Sunday, July 24, 2016

Evidence-Based Interventions for Autism



The National Autism Center has released its review and analysis of interventions for autism spectrum disorder (ASD) based on research conducted in the field from 2007 to 2012. The second phase of the National Standards Project (NSP2) provides an update to the summary of empirical intervention literature evaluated by Phase 1 of the National Standards Project (or NSP1) published in 2009. The National Standards Project is the only systematic review of ASD interventions for individuals across the lifespan based on behavioral and educational studies.
The primary goal of the Project was to provide critical information about which interventions/treatments have been shown to be effective for children, adolescents, and young adults with ASD. Nationally recognized experts in autism, as well as other leaders representing diverse fields of study, were involved in both phases of the National Standards Project and guided the process of evaluation. Dozens of article reviewers analyzed 1,165 studies related to interventions for ASD throughout both phases of the project. The combined the results of Phases 1 and 2 have produced the largest compilation of studies reviewed to date.
Interventions

The interventions were subsequently categorized as 1) Established, and producing beneficial outcomes known to be effective; 2) Emerging, with some evidence of effectiveness, but still requiring more research, and 3) Unestablished, and having little or no evidence of effectiveness. NSP2 updated the original findings, added information, and determined whether any of the Emerging interventions in NSP1 had moved into the Established or Unestablished categories.
For children, adolescents, and young adults under 22 years of age, the researchers identified fourteen (14) “Established’ interventions; eighteen (18) “Emerging” interventions; and thirteen (13) “Unestablished” interventions. This information is especially important to service providers, educators, caregivers and parents as it identifies evidence-based treatments and provides standards and guidelines on making treatment choices. The following interventions (alphabetically) were identified as falling into the “Established” level of evidence and have the most research support, produce beneficial outcomes, and are known to be effective.
  • Behavioral Interventions
  • Cognitive Behavioral Intervention 
  • Comprehensive Behavioral Treatment for Young Children
  • Language Training (Production)
  • Modeling
  • Natural Teaching Strategies
  • Parent Training
  • Peer Training 
  • Pivotal Response Training
  • Schedules
  • Scripting
  • Self-Management
  • Social Skills Training
  • Story-based Intervention
“The National Standards Project is an ongoing effort designed to give educators, families, practitioners, and organizations the information and resources they need to make informed choices about effective interventions that will offer individuals with ASD the greatest hope for their futures,” said Hanna C. Rue, Ph.D., BCBA-D, Executive Director of the National Autism Center.


Implications

It is important to note that the NSP2 ratings are not intended as an endorsement or a recommendation as to whether or not a specific intervention is suitable for a particular child with ASD. The document cautions readers that “research findings” are only one component of evidence-based practice to consider when selecting interventions. NSP2 is not intended to dictate which interventions can or cannot be used for individuals with ASD. Moreover, it should not be assumed that these interventions will universally produce positive outcomes for all individuals with ASD. The researchers also note that intervention selection is complicated and should be made by a team of individuals who can consider the unique needs and history of the individual with ASD, along with his or her environment. Likewise, the judgment of the professionals with expertise in ASD must be taken into consideration in the decision-making process, together with stakeholder values and preferences. 
 
About the National Autism Center
The National Autism Center is May Institute’s Center for the Promotion of Evidence-based Practice. It is a nonprofit organization dedicated to serving children and adolescents with autism spectrum disorder (ASD) by providing reliable information, promoting best practices, and offering comprehensive resources for families, practitioners, and communities. For more information about the National Autism Center, please visit http://www.nationalautismcenter.org/.

Monday, July 18, 2016

Gross Motor Skills in Children with Autism

Gross Motor Performance in Children with Autism

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in (a) social communication and (b) restricted and/or repetitive behaviors or interests that varies in severity of symptoms, age of onset, and association with other disorders. Although motor impairment is not a part of the diagnostic criteria for ASD, research suggests that many children with ASD experience delays in motor development. Gross motor skills are fundamental skills necessary for movement competence and considered the basic building blocks for more complex motor skill development. When present, gross motor problems may interfere with performance in many developmental and functional domains across home and school contexts. Consequently, researchers are increasingly considering the importance of motor function in the assessment and treatment of children with ASD.
                                                                          Research

A study published in the Journal of Child and Adolescent Behavior focused on assessing the gross motor skill performance of 21 children with ASD (M=7.57 years) and 21 age matched typically developing children (M=7.38 years) using the Test of Gross Motor Development-2 (TGMD-2). The TGMD-2 is a norm and criterion-referenced test that measures performance of 12 gross motor skills. Scores are recorded on two subtests, locomotor subtest (run, gallop, hop, leap, jump, and slide) and object-control subtest (strike, dribble, catch, kick, throw, and roll), An overall gross motor quotient score (combination of all 12 gross motor skills) can also obtained. Scores are described as very superior, superior, above average, average, below average, poor, and very poor. The researchers hypothesized that children with ASD would show motor delays in overall gross motor quotient scores, and locomotor and object control standard scores when compared to their age matched typically developing peers as measured with TGMD-2.
                                                                           Results

Statistical analysis revealed a significant performance difference between children with ASD and typically developing children on the TGMD-2. For the locomotor subtest, 67% children with ASD received poor standard scores and 40% of scores were very poor. Approximately 60% children with ASD had poor standard scores and 33% of scores were very poor on object control skills. For overall gross motor quotient scores, 81% children with ASD were below 79 and classified as poor, and approximately 76% children scored below 70 and received very poor ratings. 

Children scoring at or below the 30th percentile were considered developmentally delayed as indicated in the Individuals with Disabilities Education Act (IDEA). Based on this criterion, 91% of children with ASD in the current study were considered developmentally delayed in terms of their gross motor skill performance and in need of early supportive interventions. In contrast, the majority of typically developing children’s standard scores (96%) fell in the average or higher range.
                                                                      Implications
According to the authors, the results of this study have several important implications for educators, therapists, and practitioners and the design of effective early intervention programs for children with ASD. For example, locomotion and object control skills are fundamental motor skills in which children interact with their environment and other children. Developing a therapeutic intervention that includes these gross motor skills may have a positive effect on children’s cognitive functioning, language development, social communicative skills, and contribute positively to daily life skills. Consequently, it is vital that we understand the gross motor performance of children with ASD. Finally, the significance of motor proficiency for children with ASD should not be overlooked in assessment practice. Clinicians and practitioners should give increased attention to the assessment of motor skills and their impact on the adaptive behavior and well-being of children with ASD. A comprehensive discussion of assessment domains (e.g. communication, social, motor, sensory, academic) can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Liu T, Hamilton M, Davis L, ElGarhy S (2014) Gross Motor Performance by Children with Autism Spectrum Disorder and Typically Developing Children on TGMD-2. J Child Adolesc Behav 2: 123. doi:10.4172/jcalb.1000123
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, July 12, 2016

Predictors of Aggression in Autism

Predictors of Aggression in Autism

Aggression is a clinically significant feature of many children and adolescents with autism spectrum disorder (ASD). Children with ASD frequently have co-occurring (comorbid) psychiatric conditions, with estimates as high as 70 to 84 percent. These co-occurring problems often exacerbate the core symptoms of ASD and can lead to significant functional impairment. Among these problems, physical aggression appears to be especially challenging, and has been associated with serious negative outcomes in both the general population and among individuals with ASD and other developmental disabilities.
Comorbid Problems Relevant to Aggression 
Children with ASD experience a number of related difficulties, including sleep problems, gastrointestinal (GI) problems, sensory abnormalities, and self-injury. Many of these problems have been associated with aggression among typically developing children, and emerging evidence suggests a similar relationship in children with ASD. For example, sleep problems occur in a large percentage of children with ASD, with prevalence rates ranging from 50% to 80%. Sleep problems have been found to be highly associated with aggression in typically developing children. Likewise, research suggests that children with ASD and sleep problems are more likely to demonstrate aggression than those without sleep problems.
Sensory problems, including sensory over-responsivity, sensory under-responsivity, and sensory seeking are also common problems in children with ASD. In typical children, sensory problems have been associated with aggressive and externalizing behavior problems. Similarly, recent studies have been found correlations between sensory problems and broadly defined externalizing problem behaviors in children with ASD. However, research has yet to specifically examine the potential contributing role of sensory problems in predicting physical aggression.
Self-injurious behavior also appears to be relevant to the occurrence of aggression. Individuals with ASD are at an increased risk for demonstrating self-injurious behaviors, as compared to those without ASD, with prevalence rates ranging from 30% to 53%. Although self-injury and other forms of challenging behaviors have been considered to be distinct forms of behavior, they are often related. For example, physical aggression and self-injury have been significantly associated among individuals with severe intellectual impairment and there is evidence that self-injurious behaviors are precursors of later aggression in this population. However, similar studies have not investigated the relationship between self-injury and physical aggression in children with ASD.
Lastly, gastrointestinal (GI) problems may also have relevance to the occurrence of aggression. GI problems are common in children with ASD, with prevalence rates ranging from 24% to 70% or higher, depending on symptom definitions. Although there some evidence of an association between behavior problems and GI problems in ASD, a population-based study of children with ASD did not find significant differences in aggression when comparing children with and without GI problems.
                                                                           Research
Although the nature and developmental course of aggression have been a focus of research with typically developing populations, there have been few large-scale studies of group-level predictors of aggression among individuals with ASD. Consequently, it is unclear whether findings from the general population are applicable to children and adolescents with ASD. In an effort to investigate the extent of the problem in children and adolescents with ASD, a recent large-scale study published in Research in Autism Spectrum Disorders examined the prevalence and correlates of physical aggression in a sample of 1584 children and adolescents with ASD enrolled in the Autism Treatment Network (ATN), a multi-site network of 17 autism centers across the US and Canada. Participants in the study ranged in age from 2 to 17 years, with a mean age of 5.91 years. The term “aggression” referred specifically to physical aggression and included biting, hitting, or other physical aggression directed towards others. A number of diagnostic, medical, and behavioral measures were collected at enrollment and at regular follow-up intervals. Measures of interest included: (a) aggression, (b) sleep disturbance, (c) sensory problems, (d) communication and social functioning, (e) self-injury and gastrointestinal problems, (f) cognitive functioning, and (g) verbal/nonverbal status. Data analyses were completed in order to identify the variables most strongly associated with aggression.
                                Prevalence, Correlates and Predictors of Aggression
The results indicated that the prevalence of aggression was 53% across the entire sample of children, with highest prevalence among young children. These results are highly consistent with recently reported prevalence rates (56%) in another large-scale study of children and adolescents with ASD. The results also indicate that age-related decreases in aggression in children with ASD are similar to what has been observed in typically developing children. It should be noted, however, that a large percentage (nearly 50%) of the adolescents in the study’s sample continued to demonstrate physical aggression. Thus, the relative decrease in aggression over time must be balanced by the finding that these behaviors continued to occur at a high rate among a large portion of adolescents with ASD.
In terms of predictors, the results indicated that self-injury was highly associated with aggression among children with ASD. This is consistent with the findings of other studies showing a strong association between self-injury and other challenging behaviors. The current results add to existing literature, and suggest that children with ASD who demonstrate self-injury may be at risk for more severe behavioral problems.
Sleep problems emerged as a second significant predictor aggression. This association between sleep problems and aggression is largely consistent with previous findings among both typically developing children and those with ASD, indicating may underlie (and exacerbate) aggressive behavior patterns for many children with ASD. It should also be noted that sleep problems have been found to be associated with self-injurious behaviors among individuals with intellectual disabilities and that these two conditions may be related. In fact, there is some developing evidence suggesting shared neurobiological basis for both sleep disturbance and self-injurious behavior.
Sensory problems were also significantly associated with aggression. These findings are consistent with similar associations between sensory issues and aggression among typically developing children. While previous research has demonstrated an association between sensory problems and broadly defined behavior problems, the current results extend these previous findings by demonstrating a specific relationship between sensory problems and physical aggression.
Comparisons also indicated that children with aggression were more likely to experience GI problems, communication skill difficulties, and social skills difficulties. However, these variables did not appear as significant predictors of aggression, indicating that self-injury, sleep problems, and sensory issues accounted for the majority of the variance in predicting aggression.
In terms of potential sex differences, the results indicate that girls and boys with ASD were equally likely to engage in aggression. This finding was unexpected in that research has consistently shown a significant gender difference among children without ASD, with boys being much more likely to engage in physical aggression than girls. The results of the study suggest that the sex differential in aggression may not be salient in the ASD population.
 Implications
This study provides evidence that aggression may be much more prevalent among children with ASD than in the general population and that some comorbid problems may place individuals at risk for aggression. Aggression was significantly associated with a number of clinical features, including self-injury, sleep problems, sensory problems, GI problems, and communication and social functioning. However, self-injury, sleep problems, and sensory problems were most strongly associated with aggression. These findings indicate that co-occurring problems specific to the ASD phenotype may play an important role in the occurrence of aggression and that it is important to consider multiple domains of functioning when assessing and treating aggression in children with ASD. For example, increased attention should be given to the identification and treatment of sleep problems, self-injury, and sensory problems. Given the significant relationship between sleep problems and aggression, it is possible that treatments targeting sleep problems may help reduce maladaptive behavior. Thus, assessment and treatment of sleeping problems might be included as a standard and integrated part of the assessment and treatment of ASD. Programs for children with ASD should also integrate an appropriately structured physical and sensory milieu in order to accommodate any unique sensory processing challenges. Although assessment tools are limited, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Co-occurring disorders should also be carefully investigated when severe or worsening symptoms are present that are not responding to traditional methods of intervention.
Of course, more research is needed in order to better understand the characteristics and course of different types of aggression. For example, future research should examine the longitudinal course of aggression, the role of these associated problems in predicting improvement or worsening of aggression, and possible changes in aggression in response to treatment for these co-occurring problems. Studies are also needed to examine the role of additional family- and community-level variables in the prediction and maintenance of aggression among children with ASD.  
References

Mazurek, M. O., Kanne, S. M., & Wodka, E. L. (2013).  Physical aggression in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 455–465.

Hill, A.P., Zuckerman, K.E., Hagen, A.D., Kriz, D.J., Duvall, S.W., Santen, J., Nigg, J., Fair, D., & Fombonne, E. (2014). Aggressive behavior problems in children with autism spectrum disorders: Prevalence and correlates in a large clinical sample. Research in Autism Spectrum Disorders, 8, 1121-1133.

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


Monday, July 4, 2016

Schools Need Improved Definitions & Evaluation Procedures for Autism



The dramatic increase in the number of students qualifying for special education under autism in our schools may be due, in part, to vague definitions together with ambiguous, variable, and irrelevant evaluation procedures, according to a study published in the journal, Autism Research and Treatment. The study examined the definition of autism published by each state education agency (SEA) and the District of Columbia, as well as SEA evaluation procedures for determining student eligibility for autism. The researchers compared components of each SEA definition from two authoritative sources: DSM-IV-TR and IDEA-2004.
The results indicated that many more SEA definitions incorporate IDEA-2004 features than DSM-IV-TR features. However, despite similar foundations, SEA definitions of autism displayed considerable variability. Many of the definitions were too vague to be of much use. Evaluation procedures were found to vary even more across SEAs. There often was little concordance between the definition (what autism is) and evaluation procedures (how autism is identified). Definition components often were not addressed by evaluation features, even in a cursory way. One of the least recommended evaluation features was the requirement to administer an autism-specific evaluation as part of the eligibility process. Of the SEAs that included an autism assessment in the evaluation process, none specified the use of a recognized instrument such as the Autism Diagnostic Observation Schedule (ADOS) or the Childhood Autism Rating Scales (CARS). Although several of these SEAs did indicate the required use of a state-created autism checklist, none gave any reference to a source or psychometric characteristics of those checklists
Recommendations for state and federal policy changes are discussed. For example, the researchers suggest that the publication of DSM-5 provides SEAs with the opportunity to expand and update their current definition of autism. They note that the DSM-5 criteria for autism spectrum disorder (ASD) encompass all of the elements stated by the current IDEA definition. The DSM-5 also recognizes the salience of sensory processing problems and co-occurring (comorbid) disorders (e.g., ADHD). The study recommends that SEAs consider the DSM-5 criteria for ASD as they consider revisions to their state definition of autism and corresponding procedures by which assessors will provide data for eligibility determination. Likewise, IDEA-2004 is overdue for Congressional reconsideration and possible amendment, so there is an opportunity to also update and clarify the federal educational definition of autism. Improved, more specific definitions and evaluation procedures will enable SEAs and school districts to better serve students with autism and more efficently allocate resources.
Malinda L. Pennington, Douglas Cullinan, and Louise B. Southern, “Defining Autism: Variability in State Education Agency Definitions of and Evaluations for Autism Spectrum Disorders,” Autism Research and Treatment, vol. 2014, Article ID 327271, 8 pages, 2014. http://dx.doi.org/10.1155/2014/327271
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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