Friday, March 20, 2015

Best Practice Review: The Gilliam Autism Rating Scale: Second Edition (GARS-2)

The GARS-2 is a revision of the widely used Gilliam Autism Rating Scale (GARS). It was designed to assist psychologists, teachers, parents, and clinicians in identifying and diagnosing autism in individuals aged 3 through 22 and in estimating the severity of the disorder. The GARS-2 can be individually administered in 5 to 10 minutes and consists of 42 items describing the characteristic behaviors of persons with autism. The items are grouped into three subscales based on two definitions of autism, one from the Autism Society of America and the other from the diagnostic criteria for autistic disorder published in the DSM-IV-TR: (1) Stereotyped Behaviors, (2) Communication, and (3) Social Interaction.

The subscale standard scores are summed to produce an Autism Index (mean = 100, SD = 15). Higher standard scores and Autism Indices are indicative of more problematic behavior. Scoring also includes a Probability of Autism classification (Very Likely, Possibly, Unlikely). 

According to the test manual, the second edition reflects several positive changes such as: (a) updated, more clearly described norms; (b) rewriting of some items and the scoring guidelines to improve clarity; and (c) a section that provides specific item definitions and examples for applied behavior analysis and research projects. New to the second edition is a structured interview form for gathering diagnostically important information from the child's parents that replaces the Early Development subscale found in the original version. The GARS-2 was normed on a representative sample of 1,107 persons with autism from 48 states within the United States. Demographic characteristics of the normative sample are keyed to the 2000 U.S. Census data. Few changes were made to GARS test items in developing the GARS-2. The difference between versions exists mostly on the fourth subscale, labeled ‘Developmental Disturbance’ on the GARS and ‘Parent Interview’ on the GARS-2.

Past reports of the GARS and GARS-2 have generally found low sensitivity and specificity, and thus indicate limited clinical utility. Independent studies on the first version of the instrument have indicated less than optimal psychometric properties, with sensitivity values ranging from .38 to .53. Sensitivity is the percentage of true cases correctly identified by a screen; a sensitivity value of .80 is the accepted standard. Although there may be some psychometric support for the use of the GARS-2 as a screening tool, sensitivity estimates suggest that the instrument results in a high percentage of false negative results for ASD. For example, a recent empirical study of the GARS-2 screening sensitivity found that when it was completed by special education teaching staff, the Autism Index Score would likely miss one-third of cases with ASD. 

Despite the support reported in the GARS-2 manual, concerns have been noted regarding its test structure, standardization sample characteristics, online recruitment, and lack of diagnostic confirmation. A study of the validity of the GARS-2 three subscales did not support the subscale structure and suggests that the clinical utility of the scales is limited by factors related to item content and test development procedures, and that the Autism Index be interpreted with caution. The Probability of Autism classification also lacks a sound empirical basis and may be subject to misinterpretation. There are also questions regarding the normative sample. Group membership was determined via caregiver report of diagnosis and/or school classification. A number of participants (27%) were recruited from the Asperger Syndrome Information and Support website, suggesting that a portion of the sample may have included individuals with other pervasive developmental disorders. Moreover, diagnosis of participants was not confirmed by the ADI-R, ADOS, or a clinical evaluation. Although the norms are not based upon age, the underrepresentation of older children and young adults also suggests that practitioners need to use caution when using the instrument with individuals from these age groups. From a more positive perspective, the content of the GARS-2 reflects a number of behavioral characteristics associated with ASD which may help guide the user in understanding the core features of autism. 

According to the manual, the GARS-2 should be administered by professionals who have training and experience in working with individuals with autism such as school psychologists, educational diagnosticians, and autism specialists. Practitioners who are currently using or considering using the GARS/GARS-2 for making an autism diagnosis or assessing symptom severity should exercise caution due to significant weaknesses, including low sensitivity and questions concerning standardization and norming procedures. Although the GARS-2 may have utility as a general screening or supplementary tool for ASD. it should only be used with caution and clearly not in isolation. It is not recommended for inclusion as a core autism-specific instrument in a comprehensive developmental assessment battery for ASD or for making special education eligibility decisions. 

The most recent edition of the GARS (GARS-3) has undergone significant changes when compared with earlier versions of the instrument. The GARS-3 retained only 16 items from the previous version while adding 42 new items to the rating scale. It was also updated to reflect changes in the DSM-5 criteria. New normative data were collected in 2010-2011 that were consistent with demographic characteristics reported in the 2010 U.S. Census. A recent review of the test’s development and standardization advises examiners to use caution when using the GARS-3 to assess individuals between 20 and 22 as well as individuals from minority groups. Although the GARS-3 appears to represent some improvements over its predecessor, there is a need for independent empirical evaluation of the new edition’s diagnostic validity and utility with population-based and clinically-referred samples. 
References

Garro, A. (2006). Review of the Gilliam Autism Rating Scale-Second Edition. Seventeenth mental measurements yearbook with Tests in Print, Buros Institute of Mental Measurement. Lincoln: University of Nebraska Press.

Gilliam, J. (2006). GARS-2: Gilliam Autism Rating Scale-Second Edition. Austin, TX: PRO-ED.

Gilliam, J. E. (2014). Gilliam Autism Rating Scale–Third Edition (GARS-3). Austin, TX: Pro-Ed.

Hampton, J., & Strand, P. (2015). A review of level 2 parent-report instruments used to screen children aged 1.5-5 for autism: A meta-analytic update. Journal of Autism and Developmental Disorders, 45(3). Advance online publication. doi: 10.1007/s10803-015-2419-4.
Karren, B. C. (2017). Test Review. Gilliam, J. E. (2014). Gilliam Autism Rating Scale–Third Edition (GARS-3). Austin, TX: Pro-Ed. Journal of Psychoeducational Assessment, Vol. 35(3) 342–346.

Lecavalier L. (2005). An evaluation of the Gilliam Autism Rating Scale. Journal of Autism and Developmental Disorders, 35, 795-805.

Mazefsky, C., & Oswald, D. (2006). The discriminative ability and diagnostic utility of the ADOS-G, ADI-R, and GARS for children in a clinical setting. Autism, 10(6), 533–549.

Norris, M., & Lecavalier, L. (2010). Screening accuracy of level 2 autism spectrum disorder rating scales: A review of selected instruments. Autism, 14, 263-284.
Pandolfi V., Magyar C. I., & Dill C. A. (2010). Constructs assessed by the GARS-2: factor analysis of data from the standardization sample. Journal of Autism & Developmental Disorders, 40, 1118-30. 
Volker, M. A., Dua, E. H., Lopata, C., et al., (2016). Factor structure, internal consistency, and screening sensitivity of the GARS-2 in a developmental disabilities sample, Autism Research and Treatment, vol. 2016, Article ID 8243079, 12 pages, 2016. doi:10.1155/2016/8243079
Wilkinson, L. A. (2016). A best practice guide to assessment and intervention for autism spectrum disorder in schools. Philadelphia & London: Jessica Kingsley Publishers.

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 disorders. 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).

Monday, March 2, 2015

Improving Maternal Mental Health After a Child's Diagnosis of Autism Spectrum Disorder

Parents worldwide often experience a range of emotions when their child is first diagnosed with autism, including shock, sadness and grief, anger, and loneliness. Mothers, in particular, appear to face unique challenges that potentially have an impact on their mental health and wellbeing. This includes high levels of psychological distress, depressive symptoms, and social isolation. Almost 40% of mothers report levels of clinically significant parenting stress and between 33% and 59% report significant depressive symptoms following a diagnosis of autism spectrum disorder (ASD). The prevalence of psychological distress among mothers of children with ASD suggests a need to address parental mental health during the critical period after the child’s autism diagnosis and when parents are learning to navigate the complex system of autism services.
A study published in the journal Pediatrics examined whether a brief cognitive behavioral intervention, problem-solving education (PSE), decreases parenting stress and maternal depressive symptoms during the period immediately following a child’s diagnosis of ASD. A randomized clinical trial compared 6 sessions of PSE with usual care. Settings included an autism clinic and 6 community-based early intervention programs. Participants were mothers of 122 young children who recently received a diagnosis of ASD. The intervention group received PSE, a manualized cognitive behavioral intervention delivered in six 30-minute individualized sessions. The usual care group mothers received the services specified in the child’s Individualized Family Service Plan or Individualized Educational Plan which typically includes speech and language therapy, occupational therapy, and social skills training. Neither specifically includes parent-focused mental health services.
The results indicated that at a 3-month follow-up assessment, PSE mothers were significantly less likely than those serving as controls to have clinically significant parental stress (3.8% vs 29.3%). For depressive symptoms, the risk reduction in clinically significant symptoms did not reach statistical significance; however, the reduction in mean depressive symptoms was statistically significant. The findings demonstrate evidence of PSE’s short-term efficacy and potential to reduce clinically significant psychological distress during this critical juncture—when parents first learn of an ASD diagnosis and must navigate a complex service system on their child’s behalf.
The findings have implications for clinical practice. Practitioners need to be aware that parents experience a myriad of emotions when receiving a diagnosis of ASD and many go through stages of grief. Likewise, professionals working with families of children with an ASD should be aware of negative effects of stress and anxiety and assist in offering services that directly address parental needs and support maternal mental health. Strengthening maternal problem-solving skills might serve as a buffer against the negative impact of life stressors and thereby reduce parental stress and attenuate depressive symptoms in the months immediately following a child’s ASD diagnosis. Future research is needed to examine the effect of intervention over a longer follow-up period and to assess whether the intervention worked differently among subgroups of mothers, which could help better identify those who are most likely to benefit from the intervention.
Improving Maternal Mental Health After a Child’s Diagnosis of Autism Spectrum Disorder: Results From a Randomized Clinical Trial. Emily Feinberg, CPNP, ScD; Marilyn Augustyn, MD; Elaine Fitzgerald, DrPH; Jenna Sandler, MPH; Zhandra Ferreira-Cesar Suarez, MPH; Ning Chen, MSc; Howard Cabral, PhD; William Beardslee, MD; Michael Silverstein, MD, MPH. JAMA Pediatrics. doi:10.1001/jamapediatrics.2013.3445
Published online November 11, 2013.
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 disorders. 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).

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