The challenges of early Identification in Autism

Early Identification… early problems?

Introduction

Autism has been the focus of long-drawn study and controversial debate
(Volkmar et al, 2005). Issues related to its etiology, identification, treatment and
education continue to intrigue those who come into contact with this form of
syndrome (Zager, 1999).Children with autism spectrum disorders (ASD) should be
educated with their peers in a mainstream school environment (White Paper, 6; 2001).
Early identification provision is stated clearly in Special Educational Needs Codes of
Practice (DfES/581/2001) which describes the duties of Local Authorities and schools
about children with special educational needs. Moreover, in order to start a child's
with ASD the appropriate provision, it is important that support services and services
for early identification and intervention to be provided.
This assignment has been written to argue the issue of early identification and its
challenges as early identification in autism is an area of research which has received a
considerable amount of attention (Matson et al, 2008). The detection and diagnosis of
autism is very important as many research papers have shown the positive outcomes
of early intervention which comes after the identification. The earlier identification is
made, the better the outcomes of development of a child as the primary purpose of
identification is the child to gain access to services (Charman & Stone, 2006).
However, early identification underpins issues related to the appropriate age of
screening and identification of autism, the purpose of diagnosis and many more which
causes debates to the professional community and which will be further discussed in
this assignment.

Definition of Autism
Autism spectrum disorder is an umbrella term including Autistic Disorder,
Asperger's Syndrome, and Pervasive Developmental Disorder-Not Otherwise
Specified. It is a neuro-developmental disorder (Tager-Flusberg & Josheph, 2003) and
the main criteria for defining autism are based on behavioral characteristics which
onset prior to the third birthday (Chawarska & Volkmar, in Volkmar et al., 2005).
 However, there were theories that blamed parents (Bruno Bettelheim 1960) that
cause autism to their child (Severson et al, 2008) An example of these are the theory
of refrigerator mothers which described by Bettelheim (1956-1967). According to this
theory children develop autism because of maladaptive response to a threatening and
unloving environment.
Although, Autism Spectrum Disorders are characterized by extreme heterogeneity
in symptom expression (DSM-IV), impairments of social interaction, impairments in
social communication and impairments in imagination, known as the Triad of
Impairments (Wing, 1992). Nevertheless, a diagnosis of autism according to the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American
Psychiatric Association, 1994) and the International Classification of Diseases (World
Health Organisation, 1992) requires that the Triad of Impairments have been observed
prior to age 3.

Causal Model- a better explanation of Autism

But in order to understand what autism is, we should consider the causative
model of Morton's and Frith (1995) explanation about the spectrum. The causal model
provides a tool for thinking about neurodevelopmental disorders (Morton’s & Frith,
1995). This model can combine multiple theories of autism and to model possible
similarities and differences between the causes and consequences of different
disorders. The causative model framework has four constituent levels: the biological,
cognitive, behavioral and the environmental. Those levels interact with each other and
they give the clinical form of autism.
 Particularly, we should start from the biological level as it is generally accepted
that autism has a biological origin (Schopler & Melisov, 1987).The biological level is
the first link of the chain (Morton & Frith, 1995). There is evidence that autism is
associated with specific structural brain abnormalities for example in the cerebellum
(Townsend et al, 2001). Thus, in this level membrane proteins, receptors, and neurons
may all play a role.
The second level, the cognitive and considered as fundamental as it acts as a
mediator between biological and behavioral features (Morton & Frith, 1995). Firstly,
it is known that children with autism do not have the ability of mentalizing – our
ability to predict and explain the behavior of other humans in terms of their mental
states. The ability of mentalizing or the Theory of Mind (ToM) in children with
autism is usually missing (Baron-Cohen, 1995; Happe, 1995; Baron- Cohen, Leslie,
Frith, 1985). The dysfunction of ToM influences the social convention learning and
function of the language skills (Mundy & Markus, 1997). Yet, dysfunction of ToM
has resulted lack of imagination (Baron-Cohen et al, 1985). Another theory of ASD, is
the theory of Weak Central Coherence. Central Coherence refers to the normal
tendency to process incoming information globally and in context, thus aiding human
beings to make sense and see structure and meaning. People with ASD have a
tendency to focus on local rather than global information (Happé, 1996). This
dysfunction affects reading and communication skills of people with autism. Another
theory of autism is the Executive Dysfunction (ED). As Hill (2004) describes
“executive function is an umbrella term for functions such as planning, working
memory, impulse control, inhibition and mental flexibility, as well as for the initiation
and monitoring of action”. Lack of flexibility and the rigidity exhibited by people
with autism, their difficulties in planning and their problems with starting and
finishing actions (Turner, 1999) are some of the consequences of ED’s dysfunction.
At the behavioral level, all the dysfunctions from cognitive level are presented as
socially strange behavior, delay in language acquisition, low IQ in some cases,
difficulties in pretend play and so forth (Morton & Frith, 1995). Finally, the
environment may have an influence at any level of the model. These influences may
be protective or destructive and might include intra-uterine environment, parenting
style, diet, or relationships.

Early Identification
In the last ten years, there are many developments in the study of autism
spectrum disorders (ASD). One of the major developments is the recognition that
children can benefit from early intervention programs (Cannella, O'Reilly,& Lancioni,
2006; Ellis et al, 2006; Green et al., 2006; Matson & Minshawi, 2006a; Symes et al
2006) and the ascertainment that early detection of autism may lead to better
interventions (Ingersoll,2011). In the same vein, National Research Council (2001)
highlighted the efficacy of early intervention, many researchers engaged with the
issue of the early identification. .
The advantages of early identification of autism with ASD are twofold (Dereu et al,
2010). From a research view early identification of children at risk for a diagnosis of
ASD makes it possible to perform prospective studies into the developmental
pathways of children with ASD (Reznick et al 2007). On the other hand, an early
diagnosis can lead to early intervention which may improve the developmental
outcomes in children with ASD (Eldevik et al, 2009). If early intervention cannot
begin in preschool years this may result in missed opportunities for optimal brain
development (Branson et al, 2008).
Although, early identification prior the age of two is difficult, in recent years
research has emphasized the identification of early warning signs of ASD. But firstly,
it is increasingly difficult to recognize the symptoms of autism in very early
childhood. As it is described foregoing, autism is a neurodevelopmental disorder and
characterized by symptoms which have to present prior to the age of three
(Chawarska and Volkmar, 2005).
The preschool years are characterized by rapid development where children begin
walking and manipulate objects with greater ability. The language and functional
understanding has enormous increase and the behavioral interactions are more clearly
expressed (Charman & Stone, 2006). In the age of 2 to 4 years, most children with
autism can be now identified as having deficits in their social interaction and
communication though many parents have noticed some differences even in the first
year of a baby's life (Luyster et al.,2005). So, parents who are concerned about their
child's development so early, they usually look for professional advice and
identification (Siegel, Pliner, Eschler& Elliot, 1988).
However, in early stage the identification is difficult as most of diagnostic
instruments have been designed for children of 24 months and up. To date researchers
have identified a number of early behavioral warning signs for ASD , the “red flags”
which can be used as early symptoms for screening and early intervention of ASD
(Wetherby & Woods, 2002 in Myles et al, 2007:300). Red flags are alert signs to
parents and professionals in order to draw attention for a problem and to seek for help
(Myles, Cooper et al, 2007). As red –flags of autism could be some delays in social
behaviors such as social smiling, lack of warm expression to others with gaze, not
responding to name (Baranek, 1999; Werner & Dawson, 2005), communication
behaviors such as producing vocalizations (Maestro et al 2002; Wetherby et al, 2004)
facial expression, gestures and sounds (Colgan et al, 2006; Landa et al, 2007) and
combination of verbal and no verbal behaviors such as combination of eye contact
with vocalizations, repetitive movements of the body and absence of showing interest,
sharing interest or enjoyment (Wetherby et al 2004; Yoder et al, 2009). However, it is
not clear that we have a full and accurate picture of the behavioral manifestations of
autism in the first year of life (Zwaigenbaum et al, 2005).
Although, having considered the red flags of autism, it is also reasonable to look at
some other circumstances, the medical factors, that can play a major role to early
identification prior the age of two. In a research of Zwaigenbauma, Brysonb et al,
(2005) high-risk infants who had siblings with autism, were detected with
neurodevelopmental abnormalities which can be identified from the first year of age.
These children were diagnosed later with autism. These abnormalities include atypical
patterns of visual attention, and early delays in imitation and language skills
(Zwaigenbaum et al, 2005). Previous studies have also reported that siblings of
children with autism are at risk of having autism in the percentage of 1 in 20 of
siblings. Hence, twin studies also indicate that the rate of autism is higher in identical
than in non-identical twins with autism (Mazefsky, et al, 2008).
In addition, statistically, about 1 in 5 to 1 in 6 of preschool children with autism
experience epilepsy or seizures during the first year of their life (Tuchman et al 1997;
Tuchman, 2006). Also, 1 in 4 of individuals with autism has an associated medical
disorder with a known or presumptive cause. Among the best known of these
disorders are the fragile X syndrome and other genetic disorders, Ito's hypomelanosis,
fetal damaged caused by rubella infection, and metabolic disorders (Peeters &
Gillberg, 2004; Jamain. et al., 2003). Thus, other studies have shown that children
with autism have suffered from brain damage in pregnancy or in postnatal period
while other children who have suffered from some infections in pregnancy or in the
first year of their life are at risk to develop autism (Peeters & Gillberg, 2004).
Although, we should be aware that, despite the evidence of the studies it is still
not known how these medical conditions are related to autism (Muhle et al 2004).
However, what is generally believed is that they impair brain dysfunctions which are
indispensable for normal social and communicative development (Peeters & Gillberg,
2004).
It is clear that autism caused by genetic and specific brain problems is associated with
specific medical conditions. These medical conditions are visible or can be detected
from the very early stage of an infant's development.

Challenges of early identification

Autism spectrum disorders is one of the most common types of developmental
disabilities (Newschaffer et al, 2007; Fombonne, 2009) and for this reason the past
decade has seen an increase in research focused on early diagnosis and early
manifestations of autism symptomatology (Cox eta al, 1999; Lord, 1995; Stone et al,
1999). Earlier detection allows children to receive early diagnosis, and consequently,
to get access to early intervention services (Boyd et al, 2010). Although, despite the
fact that children can be identified from the age of 2 (Charman and Baird, 2002;
Chawarska et al, 2007; Zwaigenbaum, 2007) many children do not receive diagnoses
before the school age (Latif and Williams, 2007; Mandell et al., 2002, 2005;
Ouellette-Kuntz et al., 2009; Shattuck et al, 2009), for many reasons, resulting in last
opportunities for specialized early intervention (Coonrod & Stone, in Volkmar et al,
2005 pp 707).
Number of factors does not leave early identification of autism unchallenged (Rogers,
2001; Stone et al, 2004). The increasing focus in early identification of ASD and
developmental delays in children, continues to challenge not only professionals but
also families, early identification services/support services and policy makers. In this
way, in this section challenges in early identification concerning the screening tools of
ASD in toddlers and infants, professionals who involved in early identification,
service delivery system and policy making will be discussed.
Screening tools
Screening for autism in infants and toddlers may promote earlier diagnosis and that
could lead to appropriate intervention programs (Scottish Intercollegiate Guidelines
Network, 2007). Studies have shown that children benefit from intervention programs
that are delivered early in life (Eldevik et al, 2009; Howlin et al, 2009; Reichow and
Wolery, 2009; Rogers and Vismara, 2008) but in order to give diagnosis and the
appropriate intervention programs, the procedure of screening is very important as it
is the first step before the diagnosis (Aylward, 1997).
Screening, "is a public health service in which members of a defined population, who
do not necessarily perceive they are at risk of, or are already affected by a disease or
its complications, are asked a question or offered a test, to identify those individuals
who are more likely to be helped than harmed by further tests or treatment to reduce
the risk of a disease or its complications" (UK National Screening Committee, 2007).
To put in simple words, screening assessment of autism does not provide diagnosis
but it designates if children are in risk to develop ASD. In the same vein, scholars
have developed and validated screening tools for autism with supporting
psychometric evidence (Boyd et al, 2010).
Psychometric characteristics such as sensitivity, specificity, positive predictive
value and negative predictive value are considered when evaluating screening
measures (Stone et al, 2004) with the most frequently considered screening measures
sensitivity and specificity (Wilkinson, 2010). Sensitivity refers to the proportion of
children with developmental problems who are identified as being at risk to develop
ASD while specificity refers to the proportion of children without developmental
problems who are identified as being not at risk (Aylward, 1997). In addition, despite
sensitivity and specificity measures, it is important to know the proportion of children
identified as being at risk-or not by the screening measure that actually have or not the
disorder and this referred as positive and negative predictive values (Riegelman &
Hirsch, 1989). Positive predictive value is the proportion of children identified as
being at risk who have the disability while negative predictive value refers to the
proportion of children identified as not being at risk who do not have the disability
(Aylward, 1997). It is generally believed that standards for adequate levels of
sensitivity and specificity have been published. The proposed sensitivity levels are .80
or higher while the recommended levels of specificity range from .80 to .90. (Glascoe,
1991)
To identify a child at risk for ASD in an early stage, it is suggested that there is a need
to use the appropriate screening tools for infants and toddlers (Filipek, 1999). A
screening tool that developed by Baron-Cohen and colleagues was the Checklist for
Autism in Toddlers (CHAT; Baron -Cohen et al, 1992, 1996) and can be used to
identify 18 months-olds at risk for autism. This test can be used by professionals and
includes yes/no questions that are asked to the parents (Dereu et al, 2010). Later,
CHAT was modified into parent-report questionnaire by Robins et al (2001): the
Modified Checklist for Autism in Toddlers (M-CHAT). However these screening
tools are not recommended for infants younger than 18 month-olds. Recently,
developed another screening test parent responds based, that can be used for 14
month-olds: The Early Screening for Autistic Traits Questionnaire (ESAT; Dietz et al,
2006) and it is parent report based as M-CHAT. Another parent report for early
screening of ASD is the First Year Inventory (FYI; Reznick et al, 2007) and it is
accurate for 12 month-olds.
Although, there are some limitations of these screening instruments regarding the
specificity and sensitivity. For instance, CHAT has very good specificity of 98 but
low sensitivity of 35 while M-CHAT has sensitivity of 97 and specificity of 99
(Robins et al. 2001) but the data were based on limited sample of 1,122 children of
18-30 months from non-selected population (Dereu et al, 2010). On the other hand,
ESAT has very high specificity of 99 but a very low sensitivity of 23 (Groen et al,
2007). In other words, the available screening tools for ASD have low sensitivity
(CHAT and ESAT) and it is necessary a perspective study which can clarify the
validity of these instrument in general population.
But sensitivity and specificity levels are not the only limitation. In addition, previous
studies have shown that many professionals are not familiar with the procedure of
screening or the terms specificity/sensitivity. For instance, in a study about
pediatricians' screening habits, it is founded that 82% regularly screened for general
developmental delay, but only 8% screened for ASD because of time constraints and
lack of familiarity with autism screening instruments (Dosreis et al, 2006). Regarding
to the knowledge of the terms sensitivity/specificity, a recent study indicates that
some professionals do not understand how test psychometrics can be affected by the
prevalence rates of a disorder (Clark & Harrington, 1999). Knowledge of sensitivity,
specificity and so on, is very important as there are different prevalence rates of the
disorder depending on the sample being screened (population based or clinic based).
So, it is very important professionals who use screening tools to be familiar with these
terms not only the general meaning of them but how these values are affected by the
specific setting in which the screening tool is used.
Another challenge is the way in which information is gathered. There are many
practices through which Screening information can be picked up. These are parental
report, observations of the child, or direct interactions with the child. Each method has
its advantages and disadvantages. Among the merits of parental reports are the ease
and speed of administration, while disadvantages are the potential sources of reporter
bias (Glascoe, 2000; Stone, Hoffman, Lewis, & Ousley, 1994). For example, some
parents may fail to recognize abnormal behaviors, while others may view
developmentally appropriate behaviors as pathological. Consequently, it is possible to
give inaccurate information which will lead to misdiagnosis.

Early intervention services and professionals

Other studies in the past have reported that parents of children with autism and
generally developmental disorders, suffer from high levels of stress in comparison
with parents of children with normal development (Hodapp et al., 2003; Johnson et
al., 2003). Parental stress is linked with the type of disability eminent in the child
(Gupta, 2007). A number of authors have reported higher levels of stress in mothers
of children with autism compared with mothers of children with other developmental
disabilities, e.g. Down syndrome, fragile X syndrome, severe intellectual disability
(Abbeduto et al., 2004; Weiss, 2002; White & Hastings, 2004), parents of children
with health care needs with normal development (Schieve et al., 2007) or typically
developing children (Baker- Ericzén et al., 2005; Smith et al., 2001; Yamada et al.,
2007). Tomanik, et al (2004) found that 70% of mothers of children with autism in
their study showed high stress levels. Another revealing fact is that parents
themselves often use the word “stressful” when talking about raising a child with
autism (e.g. Gray, 2002a). Hence, it has been identified that early diagnosis of the
disorder can significantly decrease familial stress (Renty & Roeyers, 2006).
But despite the benefits of the early intervention, however, most parents do not take
official diagnosis before the school age (Blumberg et al, 2013) and this can be led in
missed opportunities for early intervention (Branson et al, 2008). For these reasons,
critical issues about delivery of early intervention services (Boyd et al, 2010) and
professionals who involved in early identification (Wilkinson, 2010; Yirmiya &
Ozonoff, 2007) remain.
Autism is a behaviorally based diagnosis, and there is often a lack of familiarity with
its early behavioral manifestations among front-line professionals (Stone et al,2004:
692). As ASD considered by researchers as a neurodevelopmental disorder with
genetic risk (Dawson, 2008) and they focused on early warning signs of the disorder
(Johnson & Myers, 2007; Osterling & Dawson, 1994) practitioners and services
should be aware of that and should be recognize the early warning signs of the
disorder (Boyd et al, 2010). In the past, because of the lack of validated screening
tools, many professionals have had an attitude of waiting in order to give diagnosis.
The inexperience of a professional, who provides diagnosis of autism, is another
challenging factor as can sometimes lead to misdiagnosis (Prizant, 2012, Bogdashina,
2006). Some professionals in order to make the diagnosis they use the "surface
behaviors" (ICD-10 and DSM-IV) and ignore the underlying causes of the spectrum.
That makes the enumeration of all possible appearances of the condition impossible.
This can lead to misdiagnosis if the diagnostician "follows the prescribed textbook to
the letter" (Bogdashina, 2006:97). Therefore, it is crucial for the clinician to be
qualified and experienced. Clearly, the ASD-related experience is very important
especially when there is need for deferential diagnosis from other disabilities which
effect the social communication, the development of the language and the behavior
(Prizant, 2012).
Moreover, in many communities, diagnostic evaluations are provided in specialized
multidisciplinary centers, which often have long waiting lists (Boyd et al, 2010).
Both situations can present obstacles to early diagnosis and can delay enrollment in
early intervention. Thus this situation increases the parental stress of families with
children with ASD.
Related to services that provide early identification of ASD, there is another factor
that may affect the early detection of autism; the factor of the area that you live, that
is, to get diagnosis depends on the area where you live (Bogdashina, 2006:102). In
other words, whether this area has had services providing early identification and
intervention programs or not. In a research about the factors affecting the age at
diagnosis of ASD, which took place in Nova Scotia, Canada in 2011, stated that
children who live in rural areas may get diagnosis later than the children who live in
bigger cities (Frenette et al, 2011). Another report which support the previous
research, show rural areas and generally, geographically restricted areas have few or
no support services for children with disabilities or learning difficulties and usually
the nearest support services are inaccessible (Bachrach, 1983; Henderson et al, 1991).
These are some factors that can delay diagnosis, and consequently early intervention
which have positive outcomes to children with ASD.
Also, another barrier for early identification is that some social services in the past
have accused parents when they see a child with challenging or strange behavior who
looks physically normal (Ambikile J. & Outwater A., 2012). Due to inexperience and
the lack of knowledge of the professionals, they cannot recognize the early symptoms
of the spectrum and may be easily missed. Instead, social services think that parents
seek for diagnosis of their child to draw attention to themselves (Bogdashina,
2006:188). In this case parents get the diagnosis for themselves instead of their child.
Several cases have been reported when educational staff and other professionals
blame parents for domestic violence and child abuse as social services misread the
"weird" behavior of the children and misdoubt parents of psychological abuse
(Bogdashina, 2006:187-188). However, very few times professionals consider parents
as abused by their children. Sometimes the physical violence is often the result of
panic attacks when the child cannot control his reactions and hits, kicks or bites the
parents.

Policy of early identification and intervention of ASD

The needs of autistic children are targeted to some extent by general health, social and
educational policy. There is little autism-specific policy and this has an impact on the
ability of autistic children and their families to access services. In particular, difficulty
accessing mental health (Department of Health, 2004) and short break (Department
for Education and Skills, 2007) services have been highlighted. Indeed parents have
been confronted with the issue of how best access the service delivery system for
young children with ASD (Boyd et al, 2010). In the same vein, critical issues about
how best to access local and state service delivery system remain for many families
especially those with children with ASD. According to Educational Act part B (2004)
families with children with ASD older than 3 years with ASD, can access a free and
appropriate public education while the provision for toddlers and infants under 3,
service delivery system vary greatly in their type and intensity across the country
(Educational Act, part C, 2004).
The length of early intervention of autism has had major role. But despite the
outcomes of the early intervention especially when its duration is the recommended,
however many early intervention services do not provide the appropriate program. In
a study about the length of early intervention of service provided to infants and
toddlers with developmental delay, reported that children receive less hours than the
recommendation made by the National Academy of Sciences Committee on
Educating Children with Autism (Hebbler et al, 2007) in which stated that children be
engaged in intensive intervention services for 25 hours per week (National Research
Council, 2001).
Another challenge relating to policy of provision of autism is the funding policy
(Boyd et al, 2010; Roberts & Prior, 2006). Indeed, even if there are some benefits for
families with children with ASD, however the amount is not enough to cover the cost
of early intervention services. For instance, in Greece there is a benefit of 500 Euros
every two months for children with ASD official diagnosis and diagnosis of low
intelligence but the cost of early intervention exceeds the 500 Euros per month. It is
clearly that there has been social policy momentum and political will to fund early
intervention services for infants and toddlers with ASD. However several challenges
to the recent initiatives exist. The cost of some early intervention treatments is very
expensive than other services received by infants and toddlers with other
developmental delays. An additional challenge has been the lack of communication
and coordination between funding streams and service providers (Ruble et al, 2005).
For example, early intervention providers which founded by an organization may not
allowed to receive reimbursement for their time to meet or collaborate with educators
in public schools or other professionals. This situation may result disjointed and
potentially ineffective services for children and families.
As previously stated, it is important to ensure that families have access to the
interventions in a responsive service delivery system. Policy relating to ASD should
make early identification and intervention services equally accessible for all families
from different socioeconomic groups and racial and ethnic backgrounds. It is also
fundamental the minimizing of the cost of intervention and generally of ASD services
in order to be cost-effective for families but also for service providers.
Conclusion

Autism is a neurodevelopmental disorder with behavioral based diagnosis (Stone &

Charman, 2006). However, even when today we know so much about the biological
base of autism we still define ASD by its symptoms on a child's behavior. Although
the early identification, it is very important as, after the diagnosis, parents can now
start interventions. The earlier the intervention the better the outcome will be.
Doubtless to say, early intervention is a bright ray of hope for parents as its outcomes
are very positive for their child's development. But the early identification of autism is
not without its challenges. The lack of knowledge of professionals who provide the
diagnosis and their lack of familiarity with the spectrum's early behavioral
manifestations, have a great impact on the quality of the diagnosis. The misdiagnosis
or the over-diagnosis of autism (Kim & Lord, 2012) is not a rare phenomenon and has
negative implications towards to receiving the appropriate early intervention services
but also in research and public health services (Kim & Lord, 2012). Also in many
countries the evaluation of autism is made in multidisciplinary centers which very
often have a long waiting list. So, parents wait for the diagnosis while their child has
lost valuable time for early intervention.
On the other hand there are many problems with the available assessment tools. The
interviewer should be cautious with these tools as it is usually proper not to use only
one questionnaire but they should use mixed methods such as observation, video tapes
of children's reactions at home and parents' responses to interviews. Admittedly, the
environment of the interview and child's observation should be considered as well, as
it can affect the child's behavior.
In order for clinicians to be able to provide accurate diagnosis of ASD the
environmental trajectories should be considered, how ASD can be diagnosed in young
children and the limitation of the environment and the assessment tools. So
professionals should be informed about ASD underlying symptoms and must have a
good understanding of the spectrum.
Hopefully, we will start to research these factors more and we will not only deepen
our understanding of the etiology and the development of the spectrum. Finding
accurate ways to identify early ASD in earliest age is very important as it is an in
dispensability for a child with autism to start early intervention.
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