Saturday, December 7, 2013

Autism and Savant Syndrome

What are “savant skills?”
There is a long history of reports of individuals who despite having severe intellectual impairments, demonstrate remarkable skills in a particular area. The term “savant” has been variously defined as those individuals who show (a) normatively superior performance in an area and (b) a discrepancy between their performance in that area and their general level of functioning. Some researchers have differentiated “prodigious” savants (e.g., individuals possessing an exceptional ability in relation to both their overall level of functioning and the general population) from “talented” savants (e.g., individuals showing an outstanding skill in comparison with their overall level of functioning). Savant skills have been reported much more frequently in males than in females and have been identified in a wide range of neurological and neurodevelopmental disorders. The most commonly reported savant skills are mathematical skills (calendrical calculations, rapid arithmetic and prime number calculations), music (especially the ability to replay complex sequences after only one exposure), art (complex scenes with accurate perspective either created or replicated following a single brief viewing) and memory for dates, places, routes or facts. Less frequently reported are “pseudo-verbal” skills (hyperlexia or facility with foreign languages), coordination skills and mechanical aptitude.
Although there have been many single case or small group studies of individuals with autism who possess savant abilities or exceptional cognitive skills, there have been few systematic, large-scale investigations in this area. Inconsistencies in definition and wide variation in diagnostic criteria, ages and ability levels of the cases reported are problematic, as is a paucity of valid information on rates of savant skills in ASD. The objective of this research study was to investigate the nature and frequency of savant skills in a large sample of individuals with autism who had been initially diagnosed as children.
The total sample was comprised 137 individuals, first diagnosed with autism as children, who were subsequently involved in an ongoing, longitudinal follow-up study. Cognitive assessments (Wechsler Scales) were completed for all participants (100 males and 37 females) between the ages of 11 and 48 years (mean age of 24). Parental report data on savant skills were obtained approximately 10 years later at a subsequent follow-up.  Cognitive ability ranged from severe intellectual impairment to superior functioning. Savant skills were judged from parental reports and specified as “an outstanding skill/knowledge clearly above participant’s general level of ability and above the population norm.”
Results
Of the 93 individuals for whom parental questionnaire and cognitive data were available, 16 (17.2%) met criteria for a parent-rated skill, 15 (16.8%) had an exceptional cognitive skill and 8 (8.6%) met criteria for both. There were 14 calendrical calculators (one also showed exceptional memory and another also showed skill in computation and music). There were four others with computational skills (in one case combined with memory and in another case with music). Visuospatial skills (e.g., directions or highly accurate drawing) were reported in three individuals. One individual had a musical talent, one an exceptional memory skill and one had skills in both memory and art. The subtest on which participants were most likely to meet the specified criteria for an area of unusual cognitive skill was block design followed by digit span, object assembly and arithmetic.
There was a sex difference (albeit statistically non-significant) in the prevalence of savant skills. Almost one-third (32%) of males showed some form of savant or special cognitive skill compared with 19 percent of females. No individual with a non-verbal IQ below 50 met criteria for a savant skill and contrary to some earlier hypotheses; there was no indication that individuals with higher rates of stereotyped behaviors/interests were more likely to demonstrate savant skills.
Discussion
In total, 39 participants (28.5%) met criteria for a savant skill. Cognitively, 23 individuals (17% of total sample) met criteria for one or more exceptional area of skill on the Wechsler Scales. Combining the two, 37 per cent of the sample showed either savant skills or unusual cognitive skills or both, a far higher proportion than previously reported. These results suggest that the rates of savant skills in autism are significant, particularly among males, and although these estimates are higher than reported by other researchers, the findings parallel those of previous studies. Based on these findings, it appears likely that at least a third of individuals with autism show unusual skills or talents that are both above population norms and above their own overall level of cognitive functioning. However, these data offer no support to claims that savant skills occur most frequently in individuals with autism who are intellectually impaired or that individuals with higher rates of stereotyped behaviors/interests were more likely to demonstrate savant skills.
Apart from the need for further research examining the underlying basis of savant skills and why certain individuals go on to develop any area of exceptional skill and why these skills encompass such different areas, there is a more practical and pressing question; “how can these innate talents be developed to form the basis of truly ‘functional’ skills?” In the present study, only five individuals with exceptional abilities (four related to math and one related to visuospatial ability) had succeeded in using these skills to find permanent employment. For the majority, the isolated skill remained just that, leading neither to employment nor greater social integration. As the authors conclude, “The practical challenge now is to determine how individuals with special skills can be assisted, from childhood onward, to develop their talents in ways that are of direct practical value (in terms of educational and occupational achievements), thereby enhancing their opportunities for social inclusion as adults.”
Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2009). Savant skills in autism: Psychometric approaches and parental reportsPhil. Trans. R. Soc. B, 364, 1359–1367.
doi:10.1098/rstb.2008.0328
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. Dr. Wilkinson is also editor of a best-selling 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).

Saturday, November 30, 2013

Book Review: Chaos to Calm: Discovering Solutions to the Everyday Problems of Living with Autism


The demands placed on parents caring for a child with autism can contribute to a high level of parental distress and adversely affect family functioning. Unfortunately, families are often exposed to unsubstantiated, pseudoscientific theories, and related clinical practices that are ineffective and compete with validated treatments. The time, effort, and financial resources spent on ineffective treatments can create an additional burden on families. As a result, parents and caregivers everywhere are eager for credible, research-based information on the most effective treatments for autism. Chaos to Calm: Discovering Solutions to the Everyday Problems of Living with Autism by Martha Gabler describes an evidence-based method that can be used by parents and caregivers to address the everyday challenges associated with autism and improve the quality of life for their children and families.
The book is a personal account of Martha Gabler’s journey from chaos to calm and how she discovered and implemented an effective teaching method for decreasing the challenging behaviors of her non-verbal son Doug, who was diagnosed with severe autism. Gabler shows parents how to use a method called TAGteach to address many of the common and difficult problems of autism. Briefly, the acronym TAG stands for “Teaching with Acoustical Guidance.” The method utilizes an acoustical signal such as a click or a hand clap to “mark” the behavior that will earn positive reinforcement. TAGteach is based on the principles of applied behavior analysis (ABA) and relies on the use of positive reinforcement, prompting, fading, and shaping to increase desired behaviors. It is a completely positive approach that is relatively easy to learn and implement by parents and other “non-experts.”
Chaos to calm consists of 15 chapters. The first chapter introduces the reader to TAGteach and describes how the method works. At the outset, Gabler takes a reasoned and reasonable approach by commenting that TAGteach is not a substitute or replacement for other behavioral methods, but one that can serve as a powerful adjunct to these and other teaching strategies. She also notes that TAGteach is not a cure for autism, but a method that was uniquely successful at teaching her son functional behaviors that allowed her family to experience a better quality of home life. The subsequent chapters are arranged to describe what Gabler feels are a logical progression of skills to learn. She begins by describing step-by-step how the TAGteach process can be applied to a single, less challenging task (“Quiet Mouth” behavior) and then to more complex and difficult problems such as tantrums and transitions; self stimulatory behaviors; aggression, self-injurious, and destructive behavior; and arguably one of the most challenging and stressful behaviors of children with autism, chronic sleep problems. There are also chapters focusing on “going into the community” and social, life, and play skills. The final chapters provide a summary of the TAGteach approach, answers to some common questions regarding application of the method, and future directions for the use of TAGteach.
Chaos to calm is more than a “how to” book or guide to behavior management. Gabler puts a human face on applied behavioral methods and describes her challenges and experiences with thoughtfulness, compassion, and humor. She also emphasizes the importance of responsibility; following rules and understanding limits; and “learning the rules of society.” As Gabler notes, it’s important to teach the concept of a rule for the child. She also reminds adults to follow a very important rule: only ask your children to do what they are capable of doing.
Chaos to Calm: Discovering Solutions to the Everyday Problems of Living with Autism is highly recommended to parents and caregivers of children across the autism spectrum who will find the book a source of inspiration and encouragement as they begin their own personal journey from chaos to calm. Professionals will also find the book a valuable resource for use with families and teachers who have a pressing need for practical, evidence-based interventions to deal with the daily struggles and challenging behaviors of children with autism.
Gabler, M. (2013). Chaos to calm: Discovering solutions to the everyday problems of living with autism. Waltham, MA: TAGteach International.
Reviewed by Lee A. Wilkinson, PhD
© Lee A. Wilkinson

Saturday, September 28, 2013

Court Upholds ABA Therapy Order in Florida

A federal appeals court has upheld a ruling that lower income children with autism in Florida cannot be denied a costly but effective treatment that can help them lead more functional, productive, and happy lives. The 11th U.S. Circuit Court of Appeal in Atlanta has ruled that U.S. District Judge Joan Lenard of Miami was justified when she ordered the Florida Agency for Health Care Administration (AHCA) to pay for the treatment. Lenard’s ruling could affect thousands of Florida children with autism, allowing them to receive ABA (applied behavior analysis) therapy, an intensive treatment that helps develop and build functional skills.
Applied Behavior Analysis (ABA) is a scientifically validated and established treatment that focuses on the principles and techniques of learning theory to help improve social behavior. ABA therapy helps to (1) develop new skills, (2) shape and refine previously learned skills, and (3) decrease socially significant problem behaviors. ABA techniques have been associated with favorable outcomes for individuals diagnosed with autism and are effective with a wide range of target skills and behaviors (e.g., communication skills, interpersonal (social) and play skills, learning readiness, self-regulation, and problem behaviors).
The lawsuit was filed by Legal Services of Greater Miami on behalf of three children diagnosed with autism who were denied access to ABA therapy by Medicaid, Florida’s insurance program for low-income and disabled people. Medicaid called ABA treatment, “experimental,” and therefore not medically necessary for a child’s treatment. But following a lengthy trial, Lenard found that “there exists in the scientific and medical peer-reviewed literature a plethora of meta-analyses, studies and articles that clearly establish ABA as an effective and significant treatment to prevent disability and to restore children to their best possible functional level and restore their developmental skills” and that the state was discriminating against lower income children by denying access to the therapy. The appeals court, however, did remand the case to Lenard to clarify that AHCA retains the authority to determine the medical necessity for ABA coverage on a case-by-case basis. The appeals court noted that AHCA in its appeal had dropped its claims that ABA was experimental, but was concerned Lenard's order could be misinterpreted to require blanket coverage of ABA. In Florida, like many states, private insurers are required to cover ABA treatment.
“This case will have national impact, because, while most states mandate that private insurance companies must cover ABA, most Medicaid programs do not provide coverage,” said Miriam Harmatz, lead counsel on the case.
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.


Saturday, June 29, 2013

Dog Makes a Difference for Boy with Autism


Months after being abandoned and left for dead, a dog is now making a difference in the life of a young boy with autism.
 Last year, animal rescuers found a maltreated puppy on the side of a road in Georgia. They nursed her back to health and named her “Xena” the Warrior Puppy. Xena’s recovery won fans and her story helped raise thousands of dollars for the care of abused animals.
However, it’s Xena’s relationship with her new owner that’s creating the largest impact. Now healthy, Xena was adopted by Jonny Hickey, who has autism, and his family. Once shy and withdrawn, Jonny’s family says Xena has made a major difference in his life, inspiring him to make a video to promote April’s status as both Autism Awareness Month and Prevention of Cruelty to Animals Month.
“My name is Jonny,” starts the video that aired on WXIA-TV, the Atlanta NBC affiliate, “and this is my puppy, Xena. Well, my Xena was hurt really bad. By some not-so-nice people. And I have autism. So I think we make a pretty perfect team to spread the word to be nice to animals, and nice to kids like me.”

>
Courtesy of DisabilityScoop.com

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. He is also editor of a recent volume 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 new book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT.



Sunday, June 16, 2013

Best Practice Autism Expert Interview

I recently had the privilege of connecting on Linkedin with Dr. Lee Wilkinson, a seasoned expert on the topic of autism spectrum disorders (ASD). Dr. Wilkinson holds credentials as a nationally certified school psychologist, registered psychologist, chartered scientist, and certified cognitive-behavioral therapist. His numerous publications revolve around the topics of behavioral consultation, therapy, and individuals with autism spectrum disorders. After learning about his award-winning text, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, I hoped that he might agree to share his insight and expertise with Preschoology readers. And he graciously did! The information he shares here will be particularly helpful to parents with concerns that their young child displays signs of autism.
Q: If a parent has concerns that their child displays signs of autism, what first steps would you recommend towards finding help?
A: My best practice recommendation is that a child who shows signs (red flags) of autism spectrum disorder (ASD) be immediately referred to a health care provider (pediatrician, family practitioner) for screening. If parents are worried about their child’s development, they should actively voice these concerns to the child’s pediatrician and not feel as if they are an alarmist. It is especially important that a standardized screening tool be administered at any point when parents express concerns or have questions about their child’s social, communicative, and play behaviors. In fact, the American Academy of Pediatrics (AAP) recommends that all children be screened with a standardized broadband screening tool at the 9-, 18-, 24- and 30-month visits, and an ASD-specific screening tool at the 18- and 24-month visits. When a screening indicates a possible delay, the child should be referred to an Early Intervention (EI) program (statewide interagency system providing comprehensive services to infants and toddlers with disabilities) and directly for a comprehensive assessment by an “experienced” multidisciplinary team that includes, but not limited to a developmental pediatrician, pediatric neurologist, speech/language pathologist, child/clinical psychologist, special educator, audiologist, and occupational therapist. Depending on where a parent lives, there might be a university-based autism clinic or research facility that provides diagnostic evaluations and intervention services. For children age three and older, evaluations and special services can be provided through local school districts. Finally, it is especially important that parents seek services from professionals with training and experience in assessing and treating young children with ASD.
Q: How would you advise a parent who has concerns that their very young child displays signs of autism, but who is instructed by specialists to hold off on evaluations and wait until the child is older?
A: The signs and symptoms of autism do not generally appear suddenly, but rather develop gradually during the first three years of life. The earlier the child is identified and intensive intervention can begin, the better the outcomes tend to be for children with ASD. It is important to note that there are no “absolute” clinical indicators of autism in very young children and that there is wide variability in the course and timing of typical development and personalities of infants and children. Although there is some research evidence that the cardinal features of autism can be identified very early in life, the most reliable diagnosis is generally made by trained professionals when a child reaches approximately 2 years of age. Because very young children are difficult to evaluate and diagnostic tests and procedures tend to be less reliable than those with older children, many specialists are hesitant to refer or evaluate a child before age 3 or 4. Although ASD is a complex disorder and often difficult to diagnose in young children, it is my opinion that it is best to err on the side of caution which means screening and providing services for young children who show atypical development which may be characteristics of ASD. I recommend that parents remain clear, positive, and persistent when discussing their concerns with their health care provider or specialist. This includes being proactive and indicating that they want to move forward now (and not wait) with a screening or evaluation. Even if a health care professional or specialist continues to be reluctant, parents can contact their local early intervention (EI) program themselves. The Autism Society of America has local chapters which may also be of help in locating clinicians and services. Finally, I always recommend that parents continue to be vigilant and keep an ongoing record of behavior that appears atypical or concerning. This information can be very useful in any future assessments.
Q: I’ve observed that young children might receive multiple labels before specialists determine a diagnosis of autism. For parents, this can be an emotional roller coaster and very frustrating. How do you explain this phenomenon and help ease parents through the process?
A: It is not unusual for many children to receive multiples labels before being diagnosed with ASD. The delays or atypicality in social development, communication, neurocognition, and behavior will vary in severity of symptoms, age of onset, and association with other childhood disorders. The challenge for practitioners is to determine if the symptoms observed in ASD are part of the same dimension (e.g., the autism spectrum) or whether they represent another developmental disorder. Consequently, it can be difficult to “rule out” other developmental disorders whose symptoms are often observed in ASD. Moreover, differences in professional opinions are particularly evident for young children with atypical developmental concerns. A child might present with a delay in language development and be later diagnosed with a receptive or expressive language disorder but not demonstrate the social impairment characteristic of ASD. A global developmental delay might also be diagnosed. Many children identified with ASD receive an initial diagnosis of attention-deficit hyperactivity disorder (ADHD) or a sensory processing disorder. If a child does not receive a diagnosis of ASD, I recommend that parents ask for an explanation as to why their child does not currently meet the diagnostic criteria. Because ASD is a behaviorally-based diagnosis, I suggest that parents continue to observe and carefully monitor their child’s social and communication development. If a parent continues to have concerns about ASD, they should seek a second opinion or ask for a reevaluation in 6 months or a year.
For more information regarding Dr. Wilkinson’s featured text, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in School, visit: 
Dr. Wilkinson also hosts the website http://bestpracticeautism.com
This wonderful resource features up-to-date information on scientifically validated treatment options for children with ASD and a list of best practice books, articles, and links to relevant organizations.
Interview courtesy of http://Preschoology.com





Wednesday, June 12, 2013

College Students on the Autism Spectrum


The term Autism Spectrum Disorder (ASD) refers to a single diagnostic category that includes two core-defining features: impairments in (a) social communication and (b) restricted and repetitive behaviors or interests (American Psychiatric Association [APA], 2013). There is, however, marked variability in the severity of symptomatology and need for support across individuals with ASD.  Symptom expression falls on a continuum and will vary from the significant impairment to more capable individuals with higher cognitive and linguistic abilities.  For example, the level of intellectual functioning can range from persons with cognitive impairment to those who score in the superior range on traditional IQ tests, from those who are socially intrusive to those who are social isolates, and from those with limited communication skills to those with precocious and advanced vocabulary.
Despite having impaired social interaction skills and unusual, idiosyncratic and sometimes intense interests and a high degree of rigidity, many secondary school students diagnosed with ASD possess the cognitive ability and verbal skills necessary for higher education. Unfortunately, many capable adolescents and young adults either do not seek or gain entry into college, or drop out prematurely due to social isolation, difficulty with changing routines and new schedules, problems living independently, and lack of external supports and guidance. Although young adults on the autistic spectrum may qualify academically for college, they often have difficult managing other aspects of college life. Indeed, the rates of post-secondary educational participation for youth with an ASD are substantially lower than the general population, with previous studies indicating 40% or fewer ever attend college and very few receive a degree (Shattuck, et al., 2012)
The dramatic increase in the prevalence of ASD among children indicates that a correspondingly large number of youth will be transitioning into adulthood in the coming years. In fact, approximately 50,000 adolescents with autism will turn 18 years old this year in the U.S. As a result, colleges and universities can expect to enroll more students who have been diagnosed with ASD in the near future. As more young people are identified with ASD without co-occurring intellectual disability, it is imperative that we begin to study the needs of young adults as they transition into postsecondary employment and education.
A study published in the journal, Autism, examined the prevalence of higher functioning students with ASD at a single university both diagnostically and dimensionally, and surveyed students on the characteristics, problems, and risks associated with ASD. Researchers found that between .7% and 1.9% of a large sample of students (n = 667) could meet criteria for ASD depending on whether ASD is viewed categorically or continuously, and that the true prevalence likely falls somewhere between these two estimates. This suggests that symptoms of ASD are fairly common among college students in this sample and that upwards of 1 in 100 students may meet criteria for an ASD diagnosis. An important finding was that none of the students who met the formal criteria for receiving a diagnosis of ASD had been diagnosed previously. Thus, it is possible that some college students who would meet ASD diagnostic criteria begin their college careers unidentified. This is concerning given the degree to which ASD symptoms were found to correlate with other mental health problems, most notably social anxiety and dissatisfaction with college and life overall. For example, symptoms of ASD were fairly common among students surveyed. From a dimensional perspective, those students scoring above the clinical threshold for symptoms of autism self-reported more problems with social anxiety than a matched comparison group of students with lower autism severity scores. In addition, symptoms of ASD were significantly correlated with symptoms of social anxiety, as well as depression and aggression.
These results have implications for clinical and educational practice, and illustrate the importance of screening for autism-related impairment among university students. In the coming years, colleges and universities may expect to enroll more students who have been diagnosed with ASD, students who meet criteria for the disorder but who not been identified, and students who would fall into the category of the broad autism phenotype. University administrators, educators, and the personnel who serve students with disabilities must be attentive of this group of individuals and identify approaches to make college a successful and rewarding experience. Unfortunately, we know little about how best to facilitate success and ease transitions for these students. The evidence base informing strategies for helping this population is poorly developed. Their needs are diverse and include problems with time management and scheduling, self-advocacy, isolation, interpersonal difficulties, and study skills development. The presence of psychiatric comorbidities (e.g., depression) and academic/ life dissatisfaction must also be included among the list of potential concerns. Although the number of 2-year and 4-year college providing opportunities for young adults with autism has been growing in recent years, there is a need for wider adoption of programs and resources to support young adults with ASD as they transition into and from college. The focus of intervention/treatment must shift from remediating the core deficits in childhood to promoting adaptive behaviors that can facilitate and enhance ultimate functional independence and quality of life in adulthood. This includes new developmental challenges such as independent living, vocational engagement, postsecondary education, and family support. 
Shattuck, P. T., Narendorf, S. C., Cooper, B., Sterzing, P. R., Wagner, M., & Taylor, J. L (2012) Postsecondary education and employment among youth with an autism spectrum disorder. Pediatrics, 129(6), 1042-1049. doi:10.1542/peds.2011-2864
U.S. Centers for Disease Control and Prevention. (2012). Prevalence of autism spectrum disorders. Autism and developmental disabilities monitoring network, 14 sites, United States, 2008. Morbidity and Mortality Weekly Report Surveillance Summaries, 61(3), 1-19. Atlanta, GA: Author.
White, S. W., Ollendick, T. H., & Bray, B. C. (2011). College students on the autism spectrum : Prevalence and associated problems. Autism, 15(6), 683–701 doi: 10.1177/1362361310393363
The online version of this article can be found at http://aut.sagepub.com/content/15/6/683 
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 editor of a best-selling text in the American Psychological Association (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 CBT. Dr. Wilkinson's most recent book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools, (2nd Edition).

Thursday, March 28, 2013

National Autism Awareness Month


April has been designated national Autism Awareness Month and provides a special opportunity for individuals across our country to educate and raise awareness in their neighborhoods, workplaces, schools and local communities. Recent studies indicate that the prevalence rate for autism spectrum disorders (ASD) is 78% higher than just 10 years ago. The pervasive developmental disorder (PDD) category, also commonly referred to as ASD, represents one of the fastest growing disability categories in the world. In the United States, ASD is more prevalent in the pediatric population than cancer, diabetes, spina bifida, and Down syndrome. The U.S. Centers for Disease Control and Prevention (CDC) now estimates that 1 in 88 8-year-old children have an autism spectrum disorder. In fact, prevalence and incidence figures suggest that over 1.5 million Americans are affected by autism.
Research indicates that the outcomes for children with ASD can be significantly improved by early identification and intensive intervention. It is critically important to identify those children who are at-risk in order to reduce the time between symptom appearance and formal diagnosis and treatment. An important goal of Autism Awareness is to alert new parents and others of the early behavioral signs of autism. The signs and symptoms typically appear during the first three years of life and relate to language, social behavior, and behaviors concerning objects and routines. The red flags or key warning signs of autism include:
• Does not smile by the age of six months
• Does not respond to his name
• Does not cry
• Does not babble or use gestures by 12 months
• Does not point to objects by 12 months
• Does not use words by 16 months
• Does not use two-word phrases by 24 months
• Regresses after mastering skills/loses previously mastered skills
• Delays in milestones like crawling and walking.
Children with ASD (but not always) experience delays in speech and communication skills. Not only will they often develop spoken language later, but they are less likely to develop non-verbal communication skills such as pointing, joint attention, or gesturing. 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, play behaviors, or where there is a family history of autism or related disabilities. Because ASDs continue to grow at such a dramatic rate, it is an issue that deserves our attention not only in April, but throughout the year!
The following resources provide important information about early identification and intervention.
American Academy of Pediatrics. Understanding Autism Spectrum Disorders [pamphlet]. Elk Grove Village, IL: American Academy of Pediatrics; 2005. <http://www.pediatrics.org>
Best Practice Autism <http://bestpracticeautism.com>
National Autism Center
National Institute of Child Health and Human Development Autism Site
Organization for Autism Research
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.


Wednesday, February 13, 2013

Mental Health Services and School Psychologists



According to the U.S. Surgeon General, over the course of a year, approximately 20% of children and adolescents in the U.S. experience signs and symptoms of a mental health problem and 5% experience “extreme functional impairment.” Although more than 2 million adolescents aged 12 to 17 suffered a major depressive episode in the past year, nearly 60% of them did not receive treatment. Statistics also suggest that the dropout rate for students with severe emotional and behavioral needs is approximately twice that of other students. 

Most children with mental health problems receive no services and of those who do, 70 to 80% receive them from school-based providers. School psychologists are among the school-based personnel (e.g., guidance counselors, school social workers) who are typically called upon to provide mental health services. In order for school psychologists to be effective mental health service providers, they must be competent to fulfill that role and function. This article discusses education and training issues, and related ethical and professional practice issues associated with school psychologists’ role in providing mental health services in the schools.
 Role and Function of School Psychologists
Surveys consistently indicate that school psychologists spend a majority of their time in assessment activities rather than delivering direct mental health services (e.g., counseling) to students. This includes determining special education eligibility and working with youth within the context of special education. Indeed, the majority of school psychologists report spending less than 10% of their time per week providing evidence-based mental health services to children and adolescents. Despite the limited amount of time devoted to mental health service delivery, school psychologists are increasingly being called on to serve in this role.  Moreover, school psychologists themselves report wanting to spend more time doing activities such as counseling and direct intervention, further supporting the profession’s desire to serve in the mental health service provider role. However, role expansion may prove to be problematic due to training issues and lack of administrative support.
 Training and Preparation
Research suggests that training in the diagnosis and treatment of mental disorders and counseling are determinates of the provision of mental health services by school psychologists. According to National Association of School Psychologists (NASP), the term “child psychologist” refers to doctoral-level clinical psychologists who specialize in children. “School psychologist” specifically refers to professionals who bridge psychology and education to address school related issues, including those that concern children, teachers, parents and families, as well as school organizations. School psychologists' training includes study in education and special education, but compared to clinical psychology, there is less emphasis on psychopathology and counseling. The majority of states require the completion of a 60 graduate semester master’s or specialist-level program in school psychology, including a 1200-hour internship, along with passing a Teacher Certification Test, which has a specialty component for school psychology. In contrast, a doctoral degree (e.g., PhD) generally requires about 5 years of full-time graduate study, culminating in a dissertation based on original research. Doctoral programs in child clinical-school psychology usually include further training and coursework and preparation in child and adolescent psychopathology, behavioral and child therapy, pediatric pharmacology, neuropsychology, advanced research, and a clinical practicum.
Ethical Considerations
Ethical issues are especially important in this discussion. School psychologists must be familiar with the ethical codes that apply to their specialization, as well as to psychology in general. For example, school psychologists must practice within the boundaries of their experience and training. Professional competency standards require school psychologists to recognize the strengths and limitations of their training and experience, and only practice in areas for which they are "qualified." In fact, the issue of practitioner competence is paramount in the ethics codes of the American Psychological Association (APA), American Counseling Association (ACA), and National Association of School Psychologists (NASP). The parameters of competence involve (a) recognizing one's professional limitations and needs, (b) understanding one's professional strengths, (c) confining consultation practice to one's competence, (d) knowing when to decline work and when to refer to other professionals, (e) ensuring that recommended interventions have an empirical basis, and (f) maintaining a high level of professionalism. Practitioners should seek continuing education and training in areas in which they lack competence and experience and refer to colleagues with the requisite experience and/or community resources.
 Implications
While the domains of professional school psychology practice include competencies in "prevention, wellness promotion, and crisis intervention," most school-based practitioners have not received intensive training in child and adolescent psychopathology, counseling and therapeutic intervention. Nor are most school psychologists licensed in another mental health specialty. Consequently, it is especially important for administrators, teachers, and parents to understand the limitations and parameters of school psychology practice and not assume that school psychologists possesses the clinical training to assess and intervene with complex childhood disorders. Schools often do not draw a distinction made between the specialist and the doctoral level school psychologist. Distinctions may not be critical when school psychologists are performing psychoeducational assessment services, as both sub-doctoral and doctoral level school psychologists receive comparable preparation for these important services. However, the academic and professional preparation of doctoral level school psychologists typically emphasizes clinical issues important to children's mental health, including methods for working with children and youth, their parents and teachers. In fact, research suggests that school psychologists with a specialist degree provide fewer mental health services than individuals with doctorates.
Recommendations
The educational setting is the most likely setting for students to receive mental health services. Unfortunately, a majority of children and youth who are in need of mental health services do not actually receive them.  If psychological services are to be expanded in schools to include a major focus on mental health services, school psychologists must be trained as broadly as possible, so that they are capable of working in different settings and prepared to address a range of issues.  In this regard, changes must be made in the graduate-level curriculum of school psychology programs. For example, graduate training programs should provide additional preparation in evidence based mental health services, including individual and group counseling, to ensure school psychologists have the tools they need to help students be successful. Training programs also need to provide practice experiences in the application of evidence-based therapeutic interventions, with a practicum supervised by school psychologists who are competent in the application of these services. A viable service model may call for subdoctoral school psychologists to assume leadership for continuing to provide psychoeducational assessment services for special education and for doctoral level school psychologists to assume leadership for initiatives aimed at promoting children's mental health. While students in nondoctoral programs may receive a basic introduction to mental health services, they will likely need to pursue further postgraduate training and continuing education/professional development in mental health services. Simply stated, school psychologists cannot be expected to provide mental health services without adequate, appropriate training.
Perfect, M. M., & Morris, R. J. (2011). Delivering school-based mental health services by school psychologists: Education, training, and ethical issues. Psychology in the Schools, 48, 1049–1063. doi: 10.1002/pits.20612

Lee A. Wilkinson, PhD, NCSP,CCBT is a nationally certified school psychologist, licensed school psychologist and certified cognitive-behavioral therapist. He is also a university educator and serves on the school psychology faculty at Nova Southeastern University. His research and professional writing has focused primarily on behavioral consultation and therapy, and children and adults with autism spectrum disorders. He has published widely on these topics, both in the US and internationally. Dr. Wilkinson 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. He is also the editor of a best-selling 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).

Sunday, February 10, 2013

Early Detection Critical for Autism



It is well established that early intervention is a critical determinant in the course and outcome of autism spectrum disorders (ASD). Nevertheless, it is estimated that the US is facing $90 billion annually in costs related to autism. Research suggests that costs can be reduced by 2/3 with early diagnosis and treatment/intervention. The signs and symptoms of autism do not generally appear suddenly, but rather develop gradually during the first three years of life. The earlier the child is identified and intensive intervention can begin, the better the outcomes tend to be for children with ASD. In fact, numerous studies have described the benefits of early identification and intervention for children with developmental disabilities and, particularly, for children on the autistic spectrum. There is strong empirical support for the use of intensive behavioral programs for young children with ASD. In addition to increasing cognitive, linguistic, social, and self-help skills, early intervention helps to minimize the potential for secondary behavioral and emotional problems (e.g., anxiety, depression). Because most children with ASD are educated in public school settings, early identification and intervention also help to insure the implementation of appropriate and effective teaching methods to address the core social-communication deficits of ASD. While the components of intervention programs might vary, it is generally agreed that program intensity combined with early identification can lead to substantial improvement in child functioning.
At present, early intensive behavioral intervention (EIBI) is considered the central feature of intervention programming for children with autism. EIBI programs are among the most and best researched of the psychoeducational interventions. Several research publications and meta-analysis indicate that early intensive behavioral intervention (EIBI) may improve the quality of life and level of functioning for children with autism spectrum disorders (ASD). EIBI programs are based on applied behavior analysis (ABA), a behavioral approach that is well supported in the research literature.  Although there is general professional agreement that EIBI is an effective treatment, on average, for children with autism, we should be mindful that it does not produce significant changes in all areas of children’s functioning or result in similar gains for all children. Moreover, EIBI may not be appropriate for all children. Because no two children are alike, no one program exists that will meet the needs of every child with autism. 
There are no interventions or treatments that can cure autism, and there are very few which have been scientifically shown to produce significant, long-term benefits. At the present time, the most effective treatment is a comprehensive and intensive program consisting of educational interventions, developmental therapies, and behavior management with a focus on reducing symptom severity and improving the development course of the child. Unfortunately, intervention research cannot predict, at the present time, which particular intervention approach works best with which children. No single approach, intervention strategy, or treatment is effective for all children with ASD, and not all children will receive the same level of benefit. Generally, it is best to integrate scientifically validated approaches according to a child’s unique needs and abilities.
Despite the increased awareness and prevalence of ASD and the benefits of early intervention, studies continue to indicate a delay in identification and acquisition of services. Because many children are not identified until well after five years of age, future efforts should place an emphasis on recognition and diagnosis among school-aged children, not just among young children. Accurate differential identification and provision for services are critical since a high proportion of children may be overlooked, misdiagnosed with another psychiatric condition, or present with comorbid psychiatric disorders such as depression and anxiety.
The following resources provide important information about early identification and intervention. 
American Academy of Pediatrics. Understanding Autism Spectrum Disorders [pamphlet]. Elk Grove Village, IL: American Academy of Pediatrics; 2005. http://www.pediatrics.org
Autism Society of America  http://www.autism-society.org
Best Practice Autism  http://bestpracticeautism.com
National Autism Center  http://www.nationalautismcenter.org/
National Institute of Child Health and Human Development Autism Site
National Professional Development Center on Autism Spectrum Disorders
Organization for Autism Research
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.














Saturday, January 26, 2013

Top 10 Parenting Books on Autism




Many authors of parenting books on autism often comment that they wrote their book because of difficulty in finding a practical, informative book on the topic of raising a child with autism spectrum disorder (ASD).  However, over the past few years many autism parenting books have been published and parents of a newly diagnosed child with autism can find some very good offerings. The Special Needs Book Review has listed their TOP TEN Books for parents raising a child with autism. Please note that Special Needs Book Review is not paid for reviewing books. The reviews and TOP TEN Books on autism are entirely their opinions. The ten books are in random order. Readers can follow the link in each paragraph to the complete review of each book. Many of the authors have participated in the Special Needs Book Review Author Interview Series and you will find a link to the interviews with the review of their book. 
TOP TEN Parenting Books on Autism 
1. Different . . . Not Less: Inspiring Stories of Achievement and Successful Employment from Adults with Autism, Asperger’s, and ADHD -by Temple Grandin, PhD. ~  Dr Temple Grandin found the perfect words, Different…Not Less, to describe herself and the fourteen contributors of her new book who all have autism or Asperger’s. In the foreword, Dr Tony Attwood writes, “This is an inspiring book.” Each contributor has a chapter and their story is told in their own words. Dr. Grandin chose individuals from a wide variety of skill sets, from different countries, ranging in age from their 30’s to 60’s but the topics addressed are similar: early years, school years, parental support, bullying, college, family relationships, employment, diagnosis, mentors, etc.  Review
2. 1001 Great Ideas for Teaching & Raising Children with Autism or Asperger’s: Expanded 2nd Edition -by Ellen Notbohm and Veronica Zysk  ~  Looking for advice, support and encouragement in your overwhelming journey raising a child with autism or Asperger’s? This is the book you need. Teachers, friends, and family of autistic children read this empowering book crammed with information, solutions, and explanations to make the lives of these children better.  Review 
3. What I Wish I’d Known About Raising a Child with Autism: A Mom and a Psychologist Offer Heartfelt Guidance for the First Five Years  ~  Bravo to authors Bobbi Sheahan and Kathy DeOrnellas, Ph.D. in achieving what they set out to do. Write a book to assure those who love and care for an individual on the autism spectrum that life goes on; it doesn’t have to be all depressing, hard work.  If you are an educator, or know a family with an autistic child, this book is also for you because you will understand the challenges these families face. Reading their book will bring understanding and compassion to others… hopefully those standing in line with you at the checkout counters. Review
4. Look at my Eyes: Autism Spectrum Disorders: Autism and PDD-NOS  -by Melanie and Seth Fowler~  I love this gem of a book from cover to cover! I recommend it to the general public so they can know what it is like to raise a child with autism, in this case a boy diagnosed with PDD-NOS (pervasive developmental disorder-not otherwise specified). I recommend this book to new parents who are questioning if their toddler is on track with his developmental milestones. Most of all Look at my Eyes in a must-read if you have a child newly diagnosed as being on the autism spectrum. Review 
5. Thinking Person’s Guide to Autism: What you really need to know about autism from autistics, parents, and professionals  ~ Edited by Shannon Des Roches Rosa, Jennifer Byde Myers, Liz Ditz, Emily Willingham and Carol Greenburg.  This awesome book has fifty-five essays written by contributors from the autism community in all walks of life. The autism spectrum disorder community, especially parents of newly diagnosed children, needs this book. It is filled with positive, evidence-based autism information and advice.  There are nine broad themes/chapters and the essays are grouped together accordingly. To quickly retrieve an essay on a particular topic, Thinking Person’s Guide to Autism has a comprehensive index… something so many books lack. Review   
6. Crazy Love: A Traumedy about Life with Autism  -by  Sharie Walter ~ This book  tickles your funny bone from cover to cover. In her memoir, Sharie keeps you entertained with her amusing stories of life with autism raising her 5 year old daughter. Ms. Walter is surely a talented wordsmith that keeps you chuckling with her brilliantly written snippets of life with autism. Laugh a lot and learn a lot from Sharie Walter’s beautifully written book. Review
7. The Way I See It: A Personal Look at Autism and Asperger’s -by Temple Grandin, Ph.D.  ~What an amazing accomplishment on the part of her parents, the professionals, caregivers and friends who helped her and on Temple herself to have overcome or learned to cope with many of her challenges caused by autism. Readers will rejoice and be filled with hope for their own loved ones with autism or Asperger’s as they read Temple’s story on how she was motivated to forge ahead and adapt. Review
8. The Child with Autism at Home & in the Community: Over 600 Must-Have Tips  -by Kathy Labosh and LaNita Miller  ~  600 bullet points providing practical tips and tried-out strategies for families and educators to use to meet the needs of autistic children. You will find TIPS to make your home life happier and easier on picky eating, shampoos, and locking doors to prevent elopements, etc. Then you find the hundreds of suggestions on how to go out and enjoy your community. Learn what to do to enjoy the community playground, restaurant, mall, grocery store, movie theater, church, library, and sporting events, etc. Review
9. Challenging the Myths of Autism: Unlock New Possibilities and Hope -by Jonathan Alderson, Ed.M ~  In this book, Jonathan examines seven stereotypical characterizations or “myths of autism”. He has a chapter on each of these perennially inaccurate descriptions. Each chapter explains the origins of  the seven myths and discusses the evidence refuting them. The author invites the reader to put aside their preconceived notions of autism which can mislead parents, therapists, and the general public to underestimate the potential of children with autism. Alderson’s book is crammed with heartwarming stories and useful information. Review
10. Developing Leisure Time Skills for Persons with Autism: Structured Playtime Activities with Valuable Support Strategies for Adults -by Phyllis Coyne, Colleen Nyberg, and Mary Lou Vandenburg  ~ This book is a detailed guide with comprehensive, structured strategies to help adults introduce meaningful, leisure activities to children with ASD.  The method used is to narrow down the personal preferences and strengths of these individuals and use this knowledge to assist them to be more independent and self-directing in participating in more enjoyable and meaningful leisure activities. Review
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.

Sunday, January 13, 2013

Test Review: Social Responsiveness Scale, Second Edition (SRS-2)



The second edition of the widely administered Social Responsiveness Scale (SRS-2; Constantino & Gruber, 2012) maintains continuity with the original instrument as an efficient quantitative measure of the various dimensions of interpersonal behavior, communication, and repetitive/stereotypic behavior characteristic of autism spectrum disorders (ASD). The SRS-2 extends the age range from 2.5 years through adulthood. There are now four forms, each consisting of 65 items and for a specific age group: Preschool Form (ages 2.5 to 4.5 years); School-Age Form (4 to 18 years); Adult Form (ages 19 and up); and Adult Self-Report Form (ages 19 and up). Nationally representative standardization samples were collected to support each form. These samples consist of a total of 4,709 ratings of 1,963 individuals: 474 ratings of 247 preschool children, 2,025 ratings of 1,014 school-age children, and 2,210 ratings of 702 adults.
Content
The individual items of the SRS-2 show strong parallels across forms. While most of the 65 items are the same, some were changed and reference activities and social behavior that are specific and appropriate to the ages covered by their respective form. Only the School-Age form is unchanged in its item content from the first edition of the SRS. Each item is scored on a 4 point scale Likert-scale: 1 (“not true”); 2 (“sometimes true); 3 (often true); and 4 (“almost always true”). Scores are obtained for five Treatment Subscales: Social Awareness; Social Cognition; Social Communication; Social Motivation; and Restricted Interests and Repetitive Behavior. There are also two DSM-5 Compatible Subscales (Social Communication and Interaction and Restricted Interests and Repetitive Behavior) that allow comparison of symptoms to the new DSM-5 ASD diagnostic criteria.  
 Interpretation
Interpretation is based on a single score (Total Score) reflecting the sum of responses to all 65 SRS questions which serves as an index of severity of social skills across the autism spectrum. The SRS-2 Total score is expressed in raw and T-scores. Raw scores are converted to T-scores for gender and respondent. T-score guidelines provide interpretive language applicable to the specific age rages covered by the various forms (preschool, school-age, and adult). A total T-score of 76 or higher is considered severe and strongly associated with clinical diagnosis of Autistic Disorder. T-scores of 66 through 75 are interpreted as indicating Moderate deficiencies in reciprocal social behavior that are clinically significant and lead to substantial interference in everyday social interactions, whereas T-scores of 60 to 65 are in the Mild range and indicate mild to moderate deficits in social interaction. T scores of 59 and below are considered to be within typical limits and generally not associated with clinically significant ASD. A Profile Sheet for each form provides T-score results and a brief summary statement to facilitate interpretation and discussion of results. Raters can complete the 65 items in approximately 15 to 20 minutes. Scoring and graphing can be completed in approximately 5 to 10 minutes. The manual provides a series of case examples to illustrate application of the SRS-2 at different points across the lifespan (preschool, school-age, and adult). Although the SRS-2 is relatively easy to administer and score, interpretation and application of the results require professional training and experience in child development, psychology, or education.
Psychometric Characteristics
More than 40 research studies and independent resources support the diagnostic validity of SRS-2 and the instrument’s application in a wide variety of clinical and educational contexts. Based on research analyses, a total raw score cutpoint value of 70 is associated with a sensitivity value of .78 and specificity value of .94 for any ASD (autistic disorder, Asperger's disorder, or PDD-NOS) in unselected general-population groups. In terms of positive predictive value (PPV), 93% of children whose scores fall above this cutpoint will, upon completion of a comprehensive assessment, receive a diagnosis of ASD. In most clinical and school settings, raw scores at or above 85 from two separate informants provide very strong evidence of ASD. In a large clinical sample (School-Age Form), ROC (receiver operating characteristics) analyses indicate an area under the curve (AUC) of .968 and a sensitivity and specificity value of .92 at a raw score of 62. This suggests that the SRS-2 is a robust instrument for discriminating between individuals with ASD and those unaffected by the condition. Large samples also provide evidence of good interrater reliability, high internal consistency, and convergent validity with the Autism Diagnostic Interview-Revised (ADI-R), Autism Diagnostic Observation Schedule (ADOS), and Social Communication Questionnaire (SCQ).
 Conclusion
A significant strength of the SRS-2 is its facility in quantitatively measuring autistic traits and symptoms across the complete range of severity (mild to severe). This is especially important when identifying the more subtle characteristics of autism and more capable and less severely affected individuals with ASD (without intellectual disability). The SRS-2 forms should also be useful for quantifying response to intervention/treatment over time. Extending the age range of the SRS-2 adds to its versatility as a screening and diagnostic measure of symptoms associated with ASD. The Preschool and Adult Forms afford multiple perspectives throughout the life span and provide important tools for both clinicians and researchers to assess these populations. The subscales corresponding to the two symptom domains: Social Communication (SCI) and Restricted Interests and Repetitive Behavior (RRB) will also align the SRS-2 with the recently approved DSM-5 criteria for Autism Spectrum Disorder and Social Communication Disorder. Because a majority of independent research has been limited to the School-Age form, studies are needed to provide further information relative to the diagnostic validity of the Preschool and Adult Forms. Likewise, research is needed to examine the relationship between social impairment and intellectual disability and the more severe forms of ADHD. In sum, the SRS-2 can be used confidently in school and clinical contexts as an efficient measure of ASD symptomatology and severity. However, the results of questionnaire measures should not replace clinical assessment and must be integrated with information from different sources. The SRS-2 should be used within the context of a comprehensive evaluation, including developmental history and assessment of intellectual, language, and adaptive behavior functioning.
Constantino, J. N., & Gruber, C. P. (2012). Social Responsiveness Scale, Second Edition. Los Angeles, CA: Western Psychological Services.
Wilkinson, L. A. (2016). A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Ed.). London, UK: Jessica Kingsley Publishers. 

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