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Posts Tagged ‘Autism spectrum’

Logo2012 was a great year for the Applied Behavioral Strategies blog. We had almost 100,000 visitors in total. Here is a list of the most visited blog postings last year. The great news is that I wrote some of the most visited posts in 2011. I am pleased that my posts remain relevant for readers.

#5. Early Morning School Routines. Who doesn’t need help with this? Seriously, it is THE most stressful time of the day for my house.

#4 Just Say No. I can see why this one has staying power. Almost daily, I hear myself saying “Parents need to learn to say no.” You don’t even have to state a reason. Just know that your child needs to learn to accept being told no. (And despite how it may feel or sound, it will NOT be the end of the world.)

#3 Autism Awareness Apps. I really need to update this link. I will be sure to do so in time for April give aways. Keep in mind that I’m also presenting on this topic at SXSW in Austin, TX in March, 2013.

#2. Do You Use Visual Schedules? Wow. I am pleased that this topic is still a hit. If you aren’t using visual schedules, you should! In my home, we use a homework whiteboard every day and it makes our afternoons a BREEZE!

#1. Using ABA to Teach Math. I had no idea when I wrote this post that it would become so popular. The great news is that ABA may be used for a variety of skills!

I cannot thank you enough for your readership! Keep the reading, following, sharing, ideas, feedback, and questions for Ask Missy Monday coming!

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Rethink Mental Illness

Rethink Mental Illness (Photo credit: Wikipedia)

Here at Applied Behavioral Strategies, the mission is to improve the quality of life through effective intervention. One way we hope to do that is by reviewing research articles for readers. Today’s topic is in direct response to the Newtown Shootings. People have asked if Asperger’s is related and clearly it is not.

Is mental illness related to the shootings? We are still unclear on this; but we do know that mental illness has been associated with many if not all of the previous shootings. And sadly, mental illness can find its way in to anyone’s life at any time. Thus, today’s research review is on an article about mental illness and Asperger’s syndrome.

Luigi Mazzone, Liliana Ruta, and Laura Reale authored the article called “Psychiatric Comorbidities in Asperger’s Syndrome and High Functioning Autism”. The Annals of General Psychiatry published the paper in 2012.

Background Information

Individuals with Asperger’s and High Functioning Autism must exhibit several characteristics in order to be diagnosed with the condition. Specifically, individuals must:

  • show delays or differences in language skills
  • exhibit deficits in social skills
  • engage in stereotyped or ritualistic behaviors

Because of the language delays, professionals may have difficulty identifying signs of other comorbid psychiatric conditions. Additionally, the stereotyped or ritualistic behaviors may also make it difficult to determine if challenging behaviors are related to the Asperger’s and Autism spectrum or if those behaviors are signs of some comorbid condition.

Purpose of the Paper

The authors conducted a literature review. The authors stated that the purpose of their paper was to “examine the interplay between common psychiatric comorbidities and Asperger’s Syndrome and High Functioning Autism.” The authors planned to “discuss which psychiatric disorders have been more frequently reported in association with Asperger’s Syndrome and High Functioning Autism.” The authors wanted to identify the difficulties that clinicians and researchers face when making a correct diagnosis of a comorbid condition in Asperger’s Syndrome. Finally, the authors wanted to discuss the role of the environment and comorbid conditions.

Method

The authors conducted a term search to identify all related articles. Next, the authors reviewed the reference lists in each article to find additional related articles. Once the authors located all the articles, they screened the articles for scientific quality and eliminated studies that lacked scientific rigor.

Results

Internalizing Conditions. Internalizing conditions result in individuals having internal thoughts and sensations that are not easily identified by observers. The authors found that a number of studies reported internalizing comorbid conditions with Asperger’s syndrome and high functioning autism. These conditions included:

  • depression
  • bipolar disorder
  • anxiety
  • obsessive compulsive disorder

Externalizing Conditions. Externalizing conditions result in individuals engaging in behaviors that are observable to observers. The authors reported that a number of studies reported externalizing comorbid conditions with Asperger’s and High Functioning Autism. Due to diagnostic criteria, professionals cannot label a child with Asperger’s and ADHD. However, professionals know that many children with Autism Spectrum Disorders (including Asperger’s) also have attention issues and high levels of activity.

The authors noted that “high-functioning autism disorders are over-represented in the criminal population” but that this may be due to undiagnosed comorbid psychiatric conditions. The authors go on to point out that individuals with Asperger’s syndrome have issues with theory of mind (e.g., perspective taking, understanding the thoughts and feelings of others) and that this deficit may impair their social judgment resulting in “the risk of violating norms and laws.” The second point the authors make is that “individuals with Asperger’s Syndrome often show a strong sense of right and wrong, and once they have understood the rules they are likely to stick to them more rigidly than most people.”

Tic Disorders. The authors noted that a number of studies reported a comorbidity of Asperger’s syndrome and high functioning autism with tic disorders such as Tourette syndrome.

Difficulties in Diagnosing

The authors discussed the difficulties in appropriate diagnosing individuals with Asperger’s syndrome and high functioning autism. They noted, in particular, that several diagnostic scales are available. However, they also pointed out that those scales were not normed on individuals with Asperger’s syndrome and high functioning autism. Thus, professionals must use caution.

The authors note that additional research is needed in order to fully understand the relationship between autism spectrum disorders and risks for comorbid psychopathology.

The Role of the Environment

The authors discussed how the environment may influence the expression of psychiatric disorders. The authors identified the role of stress in the family. For many years, research has shown that stress is high for parents, and in particular, mothers.

The authors also discuss the role of the respondent during the diagnostic process. The authors noted that parents and teachers report behaviors differently. The differences may be attributed to the context of the respondent or it may be due to the fact that the individual’s behaviors are different in each context.

The authors also discussed the role of genetics in that individuals with Asperger’s syndrome tend to have relatives with other psychiatric conditions. Professionals need to complete an appropriate family history as part of the initial evaluation.

Finally, the authors discuss the role of social relationships. Given the social and behavioral difficulties experienced by individuals on the spectrum, they are much more likely to have social difficulties (e.g., making and keeping friends, engaging in social routines and activities). This may lead to depression and anxiety leading to a vicious cycle and potentially to the onset of comorbid conditions.

Suggestions

The authors close with implications for practice and these are important for all of us.

  1. Correct diagnosis. Teachers and parents are closest to children on the spectrum. They have a responsibility to make sure that individuals obtain additional diagnoses if they suspect comorbid conditions.
  2. Appropriate assessment tools. Researchers need to develop appropriate assessment tools so that professionals may appropriately diagnose individuals with comorbid conditions.
  3. Treatment. All individuals need appropriate intervention for the conditions in which they are diagnosed.

Readers, how many of your children/clients have been diagnosed with comorbid conditions? How long did it take to get that diagnosis? Has treatment changed as a result of the diagnosis?

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ADHDHi and welcome to Ask Missy Mondays where I respond to a question from readers. Today’s question comes from Andrea who asks,

“I have a 4-year-old who was diagnosed with autism within the last 6 months. He is extremely hyperactive and inattentive. What medication do you find to be most helpful?”

Hi Andrea, and thanks for taking the time to write. I am sorry to hear about your child being diagnosed with autism but he is young so there is ample time to get appropriate intervention to help him.

Please know that as a behavior analyst and special educator, I am not licensed to practice medicine. So, making recommendations about medication is out of my preview.

However, as behavior analysts, we are trained to address all types of behaviors, including hyperactive and inattentive behaviors.

Assessment

Before we address any behaviors, we first complete assessments to better understand why the behaviors are happening. The assessment includes record reviews, interviews, and asking those who know the child to complete rating scales. The assessments also include observations of the child to better understand when the behaviors are good versus when the behaviors are bad. Finally, we may even conduct analyses to determine which environmental conditions directly affect the behavior.

Intervention

Once the assessments have been completed, the behavior analyst will help design interventions to address the behaviors of concern. Behavioral interventions can be designed to address attentive behaviors, impulsive behaviors, and skills related to following instructions.

Health Interventions

In addition to behavioral intervention, parents should also consider whole body interventions that address the overall health of the child. Children need daily physical activity and I am not talking about using their fingers to control the remote or the iPad. Children need full body physical activity every single day.

Children also need a healthy diet. If your child eats mostly processed foods full of sugars, fake color, and other artificial ingredients, then you should change the diet before considering the use of medication to treat behaviors that may very well be caused by foods.

Finally, children need far more sleep than they are getting. Children need at least 10 hours of sleep each night. Children (nor adults) can make up for lost sleep so make sure that your child goes to bed early and sleeps as late as possible.

When All Else Fails

If you have followed all of the other advice above (consistently) and your child continues to have behavioral issues, then consider seeing a behavioral pediatrician to assist you in determining if medication is the right thing for your child. Medication should not be your first stop, it should be your last.

If you have a behavioral question for me, email askmissy at applied behavioral strategies dot com.

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In the course of our clinical work, we experience of number of odd rituals or strange feeding behaviors in our clients. One of the behaviors we address through the course of intervention is tantrumming, crying, or refusing to eat food after it has touched another food.

Remember, we serve children with and without disabilities so today’s post is not just about autism. To prove it, we have two cartoons. You see, cartoons demonstrate that these types of behaviors are common place–or how else would the theme end up in a cartoon?

Please share? Is this your child? Do you have plates with compartments to prevent meal time tantrums? Do you cook extra food in the event that you have to replace “dirty” or “contaminated” food?

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My parents were told to put me in an institution…They are… it’s called Harvard.  I am recovered thanks to them and TACA.”

—Simran, CA

In case you haven’t been following the news out in California, the LA Times recently ran a four-part series on autism. One part focused on recovery and you can read it here. If you want to read the other articles, you may find them here.

We are happy to hear people talk about the possibility of autism recovery despite its controversial nature.

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We know recovery is possible and we have personally seen children recover. So, we thought we would review a peer-reviewed article on autism recovery.

Neuropsycholgy Review published the article and Molly Helt, Elizabeth Kelley, Marcel Kinsbourne, Juhi Pandey, Hilary Boorstein, Martha Herbert, and Deborah Fein served as authors. You may find a copy of the article here.

Recovery Defined

The authors first defined “recovered”.

  1. First, the child’s medical or psychological records must have a convincing history of autism spectrum disorder.
  2. The medical or psychological records must demonstrate that the child had a history of delayed or slowed development.
  3. The child must currently be learning and on a typical developmental trajectory in all areas.
  4. The child must no longer meet the definition of autism spectrum disorders as measured by an independent psychologist.

Predictors Associated with Recovery

After defining recovery, the authors go on to review research articles describing recovery. Following the review, the authors discuss predictors of recovery. By this, they sought to examine pre-treatment characteristics that were associated with positive treatment outcome. Before reviewing the predictors, it is important to note that the predictors are associated with positive outcome and do not guarantee recovery. It is also important to note that children who lack one or more predictors may still go on to recover.

  1. Early communication and language
  2. IQ
  3. Motor development
  4. Rate of learning after intervention begins

Predictors Associated with Poor Outcome

Next the authors review characteristics that have been associated with poorer outcome. Again, these are merely associations and do not guarantee that a child who exhibits these traits will have a poor outcome.

  1. Accelerated head circumference
  2. Seizures
  3. Pre-existing condition such as Down syndrome, tuberous sclerosis
  4. Other sensory impairments (blindness, deafness)
  5. High rates of stereotypical behaviors

Treatments Associated with Recovery

Applied Behavior Analysis (ABA) is the treatment most often associated with recovery from autism. Research has shown that intensive intervention (40 hours per week) for a period of 2 years or more is most often associated with recovery.

The authors discuss other treatments with promising outcomes such as pivotal response training and the Denver Model. The authors also discuss the importance of biomedical interventions to address the illnesses often seen in children with autism (e.g., GI disease, food allergies, and metabolic disorders).

Summary

Recovery from autism is possible. While many factors are associated with positive outcome, scientists have yet to find the one approach that works for every child. Even with intensive intervention, there is no guarantee that a child will recover.

Additional Information on Recovery

Talk About Curing Autism (TACA) has quite a few recovery stories available on their website. We used the Zach’s story for our photos in this blog. If you would like to see some videos on recovery, we like the video produced by the Center for Autism and Related Disorders (CARD), Recovered. You may also find these videos at TACA helpful.

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Yesterday we discussed questions to ask an ABA provider during an assessment. Today we will address what to expect in an ABA assessment. We would like to clarify that this process should not be limited to ABA providers only. A full and initial evaluation of a child as part of the special education process should also follow this model.

Currently, the field of ABA has no rules and regulations  regarding initial assessments for ABA services. Thus, each agency will follow its own assessment protocol. Early intervention and special education services, on the other hand, have specific rules and regulations regarding assessments. You will find more information about those rules here for children age 3-22 or here for children under the age of 3.

We will attempt to describe a variety of assessments commonly conducted as part of an assessment for children with autism. Our advice to you is to become informed so that you know how to ask for assessments that your child needs.

We have described the different types of assessments on our website. In summary, your child should have a formal diagnosis so that the severity of autism is documented. The diagnostic assessment should be conducted each year as one measure of your child’s progress. The diagnostic assessment should be completed by a licensed psychologist. Texas Education Agency has a helpful list of diagnostic and screening tools related to autism.

Following the diagnostic assessment and before services begin, your child should have a comprehensive developmental assessment for every area of development.  Our recommendation is that norm-referenced assessments be completed annually as a second measure of progress. At a minimum, your child should be assessed in speech and language, adaptive skills, fine and gross motor, social and emotional development, and cognition. The Texas Education Agency has provided resources related to developmental assessments here.

The developmental assessments provide information about where your child is functioning compared to his/her same age peers. Norm-referenced developmental assessments should not be used to develop program goals and objectives.

Your ABA provider may provide some or all of the aforementioned assessments depending on the type of personnel employed by the agency. In order for an agency to develop a program for your child, other types of assessments will be needed. These are the assessments we will focus on.

Standardized Assessments

Criterion-Referenced Assessments

A number of criterion-referenced assessments are available for use by ABA providers. The Brigance is a widely used assessment with substantial research to support its reliability and validity. This assessment provides information about the skills children have acquired as well as what skills should be learned next. The assessment covers all areas of development and may be repeated as a measure of progress towards goals and objectives. The Brigance has been used to assess children with and without disabilities and is not autism specific.

The Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP) is an autism specific assessment that may be used to determine which skills a child has mastered as well as which skills should be taught next. The VB-MAPP focuses on language and challenging behaviors. Thus, additional assessments should be used in combination with the VB-MAPP. Peer-reviewed research studies regarding reliability and validity are still needed.

The Assessment of Basic Language and Learning Skills (ABLLS). The ABLLS provides information regarding skill development in a number of areas including language, social interaction, self-help, academic and motor. Peer-reviewed research studies regarding reliability and validity of the measure are still needed.

We mentioned the SKILLS assessment and curriculum yesterday. This tool assesses skills in all areas of development. Unlike the ABLLS and VB-MAPP, peer-reviewed studies have been completed on the SKILLS.

Providers of services for infants and toddlers may use an assessment called the Hawaii Early Learning Profile (HELP). This tool has substantial peer-reviewed research related to its reliability and validity. The tool is also comprehensive and assesses all areas of development. The tool is designed to develop IFSPs and would thus be appropriate when developing your child’s ABA program. However, the assessment should not be used to determine your child’s eligibility for services.

Your provider may use other measures for program development. These may include checklists, rating scales, and parent report/interview.

Other Assessments

Other standardized assessments are available for your ABA provider to complete. These assessments may or may not be used during the initial assessment. They will most certainly be used over the course of the program.

When children engage in challenging behavior, a functional behavioral assessment (FBA) is required in order to assess the behavior and develop an appropriate Behavior Intervention Plan (BIP). At a minimum, the assessment will include a record review, parent/teacher interviews, and direct observations of your child. Providers may also use rating scales completed by parents and/or teachers. Finally, providers may complete a functional analysis where conditions are manipulated to assess how environmental changes affect your child’s behavior.

At some point in a program, providers will complete preference assessments for your child. Formal preference assessments include the systematic presentation of items to determine if your child interacts with or engages with various stimuli. Informal preference assessments may be completed on a daily basis in order to determine how to best motivate your child to work. The provider may simply watch how your child uses toys and which toys your child gravitates toward during free play. Providers may also ask you to limit your child’s access to highly preferred toys and activities to keep him/her interested in them during therapy.

Informal Assessments

ABA providers, early intervention personnel, and school staff may also complete a number of informal assessments. Most likely, they will request copies of records from your child’s medical and related service personnel. A comprehensive record review is almost always utilized during program development.

Providers may create agency specific forms they use when developing programs. Providers may also ask families to complete intake forms in order to gather information from parents and other providers. Completing and returning these forms as soon as possible will help your provider prepare for any upcoming visits or assessments.

Providers may complete observations of your child in a variety of settings such as home, school, and community. Providers will be able to develop better programs after observing your child in as many different settings and activities as possible. It will be important for providers to observe your child under his/her best performance. However, it is equally important for providers to be able to see situations when your child is not successful.

Providers may also complete skill probes. These are mini-tests where the provider asks your child to engage in a skill to see if your child complies or if your child is capable of performing the skill. For example, the provider may introduce a toy set. After playing with your child for a few minutes, the provider may ask the child to find a red car. The provider may document if the child completes the skill as asked. Skill probes may be conducted prior to program development. However, they may also be completed within the first couple of weeks of your child’s program.

As we have stated, this list is certainly not comprehensive or all-inclusive. Hopefully, it will help prepare you for your child’s initial assessment and program development.

Has your child recently completed an assessment? What would you add to help first timers through this process?

 

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Hi and welcome to Ask Missy Mondays where I respond to email questions from readers who have questions about behavior. Today’s question comes from Tracy, who asks:

“My child is having his first ABA Assessment soon, what questions should I ask? What should I expect?”

Tracy, thanks for asking! You have been an amazing help to me on Twitter so helping you in this way is the least I could do. You have definitely opened a can of worms with this question but hopefully I can give you some insight.

Recovery

Your first question to the provider should be, “Do you believe in and work towards recovery from autism?” I realize that this question may offend some readers with autism. Please understand that I would never suggest that any individual who is capable of self-advocating be treated without consent. However, for young children, we know that the symptoms of autism can be successfully treated so that the child can go on to function in school without special education. The child can go on to function in adulthood without supports. The recovery rate is not high (around 48% of treated children). However, even if children do not fully recover, early intervention can lead to great improvements in IQ, adaptive behavior, and communication. “Shoot for the moon. Even if you miss it, you will land among the stars.” -Les Brown.

Reinforcement and Punishment

The second question you should ask is, “What is your philosophy on reinforcement and punishment?” A good ABA team will use a variety of reinforcers to help your child learn. Over reliance on edible reinforcers can be problematic. We have written a little bit about reinforcement here. Check it out. Preference Assessments are a must. Read about them here.

A good ABA team should deflect the question on punishment and talk more specifically about using reinforcement to address challenging behavior. Do not get me wrong. Punishment strategies are important and warranted in many cases. However, in a comprehensive ABA program, the team should be modifying antecedents to prevent challenging behavior, teaching replacement behaviors for challenging behavior, and severing the association between reinforcement and challenging behavior. New, appropriate behaviors should be reinforced and challenging behaviors should not be reinforced.

Curriculum

The third question you should ask is, “What curriculum do you use?” My favorite response to this question is “We use a variety of resources to determine what to teach your child.” Any agency who relies on one tool to drive their programming for your is setting your child up for failure. Your child with autism needs a comprehensive program to address all areas of development including receptive and expressive communication, fine and gross motor, social and emotional skills, pre-academic and academic skills. As your child ages, other skills such as pragmatics, perspective taking, and theory of mind skills will be important.

An exception here is the SKILLS assessment and curriculum. Having worked for CARD for several years, I know that the SKILLS curriculum was developed using multiple resources. CARD also completed several research studies on reliability and validity of the measure. While the curriculum may appear to be one tool, it is actually quite comprehensive.

Inclusion

The fourth question you should ask is, “What is your philosophy on inclusion?” The research on ABA (and on inclusion) supports that children should be educated alongside their typically developing peers as soon as possible. Depending on the severity of your child’s autism, he/she may need initial instruction in a very small, distraction-free environment. Once your child learns how to learn, he/she will be transitioned to a larger room with distractions. Once your child is able to imitate and learn from watching others, he/she needs to start regularly scheduled play dates to practice skills with other children. Finally, your child should be transitioned to a preschool with support. The support should be systematically faded until your child is functioning in general education with no supports.

Assessment

Finally, your last question should be, “What is your philosophy about assessment?” This is a loaded question but their response will be informative. We have written a little bit about assessment here. The bottom line is that an agency should either refer you to or assist you with a variety of assessments. Obviously, the first is the diagnostic assessment where your child received the autism label. After that, a comprehensive developmental assessment is needed so that your child’s current level of functioning is assessed compared to his/her peers. This assessment should be norm-referenced and it should occur about once per year so that you will see how your child is progressing.

The agency should complete informal preference assessments daily. This will help them better understand how to motivate your child to work. Formal preference assessments may also be needed initially and periodically throughout your child’s program.

The agency should collect on-going data to monitor your child’s progress towards his/her learning objectives. The data should be collected by each therapist for every therapy session. Data should be graphed following each therapy session. The graphs should be examined to ensure that your child is making adequate progress. Changes should be made to your child’s program if he/she is not making adequate progress.

Supervision and Clinical Team Meetings

Your child’s program should be supervised by a BCBA with extensive training and experience in autism. The supervisor should oversee and train all the therapists on your child’s team. The supervisor should hold clinical team meetings at least twice per month and those meetings should include every therapist and both parents. When possible, related therapy providers (SLP, OT, PT), and school staff should be invited to attend.

The supervisor should also conduct visits of your child during regularly scheduled therapy sessions to ensure that the program is being implemented as planned.

I realize that this was a long-winded answer. Hopefully, it will help you prepare for your meeting! I hope it goes well. We can also schedule some Skype time if you want to talk more.

Readers, if you have a question that you need help with, email me at askmissy at appliedbehavioralstrategies dot com.

 

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