Friday, June 19, 2015

Best Practice Review: Childhood Autism Rating Scale, Second Edition (CARS 2)

The Childhood Autism Rating Scale, Second Edition (CARS 2), consists of two 15-item rating scales completed by the practitioner and a Parent/Caregiver Questionnaire. The Standard Version Rating Booklet (CARS 2-ST) is equivalent to the original CARS and is used with children younger than 6 years of age and those with communication difficulties or below-average cognitive ability. The High-Functioning Version Rating Booklet (CARS 2-HF) is an alternative for assessing verbally fluent children and youth, 6 years of age and older, with average or above intellectual ability. The Questionnaire for Parents or Caregivers (CARS 2-QPC) is an unscored questionnaire designed to obtain pertinent developmental information from parents or caregivers. 

The CARS 2-ST and CARS 2-HF each include 15 items addressing the following functional areas:
  • Relating to People
  • Imitation (ST); Social-Emotional Understanding (HF)
  • Emotional Response (ST); Emotional Expression and Regulation of Emotions (HF)
  • Body Use
  • Object Use (ST); Object Use in Play (HF)
  • Adaptation to Change (ST); Adaptation to Change/Restricted Interests (HF)
  • Visual Response
  • Listening Response
  • Taste, Smell, and Touch Response and Use
  • Fear or Nervousness (ST); Fear or Anxiety (HF)
  • Verbal Communication
  • Nonverbal Communication
  • Activity Level (ST); Thinking/Cognitive Integration Skills (HF)
  • Level and Consistency of Intellectual Response
  • General Impressions
Items on the Standard form duplicate those on the original CARS, while items on the HF form have been modified to reflect current research on the characteristics of higher functioning children with autism spectrum disorder (ASD). To complete the ratings on the CARS 2-HF, the professional must have convergent information from MULTIPLE sources such as direct observation, parent and teacher interviews, prior assessments of cognitive functioning and adaptive behavior, and information from the Questionnaire for Parents or Caregivers (CARS 2-QPC). Ratings are based not only on frequency of the behavior in question, but also on its intensity, atypicality, and duration. Rating values for all items are summed to produce a Total Raw Score. Each form includes a graph that allows the practitioner quickly convert the Total Raw Score to a standard score or percentile rank (based on a clinical sample of individuals diagnosed with autism spectrum disorders). 
The psychometric properties of the CARS 2-HF indicate a high degree of internal consistency and good interrater reliability. Validity information reports an overall discrimination index value of .93, with sensitivity and specificity values of .81 and .87, respectively. The HF form also demonstrates a relatively strong relationship with the “gold standard” Autism Diagnostic Observation Schedule (ADOS).

The following are critical features of the CARS 2-HF.
1. Parents and teachers should NOT be asked to complete the CARS 2 forms. Only well-informed professionals should complete the ratings.
2. The CARS 2 should NOT be used for screening in the general school-age population.
3. The practitioner must have a good understanding of the criteria for making the ratings and be in a position to collect information from multiple sources (direct observation, parent and teacher reports, prior assessments and clinical impressions).
4. The ratings from the CARS 2 should be considered as only one part of a multimodal, multidisciplinary decision-making process in the identification of children with ASD.
5. Direct observation and a developmental history MUST always be included in the assessment process.
6. Scores on the CARS 2 are interpreted relative to the level (severity) of autism-related behaviors compared to a clinical sample of individuals diagnosed with autism, NOT the typical individual.
In summary, The CARS 2-HF represents an important alternative that will be welcomed by school-based professionals such as school psychologists and speech/language pathologists. It is a sensitive and reliable instrument that will find a place in the school-based professional’s assessment “Tool Box.” Given the dramatic increase in the numbers of students being referred for screening and assessment, the CARS 2-HF is a useful instrument that helps quantify the level of symptom severity and importantly, assist with intervention and program planning. The CARS 2-HF scores are particularly helpful in identifying more capable children with autism spectrum disorder. Of course, the CARS 2 is not intended to be and should not be used as the sole instrument in making diagnostic or classification decisions. An example of a comprehensive assessment battery can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).
Schopler, E, Van Bourgondien, M. E., Wellman, G. J., & Love, S. R. (2010). Childhood Autism Rating Scale, Second Edition. Los Angeles, CA: Western Psychological Services.
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)

Thursday, June 18, 2015

Gross Motor Performance in Children on the Autism Spectrum

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. Although motor impairment is not a part of the diagnostic criteria for ASD, research suggests that many children with ASD experience delays in motor development. Gross motor skills are fundamental skills necessary for movement competence and considered the basic building blocks for more complex motor skill development. When present, gross motor problems may interfere with performance in many developmental and functional domains across home and school contexts. Consequently, researchers are increasingly considering the importance of motor function in the assessment and treatment of children with ASD.
                                                                          
           Research

A study published in the Journal of Child and Adolescent Behavior focused on assessing the gross motor skill performance of 21 children with ASD (M=7.57 years) and 21 age matched typically developing children (M=7.38 years) using the Test of Gross Motor Development-2 (TGMD-2). The TGMD-2 is a norm and criterion-referenced test that measures performance of 12 gross motor skills. Scores are recorded on two subtests, locomotor subtest (run, gallop, hop, leap, jump, and slide) and object-control subtest (strike, dribble, catch, kick, throw, and roll), An overall gross motor quotient score (combination of all 12 gross motor skills) can also obtained. Scores are described as very superior, superior, above average, average, below average, poor, and very poor. The researchers hypothesized that children with ASD would show motor delays in overall gross motor quotient scores, and locomotor and object control standard scores when compared to their age matched typically developing peers as measured with TGMD-2.
                                                                                Results

Statistical analysis revealed a significant performance difference between children with ASD and typically developing children on the TGMD-2. For the locomotor subtest, 67% children with ASD received poor standard scores and 40% of scores were very poor. Approximately 60% children with ASD had poor standard scores and 33% of scores were very poor on object control skills. For overall gross motor quotient scores, 81% children with ASD were below 79 and classified as poor, and approximately 76% children scored below 70 and received very poor ratings. Children scoring at or below the 30th percentile were considered developmentally delayed as indicated in the Individuals with Disabilities Education Act (IDEA). Based on this criterion, 91% of children with ASD in the current study were considered developmentally delayed in terms of their gross motor skill performance and in need of early supportive interventions. In contrast, the majority of typically developing children’s standard scores (96%) fell in the average or higher range.

                                                                            Implications
According to the authors, the results of this study have several important implications for educators, therapists, and practitioners and the design of effective early intervention programs for children with ASD. For example, locomotion and object control skills are fundamental motor skills in which children interact with their environment and other children. Developing a therapeutic intervention that includes these gross motor skills may have a positive effect on children’s cognitive functioning, language development, social communicative skills, and contribute positively to daily life skills. Consequently, it is vital that we understand the gross motor performance of children with ASD. Finally, the significance of motor proficiency for children with ASD should not be overlooked in assessment practice. Clinicians and practitioners should give increased attention to the assessment of motor skills and their impact on the adaptive behavior and well-being of children with ASD. A comprehensive discussion of assessment domains (e.g. communication, social, motor, sensory, academic) can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Liu T, Hamilton M, Davis L, ElGarhy S (2014) Gross Motor Performance by Children with Autism Spectrum Disorder and Typically Developing Children on TGMD-2. J Child Adolesc Behav 2: 123. doi:10.4172/jcalb.1000123
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)

Friday, June 12, 2015

Best Practice Review: Autism Spectrum Rating Scales™ (ASRS)



The Autism Spectrum Rating Scales™ (ASRS®; Goldstein & Naglieri, 2009) are designed to measure behaviors, symptoms, and features associated with the Autism Spectrum Disorders (ASD) in children and adolescents aged 2 through 18 years. This standardized, norm-referenced instrument was initially developed to assess a wide range of behaviors associated with Autistic Disorder, Asperger’s Disorder (syndrome), and PDD-NOS, and incorporates symptom criteria from the DSM-IV-TR. The ASRS was standardized and normed on a large sample of 2,560 participants approximating the U.S. general population. Clinical samples were also created by collecting ratings from children and youth with clinical diagnoses (ASD, ADHD, Mood Disorders, Anxiety Disorders, Developmental Delay, and Communication Disorders).  

The ASRS have been updated to align with the revised Autism Spectrum Disorder (ASD) criteria published in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This includes the replacement of the DSM-IV-TR Scale with the new DSM-5 Scale (this scale now includes items related to hyper and hypo-reactivity to sensory input, or unusual interest in sensory aspects of the environment). A DSM-IV-TR scoring option is still available to accommodate those users who would like to continue to generate reports with the DSM-IV-TR Scale. The terminology used in the reports has also been updated to match the changes in the DSM-5. For example, references to Autistic disorder or Asperger’s disorder have been removed, and the plural term “Autism Spectrum Disorders” has been replaced with the single diagnostic category “Autism Spectrum Disorder.” The final change includes the removal of the Delay of Communication items from the scoring algorithms.
The ASRS has full-length and short forms for young children aged 2 to 5 years, and for older children and adolescents aged 6 to 18 years. The full-length ASRS (2−5 Years) consists of 70 items, and the full-length ASRS (6−18 Years) contains 71 items. Separate parent (ASRS Parent Ratings) and teacher (ASRS Teacher Ratings) rating forms are available for each age group. The full-length form provides the most comprehensive assessment information, including the Total Score, ASRS Scales, and DSM Scale. 
The ASRS Short Form contains items that best differentiated the nonclinical group from those diagnosed with ASD. The ASRS Short Form (2–5 Years) and ASRS Short Form (6–18 Years) both have 15 items, with parents and teachers completing the same form. This form provides a single total score, and can be used as a screening measure to determine which children and youth are likely to require a more comprehensive assessment for an ASD. The ASRS Short Form is also suitable for monitoring response to treatment/intervention.
The ASRS can be scored via paper-and-pencil and electronically. The ASRS Scoring Software and ASRS Online Assessment Center offer three report options: (1) an Interpretive Report with detailed results from one administration, (2) a Comparative Report providing a multi-rater perspective by combining results from up to five different raters, and (3) a Progress Monitoring Report that provides an overview of change over time by combining results of up to four administrations from the same rater. The ASRS Technical Manual provides step-by-step interpretation guidelines and an illustrative case study. An especially useful feature of the ASRS is the ability to compare results across raters. This can help determine if there is consistency across home and school contexts. Discrepancies can provide insight into differential responses and determine which symptoms are more prevalent in a particular setting.
The ASRS has strong psychometric qualities. Reliability data indicate high levels of internal consistency, good inter-rater agreement, and excellent test-retest reliability. Discriminative validity (classification accuracy) of both the ASRS full-length and ASRS Short Form indicate that the scales were able to accurately predict group membership with a mean overall correct classification rate of 90.4% on the ASRS (2-5) and 90.1% on the ASRS (6-18). Although the ASRS Technical Manual reports a moderate relationship between the ASRS Total Score and the Gilliam Autism Rating Scale, Second Edition (GARS-2) and the Gilliam Asperger’s Disorder Scale (GADS), criterion-related validity would have been enhanced by examining the consistency of the ASRS with a gold standard instrument such as the ADOS or ratings scales such as the Social Communication Questionnaire (SCQ) and Social Responsiveness Scale (SRS). The GARS and GADS are not currently recommended and should be used with caution due to significant weaknesses, including poor diagnostic utility and sensitivity in identifying ASD, and questions concerning standardization and norming procedures (Campbell, 2005; Norris & Lecavalier, 2010; Wilkinson, 2016).
In summary, the ASRS is a valuable tool that can help guide diagnostic and educational eligibility decisions, as well as for use in monitoring response to intervention and evaluating treatment outcomes. It is a reliable and valid instrument for assessing symptom severity across home and school contexts. Consistent with best practice, the ASRS should be used only as part of a more comprehensive developmental assessment that includes interviews and direct observation, together with a multidisciplinary assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, atypical behaviors, and cognitive functioning. An example of a comprehensive assessment battery can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).
References

Campbell, J. M. (2005). Diagnostic assessment of Asperger’s Disorder: A review of five third-party rating scales. Journal of Autism and Developmental Disorders, 35, 25-35.
Goldstein, S., & Naglieri, J. A. (2009). Autism Spectrum Rating Scales (ASRS) Technical Manual. Tonawanda, NY: Multi-Health Systems, Inc. 
Goldstein S., & Naglieri, J. (2014). Autism Spectrum Rating Scales (ASRS) Technical Report #2. Toronto, Ontario, Canada: Multi-Health Systems.
Norris, M., & Lecavalier, L. (2010). Screening accuracy of level 2 autism spectrum disorder rating scales: A review of selected instruments. Autism, 14, 263-284. 
Wilkinson, L. A. (2016). A best practice guide to assessment and intervention for autism spectrum disorder in schools, second edition. London and 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 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)

Self-Management Strategies for Students on the Autism Spectrum


The dramatic increase in the number of school-age children identified with autism spectrum disorder (ASD) has created an urgent need to design and implement positive behavioral supports in our schools’ classrooms. Only 3% of children with ASD are identified solely by non-school resources. All other children are identified by a combination of school and non-school resources (57%), or by school resources alone (40%). As a result, schools today face the challenge of providing appropriate services to a diverse and increasingly numerous student population diagnosed with ASD. Unfortunately, educators and service providers are often faced with confusing and conflicting information about the numerous treatments and interventions available for autism.
Although there is no "one size fits all" or single effective intervention, evidence-based strategies such as self-management have shown considerable promise in addressing the attention/concentration difficulties and poor behavioral regulation of students with ASD. According to the National Autism Center’s (NAC; 2015) second phase of the National Standards Project (NSP-2) and the National Professional Development Center on Autism Spectrum Disorders (NPDC on ASD; 2015), Self-management is an evidence-based intervention/practice. These strategies involve teaching individuals with ASD to evaluate and record the occurrence/nonoccurrence of a target behavior and secure reinforcement. The objective is to be aware of and regulate their own behavior so they will require little or no assistance from adults.
Defining Self-management
Self-management strategies have been implemented successfully for students with a wide range of academic and behavioral challenges. This group of procedures typically involve the components of self-observation and self-recording, which together comprise self-monitoring. Students are instructed to (a) observe specific aspects of their own behavior and (b) provide an objective recording of these observations. The procedure involves providing a cue or prompt to the student and having he or she determine whether or not they engaged in a specific behavior at the moment the cue was supplied. The activity of focusing attention on one’s own behavior and self-recording these observations can have a positive “reactive” effect on the behavior being monitored.
Benefits of Self-Management
One of the prominent features of more capable students with ASD is an absence of, or a poorly developed set of self-management skills. This includes difficulty directing, controlling, inhibiting, or maintaining and generalizing behaviors required for adjustment across home and school settings. By learning self-management techniques
• students become more independent, self-reliant, and responsible for their own behavior and less dependent on external controls and continuous supervision
• have an opportunity to participate in the design and implementation of their own behavior management programs, rather than traditional “top down” external contingency approaches
• acquire a “pivotal” skill that facilitates generalization of adaptive behavior, supports autonomy, and has the potential to produce long lasting behavioral improvements across a range of contexts.
It is important to note that self-management interventions are intended to complement, not replace, positive reinforcement procedures already in place in the classroom. They should not be considered as static and inflexible procedures, but rather a “framework” in which to design and implement effective interventions to facilitate the inclusion of students with ASD and other disabilities in general education settings.
Designing a Self-management Plan
Designing and implementing a self-management strategy need not be a complicated or difficult undertaking. However, there are several questions to consider:
• What is the target behavior(s)?
• In what setting(s) will the student self-monitor?
• What type of prompt (cue) is most appropriate?
• How often will the student self-monitor?
• What external incentive or rewards will be used?
The following steps provide a general guide to preparing and implementing a self-management plan in the classroom. They should be modified as needed to meet the individual needs of the student.
Step 1: Identify a preferred behavioral target. The initial step is to identify and define the target behavior(s). It is best to monitor one or a small number of appropriate, desired behaviors at first. Describe the behavior in terms of what the student is supposed to do, rather than what he or she is not supposed to do. This establishes a positive and constructive “alternative” behavior.
Step 2: Determine how often the student will self-monitor the target behavior. The schedule of self-monitoring will depend on the student’s age, cognitive level, and the severity of the problem behavior. Some students will need to self-monitor more frequently than others. For example, if the goal is to decrease a challenging behavior that occurs repeatedly, then the student should self monitor a positive, replacement behavior at more frequent intervals.
Step 3: Meet with the student to explain self-monitoring, and identify goals and rewards contingent upon achieving those goals. Active student participation is a necessity as it increases proactive involvement and a perception of “ownership” in the plan. It is important to provide the student with a definition of self-management and the benefits of managing one’s own behavior.
Step 4: Create a student self-monitoring form. Develop a form for the student to monitor and record his or her behavior(s). The form should also include a method of recording responses (plus or minus; yes or no; happy face or sad face) to the questions and specify the student's daily behavioral goal (e.g., was I following the classroom rules?).
Step 5: Teach the Student. After the targeted behaviors, goals, and incentives are identified and defined, the student should be taught to use the self-monitoring procedure. Ideally, teaching should take place in the actual setting (classroom) in which the behavior occurs. Ask the student to observe while you simulate a classroom scenario and demonstrate the process of self assessment and recording with the self-monitoring form. The student should also be encouraged to role play both desired and undesired behaviors at various times during practice, and to accurately self-monitor these behaviors.
Step 6: Implement the self-management plan. The student should rate his or her behavior on the self-monitoring form at the specific time interval established. For example, a student might be prompted (cued) to record his behavior at 5 or 10 minute intervals. When prompted, the student records his or her response to the self-monitoring question (e.g., was I paying attention to my seat work?) on the form.
Step 7: Meet with the student to review the self-monitoring results each day and determine whether the behavioral goal was achieved. As soon as possible, hold a "brief" conference with the student to determine whether the behavioral goal indicated on the self-monitoring form was met for that day. Praise the student for completing the self-monitoring form and provide the agreed upon reward for achieving the behavioral goal.
Step 8: Provide the rewards when earned. Although self-monitoring can sometimes be effective without incentives, positive reinforcement increases the impact of the intervention and makes self-monitoring more motivating, even for the most difficult child.
Step 9: Incorporate the plan into a school-home collaboration scheme by sending the self-monitoring form home for parent review and signature. Autism professionals agree that a parent-teacher partnership is fundamental to effective educational intervention. The self-monitoring form should be sent home each day for parent signature to ensure that the student receives positive reinforcement across settings.
Step 10: Fade the self-monitoring plan. The procedure should be faded once the student demonstrates that the “new” behavior is firmly established. This typically involves gradually increasing the time interval between both the prompt and rewards. The ultimate goal for the student is to monitor his or her behavior independently without recording, external cues, and incentives.
Conclusion
Self-management procedures are cost efficient and can be especially effective when used as a component of a comprehensive intervention program (e.g., functional assessment, social groups, curricular planning, sensory accommodations, and parent-teacher collaboration). While the research on the effectiveness of interventions for children with autism is still in a formative stage, self-management is an evidence-based strategy for fostering independence and self-control in high-functioning students with ASD.

                                                                         Key References 

National Autism Center (2015). National Standards Project-Addressing the need for evidence-based practice guidelines for autism spectrum disorders. Randolph, MA: National Autism Center.

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

Wilkinson, L. A. (2008). Self-management for high-functioning children with autism spectrum disorders. Intervention in School and Clinic, 43, 150-157. Free download: http://isc.sagepub.com/content/43/3/150.full.pdf+html
Wilkinson, L. A. (2005). Supporting the inclusion of a student with Asperger syndrome: A case study using conjoint behavioural consultation and self-management. Educational Psychology in Practice, 21, 307-326. http://www.tandfonline.com/doi/abs/10.1080/02667360500344914
Wilkinson, L. A. (2006, September-October). Self management: A proactive strategy for students with Asperger syndrome. Autism-Asperger’s Digest Magazine, 32-38.

Wilkinson, L. A. (2016). A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition). London and Philadelphia: Jessica Kingsley Publishers.
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. 

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)

© 2016 Lee A. Wilkinson, PhD

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