Addressing Mental Health Problems in Youth on the Spectrum: - - PowerPoint PPT Presentation

1

Addressing Mental Health Problems in Youth on the Spectrum: Individual and Contextual Solutions

Jonathan A. Weiss, Ph.D., C.Psych.

Oklahoma Statewide Autism Conference, November 2018

2

Overview

• Individual-contextual approach to mental health
• The individual as the target
• The family as target
• The community as target

3

Mental health problems in youth with autism

• 4-5x greater than youth in the general population (Totsika et
• al. 2011)
• 70% will meet criteria for at least one psychiatric disorder,

and many meet criteria for multiple conditions (Simonoff et al., 2008)

• Overall rates may be inflated due to miscoding autism

symptoms, but the same pattern emerges (Mazefsky et al, 2012)

4

It’s not just about autism

19 22 18 84 64 74 63 46 42 87 65 71 10 20 30 40 50 60 70 80 90 100 Hyperactivity Conduct problems Emotional problems % Comparison ASD ID ASD/ID

• Population based study of 5 to 16 year olds in the UK; M

age = 10 years (SD = 3.0) (Totsika et al., 2011)

5

It’s not just about kids

Weiss et al. (2017)

Young adults (18-24 years of age)

6

It’s not just about anxiety

• Transdiagnostic processes
• Anxiety can be the tip of

the iceberg

• Depression and anxiety

are correlated with externalizing issues (noncompliance, aggressive behaviour, and irritability)

• Many psychiatric

diagnoses at the same time

7

Interactions (Wood & Gadow, 2010)

In Wood, J., & Gadow, K. (2010). Clinical Psychology: Science and Practice, 14, 281-291.

8

Take a moment

• Think about a child / teen / adult

Domains Biological Psychological Social- Relationship Social- Environmental Factors Genetic, developmental, medical, toxicity, tempermental factors Cognitive style, psychological conflicts, self- image, meaning, schema Family, peers,

• thers

Culture/ethnicity, social risk factors, systems issues Predisposing (vulnerabilities) Precipitating (stressors) Perpetuating (maintaining) Protective (strengths)

Winters, N. C., Hanson, G., & Stoyanova, V. (2007). The case formulation in child and adolescent psychiatry. Child and Adolescent Psychiatric Clinics of North America, 16, 111-132.

9

Health is Developmental- Contextual

http://www.beststart.org/

10

Move beyond a deficit focused approach

• The absence of mental health problems is not exactly

the same thing as good mental health

• If I were to ask you to describe how mentally healthy you

are, what words would you use?

• Positive outcomes need to be defined by positive

constructs

• If I were to ask you to describe what successful living

means to you, what words would you use?

11

A role for positive psychology

• Most of the field of developmental disabilities has been

a deficit and pathology model (Dykens, 2006)

• Understanding what’s wrong with people only tells us so

much about what contributes to people doing well

(Seligman, 2002)

• Happiness, flow, thriving beyond simply reducing

psychological suffering

• In the general population, it is related to improved problem

solving, learning, health and longevity (Fredrickson, 2001)

• More work is needed
• To inform operationalization and measurement, and

ultimately to treatment planning

12

Mental health as an individual- contextual developmental process

Key ecological assets in school, family, and community:

• Positive people
• Physical and institutional

resources

• Collective activity
• Positive opportunities

Key individual strengths (including intentional self- regulation):

• Academic
• Cognitive
• Social
• Physical
• Emotional

Positive Development: Competence Confidence Connections Character Caring Contribution to: Self Family Community Civic society Internalizing and externalizing problems (mental health problems) +

• Mueller… Lerner et al., 2011

13

ORIGINAL PAPER

Thriving in Youth with Autism Spectrum Disorder and Intellectual Disability

Jonathan A. Weiss1 • Priscilla Burnham Riosa1

The Author(s) 2015. This article is published with open access at Springerlink.com

Abstract Most research on mental health in individuals with autism spectrum disorder (ASD) and intellectual dis- ability (ID) has focused on deficits. We examined indi- vidual (i.e., sociocommunicative skills, adaptive behavior, functional cognitive skills) and contextual (i.e., home, school, and community participation) correlates of thriving in 330 youth with ID and ASD compared to youth with ID

• nly, 11–22 years of age (M = 16.74, SD = 2.95). Youth

with ASD and ID were reported to thrive less than peers with ID only. Group differences in sociocommunicative ability and school participation mediated the relationship 2014; Simonoff et al. 2008; White et al. 2009). In the most recent CDC (2014) report, 31 % of youth with ASD had intellectual skills in the ID range (with another 23 % in the borderline range), although estimates across studies range widely, from 26 to 68 % (CDC 2012; Fombonne 2005; Yeargin-Allsopp et al. 2003). We also know a great deal about the correlates of these pervasive needs, at individual (e.g., age, sex, diagnosis: Anagnostou et al. 2014), family (e.g., parent stress: Witwer and Lecavalier 2008), and more distal social levels (e.g., socio-economic status: Emerson and Hatton 2007). Understandably, research has largely

J Autism Dev Disord DOI 10.1007/s10803-015-2412-y

Mental health is not just about symptom alleviation

Competence Confidence Connectedness Caring Character Contribution

14

Components of thriving

• Competence: My child has the skills to succeed in school, in

social situations with friends and adults, in play, and at home. My child knows how to behave and does what is needed to do well.

• Confidence: My child believes that he/she can succeed and

do what is needed to do well in the family, in school, in social situations with friends and adults, in play and in other areas that are important to him/her (for example, sports, music, religious activities).

• Connectedness: My child has positive relationships with

his/her parents, siblings, and other family members, and with friends, teachers, coaches, or mentors

Adapted with permission from the 4-H Study of Positive Youth Development. PI: Richard M. Lerner, Tufts University

15

Components of thriving

• Caring: My child cares about other people. He or she is concerned

about whether others have what they need (shows sympathy) and shows a sense of compassion (empathy). My child is both sympathetic and empathetic to others.

• Character: My child knows what is right and wrong; and does the

right thing; My child is open to others’ perspectives and believes in social justice for all. My child is honest.

• Contribution to self/others/community: My child tries to do things

to help the family, to help neighbors, and to help the community. My child tries to also help himself/herself by staying healthy (eating right, exercising, getting enough sleep).

Adapted with permission from the 4-H Study of Positive Youth Development. PI: Richard M. Lerner, Tufts University

16

ASD status Thriving

c’

Cognitive ability Sociocommunicative Home participation School participation Community participation

a (p < .001) a (p < .01) b (p < .001) b (p < .001) b (p < .01) b (p < .001)

Adaptive behaviour

a (p < .001)

Age Gender

17

We can work with the individual

• In any one domain, or in many, we can struggle
• It may also be our relative strength

Self- regulation Cognitive Academic Social Physical Emotional Spiritual

18

Lots of manuals

• Facing Your Fears (Reaven, et

al., 2011). Paul Brookes.

• Child anxiety disorders: A

family-based treatment manual for practitioners (Wood, et al., 2008). WW Norton & Co.

• Exploring Feelings (anger /

anxiety) Attwood, 2004). Future Horizons.

• Coping Cat (Kendall & Hedtke,

2006). Workbook Pub.

19

Where’s the evidence?

• Overall effectiveness of CBT
• Recent systematic review and meta analysis (Weston,

Hodgekins & Langdon, 2016)

• 48 studies met inclusion criteria
• High risk of bias
• 24 studies addressed affective problems
• 17 were < 18 years
• 15 group based
• 19 targeted anxiety
• 14 were RCTs
• Small to medium effect sizes, when using informant report or

clinician ratings

19

20

Where’s the evidence?

• CBT reduces symptoms of anxiety
• Most between 8 – 15 years of age
• Usually 14-16 sessions, but can go as high as 32
• 50% to 70% show considerable improvement
• We know little in terms of long term maintenance
• Participants without ID
• Perhaps anger (Sofronoff, Attwood, Hinton, & Levin, 2007)
• Maybe emotion regulation (
• ABA to shape behaviour, including reducing maladaptive

behaviour, evidence base throughout development (Wong et

• al. 2013)
• Focus on shaping individual behaviour, but also address

contingencies with environment and antecedent strategies can involve altering the environment

21

Categories of issues and challenges reported by therapists

• Rigidity or B&W thinking
• Pacing (needing to go slower)
• Communication issues (e.g., literal

use of language)

• Problems with therapeutic

relationship

• Adaptive or including written

materials

• Difficulty recognizing and

understanding emotions

• Co-occurring problems

and problem identification

• Difficulties generalizing
• Systemic factors
• Not completing

homework

• Sensory issues

Cooper, K., Loades, M., Russell, A. Adapting psychological therapies for

• autism. Research in Autism Spectrum Disorders, 45, 43-50.

22

CBT to focus on emotion regulation

23

An RCT to evaluate CBT targeting emotion regulation: SAS:OR

The Secret Agent Society: Operation Regulation was developed by Dr. Renae Beaumont (University of Queensland, Australia), based on the evidence-based Secret Agent Society Support from the CIHR Chair in ASD Treatment and Care Research

24

Review of Materials

• Handbooks
• Cadet Handbook
• Parent Handbook
• Teacher Handouts
• Facilitator Manual
• Weekly therapist forms
• Weekly parent/child feedback forms
• SAS-OR Session Materials:
• Challenge Card
• Manipulatives: Codecards, holder,

stress ball

• Emotionometer and Stickers
• Computer game

25

Parent report of ER

• Overall emotion regulation in social situations (ERSSQ)
• F (1, 57) = 12.94, p = .001, d = .96
• Pairwise
• TI change, p < .001 vs WLC change, p =.59

26

• Overall psychiatric symptom severity (ADIS Severity

Score)

• F (1, 57) = 4.56, p = .04, d = .56
• Pairwise
• TI change, p < .001 vs WLC change, p =.54

Clinician ratings

27

Where’s the evidence?

• Recent attention to mindfulness-based therapy (Cachia

et al. 2016)

• 6 studies identified: 3 pre-post design, 2 multiple baseline

design, 1 employed an RCT

• Anxiety and thought problems in children
• Aggression, well-being and social responsiveness in

teens

• Reduced anxiety, depression and rumination in adults

28

But

• CBT (ERP) vs. anxiety management therapy to address

OCD in teens and adults with autism (Russell et al. 2013)

• CBT vs. non-directive person-centered counselling to

address anxiety in teens with autism (Murphy et al. 2017)

• CBT vs. MBSR to address anxiety and depression in adults

with autism (Sizoo & Kuiper, 2017)

• Group CBT vs. group recreational activities for adults with

autism to improve quality of life, self-esteem and psychiatric symptoms (Hesselmark, Plenty & Beejerot, 2014)

• CBT vs. a social recreation program in adolescents with

autism to address anxiety (Sung et al. 2011)

• CBT vs. treatment as usual to address anxiety disorders in

adults with autism (Langdon et al. 2016)

29

MYMind: Parent-youth concurrent treatment

Youth

• awareness, self-control,

distress tolerance Parents

• impact of reactivity, attend

to youth non-judgmentally, acceptance of youth and their own feelings about parenting

Funded by Kids Brain Health Network (formerly NeuroDevNet)

30

Where’s the evidence?

• Psychotropic medication use (Jobski, Hofer, Hoffman &

Bachmann, 2016)

• 47 studies
• Some evidence for “ASD related irritability” children and

teens, ADHD medication for ADHD symptoms in ASD

• Evidence for anti-depressants is very limited
• Many reviews seems to suggest the need for far more

work and some form of caution in use of medication to address mental health problems (Dove et al., 2012; McPheeters et al., 2011)

31

We can work with broader contexts

• Context matters greatly

Social inclusion Personal resources Positive people Collective activity Positive

• pportunities

Positive places Institutional resources

32

Parental positive affect is a resiliency factor

33

Positive peers

• Peer relationships or supports
• The challenge of inclusive education (Rotheram-Fuller, Kasari,

Chamberlain & Locke, 2010)

• Less likely to be accepted and fewer reciprocal friendships
• More likely to be isolated or peripheral to social

relationships, with increasing isolation with grade

• “Promoting children with ASD’s skills in popular activities

to share with peers in early childhood may be a key preventive intervention...”

• Social inclusion is the experience of belonging while

participating in meaningful social activities

34

Positive peers

Theme 1: Connectedness Theme 2: Training in Sport

35

Positive people

• Mentorship

programs

• SFU’s Autism

Mentorship Program

• York U’s Asperger

Mentorship Program

Supporting students on the autism spectrum

student mentor guidelines

By Catriona Mowat, Anna Cooper and Lee Gilson

36

Positive opportunities

• Self-reported recreation activities as moderator of the

relation of perceived stress and QoL in adults with autism (Bishop-Fitzpatrick, Smith DaWalt, Greenberg, & Mailick, 2017)

Bishop-Fitzpatrick, L., Smith DaWalt, L., Greenberg, J. S., & Mailick, M. R. (2017). Participation in recreational activities buffers the impact of perceived stress on quality of life in adults with autism spectrum disorder. Autism Research, 10(5), 973–982. http://doi.org/10.1002/aur.1753

37

Working with communities

38

39

http://bcove.me/0y5opj7c

40

Final thoughts

n Skills to manage stress n Good physical health and physical activity n Sense of control over one’s life n Reciprocal, non-stressful relationships n Caregivers who are nurtured and supported to promote mental health in those they care for n A safe place to live and learn n An environment with limited stresses n Meaningful activities in community

Individual Family Environment Society

41

• Identify at least two things you learned during this

presentation to apply in your personal or professional life.

• Identify three steps you will take in the next month to

implement what you learned in your personal or professional life

42

Thank you! Questions?

Jonathan Weiss, PhD,CPsych Associate Professor

• Dept. of Psychology

York University jonweiss@yorku.ca Tel: 416-736-5891

http://www.tedxyorkusalon.org http://asdmentalhealth.blog.yorku.ca/

43

References

• Cachia, R. L., Anderson, A., & Moore, D. W. (2016). Mindfulness in Individuals with Autism

Spectrum Disorder: a Systematic Review and Narrative Analysis. Review Journal of Autism and Developmental Disorders, 3(2), 165–178.

• Dykens, E. M. (2006). Toward a positive psychology of mental retardation. American

Journal of Orthopsychiatry, 76(2), 185–193.

• Mazefsky, C. A., Oswald, D. P., Day, T. N., Eack, S. M., & Minshew, N. J. (2012). ASD, a

psychiatric disorder, or both? Psychiatric diagnoses in adolescents with high-functioning

• ASD. … Child & Adolescent …, 41(4), 516–523.
• Mueller, M. K., Phelps, E., Bowers, E. P., Agans, J. P., Urban, J. B., & Lerner, R. M. (2011).

Youth development program participation and intentional self-regulation skills: Contextual and individual bases of pathways to positive youth development. Journal of Adolescence, 34(6), 1115–1125.

• Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008).

Psychiatric Disorders in Children With Autism Spectrum Disorders: Prevalence, Comorbidity, and Associated Factors in a Population-Derived Sample. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 921–929.

44

References

• Sofronoff, K., Attwood, T., Hinton, S., & Levin, I. (2007). A randomized controlled trial of a

cognitive behavioural intervention for anger management in children diagnosed with Asperger syndrome. Journal of Autism and Developmental Disorders, 37(7), 1203–1214.

• Taylor, J. L., & Seltzer, M. M. (2012). Developing a Vocational Index for Adults with Autism

Spectrum Disorders. Journal of Autism and Developmental Disorders, 42(12), 2669–2679.

• Tint, A., Thomson, K., & Weiss, J. A. (2017). A systematic literature review of the physical

and psychosocial correlates of Special Olympics participation among individuals with intellectual disability. Journal of Intellectual Disability Research, 61(4), 301–324.

• Totsika, V., Hastings, R. P., Emerson, E., Berridge, D. M., & Lancaster, G. A. (2011).

Behavior Problems at 5 Years of Age and Maternal Mental Health in Autism and Intellectual Disability. Journal of Abnormal Child Psychology, 39(8), 1137–1147.

• Rotheram-Fuller, E., Kasari, C., Chamberlain, B., & Locke, J. (2010). Social involvement of

children with autism spectrum disorders in elementary school classrooms. Journal of Child Psychology and Psychiatry, 51(11), 1227–1234.

45

References

• Sung, M., Ooi, Y. P., Goh, T. J., Pathy, P., Fung, D. S. S., Ang, R. P., … Lam, C. M. (2011). Effects of

Cognitive-Behavioral Therapy on Anxiety in Children with Autism Spectrum Disorders: A Randomized Controlled Trial. Child Psychiatry & Human Development, 42(6), 634–649.

• Weiss, J. A. (2014). Transdiagnostic Case Conceptualization of Emotional Problems in Youth with ASD:

An Emotion Regulation Approach. Clinical Psychology: Science and Practice, 21(4), 331–350.

• Weiss, J. A., & Burnham Riosa, P. (2015). Thriving in Youth with Autism Spectrum Disorder and

Intellectual Disability. Journal of Autism and Developmental Disorders, 45(8), 2474–2486.

• Weiss, J. A., Cappadocia, M. C., Tint, A., & Pepler, D. (2015). Bullying Victimization, Parenting Stress,

and Anxiety among Adolescents and Young Adults with Autism Spectrum Disorder. Autism Research, 8(6), 727–737.

• Weiss, J. A., Thomson, K., Burnham Riosa, P., Albaum, C., Chan, V., Maughan, A., … Black, K. (2018).

A randomized waitlist-controlled trial of cognitive behavior therapy to improve emotion regulation in children with autism. Journal of Child Psychology and Psychiatry.

46

References

• Weiss, J. A., Isaacs, B., Diepstra, H., Wilton, A. S., Brown, H. K., McGarry, C., & Lunsky, Y.

(2017). Health Concerns and Health Service Utilization in a Population Cohort of Young Adults with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders.

• Weston, L., Hodgekins, J., & Langdon, P. E. (2016). Effectiveness of cognitive behavioural

therapy with people who have autistic spectrum disorders: A systematic review and meta-

• analysis. Clinical Psychology Review.
• Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S., … Schultz, T.
• R. (n.d.). Evidence-Based Practices for Children, Youth, and Young Adults with Autism

Spectrum Disorder: A Comprehensive Review. Journal of Autism and Developmental Disorders.

• Winters, N. C. (2007). The case formulation in child and adolescent psychiatry., 16(1),

111– 132.

• Wood, J. J., & Gadow, K. D. (2010). Exploring the Nature and Function of Anxiety in Youth

with Autism Spectrum Disorders. Clinical Psychology: Science and Practice, 17(4), 281- 292.