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

Wednesday, June 6, 2018

Emotional Destiny on the Autism Spectrum

Autism and Your Emotional Destiny

“Whatever may be, I am still largely the creator 
and ruler of my emotional destiny.” - Albert Ellis

Regardless of whether you identify as autistic, Aspergers, neurodivergent, or on the autism spectrum, you have the capacity for self-awareness and the power to control your own emotional destiny. We are not born with specific thoughts, feelings, and behaviors. Nor do our environment or surroundings directly make us act or feel in a certain way.

Although our genetic makeup and social background can have a strong influence on our behavior, we have the ability to change our thoughts, feelings, and actions. While it may be helpful to discuss our past experiences and understand how our history might have influenced our lives, effective self-help strategies focus on the “here and now” problems and ways to improve your emotional well-being in the present.

Understanding your past experiences and how and when you first upset yourself are not critical to overcoming your anxiety and depression. Conventional insight, even when correct, will not tell you what really caused you to become upset or what you can do to overcome it. In fact, it may actually block effective problem-solving.

It is your present system of beliefs and ideas that are important, regardless of where they originated. So, no matter what your past history, or how your parents, teachers or significant others in your life may have helped you to feel upset, you continue to be upset because of the vicious cycle of unrealistic and unhelpful thoughts you originally held.

Step back and objectively examine your own ideas and beliefs and identify and question them. While it is impossible to change the behavior of others, you have the ability to control and change your own thoughts and behaviors. So, avoid thinking that your past is all important and that because someone or something at one time influenced your life, it must also determine your feelings and behavior today. If you let yourself be strongly influenced by the past, you will stop looking for alternative solutions to your current problems. When you unconditionally accept the influences of your past, you are being unrealistic because the present is significantly different from the past. Keep in mind that the past has passed and it has no automatic effect on your present and future behavior. You have the power to overcome your past and control your emotional destiny!

Adapted from Wilkinson, L. A. (2015). Overcoming Anxiety and Depression 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



Sunday, June 3, 2018

Triggers for Anxiety on the Autism Spectrum




Triggers for Anxiety on the Autism Spectrum

Anxiety is a frequent co-occurring (comorbid) problem for children and youth with autism spectrum disorder (ASD). Although prevalence rates vary from 11% to 84%, most studies indicate that approximately one-half of children with ASD meet criteria for at least one anxiety disorder. Moreover, rates of anxiety are reportedly higher than those in children with language disorders, conduct disorder, or in clinically anxious typically developing children. 

Despite promising advances in the research and practice literature, our understanding of the prevalence, phenomenology and treatment of anxiety in ASD remains somewhat limited. Importantly, there is a paucity of information on the difference between ASD and non-ASD populations in regards to the manifestation of anxiety symptoms. Understanding more about the factors triggering and maintaining anxiety in ASD, and how children with ASD and their families experience, think and speak about anxiety, could inform the development and implementation of autism-specific interventions for anxiety in this population.
An exploratory study published in the journal Autism reported on a series of 5 focus groups with parents of children and adolescents with ASD and anxiety as a first step in identifying the triggers, behavioral signs and cognitive processes associated with anxiety. Seventeen mothers of 19 children with a diagnosis of ASD participated in the focus groups. All children (12 boys and 7 girls) had received ASD diagnoses from local clinical services and were reported to experience significant levels of anxiety that had an impact on their functioning.
Results
The following is a summary of key themes identified by parents in relation to triggers, symptoms and impact of anxiety in their children with ASD.
Anxiety triggers/Stressors:
1. Change or disruption to routine.
2. Confusion and worries about social and communication situations.
3. Specific fears and phobias.
4. Sensory oversensitivity and overstimulation.
5. Being prevented from preferred repetitive behaviors and interests.
6. Too many demands or expectations.
Presentation of anxiety:
1. Increase in challenging behavior.
2. Avoidance/withdrawal/escape.
3. Increase in levels of arousal.
4. Increase in sensory, repetitive, and ritualistic behavior.
5. Physical sensations associated with anxiety.
6. Cognitive distortions and errors in thinking.
Impact of anxiety:
1. Personal distress in children, parents, and siblings.
2. Increase in challenging behavior and stereotyped behaviors.
3. Restriction of activities/opportunities.
4. Negative impact on quality of life for child and family.
Discussion
Across groups, parents gave markedly similar descriptions of the triggers and behavioral signs associated with anxiety. Parents’ perspectives on the anxieties of their children indicate that there are many overlaps with anxiety as experienced in the general population. Shared triggers included social worries, specific phobic stimuli, and expectations that are, or are perceived to be, too demanding. Common features of the presentation of anxiety include an increase in arousal and avoidance/escape behaviors.
There were, however, a number of autism-specific triggers and symptoms of anxiety identified in children with ASD. Key features were the intensity, pervasiveness and persistence of the anxiety. Changes and disruptions to routines, sensory sensitivities and social difficulties associated with difficulties in perspective-taking and social expectations appeared to be ASD-specific triggers. Situations that were reported to trigger anxiety often reflected autism-related difficulties in processing style or sensory sensitivity. The majority of comments about the presentation of anxiety fell into the categories of challenging behavior and avoidance/withdrawal, indicating that behavioral manifestations are the major expressions of anxiety in children with ASD. When asked about their anxious thoughts, the most prominent theme that emerged was the difficulty that children with ASD have in expressing their anxiety verbally, particularly at times of severe distress. Although this is also occurs with many typically developing children, it may be a particular difficulty for children with ASD given the challenges they face in understanding and expressing emotions and pragmatic language difficulties. In addition to similar descriptions of the triggers and behavioral signs associated with anxiety, the impact of anxiety was reported to be often times more substantial than the impact of ASD itself.
Implications
Although this study did not specifically address assessment and intervention/treatment issues, several implications in these areas emerged. For example, when parents and children with ASD are asked to describe their experiences in a semi-structured, non-directed manner, they largely focus on features more specific to the ASD population that are not typically measured on most standard anxiety measures. Although there are broad-based measures that evaluate emotional/behavioral difficulties in children with neurodevelopmental disabilities, a significant gap remains in the resources available to clinicians and researchers for measuring ASD-specific aspects of anxiety. This argues for the inclusion of observational methods in the assessment of anxiety: using multiple informants, multimodal assessment techniques, and methods.
Identification of specific triggers/stressors and presentation of anxiety in children with ASD can help educators and interventionists improve programs and services for this group of students. These findings may also be useful for clinicians working with children and youth with ASD, particularly those utilizing CBT as a treatment approach. Although recent randomized controlled trials suggest that enhanced and adapted CBT can successfully treat anxiety disorders in high functioning children with ASD, it is unclear which adaptations are critical or which modifications are required for which anxiety disorder.  Nevertheless, the authors note that their findings support the view that adaptations to CBT, such as adding ASD-specific components to the treatment protocol, are important, relevant and acceptable to parents of children with ASD.  They also caution that even though CBT can be an effective means of treating anxiety in youth with ASD, clinicians may need to consider whether CBT is the most appropriate intervention or whether other approaches such as behavioral strategies or environmental modifications may be more suitable, as accessing or modifying cognitions may prove too challenging for some youth with ASD. Yet, CBT is clearly an effective intervention for many children with ASD, and the involvement of parents can further improve outcomes.
Recommendations for future research include focusing on larger groups and control samples, and systematically investigating the link between ASD cognitive processing styles and anxiety. The authors propose that further exploration of the similarities and differences between shared and ASD-specific triggers, manifestations, and effects of anxiety using a variety of methodologies will contribute to the development of more appropriate assessment measures and ASD-specific models of anxiety which can then guide treatment for more effectively.
Ozsivadjian, A., Knott, F., & Magiati, I. (2012). Parent and child perspectives on the nature of anxiety in children and young people with autism spectrum disorders: a focus group study. Autism, 16, 107-121. DOI: 10.1177/1362361311431703
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 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 CBTHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd edition).

Wednesday, May 30, 2018

Response to Intervention (RtI) and Autism

Response to Intervention (RtI) 
Response to Intervention, commonly referred to as RtI, is defined as “the practice of providing high-quality instruction and interventions matched to student need, monitoring progress frequently to make decisions about changes in instruction or goals, and applying child response data to important educational decisions” (Batsche et al., 2005, p. 3). It is considered a prevention oriented approach to linking assessment and instruction that can inform educators’ decisions about how best to teach their students. RtI employs a multi-level system which includes three levels of intensity or three levels of prevention (primary, secondary, and tertiary), which represent a continuum of supports. Schools use RtI data to identify students at risk for poor learning outcomes, monitor student progress, provide evidence-based interventions and adjust the intensity and nature of those interventions depending on a student’s responsiveness (National Center on Response to Intervention, 2010).
IDEA 2004 allows states to use a process based on a student’s response to scientific, research-based interventions (i.e., RtI) to determine if the child has a specific learning disability (SLD). However, federal law does not require schools to use RtI to determine eligibility for all disabilities. The Office of Special Education Programs (OSEP) has clarified that the IDEA does not address the use of an RtI model for children suspected of having disabilities other than SLD and has emphasized while RtI may be used to determine if a child responds to scientific, research-based intervention as part of the evaluation process, RtI is not, in itself, the equivalent to or replacement for a comprehensive evaluation (United States Department of Education, 2007; Hale, 2008). Schools must use a variety of assessment tools and strategies to gather relevant functional, developmental, and academic information about the child, including information provided by the parent, which may assist in determining eligibility and not use any single measure or assessment as the sole criterion for determining whether a child has a disability, and for determining an appropriate educational program. This requirement applies to all children suspected of having a disability (IDEA, 2004).
RtI and the Autism Spectrum
Although RtI is an important advancement in educational practice, there are serious concerns about identifying a child with autism spectrum disorder (ASD) utilizing the RtI process. The heterogeneity of needs and high level of co-occurring problems demonstrated by children and youth with autism may affect the overall use and generalizability of the RtI model (Gilmartin, 2014). For example, intervention research cannot predict, at the present time, which particular intervention approach works best with which children. Similarly, the needs of children with ASD are complex and often more difficult to identify than those with other disabilities. A lack of understanding of ASD and some of the subtler symptoms of ASD might also result in the use of interventions and teaching methods that are inappropriate for this group of children (Twachtman-Cullen & Twachtman-Bassett, 2011). Moreover, some intervention and assessment procedures for ASD require a specific knowledge base and skills for successful implementation. Teachers may not have the skills to implement scientifically-based instructional practices and assessments. There is research to suggest that school personnel (i.e., general education and special education teachers, school counselors, and paraprofessionals) factual knowledge about the assessment/diagnosis and treatment of autism is low and that few teachers receive training on evidence-based practices for students with ASD (Hendricks, 2011; Williams, Schroeder, Carvalho, & Cervantes, 2011). Even with adequate teacher training, it is difficult to determine if the interventions were implemented with integrity (i.e., accurately and consistently). Although the importance of treatment integrity 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. For example, a recent survey of practicing certified school psychologists’ knowledge and use of treatment integrity in academic and behavioral interventions found that only 18% 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 (Skolnik, 2016). 
Concluding Comments
While evidence-based interventions delivered across the levels of RtI might be considered as part of the assessment process, RtI is not a substitute for a comprehensive evaluation in determining a student’s eligibility for special education under the IDEA disability category of autism. The determination of autism should include a variety of information sources and measures, and should not be based on a single measure, process, or information source. At present, the comprehensive development assessment model represents best practice in the evidence-based assessment and identification of ASD in the school context. This approach requires the use of multiple measures including, but not limited to, verbal reports, direct observation, direct interaction and evaluation, and third-party reports. Interviews and observation schedules, together with an assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, atypical behaviors, and cognitive functioning are recommended best practice 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 in order to guide intervention planning.
Adapted from Wilkinson, L. A. (2016). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.
 Key References and Further Reading
Batsche, G., Elliott, J., Graden, J. L., Grimes, J., Kovaleski, J. F., Prasse, D…Tilly, W. D. (2005). Response to intervention policy considerations and implementation. Reston, VA: National Association of State Directors of Special Education.
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.

Gilmartin, Caitlin E., "Autism Interventions in Educational Settings: Delivery within a Response to Intervention Framework" (2014). PCOM Psychology Dissertations. Paper 306. 

Hale, J. B. (2008). Response to intervention: Guidelines for parents and practitioners. Available from http://www.wrightslaw.com/idea/art/rti.hale.pdf
Hendricks, D. (2011). Special education teachers serving students with autism: A descriptive study of the characteristics and self-reported knowledge and practices employed. Journal of Vocational Rehabilitation, 35, 37–50. doi:10.3233/JVR-2011-0552
Individuals with Disabilities Education Improvement Act of 2004. Pub. L. No. 108-446, 108th Congress, 2nd Session. (2004).
Lane, K. L., Bocian, K. M., MacMillan, D. L. & Gresham, F. M. (2004). Treatment integrity: An essential – but often forgotten – component of school-based interventions, Preventing School Failure, 48, 36–43.
National Center on Response to Intervention (March 2010). Essential components of RTI - A Closer look at response to intervention. Washington, DC: U.S. Department of Education, Office of Special Education Programs, National Center on Response to Intervention.
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.
Sanetti, L. M., & Kratochwill, T. R. (2014). Introduction: Treatment integrity in psychological research and practice. In L. M. Sanetti & T. R. Kratochwill (Eds.), Treatment integrity: A foundation for evidence-based practice in applied psychology. Washington, DC: American Psychological Association.

Skolnik, Samantha, "School Psychologists’ Integrity of Treatment Integrity" (2016). PCOM Psychology Dissertations. 397. http://digitalcommons.pcom.edu/psychology_dissertations/397
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.
U.S. Department of Education Office of Special Education Programs. Questions and Answers on Response to Intervention (RTI) and Early Intervening Services (EIS), 47 IDELR ¶ 196 (OSERS 2007).
Wilkinson, L. A. (2016). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.
Williams, K., Schroeder, J. L., Carvalho, C., & Cervantes, A. (2011). School personnel knowledge of autism: A pilot survey. The School Psychologist, 65, 7-9.
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, May 3, 2018

Toward an Evidence-Based Assessment of Autism Spectrum Disorder in Schools


Toward an Evidence-Based Assessment for Autism Spectrum Disorder

The number of children identified with autism has more than doubled over the last decade. The dramatic increase in prevalence, together with the clear benefits of early intervention, have created a pressing need for schools to identify children who may have an autism spectrum disorder (ASD). As a result, specialized support personnel such as school psychologists are now being asked to participate in the screening, assessment, and educational planning for children and youth on the autism spectrum more than at any other time in the recent past. Moreover, the call for greater use of evidence-based practice has increased demands that professionals be prepared to recognize the presence of risk factors, engage in case finding, and be knowledgeable about evidence-based assessment (EBA) and intervention practices for ASD.

Evidence Based Practice

The challenge to improve the services to children with ASD in our schools is dependent on the adoption of evidence-based practices in diagnosis/identification, assessment, and intervention. The scientific literature identifies two primary elements of evidence-based practice: (a) intervention that includes, but is not limited to, those treatment programs for which randomized controlled trials have shown empirical support for the target population and (b) assessment that guides identification/diagnosis, intervention planning, and outcome evaluation. Evidence-based assessment (EBA) emphasizes the use of research and theory to inform the selection of assessment targets, the methods and measures used in the assessment, and the assessment process itself. Elements of EBA in ASD include the following: (a) the use of psychometrically sound assessments; (b) a developmental perspective that characterizes abilities over the lifespan; (c) assessment of core areas of impairment associated with ASD; and (d) the use of information from multiple sources, including direct and indirect observation from parents and teachers.  

Unfortunately, current research suggests that EBA practices are not implemented in our schools with consistency. For example, a recent nationwide survey of school psychologists’ knowledge of and training and experience with ASD on assessment practices found that less than 25% engaged in EBA (Aiello, Ruble, & Esler, 2017). Most school psychologists reported that they did not engage in comprehensive assessment of ASD, which was defined as assessments that consider all areas of development in addition to the use of psychometrically sound ASD-specific instruments. Even among school psychologists who implemented EBA, the majority relied on ASD checklists that provide limited information and, in the case of the GARS-2, have weak psychometric properties (Aiello et. al., 2017; Norris & Lecavalier, 2010; Wilkinson, 2016). These results indicate a significant gap between best and current practices and the need for guidance regarding which tools demonstrate the strongest psychometric properties for identifying students with ASD.

Psychometric Properties

It is imperative that school psychologists have an understanding of the basic psychometric properties that underlie test use and development when assessing children and youth for ASD. For example, sensitivity and specificity are especially important psychometric characteristics to consider when evaluating the quality and usefulness of tests and rating scales. Sensitivity and specificity are measures of a test's ability to correctly identify someone as having a given disorder or not having the disorder. Sensitivity refers to the percentage of cases with a disorder that screen or test positive. A highly sensitive test means that there are few false negative results (individuals with a disorder who screen negative), and thus fewer cases of the disorder are missed. Specificity is the percentage of cases without a disorder that screens negative. A highly specific test means that there are few false positive results (e.g., individuals without a disorder who screen positive). False negatives decrease sensitivity, whereas false positives decrease specificity. An efficient ASD-specific assessment tool should should have high sensitivity and minimize false negatives, as these are individuals with a likely disorder who remain unidentified. Sensitivity and specificity levels of .80 or higher are generally recommended. 

Positive Predictive Value (PPV) and Negative Predictive Value (NPV) are also important validity statistics that describe how well a screening tool or test performs. The probability of having a given disorder, given the results of a test, is called the predictive value. PPV is interpreted as the percentage of all positive cases that truly have the disorder. PPV is a critical measure of the performance of a diagnostic or screening measure, as it reflects the probability that a positive test or screen identifies the disorder for which the individual is being evaluated or screened. NPV is the percentage of all cases screened negative that are truly without the disorder. The higher the PPV and NPV values, the more efficient the instrument at correctly identifying cases. It is important to recognize that PPV is influenced by the sensitivity and specificity of the test as well as the prevalence of the disorder in the sample under study. For example, an ASD-specific measure may be expected to have a higher PPV when utilized with a known group of high-risk children who exhibit signs or symptoms of developmental delay, social skills deficits, or language impairment. In fact, for any diagnostic test, when the prevalence of the disorder is low, the positive PPV will also be low, even using a test with high sensitivity and specificity.

Conclusion

All school psychologists should be able to conduct psychoeducational assessments of students with ASD to determine learning strengths and challenges, as well as to help determine special education eligibility and develop Individualized Education Plan (IEP) goals and objectives. Given that ASD is no longer considered a low incidence disability, there is an urgent need for practitioners to be well informed, trained, and skilled in the screening and assessment of ASD. Evidence-based assessment (EBA) requires using instruments with strong reliability and validity for the accurate identification of children’s problems and disorders, for ongoing monitoring of children’s response to interventions, and for evaluation of treatment outcomes. We should select and utilize assessments in a manner consistent with available evidence, choose tests that have sound psychometric qualities, and rely on multiple measures to guide high-stakes educational decisions.

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

Aiello, R., Ruble, L., & Esler, A. (2017). National Study of School Psychologists’ Use of Evidence-Based Assessment in Autism Spectrum Disorder. Journal of Applied School Psychology33(1), 67-88. DOI: 10.1080/15377903.2016.1236307

American Educational Research Association, American Psychological Association, & National Council on Measurement in Education. (2014). Standards for educational and psychological testing. Washington, DC: American Educational Research Association.

American Psychological Association Statement Policy Statement on Evidence-Based Practice in Psychology (2005). Retrieved on October 26, 2012 from

American Psychological Association Task Force on Evidence-Based Practice for Children and Adolescents. (2008). Disseminating evidence-based practice for children and adolescents: A systems approach to enhancing care. Washington, DC: Author.

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.

Hixson, M. D., Christ, T. J., & Bruni, T. (2014). Best practices in the analysis of progress monitoring data and decision making. In P. L. Harrison & A. Thomas (Eds.), Best practices in school psychology: Foundations (6th ed., pp. 343–354). Bethesda, MD: National Association of School Psychologists.

Kratochwill, T. R. (2007). Preparing psychologists for evidence based school practice: Lessons learned and challenges ahead. American Psychologist, 62, 826-843.

Kratochwill, T. R., & Hoagwood, K. E. (2006). Evidence-based interventions and system change: Concepts, methods and challenges in implementing evidence-based practices in children’s mental health. Child and Family Policy and Practice Review, 2, 12-17.

Mash, E. J., & Hunsley, J. (2005). Evidence-based assessment of child and adolescent disorders: Issues and challenges. Journal of Clinical Child and Adolescent Psychology, 34, 362-379.

National Association of School Psychologists. (2016). School Psychologists’ Involvement in Assessment. Bethesda, MD: Author.

Ozonoff, S., Goodlin-Jones, B. L., & Solomon, M. (2005). Evidence-based assessment of autism spectrum disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34, 523–540.

Reynolds, C. R., & Livingston, R. B. (2014). A psychometric primer for school psychologists. In P. L. Harrison & A. Thomas (Eds.), Best practices in school psychology: Foundations (pp. 281–300). Bethesda, MD: National Association of School Psychologists.

Skolnik, Samantha, "School Psychologists’ Integrity of Treatment Integrity" (2016). PCOM Psychology Dissertations. 397. http://digitalcommons.pcom.edu/psychology_dissertations/397

Wilkinson, L. A. (2016). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London 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 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

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