Monday, December 24, 2012

Impact of ADHD Symptoms on Children with ASD

One of the most controversial comorbidities in children with ASD is the co-occurrence of Attention Deficit Hyperactivity Disorder (ADHD). Comorbidity refers to the presence of more than one diagnosis occurring in an individual at the same time. Although there continues to a debate about ADHD comorbidity in ASD, research, practice and theoretical models suggest that comorbidity between these disorders is relevant and occurs frequently. For example, a study of comorbid psychiatric disorders in children with ASD found that approximately 71% of cases had a least one comorbid psychiatric disorder, with the most common comorbidities being social anxiety (29%), ADHD (28%), and Oppositional Defiant Disorder (28%). Although the current DSM-IV-TR hierarchical rules prohibit the concurrent diagnosis of ASD/PDD and ADHD, there is a relatively high frequency of impulsivity and inattention in children with ASD. In fact, ADHD is a relatively common initial diagnosis in young children with ASD. Some researchers suggest that there are sub-groups of children with ASD with and without ADHD symptoms.

Current Research 

Although comorbid psychiatric disorders in children with ASD have been studied previously, there is a need to examine the impact of co-occurring ADHD symptoms in children with ASD. A recent study published in the journal Pediatrics evaluated the frequency of co-occurring ADHD symptoms in a well-defined cohort of children with ASD and examined the relationship between ADHD symptoms and both adaptive functioning and health-related quality of life as reported by parents or other primary caregivers. The purpose of the study was to: (a) document the frequency of parent-reported ADHD symptoms in a large, geographically diverse population of children with ASD, and (b) further evaluate the differences between children with ASD and ADHD symptoms and those with few or no ADHD symptoms, with an emphasis on parent-report measures of adaptive functioning and health-related quality of life (HRQoL). Based on a review of previous studies, the researchers hypothesized that children with ASD and comorbid ADHD symptoms would have poorer HRQoL and greater impairment in adaptive functioning than children with ASD and few or no ADHD symptoms.
 Method and Outcome Measures
The research was conducted as part of the activities of the Autism Speaks Autism Treatment Network (ATN), a registry collecting data on children with ASD across 14 sites in the United States and Canada. A total of 3066 children and adolescents ages 2 to 18 were eligible for participation in the study. All participants had a clinical diagnosis of ASD based on one or more diagnostic measures.
Parents completed the Child Behavior Checklist (CBCL), a parent/caregiver measure of a variety of problems exhibited during childhood. T-scores on 2 ADHD-related scales from the CBCL were used to indicate the presence of ADHD symptoms. Participants were divided into groups based on whether their parents/caregivers rated them as having clinically significant T-scores on the Attention Problem and Attention Deficit Hyperactivity Problem subscales of the CBCL. Parents were interviewed to complete the Vineland Adaptive Behavior Scales, Second Edition (VABS-II). Standard scores from VABS-II and raw scores from the parent report version of Pediatric Quality of Life Inventory (PedsQL) were then compared between groups with the use of multivariate analyses.
Results indicated that 41% of the 3,000 participants had elevated scores on one CBCL ADHD-related subscale and 19% on both subscales. Analysis of responses to the PedsQL revealed that the ASD/ADHD group had lower scores in all health-related areas measured (School Functioning, Physical Functioning, Emotional Functioning, and Social Functioning) in comparison with the group of children with ASD alone. The ASD/ADHD group also obtained statistically significantly lower scores on all adaptive behavior domains of the VABS-II (Communication, Daily Living Skills, Socialization, and Adaptive Composite) when compared with the group of children with only ASD.
 Conclusion and Implications
Overall results of the study suggest greater impairment in adaptive functioning and a poorer health-related quality of life for children with ASD and clinically significant ADHD symptoms in comparison with children with ASD and fewer ADHD symptoms. This supports previous research on the negative relationship between ADHD symptoms and the development of functional life and other adaptive skills and provides further documentation regarding the relationship between comorbid symptoms and overall health-related quality of life. The results also suggest the need for additional research. For example, it would be important to determine if children with ASD that meet diagnostic criteria for ADHD differ significantly from children with ASD and ADHD symptoms in the areas of adaptive skill development and HRQoL, as well as other important areas. This question is particularly important with the impending publication of DSM-V which will remove the restriction on the comorbid ADHD diagnosis in children with ASD.
These results of the study have important implications for practitioners in health care, mental health, and educational contexts. Externalizing behavior problems, including ADHD symptoms, have been found to have a strong negative relationship with family functioning and parenting stress in children with ASD. Reducing ADHD symptoms in children with ASD, in addition to treating core symptoms, may result in greater improvement in HRQoL and adaptive functioning. Improving adaptive functioning is especially important in that a child’s level of adaptive functioning can directly influence their type of educational setting and future adjustment. Children with better adaptive skills have more opportunity to participate in grade-level activities with typical peers. Consequently, clinicians and health-care professionals should screen for symptoms of ADHD in children with ASD and, if present, consider these symptoms when developing interventions and treatment protocols.
Sikora, D. M., Vora, P., Coury, D. L., & Rosenberg, D. (2012). Attention-Deficit/Hyperactivity Disorder Symptoms, Adaptive Functioning, and Quality of Life in Children With Autism Spectrum Disorder. Pediatrics, 130, S91-97. DOI: 10.1542/peds.2012-0900G
Kuhlthau K., Orlich F., Hall T.A., et al. (2010). Health- Related Quality of Life in children with autism spectrum disorders: results from the autism treatment network. Journal of Autism and Developmental Disorders, 40(6), 721–729.
Murray M.J., (2010). Attention-deficit/hyperactivity disorder in the context of autism spectrum disorders. Current Psychiatry Reports, 12(5), 382–388.
Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also the editor of a recent volume 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 new book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT.


Monday, December 10, 2012

DSM-5 ASD Criteria Unlikely to Exclude Many Individuals

The American Psychiatric Association voted to approve the revised fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5) on December 1, 2012. The manual is used by clinicians nationwide to diagnose mental health conditions and will be published in spring 2013. Among other changes, the revision introduces fundamental changes in the diagnosis of autism. It collapses the previously distinct autism subtypes, including autistic disorder, Asperger’s disorder (syndrome), and pervasive developmental disorder-not otherwise specified (PDD-NOS) into a single unifying diagnosis of autism spectrum disorder (ASD). Further, the current DSM-IV-TR three symptom domains (triad) of social impairment, communication deficits and repetitive/restricted behaviors, interests, or activities will be replaced with two domains, social communication impairment and repetitive/restricted behaviors or interests. Changes also include greater flexibility in the criteria for age of onset and addition of symptoms not previously included in the DSM-IV-TR such as sensory interests and aversions.
The new DSM-5 criteria for ASD have created significant controversy with predictions that it would exclude many individuals from an autism diagnosis and thus make it difficult for them to access services. Critics suggest that the new criteria are too narrow and will leave out a large number of people currently diagnosed with Asperger syndrome and PDD-NOS). However, early studies suggest that fears that many individuals will be excluded appear to be largely unfounded. For example, a recently published field trial suggests that the revisions increase the reliability of diagnosis, while identifying the large majority of those who would have been diagnosed under the DSM-IV-TR. Of the small numbers who were not included, most received the new diagnosis of “social communication disorder.” The DSM-5 criteria also proved highly reliable, meaning that two different clinicians using them were likely to diagnose the same person with the same disorder.
A comprehensive study published in the American Journal of Psychiatry also lends support to application of the DSM-5 criteria. Researchers evaluated the new criteria in children with DSM-IV diagnoses of pervasive developmental disorders (PDD) and non-PDD diagnoses and found that the DSM-5 criteria identified a majority of children with clinical DSM-IV diagnoses. The study used three data sets from 4,453 children with DSM-IV clinical PDD diagnoses and 690 with non-PDD diagnoses (e.g., language disorder).  Items from a parent report measure of ASD symptoms (Autism Diagnostic Interview–Revised) and a clinical observation instrument (Autism Diagnostic Observation Schedule) were matched to DSM-5 criteria and used to evaluate the sensitivity (percentage individuals with ASD who are correctly identified) and specificity (percentage of individuals without ASD who are correctly identified) of the DSM-5 criteria and current DSM-IV criteria when compared with clinical diagnoses. According to the results, the majority of children with clinical diagnoses of PDD met the DSM-5 ASD criteria according to item scores on the Autism Diagnostic Interview–Revised and the Autism Diagnostic Observation Schedule. Application of the DSM-5 criteria demonstrated adequate sensitivity across all groups, On the basis of either parent report or clinical observation, DSM-5 sensitivity ranged from 0.97 to 0.99 for any PDD. Overall, the sensitivity values of the DSM-5 and DSM-IV criteria were comparable. Moreover, the accuracy of non-spectrum classification (specificity) made by DSM-5 was better than that of DSM-IV, indicating greater effectiveness in distinguishing ASD from non-spectrum disorders such as language disorders, intellectual disability, attention deficit hyperactivity disorder, and anxiety disorders. The researchers conclude that “Based on symptom extraction from previously collected data, our findings indicate that the majority of children with DSM-IV PDD diagnoses would continue to be eligible for an ASD diagnosis under DSM-5. Additionally, these results further suggest that the revisions to the criteria, when applied to records of children with non-PDD diagnoses, yield fewer misclassifications.”
Autism researcher Geraldine Dawson, chief science officer for Autism Speaks, commented that although the new criteria appear to be effective, it will be critical to monitor so that children don't lose services. According to an open letter from Dawson, “We are reassured that the DSM-5 committee has stated that all individuals who currently have a diagnosis on the autism spectrum, including those with Asperger syndrome, will be able to retain an ASD diagnosis. This means that no one with a current diagnosis on the autism spectrum should “lose” their diagnosis because of the changes in diagnostic criteria. Also, the committee has stressed that the new DSM-5 criteria represent a “living document in which changes can and likely will be made as new studies are conducted.” “Today, after careful consideration, we are acknowledging the APA’s approval of the DSM-5 with cautious optimism” she said.
Huerta, M., Bishop, S. L., Duncan, A., Hus, V., & Lord, C. (2012). Application of DSM-5 Criteria for Autism Spectrum Disorder to Three Samples of Children With DSM-IV Diagnoses of Pervasive Developmental Disorders. American Journal of Psychiatry, 169, 1056–1064.
Lord, C. et al. (2011). A multisite study of the clinical diagnosis of different autism spectrum disorders. Archives of General Psychiatry. doi:10.1001/archgenpsychiatry.2011.148

Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also editor of a recent volume 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 new book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT.

Thursday, December 6, 2012

Book Review: Autism and Asperger's in Schools

Book Review: A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools by Lee A. Wilkinson
I have had to read many research-based guides during my professional career and most of them were well written yet very technical and difficult to understand. I am pleased to say that I did not find that to be the case with A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools by Lee Wilkinson. The author not only presents academic research but he translates it all into words that are easy for anyone to comprehend.

All 208 pages of this book are filled with research-based information about the best practices schools should adhere to when assessing and intervening with children in schools. The author does a wonderful job presenting all of the data, facts, figures and statistics in a very structured layout that is straightforward, practical and convenient to access.

As the prevalence of Autism Spectrum Disorders continues to expand, this book is a crucial addition to any school library. It is no longer possible for school systems to ignore or continue to deal with developmental delays in piecemeal fashion and Lee Wilkinson has put together an excellent comprehensive manual to guide school personnel in addressing these issues.
The increased prevalence of Autism Spectrum Disorders requires professionals to identify children as early as possible in their school experience. Whether a child comes to school diagnosed or not Lee Wilkinson’s book is the perfect guide for schools to follow in order to set the ball in motion to access the earliest intervention services possible.
I found this to be a very user-friendly book as evidenced by the following:
  • The two case studies Wilkinson includes in the book helps the reader comprehend all the information presented by actually seeing the best practices in action and how they apply in real life situations.
  • The author was very thoughtful to include a glossary of terms and acronyms to help those who are new to the arena of Autism Spectrum Disorders translate meaning and decipher what the abbreviated codes stand for quickly.
  • Frequently asked questions and an abundance of forms such as worksheets and checklists make this book a convenient one stop shopping experience for the reader.
  • The “Quick Reference” boxes at the end of each chapter help to summarize the chapter information even further or highlight a specific strategy that was presented.
  • I was extremely impressed with the detailed “index to best practice recommendations” which not only summarizes the process at the various stages but the index also supplies the corresponding page for the reader to access more detailed information about each practice.
As a school social worker who worked in the public school system with special needs children for seventeen years this book would have been a very helpful tool for all school based professionals to access. With the rising incidence of children being diagnosed on the Autism spectrum, this guide should be required reading for all direct service providers who work with children in the school setting. On behalf of the Autism community I extend a sincere thank you to Lee Wilkinson for this impressive and most valuable resource!

Reviewed by Connie

Parent Coaching for Autism

Monday, December 3, 2012

American Psychiatric Association Approves DSM-5 ASD Category

The American Psychiatric Association’s recommendation to delete (remove) Asperger’s disorder as a separate diagnostic category from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was approved on December 1st by the by the Association's Board of Trustees.  Specifically, DSM-5 will include a new category of “autism spectrum disorder,” which subsumes the current diagnoses of autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). This new category reflects DSM-V Work Group members’ conclusion that “a single spectrum disorder” better describes our current understanding of the neurodevelopmental disorders. 

The objective of the new ASD criteria is that every individual who has significant “impairment” in social-communication and restricted and repetitive behavior or interests (RRBI) meet the diagnostic criteria for autism spectrum disorder. Language impairment/delay will no longer be a necessary criterion for diagnosis of ASD. Therefore anyone who demonstrates severe and sustained impairments in social skills and restricted, repetitive patterns of behavior, interests, or activities in the presence of generally age-appropriate language acquisition and cognitive functioning, who might previously have been given a diagnosis of Asperger’s disorder, would now meet the criteria for the new category of ASD. The criteria also feature dimensions of severity that include current levels of language and intellectual functioning. Additionally, symptom examples are expected to be provided for all ages and language levels, so that ASD will not be overlooked in persons of average or superior IQ who are experiencing “clinical” levels of difficulty. Full details of all the revisions will be available in May 2013 when the American Psychiatric Association's new diagnostic manual is published. 

Critics of the new category of ASD expressed concern that individuals would lose their current diagnoses and no longer be eligible for special services. But the revision will not affect their education services, experts say. The term "autism spectrum disorder (ASD)," is used by many experts and practitioners in the field. The new category will include the complete autism spectrum, from mild to the more severe forms of the disorder. Catherine Lord, an autism expert at Weill Cornell Medical College in New York and member of psychiatric group's autism task force, commented that anyone who met criteria for Asperger's Disorder (syndrome) in the current manual (DSM-IV-TR) would be included in the new diagnosis. Lord also comments that although there has been much controversy about whether there should be separate diagnoses, "Most of the research has suggested that Asperger syndrome really isn't different from other autism spectrum disorders." "The take-home message is that there really should be just a general category of autism spectrum disorder, and then clinicians should be able to describe a child's severity on these separate dimensions." Another reason for the change is that some states and school systems don't provide services for children and adults with Asperger's, or provide fewer services than those given an autism diagnosis, she said. Autism researcher Geraldine Dawson, chief science officer for the advocacy group Autism Speaks, said small studies have suggested the new criteria will be effective. But she commented that it will be critical to monitor so that children don't lose services. While including Asperger’s Disorder under the new category of “autism spectrum disorder” may well require a period of transition and adjustment, the proposed “dimensional” approach to diagnosis will likely result in more effective identification, treatment, and research for individuals on the spectrum.

A more detailed summary and discussion of the proposed revisions to DSM disorders and criteria are available at <> 

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders. Washington, DC: Author.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.) Washington, DC: Author.

American Psychiatric Association (2011). DSM-5 development. A 09 Autism Spectrum Disorder.
Lord, C. et al. (2011). A multisite study of the clinical diagnosis of different autism spectrum disorders. Archives of General Psychiatry. doi:10.1001/archgenpsychiatry.2011.148
Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for Asperger syndrome and autism in schools. London: Jessica Kingsley Publishers.

Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers.

Sunday, December 2, 2012

Autism and Inclusive Education

The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) (P.L. 108-446) ( guarantees a free and appropriate public education (FAPE) in the least restrictive environment (LRE) for every student with a disability. The LRE provision mandates that “to the maximum extent appropriate, children with disabilities, including children in public or private institutions or other care facilities, are educated with children who are not disabled, and special classes, separate schooling, or other removal of children with disabilities from the regular educational environment occurs only when the nature or severity of the disability of a child is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily.”  In general, inclusion (or inclusive education) with typical peers is often considered to be the best placement option for students with disabilities. However, a study published in Pediatrics, the official journal of the American Academy of Pediatrics, calls into question whether or not inclusive education actually leads to better outcomes in the long term for children with autism.
The Study
Researchers from the University of Alabama at Birmingham and Johns Hopkins University sought to determine whether the proportion of time spent in an inclusive educational setting, a process indicator of the quality of schooling for children with autism, improves key outcomes. The participants were 484 children and youth educated in special education with a primary diagnosis of autism in the National Longitudinal Transition Study-2 (NLTS2). The NLTS2 is a 10-year study of youth with disabilities who were receiving special education services in public or state-supported special schools. The NLTS2 uses a nationally representative sample of youth in special education who were between the ages of 13 and 16 on December 1, 2000.
The primary exposure of interest in this analysis was the proportion of time the youth spent in a general education classroom. A school program questionnaire was used to collect data on the courses that each student took during the 2003 school year and whether each course was taken in a general education or special education classroom. The proportion of time spent in an inclusive setting was categorized as 0%, 1% to 74%, or 75% to 100% of courses taken in a general education classroom.
Key Outcomes
Three outcomes were assessed in the study’s analysis: (1) not dropping out of high school, (2) any college attendance, and (3) a cognitive functional scale. Youth were coded as not dropping out if the parent reported that they graduated, received a certificate or General Educational Development certificate, or were still in high school at the time of data collection. Any college attendance was based on parent report of whether the youth attended any type of postsecondary school in the previous 2 years, including postsecondary classes to earn a high school degree, a 2-year or 4-year college, or postsecondary vocational school. The functional cognitive scale measured a combination of parent-reported cognitive, sensory, and motor skills used in performing daily activities (such as counting change). Parents rated their child on a scale of 1 (“not at all well”) to 4 (“very well”) for each of these skills. The rating for each skill was added to create the functional cognitive scale, which ranged from 4 (not at all well for any of the skills) to 16 (very well for all of the skills).
Compared with children with autism who were not educated in an inclusive setting, children with autism who spent 75% to 100% of their time in a general education classroom were no more likely to attend college, not drop out of high school, or have an improved functional cognitive score after controlling for key confounders. The researchers state that “In general, our analyses suggest that inclusivity does not improve educational or functional outcomes for children with autism.”  They also note that although the link between inclusivity and outcome remains weak, “inclusive education” that is well implemented and supported might have substantial benefits. Recommendations for further research include investigation of educational and functional outcomes from data on large samples of children in real-world settings. There is also a need for developing future indicators to measure the “quality” of special education for children with autism. This includes a careful description of the learning environment and experiences within and between communities as well as key measures specific to the characteristics and education of children with autism. The authors conclude that the study illustrates the challenges of understanding the effect of real-world services and treatments and that a “A fuller understanding of inclusivity and other potential measures of educational quality may have to wait for better data and methods.”
Foster, E. M., & Pearson, E. (2012). Inclusivity an Indicator of Quality of Care for Children With Autism in Special Education? Pediatrics, 130, S179-S184. DOI: 10.1542/peds.2012-0900P
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).

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