Triggers for Anxiety in Children with Autism

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.

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 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, is a licensed and nationally certified school 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 the editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd edition).

Autism and Co-Occurring Conditions

Psychiatric Comorbidity in Autism

Children with autism spectrum disorder (ASD) frequently have co-occurring (comorbid) psychiatric conditions, with estimates as high as 70 to 84 percent.  A Comorbid disorder is defined as a disorder that co-exists or co-occurs with another diagnosis so that both share a primary focus of clinical and educational attention. Research indicates that autistic children and youth have a high risk for meeting criteria for other disorders, such as mood and anxiety disorders, attention deficit/hyperactivity disorder (ADHD), and disruptive behavior disorders, all which contribute to overall impairment.

Internalizing Problems

Studies have consistently reported an association between ASD and internalizing symptoms, in particular, anxiety and depression. A bidirectional association has been identified between internalizing disorders and autistic symptoms. For example, both a higher prevalence of anxiety disorders has been found in ASD and a higher rate of autistic traits has been reported in youth with mood and anxiety disorders. Autistic individuals also display more social anxiety symptoms compared to typical individuals, even if these symptoms were clinically overlapping with the characteristic social problems of ASD. In addition, there is some evidence to suggest that adolescents and young adults with ASD show a higher prevalence of bipolar disorders as compared to controls.

Depression is one of the most common comorbid conditions observed in individuals with ASD, particularly higher functioning youth. A study 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 another documented association is with obsessive-compulsive disorder (OCD), it is difficult to determine whether observed obsessive-repetitive behaviors are an expression of a separate, comorbid OCD, or an integral part of the core diagnostic features of ASD (i. e., restricted, repetitive patterns of behavior, interests, or activities).

Externalizing Problems

An association between ASD and attention-deficit/hyperactivity disorder (ADHD) and other externalizing problems (i. e., oppositional defiant disorder) have been reported. Studies have found that children with ASD in clinical settings present with co-occurring symptoms of ADHD with rates ranging between 37% and 85%. Although there continues to a debate about ADHD comorbidity in ASD, research, practice and theoretical models suggest that co-occurrence between these conditions is relevant and occurs frequently. For example, case studies suggest that ADHD is a relatively common initial diagnosis in young autistic children. 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.

Other Comorbidities

Tourette Syndrome (TS) and other tic disorders have been found to be a comorbid condition in many children with ASD. A Swedish study showed that 20% of all school-age children with ASD met the full criteria for TS. There also appears to be a higher incidence of seizures in children with autism compared to the general population. The comorbidity of ASD and psychotic disorders has received some research attention. A study of children with ASD who were referred for psychotic behavior and given a diagnosis of schizophrenia showed that when psychotic behaviors were the presenting symptoms, depression and not schizophrenia, was the likely diagnosis. Thus, autistic individuals may present with characteristics that could lead to a misdiagnosis of schizophrenia and other psychotic disorders.

Implications

Children and youth with ASD frequently have comorbid conditions, with rates significantly higher than would be expected from the general population. The most common co-occurring diagnoses are anxiety and depression, attention problems, and disruptive behavior disorders. The core symptoms of ASD can often mask the symptoms of a comorbid condition. The current challenge for practitioners is to determine if the symptoms observed in ASD are part of the same dimension (i. e, the autism spectrum) or whether they represent another condition. Although various psychometric instruments, such as clinical interviews, self-report questionnaires and checklists, are widely used to assist in diagnosis, these tools are designed and standardized to identify symptoms in the general population, and may not be appropriate and valid for use with ASD. Likewise, their administration may be problematic in that autistic individuals may have difficulties in sustaining a reciprocal conversation, reporting events, and perspective taking. Nevertheless, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, impulsivity, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Co-occurring conditions should also be carefully investigated when severe or worsening symptoms are present that are not responding to intervention or treatment.

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, 2017, 1-5. doi:10.1155/2017/5781781

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.

Duerden, E. G., Oatley, H. K., Mak-Fan, K. M., McGrath, P. A., Taylor, M. J., Szatmari, P., & Roberts, S. W. (2012). Risk factors associated with self-injurious behaviors in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42:2460–2470. DOI 10.1007/s10803-012-1497-9

Maenner, M. J., Arneson, C. L., Levy, S. E., Kirby, R. S., Nicholas, J. S., & Durkin, M. S. (2012). Brief report: Association between behavioral features and gastrointestinal problems among children with autism spectrum disorder. J Autism Dev Disord 42:1520–1525. DOI 10.1007/s10803-011-1379-6

Mayes, S. D., Calhoun, S. L., Murray, M. J., & Zahid, J. (2011). Variables associated with anxiety and depression in children with autism. Journal of Developmental and Physical Disabilities, 23, 325–337.

Mazurek, M. O., Vasa, R. A., Kalb, L. G., Kanne, S. M., Rosenberg, D., Keefer, A., et al. (2013). Anxiety, sensory over-responsivity, and gastrointestinal problems in children with autism spectrum disorders. Journal of Abnormal Child Psychology, 41, 165–176.

Mazurek, M. O., Kanne, S. M., & Wodka, E. L. (2013).  Physical aggression in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 455–465.

Mazzone, L., Ruta, L., & Reale, L. (2012). Psychiatric comorbidities in Asperger syndrome and high functioning autism: diagnostic challenges. Annals of General Psychiatry, 11:16. doi:10.1186/1744-859X-11-16

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

Strang, J. F., Kenworthy, L., Daniolos, P., Case, L., Wills, M. C., Martin, A., et al. (2012). Depression and anxiety symptoms in children and adolescents with autism spectrum disorders without intellectual disability. Research in Autism Spectrum Disorders, 6(1), 406–412.

Tureck, K., Matson, J. L., May, A., Whiting, S. E., & Davis, T. E., III. (2013). Comorbid symptoms in children with anxiety disorders compared to children with autism spectrum disorders. Journal of Developmental and Physical Disabilities. doi: 10.1007/s10882-013

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

Wilkinson, L. A. (2017).  A best practice guide to assessment and intervention for autism spectrum disorder in schools (2nd ed.). London & Philadelphia : Jessica Kingsley Publishers.

Lee A. Wilkinson, PhD, is a licensed and nationally certified school 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 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Autism: Parent Acceptance and Empowerment

Parent Acceptance and Empowerment

Parents are often overwhelmed by the challenges presented by a child with autism. Research has shown that parents of children on the spectrum exhibit a characteristic stress profile which includes anxiety related to the child's uneven intellectual profiles, deficits in social relatedness, disruptive and maladaptive behaviors (internalizing and externalizing problems) and long-term care concerns. Among these stressors, the child’s maladaptive behavior profile is most reliably linked to parent stress. 

Studies indicate that raising children with autism is associated with higher levels of parenting stress and psychological distress than parenting typically developing children, children with a physical disability, or children with developmental delays without autism. Mothers, in particular, appear to face unique challenges related to the characteristics of autism. 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.

Research

Increased attention is now being given to the psychological well-being of parents of children and youth with autism. A number of studies have examined the factors that can influence the impact of children’s problem behavior on parent mental health. A study in the Journal Autism examined the relationships between child problem behavior, parent mental health problems, psychological acceptance (e.g., accepting and not being adversely influenced by negative emotions and thoughts that a parent may have about their child), and parent empowerment (e.g., actively attempting to change or eliminate potentially stressful events through the application of knowledge and skills).

The researchers found that the more positive parents’ psychological acceptance and empowerment, the less they reported severe mental health problems. Although greater parent empowerment was associated with fewer parent mental health problems, psychological acceptance had the greatest impact on parent mental health problems, after controlling for ASD symptomatology, negative life events, parent and child gender, and child age. 

Implications

This study has several important implications. The relatively chronic nature of behavior problems in children with autism may explain why acceptance is a more significant psychological construct for explaining parent mental health than is empowerment. If difficulties are manageable and support readily available, then an active, problem-focused coping style would be related to improved parent adjustment. However, for children with autism who exhibit more persistent behavior problems, or for highly stressed and frustrated parents, a problem-focused process may not be enough to ensure positive parent adjustment. If problems are less controllable and/or support less accessible, it may be impossible for parents to focus exclusively on trying to change or avoid their current experience. The authors comment, “In these situations, parents need a different coping strategy, one that allows them to acknowledge their current experience without trying to change it or avoid it.”  Therefore, it may be critically important to understand and evaluate the situation of the family, and offer parents both types of coping skills (acceptance and empowerment) for use across different situations.

This study supports the exploration of acceptance and mindfulness-based interventions as effective approaches for parents of children with autism and underscores the importance of considering the parent psychological experience when developing interventions. The authors conclude, “Child-focused therapy should not focus exclusively on the child. At the same time that we provide parents with skills and supports to improve their children’s experience, we must also invest in helping parents to deal with their own emotions and coping strategies.” 

Weiss, J. A., Cappadocia, M. C., MacMullin, J. A., Viecili, M., & Lunsky, Y. (2012). The impact of child problem behaviors of children with ASD on parent mental health: The mediating role of acceptance and empowerment. Autism, 16, 261-274. DOI: 10.1177/1362361311422708

Lee A. Wilkinson, PhD, is a licensed and nationally certified school 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 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).

Autistic Girls, Boys Differ in Social Communication

Autistic girls, boys differ in how they talk about social groups

CHARLES Q.CHOI 

During conversations, girls with autism use “we,” “they” and other words related to social groups differently than autistic boys do, according to a new study.

The findings could help parents and clinicians identify autism in girls, who tend to be diagnosed less often and later than boys, researchers say.

The failure to recognize autism in girls can put them at an increased risk of mental health problems such as anxiety, depression and suicidality.

“If girls with autism are not properly understood, then these girls may not get access to the proper resources they need early in life to get the support they need to flourish and reach their full potential,” says lead investigator Julia Parish-Morris, assistant professor of psychiatry at the University of Pennsylvania.

To gain insight into gender differences in problems with social communication — a core trait of autism — Parish-Morris and her colleagues analyzed how girls and boys with and without autism talk about other people during unscripted conversations.

“This is one of the few studies that have used natural language samples and not just responses to standardized tests to examine the difference in social interest between boys and girls with autism and typically developing boys and girls,” says Jenny Burton, a speech-language pathologist who was not involved with the study. It is also one of few studies to support the idea that, compared with autistic boys, girls with the condition have strengths in social interaction and motivation, she says.

Word search:

The scientists recorded audio and video as each participant took part in an informal five-minute ‘get to know you’ conversation with an undergraduate student or research assistant. The sample included 17 girls and 33 boys with autism, and 15 girls and 22 boys without the condition, all aged 8 to 17 and matched for age and intelligence quotient. They also matched the autistic children for levels of social impairment.

Computer programs transcribed the conversations and counted the number of plural personal pronouns — those that refer to groups of people, such as “we,” “us,” “they” and “them” — as well as words with social connotations, such as “family” and “friends.” The researchers then calculated how often a child used these words relative to the total number of words he or she said overall.

Autistic girls use plural personal pronouns almost twice as often as autistic boys do, and they use social words more often as well, the researchers found. The study was published in November in the Journal of Child Psychology and Psychiatry.

The findings may indicate that girls are “pressured to conform socially,” Parish-Morris says. “Pronouns can give hints about social embeddedness or the sense of social belonging, which matters with conditions with social challenges such as autism.”

The findings agree with previous research suggesting that autistic girls are more motivated to socialize than autistic boys — for instance, autistic girls tend to hover near other children on playgrounds, whereas autistic boys tend to play alone.

Autistic girls also use “they” and “them” more often than non-autistic girls do, the study found. Such heightened discussion of groups autistic girls are not members of may indicate they are aware of their social exclusion, the scientists note. “Saying ‘we did this and that’ is a very different frame of reference from saying ‘they did this or that,’” Parish-Morris says.

Not a monolith:

Overall, the study shows that autistic children and adolescents use significantly fewer plural personal pronouns than their non-autistic peers do. If the same pattern holds true for even younger children, diminished or atypical use of personal pronouns might prove useful to flag children for diagnosis, the researchers suggest.

The findings underscore the idea that “autism is not a monolith — it manifests differently across sexes and genders and ages and cultures,” Parish-Morris says.

As a next step, researchers could explore how autistic girls and boys differ when talking with other children instead of with adults.

Future studies could also analyze the specific socially connoted words autistic girls and boys use.

“It would be interesting knowing whether they are referencing family versus peers, due to potentially fewer social activities with peers and more time with family,” says Rene Jamison, associate professor of pediatrics at the University of Kansas in Kansas City, who did not take part in the new research. “In my research, we have found that when girls are in the 8 to 12 age range, both girls with and without autism would reference their family more than their peers, but as they grow older, we would expect girls without autism to shift to more external social groups, but girls with autism would not shift as much.”

           This article was published on Spectrum, the leading site for autism research news.

                                                                                                                                                  

https://www.spectrumnews.org/news/autistic-girls-boys-differ-in-how-they-talk-about-social-groups/

Lee A. Wilkinson, PhD, is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

Co-Occurring ADHD in Autistic Children

Co-Occurring 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, is a licensed and nationally certified school 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 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).

The Empathy Myth in Autism

Understanding Affective and Cognitive Empathy in Autism

One of the most common myths about autistic individuals is that they don’t feel empathy towards others. There are two interrelated types of empathy: affective or emotional empathy, which involves feeling an appropriate emotional response to another person’s emotion, and cognitive empathy, or Theory of Mind (ToM), which involves understanding or predicting another person’s perspective. The affective component of empathizing involves feeling an appropriate emotion triggered by seeing/learning of another’s emotion. When engaged in affective empathy, we vicariously experience the emotional states of others, understanding that our feelings are not ours, but rather those of the other person. Sympathy is also considered an affective component of empathy. It is the feeling or emotion triggered by seeing or learning of someone else’s distress which moves you to want to take an action that will help ease their suffering.

The cognitive or ToM component of empathy involves the understanding and/or predicting what someone else might think, feel, or do. It is the ability to identify cues that indicate the thoughts and feelings of others and “to put oneself into another person’s shoes.” It is also referred to as “mentalizing,” “mindreading,” and “perspective taking.” The ability to reflect on one’s own and other people’s minds (beliefs, desires, intentions, imagination and emotions) allows us to interact effectively with others in the social world. ToM may also be thought of existing on a continuum with some individuals able to “mindread” relatively easily and intuitively, while others experience varying degrees of problems interpreting and predicting another person’s behavior. Most (but not all) typical individuals are able to mindread relatively easily and intuitively. They can read another person’s facial expression and body language, and tone of voice and recognize his or her thoughts and feelings, and the likely course of their behavior. In other words, they interpret, predict, and participate in social interaction automatically, and for the most part, intuitively. Often referred to as "mindblindness," it is this cognitive component of empathy that is delayed in autism.

Unfortunately, the failure to understand the difference between affective (emotional) empathy and cognitive empathy has led to a persistent myth and stereotype that people with autism lack empathy and cannot understand emotion. It’s critically important to recognize that autism is characterized by challenges associated with cognitive empathy (ToM), not emotional empathy which is intact. Although autistic individuals may have difficulty with social cues and understanding and predicting another’s thoughts, motives and intentions, they have the ability to care and be concerned about other people’s feelings. 

Autism does not deprive someone of emotional empathy! Autistic people can and do experience feelings and emotions intensely as everyone else, even though it may not always be obvious to others in a "typical" way. - Dr. Lee A. Wilkinson

Key References and Further Reading

Baron-Cohen, S. (1991). The theory of mind deficit in autism: how specific is it? British Journal of Developmental Psychology, 9. 301-314.

Baron-Cohen, S., Jolliffe, T., Mortimore, C., & Robertson, M. (1997). Another advanced test of theory of mind: evidence from very high functioning adults with autism or Asperger Syndrome. Journal of Child Psychology and Psychiatry, 38. 813-822.

Baron-Cohen, S., Ring, H. A., Bullmore, E. T., Wheelwright, S., Ashwin, C., & Williams, S. C. R. (2000). The amygdala theory of autism. Neuroscience & Biobehavioral Reviews, 24(3), 355-364.

Baron-Cohen, S., & Swettenham, J. (1997). Theory of mind in autism: Its relationship to executive function and central coherence. Handbook of autism and pervasive developmental disorders, 880-893.

Baron-Cohen, S. (2000). Theory of mind in autism: A fifteen year review. In S. Baron-Cohen, H. TagerFlusberg, & D. J. Cohen (Eds.), Understanding other minds: Perspectives from developmental cognitive neuroscience (pp. 3–20). New York: Oxford University Press

Fletcher-Watson, S, McConnell, F, Manola, E & McConachie, H 2014, 'Interventions based on the Theory of Mind cognitive model for autism spectrum disorder (ASD)' Cochrane database of systematic reviews. DOI: 10.1002/14651858.CD008785.p

Begeer S. Theory of mind interventions can be effective in treating autism, although long-term success remains unproven Evidence-Based Mental Health 2014;17:120.

Fletcher-Watson S, McConnell F, Manola E, McConachie H. Interventions based on the Theory of Mind cognitive model for autism spectrum disorder (ASD). Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD008785. DOI: 10.1002/14651858.CD008785.pub2

Gray, C. A. (1998). Social stories and comic strip conversations with students with Asperger Syndrome and high-functioning Autism. In E. Schopler, G. B. Mesibov, & L. J. Kunce (Eds.), Asperger syndrome or high functioning autism? (pp. 167-194). NY: Plenum Press.

Hutchins, T., & Prelock, P. A. (2008). Supporting theory of mind development: Considerations and recommendations for professionals providing services to individuals with ASD. Topics in Language Disorders, 28 (4), 340-364.

O’Brien, K., Slaughter, V. & Peterson, C.C. (2011). Sibling influences on theory of mind development for children with ASD. J Child Psychology & Psychiatry, 52(6), 713-719.

O’Hare, A.E., Bremner, L., Nash, M., Happe, F., Pettigrew, L.M. (2009). A clinical assessment tool for advanced theory of mind performance in 5 to 12 year olds. JADD, 39(6), 916-928.

Sprung, M. (2010). Clinically relevant measures of children’s theory of mind and knowledge about thinking: Non-standard and advanced measures. Child and Adolescent Mental Health, 15(4), 204-216.

Tager-Flusberg, H. (2001). A reexamination of the theory of mind hypothesis of Autism. In J. A. Burack, T. Charman., N. Yirmiya., & P. R. Zelazo (Eds.), The development of autism: Perspectives from theory and research (pp.173-193). Mahwah, NJ: Lawrence Erlbaum.

Wellman, H. M., Baron-Cohen, S., Caswell, R., Gomez, J. C., Swettenham, J., Toye, E., & Lagattuta, K. (2002). Thought-bubbles help children with autism acquire an alternative to a theory of mind. Autism, 6(4), 343-363.

Wilkinson, L. A. (2011). Mindblindness in Encyclopedia of Child Behavior and Development, Part 13, 955-956, DOI: 10.1007/978-0-387-79061-9_1795

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

Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. Jessica Kingsley Publishers. London and Philadelphia.

Lee A. Wilkinson, PhD, is a licensed and nationally certified school 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 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).

Genes’ Influence On Social Behaviors Shifts With Age

 Genes’ Influence On Social Behaviors Shifts With Age

Reciprocal social behavior — the give and take of information or objects during interactions with others — is strongly heritable, according to an analysis of twins.

Some social behaviors associated with autism are heritable, according to a new study. But the extent to which genes and the environment influence these behaviors changes as a child grows, the results show.

The researchers examined toddlers’ so-called reciprocal social behavior, or the ability to engage in interactions such as sharing toys or conversing. Reciprocity skills vary in the general population, and prominent difficulties in this area can be a sign of autism. To estimate the heritability of these behaviors, the team measured them in a group of twins — including identical twins, who share nearly all of their DNA, and fraternal twins, who share about half.

Identical twins tend to have more similar scores on measures of their social behaviors than fraternal twins do, the researchers found, suggesting a strong genetic component. But the degree of heritability changed as the twins developed, suggesting that the influence of genetics and the environment on behavior is not stable, says lead investigator Natasha Marrus, assistant professor of psychiatry at Washington University in St. Louis, Missouri.

“Development doesn’t look static when we watch it, and I don’t think the biology underneath it is static either,” she says.

Because differences in social reciprocity are observable before the age at which autism is usually diagnosed, understanding how it develops could help researchers chart the condition’s early trajectory, Marrus says.

The paper is an important first step toward creating measures of behavioral dimensions that appear in early development in autistic children, says Peter Mundy, professor of education at the University of California, Davis, who was not involved in the work. And it solidifies the idea that genetics influences these behaviors.

“That’s unassailable,” Mundy says. “It’s a good contribution.”

Social factors:

The researchers analyzed data from the parents of 1,563 18-month-olds. The parents watched a video of a typically developing 19-month-old interacting with an adult, rated how their child compared with the girl in the video on 13 items, and answered 31 additional questions about their child’s social behaviors, such as whether the child understands verbal requests or tries to play with other people. They repeated both tests when the children were 24 months old.

An analysis revealed that the children’s scores on some survey items tended to be correlated. A child who responds to her name, for example, is also likely to be interested in what others are doing, the researchers found. Based on these correlations, they identified five ‘dimensions’ of reciprocal social behavior: social motivation; functional communication; restricted interests and repetitive behaviors; social avoidance; and social orienting.

The team repeated the tests in a group of 134 identical twin pairs and 205 fraternal pairs, also at 18 and 24 months of age, and measured how similarly the twins scored on each of the five dimensions. They did additional modeling to differentiate the effects of genetics and shared and unshared environmental factors.

At both ages and for all five dimensions, identical twins had stronger similarities than fraternal twins, indicating that reciprocal behaviors are strongly heritable.

But the heritability of each dimension changed as the children grew. The influence of genetics on social motivation and functional communication waned from 18 to 24 months. By contrast, its influence on social orienting nearly doubled between screenings; it also increased, although to a lesser extent, for social avoidance and repetitive behaviors.

The results suggest that the interplay between genetics and environmental factors changes over time, Marrus says, with the environment playing a stronger role at some points than at others.

“Just because something is heritable, it doesn’t mean that exact same level of genetic influence operates over the entire course of your life,” Marrus says.

New measures:

The apparent change in genetic influence may actually reflect decreasing errors in the measures used, Mundy says. A child’s language abilities, for example, would play a key part in the parent’s assessment of the child’s social skills, and language development is more varied in 18-month-olds than in 24-month-olds.

“I interpret this as consolidation of true score over time,” Mundy says. “I would think it’s not reflecting a major biological change.”

Dividing the broad category of ‘social behavior’ into specific dimensions could ultimately help researchers assess which interventions are effective, when and for whom, says Giacomo Vivanti, associate professor in the Early Detection and Intervention program at the Drexel Autism Institute in Philadelphia, Pennsylvania, who was not involved in the work.

“The boundaries between these constructs are really fuzzy,” Vivanti says. “We need a more fine-grained understanding of, ‘What are we talking about when we talk about social behavior?’

The findings could help clinicians identify behaviors that may indicate autism in children too young to be diagnosed, Marrus says. A child with difficulties in several categories of reciprocal social behavior, for example, may have more underlying genetics linked to autism and be more likely to have the condition than a child with difficulties in only one category.

“Being able to understand how to weigh all of those dimensions within an individual could be very important, especially early in life, to figuring out what is this child’s level of risk,” Marrus says.

That approach could also help researchers tease apart the heritable dimensions of other autism traits, such as motor skills development, Marrus says. Marrus and others have shown that eye-contact patterns, another indicator of social behavior, are heritable.

                                                              

           This article was published on Spectrum, the leading site for autism research news.

https://www.spectrumnews.org/news/genes-influence-on-social-behaviors-shifts-with-age/

      Lee A. Wilkinson, PhD, is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)