Sunday, December 1, 2019

Holiday Tips for Families of Children with Autism

Reducing Holiday Stress

The holiday season can be a stressful time of year for everyone, especially for parents of children on the autism spectrum. The sights and sounds of the holidays can be stressful and over-stimulating. There are many changes in routine, family events, parties, and vacations that need to be planned. Sometimes the stress of these changes can become overwhelming and the joy and happiness of the holidays might be lost. Here are some helpful tips to lessen your child’s anxiety and increase your family’s enjoyment of the holiday season: 

 Decorating and Shopping  
  • If your child has difficulty with change, you may want to gradually decorate the house. Decorate in stages, rather than all at once. It may also be helpful to develop a visual  schedule or calendar that shows what will be done on each day.
  • Allow your child to interact with the decorations and help put them in place.
  • Flashing lights or musical decorations can disturb some children. To see how your child will respond, provide an opportunity experience these items in a store or at elsewhere first. 
  • Last minute holiday shopping can be stressful for children who rely on routines. If you do take your child shopping, allow enough time to gradually adapt to the intense holiday stimuli that stores exhibit this time of year.
 Family Routines and Travel
  • Meet as a family to discuss how to minimize disruptions to established routines and how to  support positive behavior when disruptions are inevitable. 
  • Continue using behavior support strategies during the holidays. For example, use social stories to help your child cope with changes in routine and visual supports to help prepare for more complicated days.
  •  Use a visual schedule if you are celebrating the holidays on more than one day to show when there will be parties/gifts and when there will not. 
  • Use rehearsal and role play to give children practice ahead of time in dealing with new social situations, or work together to prepare a social story that incorporates all the elements of an upcoming event or visit to better prepare them for that situation 
  • If you are traveling for the holidays, make sure you have child’s favorite foods, books or toys available. Having familiar items readily available can help to calm stressful situations. 
  • If you are going to visit family or friends, make sure there is a quiet, calm place to go to if needed. Teach your child to leave a situation and/or how to access support when a situation becomes overwhelming. For example, if you are having visitors, have a space set aside for the child as his/her safe/calm space. He or she should be taught ahead of time that they should go to their space when feeling overwhelmed. This self- management strategy will also be helpful in future situations.
 Gifts and Play Time
  • If you put gifts under the Christmas tree, prepare well ahead of time by teaching that gifts are not to be opened without the family there. Give your child a wrapped and a reward for keeping it intact. 
  • Practice unwrapping gifts, taking turns and waiting for others, and giving gifts. Role play scenarios with your child in preparation for him/her getting a gift they may not want 
  • Take toys and other gifts out of the box before wrapping them. It can be more fun and less frustrating if your child can open the gift and play with it immediately. 
  • When opening gifts as a family, try passing around an ornament to signal whose turn it is to open the next gift. This helps alleviate disorganization and the frustration of waiting. 
  • Prepare siblings and young relatives to share their new gifts with others. 
  • If necessary, consider giving your child a quiet space to play with his/her own gifts, away from the temptation of grabbing at other children’s toys 
  • Prepare family members for strategies to use to minimize anxiety or behavioral incidents, and to enhance participation. Provide suggestions ahead of time that will make for a less stressful holiday season. 
  • Keep an eye out for signs of anxiety or distress, including an increase in behavior such as humming or rocking - this may indicate it's time to take a break from the activity.
  •  Understand how much noise and other sensory input your child can manage. Know their level of anxiety and the amount of preparation it may require. 
  • Try to relax and have a good time. Do everything possible to help reduce the stress level for your child and family during the holidays. If you are tense your child may sense that something is wrong. Don’t forget to prepare yourself! A calm and collected parent is better able to help their family enjoy this wonderful time of year.

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).

Tuesday, November 5, 2019

Adverse Childhood Experiences (ACEs) in Autism


Adverse Childhood Experiences (ACEs) and Trauma

Research is advancing our understanding of the nature of childhood stress and trauma in autistic individuals and its subsequent impact on mental health and wellbeing. The DSM-5 notes that psychological distress associated with stress and trauma is varied and may include anxiety or fear-based reactions, changes in mood, anger, irritability, aggression or dissociation. Although there is a specific diagnostic category for trauma and stressor-related disorders, stress and trauma are identified as risk factors for several other disorders including depression and anxiety.

An important development in understanding the impact of stress and trauma on mental health in the general population has been the adverse childhood experience (ACE) studies. Adverse childhood experiences (ACEs) are potentially traumatic events that can have negative, lasting effects on health and well-being. The more adversities an individual has experienced, the higher the likelihood that individual will have serious mental and physical health problems later in life. ACEs include all types of abuse, neglect, and other stressful and traumatic experiences (e.g., bullying, peer rejection, neighborhood violence, poverty, financial hardship, parental divorce, incarceration, death, domestic violence, household substance abuse problems, and family mental health concerns).

There is mounting evidence for stress and trauma as a risk factor for comorbidity and the worsening of the core symptoms in ASD. These findings are consistent with research on the psychological consequences of adverse childhood experiences (ACEs) in the general population. A recent study to identify rates of ACEs in children with ASD found that a diagnosis of ASD was significantly associated with a higher probability of reporting one or more ACEs. The number of children with ASD who were exposed to four or more ACEs was twice as high compared to their typically developing peers.

The core symptoms of ASD may themselves predispose children to stressful and traumatic situations. For example, difficulty with socialization could lead to increased social anxiety or peer rejection. Experiences known to be distressing for autistic individuals such as unexpected schedule changes, the prevention or discouragement of repetitive or preferred behaviors, and sensory sensitivities, could be perceived as traumatic particularly when such distress occurs on a consistent basis, adding to the potential for comorbidity. These core symptoms would make  every day social situations and new or unexpected experiences highly stressful for someone with ASD. It is possible that consistent rumination on stressful or traumatic experiences could lead to co-occurring symptoms of depression, anxiety or even PTSD if a significant traumatic event has taken place.

 Implications

Research suggests that autistic individuals may be at high risk for experiencing stressful and traumatic life events, the consequences of which can negatively impact mental health through the development of comorbid disorders (e.g., anxiety, depression) and/or worsening of the core symptoms of ASD. Exposure to stressful and potentially traumatic events may manifest as symptoms of aggression, difficulty concentrating, social isolation, increased relational difficulties, regression in daily living skills, and increased repetitive or stereotypic behavior. As many of these symptoms are commonly associated with ASD, the stress and/or trauma underlying these symptoms may go untreated. Stressful and traumatic life events should be considered by mental health professionals when conducting assessments and determining appropriate treatment plans for autistic individuals experiencing comorbid symptomatology and or/an exacerbation of core ASD symptoms to help ensure that underlying causes of these symptoms are not overlooked. Formal screening and identification of ACEs can lead to trauma-informed interventions and treatment goals that can help to mitigate negative outcomes while promoting an environment that is supportive and affirmative of the experience of having ASD.
 
Key Resources and Further Reading

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

Beck, J. (2011). Cognitive behavior therapy: Basics and beyond ( 2nd ed.). New York: Guilford Press.

Berg, K. L., Shiu, C. S., Acharya, K., Stolbach, B. C., & Msall, M. E. (2016). Disparities in adversity among children with autism spectrum disorder: A population based study. Developmental Medicine & Child Neurology, 58, 1124–1131. https://doi.org/10.1111/ dmcn.13161.

Bishop Fitzpatrick, L., Mazefsky, C. A., Minshew, N. J., & Eack, S. M. (2015). The relationship between stress and social functioning in adults with autism spectrum disorder and without intellectual disability. Autism Research, 8(2), 164–173.

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.

Earl, R.K., Peterson, J., Wallace, A.S., Fox, E., Ma, R., Pepper, M., & Haidar, G. (2017. Trauma and autism spectrum disorder: A reference guide. Bernier Lab, Center for Human Development and Disability, University of Washington. bernierlab.uw.edu

Fuld, S (2018). Autism spectrum disorder: The impact of stressful and traumatic life events and implications for clinical practice. Clinical Social Work Journal, 46, 210-219.

García Villamisar, D., & Rojahn, J. (2015). Comorbid psychopathology and stress mediate the relationship between autistic traits and repetitive behaviours in adults with autism. Journal of Intellectual Disability Research, 59(2), 116–124. https://doi.org/10.1111/jir.12083.

Harvey, K. (2012). Trauma-informed behavioral intervention: What works and what doesn’t. Washington D.C.: American Association on Intellectual and Developmental Disabilities.

Kerns, C. M., Newschaffer, C. J., & Berkowitz, S. J. (2015). Traumatic childhood events and autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(11), 3475–3486. https://doi.org/10.1007/s10803-015-2392-y.

Kerns, C. M., Rump, K., Worley, J., Kratz, H., McVey, A., Herrington, J., & Miller, J. (2016). The differential diagnosis of anxiety disorders in cognitively-able youth with autism. Cognitive and Behavioral Practice, 23(4), 530–547.

Mannion, A., Brahm, M., & Leader, G. (2014). Comorbid psychopathology in autism spectrum disorder. Review Journal of Autism and Developmental Disorders, 1(2), 124–134. https://doi.org/10.1007/s40489-014-0012-y.

Matson, J. L., & Williams, L. W. (2014). Depression and mood disorders
among persons with autism spectrum disorders. Research in Developmental Disabilities, 35, 2003–2007. https://doi.org/10.1016/j.ridd.2014.04.020

Mayes, S. D., Gorman, A. A., Hillwig-Garcia, J., & Syed, E. (2013). Suicide ideation and attempts in children with autism. Research in Autism Spectrum Disorders, 7(1), 109–119. https://doi.org/10.1016/j.rasd.2012.07.009.

Mehtar, M., & Mukaddes, N. M. (2011). Posttraumatic stress disorder in individuals with diagnosis of autistic spectrum disorders. Research in Autism Spectrum Disorders, 5(1), 539–546. https://doi.org/10.1016/j.rasd.2010.06.020.

Reinvall, O., Moisio, A. L., Lahti-Nuuttila, P., Voutilainen, A., Laasonen, M., & Kujala, T. (2016). Psychiatric symptoms in children and adolescents with higher functioning autism spectrum disorders on the development and well-being assessment. Research in Autism Spectrum Disorders, 25, 47–57. https://doi.org/10.1016/j.rasd.2016.01.009.

Roberts, A. L., Koenen, K. C., Lyall, K., Robinson, E. B., & Weisskopf, M. G. (2015). Association of autistic traits in adulthood with childhood abuse, interpersonal victimization, and posttraumatic stress. Child Abuse & Neglect, 45, 135–142.

Schilling, E. A., Aseltine, R. H., & Gore, S. (2007). Adverse childhood experiences and mental health in young adults: A longitudinal survey. BMC Public Health, 7(1), 30.

Spratt, E. G., Nicholas, J. S., Brady, K. T., Carpenter, L. A., Hatcher, C. R., Meekins, K. A., … & Charles, J. M. (2012). Enhanced cortisol response to stress in children in autism. Journal of Autism and Developmental Disorders, 42(1), 75–81. https://doi.org/10.1007/s10803-011-1214-0.

Taylor, J. L., & Gotham, K. O. (2016). Cumulative life events, traumatic
experiences, and psychiatric symptomatology in transition-aged youth with autism spectrum disorder. Journal of Neurodevelopmental Disorders, 8(1), 28. https://doi.org/10.1186/s11689-016-9160-y.

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.

Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk,
S., … Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental
Disorders, 45(7), 1951–1966. https://doi.org/10.1007/ s10803-014-2351-z.


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 disorder. 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, October 2, 2019

Savant Skills in Autism


What are savant skills?
There is a long history of reports of individuals who despite having severe intellectual impairments, demonstrate remarkable skills in a particular area. The term “savant” has been variously defined as those individuals who show (a) normatively superior performance in an area and (b) a discrepancy between their performance in that area and their general level of functioning. Some researchers have differentiated “prodigious” savants (e.g., individuals possessing an exceptional ability in relation to both their overall level of functioning and the general population) from “talented” savants (e.g., individuals showing an outstanding skill in comparison with their overall level of functioning). 



Savant skills have been reported much more frequently in males than in females and have been identified in a wide range of neurological and neurodevelopmental disorders. The most commonly reported savant skills are mathematical skills (calendrical calculations, rapid arithmetic and prime number calculations), music (especially the ability to replay complex sequences after only one exposure), art (complex scenes with accurate perspective either created or replicated following a single brief viewing) and memory for dates, places, routes or facts. Less frequently reported are “pseudo-verbal” skills (hyperlexia or facility with foreign languages), coordination skills and mechanical aptitude.
Research
Research in the past 10 years has generated some controversy about the actual incidence of savant syndrome in autism. Once thought to be rare in people with autism, found in no more than 1 out of 10 individuals, research over the past few years suggests savant skills may be more common than previous estimates. Although there have been many single case or small group studies of individuals with autism who possess savant abilities or exceptional cognitive skills, there have been few systematic, large-scale investigations in this area. Inconsistencies in definition and wide variation in diagnostic criteria, ages and ability levels of the cases reported are problematic, as is a paucity of valid information on rates of savant skills in ASD. The objective of this research study was to investigate the nature and frequency of savant skills in a large sample of individuals with autism who had been initially diagnosed as children.
The total sample was comprised 137 individuals, first diagnosed with autism as children, who were subsequently involved in an ongoing, longitudinal follow-up study. Cognitive assessments (Wechsler Scales) were completed for all participants (100 males and 37 females) between the ages of 11 and 48 years (mean age of 24). Parental report data on savant skills were obtained approximately 10 years later at a subsequent follow-up.  Cognitive ability ranged from severe intellectual impairment to superior functioning. Savant skills were judged from parental reports and specified as “an outstanding skill/knowledge clearly above participant’s general level of ability and above the population norm.”
Results
Of the 93 individuals for whom parental questionnaire and cognitive data were available, 16 (17.2%) met criteria for a parent-rated skill, 15 (16.8%) had an exceptional cognitive skill and 8 (8.6%) met criteria for both. There were 14 calendrical calculators (one also showed exceptional memory and another also showed skill in computation and music). There were four others with computational skills (in one case combined with memory and in another case with music). Visuospatial skills (e.g., directions or highly accurate drawing) were reported in three individuals. One individual had a musical talent, one an exceptional memory skill and one had skills in both memory and art. The subtest on which participants were most likely to meet the specified criteria for an area of unusual cognitive skill was block design followed by digit span, object assembly and arithmetic.
There was a sex difference (albeit statistically non-significant) in the prevalence of savant skills. Almost one-third (32%) of males showed some form of savant or special cognitive skill compared with 19 percent of females. No individual with a non-verbal IQ below 50 met criteria for a savant skill and contrary to some earlier hypotheses; there was no indication that individuals with higher rates of stereotyped behaviors/interests were more likely to demonstrate savant skills.
Discussion
In total, 39 participants (28.5%) met criteria for a savant skill. Cognitively, 23 individuals (17% of total sample) met criteria for one or more exceptional area of skill on the Wechsler Scales. Combining the two, 37 per cent of the sample showed either savant skills or unusual cognitive skills or both, a far higher proportion than previously reported. These results suggest that the rates of savant skills in autism are significant, particularly among males, and although these estimates are higher than reported by other researchers, the findings parallel those of previous studies. Based on these findings, it appears likely that at least a third of individuals with autism show unusual skills or talents that are both above population norms and above their own overall level of cognitive functioning. It should be noted that these data offer no support to claims that savant skills occur most frequently in individuals with autism who are intellectually challenged or that individuals with higher rates of stereotyped behaviors/interests are more likely to demonstrate savant skills.
Implications

Apart from the need for further research examining the underlying basis of savant skills and why certain individuals go on to develop any area of exceptional skill and why these skills encompass such different areas, there is a more practical and pressing question; “how can these innate talents be developed to form the basis of truly ‘functional’ skills?” In the present study, only five individuals with exceptional abilities (four related to math and one related to visuospatial ability) had succeeded in using these skills to find permanent employment. For the majority, the isolated skill remained just that, leading neither to employment nor greater social integration. As the authors conclude, “The practical challenge now is to determine how individuals with special skills can be assisted, from childhood onward, to develop their talents in ways that are of direct practical value (in terms of educational and occupational achievements), thereby enhancing their opportunities for social inclusion as adults.”
Key References

Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2009). Savant skills in autism: Psychometric approaches and parental reportsPhilosophical Transactions of the Royal Society B: Biological Sciences, 364, 1359–1367. doi:10.1098/rstb.2008.0328 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677586/

Marsa, L. (2016). Extraordinary minds: The link between savantism and autism. https://spectrumnews.org/features/deep-dive/extraordinary-minds-the-link-between-savantism-and-autism/

Treffert D. (2000). Extraordinary people: Understanding savant syndrome. Ballantine Books: New York, NY.

Treffert, D. (2009). The Savant Syndrome: An Extraordinary Condition. A Synopsis: Past, Present, Future. Philosophical Transactions of the Royal Society B: Biological Sciences, 364, 1351–1358.

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 disorder. 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, August 7, 2019

Back to School Tips for Parents of Children on the Autism Spectrum


Back to School Tips for Parents of Children with Autism

Students throughout the country will soon be making the transition to a new school year. This includes an increasing number of special needs children identified with autism spectrum disorder (ASD). Since Congress added autism as a disability category to the Individuals with Disabilities Education Act (IDEA) in 1990, there has been a dramatic increase in the number of students receiving special education services under this category.  In fact, the number of students receiving assistance under the special education category of autism over the past decade has increased from 1.5 percent to 9 percent of all identified disabilities. Autism now ranks fourth among all IDEA disability categories for students age 6-21.



The beginning of a new school year is an exciting yet anxious time for both parents and children. It typically brings a change in the daily routine established over the summer months. Although transitioning back to school can be especially challenging for children on the autism spectrum, the following tips will help parents prepare them for a new school year. 

1. Prepare and reintroduce routines.
  • Familiarize and reintroduce your child to the school setting. This may mean bringing your child to the school or classroom, showing your child a picture of their teacher and any classmates, or meeting the teacher before the first day of school. If possible, arrange to visit the teacher or the school a week or two before the first day. If this isn’t feasible, visit the school building or spend some time on the playground. Driving by the school several times is another good idea. You may also want to drive your child on the first day if they ride a bus to school. For many children, riding a bus to school on the first day can result in a sensory “overload.” Ask to meet the bus driver so your child feels comfortable riding the bus. You might even ask if you and your child can do a ride-along to the school. Gradually easing into the transportation routine will be helpful for everyone.
2. Review your child's Individualized Education Plan (IEP).
  • The IEP is a legal document and the cornerstone for your child’s education. It includes academic goals, appropriate accommodations and modifications and a description of all specific special education and related services, including individualized instruction and related supports and services (e.g., counseling, occupational, physical, and speech/language therapy; transportation), together with the specific setting in which the services will be provided. Parents should always have the IEP available to reference this essential information throughout the school year. If you do not have a copy, request one from the Special Education/Services Department in your school district. If appropriate, make certain a behavior intervention plan (BIP) is in place the first day of school. If your child has a plan that’s been effective, ask that it be shared with his or her new teacher and implemented immediately at the start of the year.
3. Expect the unexpected.
  • Parents cannot anticipate everything that might happen during the school day. Allow more time for all activities during the first week of school. Prepare your child for situations that may not go as planned. Discuss a plan of action for free time, such as lunch and recess. Use social stories to familiarize your child with routines and how to behave when an unexpected event occurs. Anticipate sensory overload. The activity, noise and chaos of a typical classroom can sometimes be difficult to manage. Establish a plan of action for this situation, possibly a quiet room where the child can take a short break. If your child has dietary issues, determine in advance how this will be managed so as to avoid any miscommunication.
4. Review and teach social expectations.
  • Although many children may transition easily between the social demands of summer activities and those required in the classroom, children on the autism spectrum may need more clear-cut (and literal) reminders. Review the “dos and don’ts” of acceptable school behavior. You can also create a schedule of a typical school day by using pictures and talk about how the school day will progress. Create a social story or picture schedule for school routines. Start reviewing and practicing early. If possible, meet with teachers and administrators to discuss your child’s strengths and challenges. Remember, you are your child’s best advocate. Establish tech-based or written communication early to develop positive relationships with your child’s teacher and school. Volunteer opportunities, open houses, parent-teacher conferences, and after-school events are ways you can apply in-person communication. Rehearse new classroom activities. Ask the teacher what new activities are planned for the first week. Then, prepare your child by performing, practicing, and discussing them. This rehearsal will reduce anxiety when new activities take place during the beginning of school.
In summary, do everything possible to help reduce the stress level for your child and family during this transition time. Last but not least, don’t forget to prepare yourself! Children sense anxiety, worry, and negativity in others. A calm, collected, and positive approach will help your child make a successful transition back to school.

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered 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 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 Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Thursday, August 1, 2019

Multi-Tiered Screening for Autism in Schools

A Multi-Tiered Approach to Screening for Autism in Schools

There has been a dramatic worldwide increase in reported cases of autism over the past decade. Yet, compared to population estimates, identification rates have not kept pace in our schools. It is not unusual for children with less severe symptoms of ASD to go unidentified until well after entering school. As a result, it is critical that school-based support personnel (e.g., school psychologists, special educators, school counselors, speech/language pathologists, 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-Tier 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: Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd ed.). 


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, July 9, 2019

Alternative Therapies for Autism: Are They Effective?

Complementary and Alternative Medicine (CAM) 

Controversial therapies and interventions continue to be a significant part of the history of children and youth with autism, perhaps more so than any other childhood disorder. Unfortunately, families are often exposed to unsubstantiated, pseudoscientific theories, and related clinical practices and therapies that are ineffective and compete with validated treatments, or that have the potential to result in physical, emotional, or financial harm. Many treatments are recommended to families based on anecdotal reports that make exaggerated claims, often appearing on the internet or in the popular media that do not qualify as scientific research. Given that autism has no known cure, parents and advocates will understandably pursue interventions and treatments that offer the possibility of helping the child with autism, particularly if they are perceived as unlikely to have any adverse effects and are generally accepted or popularized.

CAM Therapies

Complementary and alternative medicine (CAM), also called integrative medicine, is an approach widely used by families caring for individuals with autism. 
CAM is defined as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.” Current research estimates that
between 30 and 95 percent of children with autism spectrum disorder (ASD) have tried complementary or alternative medicine therapies, and up to 10% may be using a potentially dangerous treatment. The most commonly used CAM treatments for ASD fall into the categories of "biological" and “non-biological.” Examples of biological therapies include immunoregulatory interventions (e.g., dietary restriction of food allergens or administration of immunoglobulin or antiviral agents); detoxification therapies (e.g., chelation); stem-cell therapy; hyperbaric oxygen therapy (HBOT); gastrointestinal treatments (e.g., digestive enzymes, antifungal agents, probiotics, and gluten/casein-free diet); cannabidiol (CBD), and dietary supplement regimens (e.g., vitamin A, vitamin C, vitamin B6 and magnesium, folinic acid, vitamin B12, dimethylglycine and trimethylglycine, carnosine, omega-3 fatty acids, inositol, and various minerals). Non-biological interventions include treatments such as auditory integration training; sensory integration therapy; neurofeedback; pet therapy; massage therapy; aromatherapy; behavioral optometry; craniosacral manipulation; acupuncture; chiropractic treatment, and facilitated communication. These CAM therapies are generally described as pseudoscience and typically involve claims of scientifically supported evidence, which is in fact, lacking or misinterpreted.
At present, the empirical and treatment literature does not support and recommend the use of either biological or non-biological CAM treatments for children with ASD. Overall, there is sparse evidence on the usefulness of CAM treatments with autism. Although some CAM practices appear to have emerging evidence to support their use in traditional medical practice (i.e., melatonin), there are no CAM interventions with sufficient evidence to suggest they are effective. The most extensively evaluated biological CAM treatment for autism, the hormone secretin, has been thoroughly evaluated and shown to be ineffective with respect to core symptoms of ASD, including self-stimulatory behaviors, impaired communication, restrictive and repetitive behaviors, and gastrointestinal problems.  Additionally, research does not support the use of biological detoxification therapies such as chelation for ASD. According to the U. S. Food and Drug Administration, there are serious safety issues associated with chelation products. Similarly, the FDA has announced that hyperbaric oxygen treatment (HBOT) is not an approved or effective treatment for autism.
Implications

Unfortunately, pseudoscience is commonly practiced with ASD. Professionals in clinical and school contexts play an important role in helping parents and caregivers to differentiate empirically validated treatment approaches from treatments that are unproven and potentially ineffective and/or harmful. The major risk of CAM treatments is not only the potential for harm (e.g., chelation products), but the time and resources devoted to ineffective therapies at the expense of evidence-based interventions that have demonstrated effectiveness. The time, effort, and financial resources spent on pseudo and ineffective treatments can create an additional burden on families. 

All treatment selections should be evidence-based and include peer-reviewed studies with well-defined populations, randomized, large samples, control for confounding factors, and the use of validated outcome measures. There are few peer-reviewed, well-controlled, independent studies about CAM therapies, both for autism and many other health conditions. The paucity of validated, evidence-based data limits the ability to make fully informed decisions about the appropriateness of these treatments, particularly when considering that some CAM therapies are initiated without the guidance of a medical professional. 

More methodologically sound research needs to be completed on CAM treatments, and this information disseminated to families by well-informed professionals, so that parents can make educated judgments in selecting interventions. Parents and professionals should exercise caution when considering interventions and treatments that (a) are based on overly simplified scientific theories; (b) make claims of recovery and/or cure; (c) use case reports or anecdotal data rather than scientific studies; (d) lack peer-reviewed references or deny the need for controlled research studies; or (e) are advertised to have no potential or reported adverse effects. 
Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.
                                              Key References and Further Reading
American Academy of Pediatrics, Section on Complementary and Integrative Medicine and Council on Children with Disabilities, Policy Statement (2012). Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics, 1186-1189. doi: 10.1542/peds.2012-0876. 
Autism Science Foundation. Beware of Non-Evidence-Based Treatments. Available from https://autismsciencefoundation.org/what-is-autism/beware-of-non-evidence-based-treatments/
Brondino, N., Fusar-Poli, L., Rocchetti, M., Provenzani, U., Barale, F., & Politi, P. (2015). Complementary and Alternative Therapies for Autism Spectrum Disorder. Evidence-Based Complementary and Alternative Medicine. Article ID 258589, 31 pages http://dx.doi.org/10.1155/2015/258589
Christon, L. M., Mackintosh, V. H., & Myers, B. J. (2010). Use of complementary and alternative medicine (CAM) treatments by parents of children with autism spectrum disorders. Research in Autism Spectrum Disorders, 4, 249–259.
Green, G., & Perry, L. (1999). Science, Pseudoscience and Antiscience. Science in Autism Treatment, 1(1), 5-6.
Granpeesheh, D., Tarbox, J., Dixon, D. R., Wilke, A. E., Allen, M. S., & Bradstreet, J. J. (2010). Randomized trial of hyperbaric oxygen therapy for children with autism. Research in Autism Spectrum Disorders, 4, 268-275.
Hopf, K. P., Madren, E., & Santianni, K. A. (2016). Use and Perceived Effectiveness of Complementary and Alternative Medicine to Treat and Manage the Symptoms of Autism in Children: A Survey of Parents in a Community Population. Journal of alternative and complementary medicine (New York, N.Y.)22(1), 25–32. doi:10.1089/acm.2015.0163
Huffman, L. C., Sutcliffe, T. K., Tanner, I. S. D., & Feldman, H. M. (2011). Management of symptoms in children with autism spectrum disorders: A comprehensive review of pharmacologic and complementary-alternative medicine treatments. Journal of Developmental and Behavioral Pediatrics, 32, 56-68. 
Hyman, S. L., Stewart, P. A., Foley, J., Cain, U., Peck, R., Morris, D. D…Smith, T. (2016). The gluten-free/casein-free diet: A double-blind challenge trial in children with autism. Journal of Autism and Developmental Disorders, 46, 205-220. doi.10.1007/s10803-015-2564-9
Lange, K.W., Hauser, J., & Reissmann, A. (2015). Gluten-free and casein-free diets in the therapy of autism. Current Opinion in Clinical Nutrition & Metabolic Care, 18, 572-575.
Lang, R., O’Reilly, M., Healy, O., Rispoli, M., Lydon, H., Streusand, W…Giesbers, S. (2012). Sensory integration therapy for autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 6, 1004-1018. doi:10.1016/j.rasd.2012.01.006
Levy, S. Complementary and Alternative Medicine Among Children Recently Diagnosed with Autistic Spectrum Disorder; Journal of Developmental and Behavioral Pediatrics, December 2003; vol 24: pp 418-423. News release, Health Behavior News Service.
Levy, S. E., & Hyman, S. L. (2008). “Complementary and Alternative Medicine Treatments for Children with Autism Spectrum Disorders.” Child and Adolescent Psychiatric Clinics of North America17(4), 803–ix. http://doi.org/10.1016/j.chc.2008.06.004
Lindly, O.J., Thorburn, S., Heisler, K. et al. (2018).  Parents’ Use of Complementary Health Approaches for Young Children with Autism Spectrum Disorder. Journal of  Autism and Developmental Disorders, 48: 1803-1818. https://doi.org/10.1007/s10803-017-3432-6
Mulloy, A., Lang, R., O’Reilly, M., Sigafoos, J., Lancioni, G., & Rispoli, M. (2010). Gluten-free and casein-free diets in the treatment of autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 4, 328-339.
Nath, D. (2017). Complementary and Alternative Medicine in the School-Age Child With Autism. Journal of Pediatric Health Care, vol. 31, no. 3, pp. 393–397.

National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author. Available from: http://www.nationalautismcenter.org/national-standards-project/phase-2/
National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices. Available from: http://autismpdc.fpg.unc.edu/evidence-based-practices
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.
Odom, S. L., & Wong, C. (Summer, 2015). Connecting the dots: Supporting students with autism spectrum disorder. American Educator, 12-19.
Rubenstein, E., Schieve, L., Bradley, C., DiGuiseppi, C., Moody, E., Thomas, K., & Daniels, J. (2018). The prevalence of gluten free diet use among preschool children with autism spectrum disorder. Autism research: official journal of the International Society for Autism Research11(1), 185–193. doi:10.1002/aur.1896
Salgado, C. A., & Castellanos, D. (2018). Autism Spectrum Disorder and Cannabidiol: Have We Seen This Movie Before? Global pediatric health5, 2333794X18815412. doi:10.1177/2333794X18815412
Sathe Nila, Andrews Jeffrey C, McPheeters Melissa L, Warren Zachary E. Nutritional and dietary interventions for autism spectrum disorder: A systematic review. Pediatrics. 2017;139(6)
Umbarger, G. T. (2007). State of the Evidence Regarding Complementary and Alternative Medical Treatments for Autism Spectrum Disorders. Education and Training in Developmental Disabilities, 42, 437– 447
U.S. Food and Drug Administration (2014). Beware of False or misleading claims for treating autism. Available from www.fda.gov/forconsumers/consumerupdates/ucm394757.htm
Warren, Z., Veenstra-VanderWeele, J., Stone, W., Bruzek, J. L., Nahmias, A. S., Foss-Feig, J. H…McPheeters, M. (2011). Therapies for children with autism spectrum disorders. Comparative Effectiveness Review, Number 26. AHRQ Publication No. 11-EHC029-EF. Rockville, MD: Agency for Healthcare Research and Quality. 
Wong, C., Odom, S. L., Hume, K. A., Cox, C. W., Fettig, A., Kurcharczyk…Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders, 45, 1951-66. doi: 10.1007/s10803-014-2351-z
Lee A. Wilkinson, PhD, 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. 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 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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