Understanding the Intersection of Anxiety and Autism

Transcription

1 Understanding the Intersection of Anxiety and Autism Tiffany L. Otero, Ph.D., BCBA Postdoctoral Psychology Fellow Ellen F. Geib, M.S. Predoctoral Psychology Intern 1

2 Acknowledgements Facing your Fears Clinic Marybeth Graham, Ph.D. Judy Reaven, Ph.D. Participants and Facilitators 2

3 Objectives At the end of this presentation, participants will be able to: Describe common symptoms of anxiety and the cycle of anxiety. Understand the unique features of anxiety in children with ASD. Identify key components of cognitive behavioral intervention for children with ASD and anxiety. Describe practical strategies for addressing anxiety in children with ASD. 3

4 Case Study Name: "Dan" Age/Grade: 12 years old, 7th grade Diagnoses: Previous diagnosis of Asperger Syndrome, now identified as ASD (Level 1 for social communication and Level 1 for repetitive and restricted behaviors and interests.); Generalized Anxiety Disorder Interests: Pokémon, Anime Fears: Loud noises, dogs, being left alone, bad grades Strengths: Performing arts, good student, strong visual memory Challenges: Poor receptive communication, low tolerance for auditory input (hates music), poor fine motor skills. 4

5 Anxiety disorders among children and adolescents with ASD Many children with autism experience clinically significant symptoms of anxiety (Bellini, 2004; Lopata et al., 2010; White, Oswald, Ollendick, & Scahill, 2009) In contrast to their typically developing peers, children with ASD experience elevated rates of internalizing symptoms (Bellini, 2004; McPheeters, Davis, Navarre, & Scott, 2011) 5

6 Anxiety is described as a perceived physical or psychological threat to one s own domain (Beck & Clark, 1988). What is anxiety? 6

7 Cognitive Biases Attentional vigilance to cues associated with threat Negative perceptual bias/ pessimistic outlook Increased perception of the likelihood of threatening events (Mathews, Mackintoch & Fulcher, 1997) 7

8 Common Symptoms of Anxiety Disorders Symptoms of anxiety include: Specific fears, worries, and phobias Restlessness or feeling keyed up Easily fatigued Difficulty concentrating Irritability Muscle tension Sleep disturbance 8

9 The Cycle of Anxiety Trigger Negative thoughts Behavioral Avoidance/ Coping Physiological Symptoms ( fight or flight response ) 9

10 Common Physiological Responses Dizziness trembling Muscle tension Stomachache or pain Diarrhea Restlessness Loss of energy Sleeplessness Sweating Trouble concentrating Cold, clammy hands Racing heartbeat Chest pain Fast breathing Dry mouth Shaking/ 10

11 Behavioral Avoidance and Maladaptive Coping Strategies Increasing avoidance reduces opportunities to practice adaptive skills Social skills Coping strategies Emotional regulation Increase use of maladaptive coping strategies Self-injury Compulsions or rituals 11

12 Anxiety Disorders according to the DSM- 5 Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder Panic Disorder Agoraphobia Generalized Anxiety Disorder Anxiety Disorder due to Another Medical Condition Other or Unspecified Anxiety Disorder 12

13 Autism Spectrum Disorders according to the DSM-5 Level 1 Requiring Support Level 2 Requiring Substantial Support Level 3 Requiring very substantial support Social Communication Deficits Restricted or Repetitive Behaviors or Interests (RRBs) ASD 13

14 Anxiety in Children with ASD Emerging research supports: Anxiety (as a co-occurring disorder) is common in children with ASD; 40-50% incidence rate (van Steensel, Bogels & Perrin, 2011) Is similar in presentation when compared to children without ASD (Kerns & Kendall, 2012) Is distinct from core deficits of ASD Independent of ASD severity (Renno & Wood, 2013) 14

15 Implications for Children with ASD and Anxiety Children with autism and anxiety face additional social and developmental challenges throughout their life including The emergence of social difficulties related to awareness of being different from others in adolescence Navigating the increasingly complex peer environments during middle and high school (Tantam, 2003) 15

16 Cycle of Anxiety may be Impacted by ASD Trigger Perseverative thought processes Negative thoughts Restricted and repetitive behaviors: selfstimulation, rituals, selfharm, etc. Behavioral avoidance/ coping Sensory perception differences, Physiological physiological hyperarousal symptoms/ fear response (Bellini, 2006) 16

17 Unique features of anxiety in children with ASD- Social Communication Deficits The core symptomology of autism (i.e., social communication impairments) can create stressful experiences that may promote anxiety (Wood and Gadow, 2010) Anxiety may compound the social deficits in individuals with ASD (White et al., 2010) 17

18 Unique features of anxiety in children with ASD- Social Communication Deficits, cont. Specific temperament profiles in ASD lead to social withdrawal, social skill deficit, and negative peer interactions. These negative peer interactions then maintain future social anxiety (Bellini, 2006) Anxiety also serves as a maintaining factor to future anxiety as it becomes a barrier to the future social interactions (Chang, Quan, and Wood, 2012) 18

19 Unique features of anxiety in children with ASD- Restricted and Repetitive Behaviors (RRB) RRBs, such as strict schedules and behavioral patterns, may represent negative reinforcement to relieve anxiety (Sukhodolsky et al., 2008) Ambiguous fears and worries related to highly specific items or specific ASD symptomatology (e.g., perseveration, social difficulties, sensory challenges) Fears/worries also may be related to specific routines, novelty experiences 19

20 Anxiety in "High-Functioning" Children with ASD Anxiety has a high comorbidity in individuals with higher language and adaptive functioning skills, sometimes a group described as high functioning autism (HFA) de Bruin et al. (2007) report that 80% of children in this higher functioning autism group also have one or more concurrent anxiety disorder. 20

21 Anxiety in "High Functioning" Children with ASD Orlich (2011) suggests that the correlation between anxiety and social deficits may be high because these individuals have the capacity to understand their social deficits and learn social skills. However, learning practicing these skills in social situations is anxiety provoking. Bellini (2004) proposed that awareness of social deficits and then failures to use those skills serve as factors for heightened anxiety. Self-awareness may serve as a maintaining factor to anxiety, however the literature represents varied analyses of selfawareness and anxiety 21

22 Common Anxiety Triggers Anxiety provoking situations Answering questions in class Taking tests Starting or joining a conversation Speaking to adults Talking to unfamiliar people Being ask to do something you don t really want to do Dating Joining a group Writing on the board in class 22

23 Common Anxiety Triggers Specific Phobias Snakes, spiders, dogs, bees/insects High places Thunderstorms/lig htening Getting shots Having a blood draw Visiting the doctors/dentists Loud noises (e.g., fireworks) Catching a disease 23

24 Common Anxiety Triggers Fears/Worries School Performance Social/interperson al Preoccupation with little things Perfectionism Health Family World issues (e.g., war, crime, community, world affairs) 24

25 Case Study Name: "Dan" Age/Grade: 12 years old, 7th grade Diagnoses: Previous diagnosis of Asperger Syndrome, now identified as ASD (Level 1 for social communication and Level 1 for repetitive and restricted behaviors and interests.); Generalized Anxiety Disorder Interests: Pokémon, Anime Fears: Loud noises, dogs, being left alone, bad grades Strengths: Performing arts, good student, strong visual memory Challenges: Poor receptive communication, low tolerance for auditory input (hates music), poor fine motor skills. How is Dan impacted by the intersection of his diagnoses of ASD and Anxiety? 25

26 Perseverates on mistakes Sensory sensitivity to auditory input Understanding of social expectations, but lacking skills Difficulty understanding what is said to him and around him Limited means of expression Difficulty with changes in routines or starting something new (intolerance of uncertainty). Limited adaptive emotional regulation skills 26

27 Treatment for Children with ASD and Anxiety 27

28 Evidence-Based Treatment for Children Psychotherapy Cognitive-Behavior Therapy Cognitive Therapy *Acceptance and Commitment and Mindfulness (emerging research support with adults) Pharmacotherapy SSRI SNRI (Anxiety and Depression Association of America, 2018) 28

29 Cognitive-Behavior Therapy (CBT) Attempts to break the cycle of anxiety with a combination of talk therapy and behavior therapy Practice coping strategies in real world exposure to triggers Identify triggers Recognize and reframe negative thinking patterns Become mindful of emotions and beliefs about triggers 29

30 The Cycle of Anxiety: Afraid of dogs Dog Approaches Negative thoughts: It s going to bite me. I m going to be attacked. Behavioral Avoidance/ Coping: Don t walk around neighborhood, can t visit family with dogs. Physiological Symptoms: Heart races, sweating, short breaths. 30

31 The Cycle of Anxiety: Giving a presentation Giving a presentation Negative thoughts: Behavioral Avoidance/ Coping: Physiological Symptoms: 31

32 Treatment for children with ASD and anxiety Cognitive-behavioral therapy (CBT) interventions to reduce anxiety must consider both ASD symptomology and symptoms of anxiety. Bellini (2004) proposed that awareness of social deficits and then failures to use those skills serve as factors for heightened anxiety. Wood et al. (2009) proposed that social communication deficits serve as the greatest barriers to a CBT intervention to reduce anxiety 32

33 Core Components of CBT Intervention and Considerations for Support CBT Core Features Psychoeducation Strategies for Emotional Regulation Self-Awareness Relaxation Cognitive Reframing Graduated Exposure Considerations Increase use of visuals Increase in vivo practice Reduce abstraction of concepts Educate parents Promote generalization Promote social engagement Motivate participation (Kendall & Hedtke, 2006; Reaven, et al., 2012) 33

34 Psycho-Education: Visual Strategies Real Danger False Alarm 34

35 Psycho-Education: Reduce Abstraction Worry Bug 35

36 Promote Self-Awareness 36

37 Strategies for Emotional Regulation Breathing Distraction Self-talk Helpful thoughts Music, poetry, quotes Healthy Lifestyle Physical activity Good sleep Stress-o-meter Plan to get to green (Reaven & Hepburn, 2006) 37

38 Working with Family Members Psychoeducation Self-Awareness Coaching Adaptive versus excessive protection Implement behavioral strategies/ promote motivation 38

39 Graded Exposure Goal Bigger worry A bit more worrisome Tolerable worry 39

40 Graded Exposure: Fear of Dogs 5. Pet neighbor s dog 4. Stand in yard with dog nearby 3. Stand by gate with dog on other side 2. Walk by gate with dog on other side 1. Stand in own front yard while dog in neighbor s back yard What do you want to be able to do? What are you willing to try now? 40

41 Graded Exposure: Getting a shot 4. What do you want to be able to do? What are you willing to try now? 41

42 Anxiety over Time Avoidance (Reaven, et al., 2011) image credit: 42

43 Motivation Reinforcer Surveys Plan for Rewards Individual Rewards Participation Parent-provided Naturalistic when possible Group rewards Facing Fears 43

44 Case Study Name: "Dan" Age/Grade: 12 years old, 7th grade Diagnoses: Previous diagnosis of Asperger Syndrome, now identified as ASD (Level 1 for social communication and Level 1 for repetitive and restricted behaviors and interests.); Generalized Anxiety Disorder Interests: Pokémon, Anime Fears: Loud noises, dogs, being left alone, bad grades Strengths: Performing arts, good student, strong visual memory Challenges: Poor receptive communication, low tolerance for auditory input (hates music), poor fine motor skills. 44

45 Graded Exposure: Hierarchy for being alone 5. Stay alone at home while parents run an errand. 4. Stay alone while parents take a walk in neighborhood. 3. Sit in coffee shop with book in store while parents buy something. 2. Stay alone inside while parents work in yard. 1. At grocery store, go into next aisle over alone. What are you willing to try now? What do you want to be able to do? 45

46 Perseverates on mistakes Sensory sensitivity to auditory input Understanding of social expectations, but lacking skills Difficulty understanding what is said to him and around him Limited means of expression Difficulty with changes in routines or starting something new (intolerance of uncertainty). Limited adaptive emotional regulation skills 46

47 Support for Intervention Skills to Teach and Added Support - Visual list of emergency contacts - Menu of calming activities (i.e. headphones, favorite books) - Visual for how to call parents to check in. - Modeling and role play how to ask for help. 5. Stay alone at home while parents run an errand. 4. Stay alone while parents take a walk in neighborhood. 3. Sit in coffee shop with book in store while parents buy something. 2. Stay alone inside while parents work in yard. 1. At grocery store, go into next aisle over alone. Skills to Reward - Use of adaptive calming strategies when stressed - Successful completion of each step of hierarchy - Use of social skills 47

48 Questions 48

49 References American Psychiatric Association. (APA, 2013). Diagnostic and statistical manual of mental disorders DSM-5. Washington, DC: American Psychiatric Association. Anxiety and Depression Association of America. (2018). Treatment. Retrieved from: Beck, A.T. & Clark, D.A. (1988). Anxiety and depression: An information processing perspective. Anxiety Research, 1, Bellini, S. (2004). Social skill deficits and anxiety in high-functioning adolescents with autism spectrum disorder. Focus on Autism and Other Developmental Disabilities, 19, doi: / Bellini, S. (2006). Social skills deficits and anxiety in high-functioning adolescents with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 19, doi: / Chang, Y. Quan, J. & Wood J.J. (2012). Effects of anxiety disorder severity on social functioning in children with autism spectrum disorders. Journal of Developmental and Physical Disabilities, 24, doi: /s de Bruin, E.I., Ferdinand, R.F., Meesters, S., de Nijs, P.F.A., & Verheij, F. (2007). High rates of psychiatric co-morbidity in PDD-NOS. Journal for Autism and Developmental Disorders, 37, doi: /s x Kendall, P.C. & Hedtke, K.A. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual. 3. Ardmore, PA: Workbook Publishing. Kerns, C. M., & Kendall, P. C. (2012). The presentation and classification of anxiety in autism spectrum disorder. Clinical Psychology: Science and Practice, 19, Lopata, C., Toomey, J.A., Fox, J.D., Volker, M.A., Chow, S.Y., Thomeer, M, L.Smerbeck, A.M. (2010). Anxiety and depression in children with HFASDs: Symptom levels and source differences. Journal of Abnormal Child Psychology, 38(6), Orlich, F. (2011). Coping with anxiety. [PDF document]. Retrieved from: Mathews, A., Mackintosh, B., Fulcher, E. (1997). Cognitive biases in anxiety and attention to threat. Trends in Cognitive Sciences, 1(9), McPheeters, M.L., Davis, A., Navarre, J.R., Scott, T.A. (2011). Family report of ASD concomitant with depression or anxiety among US children. Journal of Autism and Developmental Disorders, 41(5),

50 References Reaven, J., Blakeley-Smith, A., Nichols, S., & Hepburn, S. (2011). Facing Your Fears: Group Therapy for Managing Anxiety in Children with High-Functioning Autism Spectrum Disorders, Paul Brookes Publishing Company, Baltimore. Reaven, J., Blakeley-Smith, A., Culhane-Shelburne, K., & Hepburn, S. (2012). Group cognitive behavior therapy for children with high-functioning autism spectrum disorders and anxiety: A randomized trial. Journal of Child Psychology and Psychiatry, 53(4), Reaven, J. & Hepburn, S. (2006). The parent s role in the treatment of anxiety symptoms in children with high-functioning autism spectrum disorders. Mental Health Aspects of Developmental Disabilities, 9(3), Renno, P., & Wood, J. J. (2013). Discriminant and convergent validity of the anxiety construct in children with autism spectrum disorders. Journal of Autism and Developmental Disorders, Sukhodolsky, D. G., Scahill, L., Gadow, K. D., Arnold, L. E., Aman, M. G., McDougle, C. J. et al. (2008). Parent-rated anxiety symptoms in children with pervasive developmental dis- orders: Frequency and association with core autism symptoms and cognitive functioning. Journal of Abnormal Child Psychology, 36, doi: /s Tantam, D. (2003). The challenge of adolescents and adults with Asperger syndrome. Child and Adolescent Psychiatric Clinics of North America, 12( ), vii viii. Van Steensel, F. J., Bögels, S. M., & Perrin, S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta-analysis. Clinical child and family psychology review, 14(3), White, S. W., Oswald, D., Ollendick, T. & Scahill, L. (2009). Anxiety in children and adolescents with autism spectrum disorders. Clinical Psychology Review, 29, doi: /j.cpr White, S.W., Albano, A. M., Johnson, C. R., Kasari, C., Ollendick, T., Klin, A. et al. (2010). Development of a cognitive-behavioral intervention program to treat anxiety and social deficits in teens with high-functioning autism. Clinical Child and Family Psychology Review, 13, doi: /s Wood, J. J. & Gadow, K. D. (2010). Exploring the nature and function of anxiety in youth with autism spectrum disorders. Clinical Psychology: Science and Practice, 17, doi: /j x 50