Objectives. Co-Morbidity. Overview 4/19/16. Importance of Diagnosing Other Conditions. Difficulties with Dual Diagnosis. Caitlin Walsh, PhD 1

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1 When it Isn t Just Autism: Co-Morbid Mental Health Conditions and ASD Caitlin Walsh, PhD Objectives 1. Report on prevalence of most common disorders that are co-morbid with ASD. 2. Identify difficulties with differential diagnosis of ASD and co-morbid conditions. 3. Understand the importance of diagnosing comorbid conditions. 4. Learn basic information regarding evidencebased treatment of co-occurring mental health conditions for individuals with ASD. November 5, 2016 Co-Morbidity The co-occurrence of two or more conditions/disorders in the same person. Overview 70-90% of individuals with ASD experience co-occurring psychiatric condition 4-6X higher than general population Complex issues related to comorbid Dx Changes with aging DSM-5 (de Bruin, 2007; Mattila et al., 2010) Diagnostic overshadowing Difficulty assessing or measuring other Dx Symptom overlap Difficulties with Dual Diagnosis Importance of Diagnosing Other Conditions Targeted interventions Psychopharmacology Cognition and communication/verbal ability Different symptom presentations How we think about the child is different Baseline exaggeration Reaven & Wainer, 2015 Caitlin Walsh, PhD 1

2 Most Common Disorders Disorder Anxiety 40% Specific Phobias, OCD, Social Anxiety Attention Deficit Hyperactivity Disorder Prevalence In Youth with ASD 30-40% Depression % Anxiety Anxiety Anxiety in ASD Behaviors Physical Feelings Thoughts Avoidance Increased ritualized/rigid behavior Increased resistance to change in routines Perfectionism Social withdrawal Seeks frequent reassurance Unusual phobias Anxiety in ASD Unusual phobias Left/right turns Toilets Obsessive compulsive disorder Rituals involving others needing to do something a certain way. Need to tell/ask or repeat statements Depression Caitlin Walsh, PhD 2

3 Symptoms Depression in ASD Sadness or irritability Loss of interest or pleasure Sleep disturbances Change in eating Fatigue/restlessness Trouble concentrating Thoughts of death Increase in irritability Loss of interest (including special interests) Resistance to participating Agitation/Restlessness Increased aggression/tantrums Sleep changes In less verbal individuals, more vegetative symptoms common; changes in functioning Decreases in adaptive functioning Ghaziuddin et al., 2002 Symptoms Attention Deficit Hyperactivity Disorder Inattention Lack of focus Careless mistakes Difficulty sustaining attention Forgetful Not listening Easily distracted Symptoms Hyperactivity/Impulsivity Fidgety Walking/running/climbing Gets out of seat Has trouble playing quietly Always on the go Talks excessively ADHD in ASD Mostly similar presentation to typically developing children Inattentive symptoms may be more prominent Caitlin Walsh, PhD 3

4 Symptoms Bipolar Disorder Inflated self-esteem or grandiosity Unusual talkativeness Decreased need for sleep Racing thoughts Distractibility Goal directed activity or agitation Risky behavior Bipolar Disorder in ASD Elated mood Decreased frustration tolerance Active at night Increase in preoccupation Increase in compulsive behaviors Increase in disinhibition Inability to follow previously learned rules Treatment How do we treat co-morbid diagnoses in ASD? Traditional CBT Cognitive behavior therapy Caitlin Walsh, PhD 4

5 Mom, am I healthy? 4/19/16 Psychoeducation Provide information about nature of anxiety/depression, etc. Define it Normalize it Anxiety/depression has a function or purpose Externalize it Explain rationale for treatment Graded Exposure Gradually exposed to increasing proximity, intensity, or amount of feared stimulus/situation Learn that you will habituate Learn that feared consequences do not come true Fear Ladder Gradually confront easy to hard Step 1 Step 2 Step 3 Step 4 Goal! Step 5 Cognitive Restructuring The spider probably won t crawl on me and, even if it does, what s the worst Challenge anxious thoughts that can happen? I ll just swat it. Do I know for certain that? Do I have a crystal ball? What evidence do I have that? Is there another explanation for? What is the worst thing that can happen? How bad is that? How can I cope with that? Skills training/behavioral alternatives Role playing/modeling Behavioral activation Coping self-talk/ Boss-back talk I ve handled this before and I will handle it again. My brain is just stuck right now; I don t have to do this! Rewards! Reinforce brave behavior! Reinforce versus bribes What is reinforcing for your child? Timing Consistency Tangible rewards versus privileges Reinforce partial success or attempts 4:00 4:30 4:30 5:00 5:00 5:30 5:30 6:00 6:00 6:30 6:30 7:00 7:00 7:30 7:30 8:00 Total Sticker Chart for Ed for Brave Behavior Mon Tues Wed Thur Fri Sat Sun You get 1 sticker if you are brave and don t ask any Undertaker questions for 30 minutes. 1 sticker = 3 stickers = 4 stickers = 6 stickers = 8 stickers = 16 stickers = 24 stickers = BRAVE BUCK CBT Interventions Modified for Youth with ASD Caitlin Walsh, PhD 5

6 Increased Structure & Predictability Visual strategies Visual schedules Multiple choice lists for new concepts Use of drawing and other creative ( active ) strategies Reaven et al., 2011 What to Do When In Red Goal: Be safe and get to yellow How To: Give space, reduce or eliminate talking What to Do When In Yellow Goal: Continue to use tools to get to green How to: Remain calm, prompt strategies that work best for the child/teen What to Do When In Green Goal: Learn and practice strategies needed to stay in green How to: Teach, teach, teach! Practice and role play different scenarios, praise for using strategies to stay in green, teach problem solving skills Walsh & Reaven, 2015 Walsh & Reaven, 2015 My Plan to Get to Green When I m In Red My Goal: What I Can Do: What Mom or Dad Can Do: When I m In Yellow My Goal: What I Can Do: What Mom or Dad Can Do: When I m In Green My Goal: What I Can Do: What Mom or Dad Can Do: Cognitive Restructuring Incorporation of Special Interests Focus on strengths and talents Reaven et al., 2011 Caitlin Walsh, PhD 6

7 Helps to improve generalization Parent teaching Increasing Parent Involvement Behavior management techniques Emotion game Emotion Education Recognizing emotional triggers Reaven et al., 2011 CBT Works! Most studies on treatment of anxiety; show decreased anxiety Wood et al., 2009; Reaven et al., 2009, 2012; Sung et al., 2011; White et al., 2009 Several studies on modified CBT strategies to treat depression, anger, and attentional issues. Hare, 1997; Solomon et al., 2004; Sofronoff et al., 2007; Aman et al., 2009; Solomon et al., 2008 More research is needed on treatment modifications for youth with ASD and cooccurring mental health disorders. How to know if it is more than ASD Difference from baseline Significant impairment Considering primary and secondary diagnoses Traditional interventions for ASD not working Family history Resources - Websites Resources - Books National Associate of State Directors of Developmental Disabilities Services (NASDDD) JFK Partners at University of Colorado Parent training - CHADD The National Resource on ADHD CBT for Children and Adolescents with High Functioning Autism Spectrum Disorders by Scarpa, White, & Attwood Helping Your Anxious Child by Ronald Rapee Cognitive Behavior Therapy for Adult Asperger Syndrome by Valerie Gaus Managing Anxiety in People with Autism: A Treatment Guide for Parents, Teachers, and Mental Health Professionals by Anne Chalfant Facing Your Fears by Reaven, Blakeley-Smith, Nichols, & Hepburn Caitlin Walsh, PhD 7

8 Questions? Contact Information Caitlin Walsh, PhD Caitlin Walsh, PhD 8