Guest Post! - Conducting Comprehensive Autism Evaluations

Another marvelous guest post, and very timely since April is Autism Awareness Month! Today, we discuss best practices for Autism evaluations from an expert. “Dr. Tonya” Gscheidle, NCSP received her PhD in School Psychology from UNC-Chapel Hill, which is the home of TEACCH. She has been actively participating, leading, and/or training others in the art of Autism evaluations for the past 7 years. Tonya currently has the pleasure of “torturing” public school kiddos through evaluation in the Oklahoma City area. 

Conducting Comprehensive Autism Evaluations

According to the CDC, 1 in 88 children have been diagnosed with an Autism Spectrum Disorder (ASD), with boys four times more likely than girls to receive that diagnosis. While no one cause for Autism has been identified, many debates are ongoing with various hypotheses about a cause(s), as well as if Autism is being overly diagnosed. The rapid increase in prevalence also prompted significant changes to the diagnostic criteria for Autism in the soon-to-be-published DSM-5, due to be released May 2013.  One way we, as school psychologists, can help ensure that only students who meet diagnostic criteria are labeled as having Autism is by conducting comprehensive evaluations. How can we be sure our evaluations cover all bases?  

• Screen, screen, screen! How many times have you been pulled aside by a teacher or parent stating that a student may have Autism because they do not make eye contact? Or does not speak in class? Prefers to play alone? Each one of those observations is a symptom of ASD, but in isolation, does not necessarily mean a child warrants a formal diagnosis of an Autism spectrum disorder. Just as we do not automatically rush to evaluate for Emotional Disturbance based on a single tantrum or ADHD if they are easily distracted, it is best practice to do classroom observations and gather information to develop a profile of behaviors for a particular student before rushing to obtain consent for an evaluation for special education. Screening is a relatively quick and easy way to do that – and there are screeners published for both the home and school settings. (We use the Autism Screening Instrument for Educational Programming – 3^rd Ed (ASIEP-3) for school and Social Communication Questionnaire (SCQ) for parents.) Screeners help you know how to proceed with your evaluation, as well as to help further educate parents and teachers. If they are insistent on an Autism evaluation based on one isolated symptom (e.g., does not make eye contact) but the screeners do not show that a full evaluation is warranted, you have documentation that you addressed their concern and can provide that information to the team without completing a full Autism evaluation (though an evaluation in another area may be indicated). 
• Social-Developmental/Medical History is crucial! Diagnostic criteria clearly state that symptoms must be present before age 3 for a student to be diagnosed with Autism. How else can you gather that information other than interviewing a parent?  Although some questionnaires can be sent home with a student for the parent to complete and return, I have found that it is better to do these interviews face to face or via phone conference so that you can ask follow up questions. Remember to include questions about sensory differences, responses to transitions/schedule changes, and family/peer relationships in any interview you use. Part of the history gathering should also include a medical history to rule out any possible diagnosis that could be causing the behaviors of concern.
• 

  There is no “I” in play based evaluations! ASD is characterized by significant disruptions in language and communication, reciprocal social interactions, and repeated/restricted stereotyped behaviors. The best way to assess those areas is thru a structured play-based assessment. The Psychoeducational Profile – 3^rd Ed (PEP-3) and Autism Diagnostic Observation Schedule – 2^nd Ed (ADOS-2) are the two most commonly used standardized play-based assessments used in Autism evaluations and allow direct assessment of those specific areas through activities or presses. As communication and sensory differences are two main diagnostic areas, Autism evaluations should be completed using a multi-disciplinary team approach to the greatest extent possible. If that is not the practice in your school district, consider seeking out your Speech/Language Pathologist or Occupational Therapist to see if the findings they found in the course of their evaluations support or contradict your own. The ADOS-2 has a scoring algorithm built in to quantify observations through ratings to determine if a student’s behaviors rise to the diagnosis of an ASD. When doing the PEP-3, teams in my district complete the CARS-2 rating scales to quantify our observations. The focus of your report should be on the behaviors observed in response to the presses/activities and NOT on the scores obtained.  In fact, the authors of the ADOS-2 advise NOT to report scores from the ADOS-2 in the report.  
• What – more behavior rating scales? In most instances, Autism is considered to be a life-long disability. A student may (and should!) learn compensatory strategies to be productive in school and the community, but in most cases Autism will always be present.  This “life-long disability” label should not be taken lightly. Additional rating scales can be collected to further validate your observations. Preferred rating scales for teams I have been involved with include the Social Responsiveness Scale (SRS) and Gilliam Autism Rating Scale-2^nd Ed (GARS-2). 

A word about cognitive testing: I would strongly recommend using low-verbal batteries that utilize manipulatives such as the KABC-II NVI or Stanford-Binet 5.  Remember that while we engage our worlds socially and through language, those with ASD tend to engage through the sensory realm.  It may help to start a student with a brief sensory activity (e.g., using a Rain Stick, Bumble Ball, texture bocks, or digging through a bucket of dried beans) to help them regulate emotionally before putting academic stressors on them. To keep sessions structured, I almost always use a sticker chart and allow students to put a sticker in a box for every activity (subtest) completed. The chart gives students a visual of the progress made, how much is left, and something to take with them as tangible evidence of how much was able to be completed during a given session.

Recommendations should address particular concerns that drove the initial referral as well as behaviors observed throughout the evaluation. Commonly, recommendations include strategies to increase structure in the classroom (including structuring play scenarios for younger students), warn students of impending transitions, provide frequent sensory breaks, and explicit teaching of expected behaviors followed by immediate consequences or rewards.  Often, it takes students with ASD a significantly longer time to directly associate specific behaviors with rewards or consequences. Many more discreet trials are often needed. Visual supports and hands-on learning may also be considered depending on the needs of the student.

I end with a few recommendations of my own. The number of resources out there for Autism is exponential but there is a handful that I use regularly when consulting with parents and teachers and keep close when asked for resources that I will share with you lucky readers out there. This list is not at all meant to be comprehensive, rather just “tried and true” suggestions you may want to consider adding to your toolbox.

Parent/Teacher Resources

-Practical Ideas That Really Work for Students with Autism Spectrum Disorders – Kathleen Mc Connell and Gail R. Ryser

-Educating the Young Child with Autism Spectrum Disorders – Michael Abraham

-*Anything* by Temple Grandin [side note from Musings--I'm reading The Way I See It, 2nd Edition and it's stellar)

Student Resources (fictional stories about living with an Autism spectrum disorder)

-Understanding Sam and Asperger’s Syndrome – Clarabelle van Niekerk and Liezl Venter

-Mockingbird – Kathryn Erskine

Websites

www.do2learn.com (picture cards and picture schedules)

www.autism-society.org

www.autismspeaks.org

www.teacch.com

Please consider “Lighting it Up Blue” this April to show support for those with Autism Spectrum Disorders! 

Don't forget to check out and "Like" my Facebook page!

Analyzing Your Friends: A Fun Party Trick

I'm sure that many of you, when telling others that you're a school psychologist, have encountered those folks who get nervous that you're analyzing them or are eager to tell you their problems (or they ask if you're a school counselor, whatevs). Sure, we joke and laugh, but maybe you are psychoanalyzing or evaluating them in some way unintentionally (or on purpose, I won't judge). Honestly, as psychologists, we have more insight into human behavior than the average Joe, and maybe we're scrutinizing those we meet just a little more.

For me, this means seeing dysfunction where it doesn't actually exist.

Fiance and his college roommates went as the Channel 4 News Team one year
for Halloween. He was Brian Fantana, at left, with a legit dirty mustache.

Fiance went to high school with a group of guys who are still all very close and are very happy to revert to Frat Pack silliness when they're together (think The Hangover and Anchorman bromances). One of the guys, Chewy, is a little younger than the rest and therefore often the butt of silliness. I'll begin by stating that Chewy has no mental health concerns or developmental disabilities... but that doesn't stop me from very jokingly and in no way seriously finding them (in his defense, I tease him about this often and he takes it in stride and without offense).

Thus, I bring you, Why I Think Chewy May Have an Autistic Spectrum Disorder (as substantiated by NY State Part 200 educational regulations and DSM-IV diagnostic criteria):

• Use of repetitive phrases, especially movie quotes (i.e. Anchorman, I Love You, Man, Superbad, Wedding Crashers, etc). Also, echoing statements of friends and peers for days and weeks after it was first stated (i.e. "adorable," "cupcake," "it's not not hot out," "chicks chicks chicks," "so good! so good!,") Meets Part 200 and DSM-IV criteria B3
• Encompassing preoccupation with women, or "chicks" - looking at women, chatting up women, trying to pick up women, going on dates with women. Will then work a certain girl into repetitive phrasing (i.e. "omg I love her so much," "love her, need her, Chewy," repeating the girl's name over and over). Meets Part 200 and DSM-IV criteria C1
• Use of repetitive/stereotyped gestures and poses, which often coincide with said repetitive phrases (i.e. pumping his arms in the air above his head while squatting and cheering, "It's free!"; flicking his wrist and fingers while stating, "Obviously.")  Meets Part 200 and DSM-IV criteria C3
• Adheres to routines in most weekend locales, food, and drink (i.e. same group of watering holes, vodka tonics, Bud Light Limes, Raspberry BBQ chicken wings). Meets Part 200 criteria

Actual diagnosis/classification: typical mid-20 something male. But super psychologist me sees a little bit of the Autism spectrum, for amusement's sake.

Please tell me I'm not the only one. :)

Don't forget to check out and "Like" my Facebook page!

My Lunch Buddy is on "Vacation"

You may remember my Michael Jackson-loving, big dreamer blog star, H. A quick recap for our viewers at home: H is diagnosed with Asperger Syndrome and exhibits "classic" symptoms: rote, bookish speech (and hilarious one-liners), poor peer social interactions and a preference for being with adults, resistance to changes in routine, and extreme negative reactions to overstimulating (loud, noisy, busy, overpopulated) environments.

H was a case I looked at due to our ongoing state review, but was one we had already planned to reevaluate. H was receiving Integrated Co-Teaching (ICT) services within the general education classroom. When she moved up to first grade, she began having an extremely difficult time maintaining herself in the large classroom, and would shut down for hours at a time when overwhelmed. She would cry, sob, refuse to do work, and “ramble” incoherently. She also was refusing to go into the lunchroom, saying she is “scared” of the noise. She was unable to calm herself independently, a teacher is generally needed to do so, or removal from the overstimulating environment. Crying/shutting down episodes typically happened 2-3 times per half an hour period, and the crying lasted for up to 30 minutes afterwards.

H's special education teacher started interventions at the beginning of the year. Here's a quick list, none of which made a significant impact on her behavior, as little change occurred in her shutting down:

-planned breaks following periods of appropriate work.

-pulled into small groups within the class, to isolate her from the whole class.

-attempts to console, soothe, and calm her within the classroom (almost always had to be removed due to the disruption and intensity).

-given headphones to wear within the classroom to help her block out some of the noise of the other children. 

-lunch in my office, outside of the overstimulating lunch room (always a hoot).

-individual counseling on coping, calming down, and problem-solving skills at least 3x/week.

As a result of the reevaluation, we decided to move H to a classroom specifically for students with Autism. It proved to be a fantastic move that all of the Committee on Special Education (CSE) was pleased with (including H, who was reportedly needing "a vacation" from our school). The self-contained classes for students with Autism in our district not only target the academic needs of these students, but also do intense social, problem-solving, and coping skill training. The kiddos get to socialize with students "like them" within a controlled setting, teaching them age-appropriate interactions and helping them to overcome social and emotional deficits inherent in the disorder. They also learn more appropriate ways to cope with frustrations, changes in routine, and other upsets, as the "default" coping mechanism for many students with Autism is to cry/shut down, self-stimulate, or in extreme cases, self-injure (bite, scratch, or head-bang). 

H is reportedly doing great over at her new school, and while I will miss my daily lunch buddy and her fantastic (if inadvertent) humor, she's in a much more appropriate educational setting. Enjoy your "vacation," H!

Don't forget to check out and "Like" my Facebook page!

Thriller!

One of my favorite parts about the Halloween season (seeing as every holiday is becoming it's own 2-month ordeal, these days) is all the scary stuff on TV. Fiance and I spend our Wednesdays watching Ghost Hunters and American Horror Story on FX. I remember being younger and watching Michael Jackson's "Thriller" music video on MTV with my dad around Halloween.

One of my first grade friends, and former blog star, H has been having some trouble in the classroom. H is diagnosed with Asperger Syndrome and has great difficulty in loud, chaotic environments. Almost daily she has crying breakdowns because her classroom can be so overwhelming and overstimulating. Our school increased class sizes significantly this year, so H went from a kindergarten classroom of about 20 kiddos to a first grade classroom with about 28 (and some are rather... rambunctious). H has a lot of difficulty with yelling and lots of noise, so we decided to try having her wear headphones during instruction to help block out some of the noise.

(I swear I'm about to make the connection, hang on!)

H walked into my office this afternoon to have lunch with one of the mental health graduate interns, wearing her headphones, which for some reason have a microphone attached to them (not sure why it wasn't removed). H was holding the microphone to her mouth and stopped to say, in her adorable, rote, robotic voice tone, "Hi, it's me, H. Wait, I'm not H, I'm Michael Jackson!"

I almost want to bring in a sparkly glove for her. Too much?

Don't forget to check out and "Like" my Facebook page!

Accomplishment: Autism

As the school year is drawing to a close, I'm going to be doing a lot of looking back and making observations on my first year as a school psychologist (assuming I have time, since the end of the year is B-A-N-A-N-A-S right now). One case I want to highlight is A, one of the boys in my social skills/anger management group.

Mrs. C, A's teacher, came to me with concerns that A exhibits characteristics of an autistic spectrum disorder. These are signs that I noticed in the times I visited the classroom prior to beginning group, and have also documented a little bit in blogging about our sessions. Mrs. C's primary concerns were A's severe lack of social skills, resistance to changes in his environment, and his unusual reactions to his environment (i.e. smells, sounds, touches). She noted that these are really interfering with his ability to make friends and function fully within the room. In a 6:1+1 classroom of severely learning disabled and emotionally disturbed kids, A doesn't quite fit.

The Committee on Special Education began the reevaluation process, so that we could take a look at A's classification and program to determine if he needed something more or different to better meet his needs. I ran into a little roadblock because A is not currently diagnosed as autistic from a medical doctor, something I was worried would impede me from possibly classifying him as a student with autism. However, after talking to my psychologist colleagues, I got a resounding "YES," I could classify A as a student with autism, despite the fact that he does not have a diagnosis. One of the psychs summed it up best, "There is a medical model diagnosis and an educational model diagnosis. We are making educational classifications, not medical diagnoses."

In order to evaluate whether A may be educationally disabled due to an autistic spectrum disorder, I gave Mrs. C oodles of ratings scales to fill out to gain more information about A's behavior, including the Asperger Syndrome Diagnostic Scale (ASDS), the Childhood Autism Rating Scale (CARS), and the Vineland II Adaptive Behavior Scale. I also observed A within the classroom, which was easy because I see him for group every week. The rating scale results, Mrs. C's notes, and my observations all showed overwhelming evidence that A may have an autistic spectrum disorder.

I did a record review of A's previous evaluations and reports. What I found was both surprising and upsetting. The more I reviewed old documents, the more I realized that A has grown exponentially over the past five years. He started out nonverbal, violent, and what appeared to be very mentally delayed. Today, he scores with generally average intelligence and academic skills. However, I also found that for just as long, folks have noticed "oddities" that have been described as those similar to an autistic spectrum disorder. What frustrated me the most was A's most recent psychological evaluation. He was described very plainly as having autistic behaviors, but his classification was changed to Learning Disabled, despite him having fairly average skills across the board. Why had no one investigated the possibility of a classification of autism for A?

It seemed totally unfair to A that no one had stepped up to the plate. True, "autism" can spook the best psychologists, so it certainly spooks me (since I can in no way claim to be in the "best" category). It's like Mental Retardation or Emotional Disturbance: it sticks and it can be harsh. But, for all my reservations, it became extremely important to me to "do right" by A and get him services that would benefit him. Our district has a program at one of it's schools solely for high-functioning students with autism. It provides them with great social skills training, job training and transition help, and just real life skills in general. A's mom, Mrs. C, and I all thought this would be a great program for him.

At A's CSE meeting this week, I changed his classification from Learning Disabled to Autism. We're in the process now of getting paperwork together so A can attend the specialized program for students with autism next year (if all goes according to plan). Rock on.

In no way do I mean for this blog post to be self-serving or "tooting my own horn." For those that know me, I put others before myself constantly, maybe more than I should, and don't really want much in return. For me, it's for the kids, not any pats on the back I may get. So, I call this blog post "Accomplishment: Autism" because if I look back and find nothing else to be proud of after this year (unlikely), I can be happy knowing that A will be in the right setting for him next year with the right classification. That's what matters!

Dreams

A little girl with autism, H, transferred to our district from another state this year, and I did an evaluation on her last week to determine if a regular kindergarten would be the right classroom for her to be in. I stopped by H’s room this morning to see if her teacher had some paperwork I needed. When I was leaving, she followed me to the door and threw her arms around my waist. As I crouched down to see what was up, I found out that she was crying. I comforted her and asked her why she was upset, and she sobbed out, “I just want all my dreams to come true.”

School's out... and I'm stuck in the gym

It's only the fourth day of school and already my PM duty is starting to grind my gears. Every afternoon, I report to the gym to supervise students who wait there for their bus to arrive. There's about 40 PreK-8th grade students that wait in the gym for my assigned bus, and another 35 or so that wait for another bus on the other side of the gym. The gym itself is about the size of a run-down studio apartment. I am barely exaggerating. I know what you're thinking. "Aimee, why are you complaining? Having 70+ kids anxiously waiting for their four-wheeled ticket to freedom (which is always the LAST BUS to arrive) in a small, hot, loud stress chamber is a blast!" ...... I can't even make a witty, sarcastic retort for that, because that statement sums up the hell that is PM duty pretty darn well.

Regardless, as in all things, I try to find the positive: helping all the little lost Pre-K'ers find their way; watching an older "cool" girl hold the hands of two nervous kindergarteners on the walk to the bus; making a squirmy fourth grade boy who wanders and refuses to sit on the bench with the rest of the troupe sit in the middle of the gym floor to wait, then devising an incentive plan to help him keep his backside where it belongs (we're trying it tomorrow); getting waves and hugs from children I have never seen before; seeing that awkward middle school flirting hasn't changed since I was in school.

But by far the best experience I've had in PM duty thus far has involved M, a first grader with autism. M is a student who has a one-on-one aide throughout the school day to help keep him on task and keep him safe (he wanders, runs off without warning, and has difficulty navigating the stairs). Since the school year started, M has been without his aide, and has had random people filling in for parts of the day. Consistency and structure are hugely important for children with autism, and disruptions in their routine have the potential to be disastrous. M also reacts poorly to lots of commotion and noise. You may think that sitting in a gym with 70 other students would be a bad idea. You'd be right.

This particular day was very difficult for M. By the time dismissal came around, the woman who was his aide for the day had to leave to go to a doctor's appointment, so I volunteered to make sure M got on his bus safely. About the time I got M finally seated for more than 15 seconds (he repeatedly rolls on the floor), a little girl was dropped off in the gym and promptly starting crying because she was anxious to go home. I seated her next to M so that I could keep an eye on them both. M was quite startled to having a crying ball of Pre-K next to him, but turned to her looking quite concerned. What happened next made me all warm in my tummy. M started patting her forearm and wiping the tears from her cheeks with the crumpled paper towel she was holding. It was precious. And, for those of you who are familiar with autism know, children with autism can have great difficulty with social understanding, including interacting with peers and showing empathy, so to see M react to her in such a way was uncharacteristic and fantastic. Ahhh kids.