Friday, August 21, 2015

Autistic Traits and Sensory Experiences in Adults

Unusual sensory processing experiences are common among individuals with autism spectrum disorder (ASD), and are now part of the Diagnostic and Statistical Manual 5th Edition (DSM-5) diagnostic criteria. Although previous research indicates that ASD traits are associated with sensory scores in the general population, it is unclear whether they characterize the “broader phenotype” of ASD which includes individuals with mild impairments in social and communication skills that are similar to those shown by individuals with ASD, but exhibited to a lesser degree. 

A study published in the Journal of Autism and Developmental Disorders sought to replicate the reported relationship between ASD traits and sensory traits across the entire range of symptom severity, and to investigate its specificity in a large sample of adults both with and without ASD. Adults (n = 772) with and without an ASD were administered the Autism Spectrum Quotient (AQ) together with the Adult/Adolescent Sensory Profile (AASP), the Cardiff Anomalous Perceptions Scale (CAPS), and the Glasgow Sensory Questionnaire (GSQ), all questionnaire measures of abnormal sensory responsivity. Of the 772 participants, 23 reported having autism and 55 reported a first-degree relative with the disorder. Another 147 participants indicated having another psychiatric condition, such as depression, and 85 reported having migraine headaches on a regular basis.
The results indicated that self-reported abnormal sensory experiences were positively correlated with ASD trait scores on all three sensory questionnaires. The more autistic traits, the more sensory problems he or she reported. Individuals with the most autism traits, such as narrow interests or social difficulties, showed high levels of atypical sensory behavior on all three questionnaires. Although the study’s sample was predominantly (72 %) female, the investigators found that the relationship between sensory symptoms and ASD traits was very similar for both genders. They also found that ASD traits were correlated with levels of anxiety symptoms. Participants who reported being anxious had both more autism traits and more unusual sensory responses than those who were not anxious. This suggests that abnormalities with sensory processing and anxiety symptoms are related, yet separate, phenomena.
These results have implications for the integration of sensory processing abnormalities into the diagnosis and assessment of ASD. For example, the study confirms the association between sensory experiences and autism across the entire autism spectrum, suggesting that sensory traits might serve as a dimensional measure of the severity of ASD. It should be noted, however, that unusual sensory experiences are not unique to ASD. The researchers found that trait anxiety, a history of psychiatric conditions, and a history of migraines were all associated with higher sensory scores, even after controlling for ASD traits. Thus, individuals with these conditions may report high levels of unusual sensory experiences, which could potentially lead to a misdiagnosis of ASD. It also appears unlikely that abnormal sensory experiences underpin all ASD symptoms. Even so, it does appear that if sensory symptoms were treated successfully, then some core ASD symptoms, such as stereotypies, might also be reduced (or vice versa). Further research is needed to examine this issue. Finally, the cognitive/biological basis of the relationship between autistic traits and sensory problems is unknown, and further work is required to determine whether improving sensory processing could effectively reduce the severity of ASD symptoms.
Horder, J., Wilson, C. E., Mendez, M. A., & Murphy, D. J. (2014). Autistic traits and abnormal sensory experiences in adults. Journal of Autism and Developmental Disorders, 44, 1461-1469.
Published online Dec 5, 2013. doi:10.1007/s10803-013-2012-7
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. 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 CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Wednesday, August 19, 2015

National Indicators Report on Autism & Adolescent Transitions

Young adults with autism are facing significant challenges as they transition to adulthood, a national report suggests, with many on the spectrum finding themselves unemployed, isolated, and lacking services. The "National Autism Indicators Report: Transition into Young Adulthood" from Drexel University’s A.J. Drexel Autism Institute is a comprehensive report (available free online) that presents new findings about a wide range of experiences and outcomes of youth on the autism spectrum between high school and their early 20s. The report is a collection of indicators that focuses national attention on outcomes which are almost universally lower for those on the autism spectrum compared to their peers with other types of disabilities and serves as a call to action to fill the remaining large gaps in knowledge. Key findings include:
  • Over one-third (37 percent) of young adults were disconnected during their early 20s, meaning they never got a job or continued education after high school. In comparison, less than eight percent of young adults with other types of disabilities were disconnected.
  • Approximately 26 percent of young adults and 28 percent of those unemployed and not in school received no services which could help them with employment, continue their education, or live more independently.
  • Just 58 percent of young adults worked for pay outside the home between high school and their early 20s, a rate far lower than young adults with other types of disabilities. Those with jobs generally worked part-time for relatively low wages.
  • Approximately one in four young adults were socially isolated, meaning they never saw or talked with friends and were never invited to social activities within the past year.
  • Only about one in five ended up living independently (without parental supervision) in the period between high school and their early 20s.
  • Sixty percent of youth had at least two health or mental health conditions in addition to autism spectrum disorder. Over half of youth had co-occurring ADD/ADHD and anxiety issues in adolescence. Three-quarters of youth took at least one kind of medication on a regular basis for any health or mental health issue.
  • Nearly 50% of youth experienced threats and bullying during high school. Over one-quarter (27 percent) of adolescents engaged in some type of wandering behavior in which they impulsively left a supervised situation, increasing their risk of becoming lost and going missing.
  • Transition Planning, a key process for helping youth build skills and access services as they enter adulthood, was frequently delayed. Just 58 percent of youth had a transition plan by the federally required age.
The creation of effective and affordable programming tailored to meet the needs of the 50,000 individuals with autism who leave high school each year - each with unique strengths, interests, and challenges - is an urgent task facing our society. It is clear that we are not succeeding as a nation in helping autistic adults to thrive to the best of their abilities and attain a high quality of life. It is time for new approaches.
“This is the most comprehensive report to date describing what we know about young adults with autism as a whole and across the various parts of their lives. Yet, it represents only a fraction of what we need to know. Huge gaps remain,” said Anne M. Roux, MPH, research scientist at the A.J. Drexel Autism Institute in the Life Course Outcomes Research Program and lead author of the report. Although these indicators don’t tell us why outcomes are worse for those with autism compared to youth with other disabilities, this report is an important first step toward addressing the gaps in what we know, as we work to build an evidence base about how to help achieve better outcomes.
The link to the report download page is
Roux, Anne M., Shattuck, Paul T., Rast, Jessica E., Rava, Julianna A., and Anderson, Kristy, A. National Autism Indicators Report: Transition into Young Adulthood. Philadelphia, PA: Life Course Outcomes Research Program, A.J. Drexel Autism Institute, Drexel University, 2015.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered psychologist, registered psychologist, and certified cognitive-behavioral therapist. Dr. Wilkinson 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. He is also editor of a best-selling text in the American Psychological Association (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 Ed.).

Tuesday, August 11, 2015

Autism and Improvisational Music Therapy

Music therapy has become an integral part of many programs for children with autism. The broad category of music therapy is generally described as interventions that seek to teach individual skills or goals through music. Music therapists use their training as musicians, clinicians, and researchers to effect changes in cognitive, physical, communication, social, and emotional skills.  According to the National Autistic Society, “Music therapy aims to encourage increased self-awareness/self-other awareness, leading to more overt social interactions. The therapy stimulates and develops the communicative use of voice and pre-verbal dialogue with another, establishing meaning and relationship to underpin language development. The client may also benefit from increased tolerance of sound, tolerance of and capacity for two-way communication.” 
Research Autism reports strong positive evidence from peer-reviewed journals that support the effectiveness of music therapy for individuals with autism spectrum disorders (ASD). Based on the literature to date, music therapy has shown good effects in influencing joint attention, social interaction, verbal and gestural communication and behavior. It is considered to be a useful intervention, particularly with young children, and where language acquisition is either delayed or disordered to a severe degree. Currently, music therapy is identified as an emerging intervention by the National Autism Center (2015) and incorporates many of the identified ASD-specific evidence-based practices.Supporters of music therapy emphasize that it can be used to develop social engagement, joint attention, communication abilities, while also addressing emotional needs and quality of life.
A study published in the journal Autism provides further support for the effectiveness of music therapy with ASD. This study investigated the social-motivational aspects of musical interaction between the child and the therapist in improvisational music therapy by measuring emotional, motivational and interpersonal responsiveness in children with autism during joint engagement episodes. Improvisational music therapy is an individualized intervention that facilitates moment-by-moment motivational and interpersonal responses in children with autism. Compared with other therapeutic interventions utilizing music as a background or contingent stimulus, improvisational music therapy involves the interactive use of live music for engaging clients to meet their therapeutic needs. It is gaining growing recognition as an effective intervention addressing fundamental levels of spontaneous self-expression, emotional communication and social engagement for individuals with a wide range of developmental disorders.
This randomized controlled exploratory study employed a single subject comparison design in two different conditions (improvisational music therapy versus toy play sessions) and two different parts of a session (an undirected/child-led part versus a more directed/therapist-led part) in each condition. The objective was to compare the effects of these two different media (music versus toys) and to determine how children respond in a musical context with or without direction, compared with a non-musical context such as play activities with toys with or without direction.
Participants and Procedure
Participants were children aged between 3 and 5 who were not previously treated with either music therapy or play therapy. A total of ten children (all male) completed the clinical trials. Five children were non-verbal while the other five were verbal with varying degrees of language skills. Eight children were in preschool special education, and two were in mainstream preschool programs that included additional therapeutic supports, such as speech language therapy. The children were randomly assigned either to have the music therapy sessions first and the toy play sessions later (group 1), or vice versa (group 2). In order to differentiate the media used in these two conditions, the therapists in music therapy were instructed to interact with the child mainly through music, whereas the therapists in the toy play condition were instructed to engage the child by any means, but to avoid any musical media, such as singing or rhythmic playing.
Observed behaviors were recorded in terms of both their frequency and their duration for two broad categories. The first category concerned the participant’s emotional and motivational responsiveness (joy, emotional synchronicity, initiation of engagement) towards different types of attunement promoted by the therapist in these two conditions. The second category concerned two different types of responsiveness towards the therapist’s initiation of interaction (social invitation and interpersonal demands). Joy referred to an event when the child either smiled (facial expression duration only), or laughed (facial expression with vocal sound) during the interaction with the therapist. Emotional synchronicity referred to an event when the child and the therapist shared a moment of emotional affect duration (happiness or sadness) while engaged with each other. Initiation of engagement referred to an event where the child spontaneously initiated interaction with the therapist, or initiated a change during ongoing interaction, and then expected the therapist to follow.
Results and Discussion
Improvisational music therapy produced markedly more and longer events of joy, emotional synchronicity and initiation of engagement behaviors in the children than toy play sessions. In response to the therapist’s interpersonal demands, ‘compliant (positive) responses’ were observed more in music therapy than in toy play sessions, and ‘no responses’ were twice as frequent in toy play sessions as in music therapy. In the music therapy condition, there were more joy, emotional synchronicity and initiation of engagement events in the undirected part than the directed part, suggesting that children were happier, more able to express their happy emotions and more able to share their affects with the therapist when leading. These results suggest that musical attunement enhances musical-emotional communication together with joy and emotional synchronicity, which results in children’s spontaneous willingness to respond, initiate and engage further.
According to the authors, “The temporal structure of music and the specific use of musical attunement in improvisational music therapy suggests that we can help children with autism experience and develop affective skills in a social context.”  Creating music relates to the child’s expression, interest and focus of attention may evoke responses from the child to a therapist creating such relational music for them. Moreover, improvising music together is an emotionally engaging process. Music can be an attractive medium, allowing the child his/her own space and the choice of objects, at the same time engaging the child with different objects of the therapist’s choice.
Of course, this “exploratory” study has limitations.  For example, the small sample makes any generalizable conclusion premature. The test power is low and should be considered when interpreting the results. Likewise, the small sample limits the relevance of subgroup analyses (language, age, severity) as well as therapists’ effects which would be helpful to understanding how children with different developmental needs respond to this type of intervention different therapists.
In conclusion, the results of this exploratory study found significant evidence supporting the value of music therapy in promoting social, emotional and motivational development in children with autism. The findings highlight the importance of social-motivational aspects of musical interaction between the child and the therapist, the therapeutic potential of such aspects in improvisational music therapy, and the relative value of less directed and more child centered approaches for children with autism. The authors conclude, “Both previous and the current study indicate that we should use music within the child’s focus of attention, behavioral cue and interests, whether it is improvised or precomposed. A future study should perhaps look at the differential effect on response of improvised and precomposed music with young children with autism.”

Monday, August 10, 2015

Asperger's Syndrome Revisited

The deletion of Asperger’s disorder (Asperger's syndrome) as a separate diagnostic category from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been widely publicized. The new DSM-5 category of autism spectrum disorder (ASD), which subsumes the previous DSM-IV diagnoses of autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorderand pervasive developmental disorder not otherwise specified (PDD-NOS), reflects the scientific consensus that symptoms of the various DSM-IV subgroups represent a single continuum of impairment that varies in level of severity and need for support.
An important feature of the DSM-5 criteria for ASD is a change from three symptom domains (triad) of social impairment, communication deficits and repetitive/restricted behaviors, interests, or activities to two domains (dyad); social/communication deficits and fixated and repetitive pattern of behaviors. Several social/communication criteria were merged to clarify diagnostic requirements and reflect research indicating that language deficits are neither universal in ASD, nor should they be considered as a defining feature of the diagnosis. The criteria also feature dimensions of severity that include current levels of language and intellectual functioning as well as greater flexibility in the criteria for age of onset and addition of symptoms not previously included in the DSM-IV such as sensory interests and aversions.
DSM-IV Criteria in Practice
Problems in applying the DSM-IV criteria were a key consideration in the decision to delete Asperger’s disorder as a separate diagnostic entity. Numerous studies indicate that it is difficult to reliably distinguish between Asperger syndrome, autism, and other disorders on the spectrum in clinical practice (Attwood, 2006; Macintosh & Dissanayake, 2006; Leekam, Libby, Wing, Gould & Gillberg, 2000; Mayes & Calhoun, 2003; Mayes, Calhoun, & Crites, 2001; Miller & Ozonoff, 2000; Ozonoff, Dawson, & McPartland, 2002; Witwer & Lecavalier, 2008). For example, children with autism who develop proficient language have very similar trajectories and later outcomes as children with Asperger disorder (Bennett et al., 2008; Howlin, 2003; Szatmari et al., 2000) and the two are indistinguishable by school-age (Macintosh & Dissanayake, 2004), adolescence (Eisenmajer, Prior, Leekam, Wing, Ong, Gould & Welham 1998; Ozonoff, South and Miller 2000) and adulthood (Howlin, 2003). Individuals with Asperger disorder also typically meet the DSM-IV communication criterion of autism, “marked impairment in the ability to initiate or sustain a conversation with others,” making it is possible for someone who meets the criteria for Asperger’s disorder to also meet the criteria for autistic disorder.
Treatment and Outcome
Another important consideration was response to treatment. Intervention research cannot predict, at the present time, which particular intervention approach works best with which individual. Likewise, data is not available on the differential responsiveness of children with Asperger’s disorder and high-functioning autism to specific interventions (Carpenter, Soorya, & Halpern, 2009). There are no empirical studies demonstrating the need for different treatments or different responses to the same treatment, and in clinical practice the same interventions are typically offered for both autism and Asperger’s disorder (Wilkinson, 2010). Treatments for impairments in pragmatic (social) language and social skills are the same for both groups.
Application of DSM-5 Criteria
It’s important to remember that in the DSM, a mental disorder is conceptualized as a clinically important collection of behavioral and psychological symptoms that causes an individual distress, disability or impairment. The objective of the DSM-5 criteria for ASD is that every individual who has significant “impairment” in social interaction and communication, and restricted and repetitive behavior or interests should meet the diagnostic criteria for ASD. Because language impairment/delay is not a necessary criterion for diagnosis, anyone who demonstrates severe and sustained impairments in social skills and restricted, repetitive patterns of behavior, interests, or activities in the presence of generally age-appropriate language acquisition and cognitive functioning, who might previously have been given a diagnosis of Asperger’s disorder, now meet the criteria for ASD. Specifiers are used to indicate level of severity and "without accompanying intellectual impairment and language impairment."
The DSM-5 criteria for ASD have created significant controversy over concerns that it would exclude many individuals currently diagnosed with Asperger syndrome and PDD-NOS, and thus make it difficult for them to access services. However, recently published field trials suggest that the revisions actually increase the reliability of diagnosis, while identifying the large majority of those who would have been diagnosed under the DSM-IV-TR. Of the small numbers who were not included, most received the new diagnosis of “social communication disorder.” Moreover, the accuracy of non-spectrum classification (specificity) made by DSM-5 was better than that of DSM-IV, indicating greater effectiveness in distinguishing ASD from non-spectrum disorders such as language disorders, intellectual disability, attention-deficit/hyperactivity disorder (ADHD), and anxiety disorders. It is also important to note that all individuals who have a DSM-IV diagnosis on the autism spectrum, including those with Asperger syndrome and PDD-NOS, will be able to retain an ASD diagnosis. This means that no one should “lose” their diagnosis because of the changes in diagnostic criteria.  According to DSM-5, individuals with a well-established DSM-IV diagnosis of Autistic Disorder, Asperger’s Disorder, or PDD-NOS should be given a diagnosis of ASD.  Those who have marked deficits in social communication, but whose symptoms do not meet the criteria for ASD, should be evaluated for Social (Pragmatic) Communication Disorder.
In conclusion, the DSM-5 category of autism spectrum disorder (ASD), which subsumes the current diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS), better describes our current understanding about the clinical presentation and course of the neurodevelopmental disorders. Conceptualizing autism as a spectrum condition rather than a categorical diagnostic entity is in keeping with the extant research suggesting that there is no clear evidence that Asperger’s disorder and high-functioning autism are different disorders. As Gillberg (2001) notes, the terms Asperger's syndrome and high-functioning autism are more likely “synonyms” than labels for different disorders. Lord (2011) also comments that although there has been much controversy about whether there should be separate diagnoses, "Most of the research has suggested that Asperger's syndrome really isn't different from other autism spectrum disorders." "The take-home message is that there really should be just a general category of autism spectrum disorder, and then clinicians should be able to describe a child's severity on these separate dimensions." Unfortunately, many individuals may have been advised (or assumed) that a diagnosis of Asperger’s disorder was separate and distinct from autism and that intervention/treatment, course, and outcome were clinically different for each disorder. While including Asperger’s Disorder under the DSM-5 category of ASD will likely continue to require a period of transition and adjustment, the proposed dimensional approach to diagnosis will likely result in more effective identification, treatment, and research for individuals on the spectrum.
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Attwood, T. (2006). The complete guide to Asperger’s syndrome. London: Jessica Kingsley.
Carpenter, L. A., Soorya, L. & Halpern, D. (2009). Asperger’s syndrome and high- functioning autism. Pediatric Annals, 38, 30-35.
Eisenmajer, R., Prior, M., Leekam, S., Wing, L., Ong, B., Gould, J. & Welham, M. (1998)
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Lee A. Wilkinson, PhD, CCBT, NCSP 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 CBTHis most recent book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Monday, August 3, 2015

Reclassification May Account for Rise in Autism

The dramatic increase in the rate of autism among children enrolled in special education programs in the United States between 2000 and 2010 may be due in large part to the reclassification of students who previously would have been given other disability labels, according to new research. In a paper published online in the American Journal of Medical Genetics, scientists at Penn State reported their analysis of 11 years of data from the United States Individuals with Disabilities Education Act (IDEA) for students enrolled in special education programs. Under IDEA, individuals are classified into one of 13 disability categories including autism, intellectual disability, emotional disturbance, other health impairment and specific learning disability.
The researchers found that between 2000 and 2010, the number of children in the autism category more than tripled from 93,624 in 2000 to 419,647 a decade later. Yet nearly 65 percent of this increase was significantly associated with a corresponding decline in the number of students classified under the intellectual disability category in the IDEA data. The researchers estimate that, for 8 year-olds, approximately 59 percent of the observed increase in autism is accounted for by reclassification, but by age 15, reclassification accounts for as much as 97 percent of the increase in autism. Likewise, the researchers found the category of specific learning disability as another potential contributor to diagnostic reclassification. They also note that the relationship between autism cases and disability categories varied state-by-state, suggesting that state-specific health policy may be a significant factor in estimates of autism prevalence.
Although a broadening of diagnostic criteria, improved assessment practices, increased awareness of autism, and strategic use of diagnosis to gain access to services have all had a significant effect on the prevalence of autism, this new research provides the first direct evidence that much of the increase may be attributable to a reclassification of children with related disorders (or diagnostic substitution) rather than to an actual increase in the rate of new cases of autism. The researchers conclude that the large increase in the prevalence of autism is likely the result of students being moved from one category to another and is complicated by the variability of autism and its overlap with other related disorders. Current prevalence estimates are based on specific clinical features of autism and do not consider co-occurring disorders that may confound diagnosis and classification. "Because features of neurodevelopmental disorders co-occur at such a high rate and there is so much individual variation in autism, diagnosis is greatly complicated, which affects the perceived prevalence of autism and related disorders," said Santhosh Girirajan, assistant professor of biochemistry and molecular biology and of anthropology at Penn State and the leader of the research team. "For quite some time, researchers have been struggling to sort disorders into categories based on observable clinical features, but it gets complicated with autism because every individual can show a different combination of features. The tricky part is how to deal with individuals who have multiple diagnoses, because the set of features that define autism is commonly found in individuals with other cognitive or neurological deficits."
Polyak A, Kubina RM, Girirajan S. 2015. Comorbidity of intellectual disability confounds ascertainment of autism: implications for genetic diagnosis. Am J Med Genet Part B 9999:1–9.
Lee A. Wilkinson, PhD, NCSP 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. He is also editor of a best-selling text in the American Psychological Association (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).

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