The Treatment of Emotional
Disorders in High Functioning
Autism
Wednesday 19th March 2014
1:30pm – 3:00pm AEDT
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PRESENTERS:
Dr Katie Wood
Clinical Psychologist
Swinburne University of Technology
Dr Fiona Zandt
Clinical Psychologist
Royal Children’s Hospital
Facilitator: Harry Lovelock, Senior Executive
Manager APS
The Treatment of Emotional
Disorders in High Functioning
Autism
Dr Katie Wood
Clinical Psychologist
19th March 2014
Brief Background: ASD overview
•
Neuro developmental disorders associated with patterns of delay across
multiple areas.
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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)
Brief Background: ASD overview
• 2012 - 1 in 110* means...
Half a million Australian Families affected by
ASD
• Cost of intervention ($, time)
• Impact on the family
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.
What’s new in the DSM-V 2?
• 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.
See DSM-V website
http://www.dsm5.org/Documents/Autism20Spectrum20Disorder20Fact20Sheet.pdf
The Family Environment
Child
behaviour
Parent Behaviour
Parent Wellbeing
Family Functioning
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.
Parent Strategies cont./
•
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
www.bubhub.com.au/rewardharts/school2.pdf;
www.bubhub.com.au/rewardcharts/homefromschool1.pdf
•
Other
step-by-step
visuals
elearning.autism.net/visuals/main.php?g2_itemId=57
•
Combine with use of visuals with language.
–
–
see
see
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./
•
•
•
•
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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).
Effective strategies depend
on an environment that provides
opportunities for:
•
•
•
•
•
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Support
Shaping
Modelling
Prompting
Positive Reinforcement and Praise
Generalisation strategies
Specific support for parents
•
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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
References/Readings
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, 12781291
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.
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 Zandt
Clinical 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 ASD
 A 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)
Further thoughts on working together
• 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
And Parents
• 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.)
• 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
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–
–
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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/act
now
• 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
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Statewide program for parents of children with an ID or
developmental delay
• http://raisingchildren.net.au/children_with_autism/childr
en_with_autism_landing.html
•
Good information for parents, including video clips
www.do2learn.com
– Good info and lots or free resources and picture cards
www.usevisualstrategies.com
– Good info on using visual supports and printable
pictures
• Dr Fiona Zandt
• Clinical Psychologist
• fiona.zandt@bigpond.com
QUESTIONS &
ANSWERS
REMINDERS
•
Contact The ATAPS CMHS Clinical Support Service. Phone
1800 031 185 or email clinicalsupport@psychology.org.au
•
Two further CMH webinars will be organised in the coming months
– See the ATAPS Clinical Support Service web portal for details.
•
A recording of this webinar will be available on the APS ATAPS
Clinical Support Service web portal - see
http://www.psychology.org.au/ATAPS/networking_CMHS/
•
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•
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