Understanding & Alleviating Fear & Anxiety in Children & - PowerPoint PPT Presentation

� Understanding & Alleviating Fear & Anxiety in Children & Adolescents with ASD � Laura B. Turner, Ph.D., BCBA � � Presented at the Hudson Valley Regional Center for Autism Spectrum Disorders 3 rd Annual Fall Conference – 10/30/2015 �

The purpose of this presentation is to provide… � 1. An overview on the etiology and prevalence of fear and anxiety in children and adolescents with ASD � 2. An overview of Cognitive Behavior Therapy and common modifications for 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 �

Where does fear/anxiety come from? � • Learning ▫ Direct experiences ▫ Indirect experiences: observing & listening to others • Genetic & biological factors (e.g., heritability, temperament) Aktar et al., 2013; Askew & Field, 2007; Bandura, 1977; Dubi et al., 2008; Gerull & Rapee, 2002; Rachman, 1977; Watson & Raynor, 1920

How is fear/anxiety displayed by 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

With that caveat…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) � ▫ 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: A Psychological 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) �

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 is a function of the environment (e.g., Skinner, 1938) � • Underlying assumption is that fear/anxiety is learned � • Emphasis on collaboration, goal setting, the present, frequent measurement of progress, and parent involvement �

Step 1. Psycho-Education: Understanding Your Anxiety � • Evaluating & developing emotional competence � • 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 � ▫ Positive self-talk, self-instructions � ▫ “Worry time” � ▫ Relaxation techniques, e.g., � – Diaphragmatic breathing � – Progressive muscle relaxation � • Teaching Considerations � ▫ Use prompts and reinforcers � ▫ Teach to fluency in a calm state ▫ Program for generalization

Step 3. In-Vivo Exposure* – Practice in Context � • Considered the most important step! • Preventing escape from or avoidance of feared stimulus/situation, until the stimulus is no longer associated with a fear response ▫ Note: This is correlated with more aggression in children with an ASD than typically developing children (Evans et al., 2005) • Developed out of the work on systematic desensitization (Wolpe, 1958) Qualitative Ratings Habituation � of Anxiety � *Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008) �

Graduated Exposure – Using a Fear Hierarchy* � • Using small steps that progress to complete exposure to the feared stimulus (shaping approach responses) • How To: ▫ Following a multi-component and individualized assessment, collaboratively develop a fear hierarchy *Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008) �

Graduated Exposure – Using a Fear Hierarchy* � • How To Continued: � ▫ Start with situation that elicits mild- moderate anxiety – ensure success! � ▫ Provide prompts * (e.g., verbal, visual, model *) to engage in the approach behavior � ▫ Provide contingent reinforcement * for absence of escape behaviors � ▫ Ensure success before moving on to next step – measurement is key. � *Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008) �

Modified CBT for Children & Adolescents with ASD: A Few Noteworthy Studies & Manuals � Attwood & Scarpa, 2013; McNally Keehn et al., 2013; Reaven et al., 2011; White et al., 2015; Wood et al., 2015 �

Modifications to CBT approaches with children and adolescents with ASD � • *Match to cognitive, language and social-emotional abilities � • Inclusion of social skills training (e.g., perspective taking) � • Inclusion of adaptive skills training � • Expansion of emotional education � • Increased duration, number & frequency of sessions � • Increased parent training & involvement � Attwood & Scarpa, 2013; McNally Keehn et al., 2013; Reaven et al., 2011; White et al., 2015; Wood et al., 2015 �

Modifications to CBT approaches with children and adolescents with ASD � • Incorporation of concrete language and examples � • Addition of written and visual materials � • Increased focus on flexible thinking � • Consideration of motivation for change and to attend sessions � • Inclusion of clear session 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 �

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

lbturner@usj.edu