Slide 1 BEHAVIORAL AND MENTAL HEALTH INTERVENTIONS … · BEHAVIORAL AND MENTAL HEALTH...

BEHAVIORAL AND MENTAL HEALTH

INTERVENTIONS FOR CHILDREN WITH ASD

Crystal Gray, Ph.D. Clinical Psychologist & Autism SpecialistPuget Sound Psychology & Consulting

www.pugetsoundpsychology.com206-883-6175

[email protected]

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Slide 2 Overview

Part I: Understanding ASD Part II: Comorbid Mental Health Conditions Part III: Strategies for Promoting Behavior Change

& Independence

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Slide 3

PART I: UNDERSTANDING ASD

1. The Autism Spectrum2. Diagnosis3. Characteristics

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Pervasive Developmental Disorders

The Autism Spectrum

-------Autism----Asperger’s----PDD-NOS-----

Autism Spectrum Disorders are a collection of overlapping groups of symptoms

(behavior, communication, social skills)that vary from child to child.

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Slide 5 What is Autism ?

A. Impairment in each of the following:

(1) Qualitative Impairment in Social Interaction

(2) Qualitative Impairment in Communication

(3) Restricted & Repetitive Patterns of Behavior

B. Delay in one of the above areas prior to age 3.

C. Not better accounted for by Rett’s or CDD

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Slide 6 What is Asperger’s Syndrome?

Generally noticed after age 3 (often at 5, 6, or 7)A. Qualitative impairment in social interactionB. Restricted, repetitive, and stereotyped patterns of

behavior.C. Impairment in social, educational or occupational

functioningD/E. There is no:

Clinically significant general delay in language Clinically significant delay in cognitive development, age-appropriate self-

help skills, adaptive behavior, or curiosity about the environment.

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What is PDD-NOS?

Pervasive Developmental Disorder – Not Otherwise Specified

Severe and pervasive impairment in: Social interaction

Verbal and nonverbal communication skills

Stereotyped behavior, interests, and activities

Not better accounted for by a specific PDD

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Slide 8 PDD Symptom Phenotype

1. Social-communication2. Inflexible language and behavior3. Repetitive sensory and motor behavior

J. Am. Acad. Child Adolesc. Psychiatry, 2007; 46(2):188-196.

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Slide 9 Characteristics

Core Traits:1. Social2. Communication3. Restricted, Repetitive

Stereotyped BehaviorRelated Traits:1. Sensory 2. Motor 3. Attention4. Academics5. Emotional

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1. Social Impairment

Impairment in the use of non-verbal behaviors

Poor sustained eye-contact on the speaker diminishes understanding of the total communicative message.

Does not observe/may miss other’s social cues Does not process/may miss the meaning of their message. Difficulty recognizing and incorporating other person’s

perspectives into how to regulate social relationships.

Failure to develop age appropriate relationships Poor imitation skills

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Slide 11

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Slide 12 2. Pragmatic Communication

Stereotyped or idiosyncratic speech– “cat”

Abnormal pitch, intonation, rhythm, stress

Grammatical structure may appear immature

Difficulty understanding & interpreting pragmatic language Literal interpretation

Difficulty initiating social interactions, asking for help, getting started

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3. Restricted, Repetitive, & Stereotyped Patterns of Behavior

Fascination with activities, topics or objects that are abnormal in focus or intensity

Stereotyped, repetitive or unusual motor mannerisms

Behavior that seem compulsive, including an unusual insistence on routine

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Slide 14 Purpose of Interests

Facilitate conversation Indicate intelligence Provide an enjoyable activity Serve as a means of relaxation Provide order and consistency in the person’s life

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Slide 15 Characteristics

Core Traits:1. Social2. Communication3. Restricted, Repetitive Stereotyped Related Traits:1. Sensory 2. Motor 3. Attention4. Academics5. Emotional

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1. Sensory Impairments

Hyper or hypo sensitivity: Sounds Tastes Visual input Textures Smell

Insensitivity to pain

Limited awareness of the physical presence or needs of others

Unaware of their bodies place in space

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Slide 17 2. Motor Characteristics

Poor fine & gross motor skills

Difficulty with coordination

Balance problems

Writing is extremely difficult & laborious sloppy, off the lines, out of

the boundaries Playground & sports may

be awkward, difficult, & frustrating

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Slide 18 3. Attention & Organization

Poor Concentration Often off task Distractible Overloads easily May be disorganized Difficulty sustaining attention

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Attention & Organization cont…

Poor organizational skills May lose papers, assignments, etc. Desk may be messy Backpack never emptied May not be able to predict or organize things needed for

homework: book, packet, etc. May not remember homework Papers can be messy and written work unorganized Difficulty knowing how and where to start work

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Slide 20

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Slide 21 4. Academics

Difficulty inferring meaning from social cues or deciphering meaning from words Limited ability to infer meaning from books and lectures.

Not good at tracking how language fits into the overall concept being discussed Tangential Off topic remarks

Attends to details but misses the underlying concept of assignments.

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Academics cont…

Very literal in interpretation Very fact based, inference is next to impossibleWriting can be tangential or misses the point.Difficulty staying with the concept of group work

and cooperative learning.Comprehension problems (but may be hyperlexic)Difficulty with abstract conceptsPoor problem solving (but may do well with math

computations) Difficulty with generalization & maintenance

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Slide 23 5. Emotional Vulnerability

Difficulties coping with the social and emotional demands of school/work

Easily stressed, inflexible, perfectionist Low self-esteem Difficulty tolerating mistakes (self and others) Prone to depression and anxiety May have rage reactions and temper outbursts

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Slide 24 On the flip side…

Usually have a great sense of humor, but may miss the subtleties of humor. May not understand the difference of being laughed at

or laughed with. The student may produces inappropriate humor in the

class as an attempt to engage others.

Likely respond well to a teacher/supervisor who has a bit more of a relaxed, humorous style, but is still able to follow a fairly structured routine.

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A Trip to the Store

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Slide 26

PART II: COMORBID MENTAL HEALTH CONDITIONS

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Slide 27

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Comorbidity of autism & asperger

Aggression

ADHD

Psychosis

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Slide 29 Comorbidity

ADHD Depression Anxiety Psychotic Disorders Tic & Movement Disorders

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Slide 30

ATTENTION DEFICIT HYPERACTIVITY DISORDER

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Attention Deficit Hyperactivity DisorderADHD/ADD (attention deficit disorder)

3 Types = Hyperactive, Inattentive and Mixed

Rates = 5% of school age children in the US Gender = More common in males v. females

Girls = inattentive w/ more social problems Boys = hyperactive/impulsive w/behavior problems

Cause = combination of genes & environment Brain imaging = abnormalities in frontal lobes Treatment

Medication + Behavior therapy

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Slide 32 Symptoms

Inattention Easily distracted, poor short term memory

Forgets instructions, fails to finish tasks

Disorganized, appears not to hear

Learning difficulties

Hyperactivity Excessive restlessness, in constant motion

Difficulty sitting still or staying seated

Has a ‘driven’ quality, runs and jumps

Insatiable (never satisfied, never enough)

Impulsivity Acts without thought or sense

of safety

Unpredictable behavior

Needs constant supervision

Interrupts, intrudes on others

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Slide 33 ADHD in ASD

Can it occur? Yes Prevalence

No exact estimates knownADHD = 31% (varies from 29-73%)Subsyndromal = 55%Attention problems = 95% Impulsiveness = 50%

12% of children with ASD are prescribed stimulant medications

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MOOD DISORDERS/ DEPRESSION

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Slide 35 Depressive Symptoms

Depressed or irritable mood Diminished interest and pleasure in all (almost all)

activities Weight loss (without dieting) or decrease/increase in

appetite Insomnia/hypersomnia Psychomotor agitation Fatigue Worthlessness Decreased concentration/indecisiveness Thoughts of suicide/death

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Slide 36 Depression

Rates Adults 10% Teens 10-14% School-age (pre-teen) 1.5-3% Pre-school <1% Average age is late adolescence to early adulthood

Gender Childhood: boys = girls Adolescence & Adulthood: female 2x > male

Cause: genetic & environmental factors

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Depression in ASD

Depression = 10-30% Special features of Depression in ASD:

Increase in social withdrawal and isolation Increase in obsessive compulsive/ ritualistic behavior Change in the character of obsessions => depressive Irritability => anger & aggression Regression of skills (especially in more severe autism) Psychotic behavior

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Slide 38 Depression in ASD: Causes & Contributors

Family history/ genetic predisposition Medical conditions (e.g. seizure disorders) Other mental health conditions (i.e. anxiety, ADHD) Environment

Peer victimization – frequent teasing and bullying Loneliness and desire for friendships Awareness and insight into differences

Individuals with less social impairment, higher cognitive ability & higher rates of other psych sx

Tx: Medications, CBT, Social Skills, Address Problems

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Slide 39

ANXIETY DISORDERS

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Anxiety Disorders

Types Obsessive Compulsive Disorder Social Phobia/Anxiety Separation Anxiety Specific Phobia (e.g. fear of heights, snakes, spiders)

Also: Panic Disorder Generalized Anxiety Disorder Post Traumatic Stress Disorder

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Slide 41 Anxiety- Obsessive Compulsive Disorder

What is it? Obsessions – thoughts that intrude into a persons mind Compulsions – acts and rituals that have to be carried out

in a repetitive manner (meant to decrease anxiety)

Time consuming, distressing & interfere with daily life functions (children may not identify them as so).

http://realtimehealth.com/conditions/obsessivecompulsivedisorder

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Slide 42 OCD …

“I couldn’t do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn’t. It took me longer to read because I’d count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn’t add up to a ’bad’ number.”

“I knew the rituals didn’t make sense, and I was deeply ashamed of them, but I couldn’t seem to overcome them until I had therapy.”

“Getting dressed in the morning was tough, because I had a routine, and if I didn’t follow the routine, I’d get anxious and would have to get dressed again. I always worried that if I didn’t do something, my parents were going to die. I’d have these terrible thoughts of harming my parents. That was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me.”

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Anxiety- Obsessive Compulsive Disorder

Rate 2.5% (lifetime prevalence) Males > Females Bimodal age distribution: 10-12 yr & early adulthood Cause: genetic & environmental factors

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Slide 44 OCD in ASD

Core component(s) of ASD: Verbal and motor rituals, obsessive questioning, fixation on

routines, preoccupation with detail, desire for sameness

Differentiation: Exacerbation of symptoms with clear history & onset

Main clinical focus

Egodystonic

Rates of OCD in ASD = 2% (range 1.5 - 81%)

First line treatment of OCD CBT with Exposure & Response Prevention Serotonin Reuptake Inhibitors (SRI)

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Slide 45 Anxiety – Social Phobia

Marked and persistent fear (i.e. anxiety) of one or more social or performance situation in which the person fears that embarrassment may occur.

13.3% (lifetime prevalence) Onset – adolescence (common in childhood) Treatment

Medications – Antidepressants Therapy – Cognitive Behavior Therapy

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Social Phobia in ASD

Rates = 7.4% According to the DSM-IV-TR, a dx of social anxiety

should not be made in the presence of ASD Implies that social phobia is a part of the disorder ASD = social deficits => social anxiety Correlated with higher IQ, Social Skills and Insight Treatment Medications – Antidepressants Therapy – Cognitive Behavior Therapy Social Skills instruction

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Slide 47 Anxiety – Separation Anxiety

Excessive anxiety and fear concerning separation from home or from a primary caregiver.

4.1% (prevalence rate) Onset – childhood

5-8: fear of harm befalling parent, nightmares, school refusal

9-12: distress at the time of separation 13-16: somatic complaints and school refusal

Often progresses from mild to severe avoidance

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Slide 48 Separation Anxiety in ASD

Rates = 12% According to the DSM-IV-TR, a dx of separation

anxiety should not be made in the presence of ASD Implies that separation anxiety is a part of the disorder

ASD = fear of change + social deficits + difficulty in school => separation anxiety + school refusal

Correlated with a higher level of intelligence & some level of obsessive behaviors

Treatment: Antidepressants, CBT, social skills

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Specific Phobia

What is it? Marked and persistent fear of specific objects or situations. Unrelated to social phobia (fear of embarrassment in public

or performance) or fear of panic attacks Phobias are avoided or endured with distress

Common childhood phobias – heights, darkness, loud noises, injections, insects, dogs

Prevalence: 4-8% Age of onset:

Prior to age 7: animals, darkness insects, blood, and injury Increased risk 10-13 years, but can occur across the life span

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Slide 50 Specific Phobia in ASD

Prevalence - 44% (10% to loud noises) Excessive fearfulness to common objects and

situations (associated feature of ASD)

Treatments: Antidepressant medications CBT with Exposure & Response Prevention

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Slide 51

SCHIZOPHRENIA & THOUGHT DISORDERS

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Schizophrenia (Thought Disorders)

Severe mental disorder characterized by impairment of thought, mood and perception (i.e. presence of hallucinations and/or delusions)

1% (Prevalence) Males > females Age of onset = early adulthood (uncommon in children) Childhood onset = Poor premorbid adjustment

Poor social relationships Communication abnormalities (difficulties with eye contact) Motor abnormalities (clumsiness and lack of coordination)

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Slide 53 Schizophrenia (Thought Disorders) in ASD

Prevalence: few studies, but considered rare Children (8-17yrs) with ASD exhibit significantly more

illogical thinking and loose associations Illogical thinking related to aspects of cognitive

functioning and to executive control. Loose associations were related to autism communication

symptoms and to parent reports of stress and anxiety. When TD is present in ASDs, it generally is not a co-

morbid schizophrenia symptom, but is related to pragmatic language abnormalities found in ASDs. (Solomon et al., 2008)

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Slide 54 McDD (Multiple Complex DD)

Multiple complex developmental disorder: Under study as a separate & new disorder Social impairments, affective dysregulation, and

thought disturbance These symptoms are currently diagnosed as PDDNOS

or related disorders

(initial studies, ASD and McDD = 8%)

(deBruin et al, 2006; Strum, Fernell, Gillberg, 2004; Leyfer et al., 2006)

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TIC DISORDERS

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Slide 56 Tic Disorders

What are tics? Sudden, rapid, recurrent stereotyped motor mannerisms or

vocalizations. Types: Motor (simple: jerk, eye blink, twitch) or (complex: grooming

behavior, facial gestures) Vocal (simple: grunts, throat clearing) or (complex: repeating words

or phrases out of context, uttering obscenities, echolalia)

Tic Disorders: Chronic motor or vocal tic disorder Tourette’s disorder Transient Tic Disorder Tic Disorder – Not Otherwise Specified

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Slide 57 Tourette’s Video

http://video.google.com/videoplay?docid=-5419952820725946842&hl=en

National Tourette Syndrome Associationhttp://www.tsa-usa.org/ 42-40 Bell Blvd., Suite 205Bayside, NY 11361-2820718-224-2999

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Tic Disorders cont…

Rates 1:1000 (thought to be an underestimate) 10% of children have transient tics 50% of tics disappear by 18 yr 3x more common in boys Cause is biological (and environmental):

Basal ganglia-thalamo-cortical network abnormalities (imaging studies)

Stimulant medications can precipitate tics (may trigger a pre-existing genetic propensity?)

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Slide 59 Tic Disorder in ASD

Stereotyped and repetitive motor mannerisms are considered a core symptom of the disorder

Separate Tic Disorder should be dx if the symptoms are severe and interfere with functioning = 4%

Treatment of Tics: Atypical antipsychotics, clonidine (hypertensive),

pimozide (2nd line antipsychotic) Behavioral suppression and replacement

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Slide 60 PART III: STRATEGIES FOR

PROMOTING BEHAVIOR CHANGE & INDEPENDENCE

Do what you can with what you have, where you are.

~Theodore Roosevelt

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Strategies

The good newsThe good news……what works for children what works for children with ASD, will be helpful for with ASD, will be helpful for allall childrenchildren……

A. Be clear, concise & consistentB. Use rewardsC. Develop a behavior planD. Support friendship and social thinking

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Slide 62

1. Provide rules2. Make expectations explicit3. Use routines & schedules

A. Clear, Concrete & ConsistentA. Clear, Concrete & Consistent

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Slide 63 1. Provide Rules:Social Behavior Map

Expected Behaviors

Feelings of Others

Consequence How people react

How you feel

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2. Clear Expectations

Add a visual cue, such as holding up the materials you are asking them to get

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Slide 65 3. Use Routines & Schedules

Many children will need an individual schedule

Helps them organize and become more independent

Helps make their day predictable

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Slide 66 A Mini-Schedule for Tasks

Can be very helpful for the visual learner to recall the steps to a task or activity

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What would you attempt to do if you knew you

could not fail.

~Robert Schuller

B. Motivate and ReinforceB. Motivate and Reinforce

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Slide 68 Motivate and Reinforce

Motivate Set realistic goals

Identify reinforcing activities, games, phrases Free timeAsking directlyPresenting choicesSpecial interests

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Slide 69

Set up and utilize a reinforcement scheduleProvide rewards for attaining goalsStart heavy and fade as performance improves Identify baseline and initially make sure they earn

the rewardHave the child choose what they want to work for

each day. Utilize a visual system Scheduled Token system First then Break

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Slide 71

The last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.

~Victor Frankl

C. SelfC. Self--RegulationRegulation

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Slide 72 Self-Regulation

1. Identify stressors & meaning of behavior2. Create a safe place3. Teach relaxation/coping strategies4. Meet sensory needs

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Slide 74 1. Discovering the Function of Behavior

BEHAVIOR =COMMUNICATION Obtaining attention Getting help Getting feedback or approval Making a need known Protesting an unwanted event Increasing or decreasing stimulation in the

environment Reducing anxiety or nervousness Reducing boredom

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Slide 75

Fulfill a ritual Obtain rest Prevent the interruption of a favored activity Gain predictability about future events Protest/reverse a change in routine Escape punishment, task demands, a certain peer,

criticism Get help or express confusion

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But, how do we figure out the meaning of behavior?

Looking for patterns…

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Slide 77 Collect Information: Antecedent

Antecedent events determine the person, place, or times where behavior occurs. Environmental and/or sensory input Time of the day, day of the week Person (s) Curriculum and Instruction

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Slide 78 Antecedent: Diagnostic Questions

Are there people, times, situations when the behavior is more/less likely to occur?

Does the behavior increase when: a) task demands are made, b) when the individual is alone, c) a request is rejected?

Can we create an environment (zero baseline) in which the behavior is highly unlikely to occur?

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Collect Information: Setting Events

Exaggerate the likelihood of problem behaviors In themselves do not trigger problem behavior. Increase the probability of an antecedent event

triggering a behavior. Are often Physiological/Emotional Conditions

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Slide 80 Setting Event: Diagnostic Questions

Could there be a medical problem? Is the child sick? Has the child had a seizure?

Could there be a drug problem? Is the child anxious, depressed, scared?

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Slide 81 The Behavior Itself: Diagnostic Questions

How intense is it (scale of 0-10)? Is it more intense in certain situations? How long does the behavior last (duration)? Does the frequency, intensity, and duration vary from

incident to incident, location to location, person to person?

What is the escalation pattern of the behavior?

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Collect Information: Consequences

Determine the consequences: what typically happens after the behavior occurs?1. Obtain item or attention2. Escape or avoid a situation3. Sensory input4. Actual consequence of the event

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Slide 83 Create an Intervention

Positive behavior supports 90% reduction in problem behavior!

(National Research Council, 2001; Horner et al. 2002)

1. Modify the environment or instruction to match the identified need

(and/or)

Find & teach appropriate replacement behaviors to serve the same function.

2. Positive behaviors are then reinforced to reduce negative behaviors.

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Slide 84 2. Create a Home Base

Foster comfortable relationships with multiple adults

Always have a Plan B Provide a safe place or home base

Supportive, not punitive Schedule after stressful times or classes Consider using at start and end of day Allow as needed Addresses sensory needs Provides a place to calm down and problem

solve

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1. What goes into a safe area?2. Teach use of safe area

1. Create a card or symbol for the safe area2. Introduce the safe area during calm times3. Cue the student to use the safe area at the earliest

signs of agitation4. Allow the student to continue work in the safe area5. Have a calming plan in the safe area…

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Slide 86

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Slide 87 3. Teach Coping Strategies

Teach relaxation strategies Deep breathing, Progressive Muscle Relaxation, Shoulder Roles, Visualization Sensory: Oral, movement,

touch, visual, listen

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4. Meet Sensory Needs:

•Make planned breaks part of the daily schedule•Allow strategies such as gum chewing, a personal CD player, or the opportunity to stand and work•Include heavy work in everyday routines

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Slide 89

Our differences are no longer stumbling blocks to communication and progress. Instead they become the stepping stones to synergy.

~Stephen R. Covey

D. Support Friendship & D. Support Friendship & Social ThinkingSocial Thinking

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Slide 90 Social Skills

Peer supports Social skills instruction Facilitate & provide opportunity for social

interactions

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1. Peer Supports

Description: Peers are explicitly taught how to initiate interactions,

prompt social responses, give feedback, and reinforce Adults monitor the interactions and provide support.

Peer Mediated: 20+ years of experimentally controlled support for increase in skills & frequency & length of interactions + maintenance & generalization .

(DiSalvo and Oswald, 2002; Kalyva and Avramidis, 2005; Morrison, Garcia, and Parker, 2001).

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Slide 92

Give students basic information on ASD Provide simple guidelines for interactions:

E.g. stay near the student with ASD, praise them for small interactions, join their activity, make comments, be persistent.

Role play possible scenarios with the peer.

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Slide 93 2. Teach Social Skills

Make the components of the social situation explicit: List the unspoken rules of a social situation. Break complex behaviors into steps Who, what, when and why? Help the student understand how the other person is

thinking and feeling.

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How to teach social skills?

1. Use observational learning2. Consider class wide/grade/building curricula:

1. Second Step2. Superflex3. Social Thinking

3. Create a social skills groups4. Use social supports

1. Comic strips2. Social stories

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Slide 95

Taken from 'The New Social Story Book', p. 54

Sample Social Story: Listening to the Teacher

It is good to listen to the teacher. The teacher helps us learn.Listening makes it easier to learn. The teacher likes it when the children listen.

If I have a question, its okay to raise my hand and wait for theteacher or someone who will help me.

I will try to listen when the teacher is talking.Sometimes we might have a substitute teacher. When this

happens, I will try to listen to the substitute teacher.

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Slide 96 3. Provide Social Opportunities

Lunch bunch Social skills groups Clubs: Boy /Girl Scouts Sports programs Special interest school programs Specialty camps On-line opportunities Create mentoring opportunities.

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IN REVIEW

Strategies for behavior and independence

A. Understand the autism spectrum & related conditions

B. Be clear, concise & consistentC. Use rewardsD. Develop a behavior planE. Support friendship and social

thinking

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Slide 98 For more information

Puget Sound Psychology & Consulting www.pugetsoundpsychology.com

WA State Autism Outreach Project 888-704-9633; www.nwesd.org/autism

Autism Speaks – www.autismspeaks.org Autism Society of America – www.autism-society.org

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Slide 99 Downloadable Resources

Washington State Autism Guidebookhttp://www.doh.wa.gov/cfh/mch/Autism/Documents/Guidebook/Guidebook.pdf

The Educational Aspects of Autism Spectrum Disorders http://www.k12.wa.us/SpecialEd/pubdocs/Autism%20Manual.pdf

99

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Key Concept

Remember, no single approach is likely to be right for every child. If at first you don’t succeed, redefine and intervene!

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