The Treatment of Emotional Disorders in High Functioning

Autism

Wednesday 19th March 20141:30pm – 3:00pm AEDT

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PRESENTERS:

Dr Katie WoodClinical Psychologist

Swinburne University of Technology

Dr Fiona ZandtClinical PsychologistRoyal Children’s Hospital

Facilitator: Harry Lovelock, Senior Executive Manager APS

The Treatment of Emotional Disorders in High Functioning

Autism

Dr Katie WoodClinical Psychologist

19th March 2014

Brief Background: ASD overview • Neuro developmental disorders associated with patterns of delay across

multiple areas.

• Range in severity with variation in intelligence, abilities & behaviour.

• Common link - different way of thinking & learning, which impacts on socialisation & communication (see Attwood, 2006;2009).

• Thought to develop during the pre natal period.

• Mean age of onset for ASDs is approx 4 years. However onset of symptoms can vary during first two years of life. This means that a one-off screening approach at a given age is not appropriate (Dissanayake, 2012)

• 2012 - 1 in 110* means...Half a million Australian Families affected by ASD

• Cost of intervention ($, time)• Impact on the family

Brief Background: ASD overview

ASPECT website

What’s new in the DSM-V?• Autism Spectrum Disorder, with no separate labels for Autistic Disorder, Asperger’s

Disorder or PDD-NOS. Rhett’s disorder moved in with Genetic Disorders.

• A key distinction is made according to levels of severity. These levels are based on the amount of support needed in response to difficulties associated with social communication, & restricted interests & repetitive behaviours. For example, a child might be diagnosed with ASD, Level 1 – the child “requires support” with a description of what it means to have level 1 support in each of the domains.

• The reasons for using the umbrella term of “Autism Spectrum Disorder” are

1) Previous criteria not precise enough; meaning that different clinicians diagnose the same person with different disorders, & change their diagnosis over time.

2) Autism is characterised by a common set of behaviours, and therefore should be describe by a single name according to severity.

• The new criteria encourage diagnoses to be made earlier in childhood.

• The new criteria are thought to be stricter & more thorough than the DSM-IV-TR criteria. For example, more symptoms are needed to meet criteria within the domain of fixated interests & repetitive behaviours.

• In DSM-IV-TR, the domains for Autistic Disorder include impairments in Communication, Social Interaction, & Restricted Interests/Repetitive Behaviours. In the DSM-V, the Communication & Social Interaction domains are joined into “Social/Communication Deficits.”

• The requirement of a language delay is no longer required for a diagnosis.

What’s new in the DSM-V 2?

See DSM-V website http://www.dsm5.org/Documents/Autism20Spectrum20Disorder20Fact20Sheet.pdf

The Family Environment

Child behaviour

Family Functioning

Parent Behaviour

Parent Wellbeing

Why do Family / Parent Work? • Challenges associated with raising a child with Autism are life long.

• The family are usually the most stable and consistent influence in the child’s life (Campbell & Kozloff, 2007).

• Families experience multiple stressors/difficulties that can impact the whole family system.

• Increased risk for stress and depression (Baker et al., 2002)

• More fatigue and poorer sleep quality (Giallo et al., 2011; Seymour et al., 2013)

• Strain on the family system (Sivberg, 2002)

• Strain on the marital relationship (Hutton & Caron, 2005)

• Poor Coping (Seymour et al., 2013)

• Higher levels of child behaviour problems are associated with:• Higher parental stress (Estes et al., 2009; Seymour et al., 2012)

• Higher parental depression (Bristol et al., 193)

• Higher parental fatigue (Seymour et al., 2012)

• Poorer quality of life (Allik et al., 2006)

Why do Family / Parent Work?

• The relationship between maternal stress and child behaviour problems found to be mediated by maternal fatigue. That is, the behaviour problems seen in pre school aged children with ASD are associated with high levels of maternal fatigue, which in turn are associated with maternal stress (Seymour et al., 2013).

Why do Family / Parent Work 2? • The emotional and behavioural problems associated with ASD can

interfere with treatment and can worsen functional impairment (Lane et al., 2010) as well as parental distress, and the parent-child relationship (Davis & Carter, 2008).

• Parenting interventions are an effective way to target the behavioural and emotional difficulties associated with ASD (Tellegen & Sanders, 2013)

(See Campbell & Kozloff, 2007)

How to understand needs of parents • Clinical assessment, including family history, parenting

styles, treatment history, capacity to engage in treatment, resources and support networks.

• Questionnaires to measure parent wellbeing and family

functioning - • DASS-21• Fatigue Assessment Scale (FAS) • Parenting Stress Index (PSI)

• Family Assessment Device (FAD)

Parenting Interventions

• Need to target – Parenting issues – Grief and Loss issues – Emotional and behavioural dysregulation in the

child– Broader family context, including sibling issues

How to support parents

Where to start ?• Psychoeducation – not just about the Autism and associated

child difficulties but also about impact on parents. For example, psychoeducation about parental fatigue and its impact on wellbeing and coping.

• Regular Parent Meetings

• Regular School Meetings

• Professional liaison

Parenting strategies for managing emotional difficulties in children with Autism

• Understand the triggers for anxiety/dysregulation – (e.g., change)

• How does the anxiety manifest – (e.g., meltdowns, self stimulatory behaviours)

• Chain analysis• Behavioural Principles - Positive reinforcement (see Campbell & Kozloff, 2007) - Unrewarded coercion - Unrewarded threat, earning - Single signals/Cooperation training

Parenting strategies cont./

• Use the behavioural principles to develop a family/school plan to manage specific behaviours. Rehearse the plan.

• Role of punishment – Type 1 or Type 2

• Use Schedules that incorporate visual symbols. Start with simple daily schedules (shopping, doctor – illustrated with visual symbols). Can use mini-schedules for specific daily routines. Can use schedules with moveable pieces - these are good when there are changes to the routine.

• Bubbles – can be used to tempt the child into communication; they can also be used as a distractor & motivator.

• Other tempters for communication include Thomas the Tank Engine, balloons, having toys in clear plastic containers that he/she is unable to open.

• Visual Cues – these are critical for children with Autism because they often have strengths in the visual domain.

• Visuals can be objects, parts of objects, pictures, photographs, drawings, & symbols produced on the computer. Print name of visual so all use same word.

Parent Strategies cont./

• Use visual timetables & routines – see www.bubhub.com.au/rewardharts/school2.pdf; www.bubhub.com.au/rewardcharts/homefromschool1.pdf

• Other step-by-step visuals – see elearning.autism.net/visuals/main.php?g2_itemId=57

• Combine with use of visuals with language.

Parent Strategies cont./

• Teaching Emotions (Emotion Coaching) • Autism Xpress – download APP

• Games on Feelings & Facial Expressions – download from www.do2learn.com

• Thomas the Tank Engine Emotions Game – download from www.thomasandfriends.com.au/Thomas.mvc/Games/Home

• Strength Cards – see Innovative Resources • Can do Dinosaurs – see Innovative Resources • Stress Scale Thermometer

Parent Strategies cont./

• Anticipation • Preparation• Problem Solving • Rehearsal • Coaching

As much as possible children with Autism need to be prepared for change and new situations; important to respect their anxiety associated with this, and prepare in advance where possible (home and school settings).

Parent Strategies cont./

Effective strategies depend on an environment that provides opportunities for:

• Support• Shaping • Modelling• Prompting• Positive Reinforcement and Praise• Generalisation strategies

Specific support for parents

• Individual therapy- stress management, mood management, supportive psychotherapy

• Grief and Loss work • Couple therapy• Parents as co therapists • Parents as advocates

Parenting Programs ..example • Stepping Stones Triple P (SSTP) (Sanders et al.,2004)

• Relies on a public health approach to parenting • Programs vary depending on the level of intervention required. • Five levels of intervention are available

– Media and Communication Strategy– Brief Selective Intervention (e.g., large group seminar) – Narrow Focus Training (brief, tailored interventions to

families)– Broad Focus Training (individual, group, self-directed

formats – 10 sessions)– Intensive Additional Modules

American Psychiatric Association. (2013). Diagnostic and Statistical Manual for Mental Disorders. USA: American Psychiatric Association.

Bristol,M.M., Gallagher, J.J., & Holt, K.D. (1993). Maternal depressive symptoms in Autism: Response to psychoeducational intervention. Rehabilitation Psychology, 38, 3-10.

Benderix, Y., Nordström, B., & Sivberg, B. (2007). Parents’ experience of having a child with autism and learning disabilities living in a group home: A case study. Autism, 10, 629-641.

Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh sleep quality index: A new instrument for psychiatric practices and research. Psychiatry Research, 28, 193-213.

Campbell, M., & Kozloff, M. (2007). Comprehensive programs for families of children with autism. In J.M. Briesmeister & C.E., Schaefer, (Eds). Handbook of parent training: Helping parents prevent and solve behaviours. Wiley: USA.

Davis, N. & Carter, A. (2008). Parenting stress in mothers and fathers of toddlers with autism spectrum disorders: Associations with child characteristics. Journal of Autism and Developmental Disorders, 38, 1278-1291

Eisenhower, A. S., Baker, B. L., & Blacher, J. (2005). Preschool children with intellectual disability: syndrome specificity, behaviour problems, and maternal well-being. Journal of Intellectual Disability Research, 49, 657-671.

Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (1983). The McMaster Family Assessment Device. Journal of Marital and Family Therapy, 9, 171-180.

Giallo, R., Wood, C.E., Jellett, R., & Porter, R. (2012). Fatigue, wellbeing and parental self-efficacy in mothers of children with an autism spectrum disorder. Autism: International Journal of Research and Practice http://dx.doi.org/10.1177/1362361311416830

Hastings, R. P. (2002). Parental stress and behaviour problems of children with developmental disability. Journal of Intellectual and Developmental Disability, 27, 149-160.

Herring, S., Gray, K., Taffe, J., Tonge, B., Sweeney, D., & Einfeld, S. (2006). Behaviour and emotional problems in toddlers with pervasive developmental disorders and developmental delay: Associations with parental mental health and family functioning. Journal of Intellectual Disability Research, 50, 874-882.

Kelly, A.B., Garnett, M.S, Attwood, T., & Peterson, C. (2008). Autism Spectrum symptomatology in children: The impact of family and peer relationships. Journal of Abnormal Child Psychology, 36, 1069-1081.

Kuhn, J. C., & Carter, A.S. (2006). Maternal self-efficacy and associated parenting cognitions among mothers of children with autism. American Journal of Orthopsychiatry, 76, 564-575.

References/Readings

Larkey, S., & von Ess, G. Early years: The foundations for all learning.

Larkey, S., & von Ess, G. (2010). Developing social skills: Practical ideas for teaching children with Autism Spectrum Disorders and other developmental delays

Lopez-Wagner, M. C., Hoffman, C. D., Sweeney, D. P., Hodge, D. & Gilliam, J. E. (2008). Sleep problems of parents of typically developing children and parents of children with autism. The Journal of Genetic Psychology, 169, 245-259.

Maskey, M., Warnell, F., Parr, J.R., Le Couteur, A., & McConachie, H. (2013). Emotional and behavioural problems in children with Autism Spectrum Disorder. J Autism Dev Disord, 43, 851-859.

Michielsen, H. J., De Vries, J., & Van Heck, G.L. (2003). Psychometric qualities of a brief self-rated fatigue measure: The fatigue assessment scale. Journal of Psychosomatic Research, 54, 345-352.

Notbohm, E., & Zysk, V. (2010). 1001 great ideas for teaching and raising children with Autism or Asperger’s. Texas: Future Horizons.

O’Reilly, B., & Smith, S. (2009). Australian Autism Handbook. New South Wales:Jane Curry Publishing. Prior, M., & Roberts, J. (2006). Early intervention for children with Autism Spectrum Disorders: Guidelines for Best

Practice. Rogers, S.J., & Vismara, L.A. (2008). Evidence-based comprehensive treatments for early Autism. Journal of Clinical

Child & Adolescent Psychology, 37, 8-38.Ryan, C. E., Epstein, N. B., Keitner, G. I., Miller, I. W., & Bishop, D. S. (2005). Evaluating and treating families: The

McMaster approach. New York: Routledge. Seymour, M., Giallo, R., Wood, C. (2012). Behaviour difficulties in young children with an ASD:    Relationships with

parental stress, fatigue and coping. Autism: International Journal of Research and Practice. DOI: 10.1007/s10803-012-1701-y.

Tellegen, C.L., & Sanders, M.R. (2013). Stepping Stones Triple P-Positive Parenting Program for children with disability: A systematic review and meta-analysis. Research in Developmental Disabilities, 34, 1556-1571.

Vickers, M., Parris, M., & Bailey, J. (2004). Working mothers of children with chronic illness: Narratives of working and caring. Australian Journal of Early Childhood, 29, 39-44.

References/Readings

Acknowledgements

Dr Rebecca Giallo

Rachel Jellett

Monique Seymour

Rachelle Porter

Rebecca Ferrarotto

Lauren Rawlings

The Treatment of Emotional Disorders in Children with High

Functioning Autism

Dr Fiona ZandtClinical Psychologist

ASD and Mental Health Difficulties

• Research suggests that as many as 70% of children and adolescents with ASD have comorbid mental health problems

• A large percentage use mental health services – Narendorf et al. (2011) found 46% had used a

service in the last year

Why so high?

• Poor understanding of social world– Difficulty understanding thoughts – own and

others• Difficulty regulating emotions• Strong preference for sameness• Changes in routine• Language difficulties• Learning difficulties• Sensory processing difficulties

Evidence for CBT in ASDA number of large studies have also found CBT to

be effective for reducing anxiety in children and adolescents with ASD

Group programs typically involving an adoption of a program for typically developing kids, such as “Cool Kids”Reaven et al. (2012)McNally et al. (2013)McConachie et al. (2013)Sofronoff, Attwood, and Hinton (2005)Chalfant, Rapee, and Caroll (2007)Wood et al. (2009) – Individual therapy

• “These studies provide initial support for using CBT in the treatment of mental health problems of young people with a diagnosis of AS.” (Donoghue et al., 2011).

• The literature has focused on anxiety –– Anxiety may precede later mood difficulties– Many of the CBT strategies aimed at helping

anxiety may also be helpful for lowered mood– Anxiety may be more present in the under 12

age group

–“it is necessary to accommodate the cognitive profile of the child with AS when conducting CBT and modify the approach to achieve this” (Sofronoff et al. 2005, pg 1153)

Stallard’s (2005) PRECISE acronym

• Based on Partnership working• Pitched at the Right developmental level• Promotes Empathy• Is Creative• Encourages Investigation and experimentation• Facilitates Self-discovery and efficacy• Is Enjoyable

Donoghue et al. (2011) considered how this could be applied to ASD

• Partnership working –– Complicated as relationships can be a source of

anxiety and confusion– Be explicit and clarify what the expectations are– Use a written schedule to maintain focus in

sessions– Use activities that provide a focus other than the

social interaction to decrease anxiety (e.g. drawing, playdoh, throwing a ball)

• Consider parents and children’s capabilities, who the problem effects and who is motivated to change it. What is the role of the broader system?

• Ongoing relationship with a therapist is often helpful for children with ASD

• Blocks of therapy at times of need likely to be most appropriate

• Review appointments may assist in managing symptoms and reduce the number of blocks of therapy an individual requires

Further thoughts on working together

• Experience a considerable amount of parenting stress

• May have similar traits– Often these traits can impact on therapy

• May have their own mental health issues (anxiety, OCD, etc.)

And Parents

• It is helpful to –– Articulate similarities and utilise these to foster

insight– Articulate differences, encourage appreciation of

each other’s perspective and work towards a middle ground

– Work towards more effective patterns of relating– Encourage a balance between intervention and

acceptance

Right developmental level

• Use precise and concrete language (and be prepared to explain when you haven’t)

• Make the goals realistic and manageable• Represent emotional material visually• Involve parents as co-therapists, with a view to

assisting with generalisation– (Remember children with ASD often have a

scattered developmental profile and their emotional and social development is impaired)

Empathy

• Often the social interaction between client and therapist will be unusual

• May need to maintain a task based approach

Your role in facilitating empathy

• May be helpful to reflect on your feelings and thoughts

• Overt the expectations of the therapy space and reflect on how these are similar and different to other spaces the child inhabits and relationships that the child has

• For example, Sally and the not talking

Creativity

• It is often helpful to use other media and rely less on talking

• Using technology is encouraged (though you will need to have some clear guidelines around this)

• Programs specifically designed for use with the ASD population may also be of help –– SAS – Social stories and Comic Strip conversations by

Carol Gray

Visual supports

• A picture or object that the child can see that enhances comprehension and learning.

• A considerable body of evidence shows that visual supports –– Improve understanding– Improve expressive ability– Increase emotional resilience– Decrease challenging behaviour– For review see Arthur-Kelly et al. (2009)

Draw what happened

What I did

What I would do next time

Investigation and experimentation

• Children with ASD often have trouble reflecting on their thoughts and feelings

• Focusing on the cognitive is often less important– Remember cognitions change through doing

• While it is often helpful to do some work around cognitions this is likely to need more structuring for children with ASD– Look for helpful rules/thoughts that can be

applied across situations

Self discovery and efficacy

• Highlight the skills the child is currently using• Use metaphors and social observation to

encourage children to learn about their own social skills and those of others

Rosie’s social map

Enjoyable

• Use non-verbal materials• Have shorter sessions if need be• Use humour• MAKE IT FUN!

Is it a Brontosaurus size problem or a Pterodactyl size one?

• Try to incorporate a child’s interests in sessions as this will make it more enjoyable

• Other examples include –– Blow angry/sad thoughts into a balloon as you

name them. Decide whether to let them go, tie them up etc.

– Try racing down the hall, stepping forward when you can think of a helpful coping strategy.

– Get out of your chair and have some fun.

Emotional difficulties and social skills –Can we work on these separately?

• A preliminary study using the Multimodal Anxiety and Social Skill Intervention (MASSI) was found to improve social skills and decrease anxiety (White et al., 2013).

• Develop social skills and promote empathy– Use the relationship and reflect on your

thoughts and feelings

– Therapy itself is often therapeutic

Jake’s Aha Moment

• 7 year old, with little early intervention• Significant receptive language difficulties,

better expressive language (though very poor pragmatic language skills)

• High levels of anxiety around anything that is new, transitions, etc., associated with avoidance

• Worked on social skills and emotional understanding in combination with supporting parents to better manage anxiety

• “Ah, look at him now!”

Further thoughts about what is helpful

• Sensory issues –– Manage during the session– Identify triggers and maintaining factors that be

related to issues with sensory processing

Oscar’s Tent

• Recently commenced primary school• Bright child, though very much functioning

according to his own agenda• First, then scheduling used for brief periods of

work, following time with a favoured activity• Used a tent so that Oscar could request time

out appropriately, rather than distracting the other children

Chris and the running away

• Long-history of running away when overwhelmed– Often triggered by work being too difficult,

feeling excluded socially, or change– Several times placed himself in dangerous

positions

• Therapy focussed on –– Understanding the impact on others– Identifying a safe area he could retreat to– Working on a signal to let the Teacher know– Developing anxiety management skills, greater

awareness of own feelings, positive self statements, single deep breath

– Worked on ensuring work was appropriate– Arranged for tutoring in maths

Helpful Resources• Amaze

– http://www.amaze.org.au/

• National Autistic Society– www.nas.org.uk

• Autism Help– www.autismhelp.info

• ACT NOW– www.med.monash.edu.au/sppm/research/devpsych/actno

w

• Carol Gray’s website – www.thegraycenter.org

• Tony Attwood’s website– www.tonyattwood.com.au

• http://accessmq.com.au/node/163• Cool kids for children with Autism and Aspergers

kit (Macquarie University)• www.signposts.net.au

• Statewide program for parents of children with an ID or developmental delay

• http://raisingchildren.net.au/children_with_autism/children_with_autism_landing.html• Good information for parents, including video clips

www.do2learn.com– Good info and lots or free resources and picture cardswww.usevisualstrategies.com– Good info on using visual supports and printable

pictures

• Dr Fiona Zandt• Clinical Psychologist• fiona.zandt@bigpond.com

QUESTIONS & ANSWERS

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