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Thaler H, Falter-Wagner C. [Autism spectrum disorder in adulthood]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2023; 91:466-478. [PMID: 37944552 DOI: 10.1055/a-1898-5347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Autism is a neurodevelopmental disorder that starts in early childhood and persists over the lifespan. A combination of genetic factors and environmental factors around birth contribute to its etiology. Autistic individuals show differences and difficulties in social interaction and communication as well as repetitive, stereotypical behavior and interests. The diagnostic procedure is complex and should be carried out in a specialized assessment unit. Diagnostic assessment is based on behavioral observation and a careful evaluation of developmental history. A wide range of potential differential diagnoses should be considered. Autistic adults have a higher risk of developing psychiatric disorders such as anxiety and depression. Psychotherapeutic treatment that is adapted to autism-related difficulties can be helpful. Co-occurring conditions should be treated in accordance with disorder-specific guidelines. Psychopharmacological treatment of co-occurring conditions is, in most cases, only recommended as an addition to behavioral interventions. Autistic people often experience difficulties in social participation, which can be targeted with sociotherapeutic interventions.
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David N, Dückert S, Gewohn P, König H, Rahlff P, Erik F, Vogeley K, Schöttle D, Konnopka A, Schulz H, Peth J. Mixed-methods investigation of barriers and needs in mental healthcare of adults with autism and recommendations for future care (BarrierfreeASD): study protocol. BMJ Open 2022; 12:e061773. [PMID: 35998965 PMCID: PMC9403111 DOI: 10.1136/bmjopen-2022-061773] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Autism refers to an early-onset neurodevelopmental condition with characteristic impairments and difficulties in practical living skills, which persist across the lifespan such that adults with autism often require substantial support and comprehensive care. Yet, mental health and other services are frequently unavailable for adults with autism despite considerable need for mental healthcare and individual, familial and socioeconomic burdens. This study will (1) examine current needs, barriers and burdens related to ineffective healthcare of adults with autism in Germany, (2) develop specific recommendations for a need-oriented mental healthcare model and (3) evaluate its future implementation. METHODS AND ANALYSIS A mixed-methods design with three phases will be conducted. In phase 1, current mental healthcare for adults with autism will be assessed at three levels (individual, structural and professional) and from three perspectives (adults with autism, relatives and healthcare providers) using (1) focus groups/interviews (qualitative data) and (2) large-scale online surveys (quantitative data). Furthermore, service utilisation and related costs will be estimated. In phase 2, recommendations for a future healthcare model will be derived based on phase 1, considering the heterogeneous and complex needs within the autism spectrum and specifying indications for recommended services. In phase 3, these will again be evaluated by the three stakeholder groups using mixed-methods and analysed regarding feasibility of implementation and cost-effectiveness. Our study will, thus, contribute to a better translation of recommendations into practice to reduce disability, burden and costs related to ineffective healthcare and improve mental health outcomes for adults with autism and those who support them. ETHICS AND DISSEMINATION This study was approved by the Local Psychological Ethics Commission of the Center for Psychosocial Medicine at the University Medical Center Hamburg-Eppendorf (LPEK-0227). Findings will be disseminated via scientific meetings and peer-reviewed journals. Cooperating partners and associations will be informed about the study's course and findings by regular newsletters and meetings. TRIAL REGISTRATION NUMBER This study protocol was preregistered at the Open Science Framework (osf.io/5x8pg).
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Affiliation(s)
- Nicole David
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sophia Dückert
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Petia Gewohn
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannah König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pascal Rahlff
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frank Erik
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kai Vogeley
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Daniel Schöttle
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Konnopka
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department Psychology, Medical School Hamburg, Hamburg, Germany
| | - Holger Schulz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Judith Peth
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Lipinski S, Boegl K, Blanke ES, Suenkel U, Dziobek I. A blind spot in mental healthcare? Psychotherapists lack education and expertise for the support of adults on the autism spectrum. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2021; 26:1509-1521. [PMID: 34825580 PMCID: PMC9344568 DOI: 10.1177/13623613211057973] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Most adults on the autism spectrum have co-occurring mental health
conditions, creating a high demand for mental health services –
including psychotherapy – in autistic adults. However, autistic adults
have difficulties accessing mental health services. The most-reported
barriers to accessing treatment are therapists’ lack of knowledge and
expertise surrounding autism, as well as unwillingness to treat
autistic individuals. This study was conducted by a participatory
autism research group and examined 498 adult-patient psychotherapists
on knowledge about autism and self-perceived competency to diagnose
and treat autistic patients without intellectual disability compared
to patients with other diagnoses. Psychotherapists rated their
education about autism in formal training, and competency in the
diagnosis and treatment of patients with autism, lowest compared to
patients with all other diagnoses surveyed in the study, including
those with comparable prevalence rates. Many therapists had
misconceptions and outdated beliefs about autism. Few had completed
additional training on autism, but the majority were interested in
receiving it. Greater knowledge about autism was positively linked to
openness to accept autistic patients. The results point to an alarming
gap in knowledge necessary for adequate mental health care for
individuals with autism.
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Affiliation(s)
| | | | - Elisabeth S Blanke
- Humboldt-Universität zu Berlin, Germany.,Friedrich-Schiller-Universität, Germany
| | | | - Isabel Dziobek
- Humboldt-Universität zu Berlin, Germany.,Charité - Universitätsmedizin Berlin, Germany.,Freie Universität Berlin, Germany.,Berlin Institute of Health, Germany
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Krämer K, Vetter A, Schultz-Venrath U, Vogeley K, Reul S. Mentalization-Based Treatment in Groups for Adults With Autism Spectrum Disorder. Front Psychol 2021; 12:708557. [PMID: 34456821 PMCID: PMC8397374 DOI: 10.3389/fpsyg.2021.708557] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/16/2021] [Indexed: 11/13/2022] Open
Abstract
In order to successfully interact with others in social encounters, we have to be attentive to their mental states. This means, we have to implicitly and explicitly interpret our own actions as well as the actions of others as meaningful on the basis of the ascription of intentional mental states. However, this ability, often referred to as mentalizing, seems to be impaired in autism spectrum disorder (ASD). Individuals with ADS show specific deficits relating to the representation of mental states of others. Especially, the spontaneous, intuitive attribution of and reaction to others' mental states seem to be impaired. Mentalization-Based Treatment (MBT) is a form of psychotherapy in individual and group settings that focuses on the education and enhancement of mentalizing. Although the scope of MBT is broad and MBT has been already proven to be useful in a variety of mental disorders, no attempt has been made to apply MBT in patients with ASD. In our study, we adapted MBT for adults with ASD in a therapeutic group setting to examine the feasibility as well as the effectiveness of the treatment in this patient group. During 15-20 weeks of weekly group therapy, we surveyed the patients' acceptability of the intervention. Additionally, changes in mentalizing difficulties were measured before and after treatment. Results show a high acceptance of the treatment and an improvement in the patients' mentalizing abilities, presenting MBT as a promising treatment option for ASD.
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Affiliation(s)
- Katharina Krämer
- Department of Psychiatry, University Hospital Cologne, Cologne, Germany.,Rheinische Fachhochschule Köln, University of Applied Sciences, Cologne, Germany
| | - Annekatrin Vetter
- Department of Psychiatry, University Hospital Cologne, Cologne, Germany
| | - Ulrich Schultz-Venrath
- Private Practice for Psychosomatic Medicine and Psychotherapy, Cologne, Germany.,University of Witten/Herdecke, Witten, Germany
| | - Kai Vogeley
- Department of Psychiatry, University Hospital Cologne, Cologne, Germany
| | - Sophia Reul
- Department of Psychiatry, University Hospital Cologne, Cologne, Germany
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Lipinski S, Blanke ES, Suenkel U, Dziobek I. Outpatient Psychotherapy for Adults with High-Functioning Autism Spectrum Condition: Utilization, Treatment Satisfaction, and Preferred Modifications. J Autism Dev Disord 2019; 49:1154-1168. [PMID: 30415320 DOI: 10.1007/s10803-018-3797-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Many adults with autism spectrum condition (ASC) desire outpatient psychotherapy (PT). This study compared reasons for seeking PT, experiences with PT, and modifications preferred with respect to PT of individuals with ASC to non-autistic individuals with depression (MDD). Furthermore, factors predictive for treatment satisfaction were identified in individuals with ASC. A total of 262 adults with ASC without intellectual impairment and 304 non-autistic controls with MDD were surveyed. In this pilot study both groups predominantly sought treatment for depressiveness. A low level of expertise with autism was the main reason for being declined by therapists and a contributing factor to the overall treatment dissatisfaction of patients with ASC. ASC patients desire adjustments such as written communication, and clearly structured sessions.
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Affiliation(s)
- Silke Lipinski
- Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Unter den Linden 6, 10099, Berlin, Germany.
| | - Elisabeth S Blanke
- Lebenswissenschaftliche Fakultät, Institut für Psychologie, Humboldt-Universität zu Berlin, Unter den Linden 6, 10099, Berlin, Germany
| | - Ulrike Suenkel
- Hertie Institute for Clinical Brain Research (HIH), Center of Neurology, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Isabel Dziobek
- Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Unter den Linden 6, 10099, Berlin, Germany
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Haker H, Schneebeli M, Stephan KE. Can Bayesian Theories of Autism Spectrum Disorder Help Improve Clinical Practice? Front Psychiatry 2016; 7:107. [PMID: 27378955 PMCID: PMC4911361 DOI: 10.3389/fpsyt.2016.00107] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 06/03/2016] [Indexed: 11/13/2022] Open
Abstract
Diagnosis and individualized treatment of autism spectrum disorder (ASD) represent major problems for contemporary psychiatry. Tackling these problems requires guidance by a pathophysiological theory. In this paper, we consider recent theories that re-conceptualize ASD from a "Bayesian brain" perspective, which posit that the core abnormality of ASD resides in perceptual aberrations due to a disbalance in the precision of prediction errors (sensory noise) relative to the precision of predictions (prior beliefs). This results in percepts that are dominated by sensory inputs and less guided by top-down regularization and shifts the perceptual focus to detailed aspects of the environment with difficulties in extracting meaning. While these Bayesian theories have inspired ongoing empirical studies, their clinical implications have not yet been carved out. Here, we consider how this Bayesian perspective on disease mechanisms in ASD might contribute to improving clinical care for affected individuals. Specifically, we describe a computational strategy, based on generative (e.g., hierarchical Bayesian) models of behavioral and functional neuroimaging data, for establishing diagnostic tests. These tests could provide estimates of specific cognitive processes underlying ASD and delineate pathophysiological mechanisms with concrete treatment targets. Written with a clinical audience in mind, this article outlines how the development of computational diagnostics applicable to behavioral and functional neuroimaging data in routine clinical practice could not only fundamentally alter our concept of ASD but eventually also transform the clinical management of this disorder.
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Affiliation(s)
- Helene Haker
- Translational Neuromodeling Unit (TNU), Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Maya Schneebeli
- Translational Neuromodeling Unit (TNU), Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Klaas Enno Stephan
- Translational Neuromodeling Unit (TNU), Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
- Wellcome Trust Centre for Neuroimaging, University College London, London, UK
- Max Planck Institute for Metabolism Research, Cologne, Germany
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Abstract
Purpose
– Adults on the autism spectrum experience difficulties in receiving health care, and health care providers face difficulties in offering health care to adults on the autism spectrum. The purpose of this paper is first, to assess the various difficulties and second, to provide strategies to overcome them.
Design/methodology/approach
– In this qualitative research project, current barriers and facilitators to health care services were sampled from a collaboration of autistic self-advocates and autism professionals in Berlin, Germany. The findings were complemented by a review of practical guidelines and research about the service accessibility of patients on the autism spectrum.
Findings
– A comprehensive list of barriers to health care was compiled and structured according to various aspects, such as “making appointments”, “waiting area”, “communication”, and “examination”. Strategies considering the perceptual and communicative peculiarities of autism were found to improve access to health care for autistic adults.
Practical implications
– Providing access to the health care system may improve the diagnosis and treatment of mental and somatic illnesses, and thereby, the health status and quality of life for people on the autism spectrum. This recognition of the needs of adults on the autism spectrum may serve as a model for other areas in society, such as education and employment.
Originality/value
– Data acquisition in this project is of special value because it resulted from collaboration between an autistic self-advocacy organization and professionals working in the field of intellectual developmental disabilities considering the experiences of autistic adults in the entire range of intellectual functioning.
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Georgescu AL, Kuzmanovic B, Roth D, Bente G, Vogeley K. The use of virtual characters to assess and train non-verbal communication in high-functioning autism. Front Hum Neurosci 2014; 8:807. [PMID: 25360098 PMCID: PMC4197646 DOI: 10.3389/fnhum.2014.00807] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 09/22/2014] [Indexed: 12/31/2022] Open
Abstract
High-functioning autism (HFA) is a neurodevelopmental disorder, which is characterized by life-long socio-communicative impairments on the one hand and preserved verbal and general learning and memory abilities on the other. One of the areas where particular difficulties are observable is the understanding of non-verbal communication cues. Thus, investigating the underlying psychological processes and neural mechanisms of non-verbal communication in HFA allows a better understanding of this disorder, and potentially enables the development of more efficient forms of psychotherapy and trainings. However, the research on non-verbal information processing in HFA faces several methodological challenges. The use of virtual characters (VCs) helps to overcome such challenges by enabling an ecologically valid experience of social presence, and by providing an experimental platform that can be systematically and fully controlled. To make this field of research accessible to a broader audience, we elaborate in the first part of the review the validity of using VCs in non-verbal behavior research on HFA, and we review current relevant paradigms and findings from social-cognitive neuroscience. In the second part, we argue for the use of VCs as either agents or avatars in the context of "transformed social interactions." This allows for the implementation of real-time social interaction in virtual experimental settings, which represents a more sensitive measure of socio-communicative impairments in HFA. Finally, we argue that VCs and environments are a valuable assistive, educational and therapeutic tool for HFA.
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Affiliation(s)
| | - Bojana Kuzmanovic
- Department of Psychiatry and Psychotherapy, University Hospital Cologne, Cologne, Germany
- Ethics in the Neurosciences (INM-8), Institute of Neuroscience and Medicine, Research Center Juelich, Juelich, Germany
| | - Daniel Roth
- Department of Psychology, University of Cologne, Cologne, Germany
| | - Gary Bente
- Department of Psychology, University of Cologne, Cologne, Germany
| | - Kai Vogeley
- Department of Psychiatry and Psychotherapy, University Hospital Cologne, Cologne, Germany
- Cognitive Neuroscience (INM-3), Institute of Neuroscience and Medicine, Research Center Juelich, Juelich, Germany
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Vogeley K, Kirchner JC, Gawronski A, Tebartz van Elst L, Dziobek I. Toward the development of a supported employment program for individuals with high-functioning autism in Germany. Eur Arch Psychiatry Clin Neurosci 2013; 263 Suppl 2:S197-203. [PMID: 24077909 DOI: 10.1007/s00406-013-0455-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 09/16/2013] [Indexed: 12/28/2022]
Abstract
Human-human interactions are of central relevance for the success in professional and occupational environments, which also substantially influence quality of life. This is especially true in the case of individuals with high-functioning autism (HFA), who experience deficits in social cognition that often lead to social exclusion and unemployment. Despite good education and high motivation, individuals with HFA do not reach employment rates that are substantially higher than 50 %. This is an alarmingly high rate of unemployment considering that the United Nations have recently emphasized the inclusion of handicapped persons as a mandatory human right. To date, the specific needs of autistic persons with respect to their working environment are largely unexplored. It remains moreover an open question how support systems and activities, including newly developed communication devices for professional environments of individuals with HFA, should look like. The German health and social care systems are not adequately prepared for the proper support of this population. This leads us to suggest that supported employment programs should be developed for adults with HFA that specifically address their needs and requirements. Such programs should comprise (1) the adequate assessment of HFA, including a neuropsychological profile and an individual matching of persons' preferences with requirements of the working place, (2) on-the-job coaching activities that include systematic communication and interaction training, and (3) instruction of non-autistic peers, including colleagues and supervisors, about weaknesses and strengths of HFA.
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