Tuesday, November 20, 2018

Supporting Autism Families in Our Schools

Parent Perspectives and Need for Support
Studies indicate that the demands placed on parents caring for an autistic child contribute to a higher overall incidence of parental stress, depression, and anxiety which adversely affects family functioning and marital relationships compared with parents of children with other disabilities. It is well established that social support is protective of optimal parent well-being and, therefore, a key element of intervention and treatment. Supporting and ensuring the family system’s emotional and physical health is a critical component of best practice.
School professionals working with families of children with an ASD should be aware of the negative effects of stress and anxiety and assist in offering services that directly address parental needs and support mental health. Negative outcomes include: (a) increased risk of marital problems; (b) decrease in father’s involvement; (c) greater parenting and psychological distress; (d) higher levels of anxiety and depression; (f) added pressure on the family system; (g) more physical and health related issues; (h) decrease in adaptive coping skills; and (i) greater stress on mothers than fathers. Parents often experience stress as they decide how to allocate their attention and energy across family members. For example, they may feel guilty about the limited time they spend with their spouse and other children, when so much of their attention is focused on the child with ASD.
Understanding parent perspectives and targeting parental stress is critical in enhancing well-being and the parent-child relationship. School professionals who have knowledge and understanding of the stressors parents face are able to provide more effective assistance and support to the family. When families receive a diagnosis of autism, a period of anxiety, insecurity, and confusion often follow. Some autism specialists have suggested that parents go through stages of grief and mourning similar to the stages experienced with a loss of a loved one (e.g., fear, denial, anger, bargaining/guilt, depression and acceptance). Sensitivity to this process can help school professionals provide support to families during the critical period following the child’s autism diagnosis when parents are learning to navigate the complex system of autism services.
Mothers, in particular, may experience high levels of psychological distress, depressive symptoms, and social isolation. Research has found that nearly 40% of mothers reported clinically significant levels of parenting stress and between 33% and 59% experienced significant depressive symptoms following their child’s diagnosis of ASD. Challenges in obtaining a timely ASD diagnosis and lack of appropriate treatment services and education were contributors to parental stress and dissatisfaction. Frequently reported important unmet needs include (1) financial support; (2) break from responsibilities; (3) rest/sleep; and (4) help remaining hopeful about the future.
Support, Educate, Advocate

School professionals can support parents by educating them about ASD; provide guidance and training; assist them in obtaining access to resources; offer emotional support by listening and talking through problems; and help advocate for their child’s needs. It is especially important to acknowledge the value of parents’ unique and important perspective, validate their observations and concerns, and reinforce their roles as important contributors to the educational process. Professionals should also help the family understand what the identification or diagnosis of ASD means and what the next steps are in addressing the issues of support and educational planning. This includes helping parents achieve a better understanding of how their child thinks and learns differently and become familiar with strategies that might help both at home and school. For example, parents can be taught evidence-based strategies that successfully support their children with ASD. Parent-implemented interventions have the potential to improve the child’s communication skills and reduce aggression and disruptive behaviors, as well as increase the functioning of the family system. Parents can learn to implement story-based interventions, visual supports/schedules, and Pivotal Response Treatment (PRT) strategies in their home and/or community through individual or group training formats. Professionals can also assist families by offering parent training in behavior management, which has been shown to increase parents’ self-efficacy and decrease their child’s problematic behaviors. Establishing a school-based parent support group may also be consideration.
Another major strategy for helping families with children with ASD is providing information on the access to ongoing supports and services. This includes publicly funded, state-administrated programs such as early intervention, special education, vocational and residential/living services, and respite services. Professionals and family advocates need to be aware of the various programs and their respective eligibility requirements and help parents to access these services. Parents will also need timely and appropriate information regarding their children’s programs and services and may have questions about long-term educational planning. It is important to openly communicate the student’s strengths and weaknesses and encourage parents to play an active role in developing and implementing intervention plans and IEPs. Professionals should also remember that parents have a life-long role in their child’s development and realize that the family’s needs will change over time, and that they have other family responsibilities in addition to their child with autism. When schools use a family-centered approach and work to increase parental involvement and support, not only do the parents and children benefit, but school personnel do as well.

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. 

Key References & Further Reading
Barnhill, G. P. (2014). Collaboration between families and schools. In L. A. Wilkinson (Ed.), Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 219-241). Washington, DC: American Psychological Association.

Estes, A., Munson, J., Dawson, G., Koehler, E., Zhou, X., & Abbott, R. (2009). Parenting stress and psychological functioning among mothers of preschool children with autism and developmental delay. Autism, 13, 375-387.

Feinberg, E., Augustyn, M., Fitzgerald, E., Sandler, J., Ferreira-Cesar Suarez, Z., Chen, N…Silverstein, M. (2014). Improving maternal mental health after a child’s diagnosis of autism spectrum disorder: Results from a randomized clinical trial. JAMA Pediatrics, 168(1), 40-46. doi:10.1001/jamapediatrics.2013.3445.

Giallo, R., Wood, C. E., Jellett, R., & Porter, R. (2013). Fatigue, wellbeing and parental self-efficacy in mothers of children with an Autism Spectrum Disorder. Autism, 17, 465-480.

Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J…Minjarez, M. B. (2015), A randomized controlled trial of Pivotal Response Treatment Group for parents of children with autism. Journal of Child Psychology and Psychiatry, 56, 884-892. doi: 10.1111/jcpp.12354

Hoffman, C. D., Sweeney, D. P., Hodge, D., Lopez-Wagner, M. C., & Looney, L. (2009)
Parenting stress and closeness: Mothers of typically developing children and mothers of children with autism. Focus on Autism and Other Developmental Disabilities, 24, 178-187.

Kiami, S. R., & Goodgold, S. (2017). Support Needs and Coping Strategies as
Predictors of Stress Level among Mothers of Children with Autism Spectrum Disorder. Autism Research and Treatment Volume 2017, Article ID 8685950, https://doi.org/10.1155/2017/8685950

Myers, S. M., & Johnson, C. P. (2007). Management of children with autism spectrum disorders. Pediatrics, 120, 1162-1182. doi: 10.1542/peds.2007-2362

National Autism Center. (2015). Evidence-based practice and autism in the schools: An educator’s guide to providing appropriate interventions to students with autism spectrum disorder (2nd ed.). Randolph, MA: Author

Rogers, S. J., & Vismara, L. A. (2008). Evidence-based comprehensive treatments for early autism. Journal of Clinical Child & Adolescent Psychology, 37, 8-38.

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. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools (2nd Edition). London and Philadelphia: Jessica Kingsley Publishers.

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, 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).

Wednesday, November 14, 2018

Best Practice Guidelines for Assessment of Autism Spectrum Disorder (ASD) in Schools


Best Practice Guidelines for Assessment of Autism Spectrum Disorder

The number of children identified with autism has more than doubled over the last decade. School-based and mental health professionals are now being asked to participate in the screening, assessment, and educational planning for children and youth on the spectrum more than at any other time in the recent past. Moreover, the call for greater use of evidence-based practice has increased demands that professionals be prepared to recognize the presence of risk factors, engage in case finding, and be knowledgeable about “best practice” guidelines in assessment and intervention for autism spectrum disorder (ASD) to ensure that students are being identified and provided with the appropriate programs and services.

Best practice guidelines are developed using the best available research evidence in order to provide professionals with evidence-informed recommendations that support practice and guide practitioner decisions regarding assessment and intervention. Best practice requires the integration of professional expertise, each student’s unique strengths and needs, family values and preferences, and the best research evidence (rigorous peer-review) into the delivery of services. Professionals and families collaborate and work together as partners to prioritize domains of functioning for assessment and intervention planning. Best practices for school-based practitioners are best practices for students and their families.    
    
Comprehensive Developmental Assessment

The primary goals of conducting an autism spectrum assessment are to determine the presence and severity of an autism spectrum disorder (ASD), develop interventions for intervention/treatment planning, and collect data that will help with progress monitoring. Professionals must also determine whether an ASD has been overlooked or misclassified, describe co-occurring (comorbid) disorders, or identify an alternative classification. There are several important considerations that should inform the assessment process. First, a developmental perspective is critically important. While the core symptoms of are present during early childhood, ASD is a lifelong disability that affects the individual’s adaptive functioning from childhood through adulthood. Utilizing a developmental assessment framework provides a yardstick for understanding the severity and quality of delays or atypicality. Because ASD affects multiple developmental domains, the use of an interdisciplinary team constitutes best practice for assessment and diagnosis of ASD. A team approach is essential for establishing a developmental and psychosocial profile of the child in order to guide intervention planning. The following principles should guide the assessment process.
  • Children who screen positive for ASD should be referred for a comprehensive assessment.  Although screening tools have utility in broadly identifying children who are at-risk for an autism spectrum condition, they are not recommended as stand alone diagnostic instruments or as a substitute for a more inclusive assessment.
  • Assessment should involve careful attention to the signs and symptoms consistent with ASD as well as other coexisting childhood disorders.
  • When a student is suspected of having an ASD, a review of his or her developmental history in areas such as speech, communication, social and play skills is an important first step in the assessment process.
  • A family medical history and review of psychosocial factors that may play a role in the child’s development is a significant component of the assessment process. 
  • The integration of information from multiple sources will strengthen the reliability of the assessment results.
  • Evaluation of academic achievement should be included in assessment and intervention planning to address learning and behavioral concerns in the child’s overall school functioning.
  • Assessment procedures should be designed to assist in the development of  instructional objectives and intervention strategies based on the student’s unique pattern of strengths and weaknesses.
  • Because impairment in communication and social reciprocity are core features of ASD, a comprehensive developmental assessment should include both domains
  • Restricted, repetitive patterns of behavior, interests, or activities (RRB) are a defining feature of ASD and should be a focus of assessment.
A comprehensive developmental assessment approach requires the use of multiple measures including, but not limited to, verbal reports, direct observation, direct interaction and evaluation, and third-party reports. Assessment is a continuous process, rather than a series of separate actions, and procedures may overlap and take place in tandem. While specific activities of the assessment process will vary and depend on the child’s age, history, referral questions, and any previous evaluations and assessments, the following components should be included in a best practice assessment and evaluation of ASD in school-age children.
  •  Record review
  •  Developmental and medical history
  •  Medical screening and/or evaluation
  • Parent/caregiver interview
  • Parent/teacher ratings of social competence/interaction
  • Direct child observation
  • Cognitive assessment
  • Academic assessment
  • Adaptive behavior assessment
  • Social communication and language assessment
  • Assessment of RRB (including sensory issues)
Children with ASD often demonstrate additional problems beyond those associated with the core domains. Therefore, other areas should be included in the assessment battery depending on the referral question, history, and core evaluation results. These may include:
  • Sensory processing
  • Executive function, memory, and attention
  •  Motor skills
  • Family system 
  • Co-occurring (comorbid) behavioral/emotional problems   
The above referenced principles and procedures for the assessment of school-age children with ASD are reflected in recommendations of the American Academy of Neurology, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and a consensus panel with representation from multiple professional societies. A detailed description of the comprehensive developmental assessment model and specific assessment tools recommended for each domain can be found in 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, 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, November 12, 2018

First Impressions Matter: Facial Expressivity & Peer Acceptance in Autism

First Impressions Matter

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by two core-defining features: impairments in (a) social communication and (b) restricted and repetitive behaviors or interests (American Psychiatric Association [APA], 2013). Social-communication deficits include difficulties making affective (emotional) contact with others. This includes deficits in nonverbal communicative behaviors used for social interaction which range from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to a lack of facial expression or gestures.

Many individuals on the autism spectrum have a “flat affect” or reduced facial display. “Flat affect” is a term used to describe a lack of emotional reactivity or expressivity. With a flat affect, expressive gestures are minimal, and there is little animation in facial expression or vocal inflection. Facial expressions are a form of non-verbal communication essential to interpersonal relationships. An inability to read facial and social cues makes “connecting” to others very difficult. Likewise, reduced expres­sivity may impede social discourse or provoke negative initial reactions to the person with autism. 
Research
A study published in the journal Autism examined the impact of facial expressivity on first impression formation and found that typically developing children formed their impressions of peers with ASD in as little as 30 seconds. Videos of children with ASD were initially rated for facial expressivity by adults who were unaware of the condition. Researchers further investigated the friendship ratings given by 44 typically developing children to the same videos. The children making friendship judgments were also unaware that they were rating children with autism. These ratings were compared to friendship ratings given to video clips of typically developing children. Adult participants rated children with autism as being less expressive than typically developing children. The 44 child participants also rated peers with autism lower than typically developing children on all aspects of friendship measures. Autistic children were rated not as trustworthy as the typically-developing children in the films. Moreover, study participants were less likely to say that they wanted to play with or be friends with the video subjects on the spectrum. These results suggest that impression formation is less positive towards autistic children than towards typically developing children even when exposure time is brief.
Implications
The findings of this study have important implications for intervention. First impressions make a difference: whether you are looking at facial expressions, gestures, or just general appearance, people are quick to form judgments about others. Autistic children experience more peer rejection and have fewer friendships than their typically developing peers. Limited facial expres­sivity may further remove children with autism from meaningful interactions and reciprocal emotional related­ness with others. Negative peer responses can be especially upsetting for more socially aware autistic children who may be strive but fail to form friendships. Further, distress often increases as children approach adolescence and the social milieu becomes more complex. 
Social relationship skills are critical to successful social, emotional, and cognitive development and to long-term outcomes for all students. An increase in the quality of social relationships can have a major influence on the social and academic development of both typically developing children and those with autism. Consequently, intervention needs to be focused on both groups in potential interactions rather than solely on the child with autism. This includes strategies designed to promote skill acquisition in building social relationships such as direct instruction, modeling, role-play, structured activities, social stories, formal social groups, pivotal response teaching, self-monitoring, and coaching. 

Students in general education can help the process of cohesion by serving as prosocial role models for autistic students. Teachers may also provide reinforcement for prosocial behavior or assign students in general education to work with students with autism in small groups on class projects together to promote positive interaction. Schools should make a dedicated effort to educate typically developing children about autism and associated symptoms. Educating children and increasing awareness will hopefully encourage a more thoughtful first impression formation process. Teaching social skills can have both preventive and remedial effects that can help reduce the risk for negative outcomes not only for children on the autism spectrum, but also for all children. 
Does facial expressivity count? How typically developing children respond initially to children with Autism. Steven D Stagg, Rachel Slavny, Charlotte Hand, Alice Cardoso and Pamela Smith. Autism published online 11 October 2013 DOI: 10.1177/1362361313492392 
The online version of this article can be found at: http://aut.sagepub.com/content/early/2013/10/10/1362361313492392
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).

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