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Autism Spectrum Disorders
- 1. A Systemic Approach to the Treatment of the Autism Spectrum Disorders Greater Washington Society for Clinical Social Work Jonah Green, MSW January 18, 2009 Schedule: 10-10:15-Introduction/Overview 10:15-11:00-Part I 11:00-11:15—Break 11:15-11:45—Video of individual with ASD 11:45-12:30—Part II/Video 12:30-12:45—Break 12: 45-1:30—Part III 1:30-:45--Discussion 1:45-2:00-Evaluations 1
- 2. Introduction ___________________ Part I ___________________ Defining Autism, ___________________ Symptoms, Etiology, ___________________ Screening/Diagnostic ___________________ Process, Differential ___________________ Diagnosis, Co-Morbidity, ___________________ Effects on Functioning, ___________________ Epidemiology, Non- ___________________ Systemic Approaches to ___________________ Treatment ___________________ ___________________ 2
- 3. Part II ___________________ ___________________ The Systemic Context— ___________________ Effects on Overall Family ___________________ System/Interactions ___________________ Outside of the Family, ___________________ Effects at Particular Life ___________________ Stages, Effects on ___________________ Specific Family ___________________ Relationships ___________________ ___________________ ___________________ 3
- 4. Part III ________________________ ________________________ Systemic Approaches to ________________________ Treatment ________________________ Support and Problem- ________________________ Solving: the “Family Focus” ________________________ Approach ________________________ Generating a Stronger ________________________ Family Structure:The ________________________ Contemporary Structural ________________________ Framework ________________________ Couples therapy when one ________________________ partner has Asperger’s 4
- 5. Part I: Understanding Autism and Non- Systemic Approaches to Treatment ___________________________ ___________________________ Definition of Autism and the Autism ___________________________ Spectrum ___________________________ “The Triad” of symptoms: impaired ___________________________ relationships, difficulty with ___________________________ communication, restricted ___________________________ interests/behaviors ___________________________ The 5 discrete diagnoses: Autistic D/O, ___________________________ Asperger’s, PDD-NOS, Rett’s, ___________________________ Disintegrative D/O ___________________________ The three primary diagnoses and their ___________________________ different symptoms; Asperger’s lacks ___________________________ delay in verbal IQ, PDD-NOS lacks full ___________________________ symptomatology ___________________________ Additional symptoms/challenges for people on the spectrum: sensory ___________________________ processing, sleep, gi issues, Effects on Functioning throughout the Life Span The drive for comfort and stimulation Common Strengths for people with ASDs:visual abilities, memory, splinter skills 5
- 6. The Question of Etiology Medical Screening: Modified Checklist for Autism ________________________ ________________________ Making the Diagnosis: Team of psychologist, OT SPLP, ________________________ educator, social worker ________________________ The Various Rating Scales: ________________________ Gilliam, Autism Rating Scale ________________________ Resources for making the ________________________ Diagnosis: DDA/School ________________________ System/Private providers ________________________ Differential Diagnosis: OCD, ________________________ ADHD, Social Anxiety Co-Morbidity: OCD, ADHD, mood issues Epidemiology: 1 in 150 6
- 7. Common Non-Systemic Approaches to Treatment _________________________________ _________________________________ _________________________________ Characteristics of Successful _________________________________ Approaches: begins early, intensive, _________________________________ involves family, structured, utilizes _________________________________ behavioral principles _________________________________ “Normalization”, or helping kids to “feel _________________________________ normal” vs. “Treatment” _________________________________ Applied Behavioral Analysis; intense, _________________________________ specific skill-building _________________________________ _________________________________ TEACHH:visual structure and _________________________________ organization _________________________________ LEAP: educational inclusion _________________________________ Picture-Exchange Communication _________________________________ Systems: communicating with pictures _________________________________ Greenspan/Denver/DIR Model: play _________________________________ which develops reciprocity _________________________________ _________________________________ Social Skills Groups: teaching specific _________________________________ skills Educational Supports (504s, IEPs, accommodations/special programs, FastForward, Cogmed, Kurzweil) 7
- 8. Language-Communication Therapy: _________________________________ intense teaching of pragmatic language _________________________________ Functional Behavioral Analysis; _________________________________ addressing the function of behaviors _________________________________ _________________________________ Medication: anti-depressants, stimulants, _________________________________ anti-psychotics _________________________________ Collaborative-Problem Solving: relating _________________________________ more flexibly _________________________________ Relationship Development Intervention _________________________________ (RDI): making use of ‘productive _________________________________ uncertainty’ _________________________________ Sensory Integration Therapy: modulating _________________________________ sensitivities and increasing awareness _________________________________ _________________________________ Dietary Interventions: reducing gluten and _________________________________ casein, adding Omega-3s _________________________________ Emphasizing Strengths; memory, visual _________________________________ abilities, etc. _________________________________ Individualized sports: karate, tennis, etc. _________________________________ Mentor programs _________________________________ Play Dates/Controlled social events Social Stories: improving behavior and teaching skills The battle against screen time 8
- 9. Individual therapy: ________________________ Make concepts concrete: ________________________ play-dough, rubber bands, ________________________ Offer specific guidance: ask ________________________ when, where, with whom, use ________________________ cartoons and role plays developing the ‘theory of ________________________ mind’ using speech bubbles ________________________ Using sociograms or ________________________ “closeness circles” to identify ________________________ and improve relationships ________________________ using the relationshipL “I ________________________ wonder if you do this when?” Use active empathy but avoid intrusiveness The need for patience Meeting with counselors and friends Decision-making analysis The Reality Principle; getting 9 these guys to look beyond typical women
- 10. Part II: The Systemic Context of Autism _______________________ Common Family Dynamics: time/resource demands, stigma,isolation, _______________________ behavior issues, guilt/blame, parental _______________________ strife, problems with other siblings The Stages of Grief Model: shock, denial, _______________________ anger, bargaining,acceptance. Family _______________________ members can be at different stages, need to grieve again at each developmental _______________________ stage _______________________ Common Ways of Coping: Normalization (addressing autism within the context of _______________________ other needs), Crusadership (illness as an _______________________ occupation), Altruism (can neglect own needs), Resignation (can lead to _____________ depression) Positive Effects of Having An Autistic Member of the Family: increased cohesion, empathy among siblings, personal growth 10
- 11. Challenges for Families At Particular Developmental ___________________ Stages Infant and Toddler Stage: the stress ___________________ of diagnosis, difficulty bonding, ___________________ negotiating different family ___________________ reactions, finding supports School-Age: Need for advocacy, ___________________ arranging treatments/child care, ___________________ managing behaviors Adolescence: coping with chronicity, ___________________ isolation/peer rejection, need to ___________________ build functional living skills, facing dangerous tantrums ___________________ The Transition to Adulthood: ___________________ coordinating services ___________________ Adulthood (Autism vs. Asperger’s): maximizing independence and ___________ supports/ongoing demands 11
- 12. Typical Challenges for Particular Family Relationships (in middle- class America) _______________________ Mother-Father: enmeshment vs. _______________________ disengagement _______________________ Mother (typically)-Autistic Child: “doing for” autistic child, depression/guilt in _______________________ Mother _______________________ Father (typically)-Autistic Child: Father can be rejecting/withdrawing, focused on _______________________ behavior and achievement, Father’s self- _______________________ esteem effected Mother or Father—non-autistic child: may _______________________ neglect needs of child, pressure child to _______________________ care for or ‘make up’ for autistic child Autistic child-non-autistic child: jealousy, _______________________ “survivor’s guilt”, embarrassment _______________________ Grandparents-parents: can be critical and non-supportive _______________________ Caveats: these responses are typical of dominant social group, all families and relationships are different, and the presence of the autistic child can also 12 have positive effects
- 13. Part III: Systemic Approaches to Addressing ___________________ the Challenge of Autism ___________________ Goals: Maximizing functioning for all family ___________________ members, increasing ___________________ normalization, increasing ___________________ support, knowledge, and ___________________ capacities of family to ___________________ manage stress, advocate, and manage the treatment ___________________ The Need for support as well ___________________ as re-structuring ___________________ The need to address ___________________ systems issues beyond the ___________ family 13
- 14. Initial Systemic Approaches for Families with Young _______________________ Children _______________________ Initial Engagement: _______________________ Normalizing, reframing, and the _______________________ drawing out of individual _______________________ narratives _______________________ Considerations for segmenting _______________________ sessions _______________________ Assisting in Generating Order, _______________________ Obtaining Resources, and _______________________ trouble-Shooting _______________________ Empowering the “Treatment _______________________ Managers: Offering Information and Support Facilitating Positive Ways of Coping: Advising them to look at needs of family, individual needs, and other relationships 14
- 15. Systemic Approaches in Working With Older Adolescents and _______________________________ Adults _______________________________ _______________________________ _______________________________ Navigating systems: Obtaining vocational _______________________________ assistance, education, getting benefits, housing, _______________________________ finding respite care, transportation, peer groups _______________________________ Addressing isolation, overuse of t.v., _______________________________ pornography _______________________________ engaging staff and family: meet both with adults _______________________________ with autism and without, and coordinate with agencies _______________________________ _______________________________ _______________________________ Strengthening the Family Structure (for _______________________________ Families who Have Autistic _______________________________ Children at Home) _______________________________ _______________________________ Continuing with Normalization, Reframing, and _______________________________ Supportive Interventions, and developing a _______________________________ systemic worldview via relational questions _______________________________ Applying a Contemporary Structural Approach: _______________________________ What it is and why it works with these families _______________________________ (see handout) _______________________________ _____________ 15
- 16. _______________________________ Goals of Family Therapy And _______________________________ _______________________________ Interventions to Achieve Them: _______________________________ _______________________________ The Strengthening of the _______________________________ Hierarchy _______________________________ _______________________________ Putting parents in charge of _______________________________ discipline _______________________________ Encouraging parents to position _______________________________ _______________________________ themselves as a unit _______________________________ Assisting parents with collaborative _______________________________ problem-solving, limit-setting _______________________________ _______________________________ Applying the “guard rail” technique _______________________________ Cautions/considerations: especially _______________________________ watch for “unbalancing” against the _______________________________ “enmeshed Mom” _______________________________ _______________________________ _______________________________ _______________________________ _____________ 16
- 17. The Development of Caretakers’ Nurturing and Understanding _______________________________________ _______________________________________ Encourage both parents to position _______________________________________ themselves to offer nurturance _______________________________________ Ask children’s opinions of parents’ _______________________________________ _______________________________________ remarks _______________________________________ Maintaining a connection with parents _______________________________________ Scripting parents in “practical empathy” _______________________________________ _______________________________________ (wanting as opposed to feeling) _______________________________________ The Development of “Skill-Building _______________________________________ Skills” by parents _______________________________________ _______________________________________ Showing them how to build a theory of _______________________________________ mind in their children: getting them to ask _______________________________________ kids what others may want or think _______________________________________ Showing parents how to coach kids in _______________________________________ _______________________________________ emotion regulation: getting kids, to slow _______________________________________ down, separate, ask “So what?” _______________________________________ Role-playing (including puppets and _______________________________________ figures) to develop problem-solving skills _______________________________________ _______________________________________ Games such as “Stop, Relax, and Think” _______________________________________ 17
- 18. The Development of _______________________________________ Emotional Bonds Between _______________________________________ Particular Parents and _______________________________________ _______________________________________ Children _______________________________________ _______________________________________ Hold sessions with the “less _______________________________________ close” parent and child(ren) _______________________________________ _______________________________________ Filial Play Therapy, encouraging _______________________________________ _______________________________________ reflection and empathy _______________________________________ Encourage enjoyable activities, _______________________________________ _______________________________________ physical closeness _______________________________________ _______________________________________ Breaking Down Dysfunctional _______________________________________ Coalitions _______________________________________ _______________________________________ Supporting the “less competent” _______________________________________ _______________________________________ parent _______________________________________ _______________________________________ Blocking (and supporting) the _______________________________________ enmeshed parent _______________________________________ Blocking inappropriate cross- generational alliances 18
- 19. _______________________________________________ _______________________________________________ Minimizing Scapegoating _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Allying with the scapegoat (sitting _______________________________________________ _______________________________________________ next to) _______________________________________________ _______________________________________________ Checking in with the scapegoat _______________________________________________ _______________________________________________ The Alter Ego Technique (“speaking _______________________________________________ _______________________________________________ for”) _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Strengthening the parental _______________________________________________ relationship _______________________________________________ ___________________________________ “Turning towards”/time for themselves Improving communication Making a safe space for emotions Generating more equity/more flexible roles 19
- 20. Supporting the non-autistic child ____________________________________________ Position them close to you and parents ____________________________________________ ____________________________________________ Offer individual sessions and filial ____________________________________________ sessions ____________________________________________ ____________________________________________ Strengthening the sibling relationship ____________________________________________ ____________________________________________ Sibling sessions—foster fun and problem- ____________________________________________ solving ____________________________________________ ____________________________________________ Developing Family Unity ____________________________________________ ____________________________________________ Games and exercises—Family Sandtray, ____________________________________________ Life Stories game, play with puppets and ____________________________________________ characters ____________________________________________ ____________________________________________ Improving the relationship with ____________________________________________ ____________________________________________ grandparents/other family members ____________________________________________ Encourage their support and block ____________________________________________ ____________________________________________ criticism/intrusion ____________________________________________ ____________________________________________ ____________________________________________ The vision: An adaptable and functional family ____________________________________________ ____________________________________________ that is supported and supported, supports ____________________________________________ each member’s needs, attends to each ____________________________________________ relationship, and supports and empowers the person with autism Addendum: Couples Work when one 20 partner has Asperger’s Disorder