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<p>With more attention from media and increased public awareness, caregivers are increasingly concerned about the possibility that their child is autistic. Before jumping into addressing that concern, let&rsquo;s review the history and diagnosis of Autism Spectrum Disorder for some background context.</p> <h3>The history of Autism Spectrum Disorder</h3> <p>The word &ldquo;autism&rdquo; first emerged in the literature in 1911 when a Swiss psychiatrist used it to describe his schizophrenic patients. Until the 1970s, the terms autism, &ldquo;psychosis&rdquo; and &ldquo;childhood schizophrenia&rdquo; were used interchangeably. In 1979, autism and schizophrenia were differentiated in the literature when Eric Schopler published an article explaining the distinction. At this time, more and more interest on the subject arose and old ideas about autism being caused by &ldquo;refrigerator mothers&rdquo; was replaced with an explanation that involved biology and science. In the 1980&rsquo;s, research began to focus on the brain activity of children with autism and the 1990&rsquo;s began to focus on the role of genetics. Autism first appeared as a separate disorder in the 1980&rsquo;s, was revised and broadened in 1987, then narrowed again in 1994. The most current diagnosis (DSM-5, 2013) includes a broad category of &ldquo;Autism Spectrum Disorders (ASD)&rdquo; (Sole-Smith, 2015). The older diagnosis of Asperger&rsquo;s Syndrome was discontinued and children who fell under that diagnosis were placed under the umbrella of ASD.</p> <p>Currently, the diagnosis of ASD is considered a &ldquo;family of neurodevelopmental disorders&rdquo; (W&ouml;hr &amp; Scattoni, 2013) that manifests before age three and involves &ldquo;(A) Persistent deficits in social communication and social interaction across multiple contexts and (B) Restricted, repetitive patterns of behavior, interests, or activities that cause clinically significant impairment in social, occupational, or other important areas of current functioning&rdquo; (American Psychiatric Association, 2013). A diagnosis includes specifying the severity level of deficits in both domains (Social Communication and Restrictive and Repetitive Behavior).</p> <h3>Is autism on the rise? </h3> <p>Another common question relates to whether or not autism is on the rise. Epidemiological research shows that early estimates of ASD were 4 children out of 10,000. Currently, the prevalence rate as reported by the Center for Disease Control and Prevention (CDC, 2018) is 1 in 59 children. Many people attribute this increase to a combination of factors such as a broader diagnosis and increased public awareness. However, due to limited knowledge about the exact causes of ASD and the inability to accurately perform historical research, one cannot rule out the possibility that Autism Spectrum Disorders could be on the rise.</p> <h3>What are red flags of ASD?</h3> <p>Autism is a complex disorder and one child with ASD may present entirely different than another child with ASD (hence the importance of an individualized evaluation). That said, there are some signs and symptoms that may warrant further evaluation to determine if these behaviors are the result of ASD. According to the CDC, these include:</p> <ul> <li>Not responding to their name by 1 year</li> <li>Not using nonverbal gestures (pointing, waving) to objects OR not responding to other&rsquo;s nonverbal gestures</li> <li>Not engaging in pretend play by age 1.5 years</li> <li>Making limited eye-contact and preferring to be alone</li> <li>Seeming unaware of others and their own emotions or feelings</li> <li>Having delayed speech and language</li> <li>Repeating words or phrases (this is called echolalia)</li> <li>Being overly interested in restricted topics (watching the same episode of Thomas the Train over and over)</li> <li>Being upset by transitions or minor changes</li> <li>Engaging in hand flapping, body rocking, spinning, or other stereotyped motor movements</li> <li>Reacting unusually to sensory experiences (tastes, sounds, smells, appearance, or texture)</li> <li>Shows no interests in others preferences</li> <li>Only interacts socially to accomplish a goal</li> <li>Avoids social contact</li> <li>Neglects social rules about personal space and boundaries</li> <li>Has flat, constricted, or inappropriate facial expressions</li> <li>Uses flat, high-pitched, or robotic speech</li> <li>Reverses pronouns (says you instead of I)</li> <li>Doesn&rsquo;t seem to understand jokes or sarcasm</li> <li>Lining toys up or insisting objects be placed in a particular way</li> <li>Overly focused on parts of objects (watching the wheels of a toy car spin over and over rather than playing with the car)</li> <li>Insisting on routine (disruptions in routine lead to tantrums)</li> </ul> <p>Some of the signs listed above may also occur due to other difficulties, such as a developmental delays, a speech or language disorder, or another neurodevelopmental or mental health disorder; additionally, children with ASD may also have additional mental health concerns. It is possible that a child has both ASD and AD/HD. It is also possible that a child who is flagged as having ASD actually has a speech and language disorder and is becoming frustrated by their inability to communicate their needs effectively. The best way to clarify the diagnostic presentation is through an evaluation with a developmental pediatrician, a child psychologist, or some other specialist who is familiar with autism diagnostics.&nbsp;</p> <h3>Case Examples</h3> <p>Given the broad range of presentations in ASD and the varying levels of severity, let&rsquo;s look at some case examples with diagnostic data.</p> <p>Let&rsquo;s start with this example. A 14-year-old boy, named Jacob, diagnosed with Autism Spectrum Disorder with the specifiers (severity levels) of Level 1&mdash; Social Communication and Level 1&mdash; Restricted and Repetitive Behaviors. His parent&rsquo;s primary concern was that he does not seem able to conform to classroom rules, gets into trouble for talking out of turn, and makes comments that offend others without understanding how such comments are inappropriate. His presentation was observed and he demonstrated generally flat affect, limited eye contact, excessive talking, and limited interest into others&rsquo; experiences. He has a reportedly close relationship with his parents but they stated he lacks social awareness and becomes &ldquo;stuck&rdquo; on preferred topics and activities. His friendships are okay as long as they revolve around his interest in video gaming. Intellectually, he performs a little bit below others but has some strength related to solving problems that rely on abstract logic (e.g., he can provide elaborate details on the similarities between different gaming theories and is generally able to understand how concepts relate to one another). He really struggles when he has to quickly perform tasks that require eye-hand coordination, which has negatively impacted his ability to enjoy many sports and also interfere with his ability to quickly take notes in class. Other possible diagnoses, such as anxiety and attention deficit/ hyperactivity disorder, were ruled out by an evaluation. His treatment needs will require minimal support to help him function.</p> <p>Now, let&rsquo;s do another example. An 11-year-old girl named Jana, diagnosed with Autism Spectrum Disorder with the specifiers (severity levels) of Level 3- Social Communication and Level 3- Restricted and Repetitive Behaviors. Her parents reported primary concerns regarding her behavior, which can be very violent towards herself and others. They also reported concern relating to her obsession with YouTube videos about beanie babies, which is the only activity she will participate in without becoming dysresgulated. She is especially fascinated by one clip that shows a beanie baby being tossed up and down over and over. She has an IEP and is placed in special education, under the eligibility of Autism. Her parents reported that they are having a very difficult time parenting her, and that it is negatively impacting their marriage. Her daily living skills are below expected for her age and she requires the same amount of parental guidance as her 7-year-old sibling. She refuses to eat anything soft and covers her ears anytime someone uses a vacuum cleaner, hand dryer, or makes a loud noise. When she is upset, she rarely seeks out comfort from others. Other possible diagnoses, such as intellectual disability, pervasive developmental delay, and traumatic stress were ruled out by an evaluation. Ultimately, it was determined she has several difficulties related to her ASD, and will likely need very substantial interventions to help her function.</p> <p>Based on these case examples, you should be able to see that there is no one profile of a child with autism. &nbsp;Because of this, there is also not one particular treatment that will work best for all children with autism. Again, this highlights the importance of finding the best fit for the child given their needs and abilities.</p> <h3>How can I get an evaluation?</h3> <p>Sharing concerns with your child&rsquo;s primary care physician is one way to get the ball rolling. Most pediatricians are trained to screen for ASD as part of their wellness check-ups. Alternatively, schools may be a resource if you have concerns and they may be able to direct you to providers. A trained clinician will likely be the person who will determine if your child meets criteria for ASD through a comprehensive evaluation. An ideal evaluation consists of a battery of tests including several components: an ASD screener, parent/caregiver interview, cognitive and developmental testing, personality testing, speech and language testing, observational assessment, adaptive functioning assessment, sensory and motor testing, and measures of executive functioning. This comprehensive evaluation leads to individualized results, which would then inform symptom severity and ultimately inform treatment. Diagnosis informs treatment and opens up a world of resources for those who might benefit.</p> <h3>Then what?</h3> <p>There are several treatments and treatment combinations that can be used in the treatment of ASD and the process of matching a child to the appropriate therapy can be overwhelming. This process is especially made difficult by barriers such as insurance coverage, treatment availability, and clinicians who do not stay up to date on new treatment options. This is an evolving field and interventions are continually being developed. Similar to other providers, it is important for families to do some research and find providers that are a good fit for their family needs and who stay current on autism research. Broadly speaking, the following recommendations commonly follow a diagnosis of autism spectrum disorder:</p> <ul> <li>caregiver psychoeducation, </li> <li>autism specific intervention, </li> <li>&middot;occupational therapy, </li> <li>speech therapy, </li> <li>assistive technology, </li> <li>academic accommodations (e.g., IEP, 504 Plan, Educational Therapist, School Advocate), </li> <li>psychiatric evaluation (especially when co-morbid diagnoses are present),</li> <li>sleep hygiene, </li> <li>consistency across settings, </li> <li>Comparative Genomic Hybridization (CGH) microarray testing and analysis, and </li> <li>maintenance of general medical appointments.</li> </ul> <p>If you need help figuring out where to begin, our <a href="https://1in5minds.org/learn/handbooks/parent-guide"><strong>free guidebook for parents</strong></a> can direct you through the process and answer some of your big picture questions.</p> <h3>Where can I learn more about ASD? </h3> <ul> <li>http://www.nationalautismcenter.org/resources/ </li> <li>https://www.autismspeaks.org/what-autism/diagnosis/dsm-5-diagnostic-criteria </li> <li>https://www.autismspeaks.org/family-services/tool-kits/100-day-kithttps://www.autismspeaks.org </li> <li>http://www.autism-society.org </li> <li>http://www.autism.com </li> <li>https://www.cdc.gov/ncbddd/autism/signs.html</li> <li>http://autismsciencefoundation.org </li> <li>http://www.asha.org </li> <li>http://www.neurodiversity.com </li> <li>http://the-art-of-autism.com </li> </ul> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <br />
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<a href="http://https://www.claritycgc.org/patient-families/learn-about-clarity/meet-our-psychiatrists-and-therapists/sara-gill">By: Sara Gill, PhD</a><br /> <br /> <p>Defining trauma has been a challenge across many fields over the past few decades.&nbsp; This is in part because it must go beyond identifying specific events or types of events, and instead must focus on the experience and perceptions that create the trauma.&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; <br /> <br /> According to leading researchers (Cohen et al., 2006), the best definitions of trauma incorporate the following features when distinguishing traumatic events:</p> <ol> <li>Sudden or unexpected events</li> <li>The shocking nature of such events</li> <li>Death or the threat to life or bodily integrity</li> <li>The subjective feeling of intense terror, horror, or helplessness</li> </ol> <p>Common examples of such events can include witnessing or being a victim of domestic violence, a car collision, an environmental disaster, a physical illness that is potentially life threatening, the death of a loved one, and exposure to high stress living conditions. </p> <p>However, traumatic events are not always easily identified or defined. Those who are affected, are impacted in different ways. While the examples listed above may seem fairly self-evident, there are any number of events that can be experienced as traumatic by the individual going through them. These events may be one time events, such as an accident, or they may be long-term or chronic events that, due to the buildup of stress over time, become traumatic. <br /> <br /> Individuals or families may often experience a combination of these types of experiences. For example, a specific event may occur, such as an unexpected death, that leads to chronic stresses in the environment, such as the loss of income.&nbsp; In this situation both the initial death and the ongoing fears and stresses related to the loss of income, such as insecure housing, are experienced as trauma.&nbsp; The National Stress Network lists the following 14 categories of trauma:</p> <ol> <li>Sexual Abuse or Sexual Assault: This includes but is not limited to physical contact. It can also involve exposure to inappropriate sexual material or environments. </li> <li>Physical Abuse or Assault: This includes both actual or attempted infliction of pain.</li> <li>Emotional Abuse/Psychological Maltreatment: This includes verbal abuse, emotional abuse, excessive demands on a child&rsquo;s performance, emotional neglect, or intentional social deprivation.</li> <li>Neglect</li> <li>Serious Accident or Illness/Medical Procedure</li> <li>Witness to Domestic Violence</li> <li>Victim/Witness to Community Violence</li> <li>School Violence</li> <li>Natural or Man-made Disaster</li> <li>Forced Displacement</li> <li>War/Terrorism/Political Violence</li> <li>Victim/Witness to Extreme Personal/Interpersonal Violence</li> <li>Traumatic Grief/Separation</li> <li>System-Induced Trauma: This can include removal from home, placement in a foster home, sibling separation, or multiple placements in a short amount of time. </li> </ol> <p>Others have grouped the causes of physical and mental trauma into broader categories.&nbsp; One such system includes the following:</p> <ol> <li><em>One-time events: </em>This includes accidents and injuries. Events in this category seem to be particularly impactful if they occur in childhood.</li> <li><em>Ongoing relentless stress:</em> This includes neglect, bullying, living with a chronic illness, or living in chronic poverty. </li> <li><em>Commonly overlooked causes</em>: This includes surgeries (specifically in for children 3 years old and younger), a break up, a humiliating or cruel experience. </li> </ol> <p>As noted above, there can be significant differences in how individuals experience an event, which directly impacts whether it is considered to be a trauma. This is often due to the fourth factor listed above, namely the feelings of intense terror, horror, or helplessness. <br /> <br /> How an individual experiences an event and how they are then able to process it or make meaning of it helps to determine whether that event is experienced as traumatic. Said another way, two individuals may experience the exact same situation, but have markedly different experiences and outcomes. One person may have resources and supports, as well as other coping skills that prevent them from being overwhelmed by negative emotions and may help to prevent them from feeling truly helpless and terrified.&nbsp; Conversely, the other person may have his or her coping skills completely overwhelmed by such feelings. In this case, it would be much more likely that the second person would exhibit symptoms related to trauma.</p> <p>As you might imagine, this picture becomes even more complicated when talking about children and families. A child&rsquo;s age, developmental stage, individual attributes, and more all impact whether or not they experience an event as traumatic. The Early Trauma Treatment Network defines trauma for children under the age of six years old as, &ldquo;An exceptional experience in which powerful and dangerous stimuli overwhelm the child&rsquo;s capacity to regulate emotions.&rdquo;&nbsp; They also note that for children under the age of four years old, seeing an adult caregiver physically threatened can be a particularly powerful or potent form of trauma.</p> <p>Taken together, this means that children and adolescents are particularly vulnerable to experiencing trauma depending on the resources that are available to them. And research has shown that childhood trauma can continue to impact an individual throughout his or her lifetime and leave them at increased risk of experiencing additional traumatic events in the future.</p> <p>The emotions and behaviors exhibited by individuals who have experienced trauma can vary greatly.&nbsp; In children it can become even more varied as their reactions may change over time as their understanding of different events matures. Symptoms of trauma can include, but are not limited to, the following:</p> <p><em>Emotional and psychological symptoms:</em></p> <ol> <li>Shock, denial, or disbelief</li> <li>Confusion, difficulty concentrating</li> <li>Anger, irritability, mood swings</li> <li>Anxiety and fear</li> <li>Guilt, shame, self-blame</li> <li>Withdrawing from others</li> <li>Feeling sad or hopeless</li> <li>Feeling disconnected or numb</li> </ol> <p><em>Physical symptoms:</em></p> <ol> <li>Insomnia or nightmares</li> <li>Fatigue</li> <li>Being startled easily</li> <li>Difficulty concentrating</li> <li>Racing heartbeat</li> <li>Edginess and agitation</li> <li>Aches and pains <ul> <li>In children this may also take the form of stomachaches and/or headaches.</li> </ul> </li> <li>Muscle tension</li> </ol> <p>Not all individuals, whether adults or children, who experience a traumatic event need treatment. However, it is incredibly important to seek help when symptoms being to impact the individual&rsquo;s ability to engage in daily activities.&nbsp; Providing a child or adolescent with additional support can be an important step in helping them gain the resources they need to process the range of feelings they are likely experiencing related to their trauma. Individual, family, and group therapy can all be important resources as your child works to process his or her trauma.&nbsp; It is important to speak with a qualified provider to determine the best course of treatment for you and your family.</p> <p>&nbsp;</p>
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<a href="https://www.claritycgc.org/patient-families/learn-about-clarity/meet-our-psychiatrists-and-therapists/sara-gill">By: Sara Gill, PhD</a><br /> <br /> <p>Raising a child with an ex-partner after a separation or divorce can present many unique challenges to an already complicated task. This can become particularly difficult when there has been a high level of conflict between the parents. Parents often express concern regarding issues like their ex-partner&rsquo;s parenting style, increased financial stress, and resentment related to past events in the relationship. These are just a few of examples of the types of issues that can directly impact how ex-partners engage with one another and the care of their child(ren).</p> <p><strong>Co-Parenting</strong></p> <p>Co-parenting is often defined as having both parents engage actively in their child&rsquo;s daily life. It has been found to be an effective strategy for meeting the needs of the children as they maintain a relationship with both parents. Additionally, there is support for the idea that when parents can engage in a functional style of co-parenting, it has a positive impact on children&rsquo;s mental health outcomes, with children less likely to experience symptoms of depression and anxiety. </p> <p>However, it is important to consider that it is not appropriate for all families or in all situations. In many families that have experienced or are currently experiencing domestic violence, abuse or neglect, and/or substance abuse, co-parenting may not be a safe option. At a less extreme level, there is also evidence that the development of a productive co-parenting relationship requires that both parents have a basic level of respect for the other parent&rsquo;s role in their child&rsquo;s life. If a family is not safe or if there is an essential level of respect, a form of parallel parenting (discussed below) may be a better fit for the family. </p> <p><strong>Tips for Co-Parenting:</strong></p> <p><strong>1. Separate your feelings about your spouse from your relationship with your children.</strong></p> <p>a. After a separation or divorce, you and/or your partner may be understandably experiencing negative emotions towards each other, such as hurt and anger. However, it is important to remember that those feelings are not appropriate to direct at your child. He or she is not responsible for what their other parent has said or done, nor is it their job to help manage your reactions. </p> <p>b. Instead, put effort into ensuring that you have a strong support system of other adults who can provide you with a safe and appropriate space in which you can process any thoughts and feelings about your ex-partner. This support can take any number of forms such as a close friendship, a therapist, a support group, and/or a religious community. The more sources of support, the better!</p> <p><strong>2. Be thoughtful about how you speak about your child&rsquo;s other parent to your child. </strong></p> <p>a. It is important to recognize that just because you and your ex are no longer in a relationship, they remain your child&rsquo;s other parent and serves an important role in your child&rsquo;s life. When you speak negatively about your child&rsquo;s other parent (either explicitly or implicitly), you risk placing them in an inappropriate role. For example, they may feel as if they are being asked to choose between you and their other parent. They may also feel as if they have to keep secrets in order to avoid conflict or hurting your feelings. </p> <p><strong>3. Keep the</strong> <strong>focus of communication with your ex on the children. </strong></p> <p>a. Maintaining clear communication with your ex-partner is important. It can be helpful to remember that at this point your children&rsquo;s interests are the priority. Therefore, by keeping the focus on them, it can help keep your interactions with your ex-spouse from deteriorating.</p> <p>b. When it comes to communication, it can be helpful to maintain a business-like tone. This translate to communications being direct and polite. You don&rsquo;t have to be overly friendly but should strive to maintain at least a neutral tone. </p> <p>c. Keep in mind that communicating with your ex may require you to develop strategies to keep your stress level manageable, which in turn will help you maintain appropriate boundaries and communications. Thisis another time where having a support system or working with a professional to develop specific techniques can be very important for navigating these difficult processes. </p> <p><strong>4. Don&rsquo;t put your children in the middle.</strong></p> <p>a. Related to the above point, it is essential that you and your child&rsquo;s other parent have can communicate to some degree directly with each other. You never want to place your child in the middle of the two of you, such as having them carry messages to the other parent. Resolve any conflict between you and your child&rsquo;s other parent, without the child&rsquo;s participation. </p> <p><strong>5. Try to develop some degree of consistency between the two households.</strong></p> <p>a. Ideally, it can be helpful for children if there is a similar structure in place across households. This structure means both parents are creating similar expectations of behavior, similar rules, similar ways of disciplining, and even similar routines. For children, this type of consistency creates a sense of stability even as they have to transition between parents.</p> <p>b. However, it is essential to remember that no two people are going to parent in exactly the same manner, and therefore you have to allow a certain amount of latitude for minor differences in parenting style. You each have your own strengths, and it is important to allow for them, even if that means your ex doesn&rsquo;t do things exactly as you would do them. </p> <p><strong>6. Develop a strategy for resolving conflicts.</strong></p> <p>a. Being a parent is hard! Even in the best of relationships, raising a child with another person is going to create conflict. Given that you are now raising a child with an ex-partner, it is likely that there will come a time when you disagree with each other. It can be beneficial to plan ahead (when you are both calm) and strategize for how you would like to resolve conflicts </p> <p>i. These strategies should focus on maintaining respect for each other.</p> <p>ii. It may be helpful to discuss what you both consider to be minor issues that can be let go, versus what types of issues require more extensive efforts to resolve.</p> <p>iii. It may be helpful to discuss what forms of communication might work best. </p> <p>iv. REMEMBER THAT IT ISN&rsquo;T ABOUT YOUR OR YOUR CHILD&rsquo;S OTHER PARENT WINNING! It is about figuring out what is truly in your child&rsquo;s best interest. This may require compromise on all ends. </p> <p><strong>7. Regarding visitation:</strong></p> <p>a. Each parent should work with the child on strategies to help them anticipate their transition between households. This process can involve developing ways of reassuring them or even just helping them to remember their schedule. It can include having special rituals to help ease them through the change.</p> <p>b. Allow the children to keep familiar items with them for comfort. </p> <p>c. When your child first arrives, keep things low-key. It is important to allow them time to transition/adjust. Give your child time to themselves or engage in an activity such as reading together.</p> <p>d. Keep essentials such as basic toiletries at both houses, so children don&rsquo;t have to pack them each time. Related to this, also ensure that each child has a way of making both homes feel as if they are &ldquo;theirs.&rdquo; Allow your child to put up decorations or create a specific space for them.</p> <p>e. Recognize that visitation schedules may have to be adjusted as children get older. The schedule that works best for a 5-year-old may not work well for a 15-year-old as their needs and demands on their time changes. If at all possible, it is helpful to maintain a certain level of adaptability to adjust to the needs of your child.</p> <p><strong>Parallel Parenting</strong></p> <p>Parallel parenting is a strategy that allows the parents to both be involved with their child but minimizes their interactions with one another. In situations where one or both parents has not been able to communicate respectfully, parallel parenting allows for the adults to disengage from each other and limits direct contact, thus limiting the conflict that may occur. </p> <p>Five tips have been recommended to help create an effective parallel parenting relationship.</p> <p>1. Communication between the parents should focus on information related to the child or children, </p> <p>2. Communication between the parents should be non-personal (contains no personal information) and maintain a business-like tone. </p> <p>3. Children should not be used as messengers between their parents.</p> <p>4. Any changes to the set schedule require a written agreement (e.g., informal changes made through verbal exchanges should not be considered).</p> <p>5. Schedules should be managed through a shared calendar and in writing to limit contact and conflict. </p> <p>In some situations, parents who can engage in parallel parenting may be able to move towards co-parenting as hostilities decrease and they develop improved communication skills. In other families, parallel parenting may continue to be the best option to limit conflict.</p>
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