Thursday, December 21, 2017

A Multi-Tiered Approach to Screening for Autism

A Multi-Tiered Approach to Screening for Autism

There has been a dramatic worldwide increase in reported cases of autism over the past decade. Yet, compared to population estimates, many students remain underidentified and underserved in our schools. It is not unusual for children with less severe symptoms of autism spectrum disorder (ASD) to go unidentified until well after entering school. As a result, it is critical that school-based educational support personnel (e.g., school psychologists, speech/language pathologists, special educators, counselors, and social workers) give greater priority to case finding and screening to ensure that children with ASD are identified and have access to the appropriate programs and services. 
   Screening and Identification

Until recently, there were few validated screening measures available to assist school professionals in the identification of students with the core ASD-related behaviors. However, our knowledge base is expanding rapidly and we now have reliable and valid tools to screen and evaluate children more efficiently and with greater accuracy. The following tools have demonstrated utility in screening for ASD in educational settings and can be used to determine which children are likely to require further assessment and/or who might benefit from additional support. All measures have sound psychometric properties, are appropriate for school-age children, and time efficient (10 to 20 minutes to complete). Training needs are minimal and require little or no professional instruction to complete. However, interpretation of results requires familiarity with ASD and experience in administering, scoring, and interpreting psychological tests.
The Autism Spectrum Rating Scales (ASRS; Goldstein & Naglieri, 2009) is a norm-referenced tool designed to effectively identify symptoms, behaviors, and associated features of ASD in children and adolescents from 2 to 18 years of age. The ASRS can be completed by teachers and/or parents and has both long and short forms. The Short form was developed for screening purposes and contains 15 items from the full-length form that have been shown to differentiate children diagnosed with ASD from children in the general population. High scores indicate that many behaviors associated with ASD have been observed and follow-up recommended.
The Social Communication Questionnaire (SCQ; Rutter, Bailey, & Lord, 2003), previously known as the Autism Screening Questionnaire (ASQ), is a parent/caregiver dimensional measure of ASD symptomatology appropriate for children of any chronological age older than four years. It is available in two forms, Lifetime and Current, each with 40 questions. Scores on the questionnaire provide a reasonable index of symptom severity in the reciprocal social interaction, communication, and restricted/repetitive behavior domains and indicate the likelihood that a child has an ASD. The lifetime version is recommended for screening purposes as it demonstrates the highest sensitivity value. 
The Social Responsiveness Scale, Second Edition (SRS-2; Constantino & Gruber, 2012) is a brief quantitative measure of autistic behaviors in 4 to 18 year old children and youth. This 65-item rating scale was designed to be completed by an adult (teacher and/or parent) who is familiar with the child’s current behavior and developmental history. The SRS items measure the ASD symptoms in the domains of social awareness, social information processing, reciprocal social communication, social anxiety/avoidance, and stereotypic behavior/restricted interests. The scale provides a Total Score that reflects the level of severity across the entire autism spectrum.
A Multi-Tiered Screening Strategy
The ASRS, SCQ, and SRS-2 can be used confidently as efficient first-level screening tools for identifying the presence of the more broadly defined and subtle symptoms of higher-functioning ASD in school settings. School-based professionals should consider the following multi-step strategy for identifying at-risk students who are in need of an in-depth assessment.
Tier  one. The initial step is case finding. This involves the ability to recognize the risk factors and/or warning signs of ASD. All school professionals should be engaged in case finding and be alert to those students who display atypical social and/or communication behaviors that might be associated with ASD. Parent and/or teacher reports of social impairment combined with communication and behavioral concerns constitute a “red flag” and indicate the need for screening. Students who are identified with risk factors during the case finding phase should be referred for formal screening.
Tier two. Scores on the ASRS, SCQ, and SRS-2 may be used as an indication of the approximate severity of ASD symptomatology for students who present with elevated developmental risk factors and/or warning signs of ASD. Screening results are shared with parents and school-based teams with a focus on intervention planning and ongoing observation. Scores can also be used for progress monitoring and to measure change over time. Students with a positive screen who continue to show minimal progress at this level are then considered for a more comprehensive assessment and intensive interventions as part of Tier 3.  However, as with all screening tools, there will be some false negatives (children with ASD who are not identified). Thus, children who screen negative, but who have a high level of risk and/or where parent and/or teacher concerns indicate developmental variations and behaviors consistent with an autism-related disorder should continue to be monitored, regardless of screening results.
Tier three. Students who meet the threshold criteria in step two may then referred for an in-depth assessment. Because the ASRS, SCQ, and SRS-2 are strongly related to well-established and researched gold standard measures and report high levels of sensitivity (ability to correctly identify cases in a population), the results from these screening measures can be used in combination with a comprehensive developmental assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, and cognitive functioning to aid in determining eligibility for special education services and as a guide to intervention planning.
Limitations

Although the ASRS, SCQ, and SRS can be used confidently as efficient screening tools for identifying children across the broad autism spectrum, they are not without limitations. Some students who screen positive will not be identified with an ASD (false positive). On the other hand, some children who were not initially identified will go on to meet the diagnostic and/or classification criteria (false negative). Therefore, it is especially important to carefully monitor those students who screen negative to ensure access to intervention services if needed. Gathering information from family and school resources during screening will also facilitate identification of possible cases. Autism specific tools are not currently recommended for the universal screening of typical school-age children. Focusing on referred children with identified risk-factors and/or developmental delays will increase predictive values and result in more efficient identification efforts.

Concluding Comments
Compared with general population estimates, children with mild autistic traits appear to be an underidentified and underserved population in our schools. There are likely a substantial number of children with equivalent profiles to those with a clinical diagnosis of ASD who are not receiving services. Research indicates that outcomes for children on the autism spectrum can be significantly enhanced with the delivery of intensive intervention services. However, intervention services can only be implemented if students are identified. Screening is the initial step in this process. School professionals should be prepared to recognize the presence of risk factors and/or early warning signs of ASD, engage in case finding, and be familiar with screening tools in order to ensure children with ASD are being identified and provided with the appropriate programs and services. 

Best practice screening and assessment guidelines are available from: 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 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).

Wednesday, December 20, 2017

Autism: Parent Acceptance and Empowerment


Patent Acceptance and Empowerment

Parents are often overwhelmed by the challenges presented by a child with autism. Research has shown that parents of children on the spectrum exhibit a characteristic stress profile which includes anxiety related to the child's uneven intellectual profiles, deficits in social relatedness, disruptive and maladaptive behaviors (internalizing and externalizing problems) and long-term care concerns. Among these stressors, the child’s maladaptive behavior profile is most reliably linked to parent stress. 

Studies indicate that raising children with autism is associated with higher levels of parenting stress and psychological distress than parenting typically developing children, children with a physical disability, or children with developmental delays without autism. Mothers, in particular, appear to face unique challenges related to the characteristics of autism. Because autism impairs social relatedness and adaptive functioning, parent stress can decrease helpful psychological processes and directly influence the parent or caregiver’s ability to support the child with disabilities.
Research

Increased attention is now being given to the psychological well-being of parents of children and youth with autism. A number of studies have examined the factors that can influence the impact of children’s problem behavior on parent mental health. A study in the Journal Autism examined the relationships between child problem behavior, parent mental health problems, psychological acceptance (e.g., accepting and not being adversely influenced by negative emotions and thoughts that a parent may have about their child), and parent empowerment (e.g., actively attempting to change or eliminate potentially stressful events through the application of knowledge and skills).
The researchers found that the more positive parents’ psychological acceptance and empowerment, the less they reported severe mental health problems. Although greater parent empowerment was associated with fewer parent mental health problems, psychological acceptance had the greatest impact on parent mental health problems, after controlling for ASD symptomatology, negative life events, parent and child gender, and child age. 
Implications

This study has several important implications. The relatively chronic nature of behavior problems in children with autism may explain why acceptance is a more significant psychological construct for explaining parent mental health than is empowerment. If difficulties are manageable and support readily available, then an active, problem-focused coping style would be related to improved parent adjustment. However, for children with autism who exhibit more persistent behavior problems, or for highly stressed and frustrated parents, a problem-focused process may not be enough to ensure positive parent adjustment. If problems are less controllable and/or support less accessible, it may be impossible for parents to focus exclusively on trying to change or avoid their current experience. The authors comment, “In these situations, parents need a different coping strategy, one that allows them to acknowledge their current experience without trying to change it or avoid it.”  Therefore, it may be critically important to understand and evaluate the situation of the family, and offer parents both types of coping skills (acceptance and empowerment) for use across different situations.
This study supports the exploration of acceptance and mindfulness-based interventions as effective approaches for parents of children with autism and underscores the importance of considering the parent psychological experience when developing treatments for child problem behavior. The authors conclude, “Child-focused therapy should not focus exclusively on the child. At the same time that we provide parents with skills and supports to improve their children’s experience, we must also invest in helping parents to deal with their own emotions and coping strategies. 
Weiss, J. A., Cappadocia, M. C., MacMullin, J. A., Viecili, M., & Lunsky, Y. (2012). The impact of child problem behaviors of children with ASD on parent mental health: The mediating role of acceptance and empowerment. Autism, 16, 261-274. DOI: 10.1177/1362361311422708
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Tuesday, December 12, 2017

The Gender Gap in Autism: Where are the Girls?


The Gender Gap in Autism: Where are the Girls?

There has been a dramatic increase in reported cases of autism over the past decade. Prevalence rates have risen steadily, from one in 150, to one in 110, and now to one in every 59 children (or 16.8 per 1,000 8-year-olds). According to the CDC's Autism and Developmental Disabilities Monitoring (ADDM) Network, autism is 4 times more common among boys (1 in 37) than among girls (1 in 151). Statistics also indicate that referrals for evaluation of boys are nearly ten times higher than for girls. Moreover, girls are diagnosed with autism at later ages compared to boys. This gender “gap” raises serious questions because many female students with ASD are being overlooked and will not receive the appropriate educational supports and services. 
Why are fewer girls being identified?  Why do parents of girls experience a delay in receiving a diagnosis?  Are there gender differences in the expression of the disorder? Answers to these questions have practical implications in that gender specific variations may have a significant impact on identification practices and the provision of clinical and educational services. Although few studies have examined gender differences in the expression of autism spectrum disorders, we do have several tentative explanations for the underdiagnosis and late identification of girls with ASD. They include the following. 
  • Social communication and pragmatic deficits may not be readily apparent in girls because of a non-externalizing behavioral profile, passivity, and lack of initiative. Girls who have difficulty making sustained eye contact and appear socially withdrawn may also be perceived as “shy,” “naive,” or “sweet” rather than   having the social impairment associated with an autism spectrum disorder.
  • The diagnosis of another disorder often diverts attention from autism-related symptomatology. In many cases, girls tend to receive unspecified diagnoses such as a learning disability, processing problem, or internalizing disorder. A recent survey of women with Asperger syndrome indicated that most received a diagnosis of anxiety or mood disorder prior being identified with an autism spectrum disorder.
  • The perseverative and circumscribed interests of girls with autism spectrum disorders may appear to be age-typical. Girls who are not successful in social relationships and developing friendships might create imaginary friends and elaborate doll play that superficially resembles the neurotypical girl.
  • Although Students with ASD are more likely to be the target of bullying than typical peers, this may not be recognized in girls due to gender differences in preferred modes of aggression. For example, girls may use covert verbal, social, and psychological forms of aggression while boys tend to rely on confrontational and direct modes of bullying. As a result, the more subtle nature of relational and indirect aggression (social exclusion and rejection) used by girls may be taken less seriously than the more obvious, direct aggression exhibited by boys.
  • Although girls may appear less symptomatic than boys, the genders do share similar profiles. Research suggests that when IQ is controlled, the main gender difference is a higher frequency of idiosyncratic and unusual visual interests and lower levels of appropriate play in males compared to females. As a result, the behavior and educational needs of boys are much more difficult to ignore and are frequently seen by teachers and parents as being more urgent, further contributing to a referral bias.
  • Over reliance on the male model with regard to diagnostic criteria might contribute to a gender “bias” and underdiagnosis of girls. Clinical instruments also tend to exclude symptoms and behaviors that may be more typical of females with ASD. For example, assessment instruments such as the Autism Spectrum Rating Scales (ASRS) and Social Responsiveness Scale (SRS) have generally reported higher mean scores for boys than girls. The lower symptom scores for girls may reflect gender differences and expression of the phenotype. Recent research suggests that certain single test items may be more typical of girls than of boys with ASD, and examining symptom gender differences at the individual level might lead to a better understanding of the gender difference in ASD.
  • Apart from biases in reporting or diagnosis, there is significant evidence to suggest that multiple biological factors contribute to the sex differences seen in autism. These include genetic and hormonal differences between males and females that may provide a “protective” mechanism for girls and lead to differences in symptoms and vulnerability to the disorder.
If girls do process language and social information differently than boys, 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. If gender specific variations do exist, then the predictive validity of the diagnosis and developmental course may well differ between the sexes. Unfortunately, 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 on the autism spectrum. 

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 “unusual” or “different” by parents, teachers and peers, the possibility of an ASD should be given consideration. Clinicians and school-based professionals might also question the presence of ASD in girls referred for internalizing disorders such as anxiety or depression. 

Best practice assessment and intervention guidelines are available from: A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition.) and Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. 
Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools (2nd Edition.). London and Philadelphia: Jessica Kingsley Publishers.

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered psychologist, registered psychologist, and certified cognitive-behavioral therapist. He is also a university educator and trainer, and has published widely on the topic of autism spectrum disorders both in the US and internationally. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

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