Sunday, December 13, 2020

Autism Traits in Childhood Linked to Eating Disorders in Adolescence

Autism Traits in Childhood Linked to Eating Disorders in Adolescence

BY LAURA DATTARO  /  4 JUNE 2020

Children with social difficulties are more likely than those without to develop disordered eating by age 14, according to a recent study. The researchers analyzed data from a longitudinal study to understand the relationship between autism and eating disorders over time.

At least 20 percent of adults and 3 percent of children with eating disorders also have autism. But much of what researchers know about link between the two conditions has come from studies of people seeking treatment for eating disorders, which makes it difficult to understand whether one condition sets the stage for the other or something else explains the overlap.

It is possible that eating disorders can cause traits that look like autism, says lead investigator Francesca Solmi, senior research fellow at University College London in the United Kingdom. Research suggests, for example, that the starvation associated with anorexia nervosa can cause problems with emotional processing.

“From all the research we had so far, we cannot see really well whether autism comes first and eating disorders second, or whether people with eating disorders have high levels of autistic traits because it’s somehow a manifestation of the eating disorder,” Solmi says.

Mapping Trajectories:

To investigate whether autism traits precede disordered eating, Solmi and her colleagues analyzed data from the Avon Longitudinal Study of Parents and Children, which tracks nearly 14,000 people born in Bristol, England, in 1991 and 1992.

Mothers of individuals in the cohort filled out a questionnaire about social behaviors associated with autism, such as persistent interrupting or being unaware of others’ feelings, when their children were 7, 11, 14 and 16 years old. At age 14, the children answered questions about their eating habits, such as whether and how often they fasted, purged, or used diet pills to lose weight. They were also asked about the frequency of binging behavior.

Of the 5,381 adolescents included in the new study, 421 — nearly 8 percent — engaged in some type of disordered eating at least monthly. Almost 3 percent, or 148 children, did so every week. Girls were roughly three times as likely to report such behaviors as boys were.

The Avon study does not include data on food habits before age 14, but other work shows that disordered eating rarely occurs before puberty.

The researchers found that adolescents with disordered eating habits had more autism traits at ages 7, 11 and 14, suggesting that these traits raise the odds of developing an eating disorder. The more autism traits a teenager had, the more frequent her disordered eating behaviors.

Those patterns held true for both boys and girls, which was surprising, Solmi says. Autism tends to be underdiagnosed in girls, and eating disorders are underdiagnosed in boys, making it difficult to study both conditions in people seeking treatment.

The work was published 3 May in the Journal of Child Psychology and Psychiatry.

Common Biology: 

The study could help researchers better understand early childhood behaviors that lead to eating disorders, says Susanne Koch, associate professor of clinical medicine at the University of Copenhagen in Denmark, who was not involved in the research.

“It’s not enough just to look at persons when they have had an eating disorder,” Koch says. “We need to look at the development of the eating disorder.”

The emergence of disordered eating may be related to the social stresses of adolescence, Solmi says, and that stress can be particularly intense for people with autism traits.

“If you have difficulties relating to your peers, this might result in feelings of anxiety or depression,” Solmi says. “In the case of eating disorders, it could be that eating then becomes one way in which people cope.”

Other experts say further work is needed to understand the mechanisms underlying both social difficulties and eating disorders. It is likely that they share common biology, rather than one condition causing the other, says Walter Kaye, executive director of the Eating Disorders Program at the University of California, San Diego, who was not involved in the work.

“Until we understand more about mechanisms and neurobiology, it’s going to be hard to come up with better treatments,” Kaye says.

Regardless, the study may hold a valuable message for clinicians who work with autistic people and those who treat eating disorders, says Jennifer Wildes, associate professor of psychiatry and behavioral neuroscience at the University of Chicago in Illinois, who was not involved in the research. They can be on the lookout for eating disorders in autistic people as adolescence approaches and watch for social difficulties in people struggling with eating disorders, including typically developing individuals.

“That may inform how they work with those people in treatment and how they work with their families as well,” Wildes says.

References:

1.       Solmi F. et al. J. Child Psychol. Psychiatry Epub ahead of print (2020) PubMed

2.      Oldershaw A. et al. Eur. Eat. Disord. Rev. 20, 502-509 (2012) PubMed

3.      Hudson J.I. et al. Biol. Psychiatry 61, 348-358 (2007) PubMed

4.      Sonneville K.R. and S.K. Lipson Int. J. Eat. Disord. 51, 518-526 (2018) PubMed

This article was published on Spectrum, the leading site for autism research news. 


Lee A. Wilkinson, PhD, is author of the award-winning books,  A Best Practice Guide to
Guide Using CBTHe is also editor of a text in the APA School Psychology Book

Saturday, December 5, 2020

Autism: Empathizing-Systemizing Cognitive Styles

 


The empathizing-systemizing (E-S) theory describes a distinct cognitive style or way of thinking. The E-S theory attempts to explain many of the social-communication problems experienced by autistic individuals by focusing on two factors or psychological dimensions, empathizing (E) and systemizing (S). Empathizing (E) is defined as the drive to identify emotions and thoughts in others and to respond to these appropriately. In contrast, Systemizing (S) is defined as the drive to analyze and construct systems, with the goal of identifying and understanding rules in order to predict systemic behavioral events. The Systemizing Mechanism theory seeks out If-and-then patterns.

Five Cognitive Styles

The E-S model assumes that we all have both systemizing and empathizing skills and that they are normally distributed across the population and independent of each other. According to Baron-Cohen, about one-third of all people (40 percent of women and 24 percent of men) are Type E — strong on empathy and somewhat weaker on systemizing, another third of all people (40 percent of men and 26 percent of women) are Type S — strong on systemizing and weaker on empathy, and a final third are Type B — with balanced abilities.  People who are Extreme Type E have very strong empathy (hyper-empathizers) but are below average on systemizing. In contrast, Extreme Type S individuals are very strong at systemizing (hyper-systemizers) but below average on empathy. These five brain types are defined by where individuals fall on the empathy and systemizing dimensions and is consistent with the viewpoint of “neurodiversity.” Autistic individuals and hyper-systemizers should be seen as just one of many types of brains and that add to human neurodiversity. 

Baron-Cohen posits that autistic people have a more "masculinized" profile. that is they show the Type S or Extreme Type S brain types that are more common in the male population and where their systemizing is higher than their empathy. An extension of the E-S theory, the Extreme Male Brain (EMB) theory suggests that autistic people, on average, will score lower than the typical population on tests of empathy (E) and will score the same as if not higher than the typical population on tests of systemizing (S).
The E-S theory seeks to explain the following strengths and weaknesses in autism by referring
to delays and deficits in empathy (E), and intact or even superior skill in systemizing (S).
  • talented in mathematics or music
  • superior attention to detail
      •  excellent understanding of a whole system

      •  preference for repetition 

      •  difficulty reading emotions

      •  difficulty coping in social groups

      •  difficulty seeing another person’s perspective

      •  a tendency for black and white thinking

      •  sensory hypersensitivity.

A final comment regarding the E-S theory of autism. Theories are used to provide a model for understanding human thoughts, emotions, and behaviors. By definition, a theory is an idea or set of ideas that is intended to explain facts or events, but is not known or proven to be true. It is important to remember that the E-S theory is among several that seek to explain the behavior and psychological profile of individuals with autism. Likewise, it may not explain all of the characteristics or features associated with being on the autism spectrum or account for the whole range of autistic traits.

Adapted from Wilkinson, L. A. (2015). Overcoming anxiety and depression on the autism spectrum: A self-help guide using CBT. London: Jessica Kingsley Publishers.

                                                         References and Further Reading

Baron-Cohen, S. (2004) The Essential Difference: Male and Female Brains and the Truth about Autism. New York, NY: Basic Books.

Baron-Cohen, S. (2008) Autism and Asperger Syndrome: The Facts. New York, NY: Oxford University Press.

Baron-Cohen, S., Richler, J., Bisarya, D., Gurunathan, N., and Wheelwright, S. (2004) ‘The Systemizing Quotient: An Investigation of Adults with Asperger Syndrome or High-Functioning Autism, and Normal Sex Differences.’ In U. Frith and E. Hill (eds) Autism: Mind and Brain. New York, NY: Oxford University Press.

Baron-Cohen, S., and Wheelwright, S. (2004) ‘The Empathy Quotient (EQ ): An investigation of adults with Asperger Syndrome and high-functioning autism, and normal sex differences.’ Journal of Autism and Developmental Disorders, 34, 163–175.

Baron-Cohen, S., Wheelwright, S., Lawson, J., Griffin, R., Ashwin, C., Billington, J., and Chakrabarti, B. (2005) ‘Empathizing and Systemizing in Autism Spectrum Conditions.’ In F. R. Volkmar, R. Paul, A. Klin, and D. Cohen (eds.) Handbook of Autism and Pervasive Developmental Disorders, Volume 1: Diagnosis, Development, Neurobiology, and Behavior (third edition). Hoboken, NJ: Wiley.

Baron-Cohen S, Auyeung B, Nørgaard-Pedersen B, Hougaard DM, Abdallah MW, Melgaard L, Cohen AS, Chakrabarti B, Ruta L, Lombardo MV. Elevated fetal steroidogenic activity in autism. Mol Psychiatry. 2015 Mar;20(3):369-76. doi: 10.1038/mp.2014.48. Epub 2014 Jun 3. PMID: 24888361; PMCID: PMC4184868.

Baron-Cohen S (2020). The Pattern Seekers: How Autism Drives Human Invention. New York, NY: Basic Books.

Wilkinson, L. A. (2015). Overcoming anxiety and depression on the autism spectrum: A self-help guide using CBT. London: Jessica Kingsley Publishers.

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 CBTHe 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).

Tuesday, December 1, 2020

Holiday Tips for Families of Children with Autism

Managing Holiday Stress

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

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

Lee A. Wilkinson, PhD, 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 CBTHe 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).

Monday, November 2, 2020

Social (Pragmatic) Communication Skills and Autism

Social (Pragmatic) Communication Skills and the Autism Spectrum

The DSM-5 diagnostic criteria for autism spectrum disorder (ASD) include persistent deficits in social communication and social interaction across multiple contexts. Poor pragmatic/social use of language or impairment in the ability to understand and use language in social-communicative contexts is a core feature of ASD. Pragmatic skills involve: (a) using language for different purposes; (b) changing language according to the needs of a listener or situation; (c) understanding non-literal language; and (d) following rules for conversations. 

There are many unwritten rules in society that govern our behavior. While most of us intuitively understand these rules, many autistic individuals have not automatically learned the conventions and nuances that make up their social environment. These unspoken or “hidden” social standards can make the world a confusing place and result in life-long challenges. For example, social expectations such as “it is not polite to interrupt others while they are talking,” “take turns in conversation” and “discuss other topics besides only those you are interested in” are not taught and are assumed to be known and understood. We seem to have an “unconscious” navigator that allows us to make intuitive sense of the unspoken rules in society and adjust to the social demands of our everyday lives.
Figurative Language

The unspoken rules of social engagement involve the use of the pragmatic, social communicative functions of language (e.g., turn taking, understanding of inferences and figurative expressions) as well as nonverbal skills needed to communicate and regulate interaction (e.g., eye contact, gesture, facial expression). This includes body language and idioms, metaphors, sarcasm, or slang – phrases and meanings that we intuitively assimilate or learn through observation or subtle cues. Individuals with autism tend to interpret language literally and may be puzzled by the common everyday expressions used by a typical peer or adult. Consider how idioms such as “how the cookie crumbles,” “curiosity killed the cat,” and “when it rains, it pours” might have a totally different meaning and result in confusion if taken literally. In order to understand language, we must understand what the idioms in that language mean. If you try to figure out the meaning of an idiom literally (word by word), you will be bewildered. While the typical individual might understand that the phrase “that’s the way the cookie crumbles,” and accompanying body language (e.g., voice, body) communicates to the listener that something unfortunate has happened, to someone with a pragmatic social-communication problem, this idiom will have a completely different meaning and be confusing. The following are but a few of well over 3,000 idioms in the English language.
  • Bite off More than you can chew  
  • Cross that bridge when you come it
  • Everything but the kitchen sink 
  • Get up on the wrong side of the bed 
  • Have a bone to pick with you 
  • Have your cake and eat it too 
  • Kill two birds with one stone  
  • Put all your eggs in one basket 
  • Raining cats and dogs 
  • Run circles around someone 
  • Till the cows come home
Assessment

Because social communication deficits are among the core challenges of ASD, a best practice student assessment should include an evaluation of pragmatic competence and not be limited to the formal, structural aspects of language (i.e., articulation and receptive/ expressive language functioning). As a group, more capable autistic students tend to demonstrate strength in formal language, but a weakness is pragmatic and social skills.  As a result, they often fail to qualify for speech-language services because they present strong verbal skills and large vocabularies, and score well on formal language assessments. Particular attention should be given to the pragmatic, social communicative functions of language (e.g., turn taking, understanding of inferences and figurative expressions) as well as to the nonverbal skills needed to communicate and regulate interaction (e.g., eye contact, gesture, facial expression, and body language). 

Assessments to identify pragmatic language deficits tend to be less well developed than tests of language fundamentals. There are fewer standard measures available to assess these skills in children with autism. Valid norms for pragmatic development and objective criteria for pragmatic performance are also limited. Among the standardized instruments that focus on the social communicative functions of language are the Comprehensive Assessment of Spoken Language (CASL; Carrow-Woolfolk, 1999), Test of Pragmatic Language, 2nd Edition (TOPL-2; Phelps-Terasaki & Phelps-Gunn, 2007), Social Language Development Test-Elementary (SLDT-E; Bowers, Huisingh, & LoGiudice, 2008), Children's Communication Checklist, Second Edition (CCC-2; Bishop, 2006) and Pragmatic Language Skills Inventory (PLSI; Gilliam & Miller, 2006). 
Significant and severe deficits in the ability to communicate and interact with others can limit students' participation in mainstream academic settings and community activities. Moreover, pragmatic deficits tend to become even more obvious and problematic as social and educational demands increase with age. Because pragmatic language is a critical part of everyday social interaction, it is imperative that speech/language services for children with ASD include a focus on social communication skills. Students with pragmatic language deficits who do not meet the DSM-5 ASD criteria for restricted, repetitive patterns of behavior should be evaluated for social (pragmatic) communication disorder (SCD). 


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 CBTHe is also the editor of a 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). 
© Lee A. Wilkinson, PhD

Sunday, October 11, 2020

Self-Injurious Behavior (SIB) in Autistic Children

Predictors of Self-Injurious behavior in Autism

Children with autism spectrum disorder (ASD) frequently engage in maladaptive behaviors such as aggression and rituals. The most distressing to caregivers and challenging for health care providers are self-injurious behaviors (SIB). Although self-injury is not a symptom of autism, certain symptoms, situations, and comorbidities related to ASD can lead some autistic individuals people to engage in self-injurious behavior. The most common types of SIB in children and adults with ASD include hand biting, head banging and scratching. This might include head banging on floors, walls or other surfaces, hand or arm biting, hair pulling, eye gouging, face or head slapping, skin picking, scratching or pinching, forceful head shaking. SIB varies from case to case can be understood as existing on a continuum in relation to frequency and intensity, ranging from mild and infrequent to severe and chronic. 

In many cases, self-injury begins as a means of communication. Often a child is trying to convey a feeling or idea they may not be able to express in words. Biting, headbanging or other self-injury behaviors may be attempts to express pain, fear, displeasure, or anxiety. Self-injury can also be a form of sensory stimulation. An individual with autism may self-injure as a way to increase or decrease their level of arousal. An increased understanding of the incidence and risk factors associated with SIB in autism is needed to develop treatment options.

Research
A study in the Journal of Autism and Developmental Disorders assessed 7 factors that may influence self injury in a large group of 250 children and adolescents with ASD: (a) atypical sensory processing; (b) impaired cognitive ability; (c) impaired functional communication; (d) deficits in social interaction; (e) age; (f) the need for sameness; and (g) ) compulsive or ritualistic behavior. Other factors that may influence SIB incidence such as gender and ASD severity were also assessed. A series of diagnostic tests were administered either directly to the children and adolescents or to their parents to assess: (a) autism severity; (b) cognitive and adaptive ability; (c) and receptive and expressive language; (d) repetitive behaviors; and (e) self-injury.
The results indicated that half of the children and adolescents demonstrated SIB. Atypical sensory processing was the strongest single predictor of self-injury followed by sameness, impaired cognitive ability and social functioning. Age, impaired functional communication, and ritualized behavior did not contribute significantly to self-injury. No significant effects of gender or severity of autistic symptoms were found in the study.
Implications

Self-injurious behavior is an important public health problem in individuals with autism spectrum disorder (ASD). SIB is a debilitating behavior that occurs in a significant proportion of children, teens, and adults with ASD. Atypical sensory processing and the need for sameness were contributors to SIB in this study. Research has also found significant associations between SIB and behavioral (aggression, hyperactivity, anxiety) developmental (adaptive behaviors, nonverbal IQ), and somatic (sleep and GI problems ) factors. Current and previous research findings support the need for a comprehensive and multidisciplinary approach for assessing and managing SIB in ASD. It is critical that interventions that target the risk factors associated SIB be identified and implemented in clinical practice. Providing empirically supported behavioral interventions to autistic individuals with self-aggressive behavior will not only impact directly on the problem behavior, but will their enhance social, educational, and adaptive functioning as well. Further research is clearly needed to better understand additional contributing factors that may influence these complex behaviors in children with ASD. For example, temperament, ability to self-regulate emotions, and medication usage might contribute to increased self injury.
Key References 
Christensen T, Ringdahl J, Bosch J, et al. (2009). Constipation associated with self-injurious and aggressive behavior exhibited by a child diagnosed with autism. Education & Treatment of Children, 32, 89–103.

Devine D. (2014). Self-injurious behaviors in autistic children: a neuro-developmental theory of social and environment isolation. Psychopharmacology, 231, 979–997. 

Duerden, E. G., Oatley, H. K., Mak-Fan, K. M., McGrath, P. A., Taylor, M. J., Szatmari, P., & Roberts, S. W. (2012). Risk factors associated with self-injurious behaviors in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42:2460–2470. DOI 10.1007/s10803-012-1497-9

Mahatmya, D., Zobel, A., & Valdovinos, M. G. (2008). Treatment approaches for self-injurious behavior in individuals with autism: Behavioral and pharmacological methods. Journal of Early and Intensive Behavior Intervention, 5, 106-118.

Moseley, R. L., Gregory, N. J., Smith, P., Allison, C., & Baron-Cohen, S. (2019). A 'choice', an 'addiction', a way 'out of the lost': exploring self-injury in autistic people without intellectual disability. Molecular autism10, 18. doi:10.1186/s13229-019-0267-3

Soke, G. N., Rosenberg, S. A., Hamman, R. F., Fingerlin, T., Rosenberg, C. R., Carpenter, L., … DiGuiseppi, C. (2017). Factors associated with self-injurious behaviors in children with autism spectrum disorder: Findings from two large national samples. Journal of autism and developmental disorders47(2), 285–296. doi:10.1007/s10803-016-2951-x

Summers, J., Shahrami, A., Cali, S., D'Mello, C., Kako, M., Palikucin-Reljin, A., … Lunsky, Y. (2017). Self-Injury in autism spectrum disorder and intellectual disability: Exploring the role of reactivity to pain and sensory input. Brain sciences7(11), 140. doi:10.3390/brainsci7110140

Waters, P., & Healy, O. (2012). Investigating the relationship between self-injurious behavior, social Deficits, and co-occurring behaviors in children and adolescents with autism spectrum disorder. Autism research and treatment2012, 156481. doi:10.1155/2012/156481

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 and Philadelphia: Jessica Kingsley Publishers.

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 CBTHe 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).

Wednesday, September 2, 2020

Transition Planning for Students with Autism

Transition Planning for Students with Autism
Once the young person with autism leaves the school system, the educational entitlements of the Individuals with Disabilities Education Improvement Act of 2004 (IDEA 2004) are no longer available. The need for supports and services to help adolescents transition to greater independence has become a critical issue as a growing number of youth face significant challenges, with many on the spectrum unemployed, isolated, and lacking services (Orsmond, Shattuck, Cooper, Sterzing, & Anderson, 2013). Research indicates that outcomes are almost universally lower for youth on the autism spectrum compared to their peers. 

According to the National Autism Indicators Report: Transition into Young Adulthood (Roux, Shattuck, Rast, Rava, & Anderson, 2015): (a) only about one in five lived independently (without parental supervision) in the period between high school and their early 20s; (b) approximately 26 percent of young adults and 28 percent of those unemployed and not in school received no services which could help them with employment, continue their education, or live more independently; (c) Over one-third (37 percent) of young adults were disconnected during their early 20s, meaning they never got a job or continued education after high school; and (d) transition planning, a key process for helping youth build skills and access services as they enter adulthood, was frequently delayed. Just 58 percent of youth had a transition plan by the federally required age.

The Transition Plan
The transition from school to adulthood is a process that begins when students and their parents begin planning for their post high school life. A transition plan is critical for young people with autism to be successful and participate to the fullest extent possible in society. The focus of intervention planning must shift from addressing the core deficits in childhood to promoting adaptive behaviors that can facilitate and enhance functional independence and quality of life in adulthood. This includes new developmental challenges such as independent living, self-advocacy, vocational engagement, postsecondary education, and family support.
IDEA requires that transition plan activities for students with disabilities begin no later than the first IEP to be in effect when the child turns 16, or younger if determined appropriate by the IEP team or state education agency. Transition services are a coordinated set of activities that focus on improving the academic and functional achievement of the student with a disability to facilitate the movement from school to post-school activities, including postsecondary education, vocational education, integrated employment (as well as supported employment); continuing and adult education, adult services, independent living, or community participation. Responsibilities of the IEP team include coordinating communication and services between school and community-based service providers; addressing environmental, sensory, behavioral and/or mental health concerns; identifying potential careers and employers; and teaching work behaviors, job skills, and community living skills (Virginia Department of Education, 2010). Just as with other educational services in a student’s IEP, schools must provide the services necessary for the student to achieve the transition goals stated in the IEP. 

The IEP must include: (a) appropriate measurable postsecondary goals based upon age-appropriate transition assessments related to training, education, employment and, where appropriate, independent living skills; (b) the transition services (including courses of study) needed to assist the child in reaching those goals; and (c) beginning not later than one year before the child reaches the age of majority under state law, a statement that the child has been informed of the child’s rights under Part B, if any, that will transfer to the child on reaching the age of majority. The school must also invite the student to his or her IEP meeting if a purpose of the meeting will be the consideration of the postsecondary goals for the child and the transition services needed to assist the child in reaching these goals (IDEA, 2004).
Implications
Students with autism face significant challenges as they transition to adulthood. Postsecondary outcome studies reveal poor long-term outcomes in living arrangements, employment, and community integration when compared to their peers with other types of challenges. Research indicates that many are socially isolated and that the vast majority of young autistic adults will be residing in the parental or guardian home during the period of emerging adulthood (Anderson, Shattuck, Cooper, Roux, & Wagner, 2014; Orsmond, Shattuck, Cooper, Sterzing, & Anderson, 2013). A consistent theme for parents of adolescents with autism is the fear that their child will “fall through the cracks” when transitioning from child to adult services. Unfortunately, access to needed supports and services drops off dramatically after high school - with many receiving little or no assistance.
As we know, no two people with autism are alike. The characteristics, strengths, and challenges vary widely across individuals. Support and service needs also differ and continually change as individuals with autism age. Comprehensive transition planning and support for students leaving high school and exiting special educational programming, each with unique strengths, interests, and challenges, is an urgent task confronting our communities and schools (Roux, Shattuck, Rast, Rava, & Anderson, 2015). Greater emphasis must be placed on transition planning as a key process for helping autistic youth build skills and access services as they leave school and enter adulthood. This includes a focus on independent living skills, self-advocacy, vocational engagement, postsecondary education, family support, and a continuum of mental health services for those experiencing comorbid (co-occurring) mental health issues (Lake, Perry, & Lunsky, 2014). 

Image courtesy of http://advocacyinaction.net/autism-preparing-your-child-for/
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.
Anderson, K. A., Shattuck, P. T., Cooper, B. P., Roux, A. M., & Wagner, M. (2014). Prevalence and correlates of postsecondary residential status among young adults with an autism spectrum disorder. Autism, 18, 562-570.  doi: 10.1177/1362361313481860
Individuals with Disabilities Education Improvement Act of 2004. Pub. L. No. 108-446, 108th Congress, 2nd Session. (2004).
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. doi:10.1155/2014/502420
Orsmond, G. I., Shattuck, P. T., Cooper, B. P., Sterzing, P. R., & Anderson, K. A. (2013). Social participation among young adults with an autism spectrum disorder. Journal of Autism and Developmental Disorders, 43, 270-2719. doi 10.1007/s10803-013-1833-8
Roux, A. M., Shattuck, P. T., Rast, J. E., Rava, J. A., & Anderson, K. A. (2015). National Autism Indicators Report: Transition into Young Adulthood. Philadelphia, PA: Life Course Outcomes Research Program, A.J. Drexel Autism Institute, Drexel University. Available from http://drexe.lu/autismindicators
Ohio Center for Autism and Low Incidence (OCALI). Transition to Adulthood Guidelines.
http://www.ocali.org/project/transition_to_adulthood_guidelines
Virginia Department of Education, Office of Special Education and Student Services (October, 2010). Autism Spectrum Disorders and the Transition to Adulthood.
Wagner, S. (2014). Continuum of services and individualized education plan process. In L. A. Wilkinson (Ed.). Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 173-193). Washington, DC: American Psychological Association.
Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. Philadelphia & London: Jessica Kingsley Publishers.
Wrightslaw. Transition Planning. http://www.wrightslaw.com/info/trans.index.htm
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 CBTHe 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).

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, 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).

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