Title of Course: Autism Spectrum Disorders in Schools: Evidence-Based Screening and Assessment CE Credit: 3 Hours Instruction Level: Intermediate Author: Lee A. Wilkinson, PhD, NCSP Abstract: Epidemiological studies indicate a progressively rising prevalence trend in the number of children identified with an autism spectrum disorder (ASD) over the past decade. Yet, compared with general population estimates, students with mild to moderate symptoms of ASD remain an underidentified and underserved population in our schools. The DSM-5 conceptualizations of autism require professionals to update their knowledge about the spectrum. In addition, school professionals should be prepared to recognize the presence of risk factors and/or early warning signs of ASD and be familiar with screening and assessment tools in order to ensure that students with ASD are being identified and provided with the appropriate programs and services. The objective of this course is to identify DSM-5 diagnostic changes in the ASD diagnostic criteria and summarize the empirically-based screening and assessment methodology in ASD and to describe a comprehensive developmental approach for assessing students with ASD. Course adapted with permission from Wilkinson, L. A. (2010). Autism and Asperger Syndrome in Schools: A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, London & Philadelphia: Jessica Kingsley Publishers Ltd.
Learning Objectives: 1. 2. 3. 4. 5. 6.
Identify the changes in the new DSM-5 criteria for ASD Distinguish between DSM diagnosis and IDEA classification schemes Identify the three levels of a multi-tier assessment strategy to screen students with ASD List the components of a comprehensive developmental assessment for ASD Name co-occurring conditions commonly found in students with ASD Name key components of educational programs and services for students with ASD
About the Author: Lee A. Wilkinson, PhD, NCSP, is an author, applied researcher, and practitioner. He is a nationally certified school psychologist, registered psychologist, chartered scientist, and certified cognitive-behavioral therapist. Dr. Wilkinson is currently a school psychologist in the Florida public school system where he provides diagnostic and consultation services for children with autism spectrum disorders and their families. He is also a university educator and teaches graduate courses in psychological assessment, clinical intervention, and child and adolescent psychopathology. His research and professional writing has focused on behavioral consultation and therapy, and children and adults with Asperger syndrome and high-functioning autism spectrum disorders. He has published numerous journal articles on these topics both in the United States and the United Kingdom. Dr. Wilkinson can be reached at http://bestpracticeautism.com.
© 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 1 of 41
Autism Spectrum Disorder in Schools: Evidence-Based Screening and Assessment Introduction More children and youth are being diagnosed with autism spectrum disorder (ASD) than ever before. Epidemiological research indicates a progressively rising prevalence trend for ASD over the past decade (Wing & Potter, 2009). Autism is much more prevalent than previously thought, especially when viewed as a spectrum condition with varying levels of symptom severity. Surveys focusing on this broader definition of autism indicate that ASD is one of the fastest growing disability categories in the world. Recent findings of the Centers for Disease Control and Prevention (CDC) Autism and Developmental Disabilities Monitoring Network ADDM (2012) indicate that one in every 88 school-age children in the United States has an autism spectrum disorder (ASD). This represents an estimated increase of 78% in the prevalence of ASD when compared with the data for earlier surveillance years. Autism is now considered the second most serious developmental disability after intellectual disability and more prevalent among children than cancer, diabetes, and Down syndrome (Filipek et al., 1999, Wilkinson, 2010a). The incidence of ASD is also evident in the number of students with receiving special educational services. For example, the number of students receiving assistance under the special education category of autism quadrupled from 2001 to 2010 (US Department of Education, 2010), increasing from 1.5 percent to 5.8 percent of all identified disabilities. A number of explanations for this dramatic increase in the incidence and prevalence of ASD have been proposed. They include: changes in diagnostic criteria; improved identification; growing awareness among parents and professionals; conception of autism as a spectrum disorder; and greater availability of services (Fombonne, 2005; Wing & Potter, 2009). Whatever the reasons, autism spectrum disorders are no longer rare conditions and it is likely that most school-based support professionals such as school psychologists, speech/language pathologists, and special educators will encounter an increasing number of children with ASD who may comprise approximately 1% of the student population.
Pervasive Developmental Disorder The term Pervasive Developmental Disorder (PDD) refers to a continuum of associated neurobehavioral disorders characterized by three core-defining features (autistic triad): impairments in (a) reciprocal social interactions; (b) verbal and nonverbal communication; and (c) restricted and repetitive behaviors or interests (American Psychiatric Association [APA], 1994). These delays or atypicality in social development, communication, neurocognition, and behavior vary in severity of symptoms, age of onset, and association with other childhood disorders (National Research Council, 2001). The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [DSM-IV-TR]; American Psychiatric Association, 2000) and the 10th edition of the International Classification of Diseases (ICD-10; World Health Organization [WHO], 1993) list categories of pervasive developmental disorders (PDD) which include autism and four other associated disorders. The five pervasive developmental disorders are: (1) austistic disorder (autism), (2) Asperger’s disorder, (3) Rett’s disorder, (4) childhood disintegrative disorder, and (5) pervasive developmental disorder not otherwise specified (PDD-NOS). As continuous and generally lifelong disorders, all have serious clinical implications for personal, social, educational and other important areas of functioning. The features of each PDD are summarized below.
Autistic Disorder (Autism) Autistic disorder is the clinical term for what is frequently called autism. First decribed by Leo Kanner over 60 years ago, autism is the most common and typical of the PDD subtypes. It is generally described as a developmental disorder of neurobiologic origin defined on the basis of behavioral and developmental features. Children diagnosed with autistic disorder must demonstrate impairments in the three core developmental areas, with delays or abnormalities in at least one of these categories present prior to 3 years of age. In the social domain, symptoms include impaired use of © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 2 of 41
nonverbal behaviors (e.g., eye contact, gestures), failure to develop appropriate peer relationships, and limited socialemotional reciprocity. Delays or impairment in communication include problems with reciprocity in conversation, peculiar or repetitive speech and language, and deficits in joint attention and imaginary play. Behavioral features are characterized by circumscribed interests, inflexible adherence to routines, stereotyped body movements, and preoccupation with sensory qualities of objects.
Asperger’s Disorder (Asperger Syndrome) First described by Hans Asperger in 1944, Asperger’s disorder, also known as Asperger syndrome (AS), was initially added to the DSM-IV and ICD-10 (DSM-IV; American Psychiatric Association, 1994). The clinical description of Asperger syndrome consists of severe and sustained impairment in social reciprocity and restricted, repetitive patterns of behavior, but without cognitive impairment or history of delayed language development as in autistic disorder. Because it is often difficult to identify individuals with significant impairment in social and behavioral domains who do not have some degree of atypical communication, it is possible that someone who meets the DSM-IV-TR criteria for Asperger’s disorder will also meet the criteria for autistic disorder. According to the DSM-IV-TR classification system, if the criteria for autistic disorder are met, this precludes a diagnosis of Asperger syndrome.
Childhood Disintegrative Disorder Also known as Heller’s syndrome, childhood disintegrative disorder is a rare condition that has symptoms similar to autism, including both impaired social interaction and stereotyped patterns of interests and behaviors. Children with this disorder are likely to be male and demonstrate severe deficits in cognitive functioning, self-help, and other skills areas. The DSM-IV-TR criteria include a significant regression in skills following 2 years of typical development in at least two of the following: language, social skills or adaptive behavior, bowel or bladder control, play, or motor skills. Although the course of childhood disintegrative disorder is similar to that of autism, it is the distinct pattern of regression leading to profound impairment that distinquishes childhood disintegrative disorder from autistic disorder. If the loss of skills occurs before 2 years of age (sometimes called autistic regression), a diagnosis of autism is given rather than childhood disintegrative disorder. Childhood disintegrative disorder can be difficult to diagnose since it is often unclear whether a marked regression has actually occurred or whether the regression is associated with a neuropathological progression.
Rett’s Disorder Rett’s Disorder is a very rare progressive neurodevelopmental disorder affecting girls exclusively. Although childtren with Rett’s disorder experience no problems in prenatal or perinatal development and show normal motor development throughout the first 5 months of life, progressive deterioration of function begins in the first or second year of development. Previously acquired fine motor skills are lost and the characteristic hand-wringing movement of the disorder appears. Affected girls also develop a wide-based gait and gradually lose gross motor function. The concomitant loss of language skills, interest in the environment, and social interaction result in a presentation similar to autism. Rett’s disorder is usually associated with severe or profound levels of cognitive impairment and is one of most common causes of intellectual disability in females.
Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) This subthreshold category tends to be used quite frequently and is often referred to as a diagnosis of exclusion. Children diagnosed with pervasive developmental disorder not otherwise specified (sometime called atypical autism) experience difficulty in at least two of the three symptom categories of autistic disorder, but do not meet the complete diagnostic criteria for any other ASD. Although children with this diagnostic classification typically have milder symptoms, PDD-NOS is often used when there is a severe and pervasive impairment in the development of reciprocal social interaction along with impairment in either verbal or nonverbal communication skills or with the presence of stereotyped behaviors, interests, and activities. Clinicians and researchers tend to use this DSM-IV-TR category when © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 3 of 41
case history information is unavailable or inadequate; when impairment in one of the core areas (social, communication, restricted interests) is very mild or absent; when onset is over 3 years of age; and for conditions other than autism where there is a significant impairment in social skills (Towbin, 2005).
Autism Spectrum Disorder Since the publication of the DSM-IV, research has prompted changes to the definition and diagnostic framework of autism. The fifth edition of the Diagnostic Statistical Manual of Mental Disorders (DSM-5) includes a new category of Autism Spectrum Disorder (ASD), which collapses the previously mentioned distinct DSM-IV-TR subtypes, including autistic disorder, Asperger’s disorder (syndrome), childhood disintegrative disorder, and pervasive developmental disorder-not otherwise specified (PDD-NOS) into a single unifying diagnosis. Further, the DSM-IV-TR three symptom domains (autistic triad) of social impairment, communication deficits and repetitive/restricted behaviors, interests, or activities have been replaced with two domains, (a) social communication impairment and (b) repetitive/restricted behaviors or interests (RRB). Changes also include greater flexibility in the criteria for age of onset and addition of symptoms not previously included in the DSM-IV-TR such as sensory issues and aversions. For example, the criteria now state that although ASD must be present from infancy or early childhood, it may not be identified until later in the child’s development. Likewise, unusual sensory responses are now included in the DSM-5 symptom criteria for restricted, repetitive patterns of behavior, interests, or activities (RRB). The criteria also feature dimensions of severity that include current levels of language and intellectual functioning to capture the “spectrum" nature of ASD. Individuals meeting criteria for ASD receive a rating of 1, 2, or 3, with each level indicating an increase in symptom severity and need for support. Another significant change in the criteria involves the diagnosis of co-occurring (comorbid) disorders. Unlike the DSM-IV-TR, the DSM-5 no longer prohibits the comorbid diagnosis of attention-deficit/ hyperactivity disorder (ADHD) in children with ASD. When the criteria are met for both disorders, both diagnoses are given. The DSM-5 also includes a new diagnostic category of Social (Pragmatic) Communication Disorder that is designed to capture social communication impairments not accompanied by restrictive and repetitive behavior/interests (RRB). Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present. Individuals who have marked deficits in social communication, but whose symptoms do not meet the criteria for ASD, may be evaluated for social (pragmatic) communication disorder. It should be noted that according to the DSM5, individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive disorder not otherwise specified (PDD-NOS) should be given the diagnosis of ASD. Although space limitations preclude a comprehensive discussion of the changes in the DSM-5, this course reflects current best practice in assessment and identification of ASD based on the DSM-5 symptom criteria.
Clinical vs. Educational Classification The specific criteria for autism differ among the different diagnostic and classification schemes. Although a variety of systems exist, the Individuals with Disabilities Education Act of 2004 (IDEA) and the aforementioned Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) have the greatest impact on the assessment and classification of children In psychiatry and psychology, the most widely used diagnostic system is the DSM-5, which was first developed by the American Psychiatric Association in 1952 and is now in its fifth edition. Unlike the DSM-5, which is intended as a diagnostic and classification system for psychiatric disorders, the IDEA is federal legislation enacted to ensure the appropriate education of children with special educational needs. The IDEA also recognizes only a limited number of disability categories. The definitions of these categories, including autism, are controlling in terms of determining eligibility for special educational services in our schools (Individuals with Disabilities Education Improvement Act, 2004). As defined by IDEA, the term "student with a disability" means a student: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 4 of 41
disabilities; and who, by reason thereof, needs special education and related services" (Individuals with Disabilities Education Improvement Act, 2004). According to the 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, which adversely affects a student’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 student’s educational performance is adversely affected primarily because the student has an emotional disturbance, as defined in this section. (ii) A student 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. IDEA shares a number of features with the DSM-5. Both are categorical systems (e.g., a student meets or does not meet criteria) that focus on the description rather than the function of behavior and have been used in legal decision making regarding special education placement and clinical treatment. Both definitions include deficits in social communication and restricted, repetitive patterns of behavior/interests. The DSM-5 conceptualizes ASD as a clinically significant syndrome or pattern associated with disability or impairment in one or more important areas of functioning (American Psychiatric Association, 2013). The IDEA definition also requires that the core behaviors of autism impair or have a negative impact on the student’s educational performance. Of course, all spectrum disorders are characterized by significant functional impairments and it is rare that a student with ASD will not need special education and related services (National Research Council, 2001). In fact, the National Research Council (2001) recommends that all children identified with ASD be made eligible for special educational services under the IDEA category of autism. Unlike the DSMIV which required onset of symptoms prior to age 3, the DSM-5 and IDEA do not preclude a diagnosis or classification at a later age. This is especially important because many students with ASD are not diagnosed in early childhood and can be identified for special education at later ages. At the present time, the educational definition of autism appears to be sufficiently broad and operationally acceptable to accommodate both the clinical and educational descriptions of ASD. Despite the similarities between the two systems, school professionals should be aware that while the DSM-5 is considered the primary authority in the fields of psychiatric and psychological diagnoses, the IDEA definition is the controlling authority with regard to eligibility decisions for special education (Fogt, Miller, & Zirkel, 2003; Mandlawitz, 2002). While the DSM-5 criteria for ASD are professionally helpful, they are neither legally required nor sufficient for determining educational placement. School professionals should be certain that students meet the criteria for autism as outlined by IDEA and use the DSM-5 to the extent that the diagnostic criteria include the same core behaviors (e.g., impairment in social communication and restricted, repetitive patterns of behavior/interests). We should remember that when it comes to special education, it is state and federal education codes and regulations (not DSM criteria) that drive eligibility decisions (Fogt et al., 2003).
Gender Differences ASD is much more common in males than females in the general population. In fact, boys are three to four times more likely than girls to be identified with ASD. Likewise, referrals for evaluation of boys are ten times higher than for girls (Attwood, 2006). This has led some researchers to suggest that males have more autistic traits than females and that these traits may be related to a sex-linked biological factor (Baron-Cohen, 2008b). Research also suggests that higherfunctioning girls on the spectrum tend to show less severe forms of ASD compared to higher-functioning boys (Klinger, Dawson, & Renner, 2003). Although few studies have examined gender differences in the expression of autism, there are some tentative explanations for this disparity. Since females are socialized differently, ASD may not be manifested in the same way as typical male behavioral symptoms (Wilkinson, 2008). For example, girls might not come to the attention of parents and teachers because of better coping mechanisms and the ability to “disappear” in large groups (Attwood, 2006). Girls on the higher end of the spectrum also tend to have fewer special interests, better superficial social skills, better language © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 5 of 41
and communication skills, and less hyperactivity and aggression than boys. Social impairment and pragmatic deficits may not be readily apparent because of a non-externalizing behavioral profile, passivity, and lack of initiative. Girls who have difficulty making sustained eye contact and appear socially withdrawn may also be perceived as “shy,” “naive,” or “sweet” rather than having the social impairment associated with ASD (Wagner, 2006). This lessens the probability of a girl being identified as having the core symptoms of ASD. Over reliance on the male model with regard to diagnostic criteria might also contribute to a gender “bias” (Wilkinson, 2008). Clinical instruments tend to exclude symptoms and behaviors that may be more typical of females with ASD. Although a comprehensive review of this subject is beyond the scope of this course, we should recognize that there may be sex differences in the expression of the autism phenotype and that a qualitative difference in social connectedness and reciprocity may well differentiate the genders (Attwood, 2006; Wilkinson, 2008a).
Screening, Diagnosis, and Assessment The term screening refers to the process of identifying school-age children most likely to have an ASD and/or developmental delay. Referral is the process of initiating an evaluation of a student in this age group. The terms diagnostic evaluation, diagnosis, and classification refer to the process of assigning a specific diagnostic or special education label; whereas, assessment is used to describe the process of evaluating the student’s level of functioning in multiple developmental areas and his or her unique pattern of strengths and weaknesses. Although these functions and procedures are considered separately, in practice, they may take place concurrently. We should keep in mind that screening instruments are not intended to provide diagnoses, but rather to suggest a need for further diagnostic evaluation and intervention planning assessment.
Psychometric Characteristics The most important psychometric characteristics to consider when evaluating rating scales, tests, and questionnaires are sensitivity and specificity. Both are important validity statistics that describe how well a test can identify true cases of a disorder. Sensitivity is the percentage of the true cases that are correctly identified by a test or rating scale. Specificity is the percentage of non-cases correctly identified. Sensitivity values of .80 or higher are generally recommended. This indicates that at least 80% of children who truly have a condition or disorder (as determined by a more comprehensive evaluation) should be identified by their scores on a measure or scale. Specificity levels of .80 and higher are also recommended, indicating that 80% or more of children who do not have the disorder should be identified as not at risk. Lowering a test’s cutoff score to identify cases increases sensitivity while raising the test threshold decreases sensitivity and increases specificity. False negatives (children with a disorder who test negative) decrease sensitivity, while false positives (children without a disorder who test positive) decrease specificity. An efficient ASD-specific tool should have high sensitivity and minimize false negatives as these are children with likely ASD who remain unidentified (Goin-Kochel et al., 2006; Johnson, Meyers et al., 2007; National Research Council, 2001). It is also important to understand that an instrument’s predictive value will depend on the prevalence of the disorder in the population or group under consideration. For example, an ASD-specific rating scale may be expected to have higher positive predictive value and sensitivity when utilized with at-risk children who exhibit signs or symptoms of developmental delay, social skills deficits, or language impairment (Posserud, Lundervold, & Gillberg, 2006).
Practitioner Qualifications Professionals interpreting ASD-specific measures must be familiar with the respective test manuals and adhere to the standards for educational and psychological testing (e.g., American Educational Research Association, 1999). Although many rating scales can be administered and scored by individuals who do not have an advanced degree or training in psychometrics, interpretation should be conducted by professionals with training and experience in assessment and who are knowledgeable about ASD. This should include an understanding of the test’s theoretical basis, psychometric properties, research and development, administration and scoring, and interpretation guidelines. For a more detailed © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 6 of 41
discussion of best practice guidelines for screening and assessing children with ASD, together with illustrative case examples please see Wilkinson (2010).
Evidence-Based Screening The increased awareness and prevalence of autism, together with the benefits of early intervention, have created an urgent need for school professionals to identify students who may have an ASD. (Bryson et al., 2003; Rogers & Vismara, 2008). Behavioral screening is an important first step in this process. Although children with severe symptoms are often identified at an early age, it is not unusual for children with mild impairments to go undiagnosed until well after entering school (Brock, Jimerson, & Hansen, 2006). For example, a survey of parents in the United Kingdom found that on average, more capable children with ASD were not identified until 11 years of age. In many instances, parents waited more than 5 years before a diagnosis was confirmed (Howlin & Moore, 1997; Howlin & Asgharian, 1999). A recent sample of parents of school-age children with ASD across five countries found a consistent concern with the timeliness of identification (e.g., average age of 7.5 years) and frustration with the delay in accessing services. A study examining the timing of identification among children with autism using a population-based sample from an ongoing surveillance effort across 13 sites in the United States found the gap between potential and actual age of identification (for those identified) to be in the range of 2.7 to 3.7 years. Combined with the fact that more than one quarter of cases were never identified as having ASD through age 8, this gap is characteristic of the weakness in our overall system of screening and identification for ASD (Shattuck et al., 2009). Because many children are not identified until well after entering school, an emphasis should be placed on the identification of school-aged children, not just among young preschool children. Accurate differential identification and provision for services are critical since a high proportion of students may be overlooked, misdiagnosed with another psychiatric condition, or present with comorbid disorders such as depression and anxiety. Whatever the reasons for the reported delay in identification, a late diagnosis postpones the timely implementation of intervention services and may contribute to parental distress in coping with ASD (Goddard, Lehr, & Lapadat, 2000; GoinKochel et al., 2006). It is well established that early interventions for children with developmental disabilities are important in increasing cognitive, linguistic, social, and self-help skills (Rogers 1998, Dawson & Osterling, 1997). Assisting parents to develop effective management techniques is also likely to avoid or minimize the potential for secondary behavioral and emotional problems (Howlin & Rutter, 1987, Howlin, 1998). Because students with mild symptoms of ASD are likely to be educated in general education classrooms, delayed recognition of their problems can also result in the implementation of ineffective or inappropriate teaching methods that fail to address the core social communication deficits of ASD. Likewise, delays in diagnosis and identification have wide implications for families. It is now accepted that autism is most likely among the most heritable of all childhood disorders and that for any family with a child with ASD, there is considerable risk that other children in the family may have social, language, or other neurocognitive problems (Bailey, Phillips, & Rutter, 1996). Family histories of autism or autistic-like behavior or having an older sibling with autism are known risk factors. As a result, a delay in identification may result in siblings with the ‘broader phenotype’ being overlooked and as a result, not receive the help needed to address their problems (Howlin & Asgharian, 1999). Thus, it is critical that school professionals devote increased attention to the screening and early identification of students who may have symptomatology of an autism-related condition (Brock et. al., 2006).
Screening Tools Developing screening tools to identify children with ASD has been especially difficult because of varying degrees of symptom severity (Wing, 2005). Until recently, there were few validated screening measures available to assist professionals in the identification of students with mild deficits (Campbell, 2005; Lord & Corsello, 2005). Likewise, the use of screening instruments has not been especially widespread in our schools. However, our knowledge of ASD is expanding rapidly and we now have more reliable and valid tools to screen and evaluate children efficiently and with greater accuracy (Yeargin-Allsopp et. al., 2003; Wilkinson, 2010). These instruments may be used with children who present with risk factors (e.g., sibling or family history of autism) and/or when parents and teachers, or health care professionals observe or identify the presence of “red flags” (e.g., social communication and behavioral concerns) of a © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 7 of 41
neurodevelopmental disorder. Both parent and teacher screening tools are especially ideal for identifying children who are in need of a more comprehensive evaluation. They yield important information from individuals who know the student the best and are relatively easy to administer and score (Wiggins, Bakeman, Adamson, & Robins, 2007). The following tools have demonstrated utility in screening for ASD in educational settings and can be used to determine which children are likely to require further assessment and/or who might benefit from additional support. All measures have strong psychometric qualities and are appropriate for school-age children and time efficient. Although training needs are minimal and require little or no professional instruction to complete, interpretation of the results requires familiarity with ASD and experience in administering, scoring, and interpreting psychological tests.
Autism Spectrum Rating Scales (Short Form) The Autism Spectrum Rating Scales (Short Form) (ASRS; Goldstein & Naglieri, 2009) is a norm-referenced instrument designed to effectively identify symptoms, behaviors, and associated features of ASD in children and adolescents from 2 to 18 years of age. The psychometric properties of the ASRS provide strong evidence that the measure can accurately distinguish ASD from general population groups as rated by teachers and parents (Goldstein & Naglieri, 2009). The ASRS has both full-length and short forms for young children (2-5) and youth (6-18). The Short Form was developed for screening purposes and contains 15 items from the full-length form that have been shown to differentiate children diagnosed with ASD from children in the general population. High scores indicate that many behaviors associated with ASD have been observed and that there is a need for a more comprehensive assessment. The ASRS Short Form (6-18) has excellent test-retest reliability and good inter-rater consistency. Sensitivity values for parent and teacher informants are .93 and .95, respectively. Specificity is .94 for both parent and teacher ratings (Goldstein & Naglieri, 2009).
Social Communication Questionnaire The Social Communication Questionnaire (SCQ; Rutter, Bailey, & Lord, 2003), previously known as the Autism Screening Questionnaire (ASQ), was initially designed as a companion screening measure for the Autism Diagnostic InterviewRevised (ADI-R; Rutter, Le Couteur & Lord). The SCQ is a parent/caregiver dimensional measure of ASD symptomatology appropriate for children of any chronological age older than fours years. It is available in two forms, Lifetime and Current, each with 40 questions. Scores on the questionnaire provide an index of symptom severity in the reciprocal social interaction, communication, and restricted/repetitive behavior domains and indicate the likelihood that a student has an ASD. Compared to the other measures, the SCQ is the most researched of the ASD-specific screening tools (Norris & Lecavalier, 2010). The scale has been found to have good discriminative validity and utility as an efficient screener for atrisk groups of school-age children (Charman et al., 2007). The sensitivity value is .85 and specificity value .75 when discriminating between ASD and non-ASD groups. Adjusting the cutoff score to a lower level results in a sensitivity value of .93 and a specificity value of .58 (Norris & Lecavalier, 2010).
Social Responsiveness Scale (Second Edition) The second edition of the Social Responsiveness Scale (SRS-2; Constantino & Gruber, 2012) identifies the various dimensions of interpersonal behavior, communication, and repetitive/stereotypic behavior characteristic of ASD and quantifies symptom severity. The SRS-2 maintains continuity with the original instrument and extends the age range from 2.5 years through adulthood. There are four forms, each consisting of 65 items: Preschool Form (ages 2.5 to 4.5 years); School-Age Form (4 to 18 years); Adult Form (ages 19 and up); and Adult Self-Report Form (ages 19 and up). The School-Age Form is unchanged in its item content from the first edition of the SRS and can be completed in 15-20 minutes by informants (e.g., parents, teachers, day-care providers). Scores are obtained for five Treatment Subscales: Social Awareness, Social Cognition, Social Communication, Social Motivation, and Restricted Interests and Repetitive Behavior. There are also two DSM-5 Compatible Subscales (Social Communication and Interaction and Restricted Interests and Repetitive Behavior) that allow comparison of symptoms to the new DSM-5 diagnostic criteria for ASD. Sensitivity and specificity values of .92 suggest that the SRS-2 is a robust instrument for identifying students with ASD. Large samples also provide evidence of good interrater reliability, high internal consistency, and convergent validity with © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 8 of 41
the Autism Diagnostic Interview-Revised (ADI-R), Autism Diagnostic Observation Schedule (ADOS), and Social Communication Questionnaire (SCQ).
A Multi-Tier Screening Strategy The following is a suggested multi-tier strategy for screening students who demonstrate risk factors and/or warning signs of atypical development or where caregiver/parent concerns strongly suggest the presence of ASD symptoms (Wilkinson, 2009, 2010).
Tier One This initial step involves the ability to recognize the risk factors and/or warning signs of ASD. All school professionals should be alert to those students who display atypical social and/or communication behaviors that might be associated with ASD. For example, the failure to make friends, understand social rules and conventions, or display social reciprocity in interpersonal relationships are considered a warning signs at all age and grade levels. Recognizing risk factors also requires that we attend to not only teachers’ concerns about children’s development, but to parents’ worry as well. Parent and/or teacher reports of social impairment combined with communication and behavioral concerns constitute a “red flag” and indicate the need for screening. Students who are identified with risk factors should be referred for formal screening.
Tier Two Once screened, scores on the ASRS, SCQ, and SRS-2 may be used as an indication of the approximate severity of ASD symptomatology for students who presented with elevated developmental risk factors and/or warning signs of ASD. Screening results are shared with parents and school-based teams with a focus on intervention planning and ongoing observation. Scores can also be used for progress monitoring and to measure change over time. Students with a positive screen who continue to show minimal progress at this level are then considered for a more comprehensive assessment and intensive interventions as part of Tier 3. However, as with all screening tools, there will be some false negatives (children with ASD who are not identified). Thus, children who screen negative, but who have a high level of risk and/or where parent and/or teacher concerns indicate developmental variations and behaviors consistent with ASD should continue to be monitored, regardless of screening results.
Tier Three Students who meet the threshold criteria in tier two may then referred for an in-depth assessment. Because the ASRS, SCQ, and SRS-2 report good reliability and high levels of diagnostic validity (ability to correctly identify cases in a population), the results from these screening measures can be used in combination with a comprehensive developmental assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, and cognitive functioning to assist in determining eligibility for special education services and as a guide to intervention planning (National Research Council 2001; Wilkinson, 2010).
Limitations Although the ASRS, SCQ, and SRS-2 are recommended as reliable and valid tools for identifying students across the broad autism spectrum, they are not without limitations. As with any screening instrument, some students who screen positive will not be diagnosed or identified with a disorder. On the other hand, some students who are not identified will go on to meet the eligibility criteria for ASD. Thus, it is especially important to carefully monitor those students who screen negative so as to minimize misclassification and ensure access to intervention services (Bryson et. al., 2003). Gathering information from family and school resources during screening will also facilitate identification of possible cases (Posserud et. al., 2006). © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 9 of 41
Gender differences should also be taken into consideration when screening and evaluating students for ASD. Although few studies have examined effects of gender-specific differences on various screening measures, the ASRS and SRS-2 have generally reported higher mean scores for boys than girls (Williams et al., 2006). For instance, the SRS-2 identifies two separate total raw score cut-offs, with a lower threshold for girls than for boys (Constantino & Gruber, 2005). A screening tool’s efficiency will be influenced by the practice setting in which it is used. Practitioners must weigh the disadvantages of an inaccurate classification against the consequences of a delayed or missed diagnosis (Goin-Kochel et. al., 2006). ASD-specific tools are not currently recommended for the universal screening of typical school-age children (Allison et. al., 2007; Johnson et. al., 2007). Focusing on referred students with identified risk-factors and/or developmental delays (second-level screening) will increase predictive values and result in more efficient identification efforts (Coonrod & Stone, 2005; Lee, David, Rusyniak, Landa, & Newschaffer, 2007). Although screening tools may have utility in broadly identifying students with ASD, they are not a substitute for a more thorough assessment. Screening tools are not recommended as stand-alone diagnostic instruments and should be used only as part of a more comprehensive diagnostic assessment. Interviews and observation schedules, together with a multidisciplinary assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, atypical behaviors, and cognitive functioning are best suited for diagnosis and educational classification (National Research Council 2001; Wilkinson, 2010).
Evidence-Based Assessment The primary goals of conducting an autism spectrum assessment are to determine the presence and severity of an ASD, develop interventions for educational planning, and collect data that will help with progress monitoring (Shriver et al., 1999). School professionals must also determine whether a student with ASD has been overlooked or misclassified, describe co-occurring (comorbid) disorders, or identify an alternative classification. Interviews and observation schedules, together with an interdisciplinary assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, atypical behaviors, and cognitive functioning are recommended best practice procedures (National Research Council 2001; Wilkinson, 2010). This section describes a comprehensive developmental assessment model and focuses on evidence-based tools and procedures for the assessment and identification of ASD included in recommendations of the American Academy of Neurology (Filipek et al., 2000), the American Academy of Student and Adolescent Psychiatry (Volkmar, Cook, Pomeroy, Realmuto, & Tanguay, 1999), and a consensus panel with representation from multiple professional societies (Filipek et al., 1999).
Comprehensive Developmental Assessment Model There are several important considerations that should inform the assessment process. First, a developmental perspective is critically important. Evaluating the student within a developmental assessment framework provides us with a yardstick for understanding the severity and quality of delays or atypicality (Klin, Saulnier, Tsantsanis, & Volkmar, 2005; Klin & Volkmar, 2000). Because ASD affects multiple developmental domains, a team approach is essential for establishing a developmental and psychosocial profile of the student in order to guide intervention planning. A team of professionals including, but not limited to, a school psychologist, general and special educators, speech/language pathologist, occupational therapist, and in some cases a physician, should evaluate the student and collaborate to determine an appropriate classification or diagnosis. The following principles should guide the assessment process (Filipek et al., 1999, 2000; Klin et al., 2005; Klin & Volkmar, 2000; Volkmar et al., 1999). • • •
Students who screen positive for ASD should be referred for a comprehensive assessment. Assessment should involve careful attention to the signs and symptoms consistent with ASD as well as other cooccurring (comorbid) childhood disorders When a student is suspected of having an ASD, a review of his or her developmental history in areas such as speech, communication, social and play skills is an important first step in the assessment process. © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 10 of 41
• • • • •
A family medical history and review of psychosocial factors that may play a role in the student’s development is a significant component of the assessment process. The integration of information from multiple sources will strengthen the reliability of the assessment results. Evaluation of academic achievement should be included in assessment and intervention planning to address learning concerns in the student’s overall school functioning. Assessment procedures should be designed to assist in the development of instructional objectives and intervention strategies based on the student’s unique pattern of strengths and weaknesses. Because impairment in communication and social reciprocity are core features of ASD, a comprehensive developmental assessment should include both domains.
The comprehensive developmental assessment model requires the use of multiple measures including, but not limited to, verbal reports, direct observation, direct interaction and evaluation, and third-party reports (Filipek et al., 1999; Shriver et al., 1999). Table 1 shows the recommended core domains and measures included in a comprehensive developmental assessment. (California Department of Developmental Services, 2002; Filipek et al., 1999; Johnson et al., 2007; National Research Council, 2001; Volkmar et al., 1999). Although not exhaustive, these tools provide a reliable and valid assessment of the DSM-5 symptom criteria for ASD. Their selection is based on relevance to identification, differential diagnosis and classification, intervention planning, research, evidence-based practice, and professional experience. Table 1 Core Assessment Battery for ASD _____________________________________________________________________________________ Measure Format Age Range Time _____________________________________________________________________________________ Direct Observation: ADOS-2 Direct Testing 2 years to adult 30 to 50 min CARS-2 Rating Scale 2 years to adult 5 to 10 min Parent/Teacher Report: ADI-R Interview 18 months to adult 1 to 2.5 hrs ASRS Rating Scale 2 to 18 years 5 to 15 min SCQ Rating Scale 4 years to adult 10 to 15 m SRS-2 Rating Scale 4 to 18 years 10 to 15 min Achievement: WIAT-III Direct Testing 4 to adult Varies WJ-III Direct Testing 2 to adult 60 to 70 min Cognitive: DAS-II Direct Testing 2.6 to 17 years 45 to 60 min SB-5 Direct Testing 2 to 85 45 to 75 min WISC-IV Direct Testing 6 to 16 years 60 to 90 min WPPSI-IV Direct Testing 2 to 7 years 30 to 60 min Communication: CASL Direct Testing 3 to 21 years 30 to 45 min CCC-2 Rating Scale 4 to 16 years 10 to 15 min PLSI Rating Scale 5 to 12 years 5 to 10 min TOPL Direct Testing 6 to 18 years 45 to 60 min Adaptive Behavior: ABAS-II Rating Scale Birth to Adult 15 to 20 min VABS-II Interview Birth to 18 years 20 to 60 min ____________________________________________________________________________ © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 11 of 41
Note. ADOS-2-Autism Disorder Observation Scale; ASRS-Autism Spectrum Rating Scales; CARS-2-Childhood Autism Rating Scale; ADI-R-Autism Diagnostic Interview; SCQ-Social Communication Questionnaire; SRS-Social Responsiveness Scale; WIAT-III-Wechsler Individual Achievement Test; WJ-III-Woodcock Johnson Psychoeducational Battery; DAS-II-Differential Abilities Scales; SB-5-Stanford-Binet Intelligence Scales-Revised; WISC-IV-Wechsler Intelligence Scale for Children; WPPSI-IV-Wechsler Preschool and Primary Scale of Intelligence; CCC-2-Children’s Communication Checklist; CASLComprehensive Assessment of Spoken Language; PLSI- Pragmatic Language Skills Inventory; TOPL-Test of Pragmatic Language; VABS-II-Vineland Adaptive Behavior Scales; ABAS-II-Adaptive Behavior Assessment System
The Core Assessment Battery Record Review The first step in the assessment process is to review the student's early developmental history and current concerns with parents or caregiver. The focus of the record review is to look at past behavior and help determine developmental trends. Sources of information may include previous medical, school, and psychological records. Data from other evaluations or intervention reports (e.g., behavioral, speech/language) are especially valuable sources of information.
Developmental/Medical History A comprehensive developmental/medical history, generally in the form of a parent or caregiver interview, is an important foundation component of the assessment process. The parent or caregiver typically serves as the source for obtaining the student’s developmental history and information regarding behaviors and milestones. Inquiry should be made as to any history of developmental, learning and/or psychiatric problems in the family. Likewise, the interviewer should specifically question the immediate and extended family for autism, intellectual disability, and fragile X syndrome because of their association with ASD.
Medical Screening/Evaluation Hearing and visual acuity should be routinely checked as part of the assessment process since both are frequent impairments in students with developmental disabilities. All students suspected of ASD should have their vision and hearing screened using appropriate methodology and be referred for a formal assessment if concerns are present. The need for additional medical and/or laboratory tests may become obvious, based upon the history and physical examination. In many cases, children under the age of ten may have had significant medical testing. This is particularly true in children with identified with intellectual impairment or learning disability for which the presence of an ASD is being questioned. Similarly, cases where several years of normal development are followed by a marked developmental regression may suggest the need for further medical referral and evaluation (Volkmar et al., 1999). With older children, the presence of a seizure disorder should also be questioned, particularly in students with lower cognitive functioning or who demonstrate a noticeable regression in their behavior.
Parent/Caregiver Interview Formal interview instruments play an important role in evaluating a student’s developmental history and assessing behaviors associated with ASD (Lord et al., 1997). At present, the Autism Diagnostic Interview, Revised (ADI-R; Lord et al., 1994) is the most reliable standardized measure that can be used to obtain an early developmental history of autistic behaviors (Lord et al., 1994; Rutter et al., 2003). The ADI-R is considered the “gold standard” parent interview that identifies symptoms closely linked to the diagnostic criteria of the DSM-IV-TR and ICD-10 (Lord & Corsello, 2005). It is typically administered by a trained clinician using a semistructured interview format. The items that empirically distinguish children with autism from those with other developmental delays are summed into three functional domains: Language and Communications, Reciprocal Social Interactions, and Restricted, Repetitive, and Stereotyped Behaviors and Interests. The scores on these items discriminate children with autism from those with other disorders, such as © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 12 of 41
severe receptive language disorders and general developmental delays (Lord et al., 1994). The long version of the ADI-R requires approximately two and one-half to three hours for administering and scoring. A shorter version is available which includes only the items on the diagnostic algorithm, takes less time, (approximately 90 minutes), and may be used for clinical assessment (Lord et al., 1994). Although the ADI-R is able to identify the likelihood of autism, its validity is highly dependent on the interviewer’s training and experience. Because the items of the Social Communication Questionnaire (SCQ; Rutter, Bailey, & Lord, 2003) were selected to match the ADI-R items found to have discriminative validity, the SCQ may be considered as an alternative measure when time and training opportunities are limited (Naglieri & Chambers, 2009). Although the SCQ produces subscores that parallel the longer interview form (Reciprocal Social Interaction, Qualitative Abnormalities in Communication, and Restricted, Repetitive, and Stereotyped Patterns of Behavior), the interpretation of results should be made by a professional with training and experience in ASD.
Parent/Teacher Ratings Because social communication impairment is a defining core feature of ASD, the assessment of this domain is fundamental to the evaluation process and requires data collection from multiple sources. Questionnaires completed by parents and teachers are one of the most vital sources of information about the student’s social responsiveness and social communication skills. As we have seen, SCQ and SRS-2 are well researched and validated instruments that are userfriendly and efficient. The SCQ has high agreement with the more labor-intensive ADI-R and can be an efficient tool to obtain diagnostic information (Bishop & Norbury, 2002; Naglieri & Chambers, 2009). The SRS-2 also has high correlation with the ADI-R and demonstrated utility as a measure of social responsiveness across home and school contexts. It may be incorporated into the core assessment battery as well (Constantino & Gruber, 2012). Although the ASRS Short Form provides an efficient way to screen students for possible ASD, the full length form is recommended for inclusion in the core battery. The full-length ASRS (6−18 Years) consists of 71 items with separate parent (ASRS Parent Ratings) and teacher (ASRS Teacher Ratings) rating forms. Parents and teachers are asked to evaluate how often they observed specific behaviors in the student or adolescent in areas such as socialization, communication, unusual behaviors, behavioral rigidity, sensory sensitivity, and self-regulation. This form provides the most complete assessment information, including Total Score, ASRS Scales, DSM-IV-TR Scale, and Treatment Scales. All raw scores are converted to standardized scores (T-scores) with a mean of 50 and a standard deviation of 10. Scores can also be described in terms of percentile ranks. The full-length form (6-18) has excellent reliability and discriminative validity. Sensitivity is reported as .90 (parent) and .92 (teacher) for the Total Score. When used in combination with other assessment information, results from the ASRS can help guide diagnostic and classification decisions (Goldstein & Naglieri, 2009). Popular third party rating scales such as the Gilliam Autism Rating Scale (GARS; Gilliam, 1995), the Asperger Syndrome Diagnostic Scale (ASDS; Myles & Simpson, 2001), the Gilliam Asperger’s Disorder Scale (GADS; Gilliam, 2001), and the Autism Behavior Checklist (ABC; Krug et al., 1988)] are not recommended and should be used with caution due to significant weaknesses, including the underidentification of ASD and questions concerning standardization and norming procedures (Brock et al., 2006; Campbell, 2005; Coonrod & Stone, 2005; Goldstein, 2002; Ozonoff, Goodlin-Jones, & Solomon, 2005; Lord & Corsello, 2005; Norris & Lecavalier, 2010; South et al., 2002; Wilkinson, 2010).
Direct Observation Direct observation should take place throughout the assessment and intervention planning process. The specific format can be either formal or informal. The Autism Diagnostic Observation Schedule (ADOS; Lord et al., 2000) is considered the "gold standard" for directly assessing and diagnosing autism across ages, developmental levels, and language skills. The ADOS is a semistructured interactive assessment consisting of four different modules, graded according to language and developmental level. The module chosen is based upon the language level of the child or adolescent. The algorithm for the ADOS includes social and communication symptoms, but not the presence of repetitive and stereotyped behaviors. Two empirically-defined cutoff scores, one for autistic disorder and the other for ASD are provided. Information obtained on the child’s social and language functioning by the ADOS can be especially useful in quantification of ASD © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 13 of 41
domains and in intervention and educational planning (Lord & Corsello, 2005). The second edition of the ADOS (ADOS-2; Lord et al., 2012) offers revised algorithms and a new Comparison Score for Modules 1 through 3 indicating level of autism spectrum-related symptoms compared to children with ASD who are the same age and have similar language skills, a new Toddler Module, and updated protocols with clearer administration and coding guidelines for all modules. As with the ADI-R, the ADOS is a sophisticated instrument that requires specialized training, background and experience in the treatment of autism, and practice to be utilized effectively. The Childhood Autism Rating Scale, second edition (CARS-2; Schopler, Van Bourgondien, Wellman, & Love, 2010) may be considered as an alternative to the ADOS in the school context. The CARS-2 is time efficient and requires less training. Knowledgeable professionals such as special educators, educational and school psychologists, and speech/language pathologists who have had some exposure to autism can be trained to use the CARS-2 effectively. The CARS-2 consists of two 15-item rating scales completed by the practitioner and a Parent/Caregiver Questionnaire. The Standard Version Rating Booklet (CARS 2-ST) is equivalent to the original CARS and is used with children younger than 6 years of age and those with significant communication difficulties or below-average cognitive ability. The High-Functioning Version Rating Booklet (CARS 2-HF) is an alternative for assessing verbally fluent children and youth, 6 years of age and older, with average or above intellectual ability. To complete the ratings on the CARS 2, the professional (e.g., school psychologist, speech/language therapist) must have convergent information from multiple sources such as direct observation, parent and teacher interviews, prior assessments of cognitive functioning and adaptive behavior, and developmental history. Item ratings are based on frequency, intensity, atypicality, and duration of the specific behavior. The psychometric properties of the CARS 2-HF indicate a high degree of internal consistency and good interrater reliability. Validity information reports an overall discrimination index value of .93, with sensitivity and specificity values of .81 and .87, respectively. The CARS 2-HF form also demonstrates a relatively strong relationship with the “gold standard” ADOS. Informal measures can be used as part of the assessment process when observing, interviewing the parent/teacher, and/or directly interacting with the student. They should focus on observing and recording behaviors in each of the core developmental areas such as reciprocal turn-taking; shared attention; social reciprocity; eye contact; repetitive behaviors; pretend play; spontaneous giving/showing; social language; and use of toys and objects. When using informal observation measures, it is very important to have an understanding of how students, both those with ASD and their typical peers, respond at various ages and developmental levels.
Intellectual Functioning The primary goal of conducting an intellectual evaluation includes establishing a profile of the student's cognitive strengths and weaknesses in order to facilitate educational planning and to help determine the presence of any cognitive limitations that might warrant eligibility for special educational services. The level of intellectual functioning is associated with the severity of ASD symptoms, skill acquisition and learning ability, and level of adaptive functioning, and is one of the best predictors of long-term outcome. Assessment of cognitive strengths and weaknesses is particularly important because of the characteristically uneven profile of skills demonstrated by students with ASD. It is important that the individual test chosen (a) be appropriate for both the chronological and the mental age of the student, (b) provides a full range of standard scores, and (c) measures both verbal and nonverbal skills (Filipek et al., 1999). It should be noted that the cognitive measures described in this section are not appropriate for children who have little or no useful speech or whose structural language is severely impaired. Nonverbal instruments should be used with children who are nonverbal or older children with severely limited vocabulary and language skills (e.g., ability to communicate with only single words). Although there is no single best measure of intellectual functioning for students with ASD, the Wechsler Scales of Intelligence are the most commonly used measures and often considered the “gold standard” in the evaluation of intellectual functioning across age groups. The Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV; Wechsler, 2003) is the most widely used intelligence test in our schools for students 6 to 16 years of age. The WISC-IV provides a Full Scale IQ and Composite Indexes that yield information about specific cognitive abilities (Verbal Comprehension Index, Perceptual Reasoning Index, Working Memory Index, and Processing Speed Index). The Wechsler Preschool and Primary Intelligence Scale-Fourth Edition (WPPSI-IV; Wechsler, 2012) is used with two age groups: ages © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 14 of 41
2.6 to 3.11 and 4.0 to 7.7. The WPPSI-IV provides Full Scale IQ (FSIQ), Primary Index Scores, and Ancillary Index Score for both age bands. Earlier studies using the Wechsler Intelligence Scale for Children, Third Edition (WISC-III; Wechsler, 2002) found that some students with autism exhibited uneven subtest profiles with the Performance IQ (PIQ) significantly higher than Verbal IQ (VIQ). However, this finding is not universal for children with ASD. Intelligence test profiles should never be used for diagnostic confirmation or differential diagnosis of ASD subtypes (Klinger et al., 2009; Lincoln, Allen, & Kilman, 1995; Siegel, Minshew, & Goldstein, 1996). Likewise, the use of any single score to describe the intellectual abilities of a student with ASD is clearly inappropriate. However, when a specific intellectual profile is evident, this can have an important implication for how the student learns best and what intervention activities may be most effective. The Stanford-Binet Intelligence Scales, Fifth Edition (SB-5; Roid, 2003) is also a well known and popular instrument for measuring intelligence in individuals from 2 to 85 years of age. The SB-5 contains separate sections for Verbal IQ (based on five verbal subtests) and Nonverbal IQ (based on five nonverbal subtests). Factor scores can be calculated for Fluid Reasoning, Knowledge, Quantitative Reasoning, Visual-spatial Processing, and Working Memory, which can be useful for identifying strengths and weaknesses in students with ASD. The SB-5 may be an appropriate IQ test for assessing older children with developmental delay or mild intellectual disability, or as an outcome measure to assess intervention effectiveness over time. The Differential Abilities Scales (DAS-II; Elliott, 2007) may be considered an option for evaluating cognitive ability in students with ASD. The DAS-II assesses both intellectual and academic skills. It can be administered to children across a wide chronological and mental age range (2.5 through 17 years), making it appropriate for repeat administrations, to track progress, and for research projects in which the developmental range of participants may vary considerably. Especially helpful for the ASD population is the option of out-of range testing (e.g., administration of tests usually given to children of a different age). The DAS-II also provides a Special Nonverbal Composite (SNC) score which summarizes the nonverbal domains. The SNC is particularly useful when testing students with ASD who are verbal but may have a mild to moderate language impairment. Many school-age children are already placed in special education programs and may have had a recent psychoeducational evaluation. There may also be occasions where cognitive and academic performance is not a direct concern. For example, a child may be functioning at or above grade level and not have academic or learning challenges. Rather, concerns might center on significant problems in behavioral and/or social functioning. In this circumstance, other assessment domains (e.g., adaptive, communication, behavioral/emotional) may be the primary focus of attention. When records of standardized testing indicate stable cognitive abilities over time or when a more extensive battery is not needed, instruments such as the Reynolds Intellectual Assessment Scales (RIAS; Reynolds & Kampaus, 2003) or the Wechsler Abbreviated Scales of Intelligence (WASI; Wechsler, 1999) may provide sufficient data for assessment purposes.
Academic Achievement The assessment of academic ability is necessary for the purposes of educational decision making and intervention planning. An evaluation of academic functioning will often reveal a profile of strengths and weaknesses or suggest the presence of a learning disability. For school-age children, the most frequently used general achievement tests include the Woodcock-Johnson III NU Tests of Achievement (WJ-III NU; Woodcock, McGrew & Mather, 2007) and the Wechsler Individual Achievement Test-Third Edition (WIAT-III; Wechsler, 2009). The WJ-III and WIAT-III are useful tools for assessing current school performance across a number of curriculum areas and key academic skills. The WJ-III NU is a comprehensive achievement battery designed to assess five curriculum areas: reading, oral language, mathematics, written language, and academic knowledge. A total of 22 subtests are included in the standard and extended batteries which are combined to produce a number of cluster scores (e.g., Broad Reading, Reading Comprehension, Math Calculation Skills, Broad Written Language). The WIAT-III is a general achievement test consisting of 16 subtests that combine to yield 8 composites: Oral Language, Total Reading, Basic Reading, Reading Comprehension and Fluency, © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 15 of 41
Written Expression, Mathematics, Mathematics Fluency and Total Achievement. Administration time varies depending on the grade level of the student and the number of subtests administered.
Adaptive Behavior This domain is a fundamental component of a core ASD assessment battery. The assessment of adaptive behavior should always accompany intellectual testing, because identification of an intellectual disability cannot be made unless performance is compromised on both standardized tests of intelligence and measures of adaptive functioning. Measuring adaptive behavior is also important for setting appropriate goals in treatment and intervention planning, and for measuring intervention outcomes (Freeman, Del'Homme, Guthrie, & Zhang, 1999; Szatmari, Bryson, Boyle, Streiner, & Duku, 2003). Adaptive functioning is an indication of the extent to which the student is able to use his or her ability to adapt to environmental demands (Klin, Sparrow, et al., 2000). Often with ASD, the social and communication domains are measured significantly below estimated intellectual ability (Liss, Bullard, Robins, & Fein, 2000). For example, many higher functioning students with ASD, while scoring in the normal range and above on IQ tests, are functionally impaired because they are unable to translate their cognitive abilities into efficient adaptive behavior. Research indicates that children with ASD consistently demonstrate adaptive behavior levels (e.g., social skills) lower than their measured intellectual ability, and that this pattern is most evident for more capable students on the autism spectrum (Bolte & Poustka, 2002). The most widely used adaptive measure with children suspected of ASD is the Vineland Adaptive Behavior Scales-II (VABS-II; Sparrow, Balla, & Cicchetti, 2005). The scales of the VABS-II are organized within a three domain structure: Communication, Daily Living, and Socialization. An Adaptive Behavior Composite score summarizes functioning in these domains. A Motor Skills Domain and an optional Maladaptive Behavior Index are also available to provide further information about a student’s functioning. The VABS-II is completed during a semi-structured interview with a parent or teacher and is appropriate for individuals from birth to adulthood. It provides four forms to gather in-depth information: the Survey Interview Form; Parent/Caregiver Rating Form; Expanded Interview Form; and Teacher Rating Form. The Adaptive Behavior Assessment System-Second Edition (ABAS-II; Harrison, & Oakland, 2003) is an option when time is a constraint, as it can be administered via questionnaire-checklist procedures, rather than an interview, in approximately 15 to 20 minutes. The ABAS-II is a valid and reliable instrument designed to measure the adaptive behavior skills of infants, children, and adults from birth to 89 year of age (Sattler & Hoge, 2006). Research indicates that the VABS-II and the ABAS-II provide similar levels of overall adaptive functioning for individuals aged 5 to 20 (Sparrow et al., 2005).
Social Communication and Language The assessment of communication skills is vital component of a comprehensive ASD assessment battery. The level of expressive language, together with IQ, is a good predictor of long-term outcome, so it is an especially important domain to measure in terms of intervention planning (Marans, 1997; Stone & Yoder, 2001; Twachtman-Cullen, 1998). An evidence-based communication assessment should not be limited to the formal, structural aspects of language (e.g., articulation and receptive/ expressive language functioning). Particular attention must 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), Although standardized measures provide important information about specific parameters of speech and language, they provide only limited information about social pragmatic skills which are typically difficult to identify in more capable children with ASD (Wetherby, Schuler & Prizant, 1997). As a group, higher functioning students with ASD tend to demonstrate strength in formal language, but a weakness is pragmatic and social skills (Landa, 2000; Tager-Flusberg, Paul, & Lord, 2005). As a result, they often fail to qualify for © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 16 of 41
speech-language services because they present strong verbal skills and vocabularies, and score well on formal language assessments. Nonetheless, significant deficits in the ability to communicate and interact with others can limit their participation in general education settings and community activities (Klin et al., 2000). Moreover, pragmatic deficits tend to become even more obvious and problematic as social and educational demands increase with age (Paul & Wilson, 2009). A variety of traditional instruments, such as the Peabody Picture Vocabulary Test-Fourth Edition (PPVT-4; Dunn & Dunn, 2007), Expressive One-Word Picture Vocabulary Test, Fourth Edition (EOWPVT-4; Brownell, 2010), and Clinical Evaluation of Language Fundamentals-Fifth Edition (CELF-5; Semel, Wiig, & Secord, 2013) have been used to measure the receptive and expressive language skills of school-age students with ASD. As noted, many students with ASD demonstrate age-appropriate skills on traditional tests of language, including articulation, fluency, vocabulary, syntax and reading (Minshew, Goldstein & Siegel, 1995). Unfortunately, assessments to identify pragmatic language deficits are not as well developed as tests of language fundamentals. Few standard measures are available to assess these skills in higher functioning students with ASD. Valid norms for pragmatic development and objective criteria for pragmatic performance are also limited (Young, Diehl, Morris, Hyman, & Bennetto, 2005). Available standardized instruments that focus specifically on pragmatic or social language include the Test of Pragmatic Skills (TPS; Shulman, 1985), the Comprehensive Assessment of Spoken Language (CASL; Carrow-Woolfolk, 1999), the Test of Pragmatic Language, 2nd Edition (TOPL-2; Phelps-Terasaki & Phelps Gunn, 2007), the Test of Language Competence (TACL; Wiig & Secord, 1989), the Children's Communication Checklist-Second Edition (CCC-2; Bishop, 2003) and the Pragmatic Language Skills Inventory (PLSI; Gilliam & Miller, 2006). The CCC-2 and PLSI are third party checklists and have the advantage of sampling pragmatic skills in the student’s natural environment (Verts et al., 2006). Of course, these instruments should not be used in isolation to make decisions regarding classification and intervention planning. Results from other instruments, direct observations, and parent interviews provide valuable information for identifying a pragmatic language disorder.
Additional Domains of Assessment Because children with ASD experience high rates of co-occurring psychiatric conditions, such as attention deficit/hyperactivity disorder (ADHD), disruptive behavior disorders, and mood and anxiety disorders, assessment should include additional domains to address areas of concern. The areas included in the assessment battery will depend on the referral question, history, and core evaluation results. A list of these domains and assessment tools are displayed in Table 2. Table 2 Assessment Tools for Additional Domains _____________________________________________________________ Measure Format Age Range Time ______________________________________________________________________________ Behavioral/Emotional Problems: BASC-2 Checklist 2 to 21 years 5 to 10 min ASEBA Checklist 6 to 18 years 10 to 20 mi CDI-2 Self-Report 7 to 17 years 15 min RCMAS-2 Self-Report 6 to 19 years 10 to 15 min Executive Function and Attention: BRIEF Questionnaire 5 to 18 years 10 to 20 min Conners-3 Questionnaire 3 to 17 years 10 to 20 min WRAML-2 Direct Testing 5 to 90 years 45 min Family System: PSI-3 Questionnaire <12 years 20 to 25 min Motor: VMI-6 Direct Testing 2 to Adult 10 to 15 min © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 17 of 41
BOT-2 (Short Form) Direct Testing 4 to 21 15 to 20 min Sensory Processing: SP (Short Form) Questionnaire 3 to 10 years 10 min SP (Teacher) Questionnaire 3 to 11 years 15 min _________________________________________________________________________ Note. BASC-2-Behavior Assessment System for Children; ASEBA-Achenbach System of Empirically Based Assessment; CDI-2-Children’s Depression Inventory; RCMAS-Revised Children’s Manifest Anxiety Scale; BRIEF-Behavior Rating Inventory of Executive Function; Conners-3 Rating Scales; WRAML-2-Wide Range Assessment of Memory and Learning; PSI-Parenting Stress Index; SP-Sensory Profile; VMI-6-Test of Visual Motor Integration; BOT-2-Bruininks-Oseretsky Test of Motor Proficiency; SSP-Sort Sensory Profile.
Sensory Processing Unusual sensory responses are present in many children with ASD and are often one of the earliest indicators in childhood (Baranek, 2002; O’Neill & Jones, 1997; Crane, Goddard, & Pring, 2009). Because sensory issues are now included in the DSM-5 domain of restricted, repetitive patterns of behavior/interests (RRB) and often overlooked in many ASD assessment procedures, attention to sensory problems should be an important component of an evaluation (Dunn, 2001; Harrison & Hare, 2004). One of the most widely used tools to assess sensory processing is the Sensory Profile (SP; Dunn, 1999). The SP is a caregiver questionnaire which measures children’s (3-10 years of age) responses to certain sensory processing, modulation, and behavioral/emotional events in everyday situations. A short version (Short Sensory Profile) is available for screening. The Sensory Profile School Companion, a school-based measure, is also available to evaluate a student’s sensory processing skills in the classroom setting. This measure can be used in conjunction with the Sensory Profile to provide a comprehensive evaluation of sensory behavior across home and school contexts (Dunn 2001; Kern et al., 2007; Crane et al., 2009).
Executive Function and Attention Research evidence suggests that deficits in executive function may be an important feature of ASD (Hill, 2004; Ozonoff, South, & Provencal, 2005; Pennington & Ozonoff, 1996; Ozonoff, 1997). Executive function is a broad term used to describe the higher-order cognitive processes such as response initiation and selection, working memory, planning and strategy formation, cognitive flexibility, and inhibition of response. Executive functions include the many of the skills required to prepare for and execute complex behavior, such as planning, inhibition, organization, self-monitoring, cognitive flexibility, and set-shifting. Markers of executive dysfunction include difficulty in initiating action, planning ahead, inhibiting inappropriate responses, transitioning, and poor self-monitoring. The Behavioral Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) is a parent- or teacher-rated questionnaire for children ages 5 to 18 years of age that can be used to assess executive functioning in ASD. The BRIEF is comprised of eight subscales representing specific domains of executive functioning: Inhibit, Shift, Emotional Control, Initiate, Working Memory, Plan/Organize, Organization of Materials and Monitor. Because executive functions are important to school success, the inclusion of the BRIEF as an additional measure enables us to assess impaired multi-task performance, document the impact of executive function deficits on real-world functioning, and to plan educational accommodations (Clark, Prior, & Kinsella, 2002). The Wide Range Assessment of Memory and Learning, Second Edition (WRAML2; Sheslow & Adams, 2003) is a direct assessment of memory function that can also be useful in evaluating learning and school-related problems of students with ASD. This comprehensive measure includes a Core Battery and supplemental subtests that provide index scores for General Memory, Verbal Memory, Visual Memory, Working Memory, and Attention and Concentration. A brief four subtest Memory Screening Form that correlates highly with the full test is also available. School-age children with ASD frequently demonstrate symptoms associated with attention-deficit/hyperactivity disorder (ADHD) (Ghaziuddin, 2002; Goldstein, Johnson, & Minshew, 2001). Research indicates that ADHD is a common initial © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 18 of 41
diagnosis for many students with ASD. These symptoms may include inattention, impulsivity, hyperactivity and other features such as low frustration tolerance, poor self-monitoring, temper and anger management problems, and mood changes in the classroom (Loveland & Tunali-Kotoski, 1997; Towbin, 2005). As noted earlier in the course, the DSM-5 does not prohibit the concurrent diagnosis of ASD and ADHD. Thus, an assessment of ADHD characteristics should be included whenever inattention and/or impulsivity are indicated as presenting problems. Measures such as the Connors Third Edition (Conners-3; Conners, 2008) can be used to assess attention-deficit/hyperactivity disorder (ADHD) and related problems in children. Short and long versions of parent, teacher, and self-report forms are available for students aged 6 through 18 years. The short version of the Conners-3 is particularly useful when time is limited or when a screening is needed.
Motor Skills Although motor skills are often less affected than other developmental skills, many students with ASD have problems in fine and/or gross motor functioning and visual-motor integration. Some students may demonstrate atypical motor development, poor coordination, or deficits in praxis (motor planning, execution, and sequencing). Because visual-motor processing and motor skills are important to learning, this domain might be an additional component of an assessment battery. A measure such as the Beery–Buktenica Developmental Test of Visual-Motor Integration-Sixth Edition (VMI-6; Berry & Berry, 2010) can be used to evaluate graphic and motor skills, perceptual accuracy, and eye-hand coordination. The Short Format and Full Format of the VMI tests present drawings of geometric forms arranged in order of increasing difficulty that the child is asked to copy. The Full Format can be administered either individually or to a group in about 15 minutes. The VMI also provides supplemental Visual Perception and Motor Coordination tests, which use the same stimulus forms as the Short and Full Format tests. These optional assessments are designed to be administered after results from the Short or Full Format test show the need for further testing, and to help compare an individual's test results with relatively pure visual and motor performances (one or both of the supplemental tests may be used). A comprehensive measure of gross and fine motor skills may be completed with the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2; Bruininks & Bruininks, 2006). The BOT-2 provides composite scores in four motor areas and one comprehensive measure of motor proficiency. Separate measures of gross and fine motor skills are included, making it possible to obtain meaningful comparisons of performance in two areas. Special education professionals and occupational therapists can use the BOT-2 to assess motor proficiency, ranging from normal development to moderate motor-skill deficits. Although the complete form requires 45 to 60 minutes, the short form can be completed in 15 to 20 minutes.
Family System Parents are often overwhelmed by the challenges of a student with ASD (Estes et al., 2009). Research has shown that parents of children with autism exhibit a characteristic stress profile which includes anxiety related to the student's uneven intellectual profiles, deficits in social relatedness, disruptive behaviors and long-term care concerns (Hoffman, Sweeny, Hodge, Lopez-Wagner, & Looney, 2009; Osborne, McHugh, Saunders, & Reed, 2008). Because symptoms of ASD impair social relatedness and adaptive functioning, parent stress can directly influence the parent or caregiver’s ability to support the student with disabilities (Estes et al., 2009). Targeting problem behaviors may help reduce parenting stress and thus, increase the effectiveness of interventions. The identification of parenting stress and parent-student relationship problems can also alert the assessment team to the need for additional support or counseling. An instrument with established psychometric properties that has been used with the ASD population is the Parenting Stress Index-Third Edition (PSI-3; Abidin, 1995). The PSI is designed as a screening and diagnostic instrument that measures the degree of stress in the parent-student system. It consists of 120 items and takes 20 to 30 minutes for the parent to complete. The PSI yields a Total Stress Score, plus scale scores for both Student and Parent Characteristics, which pinpoint sources of stress within the family. A Short Form is also available and can be completed in 10 to 15 minutes. It is useful when time with the parent is limited, or as a progress monitoring tool.
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Emotional/Behavioral Problems Research indicates that children with ASD have a high risk of developing emotional and behavioral problems which contribute to overall impairment (Ghaziuddin, Weidmer-Mikhail, & Ghaziuddin, 1998; Ghaziuddin, 2002; Wilkinson, 2005). For example, studies suggest that anxiety and depression are more common in ASD than in the general population, with comorbid estimates as high as 65 percent (Kim, Szatmari, Bryson, Streiner, & Wilson, 2000). These 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. The presence of co-occurring disorders should also be carefully investigated when severe or worsening symptoms are present that are not responding to traditional methods of intervention (Lainhart, 1999). The assessment of behavior/emotional problems is challenging because we have no ASD-specific tools designed for this purpose (Deprey & Ozonoff, 2009). However, popular self-report measures such as the Children’s Depression Inventory 2 (CDI-2: Kovacs, 2010) and the Revised Manifest Anxiety Scale-Second Edition (RCMAS-2; Reynolds & Richmond, 2008) can be used to assess symptoms of anxiety and depression in school-age children and adolescents. The CDI-2 is a 27item measure designed to assess cognitive, affective, and behavioral symptoms of depression in students 7 to 17 years of age. Three forms, Self-Report, Teacher Report, and Parent Report, provide information to accurately discriminate children with major depressive or dysthymic disorders from typical students and from those with other psychiatric conditions. The CDI-2 is an efficient and cost-effective tool for screening children for depression and related problems. The RCMAS-2 is a brief measure of the level and nature of anxiety in 6- to 19-year-olds. The test is composed of 49 items covering the following scales: Physiological Anxiety; Worry; Social Anxiety; Defensiveness; and an Inconsistent Responding index. The RCMAS-2 can be completed in 10 to 15 minutes and may be used to provide information on problems such as stress, test anxiety, school avoidance, and peer and family conflicts. It is important to recognize, however, that the CDI 2 and RCMAS-2 do not have a normative database for ASD and lack empirical investigation with these disorders. Third party behavior rating scales/checklists can also provide important information about emotional/behavioral problems in students with ASD. The Achenbach System of Empirically Based Assessment (ASEBA) is a widely used behavior rating system for identifying co-occurring internalizing and externalizing problems across home and school contexts. Although it does not provide an autism factor per se, studies have suggested that certain patterns, such as elevated scores on the Social Problems and Thought Problems scales, may be associated with ASD (Bolte, Dickhut, & Poustka, 1999; Duarte, Bordin, de Oliveira, & Bird, 2003). The ASEBA includes both the Student Behavior Checklist/6-18 (CBCL/6-18; Achenbach & Rescorla, 2001) which obtains reports from parents, close relatives, and/or guardians regarding children’s competencies as well as the Teacher Report Form (TRF; Achenbach & Rescorla, 2001), designed to obtain teachers’ reports of student’s academic performance, adaptive functioning, and behavioral/emotional problems. Ratings from the CBCL/6-18 and TRF are scored in the areas of Aggressive Behavior; Anxious/Depressed; Attention Problems; Rule-Breaking Behavior; Social Problems; Somatic Complaints; Thought Problems; and Withdrawn Behavior. The ASEBA also includes scales related to DSM-IV diagnostic categories; Affective Problems, Anxiety Problems; Somatic Problems; Attention Deficit/Hyperactivity Problems; Oppositional Defiant Problems; and Conduct Problems. Another broad-based measure for assessing co-occurring problems in students with ASD is the Behavioral Assessment System for Children-Second Edition (BASC-2; Reynolds & Kamphaus, 2004). The BASC-2 is a comprehensive set of rating scales and forms including the Teacher Rating Scales (TRS), Parent Rating Scales (PRS), Self-Report of Personality (SRP), Student Observation System (SOS), and Structured Developmental History (SDH). The self-report form measures "sense of inadequacy" and "sense of atypicality," and may be helpful for understanding the problems of student’s with ASD who can provide a valid report (Ozonoff, Provencal, & Solomon, 2002). The BASC-2 may also prove useful for measuring the effects of intervention and treatment in students with ASD (Ozonoff, Provencal, et al., 2002).
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Assessment and diagnosis are only of value when they provide access to the delivery of appropriate intervention and educational services. Research supports the importance of initiating educational service as soon as a child is suspected of having an ASD. Increased opportunities for early intervention, improved educational programs and services, and parent and family support substantially increase the possibility of a more favorable outcome. As we have seen, the primary goals of conducting a comprehensive developmental assessment are to determine the presence and severity of ASD, develop interventions for educational planning, and collect baseline data that will help with progress monitoring. We must also determine whether an ASD that has been overlooked or misclassified, describe co-occurring (comorbid) disorders, or identify an alternative classification. The comprehensive assessment approach includes evaluation of multiple domains of functioning in order to differentiate ASD from other conditions and provide a complete profile of the child to facilitate intervention planning. Assessment for educational and intervention planning involves determining the child’s unique strengths and weaknesses across several domains of functioning with the primary objective of planning treatment and intervention based upon his or her individual profile. While children with ASD share a common diagnostic label, each has individual needs. Because of these individual differences, an individualized approach is needed that addresses the core deficits of the disorder (e.g., communication, social, sensory, academic difficulties) and matches each child’s unique needs and family preferences. The team approach provides a coordinated effort among the various disciplines (e.g., education, speech/language pathology, psychology, medicine) to complement (rather than duplicate) efforts and to develop a cohesive intervention plan and/or arrive at a diagnostic conclusion. The intervention plan is designed to maximize child development and functional skills across both school and family contexts. There are no interventions or treatments that can cure autism, and there are few which have been scientifically shown to produce significant, long-term benefits. With little exception, the evidence base for interventions for students with ASD is in the formative stage. Although robust, impartial research is still needed, the most effective programs are those that incorporate a variety of evidence-based practices designed to address and support the unique needs of individual students and families (National Research Council, 2001). According to the National Autism Center, the following are evidence-based or “established” interventions for ASD. • • •
• • •
Antecedent Package (These interventions involve the modification of situational events that precede the occurrence of a target behavior in order to increase the likelihood of success or reduce the likelihood of problems occurring. Strategies include applied behavior analysis (ABA) and positive behavior support). Behavioral Package (These interventions are based on behavioral principles and are designed to reduce problem behavior and teach functional alternative behaviors). Comprehensive Behavioral Treatment for Young Children (These programs involve early behavioral interventions that target a range of essential skills (e.g., communication, social) and involve a combination of applied behavior analytic procedures (e.g., discrete trial, incidental teaching). They are often termed ABA programs or early intensive behavioral intervention). Joint Attention Intervention (Joint attention refers to behavior of two individuals simultaneously focusing on and object or activity. These interventions involve building foundational skills involved in regulating the behaviors of others by teaching a child to respond to the nonverbal bids of others or to initiate joint attention interactions). Modeling (These interventions rely on an adult or peer providing a demonstration of the target behavior. The goal of modeling (live and video) is to correctly demonstrate a target behavior to the person learning a new skill, so that person can then imitate the model). Naturalistic Teaching Strategies (These teaching strategies primarily involve child-directed interactions to teach real-life skills (communication, interpersonal, and play skills) in natural environments. Examples include incidental teaching, milieu teaching, and embedded teaching). Peer Training Package (These interventions facilitate growth for children with ASD by training peers on how to initiate and respond during social interactions with a child on the spectrum. Common names include peer networks, circle of friends, and peer-initiation training). © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 21 of 41
• • •
Pivotal Response Treatment (This treatment is also referred to as Pivotal Response Teaching and focuses on teaching children to respond to various teaching opportunities within their own natural environment, and to increase independence from prompting. Pivotal behavioral areas include motivation, self-initiation, and selfmanagement). Schedules (This intervention involves presentation of a task list to increase independence, improve selfregulation skills, and allow the child to plan for upcoming activities. Schedules may be presented in multiple formats (e.g., photos or pictures, written or typed words, 3-D objects). Self-management (These strategies involve teaching individuals with ASD to evaluate and record the occurrence/nonoccurrence of a target behavior and secure reinforcement. The objective is to be aware of and regulate their own behavior so they will require little or no assistance from adults). Story-based Intervention package (These interventions identify a target behavior and involve a written description of the situation under which specific behaviors are expected to occur. Most stories aim to improve perspective-taking skills and may be supplemented with additional components (e.g., reinforcement, prompting, and discussion). The most well-known story-based intervention is Social Stories).
While children with ASD share a number of similar behavioral and other characteristics, every child is unique. Therefore, intervention approaches must be sensitive to their uniqueness and individuality. The selection of a specific intervention should be based on goals developed from a comprehensive developmental assessment as well as professional judgment and the values and preferences of parents, caregivers, and the individual child. Educational provision is considered to be among the most effective treatment programs for children with autism. However, educators are faced with some unique challenges. Children with ASD have intellectual and academic profiles that can differ to a large degree. Because no two children are alike, no one program exists that will meet the needs of every child with autism. Additionally, children with autism learn differently than typical peers or children with other types of developmental disabilities. To meet the needs of the individual child, it is critical to assess and quantify the child’s strengths, weaknesses and unique needs in order to determine the appropriate educational placement and developing a program of special services. The comprehensive developmental approach and evidence-based assessment provide this opportunity. All children and youth diagnosed or classified with ASD will benefit from individualized and specialized objectives and plans. Federal law in the United States entitles all students with disabilities to a free appropriate public education (FAPE). As we have seen, the National Research Council (2001) recommends that all children identified with ASD be made eligible for special educational services under the IDEA category of autism. The IDEA provisions require that when a child is identified as having special educational needs, he or she is provided with an individualized education program (IEP) that specifies the services the student will receive during the school year. The IEP is a planning, teaching and progress monitoring tool and a working document for all children with special educational needs. The key to any child’s special education program lies in the objectives specified in the IEP and the manner in which they are addressed. Parents, teachers and support professionals play a important role in the development, implementation, and evaluation of the child’s IEP. All share the responsibility for monitoring the student’s progress toward meeting specific academic, social, and behavioral goals and objectives in the IEP. In addition to outlining academic objectives and goals, the IEP includes interventions, modifications, behavioral supports, related services, and learning opportunities designed to assist the child throughout school and with transition to adulthood. A comprehensive IEP should be based on the student’s strengths and weaknesses. Goals for a child with ASD usually include the areas of communication, social behavior, challenging behavior, and academic and functional skills based on the results of the student’s comprehensive developmental assessment. All areas of projected need, such as social skills, functional skills, and related services (occupational, speech/language, or physical therapy), are incorporated in the IEP, together with the specific setting in which the services will be provided and the professionals who will provide the service. Moreover, the ongoing assessment of the child’s progress in meeting his or her IEP objectives is required. The content of an IEP must include the following (Individuals with Disabilities Education Improvement Act, 2004):
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• • • •
A statement of the child's present level of educational performance (both academic and nonacademic aspects of his or her performance). Specific goals and objectives designed to provide the appropriate educational services. This includes a statement of annual goals that the student may be expected to reasonably meet during the coming academic year, together with a series of measurable, intermediate objectives for each goal. Appropriate objective criteria, evaluation procedures and schedules for determining, at least annually, whether the child is achieving the specific objectives detailed in the IEP. A description of all specific special education and related services, including individualized instruction and related supports and services to be provided (e.g., counseling, occupational, physical, and speech/language therapy; transportation) and the extent to which the child will participate in regular educational programs with typical peers. The initiation date and duration of each of the services to be provided (including extended school year services). If the student is 16 years of age or older, the IEP must include a description of transitional services (coordinated set of activities designed to assist the student in movement from school to post-school activities).
In addition to the provisions of the IEP, students with ASD who demonstrate serious and persistent behavioral challenges should be provided with an individual behavior intervention (or support) plan (BIP). IDEA requires that positive behavioral support programming be provided to eligible students who are in need; particularly when the behavior impedes learning or the learning of others. The identification and ongoing assessment of co-occurring behavior/emotional problems can be of help in identifying areas of need and for monitoring behavioral progress. As discussed earlier, parental stress can be an important factor in providing services to students with ASD. Information obtained from the comprehensive development assessment may indicate the need for parental support. Parents and siblings of children with ASD experience more stress and depression than those of children who are typically developing or even those who have other disabilities (Estes et al., 2009). Supporting the family and ensuring the system’s emotional and physical health is a very important aspect of overall management of ASD (Myers, Johnson et al., 2007). When families receive a diagnosis of autism, a period of anxiety, insecurity, and confusion often follow. Some autism specialists have suggested that parents go through stages of grief and mourning similar to the stages experienced with a loss of a loved one ( e.g., fear, denial, anger, bargaining/guilt, depression and acceptance). Assessing the level of stress and understanding this process and can help school professionals provide support to families in the effort to cope with their child’s diagnosis. Professionals can also provide support to parents by educating them about ASD; provide guidance and training; assist them in obtaining access to resources; provide emotional support by listening and talking through problems; and help advocate for their child’s or sibling’s needs (National Research Council, 2001). A major strategy for helping families with children with ASD is providing information on the access to ongoing supports and services. Formal supports include publicly funded, state-administrated programs such as early intervention, special education, vocational and residential/living services, and respite services. Local parent advocacy groups, national autism and related disability organizations, early intervention and special education administrators often are knowledgeable about various programs and their respective eligibility requirements. Support professionals should also give parents a realistic interpretation of the results of the ASD assessment and help them to understand their child’s level of cognitive and adaptive functioning. It is also important to communicate the student’s strengths and weaknesses and assure parents that they are not the cause of their child’s social communication deficits. Importantly, parents should be encouraged to play an active role in developing and implementing intervention plans and IEPs (Myers, Johnson et al., 2007; Rogers & Vismara, 2008). In summary, supporting children with ASD requires individualized and effective intervention strategies. The most effective treatment is a comprehensive and intensive program consisting of evidence-based interventions, special education, developmental therapies, and behavior management with a focus on reducing symptom severity and improving the development course of the child. Effective educational services and interventions can only be provided if © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 23 of 41
students are identified and evaluated used an evidence-based screening and assessment methodology. Although no single approach, intervention strategy, or treatment is effective for all children with ASD, the following are key components of a comprehensive educational program for a child with ASD (National Research Council, 2001; Organization for Autism Research, 2005). • • • • • • •
An effective, comprehensive educational program should reflect an understanding and awareness of the challenges presented by autism. The most effective interventions and programs are those that are based on the comprehensive assessment of an individual child’s unique needs, strengths and weaknesses. Parent-professional communication and collaboration are key components for making educational and treatment decisions. On-going training and education in autism are important 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. Inclusion with typically developing peers is important for a child with ASD 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. Assessment and progress monitoring of a student with ASD should be completed at specified intervals by an interdisciplinary team of professionals who have a knowledge base and experience in autism. A comprehensive IEP should be based on the child’s unique pattern of strengths and weaknesses. Goals for a child with ASD 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. Transition goals must also be developed when the student reaches 16 years of age. No single methodology is effective for all children with autism. Generally, it is best to integrate scientifically validated approaches according to a child’s assessed needs.
Important Points to Remember Support professionals should be trained in identifying the “red flags” of ASD and the importance of early referral for screening and assessment. School professionals play a vital role by participating in screening activities to ensure that students with ASD are being identified and provided with the appropriate programs and services. All school professionals should be able to distinguish between screening, assessment and diagnosis. Parent and teacher screening tools are ideal instruments to assist with the identification of ASD because they gather important information from people familiar with the student and are easy to administer and score. A standardized screening tool should be administered at any point when concerns about ASD are raised by a parent or teacher or as a result of school observations or questions about developmentally appropriate social, communicative, and play behaviors. Broad-based screening for school-age children should include tools such as the Autism Spectrum Rating Scales (ASRS), Social Responsiveness Scale (SRS-2), and Social Communication Questionnaire (SCQ.) Gender should be taken into consideration when screening and evaluating students for ASD. Students who screen negative should be carefully monitored so as to minimize misclassification and ensure access to intervention services. A team approach is preferred for evaluation and intervention planning for school-age children as there is a need for a broad range of assessment procedures. A comprehensive assessment should include evaluation of multiple domains of functioning in order to differentiate ASD from other conditions and provide a complete profile of the student to facilitate intervention planning. © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 24 of 41
An important step in the core assessment process is to review the student's early developmental/medical history and current concerns with his or her parents. This should include a review of communication, social, and behavioral development. All students suspected of ASD should have their vision and hearing screened using appropriate methodology and be referred for a formal hearing assessment if concerns are present. The parent or caregiver interview plays an important role in evaluating a student’s developmental history and assessing behaviors associated with ASD. Parent and teacher ratings are one of the most important sources of information about the student’s social responsiveness and social-communication skills. Direct behavior observation of the student in both structured and unstructured settings improves the accuracy in the identification of ASD. The measurement of intellectual ability is critical for identification and intervention planning purposes. Evaluation of cognitive functioning in both verbal and nonverbal domains is necessary to develop a complete diagnostic profile of the student. Assessment of academic ability is important for the purposes of educational decision making and intervention planning. Areas of strength and weakness can often go unrecognized. Adaptive functioning should be assessed for all students, as this domain is pivotal in the identification of ASD and/or co-occurring intellectual disability. Discrepancies between cognitive ability and adaptive behavior can help identify objectives and strategies for intervention and treatment. A comprehensive speech-language-communication evaluation should be conducted for all students referred for a comprehensive assessment. Deficits in pragmatic language functioning may not be identified by formal language tests and require nontraditional assessment procedures. Sensory challenges can have an adverse effect on the student’s current functioning and ability to benefit from intervention, and may be a focus of attention and evaluation. Deficits in executive function, memory, and attention can have affect the student’s learning and classroom performance and warrant assessment.. The identification of parenting stress and parent-student relationship problems can alert the assessment team to the need for additional family support or counseling. A screening of potential co-occurring (comorbid) psychiatric issues, such as ADHD, anxiety and depression, should be conducted to determine the need for a more detailed evaluation (possibly including referral to specialists). Rating scales and questionnaires should be considered as only one part of a multimodal, multidisciplinary decision-making process in the identification of children with ASD. Direct observation and a developmental history MUST always be included in the assessment process. No single measure provides a definitive diagnosis: data from an instrument must be interpreted in context as a component of the diagnostic process. There are no specific biological or test markers to determine ASD. Although ASD is a neurodevelopmental disorder, identification is made by behavioral criteria. Caution must be used when using any cut-off score to indicate a diagnosis or disability because this determination is not solely dependent on an absolute score or scores but rather on whether the measured traits result in impairments in everyday functioning or adaptive behavior and the need for specialized services. Intellectual test profiles should never be used for diagnostic confirmation or the identification of ASD. Discriminative validity statistics of sensitivity, specificity, false positive and false negative rates are important psychometric properties that reflect the effectiveness of a test’s ability to correctly identify cases. Interpreting ASD-specific measure requires experience and training in assessment and ASD issues. School professionals involved with assessments and the determination of autism eligibility (e.g., school psychologists, speech/language pathologists) should be thoroughly familiar with the criteria for autism specified in the IDEA and to keep in mind that the DSM-5 definition of ASD is not as a rule legally controlling Assessment and diagnosis are only of value when they provide access to the delivery of appropriate intervention and educational services. Behavioral and educational interventions are currently the benchmark interventions for ASD. © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 25 of 41
Effective interventions and programs are based on the comprehensive assessment of an individual child’s unique needs, strengths and weaknesses. The most effective treatment is a comprehensive and intensive program consisting of evidence-based interventions, special education, developmental therapies, and behavior management with a focus on reducing symptom severity and improving the development course of the child. The IEP should be the vehicle for planning and implementing educational objectives and services. A comprehensive IEP should be based on the student’s strengths and weaknesses. Goals for a student with ASD usually include the areas of communication, social behavior, challenging behavior, and academic and functional skills. Different approaches to intervention have been found to be effective for children with ASD, and no comparative research has been conducted that demonstrates one approach is superior to another. The selection of a specific intervention should be based evidence-based research and goals developed from a comprehensive assessment.
Concluding Comments In this course, we reviewed a multi-tier screening process, the components of an evidenced-based core assessment battery, additional assessment domains, and assessment for educational planning for students with ASD. It cannot be stressed too often that a comprehensive developmental assessment must consist of a combination of direct observation and interaction with the child, historical information from parents and teachers, and rating scales to quantify observations of the child across settings. Although we have no definitive guide to selecting among the different assessment tools discussed here, all have shown to be relevant to the evaluation, identification, diagnosis, intervention planning, and outcome measurement of ASD in evidence-based investigations. However, due to advances in autism research and development of new measures, instruments used in the assessment process for ASD must be reviewed and evaluated frequently (Eaves, Campbell, & Chambers, 2000). As our scientific knowledge and thinking about ASD continues to develop, support professionals such as school and educational psychologists, behavior interventionists, occupational therapists, social workers, and speech/language pathologists will play an increasingly important role in the assessment and educational programming of students with ASD by providing support, information, and recommendations to teachers, other school personnel and administrators, and families (Williams, et al., 2005). Therefore, it is critically important to remain current with the research and up to date on scientifically supported approaches that have direct application to the educational setting. By being knowledgeable about assessment and intervention approaches, including their strengths and limitations, we can help to form cohesive educational support networks for students with ASD (Bryson et al., 2003; Wilkinson, 2010).
Frequently Asked Questions 1. What is the cause of ASD? ASD is a neurodevelopmental disorder of unknown cause. At present, there are no biological markers or laboratory tests that can reliably diagnose autism. Growing evidence suggest that genetic factors play a significant role in its etiology. Although autism may be associated with a variety of genetic mechanisms and no specific environmental factors have been scientifically validated, ongoing studies are examining a possible gene-environmental connection. 2. Do all Children with ASD require special education? All children and youth diagnosed or classified with ASD will benefit from individualized and specialized objectives and plans. According to the National Research Council (2001), a student who receives a diagnosis of ASD should be eligible for special educational programming under the educational category of autism. Research supports the importance of initiating educational service as soon as a student is suspected of having an ASD. 3. Who should provide assessment services to children with ASD? © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 26 of 41
Both interdisciplinary and multidisciplinary processes stress the importance of gathering information from a variety of disciplines that provide unique knowledge of a particular aspect of the student and family. Professionals most often involved in the assessment and delivery of services to children with ASD include educational and school psychologists, clinical psychologists, psychiatrists, neurologists, pediatricians, speech/language pathologists, audiologists, occupational therapists, physical therapists, social workers, behavior interventionists, and special education teachers. 4. Does ASD occur with other childhood disorders? Children with ASD frequently have co-occurring (comorbid) psychiatric conditions, with overall estimates as high as 70 to 84 percent. Research indicates that children with ASD have a high risk for meeting criteria for other disorders, such as attention deficit/hyperactivity disorder (ADHD), disruptive behavior disorders, mood, and anxiety disorders, all which contribute to overall impairment. 5. At what age do children exhibit signs of ASD? Autism is a lifelong disorder that begins in early childhood. Although normally present from birth, the age at which symptoms become apparent varies significantly. Research suggests that children with ASD may show signs of the disorder by 2 to 3 years of age. While children with severe symptoms are frequently identified at early age, many children with mild impairments are not identified until after school entrance. 6. Are sensory issues part of the diagnostic criteria for ASD? Unusual sensory reactions are often observed in children with ASD. A lack of responsiveness, hypersensitivity to noise and the taste and texture of foods, and insensitivities to pain are more commonly reported in children with ASD than other developmental disabilities. Sensory issues are now incorporated in the DSM-5 diagnostic criteria for restricted, repetitive patterns of behavior, interests, or activities (RRB). 7. To what extent do children with ASD have speech and language problems? Impairment in social communication is a core feature of ASD. It is important to stress the concept of “communication” in contrast to the more common focus on speech and language assessment and intervention. Although the range of language skills exhibited by children with ASD varies, the primary difficulty is with communication or the use of pragmatic (social) language. 8. Why do more boys than girls receive a diagnosis of ASD? Boys are at greater risk for nearly all developmental, behavioral, and learning disorders and are at least four times more likely than girls to receive a diagnosis of autism. The ratio increases to 10:1 with Asperger syndrome and HFA. Although there are no documented reasons for this gender difference, some researchers have hypothesized that a genetic mechanism or gender bias might play a role. It has been hypothesized that differences in brain organization might provide a protective factor for girls and lowers the risk for developing the disorder. There is also some conjecture that expression of the behavioral phenotype might be different for girls than boys. Since females are socialized differently, ASD may not be manifest in the same way as typical male behavioral signs and patterns. There may also be a gender bias associated with a reliance on male criteria with respect to the diagnostic criteria for ASD. 9. What is meant by the broader autism phenotype? The broader autism phenotype refers to children who demonstrate various behaviors and difficulties related to ASD, but who do not meet specific criteria for a clinical diagnosis. These behavioral and cognitive characteristics are milder but qualitatively similar to the defining features of ASD. There is evidence to indicate that even mild symptom severity can have an adverse effect on school performance and adaptive behavior. 10. What tests should be used by school professionals to identify students with ASD? The ADI-R and ADOS are considered the “gold standard” instruments for assessing autism. Both require a substantial amount of experience, specialized training, and time to administer and interpret effectively. Although school professionals should be familiar with these instruments, other evidence-based tools are available and may be © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 27 of 41
included in an assessment battery to identify students with ASD. It is important to keep in mind that no single test will reliably identify ASD and that best practice requires multiple methods of assessment and sources of information.
Glossary of Terms Adaptive behavior. The age-appropriate or typical performance of daily activities based on social standards and expectations. It is an individual’s ability to adjust to and apply new skills to other situations (e.g., different environments, tasks, objects and people). Algorithm. A set of instructions or rules for performing a calculation or process to determine whether a score on a diagnostic test or set of observations meets specific criteria necessary to assign a diagnosis. Assessment for educational/intervention planning. Determination of the student’s unique strengths and weaknesses across several domains of functioning with the objective of planning treatment and intervention based upon the student’s individual profile. The intervention plan is designed to maximize student development and functional skills in both school and family contexts. Autism spectrum disorder (ASD). A new DSM-5 diagnostic category which encompasses the previous DSM-IV-TR categorical subtypes of autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). This shift from the DSM-IV-TR multicategorical model to the single diagnostic entity of ASD reflects the scientific consensus that symptoms of these subgroups represent a continuum of impairment that varies in level of severity and need for support in the two domains of social communication and restrictive repetitive behaviors/interests (RRB). Comorbid disorder. A disorder that co-occurs with another diagnosis so that both share a primary focus of clinical and educational attention. Comprehensive developmental Model. An approach that emphasizes the assessment of multiple areas of functioning and the reciprocal impact of abilities and disabilities in order to understand the departure from normal developmental expectations that characterize ASD. Developmental milestones. Markers or guideposts to a student’s learning, behavior, and development. Developmental milestones consist of skills or behaviors that most children perform by a certain age. While each student develops differently, some differences may indicate a slight delay and others may be a red flag or warning sign for greater concern. Diagnostic evaluation. The process of gathering information via interview, observation and specific testing in order to arrive at a diagnosis or categorical conclusion. Discriminative validity. Refers to a test’s ability to correctly differentiate (predict group membership) between individuals with a specific diagnosis (e.g., ASD) and those with and without another clinical diagnosis. Diagnostic efficiency statistics include sensitivity and specificity. Sensitivity refers to a test’s ability to correctly identify individuals with a given disorder, whereas specificity refers to a test’s ability to correctly identify those without the disorder. Ecological validity. Assessment of skills or abilities evidenced under natural conditions such as the classroom or home setting that may not be demonstrated in structured assessment measures and tests. Executive function. A general term that refers to the mental processes that are required to maintain goal directed problem-solving behavior. Executive functions generally include response inhibition, working memory, cognitive flexibility, emotional control, self-regulation and planning and organization. Expressive language. Refers to the language that the individual communicates to others. Generally, it indicates the ability to express thoughts, feelings, wants, and desires through oral speech. False negative rate. The percentage of individuals identified by a test as not having a disorder who do have the disorder. The lower the value, the better the test is at correctly classifying cases. An efficient test should minimize false negatives as these are individuals with a likely disorder who remain unidentified. False positive rate. The percentage of individuals identified by a test as having a disorder that do not have the disorder. The lower the value, the more effective the test is at correctly identifying cases. © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 28 of 41
Individuals with Disabilities Education Act (IDEA). A United States federal law that governs how states and public agencies provide early intervention, special education, and related services to children with disabilities. It mandates free appropriate education for children in 13 specified categories of disability. Interdisciplinary. A coordinated effort among the various disciplines to complement (rather than duplicate) efforts and to develop a cohesive intervention plan and/or arrive at a diagnostic conclusion. Compare to multidisciplinary. Joint attention. The ability to share with another person the experience of an object of interest. Joint attention generally emerges between 8 and 12 months of age. A moving toy, for example, typically elicits a pointing behavior by the student, who looks alternately at the caregiver and the object. Impairment in joint attention is considered an important “red flag” of ASD. Multidisciplinary. A process that involves separate evaluations by various professionals who often practice without benefit of collaboration with other evaluating professionals and who often reach separate conclusions based upon their particular experience. Compare to interdisciplinary. Multidisciplinary team. An assessment team in which professional members from various disciplines (e.g., education, speech/language pathology, psychology, medicine) evaluate the total student. Nonverbal communication. Involves facial expressions, tone of voice, gestures, eye contact, and other types of expression involving no or minimal use of spoken language. Research suggests that nonverbal communication is critical to social development and communication. Perseveration. The redundant repetition of a word, thought, or action without the ability to end or move forward. Includes repetitive movement or preservative speech, or rigid adherence to one idea or task. Pervasive developmental disorder (PDD). An umbrella term used in the previous edition of the DSM (DSM-IV-TR) to describe five separate disorders or subgroups characterized by delays in the development of basic functions, including socialization, verbal and nonverbal communication, and stereotyped or repetitive behavior/interests. The pervasive development disorders (PDD) are; (1) autistic disorder (autism), (2) Asperger’s disorder, (3) Rett’s disorder, (4) childhood disintegrative disorder, and (5) pervasive developmental disorder not otherwise specified (PDD-NOS). Phenotype. The observable features produced by the interaction of the genotype and the environment. The “phenotypic” expression of a disorder refers to the behavioral expression of symptoms that may or may not share a similar etiology, course or response to treatment. Pragmatics. Social rules for using functional spoken language in a meaningful context or conversation. It includes the rules about eye contact between speaker and listener, how close to stand, taking turns, selecting topics of conversation, and other requirements to ensure that satisfactory communication occurs. Persistent deficits in social (pragmatic) communication and interaction are a core diagnostic feature of ASD. Receptive language. The act of understanding that which is said, written or signed. Red flags for ASD. Refers to indicators or warning signs associated with ASD. Common warning signs for school-age children include atypical social and communication behaviors, pragmatic (social) language problems, intense and restricted interests, rigidity, and limited social reciprocity. Restricted patterns of interest. A preoccupation with a narrow range of interests and activities that is intense in focus. Also referred to as stereotyped or circumscribed patterns of interests because of the rigidity and narrowness of these interests. Ritualistic behavior. Rigid routines, such as insistence on eating particular foods or engaging in specific and seemingly meaningless behaviors repeatedly in certain situations or circumstances, such as turning the lights on and off several times when entering a room. Repetitive and restricted patterns of behavior/interests (RRB) are included in the DSM-5 diagnostic criteria for ASD. Screening. The use of a specific test, questionnaire, or scale to identify students in the population who are most likely to be at risk for a specified clinical disorder or disability. Screening for a particular disorder such as ASD may occur at a specific age or when concerns of parents and/or educators or results of routine developmental surveillance indicate that a student is at risk for developmental difficulties. Screening is not intended to provide definitive diagnoses but rather, to suggest a need for further evaluation and assessment for intervention planning. Social (Pragmatic) Communication Disorder. A new DSM-5 diagnostic category characterized by a primary difficulty with pragmatics or the social use of language and communication in naturalistic contexts and designed to capture social-communication impairments not accompanied by restrictive and repetitive behavior/interests (RRB). Because © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 29 of 41
both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present. Sensory integration. The organization of sensory input for use by the individual. Parts of the nervous system work together through sensory integration so that an individual can effectively interact with the environment. Social reciprocity. The back-and-forth flow of social interaction or how the behavior of one person influences and is influenced by the behavior of another person and vice versa. Also, mutual responsiveness in the context of interpersonal contact, such as awareness of and ability to respond appropriately to other people. Deficits in socialemotional reciprocity are included in the DSM-5 core domain of social communication and social interaction. Special educational needs. IDEA defines a "student with a disability" as a student with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities; and, who because of the condition needs special education and related services." Stereotyped behaviors. An abnormal or excessive repetition of an action carried out in the same way over time. This may include repetitive movement of objects or repetitive and complex motor mannerisms including hand or whole body movement such as clapping, finger flapping, body rocking, swaying, finger flicking, etc.). Stereotyped behaviors are featured in the DSM-5 diagnostic criteria for restricted, repetitive behavior/interests (RRB) T-score. Raw scores on norm-referenced tests that have been transformed so that they have a predetermined mean and standard deviation. Although they can vary from measure to measure, many rating scales set the mean at 50 and the standard deviation at 10. If a student’s raw score converts to a standard score of 50, the student performed at the mean or in the average range.
© 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 30 of 41
Resources Supplemental Text: Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.
Organizations: American Academy of Pediatrics American Psychiatric Association Autism Society of America Autism Speaks Best Practice Autism Center for Autism and Related Disabilities (CARD) Center for Disease Control and Prevention First Signs National Autism Center National Autistic Society National Information Center for Children and Youth with Disabilities (NICHCY) National Institute of Student Health and Human Development Autism Site National Institutes of Health Autism Research Network National Professional Developmental Center for Autism National Research Council Organization for Autism Research
Universities and Centers: Cambridge University, Autism Research Centre Indiana University, Indiana Resource Center for Autism Nova Southeastern University, Mailman Segal Institute University of California, M.I.N.D. Institute University of Kansas, Kansas Institute for Positive Behavior Support University of Michigan, Autism and Communication Disorders Center University of North Carolina, Treatment and Education of Autistic and Related Communication Handicapped Children Yale Student Study Center Developmental Disabilities Clinic
Journals: Autism: The International Journal of Research and Practice Current Psychiatry Reports Focus on Autism and Other Developmental Disabilities Intervention in School and Clinic Journal of Autism and Developmental Disorders Journal of Child Psychology and Psychiatry Journal of Clinical Student and Adolescent Psychology Journal of Positive Behavior Interventions Pediatrics Remedial and Special Education Research in Autism Spectrum Disorders © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 31 of 41
Books: Attwood, T. (2006). The complete guide to Asperger’s syndrome. London: Jessica Kingsley Publishers. Baron-Cohen, S. (2008). Autism and Asperger syndrome: The facts. New York: Oxford Klin, A., Volkmar, F. R. & Sparrow, S. S. (Eds.). (2000). Asperger’s syndrome. New York: The Guilford Press. Goldstein, S., Naglieri, J. A., & Ozonoff, S. (Eds.) (2009). Assessment of autism spectrum disorders. New York: Guilford. Ozonoff, S., Dawson, G., & McPartland, J. (2002). A parent’s guide to Asperger syndrome & high-functioning autism: How to meet the challenges and help your student thrive. New York: Guilford. National Research Council (2001). Educating Children with Autism. Washington, DC: National Academy Press. Volkmar, F. R., Paul, R., Klin, A., & Cohen, D. (Eds.) (2005). Handbook of autism and pervasive developmental disorders (3rd. ed.) (Vols. 1 & 2). Hoboken, NJ: Wiley & Sons. Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.
Magazines: Autism Spectrum Quarterly Autism-Asperger’s Digest
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Autism Spectrum Disorder (ASD) Assessment Worksheet Date: ________________ Student: ______________________________________________ Birth Date: ______________ Age: _______ Grade: _______ School: ___________________ Date of Referral: ___________ Date of Consent: ____________ Please check all assessments completed: Sensory Status: � Record/File Review � Vision Screening � Pure Tone and Tymp Screening Social/Developmental History: � Record/File Review � Parent/Caretaker Interviews Academic & Functional Performance: � Record/File Review � Wechsler Individual Achievement Test-3rd Edition (WIAT-III) � Woodcock-Johnson NU Achievement Tests-3rd Edition (WJ-III NU) � Kaufman Test of Educational Achievement-2nd Edition (KTEA-II) � Classroom observation � CBM Assessments � Other _____________________ Autism Spectrum Disorder Assessment: � Record/File Review � Parent/Teacher Interviews � Direct Behavioral Observation � Autism Spectrum Rating Scales (ASRS) � Childhood Autism Rating Scale (CARS-2) � Social Responsiveness Scale (SRS-2) � Autism Diagnostic Interview (ADI-R) � Autism Diagnostic Observation Schedule (ADOS-2) � Social Communication Questionnaire (SCQ) � Other _____________________ Communication (Language): � Record/File Review � Clinical Evaluation of Language Fundamentals-5th Edition (CELF-5) � Expressive One Word Picture Vocabulary Test-4th Edition (EOWPVT-4) � Peabody Picture Vocabulary Test-4th Edition (PPVT-4) � Test of Pragmatic Language-2nd Edition (TOPL-2) � Children’s Communication Checklist (CCC-2) � Pragmatic Language Skills Inventory (PLSI) � Test of Auditory Comprehension of Language (TACL) � Comprehensive Assessment of Spoken Language (CASL) � Language Sample � Other _____________________ © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 40 of 41
Motor Skills: � Record/File Review � Bruininks-Oseretsky Test of Motor Proficiency-2nd Edition (BOT-2) � Developmental Test of Visual Motor Integration-6th Edition (VMI-6) � Other _____________________ Intellectual/Cognitive Functioning: � Record/File Review � Wechsler Intelligence Scale for Children-4th Edition (WISC-IV) � Wechsler Preschool and Primary Scale of Intelligence-4th Edition (WPPSI-IV) � Differential Ability Scales-2nd Edition (DAS-II) � Stanford-Binet Intelligence Scale-5th Edition (SB-5) � Reynolds Intellectual Assessment Scales (RIAS) � Other _____________________ Executive Function & Attention: � Record/File Review � Conners 3rd Edition (Conners3) � Wide Range Assessment of Memory and Learning, 2nd Edition (WRAML-2) � Behavior Rating Inventory of Executive Function (BRIEF) � Other _____________________ Emotional/Social and Behavior Functioning: � Record/File Review � Direct Behavioral Observation � Interviews: Parent, Teacher, and Student � Achenbach System of Empirically Based Assessment (ASEBA) � Behavior Assessment System for Children-2nd Edition (BASC-2) � Children’s Depression Inventory-2nd Edition (CDI-2) � Revised Children’s Manifest Anxiety Scale-2nd Edition (RCMAS-2) � Other___________________________ Adaptive and Functional Skills: � Record/File Review � Direct Behavioral Observation � Interviews: Parent, Teacher, and Student � Vineland Adaptive Behavior Scales – 2nd Edition (VABS-II): Parent, Teacher � Adaptive Behavior Assessment System–2nd Edition (ABAS-II): Parent; Teacher � Developmental Profile-3rd Edition (DP-3) Sensory Processing: � Short Sensory Profile (SSP) � Sensory Profile School Companion � Other___________________________ Family System: � Interview � Parenting Stress Index (PSI) � Other___________________________ Comments: © 2013 Professional Development Resources & Lee A. Wilkinson, PhD | www.pdresources.org | #30-69 ASD in Schools | Page 41 of 41