Evidence-Based Practices for Treating Fear & Anxiety in Children - PowerPoint PPT Presentation

� Evidence-Based Practices for Treating Fear & Anxiety in Children & Adolescents with ASD � Laura B. Turner, Ph.D., BCBA-D � � Presented at the Hudson Valley Regional Center for Autism Spectrum Disorders 3 rd Annual Spring Conference – 04/29/2016 �

The purpose of this presentation is to provide… � 1. An overview of the prevalence of fear and anxiety in children and adolescents with ASD � 2. An overview of evidence-based approaches for alleviating anxiety in children and adolescents with ASD � 3. Additional readings and resources for you to be able to learn more about these techniques �

Starting with Definitions: Fear and Anxiety �

How Do we Identify Fear & Anxiety in Individuals with ASD? � • It depends on the individual’s cognitive and social-communicative abilities � • Verbalizations (content) & Vocalizations (volume, tone) � • Facial expressions � • Caution: Individuals with ASD can display atypical expression of emotional states, contextually- incongruous emotional reactions, and unreliable and atypical fearful facial expressions � • Body tenseness � • Approach/avoidance behaviors � • Noncompliance, aggression, self-injury & self-stimulatory behavior � � Hagopian & Jennett, 2008 • Issues related to diagnostic overshadowing and symptom overlap �

With those caveats…fears and anxiety disorders are highly prevalent among children & adolescents with ASD � • Approximately 40% have an anxiety disorder (APA, 2013; Leyfer et al., 2006; Muris et al., 1998; Simonoff et al., 2008; Sukhodolsky et al., 2008) (<20% in general population) � ▫ Specific Phobia: 9% - 64% (5-16% of children/adolescents without ASD) � ▫ Social Anxiety Disorder: 8% - 30% (7% of children/adolescents without ASD) � ▫ Generalized Anxiety Disorder: 2% - 23% (<1% of children/adolescents without ASD) � • Children with ASD have more intense fears than children with other developmental and intellectual disorders (Evans et al., 2005; Rodgers et al., 2011) � • Atypical presentation of fear (Evans et al., 2005; Gillis et al., 2009; Turner & Romanczyk, 2012) � ▫ More likely to have fears related to medical/dental procedures � ▫ Less likely to have fears of dangerous situations and items that could cause harm ��

Top 10 Fears Rated by Parents of Children with ASD � Rank � Fear Item � “A lot of fear” � 1 � Getting Blood Drawn � 64% � 2 � Getting a Shot � 54% � 3 � Getting Teeth Cleaned � 36% � 4 � Making Mistakes � 29% � 5 � Insects � 29% � 6 � Finger Prick � 28% � 7 � The Dark � 16% � 8 � Doctor Exam � 15% � 9 � Severe Weather � 15% � 10 � Meeting Peers � 14% � n = 41 � Turner & Romanczyk (2012) �

When to seek help? � • Does the fear/anxiety interfere with the individual’s ability to learn or gain independent skills? � • Is the fear/anxiety abnormally intense? � • Does the fear/anxiety interfere with everyday activities? � • Are there associated dangerous behaviors? �

Seeking Help: An Evidence-Based Approach to Overcoming Excessive Fear and Anxiety � • Cognitive Behavior Therapy (CBT) � ▫ Much empirical support for the effectiveness of CBT for children and adolescents without ASD (e.g., Kazdin & Weisz, 2003; Kendall, 2000) � ▫ Growing body of support for the effectiveness of CBT for high functioning children and adolescents with ASD (e.g., Reaven et al., 2011; Wood et al., 2015) � – Must match approach to the cognitive, language and social-emotional abilities of the individual � BIACA – Building Confidence

What is CBT? � • An approach that merges theory and techniques from behavior and cognitive therapy � ▫ Cognitive: Behavior is a function of faulty thinking and irrational beliefs (Beck, 1972) � ▫ Behavioral: Behavior (including verbal behavior) is a function of the environment (e.g., Skinner, 1938) � • Underlying assumption is that fear/anxiety is learned (e.g., Watson & Raynor, 1920) � • So, the focus of intervention is on the � � � acquisition of new ways of behaving. � � �

Step 1. Psycho-Education: Recognizing Your Anxiety � • Evaluating & developing emotional competence � ▫ Typically need to spend more time on this step than with individuals without ASD � • Identification of idiosyncratic internal cues � ▫ How do I know I’m anxious? � • Identification of idiosyncratic external triggers � ▫ What situations make me anxious? � • Linking behavior, thoughts and feelings � ▫ Self-monitoring �

Step 2. Teaching Alternative Skills � � • Specific Skills – Coping & Problem Solving � ▫ Cognitive Restructuring � – Challenge irrational beliefs & faulty thinking patterns � – Increased focus on flexible thinking � ▫ Positive self-talk, self-instructions � ▫ “Worry time” � ▫ Relaxation techniques, e.g., � – Diaphragmatic breathing � – Progressive muscle relaxation � • Teaching Considerations � ▫ Incorporation of concrete language and examples & visuals � ▫ Use prompts and reinforcers � ▫ Teach to fluency in a calm state � ▫ Program for generalization � Attwood & Scarpa, 2013; McNally Keehn et al., 2013; Reaven et al., 2011; White et al., 2015; Wood et al., 2015 �

Step 2 Continued. A Relatively New Approach for Individuals with ASD: Acceptance � • Acceptance & Commitment Therapy � ▫ A form of CBT; based on behavior analytic theory � • Focus isn’t on changing private events (i.e., thoughts and feelings); rather, focus is placed on changing the way an individual reacts to those thoughts and feelings. � • A few components: � ▫ Mindfulness – contact with present moment � ▫ Defusion of thoughts � Eilers & Hayes, 2015; Dixon, 2014; Hayes et al., 2001, 2012; Hoffman et al., 2016; Pahnke et al., 2014; Spek et al., 2013 �

Considerations for Conducting Sessions � • Talking about private events (e.g., thoughts and emotions) can be non-preferred, unpredictable and difficult… � • Motivation – Make it fun! � ▫ Consider motivation to change and to attend sessions � ▫ Incorporate reinforcers for participation � ▫ Incorporate idiosyncratic interests � � • Schedule � ▫ Inclusion of clear session and activity schedules � ▫ Schedules & reminders for CBT homework � Attwood & Scarpa, 2013; McNally Keehn et al., 2013; Reaven et al., 2011; White et al., 2015; Wood et al., 2015 �

Step 3. Graduated Exposure* � • ALL forms of CBT include this component - Considered the most important! • Effective for lower-functioning children with ASD • Gradually and systematically place the individual in contact with the feared stimuli(us) ▫ Respondent Extinction: Shape approach responses to break the association between the conditioned stimulus (e.g., a dog) and the unconditioned stimulus (e.g., loud bark) so the individual can learn a new association ▫ It is important that the feared stimulus not be paired with aversive events (including extreme anxiety responses) and the individual not be able to escape the situation (i.e., operant extinction) – Consideration: Preventing escape is correlated with more aggression in children with an ASD than typically developing children (Evans et al., 2005) *Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008) �

Graduated Exposure – Developing a Fear Hierarchy* � • Following a multi-component and individualized assessment, collaboratively develop a fear hierarchy – Direct observation; interview with individual and caregivers *Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008) �

Graduated Exposure – Using a Fear Hierarchy* � • Start with situation that elicits mild anxiety – ensure success with approaching! � ▫ Importance of clearly defining responses � • Provide prompts * (e.g., verbal, visual, model *) to engage in the approach behavior � • Provide contingent reinforcement * for approach responses and absence of fear responses � ▫ Importance of identifying effective reinforcers � ▫ Include goal setting � • Ensure consistent success before moving on to next step! � ▫ Can have individuals rate their anxiety during contact with stimulus to ensure success � *Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008) �

Making Exposure Collaborative by Incorporating Choice: An Example � “I’m afraid you’re going to cut my pinky toe” �

Important to Include Social Skills Training � • Particularly important when individual has social phobia � ▫ Poor social skills can produce negative outcomes for social exposures �