Saturday, November 21, 2015

Best Practice Guidelines for Assessment of Autism Spectrum Disorder (ASD)

The number of children identified with autism has more than doubled over the last decade. School-based professionals are now being asked to participate in the screening, assessment, and educational planning for children and youth on the spectrum more than at any other time in the recent past. Moreover, the call for greater use of evidence-based practice has increased demands that school personnel be prepared to recognize the presence of risk factors, engage in case finding, and be knowledgeable about “best practice” guidelines in assessment and intervention for autism spectrum disorder (ASD) to ensure that students are being identified and provided with the appropriate programs and services.

Best practice guidelines are developed using the best available research evidence in order to provide professionals with evidence-informed recommendations that support practice and guide practitioner decisions regarding assessment and intervention. Best practice requires the integration of professional expertise, each student’s unique strengths and needs, family values and preferences, and the best research evidence (rigorous peer-review) into the delivery of services. Professionals and families collaborate and work together as partners to prioritize domains of functioning for assessment and intervention planning. Best practices for school-based practitioners are best practices for students and their families.               
                                           Comprehensive Developmental Assessment

The primary goals of conducting an autism spectrum assessment are to determine the presence and severity of an autism spectrum disorder (ASD), develop interventions for intervention/treatment planning, and collect data that will help with progress monitoring. Professionals must also determine whether an ASD has been overlooked or misclassified, describe coexisting (comorbid) disorders, or identify an alternative classification. There are several important considerations that should inform the assessment process. First, a developmental perspective is critically important. While the core symptoms of are present during early childhood, ASD is a lifelong disability that affects the individual’s adaptive functioning from childhood through adulthood. Utilizing a developmental assessment framework provides a yardstick for understanding the severity and quality of delays or atypicality. Because ASD affects multiple developmental domains, the use of an interdisciplinary team constitutes best practice for assessment and diagnosis of ASD. A team approach is essential for establishing a developmental and psychosocial profile of the child in order to guide intervention planning. The following principles should guide the assessment process.
  • Children who screen positive for ASD should be referred for a comprehensive assessment.  Although screening tools have utility in broadly identifying children who are at-risk for an autism spectrum condition, they are not recommended as stand alone diagnostic instruments or as a substitute for a more inclusive assessment.
  • Assessment should involve careful attention to the signs and symptoms consistent with ASD as well as other coexisting childhood disorders.
  • When a student is suspected of having an ASD, a review of his or her developmental history in areas such as speech, communication, social and play skills is an important first step in the assessment process.
  • A family medical history and review of psychosocial factors that may play a role in the child’s development is a significant component of the assessment process. 
  • The integration of information from multiple sources will strengthen the reliability of the assessment results.
  • Evaluation of academic achievement should be included in assessment and intervention planning to address learning and behavioral concerns in the child’s overall school functioning.
  • Assessment procedures should be designed to assist in the development of  instructional objectives and intervention strategies based on the student’s unique pattern of strengths and weaknesses.
  • Because impairment in communication and social reciprocity are core features of ASD, a comprehensive developmental assessment should include both domains
  • Restricted, repetitive patterns of behavior, interests, or activities (RRB) are a defining feature of ASD and should be a focus of assessment.
A comprehensive developmental assessment approach requires the use of multiple measures including, but not limited to, verbal reports, direct observation, direct interaction and evaluation, and third-party reports. Assessment is a continuous process, rather than a series of separate actions, and procedures may overlap and take place in tandem. While specific activities of the assessment process will vary and depend on the child’s age, history, referral questions, and any previous evaluations and assessments, the following components should be included in a best practice assessment and evaluation of ASD in school-age children.
  •  Record review
  •  Developmental and medical history
  •  Medical screening and/or evaluation
  • Parent/caregiver interview
  • Parent/teacher ratings of social competence/interaction
  • Direct child observation
  • Cognitive assessment
  • Academic assessment
  • Adaptive behavior assessment
  • Social communication and language assessment
  • Assessment of RRB (including sensory issues)
Children with ASD often demonstrate additional problems beyond those associated with the core domains. Therefore, other areas should be included in the assessment battery depending on the referral question, history, and core evaluation results. These may include:
  • Sensory processing
  • Executive function, memory, and attention
  •  Motor skills
  • Family system 
  • Co-occurring (comorbid) behavioral/emotional problems   
The above referenced principles and procedures for the assessment of school-age children with ASD are reflected in recommendations of the American Academy of Neurology, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and a consensus panel with representation from multiple professional societies. A detailed description of the comprehensive developmental assessment model and specific assessment tools recommended for each domain can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools, (2nd edition).
© Lee A. Wilkinson, PhD

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 problems 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.
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.
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.

Sunday, November 15, 2015

Positive Behavior Support in the Classroom

The problem behaviors of children with autism spectrum disorders (ASD) are among the most challenging and stressful issues faced by schools and parents. The current best practice in treating and preventing undesirable or challenging behaviors utilizes the principles and practices of positive behavior support (PBS). PBS is not a specific intervention per se, but rather a set of research-based strategies that are intended to decrease problem behaviors by designing effective environments and teaching students appropriate social and communication skills. The objective of PBS is to decrease potentially problematic behavior by making environmental changes and teaching new skills rather than focusing directly on eliminating the problem behavior.
Other than families, teachers are the most influential resource for students with and without disabilities.  Effective prevention of challenging social behavior can be addressed through arranging the classroom environment and/or by adapting instruction and the curriculum. Changing the classroom environment or instruction may lessen the triggers or events that set off the challenging behavior. Teaching effective social interaction and communication as replacements for challenging behavior is also a preventive strategy for improving little used student social interaction and communication skills. Teachers can model, demonstrate, coach, or role-play the appropriate interaction skills. They can teach students to ask for help during difficult activities or negotiate alternative times to finish work. Encouraging positive social interactions such as conversational skills will help students with challenging behavior to effectively obtain positive peer attention. The following are examples of PBS strategies for improving social skills and prosocial behaviors in the classroom (Vaughn, Duchnowski, Sheffield, & Kutash, 2005; Wilkinson, 2010). 
Initiating interactions. Teachers might notice that when a student with ASD enters the classroom, group activity, or other social interaction, he or she may have particular difficulty greeting others students or starting a conversation. For example, they may joke, call another student a name, laugh, or say something inappropriate. In this situation, the student may have trouble ini­tiating interactions or conversations. The teacher might talk to the student individually and offer suggestions for ways he or she can provide an appropriate greeting or introduce a topic of conversation. The student might then be asked to practice or role-play the desired behavior.
Example: “why don’t you ask students what they did last night, tell them about a TV show you watched, or ask if they finished their homework, rather than shouting or saying ‘Hey, Stupid.’ Other students in the class want to be your friend, but you make it difficult for them to talk with you. Let’s practice the next time the class begins a new group activity.”
Maintaining interactions. Many students with ASD struggle to maintain a conversation (e.g.., turn taking). Some may dominate the conversation and make others feel that they have nothing to contribute, while other students may experience difficulty keeping up with the flow of conversation and asking questions. Students may also have lim­ited topics of interest and discuss these topics repetitively.
Example: “I’ve noticed that other students cannot share their thoughts and ideas with you when you start a conversation because you do all the talking. It may seem to them that you don’t care what they have to say. Other students will be more willing to talk if you stop once you’ve stated your idea or opinion and allow them a turn to talk. When you stop, they know you are listening. You can say to them, “What do you think?” or “Has this ever happened to you?’”
Terminating interactions. Some students with ASD may not know how to appropriately end a conversation. They may abruptly walk away, start talking with another student, or bluntly tell a student they don’t know what they’re talking about. Other students may interpret this as rude and impolite behavior. Teachers might point out to the student some ac­ceptable ways of ending a conversation.
Example: “You just walked away from that student when they were talking. Rather than walk away, you might say “‘I have to go now,’ ‘It’s time for my next class,’ ‘Or ‘I’ll see you later and we can finish our talk.’”
Recognizing body language. The recognition of body language or nonverbal cues is critical to suc­cessful social interactions. Students with ASD typically have difficulty interpreting these cues from teachers or other students. Body language tells students when they violate a person’s personal space, a person needs to leave, or they need to change behavior. Teachers can incorporate these skills into their class time or school day.
Example: Before leaving the classroom, demonstrate  nonverbal cues by holding a finger to your lips and telling students that means “quiet,” a hand held up with palm fac­ing outward means “wait” or “stop,” and both hands pushing downward means “slow down.” You may need to demonstrate facial expressions you use to “deliver messages” and what they mean. Other students can demonstrate nonverbal cues they use. When students move through the halls, you may want to teach them the “arms length” rule for personal space.
Transitions. Many students with ASD have significant problems changing from one activity to the next or moving from one location to another. They may be easily upset by abrupt changes in routine and unable to estimate how much time is left to finish an activity and begin the next one. Poor executive function skills such as disorganization may also prevent them from putting materials away from the last activity or getting ready for the next activity. They may also need closure and preparation time for the transition. Problems arise if the teacher tries to push them to transition at the last minute.
Example: About 10 minutes prior to the transition, refer to the classroom schedule and announce when the bell will ring or when the next activity will begin. Provide a 5-minute and then a 1-minute warning. This countdown helps students finish assignments or end favorite activities. For students that have difficulty getting started after a transition, place assign­ment folders on their desks so that they have their assignments and don’t have to wait for instructions or materials. They can use the same folder to submit assignments (the folders can be left on their desks at the end of the period).
Students with ASD often lack the social skills to communicate and interact effectively with peers and adults. They may use challenging or disruptive behavior to communicate their needs. These examples illustrate how PBS provides a proactive framework for assessing social interaction and communication needs and for teaching new, effective skills that replace the challenging behavior. When used consistently, these strategies fit within the framework of the classroom and can help promote positive student behavior.

 Resources for Further Information  
Alberto, P., & Troutman, A. (2006). Applied behavior analysis for teachers (7th edition). New York, NY: Prentice-Hall.
Crone, D. A., Horner, R. H., & Hawken, L. S. (2004). Responding to problem behavior in schools: The behavior education program. New York: Guilford Press.
Crone, D. A., & Horner, R. H. (2003). Building positive behavior support systems in schools: Functional behavioral assessment. New York: Guilford.
Dunlap, G., Iovannone, R., Kincaid, D., Wilson, K., Christiansen, K., Strain, P., & English, C., (2010). Prevent-Teach-Reinforce: A school-based model of positive behavior support. Baltimore: Brookes.
Horner, R. H., Sugai, G., Todd, A. W., & Lewis-Palmer, T. (2005). School-wide positive behavior support. In L. Bambara & L. Kern (Eds.), Individualized supports for students with problem behaviors: Designing positive behavior plans (pp. 359-390). New York: Guilford Press.
Martella, R. C., Nelson, J. R., & Marchand-Martella, N. E. (2003). Managing disruptive behaviors in the schools: A schoolwide, classroom, and individualized social learning approach. Boston, MA: Allyn and Bacon, Inc.
OSEP Technical Assistance Center on Positive Behavioral Interventions and Supports. 
Sprague, J. R., & Walker, H. M. (2005). Safe and healthy schools: Practical prevention strategies. New York, NY: Guilford.
Sprick, R.S., & Garrison, M. (2008). Interventions: Evidence-based behavioral strategies for individual students. Eugene, OR: Pacific Northwest Publishing.
Vaughn, B., Duchnowski, A., Sheffield, S., & Kutash, K., (2005). Positive behavior support: A classroom-wide approach to successful student achievement and interactions. Department of Child and Family Studies, Louis de la Parte Florida Mental Health Institute. Tampa, FL: University of South Florida.
Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.

Sunday, November 1, 2015

Impact of State Residence on the Educational Placement of Students with Autism

The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) (P.L. 108-446) ( 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. The findings revealed that considerable variations exist among states in placing students with autism spectrum disorder (ASD) in inclusive, mainstreaming, self-contained, and separate schools. Specifically, states vary substantially in the percentage of students with ASD educated in each setting, with some states trending consistently toward less restrictive settings (Colorado, Connecticut, Idaho, Iowa, Minnesota, Nebraska, North Dakota, West Virginia, and Wisconsin). Other states, however, are consistently representative of more restrictive settings (Alaska, Delaware, Florida, Hawaii, Louisiana, New Hampshire, New Jersey, New York, South Carolina, and Washington, D.C.). Furthermore, states in the Eastern United States tend 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. 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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