Category Archives: Anxiety

New apps part of autistic kids’ therapy

New apps part of autistic kids’ therapy.

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Executive Function and IEP/504 Plan Goals for Academic and Social Success

Dilemma:  School is back in session and Section 504 plans or Individualized Education Programs (IEPs) need to be developed, reviewed, or revised.  This is overwhelming.  Where to begin? My child is doing well in school on paper but is not connecting with others.  How long do I wait?  How about executive functions like organization or mental flexibility (i.e., moving from one subject or activity to another without difficulty) that are not graded but can significantly interfere with academic and social progress in grades 4 and up?

Solution: Consider the following video guide to a child’s social skills and executive function development:

Learn more at www.mysosh.com

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New Mobile App for ‘Tweens, Teens, and Young Adults with Asperger’s Syndrome

Sōsh, the only mobile app of its kind for children and teens with social skills difficulties, has been made available in a   Lite version in the iTunes Store.  Now everyone can have full access to all of the features of this app for a trial period of one week from the time of download before deciding whether to purchase the full version.  Don’t miss the chance to try out this app!  Members of the Asperger’s community are saying, “I have never come across something so great for people with Asperger’s.”  Experts in the field and app reviewers are saying:

  • “This is a marvelous autism app.  I haven’t seen anything like it.”
  • “It is one sweet app, is strength-based and best in breed; an app that is both dignified, and appeals to kids’ strengths while building social skills at the same time. Finally, something my tween will want!”
  • “Sōsh gives you virtually every tool you could possibly have in one electronic iPhone toolbox. It’s the Swiss Army knife of apps!”
  • “This app is the most comprehensive electronic and portable toolbox for social skills development!”

For individuals ages 9 to 22 years old with Asperger’s Syndrome, difficulty with social interactions is a leading cause of stress and one of the most common calls for help.  With over 60 screens of exercises, strategies, and practical information regarding social skills, the Sōsh app will assist with social skill development, and provide feedback and tools for parents, teachers and therapists.   Examples include tools to relieve stress, guidance for appropriate social behaviors, and self-monitoring capabilities. The app is available in the iTunes app store.

About The Developer

Dr. Mark Bowers is a Pediatric Psychologist in Ann Arbor, Michigan.  He specializes in neurodevelopmental diagnoses (i.e., Autism, Asperger’s, ADHD, and Learning Difficulties) and he is an expert in social skills.  Dr. Bowers has contributed to articles in WebMD magazine, Scholastic, and Parenting: The Early Years.  In addition to developing the Sōsh mobile app, he is the author of the book Sōsh: Improving Social Skills with Children and Adolescents.  Visit http://www.mysosh.com for a full review of the app’s potential to improve social skills.

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Typical Childhood Behavior versus OCD

Parents often ask me whether their child’s behavior is typical or something more significant such as Obsessive Compulsive Disorder (OCD).  In my clinical experience, OCD is a term that is often misused in ‘pop’ culture.   For example, I often work with parents who describe themselves as “OCD” because they are organized or meticulous in their everyday lives.  These behaviors may be orderly or repetitive, but they do not necessarily indicate obsessions or compulsions.  Another example is the junior high school or high school perfectionist I counsel who wants to have straight A’s and becomes upset if this does not occur.  Again, this is not OCD although many individuals with OCD tend to have some tendencies toward perfection.   Just because you have obsessive thoughts or perform compulsive behaviors does NOT mean that you or your child have obsessive-compulsive disorder. Many people have mild obsessions or compulsions that are strange or irrational, but are still able to lead their lives without much disruption.  In the case of obsessive-compulsive disorder, these thoughts and behaviors cause tremendous distress, take up a lot of time, and interfere with friendships, school functioning, employment, or relationships.  Thus, the amount of disruption that occurs and the amount of settings (at least two) that are affected in one’s life help to define true OCD from someone who is orderly, ‘anal,’ or a perfectionist.

When it comes to determining the presence of OCD in children, the following need to be considered:

Children and adolescents with obsessive-compulsive disorder (OCD) suffer intensely from recurrent, unwanted thoughts (obsessions) or rituals (compulsions), which they feel they cannot control. Rituals such as hand washing, counting, checking, or cleaning are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these rituals, however, provides only temporary relief, and not performing them markedly increases anxiety. Left untreated, obsessions and the need to perform rituals can take over a person’s life.

It looks like this:

The Sequence of OCD Symptoms:

1) Evoking Event

2) Obsessing Begins

3) Distress & Anxiety

4) Urge to Ritualize

5) Ritualizing

6) Relief and Self-Criticism

While the onset of obsessive-compulsive disorder usually occurs during adolescence or young adulthood, younger children sometimes have symptoms that look like OCD.  However, the symptoms of other disorders, such as ADD, autism, and Tourette’s syndrome can also look like obsessive-compulsive disorder, so a thorough medical and psychological exam is essential before any diagnosis is made.  It is also important to note that OCD is an anxiety disorder, and in children, the symptoms of anxiety usually change over time.  So a child with OCD symptoms will not necessarily have OCD as an adult.  What is most important is to make environmental and behavioral changes to help reduce your child’s anxiety and provide support, yet do not give in to the anxiety or change your routine significantly in response to it.  Remember, some anxiety is good..it tells us when we need to fight or flee.  Making too many accommodations for your child’s anxieties will only serve to reinforce the fears.  As the old saying goes:  If you see a ghost in a graveyard, you should run toward it.  This is the essence of exposure and response prevention treatment for OCD, which will be detailed in future blog postings.

Dr. Mark Bowers is a Licensed Pediatric Psychologist at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

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Social Skills Part II: Behavior then Mood

I want my clients to begin their experimentation into the social world by making impressions.  In order to do this, they must be out and about.  Often times, individuals I work with do not come in to visit with me until self-esteem has begun to suffer.  As a result, I may also be dealing with some mood difficulties.  My role, provided that we are not dealing with a clinically significant major depressive disorder, is to begin coaching the individual with regard to the behavior preceding the mood.  In other words, my clients often times do not feel like they would like to go to the football game on Friday or feel up to attending the homecoming dance.  This consistently comes up in my social skills groups where at least one child does not want to participate or feel like they need to be a part of the group.  They have yet to experience the behavior of being in the group so how in the world would they know that they won’t like it?  Despite the potential to sustain the current social difficulties, there is usually at least one parent who gives in and allows their child to avoid attending the group.   Progress can never be made when this happens.

Staying home will do nothing more than exacerbate the current feeling (I don’t need to go to a group or be social).  Instead, the behavior must come before the desired feeling.  Specifically, individuals must attend the football game or they must attend the dance before they can begin to truly experience the feeling of improved self-esteem, for example.  Most of my clients, although they object to this initially, return to my office to inform me that although going to the dance or football game was the very last thing that they wanted to do on that particular evening, once they were there it was not so bad and they actually ended up enjoying themselves.  Keep in mind that although I use dances and sports games as examples, the behaviors preceding the mood applies to all ages: going to the playgroup, playground, birthday party, etc.

I think it’s also important to illustrate that we must take the pressure of social skills off of these individuals.  In other words, there is no expectation when we are just getting started with making impressions other than the individual simply must attend events.  That’s it, plain and simple: attend the event or activity.  I don’t care if you talk to anyone.  I don’t care if you make any eye contact with anyone.  We have plenty of time to work on that.  One of the biggest hurdles that I see is getting my clients to leave their home because they often do not feel like it.  This is the time that I remind individuals that the behavior must often precede the mood.

This is important because individuals who are feeling dejected or otherwise depressed in any manner may not have the energy, confidence, or motivation to make that initial leap into the social world.  My response is that continuing to avoid the social world only exacerbates the current difficulties.  I am not asking for these individuals to go out on any particular evening or to attend any particular event and come home with a new friend or social group.  I am simply asking that they be seen in the social environment and thus make an impression.  The behavior preceding the mood is important because these individuals may not feel like being social on any particular evening.  In fact, this often perpetuates the addiction cycle of video games as a self-medicating remedy.  Indeed, they will use video games as means of avoidance or as an excuse for why they won’t attend (“I don’t want to go because I’m really into this game…don’t bother me!”).

Client after client returns to my office to tell me that although they were very upset with me and did not want to go to the school dance or football game they took a risk (with the help of sufficient support and encouragement) and they went.  Although they felt ‘awful’ prior to attending the event, once they were there they realized it wasn’t so bad.  Further, the strategy of simply being in the social environment paid off because there were no pressures to achieve any outcome other than attendance.  I know we would all like to jumpstart this process and in our typical American fashion get to the outcome quicker and without much work.  Unfortunately, it does not work that way when dealing with social interactions.  If you are not prepared to take the preliminary steps you will not be successful.  If you rush this process you will not be successful.  Take your time and be willing to take a risk.  Some discomfort is inevitable before progress can be achieved.

“Progress always involves risk; you can’t steal second base and keep your foot on first.” –Frederick Wilcox

Dr. Mark Bowers is a Licensed Pediatric Psychologist at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

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‘Tis the Season: Preparing Your Child for the Holidays

No matter the holiday traditions or customs you observe, one thing is for certain: the children will be home for a week or two beginning very soon!  No reason to panic.  After all, adults never experience any stress over the holidays so why should kids?  I tried to effectively demonstrate a tongue-in-cheek tone with that last sentence.  I was testing your electronic social skills.  Okay, back to the topic at hand.  The children will be home for a while and you are becoming anxious that tempers may begin to flare or boredom may ensue.  I offer the following general suggestions to hopefully sustain your holiday cheer throughout the school break.

  • Increase predictability at home.  This involves some scheduling, although flexibility should be allowed.  For teens who need to catch up on some sleep, there should be parameters such as “awake by noon” but no need to be so scheduled (“Be up by nine because I said so!”) that arguments are inevitable .  The more that children know what to expect, the less stress that will result when making transitions.
  • Have a portion of each day scheduled but plan the rest of the time with the child by allowing for their input.  You may need to offer a list of suggestions for them to choose from, but you should not be trying to win the contest for Entertainer of the Year.  thus, it is not your responsibility to ensure that your child is having fun all the time!  It may be useful to have a written or picture schedule for some children.  This is especially helpful when you are resting in the afternoon and your child comes to you to say, “I’m booooored!”  You can calmly refer them to the schedule and add, “I know you will figure out something fun to do from all those options, honey.”
  • Keep an eye on your own stress level as there is a trickle down effect.  As we reunite with family, all of those fun dynamics from childhood tend to surface.  Children generally have fewer demands on them during breaks which is why they tend to do better behaviorally.  If you need a break from your relatives, then don’t over schedule.  Your kids will pick up on your stress and react accordingly.
  • Remember to limit television time.  I know this sounds crazy.  After all it serves as an effective pacifier and most parents will ignore this suggestion.  However, trying to get the child away from the TV after they are allowed unlimited viewing will not likely be met with willingness from the child.  The recommendation for television viewing during the holidays is 1-2 hours each day (which includes other screen time such as computers and video games).  Some children can effectively manage more, other cannot.  Certainly, exceptions can be made for holiday movies, family videos, etc.  The general rule is to keep an eye on the time, though, because school will again be in session and the child will then have to “detox” from all the television viewing as they begin to focus on the “boring” schoolwork again.  Maybe reading a fun book in exchange for some of that TV time might keep the old brain cells fresh and sharp?
  • Whenever possible, prepare the child in advance for holiday visits.  If only someone would prepare you!  It never hurts to discuss who will be there, what will take place (as much as you can anticipate before the first family argument occurs), and how long the visit will last.  Children with sensory issues may need an escape plan that can be determined upon arriving to the party or gathering (or in advance if the location is familiar).  The child can use this “escape” for a set period of time to regulate him/herself and then must return to the gathering.  Bring a familiar item from home if your child is anxious about these visits.  Also, talk to your family members in advance and if your child is shy or anxious, remind them to let the child warm up and not force hug, kisses, etc. upon greeting the child.
  • Finally, prepare the child for transitions.  My colleague, Dr. Rick Solomon, has devised 20 Transition Tricks that he recommends for parents who have a child who cannot shift easily from one activity to another.  His general rule of thumb is to acknowledge the child’s feeling of not wanting to transition but then to begin to prepare them for what awaits.  There are a variety of strategies such as time warnings, use of humor, and bribes-but ultimately the child needs to go where we need them to or there will be a consequence.  Try to avoid these control battles whenever possible, though, and with some scheduling and preparation this will hopefully be a safe and happy holiday for everyone!  If it’s not the “Most Wonderful Time of the Year,” then join the club.  By keeping expectations reasonable and being able to laugh off some of the family dynamics that play themselves out across most households, this may result in the impression of a relaxing and enjoyable holiday!

Dr. Mark Bowers is a Licensed Pediatric Psychologist at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

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Social Skills Part I: ‘Impressions’ and Being ‘Out and About’

night_game

This is the first in an ongoing series I will be presenting on Social Skills.  I spend a significant portion of my clinical practice working with children and teens on social skills.  Many parents are curious about my approach and philosophy on teaching social skills, so I thought I would begin posting my thoughts on the matter (in no specific order).  I will being by discussing ‘impressions’ and the initial need to be seen and not heard.

I often discuss social interactions as similar to advertising impressions.  For example, when businesses buy billboard advertising on the side of highways, they often first collect statistics on how many “impressions” their billboard location has on a particular day.  The advertisers want to know specifically how many individuals will see their advertisement over the course of a day, week, month, or year.

Individuals with social skills difficulties often become dejected and suffer a loss of self-esteem when they make one or perhaps even a handful of attempts at engaging others in a social interaction and these attempts are unsuccessful.  I am often able to use my advertising analogy with my clients who will begin to understand that not every person who drives by the Pepsi billboard on the highway is going to purchase that particular product.

When the available options for friendships is smaller such as in an elementary school, certainly the stakes are higher and each impression that is made must count.  However, I often coach my high school-age clients that they cannot expect to sit in their basement playing video games every weekend and then come into my office wondering why they are not more popular in school.  We often discuss the ‘content and process’ approach to social interactions which can be loosely applied to various junior high school and high school activities.

For example, I may work with individuals who have little interest in sports especially when it comes to participating in them.  However, anyone who has attended high school is well aware of the fact that, especially during the fall and early winter months, the place to be is the local high school football game on Friday night.  When it comes to “impressions” such as those found in advertising, being seen even if not heard is a basic starting block for my clients.

I have to remind these individuals to relax initially and just be there rather than try to initiate interactions with others or practice social skills techniques they may have learned by reading a book or from a counseling session or group.  I am generally opposed to social skills techniques being ‘taught’ because the nature of individuals with social difficulties is to study and memorize something in a rote fashion or linear manner and social interactions are far from rote or linear.  More on that topic in a future posting…

Indeed, although these individuals would love nothing more than to reduce social interactions down into a mathematical formula where there is a very specific path that must be followed in order to reach the appropriate or correct outcome, social interactions are generally not linear or rote, and are instead fluid and contain millions of variables and exponents that might be comparable to the mathematical variable of (Pi).  Thus, I want my clients to begin their experimentation into the social world by making impressions.  In order to do this, they must be out and about.

Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.  Learn more about his Social Skills groups here.

© 2009 Mark Bowers, Ph.D.

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Autism and OCD in Children

hand_washingAutism Spectrum Disorders (ASDs) and Obsessive-Compulsive Disorder (OCD) can and do occur at the same time.  OCD is a specific diagnosis under a larger umbrella of anxiety.  Children with OCD experience unwanted and intrusive thoughts that they can’t seem to get out of their heads (obsessions), often compelling them to repeatedly perform ritualistic behaviors and routines (compulsions) to try and ease their anxiety.  Children with ASD generally have repetitive, perseverative thoughts that are intense in nature, much like children with purely OCD symptoms.  The big difference is that children with OCD do not like the experience of having repetitive thoughts and would do anything to get rid of the thoughts (such as washing one’s hands 25 times).  Children with Autism Spectrum diagnoses are not bothered by their repetitive behaviors and thoughts, and instead are usually comforted by them (such as playing with a train in a repetitive fashion for hours at a time).

Anxiety is highly prevalent among children with Autism Spectrum diagnoses (greater than 35% of children experience both).  This is due to a combination of genetics, brain development, and higher levels of stress.  The error that many schools and therapists often make is attributing a child’s anxiety symptoms to his or her Autism diagnosis (i.e., “The only way to really reduce  anxiety and aggression is to treat the Autism.”)  For example, many children are referred into social skills groups when what they really need is help with anxiety that is interfering with their social functioning.  Highly anxious children with OCD may begin to act out behaviorally in school prompting teachers to encourage (some might say ‘coerce’ or ‘force’) parents to begin medicating the behavior.  The concerns here is twofold: 1) the behavior is numbed with medication and the root anxiety is never truly addressed (i.e., stop the medication and everything returns to the way it was), and 2) the school may begin to implement safety nets such as increased para support to keep the behaviors from occurring while again failing to adequately address the underlying anxiety symptoms.

The question often asked is, “Can you really treat a child who has both an autism spectrum diagnosis and OCD?”  The answer is “yes” and new research is beginning to show that there are some exciting recent behavioral treatments out there for these children.  Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for anxiety that has been established by the American Psychological Association as effective for children.  A recent study of CBT for neurotypical children with anxiety (Wood et al., found):

  • Childrens’ school performance improved & they attended school more regularly
  • Children had more friends & better quality friendships
  • Children got along better with family members
  • Children had higher self-esteem

The authors of that study have adapted the neurotypical CBT protocol for children with autism spectrum and are finding some promising results.   In general the results suggest that the authors’ adaptations of the pre-existing CBT manual can be effective for treating anxiety such as OCD in children with autism (research article link).  This treatment manual is available to practitioners and families, a sample of which can be viewed here.   Thus, there is hope for effective anxiety treatment for your child who also has an autism spectrum diagnosis.  It is highly recommended that you seek out services from a pediatric specialist who has training and experience treating children with co-occurring anxiety and autism spectrum diagnoses.

On a personal note and aside, I will be spending tomorrow with noted Asperger’s guru Dr. Tony Attwood  so stay tuned for a blog later this week where I hope to share some new ‘nuggets’ of information.

Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

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To Spank or Not To Spank…

A paper presented at the International Conference on Violence, Abuse and Trauma on Sept. 25 by sociologist  Murray Straus has caught my attention this week.  Straus and his colleague Mallie Paschall followed children over the course of four years and determined that those who were spanked had up to a 5-point lower IQ than their peers who were not spanked.  Further, the more the children were spanked, the lower their IQs.

This debate is not new.  In fact, I find myself in this debate at least a few times each month with some of the families I see.  The age old question is whether or not spanking is an effective form of discipline.  My professional stance (in conjunction with the science that supports it) is that spanking is actually punishment (not discipline) and is only effective in the short-term.  Try telling that to the ‘old school’ father who swears, “It worked on me when my father spanked me!”  With a little more investigation in my office, I am often able to reveal that while it may have garnered attention in the short-term, it fueled resentment toward the parent over the long-term.

I truly believe that the majority of spanking occurs in the form of a parental temper tantrum in which the parent has lost control and is at a loss for an effective discipline strategy.  There are a number of problems with punishment that I encourage parents to consider when deciding if they really want to employ spanking as a method of punishment.

  • Spanking focuses anger on the parent doing the spanking.  When we resort to punishment it gives children someone else to be mad at or something else (the spanking) to blame.
  • Spanking causes the behavior to stop quickly, but in the absence of spanking, the negative behavior returns.
  • Spanking does not teach accountability. The “punisher” (parent) is responsible to see that the child’s behavior changes.   The child learns nothing on their own as a result of the spanking.
  • Punishment denies a child the right to experience the real consequence of their actions.  If your child hurts someone else, for example, the other child may not want to play with your child anymore.  Your child quickly forgets this possibility when spanking is introduced.
  • A big error comes when we think that the punishment has taught the child what to do the next time a similar situation occurs. It has taught the child NOT to do something… but it has not taught them what they should do!

In case those reasons were not enough, we also know that spanking makes children anxious (especially toward the parent using this method) and spanking can lower self-esteem.  A report endorsed by the American Academy of Pediatrics in 2008 looked at 100 years of research and concluded, “There is substantial research evidence that physical punishment makes it more, not less, likely that children will be defiant and aggressive in the future.”

The full report can be read at www.phoenixchildrens.com/discipline

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