Exploring Feelings for Young Children with High-Functioning Autism or Asperger's Disorder

The STAMP Treatment Manual

Tony Attwood, Angela Scarpa, Anthony Wells

• Publisher: Jessica Kingsley Publishers
• Year: 2012
• Print ISBN:
  9781849059206
• eBook ISBN:
  9780857006813
• Topic: Psychology
• Subtopic: Autism Spectrum Disorders
• Index: Psychology

Young children with autism have particular difficulty in understanding and controlling their emotions, especially when those emotions are negative. This practical manual for professionals provides a set of simple strategies to help children with high-functioning autism or Asperger's syndrome who suffer from mood difficulties to decrease negative feelings and increase positive feelings in daily life.

Using a Cognitive Behavioral Therapy approach, The Stress and Anger Management Program (STAMP) is designed specifically for young children in their pre-school and early school years. The book outlines a 9-session group program using methods, games and activities that are developmentally appropriate. Treatment components include affective education, cognitive restructuring, social and group stories, and the emotional toolbox. The group therapy can be tailored for individual therapy when needed. A parental component is also included to support practice at home and promote generalization outside of the classroom or therapy setting.

This is a dynamic and effective resource for professionals working with young children with autism spectrum disorders including teachers, guidance counselors, psychologists, speech therapists, behavioral therapists, occupational therapists, and social workers.

PART 1

Introduction

1

OVERVIEW

This manual outlines the Stress and Anger Management Program (STAMP), which is a structured treatment that provides children with high-functioning autism (HFA) or Asperger’s disorder with a set of strategies for decreasing negative feelings and increasing positive feelings in daily life. The program is considered an extension of Dr. Tony Attwood’s cognitive-behavioral program for children with HFA and Asperger’s disorder who may suffer from mood difficulties, particularly anger and anxiety (Sofronoff, Attwood, & Hinton, 2005; Sofronoff, Attwood, Hinton, & Levin, 2007). Dr. Attwood’s treatment was developed for middle childhood (ages 9–13 years old), yet STAMP addresses the needs of early childhood (ages 5–7 years old) using methods that are more developmentally appropriate for younger children. Even more important than the age of the child is the consideration of the child’s developmental level, which should be in the range of preschool to first grade. Treatment components of the nine-session program include affective education, cognitive restructuring, and the emotional toolbox (i.e., emotion regulation skills). A parental component is also added to encourage practice at home and therefore promote generalization outside of the therapy setting.

2

BACKGROUND

WANDERING IN THE SOCIAL–EMOTIONAL TERRAIN

Autism was first identified by Kanner (1943) and originally thought to be a relatively rare disorder that affected approximately 3 in 10,000 children. Currently, autism is thought to be the fastest growing neurodevelopmental disability in the United States. A recent survey found that an average of 1 in 88 children is affected with an autism spectrum disorder (ASD) in the United States (Centers for Disease Control and Prevention, 2012). According to current diagnostic criteria (American Psychiatric Association (APA), 1994, 2000), the diagnosis of autism requires impairments in three core areas: social functioning, communication, and repetitive behaviors, interests, or activities—with onset prior to age 3.

At the same time as Kanner’s initial work, Asperger (1944) described a group of children with similar characteristics to autism, but who had no language or cognitive delay. This cluster of symptoms is currently referred to as Asperger’s disorder and was formally published in the Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV) in 1994. In contrast to autism, the Asperger’s disorder diagnosis does not require clinically significant delay in language development, self-help skills, adaptive behavior, and curiosity about the environment. There is some dispute regarding the practical differences between Asperger’s disorder and HFA. The language delay of autism is the most noticeable difference, yet beyond early childhood, the two diagnoses appear to involve the same fundamental symptomatology (Ozonoff, South, & Miller, 2000), and it is being recommended that the next edition of the DSM collapse these disorders under the umbrella of autism spectrum disorder (ASD).

Youth with ASD demonstrate emotional and behavioral disturbances across the lifespan. For example, children with HFA and Asperger’s disorder both present with clinically significant disruptive behaviors, anxiety, and depression (Tonge, Brereton, Gray, & Einfeld, 1999; Kim, Szatmari, Bryson, Streiner, & Wilson, 2000; Gillott, Furniss, & Walter, 2001). Furthermore, they may have difficulty understanding their own inner emotional states and the emotional states of others, which is often referred to as “theory of mind” (Baron-Cohen, Leslie, & Firth, 1985). In addition, these children may not be able to identify or describe feeling states and may not understand their own bodily sensations of emotional arousal (Hill, Berthoz, & Frith, 2004). One reason for the difficulty that children with ASD may have in understanding and managing their emotions involves delays in executive functioning. Executive functioning includes planning, organizing, inhibiting behavior, and regulating arousal. Consequently, children with ASD may appear as difficult to manage, but their difficulties stem from problems with behavior and regulation that are part of executive dysfunction (Klin, McPartland, & Volkmar, 2005).

Therefore, delays in executive functioning can lead to problems regulating emotions. Emotion regulation is defined as the ability to change an ongoing emotion as needed in order to achieve some goal. Developmentally, emotion regulation begins with the infant’s ability to self-soothe when physiologically aroused, and is often dependent on the help of caregivers. Such regulation is believed to become more self-guided as the child matures, and these abilities are typically in place by 36 months of age (Kopp, 1982). In addition to executive dysfunction, children with ASD often have additional barriers that interfere with emotion regulation as they grow, including sensory issues, poor facial processing and social orienting in infancy, and difficulties with communication. These challenges can offset early emotion regulation by increasing arousal and frustration and interfering with the ability to use caregivers or others as soothing social agents. Poor emotion management, in turn, can further disrupt learning and social interactions.

3

TREATMENT DEVELOPMENT

MARCH TOWARD COMPETENCY

For these reasons, it is crucial that we find ways to help children with ASD learn to manage their stress and anger as early as possible. Unfortunately, very few treatments have been developed specifically addressing emotional difficulties in children with ASD. Dr. Tony Attwood and his colleagues have had promising results, however. Their program, called Exploring Feelings, consists of cognitive-behavioral treatments for children with HFA and Asperger’s disorder in the middle childhood age range. To date, they have conducted two randomized, controlled trials of the Exploring Feelings cognitive-behavioral program.

One study examined the efficacy of the program for improving anger management (Sofronoff et al., 2007). Forty-five children aged 9–13 with diagnosed Asperger’s disorder participated in the study. To be eligible for the study, children had to display the presence of anger. The children were randomly assigned to an intervention group or to a wait-list control group (whose treatment was delayed so they could be compared with those receiving the intervention earlier). The intervention was conducted over six two-hour weekly sessions designed to be highly structured, informative and entertaining. The children were taught anger-management strategies such as relaxation, anger recognition, emotional release and social contact. The children developed individualized plans based on the strategies learned. Meanwhile, the parents engaged in a parent group, where a therapist discussed the principles of the sessions with them. Parents indicated reduced anger episodes and improvement in the areas of frustration, peer relationships and authority relationships. Parents and children also reported increased confidence with managing the child’s anger. In a teacher survey, 88 per cent reported a positive change in the children. Of those who noticed a change, 19 per cent reported the child would ask to withdraw from class when angry, and 56 per cent reported that the child would discuss their anger and reduce outbursts.

The other study examined the efficacy of the program for improving anxiety management (Sofronoff et al., 2005). This study also examined whether intensive parental involvement would increase a child’s ability to manage anxiety outside of the clinic. Seventy-one children aged 10–12 with diagnosed Asperger’s disorder participated in the study. The children had to display anxiety to be eligible for the study. The children were randomly assigned to one of three groups: an intervention group where the child was treated in a group without parents, an intervention group with parental involvement, or a wait-list control group. The intervention was conducted over six two-hour weekly sessions using the same components described above, but specifically targeted anxiety. The reality and probability of their fears were also discussed in one of the sessions. Parents reported overall improvement in their child’s anxiety (including obsessive compulsive, generalized anxiety, and social fear tendencies), with greater improvements in the format that added parental involvement. Children in both intervention groups also showed an increase in the strategies they could name to manage anxiety, again with greater increases in the group with parental involvement.

Taken together, these two studies provide support for the use of cognitive-behavioral therapy to treat anger and anxiety in children with HFA/Asperger’s disorder. We believe it is critical to now extend the treatment to younger children, since early intervention is optimal and recommended for children with ASD.

4

STAMP

The program described in this manual extends this cognitive-behavioral approach to 5–7-year-old children with HFA or Asperger’s disorder. The children are most likely to be in preschool to first grade, so the program uses games and activities that are often seen in these early school years as a means for teaching various skills and concepts. The primary strategies used in this program include: affective education, skill-building (by introducing the emotional toolbox), and cognitive restructuring. Children meet once weekly as a group for one hour per session over nine weeks. Parents meet simultaneously with another therapist who reviews the skills with parents, troubleshoots, and describes practice assignments that the parent and child should do together for the following week.

STAMP Components

Affective Education

Affective education is a term used to mean that we are teaching children about feelings. Specifically, we teach the children the range of both positive and negative emotions and the vocabulary words to be able to express their emotions accurately. The children are also taught the bodily sensations, thoughts, and behaviors that occur when we are upset and that can often serve as early warning signs or clues of emotional escalation.

Skill-Building (The Emotional Toolbox)

The emotional toolbox, a concept developed by Dr. Attwood, is used as part of teaching children ways to handle their anger and anxiety. It is a metaphor of a toolbox with different types of “tools” to help “repair” the problems related to feeling anxiety, anger, or sadness. The tools consist of different strategies that help to release (i.e., physical tools like exercise) or to soothe (i.e., relaxation tools like deep breathing) emotional arousal. Other tools include social, cognitive, and special interest tools to improve help-seeking behaviors, thoughts, and pleasurable activities, respectively.

Cognitive Restructuring

The primary goal of cognitive restructuring is to help the children learn that their thoughts can affect how they feel and act; therefore, they can sometimes change their thoughts to feel better. In cognitive restructuring, the children learn to identify thoughts that may increase their anxiety/anger (e.g., “They will laugh at me”) and then replace those thoughts with antidotes (e.g., “I can stay calm”). This is used to challenge distorted thoughts or misinterpretations that may arise out of delayed theory of mind abilities, literal or concrete thinking, or poor pragmatics (both understanding the meaning of a situation as well as seeking clarification of others’ comments). The children are also taught that they can use pleasant thoughts to counteract the effects of unpleasant thoughts.

5

SESSION OVERVIEWS

Session 1: Exploring Positive Feelings (Happiness)

The primary goal for the first few sessions is to introduce different feelings. We start with positive feelings in order to develop rapport with the children and begin with a positive tone. The children are more comfortable and find it easier to learn the concepts when we relate it first to happy feelings. Therefore, in the first session we focus on feeling happy and the different degrees of happiness that someone might experience. The Singing and Story Time Activities are used to prime the children for thinking about happy feelings. The Ruler Game is designed to explore degrees of happiness, because children with ASD may have difficulty identifying feelings that are not very strong or that might be early clues that something is bothering them. As part of the game, for example, the child may experience having his favorite cereal at breakfast as satisfying, and place that feeling in the middle of the ruler. Getting presents at his birthday party, however, might be experienced as “exciting,” and placed very high on the ruler. We also introduce the purpose and goals of the program. The primary goal of STAMP is to learn how to understand and manage feelings, especially anger and anxiety. The four main reasons we would want to do this are so that we feel better, think better, stay out of trouble, and make friends. Therapists are encouraged to remind the children and parents of the main goal and these reasons regularly throughout the program.

In Session 1, children may not understand where to place their feelings on the ruler and may consistently place all their feelings on either the low end or the high end of the continuum. This is not uncommon, since they often recognize the extremes, but not the middle levels of emotions. Therapists can teach them by comparing the number ratings for each feeling and comparing situations to each other (e.g., “How did you feel when you went to Disneyworld?” versus “How did you feel when you sat down to watch TV?”).

Session 2: Exploring Positive Feelings (Relaxation) and Anger/Anxiety—Emotional Toolbox Introduction

Session 2 continues with exploring positive feelings and focuses on the feeling of being relaxed, also introducing the feelings of anger and anxiety and discussing how those feelings compare with feeling relaxed. Because children with ASD may not fully understand how emotions affect us, this session has a strong focus on how we feel inside our bodies and how we act when we are relaxed versus when we are angry or anxious. We start with defining and describing the feelings of anger and anxiety, and perform several activities. The Singing and Story Activities are used to help the children start thinking about relaxation. The Body Trace Activity is used to describe bodily sensations associated with relaxation (such as a slow-beating heart, slow breathing, loose muscles), and then we will contrast relaxed feelings with angry and anxious feelings (such as a fast heart, heavy breathing, tense muscles). Finally, the “emotional toolbox” is introduced to provide the children with a set of tools they can use to “fix” their feelings of anger and anxiety. The toolbox includes physical tools, relaxation tools, social tools, thinking tools, and special interest tools. These tools provide strategies based on relaxation, energy release, social contact, and changing thoughts. The emotional toolbox forms the crux of STAMP and is reviewed in detail in each of the remaining sessions.

In Session 2, it is very important to provide simple definitions of anger and anxiety because young children may not understand what those words mean. Anger is described as when children sometimes feel mad, annoyed, frustrated, or even furious. Anxiety is described as when children feel scared, worried, or nervous about something that they think might happen. Children also...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Part 1: Introduction
• Part 2: Using the Manual
• Part 3: Sessions and Resources
• Appendix A: Children’s Stories Used in Stamp
• Appendix B: Parent Assessments
• Appendix C: Child Assessments