1. Mental health issues for children with ASD Dr Sarah Lister Brook NHS Consultant Clinical Psychologist & Social Communication Consultancy www.socialcommunication.co.uk

2. What are the types of MH problems with onset in childhood/adolescence? Hyperkinetic disorders Attention deficit disorder without hyperactivity Conduct disorders Oppositional defiant disorder Mixed disorders of conduct and emotions Emotional disorders (separation anxiety; phobic anxiety; social anxiety) Disorders of social functioning (elective mutism; attachment disorders)

3. MH problems in children cont. Tic disorders Enuresis/ encopresis – non-organic cause Feeding disorder Pica Stereotyped movements Stuttering/cluttering Excessive masturbation/nail biting/nose- picking/thumb sucking

4. Mental Health problems with later onset Schizophrenia, schizotypal and delusional disorders Mood [affective] disorders (mania; bipolar; depression) Neurotic, stress-related and somatoform disorders (OCD; phobias; anxiety) Behavioural syndromes associated with physiological disturbances and physical factors (eating disorders) Disorders of adult personality and behaviour Mental and behavioural disorders due to psychoactive substance use

5. Co-Morbidity or ‘symptom sharing’ ASD & the triad Of Social impairments Psychiatric Diagnoses, Conduct disorder, Depression, GAD, Phobias, PTSD, OCD, delusional disorder, paranoia Other neurodevelopment Disorders epilepsy, behavioural phenotypes Tourette (tics), DMCD, DAMP, NVLDs, SPDo ADHD

7. Factors that affect our mental well- being Social support /relationships Quality of attachment to primary caregiver Acute/chronic stress Neurological/ neuro- chemical factors Psychosocial context

8. What promotes mental well-being in children ?

9. Why are children with ASD more at risk for MH difficulties ? Primary impairments in ASD are in the development of social communication and imagination, which in turn affects: 1.Quality of infant attachment & subsequent ability to develop social relationships 2.Opportunities for peer support 3.Problems with recognising, expressing and processing emotions 4.Problem solving skills and ‘cognitive style’ 5.Increased levels of stress

10. 1.Disruption of early attachment Compromised learning of foundation skills in social communication, e.g. turn-taking, shared attention, use of eye-contact. Compromised learning of affect regulation, e.g. ‘receiving’ comfort and later requesting comfort

11. 2.Limited opportunities for peer support Few friends to talk things through with Less likely to feel popular and liked by others Less likely to feel the support from and identity with a peer group

12. 3.Difficulties with emotional processing Problems recognising and decoding emotions in others Problems recognising and decoding emotions in self Difficulties with regulating affect emotions thoughts behaviour

13. 4.Reduced capacity for problem solving Rigid thinking style, difficulty generating alternative options Linear in approach Prone to ‘thinking errors’, e.g. black- white thinking Less likely to use contextual factors, e.g. more concrete and literal in perceptions and understanding.

14. 5. Stress factors Constantly challenged: task demands for lots of things are high across different aspects of their lives. Being in a social world is stressful, even if they are ‘socially proactive’. Sensory integration difficulties means that ordinary stimuli can become acutely irritating. The need to ‘maintain sameness’ is very demanding of self – energy for other things can easily become depleted.

15. What are the effects of stress ? Acute stress often induces high levels of anxiety around a specific event/ trigger and these can become very quickly generalised. Chronic stress can have a negative affect on mood states, i.e. lead to depression

16. How might children with ASD present with a mental health problem ? In some cases the presentation of the mental/behavioural disorder may be very like a typically developing child, alternatively, it may be less obvious and need more expert assessment to provide clarification. Within the systems of classification, a lot of the ‘diagnostic categories’ for mental/behavioural problems with onset in childhood can not be applied if the child has ASD. This means that in many generic CAMHS teams the mental health needs of children with ASD go unrecognised – their difficulties are often all put down to their ASD.

17. Common emotional/behavioural issues in children with ASD high levels of anxiety (e.g. increased rituals, frequent temper tantrums, enuresis, separation anxiety) difficulties with conduct (e.g. aggression) oppositional (e.g. because of need to maintain sameness) disorganised activity (e.g. difficulties regulating activity levels) attention deficits (e.g. primary problem with developing integrated attention) feeding problems (e.g. persistent neophobia)

18. Thinking about cases

19. Recognising when a child is in need of more expert help Frontline detectives: noticing persistent and significant changes. Usual strategies not effective. Difficulty in unpicking ‘the tangle’.

20. What help is out there ? Support Networks, parent groups Open communication Counselling Respite Benefits Therapies for family Couples therapy Family therapy Individual therapy Therapies for child Speech and Language (communication) Occupational (sensory integration) Cognitive Behaviour Approaches Psychotherapy Medication

21. PROBLEM SOLVING APPROACH

22. What can parents do ? Take care of your own MH Observe your child, keep a log Think about activity levels Try to keep POSITIVE & keep CALM Get help

23. What treatments work ? Educational approach is key to success in terms of minimising impact of ASD on individual well- being and decreasing the likelihood of secondary emotional/behavioural problems (TEACCH principles) Cognitive behaviour approaches to managing emotional/behavioural issues are expanding. There is an emerging evidence base for these approaches. Medication also has its place in dampening the symptoms of emotional/behavioural disorders.

24. Cognitive behaviour model: the hot cross bun

25. Cognitive behaviour approaches Cognitive Behaviour Approaches system family individual Desensitisation to stimuli Progressive relaxation Anger management Psycho education Scaling emotional responses Social Stories Cognitive restructuring

27. Social stories: www.thegraycenter.org

30. Cognitive behaviour approaches are aimed at making changes in cognition (thoughts) and behaviour but most importantly they are helping the child to learn to regulate his/her affect. This in turn will reduce the likelihood of them developing a emotional/behavioural disorder.