Tuesday, November 17, 2015

The Crisis in Mental Health Services for Young Adults on the Autism Spectrum


The dramatic increase in the prevalence of autism spectrum conditions among children over the past decade indicates that a correspondingly large number of youth will be transitioning into adulthood in the coming years. It is estimated that more than 50,000 adolescents with autism will turn 18 years old this year in the U.S. As these numbers continue to rise, there is an urgent need to address the mental health issues faced by many adults on the autism spectrum.
Although we know that children with autism grow up to be adults with autism, there are fewer mental health services available for adults on the spectrum, particularly for individuals who are not intellectually challenged. A review in the open access journal, Autism Research and Treatment, highlights the service needs and the corresponding gaps in care for this population. The authors posit that the mental health system is in crisis and that although the rates of mental health issues for adults on the spectrum is high, accessing services to address these symptoms remains difficult. Poor recognition tends to occur for a number of different reasons, including restrictive intake criteria, misdiagnosis, limited knowledge or awareness of autism spectrum conditions, clinicians who lack confidence or experience in caring for this group of adults, and the belief that other service providers will provide this care. Consequently, many adolescents and adults on the autism spectrum, because of their diagnosis, are excluded from community mental health services, leaving them grossly underserved.
Mental Health Issues
Comorbid (co-occurring) psychiatric disorders are well documented in individuals with autism across the lifespan. Research suggests that a very high proportion of adults and teens on the spectrum present with co-occurring (comorbid) psychiatric conditions, particularly depression and anxiety. For example, recent studies examining psychiatric comorbidity in young adults with autism spectrum conditions found that 70% had experienced at least one episode of major depression, 50% had suffered from recurrent depressive episodes, and 50% met criteria for an anxiety disorder. Unfortunately, it appears that co-occurring psychiatric disorders and even the diagnosis of an autism spectrum condition itself often go unrecognized among more capable adolescents and adults on the spectrum seeking psychological or psychiatric care. Many youth and young adults report significant difficulties accessing healthcare services, particularly comprehensive health services. Part of the reason for this difficulty may stem from service providers feeling ill equipped to work with individuals with autism, particularly individuals with co-occurring mental health issues. As a result, adolescents and adults with autism spectrum conditions have access to significantly fewer programs than adolescents and adults with other types of developmental disabilities. Not surprisingly then, a consistent theme for parents of individuals with autism is the fear that their child will fall through the cracks when transitioning from child to adult services. Similar concerns have been voiced by the individuals on the spectrum themselves, who describe how their needs are infrequently recognized and the programs and services available are not designed for people with autism spectrum conditions in mind.
Conclusions
Adolescents and adults on the autism spectrum represent a complex and underserved population. Of the studies completed to date, findings suggest that this group of adolescents and adults faces a multitude of psychiatric and psychosocial issues, alongside significant challenges in accessing services. Social skills deficits for individuals on the spectrum persist into adulthood, and adults appear to be at an increased risk for developing depression and anxiety. Despite this, very few studies have examined treatment approaches and interventions (pharmacological and psychosocial) for adolescents and adults with autism spectrum conditions. While evidence is beginning to emerge for interventions targeting this population, including cognitive-behavioral therapy (CBT), mindfulness-based therapy (MBT), and social skills training (SST), further large-scale studies which compare the effectiveness of, for example, CBT or MBT versus other treatment options (e.g., medication, counseling, etc.) are required. Likewise, there is an immediate need for mental health clinicians who are trained to apply these techniques. In developing interventions, programs must also consider what adolescents and adults want. For example, adolescents and adults on the spectrum may be more interested in interventions which focus on vocational opportunities than interventions targeting social skills. Moreover, both individuals and their family must be viewed as valuable contributors and fully involved in this process. Lastly, researchers must look at issues of service cost and efficiency when evaluating the impact of interventions.
Recommendations
The findings of this review article point to the following important practice recommendations.
1. Developmental disability agencies or agencies supporting individuals with autism spectrum conditions must partner with community mental health agencies to help train, mentor, and build capacity to care for this group across the lifespan. It is important to note that many clinicians working within community mental health agencies already have the skills to effectively deliver this care, but programs either preclude their ability to do so or they lack the confidence to work with this population.
2. There is a critical need for community mental health agencies to review their exclusion criteria to include persons with autism spectrum conditions. For example, agencies providing care for persons with mood or anxiety disorders should not exclude individuals on the basis of a diagnosis of autism. Community mental health agencies have the resources and expertise in mental health, along with the programs to deliver services for individuals with mental health issues (e.g., vocational programs, counseling, and therapies), but will need guidance from developmental disability agencies to successfully adapt these programs for adults on the autism spectrum.
3. Developmental disability agencies must reevaluate their inclusion criteria to include persons with autism spectrum conditions, regardless of IQ, and across the lifespan. Organizations must work together, combining expertise in autism from developmental disability agencies with knowledge and resources from community mental health agencies.
4. There is a need to study and identify programs and supports that are most effective in both school and community settings. This will require a full continuum of mental health services including counseling, vocational training, supported employment, inpatient services, and outpatient services. It will also require a network of experienced clinicians and community partners. Many of these efforts are already underway in pediatric settings; however, these same efforts are required in adolescent and adult mental health services.
5. Finally, there is a need to prepare and equip older youth with autism spectrum conditions for the transition to adult services.
Johanna K. Lake, J. K., Perry, A., & Lunsky, Y. (2014). Mental Health Services for Individuals with High Functioning Autism Spectrum Disorder. Autism Research and Treatment, Volume 2014, Article ID 502420. http://dx.doi.org/10.1155/2014/502420

Wednesday, November 11, 2015

First Impressions Matter: Facial Expression & Peer Acceptance in Autism

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by two core-defining features: impairments in (a) social communication and (b) restricted and repetitive behaviors or interests (American Psychiatric Association [APA], 2013). Social-communication deficits include difficulties making affective (emotional) contact with others. This includes deficits in nonverbal communicative behaviors used for social interaction which range from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to a lack of facial expression or gestures.
Research investigating facial expressivity in children with ASD has reported “flat affect” or odd facial expressivity within this population. “Flat affect” is a term used to describe a lack of emotional reactivity. With a flat affect, expressive gestures are minimal, and there is little animation in facial expression or vocal inflection. Facial expressions are a form of non-verbal communication essential to interpersonal relationships. An inability to read facial and social cues makes “connecting” to others very difficult. Likewise, reduced or odd expres­sivity may impede social discourse or provoke negative initial reactions to the person with ASD. 
Research
A study published in the journal Autism examined the impact of facial expressivity on first impression formation and found that typically developing children formed their impressions of peers with ASD in as little as 30 seconds. Videos of children with ASD were initially rated for facial expressivity by adults who were unaware of the condition. Researchers further investigated the friendship ratings given by 44 typically developing children to the same videos. The children making friendship judgments were also unaware that they were rating chil­dren with ASD. These ratings were compared to friendship ratings given to video clips of typically developing children. Adult participants rated children with ASD as being less expressive than typically developing children. The 44 child participants also rated peers with ASD lower than typically developing children on all aspects of friendship measures. Children with ASD were rated not as trustworthy as the typically-developing children in the films. Moreover, study participants were less likely to say that they wanted to play with or be friends with the video subjects on the spectrum. These results suggest that impression formation is less positive towards children with ASD than towards typically developing children even when exposure time is brief.
Implications
The findings of this study have important implications for intervention. First impressions make a difference: whether you are looking at facial expressions, gestures, or just general appearance, people are quick to form judgments about others. Children with ASD experience more peer rejection and have fewer friendships than their typically developing peers. Limited facial expres­sivity may further remove children with ASD from meaningful interactions and reciprocal emotional related­ness with others. Negative peer responses can be especially upsetting for more socially aware children with ASD who may be strive but fail to form friendships. Further, distress often increases as children approach adolescence and the social milieu becomes more complex. 
Social relationship skills are critical to successful social, emotional, and cognitive development and to long-term outcomes for all students. An increase in the quality of social relationships can have a major influence on the social and academic development of both typically developing children and those with ASD. Consequently, intervention needs to be focused on both groups in poten­tial interactions rather than solely on the child with ASD. This includes strategies designed to promote skill acquisition in building social relationships such as direct instruction, modeling, role-play, structured activities, social stories, formal social groups, pivotal response teaching, self-monitoring, and coaching. Students in general education could help the process of cohesion by serving as prosocial role models for students with ASD. Teachers may also provide reinforcement for prosocial behavior or assign students in general education to work with students with ASD in small groups on class projects together to promote positive interaction. Schools should make a dedicated effort to educate typically developing children about autism and associated symptoms. Educating children and increasing awareness will hopefully encourage a more thoughtful first impression formation process. Teaching social skills can have both preventive and remedial effects that can help reduce the risk for negative outcomes not only for children on the autism spectrum, but also for all children. 
Does facial expressivity count? How typically developing children respond initially to children with Autism. Steven D Stagg, Rachel Slavny, Charlotte Hand, Alice Cardoso and Pamela Smith. Autism published online 11 October 2013 DOI: 10.1177/1362361313492392 
The online version of this article can be found at: http://aut.sagepub.com/content/early/2013/10/10/1362361313492392

Sunday, November 1, 2015

Inclusion for Students with Autism Varies by State


The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) (P.L. 108-446) (http://idea.ed.gov/) guarantees a free and appropriate public education (FAPE) in the least restrictive environment (LRE) for every student with a disability. The LRE provision mandates that “to the maximum extent appropriate, children with disabilities, including children in public or private institutions or other care facilities, are educated with children who are not disabled, and special classes, separate schooling, or other removal of children with disabilities from the regular educational environment occurs only when the nature or severity of the disability of a child is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily.”  In general, inclusion (or inclusive education) with typical peers is often considered to be the best placement option for students with disabilities. 

Child characteristics such as severity of autism symptoms are thought to determine educational placement. However, where a child lives may significantly impact whether they are placed in an inclusive or segregated classroom, a national analysis suggests. The study published online in the journal Focus on Autism and Other Developmental Disabilities examined external factors, including state of residence and state funding formulas, to determine their potential influence on placement outcomes. On average, about 37 percent of students on the autism spectrum spent at least 80 percent of their school day in inclusive environments. But the numbers varied considerably from one state to the next, ranging from just 8 percent in Washington, D.C. to 62 percent in Iowa. 

There was considerable variation among states in placing students with autism spectrum disorder (ASD) in inclusive, mainstreaming, self-contained, and separate schools. Specifically, states varied substantially in the percentage of students with ASD educated in each setting, with some states consistently favoring inclusion (Colorado, Connecticut, Idaho, Iowa, Minnesota, Nebraska, North Dakota, West Virginia, and Wisconsin). Other states, however, generally leaned toward more restrictive settings (Alaska, Delaware, Florida, Hawaii, Louisiana, New Hampshire, New Jersey, New York, South Carolina, and Washington, D.C.). States in the Eastern United States tended to have more restrictive placement rates than states in the Western United States. State special education funding was found to have a minimal impact on placement outcomes.
These findings suggest that factors that are external to child characteristics (e.g., severity of ASD symptoms) influence educational placement decisions for students with ASD. “If child-specific factors were solely responsible for education placement decisions, one would expect states to have similar rates of inclusive, self-contained, mainstreaming and separate school placements for students with ASDs,” the author commented. “Instead, … results indicate that educational placement varies by state.” 

Overall, it is unlikely that child characteristics alone determine placement outcomes. Although it is arguably safe to assume that the first placement for a student with ASD would be an inclusive setting, analysis of the public data presented in this study suggests that many states are still falling short of including students with ASD in general education settings for significant portions of the day. The argument must now shift from should we include students with ASD in general education to understanding how to include students with ASD meaningfully and successfully in inclusive settings. It is critical to identify how those practices that benefit students with ASD, including structure (visual supports, communication supports, and social supports), positive behavior supports, and systematic instruction, can be implemented meaningfully and seamlessly in general education settings. Lastly, those who place students with ASD in educational settings should determine the unique needs of the individual, and match those needs to specific supports and services that will be provided in general education settings.
Jennifer A. Kurth,  Educational Placement of Students With Autism: The Impact of State of Residence, Focus on Autism and Other Developmental Disabilities, first published on September 3, 2014 doi:10.1177/1088357614547891.

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