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.”
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.
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.
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.

Thursday, September 12, 2013

GI Distress in Children with Autism Spectrum Disorder (ASD)

A number of clinical and epidemiological studies have indicated that children with autism spectrum disorder (ASD) are at increased risk for gastrointestinal (GI) problems. Research suggests that certain behaviors among children with ASD may reflect underlying GI problems and that the presence of these behaviors may indicate the need to evaluate a child with ASD for GI problems. Specific behavior problems proposed as possible expressions of GI distress include sleep disturbances, stereotypic or repetitive behaviors, self-injurious behaviors, aggression, oppositional behavior, irritability or mood disturbances, and tantrums. A recent pediatric consensus report called for additional research on the association between problem behaviors and GI problems, and for the development of a screen for GI problems in children with ASD.            

A brief report published in the Journal of Autism and Developmental Disabilities compared the behavioral features of children with and without a history of GI problems. The purpose of this population-based study of 487 children with ASD, including 35 (7.2%) with a medically documented history of GI problems, was to determine whether particular behavioral characteristics occur more frequently among those who have been diagnosed with a GI problem than those without a medically documented history of GI problems. The researchers implemented a cross-sectional study of children who were 8 years of age and met the case definition for ASD through the Centers for Disease Control and Prevention’s Autism and Developmental Disabilities Monitoring (ADDM).  
Eight behavioral features were identified that may be indicative of GI problems among children with ASD which had analogous measures in the ADDM data set: 1. abnormalities in sleeping; 2. stereotyped and repetitive motor mannerisms; 3. self-injurious behaviors; 4. abnormal eating habits, 5. abnormalities in mood or affect; 6. argumentative, oppositional, defiant, or destructive behaviors; 7. aggression; and 8. temper tantrums. Demographic data, healthcare and medical records, descriptions of behaviors, diagnostic summaries, psychometric test results, and information about co-occurring disorders or disabilities were collected and entered into a centralized composite record and reviewed by trained clinicians according to a specified protocol to determine case status and associated behavioral features (e.g., abnormalities in sleeping).
The results indicated that children with sleep abnormalities were more likely to have a medically documented history of GI problems (11%) than those without sleep problems (3.6%). Similar associations were seen for argumentative, oppositional or destructive behavior, abnormal eating habits, mood disturbances and tantrums, although the associations for mood disturbances and tantrums did not reach statistical significance. In contrast, the researchers found no associations between the presence of GI problems and stereotypic/repetitive behaviors and self-injurious behaviors.  Notably, nearly all of the children with ASD, including all 35 with a documented history of GI problems, exhibited at least one of the behavior problems hypothesized to be potential indicators of GI distress. For this reason, these behaviors would not be useful as a potential screen for GI problems in that virtually all children with ASD would potentially be referred for GI evaluations.
This study provides some support for the hypothesized association between selected behavioral characteristics in children with ASD and the occurrence of GI problems. The study found significant positive associations for several behaviors hypothesized to be expressions of GI problems in children with ASD. Certain behaviors, including abnormalities in sleep patterns, abnormalities in eating habits, and argumentative, oppositional, defiant or destructive behavior were described significantly more often in children with ASD who also had GI problems than in those with ASD and no history of GI problems.
Perhaps the most important contribution of this study is the finding that the behavioral characteristics hypothesized to be expressions of GI problems are very common in children with ASD, yet not specific to those with GI problems. Although GI problems may contribute to selected behaviors in some children with ASD, these behaviors are also frequent in children with ASD and no GI problems (nearly all children had 1 or more behaviors) and are unlikely to efficiently predict GI problems in children with ASD. As a result, the presence of these behaviors would not be useful on their own for screening or identifying children requiring GI evaluation.
Nevertheless, practitioners should be aware that certain behavioral problems observed in children with ASD may be indicative of a child’s response to, or attempt to communicate the discomfort of, an underlying GI problem. This condition can seriously affect the individual’s quality of life and ability to participate education and therapeutic activities. Consideration of medical, biological, or physiological co-occurring conditions, genetic susceptibility, diet and nutrition, and medication use are necessary to determine whether co-occurring behavioral problems and GI distress may be present in a child with ASD. Indeed, a comprehensive developmental assessment approach requires the use of multiple measures including, but not limited to, verbal reports, direct observation, direct interaction and evaluation, and third-party reports. This should include a record review, developmental and medical history, further medical screening and/or evaluation, and parent/caregiver interview. Lastly, further research is needed to develop recommendations for diagnostic evaluation and management of GI problems for individuals on the spectrum. 
Maenner, M. J., Arneson, C. L., Levy, S. E., Kirby, R. S., Nicholas, J. S., & Durkin, M. S. (2012). Brief report: Association between behavioral features and gastrointestinal problems among children with autism spectrum disorder. J Autism Dev Disord 42:1520–1525. DOI 10.1007/s10803-011-1379-6
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 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools, (2nd Edition).

Monday, July 29, 2013

Comorbid ADHD in Children with Autism Spectrum Disorder (ASD)

Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are neurodevelopmental disorders with onset of symptoms in early childhood. There is an overlap in the clinical presentation of ASD and ADHD with epidemiological studies indicating an increase in prevalence rates of ASD and ADHD over the past decade. Symptoms associated with both disorders often result in significant behavioral, social, and adaptive problems across home, school, and community settings  Research suggests that when ADHD is comorbid with ASD, the risk for increased severity of psychosocial problems increases. More severe externalizing, internalizing  and social problems, as well as more impaired adaptive functioning, have been reported in children with comorbid ASD and ADHD than children identified with only ASD.
Although there continues to a debate about ADHD comorbidity in ASD, research, practice and theoretical models suggest that comorbidity between these disorders is relevant and occurs frequently. For example, studies conducted in the US and Europe indicate that children with ASD in clinical settings present with comorbid symptoms of ADHD with rates ranging between 37% and 85%. However, little is known, about comorbidity rates in nonclinical (community) populations of children. Consequently, there is a major need in the field of autism research to better understand how often clinically significant ADHD symp­toms co-occur with ASD in nonclinical populations, and whether the comorbidity of ADHD with ASD is related to differences in other behavioral characteristics.
 Current Research
A study published in the journal Autism examined rates of parent-reported clinically significant symptoms of ADHD in a community sample of school-aged children (4-8 years) with ASD. The researchers hypothesized that children with ASD and comorbid ADHD would exhibit a more severe behavioral phenotype than those with only ASD. Specifically, they speculated that the comorbid group would have lower cognitive functioning, greater delays in adaptive func­tioning, higher rates of internalizing problems, and more severe social impairment than children with only ASD when these groups were of similar age. Participants included a sample of 153 children 4 to 8 years of age, consisting of the following classification groupings: Non-ASD (n = 91), ASD-Only (n = 44), and ASD+ADHD (n = 18). Children were evaluated on measures of cognitive functioning, internalizing psychopathology, social functioning and autism mannerisms, and adaptive behavior.
Data analysis indicted significant between-group differences. Results revealed that mean scores were in the “healthy” range for the Non-ASD group, in the mild to moderately impaired range for the ASD-Only group, and in the severely impaired range for the ASD+ADHD group on measures of social functioning and adaptive functioning, representing a continuum of impairment across groups. Children with ASD and ADHD also had lower cognitive functioning than the ASD-Only group. There were no group differences in parent ratings of symptoms of internalizing psychopathology (mood and anxiety disorders), with none of the groups demonstrating elevated rates of internalizing problems. The researchers suggest that an explanation for this finding may be that symptoms of inattention or hyperactiv­ity may obscure symptoms of anxiety in younger school-aged children. In addition, internalizing problems may be difficult to distinguish in young children with ASD as they may not be aware­ of their internal emotional states and may have difficulty expressing their emotional condition to others due to their ASD-related communication impairment.
The overall results of this study indicate greater impairment in cognitive, social, and adaptive functioning for children with ASD and clinically significant ADHD symptoms in comparison with children identified with only ASD. These findings suggest that ADHD comorbidity may constitute a distinctive subtype of ASD and that these children may be at higher risk of social impairment and adjustment problems. The findings are also consistent with other research reports of more severe social problems and maladaptive behav­iors in children with comorbid ASD and ADHD than children with only ASD.
The findings of the study have important implications for practitioners in health care, mental health, and educational contexts. Overall, 29% of children with ASD also exhibited clinically significant levels of ADHD. Although lower than rates in clinical samples, the rate of comorbid ADHD indicates that young school-age children with ASD should be assessed for ADHD. If clinically significant ADHD symptoms are identified, and social development does not appear to be responding to intervention, changes in the intervention pro­gram (e.g. intensity, strategies, and goals) may be required. It is also important to note that a significant change in the DSM-5 is removal of the DSM-IV-TR hierarchical rules prohibiting the concurrent diagnosis of ASD and ADHD. When the criteria are met for both disorders, both diagnoses are given. Thus, an assessment of ADHD characteristics should be included whenever inattention and/or impulsivity are indicated as presenting problems. It is imperative that practitioners recognize the high co-occurrence rates of these two disorders as well as the potential increased risk for social and adaptive impairment associated with comorbidity of ASD and ADHD. More research is needed to further clarify the behavioral characteristics of children with co-occurring ASD and ADHD so that specialized treatments and interventions may be designed to improve outcomes and quality of life for this subgroup of children. This is important because children who present with the two disorders may have a higher risk for sub-optimal outcomes and may benefit from different treatment methods or intensities than those with identified with only ASD.
Rao, P. A., & and Landa, R. J. (2013). Association between severity of behavioral phenotype and comorbid attention deficit hyperactivity symptoms in children with autism spectrum disorders. Autism. June 5, 2013;{Epub ahead of print]. DOI: 10.1177/1362361312470494
The online version of this article can be found at:

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

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
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

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 
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. <>
Best Practice Autism <>
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.
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.
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.
Autism Society of America
Best Practice Autism
National Autism Center
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.

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