Monday, June 25, 2018

Comorbid ADHD in Autistic Children

Comorbid ADHD in Autistic Children

Interest in the co-occurrence of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) has grown in the last decade. Both are neurodevelopmental disorders with onset of symptoms in early childhood. Research, practice and theoretical models indicate that these disorders 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%. In fact, ADHD is a relatively common initial diagnosis in young children with ASD. Some researchers suggest that there are sub-groups of children with ASD with and without ADHD symptoms.

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. For example, 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. Symptoms included inattention, impulsivity, hyperactivity and other features such as low frustration tolerance, poor self-monitoring, temper and anger management problems, and mood changes in the classroom. They were also more likely to have significant cognitive delays and display more severe autism mannerisms, such as stereotypic and repetitive behaviors in comparison with children identified with only ASD.
It is imperative that practitioners 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.
If clinically significant ADHD symptoms are identified, and social development does not appear to be responding to intervention, changes in the intervention pro­gram (e.g. intensity, strategies, and goals) may be required. It is also important to note that a significant change in the DSM-5 is removal of the DSM-IV-TR hierarchical rules prohibiting the concurrent diagnosis of ASD and ADHD. When the criteria are met for both disorders, both diagnoses are given. Thus, an assessment of ADHD characteristics should be included whenever inattention and/or impulsivity are indicated as presenting problems. 

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 addition to rating scales, an examination of the child’s neuropsychological characteristics and profile may be helpful in identifying the comorbidity of ASD and ADHD. For example, 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. More research is needed to further clarify the behavioral characteristics of children with co-occurring ASD and ADHD so that specialized treatments and interventions may be designed to improve outcomes and quality of life for this group of children. 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)
Key References and Further Reading

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author.

Colombi, C., & Ghaziuddin, M. (2017). Neuropsychological Characteristics of Children with Mixed Autism and ADHD. Autism Research and Treatment, 1-5. 

Doepke, K. J., Banks, B. M., Mays, J. F., Toby, L. M., & Landau, S. (2014). Co-occurring emotional and behavior problems in children with Autism Spectrum Disorders. In L. Wilkinson (Ed.), Autism Spectrum Disorders in Children and Adolescence: Evidence-based Assessment and Intervention in Schools (pp. 125-148). Washington, DC: American Psychological Association.

Kuhlthau K., Orlich F., Hall T.A., et al. (2010). Health- Related Quality of Life in children with autism spectrum disorders: results from the autism treatment network. Journal of Autism and Developmental Disorders, 40(6), 721–729.

Loveland K. A., Tunali-Kotoski, B. (2005), The school age child with autism. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders: Vol. 1. Diagnosis, development, neurobiology, and behavior (3rd ed., pp. 247-287). New York: Wiley.

Murray M.J., (2010). Attention-deficit/hyperactivity disorder in the context of autism spectrum disorders. Current Psychiatry Reports, 12(5), 382–388.

Rao, P. A., & and Landa, R. J. (2014). Association between severity of behavioral phenotype and comorbid attention deficit hyperactivity symptoms in children with autism spectrum disorders. Autism, 18, 272-280.

Sikora, D. M., Vora, P., Coury, D. L., & Rosenberg, D. (2012). Attention-Deficit/Hyperactivity Disorder Symptoms, Adaptive Functioning, and Quality of Life in Children With Autism Spectrum Disorder. Pediatrics, 130, S91-97. DOI: 10.1542/peds.2012-0900G
Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London & Philadelphia: Jessica Kingsley Publishers.

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, June 10, 2018

Loneliness and Well-Being in Autistic Adults

Individuals with autism spectrum disorder (ASD) experience significant difficulties in social functioning, including deficits in core social abilities and problems establishing and maintaining peer relationships. These social and interpersonal problems generally persist and sometimes worsen in adulthood, contributing to functional impairment. Despite the increase in ASD prevalence, few studies have focused on the experiences of autistic adults, or on the factors that may relate to their social and emotional functioning. 

There is considerable evidence that loneliness and social support have a strong influence on overall well-being in the general population. However, this has yet to be examined among adults with ASD. Contrary to historical assumptions, autistic individuals do not always prefer solitude and social isolation. They often want to develop relationships but face barriers in developing relationships due to social competence difficulties. Thus, loneliness appears to be a clinically important consideration for adults on the autism spectrum.

A study published in the journal Autism examined the relations among loneliness, friendship, and emotional functioning in adults (N = 108) with autism spectrum disorders. Participants completed self-report measures of symptoms of autism spectrum disorders, loneliness, number and nature of friendships, depression, anxiety, life satisfaction, and self-esteem. The results indicated that loneliness was associated with increased depression and anxiety and decreased life satisfaction and self-esteem, even after controlling for symptoms of autism spectrum disorders. In addition, greater quantity and quality of friendships were associated with decreased loneliness among adults with autism spectrum disorders. Multivariate models indicated that friendship did not moderate the relationship between loneliness and well-being; however, number of friends provided unique independent effects in predicting self-esteem, depression, and anxiety above and beyond the effects of loneliness.

This study provides an important evaluation of the social and emotional experiences of autistic adults. The findings extend current knowledge and highlight the clinical importance of loneliness. Significant correlations were found between loneliness and a number of negative emotional experiences, including increased depression and anxiety, and reduced well-being. Because individuals with ASD are already at increased risk of anxiety and depression, loneliness may represent an important factor in the developmental course of internalizing problems through adolescence and adulthood. A better understanding of the developmental course and consequences of loneliness is essential to inform our understanding of social and emotional well-being in autistic individuals. Lastly, strategies to reduce and prevent loneliness in adults with ASD should be important objectives for future research and clinical practice.
Mazurek, M. O. (2014). Loneliness, friendship, and well-being in adults with autism spectrum disorders. Autism, 18, 223-232. doi: 10.1177/1362361312474121

Wednesday, June 6, 2018

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 Aspergers, autistic, neurodivergent, or on the autism spectrum, you have the the power to create and 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.  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. 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 in Autistic Children

What Triggers Anxiety for Autistic Children and Teens?

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 autistic children meet criteria for at least one anxiety disorder. Despite promising advances in the research and practice literature, our understanding of the 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 autistic children and their families experience, think and speak about anxiety, will help inform the development and implementation of autism-specific interventions for anxiety.
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.

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.
Parent Perspectives
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 and youth 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.
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 autistic children and youth, 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, 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 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 SchoolsHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd edition).

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