Wednesday, September 19, 2018

Sensory Processing in Autism: Assessment & Intervention Strategies

Sensory Processing in Autism: Assessment and Intervention

Unusual sensory responses (i.e., sensory over-responsivity, sensory under-responsivity, and sensory seeking) are relatively common in children with autism spectrum disorder (ASD). Sensory issues are now included in the DSM-5 ASD symptom criteria for restricted, repetitive patterns of behavior, interests, or activities (RRB), and include hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment; such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects (American Psychiatric Association, 2013). When present, these problems can interfere with adaptability in many areas of life (communication, daily living, socialization, occupational). For example, sensory processing problems have been found to be associated with eating problems and physical aggression in children with ASD (Mazurek, Kanne, & Wodka, 2013; Nadon, Feldman, Dunn, & Gisel, 2011). 
Assessment
Understanding that sensory features can have a negative impact on daily life skills of children with ASD, efforts should be made to ensure early identification of these sensory features to improve their functional and psychosocial outcomes. Although ASD measures such as the ASRS, SRS-2, and CARS-2 include items that assess sensory sensitivity and unusual sensory interests, questionnaires are available that focus “solely” on the sensory processing domain. For example, the Sensory Profile, Second Edition (SP-2; Dunn, 2014) and the Sensory Processing Measure (SPM; Parham, Ecker, Miller Kuhaneck, Henry, & Glennon,, 2007) are both questionnaires that can be used to assess sensory processing and behaviors across various childhood environments (home and school). 

The SP-2 is a widely administered family of questionnaires which measure children’s responses to certain sensory processing, modulation, and behavioral/emotional events in the context of home, school, and community-based activities. Each form provides a combination of Sensory System (Auditory, Visual, Touch, Movement, Body Position, Oral), Behavior (Conduct, Social-Emotional, Attention), and Sensory Pattern (Seeking, Avoiding, Sensitivity, Registration) scores. A short version (Short Sensory Profile-2) is available for screening and can be completed in 5 to 10 minutes. The Sensory Profile School Companion-2, a school-based measure, is also available to evaluate a child’s sensory processing skills and their effect on classroom behavior. It can be used in conjunction with other SP-2 measures to provide a comprehensive evaluation of sensory behavior across home and school settings (Dunn 2001; Kern et al., 2007; Crane, Goddard, & Pring, 2009).
The SPM is a norm-referenced assessment that produces scores for two higher level integrative functions (praxis and social participation) and five sensory systems (visual, auditory, tactile, proprioceptive and vestibular functioning). Processing vulnerabilities within each system include under- and over-responsiveness, sensory-seeking behavior, and perceptual problems. Three forms comprise the SPM (Home Form, Main Classroom Form, and School Environments Form), which provide a comprehensive picture of children's sensory processing difficulties at home and school. Each requiring 15 to 20 minutes, the Home and Main Classroom Forms yield eight parallel standard scores: Social Participation; Vision; Hearing; Touch; Body Awareness (proprioception); Balance and Motion (vestibular function); Planning and Ideas (praxis); and Total Sensory Systems. An Environment Difference score allows direct comparison of the child’s sensory functioning at home and at school. Both the SP-2 and SPM have been used with children with ASD and have utility in program planning and developing accommodations for unusual sensory responses. Regardless of the questionnaire used, practitioners should use several other sources of information when documenting sensory features in children with ASD, including interviews with parents and teachers along with behavioral observations.
                                                               Intervention Strategies
Best practice guidelines indicate that when needed, comprehensive educational programs for children with ASD should integrate an appropriately structured physical and sensory milieu in order to accommodate unique sensory processing patterns (Wilkinson, 2016). Students with ASD frequently require accommodations and modifications to prevent the negative effects that school and community environments can have on their sensory systems. These include (a) reducing the amount of material posted on classroom wall for a student who has problems with excessive visual stimulation; (b) teaching the student to recognize the problem and ask in their mode of communication to leave the area; (c) providing a low distraction, visually clear area for work; (d) providing alternative seating and a quiet/calming space when students become overwhelmed; and (e) using headphones or similar device to minimize high noise levels. Practitioners employing sensory integration therapy (SIT) should use clinical reasoning, existing evidence, and outcomes to create a comprehensive, individualized program for each student, rather than utilizing isolated, specific sensory interventions. Parents and professionals might also be advised that the research regarding the effectiveness of SIT is limited and inconclusiveAccommodations, modifications, and support services needed to address sensory issues should be integrated into the student’s individualized educational program (IEP) and/or treatment plan. The collaboration of knowledgeable professionals (e.g., occupational therapists, speech/language therapists, physical therapists, adaptive physical educators) is necessary to provide guidance about supports and strategies for children whose sensory processing and/or motoric difficulties interfere with educational performance and access to the curriculum. 
                                                                 Concluding Comments
Unusual sensory responses (i.e., sensory over-responsivity, sensory under-responsivity, and sensory seeking) are relatively common in children with ASD and when present, may interfere with performance in many developmental and functional domains across home and school contexts. Practitioners must be alert to the presence of certain sensory features specific to children with ASD, including hyporeactive and sensory-seeking profiles, along with difficulties in the hearing, tactile, gustatory, olfactory, and proprioceptive domains (Dugas, Simard, Fombonne & Couture, 2018). The persistence of sensory features from an early age highlights the need for identification and management to improve functional and psychosocial outcomes. Because they are often overlooked in many ASD assessment procedures, attention to sensory problems should be an integral component of a comprehensive developmental assessment as they are often a prominent and concerning feature of the individual’s behavioral profile (Dunn, 2001; Harrison & Hare, 2004). Interviews and observation schedules, together with an evaluation of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, atypical behaviors, and cognitive functioning are recommended best practice assessment procedures (Campbell, Ruble, & Hammond, 2014; National Research Council 2001; Ozonoff, Goodlin-Jones, & Solomon, 2007; Wilkinson, 2016). Because ASD affects multiple areas of functioning, an interdisciplinary team approach is essential for establishing a developmental and psychosocial profile of the child to guide intervention planning. Further information on best practice guidelines for assessment and intervention is available from A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).
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.
                                                Key References and Further Reading
American Academy of Pediatrics, Section on Complementary and Integrative Medicine and Council on Children with Disabilities, Policy Statement (2012). Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics, 1186-1189. doi: 10.1542/peds.2012-0876. Available from http://pediatrics.aappublications.org/content/early/2012/05/23/peds.2012-0876.full.pdf+html
American Occupational Therapy Association. (2010). The scope of occupational therapy services for individuals with an autism spectrum disorder across the life course. American Journal of Occupational Therapy, 64 (Suppl.), S125–S136.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author.
Baranek, G. T. (2002). Efficacy of sensory and motor interventions for children with autism. Journal of Autism and Developmental Disorders, 32, 397-422.
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.
Constantino, J. N., & Gruber, C. P. (2012). Social Responsiveness Scale (2nd ed.). Los Angeles, CA: Western Psychological Services.
Crane, L., Goddard, L., & Pring, L. (2009). Sensory processing in adults with autism spectrum disorders. Autism, 13, 215-228.
Dugas, C., Simard, M.-N., Fombonne, E., & Couture, M. (2018). Comparison of two tools to assess sensory features in children with autism spectrum disorder. American Journal of Occupational Therapy, 72, 7201195010. https://doi. org/10.5014/ajot.2018.024604

Dunn, W. (2014). Sensory Profile-2. San Antonio, TX: Pearson.
Goldstein, S., & Naglieri, J. A. (2010). Autism Spectrum Rating Scales. North Tonawanda, NY: Multi-Health Systems, Inc.
Kern, J. K., Trevidi, M. H., Grannemann, B. D., Garver, C. R., Johnson, D. G., Andrews, A. A… Schroeder, J. L. (2007). Sensory correlations in autism. Autism, 11, 123-134.
Mazurek, M. O., Kanne, S. M., & Wodka, E. L. (2013).  Physical aggression in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 455–465.
Nadon, G., Feldman, D. E., Dunn, W., & Gisel, E. (2011). Association of sensory processing and eating problems in children with autism spectrum disorders. Autism Research and Treatment, Article ID 541926, 8 pages. doi:10.1155/2011/541926
National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author. Available from: http://www.nationalautismcenter.org/national-standards-project/phase-2/
National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices. Available from: http://autismpdc.fpg.unc.edu/evidence-based-practices
National Research Council (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism. C. Lord & J. P. McGee (Eds). Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.
O’Neil, M. & Jones, R. S. (1997) Sensory-perceptual abnormalities in autism: A case for more research? Journal of Autism and Developmental Disorders, 3, 283–93.
Ozonoff, S., Goodlin-Jones, B. L., & Solomon, M. (2007). Autism spectrum disorders. In E. J. Mash & R. A. Barkley (Eds.). Assessment of childhood disorders (4th ed., pp. 487-525). New York: Guilford.
Parham, L., Ecker, C., Miller-Kuhanek, H., Henry, D. A., Glennon, T. J. (2007). Sensory Processing Measure. Torrance, CA: Western Psychological Services.
Perez Repetto, L., Jasmin, E., Fombonne, E., Gisel, E. and Couture, M. (2017). Longitudinal Study of Sensory Features in Children with Autism Spectrum Disorder. Autism Research and Treatment, 2017, pp.1-8. https://doi.org/10.1155/2017/1934701

Research Autism. Sensory Integration and Autism. Available from: http://researchautism.net/interventions/28/sensory-integrative-therapy-and-autism
Schopler, E, Van Bourgondien, M. E., Wellman, G. J., & Love, S. R. (2010). Childhood Autism Rating Scale (2nd ed.). Los Angeles, CA: Western Psychological Services.
Wilkinson, L. A. (2016). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.
Wong, C., Odom, S. L., Hume, K. A., Cox, C. W., Fettig, A., Kurcharczyk…Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders, 45, 1951-66. doi: 10.1007/s10803-014-2351-z

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

Friday, August 17, 2018

The IEP: Educating Children with Autism


The IEP: Educating Children with Autism

Education has been shown to be among the most effective intervention/treatment for children with autism spectrum disorder (ASD). The most recent reauthorization of the Individuals with Disabilities Education Act (IDEA 2004) entitles all students with disabilities to a free appropriate public education (FAPE). In fact, the National Research Council (2001) recommends that all children identified with ASD, regardless of severity, be made eligible for special educational services under the IDEA category of autism. FAPE encompasses both procedural safeguards and the student’s individualized education program or plan (IEP). The IEP is the cornerstone for the education of a child with ASD. When a student is determined eligible for special education services, an IEP planning team is formed to develop the IEP and subsequently determine placement. Parents, teachers and support professionals play a key role in the development, implementation, and evaluation of the child’s IEP. All share the responsibility for monitoring the student’s progress toward meeting the plan's specific academic, social, and behavioral goals and objectives. 
Although the type and intensity of services will vary, depending on the student’s age, cognitive and language levels, behavioral needs and family priorities, the IEP should address all areas in which a child needs educational assistance. These include academic and non-academic goals if the services will provide an educational benefit for the student. All areas of projected need are incorporated in the IEP, together with the specific setting in which the services will be provided and the professionals who will provide the service. School districts should ensure that the IEP process follows the procedural requirements of IDEA. This includes actively involving parents in the IEP process and adhering to the time frame requirements for assessment and developing and implementing the student’s IEP.  Moreover, parents must be notified of their due process rights. It’s important to recognize that parent-professional communication and collaboration are key components for making educational and program decisions.
The content of an IEP should include the following (Individuals with Disabilities Education Improvement Act, 2004):
  • The IEP should be based on the child’s unique pattern of strengths and weaknesses. Goals for a child with ASD commonly include the areas of communication, social behavior, adaptive skills, challenging behavior, and academic and functional skills. The IEP must address appropriate instructional and curricular accommodations and modifications, together with related services such as counseling, occupational therapy, speech/language therapy, physical therapy and transportation needs. Evidence-based instructional strategies should also be adopted to ensure that the IEP is implemented appropriately.
  • A statement of the child's present level of educational performance (both academic and nonacademic aspects of his or her performance). 
  • Specific goals and objectives designed to provide the appropriate educational services. This includes a statement of annual goals that the student may be expected to reasonably meet during the coming academic year, together with a series of measurable, intermediate objectives for each goal. 
  • Appropriate objective criteria, evaluation procedures and schedules for determining, at least annually, whether the child is achieving the specific objectives detailed in the IEP. 
  • A description of all specific special education and related services, including individualized instruction and related supports and services to be provided (e.g., counseling, occupational, physical, and speech/language therapy; transportation) and the extent to which the child will participate in regular educational programs with typical peers. 
  • Accommodations should be specifically documented in the IEP. Accommodations refer to the adjustments made to ensure that the student has equal access to educational programming by removing, to the extent, possible, barriers to successful classroom performance. Adjustments may be made to (a) instructional methods, teaching style, and curricular materials; (b) classroom and homework assignments; (c) assessment tools and ways of responding; (d) time requirements; and (e) environmental setting. Once accommodations are made, the student with special needs is expected to meet the standards of all students.
  • The initiation date and duration of each of the services to be provided (including extended school year services). 
  • If the student is 16 years of age or older, the IEP must include a description of transitional services (coordinated set of activities designed to assist the student in movement from school to post-school activities).
School districts should assure that progress monitoring of students with ASD is completed at specified intervals by an interdisciplinary team of professionals who have a knowledge base and experience in autism. This includes collecting evidence-based data to document progress towards achieving IEP goals and to assess program effectiveness. School districts should also provide on-going training and education in ASD for both parents and professionals. Professionals who are trained in specific methodology and techniques will be most effective in providing the appropriate services and in modifying curriculum based upon the unique needs of the child.

Adapted from Wilkinson, L. A. (2016). Best practice in special education. In L. A. Wilkinson, A best practice guide to assessment and intervention for autism spectrum disorder in schools (pp. 157-200). London: Jessica Kingsley Publishers.


Key References and Further Reading
Information and tips on writing and developing measurable IEP goals for learners with ASD are available from the following:
Kabot, S., & Reeve, C. (2014). Curriculum and Program Structure. In L. A. Wilkinson (Ed.), Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 195-218). Washington, DC: American Psychological Association.
Myles, B. S., Adreon, D. A., Hagen, K., Holverstott, J., Hubbard, A., Smith, S. M., et al. (2005). Life journey through autism: An educator’s guide to Asperger syndrome. Arlington, VA: Organization for Autism Research.
National Research Council (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism. C. Lord & J. P. McGee (Eds). Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.
Twachtman-Cullen, D., & Twachtman-Bassett, J. (2011). The IEP from A to Z: How to create meaningful and measurable goals and objectives. San Francisco, CA: Jossey-Bass.
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. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.
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 (2nd edition). London: Jessica Kingsley Publishers.
Wilmshurst, L. & Brue, A. (2010). The complete guide to special education: Expert advice on evaluations, IEPs, and helping kids succeed (2nd edition). San Francisco, CA: Jossey-Bass.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. 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 and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also the 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 SchoolsHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Monday, August 13, 2018

Transitioning Back to School: Tips for Parents of Students with Autism

Transitioning Back to School: Tips for Parents of Students with Autism

Students throughout the country will soon be making the transition to a new school year. This includes an increasing number of special needs children identified with autism spectrum disorder (ASD). Since Congress added autism as a disability category to the Individuals with Disabilities Education Act (IDEA) in 1990, there has been a dramatic increase in the number of students receiving special education services under this category.  In fact, the number of students receiving assistance under the special education category of autism over the past decade has increased from 1.5 percent to 9 percent of all identified disabilities. Autism now ranks fourth among all IDEA disability categories for students age 6-21.

The beginning of a new school year is an exciting yet anxious time for both parents and children. It typically brings a change in the daily routine established over the summer months. This transition can be especially challenging for families with children on the autism spectrum. While change can be difficult, the followng tips will help prepare a child with ASD for the new school year. 

1. Prepare and reintroduce routines.
  • Familiarize and reintroduce your child to the school setting. This may mean bringing your child to the school or classroom, showing your child a picture of their teacher and any classmates, or meeting the teacher before the first day of school. If possible, arrange to visit the teacher or the school a week or two before the first day. If this isn’t feasible, visit the school building or spend some time on the playground. Driving by the school several times is another good idea. You may also want to drive your child on the first day as well if they ride a bus to school. For many children with ASD, riding a bus to school on the first day can result in a sensory “overload.” Gradually easing them into the transportation routine will be helpful for everyone.
2. Review your child's Individualized Education Plan (IEP).
  • The IEP is a legal document and the cornerstone for your child’s education. It includes academic goals, appropriate accommodations and modifications and a description of all specific special education and related services, including individualized instruction and related supports and services (e.g., counseling, occupational, physical, and speech/language therapy; transportation), together with the specific setting in which the services will be provided. Parents should always have the IEP available to reference this essential information throughout the school year. If you do not have a copy, request one from the Special Services Department in your school district.
3. Expect the unexpected.
  • Parents cannot anticipate everything that might happen during the school day. Allow more time for all activities during the first week of school. Prepare your child for situations that may not go as planned. Discuss a plan of action for free time, such as lunch and recess. Use social stories to familiarize your child with routines and how to behave when an unexpected event occurs. Anticipate sensory overload. The activity, noise and chaos of a typical classroom can sometimes be difficult to manage. Establish a plan of action for this situation, possibly a quiet room where the child can take a short break. If your child has dietary issues, determine in advance how this will be managed so as to avoid any miscommunication.
4. Review and teach social expectations.
  • Although many children may transition easily between the social demands of summer activities and those required in the classroom, children on the autism spectrum may need more clear-cut (and literal) reminders. Review the “dos and don’ts” of acceptable school behavior. You can also create a schedule of a typical school day by using pictures and talk about how the school day will progress. Create a social story or picture schedule for school routines. Start reviewing and practicing early. If possible, meet with teachers and administrators to discuss your child’s strengths and challenges. Remember, you are your child’s best advocate. Establish communication early to develop positive relationships with your child’s teacher and school. Rehearse new activities. Ask the teacher what new activities are planned for the first week. Then, prepare your child by performing, practicing, and discussing them. This rehearsal will reduce anxiety when new activities take place during the beginning of school.
In summary, do everything possible to help reduce the stress level for your child and family during this transition time. Don’t forget to prepare yourself! Children sense anxiety, worry, and negativity in others. A calm, collected, and positive approach will help your child make a successful transition back to school.

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. 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 and Depression on the Autism Spectrum: A Self-Help Guide Using CBT, both 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. Dr. Wilkinson's latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Sunday, July 29, 2018

Tips to Help Manage Noise Sensitivity in Autism


Tips to Help Manage Noise Sensivity
Unusual sensory responses (i.e., sensory over-responsivity, sensory under-responsivity, and sensory seeking) are relatively common in autism (ASD). While no single type of sensory problem is consistently associated with ASD, one of the most commonly reported challenges for people with autism spectrum conditions is hypersensitivity to noise. Many of the daily sounds that other people take for granted can be very intrusive and painful to children and adults on the spectrum. This article from Friendship Circle lists the types of noise sensitivity and offers some tips on how to help a highly sensitive person cope with everyday noisy situations.
1. Know the types of sensitivity
There are several different types of noise sensitivity, and there are different treatments for each type. Consult with an audiologist to pinpoint which type of sensitivity is affecting your quality of life. These are the 5 most common types of sensitivities, but keep in mind that a person may be affected by more than one issue. For example, my son has hyperacusis in addition to phobias of specific sounds.
  • Hyperacusis is an intolerance of everyday environmental sounds and is often associated with tinnitus, a ringing in the ears.
  • Hypersensitive hearing of specific frequencies is often (but not always) associated with autism. A person is able to tolerate most sounds at normal levels, but certain frequencies are intolerable, especially above 70 decibels. For example, a person may have no difficulty being near a noisy dishwasher, but the higher frequency and higher decibel level of the vacuum cleaner will be painful.
  • Recruitment is directly related to sensorineural hearing loss. It is defined as an atypical growth in the perception of loudness. Hair cells in the inner ear typically “translate” sound waves into nerve signals. Damaged or dead hair cells cannot perceive sound, but at a certain decibel level, surrounding healthy hair cells are “recruited” to transmit, and the person experiences a sudden sharp increase in sound perception that can be shocking and painful.
  • Phonophobia (also called ligyrophobia or sonophobia) is a persistent and unusual fear of sound, either a specific sound such as an alarm or general environmental sounds. People with phonophobia fear the possibility of being exposed to sounds, especially loud sounds, in present and future situations, and sometimes become homebound due to this anxiety.
  • Misophonia is an emotional reaction, most often anger or rage, to specific sounds. The trigger is usually a relatively soft sound related to eating or breathing and may be connected to only one or a few people who are emotionally close to the affected person. For example, my friend Lisa’s son Nate becomes angry and runs out of the dining room because his father makes sounds while chewing food, but Nate does not become angry when his mother and sister make similar sounds.
2. Provide relief
Headphones and earplugs offer instant comfort and relief. Noise-canceling headphones are the most effective, because they replace irritating environmental noise by producing calming white noise. Earplugs are usually made of either foam or wax, and it is worth trying both types to determine which is more comfortable.
However, most audiologists, physicians, therapists and educators recommend against frequent use of headphones and earplugs, because a person can quickly become dependent on them. In the long run, blocking out noise can reduce coping skills and increase social withdrawal.
3. Identify safe environments
One of the first steps that I took for my son was to make a list of his “safe” places and increase his participation there. Depending on an individual’s needs, this could mean:
  • volunteering at the library
  • attending library storytime
  • taking a walk in a nature area every day
  • visiting a park that is near a railroad crossing or helicopter landing pad
  • attending services, prayers or social events at the Shul more often
4. Allow control over some types of noise
At its heart, anxiety is a fear of being unable to control reactions and situations. When my son had a phobia of bells, I gave him several different types of bells to handle and experiment with at home. When we saw bells at customer service desks or in other public places, I allowed him to ring the bell. He gradually became comfortable with the sounds, and he even began identifying speaker systems, alarm systems and other sources of sounds everywhere we went.
5. Allow distractions
When my husband and I took a Lamaze childbirth class many years ago, we learned about the power of distraction in pain management. By giving a person something like an iPad to focus on or an unusual privilege such as bringing along a favorite toy from home, it becomes possible to direct attention away from the offending noise.

[Source: Wang, K. (2014). Noise Control: 11 Tips for Helping your Child with Autism Deal with Noise. Special Needs Resources. Friendship Circle. https://www.friendshipcircle.org/]

Lee A. Wilkinson, PhD is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Wednesday, July 11, 2018

Social Skills Intervention Improves Executive Function (EF) in Autism


             Social Skills Intervention Improves Executive Function (EF) in Autism

Social Skills

Impairment in social communication and interaction is a core feature of autism spectrum disorder (ASD). Social skills deficits include difficulties with initiating interactions, maintaining reciprocity, taking another person’s perspective, and inferring the interests of others. Social relationship skills are critical to successful social, emotional, and cognitive development and to long-term outcomes for students. Research evidence suggests that when appropriately planned and systematically delivered, social skills instruction has the potential to produce positive effects in the social interactions of children with ASD. Both the National Professional Development Center (NAC) and the National Autism Center (NAC) have identified social skills training/instruction as an evidence-based intervention and practice.  
Executive Function

Executive function (EF) is a broad term used to describe the higher-order cognitive processes such as response initiation and selection, working memory, planning and strategy formation, cognitive flexibility, inhibition of response, self-monitoring and self-regulation. EF skills allow us to plan and organize activities, sustain attention, persist to complete a task, and manage our emotions and monitor our thoughts in order to work more efficiently and effectively. Executive function and self-regulation (EF/SR) problems have been demonstrated consistently in school-age children and adolescents on the autism spectrum. Research suggests that operations and activities that require mental flexibility, including shifting of cognitive set and shifting of attention focus are impaired in children and youth with autism. This includes difficulty directing, controlling, inhibiting, maintaining, and generalizing behaviors required for adjustment both in and outside of the classroom without external support and structure from others. EF/SR skills have been linked to many important aspects of child and adolescent functioning, such as academic achievement, self-regulated learning, social-emotional development, physical well-being, and behavioral problems. Research shows that children with strong EF/SR skills are better prepared for school and have more positive social, adaptive, and academic outcomes.

Research

A study published in the open access journal Autism Research and Treatment examined potential changes in executive function performance associated with participation in the Social Competence Intervention (SCI) program, a short-term intervention designed to improve social skills in adolescents with ASD. The Social Competence Intervention-Adolescent (SCI-A) is based on cognitive-behavioral intervention and applied behavior analysis and targets EF, theory of mind (ToM), and emotion recognition as key constructs in addressing social skills impairments.

Behavioral performance measures were used to evaluate potential intervention-related changes in executive function processes (i.e., working memory, inhibitory control, and cognitive flexibility) in a sample of 22 adolescents with ASD both before and after intervention. For comparison purposes, a demographically matched sample of 14 individuals without ASD was assessed at the same time intervals. Intervention-related improvements were observed on the working memory task, with gains evident in spatial working memory and, to a somewhat lesser degree, verbal working memory. The finding of improved working memory performance for the intervention group is consistent with research suggesting that working memory represents an aspect of cognition that may be malleable and responsive to intervention.

Additional research is needed to evaluate to what extent the presently observed gains in EF performance may translate to other age ranges, levels of symptom severity, and other social skills interventions. Further research is also required to examine whether the presence/absence of comorbid ADHD symptomatology may influence the effectiveness of interventions for improving not only social skills but also underlying core EF processes such as cognitive flexibility and working memory.

Implications

Previous research indicates that EF represents an area of weakness for individuals with ASD even after accounting for comorbid conditions such as ADHD. Reviews of the existing literature suggest that cognitive flexibility, working memory, and inhibitory control are often impaired in individuals with ASD. Each of these EF component processes play an important role in the acquisition of knowledge and social skills; the better children are at focusing and refocusing their attention, holding information in mind and manipulating it (i.e., working memory), resisting distraction, and adapting flexibly to change, the more positive the social, adaptive, and academic outcomes. The aforementioned research findings contribute to the growing evidence that children with ASD who participate in social skills interventions that integrate EF skills such as working memory, cognitive flexibility, emotional recognition, and self-regulation experience not only an improvement in social competence, but also underlying core neurocognitive EF processes. Executive dysfunction places a child at-risk and is likely to have an adverse impact on many areas of everyday life and affect adaptability in several domains (personal, social and communication). Systematic social skills instruction that incorporates EF process components in program delivery can help reduce the risk for negative outcomes for children on the autism spectrum. Likewise, an assessment of EF skills can add important information about the child’s strengths and weaknesses and inform intervention/treatment planning. Best practice guidelines for assessment and intervention are available from A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Reference

Social Skills Intervention Participation and Associated Improvements in Executive Function Performance. Shawn E. Christ, Janine P. Stichter, Karen V. O’Connor, Kimberly Bodner,
Amanda J. Moffitt, and Melissa J. Herzog. Autism Research and Treatment
Volume 2017, Article ID 5843851, 13 pages https://doi.org/10.1155/2017/5843851

Lee A. Wilkinson, PhD 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. 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

Saturday, June 30, 2018

Social Communication Skills and Autism

Social Communication Skills and the Autism Spectrum

The DSM-5 diagnostic criteria for autism spectrum disorder (ASD) include persistent deficits in social communication and social interaction across multiple contexts. Poor pragmatic/social use of language or impairment in the ability to understand and use language in social-communicative contexts is a core feature of ASD. Pragmatic skills involve: (a) using language for different purposes; (b) changing language according to the needs of a listener or situation; (c) understanding non-literal language; and (d) following rules for conversations. 

There are many unwritten rules in society that govern our behavior. While most of us intuitively understand these rules, individuals with ASD have not automatically learned the conventions and nuances that make up their social environment. These unspoken or “hidden” social standards can make the world a confusing place and result in life-long challenges. For example, social expectations such as “it is not polite to interrupt others while they are talking,” “take turns in conversation” and “discuss other topics besides only those you are interested in” are not taught and are assumed to be known and understood. We seem to have an “unconscious” navigator that allows us to make intuitive sense of the unspoken rules in society and adjust to the social demands of our everyday lives.
Figurative Language

The unspoken rules of social engagement involve the use of the pragmatic, social communicative functions of language (e.g., turn taking, understanding of inferences and figurative expressions) as well as nonverbal skills needed to communicate and regulate interaction (e.g., eye contact, gesture, facial expression). This includes body language and idioms, metaphors, or slang – phrases and meanings that we intuitively assimilate or learn through observation or subtle cues. Individuals with ASD tend to interpret language literally and may be puzzled by the common everyday expressions used by a typical peer or adult. Consider how idioms such as “how the cookie crumbles,” “curiosity killed the cat,” and “when it rains, it pours” might have a totally different meaning and result in confusion if taken literally. In order to understand language, we must understand what the idioms in that language mean. If you try to figure out the meaning of an idiom literally (word by word), you will be bewildered. While the typical individual might understand that the phrase “that’s the way the cookie crumbles,” and accompanying body language (e.g., voice, body) communicates to the listener that something unfortunate has happened, to someone with a pragmatic social-communication problem, this idiom will have a completely different meaning and be confusing. The following are but a few of well over 3,000 idioms in the English language.
  • Bite off More than you can chew  
  • Cross that bridge when you come it
  • Everything but the kitchen sink 
  • Get up on the wrong side of the bed 
  • Have a bone to pick with you 
  • Have your cake and eat it too 
  • Kill two birds with one stone  
  • Put all your eggs in one basket 
  • Raining cats and dogs 
  • Run circles around someone 
  • Till the cows come home
Assessment

Because social communication deficits are among the core challenges of ASD, a best practice student assessment should include an evaluation of pragmatic competence and not be limited to the formal, structural aspects of language (i.e., articulation and receptive/ expressive language functioning). As a group, more capable students with ASD tend to demonstrate strength in formal language, but a weakness is pragmatic and social skills.  As a result, they often fail to qualify for speech-language services because they present strong verbal skills and large vocabularies, and score well on formal language assessments. Particular attention should be given to the pragmatic, social communicative functions of language (e.g., turn taking, understanding of inferences and figurative expressions) as well as to the nonverbal skills needed to communicate and regulate interaction (e.g., eye contact, gesture, facial expression, and body language). 

Assessments to identify pragmatic language deficits tend to be less well developed than tests of language fundamentals. There are fewer standard measures available to assess these skills in children with ASD. Valid norms for pragmatic development and objective criteria for pragmatic performance are also limited. Among the standardized instruments that focus on the social communicative functions of language are the Comprehensive Assessment of Spoken Language (CASL; Carrow-Woolfolk, 1999), Test of Pragmatic Language, 2nd Edition (TOPL-2; Phelps-Terasaki & Phelps-Gunn, 2007), Social Language Development Test-Elementary (SLDT-E; Bowers, Huisingh, & LoGiudice, 2008), Children's Communication Checklist, Second Edition (CCC-2; Bishop, 2006) and Pragmatic Language Skills Inventory (PLSI; Gilliam & Miller, 2006). 
Significant and severe deficits in the ability to communicate and interact with others can limit students' participation in mainstream academic settings and community activities. Moreover, pragmatic deficits tend to become even more obvious and problematic as social and educational demands increase with age. Because pragmatic language is a critical part of everyday social interaction, it is imperative that speech/language services for children with ASD include a focus on social communication skills. Students with pragmatic language deficits who do not meet the DSM-5 ASD criteria for restricted, repetitive patterns of behavior should be evaluated for social (pragmatic) communication disorder (SCD). 


Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and cognitive-behavioral therapist. He 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 the 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. 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

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