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+autobiographical writings of individuals with a neurodevelopmental disorder. Some researchers have compared the autobiographical writings of adults with autism with those of adults with schizophrenia (see Happé 1991, for a comparison of Grandin’s autobiographical writing with that of a female with schizophrenia), but these comparisons are limited. The selection of a suitable comparison group is also confounded by the lack of interest in works of fiction that is commonly noted in individuals with autism (Happé 1991). As this group may not read fictional works to the same degree as typical adults, this may influence the content and structure of their autobiographical writings. These difficulties mean that it is problematic to draw inferences on the typicality or atypicality of the autobiographical writings of this group, or to determine how they are similar to or different from the writings of individuals without autism. The selection of a range of appropriate comparison works is crucial for future research in this area.
+
+Another important direction for future research is to establish the degree to which the autobiographical writings of individuals with autism are the work of the individual themselves. Published autobiographical writings (in particular, life stories, memoirs, and autobiographies) are often subject to high levels of editing or rewriting by publishers, editors, or cowriters. Indeed, Temple Grandin’s autobiographical work Emergence was cowritten with a children’s writer who rewrote and formatted sections of the book and structured it to make it easier to read. This significantly limits the conclusions that can be drawn from the autobiographical text itself. Indeed, Grandin’s autobiographical writing My Experiences as an Autistic Child is markedly different to Emergence and displays several characteristics that are typical of an adult on the autism spectrum (e.g., switching between topics, failing to provide the reader with pertinent background knowledge regarding a topic). Analysis of writings that clearly delineate the text composed by individuals with autism and that inserted or changed by editors or cowriters is important for future research, as is the analysis of online writings, which tend to be solely the work of the individual with autism (without subsequent editing).
+
+Future research could also consider gender differences in the autobiographical writings of individuals with autism. Despite a higher number of males than females being diagnosed with autism, it appears that more women with autism express themselves in writing and publish their work. Future work should therefore aim to compare the autobiographical writings of males and females with autism, to ascertain whether there are similarities or differences in the expressions of these writings.
+
+A final point to note regarding the autobiographical writings of individuals with autism concerns their recall of personal experiences. Research on autobiographical memories has shown that memories of personal events are not veridical representations of the past – they are reconstructions of experiences. As such, doubts can be raised concerning the accuracy of the events and experiences referred to in the autobiographical writings of individuals with (and without) autism. This is an important factor to take into account when evaluating, and drawing inferences from, the autobiographical writings of individuals with autism (as well as the writings of typical comparison adults).
+
+Autonomic Nervous System
+Jonathan Kopel
+Texas Tech University Health Sciences Center (TTUHSC), Lubbock, TX, USA
+
+Synonyms
+Central nervous system (CNS); Peripheral nervous system (PNS)
+
+Definition
+The autonomic nervous system (ANS) coordinates the body’s fight or flight and rest and digest response through the central and peripheral nervous systems (Rees 2014). Specifically, the ANS maintains homeostasis and adapts physiolog-ical, psychological, and behavioral responses to external stressors (Klusek et al. 2015; Rees 2014). Dysfunction of the ANS increases the risk of numerous psychological disorders including panic disorder, anxiety, post-traumatic stress disorder (PTSD), and schizophrenia (Klusek et al. 2015). Several studies showed Autistic Spectrum Disorder (ASD) children revealed diminished parasympathetic response, autonomic response, and vagal tone (Benevides and Lane 2013; Järvinen et al. 2015; Klusek et al. 2015).
+
+In addition, ASD children showed hyperarousal and high sensitivity to facial expressions, particularly those with fearful, happy, or no emotion (Järvinen et al. 2015). However, the ANS dysfunctions among ASD patients occurs only during goal-directed activities and disappears under normal physiological conditions (Benevides and Lane 2013). As a result, further investigation is needed to elucidate the coordinated interactions between sympathetic and parasympathetic systems, and the behavioral and physiological differences seen in ASD patients.
+
+Autonomous Living
+▶Independent Living
+
+Autonomy
+▶Self-Advocacy
+
+Autosomal Recessive Disorder
+▶Gangliosidoses
+
+AUTS18
+▶CHD8
+
+Aventyl Hydrochloride
+▶Nortriptyline
+
+Aversive/Nonaversive Interventions
+Michael D. Powers
+The Center for Children with Special Needs, Glastonbury, CT, USA
+
+Definition
+Aversive and nonaversive interventions refer as much to a dynamic yet functional definition of both terms as to a set of intervention procedures. From a technical point of view, an aversive intervention involves the application of an aversive stimulus. This would include a noxious event that serves as a punisher when it follows behavior, one that evokes a behavior that has terminated the noxious stimulus in past circumstances, or one that functions as a reinforcer when it is removed after the occurrence of a behavior (Cooper et al. 2020). A nonaversive intervention involves the application of positive reinforcement and/or extinction contingencies as a consequence to a behavior or alteration of the intensity, duration, or magnitude of a behavior contingent upon the removal or presentation of an antecedent stimulus.
+
+Historical Background
+While treatment in autism has, over the years, had many controversies, perhaps none has been so heated as the discussion of the viability and appropriateness of aversive and nonaversive pro-cedures to treat a variety of problems common to the disorder (and to those with other neurodevelopmental disorders as well). These controversies have pitted, in somewhat of a dichotomous fashion, empirical science against social validity. The result was at once unfortunate and the stimulus for a paradigmatic shift. When in its relative infancy, the science of the experimental analysis of behavior served a very important function: to prove that even the most recalcitrant of human behaviors are subject to the laws of learning and can be improved upon. For generations of clinicians raised on the belief that change was only possible in small increments for those severely affected by autism and then only through rather drastic psychopharmacologic interventions, the opportunity to demonstrate progress in reducing self-injury, aggression, and other destructive behaviors as well as to increase prosocial, adaptive behavior was a breakthrough. Applications of more basic operant conditioning principles such as positive and negative reinforcement, extinction, and pun-ishment were tactics of choice during this period. Indeed, clinical significance was often defined only in terms of the magnitude of behavior reduc-tion (the end product) but rarely so by the means of reduction.
+
+As the 1960s progressed through to the late 1970s, however, means of intervention appropriately became a more prominent consideration. The seminal work on social valid-ity by Kazdin (1977) and Wolf (1978) reshaped the narrative around three key points: not only must the outcome of intervention be socially valid but also the target of intervention (behavior to be changed) and also the means to achieve that outcome. As a construct, social validity imposes the requirement that all factors be considered before, during, and after treatment. This demand served several important functions. It posed the important question, “socially valid for whom?” Were targets, procedures, and outcomes socially valid for the client, the family, and institutionally based caregivers? Social validity also raised the question of relativity. At different points in time, for different clients, and under particular circumstances, a treatment procedure or outcome might or might not be acceptable. But very importantly, at its base, the question of social validity also raised the issue of the generalizability of behavior change. While behavior analysis had evolved very good technologies of generalization and maintenance (Horner et al. 1988), things did not always work out as planned. So-called treatment failures continued to occur, often under the contingencies of more remote or diverse (and sometimes less well-understood) events. By imposing the demand to assess for social validity, interventionists had a tool to begin to predict potential func-tional relationships between change agents and the consumers of change and to begin to modify those contingencies that might interfere with long-term maintenance and generalization.
+
+Within the span of a few years, however, a number of flash point events occurred that sharpened the issues concerning treatment of those whose autism placed themselves, and others, at the greatest risk. Highly publicized reports of the deaths of clients in the care of otherwise well-known residential programs following the use of contingent aversive procedures (e.g., white noise) changed the conversation from one of science alone to a discussion of human dignity and the right to effective treatment. Suffice it to say that while at times mean-spirited, personal, and derogatory, the power of the objectivity of science won out. Indeed, not only did the National Institutes of Health fund a number of collaborative research centers with the mandate to investigate and develop effective interventions that were non-aversive, but the NIH later convened a consensus conference (National Institutes of Health 1991) in order to issue guidelines for the use of behavior reduction procedures (including punishment strategies) when treating destructive behavior in those with developmental disabilities. The efforts of established collaborative research centers, other scientists working in basic and applied settings, and the general understanding of the effects (and negative effects) of punishment have led over the past 20 years to a highly developed, evolving, evidence-based technology of behavior change based upon the use of antecedent and consequent control procedures that do not involve the use of aversive stimuli. To be certain, the controversy has not ended entirely, as those who empirically demonstrate the effective use of punishment pro-cedures as a component of a comprehensive treatment package would argue (Axelrod 1990). But, as importantly, the exceptional science being developed to understand the often complex func-tional motivators behind severe behavior con-tinues as well and is especially visible in the efforts of those promoting positive behavior sup-port initiatives in public schools.
+
+Rationale or Underlying Theory
+Given the extensive research base for both aversive and nonaversive interventions, it is reasonable to conclude that considerations about each are evidence-based. The important consider-ations, however, lie in the issue of negative effects and generalizability of effects. Both sets of pro-cedures are based on the principles of operant conditioning earlier described by Skinner, with many decades of subsequent and substantive empirical extensions of that work. What has evolved over the years is a toolbox of intervention strategies, many working best as part of multi-component procedures. While there may well be occasions for which a punishment procedure – in combination with positive reinforcement proce-dures designed to increase functionally equiva-lent, alternative prosocial behavior – is the least restrictive intervention option, intervention based on punishment alone is rarely advised. Nonaversive interventions are broadly orga-nized around antecedent strategies (those that occur before the problematic behavior is emitted), with the intention of altering the stimulus control and reinforcing value of the existing antecedent “triggers” for the behavior. Consequent proce-dures are those delivered after behavior has been demonstrated. They can include reinforcement-based procedures, extinction, and variants of interruption and redirection. In contrast, aversive interventions involve the application of an aver-sive or unpleasant stimulus immediately follow-ing the problem behavior, designed to discourage future occurrence of the behavior. In all cases, however, whether an intervention is aversive or reinforcing to a client is a functional question. If the application of a stimulus immediately following demonstration of a specific behavior increases the probability of that behavior occur-ring, the stimulus was reinforcing. If presentation of the stimulus immediately following the behavior reduces the likelihood of behavior reoccurrence, then the stimulus was aversive. Referring back to the discussion of social validity earlier, what is aversive to one person may be reinforcing to another. The only solution is to assess functionally before and during treatment implementation. Ultimately, the rationale about which interven-tion strategies to employ in a particular case is a functional one, clarified by a thorough functional behavior assessment/analysis and subjected to rigorous outcome evaluation. In the final analysis, intervention must be effective, that is, it must be successful in its outcome and have minimal or no negative effects associated with it. Treatment strategies that are socially valid and empirically based will best serve the interests of persons with autism and related neurodevelopmental disorders.
+
+Goals and Objectives
+The selection of intervention strategies is based on behavioral function, not form. Function can be described in several ways. For example, behavior can serve to access positive reinforcement in the form of social attention or access to preferred materials. The behavior can be functionally rein-forced by its ability to terminate an aversive or unpleasant event (negative reinforcement). These functions can be observed in the presence of others or when the client is alone. In this latter case, we suggest that the behavior can be maintained by the positive or negative reinforcing contingencies of sensory stimuli impinging on the client. In all cases, the stated goal of intervention should be to improve the behavior of the person with autism by teaching appropriate replacement skills while simultaneously reducing or eliminating the behavior that is problematic or that interferes with more adaptive functioning. Specific procedures to accomplish this are discussed below.
+
+Treatment Participants
+Treatment procedures for any given client are selected based upon the results of the functional assessment/analysis but may be modified to address the specific target behaviors selected, the learning history (history of reinforcement) of the client with the particular behavior, and the avail-ability of resources and competencies of intervenors. Consideration is also given to such factors as severity, duration, pervasiveness, and frequency of the target behavior when determining priorities for intervention.
+
+Treatment Procedures
+Treatment procedures for nonaversive interven-tions can be broadly divided into two groups: antecedent interventions that occur prior to the behavior and consequent procedures that are implemented after the behavior has been emitted. Both seek to reduce the likelihood of behavioral expression in the future by emphasizing the use of positive reinforcement procedures as a key or collateral component of the treatment package. Most importantly, all treatment should be preceded by a thorough functional behavior assessment or analysis in order to determine which stimuli in the environment exert control over the target behavior. Antecedent procedures include errorless learn-ing, whereby the student is prompted to the cor-rect response immediately after the presentation of the request; interspersing mastered or easy tasks with difficult tasks in teaching (Weber and Thorpe 1992); the use of choice in the selection of tasks and reinforcers (Dyer et al. 1990); reducing the information-processing demands of the task or providing an alternative mode of task presenta-tion; use of a high-probability request sequence (Zuluaga and Normand 2008); functional commu-nication training (Carr and Durand 1985); stimu-lus change procedures, whereby a novel stimulus that is not an antecedent or a consequence to the behavior is interjected into a behavioral sequence, interrupting the response-reinforcer relationship (Carr et al. 1990); and environmental modifica-tions such as use of visual schedules, curriculum adjustment, etc. (Flannery and Horner 1994; Kern and Dunlap 1998). Consequent procedures with demonstrated efficacy include positive reinforcement, differen-tial reinforcement, and its variants (differential reinforcement of other, incompatible, high rates or alternative behavior); response interruption and redirection (Underwood et al. 1989); extinction (Lerman and Iwata 1996); and noncontingent reinforcement, whereby reinforcing stimuli are provided to a client independent of the client’s behavior (Carr et al. 2009). Aversive stimuli are noxious events that serve as punishers when following a behavior, evoke a behavior that has terminated the noxious stimulus in past circumstances, or function as a reinforcer when removed after the occurrence of a behavior (Cooper et al. 2020). While the function of an aversive stimulus is always to cause the cessation of a behavior, its forms are virtually limitless (Repp and Singh 1990) and have included smelling aromatic ammonia, contingent water mist to the face, the application of “white noise,” and electric shock. It is noteworthy that while the NIH consen-sus conference clearly emphasized the importance of using treatment procedures based on positive behavioral supports, it also provided clear guide-lines for the use of punishment procedures when they might be deemed clinically necessary.
+
+Efficacy Information
+The efficacy of antecedent strategies to treat behavior problems has been well documented in the research literature, and several in particular have been identified as evidence-based proce-dures (Cooper et al. 2020; Powers et al. 2011). It is important to remember, however, that the use of an antecedent (or any other) strategy does not guarantee success. Rather, the use of the proce-dure must be based on the results of the functional behavior assessment/functional analysis, must be implemented with fidelity, and must be evaluated accurately and objectively. Violation of any of these tenets can (and likely will) reduce the effi-cacy and efficiency of the correctly chosen treat-ment strategy.
+
+Outcome Measurement
+Objective and reliable measurement of treatment effects and outcomes is essential to the correct use of any procedure designed to increase desir-able behavior or to reduce problem behavior. Fortunately, the use of single-subject experi-mental designs (SSEDs) has predominated in the literature (Kazdin 1982), establishing a robust arsenal of potential designs for outcome measure-ment. When well used, SSEDs provide excellent internal and external validity, support the devel-opment of reliable observations, and ultimately contribute to the serial replication of findings. To this latter point, the aggregation of large numbers of individual studies, each with a small subject pool, can generate strong findings of efficacy (Reichow et al. 2011).
+
+Qualifications of Treatment Providers
+While certainly effective when used correctly, the technology of intervention requires training in the principles and strategies of applied behavior analysis. Obviously, with behavior problems of greater significance (e.g., where personal safety of the client or others is at risk and where health status can/may be compromised), the demand for greater levels of sophistication and competency is critical. At a minimum, supervi-sion of assessment and treatment protocols by an individual with Board Certification as a Behavior Analyst (BCBA) or by a clinician with equivalent training and experience would be appropriate. In cases where more extraordinary interventions are necessary or where the risk of harm is greater, it is strongly advisable to have all clinical aspects peer reviewed and vetted by a human rights committee.
+
+AVLT
+▶Rey Auditory Verbal Learning Test (Rey AVLT)
+
+Avoidant Personality Disorder
+Daniel F. Becker
+Department of Psychiatry, University of California, San Francisco, USA
+
+Synonyms
+Anxious Personality Disorder
+
+Short Description or Definition
+In the most recent DSM revision, the DSM, Fifth Edition (DSM-5; American Psychiatric Association [APA] 2013), AVPD is classified as a personality disorder and is described as “a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative eval-uation that begins by early adulthood and is pre-sent in a variety of contexts” (p. 673). As for all personality disorders, “this pattern of inner expe-rience and behavior. . . deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible,. . . is stable over time, and leads to distress or impairment” (p. 645).
+
+Categorization
+As indicated above, AVPD is classified within the Personality Disorders section in DSM-5. Based largely on an earlier, theoretically derived con-struct (Millon 1981), AVPD first appeared as a diagnostic entity in DSM, Third Edition (DSM-III; APA 1980). This category grew from a trifur-cation of the DSM, Second Edition (DSM-II; APA 1968) diagnosis, schizoid personality – which described individuals with “shyness, over-sensitivity, seclusiveness, avoidance of close or competitive relationships, and often eccentricity” (p. 42). The broader DSM-II schizoid personality construct was, in DSM-III, subdivided into a more narrowly defined schizoid personality disorder, as well as schizotypal and avoidant personality disorders. Schizotypal personality disorder was thought to describe those individuals who had previously been diagnosed with borderline schizophrenia and encompassed the eccentricity noted in the DSM-II description. The distinction between DSM-III avoidant and schizoid personal-ity disorders was construed as centering on whether or not the individual had the motivation and capacity for emotional involvement with others (APA 1980; Millon 1981). Beginning with DSM-III, personality disorders were placed on axis II within a recommended “multiaxial” approach to psychiatric diagnosis; axis II encompassed specific developmental dis-orders as well as personality disorders and was felt to be useful in ensuring that “consideration is given to the possible presence of disorders that are frequently overlooked when attention is directly toward the usually more florid Axis I disorder” (p. 23). Beginning with DSM, Third Edition, Revised (DSM-III-R; APA 1987), AVPD was placed in the cluster C subcategory of per-sonality disorders, which are characterized by “anxious or fearful” (p. 337) clinical presenta-tions. DSM-III-R aligned AVPD with the clinical concept of “phobic character” (p. 429) and no longer suggested that it needed to be mutually exclusive with schizoid personality disorder. In DSM, Fourth Edition (DSM-IV, APA 1994), AVPD remained in cluster C, along with depen-dent and obsessive-compulsive personality disor-ders, as it does now in DSM-5. It is worth noting, however, that the multiaxial system has been eliminated in the current diagnostic manual – and personality disorders are now classified alongside all other relevant diagnoses. Although initially formulated in DSM-III as a monothetic criterion set – requiring, for the diag-nosis, all five possible symptom criteria – subse-quent revisions have constructed AVPD as a polythetic set, requiring any four of seven possi-ble criteria. Each successive revision – from DSM-III to DSM-III-R, and from DSM-III-R to DSM-IV – involved adding, deleting, and rewording various criteria. These changes have been based, in part, on empirical evidence (Baillie and Lampe 1998; Becker et al. 2009; Grilo 2004; Hummelen et al. 2006). No further changes were made to the AVPD criteria in the transition from DSM-IV to DSM-5.
+
+Epidemiology
+Investigations in clinical samples have shown AVPD to be among the most frequently diagnosed personality disorders (Alnæs and Torgersen 1988; Stuart et al. 1998). Although DSM-III and DSM-III-R had indicated only that AVPD is “apparently common” (APA 1980, p. 323, 1987, p. 352) in the general population, and DSM-IV stated that the general prevalence of this disorder is between 0.5% and 1.0% (APA 1994), DSM-5 cited a prev-alence of 2.4% (APA 2013). However, two large, community-based studies – using DSM-III-R (Torgersen et al. 2001) and DSM-IV (Ekselius et al. 2001) criteria – both yielded much higher rates of 5.0% and 6.6%, respectively. In the former study, AVPD was more prevalent than any other personality disorder; in the latter study, it was the second most prevalent among these disorders. Ekselius et al. (2001) observed gener-ally that individuals with personality disorders more often were younger, were students or unem-ployed, received psychiatric treatment, and lacked social supports.
+
+Natural History, Prognostic Factors, and Outcomes
+Unfortunately, relatively few studies have directly examined AVPD (Alden et al. 2002). Instead, most have considered AVPD along with other personality disorders – in the service of under-standing personality pathology more broadly or within the context of studying the effects of comorbid AVPD on axis I psychiatric disorders. As a result, relatively little is known about the natural history and progression of AVPD. DSM-5 (APA 2013) notes that avoidance often begins in childhood with shyness – but that, while shyness in most individuals dissipates with age, those who progress to develop AVPD will often become increasingly shy and avoidant during adolescence and young adulthood. Evalu-ation of the childhood antecedents of AVPD has shown that adults with AVPD – in relation to relevant clinical comparison groups – report poorer athletic performance during childhood and adolescence, less involvement in hobby activ-ities during adolescence, and diminished adoles-cent popularity (Rettew et al. 2003). Personality disorder stability has been shown, in general, to be modest; for AVPD, 2-year remis-sion rates as high as 50% have been reported by the Collaborative Longitudinal Personality Disor-ders Study (Grilo et al. 2004). These investigators have also suggested that personality disorders are hybrids of traits and symptomatic behaviors, with the former being more stable. The interaction of these elements over time helps to determine diag-nostic stability. For AVPD, the trait-like criteria – which are the most prevalent and stable – include regarding oneself as socially inept, feeling inade-quate compared to others, and wanting evidence of being liked before making social contact (McGlashan et al. 2005). These observations sug-gest that the course, persistence, and severity of AVPD – as for all personality disorders – depend upon an interaction of personality traits and the individual’s behavioral adaptations to these traits (Lilienfeld 2005). The functional consequences of AVPD are generally significant – having a more profound effect on psychosocial adaptation than, for instance, major depression (Skodol et al. 2002).
+
+Clinical Expression and Psychopathology
+In a seminal description of the AVPD construct, Millon (1981) describes four levels of clinical data that may help in the diagnosis: (1) behavioral features (e.g., shyness or timidness, apprehensive-ness or guardedness, touchiness, evasiveness, restraint of emotional expression, and physical underactivity with periodic bursts of fidgeting); (2) self-descriptions or complaints (e.g., feeling anxious or ill-at-ease, viewing others as critical or humiliating, and uncertainty about one’s self-worth); (3) interpersonal coping style (e.g., antic-ipation of censure and derision, minimizing involvements that might reactivate or duplicate past humiliations, and diminishing the importance of interpersonal relationships); and (4) inferred intrapsychic dynamics (e.g., conflict between mis-trust and the desire for affection, tension between derogation by others and self-deprecation, and tension between the surrounding distress and the emptiness within). As noted above, DSM-5 (APA 2013) requires four of seven possible diagnostic criteria:
+*   Avoids occupational activities that involve sig-nificant interpersonal contact, because of fears of criticism, disapproval, or rejection.
+*   Is unwilling to get involved with people unless certain of being liked.
+*   Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
+*   Is preoccupied with being criticized or rejected in social situations.
+*   Is inhibited in new interpersonal situations because of feelings of inadequacy.
+*   Views self as socially inept, personally unap-pealing, or inferior to others.
+*   Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
+Given the polythetic nature of this and other DSM-5 personality disorder constructs, psycho-metric studies – especially those demonstrating a simple factor structure and good internal consis-tency – have played a key role in establishing construct validity of AVPD. Overall, such studies have demonstrated high internal consistency and a unidimensional structure for the AVPD criterion set adopted in DSM-IV and maintained in DSM-5 (Becker et al. 2009; Grilo 2004; Hummelen et al. 2006).
+
+Evaluation and Differential Diagnosis
+Although few data exist regarding the diagnostic process as it relates to AVPD, some evidence has been offered with regard to other personality disorders (Zimmerman and Mattia 1999) or to personality disorders more generally (Zimmerman 1994). Such disorders tend to be diagnosed relatively infrequently within the clinical interview process as compared to when semistructured diagnostic interviews are utilized (Zimmerman and Mattia 1999). This may be due to a general inattention to personality disorder in many clinical settings – or, perhaps, to the polythetic nature of these diagnoses. Although it is therefore preferable that a semistructured diagnostic interview be used in evaluating patients for personality disorders, there is con-siderable variability among such instruments. Another concern about the assessment process is that the diagnosis of personality disorders is likely to be biased by the patient’s acute clinical state (Zimmerman 1994). With regard to differential diagnosis, consider-ation should be given especially to social anxiety disorder (social phobia), which is classified as an anxiety disorder in DSM-5. Its essential feature is “a marked. . . fear or anxiety of social situations in which the individual may be scrutinized by others” (APA 2013, p. 203); social anxiety disorder is therefore phenomenologically similar to AVPD. Indeed, genetic studies have suggested that there is a common genetic vulnerability underlying both disorders (Reichborn-Kjennerud et al. 2010). Consideration should be given as well to agoraphobia, which is another DSM-5 (APA 2013) anxiety disorder characterized by avoid-ance. Finally, with regard to differential diagnosis, some other personality disorders should be considered. These include the other cluster C dis-orders, characterized by anxiety and fearfulness – especially dependent personality disorder, which can similarly be marked by feelings of inade-quacy, sensitivity to criticism, and need for reas-surance – as well as the phenomenologically reminiscent, but somewhat more disabling, cluster A conditions: schizoid, schizotypal, and paranoid personality disorders (APA 2013).
+
+Treatment
+Studies have shown that psychotherapeutic inter-vention is the treatment of choice for personality disorders in general – and that this conclusion holds specifically, as well, for AVPD (Verheul and Herbrink 2007). In particular, psychodynamic and cognitive-behavioral therapies have proven effec-tive – especially as individual outpatient modalities but also in group settings and within structured treatment contexts. There is less evidence in support of pharmacotherapeutic intervention, although some have suggested treatment with antidepressant medications – such as selective serotonin reuptake inhibitors – based, in part, on the potential relation-ship between AVPD and social anxiety disorder (Deltito and Stam 1989; Kapfhammer and Hippius 1998; Ripoll et al. 2011).
+
+AXCAM
+▶CNTN4: Contactin 4
+
+Ayres, A. Jean
+Winifred Schultz-Krohn
+Department of Occupational Therapy, San José State University, San José, CA, USA
+
+Name and Degrees
+A. Jean Ayres, PhD, OTR, FAOTA.
+Graduated with a BA in Occupational Therapy from University of Southern California in 1945.
+Graduated with an MA in Occupational Therapy from University of Southern California in 1954.
+Graduated with a PhD in Educational Psychology from University of Southern California in 1961.
+
+Major Appointments (Institution, Location, Dates)
+Faculty member in the Department of Occupa-tional Therapy at the University of Southern California (USC) from 1955 to 1964.
+Professor in the Department of Special Education at the USC from 1966 to 1977.
+Adjunct faculty member in the Department of Occupational Therapy at USC from 1976 to 1984 while running her clinic devoted to serv-ing children with sensory integrative disorders.
+
+Major Honors and Awards
+Awarded Fellow of the American Occupational Therapy Association (FAOTA).
+Awarded the Eleanor Clark Slagle lectureship in 1963.
+Received the highest honor from the American Occupational Therapy Association in 1965, the Award of Merit.
+Named as one of the Outstanding Educators of America in 1971.
+Charter member of the American Occupational Therapy Association Academy of Research.
+Honored by the American Occupational Therapy Association in 1988 with the initiation of the award entitled the A. Jean Ayres Award for Theory Development and Application.
+
+Landmark Clinical, Scientific, and Professional Contributions
+Dr. A. Jean Ayres originated the Ayres Sensory Integration theory. She developed the theory into principles of intervention and assessment instru-ments including the Southern California Sensory Integration Tests (SCSIT) and then revised this instrument as the Sensory Integration and Praxis Tests (SIPT). As an occupational therapist, she introduced the profession to this client-centered, neuroscience-based theory and practice approach to support children with sensory integration dis-orders/sensory processing disorders.
+
+Short Biography
+Dr. A. Jean Ayres was born in 1920 in Visalia, CA, and reportedly had challenges learning as a young child, particularly processing various types of sensory information. She attended the University of Southern California and successfully com-pleted her BA in Occupational Therapy in 1945, her MA in Occupational Therapy in 1954, and her PhD in Educational Psychology in 1961. She completed her postdoctoral training at University of California, Los Angeles (UCLA), Brain Research Institute working with the leading neu-rophysiologists at that time. Her clinical skills in occupational therapy, with a foundation in the engagement in purposeful activity, and her neuro-science training provided her with the unique perspective to understand how the nervous system can influence functional behaviors. Dr. Ayres had a long history in academia and was a faculty member in the Department of Occu-pational Therapy at the University of Southern California (USC) from 1955 to 1964. She then was a professor in the Department of Special Education at the USC from 1966 to 1977. She returned as an adjunct faculty member in the Department of Occupational Therapy at USC from 1976 to 1984 while running her clinic devoted to serving children with sensory integra-tive disorders. Dr. Ayres’ work as an occupational therapist with children who had learning disabilities and sensory processing challenges served as the impetus for her conceptualization of sensory integrative dysfunc-tions. She encountered individuals who would com-plain of how painful it was to have their hair brushed or to wear specific fabrics. This furthered her research endeavors in the area of sensory integration dysfunction and theory development. Her develop-ment of the theory of sensory integration expanded, and her numerous publications, books, and app-roximately 50 scholarly articles provided further evidence of this phenomenon. As a clinician, researcher, and academic, Dr. Ayres recognized the need to establish a mechanism to identify sensory integrative dysfunction and link theory to practice. She developed the Southern California Sensory Integration Tests (SCSIT) in 1972 with intensive training courses on theory, test administration, and interpretation seminars. As the research and theory developed further, Dr. Ayres revised the assessment tool and the Sensory Integration and Praxis Test was published in 1989. As an occupational therapist, Dr. Ayres sought to support children and provide intervention directed not only to fostering improved functional skills but to develop an explanation regarding the challenges faced by children with sensory integra-tive disorders. Her scholarship, clinical expertise, and dedication were recognized in several arenas. She was awarded the prestigious Eleanor Clark Sagle lectureship in 1963 by the American Occu-pational Therapy Association. In her address, she described the theory and practice of sensory inte-gration and how this unique perspective supports participation in everyday tasks. Her substantial contributions to advance the profession of occu-pational therapy were further recognized when she received the Award of Merit in 1965. This is the highest honor awarded by the American Occupational Therapy Association. In 1971, Dr. A. Jean Ayres was named as one of the Out-standing Educators of America. Dr. Ayres was a charter member of the Academy of Research of the American Foundation of Occupational Ther-apy, and in 1988, the A. Jean Ayres Award for Theory Development and Application was established in her honor by the American Foun-dation of Occupational Therapy. Dr. A. Jean Ayres married Franklin Baker in 1969. She died on December 16, 1988, from com-plications of cancer. Franklin Baker died on September 2, 1989.
+
+Azaleptin
+▶Clozapine
+
+Babbling
+Kelly Macy
+Department of Communication Sciences, The University of Vermont, Burlington, VT, USA
+
+Definition
+Babbling can be defined as a type of prelinguistic, non-cry vocalization, which typically emerges by 6 or 7 months of age with repetition of the same consonant vowel (CV) syllable (“ba ba”) (Johnson 2008; Paul 2007). This can also be referred to as canonical babbling (Oller et al. 1998) or reduplicative babbling and is an impor-tant part of the developmental process of emerg-ing speech and language. Utterances produced with full stop consonants such as /p/, /b/, /t/, and /d/ and vowels are most common at this stage, resulting in utterances such as /baba/ and /dIdI/ (“dee dee”). Variegated babbling, where succes-sive syllables are not identical, begins to appear between 6 and 10 months of age (Paul 2007; Proctor 1989). This consists of a variety of CV and consonant-vowel-consonant (CVC) syllables that are not identical (“pa ta”). By the end of the first year, babbling should begin to imitate the intonation and prosody of adult speech. This is also referred to as jargon babble (Paul 2007).
+
+Historical Background
+Research findings from the past several decades on the nature of babbling have documented a shift in the scientific and clinical evidence regarding the connection between babbling and speech and language acquisition. Early literature reported a weak relationship between babbling and early speech development (e.g., Jakobson 1941; Lenneberg 1967). It was not viewed as being composed of linguistic units but rather a biome-chanical action where the infant lacks control over the sounds produced. This view, known as the motoric hypothesis, asserts that babbling is just a by-product of motor development. There was also a common misconception that babbling ended prior to the emergence of first words. In recent decades, however, there has been a shift to a linguistic hypothesis, which maintains that bab-bling has a neurolinguistic foundation and there is a continuity between babbling and early speech forms (Petitto et al. 2000; Vihman et al. 1986). This shift in opinion is based on a strong body of research suggesting that babble and speech share phonological characteristics within target lan-guages and within individual children (Whitehurst et al. 1991).
+
+Current Knowledge
+Progression and presentation of babbling, as well as the acquisition and use of speech and language, can vary greatly among children with autism. It is possible for babbling and other communication milestones to develop normally in this population but then later regress. Approximately 25–30% of children with autism exhibit babbling and begin to say words but then stop speaking between the ages of 15 and 24 months (Johnson et al. 2007). This has been documented by home videos of children who were typically developing, children with early-onset autism, and children with regressive-type autism and reported in a study by Dawson and Werner (2005). They found that the regressed children used complex babbling and words significantly more often than the early-onset children did. Furthermore, the children with regressive-type autism used complex babble nearly twice as often as typical children. Certain children who present with develop-mental delays, including those with early-onset autism, may be unusually quiet and make few vocalizations. Others may produce atypical vocal-izations such as humming and grunting, and fail to exhibit the typical canonical and variegated bab-bling within the expected time frames (Johnson 2008). Lack of canonical babbling by 10 months of age has been shown to predict delays in lan-guage development in the second year of life (Oller et al. 1998). Current research with infants who are typically developing and those with developmental delays has supported the continu-ity between babbling and its relationship to pat-terns in early speech (Davis and MacNeilage 1995; Mitchell 1997). Typically developing infants exhibit a back-and-forth type pattern of babbling and apparent listening that is coordinated with the caregiver’s speech and is similar to the conversational turn-taking that is used by older children (Johnson 2008). Children with autism may continue to vocalize as if they are not aware of the caregiver’s speech, with overlapping vocalizations and lack of eye contact. Parents may report that their child does not seem to recognize their voice or notice when they enter or leave the room. At the jargon babble stage near 1 year of age, they may lack inflection and prosody that is common by this stage. Since differences and delays in babbling are frequently found in children with autism, an anal-ysis of the child’s pre-speech vocalizations by a speech-language pathologist may help to identify children who are at risk (Mitchell 1997). Children who exhibit a loss of babbling should also be referred for an evaluation, as this is a serious red flag. Hearing loss, delayed motor development, and lack of social interactions may also contribute to delays in babbling. For children who were born prematurely, corrected gestational age (CGA) should be used to compare early developmental milestones related to babbling. A pediatrician can screen children for speech and language delays and may recommend further evaluation by a specialist, such as a speech-language pathologist. Proctor (1989) and Mitchell (1997) have provided instruments and guidelines for assessing vocal development of infants. Stan-dardized evaluation tools, such as the Communica-tion and Symbolic Behavior Scales Developmental Profile (Wetherby and Prizant 1993), and criterion-referenced assessments such as the Rossetti Infant and Toddler Language Scale (Rossetti 2006) can also be utilized to assess language in the pre-linguistic period. For children who do not follow the expected progression of babbling and demonstrate a delay in speech and language development, early inter-vention which is specifically tailored to the indi-vidual, targets behavior and communication, and involves the parents or primary caregivers is the best treatment. Typically, a speech-language pathologist implements this intervention.
+
+Future Directions
+Many children who are later diagnosed with autism first present to their pediatrician with delays and differences in speech and language development (Johnson 2008). Still, autism is not typically diagnosed until about 3–5 years of age. Research has shown that early intervention by 2–3 years of age results in more positive outcomes for children with autism (Osterling and Dawson 1994). Since language and communication impairments are part of the diagnostic criteria for autism, and babbling is one of the earliest devel-opmental communication milestones which has been shown to be an important initial phase of speech production ability, lack of babbling by the end of the first year or regression of early speech skills should be recognized as a red flag. More studies on the different patterns and progressions of babbling in children with autism spectrum dis-orders would help professionals to better under-stand the link with later speech and language development and help to support earlier identifi-cation of children who may be at risk.
+
+Babysitter Training Guide for Families with Individuals with ASD
+Kimberly M. Bean1, Karen Meers2, Barbara A. Cook3 and Ruth Eren2
+1Department of Special Education, Center of Excellence on Autism Spectrum Disorders, Southern Connecticut State University, New Haven, CT, USA
+2Center of Excellence on Autism Spectrum Disorders, Southern Connecticut State University, New Haven, CT, USA
+3Department of Communication Disorders, Center of Excellence on Autism Spectrum Disorders, Southern Connecticut State University, New Haven, CT, USA
+
+Synonyms
+Caregiver training program
+
+Definition
+A training program with supplemental informa-tional materials has been developed with strate-gies to support short-term care for individuals with autism spectrum disorders (ASD). This pro-gram, entitled Sit for Autism, was originally designed to inform babysitters by increasing their understanding of young children with ASD and how to best support their needs. However, as the training program began to be implemented, the trainers determined that birth parents, foster parents, grandparents, and other caregivers can benefit from the information presented. These diverse caregivers could then use the tools pro-vided to assist babysitters in caring for their children with ASD. This entry includes a general description of the program and next steps for implementation. The Sit for Autism 2-h training session includes delivery of factual-based information and hands-on activities. In the initial portion of the training, a PowerPoint presentation is used to share foundational content, including the definition of ASD, strengths of children with ASD, and com-mon social, communication, and behavior charac-teristics of individuals with ASD. Key theories [Theory of Mind (Baron-Cohen 1995)] and chal-lenges exhibited in the realms of behavior and social communication are explored through con-tent and active engagement of the participants. Along with related content about ASD, targeted evidence-based practices (EBPs) (Wong et al. 2013) are defined and modeled, and a detailed babysitter preparation packet is also provided. Suggestions for implementing the target EBPs in the home and/or community setting are discussed and applied to scenarios presented by the trainer and participants. Opportunities for the partici-pants to reflect on their personal experiences, ask questions, share strategies, and actively engage in dialogue are available throughout the training. Each participant is given the opportunity to prac-tice using these tools during the training session and benefit from presenter feedback. Participants are given a “Sit Kit” containing PowerPoint with factual information and explana-tion, written instructions for use of each EBP strategy, Babysitter Sit Preparation guide booklet, and visual supports related to the presented EBPs (visual schedule options, choice board, communi-cation pages, and timer options). A visual timer and instructions on its use are included in each kit. The included “Babysitter Sit Preparation” guide booklet is to be completed by the caregiver before leaving their child as a means of sharing with the babysitter or other potential temporary caregivers ways to support and understand their child. The information presented in the guide pro-vides the caregiver with a breakdown of the child’s skills and challenges in social, communi-cation, and behavior and allows for personaliza-tion of strategies to utilize during the time of short-term care. Pages referred to as “The Sit Prep Kit” components provide the opportunity to share emergency contact information, medical information, food preferences, the child’s typical schedule, special equipment needed, the bedtime routine, adaptive areas in need of assistance, homework routine, activity preferences, and information about siblings and what the child likes to do with the siblings. The final page includes a space to write down the expected schedule of activities for the time of the babysit-ting/temporary care event. At the conclusion of the training, ten tips for success when providing short-term care to an individual with autism are reviewed. These include providing structure; being consistent; using visuals; providing warning time when an activity is over; giving short, clear directions; limiting verbal language; leaving time for the child to answer; being attentive; being under-standing and supportive; and supporting with humility. A final question and answer session concludes the training. Trainer contact informa-tion is provided to the participants for any follow-up they would like to have with the trainer. This Sit for Autism training has been conducted 55 times from 2013 through April 2019. A total of 526 participants from a variety of socioeconomic and ethnic backgrounds throughout the state of Connecticut attended the training. In an effort to expand access of the mate-rials by more families, all of the materials have been translated into Spanish. Translators to sup-port the presenters have attended several sessions, with an exclusive training session in Spanish piloted. “Sit Kits” are offered to participants in electronic format so that parents and caregivers can personalize them and use them on more than one occasion. A Train the Trainer model has been developed to begin to train other professionals in order to reach more families in the state.
+
+Bad Science
+▶Pseudoscience
+
+Balovaptan
+Zachary J. Williams1,2 and James C. McPartland3
+1Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, TN, USA
+2Yale Child Study Center, New Haven, CT, USA
+3School of Medicine, Child Study Center, Yale University, New Haven, CT, USA
+
+Synonyms
+RG7314; RO 5028442; RO-5285119
+
+Definition
+Balovaptan (previously RG7314) is an investiga-tional drug candidate developed by Hoffman-La Roche for the potential treatment of autism spec-trum disorder (ASD). It is an orally active non-peptide vasopressin receptor antagonist (vaptan) with reported selectivity for the vasopressin V1a receptor. Balovaptan is the first vaptan drug to be tested in psychiatry, and its therapeutic potential is yet unknown. Based on the results of a recent phase II clinical trial in adults with ASD (Bolognani et al. 2017), balovaptan was granted “breakthrough therapy” designation by the United States Food and Drug Administration in January 2018. The drug is currently undergoing a phase II clinical trial in children and adolescents with ASD for the alleviation of core ASD symptoms. To date, data on the safety or efficacy of balovaptan have not been published.
+
+Vasopressin, also known as antidiuretic hor-mone, is a small peptide produced in the hypo-thalamus. It is a major physiological regulator of water homeostasis, affecting urine concentration and blood volume. Vasopressin binds to three different receptors, V1a, V1b (also called V3), and V2. Activation of V1a receptors on vascular smooth muscle causes vasoconstriction, and acti-vation of V2 receptors promotes water reabsorption in the kidneys. V1a receptors are also expressed on neurons throughout the central nervous system, and vasopressin is known to act as a neuromodulator. The physiological effects of the V1b receptor are less well characterized, though V1b activation is thought to promote the release of adrenocorticotropic hormone (see ▶“Hypothalamic-Pituitary-Adrenal Axis”). The study of vaptan drugs has primarily focused on agents that antagonize renal V2 receptors (e.g., conivaptan, tolvaptan) and their ability to treat conditions characterized by hyponatremia and fluid overload (Ali et al. 2007). However, a single-dose proof-of-mechanism study testing a small-molecule V1a antagonist (RG7713) in adults with ASD has provided preliminary evi-dence that targeting this receptor improves social cognition (Umbricht et al. 2017). Thus, in addi-tion to promoting diuresis, vaptan drugs are potentially useful as therapeutics for neuropsychi-atric disorders.
+
+Though there is limited evidence supporting vasopressin system dysfunction in the pathogen-esis of ASD, both vasopressin and the related neuropeptide oxytocin (see ▶“Oxytocin”) have been implicated in the regulation of social cogni-tion and behavior (Meyer-Lindenberg et al. 2011). Oxytocin and vasopressin interact with a number of other neurotransmitter systems, and the mech-anisms by which they alter social functioning in humans have yet to be fully understood. Never-theless, the oxytocin and vasopressin systems remain feasible targets for novel therapeutics that aim to address the social-communicative symptoms of ASD (Baribeau and Anagnostou 2015). A phase I clinical trial of balovaptan was completed in 2015, testing the drug in healthy adults between 18 and 45 years of age. The phase I trial attempted to replicate previously reported effects of vasopressin administration on brain activity and functional connectivity during functional MRI tasks. Notably, this trial only included males, as the effects of oxytocin and vasopressin are thought to differ by sex. To estab-lish proof of mechanism, the study assessed the ability of balovaptan to modulate vasopressin-induced changes in brain activity. The results of the trial were not published, though the drug has continued to the next stage of testing. The most recent data on balovaptan’s effects come from the VANILLA (Vasopressin ANtago-nist to Improve sociaL communication in Autism) study, a phase II clinical trial in adult males with ASD and normal intellectual functioning, primarily investigating the compound’s safety and efficacy in this population. Results of this study were pre-sented at the 2017 International Meeting for Autism Research (Bolognani et al. 2017). A total of 223 patients were randomized to either the pla-cebo condition or 1 of 3 dosages (1.5 mg, 4 mg, 10 mg) for 12 weeks, and of those individuals, 192 (86%) completed the trial. Although the drug appeared to be safe and well-tolerated over the treatment period, there was no change in the pri-mary endpoint (caregiver reported Social Respon-siveness Scale Scores) between drug and placebo groups. However, at the 4 and 10 mg doses, signif-icant differences emerged between drug and pla-cebo on the Vineland Adaptive Behavior Scales (VABS), one of the secondary endpoints. Between baseline and the 12-week endpoint, VABS com-posite scores improved over placebo with effect sizes of 0.59 in the 4 mg group and 0.49 in the 10 mg group. Further analyses of this effect found the improvement in composite scores to be driven by the social and communication domains of the VABS. No consistent treatment effects were noted in any of the other secondary endpoints, including the Aberrant Behavior Checklist (ABC); the Repet-itive Behavior Scale-Revised (RBS-R); the State-Trait Anxiety Inventory (STAI); the Anxiety, Depression, and Mood Scale (ADAMS); and the CGI-I score. While the primary endpoint was not significant in this trial, the compound’s effect on VABS scores has caused the drug maker to alter its methods for future investigations. Currently, a sec-ond phase II trial of balovaptan (aV1ation; NCT02901431) is under way in children and ado-lescents with ASD, this time utilizing the VABS as the primary endpoint.
+
+Banophen™[OTC]
+▶Diphenhydramine
+
+Banophen™Anti-itch [OTC]
+▶Diphenhydramine
+
+Barbiturates
+▶Sedative Hypnotic Drugs
+
+Barnes Akathisia Scale
+Wouter Staal
+Neuroscience, Radboud University Nijmegen Medical Centre Karakter, Nijmegen, The Netherlands
+
+Definition
+The Barnes Akathisia Scale is a scale designed to rate the severity of drug-induced or Parkinson disease-based akathisia. Akathisia – literally meaning not sitting – is characterized by an inner restlessness, causing constant motion of hands or feet. Symptoms of akathisia can persist for years, even after discontinuing the precipitat-ing drug. The assessment of akathisia with the Barnes Akathisia Scale includes objective and subjective questions.
+
+Barriers and Facilitators that Prevent and Enable Physical Healthcare Services Access for Autistic Adults
+David Mason1, Barry Ingham2 and Jeremy Parr1,3
+1Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
+2Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle, UK
+3Sir James Spence Institute, Institute of Health and Society, Newcastle University, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
+
+Definition
+A barrier to physical healthcare access is any component of healthcare provision that negatively impacts the healthcare service access of autistic people. Conversely, facilitators are components of healthcare provision that improve the healthcare service access of autistic people. Barriers that affect the physical healthcare access of autistic people include communication, health profes-sional’s knowledge about autism, sensory sensi-tivities, and cognitive factors (Mason et al. 2019). Brief information is given below about these factors, with examples; more information is contained in the referenced papers.
+
+Autistic people’s communication style (e.g., difficulty describing symptoms, particularly those that involve abstract concepts or hyper-specific language) can be a barrier to healthcare provision (Nicolaidis et al. 2015). Moreover, some autistic people may not provide key infor-mation unless questions directly ask for this information (Bradshaw et al. 2019). But it is important to be mindful that communication involves two parties, so a clinician’s responsive-ness (or lack thereof) to alternative communica-tion styles (e.g., written notes) can act as a facilitator (or barrier) to healthcare provision (Mason et al. 2019).
+
+Autistic people report that some clinicians have limited knowledge about autism. This can lead to clinicians making assumptions about the capabilities of autistic people (e.g., that the autis-tic person is not fully competent if they attend an appointment with a friend/family member) or clinicians assuming that behavioral expressions of symptoms (e.g., pain) are a part of autism (Nicolaidis et al. 2015). This agrees with many studies which have also identified that clinicians report a lack of knowledge about, but desire to learn more about, autism (Morris et al. 2019). (Note, some data indicate that many clinicians do know the key features of autism; Unigwe et al. 2017.)
+
+Sensory sensitivities can affect multiple aspects of a healthcare visit: travel to a visit, waiting rooms, and during the visit itself. Autistic people can experience sensory issues when using busy or noisy public transport (Bradshaw et al. 2019). Waiting rooms can be problematic for autistic people due to lighting (e.g., bright fluo-rescent light) or being crowded; this may mean autistic people avoid seeking appointments if this environment cannot be avoided. Likewise, lighting during a healthcare visit may be too bright, or the walk from the waiting room to the healthcare provider’s office may be disorientating.
+
+The cognitive factors unique to each autistic person can also be a barrier to healthcare access. Due to the cognitive load of managing social presentation, or trying to process verbal informa-tion in “real time,” autistic people find it difficult to understand information from health profes-sionals (Mason et al. 2019; Raymaker et al. 2017). Moreover, prospective memory difficulties (e.g., accurately recording future appointments or remembering to take medication) can be a barrier. Therefore, autistic people may need more support in how healthcare information is disseminated (e.g., audio recordings of appointments or a clearly phrased written summary of the appoint-ment) (Mason et al. 2019).
+
+These barriers can interact. For instance, the anxiety brought about by being in a waiting room has a consequence for the subsequent healthcare appointment. An autistic person who is anxious (or exhausted from attempting to manage typical healthcare settings) may then find interacting with the healthcare provider more difficult or may find processing healthcare information, or providing information about their needs, more challenging. This means more time in the appointment will be spent on maintaining the conversation and coping with anxiety, with less time spent pro-cessing the content of the healthcare discussion. Thus, the autistic person may leave without suffi-cient knowledge about the discussion or with multiple questions that were not addressed in the appointment.
+
+Barriers to and Facilitators of Successful Early School Transitions for Children with Autism Spectrum Disorders
+Laura Fontil1, Emily Beaudoin2, Jalisa Gittens2 and Ingrid E. Sladeczek2
+1Department of Educational and Counselling Psychology, School/Applied Child Psychology, McGill University, Montreal, QC, Canada
+2McGill University, Montreal, QC, Canada
+
+Synonyms
+Early school beginnings; Successful school transition; Transition support practices
+
+Definition
+The shift from an early childhood setting (e.g., home, preschool) to elementary school can be challenging for children, their families, and their teachers. Families must adapt to important changes once children transition to school (TTS), such as increased academic and social demands, decreased family support, and more transitions throughout the school day (Rimm-Kaufman et al. 2000). This shift tends to be par-ticularly challenging for children with neurodeve-lopmental disorders, such as autism spectrum disorder (ASD). In addition to the challenges experienced by neurotypical children, the social/communication deficits and challenges adapting to change experienced by children with ASDS make the transition to a novel, social environment like school particularly problematic for children with ASDs and their families (Forest et al. 2004). Research suggests that the implementation of collaborative transition practices can facilitate the TTS for children with ASDs and their families (Fontil et al. 2019a, b). Transition support prac-tices can be defined as a series of activities that are implemented before, during, and/or after the TTS to support the child and family as they move from one educational environment to the next. Exam-ples of transition support practices include transi-tion planning meetings, school visits, and school orientations. The implementation of high-quality TTS supports (i.e., supports that are individual-ized to the child and their family’s needs and involves direct contact with families) has been correlated with positive social and academic out-comes for children.
+
+Collaboration between key stakeholders in a child’s life is essential to facilitating successful school beginnings. That is, home, the sending school (e.g., preschool, intervention center, day care), and the receiving school should be in com-munication (e.g., transition meetings, sharing infor-mation concerning the child between early childhood settings and schools) and aim to develop meaningful partnerships characterized by open communication, valuing insights provided by fam-ily members, and considering the needs and values of families. Parents of children with ASDs have reported experiencing more stress than parents of children with other developmental disabilities (DDs; Griffith et al. 2010), which could be attrib-uted to distinct characteristics that are associated with ASDs (i.e., delayed diagnosis, more behav-ioral problems, lack of reciprocity; Griffith et al. 2010). Furthermore, a common theme in the liter-ature among parents of children with ASDs is a lack of collaboration between home and school during the transition planning (Fontil et al. 2019b). Given that the TTS is often especially stressful for families with children with ASDs, mutual respect and meaningful partnerships need to be underscored and made a priority.
+
+Although collaboration is integral in facilitat-ing successful school beginnings, several other important transition support practices have been highlighted in the literature for children with and without DDs. Child classroom visits, teacher home visits, and caregiver orientation services are significant predictors of academic achieve-ment (Schulting et al. 2005). Furthermore, increasing the number of school visits (i.e., 5–7 visits), prior to the TTS, is more valuable than having the child visit the receiving school a few times (Schischka et al. 2012), and implementing a greater variety of transition practices is correlated with improved academic outcomes (Ahtola et al. 2011). Early intervention program staff, servicing children with ASDs, report using a diverse set of transition supports to facilitate elementary school entry. For example, program staff provide receiv-ing schools with information concerning a child, discuss the TTS with families, meet staff at the receiving school, encourage families to visit and meet staff at the receiving school, and hold tran-sition planning meetings (Fontil et al. 2019a).
+
+Despite the social and academic implications of implementing high-quality transition supports, several barriers impede the implementation of collaborative transition practices. Commonly cited barriers to collaborative transition support practices for families with children with ASDs include lack of time, lack of resources, insufficient school staff training, and divergent beliefs concerning the transition planning process (Fontil et al. 2019b). Furthermore, families of children with ASDs report being unsatisfied with receiving school support, lack of continuity of care between sending and receiving programs, and a lack of collaboration between home and the receiving school (Fontil et al. 2019b).
+
+The extant literature on TTS has highlighted that there are more commonalities than differ-ences when we compare transition experiences of children with ASDs to those of children with other DDs, with the exception that children with ASD have more difficulty with horizontal transi-tions (i.e., smaller transitions throughout the day; e.g., moving from classroom to playground). These smaller, daily transitions are more common in elementary schools in comparison to the pre-school environment (Fontil et al. 2019b). Addi-tionally, elementary school staff report exhibiting an insufficient amount of ASD-specific knowl-edge, which may have an impact on their capacity to successfully integrate students (Fontil et al. 2019b). Similarly, global comparisons, between countries, reveal an international shift in attention toward TTS policy and practices which are supported by the growing number of TTS studies over time (Fontil et al. 2019b). Based on the literature, systemic changes are needed to promote better TTS for children with ASD. Provided with sufficient financial support, school teachers could be provided with resources to develop their knowledge to facilitate transition practices (i.e., workshops and training on individ-uals with diverse needs, release time to visit chil-dren’s sending programs). Additionally, families and caregivers need to be supported throughout the transition process (i.e., providing information about school supports). Finally, transition support practices require involvement of all key stake-holders to facilitate collaborative transition prac-tices; this includes active engagement between families, teachers, and other professionals (i.e., occupational therapists or resource teachers). Future research should focus on evaluating the effectiveness of specific TTS supports for students with ASD. Current research investigating transi-tion supports tend to be descriptive in nature. Future research should investigate efficacy through randomized control trials. Furthermore, it is important to more clearly differentiate the needs of children with ASDs from those with other DDs at the point of school entry to facilitate a clearer understanding of the specific supports that facilitate TTS for children with ASD.
+
+Barriers to Formal Diagnosis of Autism Spectrum Disorder in Adults
+Laura Foran Lewis
+College of Nursing and Health Sciences, University of Vermont, Burlington, VT, USA
+
+Definition
+Factors that complicate the process of receiving a medical diagnosis of “autism spectrum disorder” by a qualified professional for autistic adults who were not diagnosed in childhood.
+
+Historical Background
+Known prevalence of autism in adults is approx-imately 1.1%, but this is likely underestimated (Brugha et al. 2016). Experts estimate that as many as 40% of autistics are not diagnosed in childhood (Baron-Cohen et al. 2009). Those at highest risk of being misdiagnosed or not recog-nized during childhood include females, middle-aged and older adults, and individuals with more subtle traits and without cognitive or language delays. In general, females are at a disproportionate risk of misdiagnosis, delayed diagnosis, and not receiving a diagnosis compared to males across age groups (Loomes et al. 2017). There are many theories on the causes of missed diagnosis of autism among females. Emerging evidence shows a slightly different clinical presentation of autism among females, often referred to as the female autism phenotype, which might be missed by clinicians, parents, teachers, and others looking for “classic” traits more common in males. Females may be more likely to exhibit subtle and internalized symptoms and less likely to show overt restricted interests than males (Bargiela et al. 2016; Loomes et al. 2017). “Camouflaging” is also common among females, in which individuals learn strategies to mask autistic traits and model typical social behaviors, making it more difficult to detect a diagnosis. Little is known about the impact of gender bias on diagnosing individuals who identify with a gender other than sex assigned at birth (e.g., agender, non-binary, genderqueer, transgender), but it is likely that these individuals are also at increased risk of missed diagnosis due to a reliance on male norms for the development of current diagnostic tools. Middle-aged and older adults are also at risk of missed diagnosis due to lack of awareness and understanding of autism during their childhood, particularly since the categorization of autism in the Diagnostic and Statistical Manual of Mental Disorders (DSM) has changed significantly over time. Autism did not appear in the DSM until 1980, and prior to the release of the DSM-III-R in 1987, diagnostic criteria for autism limited this label to individuals with severe symptoms and onset by age 30 months. The DSM-IV, released in 1994, was the first edition to identify autism as a “spectrum” and included the category of Asperger’s disorder for the first time, which could include individuals with more subtle traits. Many adults who grew up prior to these changes in the DSM were not diagnosed with autism because the criteria had not yet been established. In the most recent edition, the DSM-5 elimi-nated the term “Asperger’s” and categorized autism as a continuous spectrum called “autism spectrum disorders.” The latest categorization identifies traits that may appear across the lifespan and does not identify a specific window of onset, which may increase clinician’s ability to apply this diagnosis to adults meeting the criteria. However, there is growing evidence that the latest criteria are more likely than the previous categorization to exclude females, older individuals, individuals with above average intelligence, and individuals with subtle traits (Mazurek et al. 2017). Adults are increasingly becoming aware of their own autistic identity with a rise in media representation of autism, biographical accounts of diagnosis during adulthood, and online pres-ence of support groups and forums related to autism. In addition, many adults recognize their own autistic traits when their children are diag-nosed with autism. Self-diagnosis of autism is a growing phenomenon, and many individuals report they are satisfied with a self-diagnosis and confident in their autistic identity without seeking a formal diagnosis (Lewis 2016a). However, others who are self-diagnosed report recurring self-doubt about their autism status and experi-ence unresolved cyclical grief. Without a formal diagnosis, individuals are also ineligible for pro-fessional support of any kind and typically lack access to community resources. There are known benefits to obtaining a diagnosis beyond increased access to services. Individuals who are formally diagnosed report that awareness of their autistic identity was often a relief and led to a new sense of belonging, empowerment, understanding of strategies to improve quality of life, and increased self-acceptance (Crane et al. 2018; Lewis 2016b). Many autistics are unaware of their diagnosis until adulthood, and awareness of autism can significantly benefit their mental health.
+
+Current Knowledge
+Autistic adults seeking diagnosis face significant barriers, and 80% report that obtaining a formal diagnosis was difficult or not possible (Taylor and Marrable 2011). The process of obtaining a formal diagnosis typically takes years, and on average adults see five professionals before receiving a diagnosis (Jones et al. 2014; McKenzie et al. 2015). Barriers identified by adults seeking formal diagnosis include anxiety; cost; lack of access to adult specialists and limited awareness of autism by most professionals; inability to describe their symptoms; fear of not being believed or under-stood; fear of not being believed or under-stood; lack of rapport or mistrust of healthcare pro-fessionals; stigma; and complexity of the healthcare system (Crane et al. 2018; Lewis 2017; Taylor and Marrable 2011; Vogan et al. 2017). Characteristics of autism can exacerbate these barriers, creating a gap that precludes diagnosis for those with challenges not severe enough to be detected in childhood but too severe to pursue a diagnosis in adulthood. For example, deficits in social functioning often lead to social anxiety, which may prevent individuals from making an appointment with a healthcare professional due to worries about social interactions with reception-ists, clinicians, etc. Individuals may also feel anx-iety about the sensory experience of the waiting room or office that prevents them from making an appointment or following up. In addition, approximately half of autistics experience alexithymia, or difficulty identifying and verbalizing their own feelings and emotions, which may make it difficult for them to commu-nicate their symptoms adequately to a profes-sional who does not specialize in autism (Trammell et al. 2013). They may also struggle with introspection or be unable to recognize their own autistic traits. Individuals who have challenges with executive functioning, which includes tasks such as organizing, focusing, and multitasking, may have difficulty navigating the healthcare system, planning for transportation, keeping appoint-ments, or coordinating other tasks needed to pursue a diagnosis. Many individuals seeking a diagnosis of autism are also unemployed or employed part time (Happé et al. 2016), which may prohibit them from being able to maintain insurance or to afford the costs associated with evaluation and diagnosis.
+
+Fear of not being believed, being dismissed by clinicians, or being blamed for symptoms is very common among adults seeking diagnosis, partic-ularly among females (Crane et al. 2018; Lewis 2017). Adults report that they feel they are at the mercy of their clinicians for referrals as gate-keepers of diagnosis and fear that lack of clinician awareness of autism presentation in adults or in females may prevent them from receiving a diag-nosis. Many fear detrimental effects on their iden-tity formation if they are evaluated and told they do not meet criteria for a diagnosis of autism.
+
+Beyond those barriers identified by autistics, clinicians also cite significant barriers to making a diagnosis of autism in adults. Since autism is a neurodevelopmental condition, it is characterized by the presence of autistic traits in the develop-mental period. One significant barrier to clinicians making a diagnosis is the practicality of inter-viewing a parent or other reliable individual who can speak to the presence of these traits during childhood (Lai and Baron-Cohen 2015; Trammell et al. 2013). There may be limitations such as the willingness or availability of informants to meet, their ability to recall details from the individual’s early childhood, or their perception of key events compared to the individual seeking a diagnosis (e.g., what they view as culturally “typical” vs. “atypical” behavior). If a parent or childhood caregiver cannot provide this information, clinicians may opt to meet with other informants who can speak to the individual’s childhood such as an older sibling or other relatives. If no such informants are available, clinicians must rely on educational and medical records and the adult’s recollection of childhood for information on the developmental period, which may lack sufficient detail to make a diagnosis. Clinician knowledge of autism is another significant barrier to adult diagnosis. Few instru-ments exist to assist in the assessment of adults, and even fewer have validated norms for adults. While the Autism Diagnostic Observation Schedule (ADOS) module 4 is the only validated tool for adult diagnosis, this must be used with caution due to its limited sensitivity to detect symptoms in females and individuals who have learned strategies that may camouflage symptoms (Lai and Baron-Cohen 2015; Trammell et al. 2013).
+
+Adult diagnosis of autism relies heavily on clinician expertise, and few clinicians special-ize in evaluating adults for autism. Primary care providers report limited understanding and lack of training about autism in general, with three out of four clinicians rating their knowledge and skills in providing care to autistic patients as poor or fair (Zerbo et al. 2015). Diagnosis is further complicated because more than 70% of autistics have at least one co-occurring medical, psychiatric, or develop-mental condition, most often including anxiety and mood disorders (Happé et al. 2016; Lai and Baron-Cohen 2015; Trammell et al. 2013). Since many differential diagnoses have overlapping symptoms or traits, clinicians may struggle to determine whether characteristics are related to autism, a co-occurring condition, or a differential diagnosis. Making a differential diagnosis is espe-cially challenging when clinicians are missing key information about onset of traits and the developmental period. Person-environment fit and cultural norms can also significantly impact interpretation of behav-iors and traits and prevent diagnosis (Lai and Baron-Cohen 2015). That is, what is considered typical social behavior in one environment may be considered atypical in another environment. Therefore, an individual with many autistic traits but whose traits do not interfere with functioning might not meet criteria for diagnosis, while an individual with fewer autistic traits that do inter-fere with functioning might meet criteria for diagnosis. These nuances may complicate the process of determining a diagnosis in adulthood where developmental milestones are more ambiguous. Given these factors, even if the autistic indi-vidual is able to overcome the significant barriers that may prevent them from meeting with a clini-cian and accurately communicating information about their autistic traits, clinicians still might not be able to make an accurate diagnosis. For those who actually receive a diagnosis, experiences are often negative, with 40% of autistics reporting they were “very/quite dissatisfied” with the diag-nostic process (Jones et al. 2014).
+
+Future Directions
+Given the potential benefits of recognizing autism for identity building and self-acceptance, it is critical to increase access to diagnosis for those on the spectrum. The World Health Organization recommends screening all children for autism as part of routine care (World Health Organization 2018), and over time, this practice should help reduce the number of adults who were not diag-nosed in childhood. There continues to be a paucity of validated tools for screening and diagnosis of autism in adults, which is a research priority (Wigham et al. 2018). Increased attention must be paid to developing diagnostic tools for all ages that rec-ognize subtle and internalized traits that are more likely to be seen in females and individuals with-out cognitive impairment or language delays. Clinicians across practice settings also require increased training on autism. Primary care pro-viders may be the only healthcare professionals in position to detect autism in undiagnosed adults, so knowledge of common presentation is critical. There is a need for increased education in under-graduate and graduate settings for healthcare pro-fessionals to increase identification of autism and to minimize the negative experiences of those who feel that their autistic characteristics are dismissed by clinicians who lack understanding of adult presentation (Zerbo et al. 2015). All professionals must also be mindful of the significance of self-diagnosis in adults who believe they are autistic. Since such significant barriers to diagnosis exist, many adults rely on a self-diagnosis for autistic identity formation (Lewis 2016a). Dismissal of a self-diagnosis by a professional may be detrimental to self-acceptance and understanding. Professionals must be mindful of their own preconceptions about self-diagnosis and remain open to exploring the potential of an autism diagnosis in those who perceive themselves as being on the autism spec-trum even if “classic” autistic traits are absent. For those who do receive an autism diagnosis in adulthood, little to no post-diagnostic support is offered. Most individuals indicate that they would like counseling, social skills training, and access to support groups. However, as many as 77% receive no support whatsoever after diagnosis (Jones et al. 2014; Taylor and Marrable 2011), and qualitative studies indicate that individuals often feel lost and directionless and lack support after diagnosis (Crane et al. 2018; Lewis 2016b). There is a need for an effec-tive and evidence-based approach to assist adults in managing mental health challenges as well as providing practical supports and resources after diagnosis. Though formal services are limited, there are several online communities that promote positive images of autism and neurodiversity. Many adults utilize these websites to seek information and connection while working through the diagnostic process and beyond. Table 1 provides examples of some of these sites. There are many severe barriers to formal diag-nosis of autism in adulthood. Primary barriers include autistic traits themselves that prevent the individual from obtaining an assessment, lack of understanding of adult presentation of autism by clinicians, the impracticality of including infor-mants from the developmental period in assess-ment, and the lack of appropriate tools for adult diagnosis. Given the potential mental health ben-efits of being aware of autism identity, researchers and clinicians must prioritize interventions and tools that increase early screening and access to diagnosis for autistic adults.
+
+Table 1 Examples of online communities for adults with ASC
+| Community Name | URL |
+|---|---|
+| Asperger/Autism Network | https://www.aane.org/ |
+| Autism Self Advocacy Network | https://autisticadvocacy.org/ |
+| Autism Empowerment | https://www.autismempowerment.org/ |
+| Autism Self Advocacy Network | https://autisticadvocacy.org/ |
+| Reddit [Autism Subreddit] | https://www.reddit.com/r/autism/ |
+| Twainbow | https://www.twainbow.org/ |
+| Wrongplanet | https://wrongplanet.net/ |
+
+Basal Ganglia
+Youngsun T. Cho
+Yale Child Study Center, New Haven, CT, USA
+
+Synonyms
+Striatum; Sub-cortical ganglia
+
+Definition
+“Basal Ganglia” refers to a collection of sub-cortically (beneath the cortex) located nuclei in the brain. Originally, these nuclei were collec-tively identified as a conduit for information to pass from cortical association regions to motor cortex for the initiation and control of movement. Today, the function of the basal ganglia is thought to include not only the shaping of motor responses, but also the integration of emotional, motivational, and cognitive information. The inte-gration of such a wealth of information has been shown to contribute to motivated behaviors, habit formation, and motor learning. As part of these functions, the basal ganglia provides a locus of control for movement – simultaneously suppressing unwanted movement and enhancing desired movement (Mink 1996). The subcortical structures typically included as part of the basal ganglia are: caudate nucleus and putamen (collectively called the striatum), nucleus accumbens (included in the ventral stria-tum), globus pallidus (both internal (GPi) and external (GPe) segments), substantia nigra (both pars compacta (SNpc) and pars reticulata (SNpc)), and the subthalamic nucleus (Groenewegen 2003). The interconnections between the nuclei of the basal ganglia allow for this collection of regions to act as a unit (Fig. 1). Together, they allow the impulses for movement and other behaviors that originate in the cortex to be refined towards a final output and expression. The main input region of the basal ganglia is considered to be the striatum. The striatum receives cortical information that is topographically distrib-uted based on the type of information. Emotional, associative, cognitive, and motor information from the cortex uniquely arrive in specific regions of the striatum, distributed in a ventral (bottom) to dorsal (top) manner, respectively. Information from the striatum then splits into two main pathways. The “direct” pathway channels information from the striatum to either the substantia nigra or the globus pallidus interna, the two major output regions of the basal ganglia. From these regions, information is then sent to the thalamus; the thalamus sends this, now processed, information back to the cor-tex. By contrast, the “indirect” pathway passes information first from the striatum to the globus pallidus externa and subthalamic nucleus, and then to the globus pallidus interna and substantia nigra for output to the thalamus. As with the direct path-way, the information sent to the thalamus is directed back to the cortex. The indirect and direct paths have distinct neurotransmitters and receptor profiles, and together form the “cortico-basal-ganglia-thalamo-cortical loops” that contain dis-tributed emotional, motivational, associative, cog-nitive, and motor information (Alexander et al. 1986). These loops allow the impulses that origi-nate in the cortex to be refined through the basal ganglia, and then sent back to cortex for a motor response output. Abnormalities in the basal ganglia have been proposed to account for some of the symptoms of autism, including repetitive motor behaviors, decreased social interest/ability, and general motor dysfunction. The caudate nucleus, in particular, has been shown to have accelerated growth in children with autism, compared to typically developing chil-dren (Langen et al. 2014). This fits with other stud-ies demonstrating an enlarged striatum in patients with autism. In animal models of autism, abnormal-ities in striatal interneurons, the small, local neurons that are key for regulating the neurons in the striatum that project to other regions, are thought to underlie striatal pathology. Decreased anticipation and processing of social rewards, and rewards in general, along with decreased recruitment of the ventral striatum have been noted, identifying a potential mechanism for decreased sociability in autism. Given these striatal abnormalities, the ques-tion of whether motor abnormalities are primary, and the resulting symptoms of autism are merely secondary to those motor abnormalities, has been raised (Subramanian et al. 2017). Further research is needed to test this and to better understand the specific basal ganglia abnormalities in autism.
+
+BASC-2
+▶Behavior Assessment System for Children, 2nd Edition
+
+BASC-3
+▶BASC-III
+
+BASC-III
+Kimberly Ho Misiaszek
+Yale Child Study Center, New Haven, CT, USA
+
+Synonyms
+▶BASC-3
+
+Description
+The Behavior Assessment System for Children, Third Edition (BASC-3) is a multimethod, multi-dimensional system that provides a comprehen-sive assessment of behavioral and emotional functioning in children, adolescents, and young adults from ages 2 to 25 (Reynolds and Kamphaus 2015). Its multiple components (hence multimethod) can be used individually or in combination and include: The Behavioral and Emotional Screening System (BESS), Teacher Rating Scales (TRS), Parent Rating Scales (PRS), Self-Report of Personality (SRP), Structured Developmental History (SDH), Stu-dent Observation System (SOS), Behavior Inter-vention Guide, Behavioral and Emotional Skill Building Guide, Flex Monitor, and Parenting Relationship Questionnaire (PRQTM). Used together, the information yielded from the com-ponents aid in clinical diagnosis and identifying educational supports and services (Reynolds and Kamphaus 2015). Emotional and behavioral functioning specific to a certain setting or context is provided when used individually. Additionally, the BASC-3 assesses positive and negative aspects of personality and behavior, making it multidimensional in nature (Altmann et al. 2018). A detailed review of each component is pro-vided in the manual (Reynolds and Kamphaus 2015) thus only a brief description of each follows:
+*   The TRS and PRS each have three age level forms (preschool, child, and adolescent) and measure adaptive and problem behavior in the school and home setting using a four-point Likert scale ranging from Never to Almost Always.
+*   The SRP captures respondents’ feelings, behaviors, and self-perceptions and has forms for children, adolescents, and young adults (Reynolds and Kamphaus 2015).
+*   The SDH captures developmental information across a variety of domains that can aid in diagnosis and treatment.
+*   The SOS allows for a 15-min period of a stu-dent’s behavior in a classroom to be recorded and evaluated.
+The following descriptions are on the BASC-3 components that identify, monitor, and promote optimal behavioral and emotional functioning:
+*   The BESS is a quick screener that identifies behavioral and emotional problems in children and adolescents and can be filled out by teachers, parents, and students ages 8–18.
+*   The Behavior Intervention Guide is a compila-tion of evidence-based strategies for common emotional and behavioral problems that can be applied by a variety of behavioral professionals (Altmann et al. 2018).
+*   The Behavioral and Emotional Skill Building Guide provides small-group activities that pro-mote and enhance positive behavioral and emotional skills (Reynolds and Kamphaus 2015).
+*   The Flex Monitor is an Internet-based tool that allows professionals to monitor and track a customizable set of emotions or behaviors which can be compared to a nationally repre-sentative population sample, in order to mea-sure behavioral change over a period of time (Reynolds and Kamphaus 2015).
+*   The PRQ captures the parent’s perceived rela-tionship between themselves and the child, and assesses dimensions such as attachment, involvement, parenting style, stress, and school satisfaction (Reynolds and Kamphaus 2015).
+
+Historical Background
+In 1992, after seven years of development, stan-dardization, and validation, the Behavior Assess-ment System for Children (BASC) was published due to the need for a psychometrically sound and integrated assessment of child and adolescent emotions and behaviors, appropriate for multiple settings (Reynolds and Kamphaus 2015). In 2004, the BASC-2 was released and quickly became the most commonly used set of behavior rating scales in public schools in the USA and internationally (Reynolds and Kamphaus 2015). In 2015, the third edition was published, with the addition of electronic administration and scoring, improved interpretive reporting, and Flex Monitor (see above in “Description” section) (Reynolds and Kamphaus 2015).
+
+Psychometric Data
+The TRS, PRS, and SRP were designed based on a combination of theory and empirical data. Over 120 teachers, 100 parents, and 400 students were surveyed about negative and positive behaviors observed in home and classroom settings (Reynolds and Kamphaus 2015). Approximately 90 negative and 50 positive behaviors were iden-tified and compared to the BASC-2 item pool, and around 10–15 new items were written for the BASC-3 TRS, PSR, and SRP standardization forms (Reynolds and Kamphaus 2015). To ensure each domain had content that was adequate and relevant, a review of the BASC-2 forms, the newly written items, and items on the original BASC served as the basis of the standardized form items (Reynolds and Kamphaus 2015). Gen-eral norms were derived from data collected from a large and representative sample of children across the United States, while children with a diagnosis of one or more emotional or behavioral problems ages 4 through 18 comprised the clinical norms sample (Reynolds and Kamphaus 2015). The BASC-3 Manual provides evidence of reliability by reporting internal consistency, test-retest reliability, and interrater reliability for the TRS, PRS, and SRP (Reynolds and Kamphaus 2015). Overall, the scales and com-posites were found to have reliability coefficients of 0.80 and above, thus demonstrating the ability to reliably estimate behavior for diagnostic and treatment planning. Extensive validity evidence is also provided in the BASC-3 Manual for each scale including scale intercorrelations and factor analyses, correlations with other rating scales, and score profiles of groups of children with particular clinical diagnoses or educational clas-sifications (Reynolds and Kamphaus 2015). Additionally, the BASC-3 contains validity indices that allow for the detection of untruthful responding, carelessness, extreme responding, or other validity threats (Reynolds and Kamphaus 2015).
+
+Clinical Uses
+The BASC-3 and its components (TRS, PRS, SRP, SDH, and SOS) can be used in a variety of settings and thus has wide applications including aiding in clinical diagnosis, educational classifi-cation, manifestation determination, assessment of individuals with limitations of vision and hear-ing, program evaluation, forensic evaluation, and research (Reynolds and Kamphaus 2015). In regards to clinical diagnosis, the BASC-3 assesses symptoms found in the DSM-5 for dis-orders in childhood or adolescence. The rating scales are also sensitive to a variety of classroom problems, which help differentiate academic dif-ficulties from behavioral problems. They also help assess severe emotional disturbance as called for by IDEA (2004) (Reynolds and Kamphaus 2015). The BASC-3 is effective in determining the origins of behavior and can be used by experienced individuals to evaluate chil-dren with sensory impairments (Reynolds and Kamphaus 2015). Lastly, the BASC-3 has been found to be helpful in the evaluation of children’s progress in programs and/or their response to interventions when administered over multiple time points, as well as in legal or forensic settings given its psychometric properties and ability to detect dissimulation (Reynolds and Kamphaus 2015).
+
+Baseline
+Cate Kraper
+Clinical Psychology, University of Massachusetts Boston, Boston, MA, USA
+
+Definition
+An assessment of abilities that serves as an anchor for monitoring subsequent change over time when combined with follow-up assessments. A baseline assessment may occur prior to a child entering school, or, if a child is enrolled in an intervention study, prior to administering the treatment. A baseline assessment may involve more than one assessment point, to determine the stability of a behavior prior to introducing an experimental manipulation (e.g., an intervention designed to change the behavior assessed during the baseline period). Later assessments can be compared to the baseline assessment, so that symptoms or abilities may be tracked over time, and improvements or deterioration in abilities may be noted. This may be especially helpful for developmental disorders such as autism, in which the symptoms and their severity can change dramatically over time. In cases in which deterioration of skills occurs, the combination of a thorough baseline assessment and appropriate follow-up assessments can help identify specific skills that can be targeted in treat-ment. Baseline assessments might include mea-sures of language and communication, social skills, self-help skills, play, and IQ.
+
+Bayley Scales of Infants Development-II
+Amanda Steiner
+Yale Child Study Center, New Haven, CT, USA
+
+Synonyms
+Bayley-III
+
+Description
+The Bayley-III is a standardized developmental assessment that evaluates the functioning of infants and young children from 1 month to 42 months of age. It is designed to identify chil-dren with developmental delays and aid in inter-vention planning. The test assesses multiple developmental domains, including cognitive, lan-guage (both receptive and expressive), motor (both fine and gross), as well as social emotional and adaptive behavior. The cognitive, language, and motor scales are based primarily on direct assessment, whereas the social-emotional and adaptive behavior scales are caregiver question-naires. Scaled scores are provided for each sub-test, with composite scores and percentile ranks for each overall scale. Developmental age equiv-alents are also provided for cognitive, language, and motor subtests. Growth scores can also be calculated to evaluate a child’s growth over time for cognitive, language, and motor subtests.
+
+Historical Background
+The Bayley Scales of Infant Development (BSID) were first published in 1969, with revisions in 1993 (BSID-II) and 2006 (Bayley-III). In its most recent edition, the test was updated to reflect updates in the field of child development research, including information processing and preverbal intelligence. However, the Bayley-III still retains its focus on more classic themes in child develop-ment (e.g., Piaget, Vygotsky). Additionally, many items from the BSID-II were removed or changed and new items were developed.
+
+Psychometric Data
+Normative data for the cognitive, language, and motor scales was collected from 1700 children aged 1 month to 42 months (with 100 individuals in 17 separate age groups) and closely reflected the 2000 US Census in terms of parental educa-tion level, race/ethnicity, and geographic region. Only children born between 36 and 42 weeks were included. Children with mental, physical, or behavioral difficulties constituted about 10% of the total sample. The social-emotional scale was normed using 456 children, and the adaptive behavior scale included 1350 children.
+
+Clinical Uses
+The Bayley-III is designed to be used to identify children with developmental delays. It is recommended that the Bayley-III be administered by an individual with formal graduate or profes-sional training in developmental assessment. While it is possible for a psychometrician to administer the Bayley-III, test interpretation should occur by an individual with appropriate training to interpret test data.
+
+Bayley-III
+▶Bayley Scales of Infants Development-II
+
+BCaBA
+▶Board Certified Associate Behavior Analyst
+
+BCBA
+▶Board Certified Associate Behavior Analyst
+
+BCBA-D
+▶Board Certified Associate Behavior Analyst
+
+Behavior Analyst Certification Board
+Mary Jane Weiss and Samantha Russo
+Institute for Behavioral Studies, Endicott College, Beverly, MA, USA
+
+The Behavior Analyst Certification Board®, Inc. (BACB®) is a nonprofit corporation established in 1998 to meet professional credentialing needs identified by behavior analysts, governments, and consumers of behavior analysis services. The BACB’s mission is to develop, promote, and implement an international certification pro-gram for behavior analyst practitioners. The BACB has established uniform content, stan-dards, and criteria for the credentialing process that are designed to meet:
+1. The legal standards established through state, federal, and case law
+2. The accepted standards for national certifica-tion programs
+3. The “best practice” and ethical standards of the behavior analysis profession
+Prior to the creation of the BACB, no uniform standards existed for evaluating the education, training, and experience of a behavior-analytic service provider. Since its inception, the BACB has set the standards for education and training in the field of applied behavior analysis and has certified more than 25,000 individuals (as of 2017). The BACB adheres to the national standards for organizations that grant professional creden-tials. The BACB certification procedures and examination content undergo regular psychomet-ric review and validation, pursuant to a job anal-ysis survey of the profession and standards established by content experts in the field. In 2015, in order to better control experience hours, all BCBAs were required to complete and pass a supervision training curriculum. This change was also supplemented by the change in degree requirements of 2016. In order to be qual-ified to be a BCBA, the individual must hold a master’s degree in behavior analysis, psychology, or education. Other related fields, which were previously accepted by the BACB, are no longer accepted. The BACB offers four different credentials, BCBA-D, BCBA, BCaBA, and RBT. The RBT credential went into effect in 2016. With the addi-tion of the RBT credential, the BACB became the only organization in the field of behavior analysis to offer credentials at every educational level (graduate, undergraduate, and high school). The Behavior Analyst Certification Board’s BCBA, BCaBA, and RBTcredentialing programs are accredited by the National Commission for Certifying Agencies, the accreditation body of the Institute for Credentialing Excellence. The BACB is endorsed by the Association of Profes-sional Behavior Analysts, the Association for Behavior Analysis International, Division 25 (Behavior Analysis) of the American Psycholog-ical Association, and the European Association for Behaviour Analysis. The most up-to-date information on the BACB can be found at www.bacb.com.
+
+Behavior Assessment System for Children, 2nd Edition
+Felice Orlich
+Autism Psychology Services, Seattle Children’s Hospital CAC – Autism Center, Seattle, WA, USA
+
+Synonyms
+BASC-2
+
+Definition
+Acronym: BASC-2
+Author: Kamphaus, Randy W.; Reynolds, Cecil R.
+Purpose: Designed to determine behavioral and emotional functioning in children and adoles-cents in preschool through high school
+Administration time: 10–20 min (teacher: TRS and parent: PRS), 30 min (self: SRP)
+Scores: Scores/Interpretation: Tscores and per-centiles for general population and clinical populations
+Ages/grades: Ages: 2:0 through 21:11 (TRS and PRS); 6:0 through college age (SRP). English and Spanish forms are available.
+Scoring/administration programs: BASC-2 ASSIST and ASSIST-plus provide scoring, reporting, and relationship to DSM-IV-TR diag-nostic criteria. Online administration, scoring, and reporting are available for the TRS and PRS scales.
+Publisher: Pearson
+Publisher address: Pearson, 19500 Bulverde Road, San Antonio, TX 78259; Telephone: 800-627-7271; FAX: 800-632-9011; E-mail: pearsonassessments@pearson.com; Web: www.pearsonassessments.com.
+The Behavior Assessment System for Chil-dren, 2nd Edition (BASC-2) is a commonly stan-dardized set of rating scales and forms used to assess behavior in children and adolescents. The BASC-2 is normed on current US census popula-tion characteristics. Specific norms are not avail-able for individuals with autism spectrum disorders (ASD) or neurodevelopmental disor-ders.
+
+Available scales include the Teacher Rating Scales (TRS), Parent Rating Scales (PRS), Self-Report of Personality (SRP), Student Observation System (SOS), and a Structured Developmental History (SDH).
+
+The Teacher Rating Scales (TRS) measure adaptive and problem behaviors in the pre-school or school setting. Teachers or other qual-ified observers can rate specific behaviors on a four-point scale of frequency, ranging from “Never” to “Almost Always.” The TRS con-tains 100–139 items. The Parent Rating Scales (PRS) measure both adaptive and problem behaviors in the community and home setting. The form requires a fourth grade reading level and is available in Spanish. Similar to the TRS, parents or caregivers can complete forms at three age levels – preschool (ages 2–5), child (ages 6–11), and adolescent (ages 12–21). The PRS contains 134–160 items and uses a four-choice response format. Both scales capture internalizing and externalizing behavioral adjustment reflected in an overall Behavioral Symptoms Index (BSI). Scales uniquely appli-cable to children and adolescents with ASD include assessment of functional communica-tion and social skills.
+
+The Self-Report of Personality (SRP) provides self-assessment of a child or adult’s thoughts and feelings. Each form – child (ages 8–11), adolescent (ages 12–21), and college (ages 18–25) – takes about 30 min to complete. The SRP-Interview (SRP-I) form for children 6–7 provides simple yes-or-no responses to questions asked by an examiner. The SRP-I takes about 20 min to com-plete. Spanish versions are available for the child and adolescent forms. In addition to measuring, internalizing (depression/anxiety/self-esteem), and externalizing problems (impulsivity/attention), the SRP offers self-assessment of interpersonal rela-tionships and social stress.
+
+Recent validity studies of the BASC-2 for use in individuals with ASD have found that the BASC-2 TRS and PRS forms can be effective in differentiating between children with high-functioning autism and typically developing peers. In a recent study (Ensign 2010), significant differences were found between individuals and typically developing groups on all PRS scales. DSM-IV-TR screening indices suggested that the Developmental Social Disorders Scale was highly effective in differentiating between the two groups. Hass et al. (2010) found similar results on the TRS in children receiving an edu-cational classification of autism spectrum disorder.
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+Behavior Development Questionnaire
+Corey Ray-Subramanian
+Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
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+Synonyms
+BDQ; Wing Subgroups Questionnaire (WSQ)
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+Description
+The Behavior Development Questionnaire (BDQ), formerly referred to as the Wing Sub-groups Questionnaire, is an assessment tool used to classify individuals with autism spectrum dis-orders into one of three categories based on Wing and Gould’s (1979) categorization scheme: aloof, passive, and active-but-odd (Castelloe and Dawson 1993). These classifications are distin-guished based on the individual’s quality of social interaction. The aloof group is considered to rarely display spontaneous social approaches to others, other than for the purpose of making requests, and often rejects social contact from others. The passive group shares this lack of spon-taneous social approaches but does not reject social approaches from others. The active-but-odd group is described as being willing to make social approaches to others, but the approaches are considered unusual in quality (Castelloe and Dawson 1993).
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