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Addressing Trauma in Therapy with Individuals with Autism Spectrum Disorder

Addressing Trauma in Therapy with Individuals with Autism Spectrum Disorder. Arianne Wallace, PhD Clinical Psychologist, Research Scientist Clinical Director, Bernier Lab, CHDD, University of Washington Lucy Berliner, MSW Director, Harborview Center for Sexual Assault and Traumatic Stress

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Addressing Trauma in Therapy with Individuals with Autism Spectrum Disorder

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  1. Addressing Trauma in Therapy with Individuals with Autism Spectrum Disorder Arianne Wallace, PhD Clinical Psychologist, Research Scientist Clinical Director, Bernier Lab, CHDD, University of Washington Lucy Berliner, MSW Director, Harborview Center for Sexual Assault and Traumatic Stress Clinical Associate Professor, University of Washington November 5, 2018

  2. Overview and Objectives • Introduction – Needs of community providers • Definitions: PTSD – DSM-5, Traumatic Event, Trauma Exposure, Stressors • Social-Cognitive features associated with ASD to consider in trauma work • Review of Research Literature – ASD and Trauma • Theories • Rates of PTSD • Assessment • Traumas and Adversities • Treatment • Summary and Future Directions

  3. Introduction • Collaboration between Harborview Sexual Assault and Trauma Center, UW CHDD, & Seattle Children’s Autism Center • Needs of and requests from community providers • More information and education about ASD in general • Increase understanding of clinical manifestations of trauma in individuals with ASD • Suggestions for trauma-focused therapies and applications • Collaborations resulting in: • Reference Guides, CBT + Advanced Presentation Fall 2017, Paper

  4. Definitions - Posttraumatic Stress Disorder (DSM-5) • Exposure to actual or threatened death, serious injury, or sexual violence • Presence of intrusive symptoms associated with the event • recurrent distressing memories or dreams, dissociative reactions (flashbacks), distress when exposed to cues or “triggers” • Persistent avoidance of stimuli associated with the event • memories, thoughts, external reminders (people, places, activities) • Negative changes in thoughts and mood associated with the event • Significant changes in arousal and reactivity associated with the event • hypervigilance, irritability, concentration or sleep problems • Problems last at least one month • Clinically significant distress or impairment

  5. Definitions • DSM-5: distinguishes between “traumatic and stressful event(s)” • Traumatic Event: event experienced as threatening and has immediate and/or prolonged effects on functioning in environment and relationships (Kern et al., 2015) • Traumatic Exposure: witnessing or being a victim of an accident or disaster, witnessing or being a victim of violence, physical abuse, sexual abuse, or multiple traumas (Mehtar & Mukkades, 2011) • Stressful events: events that may not have been life-threatening but followed by PTSD-like symptoms (e.g., major arguments with a loved one, bullying, loss, work, life transitions, medical or physical struggles, perceived lack of achievement (APA, 2013; Fuld, 2018; Mevissen et al., 2011)

  6. Social-Cognitive Features Associated with ASD Communication Social Emotional Reciprocity Relationships Restrictive & Repetitive Behaviors Central Coherence Theory of Mind Executive Functioning Face Perception Memory Cognition/ Learning Emotion Recognition, Processing, and Expression

  7. Social-Cognitive Strengths Associated with ASD Rote Memory Visual Processing Attention to Details Analytic Processing Inhibition Exceptional skills Routines Cognition/ Learning Interests Rule based learning

  8. Social-Cognitive Features – Why Important to Consider? • Social-cognitive features associated with ASD may: • Increase risk for trauma • Impact experience of trauma • Necessitate flexibility in treatment

  9. Theories: Susceptibility to the Expression of Trauma Symptoms • More susceptible • Differences in information processing, language comprehension, emotion processing and emotion regulation; experience of social isolation • Neurobiological vulnerabilities to arousal (e.g., increased cortisol levels in response to stressful stimuli) • Less susceptible • Altered ability to interpret or perceive an event as traumatic due to differences in social perception, awareness, and difficulties describing emotional experiences • Similiar to general population

  10. Theories: Increased Risk for Potentially Traumatic Events

  11. Theories: Stressors May Lead to Anxiety “Traumatic conditioning process” • Kerns, Newschaffer, & Berkowitz, 2015; Wood & Gadow, 2010

  12. Theories: Transactional Relationship Between Trauma and ASD Kerns, Newschaffer, & Berkowitz, 2015 - Traumatic Childhood Events and Autism Spectrum Disorder Informed by prior theoretical models proposed by Lazarus & Folkman, 1987; Felitti et al., 1998, Wood & Gadow, 201

  13. What Do We Know About Rates of PTSD? Sleep Challenges • What about PTSD??? Social Impairments PTSD???

  14. Rates of PTSD and Trauma Exposure ASD Samples Challenges No large-scale, well-controlled population studies Participants typically recruited from university clinic samples Assessment tools and approaches varied Studies conducted in multiple countries (Turkey, Finland, France, Sweden, and the Netherlands) Mostly or entirely male samples PTSD assessed in samples of individuals seeking treatment for another anxiety disorder • 0%-17% of individuals with ASD met criteria for PTSD across studies (Brenner et al., 2017; De Bruin et al., 2007; Hofvander et al., 2009; Mehtar & Mukaddes, 2011; Reinvall et al., 2016; Storch et al., 2007) • 17%-56% of youth with ASD exposed to a traumatic event (Mandell et al., 2005; Mehtar & Mukaddes, 2011; Taylor & Gotham, 2016)

  15. Barriers to Identifying Trauma Symptoms • Diagnostic overshadowing (Reiss et al., 1982) • Overlap in ASD and PTSD diagnostic criteria (Brenner et al., 2017; APA, 2013) • ASD symptoms in children with early abuse or neglect (Green et al., 2016; Rutter et al., 1999) • Comorbid conditions with ASD (e.g., anxiety, depression) may obscure presentation • Lack of knowledge of exposure to traumatic event • Challenges with self-reporting (e.g., language; emotional experiences) (Mazefsky et al., 2011; Shalom et al., 2006) • Lack of appropriate assessment measures

  16. Assessment - Diagnosis of PTSD • PTSD typically diagnosed using a structured clinical interview with the caregiver or adult with ASD: • Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime • Diagnostic Interview Schedule for Children IV • Structured Clinical Interview for DSM-IV • Developmental and Well-Being Assessment • Anxiety Disorder Interview Schedule, Child and Parent versions • One study used consensus diagnosis by a treatment team (Brenner et al., 2017) • Family history, caregiver report, and previous medical records helpful in identifying trauma hx and diagnosing PTSD

  17. Assessment - Effect of Traumatic Events on Core Symptoms of ASD Mehtar & Mukaddes, 2011

  18. Traumas and Adversities • Physical and sexual abuse or assault • Exposure to accidents or natural disasters • Witnessing or experiencing violence • Bullying and verbal harassment • Major stressful life events (e.g., separation of parents, family member coping with addiction)

  19. Traumas and Adversities • PTSD-like symptoms: flashbacks, intrusive thoughts, nightmares, sleep and appetite disturbance, crying, bedwetting, fearful behavior, hypervigilance, strong emotional responses to triggers • Increased aggression and disruptive behavior • Decreased social-communication and self-help skills • Suicidal thoughts and suicide attempts • Mood challenges • Sexual acting out and running away from home

  20. Treatment • Modifications of existing treatments for PTSD: • Cognitive Behavioral Therapy • Eye Movement Desensitization and Reprocessing Therapy • Child-Parent Psychotherapy • No studies specifically utilized Trauma-Focused Cognitive Behavioral Therapy • Reported reductions in PTSD symptoms and other symptoms (e.g., aggression, anxiety) • Reported improved quality of life (e.g., relationships, school) and improvement in ASD symptoms (e.g., eye contact, social overtures)

  21. Treatment • Common Treatment Modifications: • Increased involvement and training of family and caregivers • Increased structure in sessions and repetition of concepts • Increased focus on addressing present concerns and current symptoms • Metaphors and visual aids to teach concepts

  22. Assessment and Treatment Applications • Bernier Lab UW ASD Reference Guide 2017 • Bernier Lab UW Trauma and ASD Reference Guide 2017 • Proposed applications of trauma-focused interventions are informed by: • What we know about ASD social-cognitive features and symptoms • ASD Evidence Based Practices • Cognitive Behavioral Therapy for Anxiety in individuals with ASD • Applications of Trauma-Focused Cognitive Behavioral Therapy with children and children with developmental disabilities • Applications of Cognitive Behavioral Therapy based trauma treatment with individuals with intellectual disability • Trauma-Focused Cognitive Behavioral Therapy • Strong empirical support to address trauma • Applications have been developed for various populations • ASD sensitive applications could be effective tx • Research is needed in this area!

  23. Assessment and Treatment Applications • General Treatment Strategies: • Flexibility is key • Adapt to client’s individual needs, developmental level, learning styles • Address most pressing concern – important to inform treatment planning • Increased time and repetition • Caregiver/family involvement • Communication: concrete language, clear instructions, utilize caregivers, augmentative and alternative communication methods, visuals/technology, break down small steps • Social: more time to build rapport, explicitly teach social skills, practice skills in multiple contexts, praise desired behaviors • Restrictive and Repetitive Behaviors: interests can be source of motivation, avoid punishment, capitalize on routine, rule-based learning, structure and repetition • Sensory: identify interests and aversions, relaxation strategies that are mindful of sensory needs

  24. Assessment and Treatment Applications • Trauma-Focused Cognitive Behavioral Therapy: • Trauma Exposure Screening: multiple reporters, augmentative and alternative communication methods, provide lists of symptoms orally/writing, alternate means to share experience (puppets, drawing, cartoons) • Skill-building (psychoeducation, affect modulation, relaxation skills, cognitive coping): tailor to developmental and language levels, additional time and practice, incorporate preferred interests/sensory needs • Trauma narrative: simple and concrete; create through visual aids, short stories, familiar concrete play; draw pictures with short captions

  25. Summary and Future Directions • Limited information about true prevalence as well as perception, experience, and presentation of trauma/PTSD in individuals with ASD • Extant studies support an increased risk of exposure to certain kinds of trauma or adversities and provide possible symptoms to assess for • Various definitions, samples, measures, types of studies in play • Consider core symptoms, challenges, and strengths of individuals with ASD and possible influences on: • 1) risk for experiencing trauma, 2) perception of trauma, 3) treatment • No one size fits all

  26. Summary and Future Directions • Empirical research and cross-discipline collaborations incorporating the perspectives of individuals with ASD • Large-scale studies examining presentation, risk factors, and rates of traumatic stress and trauma exposure in individuals with ASD • Differences in rates, presentation, and treatment response across age and gender • Efficacy of new and existing tools for assessing trauma exposure and symptoms • Applications of evidence-based PTSD treatments for individuals with ASD (e.g., Trauma-Focused Cognitive Behavioral Therapy)

  27. Thank you! • Thank you to the postdoctoral fellows, graduate students, and staff of the Bernier Lab at UW CHDD and Seattle Children’s Autism Center! • Particularly Jessica Berg Peterson, Ph.D., Rachel Earl, M.Ed., Eva Kurtz-Nelson, Ph.D., Emily Fox • Thank you to Lucy Berliner!

  28. Links Bernier Lab UW Trauma and ASD Reference Guide 2017 Bernier Lab UW ASD Reference Guide 2017

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