Asperger Disorder: Emotional Challenges and Interventions
EMOTIONAL & PSYCHIATRIC CHALLENGES: As children with AS and HFA grow older, other emotional and behavioral symptoms often emerge. A study in Finland examined co-morbid psychiatric disorders associated with Asperger syndrome (AS)/high-functioning autism (HFA) in a combined community- and clinic-based sample of fifty 9- to 16-year-old children and youth. The prevalence was 74% with some type of mental health challenge, and often multiple co-morbid psychiatric disorders in AS/HFA. Behavioral disorders were shown in 44%, anxiety disorders in 42% and tic disorders in 6%. Oppositional defiant disorder, major depressive disorder and anxiety disorders as comorbid conditions indicated significantly lower levels of functioning. To target interventions, routine evaluation of psychiatric co-morbidity in subjects with AS/HFA is emphasized. Parents of late adolescent and young adults with AS should take these susceptibilities and needs for support in planning for adult transitions.
INTERVENTIONS: Don’t be fooled. Just because your son or daughter with AS talks up a storm and is smarter than all get out, doesn’t mean you can simply plunk him or her down in the midst of a group of 25-30 regular education students and expect your child to make a smooth adjustment. Most children with AS require preparation before entering school and additional supports during transition to school for the experience to be successful.
The most important interventions for children with AS are designed to to improve a child's ability to interact with other people and function effectively in society and be self-sufficient. Many children with AS profit from an Early Intensive Behavioral Intervention approach that incorporates some naturalistic (Incidental) teaching strategies along with limited use of Discrete Trial Interventions. Many children with AS may not require 30+ hours per week of EIBI therapy, but most profit from 10-20 hours of combined naturalistic and some discrete trial teaching, depending on severity of symptoms when beginning intervention (Thompson, in press).
While some children with AS adjust well to regular education settings, others are overwhelmed by the social demands and lack of structure. The non-compliant behavior of children with AS is often misinterpreted by school personnel as willful disobedience. Parents and teachers of youngsters with AS are often misled by their large vocabularies and apparent understanding of most adult conversation. In practice, their practical understanding may be limited and their ability to act on the information may be even more limited. Parents should be less concerned about academics than communication and social skills. Parents seeking an appropriate school setting for their child should look for:
Small work groups with individual attention.
A communication specialist with an interest in social skills training.
Opportunities for social interaction in a structured setting and in supervised activities.
A concern for teaching real-life skills and encouraging a child's special interests and talents.
A willingness to individualize the curriculum. Even though the child may have an IQ within the average or above range, his/her other characteristics usually requires some acomodation.
A sensitive and knowledgeable school “point person,” who is the liaison between the child, home and schoool
An emphasis on respect for diversity and empathy for students with the faculty and student body. Children with AS are especially prone to bullying because of their compulsive rituals and anxiety problems.
Social Skills Training & Cognitive Behavior Therapy
Social Stories® and other social skills training programs are extremely popular among parents, school personnel and many therapists, but few have been rigorously evaluated. Social skills training methods generally assume a level of language complexity that exceeds that of many younger children with AS. There have been numerous problems in studies of social skills training, beginning with disagreements about exactly what one means by social skills.
Many of the reports have involved ratings by practitioners providing the services, and have been seldom blind to treatment conditions. In most instances, the gains associated with their implementation have been modest. Incorporating social skills activities within more structured intervention at home and curriculum at school is a good idea, but ought not be a free-standing activity that is an end in itself. The purpose should be to enable the child to function in family or school typical social context. A recent review article of this literature concluded, “Overall, it is clear that, despite their widespread clinical use, empirical support for SST programs for children with AS/HFA is minimal at this time” (Raio, Biedel and Murray, 2010).
Cogntive Behavior Therapy techniques are also popular, particularly with children in middle school and older. Perhaps the most widely adopted approach is Tony Attwood’s. Despite their popularity, evidence to support their effectiveness is limited. Sottronoff, Attwood and Hinton (2005) reported, that, “The intervention was endorsed by parents as a useful programme for children diagnosed with Asperger syndrome and exhibiting anxiety symptoms, and active parent involvement enhanced the usefulness of the programme.” In another study, Sottronoff, Attwood et.al (2007) reported, “Parent reports indicated a significant decrease in episodes of anger following intervention and a significant increase in their own confidence in managing anger in th
eir child.” It is difficult to know what to make of such evaluations based entirely on subjective parent impressions. The lack of independent evaluation by professionals blind to the children’s treatment status weakens support for these methods.
Most clinical reports of CBT claim significant gains, often from complex treatment involving several components. For example, (Wood et. al., 2009) used a “…CBT model (that) emphasized behavioral experimentation, parent-training, and school consultation,” within a randomized clinical trial and claimed positive outcomes. Lang et. al (2010) concluded “CBT has been modified for individuals with ASD by adding intervention components typically associated with applied behaviour analysis (e.g. systematic prompting and differential reinforcement),” pointing out that it is impossible to know what aspects of treatment have contributed to outcomes.
Cogntiive behavior therapy study data suggests that these methods may be helpful for some children and young adults, but it is unclear whether intervention based on verbal cognitive mediation alone is effective for very many people with AS or HFA. It is a very popular idea which affords the possibility of being less time intensive and costly than typical applied behavior analytic interventions, but the combination may be more likely to be effective.
Blended Behavioral Intervention:
In our experience, children like Ashley and Yasar described in the first part of this report, do very well in a Blended behavioral intervention approach incorporating some Discrete Trial Intervention when introducing new skills and employing largely Incidental Teaching methods thereafter working whenever possible in natural environments, and focusing on the child’s strengths and interests. In our experience, children with AS in Blended Intervention make significant gains with 10-20 hours per week of intervention and seldom require 30+ hours per week. Children with AS prosper when expectations are clear, rules are followed (that's the way they view it), and consequences are reliable. Combining some CBT techniques with Blended Intervention makes a lot of sense, but hasn't been evaluated empirically.
Attwood, T (2004) Exploring Feelings: Anxiety: Cognitive Behavior Therapy to Manage Anxiety. Fugure Horizons.
Lang, R. et. al. (2010) Treatment of anxiety in autism spectrum disorders using cognitive behaviour therapy: A systematic review.Dev. Neurorehabil. 13: 53-63
Rao, PA et. al. (2008) Social skills interventions for children with Asperger's syndrome or high-functioning autism: a review and recommendations. J. Autism Dev Disord. 38: 353061
Sofronoff, K, Attwood T. et.al. (2007) A randomized controlled trial of a cognitive behavioural intervention for anger management in children diagnosed with Asperger syndrome. J. Autism Dev. Disord. 37:1203-14.
Sofronoff, K, Attwood, T. Hinton, S. (2005) A randomised controlled trial of a CBT intervention for anxiety in children with Asperger syndrome. J. Child Psychol Psychiatry 46:1152-60.
Thompson, T. (2011 in press) Individualized Autism Intervention. Baltimore; Paul H. Brookes Publishing Co,
Wood JJ et. al. (2009) Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: a randomized, controlled trial. J. Child Psychol Psychiatry. 50: 224-34.