FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY

Frequency of SIB varied by types of anxiety in adolescents with Aspergers disorder Jaylene Bettcher APSY 605: Research Proposal Dr. David W. Nordstokke April 12, 2011

FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY Frequency of SIB varied by types of anxiety in adolescents with Aspergers disorder Introduction The purpose of this research proposal is to examine the frequency of self-injurious behaviour (SIB) varied by generalized anxiety, separation anxiety, and specific phobia in adolescents with Aspergers disorder. According to Lainhart (1999), the comorbidity rate of autism and anxiety disorders ranges from 7% to 84%, with generalized anxiety, separation anxiety, and specific phobia being the most common. Furthermore, symptoms of anxiety disorders are often associated with challenging behaviours, particularly SIB, which often results detrimental outcomes and may consequently diminish an individuals quality of life (Matson, Mahan, Sipes, & Kozlowski, 2010). By investigating the frequency of SIB varied by the three most prevalent types of anxiety disorders in adolescents with Aspergers disorder, better interventions may be implemented to treat specific anxiety symptoms and reduce SIB. Literature Review Aspergers disorder is a heterogeneous neurodevelopmental disorder that is characterized not only by impairments in social interaction and communication, but also by repetitive behaviours and idiosyncratic interests (Klinger, Dawson, & Renner, 2003). According to the DSM-IV-TR, these sustained impairments in social interaction and repetitive behaviours and interests significantly impair the individuals social and occupational domains of functioning. The DSM-IV-TR also maintains that individuals with Aspergers disorder must neither present with a clinically significant language delay, nor a clinically significant cognitive delay. SIB is defined as any behaviour that an individual initiates and directs toward him/herself that results in tissue and or internal damage (Symons, Harper, McGrath, Breau, & Bodfish, 2009a). Individuals with Aspergers disorder who self abuse generally exhibit a pattern of

FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY forceful, repetitive, and localized abuse to specific body parts, rather than an arbitrary pattern of abuse to various body parts (Symons et al., 2009b). According to Symons et al. (2009b) individuals typically bang a specific spot on their head, bite a specific area of their hand, or pick at a specific area of skin, all of which may result in bruising, bleeding, lacerations, fractures, and tissue damage. Symons et al. (2009a) believe that SIB is the most destructive behaviour displayed by individuals with Aspergers disorder; in fact, some individuals inflict enough force on themselves to permanently damage tissue, which may result in disfigurement, brain damage, and or death. Anxiety is often a typical reaction to a stressor; however, when anxiety persists and becomes overly intense it may be classified as an anxiety disorder (Albano, Chorpita, & Barlow, 2003). Although there are numerous types of anxiety disorders, for the purpose of this study, we will merely examine the diagnostic criteria in the DSM-IV-TR for generalized anxiety disorder (GAD), separation anxiety disorder (SAD), and specific phobias (SP). GAD is characterized by unrealistic and excessive worrying, which has persisted for at least six months, about numerous events and activities. This excessive worrying must result in impairment to at least one physiological symptom, for instance, muscle tension or sleep disturbance. SAD is defined by an overwhelming concern or fear of separation from home or major attachment figures that is inappropriate for the individuals age and developmental level. Finally, SP is characterized by an intense and persistent fear to specific objects or situations, leading to interference in daily functioning. Although it is uncertain if symptoms of Aspergers disorder predispose adolescents to anxious symptoms, there has been an abundance of literature confirming that anxiety disorders are often comorbid with Aspergers disorder (Kim, Szatmari, Bryson, Streiner, & Wilson, 2000).

FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY The comorbidity rate of autism spectrum disorders (ASD), which includes Aspergers disorder, and anxiety disorders ranges from 7% to 84% depending on the type of anxiety disorder and the severity of autism (Lainhart, 1999). According to Klinger et al. (2003), anxiety symptoms are more frequently reported in adolescents with Aspergers disorder than in any other age demographic and developmental disorder. A comparison study by Kim et al. (2000), confirms that when compared to typically developing adolescents and adolescents with other developmental disorders, adolescents with Aspergers disorder are more likely to have a comorbid anxiety disorder. In addition, a comparison study by Lainhart (1999) reports that adolescents with Aspergers disorder are more likely to exhibit symptoms of GAD, SAD, and SP than typically developing adolescents and developmentally delayed adolescents. Moreover, Lainharts (1999) findings indicate that out of the 19 participants with Aspergers disorder in her study, 50% displayed generalized anxiety, 14% displayed separation anxiety, and 7% displayed specific phobias. According to Symons and Danov (2005), 30-50% of individuals with ASD display SIB at some point during their lifetime. A comparison study by Matson et al., (2010) indicates that children with ASD and comorbid anxiety tend to exhibit more challenging behaviours, which include SIB, than both children with ASD without comorbid anxiety and children with a developmental disorder (other than ASD) and comorbid anxiety. Furthermore, Matson et al. (2010) found that children with ASD and comorbid anxiety were typically more aggressive towards others and themselves. Matson et al. (2010) suggests that treating comorbid psychopathologies, particularly anxiety, in individuals with ASD may consequently decrease aggressive behaviours. However, more effective treatment interventions may be implemented if the type of anxiety that is associated with the greatest frequency of SIB was known. This study

FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY aims to create a better understanding of the type of anxiety that is often associated with SIB in adolescents with Aspergers disorder. Hopefully this study, as well as subsequent studies, will aid in advancing interventions for comorbid anxiety disorders in adolescents with Aspergers disorder. There are several limitations to studying comorbid anxiety disorders in adolescents with Aspergers disorder. First of all, it is often difficult to determine if anxiety symptoms indicate an anxiety disorder or if they are merely symptoms of Aspergers disorder (Kerlinger et al., 2003). Second of all, diagnostic boundaries between different types of anxiety disorders are often unclear and there is typically an overlap of symptoms, which may make diagnosing specific types of anxiety disorders difficult (Kim et al., 2000). Finally, although there is an association between comorbid anxiety disorders and SIB in individuals with ASD, this association is poorly understood and it is plausible that there may many confounding factors that influence SIB. Research Questions and Hypotheses This study aims to examine the frequency of self-injurious behaviour varied by generalized anxiety, separation anxiety, and specific phobia in adolescents with Aspergers disorder. As such, the following research questions are proposed: 1. Is there a variance in frequency of SIB among participants with Aspergers disorder and comorbid generalized anxiety, separation anxiety, and specific phobia? 2. If a variance exists, which type of anxiety disorder is associated with the greatest frequency of SIB? 3. If a variance exists, which type of anxiety disorder is associated with the lowest frequency of SIB? In response to the previous research questions, the following hypotheses are proposed:

FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY 1. A variance in frequency of self-injurious behaviour among participants with Aspergers disorder and comorbid generalized anxiety, separation anxiety, and specific anxiety will be present; therefore, the null hypothesis will be rejected. 2. Participants with Aspergers disorder and generalized anxiety will exhibit a greater frequency of self-injurious behaviour than those participants with Aspergers disorder and separation anxiety or specific phobias. 3. Participants with Aspergers disorder and specific phobias will exhibit a lower frequency of self-injurious behaviour than those participants with Aspergers disorder and generalized anxiety or separation anxiety. Methodology Participants The proposed sample is to consist of adolescents aged 13- 17 years that have been diagnosed with Aspergers disorder based on the criteria from the DSM-IV (TR) and/or Krug Aspergers Disorder Index (KADI). According to the participants parent or guardian, the participant must have exhibited at least one incident of SIB (while awake) within the past six months. The participants will be recruited from Autism Calgary Association (ACA), Autism Society of Central Alberta (ASCA), which is based in Red Deer, and Chinook Autism Society (CAS), which is based in Lethbridge. A parent or guardian from each participant is also required to participate in the study, and they will be notified of the requirements before they agree to participate. The participants will be required to travel to the University of Calgary, where they will have a scheduled meeting at the U-CAPES clinic with a U-CAPES student clinician. The participants will be administered the Wechsler Intelligence Scale for Children- Fourth Edition

FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY (WISC-IV) in order to assess their full-scale intelligence quotient (FSIQ). Participants will also be required to complete the Multidimensional Anxiety Scale for Children (MASC) in order to determine if they display symptoms of GAD, SAD, or SP. If either of these assessment measures has been administered in the past year, it is advised that they are not re-administered due to practice effects and time constraints, and therefore, participants can email or fax their student clinician their previous assessment reports. Participants with a FSIQ over 70 and a clinically significant or at-risk score on the GAD, SAD, or SP index will be asked to continue with the study. The number of continuing participants will depend on stringent criteria, availability, and interest, however, it is anticipated that there will be at least 105 participants in the study. Based on the type of anxiety that was prominently endorsed, the continuing participants will be placed into one of three groups: GAD, SAD, or SP. It is possible that more than one type of anxiety will be endorsed, in which case the participant will be placed in the group that they scored the highest on. In the event of similar scores, a student clinician will be responsible for deciding the predominant type of anxiety according to the criteria in the DSM-IV-TR. It is important to note that an overlap in the types of anxiety will not compromise the results of the study, as many anxiety disorders overlap making it an accurate reflection of the population. Participants will be excluded from the study if their FSIQ is under 70, as in accordance with the DSM-IV-TR, a FSIQ score under 70 is indicative of mental retardation. Participants will also be excluded if they did not acquire a clinically significant or at-risk score for GAD, SAD, or SP. Additional exclusion criteria are comorbid disorders (besides SIB and anxiety), such as mental retardation, depression, tic disorders, and seizure disorders. Participants will also be excluded if they are currently being administered selective serotonin reuptake inhibitors

FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY (SSRIs) or anti-depressants, as these drugs have been found to reduce anxiety and aggressive behaviour (Mahatmya , Zobel, & Valdovinos, 2008). Furthermore, the only medication that is to be permitted is the antipsychotic, Risperidone, also known as Risperidal in Canada, to ensure consistency in behaviour as well as safety for parents or guardians and clinicians. Measures Wechsler Intelligence Scale for Children- Fourth Edition (WISC-IV). The WISC-IV is a standardized intelligence test, which includes ten core subtests and five additional subtests that measure an individuals intellectual functioning in accordance to their same age peers (Baron, 2005). The full scale intelligence quotient (FSIQ), which is a good indicator of general intelligence, encompasses scores from four test domains: verbal comprehension, perceptual reasoning, working memory, and processing speed (Baron, 2005). According to Sattler (2008), the WISC-IV has outstanding reliability, .96 to .97 for FSIQ, and satisfactory criterion validity. Not only is the WISC-IV an excellent indicator of general intelligence, but also, it uses Canadian norms (Sattler, 2008). Multidimensional Anxiety Scale for Children (MASC). The MASC is a standardized, 39 item, self report measure that assesses a variety of anxiety symptoms across several indexes, which include, generalized anxiety, separation anxiety, specific anxiety, and social anxiety (Thaler, Kazemi, & Wood, 2010). The MASC also encompasses the anxiety disorders index, which measures the probability that an anxiety disorder is actually present, and the inconsistency index, which protects against random and inconsistent responses (Thaler et al., 2010). According to Gastel and Ferdinand (2008) the MASC is considered one of the psychometrically strongest self report scales, as internal consistency ratings range from .70 to .83 and test-rest reliabilities are deemed to exceed satisfactory. Not only is the MASC considered a strong self

FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY report scale for anxiety, but also its indexes coincide with the three most prevalent anxiety disorders in adolescents with Aspergers disorder. Descriptive Analysis Research Design and Procedures After participants parent or guardian give consent, participants will be assessed with the measures that were previously discussed. Participants with a FSIQ over 70 and clinically significant or at-risk score on the GAD, SAD, or SP index will be asked to continue with the study. Based on the type on anxiety that was prominently endorsed, participants will be placed into one of three groups: GAD, SAD, or specific phobia. To ensure that there are a relatively equal number of participants in each group, groups will be required to have a minimum of 35 participants and a maximum of 40 participants. If a group has 40 participants subsequent participants with that type of anxiety will be excluded. Data collection will continue until each group has a minimum of 35 participants. After participants have been assigned to a group, they are allowed to leave the U-CAPES clinic and return to their home. Within the next 10 days the participants parent or guardian will be responsible for conducting a descriptive analysis on the frequency of SIB exhibited by the participant during a given time frame. To ensure consistency with data collection, parents or guardians are required to tally the frequency of SIB between the hours of 6:30- 8:00 and 17:3022:00 for two days (do not have to be two consecutive days). Accommodations will be made for parents and guardians who have prior commitments during that time-frame. However, parents or guardians are given 10 days to complete the descriptive analysis so time constraints are not suspected to be a problem. A mass email will be sent every other day to remind parents and guardians of their responsibility. Once data has been collected, parents or guardians can either

FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY email or fax the data to their student clinician. This flow chart is a depiction of the overall sequence of events: Recruitment of participants Consent from participants parent/guardian

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WISC-IV

FSIQ > 70

FSIQ < 70

MASC

GAD

SAD

SP

None or Other

Descriptive analysis

Forward results to student clinician

Data Analysis The frequency data from both days will be added together to form a total score for each participant. This data will be analyzed using a one-way analysis of variance (ANOVA) through statistical package for the social sciences (SPSS). A one-way ANOVA was chosen for this study because ANOVA partitions total variability of data (SST) into variability within groups (SSW) and between groups (SSB). The dependent variable will be the frequency of SIB exhibited by adolescents with Aspergers disorder, while the independent variables will be the types of anxiety: GAD, SAD, and SP. After the one-way ANOVA is complete and the null hypothesis is either rejected or failed to be rejected, a Scheffe Post Hoc test will be conducted. A Scheffe Post

FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY Hoc test was chosen because it is the most conservative Post Hoc test and it allows the researcher to explicitly see statistically significant differences between groups. Therefore, research question 2 and 3 can be answered by examining if there is a statistically significant difference by anxiety type for the frequency of SIB exhibited by adolescents with Aspergers disorder. Expected Results and Significance It is expected that there will be a variance in frequency of SIB among participants with Aspergers disorder and comorbid GAD, SAD, and SP, and as a result, it is expected that the null hypothesis will be rejected. It is also expected that participants with Aspergers disorder and GAD will exhibit a greater frequency of SIB than those participants with Aspergers disorder and SAD or SP. In addition, participants Aspergers disorder and SP will exhibit a lower frequency of SIB than those participants with Aspergers disorder and GAD or SAD. These expectations have been formulated from the literature which has demonstrated that SIB is commonly exhibited in individuals with Aspergers disorder and comorbid anxiety (Matson et al., 2010). Furthermore GAD, SAD, and SP (respectively) are the most prevalent anxiety disorders diagnosed in adolescents with Aspergers disorder, and therefore it is suspected that the frequency of SIB will vary accordingly (Lainhart, 1999). Implications from the results of this study may assist in developing effective treatment programs for adolescents with Aspergers disorder and comorbid anxiety disorders. According to Reaven (2011), the current choice of treatment for anxiety disorders is cognitive behaviour therapy (CBT), whereby graded exposure, cognitive restructuring, and cognitive modeling are employed. Although the majority of literature on CBT involves typically developing individuals, literature exploring the effects of CBT on individuals with Aspergers disorder and comorbid anxiety disorders is starting to emerge. Reaven (2011) reveals that current studies are focusing

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FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY on alleviating GAD and SAD symptoms in youth with Aspergers disorder. Reaven (2011) also discloses that although the affects of CBT on youth with Aspergers disorder and comorbid anxiety disorders are being studied extensively, the affects of CBT on adolescents with Aspergers disorder and comorbid anxiety disorders have yet to be confirmed. The results from this study may aid in the understanding of which anxiety symptoms need to be targeted through CBT in order reduce anxiety and frequency SIB in adolescents with Aspergers disorder. By reducing anxiety and subsequently SIB, adolescents with Aspergers disorder may display a significant improvement in adaptive functioning, which in turn may significantly improve their quality of life.

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FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY

References Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood anxiety disorders. In R. A.

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Barkley, & E. J. Mash (Eds.). Child psychopathology, 2nd edition (p. 279-329). New York: Guilford Press American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. Baron, I. S. (2005). Test review: Wechsler intelligence scale for children-fourth edition (WISCIV). Child Neuropsychology, 11, 471-475. doi: 10.1080/09297040590951587 Gastel, W., & Ferdinand, R. F. (2008). Screening capacity of the multidimensional anxiety scale for children (MASC) for DSM-IV anxiety disorders. Depression and Anxiety, 25, 10461052. doi: 10.1002/da.20452 Kim, J. A., Szatmari, P., Bryson, S. E., Streiner, D. L., & Wilson, F. J. (2000). The prevalence of anxiety and mood problems among children with autism and apergers syndrome. Autism, 4, 117- 132. doi:10.1177/1362361300004002002 Klinger, L., Dawson, G., & Renner, P. (2003). Autistic disorder. In R. A. Barkley, & E. J. Mash (Eds.). Child psychopathology, 2nd edition (p. 409-454). New York: Guilford Press Lainhart, J. E. (1999). Psychiatric problems in individuals with autism, their parents and siblings. International Review of Psychiatry, 11, 278- 298. Mahatmya, D., Zobel, A., & Valdovinos, M. G. (2008). Treatment approaches for self-injurious behavior in individuals with autism: Behavioral and pharmacological methods. Journal of Early & Intensive Behaviour Intervention, 5, 106-118. Retrieved from the Academic Search Complete database on November 3, 2010. Matson, J. L., Mahan, S., Sipes, M., & Kozlowski, A. M. (2010). Effects of symptoms of comorbid psychopathology on challenging behaviours among atypically developing

FREQUENCY OF SIB VARIED BY TYPES OF ANXIETY infants and toddlers assessed with the baby and infant screen for children with autism traits (BISCUIT). Journal of Mental Health Research in Intellectual Disabilities, 3, 164176. doi: 10.1080/19315864.2010.495920 Reaven, J. (2011). The treatment of anxiety symptoms in youth with high-functioning autism spectrum disorders: Developmental considerations for parents. Brain Research, 255-263. doi:10.1016/j.brainres.2010.09.075. Sattler, J.M. (2008). Assessment of Children: Cognitive Foundations (5th Edition). San Diego, CA: J. Sattler. Symons, F. J., & Danov, S. E. (2005). A prospective clinical analysis of pain behavior and selfinjurious behaviour. Pain, 117, 473-477. doi:10.1016/j.pain.2005.07.010 Symons, F. J., Harper, V. N., McGrath, P. J., Breau, L. M., & Bodfish, J. W. (2009a). Evidence of increased non-verbal behavioural signs of pain in adults with neurodevelopmental disorders and chronic self-injury. Research in Developmental Disabilities, 30, 521-528. Symons, F. J., Harper, Wendelschafer-Crabb, G., Kennedy, W., Heeth, W., & Bodfish, J. W. 2009b). Degranulated mast cells in the skin of adults with self-injurious behavior and neurodevelopmental disorders. Brain, Behavior, and Immunity, 23, 365-370. doi:10.1016/j.bbi.2008.11.003 Thaler, N. S., Kazemi, E., & Wood, J. J. (2010). Measuring anxiety in youth with learning disabilities: Reliability and validity of the multidimensional anxiety scale for children (MASC). Child Psychiatry and Human Development, 41, 501-504. doi: 10.1007/s10578010-0182-5

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