Developments from Minds

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Developments from Minds Hearts A specialist
clinic for autism and Aspergers syndrome

• Presenters
• Michelle Garnett
• Keely Harper-Hill,
• Tony Attwood
• ARMS Global Autism Conference,
• Oct 2006

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M I N D S H E A R T S

• Michelle Garnett
• Clinic Director
• MPsych(Clin) MAPS MCCP
•  
• Professor Tony Attwood
• Senior Consultant
• MSc PhD AFBPsS MAPS MCCP
•  
• Julie Fox
• Psychologist
• MPsych(Public Health) AMAPS
•  
• Winnie Yu Pow Lau
• Psychologist
• MPsych(Ed) PGradDip(ChFamPsych) MAPS

• Keely Harper-Hill
• Speech Pathologist
• BSc Hons(SH) MRCSLT MSPA
• Stephen Underwood
• Clinical Psychologist
• MPsych(Clin) MAPS
• Dr Heather Ward
• Educational Psychologist
• BPsych (Hons) PhD
• Dr Isabelle Henault
• Sexologist
• MPsych(Clin) PhD

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M I N D S H E A R T S

• Diagnostic assessments and problem-solving

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M I N D S H E A R T S

• Therapy all ages
• Cognitive Behaviour Therapy
• Family Therapy
• Couples Therapy
• Sex Therapy

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M I N D S H E A R T S

• Group Therapy
• Friendship
• Affection
• Becoming a Man
• Becoming a Woman
• Sex Education

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M I N D S H E A R T S

• Intellectual, educational and behavioral
  assessments

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M I N D S H E A R T S

• Workshops and seminars

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M I N D S H E A R T S

• EXPLORING
• AFFECTION
• A GROUP PROGRAM CONDUCTED BY PROFESSOR TONY
  ATTWOOD AND MICHELLE GARNETT
• MARCH 2006

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M I N D S H E A R T S

• EXPLORING
• FRIENDSHIP
• A GROUP PROGRAM CONDUCTED BY WINNIE LAU AND
  JULIE FOX
• Sep-Oct, 2006

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Hans Asperger - 1930s
Vienna University Childrens Clinic
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What is needed?

• Reliable, valid caregiver questionnaire to assist
  in diagnosis
• Designed to specifically measure AS
• Distinguish between AS and autism but not autism
  and HFA
• Adequate sample size
• Confirmatory diagnostic testing
• Use of a Likert scale

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ASASR What do we measure to measure Aspergers
Syndrome?

• 8 dimensions
• Social ability
• Emotional ability
• Language profile
• Special interests
• early development and severity

• Motor skills
• Cognitive skills
• Routines
• Sensory Issues

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Diagnostic Process

• 2 experts (TA 30 years experience MG 13
  years)
• Diagnostic interview semi-structured, with
  parents and child (1-2 hrs), plus
• Observations of child in Clinic
• Review of previous reports
• Telephone interview with class or learning
  support teacher (as necessary)

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Diagnostic Definitions

• Aspergers syndrome Ehlers Gillbergs (1993)
• Autism DSM-IV-TR (APA, 2000)/ICD-10 (WHO, 1993)

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Questionnaire Administration

• Parent/caregiver ratings
• Recruitment through databases of 2 clinics
  specialising in PDD
• Information package sent to each parent
• Questionnaires administered via a secure website

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People involved

• Aspergers Syndrome (N 265)
• Autism (n96)
• Neither diagnosis (n80)

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• The following questionnaire is designed to
  identify behaviours and abilities indicative of
  Aspergers Syndrome in children who are aged
  between 6 and 12 years. Each question or
  statement has a rating scale from 1 to 5.
  Rate each item using the scale to indicate the
  frequency with which the child you are rating
  shows the behaviour described. The scale is shown
  below.
• While completing the questionnaire please compare
  the child you are rating with typically
  developing children you know who are the same age
  and sex as him or her.

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Other measures

• ASSQ (Ehlers et al., 1999) check for construct
  validity
• Checks for divergent validity
• Spence Questionnaires (Spence, 1995)
• Social Competence Questionnaire
• Social Skills Questionnaire
• Strengths and Difficulties Questionnaire
  (Goodman, 1997)

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What does the ASAS- R measure?

• Factor analysis resulted in a solution
  significant at the plt.0001 level
• 6 factors
• Difficulty understanding emotion (Emotional
  ability)
• Fact-oriented (Special interests)
• Sensory Issues
• Perspective-taking (Social ability)
• Adherence to routines (Routines)
• Pragmatic language problems (Language profile)

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ASAS-R

• 50 items
• Explained 49.6 of the total variance between the
  3 groups

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• Dimensions of AS deemed to be important but not
  represented in new questionnaire
• Motor skills
• Cognitive skills

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Reliability of the ASAS-R

• Internal consistency was high for each subscale
  (alpha range .72-.93)
• Test-retest reliability (r.92)

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Validity of the ASAS-R

• ASAS-R and ASSQ (r.53, plt.0001)
• ASAS-R and SCQ (r-.06, p.39)
• ASAS-R and SSQ (r.05 p.52)
• ASAS-R and SDQ (r.39, plt.01)

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How well does the ASAS-R discriminate between AS
and autism?

• Overall percentage of accurate prediction was
  76.2
• AS predicted at 95.4
• Autism predicted at 47
• Neither predicted at 0

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Conclusions

• The ASAS-R
• is a reliable and valid measure of AS
• Over-estimates Aspergers syndrome
• Cannot discriminate between autism and AS
• Usefulness
• To identify people who may be on the autism
  spectrum (high accuracy for AS and high false
  positive rate)

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Conclusions

• results lend more evidence to the notion that
  autism and AS have considerable overlap
• Results suggest that if AS and autism are not
  distinguished at assessment by developmental
  history, intellectual level, or severity of
  symptoms, other characteristics do not
  distinguish them

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The Art of Conversation

• Environmental strategies
• Visual strategies
• Video strategies

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Environmental strategies

• Used by communication partners
• Part of a process

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• Minimise the amount of information to process
• Slow it down
• Pause

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• Make the process explicit
• meeting of two minds
• Ask questions make comments
• Make explicit links
• Temptations

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Tools for talking together

• Joint attention turn-taking listening
• Recognition of talking/not talking
• Recognition of looking at me/not looking at me
• Question forms
• Mental state vocabulary e.g. think, know, guess
• Metalinguistic vocabulary ask say question
  topic.
• Link these two e.g. you ask when you dont know.

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Knowing does not equal doing!!!

• Practice, practice, practice
• Tasks that encourage particular skills
• Make the specific skills explicit use visuals
  and structure to do this e.g. the turn-taking
  object the topic box
• Make it asd specific - remember that thinking
  style dictates communication style.

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Making it dynamic

• Show the topic when do we move outside the
  topic zone?
• Show how what we say is related to the
  preceding utterance or to the topic
• Help the person make the link with the topic (say
  something) and then the person (ask a question)
• Contingency trees
• Learn to write fast
• Colour code

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Video strategies

• Powerful caution
• Desensitise
• Intransient tool for reflection and discussion
  (of all involved!)
• Objective measure of improvement
• Allows us to return to the footage

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• Self-monitoring/ monitoring of others make the
  behaviours straightforward and measurable.
• Link with visual strategies.

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Exploring Affection
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The Understanding and Expression of Affection

• Ability to read the signals when someone expects
  affection.
• Ability to express the appropriate level of
  affection.

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The Understanding and Expression of Affection

• Affection to repair someones feelings.
• An immature expression of affection.
• A limited vocabulary of expression that may not
  include subtle or age appropriate expressions.
• Sometimes needing frequent expressions of
  affection for reassurance.

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• We feel and show affection but not often enough,
  and at the wrong intensity

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Edgar Schneider

• At one point my mother, exasperated at me, said,
  You know what the trouble is? You dont know how
  to love! You need tp learn how to love! I was
  taken aback totally. I hadnt the faintest notion
  what she meant. I still dont.

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The Aspergers Perspective

• Why are typical people so obsessed with
  expressing reciprocal love and affection?
• A hug can be an uncomfortable, constricting
  squeeze.
• Dont cry because someone will squeeze you.
• Not comforted by affection to the degree that
  neurotypicals expect.

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The Aspergers Perspective

• Enjoy a very brief and low intensity expression
  of affection.
• Confused or overwhelmed with greater levels of
  expression.

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The Aspergers Perspective

• Compassion for someones physical suffering
  (broken wrist) and a practical expression of love
  and affection.
• Comfortable with expressing affection for an
  animal.

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Aspergers Perspective

• Intense dislike of public praise that includes
  words and gestures of affection.
• The capacity for affection, a cup versus a bucket.

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Chris Slater Walker

• Limited tolerance of sentimental behaviour.
• I detest sentimentality, which I think is a
  wilful display of empty emotion over matters of
  no consequence, and it really should be avoided
  because it devalues the true expression of
  feeling.

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Parents or Partners Perspective

• Rare use of gestures and words of affection
  lamented by a parent or partner.
• Not being soothed or comforted by gestures and
  words of affection.
• Too intense an adoration or crush on someone
  who has expressed an act of kindness.

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The Exploring Affection Program

• For children (10 to 13 years old) who have
• Immaturity in the understanding or expression of
  affection.
• Anxiety or become agitated in family situations
  when affection is expected or expressed.

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Aims of the Program

• Affection education to de-mystify affection.
• To understand why people need and enjoy
  affection.
• Explain and encourage appropriate expressions of
  affection.
• Explain to parents the perspective of the child
  with Aspergers syndrome.

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Program

• 4 sessions, each session was for one hour with
  the children, then 30 minutes with their parents.
• Practical and entertaining activities.
• Social Stories.
• Projects.

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Session 1

• Ten activities or experiences you enjoy.
• Write the number from 0 to 100 for how much you
  like each one.
• Each activity written on a Post It and placed
  on a thermometer to measure the degree of
  enjoyment.

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Session 1

• Ten people you like and how much you like that
  person (pets).
• Each persons name written on a Post It and
  placed on a thermometer to measure the degree
  of liking or loving.
• Explanation of the dimension from like to love.

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Session 1

• How do those people express their feelings that
  they like or love you?
• Reasons why we express our feelings of liking or
  loving someone.
• The things that are nice and not so nice about
  being liked or loved.
• Social Story

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How liking or loving someone can affect your
feelings, thoughts and abilities

• When someone likes or loves you, there can be a
  change to the way you feel, think and what you
  can do.
• The feelings you can have when someone likes or
  loves you are feelings of being happy, excited,
  comfortable and warm. These are really nice
  feelings that can make you feel good.
• Your thinking can be better when someone likes or
  loves you. You can think you are Okay, likeable,
  and that life is good.

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• When someone likes or loves you, you are able to
  relax, talk to the person, and express your
  feelings.
• There are some not so nice things about being
  liked or loved.
• The person could worry about you and you could
  worry about them. They could disappear from your
  life and you would feel sad and miss them. They
  could be annoying sometimes.
• But if you like someone or love someone, they can
  play with you, talk to you, say nice things about
  you, buy things for you, protect you and help
  you.
• Life is easier and happier when people like and
  love each other.

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Project

• Collect pictues or drawings of people your age
  expressing that they like or love someone.
• Discover with your family, situations where they
  would expect you to express that you like or love
  them, but that you find difficult.

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Session 2

• Placing the pictures collected for the project on
  the like to love thermometer.
• What can you say or do to show that you like
  someone?
• For each suggestion, how much liking does this
  show from 1-50.

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Session 2

• What can you say or do to show that you love
  someone?
• For each suggestion, how much love does this show
  from 51-100.

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Session 2

• When do we show affection and how much?
• Getting the balance right.
• Game of matching the type of affection for each
  person.
• List of people (from strangers to a parent) and
  types of affection (from a smile to a kiss)

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Project

• The situations at home that someone expects an
  expression of affection that the child finds
  difficult to express.
• Think of one situation.
• What was that situation?

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Project

• Think of some of the expressions discussed today
  that you could use in that situation.
• Have a go at expressing affection.

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Session 3

• Review the project, when, what type of affection,
  what did the person say or do, how did you feel?

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Session 3

• When do we use affection?
• Game of matching a list of situations with
  different types of affection.

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Session 3

• How can you tell if someone needs affection?
• How can you tell if you have given too much
  affection?
• How can you tell if you have given not enough
  affection?

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Project

• A log book for the child and a parent that
  provides a record of when the child expressed
  affection and some examples of the type of
  affection.

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Person completing the log book of
affection Please place a ? in the box when you
have expressed each type of affection. See if you
can express each type of affection at least twice
a day.
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Session 4

• Why do we give affection?
• What would happen if nobody showed you that they
  liked or loved you?
• How would you feel, what would you say, what
  would you do?
• What would happen if you stopped showing your
  friends that you liked them?
• How would your friend feel etc.

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Session 4

• If you did not get enough affection, how could
  you make yourself feel better?
• Review of the program, what have you learned?
• What can you do in the future?
• Certificate of achievement.

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Temple Grandin

• My brain scan shows that some emotional circuits
  between the frontal cortex and the amygdala just
  arent hooked up- circuits that affect my
  emotions and are tied to my ability to feel love.
  I experience the emotion of love, but its not
  the same way that most neurotypical people do.
  Does this mean my love is less valuable than what
  other people feel?