Wednesday, December 10, 2014

Unusual Fears and Phobias in Children on the Autism Spectrum


     
Fears and Phobias in ASD
Anxiety Disorders are a frequent co-occurring (comorbid) problem for children and youth with autism spectrum disorder (ASD). Although prevalence rates vary from 11% to 84%, most studies indicate that approximately one-half of children with ASD meet criteria for at least one anxiety disorder. Of all types of anxiety disorders, specific phobia is the most common, with prevalence estimates ranging from 31% to 64%. In contrast, estimates of phobias in children in the general population range from 5% to 18%.
Unusual fears have long been recognized as a feature of autism. In fact, 70 years ago, Leo Kanner wrote in his initial account of autism that “loud noises and moving objects” are “reacted to with horror” and things like “tricycles, swings, elevators, vacuum cleaners, running water, gas burners, mechanical toys, egg beaters, even the wind could on occasions bring about a major panic.” We now know that children with autism perceive, experience, and respond to the world very differently than children without autism. Experiences that may be tolerable for most typical children might be frightening, disturbing, or irritating for a child with ASD. Children with autism may also be unresponsive to other experiences (e.g., insensitive to pain), may not show stranger or separation anxiety, and may be seemingly unaware of obvious dangers (e.g., running into traffic).
Research
Previous research examining the types and frequencies of fears in children with autism have found odd and intense fears in approximately 40% of children with autism, whereas unusual fears were present in only 0–5% of children without autism, including children with a learning disability, language disorder, ADHD, intellectual disability, and typical development. Studies also indicate that while some of the most common fears for children with autism and typical development overlap, children with autism have frequent fears that were not amongst the most frequently reported for typical children. These include fear of thunderstorms, large crowds, and closed spaces.
A large scale study reported in Research in Autism Spectrum Disorders investigated unusual fears in a sample of 1033 children ages 1-16 with autism. The purpose of the study was to categorize and determine specific types of unusual fears in children with autism as well as identify variables related to the presence or absence of these fears. Unusual fears were reported in 421 (40.8%) of the 1033 children with autism. A total of 487 unusual fears were reported, representing 92 different fears. The most common unusual fear was fear of toilets, accounting for 11.7% of the unusual fears. For children with unusual fears, 60.0% had one fear, 27.6% had two, 10.2% had three, 1.9% had four, and one child had five fears. Unusual fears fell into 14 categories. More than half of the 421 children with unusual fears had fears of mechanical things, heights, and/or weather. The most common category was fear of mechanical things, which accounted for 23.8% of the types of fears reported. For children with unusual fears, 71.1% had fears in only one category, 21.9% in two categories, 6.7% in three categories, and 0.3% in four categories. Many children also had common childhood fears and phobias (including fear of dogs, bugs, spiders, snakes, the dark, doctors, barbers, monsters, people in costumes, mechanical toys, sleeping alone, fire, and swimming), which increased the overall proportion of children with autism who had intense fears and phobias to more than 50%.
Categories and Frequency of Unusual Fears
The most frequently reported categories of unusual fears were:
§         Mechanical things (Blenders, can openers, cassette players, ceiling fans, clothes, dryers, drills, electric toothbrushes, exhaust fans, hair dryers, hand dryers, leaf blowers, toilets, vacuum cleaners, washing machines, water fountains, wheelchairs, windshield wipers) 
§         Heights (Elevators, escalators, heights, steps) 
§         Weather (Cloudy weather, natural disasters such as floods, droughts, hurricanes, tornadoes, rain, thunderstorms, wind) 
§         Non-mechanical things (Balloons, black television screen, buttons, clam shells, crayons, dolls, drains, electrical outlets, eyes on toys garden hose, glass tabletops, glow in dark stars, gum under table, hair in bathtub, lights, mole on person’s face, moon, shadows, strings, stuffed animals, swinging or rocking things, tall things, things on ceiling, vent on house)
§         Places (Bathroom, bedroom, certain house or restaurant, closed or small spaces, garage, large or open space, room with doors unlocked or open)
§         Worries Dying (e.g., bone breaking through chest, car accident, drowned, eaten by fleas, heart attack, murdered, natural disaster, poisoned, spleen exploding, world ending), germs or contamination, running out of certain foods, running out of gas, something falling over, swallowing something when did not, toilet overflowing, tree falling on house)
§         Visual media (Characters in or segments of movies, television shows, commercials, computer games)
Types and Frequency of Unusual Fears
Unusual fears reported by parents fell into two categories: (1) uncommon fears not typically reported in children in the general population or in children with specific phobias and (2) fears that have been reported in studies of children without autism but which were considered unusual by parents because of their intensity, obsessiveness, irrationality, or interference with functioning. Of the total number reported, the most common unusual fears in three or more children with autism were:
§         Toilets
§         Elevators
§         Vacuum cleaners
§         Thunderstorms
§         Tornadoes
§         Heights
§         Worry dying (e.g., bone breaking through chest, car accident, drowned, eaten by fleas, heart attack, murdered, natural disaster, poisoned, sick, spleen exploding, or world ending)
§         Visual media (characters in or segments of movies, television shows, commercials, or computer games)
Associated variables
Children with and without unusual fears did not differ in age, IQ level, mental age, autism severity, race or parent occupation. Of all the demographic variables, only female gender was associated with the presence or absence of unusual fears. More girls had unusual fears (48.8%) than did boys (39.1%). This is consistent with the earlier studies indicating that girls with autism had more fears than boys and with general population studies showing that girls had more fears and higher fear survey scores than boys. The finding that children with and without unusual fears did not differ in age suggests that unlike most typical children, those with autism may not outgrow unusual fears. Likewise, the findings regarding autism severity and parent occupation suggest that the presence of unusual and intense fears may be present across SES and the entire autism spectrum. The authors note that the lack of demographic differences in the study may suggest a neurobiological basis for fears overriding developmental and environmental influences.
Conclusion and Implications
Research suggests that it is critical to assess for unusual and intense fears in children with ASD because they are common and can interfere significantly with functioning. Specific fears and phobias have been cited as frequent anxiety triggers/stressors for children with ASD. The impact of anxiety includes personal distress in children, parents, and siblings, increase in challenging behavior and stereotyped behaviors, restriction of activities/opportunities and negative impact on quality of life for child and family. For example, children with autism may avoid necessary life situations (e.g., refusing to go to school because there may be a fire drill) or be in a constant state of anxiety and unable to function optimally because of their fears.
Identification of specific fears and phobias in children with ASD can help educators and interventionists improve programs and services for this group of students. This information may be especially useful for clinicians, particularly those utilizing CBT as a treatment approach for children and youth with ASD. There is evidence to suggest that the interventions used to treat intense fears and phobias in children without autism (exposure, desensitization, modeling, shaping, and reinforcement) might also be effective for children who have autism. Lastly, further research is needed to investigate why some specific unusual fears are common to autism but not the general population. As more individuals with ASD communicate about their fears and reasons for their idiosyncrasies, we may come to a better understanding of autism and its symptoms.
Mayes, S. D., Calhoun, S. L., Aggarwal, R., Baker, C., Mathapati, S., Molitoris, S., & Mayes, R. D. (2013). Unusual fears in children with autism. Research in Autism Spectrum Disorders, 7, 151–158.
Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2, 217–250.
Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. Dr. Wilkinson is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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

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: 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.

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, October 6, 2014

Independent Living and Young Adults with ASD

There has been a dramatic worldwide increase in reported cases of autism over the past decade. The prevalence rates in the US have risen steadily, from one in 150, to one in 110, and now to one in every 68 American children. This represents a 78 percent increase in the number of children identified with an autism spectrum disorder (ASD) over the past decade. The 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. It is estimated that approximately 50,000 adolescents with autism will turn 18 years old this year in the U.S. As these numbers continue to rise, there is a pressing need to understand the transition experience of young adults with ASD in today’s world.
According to a study published in the journal Autism, young adults with ASD are more likely to live with their parents and least likely to live independently after leaving high school as compared to those with other types of disabilities. For the study, researchers examined the prevalence and correlates of three living arrangements (with a parent or guardian, independently or with a roommate, or in a supervised setting) among a nationally representative sample of 620 postsecondary young adults with ASD since leaving high school. They were compared with 450 individuals with intellectual disability (InD), 410 with learning disabilities (LD) and 380 with emotional disturbance (ED) who were all part of the National Longitudinal Transition Study-2, a long-term federally-funded survey of students in special education and their parents.
Compared with young adults with other disability types, young adults with an ASD were significantly more likely to have ever lived with a parent or guardian (87.1%) and less likely to have ever lived independently (16.6%) since leaving high school. In follow-up analyses, the researchers found no independent living among young adults with ASD who had been out of high school for 2 years or less at the time of the survey. In contrast, the comparable rate was 22.2% for youth in InD group.
Overall, the study’s findings show that young adults with an ASD have a different residential transition experience than their peers with LD, ED, or InD. Young adults with an ASD resided with a parent or guardian at higher rates and for longer periods of time after leaving high school than young adults with other disabilities. Moreover, young adults with an ASD had the highest rate of supervised living arrangements and the lowest rate of independent living since leaving high school. These results suggest that young adults with an ASD are particularly vulnerable during the initial years in the transition to adulthood where they experience a shift in service provision after leaving high school. Consequently, many young adults with an ASD are not experiencing opportunities to explore various residential options as young adults.
The evidence presented in this study suggests that the vast majority of young adults with ASD will be residing in the parental or guardian home during the period of emerging adulthood. The lack of services available to help young adults with ASD transition to greater independence has been noted by researchers for a number of years and has become an increasingly important issue as children identified with ASD reach adolescence and adulthood. More research is needed to identify ways to effectively implement residential transition plans that best meet the needs and pref­erences of young adults with ASD and their families. Research suggests that prolonged caregiving of an adult child with autism can adverse effects on maternal well-being. Thus, investigating a variety of in-home interventions that might improve the qual­ity of life for families and adults with ASD may be helpful in that the vast majority of young adults are residing in the parental home. Lastly, the focus of intervention/treatment must shift from remediating the core deficits in childhood to promoting adaptive behaviors in secondary education that can facilitate and enhance ultimate functional independence and quality of life in adulthood. This includes addressing new developmental challenges such as independent living, vocational engagement, postsecondary education, and family support.
Prevalence and correlates of postsecondary residential status among young adults with an autism spectrum disorder. Kristy A Anderson, Paul T Shattuck, Benjamin P Cooper, Anne M Roux and Mary Wagner. Autism published online 30 August 2013. DOI: 10.1177/1362361313481860
The online version of this article can be found at: http://aut.sagepub.com/content/early/2013/08/27/1362361313481860

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.

Thursday, August 21, 2014

Autistic Traits and Sensory Experiences in Adults

Unusual sensory processing experiences are common among individuals with autism spectrum disorder (ASD), and are now part of the Diagnostic and Statistical Manual 5th Edition (DSM-5) diagnostic criteria. Although previous research indicates that ASD traits are associated with sensory scores in the general population, it is unclear whether they characterize the “broader phenotype” of 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. 

A study published in the Journal of Autism and Developmental Disorders sought to replicate the reported relationship between ASD traits and sensory traits across the entire range of symptom severity, and to investigate its specificity in a large sample of adults both with and without ASD. Adults (n = 772) with and without an ASD were administered the Autism Spectrum Quotient (AQ) together with the Adult/Adolescent Sensory Profile (AASP), the Cardiff Anomalous Perceptions Scale (CAPS), and the Glasgow Sensory Questionnaire (GSQ), all questionnaire measures of abnormal sensory responsivity. Of the 772 participants, 23 reported having autism and 55 reported a first-degree relative with the disorder. Another 147 participants indicated having another psychiatric condition, such as depression, and 85 reported having migraine headaches on a regular basis.
The results indicated that self-reported abnormal sensory experiences were positively correlated with ASD trait scores on all three sensory questionnaires. The more autistic traits, the more sensory problems he or she reported. Individuals with the most autism traits, such as narrow interests or social difficulties, showed high levels of atypical sensory behavior on all three questionnaires. Although the study’s sample was predominantly (72 %) female, the investigators found that the relationship between sensory symptoms and ASD traits was very similar for both genders. They also found that ASD traits were correlated with levels of anxiety symptoms. Participants who reported being anxious had both more autism traits and more unusual sensory responses than those who were not anxious. This suggests that abnormalities with sensory processing and anxiety symptoms are related, yet separate, phenomena.
These results have implications for the integration of sensory processing abnormalities into the diagnosis and assessment of ASD. For example, the study confirms the association between sensory experiences and autism across the entire autism spectrum, suggesting that sensory traits might serve as a dimensional measure of the severity of ASD. It should be noted, however, that unusual sensory experiences are not unique to ASD. The researchers found that trait anxiety, a history of psychiatric conditions, and a history of migraines were all associated with higher sensory scores, even after controlling for ASD traits. Thus, individuals with these conditions may report high levels of unusual sensory experiences, which could potentially lead to a misdiagnosis of ASD. It also appears unlikely that abnormal sensory experiences underpin all ASD symptoms. Even so, it appears likely that if sensory symptoms were treated successfully, then some core ASD symptoms, such as stereotypies, might also be reduced (or vice versa). Further research is needed to examine this issue. Finally, the cognitive/biological basis of the relationship between autistic traits and sensory problems is unknown, and further work is required to determine whether improving sensory processing could effectively reduce the severity of ASD symptoms.
Horder, J., Wilson, C. E., Mendez, M. A., & Murphy, D. J. (2014). Autistic traits and abnormal sensory experiences in adults. Journal of Autism and Developmental Disorders, 44, 1461-1469.
Published online Dec 5, 2013. doi:10.1007/s10803-013-2012-7

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

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