Autism Spectrum Disorder Arianne Wallace PhD Clinical Psychologist Research Scientist Clinical Director Bernier Lab CHDD University of Washington Lucy Berliner MSW Director Harborview Center for Sexual Assault and Traumatic Stress ID: 775013
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Addressing Trauma in Therapy with Individuals with Autism Spectrum Disorder
Arianne Wallace, PhD
Clinical Psychologist, Research Scientist
Clinical Director, Bernier Lab, CHDD, University of Washington
Lucy Berliner, MSW
Director, Harborview Center for Sexual Assault and Traumatic Stress
Clinical Associate Professor, University of Washington
November 5, 2018
Slide2Overview and Objectives
Introduction – Needs of community providersDefinitions: PTSD – DSM-5, Traumatic Event, Trauma Exposure, StressorsSocial-Cognitive features associated with ASD to consider in trauma workReview of Research Literature – ASD and TraumaTheories Rates of PTSD AssessmentTraumas and Adversities Treatment Summary and Future Directions
Slide3Introduction
Collaboration between Harborview Sexual Assault and Trauma Center, UW CHDD, & Seattle Children’s Autism CenterNeeds of and requests from community providersMore information and education about ASD in generalIncrease understanding of clinical manifestations of trauma in individuals with ASDSuggestions for trauma-focused therapies and applications Collaborations resulting in: Reference Guides, CBT + Advanced Presentation Fall 2017, Paper
Slide4Definitions - Posttraumatic Stress Disorder (DSM-5)
Exposure to actual or threatened death, serious injury, or sexual violencePresence of intrusive symptoms associated with the eventrecurrent distressing memories or dreams, dissociative reactions (flashbacks), distress when exposed to cues or “triggers”Persistent avoidance of stimuli associated with the eventmemories, thoughts, external reminders (people, places, activities)Negative changes in thoughts and mood associated with the eventSignificant changes in arousal and reactivity associated with the eventhypervigilance, irritability, concentration or sleep problemsProblems last at least one monthClinically significant distress or impairment
Slide5Definitions
DSM-5: distinguishes between “traumatic and stressful event(s)” Traumatic Event: event experienced as threatening and has immediate and/or prolonged effects on functioning in environment and relationships (Kern et al., 2015) Traumatic Exposure: witnessing or being a victim of an accident or disaster, witnessing or being a victim of violence, physical abuse, sexual abuse, or multiple traumas (Mehtar & Mukkades, 2011)Stressful events: events that may not have been life-threatening but followed by PTSD-like symptoms (e.g., major arguments with a loved one, bullying, loss, work, life transitions, medical or physical struggles, perceived lack of achievement (APA, 2013; Fuld, 2018; Mevissen et al., 2011)
Slide6Social-Cognitive Features Associated with ASD
Social Emotional Reciprocity
Relationships
Restrictive & Repetitive Behaviors
Executive Functioning
Theory of Mind
Face Perception
Central Coherence
Memory
Cognition/ Learning
Emotion Recognition, Processing, and Expression
Communication
Slide7Social-Cognitive Strengths Associated with ASD
Visual Processing
Attention to Details
Analytic Processing
Inhibition
Rule based learning
Interests
Routines
Cognition/ Learning
Exceptional skills
Rote Memory
Slide8Social-Cognitive Features – Why Important to Consider?
Social-cognitive features associated with ASD may: Increase risk for traumaImpact experience of traumaNecessitate flexibility in treatment
Slide9Theories: Susceptibility to the Expression of Trauma Symptoms
More susceptible Differences in information processing, language comprehension, emotion processing and emotion regulation; experience of social isolation Neurobiological vulnerabilities to arousal (e.g., increased cortisol levels in response to stressful stimuli) Less susceptibleAltered ability to interpret or perceive an event as traumatic due to differences in social perception, awareness, and difficulties describing emotional experiences Similiar to general population
Slide10Theories: Increased Risk for Potentially Traumatic Events
Communication impairments, cognitive and physical
disability (Sullivan & Knutson, 2000)Increase risk of being target/victim of abuseChallenging behaviors (e.g., restricted repetitive behaviors, emotional lability/tantrums) Increase risk of abuse/maltreatment by caregivers (Stictch et al., 2009)Differences in social cognition (social naïveté, ToM differences, social boundaries, decreased ability to detect violation of social rules or inappropriate behavior)Increased risk for interpersonal victimization (Hong, Neely, & Lund, 2015; Sterzing, Shattuck, Narendorf, Wagner, & Cooper, 2012).Increased risk of physical injury and extended psychiatric hospitalizations (Coren et al., 2006; McDermott, Zhou, & Mann, 2008).Chronic exposure to daily ASD-related stressors
Slide11Theories: Stressors May Lead to Anxiety
“Traumatic conditioning process”Kerns, Newschaffer, & Berkowitz, 2015; Wood & Gadow, 2010
Slide12Theories: Transactional Relationship Between Trauma and ASD
Kerns, Newschaffer, & Berkowitz, 2015 - Traumatic Childhood Events and Autism Spectrum Disorder
Informed by prior theoretical models proposed by Lazarus & Folkman, 1987; Felitti et al., 1998, Wood & Gadow, 201
Slide13What Do We Know About Rates of PTSD?
What about PTSD???
PTSD???
Social
Impairments
Sleep
Challenges
Slide14Rates of PTSD and Trauma Exposure
ASD Samples
0%-17% of individuals with ASD met criteria for PTSD across studies (Brenner et al., 2017; De Bruin et al., 2007; Hofvander et al., 2009; Mehtar & Mukaddes, 2011; Reinvall et al., 2016; Storch et al., 2007)17%-56% of youth with ASD exposed to a traumatic event (Mandell et al., 2005; Mehtar & Mukaddes, 2011; Taylor & Gotham, 2016)
Challenges
No large-scale, well-controlled population studies Participants typically recruited from university clinic samples Assessment tools and approaches variedStudies conducted in multiple countries (Turkey, Finland, France, Sweden, and the Netherlands) Mostly or entirely male samplesPTSD assessed in samples of individuals seeking treatment for another anxiety disorder
Slide15Barriers to Identifying Trauma Symptoms
Diagnostic overshadowing (Reiss et al., 1982)Overlap in ASD and PTSD diagnostic criteria (Brenner et al., 2017; APA, 2013)ASD symptoms in children with early abuse or neglect (Green et al., 2016; Rutter et al., 1999)Comorbid conditions with ASD (e.g., anxiety, depression) may obscure presentationLack of knowledge of exposure to traumatic eventChallenges with self-reporting (e.g., language; emotional experiences) (Mazefsky et al., 2011; Shalom et al., 2006)Lack of appropriate assessment measures
Slide16Assessment - Diagnosis of PTSD
PTSD typically diagnosed using a structured clinical interview with the caregiver or adult with ASD:Kiddie Schedule for Affective Disorders and Schizophrenia, Present and LifetimeDiagnostic Interview Schedule for Children IV Structured Clinical Interview for DSM-IV Developmental and Well-Being Assessment Anxiety Disorder Interview Schedule, Child and Parent versions One study used consensus diagnosis by a treatment team (Brenner et al., 2017)Family history, caregiver report, and previous medical records helpful in identifying trauma hx and diagnosing PTSD
Slide17Mehtar & Mukaddes, 2011
Assessment - Effect of Traumatic Events on Core Symptoms of ASD
Slide18Traumas and Adversities
Physical and sexual abuse or assaultExposure to accidents or natural disasters Witnessing or experiencing violence Bullying and verbal harassment Major stressful life events (e.g., separation of parents, family member coping with addiction)
Slide19Traumas and Adversities
PTSD-like symptoms: flashbacks, intrusive thoughts, nightmares, sleep and appetite disturbance, crying, bedwetting, fearful behavior, hypervigilance, strong emotional responses to triggersIncreased aggression and disruptive behavior Decreased social-communication and self-help skillsSuicidal thoughts and suicide attempts Mood challengesSexual acting out and running away from home
Slide20Treatment
Modifications of existing treatments for PTSD: Cognitive Behavioral Therapy Eye Movement Desensitization and Reprocessing TherapyChild-Parent Psychotherapy No studies specifically utilized Trauma-Focused Cognitive Behavioral TherapyReported reductions in PTSD symptoms and other symptoms (e.g., aggression, anxiety)Reported improved quality of life (e.g., relationships, school) and improvement in ASD symptoms (e.g., eye contact, social overtures)
Slide21Treatment
Common Treatment Modifications: Increased involvement and training of family and caregiversIncreased structure in sessions and repetition of concepts Increased focus on addressing present concerns and current symptoms Metaphors and visual aids to teach concepts
Slide22Assessment and Treatment Applications
Bernier Lab UW ASD Reference Guide 2017Bernier Lab UW Trauma and ASD Reference Guide 2017Proposed applications of trauma-focused interventions are informed by:What we know about ASD social-cognitive features and symptomsASD Evidence Based Practices Cognitive Behavioral Therapy for Anxiety in individuals with ASDApplications of Trauma-Focused Cognitive Behavioral Therapy with children and children with developmental disabilities Applications of Cognitive Behavioral Therapy based trauma treatment with individuals with intellectual disabilityTrauma-Focused Cognitive Behavioral Therapy Strong empirical support to address traumaApplications have been developed for various populations ASD sensitive applications could be effective tx Research is needed in this area!
Slide23Assessment and Treatment Applications
General Treatment Strategies:Flexibility is keyAdapt to client’s individual needs, developmental level, learning stylesAddress most pressing concern – important to inform treatment planningIncreased time and repetitionCaregiver/family involvementCommunication: concrete language, clear instructions, utilize caregivers, augmentative and alternative communication methods, visuals/technology, break down small stepsSocial: more time to build rapport, explicitly teach social skills, practice skills in multiple contexts, praise desired behaviorsRestrictive and Repetitive Behaviors: interests can be source of motivation, avoid punishment, capitalize on routine, rule-based learning, structure and repetitionSensory: identify interests and aversions, relaxation strategies that are mindful of sensory needs
Slide24Assessment and Treatment Applications
Trauma-Focused Cognitive Behavioral Therapy:Trauma Exposure Screening: multiple reporters, augmentative and alternative communication methods, provide lists of symptoms orally/writing, alternate means to share experience (puppets, drawing, cartoons)Skill-building (psychoeducation, affect modulation, relaxation skills, cognitive coping): tailor to developmental and language levels, additional time and practice, incorporate preferred interests/sensory needsTrauma narrative: simple and concrete; create through visual aids, short stories, familiar concrete play; draw pictures with short captions
Slide25Summary and Future Directions
Limited information about true prevalence as well as perception, experience, and presentation of trauma/PTSD in individuals with ASDExtant studies support an increased risk of exposure to certain kinds of trauma or adversities and provide possible symptoms to assess forVarious definitions, samples, measures, types of studies in play Consider core symptoms, challenges, and strengths of individuals with ASD and possible influences on:1) risk for experiencing trauma, 2) perception of trauma, 3) treatment No one size fits all
Slide26Summary and Future Directions
Empirical research and cross-discipline collaborations incorporating the perspectives of individuals with ASDLarge-scale studies examining presentation, risk factors, and rates of traumatic stress and trauma exposure in individuals with ASDDifferences in rates, presentation, and treatment response across age and genderEfficacy of new and existing tools for assessing trauma exposure and symptoms Applications of evidence-based PTSD treatments for individuals with ASD (e.g., Trauma-Focused Cognitive Behavioral Therapy)
Slide27Thank you!
Thank you to the postdoctoral fellows, graduate students, and staff of the Bernier Lab at UW CHDD and Seattle Children’s Autism Center!Particularly Jessica Berg Peterson, Ph.D., Rachel Earl, M.Ed., Eva Kurtz-Nelson, Ph.D., Emily FoxThank you to Lucy Berliner!
Slide28Links
Bernier Lab UW Trauma and ASD Reference Guide 2017
Bernier
Lab UW ASD Reference Guide 2017