BEHAVIOUR AND EMOTIONAL ASPECTS OF ASD

1. BEHAVIOUR AND EMOTIONAL ASPECTS OF ASD Dr Clodagh Doyle Consultant Clinical Psychologist Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

2. Aims of Session • An explanation of behaviour • To gain awareness of behaviour and emotional concerns and associated difficulties in ASD • To offer some practical strategies and management advice Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

3. Exercise • What makes you angry/ cross? Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

4. Behaviour • How do you know you are angry/upset/cross? • What do others notice? • What do you notice about your child/young person when they are cross? • ISSUE is that often your child/young person is not self-aware : we must help them develop these skills and know their triggers and signs. Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

5. Behaviour • What is your child/young person trying to do with their behaviour? Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

6. Behaviour • We all have behaviour that challenges • What challenges me may not challenge you! • Part of what make us human • Behaviour is communication • Behaviour is individual to person and environment Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

7. Behaviour Behaviour is communication Behaviour is meaningful to the person Behaviour is about control Behaviour is about comfort states Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

8. Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

9. Reasons for Behaviour Difficulties • Personality/temperament • Our mood • Rules and limit setting • Our environment • Tasks/activities • Life events • Skills deficits/lack of personal resources • Medical conditions and health Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

10. Some Reasons for Behaviour Difficulties in ASD • Biology/medical conditions • Skills deficits • Difficulties with communication • Difficulties with social interaction • Difficulties with flexibility/imagination • Lack of self-awareness/self-regulation • Sensory • Anxiety • + FACTORS THAT AFFECT ALL OF US Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

11. What Types of Behaviour • Aggression • Temper outbursts • Destructive behaviour • Withdrawn behaviour and low mood • Anxiety • Obsessional and repetitive behaviour • “non-compliance” • Hyperactivity • Lack of danger and many many more you live with Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

12. Associated Behaviours and conditions • ADHD • OCD • Anxiety disorders • Mood disorders • Mental health difficulties • Toileting • Dietary • Sensory Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

13. Co-existing conditions % Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

14. Difficulties with social communication • Lack of appropriate verbal skills and non-verbal skills – eg will use aggression to get needs met as often frustrated. • Limited and literal understanding • Slow processing • May come across as argumentative and stubborn • Can be honest to the extent of bluntness or rudeness Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

15. Difficulties with social interaction • Poor turn-taking and sharing – can lead to fights, wanting own way, own rules – isolation, lack of friends • Invading space – may be perceived as threatening, leading to rows/fights • Difficulties with two way interaction – can dominate conversation, leading to isolation • Poor NVB- difficulties with reading facial cues – may be perceived as not caring, behaving odd. Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

16. Difficulties with flexibility/imagination • Difficulties with new people; new situations – may lead to extreme anxiety, temper melt-downs • Difficulties with transitions and changing activity – again may lead to anxiety • Making choices is difficult • Unplanned events eg a small detour on the way home may cause an outbursts Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

17. Difficulties with flexibility/imagination • Difficulties seeing the consequences of actions • Wanting to keep things the same. – frustration, anger, seen as being stubborn, withdrawal • Difficulty planning ahead; accepting the future Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

18. What is the Function • Avoidance/escape! • Tangible • Sensory • Access to social attention • Behaviour is reasonable from their perspective Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

19. What can you do? • Try and figure out what’s going on • What is the problem • Where • Where less likely to occur • When • Who • Triggers • = FUNCTION Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

20. Functional Analysis • Try to understand meaning and function for the young person • Knowing function = preventative action • Knowing function = alternative strategies. • Difficult behaviour is their solution to a problem Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

21. Anger • Fight or flight response - constant • Think behaviour like a volcano - simmering stage - erupting/meltdown - recovery • KNOW THE SIGNS IN YOUR CHILD • Aim for prevention • Anxiety can fuel anger Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

22. Anger • Simmering stage: • Use signs/cues that let your child know that you are aware they are upset • Distract if possible • Re –direct • If appropriate accept/acknowledge the situation is difficult • Remind of strategies – eg breathing, count etc, self –talk, calming and soothing • Offer escape routes/places Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

23. Anger • Erupting stage/meltdown phase • Try and get child to a safe place or remove others in the area • Don’t try to talk and reason in this stage – wait until calm • Remain calm • Suggest calming strategy if appropriate Recovery stage: If appropriate talk through be supportive Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

24. Anger • Long –term: anger management skills • Teach recognition of feelings: emotional education • Teach physical signs of anger: body signs • Teach to recognise triggers • Teach alternative strategies Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

25. Emotional Issues • ASD can make young people vulnerable to mental health problems such as anxiety and depression, especially in late adolescence and early adult life (Tantam & Prestwood, 1999) • "the inability of people with autism to communicate feelings of disturbance, anxiety or distress can also mean that it is often very difficult to diagnose depressive or anxiety states, particularly for clinicians who have little knowledge or understanding of developmental disorders“ Howlin (1997) Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

26. Depression WHY? • increased awareness of difference to peers • Social isolation • Increased awareness of their difficulties • Relationship issues • Bullying/abuse • Feeling lonely • Low self esteem Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

27. Symptoms in ASD • General symptoms of depression • Regression – eg back to early special interests and obsessions • Increase in ritualistic behaviour • Increased withdrawal • Increase/decrease in agitation, aggressive behaviour • Increase in “autistic” behaviours eg hand-flapping,echolalia • Must know what is “normal” for the child/young person to know there is something going on Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

28. Anxiety • 84.1% of children with pervasive developmental disorder met the full criteria of at least one anxiety disorder Muris et al (1998) 35% of children with ASD met criteria for an anxiety disorder (Wood & Sze, 2007) • Why? - rigidity of thought and behaviour - difficulties with change; transitions; social situations - communication and language difficulties - sensory difficulties Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

29. Some strategies for emotional difficulties • Self –regulation techniques • Teach basic emotional education • Relaxation • Social skills training • Physical exercise • Make use of obsessions and special interests as calming things – but control! • 5 point scale; emotional thermometer • Visual cues and schedules • CBT • TOOL-BOX (Tony Atwood) Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

30. TOOL BOX PHYSICAL ACTIVITY TOOLS THINKING TOOLS SOLITUDE SPECIAL INTERESTS SOCIAL TOOLS RELAXATION TOOLS Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

31. EMOTIONAL THERMOMETER Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

32. General Strategies • Use visuals = structure/predictability • First – then; when-then cards/requests • Be aware of our language • Use child’s language/words • Don’t assume – say and be specific • Plan ahead; plan for transitions • See things through child’s eyes • Teach social skills • Exposure Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

33. Strategies • Teach alternative strategies/ways of communicating/appropriate behaviour • Think of functionally equivalent behaviours • Self-regulation • Anger management skills • Model and explain • Emotional/social coaching • Structure the environment Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

34. Role play • Social stories • Use special interests constructively • Teach consequences – social autopsies • Long term- CBT type techniques • Don’t be afraid of boundaries and rules • Positive reinforcement Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

35. Final thought • Try to understand the child/young persons experience of the world - SEE THINGS THROUGH THEIR EYES • Remember they are trying to tell you something – maybe not in the most appropriate way, but the only way they know • Never under-estimate the use of visuals to enhance predictability and structure = less anxiety = less outbursts • Say what you want them to do, not what you don’t want them to do. • TRY TO REMAIN CALM AND POSITIVE Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT

36. Thank you for listening Dr Clodagh Doyle, Consultant Clinical Psychologist, NHSCT