Autism Spectrum Disorder; From Understanding to Action in … · 2019-05-23 · 4/27/14 1 Autism Spectrum Disorder; From Understanding to Action in Childhood and Adolescence!! MACMH

4/27/14

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Autism Spectrum Disorder; From Understanding to Action in Childhood and Adolescence!

!

MACMH Conference 2014

Mitch Leppicello, LICSW!Clinical Social Worker and Owner!

East Metro Family Counseling, LLC"

April 29, 2014!

Understanding ASD to Action for ASD

!   The more we understand Autism Spectrum Disorder, the better action we can take to help it.

!   Why should we understand the complexities of ASD?

!   Why will making our understanding ASD help us take better action?

Why ASD for me? The help individuals with ASD reach their potential by…

!   Counseling and therapy to help those resolve problems with ASD and haven’t had the understanding and action to declare “I think differently a I’m ok!”

!   Support as consultant to parents, educators, groups, and organizations

!   Education through professional development and seminars about the problems and dispel the myths and misconceptions of ASD

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Understanding ASD to Action for ASD

!   The more we understand Autism Spectrum Disorder, the better action we can take to help it.

!   Wrong understanding leads to… ! Mis-understanding behaviors associated with ASD

! Mis-treating or mis-intervening

! Mis-guided attempts to help the individual’s “problems”

!   Inaccurate labels, often leading to pejorative descriptors like lazy, rude, doesn’t care about anyone except themselves…

!   TOO often leading to unintentional but deeply pervasive harm to individuals with ASD

Understanding ASD !   Understanding the PERSON with (ASD) !   Historical Context !   Signs, Symptoms, and Characteristics !   Developmental Perspective aka “Growing

Up with ASD”

Understanding Individuals with ASD

!   Understanding the child and adolescent with ASD means: !   Communication must be viewed and understood

through their emotions and behaviors… language comes later.

!   “Diagnosis can provide a framework for labeling, understanding and learning about the behavioral and emotion challenges that have perhaps seemed inexplicable up to this point. This can diminish shame, lead to a greater sense of community and begin the process of learning to live more adaptively with an Asperger’s brain. It may also help other in your life understand and respond differently.” by Lisa Jo Rudy: Top 10 Reasons for Adults to Seek an Asperger Syndrome Diagnosis; 6/2007

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Action for ASD

!   Action for the PROBLEMS with ASD: !   What about the problem is ASD? !   Person - Problem

!   How do we take the right action to better hit the target of ASD? !   Action is something we do WITH ind

with ASD not TO them !   Common strategies and interventions we

KNOW help individuals with ASD

Understanding… A Historical on the DSM

!   DSM I (1952 & DSM II (1968) !   No term called “Autism” or “Pervasive Developmental

Disorder”

!   Closest term called: Schizophrenic Reaction (Childhood type)

!   DSM III (1980) !   Pervasive Developmental Disorders (PDD)

!   Childhood Onset PDD

!   Infantile Autism

!   Atypical Autism

!   DSM III-R (1987) !   PDD-NOS

!   Autistic Disorder


!   DSM IV (1994) !   Pervasive Developmental Disorders (PDD)

!   PDD NOS (New description in DSM IV)

!   Autistic Disorder

!   Asperger Disorder (New in DSM IV)

!   Childhood Disintegrative Disorder (New in DSM IV)

! Rett Syndrome (New in DSM IV)

!   DSM IV-TR (2000) – basically stays the same for Autism

!   Text correction for PDD NOS

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!   DSM IV (1994) !   Asperger Disorder (Asperger Syndrome)

!   Impairment in Social Interactions !   Impairment in Communications and use of language

in social contexts

!   Restricted repetitive behavior, interests, activities

!   Language use delay before 3 yo (y or n)

!   Cognitive delay, except social interaction (y or n)

Asperger Syndrome – “The Triad” of Impairment

Social Interactions

& Relationships

Social Language/

Communication Problems

Repetitive Behaviors &

Restricted Interests

ADHD

OCD

Social Anxiety Sensory Integration Disorder

Fine Motor / Gross Motor

Oppositionality Resistance

Refusal

Sleep Problems

Epilepsy EEG abnormalities

Depression

Aggression

Learning Disorders


!   DSM IV (1994)… in transition ! Pervasive Devlepmental Disorders (PDD)

! PDD NOS

! Asperger Disorder ! Childhood Disintigrative Disorder

! [Rett Syndrome] moved into another category

!  Autistic Disorder (changed to Autism Spectrum Disorder ASD)

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Autism Spectrum Disorder (ASD) DSM 5 (2013)

!   Impairment in Social Communication and Social Interaction in multiple contexts (all 3)

!   Deficits in Reciprocity ranging from - back and forth, less sharing of interests, emotions, or affect failure to initiate or respond to social interactions

!   Non-verbal communication behaviors used for social interaction poorly integrated verbal and non-verbal communication to problems with eye contact body language to total lack of facial expressions

!   Deficits in developing, maintaining, and understanding relationship, ranging, for example from difficulties adjusting behavior to suit various social contexts to difficulties sharing imaginative paly or in making friends to absence of interest in peers (American Psychiatric Assn 2013)


!   Deficits in developing, maintaining, and understanding relationship, ranging, for example from difficulties adjusting behavior to suit various social contexts to difficulties sharing imaginative paly or in making friends to absence of interest in peers

!   Social Interaction Problems (My 3 subtypes) !   Socially Avoidant (Aversive and Anxious) !   Socially Awkward (Wanting) !   Socially Apathetic (“eh”… Indifferent)


!   Restricted repetitive behavior, interests, activities (2 minimum)

!   Stereotyped or repetitive motor movements, us of objects, or speech, echolalia, idiosyncratic phrases

!   Cognitive delay, except social interaction (y or n) !   Insistence on sameness, inflexible, adherence to

routines or ritualized pattern of behavior, problems with transitions, rigid thinking

!   Highly restricted fixated interests that are abnormal in intensity or focus, preoccupation or attachment

!   Hyper or hyper-reactivity to sensory input or unusual interests in sensory aspects of the environment (7 senses)

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Autism Spectrum Disorder 2013

Speech Language



ADHD

OCD

Social Anxiety

Sensory Integration Disorder



Refusal

Sleep Problems


Aggression

Executive Functions

Social Communication

& Social Interaction Problems

Depression

Learning Disorders


!   (DSM-5) Note:

!   Individuals with a well established DMS-IV diagnosis of autism disorder, Asperger disorder, or PDD NOS should be given the diagnosis of ASD. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for ASD, should be evaluated for Social (Pragmatic) Communication Disorder (SCD).

New! Severity Levels for both Social Communication and

Restricted, Repetitive Behaviors

!   Level 1 (Mild) !   Without supports… marked deficits and impairments

!   Requiring support

!   Level 2 (Moderate) !   With supports… marked deficits and impairments

!   Requiring substantial support

!   Level 3 (Severe) !   Significant and severe deficits and impairments

!   Requiring VERY substantial support

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Social Communication Disorder (SCD) DSM V (2013)

!   Persistent problems with verbal and non-verbal communication in social situations !   Social purposes, greetings, use in social contexts !   Adapt communication to match environment !   Follow rules in social communication, turn

taking !   Uses of many social languages, figures of speech

!   Problems functioning (academically, relationally, occupationally/vocationally) socially as a result of above

Social (Pragmatic) Communication Disorder

ADHD Social Anxiety




Refusal

Sleep Problems


Aggression



Social Communication

& Social Interaction Problems

Depression


Learning Disorders

Speech Language

Understanding Pragmatic Language Problems !   Language Usage

!   Greetings !   Requesting !   Informing

!   Language Changes !   Talking differently to a baby or toddler than a peer !   Giving background info to a stranger or listener unfamiliar with the

story !   Speaking different in the school library than in the gym

!   Language Rules of Conversation !   Verbal and non-verbal cues in conversation !   Introducing topics !   Maintaining and ending conversations !   Clarifying miscommunication either reception or expression

http://www.asha.org/public/speech/development/Pragmatics/

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Action for Pragmatic Language Problems

!   Language Usage !   Take advantage of natural situations and during low stress and

positive emotive states… greetings

!   Give choices about topics of conversation

!   Language Changes !   Role model, role play, rehearse what you want learned

!   “Friend” talk and “Teacher” talk

!   Language Rules of Conversation !   Rehearse telling stories, events sequentially with cartooning

!   Use visual cues like schedules, calendars, stress scales, family photos

!   Reflect facial expression versus internal feelings/emotions

!   “It’s your turn to talk” http://www.asha.org/public/speech/development/Pragmatics/

Action for Pragmatic Language Problems SAY… TO ACHIEVE…

Tell me about…? How did that go when…? What was best part about….?

Comments and opinions (elicit specifics)

Do you want the paper or the pencil? Ask your friend for a turn, like this… Ask the lunch aid if you have a choice?

Requests (initiating communication)

What’s the first part of the story? What’s the second thing that happened?

Conversation

Do you have a word to use to match that feeling? Was the feeling good or bad?

(Safe) Expression of Emotions

To Better Understand the Individual with ASD !   What are general characteristics of individuals with ASD? Obtain

information from multiple sources past and current.

!   How, where, and when ASD diagnosis was identified

!   What are the strengths, gifts, and hidden talents of their ASD?

!   Where on the continuum is your child with ASD with regard to: support, security, understanding, and assistance?

0 1 2 3 4 5 Little to none Some areas, needs more Greatly supported

!   What is the individual’s experience of validation, acceptance of their ASD?

!   Lastly, it’s important to understand how the individual’s ASD was mis-identified, mis-understood, mis-diagnosed, and even perhaps mis-treated.

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Developmental Overview of Individuals with ASD !   Early childhood – Elementary years

!   Very intelligent, bored with rudimentary work in school !   Groups of acquaintances, classmates, absence of cliques !   Quirky “obsessions” more difficult – more acceptable obsessions,

the more tolerant their peers

!   Pre-teen – MS/JH years (often the most difficult years) !   Puberty! Smaller groups, start of close friends, loner feelings !   School and other life stressors increase dramatically !   “Social jousting” [Leppicello] Initial teasing and taunting by peers

!   Adolescence – HS years !   Solid friendships forming, difficult to form or break into tightknit

social groups !   … Teasing, taunting, and torment = social trauma !   Interests in romance and courting, sexual anxieties, new challenges !   More pressure to work, pursue social clubs and org, school

pressures

Early Childhood (Pre-school – 3rd Grade) !   Problems may first seem to surface in pre-school setting where socialization

begins

!   Separation problems with primary caregiver, slow to “warm-up”

!   Overly dependent and preference for adult care attention, while problems engaging peer groups in play

!   Sudden emotional outbursts and behavior problems

!   Severely negative and resistant reactions to transitions and changes in the setting

!   Play is repetitive and isolates from others, preference for alone vs parallel play OR may make attempts to join in… don’t go well

!   First signs of sensory problems to touch, sounds, taste, and smell

!   Intolerant to abrupt or sudden transitions

!   Problems responding to verbal reassurance, physical comforting or soothing - may actually increase child’s distress

Children: Early Elementary !   Social isolation or awkward socialization, but usually accepted by

peers and “class” of friends

!   Penchant for facts and details in area of interest not typical for other’s their age

!   Misunderstands and misinterprets social communication and interactions

!   May act out aggressively towards self or others in obvious fashion

!   Friendly, but can’t establish friends

!   Seeks socialization, but not often reciprocated, begins feeling different, rejected, not fitting in with peers

!   Knows classroom and playground rules… problems integrating rules to their way of thinking. Feels like “it doesn’t apply to me”

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Children: Middle Elementary !   Strong vocab and high cognitive ability begins “I’m

different…” or “something’s wrong with me…”

!   Their peers avoid these students for unstructured play or group activities. Kids with ASD “picked last…”

!   Gross motor limitations are bigger factor, liability with peers

!   More disparity between social behaviors and cognitive ability. “How can a child so smart act so immature?” Causes confusion for teachers and parents

!   Beginning of puberty for some… hygiene problems

!   Rigid thinking and behavior more problematic - complies when task is of interest or is associated with minimal distress

Teenagers: Junior high/Middle school !   Typically the most difficult age for kids with ASD: classroom

friendships peeling off into smaller social groupings

!   ASD is at greatest Developmental Disparity (Leppicello, 2011): more sleepover, birthdays, less parent organized “play dates”

!   Many are identified by this age due to increase pressure for social and communication skills

!   Puberty in beginning (aka akward) stages: b.o., acne, etc…

!   Children of this age have experienced five or more years of teasing, feeling different than their peers, emotionally and socially disconnected and misunderstood by teachers, parents, and other “helping” professionals

!   Sum of all these negative experiences = persistent low level trauma

!   Depression, anxiety, general distress and discomfort… neg behav.

Teenagers: High school !   Though stressful social experiences exist, less traumatic as

there is less pressure to fit-in to certain social circles

!   Teens this age have a chance of finding “others who think like me…”

!   Stress of social outings = more time at home in their “cave”

!   Unknown or misunderstood rules for romance

!   Most vulnerable to violate “adult” laws (stalking, harassment, terroristic threats)

!   Learning to drive - coordination problems

!   Some substance abuse experimentation, but generally not

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A Perspective of Growing-up with ASD

!   Negative experiences past……..present !   Often felt, but rarely communicated directly !   Persistent teasing, torment, and taunting = TRUAMA !   Trauma is big “T” and little “t” = Bullied, teased, ridiculed

by peers, siblings, parents, teachers, therapists, coaches, clergy, and many other adults who don’t understand ASD

!   History of social problems and negative social experiences - social isolation from as early as pre-school to the present

!   General sense of growing-up feeling lost and confused

!   Misunderstood, misdiagnosed, and mistreated, by family, friends, and professionals

Understanding Autism Spectrum Disorder: Person AND Problems with ASD

Understanding the "Person Children with ASD: !

!Attentive Strong Reader!!Sense of Humor Employed!!Supportive Family !!Skilled, Interests in Motors!!Likable by peers and teachers!!!!! !!

Understanding the " Problems with ASD:"

! Language & Communication Learning & Cognitive

!Disparity!! Rigid & Inflexible Thinking!! Sensory Integration Regulation! Co-morbidity with ADHD, Anxiety, Depression, OCD…

Positive Coping Zone

An Autism Spectrum Disorder: Person vs. Problem with ASD

Individuals with ASD have the greatest difficulty coping when the problem with ASD interferes with the person.

Understanding the "Person with ASD: !

!Internal supports:!worthwhile, capable!!External supports:!calm, supportive !living and learning !environments!

!!

Understanding the Characteristics of ASD: !

!“List” of ASD Characteristics: !

Sensory integration !Repetition, preoccupation !

Preference for routine !Awkward social demeanor!

Narrow social skill develop !Mental health comorbidities!

Language and !communication!

Problem coping with

ASD negatively affects the

persons thoughts

and feelings = High!Stress!

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Autism Spectrum Disorder: Person vs. Problem with ASD

Understanding the "Person with ASD: !

!Internal supports:!strong cognitive!abilities!!External supports:!calm, supportive !living and learning !environments!

!!

Understanding the " Characteristics of ASD: !!

ASD Characteristics: !Sensory integration !

Rigidity, preoccupation !Preference for routine !

Narrow social skills!Limited friend base!

Comorbidities!Language and !

communication!

Problems coping with high STRESS!

!

Negative thoughts and feelings grow = "

"

More Negative Behaviors!

Autism Spectrum Disorder: Person vs. Problem with ASD

Understanding "the Person "with ASD: !

!Internal supports:!loyal to friend!and family!!External supports:!calm, supportive !living and learning !environments!

!!

Understanding the Characteristics "

of ASD: !!

List of !Characteristics!

of !Children !

and Teens ! with ASD!

!

Problems for !individuals of ALL

ages with ASD:!Maladaptive coping with shame, anxiety,

social confusion, depression, etc…!bad behaviors !

ACTION for ASD: 5 Steps to Understanding and Helping ASD !   Premise: Individuals with ASD have the greatest difficulty

coping when the problem with the ASD interferes with the individual’s developmental tasks and is compromised by the “Problem with their ASD”.

!   Objective: 1) Early and effective intervention

2) Extricate the person from the problem of ASD

3) Plan for the problem with ASD

4) Plan for the person’s negative thoughts, feelings, and behaviors

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Why Early (Intervention) Action? Parent Testimonial: Disclosure & Early Identification for ASD

I'd like to comment as a parent of an AS child who wasn't diagnosed until she was a college student. She self-identified as AS during an evaluation for possible ADD or related issues following her meltdown as a first year college student. The good news, she was just accepted with full funding into a Master's program in Biochemistry. So, I guess I'm offering hope that AS is not the disaster that it might appear. The diagnosis of AS came as a relief. Now we had a label for what we'd been watching for 19 years. Fortunately, she was in an educational environment that was full of willingness to work with her, to find suitable accommodations, and to push her to reach her potential.

Asperger Disorder Homepage Blogger “halbert” March 8, 2007

Step #1: What’s the Problem? !   Step 1. What’s the Problem?

!   Help find or identify the specific problem or negative behavior: The more specific the problem, the better the solution !   What’s the bad behavior as perceived by the individual, parent,

close friend/romantic partner, employer, classmate, etc…

!   “She’s always writing in her notebooks… not about school”

!   “They always pick me last…. so I swore at them”

!   “I don’t like to look at people when I talk to them…”

!   “My mom didn’t cry at my Grandma’s funeral… I cried a lot!”

!   “I already took a shower…” (knowing they didn’t or get clean)

!   “He’s not getting up for class…”

!   “He threw his shoes and tipped his desk over…”

Step #2: Personal Negative Thoughts and Beliefs

!   Step 2. What are Personal Negative Beliefs about the problem?

!   The Personal Negative Belief refers to negative thoughts individual has about the problem

Problem Negative Belief

Late for work I’m not succeeding… failure

Poor grade on test I’m not good enough

Not doing what parents others want I’m a disappointment

Obsessed with animals I’m weird

Can’t call a friend on phone, use the phone I’m different… a failure

Watching peers play… not invited to join I’m left out, alone… bad, wrong w/ me

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Step #2: Personal Negative Thoughts and Beliefs

!   Finding and healing negative beliefs for people has been a cornerstone of cognitive behavioral therapy for decades.

!   Negative beliefs are not truths, but strong beliefs

!   Fundamental part of changing how people feel, think, and behave regardless of their diagnosis or condition.

!   Dr. Daniel Amen: “Automatic Negative Thoughts (ANT’s)”

!   Dr. Tony Atwood: “Poisonous thoughts”

!   Dr. Francine Shapiro: “Negative Cognitions (NC and PC)”

!   Michelle Garcia Winner: “Unthinkables” invading the brain

Negative Belief – “Something’s wrong with me” !   I have rigid thinking… about everything

!   I perseverate and ruminate

!   I don’t do well with open ended questions about my likes or thoughts

!   Unaware of what other’s feel in certain situations

!   I’m unaware of what I feel

!   I have problems “reading” other’s intentions

!   Why do I always meltdown at bedtime?

!   I have problems planning, organizing tasks, remembering things, processing social information, etc… (executive functions)

!   I know the rules, I know right and wrong, I just can’t do it!

!   I’m easily overwhelmed… even though I don’t look like it

!   I don’t know what to say to other swimmers in the locker room…

!   They think I’m weird, different because I always want to talk about…

An Autism Spectrum Disorder: Person and Problem with ASD

Step 2"PERSON"WITH ASD: !Negative feelings!belief about myself:!!I’m different, !I don’t fit in,!I’m wrong, !I’m a dis-!appointment,! I’m a loser!!

!!

Step 3."PROBLEM"

of ASD: !!

Step 1.!State the Problem:!

I can’t keep track of my homework.!

He doesn’t wash himself when he’s in the shower for

15 min.!Overwhelming feelings of:

shame, sadness, fear, worry, worthlessness, anger, resentment, confusion!

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Step #3: What about the problem is ASD?

!   Choose from the List of ASD Characteristics of individuals with ASD !   All characteristics differ and manifest themselves differently

depending on age, grade, stage of development, severity of ASD

!   Consult your child or teen with ASD

!   See Mitch’s partial list attached

!   Find additional characteristics from other sources on the topic ASD

An Autism Spectrum Disorder: Person and Problem with ASD

Step 2"PERSON"WITH ASD: !

!Negative !feelings and!belief about !myself:!!I’m different, !I don’t fit in!!

!!

Step 3."PROBLEM"

of ASD: !!

Problems !starting a !

conversation !!

Fixation on… !“crustaceans”!

!

Step 1.!State the Problem!

Problems coping, poor social skills, behaving bad,

feeling shame, anxiety, depression, etc…!

Step #4: Separate the Person from the Problem

!   Step 4. Is this characteristic of ASD different from the negative belief our self? Yes or No

!   This is where we separate the person with ASD from the problems with ASD.

!   It’s hard to “solve a person” (with ASD). Let’s instead solve the problem (with ASD).

!   Extricating the person from the problem is the key to improving positive thoughts about how to think, feel, and behave about our self and others.

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Step #5: Create a plan to solve the problem

!   Step 5. What’s the plan to solve the problem I have with my ASD and or the negative thoughts I have about myself?

!   Plan to solve the problem with ASD !   “It’s not whether I solve these problems, but HOW I solve

them.” !   “Who’s help do I need to create a plan and solve the

problem?”

!   Plan to solve the problem about negative thoughts – change to the POSITIVE! !   “My ASD is another thing about me. I am NOT my ASD.”

Step #5: Interventions that support the Plan

!   Plans include: !   Structured schedules !   Help sensory integration !   Social stories !   Visuals for stories, communication !   Include “Protective Partners” to the team !   Pre-emptive parenting “The 7 R’s of Parenting” !   “Front load” supports and interventions… don’t wait for the crisis

!   Approach solve the problem with ASD by… !   “It’s not whether we help them solve the problem, but HOW we

help them solve the problem.”

!   Plan to solve the problem about negative thoughts – change to the POSITIVE! !   “My ASD is another thing about me. I am NOT my ASD.”

My ASD is ONLY a part of me, not the whole of who I am.

My !ASD!

My girlfriend likes my jokes!

My sister asks ME for help!

Dependable helper in my

classroom!

Fixing my parents

computer!

I’m good at playing with

my cousin!

Snowboard puzzles, baking!

The many parts of ME:!

I like the piano!

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Individuals with ASD: From Understanding To Action!

Handouts online

ASD and Comorbidity by Mitch Leppicello: http://www.connectwc.org/autism-spectrum-disorders-and-comorbidity.html

MACMH http://www.macmh.org/free-macmh-downloads/fact-sheets/ Fraser: http://www.fraser.org/Resources/Fraser-Expertise---Information

The End""

Discussion and Questions "

Thank You!""

Please complete the evaluation.!

Mitch Leppicello, LICSW!Clinical Social Worker, Owner!

East Metro Family Counseling, LLC"

651-408-5132!

www.eastmetrofamilycounseling.com!

!

and @MitchLICSW!

!

Documents

Autism Spectrum Disorder; From Understanding to Action in … · 2019-05-23 · 4/27/14 1 Autism Spectrum Disorder; From Understanding to Action in Childhood and Adolescence!! MACMH