Thursday, December 9, 2010

Executive Dysfunction and ASD

Research evidence suggests that deficits in executive function are an important feature of ASD. Executive function is a broad term used to describe the higher-order cognitive processes such as response initiation and selection, working memory, planning and strategy formation, cognitive flexibility,  inhibition of response, self-monitoring and self-regulation. It is generally acknowledged that the frontal brain system (including frontal lobes) is responsible for these functions. Executive functions include the many of the skills required to prepare for and execute complex behavior, such as planning, inhibition, organization, self-monitoring, cognitive flexibility, and set-shifting. Markers of executive dysfunction in include difficulty in initiating action, planning ahead, inhibiting inappropriate responses, transitioning, and poor self-monitoring. Poor performance monitoring and self-regulation may be associated with the core features of ASD such as a lack of social reciprocity and intense emotional responses to change (e.g., meltdowns). 
We should note, however, that executive function deficits are not experienced by all individuals on the autism spectrum nor are they specific to ASD. Several childhood disorders such as Attention-Deficit/Hyperactivity Disorder (ADHD) and Obsessive-Compulsive Disorder share deficits in executive function.  Nevertheless, executive dysfunction is likely to have an adverse impact on many areas of everyday life and affect adaptability in several domains (personal, social and communication). An assessment of executive function can add important information about the child’s strengths and weaknesses and assist with intervention planning. For example, the Behavioral Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000), a parent- or teacher-rated questionnaire for children ages 5 to 18 years of age, can be used to assess executive functioning in children with ASD and may be included in a comprehensive assessment battery. 
Further information on assessment and intervention is available from
Gioia, G. A., Isquith, P. K., Guy, S. C, & Kenworthy, L. (2000). Behavior rating inventory of executive function. Lutz, FL: Psychological Assessment Resources.
© Lee A. Wilkinson, PhD

Tuesday, November 23, 2010

Test Review: The Childhood Autism Rating Scale, Second Edition (CARS 2)

The Childhood Autism Rating Scale, second edition (CARS 2), consists of two 15-item rating scales completed by the practitioner and a Parent/Caregiver Questionnaire. The Standard Version Rating Booklet (CARS 2-ST) is equivalent to the original CARS and is used with children younger than 6 years of age and those with communication difficulties or below-average cognitive ability. The High-Functioning Version Rating Booklet (CARS 2-HF) is an alternative for assessing verbally fluent children and youth, 6 years of age and older, with average or above intellectual ability. The Questionnaire for Parents or Caregivers (CARS 2-QPC) is an unscored questionnaire designed to obtain pertinent developmental information from parents or caregivers. 

The CARS 2-ST and CARS 2-HF each include 15 items addressing the following functional areas:
  • Relating to People
  • Imitation (ST); Social-Emotional Understanding (HF)
  • Emotional Response (ST); Emotional Expression and Regulation of Emotions (HF)
  • Body Use
  • Object Use (ST); Object Use in Play (HF)
  • Adaptation to Change (ST); Adaptation to Change/Restricted Interests (HF)
  • Visual Response
  • Listening Response
  • Taste, Smell, and Touch Response and Use
  • Fear or Nervousness (ST); Fear or Anxiety (HF)
  • Verbal Communication
  • Nonverbal Communication
  • Activity Level (ST); Thinking/Cognitive Integration Skills (HF)
  • Level and Consistency of Intellectual Response
  • General Impressions
Items on the Standard form duplicate those on the original CARS, while items on the HF form have been modified to reflect current research on the characteristics of higher functioning children and youth with autism (HFA) or Asperger Syndrome. To complete the ratings on the CARS 2-HF, the professional must have convergent information from MULTIPLE sources such as direct observation, parent and teacher interviews, prior assessments of cognitive functioning and adaptive behavior, and information from the Questionnaire for Parents or Caregivers (CARS 2-QPC). Ratings are based not only on frequency of the behavior in question, but also on its intensity, atypicality, and duration. Rating values for all items are summed to produce a Total Raw Score. Each form includes a graph that allows the practitioner quickly convert the Total Raw Score to a standard score or percentile rank (based on a clinical sample of individuals diagnosed with autism spectrum disorders). 
The psychometric properties of the CARS 2-HF indicate a high degree of internal consistency and good interrater reliability. Validity information reports an overall discrimination index value of .93, with sensitivity and specificity values of .81 and .87, respectively. The HF form also demonstrates a relatively strong relationship with the “gold standard” Autism Diagnostic Observation Schedule (ADOS).
The following are critical features of the CARS 2-HF.
1. Parents and teachers should NOT be asked to complete the CARS 2 forms. Only well-informed professionals should complete the ratings.
2. The CARS 2 should NOT be used for screening in the general school-age population.
3. The practitioner must have a good understanding of the criteria for making the ratings and be in a position to collect information from multiple sources (direct observation, parent and teacher reports, prior assessments and clinical impressions).
4. The ratings from the CARS 2 should be considered as only one part of a multimodal, multidisciplinary decision-making process in the identification of children with ASD.
5. Direct observation and a developmental history MUST always be included in the assessment process.
6. Scores on the CARS 2 are interpreted relative to the level (severity) of autism-related behaviors compared to a clinical sample of individuals diagnosed with autism, NOT the typical individual.
In summary, The CARS 2-HF represents an important alternative that will be welcomed by school-based professionals such as school psychologists and speech/language pathologists. It is a sensitive and reliable instrument that will find a place in the school-based professional’s assessment “Tool Box.” Given the dramatic increase in the numbers of students being referred for screening and assessment, the CARS 2-HF is a useful instrument that helps quantify the level of symptom severity and importantly, assist with intervention and program planning. The CARS 2-HF scores are particularly helpful in identifying more capable children on the autism spectrum. Of course, the CARS 2 is not intended to be and should not be used as the sole instrument in making diagnostic or classification decisions. An example of a comprehensive assessment battery can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools, (2nd Edition).
Schopler, E, Van Bourgondien, M. E., Wellman, G. J., & Love, S. R. (2010). Childhood autism rating scale, second edition. Los Angeles, CA: Western Psychological Services.

A New Approach to Teaching Youth With Autism

Source: Medical News Today
As the number of children diagnosed with autism spectrum disorders continues to increase, the one thing that won’t change is the need for those children to develop social skills. Statistics show that if these students are able to communicate effectively, they can achieve success in the classroom, and later, in the workplace. In addition to the challenges facing each individual student, educators find themselves facing dwindling resources. Now, researchers at the University of Missouri are developing an effective social competence curriculum, with a virtual classroom component, that could help educators meet the demand of this growing population.

Janine Stichter, a professor of special education at the MU College of Education, and her team have developed a curriculum that has shown success in an after-school format and is now being tested during daily school activities, with help from two three-year grants from the Institute of Educational Sciences in the U.S. Department of Education. The key factors in Stichter’s curriculum focus on specific needs and behavioral traits within the autism spectrum. By doing this, the instructor is able to deliver a more individualized instruction within a small group format and optimize the response to intervention.

Sunday, November 21, 2010

Regressive Autism

 The topic of regressive autism has attracted considerable research interest in last 15 years, in part due to the interest in the link to vaccines. Other terms used to describe regression in children with autism are autism with regression, autistic regression, late-onset autism, and acquired autistic syndrome. Studies suggest that nearly 25 % of children with autism have experienced some level of developmental regression. Unfortunately, there is no standard definition for regression, and the prevalence of regression varies depending on the definition used.

In general, regressive autism is evident when a child appears to develop typically but then begins to lose language and/or social skills, typically between the ages of 15 and 30 months, and is subsequently diagnosed with autism. Some children lose social development rather than language, while some lose both. Therefore, language might be preserved but social interaction significantly impaired. Skill loss may be quite rapid or slow and preceded by an extended period of minimal skill progression. The loss may be accompanied by markedly reduced social play and interaction, repetitive behaviors, or increased irritability. Following the onset of regression, the child follows the standard pattern of autistic neurological development.

There is some research to suggest that regressive autism is early-onset autism that was recognized at a later date and that if there is a regressive phenotype of ASD, it is not characterized by normal or near-normal pre-loss development. In fact, research suggests that many children identified with regressive autism had some delay in communication and social skills prior to onset. Likewise, there was is no evidence that the onset of autistic symptoms or regression is related to measles-mumps-rubella vaccination. However, there might be an early vulnerability in the development of the nervous system and that these children weren't developing normally. Although the phenomenon of regressive autism is poorly understood, best practice requires that any child who presents with the “red flags” of autism be screened and if indicated, provided with a comprehensive developmental assessment. A complete guide to screening and assessment for ASD is available from A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools.

© Lee A. Wilkinson, PhD

Saturday, October 30, 2010

Outstanding Autism Resource for the School Professional

A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools
by Lee A. Wilkinson, PhD, NCSP, was recently honored as an Award-Winning Finalist in the Education/Academic category of the "Best Books 2010" Awards sponsored by USA Book News. USA Book is the premiere online magazine and review website for mainstream and independent publishing houses. Over 500 winners and finalists were announced in over 140 categories covering print and audio books. 
Filling a critical void in the autism literature, this authoritative yet accessible book provides school psychologists, educators, support professionals, and parents with a best practice guide to screening, assessment, and intervention for school-age children with autism spectrum disorders (ASD). Grounded in the latest research, special features include illustrative case examples and an index to 50 evidence-based best practice recommendations. This book makes an ideal text for graduate-level training courses in school psychology and is certain to become a widely used resource that will meet the needs of both experienced psychologists and those new to the profession.
                              ISBN: 978-1-84905-811-7
                                List: $24.95; 208 Pages 
                      Order your copy today!     
                    Toll Free: 1-866-416-1078 or online:


Saturday, October 16, 2010

Girls with ASD: Suffering in Silence

Although there has been a dramatic increase in the number of children diagnosed with autism spectrum disorders (ASD) over the past decade, statistics indicate that boys are being referred and identified in far greater numbers than girls (Attwood, 2006; Wagner, 2006).  In fact, referrals for evaluation of boys are approximately ten times higher than for girls (Attwood, 2006). Girls are also diagnosed with autism spectrum disorders at later ages relative to boys (Goin-Kochel, Mackintosh, & Meyers, 2006). This gender “gap” raises serious questions because many female students with ASD are being overlooked and will not receive the appropriate educational supports and services (Wilkinson, 2008).
Why are fewer girls being identified?  Why do parents of girls experience a delay in receiving a diagnosis?  Are there gender differences in the expression of the disorder? Answers to these questions have practical implications in that gender specific variations may have a significant impact on identification practices and the provision of educational services. Although few studies have examined gender differences in the expression of autism spectrum disorders, we do have several tentative explanations for the underdiagnosis and late identification of girls with ASD. They include the following.
  • Social communication and pragmatic deficits may not be readily apparent in girls because of a non-externalizing behavioral profile, passivity, and lack of initiative. Girls who have difficulty making sustained eye contact and appear socially withdrawn may also be perceived as “shy,” “naive,” or “sweet” rather than   having the social impairment associated with an autism spectrum disorder (Wagner, 2006).
  • The diagnosis of another disorder often diverts attention from autism-related symptomatology. In many cases, girls tend to receive unspecified diagnoses such as a learning disability, processing problem, or internalizing disorder. A recent survey of women with Asperger syndrome indicated that most received a diagnosis of anxiety or mood disorder prior being identified with an autism spectrum disorder (Bashe & Kirby, 2005).
  • The perseverative and circumscribed interests of girls with autism spectrum disorders may appear to be age-typical. Girls who are not successful in social relationships and developing friendships might create imaginary friends and elaborate doll play that superficially resembles the neurotypical girl (Attwood, 2006).
  • Although Students with ASD are more likely to be the target of bullying than typical peers, this may not be recognized in girls due to gender differences in preferred modes of aggression. For example, girls may use covert verbal, social, and psychological forms of aggression while boys tend to rely on confrontational and direct modes of bullying (Besag, 2006). As a result, the more subtle nature of relational and indirect aggression (social exclusion and rejection) used by girls may be taken less seriously than the more obvious, direct aggression exhibited by boys.
  • Although girls may appear less symptomatic than boys, the genders do share similar profiles. Research suggests that when IQ is controlled, the main gender difference is a higher frequency of idiosyncratic and unusual visual interests and lower levels of appropriate play in males compared to females (Lord, Schopler, & Nevicki, 1982). As a result, the behavior and educational needs of boys are much more difficult to ignore and are frequently seen by teachers and parents as being more urgent, further contributing to a referral bias (Wilkinson, 2010).
  •  Over reliance on the male model with regard to diagnostic criteria might contribute to a gender “bias” and underdiagnosis of girls (Kopp & Gillberg, 1992; Nyden et al., 2000). Clinical instruments also tend to exclude symptoms and behaviors that may be more typical of females with ASD.
If girls do process language and social information differently than boys, then clinical and educational interventions based largely on research with boys may be inappropriate Wilkinson, 2008). If gender specific variations do exist, then the predictive validity of the diagnosis and developmental course may well differ between the sexes. Meanwhile, educators and school personnel should question the presence of an ASD in girls referred for internalizing disorders such as anxiety or depression. Best practice recommends that when a girl presents with a combination of social immaturity, restricted interests, limited eye gaze, repetitive behaviors, social isolation, and is viewed as “unusual” or “odd” by parents, teachers and peers, the possibility of an ASD should be given consideration (Wagner, 2006; Wilkinson, 2010).
Reference List is available and supplied upon request - 

Lee A. Wilkinson, PhD is the author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers.

©Lee A. Wilkinson

Friday, October 15, 2010

Best Practice Research: Hyperbaric Oxygen Therapy (HBOT) for Autism

Parents of children with autism spectrum disorder (ASD) often use complementary and alternative medicine (CAM) treatments with their children as an alternative, or in addition to, conventional treatments. CAM treatments are controversial and, for most, their efficacy has not been scientifically established. Hyperbaric oxygen therapy (HBOT), a scientifically supported treatment for decompression sickness, is being increasingly recommended as a treatment for autism. Although anecdotal evidence may exist, there is a need for rigorous controlled scientific research to evaluate the treatment effects of HBOT on the core symptoms of ASD.
The journal Research in Autism Spectrum Disorders reports the results of a randomized double-blind placebo-controlled trial study comparing HBOT to placebo in children with autistic disorder who received 80 sessions of treatment over a 15-week period. Multiple standardized instruments and direct behavioral observations were used to evaluate treatment effects on ASD symptoms. The results indicated no significant differences between HBOT and placebo groups across any of the outcome measures (social reciprocity, communication, and repetitive behaviors). The study concludes that HBOT does not result in a clinically significant improvement of the symptoms of autism and that it is not recommended for the treatment of ASD symptoms.

The Food and Drug Administration (FDA) recently announced that hyperbaric oxygen treatment is not an approved or effective treatment or cure for autism. Companies and websites claiming hyperbaric oxygen can treat or cure autism are misleading the public, according to the FDA. "Patients may incorrectly believe that these devices have been proven safe and effective for uses not cleared by FDA, which may cause them to delay or forgo proven medical therapies," says Nayan Patel, a biomedical engineer in FDA's Anesthesiology Devices Branch. "In doing so, they may experience a lack of improvement and/or worsening of their existing condition(s)."

Granpeesheh, D., Tarbox, J., Dixon, D. R., Wilke, A. E., Allen, M. S., & Bradstreet, J. J. (2010). Randomized trial of hyperbaric oxygen therapy for children with autism. Research in Autism Spectrum Disorders, 4, 268-275.
Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers.

Friday, October 1, 2010

Gluten-Free/Casein-Free Diets for Autism

The gluten-free, casein-free diet (GF/CF diet) continues to be a popular and widely used treatment by parents of children with. The premise is that avoiding gluten and/or casein (proteins found in wheat, barley, rye and dairy) might directly affect brain function and produce improvements in the cognitive and behavioral symptoms associated with ASD. Surveys suggest that nearly a third of parents of children with mild autism have used an alternative diet in the treatment of their children. The use of alternative diets in the treatment of ASD has also been encouraged by anecdotal reports of effectiveness from parents, celebrities, and the popular media. Given that autism has no know cure, parents and advocates will understandably pursue interventions/treatments that offer the possibility to improving symptoms, especially if the treatment appears to do no harm and is generally accepted. However, there continues to be controversy and debate as to effectiveness and risks of diets as a treatment for ASD (Wilkinson, 2010).

A study appearing in the peer-reviewed journal, Research in Autism Spectrum Disorders, examined 14 articles related to research on the effects of gluten-free and/or casein-free (GFCF) diets in the treatment of ASD. Each study was analyzed and summarized in terms of (a) participants, (b) methodological quality (c) specifics of the intervention, (d) dependent variables, (e) outcome, and (e) conclusive evidence. Based on their review, the researchers determined that the published studies do not support the use of GFCF diets in the treatment of ASD (Mulloy, Lang, O’Reilly, Sigafoos, Lancioni, & Rispoli, 2010). They recommend, “Until conclusive evidence is found in support of GFCF diets, restrictive diets should only be implemented in the event a food allergy or intolerance is detected” (p. 335) and “Adverse consequences potentially associated with GFCF diets (e.g., stigmatization, diversion of treatment resources, reduced bone cortical thickness) further the argument against the diet’s therapeutic use.” (p. 337). They also suggest that if future research supports the use of GFCF diets (beyond avoiding allergens), then controlled trials might be initiated to determine whether a GFCF diet has any further benefit for individuals with ASD (Mulloy et al., 2010).

Mulloy, A., Lang, R., O’Reilly, M., Sigafoos, J., Lancioni, G., & Rispoli, M. (2010). Gluten-free and casein-free diets in the treatment of autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 4, 328-339.

Wilkinson, L. A. (2010). A best Practice Guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.

Thursday, September 23, 2010

Sensory Integration Therapy

Unusual sensory responses are relatively common in children with ASD and often one of the earliest indicators of autism in childhood. Although considered a “nontriadic” feature, when present, sensory issues may interfere with performance in many developmental and functional domains across home and school contexts. Best practice guidelines indicate that when needed, educational programs for children with ASD should integrate an appropriately structured physical and sensory milieu in order to accommodate any unique sensory processing challenges.

Sensory integration (SI) therapy is often used individually or as a component of a broader program of occupational therapy for children with ASD. While sensory activities may be helpful as part of an overall educational program, we have no reliable and convincing empirical evidence that sensory-based treatments have specific effects. It should be noted, however, that a lack of empirical data does not infer that the intervention or treatment is ineffective, but rather that efficacy has not been objectively demonstrated or validated. Interventions to address sensory related problems, when utilized, should be integrated at various levels into the student’s individualized educational program (IEP). Comprehensive educational programming may also include consultation with knowledgeable professionals (e.g. occupational therapists, speech/language therapists, physical therapists, adaptive physical educators) to provide guidance about potential interventions for children whose sensory processing or motoric difficulties interfere with educational performance.
All interventions and treatments should be based on sound theoretical constructs, robust methodologies, and empirical studies of effectiveness. Different approaches to intervention have been found to be effective for children with autism, and no comparative research has been conducted that demonstrates one approach is superior to another. The selection of specific interventions should be based on goals developed from a comprehensive assessment of each child’s unique needs and family preferences. A more detailed discussion of assessment domains (e.g. communication, social, sensory, academic) can be found in “A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools.

©Lee A. Wilkinson

Tuesday, August 31, 2010

Evidence-Based Screening for Autism Spectrum Disorders

Epidemiological studies indicate a progressively rising prevalence trend for ASD over the past decade. Yet, compared with general population estimates, children with mild to moderate autistic traits remain an underidentified and underserved population in our schools. There are likely a substantial number of children with equivalent profiles to those with a clinical diagnosis of ASD who are not receiving services. Research indicates that outcomes for children on the autism spectrum can be significantly enhanced with the delivery of intensive intervention services. However, intervention services can only be implemented if students are identified. Screening is the initial step in this process. School professionals and clinicians should be prepared to recognize the presence of risk factors and/or early warning signs of ASD and be familiar with screening tools in order to ensure children with ASD are being identified and provided with the appropriate programs and services.

The following evidence-based tools have demonstrated utility in screening for ASD in educational settings and can be used to determine which children are likely to require further assessment and/or who might benefit from additional support. All measures have sound psychometric properties, are appropriate for school-age children, and time efficient (10 to 20 minutes to complete). Training needs are minimal and require little or no professional instruction to complete. However, interpretation of results requires familiarity with ASD and experience in administering, scoring, and interpreting psychological tests.
  • The Autism Spectrum Rating Scales (Short Form) (ASRS; Goldstein & Naglieri, 2009).
  • The Autism Spectrum Screening Questionnaire (ASSQ; Posserud, Lundervold, & Gillberg, 2006).
  • The Childhood Autism Spectrum Test (CAST; Williams, Allison, Scott, Stott, Baron-Cohen, & Brayne, 2006).
  • The Social Communication Disorders Checklist (SCDC; Skuse, Mandy, & Scourfield, 2005).
  • The Social Communication Questionnaire (SCQ; Rutter, Bailey, & Lord, 2003).
  • The Social Responsive Scale (SRS; Constantino & Gruber, 2005).
Of course, none of these screening measures can differentiate between the autism spectrum subtypes. A screening tool’s efficiency will also be influenced by the practice setting in which it is used. Autism-specific tools are not currently recommended for the universal screening of typical school-age children. Focusing on case finding and children with identified risk-factors and/or developmental delays increases predictive values and results in more efficient screening.

A multi-tier screening algorithm and step-by-step assessment guidelines are available from:

© Lee A. Wilkinson, PhD

Sunday, August 1, 2010

Can School Professionals Diagnose Autism?

Since Congress added autism as a disability category to the Individuals with Disabilities Education Act (IDEA) in 1990, the number of students receiving special education services in this category has increased over 900 percent nationally. It’s critically important that educators understand the provisions for providing legally and educationally appropriate programs and services for students identified with ASD. More children than ever before are being diagnosed with autism spectrum disorders (ASD). The U.S. Centers for Disease Control and Prevention (CDC) now estimates that 1 in 68 eight year-old children has an ASD. This dramatic increase in the prevalence of children with ASD over the past decade, together with the clear benefits of early intervention, have created a need for schools to identify children who may have an autism spectrum condition. Understanding the differences between a medical diagnosis and an educational determination of eligibility for special education services can help both parents and professionals become better advocates.
The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are the two major systems used to diagnose and classify children with ASD. The DSM-5 is considered the primary authority in the fields of psychiatric and psychological (clinical) diagnoses, while IDEA is the authority with regard to eligibility decisions for special education. The DSM was developed by clinicians as a diagnostic and classification system for both childhood and adult psychiatric disorders. The IDEA is not a diagnostic system per se, but rather federal legislation designed to ensure the appropriate education of children with special educational needs in our public schools. Unlike the DSM-5, IDEA specifies categories of ‘‘disabilities’’ to determine eligibility for special educational services. The definitions of these categories (there are 13), including autism, are the most widely used classification system in our schools. According to IDEA regulations, the definition of autism is as follows:
(c)(1)(i) Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The term does not apply if a child’s educational performance is adversely affected primarily because the child has an emotional disturbance, as defined in this section.
(ii) A child who manifests the characteristics of ‘‘autism’’ after age 3 could be diagnosed as having ‘‘autism’’ if the criteria in paragraph (c)(1)(i) of this section are satisfied.
This educational definition is considered sufficiently broad and operationally acceptable to accommodate both the clinical and educational descriptions of autism and related disorders. While the DSM-5 diagnostic criteria are professionally helpful, they are neither legally required nor sufficient for determining educational placement. A medical diagnosis from a doctor or mental health professional alone is not enough to qualify a child for special education services. It is state and federal education codes and regulations (not DSM-5) that drive classification and eligibility decisions. In fact, the National Research Council (2001) recommends that all children identified with ASD, regardless of severity, be made eligible for special educational services under the IDEA category of autism. Thus, school professionals must ensure that children meet the criteria for autism as outlined by IDEA or state education agency (SEA) and may use the DSM-5 to the extent that the diagnostic criteria include the same core behaviors. All professionals, whether clinical or school, should have the appropriate training and background related to the diagnosis and treatment of neurodevelopmental disorders. The identification of autism should be made by a professional team using multiple sources of information, including, but not limited to an interdisciplinary assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, and cognitive functioning to help with intervention planning and determining eligibility for special educational services.
Legal and special education experts recommend the following guidelines to help school districts meet the requirements for providing legally and educationally appropriate programs and services to students who meet special education eligibility for autism.
1. School districts should ensure that the IEP process follows the procedural requirements of IDEA. This includes actively involving parents in the IEP process and adhering to the time frame requirements for assessment and developing and implementing the student’s IEP. Moreover, parents must be notified of their due process rights. It’s important to recognize that parent-professional communication and collaboration are key components for making educational and program decisions.
2. School districts should make certain that comprehensive, individualized evaluations are completed by school professionals who have knowledge, experience, and expertise in ASD. If qualified personnel are not available, school districts should provide the appropriate training or retain the services of a consultant.
3. School districts should develop IEPs based on the child’s unique pattern of strengths and weaknesses. Goals for a child with ASD commonly include the areas of communication, social behavior, adaptive skills, challenging behavior, and academic and functional skills. The IEP must address appropriate instructional and curricular modifications, together with related services such as counseling, occupational therapy, speech/language therapy, physical therapy and transportation needs. Evidence-based instructional strategies should also be adopted to ensure that the IEP is implemented appropriately.
4. School districts should assure that progress monitoring of students with ASD is completed at specified intervals by an interdisciplinary team of professionals who have a knowledge base and experience in autism. This includes collecting evidence-based data to document progress towards achieving IEP goals and to assess program effectiveness.
5. School districts should make every effort to place students in integrated settings to maximize interaction with non-disabled peers. Inclusion with typically developing students is important for a child with ASD as peers provide the best models for language and social skills. However, inclusive education alone is insufficient, evidence-based intervention and training is also necessary to address specific skill deficits. Although the least restrictive environment (LRE) provision of IDEA requires that efforts be made to educate students with special needs in less restrictive settings, IDEA also recognizes that some students may require a more comprehensive program to provide FAPE.
6. School districts should provide on-going training and education in ASD for both parents and professionals. Professionals who are trained in specific methodology and techniques will be most effective in providing the appropriate services and in modifying curriculum based upon the unique needs of the individual child.
References and further reading:
Individuals with Disabilities Education Improvement Act of 2004. Pub. L. No. 108-446, 108th Congress, 2nd Session. (2004).
National Research Council (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism. C. Lord & J. P. McGee (Eds). Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.
Twachtman-Cullen, D., & Twachtman-Bassett, J. (2011). The IEP from A to Z: How to create meaningful and measurable goals and objectives. San Francisco, CA: Jossey-Bass.
Wrightslaw: Special Education Law, 2nd Edition (2007).
Yell, M. L., Katsiyannis, A, Drasgow, E, & Herbst, M. (2003). Developing legally correct and educationally appropriate programs for students with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 18, 182-191.
Zirkel, P. A. (2014). Legal issues under IDEA. In L. A. Wilkinson (Ed.). Autism spectrum disorder in children and adolescents: Evidence-based assessment and intervention in schools (pp 243-257). Washington, DC: American Psychological Association.

Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also the editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools, (2nd edition).

Friday, July 30, 2010

Back to School: Best Practice Recommendations

As our scientific knowledge and thinking about ASD continues to develop, professionals such as school and clinical psychologists, speech/language pathologists, behavior interventionists, social workers, special educators, and occupational therapists will be expected to play an important role in the educational planning of children with ASD by providing support, information, and recommendations to teachers, other school personnel and administrators, and families.

“A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools” features 50 best practice recommendations for screening, assessment, and treatment/intervention. Each provides the guidance needed by school and clinical professionals to make informed and scientifically-based decisions regarding the assessment, identification, and treatment of school-age children with autistic spectrum disorders (ASD). The following “best practice” suggestions are adapted from the text.
  • A standardized screening tool should be administered at any point when concerns about ASD are raised by a parent or teacher or as a result of school observations or questions about developmentally appropriate social, communicative, and play behaviors. 
  • A comprehensive assessment should include evaluation of multiple domains of functioning in order to differentiate ASD from other conditions and provide a complete profile of the child to facilitate intervention planning.
  • A thorough speech-language-communication evaluation should be conducted for all students referred for a comprehensive assessment. Deficits in pragmatic language functioning may not be detected on formal language tests and require nontraditional assessment procedures.
  • No one methodology is effective for all children with autism. Generally, it is best to integrate approaches according to a student’s individual needs and responses.
  • Advocacy should not interfere with being a scientist. School professionals should focus on empirically-based strategies and outcomes and not attempt to prove that one intervention is better than another.
  • Children with any identified ASD, regardless of severity, should be eligible for special educational services under the category of autism spectrum disorders, as opposed to other terminology used by school systems (e.g., other health impaired, developmentally delayed, neurologically impaired).
Adapted from Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.

Copyright 2010 Lee A. Wilkinson. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.

Thursday, July 1, 2010

The School Psychologist

As we know, there has been a dramatic increase in the prevalence of autism spectrum disorders (ASD) over the past decade. Yet, compared to estimates, identification rates have not kept pace in our schools. It is not unusual for children with milder forms of autism (e.g., Asperger syndrome, pervasive developmental disorder-NOS, high-functioning autistic disorder) to go undiagnosed (if at all) until well after entering school. Likewise, despite a marked increase in the percentage of children receiving special educational services under the Individual with Disabilities Education Improvement Act (IDEA, 2004) definition of autism, there are substantial numbers of children who have not been identified, especially more capable students on the spectrum.

Our increased awareness of autism, together with the clear benefits of early intervention, have created an urgent need for school professionals to identify children who may have an autism spectrum condition. As a result, school psychologists are now more likely to be asked to participate in the screening and identification of children with ASD than at any other time in the past. School psychologists are especially well prepared to conduct behavioral screening of students who have risk factors and/or present with warning signs of a spectrum condition. They play a critical role in case finding and by contributing to diagnostic activities, conducting psychoeducational evaluations, and guiding educators and parents to empirically supported interventions. Therefore, it is critically important to remain current with the research and up to date on scientifically supported “best practice” approaches that have direct application to the educational setting. By being knowledgeable about assessment and intervention and treatment approaches, including their strengths and limitations, school psychologists can help to ensure that children with ASD are being identified and provided with the appropriate programs and services.

Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.

Brock, S. E., Jimerson, S. R., & Hansen, R. L. (2006). Identifying, assessing, and treating autism at school. New York: Springer.

National Research Council (2001). Educating Children with Autism. Washington, DC:
National Academy Press.

Sunday, April 11, 2010

A Dimensional Approach to Autism

The pervasive developmental disorders (PDD) have traditionally been viewed as categorical diagnoses. With a categorical or dichotomous scheme, disorders are either present or absent. For example, the DSM-IV-TR and ICD-10 list specific criteria for each disorder that must be met to receive a diagnostic classification. Similarly, the Individuals with Disabilities Education Act (IDEA) specify categories of special education disability. Both are categorical rather than dimensional systems of classification (e.g., a child meets or does not meet criteria) and both focus on a description of behavior rather than function.
       We now question whether autism should be conceptualized as a distinct clinical entity or as a continuum of severity. For example, children with the same diagnostic classification are likely to be heterogeneous and many childhood disorders, including autism, fall along a continuum in the general population. Categorical classification fails to account for these quantitative differences between children with the same core symptoms. In fact, there is a growing consensus among professionals who work with children with PDD that the differences between the higher functioning subtypes are not particularly useful in terms of either intervention or outcome and that autism is more appropriately conceptualized as a spectrum condition rather than an “all-or-nothing” diagnostic entity. We also recognize that traits similar to those observed in PDD are not restricted to children with a clinical diagnosis. This is especially important because even mild degrees of autistic symptomatology can have an adverse effect on a child’s adaptive and school functioning. Thus, while categories are much easier to conceptualize, they tend to be of minimal use in actual practice.
       This dimensional perspective is reflected in the American Psychiatric Association’s recently released draft diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Specifically, the proposal for a new category of “autism spectrum disorder,” which incorporates the current diagnoses of autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). This single “spectrum disorder” better describes our current understanding about the clinical presentation and course of the pervasive developmental disorders (PDDs), and should facilitate more effective identification and treatment going forward.

Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.

Friday, February 12, 2010

Proposed Draft Revisions to DSM Disorders and Criteria

The American Psychiatric Association has released the proposed draft diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
These are initial drafts of the recommendations made to date by the DSM-5 Work Groups. One of the most significant proposed revisions is in the diagnostic category of Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. Specifically, Work Group members propose a new category of “autism spectrum disorder,” which incorporates the current diagnoses of autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). This category reflects members’ conclusion that “a single spectrum disorder” better describes our current understanding about pathology and clinical presentation of the pervasive developmental disorders.

A critically important feature of the proposed criteria for ASD is a change from three (autistic triad) to two domains; “social/communication deficits” and “fixated and repetitive pattern of behaviors.” Several social/communication criteria were merged to clarify diagnostic requirements and reflect research indicating that deficits in communication are “inseparable and more accurately considered as a single set of symptoms...”  Members also note that language deficits are neither universal in ASD, nor should they be considered as a defining feature of the diagnosis. This is consistent with Simon Baron-Cohen’s (2008) notion that the social and communication domains cannot be separated, as “communication is always social.” Likewise, Wilkinson (2010) notes that in actual practice, it is very difficult to identify individuals with significant impairment in social and behavioral domains who do not have some degree of communication deficit. Thus, it is possible that someone who meets the DSM-IV-TR criteria for Asperger’s disorder will also meet the criteria for autistic disorder. The proposed elimination of Asperger’s disorder from the DSM is also consistent with Lorna Wing’s initial contention that this pervasive developmental disorder is part of a spectrum of conditions and that there are no clear boundaries separating it from other autistic disorders (Wing, 2005).

Another significant revision in the criteria involves the requirement that “delays or abnormal functioning in at least one of the three core developmental areas be present by the age of three.” The proposed criteria now state that although an autism spectrum disorder must be present from infancy or early childhood, it may not be identified until later in the child’s development. This is consistent with the Individuals with Disabilities Education Act (IDEA) definition of autism in which a child who manifests the characteristics of ‘‘autism’’ after age 3 could still be diagnosed as having the disorder. This revision is especially important because many capable children with ASD are not diagnosed in early childhood and can be identified for intervention and treatment at later ages.

The proposed criteria for the new category of autism spectrum disorder are as follows:

Autism Spectrum Disorder

Must meet criteria 1, 2, and 3:

1. Clinically significant, persistent deficits in social communication and interactions, as manifest by ALL of the following:

a. Marked deficits in nonverbal and verbal communication used for social interaction:

b. Lack of social reciprocity;

c. Failure to develop and maintain peer relationships appropriate to developmental level

2. Restricted, repetitive patterns of behavior, interests, and activities, as manifested by at least TWO of the following:

a. Stereotyped motor or verbal behaviors, or unusual sensory behaviors

b. Excessive adherence to routines and ritualized patterns of behavior

c. Restricted, fixated interests

3. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

A more detailed summary and discussion of the proposed draft revisions to DSM disorders and criteria are available from A reminder that these are initial drafts of the recommendations of the DSM Work Groups and that comments are invited. The public will be able to submit comments until April 20, 2010. The final approved version of the fifth edition is expected in 2013.

Baron-Cohen, S. (2008). Autism and Asperger syndrome: The facts. New York: Oxford University Press.

Wing, L. (2005). Problems of categorical classification systems. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders: Vol. 1. Diagnosis, development, neurobiology, and behavior (3rd ed., pp. 583–605). New York: John Wiley.

Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.

Tuesday, February 2, 2010

The National Autism Center's National Standards Project

The National Autism Center has completed its National Standards Project on addressing the need for evidence-based practice guidelines for autism spectrum disorders (ASD). The primary goal of the project was to provide critical information about which treatments have been shown to be effective for children, adolescents, and young adults with ASD. This multiyear and comprehensive analysis examines and quantifies the level of research supporting interventions and treatments that target the core deficits of ASD. The findings include the identification of eleven (11) “established’ treatments; twenty-two (22) “emerging” treatments; and five (5) “unestablished” treatments. The report is available from the National Autism Center at their website ( This information is especially important to service providers, educators, caregivers and parents as it identifies evidence-based treatments and provides standards and guidelines on making treatment choices. Interventions or treatments identified as categories of “established” and effective treatments include the following.

• Antecedent Package
• Behavioral Package
• Comprehensive Behavioral Treatment for Young Children
• Joint Attention Intervention
• Modeling
• Naturalistic Teaching Strategies
• Peer Training Package
• Pivotal Response Treatment
• Schedules
• Self-management
• Story-based Intervention package.

Treatment strategies associated with these categories include applied behavior analysis (ABA), positive behavior support, discrete trial training, incidental teaching, peer-mediated interactions, pivotal response teaching, schedules, self-monitoring, and perspective taking activities such as social stories. More detailed descriptions are available from the National Standards Report (2009). The report also suggests that practitioners continue to follow the recommendations for the provision of services provided by the National Research Council (2001). Specifically, educational services provided as soon as the child is identified with an autism spectrum disorder and scientifically validated approaches implemented according to each child’s unique educational and developmental needs.

National Autism Center (2009). National Standards Project-Addressing the need for evidence-based practice guidelines for autism spectrum disorders. Randolph, MA: National Autism Center.

National Research Council (2001). Educating children with autism. Committee on Educational Interventions for Children Autism, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

Friday, January 1, 2010

The IEP: Educating Children with Autism

Education has been shown to be the most effective treatment for children with autism spectrum disorders (ASD). The most recent reauthorization of the Individuals with Disabilities Education Act (IDEA 2004) entitles all students with disabilities to a free appropriate public education (FAPE). In fact, the National Research Council (2001) recommends that all children identified with ASD, regardless of subtype or severity, be made eligible for special educational services under the IDEA category of autism.

The individualized education plan (IEP) is the cornerstone for the education of a child with ASD. It should identify the services a student needs so that he/she may grow and learn during the school year. Parents, teachers and support professionals play a key role in the development, implementation, and evaluation of the child’s IEP. All share the responsibility for monitoring the student’s progress toward meeting specific academic, social, and behavioral goals and objectives in the IEP. Although the type and intensity of services will vary, depending on the student’s age, cognitive and language levels, behavioral needs and family priorities, the IEP should address all areas in which a child needs educational assistance. These include academic and non-academic goals if the services will provide an educational benefit for the student. All areas of projected need, such as social skills, functional skills, and related services (occupational, speech/language, or physical therapy), are incorporated in the IEP, together with the specific setting in which the services will be provided and the professionals who will provide the service.

The content of an IEP must include the following (Individuals with Disabilities Education Improvement Act, 2004):

  • A statement of the child's present level of educational performance (both academic and nonacademic aspects of his or her performance).
  • Specific goals and objectives designed to provide the appropriate educational services. This includes a statement of annual goals that the student may be expected to reasonably meet during the coming academic year, together with a series of measurable, intermediate objectives for each goal.
  • Appropriate objective criteria, evaluation procedures and schedules for determining, at least annually, whether the child is achieving the specific objectives detailed in the IEP.
  • A description of all specific special education and related services, including individualized instruction and related supports and services to be provided (e.g., counseling, occupational, physical, and speech/language therapy; transportation) and the extent to which the child will participate in regular educational programs with typical peers.
  • The initiation date and duration of each of the services to be provided (including extended school year services).
  • If the student is 16 years of age or older, the IEP must include a description of transitional services (coordinated set of activities designed to assist the student in movement from school to post-school activities).
Information and tips on writing and developing measurable IEP goals for learners with ASD are available from the following:

Myles, B. S., Adreon, D. A., Hagen, K., Holverstott, J., Hubbard, A., Smith, S. M., et al. (2005). Life journey through autism: An educator’s guide to Asperger syndrome. Arlington, VA: Organization for Autism Research.

Twachtman-Cullen, D., & Twachtman-Reilly, J. (2003). How Well Does Your Child's IEP Measure Up? Quality Indicators for Effective Service Delivery. London: Jessica Kingsley Publishers.

Twachtman-Cullen, D., & Twachtman-Bassett, J. (2011). The IEP from A to Z: How to create meaningful and measurable goals and objectives. San Francisco, CA: Jossey-Bass. 

National Research Council (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism. C. Lord & J. P. McGee (Eds). Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.

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