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).

Friday, November 29, 2019

Effectiveness of CBT for anxiety in autistic Children



  Introduction
Children with autism spectrum disorders (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. Although anxiety is not a defining characteristic of ASD, prevalence rates are significantly higher in children with ASD than in typically developing children, children with language disorders, chronic medical conditions, disruptive behavior disorders, and intellectual disability or epilepsy. In fact, research suggests that approximately one-half of children with ASD would meet the criteria for at least one anxiety disorder. Several studies have also reported a bidirectional association 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 youths with mood and anxiety disorders. Individuals with ASD also appear to display more social anxiety symptoms compared to typical control individuals, even when these symptoms are clinically overlapping with the characteristic social problems typical of ASD. With comorbidity rates so elevated in the ASD population, treatment options for anxiety have become increasingly important.
Cognitive-Behavioral Therapy
There is a strong evidence base for the use of cognitive-behavioral therapy (CBT) interventions for depression and anxiety in non-ASD populations. There are a variety of CBT approaches, but most share some common elements. The primary goals of traditional CBT are to identify and challenge dysfunctional beliefs, catastrophic cognitions, and automatic thoughts as well as change problematic behavior. With a therapist’s help, the individual is encouraged to challenge his or her beliefs and automatic thoughts through a variety of techniques. Through CBT, the individual learns skills to modify thoughts and beliefs, as well as problem-solving strategies to improve interaction with others in effective and appropriate ways, thereby promoting self-regulation.
CBT models for the treatment of anxiety attempt to create a new coping pattern by using behavioral techniques such as modeling, exposure, and relaxation as well as cognitive techniques addressing cognitive distortions and deficiencies. These treatment models generally emphasize four critical components of therapy: assessment, psychoeducation, cognitive restructuring, and exposure. Using these four components, CBT has been shown to be an empirically supported treatment for typically developing children with anxiety issues. The most commonly used techniques to treat anxiety in children are exposure, relaxation, cognitive restructuring, and modeling in that order.
Cognitive-Behavioral Therapy for ASD
Although CBT has been shown to be an effective empirically supported treatment for typical children, there is a question as to whether or not it can be used with other populations. In recent years, there have been a number of attempts to adapt CBT for children and teens on the autism spectrum. Although there is no agreed upon set of modifications, there appears to be a general consensus that with certain specific modifications, CBT can be used to effectively lessen anxiety symptoms in higher functioning children with ASD. Evidence from the current literature supports a specific blend of techniques and strategies as the most effective approach to modify CBT for use with children who have an ASD. The primary modifications to CBT that have been shown to make them more viable for anxious children with ASD are the development of disorder specific hierarchies, the use of more concrete, visual tactics, the incorporation of child specific interests, and parent participation.
A study published in the Journal of Child Psychology and Psychiatry illustrates how a standard CBT program can be adapted to include multiple treatment components designed to accommodate or remediate the social and adaptive skill deficits of children with ASD that serve as barriers to anxiety reduction. The study tested a modular CBT program incorporating separate modules focusing specifically on deficits associated with ASD such as poor social skills, self-help skills, and stereotypies as well as a modified version of a traditional CBT protocol utilizing primarily cognitive restructuring and exposure techniques. 

The participants were forty children (7–11 years of age) who met the criteria for ASD and one of the following anxiety disorders: separation anxiety disorder (SAD), social phobia, or obsessive-compulsive disorder (OCD). They were randomly assigned to 16 sessions of CBT or a 3-month waitlist (36 children completed treatment or waitlist). The CBT model emphasized coping skills training (e.g., affect recognition, cognitive restructuring, and the principle of exposure) followed by in vivo exposure. The parent training components focused on supporting in vivo exposures, positive reinforcement, and communication skills. Independent evaluators blind to treatment condition conducted structured diagnostic interviews and parents and children completed anxiety symptom checklists at baseline and posttreatment/postwaitlist. The researchers found that 92.9% of children in the active treatment group met criteria for positive treatment response post-treatment compared to only 9.1% of children in the waitlist condition. In addition, 80% of children in the active treatment group were diagnosis free at follow up. From these results, it is reasonable to draw the conclusion that with specific modifications, CBT can be an effective treatment for children with ASD and comorbid (concurrent) anxiety disorders.
implications
The above referenced study, together with case studies and other clinical trials, provides evidence that incorporating disorder specific hierarchies, use of more concrete, visual tactics, incorporation of child specific interests, and parental involvement can facilitate successful results when conducting CBT for anxiety in children with ASD. Although there is support for the efficacy of an enhanced CBT program, there are some limitations to these modifications and adapted models. Specifically, the child’s level of functioning, variation in the use of each modification, and the utilization of different CBT programs across studies affect the generalization of the outcomes. Moreover, there is a need to examine to what extent CBT with these modifications could be used with more severe cases of ASD or in cases where there is more severe intellectual impairment. Children with higher functioning ASD may be able to better process the cognitive components of traditional and modified CBT than those who are lower functioning. Additionally, different CBT programs may emphasize different components of CBT making it difficult to determine which components are the most critical for treating anxiety in children with ASD. The next step for future research should be to focus on developing a standardized approach to treatment which incorporates specific modifications, randomized clinical trials to test the approach, and explorations of the boundaries within the ASD population for use and effectiveness of treatment. Given the elevated comorbidity rates, finding an effective, empirically supported treatment for anxiety in children with ASD is critical.

Key References and Further Reading

Kurz, René et al. (2018). Cognitive behavioral therapy for children with autism spectrum disorder: A prospective observational study. European Journal of Paediatric Neurology, 22 (5), 803 – 806.
Moree, B. N., & Davis III, T. E. (2010). Cognitive-behavioral therapy for anxiety in children diagnosed with autism spectrum disorders: Modification trends. Research in Autism Spectrum Disorders, 4, 346–354.

National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author. http://www.nationalautismcenter.org/national-standards-project/

National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices. http://autismpdc.fpg.unc.edu/evidence-based-practices

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

Wilkinson, L. A. (2017).  A best practice guide to assessment and intervention for autism spectrum disorder in schools. Philadelphia & London: Jessica Kingsley Publishers.

Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S… Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group. cidd.unc.edu/Registry/Research/Docs/31.pdf

Weitlauf AS, McPheeters ML, Peters B, Sathe N, Travis R, Aiello R, Williamson E, Veenstra-VanderWeele J, Krishnaswami S, Jerome R, Warren Z. Therapies for Children With Autism Spectrum Disorder: Behavioral Interventions Update. Comparative  Effectiveness Review No. 137. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2012-00009-I.) AHRQ Publication No. 14-EHC036-EF. Rockville,  MD: Agency for Healthcare Research and Quality; August 2014. http://www.effectivehealthcare.ahrq.gov/reports/final.cfm

Weston, L., Hodgekins, J., &  Langdon, P. E. (216). Effectiveness of cognitive behavioural therapy with people who have autistic spectrum disorders: A systematic review and meta-analysis. Clinical Psychology Review, Volume 49, 41-54.

Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224–234. http://doi.org/10.1111/j.1469-7610.2008.01948.x

Wood, J. J., Ehrenreich-May, J., Alessandri, M., Fujii, C., Renno, P., Laugeson, E., … Storch, E. A. (2015). Cognitive behavioral therapy for early adolescents with autism spectrum disorders and clinical anxiety: a randomized, controlled trial. Behavior therapy46(1), 7–19. doi:10.1016/j.beth.2014.01.002

Wood JJ, Kendall PC, Wood KS, et al. Cognitive Behavioral Treatments for Anxiety in Children With Autism Spectrum DisorderA Randomized Clinical TrialJAMA Psychiatry. Published online November 22, 2019. doi:10.1001/jamapsychiatry.2019.4160

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

Trauma and Adverse Childhood Experiences (ACEs) in Autism


 Trauma and Adverse Childhood Experiences (ACEs)

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).
Trauma and ACEs in Autism 

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 autistic children 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).

Tuesday, July 9, 2019

Pseudoscience in Autism Treatment

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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