power to differentiate children with and
without ASD (Kruizinga et al., 2014)
• For children 12–36 months of age
• Parent report, total problems score,
competence score, autism composite
• 7–10 min to complete
10 Assessment Related to Developmental Disabilities … 213

Toddlers (CHAT) and has been recently revised as the M-CHAT-R/F (Robins,
Fein, & Barton, 2009) as a two part-screener with simplified language, a few less
items and recommended follow-up interview for positively screened children. The
M-CHAT-R/F was designed and validated to address issues of sensitivity and high
false positives from the M-CHAT. The addition of the parent interview with
follow-up questions to the M-CHAT-R/F also follows recommended best practices
and helps clinicians better understand parental responses (Zwaigenbaum et al.,
2009). The most common early signs captured by the M-CHAT are impairments or
delays in early emerging social communication behaviors, though sensory sensi-
tivities or restricted play might also be early indicators of later ASD. Clinicians are
cautioned about interpreting the early signs documented in the screening because
these behaviors are not necessarily specific to ASD and might be representative of
other neurodevelopmental disorders (Charman & Gotham, 2013). Having a parent
expand upon the concerns they identified in the screening (e.g., what do they notice,
when, how often, and under what circumstances) will provide necessary informa-
tion to understand the child’s functioning and determine if referral for a compre-
hensive psychological evaluation is warranted. Information about how the child
interacts in other social environments (e.g., child care) should also be gathered
when possible. Hearing should be assessed by an audiologist.
The CDC provides information about other common measures used in autism
screening, including the Ages and Stages Questionnaire (ASQ), the Parents
Evaluation of Developmental Status (PEDS) and the Screening Tool for Autism in
Toddlers and Young Children (STAT) (See http://www.cdc.gov/ncbddd/autism/
hcp-screening.html for information regarding these measures. In addition, there are
instruments that aim to screen for ASD with infants. For example, The First Year
Inventory (FYI; Baranek, Watson, Crais, & Reznick, 2003; Reznick, Baranek,
Reavis, Watson, & Crais, 2007) is a parent-report measure that contains items in the
social communication and sensory regulatory domains. Although the FYI is still
only available for research purposes, the developers have conducted several vali-
dation studies, a retrospective study, and an outcomes study and translated the tool
into several different languages, including Spanish, Hebrew, Dutch-Flemish, Italian,
and Chinese.
Following a developmental screening, a child determined to manifest risk for
autism should be referred for a diagnostic assessment. Diagnosis of an ASD is most
valid and reliable when derived from a multifaceted assessment approach. Use of
standardized measures as well as interviews, behavioral observations, and review of
records are essential for accurate diagnosis. Interviews with parents and/or other
caregivers should be thorough and cover information about pregnancy, delivery,
medical history, and developmental milestones, as well as psychosocial stressors
and trauma exposure, both to rule out other disorders and better understand the
child’s functioning. Behavioral observations should be conducted across settings to
the greatest extent possible to provide information about the consistency of the
child’s skills and functioning in different contexts. Vision and hearing screens
should be performed to understand sensory functions. Standardized cognitive,
language, and motor tests should be administered. For children under age 3, the
214 K.M. Ellingsen et al.

Bayley Scales of Infant and Toddler Development (Bayley-III) can be used to

assess these domains. Parents and teachers/caregivers should also complete stan-
dardized scales related to adaptive and social-emotional functioning. During the
assessment, psychologists should note how the child responds to parents, new
adults, and requested tasks, and should also carry out unstructured play activities
while attending to nonverbal communication, shared attention and enjoyment,
social interaction and sensory seeking behaviors. Clinical judgment is also neces-
sary to interpret behavioral presentation and developmental history. Evaluations
may be conducted in a multidisciplinary setting by a team of pediatric professionals
including a psychologist, physician, speech-language pathologist, and occupational
therapist. A psychologist might also be asked to conduct a comprehensive evalu-
ation independently through private practice, outpatient behavioral health clinic in a
hospital setting, or within a school to determine educational impact and eligibility
for special education services.
As noted above, the DSM-5 (APA, 2013a) made major revisions related to
autism. In addition to the collapsing of the former categories in the DSM-IV into
one ASD diagnosis, other changes were made. For example, the DSM-5 indicates
that a person must meet all three of the criteria under problems in social interaction
and communication, which include deficits in: (a) social-emotional reciprocity,
(b) nonverbal communication used in social interaction, and (c) development and
maintenance of relationships. For each of these three, more specific behaviors are
delineated. Under the category of restrictive, repetitive patterns of behavior,
interests or activities, individuals must show at least two of the four symptoms
listed. The DSM-5 also outlines three levels of severity specifiers for ASD symp-
toms, and severity level may change Ìover time and across environments due to
many factors including development, acquisition of new skills, and changes in
environmental demand.
Autism-specific measures include standardized play-based direct assessment,
parent questionnaires and interviews, and structured clinician observations. One of
the most highly regarded instruments is the Autism Diagnostic Observation
Schedule (ADOS). The most recent version is the ADOS-2 (Lord et al., 2012)
which contains five modules, including the Module T (Toddler). This revision was
done to address the limited utility of the ADOS-G (Lord et al., 2000) to assess
young children. The ADOS-2 Model T was created for use with children under
30 months of age with a nonverbal mental age of at least 12 months. Module 1 of
the ADOS-2 is better for children over 30 months unless the child has sufficient
language for Module 2 (Luyster et al., 2009). It is important for clinicians to be
aware of the behaviors of infants and toddlers in an unknown context with unknown
adults and toys to determine if the behaviors are typical for the child; therefore, a
parent or familiar caregiver is always in the room to confirm if the behavior is
representative of other contexts and clinicians should attempt to explain the key
observations to parents in behavioral terms (Luyster et al., 2009). Regarding clin-
ician observation measures, the CARS is a popular instrument and the ADI-R is
often used as a comprehensive parent interview (Lord et al., 1994). These measures
are described briefly in Table 10.3.
10 Assessment Related to Developmental Disabilities … 215

Table 10.3 Autism Specific Measures

Autism Diagnostic Observation • The ADOS-2 is a semi-structured,
Schedule-Second Edition (ADOS-2) (Lord standardized play-based assessment of ASD
et al., 2012) behaviors (Lord et al., 2012)
• The measure includes separate (but
overlapping) modules for individuals of
different ages and language abilities
• The ADOS-2 has 5 modules and takes
between 40 and 60 min administration time
• Administered in a child-friendly, small room.
Each activity provides a hierarchy of presses
for the examiner on a 3-point scale with
higher scores indicating greater severity of
symptoms
Autism Diagnostic Interview-Revised The ADI-R is a standardized, semi-structured
(ADI-R) (Rutter et al., 2003) parent interview that is administered
face-to-face by a trained clinician in
approximately 90–150 min
• 93 items focusing on early development,
language/communication, reciprocal social
interactions, and restricted, repetitive
behaviors and interests
• The validity for young children is problematic
(when mental age is under 18 months and it
tends to over diagnose nonverbal children)
Childhood Autism Rating Scale, Second For Children 2 years of age and older
Edition (CARS2) (Schopler, Van The child is rated on 15 subscales based on
Bourgondien, Wellman, & Love, 2010) observation with 5–10 min to complete the
form after the observation
15 items rated
Social Responsiveness Scale Second The SRS-2 identifies level of Social
Edition (SRS-2) (Constantino, 2012) Impairment
65-item rating scale that is completed by
parents/teachers
Provides information about social functioning
including social awareness, social reciprocal
communication, social anxiety and stereotypic
behavior/restricted interests
Each item rated on a 4 point scale from “not
true” to “always true”
15–20 min administration time
For Ages 3 through 99 years

Attention Deficit Hyperactivity Disorder (ADHD)

ADHD is the most common neurobehavioral disorder of childhood (Hendriksen

et al., 2015). Recent clinical estimates for prevalence of ADHD range from 5 %
(APA, 2013b) to 6.69 % (Boyle et al., 2011). National data examining community
samples have documented up to 11 % of children as ever having received this
216 K.M. Ellingsen et al.

diagnosis based upon parental report (Visser et al., 2014). ADHD can profoundly
affect children’s social interactions, interpersonal relationships, educational per-
formance, and overall wellbeing (American Academy of Pediatrics, 2011).
Common referral concerns for ADHD include behaviors such as high activity level,
impulsivity, and poor attention. Most referrals for an evaluation and diagnosis occur
between the ages of 7–9 years (Smith & Corkum, 2007) with the average age of
diagnosis at 7 years of age. However, initial age of symptom onset often occurs
earlier, between ages 3–4 (Smith & Corkum, 2007). Also, Visser et al. (2015) note
that children who exhibit more severe symptoms are generally diagnosed earlier,
usually around 4 years of age.
Although there is less information about ADHD in younger children, research
suggests that prevalence rates for preschoolers are similar to those in older children
(Egger & Angold, 2006; Egger, Kondo, & Angold, 2006). In addition, research
indicates that preschoolers with ADHD show profiles of symptoms (e.g., high
levels of inattention, impulsivity and overactivity) and deficits that are quite similar
to those in school-age and older children with the disorder (Gadow & Nolan, 2002;
Wahlstedt, Thorell, & Bohlin, 2008). Despite these factors, many researchers and
practitioners often regard accurate diagnosis of ADHD in younger children as more
difficult compared to diagnosis in school-age children and adolescents. Also, there
is ongoing controversy regarding assessment and diagnosis of the disorder for
younger children (Smith & Corkum, 2007). While the American Academy of
Pediatrics guidelines (2011) suggest that children as young as four can be diag-
nosed with ADHD, many question why an increasing number of ADHD diagnoses
are being given to preschool-age children each year and concerns remain about the
use of stimulant medication with young children.
Some research has examined etiology of ADHD as well as trajectories of
development. According to the research and conceptualizations of Larsson,
Larsson, and Lichtenstein (2004) and Daley, Jones, Hutchings, and Thompson
(2009), gene–environment interaction is the best predictive model in explaining
ADHD. According to Daley et al., there are two specific theoretical models that
have been examined to explain the development and maintenance of ADHD. One
of these is the model of cognitive dysregulation espoused by Barkley (1997) as well
as Thorell and Wahlstedt (2006). According to this model, children with ADHD
show deficits in executive functioning, particularly problems when it comes to
inhibiting responses. These deficits make it more likely for them to behave
impulsively and become distracted by stimuli in their environment as compared to
other children their age. The other primary model focuses on motivational processes
and posits that children with ADHD behave impulsively and become fidgety and
distractible because they are trying to avoid delay from preferred objects and
activities in their environment (Sonuga-Barke, Houlberg, & Hall, 1994). Both of
these models have received empirical support in studies of preschool children with
ADHD (Kuntsi, Oosterlaan, & Stevenson, 2001; Sonuga-Barke, Dalen, &
Remmingtom, 2003; Thorell & Wahlstedt, 2006).
One of the primary challenges with diagnosis in the preschool period is difficulty
differentiating true ADHD symptoms from behavior that would be considered
10 Assessment Related to Developmental Disabilities … 217

typical in younger children. For example, younger children are often quite active, so
practitioners might be hesitant to state that a three- or four-year old is showing an
excessive activity level, which is one of the possible symptoms of ADHD.
Similarly, from a developmental perspective, preschoolers do not have the same
attention span as school-age children, and teachers, parents, and clinicians might
have difficulty delineating a clear line as to what constitutes attentional difficulties.
Therefore, it is important for psychologists and mental health professionals to know
how to understand appropriate age-based behaviors; parent concerns about attention
and activity level are common during early childhood. One general guideline that
clinicians should apply in assessing ADHD in a younger child is to ask: Is this
behavior more frequent or intense than what is seen in other children of the same
age. This guideline requires knowledge and experience working with younger
children to understand what is considered typical and atypical.

According to Mahone (2012) early signs of possible ADHD include:

• Dislikes or avoids activities that require paying attention for more than a few
minutes
• Loses interest and moves on to another activity after engaging in an activity
quickly
• Talks more and makes more noise compared to same age peers,
• Climbs on things even when told not to
• Not able to hop on one foot by age 4
• Almost always restless (e.g., consistently moving feet, twisting around in seat,
insisting on getting up from seat)
• Fearlessness results in getting into dangerous situations
• Warms up too fast to strangers
• Frequently aggressive with peers; has been removed from preschool/daycare for
aggression
• Receives injuries because of moving too fast or running when told not to do so
According to Nass (2006) characteristics of preschool children with ADHD
include:
• Rushes through tasks and pays little attention to details
• Difficulty paying attention to tasks or play activities appropriate for chrono-
logical age
• Not seeming to listen
• Shifts frequently from one activity to another
• Difficulty organizing activities that other children can organize
• Avoids doing tasks that require mental effort
• Frequently or easily loses items
• More easily distracted than other children the same age
• Is forgetful
• Fidgets or squirms
• Has difficulty remaining seated
218 K.M. Ellingsen et al.

• Runs about or climbs on things when asked not to

• Has difficulty playing quietly
• Always on the go
• Talks excessively
• Blurts out answers before the question is complete
• Shows difficulty waiting for his/her turn or taking turns
• Interrupts people or disrupts group activities
Assessment guidelines and recommendations. The DSM-5 defines ADHD as a
persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with
functioning or development. Symptoms must negatively impact functioning in
social, school/academic or occupational domains (APA, 2013b). There are three
presentation types: Inattentive, Hyperactive-Impulsive, and Combined
Inattentive/Hyperactive-Impulsive. Inattention includes difficulty sustaining focus,
disorganization, high distractibility, and poor persistence with tasks. Hyperactivity
is excessive motoric activity that is inappropriate for the situation/environment.
Impulsivity reflects actions without forethought. There is a higher probability for
potential harm with behaviors that are impulsive. Impulsive behaviors are often
prompted by desire for immediate gratification. Symptom manifestation must be
present in more than one setting; however symptom presentation may vary across
settings. In the DSM-5, symptoms are grouped under the two main categories of
Inattention and Hyperactivity and Impulsivity. Children must demonstrate six or
more symptoms listed under one or both categories, and symptoms must be present
for at least 6 months. The DSM-5 highlights that “symptoms are not solely a
manifestation of oppositional behavior, defiance, hostility, or failure to understand
tasks or instructions” (American Psychiatric Association, 2013b). Clinicians must
also document the level of severity of ADHD as “mild,” “moderate,” or “severe”
(see DSM-5 for definitions). A review of diagnostic criteria can also be found at
http://www.cdc.gov/ncbddd/adhd/diagnosis.html.
Diagnosis is a multi-step process. Assessment of ADHD in preschoolers needs to
be a careful, multifaceted process that involves a variety of methods and measures
(Smith & Corkum, 2007; CDC, 2016). There is no one test of ADHD, but a
comprehensive evaluation should include parent/caregiver interviews, including
gathering of a medical and developmental history; standardized behavioral rating
scales; and behavioral observations. For many children, direct assessment of cog-
nitive, language, and motor functioning is helpful for understanding the child’s
symptoms and functioning and also for purposes of differential diagnosis and
establishing co-morbid diagnoses. On cognitive measures, children with ADHD
may show lower performance on Working Memory and Processing Speed Indices.
Academic or pre-academic testing might be beneficial for some children. This can
help identify co-occurring learning problems and/or examine the potential impact of
inattention and other symptoms on educational performance.
The diagnostic assessment should begin with an intake interview to obtain
background information about parent concerns and description and chronicity of
behaviors. In fact, the history/intake interview has been referred to as the
10 Assessment Related to Developmental Disabilities … 219

“cornerstone of diagnostic assessment” for ADHD (Nass, 2006). Information about

medical and developmental history including pregnancy, birth, and hospitalizations,
chronic health conditions, medications, sleep and early education or caregiving
environments should be obtained. Prenatal, perinatal, and other early environmental
factors that may increase risk for ADHD include maternal smoking and/or
alcohol/drug use during pregnancy, prematurity and/or low birthweight, brain
injury, and exposure to lead or pesticides (Froehlich, 2011). In addition, clinicians
should ask about family health history, recent stressors, including potential expo-
sure to trauma, and other psychosocial risks (e.g., financial strains, family conflict,
etc.). While these are not considered causal factors in the development of ADHD,
they can impact how symptoms are manifested and how the family responds to
symptoms. In addition, in some cases, young children show behaviors that seem
characteristic of ADHD but are connected to other psychological problems. For
example, anxiety may cause restlessness that is interpreted as hyperactivity, and
chronic worrying may cause a child to be inattentive.
A comprehensive evaluation should also include measures that are designed to
document behaviors and functioning that reflect diagnostic criteria for ADHD.
Parents and other caregivers, such as preschool teachers, should complete stan-
dardized behavioral ratings scales. These may be general (e.g., CBCL) or ADHD
specific (e.g., Conners). It is helpful for initial evaluations to include both general
and specific measures to inform an initial diagnosis, rule out other disorders, and/or
make a dual diagnosis. Diagnosis of ADHD requires problematic behaviors over
time in more than one setting, so it is crucial to gather information from multiple
informants. Results from rating scales should be compared to assess functioning
across different environments. It is important to note that differences in results across
informants might be due to varying perspectives of teachers, parents, and other
caregivers or due to actual differences in how the child behaves in these contexts.
Table 10.4 describes measures that are commonly used in the assessment of
ADHD. All of these standardized instruments can be used to aid the diagnostic
process, but none of them should be used in isolation to make a diagnosis.

Table 10.4 Instruments for Assessing ADHD in Young Children

Conners Early Childhood (Conners EC) • Goal is to “aid in the identification of
(Conners, 2007) behavioral, social and emotional problems”
• For children ages 2–6 years
• 15 min to complete; administered online or
paper-pencil
• Spanish version available; parent version
(190 items) and teacher/child care provider
version (186 items)
• There are also Conners EC developmental
milestones and Conners early childhood
behavior forms when milestones have been
met
(continued)
220 K.M. Ellingsen et al.

Table 10.4 (continued)

The Behavior Rating Inventory of • Standardized measure of executive
Executive Function-Preschool Version functioning for children ages 2–5 years
(BRIEF-P) (Gioia, Isquith, Guy, & • Can serve as a screening tool for possible
Kenworthy, 2000) executive function difficulties
• 63 items that produce scores for five scales
that form the Global Executive Composite
(GEC) (i.e., inhibit, shift, emotional control,
working memory, and plan/organize)
• Three overlapping summary indexes (i.e.,
Inhibitory Self-Control Index (ISCI), which
consists of the Inhibit and Emotional
Control scales, the Flexibility Index (FI),
Emergent Metacognition Index (EMI),
which is composed of Working Memory
and Plan/Organize scales
Behavior Assessment System for • BASC-3 is a broad-band instrument and is
Children-Third Edition (BASC-3) not a specific ADHD diagnostic instrument
(Reynolds & Kamphaus, 2015) • Parent Report Scale-Preschool (PRS-P) and
Teacher Rating Scale-Preschool (TRS-P)
are applicable to children ages 2–5 years
• Both PRS-P and TRS-P have the following
composites:
(a) Externalizing problems
(b) Internalizing problems
(c) Adaptive skills
(d) Behavioral symptoms index
• Externalizing Problems composite includes
Hyperactivity and Aggression scales, both
of which can be applicable to assessment
for ADHD
• Internalizing Problems composite includes
Anxiety, Depression, and Somatization
scales
• Adaptive Skills composite of both PRS-P
and TRS-P includes Adaptability, Social
Skills, and Functional Communication
scales; on the PRS-P this composite also
includes Activities of Daily Living scale
• Behavioral Symptoms Index includes the
Attention Problems, Atypicality,
Withdrawal, Depression, Hyperactivity and
Aggression scales
• Includes a new Parenting Relationship
Questionnaire (PRQ) designed to assess the
parent’s perspective on relationship with
child
• Structured Developmental History
(SDH) can be completed by clinician or
parent to provide specifics about child’s
medical and developmental history and can
provide useful information for ADHD
assessment
(continued)
10 Assessment Related to Developmental Disabilities … 221

Table 10.4 (continued)

The Child Behaviour Checklist (CBCL • Includes DSM oriented scales for ADHD,
1.5-5) (Achenbach & Rescorla, 2001) ASD, depressive problems, anxiety
problems, and ODD problems which can
contribute to diagnostic process
• The Externalizing Problems Scale contains
subscales for Attention Problems and
Aggression which can also help inform
clinical diagnosis

Oppositional Defiant Disorder (ODD)

At certain stages of a child’s development the exhibition of oppositional behavior is

normal. Increased sense of autonomy and experience, developing cognitive abilities
and refining motoric and language skills equate to more strong-willed behavior in
early childhood. So how do we distinguish between developmental norms and
atypical oppositional behavior? Key considerations in distinguishing between
behaviors that are normative and symptoms of ODD include frequency and per-
sistence of problematic behaviors, number of diagnostic criteria met over the pre-
ceding 6 month period, and identifying whether or not there is a pattern of
problematic interactions with others. There has been an increased focus on exter-
nalizing behaviors in early childhood due, in part, to the limited effectiveness of
treatment for older children diagnosed with conduct disorder (Shaw, Owens,
Giovannelli, & Winslow, 2001).
According to the American Academy of Child and Adolescent Psychiatry
(AACAP, 2009) estimates of prevalence rates for children and adolescents with
ODD range from 1 to 16 %. However, rates for preschool children are difficult to
establish due to lack of confirmatory information for this age group. Regarding
predictive validity of an early childhood ODD diagnosis, Keenan et al. (2011)
examined the stability of this diagnosis for a group of 223 preschoolers referred to a
child psychiatric clinic. About half had been referred due to problems with temper,
aggression and defiance and the other half were recruited from pediatric offices. The
researchers found evidence for some stability in diagnosis. Among those children
diagnosed with ODD, 72 % met criteria for diagnosis one year later, 66.3 % met
criteria at a two-year follow-up and 51.7 % of children continued to meet the
diagnosis for ODD at the three-year follow-up. It has been hypothesized that
externalizing disorders, such as ODD and ADHD, are influenced by
under-regulation of negative affect as emotion regulatory deficits have been found
to precede externalizing problems (Halligan et al., 2013).
ODD is in the category of Disruptive, Impulse-control and Conduct disorders in
the DSM-5. The common thread and unique feature is that ODD involves emotional
and/or behavioral regulation difficulties and behaviors that “violate the rights of
others” causing significant conflict in the child’s various environments (e.g., home,
222 K.M. Ellingsen et al.

school, society) (APA, 2013d). ODD is characterized by a pattern of excessive

anger/irritability/; defiance or argumentative behavior, and/or vindictive conduct.
Symptoms of ODD may include (American Academy of Child and Adolescent
Psychiatry, 2013):
Frequent temper tantrums
Excessive arguing with adults
Questioning rules often
Active defiance and refusal to comply with adult requests
Deliberate attempts to annoy or upset others
Blaming another person for his or her mistakes or misbehavior
Often touchy or easily annoyed by others
Frequent anger and displays of resentment
Mean and hateful talk when upset
Spiteful attitude and revenge seeking
High level of negativity
Assessment guidelines and recommendations. As is the case with ADHD,
diagnosis of ODD in younger children often presents challenges. This is due to the
fact that some of its associated behaviors/symptoms (e.g., defiance, temper tan-
trums) are often commonly seen in toddlers and preschoolers. However, accurate
diagnosis of ODD in younger children requires that the behaviors show greater
intensity and/or frequency than what is usually seen in children of the same age.
Therefore, clinicians must have knowledge and understanding of typical and
atypical behavior in younger children. It is also crucial that they be able to gather
comprehensive information from parents, other caregivers, and teachers, if appli-
cable, to understand if the child’s behavior constitutes a pattern. The symptoms
must also negatively impact one or more areas of functioning or cause distress for
the child or someone in his/her immediate context (e.g., parents, teachers, etc.).
Interviews can also be beneficial in understanding triggers, after-effects and impact
of the child’s behaviors.
The DSM-5 criteria for diagnosis of ODD include both emotional and behavioral
symptoms that are categorized into (a) Angry and irritable mood (b) Argumentative
and defiant behavior, and (c) Vindictiveness. Children younger than five years of
age must exhibit the behaviors on most days for a time period lasting at least 6
months and to an extent more often than is typical for same age peers (American
Psychiatric Association, 2013d). Symptoms of ODD are almost always present
prior to early teen years, and can present as early as preschool age. Clinicians must
specify the severity of ODD (i.e., mild, moderate, or severe) based upon the number
of settings where symptoms are present.
Similar to ADHD, ODD evaluations should include broad measures of behavior
and social-emotional functioning completed by multiple informants such as the
BASC and CBCL, which can inform whether ratings are normative or behaviors
fall within a clinical range. Clinicians should carefully assess child developmental
history and psychosocial risk factors, with a focus on parent–child relationship and
10 Assessment Related to Developmental Disabilities … 223

conflicted interactions. In addition, measures such as the DECAI/T, or DECA-C

include both protective factors (e.g., attachment to parents) and problem factors to
provide better understanding of parent–child relationships. Functional Behavioral
Assessments (FBAs) can be beneficial for both diagnostic assessment and inter-
vention planning. Documenting the antecedents and consequences of behavior will
provide information about what might be reinforcing problematic behaviors, which
helps inform environmental adaptations/interventions as well as parent education
and training. As noted previously, there is a high rate of co-morbidity of ADHD for
children diagnosed with ODD. Evaluating for dual diagnosis and differential
diagnosis is important. Several factors can help differentiate diagnosis for young
children, including duration and intensity of anger, triggers for temper tantrums,
mood symptoms, and peer conflict. For children with ODD, destructiveness or
misbehavior is generally a result of anger rather than carelessness or accident as
seen in children with ADHD. A child with ADHD may also have temper tantrums
as a result of sensory or affective overstimulation (e.g., transitions) rather than be
generally triggered by limit setting and conflict with authority.

Implications for Practice: Linking Assessment

to Intervention

Training and competency in the assessment of early childhood developmental

disabilities and externalizing disorders enable psychologists to positively contribute
to early identification and involvement in early intervention/treatment which, in
turn, can prevent secondary conditions and improve long-term outcomes for chil-
dren. Comprehensive and informed assessment is necessary to differentiate among
common disability diagnoses that have overlapping symptoms and diagnostic cri-
teria. It requires a multifaceted approach to understand functioning across settings
and the use of valid and reliable measures, keen observational skills, and thorough
interviewing of important caregivers. All assessment data should be carefully
integrated and used to make targeted recommendations for treatment or interven-
tion. Intervention plans should follow a biopsychosocial framework. Consider the
individual child, family, culture, resources, and circumstances. Examining envi-
ronmental barriers and facilitators to optional health and functioning is important
for understanding a child and intervention planning. Functional assessments and
treatment planning using a biopsychosocial framework can be enhanced with the
use of the International Classification of Functioning, Disability, and Health for
Children and Youth (ICF-CY) (http://www.who.int/classifications/icf/en/; www.
ICF-CYDevelopmentalCodeSets.com).
There are several empirically supported interventions for young children with
ASD, ADHD, and ODD. A list of resources is displayed below in Table 10.5.
While medication may be prescribed for children with these disabilities, interven-
tions that include parent–child relationship work and behavioral strategies are
224 K.M. Ellingsen et al.

Table 10.5 Resources for Intervention Planning

Interventions
ASD For evidence-based interventions see http://autismpdc.fpg.
unc.edu/sites/autismpdc.fpg.unc.edu/files/2014-EBP-
Report.pdf
Wong et al. (2014)
https://www.autismspeaks.org/family-services/tool-kits/
asperger-syndrome-and-high-functioning-autism-tool-kit/
interventions-and-t
http://autismguidelines.dmh.mo.gov/documents/
Interventions.pdf
http://www.apa.org/monitor/2012/10/autism.aspx
http://www.firstsigns.org
ADHD http://effectivechildtherapy.org/content/behavior-therapy-
adhd)
http://www.cdc.gov/ncbddd/adhd/guidelines.html
http://www.nasponline.org/resources/handouts/05-1_S8-
05_ADHD_Classroom_Interventions.pdf
http://www.apa.org/pi/families/resources/child-medications.
pdf
http://www.nichq.org/childrens%20health/adhd/resources/
adhd%20toolkit
ODD https://www.aacap.org/App_Themes/AACAP/docs/
practice_parameters/odd_practice_parameter.pdf
Parenting and parent–child Parent Child Interaction Therapy (PCIT): http://www.pcit.
relationship interventions org
https://www.aacap.org/aacap/Families_and_Youth/
Resource_Centers/Oppositional_Defiant_Disorder_
Resource_Center/Home.aspx
The Incredible Years: http://incredibleyears.com
Triple P: http://www.triplep-parenting.net/glo-en/home/
http://www.triplep.net/glo-en/home/
http://www.promisingpractices.net/programs.asp

essential to promoting optional development and functional outcomes for children.

Factors such as parent depression and maladaptive parenting practices should also
be targeted, particularly during screening and referral when prevention and
reduction of significant behavioral problems can occur.

Case Study 1

Referral: Charlie is a four-year-old boy who was referred for a comprehensive

psychological evaluation by his parents to address persistent behavioral concerns
including hyperactivity, impulsivity, aggression, and noncompliance.
10 Assessment Related to Developmental Disabilities … 225

Background: Charlie’s parents, Mr. and Mrs. Roberts reported an uncompli-

cated pregnancy and delivery. Charlie has had no hospitalizations but does have a
history of asthma and ear infections. His developmental milestones were reportedly
achieved within the expected age ranges. Family psychiatric health history is
remarkable for paternal anxiety and ADHD and maternal depression, as well as
learning disabilities and substance abuse issues in his extended family. As a toddler,
Charlie was observed to exhibit extreme temper tantrums that included kicking,
hitting, throwing objects, biting, and head banging. During parental interview, Mr.
and Mrs. Roberts stated that he has a history of explosiveness and rapid escalation
of anger as well as physical aggression, including kicking peers at his former
daycare and physical fights with his older sister. Charlie is described as frequently
negative and angry; much of his anger is directed at his mother. Mr. and Mrs.
Roberts indicated that they have received reports from his preschool teachers that he
is very active and has very low frustration tolerance.

Discussion Questions:
1. What diagnoses are you considering based on the referral concerns and back-
ground information?
2. What domains will need to be assessed?
3. What other background information will you need to collect to understand
behavioral concerns?
4. Describe the measures and methods you will use as part of a diagnostic
assessment process.
Behavioral Observations: Charlie presented as an active and social young boy.
He demonstrated appropriate eye contact, warmed quickly to the examiner and
easily shared stories about activities he enjoyed. His interactions with his parents
during the intake interview were minimal and he chose to play alone with toys. He
ignored repeated requests by his mother to clean up before testing began; she picked
up the toys and grabbed his arm, expressing with frustration “he never listens.”
During the evaluation, his engagement and level of compliance varied by assess-
ment task; at times, he was highly engaged and excited to participate as well as
celebrate his accomplishments. Other times, Charlie refused to perform items,
particularly when tasks seemed more difficult. He impulsively touched items on the
table and had a hard time sitting still during the cognitive tasks, often choosing to
stand. To complete all of the standardized assessment activities, Charlie required
frequent breaks, as well as the implementation of a reward system with stickers.
Scores on Standardized Measures: Charlie’s full-scale IQ (FSIQ) on the
WPPSI-IV was 124, which falls in the 95th percentile compared to same age peers.
On the Bracken Basic Concept Scale-Third edition: Receptive Form, he obtained a
standard score of 118, which falls in the high average range compared to same age
peers. On the Drawing subtest from the Wide Range Assessment of Visual Motor
Ability (WRAVMA), Charlie’s visual-motor skills fell within the Average range
(Standard Score = 101; 55th percentile). Information obtained from parent ques-
tionnaires revealed significant, persistent impairments in social-emotional
226 K.M. Ellingsen et al.

functioning. On the BRIEF-P, Mr. and Mrs. Roberts indicated that Charlie has
significant difficulties with Inhibition and Emotional Control (99th percentile and
92nd percentile, respectively). Ratings by Charlie’s preschool teacher were con-
sistent with parent ratings. Charlie’s parents and teacher also completed the BASC-
3. On this measure, parents endorsed items resulting in clinically significant ele-
vations (i.e., standard T scores greater than 70) on the following scales:
Hyperactivity (T = 90, 99th percentile), Aggression (T = 73, 97th percentile),
Externalizing Problems (T = 84, 99th percentile), Atypicality (T = 73, 97th per-
centile), and Attention Problems (T = 71, 98th percentile). Ratings from his teacher
indicated somewhat less problematic behavior in this environment compared to
home, although he obtained elevated scores on the Hyperactivity (T = 87, 99th
percentile) and Attention Problems (T = 71, 98th percentile) scales.
On the DECA-C, Mr. and Mrs. Roberts reported significant concerns about
Charlie across all clinical scales. Specifically, scores for Attention problems fell
within the 99th percentile, suggesting that Charlie displays difficulty focusing on a
task and ignoring noise or other stimuli in his environment and has significantly
higher levels of distractibility, impulsivity, and hyperactivity than other same age
children. He was rated to have frequent problems associated with: temper tantrums,
becoming easily frustrated, high distractibility, short attention span, squirming, and
fidgeting. Parents rated Charlie as having low protective factors with respect to
Self-Control and Attachment but close to the normative range for Initiative.

Discussion Questions

1. Based upon the additional data, what would you describe as Charlie’s most
problematic areas of functioning? What are his strengths/areas of asset?
2. What information supports a diagnosis of ADHD and/or ODD?
3. What other diagnoses would you consider based on the referral concerns? What
additional information do you need to make a diagnosis?

Case Study 2

Liam is a three-year-old boy who was referred for an intake consultation by his
primary care pediatrician due to parent concerns about a suspected ASD. Parents
described persistent behavioral and sensory concerns, including problems with
sleep and eating, recently observed repetitive motor movements and limited social
interactions with peers. They reported that problems with feeding and sleep started
in infancy. Liam’s mother described her pregnancy as a highly stressful time, which
included the family’s move between states and her husband beginning a new job.
Liam was born at 35 weeks gestation. His early health history is remarkable for
10 Assessment Related to Developmental Disabilities … 227

chronic otitis media. Liam received several rounds of antibiotics from 18 months to
30 months of age. His sleep issues include frequent waking during the night and
difficulty falling asleep. Liam’s parents report that he more readily engages with
them and little with peers. Liam’s preschool teacher also has concerns about a
perceived lack of social interest and peer play. Liam started preschool two months
prior to his referral without participation in any other formal childcare on a regular
basis. Early motor and language developmental milestones were reported as
delayed. Liam did not begin speaking words until close to age of 2 years. He began
walking at 18 months of age. Liam’s current expressive language skills are
described by both his parents and teacher as limited. He does not use sentences and
tends to mix real words with other language that is garbled. Liam’s receptive
language skills are not as limited, but still below age expectations. He can point to a
range of pictures of common objects and events. Liam is inconsistent in following
directions. He cannot follow commands that are more than one step. Liam’s parents
indicate that he continues to show “clumsiness” and resistance to performing
complex fine motor tasks.

Discussion Questions

1. What developmental domains do you need to assess for an autism evaluation?

2. What background information is important?
3. How would you determine if Liam met criteria in the DSM-5 for an ASD?

References

Achenbach, T., & Rescorla, L. (2000). Manual for the ASEBA preschoool forms and profiles.
Burlington, VT: University of Vermont, Research Centre for Children, Youth, & Families
American Academy of Child and Adolescent Psychiatry. (2009). ODD: A guide for families by the
American Academy of Child and Adolescent Psychiatry. Retrieved January 18, 2015 from
http://www.aacap.org/App_Themes/AACAP/docs/resource_centers/odd/odd_resource_center_
odd_guide.pdf
American Academy of Child and Adolescent Psychiatry. (2013). Facts for families: Children with
oppositional defiant disorder. Retrieved January 18, 2015 from http://www.aacap.org/AACAP/
Families_and_Youth/Facts_for_Families/Facts_for_Families_Pages/Children_With_
Oppositional_Defiant_Disorder_72.aspx
American Academy of Pediatrics (2011). ADHD: Clinical practice guideline for the diagnosis,
evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.
SUBCOMMITTEE ON ATTENTION-DEFICIT/HYPERACTIVITY DISORDER,
STEERING COMMITTEE ON QUALITY IMPROVEMENT AND MANAGEMENT.
Pediatrics (originally published online October 16, 2011). doi:10.1542/peds.2011-2654
American Psychiatric Association. (2013a). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: American Psychiatric Association. doi:10.1176/appi.books.
9780890425596.295735
228 K.M. Ellingsen et al.

American Psychiatric Association. (2013b). Attention-deficit hyperactivity disorder. In Diagnostic

and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric
Association. doi:10.1176/appi.books.9780890425596.295735
American Psychiatric Association. (2013c). Autism spectrum disorder. In Diagnostic and
statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric
Association. doi:10.1176/appi.books.9780890425596.295735
American Psychiatric Association. (2013d). Oppositional defiant disorder. In Diagnostic and
statistical manual of mental disorders (5th ed.). doi:10.1176/appi.books.9780890425596.
295735
Baio, J. (2014). Prevalence of autism spectrum disorder among children aged 8 years—Autism
and developmental disabilities monitoring network, 11 Sites, United States, 2010. Surveillance
Summaries of the Morbidity and Mortality Weekly Report (MMWR) of the Centers for
Disease Control and Prevention, 63(SS02), 1–21. Retrieved February 12, 2015 from https://
www.cdc.gov/mmwr/preview/mmwrhtml/ss6302a1.htm
Barkley, R. A. (1997). Behavioural inhibition, sustained attention, and executive function:
Constructing a unifying theory of ADHD. Psychological Bulletin, 121, 65–94.
Baranek, G, T., Watson, L. R., Crais, E., & Reznick, S. (2003). First-Year Inventory (FYI) 2.0.
Chapel Hill, NC: University of North Carolina.
Boyle, C. A., Boulet, S., Schieve, L. A., Cohen, R. A., Blumberg, S. J., Yeargin-Allsopp, Y., ...
Kogan, M. D. (2011). Trends in the prevalence of developmental disabilities in US children,
1997–2008. Pediatrics, 127(6). doi:10.1542/peds.2010-2989
Briggs-Gowan, M. J., & Carter, A. S. (2006a). Infant-toddler social and emotional assessment
examiners manual. San Antonio, TX: PsychCorp, Harcourt Assessment.
Briggs-Gowan, M. J., & Carter, A. S. (2006b). Brief infant-toddler social and emotional
assessment (BITSEA) manual. San Antonio, TX: PsychCorp, Harcourt Assessment.
Centers for Disease Control and Prevention (CDC). (2015a). Facts about developmental
disabilities. Retrieved March 2, 2015 from http://www.cdc.gov/ncbddd/
developmentaldisabilities/facts.html
Centers for Disease Control and Prevention (CDC). (2015b). Autism spectrum disorder-signs and
symptoms. Retrieved May 2, 2015 from http://www.cdc.gov/ncbddd/autism/signs.html
Centers for Disease Control and Prevention (CDC). (2016). Attention-deficit/hyperactivity disorder
(ADHD). Retrieved from http://www.cdc.gov/ncbddd/adhd/data.html
CDC. (2010). Prevalence of autism spectrum disorder among children aged 8 years—Autismand
developmental disabilities monitoring network, 11 sites, United States. MMWR 2014, 63(SS2),
1–2.
Charman, T., & Gotham, K. (2013). Measurement issues: Screening and diagnostic instruments for
autism spectrum disorders—Lessons from research and practice. Child and Adolescent Mental
Health, 18(1), 52–64. doi:10.1111/j.1475-3588.2012.00664.x
Cohen, I. L. The PDD Behavior Inventory (PDDBI) [PowerPoint slides]. Retrieved from www4.
parinc.com/webuploads/ppt/pddbi.ppt
Connors, K. (2007). Using the Conners 3 and Conners CBRS: Identification and intervention
[PowerPoint slides]. Retrieved from http://www4.parinc.com/webuploads/ppt/
POWERPOINTConners3CBRS-Using_0609.ppt
Constantino, J. N. (2012). Social Responsiveness Scale—Second Edition (SRS-2). Los Angeles,
CA: Western Psychological Service.
Daley, D., Jones, K., Hutchings, J., & Thompson, M. (2009). Attention deficit hyperactivity
disorder in pre-school children: Current findings, recommended interventions and future
directions. Child: Care, Health and Development, 35(6), 754–766. doi:10.1111/j.1365-2214.
2009.00938.x
Del Gaudio Weiss, A., & Fantuzzo, J. W. (2001). Multivariate impact of health and caretaking risk
factors on the school adjustment of first graders. Journal of Primary Prevention, 15, 247–260.
Egger, H. L., & Angold, A. (2006). Common emotional and behavioral disorders in preschool
children: Presentation, nosology, and epidemiology. Journal of Child Psychology and
Psychiatry, 47, 313–337.
10 Assessment Related to Developmental Disabilities … 229

Egger, H., Kondo, D., & Angold, A. (2006). The epidemiology and diagnostic issues in preschool
attention-deficit/hyperactivity disorder: A review. Infants and Young Children, 19(2), 109–122.
doi:10.1097/00001163-200604000-00004
Eyberg, S. Parent-child interaction therapy [PowerPoint slides]. Retrieved from https://www.
google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=Parent+child
+interaction+therapy+power+point
Fenstermacher, K., & Tsandes, N. (n.d). Ages and stages questionnaires: Social-emotional
[PowerPoint slides]. Retrieved from https://www.google.com/webhp?sourceid=chrome-
instant&ion=1&espv=2&ie=UTF-8#q=ages+and+stages+questionnaire+powerpoint
Fombonne. (2008). Is autism getting commoner? British Journal of Psychiatry, 193, p. 59.
Frazier, T. W., Youngstrom, E. A., Speer, L., Embacher, R., Law, P., Constantino, J., ... Eng, C.
Validation of proposed DSM-5 criteria for autism spectrum disorder. Journal of the American
Academy of Child and Adolescent Psychiatry, 51(1), 28–40.
Froehlich, T. E. (2011). Update on environmental risk factors for attention-deficit/hyperactivity
disorder. Current Psychiatry Reports, 13(5), 333–344.
Gadow, K., & Nolan, E. (2002). Differences between preschool children with ODD, ADHD, and
ODD & ADHD symptoms. Journal of Child Psychology and Psychiatry, 43, 191–201.
Gioia, G. A., Isquith, P. K., Guy, S. C., & Kenworthy, L. (2000) Behavior Rating Inventory of
Executive Function. Odessa, FL: Psychological Assessment Resources.
Guthrie, W., Swineford, L. B., Nottke, C., & Wetherby, A. M. (2013). Early diagnosis of autism
spectrum disorder: Stability and change in clinical diagnosis and symptom presentation.
Journal of Child Psychologt and Psychiatry, 54, 582–590.
Halligan, S. L., Cooper, P. J., Fearon, P., Wheeler, S. L., Crosby, M., & Murray, L. (2013). The
longitudinal development of emotion regulation capacities in children at risk for externalizing
disorders. Developmental Psychopathology, 25(2), 391–406. doi:10.1017/
S0954579412001137
Keenan, K., Boeldt, D., Chen, D., Coyne, C., Donald, R., Duax, J., ... Hill, C. (2011). Predictive
validity of DSM-IV oppositional defiant and conduct disorders in clinically referred
preschoolers. The Journal of Child Psychology and Psychiatry, 52(1), 47–55. doi:10.1111/j.
1469-7610.2010.02290.x
Kleinman, J. M., Ventola, P. E., Pandey, J., Verbalis, A. D., Barton, M., Hodgson, S., ... Fein, D.
(2008). Diagnostic stability in very young children with autism spectrum disorders. Journal of
Autism and Developmental Disorders, 38(4), 606–615.
Kogan, M. D., Blumberg, S. J., Schieve, L. A., Boyle, C. A., Perrin, J. M., Ghandour, R. M., ...
van Dyck, P. C. (2009). Prevalence of parent-reported diagnosis of autism spectrum disorder
among children in the US, 2007. Pediatrics, 124(5), 1395–1403. doi:10.1542/peds.2009-1522
Kruizinga, I., Visser, J. C., van Batenburg-Eddes, T., Carter, A. S., Jansen, W., & Raat, H. (2014).
Screening for autism spectrum disorders with the brief infant-toddler social and emotional
assessment. PLoS ONE, 9(5), e97630. doi:10.1371/journal.pone.0097630
Kuntsi, J., Oosterlaan, J., & Stevenson, J. (2001) Psychological mechanisms in hyperactivity: I
response inhibition deficit, working memory impairment, delay aversion, or something else?
Journal of Child Psychology and Psychiatry, 42, 199–210.
Larsson, J. O., Larsson, H., & Lichtenstein, P. (2004). Genetic and environmental contributions to
stability and change of ADHD symptoms between 8 and 13 years of age: A longitudinal twin
study. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 1267–1275.
LeBuffe, P. A., & Naglieri, J. A. (2003). The Devereux Early Childhood Assessment Clinical Form
(DECA-C): A measure of behaviors related to risk and resilience in preschool children.
Lewisville, NC: Kaplan.
LeBuffe, P. A., & Naglieri, J. A. (2012). The Devereux Early Childhood Assessment for
Preschoolers, Second Edition (DECA-P2): Technical manual, and user’s guide. Lewisville,
NC: Kaplan.
Levy, S. E., Giarelli, E., Lee, L. C., Schieve, L. A., Kirby, R. S., Cunniff, C., ... Rice, C. E. (2010).
Autism spectrum disorder and co-occurring developmental, psychiatric, and medical conditions
230 K.M. Ellingsen et al.

among children in multiple populations of the United States. Journal of Developmental and
Behavioral Pediatrics, 31(4), 267–275.
Lord, C., Petkova, E., Hus, V., Gan, W., Lu, F., Martin, D. M., ... Algermissen, M. (2012).
A multi-site study of the clinical diagnosis of different autism spectrum disorders. Archives of
General Psychiatry, 69, 306–313.
Lord, C., Risi, S., Lambrecht, L., Cook Jr, E. H., Leventhal, B. L., DiLavore, P. C., ... Rutter, M.
(2000). The autism diagnostic observation schedule-generic: A standard measure of social and
communication deficits associated with the spectrum of autism. Journal of Autism and
Developmental Disorders, 20(3), 205–223.
Lord, C., Rutter, M., & Couteur, A. L. (1994). Autism diagnostic interview-revised: A revised
version of a diagnostic interview for caregivers of individuals with possible pervasive
developmental disorders. Journal of Autism and Developmental Disorders, 24(5), 659–685.
Luyster, R., Gotham, K., Guthrie, W., Coffing, M., Petrak, R., Pierce, K., ... Richler, J. (2009). The
autism diagnostic observation schedule—Toddler module: A new module of a standardized
diagnostic measure for autism spectrum disorders. Journal of Autism and Developmental
Disorders, 39(9), 1305–1320.
Macintosh, K. E., & Dissanayake, C. (2004). Annotation: The similarities and differences between
autistic disorder and Asperger’s disorder: A review of the empirical evidence. Journal of Child
Psychology and Psychiatry, 45(3), 421–434.
Mackrain, M., LeBuffe, P. A., & Powell, G. (2007). The Devereux Early Childhood Assessment
for Infants and Toddlers (DECA-I/T), technical manual, and user’s guide. Lewisville, NC:
Kaplan.
Mahone, E. M. (2012). Is it ADHD or typical toddler behavior? Ten early signs of ADHD risk in
preschool age children. Retrieved October 13, 2015 from http://www.kennedykrieger.org/
overview/news/it-adhd-or-typical-toddler-behavior-ten-early-signs-adhd-risk-preschool-age-
children
Matson, J. L., & Kozlowski, J. M. (2011). The increasing prevalence of autism spectrum disorders.
Research in Autism Spectrum Disorders, 5, 418–425.
Miller, J. N., & Ozonoff, S. (2000). The external validity of Asperger disorder: Lack of evidence
from the domain of neuropsychology. Journal of Abnormal Psychology, 109(2), 227–238.
doi:10.1037//0021-843X.109.2.227
Nass, R. D. (2006). Evaluation and assessment issues in the diagnosis of attention deficit
hyperactivity disorder. In Seminars in pediatric neurology (Vol. 12(4), pp. 200–216).
Philadelphia: WB Saunders.
Oliver, W. (n.d.). Early childhood assessment tools. Miami, FL: Florida International University.
Retrieved from http://www2.fiu.edu/*aip/documents/AssessmentTools.pdf
Pearson. (n.d.). Brief Infant Toddler Social Emotional Assessment (BITSEA). Retrieved from http://
www.pearsonclinical.com/childhood/products/100000150/brief-infant-toddler-social-
emotional-assessment-bitsea.html
Pearson. (n.d.). Infant toddler social emotional assessment (ITSEA). Retrieved from http://www.
pearsonclinical.com/childhood/products/100000652/infant-toddler-social-emotional-
assessment-itsea.html
Psychological Assessment Resources (PAR). (n.d.). Pediatric Behavior Rating Scale (PBRS).
Retrieved from http://www4.parinc.com/Products/Product.aspx?ProductID=PBRS
Reichow, B. (2012). Overview of meta-analyses on early intensive behavioral intervention for
young children with autism spectrum disorders. Journal of Autism and Developmental
Disorders, 42, 512–520. doi:10.1007/s10803-011-1218-9
Reynolds, C., & Kamphaus, R. (2015). Behavioral Assessment System for Children—Third edition
(BASC-3).
Reznick, J. S., Baranek, G. T., Reavis, S., Watson, L. R., & Crais, E. R. (2007). A parent-report
instrument for identifying one-year-olds at risk for an eventual diagnosis of autism: The first
year inventory. Journal of Autism and Developmental Disorders, 37(9), 1691–1710.
Robins, D., Fein, D., & Barton M. (n.d.). M-CHAT general information. Retrieved from https://m-
chat.org/about.php
10 Assessment Related to Developmental Disabilities … 231

Robins, D. L., Fein, D., & Barton, M. (2009). The Modified Checklist for Autism in Toddlers,
Revised with Follow-up (M-CHAT-R/F). Self-published
Robins, D. L., Fein, D., Barton, M. L., & Green, J. A. (2001). The Modified Checklist for Autism
in Toddlers: An initial study investigating the early detection of autism and pervasive
developmental disorders. Journal of Autism and Developmental Disorders, 31, 131–144.
Shattuck, P. T., Durkin, M., Maenner, M., Newschaffer, C., Mandell, D. S., Wiggins, L., ... Baio,
J. (2009). Timing of identification among children with an autism spectrum disorder: Findings
from a population-based surveillance study. Journal of the American Academy of Child and
Adolescent Psychiatry, 48(5), 474–483. doi:10.1097/CHI.0b013e31819b3848
Shaw, D. S., Owens, E. B., Giovannelli, J., & Winslow, E. B. (2001). Infant and toddler pathways
leading to early externalizing disorders. Journal of the American Academy of Child and
Adolescent Psychiatry, 40(1), 36–43.
Smith, K. G., & Corkum, P. (2007). Systematic review of measures used to diagnose
attention-deficit/hyperactivity disorder in research on preschool children. Topics in Early
Childhood Special Education, 27(3), 164–173. doi:10.1177/02711214070270030701
Sonuga-Barke, E. J. S., Houlberg, K., & Hall, M. (1994). When is impulsiveness not impulsive—
The case of hyperactive children’s cognitive style. Journal of Child Psychology and
Psychiatry, 35, 1247–1253.
Sonuga-Barke, E. J. S., Dalen, L., & Remmingtom, B. (2003). Do executive deficits and delay
aversion make independent contributions to preschool attention-deficit/hyperactivity disorder?
Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1335–1342.
Squires, J., Bricker, D., & Twombly, E. (2015). Ages and Stages Questionnaires:
Social-emotional. Baltimore, MD: Paul H Brookes Publishing.
Sunita, & Bitszta, J. L. C. (2013). Early identification of autism: A comparison of the checklist for
autism in toddlers and the modified checklist for autism in toddlers. Journal of Pediatrics and
Child Health, 49(6), 438–444. doi:10.1111/j.1440-1754.2012.02558.x
Thorell, L. B., & Wahlstedt, C. (2006). Executive function deficits in relation to symptoms of
ADHD and/or ODD in preschool children. Infant and Child Development, 15, 503–518.
Triple P. Triple P in a nutshell. Retrieved from http://www.triplep.net/glo-en/find-out-about-triple-
p/triple-p-in-a-nutshell/
Visser, S. N., Bitslco, R. H., Danielson, M . L., Gandhour, R., Blumberg, S. J., Schieve, L., ...
Cuffe, S. (2015). Treatment of attention-deficit/hyperactivity disorder among children with
special health care needs. Journal of Pediatrics published online April 1, 2015.
Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook, J. R., Kogan M. D., Ghandour, R. M., ...
Blumberg, S. J. (2014). Trends in the parent-report of health care provider-diagnosed and
medicated attention-deficit/hyperactivity disorder: United States, 2003–2011, Journal of the
American Academy of Child & Adolescent Psychiatry, 53(1) 34–46.
Wahlstedt, C., Thorell, L. B., & Bohlin, G. (2008). ADHD symptoms and executive function
impairment: Early predictors of later behavioral problems. Developmental Neuropsychology,
33(2), 160–178. doi:10.1080/87565640701884253
White, S. W., Oswald, D., Ollendick, T. H., & Scahill, L. (2009). Anxiety in children and
adolescents with autism spectrum disorders. Clinical Psychology Review, 29, 216–229.
Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S., ... Schultz, T. R.
(2014). Evidence-based practices for children, youth, and young adults with autism spectrum
disorder. Chapel Hill, NC: The University of North Carolina, Frank Porter Graham Child
Development Institute, Autism Evidence-Based Practice Review Group
Zwaigenbaum, L., Bryson, S., Lord, C., Rogers, S., Carter, A., Carver, L., et al. (2009). Clinical
assessment and management of toddlers with suspected autism spectrum disorder: Insights
from studies of high-risk infants. Pediatrics, 123(5), 1383–1391.