Anxiety and High Functioning Autism or Asperger Syndrome

1
Anxiety and High Functioning Autism or Asperger
Syndrome

• Dr Kate Sofronoff
• School of Psychology
• The University of Queensland

2
Prevalence

• Research shows that about 85 of children with
  high functioning autism or Asperger syndrome
  experience significant anxiety
• Adults report that they continue to experience
  debilitating anxiety
• Source of anxiety may be different for each
  individual
• Performance issues
• Uncertainty
• Bullying
• Sensory issues
• Specific fears/phobias
• Social fears

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Presentation

• May present as a typical fear
• Fear of the dark
• May present as frustration and irritation
• Irritated by a change in timetable at school
• May present through non-compliant behaviour
• Refusal to leave the classroom at lunchtime
• May present as another disorder
• encopresis
• May not be diagnosed or treated at all
• Part of the ASD
• Seen as a behaviour problem

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Why Treat Anxiety if it is Part of Asperger
Syndrome?

• It is not a phase and will not go away on its own
• Emotional regulation is necessary if we want
  better outcomes for the child
• Anxiety may cause other dysfunctional behaviours
• Need to treat the cause not result if possible
• Anxiety will increase and exacerbate rigid and
  inflexible behaviours
• Can become extreme and debilitating in
  adolescence
• Risk for alcohol and/or substance abuse
• BECAUSE WE CAN!

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Managing AnxietySofronoff, Attwood Hinton
(2005). Journal of Psychology and Psychiatry and
Allied Disciplines, 46, 1152-1160.

• Program developed by Tony Attwood
• Exploring Feelings
• Multiple Randomised Controlled Trials at UQ
• Current trial in UK
• Six 2 hour sessions 3 children with 2
  therapists
• Trial evaluated child only, child parent and
  wait-list control
• Wanted to evaluate the importance of parent
  involvement
• Child parent condition showed best results
• Parents also much preferred to be involved even
  though more effort for them

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Using Cognitive Behaviour Therapy

• CBT needs to be modified to accommodate the
  profile
• Do not use a program developed for typical
  children
• Teach about emotions
• Use visual aids to work through scenarios
• Use concrete methods to demonstrate degrees of
  emotion
• Incorporate meaningful analogies
• special interest if possible

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Teaching About Emotions

• More psychoeducation than with a typical child
• will often enjoy acquiring new information
• Physiological responses
• use visual aids such as rope or thermometer to
  demonstrate variations
• start with positive emotions
• increase vocabulary related to emotions in a
  meaningful way
• Pictorial hierarchy

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Happiness

• Happiness diary (Attwood, 2003)
• personalized record that the young person can
  create
• used to repair negative feelings
• concrete example that the child or adolescent has
  good things in their life
• may work better than positive self talk because
  it is visual and concrete

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Emotional Toolbox

• The program deals with each of the different
  types of tools in detail
• physical tools
• relaxation tools
• social tools
• thinking tools
• other tools
• inappropriate tools
• Each childs toolbox is individual

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Creative Use of Strategies

• Teach and insist on compromise
• Teach the concept of time
• Teach the concept of schedules and diaries
• A daily board of events can be used - good visual
  cues - use pictures if helpful
• A calendar with clearly defined weekends
• A picture schedule of jobs to be done for the
  week

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Adapting to Changes

• When a change is to occur warn the child and use
  written and visual cues to illustrate the change
• Put the change in context on the board of the
  days events
• Grandma coming to visit
• Plain clothes day at school
• Excursion at school
• Going on holiday

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Difficulties with Literal Interpretation

• You may need to explain that phrases such as
  these are just a figure of speech
• walk on ahead
• he changed his mind
• I caught his eye
• Its time to toast the bride
• In some cases a social story can be used
• You can turn it into a game - ask the child to
  guess what some of these phrases mean
• You can write short situations to illustrate when
  a figure of speech may be used

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Social Stories

• A child with Asperger syndrome can appear to lack
  social common sense
• Some will think them rude
• They can, however, learn what to do if someone
  provides the appropriate explanation
• A Social Story can provide that explanation
• It does not tell them what to do in a
  prescriptive manner
• The story is written for the individual child in
  order to explain and describe a specific social
  situation in terms of the social cues that are
  relevant, the actions that are expected, and
  information on what is occurring and why it is
  occurring. It allows the child access to social
  understanding of a specific situation.

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Changing Ones Mind

• Sometimes a person says Ive changed my mind
  (descriptive)
• This means they had one idea but now they have a
  new idea (persective)
• Or they said they were going to do something but
  now they are going to do something else
  (perspective)
• It is usually okay to change your mind as long as
  you let people know (perspective)
• I will work on staying calm when someone changes
  their mind (directive)
• When someone says Ive changed my mind, I can
  think of someone writing something down,
  scratching it out and writing something new
  (control)

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Antidotes to Poisonous Thoughts

• Antidotes to Poisonous Thoughts (Attwood, 2003)
• identify negative thoughts
• what purpose do these serve?
• Can we develop antidotes to these?
• What would they be?
• When can they be used?
• Using an analogy that is accessible to the child

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Results From the Program

• Significant improvement reported by parents on
  measures of anxiety
• Child Parent group superior to Child Only Group
  and both intervention groups superior to
  Treatment as Usual
• Significant increase in knowledge of how to
  manage anxiety by child report
• Qualitative information from parents very useful

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Social Worries

• main effect for Time
• F2,78 13.82, plt.0001
• no main effect for Group
• Time x Group Interaction F4,15814.15, plt.0001
• Post hoc tests
• Intervention groups showed
• significantly lower parent
• ratings between T1 and T3
• Difference between
• intervention groups at T3
• approached significance
• Both interventions different
• from wait-list at T3

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Separation Anxiety

• main effect for Time
• F2,78 13.69, plt.0001
• main effect for Group
• F2,78 5.24, plt.01
• Time x Group Interaction F4,15810.65, plt.0001
• Post hoc tests
• Intervention groups reported significantly lower
  parent ratings at T3
• Difference between intervention groups at T3
  significant

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Obsessive Compulsive Symptoms

• Main effect for Time F2,78 16.69, plt.0001
• No main effect for Group
• Time x Group Interaction F4,15810.13, plt.0001
• Post hoc tests of simple interaction effects
• Both intervention groups significantly lower at
  T2 and T3 compared with T1
• Intervention groups reported significantly lower
  parent ratings compared with WL at T3
• No difference between intervention group 1 and
  control at T2

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James and the Maths Test

• main effect for Time
• F2,78 104.76, plt.0001
• main effect for Group
• F2,78 38.19, plt.0001
• Time x Group Interaction F4,15828.31, plt.0001
• Post hoc tests
• Both intervention groups significantly higher at
  T2 and T3 compared with T1
• Intervention groups significantly different from
  waitlist at T2 and T3
• Intervention groups significantly different from
  each other at T2 and T3

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Conclusions

• Intervention demonstrated effectiveness in
  changing some behaviours for some children
• Parents very positive about the groups
• Many children made friends
• Many parents formed support groups
• Greater parent involvement led to better outcomes

• Intervention too short for some children
• Many changes not captured by measures
• Population likely to benefit from ongoing contact
• Excellent training opportunity for students
• Are there more effective and less resource
  intensive means of disseminating the
  intervention?

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Program Developments

• Program used with teens with ASD who were lower
  functioning cognitively
• Removed all reading and worked through concrete
  examples and rehearsal
• Program used by parents trained in two workshops
• Program undergoing evaluation in UK
• Adding a pre-intervention session
• Program will be offered in 2010 at the psychology
  clinic at UQ
• We need a program for adolescents and adults

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Questions?

• Kate Sofronoff
• School of Psychology
• University of Queensland
• kate_at_psy.uq.edu.au