* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Autism Spectrum Disorders
Depersonalization disorder wikipedia , lookup
Schizoaffective disorder wikipedia , lookup
Mental status examination wikipedia , lookup
Conversion disorder wikipedia , lookup
Conduct disorder wikipedia , lookup
History of psychiatry wikipedia , lookup
Antisocial personality disorder wikipedia , lookup
Emergency psychiatry wikipedia , lookup
Mental disorder wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
Rumination syndrome wikipedia , lookup
Rett syndrome wikipedia , lookup
Separation anxiety disorder wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Narcissistic personality disorder wikipedia , lookup
Abnormal psychology wikipedia , lookup
Developmental disability wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
History of mental disorders wikipedia , lookup
Factitious disorder imposed on another wikipedia , lookup
Classification of mental disorders wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Child psychopathology wikipedia , lookup
Spectrum disorder wikipedia , lookup
Epidemiology of autism wikipedia , lookup
Autism therapies wikipedia , lookup
Autism Spectrum Disorders: Asperger Syndrome/PDD-NOS/ High Functioning Autism Susan Ridenour, MSW, LSCSW For Kansas Health Solution Aug 26, 2009 Welcome! • This presentation is for the purpose of offering training for Autism Spectrum Disorders • Your host today is: ▫ Kansas Health Solutions 2 Courtesy Items • In order to cut down on background noise, your phone was automatically muted when you joined the conference. When it is time for questions you will be unmuted in order to ask your questions. • Please do NOT place your phone on hold. • Should you experience sound quality issues, hang up and dial back in. If this persists, press *O. This will connect you to an operator. If you have call waiting, please turn this feature off for the duration of the call. 3 Meeting Process This webinar is one hour in length. • Type questions/comments into the box in the upper right portion of the screen called “Chat or Q& A”– you may need to press the arrow in order to drop this section. We will call on you specifically. • If we need clarification on your question, we will un-mute your phone and you may ask your question. After asking your question, we will re-mute your phone. Please ask only the question indicated. Thank you. 4 Introductions Speaker/Presenter Susan Ridenour, MSW, LSCSW 5 Objectives • • • • • • Overview of History Assessment KHS Diagnostic Implications Co-occurring Disorders Treatment and Resources Screening Tools History of diagnostic terms: Differentiating Autism vs. Asperger Syndrome • 1944: Vienna based pediatrician Hans Asperger • wrote “Autistic Psychopathies of Childhood” • Leo Kanner – a contemporary of Asperger – based in United States • studied similar population referred to as “Infantile Autism” • Lorna Wing, reviewed work in 1981 • Changed diagnosis name to Asperger’s Syndrome (AS) • Views AS as a type of Autism and part of the Spectrum History (cont.) • In 1993 International Classification of Diseases, 10th Edition (ICD-10) • 1994 DSM-IV-TR legitimized the diagnosis of Asperger Syndrome and transformed our understanding of autism. • The broad diagnostic category in the DSM-IVTR is Pervasive Developmental Disorders ▫ currently referred to as Autism Spectrum Disorders (ASD). Pervasive Developmental Disorders • Symptoms are defined by a certain set of behaviors that on a continuum can range from mild to severe. • The following 5 ASD diagnostic codes are more common in the pediatric population than diabetes, spinal bifida, or Down Syndrome. ▫ Autistic Disorder ▫ Asperger’s Disorder (Syndrome) ▫ Pervasive Developmental Disorder Not Otherwise Specified (including Atypical Autism) ▫ Rett’s Disorder ▫ Childhood Disintegrative Disorder Pervasive Developmental Disorders • Comparatively, Asperger Syndrome is considered to be a milder pervasive developmental disorder, distinguished by a pattern of symptoms. These symptoms will be reviewed in later slides. • Summary of literature review: ▫ Asperger Syndrome appears to result from developmental factors that affect many or all functional brain systems, as opposed to localized effects. Muller RA (2007). “The study of autism as a distributed disorder”. Ment Retard Dev Disabil Res Rev 13 (1): 85-95. I Impairments result from maturation-related changes in various systems of the brain. World Health Organization (2006). Prevalence • To date, numerous well-designed scientific studies have found the prevalence of Asperger’s to be 2.5 cases per 1,000. Attwood uses Gillberg’s criteria – 1 in 280 children (1999) • The CDC estimated the prevalence of all Autism Spectrum Disorders among 8 year old children to be 1 in 150 based on the combined data from studies completed in 2000 and 2002. • Research reported a prevalence of males to females 4.3:1. Although sex differences have been observed, the ratio studies have not supported this claim. (Fombonne & Chakrabarti, 2001; Honda, Shimizu, & Rutter, 2005; Madsen et al., 2002; Smeeth et al., 2004; Taylor et al., 1999). • Attwood noted there is a 2:1 ratio of men to women who have AS in his adult practice. • Girls more difficult to recognize due to their social imitation coping skills and camouflaging mechanisms. Autism Spectrum Disorders Project • Revision of Attwood’s ASAS-R was for ages 5-18 • Only scale supported by current research (2008) that differentiates: ▫ children and adolescents with AS from those who did not have ASD ***on every dimension of AS*** ▫ children with AS from those with autism ▫ Children were referred to an ASD clinic but who did not receive a diagnosis. • Keep abreast of the release date on Tony Attwood’s website: www.tonyattwood.com.au CORE dimensions of Asperger Syndrome Common Theory Attwood’s Theory • Theory of Mind/“Mindblindness” • Perspective Taking (Carlson, VS etal. 2004.) (Baron-Cohen & Swettenham 1997) • Executive Functioning Difficulties - not exclusive to AS, also seen in ADHD, OCD and Toruette’s VS • Rigid Adherence to Routine (Hill & Frith 2003) • ------------------------ • Weak Central Coherence (Baron-Cohen & Swettham, 1997) (Hill & Frith, 2003) • Sensory Sensitivity*** VS VS • Fact Oriented *** Of Interest - All of the core dimensions except one have been discovered to be the core characteristics in earlier studies Diagnostic Process with KHS • KHS reimburses for mental health services when a Member has either a diagnosis of Asperger Syndrome or Rett Disorder. • Other Pervasive Developmental Disorder diagnostic codes billed to KHS, must also have a psychiatric diagnosis. (dual diagnosis) • Service documentation must clearly identify the treatment plan goals and interventions that relate to the presenting psychiatric issue(s). Diagnostic Process with KHS • Confusion can arise in terms of which program is responsible to provide the complex web of services needed by this population. ▫ It is not always easy to differentiate the psychiatric symptoms from the core issues of the broader pervasive disability. • SHCN identification provides opportunity for additional Care Coordination assistance through KHS. Diagnostic Process with KHS • If primary symptomology is due to significant cognitive impairment or substance abuse, refer to appropriate program. Although with dual diagnoses there may be transitions between or collaboration among programs. CO-MORBIDITY - Dx Implications • 1998 study: 65% of individuals with ASD had at least one other psychiatric disorder. (Ghaziuddin, Weidmer-Mikhail, and Ghaziuddin) • All of Asperger’s cases appeared to have co-morbid behavioral and psychiatric disorders. (Ghaziuddin, 2002) • In a review of the literature, no environmental factor has been confirmed by scientific investigation. • Research studies have made no connection between Asperger Syndrome and childhood trauma, abuse or neglect. Rutter M (2005). “Incidence of autism spectrum disorders: changes over time and their meaning”. Acta Paediatr 94 (1): 2-15 CO-MORBIDITY • Peer and family environments cannot cause ASD (Attwood 2008) • Some issues may result from the various challenges these individuals struggle with on a daily basis: ▫ severe social impairments, ▫ lack of meaningful age-appropriate relationships, ▫ increased potential of being victimized by others. Medical Co-Morbidity • Epilepsy with classic autism. • Fragile X syndrome, Phenylketonuria (PKU), and Tuberous Sclerosis also may be present with Autism. • Most, if not all, individuals diagnosed with an ASD have significant differences in motor functioning. • Catatonia , is seen in a higher frequency in people diagnosed with ASD than in the general population. ▫ 6% to 17% of those with ASD who are over the age of 15 experience a serious “catatonia like deterioration” Learning Disabilities w/ Asperger: (Developmental Considerations) • Higher than normal rate of specific disability in math and reading. • Poor Reading Comprehension – problems applying concepts in real-life context. • Non-verbal Learning Disability – significant discrepancy between verbal reasoning abilities and visual-spatial reasoning • Specific Learning Disability in Written Expression. Learning Disabilities (cont.) • Although an Asperger Syndrome diagnosis is usually given if the person has an IQ within the average to superior range, • The profile of abilities on a standardized test of intelligence tends to be remarkably uneven. • Clinicians may include some cases with a borderline intellectual impairment when some cognitive skills are within the normal range. (Attwood 2007) Psychiatric Co-Morbidity • Mood Disorders: Some indication AS runs in families, particularly in families with histories of depression and bipolar disorder. (APA 2000; Kim, Szatman, Bryson, Streiner, & Wilson, 2000; Ghaziuddin et al. 1998; Green, Gilchrist, Burton, & Cox, 2000; Rumsey et al. 1985; Wing, 1981) ▫ Presentation: The child shows thought disorder, irritability, has dangerous special interest(s), tends to be hypo-manic in the evening • However, neurological immaturity also helps explain why the AS child under stress is less able to access the thinking area of the brain and therefore does not act in what others perceive to be a logical or rational manner. (Myles 2005) Anxiety Disorders • Some research shows a genetic reason for anxiety and depression. (Kim et al., 2000) • Depression and anxiety are more common among higher functioning individuals with AS. (Kim et al., 2000) ▫ Between 70-85% of children with AS have extreme sensitivity to specific sounds. (Smith Myles 2000) ▫ Over 50% have olfactory and taste sensitivity. (Bromley et al. 2004; Smith Myles et al. 2000) ▫ 1 in 5 children with AS experience bright sunlight as almost blinding and specific colors as too intense. • These “dynamic sensory surges” are experienced as extremely stressful and aversive ; anticipatory anxiety can become so severe, an anxiety disorder or phobia can develop. (Jackson 2002) Anxiety Disorders • Common response to anxiety: retreating into solitude or the enjoyment of a special interest or self medication with substances. • The most common types of anxiety disorders for children and adults with AS are (Ghaziuddin 2005b.): ▫ ▫ ▫ ▫ ▫ OCD, PTSD, School Refusal, Selective Mutism, and Social Anxiety Disorder. Additional Co-Morbidity • ADHD is often the first diagnosis. • 75% meet the criteria for a clinical diagnosis of ADHD. (Sturm, Fernell, & Gillberg, 2004) • Obsessive-Compulsive Disorder (OCD) - 25% of adults with AS also have the clear clinical signs of OCD. (Russell et al. 2005) • PTSD develops typically as a consequence of experiencing a traumatic event or series of events. (Atwood; Russell and Sofronoff 2004) ▫ Severe and repeated bullying can precipitate the clinical signs of PTSD in children with AS. Additional Co-Morbidity • Depression – People with AS appear vulnerable to feeling depressed, 1 in 3 children and adults have a clinical depression. “I feel I don’t belong” is a common theme. (Ghaziuddin et al. 1998; Kim et al. 2000; Tantam 1988a; Wing 1981.) • May be no emotion assigned to this state of mind or experience. • Special interest can become morbid and the person is preoccupied with aspects of death. Bullying • BULLYING IS VERY COMMON in this population. ▫ Minds and Hearts website www.mindsandhearts.net • More than 90% of mothers of with AS reported in a recent survey: ▫ Their children had been the target of some form of bullying within the previous year. (ages 4 and 17) ANGER • Commonality is unknown. (Attwood 2007) • Appears to be a faulty emotion regulation/control mechanism for expressing anger. • Critical to understand the underlying causes or antecedents that serve as triggers for anger. **Anger typically seen in 3 Stages** Rumbling stage, Rage stage, Recovery stage each stage is of variable length (Myles et al. 2005) Anger/Tourette’s • Confrontational, oppositional and aggressive behavior is usually not modeled on a member of the family. The parents who are subjected to threats and acts of violence are often very meek people who may lack assertiveness in conflict situations. • Negotiation, compromise and cooperation are strategies not obvious to kids with AS and they may rely on immature confrontation strategies. • Tourette Syndrome: Children with a combination of AS and Tourette’s are at greater risk of: ▫ Having signs of ADHD, ▫ Developing an anxiety disorder such as Obsessive Compulsive Disorder. Research has indicated that between 20 and 60% of children with AS develop tics. Five Compensatory & Adjustment Strategies 1. Pathological Demand Avoidance (Newsom) 2. Reactive Depression (Attwood) 3. Escape into Imagination 4. Denial and Arrogance 5. Imitation Relationship Issues in Therapy • The lack of demonstrated empathy has been noted as possibly the most dysfunctional aspect of Asperger Syndrome from a social and relationship aspect. • Individual with AS may experience aversion to physical touch due to a problem with sensory issues rather than a lack of love and commitment to the relationship. Relationship Issues in Therapy • Typical partner may resent the obvious lack of enjoyment and the rarity of such affectionate gestures. • Compensatory & adjustment strategies, in addition to underlying characteristics of AS, create ongoing problems in relationships and present complex challenges for service providers. Strategies for Intervention • The Ziggurat Model A Framework for Designing Comprehensive Interventions for Individuals with HighFunctioning Autism and Asperger Syndrome Winner of the 2008 ASA Award for Outstanding Book of the Year Strategies for Intervention • The Ziggurat model expands the TEACCH approach created by the Treatment and Education of Autistic and Communication Handicapped Children. • TEACCH emphasizes the importance of identifying underlying strengths and needs of the disorder. Strategies for Intervention • The Underlying Characteristics Checklist assists in identification of underlying factors as well as an analysis of patterns of behavior. ▫ The ABC (antecedent/behavior/ consequence.) • Also included is the Individual Strengths and Skills Inventory. Strategies for Intervention • The results are used to develop a comprehensive intervention incorporating each of five levels: ▫ ▫ ▫ ▫ ▫ Sensory and Biological, Reinforcement, Structure and Visual/Tactile Supports, Task Demands, and Skills to Teach. Strategies for Intervention • Additional tools utilized by practitioners include: ▫ power cards, social stories and scripts, narratives, video modeling review of hidden social curriculums • The strategy of the Emotional Toolbox is to identify different types of “tools” to fix the problems associated with negative emotions. Strategies for Intervention • K-CART (Kansas Center for Autism Research and Training) suggests: ▫ ▫ ▫ ▫ ▫ ▫ ▫ Floor-time Therapy (Greenspan), Speech Therapy, Occupational Therapy, PECS (early communication program), Sensory Integration Therapy, Relationship Development Intervention, and Verbal Behavior Intervention as useful interventions. For more information: www.autismspeaks.org/ Strategies for Intervention • Play Therapy and play based activity, role play, etc. are useful modalities to build relationship and introduce/practice social cues and skills. • Published case studies and objective scientific evidence has shown that CBT significantly reduces mood disorders in children and adults with AS. Strategies for Intervention • Using psychotropic medications is one of the most common forms of treatment for individuals with ASD. ▫ One study found that approximately 46% of individuals with ASD were prescribed one medication while roughly 21% were taking two or more. • Other medical, vitamin and homeopathic remedies as well as special diets eliminating gluten and casein are popular with many families – research is not available to support the effectiveness on a large scale RESOURCES • Tiny-K (birth-three) provides services to children with an area of least 25% developmental delay. ▫ They routinely coordinate services with other community based programs that provide a variety of services to children and families. • The Early Childhood Special Education Department in each school district evaluates and provides services to children ages three to five. ▫ A similar process occurs in elementary and secondary education/special services. Services can be provided at no cost to the family if the child is eligible. RESOURCES • The Autism Waiver is provided through Kansas Social Rehabilitation Services for children from the age of diagnosis through the age of five. ▫ Unfortunately, only a limited number of applicants can be served, however applications can be obtained through your local SRS office. RESOURCES • Kansas Institute of Positive Behavior Supports at www.kipbs.org. ▫ Services covered by Medicaid or private pay. • Early Childhood Autism Project (ECAP) at 785865-5520 ext. 320. ▫ Services covered by Medicaid or private pay. • Waivers through the mental health system are also available when a child has a diagnosis of Asperger Syndrome or co-occurring psychiatric symptoms are negatively impacting daily functioning. RESOURCES • The Kansas Community Developmental Disability Organization (CDDO) provides Home and Community Based services or direct financial support options if the child is determined eligible. ▫ The MR/DD waiver waiting list is lengthy, and the child must be five years or older. • Resources for organizations that work directly with schools: ▫ Neurological Disabilities Support Project at www.ksndsp.org and ▫ Project Stay at www.projectstay.com RESOURCES • Children’s Mercy and KUMC specialize in Autism Spectrum Disorder evaluation. ▫ There are also developmental pediatricians with expertise in this area. • The Kansas Center for Autism Research and Training (K-CART) offers clinical services through its alliance with the Center for Child Health and Development (CCHD) at KUMC. RESOURCES • K-CART (Kansas Center for Autism Research and Training) offers training for service providers and school district personnel for implementation of social skills for ASD at http://kcart.ku.edu/autism_training/ • Challenging Behaviors: CCHD Developmental Disabilities Pediatric Problem Behavior Clinic at www.kumc.edu/cchd or 913-588-5900 (Social Skills Groups available) RESOURCES • The Autism Alliance of Greater Kansas City has compiled a resource directory that lists services by topic. ▫ Go to http://www.kcautismservices.com/ • Keys For Networking ▫ www.keys.org • Families Together – Parent to Parent support ▫ www.familiestogetherinc.org Screening Tools • The Childhood Asperger Syndrome Test (The CAST): ▫ Preliminary development of a UK screen for mainstream primary school age children. • Modified Checklist for Autism in Toddlers (MCHAT): ▫ An initial study investigating the early detection of autism and pervasive developmental disorders. • Australian Scale for Asperger’s Syndrome (ASAS): ** Revised version upcoming. ** Screening Tools • Autism Spectrum Disorders in Adults Screening Questionaire (ASDASQ) • Autism Spectrum Screening Questionnaire (ASSQ): ▫ Screening questionnaire for AS and other highfunctioning spectrum disorders in school age children. • Asperger Syndrome Diagnostic Scale (ASDS) • Asperger Syndrome Diagnostic Interview (ASDI) Screening Tools • Sensory Profile, Checklist Revised • The Adult Asperger Assessment, or AAA, uses two screening instruments, the Autism Spectrum Quotient (ASQ) and the Empathy Quotient (EQ): ▫ the original research was conducted at the Cambridge Lifespan Asperger Syndrome Service (CLASS) in the United Kingdom. Where to Find the WebEx Presentation • Go to the KHS website at: ▫ www.kansashealthsolutions .org Click on the PROVIDERS tab (bottom left hand corner with the ball cap) On the next screen, click on the TRAINING button (left hand list about half way down) A side box will show, click on WEBEX Toward the bottom of the page look for RECENT WEBEX TRAININGS Click on the name of the WebEx you would like to view