What To Look for in Your Child’s Autism Assessment

Determining when and where to get an assessment for autism can be a daunting task for parents. Time, money, and finding a clinician trained in autism assessment in your area are all things that have to be considered.

Luckily, experts in autism have devoted extensive time to help determine the best procedures for providing a valid autism diagnosis. Below I have outlined a “best practices” core assessment battery for children when autism is suspected.

An Autism Diagnostic Assessment May Include:
  1. Parent Interview – The parent interview about the developmental history, family history, and the child’s individual strengths and challenges is the foundation of the assessment.
  2. Direct Observation – The child should be observed engaging in various social interactions. The Autism Diagnostic Observation Schedule – 2nd Edition (ADOS-2) and the Childhood Autism Rating Scales-2nd Edition (CARS-2) are well-researched measures that provide robust information about the child’s behavior as it relates to symptoms of autism. Using the ADOS-2 or the CARS-2 as a direct observation measure is very beneficial to describe the child’s social strengths and weaknesses.
  3. Assessment of Cognitive Development – Cognitive functioning and problem-solving are an important part of a child’s development. An assessment of your child’s cognitive development can help inform intervention. It can also provide a baseline of your child’s functioning. Intensive applied behavior analysis (ABA) therapy has been shown to increase cognitive and problem-solving abilities in some children.
  4. Assessment of Language – An assessment of your child’s understanding and use of language is very important. Most cognitive assessments will include an assessment of verbal reasoning and vocabulary knowledge that will provide some information about your child’s language skills. Additionally, direct observation of your child during the assessment can provide an informal assessment of language and communication skills.
  5. Adaptive Behavior Assessment – Adaptive behavior describes what a child is able to do on their own. An adaptive behavior assessment can help determine what level of assistance a child needs when compared to others their age.

The information from each domain above should be integrated into a report by a licensed psychologist (PhD or PsyD) or a physician (MD or DO) that details the diagnostic classification that best describes your child. Recommendations based on the best available research and the priorities for treatment should also be included.

Remember that the above outline is describing the essentials of a “best practices” autism assessment. Additional assessment of other areas of functioning may be needed depending on the concerns for your child. The psychologist or physician will let you know if other areas should be added to the core autism assessment.

This post was written by Dr. Mariel Cannady, psychologist at Texas Child Study Center.

Behavioral Treatment for Specific Fears and Phobias

Fears and phobias are increasingly common in children. A fear of needles is a particularly common fear that usually starts in early childhood and can result in significant avoidance of  medical procedures in general.

What Research Says

A recent NPR story describes a research study published in 2012. The researchers surveyed over 800 parents and 1000 children. In the study, 24% of the parents and 63% of the children reported a fear of needles! This is concerning because specific fears and phobias can lead to avoidance of health-related procedures.

Cognitive Behavior Treatment

Luckily, there is behavioral treatment for specific fears and phobias. Behavior therapy or cognitive behavior therapy (CBT) can help children overcome their fears. The most effective behavioral treatment for specific fears and phobias is called graded exposure therapy. In graded exposure therapy the child is introduced to the feared situation or object in small steps until they are able to participate in the situation on their own.

For example, if a child has a fear of going to the dentist, the treatment can start out with the child reading a book about the dentist, looking at a picture of a dentist’s office, and observing a parent participate in a dental visit. Then the situations are gradually increased until the eventual goal of participating in a dental procedure is achieved. Kids with specific phobias and fears benefit from parent participation in the treatment process.

Practice at home will provide faster progress. Depending on the age and learning history with the feared object or situation, treatment can progress quickly or may take more time to break down the situation into smaller steps. Either way, behavior therapy or cognitive behavior therapy can help a child overcome their fears and phobias.

My Child Just Got Diagnosed with Autism, Now What Do I Do?

A diagnosis of autism can be an uncertain time for a family. Many parents are sent into a whirlwind of emotions and left wondering unanswerable questions: Why is this happening? How did this happen? What will their future look like? What do I do now?

Some questions are easier to answer than others. First, knowing which specialists are available to help can bring peace of mind. Some services are evidence-based, versus “fad treatments” or experimental treatments with no research supporting their use or effectiveness. Evidence-based treatments are interventions that have been supported by peer reviewed studies that have been replicated, often through years of research. When a provider tells you they can help your child with autism, don’t be afraid to ask them, “Can you tell me about the research supporting your services?” and “Is your treatment recommended by the National Institutes of Health for treating people with autism?”

Children with autism often receive a variety of support from different sources; evidence-based services include ABA therapy from a Board Certified Behavior Analyst (BCBA), speech therapy from a Speech Language Pathologist (SLP), ongoing care from a pediatric neurologist, and possible treatment with a doctoral psychologist or psychiatrist.

Wow, that’s a long list! Does my child need all of those services?

The answer is each child is different, and your child’s needs will change over time so it’s best to know what options are out there! Some services may require more time than others. ABA therapy, or applied behavior analysis therapy, typically ranges from 10 to 40 hours per week depending on a child’s needs. The programs are intensive, which requires a higher number of therapy hours. Research indicates a lower number of therapy hours does not produce meaningful outcomes, hence the greater time requirement (Granpeesheh et al, 2009).

Search for ABA centers in your area to learn more.

Speech therapy with a private SLP typically ranges from 1 to 2 hours per week. Many provide in-clinic and in-home services. To find a private speech therapist, search for speech language pathology clinics in your area. Public schools in Texas also offer speech therapy, typically about 30 minutes per week. Contact your child’s teacher and school psychologist to see if they are eligible to receive services at school. If they are currently not eligible, inquire if the school can evaluate them to see if they need support (they can!). Pediatric neurologists provide initial diagnoses and ongoing screenings or check-ups one to two times per year. If additional diagnoses are warranted, they can evaluate your child and refer you to recommended specialists if need be. Neurologists can diagnose developmental disorders, seizure disorders, brain injuries, and nerve-muscle disorders. Psychiatrists and licensed psychologists can also provide a diagnosis of autism. Psychiatrists can provide treatment through medication if severe behavioral issues (such as severe self-injury or aggression) persist in spite of intensive ongoing behavior therapy. Licensed psychologists can provide a variety of therapy options, including PCIT, or Parent-Child Interaction Therapy. PCIT is a type of evidence-based therapy that teaches parents effective ways to engage their children to produce meaningful behavior change and skill acquisition.

Collaboration is Key

Hands down, collaboration among all specialists will result in better outcomes for your child. Encourage your child’s team to communicate on a regular basis! For example, BCBAs or speech pathologists can attend doctor visits with the neurologist or psychiatrist to discuss specific behaviors that are observed during day-to-day therapy. Doing so will give doctors more complete information and allow them to make the most informed decisions. Also, BCBAs can include recommendations from a psychologist in their skill acquisitions programs and individualized behavior plans. The two specialists can also discuss if other evidence-based treatments are needed, for instance in a child has multiple diagnoses that require a variety of behavior therapies.

Moving Forward

In addition to knowing how to navigate through the sea of specialists, many families benefit from reaching out to one another. Parent support groups that connect parents of children with special needs are a great place to find compassion and understanding for a process that can be emotionally taxing. Further, many states have conferences, such as Texas Parent to Parent Conferences that provide parents with information and foster connections with other families. You’re not alone, don’t be afraid to reach out! Learn more about reducing stress in your life with these simple techniques and tips.

Decrease Autism-Related Shopping Meltdowns

Meltdowns happen. But, there are ways to decrease the likelihood your child will have a shopping meltdown. In my previous blog I discuss tips to understand shopping meltdowns. In this blog, I outline simple ways to decrease autism-related shopping meltdowns.

Tend to basic needs first

Before a shopping trip, tend to your child’s basic needs. Make sure they are not hungry, they are rested, and they have received positive interactions with others such as play time with parents, peers, or siblings. Hunger and fatigue make children (and adults) more irritable. Before shopping, you could have a snack with your child and ensure you are attending to and delighting in their positive behaviors. From your child’s point of view, shopping likely means a lot of difficult to manage sensory experiences (sights, sounds, and smells) and adult correction. Therefore, it is important to ensure positive interactions (even for 5 minutes) before a potentially stressful shopping trip.

Use a visual schedule and list

As much as possible, let your child know about the shopping trip before it happens. Visual schedules are incredibly useful for children with autism. Add shopping trips to your child’s schedule, and better yet, try to have a routine grocery shopping or errand day each week. This will help increase predictability for your child. A visual shopping list with smart phone apps, pictures, or clip art can also help your child actively participate in shopping.

Identify meltdown triggers

Identifying meltdown triggers can help caregivers stay one step ahead of potential meltdowns. Some caregivers find that headphones, sunglasses, a soft object to hold, or the child’s favorite foods can help reduce meltdowns. If you observe your child is becoming upset, take a moment to help them calm down before the frustration builds. This may require a pause in shopping so a full meltdown does not occur.

Teach calm shopping behaviors

Children need to learn what behaviors are expected. Some children need explicit teaching and modeling. Social stories and video modeling can help children learn appropriate social behaviors. Video modeling can include having your child watch a video of another child successfully shopping with an adult or a short clip of themselves engaging in calm behavior while shopping. Children may need specific reminders and prompts at different points of the video to ensure understanding. Parents can also attend to calm behaviors during the shopping trip with praise (“Nice inside voice!”) and positive gestures such as a high five, or introducing small portions of food for the child’s “calm” behaviors.

Plan

Planning can help prevent meltdowns. Make a shopping list, decide what shopping items are most important so you can get those items first, and try to reduce the total shopping time. If you ensure you have plenty of planned strategies to help your child stay calm, your child can learn how to manage the stresses of shopping.

Understanding Autism-Related Shopping Meltdowns

Children do not always go along with the shopping plan easily. Autism-related meltdowns can make shopping even more difficult. Understanding autism-related shopping meltdowns can help you and your child experience less stress during a shopping trip.

Carefully observe your child’s triggers

Observe what happens before your child has difficulties. Most children are more likely to have a meltdown if they are hungry or tired. A common trigger for children with autism also includes sensory overload. The lights, sounds, smells, and crowds from a shopping trip can trigger a meltdown. Shopping at the popular grocery store on a Saturday may be more stressful for your child because it is loud and chaotic. You might observe that the smaller, less-crowded grocery store does not trigger a meltdown.

Understand the difference between meltdowns and tantrums

Both meltdowns and tantrums can include screaming, crying, falling on the floor, self-injury, and destruction. But, meltdowns and tantrums happen for different reasons. I define a meltdown as the visual display of a child becoming overwhelmed in response to a trigger. Meltdowns do not immediately stop when a child is given what they want or when they are taken out of an unpleasant situation. The intensity of emotion during a meltdown may take a minute (or more) to decrease.

Children throw tantrums to gain access to something (attention, food, toy,  etc.). Children also throw tantrums to avoid something (unpleasant activity, ending play, bedtime, mealtime, etc.). You can usually stop a tantrum by giving the child what they want (leaving the store, that special toy, attention, etc.). A child having a tantrum may also watch for your reaction to see if the tantrum is working.

Conduct an experiment

Parents can carefully observe and implement systematic changes to decrease the likelihood of a meltdown. If you know your child’s triggers, you may be able to modify the trigger. For example, if a change in your child’s drive home from school triggers a meltdown, plan to give him or her ample notice (verbally or visually) that a shopping trip will occur. If the grocery store’s fluorescent lights are too bright, consider ways to reduce the child’s exposure to the lights.

Understanding autism-related shopping meltdowns gets us one step closer to improving your errand-running experience! On my next blog, I will provide tips to prevent meltdowns.

Stress Reduction for Parents of Children with ASD

Your well-being as a parent of a child with ASD is critical to your child’s functioning. I have listed some simple stress reduction strategies to help improve your emotional well-being as a parent of a child with ASD.

Social Support

Connecting with friends, family and others in the ASD community is a simple stress reduction activity. When you connect with others, it reduces loneliness and helps you feel supported. If you connect with other parents in the ASD community it can allow you to share triumphs as well as discuss challenges with others who have shared experiences. For social support within the ASD community, check out ABA Connect’s Facebook page and the Autism Society of Central Texas Calendar. Both of these sites are updated regularly and are full of events just for you!  Also, reference our Resources page to find organizations who design programs for persons with ASD and their families.

Schedule Time To Be “Mindful”

Take some time each day to focus on the present through a practice called mindfulness. Resist the urge to think about your child’s therapies, what’s for dinner, or anything else competing for your attention. Take some time, even if it is 10 minutes, just for you. Sit with your thoughts without judging them and focus on your surroundings, feelings, and any sensations you may feel without trying to change them. Mindfulness can include meditation or it can just be a specific focus on what you are doing in the moment. To learn more about mindfulness and how it promotes well-being and reduces stress, see the University of Berkeley Greater Good Science Center website. 

Delight In Your Child

Parent optimism has been associated with stress reduction, better parenting, and positive well-being. That does not mean parents walk around with rose-colored glasses. But, an increased focus on your child’s positive qualities and strengths can increase hope and optimism. Think of a cute thing your child did, a tender touch, or anything your child does that makes your heart melt. Reflect on those moments to boost your mood. If these moments do not readily come to mind, start today by looking out for things that make you smile about your child. One mother did this through an Autism Speaks blog that outlines five of her child’s personal gifts.

Foster Gratitude

Research in positive psychology shows that regular gratitude can improve happiness and life satisfaction. One way to do this is to write down three things that went well during the day before going to bed. You may start by doing this for just a week or you may try practicing it consistently. Once you develop the well-being habit of noticing the small things that go well during your day, it can increase positive feelings and decrease stress.

Ask For Help When Needed

Know if you are experiencing “caregiver fatigue.”  Caregiver fatigue can interfere with your ability to enjoy your child and engage in positive interactions.  Respite care for your child or help from family and friends can decrease stress and enhance caregiver well-being. If you feel you need additional help, consider joining a parent group led by someone experienced in children with developmental disabilities or consider individual therapy. HelpGuide.org offers good information about the signs of caregiver burnout and caregiver fatigue.

If you feel you need professional assistance, consider contacting our separate, but affiliated practice, ApaCenter. ApaCenter offers therapy and consultations for individuals, parents, and couples who want to improve their emotional and relational well-being.

Transitioning Back to School: Tips for Parents

Beginning a new school year is both exciting and nerve-racking for parents and children. The transition is especially challenging for families with children on the autism spectrum. While transitions are difficult, there are things families can do to help prepare their children for the new school year. Keep these tips in mind to make the transition back to school a success:

Prepare your child for change

The beginning of a new school year brings many changes at once. Familiarize your child with anything new related to school as much as possible. This may mean bringing your child into their school or classroom, showing your child a picture of their teacher and any classmates, or even meeting the teacher before the first day of school.

Resume routines

Over summer vacation your child’s morning and evening routines may have changed. They may be waking up and going to bed at different times. Start adjusting your child to the school year schedule and routine well before the school year actually begins.

Prepare your child’s teacher

When it comes to your children, you are the expert! Just as your child may need some preparation for a new teacher, your child’s teacher will benefit from getting to know your child ahead of time. Make sure to share any tips or tricks you have learned about your child, including strengths and challenges, what motivates him/her, and how to respond when he/she is upset.

Review the “hidden curriculum”

While many children switch easily between the social demands of summer and those required in a classroom, children on the autism spectrum may need more explicit reminders. The hidden curriculum refers to social information that is not directly taught, but is assumed that everyone knows. Go over the “dos and don’ts” of acceptable school behavior. More information regarding the hidden curriculum can be found here.

Myths and Realities of ABA

A recent article highlighted many of the misunderstandings of what current ABA practices include. As mentioned in the article, and observed through personal experience, some parents and therapists alike reject the use of ABA, but tend to have some confusion about what ABA truly entails, how it is delivered, and for whom it can be helpful. As ABA is a very effective and evidence-based intervention for children with autism, as well as other developmental concerns, this very informative and insightful article prompted an interest in summarizing some of the myths and realities of ABA:

ABA Is Only for Children with Autism

Although ABA is an evidence-based intervention for children with autism, the true definition of ABA describes a much broader science of learning and human behavior. Many of the learning principles that guide the practice of ABA are applicable to broader group of children with other disabilities, typically developing children, and even adults! We all have things that motivate and shape our behavior, sometimes it just takes some extra work and creativity to use those motivations to help children with autism learn from and connect with their world!

ABA Equals Discrete Trial Training

Many parents fear that ABA means your child will be sitting at a table for 40 hours per week completing learning drills that will turn him or her into a robot. Although this sort of technique has been used in the past (and may still exist at some practices), recent research suggests that a much more flexible, and play-based approach to learning is better for child development and generalization of skills to other settings. While some skills are still taught at the table, particularly those that are designed to prepare children for school-readiness, parents are encouraged to pursue ABA therapy that is described as play-based.

ABA Rejects Sensory Needs

It is often obvious to parents and therapists that some children with autism have unique sensory aversions or interests. These strong sensory preferences can sometimes cause challenging behavior–whether that is to escape an environment that is unpleasant, or to gain access to preferred sensory input. The trick is to be mindful of how and when access to these preferences takes place. For example, children may quickly learn that throwing a tantrum gains them access to pleasant things, such as the sensory room. However, ABA therapists would encourage (1) teaching the child to appropriately request access to sensory input, or (2) providing sensory input in a proactive way (e.g., before tantrums or other challenging behavior occurs), and/or (3) using sensory input as a reward for other behaviors. Put simply, we don’t want to teach that tantrums gain rewards, whether it’s candy from the grocery store, or deep pressure from the squeeze machine.

ABA Doesn’t Allow Play

As the field of ABA has developed over time, so has our understanding of how best to teach children with autism. Not surprisingly, the best way to teach children with autism is most similar to how we teach all children-through play! Contributions from the fields of behavioral science and developmental science have come together to hone in on the optimal strategies for teaching children with autism. Access to toys, movement, and preferred motivating rewards are now hallmarks of play-based ABA.

Parents should be encouraged to ask their therapists questions about the ABA strategies being used, and be thoughtful consumers about which ABA practice best fits their child’s needs. As always, open communication between parents and therapists is key! Further information about ABA can be found here.

Medicaid coverage for Applied Behavior Analysis (ABA)

I recently read a quote from a parent of a child with autism: “The hardest part about autism is knowing what treatments and therapies your child could benefit from, and not having the financial resources to get him the help.” (autismspeaks.org) For many parents, this is a heartbreaking reality. For families living in the state of Texas, this is even more challenging.

Currently, Texas denies Medicaid coverage for Applied Behavior Analysis (ABA), an evidence-based, behavioral therapy that has proven effective in treating the behavioral symptoms of autism. In 2014, federal guidance from the Centers for Medicare & Medicaid Services (CMS) advised states that they should cover medically necessary care for Medicaid-eligible children diagnosed with autism through the age of 21. These services include ABA, as well as speech, occupational, and physical therapy. Although other states quickly adopted this policy (e.g., California, Virginia), others required legal prodding (e.g., Florida), and still Texas maintains its stronghold in denying coverage.

Much of the controversy involves a complicated debate regarding licensure versus certification of ABA therapists. What is not up for debate is the profound benefit of early behavioral interventions for children with autism. Research has shown that early, play-based ABA can improve positive outcomes for cognitive abilities, communication, and social interaction skills (Rogers & Dawson, 2009). In addition, research suggests that the state of Texas would save over 2 billion dollars if funds were allocated to early intervention, rather than 18 years of special education costs through school (Chasson, Harris, & Neely, 2007).

It is important for parents to remain well informed about the policies in place that affect access to care. For a list of helpful organizations and websites to remain connected to the latest in autism news, please visit: https://www.abaconnect.com/autism-resources/websites/

Coping with the Relaxed Summer Schedule

Summer break is a time for relaxation, vacations, and fun. However, for many children with autism and their families, summer break also means a transition from the structured schedule of the school year. This can prove difficult for children and families who rely on predictability and routine to help their children navigate their days. The following tips can help children cope with a more relaxed summer schedule:

Create a Consistent Schedule at Home

Children get used to daily predictability of the school routine. It can be very helpful to maintain as much of this schedule as possible, including when your child eats lunch, break/play time, structured activity time, and bedtime. To assist with this, it can be very helpful to create a visual of this schedule and post it for the whole family to see.

Prepare for Changes in Routine

It can be tough to stick to a schedule during the summer. Preparing your child for the possibility of changes in the schedule can help prevent meltdowns. For example, if you are planning a trip to the beach for the following day, it is important to discuss the possibility that the plans may change due to bad weather, and prepare your child with a plan B in case this occurs.

Limit Screen Time

Summer is often a time that parents must help their children stay engaged and entertained in activities. It is easy to fall back on electronics as a form of entertainment and occupation for your child. However, increased screen time often leads to increases in social isolation, as well as challenging behavior when limits are imposed on the electronics. Continue to use screen time as a reward for completing other activities throughout the day, and maintain your limits on the amount of electronic use allowed daily. A daily schedule of other activities can help your child make other choices for entertainment.

Maintain Consistent Behavior Management

Summer is a time when we all enjoy some rest and relaxation. However, it is critical to uphold the normal house rules over the summer. Inconsistent behavior management can actually increase anxiety and a sense of unpredictability in children. Maintaining consistent behavior management can actually provide a sense of consistency and security. And remember, rewarding appropriate behavior is more effective than punishing inappropriate behavior. Be on the look out for your child’s successes, and the whole family can enjoy the rewards!

Summer should be a time of relaxation and fun for the whole family. Planning ahead (while preparing for change) can go a long way in ensuring a safe and happy summer!