Typical And Atypical Development Flashcards
Suicidality
from thoughts to behaviours, can be current (now) or lifetime (any point in your life)
•‘Ended their life’, ‘died by suicide’, ‘attempted suicide’ preferred to ‘unsuccessful suicide’, ‘commit suicide’, ‘completed suicide’
To be diagnosed-
- needs to be causing distress
- Meet set criteria in DSM-V
- Clinical judgment
Co-occurring conditions such as autism could effect liklihood of experiencing many of these factors
Environment
Societal
Biological
Psychological
Environmental factors
•Stress •Bereavement Finances Bullying Unemployment
Societal Factors
•Attitudes
•Stigma
Policy - service provision
Poverty
Biological factors
Genetic - predisposition (family history)
Brain structure and function
Psychological
Thinking style
Coping strategies
Resilience
Autism mental health problems
Socialisation/communication
Sensory
Imagination
Narrow Interests
Imagination
Difficulty putting ur self in another’s shoes
Sensory
Difficulty coping with strong smells, noise, lighting, texture and touch.
Socialisation / communication
Difficulties forming stable long lasting relationships, holding a two way conversation, reciprocal social interaction.
Narrow interests
Unusual narrow circumscribed interests which interfere with carrying out day to day activities, and cause distress when interrupted.
May include ritualised behaviours (e.g. having to do things in a certain way or order), and be repetitive.
Mental health difficulties described in Kanners first clinical reports in 1943:
–Fear and anxiety around objects and events
–Depression also noted
- “Insistence on Sameness” part of current diagnostic criteria, and anxiety commonly seen
- Recently been explored among other conditions to improve diagnosis and treatment
Life experiences in Autism
Diagnosis
- ~5 years for classic autism (Howlin and Asgharian, 1999) vs. ~11 years or even adulthood for AS (e.g. Jones et al., 2014; Powell, 2002)
- Lack of support post diagnosis for children and adults (Crane et al. 2015)
Life experiences in Autism
Shtayermman, 2007; 2008
Bullying and peer victimisation
Transition to adulthood:
•Lack of support services (Pilling et al. 2012)
•Health and social difficulties (Balfe and Tantam, 2010)
•Poor quality of life, low occupational achievement (Howlin et al. 2013)
•Social exclusion and isolation (Howlin 2000; Baron-Cohen, 2008)
Associated with poor mental health in the general population – what about autism?
Autistic people have difficulty recognising others
emotions, interpreting and predicting others behaviour, and responding appropriately
Sheppard et al. 2017
autistic people may be less
readable by non-autistic people
Sasson et al 2017
Could contribute to
social exclusion
This could result in a ‘Double Empathy Problem’
Autistic people more likely to experience:
–social isolation
–Loneliness
–Those with high autistic traits more likely to experience thwarted belongingness
Heldey et al. 2018; Pelton and Cassidy, 2017) autism
Associated with
Associated with depression and self-harm
Research yet to explore direct impact of double empathy on mental health in ASD …
Camouflaging’ autism to cope in social situations
–Argued to be more common in autistic women, and contribute to under / misdiagnosis of this group –Reported to take a toll on mental health –Loss of identify –Exhausting –But helps to fit in NT society
Mental Health Conditions
- Depression
- Anxiety
- Anorexia Nervosa
- Borderline Personality Disorder
Depression prevalence
UK population
23% of the UK population experience a mental health problem, with depression the most common
Depression prevalence
Autistic adults
79% of autistic adults meet criteria for a psychiatric condition at some point, with depression most common (Lever and Geurts, 2016)
Depression prevalence
Depression present in 30 – 50% of autistic adults (e.g. Cassidy et al. 2014; Lugnegård et al. 2011; Hofvander et al. 2009; Sterling et al. 2008), and 30% of children (e.g. Strang et a
Increased experience of psycho-social risk factors?
–Social Isolation
–Unemployment
–Loneliness
–Awareness of own shortcoming and struggles
•Cognitive style (Cassidy et al. 2014)
Inflexible thinking
Memory biases
Inflexible thinking
- Unable to see a way out of current mood or circumstance
- Difficulty in changing behavior
- Increased rumination
Memory biases
Difficulties with autobiographical memory in autism – important protective factor against MH problems in gen pop
issues with effective identification of depression in autism?
–Overlap of symptoms / behaviours in autism and depression = “Diagnostic Overshadowing”
•Over-estimate depression in autism
–Lack of autism specific/relevant items
•Under estimate depression in autism
–Cognitive style affecting interpretation of questions
Psycho-social factors
Self-reported autistic traits associated with current self reported depression, significantly mediated by difficulties in social problem-solving skills
•Suicidality part of diagnostic criteria for depression
- Over 90% of those who die by suicide were diagnosed with depression (Baraclough, 1974)
- Evidence suggests those with autism at significantly increased risk of suicidality
374 newly diagnosed adults with Asperger Syndrome;
suicidal ideation 66%; suicide plans/attempts 35%, depression 31%
–Significantly higher than general UK population (17%) and patients with psychosis (59%)
–Autistic traits and depression risk factors for suicidality (Cassidy et al. 2014)
–However, less people depressed than experiencing suicidal ideation
Do not assume that it is not possible to treat mental health conditions in autism
–It is possible, but may need adaption and could take longer than usual
•Difficult to if there is fixed option and number of sessions (6 sessions of CBT)
Do not assume that mental health problems are part of autism
–Needs diagnosis and treatment in its own right
Virtual reality to treat anxiety in ASD
•Individualised VR environment gradually exposed 9 autistic children to specific phobias (e.g. pigeons, crowded buses) •After study 8/9 children were able to tackle their phobia situation
Implications for treatment
- High sensory sensitivity, and rigidity associated with anxiety in autism – makes it difficult to treat
- Autistic adults can benefit from psychological therapy to treat mental health difficulties such as anxiety, but it takes much longer
Implications for treatment
•Presentation of autism can
Also affect ability to
engage with traditional
treatments
•Cognitive behavioural therapy
requires high degree of emotional literacy – an area autistic people find difficult (see emotional development lecture)
–Alexythymia – may need training in emotional literacy first
Participatory research project showed young autistic adults have difficulty obtaining a mental health diagnosis and appropriate treatment:
–Difficulties evaluating their mental health (Alexythymia)
–Report high levels of stigma
–Often face severe obstacles when trying to access mental health support
•Lack of tailored support, staff trained in ASD
Crane et al. 2015
Mental health problems are the most common area of first concern prior to adults obtaining an autism diagnosis
Raja, 2014
Many psychiatrists however are not trained in autism or developmental conditions
Lai and Baron-Cohen, 2015
Leads to many autistic adults slipping through the net
A number of mental health conditions overlap with
symptoms of autism
Leads to challenges in
effective identification and diagnosis
Research in the area is very
recent but rapidly growing
Adapted assessments to more effectively identify
autism specific presentation (e.g. depression and anxiety) currently being developed
Case series using gold standard diagnostic assessments (ADOS) of 10 female patients diagnosed with ED
- Attempted to disentangle superficial or real autism in those with ED
- 5 met criteria for autism spectrum disorder using the ADOS, difficulties since childhood prior to onset of ED
- Suggests this is not an effect of starvation
- Are the behaviours being picked up on not truly autistic?
* Result of co-morbid OCD, depression, anxiety and starvation (Pellicano and Hiller, 2013)
–Overlap with autism symptoms
–Starvation temporarily increases rigidity and obsession with food
–Mistaken for autism (e.g. narrow obsessive interest, sensory difficulties, social difficulties, rituals)
concern that autism could increase risk of ED’s (Gillberg, 1983)
–Underlying lack of flexibility and difficulties in social functioning in some women with ED’s
–Indicative of undiagnosed autism?
increased prevalence of autism in ED samples:
–0.3% female autism prevalence in the general population (Baird et al. 2006)
–8-37% females autism prevalence in ED samples (Huke et al. 2013)
- Large population study in Sweden
* Adults with autism significantly more likely to die by suicide than the general population
–Being female, autism without ID, and depression are risk factors (Hirvikoski et al. 2015)
–Opposite to the general population where men are more at risk
–Mental health problems and suicidality highest in autistic women (Cassidy et al. 2014)
Hedley et al. 2017
Psycho social factors
Lack of social support in ASD increases depression and in turn suicidal ideation
Hedley et al. 2018
Psycho-social factors
Feelings of loneliness increases depression and thoughts of self-harm
Autistic traits predict TB
Thwarted belonging
Isolation and loneliness
Autistic traits predict
PB
Perceived burdensomeness
Caregiver burden
Unemployment
Autistic traits predict CFS
Capability for suicide
Weakening of association between PB and TB
And suicidal behaviour due to autistic traits
163 general population young adults (18-30 years)
Psychosocial factors
- Autistic traits associated with depression
- Autistic traits associated with suicidality through perceived burdensomeness and thwarted belongingness (Pelton and Cassidy, 2017)
Autism and autistic traits in the general population are associated with
increased risk of depression
Depression also associated with increased risk of
self-harm and suicidality
Social difficulties and lack of social support may mediate this association:
–Loneliness
–Lack of social support
–Thwarted belongingness
–Perceived burdensomeness
Crucial to effectively diagnose depression in ASD ….
BUT – Challenges for measurement:
- Cognitive (interpretation of questions)
- Behavioural (similarity in signs and symptoms – diagnostic overshadowing)
Cognitive Aspects of ASD
Alexythymia
Theory of Mind:
Literal Interpretation
Reduced flexibility in thinking:
Cognitive Aspects of ASD
Alexythymia
difficulty verbalising internal thoughts and feelings prevalent in autism (Bird et al. 2010)
Cognitive Aspects of ASD
Theory of Mind:
difficulty putting yourself in another’s shoes (Baron-Cohen et al. 1985)
Cognitive Aspects of ASD
Literal Interpretation:
language, taking things at face value, difficulty ‘reading between the lines’ (Happe, 1995)
Cognitive Aspects of ASD
Reduced flexibility in thinking:
Sticking on one train of thought, difficult to consider other alternatives – Executive Function (Ozonoff,
DSM-V Criteria
- Depressed mood
- Loss of interest or pleasure
- Change in weight or appetite
- Insomnia or hypersomnia
- Psychomotor retardation or agitation
- Loss of energy or fatigue
- Worthlessness or guilt
- Impaired concentration or indecisiveness
- Thoughts of death or suicidal ideation
Autism symptoms
- Social withdrawal
- Difficulties with sleep
- Flat affect
- Reduced eye contact
Overlap with presentation of depression –
leads to diagnostic overshadowing
Lack of autism specific items (Stewart et al. 2006)
What makes a good assessment tool?
•High quality studies assessing measurement properties:
–Structural validity and Internal consistency “Do the items measure the same latent construct?”
–Hypothesis testing “Does the tool perform the way we expect it to?”
•Group differences (depressed vs. non depressed)
–Criterion validity “Does the tool correlate with the gold standard assessment?”
–Content validity “Are the questions relevant, understandable to the target group?”
Depression tools in ASD?
- Systematic review assessed quality of previous studies using research tool (COSMIN)
- Only 1 low quality study assessing BDI-II in autistic adults
- Weak evidence compared to gen pop
Depression measurement in autism
- Study assessed measurement properties of BDI-II in verbal adults with autism
- Mild-moderate correlations with other measures, and clinical diagnosis of depression
- Many properties not assessed …
Supporting evidence for increased prevalence of autism in ED samples:
–0.3% female autism prevalence in the general population (Baird et al. 2006)
–8-37% females autism prevalence in ED samples (Huke et al. 2013)
ED’s and Autism
•At first glance have little in common
•Autism primarily affects social function and flexibility, onset early in development (within 1st 3 years) (Osterling and Dawson, 1994)
•ED’s primarily affect eating behaviour, onset in adolescence or adulthood (Steinhausen, 2009)
•ED’s more prevalent in females (Smink et al. 2014), autism in males (Mandy et al. 2012)
–But autism under-diagnosed in females (Bargiela et al. 2016)
Eating Disorders
- Persistent restriction of energy intake leading to significantly low body weight
- Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain
- Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
Symptoms of BPD and autism overlap in areas and could lead to
misdiagnosis
Those diagnosed with both ASD and BPD appear to show increased
social difficulties and self-harm behaviours
Important therefore to identify ASD and BPD
BPD and Autism
- Elevated autistic traits in those with BPD – similar level to those with autism
- Those with comorbid BPD and autism have highest autistic traits
- Given similarities easy to misdiagnose
BPD and Autism
•Autism diagnosis over-represented in BPD population
–15% of BPD patients met criteria for co-occurring autism assessed with clinical interviews (1% in gen pop)
–Patients with ASD and BPD were at significantly higher risk for suicide attempts than BPD only
–Also significantly lower more negative self-image
Diagnostic overshadowing
DSM-V criteria
•One latent variable in GP
–All items assess depression
–One factor, strong internal consistency found in previous research
Diagnostic overshadowing
Insomnia, depressed mood, loss of energy, worthlessness or guilt
•One latent variable in ASD?
–Some items assess autism?
–Different factor structure?
–Lower internal consistency of items?
Depression assessment in ASD
•Measurement properties of mental health assessment tools likely different in ASD compared to the general population (Cassidy et al. 2018)
–Content validity
•Need to ensure questions are relevant and understandable, taking into account cognitive characteristics of autism (interpretation)
Depression assessment in ASD
•Structural validity and internal consistency
–Need to include autism specific items which capture unique presentation of depression in autism (Cassidy et al. 2018; Stewart et al. 2006)
•Loss of interest in a previously intense interest
•Change in: eating, sleep, movement
•Include Q’s on: sensory sensitivity, camouflaging?
–Associated with depression in ASD (Hull et al. 2017; Serifani et al. 2017; Bitsika, Sharpley and Mills, 2016)
–BUT sensory hypo-sensitivity and depression look similar! – Additional measurement issue!
Depression assessment in ASD
•Hypothesis testing
–Check that autistic people with depression score higher than autistic people without depression
–Compare structural validity and internal consistency of original to adapted measures
•Criterion validity
–Tricky – what is the ‘gold standard’ to compare?
–Could compare performance of original and adapted tools against clinical assessment
•Depression appears highly prevalent in autism
Could be due to
increased experience of psycho-social risk factors for depression in autism
•Could also be due to difficulties in accurate identification of depression
–Over estimate (overlapping behaviours)
–Under estimate (fail to capture autism specific factors)
•Adapted assessments needed and currently being developed here (mhautism.coventry.ac.uk)
•Anxiety and worry are associated with three or more of the following six symptoms (with some present for most days over 6 months)
–Restlessness or feeling on edge –Easily fatigued, difficulties concentrating –Irritability –Muscle tension –Sleep disturbance
Anxiety in Autism
- Part of initial clinical reports – insistence on sameness, rituals
- Associated with intolerance of uncertainty, RRBs and sensory processing (see sensorimotor lecture; Wigham et al. 2015)
- These could affect the presentation of anxiety in autism, and must be taken into account in assessment
Anxiety in autism
•Sensory difficulties a core feature of autism and associated with RRBs and anxiety
•Repetitive behaviours (RRBs) also a core feature = insistence on sameness and repetitive motor movements
•“What time is it?” – anecdotally, these behaviours associated with anxiety in autism
–“Intolerance of uncertainty”
Are these related?
Anxiety in Autism
•E.g. social anxiety
–In general population, fear of negative evalutation
–In autism, fear of violation of logical rules or unpredictability of social situations (Kerns et al., 2014; Zainal et al., 2014)
•Need to reconceptualise anxiety for this group and in assessments?
Anxiety Autism Assessment
•Revised Child Anxiety and Depression Scale (RCADS) adapted for children with autism (ASC-ASD)
- Literature search identified additional autism specific areas to include in the measure (sensory anxiety, intolerance of uncertainty, and phobias)
- Focus groups with parents to refine content validity
•Challenging to assess common mental health difficulties (depression and anxiety) in autism
–Overlapping of symptoms (over-estimate)
–Lack of autism specific items (under-estimate)
•Recent and ongoing work is developing new adapted autism specific mental health assessments
BUT
are we changing criteria for mental health diagnosis?
BPD and autism
•Overlap in symptoms between BPD and autism:
–Social difficulties
–Emotion regulation difficulties
–Frequent suicidal gestures
Can appear to have very unstable and chaotic lifestyle –
frequent changes or inappropriate friendships
Camouflaging’ in autism could present as problem with
Identity
BPD and autism
•Overlap in symptoms between BPD and autism:
–Social difficulties
–Emotion regulation difficulties
–Frequent suicidal gestures
•Can appear to have very unstable and chaotic lifestyle – frequent changes or inappropriate friendships
•‘Camouflaging’ in autism could present as problem with identity
BPD and Autism
- BPD more commonly diagnosed in females (Grant et al. 2008)
- Autism under diagnosed in females (Bargiela et al. 2016)
- High prevalence of suicidality / self injury in particularly in autistic females (Hirvikoski et al. 2016; Cassidy et al. 2014)
- Camouflaging may be more prevalent in autistic females?
- Could potentially lead to misdiagnosis of autistic females as BPD or miss co-occurring conditions
BPD and Autism
•Autism diagnosis over-represented in BPD population
–15% of BPD patients met criteria for co-occurring autism assessed with clinical interviews (1% in gen pop)
–Patients with ASD and BPD were at significantly higher risk for suicide attempts than BPD only
–Also significantly lower more negative self-image
BPD and Autism
- Elevated autistic traits in those with BPD – similar level to those with autism
- Those with comorbid BPD and autism have highest autistic traits
- Given similarities easy to misdiagnose
Summary
- Symptoms of BPD and autism overlap in areas and could lead to misdiagnosis
- Those diagnosed with both ASD and BPD appear to show increased social difficulties and self-harm behaviours
- Important therefore to identify ASD and BPD
