Autism severity,co-occurring psychopathology,and intellectual functioning predict supportive school services for youth with autism spectrum disorder

Abstract

Supportive school services are a primary service modality for youth with autism spectrum disorder. Autism spectrum disorder, as well as co-occurring psychiatric symptoms and low intellectual abilities, interfere with academic achievement and therefore influence decisions about school services. Therefore, we examined the association of parent, teacher, and clinician ratings of autism spectrum disorder and co-occurring psychiatric symptom severity and intellectual functioning with school services. In total, 283 youth with autism spectrum disorder were assessed with clinical evaluation via the Autism Diagnostic Observation Schedule and parent and teacher versions of the CASI-4R (Child and Adolescent Symptom Inventory). Full Scale Intelligence Quotient scores were obtained from case records. Clinical and teacher evaluations of autism spectrum disorder severity predicted services and were more strongly associated with school services than parent ratings. Teacher ratings were only associated with common school services (e.g. speech/language therapy, occupational therapy, and/or social skills training) frequency at medium and high levels of clinician-rated autism spectrum disorder severity. Higher IQ and parent-rated externalizing symptoms predicted lower likelihood of receiving school services, whereas internalizing symptoms were not predictive of school services. Autism spectrum disorder symptoms may overshadow externalizing and internalizing symptoms when considering school service supports. Results highlight the importance of evaluating autism spectrum disorder severity via multiple sources, especially in cases of unclear symptom presentation, when examining correlates of school services for youth with autism spectrum disorder.

Keywords

autism spectrum disorder comorbidity informant service delivery special education

Public schools in the United States are mandated to provide a free and appropriate education in the least restrictive environment, with supports and services as needed to obtain optimal educational outcomes (Individuals with Disabilities Education Act, 2004). Legally mandated, supportive school services (Hess et al., 2008) are a primary service modality for youth with autism spectrum disorder (ASD) in the United States (Mandell et al., 2005). Schools are obligated to determine how a student’s disability interferes with their educational progress and provide appropriate services. These services are provided at no cost and are therefore crucial for ensuring equitable provision of services for all who are in need of them, including youth with ASD (Christensen et al., 2016).

ASD symptoms interfere with academic achievement (Minshew et al., 1994), and extant research suggests that school services increase with ASD symptom severity, at least according to parent report (Goin-Kochel et al., 2007; Green et al., 2006; Patten et al., 2014; Wei et al., 2014; White et al., 2007). Importantly, ASD symptoms typically vary across home, school, or clinical settings (De Los Reyes and Kazdin, 2005; Gadow et al., 2004, 2005; Lerner et al., 2017; Szatmari et al., 1994). Therefore, each informant (e.g. parent, teacher, clinician) may add useful information in determining optimal intervention strategies.

It is generally presumed that greater ASD symptom severity necessitates more intensive and frequent school supports (e.g. Goin-Kochel et al., 2007). However, in addition to ASD severity, co-occurring psychiatric symptoms and low intellectual functioning may also interfere with a student’s academic progress (Barry et al., 2002; Chiang et al., 2018). Therefore, co-occurring psychiatric symptoms and intellectual functioning should also influence school service determination. Unfortunately, relatively little is known about their independent and combined associations with the delivery of school services for youth with ASD.

ASD severity and school services

Studies that examined the association of ASD severity with school services have used varying informants and methods. For example, Goin-Kochel et al. (2007) measured ASD severity by obtaining parent-reported diagnoses (e.g. autism, Asperger’s diagnosis, pervasive developmental disorder not otherwise specified (PDD-NOS)) via a questionnaire. Results suggested that children with a diagnosis of autism or PDD-NOS utilized more total services including occupational therapy (OT), physical therapy, and speech therapy. However, in that study, social skills training was utilized more by those with an Asperger’s diagnosis, while the study did not specify the setting (e.g. home, school, clinic) in which these services were delivered. Similarly, Green et al. (2006) used parent-reported ASD diagnoses (e.g. autism, mild autism, severe autism) via a questionnaire and found that overall service use increased with severity of ASD diagnosis. Moreover, those with a more severe disorder were more likely to use a range of therapies spanning different categories (e.g. standard therapies, skills-based therapies, applied behavior analysis), though associations between severity and specific therapy modalities were not examined. Again, the study did not examine the setting in which these therapies were delivered. Taken together, both studies suggest that likelihood and intensity of service delivery are related to ASD severity, though it remains unclear whether these findings are specific to school service delivery.

Alternatively, Patten et al. (2014) measured ASD severity using parent ratings of sensory difficulties via the Sensory Profile (SP; Dunn, 1999) and clinician ratings of ASD severity via the Childhood Autism Rating Scale (CARS; Schopler et al., 1988); results revealed that only parent ratings of sensory difficulties were associated with service delivery. However, it was not examined whether this association was specific to school services. On the other hand, Wei et al. (2014) did evaluate association of school services with ASD severity, as reported by parents on a survey. In this study, ASD severity was measured by a continuous severity index, created from the results of a parent survey; results revealed that only the communication/conversation dimension predicted higher likelihood of receiving school services, in addition to a greater number of these services.

Whereas the extant literature suggests that ASD severity is associated with a greater intensity (e.g. number of services), and likelihood of services, to date, only one study has reported on the association of ASD severity to school services specifically (Wei et al., 2014), even though they are the primary, and most consistent, service modality for many youth with ASD (Christensen et al., 2016). Moreover, the association of teachers’ and clinicians’ perception of ASD severity with likelihood and intensity of school services has not been explored. The opinions of teachers and parents play a legally mandated role in the Individualized Education Program (IEP) process, and input from experts external to the school are likely to be considered as well (Individuals with Disabilities Education Act, 2004; Noland and Gabriels, 2004). Parents of youth with ASD are likely to report dissatisfaction with school services (Spann et al., 2003), which may result from less involvement in the IEP process compared to educators (Childre and Chambers, 2005). Given that the IEP process determines the school services a child receives (Individuals with Disabilities Education Act, 2004), these associations warrant further examination.

Psychiatric comorbidity and intellectual functioning

To date, however, few studies have examined the contributions of psychiatric comorbidity and intellectual functioning to the delivery of school services for individuals with ASD, though these associations are well established in non-ASD samples (e.g. Jones and Foster, 2009). One study considered whether co-occurring attention deficit hyperactivity disorder (ADHD) was associated with a greater need for services among youth with ASD, but found that comorbid ADHD did not predict school services (Narendorf et al., 2011). However, the potential influence of other externalizing symptoms was not examined in this study, nor were internalizing symptoms, ASD severity, or intellectual functioning.

Research examining the association of intellectual functioning or ASD severity with school services has yielded mixed results. One study found that IQ was associated with special education placement compared to clinical evaluation of ASD symptoms in a sample of youth with ASD (White et al., 2007). However, a separate study found that parent ratings of ASD severity predicted school services, even after controlling for IQ (Spaulding et al., 2016). To date, however, no study has examined the association of ASD severity, psychiatric comorbidity, and intellectual functioning in tandem to parse their relative and joint contributions to school service delivery. Moreover, there are no studies of the implications of informant discrepancy for understanding these associations.

The present study

The primary aim of this study was to examine the association of ASD symptom severity with the likelihood and frequency of school services in a large sample of youth with ASD referred for clinical evaluation, and whether this association differed by teacher and parent ratings and clinical evaluation. A secondary aim was to examine whether the severity of co-occurring psychiatric symptoms and level of intellectual functioning were also associated with receipt and frequency of school services. Based on the findings of prior research (e.g. Patten et al., 2014; Wei et al., 2014), we expected that (1a) teacher, (1b) clinical evaluation, and (1c) parent ratings of ASD symptom severity would be positively correlated with frequency of school services. Moreover, we also predicted that (2a) teacher ratings of ASD severity would correlate more strongly than clinical evaluation which, in turn, (2b) would correlate more strongly than parent ratings of ASD severity with frequency of school services, owing to prior research supporting differentially greater involvement of teachers in the IEP process compared to parents and clinicians (e.g. Arivett et al., 2006; Childre and Chambers, 2005).

Similarly, we examined whether (3a) clinician evaluation, after controlling for parent ratings of ASD severity, would predict supportive services and whether (3b) teacher ratings, after controlling for both parent ratings and clinician evaluation, would also predict school services (i.e. presence and frequency). In regard to our secondary aim, we hypothesized that (4) lower IQ and higher levels of co-occurring psychiatric symptoms would predict school services, even after controlling for ASD severity, given prior literature suggesting that both variables predict informant ratings of ASD severity (Havdahl et al., 2016; Hus et al., 2013).

Method

Participants

Case records for consecutive referrals to a university hospital developmental disabilities specialty clinic located on Long Island, NY, were screened for youth who were between 6 and 18 years old at time of initial evaluation, diagnosed as having an ASD according to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) diagnostic criteria (see section “Procedure”), and assessed with relevant measures (see section “Measures”) at the time of their initial diagnostic evaluation. Case records for 283 patients met these criteria. The majority of participants were male, White, and receiving special education services (see Table 1). Under half (42.4%) of the sample was receiving psychotropic medication. Most (85%) were verbal at time of evaluation, and IQ scores were obtained from school records for 78% of youth. This study was approved by a university Institutional Review Board, and appropriate measures were taken to protect child and caregiver confidentiality.

Table 1.

Descriptive statistics for participants and type of supportive school service.

	M (SD)	Range	N ^a
Age	10.45 (3.28)	6–18	283
Parent report ASD symptom severity^b	16.19 (8.21)	0–36	278
Teacher report ASD symptom severity^b	16.61 (9.43)	0–36	223
Clinical evaluation ASD symptom severity^c	10.02 (7.19)	0–31	164
IQ	85.81 (23.50)	32–148	220
Parent report externalizing symptoms^b	38.56 (17.99)	4–92	277
Teacher report externalizing symptoms^b	34.48 (18.35)	0–89	223
Parent report internalizing symptoms^b	18.49 (12.49)	0–61	272
Teacher report internalizing symptoms^b	14.59 (8.58)	0–41	223
	N (%)
Male	233 (82.3)
Caucasian	229 (80.9)
Receiving psychotropics	120 (42.4)
Receiving special education services	212 (74.9
Receiving speech, OT + SST	1 (0.4)
Receiving SST only	6 (2.1)
Receiving speech + SST only	1 (0.4)
Receiving OT + SST only	2 (0.7)
Receiving speech + OT only	95 (33.6)
Receiving speech only	41 (14.5)
Receiving OT only	13 (4.6)
Services not reported	87 (30.7)
Not receiving OT, speech, or SST	37 (13.1)

Speech: speech therapy; OT: occupational therapy; SST: social skills treatment.

Owing to missing data from the case records, these values varied.

Symptom severity scores obtained via Child and Adolescent Symptom Inventory.

Symptom severity scores obtained via the Autism Diagnostic Observation Schedule.

Procedure

Prior to their initial diagnostic evaluation, parents completed an intake assessment battery that included the Child and Adolescent Symptom Inventory (CASI-4R; Gadow and Sprafkin, 2005), Parent Questionnaire (Gadow et al., 2008), and permission for release of school reports. Parents delivered a similar packet of materials to the school with instructions that requested teachers to complete the CASI-4R and for the school to provide copies of psycho-educational evaluations and IQ testing results. Schools mailed their information directly to the clinic. Parent ratings were completed primarily by the youth’s mother (>90%).

DSM-IV-based ASD diagnoses were confirmed by an expert diagnostician and based on six sources of information: (1) comprehensive developmental history, (2) clinician interview with youth and caregiver(s), (3) direct observations of the youth, (4) review of validated ASD rating scales including the CASI-4R (Gadow and Sprafkin, 2005) for current ASD symptoms and the Social Communication Questionnaire (SCQ) Lifetime Version (Berument et al., 1999) for lifetime symptoms, (5) prior school and clinician evaluations, and (6) in the majority of cases (58%), scores were available from the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 1999), which was administered by a certified, clinically trained examiner. The only exceptions were youth with a prior well-documented diagnosis of ASD (e.g. prior clinician or school evaluations) who received all aforementioned assessments but not the ADOS. As previously reported (Gadow and DeVincent, 2012), these cases were more likely to have lower IQ scores, current special education services, and more severe ASD communication deficits than the ADOS-assessed group.

Measures

ASD symptom severity

Parent and teacher ratings and clinical evaluation of ASD severity were obtained using well-established, standardized metrics. Parent and teachers rated youth’s ASD symptoms with the corresponding version of the CASI-4R (Gadow and Sprafkin, 2005). Individual items bear one-to-one correspondence with DSM-IV symptoms and are rated on a Likert-type scale from 0 (never) to 3 (very often). The results of several factor analytic studies support the internal construct validity of CASI-4R ASD scores (Kim et al., 2017; Lecavalier et al., 2009), as well as satisfactory sensitivity and specificity in identifying children with ASD in three independent studies (DeVincent et al., 2008; DeVincent and Gadow, 2009; Gadow et al., 2008).

Clinical evaluation was obtained via the ADOS (Lord et al., 1999), a well-established, semi-structured observational assessment instrument for diagnosing ASD. Subsets of the items scored during observation are used to determine whether a person meets diagnostic cutoffs for autism or ASD. The ADOS has satisfactory interrater and test–retest reliability as well as discriminant validity for ASD and non-ASD diagnoses. The standard ADOS algorithm was used to calculate symptom severity ratings. For this sample, the internal consistency reliabilities were fairly high for all four modules (αs = 0.76–0.92). All administrators of the ADOS were trained to be clinically-reliable in their administration.

The revised ADOS-2 algorithm was used to ascertain diagnostic cutoffs for ASD, as well as ASD severity (little-to-no-evidence, low, moderate, or high calibrated severity score (CSS) category; Gotham et al., 2007). The ADOS is frequently used in large samples as a means of assessing ASD and ascertaining subgroups within the population (Gotham et al., 2012; Lord et al., 2012).

Psychiatric comorbidity

Parents and teachers evaluated the severity of co-occurring psychiatric symptoms with the CASI-4R. Anxiety and depression symptoms (internalizing problems) were determined by summing CASI-4R symptom severity scores from the generalized anxiety, social phobia, separation anxiety, and major depressive episode subscales. Externalizing symptoms were the sum of symptom severity scores from the ADHD, oppositional defiant disorder (ODD), and conduct disorder subscales (Rodriguez-Seijas et al., 2018). Numerous studies indicate that the CASI-4R demonstrates satisfactory psychometric properties. Specifically, individual symptom dimensions evidence satisfactory internal consistency (Cronbach’s alpha), test–retest reliability, and convergent and divergent validity with respective measures from a range of relevant assessment instruments and diagnostic procedures in ASD samples (Gadow et al., 2013; Gadow and Sprafkin, 2002, 2008; Kaat et al., 2013; Lecavalier et al., 2008). The results of several factor analytic studies support the internal construct validity of DSM-IV-referenced CASI-4R syndromes in children with ASD (Hallett et al., 2013; Lecavalier et al., 2008, 2011).

Intellectual functioning

IQ scores were obtained from school records for 78% of youth and were from various tests: Wechsler Intelligence Scale for Children (59.1%), Wechsler Preschool and Primary Scale of Intelligence (13.6%), Stanford–Binet Scale (6.4%), Bayley Scales of Development (3.6%), Vineland Adaptive Scales (3.2%), or other (11.8%) test (2.3% of the case records provided Full Scale Intelligence Quotient (FSIQ) without mention of the test name).

Supportive school services

The Parent Questionnaire (Gadow et al., 2008) obtains information about child, family, medical, and treatment characteristics. The Parent Questionnaire asks parents to provide information about the youth’s special educational label, classroom type, and other retrospective educational history. Parents are also asked to indicate whether their youth is receiving special education services as well as supportive services, and how many times a week each service is provided.

Receipt of common school services refers to whether or not (yes/no) the youth was receiving at least one of three school services that are most commonly provided for youth with ASD: speech/language therapy, OT, and/or social skills training (e.g. Goin-Kochel et al., 2007; Thomas et al., 2007). Total school services include both common school services and any other school services (e.g. adaptive physical education, and counseling). Frequency of school services refers to the average number of times per week youth received common school services. Average weekly frequencies were calculated for the common and total school services.

Data analytic plan

To test our first hypothesis (1a), we examined bivariate correlations between frequency of school services and ADOS scores, and parent and teacher CASI-4R ratings of ASD symptom severity. Next, using the Fisher r-to-z transformation, we tested for significant differences between these correlations to determine whether (2a) teacher ratings of ASD severity would correlate more strongly than ADOS scores, which, in turn, (2b) would correlate more strongly than parent CASI-4R severity ratings with frequency of school services.

Next, we tested our hypothesis that (3a) clinical evaluation, after controlling for parent ratings, would predict school services, and our hypothesis that (3b) teacher ratings, after controlling for both parent and clinical evaluation, would also predict school services. Toward that end, we conducted a hierarchical logistic regression analysis to identify each measure of ASD symptom severity’s relative contribution to school services. In this model, we controlled for age at step 1, added parent CASI-4R ASD severity ratings at step 2, clinical evaluation (ADOS scores) at step 3, and teacher CASI-4R ASD severity ratings at step 4. Next, two hierarchical multiple regression analyses were conducted to examine associations of ASD symptom severity with frequency for each measure separately, one which predicted frequency of school services, and one which predicted frequency of total school services.

IQ and parent and teacher CASI-4R externalizing and internalizing scores were added to the final hierarchical models of hypotheses (3a) and (3b) to test whether (4) lower IQ and higher levels of co-occurring psychiatric symptoms would predict school services. Specifically, we added a step in which we utilized a forward stepwise entry approach, to see whether these variables also contribute to school services. The resultant three models were therefore hybrid models of the hierarchical (i.e. the three final models from hypotheses (3a) and (3b)) and forward stepwise (i.e. the addition of IQ and externalizing and internalizing symptoms in a forward stepwise manner for hypotheses (5a) and 5b)) regressions. For the forward regression step, inclusion criterion for each predictor was p < 0.05 and exclusion criterion was p > 0.10. Cohen’s (1992) criteria were used to classify correlations of 0.10, 0.30, and 0.50, and changes in R² values of 0.02, 0.13, and 0.26, as small, medium, and large effect sizes, respectively.

Results

Description of service delivery

In the total sample, the largest group of those receiving at least one common school service was receiving speech and OT. About 17.3% of participants did not report receiving any common school services.

Frequency of school services and ASD symptom severity

Consistent with hypotheses (1a), (1b), and (1c), teacher ratings, clinical evaluation, and parent ratings of ASD symptom severity positively correlated with frequency of common and total school services (though the correlation between parent ratings and frequency of school services was marginally significant; see Table 2). The correlation between teacher ratings and frequency of common and total school services was medium in effect. Whereas the correlation between ADOS scores and school service frequency was medium in effect, it was large for total frequency. Correlations between parent CASI-4R ratings and frequency of common and total school services were small (see Table 2).

Table 2.

Correlations between age, frequency of supportive school services, and ASD symptom severity ratings by informant.

	1.	2.	3.	4.	5.	6.
1. Age	1
2. Total school services frequency	−0.13	1
3. Common school services frequency	−0.09	0.89***	1
4. Parent report symptom severity^b	−0.07	0.21**, ^a	0.17^{+, a}	1
5. Teacher report symptom severity^b	−0.24***	0.37***	0.41***, ^a	0.38***	1
6. Clinical evaluation symptom severity^c	−0.22**	0.51***, ^a	0.38***	0.43***	0.43***	1

ASD: autism spectrum disorder.

Reported effects are two-sided Pearson’s r correlations. School services: supportive school services.

Significantly different from one another using Fischer’s r-to-z transformation.

Symptom severity scores obtained via Child and Adolescent Symptom Inventory—Fourth Edition, Revised.

Clinical evaluation was determined via the Autism Diagnostic Observation Schedule (ADOS).

p < 0.10; *p ⩽ 0.05; **p ⩽ 0.01; ***p ⩽ 0.001.

The correlation between teacher ratings of ASD severity and common and total school service frequency was not significantly different than those for ADOS scores (see Table 2), which was contrary to hypothesis (2a). However, correlations between teacher ratings and school service frequency were significantly greater than that between parent ratings for common but not total school service frequency. Whereas the association between school service frequency and ADOS scores was not greater than that of parent ratings for common school service frequency, it was for total school service frequency, which was partially consistent with hypothesis (2b).

Consistent with hypothesis (3a), after controlling for parent ratings, ADOS scores exhibited a small incremental effect in predicting school services (see Table 3), such that a one-unit increase in ADOS severity was associated with a 19% increase in likelihood of receiving any common school service. Similarly, ADOS scores were associated with a medium-size increase in common school service frequency (see Table 4); they were also associated with a medium incremental effect in predicting total school service frequency (see Table 5). Whereas teacher ASD ratings, after controlling for parent and ADOS scores, did not predict receipt of common school services¹ (see Table 3), teacher ratings predicted school service frequency with a small incremental effect, as measured by common and total school service frequency (see Tables 4 and 5). Thus, hypothesis (3b) was partially supported.

Table 3.

Regression analysis for variables predicting receipt of common school supportive services.

Variable	Hierarchical logistic regression^a					Hybrid regression
	Model 1	Model 2	Model 3	Model 4		Model 5
	OR	OR	OR	OR	95% CI	OR	95% CI
Constant	25.73***	20.28**	5.49	5.10		67.51*
Age	0.82**	0.83**	0.85*	0.85	0.72, 1.00	0.83	0.68, 1.02
Parent report of ASD symptom severity^b		1.01	0.99	0.99	0.92, 1.06	1.03	0.93, 1.13
ADOS			1.19**	1.19**	1.05, 1.34	1.18*	1.01, 1.38
Teacher report of ASD symptom severity^b				1.00	0.93, 1.08	1.01	0.92, 1.10
Parent report of externalizing symptom severity^b						0.93**	0.89, 0.98
Cox and Snell R²	0.07	0.07	0.18	0.18		0.29
χ ²	7.00**	7.21*	19.02***	19.03***		26.68***
Cox and Snell ∆R²		0.00	0.11	0.00		0.11
∆χ²		0.21	11.81	0.01		10.93

ASD: autism spectrum disorder; OR: odds ratio; CI: confidence interval; ADOS: Autism Diagnostic Observation Schedule.

For the hierarchical regression, N = 98 cases, whereas for the hybrid regression, N = 78 cases, as pairwise deletion was used in the hierarchical regression, whereas listwise deletion was used in the hybrid regression.

ASD and externalizing symptom severity scores obtained via Child and Adolescent Symptom Inventory—Fourth Edition, Revised.

p ⩽ 0.05; **p ⩽ 0.01; ***p ⩽ 0.001.

Table 4.

Hierarchical regression analysis for variables predicting frequency of common school supportive services (N = 283).

Variable	Hierarchical regression					Hybrid regression
	Model 1	Model 2	Model 3	Model 4		Model 5
	B	B	B	B	95% CI	B	95% CI
Constant	3.67***	3.31***	2.83***	2.37***	1.35, 3.39	4.95***	2.99, 6.91
Age	−0.03	−0.03	0.00	0.01	−0.06, 0.09	−0.02	−0.09, 0.06
Parent report of ASD symptom severity^a		0.02	0.00	−0.01	−0.04, 0.02	−0.01	−0.04, 0.02
ADOS			0.06**	0.04*	0.00, 0.08	0.00	−0.04, 0.05
Teacher report of ASD symptom severity^a				0.04*	0.01, 0.06	0.03*	0.00, 0.05
IQ^b						−0.02**	−0.03, −0.01
R ²	0.01	0.03	0.14	0.22		0.31
F	0.56	1.19	3.78*	4.78**		6.10***
∆R²	0.01	0.03	0.11	0.08		0.09
∆F	0.56	1.82	8.70**	6.83*		9.08**

ASD: autism spectrum disorder; ADOS: Autism Diagnostic Observation Schedule; CI: confidence interval.

ASD symptom severity scores obtained via Child and Adolescent Symptom Inventory—Fourth Edition, Revised.

IQ scores obtained from school records. Age: N = 283. Parent Report of ASD Symptom Severity: N = 278. ADOS: N = 164. Teacher report of ASD symptom severity: N = 223. IQ: N = 220. Common supportive service frequency: N = 135.

p ⩽ 0.05; **p ⩽ 0.01; ***p ⩽ 0.001.

Table 5.

Hierarchical regression analysis for variables predicting total frequency of supportive school services (N = 283).

Variable	Model 1	Model 2	Model 3	Model 4		Hybrid regression
Variable	B	B	B	B	95% CI	B	95% CI
Constant	3.57***	3.08***	2.43***	2.13***	1.26, 3.00	3.93***	2.21, 5.66
Age	−0.04	−0.04	−0.01	0.01	−0.06, 0.07	−0.02	−0.08, 0.05
Parent report of ASD symptom severity^a		0.03*	0.000	−0.01	−0.03, 0.02	−0.01	−0.04, 0.02
ADOS			0.08***	0.07***	0.04, 0.10	0.04*	0.00, 0.08
Teacher report of ASD symptom severity^a				0.02*	0.00, 0.05	0.02	−0.01, 0.04
IQ^b						−0.01*	−0.03, 0.00
R ²	0.02	0.06	0.26	0.29		0.33
F	1.51	2.77	10.20***	8.90***		8.64***
∆R²	0.02	0.04	0.20	0.03		0.04
∆F	1.51	3.98*	23.66***	3.98*		5.70*

ASD: autism spectrum disorder; ADOS: Autism Diagnostic Observation Schedule; CI: confidence interval.

ASD symptom severity scores obtained via Child and Adolescent Symptom Inventory—Fourth Edition, Revised.

IQ scores obtained from school records. Age: N = 283. Parent report of ASD symptom severity: N = 278. ADOS: N = 164. Teacher report of ASD symptom severity: N = 223. IQ: N = 220. Total supportive service frequency: N = 165.

p ⩽ 0.05; **p ⩽ 0.01; ***p ⩽ 0.001.

ASD severity, intellectual functioning, and psychiatric comorbidity

IQ was negatively associated with receipt of common school services (r = −0.29, p < 0.01) with a medium effect, as well as common (r = −0.51, p < 0.01) and total (r = −0.51, p < 0.01) school service frequency with a large effect. Neither parent nor teacher ratings of externalizing symptoms correlated with school service receipt and frequency (all p > 0.05). Parent ratings of internalizing symptom severity were negatively associated with receipt of common school services (r = −0.15, p < 0.05) with a small effect and common school service frequency (r = −0.22, p < 0.05) with a medium effect. However, parent ratings of internalizing symptoms were not significantly correlated with total school service frequency (r = −0.13, p > 0.05). No significant associations were found between teacher ratings of internalizing symptoms and school service receipt or frequency (all p > 0.05).

When IQ, externalizing, and internalizing symptoms were added to the hierarchical regressions that tested hypotheses (3a) and (3b), only parent ratings of externalizing symptoms predicted receipt of common school services (see Table 3); specifically, greater externalizing symptoms predicted lower likelihood of receiving common school services, such that for every additional externalizing symptom, there was a 7% decrease in likelihood of receiving common school services. This pattern of results was contrary to hypothesis (4). This incremental effect was small, and ADOS scores continued to predict receipt of common school services.

Lower IQ predicted greater common school service frequency, with a small incremental effect (see Table 4), which partially supported hypothesis (4). Although teacher ratings of ASD severity continued to predict common school service frequency, clinical evaluation no longer predicted common school service frequency in the final model (see Table 4). Lower IQ also predicted higher total school service frequency with a small incremental effect in the final model (see Table 5), which also supported hypothesis (4). ADOS scores continued to predict total school service frequency in the final model.² For a summary of this study’s primary findings, see Table 6.

Table 6.

Summary of significant predictors of final regression models.

	Measure of school service
	Presence of services commonly used for ASD	Frequency of services commonly used for ASD	Frequency of total services received
ASD severity predictor
Parent report of ASD symptom severity^a	–	–	–
ADOS	Predicted increased likelihood before and after controlling for psychiatric symptoms and IQ	Predicted increased frequency, only before controlling for psychiatric symptoms and IQ	Predicted increased frequency, before and after controlling for psychiatric symptoms and IQ
Teacher report of ASD symptom severity^a	–	Predicted increased frequency, only at average and high clinician (ADOS) ratingsPredicted increased frequency before and after controlling for psychiatric symptoms and IQ	Predicted increased frequency, only before controlling for psychiatric symptoms and IQ
Co-occurring psychiatric symptom severity predictor
Parent report of externalizing symptom severity^a	Predicted lower likelihood	–	–
Teacher report of externalizing symptom severity^a	–	–	–
Parent report of internalizing symptom severity^a	–	–	–
Teacher report of internalizing symptom severity^a	–	–	–
Intellectual functioning predictor
IQ^b	–	Predicted decreased frequency	Predicted decreased frequency

ASD: autism spectrum disorder; ADOS: Autism Diagnostic Observation Schedule.

– = Did not predict in final model.

ASD, externalizing, and internalizing symptom severity scores obtained via Child and Adolescent Symptom Inventory—Fourth Edition, Revised.

IQ scores obtained from school records.

Post hoc analyses

Owing to the correlation between informants’ ratings of ASD symptom severity (see Table 2), it is plausible that the aforementioned effects are not independent of one another. As such, post hoc analyses were conducted to assess effects of the interaction of different informants’ ratings of ASD severity (e.g. clinician*parent, parent*teacher, teacher*clinician) on school service variables. Specifically, we re-ran the final regression models, above, with these three interaction terms added (all variables mean-centered). The only significant interaction term was that of teacher and clinician ASD severity ratings in predicting common school service frequency (B = 0.01, p = 0.02), such that teacher ratings of ASD severity predicted common school service frequency at average (B = 0.09, p = 0.01) and high levels (B = 0.15, p = 0.02) of clinician ASD severity ratings, but not at low levels of clinician ASD severity ratings (B = 0.04, p = 0.30).

Discussion

This is the first published study examining associations among multiple informants’ ratings of ASD symptom severity, co-occurring psychiatric symptoms, and school services for youth with ASD. Compared to parent ratings, clinical evaluation and teacher ratings of ASD severity showed the strongest and most consistent associations with receipt and frequency of school services. Moreover, clinical evaluation demonstrated more consistent associations with school services than teacher report. Higher IQ predicted decreased frequency of school services, whereas externalizing symptoms predicted lower likelihood of service receipt.

Of our three methods of ASD symptom assessment, parent ratings demonstrated the least associations with school services. This is likely a function of the fact that children with ASD behave differently in different settings and schools tailor their intervention efforts based on behaviors observed in the school setting. Nonetheless, this finding is consistent with research indicating parents feel they have less influence in the IEP process compared to their child’s educators (Childre and Chambers, 2005). Importantly, higher levels of parental involvement are associated with increased satisfaction with school-provided services (Hoover-Dempsey and Sandler, 1997; Zablotsky et al., 2012).

Our results underscore the complexity of interrelations among caregiver reports, domains of disability, and three different parameters of school services. For example, clinical evaluation of ASD severity was associated with receipt of common school services, whereas teacher ratings were not. Although both clinical evaluation and teacher ratings were related to total school services frequency, teacher ratings were only associated with common school service frequency at medium and high levels of clinician-rated ASD severity. Thus, whereas clinician ratings of severity correlate with amount of ASD-specific services at all levels of ASD severity, teacher ratings only kick in at higher levels of clinician-rated severity. It is plausible that youth with ASD who evince higher levels of agreement among reporters in terms of their severity represent a distinct subgroup (Lerner et al., 2017) that is seen as particularly in need of additional services, possibly eliciting an additive influence on the services offered by the IEP team (i.e. when the team agrees, the door is opened to a richer, wider array of services). Relatedly, then, future studies should investigate whether the service needs of children with more ambiguous symptom presentation may be overlooked, particularly when only input from one source is considered.

Overall, then, school services related most strongly and consistently to clinician ratings, compared to teacher and parent ratings. These findings are somewhat counterintuitive, given that teachers and parents, but not necessarily clinicians, are mandated members of the IEP team. Therefore, it may be that clinical assessment itself, or the clinical context, in practice plays a stronger role in school service determination than previously thought (e.g. Martin et al., 2004). The IEP process may offer a valuable venue for testing this question, and future, in-depth analyses of the role of each stakeholder in the IEP process would be useful toward answering this question. Such studies should prospectively consider if and how such ratings are related to school services that are in alignment with each child’s unique treatment needs (e.g. Green et al., 2006; White et al., 2007), including those that are related to intellectual abilities and psychiatric comorbidity.

After considering IQ and comorbid psychopathology, IQ predicted higher rates of common and total school service frequency. White et al. (2007) found that IQ, rather than ASD severity, was associated with special education placement, whereas Spaulding et al. (2016) found that ASD severity was related to special education placement, even after accounting for IQ. Similarly, ASD severity (though not IQ) was related to increased likelihood of receiving common school services in this study. It may be that when considering frequency of school services, rather than receipt or placement, both IQ and ASD severity play an influential role. This could be due to additional impairment associated with intellectual functioning that necessitates more intensive service delivery for youth with ASD. Importantly, these relations were evident after controlling for psychiatric comorbidity, suggesting that IQ and ASD severity evidence specific and independent associations with school service frequency. These findings may also support conceptualizations of ASD symptoms as distinct from cognitive abilities and psychiatric comorbidity (Hus et al., 2013).

Parent ratings of externalizing symptoms were associated with less likelihood of receiving common school services. A prior study by Narendorf et al. (2011) found that externalizing symptoms, as indexed by the presence of an ADHD diagnosis, did not predict school services in a sample of youth with ASD. Examining externalizing symptoms more broadly (not only ADHD, but also ODD and conduct disorder) may have allowed us to detect the association between these symptoms and receipt of school services. These findings suggest that parents recognize co-occurring externalizing symptoms in youth with ASD and seek prioritized services targeted to those symptoms, rather than to ASD-related deficits.

Limitations and future directions

These results are subject to several qualifications. First, the study sample comprised youth who were referred for outpatient evaluation and therefore may not be representative of broader community-based samples. Second, school services were already being received prior to parent, teacher, and clinician ratings and were not directly used for service determination in this study. Future examinations of the role of each stakeholder in the IEP process are needed to elucidate who has most influence over school services, and whether these services are adequately targeting each child’s complex treatment needs (e.g. Green et al., 2006; White et al., 2007). Third, school services were reported by parents, who may have misrepresented the exact type or frequency of their children’s school services. Finally, because school services were generally received prior to obtaining caregiver ratings, they may have influenced raters’ perceptions of severity.

Additionally, there are several methodological considerations regarding comparison of CASI-4R and ADOS data. For example, the CASI-4R is a brief, caregiver-completed behavior rating scale, whereas the ADOS is a clinic-based, task completion evaluation. In addition, the ADOS is calibrated to verbal ability, whereas the CASI-4R is not. Ideally, comparing associations of different sources and informants should use parallel measures to reduce method variance, which may be especially important when assessing ASD severity (Hus et al., 2013). Further, we did not examine communication deficits, which may have also influenced the obtained results. A small percentage of the sample (2.1%; see Table 1) was reported to be receiving social skills training. For instance, given that social skills training is often indicated for youth with externalizing behaviors (e.g. Daley et al., 2014), this study may have been underpowered to detect associations between those with higher externalizing symptoms and frequency of social skills training.

Conclusion

Together, present findings suggest some specificity regarding relations of domains of symptoms with school service determination. Whereas associations were found between school services and ASD severity and IQ, no associations were found between internalizing symptoms and school service presence and frequency and between externalizing symptoms and school service frequency. It may be that, in terms of the amount of services received, externalizing and internalizing symptoms are overshadowed by ASD symptoms. In other words, once children are flagged as needing ASD-related services, parents and teachers may conceptualize co-occurring challenges as ASD symptomatology (Mazefsky et al., 2011; Rosen et al., 2018) rather than as separate challenges. This may especially be the case for co-occurring internalizing symptoms; due to their more covert presentation, internalizing symptoms may be harder to reliably assess compared to externalizing symptoms, particularly when the child is not interviewed. However, these co-occurring psychiatric symptoms can interfere with academic achievement, above and beyond that caused by ASD symptoms alone; therefore, it is crucial that co-occurring symptoms are considered when awarding school services to youth with ASD.

Supplemental Material

AUT809690_Lay_Abstract – Supplemental material for Autism severity, co-occurring psychopathology, and intellectual functioning predict supportive school services for youth with autism spectrum disorder

Supplemental material, AUT809690_Lay_Abstract for Autism severity, co-occurring psychopathology, and intellectual functioning predict supportive school services for youth with autism spectrum disorder by Tamara E Rosen, Christine J Spaulding, Jacquelyn A Gates and Matthew D Lerner in Autism

Footnotes

Acknowledgements

The authors gratefully acknowledge and thank Kenneth D Gadow for his numerous helpful comments on prior drafts of this paper. The authors wish to thank Dr John Pomeroy, MD, for directing the ASD diagnoses and Carla DeVincent, PhD, for coordinating data collection.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported, in part, by the Matt and Debra Cody Center for Autism and Developmental Disabilities.

ORCID iD

Matthew D Lerner

Notes

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