CBT for Anxiety in Children with Autism

  Introduction

Children with autism spectrum disorder (ASD) frequently have co-occurring (comorbid) psychiatric conditions, with estimates as high as 70 to 84 percent. A Comorbid disorder is defined as a disorder that co-exists or co-occurs with another diagnosis so that both share a primary focus of clinical and educational attention. 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 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. 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. (2016). 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 therapy, 46(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 Disorder: A Randomized Clinical Trial. JAMA Psychiatry. Published online November 22, 2019. doi:10.1001/jamapsychiatry.2019.4160

Lee A. Wilkinson, PhD, is a licensed and nationally certified school 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 CBT. He is also editor of a 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).

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

Best Practice Guidelines for Assessment of Autism Spectrum Disorder

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

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

    

Comprehensive Developmental Assessment

The primary goals of conducting an autism spectrum assessment are to determine the presence and severity of an autism spectrum disorder (ASD), develop interventions for intervention/treatment planning, and collect data that will help with progress monitoring. Professionals must also determine whether an ASD has been overlooked or misclassified, describe co-occurring (comorbid) disorders, or identify an alternative classification. There are several important considerations that should inform the assessment process. First, a developmental perspective is critically important. While the core symptoms of are present during early childhood, ASD is a lifelong disability that affects the individual’s adaptive functioning from childhood through adulthood. Utilizing a developmental assessment framework provides a yardstick for understanding the severity and quality of delays or atypicality. Because ASD affects multiple developmental domains, the use of an interdisciplinary team constitutes best practice for assessment and diagnosis of ASD. A team approach is essential for establishing a developmental and psychosocial profile of the child in order to guide intervention planning. The following principles should guide the assessment process.

• Children who screen positive for ASD should be referred for a comprehensive assessment.  Although screening tools have utility in broadly identifying children who are at-risk for an autism spectrum condition, they are not recommended as stand alone diagnostic instruments or as a substitute for a more inclusive assessment.
• Assessment should involve careful attention to the signs and symptoms consistent with ASD as well as other coexisting childhood disorders.
• When a student is suspected of having an ASD, a review of his or her developmental history in areas such as speech, communication, social and play skills is an important first step in the assessment process.
• A family medical history and review of psychosocial factors that may play a role in the child’s development is a significant component of the assessment process. 
• The integration of information from multiple sources will strengthen the reliability of the assessment results.
• Evaluation of academic achievement should be included in assessment and intervention planning to address learning and behavioral concerns in the child’s overall school functioning.
• Assessment procedures should be designed to assist in the development of  instructional objectives and intervention strategies based on the student’s unique pattern of strengths and weaknesses.
• Because impairment in communication and social reciprocity are core features of ASD, a comprehensive developmental assessment should include both domains
• Restricted, repetitive patterns of behavior, interests, or activities (RRB) are a defining feature of ASD and should be a focus of assessment.

A comprehensive developmental assessment approach requires the use of multiple measures including, but not limited to, verbal reports, direct observation, direct interaction and evaluation, and third-party reports. Assessment is a continuous process, rather than a series of separate actions, and procedures may overlap and take place in tandem. While specific activities of the assessment process will vary and depend on the child’s age, history, referral questions, and any previous evaluations and assessments, the following components should be included in a best practice assessment and evaluation of ASD in school-age children.

•  Record review
•  Developmental and medical history
•  Medical screening and/or evaluation
• Parent/caregiver interview
• Parent/teacher ratings of social competence/interaction
• Direct child observation
• Cognitive assessment
• Academic assessment
• Adaptive behavior assessment
• Social communication and language assessment
• Assessment of RRB (including sensory issues)

Children with ASD often demonstrate additional problems beyond those associated with the core domains. Therefore, other areas should be included in the assessment battery depending on the referral question, history, and core evaluation results. These may include:

• Sensory processing
• Executive function, memory, and attention
•  Motor skills
• Family system 
• Co-occurring (comorbid) behavioral/emotional problems   

The above referenced principles and procedures for the assessment of school-age children with ASD are reflected in recommendations of the American Academy of Neurology, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and a consensus panel with representation from multiple professional societies. A detailed description of the comprehensive developmental assessment model and specific assessment tools recommended for each domain can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

 Click here to read a free preview of “A Best Practice Guide…”

Lee A. Wilkinson, PhD, is a licensed and nationally certified school 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 CBT. He is also editor of a text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© Lee A. Wilkinson, PhD

Autism and Childhood Trauma

 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 autism. 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 autistic children who were exposed to four or more ACEs was twice as high compared to their typically developing peers.

The core symptoms of autism 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 an autistic individual. 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 autism. 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 autism, 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 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 autism.
 

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 (2^nd 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, 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 CBT. He is also editor of a 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).

A Best Practice Guide to Assessment & Intervention for Autism in Schools

A Best Practice Guide to Assessment & Intervention for Autism in Schools

Fully updated to reflect DSM-5 and current assessment tools, procedures and research, this second edition of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools provides a practical and scientifically-based approach to identifying, assessing, and treating children and adolescents with an Autism Spectrum Disorder (ASD) in school settings. 

Each chapter features a consolidated and integrative description of best practice assessment and intervention/treatment approaches for children and youth with ASD. It brings the topics of assessment and intervention together in a single authoritative resource guide consistent with recent advances in evidence-based practice.  Illustrative case examples, glossary of terms, and helpful checklists and forms make this the definitive resource for identifying and implementing interventions for school-age children and youth with ASD.

This guide will meet the needs of psychologists, counselors, speech/language pathologists, occupational therapists, social workers, administrators, and general and special education teachers. Parents and advocates will also find this guide a valuable resource.

👉 Click here to read a free preview of "A Best Practice Guide..."

Editorial Reviews  

“It is rare that one book can pack so many resources and easy to digest information into a single volume!  Families, school personnel, and professionals all need the extensive, and up-to-date tips, guides, and ‘must-knows’ provided here. It’s obvious the author is both a seasoned researcher and practitioner – a winning combination.”

 

— Dr. Debra Moore, psychologist and co-author with Dr. Temple Grandin, of The Loving Push: How Parents & Professionals Can Help Spectrum Kids Become Successful Adults

“Dr Wilkinson has done it again. This updated and scholarly Second Edition reflects important recent changes regarding diagnosis and services for students with Autism Spectrum Disorder. With its numerous best-practice suggestions, it is a must-read for school psychologists, school social workers, and those who teach in general and special education.”

— Dr Steven Landau, Professor of School Psychology in the Department of Psychology, Illinois State University

“This book is an essential resource for every educator that works with students with ASD! The easy-to-read format is complete with up to date research on evidence-based practices for this population, sample observation and assessment worksheets and case studies that allow the reader to apply the information presented.”

 — Gena P. Barnhill, PhD, NCSP, BCBA-D, LBA, Director of Special Education Programs at Lynchburg College, Lynchburg, VA  

Availability

A Best practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Ed.) is available from Jessica Kingsley Publishers, Amazon.com, Barnes & Noble, Books-A-Million, Walmart.com, Book Depository, and other booksellers. The book is available in both print and eBook formats.

Lee A. Wilkinson, PhD, is a licensed and nationally certified school 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 CBT. He is also editor of a 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).

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 autistic individuals 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 autism. 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 autistic individuals 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 autistic 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 reports. Philosophical 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, is a licensed and nationally certified school 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 CBT. He is also editor of a 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).

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, is a licensed and nationally certified school 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 CBT. He is also editor of a 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).