Monday, December 21, 2015

Multi-Tiered Screening for Autism in Schools

A Multi-Tiered Approach to Screening for Autism in Schools

There has been a dramatic worldwide increase in reported cases of autism over the past decade. Yet, compared to population estimates, identification rates have not kept pace in our schools. It is not unusual for children with less severe symptoms of ASD to go unidentified until well after entering school. As a result, it is critical that school-based support personnel (e.g., school psychologists, special educators, school counselors, speech/language pathologists, and social workers) give greater priority to case finding and screening to ensure that children with ASD are identified and have access to the appropriate programs and services. 

 Screening and Identification
Until recently, there were few validated screening measures available to assist school professionals in the identification of students with the core ASD-related behaviors. However, our knowledge base is expanding rapidly and we now have reliable and valid tools to screen and evaluate children more efficiently and with greater accuracy. The following tools have demonstrated utility in screening for ASD in educational settings and can be used to determine which children are likely to require further assessment and/or who might benefit from additional support. All measures have sound psychometric properties, are appropriate for school-age children, and time efficient (10 to 20 minutes to complete). Training needs are minimal and require little or no professional instruction to complete. However, interpretation of results requires familiarity with ASD and experience in administering, scoring, and interpreting psychological tests.
The Autism Spectrum Rating Scales (ASRS; Goldstein & Naglieri, 2009) is a norm-referenced tool designed to effectively identify symptoms, behaviors, and associated features of ASD in children and adolescents from 2 to 18 years of age. The ASRS can be completed by teachers and/or parents and has both long and short forms. The Short form was developed for screening purposes and contains 15 items from the full-length form that have been shown to differentiate children diagnosed with ASD from children in the general population. High scores indicate that many behaviors associated with ASD have been observed and follow-up recommended.
The Social Communication Questionnaire (SCQ; Rutter, Bailey, & Lord, 2003), previously known as the Autism Screening Questionnaire (ASQ), is a parent/caregiver dimensional measure of ASD symptomatology appropriate for children of any chronological age older than four years. It is available in two forms, Lifetime and Current, each with 40 questions. Scores on the questionnaire provide a reasonable index of symptom severity in the reciprocal social interaction, communication, and restricted/repetitive behavior domains and indicate the likelihood that a child has an ASD. The lifetime version is recommended for screening purposes as it demonstrates the highest sensitivity value. 
The Social Responsiveness Scale, Second Edition (SRS-2; Constantino & Gruber, 2012) is a brief quantitative measure of autistic behaviors in 4 to 18 year old children and youth. This 65-item rating scale was designed to be completed by an adult (teacher and/or parent) who is familiar with the child’s current behavior and developmental history. The SRS items measure the ASD symptoms in the domains of social awareness, social information processing, reciprocal social communication, social anxiety/avoidance, and stereotypic behavior/restricted interests. The scale provides a Total Score that reflects the level of severity across the entire autism spectrum.
A Multi-Tier Screening Strategy
The ASRS, SCQ, and SRS-2 can be used confidently as efficient first-level screening tools for identifying the presence of the more broadly defined and subtle symptoms of higher-functioning ASD in school settings. School-based professionals should consider the following multi-step strategy for identifying at-risk students who are in need of an in-depth assessment.
Tier  one. The initial step is case finding. This involves the ability to recognize the risk factors and/or warning signs of ASD. All school professionals should be engaged in case finding and be alert to those students who display atypical social and/or communication behaviors that might be associated with ASD. Parent and/or teacher reports of social impairment combined with communication and behavioral concerns constitute a “red flag” and indicate the need for screening. Students who are identified with risk factors during the case finding phase should be referred for formal screening.
Tier two. Scores on the ASRS, SCQ, and SRS-2 may be used as an indication of the approximate severity of ASD symptomatology for students who present with elevated developmental risk factors and/or warning signs of ASD. Screening results are shared with parents and school-based teams with a focus on intervention planning and ongoing observation. Scores can also be used for progress monitoring and to measure change over time. Students with a positive screen who continue to show minimal progress at this level are then considered for a more comprehensive assessment and intensive interventions as part of Tier 3.  However, as with all screening tools, there will be some false negatives (children with ASD who are not identified). Thus, children who screen negative, but who have a high level of risk and/or where parent and/or teacher concerns indicate developmental variations and behaviors consistent with an autism-related disorder should continue to be monitored, regardless of screening results.
Tier three. Students who meet the threshold criteria in step two may then referred for an in-depth assessment. Because the ASRS, SCQ, and SRS-2 are strongly related to well-established and researched gold standard measures and report high levels of sensitivity (ability to correctly identify cases in a population), the results from these screening measures can be used in combination with a comprehensive developmental assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, and cognitive functioning to aid in determining eligibility for special education services and as a guide to intervention planning.
Limitations

Although the ASRS, SCQ, and SRS can be used confidently as efficient screening tools for identifying children across the broad autism spectrum, they are not without limitations. Some students who screen positive will not be identified with an ASD (false positive). On the other hand, some children who were not initially identified will go on to meet the diagnostic and/or classification criteria (false negative). Therefore, it is especially important to carefully monitor those students who screen negative to ensure access to intervention services if needed. Gathering information from family and school resources during screening will also facilitate identification of possible cases. Autism specific tools are not currently recommended for the universal screening of typical school-age children. Focusing on referred children with identified risk-factors and/or developmental delays will increase predictive values and result in more efficient identification efforts.

Concluding Comments
Compared with general population estimates, children with mild autistic traits appear to be an underidentified and underserved population in our schools. There are likely a substantial number of children with equivalent profiles to those with a clinical diagnosis of ASD who are not receiving services. Research indicates that outcomes for children on the autism spectrum can be significantly enhanced with the delivery of intensive intervention services. However, intervention services can only be implemented if students are identified. Screening is the initial step in this process. School professionals should be prepared to recognize the presence of risk factors and/or early warning signs of ASD, engage in case finding, and be familiar with screening tools in order to ensure children with ASD are being identified and provided with the appropriate programs and services. 

Best practice screening and assessment guidelines are available from: Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd ed.). 


Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

Friday, December 18, 2015

Adults with Autism Face Many Health Problems

A study found that adults with autism are at higher risk for a number of health problems, ranging from diabetes and obesity to heart failure. In a review of insurance records for more than 23,000 adults, researchers found that medical and psychiatric issues are much more prevalent in those with autism as compared to individuals without the neurodevelopmental disorder. Nearly all medical conditions were significantly more common in adults with autism than controls, including diabetes, gastrointestinal (GI) disorders, epilepsy, sleep disorders, dyslipidemia, hypertension and obesity, researchers reported in a summary of their findings presented at the International Meeting for Autism Research.
Eating disorders, mechanical falls, vision and hearing impairments, osteoporosis and chronic heart failure were significantly more common among adults with autism than controls. Depression and anxiety were more than twice as common for those on the spectrum while bipolar disorder was eight times as likely. There was also 12-fold increase in the risk of epilepsy for this group. Nearly a third of those with autism in the study had obesity or hypertension, conditions that affected less than 20 percent of those without the neurodevelopmental disorder. Cancer rates, however, were similar for those with and without autism.
Although it’s well-known that children with autism face more medical and psychiatric diagnoses than their peers, this is the first large study to examine how common these issues are in adults. Researchers suggest that one reason for the high prevalence of health problems among adults with autism could be that the social and communication difficulties as well as the sensory sensitivities common among this population may lead to reduced preventive care. They conclude that physicians need better training on how to treat individuals on the spectrum throughout the life span and improvements needed in the transition from pediatric to adult medical care systems.

Sunday, November 1, 2015

Inclusive Education for Students with Autism


Inclusive Education for Students with Autism

The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) (P.L. 108-446) (http://idea.ed.gov/) 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 considered to be the best placement option for students with disabilities. It should also be noted that while the least restrictive environment (LRE) provision of IDEA requires that efforts be made to educate students with special needs in less restrictive settings, IDEA also recognizes that some students may require a more comprehensive program and intensive level of service.

Child characteristics such as severity of autism symptoms are thought to determine educational placement. However, where a child lives may significantly impact whether they are placed in an inclusive or segregated classroom, a national analysis suggests. The study published online in the journal Focus on Autism and Other Developmental Disabilities examined external factors, including state of residence and state funding formulas, to determine their potential influence on placement outcomes. On average, about 37 percent of students on the autism spectrum spent at least 80 percent of their school day in inclusive environments. But the numbers varied considerably from one state to the next, ranging from just 8 percent in Washington, D.C. to 62 percent in Iowa. 

There was considerable variation among states in placing students with autism spectrum disorder (ASD) in inclusive, mainstreaming, self-contained, and separate schools. Specifically, states varied substantially in the percentage of students with ASD educated in each setting, with some states consistently favoring inclusion (Colorado, Connecticut, Idaho, Iowa, Minnesota, Nebraska, North Dakota, West Virginia, and Wisconsin). Other states, however, generally leaned toward more restrictive settings (Alaska, Delaware, Florida, Hawaii, Louisiana, New Hampshire, New Jersey, New York, South Carolina, and Washington, D.C.). States in the Eastern United States tended to have more restrictive placement rates than states in the Western United States. State special education funding was found to have a minimal impact on placement outcomes.
These findings suggest that factors that are external to child characteristics (e.g., severity of ASD symptoms) influence educational placement decisions for students with ASD. “If child-specific factors were solely responsible for education placement decisions, one would expect states to have similar rates of inclusive, self-contained, mainstreaming and separate school placements for students with ASDs,” the author commented. “Instead, … results indicate that educational placement varies by state.” 

Overall, it is unlikely that child characteristics alone determine placement outcomes. Although School districts should make every effort to place students in integrated settings to maximize interaction with typical peers, analysis of the public data presented in this study suggests that many states are still falling short of including students with ASD in general education settings for significant portions of the day. Inclusion with typically developing students is important for a child with ASD as peers provide the best models for language and social skills. However, inclusive education alone is insufficient, evidence-based intervention and training is also necessary to address specific skill deficits. The argument must shift from should we include students with ASD in general education to understanding how to include students with ASD successfully in inclusive settings. It is critical to identify how practices that benefit students with ASD, including structure (visual, communication, and social supports), positive behavior supports, and systematic instruction, can be implemented effectively in general education settings. 
Jennifer A. Kurth,  Educational Placement of Students With Autism: The Impact of State of Residence, Focus on Autism and Other Developmental Disabilities, first published on September 3, 2014 doi:10.1177/1088357614547891.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Saturday, October 31, 2015

Group Pivotal Response Treatment for Parents of Children with Autism

Group Pivotal Response Treatment for Parents

More children than ever before are being diagnosed with autism spectrum disorder (ASD). The dramatic increase in the prevalence of children with ASD has created an urgent need for effective and efficient service delivery models. Parents and caregivers everywhere are eager for credible, research-based information on the most effective treatments for ASD. 

Utilizing a group training format, researchers have found that parents can learn to successfully incorporate an established treatment for ASD into everyday interactions with their children. According to findings published in the Journal of Child Psychology and Psychiatry, parents learned to successfully apply an evidence-based therapy method called Pivotal Response Treatment (PRT), also referred to as Pivotal Response Training, and observed meaningful improvement in their children.

PRT is one of the best studied and validated behavioral treatments for autism. It is a naturalistic behavioral intervention derived from the principles of Applied Behavior Analysis (ABA). PRT builds on learner initiative and interests, and is particularly effective for developing communication, language, play, and social behaviors. PRT was developed to create a more efficient and effective intervention by enhancing four pivotal learning variables: motivation, responding to multiple cues, self-management, and self-initiations. According to theory, these skills are pivotal because they are the foundational skills upon which learners with ASD can make widespread and generalized improvements in many other areas.

The objective of the study was to evaluate a PRT parent training group (PRTG) for targeting language deficits in young children with ASD. For the study, researchers randomly assigned parents of 53 children with autism to participate in 12 weeks of classes on PRT or a psychoeducation group (PEG). All of the children were between the ages of 2 and 6 and had language delays. The PRTG taught parents behavioral techniques to facilitate language development. The PEG taught general information about ASD. All of the children were assessed at the outset of the study, at six weeks and at 12 weeks to determine their language abilities. Parents were also videotaped at six and 12 weeks to measure how well they were applying the treatment.

The results indicated that parents were able to learn PRT in a group format, as the majority of parents in the PRTG (84%) were using it correctly by the end of the study. Children also demonstrated improvement in adaptive communication skills. Children whose parents learned the technique reported greater gains in both the number of words used and how they used them as compared to children in the psychoeducation (control) group.

This study is considered the first randomized controlled test of group-delivered PRT and one of the largest experimental investigations of the PRT model to date. The findings suggest that specific instruction in PRT results in greater skill acquisition for both parents and children, especially in functional and adaptive communication skills. Even with the improvements, researchers said that parent-implemented approaches are intended to augment, not replace, autism therapies from professionals. Likewise, further research in PRT is warranted to replicate the observed results and address other core ASD symptoms. It should also be noted 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.

Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., Frazier, T. W. and Minjarez, M. B. (2014), A randomized controlled trial of Pivotal Response Treatment Group for parents of children with autism. Journal of Child Psychology and Psychiatry. doi: 10.1111/jcpp.12354

Tuesday, October 27, 2015

Sibling Study Reveals Early Signs of Autism


Younger siblings of children with autism spectrum disorder (ASD) are at high risk for developing ASD as well as features of the broader autism phenotype. About 20% of younger siblings of children with Autism Spectrum Disorder (ASD) will develop the condition by age 3. A study by Yale School of Medicine researchers has found that 57% of these younger siblings who later develop the condition already showed warning signs like poor eye contact and repetitive behaviors at just a year and a half old. Published in the Journal of the American Academy of Child & Adolescent Psychiatry, this is the first large-scale, multi-site study aimed at identifying specific social-communicative behaviors that distinguish infants with ASD from their typically and atypically developing high-risk peers as early as 18 months of age. For the study, researchers looked at data on 719 infants who had older siblings on the spectrum. The children were assessed at 18 months and again at 36 months to identify social, communication and repetitive behaviors that could be predictive of autism.

Three distinct combinations of features at 18 months were predictive of ASD outcome: 1) poor eye contact combined with lack of communicative gestures and giving; 2) poor eye contact combined with a lack of imaginative play; and 3) lack of giving and presence of repetitive behaviors, but with intact eye contact. These 18-month behavioral profiles predicted ASD versus non-ASD status at 36 months with 82.7% accuracy in an initial test sample and 77.3% accuracy in a validation sample. Clinical features at age 3 among children with ASD varied as a function of their 18-month symptom profiles. Children with ASD who were misclassified at 18 months were higher functioning, and their autism symptoms increased between 18 and 36 months.

"While the majority of siblings of children with ASD will not develop the condition themselves, for those who do, one of the key priorities is finding more effective ways of identifying and treating them as early as possible," said lead author Katarzyna Chawarska, associate professor in the Yale Child Study Center and the Department of Pediatrics at Yale School of Medicine. "Our study reinforces the need for repeated diagnostic screening in the first three years of life to identify individual cases of ASD as soon as behavioral symptoms are apparent." Early detection, especially when toddlers have siblings with autism, is critical. Chawarska added, "Linking these developmental dynamics with underlying neurobiology may advance our understanding of causes of ASD and further efforts to personalize treatment for ASD by tailoring it to specific clinical profiles and their developmental dynamics."

Other authors of the study included: Suzanne Macari, Frederick Shic, Daniel J. Campbell, Jessica Brian, Rebecca Landa, Ted Hutman, Charles A. Nelson, Sally Ozonoff, Helen Tager-Flusberg, Gregory S. Young, Lonnie Zwaigenbaum, Ira L. Cohen, Tony Charman, Daniel S. Messinger, Ami Klin, Scott Johnson, and Susan Bryson.

“18-Month Predictors of Later Outcomes in Younger Siblings of Children With Autism Spectrum Disorder: A Baby Siblings Research Consortium Study.” Published online 06 October 2014. Journal of the American Academy of Child & Adolescent Psychiatry.

Citation: JACC doi: 10.1016/j.jaac.2014.09.015


Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Wednesday, October 21, 2015

Identification of Latino Children At-Risk for Autism



It is well established that early intervention is a critical determinant in the course and outcome of autism spectrum disorder (ASD). The earlier the child is identified and intensive intervention can begin, the better the outcomes tend to be for children with ASD. In fact, numerous studies have described the benefits of early identification and intervention for children with developmental disabilities and, particularly, for children on the autistic spectrum. However, many children meeting ASD diagnostic criteria may be missed or diagnosed years after onset of symptoms. Moreover, studies have shown racial and ethnic differences in ASD diagnostic trends. For example, there is evidence to suggest that Latino children are diagnosed with ASD 2.5 years later than white children and have more severe symptoms at time of diagnosis.
The reasons for low rates of ASD diagnosis and diagnostic delay among Latino children are poorly understood. Delays may reflect family factors, including ethnic differences in parent knowledge, beliefs, and concerns about overall child development and developmental delay. A study published in the journal Pediatrics sought to examine why Latino children are diagnosed with ASD less often and later than white children. Researchers mailed a self-administered survey to a random sample of California pediatricians to assess rates of bilingual general developmental and ASD screening, perceptions of parent ASD knowledge in Latino and white families, reports of difficulty assessing for ASD in Latino and white children, and perceptions of barriers to early ASD identification for Latinos.
The results indicated that although 81% of respondents offered some form of developmental screening, 29% of pediatricians offered Spanish ASD screening per American Academy of Pediatrics guidelines, and only 10% offered both Spanish general developmental and Spanish ASD screening per American Academy of Pediatrics guidelines. Most practitioners thought that Latino (English and Spanish primary family language) parents were less knowledgeable about ASD than other parents. They also had more difficulty assessing ASD risk for Latino children with Spanish primary family language than for white children. The most frequent barrier to ASD identification in Latinos was access to developmental specialists.
These findings have important practice and policy implications. For example, rates of Spanish language developmental and ASD screening need targeted improvement. Developing and promoting free or low-cost screening resources could improve early identification and reduce language-based disparities. Pediatricians may also need information about bilingualism and language development, accurate interpretation of screening results in Latino children, and strategies for discussing this difficult topic with parents from a different culture.  In sum, promoting language appropriate screening, disseminating culturally appropriate ASD materials to Latino families, improving the specialist workforce, and providing practitioner support in screening and referral of Latino children may be important ways to reduce racial and ethnic differences in care.
Pediatrician Identification of Latino Children at Risk for Autism Spectrum Disorder Katharine E. Zuckerman, Kimber Mattox, Karen Donelan, Oyundari Batbayar, Anita Baghaee and Christina Bethell. Pediatrics; originally published online August 19, 2013 DOI: 10.1542/peds.2013-0383

Lee A. Wilkinson, PhD, 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 best-selling text 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 book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Thursday, October 1, 2015

Group Cognitive Behavioral Therapy (CBT) for Adults on the Autism Spectrum

The dramatic increase in the prevalence of autism spectrum conditions among children and adolescents and the correspondingly large number of youth transitioning into adulthood has created an urgent need to address the problems faced by many adults on the autism spectrum. Unfortunately, there are few validated treatment options are available for adults with autism spectrum disorder (ASD). Much of the published literature is clinical or anecdotal, or purely based on theory. There is unquestionably a need for the development of treatment options for adults with ASD. At present, alternative treatment options to psycho-therapeutical interventions are social training programs and other group activities. Group settings enable social interaction and sharing experiences with others, thereby reducing social isolation. 

A study published in the peer reviewed journal Autism assessed the effectiveness of two group interventions for adults with ASD: cognitive behavioral therapy (CBT) and recreational activity. A total of 68 adults with ASD participated in the study and were stratified by gender and blindly randomized to one of the two treatment conditions. Both interventions comprised 36 weekly 3-hour sessions led by two therapists in groups of 6–8 participants. The CBT group intervention was adapted to suit adults with ASD and consisted of five elements: (a) structure, (b) group setting, (c) psycho-education (e.g. lectures and discussions on ASD and psychiatric symptoms, including learning to identify and reappraise maladaptive thoughts), (d) social training (e.g. skill building such as practicing phone calls and asking for help) and (e) cognitive behavioral techniques (e.g. setting goals, role-playing, exposure exercises and conducting behavior analysis). A manual describing the 36 individual sessions was created prior to starting the treatment. Each session followed a strict agenda: (a) introduction and presentation of the agenda of the day, (b) review of homework assignments from the previous session, (c) psycho-educative lecture and discussions on the session topic, (d) coffee break with buns or sandwiches and social interaction, (e) relaxation or mindfulness exercise, (f) discussions and exercises on the session topic, (g) distribution of homework and (h) evaluation and end of session.
The purpose of the recreational activity intervention was to facilitate social interaction and to break social isolation. The therapists did not provide any deliberate techniques, such as psycho-education, social training, or CBT. Rather, this intervention relied on structure and group setting only. During the first session, participants were asked to write down group activities they would like to engage in. The therapists created a list of the suggested activities, such as visiting museums, playing board games, cooking, restaurant visits, boating, cinema, and taking walks. Each week, participants voted for the next session’s activity.
The researchers hypothesized that both interventions would lead to improvement in primary measures of quality of life, sense of coherence, and self-esteem, as well as in the exploratory analysis of the secondary measures of psychiatric symptoms. A greater effect in the CBT intervention compared to recreational activity was also expected, due to participants in the CBT intervention receiving a wider range of psychotherapeutic techniques. Several self-report questionnaire measures were administered to the adults before and after the interventions: Quality of Life Inventory (health, relationships, employment, and living conditions), Sense of Coherence (manageability and meaningfulness in life), Rosenberg Self Esteem Scale and an exploratory analysis on measures of psychiatric health (e.g., anxiety and depression). A long-term follow-up was conducted which ranged from 8 to 57 months after treatment termination.
Participants in both treatment conditions reported an increased quality of life at post-treatment, with no significant difference between the group CBT and group recreational activity interventions. Comorbid psychiatric symptoms, sense of coherence, and self-esteem were not affected by either intervention. CBT resulted in less attrition (drop out) than recreational activity. Participants who received CBT also rated themselves as more improved at post-treatment. At follow-up, CBT participants reported better well-being, greater understanding of their own difficulties and improved ability to express needs, compared to participants in the recreational activity intervention. This may reflect the recreation activity intervention’s focus on the intervention elements of structure and group setting, while the CBT intervention also included the elements of psycho-education, social training and CBT techniques. As a result, participants in CBT may have developed greater understanding of their own difficulties and improved ability to express needs and receive support because the objective of psycho-education and social training is to enhance these capabilities. The difference in well-being scores at follow-up may also represent greater insight gained from CBT rather than recreational activity.
Both interventions appear to be promising treatment options for adults with ASD, as they appeared to improve the participants’ quality of life. The similar efficacy of the interventions may be due to the common elements of structure and group setting. The group setting of both interventions enabled social interaction and sharing experiences. This may have promoted participants’ self-acceptance by allowing them to gain insight into both the impairments and the strengths that characterize ASD, and to recognize that others share similar challenges. CBT may be additionally beneficial in terms of increasing specific skills, greater understanding and insight, and minimizing dropout. Future studies on treatment of comorbid psychiatric symptoms in ASD should include larger samples to differentiate between adults with specific psychiatric problems in order to more effectively assess treatment effects.
Hesselmark, E., Plenty, S., & Bejerot, S. (2014). Group cognitive behavioural therapy and group recreational activity for adults with autism spectrum disorders: A preliminary randomized controlled trial. Autism, 18(6) 672–683. doi: 10.1177/1362361313493681

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

Wednesday, August 19, 2015

Autism and the Transition to Adulthood

Autism and the Transition to Adulthood

Young adults with autism are facing significant challenges as they transition to adulthood, a national report suggests, with many on the spectrum finding themselves unemployed, isolated, and lacking services. The "National Autism Indicators Report: Transition into Young Adulthood" from Drexel University’s A.J. Drexel Autism Institute is a comprehensive report (available free online) that presents new findings about a wide range of experiences and outcomes of youth on the autism spectrum between high school and their early 20s. The report is a collection of indicators that focuses national attention on outcomes which are almost universally lower for those on the autism spectrum compared to their peers with other types of disabilities and serves as a call to action to fill the remaining large gaps in knowledge. Key findings include:
  • Over one-third (37 percent) of young adults were disconnected during their early 20s, meaning they never got a job or continued education after high school. In comparison, less than eight percent of young adults with other types of disabilities were disconnected.
  • Approximately 26 percent of young adults and 28 percent of those unemployed and not in school received no services which could help them with employment, continue their education, or live more independently.
  • Just 58 percent of young adults worked for pay outside the home between high school and their early 20s, a rate far lower than young adults with other types of disabilities. Those with jobs generally worked part-time for relatively low wages.
  • Approximately one in four young adults were socially isolated, meaning they never saw or talked with friends and were never invited to social activities within the past year.
  • Only about one in five ended up living independently (without parental supervision) in the period between high school and their early 20s.
  • Sixty percent of youth had at least two health or mental health conditions in addition to autism spectrum disorder. Over half of youth had co-occurring ADD/ADHD and anxiety issues in adolescence. Three-quarters of youth took at least one kind of medication on a regular basis for any health or mental health issue.
  • Nearly 50% of youth experienced threats and bullying during high school. Over one-quarter (27 percent) of adolescents engaged in some type of wandering behavior in which they impulsively left a supervised situation, increasing their risk of becoming lost and going missing.
  • Transition Planning, a key process for helping youth build skills and access services as they enter adulthood, was frequently delayed. Just 58 percent of youth had a transition plan by the federally required age.

The creation of effective and affordable programming tailored to meet the needs of the 50,000 individuals with autism who leave high school each year - each with unique strengths, interests, and challenges - is an urgent task facing our society. It is clear that we are not succeeding as a nation in helping autistic adults to thrive to the best of their abilities and attain a high quality of life. It is time for new approaches.
“This is the most comprehensive report to date describing what we know about young adults with autism as a whole and across the various parts of their lives. Yet, it represents only a fraction of what we need to know. Huge gaps remain,” said Anne M. Roux, MPH, research scientist at the A.J. Drexel Autism Institute in the Life Course Outcomes Research Program and lead author of the report. Although these indicators don’t tell us why outcomes are worse for those with autism compared to youth with other disabilities, this report is an important first step toward addressing the gaps in what we know, as we work to build an evidence base about how to help achieve better outcomes.
The link to the report download page is http://drexe.lu/autismindicators.
Roux, Anne M., Shattuck, Paul T., Rast, Jessica E., Rava, Julianna A., and Anderson, Kristy, A. National Autism Indicators Report: Transition into Young Adulthood. Philadelphia, PA: Life Course Outcomes Research Program, A.J. Drexel Autism Institute, Drexel University, 2015.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

Tuesday, August 11, 2015

Autism and Improvisational Music Therapy



Autism and Music Therapy

Music therapy has become an integral part of many programs for children with autism. The broad category of music therapy is generally described as interventions that seek to teach individual skills or goals through music. Music therapists use their training as musicians, clinicians, and researchers to effect changes in cognitive, physical, communication, social, and emotional skills.  According to the National Autistic Society, “Music therapy aims to encourage increased self-awareness/self-other awareness, leading to more overt social interactions. The therapy stimulates and develops the communicative use of voice and pre-verbal dialogue with another, establishing meaning and relationship to underpin language development. The client may also benefit from increased tolerance of sound, tolerance of and capacity for two-way communication.” 
Research Autism reports strong positive evidence from peer-reviewed journals that support the effectiveness of music therapy for individuals with autism spectrum disorders (ASD). Based on the literature to date, music therapy has shown good effects in influencing joint attention, social interaction, verbal and gestural communication and behavior. It is considered to be a useful intervention, particularly with young children, and where language acquisition is either delayed or disordered to a severe degree. Currently, music therapy is identified as an emerging intervention by the National Autism Center (2015) and incorporates many of the identified ASD-specific evidence-based practices.Supporters of music therapy emphasize that it can be used to develop social engagement, joint attention, communication abilities, while also addressing emotional needs and quality of life.
A study published in the journal Autism provides further support for the effectiveness of music therapy with ASD. This study investigated the social-motivational aspects of musical interaction between the child and the therapist in improvisational music therapy by measuring emotional, motivational and interpersonal responsiveness in children with autism during joint engagement episodes. Improvisational music therapy is an individualized intervention that facilitates moment-by-moment motivational and interpersonal responses in children with autism. Compared with other therapeutic interventions utilizing music as a background or contingent stimulus, improvisational music therapy involves the interactive use of live music for engaging clients to meet their therapeutic needs. It is gaining growing recognition as an effective intervention addressing fundamental levels of spontaneous self-expression, emotional communication and social engagement for individuals with a wide range of developmental disorders.
Design
This randomized controlled exploratory study employed a single subject comparison design in two different conditions (improvisational music therapy versus toy play sessions) and two different parts of a session (an undirected/child-led part versus a more directed/therapist-led part) in each condition. The objective was to compare the effects of these two different media (music versus toys) and to determine how children respond in a musical context with or without direction, compared with a non-musical context such as play activities with toys with or without direction.
Participants and Procedure
Participants were children aged between 3 and 5 who were not previously treated with either music therapy or play therapy. A total of ten children (all male) completed the clinical trials. Five children were non-verbal while the other five were verbal with varying degrees of language skills. Eight children were in preschool special education, and two were in mainstream preschool programs that included additional therapeutic supports, such as speech language therapy. The children were randomly assigned either to have the music therapy sessions first and the toy play sessions later (group 1), or vice versa (group 2). In order to differentiate the media used in these two conditions, the therapists in music therapy were instructed to interact with the child mainly through music, whereas the therapists in the toy play condition were instructed to engage the child by any means, but to avoid any musical media, such as singing or rhythmic playing.
Observed behaviors were recorded in terms of both their frequency and their duration for two broad categories. The first category concerned the participant’s emotional and motivational responsiveness (joy, emotional synchronicity, initiation of engagement) towards different types of attunement promoted by the therapist in these two conditions. The second category concerned two different types of responsiveness towards the therapist’s initiation of interaction (social invitation and interpersonal demands). Joy referred to an event when the child either smiled (facial expression duration only), or laughed (facial expression with vocal sound) during the interaction with the therapist. Emotional synchronicity referred to an event when the child and the therapist shared a moment of emotional affect duration (happiness or sadness) while engaged with each other. Initiation of engagement referred to an event where the child spontaneously initiated interaction with the therapist, or initiated a change during ongoing interaction, and then expected the therapist to follow.
Results and Discussion
Improvisational music therapy produced markedly more and longer events of joy, emotional synchronicity and initiation of engagement behaviors in the children than toy play sessions. In response to the therapist’s interpersonal demands, ‘compliant (positive) responses’ were observed more in music therapy than in toy play sessions, and ‘no responses’ were twice as frequent in toy play sessions as in music therapy. In the music therapy condition, there were more joy, emotional synchronicity and initiation of engagement events in the undirected part than the directed part, suggesting that children were happier, more able to express their happy emotions and more able to share their affects with the therapist when leading. These results suggest that musical attunement enhances musical-emotional communication together with joy and emotional synchronicity, which results in children’s spontaneous willingness to respond, initiate and engage further.
According to the authors, “The temporal structure of music and the specific use of musical attunement in improvisational music therapy suggests that we can help children with autism experience and develop affective skills in a social context.”  Creating music relates to the child’s expression, interest and focus of attention may evoke responses from the child to a therapist creating such relational music for them. Moreover, improvising music together is an emotionally engaging process. Music can be an attractive medium, allowing the child his/her own space and the choice of objects, at the same time engaging the child with different objects of the therapist’s choice.
Of course, this “exploratory” study has limitations.  For example, the small sample makes any generalizable conclusion premature. The test power is low and should be considered when interpreting the results. Likewise, the small sample limits the relevance of subgroup analyses (language, age, severity) as well as therapists’ effects which would be helpful to understanding how children with different developmental needs respond to this type of intervention different therapists.
Conclusion
In conclusion, the results of this exploratory study found significant evidence supporting the value of music therapy in promoting social, emotional and motivational development in children with autism. The findings highlight the importance of social-motivational aspects of musical interaction between the child and the therapist, the therapeutic potential of such aspects in improvisational music therapy, and the relative value of less directed and more child centered approaches for children with autism. The authors conclude, “Both previous and the current study indicate that we should use music within the child’s focus of attention, behavioral cue and interests, whether it is improvised or precomposed. A future study should perhaps look at the differential effect on response of improvised and precomposed music with young children with autism.”
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

Monday, August 10, 2015

Asperger Syndrome Revisited


Asperger Syndrome Revisited

The removal of Asperger’s disorder (Asperger syndrome) as a separate diagnostic category from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been widely publicized. The new DSM-5 category of autism spectrum disorder (ASD), which subsumes the previous DSM-IV diagnoses of autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorderand pervasive developmental disorder not otherwise specified (PDD-NOS), reflects the scientific consensus that symptoms of the various DSM-IV subgroups represent a single continuum of impairment that varies in level of severity and need for support.
An important feature of the DSM-5 criteria for ASD is a change from three symptom domains (triad) of social impairment, communication deficits and repetitive/restricted behaviors, interests, or activities to two domains (dyad); social/communication deficits and fixated and repetitive pattern of behaviors. Several social/communication criteria were merged to clarify diagnostic requirements and reflect research indicating that language deficits are neither universal in ASD, nor should they be considered as a defining feature of the diagnosis. The criteria also feature dimensions of severity that include current levels of language and intellectual functioning as well as greater flexibility in the criteria for age of onset and addition of symptoms not previously included in the DSM-IV such as sensory interests and aversions.
DSM-IV Criteria in Practice
Problems in applying the DSM-IV criteria were a key consideration in the decision to delete Asperger’s disorder as a separate diagnostic entity. Numerous studies indicate that it is difficult to reliably distinguish between Asperger syndrome, autism, and other disorders on the spectrum in clinical practice (Attwood, 2006; Macintosh & Dissanayake, 2006; Leekam, Libby, Wing, Gould & Gillberg, 2000; Mayes & Calhoun, 2003; Mayes, Calhoun, & Crites, 2001; Miller & Ozonoff, 2000; Ozonoff, Dawson, & McPartland, 2002; Witwer & Lecavalier, 2008). For example, children with autism who develop proficient language have very similar trajectories and later outcomes as children with Asperger disorder (Bennett et al., 2008; Howlin, 2003; Szatmari et al., 2000) and the two are indistinguishable by school-age (Macintosh & Dissanayake, 2004), adolescence (Eisenmajer, Prior, Leekam, Wing, Ong, Gould & Welham 1998; Ozonoff, South and Miller 2000) and adulthood (Howlin, 2003). Individuals with Asperger disorder also typically meet the DSM-IV communication criterion of autism, “marked impairment in the ability to initiate or sustain a conversation with others,” making it is possible for someone who meets the criteria for Asperger’s disorder to also meet the criteria for autistic disorder.
Treatment and Outcome
Another important consideration was response to treatment. Intervention research cannot predict, at the present time, which particular intervention approach works best with which individual. Likewise, data is not available on the differential responsiveness of children with Asperger’s disorder and high-functioning autism to specific interventions (Carpenter, Soorya, & Halpern, 2009). There are no empirical studies demonstrating the need for different treatments or different responses to the same treatment, and in clinical practice the same interventions are typically offered for both autism and Asperger’s disorder (Wilkinson, 2010). Treatments for impairments in pragmatic (social) language and social skills are the same for both groups.
Application of DSM-5 Criteria
It’s important to remember that in the DSM, a mental disorder is conceptualized as a clinically important collection of behavioral and psychological symptoms that causes an individual distress, disability or impairment. The objective of the DSM-5 criteria for ASD is that every individual who has significant “impairment” in social interaction and communication, and restricted and repetitive behavior or interests should meet the diagnostic criteria for ASD. Because language impairment/delay is not a necessary criterion for diagnosis, 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, now meet the criteria for ASD. Specifiers are used to indicate level of severity and "without accompanying intellectual impairment and language impairment."
The DSM-5 criteria for ASD have created significant controversy over concerns that it would exclude many individuals currently diagnosed with Asperger syndrome and PDD-NOS, and thus make it difficult for them to access services. However, recently published field trials suggest that the revisions actually 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.” 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 (ADHD), and anxiety disorders. 

It is important to note that all individuals who have a DSM-IV diagnosis on the autism spectrum, including those with Asperger syndrome and PDD-NOS, will be able to retain an ASD diagnosis. This means that no one should “lose” their diagnosis because of the changes in diagnostic criteria.  According to DSM-5, individuals with a well-established DSM-IV diagnosis of Autistic Disorder, Asperger’s Disorder, or PDD-NOS should be given a diagnosis of ASD.  Those who have marked deficits in social communication, but whose symptoms do not meet the criteria for ASD, should be evaluated for Social (Pragmatic) Communication Disorder.
Conclusion
In conclusion, the DSM-5 category of autism spectrum disorder (ASD), which subsumes the current diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS), better describes our current understanding about the clinical presentation and course of the neurodevelopmental disorders. Conceptualizing autism as a spectrum condition rather than a categorical diagnostic entity is in keeping with the extant research suggesting that there is no clear evidence that Asperger’s disorder and high-functioning autism are different disorders. As Gillberg (2001) notes, the terms Asperger's syndrome and high-functioning autism are more likely “synonyms” than labels for different disorders. Lord (2011) also comments that although there has been much controversy about whether there should be separate diagnoses, "Most of the research has suggested that Asperger's 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." Unfortunately, many individuals may have been advised (or assumed) that a diagnosis of Asperger’s disorder was separate and distinct from autism and that intervention/treatment, course, and outcome were clinically different for each disorder. While including Asperger’s Disorder under the DSM-5 category of ASD will likely continue to require a period of transition and adjustment, this dimensional approach to diagnosis will likely result in more effective identification, treatment, and research for individuals on the spectrum.
Key References & Further Reading
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 (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Attwood, T. (2006). The complete guide to Asperger’s syndrome. London: Jessica Kingsley.
Carpenter, L. A., Soorya, L. & Halpern, D. (2009). Asperger’s syndrome and high- functioning autism. Pediatric Annals, 38, 30-35.
Eisenmajer, R., Prior, M., Leekam, S., Wing, L., Ong, B., Gould, J. & Welham, M. (1998)
Delayed Language Onset as a Predictor of Clinical Symptoms in Pervasive Developmental Disorders. Journal of Autism and Developmental Disorders, 28, 527–34.
Gillberg, C (2001). Asperger’s syndrome and high functioning autism: Shared deficits or
different Disorders? Journal of Developmental and Learning Disorders, 5, 79-94.
Howlin, P. (2003). Outcome in high-functioning adults with autism with and without early language delays: Implications for the differentiation between autism and Asperger syndrome. Journal of Autism and Developmental Disorders, 33, 3–13.
Leekam, S., Libby, S., Wing, L., Gould, J. & Gillberg, C. (2000) Comparison of ICD-10 and Gillberg’s criteria for Asperger syndrome. Autism, 4, 11–28.
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
Macintosh, K., & Dissanayake, C. (2006). Social skills and problem behaviors in school aged children with high-functioning autism and Asperger’s disorder. Journal of Autism and Developmental Disorders, 36, 1065–1076.
Macintosh, K.E., & Dissanayake, C. (2004). Annotation: The similarities and differences between autistic disorder and Asperger’s disorder: A review of the empirical evidence. Journal of Child Psychology and Psychiatry, 45, 421–434.
Mayes, S., & Calhoun, S. (2003). Relationship between Asperger syndrome and high functioning autism. In M. Prior (Ed.), Learning and behavior problems in Asperger syndrome (pp. 15-34). New York: Guilford Press.
Mayes SD, Calhoun SL, Crites DL (2001) Does DSM-IV Asperger’s disorder exist? Journal of Abnormal Child Psychology, 29, 263–271.
Miller, J. N., & Ozonoff, S. (2000). The external validity of Asperger disorder: Lack of evidence from the domain of neuropsychology. Journal of Abnormal Psychology, 109, 227–238.
Ozonoff, S., Dawson, G., & McPartland, J. (2002). A parent’s guide to Asperger syndrome and high-functioning autism: How to meet the challenges and help your child to thrive. New York: Guilford Press.
Ozonoff, S., South, M., & Miller, J. N. (2000). DSM-IV-defined Asperger syndrome: Cognitive, behavioral and early history differentiation from high-functioning autism. Autism, 4, 29–46.
Szatmari, P., Bryson, S.E., Streiner, D.L., Wilson, F.J., Archer, L., & Ryerse, C. (2000). Two year outcome of preschool children with autism or Asperger’s syndrome. American Journal of Psychiatry, 15, 1980–1987.
Szatmari, P., Bryson, S., Duku, E., Vaccarella, L., Zwaigenbaum, L., Bennett, L. & Boyle, M.H. (2009). Similar developmental trajectories in autism and Asperger syndrome: from early childhood to adolescence. Journal of Child Psychology and Psychiatry, 50, 1459-1467.
Wilkinson, L. A. (2008). Adults with Asperger syndrome: A childhood disorder grows up. The Psychologist, 21, 764-770.
Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for Asperger syndrome and autism in schools. London: Jessica Kingsley Publishers.
Wilkinson, L. A. (Ed.) (2014). Autism spectrum disorder in children and adolescents: Evidence-based assessment and intervention in schools. American Psychological Association (APA): Washington, DC.
Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for Asperger autism spectrum disorder in schools. London: Jessica Kingsley Publishers.

Williams, K., Tuck, M., Helmer, M., Bartak, L., Mellis, C. & Peat, J.K. (2008). Diagnostic labelling of autism spectrum disorders in NSW. Journal of Paediatrics and Child Health, 44, 108-113.
Wing, L. (2005). Problems of categorical classification systems. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders: Vol. 1. Diagnosis, development, neurobiology, and behavior (3rd ed., pp. 583–605). New York: John Wiley.
Witwer, A.N., & Lecavalier, L. (2008). Validity of autism spectrum disorder subtypes. Journal of Autism and Developmental Disorders, 38, 1611–1624.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

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