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AUTISM SPECTRUM DISORDERS ++

AUTISM SPECTRUM DISORDERS ++. DR RUKSANA AHMED - BSC(HONS),CPSYCHOL,AFBPSS CONSULTANT CLINICAL PSYCHOLOGIST 19TH JUNE 2013. AIMS OF PRESENTATION. TYPES OF DIFFICULTIES & DISORDERS THAT CAN ARISE PREVALANCE OF ASSOCIATED DIFFICULTIES & DISORDERS CHALLENGES TO CONSIDERING ASD ++

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AUTISM SPECTRUM DISORDERS ++

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  1. AUTISM SPECTRUM DISORDERS ++ DR RUKSANA AHMED - BSC(HONS),CPSYCHOL,AFBPSS CONSULTANT CLINICAL PSYCHOLOGIST 19TH JUNE 2013

  2. AIMS OF PRESENTATION • TYPES OF DIFFICULTIES & DISORDERS THAT CAN ARISE • PREVALANCE OF ASSOCIATED DIFFICULTIES & DISORDERS • CHALLENGES TO CONSIDERING ASD ++ • CONCLUSIONS & REFLECTIONS DR RUKSANA AHMED - 19.06.13

  3. TYPES OF DIFFICULTIES & DISORDERS THAT CAN ARISE • MEDICAL ISSUES INC SLEEP DISORDERS, GI, GENETIC DISORDERS • NEUROLOGICAL DISORDERS • LEARNING DISABILTIES & SPECIFIC LEARNING DIFFICULTIES • PSYCHIATRIC DISORDERS - INTERNALISING DISORDERS • PSYCHIATRIC DISORDERS - EXTERNALISING DISORDERS DR RUKSANA AHMED - 19.06.13

  4. LEARNING DISABILITIES & SPECIFIC LEARNING DIFFICULTIES • STUDIES SUGGEST THAT APPROXIMATELY 20-70% OF INDIVIDUALS WITH ASD WILL HAVE INTELLECTUAL IMPAIRMENTS • STUDIES SUGGEST 70% IQ LOWER THAN 70 • SPECIFIC PROFILES HAVE BEEN SUGGESTED • IN THE CASE OF CHILDREN & ADOLESCENTS WITH IQ BELOW 70 PROFILE SUGGESTED IS ONE OF BETTER PERCEPTUAL SKILLS OVER VERBAL SKILLS DR RUKSANA AHMED - 19.06.13

  5. LEARNING DISABILITIES & SPECIFIC LEARNING DIFFICULTIES (CONTD) • IN THE CASE OF CHILDREN AND ADOLESCENTS WITH IQ HIGHER THAN 70 STUDIES HAVE SUGGESTED INDIVIDUALS HAVE BETTER VERBAL SKILLS THAN PERCEPTUAL SKILLS, HOWEVER THIS IS NOT ALWAYS THE CASE • EQUALLY AN UNEVEN PROFILE IS OFTEN SEEN BUT AGAIN THIS IS NOT ALWAYS THE CASE • CHILDREN AND ADOLESCENTS MAY HAVE AN IQ ABOVE 70 HOWEVER PRESENT WITH SIGNIFICANTLY IMPAIRED ADAPTIVE SKILLS, DYSEXECUTIVE SYNDROME ETC • THEREFORE NEED TO CONSIDER THE BENEFITS OF COMPLETING NEUROPSYCHOLOGICAL ASSESSMENTS TO PRODUCE INDIVIDUALISED PROFILES DR RUKSANA AHMED - 19.06.13

  6. CO-MORBID PSYCHIATRIC DISORDERS SOME GENERAL FINDINGS • STUDIES SHOW THAT 70% OF CHILDREN AND ADOLESCENTS WITH ASD WILL HAVE ONE OTHER PSYCHIATRIC DISORDER (ANY DISORDER) AND 41% WILL HAVE TWO OR MORE DISORDERS • 31% WILL HAVE THREE OR MORE DISORDERS • THESE CAN INCLUDE INTERNALISING AND EXTERNALISING DISORDERS • IT APPEARS THAT THE TYPE ASD DOES NOT AFFECT PREVALENCE ALTHOUGH SOME SPECIFIC RECENT FINDINGS HAVE CHALLENGED THIS DR RUKSANA AHMED - 19.06.13

  7. CO-MORBID DISORDERS - INTERNALISING DISORDERS • DEPRESSION - SOME STUDIES HAVE SHOWN VARIABLE RATES OF MAJOR DEPRESSIVE DISORDER • ONE STUDY APPEARED TO SHOW LOW RATE OF OCCURRENCE OF 3%, BUT 10% HAD SIGNIFICANT EPISODE OF DEPRESSION NOT MEETING CRITERIA • MORE RECENT STUDIES WITH CHILDREN WITH AS/HFA HAVE FOUND THAT 70% HAD EXPERIENCED ONE EPISODE OF MAJOR DEPRESSION 50% REPORTED RECURRENT EPISODES OF MAJOR DEPRESSION • LINK BETWEEN DEPRESSION AND PSYCHOTIC SYMPTOMS DR RUKSANA AHMED - 19.06.13

  8. CO-MORBID DISORDERS - INTERNALISING DISORDERS (CONTD) • ANXIETY DISORDERS ARE ONE OF MOST COMMON CO-MORBID DISORDERS IN CHILDREN AND ADOLESCENTS WITH ASD, BUT THESE CAN INCLUDE A RANGE OF ANXIETY DISORDERS • SOCIAL ANXIETY CAN BE PRESENT IN 29% • GENERALISED ANXIETY DISORDER 13% • OCD HAS BEEN REPORTED AT LOW RATE OF OCCURRENCE BUT MORE RECENTLY IN CHILDREN AND ADOLESCENTS WITH AS/HFA HAS BEEN SEEN TO BE PRESENT IN 25% DR RUKSANA AHMED - 19.06.13

  9. CO-MORBID DISORDERS - INTERNALISING DISORDERS (CONTD) • SPECIFIC PHOBIAS • PANIC DISORDER 10% • SEPARATION ANXIETY • BIPOLAR DISORDER SEEMS TO EXIST AT AN INCREASED RATE IN CHILDREN AND ADOLESCENTS WITH AS/HFA • PTSD • ENURESIS 10% DR RUKSANA AHMED - 19.06.13

  10. CO-MORBID DISORDERS - EXTERNALISING DISORDERS • THERE ALSO APPEARS TO BE A HIGHER PREVALANCE OF CO-MORBID EXTERNALISING DISORDERS • 29% OF CHILDREN WITH ASD HAVE BEEN REPORTED TO PRESENT WITH ADHD • CONTROVERSIAL DUE TO DIAGNOSTIC SYSTEMS • 28% OF CHILDREN WITH ASD HAVE BEEN REPORTED TO PRESENT WITH OPPOSITIONAL DEFIANT DISORDER DR RUKSANA AHMED - 19.06.13

  11. CO-MORBID DISORDERS - EXTERNALISING DISORDERS (CONTD) • LOWER RATES OF CONDUCT DISORDER • 20% OF CHILDREN WITH ASD HAVE BEEN REPORTED TO PRESENT WITH TOURETTE SYNDROME • CHRONIC TIC DISORDERS ARE ALSO REPORTED AS PREVALENT DR RUKSANA AHMED - 19.06.13

  12. CHALLENGES TO CONSIDERING ADDITIONAL DIFFICULTIES • DIAGNOSTIC OVERSHADOWING • LEARNING/INTELLECTUAL DISABILITY WHERE ALL SYMPTOMS WERE ATTRIBUTED TO MAIN DIAGNOSIS OF LEARNING DISABILITY • THIS IS ALSO THE CASE IN ASD • STANDARDISED TOOLS AND THEIR LACK OF APPROPRIATENESS FOR CHILDREN & ADOLESCENTS WITH ASD DR RUKSANA AHMED - 19.06.13

  13. CHALLENGES TO CONSIDERING ADDITIONAL DIFFICULTIES (CONTD) • VERBAL COMMUNICATION DEFICITS IMPACT ON ABILITY TO ASSESS AND DIAGNOSE CO-MORIBID DISORDERS • DISSONANCE BETWEEN FACIAL EXPRESSIONS AND AFFECT • SYMPTOMS CAN BE ENVIRONMENT SPECIFIC • DIAGNOSTIC CLASSIFICATION SYSTEMS • COMORBID SYMPTOMS AND COMORBID DISORDERS • CULTURAL SHIFT REQUIRED THAT ALLOWS A WILLINGNESS TO CONSIDER OTHER DIFFICULTIES IN A SENSITIVE AND HELPFUL MANNER DR RUKSANA AHMED - 19.06.13

  14. CONCLUSIONS & REFLECTIONS • BENEFITS AND STRENGTHS TO CONSIDERING ADDITIONAL DIFFICULTIES • MORE HOLISTIC ACCURATE REFLECTION OF OUR CHILDREN AND ADOLESCENTS WITH ASD • CAN LEAD TO REDUCTION IN ADDITIONAL DISTRESSING, NEGATIVE SYMPTOMS • POSSIBLE REASON BEHIND TREATMENT RESISTANCE • CAN LEAD TO MORE OPTIMUM OUTCOMES FOR OUR CHILDREN AND YOUNG PEOPLE WITH ASD AND IMPROVEMENTS IN THEIR’S AND THEIR FAMILYS’ QUALITY OF LIFE DR RUKSANA AHMED - 19.06.13

  15. STRATEGIES & INTERVENTIONS TO HELP CHILDREN & ADOLESCENTS WITH ASD WHO ARE ALSO EXPERIENCING ADDITIONAL DIFFICULTIES DR RUKSANA AHMED - 19.06.13

  16. AIMS OF THE PRESENTATION • TO BRIEFLY REVIEW EVIDENCE BASED INTERVENTIONS • TO PROVIDE FURTHER RECOMMENDATIONS ON SPECIFIC STRATEGIES AND INTERVENTIONS FOR CHILDREN AND ADOLESCENTS WITH ASD & LD & CO-MORBID DISORDERS • TO DISCUSS SPECIFIC STRATEGIES AND INTERVENTIONS FOR CHILDREN & ADOLESCENTS WITH ASD & CO-MORBID DISORDERS DR RUKSANA AHMED - 19.06.13

  17. INTERVENTIONS FOR CHILDREN & ADOLESCENTS WITH ASD • PARENT MEDIATED EARLY INTERVENTION • MODIFIED PARENT TRAINING • COMMUNICATION INTERVENTIONS • BEHAVIOURAL INTERVENTIONS - INTENSIVE AND SPECIFIC • MODIFIED COGNITIVE BEHAVIOURAL THERAPY • WORKING WITH SYSTEMS DR RUKSANA AHMED - 19.06.13

  18. SPECIFIC BEHAVIOURAL INTERVENTIONS • CHILDREN AND ADOLESCENTS WITH ASD WHO HAVE LEARNING DISABILITIES WILL OFTEN PRESENT ASSOCIATED DIFFICULTIES THROUGH THEIR BEHAVIOUR • OFTEN ANXIETY, DEPRESSION & MOOD LABILITY CAN PRESENT AS CHALLENGING BEHAVIOUR • THEREFORE NEED TO ASSESS BEHAVIOUR TO TAKE INTO ACCOUNT THE FOLLOWING FACTORS DR RUKSANA AHMED - 19.06.13

  19. FACTORS TO CONSIDER WHEN ASSESSING BEHAVIOUR • CO-MORBID MENTAL HEALTH DIFFICULTIES • COMMUNICATION • ENVIRONMENTAL FACTORS • ANXIETY • BEING UNAWARE OF CONSEQUENCES • DIFFICULTIES UNDERSTANDING OTHERS’ INTENTIONS • REACTIONS TO OTHERS • LACK OF SELF-AWARENESS • BIOLOGICAL FACTORS DR RUKSANA AHMED - 19.06.13

  20. TYPES OF BEHAVIOURS THAT MAY BE OBSERVED • RUNNING • ANXIETY & PANIC • INDISCRIMINATE AROUSAL • REDUCED MOTIVATION & WITHDRAWAL • INCREASE IN RITUALISTIC BEHAVIOURS • AGGRESSION • SELF-INJURIOUS BEHAVIOUR DR RUKSANA AHMED - 19.06.13

  21. PRIORITISING BEHAVIOURAL INTERVENTIONS • ONCE CO-MORBID DIFFICULTIES HAVE BEEN IDENTIFIED CAN THEN PRIORITISE SPECIFIC BEHAVIOURS AS PART OF MULTI-MODAL INTERVENTION • BEHAVIOUR IS DANGEROUS • EFFECT ON OTHERS • INTERFERENCE & RESTRICTION • SOCIALLY INAPPROPRIATE BEHAVIOUR DR RUKSANA AHMED - 19.06.13

  22. ANALYSIS OF BEHAVIOUR • BASIC ANALYSIS • DEFINING THE BEHAVIOUR • TOPOGRAPHY • CYCLE • COURSE • STRENGTH DR RUKSANA AHMED - 19.06.13

  23. FUNCTIONAL ANALYSIS • SYSTEMATIC TECHNIQUE OF COLLECTING INFORMATION FROM WHICH HYPOTHESES & STRATEGIES CAN BE DERIVED • ABC CHARTS- ANTECEDENTS, BEHAVIOUR, CONSEQUENCES • STAR MODEL DR RUKSANA AHMED - 19.06.13

  24. PROACTIVE MANAGEMENT STRATEGIES • CONTEXTUAL & ENVIRONMENTAL FACTORS • STRUCTURE & ROUTINE • STRUCTURED TIME • UNSTRUCTURED TIME • USE OF VISUAL AIDS DR RUKSANA AHMED - 19.06.13

  25. PROACTIVE MANAGEMENT STRATEGIES(CONTD) • COMMUNICATION SYSTEMS • POSITIVE REINFORCEMENT • REWARD SYSTEMS • ANXIETY & STRESS REDUCTION STRATEGIES • SKILLS REPLACEMENT • SYSTEMS APPROACH DR RUKSANA AHMED - 19.06.13

  26. REACTIVE MANAGEMENT STRATEGIES • MODEL OF PHASES OF BEHAVIOUR • STRATEGIES DEPENDENT UPON PHASE OF BEHAVIOUR • TRIGGER PHASE • BUILD-UP PHASE • EXPLOSION PHASE • RECOVERY PHASE DR RUKSANA AHMED - 19.06.13

  27. TRIGGER PHASE STRATEGIES • WHERE APPROPRIATE REMOVAL OF TRIGGER • DISTRACTION STRATEGIES • ANXIETY MANAGEMENT STRATEGIES • COMMUNICATION DR RUKSANA AHMED - 19.06.13

  28. BUILD-UP PHASE STRATEGIES • PROMPTING • REMINDERS • SIDE-STEPPING STRATEGIES • CALMING DOWN & ANXIETY REDUCTION TECHNIQUES • CHANGING DEMAND DR RUKSANA AHMED - 19.06.13

  29. EXPLOSION PHASE STRATEGIES • RISK ASSESSMENT • ‘CLEARING THE DECKS’ • GETTING SUPPORT & HELP • USE OF SAFE SPACE • ‘LOW KEY’ VERBAL RESPONSES DR RUKSANA AHMED - 19.06.13

  30. RECOVERY PHASE STRATEGIES • TIME • LIMITED INTERACTIONS/ EXPLANATIONS • NEUTRAL INTERACTION IF NECESSARY • AT APPROPRIATE TIME GETTING BACK TO ROUTINE DR RUKSANA AHMED - 19.06.13

  31. ADDITIONAL ISSUES RELEVANT TO BEHAVIOURAL MANAGEMENTOF ADDITIONAL DIFFICULTIES • RETURN TO & MAINTAIN PROACTIVE STRATEGIES • REGULAR MONITORING & REVIEW • COMBINED USE OF PHARMACOLOGICAL & NON-PHARMACOLOGICAL INTERVENTIONS • FAMILY SUPPORT DR RUKSANA AHMED - 19.06.13

  32. CBT FOR CHILDREN WITH AS/ASD & ADDITIONAL DIFFICULTIES • BENEFIT OF CBT FOR CHILDREN WITH PSYCHOLOGICAL DIFFICULTIES IS WELL ESTABLISHED • CHILDREN WITH ASD HAVE A RANGE OF COGNITIVE, SOCIAL & EMOTIONAL ABILITIES AND CBT NEEDS TO BE MODIFIED TO TAKE THIS INTO ACCOUNT • MODIFIED CBT FOR CHILDREN & ADOLESCENTS WITH ASD & ANGER, ANXIETY AND DEPRESSION HAS BEEN DEVELOPING OVER THE LAST FEW YEARS DR RUKSANA AHMED - 19.06.13

  33. MODIFICATIONS THAT NEED TO BE CONSIDERED • AFFECTIVE EDUCATION • MEANINGFUL & CONCRETE MEASURES OF EMOTIONS • COGNITIVE RESTRUCTING • TECHNIQUES • GENERALISATION ISSUES DR RUKSANA AHMED - 19.06.13

  34. AFFECTIVE EDUCATION • GOAL IS TO INFORM CHILDREN & ADOLESCENTS ABOUT EMOTIONS, WHAT THESE LOOK LIKE, HOW THEY ARE EXPRESSED & UTILISED • RANGE OF TECHNIQUES CAN BE USED TO DO THIS INCLUDING SCRAP BOOK WITH PICTURES ETC • LEVEL OF EMOTIONAL AWARENESS & UNDERSTANDING & DISCREPANCIES BETWEEN ASSUMPTIONS CAN BE IDENTIFIED AT THIS STAGE • THIS STAGE OF THERAPY CAN TAKE PLACE OVER SEVERAL SESSIONS DR RUKSANA AHMED - 19.06.13

  35. COGNITIVE RESTRUCTURING & THE EMOTIONAL TOOLBOX • COGNITIVE RESTRUCTURING REFERS TO THE CHALLENGING & REFORMULATION OF COGNTIVE DISTORTIONS & DYSFUNCTIONAL BELIEFS THAT CAN ARISE IN MOOD DISORDERS • THE EMOTIONAL TOOLBOX HAS BEEN DEVELOPED AS A SPECIFIC TECHNIQUE FOR COGNITIVE RESTRUCTURING WITH CHILDREN & ADOLESCENTS WITH AS DR RUKSANA AHMED - 19.06.13

  36. THE EMOTIONAL TOOLBOX • DIFFERENT TYPES OF TOOLS IN THE TOOLBOX • PHYSICAL TOOLS • RELAXATION TOOLS DR RUKSANA AHMED - 19.06.13

  37. THE EMOTIONAL TOOLBOX (CONTD) • SOCIAL TOOLS PETS HELPING OTHERS • SPECIAL INTEREST TOOLS PROVIDES AN EXPERIENCE OF ENJOYMENT, SECURITY, COMFORT & RELAXATION & ALLOWS FACILITATION/AVOIDANCE OF SOCIAL INTERACTIONS DR RUKSANA AHMED - 19.06.13

  38. THE EMOTIONAL TOOLBOX (CONTD) • OTHER TOOLS MEDICATION – SUPPORTS CHILD’S UNDERSTANDING & COMPLIANCE WITH PHARMACOLGICAL INTERVENTION ENVIRONMENTAL TOOLS REINFORCERS & MOTIVATORS • INAPPROPRIATE TOOLS VIOLENCE, RETALIATION, SELF-INJURY, SUICIDAL THOUGHTS FANTASY WORLDS – BOUNDARY ISSUES ADOLESCENTS – USE OF DRUGS & ALCOHOL DR RUKSANA AHMED - 19.06.13

  39. FURTHER SUGGESTIONS FOR MODIFICATIONS TO CBT (CONTD) • USE OF TECHNOLOGY INCREASE IN RESEARCH SUGGESTING THE BENEFITS OF USING TECHNOLOGY • GENERALISATION OF SKILLS CHILDREN WITH ASD HAVE ONGOING DIFFICULTIES OF GENERALISING SKILLS ACROSS CONTEXTS • PARENTAL INVOLVEMENT PARENTS AS CO-THERAPISTS • SYSTEMIC ISSUES & INTERVENTIONS DR RUKSANA AHMED - 19.06.13

  40. CONCLUSIONS • MODIFIED BEHAVIOURAL INTERVENTIONS CAN CONTRIBUTE TO HELPING CHILDREN WITH ASD & ASSOCIATED DIFFICULTIES • MODIFIED CBT IS CLINICALLY VALUABLE AS INTERVENTION FOR CHILDREN & ADOLESCENTS WITH ASD & ASSOCIATED DIFFICULTIES • HOWEVER ONGOING CHALLENGES REMAIN; DEVELOPMENT OF APPROPRIATE MEASURES, SYSTEMATIC EVALUATION & RESEARCH NEEDED AND RESOURCE IMPLICATIONS DR RUKSANA AHMED - 19.06.13

  41. SHARED CHALLENGES & MOVING FORWARD TOGETHER DR RUKSANA AHMED - 19.06.13

  42. DIAGNOSTIC CLASSIFICATION SYSTEMS • RESOURCE ISSUES • STIGMA & DISCRIMINATION • SERVICE MODELS • RESEARCH • TRAINING DR RUKSANA AHMED - 19.06.13

  43. REFERENCES Attwood T. "Frameworks for behavioral interventions." Child Adolesc Psychiatr Clin N Am. 2003 Jan;12(1):65-86. Caron C, Rutter M. Comorbidity in child psychopathology: concepts, issues and research strategies. J Child Psychol Psychiatry. 1991;32: 1063-1081.2005;186:115-120. Ghaziuddin M, Tsai L, Ghaziuddin N. Comorbidity of autistic disorder in children and adolescents. Eur Child Adolesc Psychiatry. 1992;1: 209-213. Lainhart JE, Folstein SE. Affective disorders in people with autism: a review of published cases. J Autism Dev Disord. 1994;24:587-601. Santosh P, Mijovic A. Social impairment in hyperkinetic disorder: relationship to psychopathology and environmental stressors. Eur Child Adolesc Psychiatry. 2004;13:141-150. Simonoff E, Pickles A, Wood N, Gringras P, Chadwick O. ADHD symptoms in children with mild intellectual disability. J Am Acad Child Adolesc Psychiatry. 2007;46:591-600. Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas , T. & Baird, G. Psychiatric Disorders in Children with Autism Spectrum Disorders: Prevalance, Comoribity, and Asssociated Factors in a Population-Derived Sample.. J . Am . Acam . Child Adolesc . Psychiatry , 2008; 47: 8 , Sofronoff K, Attwood T, Hinton S, Levin I. "A Randomized Controlled Trial of a Cognitive Behavioural Intervention for Anger Management in Children Diagnosed with Asperger Syndrome." Autism Dev Disord. 2006 Nov 3. Sofronoff K, Attwood T, Hinton S. "A randomised controlled trial of a CBT intervention for anxiety in children with Asperger syndrome. J Child Psychol Psychiatry. 2005 Nov;46(11):1152-60. DR RUKSANA AHMED - 19.06.13

  44. THANK YOU!! drruksanaahmed@gmail.com DR RUKSANA AHMED - 19.06.13

  45. DR RUKSANA AHMED - 19.06.13

  46. DR RUKSANA AHMED - 19.06.13

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