Social-Emtional Skills To Adolescents With ASD

12/11/2018
School Counsellors & Psychologists (SCAP) Conference: November 15th 2018
TEACHING SOCIAL-EMOTIONAL SKILLS TO

ADOLESCENTS WITH
AUTISM SPECTRUM DISORDER
DR BELINDA RATCLIFFE
CLINICAL PSYCHOLOGIST/ LECTURER IN CLINICAL PSYCHOLOGY
SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.
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OVERVIEW
1. Introduction to Neurodevelopmental Disorders:

• DSM-5: ASD & ID
o p
2. Mental Health in ASD
3. Social-emotional needs of adolescents with ASD
4. Building social-emotional skills in ASD
• Westmead Feelings Program (as an example!)
5. Summary and Conclusions
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NEURODEVELOPMENTAL DISORDERS
Autism Spectrum
Disorder Intellectual Disability
Global Developmental
Delay (<5 years)
If can’t assess severity
Specific Learning
Disorder Neurodevelopmental
Disorders
(DSM-5)
Communication Disorders
Language Disorder
Speech Sound Disorder
Childhood-Onset Fluency
Disorder (Stuttering)
Social(Pragmatic
ADHD Communication Disorder)
Unspecified Communication
Motor Disorder Developmental Disorder
Co-ordination Disorder
Stereotypic
Movement Disorder
Tic Disorders
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NEURODIVERSITY
“The range of differences in
individual brain function and
behavioural traits, regarded as
part of normal variation in the
human population (used
especially in the context of
autistic spectrum disorders)”.
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LANGUAGE…
I’m a person I’m have I’m I’m an I’m I’m high-
with Autism ASD Aspie Autistic Autistic functioning
person
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DSM-IV DIAGNOSIS OF AUTISM SPECTRUM DISORDER
Other terms used

colloquially (not in
DSM):
“High functioning”
“Low functioning”
“Aspie”
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THE TRIAD OF IMPAIRMENTS
DSM-IV
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DSM-5 AUTISM SPECTRUM DISORDER
Merging of all ASD’s into a single diagnosis
• Autism Spectrum Disorder
Three domains of impairments reduced to two
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1. Social-communication impairment
2. restricted, repetitive patterns of behaviour, interests or activities
•Severity ratings (Level 1, 2 or 3) for each domain
•Specify with/without intellectual disability, language impairment,
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medical/genetic/environmental factors, associated disorders.

•50-75% of individuals diagnosed under DSM-IV would receive a diagnosis
under DSM-5.

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DSM-5 AUTISM SPECTRUM DISORDER
Social- Restricted,
Communication Repetitive
Deficits Behaviours
Level 3 Requiring very substantial support Level 3
Level 2 Requiring substantial support Level 2
Level 1 Requiring support Level 1

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CRITERION A
Persistent deficits in social communication and social interaction across multiple
contexts, as manifested by all of the following, currently or by history (examples are
illustrative, not exhaustive; see text):
1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social
approach and failure of normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviours used for social interaction,
ranging, for example, from poorly integrated verbal and nonverbal communication; to
abnormalities in eye contact and body language or deficits in understanding and use of
gestures; to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for
example, from difficulties adjusting behaviour to suit various social contexts; to difficulties
in sharing imaginative play or in making friends; to absence of interest in peers.
Specify current severity:
Severity is based on social communication impairments and restricted, repetitive
patterns of behaviour (see Table).
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CRITERION B
Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least two of
the following, currently or by history (examples are illustrative, not exhaustive; see text):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor
stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or
nonverbal behaviour (e.g., extreme distress at small changes, difficulties with transitions, rigid
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thinking patterns, greeting rituals, need to take same route or eat same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative
interests).
4. Hyper- or hypo reactivity to sensory input or unusual interest in sensory aspects of the
environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds
or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
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Specify current severity:

Severity is based on social communication impairments and restricted, repetitive patterns of
behaviour (see Table).

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SEVERITY LEVELS
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CRITERION C, D, E
C. Symptoms must be present in the early developmental period (but may not
become fully manifest until social demands exceed limited capacities, or may be
masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or
other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual
developmental disorder) or global developmental delay. Intellectual disability and
autism spectrum disorder frequently co-occur; to make comorbid diagnoses of
autism spectrum disorder and intellectual disability, social communication should be
below that expected for general developmental level.
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DSM-IV / DSM-5 DISCREPANCY?
Note:
• Individuals with a well-established DSM-IV diagnosis of autistic disorder,
Asperger’s disorder, or pervasive developmental disorder not otherwise
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specified should be given the diagnosis of autism spectrum disorder.
• Individuals who have marked deficits in social communication, but whose symptoms
do not otherwise meet criteria for autism spectrum disorder, should be evaluated for
social (pragmatic) communication disorder.
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EPIDEMIOLOGY OF ASD
However, females with ASD might

have been under-recognised
(Baron-Cohen et al., 2011).
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RISK & PROTECTIVE FACTORS

• Causes of ASD unclear, but strong GENETIC basis (Lai, Lombardo, & Baron-Cohen, 2014; Li et al.,
2012)
• 10% have an identifiable co-occurring genetic, neurologic or metabolic disorder, such as the fragile X
syndrome or tuberous sclerosis (Caglayan, 2010).
• 25-fold risk in siblings (Abrahams & Geschwind, 2008).
• Twin studies:
• Identical: 60–90% chance of being concordantly diagnosed with ASD and
• Nonidentical: 0–24% in non-identical twins (Bailey et al., 1998).
• ENVIRONMENTAL factors important too

• Advanced paternal or maternal reproductive age, or both increases risk (Lampi et al., 2013; Sandin
et al., 2012)
• Folic acid supplements before conception and during early pregnancy seem to be protective (Suren
et al., 2013).
• Silicon Valley, pollution & toxins
• There is no evidence that the MMR (measles, mumps, and rubella) vaccine (Madsen et al., 2002),
thimerosal-containing vaccines (Parker, Schwartz, Todd, & Pickering, 2004) cause ASD.
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DSM-5 DIAGNOSIS – SPECIFIERS
(INC CO-OCCURRING CONDITIONS)
• A recent report of Autism in Australia found that 88% of individuals with ASD are also diagnosed with a co-
occurring disability (Australian Institute of Health and Welfare, 2017).
Autism Spectrum Disorder (299.00 DSM-5)

o p
• Severity level (use wording e.g. “requiring support”)
• With or without accompanying intellectual impairment
• 50-70% with ASD have ID
• With or without accompanying language impairment (provide examples)
• Associated with a known medical (e.g. epilepsy) or genetic disorder (e.g. Fragile X) or a history of
environmental exposure (e.g. foetal alcohol syndrome)
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• 10% have an identifiable co-occurring genetic, neurologic or metabolic disorder (fragile X syndrome,
tuberous sclerosis)
• Associated with another mental or behaviour disorder (e.g. Anxiety Disorder)
• 70-75% have ASD + Co-occurring Mental Health Issues
• With catatonia

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A NATIONAL GUIDELINE FOR THE ASSESSMENT

AND DIAGNOSIS OF AUTISM SPECTRUM
DISORDERS IN AUSTRALIA (2018)
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ASD DIAGNOSTIC ASSESSMENT

GOLD STANDARD
• An assessment, usually includes a multidisciplinary team
• Role of Psychologist – (take a 5 pillar approach!)
1. Clinical interview – child, parent/carer, day-care/teacher
2. Clinical observations
3. Screening questionnaires – screening for ASD, co-occurring mental health issues
4. File Review
5. Formal Testing: Cognitive / Developmental / Adaptive Assessment (if not done
already)
• DIAGNOSTIC tools:
• Autism Diagnostic Observation Schedule (ADOS-2)
• Autism Diagnostic Interview (ADI-R)
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Intellectual Disability
• 50-70% of individual with ASD have ID
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• ASD and ID are a neurodevelopmental disorders, with onset occurring during the
developmental period
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Diagnosis of ID is based on clinical assessment AND standardised testing of

intellectual AND adaptive functions (American Psychiatric Association, 2013).
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MENTAL HEALTH
• 70-75% have ASD + mental health disorder. Compared to:
• Children with ID alone: 40%
• Typically developing children: 14%
• Internalising
• Anxiety, OCD, mood disorders.
• Externalising
• ADHD, ODD, CD, challenging behaviour
• Significant impact on families:
• Parents of children with ASD at significantly increased risk of
mental health issues
• Very high rates of divorce
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Clinical Context
Case of James:
• 14 years old boy with ASD and Mild ID
• Social-Communication –verbal unusual tone/prosody, one-sided, some echolalia, unusual accent
• Restricted/Repetitive Behaviour: sensory issues, rigid thinking, some hand flapping, LOVES “trains”
• ++Hx of bullying (+ other psychosocial stressors)
• Moves house – goes to new (mainstream) school.
• Trigger significant mental health crisis
• Distress, crying, reduced eating, regression of skills
• Presents to hospital: “not severe enough symptoms for admission”
• Presents to disability: “we don’t do mental health”
• Presents to mental health: “we don’t do autism”
• Education: Partial attendance (mornings only) “we don’t have any places in our autism support
unit”
• Mum has to stop working - significant financial stress - relationship breakdown says: “I just can’t
cope – I can’t do this anymore, I don’t think I can go on caring for James….”
• James continues to experiencing severe (worsening) distress
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Clinical Context
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Mental Health in ASD
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ROLE OF SCHOOL COUNSELLORS &

PSYCHOLOGISTS?
• Screening
• Observations in classroom/playground
• Psychoeducation
• Home-school communication
• Triage-referral
• Prevention
• Early intervention
• Play a role in a treatment plan
• Skill-building
• What else?
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Social-Emotional Skills & Mental Health
• Children with ASD/ ID are at very high risk of mental health
issues.
• There is a strong association between social-emotional skills
and mental health in children with ASD, with and without ID
(Ratcliffe et al 2015).
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• Social-emotional skills might be a modifiable risk factor to
target for therapy.
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Delays in Social-Emotional Skills

• Poor social functioning • Facial expression incongruent to the
• Less aware of others situation
• Solitary or limited play • Emotional extremes or flat affect
• Inappropriate social behaviour • Difficulties with emotion perception
• Poor joint attention • Difficulties with affective sharing
• Poor imitation • Theory of mind deficits
• Difficulty understanding social
norms
• Poor social problem solving
Focus of research:
Younger/school-age children.
Proxy report – parent/teacher Bernard-Opitz et al, 2001; Bernier et al, 2006; de Brindley
& Frith, 2009; Ziv et al, 2014
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LIVED EXPERIENCE
• I find it hard to understand the expressions on people’s faces so its difficult to know
how people are feeling
• Although I might understand words, I find it difficult to make sense of tone of voice
• I find it difficult to know what to do and what to say around other people
• Loud noises can be painful
• When I’m in a group or crowds I often feel confused and stressed out
• I can get upset if there’s a change of plans or something happens that I haven’t been
warned about
• I feel happy and relaxed when doing or talking about my special interests
Me: “Hi Sam – good to see you! How are you?
‘Sam’ – 15 ASD: Oh no! Dipsy thought his hat smelled lovely. Dipsy thought his hat
smelled nice! Urgh! Urgh! Oh, no! Run away!
Me: Oh you’ve been watching Teletubbies?
Sam – #smiles “Teletubbies do you know how to spell Teletubbies? I do?
Me: No time to respond!
Sam – ‘T.E.L.E.T.U.B.B.I.E.S!” #smiles
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ADOLESCENT ASD/ID FOCUS GROUPS
• Emotion Dysregulation: • A time of Adolescence
• Frequent and high levels of intense • Expanding of the social
emotion network
• Complex, large and diverse array of • What makes angry and sad?
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triggers • It’s not fair!
• Poor coping strategies • Being banned from the
computer, losing their
• Limited Emotions Competence phone as a punishment, or
Skills annoying sibling
• Hardship of school and peers
• Poor emotion labelling and recognition
• Struggling with identity and
• Limited expressive emotions language difference
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skills
• Withdrawal and other emotion coping • ASD-specific
strategies • Sensory sensitivities
Gardner, Ratcliffe & Wong (2018 – under review)

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ADOLESCENT ASD/ID FOCUS GROUPS
“Wiggles is just so babyish – I

only watched that when I was 4!”
Teen Boy (ASD+MID) – aged 14 years
Gardner, Ratcliffe & Wong (2018)
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EMOTIONAL REGULATION STRATEGIES

• Currently used by Adolescents with ASD and Mild ID as reported by
parent, teachers and professionals
• Thought-based strategies, word-based strategies and action-based
ER strategies.
Gardner, Ratcliffe & Wong (2018)
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SELF REGULATION VS CO-REGULATION
• Adolescents with Autism were
sometimes reported to self-regulate,
but more often ER required co-
regulation with a carer.
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• Most commonly adolescent with
ASD were unable to regulate
their emotions by themselves
and they required others to
support them to either initiate a
strategy or to distract them to
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something else (carer-

guided).
SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe. Gardner, Ratcliffe & Wong (2018)
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SOCIAL-EMOTIONAL SKILLS INTERVENTION

• In general, social skills interventions can produce positive changes in the
social behaviour from toddlers (Landa, Holman, O'Neill, & Stuart, 2011)
through to school-age children, adolescents, and adults.
• Effective social skills interventions techniques for children with ASD include
a range of ‘visual’ teaching strategies including:
• Video modelling (Reichow & Volkmar, 2010),
• Social stories (Stary, Everett, Sears, Fujiki, & Hupp, 2012),
• Comic strip conversations (Ahmed-Husain & Dunsmuir, 2014),
• Scripts (Ganz & Flores, 2008), and
• Visual activity schedules (Betz, Higbee, & Reagon, 2008).
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SOCIAL-EMOTIONAL SKILLS INTERVENTION

• These visual teaching techniques can be used to teach pragmatic social
skills, emotional understanding, theory of mind and perspective taking skills
(LeBlanc et al., 2003).
• Individual
• Group
• Parental involvement
• Peer-mediated
BUT limitations to research are significant:
• Participant samples are often small and heterogeneous in regard to age,
gender, co-morbid issues, and level of disability
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Social-Emotional Skills & Mental Health
• Significant gap in available clinical resources and published resources on emotion
skills in ASD (with and without ID)
• (Almost exclusive!) focus on ASD without ID (Asperger’s)
• Published books without evidence-base
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• Evidence-base peer-reviewed interventions but manuals not published
• Focus on pragmatic social skills (not emotion skills)
• Focus on anxiety treatment
• Focus on either younger or teens (not primary school age)
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• No prevention/early intervention program

• No comprehensive programs (child, teacher, parent)
• Limited training for practitioners in how to use resources
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The Model
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12/11/2018
THE WESTMEAD FEELINGS PROGRAM

Aimed at PRIMARY SCHOOL aged children
2017: WFP 1 (Ratcliffe et al)

• Emotion-based Learning for Children with ASD and Mild ID
• Verbal (but don’t necessarily read and write)
• Academic skills at K-1 level
• Designed/evaluated for group delivery
• Clinically adaptable for individual delivery
2018: WFP 2 (Wong et al)
• Emotion-based Learning for Children with ASD without ID
• Verbal (MUST read and write)
• Academic skills at least year 2-3 level
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Aimed at HIGH SCHOOL aged students
2018/2019 (under development) (Gardner et al)

Emotion-based Learning for Adolescents with ASD and Mild ID
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• Verbal (basic literacy skills)
• Academic skills at 2-3 level
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Module Children Parents & Teachers
1 Identifying emotions: Psychoeducation
Happy Emotion coaching
Sad Emotionally attuned
Worried parenting
Angry
2 Emotions problem Emotional problem solving
solving Promoting theory of mind
Understanding others’
emotions
3 Managing emotions Managing emotions
Theory driven:
Emotional Competence, Emotional Development, Emotional Intelligence
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KEY ELEMENTS
• Same curriculum across version (WFP 1, WFP 2, WFP 3)
• Content based on theoretical models of emotional development
• Developmental adaptations
• Teaching strategies based on best available evidence on what works in
ASD
• Less talking, more visuals (social stories, videos, visual worksheets)
• Promote generalisation – parent and teachers as ‘emotion coaches’
• Across each program
• Positive behaviour support (PBS) is embedded, for example:
• Visual schedule
• Visual rules
• Reward chart
• Descriptive Praise
• Originally designed for small groups (3-8)
• Adapted for individual
• Adapted for classes
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PROGRAM STRUCTURE
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EVIDENCE-BASED TECHNIQUES
Information Processing Generalisation
• Visual cues • Practice through home-based tasks
• Video modeling • Parent and teacher programs, handouts,
and visual cues
• Written and video social stories
• Live modeling
• Promote parent and teacher self-evaluation
and monitoring
• Repetition of key points using varied
• Use of rewards to motivate
teaching methods
• Structured breaks and games

• Practice through role plays
• Modify pace
• Breaks between modules
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POSITIVE BEHAVIOUR SUPPORT
Session
Schedule
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POSITIVE BEHAVIOUR SUPPORT
Reward chart
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MODULE 1: UNDERSTANDING EMOTIONS
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WFP1
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WFP1
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UNDERSTANDING FEELINGS: WFP1 VS WFP 2
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WFP3: ADOLESCENT ADAPTATIONS
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KEY CLINICAL FINDING –
VISUALs continue to be KEY
(e.g. ‘THOUGHT’)
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WFP3: ADOLESCENT ADAPTATIONS
• Age-appropriate actors
• Teens – real teen issues
• More ROLE-PLAYS
• More filming and dissecting
role-plays
• More psychoeducation about
adolescent brain
development, mood swings
etc
• For teens +
parents/carers
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MODULE 2: PROBLEM SOLVING
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MODULE 2: WFP 1 VS WFP 2
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MODULE 2: ADOLESCENT
• Continue to show preference for teens

(not kids or adults):
• Videos
• Photos (not pictures)
• Language (e.g. problem solving
“TECHnique)
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THEORY OF MIND - VIDEO
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THEORY OF MIND
WFP 1 VS WP2
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CUP CHARACTERS
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12/11/2018
THOUGHT CHALLENGING?
• Michael 14 years old ASD (Level 1).
• High Average cognitive ability
• Moving from current High School – Autism Unit (homeroom) with lots of regular mainstream
(closing Unit) to a new Autism Support Unit in a new HS.
• I’ll be around other kids who have more of a disability than me

• The kids in mainstream won’t talk to me
• The kids in mainstream won’t hang out with me or invite me to the
parties
• I’ll get teased by the mainstream boys
• People will think I’m a ‘special’
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MODULE 3:
MANAGING EMOTIONS
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MANAGING EMOTIONS: WFP 1 VS WP2
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12/11/2018
WRAP AROUND MODEL
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STUDIES & COLLABORATORS
Hospital Pilot Studies Effectiveness in Schools Teacher Delivery Impact:
Children,
Teachers,
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Parents &
Facilitators
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SCIENTIST PRACTITIONER MODEL:

RESEARCH RESULTS
WFP significantly improves:

• Emotional Competence
• Mental Health
• Social Skills
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RESEARCH RESULTS
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RESEARCH RESULTS
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RESEARCH TRANSLATION:
FACILITATOR TRAINING (OPTIONAL)
2-day Face-to-Face Training Online Training
• Day 1: Didactic teaching; Role • 20 hours (Equivalent to Face-to-face)
play demonstration; Activities
• Interactive, facilitated, demonstrations
• Day 2: Quiz; Certification via
role plays and competency • Quiz; Certification via role plays and
assessment competency assessment
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SUMMARY
• Children with ASD have difficulties with social-emotional skills
• Children with ASD can learn skills to develop emotional competence
• Learning social-emotional skills might be protective for mental health issues
• Teaching strategies must be tailored to ASD learning strengths
• Teaching strategies must be tailored to age and developmental needs
• WFP is a novel Australia-based ASD social-emotional intervention with a
growing global reach
• There is still much more work to be done in the ASD/mental health space!
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Acknowledgements
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QUESTIONS & COMMENTS
b.ratcliffe@westernsydney.edu.au
@belindaratcliff
Dr Belinda Ratcliffe
Westmead Feelings Program: www.acer.org/westmead-feelings-program
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12/11/2018

School Counsellors & Psychologists (SCAP) Conference: November 15th 2018

TEACHING SOCIAL-EMOTIONAL SKILLS TO

1. Introduction to Neurodevelopmental Disorders:

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

DSM-IV DIAGNOSIS OF AUTISM SPECTRUM DISORDER

Other terms used

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

THE TRIAD OF IMPAIRMENTS

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

medical/genetic/environmental factors, associated disorders.

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

DSM-5 AUTISM SPECTRUM DISORDER

Level 3 Requiring very substantial support Level 3

Level 2 Requiring substantial support Level 2

Level 1 Requiring support Level 1

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

Specify current severity:

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

However, females with ASD might

RISK & PROTECTIVE FACTORS

• ENVIRONMENTAL factors important too

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

Autism Spectrum Disorder (299.00 DSM-5)

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

A NATIONAL GUIDELINE FOR THE ASSESSMENT

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

ASD DIAGNOSTIC ASSESSMENT

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

Diagnosis of ID is based on clinical assessment AND standardised testing of

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

Mental Health in ASD

ROLE OF SCHOOL COUNSELLORS &

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

Delays in Social-Emotional Skills

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

Gardner, Ratcliffe & Wong (2018 – under review)

ADOLESCENT ASD/ID FOCUS GROUPS

“Wiggles is just so babyish – I

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

EMOTIONAL REGULATION STRATEGIES

Gardner, Ratcliffe & Wong (2018)

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

something else (carer-

SOCIAL-EMOTIONAL SKILLS INTERVENTION

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

SOCIAL-EMOTIONAL SKILLS INTERVENTION

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

• No prevention/early intervention program

THE WESTMEAD FEELINGS PROGRAM

2017: WFP 1 (Ratcliffe et al)

2018/2019 (under development) (Gardner et al)

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

THE WESTMEAD FEELINGS PROGRAM

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.

• Structured breaks and games

SCAP Conference: November 15th 2018, Dr Belinda Ratcliffe.