Depression in Adolescents with ASD Damian Santomauro

Early Diagnosis Diagnosed with Asperger’s Syndrome at 5 years old Received tremendous amounts of support from speech pathologists, teacher aides, the Brighton Autistic Therapy Centre, and my mother

Personal Depression Severe depression Suicidal ideation Admitted to Royal Brisbane Hospital, Adolescent Mental Health Unit

Depression in ASD Estimates between 17% to 44% (e.g., Green et al., 2000; Kim et al., 2000; Strang et al., 2012) Survey from my PhD revealed: – 65% with moderate severity or worse – 38% with severe severity or worse Suicidal behaviour also high: – 7% to 42% in adolescents and young adults with ASD (Hannon & Taylor, 2013) – Compared to 4% to 8% in typical adolescents and young adults (Cash & Bridge, 2009; Gmitrowiez et al., 2003; Resch et al., 2008)

Cognitive Behaviour Therapy Shown to help reduce depression in typical adolescents (Garvik, Idsoe, & Bru, 2014; Poirier et al., 2013; Stallard, Richardson, Velleman, & Attwood, 2011; Stasiak, Hatcher, Frampton, & Merry, 2014) Shown to help reduce anxiety in children with ASD (Chalfant, Rapee, & Carroll, 2007; Lang, Regester, Lauderdale, Ashbaugh, & Haring, 2010; Moree & Davis, 2010; Sofronoff et al., 2005; White et al., 2010) Non-randomised trial showed promise for CBT for depression in adolescents and young adults with ASD (McGillivray & Evert, 2014)

Exploring Depression Programme Designed by Professor Tony Attwood and Dr. Michelle Garnett Psycho-education Tools to reduce depression: – Self-awareness – Improving self-esteem – Promoting activities that help with depression (e.g., physical activity, art and music, hobbies) – Thinking strategies Weekly diary and homework Planning for the future Safety Plans

Randomised Controlled Trial Participants : – EXTREME difficulty in recruitment – 11 months of recruitment resulted in 93 enquiries, of which 42 were assessed for eligibility 7 BDI < 14, 4 WASI VIQ < 85, 6 high suicide risk, 2 no diagnosis. – 23 eligible participants were randomly assigned to treatment or wait-list control group – 3 withdrew, leaving only 10 in each group to start the programme – Mean age was years (SD = 1.37), 12 males, 8 females

Randomised Controlled Trial Timeline: Treatment Group (n = 10) Control Group (n = 10) 5 weeks BDI 10 weeks BDI & DASS 10 weeks BDI & DASS Begin Program 14 weeks BDI & DASS 30 weeks BDI & DASS

Randomised Controlled Trial Mixed Depression Results: – BDI showed no significant improvement – DASS Depression showed significant improvement for the treatment group but not the wait-list control group.

Study 3: Randomised Controlled Trial

Feasibility and Acceptability Participant Recruitment: – Extreme difficulty recruiting participants despite evidence for need – Many parents called asking about the programme, while expressing concern that their child would not agree to it – Adolescents refusing to participate because they were “sick of being studied like a guinea pig” – Almost half of the participants assessed for eligibility were not eligible for the programme – Most common exclusions being scoring too low on the BDI at baseline or being a moderate to high suicide risk

Feasibility and Acceptability Programme Attendance: – In total, 19 adolescents started the intervention (1 control participant withdrew at 10 weeks) – Of those 19 adolescents, only 1 withdrew from the 10th session for personal reasons and never returned – Of the 18 adolescents who finished the programme, if an adolescent missed a session, then they had the opportunity to attend a one-on-one catch-up session with the psychologists This opportunity was accepted on every occasion – A total of 23 one-on-one catch-up sessions were arranged – The most a single participant received was 4

Participant Satisfaction Booster sessions at 14 weeks ran like a focus group for feedback on the programme For 15 adolescents and 7 parents, the booster sessions were audio-recorded 14/15 adolescents reported enjoying the programme 15/15 adolescents reported they would recommend the programme to others The group setting was considered the most helpful element by most of the adolescents

Participant Satisfaction “Well I noticed that I have no life now (that the programme has finished), that my Saturdays are a bit boring. I quite liked it, the people were awesome and it was really nice… I’ve been a lot happier since.” Claire, 14 year old female with ASD.

Participant Satisfaction “I’m happy about this because I actually made some new friends, which I’ve been having really hard trouble making friends that actually accept me for who I am, and actually have the same problems I have, so I don’t feel alone, like, they understand what I’ve been going through” Daniel, 13 year old male with ASD.

Participant Satisfaction “I know Jason said what he found most helpful was the social group, not being alone, the meditation, he really really liked mindfulness, and the thinking tools, but I would agree from the outside the thinking tools were kind of the most… it was the most marked difference.” Lauren, mother of a 17 year old male with ASD.

Suggested Changes More adolescents per group Male-only groups requested a better mix of genders Shorter sessions but more of them to cover everything Later start time: – A start time of 10:00am or 11:00am was thought to provide sufficient lead time for adolescents to attend the sessions.

Participant Satisfaction “That would be my only thing is the time which is really really difficult in teenagers. We wouldn’t have had any problem at all getting here if it was in the afternoon. Mornings were like… we missed like 4 of them just because it was so hard.” Lauren, mother of a 17 year old male with ASD.

Conclusions Preliminary evidence that programme can successfully reduce symptoms of depression More research is needed, especially with more participants, but will be extremely difficult to conduct Very specific and unmotivated population Ethical problems, suicide risk a barrier for participants 19% of potential participants either excluded for high suicidality or were hospitalised for suicidal ideation or self- harm

Conclusions I strongly believe this programme helps with depression Next step is to look into what will motivate adolescents to participate in these programmes and relapse prevention