Depression and suicidal ideation in autism and related disorders naa 021512

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Depression and Suicidal Episodes in Autism and Related Disorders Josh Feder, MD NAA February 15 2012

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Depression and Suicidal Episodes in Autism and Related Disorders Josh Feder, MD NAA February 15 2012

Joshua D Feder MD Director of Research, Graduate School, Interdisciplinary Council on Developmental and Learning Disorders Assistant Clinical Professor, Voluntary Dept of Psychiatry, University of California at San Diego School of Medicine

Feder 411 • Math, Engineering, and Developmental Disorders beginning 1978. • US Navy – Child Psychiatry • Mike – 1990 (1992) • Greenspan and Wieder – 1993 • Career expansion: clinic, teaching, research, advocacy, tech development and arts & media.

Disclosures ICDL CAPTN/Pfizer SymPlay Cherry Crisp

Commercials… • Because we build ideas together • And you can join us in the effort!

Working Together for

Parent Choice!

The Southern California DIR/Floortime Regional Training Program

Pasadena, California February 24-26, 2012 Pasadena Child Development Associates, Inc. (PCDA)

Thank You! • Families – say a silent thank you • NAA • Chantal Sicile-Kira! • Mentors: Greenspan & Wieder • Students at the ICDL Graduate School • So many others…

Outline • Depression, and depression in ASD • Suicidal thinking, and in ASD • ‘Normal’ sadness ‘ • Risk Factors & Signs to look for • When to worry &What to do • Mental Health Care • Conclusion: How to keep moving forward • Questions

Depression • Sad, really sad • Probably anxious • Maybe mad too • So bad that it gets in the way of things • Negative about oneself, the world, the future • Kids - withdrawal, irritability • Babies – listless, withdrawn, poor feeding

Depression in DSM-IV • Sleep - more or less, up early is classic • Loss of Interest in usual activities, incl. sex • Negative thoughts, often over and over • Energy – usually down, might be agitated • Poor concentration, e.g., reading • Appetite – down, or up • Sluggish body – stooped, slow, leaden • Suicidal thinking

General Rates of Depression • General population: 20-25% • Recurrence: 50% • Re-recurrence: 75%+ • Suicide rates: 15%+ • Earlier onset may mean worse condition • Family history adds to risk • Bipolar: 1% overall; 20%+ of depressed youth

Depression in ASD • Many reports, little data, likely high rates • Chronic emotional pain from trouble relating and communicating with others, from sensory processing and modulation difficulties, etc. • ‘Excellent’ recall of negative life events – e.g. bullying, but even minor disappointments • May be even more persistent in negative thinking • Might not ‘show’ sadness the same way – might be harder to tell • Still, look for the usual kinds of signs

Suicide • Adults in emotional pain with ‘no other options’ and a need to act now • Top risk factors: depression and substance use • Adolescents/ young adults at higher risk: less likely to consider consequences • Highest risk in the elderly • Children have trouble following through but some children do high risk things (run into traffic, jump into deep water)

Suicidal Ideation in ASD • Chronic emotional pain • High risk for substance abuse in ASD • Hard to see other options • Often acting without reflecting • May be more persistent in following through with ideas to hurt self – including chidren

What about ‘normal’ sadness? • Common losses, e.g. a pet dies, a friend moves • People with ASD often react ‘all or nothing’, i.e., distraught or unemotional • We are relieved when our kids with ASD show empathy, e.g., for a hurt classmate • We are worried when people with ASD do not seem to mourn a loss they way others do • We work to help them build a range of emotions • But how do we tell the difference between normal sadness and depression?

They are different… ‘Normal’ Sadness


Might temporarily get in the way of function Usually caused by a sad experience Understandably sad – important to learn and grow from it, becoming stronger and improving function

Really gets in the way of function Not always triggered by a sad experience (50%) Maybe understandably depressed (e.g. cancer) or maybe not - but not ‘growing’ from it, robs function

When to worry • Always..? • Always take suicidal episodes seriously • ‘Manipulation’ is a risk factor for real action • ASD: tend to do what they say they will do • Always working on prevention, i.e., on improving ability to cope with distress

What to do: Supervision and Solving Problems • Safety first – supervision, maybe 24/7 • Build emotional range & regulatory range • Manage the environment • Mental Health Care

Supervision • By whom? • May need more people • May need people with specialized training • Issue of training law enforcement • Psychiatric Emergency Response Team (PERT) • May need a specialized place to be safe

Building Better Stress Coping • Co-regulation: help someone be more regulated and then learn self-regulation • Building emotional connection • Repair of emotional connections • Building range of emotions and ability to tolerate emotions • Dealing with expectations – the ‘rule of life’: nothing ever happens the way we expected

Managing the World surrounding the person

• Promoting connection in everyday life • Supervision to prevent bullying • Facilitate social relating: slow it all down to help everyone be part of what’s going on • Giving cues and space to build initiation

Mental Health Care • Cognitive-Behavioral Therapy (CBT) – change thought & behaviors to change mood, e.g., gently challenge beliefs, nudge to stay active • Rational Emotive Therapy – it’s not what happens but how you think about it that upsets you, e.g., ‘The Rule of Life’ – nothing happens as expected • Relationship based therapy (DIR/Floortime , etc., all ages) – co-regulation, connection, repair, symbolic, from blankets to highway ‘gestures’.

Symbolic Solutions • Best ones we have – generates creative solutions that can be portable and shared • All around us so can be hard to ‘see’ • E.g., Anger becomes competition as in Olympics, or becoming a surgeon lets you cut people… • E.g., Fear mastered by cuddling a doll or by holding hands on the tarmac during takeoff, or opening fortune cookie • E.g., Sadness expressed in creating or experiencing art (rocket shells to tulips), tearful movies or books

Hospitalization? • When all else fails and you need a safe place • Staff might not understand ASD, and in particular your family member’s ASD • Figure out now where they do a good job • Create a ‘quick guide’ – three most important things to know about your family member • Hard to get good communication • Hard to get good transition • Day treatment • Residential care – what happens afterward? • Wraparound care

Quick Guide Example • Give him time to answer • Do not assume that he understands you • Noises make him very upset – sooth him with gentle reassurance and a quiet place to rest

Medication? • Might be a lifesaver • Probably will have side effects –e.g. ‘activation’ • Probably prevents suicide: drop in suicide rates when SSRI prescription rose in the 1990’s, rise in suicides with the fall in prescriptions to youth after the ‘suicide warning in 2004’ • But people DO sometimes have suicidal thoughts specific to a medication, including SSRIs. So, as always, be careful and ask.

Suicide Rates in US Children & Adolescents 1988- 2005

Conclusion: How to keeping moving forward

• Parallel Process: Colleagues support professionals who support parents & caregivers who support people with ASDs • Reflective style: don’t tell people what to do, but help them problem solve – creates confidence in one’s own competence to solve problems in everyday life and intervention • Platinum rule: treat others as you would like them to treat others.


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