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 – 3rd 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 – 3rd Ed (PEP-3) and Autism Diagnostic Observation Schedule – 2nd 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-2nd 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)
Please
consider “Lighting it Up Blue” this April to show support for those
with Autism Spectrum Disorders!
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