Wednesday, April 18, 2018

Autism & Parenting: Dads' Caregiving Improves Moms' Mental Health

In contrast to the large body of research on mothers, there has been little research on fathers of children with autism spectrum disorder (ASD). Greater involvement of fathers in caring for their children with autism may be especially important, as previous research has shown that mothers of autistic children often experience higher levels of stress, depression and anxiety than other mothers. A study conducted at the University of Illinois found that fathers who read to their infants with autism and take active roles in caregiving activities not only promote healthy development in their children, they improve mothers’ mental health as well.
Research

The study examined the longitudinal association between fathers’ early involvement in routine caregiving, literacy, play, and responsive caregiving activities at 9 months and maternal depressive symptoms at 4 years. Data for 3,550 children and their biological parents were drawn from the Early Childhood Longitudinal Study-Birth Cohort, including 50 children with autism spectrum disorders and 650 children with other disabilities. Information was collected on mothers' well-being and fathers' involvement in several parenting activities: literacy; play; routine caregiving, such as bathing; and responsive caregiving. Analyses examined whether the association between father involvement and maternal depressive symptoms differed for families of children with autism spectrum disorder (ASD) and for families of children with other disabilities or delays from families of children who were typically developing.
Results indicated that father literacy and responsive caregiving involvement were associated with lower levels of depressive symptoms for mothers of children with ASD. Mothers of children with autism reported fewer depressive symptoms when their children were 4 years old if the child's father engaged in literacy and responsive caregiving activities such as comforting children when they were upset or taking the child to the doctor when the child was 9 months old. 
Implications

Fathers who read to their children, or respond when the child cries, can give the mothers respite, enabling mothers to perform other tasks or engage in self-care activities that improve their mood and reduce stress, commented lead author Daniel J. Laxman.  "One of the key criteria of autism is difficulty with communication, which may explain why these children's mothers are especially susceptible to stress and depression," Laxman said. "It can be very frustrating for parents -- and upsetting for children -- when children struggle with communication. If fathers are reading to their kids, telling stories or singing songs, it is going to be very beneficial for the child's development of communication skills and learning words. By improving children's communication skills, fathers' literacy activities may help alleviate some of the mothers' concerns and stress related to these problems."
"Prior research and work by early interventionists has focused solely on mothers' parenting of their children with autism, reflecting societal expectations that fathers are less involved, said co-author Brent A. McBride. "In family systems that include children with autism, the stressors are huge, and mothers need all the support they can grasp. Whether it comes from the child's father, their social network or online resources, mothers need additional support to be able to continue functioning in an effective way. We, as a society, have to ask men to become involved, and it's very important that men fully understand the reasons why their support and active engagement in parenting is so critical for the family's functioning and for the child." Training and professional development opportunities must be made available to early interventionists and other professionals who work with families, so they can find ways to get fathers more involved in parenting activities.
Source:
University of Illinois at Urbana-Champaign. "Dads' parenting of children with autism improves moms' mental health: Fathers' engagement in literacy, caregiving activities reduces mothers' depression, stress." ScienceDaily, 14 July 2015.
Journal Reference:
Daniel J. Laxman, Brent A. McBride, Laurie M. Jeans, W. Justin Dyer, Rosa M. Santos, Justin L. Kern, Niwako Sugimura, Sarah L. Curtiss, Jenna M. Weglarz-Ward. Father Involvement and Maternal Depressive Symptoms in Families of Children with Disabilities or Delays. Maternal and Child Health Journal, 2014; 19 (5): 1078 DOI: 10.1007/s10995-014-1608-7
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered 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. 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).

© 2018 Lee A. Wilkinson, PhD

Tuesday, April 3, 2018

Girls with Autism Face High Risk for Depression

Girls with Autism Face High Risk for Depression

The U.S. Centers for Disease Control and Prevention (CDC) estimates that 1 in 54 eight year-old children in the US has an autism spectrum disorder (ASD). Prevalence estimates indicates that autism is more than 4 times more common among boys than among girlsAccording to the CDC, approximately one in 34 boys and one in 144 girls were identified as having ASD. Studies also suggest that while boys are being referred for evaluation in greater numbers in our schools, this is not the case for girls. Girls are also diagnosed with ASD at later ages compared to boys. This “gender gap” raises serious questions because many females with ASD may be overlooked and not receive the appropriate supports and services. 
                                                                            Girls with Autism
Gender role socialization is critical to understanding why girls with ASD might be underidentified in the general population. Since females are socialized differently, autism may not manifest in the same way as typical male behavioral pattern. For example, girls might not come to the attention of parents and teachers because of better coping mechanisms and the ability to “disappear” in large groups. Girls on the higher end of the spectrum also have fewer special interests, better superficial social skills, better language and communication skills, and less hyperactivity and aggression than boys. Likewise, girls are more likely than boys to be guided and protected by same gender peers and to have special interests that appear to be more gender appropriate. These characteristics lessen the probability of a girl being identified as having impaired social skills, the core symptom of ASD.  In fact, it may be a qualitative difference in social connectedness and reciprocity that differentiates the genders. As a result, parents, teachers, and clinicians may not observe the obvious characteristics associated with the male prototype of higher functioning ASD. Over reliance on the male model with regard to diagnostic criteria might also contribute to a gender “bias” and under-diagnosis of girls. For example, clinical instruments tend to exclude symptoms and behaviors that may be more typical of females with autism.
Unfortunately, the sex differences in the ASD phenotype continue to be poorly understood. As a result, there has been relatively little research on girls with ASD. Moreover, the extant findings are complex and often difficult to interpret. While the gender gap in autism has yet to be empirically investigated, if there is a gender difference in the autism phenotype, then clinical and educational interventions based largely on research with boys may be inappropriate. As a result, girls may receive less than optimal academic and behavioral interventions. Moreover, the consequences of a missed or late diagnosis can result in social isolation, peer rejection, lowered grades, and a greater risk for mental health and behavioral distress such as anxiety and depression during adolescence and adulthood. As a result, there is an urgent need for research to compare autistic girls to typical boys and girls to more fully comprehend the implications of being a girl with autism.
Comorbid Depression

In addition to understanding sex differences in ASD symptoms, a clinically significant issue is whether autistic girls have an elevated risk for affective disorders. Studies indicate that children, teens, and adults with ASD demonstrate increased internalizing problems relative to typical individuals.  Depression is one of the most common comorbid conditions observed in individuals with autism, particularly higher functioning youth.  For example, evaluation of psychiatric comorbidity in young autistic adults revealed that 70% had experienced at least one episode of major depression and 50% reported recurrent major depression. Although typical boys and girls show similar levels of depression in childhood, the risk for internalizing disorders in girls increases dramatically in adolescence. Therefore, autistic girls may be at especially high risk for depression.
A study in the Journal of Autism and Developmental Disorders compared autism and internalizing symptoms in a clinical sample of 8-18 year-old girls (n = 20) and boys (n = 20) with ASD and typically developing girls (n = 19) and boys (n = 17) using clinician-, parent-, and child- report measures. The researchers found that boys and girls were similarly impaired as evidenced by comparable diagnostic and non-diagnostic ASD symptom scores. However, girls with ASD differed markedly from typical girls on symptom measures such as language and social skills. Autistic girls also appeared to be at greater risk for internalizing psychopathology than boys with ASD and typical girls. In adolescence, autistic girls had significantly higher parent-reported internalizing scores than boys with autism and typical girls. This suggests that being female and having a neurodevelopmental disorder may result in a high risk of anxiety and depression in the teen years.
                                                                             Implications
Understanding elevated levels of internalizing symptoms in autistic girls and how to treat comorbid affective symptoms is critical. Developing and implementing cognitive, behavioral and psychotropic interventions to address internalizing symptoms in this high risk population of girls is essential to help improve interpersonal functioning and quality of life, as well as reduce the negative outcomes frequently associated with adolescent depression, including psychiatric hospitalization and suicidal ideation. Girls who are diagnosed with ASD should be screened for internalizing problems and closely monitored for symptom occurrence. Additionally, practitioners should question the presence of ASD in girls referred for internalizing disorders such as anxiety or depression. Best practice recommends that when a girl presents with a combination of social immaturity, restricted interests, limited eye gaze, repetitive behaviors, social isolation, and is viewed as “atypical” or “unusual," the possibility of ASD should be given serious consideration. 

In terms of treatment, cognitive-behavioral strategies have shown promise in addressing anxiety in higher-functioning autistic children and might be adapted to address depression in this population. Interpersonal therapy techniques have also to be effective in treating typical adolescents with depression. In addition, evidence is accumulating in the empirical literature that social skills interventions are likely to be appropriate for many children and youth with autism. Commonly used approaches include individual and group social skills training, providing experiences with typically developing peers, and peer-mediated social skills interventions, all targeting the core social and communication domains. In conclusion, the study of girls with ASD represents a critical area for future research. They appear to be at significant risk for developing affective symptoms (depression) in adolescence, indicating the need for increased awareness, screening, identification, and intervention. Lastly, population-based studies are needed to determine to what extent autistic girls within the “general community” are less impaired and/or under-identified relative to boys.
Solomon, M., Miller, M., Taylor, S. L., Hinshaw, S. P., & Carter, C. S. (2012). Autism symptoms and internalizing psychopathology in girls and boys with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 48–59
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered 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 CBTHe 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).

Sunday, April 1, 2018

Neuropsychological Profiles of Children with Comorbid Autism and ADHD


Neuropsychological Profiles of Children with Comorbid Autism and ADHD
Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are neurodevelopmental disorders with onset of symptoms in early childhood.  In addition to the core features of social communication impairment and restricted/repetitive behaviors and interests, a significant number of children with ASD present with the symptoms of hyperactivity, inattention, and impulsivity, which may meet the DSM-5 diagnostic criteria for attention deficit hyperactivity disorder (ADHD). In fact, research, practice and theoretical models indicate that these conditions frequently overlap and co-occur. For example, studies conducted in the US and Europe indicate that children with ASD in clinical settings present with comorbid (co-occurring) symptoms of ADHD with rates ranging between 37% and 85%. While the prevalence is difficult to estimate, a large number of children with ADHD also present with symptoms of ASD.
It is critical to identify the comorbidity between ASD and ADHD because of its intervention and treatment implications. For example, more severe externalizing, internalizing and social problems, as well as more impaired adaptive functioning, and more autistic traits and maladaptive behaviors have been reported in children with both ASD and ADHD than children identified with only ASD. Researchers have found that early school-age children with co-occurrence of ASD and ADHD were significantly more impaired than children with only ASD on measures of cognitive and social functioning, as well as in the ability to function in everyday situations. They were also more likely to have significant cognitive delays and display more severe stereotypic and repetitive behaviors in comparison with children identified with only ASD. In addition, children with the co-occurring ASD and ADHD were found to share impairment in both flexibility and planning with ASD, while sharing the response inhibition deficit with ADHD. Despite the group differences described in the literature, it can be particularly difficult to differentiate between ASD and ADHD in individual cases. For example, social deficits occur in both the conditions. Although the social deficits of autism are typically described as being “reciprocal” in nature and those of ADHD are considered to be the result of inattention and disinhibition, the distinction is not always easy to make in real-world practice. In this regard, an examination of the child’s neuropsychological characteristics and profile may be helpful in identifying the comorbidity of ASD and ADHD.
 Current Research
A study published in the open access journal Autism Research and Treatment sought to extend the work on the neuropsychological profile of individuals with ASD + ADHD and to further explore the hypothesis that children with ASD + ADHD show higher degrees of impairment in social cognition than those with ASD only. The participants were drawn from referrals to an ASD clinic and consisted of 22 children with ASD and 25 children with mixed ASD and ADHD. Neuropsychological measures were administrated using standardized procedures and included evaluation of cognitive functioning, emotion recognition, Theory of Mind (ToM), executive functions, and motor abilities.
 Results
Overall results of the study indicate greater impairment in cognitive, social, and adaptive functioning for children with ASD and clinically significant ADHD symptoms in comparison with children identified with only ASD. Compared to children with ASD, those with ASD + ADHD were more impaired in their ability read other people’s emotions and feelings and to hold and manipulate critical periods of information (working memory). Children with ASD + ADHD also showed higher levels of anxiety. The more severe deficits in emotion recognition and working memory, along with the higher levels of anxiety found in children with ASD + ADHD, supports previous research indicating that having additional ADHD increases the level of their impairment and negatively impacts management and outcome. These findings also suggest that ADHD comorbidity may constitute a distinctive subtype of ASD and that these children may be at higher risk of social impairment and adjustment problems. 
Implications

It should be noted that the sample consisted only of participants with normal levels of intellectual functioning. Thus, the findings may not apply to lower functioning children with ASD and ADHD. The risk of intellectual disability (InD) increases the risk of both ASD and ADHD, acting alone and in combination with other factors. Future studies should include subjects with a wider range of cognitive abilities, using larger sample sizes of different age groups, to better define the profiles of individuals with ASD + ADHD and identify effective treatment/interventions.
Identifying symptoms of ADHD in children with ASD has important diagnostic and treatment implications for practitioners in health care, clinical/mental health, and educational contexts. It is imperative to recognize the high co-occurrence rates of these two disorders as well as the potential increased risk for social and adaptive impairment associated with comorbidity of ASD and ADHD. Children with the combined presence of ASD and ADHD may need different treatment methods or intensities than those with ASD only in order to achieve better outcomes. Examining the neuropsychological characteristics and profiles of children with both the conditions can help facilitate diagnosis and inform treatment. Thus a comprehensive developmental assessment may include measures of neuropsychological functions such as working memory, planning and strategy formation, cognitive flexibility, response inhibition, and self-regulation. Further information on best practice guidelines for assessment of ASD is available from A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).
Colombi, C., &  Ghaziuddin, M. (2017). Neuropsychological Characteristics of Children with Mixed  Autism and ADHD. Autism Research and Treatment, 2017, 1-5. doi:10.1155/2017/5781781 https://doi.org/10.1155/2017/5781781
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered 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 disorders. 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).

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