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Home , Asperger syndrome, Autism

Au t i s m Issues&

A guidebook on mental health issues affecting individuals with

Introduction to Autism& Mental Health

utism is a neuro-developmen- performance and sustainability. For example, tal disorder that is typically studies have looked at students diagnosed diagnosed by age three and is with ADHD, pediatric , a lifelong . It has an and anxiety, and have found simi- impact on three main areas in lar outcomes. Van Ameringen, Mancinia, Aa person’s life: social development, commu- and Farvoldenb (2003)1 found that anxiety nication skills and restricted interests. As a disorders are associated with a higher rate of spectrum disorder, autism can affect some- early school withdrawal. Pavuluri, O’Connor, one in mild to severe ways in these areas. Harral, Moss and Sweeney (2006)2 studied In addition, we see sensory and behavioral pediatric bipolar disorder and ADHD and differences that can become barriers to fully noted that no difference between these two participating in one’s education. groups of students existed when looking at academic performance. Both groups expe- Students on the often rienced difficulties with attention, memory, have a co-existing mental health disorder and problem solving. All of these issues that may be undiagnosed. Professionals served to contribute to poor academic per- have little information on this topic and formance. Similarly, students diagnosed with frequently miss the of a depressive disorders have been related co-existing mental health disorder. Teachers to lower academic achievement3. There is a are left unequipped in their classrooms to high percentage of students diagnosed with determine what is motivating their stu- Pervasive Not Oth- dents with autism to behave in ways that erwise Specified who have been determined challenge their education. The assump- to have a co-existing mental health issue. tion of most people is that all behaviors are related to a student’s autism diagnosis. The information contained in this docu- This assumption will leave mental health ment is to provide the reader with signs issues that exist untreated and may, in fact, and symptoms of autism and mental health exacerbate symptoms. concerns, what educators need to know, managing a crisis, and resources that are The research indicates that mental health available to support students, their families issues have a negative impact on academic and educators.

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Ab o u t Me n t a l He a l t h Sc r e e n i n g addition, the Autism Spectrum Disorder- for Comorbid for Children (ASD-CC) is a 49-item informant based rating scale Mental health screening tools designed to identify emotional difficulties Comorbid that commonly occur with ASD. A mental health screening tool is a brief, Psychiatric culturally sensitive questionnaire for identify- Important steps to remember when ing individuals who may have mental health implementing and interpreting the challenges that merit further attention, Conditions in intervention, or evaluation4,5 screen 1. Obtain parental consent and student • Screening tools can serve three pri- assent before administering screening. Students with mary purposes: 2. Administer screening in a confidential 1. Assess an individual’s symptoms. area, and prioritize privacy of results. Autism Spectrum 2. Measure progress after intervention has begun. 3. Remember clinical judgment can over- ride results from a screening assessment. Disorders 3. Provide a framework for discussing an A student who does not meet a particular individual’s challenges. cut-off score on a screening tool may still • A screening tool is not a diagnostic tool need further evaluation. but rather a “triage” process. A positive 4. Notify and offer assistance in connect- screen does not necessarily mean a stu- ing parents of any student found to be in dent meets criteria for a diagnosis. Only a need of further evaluation with a local trained clinician is qualified to interpret mental health professional. screening results. 5. Immediately refer to a trained profes- First steps in implementing the sional any student who screens positive screening process6 for suicidal or homicidal ideation. • Develop a planning committee comprised of parents, educators, mental e x t t e p s health experts, primary care providers, N S and other representatives from the com- munity. The planning team will: 1. Formulate a “Planning Team” com- prised of relevant individuals from school »» Develop policy ensuring confidential- ity safeguards are in place. and community to develop confidential- ity policy, formalize community liaisons, »» Draft agreements between schools and make critical decisions about the and collaborating community providers screening process (e.g., when to screen clarifying responsibilities in order to facilitate the collaborative process and and what tools to use). address liability issues. 2. Ensure adequate staff training on »» Ensure policies are approved by screening tool implementation, scoring, appropriate education and mental and interpretation. health boards. 3. Designate contact person within the »» Determine when to administer the school to oversee the screening process. screen (e.g., transitional grades: 6th–7th, 4. Obtain parent consent and student and 9th–10th) and what tools to use. assent before administering screen. »» Ensure adequate staff training and 5. Make appropriate referrals based on supervision on how to administer, screening results, including immediate score, interpret the data, and refer to referral for positive screen for suicidal or community providers, etc. homicidal ideation. »» Identify a “Screening Coordinator” (e.g., guidance counselor, nurse) who assumes responsibility for the screening process. • A list of recommended screening tools can be found at http://www2.massgen- eral.org/schoolpsychiatry. The majority of these screening tools have not been stud- ied in individuals with ASD, and results should be interpreted cautiously. In

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While the core deficits of autism have been • This policy warrants reconsideration due to Signs of Possible well-studied, a less investigated cause of the large number of individuals with clini- impairment in individuals with ASD is the cal symptoms in these areas and the impli- occurrence of comorbid psychiatric disorders. cations for treatment that this presents. Mental Health Recent epidemiological studies have suggested that nearly three out of every four individuals ADHD with ASD meet criteria for another (comor- Conditions in ADHD may be the most common co- bid) mental health disorder7. Unfortunately, occurring psychiatric disorder among chil- are often overlooked in the ASD Persons with dren with ASD, occurring in approximately population, with serious negative consequences 50% of one sample8. on , school and family function- Autism Spectrum ing, and access to appropriate treatment. • Other studies have estimated rates as fall- ing between 28.2% and 31%7,13. Disorders • The rate increased to nearly 55% when 13 Pr e v a l e n c e o f Me n t a l He a l t h sub-threshold cases were included . Iss u e s i n ASD • ADHD in combination with ASD may confer significantly increased risk for a more complicated symptom presentation; Research has consistently indicated that nearly 85% of individuals with comorbid persons with ASD exhibit an increased risk ASD/ADHD met criteria for an addi- of developing psychiatric disorders, when tional disorder13. compared to the general population. • Studies within the last decade reveal rates Anxiety 7,8 between 67% and 70.8% of individu- Anxiety symptoms seem to be “part and als with ASD who would meet criteria parcel” of the everyday experience of many for an additional mental health disorder individuals with ASD, with a large number described within the Diagnostic and (over 40%) meeting DSM-IV criteria for Statistical Manual of Mental Disorders- specific anxiety conditions7. The most com- 9,10 Fourth Edition (DSM-IV) . mon anxiety diagnoses appear to be: • Having a comorbid psychiatric condition significantly increases the risk of multiple • Specific or fears (44%)—fear of diagnoses. specific objects, activities, or situations (e.g., heights, insects, the dark, storms, etc.). »» 41% of the entire sample had 2 or more co-occurring disorders in addition to • (29.2%)—fear of being ASD, with 17% having 2 disorders and negatively evaluated in social situations. 24% having 3 or more7. • Generalized Anxiety (13.4%)—persistent, • Evidence also suggests that individu- excessive, uncontrollable anxiety/worrying. als with ASD may be twice as likely to • (10.1%)—recurrent exhibit comorbid disorders when com- panic attacks that are not associated with pared to those with non-ASD intellectual any specific stimuli. or developmental disabilities11,12. • Obsessive Compulsive Disorder (OCD) is also very common, although rates in rates for the most common individuals with ASD have varied across co-occurring psychiatric disorders: studies from approximately 8% to more One of the challenges to diagnosing comor- than 33%7,13. bid psychiatric conditions in ASD is the »» However, some level of compulsive result of specific exclusionary criteria within behavior may be observed in the major- the DSM-IV diagnostic system9,10. ity (>85%) of individuals with ASD14 indicated that the vast majority (86%) • In the DSM-IV, a diagnosis of autism of their sample exhibited some level of precludes making a formal diagnosis of . a number of other psychiatric disorders, • Disorders which commonly co-occur including Attention Deficit Hyperactivity with anxiety disorders in the general Disorder (ADHD), Obsessive Compul- population, including Tourette sive Disorder (OCD) and Social Anxiety and other disorders, have also been Disorder, thus making it impossible to observed in ASD. receive a comorbid clinical diagnosis of these mental health conditions.

4 Depression and Mood Disorders ated with psychiatric . to the ASD condition itself (e.g., all Depression and Mood Disorders have pro- challenging behaviors are attributed to • Examples include the known disorder), effectively ruling duced the most variable comorbidity rates (associated with hyperactivity and social of all the mental health conditions, ranging out the possibility of the presence of anxiety), Prader-Willi syndrome (asso- another disorder. from very rare (less than 1%) to upwards of ciated with compulsive behavior) and 30%. More is known about prevalence rates seizure disorders (which can be associated • Baseline exaggeration is a related of depression in ASD than is known about with and/or anxiety). concept in which behaviors signaling the comorbidity with bipolar disorder. development of a psychiatric condition Familial genetic factors simply reflect an increase, or exacerbation • Depression of, long-standing behavioral difficulties. »» In one study, 10% of the children with There is increasing evidence that the inci- This increase in severity of challenging autism had at least 1 episode of major dence of autism and mood disorders seem to behaviors may be a of depression meeting DSM-IV criteria13. cluster in families. internal distress (agitation, depression, hypomania, anxiety) and is especially »» Rates for sub-threshold symptoms • Bipolar disorder might be more com- (a period of depression or irritability likely to occur for symptoms that com- mon in first- and second-degree relatives which did not meet DSM-IV depres- monly occur in autism, such as hyperac- families with . sion/dysthymic disorder criteria) range tivity or obsessiveness. 7,13 • An association between symptoms of from 11% to nearly 25% . • Applicability of current diagnostic OCD in parents of children with autism »» As in the general population, rates of criteria to individuals with ASD is and repetitive and restricted behaviors in mood/depressive disorders seem to questionable, particularly for those with their children has also been observed17. increase in adolescence and adulthood, intellectual and/or significant occurring in 25% and 30-37% of indi- communication challenges. Symptoms viduals, respectively8,15. Psychosocial factors may “look” different in individuals with • Bipolar Disorder These may also contribute to the development ASD than they do in typically-developing »» One study indicated that the prevalence of comorbid psychiatric conditions, both in individuals, while others cannot be of bipolar disorder was 3 times that of the general population and in individuals evaluated as accurately in non-verbal or major depressive disorder, accounting for with ASD (e.g., peer rejection, low levels of minimally-verbal persons with ASD. 75% of their sample of individuals with , academic difficulties, etc.). »» Since many diagnoses, such as depression ASD and comorbid mood disorders15. • Individuals may be at increased risk and anxiety, rely in part on subjective »» Family history of mood disorders in complaints ( of sadness, restless- for encountering these psychosocial fac- first- and second-degree relatives may ness, loss of pleasure, worries or intru- exacerbate risk for developing bipolar tors due to their social and communica- sive thoughts), less-verbal individuals disorder. Only 10.7% of individuals tion deficits and behavioral patterns. will often not meet diagnostic criteria. with ASD without a comorbid mood • Cognitive and processing limitations disorder had a family history of mood These roadblocks to making comorbid diag- (such as problem-solving/coping skills) noses are especially dangerous because they disorder, compared with 37.5% of those are often less well-developed in persons with comorbid ASD/mood disorder15. limit access to psychiatric condition-specific with ASD, which further increases their treatment and may prevent the diagnosis Identification and treatment of mood risk of adverse psychosocial experiences. and treatment of other serious psychological disorders in ASD is critical, as research • Many individuals with ASD are aware impairments. Identification and treatment indicates that the presence of clinically sig- of their difficulties and this awareness of comorbid disorders is associated with nificant depressive symptoms is linked to less often increases during puberty. Awareness better long term outcomes than treating optimal long term outcomes16. of one’s “differentness” may underlie the core symptoms of autism alone13. development of anxiety and depression.

Fa c t o r s w h i c h ma y i n c r e as e Po t e n t i a l In d i c a t o r s o f a n r i s k f o r c o m o r b i d i t y Fa c t o r s Wh i c h ma y Hi n d e r Un d e r l y i n g Me n t a l He a l t h Id e n t i f i c a t i o n a n d Di a g n o s i s ss u e i n n d i v i d u a l s w i t h Certain factors may play a role in increas- I I ASD ing the likelihood of developing a comorbid Individuals with ASD often are under-diag- disorder and may underlie the high preva- nosed and therefore go untreated. Commu- This section describes common symptoms of lence rates of psychiatric conditions among nity professionals may face specific challenges specific psychiatric disorders in the general individuals with ASD: in making an accurate diagnosis of psychiat- population, along with behaviors that may ric conditions among individuals with ASD. be noticed in an individual with ASD. It is important to note that symptoms of anxiety Associated medical conditions & Some of the more common roadblocks to accurate diagnosis include: and mood disorders (depression/bipolar) often can only be recognized as deviations Individuals with ASD have additional • Diagnostic Overshadowing: this term from previously exhibited behavior, especially comorbid medical conditions that are associ- refers to the tendency to attribute the when the individual’s level of cognitive and/ development of new problems/behaviors or language ability is limited and/or there is

5 no well-developed augmentative communica- which is difficult to control and which »» Another frequent compulsive behavior tion strategies. occurs in a wide range of situations, for children with ASD was the ‘‘need to activities and subjective feelings of tell/ask’’, which typically involves hav- restlessness or being “keyed-up” or “on ing to ask the same question in exten- ADHD edge” and/or irritability. sive question-asking rituals or having to Symptoms of ADHD in the general popula- »» Behavioral symptoms include agita- say the same statement over and over. tion include the following main symptom tion (fidgeting, playing with objects, “clusters”: hyperactivity, impulsivity, and difficulty sitting still, pacing), difficulty Depression inattention. Individuals can be diagnosed with separating from caregivers, avoidance of • The most essential features of major certain objects and/or activities or dis- 3 different “subtypes” of ADHD, based on depression in DSM-IV are change of which symptom cluster their behavior reflects. tress (freezing, crying, trembling) when these objects/activities are encountered. mood and loss of interest. Depressed 1. The predominantly hyperactive/ mood is typically indicated by either Behaviors which may indicate an anxiety subjective report (e.g., feels sadness or impulsive subtype, consists of symptoms disorder in individuals with ASD: such as interrupting others, blurting out emptiness) or observation made by others answers, being “on the go,” difficulty sit- • Avoidance of new people, tasks, environ- (e.g., appears tearful or irritable). ting still and talking excessively. ments and/or materials. • Additional symptoms include: feelings of 2. The predominantly inattentive sub- • Increases in performance of rituals and/ lethargy, fatigue, or loss of energy, changes type is characterized by distractibility, or rigid and inflexible behavior. in sleep and/or eating habits (either too much or too little), reported feelings of forgetfulness, difficulty with sustaining • Increases in reliance to or scripts. worthlessness or excessive or inappropriate focus on tasks or activities, organizational • Increases in resistance to transitions or problems, and making careless errors. guilt, difficulty concentrating or indeci- changes to routine. siveness, and recurrent thoughts of death, 3. The combined subtype includes symp- • Narrowing of focus of attention on suicidal thoughts, suicide attempts or toms from both hyperactivity/impulsivity special interest. plans for committing suicide. and inattention. • Withdraws from social situations or • In individuals with autism, the most com- Behaviors which may be observed in indi- begins to avoid social situations. mon presenting symptoms of depression viduals with ASD: • Low tolerance and/or tan- may be significantly increased agitation, • All of the symptoms of ADHD may be trums when things don’t go “as expected.” self-injury, and/or temper outbursts18. observed in a similar manner in individu- • Perfectionistic behavior (may be related Behaviors which may indicate depression als with ASD. to anxiety over performance). in individuals with ASD: • However, children with ASD are sig- • Seeks constant reassurance through • Increase in tearfulness or irritability nificantly more likely to exhibit the repetitive questioning and/or checking and/or absence of “happiness” or smiling inattentive subtype (rates of 65% in a behaviors. in individuals who frequently did so in recent ASD sample) and children without In addition, the following may also differen- the past. developmental disorder typically exhibit tiate the symptoms seen in individuals with the combined subtype13. • Loss of interest in activities or friends. ASD from those in the general population. • Resistance to participating in activities Anxiety • Specific phobias13: that were once engaged in willingly. • Our current diagnostic system contains »» Common phobias in typically devel- • Agitation or restlessness, pacing, hyper- a variety of specific anxiety disorders, oping children (such as fear of flying, activity, or . which differ primarily in the object or stores, standing in lines, bridges, and • Development of, or an increase in tan- source of the anxiety, as opposed to the tunnels) seem to occur at much lower trums, meltdowns, or aggression. rates in children with autism. specific symptoms displayed. • Development of, or an increase in stereo- »» The most common phobias in children • All anxiety disorders result in avoidance typed behaviors. with ASD (found in 32% of one of the source of anxiety, or experiences sample) were fear of needles and/or • Decreased or increased sleep, resists bed- of extreme distress when the source is shots and crowds. time and/or wakes up frequently at night. encountered. »» Over 10% of the children with autism • Difficulty staying awake during the day. • Symptoms can be physiological, behav- also had a of loud noises, which • Decrease in attention to tasks. ioral and/or cognitive: is not common in typically developing • Decrease in productivity and/or apathy. »» Physical reactions include sleep diffi- children. culties (e.g., problems falling or staying • Obsessive-compulsive disorder (OCD)13: • Self-deprecating comments. asleep), muscle tension, being easily »» The most common type of compul- • Deliberate, potentially lethal acts. fatigued, headaches, stomachaches, sion in children with ASD was a ritual shortness of breath, rapid heartbeat, and involving other individuals; nearly half Bipolar Disorder sweaty palms. of the children diagnosed with OCD »» Cognitive symptoms include dif- • In the general population, bipolar disor- had compulsions that involved others der is defined by distinct periods where ficulty concentrating (inattention) or having to do things a certain way. having one’s mind go “blank,” worry

6 mood is persistently and abnormally flags” for the consideration of a comor- »» Change in behavioral patterns that elevated, expansive, or irritable. bid psychiatric disorder. persist longer than expected after an • Individuals with bipolar disorder may have • Identify professionals with expertise in environmental change. a decreased need for sleep (often going psychiatric/psychological disorders who »» Sudden development of new behaviors. for days without sleeping) and an inflated can participate in the assessment and treat- »» Any time a functional behavior assess- sense of self-esteem or importance (feels ment/educational decision-making teams ment is being conducted or a change of one is “special” and/or “invincible”). when a comorbid disorder is suspected. placement (due to challenging behav- iors) is being considered for a student. • Additional symptoms include distract- • Consider the possibility of a comorbid ibility, racing thoughts, a pressure to mental health condition for individuals • Refer student for screening/evaluation keep talking, and/or excessive risk-taking with ASD exhibiting any of the following: of mental health concerns. behaviors or involvement in pleasurable »» Changes in behavioral patterns that • Provide teachers and family members activities with high potential for harmful cannot be explained by medical condi- with information and strategies to consequences (such as sexual activity, drug tions or recent environmental changes. assist student while they await screening use, compulsive gambling, shopping, etc.). and diagnosis Behaviors which may indicate bipolar disorder in individuals with ASD: Add i t i o n a l Re ad i n g s • Mood is inflated, elated, irritable, angry or fluctuates between happy and • Centers for Control and Prevention (2007). Prevalence of Autism Spectrum irritable throughout the day regardless of Disorders — Autism and Developmental Disabilities Monitoring Network, 14 circumstances. Sites, United States, 2002. Surveillance Summaries, MMWR,56 SS-1, 12-28. • Decreased frustration tolerance, • Dekker, M. C., & Koot, H. M. (2003). DSM-IV disorders in children with borderline overactivity/hyperactivity. to moderate . I: Prevalence and impact. Journal of American • Aware at night and active about the Academy of Child Adolescent , 42, 915–922. house or awakens early and appears ener- • Dekker, M. C., Koot, H. M., van der Ende, J., & Verhulst, F. C.(2002). Emotional and getic despite their lack of sleep. behavioral problems in children and adolescents with and without intellectual • In relationship to developmental level, an disability. Journal of Child & Psychiatry & Allied Disciplines, 43, 1087–1098. individual feels they can do or achieve more than is typical for them. • Dykens, E. M. (2000). in children with intellectual disability. Journal of Child Psychology & Psychiatry & Allied Disciplines, 41, 407–417. • May create new tasks or take on new jobs or work that are not realistic. • Ghaziuddin, M. (2002). Asperger syndrome: Associated psychiatric and medical conditions. Focus on Autism and Other Developmental Disabilities, 17, 138-144. • Increase in the frequency and/or inten- sity of vocal stereotypes, perseverative • Ghaziuddin, M. (2005). Mental health aspects of autism and Asperger syndrome. London questioning and/or repetitive speech. England: Jessica Kingsley Publishers. • Increase in preoccupation with hobbies • Sinzig, J., Bruning, N., Morsch, D. & Lehmkuhl G. (2008). Attention profiles or recreational activities. in autistic children with and without comorbid hyperactivity and attention • Increase in the frequency or intensity problems. Acta Neuropsychiatrica, 20, 207-215. of ritualistic or compulsive activities, • Tsiouris, J. A. (2001). Diagnosis of depression in people with severe/profound rituals may become rapid or disorganized. intellectual disability. Journal of Intellectual Disability Research, 45, 115–120. • Increase in the intrusiveness of interactions with others; less inhibited (disinhibition). Jo u r n a l s a n d We b s i t e s • Increase in obvious sexual interests. • Inability to follow previously under- • National Association for the Dually Diagnosed (NADD)— www.thenadd.org stood rules and limits. • Journal of Autism and Developmental Disorders • Hallucinations, , and paranoid • Mental Health Aspects of Developmental Disabilities thoughts. • Diagnostic Manual—Intellectual Disability (DM-ID): A Textbook of Diagnosis of Mental Disorders »» An adaptation of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Ne x t St e p s Edition—Text Revision (DSM-IV-TR). »» The goal of this text is to facilitate a more accurate psychiatric diagnosis of people with • Provide training to families and ID. Chapters cover individual DSM-IV categories and special issues (i.e., assessment school/community personnel working and diagnostic procedures and presentations of behavioral of genetic disor- with students with ASD with informa- ders). For each disorder, descriptive text and details of how to apply diagnostic criteria, tion about mental health disorders and as well as tables of adapted diagnostic criteria are included. behaviors which should serve as “red

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Pr o a c t i v e Me as u r e s t o Su p p o r t »» Encourage the student with praise for Awaiting Diagnosis: success as well as attempts. Me n t a l He a l t h Iss u e s »» Make it meaningful to the student. Supporting • Keep it simple and short. Take A Public Health Approach19 »» Practice often for short periods of time. Individuals with • Know the students. • Teach by example. Autism Spectrum »» Take data on the mental health of students »» Demonstrate relaxation skills; model »» Are mental health needs being met? what the student should do to relax. »» Are there gaps in mental health • Focus on the goal. Disorders & services? »» Focus on a student using these skills »» Use data to identify risk factors and when situations arise. Mental Health protective factors for students. 21 • Identify risk and protective factors. Be Prepared Concerns »» Risk factors: conditions that increase • Know community resources and con- the likelihood of problem behavior. tact information. »» Protective factors: conditions that • Establish relationships with related interact with risk factors to reduce the community professionals. likelihood of problem behavior. »» , psychiatrists, physicians, »» Balance a deficit approach to reduce law enforcement officials, crisis teams, etc. risk factors with a strengths-based • Educate law enforcement officials about approach to promote protective factors. potential crises. Promote Physical Health • Teach student with ASD how to com- municate with law enforcement officers, • Provide information regarding healthy firefighters, emergency medical techni- eating, exercise, sleep, etc. cians, and other community helpers. • Provide information regarding • Teach the student with ASD whom to management. call in different situations.

Teach Coping Skills Establish a Crisis Plan with the • Support the development of self-aware- Student and their Family ness, particularly of one’s emotional experi- • Provide the student with ASD a lami- ences (i.e. Anger Scale or Anger-mometer). nated information card including: • Teach self-regulation techniques (i.e. name, diagnosis, symptoms/behaviors, deep breathing, progressive muscle relax- , allergies, and guardian’s ation, sensory breaks, etc.). name and contact information. • Establish primary contact (physician et Teach a Student to Relax20 al) as well as back-up contact in • Remember that relaxation is a skill. the event of an emergency. »» Teach explicitly, practice regularly, and • Enter the student in a community iden- monitor progress (data collection). tification system, if possible. • Pick the right time. • Consider a MedicAlert bracelet. »» Without distractions to promote concentration. • Make the time. Me t h o ds t o Ca l m a n »» Set aside a regular time to teach and Es c a l a t i n g Si t u a t i o n practice relaxation skills. • Create a habit. »» Practice consistently until relaxation Responding Constructively to 21 skills become a ritual or habit. Emotional Outbursts • Create a relaxing environment. • Recognize that “meltdowns” do not »» Provide a quiet, comfortable area for “come out of nowhere.” the student to learn and practice. • Recognize that you can make a differ- • Use praise and make it fun! ence; avoid the assumption that there is “nothing” you can do.

8 • Recognize that you may experience • Wait patiently; don’t rush. • Teaching self-awareness, self-regulation, emotions during the process as well. • Provide appropriate distance for the and relaxation skills. »» Remain calm; avoid a power struggle individual student (be close or allow space). • Providing opportunities to practice with the student. • Reverse some yes/no, short list or either/ skills prior to distress. • Recognize the warning signs or triggers or questions for clarity. • Learning community resources and con- for a “meltdown.” • Keep your facial expressions to a mini- tact information (including school security). • Reduce the stressors in the environment. mum. Facial expressions are often • Establishing relationships with com- »» Remove distractions from the environ- difficult to interpret for many individuals munity resources and shared necessary ment or remove the student from the with ASD and may be distracting. information. stressful environment. • Teaching student with ASD appropri- • Respond to the student RATHER than Interventions to Manage a Crisis ate contacts for different situations. the behavior. Situation • Teaching student with ASD how to • Focus on the present moment and issue 1. Remain Calm, to the extent possible. communicate with community contacts. at hand. 2. Assess the severity of the situation. • Establishing Crisis Plan with student, • Be concise; less is more with verbal 3. Follow the Crisis Plan. family of student, and related professionals. directions. 4. Determine whom to contact. »» Avoid teaching, preaching, or explaining Calming an Escalating Situation until the student recovers from distress. »» Visit http://www.211atyourfingertips. org to locate appropriate services. • Carefully review and learn the methods »» Focus directions on what you want the to calm an escalating situation. person to do rather than what you don’t »» Dial 211: Free, Confidential Crisis want them to do. Counseling. • Discuss methods to calm an escalating situation with related staff/team. • Use simple, direct language. »» Dial 911: Emergency mental health and basic life support ambulance services. • Create materials to support the student » » Avoid rhetorical questions, ultimatums, during escalating situations or distress. generalizations, sarcasm, or gentle teasing. 5. Dial 9-1-1 only for an emergency (www. tampagov.net). »» Speak to the student one-on-one, if • Practice self-regulation techniques as a possible. • An Emergency is: responsible adult during times of distress. • Try to encourage the student to re- »» Any serious medical problem (chest • Minimize stressors in environment. phrase, in his/her own words, important pain, seizure, bleeding, serious wounds). • Create materials or developed area for points you want them to retain to make »» Any type of fire. downtime following recovery from distress. sure they’ve understood. »» Any life threatening situation (fights, • Implement methods to calm an escalat- • Mean what you say and say what you person w/ weapons, gas leaks, etc.). ing situation, as needed. mean; follow-up words with actions. »» Any crime in progress (whether or not a • Debrief escalated situation with • Maintain realistic expectations for the life is threatened). student as well as related staff/team student. 6. Dial 813-231-6130 (Hillsborough AFTER situation occurs. »» Recognize that the student may County) for non-emergencies. struggle to understand you, particularly • Non-emergencies include: Manage a Crisis via non-verbal communication (i.e. »» Delayed or "not in progress" offenses. • Remain calm by using self-regulation facial expression, , etc.). »» Intoxicated persons who are not techniques. • Focus on emotional equilibrium then disorderly. • Assess the severity of the situation. provide support for recovery after equilib- »» Cars blocking the street or driveway. rium is regained. • Determine the appropriate contact. »» Non-injury auto accidents. »» Allow quiet downtime with a relaxing • Contact the appropriate resources. activity. »» Minor complaints. »» Praise student for positive aspects of situation, explicitly and generously. Re l a t e d We b s i t e s »» After recovery, teach the student how Ne x t St e p s to respond appropriately in future • The National Association for the similar situations. Dually Diagnosed Proactive Measures http://www.thenadd.org Tips on Communicating During an • Taking data on mental health of all • The City of Tampa Escalating Situation22 students. www.tampagov.net • Be gentle; Use a soft but firm . • Identifying risk factors and protective • Be tactful. factors from data. • Start with an open and positive attitude. • Promoting protective factors and reduc- ing risk factors. • Keep it short.

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1. Van Ameringen, M., Mancinia, C., & Farvolden, 12. Bryson, S.E, & Smith, I.M. (1998). End Notes/ P. (2003). The impact of anxiety disorders of autism: prevalence, on educational achievement. Journal of associated characteristics, and implications Anxiety Disorders, 17, 561-571. for research and service delivery. Mental References 2. Pavuluri, M., O’Connor, M., Harral, E., Moss, Retardation and Developmental Disabilities M., Sweeney, J. (2006). Impact of Research Review, 4, 97-103. Neurocognitive Function on Academic 13. Leyfer, O. T., Folstein, S. E., Bacalman, S., Difficulties in Pediatric Bipolar Disorder: Davis, N. O., Dinh, E., Morgan, J., et al. A Clinical Translation. Biological (2006). Comorbid psychiatric disorders Psychiatry, 60, 951-956. in children with autism: interview 3. Aluja, A., Blanch, A. (2004). Depressive Mood development and rates of disorders. and Social Maladjustment: Differential Journal of Autism and Developmental Effects on Academic Achievement. Disorders, 36, 849-861. European Journal of Psychology of 14. Cath, D. C., Ran, N., Smit, J. H., van Education, 19, 121-131. Balkom, A. J. L. M. & Comijs, H. C. (2008). Symptom overlap between 4. Grisso, T., & Barnum, R. (2000). Massachusetts autism spectrum disorder, generalized Youth Screening Instrument second social and obsessive- version: User manual and technical compulsive disorder in adults: A report. Worchester, MA: University of Massachusetts Medical School. preliminary case-controlled study. Psychopathology, 41, 101-110. 5. Trupin, E., & Boesky, L. (1999). Working 15. Munesue, T., Ono, Y., Mutoh, K., Shimoda, together for change: Co-occurring mental K., Nakatani, H. & Kikuchi, M. (2008). health and substance use disorders among High prevalence of bipolar disorder youth involved in the juvenile justice comorbidity in adolescents and young system: Cross training, juvenile justice, adults with high-functioning autism mental health, substance . Delmar, NY: The National GAINS Center spectrum disorder: A preliminary study of 44 outpatients. Journal of Affective 6. Weist, M., Rubin, M., Moore, E., Adelsheim, Disorders, 111, 170-175 S., & Wrobel, S. (2007). Mental health 16. Matson, J. L., & Nebel-Schwalm, M. S. (2007). screening in schools. Journal of School Comorbid psychopathology with Health, 77 (2), 53-58. autism spectrum disorder in children: 7. Simonoff, E., Pickles, A. C., Chandler, S., an overview. Research in Developmental Loucas, T., & Baird, G. (2008). Disability, 28, 341-352. Psychiatric disorders in children with autism spectrum disorders: prevalence, 17. Abramson, R., Ravan, S., Wright, H., Wieduwilt, comorbidity, and associated factors in K., Wolpert, C., Donnelly, S, Pericak- Vance, M.A. & Cuccaro, M.L. (2005). a population-derived sample. Journal The relationship between restrictive of the American Academy of Child and and repetitive behaviors in individuals Adolescent Psychiatry, 47, 921-929. with autism and obsessive compulsive 8. Ghaziuddin, M., Weidmer-Mikhail, E. & symptoms in parents. Child Psychiatry & Ghaziuddin, N. (1998). Comorbidity Human Development, 36, 155-165 of Asperger syndrome: A preliminary 18. Lainhart, J., & Folstein, S. (1994, October). report. Journal of Intellectual Disability Affective disorders in people with autism: Research, 42, 279-283. A review of published cases. Journal of 9. American Psychiatric Association. (1994). Autism and Developmental Disorders, 24, Diagnostic and Statistical Manual 587-601. of Mental Disorders-Fourth Edition 19. Kutash, K., Duchnowski, A.J., & Lynn, N. (DSM-IV). Washington, DC: American Psychiatric Association. (2006). School-Based Mental Health: An Empirical Guide for Decision-Makers. 10. American Psychiatric Association. (2000). Tampa, FL: Research and Training Diagnostic and Statistical Manual of Center for Children’s Mental Health, Mental Disorders-Fourth Edition Text Department of Child and Family Revision (DSM-IV-TR). Washington, Studies, Florida Mental Health Institute, DC: American Psychiatric Association. University of South Florida. 11. Bryson SE. (1997). : 20. Rapee, R.M., Spence, S.H., Cobham, V., Prevalence, Associated Characteristics and Wignall, A. (2000). Helping Your Implications for Service Delivery. Paper Anxious Child. Oakland, CA: New presented at the Autism Workshop of the Harbinger Publications, Inc. U.S. Centers for Disease Control and Prevention and the National Alliance for 21. Bashe, P.R. & Kirby, B.L. (2005). The OASIS Autism Research, Atlanta, GA. Guide to Asperger Syndrome. New York: Crown Publishing Group. 22. Ryan, R. (2001). The Handbook of Mental Health Care for Persons with Developmental Disabilities. Canada: Diverse City Press.

10 11 Florida’s First Choice for Autism Support

The Center for Autism & Related Disabilities (CARD) provides support and assistance with the goal of optimizing the potential of people with autism and related disabilities.

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