Cognitive Behavioral Therapy & Co-Morbid Mental Health Problems With Asperger Syndrome, ADHD, etc..

Michelle G Winner

www.socialthinking.com

What is social cognition?

How do we use this?

What is social thinking

What are social skills?

What is are mental health problems?

• Anxiety, depression, Obsessive Compulsive Disorders, etc.. .

• All relate to social emotional coping within themselves and society, regardless of the cause.

Who Has Social Cognitive Deficits?

• Autism spectrum disorders:– Autism, PDD, Asperger Syndrome

• Many diagnosed as emotionally disturbed.

• Non-verbal learning disability.

• ADHD

• Murky undiagnosed person falling outside of the “norm”.

Diagnostic Distinctions: How good are we at this?

• Co-morbid/co-mingled(?) labels often associated with ASD:– Bipolar– ADHD– Depression– Anxiety Disorder– Social Phobia/Social Anxiety– Schizophrenia – Schizoid personality– Paranoia– Societal misconduct

Anxiety and Related Mental Health Issues are REAL and

Have to be Part of the Treatment for many higher functioning

persons with ASD

Research: Anxiety & Social Cog.

• Abell, F. & Hare, D. (2005)

• Bellini, S. (2004)

• Hedley, D. & Young, R. (2006)

• Farrugia, S. and Hudson, J. (2006)

• Stewart, M., Barnard, L., Pearson, J., Hasan, R. & O’Brien, G. (2006)

The Higher the Level the Social Problem, it Appears the More we

can Predict Serious Mental Health Issues

Avoid thinking bright kids are immune to serious mental health problems as a

compensation to the school-based pressures (academic and social)

What happens with lack of social relatedness?

• What happened with Cho from Virginia Tech? – History of social communicative challenges.– IEP for speech therapy 1x a month.

• Social challenges are not easily discussed by a team.

• How did the autism society chapter react to it? • Is this an isolated event? • Do we notice who these kids are?• What can we do to help?

How does the school day “break” a smart kid?

• Being “bright” isn’t everything!– Executive function disorders– Concrete intelligence without being able to work as a

part of a team or working as part of a group. – Social exclusion leads to paralyzing depression. – Selective mutism. – Inability to tell people they don’t understand things

because they are supposed to be “smart”.– What is the IQ of many of the homeless? – Test scores don’t guarantee success academically or

socially.

If the Mainstream Classroom is a Pressure Cooker, Take it Off the Flame

• Allow for alternatives in the school day

• Adults (parents & teachers working together) should offer them before the student forces us

to make alternative in the day due to maladaptive coping behaviors

– outburst, physical altercation, refusing to come to school; failing grades, psychotic break

Avoiding the Cave Start Before the Cave is Built

• Mental health problems put us into the cave

• Can’t cope but can live in cyberspace from their bedrooms

Example from Cool Kids for Adolescents

• Lyneham, H.J., Schniering, C.A., Widnall, A. & Rapee, R.M. (2006) Chilled: The Cool Kids Anxiety Program- Adolescent Workbook. Centre for Emotional Health, Macquarie University, Sidney.

Evolving in one’s thinking

1. What is your initial thought and emotion (self-defeating thought)?

2. What is the evidence for that thought (unbiased judge)

3. What are the realistic consequences (what honestly happens).

4. Realistic thinking (Inner Coach), how do you tell yourself you CAN do this?

Accountability and Ownership

• Own how you are impacting yourself and others

• Accountability worksheet

• Anxiety treatment uses social thinking strategies, choosing the new way

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How do you alter your own thoughts and behaviors to climb

over this philosophical mountain?

How do you convey this to others in your school or home?

1.

What’s EXPECTED for: ____________________________________

Expected Behaviors How they make people FEEL

How People React To How They Feel About Your Behavior

How the person feels about him or herself.

1.

2.

3.

4.

5.

6.

7.

1.

What’s UNEXPECTED for: ____________________________________

Expected Behaviors How they make people FEEL

How People React To How They Feel About Your Behavior

How the person feels about him or herself.

1.

2.

3.

4.

5.

6.

7.

A more advanced strategy for teens after they have the core concepts:

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When can we teach thinking versus when do we assume thinking in

order to produce the skill?

1. THINKING

(kicks it all off!)

2. REMINDER

EXCUSES

3. DOING

(the skill comes last!)

Eg:

Remember about people you like.

Sticky note: remember to remember!

Ask a question about other people. Too tired

??

Co-treat with Mental Health Providers! • Caregivers need to acknowledge their children’s

challenges go far beyond the school or workday

• Our students need counselors to teach practical strategies but they also need counseling time just to be “heard”

• Our students often don’t get social validation from their peers and need to know that someone is paying attention to them

Parents and Counselors: A LABEL DOES NOT MEAN A CURE!

• Parents benefit from counselors working with them on disability awareness and the impact of a social learning disability across a lifespan

• Our children’s anxiety can at times be fed by parent’s anxiety about the student’s lack of success

• Students are not the only ones who have to adjust their own approach to the world. Parents have to adjust expectations. This can be very challenging for “white collar” families. Our culture demands performance and does not understand mental health as part of the decision making process!

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What is a Cognitive Behavioral Classroom or Therapy session?

Treatment: Cognitive Behavioral Strategies

Core concepts of Cognitive Behavioral Therapy

1. Cognitive behavior affects activity2. Cognitive activity may be monitored and altered3. Desired behavior change may be effected through cognitive

changeDobson, K. & Dozois, D. (2001) Historical and philosophical

bases of the cognitive-behavioral therapies. In K. Dobson (Ed.) Handbook of Cognitive Behavioral Therapies (pp.3-39). New York, NY: The Guilford Press.

Excellent book: Gaus, V. (2007) Cognitive-Behavioral Therapy for Adult Asperger Syndrome. The Guilford Press

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Difference between a “Behavioral Classroom” and a

“Social Cognitive Classroom”

• More and more we are talking about teaching social cognitive activities, but do these teachings fit into a behavioral classroom?

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Differentiating between Behavioral and Social Cog Classroom

BEHAVIORISM

• Focuses on the end point of the behavior performed or exhibited.

COGNITIVE BEHAVIORISM

• Focuses on the thinking that contributes to the behavior and then describes how your behavior should change.

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We think and then respond: There is a space between stimulus and

response.

We are expected to think about our situation and the people within it as we determine our response. Here we have a lot of choices, if we teach our students to think about their own and other’s perspectives.

Behavioral End point is the resulting behavior, or

The behavioral response.

Classic behaviorists teach at this point:

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Cognitive Behaviorists teach the process of working towards the behavioral response based on

cognitive reasoning: • Social stories

• Comic Strip conversations

• The 5 Point scale

• Social Behavior Mapping

• Teaching perspective taking, etc..

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Classroom DistinctionsBEHAVIORISM:• “Teaching” through positive,

often token rewards.

• Punishing negative outcomes through removal of reward, without detailed discussion.

• Sending a child home from school when the continue to misbehave.

• Focus on your own behavior and the rewards or punishments you received in the day.

(Most classrooms practice Behaviorism as their primary group learning tool)

COGNITIVE BEHAVIORISM• Teaching through processing what

is happening around them when they are doing well.

• Teaching what other people are thinking and feeling when they don’t do well.

• Always being responsible to the group, which is larger than yourself.

• Goal is towards naturalistic social consequences and getting them to notice how things are better for them when they do what is “expected”.

• Working with them to want to re-enter the situation in which they had difficulty.

Progress with Our Little Clients

• While almost impossible to measure at this point, we are seeing students in elementary school get a far better grasp of their own learning and emotional coping as they approach middle and high school

• Crooke, P.J., Hendrix, R.E., Rachman, J.Y., (2007) study published on social thinking efficacy

Don’t Wait!

• Begin to work NOW on strategies that address anxiety and depression, in a proactive way if the student has social learning challenges– Even if the child is in 2nd grade.– If adults, anxiety paired with social learning.

Assume they are partners.

• The Superflex Curriculum is one strategy that helps to open the door to that discussion

Superflex: A Superhero Social Thinking Curriculum

A Fun and Motivating

Way to Explore Social

Thinking Behavior

Excellent Books:

Paxton and Estay, (2007). Counseling People on the Autism Spectrum Jessica Kingsley Publishing.

Rapee, Spence, Cobharn & Wignal, (2000), Helping Your Anxious Child: A Step by Step Guide

for Parents New Harbinger Publications.

Attwood, T. (2006). The Complete Guide to Asperger Syndrome. Jessica Kingsley Press: New

York.

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