Counseling Individuals with Asperger’sWho Changes?

Goals of Class

•Review therapeutic techniques•(more importantly) raise critical issues

regarding use of these techniques•Who decides? Who changes?•Social vs. Individual Change

Today’s Agenda•Who are you? Why are you here?•Neurodiversity as the new

multiculturalism?•AS/HFA Described•Behavioral and Cognitive Approaches•Language•Peer Mentoring•Sex and Dating

Big Points•A few good ideas about how to help•Pathologize vs. Normalize (Consequences)•Reciprocal Benefits (Does AS help

Typicals?)•Hear the point of view of persons with

A.S. (News from WrongPlanet) http://www.wrongplanet.net/article432.html

•Contribute our Ideas both locally and globally on Asperger’s

•Neuroplasticity

Politics of Autism

•Cure Autism Now PSA http://www.youtube.com/watch?v=j_cJp714jXQ

•E.g. Response to Cure Autism Now http://www.youtube.com/watch?v=JFmi1o0JEaM&feature=related

•Comparing Autism Speaks to Women Speaks http://www.dailykos.com/story/2007/05/19/336513/-An-Autistic-Speaks-About-Autism-Speaks#

Politics of Autism• Leave us alone • Diagnose and treat! (Autism speaks)

http://bit.ly/UMeVrS

• Aspergian Culture http://www.aspergianpride.com/

• Asperger’s as a advantage http://autism-culture.com/parents/dont-mourn-for-us/#more-18 (“I urge parentsto make radical changes in their perceptions of what autism means”)

• Eliminate Asperger’s? http://www.npr.org/templates/story/story.php?storyId=123527833

More Politics

•Does Neurodiversity precede Biodiversity? http://www.youtube.com/watch?v=4wc8dYYxmos

•*A new kind of multiculturalism? (from the Pumpkin Festival) http://www.youtube.com/watch?v=NZS_1MogtQk

Local and Global Ideas

•Consider blogging•Tweeting (Behavior Babe); ABA Chat•Mainstream Literature vs. Tribe of

Interested Counselors, Educators, Parents•Post-Modern Point: Your ideas just as

important

Blogs seem old-fashion

Personal Advantages of blogs

•Blogs as Personal Lab Notebooks (ethnography, Anthropology & half-baked ideas)

•Writing helps you think•Blogs have impact•Blogs as Resume

Autism, AS, Blog Impact•Kathleen Seidel

http://www.neurodiversity.com•Kachina 17 yr. old with Autism

http://kla.typepad.com•Andy Sylvia Keene State College Student and

politician with AS https://secure.actblue.com/page/andrewsylvia

• Jenn Macintosh http://www.cerebralpalsychatgirl.blogspot.com/

& on video: http://bit.ly/uvMBUd

Antioch ASD Student Blogs

• Hanako Jones http://hanashimonaka.blogspot.com/2009/11/introductions.html

Gina Colby’s Blog!

•http://ginacolby.blogspot.com/

Creating Online Communities/using tech•Virtual vs. Real Conferencing

(Accomodating social deficits?) http://blip.tv/file/88852

•*Kinect http://vimeo.com/27257317•*Recent 60 minutes on Autism Apps

http://www.youtube.com/watch?v=F_8b7PgnNQQ

Asperger’s/HFA

•Who are these kids?•Who are these adults?

DSM 5 Proposed Criteria ASD

1) social interaction and communication (e.g., maintaining eye-to-eye gaze, ability to sustain a conversation and peer-relations) and 2) the presence of repetitive behaviors and fixated interests and behaviors. Additionally, in recognition of the neurodevelopmental nature of the disorder, the criteria require that symptoms begin in early childhood.

DSM IV Diagnostic Criteria for Asperger's• (I) impairment in social interaction, as manifested by

at least two of the following:

(A)marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction

(B) failure to develop peer relationships appropriate to developmental level

(C) a lack of spontaneous seeking to share enjoyment, interest or achievements with other people, (e.g.. by a lack of showing, bringing, or pointing out objects of interest to other people

(D) lack of social or emotional reciprocity

DSM (cont.)• (II) Restricted repetitive & stereotyped

patterns of behavior, interests and activities; by at least one of the following:

(A) preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

(B) inflexible adherence to specific, nonfunctional routines or rituals

(C) stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements)

(D) persistent preoccupation with parts of objects

Controversies in Diagnosis: Should Asperger’s Disappear?•Will The AS diagnosis disappear from NY

Times•Simon Baron-Cohen’s plea to save AS diag

nosis

Changing DSM Criteria Graphic

•http://www.nytimes.com/interactive/2012/01/20/us/redefining-autism.html?scp=2&sq=autism%20dsm&st=cse

Changing Autism Criteria: Volkmar Comments•http://www.nytimes.com/2012/01/20/healt

h/research/new-autism-definition-would-exclude-many-study-suggests.html?pagewanted=1&_r=1&sq=autism%20dsm&st=cse&scp=3

What’s the difference?

Under the current criteria, a person can qualify for the diagnosis by exhibiting 6 or more of 12 behaviors; under the proposed definition, the person would have to exhibit 3 deficits in social interaction and communication and at least 2 repetitive behaviors, a much narrower menu.

Comments from GRASP

•http://welkowitz.typepad.com/aspergers_conversations/2012/01/change-in-asd-diagnosis-word-from-the-street.html

Arguments for DSM Change

For:1.ASD reflects continuumAgainst:1.Don’t know yet if AS is distinct from

Autism genetically/biologically2.Parents/Families have organized around

AS label

Challenge Question

•Your thoughts on changes in diagnostic criteria.

•Do changes simply serve the needs of psychiatry?

Billy The Kid

•Video clips

If I could say it in words

•http://www.youtube.com/watch?v=NhzgNMTcioM&feature=player_embedded

Galen Clip I: Breaking down by symptoms http://bit.ly/bdfwjv •Halting speech- odd patterning of pauses•Vocal Intensity- a bit loud…but little

variability (prosody)•Content- no problem with saying he’s

working on social skills, “etiquette”•Rocking-•Closing-doesn’t say anything

Galen Clip II: break down

•Halting speech•Odd content•Some odd attempts at prosody (we’re

working on that)•Clipped responses: “Food Court, Candy

store, arcade”•Closing-walks out of my room

Galen’s Deficits: Comments• 1. Blink- People make fast judgements (so

much of our story is about OTHER PEOPLE)…15-30 secs…people rely on intuition…but their intuition is sometimes right and sometimes wrong

BIG Point: We need to coach both the person with AS and their conversational partners.• Good social skills are a strong predictor of

success (e.g., children on playground: questions vs. statements.

Perspectives

•Doubling a penny•Power of 10

http://www.youtube.com/watch?v=0fKBhvDjuy0

•Bill Gates & Malaria http://bit.ly/TKomXu

Levels of Intervention

Therapist Intervenes

Person with AS/HFA Community Family

Know Your Role!• hub of the wheel for information (a good case

mgr)• consultant on all aspects of a program:

educational, ancillary services/ot/pt/adaptive p.e./medical/recreational

• Advocate: Promote ASSETS vs. DEFICITS (e.g., Galen at work---works hard…not good at down time…I play up the “good at work” part); Educational Opportunities!

• Family Therapist- Support, problem solving, consultant, more support

• Contributors to larger discussion about AS/HFA through blogging, community talks, conferences

Therapy Orientations: CBT vs. Traditional Orientations• Rogerian Methods: Unconditional Regard;

Reflection; Transparent Self (helps AS know they are understood).• Insight oriented approach limited but

ASers had difficult early childhoods which need to be put in perspective; Use the “time tunnel” technique: “What was this like when you were younger?” Billy: Now I understand that many problems were due to AS

Therapy Orientations (cont)

• Behavioral theory/techniques- Both typical and non-typical individuals benefit from “setting goals” and “building new repertoires of skills” in pragmatic ways.

(e.g., building dating skills involve step-by-step increases in social activites…asking someone out for coffee asking 2 people out for coffee asking one of them out to a movie gradually increasing intimate behaviors…etc.

Therapy Orientations (cont)

• Cognitive theory- focusing on the details of positive or negative thoughts, pursuing ideas that interfere with progress (e.g., “I can’t do that” or “That’s not me to say things like that.”)

Orientations Summary

•Cognitive-thinking•Behavioral-behavior•Rogerian-affect/feelings•Psychodynamic-unconcious

Challenge Question

•What is your orientation or style in counseling individuals with ASD?

Direct vs. Indirect Treatments

•In therapy with AS we do both•E.g., social communication:

▫Direct speech training (speechmatch)▫Social skills training▫Social networking via mentoring▫Scripts and Social Stories

Parameters of Speech

•Vocal intensity (Volume)•Lengths of pauses•Lengths of switching pauses•Lengths of vocalizations•Pitch•Rhythm

Matching Speech Patterns

•Vocal Congruence•Visual Display•Talking like others do•Empathy, warmth, understanding

(Rogers!)

Teaching Conversational Reciprocity

Biofeedback for Arrythmias

Using Audacity

•Free download: http://audacity.sourceforge.net/

•Audacity Clip http://www.youtube.com/watch?v=k88peetnAp8

•Speechmatch Pilot http://www.youtube.com/watch?v=TAYOhi7uxqM

•Demonstrate Audacity

D. Githmark & L. Welkowitz, Mensa Rsch. Journal, Fall, ‘09

iPad App Demo

•Volume, Rhythm, Pitch, Overall % Match•Neuroplasticity•Tuning in

iPad Trial: Normal Control

Current iPad Study at KSC

•10 subject with Autism•20 hours training•Experimenters work in teams•Pre/post conversation recordings

What an iPad speechmatch trial looks like…•http://www.youtube.com/watch?v=JLW9M

WT8fzg

Preliminary Findings

•Happy, Sad vs. Unpleasant/Pleasant Surprise

•Volume vs. Pitch vs. Rhythm•Child studies (coming up)•Generalization to real life•Component of social skills program

(awareness of talk)

iPad Collaboration with MuseAmi, Inc. •Demo iPad APP•Preliminary Results:•fMri Studies at Dartmouth Medical Center

with Karen Jennings, Ph.D. (KSC) & Laura Flashman, Ph.D. (Dartmouth):

Plan A: Resting fMri with AutismPlan B: Pre-Post fMri with Speechmatch

training

Speechmatch as therapy and as outcome measure•Does Speechmatch improve Prosody?•Does Speechmatch measure changes in

Prosody?

Point Light Pilot

•Screencast on PointLight•Pilot study- biomotions lab

KSC student Katey Wichland Catalogs Observations

Male:

• Arms swing outward while they walk. Elbows pointing away from the body, and wrists pointing towards the hips.

• Broader shoulders

• Torso makes the shape of a goblet where the shoulders curve inward towards the hips.

• Hips are narrow

• Men’s hips don’t swing with each step like a woman’s does, causing men to use more force in the calves and knees when walking.

• When trying to picture a man walk, think of a male gorilla and how the shoulders are hunched over, father from the body.

• When nervous, shoulders will move up towards the ears. The more relaxed, the further the shoulders are from the ears.

• Pace is quickened when stressed. Pace slows when relaxed. Longer swing in the arms when relaxed.

• When happy, males tend to have a bounce when they walk, radiating from each footstep.

• When sad, pace is slowed, shoulders are hunched, and the arms do not swing as wide.

• Larger men tend to move slower, elbows are further from the body, and more pressure is put on the knees when walking. Lighter men tend to walk a little faster and have more bounce in their step.

Wichland Observations Cont.• When trying to picture a man walk, think of a male

gorilla and how the shoulders are hunched over, father from the body.

• When nervous, shoulders will move up towards the ears. The more relaxed, the further the shoulders are from the ears.

• Pace is quickened when stressed. Pace slows when relaxed. Longer swing in the arms when relaxed.

• When happy, males tend to have a bounce when they walk, radiating from each footstep.

• When sad, pace is slowed, shoulders are hunched, and the arms do not swing as wide.

• Larger men tend to move slower, elbows are further from the body, and more pressure is put on the knees when walking. Lighter men tend to walk a little faster and have more bounce in their step.

Wichland Observations Cont.

•When sad, pace is slowed, shoulders are hunched, and the arms do not swing as wide.

•Larger men tend to move slower, elbows are further from the body, and more pressure is put on the knees when walking. Lighter men tend to walk a little faster and have more bounce in their step.

Observations by KSC student with diagnosed A.S.

Male: • Arms wider, legs closerMale Heavy: • Slower, less movement from side to sideMale Light: • Arms closer to the body, walks a lot fasterMale Nervous: • Faster movement, elbows way up, hands

in front of body, “ready to defend himself”, looks nervous in the general gate and how he holds himself

Katie Wichland Catalogs observations of AS student•Point_Light_Research.doc

Challenge Question

•How important is speech style to you in getting along with others? Do certain styles turn you off?

iPad Apps for Autism

•More on iPads and ASD: http://www.youtube.com/watch?v=F_8b7PgnNQQ (60 minutes broadcast) Comment: But no data!

Need to UNPLUG

•YELP (with apologies to Allen Ginsburg) http://www.youtube.com/watch?v=UowVsL3dXjM

Social Communication II: Errorless Modeling•Conversation with prompts•Conversation without Prompts

http://welkowitz.typepad.com/aspergers_conversations/2006/02/errorless_model.html

•Behavioral Test (BAT) http://www.youtube.com/watch?v=fBj-QGxdGTI

Social Communication III: Scripts

Initial Contact ScriptInstructions: This is a suggested script for

the student’s initial contact with a potential site supervisor. Feel free to use all our part of this script as a guide for this initial conversation.

Student: Hello, my name is _________________. I am a student in the Department of Psychology at Keene State College and I’m calling to speak with you about the possibility of doing a practicum/internship at your agency.

Pros and Cons of Scripts

•Helpful in inserting new behaviors in social repertoires

•Creates “sameness” to conversations (not natural)

•Are overused or used inappropriately

Social Communication: Children• poor social reciprocity - games for increasing back and forth in

conversation:▫ collaborative story telling▫ using a magic stick (exchange during

floor shifts)▫ eye contact as punctuation (fun to do!)▫ Skillstreaming-

Skillstreaming: Having a Conversation1. The Greeting2. small talk3. big point4. closing5. Autopsy

Reading Faces

•watch videos (stop and chat)•practice making faces in the office•Brattleboro face project (KLA)•Ekman Faces

More on Decoding others’ emotions• Use Cartoons!• Bubbles over characters to infer

thoughts and feelings

Empirically Validated approaches to empathy•http://www.parentingscience.com/teachin

g-empathy-tips.html

Other Social Conversation Interventions• CBT for SP• ID difficult social situations• ID neg cognitions• Challenge neg cognitions and develop coping

responses• Design exposure/role play• Set Goal• Begin Role-play• Monitor anxiety at 1 min intervals• End Role-play• Review Goal• Cognitive Autopsy

Challenge Question

•Is there a continuum of ability in decoding emotion in speech and language?

•What common understandings of “how to decode” can we offer others?

Anthropology

•Ethnography•Student Center to study college student

greetings•Playgrounds for younger children

Anthropology II:We study them•Education is Key (British Video Clip)

Constructional Approach

•Current Accomplishments•Weekly Goals•Program Notes

Constructional Approach (cont)

•Antidote to Pathological Approach•What’s wrong vs. What needs to be added•How will you be different•How will others see you as different•(for little kids)…people come from outer

space, what changes in you will they report?

Managing Emotional Problems: Anger•Using Visual Guides (e.g., scaling anger)•Novaco: Cognitive, physiological,

behavioral•2 Big Cognitive errors•I’m going to kill Jeremy (interpreting

anger)•Self-monitoring

CBT

•Depression: Cognitive Therapy•Depression: Frequency of Pleasant

Activities•Self-Reinforcement

More of Today’s Agenda

• Your work• Trends in Neuroscience• Special Interests• Peer mentoring• Co-morbidity deconstructed• Sexuality• Turnaround

Tina Jaillet’s Link

“Connectedness leads to communication, collaboration, and creation. All of this enables, if not enhances, learning. Learning is what our profession is about.” –Tom Whitby

From blogger: http://tomwhitby.wordpress.com/2011/11/08/what’s-a-connected-educator/

And tweeter: https://twitter.com/#!/tomwhitbyAnd Tina’s Twitter:

https://twitter.com/#!/t_jaillet

Sharon Shirley-Bailey

“Understanding (and truly embracing) the concept of neurodiversity was inspiring to me. I feel this way because of the work that I do with emotionally disturbed deaf adolescents and children. Not only because of that, but because my parents were deaf so I had to endure both surprise and ignorance from the general population about deafness.”

-From Shirley’s paper

Carolyn Sprague

“Because of the many advantages of a constructional approach, I’ve begun to think about how I could apply it to building my thirteen year old son’s conversation skills.”

-Carolyn

Tammy Massengill

“. What a brain buzz! I thought that I returned to higher education to learn what I was missing, forgot that I am an inventor, also. Thanks Dr. W for breaking me out of my shell and causing me to participate in the Big Picture, once again.”

-Tammy

Important Trends

•Mirror Neurons: Positive Support http://news.sciencemag.org/sciencenow/2005/12/05-01.html

•Mirror Neurons/Autism conflicting evidence http://news.sciencemag.org/sciencenow/2010/05/a-crack-in-the-mirror-neuron-hyp.html

•Unanswered question: Do mirror neuron deficits explain empathy deficits?

Mirror neurons

http://www.youtube.com/watch?v=BOd3N20XNC4

Trends (cont): Oxytocin

•http://www.sciencedaily.com/releases/2010/02/100216221350.htm

•Largest Study 13 subjects•Looked more at upper face vs. lower face•Discriminated types of games children

were playing

Did Disney rip off Welkowitz?

•Speechmatch: http://www.youtube.com/watch?

v=k88peetnAp8 •Wall-E

http://adisney.go.com/disneyvideos/animatedfilms/wall-e/games/sayit/

AS and Oppositional Behavior

•Behavior Chains•Meeting Special Interests (Hunter Clip

http://www.youtube.com/watch?v=D1T-zY1DXQk )

•Going With rather than against re: special interests

Going with Special Interests

•e.g.2 Ben- The Cloud Room…Hey Now Now

•e.g. 3 Billy- sports statistics…and began a blog about the LA Dodgers

this summer

Death Metal in Norway and Asperger Academic Success•http://www.npr.org/templates/story/

story.php?storyId=90126955•Clip of Norwegian Black Metal Band

http://www.youtube.com/watch?v=i4U33U_UyzQ (ability to view disturbing info differently; objectively)

Perspective Taking

•Are neurotypicals MORE RIGID in thinking due to cultural restraints?

•Are we more likely to “go with the majority” and spurn unusual ideas?

•E.g., medical students and interest in preventative medicine

•E.g., A.S. member of religious family declares his atheism

Social Networking: Mentoring as Intervention•The Insider-Outsider Problem•Challenging the notion that ALL

INSIDERS are enemies•Challenging the notion that ALL INSIDER

activities are unethical•Work to Move AS person to Insider status

Gaining Insider Status

•Quirky Groups (Drama, Band, Geography, Math)

•Quirky skills (magic; knife throwing) http://bit.ly/gHXWEH

•Hit Your Connectors•Ask Your Mavens to ID Connectors•Peer Mentoring

Peer Mentoring

• Doug Flutie Jr. Grant• Up to 12 peer mentors at KSC• ID AS individuals (close connections to

Counseling and Disability office)• Peer Mentors provide support, advice

giving, friendship• Meet regularly; introduce to friends;

Networks Expand

Peer Mentoring: Social Network Development•Networks serve as buffers against stress•Networks serve as buffers against

depression•Networks serve as important source of

information•Networks serve as important source of

activities

Peer Mentoring Issues

•Mentors meet regularly to discuss problems

•Confidentiality (Inner vs. Outer Circle)•Relationship Boundaries•Handling Difficult Problems•Ethical Dilemmas

Reinforcing the Reinforcer

•Volunteers vs. Salaried Workers•Use of Practicum or Independent Study•Regular contact (fielding calls; dealing

with emergencies)

Peer Mentoring: Outcome• Anecdotal Reports: Benefits are clear• Quality of Life Increases• Parent testimonials• School Retention• Interest in Program• Service Learning (new!)• Dana Githmark Clip• Mike Hayes Clip

Peer Mentoring: Outcome II

•Seth Clip http://www.youtube.com/watch?v=PRwCHp1on-E

AS and Comorbidity

• People like simple answers: With one diagnosis we can “put people in a box” and we feel better that we have a grasp on the problem and ideas for

• Leads to Prescriptive Approach: Matching Problem with Solution

• Topography vs. Function (Goldiamond)• Makes Outcome Studies Manageable

OCD and Comorbidity• Data from the National Anxiety Screening

Day Study:Obsessive-Compulsive Disorder & Co-

Morbid Anxiety in A National Screening SampleLawrence A. Welkowitz, Ph.D., Keene State College; Elmer Streuning, Ph.D., Columbia University; John Pittman, M.A., Columbia University; Mary Guardino, Freedom From Fear, Staten Island, NY

Request for More Details on Co-Morbidity

AS and OCD

A B CAntecedent Behavior

Consequence

Tension UP Ritual Tension DOWN

(exposed toWashes (Reinforces Ritual) Contaminant)

AS and OCD: Eg. 2

A B C

Exposed Ritual Decreased Tension

To oven

Tension UPChecks Oven Decreased

Tension/Anxiety

AS and OCD: Treatment

•Exposure with Response Prevention•Extinction that leads to elimination of

ritual behaviors. This is good since:If not stopped…AS/HFA individuals will fail to resist OCD behaviors in public since they are less tuned in to SOCIAL CONSEQUENCES.

Issues in treating co-morbid OCD • May need “coach” to increase motivation• need to make social consequences of

“odd” public behaviors clear• Reassure pt by discussing difference

between OCD and Psychosis

AS and ADHD• Lots of overlap…but also lots of differential

dx errors due to similar “topography” of behavior:• e.g. impulsiveness- As pts may “seem”

impulsive because they are less likely to respond to social cues/consequences• inattention- may be due to lack of interest

rather than inability to focus…or lack of eye contact may be due to sensory aversion.• Hyperactivity- may be linked to not

understanding the “social demands” in a particular situation.

AS & Depression• due to chronic outsider status• Pts get worse as their AS improves…

recognize their social failings; desire insider status but realize how tough it is…may even miss their “splendid isolation.”

• lack of social reinforcement (just think of how much reinforcement a typical person receives throughout the day)…

• lack of social networks which serve as a BUFFER against stress and anxiety

• bullying and teasing (Seligman’s Learned Helplessness…dogs unable to escape shock)

• assaults on self-esteem- low rates of praise

Treatment Issues: Depression• Cognitive Therapy helpful• Lewinshon’s Freq. of Pleasant Events• Low Rates of Behavior• Physical Activity• Help shift AS/HFA individuals from

“outsider” to “insider” status (e.g., mentoring, circle of friends, teaching them special skills that other like…such as magic or knife throwing)

Treatment of Depression cont.• Err on the side of “reinforcing gains” rather

than “focusing on deficits”…heap lots of positives on kids and adults

• encourage friends, spouses, teachers to focus on positives and ignore minor negative behaviors (e.g., “catch me when I’m good”)

• Provide “outs” for kids to escape aversive environments (e.g., escape from crowded hallways where kids get shoved against lockers or bullied)

• SSRI’s or MAOI’s for socially avoidant individuals with high interpersonal sensitivity

Validation

•Validation Clip

Clinical Exercise

•Pick any problem or disorder that you have seen (or heard of) that co-occurred with Autism or Asperger’s. How did the two mix? What ideas do you have for therapy?

Depression and Bullying at College Level•E.g.s. of college level bullying (dorms,

gym, class)•Team Approach (counseling staff, profs,

residential life staff)•Identify Save Havens•High Status Mentors as “Protectors” and

“Promoters”•Teaching Assertive Behavior

AS and psychotic disorders

•“Hallucinations”/”Delusions” may be due to chronic outsider status rather than schizophrenia (Attwood)

•Relentless CBT to treat irrational ideas (e.g., “The FBI told me to ignore what my parent’s say”; “My father is out to get me”)

CBT for Irrational Thoughts• Are you sure your father is out to get you?• Have you ever felt this way before and it

turned out that he was not out to get you?• When did the FBI contact you?• What were the names of the FBI agents?• “Is this a highly irrational idea you are

experiencing…or is it grounded in reality?”• Dogged Pursual leads to “revised

cognition”

Schizophrenia Symptoms vs. AS

▫ Delusions vs. radical thinking (recent story by professor about her brother)

▫ Paranoid thinking- due to chronic attacks by NT’s?

▫ Hallucinations vs. “Visions” or highly valued ideas

▫ negative symptoms: anhedonia, alogia (lack of initiating speech, action, pleasure). Are these due to lack of social connection or does it have “an organic feel”??

Concrete to Abstract Leap: AS vs. Schizophrenia• Both groups can not decipher “sayings” or

metaphors:“A rolling stone gathers no moss”“A stitch in time saves nine”“Don’t put the cart before the horse”“I was pouring on the coals on the highway this morning”“That’s icing on the cake”

Egs. Of Psychotic-Like Behavior• e.g. 2 KLA (age 18) “The Easter Bunny will

visit my home and scare me)…solved by explaining that the easter bunny is “not real.”

(different from psychotic delusions…can’t explain them away!)

• e.g. 3 Jacob (age 10) and 9/11: The end of MLB!! Me: No, MLB will continue. School staff feared an anxiety/trauma response to 9/11…simply due to misperception (i.e., not a delusion)

• Comment: If reality testing is grossly impaired and doesn’t respond to CBT, then co-morbid psychotic disorder is possibility and anti-psychotic meds should be considered.

AS and Humour

•Can only understand very obvious humour: e.g., Monty Python

•Counseling Tip: Make communications clear (surface vs. deep structure of language)

AS and Social Phobia• SP: Hallmark feature is “Fear of Negative

Evaluation”AS: Often immune to Negative

Evaluation• SP: Social skills can be intact

AS: Poor Social Skills• SP: Over focusing on social cues and

events…e.g., notices people frowning, rolling eyes, etc

AS: Doesn’t look at faces; don’t understand faces

Social Phobia vs. AS

•Many ASers call themselves “shy” but are they really?

•Misinterpret social inadequacy for social anxiety?

•Become anxious as a result of poor social abilities?

Treatment for Social Phobia

• SP: focus on certain cognitive errors: ▫ Mind reading▫ Fortune telling error▫ overgeneralization

AS and social problems

• AS: Focus on constructing social behaviors:

▫ Constructional Approach▫ Exposure to social activities▫ Basic friendship skills▫ Some CBT around misconceptions of

other peoples’ intentions

AS and Oppositional Behavior•e.g., 1. Colin Age 10 refusing to do math

that he feels is “insulting” “repetitive” “too easy”

•e.g., 2 Hunter age 11 with “genius IQ”, slipping on homework compliance

•e.g. 3 Seth (age 20) taking “Gen Ed” classes that are “too easy.”]

•e.g. 3 Annika’s classmate with obsessive interest in spiders

Prevent ODD with Accomodation•Must LISTEN and MAKE

ARRANGEMENTS for more challenging educational experiences…But schools not geared this way!

•Having kids take advanced courses…•Make rules clear (rule governed behavior)

Going with Special Interests

•e.g.2 Ben- The Cloud Room…Hey Now Now

•e.g. 3 Billy- sports statistics…and began a blog about the LA Dodgers

this summer

Very ODD: When all else fails

•Contingency management•The List•The Hook (Contingent access to special

interests/activities)•Computer Addiction

AS and PTSD

•Effects of Pervasive Bullying and Teasing•Model for Understanding PTSD:

▫Classical Conditioning (Associated Stimuli such as kids, classes, teachers Anxiety)

▫Operant Conditioning (Escape is reinforced)▫Stimulus Generalization (high school

college)▫Subjective Meaning of trauma stimuli (AS

kid told that high school kids will follow to college)

PTSD Treatment: CBT and Exposure to trauma stimuli• Challenge notions that “all kids are

dangerous”• gradual exposure to non-dangerous kids

and school situations• Safe and secure environments• on-going monitoring

AS/HFA and Dichotomous Thinking• e.g., Collegues complaint about her brother

rejecting Church (“Religon is the source of All hatred and violence”)

• e.g. G.’s absolute thinking “My father hates me because he won’t take me to a mall this weekend…and he must be punished”

• e.g., “Joe Lieberman is a Nazi”• e.g., Andy: “Republicans deserve to die”• e.g., Patrick Henry: “Give me Liberty, or

Give me Death”• e.g., Luke Skywalker “We must risk our lives

to fight Darth Vader and all Evil”

Treating AS plus PTSD

•Obsessive nature of AS probably makes treatment more difficult

•But argument can be made for effective treatment

Arguments for treating AS plus PTSD• Many AS kids have elements of PTSD (90%

report some form of bullying or assault…many report sexual assault as well)

• Foa and colleagues rsch. (Annenberg Found. Consensus Reports): CBT for PTSD in Kids effective

• Recent studies by Sofronoff & Attwood: CBT directed toward Anx. Disorders effective, espec. With strong parental involvement!

• Anger MGT helpful because AS kids “lash out” when confronted with trauma-related stimuli…unable to manage emotional stimuli effectively (Amygdala abnormalities?; executive functioning deficits?)- See Attwood Program:

Clinical Exercise

•Think of a problem you have seen (or heard of) in Autism/Asperger’s that might be helped if the person with autism can “take a different perspective”…think about things differently. How would you go about encouraging a new way of thinking?

Clinical Exercise

•Think of a problem that you have seen in Autism/Asperger’s that might lend itself to straightforward EXPOSURE therapy (ie., just doing it).

Behavior Chain

Antecedent

Crisis

Key to Intervention

•Break chain as early as possible•Break chain at weakest link

Behavior Chain II: MeltdownWakes up late

Favorite ClothesNot available

Teased on Bus

Loses Homework

MisinterpretsReprimand

Given InstructionTo do “boring”

taskMELTDOWN

Meltdown Interventions• Wakes up late• Favorite clothes not

available• Teased on bus• Loses homework• Misinterprets

reprimand• Instructions to do

boring task• MELTDOWN

• Scheduling control• Deal with sensory issues;

use gradual exposure• Anti-bullying programs• Organizational training• Be Clear; avoid sarcasm• Assess interest in task;

go with special interests• Stay calm; Contain child

Common Stressors

1. Going Against vs. Going With Special Interests

2. Stimulus Overload 3. Using facial expressions as

instructions4. Physical Proximity 5. Olfactory stimulation

More Stressors…

6. Ambiguous social situations7. Intense eye contact (“look at me”)8. Disrupting pleasant activities9. Strong criticism 10.Unpleasant Physical Activities

Clinical Exercise

•Pair off, select a behavior problem, do a Behavior Chain Analysis

Stigma

•Negative “halo effect”•Wahl (2002) concluded: Negative

attitudes toward persons with SMI evident by 3rd grade.

•Perceptions of Violence

Reducing Stigma

• Promote Contact (Racism literature: “contact hypothesis”…contact effects strongest when the individuals:

meet as equals work cooperatively target person moderately disconfirms a

stereotype (someone who greatly disconfirms a stereotyped is dismissed as “an exception”)

AS and Sexuality

•Disconnect between AS skills and complexity of sexual activities

•Adolescence and hormonal change•Lack of social influence leads to “what

feels good” versus “what is acceptable”•Lack of information

Sexuality: Problems that Arise

•Inappropriate advances•Stalking like behaviors•Compulsive masturbation•Gender identity problems•Sensory difficulties (light touch vs.

moderate touch; soft music vs. loud)

Sexuality Interventions

•Education•Problem solving•Friendship•Obtaining Consent at Every Level of

Intimate Advancement (Antioch Rules for Sexual Activity)

•Monitoring conversations

Monitoring Conversations/moodsConversation MonitoringWhat I Said What they saidWhat I said

Monitoring MoodsTime Situation 0-10 Mood

Rating

Deep Survival

•Laurence Gonzales on Key Elements of Survival: Link to AS?

Them vs. Us

•Extending these ideas to “typical” individuals

•Changing our own ways of thinking and Culture to “fit the person with AS” versus “changing the person with AS to fit the culture”

AS and Culture

•Dominant Culture Forces its views•Perceived Racism•How we treat AS individuals reflects the

kind of world we want to live in•How we treat AS individuals reflects our

own feelings about our own “inner geek”

Other Counseling Issues•Physical Activity•Being clear•Assessing Readiness (e.g., to hear about

diagnosis; to advance to next step in treatment)

•Teaching how to ask questions•Using alternative methods of

communication•Meeting out of office

Challenge Question

•How do you feel about using non-traditional counseling methods?

Case Study

•Present Your Cases•How would you incorporate elements of

today’s class to these people’s lives?

Getting Funding

•Changemakers•Doug Flutie Jr. Foundation•N.I.H.•Autism Speaks•Ben and Jerry’s•Local Developmental Services (MDS)

Turnaround

•Anything you would like to say?•Questions?