Saturday, July 29, 2017

Comorbid ADHD in Children with Autism

Comorbid ADHD in Autism

Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are neurodevelopmental disorders with onset of symptoms in early childhood. There is an overlap in the clinical presentation of ASD and ADHD with epidemiological studies indicating an increase in prevalence rates of ASD and ADHD over the past decade. Symptoms associated with both disorders often result in significant behavioral, social, and adaptive problems across home, school, and community settings  Research suggests that when ADHD is comorbid with ASD, the risk for increased severity of psychosocial problems increases. More severe externalizing, internalizing  and social problems, as well as more impaired adaptive functioning, have been reported in children with comorbid ASD and ADHD than children identified with only ASD.
Although there continues to a debate about ADHD comorbidity in ASD, research, practice and theoretical models suggest that comorbidity between these disorders is relevant and occurs frequently. For example, studies conducted in the US and Europe indicate that children with ASD in clinical settings present with comorbid symptoms of ADHD with rates ranging between 37% and 85%. However, little is known, about comorbidity rates in nonclinical (community) populations of children. Consequently, there is a major need in the field of autism research to better understand how often clinically significant ADHD symp­toms co-occur with ASD in nonclinical populations, and whether the comorbidity of ADHD with ASD is related to differences in other behavioral characteristics.
 Current Research
A study published in the journal Autism examined rates of parent-reported clinically significant symptoms of ADHD in a community sample of school-aged children (4-8 years) with ASD. The researchers hypothesized that children with ASD and comorbid ADHD would exhibit a more severe behavioral phenotype than those with only ASD. Specifically, they speculated that the comorbid group would have lower cognitive functioning, greater delays in adaptive functioning, higher rates of internalizing problems, and more severe social impairment than children with only ASD when these groups were of similar age. Participants included a sample of 153 children 4 to 8 years of age, consisting of the following classification groupings: Non-ASD (n = 91), ASD-Only (n = 44), and ASD+ADHD (n = 18). Children were evaluated on measures of cognitive functioning, internalizing psychopathology, social functioning and autism mannerisms, and adaptive behavior.
 Results
Data analysis indicted significant between-group differences. Results revealed that mean scores were in the “healthy” range for the Non-ASD group, in the mild to moderately impaired range for the ASD-Only group, and in the severely impaired range for the ASD+ADHD group on measures of social functioning and adaptive functioning, representing a continuum of impairment across groups. Children with ASD and ADHD also had lower cognitive functioning than the ASD-Only group. There were no group differences in parent ratings of symptoms of internalizing psychopathology (mood and anxiety disorders), with none of the groups demonstrating elevated rates of internalizing problems. The researchers suggest that an explanation for this finding may be that symptoms of inattention or hyperactiv­ity may obscure symptoms of anxiety in younger school-aged children. In addition, internalizing problems may be difficult to distinguish in young children with ASD as they may not be aware­ of their internal emotional states and may have difficulty expressing their emotional condition to others due to their ASD-related communication impairment.

The overall results of this study indicate greater impairment in cognitive, social, and adaptive functioning for children with ASD and clinically significant ADHD symptoms in comparison with children identified with only ASD. These findings suggest that ADHD comorbidity may constitute a distinctive subtype of ASD and that these children may be at higher risk of social impairment and adjustment problems. The findings are also consistent with other research reports of more severe social problems and maladaptive behav­iors in children with comorbid ASD and ADHD than children with only ASD.
                                                                              Implications 
The findings of the study have important implications for practitioners in health care, mental health, and educational contexts. Overall, 29% of children with ASD also exhibited clinically significant levels of ADHD. Although lower than rates in clinical samples, the rate of comorbid ADHD indicates that young school-age children with ASD should be assessed for ADHD. If clinically significant ADHD symptoms are identified, and social development does not appear to be responding to intervention, changes in the intervention pro­gram (e.g. intensity, strategies, and goals) may be required. It is also important to note that a significant change in the DSM-5 is removal of the DSM-IV-TR hierarchical rules prohibiting the concurrent diagnosis of ASD and ADHD. When the criteria are met for both disorders, both diagnoses are given. Thus, an assessment of ADHD characteristics should be included whenever inattention and/or impulsivity are indicated as presenting problems. It is imperative that practitioners recognize the high co-occurrence rates of these two disorders as well as the potential increased risk for social and adaptive impairment associated with comorbidity of ASD and ADHD. More research is needed to further clarify the behavioral characteristics of children with co-occurring ASD and ADHD so that specialized treatments and interventions may be designed to improve outcomes and quality of life for this subgroup of children. This is important because children who present with the two disorders may have a higher risk for sub-optimal outcomes and may benefit from different treatment methods or intensities than those with identified with only ASD.
Key References and Further Reading

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author.

Colombi, C., & Ghaziuddin, M. (2017). Neuropsychological Characteristics of Children with Mixed Autism and ADHD. Autism Research and Treatment, 1-5. 

Doepke, K. J., Banks, B. M., Mays, J. F., Toby, L. M., & Landau, S. (2014). Co-occurring emotional and behavior problems in children with Autism Spectrum Disorders. In L. Wilkinson (Ed.), Autism Spectrum Disorders in Children and Adolescence: Evidence-based Assessment and Intervention in Schools (pp. 125-148). Washington, DC: American Psychological Association.

Kuhlthau K., Orlich F., Hall T.A., et al. (2010). Health- Related Quality of Life in children with autism spectrum disorders: results from the autism treatment network. Journal of Autism and Developmental Disorders, 40(6), 721–729.

Loveland K. A., Tunali-Kotoski, B. (2005), The school age child with autism. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders: Vol. 1. Diagnosis, development, neurobiology, and behavior (3rd ed., pp. 247-287). New York: Wiley.

Murray M.J., (2010). Attention-deficit/hyperactivity disorder in the context of autism spectrum disorders. Current Psychiatry Reports, 12(5), 382–388.

Rao, P. A., & and Landa, R. J. (2014). Association between severity of behavioral phenotype and comorbid attention deficit hyperactivity symptoms in children with autism spectrum disorders. Autism, 18, 272-280.

Sikora, D. M., Vora, P., Coury, D. L., & Rosenberg, D. (2012). Attention-Deficit/Hyperactivity Disorder Symptoms, Adaptive Functioning, and Quality of Life in Children With Autism Spectrum Disorder. Pediatrics, 130, S91-97. DOI: 10.1542/peds.2012-0900G
Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London & Philadelphia: Jessica Kingsley Publishers.

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


Friday, July 14, 2017

Evidence-Based Practice for Children with Autism

Evidence-Based Practice for Autism

Supporting children with autism spectrum disorder (ASD) requires individualized and effective intervention strategies. It is very important for families, teachers, administrators, and school-based support personnel to be knowledgeable about evidence-based approaches to adequately address the needs of students with autism and to help minimize the gap between research and practice. Although the resources for determining best practices in autism are more extensive and accessible than in previous years, school professionals face the challenge of being able to accurately identify these evidence-based strategies and then duplicate them in the classroom and other educational settings

The rapid growth of the scientific literature on ASD has also made it difficult for practitioners to stay up-to-date with research findings. Unfortunately, many proponents of ASD treatments make claims of cure or recovery, but provide little scientific evidence of effectiveness. These interventions appear in books and on websites that describe them as “cutting-edge therapies” for autism. Consequently, school-based personnel and families need to have a reliable source for identifying practices that have been shown, through scientific research, to be effective with children and youth with ASD. Evidence-based research provides a starting point for determining what interventions are most likely to be effective in achieving the desired outcomes for an individual.
Developing and implementing effective interventions and treatment for students with autism requires that they be evidence-based and supported by science. All interventions and treatments should be based on sound theoretical constructs, robust methodologies, and empirical studies of effectiveness. An evidence-based practice can be defined as a strategy, intervention, treatment, or teaching program that has met rigorous peer review and other standards and has a history of producing consistent positive results when experimentally tested and published in peer-reviewed professional journals. It excludes evidence that is supported by anecdotal reports, case studies, and publication in non-refereed journals, magazines, internet, and other media outlets.
Systematic Research Reviews
Systematic research reviews play an important role in summarizing and synthesizing the knowledge base for determining what interventions are most likely to be effective in achieving the desired outcomes for children and youth with ASD. There are two major resources available to school professionals that provide a listing, along with systematic reviews, of evidence-based interventions and practices for students with ASD: the National Autism Center’s (NAC; 2015) second phase of the National Standards Project (NSP-2), which reviewed research studies to identify established interventions for individuals with ASD, and the National Professional Development Center on Autism Spectrum Disorders (NPDC on ASD, 2015; Wong et al., 2014), which also analyzed numerous research studies and identified evidence-based practices for students with autism. Although both reviews were conducted independently, their findings are very similar and reflect a convergence across these two data sources. According to the NAC and NPDC, the following are evidence-based interventions/practices for ASD:
Behavioral Interventions: These interventions are based on behavioral principles and are designed to reduce problem behavior and teach functional alternative behaviors.
Cognitive Behavioral Intervention: Cognitive behavioral interventions are designed to change negative or unrealistic thought patterns and behaviors with the goal of positively influencing emotions and life functioning.
Modeling: This intervention relies on an adult or peer providing a demonstration (live and video) of a target behavior to the person learning a new skill, so that person can then imitate the model.
Naturalistic Interventions: These interventions primarily involve child-directed interactions to teach real-life skills (communication, interpersonal, and play skills) in natural environments. Examples include incidental teaching, milieu teaching, and embedded teaching.
Parent-Implemented Intervention: Parents provide individualized intervention to their child to improve/increase a wide variety of skills such as communication, play, or self-help, and/or to reduce challenging behavior. Parent training can take many forms, including individual training, group training, support groups, and training manuals.
Pivotal Response Training (PRT): PRT is a naturalistic intervention model that targets pivotal areas of a child's development, such as motivation, responsivity to multiple cues, self-management, and social initiations.
Peer-Mediated Instruction: Teachers/service providers systematically teach typically developing peers to interact with and/or help children and youth with ASD to acquire new behavior, communication, and social skills. Common names include peer networks, circle of friends, and peer-initiation training.
Scripting: This intervention involves developing a verbal and/or written script about a specific skill or situation which serves as a model for the child with ASD.
Self-Management: Self-management strategies involve teaching individuals with ASD to evaluate and record the occurrence/nonoccurrence of a target behavior and secure reinforcement. The objective is to be aware of and regulate their own behavior so they will require little or no assistance from adults.
Social Narratives: These interventions identify a target behavior and involve a written description of the situation under which specific behaviors are expected to occur. The most well-known story-based intervention is Social Stories™.
Social Skills Training: Social skills training involves group or individual instruction designed to teach learners with ASD ways to appropriately interact with peers, adults, and other individuals.
Visual Support: Any visual display that supports the learner engaging in a desired behavior or skills independent of prompts. Examples of visual supports include pictures, written words, schedules, maps, labels, organization systems, scripts, and timelines.
Systematic reviews synthesize the results of multiple studies and provide school professionals with summaries of the best available research evidence to help guide decision-making and support intervention practice. It must be stated, however, that these 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. Because no two individuals are alike, no one program exists that will meet the needs of every person with autism. Additionally, children with autism learn differently than typical peers or children with other types of developmental disabilities. 

The success of the intervention depends on the interaction between the age of the child, his or her developmental level and individual characteristics, strength of the intervention, and competency of the professional. Each child is different and what works for one may not work for another. Research findings are only one component of evidence-based practice to consider when selecting interventions. The selection of a specific intervention should be based on goals developed from a comprehensive developmental assessment as well as professional judgment and the values and preferences of parents, caregivers, and the individual with ASD.


References

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.
Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S… Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group.
Adapted from Wilkinson, L. A. (2017).  A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).




Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. Dr. Wilkinson 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, and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Sunday, July 9, 2017

Autism Books for Adults


Honored as an Award-Winning Finalist in the “Health: Psychology/Mental Health” category of the 2016 Best Book AwardsOvercoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT is an essential self-help book for adults on the higher end of the spectrum looking for ways to understand and cope with their emotional challenges and improve their psychological well-being. Family members, friends, and others touched by autism will also find this self-help book a valuable resource.



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