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)

Monday, June 15, 2015

Predictors of Aggression in Autism

Predictors of Aggression in Autism

Aggression is a clinically significant feature of many children and adolescents with autism spectrum disorder (ASD). Children with ASD frequently have co-occurring (comorbid) psychiatric conditions, with estimates as high as 70 to 84 percent. These co-occurring problems often exacerbate the core symptoms of ASD and can lead to significant functional impairment. Among these problems, physical aggression appears to be especially challenging, and has been associated with serious negative outcomes in both the general population and among individuals with ASD and other developmental disabilities.
Comorbid Problems Relevant to Aggression 
Children with ASD experience a number of related difficulties, including sleep problems, gastrointestinal (GI) problems, sensory abnormalities, and self-injury. Many of these problems have been associated with aggression among typically developing children, and emerging evidence suggests a similar relationship in children with ASD. For example, sleep problems occur in a large percentage of children with ASD, with prevalence rates ranging from 50% to 80%. Sleep problems have been found to be highly associated with aggression in typically developing children. Likewise, research suggests that children with ASD and sleep problems are more likely to demonstrate aggression than those without sleep problems.
Sensory problems, including sensory over-responsivity, sensory under-responsivity, and sensory seeking are also common problems in children with ASD. In typical children, sensory problems have been associated with aggressive and externalizing behavior problems. Similarly, recent studies have been found correlations between sensory problems and broadly defined externalizing problem behaviors in children with ASD. However, research has yet to specifically examine the potential contributing role of sensory problems in predicting physical aggression.
Self-injurious behavior also appears to be relevant to the occurrence of aggression. Individuals with ASD are at an increased risk for demonstrating self-injurious behaviors, as compared to those without ASD, with prevalence rates ranging from 30% to 53%. Although self-injury and other forms of challenging behaviors have been considered to be distinct forms of behavior, they are often related. For example, physical aggression and self-injury have been significantly associated among individuals with severe intellectual impairment and there is evidence that self-injurious behaviors are precursors of later aggression in this population. However, similar studies have not investigated the relationship between self-injury and physical aggression in children with ASD.
Lastly, gastrointestinal (GI) problems may also have relevance to the occurrence of aggression. GI problems are common in children with ASD, with prevalence rates ranging from 24% to 70% or higher, depending on symptom definitions. Although there some evidence of an association between behavior problems and GI problems in ASD, a population-based study of children with ASD did not find significant differences in aggression when comparing children with and without GI problems.
                                                                           Research
Although the nature and developmental course of aggression have been a focus of research with typically developing populations, there have been few large-scale studies of group-level predictors of aggression among individuals with ASD. Consequently, it is unclear whether findings from the general population are applicable to children and adolescents with ASD. In an effort to investigate the extent of the problem in children and adolescents with ASD, a recent large-scale study published in Research in Autism Spectrum Disorders examined the prevalence and correlates of physical aggression in a sample of 1584 children and adolescents with ASD enrolled in the Autism Treatment Network (ATN), a multi-site network of 17 autism centers across the US and Canada. Participants in the study ranged in age from 2 to 17 years, with a mean age of 5.91 years. The term “aggression” referred specifically to physical aggression and included biting, hitting, or other physical aggression directed towards others. A number of diagnostic, medical, and behavioral measures were collected at enrollment and at regular follow-up intervals. Measures of interest included: (a) aggression, (b) sleep disturbance, (c) sensory problems, (d) communication and social functioning, (e) self-injury and gastrointestinal problems, (f) cognitive functioning, and (g) verbal/nonverbal status. Data analyses were completed in order to identify the variables most strongly associated with aggression.
                                Prevalence, Correlates and Predictors of Aggression
The results indicated that the prevalence of aggression was 53% across the entire sample of children, with highest prevalence among young children. These results are highly consistent with recently reported prevalence rates (56%) in another large-scale study of children and adolescents with ASD. The results also indicate that age-related decreases in aggression in children with ASD are similar to what has been observed in typically developing children. It should be noted, however, that a large percentage (nearly 50%) of the adolescents in the study’s sample continued to demonstrate physical aggression. Thus, the relative decrease in aggression over time must be balanced by the finding that these behaviors continued to occur at a high rate among a large portion of adolescents with ASD.
In terms of predictors, the results indicated that self-injury was highly associated with aggression among children with ASD. This is consistent with the findings of other studies showing a strong association between self-injury and other challenging behaviors. The current results add to existing literature, and suggest that children with ASD who demonstrate self-injury may be at risk for more severe behavioral problems.
Sleep problems emerged as a second significant predictor aggression. This association between sleep problems and aggression is largely consistent with previous findings among both typically developing children and those with ASD, indicating may underlie (and exacerbate) aggressive behavior patterns for many children with ASD. It should also be noted that sleep problems have been found to be associated with self-injurious behaviors among individuals with intellectual disabilities and that these two conditions may be related. In fact, there is some developing evidence suggesting shared neurobiological basis for both sleep disturbance and self-injurious behavior.
Sensory problems were also significantly associated with aggression. These findings are consistent with similar associations between sensory issues and aggression among typically developing children. While previous research has demonstrated an association between sensory problems and broadly defined behavior problems, the current results extend these previous findings by demonstrating a specific relationship between sensory problems and physical aggression.
Comparisons also indicated that children with aggression were more likely to experience GI problems, communication skill difficulties, and social skills difficulties. However, these variables did not appear as significant predictors of aggression, indicating that self-injury, sleep problems, and sensory issues accounted for the majority of the variance in predicting aggression.
In terms of potential sex differences, the results indicate that girls and boys with ASD were equally likely to engage in aggression. This finding was unexpected in that research has consistently shown a significant gender difference among children without ASD, with boys being much more likely to engage in physical aggression than girls. The results of the study suggest that the sex differential in aggression may not be salient in the ASD population.
 Implications
This study provides evidence that aggression may be much more prevalent among children with ASD than in the general population and that some comorbid problems may place individuals at risk for aggression. Aggression was significantly associated with a number of clinical features, including self-injury, sleep problems, sensory problems, GI problems, and communication and social functioning. However, self-injury, sleep problems, and sensory problems were most strongly associated with aggression. These findings indicate that co-occurring problems specific to the ASD phenotype may play an important role in the occurrence of aggression and that it is important to consider multiple domains of functioning when assessing and treating aggression in children with ASD. For example, increased attention should be given to the identification and treatment of sleep problems, self-injury, and sensory problems. Given the significant relationship between sleep problems and aggression, it is possible that treatments targeting sleep problems may help reduce maladaptive behavior. Thus, assessment and treatment of sleeping problems might be included as a standard and integrated part of the assessment and treatment of ASD. Programs for children with ASD should also integrate an appropriately structured physical and sensory milieu in order to accommodate any unique sensory processing challenges. Although assessment tools are limited, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Co-occurring disorders should also be carefully investigated when severe or worsening symptoms are present that are not responding to traditional methods of intervention.
Of course, more research is needed in order to better understand the characteristics and course of different types of aggression. For example, future research should examine the longitudinal course of aggression, the role of these associated problems in predicting improvement or worsening of aggression, and possible changes in aggression in response to treatment for these co-occurring problems. Studies are also needed to examine the role of additional family- and community-level variables in the prediction and maintenance of aggression among children with ASD.  
References

Mazurek, M. O., Kanne, S. M., & Wodka, E. L. (2013).  Physical aggression in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 455–465.

Hill, A.P., Zuckerman, K.E., Hagen, A.D., Kriz, D.J., Duvall, S.W., Santen, J., Nigg, J., Fair, D., & Fombonne, E. (2014). Aggressive behavior problems in children with autism spectrum disorders: Prevalence and correlates in a large clinical sample. Research in Autism Spectrum Disorders, 8, 1121-1133.

Lee A. Wilkinson, PhD is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. Dr. Wilkinson 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 disorder. He is also a university educator and trainer and has published widely on the topic of autism spectrum disorders both in the US and internationally. He 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 on the Autism Spectrum: A Self-Help Guide Using CBT. 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. 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)

Thursday, June 4, 2015

The Fourth “R” – Teaching Relationship Skills in Our Schools


The three R’s - Reading, Writing and Arithmetic - reflect the traditional basic skills approach to education which focuses on academic benchmarks, measurable standards, and high-stakes testing. However, the school experience is about much more than mastering the three R’s. The ability to relate and interact with others is the foundation for successful human connection and adjustment to the social world. In fact, one of the best childhood predictors of adult adaptation and well-being is not IQ or school grades, but rather, the competence with which the children relate to both peers and adults. Given the life-long consequences of poor social functioning, we should move beyond a focus on academic competencies to include Relationship and social learning as the fourth ‘R’ in our schools. 
Although teaching the fourth R benefits all children, it has the greatest potential to help students with autism spectrum disorders (ASD). Most children with ASD are educated in general education classrooms, and even though many successfully master the 3 R’s, all experience varying degrees of social relationship problems. This includes difficulty communicating with others, establishing and maintaining reciprocal social relationships, taking another person’s perspective, and inferring the interests of others. Consequently, (social) relationship skills should be taught alongside reading, writing, and arithmetic. For children with social-communication challenges to learn relationship skills, we must teach them. Social relationship instruction commonly involves teaching specific skills (e.g., maintaining eye contact, listening, initiating conversation) through behavioral and social learning techniques. Instructional goals usually include skill acquisition, performance, generalization and maintenance of prosocial behaviors, and the reduction or elimination of competing behaviors.
The overarching goal of social skills instruction should be the development of social and communicative competency through direct teaching, modeling, coaching, and role-playing activities in real-world situations. Strategies designed to promote skill acquisition in building social relationships may include direct instruction, modeling, role-play, structured activities, social stories, incidental teaching, video role-play with feedback, communication scripts, formal social groups, pivotal response training, self-monitoring, and coaching. Although there is no “one-size-fits-all” approach that will help children to be socially successful, the following are promising strategies for facilitating and reinforcing social-communication competency in the classroom.
Increase social motivation by encouraging self-awareness - Begin with simple, easily-learned skills and intersperse new skills with those previously mastered.  Also, provide social skills training and practice opportunities in a number of settings to encourage students to apply new skills to multiple, real life situations.
Increase social initiations and improve age-appropriate social responding by making social rules clear and concrete - Teach simple social response scripts for common situations, and use natural reinforcers for social initiations and response attempts. In addition, utilize modeling and role-play to teach and reinforce prosocial skills, and build social activities around preferred activities/interests.
Promote skill generalization and coordinate peer involvement (e.g., prompting and initiating social interactions; maintaining physical proximity - Use several individuals with whom to practice skills, including parents, and provide opportunities to apply learned skills in safe, natural settings (e.g., field trips). Look for opportunities to teach and reinforce social skills as often as possible throughout the school day.
Teach effective social interaction and communication as replacements for challenging behavior - Model, demonstrate, coach, and/or role-play the appropriate interaction skills. Teach students to ask for help during difficult activities or to negotiate alternative times to finish work. Encourage positive social interactions such as conversational skills to help students with challenging behavior obtain positive peer attention. 
Social relationship skills are critical to successful social, emotional, and cognitive development and to long-term outcomes for students. Teaching the fourth R can have both preventive and remedial effects that can help reduce the risk for negative outcomes not only for children on the autism spectrum, but also for all children. If we want our children to achieve success socially, we must teach them the social skills they need to be successful in school and in life.
Adapted from:
Wilkinson, L. A.  (Spring, 2012). Relationship -The fourth “R” in our schools. Autism Spectrum Quarterly, 8-10.
Lee A. Wilkinson, PhD, NCSP 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 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).

© Lee A. Wilkinson, PhD

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