Thursday, January 15, 2015

Sleep Problems in Children on the Autism Spectrum

It is well documented that in addition to the core symptoms of social/communication deficits and restricted repertoire of behaviors, children with autism spectrum disorders (ASD) often experience other comorbid (co-occurring) conditions. In fact, studies estimate that approximately 70 to 84 percent of children with ASD might meet the criteria for a comorbid psychiatric disorder. Co-occurring conditions include mental health (anxiety, depression), neurological (seizure disorder), physical (cerebral palsy, atypical gait), and medical (allergies, asthma) conditions. In addition, unusual responses to sensory stimuli, chronic sleep problems, and low muscle tone can occur in individuals with ASD.
Most parents have had some experience with a child who has difficulty falling asleep; wakes up frequently during the night, and/or only sleeps a few hours each night. Although temporary sleep difficulties are an expected phase of child development, ongoing and persistent sleep disturbances can have an adverse effect on the child, parents and other family members. Indeed, a child’s sleeping problems can quickly become a daily parenting challenge. Consequently, we should also expect that sleep problems in children and adolescents with ASD will represent an additional burden on their families, as they attempt to deal with the challenges associated with the symptoms of ASD.  Moreover, there is evidence to suggest that insomnia in itself can aggravate autistic symptoms and further impair adaptability.
Children with ASD appear to experience sleep disturbances more frequently and intensely than typically developing children. Previous population-based and retrospective clinical studies have found a high rate of sleep onset problems in young children with ASD compared to typically developing children. Emotional and behavioral problems are related to sleep problems in the general child population, and have also been associated with sleep problems in children with ASD. For example, a previous study of children with Asperger syndrome or high-functioning autism found that those with chronic insomnia were characterized by more co-existing emotional and behavioral symptoms than their peers. Although research suggests that children with ASD have a high rate of sleep problems, even when adjusted for other mental health problems, the lack of longitudinal data and population based studies has limited our ability to understand the complex relationship between co-occurring emotional and behavioral problems and sleep difficulties in this group of children. In order to examine the need for increased sleep health care in children with ASD, sleep problems should be longitudinally studied in a total population setting. This approach allows researchers to examine potential risk factors and assess the development of sleep problems over time, as well as plan for early prevention and identification.
A longitudinally-based study published in the journal Autism examined the prevalence and chronicity of sleep problems in children with problems believed to be typical of Autism Spectrum Disorders (ASD). This large Norwegian study followed 3700 children from ages 7-9 to 11-13. The children were assessed for autistic symptoms, sleep problems, and emotional and behavioral problems. Approximately 1% of the chil­dren met the criteria for autism. Overall, the frequency of chronic insomnia was more than ten times higher in autistic children compared to non-autistic children (39.3% v 3.6%). These children also developed more sleep problems over time, with an incidence rate at of 37.5% compared to 8.6% in the controls at age 11-13 years. Likewise, sleep problems were more persistent over time in children with autistic symptomatology, with a remission rate of only 8.3% compared to 52.4% in the control group. Despite few girls being represented in the study, the authors found that sleep problems were significantly less prevalent in girls than boys, and that their sleep problems were also more transient. The presence of comorbid Attention-Deficit/Hyperactivity Disorder (ADHD) was a strong and independent risk factor for sleep problems in the ASD group. While emotional and behavioral problems explained a large proportion of the association between sleep problems and autism, children with autistic symptoms had a three-fold increased risk of sleep problems, even when taking into account other explanatory factors, such as gender, family income, parental educa­tion, and intellectual disability.
The results of this longitudinal population-based study show a clear association between autism symptoms and sleep problems and support the generally high prevalence rates of sleep problems (56–68%) reported in children with autism. The authors call for increased awareness of sleep problems in children with autistic symptoms and argue for the assessment and treatment of sleeping problems as a standard and integrated part of the assessment and treatment of ASD. This includes both behavioral and pharmacological interventions. They note that “Diagnosing and treating insomnia in children with ASD is thus important both to relieve symptoms of autism, improve quality of life for the children and their families, and may even improve long-term outcome.”
Sivertsen, B., Posserud, M., Gillberg, C., Lundervold, A. J., & Hysing, M. (2012). Sleep problems in children with autism spectrum problems: A longitudinal population-based study. Autism, 16, 139-150. DOI: 10.1177/1362361311404255

© Lee A. Wilkinson, PhD

Wednesday, January 14, 2015

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

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

Monday, January 12, 2015

Executive Function (EF) Assessment in Autism Spectrum Disorder

Research evidence suggests that deficits in executive function (EF) are an important feature of autism spectrum disorder (ASD). Executive function is a broad term used to describe the higher-order cognitive processes such as response initiation and selection, working memory, planning and strategy formation, cognitive flexibility, inhibition of response, self-monitoring and self-regulation. It is generally acknowledged that these higher order processes are associated with the prefrontal cortex, which are necessary for regulating and controlling behavior. Executive functions include the many of the skills required to prepare for and execute complex behavior, such as planning, inhibition, organization, self-monitoring, cognitive flexibility, and set-shifting. 

Markers of executive dysfunction may include difficulty initiating action, planning ahead, inhibiting inappropriate responses, transitioning, switching flexibly between response sets, and poor self-monitoring. Indeed, poor performance monitoring and self-regulation may be associated with the core features of ASD such as a lack of social reciprocity, perseverative responses, and intense emotional responses to change (e.g., meltdowns). Moreover, school success depends on mastery of basic EF skills, including remembering and following instructions, completing tasks independently and smoothly transitioning between tasks, and inhibiting inappropriate behaviors. Consequently, EF plays an important role in the acquisition of knowledge and social skills; the better children are at focusing and refocusing their attention, holding information in mind and manipulating it (i.e., working memory), resisting distraction, and adapting flexibly to change, the more positive the social, adaptive, and academic outcomes.
It is important to note, however, that executive function deficits are not experienced by all individuals on the autism spectrum nor do they appear to play a primary causal role in ASD. Nevertheless, executive dysfunction places a child at-risk and is likely to have an adverse impact on many areas of everyday life and affect adaptability in several domains (personal, social and communication). Consequently, an assessment of executive function can add important information about the child’s strengths and weaknesses and assist with intervention/treatment planning. The following measures may be included in a comprehensive developmental assessment battery for ASD.
§         The Delis-Kaplan Executive Function System (D-KEFS; Delis, Kaplan, & Kramer, 2001) was co-normed on a large and representative national sample designed exclusively for the assessment of executive functions, including flexibility of thinking, inhibition, problem solving, planning, impulse control, concept formation, abstract thinking, and creativity. The D-KEFS, is composed of nine stand alone tests that can be individually or group administered that provides a standardized assessment of executive functions in children and adults between the ages of 8 and 89.
§         The Developmental Neuropsychological Assessment, Second Edition (NEPSY–II: Korkman et al., 2007) measures several neuropsychological abilities and was normed on children 3 to 16 years to 11 months of age. The NEPSY-II assesses six domains: 1) Attention and Executive Functioning, 2) Language, 3) Memory and Learning, 4) Sensorimotor, 5) Social Perception and 6) Visuospatial processing. It offers 32 subtests that the examiner can tailor to the specific examinee. In addition to tests of memory and executive functioning, the NEPSY-II also includes tests on Theory of Mind (which assesses the ability to recognize the feelings and thoughts of others) and Affect Recognition (which measures the ability to recognize feelings expressed on faces), both of which should be useful for assessing children on the spectrum.
§         The Wide Range Assessment of Memory and Learning, Second Edition (WRAML-2; Sheslow & Adams, 2003) is a direct assessment of both immediate and delayed memory ability, as well as the acquisition of new learning that can be useful in evaluating learning and school-related problems of students with ASD. This comprehensive measure includes a Core Battery and supplemental subtests that provide index scores for General Memory, Verbal Memory, Visual Memory, Working Memory, and Attention and Concentration. A brief four subtest Memory Screening Form that correlates highly with the full test is also available.
§         The Behavior Rating Inventory of Executive Function, Second Edition (BRIEF- 2; Gioia, Isquith, Guy, & Kenworthy, 2015) is a parent-or-teacher rated questionnaire for children ages 5 to 18 years of age that can be used to assess executive functioning in ASD. The BRIEF-2 is comprised of the following scales: Inhibit, Shift, Emotional Control, Initiate, Working Memory, Plan/Organize, Organization of Materials, Task-Monitor, and Self-Monitor. Summary indexes include Behavior Regulation (BRI), Emotion Regulation (ERI), Cognitive Regulation (CRI) and an overall score, the Global Executive Composite (GEC). The BRIEF-2 also includes a self-report measure for children and adolescents 11-18 years of age.
Because executive functions are important to social competence, academic success, and overall adaptability, these measures enable practitioners to assess impaired multi-task performance, document the impact of executive function deficits on functioning, and to plan educational interventions and classroom accommodations. Further information on best practice guidelines for assessment of ASD is available from the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He 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. Dr. Wilkinson is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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