Understanding emotions and behaviour in Autism and Asperger s s Disorder

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1 Understanding emotions and behaviour in Autism and Asperger s s Disorder Dr Avril V. Brereton Prof Bruce J. Tonge Monash University Centre for Developmental Psychiatry & Psychology

2 Do children with HFA and AD have emotional problems? A number of studies have been conducted. All have found increased anxiety and depression in children with Autism and AD compared to other children Recent study at Monash University has followed 110 children with autism and their families for the past 10 years

3 Autism: Behavioural and Emotional Disturbance Over Time Bruce Tonge 1, Avril Brereton 1 Stewart Einfeld 2, David Moseley 1 John Taffe 1, Kylie Gray 1 & Emma Lourey 1 1 Monash University, Centre for Developmental Psychiatry & Psychology 2 University of New South Wales, School of Psychiatry National Health & Medical Research Council of Australia

4 DEPRESSION DEPRESSED CRIES IRRITABLE LOW SELF ESTEEM

5 DEPRESSION T1 14% - Autism with depression 9% - non-autism with depression

6 DEPRESSION T1 T2 T3 T4 Autism Non-austism Scores significantly higher (p <.001) for autism. No significant effect of gender or level of ID

7 ANXIETY SEPARATION ANXIETY FEARS / PHOBIAS TENSE / WORRIED

8 ANXIETY T2 15% - Autism with anxiety 7% - non-autism with anxiety

9 ANXIETY T1 T2 T3 T4 Autism Non autism Scores significantly higher (p <.001) for autism. No significant effect of gender

10 TYPE OF PHOBIA IN AUTISM Noise 48% New 13% Environment 12% Doctor / Dentist 15% Animals / insects 12% Haircuts / sticky surfaces / T.V. programs

11 Co Morbidity AUTISM EPI Depression % Anxiety % Depression % Anxiety % ADHD Depression

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13 Why? Let s s consider the features of High Functioning Autism and AD

14 3 Core problems in Autism Abnormal language development Abnormal social development Restricted, rigid & repetitive patterns of behaviour and interests

15 High Functioning Autism High functioning refers to the level of cognitive ability. IQ >70 (no Intellectual Disability) NOT a mild form of autism NOT Asperger s s Disorder

16 Asperger s Disorder High-functioning Autism Intact language development Social impairment Stereotyped / Repetitive behaviour Clinically significant language delay

17 Communication Problems in AD language acquisition follows normal/accelerated pattern but content of speech is pedantic little facial expression inappropriate tone of voice, monotonous intonation good verbal memory skills, absorb facts easily poor social comprehension despite superior verbal skills

18 Social impairment in AD highly anxious with a dislike of any form of criticism are seen to be odd or eccentric,, impaired in acquiring & retaining social knowledge impairment in two - way social interaction with an inability to understand the rules governing social behaviour, may be easily led impairment in joint attention victims of teasing and bullying in mainstream setting difficulties remembering who people are but remember events/statements

19 Cognitive characteristics lead to difficulties with: Cause & effect relationships Focus on details Sequencing Understanding of time Compulsiveness Distractibility anxiety and stress at school, home & in community

20 Emotional & behavioural problems Approaches to treatment

21 Do you know about each child s - learning style - the impact of core processing problems on his/her behaviour and emotions? Find out by asking yourself and others these 10 questions!

22 1. What are the child s s strengths, weaknesses & emerging skills? Cognitive (IQ) assessment 2. Any particular areas of interest or talent? 3. Does the child understand cause and effect relationships? 4. Is the child easily distracted? List 5. Does the child recognise when a task is finished?

23 6. What does the child remember easily? What s difficult to remember? 7. How does the child like to know what s s coming next? 8. Does the child adapt to new situations easily? 9. How does the child respond to being wrong/corrected? 10. What does the child do when confused or anxious?

24 General Help parents - education and skills training Improve communication (visual augmentation) Reduce and plan for change Reward achievement Improve social skills (social stories, comic strip review, role play) Schedule and expand activities of interest

25 Social Stories Carol Gray A Social Story describes a situation, skill, or concept. The goal of a Social Story is to share accurate social information in a reassuring manner that is easily understood by the child. This strategy aims to improve the child's understanding of events and encourage appropriate behaviour.

26 Social stories: from the child s s perspective Meaningfully shares social information Answers wh questions and uses positive language Always contains descriptive sentences. May also include perspective, cooperative, directive, affirmative, and/or control sentences. Has a format that is tailored to the abilities and interests of the child Includes individually tailored illustrations/photos that enhance the meaning of the text.

27 Depression Parent education and well being Reward achievement Promote self esteem (success activities, social stories) Modified CBT (positive thoughts, comic strip review, schedule pleasant events) Antidepressants (fluoxetine)

28 Anxiety Define stressors Modify environment Parent education and well being Modified CBT (e.g. relaxation exercises, role play, graded exposure to fears) Stress debriefing (e.g. social stories) Anxiolytics (SSRIs, Imipramine, Buspirone, Neuroleptics)

29 I feel anxious and worried when I am in a new place I don t know the answer to a question There are a lot of people around me I lose my things Too many people talk to me I don t know what to do When I am anxious and worried I Feel hot and sweaty Feel my heart beating fast Feel like I have to go to the toilet Feel like hiding somewhere My hands sweat Feel like I want to hit someone or break something

30 A pocket sized reminder card When I m worried or upset I can Ignore the person or thing upsetting me. Count to 10 and take deep breaths Walk way Find a teacher Talk to a friend Ask my friends to explain what is happening Use the power of my voice to tell someone how I feel

31 ADHD Developmentally excessive : Inattentiveness Distractibility Hyperactivity Impulsiveness

32 ADHD Schedule staged activities with visual prompts Reduce distractions Interact to scaffold activities Medication stimulants (short long acting) - Atomoxetine - Clonidine - Imipramine - Neuroleptics (haloperidol, risperidone)

33 PHARMACOTHERAPY Attention Deficit Hyperactivity symptoms. Stimulants (dexamphetamine, methylphenidate ). TCA s s ( imipramine in typical children, 20-50mg/day). Naltrexone Atomoxetine, novel, effective in typical children.

34 PHARMACOTHERAPY Attention Deficit Hyperactivity symptoms. Stimulants (dexamphetamine, methylphenidate ). 10+ double blind cross-over over trails N=10-30 in ID/autism 6. Dose mg/dose. 0.6mg/dose. Reduces hyperactivity, inattention & impulsiveness but less than for typical children. Higher risk of side effects: irritability, withdrawal, tics, insomnia. Teachers report more benefit than parents.

35 PHARMACOTHERAPY Frustration, Rage, Aggression, Disruptive Behaviour and Withdrawal. Neuroleptics :risperidone is the drug of choice. Naltrexone : may reduce self-injurious behaviour and hyperactivity. Parenteral, short-term term use. Anti-convulsants : some evidence for valproate & carbamazepine but not lamotrigine. Lithium :single case studies in adults with ID & autism.

36 What s s going on? A case study

37 DBC-P (parent / carer version) 96 items (95 + overall ) Within the past 6 months Scored 0, 1, 2 0=not true as far as you know 1=somewhat/sometimes true 2=very true/often true

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39 DBC-T (teacher version) 93 items DBC-P P sleep disturbance items removed Item added unpopular with other children

40 Scoring Add up scores to calculate: 1. Total Behaviour Problems Score (TBPS) 2. Scores on 5 factors

41 Subscales 5 subscales Disruptive / Antisocial Self-Absorbed Communication Disturbance Anxiety Social Relating

42 DBC case study 10 year old boy Autism Moderate intellectual disability Tourette s s syndrome

43 Teacher report Past few weeks sudden change in behaviour: Mood swings for no apparent reason Variable performance from day to day Suicidal thoughts and comments ( If( I jumped off a bridge no one would care ) Tics worse head shaking, shoulder shrugging, grimacing, throat clearing Difficult classroom behaviour non-compliant, refusal to work, not involved in any group activities

44 Parent report Not eating Not sleeping Tics worse Huge tantrums over changes in routine Renewed his old obsession with a collection of wood off cuts (slept with them in a case, never out of his sight)

45 Workup How to make sense of this range of emotional and behavioural problems? Initial discussion with teacher and parents. Neither could identify any precipitating events at school or home other than some disruption to routine because of ongoing extensions to the house

46 Workup DBC was completed by parents and teacher : high TBPS high score on social relating subscale (worsening of autism symptoms e.g. social avoidance, resistance to change, obsessions) very high score on anxiety subscale

47 Workup Consultation with child psychiatrist - What was making Sean so anxious? Why the return to earlier autistic behaviour? Draw a dream revealed this

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49 Treatment Home: Discussion with parents cause of his regression was grief and confusion about the death of his cousin. Took him to the grave, photographs of cousin in his room, visits to the cemetery with flowers whenever he wanted School: Discussion with teachers (as above). Integration aide discussion about what had happened during his 1:1 sessions with her instead of work when he wanted

50 Outcome After 4 weeks of treatment Sean came back to the clinic. DBC TBPS score reduced no longer an elevated anxiety score reduced social relating score

51 Some people go to hospital when they are sick. Nathan was at the hospital. He can t get fixed but other people can.

52 New collection: A first aid kit!

53 For more information about Autism visit our website research/devpsych/actnow/project.html Or just Google ACT NOW Monash