Evidence-Based Practice for Autism in Schools

The Single Best Autism Resource for School-Based Professionals and Clinicians 

AUTISM SPECTRUM DISORDER IN CHILDREN AND ADOLESCENTS:

EVIDENCE-BASED ASSESSMENT AND INTERVENTION IN SCHOOLS

           Edited by Lee A. Wilkinson, PhD

School professionals and clinicians share the challenge of identifying and providing interventions for the increasing number of children with autism spectrum disorder (ASD). Incorporating the many advances made in recent years, this book is an authoritative resource for professionals who need the most current and reliable information on assessing and treating this neurodevelopmental disorder. It includes procedures to help identify children using the new DSM-5 symptom criteria and offers essential guidance for assessing a variety of emotional, behavioral, and academic problems. Comprehensive and timely, the book offers practical, research-based findings that can assist educators and school psychologists in screening and assessing children – and in implementing appropriate intervention strategies. Clearly organized and easy to follow, this new guide is essential reading for anyone working with children who have, or might have ASD.

FEATURES

• Includes procedures to help identify children with ASD using the new DSM-5 diagnostic criteria.
• Offers practitioners an evidence-based assessment battery, which includes tests of cognitive, academic, neuropsychological, and adaptive functioning.
• Employs case vignettes to illustrate best practices in a school setting.
• Concludes with a primer on ASD-related litigation issues and discusses relationships between special education law, provision of services, and placement decisions.

TABLE OF CONTENTS

Part I. Evidenced-Based Assessment of Autism Spectrum Disorder  1. Overview of Autism Spectrum Disorder  2. Multitier Screening and Identification  3. Comprehensive Developmental Assessment Model  4. Cognitive, Neuropsychological, Academic, and Adaptive Functioning  5. Language and Social Communication  6. Co-Occurring Emotional and Behavioral Problems Part II. Evidence-Based Intervention for Autism Spectrum Disorder  7. Evidence-Based Interventions in the Classroom  8. Continuum of Services and the Individual Education Plan Process  9. Curriculum and Program Structure Ÿ 10. Collaboration Between Families and Schools  11. Legal Issues Under IDEA.

2014. 264 PAGES. HARDCOVER

ISBN: 978-4338-1615-4

REVIEWS

“This fantastic resource is a must-read for professionals and students across many disciplines. Contributors provide critical information on a comprehensive range of topics with an emphasis on evidence-based approaches and practical applications.” - Natacha Akshoomoff, PhD, Associate Professor, Department of Psychiatry and Center for Human Development, University of California, San Diego

“Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools" serves as an excellent resource for professionals working with children with ASD in educational settings and covers many fundamental aspects that need to be considered in assessment and intervention practices. Overall, this book thoroughly integrates current research and theory as well as relevant practice in school settings and will allow practitioners to further their conceptual understanding of assessing and treating ASD.” - Canadian Journal of School Psychology

“This concise book provides a comprehensive and very readable introduction to best practices in the assessment and treatment of ASD in school settings. It succinctly informs the professional reader about the theoretical and research foundations underlying its many suggestions for practice, which are further enhanced by the liberal use of vignettes.” – PsycCRITIQUES

 “Wilkinson has put together a book that is quite readable and interesting. Difficult concepts are explained clearly but concisely. The style and quality of writing is consistently good across chapters. A strength of this book is the breadth of coverage. The authors meet the goal of providing professionals with information on ASD, screening, assessment, and interventions for the classroom.” - Journal of Psychoeducational Assessment

The book is represented in college/university libraries worldwide and serves as an ideal text in graduate-level courses on autism, developmental disabilities, special education, clinical and school psychology and early intervention. This highly readable and evidence-based practitioner resource sets the standard for all professionals working with students and families with ASD. 

Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools can ordered from APA Books, Amazon.com, Barnes & Noble, Books-A-Million, Book Depository, and other booksellers. The book is available in both print and eBook formats. Examination and desk copies are also available to college and university faculty.

Lee A. Wilkinson, PhD, CCBT, NCSP is an applied researcher and practitioner. He is a nationally certified and licensed school psychologist, chartered psychologist, registered educational psychologist, and certified cognitive-behavioral therapist. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools(2nd edition).

Emotional Intelligence (EI) and Asperger Syndrome

Emotional intelligence (EI) is broadly defined as the ability to identify, assess, and control the emotions of oneself, of others, and of groups. The interest and research relating to EI has grown dramatically over the past decade. Currently, there are two emotional intelligence constructs: ability EI (or cognitive-emotional ability) and trait EI (or trait emotional self-efficacy). They are differentiated by the type of measurement used in the operationalization process. For example, the ability perspective conceives EI as a form of intelligence best assessed via performance tests and has stronger relationships with cognitive ability hierarchies. Thus, ability EI refers to individual differences in the ability to process and use emotional information to promote effective functioning in everyday life. Trait EI concerns behavioral dispositions and self-perceived abilities and is measured through self-report. Trait EI has stronger relationships with personality and concerns people’s perceptions of their emotional abilities (how good we believe we are in understanding and managing our own and other people’s emotions, rather than how good we actually are). These perceptions are generally stable over time and have a direct influence on mood, behavior, achievement, and action. In other words, trait EI is defined, not as a cognitive ability, but as a collection of personality traits concerning people's perceptions of their emotional abilities. 

Trait EI and ASD  

The defining feature of autism spectrum disorders (ASD) is impairment in interpersonal relating and communication. This includes difficulty communicating with others, processing and integrating information from the environment, establishing and maintaining reciprocal social relationships, taking another person’s perspective, inferring the interests of others, and transitioning to new learning environments. While all individuals with ASD experience core social-communication deficits, we now recognize that autism-related traits are quantitatively distributed in the general population and that autism is best conceptualized as a spectrum disorder, rather than a categorical diagnosis. Even mild degrees of what might be called autistic social impairment can significantly interfere with adaptive behavior. Likewise, a combination of mild autistic symptomatology and other psychological liabilities (e.g., attention problems, mood problems, aggression) can have an adverse effect on social and emotional adjustment. Unfortunately, the core features of ASD may not diminish with development. Typically, individuals do not ‘‘outgrow’’ their deficits. Distress may actually increase as the social milieu becomes more complex and challenging. These difficulties may then persist well into adulthood and lead to comorbid emotional symptoms. Indeed, high stress, anxiety and depression are regularly present in persons with ASD.

ASD involves deficits that are directly relevant to the constellation of emotional self-perceptions encompassed by trait EI. Trait emotional intelligence (trait EI) encompasses many of the aspects of social-emotional functioning that have been shown to be impaired in ASD in the form of self-perceptions. Research has begun to examine the link between higher functioning ASD (e.g., Asperger syndrome) and trait EI. A recent study compared the trait EI profiles of men and women diagnosed with Asperger syndrome (AS) with those of a normative sample, group-matched on age and gender. Participants were thirty adults diagnosed with AS (16 women and 14 men) who volunteered for the study and were subsequently group-matched with 43 typically developing adults (22 women and 21 men). There were no significant differences in the mean age of the participants with and without AS and no significant between-group differences in the distribution of gender. All participants completed the Trait Emotional Intelligence Questionnaire (TEIQue), a self-report inventory specifically designed to comprehensively measure the trait EI construct. The TEIQue consists of 153 items rated on a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree) and includes 15 subscales (facets) organized under four factors (Well-Being, Self-Control, Emotionality, and Sociability) and global trait EI. It has been shown to have satisfactory psychometric properties in various studies. Below is a list of the 15 trait EI facets, along with a brief description of each.  These facets comprise the current sampling domain of trait emotional intelligence in adults and adolescents.   

Facets                                                    High scorers perceive themselves as…

Adaptability                                           flexible and willing to adapt to new conditions.
Assertiveness                                         forthright, frank, & willing to stand up for rights.
Emotion perception (self; others)     clear about their own & other people’s feelings.
Emotion expression                             capable of communicating their feelings to others.
Emotion management (others)         capable of influencing other people’s feelings.
Emotion regulation                              capable of controlling their emotions.
Impulsiveness (low)                             reflective & less likely to give in to their urges.
Relationships                                         capable of having fulfilling personal relationships.
Self-esteem                                             successful & self-confident.
Self-motivation                                      driven & unlikely to give up in the face of adversity.
Social awareness                                   accomplished networkers with excellent social skills.
Stress management                              capable of withstanding pressure & regulating stress.
Trait empathy                                        capable of taking someone else’s perspective.
Trait happiness                                      cheerful & satisfied with their lives.
Trait optimism                                       confident & likely to “look on the bright side” of life.

Findings and Implications  

The researchers hypothesized if individuals with Asperger syndrome have limited understanding their social-communication deficits, then they would score similarly to typical adults on the TEIQue. However, if they have an accurate understanding of these deficits, then they would score significantly lower. The researchers also sought to shed light on the gender discrepancy routinely observed in ASD, particularly in those more able individuals diagnosed with ASD.

The results showed that individuals with AS had significantly lower scores on most TEIQue variables, including the global trait EI score. The Asperger group scored significantly lower on 12 out of the 15 facets of the Trait Emotional Intelligence Questionnaire (TEIQue). They rated themselves particularly low on questions relating to social awareness, emotion management, adaptability, empathy, and emotion perception. The finding appears to be consistent with the clinical presentation of ASD. Differences were much smaller, or non-existent, on questions relating to self-control (especially, impulse control and emotion control). With respect to gender, males scored higher than females, albeit with small effect sizes. Overall, the findings suggest that individuals with Asperger syndrome have insight into the nature of their condition and are aware of the strengths and weaknesses of their personality. These data also suggest that the female phenotype of AS may be associated with greater impairment than the male phenotype.

This research contributes to the evidence documenting the effect of trait EI self-perceptions and dispositions on socio-emotional development and overall psychological well-being. The well-being component of trait EI may be especially relevant in the adjustment process, since positive emotions contribute to the development of those physical, intellectual and social resources necessary to cope successfully with the demands of the social world. There are extensive individual differences in people's perceptions of their emotional abilities. Because trait EI affects behavior, self-referent cognitions and mental health, it is an important variable to consider in the evaluation and treatment of higher functioning individuals with ASD. Although individuals with ASD appear to be aware of their social-communication deficits, further study is needed into the capacity for insight and how it may be utilized in treatment/intervention. Likewise, further study is also needed to examine the relationship of trait EI variables to symptom severity and determine to what extent individual self-perceptions predict outcomes (e.g., life satisfaction, coping strategies, and job performance).  Perceived emotional self-efficacy also plays an important role in emotion management and regulation in education. Consequently, further research on trait EI should include children with ASD. A child version of the TEIQue (TEIQue-Child Form) is available for children aged between 8 and 12 years of age and measures nine distinct facets. An examination of trait EI profiles of children with ASD may assist with identification, intervention, and progress monitoring.

Petrides, K. V., Hudry, C., Michalaria, G., Swami, V., & Sevdalis, N. (2011). Comparison of the trait emotional intelligence profiles of individuals with and without Asperger syndrome. Autism, 15, 671–682. doi 10.1177/1362361310397217

Detailed information about trait EI and the various facets of the TEIQue can be found at http://www.psychometriclab.com 

The online version of this article can be found at http://aut.sagepub.com/content/15/6.toc

Lee A. Wilkinson, PhD is the 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).

Early Intensive Behavioral Intervention Effective for Autism

It is well established that early intervention is a critical determinant in the course and outcome of autism spectrum disorders (ASD). Early intensive behavioral intervention (EIBI) is considered a central feature of intervention programming for children with autism. EIBI programs are among the most and best researched of the psychoeducational interventions. A new comparative effectiveness review prepared for the Agency for Healthcare Research and Quality (AHRQ) finds that there is substantially more evidence for behavior therapy in treating autism than just a few years ago. The report, Therapies for Children With Autism Spectrum Disorder: Behavioral Interventions Update, is based on research conducted by the Vanderbilt Evidence-based Practice Center and brings practitioners up to date about the current state of evidence related to behavioral interventions.

Evidence from the original report published in 2011 and the current update suggests that early behavioral and developmental intervention based on the principles of ABA delivered in an intensive (>15 hours per week) and comprehensive (i.e., addressing numerous areas of functioning) approach can positively affect a subset of children with ASD. Across approaches, children receiving early intensive behavioral and developmental interventions demonstrate improvements in cognitive, language, adaptive, and ASD impairments compared with children receiving low- intensity interventions and diverse non–ABA-based intervention approaches. In sum, the report reflects a growing evidence base suggesting that behavioral interventions are associated with positive outcomes for some children with ASD. “We are finding more solid evidence, based on higher quality studies, that these early intensive behavioral interventions can be effective for young children on the autism spectrum, especially related to their cognitive and language skills,” said Amy Weitlauf of Vanderbilt who led the review. “But the individual response to these treatments often varies from child to child.”

The report also indicates a growing evidence base suggesting that children receiving targeted play-based interventions (e.g., joint attention, imitation, play-based interventions) demonstrate improvements in early social communication skills. Children receiving targeted joint attention packages in combination with other interventions show substantial improvements in joint attention and language skills over time. There is also evidence across a variety of play-based interventions that young children may display short-term improvements in early play, imitation, joint attention, and interaction skills. Cognitive behavioral therapy (CBT) for comorbid conditions such as anxiety had the largest number of high-quality studies in the current review. A strong evidence base now suggests that school-aged children with average to above average cognitive ability and co-occurring anxiety symptoms receiving manualized CBT therapy show substantial improvements in anxiety compared with wait-list controls.

It should be noted that the report is not intended to be a substitute for the application of clinical judgment. 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’s unique needs and abilities are also important. Unfortunately, intervention research cannot predict, at the present time, which particular intervention approach works best with which children. No single approach, intervention strategy, or treatment is effective for all children with ASD, and not all children will receive the same level of benefit. Given the heterogeneity of the expression of ASD across children, a critical area for further research is understanding which children are likely to benefit from particular interventions. To date, studies have failed to adequately describe the characteristics of interventions (or the children receiving them) in a way that helps clarify why certain children show more positive outcomes than others. Substantial scientific advances are needed to enhance our understanding of which interventions are most effective for specific children with ASD and to isolate the elements or components of interventions most associated with effects. Finally, the literature lacks studies that directly compare interventions or utilize combinations of interventions (e.g., comparing medical interventions with behavioral interventions, with educational interventions, or with allied health interventions), despite the fact that most children receive multiple concurrent treatments.

Weitlauf AS, McPheeters ML, Peters B, Sathe N, Travis R, Aiello R, Williamson E, Veenstra-VanderWeele J, Krishnaswami S, Jerome R, Warren Z. Therapies for Children With Autism Spectrum Disorder: Behavioral Interventions Update. Comparative  Effectiveness Review No. 137. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2012-00009-I.) AHRQ Publication No. 14-EHC036-EF. Rockville,  MD: Agency for Healthcare Research and Quality; August 2014.

http://www.effectivehealthcare.ahrq.gov/reports/final.cfm

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. Dr. Wilkinson 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, and author of Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools  (2nd Edition).

Best Practice Review: The Childhood Autism Rating Scale, Second Edition (CARS 2)

The Childhood Autism Rating Scale, second edition (CARS 2), consists of two 15-item rating scales completed by the practitioner and a Parent/Caregiver Questionnaire. The Standard Version Rating Booklet (CARS 2-ST) is equivalent to the original CARS and is used with children younger than 6 years of age and those with communication difficulties or below-average cognitive ability. The High-Functioning Version Rating Booklet (CARS 2-HF) is an alternative for assessing verbally fluent children and youth, 6 years of age and older, with average or above intellectual ability. The Questionnaire for Parents or Caregivers (CARS 2-QPC) is an unscored questionnaire designed to obtain pertinent developmental information from parents or caregivers. 

                                                                                
The CARS 2-ST and CARS 2-HF each include 15 items addressing the following functional areas:

• Relating to People
• Imitation (ST); Social-Emotional Understanding (HF)
• Emotional Response (ST); Emotional Expression and Regulation of Emotions (HF)
• Body Use
• Object Use (ST); Object Use in Play (HF)
• Adaptation to Change (ST); Adaptation to Change/Restricted Interests (HF)
• Visual Response
• Listening Response
• Taste, Smell, and Touch Response and Use
• Fear or Nervousness (ST); Fear or Anxiety (HF)
• Verbal Communication
• Nonverbal Communication
• Activity Level (ST); Thinking/Cognitive Integration Skills (HF)
• Level and Consistency of Intellectual Response
• General Impressions

Items on the Standard form duplicate those on the original CARS, while items on the HF form have been modified to reflect current research on the characteristics of higher functioning children and youth with autism (HFA) or Asperger Syndrome. To complete the ratings on the CARS 2-HF, the professional must have convergent information from MULTIPLE sources such as direct observation, parent and teacher interviews, prior assessments of cognitive functioning and adaptive behavior, and information from the Questionnaire for Parents or Caregivers (CARS 2-QPC). Ratings are based not only on frequency of the behavior in question, but also on its intensity, atypicality, and duration. Rating values for all items are summed to produce a Total Raw Score. Each form includes a graph that allows the practitioner quickly convert the Total Raw Score to a standard score or percentile rank (based on a clinical sample of individuals diagnosed with autism spectrum disorders). 

The psychometric properties of the CARS 2-HF indicate a high degree of internal consistency and good interrater reliability. Validity information reports an overall discrimination index value of .93, with sensitivity and specificity values of .81 and .87, respectively. The HF form also demonstrates a relatively strong relationship with the “gold standard” Autism Diagnostic Observation Schedule (ADOS). Preliminary research findings suggest that a high proportion of individuals who meet the clinical cut-off for autism on both the CARS-2-ST and CARS-2-HF meet the criteria for autism based on both the DSM-IV-TR and DSM-5 (Dawkins, Meyer, & Van Bourgondien, 2014).

The following are critical features of the CARS 2-HF.

1. Parents and teachers should NOT be asked to complete the CARS 2 forms. Only well-informed professionals should complete the ratings.

2. The CARS 2 should NOT be used for screening in the general school-age population.

3. The practitioner must have a good understanding of the criteria for making the ratings and be in a position to collect information from multiple sources (direct observation, parent and teacher reports, prior assessments and clinical impressions).

4. The ratings from the CARS 2 should be considered as only one part of a multimodal, multidisciplinary decision-making process in the identification of children with ASD.

5. Direct observation and a developmental history MUST always be included in the assessment process.

6. Scores on the CARS 2 are interpreted relative to the level (severity) of autism-related behaviors compared to a clinical sample of individuals diagnosed with autism, NOT the typical individual.

In summary, The CARS 2-HF represents an important alternative that will be welcomed by professionals such as school psychologists. It is a sensitive and reliable instrument that will find a place in the school-based professional’s assessment “Tool Box.” Given the dramatic increase in the numbers of students being referred for screening and assessment, the CARS 2-HF is a useful instrument that helps quantify the level of symptom severity and importantly, assist with intervention and program planning. The CARS 2-HF scores are particularly helpful in identifying more capable children on the autism spectrum. Of course, the CARS 2 is not intended to be and should not be used as the sole instrument in making diagnostic or classification decisions. An example of a comprehensive assessment battery can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

References

Schopler, E, Van Bourgondien, M. E., Wellman, G. J., & Love, S. R. (2010). Childhood autism rating scale, second edition. Los Angeles, CA: Western Psychological Services.

Dawkins, T., Meyer, A. T., & Van Bourgondien, M. E. (2014, May). The relationship between the Childhood Autism Rating Scale-Second Edition and clinical diagnosis utilizing the DSM-5 and the DSM-IV. Paper presented at the International Meeting for Autism Research (IMFAR), Atlanta, GA. https://imfar.confex.com/imfar/2014/webprogram/Paper17395.html

Malcolm, K. K. (2014). Test review of Childhood Autism Rating Scale, Second Edition. In J. F. Carlson, K. F. Geisinger, & L. Jonson (Eds.), The nineteenth mental measurements yearbook. Retrieved from http://marketplace.unl.edu/buros/

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