Download Conflict of Interest

ASD Track: Overview of Two
Sessions
Mental Health Symptoms in
Individuals with ASD:
A Focus on Anxiety
Interventions
Judy Reaven, Ph.D.
Associate Professor of Psychiatry and Pediatrics
JFK Partners – University of Colorado
School of Medicine
[email protected]
Acknowledgements
► Organization for Autism
► Doug Flutie Foundation
► Cure
Research (OAR)
Control (CDC) – CADDRE
network
► JFK Partners – UCEDD – Grant #90DD0561
through the Administration on Developmental
Disabilities
► NIMH: #1R21MH089291
#1R21MH089291--01
► Children/Adolescents with ASD and their families
► CBT researchers
Colleagues/Trainees and
Research/Clinical Teams
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Audrey BlakeleyBlakeley-Smith, Ph.D.
Susan Hepburn, Ph.D.
Lila Kimel,
Kimel, Ph.D.
Meena Dasari,
Dasari, Ph.D.
Alison Galansky,
Galansky, Ph.D.
Brian Wolff,
Wolff Ph.D.
Ph D
Steven Shirk, Ph.D.
Kristina Kaparich
Kaparich,, MPH
Amy Philofsky,
Philofsky, Ph.D.
Rebecca Pohlig,
Pohlig, M.A.
Irene Drmic,
Drmic, M.A.
Megan Martins, Ph.D.
Amie Williams, M.A.
Jenni Rosenberg
Mary Hetrick
Conflict of Interest:
Royalties: Facing Your Fears: Group
Autism Now (CAN)
► Autism Speaks
► Centers for Disease
►
Session 1:
 Brief overview of ASD
 Specific learning strengths and needs
 General interventions for success – school/home
► Session 2
 Mental health symptoms that coco-occur with
ASD
 Overview of Facing Your Fears program for
Children with High
High--Functioning ASD and
anxiety (and their families)
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Shana Nichols, Ph.D.
Phil Kendall, Ph.D.
Joy Browne, Ph.D.
Erin Flanigan
Katy Ridge
Alison Herndon
Kathy CulhaneCulhane-Shelburne,
Ph.D.
Celeste St.John
St.John--Larkin, M.D.
Mark Groth
Samantha Piper, Ph.D.
Michelle Shanahan, M.S.
Lauren McGrath, M.S.
Eileen Leuthe
Leuthe,, Ph.D.
Eric Moody, Ph.D.
Therapy for Managing Anxiety in
Child
Children
with
ith HighHigh
Hi h-Functioning
F ti i
Autism Spectrum Disorders
www.facingfears.org
Clinical Disorders that Frequently
Co--occur with ASD
Co
► Neurobiological:
attention (ADHD), movement
and tic disorders, learning disabilities, abnormal
sensoryy responses,
p
, dyspraxia
y p
(motor
(
planning),
p
g),
intellectual disability, etc.
► Medical conditions: Genetic disorders, seizures,
sleep, GI issues, etc.
► Psychiatric: anxiety, depression, etc.
1
Mental Health Symptoms in ASD
► Full
range of psychiatric symptoms can be present,
although diagnosing can be hard
► Depression, anxiety disorders, ADHD
► 65% of Ss with Asperger’s had co
co--morbid
psychiatric diagnosis (Ghazudian
Ghazudian,, 1998)
► HFA vs. Asperger’s
Asperger’s—
—65% of HFA and 85% of ASP
met cutoff for “caseness
“caseness”” in behavioral/emotional
disturbance (Tonge et al. 1999)
► Med use in HFPDD
HFPDD—
—65% endorsed anxiety
symptoms and 32% endorsed depressive
symptoms (Martin et al. 1999)
Considering CoCo-Morbidity
► Severe
and incapacitating problem behavior
 aggression, selfself-injury, agitation, sleep
disturbance
► Presence of clear psychiatric symptoms
► Worsening
W
i off symptoms
t
already
l d presentt (change
( h
from baseline)
 decreased communication, increased
stereotypies, decreased selfself-care and adaptive
behavior
► If individual does not respond as expected to
treatment (Hendren,
Hendren, 2003)
Diagnostic Considerations for Assessing
Co--Morbid Conditions in ASD
Co
► “First
“First--line”
2000)
methods of evaluation
(Rush & Frances,
 Interview with family/caregivers (pay attention
to “intra
“intra--individual” changes)
 Direct observation of behavior
 Medical history and physical exam
 Functional behavior assessment
 Medication and side effects evaluation
 Unstructured diagnostic interview
Mental Health Symptoms in ASD
Anxiety coco-occurs in 77-84% of children/adults with ASD
(Lainhart,
Lainhart, 1999);
► Co
Co--morbid anxiety disorders occur in > 80% of children
with HFPDD ((Muris
Muris et al., 1998)
► PDD
PDD--NOS – 80% Axis I – Bruin et al. 2007; 55 % anxiety
disorders
► Autism
A ti
Co
CoC -Morbidity
M bidit Interview
I t i
– Present
P
t and
d Lif
Lifetime
ti
–
ages 55-17 ((Leyfer
Leyfer et al. 2006); 72% met criteria for Axis I
– most common:
 Specific Phobia – 44%
 Obsessive Compulsive Disorder – 37%
 ADHD – 31%
 Major Depression – 24%
►
Factors that Influence the
Prevalence/Incidence for Individuals with
ASD
► Psychiatric”
disorders vs. “behavioral”
disorders
► Psychosocial
y
masking
g of clinical symptoms
y p
(Fuller and Sabatino,
Sabatino, 1996)
► Diagnostic
overshadowing (Reiss et al. 1982)
of immunity” (Nugent, 1997)
► Primary or secondary conditions
► “Myth
Etiology of Mental Health
Conditions
► Increased
vulnerability
 Organic/biological
 Core Deficits of ASD
 Environmental (adverse life events)
► No
single etiology
biopsychosocial model (Griffiths,
Gardner, & Nugent, 1999)
► Utilize
2
Attentional Problems in ASD
► Prevalence
is unknown; 5% in general
population
► Easier to identify in HFA or AS although
misdiagnoses common
► Co
Co--occurrence between ADHD and ASD
 Genetic vulnerability
 Cluster of ASD, ADHD and motor difficulties
Mania in ASD
► Deterioration
in cognition, language, behavior or
activity
► Regulation of affect is difficult
► Clear pattern/onset of fluctuation or cyclicity in
activity
ti it or behavior:
b h i
(i.e.
(i increased
i
d silliness,
illi
distractibility, poor judgment, intrusiveness,
laughing, aggression, pressured speech,
noncompliance, and agitation) (Frazier et al. 2002)
► Family history of Bipolar Disorder
Depression in ASD
► Increases
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

in:
crying
self--injury
self
sleep disturbances
social withdrawal
ritualistic/obsessive behavior (content is depressive)
irritability
decrease in activity
loss of interest or regression in ADLs (Frazier et al. 2002;
Ghazudian, 2005)
ASD and Childhood Onset
Schizophrenia - Differences
► Originally
ASD thought to be an early
manifestation of COS
► Separate and distinct conditions more than 30
years ago
► Age
A off onsett and
d specific
ifi pattern
tt
off symptoms
t
indicate separate disorders
► Higher co
co--occurrences of Intellectual Disability and
seizure disorders in ASD
► Family history (Ghaziuddin, 2005; Green et al., 1992; Kolvin, 1971;
Petty et al., 1984)
ASD and Schizophrenia – Symptom
Overlap
► Pre
Pre--morbid
histories of COS:
 Neurodevelopmental concerns and delays
(language, motor and social)
 Documentation of early symptoms of PDD in
several studies of COS – 25% of COS sample
had PDD (Sporn et al., 2004)
 Marked social impairments in both disorders
make diagnostic process challenging
Common Anxiety Symptoms
► Difficulty
separating
from parents
► Marked and excessive
fearful responses
p
to
objects or events
► Persistent and chronic
worry
► Excessive avoidance
► Somatic complaints
► Presence
of distressing
thoughts
► Concentration
difficulties
► Restlessness
R tl
► Fatigue
► Irritability
► Sleep disturbance
► Physiological overoverreactivity
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Symptom Expression of Anxiety
in Youth
Youth with ASD
► Avoids
novelty
from
social situations
► Resists changes in
routines
► Prefers rules
► Narrow focus of
attention
► Insists on sameness
► Withdraws
safe
escape routes
► Increases repetitive
behaviors and/or
intensity of special
interests
► Becomes irritable
easily
► Becomes explosive
suddenly
Making the Case—
Case—
Why Study Anxiety in Individuals with ASD?

Prevalence
 Anxiety symptoms are very common in persons with ASD
(Bellini, 2004; Brereton et al. 2006; Leyfer et al. 2006),
 Greater than children with other DD (Gilliott
(Gilliott et al., 2001).

Impact
 Anxietyy interferes with individual’s functioning
g in home,, school,,
work and community activities (Russell & Sofronoff,
Sofronoff, 2005)

Persistence
 Without intervention, symptoms may continue across lifespan

Potential to treat
 Anxiety
Anxiety--related behaviors are treatable in persons without ASD
using CBT (Compton et al., 2004; Walkup et al. 2008)
 Promising findings for youth with ASD (Sofronoff
(Sofronoff et al., 2005;
Chalfant et al., 2007; Wood et al., 2008)
► Develops
Overview of Facing Your Fears
Treatment Package
Modifications for ASD
 Basic
CBT content is unchanged
►
Total Duration of treatment:
treatment: 14 weeks – 1 ½ hour per
session
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Modality: varied; children alone, parents alone, dyads
and large group work
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First seven weeks
weeks:: Define anxiety symptoms, identify
anxiety provoking situations, develop a set of “tools”
(relaxation, helpful thoughts, graded exposure)
 Integrated
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Second seven weeks: Identify goals and create stimulus
hierarchy, apply “tools” across settings, inin-vivo graded
exposure, video activity to reinforce core concepts
 Group
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Booster session:
session: 4
4--6 weeks postpost-treatment
 Modifications
based on the cognitive, linguistic
and social needs of children with ASD
social skills curriculum, not a
separate module
Modifications for ASD, Cont’d

Modifications in teaching basic concepts
 Prerequisite skills (i.e. ,feeling vocabulary)
 Written worksheets
 Multiple choice lists
 Drawing and other creative outlets
 Repetition and practice
 Video modeling
 Strength based
 Incorporation of special interest

Parent component critical
structure and management
Token reinforcement program for inin-group behavior
Visual structure and predictability of routine
Careful pacing of each group session
Components
► Define
Anxiety Symptoms
(enhance self
self--awareness)
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Increase emotion vocabulary
Establish common vocabulary
Identify anxious situations
Identify physiological symptoms
Emphasis on symptom intensity and
interference
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Child Treatment Components
► Establishing
a framework
(March & Mulle,
Mulle, 1998)
 Provide factual information about anxiety
(emphasizing physiological components)
 Externalize anxiety symptoms
 Compare “anxiety” time vs. “fun” time
 Child, family, therapists and school staff all on a
team to manage anxiety
 Child strengths emphasized—
emphasized—identity expanded
beyond “anxious child”
Child Components continued
► Introduce
tools to manage symptoms
 Fine tune selfself-awareness of anxiety
 Attend to selfself-statements; substitute positive coping
thoughts
 Getting a handle on somatic symptoms—
symptoms—introduce
relaxation and other calming activities – broadened
concept
 Develop a list of calming activities and SCHEDULE
 Introduce stressstress-o-meter
Child Components continued
► Psychoeducation
Psychoeducation::
 “Active” minds (Garland & Clark, 1995)
vs. “Helpful thoughts”
 Establish the circular connection
between physiological reactions,
thoughts, and somatic response
Chansky, 2004)
 Worry’s “false alarm” (Chansky,
 Establish basic principle that
anxious feelings will pass
Teaching Emotion Regulation:
Plan to Get to Green
► Develop
a specific plan for when children
are in the “red” zone
► Move one step at a time (e.g., 8
8--7; 7
7--6; 6
6-5,
5 etc.)
etc )
► Establish child preferences for moving out of
“red” zone
► Avoid problem solving when child is in “red”
► Create reward program for using strategies
and staying in “green”
Child Components continued
► Creating
“Steps to Success”
 List anxiety provoking situation
 Rank order the situations from 1
1--8
 Choose situations that are mild
mild--moderately
stressful
st essf l
 Generate strategies for facing fears
 Practice graded exposure in session
 Encourage self
self--evaluation and
self--reward
self
► Write an Episode of “Facing Your
Fears”
VIDEO
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Facing Your Fear Videos
Public Bathrooms
Toilets Flushing
Spiders/bees
Elevators
Upper classmen
Ugly leaves
Tornados
School buses tipping over
Going outside
Going to Highlands Ranch,
CO
► Choking
► Making mistakes
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The dark
Mice/rodents/snakes
Talking to people
Losing things
Scary movies
Getting the flu
Playing new sports
activities with other kids
Staying home alone
People who look different
Change
FYF Adolescent Components
►
Increase awareness of the signs and symptoms of anxiety,
emphasize the connection between cognitions and
physiological responses to anxiety
Face Your Fears: Parent Component
► Promote
support among participants
psycho--education about anxiety
psycho
disorders; learn the basic tenets of CBT
► Establish targets
g
for graded
g
exposure
p
tasks
► Model brave behavior
► Encourage/reward brave behavior in their
children
► Discuss parental anxiety and parenting
style
► Provide
Functions of the PDA/iPod Touch
► Monitor
►
Create “tools” to manage symptoms—relaxation and
cognitive restructuring
► Remind
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Social skills module
► Guide
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Establish a fear hierarchy and teach adolescents to “face
fears” a little at a time (graded exposure)
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Include parents
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To incorporate technology (i.e. PDA/iPod Touch)
Examples of Teen Exposure
Hierarchies
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Heights
Spiders – going into the basement alone
Going to local places independently
Telling teachers about the ASD diagnosis and asking for
help
Gi i orall presentations
Giving
t ti
in
i school
h l
Going to public high school
Talking with unfamiliar people
Inviting others to get together
Loud noises – car alarms, vacuums
Talking on the telephone
Talking with parents about sensitive topics
Preparing for the driver’s license test
Tolerating changes/when others make mistakes
anxiety symptoms on a regular basis
the participants to engage in
relaxing/calming activities
participants through steps they can take
when faced with a challenging situation
► Document
► Provide
exposure practice
information regarding progress
► SymTrend
Face Your Fears: Oral Presentations
Exposure Steps Completed in
Group
Number of
People
Observing
14
Deliver a powerpoint to familiar and
unfamiliar adults
Deliver a powerpoint to familiar peers 10
and adults
Deliver a powerpoint to familiar peers 5
(e.g., fellow group participants)
Practice delivering powerpoint
0
presentation on a preferred topic
out loud at home
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JFK Treatment Program for Anxiety and
ASD – Brief Overview
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RCT: Follow
Follow--up Data
Outpatient clinical work
Case study (Reaven & Hepburn, 2003)
2003)
Initial group treatment study (Reaven et al. 2009)
2009)
 Parents reported sig reductions in anxiety (n=33)
Randomized trial ((Reaven et al. 2012)) (n=50)
(
)
 Parents reported sig reductions in anxiety severity (CSR)
 Global improvement (50%); reduction in # of dx & GAD
Adolescent pilot study (under review) (n=24)
 Sig global improvement (46% positive improvement);
decreased problem behavior
Telecopes (Susan Hepburn, Ph.D. PI)
FYF – A School Based Study
Concluding Thoughts
► Children
and teens with highhigh-functioning
ASD are psychiatrically complex
► Group
treatment for youth with ASD may
be a feasible and acceptable treatment
► Modified
CBT may be effective in reducing
anxiety symptoms in youth with highhighfunctioning ASD
Limitations/Future Directions
► Small sample size
► Lack of attention control
group
a randomized trial for teens with ASD
► Improve measurement strategies for psychiatric
assessment and outcome
► Examine follow
follow--up data
► Further examine potential moderators of
treatment response
► Train other sites to deliver FYF intervention
(Halifax, Birmingham, Cincinnati, Chapel Hill,
and Baltimore)
► Conduct
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