Wednesday, April 15, 2015

Girls with ASD Face High Risk for Depression


The U.S. Centers for Disease Control and Prevention (CDC) now estimates that 1 in 68 eight year-old children in the US has an autism spectrum disorder (ASD). Prevalence estimates of ASD are significantly higher among boys than among girls. According to the CDC, approximately one in 42 boys and one in 189 girls were identified as having ASD. Studies also suggest that while boys are being referred for evaluation and identified in greater numbers in our schools, this is not the case for girls. Girls are also diagnosed with ASD at later ages compared to boys. This “gender gap” raises serious questions because many females with ASD may be overlooked and not receive the appropriate supports and services. 

                                   Girls with ASD
Gender role socialization is critical to understanding why girls with ASD might be underidentified in the general population. Since females are socialized differently, ASD may not manifest in the same way as typical male behavioral pattern. For example, girls might not come to the attention of parents and teachers because of better coping mechanisms and the ability to “disappear” in large groups. Girls on the higher end of the spectrum also have fewer special interests, better superficial social skills, better language and communication skills, and less hyperactivity and aggression than boys. Likewise, girls are more likely than boys to be guided and protected by same gender peers and to have special interests that appear to be more gender appropriate. These characteristics lessen the probability of a girl being identified as having impaired social skills, the core symptom of ASD.  In fact, it may be a qualitative difference in social connectedness and reciprocity that differentiates the genders. As a result, parents, teachers, and clinicians may not observe the obvious characteristics associated with the male prototype of higher functioning ASD. Over reliance on the male model with regard to diagnostic criteria might also contribute to a gender “bias” and underdiagnosis of girls. For example, clinical instruments tend to exclude symptoms and behaviors that may be more typical of females with autism spectrum disorders.
Unfortunately, the sex differences in the ASD phenotype continue to be poorly understood. As a result, there has been relatively little research on girls with ASD. Moreover, the extant findings are complex and often difficult to interpret. While the gender gap in ASD has yet to be empirically investigated, if there is a gender difference in the autism phenotype, then clinical and educational interventions based largely on research with boys may be inappropriate. As a result, girls may receive less than optimal academic and behavioral interventions. Moreover, the consequences of a missed or late diagnosis can result in social isolation, peer rejection, lowered grades, and a greater risk for mental health and behavioral distress such as anxiety and depression during adolescence and adulthood. As a result, there is an urgent need for research to compare girls with ASD to typical boys and girls to more fully comprehend the implications of being a girl with ASD.
In addition to understanding sex differences in ASD symptoms, a clinically significant issue is whether girls with ASD have an elevated risk for affective disorders. Studies indicate that individuals with ASD demonstrate increased internalizing psychopathology relative to typical individuals.  Depression is one of the most common comorbid syndromes observed in individuals with ASD, particularly higher functioning youth.  For example, evaluation of psychiatric comorbidity in young adults with ASD revealed that 70% had experienced at least one episode of major depression and 50% reported recurrent major depression. Although typical boys and girls show similar levels of depression in childhood, the risk for internalizing disorders in girls increases dramatically in adolescence. Therefore, girls with ASD may be at especially high risk for internalizing psychopathology.
A study in the Journal of Autism and Developmental Disorders compared autism and internalizing symptoms in a clinical sample of 8-18 year-old girls (n = 20) and boys (n = 20) with ASD and typically developing girls (n = 19) and boys (n = 17) using clinician-, parent-, and child- report measures. The researchers found that boys and girls were similarly impaired as evidenced by comparable diagnostic and non-diagnostic ASD symptom scores. However, girls with ASD differed markedly from typical girls on symptom measures, indicating that girls with ASD differed from typical girls in terms of language and social abilities. Girls with ASD also appeared to be at greater risk for internalizing psychopathology than boys with ASD and typical girls. In adolescence, girls with ASD had significantly higher parent-reported internalizing scores than boys with ASD and typical girls. This suggests that being female and having a neurodevelopmental disorder may result in an especially high risk of internalizing psychopathology in the teen years.
                                                   Conclusion and Recommendations
Understanding elevated levels of internalizing symptoms in girls with ASD and how to treat comorbid affective symptoms is critical. Developing and implementing cognitive, behavioral and psychotropic interventions to address internalizing symptoms in this high risk population of girls is essential to help improve interpersonal functioning and quality of life, as well as reduce the negative outcomes frequently associated with adolescent depression, including psychiatric hospitalization and suicidal ideation. Girls who are diagnosed with ASD should be screened for internalizing problems and closely monitored for symptom occurrence. Additionally, practitioners should question the presence of ASD in girls referred for internalizing disorders such as anxiety or depression. Best practice recommends that when a girl presents with a combination of social immaturity, restricted interests, limited eye gaze, repetitive behaviors, social isolation, and is viewed as “atypical” or “unusual," the possibility of ASD should be given serious consideration. 

In terms of treatment, cognitive-behavioral strategies have shown promise in addressing anxiety in higher-functioning children with ASD and might be adapted to address depression in this population. Interpersonal therapy techniques have also to be effective in treating typical adolescents with depression. In addition, evidence is accumulating in the empirical literature that social skills interventions are likely to be appropriate for many children and youth with ASD. Commonly used approaches include individual and group social skills training, providing experiences with typically developing peers, and peer-mediated social skills interventions, all targeting the core social and communication domains. In conclusion, the study of girls with ASD represents a critical area for future research. This group appears to be at a significant risk for developing significant affective symptoms in adolescence, indicating the need for increased awareness, screening, identification, and intervention. Lastly, population-based studies are needed to determine to what extent girls with ASD in the “general community” are less impaired and/or under-identified relative to boys.
Solomon, M., Miller, M., Taylor, S. L., Hinshaw, S. P., & Carter, C. S. (2012). Autism symptoms and internalizing psychopathology in girls and boys with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 48–59
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).

Parents of Children on the Autism Spectrum Experience High Levels of Fatigue and Mental Distress

Parents are often overwhelmed by the challenges presented by a child with an autism spectrum disorder (ASD). Studies indicate that the demands placed on parents caring for a child with autism contribute to a higher overall incidence of parental stress, depression, and anxiety and adversely affects family functioning and marital relationships compared with parents of children with other intellectual, developmental, or physical disabilities. Mothers of children with ASD, in particular, appear to face unique challenges that potentially have an impact on their health and wellbeing.
Parents of children with ASD are increasingly involved in the provision of early intervention and learning activities to promote positive outcomes for their children. However, several studies have documented that parental stress as well as a lack of time and energy are barriers to providing early intervention activities. Because autism impairs social relatedness and adaptive functioning, parent stress can decrease helpful psychological processes and directly influence the parent or caregiver’s ability to support the child with disabilities. Consequently, understanding factors, such as lack of energy or fatigue that may limit the capacity of the parent to assist in promoting their child’s development is critical for this group.
                                                                                Research
A study published in the journal Autism examined the extent to which parents experience fatigue and its relationship to other aspects of wellbeing and parenting. Fifty mothers of children ages 2-5 years with ASD participated in the study and completed questionnaires assessing level of fatigue, parenting self-efficacy (belief about the ability to parent successfully), children’s behavioral and emotional problems, sleep quality, parent support needs, and overall physical activity. The study found that compared with mothers of typically developing children, mothers of children with ASD reported significantly higher fatigue, with overall scores in the moderate range. Factors associated with high levels of fatigue were poor maternal sleep quality, a high need for social support and poor quality of physical activity. Fatigue was also significantly related to other aspects of wellbeing, including stress, anxiety and depression, and lower parenting efficacy and satisfaction.
These findings were somewhat expected given the additional caregiving demands, parenting challenges and pressures of managing family life when raising a child with an ASD. Likewise, It is also probable that symptoms of depression, anxiety, stress and worry (body tension, increased heart rate and rumination) can be mentally taxing and contribute to, or exacerbate fatigue. The researchers also note that it was not surprising that poor sleep quality was associated with higher levels of fatigue given the large amount of research indicating that inadequate sleep and poor sleep quality is associated with a range of physical health and wellbeing difficulties. Parents of children with ASD are at particular risk of sleep disruption and poor sleep quality owing to the high rate of sleep problems in their children. Parents reported that their child waking was the primary reason for sleep disruption. For other parents in the study, stress, anxiety and not being able to wind down were stated reasons for sleep disruption.
                                                                              Implications
What are the implications of this study? The findings clearly indicate the need for interventions to specifically target parental fatigue and its impact on families affected by ASD both in the present and longer term. In addition to interventions targeting child sleep problems, parents are likely to benefit from psycho-education about fatigue and its potential effects on wellbeing, parenting and caregiving. This includes information about strategies to minimize and/or cope with the effects of sleep disruption, increase health and self-care behaviors, and strengthen opportunities for social support. It is well established that social support is protective of optimal parent wellbeing and, therefore, is an important component of any intervention to address fatigue and wellbeing of parents of children with an ASD. Parents with limited assistance to share the daily demands of caregiving and family life are likely to be at greater risk of fatigue than parents with more support. For parents with limited support, there might also be fewer opportunities to engage in self-care behaviors that are likely to alleviate or protect them from fatigue.
From a clinical perspective, professionals working with families of children with an ASD should be aware of negative effects of fatigue in addition to other wellbeing difficulties, such as stress and anxiety. An assessment of the presence and severity of the physical, cognitive and emotional symptoms of fatigue, as well as the perceived impact on daily functioning, mood, relationships, parenting and other aspects of caregiving is important. Lastly, future work in this area should involve the development and evaluation of information resources and intervention approaches to assist parents of children with an ASD to manage fatigue and promote their overall wellbeing. The longer-term benefits for parents in terms of strengthening their overall health, wellbeing and parenting should also be a focus of research. 
Giallo, R., Wood, C. E., Jellett, R., & Porter, R. (2013). Fatigue, wellbeing and parental self-efficacy in mothers of children with an Autism Spectrum Disorder. Autism, 17, 465-480.
DOI: 10.1177/1362361311416830
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).

Best Practice Guide to Assessment and Intervention for Autism & Asperger Syndrome in Schools

A best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools provides a practical and accessible step-by-step guide to screening, assessing, and educating children with autism spectrum disorder (ASD). Written by a practicing school psychologist, this award-winning text is grounded in the latest research and includes illustrative case examples, FAQs, quick reference boxes, glossary, and an index to 50 evidence-based best practice recommendations. It is an essential guide and valuable resource for practitioners in school and clinical psychology, general and special education, counseling, social work, and for graduate and pre-service students. Parents, advocates, administrators, and attorneys will also find the content informative and helpful. This text is a welcome addition to the reference libraries of all who want to further their understanding of the identification and treatment of school-age children with ASD. Highly readable and comprehensive, this book sets the standard for those working with students with ASD. This book makes also an ideal text or guide for graduate-level training courses in psychology and special education, and has become a widely used resource.
A Best Practice Guide… consists of seven chapters. Chapter 1 begins with two case vignettes and a discussion of the challenges facing school psychologists and educators. The reader is then provided with an overview of Asperger syndrome and the autism spectrum disorders (ASD). Chapter 2 focuses on the screening and identification of children in need of further assessment. Instruments are reviewed and a multi-step screening process described. Chapter 3 addresses evidence-based assessment practices, including individual instruments and a developmentally-based procedure. In Chapter 4, the case examples are presented to illustrate best practice in the assessment of ASD. Chapter 5 focuses on intervention practices and describes current scientifically-based interventions and treatments for ASD. Chapter 6 provides information on the identification of special educational needs and specialized services. Chapter 7 concludes with a discussion of the current status of the field and future directions for research.

Praise and Reviews
Autism Spectrum Quarterly calls the book “a landmark contribution destined to become a classic in the field of autism spectrum disorders” and comments, “Dr. Wilkinson has made an enormous contribution to the field by comprehensively and systematically illuminating not only what needs to be done, but also how to go about doing it. The book is exquisitely and meticulously organized, making it an easy-to-access reference guide as well as a comprehensive text book and training manual."
The Canadian Journal of School Psychology remarks, "Overall, this book presents readers with an excellent overview of autism and Asperger syndrome. The author has expertly formatted the book and each chapter so that the reader is provided with an excellent resource of recent and relevant information pertaining to screening, formal assessment, and interventions with individuals in this population. The use of two case studies helps to highlight some of the information presented throughout the book. …many school-based professionals will be able to make use of this excellent resource".
According to the Journal of Autism and Developmental Disorders "This book provides a complete source for parents, educators, researchers and clinicians seeking information related to assessment and interventions available for individuals (mostly children) diagnosed with Autism Spectrum Disorders (ASD). The main reason the book stands out is the application of all the discussed concepts in the two case examples of Jeremy and Sally. Dr. Wilkinson presents a detail and person-centered approach to the stages and issues that needs to be addressed while conducting an assessment and planning interventions for individuals diagnosed with ASD. Educators and clinicians can make use of the detailed case examples as those may be applicable to their work environment."
Ally4autism comments, “Dr. Wilkinson has created an outstanding blend of academic research and practical application in a text that is so clearly written it is a pleasure to read for professionals and parents alike. His book concisely illustrates best practices in screening, assessment, treatment and special education services. Through case examples of two children, he demonstrates how these best practices can be put into action. This book fills an important need that has existed for years. Dr. Wilkinson has created an indispensable resource that should definitely be in each school’s professional library.”
👉 A Best Practice Guide... was named the Winner in the Education/Academic category of the 2011 Next Generation Indie Book Awards and honored as an Award-Winning Finalist in the Education/Academic category of the "Best Books Awards” sponsored by USA Book News.
A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools is available in both print and eBook formats. 

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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