Wednesday, February 11, 2015

Autism in the Classroom

More children than ever before are being diagnosed with autism spectrum disorders (ASD). The U.S. Centers for Disease Control and Prevention (CDC) now estimates that 1 in 68 eight year-old children has an ASD. This dramatic increase in the prevalence of children with ASD over the past decade, together with the clear benefits of early intervention, have created a need for schools to identify children who may have an autism spectrum condition. It is not unusual for children with milder forms of autism to go undiagnosed until well after entering school. In fact, research indicates that only three percent of children with ASD are identified solely by non-school resources. As a result, school professionals are now more likely to be asked to participate in the screening and identification of children with ASD than at any other time in the past.
The Individuals with Disabilities Education Act of 2004 (IDEA) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are the two major systems used to diagnose and classify children with ASD. The DSM-5 is considered the primary authority in the fields of psychiatric and psychological (clinical) diagnoses, while IDEA is the authority with regard to eligibility decisions for special education. The DSM was developed by clinicians as a diagnostic and classification system for both childhood and adult psychiatric disorders. The IDEA is not a diagnostic system per se, but rather federal legislation designed to ensure the appropriate education of children with special educational needs in our public schools. Unlike the DSM-5, IDEA specifies categories of ‘‘disabilities’’ to determine eligibility for special educational services. The definitions of these categories (there are 13), including autism, are the most widely used classification system in our schools. According to IDEA regulations, the definition of autism is as follows:
(c)(1)(i) Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The term does not apply if a child’s educational performance is adversely affected primarily because the child has an emotional disturbance, as defined in this section.
(ii) A child who manifests the characteristics of ‘‘autism’’ after age 3 could be diagnosed as having ‘‘autism’’ if the criteria in paragraph (c)(1)(i) of this section are satisfied.
This educational definition is considered sufficiently broad and operationally acceptable to accommodate both the clinical and educational descriptions of autism and related disorders. While the DSM-5 diagnostic criteria are professionally helpful, they are neither legally required nor sufficient for determining educational placement. It is state and federal education codes and regulations (not DSM-5) that drive classification and eligibility decisions. Thus, school professionals must ensure that children meet the criteria for autism as outlined by IDEA and may use the DSM-5 to the extent that the diagnostic criteria include the same core behaviors (e.g., difficulties with social interaction, difficulties with communication, and the frequent exhibition of repetitive behaviors or circumscribed interests). Of course, all professionals, whether clinical or school, should have the appropriate training and background related to the diagnosis and treatment of neurodevelopmental disorders. The identification of autism should be made by a professional team using multiple sources of information, including, but not limited to an interdisciplinary assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, and cognitive functioning to help with intervention planning and determining eligibility for special educational services.
Legal and special education experts recommend the following guidelines to help school districts meet the requirements for providing legally and educationally appropriate programs and services to students with ASD.
1. School districts should ensure that the IEP process follows the procedural requirements of IDEA. This includes actively involving parents in the IEP process and adhering to the time frame requirements for assessment and developing and implementing the student’s IEP.  Moreover, parents must be notified of their due process rights. It’s important to recognize that parent-professional communication and collaboration are key components for making educational and program decisions.
2. School districts should make certain that comprehensive, individualized evaluations are completed by school professionals who have knowledge, experience, and expertise in ASD. If qualified personnel are not available, school districts should provide the appropriate training or retain the services of a consultant.
3. School districts should develop IEPs based on the child’s unique pattern of strengths and weaknesses. Goals for a child with ASD commonly include the areas of communication, social behavior, adaptive skills, challenging behavior, and academic and functional skills. The IEP must address appropriate instructional and curricular modifications, together with related services such as counseling, occupational therapy, speech/language therapy, physical therapy and transportation needs. Evidence-based instructional strategies should also be adopted to ensure that the IEP is implemented appropriately.
4. School districts should assure that progress monitoring of students with ASD is completed at specified intervals by an interdisciplinary team of professionals who have a knowledge base and experience in autism. This includes collecting evidence-based data to document progress towards achieving IEP goals and to assess program effectiveness.
5. School districts should make every effort to place students in integrated settings to maximize interaction with non-disabled peers. Inclusion with typically developing students is important for a child with ASD as peers provide the best models for language and social skills. However, inclusive education alone is insufficient, evidence-based intervention and training is also necessary to address specific skill deficits. Although the least restrictive environment (LRE) provision of IDEA requires that efforts be made to educate students with special needs in less restrictive settings, IDEA also recognizes that some students may require a more comprehensive program to provide FAPE
6. School districts should provide on-going training and education in ASD for both parents and professionals. Professionals who are trained in specific methodology and techniques will be most effective in providing the appropriate services and in modifying curriculum based upon the unique needs of the individual child.
References and further reading
Individuals with Disabilities Education Improvement Act of 2004. Pub. L. No. 108-446, 108th Congress, 2nd Session. (2004). 
Mandlawitz, M. R. (2002). The impact of the legal system on educational programming for young children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 32, 495-508.
National Research Council (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism. C. Lord & J. P. McGee (Eds). Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.
Wilkinson, L. A. (2010). Best practice in special needs education. In L. A. Wilkinson, A best practice guide to assessment and intervention for autism and Asperger syndrome in schools  (pp. 127-146). London: Jessica Kingsley Publishers. 
Yell, M. L., Katsiyannis, A, Drasgow, E, & Herbst, M. (2003). Developing legally correct and educationally appropriate programs for students with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 18, 182-191.

Wednesday, February 4, 2015

Medication Use in Children on the Autism Spectrum

Prescription medications do not address the core symptoms of autism and are not considered to be "first-line" interventions or treatment for children with autism spectrum disorder (ASD). At present, early, intensive, and behaviorally-based interventions are considered the most effective treatments. Nevertheless, research indicates increasing rates of psychotropic use and the simultaneous use of multiple psychotropic medications (polypharmacy) in children with ASD. Reported rates of use have ranged from 27% to 83%, with polypharmacy ranging from 10% to 20%. The most commonly prescribed medications for ASD are selective serotonin reuptake inhibitors or SSRIs such as Prozac, Zoloft, and Paxil; stimulants such as Concerta, Metadate, Methylin, Ritalin, and Adderall, and atypical neuroleptics such as Risperdal and Abilify, both with FDA approved labeling for the symptomatic (aggression and irritability) treatment of children and adolescents with ASD.
Although co-occurring problems such as hyperactivity, inattention, aggression, repetitive or compulsive behaviors, self-injury, anxiety or depression, and sleep problems may respond to a medication regimen, as well as relieve family stress and enhance adaptability, there are general concerns about these medications. For example, there is a lack of evidence documenting the safety or effectiveness of psychotropic treatment during childhood. Likewise, there is a paucity of information about the safety and effectiveness of psychotropic polypharmacy and potential interactions between and among medications that may affect individuals with complex psychiatric disorders, including ASD. As a result, detailing psychotropic use and polypharmacy among children with ASD is crucial for informing families, clinicians, and researchers.
A study published in the journal, Pediatrics, examined the use of psychotropic medications and polypharmacy by using a large and heterogeneous data set of medical and pharmacy claims for commercially insured children with ASD. Psychotropic medications included: (1) anticonvulsants/antiepileptics; (2) antidepressants; (3) antipsychotics; (4) anxiolytics; (5) attention-deficit disorder medications (both stimulants and nonstimulants); (6) lithium; and (7) anticholinergic/antiparkinsonian medications. Among 33,565 children with autism spectrum disorders, 64% used psychotropic medications and 35% had evidence of polypharmacy. Older children and those who had seizures, attention-deficit disorders, anxiety, bipolar disorder, or depression had increased risk of psychotropic use and polypharmacy. In addition, the majority of children who had seen a psychiatrist had evidence of psychotropic use.
The findings of this study indicate that despite minimal evidence of the effectiveness or appropriateness of multidrug treatment of ASD, psychotropic medications are commonly used, singly and in combination (polypharmacy), for ASD and co-occurring conditions. This has important implications for practice. Because some clinicians caring for children with ASD may not be aware of the extent and effects of psychotropic use and polypharmacy, primary care providers should carefully obtain medication histories and monitor symptoms for evidence of effectiveness. Likewise, there is an immediate need to develop standards of care around the prescription of psychotropic medications based on the best available evidence and a coordinated, multidisciplinary approach to improving the health and quality of life of children with ASD and their families. Finally, additional research is needed to understand why medications are being used (for which symptoms, behaviors, or diagnoses, and by which providers)
Spencer, D., Marshall, J., Post, B., Kulakodlu, M., Newschaffer, C., Dennen, T., Azocar, F., & Jain, A. (2013).  Psychotropic medication use and polypharmacy in children with autism spectrum disorders. Pediatrics, 132, 833–840.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He is 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. Dr. Wilkinson 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 CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Sunday, February 1, 2015

Risk Factors for Bullying Among Children with ASD

Studies exploring bullying in special education populations have reported higher rates of peer victimization among students with special needs. Although children with disabilities have been found to be at an increased risk of bullying, there are limited studies investigating predictors or “risk factors” of bullying involvement in children with autism spectrum disorder (ASD). Identifying children with ASD who are at greatest risk of involvement in bullying has important implications for clinicians, teachers, and parents who are interested in preventing bullying and promoting effective coping strategies among children who are bullied.
A study published in the journal Autism examined child and school characteristics that may place children with ASD at risk of being involved in bullying. Participants were 1221 parents of children aged 6-15 years with a current diagnosis of ASD selected from a national web-based registry. Parents completed a survey dedicated to the school and bullying experiences of their child, and analyses conducted to identify child and school risk factors for involvement as victim, bully, or bully–victim. Additional analyses examined the risk of bullying involvement based on the amount of time spent in general education classrooms.
The researchers hypothesized that higher functioning children with ASD would be at increased risk of victimization, as would children who spent more time in an inclusive educational setting. It was also hypothesized that children who present with more comorbid (co-occurring) psychiatric conditions (e.g., attention deficit hyperactivity disorder (ADHD), depression, anxiety, obsessive compulsive disorder (OCD), social anxiety, oppositional defiant disorder (ODD), learning disorders, intellectual disability) and a high number of autistic traits would be at additional risk.
The results indicated that overall, 63% of children with ASD had been victimized in their lifetime, and 38% had been victimized in the past month. In addition, 19.9% had bullied others in their lifetime, with 9.3% bullying others in the past month. Of these, 63% were bully–victims, that is, they had been both victim and perpetrator in the past month. Children diagnosed with high functioning ASD, attending a public school or a school with a general education population, were at the greatest risk of being victimized in the past month. Children with comorbid conditions and a high level of autistic traits were the most likely to be victims, bullies, and bully–victims. Lastly, children in full inclusion classrooms were more likely to be victimized than those who spend the majority of their time in special education settings.
Conclusion and Implications
The findings from the current study confirm that children across the autism spectrum are at increased risk of being bullied when compared to their typically developing peers, with children who are the highest functioning, and the most involved in general education schools and classrooms, being at the greatest risk. Several previously identified predictors of bullying behaviors among a general education population were also observed in this study, including the presence of co-occurring psychiatric conditions and difficulty making friends. The researchers note that although children with special needs in inclusion settings have been shown to benefit from increased interactions with typically developing children, it appears that they are still at risk of being isolated within the classroom and subsequently being bullied. Thus, children who spend a great deal of time in less protected, general education settings with typical peers may be at greatest risk of being bullied. The study also provides evidence that children with the greatest impairments are being protected by spending all or most of their time in special education settings
The decision of whether or not to include students with ASD continues to be a subject of debate among principals, teachers, parents, and often students themselves. Inclusion with typically developing peers is important for a child with ASD as peers provide the best models for language and social skills. However, inclusive education alone is insufficient. When children with ASD are included, it is imperative that schools ensure that they receive the supports they need to thrive at school while also protecting them from bullying. Moreover, the development and implementation of school bullying policies and inclusion programs must take into account the special vulnerability of this group of children, which can include staff and teachers being trained in identifying children who may be at additional risk of victimization. Clinicians and school-based mental health professionals (e.g., school psychologists) should also familiarize themselves with the risk factors and psychological symptoms commonly associated with bullying involvement. For example, symptom severity should be assessed and comorbid problems identified whenever significant behavioral issues (e.g., inattention, mood instability, anxiety, sleep disturbance, aggression) become evident. Finally, future research studies should be invested in developing appropriate supports for children with ASD placed in inclusive settings.
Risk factors for bullying among children with autism spectrum disorders. Benjamin Zablotsky, Catherine P Bradshaw, Connie M Anderson and Paul Law. Autism published online 30 July 2013. DOI: 10.1177/1362361313477920

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