Monday, December 21, 2015

Multi-Tiered Screening for Autism in Schools

A Multi-Tiered Approach to Screening for Autism in Schools

There has been a dramatic worldwide increase in reported cases of autism over the past decade. Yet, compared to population estimates, identification rates have not kept pace in our schools. It is not unusual for children with less severe symptoms of ASD to go unidentified until well after entering school. As a result, it is critical that school-based support personnel (e.g., school psychologists, special educators, school counselors, speech/language pathologists, and social workers) give greater priority to case finding and screening to ensure that children with ASD are identified and have access to the appropriate programs and services. 

 Screening and Identification
Until recently, there were few validated screening measures available to assist school professionals in the identification of students with the core ASD-related behaviors. However, our knowledge base is expanding rapidly and we now have reliable and valid tools to screen and evaluate children more efficiently and with greater accuracy. The following tools have demonstrated utility in screening for ASD in educational settings and can be used to determine which children are likely to require further assessment and/or who might benefit from additional support. All measures have sound psychometric properties, are appropriate for school-age children, and time efficient (10 to 20 minutes to complete). Training needs are minimal and require little or no professional instruction to complete. However, interpretation of results requires familiarity with ASD and experience in administering, scoring, and interpreting psychological tests.
The Autism Spectrum Rating Scales (ASRS; Goldstein & Naglieri, 2009) is a norm-referenced tool designed to effectively identify symptoms, behaviors, and associated features of ASD in children and adolescents from 2 to 18 years of age. The ASRS can be completed by teachers and/or parents and has both long and short forms. The Short form was developed for screening purposes and contains 15 items from the full-length form that have been shown to differentiate children diagnosed with ASD from children in the general population. High scores indicate that many behaviors associated with ASD have been observed and follow-up recommended.
The Social Communication Questionnaire (SCQ; Rutter, Bailey, & Lord, 2003), previously known as the Autism Screening Questionnaire (ASQ), is a parent/caregiver dimensional measure of ASD symptomatology appropriate for children of any chronological age older than four years. It is available in two forms, Lifetime and Current, each with 40 questions. Scores on the questionnaire provide a reasonable index of symptom severity in the reciprocal social interaction, communication, and restricted/repetitive behavior domains and indicate the likelihood that a child has an ASD. The lifetime version is recommended for screening purposes as it demonstrates the highest sensitivity value. 
The Social Responsiveness Scale, Second Edition (SRS-2; Constantino & Gruber, 2012) is a brief quantitative measure of autistic behaviors in 4 to 18 year old children and youth. This 65-item rating scale was designed to be completed by an adult (teacher and/or parent) who is familiar with the child’s current behavior and developmental history. The SRS items measure the ASD symptoms in the domains of social awareness, social information processing, reciprocal social communication, social anxiety/avoidance, and stereotypic behavior/restricted interests. The scale provides a Total Score that reflects the level of severity across the entire autism spectrum.
A Multi-Tier Screening Strategy
The ASRS, SCQ, and SRS-2 can be used confidently as efficient first-level screening tools for identifying the presence of the more broadly defined and subtle symptoms of higher-functioning ASD in school settings. School-based professionals should consider the following multi-step strategy for identifying at-risk students who are in need of an in-depth assessment.
Tier  one. The initial step is case finding. This involves the ability to recognize the risk factors and/or warning signs of ASD. All school professionals should be engaged in case finding and be alert to those students who display atypical social and/or communication behaviors that might be associated with ASD. Parent and/or teacher reports of social impairment combined with communication and behavioral concerns constitute a “red flag” and indicate the need for screening. Students who are identified with risk factors during the case finding phase should be referred for formal screening.
Tier two. Scores on the ASRS, SCQ, and SRS-2 may be used as an indication of the approximate severity of ASD symptomatology for students who present with elevated developmental risk factors and/or warning signs of ASD. Screening results are shared with parents and school-based teams with a focus on intervention planning and ongoing observation. Scores can also be used for progress monitoring and to measure change over time. Students with a positive screen who continue to show minimal progress at this level are then considered for a more comprehensive assessment and intensive interventions as part of Tier 3.  However, as with all screening tools, there will be some false negatives (children with ASD who are not identified). Thus, children who screen negative, but who have a high level of risk and/or where parent and/or teacher concerns indicate developmental variations and behaviors consistent with an autism-related disorder should continue to be monitored, regardless of screening results.
Tier three. Students who meet the threshold criteria in step two may then referred for an in-depth assessment. Because the ASRS, SCQ, and SRS-2 are strongly related to well-established and researched gold standard measures and report high levels of sensitivity (ability to correctly identify cases in a population), the results from these screening measures can be used in combination with a comprehensive developmental assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, and cognitive functioning to aid in determining eligibility for special education services and as a guide to intervention planning.
Limitations

Although the ASRS, SCQ, and SRS can be used confidently as efficient screening tools for identifying children across the broad autism spectrum, they are not without limitations. Some students who screen positive will not be identified with an ASD (false positive). On the other hand, some children who were not initially identified will go on to meet the diagnostic and/or classification criteria (false negative). Therefore, it is especially important to carefully monitor those students who screen negative to ensure access to intervention services if needed. Gathering information from family and school resources during screening will also facilitate identification of possible cases. Autism specific tools are not currently recommended for the universal screening of typical school-age children. Focusing on referred children with identified risk-factors and/or developmental delays will increase predictive values and result in more efficient identification efforts.

Concluding Comments
Compared with general population estimates, children with mild autistic traits appear to be an underidentified and underserved population in our schools. There are likely a substantial number of children with equivalent profiles to those with a clinical diagnosis of ASD who are not receiving services. Research indicates that outcomes for children on the autism spectrum can be significantly enhanced with the delivery of intensive intervention services. However, intervention services can only be implemented if students are identified. Screening is the initial step in this process. School professionals should be prepared to recognize the presence of risk factors and/or early warning signs of ASD, engage in case finding, and be familiar with screening tools in order to ensure children with ASD are being identified and provided with the appropriate programs and services. 

Best practice screening and assessment guidelines are available from: Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd ed.). 


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, December 18, 2015

Adults with Autism Face Many Health Problems

A study found that adults with autism are at higher risk for a number of health problems, ranging from diabetes and obesity to heart failure. In a review of insurance records for more than 23,000 adults, researchers found that medical and psychiatric issues are much more prevalent in those with autism as compared to individuals without the neurodevelopmental disorder. Nearly all medical conditions were significantly more common in adults with autism than controls, including diabetes, gastrointestinal (GI) disorders, epilepsy, sleep disorders, dyslipidemia, hypertension and obesity, researchers reported in a summary of their findings presented at the International Meeting for Autism Research.
Eating disorders, mechanical falls, vision and hearing impairments, osteoporosis and chronic heart failure were significantly more common among adults with autism than controls. Depression and anxiety were more than twice as common for those on the spectrum while bipolar disorder was eight times as likely. There was also 12-fold increase in the risk of epilepsy for this group. Nearly a third of those with autism in the study had obesity or hypertension, conditions that affected less than 20 percent of those without the neurodevelopmental disorder. Cancer rates, however, were similar for those with and without autism.
Although it’s well-known that children with autism face more medical and psychiatric diagnoses than their peers, this is the first large study to examine how common these issues are in adults. Researchers suggest that one reason for the high prevalence of health problems among adults with autism could be that the social and communication difficulties as well as the sensory sensitivities common among this population may lead to reduced preventive care. They conclude that physicians need better training on how to treat individuals on the spectrum throughout the life span and improvements needed in the transition from pediatric to adult medical care systems.

Tuesday, December 15, 2015

Fears and Phobias on the Autism Spectrum


Fears and Phobias in Children on the Autism Spectrum
Anxiety Disorders are a frequent co-occurring (comorbid) problem for children and youth with autism spectrum disorder (ASD). Although prevalence rates vary from 11% to 84%, most studies indicate that approximately one-half of children with ASD meet criteria for at least one anxiety disorder. Of all types of anxiety disorders, specific phobia is the most common, with prevalence estimates ranging from 31% to 64%. In contrast, estimates of phobias in children in the general population range from 5% to 18%.
Unusual fears have long been recognized as a feature of autism. In fact, 70 years ago, Leo Kanner wrote in his initial account of autism that “loud noises and moving objects” are “reacted to with horror” and things like “tricycles, swings, elevators, vacuum cleaners, running water, gas burners, mechanical toys, egg beaters, even the wind could on occasions bring about a major panic.” We now know that children with autism perceive, experience, and respond to the world very differently than children without autism. Experiences that may be tolerable for most typical children might be frightening, disturbing, or irritating for a child with ASD. Children with autism may also be unresponsive to other experiences (e.g., insensitive to pain), may not show stranger or separation anxiety, and may be seemingly unaware of obvious dangers (e.g., running into traffic).
Research
Previous research examining the types and frequencies of fears in children with autism have found odd and intense fears in approximately 40% of children with autism, whereas unusual fears were present in only 0–5% of children without autism, including children with a learning disability, language disorder, ADHD, intellectual disability, and typical development. Studies also indicate that while some of the most common fears for children with autism and typical development overlap, children with autism have frequent fears that were not amongst the most frequently reported for typical children. These include fear of thunderstorms, large crowds, and closed spaces.
A large scale study reported in Research in Autism Spectrum Disorders investigated unusual fears in a sample of 1033 children ages 1-16 with autism. The purpose of the study was to categorize and determine specific types of unusual fears in children with autism as well as identify variables related to the presence or absence of these fears. Unusual fears were reported in 421 (40.8%) of the 1033 children with autism. A total of 487 unusual fears were reported, representing 92 different fears. The most common unusual fears in three or more children with were toilets, elevators, vacuum cleaners, thunderstorms, heights, and visual media (characters in or segments of movies, television shows, commercials, or computer games). Many children also had common childhood fears and phobias (including fear of dogs, bugs, spiders, snakes, the dark, doctors, barbers, monsters, people in costumes, mechanical toys, sleeping alone, fire, and swimming), which increased the overall proportion of children with autism who had intense fears and phobias to more than 50%.
Categories and Frequency of Unusual Fears
The most frequently reported categories of unusual fears were:
§        Mechanical things (Blenders, can openers, cassette players, ceiling fans, clothes, dryers, drills, electric toothbrushes, exhaust fans, hair dryers, hand dryers, leaf blowers, toilets, vacuum cleaners, washing machines, water fountains, wheelchairs, windshield wipers) 
§        Heights (Elevators, escalators, heights, steps) 
§        Weather (Cloudy weather, natural disasters such as floods, droughts, hurricanes, tornadoes, rain, thunderstorms, wind) 
§        Non-mechanical things (Balloons, black television screen, buttons, clam shells, crayons, dolls, drains, electrical outlets, eyes on toys garden hose, glass tabletops, glow in dark stars, gum under table, hair in bathtub, lights, mole on person’s face, moon, shadows, strings, stuffed animals, swinging or rocking things, tall things, things on ceiling, vent on house)
§        Places (Bathroom, bedroom, certain house or restaurant, closed or small spaces, garage, large or open space, room with doors unlocked or open)
§        Worries - Events (car accident, heart attack, natural disaster, germs or contamination, running out of certain foods, running out of gas, something falling over, toilet overflowing, tree falling on house)
§        Visual media (Characters in or segments of movies, television shows, commercials, computer games)
Types and Frequency of Unusual Fears
Unusual fears reported by parents fell into two categories: (1) uncommon fears not typically reported in children in the general population or in children with specific phobias and (2) fears that have been reported in studies of children without autism but which were considered unusual by parents because of their intensity, obsessiveness, irrationality, or interference with functioning. Of the total number reported, the most common unusual fears in three or more children with autism were:
§         Toilets
§         Elevators
§         Vacuum cleaners
§         Thunderstorms
§         Tornadoes
§         Heights
§         Visual media 
Associated variables
Children with and without unusual fears did not differ in age, IQ level, mental age, autism severity, race or parent occupation. Of all the demographic variables, only female gender was associated with the presence or absence of unusual fears. More girls had unusual fears (48.8%) than did boys (39.1%). This is consistent with the earlier studies indicating that girls with autism had more fears than boys and with general population studies showing that girls had more fears and higher fear survey scores than boys. The finding that children with and without unusual fears did not differ in age suggests that unlike most typical children, those with autism may not outgrow unusual fears. Likewise, the findings regarding autism severity and parent occupation suggest that the presence of unusual and intense fears may be present across SES and the entire autism spectrum. The authors note that the lack of demographic differences in the study may suggest a neurobiological basis for fears overriding developmental and environmental influences.
Conclusion and Implications
Research suggests that it is critical to assess for unusual and intense fears in children with ASD because they are common and can interfere significantly with functioning. Specific fears and phobias have been cited as frequent anxiety triggers/stressors for children with ASD. The impact of anxiety includes personal distress in children, parents, and siblings, increase in challenging behavior and stereotyped behaviors, restriction of activities/opportunities and negative impact on quality of life for child and family. For example, children with autism may avoid necessary life situations (e.g., refusing to go to school because there may be a fire drill) or be in a constant state of anxiety and unable to function optimally because of their fears.
Identification of specific fears and phobias can help educators and interventionists improve programs and services for children on the autism spectrum. This information may be especially useful for clinicians, particularly those utilizing CBT as a treatment approach for children and youth with ASD. There is evidence to suggest that the interventions used to treat intense fears and phobias in children without autism (exposure, desensitization, modeling, shaping, and reinforcement) might also be effective for children who have autism. Lastly, further research is needed to investigate why some specific unusual fears are common to autism but not the general population. As more individuals with ASD communicate about their fears and reasons for their idiosyncrasies, we may come to a better understanding of autism and its symptoms.
Mayes, S. D., Calhoun, S. L., Aggarwal, R., Baker, C., Mathapati, S., Molitoris, S., & Mayes, R. D. (2013). Unusual fears in children with autism. Research in Autism Spectrum Disorders, 7, 151–158.
Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2, 217–250.
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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