Monday, April 24, 2017

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 Scale (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 efficiently 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).

Monday, April 3, 2017

Girls with Autism Face High Risk for Depression


Girls with Autism Face High Risk for Depression

The U.S. Centers for Disease Control and Prevention (CDC) now estimates that 1 in 59 eight year-old children in the US has an autism spectrum disorder (ASD). Prevalence estimates of ASD are significantly higher among boys than among girls. According to the CDC, approximately one in 37 boys and one in 151 girls were identified as having ASD. Studies also suggest that while boys are being referred for evaluation and identified in greater numbers in our schools, this is not the case for girls. Girls are also diagnosed with ASD at later ages compared to boys. This “gender gap” raises serious questions because many females with ASD may be overlooked and not receive the appropriate supports and services. 
                                                                            Girls with ASD
Gender role socialization is critical to understanding why girls with ASD might be underidentified in the general population. Since females are socialized differently, ASD may not manifest in the same way as typical male behavioral pattern. For example, girls might not come to the attention of parents and teachers because of better coping mechanisms and the ability to “disappear” in large groups. Girls on the higher end of the spectrum also have fewer special interests, better superficial social skills, better language and communication skills, and less hyperactivity and aggression than boys. Likewise, girls are more likely than boys to be guided and protected by same gender peers and to have special interests that appear to be more gender appropriate. These characteristics lessen the probability of a girl being identified as having impaired social skills, the core symptom of ASD.  In fact, it may be a qualitative difference in social connectedness and reciprocity that differentiates the genders. As a result, parents, teachers, and clinicians may not observe the obvious characteristics associated with the male prototype of higher functioning ASD. Over reliance on the male model with regard to diagnostic criteria might also contribute to a gender “bias” and underdiagnosis of girls. For example, clinical instruments tend to exclude symptoms and behaviors that may be more typical of females with autism spectrum disorders.
Unfortunately, the sex differences in the ASD phenotype continue to be poorly understood. As a result, there has been relatively little research on girls with ASD. Moreover, the extant findings are complex and often difficult to interpret. While the gender gap in ASD has yet to be empirically investigated, if there is a gender difference in the autism phenotype, then clinical and educational interventions based largely on research with boys may be inappropriate. As a result, girls may receive less than optimal academic and behavioral interventions. Moreover, the consequences of a missed or late diagnosis can result in social isolation, peer rejection, lowered grades, and a greater risk for mental health and behavioral distress such as anxiety and depression during adolescence and adulthood. As a result, there is an urgent need for research to compare girls with ASD to typical boys and girls to more fully comprehend the implications of being a girl with ASD.
Comorbid Depression

In addition to understanding sex differences in ASD symptoms, a clinically significant issue is whether girls with ASD have an elevated risk for affective disorders. Studies indicate that children, teens, and adults with ASD demonstrate increased internalizing problems relative to typical individuals.  Depression is one of the most common comorbid conditions observed in individuals with ASD, particularly higher functioning youth.  For example, evaluation of psychiatric comorbidity in young adults with ASD revealed that 70% had experienced at least one episode of major depression and 50% reported recurrent major depression. Although typical boys and girls show similar levels of depression in childhood, the risk for internalizing disorders in girls increases dramatically in adolescence. Therefore, girls with ASD may be at especially high risk for depression.
A study in the Journal of Autism and Developmental Disorders compared autism and internalizing symptoms in a clinical sample of 8-18 year-old girls (n = 20) and boys (n = 20) with ASD and typically developing girls (n = 19) and boys (n = 17) using clinician-, parent-, and child- report measures. The researchers found that boys and girls were similarly impaired as evidenced by comparable diagnostic and non-diagnostic ASD symptom scores. However, girls with ASD differed markedly from typical girls on symptom measures such as language and social skills. Girls with ASD also appeared to be at greater risk for internalizing psychopathology than boys with ASD and typical girls. In adolescence, girls with ASD had significantly higher parent-reported internalizing scores than boys with ASD and typical girls. This suggests that being female and having a neurodevelopmental disorder may result in a high risk of anxiety and depression in the teen years.
                                                                             Implications
Understanding elevated levels of internalizing symptoms in girls with ASD and how to treat comorbid affective symptoms is critical. Developing and implementing cognitive, behavioral and psychotropic interventions to address internalizing symptoms in this high risk population of girls is essential to help improve interpersonal functioning and quality of life, as well as reduce the negative outcomes frequently associated with adolescent depression, including psychiatric hospitalization and suicidal ideation. Girls who are diagnosed with ASD should be screened for internalizing problems and closely monitored for symptom occurrence. Additionally, practitioners should question the presence of ASD in girls referred for internalizing disorders such as anxiety or depression. Best practice recommends that when a girl presents with a combination of social immaturity, restricted interests, limited eye gaze, repetitive behaviors, social isolation, and is viewed as “atypical” or “unusual," the possibility of ASD should be given serious consideration. 

In terms of treatment, cognitive-behavioral strategies have shown promise in addressing anxiety in higher-functioning children with ASD and might be adapted to address depression in this population. Interpersonal therapy techniques have also to be effective in treating typical adolescents with depression. In addition, evidence is accumulating in the empirical literature that social skills interventions are likely to be appropriate for many children and youth with ASD. Commonly used approaches include individual and group social skills training, providing experiences with typically developing peers, and peer-mediated social skills interventions, all targeting the core social and communication domains. In conclusion, the study of girls with ASD represents a critical area for future research. This group appears to be at a significant risk for developing significant affective symptoms in adolescence, indicating the need for increased awareness, screening, identification, and intervention. Lastly, population-based studies are needed to determine to what extent girls with ASD in the “general community” are less impaired and/or under-identified relative to boys.
Solomon, M., Miller, M., Taylor, S. L., Hinshaw, S. P., & Carter, C. S. (2012). Autism symptoms and internalizing psychopathology in girls and boys with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 48–59
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).

Parental Stress and Autism Respite Care

 “Just one additional hour of respite care per week was related to an increase in marital quality” 
Parents of children with developmental disabilities face challenges that place them at elevated risk for distress and negative psychological outcomes. The demands placed on parents caring for a child with autism contribute to a higher overall incidence of parental stress which can adversely affect family functioning and marital relationships. Research suggests that respite care can be an appropriate and effective intervention to potentially reduce stress and improve marital quality.
For example, Harper et al. obtained survey data regarding daily responsibilities, marital quality, and the amount of respite care received from 101 mother and fathers who were together raising at least one child with an autism spectrum disorder (ASD). Parents indicated that approximately 64 percent of their children spent time with a respite care provider, including grandparents, babysitters, community agencies, and extended family members. The researchers found that the number of hours of respite care was positively related to improved marital quality for both husbands and wives and that a 1 hour increase in weekly respite care was associated with an improvement in marital quality. This relationship was significantly mediated by perceived daily stresses and uplifts (qualities that led to better relationships) in both husbands and wives. More respite care was associated with increased uplifts and reduced stress; increased uplifts were associated with improved marital quality; and more stress was associated with reduced marital quality. The number of children in the family was associated with greater stress and reduced relational quality and daily uplifts.
The study’s findings offer hope to couples parenting a child with ASD and have important implications for professionals who work with families caring for a special needs child. Respite care should be a critical component in a comprehensive family support plan because even a small increase in the number of hours of respite care has the potential to significantly improve marital quality. Counselors, therapists, psychologists, physicians, school administrators, special education teachers, social workers, and family advocates need to be aware of the respite care options available and be unified in their approach to informing and helping parents access these services.  As the researchers conclude, “A coordinated approach to helping parents obtain and navigate ongoing respite care is long overdue.” 
Harper, A., Dyches, T. T., Harper, J., Roper, S. O., & South, M. (2013). Respite care, marital quality, and stress in parents of children with autism spectrum disorders. Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-013-1812-0

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