Saturday, May 30, 2015

Best Practice Review: The Pragmatic Language Skills Inventory (PLSI)

The assessment of communication skills is vital component of a comprehensive assessment for children with autism spectrum disorders (ASD). A best practice communication assessment should provide information about the child’s communicative abilities in both the verbal and nonverbal domains, and should not be limited to the formal, structural aspects of language (e.g., articulation and receptive/ expressive language functioning). Particular attention should be given to the pragmatic, social communicative functions of language (e.g., turn taking, understanding of inferences and figurative expressions) as well as to the nonverbal skills needed to communicate and regulate interaction (e.g., eye contact, gesture, facial expression, and body language).

Assessments to identify pragmatic language deficits are not as well developed as tests of language fundamentals. Few standard measures are available to assess these skills in higher functioning children with ASD. Valid norms for pragmatic development and objective criteria for pragmatic performance are also limited. Available standardized instruments that focus specifically on pragmatic language include the Test of Pragmatic Skills (TPS), the Comprehensive Assessment of Spoken Language (CASL), the Test of Pragmatic Language, 2nd Edition (TOPL-2), the Test of Language Competence (TACL), the Children's Communication Checklist-Second Edition (CCC-2) and the Pragmatic Language Skills Inventory (PLSI). 

The Pragmatic Language Skills Inventory (PLSI) is a norm referenced rating scale designed to assess the pragmatic language skills of children between 5 and 12 years of age. It can also be used to specify therapy goals for these children, conduct follow-up evaluations, and document progress. The PLSI consists of 45 items that comprise three subscales (each with 15 items):
  • Personal Interaction Skills (initiating conversation, asking for help, participating in verbal games, and using appropriate nonverbal gestures)
  • Social Interaction Skills (when to talk and when to listen, understanding classroom rules, taking turns in conversations, and predicting consequences) 
  • Classroom Interaction Skills (using figurative language, maintaining topic, explaining how things work, writing stories, and using slang)
The test takes 5 to 10 minutes to complete by an adult (e.g., parent, teacher, teacher assistant) who assigns each item a score from 1 to 9 based on his or her knowledge of the child and that of children of the same age and gender regarding a particular skill (e.g., writing a good story, taking turns in conversation, asking for help or favors). The authors specify that the rater should know the child well and be familiar with that child's language skills. Scoring and interpretation are made by a qualified examiner (e.g., speech-language pathologist, school psychologist).
Once the rater has assigned scores for all 45 items, the examiner derives percentile ranks and standard scores (mean = 10, SD = 3) for each of the subscales. Standard scores for the three subscales are summed to determine a child's Pragmatic Language Index (PLI) score (mean = 100, SD = 15) and overall percentile rank. The PLI is considered the best estimate of a student’s pragmatic language ability and the score that should be used by examiners to identify students who may have a pragmatic language deficit. Descriptive scores for the subscales and PLI range from “Very Poor” to “Very Superior.” Generally, scores in the Below Average, Poor, and Very Poor ranges suggest a pragmatic language disorder (PLI < 89).
Psychometric Characteristics
The PLSI was standardized on 1,175 students (610 boys, 565 girls) between 5 and 12 years of age. The sample represents the U.S. population of school-age children with respect to geographic region, gender, race, ethnicity, and disability status. Reliability data are reported in the manual and indicate high levels of internal consistency, excellent interrater agreement, and good test-retest reliability.
The test manual also reports information for content, criterion, and construct validity. Construct validity is reportedly high. Criterion-related validity (concurrent validity) was established by correlating scores of the PLSI with performance on the Test of Pragmatic Language (TOPL). There was a strong relationship between the two measures, indicating that the PLSI and TOPL measure very similar constructs (e.g., pragmatic language). The diagnostic validity of the test was assessed by comparing test scores for a group of 40 students with disabilities (autism, learning disability, attention-deficit/hyperactivity disorder, and intellectual disability), a group of 45 gifted and talented students, and the normative sample. As expected, the PLI scores for the students with disabilities were significantly lower than those in the other two groups. Students with autism and intellectual disability received the lowest scores among the various diagnostic groups.
Speech-language evaluations for any child with communication concerns should include a screening of the child's social-communication skills. Norm-referenced parent and teacher report measures such Pragmatic Language Skills Inventory (PLSI) provides a time-efficient option for screening children's social-communication skills. If such screening reveals concerns about a child's skills, a more comprehensive evaluation should be completed.
As with all tests, the PLSI has strengths and weaknesses. A strength is its standardization with a representative sample of the U.S. population. The PSLI also demonstrates high levels of internal consistency, excellent interrater agreement, good test-retest reliability, and correlates highly with Test of Pragmatic Language (TOPL). The record forms are clear and easy to follow for the many individuals who are likely to administer, score, and interpret the test. The PLSI has an especially important advantage of sampling pragmatic skills in the child’s natural environment.
A relative weakness involves the selection of an individual who knows a child well enough to accurately rate his or her pragmatic skills. Although no special training is required to make PSLI ratings, the rater is expected to have some basic knowledge and experience with behavior rating scales. According to the manual, the rater should also “have a good grasp of what is typical or average behavior for the child's age and gender.” Consequently, it may be problematic to assume that a parent, teacher's assistant, or classroom teacher would know when a child was advanced, average, or behind on the type of pragmatic abilities assessed on the PLSI. It should be noted, however, that the examiner can complete the PLSI with teachers in a structured interview format. Although the authors conclude that “The work we have done so far should be sufficient to establish the PSLI as a promising alternative way of identifying students who have a pragmatic language disorder,” further research is needed to examine the instrument’s accuracy (sensitivity) in predicting group membership (normative sample and clinical groups).
In conclusion, the PSLI is a brief, quantitative measure based on naturalistic observations of parents and teachers that can be used as an effective screener in clinical or educational settings, an aid to clinical diagnosis, or a measure of response to intervention.  Of course, the PSLI should not be used in isolation to make decisions regarding classification and intervention planning. Results from other instruments, direct observations, and parent interviews provide valuable information for identifying social communication deficits in children on the autism spectrum (see Wilkinson for a description of assessment domains and recommended measures).

Gilliam, J. E., & Miller, L. (2006). Pragmatic Language Skills Inventory. Austin, TX: Pro-Ed.
Review of the Pragmatic Language Skills Inventory. Guyette, T. & Kelly, D. (2007). Buros Institute of Mental Measurements, 461-466.

Twachtman-Cullen, D., & Twachtman-Bassett, J. (2014). Language and social communication. In L. A. Wilkinson (Ed.), Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 101-124). Washington, DC: American Psychological Association.
Wilkinson, L. A. (2016). Best practice in assessment. In L. A. Wilkinson, A best practice guide to assessment and intervention for autism spectrum disorder in schools (pp. 46 -95). 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, May 11, 2015

Cognitive-Behavioral Therapy (CBT) for Children on the Autism Spectrum

Children with autism spectrum disorders (ASD) frequently have co-occurring (comorbid) psychiatric conditions, with estimates as high as 70 to 84 percent. A Comorbid disorder is defined as a disorder that co-exists or co-occurs with another diagnosis so that both share a primary focus of clinical and educational attention. Although anxiety is not a defining characteristic of ASD, prevalence rates are significantly higher in children with ASD than in typically developing children, children with language disorders, chronic medical conditions, disruptive behavior disorders, and intellectual disability or epilepsy. In fact, research suggests that approximately one-half of children with ASD would meet the criteria for at least one anxiety disorder. Several studies have also reported a bidirectional association between internalizing disorders and autistic symptoms. For example, both a higher prevalence of anxiety disorders has been found in ASD and a higher rate of autistic traits has been reported in youths with mood and anxiety disorders. Individuals with ASD also appear to display more social anxiety symptoms compared to typical control individuals, even when these symptoms are clinically overlapping with the characteristic social problems typical of ASD. With comorbidity rates so elevated in the ASD population, treatment options for anxiety have become increasingly important.
Cognitive-Behavioral Therapy
There is a strong evidence base for the use of cognitive-behavioral therapy (CBT) interventions for depression and anxiety in non-ASD populations. There are a variety of CBT approaches, but most share some common elements. The primary goals of traditional CBT are to identify and challenge dysfunctional beliefs, catastrophic cognitions, and automatic thoughts as well as change problematic behavior. With a therapist’s help, the individual is encouraged to challenge his or her beliefs and automatic thoughts through a variety of techniques. Through CBT, the individual learns skills to modify thoughts and beliefs, as well as problem-solving strategies to improve interaction with others in effective and appropriate ways, thereby promoting self-regulation.
CBT models for the treatment of anxiety attempt to create a new coping pattern by using behavioral techniques such as modeling, exposure, and relaxation as well as cognitive techniques addressing cognitive distortions and deficiencies. These treatment models generally emphasize four critical components of therapy: assessment, psychoeducation, cognitive restructuring, and exposure. Using these four components, CBT has been shown to be an empirically supported treatment for typically developing children with anxiety issues. The most commonly used techniques to treat anxiety in children are exposure, relaxation, cognitive restructuring, and modeling in that order.
Cognitive-Behavioral Therapy for ASD
Although CBT has been shown to be an effective empirically supported treatment for typical children, there is a question as to whether or not it can be used with other populations. In recent years, there have been a number of attempts to adapt CBT for children and teens on the autism spectrum. Although there is no agreed upon set of modifications, there appears to be a general consensus that with certain specific modifications, CBT can be used to effectively lessen anxiety symptoms in higher functioning children with ASD. Evidence from the current literature supports a specific blend of techniques and strategies as the most effective approach to modify CBT for use with children who have an ASD. The primary modifications to CBT that have been shown to make them more viable for anxious children with ASD are the development of disorder specific hierarchies, the use of more concrete, visual tactics, the incorporation of child specific interests, and parent participation.
A study published in the Journal of Child Psychology and Psychiatry illustrates how a standard CBT program can be adapted to include multiple treatment components designed to accommodate or remediate the social and adaptive skill deficits of children with ASD that serve as barriers to anxiety reduction. The study tested a modular CBT program incorporating separate modules focusing specifically on deficits associated with ASD such as poor social skills, self-help skills, and stereotypies as well as a modified version of a traditional CBT protocol utilizing primarily cognitive restructuring and exposure techniques. The participants were forty children (7–11 years of age) who met the criteria for ASD and one of the following anxiety disorders: separation anxiety disorder (SAD), social phobia, or obsessive-compulsive disorder (OCD). They were randomly assigned to 16 sessions of CBT or a 3-month waitlist (36 children completed treatment or waitlist). The CBT model emphasized coping skills training (e.g., affect recognition, cognitive restructuring, and the principle of exposure) followed by in vivo exposure. The parent training components focused on supporting in vivo exposures, positive reinforcement, and communication skills. Independent evaluators blind to treatment condition conducted structured diagnostic interviews and parents and children completed anxiety symptom checklists at baseline and posttreatment/postwaitlist. The researchers found that 92.9% of children in the active treatment group met criteria for positive treatment response post-treatment compared to only 9.1% of children in the waitlist condition. In addition, 80% of children in the active treatment group were diagnosis free at follow up. From these results, it is reasonable to draw the conclusion that with specific modifications, CBT can be an effective treatment for children with ASD and concurrent anxiety disorders.
The above referenced study, together with case studies and other clinical trials, provides evidence that incorporating disorder specific hierarchies, use of more concrete, visual tactics, incorporation of child specific interests, and parental involvement can facilitate successful results when conducting CBT for anxiety in children with ASD. Although there is support for the efficacy of an enhanced CBT program, there are some limitations to these modifications and adapted models. Specifically, the child’s level of functioning, variation in the use of each modification, and the utilization of different CBT programs across studies affect the generalization of the outcomes. Moreover, there is a need to examine to what extent CBT with these modifications could be used with more severe cases of ASD or in cases where there is more severe intellectual impairment. Children with higher functioning ASD may be able to better process the cognitive components of traditional and modified CBT than those who are lower functioning. Additionally, different CBT programs may emphasize different components of CBT making it difficult to determine which components are the most critical for treating anxiety in children with ASD. The next step for future research should be to focus on developing a standardized approach to treatment which incorporates specific modifications, randomized clinical trials to test the approach, and explorations of the boundaries within the ASD population for use and effectiveness of treatment. Given the elevated comorbidity rates, finding an effective, empirically supported treatment for anxiety in children with ASD is critical.

Key References and Further Reading
Moree, B. N., & Davis III, T. E. (2010). Cognitive-behavioral therapy for anxiety in children diagnosed with autism spectrum disorders: Modification trends. Research in Autism Spectrum Disorders, 4, 346–354.

National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author.

National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices.

Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S… Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group.

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.

Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224–234.
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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