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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