Submission to the Senate Prepared by Debra Goldfinch, Chief Executive Officer Dr. Jose Molina, Chief Practitioner Irabina Autism Services
August 2020
Introduction
Every young person has the right to experience their own success and live an independent life.
Who is Irabina Autism Services?
Irabina Autism Services celebrates the initiative of the Select Committee on Autism and is thankful for the opportunity to make this submission.
Irabina provides specialist services to help every individual with autism find their own success and independence. Our vision is to transform the lives of individuals with autism and their families in socially and personally meaningful ways. We view success through the eyes of these individuals and their families, whether their version of success is being better able to handle social situations, using words to communicate their needs and wants, or eating a wider range of foods. Irabina supports their journey with a team of highly qualified health professionals who respond to their individual needs. Irabina has 5 locations throughout Victoria and consults both interstate and overseas.
Founded in 1970 by two families, Irabina is a not-for-profit family-centred organisation dedicated to helping individuals with autism, along with their carers and families, to reach their full potential and become and remain active participants in their communities. Irabina provides a comprehensive range of family-centred services including: diagnosis, early intervention, training and development, education and support and school holiday programs; integrating robust clinical governance and evidence-based clinical practices delivered by highly qualified clinicians with specialised training and experience in the field of autism.
In addition, we have a range of consultancy and training services designed for allied health experts, educators, and even football coaches, to ensure that professionals and community members of all sorts have the tools to support the development of individuals with autism.
Currently, over 1000 families of individuals with autism receive support from Irabina each week. Irabina offers a multidisciplinary approach to each individual and his or her family, providing a range of assessment and treatment services. The following types of specialist staff are employed:
- Psychologists
- Speech pathologists
- Occupational therapists
- Board-certified behaviour analysts
- Paediatricians
- Specialist teachers
- Social workers
- Dieticians
- Behavioural therapists
- Youth and Disability Support Workers
Irabina aims to fulfil the needs of all individuals with autism and their families, regardless of the challenges they may present. Irabina’s multidisciplinary approach with staff and service options emphasises evidence-based practice to address these challenges.
It is critical for individuals with autism and their families to have access to high-quality, research-informed, and evidence-based services.
An Increasing Demand
Research indicates that there is an increasing prevalence of autism and a growing demand for effective, evidence-based services.
Worldwide prevalence estimates similarly show an increasing trend, with median values ranging from 0.63 to 14.41 per 1000 children (Chiaroti & Venerosi, 2020). This significant increasing trend subsequently leads to a need for high-quality services that are research-driven and available to all individuals and families in need, without exclusion (Liao & Li, 2020).
Several possible contributing factors have been considered to drive this increasing prevalence, including a greater awareness of the diagnosis by families and health care workers; improved diagnostic protocols; and a widening of the diagnostic criteria. Regardless of causes, the rapid increase in prevalence is generating a rapidly growing demand for services now and into the future, in particular for individuals with autism presenting with severe behaviours of concerns, intellectual disability, language disorder, and others, and that require very substantial support from their families and their broader community.
Unfortunately, services for individuals with more challenging behaviours and co-occurring conditions, such as those described above, are extremely limited. Irabina recognises this growing gap in services supporting individuals with autism with complex behavioural presentations. To address this gap and provide high-quality services without exclusion, Irabina made the strategic decision to become a specialised service dedicated to supporting individuals with autism presenting with the most severe behaviours of concern.
What are Severe Behaviours of Concern?
The term “severe behaviours of concern” is generally used to refer to behaviours that can result in injury to self or others, or that can significantly impair functioning and health. Individuals typically display multiple types of problem behaviour. In many cases, these behaviours can be chronic, and potentially life-threatening (Richman et al., 2012) posing a risk to the physical safety of people with autism and those around them as well as potentially limiting access to community and/or educational opportunities (Sigafoos, Arthur, & O’Reilly, 2003).
Severe challenging behaviours such as aggression, self-injury, property destruction, encopresis and enuresis, feeding disorders, and absconding, are not uncommon among young people with autism (Murphy, Healy, & Leader, 2009), particularly if these young people have comorbid (co-occurring) intellectual disability and language disorders (Newcomb & Hagopian, 2018). Problematic behaviours occur in 50% of cases of autism, with some of these behaviours escalating to more severe and challenging presentations.
Severe behaviours of concern are present in approximately 5 to 10% of all individuals with autism and related neurodevelopmental disorders (Kurtz, Leoni, & Hagopian, 2020), demonstrating a great need for more detailed research on progression of behaviour, experiences of these individuals, and more effective intervention.
All Autism Cases
(Kurtz, Leoni, & Hagopian, 2020)
50% Present Problematic Behaviours
5-10% Present Severe and Challenging Behaviours
These severe behaviours of concern present a significant risk for individuals with autism and their family, negatively impacting on their physical, emotional, and social well-being and overall quality of life (Walsh, Mulder, & Tudor, 2013). The presence of severe behaviours is a major stressor for people with a disability and their family (Emerson, 2003; Fuentes, Herves, & Howlin, 2020; Hastings, 2002; McIntyre, Blacher, & Baker, 2002), and behaviours or concern are often cited as the primary reason for referral to intervention services (Bushbacher & Fox, 2003; Donnelly et al., 2020; Hastings & Brown, 2002; Matson & Minshawi, 2006; Plant & Sanders, 2007).
The frequency and intensity of severe behaviours of concern is likely to predict the need for residential care outside the family (McIntyre et al., 2002), to increase the risk of having to be physically restrained (Harris, 1993), being given medication (Harris, 1993), being excluded from day care and other services (Kiernan & Kiernan, 1994) and being a victim of abusive behaviour from carers (Rusch, Hall, & Griffin, 1986). Young people with autism are 9 times more likely to seek emergency-room care related to mental health issues and, in some cases, may require acute psychiatric hospitalisation due to severe behaviours (Kalb et al., 2012). Additionally, if these behaviours go untreated, they are likely to persist into adulthood and continue to increase in severity as the individual matures physically (Murphy et al., 2005; Newcomb & Hagopian, 2018).
The need for effective services addressing severe behaviours of concern is well-established. Unfortunately, understanding of these behaviours from a scientific and family perspective in Australia remains limited.
A concerted effort in conducting research identifying Australian prevalence, critical factors regarding impact and occurrence, and best practice recommendations is necessary in order to further the commitment to improving the quality of life for individuals and families with autism, especially those with severe behaviours of concern and complex presentations.
This submission will address the Terms of Reference of the Select Committee on Autism with an emphasis on the experience of individuals with autism presenting with complex behaviours needs and their families.
Term of Reference (A):
Current approaches and barriers to consistent, timely and best practice autism diagnosis
Best practice guidelines for the diagnosis of autism include a full medical evaluation, developmental or cognitive assessment, an assessment of language and adaptive skills, and a standardised measure of autism symptomatology (Anagnostou et al., 2014; Baird, et al., 2011; Filipek et al., 2000). Despite these clear guidelines, clinical practice in Australia often fails to include all these components. An Australian survey showed that medical investigations are seldom included in the autism diagnostic assessment, that the inclusion of measures of cognition, language and adaptive skills is inconsistent, and that clinicians often failed to include a standardised measure of autism symptomatology as part of the diagnostic process (Schochet et al., 2016). Furthermore, the timely provision of autism diagnoses is poor at best, with many individuals and families experiencing significant delays in accessing diagnostic clinics.
Earlier access to treatment and intervention is a significant predictor of positive outcomes later in life. However, participation in early intervention tends to be limited by access to a formal diagnosis of autism (Camarata, 2014; Landa, 2007; Reichow, 2012) and may be negated to those individuals who have not had the opportunity of receive a formal diagnosis.
There is evidence indicating that absence of treatment and support for children with autism negatively impacts their developmental trajectories, diminishes their well-being, and deteriorates their quality of life and that of their families, while increasing the cost of living (Koegel et al., 2014; Lang, Hancock & Singh, 2016). Furthermore, the absence of early intervention may result in a myriad of difficulties such as dependency on specialist educational settings, comorbid mental health issues, a deterioration of core symptoms, and increased behaviours of concern (Chasson, Harris, & Neely, 2007; Koegel et al., 2014; Peters-Scheffer et al., 2012).
In view of the significant prevalence of autism, the positive impact that an accurate diagnosis and access to early intervention has on the developmental trajectory of children with autism, and the existing shortfalls in diagnostic practice in Australia, Irabina strongly advocates for the funding, development, and dissemination of clinical services that provide early diagnosis following best practice standards in a timely manner. In particular, Irabina advocates for the early recognition and documentation of behaviours of concern as part of diagnostic process, and their inclusion as essential goals of in the early stages of treatment. The provision of effective behavioural intervention targeting behaviours of concern during early intervention, alongside comprehensive training on behaviour management for parents is likely to prevent more complex behavioural presentations later in life (Hyman, Levy, & Myers, 2020).
Irabina advocates for the funding of specialist diagnostic clinics to address the growing demand for diagnostic assessments and to facilitate access to early intervention.
Irabina recommends the inclusion of functional assessments of behaviours of concern during diagnostic evaluations to improve treatment outcomes and provide epidemiological data.
Term of Reference (B):
The prevalence of autism in Australia
Worldwide prevalence of autism is largely understood and accepted, including the increasing rates in Australia. However, the prevalence and incidence rates of behaviours of concern are much less understood and documented, particularly at a national level. Thereby, Irabina recognises the need to appropriately evaluate the prevalence of behaviours of concern through a “National Survey on Disability Service Delivery for Individuals with Behaviours of Concern”.
This survey should aim to examine the experiences, impact, and reported needs of families caring for an individual with neurodevelopmental disabilities and behaviours of concern. This National Survey would provide unique and valuable insight on the experiences of families and carers during their interactions with service providers, crisis response services, and governmental agencies, thus informing national policies, strategies, and service offerings.
To fulfill the needs of Australian families, the survey should encourage families to report on the impact behaviours of concern have had on their families across personal, social, financial, and community domains in an inclusive and candid manner. Irabina is prepared to disseminate this survey in order to obtain information necessary to better accounting for prevalence of behaviours of concern and achieve meaningful improvement in families’ lives. With support from national partners, Irabina can execute this aim.
Irabina recommends the development and dissemination of a “National Survey on Disability Service Delivery for Individuals with Behaviours of Concern” to obtain epidemiological and actuarial data.
Term of Reference (D):
International best practice with regards to diagnosis, support services and education, effectiveness, cost and required intensity
As this submission focuses on the issue of severe behaviours of concern, the following section will discuss the best-practice model to support individuals with complex behavioural presentations.
The best-practice model to treat severe behaviours of concern prescribes the provision of intensive behavioural conducted by a multidisciplinary team with high inter-rater reliability interventions (Call, Parks, & Reavis, 2013; Heyvaert et al., 2014; McGuire et al., 2016). These interventions are guided by the outcomes of functional analyses of the behaviours, designed to identify the controlling antecedents and reinforcing consequences for challenging behaviours (Hagopian et al., 2013).
The effective modification of severe behaviours of concern relies on the delivery of highly structured treatment protocols aimed at teaching the individual more appropriate ways to access the very same consequences or outcomes that originally motivate said behaviours. The implementation of these protocols and resulting behavioural response must be closely monitored to rapidly respond to behavioural changes and support the individual in the gradual acquisition of more adaptive behaviours.
This proactive model of treatment aims to prevent the occurrence of behaviours of concern over time by placing an emphasis on the acquisition of alternative adaptive skills including communication, social, and leisure skills (Doehring et al., 2014). In addition, parent training and goal generalisation are imperative to this best-practice model, as it is essential that the gains made by the individual during treatment are maintained and expanded over time without the reliance on such resource-intensive levels of support (Call et al., 2013).
Following this best-practice model, Irabina has developed and implemented a Severe Behaviour Clinic, offering a Day Treatment program and a Brief Behaviour Intervention program to support individuals presenting with a wide array of behaviours of concern. These Severe Behaviour programs aim to support individuals in learning the skills required to modify their behaviours, and to support parents and carers in implementing safe and effective behaviour management strategies in the home. The Severe Behaviours programs are based on the principles of Applied Behaviour Analysis (ABA) as this framework has substantial evidence supporting its effectiveness in reducing or eliminating behaviours of concern.
The treatment approach of the Severe Behaviour programs is to identify the controlling antecedents and reinforcing consequences for each target behaviour, and then teaching the individual more appropriate ways to access those very same consequences. For example, if a child hurts others to get items he wants, the treatment would consist in teaching the child that aggressive behaviour no longer results in him acquiring the items and, instead, proper communication is now the only way the items can be obtained. This child could also be supported through programs teaching him that even proper communication will only be effective under certain circumstances and that occasional absence of desired outcomes must be tolerated. Parents and carers are equally supported by these programs as treatment success relies on the ongoing commitment and capacity for caregivers to continue to follow up the treatment strategies at home and the community.
Unfortunately, such services are rare to inexistent in Australia, and individuals with autism presenting with severe behaviours of concern are often poorly supported by ill-equipped service providers that have little capacity to bring about the sustainable behavioural changes that allow individuals with complex behavioural presentation to access and participate in their community, improve their well-being and that of those around him, and increase their levels of autonomy and independence. Therefore, Irabina advocates for the recognition of the need for services that follow this best practice model of care, and the support for initiatives that aim to address the existing gap in services for individuals with autism presenting with severe behaviours of concern.
Irabina advocates for the priority funding of internationally-informed best-practice services to support individuals with autism presenting with severe behaviours of concern.
Term of Reference (F):
The interaction between services provided by the Commonwealth, state and local governments
Including (i) health and mental health, (ii) education, (iii) employment, (iv) justice, and (v) housing.
An issue of significant concern to Irabina is the systematic failure at a national level to provide autistic individuals with complex behavioural presentations a coordinated model of care that adequately integrates the support they require from the multiple State agencies and sectors (i.e. Health, Disability, Education, Human Services).
Almost by definition, autistic individuals with severe behaviours of concern require substantial levels of care and support by their schools, communities, disability service providers, health and human services, etc. However, is often the case that instead of collaborating to address the individual needs of participants, State agencies spend time and resources disputing the mandates and remits of each particular agency. Furthermore, on the occasions when consensus is reached, long term outcomes are often undermined by a lack of accountability and monitoring that ensures a particular individual’s gains and progress is maintained.
Effective support that maintains progress should be proactive and responsive to the shifting and evolving needs of the individual and not limited or predicated upon agency divisions. Unfortunately, it is Irabina’s experience that the failure of State agencies to coordinate effective and efficient supports results in large amounts of misspent funding, excessive waiting times, poor responsiveness to rapidly-evolving situations, and an ongoing source of stress for the individuals and their families.
The lack of experienced and effective support coordinators, in addition to the siloed approach of many agencies, puts carers and families in the position of having to identify, evaluate, and approach the multiple services required by individuals with autism presenting with severe behaviours of concern. Families often report high levels of stress and even trauma resulting from having to advocate, negotiate, and coordinate with the multiple services that intersect in individuals with complex behavioural needs.
Furthermore, families are often placed in a position where they must hold agencies accountable for their inability to provide the necessary support, creating friction and an uneven dynamic were an individual or a family must litigate against a government agency. This constant tension in their interaction with the system, coupled with the stress inherent to caring for an autistic individual with complex behavioural needs, often leads to carer burnout and a significant deterioration in mental health. These gaps in the system create a situation in which those who are most vulnerable are further victimised, discriminated against, or traumatised by interacting with a system that is incapable of providing a unified approach to treatment, care, and support.
It is recommended that state and national agencies better support families and service providers with a unified and collaborative approach. Open communication with all stakeholders is recommended to achieve this goal.
Term of Reference (G):
The social and economic cost of failing to provide adequate and appropriate services, including to support key life stage transitions of autistic people
Severe behaviours of concern produce significant barriers for families in terms of social engagement and financial security. Without adequate and appropriate services, severe behaviours increase in frequency and intensity and, thusly, further impair the quality of life for families of individuals with autism spectrum disorder (ASD) across their lifespan (Newcomb & Hagopian, 2018).
Families are forced to consider survival rather than progress with inadequate services for their family member’s severe behaviour. Adequate and appropriate support is largely unavailable, as 82.9% of families with an individual with ASD reported that they did not receive some or all of the help they needed (Australian Bureau of Statistics, 2018).
Rather than plan for future transitions with support, families combat social isolation and financial distress. Irabina families report that a lack of appropriate services for challenging behaviours and their children’s complex needs lead to “stress, worry, and guilt,” “financial burden,” and “hopelessness that engulfs all of us and our actions towards [our child], ourselves and each other.”
One Irabina family further explained the social and economic impact of inadequate services for their child’s severe behaviours of concern with the following statement:
“Every aspect of our life as a family is affected. Socially, emotionally, financially. It is hard to maintain relationships, we rarely go out as a family due to my son’s ability to regulate, [our child’s] aggression and the fear that [our child] will abscond. We do not have a support network and have been socially isolated. Additional supports and specific foods are expensive and not covered by NDIS funding. I have been unable to obtain full time work due to my [child’s] behavioural issues and have to be on call to pick [my child] up from care if the behaviours are uncontrollable.”
Adequate and appropriate services for severe and complex needs for families of individuals with ASD requires evidence-based assessment and treatment planning.
High quality services alter the trajectory for families and individuals in a positive direction, allowing for improved quality of life, greater family stability, and participation in educational and community activities.
It is recommended that service providers respond to the negative impact of behaviours of concern with a comprehensive approach to support individuals in their home, school, and community settings
Term of Reference (H):
The adequacy and efficacy of the National Disability Insurance Scheme (NDIS) for autistic people
Including (i) autism understanding within the NDIS and (iii) the ability of the NDIS to support autistic people with complex needs, including those transitioning from prison settings
The advent of the National Disability Insurance Scheme (NDIS) provides individuals with autism a unique and unprecedented opportunity to access levels of funding that directly reflects the level of reasonable and necessary supports required to improve their skills and levels of independence. (National Disability Insurance Scheme Act, 2013). This funding model is substantially different than that previously available, particularly for individuals with autism who were allocated a fixed and finite level of funding, determined not by their individual needs, but by their age and the diagnosis provided by a health practitioner.
Despite the significant improvement the NDIS represents in relation to the previously existing funding structure, it is necessary to recognise the Scheme’s significant gap in terms of systems and processes to adequately identify individuals with autism presenting with significant behaviours of concern, comprehensively evaluate their presentation, and allocate levels of funding that appropriately reflect their complex supports they require in order to meet their individual goals.
As a service provider, Irabina is concerned about the significant number of cases where NDIS participants with evident complex needs associated with significant behaviours of concern have been allocated levels of funding that are far below those required to not only support their everyday activities (NDIS Core Support Funding) but to access the level of treatment and intervention (NDIS Capacity Building Funding) that will help them learn new skills, improve their behavioural presentation and fulfil their personal potential for independence and participation.
Comparison of recent client funding plans reveals this stark discrepancy between cases with less complexity that are participating in general services and those that have behaviours of concern and more complex presentations requiring specialist services.
A sample of participants with less complex presentations received, on average 79%, of their total NDIS support for use with Capacity Building resources. A comparative sample of participants with complex presentations received, on average, 39% of total NDIS funding for Capacity Building Supports, with a range of values from 29 to 55% of funding being targeted for Capacity Building.
Participants with Less Complex Presentations:
79% for use with Capacity Building resources
Participants with Complex Presentations:
39% for use with Capacity Building resources
Participants with complex needs are unable to obtain an adequate amount of funding for intervention that at least matches those with less complex needs. Families with complex and severe behaviours are thereby at a significant disadvantage.
Term of Reference (H) Continued:
It has been the experience of many of our participants and their families that the level of complexity of their behavioural presentation is not adequately recognised by the NDIS representative who first meets them. Currently, Local Area Coordinators (LAC) and NDIS planners are not sufficiently trained in evaluating individuals with autism, particularly those with complex needs. These representatives are provided with minimal training and asked to rely on prescriptive assessment tools and protocols (i.e. PEDI-CAT) which is wholly inadequate to assess the complex needs of individuals presenting with severe behaviours of concern.
Furthermore, this lack of training for planners and LACs, combined with the absence of appropriate assessment tool that may inform their decision-making process results in the questionable reliance on personal experience or pre-conceived ideas to not only determine the required level of funding but, even more concerning, provide advice or clinical recommendations to participants.
Due to the power differential inherent to this relationship, individuals with autism and their families are placed in a very vulnerable position where they may accept the inadequate funding they provided with due to:
- The perceived expertise of the planners and LACs,
- The fear that the allocated funding will be withdrawn if questioned, or
- The exhaustion and frustration derived from participating in a long process they have little control over.
The NDIS aims to provide participants with choice and control over the type of services and support they access. However, it is often the case that even when an autistic individual with severe behaviours of concern is allocated extensive levels of funding, they are denied the opportunity to exercise this choice and control as they are refused the desired services due to their complex behavioural presentation.
This is the result of a very concerning gap existing in the disability sector, particularly of services capable of supporting individuals with complex needs. Such services would be those staffed by highly specialised professionals and clinicians with specific qualifications and experience in behavioural intervention and support, and with the appropriate resources, facilities and training to safely provide support, assistance and ultimately treatment for those individuals that present with significant behaviours of concern.
The high level of demand for services in the disability sector, couples with the lack of capacity by providers to effectively support individuals with complex needs creates a very concerning situation where choice and control seems to reside not with the participants but with service providers.
Generalist service providers are unequipped, untrained, and often unwilling to support clients with complex behavioural presentations, as they perceive that these clients will make little to progress, will endanger and frustrate their staff, and will often require the use of costly equipment and facilities while attracting a similar or very similar hourly rate than a participant with few or no behaviours of concern. This creates a situation where there is little to no incentive for service providers to support those individuals with autism who are typically the most vulnerable due to their significant developmental delays and complex behavioural presentations.
It is recommended that financial support and additional incentives be provided to those agencies that can demonstrate the capacity to deliver best-practice, evidence-based treatment and supports to individuals with autism presenting with severe behaviours of concern
Term of Reference (I):
The development of a National Autism Strategy and its interaction with the next phase of the National Disability Strategy
This submission has provided extensive evidence regarding the negative impact that severe behaviours of concern has on individuals with neuro-developmental delays and their carers. Furthermore, this submission has discussed the significant barrier that behaviours of concern pose to access to appropriate levels of funding, services, and support.
To this day, the issue of severe behaviours of concern has been largely left out of the priority planning and implementation of initiatives to support individual with autism. The mission of the National Autism Strategy is to provide access to early diagnosis/identification, appropriate educational support, meaningful employment, and services to improve and maintain social-emotional health and well-being. Therefore, it is imperative that the identification, prevention, treatment, and life-long support of severe behaviours of concern be explicitly included as a priority item in the National Autism Strategy. Furthermore, research on the prevalence, impact, and best-practice treatment models for severe behaviours of concern should be provided with priority funding to adequately address the significant knowledge gaps that currently exist.
Irabina recommends that the impact of severe behaviours of concern be recognised and that funding for specialised research, services and support initiatives be prioritised within the National Autism Strategy.
Term of Reference (G):
The adequacy of funding for research into autism
Due to the changes in the business model brought about by the National Disability Insurance Scheme, and the pressure to run a financially viable practice that service providers experience, there are few opportunities or incentives for large service providers with access to large amounts to valuable clinical data to engage in scientific research and program development activities. This is further confounded by a lack of a national autism-specific research fund that is accessible to service providers interested in conducting applied autism research projects.
In particular, the issue of severe behaviours of concern and autism is poorly understood, and large-scale prevalence studies are required to ascertain the number of individuals with neuro-developmental delays (including autism) presenting with severe behaviours of concern, the impact of these behaviours on those around them, particularly their carers, and the experiences of these carers during their interactions with service providers, crisis response services, and governmental agencies, this informing National policies, strategies, and service offerings.
Similarly, national research on the best-practice model of care will provide valuable data on the efficacy and effectiveness of behavioural interventions in the Australian context, particularly how individuals with severe behaviours of concern can be supported through a comprehensive and coordinated approach that combines
- Intensive behavioural interventions,
- Psychoeducational training for carers and support workers,
- Medical and psychopharmacological treatment and monitoring,
- Comprehensive school-based academic support,
- Psychosocial support for parents and siblings, and
- Life-long availability of focused support during significant life events and transitions such as access to employment and others.
Lastly, longitudinal studies are required to ascertain the long-term financial impact of different supports and current models of care (“treatment as usual”) experienced by most individuals with autism presenting with severe behaviours of concern, including but not limited to hospital visits, intensive respite, relinquishment and care by secretary orders. These longitudinal studies should seek to compare these costs of inadequate “treatment as usual” to those incurred by individuals who have received recommended intensive behavioural interventions and support aimed at achieving sustained positive changes in their behavioural presentation.
These findings would be valuable in informing national policy and funding decisions with the view of decreasing the long-term financial impact of behaviours of concern for all stakeholders, including families and funding agencies.
Irabina recommends that priority funding for epidemiological, actuarial, and applied research on severe behaviours of concern be made available.
References
Anagnostou, E., Zwaigenbaum, L., Szatmari, P., Fombonne, E., Fernandez, B. A., Woodbury-Smith, M., Brian, J., Bryson, S., Smith, I. M., Drmic, I., Buchanan, J. A., Roberts, W., & Scherer, S. W. (2014). Autism spectrum disorder: advances in evidence-based practice. Canadian Medical Association Journal, 186(7), 509-519. https://doi.org/10.1503/cmaj.121756
Australian Bureau of Statistics (ABS). (2018). Disability, Ageing, and Carers, Australia: Summary of Findings. ABS cat. no. 4430.0. Canberra: ABS.
Baird, G., Douglas, H. R., & Murphy, M. S. (2011). Recognising and diagnosing autism in children and young people: Summary of NICE guidance. BMJ, 343, https://doi.org/10.1136/bmj.d6360
Buschbacher, P. W., & Fox, L. (2003) Understanding and intervening with the challenging behavior of young children with autism spectrum disorder. Language, Speech, and Hearing Services in Schools, 34(3), 217-227. https://doi.org/10.1044/0161-1461(2003/018)
Call, N. A., Parks, N. A., Reavis, A. R. (2013). Treating severe problem behavior within intensive day-treatment programs. In D. Reed, Ed., F. DiGennaro Reed, Ed., J. Luiselli, Ed.) Handbook of Crisis Intervention and Developmental Disabilities. Issues in Clinical Child Psychology (pp.367-391). Springer. https://doi.org/10.1007/978-1-4614-6531-7_21
Camarata, S. (2014). Early identification and early intervention in autism spectrum disorders: Accurate and effective? International Journal of Speech-Language Pathology, 16(1), 1-10. https://doi.org/10.3109/17549507.2013.858773
Chasson, G. S., Harris, G. E., & Neely, W. J. (2007). Cost comparison of early intensive behavioral intervention and special education for children with autism. Journal of Child and Family Studies, 16, 401-413. https://doi.org/10.1007/s10826-006-9094-1
Chiarotti, F., & Venerosi, A. (2020). Epidemiology of autism spectrum disorders: A review of worldwide prevalence estimates since 2014. Brain Sciences, 10, 274. doi:10.3390/brainsci10050274
Doehring, P., Reichow, B., Palka, T., Phillips, C., & Hagopian, L. (2014). Behavioral approaches to managing severe problem behaviors in children with autism spectrum and related developmental disorders: a descriptive analysis. Child and Adolescent Psychiatric Clinics, 23, 25-40. https://doi.org/10.1016/j.chc.2013.08.001
Donnelly, L. J., Cervantes, P. E., Okparaeke, E., Stein, C. R., Filton, B., Kuriakose, S., Havens, J., & Horwitz, S. M. (2020). Staff perceptions and implementation fidelity of an autism spectrum disorder care pathway on a child/adolescent general psychiatric inpatient service. Journal of Autism and Developmental Disorders. Online ahead of print. https://doi.org/10.1007/s10803-020-04509
Emerson, E. (2003). Prevalence of psychiatric disorders in children and adolescents with and without intellectual disability. Journal of Intellectual Disability Research, 47(1), 51-58. https://doi.org/10.1046/j.1365-2788.2003.00464.x
Filipek, P. A., Accardo, P. J., Ashwal, S., Baranek, G. T., Cook Jr., E. H., Dawson, G., Gordon, B., Gravel, J. S., Johnson, C. P., Kallen, R. J., Levy, S. E., Minshew, N. J., Ozonoff, S., Prizant, B. M., Rapin, I., Rogers, S. J., Stone, W. L., Teplin, S. W., Tuchman, R. F., & Volkmar, F. R. (2000). Practice parameter: Screening and diagnosis of autism. Neurology, 55(4):468-479. https://doi.org/10.1212/WNL.55.4.468
Fuentes, J., Herves, A., & Howlin, P. (2020). ESCAP practice guidance for autism: a summary of evidence-based recommendations for diagnosis and treatment. European Child & Adolescent Psychiatry. Online ahead of print. https://doi.org/10.1007/s00787-020-01587-4
Hagopian, L. P., Rooker, G. W., Jessel, J., & DeLeon, I. G. (2013). Initial functional analysis outcomes and modifications in pursuit of differentiation: a summary of 176 inpatient cases. Journal of applied behavior analysis, 46(1), 88-100. https://doi.org/10.1002/jaba.25
Harris, P. (1993). The nature and extent of aggressive behaviour amongst people with learning difficulties (mental handicap) in a single health district. Journal of Intellectual Disability Research, 37(3), 221-242. https://doi.org/10.1111/j.1365-2788.1993.tb01281.x
Hastings, R. P., & Brown, T. (2002). Behavior problems in children with autism, parental self-efficacy, and mental health. American Journal on Mental Retardation, 107(3), 222-232. https://doi.org/10.1352/0895-8017(2002)107<0222:BPOCWA>2.0.CO;2
Heyvaert, M., Saenen, L., Campbell, J. M., Maes, B., & Onghena, P. (2014). Efficacy of behavioral interventions for reducing problem behavior in persons with autism: an updated quantitative synthesis of single-subject research. Research in Developmental Disabilities, 35(10), 2463-2476. doi:10.1016/j.ridd.2014.06.017
Hyman, S. L., Levy, S. E., Myers, S. M. (2020). AAP Council on Children with Disabilities, Section on Developmental and Behavioural Pediatrics: Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics, 145. doi: 1542/peds.2019-3447
Kalb, L. G., Stuart, E. A., Freedman, B., Zablotsky, B., & Vasa, R. (2012). Psychiatric-related emergency department visits among children with an autism spectrum disorder. Pediatric Emergency Care, 28(12), 1269-1276. doi: 10.1097/PEC.0b013e3182767d96
Kiernan, C., & Kiernan, D. (1994). Challenging behaviour in schools for pupils with severe learning difficulties. Mental Handicap Research, 7(3). https://doi.org/10.1111/j.1468-3148.1994.tb00126.x
Koegel, L. K., Koegel, R. L., Ashbaugh, K., & Bradshaw, J. (2014). The importance of early identification and intervention for children with or at risk for autism spectrum disorders. International Journal of Speech Language Pathology, 16(1), 50-56. doi:10.3109/17549507.2013.861511
Kurtz, P. F., Leoni, M., & Hagopian, L. P. (2020). Behavioral approaches to assessment and early intervention for severe problem behavior in intellectual and developmental disabilities. Pediatric Clinics of North America, 67, 499-511. doi:10.1016/j.pcl.2020.02.005
References (Continued)
Landa, R. (2007). Early communication development and intervention for children with Autism. Mental Retardation and Developmental Disabilities Research Reviews, 13(1), 16-25. https://doi.org/10.1002/mrdd.20134
Lang, T. B., Hancock, & N. N. Singh (Eds.). (2016). Evidence-based practices in behavioral health. Early intervention for young children with autism spectrum disorder. Springer International Publishing.
Liao, X., & Li, Y. (2020). Economic burdens on parents of children with autism: A literature review. CNS Spectrums, 25(4), 468-474. doi:10.1017/S1092852919001512
Matson, J. L., & Minshawi, N. F. (2006). Early intervention for autism spectrum disorders: A critical analysis. Elsevier Science.
McGuire, K., Fung, L. K., Hagopian, L., Vasa, R. A., Mahajan, R., Bernal, P., Silberman, A. E., Wolfe, A., Coury, D. L., Hardan, A. Y., Veenstra-VanderWeele, J., & Whitaker, A. H. (2016). Irritability and problem behavior in autism spectrum disorder: A practice pathway for pediatric primary care. Pediatrics, 137(S2), 136-48. doi:10.1542/peds.2015-2851L
McIntyre, L. L., Blacher, J., & Baker, B. L. (2002) Behaviour/mental health problems in young adults with intellectual disability: the impact on families. Journal of Intellectual Disability Research, 46(3). https://doi.org/10.1046/j.1365-2788.2002.00371.x
Murphy, G. H., Beadle-Brown, J., Wing, L., Gould, J., Shah, A., & Holmes, N. (2005). Chronicity of challenging behaviours in people with severe intellectual disabilities and/or autism: A total population sample. Journal of Autism and Developmental Disorders, 35, 405-418. https://doi.org/10.1007/s10803-005-5030-2
Murphy, O., Healy, O., & Leader, G. (2009). Risk factors for challenging behaviors among 157 children with autism spectrum disorder in Ireland. Research in Autism Spectrum Disorders, 3(2), 474-482. https://doi.org/10.1016/j.rasd.2008.09.008
National Disability Insurance Scheme Act, 2013. https://www.legislation.gov.au/Details/C2013A00020
Newcomb, E. T. & Hagopian, L. P. (2018). Treatment of severe problem behaviour in children with autism spectrum disorder and intellectual disabilities. International Review of Psychiatry, 30, 96-109, doi: 10.1080/09540261.2018.1435513
Plant, K. M., & Sanders, M. R. (2007). Reducing problem behavior during care-giving in families of preschool-aged children with developmental disabilities. Research in Developmental Disabilities, 28(4), 362-385. https://doi.org/10.1016/j.ridd.2006.02.009
Peters-Scheffer, N., Didden, R., Korzilius H, & Matson, J. (2012). Cost comparison of early intensive behavioral intervention and treatment as usual for children with autism spectrum disorder in The Netherlands. Research in Developmental Disabilities, 33(6):1763-1772. doi:10.1016/j.ridd.2012.04.006
Reichow, B. (2012) Overview of meta-analyses on early intensive behavioral intervention for young children with autism spectrum disorders. Journal of Autism and Developmental Disorders 42, 512-520. https://doi.org/10.1007/s10803-011-1218-9
Richman, D. M., Barnard-Brak, L., Bosch, S., Thompson, S., Grubb, L., & Abby, L. (2012). Predictors of self-injurious behaviour exhibited by individuals with autism spectrum disorder. Journal of Intellectual Disability Research, 57(5), 429-439.
Rusch, R. G., Hall, J. C., & Griffin, H. C. (1986). Abuse-provoking characteristics of institutionalized mentally retarded individuals. American Journal of Mental Deficiency, 90(6), 618–624.
Shochet, I. M., Saggers, B. R., Carrington, S. B., Orr, J. A., Wurfl, A. M., Duncan, B. M., & Smith, C. L. (2016). The cooperative research centre for living with autism (autism CRC) conceptual model to promote mental health for adolescents with ASD. Clinical Child and Family Psychology Review, 19, 94-116. https://doi.org/10.1007/s10567-016-0203-4
Sigafoos, J., Arthur, M., & O’Reilly, M. (2003). Challenging behavior and developmental disability. Whurr Publishers Ltd. http://hdl.handle.net/1959.13/29355
Walsh, C. E., Mulder, E., & Tudor, M. E. (2013). Predictors of parent stress in a sample of children with ASD: Pain, problem behavior, and parental coping. Research in Autism Spectrum Disorders 7(2), 256-264. https://doi.org/10.1016/j.rasd.2012.08.010