Friday, November 21, 2014

Evidence-Based Practice for Autism in Schools


The Single Best Autism Resource for School-Based Professionals and Clinicians 
AUTISM SPECTRUM DISORDER IN CHILDREN AND ADOLESCENTS:
EVIDENCE-BASED ASSESSMENT AND INTERVENTION IN SCHOOLS
           Edited by Lee A. Wilkinson, PhD
School professionals and clinicians share the challenge of identifying and providing interventions for the increasing number of children with autism spectrum disorder (ASD). Incorporating the many advances made in recent years, this book is an authoritative resource for professionals who need the most current and reliable information on assessing and treating this neurodevelopmental disorder. It includes procedures to help identify children using the new DSM-5 symptom criteria and offers essential guidance for assessing a variety of emotional, behavioral, and academic problems. Comprehensive and timely, the book offers practical, research-based findings that can assist educators and school psychologists in screening and assessing children – and in implementing appropriate intervention strategies. Clearly organized and easy to follow, this new guide is essential reading for anyone working with children who have, or might have ASD.
FEATURES
  • Includes procedures to help identify children with ASD using the new DSM-5 diagnostic criteria.
  • Offers practitioners an evidence-based assessment battery, which includes tests of cognitive, academic, neuropsychological, and adaptive functioning.
  • Employs case vignettes to illustrate best practices in a school setting.
  • Concludes with a primer on ASD-related litigation issues and discusses relationships between special education law, provision of services, and placement decisions.
TABLE OF CONTENTS
Part I. Evidenced-Based Assessment of Autism Spectrum Disorder  1. Overview of Autism Spectrum Disorder  2. Multitier Screening and Identification  3. Comprehensive Developmental Assessment Model  4. Cognitive, Neuropsychological, Academic, and Adaptive Functioning  5. Language and Social Communication  6. Co-Occurring Emotional and Behavioral Problems Part II. Evidence-Based Intervention for Autism Spectrum Disorder  7. Evidence-Based Interventions in the Classroom  8. Continuum of Services and the Individual Education Plan Process  9. Curriculum and Program Structure Ÿ 10. Collaboration Between Families and Schools  11. Legal Issues Under IDEA.
2014. 264 PAGES. HARDCOVER
ISBN: 978-4338-1615-4

REVIEWS
“This fantastic resource is a must-read for professionals and students across many disciplines. Contributors provide critical information on a comprehensive range of topics with an emphasis on evidence-based approaches and practical applications.” - Natacha Akshoomoff, PhD, Associate Professor, Department of Psychiatry and Center for Human Development, University of California, San Diego
“Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools" serves as an excellent resource for professionals working with children with ASD in educational settings and covers many fundamental aspects that need to be considered in assessment and intervention practices. Overall, this book thoroughly integrates current research and theory as well as relevant practice in school settings and will allow practitioners to further their conceptual understanding of assessing and treating ASD.” - Canadian Journal of School Psychology
“This concise book provides a comprehensive and very readable introduction to best practices in the assessment and treatment of ASD in school settings. It succinctly informs the professional reader about the theoretical and research foundations underlying its many suggestions for practice, which are further enhanced by the liberal use of vignettes.” – PsycCRITIQUES

 “Wilkinson has put together a book that is quite readable and interesting. Difficult concepts are explained clearly but concisely. The style and quality of writing is consistently good across chapters. A strength of this book is the breadth of coverage. The authors meet the goal of providing professionals with information on ASD, screening, assessment, and interventions for the classroom.” - Journal of Psychoeducational Assessment

The book is represented in college/university libraries worldwide and serves as an ideal text in graduate-level courses on autism, developmental disabilities, special education, clinical and school psychology and early intervention. This highly readable and evidence-based practitioner resource sets the standard for all professionals working with students and families with ASD. 

Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools can ordered from APA Books, Amazon.com, Barnes & Noble, Books-A-MillionBook Depository, and other booksellersThe book is available in both print and eBook formats. Examination and desk copies are also available to college and university faculty.

Lee A. Wilkinson, PhD, CCBT, NCSP is an applied researcher and practitioner. He is a nationally certified and licensed school psychologist, chartered psychologist, registered educational psychologist, and certified cognitive-behavioral therapist. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and 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, November 10, 2014

Anxiety and Decision-Making in Adults on the Autism Spectrum



Although there has been a dramatic increase in the research and clinical studies related to children and adolescents, there is a paucity of information regarding more capable adults on the autism spectrum. It is only recently that psychologists have begun to appreciate the complex challenges faced by a “lost generation” of adults with autism spectrum disorders (ASD).  Even though the core symptoms of ASD (impairments in communication and social interaction and restricted/repetitive behaviors and interests) may improve overtime with intervention for many individuals, some degree of impairment typically remains throughout the lifespan.  Consequently, the focus of intervention/treatment must shift from remediating 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, post-secondary education, and family support. 
Decision-making is an important part of almost every aspect of life. However, several autobiographical accounts (e.g., Temple Grandin) suggest that making decisions can present significant problems for individuals with ASD. Likewise, a small number of experimental studies have suggested differences between the decision-making of adults with ASD and their neurotypical counterparts. Despite autobiographical accounts and limited studies, the extent to which, in everyday life, people with ASD experience difficulties with decision-making is largely unknown.  

Current Research 
A recent study published in the journal Autism sought to extend this important area of research by comparing the “real-life” decision-making experiences of adults with and without ASD. The researchers hypothesized that compared with a neurotypical group, participants with ASD would report: (a) more frequent experiences of problems during decision-making (e.g. feeling exhausted), (b) greater difficulty with particular features of decisions (e.g. decisions that need to be made quickly), and (c) greater reliance on rational, avoidant, and dependent styles of decision-making. In addition, it was expected that participants with ASD would report interference from their condition when making decisions.
The participants were 38 adults with ASD and 40 neurotypical comparison adults (with no family history of ASD), aged 16 to 65 years. The groups were matched for age, gender and verbal IQ. All participants completed a novel questionnaire to evaluate their decision-making experiences. The questionnaire asked participants to rate: (a) the frequency with which particular problems in decision-making were experienced; (b) the extent to which they perceived difficulties in relation to particular features of decisions; and finally, (c) the extent to which participants with ASD believed that their condition enhanced or interfered with their own decision-making. Ratings of the frequency of 12 potential problems in decision-making were indicated on a four-point Likert-type scale (from ‘never’ to ‘often’). Participants also completed the General Decision Making Style Inventory (GDMS), a 25-item questionnaire probing reliance on five, non- mutually exclusive, styles of decision-making (rational, intuitive, dependent, avoidant, and spontaneous). Levels of anxiety and depression were assessed using the well- established Hospital Anxiety and Depression Scale (HADS).

Results
The results indicated that compared with their neurotypical peers, the participants with ASD more frequently reported difficulties in decision making. Decisions that needed to be made quickly, or involved a change of routine, or talking to others, were experienced as particularly difficult, and the process of decision-making was reported to be exhausting, overwhelming, and anxiety-provoking. The participants with ASD reported significantly higher levels of anxiety and depression and were more likely to believe that their condition interfered with rather than enhanced the decision-making process. Not surprisingly, the participants with ASD were also more likely to report that they avoided decision-making.

Conclusion and Recommendations
The overall findings of the study suggest that, compared with neurotypical individuals, individuals with ASD experience greater difficulty with decision-making. Decision-making in ASD was associated with anxiety, exhaustion, problems engaging in the process, and a tendency to avoid decision-making. These findings are consistent with previous autobiographical accounts, known features of the condition, and previous studies of decision-making in ASD. In addition, the difficulties reported by the participants with ASD may be exacerbated by higher levels of anxiety and depression. The researchers found that ratings of perceived frequency of interference from ASD increased proportionally with levels of anxiety and depression. Despite limitations of the study (e.g., self-reports), the results are consistent with suggestions from the literature relating to decision-making for people with ASD. Importantly, they also have some practical implications for supporting more capable adults with ASD. For example, it may be useful to: (a) provide additional time to reach a choice, (b) minimize irrelevant information, (c) present closed questions, (d) offer encouragement and reassurance, and (e) address general issues around anxiety. Understanding how adults with ASD experience decision-making is especially relevant for family members and professionals who are involved in providing support to help these individuals achieve greater self understanding, self-advocacy and improved decision-making in lifespan activities such as employment and personal relationships.
Luke, L., Clare, I. C. H., Ring, H., Redley, M., Watson, P. (2012). Decision-making difficulties experienced by adults with autism spectrum conditions. Autism, 16(6), 612–621.
Wilkinson, L. A. (2015). Overcoming anxiety and depression on the autism spectrum: A self-help guide using CBT. London and Philadelphia: Jessica Kingsley Publishers.
 
Wilkinson, L. A. (2008). Adults with Asperger syndrome: A childhood disorder grows up. The Psychologist, 21, 764-770.
Wilkinson, L. A. (2007, May). Adults with Asperger syndrome: A lost generation? Autism Spectrum Quarterly.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He 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 CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Sunday, October 26, 2014

Emotional Intelligence (EI) and Asperger Syndrome



Emotional intelligence (EI) is broadly defined as the ability to identify, assess, and control the emotions of oneself, of others, and of groups. The interest and research relating to EI has grown dramatically over the past decade. Currently, there are two emotional intelligence constructs: ability EI (or cognitive-emotional ability) and trait EI (or trait emotional self-efficacy). They are differentiated by the type of measurement used in the operationalization process. For example, the ability perspective conceives EI as a form of intelligence best assessed via performance tests and has stronger relationships with cognitive ability hierarchies. Thus, ability EI refers to individual differences in the ability to process and use emotional information to promote effective functioning in everyday life. Trait EI concerns behavioral dispositions and self-perceived abilities and is measured through self-report. Trait EI has stronger relationships with personality and concerns people’s perceptions of their emotional abilities (how good we believe we are in understanding and managing our own and other people’s emotions, rather than how good we actually are). These perceptions are generally stable over time and have a direct influence on mood, behavior, achievement, and action. In other words, trait EI is defined, not as a cognitive ability, but as a collection of personality traits concerning people's perceptions of their emotional abilities. 
Trait EI and ASD  
The defining feature of autism spectrum disorders (ASD) is impairment in interpersonal relating and communication. This includes difficulty communicating with others, processing and integrating information from the environment, establishing and maintaining reciprocal social relationships, taking another person’s perspective, inferring the interests of others, and transitioning to new learning environments. While all individuals with ASD experience core social-communication deficits, we now recognize that autism-related traits are quantitatively distributed in the general population and that autism is best conceptualized as a spectrum disorder, rather than a categorical diagnosis. Even mild degrees of what might be called autistic social impairment can significantly interfere with adaptive behavior. Likewise, a combination of mild autistic symptomatology and other psychological liabilities (e.g., attention problems, mood problems, aggression) can have an adverse effect on social and emotional adjustment. Unfortunately, the core features of ASD may not diminish with development. Typically, individuals do not ‘‘outgrow’’ their deficits. Distress may actually increase as the social milieu becomes more complex and challenging. These difficulties may then persist well into adulthood and lead to comorbid emotional symptoms. Indeed, high stress, anxiety and depression are regularly present in persons with ASD.
ASD involves deficits that are directly relevant to the constellation of emotional self-perceptions encompassed by trait EI. Trait emotional intelligence (trait EI) encompasses many of the aspects of social-emotional functioning that have been shown to be impaired in ASD in the form of self-perceptions. Research has begun to examine the link between higher functioning ASD (e.g., Asperger syndrome) and trait EI. A recent study compared the trait EI profiles of men and women diagnosed with Asperger syndrome (AS) with those of a normative sample, group-matched on age and gender. Participants were thirty adults diagnosed with AS (16 women and 14 men) who volunteered for the study and were subsequently group-matched with 43 typically developing adults (22 women and 21 men). There were no significant differences in the mean age of the participants with and without AS and no significant between-group differences in the distribution of gender. All participants completed the Trait Emotional Intelligence Questionnaire (TEIQue), a self-report inventory specifically designed to comprehensively measure the trait EI construct. The TEIQue consists of 153 items rated on a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree) and includes 15 subscales (facets) organized under four factors (Well-Being, Self-Control, Emotionality, and Sociability) and global trait EI. It has been shown to have satisfactory psychometric properties in various studies. Below is a list of the 15 trait EI facets, along with a brief description of each.  These facets comprise the current sampling domain of trait emotional intelligence in adults and adolescents.   
Facets                                                    High scorers perceive themselves as…
Adaptability                                           flexible and willing to adapt to new conditions.
Assertiveness                                         forthright, frank, & willing to stand up for rights.
Emotion perception (self; others)     clear about their own & other people’s feelings.
Emotion expression                             capable of communicating their feelings to others.
Emotion management (others)         capable of influencing other people’s feelings.
Emotion regulation                              capable of controlling their emotions.
Impulsiveness (low)                             reflective & less likely to give in to their urges.
Relationships                                         capable of having fulfilling personal relationships.
Self-esteem                                             successful & self-confident.
Self-motivation                                      driven & unlikely to give up in the face of adversity.
Social awareness                                   accomplished networkers with excellent social skills.
Stress management                              capable of withstanding pressure & regulating stress.
Trait empathy                                        capable of taking someone else’s perspective.
Trait happiness                                      cheerful & satisfied with their lives.
Trait optimism                                       confident & likely to “look on the bright side” of life.
Findings and Implications  
The researchers hypothesized if individuals with Asperger syndrome have limited understanding their social-communication deficits, then they would score similarly to typical adults on the TEIQue. However, if they have an accurate understanding of these deficits, then they would score significantly lower. The researchers also sought to shed light on the gender discrepancy routinely observed in ASD, particularly in those more able individuals diagnosed with ASD.
The results showed that individuals with AS had significantly lower scores on most TEIQue variables, including the global trait EI score. The Asperger group scored significantly lower on 12 out of the 15 facets of the Trait Emotional Intelligence Questionnaire (TEIQue). They rated themselves particularly low on questions relating to social awareness, emotion management, adaptability, empathy, and emotion perception. The finding appears to be consistent with the clinical presentation of ASD. Differences were much smaller, or non-existent, on questions relating to self-control (especially, impulse control and emotion control). With respect to gender, males scored higher than females, albeit with small effect sizes. Overall, the findings suggest that individuals with Asperger syndrome have insight into the nature of their condition and are aware of the strengths and weaknesses of their personality. These data also suggest that the female phenotype of AS may be associated with greater impairment than the male phenotype.
This research contributes to the evidence documenting the effect of trait EI self-perceptions and dispositions on socio-emotional development and overall psychological well-being. The well-being component of trait EI may be especially relevant in the adjustment process, since positive emotions contribute to the development of those physical, intellectual and social resources necessary to cope successfully with the demands of the social world. There are extensive individual differences in people's perceptions of their emotional abilities. Because trait EI affects behavior, self-referent cognitions and mental health, it is an important variable to consider in the evaluation and treatment of higher functioning individuals with ASD. Although individuals with ASD appear to be aware of their social-communication deficits, further study is needed into the capacity for insight and how it may be utilized in treatment/intervention. Likewise, further study is also needed to examine the relationship of trait EI variables to symptom severity and determine to what extent individual self-perceptions predict outcomes (e.g., life satisfaction, coping strategies, and job performance).  Perceived emotional self-efficacy also plays an important role in emotion management and regulation in education. Consequently, further research on trait EI should include children with ASD. A child version of the TEIQue (TEIQue-Child Form) is available for children aged between 8 and 12 years of age and measures nine distinct facets. An examination of trait EI profiles of children with ASD may assist with identification, intervention, and progress monitoring.
Petrides, K. V., Hudry, C., Michalaria, G., Swami, V., & Sevdalis, N. (2011). Comparison of the trait emotional intelligence profiles of individuals with and without Asperger syndrome. Autism, 15, 671–682. doi 10.1177/1362361310397217
Detailed information about trait EI and the various facets of the TEIQue can be found at http://www.psychometriclab.com 
The online version of this article can be found at http://aut.sagepub.com/content/15/6.toc

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 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 CBT. Dr. Wilkinson's latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools, (2nd Edition).

Thursday, October 9, 2014

Role of Parental Occupation in Autism Diagnosis and Severity

Children of fathers in healthcare and finance have greater risk of having offspring with ASD while children of parents with technical occupations exhibit greater ASD severity, according to researchers at The University of Texas Health Science Center at Houston (UTHealth). The findings were presented at the International Meeting for Autism Research (IMFAR) in Atlanta and appear in the peer reviewed journal, Research in Autism Spectrum Disorders.
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in (a) social communication and (b) restricted and/or repetitive behaviors or interests that varies in severity of symptoms, age of onset, and association with other disorders. According to recent estimates, approximately 1 in 68 children in the United States has an ASD diagnosis. In addition, a recent study of parent reports suggests that prevalence of ASD in the US could be as high as 1 in 50.  Despite this growing literature on prevalence and incidence of ASD, less is known about the etiology of this complex neurodevelopmental disorder.
It has been suggested that parents of children with autism spectrum disorder (ASD) may present with less recognizable autistic-like phenotypic characteristics or traits (broader ASD phenotype), leading them to highly systemizing occupations such as science, engineering, mathematics, computer science, accounting, and medicine. Others have suggested that many professionals with highly systemizing occupations are functioning with undiagnosed ASD. Using secondary analysis of data from two previous studies of children with ASD, the researchers tested associations between parental occupations and ASD diagnosis and the association of parental occupational characteristics on ASD severity. Children for both studies were recruited from the same educational, clinical, and community sources. Suspected ASD cases were determined by clinical interview and observation.  Those meeting DSM-IV-TR criteria were administered both the Autism Diagnostic Interview, Revised (ADI-R) and Autism Diagnostic Observation Schedule (ADOS) to confirm diagnosis. Parental occupations were established through demographic questionnaires during assessment. The researchers used the Standard Occupational Classification (SOC) system to classify occupational characteristics of interest. Parents were divided into those who had more non-people-oriented jobs (technical) or more people-oriented jobs (non-technical).  For example, those working in engineering, scientific research, and accounting were considered having technical, white-collar occupations while those in healthcare professions were consider having non-technical, white-collar positions. Statistical analyses were used to explore associations of ASD status with certain white-collar occupations and occupational characteristics and to investigate differences in mean ADOS and ADI-R domain and total scores for parental occupation characteristics.
The results indicated that for paternal occupations, fathers who worked in engineering were two times as likely to have a child with an autism spectrum disorder (ASD) as compared to all other white-collar occupations. Additionally, fathers of ASD cases were seven times more likely to work in healthcare occupations and five times more likely to work in accounting/financial analysis. There was no association with a mother's occupation. However, children who had both parents in technical fields were associated with significant social impairment and a higher risk of having more severe overall autistic symptomatology.
The findings suggest that there is a joint association between parental occupation and ASD severity, as well as a relationship between paternal occupation and ASD diagnosis. These results are also supportive of a “broader ASD phenotype” in parents of children with ASD which includes individuals with mild impairments in social and communication skills that are similar to those shown by individuals with ASD, but exhibited to a lesser degree. The tendency of people with autistic-like characteristics to marry (assortative mating) might contribute to intergenerational transmission and having offspring with greater ASD severity. "Parental occupation could be indicative of autistic-like behaviors and preferences and serve as another factor in a clinician's diagnosis of a child with suspected autism. Medical students can be taught that this is one of the things to consider," said. Aisha S. Dickerson, first author of the study. More analysis should be done to determine what factors contribute to occupation choices, and how these factors, if identifiable, can add to the risk of communication or social impairment in the offspring of these individuals.
Dickerson, A. S., Pearson, D. A., Loveland, K. A., Rahbar, M. H.,  & Filipek, P. A. (2014).
Role of Parental Occupation in Autism Spectrum Disorder Diagnosis and Severity. Research in Autism Spectrum Disorders, 8, 997–1007

Monday, September 15, 2014

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.
Research
Research in the past 10 years has generated some controversy about the actual incidence of savant syndrome in autism. Once thought to be rare in people with autism, found in no more than 1 out of 10 individuals, research over the past few years suggests savant skills may be more common than previous estimates. 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 behaviours/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. It should be noted these data offer no support to claims that savant skills occur most frequently in individuals with autism who are intellectually challenged or that individuals with higher rates of stereotyped behaviors/interests are 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 onwards, 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.”
Key References
Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2009). Savant skills in autism: Psychometric approaches and parental reportsPhilosophical Transactions of the Royal Society B: Biological Sciences, 364, 1359–1367. doi:10.1098/rstb.2008.0328 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677586/

Marsa, L. (2016). Extraordinary minds: The link between savantism and autism. https://spectrumnews.org/features/deep-dive/extraordinary-minds-the-link-between-savantism-and-autism/

Treffert D. (2000). Extraordinary people: understanding savant syndrome. Ballantine Books; New York, NY.

Treffert, D. (2009). The Savant Syndrome: An Extraordinary Condition. A Synopsis: Past, Present, Future. Philosophical Transactions of the Royal Society B: Biological Sciences, 364, 1351–1358. 

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorder. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Sunday, September 14, 2014

Early Intensive Behavioral Intervention Effective for Autism

It is well established that early intervention is a critical determinant in the course and outcome of autism spectrum disorders (ASD). Early intensive behavioral intervention (EIBI) is considered a central feature of intervention programming for children with autism. EIBI programs are among the most and best researched of the psychoeducational interventions. A new comparative effectiveness review prepared for the Agency for Healthcare Research and Quality (AHRQ) finds that there is substantially more evidence for behavior therapy in treating autism than just a few years ago. The report, Therapies for Children With Autism Spectrum Disorder: Behavioral Interventions Update, is based on research conducted by the Vanderbilt Evidence-based Practice Center and brings practitioners up to date about the current state of evidence related to behavioral interventions.
Evidence from the original report published in 2011 and the current update suggests that early behavioral and developmental intervention based on the principles of ABA delivered in an intensive (>15 hours per week) and comprehensive (i.e., addressing numerous areas of functioning) approach can positively affect a subset of children with ASD. Across approaches, children receiving early intensive behavioral and developmental interventions demonstrate improvements in cognitive, language, adaptive, and ASD impairments compared with children receiving low- intensity interventions and diverse non–ABA-based intervention approaches. In sum, the report reflects a growing evidence base suggesting that behavioral interventions are associated with positive outcomes for some children with ASD. “We are finding more solid evidence, based on higher quality studies, that these early intensive behavioral interventions can be effective for young children on the autism spectrum, especially related to their cognitive and language skills,” said Amy Weitlauf of Vanderbilt who led the review. “But the individual response to these treatments often varies from child to child.”
The report also indicates a growing evidence base suggesting that children receiving targeted play-based interventions (e.g., joint attention, imitation, play-based interventions) demonstrate improvements in early social communication skills. Children receiving targeted joint attention packages in combination with other interventions show substantial improvements in joint attention and language skills over time. There is also evidence across a variety of play-based interventions that young children may display short-term improvements in early play, imitation, joint attention, and interaction skills. Cognitive behavioral therapy (CBT) for comorbid conditions such as anxiety had the largest number of high-quality studies in the current review. A strong evidence base now suggests that school-aged children with average to above average cognitive ability and co-occurring anxiety symptoms receiving manualized CBT therapy show substantial improvements in anxiety compared with wait-list controls.
It should be noted that the report is not intended to be a substitute for the application of clinical judgment. Research findings are not the only factor involved when selecting an intervention. Professional judgment and the values and preferences of parents, caregivers, and the individual’s unique needs and abilities are also important. 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. Given the heterogeneity of the expression of ASD across children, a critical area for further research is understanding which children are likely to benefit from particular interventions. To date, studies have failed to adequately describe the characteristics of interventions (or the children receiving them) in a way that helps clarify why certain children show more positive outcomes than others. Substantial scientific advances are needed to enhance our understanding of which interventions are most effective for specific children with ASD and to isolate the elements or components of interventions most associated with effects. Finally, the literature lacks studies that directly compare interventions or utilize combinations of interventions (e.g., comparing medical interventions with behavioral interventions, with educational interventions, or with allied health interventions), despite the fact that most children receive multiple concurrent treatments.
Weitlauf AS, McPheeters ML, Peters B, Sathe N, Travis R, Aiello R, Williamson E, Veenstra-VanderWeele J, Krishnaswami S, Jerome R, Warren Z. Therapies for Children With Autism Spectrum Disorder: Behavioral Interventions Update. Comparative  Effectiveness Review No. 137. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2012-00009-I.) AHRQ Publication No. 14-EHC036-EF. Rockville,  MD: Agency for Healthcare Research and Quality; August 2014.

Sunday, August 3, 2014

Loneliness and Well-Being in Adults with Autism


Individuals with autism spectrum disorder (ASD) experience significant difficulties in social functioning, including deficits in core social abilities and problems establishing and maintaining peer relationships. These social and interpersonal problems generally persist and sometimes worsen in adulthood, contributing to functional impairment. Despite the increase in ASD prevalence, few studies have focused on the experiences of adults with ASD, or on the factors that may relate to their social and emotional functioning. 


There is considerable evidence that loneliness and social support have a strong influence on overall well-being in the general population. However, this has yet to be examined among adults with ASD. Contrary to historical assumptions, individuals with ASD do not always prefer solitude and social isolation. They often want to develop relationships but face barriers in developing relationships due to social competence difficulties. Thus, loneliness appears to be a clinically important consideration for adults on the autism spectrum.
A study published in the journal Autism examined the relations among loneliness, friendship, and emotional functioning in adults (N = 108) with autism spectrum disorders. Participants completed self-report measures of symptoms of autism spectrum disorders, loneliness, number and nature of friendships, depression, anxiety, life satisfaction, and self-esteem. The results indicated that loneliness was associated with increased depression and anxiety and decreased life satisfaction and self-esteem, even after controlling for symptoms of autism spectrum disorders. In addition, greater quantity and quality of friendships were associated with decreased loneliness among adults with autism spectrum disorders. Multivariate models indicated that friendship did not moderate the relationship between loneliness and well-being; however, number of friends provided unique independent effects in predicting self-esteem, depression, and anxiety above and beyond the effects of loneliness.
This study provides an important evaluation of the social and emotional experiences of adults with ASD. The findings extend current knowledge and highlight the clinical importance of loneliness. Significant correlations were found between loneliness and a number of negative emotional experiences, including increased depression and anxiety, and reduced well-being. Because individuals with ASD are already at increased risk of anxiety and depression, loneliness may represent an important factor in the developmental course of internalizing problems through adolescence and adulthood. A better understanding of the developmental course and consequences of loneliness is essential to inform our understanding of social and emotional well-being in individuals with ASD. Lastly, strategies to reduce and prevent loneliness in adults with ASD should be important objectives for future research and clinical practice.
Mazurek, M. O. (2014). Loneliness, friendship, and well-being in adults with autism spectrum disorders. Autism, 18, 223-232. doi: 10.1177/1362361312474121
http://aut.sagepub.com/content/18/3/223

Tuesday, July 29, 2014

Comorbid ADHD in Children on the Autism Spectrum

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.
 Results
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.
                                                                              Implications 
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: http://aut.sagepub.com/content/early/2013/05/20/1362361312470494

Wednesday, July 2, 2014

Predictors of Aggression in Autism


Aggression is a clinically significant feature of many children and adolescents with autism spectrum disorders (ASD). Children with ASD frequently have co-occurring (comorbid) psychiatric conditions, with estimates as high as 70 to 84 percent. These co-occurring problems often exacerbate the core symptoms of ASD and can lead to significant functional impairment. Among these problems, physical aggression appears to be especially challenging, and has been associated with serious negative outcomes in both the general population and among individuals with ASD and other developmental disabilities.

Co-occurring Problems Relevant to Aggression 
Children with ASD experience a number of related difficulties, including sleep problems, gastrointestinal (GI) problems, sensory abnormalities, and self-injury. Many of these problems have been associated with aggression among typically developing children, and emerging evidence suggests a similar relationship in children with ASD. For example, sleep problems occur in a large percentage of children with ASD, with prevalence rates ranging from 50% to 80%. Sleep problems have been found to be highly associated with aggression in typically developing children. Likewise, research suggests that children with ASD and sleep problems are more likely to demonstrate aggression than those without sleep problems.
Sensory problems, including sensory over-responsivity, sensory under-responsivity, and sensory seeking are also common problems in children with ASD. In typical children, sensory problems have been associated with aggressive and externalizing behavior problems. Similarly, recent studies have been found correlations between sensory problems and broadly defined externalizing problem behaviors in children with ASD. However, research has yet to specifically examine the potential contributing role of sensory problems in predicting physical aggression.
Self-injurious behavior also appears to be relevant to the occurrence of aggression. Individuals with ASD are at an increased risk for demonstrating self-injurious behaviors, as compared to those without ASD, with prevalence rates ranging from 30% to 53%. Although self-injury and other forms of challenging behaviors have been considered to be distinct forms of behavior, they are often related. For example, physical aggression and self-injury have been significantly associated among individuals with severe intellectual impairment and there is evidence that self-injurious behaviors are precursors of later aggression in this population. However, similar studies have not investigated the relationship between self-injury and physical aggression in children with ASD.
Lastly, gastrointestinal (GI) problems may also have relevance to the occurrence of aggression. GI problems are common in children with ASD, with prevalence rates ranging from 24% to 70% or higher, depending on symptom definitions. Although there some evidence of an association between behavior problems and GI problems in ASD, a population-based study of children with ASD did not find significant differences in aggression when comparing children with and without GI problems.
                                                                     Current Research
Although the nature and developmental course of aggression have been a focus of research with typically developing populations, there have been few large-scale studies of group-level predictors of aggression among individuals with ASD. Consequently, it is unclear whether findings from the general population are applicable to children and adolescents with ASD. In an effort to investigate the extent of the problem in children and adolescents with ASD, a recent large-scale study published in Research in Autism Spectrum Disorders examined the prevalence and correlates of physical aggression in a sample of 1584 children and adolescents with ASD enrolled in the Autism Treatment Network (ATN), a multi-site network of 17 autism centers across the US and Canada. Participants in the study ranged in age from 2 to 17 years, with a mean age of 5.91 years. The term “aggression” referred specifically to physical aggression and included biting, hitting, or other physical aggression directed towards others. A number of diagnostic, medical, and behavioral measures were collected at enrollment and at regular follow-up intervals. Measures of interest included: (a) aggression, (b) sleep disturbance, (c) sensory problems, (d) communication and social functioning, (e) self-injury and gastrointestinal problems, (f) cognitive functioning, and (g) verbal/nonverbal status. Data analyses were completed in order to identify the variables most strongly associated with aggression.
                                Prevalence, Correlates and Predictors of Aggression
The results indicated that the prevalence of aggression was 53% across the entire sample of children, with highest prevalence among young children. These results are highly consistent with recently reported prevalence rates (56%) in another large-scale study of children and adolescents with ASD. The results also indicate that age-related decreases in aggression in children with ASD are similar to what has been observed in typically developing children. It should be noted, however, that a large percentage (nearly 50%) of the adolescents in the study’s sample continued to demonstrate physical aggression. Thus, the relative decrease in aggression over time must be balanced by the finding that these behaviors continued to occur at a high rate among a large portion of adolescents with ASD.
In terms of predictors, the results indicated that self-injury was highly associated with aggression among children with ASD. This is consistent with the findings of other studies showing a strong association between self-injury and other challenging behaviors. The current results add to existing literature, and suggest that children with ASD who demonstrate self-injury may be at risk for more severe behavioral problems.
Sleep problems emerged as a second significant predictor aggression. This association between sleep problems and aggression is largely consistent with previous findings among both typically developing children and those with ASD, indicating may underlie (and exacerbate) aggressive behavior patterns for many children with ASD. It should also be noted that sleep problems have been found to be associated with self-injurious behaviors among individuals with intellectual disabilities and that these two conditions may be related. In fact, there is some developing evidence suggesting shared neurobiological basis for both sleep disturbance and self-injurious behavior.
Sensory problems were also significantly associated with aggression. These findings are consistent with similar associations between sensory issues and aggression among typically developing children. While previous research has demonstrated an association between sensory problems and broadly defined behavior problems, the current results extend these previous findings by demonstrating a specific relationship between sensory problems and physical aggression.
Comparisons also indicated that children with aggression were more likely to experience GI problems, communication skill difficulties, and social skills difficulties. However, these variables did not appear as significant predictors of aggression, indicating that self-injury, sleep problems, and sensory issues accounted for the majority of the variance in predicting aggression.
In terms of potential sex differences, the results indicate that girls and boys with ASD were equally likely to engage in aggression. This finding was unexpected in that research has consistently shown a significant gender difference among children without ASD, with boys being much more likely to engage in physical aggression than girls. The results of the study suggest that the sex differential in aggression may not be salient in the ASD population.
 Implications
This study provides evidence that aggression may be much more prevalent among children with ASD than in the general population and that some co-occurring problems may place individuals at risk for aggression. Aggression was significantly associated with a number of clinical features, including self-injury, sleep problems, sensory problems, GI problems, and communication and social functioning. However, self-injury, sleep problems, and sensory problems were most strongly associated with aggression. These findings indicate that co-occurring problems specific to the ASD phenotype may play an important role in the occurrence of aggression and that it is important to consider multiple domains of functioning when assessing and treating aggression in children with ASD. For example, increased attention should be given to the identification and treatment of sleep problems, self-injury, and sensory problems. Given the significant relationship between sleep problems and aggression, it is possible that treatments targeting sleep problems may help reduce maladaptive behavior. Thus, assessment and treatment of sleeping problems might be included as a standard and integrated part of the assessment and treatment of ASD. Programs for children with ASD should also integrate an appropriately structured physical and sensory milieu in order to accommodate any unique sensory processing challenges. Although assessment tools are limited, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Coexisting disorders should also be carefully investigated when severe or worsening symptoms are present that are not responding to traditional methods of intervention.
Of course, more research is needed in order to better understand the characteristics and course of different types of aggression. For example, future research should examine the longitudinal course of aggression, the role of these associated problems in predicting improvement or worsening of aggression, and possible changes in aggression in response to treatment for these co-occurring problems. Studies are also needed to examine the role of additional family- and community-level variables in the prediction and maintenance of aggression among children with ASD.  
Mazurek, M. O., Kanne, S. M., & Wodka, E. L. (2013).  Physical aggression in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 455–465
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 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 CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Ed.).

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