Friday, February 10, 2017

Autism and School Psychology Practice

More children than ever before are being diagnosed with autism spectrum disorder (ASD). The U.S. Centers for Disease Control and Prevention (CDC) now estimates that 1 in 54 eight year-old children has an ASD. The occurrence of autism is also evident in the number of students with receiving special educational services. Since Congress added autism as a disability category to the Individuals with Disabilities Education Act (IDEA), the number of students receiving special education services in this category has increased over 900 percent nationally. The number of students receiving assistance under the special education category of autism over the past decade has increased from 5 percent to 11 percent of all identified disabilities. Autism now ranks fourth among all IDEA disability categories for students age 6-21. 
School psychologists and other school-based professionals are now more likely to be asked to participate in the screening, identification, and educational planning for students with ASD than at any other time in the past. Moreover, the call for greater use of evidence-based practice has increased demands that school psychologists be knowledgeable about evidence-based assessment and intervention strategies for students with ASD. Guidelines and standards have been developed recommending best practice procedures for the assessment and treatment of ASD. There is a large and expanding scientific literature base that documents the existence of two major elements of evidence-based practice: (a) assessments shown to be psychometrically sound for the populations on whom they are used and (b) interventions with sufficient evidence for their effectiveness. 

The National Association of School Psychologists (NASP) endorses the use of evidence-based assessment (EBA), and guidelines and standards are available for best practices in ASD for school psychologists (Campbell, Ruble, & Hammond, 2014; Wilkinson, 2017; Esler & Ruble, 2015; Filipek et al., 1999; Ozonoff, Goodlin-Jones, & Solomon, 2005). Elements of EBA in ASD include the following: (a) the use of psychometrically sound assessments for ASD; (b) a developmental perspective that characterizes abilities over the lifespan; (c) assessment of core areas of impairment associated with ASD; and (d) the use of information from multiple sources, including direct and indirect observation from parents and teachers to better estimate skills beyond those that may be dependent on characteristics of the environment

Although school psychologists are often called on to assume a leadership role in evaluating, identifying, and providing interventions for students with ASD in our schools, there is little research to show how closely school psychologists align their practices with the parameters of best practice. Due to the increase in the number of children receiving special education services under the classification of autism, research is needed regarding the preparedness of school psychologists and schools to address the needs of children with ASD. 

Although there is a paucity of research focusing on the delivery of school psychological services for students with ASD, there are several national and state-wide surveys which provide exploratory information regarding school psychologists’ level of knowledge in the area of autism assessment and intervention; assessment methods, measures, and techniques; level of training; and perceived level of preparation and confidence.
  • Aiello & Ruble (2011, 2017) investigated school psychologists’ knowledge and skills in identifying, evaluating, and providing interventions for students with ASD. A total of 402 participants from 50 states completed their survey. Results indicated that despite a limited amount of training received during their graduate education or pre-service training for working with the autism population, most school psychologists’ self-reported knowledge of ASD was in the expected direction for agreement. However, there were gaps in knowledge regarding the differences between emotional and behavioral disorders and autism, developmental delays and autism, and special education eligibility versus DSM diagnoses that need to be addressed through more training. The survey also indicated the need for additional training opportunities in providing interventions, strategies, and supports for students with autism in the following areas: developing family-centered educational plans; training peer mentors; and translating assessment information into teaching goals and activities.
  • Rasmussen (2009) also completed a national survey of school psychologists to determine their level of knowledge in the area of autism assessment; level of training; and perceived preparation and confidence in providing services to children with ASD. Results indicated that training positively affected school psychologists’ knowledge about autism; their levels of involvement with students with autism; and their perceived levels of preparation to work with this population. Of the 662 participants, the majority accurately identified diagnostic features and true and false statements about autism, suggesting an adequate understanding of autism. Participants with more training reported an increased level of involvement on multidisciplinary teams and an ability to diagnose autism when compared to those with less training. Brief rating scales were among the most commonly used instruments, while more comprehensive and robust instruments were among the least-often employed, suggesting school psychologists are either not trained or are limited in the time and resources needed to use evidence-based instruments. Participants felt more prepared to provide consultation and assessment services and less prepared to provide interventions. Although a majority (96.5%) of the respondents reported they had attended workshop presentations or in-service trainings on autism, less than half (43.7%) had completed formal course work in autism in their training program and less than one third (32.3%) had internship or residency experience with autism. These data and previous research suggest school psychologists need more formal training and experience in meeting the needs of individuals identified with autism.
  • Singer (2008) surveyed 199 school psychologists regarding the frequency with which they were called upon to provide services to students with an autism spectrum disorder (ASD); services they actually provided to those students; and their perceptions of the training and experience they had pertaining to the assessment and treatment of ASD. Additionally, the study surveyed 72 graduate programs in school psychology to determine the extent to which these programs prepared new school psychologists to work with children who have ASD. A majority of respondents (64%) reported using only brief screening instruments to identify students. Although able to identify the “red flag” indicators of ASD, very few school psychologists perceived their training as adequate. Only 12.6 % of respondents indicated that they had sufficient coursework in ASD and only 21% indicated that they had sufficient practicum experience. Just 15% indicated that their overall training with ASD was “completely adequate.” Only 5 of the 72 (16.9%) school psychology programs surveyed offered a specific course in ASD; most indicating that the topic was addressed in other courses. According to the author, the survey data suggest that school psychologists lack adequate knowledge about evidence-based instruments and procedures available to screen, assess, and intervene for ASD.
  • Pearson (2008) surveyed a group of Pennsylvania school psychologists regarding their training, knowledge and evaluation practices when assessing and diagnosing ASD. The aim of the study was to determine the extent to which school psychologists are prepared to meet the rapidly increasing demand for using best practice procedures when assessing and diagnosing ASD. An electronic survey was sent to 1,159 certified school psychologists with 243 completed surveys returned. Survey results found the majority of respondents indicated that they rely on the use of brief screening instruments and do not use or recommend "gold standard" instruments with students suspected of having ASD. Only 32.2% of the respondents reported they were very much prepared to recommend an IDEA classification of Autism. Less than 5% of the school psychologists surveyed received formal training in ASD at graduate institutions or internships. The overwhelming majority of school psychologists surveyed believed there is  a need for more training for school psychologists concerning the characteristics of ASD, best practice in the assessment of ASD, and differentiating ASD from other developmental or coexisting disorders.
  • Small (2012) used an online survey of 100 members of the Massachusetts School Psychology Association (MSPA) to obtain information pertaining to demographics, participants' experiences with the ASD population, participants' knowledge of ASD, as well as their use, competency, and feelings of usefulness of various assessment techniques and treatments/interventions. The results indicated that overall, school psychologists demonstrated adequate knowledge of ASD, felt competent conducting assessments, and reported that the assessment tools were useful. School psychologists spent less time on treatment/intervention and while they considered many of the treatments/interventions helpful, they did not feel competent implementing them. The results suggest that school psychologists need more training in ASD, especially regarding treatments/interventions, at the pre-service level through graduate school training and experiences (e.g., practica and internships), as well as at the practitioner level through professional development opportunities.
As more and more children are being identified with ASD and placed in general education classrooms, school psychologists will play an ever increasingly important role in identification and intervention, as well as offer support, information, consultation, and recommendations to teachers, school personnel, administration, and families. Therefore, it is essential that they be knowledgeable about evidence-based assessment and intervention strategies for this population of students.  Despite the limitations inherent in survey research, the data from these studies suggest that school psychologists are not adequately prepared to provide evidence-based assessment and intervention services to children with ASD. The survey research illustrates a significant discrepancy between best practice (evidence-based) parameters and reality when it comes to the practice of school psychology and ASD in the schools (Aiello & Ruble, 2017). 

Federal statutes require that school districts ensure that comprehensive, individualized evaluations are completed by school professionals who have knowledge, experience, and expertise in ASD. Although surveys indicate sufficient knowledge of the signs and symptoms associated with ASD, there is a critical need for school psychologists to be trained and develop competency in evidence-based assessment and identification practices with children who have or may have an ASD. For example, Aiello & Ruble (2017) found a majority of survey respondents reported using brief screening measures such the GARS and/or GADS in assessment and identification, both of which are not recommended for use in decision-making (Brock, 2004; Norris, M., & Lecavalier, 2010; Pandolfi, Magyar & Dill, 2010; Wilkinson, 2010, 2017). In contrast, evidence-based tools such as the ADOS, ADI-R, CARS, and SCQ were used less a third of the time in ASD assessment. Thus, while evidence-based instruments are available for the reliable, thorough assessment of students with ASD, school psychologists either do not have access or lack sufficient training to make them a part of their practice in the schools.
Because the knowledge base in ASD is changing so rapidly, it is imperative that school psychologists remain current with the research and up to date on scientifically supported approaches that have direct application to the educational setting. School psychologists can help to ensure that students with ASD receive an effective educational program by participating in training programs designed to increase their understanding and factual knowledge about best practice assessment and intervention /treatment approaches. 

Recommendations culled from the survey findings include the following: (a) school psychologists need more in-depth, formal training complete with supervision and consultation; (b) school psychology training programs should focus more energy on teaching intervention strategies for students with autism and include a separate course in ASD as part of the curriculum; (c) increase the use of more psychometrically sound autism instruments such as the ADOS and ADI-R in schools to provide better identification and more complete intervention strategies; (d) consider resident ASD specialists within the school and train teams of school professionals to work as a unit with the autism-related cases to ensure that the personnel are well-trained and have the experience necessary to conduct reliable and valid assessments and treatment planning; (e) provide training for all school psychologists on best practice guidelines for screening and assessment of ASD and identify measures with and without empirical support; and (g) develop closer relationships with ASD experts and service providers in the community. School districts may also want to consider levels of training, levels of education, and years of experience when assigning school psychologists who work with children who have ASD.  Finally, the National Association of School Psychologists (NASP) may consider developing guidelines and recommendations regarding the minimal competencies needed in order to work with special populations such as students with ASD.

Key References and Further Reading
Aiello, R., & Ruble, L. A. (2011, February). Survey of school psychologists’ autism knowledge, training, and experiences. Poster presented at the annual convention of the National Association of School Psychologists, San Francisco, CA.

Aiello, R., Ruble, L., & Esler, A. (2017). National Study of School Psychologists’ Use of Evidence-Based Assessment in Autism Spectrum Disorder. Journal of Applied School Psychology33(1), 67-88. DOI: 10.1080/15377903.2016.1236307
Brock, S. E. (2004). The identification of autism spectrum disorders: A primer for the school psychologist. California State University, Sacramento, College of Education, Department of Special education, Rehabilitation, and School Psychology.
Norris, M., & Lecavalier, L. (2010). Screening accuracy of level 2 autism spectrum disorder rating scales: A review of selected instruments. Autism, 14, 263-284.
Pandolfi V., Magyar C. I., & Dill C. A. (2010). Constructs assessed by the GARS-2: factor analysis of data from the standardization sample. Journal of Autism & Developmental Disorders, 40, 1118-30. 
Pearson, L. M. (2008). A survey of Pennsylvania school psychologists' training, knowledge and evaluation practice for assessing and diagnosing autism spectrum disorders. PCOM Psychology Dissertations. Paper 112.
Rasmussen, J. E. (2009). Autism: Assessment and intervention practices of school psychologists and the implications for training in the united states. Ball State University). ProQuest Dissertations and Theses, 192. UMI Number: 3379197
Small, S. H. (2012). Autism spectrum disorders (ASD): Knowledge, training, roles and responsibilities of school psychologists. University of South Florida). ProQuest Dissertations and Theses, 220. ISBN: 9781267519658 UMI Number 3308958
Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London & Philadelphia: Jessica Kingsley Publishers.

Wilkinson LA  (2013) School Psychologists Need More Training in Providing Services to Students with Autism Spectrum Disorders (ASD). Autism 3: e117. doi:10.4172/2165-7890.1000e117

Wilkinson, L.A. (Ed.). (2014). Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. Washington, DC: American Psychological Association.
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.

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered 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).

© Lee A. Wilkinson, PhD

Monday, February 6, 2017

Social Stories™ for Children on the Autism Spectrum

Social Stories™ for Students with Autism

Over the past decade Social Stories™ have shown promise as a positive and proactive classroom strategy for teaching social skills to children on the autism spectrum. They continue to be widely discussed, reviewed, and recommended as an effective and user-friendly behavioral intervention. Social stories allow the child to receive direct instruction in learning the appropriate social behaviors that are needed for success in the classroom setting. The simplicity and utility of social stories make them a popular choice for use in both general and special education settings. Both the National Autism Center (NAC; 2015) and the National Professional Development Center on Autism (NPDC; 2015) have identified story-based intervention as an evidence-based practice.
                                                                What is a Social Story?
A social story is a short story that is written in a child specific format describing a social situation, person, skill, experience, or concept in terms of relevant cues and appropriate social behavior. The objective of this intervention strategy is to enhance a child’s understanding of social situations and teach an appropriate behavioral response that can be practiced. Each story is designed to teach the child how to manage his or her own behavior during a specific social situation by describing where the activity will take place, when it will occur, what will happen, who is involved, and why the child should behave in a certain way. In essence, social stories seek to answer the who, what, when, where, and why aspects of a social situation in order to improve the child’s perspective taking. Subsequent social interactions allow for the frequent practice of the described behavioral response cue and the learning of new social behavior. Although a number of commercial publications offer generic social stories for common social situations, it is best to individualize the content of the story according to the child’s unique behavioral needs.
Writing a Social Story
Social stories follow an explicit format of approximately 5 to 10 sentences describing the social skill, the appropriate behavior, and others’ viewpoint (perspective) of the behavior. These sentences are written according to comprehension level of the child and include the following basic sentence types. 
  • Descriptive sentences which provide statements of fact and objectively define the “wh” question of the social situation.  
  • Directive sentences that describe the desired behavior and generally begin with “I will work on” or “I will try.”  
  • Perspective sentences which describe other individual’s reaction and feelings associated with the target situation. 
  • Affirmative sentences which stress a rule or directive in the story.  
  • Control sentences that help the child to remember the directive. 
  • Cooperative sentences that describe who will help and how help will be given.
The social story should be written in a way that ensures accuracy of interpretation, using vocabulary and print size appropriate for the child’s ability. Pictures illustrating the concept can be included for children who have difficulty reading text without cues. They can be simple line drawings, clip art, books, or actual photographs. An example of a social story (text only) is provided at the end of this article.
Implementing a Social Story
Social stories should not be used in isolation and are not intended to address all of the behavioral challenges of the child with ASD. Rather, they should be integrated into the student’s IEP or behavior support plan on a daily basis to complement other interventions and strategies. When the social story is first implemented, the teacher must be certain that the child understands the story and social skill being taught. The child can then read the story independently, read it aloud to an adult, or listen as the adult reads the story. The most appropriate method is dependent upon the individual abilities and needs of the child. Regardless of how the story is implemented, it is necessary for comprehension of the story to be assessed. Two approaches are recommended. The first is to have the student complete a checklist or answer questions in at the end of the story. The other is to have the student role play and demonstrate what he or she will do the next time the situation occurs. Once comprehension has been assessed, a daily implementation schedule should be created. It should be noted that there are no limitations on how long a student can use a social story. Some students will learn a new social behavior quickly while others will need to read their stories for several weeks.  A critical feature of implementing a social story is monitoring student progress and collecting data to evaluate improved social outcomes. The following steps are recommended when developing and implementing a social story intervention.
  • Identify the need for behavioral intervention.   
  • Define the inappropriate behavior.  
  • Define an alternative positive behavior.  
  • Write the story using the social story format.  
  • Include the social story in the child’s behavior plan.  
  • Implement the social story.  
  • Practice the social skill used in the social story.  
  • Evaluate comprehension.  
  • Remind the child where the social skill should be used.  
  • Prompt the child to use the social skill at appropriate times during the day.  
  •  Affirm the child when they use the appropriate social behavior.  
  • Monitor Progress. 
  • Evaluate outcome.     
Effectiveness of Social Stories
As we know, there are no interventions or treatments that can cure autism. In fact, there are very few that have been scientifically shown to produce significant, long-term benefits for children with ASD. Although the published research on social stories provides support for their effectiveness in reducing challenging behavior and increasing social interaction for children with ASD, it is uncertain whether they alone are responsible for long-lasting changes in social behaviors. Other strategies (e.g., reinforcement schedules, social skills training) implemented together with social stories may be required to produce desired changes in social behavior. As a result, social stories should be included as part of a multicomponent intervention in the classroom setting. While further outcome research is needed, social stories may be considered an effective approach for facilitating social skills in children with ASD.
Example of a Social Story
David, a second grader with ASD, has a difficult time waiting to talk with his teacher, repeatedly speaks out of turn and interrupts other students. When told to wait, he frequently experiences a “meltdown” and refuses to cooperate. His teacher developed a social story called “Waiting My Turn to Talk.”
Waiting My Turn to Talk  
  • At school I like to talk to the teacher and other students. (descriptive sentence) 
  • Many times other students want to talk with the teacher too. (descriptive sentence)  
  • Students cannot talk to the teacher at the same time. (descriptive sentence)
  • I will wait my turn to talk (directive sentence )  
  • When it is not my turn, I will try to listen to what others are saying and not interrupt.(directive sentence)  
  • These are good rules to follow (affirmative sentence)  
  • The teacher will help me by calling my name when it is my turn to talk (cooperative sentence)  
  • My teacher is happy when I am a good listener and wait for my turn to talk. (perspective sentence)  
  • The other kids will like me when I wait my turn and don’t interrupt them. (perspective sentence) 
  •  I will try to remember to be a good listener and wait for my turn to talk. (control sentence)
David’s Comprehension Questions 
  • When should I talk to my teacher? 
  • What should I do when other students are talking? 
  • Will my teacher and the other kids be happy if I wait my turn to talk?
Key References and Further Reading
Gray, C. & Garand, J. (1993). Social Stories: Improving responses of individuals with autism with accurate social information. Focus on Autistic Behavior, 8, 1-10.

Gray, C. (1994). Comic strip conversations.  Arlington, TX: Future Horizons.

Gray, C. (1998). Social Stories and Comic Strip Conversations (pp.167-198). In Schopler, E., 

Mesibov, G., and Kunce, L. (Eds.), Asperger Syndrome or High-Functioning Autism? New York: Plenum Press.

Gray, C. A. (2000). Writing social stories with Carol Gray [Videotape and workbook]. Arlington, TX: Future Horizons.

Gray, C. A. (2000). The new social story book. Arlington, TX: Future Horizons.

Gray, C. & White, A. L. (2000).  My Social Stories book. London: Jessica Kingsley Publishers.

Gray, C. (2004).  Social Stories™ 10.0.  Jenison Autism Journal: 15, (4), 2-21.

Gray, C. (2010). The new Social Story™ book: Revised and expanded 10th anniversary edition. Arlington, TX: Future Horizons.

Gray, C. (2012). The last bedtime story that we read each night. Arlington, TX: Sensory World / Future Horizons.

Gray, C. (2015). The New Social Story Book, Revised and Expanded 15th Anniversary Edition: Over 150 Social Stories that Teach Everyday Social Skills to Children and Adults with Autism and their Peers. Future Horizons, Arlington, TX.

National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author.

National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices.

Wilkinson, L. A. (2016). A best practice guide to assessment and intervention for autism spectrum disorder in schools (second Edition). London and Philadelphia: Jessica Kingsley Publishers.

Wong, C., Odom, S. L., Hume, K. A., Cox, C. W., Fettig, A., Kurcharczyk, S., et al. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-014-2351-z

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered 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 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).

© 2017 Lee A. Wilkinson, PhD

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