According to a recent ‘conservative’ estimate, there are approximately 500,000 autism spectrum cases in the United States, including perhaps as many as 1 in 150 children. Autism is the fastest growing population of special needs students in the US, having grown by over 900% between 1992 and 2001, according to data from the United States Department of Education. In 1999, the Autism incidence rate in the US was generally cited at 4.5 cases per 10,000 live births. By 2005, the US Centers for Disease Control (CDC) estimates one of every 250 babies is born with Autism, or 40 cases per 10,000. As many as 1.5 million Americans may have some form of Autism, including milder variants, and the number is rising. Epidemiologists estimate the number of autistic children in the US could reach 4 million in the next decade (Autism-Help.Org, 2008).
Autism Spectrum Disorder (ASD) includes Autism, Aspergers’ Syndrome (AS) and Pervasive Developmental Disorder, (PDD). ASD involves a history of social impairment before age three. Often the child does not maintain eye contact, does not spontaneously greet or say good bye to family members is indiscriminate to familiar persons and strangers alike does not participate in reciprocal play and does not share pleasure or interests with others.
Children with ASD often demonstrate restricted repetitive and stereotyped patterns of behavior and often talk on one or two themes, regardless of suggestions from others. The child frequently amasses facts about these restrictive interests but lacks a depth of understanding about them.
Stereotypical and repetitive motor mannerisms and preoccupation with repetitive actions, such as turning things on and off are common.
ASD includes impairment in social interaction (few or no friends of in spite of a desire to have them and ample opportunities for friendships) and a lack of social and emotional reciprocity. Self-chosen activities are usually solitary in nature.
Impairments in communication are evident with difficulty in beginning and continuing a conversation, and one-sided conversations which are repetitive, without appropriate turn-taking.
Children with ASD often display a deficit in their ability to use spoken language socially and the content of their speech is often one-sided with little interest in what others wish to bring to the conversation. They may frequently have difficulty sustaining conversation with others.
One of the most frequent problems involves not coping well with change or transitions in daily routine and becoming upset if small details of the regular environment are not maintained. The child can become agitated and distressed when things do not go as anticipated or desired.
Many children with ASD are often initially diagnosed (usually around age 6) with and Attention-Deficit Hyperactive Disorder (ADHD) due to problems with impulsiveness, inattention, distractibility and sometimes hyperactivity that are seen across settings and over time. Several studies have confirmed the relationship with ASD and ADHD. However ADHD can be over diagnosed in children with ASD because there behaviors may be due to stress and anxiety.
A substantial proportion of children with ASD have one or more co-morbid anxiety disorders. Research has demonstrated that anxiety disorders exacerbate the social difficulties and other functional impairments caused by ASD. Many children receive a diagnosis of an anxiety disorder before the ASD is correctly identified or as a secondary diagnosis once ASD is identified. Research conducted by: Susan W. White, Donald Oswald, Thomas Ollendick, and Lawrence Scahill indicate that:
Anxiety and poor stress management are common concerns in clinical samples of children with autism spectrum disorders (ASD). Anxiety may worsen during adolescence, as young people face an increasingly complex social milieu and often become more aware of their differences and interpersonal difficulties.
Other researchers have identified that individuals with ASD also often have obsessive compulsive disorder (OCD). One recent study found that children with ASD showed higher frequencies of obsessive and compulsive symptoms than did typically developing children.
Children with ASD may also be observed to have Learning Disorders/Learning Disabilities (usually prior to the 4th grade). In these cases reading, mathematics or written expression ability(s) of the child measure lower than their expected potential and the child may be identified as learning disabled.
Some children with ASD have disruptive behavior disorders and present with a pattern of defiance, anger, antagonism, hostility or irritability and often blaming others for their problems or mistakes. These behaviors can be the result of punishments and consequences for something the child does not fully understand.
How Cognitive Behavioral Therapy Can Help
According to the National Institute of Health (NIH) one of the few empirically supported therapies available for ASD is cognitive behavior therapy (CBT). CBT can help with common behavioral problems associated with ASD. For younger children or children with lower functioning forms of ASD, Behavioral Therapy (BT) a component of CBT is considered the intervention of choice.
Cognitive behavior therapy is an excellent, but often underutilized form of treatment for individuals with autism. Dr. Tony Attwood
Cognitive therapy can help the child/adolescent by teaching them to identify and change thinking patterns that are associated with their mood or behavioral problems. Children with ASD frequently have associated anxiety (social anxiety, obsessive compulsive disorders, separation anxiety disorder), depressive disorders and/or disruptive behavioral disorder. CBT involves helping the child/adolescent develop skills to recognize the connection between their thinking, behavior and moods. In addition CBT helps children/adolescents identify their thoughts and teaches them skills to evaluate the accuracy of their thinking. CBT also helps children/adolescents with ASD by developing their ability to socialize in ways that are more appropriate and that will be more rewarding. CBT addresses changes in thinking and changes in behavior utilizing principles proven to work in rigorous research studies. In order to build consistency and to extend what begins in the cbt sessions treatment is ideally based on collaboration between parents, teachers and therapist.
The Diagnostic and Statistical Manual of Mental Disorders - IV -TR is being revised and DSM - V is expected to be released in 2014. The proposed changes will tighten the diagnostic criteria and in all likelihood fewer people will be diagnosed with autism. The proposed criteria, if adapted, will mean fewer children being diagnosed on the autism spectrum and fewer children and adolescents being eligible for special education services. According to the American Psychiatric Association the recommendation is for a "new category called autism spectrum disorder which would incorporate several previously separate diagnoses, including autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified. The proposal asserts that symptoms of these four disorders represent a continuum from mild to severe, rather than a simple yes or no diagnosis to a specific disorder. The proposed diagnostic criteria for autism spectrum disorder specify a range of severity as well as describe the individual’s overall developmental status--in social communication and other relevant cognitive and motor behaviors."
The following link will take you to a January 19, 2012 New York Times article that addresses the changing diagnostic criteria: New Definition of Autism Will Exclude Many, Study Suggests
If you are interested in the proposed criteria the following link may be of interest DSM -5 Proposed Autism Diagnostic Criteria.
GAD involves an excessive worry, occurring more days than not, for at least six months, about a number of events or activities, such as work or school performance; There is difficulty controlling the worry and the worry is associated with multiple physical symptoms. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning (American Psychiatric Association).
Up to 10 percent of the school age population is likely to have mild anxiety (sensitive children) while 2 percent of the school age population meet diagnostic criteria for Generalized Anxiety Disorder (Association of Anxiety Disorders).
Anxiety is a “fight or flight” response and is associated with the perception of danger, threat or vulnerability. Cognitive therapy helps parents and children to identify, evaluate and alter thoughts and beliefs associated with anxiety the child is experiencing.
Without treatment, Generalized Anxiety Disorder can be chronic and persistent throughout lifetime. Cognitive therapy, relaxation training and behavioral therapy have demonstrated in research studies to be very effective in the treatment of Generalized Anxiety Disorder in children (Manassis, 2008).
Panic Disorder is the experience of panic attacks followed by ongoing concern and worry about having another panic attack and/or worry about the possible consequences of a panic attack. There may be avoidant behaviors associated with, and secondary to, the panic attacks. Often associated with a panic attack is a catastrophic misinterpretation of a physical sensation. These catastrophic misinterpretations include thoughts such as “I’m having a heart attack” “I’m going to die” or “I’m having a stroke”. These catastrophic thoughts further create anxiety which increases the physical sensation and strengthens the catastrophic misinterpretation.
Cognitive/behavioral therapy has shown to be effective in the treatment of Panic Disorder. Therapy consists of parental and adolescent instruction in relaxation exercises and teaching adolescents to identify evaluate and alter the thoughts that are associated with their panic attacks. This is often combined with systematically approaching situations or experiences that are being avoided because of fear of having a panic attack.
Outcome studies have shown that cognitive/behavioral psychotherapy is very effective in treating Panic Attacks and Panic Disorder in adolescents and adults. Panic Disorder rarely occurs in children.
Obsessive-Compulsive Disorder is likely to affect 2% of the child and adolescent population at some point in their life. The disorder is equally common in males and females.
Adapted from the Diagnostic and Statistical Manual of Mental Disorders – IV-TR.
Obsessions are distressing and persistent thoughts that are associated with anxiety. Obsessive thoughts frequently have a theme of contamination (germs or dirt), or doubts over something that was said or done. Many children have obsessive thoughts that have to do with rules and fairness, and contain magical or unrealistic thinking.
Compulsions, on the other hand, are behaviors or actions that are designed to reduce the anxiety associated with the obsessive thought. Compulsive behaviors are repetitive actions (behaviors) that are also designed to prevent a dreaded consequence from occurring. Compulsive behaviors include repetitive washing or cleaning, showering or doing some other activity in a particular order, checking, double-checking and triple-checking, etc., repeating phrases or thoughts or redoing actions. Compulsive behaviors frequently result in a reduction of anxiety and a temporary sense of feeling good. The most common compulsive behaviors are washing and checking.
Treatment of Obsessive Compulsive Disorder
The behavioral treatment of Obsessive-Compulsive Disorder consists of three components – exposure, response prevention and cognitive (thoughts and beliefs) therapy. Exposure involves systematic, gradual contact or exposure to events in which the obsessive thoughts and -compulsive behaviors are likely to occur. For example, a child with a fear of contamination from germs would be helped (by parents, teachers and therapist) to gradually come in contact with germs via petting a dog or a cat. This could be combined with the response prevention component of the treatment which is to not engage in the usual compulsive activity which, in this example, may be hand washing. Variations on response prevention include response delay or response restriction. Response delay means delaying immediately washing the hands for longer and longer periods of time. Response restriction, means limiting the amount of time that the hands are washed. One of the purposes of the exposure and response prevention is to see if the fear or anxiety diminishes with time and without the compulsive behavior.
The cognitive (thoughts and beliefs) component of treating OCD involves assessing and understanding the result of the exposure and response prevention exercises described above. For example, how does the child explain the fact that no disease was contracted despite touching the dog or cat, and not washing for a significant period of time? Does this new experience cause the child to rethink their assumptions about their vulnerability and the purpose of their compulsive behaviors? The cognitive therapy component of treating OCD is also designed to teach children and their caretakers’ new thinking methods and strategies that can help the child identify and alter the interpretations that they have of their obsessions.
Treatment of OCD also involves learning, practicing and implementing anxiety management strategies including progressive muscle relaxation, mental imagery or deep breathing. Becoming proficient in these relaxation strategies can make it easier for the child to approach feared and anxiety producing situations.
Cognitive behavioral therapy has shown to be effective in the treatment of Obsessive-Compulsive Disorders in children and adolescents.
Social anxiety is painful and anguishing for a child and or adolescent. It can interfere with social functioning, and relationships. Shy children often avoid situations where they might be judged. Avoidance is the behavior most often associated with social anxiety. Most people would not willingly or easily put themselves in a situation where they believe they will be judged negatively and children may protest when adults attempt to force them into social situations (Manassis, 2008).
Cognitive Behavioral Therapy of Social Anxiety
The goal of CBT for social anxiety is often increased social interaction with minimal anxiety. Successful treatment may result in the ability of the child to interact in any group or social situation without anxiety and with little or no concern about being evaluated or judged. Successful treatment may result in the elimination of avoidance behaviors.
Social anxiety disorder is very treatable. Psychotherapy research studies have shown that CBT is an effective treatment for anxiety disorders in general and social anxiety in particular.
For many families the first days of school are met with excited anticipation of new friends, new teachers, and new experiences. However as many as 5% of school aged children refuse to attend school based on fears and anxiety. Emotional meltdowns and anxiety may occur at school, in the car on the way to school, when getting out of bed in the morning or even the night before school. A common scenario is parents desperately attempting to get their fearful, emotionally distraught child out of the house, into the car or out of the car and into the school. Psychologists call this by various names including separation anxiety, school refusal or an anxiety disorder.
In young children, in order to understand school refusal it is important to first understand the nature of anxiety. Anxiety is another word for fear and is thought of as a response involving thoughts, behaviors, and physical responses. The thoughts that accompany anxiety have to do with anticipation of something terrible that is about to occur. For younger children they may be worried that something terrible may happen to their parents while they are at school. For children that are somewhat older they may anticipate something terrible happening to themselves while at school. A better understanding of school refusal occurs when we have a clear picture of the thoughts that occur when the anxiety or fear is highest. The physical reactions that occur with anxiety are what is commonly known as a “fight or flight” response. This includes a rapid heart beat, breathing changes, muscular tightness and sweating. The behavior that naturally accompanies this response is avoidance or in this case school refusal.
The early signs of childhood anxiety which can often result in school refusal include: a reluctance to fall asleep without being near parents, nightmares, extreme homesickness, as well as physical symptoms such as stomach pain and rapid heart-rate.
Family history and parenting style are extremely important components to school refusal. It is relatively easy for a parent to inadvertently strengthen a child’s anxiety by not gently requiring the child to overcome the distress and challenge their avoidance of school.
If on the first days of school your daughter does become anxious and resistant it is very important that you stay calm and do not over-react. Your daughters’ Kindergarten teacher will have experience with this problem and will help your child settle in. It is important that you do not stay and wait for your daughter to calm down. Instead leave quickly and assure her you will be there to pick her up. Staying to long with your daughter may reinforce her anxiety and perpetuate the problem.
If these steps do not solve the problem within the first weeks of school your daughter could have a Separation Anxiety Disorder. Separation Anxiety Disorder affects approximately 4% of children (Anxiety Disorders Association of America). With Separation Anxiety Disorder, a child experiences excessive anxiety when away from home or separated from parents or caregivers. While separated, it is not uncommon for these children to have fears and worries regarding the health and safety of their parents.
Evidence suggests that cognitive behavioral therapy (CBT) is effective in the treatment of childhood anxiety disorders. If your daughter’s fears and worries continue your teacher or school psychologist may be able to refer you to a psychologist who specializes in cognitive behavioral therapy for children.
Anxiety disorders have been shown to be highly responsive to cognitive behavioral therapy. School refusal can be addressed with CBT anxiety protocols such as exposure and response prevention (ERP). ERP is a treatment method available for a variety of anxiety disorders. The intervention is based on the idea that a child/adolescent is exposed to their fears and through repetitive exposure they learn to overcome their avoidance. In doing so the thoughts/cognitions associated with the fear are altered and the fear and avoidance lessens and ultimately is extinguished.
Depression affects a significant portion of the population. This includes children and teens. In 2009, US News and World Report published an article which stated, "Serious depression afflicts two million teenagers each year"
Depressive disorders consist of a variety of symptoms in the areas of mood, thinking, behaviors and physical reactions. Mood related symptoms include sadness, irritability, depression and anger. Many depressed children and adolescents are also anxious and nervous. When children and adolescents are depressed their thinking may be characterized by negative thoughts about themselves (self criticism), negative thoughts about the future and negative interpretations/ thinking about ongoing events in their lives.
Cognitive therapy is a form of psychotherapy that has been demonstrated to be effective in the treatment of depression with children and adolescents. Cognitive therapy is an active, structured, directive form of therapy that focuses on the thoughts, beliefs and behaviors that accompany depressive disorders. In cognitive therapy, the child learns to identify, evaluate and change the thoughts, beliefs and behaviors that accompany depression. (In many cases parents are also instructed in how to help the child use CBT methods to combat their depression). CBT can lead to a significant reduction in depression symptoms – often in a brief period of time.
Attention Deficit Hyperactivity Disorder (ADHD), Disruptive Behavior Disorders, Autism/Aspergers Disorders, Communication Disorders and Learning Disorders often co-exist with anxiety and depressive disorders in children and adolescents. Therefore our practice also includes a specialization in psycho-educational assessment for the purpose of diagnosis and treatment/intervention of learning and behavioral problems. Parents with concerns about their child’s cognitive processing (attention, memory, and perception), academic achievement, overall development, and psychological/social functioning are appropriate candidates for this type of assessment. These psycho educational assessments can provide important information to parents and educators about any special education needs that are appropriate for their child.
Autism, aspergers, pervasive developmental disorder not otherwise specified, pddnos, PANDAS, tourettes disorder, tic disorder, tricotillomania, skin picking, autism spectrum disorder, HFA - high functioning autism, non verbal learning disability, psychoeducational assessments, learning disability, ADD - attention deficit disorder.