Tuesday, August 28, 2018

Psychiatric Comorbidity in Autism

Psychiatric Comorbidity in Autism

Children with autism spectrum disorder (ASD) frequently have co-occurring (comorbid) psychiatric conditions, with estimates as high as 70 to 84 percent.  A Comorbid disorder is defined as a disorder that co-exists or co-occurs with another diagnosis so that both share a primary focus of clinical and educational attention. Research indicates that autistic children and youth have a high risk for meeting criteria for other disorders, such as mood and anxiety disorders, attention deficit/hyperactivity disorder (ADHD), and disruptive behavior disorders, all which contribute to overall impairment.
Internalizing Problems
Studies have consistently reported an association between ASD and internalizing symptoms, in particular, anxiety and depression. A bidirectional association has been identified between internalizing disorders and autistic symptoms. For example, both a higher prevalence of anxiety disorders has been found in ASD and a higher rate of autistic traits has been reported in youth with mood and anxiety disorders. Autistic individuals also display more social anxiety symptoms compared to typical individuals, even if these symptoms were clinically overlapping with the characteristic social problems of ASD. In addition, there is some evidence to suggest that adolescents and young adults with ASD show a higher prevalence of bipolar disorders as compared to controls.
Depression is one of the most common comorbid conditions observed in individuals with ASD, particularly higher functioning youth. A study of psychiatric comorbidity in young autistic adults revealed that 70% had experienced at least one episode of major depression and 50% reported recurrent major depression. Although another documented association is with obsessive-compulsive disorder (OCD), it is difficult to determine whether observed obsessive-repetitive behaviors are an expression of a separate, comorbid OCD, or an integral part of the core diagnostic features of ASD (i. e., restricted, repetitive patterns of behavior, interests, or activities).
Externalizing Problems
An association between ASD and attention-deficit/hyperactivity disorder (ADHD) and other externalizing problems (i. e., oppositional defiant disorder) have been reported. Studies have found that children with ASD in clinical settings present with co-occurring symptoms of ADHD with rates ranging between 37% and 85%. Although there continues to a debate about ADHD comorbidity in ASD, research, practice and theoretical models suggest that co-occurrence between these conditions is relevant and occurs frequently. For example, case studies suggest that ADHD is a relatively common initial diagnosis in young autistic children. 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.
Other Comorbidities
Tourette Syndrome (TS) and other tic disorders have been found to be a comorbid condition in many children with ASD. A Swedish study showed that 20% of all school-age children with ASD met the full criteria for TS. There also appears to be a higher incidence of seizures in children with autism compared to the general population. The comorbidity of ASD and psychotic disorders has received some research attention. A study of children with ASD who were referred for psychotic behavior and given a diagnosis of schizophrenia showed that when psychotic behaviors were the presenting symptoms, depression and not schizophrenia, was the likely diagnosis. Thus, autistic individuals may present with characteristics that could lead to a misdiagnosis of schizophrenia and other psychotic disorders.
Implications
Children and youth with ASD frequently have comorbid conditions, with rates significantly higher than would be expected from the general population. The most common co-occurring diagnoses are anxiety and depression, attention problems, and disruptive behavior disorders. The core symptoms of ASD can often mask the symptoms of a comorbid condition. The current challenge for practitioners is to determine if the symptoms observed in ASD are part of the same dimension (i. e, the autism spectrum) or whether they represent another condition. Although various psychometric instruments, such as clinical interviews, self-report questionnaires and checklists, are widely used to assist in diagnosis, these tools are designed and standardized to identify symptoms in the general population, and may not be appropriate and valid for use with ASD. Likewise, their administration may be problematic in that autistic individuals may have difficulties in sustaining a reciprocal conversation, reporting events, and perspective taking. Nevertheless, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, impulsivity, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Co-occurring conditions should also be carefully investigated when severe or worsening symptoms are present that are not responding to intervention or treatment.
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, 2017, 1-5. doi:10.1155/2017/5781781

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.

Duerden, E. G., Oatley, H. K., Mak-Fan, K. M., McGrath, P. A., Taylor, M. J., Szatmari, P., & Roberts, S. W. (2012). Risk factors associated with self-injurious behaviors in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42:2460–2470. DOI 10.1007/s10803-012-1497-9

Maenner, M. J., Arneson, C. L., Levy, S. E., Kirby, R. S., Nicholas, J. S., & Durkin, M. S. (2012). Brief report: Association between behavioral features and gastrointestinal problems among children with autism spectrum disorder. J Autism Dev Disord 42:1520–1525. DOI 10.1007/s10803-011-1379-6

Mayes, S. D., Calhoun, S. L., Murray, M. J., & Zahid, J. (2011). Variables associated with anxiety and depression in children with autism. Journal of Developmental and Physical Disabilities, 23, 325–337.

Mazurek, M. O., Vasa, R. A., Kalb, L. G., Kanne, S. M., Rosenberg, D., Keefer, A., et al. (2013). Anxiety, sensory over-responsivity, and gastrointestinal problems in children with autism spectrum disorders. Journal of Abnormal Child Psychology, 41, 165–176.

Mazurek, M. O., Kanne, S. M., & Wodka, E. L. (2013).  Physical aggression in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 455–465.

Mazzone, L., Ruta, L., & Reale, L. (2012). Psychiatric comorbidities in Asperger syndrome and high functioning autism: diagnostic challenges. Annals of General Psychiatry, 11:16. doi:10.1186/1744-859X-11-16

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

Strang, J. F., Kenworthy, L., Daniolos, P., Case, L., Wills, M. C., Martin, A., et al. (2012). Depression and anxiety symptoms in children and adolescents with autism spectrum disorders without intellectual disability. Research in Autism Spectrum Disorders, 6(1), 406–412.

Tureck, K., Matson, J. L., May, A., Whiting, S. E., & Davis, T. E., III. (2013). Comorbid symptoms in children with anxiety disorders compared to children with autism spectrum disorders. Journal of Developmental and Physical Disabilities. doi: 10.1007/s10882-013

Wilkinson, L. A. (2015). Overcoming Anxiety on the Autism Spectrum: A Self-Help Guide Using CBT. London and Philadelphia: Jessica Kingsley Publishers.

Wilkinson, L. A. (2017).  A best practice guide to assessment and intervention for autism spectrum disorder in schools (2nd ed.). 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 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 CBT. He is also editor of a best-selling text in the American Psychological Association (APA) School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in SchoolsHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Friday, August 17, 2018

The IEP for Students on the Autism Spectrum


The IEP: Educating Children with Autism

Education has been shown to be among the most effective intervention/treatment for children with autism spectrum disorder (ASD). The most recent reauthorization of the Individuals with Disabilities Education Act (IDEA 2004) entitles all students with disabilities to a free appropriate public education (FAPE). In fact, the National Research Council (2001) recommends that all children identified with ASD, regardless of severity, be made eligible for special educational services under the IDEA category of autism. FAPE encompasses both procedural safeguards and the student’s individualized education program or plan (IEP). The IEP is the cornerstone for the education of a child with ASD. When a student is determined eligible for special education services, an IEP planning team is formed to develop the IEP and subsequently determine placement. Parents, teachers and support professionals play a key role in the development, implementation, and evaluation of the child’s IEP. All share the responsibility for monitoring the student’s progress toward meeting the plan's specific academic, social, and behavioral goals and objectives. 
Although the type and intensity of services will vary, depending on the student’s age, cognitive and language levels, behavioral needs and family priorities, the IEP should address all areas in which a child needs educational assistance. These include academic and non-academic goals if the services will provide an educational benefit for the student. All areas of projected need are incorporated in the IEP, together with the specific setting in which the services will be provided and the professionals who will provide the service. 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.
The content of an IEP should include the following (Individuals with Disabilities Education Improvement Act, 2004):
  • The IEP should be 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 accommodations and 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.
  • A statement of the child's present level of educational performance (both academic and nonacademic aspects of his or her performance). 
  • Specific goals and objectives designed to provide the appropriate educational services. This includes a statement of annual goals that the student may be expected to reasonably meet during the coming academic year, together with a series of measurable, intermediate objectives for each goal. 
  • Appropriate objective criteria, evaluation procedures and schedules for determining, at least annually, whether the child is achieving the specific objectives detailed in the IEP. 
  • A description of all specific special education and related services, including individualized instruction and related supports and services to be provided (e.g., counseling, occupational, physical, and speech/language therapy; transportation) and the extent to which the child will participate in regular educational programs with typical peers. 
  • Accommodations should be specifically documented in the IEP. Accommodations refer to the adjustments made to ensure that the student has equal access to educational programming by removing, to the extent, possible, barriers to successful classroom performance. Adjustments may be made to (a) instructional methods, teaching style, and curricular materials; (b) classroom and homework assignments; (c) assessment tools and ways of responding; (d) time requirements; and (e) environmental setting. Once accommodations are made, the student with special needs is expected to meet the standards of all students.
  • The initiation date and duration of each of the services to be provided (including extended school year services). 
  • If the student is 16 years of age or older, the IEP must include a description of transitional services (coordinated set of activities designed to assist the student in movement from school to post-school activities).
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. School districts should also 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 child.

Adapted from Wilkinson, L. A. (2017). Best practice in special education. In L. A. Wilkinson, A best practice guide to assessment and intervention for autism spectrum disorder in schools (pp. 157-200). London: Jessica Kingsley Publishers.


Key References and Further Reading
Information and tips on writing and developing measurable IEP goals for learners with ASD are available from the following:
Kabot, S., & Reeve, C. (2014). Curriculum and Program Structure. In L. A. Wilkinson (Ed.), Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 195-218). Washington, DC: American Psychological Association.
Myles, B. S., Adreon, D. A., Hagen, K., Holverstott, J., Hubbard, A., Smith, S. M., et al. (2005). Life journey through autism: An educator’s guide to Asperger syndrome. Arlington, VA: Organization for Autism Research.
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.
Wagner, S. (2014). Continuum of Services and Individualized Education Plan Process. In L. A. Wilkinson (Ed.). Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 173-193). Washington, DC: American Psychological Association.
Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.
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: Jessica Kingsley Publishers.
Wilmshurst, L. & Brue, A. (2010). The complete guide to special education: Expert advice on evaluations, IEPs, and helping kids succeed (2nd edition). San Francisco, CA: Jossey-Bass.
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 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 the 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 SchoolsHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Follow by Email

Top 10 Most Popular Best Practice Posts

Search BestPracticeAutism.com

Blog Archive

Best Practice Books

Total Pageviews