Monday, August 3, 2020

Autism and Assistive Technology (AT)

Assistive Technology
Assistive technology (AT) refers to a number of accommodations and adaptations which enable individuals with disabilities to function more independently. This includes any type of technology that provides students with disabilities greater access to the general education curriculum and increases the potential to master academic content, interact with others, and enhance functional independence and quality of life. While AT is not necessary or required for every student receiving special education services, schools are required to provide the appropriate assistive technology system when it supports the child’s access to a free and appropriate public education (FAPE). There are various types of technology ranging from "low" to "high" tech that might be incorporated into the educational setting to increase children’s independent functioning skills and reduce barriers that may prevent them from performing at a similar level as their peers. For example, students may use software with word prediction capabilities that allow them to have more success with written composition. Hardware such as portable keyboards, laptop computers, and tablets may lessen the physical demand of writing for students with weak fine motor skills or difficulty coordinating ideas with writing. Similarly, a speech-generating device or voice output communication aids may meet the needs of children with limited expressive language, by providing an effective means of verbal communication.
 Augmentative and Alternative Communication (AAC)
 Communication impairments can impact an individual’s ability to communicate with others (expressive communication) and/or receive communication from others (receptive communication). Augmentative and Alternative Communication (AAC) is a type of assistive technology that can help assist children with communication impairments to increase skills in this area and to become more competent communicators. Some autistic students who have difficulty with expressive communication may be successful in social interaction and expressing their wants and needs with a low technology AAC system such as the Picture Exchange Communication System (PECS©). PECS is considered an evidence-based practice that incorporates both behavioral and developmental-pragmatic principles to teach functional communication to children with limited verbal and/or communication skills. There are six phases of PECS instruction, with each phase building on the last. The phases are: (1) Teaching the physically assisted exchange, (2) Expanding spontaneity, (3) Simultaneous discrimination of pictures, (4) Building sentence structure, (5) Responding to, “What do you want?” and (6) Commenting in response to a question. PECS relies on the principles of applied behavior analysis (ABA) so that distinct prompting, reinforcement, and error correction strategies are specified at each training phase in order to teach spontaneous, functional communication. The research evidence suggests that PECS can be used in multiple settings, including schools, homes, and therapy settings to successfully improve functional communication, play, and behavioral skills.
It is important for educational teams to consider AAC for any student with autism. For some autistic students, AAC may act as the primary mode of communication. For others, it may be a secondary form. A referral to an assistive technology specialist or speech-language pathologist for an evaluation should be made for a student who may benefit from assistive technology and/or an augmentative communication system. As with all assessment and intervention procedures, a team approach is necessary to determine the child’s strengths and limitations, and the range and scope of potential assistive technology options to address their specific needs.
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
Charlop-Christy, M. H., Carpenter, M., H., LeBlanc, L. A., & Kellet, K. (2002). Using the Picture Exchange Communication System (PECS) with children with autism: Assessment of PECS acquisition, speech, social-communicative behavior, and problem behavior. Journal of Applied Behavior Analysis, 35, 213–231.
Frost, L., & Bondy, A. (2002). The Picture Exchange Communication System Training Manual (2nd ed.). Cherry Hill, NJ: Pyramid Educational Consultants.
Ganz, J. B., Davis, J. L., Lund, E. M., Goodwyn, F. D., & Simpson, R. L. (2012). Meta-analysis of PECS with individuals with ASD: Investigation of targeted versus non-targeted outcomes, participant characteristics, and implementation phase. Research in Developmental Disorders, 33, 406-418. doi:10.1016/j.ridd.2011.09.023.
Hart, S. L., & Banda, D. R. (2010). Picture Exchange Communication System with individuals with developmental disabilities: A meta-analysis of single subject studies. Remedial and Special Education, 31, 476-488. doi: 10.1177/0741932509338354.
Individuals with Disabilities Education Improvement Act of 2004. Pub. L. No. 108-446, 108th Congress, 2nd Session. (2004).
Kabot, S., & Reeve, C. (2014). Curriculum and Program Structure. In L. A. Wilkinson (Ed.), Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 195-218). Washington, DC: American Psychological Association.
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/
Sulzer-Azaroff, B., Hoffman, A. O., Horton, C. B., Bondy, A., & Frost, L. (2009).
The Picture Exchange Communication System (PECS): What do the data say? Focus on Autism and Other Developmental Disabilities, 24, 89-103.
Twachtman-Cullen, D. & Twachtman-Bassett, J. (2014). Language and Social Communication. In L. A. Wilkinson (Ed.). Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 101-124). Washington, DC: American Psychological Association.
Wilkinson, L. A. (Ed.) (2014). Autism spectrum disorder in children and adolescents: Evidence-based assessment and intervention in schools. Washington, DC: American Psychological Association.
Wilkinson, L. A. (2014). Introduction: Evidence-Based Practice for Autism Spectrum Disorder. In L. A. Wilkinson (Ed.). Autism spectrum disorder in children and adolescents: Evidence-based assessment and intervention in schools (pp 3-13). Washington, DC: American Psychological Association.
Wilkinson, L. A. (2017). Best Practice in Special Education. In A best practice guide to assessment and intervention for autism spectrum disorder in schools (pp. 157-200). London & Philadelphia: Jessica Kingsley Publishers.
Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London & Philadelphia: Jessica Kingsley Publishers.
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 nationally certified and licensed 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 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).

Monday, July 6, 2020

Legal and Appropriate Educational Programs for Students with Autism


Individuals with Disabilities Education Act (IDEA)

Since Congress added autism as a disability category to the Individuals with Disabilities Education Act (IDEA), the number of students receiving special education services in this category has increased over 900 percent nationally. 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. It’s critically important that parents and educators understand the provisions for providing legally and educationally appropriate programs and services for students identified with autism.
Research indicates that education is the most effective treatment/intervention for children with ASD. The most recent re-authorization of the Individuals with Disabilities Education Act (IDEA 2004) entitles all students with disabilities to a free, appropriate public education (FAPE). FAPE encompasses both procedural safeguards and the student’s individual education program (IEP). The IEP is the cornerstone for the education of a child with autism. When a student is determined eligible for special education services, an IEP planning team is formed to develop the IEP and subsequently determine placement.
Although clinical diagnoses, psychiatric reports, and treatment recommendations can be helpful in determining eligibility and educational planning, the provisions of IDEA are the controlling authority with regard to decisions for special education. While clinical information is professionally helpful, it is neither legally required nor sufficient for determining educational placement. Therefore, it’s especially important for administrators, parents, advocates, teachers and non-school professionals to keep in mind that when it comes to special education, it is state and federal education codes and regulations (not clinical criteria) that determine eligibility and IEP planning decisions. 

According to IDEA regulations, the definition of autism is as follows:
(c)(1)(i) Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The term does not apply if a child’s educational performance is adversely affected primarily because the child has an emotional disturbance, as defined in this section.

(ii) A child who manifests the characteristics of ‘‘autism’’ after age 3 could be diagnosed as having ‘‘autism’’ if the criteria in paragraph (c)(1)(i) of this section are satisfied.
Guidelines

Legal and special education experts recommend the following guidelines to help school districts meet the requirements for providing legal and appropriate educational programs and services to students with autism.
1. School districts should ensure that the IEP process follows the procedural requirements of IDEA. This includes actively involving parents in the IEP process and adhering to the time frame requirements for assessment and developing and implementing the student’s IEP.  Moreover, parents must be notified of their due process rights. It’s important to recognize that parent-professional communication and collaboration are key components for making educational and program decisions.
2. School districts should make certain that comprehensive, individualized evaluations are completed by school professionals who have knowledge, experience, and expertise in autism. If qualified personnel are not available, school districts should provide the appropriate training or retain the services of a consultant.
3. School districts should develop IEPs based on the child’s unique pattern of strengths and weaknesses. Goals for a child with autism commonly include the areas of communication, social behavior, adaptive skills, challenging behavior, and academic and functional skills. The IEP must address appropriate instructional and curricular modifications, together with related services such as counseling, occupational therapy, speech/language therapy, physical therapy and transportation needs. Evidence-based instructional strategies should also be adopted to ensure that the IEP is implemented appropriately.
4. School districts should assure that monitoring of student progress is completed at specified intervals by an interdisciplinary team of professionals who have a knowledge base and experience in autism. This includes collecting evidence-based data to document progress towards achieving IEP goals and to assess program effectiveness.
5. School districts should make every effort to place students in integrated settings to maximize interaction with non-disabled peers. Inclusion with typically developing students is important for a child with autism as peers provide the best models for language and social skills. However, inclusive education alone is insufficient, evidence-based intervention and training is also necessary to address specific skill deficits. Although the least restrictive environment (LRE) provision of IDEA requires that efforts be made to educate students with special needs in less restrictive settings, IDEA also recognizes that some students may require a more comprehensive program to provide FAPE. 
6. School districts should provide on-going training and education in autism for both parents and professionals. Professionals who are trained in specific methodology and techniques will be most effective in providing the appropriate services and in modifying curriculum based upon the unique needs of the individual child.
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
Individuals with Disabilities EducationImprovement Act of 2004. Pub. L. No. 108-446, 108th Congress, 2nd Session. (2004). 
Kabot, S., & Reeve, C. (2014). Curriculum and program structure. In L. A. Wilkinson (Ed.), Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 195-218). Washington, DC: American Psychological Association.

Mandlawitz, M. R. (2002). The impact of the legal system on educational programming for young children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 32, 495-508.
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.

Wagner, S. (2014). Continuum of Services and Individualized Education Plan Process. In L. A. Wilkinson (Ed.). Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 173-193). Washington, DC: American Psychological Association.

Wilkinson, L. A. (2010). Best practice in special needs education. In L. A. Wilkinson, A best practice guide to assessment and intervention for autism and Asperger syndrome in schools (pp. 127-146). London: Jessica Kingsley Publishers. 
Wilkinson, L. A. (Ed.). (2014). Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools. Washington, DC: American Psychological Association.

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

Zirkel, P. (2014). Legal Issues Under IDEA. In L. A. Wilkinson (Ed.), Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 243-257). Washington, DC: American Psychological Association. 
Yell, M. L., Katsiyannis, A, Drasgow, E, Herbst, M. (2003). Developing legally correct and educationally appropriate programs for students with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 18, 182-191.

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 a best-selling text in the American Psychological Association (APA) School Psychology Book Series, Autism Spectrum Disorder in Children and AdolescentsEvidence-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

Sunday, June 14, 2020

Teaching Social Skills to Children with Autism

Impairment in social communication and interaction is a core feature of autism spectrum disorder (ASD). Social skills deficits include difficulties with initiating interactions, maintaining reciprocity, taking another person’s perspective, and inferring the interests of others.  Unfortunately, many autistic children do not receive consistent and intensive social skills programming in school. This is problematic, especially considering social impairments may result in negative outcomes, such as poor academic achievement, social failure, isolation, and peer rejection, which often leads to co-occurring (comorbid) anxiety and depression. 

Because social skills are critical to successful social, emotional, and cognitive development and long-term outcomes, best practice indicates that social skills instruction should be an integral component of educational programming for all children with autism. Research evidence suggests that when appropriately planned and systematically delivered, social skills instruction has the potential to produce positive effects in the social interactions of children with ASD. Both the National Professional Development Center on Autism (NPDC) and the National Autism Center (NAC) have identified social skills training/instruction as an evidence-based intervention and practice. Social skills training is typically offered as small-group instruction with a shared goal or outcome of learned social skills in which participants can learn, practice, and receive feedback. These interventions seek to build social interaction skills in children and adolescents with ASD by targeting basic responses (e.g., eye contact, name response) to complex social skills (e.g., how to initiate or maintain a conversation). 

Most often, schools are expected to assume the responsibility of delivering social skills training programs to children with social skills deficits, because these impairments significantly interfere with social relationships and have an adverse effect on academic performance. Although equipped to teach social skills, implementing social skills programming can be challenging for school personnel (teachers, counselors, psychologists, social workers), who often have limited time and resources. Recent meta-analysis research suggests that the effectiveness of social skills training can be enhanced by increasing the quantity (or intensity) of social skills interventions, providing instruction in the child’s natural setting, matching the intervention strategy with the type of skill deficit, and ensuring treatment integrity (fidelity). In order for students to learn, practice, and maintain expected social behavior, educators must teach social skills within the context of the various school settings that students encounter each day (i.e., classroom, special subject areas such as art and music, cafeteria, and playground). 
The following are guidelines are recommended when developing a social skills intervention strategy:
  • Avoid a "one size fits all" approach and adapt the intervention to meet the needs of the individual or particular group. 
  • Employ primarily positive strategies and focus on facilitating the desirable social behavior as well as eliminating the undesirable behavior. 
  • Emphasize the learning, performance, generalization, and maintenance of appropriate social behaviors through modeling, coaching, and role-playing
  • Provide social skills training and practice opportunities in a number of settings with different individuals in order to encourage students to generalize new skills to multiple, real life situations. 
  • Use assessment strategies, including functional assessments of behavior, to identify children in need of more intensive interventions as well as target skills for instruction. 
  • Enhance social skills by increasing the frequency of an appropriate behavior in "normal" or typical environments to address the naturally occurring causes and consequences. 
  • Include parents and caregivers as significant participants in developing and selecting interventions (they can help reinforce the skills taught at school to further promote generalization across settings).
The type of skill deficit (performance deficit versus skill deficit) should also be considered when developing a social skills intervention plan. A performance deficit refers to a skill or behavior that is present but not demonstrated or performed, whereas a skill acquisition deficit refers to the absence of a particular skill or behavior. School professionals should make an intensive effort to systematically match the intervention strategy to the type of skill deficit exhibited by the child. For instance, if the child lacks the skills necessary to join in an interaction with peers, an intervention strategy should be selected that promotes skill acquisition. In contrast, if the child has the skills to join in an activity but regularly fails to do so; a strategy should be selected that enhances the performance of the existing skill.
Social relationship skills are critical to successful social, emotional, and cognitive development and to long-term outcomes for students. Thus, systematic social skills instruction should be considered a critical component of treatment for children with autism. Teaching social skills can have both preventive and remedial effects that can help reduce the risk for negative outcomes not only for children on the autism spectrum, but for all children. 

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.


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 APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Thursday, June 11, 2020

The Mental Health Crisis for Autistic Teens and Young Adults


The Crisis in Mental Health Services

The increase in the prevalence of autism spectrum conditions among children over the past decade indicates that a correspondingly large number of youth will be transitioning to adulthood in the coming years. It is estimated that more than 50,000 adolescents with autism will turn 18 years old this year in the U.S. As these numbers continue to rise, there is an urgent need to address the mental health issues faced by many teens and young adults on the autism spectrum.
Although we know that children with autism grow up to be adults with autism, there are fewer mental health services available for adults on the spectrum, particularly for individuals who are not intellectually challenged. A review in the open access journal, Autism Research and Treatment, highlights the service needs and the corresponding gaps in care for this population. The authors posit that the mental health system is in crisis and that although the rates of mental health issues for adults on the spectrum is high, accessing services to address these symptoms remains difficult. Poor recognition tends to occur for a number of different reasons, including restrictive intake criteria, misdiagnosis, limited knowledge or awareness of autism spectrum conditions, clinicians who lack confidence or experience in caring for this group of adults, and the belief that other service providers will provide this care. Consequently, many autistic adolescents and adults, because of their diagnosis, are excluded from community mental health services, leaving them grossly underserved.
Mental Health Issues
Comorbid (co-occurring) psychiatric disorders are well documented in individuals with autism across the lifespan. Research suggests that a very high proportion of autistic adults and teens present with co-occurring (comorbid) psychiatric conditions, particularly depression and anxiety. For example, recent studies examining psychiatric comorbidity in young adults with autism spectrum conditions found that 70% had experienced at least one episode of major depression, 50% had suffered from recurrent depressive episodes, and 50% met criteria for an anxiety disorder. Unfortunately, it appears that co-occurring psychiatric disorders and even the diagnosis of an autism spectrum condition itself often go unrecognized among more capable adolescents and adults on the spectrum seeking psychological or psychiatric care. Many youth and young adults report significant difficulties accessing healthcare services, particularly comprehensive health services. Part of the reason for this difficulty may stem from service providers feeling ill equipped to work with individuals with autism, particularly individuals with co-occurring mental health issues. As a result, adolescents and adults with autism spectrum conditions have access to significantly fewer programs than adolescents and adults with other types of developmental disabilities. Not surprisingly then, a consistent theme for parents of individuals with autism is the fear that their child will fall through the cracks when transitioning from child to adult services. Similar concerns have been voiced by autistic individuals themselves, who describe how their needs are infrequently recognized and the programs and services available are not designed for people with autism spectrum conditions in mind.
Implications
Adolescents and adults on the autism spectrum represent a complex and underserved population. Of the studies completed to date, findings suggest that this group of adolescents and adults faces a multitude of psychiatric and psychosocial issues, alongside significant challenges in accessing services. Social skills deficits for autistic individuals persist into adulthood, and adults appear to be at an increased risk for developing depression and anxiety. Despite this, very few studies have examined treatment approaches and interventions (pharmacological and psychosocial) for adolescents and adults with autism. While evidence is beginning to emerge for interventions, including cognitive-behavioral therapy (CBT), mindfulness-based therapy (MBT), and social skills training (SST), further large-scale studies comparing the effectiveness of CBT or MBT versus other treatment options (e.g., medication, counseling, etc.) are required. Likewise, there is an immediate need for mental health clinicians who are trained to apply these techniques. In developing interventions, programs must also consider what adolescents and adults want. For example, adolescents and adults on the spectrum may be more interested in interventions which focus on vocational opportunities than interventions targeting social skills. Moreover, both individuals and their family must be viewed as valuable contributors and fully involved in this process. Lastly, researchers must look at issues of service cost and efficiency when evaluating the impact of interventions.
Recommendations
1. According to the U.S. Surgeon General, over the course of a year, approximately 20% of children and adolescents in the U.S. experience signs and symptoms of a mental health problem. Unfortunately, most children and youth who are in need of mental health services do not actually receive them. Psychological services should be expanded in schools to include a major focus on the delivery of mental health services to all students. 
2. Developmental disability agencies or agencies supporting individuals with autism spectrum conditions must partner with community mental health agencies to help train, mentor, and build capacity to care for this group across the lifespan. It is important to note that many clinicians working within community mental health agencies already have the skills to effectively deliver this care, but programs either preclude their ability to do so or they lack the confidence to work with this population.
2. There is a critical need for community mental health agencies to review their exclusion criteria to include persons with autism spectrum conditions. For example, agencies providing care for persons with mood or anxiety disorders should not exclude individuals on the basis of a diagnosis of autism. Community mental health agencies have the resources and expertise in mental health, along with the programs to deliver services for individuals with mental health issues (e.g., vocational programs, counseling, and therapies), but will need guidance from developmental disability agencies to successfully adapt these programs for adults on the autism spectrum.
3. Developmental disability agencies must reevaluate their inclusion criteria to include persons with autism spectrum conditions, regardless of IQ, and across the lifespan. Organizations must work together, combining expertise in autism from developmental disability agencies with knowledge and resources from community mental health agencies.
4. There is a need to study and identify programs and supports that are most effective in both school and community settings. This will require a full continuum of mental health services including counseling, vocational training, supported employment, inpatient services, and outpatient services. It will also require a network of experienced clinicians and community partners. Many of these efforts are already underway in pediatric settings; however, these same efforts are required in adolescent and adult mental health services.
5. Finally, there is a need to prepare and equip older youth with autism spectrum conditions for the transition to adult services.
Johanna K. Lake, J. K., Perry, A., & Lunsky, Y. (2014). Mental Health Services for Individuals with High Functioning Autism Spectrum Disorder. Autism Research and Treatment, Volume 2014, Article ID 502420. http://dx.doi.org/10.1155/2014/502420
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 APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in SchoolsHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Wednesday, May 13, 2020

Early Social Communication Indicators of Autism


It is well established that early identification and intervention are critical determinants in the course and outcome of autism spectrum disorder (ASD).  Although there are no “absolute” clinical indicators of autism, some of the early “red flags” include: • Does not smile by the age of six months • Does not respond to his or her name • Does not cry • Does not babble or use gestures by 12 months and • Does not point to objects by 12 months. Children with autism typically experience delays in speech and communication skills. Not only will they often develop spoken language later, but they are less likely to develop non-verbal communication skills such as “joint attention,” pointing, or gesturing. 
Social Communication Skills

Young children with autism spectrum disorder (ASD) typically exhibit core deficits in social communication skills, particularly in the areas of joint attention, shared affect, eye-contact, conventional and symbolic gestures, and related skills in functional and symbolic play. Children seek to share attention with others spontaneously during the first year of life. “Joint attention” is an early-developing social-communicative skill in which two people (usually a young child and an adult) use gestures and gaze to share attention with respect to interesting objects or events. Before infants have developed social cognition and language, they communicate and learn new information by following the gaze of others and by using their own eye contact and gestures to show or direct the attention of the people around them. These developments in the first two years of life are potentially important early indicators of ASD which can facilitate earlier diagnosis. Researchers have identified five core deficits (‘red flags’) evident in the early years, namely gaze shifting, gaze point following, rate of communicating, joint attention and gestures; these were the strongest predictors of symptoms of autism at three years of age.
Research

Researchers in Melbourne Australia, working on a long-term study of children from eight months to seven years of age found that those with autism used fewer gestures to communicate than other kids. Parents of 1,911 children participating in the ‘Early Language in Victoria Study’ in Melbourne, Australia, completed questionnaires about their child’s development from infancy through to school age. At four years of age, a group of children identified with an autism spectrum disorder (ASD) were compared to other children from within the study; those with a developmental delay, language impairment, or typical development. Comparisons were made between the children’s early social communication skills (including eye-gaze, non-verbal communication, gesture, and speech skills) at 8 months, 1 year, and 2 years of age. By one year of age, children with ASD used fewer early social communication skills than children with typical development. The only social communication skill that was found to be significantly different between children with ASD and all other children, however, was the use of gesture. Children with ASD used fewer gestures for communication than all other children at both 1 and 2 years of age.
Implications

Speech pathologist Carly Veness, who led the research, said there was a pattern of low gesture use among autistic children between the ages of eight months and two years. "We found that there was a decreased use of gestures like pointing, showing and giving,” she commented. The researchers noted that gestural deficits almost doubled the risk for ASD, pointing to the importance of targeting gesture deficits in infant early intervention approaches. They conclude that their results “… highlight the possibility of detecting risk signs for ASD as young as 12 months of age in a community sample, thus allowing for earlier recognition of the disorder.”
Veness, C., Prior, M., Bavin, E., Eadie, P., Cini, E., & Reilly, S. (2012). Early indicators of autism spectrum disorders at 12 and 24 months of age: A prospective, longitudinal comparative study. Autism, 16, 163-177.
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 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, May 5, 2020

Understanding Challenging Behavior in Autistic Children


Challenging Behavior

Challenging behavior is any behavior that interferes with a child’s learning, engagement, and social interactions with her peers or adults. Aggression is often observed as one form of challenging behavior in autism. Although aggression is not itself a symptom of autism and not all autistic individuals are aggressive, research suggests that rates of challenging behavior may be higher in individuals with autism compared to typically developing peers and those with other developmental disabilities. Children with autism don’t necessarily express anger, fear, anxiety or frustration in the same way as other children. However, irritability is a symptom of autism that can complicate adjustment at home and other settings, and can manifest itself in aggression, tantrums, and self-injurious behavior. 
Behavior as Communication
Children engage in problem behavior to communicate. The principles of behavior teach us that it does not occur in a vacuum – that is, behavior does not occur without regard to the context in which it is observed. When working with autistic children we should consider problem behavior as a communication attempt, and should determine what skill the child needs to learn in order to reduce the need for the problem behavior or what environmental modification makes the behavior unnecessary. The first step to developing an effective intervention strategy is to identify the function of the behavior. By function, we mean what the child is trying to access by engaging in the challenging behavior. In other words: you first must figure out what it is the child is trying to communicate. For example, a student might exhibit challenging behaviors with the goal of escape or the goal of seeking attention. When the curriculum is difficult or demanding, they may attempt to avoid or escape work through challenging behavior (e.g., refusal, passive aggression, disruption, etc.). Similarly, they may use challenging behavior to get focused attention from adults and peers, or to gain access to a preferred object or participate in an enjoyable activity. Problematic behavior may also occur because of sensory aversions. Because autistic students also have significant social and pragmatic skills deficits, they may experience difficulty effectively communicating their needs or influencing the environment. Thus, challenging classroom behavior may serve a purpose for communicating or a communicative function. 

Common Triggers

Research suggests that common triggers include disturbing breaks in routine, lack of sleep, jarring “sensory stimuli” (noises, lights, or smells) or even undiagnosed mental health problems. Children with significant aggressive behavior also tended to have mood and anxiety symptoms, and difficulty sleeping and paying attention. Clearly, it’s important to look beyond the behavior itself to identify the underlying cause or trigger. Children with significant aggressive behavior also tended to have mood and anxiety symptoms, and difficulty sleeping and paying attention. The studies also indicate that symptoms of aggression often overlap in patients with extreme anxiety and attention deficit issues. It has been reported that executive function deficits (e.g. issues with inhibition, working memory, planning and flexibility) are associated with anxiety and aggression in autism and may serve as a pathway to comorbid psychopathology (sensory stimuli, a change in routine, transition between activities, or physical reasons like feeling unwell, tired or hungry. Not being able to communicate these difficulties can lead to anxiety, anger and frustration, and then to an outburst of challenging behavior. 

                                                                             Comorbidity

Children with autism experience a number of related difficulties, including sleep problems, gastrointestinal (GI) problems, sensory issues, and self-injury. Many of these problems have been associated with aggression among typically developing children, and emerging evidence suggests a similar relationship in children with autism. For example, sleep problems occur in a large percentage of autistic children, with prevalence rates ranging from 50% to 80%. Sleep problems have been found to be highly associated with aggression in typically developing children. Likewise, research suggests that children with autism and sleep problems are more likely to demonstrate aggression than those without sleep problems.
Sensory problems, including sensory over-responsivity, sensory under-responsivity, and sensory seeking are also common problems in autistic children. In typical children, sensory problems have been associated with aggressive and externalizing behavior problems. Similarly, recent studies have been found correlations between sensory problems and broadly defined externalizing problem behaviors in autistic children. However, research has yet to specifically examine the potential contributing role of sensory problems in predicting physical aggression.

Self-injurious behavior also appears to be relevant to the occurrence of aggression. Individuals with autism are at an increased risk for demonstrating self-injurious behaviors, as compared to those without autism, with prevalence rates ranging from 30% to 53%. Although self-injury and other forms of challenging behaviors have been considered to be distinct forms of behavior, they are often related. For example, physical aggression and self-injury have been significantly associated among individuals with severe intellectual impairment and there is evidence that self-injurious behaviors are precursors of later aggression in this population. However, similar studies have not investigated the relationship between self-injury and physical aggression in autistic children.
Lastly, gastrointestinal (GI) problems may also have relevance to the occurrence of aggression. GI problems are common in autistic children, with prevalence rates ranging from 24% to 70% or higher, depending on symptom definitions. Although there some evidence of an association between behavior problems and GI problems, a population-based study of autistic children did not find significant differences in aggression when comparing children with and without GI problems.
    Predictors
Although the nature and developmental course of aggression have been a focus of research with typically developing populations, there have been few large-scale studies of group-level predictors of aggression among individuals with autism. Consequently, it is unclear whether findings from the general population are applicable to autistic children and adolescents. In an effort to investigate the extent of the problem in children and adolescents with autism, a recent large-scale study published in Research in Autism Spectrum Disorders examined the prevalence and correlates of physical aggression in a sample of 1584 children and adolescents with ASD enrolled in the Autism Treatment Network (ATN), a multi-site network of 17 autism centers across the US and Canada. The results indicated that the prevalence of aggression was 53% across the entire sample of children, with highest prevalence among young children. These results are highly consistent with recently reported prevalence rates (56%) in another large-scale study of children and adolescents with autism. The results also indicate that age-related decreases in aggression in autistic children are similar to what has been observed in typically developing children. It should be noted, however, that a large percentage (nearly 50%) of the adolescents in the study’s sample continued to demonstrate physical aggression. Thus, the relative decrease in aggression over time must be balanced by the finding that these behaviors continued to occur at a high rate among a large portion of adolescents with autism.
In terms of predictors, the results indicated that self-injury was highly associated with aggression among children with autism. This is consistent with the findings of other studies showing a strong association between self-injury and other challenging behaviors. The current results add to existing literature, and suggest that autistic children who demonstrate self-injury may be at risk for more severe behavioral problems.
Sleep problems emerged as a second significant predictor aggression. This association between sleep problems and aggression is largely consistent with previous findings among both typically developing children and those with autism, indicating may underlie (and exacerbate) aggressive behavior patterns for many autistic children. It should also be noted that sleep problems have been found to be associated with self-injurious behaviors among individuals with intellectual disabilities and that these two conditions may be related. In fact, there is some developing evidence suggesting shared neurobiological basis for both sleep disturbance and self-injurious behavior.
Sensory problems were also significantly associated with aggression. These findings are consistent with similar associations between sensory issues and aggression among typically developing children. While previous research has demonstrated an association between sensory problems and broadly defined behavior problems, the current results extend these previous findings by demonstrating a specific relationship between sensory problems and physical aggression.
Comparisons also indicated that children with aggression were more likely to experience GI problems, communication skill difficulties, and social skills difficulties. However, these variables did not appear as significant predictors of aggression, indicating that self-injury, sleep problems, and sensory issues accounted for the majority of the variance in predicting aggression.
In regards to potential sex differences, the results indicate that girls and boys with autism were equally likely to engage in aggression. This finding was unexpected in that research has consistently shown a significant gender difference among children without autism, with boys being much more likely to engage in physical aggression than girls. The results of the study suggest that the sex differential in aggression may not be salient in the autistic population.
Implications
This study provides evidence that challenging behavior may be much more prevalent among children with autism than in the general population and that some comorbid problems may place individuals at risk for aggression. Aggression was significantly associated with a number of clinical features, including self-injury, sleep problems, sensory problems, GI problems, and communication and social functioning. However, self-injury, sleep problems, and sensory problems were most strongly associated with aggression. These findings indicate that co-occurring problems specific to the autism phenotype may play an important role in the occurrence of aggression and that it is important to consider multiple domains of functioning when assessing and treating aggression in autistic children. For example, increased attention should be given to the identification and treatment of sleep problems, self-injury, and sensory problems. Given the significant relationship between sleep problems and aggression, it is possible that treatments targeting sleep problems may help reduce maladaptive behavior. Thus, assessment and treatment of sleeping problems might be included as a standard and integrated part of the assessment and treatment of autism. Programs for children with autism should also integrate an appropriately structured physical and sensory milieu in order to accommodate any unique sensory processing challenges. 

Behavioral interventions, particularly those based upon applied behavior analysis (ABA), have long had empirical support for addressing problematic behavior (for a review, see Schreibman, 2000). A comprehensive treatment plan for treating aggressive behaviors in children with autism begins with a precise and thorough assessment, followed by implementation of a comprehensive treatment plan.
Although assessment tools are limited, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Co-occurring disorders should also be carefully investigated when severe or worsening symptoms are present that are not responding to traditional methods of intervention. It is important to take the time to analyze these underlying causes of aggressive behavior in children with autism. By understanding the triggers of aggression, we are able to choose the most effective intervention strategies. Once we understand the function or goal of student behavior, we can begin to teach alternative replacement behavior and new interaction skills. 

Further research is needed in order to better understand the characteristics and course of different types of aggression. For example, future research should examine the longitudinal course of aggression, the role of these associated problems in predicting improvement or worsening of aggression, and possible changes in aggression in response to treatment for these co-occurring problems. Studies are also needed to examine the role of additional family- and community-level variables in the prediction and maintenance of aggression among children with autism.  
References and Further Reading

Cervantes P, Matson JL, Tureck K, Adams HL. The relationship of comorbid anxiety symptom severity and challenging behaviors in infants and toddlers with autism spectrum disorder. Research in Autism Spectrum Disorders. 2013;7(12):1528–1534.
Chazin, K.T. & Ledford, J.R. (2016). Challenging behavior as communication. In Evidence-based instructional practices for young children with autism and other disabilities. 
Farmer C.A. & Aman M. G. Aggressive behavior in a sample of children with autism spectrum disorders. Research in Autism Spectrum Disorders. 2011;5(1):317–323.
Farmer, C., Butter, E., Mazurek M.O, et al. Aggression in children with autism spectrum disorders and a clinic-referred comparison group. Autism. 2015;19(3):281–291.
Farmer C, Butter E, Mazurek M.O, Cowan C, Lainhart J, Cook E.H, & Aman M. Aggression in children with autism spectrum disorders and a clinic-referred comparison group. Autism. 2014
Fitzpatrick, S. E., Srivorakiat, L., Wink, L. K., Pedapati, E. V., & Erickson, C. A. (2016). Aggression in autism spectrum disorder: presentation and treatment options. Neuropsychiatric disease and treatment12, 1525–1538.
Healy O., Lydon S., Holloway J., Dwyer M. (2014). Behavioral interventions for aggressive behaviors in autism spectrum disorders. In: Patel V., Preedy V., Martin C. (eds). Comprehensive Guide to Autism. Springer, New York, NY
Hill, A. P., Zuckerman, K., Hagen, A. D., Kriz, D., Duvall, S., Van Santen, J., ... Fombonne, E. (2014). Aggressive behavior problems in children with autism spectrum disorders: Prevalence and correlates in a large clinical sample. Research in Autism Spectrum Disorders8(9), 1121-1133. 
Hodgetts, S., Nicholas, D., & Zwaigenbaum, L. (2013). Home sweet home? Families’ experiences with aggression in children with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 28(3), 166-174.
Kaartinen M., Puura K., Helminen M., Salmelin R., Pelkonen E., & Juujärvi P. (2014). Reactive aggression among children with and without autism spectrum disorder. J Autism Dev Disord., 44(10):2383–2391
Kanne, S. M., & Mazurek, M. O. (2011). Aggression in children and adolescents with ASD: Prevalence and risk factors. Journal of Autism and Developmental Disorders, 41(7), 926-937.  
Love, J.R., Carr, J. E, & LeBlanc, L.A. (2009).Functional assessment of problem behavior in children with autism spectrum disorders: a summary of 32 outpatient cases. J Autism Dev Disord., 39(2):363–372. 
Mayes, S.D., Calhoun, S.L., Aggarwal, R., Baker, C., Mathapati, S., Anderson, R., & Petersen C. (2012). Explosive, oppositional, and aggressive behavior in children with autism compared to other clinical disorders and typical children. Research in Autism Spectrum Disorders. 6:1–10
Pugliese, C. E., Fritz, M. S., & White, S. W. (2015). The role of anger rumination and autism spectrum disorder–linked perseveration in the experience of aggression in the general population. Autism19(6), 704–712.
Schreibman, L. (2000), Intensive behavioral/psychoeducational treatments for autism: research needs and future directions. J Autism Dev Disord., 30(5):373-378.
Shea, S., Turgay, A., Carroll, A. et al. (2004), Risperidone in the treatment of disruptive behavioral symptoms in children with autistic and other pervasive developmental disorders. Pediatrics, 114(5):634-641.
Tremblay, R.E., Nagin, D.S., Séguin, J.R., Zoccolillo, M., Zelazo, P.D., Boivin, M., et al. (2004). Physical aggression during early childhood: Trajectories and predictors. Pediatrics, 114(1):e43–e50.
Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London & Philadelphia: Jessica Kingsley Publishers.

Williams, D. L., Siegel, M., Mazefsky, C. A., & Autism and Developmental Disorders Inpatient Research Collaborative (ADDIRC). (2017). Problem behaviors in autism spectrum disorder: Association with verbal ability and adapting/coping skills. Journal of Autism and Developmental Disorders.

Lee A. Wilkinson, PhD 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 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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