Wednesday, September 13, 2017

Catatonia in Autism Spectrum Disorder


What is autistic catatonia?
Catatonia is a complex neuro-psychological disorder which refers to a cluster of abnormalities in movement, volition, speech and behavior. In its extreme form, it is manifested as absence of speech (mutism), absence of movement (akinesia) and maintenance of imposed postures (catalepsy). Lesser degrees of these impairments, and various other abnormalities of posture, movement, speech and behavior, are also considered to be catatonic phenomena.  
Historically, the term catatonia has been associated with schizophrenia and psychoses, but it is now recognized that it can occur with a range of conditions, including autism spectrum disorder (ASD). For example, studies suggest that between 12-18% of individuals on the spectrum may present with varying levels of catatonia-like deterioration. Although overlapping or shared symptoms (e.g., mutism, echolalia, stereotypic speech and repetitive behavior) can present a diagnostic challenge, differences in age-of-onset between catatonia and ASD can help to discriminate between the two similar symptom profiles. Specifically, the age-of-onset of catatonic regression is typically observed at a later age than symptoms of ASD and occurs most often during adolescence and young adulthood. Stressful life events, loss of routine, interpersonal conflicts, anxiety and depression, and side effects of psychiatric medication may precipitate catatonia in adolescents and teens on the spectrum. Researchers have posited that some individuals may have an inherent vulnerability to developing catatonia, which becomes overt in response to stress.
Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not recognize catatonia as a separate disorder, it is included as a specifier for ASD to indicate the presence of comorbid (co-occurring) catatonia. The DSM-5 recognizes that it is possible for individuals with ASD to experience a marked deterioration in motor symptoms and display a catatonic episode with symptoms such as mutism, posturing, grimacing, and motoric immobility.
Symptoms of catatonia in autism
Early identification and diagnosis is critically important as autism-related catatonia can result in marked stress to families and can have a deleterious effect on the quality of life of the individual. Symptoms can progress to acute catatonia which is extremely difficult to treat and lead to total immobility, dependence on all aspects of daily living, and become life-threatening. Unfortunately, autistic catatonia is infrequently identified at an early stage, and often misdiagnosed and mistreated. Clinicians may not recognize the onset and gradual presentation of catatonic-like deterioration rather than the full-scale catatonic stupor state which is more easily identified and familiar to most mental health practitioners. Co-morbid catatonia should be considered as a possible diagnosis for an individual on the autism spectrum who who shows a change in pre-existing symptoms and a marked and obvious deterioration in: (a) movement; (b) volition; (c) level of activity; (d) speech; and (e) a regression in self-care, practical skills and independence compared to previous levels.
Specific indicators of an onset of autism-related catatonia may include any of the following:
  • increased slowness and freezing during actions
  • increase in repetitive movements and hesitations
  • difficulty in crossing thresholds and completing movements
  • marked reduction in speech or complete mutism
  • aggression, extreme negativity, and difficulty initiating actions
  • increased reliance on physical or verbal prompts for functioning
  • increase in repetitive and ritualistic behaviors
  • grimacing, odd gait, and stiff, locked postures
  • impulsivity, bizarre behavior, excitement, and purposeless agitation
Treatment
There is little research evidence to guide medical treatment of autism-related catatonia. The current medical treatment algorithm for catatonia-like deterioration in ASD recommends the use of benzodiazepines, commonly lorazepam, and electroconvulsive therapy (ECT) for cases with acute catatonic stupor or cases where other approaches have been ineffective. Unfortunately, there is a lack of controlled studies examining the medical treatment of catatonic symptoms in ASD. The existing literature is limited to single-case designs and reflects serious methodological limitations. Likewise, studies have not examined the side-effects of these treatments and infrequently report long term follow-up of effects. As a result, there is little robust evidence to support any specific treatment.
There is some evidence that when catatonic symptoms in ASD become chronic a psychological treatment approach, co-occurring with medical treatments, is useful to support the management of the individual, particularly for parents and caregivers. This non-medical treatment paradigm is based on a comprehensive psychological assessment which focuses on identifying stressful life event(s), locating and eliminating any potential causes such as psychiatric medications, and restructuring the environment to effectively reduce the source(s) of the stressors. This approach is also designed to help parents and caregivers understand and conceptualize the catatonic syndrome and to work with caregivers and multi-disciplinary teams to implement a treatment/intervention plan. In addition, the use of prompts as external stimuli and physical activities, especially routine and structure are emphasized. This psychological approach can be helpful whether used together with or independently of medical treatments.
Conclusion
Given the paucity of information in the literature, it is important to recognize and diagnose autism-related catatonia as early as possible so that treatment and symptom management can be implemented. Thus, it is critically important for clinicians, autism professionals, educators, parents and caregivers to be aware of the symptoms of catatonia-like deterioration in teens and adults on the autistic spectrum. Catatonia should be assessed in any individual with ASD when there is a change in pre-existing symptoms and an obvious and marked deterioration in movement, pattern of activities, self-care, and practical skills, compared with previous levels, through a comprehensive diagnostic evaluation of medical and psychiatric symptoms. Possible physical or psychological causes should be investigated, and treated. There is some indication that screening for catatonic features and providing early support might reduce later incidence of catatonic deterioration in people with ASD. Lastly, there is an urgent need for controlled, high-quality studies examining the potential causes and treatment protocols for this underidentified and misunderstood autism-related condition. 

References & Resources
http://network.autism.org.uk/good-practice/evidence-base/catatonia-and-catatonia-type-breakdown-autism
https://www.autismspeaks.org/blog/2014/01/03/does-our-teen-have-autism-related-catatonia
DeJong, H., Bunton, P., & Hare, D. (2014).  A Systematic Review of Interventions Used to Treat Catatonic Symptoms in People with Autistic Spectrum Disorders. Journal of Autism & Developmental Disorders. Vol 44: 2127-2136.
Dhossche, D., Shah, A., & Wing, L. (2006). Blueprints for the Assessment, Treatment, and Future Study of Catatonia in Autism Spectrum Disorders. Catatonia in Autism Spectrum Disorders. International Review of Neurobiology Vol 72 P.268-283. Elsevier Inc. USA.
Ghaziuddin, N., Dhossche, D., & Marcotte, K. (2012). Retrospective Chart Review of Catatonia in Child and Adolescent Psychiatric Patients. Acta Psychiatrica Scandinavic, a, 125(1), 33-38.
Shah, A. & Wing, L. (2006). Psychological Approaches to Chronic Catatonia-Like Deterioration in Autism Spectrum Disorders. Catatonia in Autism Spectrum Disorders. International Review of Neurobiology Vol 72 P.245-260. Elsevier Inc. 

Wing, L. & Shah, A. (2000) Catatonia in autistic spectrum disorders. British Journal of Psychiatry. Vol. 176, 357-362.

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorder. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a best-selling text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Wednesday, August 30, 2017

Award-Winning Finalist in the 2016 Best Book Awards: Overcoming Anxiety & Depression on the Autism Spectrum: A Self-Help Guide Using CBT

OVERCOMING ANXIETY AND DEPRESSION ON THE AUTISM SPECTRUM: A SELF-HELP GUIDE USING CBT
Many adults on the autism spectrum experience isolation, interpersonal difficulties, anxiety, depressed mood, and coping problems. Award-winning author Dr. Lee A. Wilkinson's new book presents strategies derived from cognitive-behavioral therapy (CBT), adapted specifically for adults with on the higher end of the spectrum, to help them overcome anxiety, and depression, and improve their psychological well-being. This self-help guide is written for individuals in the early and middle years of adulthood, with and without a formal diagnosis, who share features associated with autism spectrum conditions. It is also appropriate for adults who recognize their autistic traits, even though they may not have experienced major social difficulties and clinical impairment, but who want to improve their emotional well-being.
 
The author takes the best of CBT therapeutic techniques to facilitate greater self-understanding, self-advocacy, and better decision-making in life-span activities such as employment and interpersonal relationships.
Accessible and easy-to-read, this self-help guide provides evidence-based tools that can be used to learn new self-fulfilling ways of thinking, feeling, and doing. It includes questionnaires, forms/worksheets, and exercises to help the reader:
  • Evaluate his or her autistic traits and discover their cognitive style.
  • Identify and modify the thoughts and beliefs that underlie and maintain the cycles of anxiety, depression, and anger.
  • Apply therapeutic techniques such as mindfulness, positive self-talk, guided imagery, and problem-solving.
  • Accept the past and achieve unconditional self-acceptance.
  • Deal effectively with perfectionism and low frustration tolerance.
  • Avoid procrastination and learn to maintain the positive changes to their progress.

Honored as an Award-Winning Finalist in the “Health: Psychology/Mental Health” category of the 2016 Best Book Awards, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT is an essential self-help book for adults on the higher end of the spectrum looking for ways to understand and cope with their emotional challenges and improve their psychological well-being.  Family members, friends, and others touched by autism will also find this self-help book a valuable resource.
Table of Contents
Acknowledgements. 1. Introduction. Adults on the Autism Spectrum. 2. Where Are You on the Autism Spectrum? 3. Self-Analysis and Your Cognitive Style. 4. The ABCs of Emotions. 5. Rationality and Scientific Thinking. 6. Imagery, Mindfulness and Self-Talk. 7. Maintaining Your Changes. Appendix A. Autism Quotient (AQ). Appendix B. Empathy Quotient (EQ). Appendix C. Systemizing Quotient (SQ). Appendix D. ABC Worksheet. Appendix E. Thought - Feeling Worksheet. Appendix F. Unhelpful Thinking Habits Record Form. Appendix G. CBT Self-Help Thought Record Form. Appendix H. Daily Mood and Thought Worksheet. Appendix I. Self-Talk Record Form. Appendix J. Coping Thought Worksheet. Appendix K. Problem Solving Worksheet. Appendix L. Maintaining Change Worksheet. Unhelpful Thinking Habits. Major Irrational Beliefs. Reference List. About the Author.
Reviews
'From his many years as an autism professional and cognitive-behavioural therapist, Dr Wilkinson shows an excellent understanding of perceptions and thought processes of people on the autism spectrum, which he explains so clearly in a way people on the autism spectrum can relate to. This book will not only help people on the autism spectrum to gain a stronger understanding of who they are, but also offers a way to overcome anxiety and depression by working with their thought processes rather than attempting to 'banish' or 'cure' them. An important resource for a group of people whose needs are not static.' - Chris Mitchell, author of Mindful Living with Asperger’s Syndrome and Asperger’s Syndrome and Mindfulness
'Overcoming Anxiety and Depression on the Autism Spectrum will be of great value to people with autism spectrum conditions who experience anxiety and depression. It is a self-help guide which provides practical advice on living well, tailored to individuals on the autism spectrum. Using strategies based around Cognitive Behaviour Therapy, it offers a positive approach to managing anxiety and depression.' - Jeanette Purkis, autism and mental health self-advocate, author of Finding a Different Kind of Normal: Misadventures with Asperger Syndrome, and The Wonderful World of Work: A Workbook for Asperteens
'When people ask me if there is anything I'd change about my Asperger syndrome, I offer this firm reply: I'd like to shackle and disable my anxiety and depression. They work together as twin dragons bent on disabling confident and reliable thinking. Wilkinson's accurate analysis and applicable supports give me hope and more reason to keep working on defeating these nasties.' - Liane Holliday Willey, author of Pretending to be Normal and Safety Skills for Asperger Women

Overcoming Anxiety and Depression on the Autism Spectrum is available from Jessica Kingsley Publishers, AmazonBarnes & Noble, Book DepositoryBooks-A-Million and other online book retailers.


Get the lowest price on Overcoming Anxiety and Depression on the Autism Spectrum: A Self-help Guide Using CBT from AllBookstores.com.

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He 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 best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Friday, August 11, 2017

Transitioning Back to School: Tips for Parents of Children on the Autism Spectrum

Students throughout the country will soon be making the transition to a new school year or a new grade. This includes an increasing number of special needs children identified with autism spectrum disorder (ASD). Since Congress added autism as a disability category to the Individuals with Disabilities Education Act (IDEA) in 1990, there has been a dramatic increase in the number of students receiving special education services under this category. 

The beginning of a new school year is an exciting yet anxious time for both parents and children. It typically brings a change in the daily routine established over the summer months. This transition can be especially challenging for families with children on the autism spectrum. While change can be difficult, the following tips will help prepare a child with ASD for the new school year. 
1. Prepare and reintroduce routines.
  • Familiarize and reintroduce your child to the school setting. This may mean bringing your child to the school or classroom, showing your child a picture of their teacher and any classmates, or meeting the teacher before the first day of school. If possible, arrange to visit the teacher or the school a week or two before the first day. If this isn’t feasible, visit the school building or spend some time on the playground. Driving by the school several times is another good idea. You may also want to drive your child on the first day as well if they ride a bus to school. For many children with ASD, riding a bus to school on the first day can result in a sensory “overload.” Gradually easing them into the transportation routine will be helpful for everyone.
2. Expect the unexpected.
  • Parents cannot anticipate everything that might happen during the school day. Allow more time for all activities during the first week of school. Prepare your child for situations that may not go as planned. Discuss a plan of action for free time, such as lunch and recess. Use social stories to familiarize your child with routines and how to behave when an unexpected event occurs. Anticipate sensory overload. The activity, noise and chaos of a typical classroom can sometimes be difficult to manage. Establish a plan of action for this situation, possibly a quiet room where the child can take a short break. If your child has dietary issues, determine in advance how this will be managed so as to avoid any miscommunication.
3. Review and teach social expectations.
  • Although many children may transition easily between the social demands of summer activities and those required in the classroom, children on the autism spectrum may need more clear-cut (and literal) reminders. Review the “dos and don’ts” of acceptable school behavior. You can also create a schedule of a typical school day by using pictures and talk about how the school day will progress. Create a social story or picture schedule for school routines. Start reviewing and practicing early. If possible, meet with teachers and administrators to discuss your child’s strengths and challenges. Remember, you are your child’s best advocate. Establish communication early to develop positive relationships with your child’s teacher and school. Rehearse new activities. Ask the teacher what new activities are planned for the first week. Then, prepare your child by performing, practicing, and discussing them. This rehearsal will reduce anxiety when new activities take place during the beginning of school.
In summary, do everything possible to help reduce the stress level for your child and family during this transition time. Don’t forget to prepare yourself! A calm and collected parent is better able to help their child make a successful transition back to school.

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT, both published by Jessica Kingsley Publishers. He is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. Dr. Wilkinson's latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Friday, July 14, 2017

Evidence-Based Practice for Children and Youth on the Autism Spectrum



Supporting children with ASD requires individualized and effective intervention strategies. It is very important for families, teachers, administrators, and school-based support personnel to be knowledgeable about evidence-based approaches to adequately address the needs of students with autism and to help minimize the gap between research and practice. Although the resources for determining best practices in autism are more extensive and accessible than in previous years, school professionals face the challenge of being able to accurately identify these evidence-based strategies and then duplicate them in the classroom and other educational settings

The rapid growth of the scientific literature on ASD has also made it difficult for practitioners to stay up-to-date with research findings. Unfortunately, many proponents of ASD treatments make claims of cure or recovery, but provide little scientific evidence of effectiveness. These interventions appear in books and on websites that describe them as “cutting-edge therapies” for autism. Consequently, school-based personnel and families need to have a reliable source for identifying practices that have been shown, through scientific research, to be effective with children and youth with ASD. Evidence-based research provides a starting point for determining what interventions are most likely to be effective in achieving the desired outcomes for an individual.
Developing and implementing effective interventions and treatment for students with autism requires that they be evidence-based and supported by science. All interventions and treatments should be based on sound theoretical constructs, robust methodologies, and empirical studies of effectiveness. An evidence-based practice can be defined as a strategy, intervention, treatment, or teaching program that has met rigorous peer review and other standards and has a history of producing consistent positive results when experimentally tested and published in peer-reviewed professional journals. It excludes evidence that is supported by anecdotal reports, case studies, and publication in non-refereed journals, magazines, internet, and other media outlets.
Systematic Research Reviews
Systematic research reviews play an important role in summarizing and synthesizing the knowledge base for determining what interventions are most likely to be effective in achieving the desired outcomes for children and youth with ASD. There are two major resources available to school professionals that provide a listing, along with systematic reviews, of evidence-based interventions and practices for students with ASD: the National Autism Center’s (NAC; 2015) second phase of the National Standards Project (NSP-2), which reviewed research studies to identify established interventions for individuals with ASD, and the National Professional Development Center on Autism Spectrum Disorders (NPDC on ASD, 2015; Wong et al., 2014), which also analyzed numerous research studies and identified evidence-based practices for students with autism. Although both reviews were conducted independently, their findings are very similar and reflect a convergence across these two data sources. According to the NAC and NPDC, the following are evidence-based interventions/practices for ASD:
Behavioral Interventions: These interventions are based on behavioral principles and are designed to reduce problem behavior and teach functional alternative behaviors.
Cognitive Behavioral Intervention: Cognitive behavioral interventions are designed to change negative or unrealistic thought patterns and behaviors with the goal of positively influencing emotions and life functioning.
Modeling: This intervention relies on an adult or peer providing a demonstration (live and video) of a target behavior to the person learning a new skill, so that person can then imitate the model.
Naturalistic Interventions: These interventions primarily involve child-directed interactions to teach real-life skills (communication, interpersonal, and play skills) in natural environments. Examples include incidental teaching, milieu teaching, and embedded teaching.
Parent-Implemented Intervention: Parents provide individualized intervention to their child to improve/increase a wide variety of skills such as communication, play, or self-help, and/or to reduce challenging behavior. Parent training can take many forms, including individual training, group training, support groups, and training manuals.
Pivotal Response Training (PRT): PRT is a naturalistic intervention model that targets pivotal areas of a child's development, such as motivation, responsivity to multiple cues, self-management, and social initiations.
Peer-Mediated Instruction: Teachers/service providers systematically teach typically developing peers to interact with and/or help children and youth with ASD to acquire new behavior, communication, and social skills. Common names include peer networks, circle of friends, and peer-initiation training.
Scripting: This intervention involves developing a verbal and/or written script about a specific skill or situation which serves as a model for the child with ASD.
Self-Management: Self-management strategies involve teaching individuals with ASD to evaluate and record the occurrence/nonoccurrence of a target behavior and secure reinforcement. The objective is to be aware of and regulate their own behavior so they will require little or no assistance from adults.
Social Narratives: These interventions identify a target behavior and involve a written description of the situation under which specific behaviors are expected to occur. The most well-known story-based intervention is Social Stories™.
Social Skills Training: Social skills training involves group or individual instruction designed to teach learners with ASD ways to appropriately interact with peers, adults, and other individuals.
Visual Support: Any visual display that supports the learner engaging in a desired behavior or skills independent of prompts. Examples of visual supports include pictures, written words, schedules, maps, labels, organization systems, scripts, and timelines.
Systematic reviews synthesize the results of multiple studies and provide school professionals with summaries of the best available research evidence to help guide decision-making and support intervention practice. It must be stated, however, that these ratings are not intended as an endorsement or a recommendation as to whether or not a specific intervention is suitable for a particular child with ASD. Because no two individuals are alike, no one program exists that will meet the needs of every person with autism. Additionally, children with autism learn differently than typical peers or children with other types of developmental disabilities. 

The success of the intervention depends on the interaction between the age of the child, his or her developmental level and individual characteristics, strength of the intervention, and competency of the professional. Each child is different and what works for one may not work for another. Research findings are only one component of evidence-based practice to consider when selecting interventions. The selection of a specific intervention should be based on goals developed from a comprehensive developmental assessment as well as professional judgment and the values and preferences of parents, caregivers, and the individual with ASD.
National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author.
National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices.
Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S… Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He 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. Dr. Wilkinson is also editor of a best-selling 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 latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Sunday, July 9, 2017


Honored as an Award-Winning Finalist in the “Health: Psychology/Mental Health” category of the 2016 Best Book AwardsOvercoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT is an essential self-help book for adults on the higher end of the spectrum looking for ways to understand and cope with their emotional challenges and improve their psychological well-being. Family members, friends, and others touched by autism will also find this self-help book a valuable resource.


Saturday, June 3, 2017

Triggers for Anxiety in Children on the Autism Spectrum



Anxiety Disorders are a frequent co-occurring (comorbid) problem for children and youth with autism spectrum disorder (ASD). Although prevalence rates vary from 11% to 84%, most studies indicate that approximately one-half of children with ASD meet criteria for at least one anxiety disorder. Moreover, rates of anxiety are reportedly higher than those in children with language disorders, conduct disorder, or in clinically anxious typically developing children. 

Despite promising advances in the research and practice literature, our understanding of the prevalence, phenomenology and treatment of anxiety in ASD remains somewhat limited. Importantly, there is a paucity of information on the difference between ASD and non-ASD populations in regards to the manifestation of anxiety symptoms. Understanding more about the factors triggering and maintaining anxiety in ASD, and how children with ASD and their families experience, think and speak about anxiety, could inform the development and implementation of autism-specific interventions for anxiety in this population.
An exploratory study published in the journal Autism reported on a series of 5 focus groups with parents of children and adolescents with ASD and anxiety as a first step in identifying the triggers, behavioral signs and cognitive processes associated with anxiety. Seventeen mothers of 19 children with a diagnosis of ASD participated in the focus groups. All children (12 boys and 7 girls) had received ASD diagnoses from local clinical services and were reported to experience significant levels of anxiety that had an impact on their functioning.
Results
The following is a summary of key themes identified by parents in relation to triggers, symptoms and impact of anxiety in their children with ASD.
Anxiety triggers/Stressors:
1. Change or disruption to routine.
2. Confusion and worries about social and communication situations.
3. Specific fears and phobias.
4. Sensory oversensitivity and overstimulation.
5. Being prevented from preferred repetitive behaviors and interests.
6. Too many demands or expectations.
Presentation of anxiety:
1. Increase in challenging behavior.
2. Avoidance/withdrawal/escape.
3. Increase in levels of arousal.
4. Increase in sensory, repetitive, and ritualistic behavior.
5. Physical sensations associated with anxiety.
6. Cognitive distortions and errors in thinking.
Impact of anxiety:
1. Personal distress in children, parents, and siblings.
2. Increase in challenging behavior and stereotyped behaviors.
3. Restriction of activities/opportunities.
4. Negative impact on quality of life for child and family.
Discussion
Across groups, parents gave markedly similar descriptions of the triggers and behavioral signs associated with anxiety. Parents’ perspectives on the anxieties of their children indicate that there are many overlaps with anxiety as experienced in the general population. Shared triggers included social worries, specific phobic stimuli, and expectations that are, or are perceived to be, too demanding. Common features of the presentation of anxiety include an increase in arousal and avoidance/escape behaviors.
There were, however, a number of autism-specific triggers and symptoms of anxiety identified in children with ASD. Key features were the intensity, pervasiveness and persistence of the anxiety. Changes and disruptions to routines, sensory sensitivities and social difficulties associated with difficulties in perspective-taking and social expectations appeared to be ASD-specific triggers. Situations that were reported to trigger anxiety often reflected autism-related difficulties in processing style or sensory sensitivity. The majority of comments about the presentation of anxiety fell into the categories of challenging behavior and avoidance/withdrawal, indicating that behavioral manifestations are the major expressions of anxiety in children with ASD. When asked about their anxious thoughts, the most prominent theme that emerged was the difficulty that children with ASD have in expressing their anxiety verbally, particularly at times of severe distress. Although this is also occurs with many typically developing children, it may be a particular difficulty for children with ASD given the challenges they face in understanding and expressing emotions and pragmatic language difficulties. In addition to similar descriptions of the triggers and behavioral signs associated with anxiety, the impact of anxiety was reported to be often times more substantial than the impact of ASD itself.
Implications
Although this study did not specifically address assessment and intervention/treatment issues, several implications in these areas emerged. For example, when parents and children with ASD are asked to describe their experiences in a semi-structured, non-directed manner, they largely focus on features more specific to the ASD population that are not typically measured on most standard anxiety measures. Although there are broad-based measures that evaluate emotional/behavioral difficulties in children with neurodevelopmental disabilities, a significant gap remains in the resources available to clinicians and researchers for measuring ASD-specific aspects of anxiety. This argues for the inclusion of observational methods in the assessment of anxiety: using multiple informants, multimodal assessment techniques, and methods.
Identification of specific triggers/stressors and presentation of anxiety in children with ASD can help educators and interventionists improve programs and services for this group of students. These findings may also be useful for clinicians working with children and youth with ASD, particularly those utilizing CBT as a treatment approach. Although recent randomized controlled trials suggest that enhanced and adapted CBT can successfully treat anxiety disorders in high functioning children with ASD, it is unclear which adaptations are critical or which modifications are required for which anxiety disorder.  Nevertheless, the authors note that their findings support the view that adaptations to CBT, such as adding ASD-specific components to the treatment protocol, are important, relevant and acceptable to parents of children with ASD.  They also caution that even though CBT can be an effective means of treating anxiety in youth with ASD, clinicians may need to consider whether CBT is the most appropriate intervention or whether other approaches such as behavioral strategies or environmental modifications may be more suitable, as accessing or modifying cognitions may prove too challenging for some youth with ASD. Yet, CBT is clearly an effective intervention for many children with ASD, and the involvement of parents can further improve outcomes.
Recommendations for future research include focusing on larger groups and control samples, and systematically investigating the link between ASD cognitive processing styles and anxiety. The authors propose that further exploration of the similarities and differences between shared and ASD-specific triggers, manifestations, and effects of anxiety using a variety of methodologies will contribute to the development of more appropriate assessment measures and ASD-specific models of anxiety which can then guide treatment for more effectively.
Ozsivadjian, A., Knott, F., & Magiati, I. (2012). Parent and child perspectives on the nature of anxiety in children and young people with autism spectrum disorders: a focus group study. Autism, 16, 107-121. DOI: 10.1177/1362361311431703
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He 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 the editor of a best-selling 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 CBTHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd edition).

Tuesday, May 30, 2017

Designing Positive Behavior Support Plans for Learners on the Autism Spectrum



The problem behaviors of children on the autism spectrum are among the most challenging and stressful issues faced by schools and parents. The current best practice in treating and preventing unwanted or challenging behaviors utilizes the principles and practices of positive behavior support (PBS). PBS has been demonstrated to be effective with individuals across a wide range of problem behaviors and settings. 

Although used successfully both in the classroom and school-wide, PBS is not a specific intervention per se, but rather an approach that has evolved from traditional behavioral management methods. PBS refers to a set of research-based strategies that are intended to decrease problem behaviors by designing effective environments and teaching students appropriate social and communication skills. PBS utilizes primary (universal, school-wide), secondary (targeted group), and tertiary ( individual support) levels or tiers of intervention, each level providing an increasing level of intensity and support. 
An essential component of PBS is a functional behavior assessment (FBA) to help determine the events that influence and maintain an individual student’s persistent and challenging behavior. FBA methods are considered best practice in identifying and designing behavioral intervention plans for students who demonstrate serious problem behaviors that require more intensive and individualized supports. An important goal of a functional assessment is to identify antecedents or environmental situations that will predict the occurrence and nonoccurrence of the student’s challenging behavior. Another goal is to obtain and expand information that will improve the effectiveness and efficiency of intervention strategies. FBA identifies the function(s) that the behavior appears to serve for the student. For example, a student might exhibit challenging behaviors with the goal of escape or the goal of seeking attention. When the curriculum is difficult or demanding, he or she may attempt to avoid or escape work through challenging behavior (e.g., refusal, passive aggression, disruption, etc.). Similarly, they may use challenging behavior to get focused attention from adults and peers, or to gain access to a preferred object or participate in an enjoyable activity. Problematic behavior may also occur because of sensory aversions. Because students with ASD also have significant social and pragmatic skills deficits, they may experience difficulty effectively communicating their needs or influencing the environment. Thus, challenging classroom behavior may serve a purpose for communicating or a communicative function. When we understand the goal of student behavior then we can begin to teach alternative replacement behavior and new interactional skills. 
The process of conducting an FBA is best described as (a) an strategy to discover the purposes, goals, or functions of a student’s behavior; (b) an attempt to identify the conditions under which the behavior is most likely and least likely to occur; (c) a process for developing a useful understanding of how a student’s behavior is influenced by or relates to the environment; and (d) an attempt to identify clear, predictive relationships between events in the student’s environments and occurrences of challenging behavior and the contingent events that maintain the problem behavior.   
An FBA can be conducted in a variety of ways. There are two general assessment tools to assist in the collection of information about the variables and events that surround the occurrence (or nonoccurrence) of the student’s challenging behavior. The first are interviews and rating scales that provide information from the individuals (parents, teachers) who know the student best, along with the student themselves. The second method is direct observation of the student in his or her natural daily environments. One observation strategy for collecting observational information is the A-B-C format. The observer records the Antecedent to the behavior (what happened immediately before the behavior), describes the Behavior, and the Consequence of the behavior (what happened immediately after). The following steps are a general guide to developing a comprehensive student behavior intervention or support plan. 
  • The behavior support plan should be developed collaboratively and begin with a functional behavior functional behavior assessment (FBA) of the problem behavior to understand the student and the nature of the challenging behavior in the context of the environment.
  • Next, the professional team examines the results of the functional assessment and develops hypothesis statements as to why the student engages in the challenging behavior. The hypothesis statement is an informed, assessment-based explanation of the challenging behavior that indicates the possible function or functions served for the student. This includes a description of the behavior, triggers or antecedents for the behavior, maintaining consequences, and purpose of the problem behavior.
  • Once developed, the hypothesis provides the foundation for the development of intervention strategies. The focus of intervention plan is not only on behavior reduction, but for also teaching appropriate, functional (generally communicative) skills that serve as alternative/replacement behaviors for the undesirable behavior. Changes should be identified that will be made in the classroom or other setting to reduce or eliminate problem behaviors. Prevention strategies may include environmental arrangements, personal support, changes in activities, new ways to prompt the student, and changes in expectations. These strategies should be integrated into the student's overall program and daily routines, rather than being separate from the curriculum.  
  • A positive behavior intervention plan must be implemented as planned (with integrity). Following implementation of the plan, the team regularly reviews and evaluates its effectiveness and makes modifications as needed.  The design and implementation of a behavior support plan should be considered a dynamic process rather than one with a specific beginning and end. Overtime, the plan will need to be adjusted as the student's needs and circumstances change.  
Research indicates that PBS can be effective for reducing and preventing problem behaviors of children with ASD. For example, a review of published research studies found that in cases where PBS strategies were used, there was as much as an 80% reduction in challenging behavior for approximately two-thirds of the cases studied. The Individuals with Disabilities Education Act (IDEA) has endorsed PBS as a preferred form of intervention for managing the problematic behavior of students with disabilities and requires that "positive behavioral interventions, strategies, and supports" be used when addressing the needs of students who demonstrate persistent challenging behavior that impedes their learning or the learning of others. 
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and cognitive-behavioral therapist. He 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 best-selling 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. Dr. Wilkinson's latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Sunday, May 14, 2017

Mothers of Children on the Autism Spectrum Experience High Levels of Fatigue and Mental Distress

Studies indicate that the demands placed on parents caring for a child with autism contribute to a higher overall incidence of parental stress, depression, and anxiety and adversely affects family functioning and marital relationships compared with parents of children with other intellectual, developmental, or physical disabilities. Mothers of children with ASD, in particular, appear to face unique challenges that potentially have an impact on their health and wellbeing.

Parents of children with an autism spectrum disorder (ASD) are increasingly involved in the provision of early intervention and learning activities to promote positive outcomes for their children. However, several studies have documented that parental stress as well as a lack of time and energy are barriers to providing early intervention activities. Because autism impairs social relatedness and adaptive functioning, parent stress can decrease helpful psychological processes and directly influence the parent or caregiver’s ability to support the child with disabilities. Consequently, understanding factors, such as lack of energy or fatigue that may limit the capacity of the parent to assist in promoting their child’s development is critical.

A study published in the journal Autism examined the extent to which parents experience fatigue and its relationship to other aspects of wellbeing and parenting. Fifty mothers of children ages 2-5 years with ASD participated in the study and completed questionnaires assessing level of fatigue, parenting self-efficacy (belief about the ability to parent successfully), children’s behavioral and emotional problems, sleep quality, parent support needs, and overall physical activity. The study found that compared with mothers of typically developing children, mothers of children with ASD reported significantly higher fatigue, with overall scores in the moderate range. Factors associated with high levels of fatigue were poor maternal sleep quality, a high need for social support and poor quality of physical activity. Fatigue was also significantly related to other aspects of wellbeing, including stress, anxiety and depression, and lower parenting efficacy and satisfaction.

These findings were somewhat expected given the additional caregiving demands, parenting challenges and pressures of managing family life when raising a child with an ASD. Likewise, It is also probable that symptoms of depression, anxiety, stress and worry (body tension, increased heart rate and rumination) can be mentally taxing and contribute to, or exacerbate fatigue. The researchers also note that it was not surprising that poor sleep quality was associated with higher levels of fatigue given the large amount of research indicating that inadequate sleep and poor sleep quality is associated with a range of physical health and wellbeing difficulties. Parents of children with ASD are at particular risk of sleep disruption and poor sleep quality owing to the high rate of sleep problems in their children. Parents reported that their child waking was the primary reason for sleep disruption. For other parents in the study, stress, anxiety and not being able to wind down were stated reasons for sleep disruption.

Implications

What are the implications of this study? The findings clearly indicate the need for interventions to specifically target parental fatigue and its impact on families affected by ASD both in the present and longer term. In addition to interventions targeting child sleep problems, parents are likely to benefit from psycho-education about fatigue and its potential effects on wellbeing, parenting and caregiving. This includes information about strategies to minimize and/or cope with the effects of sleep disruption, increase health and self-care behaviors, and strengthen opportunities for social support. It is well established that social support is protective of optimal parent wellbeing and, therefore, is an important component of any intervention to address fatigue and wellbeing of parents of children with an ASD. Parents with limited assistance to share the daily demands of caregiving and family life are likely to be at greater risk of fatigue than parents with more support. For parents with limited support, there might also be fewer opportunities to engage in self-care behaviors that are likely to alleviate or protect them from fatigue.

From a clinical perspective, professionals working with families of children with an ASD should be aware of negative effects of fatigue in addition to other wellbeing difficulties, such as stress and anxiety. An assessment of the presence and severity of the physical, cognitive and emotional symptoms of fatigue, as well as the perceived impact on daily functioning, mood, relationships, parenting and other aspects of caregiving is important. Lastly, future work in this area should involve the development and evaluation of information resources and intervention approaches to assist parents of children with an ASD to manage fatigue and promote their overall wellbeing. The longer-term benefits for parents in terms of strengthening their overall health, wellbeing and parenting should also be a focus of research.

Giallo, R., Wood, C. E., Jellett, R., & Porter, R. (2013). Fatigue, wellbeing and parental self-efficacy in mothers of children with an Autism Spectrum Disorder. Autism, 17, 465-480. DOI: 10.1177/1362361311416830

Lee A. Wilkinson, PhD, CCBT, NCSP 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 best-selling 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 latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Wednesday, May 3, 2017

Teaching Social Skills to Learners on the Autism Spectrum

Impairment in social communication and interaction is a core feature of autism spectrum disorder (ASD). Social skills deficits include difficulties with initiating interactions, maintaining reciprocity, taking another person’s perspective, and inferring the interests of others.  Unfortunately, many children with ASD do not receive consistent and intensive social skills programming in school. This is problematic, especially considering social impairments may result in negative outcomes, such as poor academic achievement, social failure, isolation, and peer rejection, which often leads to co-occurring (comorbid) anxiety and depression. 
Because social skills are critical to successful social, emotional, and cognitive development and long-term outcomes, best practice indicates that social skills instruction should be an integral component of educational programming for all children with ASD. Research evidence suggests that when appropriately planned and systematically delivered, social skills instruction has the potential to produce positive effects in the social interactions of children with ASD. Both the National Professional Development Center on Autism (NPDC) and the National Autism Center (NAC) have identified social skills training/instruction as an evidence-based intervention and practice. Social skills training is typically offered as small-group instruction with a shared goal or outcome of learned social skills in which participants can learn, practice, and receive feedback. These interventions seek to build social interaction skills in children and adolescents with ASD by targeting basic responses (e.g., eye contact, name response) to complex social skills (e.g., how to initiate or maintain a conversation). 

Most often, schools are expected to assume the responsibility of delivering social skills training programs to children with social skills deficits, because these impairments significantly interfere with social relationships and have an adverse effect on academic performance. Although equipped to teach social skills, implementing social skills programming can be challenging for school personnel (teachers, counselors, psychologists, social workers), who often have limited time and resources. Recent meta-analysis research suggests that the effectiveness of social skills training can be enhanced by increasing the quantity (or intensity) of social skills interventions, providing instruction in the child’s natural setting, matching the intervention strategy with the type of skill deficit, and ensuring treatment integrity (fidelity). In order for students to learn, practice, and maintain expected social behavior, educators must teach social skills within the context of the various school settings that students encounter each day (i.e., classroom, special subject areas such as art and music, cafeteria, and playground). 
The following are recommended when developing a social skills intervention strategy:
  • Avoid a "one size fits all" approach and adapt the intervention to meet the needs of the individual or particular group. 
  • Employ primarily positive strategies and focus on facilitating the desirable social behavior as well as eliminating the undesirable behavior. 
  • Emphasize the learning, performance, generalization, and maintenance of appropriate social behaviors through modeling, coaching, and role-playing
  • Provide social skills training and practice opportunities in a number of settings with different individuals in order to encourage students to generalize new skills to multiple, real life situations. 
  • Use assessment strategies, including functional assessments of behavior, to identify children in need of more intensive interventions as well as target skills for instruction. 
  • Enhance social skills by increasing the frequency of an appropriate behavior in "normal" or typical environments to address the naturally occurring causes and consequences. 
  • Include parents and caregivers as significant participants in developing and selecting interventions (they can help reinforce the skills taught at school to further promote generalization across settings).
The type of skill deficit (performance deficit versus skill deficit) should also be considered when developing a social skills intervention plan. A performance deficit refers to a skill or behavior that is present but not demonstrated or performed, whereas a skill acquisition deficit refers to the absence of a particular skill or behavior. School professionals should make an intensive effort to systematically match the intervention strategy to the type of skill deficit exhibited by the child. For instance, if the child lacks the skills necessary to join in an interaction with peers, an intervention strategy should be selected that promotes skill acquisition. In contrast, if the child has the skills to join in an activity but regularly fails to do so; a strategy should be selected that enhances the performance of the existing skill.
Social relationship skills are critical to successful social, emotional, and cognitive development and to long-term outcomes for students. Thus, systematic social skills instruction should be considered a critical component of treatment for children with autism. Teaching social skills can have both preventive and remedial effects that can help reduce the risk for negative outcomes not only for children on the autism spectrum, but for all children.  
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools. He is also editor of a best-selling 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 Edition).

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