DEVELOPMENT, AUTISM SPECTRUM DISORDER, Amy W y Weir, Psy. y.D . - - PowerPoint PPT Presentation

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Amy W y Weir, Psy. y.D.

17 th Annual PCIT Conference University of California, Los Angeles

• Sept. 28, 2017

DEVELOPMENT, AUTISM SPECTRUM DISORDER, AND TRAUMA: IDENTIFICATION AND TREATMENT RECOMMENDATIONS

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 The experience of trauma complicates behavioral symptom presentations.  Understanding the overlap and distinct features of different disorders in children (ASD and trauma)  Available screeners for identifying possible trauma and ASD  Use of comprehensive strategies for screening, assessment and diagnosis  Best practices for trauma, ASD, and dual diagnosis

OBJECTIVES FOR TODAY:

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 Crit iterio ion A n A: stresso sor  Crit iterio ion n B: i intrusi sion s n sympt ptoms ms  Crit iterio ion n C: C: a avoid idanc ance  Crit iterio ion n D: n negative al alterat ations in in c cognitions an and mo mood  Crit iterio ion E n E: a alterations i ns in a arousal usal a and d reactiv ivit ity  Crit iterio ion n F: d : dura uration  Crit iterio ion n G: f functio ional s nal signif nific icanc nce  Crit iterio ion n H: e exclus usio ion  Specify fy if: Wi f: With d h dissociative sy sympt ptoms  Specify fy if: Wi f: With d h dela layed expr press ssio ion

POSTTRAUMATIC STRESS DISORDER (DSM-5)

(American Psychiatric Association, 2013)

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Child’s symptoms of trauma understood within the context of multiple factors Traumatic events

MULTIPLE DIMENSIONS OF TRAUMA

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Ne Neurological al / / Bi Biolo logical Se Self-Regu gulation Atta tach chment Developmen pmental So Social ial r relatedn dness Beha Behavi vioral l con contr trol Co Cogni gnition

EFFECTS OF TRAUMA EXPOSURE

from Rambeau and Lukasik

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SOCIAL-COMMUNICATION (all 3) Range of expression and examples Deficits in social-emotional reciprocity

• abnormal social approach and failure of

normal back and forth conversation

• reduced sharing of interests, emotions,

affect, and response

• failure to initiate or respond to social

interactions

Deficits in nonverbal communicative behaviors used for social interaction

• poorly integrated verbal and nonverbal

communication

• abnormalities in eye contact and body

language or deficits in understanding and use of nonverbal communication

• total lack of facial expression or gestures

Deficits in developing and maintaining developmentally appropriate relationships

• difficulties adjusting behavior to suit different

social contexts

• difficulties in sharing imaginative play and

making friends

• absence of interest in people

AUTISM SPECTRUM DISORDER (DSM-5)

(American Psychiatric Association, 2013)

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RESTRICTED AND REPETITIVE BEHAVIORS OR INTERESTS (at least 2) Range of expression and examples Stereotyped or repetitive motor movements, use of objects or speech

• motor stereotypies
• lining up or flipping objects
• echolalia
• idiosyncratic speech

Insistence on sameness, inflexible adherence to routines,

• r ritualized patterns of behavior
• extreme distress at small changes
• difficulty with transitions
• rigid thinking patterns
• greeting rituals
• insistence on same route or food

Highly restricted fixated interests abnormal in intensity or focus

• strong attachment to/preoccupation with

unusual objects

• excessively circumscribed or perseverative

interests

Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment

• indifference to pain/temperature
• adverse response to sounds/textures
• excessive smelling/touching objects
• visual fascination with lights/movement/objects

AUTISM SPECTRUM DISORDER (DSM-5)

(American Psychiatric Association, 2013)

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AUTISM SPECTRUM DISORDER CONSIDERATIONS

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Wha What W We Kno now Wha What W We Don Don’t K Kno now

WHERE ARE WE NOW?

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DEVELOPMENTAL LENS TRAUMA LENS

LENS COMPARISONS

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OVERLAPPING SYMPTOMS

from Rambeau and Lukasik

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TRAUMA

 Withdrawal/lack of eye contact, no social initiation, no interest in social interaction

 due t to mistrust o

• f others

 Issues with trust, fears adults, avoids adults

• due

ue t to

• past traum

umatic e experienc nce w where trus ust

• f o
• thers was v

violated

 Depression/anxiety: difficulty identifying, expressing, and managing emotions

• due

ue to

• int

nternalization

• n of
• f t

traum uma e experienc nce

 Impact of traumatic experience on empathy, social relatedness, trust, turn-taking

• due to violation o
• f t

trust i in r rela lationships

 Tantrums, unpredictable emotional responses, anger, overreactivity

• due t

to emotiona nal l dysregula ulation

• n

ASD

 Lack of eye contact, no initiation of conversation, no pleasure shown in social interactions

• due

ue t to

• inh

nherent nt d difficulties w with s soci

• cial-emotio

ional reci ciprocity/engaging m meani ningfully w with ot

• thers

 No response to name, reduced sharing

• f interests
• due

ue t to

• inh

nherent nt d difficulties w with s soci

• cial-emotio

ional recip iprocit ity

 Reduced sharing of emotions/affect, no social initiation

• due

ue t to

• inh

nherent nt d difficulties w with s soci

• cial-emotio

ional recip iprocit ity

 Difficulty with relationships and taking another’s perspective

• due

ue t to

• deficits i

in n theor

• ry of
• f mind s

skills

 Tantrums, head banging/self-injurious behaviors

• due

ue t to

• deficits i

in n com commun unica cation s

• n skills, problems

with ch chang nges in n rout

• utine

nes, s sens nsory-seeking ng be behaviors ( (self-injurious-beh behaviors rs)

OVERLAPPING SYMPTOMS (CONTINUED)

from Jacob and Graham, 2016

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TRAUMA

 Nightmares, fears of going to sleep

• due

ue t to

• revisiting m

memor

• ries of
• f traum

uma

 Changes in appetite

• due t

to mood dysregulation

 Hypersensitivity to sounds, smells, touch, light- unaware of pain or internal physical sensations

• due

ue t to

• hyperarous
• usal/reminders of
• f t

traum uma

 Dissociation

• malad

adapt aptive c coping m g mechanism

 Deficits in language development and abstract reasoning

• Due

ue to

• early t

traum uma a and nd br brain d development nt, regression i n in s n skills

 Difficulties with changes and transitions, rigid repetitive behaviors, repeated play themes, fixated interests

• due

ue t to

• anx

nxious us r react ction t n to

• cont

control unp unpredictable na natur ure of

• f traum

uma

ASD

 Sleep problems

• due t

to problematic sleep c cycle (prob

• ble

lems f fall lling ng asle leep, mu mult ltiple wakin ings dur uring t the ni night, early morning w g wak aking) g)

 Eating problems- rituals, pickiness

• due t

to senso sory i interest sts a s and p proble lems w s with th c chang nges i s in routines es (res estricted a ed and r repetitive e beh ehaviors)

 Under- or overreactivity to sensory input

• due

ue to

• sens

nsor

• ry s

sens nsitivities

 “lives in their own world”

• due

ue t to

• inh

nherent nt d difficulties w with s soci

• cial-emotio

ional recip iprocit ity

 Difficulties with pragmatic/social use of language

• due

ue t to

• prob
• blems with

th socia ial-emotion

• nal r

reci ciprocity and nd com commonl

• nly co

co-occur urring ng l language dela lays

 Insistence on following routines, lining up toys or objects, repetitive behaviors, fixated interests

• due

ue t to

• restricted and

nd r repetitive be behaviors ( (cor core symp symptom of ASD ASD)

OVERLAPPING SYMPTOMS (CONTINUED)

from Jacob and Graham, 2016

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ASD

 Symptoms must be present in early childhood (before age 3)  Social concerns may not be evident until a child is older and social demands increase  Consistency of symptoms  Scripted speech  Fascination with movement or parts of objects (spinning, sighting)  Stereotypical movements

TRAUMA

 Exposure to trauma  Re-experiencing (e.g. flashbacks)  Hyperarousal (i.e. hypervigliance)  Hypoarousal (i.e. dissociation)  Acting in or acting out (aggression)  Disorganized attachment style (approach/withdrawal)  Increasingly restricted range with displays of affect post trauma exposure  Sensory based trauma associations  Exacerbation of typical developmental fears

DISTINCT SYMPTOMS

from Rambeau and Lukasik

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ASSESSMENT AND TREATMENT

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IMPORTANCE OF CAREGIVER PERCEPTIONS

from Rambeau and Lukasik

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TRAUMA  Brief measures:

• Trauma Symptom Checklist

for Young Children (TSCYC); Trauma Symptom Checklist for Children (TSCC)

• UCLA PTSD Reaction Index

for DSM-5

ASD

 Ages and Stages Questionnaire, Third Edition/Social-Emotional Questionnaire (ASQ-3 and ASQ:SE), looks more directly at development overall  Modified Checklist for Autism in Toddlers, Revised and Follow-Up Interview (M-CHAT-R/F)  Social Communication Questionnaire (SCQ Lifetime/Current) is a brief measure that can assist in assessing for ASD in preschool and school-age children

SCREENERS

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TRAUMA SYMPTOM CHECKLIST FOR CHILDREN (TSCC/TSCYC)

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UCLA PTSD REACTION INDEX FOR DSM-5

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AGES AND STAGES QUESTIONNAIRE, THIRD EDITION (ASQ-3 AND ASQ:SE)

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MODIFIED CHECKLIST FOR AUTISM IN TODDLERS, REVISED AND FOLLOW-UP INTERVIEW (M-CHAT-R/F)

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SOCIAL COMMUNICATION QUESTIONNAIRE (SCQ)

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ASSESSMENT COMPONENTS

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 Complete medical exam including hearing/audiology exam  CA Early Start referral (under 3 years of age)  Speech and language evaluation  Occupational Therapy Evaluation  Intervention to address behaviors/social- emotional functioning  Where to obtain services

DEVELOPMENTAL CONCERNS: NEXT STEPS

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TRAUMA

• Trauma-Focused

Cognitive Behavioral Therapy

• Parent-Child Interaction

Therapy

• Parent-Child Attunement

Therapy

• Trauma Assessment

Pathway

• Child-Parent

Psychotherapy

ASD

• Developmental/Educational
• http://resources.autismnavigator.com/asdglossary/#/section/56/mt

w

• http://resources.autismnavigator.com/asdglossary/#/section/66/ot
• Applied Behavior Analysis (includes

DTT and PRT)

• http://resources.autismnavigator.com/asdglossary/#/section/48/aba
• http://resources.autismnavigator.com/asdglossary/#/section/48/aba
• http://resources.autismnavigator.com/asdglossary/#/section/50/prt
• Early Start Denver Model
• http://resources.autismnavigator.com/asdglossary/#/section/71/esd

m

• TEACCH
• http://resources.autismnavigator.com/asdglossary/#/secti
• n/62/teacch
• Floor Time
• http://resources.autismnavigator.com/asdglossary/#/section/54/dir
• Cognitive Behavioral Therapy

TREATMENT CONSIDERATIONS

from Rambeau & Lukasik

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Limited research currently exists Misconceptions about the DD population Hallmarks of trauma treatment

TREATING CHILDREN WITH A DUAL DIAGNOSIS

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PTSD often missed TF-CBT usually considered choice of treatment Interdisciplinary collaboration Co-treatment Use of simple language, visuals, concrete metaphors, building coping skills, personalizing traumatic experience

TREATING CHILDREN WITH A DUAL DIAGNOSIS

from Jacob and Graham, 2016

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 Gather information across settings and include regular interdisciplinary consultation  Evaluate child’s response to intervention  Consult and co-treat when possible  Diagnose carefully and evaluate over time: could be trauma- related, could be ASD, could be both  Dialogue around priorities (e.g. sequence of services)

CONCLUSIONS

from Rambeau and Lukasik

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 Behavioral symptoms are complicated when a child has experienced trauma.  There is a lot of overlap between symptoms of different disorders in children.  Children change over time.  A careful and comprehensive approach to diagnosis and intervention is especially important when a child with a trauma history presents with potential concerns about autism spectrum.

MAJOR TAKEAWAY POINTS:

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 Adapting TF-CBT for those with Developmental Disabilities: http://file.lacounty.gov/SDSInter/dmh/1004667_Adapt_TF_Co g_Beh_Therapy_Pt1.pdf  Best practices for dual diagnoses in children: http://www.excellenceforchildandyouth.ca/sites/default/files/ eib_attach/DualDiagnosisTrauma_FINAL_REPORT.pdf  National Association for the Dually Diagnosed (NADD): http://thenadd.org/  Dia iagnostic ic M Manual-In Intel ellec ectua ual D Disa isabil ilit ity-2 ( (DM-ID): A : A Textbook

• k
• f D

Dia iagnosis o is of M Men ental Diso isorders in in Per erso sons wit ith In Intel ellec ectua ual Disa isabil ilit ity, authors Jarrett Barnhill, Sally-Ann Copper, and Robert J. Fletcher  National Child Traumatic Stress Network: http://www.nctsn.org/

RESOURCES: TRAUMA AND DUAL DIAGNOSIS

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 Centers for Disease Control and Prevention: Know the Signs. Act

• Early. https://www.cdc.gov/ncbddd/actearly/

 Autism Internet Modules: http://www.autisminternetmodules.org/  National Autism Center (NAC): http://www.nationalautismcenter.org/  Autism Speaks: https://www.autismspeaks.org/  Autism Navigator: http://www.autismnavigator.com/  California Autism Professional Training and Information Network (CAPTAIN): http://www.captain.ca.gov/  Center for Excellence in Developmental Disabilities (CEDD): http://www.ucdmc.ucdavis.edu/mindinstitute/centers/cedd.html  Warmline Family Resource Center: http://www.warmlinefrc.org/  Families for Early Autism Treatment (FEAT): http://www.feat.org/

RESOURCES: ASD AND DEVELOPMENT

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Than hank y you! u! QUESTIONS?

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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association. Anderson, C. (2012). Cognitive behavioral therapy and autism spectrum disorders. Therapies, Treatment, and

• Education. Retrieved from

https://iancommunity.org/cs/simons_simplex_community/cognitive_behavioral_therapy Autism Community (2011, March 9). What is TEACCH? Retrieved from http://www.autism-community.com/what- is-teacch/ Autism Speaks. Floortime. Retrieved from https://www.autismspeaks.org/what-autism/treatment/floortime Carlton, M. & Tallant, B. (2003). Trauma treatment with clients who have dual diagnoses: Developmental disabilities and mental illness. Presented at the National Child Traumatic Stress Network All Network Meeting, December 11-13, 2003. Jacob, S. & Graham, M. A. (2016, April 8). Autism Through Trauma Lens. University of New Mexico Department

• f Pediatrics Center for Development and Disability. Retrieved from

https://prezi.com/5j6rrisvombu/autism-through-trauma-lens/ Levin, A. R., Fox, N. A., Zeanah, C. H., Nelson, C. A. (2014). Social communication difficulties and autism in previously insitutionalized children. Journal of the American Academy of Child and Adolescent Psychiatry, 54(2). 108-115. Lukasik, M. & Rowe, J. Suzy’s Story: Autism Spectrum Disorder? Trauma Response? Neither? Both? What to Do When You are Unsure of the Diagnosis. PowerPoint presentation (date unknown). Ontario Centre of Excellence for Child and Youth Mental Health (2012). Evidence in-sight request summary: Dual diagnosis best practices for children. Retrieved from http://www.excellenceforchildandyouth.ca/sites/default/files/eib_attach/DualDiagnosis_FINAL_RE PORT.pdf Rambeau, A. & Lukasik, M. Autism Spectrum Disorder? Trauma Response? Neither? Both? What to Do When You are Unsure of the Diagnosis. PowerPoint presentation (date unknown). White, M. (2017, March 3). Language Delay and Autism Spectrum Disorder. PowerPoint presentation to CEDD UC Davis Medical School Module. Williams, M. E., Carson, M. C., Zamora, I., Harley, E. K., & Lakatos, P. P. (2014). Child-parent psychotherapy in the context of the developmental disability and medical service systems. Pragmatic Case Studies in Psychotherapy, 10(3). 212-226.

REFERENCES