Autism: A Neuropsychological Approach

1. Autism: A Neuropsychological Approach Vaughan Bell South London and Maudsley NHS Trust National Behaviour Disorders Unit Behavioural Genetics Clinic

2. Outline • Neuropsychology and autism • Approaches to assessment • Formulation • Intervention

3. What is Neuropsychology • Neuropsychology is the science of how the structure and function of the brain relate to psychological processes. • As a basic science it tries to understand these links experimentally. • As a clinical science it aims to understand how specific impairments relate to impaired brain mechanisms, and vice versa. • As a clinical practice it aims to improving well-being and functioning

4. Assessment vs Treatment • Neuropsychology plays a key part when working with neurodevelopmental disorders • Not least because a diagnosis of learning disability has profound effects for service provision • However, it can also contribute to the understanding and treatment of a range of emotional and behavioural problems.

5. Approach • Neuropsychology is just people • It is a tool that help us understand people on an additional level… • ...and help them in another way. • It is no more about reducing people to numbers than measuring someone’s temperature means you’re not interested in getting them back to work

6. Approach • Neuropsychology needs to be formulated • It is not just doing tests • Neuropsychologically informed treatment includes a working model of the person’s difficulties and what maintains them • Avoid ‘blood test psychology’!

7. Department of Pathology Glucose, Serum Creatinine Sodium Potassium Calcium Protein, Total, Serum 84 1.06 141 4.4 9.9 7.6

8. Department of Psychology Processing Speed Executive Function Theory of Mind Working Memory Visual Perception Verbal Comprehension 84 106 141 44 99 76

9. Approach • Neuropsychological assessment can only be understood in the context of the person’s • Life • Presentation • Problem • And relevant empirical findings

10. Relation to Theories of Autism • There are many neuropsychological theories: • Central coherence (Happe and Frith, 2006) • Hyper-systemizing (Baron-Cohen et al., 2005) • Theory of mind (Leslie and Frith, 1985) • Executive dysfunction (Ozonoff et al., 2006) • etc

11. Relation to Theories of Autism • These are informed by neuropsychological findings… • …but are not a good guide to how neuropsychological difficulties might present in individuals

12. Neuropsychological Profiles • There is a great deal of variability in many of the findings… • …partly due to differing samples and definitions of autism • But there are some general patterns

13. Learning Disability • Matson et al (2009) • About 50-70% of people with ASD have a learning disability • LaMalfa et al (2004) • About 40% of persons with learning disability have an ASD

14. Charman et al. (2011) • Better visuospatial than verbal abilities • Although less pronounced PIQ / VIQ difference than often made out • Poor theory of mind • Cognitive empathy impaired • Affective empathy intact • Below average executive function

15. Paradox of Cognitive Flexibility “Researchers and clinicians assume that inflexible everyday behaviors in autism are directly related to cognitive flexibility deficits as assessed by clinical and experimental measures.” “Based on recent studies at multiple sites, using diverse methods and participants of different autism subtypes, ages and cognitive levels, no consistent evidence for cognitive flexibility deficits was found.” Geurts et al. (2009)

16. Not DSM Diagnostic • The most consistent finding is variability within and between individuals • This is important because neuropsychology is not diagnostic for ASD

17. Nor Pseudodiagnostic • We also need to avoid descriptions like: “this person has better visual than verbal ability, in line with the common profile in ASD” • It’s a bit like: “this person has much wider shoulders than hips, in line with the common profile of a male”

18. But Very Helpful • Neuropsychological performance is one of most important predictors of outcome (Howlin and Moss, 2012)

19. An Aside on Epilepsy • Prevalence of epilepsy in ASD (Bolton et al., 2001): • General population 0.63% • People with autism 22% • More common with LD but present throughout spectrum • Epilepsy not related to severity of autism, nor family history of epilepsy

20. An Aside on Motor Function • Higher rates of co-ordination and movement difficulties in autism (Maski et al., 2011) • Poor coordination and clumsiness • Problems with skilled movement (dyspraxia) • Worse handwriting • Improves with age • Correlates with severity of autism

21. An Aside on Mental Health • Mental health problems much more common in ASD (Wilson et al., 2012) • Kohan et al. (2012): 14,000+ records of ASD patients. Lots of additional physical, mental health diagnoses • Regardless of the population prevalence… • …the people you will see, are likely to have additional mental health problems.

22. Testing

23. Key Question • Is this a problem of: • Capacity; or • Performance

24. Being Tested • Psychologists tend to forget the impact of having an assessment • It is a big, weird, event that has a significant influence on the patient’s management and future • It can therefore be anxiety-provoking, misunderstood or difficult to give your best

25. [ Exercise ]

26. Being Tested • Some misunderstandings: • It’s an exam • It’s a therapy session • It’s to ‘prove someone right’ • It’s a date • It’s a search for ‘brain damage’ • It’s to get benefits, driving license etc

27. Sources of Stress • Testing may be stressful because of its cognitive demands (e.g. attention needed to complete tasks) • Or because of its emotional consequences, especially if a patient fails a task, series of tasks or performs poorly.

28. Pre-Test Interview • The initial interview should • Explain why the assessment is being completed, what it’s for and what it does • i.e. it should help reduce test anxiety, avoid motivational bias • Gather essential information and observations to help in formulation

29. Pre-Test Interview • Are you right or left-handed? • Do you have any difficulty hearing? • Do you need glasses for reading? • Are you colour-blind? • Do you have any difficulty using a pen?

30. Pre-Test: Neuro Problems • Have you ever had epilepsy or had a seizure? (‘fits, faints or funny turns?’) • Have you had any head injuries? (‘bangs to the head’)? • If so, did you lose consciousness? Were you taken to hospital? • Any problems with your memory, concentration or problem solving?

31. Pre-Test: Other Difficulties • Are you taking any drugs or medication at the moment? • Are you being treated for any other medical conditions? • Have you ever been treated for a mental health problem? • How are you sleeping at the moment?

32. Pre-Test: Education • How was school for you? • What were your strengths and weaknesses? • Did you have any extra help at school? (Did you receive a statement of special needs?) • What qualifications / grades did you achieve?

33. Test Administration • Distraction free environment… • …including no distracting family members if possible! • Quiet • Soft lighting

34. Observations • Eye contact • Body language • Speech (tone, volume, pace, content) • Gesture use • Facial expression

35. Observations • Motivation / attitude • Reaction to failure • Need for reassurance • Awareness of mistakes • Understanding of instructions

36. Observations • Distractibility • Manual dexterity • Repetitive behaviours, echolalia • Sensory difficulties

37. Formulation

38. Formulation • Neuropsychological tests do not tell us about memory, attention, executive function etc • They only tell us how someone scored on that test at that moment in time

39. Formulation • The assessment is a formulation based on: • Results • Behaviour • History • Knowledge of neuropsychology • Referral question • In other words, being stung by a wasp during the WAIS does not reduce your IQ

40. Key Questions • What question am I trying to answer? • Diagnostic (e.g. LD) • Has the person changed over time? • Which recommendations are most appropriate?

41. Key Questions • Are difficulties a problem of: • Capacity; or • Performance

42. Key Questions • Do these difficulties play a role in the maintenance of: • Mental health problem • Unhelpful behaviour • Low treatment engagement

43. Formulation • What has changed? • Direct vs indirect testing • Importance of raw scores!

45. Intervention

46. Intervention • Cognitive rehabilitation • Mental health treatment

47. Cognitive Rehab • Bypassing or avoiding problem areas by changing the environment • Functional adaptation or finding another way to achieve a particularly goal • Use residual skills more effectively • Task specific vs task general approach

48. Mental Health • Key question: • What is the cycle of maintenance?

49. Example • JE is an adult male with a diagnosis of autism spectrum disorder and social anxiety • During social interaction JE makes inappropriate jokes and comments, leading to highly negative reactions • He rarely attempts social interaction for this reason

50. Traditional CBT Formulation • JE has anxiety due to an excessive fear of negative evaluation • In social situations he self-monitors for confirmatory evidence of how he appears to others • Counter-productive coping avoids disconfirmation and impacts on social performance • This seems to confirm the fear of social danger