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

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.

 

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

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 <http://www.dsm5.org> 

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.

http://www.dsm5.org/proposedrevision/Pages/NeurodevelopmentalDisorders.aspx

DSM-5: Rethinking Asperger’s Disorder http://bestpracticeautism.blogspot.com/2011/12/dsm-5-rethinking-aspergers-disorder.html

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.

Best Practice Review: Children’s Communication Checklist (CCC-2)

Best Practice Review: CCC-2

As a group, higher functioning students with autism spectrum disorder (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. Nevertheless, significant and severe deficits in the ability to communicate and interact with others can limit their 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. Assessments to identify pragmatic language deficits are not as well developed as tests of language fundamentals. Although there are few standard measures available to assess these skills in higher functioning children with ASD, the Children’s Communication Checklist (CCC-2) is a promising third party checklist that can be used in screening and identification of pragmatic language problems.

The Children’s Communication Checklist (CCC-2) is a measure designed to assess the communication skills of children 4 to 16.11 years of age. The purposes of the CCC-2 are the identification of pragmatic language impairment, screening of receptive and expressive language skills, and assistance in screening for ASD. The CCC-2 has shown utility in identifying children who may require further assessment for an autism spectrum disorder (ASD). Initially developed in the United Kingdom, the CCC-2 has been adapted for use in the United States (Bishop, 2006). A Caregiver Response Form is completed by an adult who has regular contact with the child, usually a parent, teacher, therapist, or other professional. The CCC-2 consists of 70 items that are divided into 10 scales, each with 7 items. The first 4 scales focus on specific aspects of language and communications skills (content and form). The next 4 scales assess the pragmatic aspects of communication. The last 2 scales measure behaviors that are usually impaired in children with ASDs. The respondent rates the frequency of the communication behavior described in each item from 0 (less than once a week or never) to 3 (several times a day or always). Interpretation is based on a General Communication Composite (GCC) and the Social Interaction Difference Index (SIDI). A significantly depressed communicative competence score, coupled with a score of less than 11 on the SIDI, suggests a profile of ASD and the need for further evaluation. The CCC-2 reports a sensitivity value of .89 and a specificity value of .97 for identifying children with autistic symptomatology and pragmatic social impairment (Bishop, 2006). Previous versions of the CCC-2 have been strongly associated with the ADI-R total score and ICD-10 diagnostic criteria.

Conclusion

The CCC-2 appears to be a well-constructed instrument that has both face validity and reliability to achieve its stated purpose of assisting in identifying children with language and communication problems, especially in the area of pragmatic communication skills. In a recent study (Volden & Phillips, 2010), the CCC–2 was found to be a more sensitive tool than the Test of Pragmatic Language (TOPL) for identifying pragmatic language impairment in high-functioning speakers with ASD who have structural language and nonverbal cognitive scores within typical limits. The CCC-2 also has the advantage of sampling pragmatic skills in the child’s natural environment. In addition to other more comprehensive communication and language assessment tools, the CCC-2 should be a welcome and useful addition as either a screening tool to identify children who are at risk and need additional assessment, or a supplemental tool to other testing.

Bishop, D. V. M. (2006). Children’s Communication Checklist (2nd ed., U.S. ed.). San Antonio, TX: Psychological Corporation.

Volden, J. & Phillips, L. (2010). Measuring pragmatic language in speakers with autism spectrum disorders: Comparing the Children’s Communication Checklist—2 and the Test of Pragmatic Language. American Journal of Speech-Language Pathology, 19, 204–212.

Lee A. Wilkinson, PhD, is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a 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).

Interventions for Adolescents and Young Adults with Autism Spectrum Disorder (ASD)

Although it would seem obvious that children with ASD will eventually transition to adolescence and adulthood, there is a paucity of information about effective interventions for these age groups compared to data for younger children. Even though the core symptoms of ASD (impairments in communication and social interaction and restricted/repetitive behaviors and interests) may improve overtime with intervention for many individuals, some degree of impairment typically remains throughout the lifespan.  Consequently, the focus of intervention/treatment must shift from remediating core deficits in childhood to promoting adaptive behaviors that can facilitate and enhance ultimate functional independence and quality of life in adulthood. This includes new developmental challenges such as independent living, vocational engagement, post-secondary education, and family support. Unfortunately, there is evidence to suggest that improvements in symptoms and problem behaviors may decrease or end once youth with ASD transition from school-based programs. This is likely due, at least in part, to the termination of services received through the secondary school system upon exiting from high school, as well as the lack of adult services. The lack of services available to help young adults with ASD transition to greater independence has been noted by researchers for a number of years and has become an increasingly important issue as the prevalence of ASD continues to grow and as children identified with ASD reach adolescence and adulthood.

Comparative Effectiveness Review

What are the effects of currently available interventions/treatments on adolescents and young adults with ASD?  To answer this question, researchers at the Vanderbilt Evidence-based Practice Center systematically reviewed evidence on therapies for adolescents and young adults (ages 13 to 30) with autism spectrum disorders (ASD). Their review focused on the outcomes, including harms and adverse effects, of interventions addressing the core symptoms of ASD; common medical and mental health comorbidities occurring with ASD; the attainment of goals toward functional/adult independence; educational and occupational/vocational attainment; quality of life; access to health and other services; and the transitioning process (e.g., process of transitioning to greater independent functioning). Researchers also addressed the effects of interventions on family outcomes including parent distress and satisfaction with interventions.

Of more than 4,500 studies on autism interventions published between 1980 and 2011, only 32 focused on interventions/therapies for individuals ages 13 to 30. Most of the studies available were of poor quality, which may reflect the relative recency of the field. Five studies, primarily of medical interventions, had fair quality. Behavioral, educational, and adaptive/life skills studies were typically small and short term and suggested some potential improvements in social skills and functional behavior. Small studies suggested that vocational programs may increase employment success for some individuals. Few data are available to support the use of medical or allied health interventions in the adolescent and young adult population. The medical studies that have been conducted focused on the use of medications to address specific challenging behaviors, including irritability and aggression, for which effectiveness in this age group is largely unknown and inferred from studies including mostly younger children. However, antipsychotic medications and serotonin reuptake inhibitors were associated with improvements in specific challenging behaviors. Similarly, little evidence supports the use of allied health interventions including facilitated communication.

Conclusion

Despite an increasing population of adolescents and young adults identified with an ASD and the need for effective intervention across the lifespan, very few studies have been conducted to assess treatment approaches for adolescents and young adults with ASD. Moreover, the available research is lacking in scientific rigor. As a result, there is little evidence available for specific treatment approaches in this population; especially for evidence-based approaches to support the transition of youth with ASD to adulthood. In particular, families have little in the way of evidence-based approaches to support interventions capable of optimizing the transition of teens with autism into adulthood. Research is needed across all intervention types on which outcomes to use in future studies. “Overall, there is very little evidence in all areas of care for adolescents and young adults with autism, and it is urgent that more rigorous studies be developed and conducted,” commented Melissa McPheeters, director of Vanderbilt’s Evidence-Based Practice Center and senior author of the report. “There are growing numbers of adolescents and adults with autism in need of substantial support. Without a stronger evidence base, it is very hard to know which interventions will yield the most meaningful outcomes for individuals with autism and their families,” said Zachary Warren of Vanderbilt who also contributed to the report.

Lounds Taylor J, Dove D, Veenstra-VanderWeele J, Sathe NA, McPheeters ML, Jerome RN, Warren Z. Interventions for Adolescents and Young Adults With Autism Spectrum Disorders. Comparative Effectiveness Review No. 65. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2007-10065-I.) AHRQ Publication No. 12-EHC063-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2012. http://www.effectivehealthcare.ahrq.gov/reports/final.cfm 

The complete report is available at:  

http://effectivehealthcare.ahrq.gov/ehc/products/271/1196/CER65_Autism-Young-Adults_20120723.pdf 

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.

Rise in autism related to changes in diagnosis, New study suggests

Over the past 10 years the prevalence rates have risen steadily, from one in 150, to one in 110, and now to one in every 88 children. This represents a 78 percent increase in the number of children identified with an autism spectrum disorder (ASD) over the past decade. What are the reasons for this dramatic increase in the prevalence of ASD? A new study suggests that the rise in the number of cases of autism may be related to changes to autism diagnostic criteria.

The criteria for assessing autism has changed over the last 20 years resulting in a broadening of autism diagnoses and the identification of cases that would not have been diagnosed by using older criteria. The current study published online in the Journal of Autism and Developmental Disorders re-examined diagnostic data from a state-wide autism prevalence study (n = 489) conducted in the 1980s to investigate the impact of broader diagnostic criteria on autism spectrum disorder (ASD) case status. Clinicians in the original study used DSM-III criteria to assess individuals as “diagnosed autistic” or “diagnosed not autistic.”  After applying current diagnostic criteria from the DSM-IV-TR to records from participants in the two-decades-old study, sixty-four (59 %) of the 108 originally “Diagnosed Not Autistic” met the current ASD case definition, while those who were found to have autism in the 1980s study continued to qualify for the diagnosis using the current criteria. The average IQ estimate in the newly identified group was also significantly lower than in the original group. Current diagnostic criteria applied to participants ascertained in the 1980s identified more cases of autism with intellectual disability. The researchers conclude, “The results of this study demonstrate a significant effect on ASD case status attributable to changing ASD criteria, particularly with regard to individuals with intellectual impairment,” They also comment, “An important caveat, however, is that we were unable to determine whether it was the broadening of the criteria themselves, or the interpretation of the criteria, which lead to this effect.”

The current study supports the theory that the rise in the number of cases of autism may be related to changes in how the disorder is diagnosed. Another aspect of the autism landscape that has changed over the past 20 years is an increase in the awareness of autism among the general public as well as healthcare professionals. While recent findings suggest that at least a portion of the increase in prevalence can be attributed to these factors, they cannot alone explain the dramatic rise in autism prevalence. According to Autism Speaks, genetic vulnerabilities and interaction with environmental factors are likely contributors to the increase in prevalence. 

Miller, J. S., Bilder, D., Coon, H., Pinborough-Zimmerman, J., Jenson, W., Rice, C. E., Fombonne, E., Pingree, C. B., and Ritvo, E., et al. (2012). Autism spectrum disorder reclassified: A second look at the 1980s Utah/UCLA Autism Epidemiologic Study. Journal of Autism and Developmental Disorders. DOI: 10.1007/s10803-012-1566-0

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

Special Needs Students Bullied More Than Others

Students with special needs continue to face a number of challenges in our nations’ schools and communities. A study published in the Journal of School Psychology found that students receiving special education services for behavioral disorders and those with more noticeable disabilities are not only more likely to be bullied than their general education peers, but are more likely to engage in bullying behavior themselves. Participants in the study were 816 students, 9 to 16 years of age, from nine Midwestern elementary and middle schools in one school district. From this total group, 686 were not receiving special education services (categorized as “no disability”), and 130 were receiving special education services (categorized as “observable disability,” “non-observable disability,” and “behavioral disability”). Data on students’ involvement in bullying, office referrals, and prosocial behavior were collected. Self-report measures were used to assess students’ experiences with bullying and victimization and how often students engaged in various aggressive and prosocial behaviors.

The results indicated that students with behavioral disorders reported the highest levels of bullying others and being bullied themselves. The study also found that students with observable disabilities (e.g.., language impairments, hearing impairments, and mild mentally handicapped) were more likely to bully others and to be victimized compared with students in general education.  As the authors comment, “The observable nature of the disability makes it easy to identify those students as individuals with disabilities, which may place them at a greater risk for being the easy target of bullying. Being frustrated with the experience of victimization, those students might engage in bullying behavior as a form of revenge.”

The study also found that students with non-observable disabilities, such as a learning disability, reported similar levels of bullying and victimization as students without disabilities. They also reported significantly less victimization compared with students with more outward behavioral disabilities. While both boys and girls engaged in bullying, there was no significant gender difference in both general education and special education students when it came to the behavior. Although fifth grade students in general education reported much more victimization than sixth-, seventh-, eighth- and ninth-graders, there was no difference for students in special education.

What are the implications of this study? The authors offer several suggestions for school-based bullying prevention and intervention programming. For example, anti-bullying interventions emphasizing prosocial skills should be implemented for students, regardless of their ability. Students in general education could help the process by serving as prosocial role models for students with disabilities. Teachers may also provide reinforcement for prosocial behavior or assign students in general education with students in special education in small groups to work on class projects together to promote positive interaction. For students with both behavioral and observable disabilities, providing support and teaching strategies to cope with peer victimization are important. Helping students with observable disabilities become better integrated into general education classes may help prevent them from being bullied. "Programming should be consistently implemented across general and special education, should occur in each grade and should be part of an inclusive curriculum," the authors recommend. "A culture of respect, tolerance and acceptance is our only hope for reducing bullying among all school-aged youth."

Swearer, S., Wang, C., Maag, J. W., Siebecker, A. B., & Frerichs, L. J. (2012). Understanding the bullying dynamic among students in special and general education. Journal of School Psychology, 50, 503–520

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 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.

Autism Continuing Education Courses

Recent studies indicate that the prevalence rate for autism spectrum disorders (ASD) is 78% higher than just 10 years ago. The pervasive developmental disorder (PDD) category, also commonly referred to as ASD, represents one of the fastest growing disability categories in the world. In the United States, ASD is more prevalent in the pediatric population than cancer, diabetes, spina bifida, and Down syndrome. The U.S. Centers for Disease Control and Prevention (CDC) now estimates that 1 in 88 eight year-old children have an autism spectrum disorder. Research indicates that the outcomes for children with ASD can be significantly improved by early identification and intensive intervention. How can you be better prepared to help these students be successful? This continuing education course prepares psychologists, special educators, general education teachers, speech/language pathologists, paraprofessionals, administrators, and parents for working with this special population.

Offered as a book-based independent course, Autism and Asperger Syndrome in Schools: A Best Practice Guide to Assessment and Intervention, provides professionals and parents with a step-by-step guide to screening, assessment, and intervention for children with this complex neurodevelopmental disorder. Written by Dr. Lee A. Wilkinson, a practicing school psychologist with extensive experience in the assessment of ASD, this award-winning authoritative, yet accessible book fills a critical void in the practice literature. Grounded in the latest research, special features include illustrative case examples and an index to 50 evidence-based best practice recommendations. The course objectives include:

• Recognize the elements and specific features in autism spectrum disorders (ASD). 
• Distinguish between DSM diagnosis and IDEA classification. 
• Learn the differences between a dimensional and categorical view of ASD.  
• Identify current screening and assessment instruments for ASD. 
• Distinguish evidenced based treatments for ASD.

This book-based course allows you to earn continuing education hours from the comfort, privacy and convenience of home or office. Purchase and read the book, and then log on to access the test and other information associated with the book. This course is suitable for: psychologists, counselors, teachers, special education teachers, speech/language therapists, occupational therapists, social workers, paraprofessionals, parents, and nurses.  Take the book as a course for continuing education credit, and then continue to use it in your practice. The book is also available in Kindle and/or e-Book formats.

The course is available from CE-CLASSES.COM and PsychContinuingEd.com.

An online continuing education course, AutismSpectrum Disorders in Schools: Evidence-Based Screening and Assessment is also available. Adapted from A Best Practice Guide…, the objective of this online course is to summarize the empirically-based screening and assessment methodology in ASD and to describe a comprehensive developmental approach for assessing students with ASD. The course objectives include:

• Recognize the characteristics of the most prevalent types of ASD.    
• Distinguish between DSM diagnosis and IDEA classification.          
• Differentiate among screening, assessment, and diagnosis.  
• Identify components of a comprehensive developmental assessment for ASD. 
• Select evidence-based assessment tools.                                      

This course is available from ProfessionalDevelopment Resources.

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.

Book Review: Respecting Autism: The Rebecca School DIR Casebook for Parents and Professionals

Respecting Autism: The Rebecca School DIR Casebook for Parents and Professionals by Stanley I. Greenspan, MD and Gil Tippy, PsyD describes the mission and program of the Rebecca School, a therapeutic day school in New York City that specializes in teaching children ages four to twenty-one who have a range of neurodevelopmental disorders, including autism and Pervasive Developmental Disorder (PDD). The book features a Foreword by Michael Koffler, Executive Director of the school, followed by an Introduction by Clinical Director and founder Dr. Gil Tippy, a brief history of Rebecca School, and 16 chapters, each featuring a different case vignette. The text concludes with a Glossary and list of acronyms to help the reader negotiate some of the “jargon” in the book.

The introduction by coauthor and Clinical Director of the school, Dr. Gil Tippy, is well-written and clearly describes the DIR/Floortime model adopted by the school. Briefly, the Developmental, Individual Difference, Relationship-based (DIR®) Model, developed by the late Dr. Stanley I. Greenspan, is a framework that helps clinicians, parents and educators conduct a comprehensive assessment and develop an intervention program tailored to the unique challenges and strengths of children with Autism Spectrum Disorders (ASD) and other developmental challenges. The objectives of the DIR® Model are to build healthy foundations for social, emotional, and intellectual capacities rather than concentrating on skills and isolated behaviors. This integrated model focuses on interaction with caregivers and the environment, biological, motor, and sensory differences and the child’s functional emotional development capability. It may include various problem-solving exercises and typically involves a team approach with speech therapy, occupational therapy, educational programs, and mental health (developmental-psychological) intervention.

The heart (and soul) of Respecting Autism is the individual students profiled in each of the 16 chapters. Each “real world” case vignette highlights the child’s unique needs, strengths, and challenges and how he or she has benefited from DIR/Floortime intervention. The reader is presented with a history of the child, including parental concerns and experiences with medical and special education programs, a summary of Sensory and Motor Strengths and Challenges as Understood and Described by the Rebecca School Staff, Dr. Greenspan’s Recommendations, and Constitutional and Maturational Variations. Each chapter ends with a Game Plan designed to enhance growth and development while respecting the child’s special unique needs, and a discussion of Program Responses to Dr. Greenspan’s Recommendations.

Respecting Autism: The Rebecca School DIR Casebook for Parents and Professionals by Stanley I. Greenspan, MD and Gil Tippy, PsyD, is recommended reading for all who live and work with children on the “developmental spectrum.” Professionals who want to expand their treatment options for children on the spectrum will find the text a valuable resource for understanding the DIR/Floortime model and its application as a developmental-pragmatic approach to intervention.

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.

© Lee A. Wilkinson, PhD

Evidence-Based Treatment for Children with Autism

Recent statistics from the Centers for Disease Control and Prevention (CDC) indicate that one in every 68 school-age children in the U.S. has an autism spectrum disorder (ASD). Over the past 10 years the prevalence rates have risen steadily, from one in 150, to one in 110, and now to one in every 68 children. This represents a 78 percent increase in the number of children identified with an autism spectrum disorder (ASD) over the past decade.

Families, educators, and service providers are faced with an ever increasing amount of confusing and often conflicting information about the myriad treatments and interventions available for autism. Intervention approaches and nontraditional therapies for ASD are routinely discussed by researchers, parents and professionals. Many approaches feature testimonials, anecdotal, and unverified reports that promise cures, or at the very least, dramatic improvement and recovery. Unfortunately, parents, caregivers, educators, and practitioners are often exposed to unsubstantiated, pseudoscientific theories, and related clinical practices that are ineffective and compete with validated treatments. The time, effort, and financial resources spent on ineffective treatments can also create an additional burden on families and practitioners. As a result, there continues to be an urgent need for evidence-based guidance on providing treatment to children and youth with autism spectrum disorders (ASD). Understanding treatment options and making informed decisions for children and youth with ASD are critical. How do we differentiate scientifically validated treatment approaches from those that are unproven and/or potentially ineffective? Where do parents and professionals find credible, research-based information on the most effective treatments for autism spectrum disorders (ASD)?

To answer these questions, the National Autism Center completed an unprecedented multi-year project, the National Standards Project, to establish a set of standards for effective, research-validated educational and behavioral interventions for children and youth on the spectrum. The Project included the support and guidance of an expert panel composed of nationally recognized scholars, researchers, and other leaders representing diverse fields of study. The culmination of this rigorous multi-year endeavor represents the most comprehensive analysis available to date about treatments for children and adolescents with ASD. The National Standards Report provides a single, authoritative source of guidance for parents, caregivers, educators, and practitioners to make informed treatment decisions and distinguish research supported treatment approaches from treatments that are unproven and/or potentially ineffective.

This groundbreaking report covers a broad range of applied treatments and identifies the level of scientific evidence available for each. It includes 775 research studies, the largest number of studies ever reviewed. For the first time, service providers, educators, caregivers and parents can find specific information about the age groups, treatment targets, and diagnostic populations to which these treatments have been applied. The findings include the identification of eleven (11) “established’ treatments; twenty-two (22) “emerging” treatments; and five (5) “unestablished” treatments. This information is especially important to service providers, educators, caregivers and parents as it identifies evidence-based treatments and provides standards and guidelines on making treatment choices for children and adolescents with ASD. Interventions or treatments identified as categories of “established” or effective treatments are listed below. More detailed descriptions of each category are available from the National Standards Report.

• Antecedent Package (These interventions involve the modification of situational events that precede the occurrence of a target behavior in order to increase the likelihood of success or reduce the likelihood of problems occurring. Strategies include applied behavior analysis (ABA) and positive behavior support).

• Behavioral Package (These interventions are based on behavioral principles and are designed to reduce problem behavior and teach functional alternative behaviors).

• Comprehensive Behavioral Treatment for Young Children (These programs involve early behavioral interventions that target a range of essential skills (e.g., communication, social) and involve a combination of applied behavior analytic procedures (e.g., discrete trial, incidental teaching). They are often termed ABA programs or early intensive behavioral intervention).

• Joint Attention Intervention (Joint attention refers to behavior of two individuals simultaneously focusing on and object or activity. These interventions involve building foundational skills involved in regulating the behaviors of others by teaching a child to respond to the nonverbal bids of others or to initiate joint attention interactions).

• Modeling (These interventions rely on an adult or peer providing a demonstration of the target behavior. The goal of modeling (live and video) is to correctly demonstrate a target behavior to the person learning a new skill, so that person can then imitate the model).

• Naturalistic Teaching Strategies (These teaching strategies primarily involve child-directed interactions to teach real-life skills (communication, interpersonal, and play skills) in natural environments. Examples include incidental teaching, milieu teaching, and embedded teaching).

• Peer Training Package (These interventions facilitate growth for children with ASD by training peers on how to initiate and respond during social interactions with a child on the spectrum. Common names include peer networks, circle of friends, and peer-initiation training).

• Pivotal Response Treatment (This treatment is also referred to as Pivotal Response Teaching and focuses on teaching children to respond to various teaching opportunities within their own natural environment, and to increase independence from prompting. Pivotal behavioral areas include motivation, self-initiation, and self-management).

• Schedules (This intervention involves presentation of a task list to increase independence, improve self-regulation skills, and allow the child to plan for upcoming activities. Schedules may be presented in multiple formats (e.g., photos or pictures, written or typed words, 3-D objects).

• Self-management (These strategies involve teaching individuals with ASD to evaluate and record the occurrence/nonoccurrence of a target behavior and secure reinforcement. The objective is to be aware of and regulate their own behavior so they will require little or no assistance from adults).

• Story-based Intervention package (These interventions identify a target behavior and involve a written description of the situation under which specific behaviors are expected to occur. Most stories aim to improve perspective-taking skills and may be supplemented with additional components (e.g., reinforcement, prompting, and discussion). The most well known story-based intervention is Social Stories).

Treatment selection should be made by a multidisciplinary team of individuals who are in the position to evaluate the unique needs and history of the child or youth with ASD. The above referenced “established” treatments have sufficient evidence of effectiveness and should be given serious consideration by decision-making teams. It should be noted, however, that research findings are not the only factor involved when selecting an intervention. Professional judgment and the values and preferences of parents, caregivers, and the individual are also important. Complete information about the Project’s treatment effect ratings, Strength of Evidence Classification System, limitations, and future directions for the scientific community is available from the National Standards Report.

The National Autism Center is dedicated to serving children and adolescents with Autism Spectrum Disorders (ASD) by providing reliable information, promoting best practices, and offering comprehensive resources for families, practitioners, and communities. An advocate for evidence-based treatment approaches, the Center identifies effective programming and shares practical information with families about how to respond to the challenges they face. The Center also conducts applied research and develops training and service models for practitioners. Finally, the Center works to shape public policy concerning ASD and its treatment through the development and dissemination of National Standards of Practice.

National Autism Center (2009). National Standards Project-Addressing the need for evidence-based practice guidelines for autism spectrum disorders. Randolph, MA: National Autism Center.

National Research Council (2001). Educating children with autism. Committee on Educational Interventions for Children Autism, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

New York State Department of Health Early Intervention Program (1999). Clinical practice guideline: Report of the recommendations. Autism/Pervasive developmental disorders, New York State Department of Health Early Intervention Program assessment, and intervention for young children. Albany, NY: New York State Department of Health Early Intervention Program.

Lee A. Wilkinson, PhD, CPsychol, NCSP, AFBPsS is a licensed and nationally certified school psychologist, chartered psychologist, registered psychologist, and certified cognitive-behavioral therapist. 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. Dr. Wilkinson is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also editor of a recent volume in the American Psychological Association (APA) School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and author of the new book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT.

Evidence-Based Practice and Autism in the Schools

School professionals are now expected to participate in the identification and treatment of children with autism spectrum disorders (ASD) more than at any other time in the recent past. Practitioners must be prepared to recognize the presence of risk factors and/or early warning signs of ASD, engage in case finding, and be familiar with assessment tools and interventions in order to ensure that students are being identified and provided with the appropriate programs and services.

There continues to be a pressing need for evidence-based guidance on providing treatment to children with autism spectrum disorders (ASD). Schools today face the challenge of providing appropriate services to a diverse and increasingly numerous student population diagnosed with ASD. In order to achieve this goal, evidence-based practice is essential in the schools. To assist school professionals as they strive to help these students reach their potential, the National Autism Center has produced a comprehensive 245-page manual, Evidence-Based Practice and Autism in the Schools. The manual outlines relevant topics, including the current state of research findings, professional judgment and data-based clinical decision making, values and preferences of families, and capacity building. Each chapter sets a course for advancing the efforts of school systems to engage in evidence-based practice for their students on the autism spectrum.

The National Autism Center has distributed 3,000 printed copies of this manual to school systems around the country. The Educator Manual is also available to individuals on the Center’s website as a pdf at http://www.nationalautismcenter.org/learning/practitioner.php

The National Autism Center is May Institute’s center for the promotion of evidence-based practice. It is a nonprofit organization dedicated to serving children and adolescents with Autism Spectrum Disorders (ASD) by providing reliable information, promoting best practices, and offering comprehensive resources for families, practitioners, and communities.

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.