Friday, May 27, 2016

Social Isolation in Young Adults on the Spectrum

The dramatic increase in the prevalence of autism spectrum disorder (ASD) among children indicates that a correspondingly large number of youth will be transitioning into adulthood in the coming years. Investigating social participation of young adults with ASD is important given that social participation is an indicator of life quality and overall adaptive functioning. A study using data from the National Longitudinal Transition Study 2 examined rates of participation in social activities among young adults who received special education services for ASD, compared to young adults who received special education for intellectual disability, emotional/behavioral disability, or a learning disability.
According to the study, young adults with ASD were significantly more likely to never see friends, never get called by friends, never be invited to activities, and be socially isolated. Nearly 40 percent of young adults with ASD never saw friends and half were not receiving any phone calls or being invited to activities. Researchers found that 28 percent had no social contact at all. The social struggles of young people with ASD were also significantly more pronounced than those of other disability groups. For example, while almost one-third of those with ASD qualified as socially isolated because they never received telephone calls or went out with friends, fewer than 10 percent of individuals with intellectual disability and only 2 to 3 percent of people with emotional disturbance or learning disabilities fell into this category.
“Difficulty navigating the terrain of friendships and social interaction is a hallmark feature of autism,” said Paul Shattuck of Washington University who coauthored the study. “Nonetheless, many people with autism do indeed have a social appetite. They yearn for connection with others. We need better ways of supporting positive social connection and of preventing social isolation.”
This study indicates that there are growing numbers of adolescents and young adults with ASD in need of substantial support. In fact, the lack of services available to help young adults with ASD transition to greater independence has been noted by researchers for a number of years and has become an increasingly important issue as the prevalence of ASD continues to grow and as children identified with ASD reach adolescence and adulthood. The focus of intervention/treatment must shift from remediating the core deficits in childhood to promoting adaptive behaviors that can facilitate and enhance ultimate functional independence and quality of life in adulthood. This includes new developmental challenges such as independent living, vocational engagement, postsecondary education, and family support.
Orsmond, G. I., Shattuck, P. T., Cooper, B. P., Sterzing, P. R., & Anderson, K. A. (2013). Social Participation among young adults with an autism spectrum disorder. Journal of Autism and Developmental Disorders. DOI 10.1007/s10803-013-1833-8
Lee A. Wilkinson, PhD 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. Dr. Wilkinson's latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition.).

Wednesday, May 4, 2016

Early Identification of Repetitive Behavior in Autism

The criteria for the new DSM-5 category of Autism Spectrum Disorder (ASD) include restricted and repetitive patterns of behavior (RRB) as a core diagnostic feature, together with the domain of social communication and social interaction deficits. Recent evidence suggests that restricted and repetitive behaviors may differentiate children who develop autism spectrum disorder (ASD) by late infancy. A study published in the Journal of Child Psychiatry and Psychology found that children who show several repetitive behaviors at their first birthday have nearly four times the risk of autism of children who don’t show repetitive behaviors.
Researchers collected parent-report data (Repetitive Behavior Scales-Revised) for 190 high-risk toddlers and 60 low-risk controls from 12 to 24 months of age. Forty-one high-risk children were classified with ASD at age 2. Profiles of repetitive behavior were compared between groups. The study found that the profiles for children diagnosed with ASD differed significantly from high- and low-risk children without the disorder on all measures of repetitive behavior. Toddlers with ASD showed significantly higher rates of repetitive behavior across at the 12-month time point. Repetitive behaviors were significantly associated with adaptive behavior and socialization scores among children with ASD at 24 months of age, but were largely unrelated to measures of general cognitive ability.
These findings suggest that as early as 12 months of age, a broad range of repetitive behaviors are highly elevated in children who go on to develop ASD. While some degree of repetitive behavior is essential to typical early development, the extent of these behaviors among children who develop ASD appears highly atypical. The study supports earlier findings that repetitive behaviors may be among the earliest-emerging signs of autism. It also points to new avenues of inquiry. While the search for early social deficits has received substantial attention from researchers, ritualistic, repetitive behaviors have largely been neglected. This is unfortunate because repetitive behaviors are often easier for a parent to notice than the absence of a social behavior. Parents of individuals with ASD also report that restricted and repetitive behaviors are one of the most challenging features of ASD due to their significant interference with daily life. Likewise, they can impede learning and socialization by decreasing the likelihood of positive interactions with peers and adults. 

Given the importance of restricted and repetitive (RRB) behavior, clinicians and practitioners should give increased attention to the assessment and presence of this behavior in screening and assessment as an early indicator and consider their impact on the psychological well-being of individuals with ASD

Restricted and Repetitive behavior (RRB) is a core diagnostic feature of ASD and should be included as a core domain in a comprehensive developmental assessment. Although broad-based measures such as the Autism Spectrum Rating Scales (ASRS; Goldstein & Naglieri, 2010) and the Social Responsiveness Scale (SRS-2; Constantino & Gruber, 2012) incorporate scales and treatment clusters assessing stereotypical behaviors, sensory sensitivity, and highly restricted interests, there are parent/caregiver questionnaires that focus solely on restricted and repetitive behaviors and provide a more complete understanding of the impact of RRB on adaptive functioning. The most commonly used are the Repetitive Behavior Scale-Revised (RBS-R; Bodfish, Symons, Parker, & Lewis, 2000) and the Repetitive Behavior Questionnaire-2 (RBQ-2; Leekam et al., 2007). Both cover a wide range of repetitive behaviors and were designed as a quantitative index of RRB. Individuals who have marked deficits in social communication, but whose symptoms do not meet the RRB criteria for ASD, may be evaluated for social (pragmatic) communication disorder (SCD).

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).
Wolff JJ, Botteron KN, Dager SR, Elison JT, Estes AM, Gu H, Hazlett HC, Pandey J, Paterson SJ, Schultz RT, Zwaigenbaum L, Piven J. Longitudinal patterns of repetitive behavior in toddlers with autism. J Child Psychol Psychiatry. 2014 Feb 19. doi: 10.1111/jcpp.12207. [Epub ahead of print]
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral  therapist. 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 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).

Tuesday, May 3, 2016

PEERS Program Improves Social Skills for Teens on the Autism Spectrum

Severe impairment in social reciprocity is the core, underlying feature of ASD. Socialization deficits are a major source of impairment, regardless of cognitive or language ability and do not decrease with development. In fact, distress often increases as children approach adolescence and the social milieu becomes more complex. Evidence accumulating in the empirical literature indicates that in general, social skills interventions are likely to be appropriate for some children and youth with high-functioning autism. 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. Child-specific social skills interventions frequently include (a) general instruction to increase knowledge and develop social problem solving skills, (b) differential reinforcement to improve social responding,(c) structured social skills training programs, (d) adult-mediated prompting, modeling, and reinforcement, and (e) various behavior management techniques such as self-monitoring.
A study appearing in the Journal of Autism and Developmental Disorders adds to research database suggesting that social interactive training is an effective and promising technique for promoting communication and social skills in youth with autism. The study examined the efficacy and durability of the UCLA PEERS Program, a parent-assisted 14-week social skills group intervention for more capable adolescents on the autism spectrum. In a series of 90-minute weekly sessions the students were taught to interact in real-world social situations through role playing and homework assignments. The teens’ parents also attended sessions to learn how to appropriately coach their kids at home. Results indicated that teens receiving PEERS significantly improved their social skills knowledge, social responsiveness, and overall social skills in the areas of social communication, social cognition, social awareness, social motivation, assertion, cooperation, and responsibility, while decreasing autistic mannerisms and increasing the frequency of peer interactions. Independent teacher ratings revealed significant improvement in social skills and assertion from pre-test to follow-up assessment. Examination of the strength of improvement indicated maintenance of gains in nearly all domains with additional treatment gains at a 14-week follow-up assessment. “This is exciting news,” commented Elizabeth Laugeson, an assistant clinical professor of psychiatry at the University of California, Los Angeles who led the study. “It shows that teens with autism can learn social skills and that the tools stick even after the program is over, improving their quality of life and helping them to develop meaningful relationships and to feel more comfortable within their social world.”
Laugeson, E. A., Frankel, F., Gantman, A., Dillon, A. R.,  &  Mogil, C. (2012). Evidence-based social skills training for adolescents with autism spectrum disorders: The UCLA PEERS Program. Journal of Autism and Developmental Disorders, 42, 1025-1036. DOI:10.1007/s10803-011-1339-1

Monday, May 2, 2016

Anxiety and Depression Common in Autism

There is robust research to suggest that 70 to 80 percent of children with ASD meet diagnostic criteria for one or more co-occurring (comorbid) disorders and 40 to 50 percent meet criteria for two or more. A Comorbid disorder is defined as a condition that co-occurs with another diagnosis so that both share a primary focus of clinical and educational attention. The most prevalent comorbid conditions are mood disorders, anxiety disorders, attention-deficit/hyperactivity disorder, disruptive behavior disorders, and chronic tic disorders, all which contribute to overall impairment.

     Internalizing Problems
Studies have consistently reported an association between ASD and internalizing symptoms, in particular, anxiety and depression. A bidirectional association has been identified between internalizing disorders and autistic symptoms. For example, both a higher prevalence of anxiety disorders has been found in ASD and a higher rate of autistic traits has been reported in youth with mood and anxiety disorders. Individuals with ASD also display more social anxiety symptoms compared to typical individuals, even if these symptoms were clinically overlapping with the characteristic social problems of ASD. In addition, there is some evidence to suggest that adolescents and young adults with ASD show a higher prevalence of bipolar disorders as compared to controls.
Depression is one of the most common comorbid conditions observed in individuals with ASD, particularly higher functioning youth. A study 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 another documented association is with obsessive-compulsive disorder (OCD), it is difficult to determine whether observed obsessive-repetitive behaviors are an expression of a separate, comorbid OCD, or an integral part of the core diagnostic features of ASD (i. e., restricted, repetitive patterns of behavior, interests, or activities).
Externalizing Problems
An association between ASD and attention-deficit/hyperactivity disorder (ADHD) and other externalizing problems (i. e., oppositional defiant disorder) have been reported. Studies have found that children with ASD in clinical settings present with co-occurring symptoms of ADHD with rates ranging between 37% and 85%. Although there continues to a debate about ADHD comorbidity in ASD, research, practice and theoretical models suggest that co-occurrence between these conditions is relevant and occurs frequently. For example, case studies suggest that ADHD is a relatively common initial diagnosis in young children with ASD. It is also important to note that a significant change in the DSM-5 is removal of the DSM-IV-TR hierarchical rules prohibiting the concurrent diagnosis of ASD and ADHD. When the criteria are met for both disorders, both diagnoses are given.
Other Comorbidities
Tourette Syndrome (TS) and other tic disorders have been found to be a comorbid condition in many children with ASD. A Swedish study showed that 20% of all school-age children with ASD met the full criteria for TS. There also appears to be a higher incidence of seizures in children with autism compared to the general population. The comorbidity of ASD and psychotic disorders has received some research attention. A study of children with ASD who were referred for psychotic behavior and given a diagnosis of schizophrenia showed that when psychotic behaviors were the presenting symptoms, depression and not schizophrenia, was the likely diagnosis. Thus, individuals with ASD may present with characteristics that could lead to a misdiagnosis of schizophrenia and other psychotic disorders.
Children and youth with ASD frequently have comorbid conditions, with rates significantly higher than would be expected from the general population. The most common co-occurring diagnoses are anxiety and depression, attention problems, and disruptive behavior disorders. The core symptoms of ASD can often mask the symptoms of a comorbid condition. The current challenge for practitioners is to determine if the symptoms observed in ASD are part of the same dimension (i. e, the autism spectrum) or whether they represent another condition. Although various psychometric instruments, such as clinical interviews, self-report questionnaires and checklists, are widely used to assist in diagnosis, these tools are designed and standardized to identify symptoms in the general population, and may not be appropriate and valid for use with ASD. Likewise, their administration may be problematic in that individuals with ASD may have difficulties in sustaining a reciprocal conversation, reporting events, and lack an understanding and empathy for the feeling of others. Nevertheless, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, impulsivity, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Co-occurring conditions should also be carefully investigated when severe or worsening symptoms are present that are not responding to intervention or treatment.
Mazzone et al.: Psychiatric comorbidities in asperger syndrome and high functioning autism: diagnostic challenges. Annals of General Psychiatry 2012 11:16. doi:10.1186/1744-859X-11-16
Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, chartered psychologist, registered psychologist, and certified cognitive-behavioral therapist. He is also a university educator and trainer, and has published widely on the topic of autism spectrum disorders both in the US and internationally. 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  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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