Rutgers, The State University of New Jersey SAMANTHA J. HERRICK Ph.D, CRC, NCC Department of Psychiatric Rehabilitation and Counseling Professions Idaho partnerships conference on human services October 8, 2015 (3:15-4:30pm) Autism Spectrum Disorder: The Professionals Tool Kit Department of Psychiatric Rehabilitation & Counseling Professions Presentation Summary Autism label in DSM-5 Autism Incidence rates Characteristics of People with ASD Common Secondary Diagnoses & Possible misdiagnoses Psychosocial Aspects of ASD Promising Practices Considerations for Counselors and related Professionals (The Counselor's Tool Kit) DSM-5, ASD Diagnostic criteria (Appendix A) DSM-5, ASD Severity Scale (Appendix B) Department of Psychiatric Rehabilitation & Counseling Professions DSM-IV-TR to DSM-5 DSM-5 label Autism Spectrum Disorder Replaced 4 of 5 DSM-IV-TR labels under Pervasive Developmental Disorders I. Autistic Disorder II. Childhood Disintegrative Disorder III. Aspergers Disorder IV. Pervasive Developmental Disorder-NOS A.Social Communication B.Restricted interests & repetitive behaviors 1.Level 1 - Requiring support 2.Level 2 - Requiring substantial support 3.Level 3 -Requiring very substantial support Department of Psychiatric Rehabilitation & Counseling Professions Rationale for Change of label 1.Difficulties with differentiating between ASDs and non- spectrum disorders 2.Difficulties with differentiating between the PDD diagnostic category labels 3.Variations in labeling across different environments 4.Diagnoses was being determined based upon 1.Severity 2.Language level 3.Intelligence (rather than diagnostic features) (APA, 2012) Department of Psychiatric Rehabilitation & Counseling Professions Rationale for Change of label 5. Autism is defined by a common set of behaviors, and therefore should be represented by a single diagnostic category 6. Concerns about the possible inflation of Autism Statistics 7. ASD, a single diagnostic label, is more representative of our current knowledge about pathology and clinical presentation 8. Previous efforts to label diagnoses were like trying to: cleave meatloaf at the joints (A PA, 2012) Department of Psychiatric Rehabilitation & Counseling Professions Changes from DSM-IV-TR to DSM-5 Diagnostic Category change: From Disorders Usually First Diagnosed in Infancy to Neurodevelopmental Disorders Subcategory: From Pervasive Developmental Disorders to Autism Spectrum Disorder Department of Psychiatric Rehabilitation & Counseling Professions Changes from DSM-IV-TR to DSM-5 Under the current criteria (DSM-IV-TR), a person can qualify for the diagnosis by exhibiting 6 or more of 12 behaviors In DSM 5: would have to exhibit: 3 deficits in social interaction and communication and at least 2 repetitive behaviors Department of Psychiatric Rehabilitation & Counseling Professions Changes from DSM-IV-TR to DSM-5 Three deficit domains become two: 1.Social/communication deficits (all 3 must be present) 1.Deficits in social-emotional reciprocity 2.Deficits in nonverbal communicative behaviors used for social interaction 3.Deficits in developing and maintaining relationships Department of Psychiatric Rehabilitation & Counseling Professions Changes from DSM-IV-TR to DSM-5 cont. 2. Fixated interests and repetitive behaviors (must have two of these four) 1.Stereotyped or repetitive speech, motor movements, or use of objects 2.Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior 3.Highly restricted, fixated interests that are abnormal in intensity or focus; 4.Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment (APA, 2012) Department of Psychiatric Rehabilitation & Counseling Professions Changes from DSM-IV-TR to DSM-5 cont. DSM-IV, multiple criteria tended to assess the same symptom and held too much weight in diagnosis; therefore these have been streamlined Greater need for multiple sources of information including clinical observation and reports from parents/caregivers/teachers due to a need to meet a higher proportion of criteria. One category with new level of severity scale (APA, 2012) Department of Psychiatric Rehabilitation & Counseling Professions ASD Levels of Severity New ASD Label will use a 3 point Level of Severity rating in the two domains now needed to satisfy a diagnosis of ASD: A.Social Communication B.Restricted interests & repetitive behaviors 1.Level 1 - Requiring support 2.Level 2 - Requiring substantial support 3.Level 3 -Requiring very substantial support Department of Psychiatric Rehabilitation & Counseling Professions Autism Spectrum Disorder Prevalance Autism Rates Nationally: 1 in 68, 8-year-olds (CDC, 2012) Autism Rates New Jersey: Highest Rates in the US 1 in 45; 8-year-olds (CDC, 2010) due largely to mandated early screening Autism Spectrum Disorder This summer 50, 000 people with ASD turn 18 yrs. old Department of Psychiatric Rehabilitation & Counseling Professions Asperger Syndrome There is a sub-culture within the ASD community that identifies with an Asperger Syndrome label They regard ASD as an evolutionary advancement ASD, specifically Aspergers as a cultural difference This cultural identification has a positive psychosocial affect on the individual Department of Psychiatric Rehabilitation & Counseling Professions ASD Cause? Cause is unknown There is no cure Believed to be due to a combination of genetic and environmental factors NOT due to vaccinations! Department of Psychiatric Rehabilitation & Counseling Professions ASD Characteristics Significant impairment social skill development Difficulties with abstract thinking Adjustment to change in routine is very difficult Maintain a very narrow focus on a single interest Area of interest may be quite unique (Attwood, 1998) Department of Psychiatric Rehabilitation & Counseling Professions ASD Characteristics Impairment in reading and understanding non-verbal cues Very Literal; significant impairment in non-literal verbal expression such as idiom and metaphoric language Often display stereotypical behaviors, repetitive movements/habits Poor ability to take the perspective of others (Attwood, 1998) Department of Psychiatric Rehabilitation & Counseling Professions ASD Characteristics cont. Poor understanding of empathy Deficits in social reciprocation Most often are male; at least 5 times as likely (suggesting genetic component) Poor insight into deficits (Attwood, 1998; Bosacki, 2000) Department of Psychiatric Rehabilitation & Counseling Professions ASD Characteristics cont. Reduced coping skills; emotional liability Sensory sensitivity o clothing o lighting o heating/cooling o noise o smell, etc. Proxemics - may have a need for more personal space (Attwood, 1998; Bosacki, 2000) Department of Psychiatric Rehabilitation & Counseling Professions ASD Characteristics cont. Difficulties with eye contact Generally not adept at lying (tend to be honest; to a fault) Gross and/or fine motor deficits athletics writing typing construction tasks labor intensive jobs etc. (Attwood, 1998; Bosacki, 2000) Department of Psychiatric Rehabilitation & Counseling Professions ASD Characteristics cont. Difficulty with executive functions o time management o organization o multi-tasking May display odd behaviors Repetitive behaviors Toe tapping Rocking etc. (Attwood, 1998; Bosacki, 2000) Department of Psychiatric Rehabilitation & Counseling Professions Common Secondary Diagnoses High incidence/co-morbidity and may also be treated for: DEPRESSION ANXIETY Obsessive Compulsive Disorder (OCD) Attention Deficit Hyperactivity Disorder (ADHD/ADD) PTSD? (Thierfeld-Brown, & Wenzel, 2010) Department of Psychiatric Rehabilitation & Counseling Professions Possible Misdiagnoses Risk of misdiagnosis: Major Depression Generalized Anxiety Disorder Obsessive Compulsive Disorder (OCD) Schizophrenia Schizoaffective Disorder Bi-Polar Disorder I or II Attention Deficit Disorder (ADHD/ADD) (Thierfeld-Brown, & Wenzel, 2010) Department of Psychiatric Rehabilitation & Counseling Professions Psychosocial Aspects of ASD Social isolation (can be extreme) Feeling misunderstood (and they really are) Feelings that the world is cruel Difficulties forming relationships/friendships High levels of frustration Are regarded by others as weird or freaks Subjected to teasing/bullying! May be verbally/physically abused by others Department of Psychiatric Rehabilitation & Counseling Professions Challenges with Community Participation Informal social interactions Work related interviews, environment, relationships Communicating needs to others Hobbies (involving others) Working or studying in groups Participation in community activities, religious activities, etc. Forming relationships: friendships, romantic, dating Involvement with legal system. Usually due to misunderstanding or strange behavior Department of Psychiatric Rehabilitation & Counseling Professions General Promising Interventions/Practices Behavioral Therapy/training Applied Behavioral Analysis Positive Behavioral Supports Functional Behavioral Assessment Cognitive-Behavioral Therapies Occupational and/or Physical therapy Department of Psychiatric Rehabilitation & Counseling Professions General Promising Interventions/Practices Cont. Family support and/or training Medication (for secondary symptoms) Counseling (individual and/or group) Social Skills Training Individual Classes Small group settings Department of Psychiatric Rehabilitation & Counseling Professions Teaching Strategies Visual/picture Supports Department of Psychiatric Rehabilitation & Counseling Professions Teaching Strategies cont. Video Modeling Video self modeling Video other modeling Department of Psychiatric Rehabilitation & Counseling Professions Teaching Strategies cont. Video Priming Audio prompting Department of Psychiatric Rehabilitation & Counseling Professions General Promising Interventions/Practices Cont. Any intervention should include: foster self-awareness and self-esteem teach new skills while reinforcing those previously learned make social rules clear and concrete model age appropriate interactions use natural re-enforcers for social initiation Department of Psychiatric Rehabilitation & Counseling Professions General Promising Interventions/Practices Cont. teach simple scripts for common social interactions reinforce social response attempts model and role play skills review socially appropriate and inappropriate behaviors (individual or group work) with video or audio tape Department of Psychiatric Rehabilitation & Counseling Professions Promising Interventions cont.: use multiple trainers and people with which to practice skills involve parents in training (if possible) provide opportunities to practice skills in safe natural settings use time between sessions to practice skills (homework) Department of Psychiatric Rehabilitation & Counseling Professions Considerations for Professionals Including: fostering a nurturing and fun environment begin with easy skills and progress to those that are more difficult initiate peer interaction (social networking) Orchestrate gatherings/events (Thierfeld-Brown, & Wenzel, 2010) Department of Psychiatric Rehabilitation & Counseling Professions Considerations for Professionals use multiple trainers and people on which to practice newly learned skills create opportunities to practice skills in safe environment in naturally occurring settings Do not touch clients with AS, even in passing Be aware that they may need more personal space than is typical (Thierfeld-Brown, & Wenzel, 2010) Department of Psychiatric Rehabilitation & Counseling Professions Considerations for Professionals o Be sensitive to and aware of sensory environment o perfume/cologne, o lighting, o heating/cooling, o volume of audio, o Noise in office o Office dcor o etc. ) o Reduce or limit your direct eye contact; at least initially (Thierfeld-Brown & Wenzel, 2010) Department of Psychiatric Rehabilitation & Counseling Professions Considerations for Professionals o Be careful not to use idiom or metaphoric language; be very literal o State communications verbally that might ordinarily be communicated non-verbally o Be aware of their heightened sense of anxiety, depression o be prepared to refer for counseling services if needed (Thierfeld-Brown & Wenzel, 2010) Department of Psychiatric Rehabilitation & Counseling Professions Considerations for Professionals o Be prepared to make medication referral (for secondary symptoms) o Be prepared to refer for or provide career counseling and advocacy o Be prepared to refer to provide social skills training o PLEASE be aware of risk of suicide/suicide ideation! (Thierfeld-Brown & Wenzel, 2010) Department of Psychiatric Rehabilitation & Counseling Professions QUESTIONS QUESTIONS SAMANTHA J. HERRICK Ph.D, CRC, NCC Rutgers, The State University of New Jersey Department of Psychiatric Rehabilitation and Counseling Professions Department of Psychiatric Rehabilitation & Counseling Professions References American Psychiatric Association (2012). American psychiatric Association: DSM-5 Development. Author. Retrieved fromon May 25, American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., TR). Washington, DC: Author. Attwood, T. (1998). Aspergers syndrome: A guide for parents and professionals. Philadelphia, PA: Jessica Kingsley Publishers. Bosacki, S. L. (2000). Theory of mind and self-concept in pre-adolescents: Links with gender and language. Journal of Educational Psychology, 92(4), Kiker Painter, K. (2006). Social skills groups for children and adolescents with Aspergers Syndrome: A step-by- step program. London and Philadelphia: Jessica Kingsley Publishers. Department of Psychiatric Rehabilitation & Counseling Professions References McPartland, J. C., Reichow, B., & Volkmar, F. R. (2012). Sensitivity and Specificity of Proposed DSM-5 Diagnostic Criteria for Autism Spectrum Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 51(4), Moyes, R. (2003). I need help with school! A guide for parents of children with autism and Asperger Syndrome. Arlington, TX: Future Horizons, Inc. Ozonoff, Dawson, & McPartland, (2002). A parents guide to Asperger Syndrome & high- functioning autism. New York, NY: Guilford Press. Thierfeld-Brown, J. & Wenzel, C. (2010, June) Social Dyslexia and Students with Autism/Asperger's Syndrome. Presentation for the Postsecondary Disability Training Institute. Saratoga, NY. Williams White, S., Keonig, K., & Scahill, L. (2007). Social skills development in children with Autism Spectrum Disorders: A review of the intervention literature. Journal of Autism and Developmental Discord, 37, Department of Psychiatric Rehabilitation & Counseling Professions Appendix A DSM-5: Diagnostic Criteria The American Psychiatric Association (APA, 2012): Autism Spectrum Disorder Must meet criteria A, B, C, and D: A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following: 1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction, Department of Psychiatric Rehabilitation & Counseling Professions 2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body- language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures. 3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people Department of Psychiatric Rehabilitation & Counseling Professions B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: 1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases). 2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes). Department of Psychiatric Rehabilitation & Counseling Professions 3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects). Department of Psychiatric Rehabilitation & Counseling Professions C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) D. Symptoms together limit and impair everyday functioning. Department of Psychiatric Rehabilitation & Counseling Professions Appendix B DSM-5 Autism Spectrum Disorder Severity Scale Department of Psychiatric Rehabilitation & Counseling Professions Severity Level for ASDSocial Communication Restricted interests & repetitive behaviors Level 1 Requiring support Without supports in place, deficits in social communication cause noticeable impairments. Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. Rituals and repetitive behaviors (RRBs) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRBs or to be redirected from fixated interest. Department of Psychiatric Rehabilitation & Counseling Professions Severity Level for ASD Social Communication Restricted interests & repetitive behaviors Level 2 Requiring substantial support Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others. RRBs and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress or frustration is apparent when RRBs are interrupted; difficult to redirect from fixated interest. Department of Psychiatric Rehabilitation & Counseling Professions Severity Level for ASDSocial Communication Restricted interests & repetitive behaviors Level 3 Requiring very substantial support Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others. Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres. Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly.