existential counselling for people with autism spectrum disorder precongress workshop 14 may 2015

Existential Counselling for People with Autism Spectrum DisordersDigby Tantam

Ciccarelli, O., Catani, M., Johansen-Berg, H., Clark, C., & Thompson, A. (2008). Diffusion-based tractography in neurological disorders: concepts, applications, and future developments. [doi: DOI: 10.1016/S1474-4422(08)70163-7]. The Lancet Neurology, 7(8), 715-727.

Sahyoun, C. P., Belliveau, J. W., & Mody, M. (2010). White matter integrity and pictorial reasoning in high-functioning children with autism. Brain And Cognition, 73(3), 180-188.

Alter Ego

Further information

Contagious emotion (STS/

DLPFC)

Agency (temporopariet

al junction)

Fight/ care-taking ?

amygdala

Narrative

Emotional dispositions/ cingulate

Autism spectrum disorder, DSM5 criteria

A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:1. Deficits in social-emotional

reciprocity2. Deficits in nonverbal

communicative behaviors used for social interaction

3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers)

B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:

1. Stereotypies2. Routines and rituals3. Special interests4. Hyper-or hypo-

reactivity to sensory input or unusual interest in sensory aspects of environment

Impaired social communication and social interaction(DSM-5)

Restricted repetitiveness(DSM-5)

Language impairment

Autistic syndrome

Enter the other’s world, butdo not expect intersubjectivity

Be aware of the importance of the past and look for commemorative activities

Provide predictability (may achieve this through behavioural means e.g. ABC approach)

Be aware that anxiety—and frustration– may not be expressed

Do not assume that a lack of social interaction is a lack of interest

Value peer support14 May 2015

WCEP



Language impairment

Autistic syndrome

Consider sameness to be a means of achieving comfort through predictabilityAn increase in repetition may indicate anxietyAn appropriate balance must be struck about how much comfort is appropriateRituals may be commemorative and acts of iImaginative reconstruction that are open to involvement and modification by kindly othersSpecial interests provide quality of lifeOCD and hoarding involve an additional element of folie de doute, or warding offRituals may come to be weapons

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WCEP



Language impairment

Autistic syndrome

Language, verbal IQ, and intellectual disability are correlatedAlternative means of communication may be usefulPeople with ID may develop simplifying concepts that can be effective tools e.g. the open and closed faceWritten language may sometimes be more comprehensibleProcessing may take longer, but get there in the endApparent verbal fluency may be deceptive: it’s understanding not language that mattersPsychotherapy may be a matter of connecting the dots…

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WCEP



Intellectual disability

Language impairment

Epilepsy

ADHD

Associated conditions

Tourette, dyspraxia, agnosias

Learning from the EE literature

Understanding impersistence

Cueing attention

Dysexecutive Autistic syndrome

How does Dad handle it?

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WCEP

Anxiety-related disorder




Language impairment

Epilepsy

ADHD

Consequential conditions

Victimization

Marginalization


Sensory issues,Information overload,melt downs

The search for the self

Meltdowns are catastrophic reactions.

They can only be prevented when tension Is at an early stage but may then be unrecognizable unless individual prodrome is known

A sensory assessment may be helpful, but should Include information demands

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WCEP




Language impairment

Epilepsy

ADHD


Victimization

Marginalization




The risk of a person with an ASD being bullied is7 times greater relative to the risk of a neurotypicalchild of the same age


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WCEP

Consequences of bullying

• Passive failure to be included• Reduced use of

community resources (social exclusion)

• Experience of being unwanted/marginalized

• Active rejection , blaming, scapegoating• Stigma as a means

of keeping threatening Other at a distance

• Bullying

Painted Bird by Edward Gafford, inspired by the novel ‘Painted Bird’ by Jerzy Kosiński, itself based on what has been claimed is a fictive war-time experience of the author in Poland

The limitless potential of social control by shaming

• A particularly wide ranging tool kit

• Readiness to consider the most intense emotional issues and in the next moment, the most practical and cognitive ones

• Having a clear grasp of the individual in front of you, not just in life experience, or temperament, but in cognitive abilities

• Be aware of shame and shaming

WCEP

Prevalence of bullying in secondary school by SEN type: Analysis of combined NPD and LSYPE data files. Naylor, P., Dawson, J., Emerson, E., and Tantam, D. (2011) N=15 770 13-14 year olds in mainstream school

• Bullied pupils and those with SEN report feeling unhappier and have less commitment to school than pupils who are not bullied and have no SEN.

• For pupils with SEN or no identified SEN, the risk of being bullied declines by approximately 9 per cent each chronological year.

• Pupils bullied in Year 9 (13-14-year-olds) are much more likely to drop out of school at Year 11 (15-16-year-olds) than those who were not bullied. This trend is even more pronounced for pupils with SEN.

Does social exclusion lead to functional movement impairment

Is there a difference in the amount of physical activity of pupils with AS compared to others?

WCEP

Mean number of steps per hour: AS group = 902, control group = 1312 (t = -2.645, p = .027)

Where were people with AS in Sheffield?

• Most living at home, even above 30.• Most had difficulties coping with changes

in everyday environments• Difficulties moving between places (for

example using public transport)• Most common places frequented were

libraries and cinemas

WCEP




Language impairment

Epilepsy

ADHD


Victimization

Marginalization




Making an impact:uproar, aggression, weaponizing

Containing the risk so that non-reinforcement is possible


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WCEP

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Language impairment

Epilepsy

ADHD


Victimization

Marginalization




Identity borrowings

Providing a healthy identityAnxiety-related disorder

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WCEP

Narrative coherence• Inability to hold up against persuasion:• A lack of an internal narrative “I could

have done that”• Acceptance of strongest narrative, or

authority’s narrative, of most recently repeated narrative

• Link with theory of mind• Bright-Paul, A., C. Jarrold, et al. (2008).

• Autobiographical memory• Bruck, M., K. London, et al. (2007)

WCEP

Coping with a lack of identity• Fads• ‘Obsessive’ relationships• Lack of identity in many

people with ASD• Adopting identity

wholesale• Joining charismatic groups• Moving places and work

• Searching for identity• ‘Transexualism’• ‘Aspie’

• Identities off the peg• Gangster• Professor• Teddy bear

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Language impairment

Epilepsy

ADHD


Victimization

Marginalization





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WCEP

WCEP14 May 2015

What motivates aggression in AS?

• Doing the right thing• Being accepted, perhaps in a

deviant group• Utilization behaviour• Effort at communication• Catastrophic reaction• Asserting dominance• Modelling• Tension relief• Hypomania, depression

"This is my son” 4 year old artist from Art Gallery on OASIS home page

Reported prevalence of psychiatric disorder in older adolescents and adults

Disorder Hutton et al

N=135

My clinic

sample

N=490

Balfe

et al

N=78

Hofvander

et al

N=122

Weighted

mean %

ADHD 43 43.0

Anxiety 16 42 47 50 39.4

Panic disorder 30 38.5

Depression 25 30 65 32.6

Obsessive-compulsive disorder 4 14 9.0

Substance misuse 4 16 4.7

Somatoform disorder 41 5 4.6

Bipolar disorder 1 3.2 8 3.3

Brief psychosis 3.4 2 2.3

Schizophrenia 3 3 2.2

Eating disorder 5 0.7

Catatonia 1 0.6

Delusional disorder 1 0.2

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 (‘flattening of

affect’)• Partial mutism (poverty of speech)

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%)

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

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%)

Options program 2.00 21 (4.4%)

Music therapy 1.72 129 (26.9%)

Auditory integration therapy 1.52 88 (18.4%)

Neurofeedback 0.67 16 (3.3%)

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 having a

project

existential counselling for people with autism spectrum disorder precongress workshop 14 may 2015

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