Saturday, June 30, 2018

Social Communication Skills and Autism

Social Communication Skills and the Autism Spectrum

The DSM-5 diagnostic criteria for autism spectrum disorder (ASD) include persistent deficits in social communication and social interaction across multiple contexts. Poor pragmatic/social use of language or impairment in the ability to understand and use language in social-communicative contexts is a core feature of ASD. Pragmatic skills involve: (a) using language for different purposes; (b) changing language according to the needs of a listener or situation; (c) understanding non-literal language; and (d) following rules for conversations. 

There are many unwritten rules in society that govern our behavior. While most of us intuitively understand these rules, individuals with ASD have not automatically learned the conventions and nuances that make up their social environment. These unspoken or “hidden” social standards can make the world a confusing place and result in life-long challenges. For example, social expectations such as “it is not polite to interrupt others while they are talking,” “take turns in conversation” and “discuss other topics besides only those you are interested in” are not taught and are assumed to be known and understood. We seem to have an “unconscious” navigator that allows us to make intuitive sense of the unspoken rules in society and adjust to the social demands of our everyday lives.
Figurative Language

The unspoken rules of social engagement involve the use of the pragmatic, social communicative functions of language (e.g., turn taking, understanding of inferences and figurative expressions) as well as nonverbal skills needed to communicate and regulate interaction (e.g., eye contact, gesture, facial expression). This includes body language and idioms, metaphors, or slang – phrases and meanings that we intuitively assimilate or learn through observation or subtle cues. Individuals with ASD tend to interpret language literally and may be puzzled by the common everyday expressions used by a typical peer or adult. Consider how idioms such as “how the cookie crumbles,” “curiosity killed the cat,” and “when it rains, it pours” might have a totally different meaning and result in confusion if taken literally. In order to understand language, we must understand what the idioms in that language mean. If you try to figure out the meaning of an idiom literally (word by word), you will be bewildered. While the typical individual might understand that the phrase “that’s the way the cookie crumbles,” and accompanying body language (e.g., voice, body) communicates to the listener that something unfortunate has happened, to someone with a pragmatic social-communication problem, this idiom will have a completely different meaning and be confusing. The following are but a few of well over 3,000 idioms in the English language.
  • Bite off More than you can chew  
  • Cross that bridge when you come it
  • Everything but the kitchen sink 
  • Get up on the wrong side of the bed 
  • Have a bone to pick with you 
  • Have your cake and eat it too 
  • Kill two birds with one stone  
  • Put all your eggs in one basket 
  • Raining cats and dogs 
  • Run circles around someone 
  • Till the cows come home
Assessment

Because social communication deficits are among the core challenges of ASD, a best practice student assessment should include an evaluation of pragmatic competence and not be limited to the formal, structural aspects of language (i.e., articulation and receptive/ expressive language functioning). As a group, more capable students with ASD tend to demonstrate strength in formal language, but a weakness is pragmatic and social skills.  As a result, they often fail to qualify for speech-language services because they present strong verbal skills and large vocabularies, and score well on formal language assessments. Particular attention should be given to the pragmatic, social communicative functions of language (e.g., turn taking, understanding of inferences and figurative expressions) as well as to the nonverbal skills needed to communicate and regulate interaction (e.g., eye contact, gesture, facial expression, and body language). 

Assessments to identify pragmatic language deficits tend to be less well developed than tests of language fundamentals. There are fewer standard measures available to assess these skills in children with ASD. Valid norms for pragmatic development and objective criteria for pragmatic performance are also limited. Among the standardized instruments that focus on the social communicative functions of language are the Comprehensive Assessment of Spoken Language (CASL; Carrow-Woolfolk, 1999), Test of Pragmatic Language, 2nd Edition (TOPL-2; Phelps-Terasaki & Phelps-Gunn, 2007), Social Language Development Test-Elementary (SLDT-E; Bowers, Huisingh, & LoGiudice, 2008), Children's Communication Checklist, Second Edition (CCC-2; Bishop, 2006) and Pragmatic Language Skills Inventory (PLSI; Gilliam & Miller, 2006). 
Significant and severe deficits in the ability to communicate and interact with others can limit students' participation in mainstream academic settings and community activities. Moreover, pragmatic deficits tend to become even more obvious and problematic as social and educational demands increase with age. Because pragmatic language is a critical part of everyday social interaction, it is imperative that speech/language services for children with ASD include a focus on social communication skills. Students with pragmatic language deficits who do not meet the DSM-5 ASD criteria for restricted, repetitive patterns of behavior should be evaluated for social (pragmatic) communication disorder (SCD). 


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 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 CBT. Dr. Wilkinson's latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition). 
© 2018 Lee A. Wilkinson, PhD

Wednesday, June 6, 2018

Emotional Destiny on the Autism Spectrum

Autism and Your Emotional Destiny

“Whatever may be, I am still largely the creator 
and ruler of my emotional destiny.” - Albert Ellis

Regardless of whether you identify as autistic, Aspergers, neurodivergent, or on the autism spectrum, you have the capacity for self-awareness and the power to control your own emotional destiny. We are not born with specific thoughts, feelings, and behaviors. Nor do our environment or surroundings directly make us act or feel in a certain way.

Although our genetic makeup and social background can have a strong influence on our behavior, we have the ability to change our thoughts, feelings, and actions. While it may be helpful to discuss our past experiences and understand how our history might have influenced our lives, effective self-help strategies focus on the “here and now” problems and ways to improve your emotional well-being in the present.

Understanding your past experiences and how and when you first upset yourself are not critical to overcoming your anxiety and depression. Conventional insight, even when correct, will not tell you what really caused you to become upset or what you can do to overcome it. In fact, it may actually block effective problem-solving.

It is your present system of beliefs and ideas that are important, regardless of where they originated. So, no matter what your past history, or how your parents, teachers or significant others in your life may have helped you to feel upset, you continue to be upset because of the vicious cycle of unrealistic and unhelpful thoughts you originally held.

Step back and objectively examine your own ideas and beliefs and identify and question them. While it is impossible to change the behavior of others, you have the ability to control and change your own thoughts and behaviors. So, avoid thinking that your past is all important and that because someone or something at one time influenced your life, it must also determine your feelings and behavior today. If you let yourself be strongly influenced by the past, you will stop looking for alternative solutions to your current problems. When you unconditionally accept the influences of your past, you are being unrealistic because the present is significantly different from the past. Keep in mind that the past has passed and it has no automatic effect on your present and future behavior. You have the power to overcome your past and control your emotional destiny!

Adapted from Wilkinson, L. A. (2015). Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTLondon and Philadelphia: Jessica Kingsley Publishers.


Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist (CCBT).  Dr. Wilkinson 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. He is also a university educator and trainer, and has published widely on the topic of autism spectrum disorders both in the US and internationally. 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 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. Dr. Wilkinson's latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© 2018 Lee A. Wilkinson, PhD



Sunday, June 3, 2018

Triggers for Anxiety on the Autism Spectrum




Triggers for Anxiety on the Autism Spectrum

Anxiety is 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).

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