Autism and Trauma: The Need for Good Diagnostics and Care in the design of Treatment Lawrence R. Sutton, Ph.D. Corrine Garland, MA

Transcription

1 Autism and Trauma: The Need for Good Diagnostics and Care in the design of Treatment Lawrence R. Sutton, Ph.D. Corrine Garland, MA Muson Centre Onikan, Lagos, Nigeria, Africa July 1, 2015

2 A program to improve Catholic religious education and family life for individuals with autism

3 Introduction Who are we: Lawrence Sutton Corrine Garland

4 Introduction A complicated topic with little evidenced based work to determine how prevalent it is or to judge how to proceed Defining terms: What is Autism What is Trauma What makes a good evaluation treatment plan What makes treating trauma in someone with ASD so much more difficult

5 Treating trauma and autism Why is it a problem? Reacting to an event versus serious sensory overload Witnessing trauma event Sexual trauma Bullying No best practice method for addressing trauma with someone who has ASD

6 Autism CDC estimates that about 1 in 50 (more recently 1 in 66) children has been identified with an autism spectrum disorder (ASD). Doctors look at the child s behavior and development to make a diagnosis. ASD can sometimes be detected at 18 months or younger. By age 2, a diagnosis by an experienced professional can be considered very reliable.

7 What is Autism? Developmental disorder onset as a toddler and it s Life long Noted impairment Language and communication Social play, talk and interactions as well as understanding (Repetitive) Behavioral and Sensory problems

8 Sutton s idea of a good evaluation for autism A Good evaluation for autism requires opinions/evaluations and information from a multidisciplinary team including: Parents Psychologist Language Pathologist (experienced with ASD) Occupational Therapist (for sensory issues) Behaviorist Others: Psychiatrist, Audiologist, Neuropsychologist

9 Autism Spectrum Disorders DSM-V - the rules are a bit different A. Persistent deficits in social communication and social interaction across multiple contexts, manifested by the following, currently or by history B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history

10 Autism Spectrum Disorder C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities; or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

11 What Is Autism? Language Impairments Difficulty understanding tone the teacher always yells at me Do not understand facial expressions Do not process people, just attributes Doesn t use non-verbal language or cues.

12 What Is Autism? Social Impairments Individual play and leisure time is often by themselves, or with younger children or by their rules only. Lack of social sense boundary concerns, social etiquette, doesn t recognize when others are done Difficulty with empathy and other emotions Demonstrate very concrete understanding

13 What Is Autism? Behavioral/Sensory Impairments Tantrums Repetitive behaviors Fears/Phobias Stims Picky eaters Sensitivity to touch, smell, texture and sounds

14 Trauma The American Psychological Association (APA) defines trauma as an emotional response to a terrible event such as an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer-term reactions include unpredictable emotions, flashbacks, strained relationships and even physical symptoms like headaches or nausea (APA, 2014)

15 Trauma Trauma can occur in many different ways. Some specific types of trauma categories are: community violence, complex trauma, domestic violence, early childhood trauma, medical trauma, natural disasters, neglect, physical abuse, refugee/war zone trauma, school violence, sexual abuse, and traumatic grief (Briere, 2006).

16 Trauma Complex psychological trauma results from exposure to severe stressors that are: 1) repetitive or prolonged, 2) involve harm or abandonment by caregivers or other ostensibly responsible adults, and 3) occur at developmentally vulnerable times in the victim s life such as early childhood or adolescence (Ford, 2009).

17 Trauma and PTSD The core features of PTSD consist of: 1) the "stressor criterion" that defines the etiologic event and 2) the set of symptoms that defines the characteristic PTSD syndrome: (a) reexperiencing the trauma, (b) numbing of responsiveness or avoidance of thoughts or acts related to the trauma, and (c) excess arousal (Breslau et al., 1998).

18 Trauma and PTSD The DSM-5 presents diagnostic criteria for PTSD as: A history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters (APA, 2013). These four clusters are (1) intrusion, (2) avoidance, (3) negative alterations in cognition and mood, and (4) alterations in arousal and reactivity.

19 Trauma and PTSD and Acute Stress PTSD and Acute Stress Disorder (another diagnosis associated with trauma) which is characterized by the development of severe anxiety, dissociative, and other symptoms that occur within one month after exposure to an extreme traumatic stressor.

20 Autism, PTSD and Acute Stress Individuals with Acute Stress Disorder may experience difficulty concentrating, feel detached from their bodies, experience the world as dream-like, or have difficulty recalling specific details of the traumatic event (dissociative amnesia).

21 Trauma Symptoms Trauma symptoms can be presented in many different ways and manifest themselves both internally and externally. Some behavioral symptoms and signs of trauma are excessive temper, aggression, regressive behavior, imitation of the traumatic experience, excessive crying, being easily startled, being withdrawn, somatic symptoms (stomachaches and headaches), sleep disturbance, and nocturnal enuresis (National Child Traumatic Stress Network, 2014).

22 Trauma Symptoms Trauma symptoms may also present themselves as emotional difficulties such as, recurrent recollections of the stressor, distress, fear, helplessness, loss of interest in previously enjoyed activities, detachment, guilt, emotional numbing, and low self-esteem (Mental Health Association New York State, 2014).

23 Trauma as Seen in Individuals With Autism Those with developmental disabilities are two times more likely to become victims of trauma than their typical peers. 18.5% of children with Autism had been physically abused, and 16.6% sexually abused. Mandell 2005 In my criminal justice study of incarcerated autistic teens, 90% were sexually assaulted before they committed their crime

24 Trauma as Seen in Individuals With Autism The Mandell study showed that physically and sexually abused children more likely had engaged in sexual acting out or abusive behavior themselves. These children also more likely had made a suicide attempt or had conduct-related or academic problems compared to those who had not experienced physical or sexual abuse

25 Autism and Trauma This is even more problematic for individuals with Autism who experience communication deficits. These deficits can cause trauma events to go unreported, or even unrecognized by those individuals.

26 Autism and Trauma Eelson 2010 noted symptoms typically attributed to Autism, such as self-stimulatory behaviors, self-injurious behaviors, and stereotypic or repetitive behaviors may intensify after a traumatic event as a way to cope or self-soothe. the effects of sexual abuse in particular, in individuals with developmental disabilities may be exacerbated by social isolation and alienation (Edelson, 2010).

27 Traditional Trauma Treatment Trauma-focused CBT involves direct discussion about the trauma, imagining or visualizing the traumatic event, and implementing stress management and coping techniques (Cohen, Mannarino, & Deblinger, 2012). This is usually accomplished through the use of thought interruption and replacement techniques, the utilization of self-affirming statements, and overall cognitive reframing (Cohen et al., 2012).

28 Traditional Trauma Therapy The importance of working through the trauma narrative is also extremely important in TF-CBT. The trauma narrative takes on an autobiographical approach that helps the client work through the specific trauma that they have experienced.

29 Limitations of CBT of Trauma in Those with Autism First, children with Autism have a reduced ability to recognize thoughts and feelings in both themselves and others (otherwise known as perspective taking). This proves problematic because it obstructs the introspection required by CBT to replace one s own thoughts and to participate in cognitive reframing.

30 Limitations of CBT of Trauma in Those with Autism Second, these individuals typically experience language and social skills deficits that may impede the formation of therapeutic relationships and the communication of complex or abstract concepts (Lang et al., 2009). It is important to remember these possible obstructions in traditional therapies when working with an individual with Autism who is also suffering from PTSD.

31 Treatment of Trauma in Those with Autism It is important to integrate known therapeutic interventions for Autism into trauma therapy. These include visual aids, social stories, associating emotions with tangible objects, coping strategies that do not require the use of abstract language, the use of alternative communication modes (i.e.: drawings), embedding perseverative interest topics into therapy sessions, and teaching social skills (Lang et al., 2009).

32 Social Stories One way to modify traditional trauma therapies is through the use of. Social Carol Gray NASP recommends, Many students with autism can be helped to comprehend behavior they observe but poorly understand through the use of social stories. The parent or teacher s explanation of what is happening can be reduced to a social story.

33 Social Stories A storybook can then be kept by the child to help reinforce the information on a concrete, basic level (NASP, 2002). Each social story utilizes four types of sentences; descriptive, perspective, directive, and affirmative. These sentences provide the basis for the story and allow it to be educational and therapeutic (Gray, 2010).

34 Comic Strip Conversations Comic Strip Conversations promote social understanding by incorporating simple figures and other symbols in a comic strip format. An educator can draw or assist a student who illustrates a social situation in order to facilitate learning (Gray, 2010).

35 Comic Strip Conversations Utilizing Comic Strip Conversations allows the therapist to employ the use of visual aides to interest the client and allow them to creatively design their own narrative from their perspective. This is especially beneficial for the use with individuals with autism, due to its reliance on a visual and hands-on modality.

36 Treatment Autism and Trauma Before Making of a Plan Identification from a confederate Symptoms as described by a confederate Any identifiable triggers Changes Appetite Sleep Relationships Self-abuse/tantrums

37 Summary Trauma Before making of a plan What treatments have been attempted Behavioral Medicine What is caregiver concerned about Or what are your goals/wishes (are they real) Then begin slowly; very slowly

38 Summary Trauma Treatment with Autism Prior to treating the child with autism: 1. make a plan on what treatment would include 2. outline first steps in the trauma story and begin with as simple social story or comic strip story as possible 3. Review plan with confederate 4. Outline plan with all caregivers and other treatment and educational personnel to alert them to possible changes that the child might undergo when treatment begins.

39 Summary Trauma Treatment with Autism Slowly then begin with either the first frames of Comic Strip or beginning of social Carol Gray by: Having the child color in the frame/story Then the therapist begins with a frame. Go slowly, the child will likely react with some sort of sensory overload When overload starts you stop and: Conclude with a warm down something soothing for the child

40 Summary Trauma Treatment with Autism Sessions will be slow and many NEVER push through, if you push too hard, the child may need urgent help or to be hospitalized If you push too hard the child may become too scared (to continue with you or at all) ONLY an EXPERIENCED TRAUMA THERAPIST who has FAMILIARITY with Treatment of children/adults with Autism should EVER attempt this work.

41 Conclusion Overall, the implementation of a social stories@ Carol Gray and Comic Strip Conversation on trauma-focused intervention for individuals with Autism, could be extremely efficacious on the autistic child who has experienced trauma. This type of intervention could prove to be extremely beneficial for autistic children if done correctly

42 Conclusion Remember, there is NO best practice for helping an autistic child or adult work through a trauma ONLY an experienced clinician in trauma therapy who is also experienced in working with autistic children and/or adults should EVER attempt this therapy. It is critical that ongoing supervision of the therapy occur while it proceeds and it is critical that the family and confederate be involved in treatment

43 Thank You Lawrence Sutton, Ph.D. Corrine Garland, M.A.