Best Practice Review: Social Responsiveness Scale, Second Edition (SRS-2)

Review: Social Responsiveness Scale, Second Edition (SRS-2)

The second edition of the widely administered Social Responsiveness Scale (SRS-2; Constantino & Gruber, 2012) maintains continuity with the original instrument as an efficient quantitative measure of the various dimensions of interpersonal behavior, communication, and repetitive/stereotypic behavior associated with autism spectrum disorder (ASD). The SRS-2 extends the age range from 2.5 years through adulthood. There are now four forms, each consisting of 65 items and for a specific age group: Preschool Form (ages 2.5 to 4.5 years); School-Age Form (4 to 18 years); Adult Form (ages 19 and up); and Adult Self-Report Form (ages 19 and up). Nationally representative standardization samples were collected to support each form. These samples consist of a total of 4,709 ratings of 1,963 individuals: 474 ratings of 247 preschool children, 2,025 ratings of 1,014 school-age children, and 2,210 ratings of 702 adults.

Content

The individual items of the SRS-2 show strong parallels across forms. While most of the 65 items are the same, some were changed and reference activities and social behavior that are specific and appropriate to the ages covered by their respective form. Only the School-Age form is unchanged in its item content from the first edition of the SRS. Each item is scored on a 4 point Likert-scale: 1 (“not true”); 2 (“sometimes true); 3 (often true); and 4 (“almost always true”). Scores are obtained for five Treatment Subscales: Social Awareness; Social Cognition; Social Communication; Social Motivation; and Restricted Interests and Repetitive Behavior. There are also two DSM-5 Compatible Subscales (Social Communication and Interaction and Restricted Interests and Repetitive Behavior) that allow comparison of symptoms to the new DSM-5 ASD diagnostic criteria.  

 Interpretation

Interpretation is based on a single score (Total Score) reflecting the sum of responses to all 65 SRS questions which serves as an index of severity of social skills across the autism spectrum. The SRS-2 Total score is expressed in raw and T-scores. Raw scores are converted to T-scores for gender and respondent. T-score guidelines provide interpretive language applicable to the specific age rages covered by the various forms (preschool, school-age, and adult). A total T-score of 76 or higher is considered severe and strongly associated with clinical diagnosis of Autistic Disorder. T-scores of 66 through 75 are interpreted as indicating Moderate deficiencies in reciprocal social behavior that are clinically significant and lead to substantial interference in everyday social interactions, whereas T-scores of 60 to 65 are in the Mild range and indicate mild to moderate deficits in social interaction. T scores of 59 and below are considered to be within typical limits and generally not associated with clinically significant ASD. A Profile Sheet for each form provides T-score results and a brief summary statement to facilitate interpretation and discussion of results. Raters can complete the 65 items in approximately 15 to 20 minutes. Scoring and graphing can be completed in approximately 5 to 10 minutes. The manual provides a series of case examples to illustrate application of the SRS-2 at different points across the lifespan (preschool, school-age, and adult). Although the SRS-2 is relatively easy to administer and score, interpretation and application of the results require professional training and experience in child development, psychology, or education.

Psychometric Characteristics

More than 40 research studies and independent resources support the diagnostic validity of SRS-2 and the instrument’s application in a wide variety of clinical and educational contexts. Based on research analyses, a total raw score cutpoint value of 70 is associated with a sensitivity value of .78 and specificity value of .94 for any ASD (autistic disorder, Asperger's disorder, or PDD-NOS) in unselected general-population groups. In terms of positive predictive value (PPV), 93% of children whose scores fall above this cutpoint will, upon completion of a comprehensive assessment, receive a diagnosis of ASD. In most clinical and school settings, raw scores at or above 85 from two separate informants provide very strong evidence of ASD. In a large clinical sample (School-Age Form), ROC (receiver operating characteristics) analyses indicate an area under the curve (AUC) of .968 and a sensitivity and specificity value of .92 at a raw score of 62. This suggests that the SRS-2 is a robust instrument for discriminating between individuals with ASD and those unaffected by the condition. Large samples also provide evidence of good interrater reliability, high internal consistency, and convergent validity with the Autism Diagnostic Interview-Revised (ADI-R), Autism Diagnostic Observation Schedule (ADOS), and Social Communication Questionnaire (SCQ).

 Conclusion

A significant strength of the SRS-2 is its facility in quantitatively measuring autistic traits and symptoms across the complete range of severity (mild to severe). This is especially important when identifying the more subtle characteristics of autism and more capable and less severely affected individuals with ASD (without intellectual disability). The SRS-2 forms should also be useful for quantifying response to intervention/treatment over time. Extending the age range of the SRS-2 adds to its versatility as a screening and diagnostic measure of symptoms associated with ASD. The Preschool and Adult Forms afford multiple perspectives throughout the life span and provide important tools for both clinicians and researchers to assess these populations. The subscales corresponding to the two symptom domains: Social Communication (SCI) and Restricted Interests and Repetitive Behavior (RRB) also align the SRS-2 with the DSM-5 criteria for Autism Spectrum Disorder (ASD) and Social (Pragmatic) Communication Disorder (SCD). Because a majority of independent research has been limited to the School-Age form, studies are needed to provide further information relative to the diagnostic validity of the Preschool and Adult Forms. Likewise, research is needed to examine the relationship between social impairment and intellectual disability and the more severe forms of ADHD. In sum, the SRS-2 can be used confidently in school and clinical contexts as an efficient measure of ASD symptomatology and severity. Consistent with best practice, the results of questionnaire measures must be integrated with information from multiple sources and interpreted within the context of a comprehensive developmental assessment (see Wilkinson for a description of assessment domains and recommended measures).

Constantino, J. N., & Gruber, C. P. (2012). Social Responsiveness Scale, Second Edition. Los Angeles, CA: Western Psychological Services.

Adapted from: Wilkinson, L. A. (2017). A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition). London & Philadelphia: Jessica Kingsley Publishers. 

                          Click here to read a free preview of “A Best Practice Guide…”

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).

Autism Litigation Under IDEA

There has been a worldwide increase in reported cases of autism over the past decade. Autism is much more prevalent than previously thought, especially when viewed as a spectrum of disorders (ASD). According to the CDC, approximately 1 in 45 children in the United States have an autism spectrum disorder (ASD) or an estimated prevalence of about 1.7%. The occurrence of autism is also evident in the number of students with ASD receiving special educational services. Since Congress added autism as a disability category to the Individuals With Disabilities Act (IDEA), the number of students receiving assistance under the special education category of autism over the past decade has increased from 1.5 percent to 9 percent of all identified disabilities. Autism now ranks fourth among all IDEA disability categories for students age 6-21.  

Autism Litigation

The increase in autism is also reflected in the frequency of autism-related litigation and court decisions. An article appearing in the Journal of Special Education Leadership (Autism Litigation Under the IDEA: A New Meaning of “Disproportionality?’) by Lehigh University professor of education and law, Dr. Perry Zirkel, explored whether the litigation concerning students with autism is disproportional to their enrollment in special education programs under IDEA. Zirkel analyzed 201 court decisions under IDEA that appeared in West’s Education Law Reporter. He limited the analysis to the overlapping FAPE (Free Appropriate Public Education) and LRE (Least Restrictive Environment) categories as previous studies showed them to be the major part of IDEA litigation. The FAPE category consisted of decisions where the parent challenged the appropriateness of the child’s individual program or placement. This category also included cases where the court decided the appropriateness of the proposed placement as the first step in the tuition reimbursement analysis. The LRE category consisted of cases where the parents and district sought different placements, and the court used the test, or set of criteria, applicable in its federal appellate jurisdiction for determining the LRE.

The study found that the child’s disability classification was identified as autism in 64 (32%) of 201 FAPE/LRE decisions analyzed between 1993 and 2008. Autism litigation accounted for an average of 37% from 1997 to 2008, ranging from 6% in the period closest to the 1990 addition of autism to the list of IDEA disability classifications to 39% in the most recent four year period 2005-2008. Most importantly, Zirkel found that when comparing the litigation percentage with the autism percentage in the special education population for the period 1993 to 2006, the ratio was approximately 10:1. Overall, the FAPE/LRE court cases are over 10 times more likely to concern a child with autism than the proportion of children with this classification in the special education population.

The study suggests that the reasons for this disproportionality (or overrepresentation) of children with autism in FAPE/LRE litigation are multifaceted. An initial explanation concerns the severity of the disability and the resulting emotional stress placed on parents/caregivers and families. Another explanation may involve “cost.” For example, children with ASD typically receive a significantly higher number of different special education and related services than students with other disabilities. As a result, the average per-pupil expenditure for special education services for school-age children with autism is often more than for other IDEA disability classifications. This relative cost represents high stakes for both parents and districts and may contribute significantly to the motivation for litigation (e.g., the number of tuition reimbursement cases in the FAPE/LRE cases for autism). A third contributing factor may be the recent attention given to autism compared to other IDEA disability classifications together with the complexity of the disorder itself. The media attention given to autism and emergence of advocacy groups have also increased parents’ knowledge, but often popularize treatments that are not supported in the scientific literature and/or viable in educational contexts. As Zirkel comments, “…with the underlying mutual motives of high costs and methodological controversy, it is not surprising that the parents of children with autism would be more prone to litigation than the parents of children with other disabilities.” 

Implications

This investigation has several important (and practical) implications. For example, school district administrators should pay particular attention to providing effective evidence-based interventions and programs for children with autism and to establishing effective communications with their parents. Parent-professional communication and collaboration are key components for making educational and treatment decisions. On-going training and education in autism are also important for both parents and professionals. Educators and support professionals who are trained in specific methodology and techniques will be most effective in providing the appropriate services and in modifying curriculum based upon the unique needs of the individual child. Given the limited success of many school districts in addressing this complex disability, school officials must also be prepared to address the expected complaints and grievances from parents of children with autism. At this point, special education leaders should investigate the use of various alternate dispute resolution mechanisms such as mediation and IEP facilitation. As Zirkel concludes, “Although such steps are appropriate with all parents, especially with those of children with disabilities, these results suggest that, without such priority extra efforts, the likelihood of the parents of students with autism filing for an impartial hearing to challenge the IEP and persisting through this costly and cumbersome adversarial process to a court decision will remain disproportionally high.”

Article: http://blogs.edweek.org/edweek/speced/Zirkel%20Article%20on%20Autism%20Litigation%20Disproportional.PDF

Zirkel, P. (2011). Autism litigation under the IDEA: A new meaning of “disproportionality?” Journal of Special Education Leadership, 24, 92-103.

Zirkel, P. (2014). Legal Issues Under IDEA. In L. A. Wilkinson (Ed.), Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 243-257). Washington, DC: American Psychological Association. 

Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.

Lee A. Wilkinson, PhD, is a nationally certified and licensed 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 the editor of a 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools, (2nd Edition)

Restricted, Repetitive Behavior (RRB) and Comorbid Symptoms in Autistic Children

Restricted, Repetitive Behavior and Comorbid Symptoms

Children with autism spectrum disorder (ASD) frequently have co-occurring (comorbid) psychiatric symptoms, with rates significantly higher than would be expected from the general population. Research indicates that the most common co-occurring diagnoses are anxiety and depression, attention problems, and disruptive behavior disorders. Previous studies also suggest that restricted, repetitive patterns of behavior, interests, or activities (RRBs) are associated with the symptoms of co-occurring psychiatric conditions in individuals with autism. 

The criteria for the DSM-5 diagnostic category of Autism Spectrum Disorder (ASD) include RRBs as a core diagnostic feature, together with the domain of social communication and social interaction deficits. According to the DSM-5, restricted, repetitive patterns of behavior, interests, or activities are defined by the presence of at least two of the following:

• Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).
• Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).
• Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
• Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects.

RRBs have been shown to cause significant challenges for both the individual with autism and their family. Likewise, they can impede learning and socialization by decreasing the likelihood of positive interactions with peers and adults. Parents of autistic individuals also report that RRBs are one of the most challenging features of autism due to their significant interference with daily life. In contrast with the core domain of social/communication deficits, RRBs have only recently been the focus of systematic research efforts.

Research

Stratis and Lecavalier (2013) investigated the relationship between RRBs and co-occurring depressive, anxiety, attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms, while considering level of functioning. Participants in the study were 72 parents of children and youth diagnosed with ASD (ages 5–17). Children’s co-occurring diagnoses included: Attention-Deficit/Hyperactivity Disorder (ADHD), Anxiety Disorders, Mood Disorders, Behavioral Disorders, and Intellectual Disability. Frequency and severity of RRBs were assessed across five domains: Stereotypic Behavior, Self-Injurious Behavior (SIB), Compulsive Behavior, Ritualistic/Sameness Behavior, and Restricted Interests. Ratings by parents were used to quantify co-occurring symptom severity for each of the following four domains: ADHD, ODD, anxiety disorders and depressive disorders. Data analyses were completed to determine which RRBs were most predictive of co-occurring symptom severity.

                                                                                Results

Autistic children with high levels of ritualistic and sameness behavior tended to show more severe symptoms of anxiety and depression. This appears consistent with the high co-occurrence of depressive and anxiety symptoms in the general population. This finding also suggests that ritualistic and sameness behaviors may be implicated in the development and maintenance of anxiety in individuals with autism. Interestingly, high levels of restricted interests were associated with less severe symptoms of depression, suggesting that restricted interests may be a protective factor against the development of depression. Although restricted interests frequently have a negative impact on interpersonal relationships, they might also have a positive effect by providing a feeling of self-validation and a means of occupying one’s time, while also serving as an incentive to increase knowledge. 

Inconsistent with previous research, all psychiatric symptom domains appeared unrelated to children’s level of functioning. However, level of functioning moderated the relationship of SIB and depressive and anxiety symptoms. For higher functioning children and youth, elevated levels of SIB were predictive of more severe depressive and anxiety symptoms whereas higher levels of SIB were predictive of less severe depressive and anxiety symptoms for lower functioning individuals. For lower functioning individuals, high levels of ritualistic and sameness behaviors predicted more severe depressive symptoms while there was no significant relationship for higher functioning individuals.

                                                                          Implications

The results of this study may help clarify the presentation of ASD phenotypes, suggesting that different types of RRBs may be predictive of co-occurring psychiatric disorders. This has implications for genetic and neurobiological research. For example, differences underlying genetic and neurobiological factors may be identified based on symptom presentation, including RRBs and co-occurring psychiatric symptoms. Moreover, if RRBs and psychiatric symptoms do share common etiologies, interventions for psychiatric symptoms may help ameliorate RRBs in autistic individuals. The possibility that RRBs such ritualistic and sameness behaviors may be involved in development and maintenance of anxiety or that restricted interests protect against the development of depressive symptoms has significant implications for treatment and should be explored in future research. Given that RRBs continue to be a core feature of ASD in DSM-5, clinicians and autism professionals should give increased attention to the assessment and presence of RRBs and their impact on common co-occurring disorders and psychological well-being of individuals with autism.

Stratis, E. A., & Lecavalier, L. (2013).  Restricted and repetitive behaviors and psychiatric symptoms in youth with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 757–766.

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).

Assessment of Executive Function (EF) in Autism

Executive Function Skills in Autism

Research evidence suggests that deficits in executive function (EF) are an important feature of autism spectrum disorder (ASD). Executive function is a broad term used to describe the higher-order cognitive processes such as response initiation and selection, working memory, planning and strategy formation, cognitive flexibility, inhibition of response, self-monitoring and self-regulation. It is generally acknowledged that these higher order processes are associated with the prefrontal cortex, which are necessary for regulating and controlling behavior. Executive functions include the many of the skills required to prepare for and execute complex behavior, such as planning, inhibition, organization, self-monitoring, cognitive flexibility, and set-shifting. 

Markers of executive dysfunction may include difficulty initiating action, planning ahead, inhibiting inappropriate responses, transitioning, switching flexibly between response sets, and poor self-monitoring. Indeed, poor performance monitoring and self-regulation may be associated with the core features of ASD such as a lack of social reciprocity, perseverative responses, and intense emotional responses to change (e.g., meltdowns). Moreover, school success depends on mastery of basic EF skills, including remembering and following instructions, completing tasks independently and smoothly transitioning between tasks, and inhibiting inappropriate behaviors. EF plays an important role in the acquisition of knowledge and social skills; the better children are at focusing and refocusing their attention, holding information in mind and manipulating it (i.e., working memory), resisting distraction, and adapting flexibly to change, the more positive the social, adaptive, and academic outcomes.

Assessment

It is important to note, however, that executive function deficits are not experienced by all individuals on the autism spectrum nor do they appear to play a primary causal role in ASD. Nevertheless, executive dysfunction places a child at-risk and is likely to have an adverse impact on many areas of everyday life and affect adaptability in several domains (personal, social and communication). Therefore, an assessment of executive function can add important information about the child’s strengths and weaknesses and assist with intervention/treatment planning. The following measures may be included in a comprehensive developmental assessment battery for ASD.

·   The Delis-Kaplan Executive Function System (D-KEFS; Delis, Kaplan, & Kramer, 2001) was co-normed on a large and representative national sample designed exclusively for the assessment of executive functions, including flexibility of thinking, inhibition, problem solving, planning, impulse control, concept formation, abstract thinking, and creativity. The D-KEFS, is composed of nine stand alone tests that can be individually or group administered that provides a standardized assessment of executive functions in children and adults between the ages of 8 and 89.

·   The Developmental Neuropsychological Assessment, Second Edition (NEPSY–II: Korkman et al., 2007) measures several neuropsychological abilities and was normed on children 3 to 16 years to 11 months of age. The NEPSY-II assesses six domains: 1) Attention and Executive Functioning, 2) Language, 3) Memory and Learning, 4) Sensorimotor, 5) Social Perception and 6) Visuospatial processing. It offers 32 subtests that the examiner can tailor to the specific examinee. In addition to tests of memory and executive functioning, the NEPSY-II also includes tests on Theory of Mind (which assesses the ability to recognize the feelings and thoughts of others) and Affect Recognition (which measures the ability to recognize feelings expressed on faces), both of which should be useful for assessing children on the spectrum.

·   The Wide Range Assessment of Memory and Learning, Second Edition (WRAML-2; Sheslow & Adams, 2003) is a direct assessment of both immediate and delayed memory ability, as well as the acquisition of new learning that can be useful in evaluating learning and school-related problems of students with ASD. This comprehensive measure includes a Core Battery and supplemental subtests that provide index scores for General Memory, Verbal Memory, Visual Memory, Working Memory, and Attention and Concentration. A brief four subtest Memory Screening Form that correlates highly with the full test is also available.

·   The Behavior Rating Inventory of Executive Function, Second Edition (BRIEF- 2; Gioia, Isquith, Guy, & Kenworthy, 2015) is a parent-or-teacher rated questionnaire for children ages 5 to 18 years of age that can be used to assess executive functioning in ASD. The BRIEF-2 is comprised of the following scales: Inhibit, Shift, Emotional Control, Initiate, Working Memory, Plan/Organize, Organization of Materials, Task-Monitor, and Self-Monitor. Summary indexes include Behavior Regulation (BRI), Emotion Regulation (ERI), Cognitive Regulation (CRI) and an overall score, the Global Executive Composite (GEC). The BRIEF-2 also includes a self-report measure for children and adolescents 11-18 years of age.

·   The Comprehensive Executive Function Inventory (CEFI; Naglieri & Goldstein, 2013) is an executive function (EF) rating scale for children and youth ages 5 to 18 years. The CEFI is designed to assess EF skills based on self, parent, and teacher reports, and provides specific and individualized intervention recommendations. The CEFI provides an overall full-scale executive functioning standard score and individual subtest standard scores on nine components of EF, including Attention, Emotion Regulation, Flexibility, Inhibitory Control, Initiation, Organization, Planning, Self-Monitoring, and Working Memory.

Because executive functions are important to social competence, academic success, and overall adaptability, these measures enable practitioners to assess impaired multi-task performance, document the impact of executive function deficits on functioning, and to plan educational interventions and classroom accommodations. Further information on best practice guidelines for assessment of ASD is available from the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

Click here to read a free preview of “A Best Practice Guide…”

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).

Stress Higher for Parents of Girls with Autism

Stress Higher for Parents of Autistic Girls 

Parents of children with autism spectrum disorder (ASD) experience higher levels of stress in comparison to parents of neurotypical children and consequently are more susceptible to negative health and social outcomes. For example, they are more likely to experience depression, anxiety, somatic complaints, isolation, and burnout. Previous research also suggests that parental stress is often correlated with child characteristics, locus of parenting control, parenting satisfaction, and social support. Additionally, challenges in obtaining a timely diagnosis and lack of appropriate treatment services and education are factors identified in the literature as contributors to parental stress and dissatisfaction.

However, less is known regarding how individual child characteristics (i.e. gender), access to comprehensive treatment services, and individual functioning intersect to impact stress levels in parents of autistic children. The gender gap is one of the most consistent findings in the field, with autism 4 times more common among boys (1 in 37) than girls (1 in 151). Previous research has acknowledged that girls may present differently than boys, making timely diagnosis more difficult given our current understanding and availability of diagnostic instruments. Research has also shown that early intervention is associated with better outcomes for children with ASD. However, if a child is identified later in life, early intervention is less likely to occur, possibly impacting the outcome of treatment services. Consequently, parents of autistic girls may experience challenges not only in obtaining a timely and accurate diagnosis, but also in connecting to treatment services and identifying sources of social support.

A study in the open access journal Autism Research and Treatment examined the relationship between parental stress and access to services in families of children with ASD, as well as how this relationship differed by the sex of the child. The researchers expected to find that families of female children with ASD have less access to services, and predicted that fewer services would be associated with greater parental stress.

The researchers found that parenting stress was higher for parents of girls than for parents of boys, and that for parents of girls (but not boys), fewer services predicted higher parental distress. The implications of this study provide important information for service providers working with children with ASD and their parents. Understanding and targeting parental stress is critical in enhancing well-being and the parent-child relationship. This is especially important for parents of autistic girls with because they may lack mental health services that target and address parental stress. Moreover, difficulty in identifying girls with ASD and focusing on their specific needs may generate additional parental stress. 

Future research comparing services before and after assessment is recommended to better understand the impact of services and support in regard to gender differences, parental stress, and access to services. Likewise, there is a need to focus on specific challenges experienced by parents of female children with ASD, including ways to increase access to comprehensive treatment services and the prevalence of educational and social support. Differences in parental stress experienced between mothers and fathers should also be examined.

Source: Irina Zamora, Eliza K. Harley, Shulamite A. Green, Kathryn Smith, and Michele D. Kipke, “How Sex of Children with Autism Spectrum Disorders and Access to Treatment Services Relates to Parental Stress,” Autism Research and Treatment, vol. 2014, Article ID 721418, 5 pages, 2014. https://doi.org/10.1155/2014/721418.

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 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)

Autism in the Schools

Autism in the Schools

More children than ever before are being diagnosed with autism spectrum disorders (ASD). The U.S. Centers for Disease Control and Prevention (CDC) now estimates that 1 in 54 eight year-old children has an ASD. This dramatic increase in the prevalence of children with ASD over the past decade, together with the clear benefits of early intervention, have created a need for schools to identify children who may have an autism spectrum condition. It is not unusual for many autistic children to go undiagnosed until well after entering school. In fact, research indicates that only three percent of children with ASD are identified solely by non-school resources. As a result, school professionals are now more likely to be asked to participate in the screening and identification of children with ASD than at any other time in the past.

IDEA

The Individuals with Disabilities Education Act of 2004 (IDEA) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are the two major systems used to diagnose and classify children with ASD. The DSM-5 is considered the primary authority in the fields of psychiatric and psychological (clinical) diagnoses, while IDEA is the authority with regard to eligibility decisions for special education. The DSM was developed by clinicians as a diagnostic and classification system for both childhood and adult psychiatric disorders. The IDEA is not a diagnostic system per se, but rather federal legislation designed to ensure the appropriate education of children with special educational needs in our public schools. Unlike the DSM-5, IDEA specifies categories of ‘‘disabilities’’ to determine eligibility for special educational services. The definitions of these categories (there are 13), including autism, are the most widely used classification system in our schools. According to IDEA regulations, the definition of autism is as follows:

(c)(1)(i) Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The term does not apply if a child’s educational performance is adversely affected primarily because the child has an emotional disturbance, as defined in this section.

(ii) A child who manifests the characteristics of ‘‘autism’’ after age 3 could be diagnosed as having ‘‘autism’’ if the criteria in paragraph (c)(1)(i) of this section are satisfied.

This educational definition is considered sufficiently broad and operationally acceptable to accommodate both the clinical and educational descriptions of autism and related disorders. While the DSM-5 diagnostic criteria are professionally helpful, they are neither legally required nor sufficient for determining educational placement. It is state and federal education codes and regulations (not DSM-5) that drive classification and eligibility decisions. Thus, school professionals must ensure that children meet the criteria for autism as outlined by IDEA and may use the DSM-5 to the extent that the diagnostic criteria include the same core behaviors (e.g., difficulties with social interaction, difficulties with communication, and the frequent exhibition of repetitive behaviors or circumscribed interests). Of course, all professionals, whether clinical or school, should have the appropriate training and background related to the diagnosis and treatment of neurodevelopmental disorders. The identification of autism should be made by a professional team using multiple sources of information, including, but not limited to an interdisciplinary assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, and cognitive functioning to help with intervention planning and determining eligibility for special educational services.

Guidelines

Legal and special education experts recommend the following guidelines to help school districts meet the requirements for providing legally and educationally appropriate programs and services to students with ASD.

1. School districts should ensure that the IEP process follows the procedural requirements of IDEA. This includes actively involving parents in the IEP process and adhering to the time frame requirements for assessment and developing and implementing the student’s IEP.  Moreover, parents must be notified of their due process rights. It’s important to recognize that parent-professional communication and collaboration are key components for making educational and program decisions.

2. School districts should make certain that comprehensive, individualized evaluations are completed by school professionals who have knowledge, experience, and expertise in ASD. If qualified personnel are not available, school districts should provide the appropriate training or retain the services of a consultant.

3. School districts should develop IEPs based on the child’s unique pattern of strengths and weaknesses. Goals for a child with ASD commonly include the areas of communication, social behavior, adaptive skills, challenging behavior, and academic and functional skills. The IEP must address appropriate instructional and curricular modifications, together with related services such as counseling, occupational therapy, speech/language therapy, physical therapy and transportation needs. Evidence-based instructional strategies should also be adopted to ensure that the IEP is implemented appropriately.

4. School districts should assure that progress monitoring of students with ASD is completed at specified intervals by an interdisciplinary team of professionals who have a knowledge base and experience in autism. This includes collecting evidence-based data to document progress towards achieving IEP goals and to assess program effectiveness.

5. School districts should make every effort to place students in integrated settings to maximize interaction with non-disabled peers. 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. Although 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 to provide FAPE. 

6. School districts should provide on-going training and education in ASD for both parents and professionals. Professionals who are trained in specific methodology and techniques will be most effective in providing the appropriate services and in modifying curriculum based upon the unique needs of the individual child.

Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.

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Key References and Further Reading

Individuals with Disabilities EducationImprovement Act of 2004. Pub. L. No. 108-446, 108th Congress, 2nd Session. (2004). 

Mandlawitz, M. R. (2002). The impact of the legal system on educational programming for young children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 32, 495-508.

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

Twachtman-Cullen, D., & Twachtman-Bassett, J. (2011). The IEP from A to Z: How to create meaningful and measurable goals and objectives. San Francisco, CA: Jossey-Bass.

Wilkinson, L. A. (2010). Best practice in special needs education. In L. A. Wilkinson, A best practice guide to assessment and intervention for autism and Asperger syndrome in schools  (pp. 127-146). London: Jessica Kingsley Publishers. 

Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.

Wrightslaw: Special Education Law, 2ndEdition (2007).

Yell, M. L., Katsiyannis, A, Drasgow, E, & Herbst, M. (2003). Developing legally correct and educationally appropriate programs for students with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 18, 182-191.

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).

© Lee A. Wilkinson, PhD