Wednesday, April 18, 2018

Autism & Parenting: Dads' Caregiving Involvement Improves Moms’ Mental Health

In contrast to the large body of research on mothers, there has been little research on fathers of children with autism spectrum disorder (ASD). Greater involvement of fathers in caring for their children with autism may be especially important, as previous research has shown that mothers of autistic children often experience higher levels of stress, depression and anxiety than other mothers. A study according conducted at the University of Illinois found that fathers who read to their infants with autism and take active roles in caregiving activities not only promote healthy development in their children, they improve mothers’ mental health as well.
The study examined the longitudinal association between fathers’ early involvement in routine caregiving, literacy, play, and responsive caregiving activities at 9 months and maternal depressive symptoms at 4 years. Data for 3,550 children and their biological parents were drawn from the Early Childhood Longitudinal Study-Birth Cohort, including 50 children with autism spectrum disorders and 650 children with other disabilities. Information was collected on mothers' well-being and fathers' involvement in several parenting activities: literacy; play; routine caregiving, such as bathing; and responsive caregiving. Analyses examined whether the association between father involvement and maternal depressive symptoms differed for families of children with autism spectrum disorder (ASD) and for families of children with other disabilities or delays from families of children who were typically developing.
Results indicated that father literacy and responsive caregiving involvement were associated with lower levels of depressive symptoms for mothers of children with ASD. Mothers of children with autism reported fewer depressive symptoms when their children were 4 years old if the child's father engaged in literacy and responsive caregiving activities such as comforting children when they were upset or taking the child to the doctor when the child was 9 months old. 
Fathers who read to their children, or respond when the child cries, can give the mothers respite, enabling mothers to perform other tasks or engage in self-care activities that improve their mood and reduce stress, commented lead author Daniel J. Laxman.  "One of the key criteria of autism is difficulty with communication, which may explain why these children's mothers are especially susceptible to stress and depression," Laxman said. "It can be very frustrating for parents -- and upsetting for children -- when children struggle with communication. If fathers are reading to their kids, telling stories or singing songs, it is going to be very beneficial for the child's development of communication skills and learning words. By improving children's communication skills, fathers' literacy activities may help alleviate some of the mothers' concerns and stress related to these problems."
"Prior research and work by early interventionists has focused solely on mothers' parenting of their children with autism, reflecting societal expectations that fathers are less involved, said co-author Brent A. McBride. "In family systems that include children with autism, the stressors are huge, and mothers need all the support they can grasp. Whether it comes from the child's father, their social network or online resources, mothers need additional support to be able to continue functioning in an effective way. We, as a society, have to ask men to become involved, and it's very important that men fully understand the reasons why their support and active engagement in parenting is so critical for the family's functioning and for the child." Training and professional development opportunities must be made available to early interventionists and other professionals who work with families, so they can find ways to get fathers more involved in parenting activities.
Source:
University of Illinois at Urbana-Champaign. "Dads' parenting of children with autism improves moms' mental health: Fathers' engagement in literacy, caregiving activities reduces mothers' depression, stress." ScienceDaily, 14 July 2015.
Journal Reference:
Daniel J. Laxman, Brent A. McBride, Laurie M. Jeans, W. Justin Dyer, Rosa M. Santos, Justin L. Kern, Niwako Sugimura, Sarah L. Curtiss, Jenna M. Weglarz-Ward. Father Involvement and Maternal Depressive Symptoms in Families of Children with Disabilities or Delays. Maternal and Child Health Journal, 2014; 19 (5): 1078 DOI: 10.1007/s10995-014-1608-7
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© 2018 Lee A. Wilkinson, PhD

Sunday, April 1, 2018

Neuropsychological Profiles of Children with Comorbid Autism and ADHD


Neuropsychological Profiles of Children with Autism and ADHD
Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are neurodevelopmental disorders with onset of symptoms in early childhood.  In addition to the core features of social communication impairment and restricted/repetitive behaviors and interests, a significant number of children with ASD present with the symptoms of hyperactivity, inattention, and impulsivity, which may meet the DSM-5 diagnostic criteria for attention deficit hyperactivity disorder (ADHD). In fact, research, practice and theoretical models indicate that these conditions frequently overlap and co-occur. For example, studies conducted in the US and Europe indicate that children with ASD in clinical settings present with comorbid (co-occurring) symptoms of ADHD with rates ranging between 37% and 85%. While the prevalence is difficult to estimate, a large number of children with ADHD also appear present with symptoms of ASD.
It is critical to identify the comorbidity between ASD and ADHD because of its intervention and treatment implications. For example, more severe externalizing, internalizing and social problems, as well as more impaired adaptive functioning, and more autistic traits and maladaptive behaviors have been reported in children with both ASD and ADHD than children identified with only ASD. Researchers have found that early school-age children with co-occurrence of ASD and ADHD were significantly more impaired than children with only ASD on measures of cognitive and social functioning, as well as in the ability to function in everyday situations. They were also more likely to have significant cognitive delays and display more severe stereotypic and repetitive behaviors in comparison with children identified with only ASD. In addition, children with the co-occurring ASD and ADHD were found to share impairment in both flexibility and planning with ASD, while sharing the response inhibition deficit with ADHD. Despite the group differences described in the literature, it can be particularly difficult to differentiate between ASD and ADHD in individual cases. For example, social deficits occur in both the conditions. Although the social deficits of autism are typically described as being “reciprocal” in nature and those of ADHD are considered to be the result of inattention and disinhibition, the distinction is not always easy to make in real-world practice. In this regard, an examination of the child’s neuropsychological characteristics and profile may be helpful in identifying the comorbidity of ASD and ADHD.
 Current Research
A study published in the open access journal Autism Research and Treatment sought to extend the work on the neuropsychological profile of individuals with ASD + ADHD and to further explore the hypothesis that children with ASD + ADHD show higher degrees of impairment in social cognition than those with ASD only. The participants were drawn from referrals to an ASD clinic and consisted of 22 children with ASD and 25 children with mixed ASD and ADHD. Neuropsychological measures were administrated using standardized procedures and included evaluation of cognitive functioning, emotion recognition, Theory of Mind (ToM), executive functions, and motor abilities.
 Results
Overall results of the study indicate greater impairment in cognitive, social, and adaptive functioning for children with ASD and clinically significant ADHD symptoms in comparison with children identified with only ASD. Compared to children with ASD, those with ASD + ADHD were more impaired in their ability read other people’s emotions and feelings and to hold and manipulate critical periods of information (working memory). Children with ASD + ADHD also showed higher levels of anxiety. The more severe deficits in emotion recognition and working memory, along with the higher levels of anxiety found in children with ASD + ADHD, supports previous research indicating that having additional ADHD increases the level of their impairment and negatively impacts management and outcome. These findings also suggest that ADHD comorbidity may constitute a distinctive subtype of ASD and that these children may be at higher risk of social impairment and adjustment problems. 
It should be noted that the sample consisted only of participants with normal levels of intellectual functioning. Thus, the findings may not apply to lower functioning children with ASD and ADHD. The risk of intellectual disability (InD) increases the risk of both ASD and ADHD, acting alone and in combination with other factors. Future studies should include subjects with a wider range of cognitive abilities, using larger sample sizes of different age groups, to better define the profiles of individuals with ASD + ADHD and identify effective treatment/interventions.
 Implications
Identifying symptoms of ADHD in children with ASD has important diagnostic and treatment implications for practitioners in health care, clinical/mental health, and educational contexts. It is imperative to recognize the high co-occurrence rates of these two disorders as well as the potential increased risk for social and adaptive impairment associated with comorbidity of ASD and ADHD. Children with the combined presence of ASD and ADHD may need different treatment methods or intensities than those with ASD only in order to achieve better outcomes. Examining the neuropsychological characteristics and profiles of children with both the conditions can help facilitate diagnosis and inform treatment. Thus a comprehensive developmental assessment may include measures of neuropsychological functions such as working memory, planning and strategy formation, cognitive flexibility, response inhibition, and self-regulation. Further information on best practice guidelines for assessment of ASD is available from A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).
Colombi, C., &  Ghaziuddin, M. (2017). Neuropsychological Characteristics of Children with Mixed  Autism and ADHD. Autism Research and Treatment, 2017, 1-5. doi:10.1155/2017/5781781 https://doi.org/10.1155/2017/5781781
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Monday, March 5, 2018

NASP Approved Continuing Education Workshop

AUTISM SPECTRUM DISORDER IN SCHOOLS

Autism spectrum disorder (ASD) is among the fastest growing diagnoses in the United States, affecting 1 in 68 children. Similarly, 8% of children ages 6–21 years receiving special education services are served under the autism eligibility category. Despite the dramatic increase in the prevalence of autism in our schools over the past decade, many estimates suggest many students are underidentified or identified and served under the other special education categories. The objective of this workshop presentation is to provide participants with guidance in the selection and use of evidence-based assessment measures and intervention strategies for school-age children and adolescents with ASD.

Approved by the National Association of School Psychologists (NASP) for 3-hrs of continuing professional development (CPD) credit.

Registration information available from:

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

Sunday, March 4, 2018

Predictors of Success for Adults with Autism


Predictors of Success for Adults on the Autism Spectrum
 Research
There is a growing literature documenting the social, employment, and mental health difficulties faced by adults with ASD. With the increasing rates of ASD diagnoses, the number of individuals with ASD entering adulthood each year is expected to double over the next 6 years. Although research indicates that outcomes are almost universally lower for adults on the autism spectrum compared to their peers, few longitudinal studies from childhood to adulthood have been conducted. Most studies have focused on the transition years from adolescence to young adulthood or on describing adult outcomes. While there is little research on the predictors of positive outcome, surveys completed for adults with ASD in middle adulthood who were diagnosed during childhood offers some important insights into the predictors of success (Klinger et al., 2015).
Interviews were conducted with caregivers to gather information on employment status, quality of life, social isolation, mental health issues (such as anxiety, depression and mood), symptom severity, and language skills. Predictors included symptom severity, adaptive behavior (self-help skills), and language ability. Childhood predictors included symptom severity, adaptive behavior, and IQ. Analyses were conducted to examine predictors of adult outcome. Results indicated that current adaptive behavior was the single best predictor of adult outcome. Symptom severity and language ability had no impact on outcome. Adaptive behavior in childhood was an equally strong predictor of outcome (employment, social isolation, depression, and quality of life), regardless of symptom severity and childhood IQ.
 Adaptive Behavior 
Adaptive behavior is the collection of conceptual, social, and practical activities and skills necessary for people to live independently and to function safely and appropriately in daily life. They include real life skills such as grooming, dressing, safety, meal-related activities, school rules, shopping, ability to work, money management, cleaning, making friends, social skills, navigational skills, and personal responsibility and other household tasks. It appears that these skills are more important than language, intellectual ability or the severity of autism symptoms when it comes to maintaining successful employment and achieving positive life outcomes. Both childhood and adult adaptive living skills were found to be strong, independent predictors of a wide variety of adult outcomes.
Implications
Research indicates that children and youth with ASD consistently demonstrate adaptive behavior levels significantly lower than their measured intellectual ability. Many individuals on the autism spectrum are functionally impaired because they are unable to translate their cognitive abilities into efficient adaptive behavior. Adaptive behavior should be included as a core component in a comprehensive developmental assessment for students who have or are suspected of having autism spectrum disorder (Wilkinson, 2016). The use of a formal adaptive behavior measure allows the assessment team to determine the student’s level of functioning in daily tasks required to be successful in the home, community, and work place. This type of assessment will assist in transition planning and ensure the student has the necessary skills to be productive when he or she leaves the school environment. While teaching social interaction and communication skills has traditionally received the most attention, there is a critical need to emphasize the importance of improving adaptive behavior across the lifespan, regardless of symptom severity, IQ, and communication skills. This includes a focus on the practical life skills necessary for the growing number of adults on the spectrum to achieve success in employment and life satisfaction.
                                                        References and Further Reading
Anderson, K. A., Shattuck, P. T., Cooper, B. P., Roux, A. M., & Wagner, M. (2014). Prevalence and correlates of postsecondary residential status among young adults with an autism spectrum disorder. Autism, 18, 562-570.  doi: 10.1177/1362361313481860
Campbell, J. M., Ruble, L. A., & Hammond, R. K. (2014). Comprehensive Developmental Approach Assessment Model. In L. A. Wilkinson (Ed.), Autism spectrum disorders in children and adolescents: Evidence-based assessment and intervention (pp. 51-73). Washington, DC: American Psychological Association.
Floyd, R. G., et al. (2015). A systematic review and psychometric evaluation of adaptive behavior scales and recommendations for practice, Journal of Applied School Psychology, 31, 83-113. doi:10.1080/15377903.2014.979384
Klinger, L. G., Klinger, M. R., Mussey, J. L., Thomas, S. P., Powell, P. S. (2015, 05). Correlates of middle adult outcome: A follow-up study of children diagnosed with ASD from 1970-1999. Paper presented at the 2015 International Meeting for Autism Research, Salt Lake City, UT. 
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. doi:10.1155/2014/502420
Ohio Center for Autism and Low Incidence (OCALI). Transition to Adulthood Guidelines. http://www.ocali.org/project/transition_to_adulthood_guidelines
Roux, A. M., Shattuck, P. T., Rast, J. E., Rava, J. A., & Anderson, K. A. (2015). National Autism Indicators Report: Transition into Young Adulthood. Philadelphia, PA: Life Course Outcomes Research Program, A.J. Drexel Autism Institute, Drexel University. Available from http://drexe.lu/autismindicators
Wagner, S. (2014). Continuum of services and individualized education plan process. In L. A. Wilkinson (Ed.). Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 173-193). Washington, DC: American Psychological Association. 
Wilkinson, L.A. (Ed.). (2014). Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. Washington, DC: American Psychological Association. 
Wilkinson, L. A. (2016). A best practice guide to assessment and intervention for autism spectrum disorder in schools. Philadelphia & London: Jessica Kingsley Publishers.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)
© 2018 Lee A. Wilkinson, PhD

Thursday, February 22, 2018

Self-Acceptance on the Autism Spectrum


What is Self-Acceptance?

Self-acceptance is an important component of cognitive-behavioral therapy (CBT). It means fully accepting yourself no matter where you are on the autism spectrum or how you perform or achieve. Self-acceptance is not the same as self-esteem, self-confidence or self-regard. These terms imply that you can accept yourself because you perform or behave in a specific way or because people accept you based on your achievements. Self-acceptance means that you non-judgmentally accept yourself for who you are without rating or evaluating yourself or requiring the approval of others.

Self-acceptance also means accepting one’s individual reality and combating perfectionism and unhelpful thinking habits. As human beings, we are fallible and highly imperfect. Demand and all-or-nothing thinking results in self-defeating behavior that invariably leads to feelings of anxiety and depression. The idea that there is an absolute and perfect solution to life’s troubles is unrealistic since few things are black and white, and typically there are many alternative solutions to a problem situation. Here are some general ideas derived from CBT for accepting your personal reality and remaining uniquely you:

  • Surrender the belief that you must perform competently in every situation. Challenge the assumption that you must always please others and achieve perfectly. Avoid the tendency to evaluate yourself and accept failure as undesirable but not awful or catastrophic. Accept compromise and reasonable rather than absolute and perfect solutions to life’s problems.
  • Strongly dispute the belief that you must feel accepted by every significant person for nearly everything that you do. Rather, keep the approval of others as desirable, but not an essential goal. Seriously consider other people’s criticisms of your traits without agreeing with their negative evaluations of you. Strive to do what you really enjoy rather than what other people think you must or should do.
  • When others behave badly towards you or in relation to themselves, ask yourself whether you should really upset yourself about their behavior. Will people change their behavior because you expect or demand that they do so? Telling yourself that the person or situation is unlikely to change no matter how much you think they should and accept that fact, will keep you from feeling inappropriately angry and resentful. People are independent entities. While we are in control of our own emotional destiny, we do not have control over the behavior of others.

Adapted from Wilkinson, L. A. (2015). Overcoming Anxiety on the Autism Spectrum: A Self-Help Guide Using CBTLondon and Philadelphia: Jessica Kingsley Publishers.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist (CCBT).  Dr. Wilkinson provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorder. 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. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety on the Autism Spectrum: A Self-Help Guide Using CBT. 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. Dr. Wilkinson's latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© 2018 Lee A. Wilkinson, PhD


Monday, February 5, 2018

One Million Page Views - Thanks a Million!

I'm pleased to announce that BestPracticeAutism.com has reached the milestone of ONE MILLION page views! Many thanks to all of you for reading and commenting on my articles.               Please share and return often.
One Million Page Views


Saturday, February 3, 2018

Pharmacological Treatment of Autism Spectrum Disorder (ASD)

Pharmacological Treatment of Autism Spectrum Disorder

Prescription medications do not address the core symptoms of autism and are not considered to be "first-line" interventions or treatment for children with autism spectrum disorder (ASD). At present, early, intensive, and behaviorally-based interventions are considered the benchmark interventions for autism. Pharmacologic interventions are often considered for maladaptive behaviors such as aggression, self-injurious behavior, repetitive behaviors, sleep disturbance, anxiety, mood lability, irritability, hyperactivity, inattention, destructive behavior, or other disruptive behaviors in children with ASD. The most commonly prescribed medications are selective serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, and Paxil; stimulants such as Concerta, Metadate, Methylin, Ritalin, and Adderall, and atypical neuroleptics such as Risperidone (Risperdal) and Aripiprazole (Abilify), both with FDA approved labeling for the symptomatic (aggression and irritability) treatment of children and adolescents with ASD. Although Methylphenidate (Ritalin) has been reported to be effective for reducing hyperactivity in some children with ASD, it has not found to be effective for treating restricted or repetitive behavior or irritability (Huffman et al., 2011). Some marginal evidence of benefit has been reported for various SSRIs in the treatment of restricted, repetitive behaviors, but more study is needed (Huffman et al., 2011; Warren et al., 2011). Although Risperdal and Abilify have been reported by caregivers to reduce problem behaviors such as irritability, hyperactivity, tantrums, abrupt changes in mood, emotional distress, aggression, repetitive behaviors, and self-injury, the risk of adverse (side) effects is considered to be quite high (Warren et al., 2011).
Research indicates increasing rates of psychotropic use and the simultaneous use of multiple psychotropic medications (polypharmacy) among children with ASD. A research study involving a large sample of children with ASD found 64% used psychotropic medications and 35% had evidence of polypharmacy (Spencer et al., 2013). Older children and those who had seizures, attention-deficit disorders, anxiety, bipolar disorder, or depression had increased risk of psychotropic use and polypharmacy. Although co-occurring problems such as hyperactivity, inattention, aggression, and anxiety or depression, may respond to a medication regimen, as well as relieve family stress and enhance adaptability, there are general concerns about these medications. For example, there is a lack of evidence clearly documenting the safety or effectiveness of psychotropic treatment during childhood. Likewise, there is a paucity of information about the safety and effectiveness of psychotropic polypharmacy and potential interactions between and among medications that may affect individuals with complex conditions, including ASD (Spencer et al., 2013). Further research is needed to assess the value of these medications when weighed against their potential for harm. Likewise, there is an immediate need to develop standards of care around the prescription of psychotropic medications based on the best available evidence and a coordinated, multidisciplinary approach to improving the health and quality of life of children with ASD and their families. Because clinicians and school-based professionals may not be aware of the extent and effects of psychotropic use and polypharmacy when working with children with ASD, they should collaborate with parents, primary care providers, and others to carefully obtain medication histories and monitor treatment effects.
Adapted from Wilkinson, L. A. (2016). A best practice guide to assessment and intervention for autism spectrum disorder in schools (Second Edition). London and Philadelphia: Jessica Kingsley Publishers.
 References and Further Reading
Huffman, L. C., Sutcliffe, T. K., Tanner, I. S. D., & Feldman, H. M. (2011). Management of symptoms in children with autism spectrum disorders: A comprehensive review of pharmacologic and complementary-alternative medicine treatments. Journal of Developmental and Behavioral Pediatrics, 32, 56-68. Available from www.jdbp.org
Spencer, D., Marshall, J., Post, B., Kulakodlu, M., Newschaffer, C., Dennen, T., Azocar, F., & Jain, A. (2013).  Psychotropic medication use and polypharmacy in children with autism spectrum disorders. Pediatrics, 132, 833–840.
Warren, Z., Veenstra-VanderWeele, J., Stone, W., Bruzek, J. L., Nahmias, A. S., Foss-Feig, J. H…McPheeters, M. (2011). Therapies for children with autism spectrum disorders. Comparative Effectiveness Review, Number 26. AHRQ Publication No. 11-EHC029-EF. Rockville, MD: Agency for Healthcare Research and Quality. Available from http://www.effectivehealthcare.ahrq.gov/ehc/products/106/656/CER26_Autism_Report_04-14-2011.pdf
Wilkinson, L. A. (2016). Best practice in treatment and intervention. In L. A. Wilkinson, A best practice guide to assessment and intervention for autism spectrum disorder in schools (pp. 136-137). London and Philadelphia: Jessica Kingsley Publishers.
Wilkinson, L. A. (2016). A best practice guide to assessment and intervention for autism spectrum disorder in schoolsLondon and Philadelphia: Jessica Kingsley Publishers.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. 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. His latest award-winning book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© 2018 Lee A. Wilkinson, PhD

Sunday, January 21, 2018

Treatment Integrity: An Essential Component of School Psychology Practice

Supporting children with special needs requires individualized and effective intervention strategies. It is very important for families, teachers, administrators, and school-based support personnel to be knowledgeable about evidence-based approaches to adequately address these unique needs and help minimize the gap between research and practice. An evidence-based practice can be defined as a strategy, intervention, treatment, or teaching program that has met rigorous peer review and other standards and has a history of producing consistent positive results when experimentally tested and published in peer-reviewed professional journals. The success of an intervention depends on the interaction between the age of the child, his or her developmental level and individual characteristics, strength of the intervention, competency of the professional, and a critical component termed treatment integrity.
  Treatment Integrity
Treatment integrity, also referred to as treatment fidelity, intervention integrity, procedural reliability, and implementation integrity is defined as the accuracy and consistency with which each part or step of a treatment or intervention plan is implemented as intended. It is an important link between the use and effectiveness of interventions in clinical and school settings, and one of the key aspects of scientific investigation. Identifying an evidence-based intervention or treatment is a necessary but insufficient provision for producing behavior change. Knowing that an intervention is effective and understanding how to use it does not guarantee its accurate implementation. For example, absent or weak treatment effects might be the result of the poor integrity of interventions, despite their demonstrated empirical support. As a result, even evidence-based based interventions may fail. This can lead to erroneous conclusions regarding treatment effectiveness. Low levels of treatment integrity also adversely affect external validity (i.e., the degree to which the results from a study can be generalized across people, settings, and behaviors) and the ability of researchers to replicate the procedures and find comparable results. This can have a negative effect on the development of effective interventions and procedures. Assuring treatment integrity is critically important for dissemination of evidence-based practices and the delivery of effective services.
Treatment Integrity in Research and Practice
Although the importance of treatment validity has been recognized in the literature, this construct has largely been ignored in research and practice. Unfortunately, the measurement of treatment integrity tends to be more the exception than the rule.  Relatively few intervention studies have monitored or systematically assessed treatment integrity. For example, a review of published behavioral intervention research studies found that only 18% assessed and reported treatment integrity data. Similarly, a recent survey of practicing certified school psychologists’ knowledge and use of treatment integrity in academic and behavioral interventions found that while the majority of participants believed that it is a critical component to the development, monitoring, and evaluation of school-based interventions, only18% of the participants consistently measured treatment integrity in a one-on-one consultation, while just 4.6% of the participants consistently measured treatment integrity within a school-based problem-solving team. 

It appears that treatment integrity is more often assumed rather than evaluated and empirically documented. This reliance on a ‘consult and hope’ strategy (consult and hope the intervention is implemented with as planned) is troublesome in that it impedes our ability to establish functional relationships between treatments and outcomes. The measurement of treatment integrity is essential when evaluating school-based interventions not only for children with ASD, but for all students with academic, behavior, and developmental concerns. Without information regarding treatment integrity, practitioners have little idea as to whether their intervention plans are effective. Clearly, establishing the integrity of treatments should be regarded as a critical aspect of practice and research.
 Monitoring Treatment Integrity
A consistent finding in the literature is that higher levels of treatment integrity are associated with better outcomes. Thus, it is essential that treatment integrity information be collected when implementing interventions so as to distinguish between ineffective interventions and potentially effective treatments implemented with poor integrity. While implementing intervention procedures with textbook accuracy consistently in “real-world” settings presents a challenge, practitioners should attempt to implement procedures with high levels of integrity as often as possible. Direct and indirect methods  can be used to document the extent to which behavioral interventions agreed upon during consultation are being implemented as intended by the change agent (e.g. teacher or parent). 

Although systematic observation is the most direct means of assessing treatment integrity, this procedure is vulnerable to reactivity effects and tends to be a labor-intensive activity, which is not always possible given the time constraints and logistical problems encountered in most practice settings. There are, however, less direct methods that can be utilized to monitor the integrity of intervention plans. They include: (a) self-reporting; (b) permanent products; (c) behavioral interviews; and (d) performance feedback. While these methods are less intrusive, they tend to be less accurate because they rely primarily on self-reports. 

The social significance of intervention outcomes or social validity is also of critical importance. Consumers must feel assured that the selected intervention strategies are effective and appropriate, and that the social objectives are important to achieve. If the intervention lacks social validity, they are less likely to apply the effort necessary to implement the intervention, thus reducing intervention fidelity. Educators, parents and families expect (and hope) that research will produce interventions and treatments that will improve quality of life of children. Thus, the measurement of treatment integrity and social validity should be a standard feature of intervention practice and research.

Key References and Further Reading
Bruhn, A. L., Hirsch, S. E., & Lloyd, J. W. (2015). Treatment integrity in school-wide programs: A review of the literature (1993-2012). The Journal of Primary Prevention, 36, 335-349.
Brand, D. (2014). Topical articles: Treatment Integrity: Why it is important regardless of discipline. Science in Autism Treatment, 14(2), 6-7, 9-11.
Cochrane, W. S., & Laux, J. M. (2007). Investigating school psychologists’ perceptions of treatment integrity in school- based interventions for children with academic and behavior concerns. Preventing School Failure, 51, 29-34.
DiGennaro Reed, F. D., & Codding, R. S. (2014). Advancements in procedural fidelity assessment and intervention: Introduction to the special issue. Journal of Behavioral Education, 23, 1-18.
Gresham, F. M., Gansle, K. A., Noell, G. H., Cohen, S. & Rosenblum, S. (1993). Treatment integrity of school-based behavioral intervention studies: 1980–1990, School Psychology Review 22, 254–72.
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Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© 2018 Lee A. Wilkinson, PhD


Wednesday, January 10, 2018

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.

Many individuals on the autism spectrum have a “flat affect” or reduced facial display. “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 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
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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