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).

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

Thursday, June 26, 2014

GI Distress in Children on the Autism Spectrum

GI Distress in Children with 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.            
                                                                    
                                                                              Research

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).
Results
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.
Conclusion
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 and without ASD (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, 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).

Thursday, June 19, 2014

Pets and Children on the Autism Spectrum



Severe impairment in social reciprocity is the core, underlying feature of ASD. Socialization deficits are a major source of impairment, regardless of cognitive or language ability and do not decrease with development. This includes difficulties in communicating with others, processing and integrating emotional information, establishing and maintaining reciprocal social relationships, taking another person's perspective, and inferring the interests of others. Intervention approaches and nontraditional therapies aimed at improving the everyday lives and social interactions of individuals with ASD are routinely discussed and advocated by researchers, parents and professionals. For example, several studies suggest that children learn prosocial behaviors through their interactions with pets. The arrival of a pet in a family has also been shown to increase the level of interactions between family members: they spend more time together and share joint attention on the new family member. Although animal-assisted therapies (AAT) are increasingly recommended, their relevant benefits for individuals with ASD are in need of research attention.
The Study
A study published in the open access journal PLoS ONE evaluated the association between the presence or the arrival of pets in families with an individual with autism and changes in his or her prosocial behaviors. Researchers hypothesized that a pet (e.g., dog, cat) at home might help individuals with autism to develop some prosocial behaviors. The study compared three situations: (1) never owned a pet, (2) owned a pet since birth (e.g., pet has been part of the individual’s environment), or (3) owned a pet after the age of 5. Of 260 individuals diagnosed with autism – on the basis of presence or absence of pets - two groups of 12 individuals and two groups of 8 individuals were assigned to: study 1 (pet arrival after age of 5 versus no pet) and study 2 (pet versus no pet), respectively. Evaluation of social impairment was assessed at two time periods using the 36-item Autism Diagnostic Interview (ADI-R) algorithm and a parental questionnaire about their child-pet relationships.
Results
Comparison of ADI-R assessment between the groups at two different time periods revealed significant changes in ADI-R scores only in the group experiencing the pet arrival in their homes. The results indicated that 2 of the 36 items changed positively between the age of 4 to 5 and time of assessment in the pet arrival group (study 1): ‘‘offering to share’’ and ‘‘offering comfort’’. Both items reflect prosocial behaviors. There appeared to be no significant changes in any item for the three other groups. The interactions between individuals with autism and their pets were more – qualitatively and quantitatively - reported in the situation of pet “arrival” than pet presence since birth. One interesting finding was that similar results were observed for the individuals who were in the presence of a pet from birth and those who never owned a pet. The sole presence of the pet did not result in a benefit for the individuals with autism. Changes were only observed in the group where the pet arrived after the age of 5.
Conclusion
This study suggests that in individuals with autism, pet arrival in the family setting may bring about changes in specific aspects of their socio-emotional development. The findings infer that with parental support, the child involvement towards a pet may influence his/her socio-emotional development. An important finding of the study was that the sole presence of the pet did not confer benefit for the individuals with autism. It appears that the quality of relationship with one’s own pet may be a direct determinant of the individual’s socio-emotional development and ‘‘pet bonding’’ is a stronger determinant of pet-associated benefits than the sole pet ownership. The researchers also suggest that the arrival of a pet strengthens the cohesion of the family and increases the levels of interactions between their members. That is, a new pet arrival might induce an increased interest of the individuals towards the pet and/or their involvement in the family’s interactions. Although these results are promising, further research is needed to explore the association between the arrival of a new pet and the change in prosocial behavior. While the study has limitations and didn’t allow the researchers to clarify the precise role of pets in the families who already owned pets, this study opens interesting areas of research exploring the efficacy of animals employed in AAT settings.

Thursday, June 12, 2014

College & University Students with Autism


College & University 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.
Research

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.
Implications

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 colleges and universities 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. 
References

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

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