Autism Flashcards
ASD
• Life-long neurodevelopmental disorder
• Characterised by –
• Difficulties with social interaction and communication
• Restricted and repetitive behaviour and interests
• First described by Kanner in 1943 and Asperger in 1944
• Describes children with a wide range of symptoms,
cognitive abilities, and adaptive functioning
prevalence
Now considered a high prevalence disorder
• Current estimates are 1 in 68
• Much debate about whether this increase reflects an Autism Epidemic –
• Broadening of the diagnostic criteria
Gender differences
•Much more prevalent in males (4:1) • Lack of recognition of ASD in girls • Significant genetic contribution •Only about 10% of cases are associated with a known genetic cause • Strong genetic component • Broader autism phenotype
Social communication difficulties
- Difficulty developing relationships
- Difficulty engaging in shared play/conversation
- Difficulty knowing what others are thinking and feeling
- Theory of Mind -capacity to understand other people by ascribing mental states to them.
- Social Thinking - helping kids figure out how to think in social situations
- Underlies much of the difficulty that children experience
Little kids social difficulties
- Independent play
- Difficulty playing cooperatively
- Limited sharing and showing (joint attention) - usually pre-verbal, toddlers can point at something and look to parent.
- Difficulty responding appropriately to emotions of others
- Difficulty with conversations
- Difficulty reading and using non verbal communication
- Literal interpretation of language
- Failure to develop appropriate friendships
Age related shifts
What we expect socially depends on their age. E.g. girls struggle when their friends stop playing in the playground and instead start sitting and talking. often we observe a lot of social issues in grade 3 - this is when we form into groups and manage group interactions.
Examples of repetitive behaviour
Being very upset by changes in routine (i have to have the blue bowl, the TV has to be on while I’m eating dinner)
Repetitive motor movements
Repetitive actions with objects
Insistence on non-functional routines
Narrow range of interests followed in an obsessional manner
repetitive behaviour
Preference for sameness (Kanner)
Need to think about frequency of repetitive behaviour - how much time are they spending on it?
What is it like when they have to stop?
Extent to which others are included - e.g. parent reading the child a book. Do you love it because of the connection it gives you?
Assessment
Assessments should be multidisciplinary, with clinicians consulting in order to reach a diagnosis
Paediatrician – physical examination, genetic testing, additional investigations
Speech Therapist – receptive and expressive language, pragmatic (social) language
Psychologist – developmental level, cognitive skills, mental health concerns
- Require experience and understanding of -
- Autism Spectrum Disorders
- A broad range of other developmental disabilities (language disorder, ID, etc.)
- Typical development
- Mental health in children and adolescents
Parts of a diagnostic assessment
- An (autism specific) developmental history
- Developmental/cognitive and speech and language assessment
- Clinical observations of the child
- Play, social skills, repetitive behaviours
- Assessment of current functioning
- Report from school
Screening tools kids
- Modified Checklist for Autism in Toddlers (M-CHAT)
- http://www.autismresearchcentre.com/arc_tests
- Childhood Autism Rating Scale (CARS 2)
- Social Responsiveness Scale (SRS 2)
Assessment tools
Autism Diagnostic Interview (ADIR)
• Autism Diagnostic Observation Schedule (ADOS 2)
• Monteiro Interview Guidelines for Diagnosing the Autism Spectrum (MIGDAS-2)
• Diagnostic Interview for Social and Communication Disorders (DISCO)
Need a very good knowledge of normal development - questions in ADOS for example ‘what is it to be a friend’, need to know a reasonable response for a 10 year old.
Screening with Adults
- Adult Autism Quotient (Baron Cohen et al., 2008)
- also Adult Aspergers Assessment (AAA)
- Both can be downloaded from -
- http://www.autismresearchcentre.com/arc_tests
• All of these instruments vary in their usefulness
• “The use of such instruments supplement, but does not
replace, informed clinical judgment”, (Volkmar et al. 2014)
ASD and Mental Health Difficulties
Up to 70% of children and adolescents with ASD have comorbid mental health problems. A large percentage use mental health services
“The developmental assessment of young children and the psychiatric assessment of all children should routinely include questions about ASD symptomology”. (Volkmar et al., 2014).
Why are MH comorbidities 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
Treating anxiety
- Cognitive behavioural therapy (CBT) has been the most commonly studied treatment for anxiety, with treatment typically consisting of a modified program
- CBT has been found to be effective for reducing anxiety in children and adolescents with ASD
- Refer to meta analysis by Ung et al. (2015)
- Also see Walters et al. (2016)
- The literature has focused on anxiety –
- May precede later mood difficulties
- May be more present in the under 12 age group
- Many of the CBT strategies aimed at helping anxiety are also helpful for lowered mood
Why CBT is well suited to ASD
Structured
• Facilitates direct discussion about thoughts and feelings
• Less focus on the relationship with the therapist
• Often uses some visual supports
Aspects of CBT that need modifying
- High language content
- Assumes awareness of emotions
- Emotional regulation
- Generalisation of learning
- Focus on cognitive strategies
Language and therapy
- Even high functioning children with ASD have difficulties with higher level language
- Use precise and concrete language (and be prepared to explain when you haven’t)
- Need to supplement with visuals
- Use drawing while talking
- Use play to support learning
Why, and how, to provide psychoeducation
- Children with ASD will need a lot more work around emotions. Helping them to –
- Name their feelings
- Link body sensations with feelings
- Notice early warning signs
- Feel comfortable with their feelings
- Recognise that others have feelings, which are often different
- Is often a precursor to being able to better manage emotions
• Encourage parents to –
Encourage parents to –
• Label their own emotions
• Identify high risk situations for their child
• Notice early warning signs
• Make tentative guesses about their child’s emotions
helping children to scale their feelings
- An important aspect of learning about emotions is helping children to scale their feelings
- Use visuals, e.g. have children show you with their hands
- Learning to recognize lower levels of feelings, e.g. frustration, is crucial
- Body noticing is key
- Focus on language and provide lots of examples
Psychoeducation about ASD for older children and adolescents
- Knowing about ASD is often very helpful for ≈
- Focus on the positives as well as the challenges
- Personalise it
- Books are often helpful –• E.g. Asperger Syndrome, the Universe and Everything.
- For younger children a strengths and weaknesses approach is often helpful
Making it meaningful - make it visual and personal
Psychoeducation is important for
parents to –
- Often helpful to revisit at various points in the child’s development
- Needs to be personalised to the child through the use of examples
- Often helps parents to see similarities and differences and helps the family to work together more effectively
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
Using play with children with ASD
Consider what play provides children with – flexibility,
generalization
Role play is very powerful and can be used to build upon social stories
Play can also be a means of taking the focus of social
interaction and thereby reduce anxiety
Helping children to generalise
Make the links overt in therapy – “That’s like when…”
Use home activities
Involve parents as co-therapists, with a view to assisting
with generalisation
Using Technology
- Lots of helpful apps that either –
- Have helpful content (e.g. smiling mind)
- Can be used as rewards or to keep children on task (e.g. token board)
- Helpful to understand online persona
- Can be useful for engaging children around interests
- Need to talk with parents about this
- Depending on the theory may need to have clear guidelines and limits
Cognitive strategies
- Lickel et al. (2011) found that children with ASD were able to –
- Discriminate thoughts, feelings and behaviours
- Engage in cognitive meditation
- as with peers
- They did however, find recognising emotions harder
- Focusing on the cognitive is less important
- Remember cognitions change through doing
- While it is often helpful to do a little work around cognitions this is likely to need more structuring for children with ASD
- Often helpful to use the ACT approach of cognitions coming and going
- If you do some cognitive restructuring, try to look for helpful rules and thoughts that can be applied across situations
More general modifications
Have shorter sessions if need be
Use a schedule to keep the session on track
Consider having a consistent way of beginning and ending sessions
Use humour
Use play
