Wednesday, May 27, 2015

Young Adults on the Autism Spectrum Struggle with Social Isolation



The dramatic increase in the prevalence of autism spectrum disorder (ASD) among children indicates that a correspondingly large number of youth will be transitioning into adulthood in the coming years. Investigating social participation of young adults with ASD is important given that social participation is an indicator of life quality and overall adaptive functioning. A study using data from the National Longitudinal Transition Study 2 examined rates of participation in social activities among young adults who received special education services for ASD, compared to young adults who received special education for intellectual disability, emotional/behavioral disability, or a learning disability.
According to the study, young adults with ASD were significantly more likely to never see friends, never get called by friends, never be invited to activities, and be socially isolated. Nearly 40 percent of young adults with ASD never saw friends and half were not receiving any phone calls or being invited to activities. Researchers found that 28 percent had no social contact at all. The social struggles of young people with ASD were also significantly more pronounced than those of other disability groups. For example, while almost one-third of those with ASD qualified as socially isolated because they never received telephone calls or went out with friends, fewer than 10 percent of individuals with intellectual disability and only 2 to 3 percent of people with emotional disturbance or learning disabilities fell into this category.
“Difficulty navigating the terrain of friendships and social interaction is a hallmark feature of autism,” said Paul Shattuck of Washington University who coauthored the study. “Nonetheless, many people with autism do indeed have a social appetite. They yearn for connection with others. We need better ways of supporting positive social connection and of preventing social isolation.”
This study indicates that there are growing numbers of adolescents and young adults with ASD in need of substantial support. In fact, the lack of services available to help young adults with ASD transition to greater independence has been noted by researchers for a number of years and has become an increasingly important issue as the prevalence of ASD continues to grow and as children identified with ASD reach adolescence and adulthood. The focus of intervention/treatment must shift from remediating the core deficits in childhood to promoting adaptive behaviors that can facilitate and enhance ultimate functional independence and quality of life in adulthood. This includes new developmental challenges such as independent living, vocational engagement, postsecondary education, and family support.
Orsmond, G. I., Shattuck, P. T., Cooper, B. P., Sterzing, P. R., & Anderson, K. A. (2013). Social Participation among young adults with an autism spectrum disorder. Journal of Autism and Developmental Disorders. DOI 10.1007/s10803-013-1833-8
Lee A. Wilkinson, PhD, NCSP, CPsychol, AFBPsS is a licensed and nationally certified school psychologist, chartered psychologist, registered psychologist, and certified cognitive-behavioral therapist. Dr. Wilkinson is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also editor of a text in the American Psychological Association (APA) School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools, and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. Dr. Wilkinson's latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Ed.).

Monday, May 11, 2015

Cognitive-Behavioral Therapy for Children on the Autism Spectrum


   Introduction
Children with autism spectrum disorders (ASD) frequently have co-occurring (comorbid) psychiatric conditions, with estimates as high as 70 to 84 percent. A Comorbid disorder is defined as a disorder that co-exists or co-occurs with another diagnosis so that both share a primary focus of clinical and educational attention. Although anxiety is not a defining characteristic of ASD, prevalence rates are significantly higher in children with ASD than in typically developing children, children with language disorders, chronic medical conditions, disruptive behavior disorders, and intellectual disability or epilepsy. In fact, research suggests that approximately one-half of children with ASD would meet the criteria for at least one anxiety disorder. Several studies have also reported a bidirectional association between internalizing disorders and autistic symptoms. For example, both a higher prevalence of anxiety disorders has been found in ASD and a higher rate of autistic traits has been reported in youths with mood and anxiety disorders. Individuals with ASD also appear to display more social anxiety symptoms compared to typical control individuals, even when these symptoms are clinically overlapping with the characteristic social problems typical of ASD. With comorbidity rates so elevated in the ASD population, treatment options for anxiety have become increasingly important.
Cognitive-Behavioral Therapy
There is a strong evidence base for the use of cognitive-behavioral therapy (CBT) interventions for depression and anxiety in non-ASD populations. There are a variety of CBT approaches, but most share some common elements. The primary goals of traditional CBT are to identify and challenge dysfunctional beliefs, catastrophic cognitions, and automatic thoughts as well as change problematic behavior. With a therapist’s help, the individual is encouraged to challenge his or her beliefs and automatic thoughts through a variety of techniques. Through CBT, the individual learns skills to modify thoughts and beliefs, as well as problem-solving strategies to improve interaction with others in effective and appropriate ways, thereby promoting self-regulation.
CBT models for the treatment of anxiety attempt to create a new coping pattern by using behavioral techniques such as modeling, exposure, and relaxation as well as cognitive techniques addressing cognitive distortions and deficiencies. These treatment models generally emphasize four critical components of therapy: assessment, psychoeducation, cognitive restructuring, and exposure. Using these four components, CBT has been shown to be an empirically supported treatment for typically developing children with anxiety issues. The most commonly used techniques to treat anxiety in children are exposure, relaxation, cognitive restructuring, and modeling in that order.
Cognitive-Behavioral Therapy for ASD
Although CBT has been shown to be an effective empirically supported treatment for typical children, there is a question as to whether or not it can be used with other populations. In recent years, there have been a number of attempts to adapt CBT for children and teens on the autism spectrum. Although there is no agreed upon set of modifications, there appears to be a general consensus that with certain specific modifications, CBT can be used to effectively lessen anxiety symptoms in higher functioning children with ASD. Evidence from the current literature supports a specific blend of techniques and strategies as the most effective approach to modify CBT for use with children who have an ASD. The primary modifications to CBT that have been shown to make them more viable for anxious children with ASD are the development of disorder specific hierarchies, the use of more concrete, visual tactics, the incorporation of child specific interests, and parent participation.
A study published in the Journal of Child Psychology and Psychiatry illustrates how a standard CBT program can be adapted to include multiple treatment components designed to accommodate or remediate the social and adaptive skill deficits of children with ASD that serve as barriers to anxiety reduction. The study tested a modular CBT program incorporating separate modules focusing specifically on deficits associated with ASD such as poor social skills, self-help skills, and stereotypies as well as a modified version of a traditional CBT protocol utilizing primarily cognitive restructuring and exposure techniques. The participants were forty children (7–11 years of age) who met the criteria for ASD and one of the following anxiety disorders: separation anxiety disorder (SAD), social phobia, or obsessive-compulsive disorder (OCD). They were randomly assigned to 16 sessions of CBT or a 3-month waitlist (36 children completed treatment or waitlist). The CBT model emphasized coping skills training (e.g., affect recognition, cognitive restructuring, and the principle of exposure) followed by in vivo exposure. The parent training components focused on supporting in vivo exposures, positive reinforcement, and communication skills. Independent evaluators blind to treatment condition conducted structured diagnostic interviews and parents and children completed anxiety symptom checklists at baseline and posttreatment/postwaitlist. The researchers found that 92.9% of children in the active treatment group met criteria for positive treatment response post-treatment compared to only 9.1% of children in the waitlist condition. In addition, 80% of children in the active treatment group were diagnosis free at follow up. From these results, it is reasonable to draw the conclusion that with specific modifications, CBT can be an effective treatment for children with ASD and concurrent anxiety disorders.
Conclusions
The above referenced study, together with case studies and other clinical trials, provides evidence that incorporating disorder specific hierarchies, use of more concrete, visual tactics, incorporation of child specific interests, and parental involvement can facilitate successful results when conducting CBT for anxiety in children with ASD. Although there is support for the efficacy of an enhanced CBT program, there are some limitations to these modifications and adapted models. Specifically, the child’s level of functioning, variation in the use of each modification, and the utilization of different CBT programs across studies affect the generalization of the outcomes. Moreover, there is a need to examine to what extent CBT with these modifications could be used with more severe cases of ASD or in cases where there is more severe intellectual impairment. Children with higher functioning ASD may be able to better process the cognitive components of traditional and modified CBT than those who are lower functioning. Additionally, different CBT programs may emphasize different components of CBT making it difficult to determine which components are the most critical for treating anxiety in children with ASD. The next step for future research should be to focus on developing a standardized approach to treatment which incorporates specific modifications, randomized clinical trials to test the approach, and explorations of the boundaries within the ASD population for use and effectiveness of treatment. Given the elevated comorbidity rates, finding an effective, empirically supported treatment for anxiety in children with ASD is critical.
Moree, B. N., & Davis III, T. E. (2010). Cognitive-behavioral therapy for anxiety in children diagnosed with autism spectrum disorders: Modification trends. Research in Autism Spectrum Disorders, 4, 346–354.
Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224–234. doi:10.1111/j.1469-7610.2008.01948.x
Lee A. Wilkinson, PhD, CCBT is a certified cognitive-behavioral therapist and author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. His most recent book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools, (2nd Edition)




Monday, May 4, 2015

Repetitive Behavior Among the Earliest Signs of Autism

The criteria for the new DSM-5 category of Autism Spectrum Disorder (ASD) include restricted and repetitive patterns of behavior (RRB) as a core diagnostic feature, together with the domain of social communication and social interaction deficits. Recent evidence suggests that restricted and repetitive behaviors may differentiate children who develop autism spectrum disorder (ASD) by late infancy. A study published in the Journal of Child Psychiatry and Psychology found that children who show several repetitive behaviors at their first birthday have nearly four times the risk of autism of children who don’t show repetitive behaviors.
Researchers collected parent-report data (Repetitive Behavior Scales-Revised) for 190 high-risk toddlers and 60 low-risk controls from 12 to 24 months of age. Forty-one high-risk children were classified with ASD at age 2. Profiles of repetitive behavior were compared between groups. The study found that the profiles for children diagnosed with ASD differed significantly from high- and low-risk children without the disorder on all measures of repetitive behavior. Toddlers with ASD showed significantly higher rates of repetitive behavior across at the 12-month time point. Repetitive behaviors were significantly associated with adaptive behavior and socialization scores among children with ASD at 24 months of age, but were largely unrelated to measures of general cognitive ability.
These findings suggest that as early as 12 months of age, a broad range of repetitive behaviors are highly elevated in children who go on to develop ASD. While some degree of repetitive behavior is essential to typical early development, the extent of these behaviors among children who develop ASD appears highly atypical. The study supports earlier findings that repetitive behaviors may be among the earliest-emerging signs of autism. It also points to new avenues of inquiry. While the search for early social deficits has received substantial attention from researchers, ritualistic, repetitive behaviors have largely been neglected. This is unfortunate because repetitive behaviors are often easier for a parent to notice than the absence of a social behavior. Parents of individuals with ASD also report that restricted and repetitive behaviors are one of the most challenging features of ASD due to their significant interference with daily life. Likewise, they can impede learning and socialization by decreasing the likelihood of positive interactions with peers and adults. Given the importance of restricted and repetitive behavior as core feature of ASD, clinicians and practitioners should give increased attention to the assessment and presence of this behavior in screening and assessment as an early indicator and consider their impact on the psychological well-being of individuals with ASD.
Wolff JJ, Botteron KN, Dager SR, Elison JT, Estes AM, Gu H, Hazlett HC, Pandey J, Paterson SJ, Schultz RT, Zwaigenbaum L, Piven J. Longitudinal patterns of repetitive behavior in toddlers with autism. J Child Psychol Psychiatry. 2014 Feb 19. doi: 10.1111/jcpp.12207. [Epub ahead of print]


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