Autism spectrum disorder and mental health Autism spectrum disorder: a lifespan perspective To be published, Jessica Kingsley, 2010 Can the world afford autistic spectrum disorder? Published Jessica Kingsley, 2009 www. dilemmas.org

Digby Tantam, Universities of Cambridge and Sheffield Dilemma Consultancy

9.30 Introduction 9.45 to 10.15 where I work, what I am looking for from the day 10.15 to 10.45 common mental health problems in ASD/ how to

recognize them/ risks 10.45-11 break 11.00 common emotional and externalizing problems in ASD/ how

to recognize them/ psychological/ medical treatments 12.30-1.15 Lunch. 1.15-1.45 work in small groups, select one challenging case where

there was never an additional diagnosis, what mental health diagnosis or category might have been applicable, consider how this would have changed management (if at all)

1.45-3 How do these mental health problems link with ASD 3-3.15 break. 3.15-4.15 answer questions and feedback

Disorder  (Seedat  et  al,  2009)   %affected  (95%  confidence  

interval)  

Social  anxiety   29.2%  (13.2%  to  45.1%)  

ADHD   28.2%  (13.3%  to  43%)  

Opposi>onal  defiant  disorder   28.1%  (13.9%  to  42.2%)  

Tic  disorder,  tricho>llomania,  

enuresis,  encopresis  

Mini-SPIN (Connor et al, 2001)

•  ‘‘Fear of embarrassment causes me to avoid doing things or speaking to people,’’

•  ‘‘I avoid activities in which I am the center of attention,’’

•  ‘‘Being embarrassed or looking stupid are among my worst fears.’’

Not at all Extremely 0 1 2 3 4 5

WHO screening questions for ADHD

•  How often does he/she have trouble finishing a task or project once the challenging parts have been done?

•  How often does he/she have difficulty getting things in order when he/she has to do a task requiring organisation?

•  How often does he/she have problems remembering appointments or obligations?

•  When he/she has a task that requires a lot of thought, how often does he/she avoid or delay getting started?

•  How often does he/she fidget or squirm with his/her hands or feet when sitting down for a long time?

•  How often does he/she seem to be overly active and compelled to do things, like he/she was being driven by a motor?

1. Rarely 2. Occasionally 3. Frequently as a child 4. Frequently as a child

•  as a child but has now stopped and still persists

%  people  with  ASD    and  with  this  disorder  

Hu5on  et  al  N=135  

My  clinic  sample  N=490  

Balfe  et  al  N=78  

Hofvander  et  al  N=122  

Weighted  mean  %  

ADHD   43   43.00  Anxiety   16   42   47   50   39.40  Depression   25   30   17.68  Obsessive-­‐compulsive  disorder   4   14   8.97  Substance  misuse   4   16   4.74  Somatoform  disorder   41   5   4.62  Bipolar  disorder   1   3.2   8   3.25  Panic  disorder   30   2.84  

Brief  psychosis   3.4   2   2.32  Schizophrenia   3   3   2.23  EaSng  disorder   5   0.74  Catatonia   1   0.59  Delusional  disorder   1   0.15  

OCD

•  Obsession: recurrent, intrusive thought. Not simply worry. anxiety

•  Compulsion: Action. anxiety •  Person realizes irrationality. Ego-dystonic

experience. Attempt at thought supression •  Lifetime prevalence: 2.5% in all cultures

OCD: Course

•  75% have both obsessions and compulsions •  Sudden onset after stress •  1/3 worsen; 1/3 improve; 1/3 stay ill •  1/3 have Major Depression •  Suicide risk

PTSD

•  Must experience extreme trauma •  Re-experience trauma •  Avoid reminders •  Numbing •  Persistent hyper-arousal •  Dissociation

Psychosis: illness features •  Positive symptoms"

•  Hallucinations"•  Disorganized thinking"•  Delusions"•  Movement disorder"

•  Negative symptoms in schizophrenia"•  Decline in social and occupational functioning "•  Reduction of nonverbal expression (ʻflattening of

affectʼ)"•  Partial mutism (poverty of speech)"

Psychosis: the affected person may: "

•  Talk to himself "•  See things"•  Gesture to himself "

Psychosis: the affected person may: "

•  Become confused in their speaking"•  Appear muddled"•  Dress in layers in any weather "•  Fail to bathe and get a haircut "•  Gain an odd interest in ordinary things (like

religion) "

Psychosis: the affected person may: "

•  May even believe he is God "•  See things"•  Feel people are out to get them "•  Believe in all sorts of conspiracies "•  Have ideas that no amount of evidence to

the contrary can dislodge

Psychosis: the affected person may: "

•  May become restless and over-active for no reason"

•  Become slowed, and sometimes immobile for long periods with long pauses in speaking"

•  Limbs may seem as if made of soft bendable metal

Psychosis: the affected person may: "

•  Be unable to work "•  Stop talking or greatly reduce conversation "•  Appear lazy, unmotivated and uninterested "•  May look like he has dementia "•  Lose the ability to get and keep friends "•  Be tense

•  Are voices always hallucinations? •  Are weird ideas always delusions? •  Is incoherent speech always thought

disorder? •  When is thought insertion, rumination?

•  physical agitation and/or anger •  expressed intent to kill or take revenge •  identification of specific victim(s) •  psychotic symptoms, especially 2nd person

command hallucinations to commit violence •  persecutory delusions •  disinhibition caused by traumatic brain injuries

and other central nervous system dysfunctions •  current use of alcohol or other drug

•  living under circumstances of violence •  environmental access to guns or other lethal

weapons •  membership of violent peer group •  poor impulse control; risk taking or reckless

behaviour •  statements to others of intent to inflict harm •  History of violence or antisocial acts

Type of medication  

Ratio of improved

to no effect or worse  

Number of children

trying this treatment (% of

sample)  

Miscellaneous GI medication   4.00   10 (2%)  

Miscellaneous herbal medication   3.33   13 (2.7%)  

Atypical antipsychotics   2.08   80 (16.7%)  

Anxiolytics   2.00   12 (2.5%)  

Stimulants   1.80   172 (35.9%)  

Mood stabilizers   1.80   70 (14.6%)  

Chelation   1.60   32 (6.7%)  

GF and/or CF dietb 1.52 155 (32.4%)  

Antidepressants   1.31   136 (28.4%)  

Other dietc   1.19   54 (11.3%)  

Miscellaneous other medication   1.17   13 (2.7%)  

Type of intervention  

Ratio of improved to

no effect or worse  

Number of children trying this

treatment (% of sample)  

Applied behavior analysis (ABA)   3.76   225 (47.0%)  

Social skills training   3.05   244 (50.9%)  

Picture exchange system (PECS)   2.88   231 (48.2%)  

TEACCH   2.86   88 (18.4%)  

Positive behavioral support   2.82   233 (48.6%)  

Sensory Integration   2.79   255 (53.2%)  

Occupational therapy   2.77   361 (75.4%)  

Physical therapy   2.68   146 (30.5%)  

Speech therapy   2.53   403 (84.1%)  

Early intervention services   2.39   331 (69.1%)  

Social stories   2.33   197 (41.1%)  

Floor time   2.10   129 (26.9%)  

What are the real drug effects? •  Reducing severe depression:

Antidepressants •  Reducing positive symptoms:

•  Antipsychotics •  Reducing anxiety

•  ?SSRIs

•  Reducing over-activity and increasing response control: •  Stimulants

•  Reducing mood fluctuations •  Lithium and anticonvulsants

Choose a drug with least side effects

Psychological treatments

•  Some specific anxiety reduction with cognitive methods

•  Some specific improvement of mood with behavioural activation

•  Otherwise there is no difference in modalities except

•  Flavour and values •  Main outcome determinant is focus

Parental or informal carer involvement

•  Reduces depression, and therefore critical comments, and hostility

•  Reduces externalizing behaviour in client •  ‘oppositional behaviour’ •  Conduct disorder •  Bloody mindedness

WHAT IS ASD?

• Impaired nonverbal communication (expression and interpretation) is the sine qua non • There is a low bandwidth ‘interbrain connection’ • Often associated with other learning difficulties and disconnection problems • People with AS are more susceptible to bullying, to emotional disorder, and therefore have worse quality of life than others with ASD • Understanding the experience of having ASD is key to more successful coping strategies

Enmeshment

•  Anxious attachment •  Caused by threat •  Identity threat to family system and work with

it, and not against it •  Define hostility as frustration •  Rage and anger as fear

The power of power

•  The rage that conceals impotence, or incapacity is inversely proportional to popularity and ‘social influencing power’

•  Outrage conceals this •  In men, anger often conceals shame

Sacar, Bradford 22 Oct 09

From The autistic spectrum OpenLearn LabSpace

Sacar, Bradford 22 Oct 09

Features of nonverbal inexpressiveness

•  Reduction of expression or occasionally idiosyncratic expressions such as unusual prosody, facial mannerisms

•  Affects all channels •  Voluntary signals e.g. social smiles

unaffected •  Is not the commonest cause of gaze

avoidance, in fact may result in staring

Sacar, Bradford 22 Oct 09

Feature of nonverbal inexpressiveness

•  Reduction of expression or occasionally idiosyncratic expressions such as unusual prosody, facial mannerisms

•  Affects all channels •  Voluntary signals e.g. social smiles

unaffected

Sacar, Bradford 22 Oct 09

Atypical Asperger syndrome: a disorder of nonverbal interpretation

•  Primary abnormality is lack of empathy, partly due to failure of non-verbal interpretation (‘face blindness’)

•  Ability to make relationships but not to keep them

•  Lack of empathy may lead to antisocial behaviour, but greater problem is lack of persuasiveness and ‘social influencing power’

Picture from the film, “Ripley’s game” starring Matt Damon as Ripley

Sacar, Bradford 22 Oct 09

Knowing about the world using non-verbal cues

Who is being shot?

Terrorists or partisans?

Sacar, Bradford 22 Oct 09

Is Asperger syndrome the future?

Bram Cohen, founder BitTorrent, and self diagnosed Aspie

Owen Thor Walker apointed to TelstraClear, who previously wrote code enabling a hacker group to steal £13.9M from bank accounts