Encourage self-evaluation evaluation and

Size: px

Start display at page:

Download "Encourage self-evaluation evaluation and"

Christopher Blair
5 years ago
Views:

1 Mental Health Symptoms in Individuals with ASD: A Focus on Anxiety Interventions Judy Reaven, Ph.D. Associate Professor of Psychiatry and Pediatrics JFK Partners University of Colorado School of Medicine judy.reaven@ucdenver.edu ASD Track: Overview of Two Sessions Session 1: Brief overview of ASD Specific learning strengths and needs General interventions for success school/home Session 2 Mental health symptoms that co-occur occur with ASD Overview of Facing Your Fears program for Children with High-Functioning ASD and anxiety (and their families) Acknowledgements Organization for Autism Research (OAR) Doug Flutie Foundation Cure Autism Now (CAN) Autism Speaks Centers for Disease Control (CDC) CADDRE network JFK Partners UCEDD Grant #90DD0561 through the Administration on Developmental Disabilities NIMH: #1R21MH Children/Adolescents with ASD and their families CBT researchers Conflict of Interest: Royalties: Facing Your Fears: Group Therapy for Managing Anxiety in Children with High-Functioning i Autism Spectrum Disorders Colleagues/Trainees and Research/Clinical Teams Audrey Blakeley-Smith, Ph.D. Shana Nichols, Ph.D. Susan Hepburn, Ph.D. Phil Kendall, Ph.D. Lila Kimel, Ph.D. Joy Browne, Ph.D. Meena Dasari, Ph.D. Erin Flanigan Alison Galansky, Ph.D. Katy Ridge Brian Wolff, Ph.D. Alison Herndon Steven Shirk, Ph.D. Kathy Culhane-Shelburne, Kristina Kaparich, MPH Ph.D. Amy Philofsky, Ph.D. Celeste St.John-Larkin, M.D. Rebecca Pohlig, M.A. Mark Groth Irene Drmic, M.A. Samantha Piper, Ph.D. Megan Martins, Ph.D. Michelle Shanahan, M.S. Amie Williams, M.A. Lauren McGrath, M.S. Jenni Rosenberg Eileen Leuthe, Ph.D. Mary Hetrick Eric Moody, Ph.D. Clinical Disorders that Frequently Co-occur occur with ASD Neurobiological: : attention (ADHD), movement and tic disorders, learning disabilities, abnormal sensory responses, dyspraxia (motor planning), intellectual disability, etc. Medical conditions: : Genetic disorders, seizures, sleep, GI issues, etc. Psychiatric: : anxiety, depression, etc. 1

2 Mental Health Symptoms in ASD Full range of psychiatric symptoms can be present, although diagnosing can be hard Depression, anxiety disorders, ADHD 65% of Ss with Asperger s had co-morbid psychiatric diagnosis (Ghazudian Ghazudian, 1998) HFA vs. Asperger s 65% of HFA and 85% of ASP met cutoff for caseness in behavioral/emotional disturbance (Tonge et al. 1999) Med use in HFPDD 65% endorsed anxiety symptoms and 32% endorsed depressive symptoms (Martin et al. 1999) Mental Health Symptoms in ASD Anxiety co-occurs occurs in 7-84% of children/adults with ASD (Lainhart, 1999); Co-morbid anxiety disorders occur in > 80% of children with HFPDD (Muris et al., 1998) PDD-NOS 80% Axis I Bruin et al. 2007; 55 % anxiety disorders Autism Co-Morbidity Interview Present and Lifetime ages 5-17 (Leyfer et al. 2006); 72% met criteria for Axis I most common: Specific Phobia 44% Obsessive Compulsive Disorder 37% ADHD 31% Major Depression 24% Considering Co-Morbidity Severe and incapacitating problem behavior aggression, self-injury, agitation, sleep disturbance Presence of clear psychiatric symptoms Worsening of symptoms already present (change from baseline) decreased communication, increased stereotypies, decreased self-care and adaptive behavior If individual does not respond as expected to treatment (Hendren, 2003) Factors that Influence the Prevalence/Incidence for Individuals with ASD Psychiatric disorders vs. behavioral disorders Psychosocial y masking of clinical symptoms (Fuller and Sabatino, 1996) Diagnostic overshadowing (Reiss et al. 1982) Myth of immunity (Nugent, 1997) Primary or secondary conditions Diagnostic Considerations for Assessing Co-Morbid Conditions in ASD First-line methods of evaluation (Rush & Frances, 2000) Interview with family/caregivers (pay attention to intra-individual individual changes) Direct observation of behavior Medical history and physical exam Functional behavior assessment Medication and side effects evaluation Unstructured diagnostic interview Etiology of Mental Health Conditions Increased vulnerability Organic/biological Core Deficits of ASD Environmental (adverse life events) No single etiology Utilize biopsychosocial model (Griffiths, Gardner, & Nugent, 1999) 2

3 Attentional Problems in ASD Prevalence is unknown; 5% in general population Easier to identify in HFA or AS although misdiagnoses common Co-occurrence occurrence between ADHD and ASD Genetic vulnerability Cluster of ASD, ADHD and motor difficulties Depression in ASD Increases in: crying self-injury sleep disturbances social withdrawal ritualistic/obsessive behavior (content is depressive) irritability decrease in activity loss of interest or regression in ADLs (Frazier et al. 2002; Ghazudian, 2005) Mania in ASD Deterioration in cognition, language, behavior or activity Regulation of affect is difficult Clear pattern/onset of fluctuation or cyclicity in activity it or behavior: (i.e. increased silliness, distractibility, poor judgment, intrusiveness, laughing, aggression, pressured speech, noncompliance, and agitation) (Frazier et al. 2002) Family history of Bipolar Disorder ASD and Childhood Onset Schizophrenia - Differences Originally ASD thought to be an early manifestation of COS Separate and distinct conditions more than 30 years ago Age of onset and specific pattern of symptoms indicate separate disorders Higher co-occurrences occurrences of Intellectual Disability and seizure disorders in ASD Family history (Ghaziuddin, 2005; Green et al., 1992; Kolvin, 1971; Petty et al., 1984) ASD and Schizophrenia Symptom Overlap Pre-morbid histories of COS: Neurodevelopmental concerns and delays (language, motor and social) Documentation of early symptoms of PDD in several studies of COS 25% of COS sample had PDD (Sporn et al., 2004) Marked social impairments in both disorders make diagnostic process challenging Common Anxiety Symptoms Difficulty separating from parents Marked and excessive fearful responses to objects or events Persistent and chronic worry Excessive avoidance Somatic complaints Presence of distressing thoughts Concentration difficulties Restlessness Fatigue Irritability Sleep disturbance Physiological over- reactivity 3

4 Symptom Expression of Anxiety in Youth with ASD Avoids novelty Withdraws from social situations Resists changes in routines Prefers rules Narrow focus of attention Insists on sameness Develops safe escape routes Increases repetitive behaviors and/or intensity of special interests Becomes irritable easily Becomes explosive suddenly Making the Case Why Study Anxiety in Individuals with ASD? Prevalence Anxiety symptoms are very common in persons with ASD (Bellini, 2004; Brereton et al. 2006; Leyfer et al. 2006), Greater than children with other DD (Gilliott et al., 2001). Impact Anxiety y interferes with individual s functioning in home, school, work and community activities (Russell & Sofronoff, 2005) Persistence Without intervention, symptoms may continue across lifespan Potential to treat Anxiety-related behaviors are treatable in persons without ASD using CBT (Compton et al., 2004; Walkup et al. 2008) Promising findings for youth with ASD (Sofronoff( et al., 2005; Chalfant et al., 2007; Wood et al., 2008) Overview of Facing Your Fears Treatment Package Total Duration of treatment: 14 weeks 1 ½ hour per session Modality: varied; children alone, parents alone, dyads and large group work First seven weeks: Define anxiety symptoms, identify anxiety provoking situations, develop a set of tools (relaxation, helpful thoughts, graded exposure) Second seven weeks: Identify goals and create stimulus hierarchy, apply tools across settings, in-vivo graded exposure, video activity to reinforce core concepts Booster session: 4-6 weeks post-treatment treatment Modifications for ASD Basic CBT content is unchanged Modifications based on the cognitive, linguistic and social needs of children with ASD Integrated social skills curriculum, not a separate module Group structure and management Token reinforcement program for in-group behavior Visual structure and predictability of routine Careful pacing of each group session Modifications for ASD, Cont d Modifications in teaching basic concepts Prerequisite skills (i.e.,feeling vocabulary) Written worksheets Multiple choice lists Drawing and other creative outlets Repetition and practice Video modeling Strength based Incorporation of special interest Parent component critical Components Define Anxiety Symptoms (enhance self-awareness) Increase emotion vocabulary Establish common vocabulary Identify anxious situations Identify physiological symptoms Emphasis on symptom intensity and interference 4

5 Child Treatment Components Establishing a framework (March & Mulle, 1998) Provide factual information about anxiety (emphasizing physiological components) Externalize anxiety symptoms Compare anxiety time vs. fun time Child, family, therapists and school staff all on a team to manage anxiety Child strengths emphasized identity identity expanded beyond anxious child Child Components continued Psychoeducation: Active minds (Garland & Clark, 1995) vs. Helpful thoughts Establish the circular connection between physiological reactions, thoughts, and somatic response Worry s false alarm (Chansky, 2004) Establish basic principle that anxious feelings will pass Child Components continued Introduce tools to manage symptoms Fine tune self-awareness of anxiety Attend to self-statements; statements; substitute positive coping thoughts Getting a handle on somatic symptoms introduce relaxation and other calming activities broadened concept Develop a list of calming activities and SCHEDULE Introduce stress-o-meter Teaching Emotion Regulation: Plan to Get to Green Develop a specific plan for when children are in the red zone Move one step at a time (e.g., 8-7; 7-6; 6-5, etc.) Establish child preferences for moving out of red zone Avoid problem solving when child is in red Create reward program for using strategies and staying in green Child Components continued Creating Steps to Success List anxiety provoking situation Rank order the situations from 1-8 Choose situations that are mild-moderately moderately stressful Generate strategies for facing fears Practice graded exposure in session Encourage self-evaluation evaluation and self-reward Write an Episode of Facing Your Fears VIDEO 5

6 Facing Your Fear Videos Face Your Fears: Parent Component Public Bathrooms Toilets Flushing Spiders/bees Elevators Upper classmen Ugly leaves Tornados School buses tipping over Going outside Going to Highlands Ranch, CO Choking Making mistakes The dark Mice/rodents/snakes Talking to people Losing things Scary movies Getting the flu Playing new sports activities with other kids Staying home alone People who look different Change Promote support among participants Provide psycho-education about anxiety disorders; learn the basic tenets of CBT Establish targets for graded exposure tasks Model brave behavior Encourage/reward brave behavior in their children Discuss parental anxiety and parenting style FYF Adolescent Components Increase awareness of the signs and symptoms of anxiety, emphasize the connection between cognitions and physiological responses to anxiety Create tools to manage symptoms relaxation and cognitive restructuring Social skills module Establish a fear hierarchy and teach adolescents to face fears a little at a time (graded exposure) Include parents To incorporate technology (i.e. PDA/iPod Touch) Functions of the PDA/iPod Touch Monitor anxiety symptoms on a regular basis Remind the participants to engage in relaxing/calming activities Guide participants through steps they can take when faced with a challenging situation Document exposure practice Provide information regarding progress SymTrend Examples of Teen Exposure Hierarchies Heights Spiders going into the basement alone Going to local places independently Telling teachers about the ASD diagnosis and asking for help Giving i oral presentations ti in school Going to public high school Talking with unfamiliar people Inviting others to get together Loud noises car alarms, vacuums Talking on the telephone Talking with parents about sensitive topics Preparing for the driver s license test Tolerating changes/when others make mistakes Face Your Fears: Oral Presentations Exposure Steps Completed in Number of Group People Observing Deliver a powerpoint to familiar and 14 unfamiliar adults Deliver a powerpoint to familiar peers 10 and adults Deliver a powerpoint to familiar peers 5 (e.g., fellow group participants) Practice delivering powerpoint 0 presentation on a preferred topic out loud at home 6

7 JFK Treatment Program for Anxiety and ASD Brief Overview Outpatient clinical work Case study (Reaven & Hepburn, 2003) Initial group treatment study (Reaven et al. 2009) Parents reported sig reductions in anxiety (n=33) Randomized trial (Reaven et al. 2012) (n=50) Parents reported sig reductions in anxiety severity (CSR) Global improvement (50%); reduction in # of dx & GAD Adolescent pilot study (under review) (n=24) Sig global improvement (46% positive improvement); decreased problem behavior Telecopes (Susan Hepburn, Ph.D. PI) FYF A School Based Study RCT: Follow-up Data Concluding Thoughts Children and teens with high-functioning ASD are psychiatrically complex Group treatment for youth with ASD may be a feasible and acceptable treatment Modified CBT may be effective in reducing anxiety symptoms in youth with high- functioning ASD Limitations/Future Directions Small sample size Lack of attention control group Conduct a randomized trial for teens with ASD Improve measurement strategies for psychiatric assessment and outcome Examine follow-up data Further examine potential moderators of treatment response Train other sites to deliver FYF intervention (Halifax, Birmingham, Cincinnati, Chapel Hill, and Baltimore) 7

Trigger. Trigger ????????? Physical feelings. Physical feelings. Sweating. Rapid heart rate. Dry mouth Headache

Trigger. Trigger ????????? Physical feelings. Physical feelings. Sweating. Rapid heart rate. Dry mouth Headache Conflict of Interest: Royalties: Facing Your Fears: Group Therapy for Managing Anxiety in Children with High- Functioning Autism Spectrum Disorders Paul Brookes Publishing Company www.brookespublishing.com