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 3rd 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

• 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
• How Do we Identify Fear & Anxiety in Individuals with ASD?

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
• ther 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

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%

Turner & Romanczyk (2012)

Top 10 Fears Rated by Parents of Children with ASD

n = 41

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)

BIACA – Building Confidence

▫ 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

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)

• So, the focus of intervention is on the
• acquisition of new ways of behaving.
• Underlying assumption is that fear/anxiety

is learned (e.g., Watson & Raynor, 1920)

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

• Attwood & Scarpa, 2013; McNally Keehn et al., 2013; Reaven et al., 2011; White et al., 2015; Wood et al., 2015

▫ Positive self-talk, self-instructions

• Specific Skills – Coping & Problem Solving

▫ Cognitive Restructuring

– Challenge irrational beliefs & faulty thinking patterns – Increased focus on flexible thinking

▫ “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

Step 2 Continued. A Relatively New Approach for Individuals with ASD: Acceptance

Eilers & Hayes, 2015; Dixon, 2014; Hayes et al., 2001, 2012; Hoffman et al., 2016; Pahnke et al., 2014; Spek et al., 2013

• 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

• Acceptance & Commitment Therapy

▫ A form of CBT; based on behavior analytic theory

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

*Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008)

• 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)

Graduated Exposure – Developing a Fear Hierarchy*

*Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008)

• Following a multi-component and

individualized assessment, collaboratively develop a fear hierarchy

– Direct observation; interview with individual and caregivers

• 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

• Ensure consistent success before moving on to

next step!

▫ Can have individuals rate their anxiety during contact with stimulus to ensure success

Graduated Exposure – Using a Fear Hierarchy*

*Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008)

• Provide contingent reinforcement* for

approach responses and absence of fear responses

▫ Importance of identifying effective reinforcers ▫ Include goal setting

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

Involving Parents…Even though this is the last slide, this is one of the most important parts of CBT!

• Parent training is important – “Co-therapists”

▫ Continue skills learned in sessions at home (e.g., psycho-education, coping skills, exposure exercises, contingency management) ▫ Target parenting behavior and the parent-child relationship

• Some support for a focus on parent anxiety

▫ Parents of children with ASD have more anxiety (and stress and depression) than parents without a child with ASD ▫ High parental anxiety is associated with negative

• child outcomes

Creswell et al., (2008); Kuusikko-Gauffun et al., 2013; Reaven & Blakeley-Smith, 2013

lbturner@usj.edu