Assessment and Formulation - ACAMH...2018/10/11  · l Development of more ASD-specific assessment tools (e.g. depression) l Use objective measures of anxiety, such as physiological

Assessment and Formulation

Optimal assessment procedures

l  Triangulateassessmentifpossible,usingparent,teacher(orother)andselfreport

l  Behaviouralmeasures–obtainbaselinemeasureoffunction

l  Mixedevidencesofaraboutparent-childagreement(Mazefsky2011,Blakeley-Smith2011,White2011)

Assessment tools

l  Clinicalinterview/structuredinterviewschedules:ADIS-C,CAPA,KiddieSADS–noneadaptedforASD

l  Self-reportmeasures(parent/teacherversionsavailableforsome):BeckYouthInventory,Spence,MASC,RCADS–againnotadaptedornormedforASD

Reviews of anxiety assessment in ASD

•  Groundhuis et al 2012

•  Lecavalier et al 2014 Appropriate (with conditions)

ADIS-C, MASC, CASI-4R, PARS Potentially appropriate

SCARED, ADAMS, RCADS Not appropriate

RCMAS, NCBRF, CBCL

See Hallet et al 2013, Sterling et al, 2015

Wigham and McConachie (2014) review

l  Of8tools,onlytheSCAS,RCADSandSCAREDwereconsideredtoberobusttoolsintermsofmeasurementproperties

l  Fewstudiesusingthesetoolsconsidercontentvalidity–iearetheitemsvalidforchildrenwithASD?Arewemeasuringwhatwethinkwe’remeasuring?

l  ConfirmatoryfactoranalysisfailedtosupporttheoriginalfactorsoftheparentratedSpenceChildren’sAnxietyScale-ParentVersion(Magiatietal.(2017)

Challenges for measuring anxiety in ASD (see Lecavalier 2014)

•  Unpicking anxiety vs autism symptoms (e.g. do the rituals cause distress?)

•  Language, IQ and self-report

•  Unique presentation of anxiety in ASD

http://www.autismsciencefoundation.org/news/autism-science-foundation-announces-2014-research-enhancement-grant-recipients

•  Kerns et al 2016

•  Adapting ADIS-C to include questions, probes and clinician-rated probes •  To facilitate differential diagnosis of anxiety and

ASD •  To capture unconventional or ambiguous anxiety-

like behaviour

Anxiety Scale for children with autism (Rodgers et al, 2016)

l  AdaptedversionoftheRCADSl  TheAnxietyScaleforChildren-ASD(ASC-ASD©)isa24item

self-reportanxietyquestionnaire,withfoursub-scales:SeparationAnxiety(SA),Uncertainty(U),PerformanceAnxiety(PA)andAnxiousArousal(AA),forusewithyoungpeopleagedbetween8-16yearswithadiagnosisofautismspectrumdisorder(ASD).

l  Nonormsasyetbutrecommendedclinicalcut-offof24l  Freetodownload

https://research.ncl.ac.uk/neurodisability/leafletsandmeasures/anxietyscaleforchildren-asd/

Other measures

l  Intoleranceofuncertainty?l  IUS-CandIUS-P

l  Cognitiveflexibility?l  BRIEF,FlexibilityScale

Other measures

l  Alexithymial  Torontoalexithymiascale(TAS-20)l  Children’sAlexithymiascale(CAM)l  ThewayIfeel(basedontheTAS-20)

l  Emotion regulation

l  Emotional Dysregulation Inventory (EDI) (Mazefsky et al., 2018)

Challenges of measuring depression in ASD (see Magnuson & Constantino, 2011)

l  Validity of self-report (e.g. language, alexithymia + self-awareness)

l  Overlapping symptoms between

depression and ASD (e.g. increased stereotypic behaviour)

l  Low functioning individuals

Depression assessment in ASD (see Magnuson & Constantino, 2011)

l  Outward behaviour changes (e.g SIB as a

proxi for negative self-view) l  Atypical affective changes (e.g. aggression,

irritability, labile moods) l  Change in autistic symptomatology

Assessment of risk factors for depression

l  Social and self-awareness l  Peer relationships esp. bullying

l  Environmental & social stressors

Mental state (Dr Osman Malik)

l  Thementalstateexamination(MSE)isastructuredwayofobservinganddescribingapatient'scurrentstateofmind,underthedomainsofappearance,behaviour,mood,affect,speech,thoughtprocess,thoughtcontent,perception,cognitionandinsight.

Assess:

l  Appearance:dress(dishevelled,‘quirky’,inappropriatefortemperature),self-care,hygiene,alertness

l  Behaviour:Agitation,Psychomotorslowing,hyperactivity,compliance,eye-contact,repetitive/ritualisticbehaviours,habits,self-injuriousbehaviour

l  Affect:Facialexpression,eyecontact,congruence,reactions(overtorunder–emotionalblunting),flatness,

l  Mood:Subjective/objective,anhedonia,apathy,motivation,suicidalthoughts/plans,referencestofutureactivities/plans

l  Speech:rate,tone,volume,flightofideas,mutism,l  Thoughts:coherence,consistency,talkingpastthepoint,

depressedcognitions,obsessionalthoughts,rumination

Mental state ctd…..

l  Delusions,hallucinationsl  Otherunusualsensoryexperiences(déjàvu,jamaisvu,depersonalisation,derealisation,intrusiveimagery)

l  Levelofinsightintotheproblem

For ASD…

l  Measurementofadaptiveandintellectualfunctionmayalsobecrucial,toputtheaboveintothecontextofthechild’sability

l  ABASorVinelandforadaptivefunction

l  Wechslerforintellectualfunction

General tips on assessment

l  Multidisciplinaryapproachl  Structuredhistorywherepossiblel  Prolongedassessment:Observationindifferentsettings,

withdifferentpeoplel  Corroborativeinformationl  Ruleoutotherexplanationsforchangesinpresentationl  Don’tunderestimatethechildoryoungpersonl  Atthesametime,donotassumetheyunderstand

withoutcheckingandconfirmingasmuchasispossible

Functional assessment

l  Getagoodbaseline:l  Frequencyl  Durationl  Intensityl  Identifyantecedentsandconsequences–essentialfor

identifyingtriggersandmaintainingfactors

l  Measures–QABF-Attention,Escape,Physical,Tangible,andNonsocial

Example function of a behaviour

l  LJhitshismothereverytimeheispreventedfromusingtheinternet.Graduallyhismotherlosesthewilltorestrictinternetuse.

l  LAhasmeltdownsafterabouttenminuteswhentakenoutshopping.EventuallyherparentsgoshoppingalonewhileoneofthemstaysathomewithLA.

l  Whatisthechildcommunicating,whatisamoreadaptivereactionorbehaviourthatcouldbetaught?

Formulation

l  Whyisitimportant?l  Broader,moredetailedandmoreindividualthan

diagnosisl  Allowsforcollaborativesharingl  Clarifiesthemaintainingfactorsandgoalsfortherapyl  Allowsfortestingofhypotheses

A typical CBT formulation

l  Vulnerabilityfactorsl  Precipitatingfactorsl  Triggersforthepresentingprobleml  Currentprobleminfoursystems:behavioural,cognitive(NATS,dysfunctionalassumptions),physiological,affect

l  Maintainingfactorsl  Externalstressors(economic,social,environmental)

A typical CBT formulation....

l  Isoftenguidedbyatheoreticalmodel,aswellasindividualassessmentinformation

l  E.g.OCD,PTSD,GAD

A detailed developmental formulation (Carr, 2000)

l  Predisposing(vulnerability)factors:personal(biological,psychological)andcontextual(familyproblems,earlystresses,parentingfactors)

l  Precipitatingfactors:e.g.divorce,changingschool,lossoffriendships,bullyingPerpetuating(maintaining)factors:biological,psychological,systemicfactors,parentingfactors,socialnetworkfactors

l  Personalandcontextualprotectivefactors

WhatmightanASD-specificformulationlooklike?

Common ASD-Predisposing factors

l  Personalpredisposingfactors:diagnosisofASD,temperament,emotionaldysregulation,geneticvulnerability,IQ

l  Contextualpredisposingfactors:over-protectiveparentingstyle,inappropriateearlyeducationalplacements

Common ASD-specific triggers

l  Changeinroutinel  Misperceptions/misunderstandingsl  Sensorysensitivities

l  Aswellasmoretypicaltriggers

Common ASD maintaining factors

l  Personal:continuingcyclesofemotionaldysregulation,intrinsiccognitiveprocessingstyle(ToM,poorglobalprocessing,rigidity),dysfunctionalcopingstrategies

l  Contextual:inadvertentparental/systemicreinforcementofbehaviour,inconsistentoroverinvolvedparenting,highfamilystress

l  Social:inappropriateeducationalplacement,socialisolationandpeerrejection

Protective factors

l  Personal:easytemperament,absenceofchallengingbehaviour,goodverbalreasoningskills,insight,motivatedtochange,cognitiveflexibility,opennesstonewideas

l  Contextual:supportiveschoolenvironment,goodhome-schoolcommunication,supportivefamilyenvironment,calmconsistentparentingstyle,highparentalself-efficacyandself-esteem,goodunderstandingofASD,friendships

Underlying beliefs may not always be obvious or fit into a model

Situation Typical underlying beliefs

Atypical underlying beliefs

Fear of detentions

fear of negative evaluation

Detentions involve litter duty ..germs…’I’ll get ill if I have a detention’’

Fear of separation

fear of something bad happening to self or parent

“I wont know what to say”

Elaborate OCD rituals

Prevention of harm

to get rid of the smell of school (no harm beliefs, just sensory sensitivity)

Early experiences Social isolation, people thinking I was being rude, getting angry with me

(Possible) Core beliefs ‘I feel inferior to other people’ ‘being disinterested in people is good’ (ie safer)

Trigger

Being asked out for a drink, performing, daily experiences at college

Activates fear of social situations Feeling Thought

lonely, stressed ‘they’re judging me’ ‘they wont like me anyway, no point trying’ Images/memories of being bullied

Behaviour Reject invitation, avoid eye contact, keep self to self

Example formulation

Future directions for research

l  DevelopmentofmoreASD-specificassessmenttools(e.g.depression)l  Useobjectivemeasuresofanxiety,suchasphysiologicalarousal(GSR,

heartrate)andattentionalbiastovalidatediagnosisl  Morelongitudinalresearchl  Furtherresearchonpsychologicalprocessingandtherelationshipto

anxietyl  Neuroanatomyandneurobiology