Understanding emotions and Understanding emotions and behaviour in behaviour in Autism and Autism and

AspergerAsperger’’s Disorders Disorder

Dr Avril V. BreretonDr Avril V. BreretonProf Bruce J. TongeProf Bruce J. Tonge

Monash UniversityMonash UniversityCentre for Developmental Psychiatry & PsychologyCentre for Developmental Psychiatry & Psychology

Do children with HFA and AD Do children with HFA and AD have emotional problems?have emotional problems?

A number of studies have been conducted. A number of studies have been conducted. All All have found increased anxiety and have found increased anxiety and depression in children with Autism and AD depression in children with Autism and AD compared to other childrencompared to other children

Recent study at Monash University has Recent study at Monash University has followed 110 children with autism and followed 110 children with autism and their families for the past 10 yearstheir families for the past 10 years

Autism: Autism: Behavioural and Emotional Behavioural and Emotional

Disturbance Over TimeDisturbance Over TimeBruce TongeBruce Tonge11, Avril Brereton, Avril Brereton11

Stewart EinfeldStewart Einfeld22, David Moseley, David Moseley11

John TaffeJohn Taffe11, Kylie Gray, Kylie Gray11 & Emma Lourey& Emma Lourey11

11Monash University, Centre for Developmental Psychiatry & Monash University, Centre for Developmental Psychiatry & Psychology Psychology

22University of New South Wales, School of PsychiatryUniversity of New South Wales, School of Psychiatry

National Health & Medical Research Council of AustraliaNational Health & Medical Research Council of Australia

DEPRESSIONDEPRESSION

DEPRESSEDDEPRESSED

CRIESCRIES

IRRITABLEIRRITABLE

LOW SELF ESTEEMLOW SELF ESTEEM

DEPRESSIONDEPRESSION

T1T1

14%14% -- Autism with depressionAutism with depression

9%9% -- nonnon--autism with depressionautism with depression

DEPRESSIONDEPRESSION

0

0.2

0.4

0.6

0.8

1

T1 T2 T3 T4

Autism Non-austismScores significantly higher (p <.001) for autism. No

significant effect of gender or level of ID

ANXIETYANXIETY

SEPARATION ANXIETYSEPARATION ANXIETY

FEARS / PHOBIASFEARS / PHOBIAS

TENSE / WORRIEDTENSE / WORRIED

ANXIETYANXIETY

T2T2

15%15% -- Autism with anxietyAutism with anxiety

7%7% -- nonnon--autism with anxietyautism with anxiety

ANXIETYANXIETY

0

0.2

0.4

0.6

0.8

1

T1 T2 T3 T4

Autism Non autismScores significantly higher (p <.001) for autism. No

significant effect of gender

TYPE OF PHOBIA IN AUTISMTYPE OF PHOBIA IN AUTISM

NoiseNoise 48%48%

New New 13%13%

EnvironmentEnvironment 12%12%

Doctor / DentistDoctor / Dentist 15%15%

Animals / insectsAnimals / insects 12%12%

Haircuts / sticky surfaces / T.V. programsHaircuts / sticky surfaces / T.V. programs

Co MorbidityCo Morbidity

AUTISM EPI

Depression%

Anxiety%

Depression%

Anxiety%

ADHD 23.2 16.4 21.2 15.2

Depression 44.0 18.4

Why?Why?

LetLet’’s consider the s consider the features of High features of High

Functioning Autism Functioning Autism and ADand AD

3 Core problems in Autism3 Core problems in Autism

Abnormal language developmentAbnormal language development

Abnormal social developmentAbnormal social development

Restricted, rigid & repetitive patterns of Restricted, rigid & repetitive patterns of behaviour and interestsbehaviour and interests

High Functioning AutismHigh Functioning Autism

High functioning refers to the level of High functioning refers to the level of cognitive ability.cognitive ability.IQ >70 (no Intellectual Disability)IQ >70 (no Intellectual Disability)NOT a mild form of autismNOT a mild form of autismNOT AspergerNOT Asperger’’s Disorders Disorder

Clinically Clinically significant significant language language delay delay

Intact Intact language language developmentdevelopment

Social Social impairmentimpairment

Stereotyped Stereotyped / Repetitive / Repetitive behaviourbehaviour

AspergerAsperger’’s s DisorderDisorder

HighHigh--functioning functioning AutismAutism

Communication Problems in ADCommunication Problems in AD

language acquisition follows normal/accelerated language acquisition follows normal/accelerated pattern butpattern but……content of speech is pedanticcontent of speech is pedanticlittle facial expressionlittle facial expressioninappropriate tone of voice, monotonous intonationinappropriate tone of voice, monotonous intonationgood verbal memory skills, absorb facts easilygood verbal memory skills, absorb facts easilypoor social comprehension despite superior verbal poor social comprehension despite superior verbal skillsskills

Social impairment in ADSocial impairment in ADhighly anxious with a dislike of any form of criticismhighly anxious with a dislike of any form of criticism

are seen to be are seen to be ‘‘oddodd’’ or or ‘‘eccentriceccentric’’, impaired in acquiring & , impaired in acquiring & retaining social retaining social ‘‘knowledgeknowledge’’

impairment in two impairment in two -- way social interaction with an inability way social interaction with an inability to understand the rules governing social behaviour, may be to understand the rules governing social behaviour, may be easily ledeasily led

impairment in joint attentionimpairment in joint attention

victims of teasing and bullying in mainstream settingvictims of teasing and bullying in mainstream setting

difficulties remembering who people are but remember difficulties remembering who people are but remember events/statementsevents/statements

Cognitive characteristics lead to Cognitive characteristics lead to difficulties with:difficulties with:

Cause & effect relationshipsCause & effect relationshipsFocus on detailsFocus on detailsSequencingSequencingUnderstanding of timeUnderstanding of timeCompulsivenessCompulsivenessDistractibilityDistractibility

anxiety anxiety and stress at and stress at school, homeschool, home& in community & in community

Emotional & Emotional & behavioural behavioural problemsproblems……

Approaches to treatmentApproaches to treatment

Do you know about each childDo you know about each child’’s s

-- learning style learning style

-- the impact of core processing the impact of core processing problems on his/her behaviour problems on his/her behaviour and emotions? and emotions?

Find out by asking yourself and Find out by asking yourself and others these 10 questions!others these 10 questions!

1. What are the child1. What are the child’’s strengths, weaknesses & s strengths, weaknesses & emerging skills? emerging skills? Cognitive (IQ) assessmentCognitive (IQ) assessment

2. Any particular areas of interest or talent?2. Any particular areas of interest or talent?

3. Does the child understand cause and effect 3. Does the child understand cause and effect relationships?relationships?

4. Is the child easily distracted? List4. Is the child easily distracted? List

5. Does the child recognise when a task is finished?5. Does the child recognise when a task is finished?

6. What does the child remember easily? What6. What does the child remember easily? What’’s s difficult to remember?difficult to remember?

7. How does the child like to know what7. How does the child like to know what’’s coming s coming next?next?

8. Does the child adapt to new situations easily?8. Does the child adapt to new situations easily?

9. How does the child respond to being 9. How does the child respond to being wrong/corrected?wrong/corrected?

10. What does the child do when confused or 10. What does the child do when confused or anxious?anxious?

GeneralGeneral

Help parents Help parents -- education and skills training education and skills training Improve communication Improve communication (visual augmentation)(visual augmentation)

Reduce and plan for changeReduce and plan for changeReward achievementReward achievementImprove social skills Improve social skills (social stories, comic strip review, (social stories, comic strip review, role play)role play)

Schedule and expand activities of interestSchedule and expand activities of interest

Social StoriesSocial Stories –– Carol GrayCarol Gray

A Social StoryA Social Story™™ describes a situation, skill, or describes a situation, skill, or concept.concept.

The goal of a Social StoryThe goal of a Social Story™™ is to share accurate is to share accurate social information in a reassuring manner that is social information in a reassuring manner that is easily understood by the child.easily understood by the child.

This strategy aims to improve the child's This strategy aims to improve the child's understanding of events and encourage understanding of events and encourage appropriate behaviour.appropriate behaviour.

Social stories:Social stories:from the childfrom the child’’s perspectives perspective

Meaningfully shares social Meaningfully shares social information information

Answers Answers ““whwh”” questions and uses positive languagequestions and uses positive language

Always contains descriptive sentences. May also include Always contains descriptive sentences. May also include perspective, cooperative, directive, affirmative, and/or perspective, cooperative, directive, affirmative, and/or control sentences.control sentences.

Has a format that is tailored to the abilities and Has a format that is tailored to the abilities and interests of the childinterests of the child

Includes individually tailored illustrations/photos that Includes individually tailored illustrations/photos that enhance the meaning of the text.enhance the meaning of the text.

DepressionDepression

Parent education and well beingParent education and well beingReward achievementReward achievementPromote self esteem Promote self esteem (success activities, social stories)(success activities, social stories)

Modified CBT Modified CBT (positive thoughts, comic strip review, (positive thoughts, comic strip review, schedule pleasant events)schedule pleasant events)

AntidepressantsAntidepressants (fluoxetine)(fluoxetine)

AnxietyAnxiety

Define stressorsDefine stressorsModify environmentModify environmentParent education and well beingParent education and well beingModified CBT Modified CBT (e.g. relaxation exercises, role play, graded (e.g. relaxation exercises, role play, graded exposure to fears)exposure to fears)

Stress debriefingStress debriefing (e.g. social stories)(e.g. social stories)

Anxiolytics Anxiolytics (SSRIs, Imipramine, Buspirone, Neuroleptics)(SSRIs, Imipramine, Buspirone, Neuroleptics)

I feel anxious and worried when…

I am in a new place

I don’t know the answer to a questionThere are a lot of people around me I lose my things

Too many people talk to me

I don’t know what to do

When I am anxious and worried I…

Feel hot and sweaty

Feel my heart beating fast

Feel like I have to go to the toiletFeel like hiding somewhere

My hands sweat

Feel like I want to hit someone or break something

A pocket sized reminder cardA pocket sized reminder card

When I’m worried or upset I can –Ignore the person or thing upsetting me.Count to 10 and take deep breathsWalk wayFind a teacherTalk to a friendAsk my friends to explain what is happeningUse the power of my voice to tell someone how I feel

ADHDADHD

Developmentally excessive : Developmentally excessive : InattentivenessInattentivenessDistractibilityDistractibilityHyperactivityHyperactivityImpulsivenessImpulsiveness

ADHDADHD

Schedule staged activities with visual promptsSchedule staged activities with visual promptsReduce distractionsReduce distractionsInteract to scaffold activitiesInteract to scaffold activitiesMedication Medication –– stimulants stimulants (short (short –– long acting)long acting)

-- AtomoxetineAtomoxetine-- ClonidineClonidine-- ImipramineImipramine-- NeurolepticsNeuroleptics (haloperidol, risperidone)(haloperidol, risperidone)

PHARMACOTHERAPYPHARMACOTHERAPY

Attention Deficit Hyperactivity Attention Deficit Hyperactivity

symptoms.symptoms.

•• Stimulants (dexamphetamine, methylphenidate ). Stimulants (dexamphetamine, methylphenidate ). •• TCATCA’’s ( imipramine in typical children, 20s ( imipramine in typical children, 20--50mg/day).50mg/day).•• NaltrexoneNaltrexone•• Atomoxetine, novel, effective in typical children .Atomoxetine, novel, effective in typical children .

PHARMACOTHERAPYPHARMACOTHERAPY

Attention Deficit Hyperactivity Attention Deficit Hyperactivity

symptoms.symptoms.

•• Stimulants (dexamphetamine, methylphenidate ). Stimulants (dexamphetamine, methylphenidate ). •• 10+ double blind cross10+ double blind cross--over trails N=10over trails N=10--30 in ID/autism30 in ID/autism66..•• Dose0.3Dose0.3--0.6mg/dose.0.6mg/dose.•• Reduces hyperactivity, inattention & impulsiveness but less thanReduces hyperactivity, inattention & impulsiveness but less than

for typical children.for typical children.•• Higher risk of side effects: irritability, withdrawal, tics, insHigher risk of side effects: irritability, withdrawal, tics, insomnia.omnia.•• Teachers report more benefit than parents.Teachers report more benefit than parents.

PHARMACOTHERAPYPHARMACOTHERAPY

Frustration, Rage, Aggression,Frustration, Rage, Aggression,

Disruptive Behaviour and Withdrawal.Disruptive Behaviour and Withdrawal.

•• Neuroleptics :risperidone is the drug of choice.Neuroleptics :risperidone is the drug of choice.•• Naltrexone : may reduce selfNaltrexone : may reduce self--injurious behaviour and injurious behaviour and

hyperactivity. Parenteral, shorthyperactivity. Parenteral, short--term use.term use.•• AntiAnti--convulsants : some evidence for valproate & convulsants : some evidence for valproate &

carbamazepine but not lamotrigine . carbamazepine but not lamotrigine . •• Lithium :single case studies in adults with ID & autism.Lithium :single case studies in adults with ID & autism.

WhatWhat’’s going on?s going on?

A case studyA case study

DBCDBC--P P (parent / carer version)(parent / carer version)

96 items (95 + 96 items (95 + ‘‘overalloverall’’))Within the past 6 monthsWithin the past 6 months

Scored 0, 1, 2Scored 0, 1, 20=not true as far as you know0=not true as far as you know1=somewhat/sometimes true1=somewhat/sometimes true2=very true/often true2=very true/often true

DBCDBC--T T (teacher version)(teacher version)

93 items 93 items

DBCDBC--P sleep disturbance items P sleep disturbance items removedremoved

Item added Item added ‘‘unpopular with other unpopular with other childrenchildren’’

ScoringScoring

Add up scores to calculate:Add up scores to calculate:

1.1. Total Behaviour Problems Score Total Behaviour Problems Score (TBPS)(TBPS)

2.2. Scores on 5 factorsScores on 5 factors

SubscalesSubscales

5 subscales5 subscalesDisruptive / AntisocialDisruptive / AntisocialSelfSelf--AbsorbedAbsorbedCommunication DisturbanceCommunication DisturbanceAnxietyAnxietySocial RelatingSocial Relating

DBC case studyDBC case study

10 year old boy10 year old boy

AutismAutism

Moderate intellectual disabilityModerate intellectual disability

TouretteTourette’’s syndromes syndrome

Teacher reportTeacher reportPast few weeks sudden change in Past few weeks sudden change in behaviour:behaviour:

Mood swings for no apparent reasonMood swings for no apparent reasonVariable performance from day to dayVariable performance from day to daySuicidal thoughts and comments (Suicidal thoughts and comments (““If I jumped off a If I jumped off a bridge no one would carebridge no one would care””))Tics worseTics worse–– head shaking, shoulder shrugging, head shaking, shoulder shrugging, grimacing, throat clearing grimacing, throat clearing Difficult classroom behaviour Difficult classroom behaviour –– nonnon--compliant, refusal compliant, refusal to work, not involved in any group activitiesto work, not involved in any group activities

Parent reportParent report

Not eatingNot eatingNot sleepingNot sleepingTics worseTics worseHuge tantrums over changes in routineHuge tantrums over changes in routineRenewed his old obsession with a Renewed his old obsession with a collection of wood off cuts collection of wood off cuts (slept with them (slept with them in a case, never out of his sight)in a case, never out of his sight)

WorkupWorkup

How to make sense of this range of How to make sense of this range of emotional and behavioural problems?emotional and behavioural problems?

Initial discussion with teacher and Initial discussion with teacher and parents. Neither could identify any parents. Neither could identify any precipitating events at school or home precipitating events at school or home other than some disruption to routine other than some disruption to routine because of ongoing extensions to the because of ongoing extensions to the househouse

WorkupWorkup

DBCDBC was completed by parents and was completed by parents and teacher :teacher :

high high TBPSTBPShigh score on high score on social relatingsocial relating subscale subscale (worsening of autism symptoms e.g. social (worsening of autism symptoms e.g. social avoidance, resistance to change, obsessions) avoidance, resistance to change, obsessions)

very high score on very high score on anxietyanxiety subscalesubscale

WorkupWorkup

Consultation with child psychiatrist Consultation with child psychiatrist --What was making Sean so anxious? What was making Sean so anxious? Why the return to earlier Why the return to earlier ““autisticautistic””behaviour?behaviour?

Draw a dream Draw a dream –– revealed thisrevealed this……

TreatmentTreatmentHome: Discussion with parents Home: Discussion with parents –– cause of his cause of his regression was grief and confusion about the regression was grief and confusion about the death of his cousin. Took him to the grave, death of his cousin. Took him to the grave, photographs of cousin in his room, visits to photographs of cousin in his room, visits to the cemetery with flowers whenever he the cemetery with flowers whenever he wantedwanted

School: Discussion with teachers (as above). School: Discussion with teachers (as above). Integration aide Integration aide –– discussion about what had discussion about what had happened during his 1:1 sessions with her happened during his 1:1 sessions with her instead of work when he wantedinstead of work when he wanted

OutcomeOutcome

After 4 weeks of treatment Sean came After 4 weeks of treatment Sean came back to the clinic. back to the clinic.

DBC TBPS score reduced DBC TBPS score reduced no longer an elevated anxiety scoreno longer an elevated anxiety scorereduced social relating scorereduced social relating score

““Some people go to hospital when they are Some people go to hospital when they are sick. Nathan was at the hospital. He cansick. Nathan was at the hospital. He can’’t t

get fixed but other people canget fixed but other people can””..

New collection:New collection:A first aid kit!A first aid kit!

For more information about Autism For more information about Autism visit our websitevisit our website

http://www.med.monash.edu.au/spppm/http://www.med.monash.edu.au/spppm/research/devpsych/actnow/project.htmlresearch/devpsych/actnow/project.html

Or just Google Or just Google ––

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