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A brief introduction to common mental health problems in people with an ASD
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Mental health issues
Digby Tantam
Ciccarelli, O., Catani, M., Johansen-Berg, H., Clark, C., & Thompson, A. (2008). Diffusion-based tractography in neurological disorders: concepts, applications, and future developments. [doi: DOI: 10.1016/S1474-4422(08)70163-7]. The Lancet Neurology, 7(8), 715-727.
Sahyoun, C. P., Belliveau, J. W., & Mody, M. (2010). White matter integrity and pictorial reasoning in high-functioning children with autism. Brain And Cognition, 73(3), 180-188.
Alter Ego
Further information
Contagious emotion (STS/ DLPFC)
Agency (temporoparietal
junction)
Fight/ care-taking ?
amygdala
Narrative
Emotional dispositions/ cingulate
Autism spectrum disorder, DSM5 criteria
A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:
1. Deficits in social-emotional reciprocity
2. Deficits in nonverbal communicative behaviors used for social interaction
3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers)
B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:
1. Stereotypies 2. Routines and rituals 3. Special interests 4. Hyper-or hypo-reactivity to
sensory input or unusual interest in sensory aspects of environment
Impaired social communication and social interaction (DSM-5)
Restricted repetitiveness (DSM-5)
Language impairment
Autistic syndrome
Enter the other’s world, but do not expect intersubjectivity Be aware of the importance of the past and look for commemorative activities Provide predictability (may achieve this through behavioural means e.g. ABC approach) Be aware that anxiety—and frustration– may not be expressed Do not assume that a lack of social interaction is a lack of interest Value peer support 22
May 2012
RSM
Impaired social communication and social interaction (DSM-5)
Restricted repetitiveness (DSM-5)
Language impairment
Autistic syndrome
Consider sameness to be a means of achieving comfort through predictability An increase in repetition may indicate anxiety An appropriate balance must be struck about how much comfort is appropriate Rituals may be commemorative and acts of iImaginative reconstruction that are open to involvement and modification by kindly others Special interests provide quality of life OCD and hoarding involve an additional element of folie de doute, or warding off Rituals may come to be weapons
22 May 2012
RSM
Impaired social communication and social interaction (DSM-5)
Restricted repetitiveness (DSM-5)
Language impairment
Autistic syndrome
Language, verbal IQ, and intellectual disability are correlated Alternative means of communication may be useful People with ID may develop simplifying concepts that can be effective tools e.g. the open and closed face Written language may sometimes be more comprehensible Processing may take longer, but get there in the end Apparent verbal fluency may be deceptive: it’s understanding not language that matters Psychotherapy may be a matter of connecting the dots…
22 May 2012
RSM
Impaired social communication and social interaction (DSM-5)
Restricted repetitiveness (DSM-5)
Intellectual disability
Language impairment
Epilepsy
ADHD
Associated conditions
Tourette, dyspraxia, agnosias
Learning from the EE literature Understanding impersistence Cueing attention Dysexecutive Autistic syndrome How does Dad handle it?
22 May 2012
RSM
Anxiety-related disorder
Impaired social communication and social interaction (DSM-5)
Restricted repetitiveness (DSM-5)
Intellectual disability
Language impairment
Epilepsy
ADHD
Consequential conditions
Victimization
Marginalization
Tourette, dyspraxia, agnosias
Sensory issues, Information overload, melt downs
The search for the self
Meltdowns are catastrophic reactions. They can only be prevented when tension Is at an early stage but may then be unrecognizable unless individual prodrome is known A sensory assessment may be helpful, but should Include information demands
22 May 2012
RSM
Impaired social communication and social interaction (DSM-5)
Restricted repetitiveness (DSM-5)
Intellectual disability
Language impairment
Epilepsy
ADHD
Consequential conditions
Victimization
Marginalization
Tourette, dyspraxia, agnosias
Sensory issues, Information overload, melt downs
The search for the self
The risk of a person with an ASD being bullied is 7 times greater relative to the risk of a neurotypical child of the same age
Anxiety-related disorder
22 May 2012
RSM
Consequences of bullying • Passive failure to be
included • Reduced use of
community resources (social exclusion)
• Experience of being unwanted/marginalized
• Active rejection , blaming, scapegoating • Stigma as a means of
keeping threatening Other at a distance
• Bullying
Painted Bird by Edward Gafford, inspired by the novel ‘Painted Bird’ by Jerzy Kosiński, itself based on what has been claimed is a fictive war-time experience of the author in Poland
The limitless potential of social control by shaming
• A particularly wide ranging tool kit
• Readiness to consider the most intense emotional issues and in the next moment, the most practical and cognitive ones
• Having a clear grasp of the individual in front of you, not just in life experience, or temperament, but in cognitive abilities
• Be aware of shame and shaming
Seeing the light – or ticking the box?
Prevalence of bullying in secondary school by SEN type: Analysis of combined NPD and LSYPE data files. Naylor, P., Dawson, J., Emerson, E., and Tantam, D. (2011) N=15 770 13-14 year olds in mainstream school
• Bullied pupils and those with SEN report feeling unhappier and have less commitment to school than pupils who are not bullied and have no SEN.
• For pupils with SEN or no identified SEN, the risk of being bullied declines by approximately 9 per cent each chronological year.
• Pupils bullied in Year 9 (13-14-year-olds) are much more likely to drop out of school at Year 11 (15-16-year-olds) than those who were not bullied. This trend is even more pronounced for pupils with SEN.
Does social exclusion lead to functional movement impairment
Is there a difference in the amount of physical activity of pupils with AS compared to others?
Seeing the light – or ticking the box?
Mean number of steps per hour: AS group = 902, control group = 1312 (t = -2.645, p = .027)
Where were people with AS in Sheffield?
• Most living at home, even above 30. • Most had difficulties coping with changes in
everyday environments • Difficulties moving between places (for example
using public transport) • Most common places frequented were libraries
and cinemas
Seeing the light – or ticking the box?
Impaired social communication and social interaction (DSM-5)
Restricted repetitiveness (DSM-5)
Intellectual disability
Language impairment
Epilepsy
ADHD
Consequential conditions
Victimization
Marginalization
Tourette, dyspraxia, agnosias
Sensory issues, Information overload, melt downs
The search for the self
Making an impact:uproar, aggression, weaponizing Containing the risk so that non-reinforcement is possible
Anxiety-related disorder
22 May 2012
RSM
22 May 2012
RSM
Impaired social communication and social interaction (DSM-5)
Restricted repetitiveness (DSM-5)
Intellectual disability
Language impairment
Epilepsy
ADHD
Consequential conditions
Victimization
Marginalization
Tourette, dyspraxia, agnosias
Sensory issues, Information overload, melt downs
The search for the self
Identity borrowings Providing a healthy identity Anxiety-related disorder
22 May 2012
RSM
Narrative coherence • Inability to hold up against persuasion: • A lack of an internal narrative “I could have done
that” • Acceptance of strongest narrative, or authority’s
narrative, of most recently repeated narrative • Link with theory of mind • Bright-Paul, A., C. Jarrold, et al. (2008).
• Autobiographical memory • Bruck, M., K. London, et al. (2007)
www.existentialacademy.com 22
Coping with a lack of identity • Fads • ‘Obsessive’ relationships • Lack of identity in many
people with ASD • Adopting identity wholesale • Joining charismatic groups • Moving places and work
• Searching for identity • ‘Transexualism’ • ‘Aspie’
• Identities off the peg • Gangster • Professor • Teddy bear
2 Nov 2010 Seeing the light – or ticking the box?
Impaired social communication and social interaction (DSM-5)
Restricted repetitiveness (DSM-5)
Intellectual disability
Language impairment
Epilepsy
ADHD
Consequential conditions
Victimization
Marginalization
Tourette, dyspraxia, agnosias
Sensory issues, Information overload, melt downs
The search for the self
Anxiety-related disorder
22 May 2012
RSM
Tuesday, 16 October 12
Lunch-time meeting, Brandon Unit, Leicester
What motivates aggression in AS?
• Doing the right thing • Being accepted, perhaps in a deviant
group • Utilization behaviour • Effort at communication • Catastrophic reaction • Asserting dominance • Modelling • Tension relief • Hypomania, depression "This is my son” 4 year old artist
from Art Gallery on OASIS home page
Reported prevalence of psychiatric disorder in older adolescents and adults
Disorder Hutton et
al N=135
My
clinic
sample
N=490
Balfe
et al
N=78
Hofvander
et al
N=122
Weighted
mean %
ADHD 43 43.0
Anxiety 16 42 47 50 39.4
Panic disorder 30 38.5
Depression 25 30 65 32.6
Obsessive-‐compulsive disorder 4 14 9.0
Substance misuse 4 16 4.7
Somatoform disorder 41 5 4.6
Bipolar disorder 1 3.2 8 3.3
Brief psychosis 3.4 2 2.3
Schizophrenia 3 3 2.2
EaJng disorder 5 0.7
Catatonia 1 0.6
Delusional disorder 1 0.2
Psychosis: illness features • Positive symptoms"
• Hallucinations"• Disorganized thinking"• Delusions"• Movement disorder"
• Negative symptoms in schizophrenia"• Decline in social and occupational functioning "• Reduction of nonverbal expression (‘flattening of
affect’)"• Partial mutism (poverty of speech)"
Type of medication
Ratio of improved
to no effect or worse
Number of children
trying this treatment (% of
sample)
Miscellaneous GI medication 4.00 10 (2%)
Miscellaneous herbal medication 3.33 13 (2.7%)
Atypical antipsychotics 2.08 80 (16.7%)
Anxiolytics 2.00 12 (2.5%)
Stimulants 1.80 172 (35.9%)
Mood stabilizers 1.80 70 (14.6%)
Chelation 1.60 32 (6.7%)
GF and/or CF dietb 1.52 155 (32.4%)
Antidepressants 1.31 136 (28.4%)
Other dietc 1.19 54 (11.3%)
Miscellaneous other medication 1.17 13 (2.7%)
What are the real drug effects? • Reducing severe depression:
Antidepressants • Reducing positive symptoms:
• Antipsychotics
• Reducing anxiety • ?SSRIs
• Reducing over-activity and increasing response control: • Stimulants
• Reducing mood fluctuations • Lithium and anticonvulsants
Type of intervention
Ratio of improved to
no effect or worse
Number of children trying this
treatment (% of sample)
Applied behavior analysis (ABA) 3.76 225 (47.0%)
Social skills training 3.05 244 (50.9%)
Picture exchange system (PECS) 2.88 231 (48.2%)
TEACCH 2.86 88 (18.4%)
Positive behavioral support 2.82 233 (48.6%)
Sensory Integration 2.79 255 (53.2%)
Occupational therapy 2.77 361 (75.4%)
Physical therapy 2.68 146 (30.5%)
Speech therapy 2.53 403 (84.1%)
Early intervention services 2.39 331 (69.1%)
Social stories 2.33 197 (41.1%)
Floor time 2.10 129 (26.9%)
Options program 2.00 21 (4.4%)
Music therapy 1.72 129 (26.9%)
Auditory integration therapy 1.52 88 (18.4%)
Neurofeedback 0.67 16 (3.3%)
Psychological treatments
• Some specific anxiety reduction with cognitive methods
• Some specific improvement of mood with behavioural activation
• Otherwise there is no difference in modalities except
• Flavour and values • Main outcome determinant is focus