Wednesday, December 21, 2016

A Multi-Tiered Approach to Screening for Autism in Schools

There has been a dramatic worldwide increase in reported cases of autism over the past decade. Yet, compared to population estimates, identification rates have not kept pace in our schools. It is not unusual for children with less severe symptoms of ASD to go unidentified until well after entering school. As a result, it is critical that school-based educational support personnel (e.g., special educators, school counselors, speech/language pathologists, social workers, and school psychologists) give greater priority to case finding and screening to ensure that children with ASD are identified and have access to the appropriate intervention services. 
Screening and Identification

Until recently, there were few validated screening measures available to assist school professionals in the identification of students with the core ASD-related behaviors. However, our knowledge base is expanding rapidly and we now have reliable and valid tools to screen and evaluate children more efficiently and with greater accuracy. The following tools have demonstrated utility in screening for ASD in educational settings and can be used to determine which children are likely to require further assessment and/or who might benefit from additional support. All measures have sound psychometric properties (e.g., discriminative validity), are appropriate for school-age children, and time efficient (10 to 20 minutes to complete). Training needs are minimal and require little or no professional instruction to complete. However, interpretation of results requires familiarity with ASD and experience in administering, scoring, and interpreting psychological tests.
The Autism Spectrum Rating Scales (ASRS; Goldstein & Naglieri, 2009) is a norm-referenced tool designed to effectively identify symptoms, behaviors, and associated features of ASD in children and adolescents from 2 to 18 years of age. The ASRS can be completed by teachers and/or parents and has both long and short forms. The Short form was developed for screening purposes and contains 15 items from the full-length form that have been shown to differentiate children diagnosed with ASD from children in the general population. High scores indicate that many behaviors associated with ASD have been observed and follow-up recommended.
The Social Communication Questionnaire (SCQ; Rutter, Bailey, & Lord, 2003), previously known as the Autism Screening Questionnaire (ASQ), is a parent/caregiver dimensional measure of ASD symptomatology appropriate for children of any chronological age older than four years. It is available in two forms, Lifetime and Current, each with 40 questions. Scores on the questionnaire provide a reasonable index of symptom severity in the reciprocal social interaction, communication, and restricted/repetitive behavior domains and indicate the likelihood that a child has an ASD.
The Social Responsiveness Scale, Second Edition (SRS-2; Constantino & Gruber, 2012) is a brief quantitative measure of autistic behaviors in 4 to 18 year old children and youth. This 65-item rating scale was designed to be completed by an adult (teacher and/or parent) who is familiar with the child’s current behavior and developmental history. The SRS items measure the ASD symptoms in the domains of social awareness, social information processing, reciprocal social communication, social anxiety/avoidance, and stereotypic behavior/restricted interests. The scale provides a Total Score that reflects the level of severity across the entire autism spectrum.
A Multi-Tier Screening Strategy
The ASRS, SCQ, and SRS-2 can be used confidently as efficient first-level screening tools for identifying the presence of the more broadly defined and subtle symptoms of higher-functioning ASD in school settings. School-based professionals should consider the following multi-step strategy for identifying at-risk students who are in need of an in-depth assessment.
Tier  one. The initial step is case finding. This involves the ability to recognize the risk factors and/or warning signs of ASD. All school professionals should be engaged in case finding and be alert to those students who display atypical social and/or communication behaviors that might be associated with ASD. Parent and/or teacher reports of social impairment combined with communication and behavioral concerns constitute a “red flag” and indicate the need for screening. Students who are identified with risk factors during the case finding phase should be referred for formal screening.
Tier two. Scores on the ASRS, SCQ, and SRS-2 may be used as an indication of the approximate severity of ASD symptomatology for students who present with elevated developmental risk factors and/or warning signs of ASD. Screening results are shared with parents and school-based teams with a focus on intervention planning and ongoing observation. Scores can also be used for progress monitoring and to measure change over time. Students with a positive screen who continue to show minimal progress at this level are then considered for a more comprehensive assessment and intensive interventions as part of Tier 3.  However, as with all screening tools, there will be some false negatives (children with ASD who are not identified). Thus, children who screen negative, but who have a high level of risk and/or where parent and/or teacher concerns indicate developmental variations and behaviors consistent with an autism-related disorder should continue to be monitored, regardless of screening results.
Tier three. Students who meet the threshold criteria in step two may then referred for an in-depth assessment. Because the ASRS, SCQ, and SRS-2 are strongly related to well-established and researched gold standard measures and report high levels of sensitivity (ability to correctly identify cases in a population), the results from these screening measures can be used in combination with a comprehensive developmental assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, and cognitive functioning to aid in determining eligibility for special education services and as a guide to intervention planning.
Concluding Comments
Compared with general population estimates, children with mild autistic traits appear to be an underidentified and underserved population in our schools. There are likely a substantial number of children with equivalent profiles to those with a clinical diagnosis of ASD who are not receiving services. Research indicates that outcomes for children on the autism spectrum can be significantly enhanced with the delivery of intensive intervention services. However, intervention services can only be implemented if students are identified. Screening is the initial step in this process. School professionals should be prepared to recognize the presence of risk factors and/or early warning signs of ASD, engage in case finding, and be familiar with screening tools in order to ensure children with ASD are being identified and provided with the appropriate programs and services. 

Best practice screening and assessment guidelines are available from: Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd ed.). 

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 CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Friday, December 2, 2016

Holiday Tips for Parents of Kids on the Autism Spectrum

The holiday season can be a stressful time of year for everyone, especially for parents of children on the autism spectrum. The sights and sounds of the holidays can be stressful and over-stimulating. There are many changes in routine, family events, parties, and vacations that need to be planned. Sometimes the stress of these changes can become overwhelming and the joy and happiness of the holidays might be lost. Here are some helpful tips to lessen your child’s anxiety and increase your family’s enjoyment of the holiday season: 

 Decorating and Shopping  
  • If your child has difficulty with change, you may want to gradually decorate the house. Decorate in stages, rather than all at once. It may also be helpful to develop a visual  schedule or calendar that shows what will be done on each day.
  • Allow your child to interact with the decorations and help put them in place.
  • Flashing lights or musical decorations can disturb some children. To see how your child will respond, provide an opportunity experience these items in a store or at elsewhere first. 
  • Last minute holiday shopping can be stressful for children who rely on routines. If you do take your child shopping, allow enough time to gradually adapt to the intense holiday stimuli that stores exhibit this time of year.
 Family Routines and Travel
  • Meet as a family to discuss how to minimize disruptions to established routines and how to  support positive behavior when disruptions are inevitable. 
  • Continue using behavior support strategies during the holidays. For example, use social stories to help your child cope with changes in routine and visual supports to help prepare for more complicated days.
  •  Use a visual schedule if you are celebrating the holidays on more than one day to show when there will be parties/gifts and when there will not. 
  • Use rehearsal and role play to give children practice ahead of time in dealing with new social situations, or work together to prepare a social story that incorporates all the elements of an upcoming event or visit to better prepare them for that situation 
  • If you are traveling for the holidays, make sure you have child’s favorite foods, books or toys available. Having familiar items readily available can help to calm stressful situations. 
  • If you are going to visit family or friends, make sure there is a quiet, calm place to go to if needed. Teach your child to leave a situation and/or how to access support when a situation becomes overwhelming. For example, if you are having visitors, have a space set aside for the child as his/her safe/calm space. He or she should be taught ahead of time that they should go to their space when feeling overwhelmed. This self- management strategy will also be helpful in future situations.
 Gifts and Play Time
  • If you put gifts under the Christmas tree, prepare well ahead of time by teaching that gifts are not to be opened without the family there. Give your child a wrapped and a reward for keeping it intact. 
  • Practice unwrapping gifts, taking turns and waiting for others, and giving gifts. Role play scenarios with your child in preparation for him/her getting a gift they may not want 
  • Take toys and other gifts out of the box before wrapping them. It can be more fun and less frustrating if your child can open the gift and play with it immediately. 
  • When opening gifts as a family, try passing around an ornament to signal whose turn it is to open the next gift. This helps alleviate disorganization and the frustration of waiting. 
  • Prepare siblings and young relatives to share their new gifts with others. 
  • If necessary, consider giving your child a quiet space to play with his/her own gifts, away from the temptation of grabbing at other children’s toys 
  • Prepare family members for strategies to use to minimize anxiety or behavioral incidents, and to enhance participation. Provide suggestions ahead of time that will make for a less stressful holiday season. 
  • Keep an eye out for signs of anxiety or distress, including an increase in behavior such as humming or rocking - this may indicate it's time to take a break from the activity.
  •  Understand how much noise and other sensory input your child can manage. Know their level of anxiety and the amount of preparation it may require. 
  • Try to relax and have a good time. Do everything possible to help reduce the stress level for your child and family during the holidays. If you are tense your child may sense that something is wrong. Don’t forget to prepare yourself! A calm and collected parent is better able to help their family enjoy this wonderful time of year.

Lee A. Wilkinson, PhD, 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 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).

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