ACT and Parent Training for Autsim and PDD: Creating a Context to Move Toward What is Important Giovanni Miselli, PhD IESCUM, ACT-Italia, AUSL RE

ACT and Parent Training for Autsim and PDD:

Creating a Context to Move Toward What is Important

Giovanni Miselli, PhDIESCUM, ACT-Italia, AUSL RE

- Psychological Flexibility as a treatment objective for childern with autsim and a teaching skill for parents

- Around the Hexaflex (contacting the processes and examples of inflexibility on kids and Parents)

- Parents as a Guide or a Gate Keeper (Experiential exercise)

- the “What I have to do?” TRAP for Parent Trainers and Cinicians

- Bring Values in the Room (Framing Reinforcement/ABA concepts and Values)

- Field experience and protocols (groups and couples)

- Matrix!

The DIFFICULTIES of PEOPLE with ASDThe DIFFICULTIES of PEOPLE with ASD

1) difficulties on social communication and social interaction

2) fixed interests and restricted repetitive patterns of behavior

Our job is taking care of those difficultiesAnd build contexts in wich learining and growing is possible

L: Dreammy dream is give you a kiss in the lipsDavide would you like to come to my house to do a date with a kiss in the lipsyes no?Write a message

D: ok Ludo but could you invite me Monday or Friday at 430pm?

L: ok

L: Dreammy dream is give you a kiss in the lipsDavide would you like to come to my house to do a date with a kiss in the lipsyes no?Write a message

D: ok Ludo but could you invite me Monday or Friday at 430?

L: ok

Sense of guilt

Difficulties in communication

Pessimism toward the future (DEMeyer, 1979)

isolation

Not understanding

Peculiarities, social Judgments

Feelings of anger, depression

diversity

Disagreement in the couple

Autism is a chronic developmental disorder that has an impact not only on the child who directly suffer from it,

but also on his/her parents (Blackledge & Hayes, 2006)

Early Intensive Behavioral Intervention have proved effective in helping the child develop cognitive and behavior skills to good functioning levels,

however they are extremely demanding on parents and children especially in contexts that do not provide a coherent and structured support for their application.

This challenging context is common all over Italy

AIMS

Context

Parents of children with autism may show the highest levels of parenting stress, relationship difficulties and mental health issues amongst parents of children of a variety of disabilities

High levels of parental distress may significantly impact parent training outcomes

Context

Gould, 2013

ACT

Improved outcomes (for parents and children) might be achieved if strategies for dealing with interfering private events were incorporated into parent training packages

Acceptance and Commitment Therapy (ACT) aims to cultivate parent vitality and well-being, while maximizing treatment outcomes, through mindfulness and values-guided action Gould, 2013

ACT Experiential approach to behavior change

Based on

o Functional Contextualism

o Relational Frame Theory (RFT)

Root of human suffering = Psychological inflexibility

Six core processes: contact with present moment, acceptance, defusion, self as context, values, and committed action.

Gould, 2013

La flessibilità psicologica

è l’abilità di essere nel momento presente con

piena consapevolezza e apertura alla nostra esperienza e di intraprendere

azioni guidate dai nostri valori.

Più semplicemente, è la capacità di

“being present, open and do what counts”.

Harris, 2011

Hayes, Strosahl e Wilson 1999

Inflexaflex

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Acceptance and Mindfulness

Processes

PsychologicalFlexibility

Commitment and Behavior

Change Processes

ACT is a modern behavioral psychotherapy based on RFT that usesthe processes of mindfulness and behavior change to establishgreater psychological flexibility.

Dangers oflife

IAs

A parent

What is reinforcingI as

A parent

I as a parent

Cairns

The Matrix

CONTENT of VALUES

VS

“VALUING” AS BEHAVIOR

Framing Reinforcement and Values

Framing Extinction and Values

THE VALUE OF THE PORFESSIONALbecome a valuable source of information

- falling on knee (valuable source of info)

- Knowing what is important (assessment of reinforcers)

- A map of the wolrd (tracking contingencies)

- the value of experience (directly contact contingencies CSB)

THE VALUE OF PARENTSOpen, Aware and Active

- Embodied Value

- Choose what to teach (objective based on values)

- Choose how (strategies, procedures and techinques)

- Try and see what works (video modelign and direct experience shaping)

- Dilute to taste!

- the example extincion

WHAT is IMPORTANT for MEBringing values in the group

- Gioco dell'oca (Snake and ladders)

- bringing what is important for me (choice, values)

- conversation on values (pairing, modeling)

Context: ABA interventionModel 1

ACT workshop before 20-25hours of home based ABA

intervention

Model 2,3,4

ACT intervention during ABA intervention 7-10hrs home based/center based, (26h of school based personalized teching with ABA supervision)

Sediorpor sitataqui beriantfrtddes deusque sed

1) Intensive ACT 2) PT + ACTgroup

3) PT Psy Flex 4) PT + ACTcouple

Format Group (children any age)

Group (3 age groups)

Group (any age) Couple (any age)

Duration 16 h 3h x 6 + 3h x 3 advanced

3h x 4 1,5h x 6

Focus Psy Flex InformationFlexible Parenting(Committed action) ar

Psy Flex in Parenting

Specific Objectives

ACT processes start

Creative Helplessnessacceptance

Values Values variable

ACT work through MetaphorsExperiential Exercises

MetaphorsTalk fo make a difference VideomodelingGroup Processes

Experiential Exercises Matrix

VariableBibliotherapy

Protocol ++ + + -

Measure Process AAQII, VLQOutcome BDI, SCL 90

Outcome PSI, QSG Process AAQII, VLQOutcome PSI

Change in target behavior

Field Testing and Findings

1) Intensive ACT 2) PT + ACT Group 3) PT Psy Flex 4) PT + ACT Couple

PROS

Significant reduction in BDI score

Increase in Valued Effective Action (VLQ)

Normalisation of scoring in Experiential Avoidance (AAQII)

Possible to work with different ages and levels of functioning

High parent satisfaction

Fast (16hours in 2 days)

Good retention at 3 month follow up

Insreased efficacy (Self reported QSG)

Delivery of informative content (e.g., prompting, data collection, reinforcement) using ACT processes and techniques (experiential exercises and metaphors)

3hours x 6 sessions evaluated as more accessible format for parents

Opportunities for practicing skills between sessions

High retention (in comparison to the same content delivered without ACT)

High parent satisfaction

Role playng and videomodeling - better generalization of skills

Video feedback from other parents - group / social processes

Same advantages of intervention 2

More willing to participate in other courses

Collaboration with parents in planning objective and procedures Independent measure of target behavior in children

Flexibility of contents



CONS

Starting with acceptance and creative helplessness may be more aversive than starting from values processes

Participant selection based on motivation to address difficult covert behavior and ability to be away form children for 48hrs

Results variable across individual participants

No independent measure of change in parent-children interactions

Need for ABA and ACT competent facilitatiors (ACT therapist used x group 30 people, 15 each)

Specific training content required organizing sub-groups based on age and functioning level of children

Need for ABA and ACT compentent facilitatiors (ACT therapist used x group 30 people, 15 each) Further training focused on specific skills may be needed

Need for ABA and ACT compentent facilitators

No exposure to group and social processes

Need to coordinate variation in procedure with all staff participating in treatment

Duration depends on individual responses



CONS

Starting with acceptance and creative helplessness may be more aversive than starting from values processes

Participant selection based on motivation to address difficult covert behavior and ability to be away form children for 48hrs

Results variable across individual participants

No independent measure of change in parent-children interactions

Need for ABA and ACT competent facilitatiors (ACT therapist used x group 30 people, 15 each)

Specific training content required organizing sub-groups based on age and functioning level of children

Need for ABA and ACT compentent facilitatiors (ACT therapist used x group 30 people, 15 each) Further training focused on specific skills may be needed

Need for ABA and ACT compentent facilitators

No exposure to group and social processes

Need to coordinate variation in procedure with all staff participating in treatment

Duration depends on individual responses

Hayes, Strosahl e Wilson 1999

intervention diagram

Information meeting parents

Intervention

Assessment

Personalised programme

Sustainability evaluation

ACT – workshop (16 hrs)

FU evaluations Other interventions if needed

ParentsChild

Home School

mandatoryIf needed

1) Intensive Experiential ACT Workshop for Parents

Acceptance and Commitment Training for parents

• Focus– To increase psychological flexibility– To expand parents adaptive behavioral repertoire

• How– 2-day workshop– Mailing list– Feedback on data and experience

1)Intensive Experiential ACT Workshop for Parents

Prima Giornata

Tempi Titolo Contenuti Modalitﾈ Strutturazione della giornata e tutela delle informazioni personali

Introduzione Lezione interattiva

Somministrazione Psicometrici T0

AAQII, VLQ, SCL90, BDI2, PLOC

Assessment T0

Prima sessione 10.00-13.00 3h

Da ABA a ACT: lo studio dei processi verbali

Supporto scientifico Lezione frontale

Pausa 1h

Raccolta e risposta ad eventuali domande dei partecipanti

Centering Exercise Entrare in contatto con il momento presente

Esercizio di mindulness

Che cosa causa lo stress: il muro delle preoccupazioni

Introduzione e discussione delle esperienze individuali

Lezione interattiva Esercizio esperienziale

Benessere e malessere Introduzione e discussione delle esperienze individuali

Lezione interattiva

Metafora del lavandino (Bond & Hayes 2002)

Consapevolezza del processo che crea sofferenza

Lezione interattiva

Cominciando lￕACT (Bond & Hayes 2002)

Come le emozioni ed i pensieri negativi interferiscono con una vita efficace e godibile

Lezione interattiva

Come ha funzionato? (Bond & Hayes 2002)

Valutazione dellￕefficacia a lungo termine delle strategie per eliminare i pensieri negativi hanno funzionato

Lezione interattiva

Metafora del poligrafo (Hayes, 1999)

Impraticabilitﾈ della modificazione diretta degli eventi interni

Lezione interattiva

Contatto con il momento presente (Hayes, 2007)

Introduzione e discussione Esercizio di mindulness

Metafora delle sabbie mobili

Valutare strategie alternative e nuove strada verso il benessere

Lezione interattiva

La disponibilit ﾈ(willingness) come strategia alternativa (Bond & Hayes 2002)


Lezione interattiva

Dolore sporco� ￓ e dolor� e pulito � (Hayes & Smith, 2005)

Identificazione degli eventi manipolabili e di quelli non manipolabili direttamente

Esercizio esperienziale

Semplicemente notare consapevolmente (Bond & Hayes 2002)

Esercitare la disponibilitﾈ Esercizio di mindfulness

Esercizio Non posso camminare

Introduzione alla defusione Esercizio Esperienziale

Direzioni di valore (Bond & Hayes 2002)

introduzione Lezione interattiva

Esercitare la disponibilit ﾈfa� ccia a facciaￓ (Bond &

Hayes 2002)

Esercizio di empowerment a coppie


Seconda sessione 14.00-18.00 4h

Il bambino interiore Identificazione dei valori e Esercizio esperienziale

Seconda Giornata

Tempi Titolo Contenuti Modalitﾈ Centering Exercise Entrare in contatto con il

momento presente Esercizio di mindulness

Ripasso per immagini Ripasso dei punti trattati nella giornata precedente

Slide show

Intrappoladita Cinese Praticare strategie di disponibilitﾈ


Esercizio etichette autovalutazione

Praticare defusione Esercizio esperienziale

Quel Posto Dolce (Wilson, 2008)

Introduzione Esercizio esperienziale a coppie

Giusto contro sbagliato (Bond & Hayes 2002)

Indebolire la fusione cognitiva

Lezione interattiva

m� aￓ (Bond & Hayes 2002)



L e�sercizio dell os� servatore (Hayes, 1999)

Aumentare la consapevolezza dei propri processi psicologici



Esercizo: ￒLatte latte �(Hayes, 1999)

Indebolire la fusione cognitiva e aumentare la consapevolezza dei propri processi psicologici


Pausa 1h


Porta la tua mente a passeggio (Hayes, 1999)



Esercizio del mostro di latta (Bond & Hayes 2002)

Promuovere l a�ccettazione Esercizio esperienziale

Esercizio Benvenuto Ve cchio Amico


Esercizio VLQII Promuovere direzioni di valore

Autovalutazione ed esercizio esperienziale

Esercizio del contatto oculare

Esercizio a coppie per esercitare la abilitﾈ aquisite


Lasciare la lotta, per raggiungere i nostri obiettivi e i nostri valori (Bond & Hayes 2002)

percorrere nuova strada verso il benessere Agire con impegno (statement pubblico o privato)


Giunto fin qui chi sono? Metafora della schacchiera

Introduzione e discussione sul se come contesto

Discussione interattiva Lezione interattiva

Pratica del se come contesto

Fare esperienza della continuitﾈ di se

Esercizio Esperienziale


Introduzione alla valutazione on-line

Domande e discussione finale

2 DAYS WORKSHOP PROTOCOL1)Intensive Experiential ACT Workshop for Parents

Prima Giornata

Tempi Titolo Contenuti Modalitﾈ Strutturazione della giornata e tutela delle informazioni personali

Introduzione Lezione interattiva

Somministrazione Psicometrici T0

AAQII, VLQ, SCL90, BDI2, PLOC

Assessment T0


Da ABA a ACT: lo studio dei processi verbali

Supporto scientifico Lezione frontale

Pausa 1h


Centering Exercise Entrare in contatto con il momento presente


Che cosa causa lo stress: il muro delle preoccupazioni

Introduzione e discussione delle esperienze individuali

Lezione interattiva Esercizio esperienziale

Benessere e malessere Introduzione e discussione delle esperienze individuali

Lezione interattiva

Metafora del lavandino (Bond & Hayes 2002)

Consapevolezza del processo che crea sofferenza

Lezione interattiva

Cominciando lￕACT (Bond & Hayes 2002)

Come le emozioni ed i pensieri negativi interferiscono con una vita efficace e godibile

Lezione interattiva

Come ha funzionato? (Bond & Hayes 2002)

Valutazione dellￕefficacia a lungo termine delle strategie per eliminare i pensieri negativi hanno funzionato

Lezione interattiva

Metafora del poligrafo (Hayes, 1999)

Impraticabilitﾈ della modificazione diretta degli eventi interni

Lezione interattiva

Contatto con il momento presente (Hayes, 2007)

Introduzione e discussione Esercizio di mindulness

Metafora delle sabbie mobili


Lezione interattiva

La disponibilit ﾈ(willingness) come strategia alternativa (Bond & Hayes 2002)


Lezione interattiva

Dolore sporco� ￓ e dolor� e pulito � (Hayes & Smith, 2005)

Identificazione degli eventi manipolabili e di quelli non manipolabili direttamente


Semplicemente notare consapevolmente (Bond & Hayes 2002)

Esercitare la disponibilitﾈ Esercizio di mindfulness

Esercizio Non posso camminare

Introduzione alla defusione Esercizio Esperienziale

Direzioni di valore (Bond & Hayes 2002)

introduzione Lezione interattiva

Esercitare la disponibilit ﾈfa� ccia a facciaￓ (Bond &

Hayes 2002)

Esercizio di empowerment a coppie



Il bambino interiore Identificazione dei valori e Esercizio esperienziale

Seconda Giornata

Tempi Titolo Contenuti Modalitﾈ Centering Exercise Entrare in contatto con il

momento presente Esercizio di mindulness

Ripasso per immagini Ripasso dei punti trattati nella giornata precedente

Slide show

Intrappoladita Cinese Praticare strategie di disponibilitﾈ


Esercizio etichette autovalutazione

Praticare defusione Esercizio esperienziale

Quel Posto Dolce (Wilson, 2008)

Introduzione Esercizio esperienziale a coppie

Giusto contro sbagliato (Bond & Hayes 2002)


Lezione interattiva

m� aￓ (Bond & Hayes 2002)



L e�sercizio dell os� servatore (Hayes, 1999)

Aumentare la consapevolezza dei propri processi psicologici



Esercizo: ￒLatte latte �(Hayes, 1999)



Pausa 1h


Porta la tua mente a passeggio (Hayes, 1999)



Esercizio del mostro di latta (Bond & Hayes 2002)


Esercizio Benvenuto Ve cchio Amico


Esercizio VLQII Promuovere direzioni di valore

Autovalutazione ed esercizio esperienziale

Esercizio del contatto oculare

Esercizio a coppie per esercitare la abilitﾈ aquisite


Lasciare la lotta, per raggiungere i nostri obiettivi e i nostri valori (Bond & Hayes 2002)

percorrere nuova strada verso il benessere Agire con impegno (statement pubblico o privato)


Giunto fin qui chi sono? Metafora della schacchiera

Introduzione e discussione sul se come contesto

Discussione interattiva Lezione interattiva

Pratica del se come contesto

Fare esperienza della continuitﾈ di se

Esercizio Esperienziale


Introduzione alla valutazione on-line

Domande e discussione finale

2 DAYS WORKSHOP PROTOCOL

• Blackledge, J.T. & Hayes, S.C. (2006). Using Acceptance and Commitment Training in the Support of Parents of Children Diagnosed with Autism. Child & Family Behavior Therapy, 28(1), 1-18. • Hayes, S. C., Strosahl, K. & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford Press.• Hayes, S. C. & Strosahl, K. D. (2005). A Practical Guide to Acceptance and Commitment Therapy. New York: Springer- Verlag.• Hayes, S. C. & Smith, S. (2005). Get out of your mind and into your

life. Oakland, CA: New Harbinger.• Hayes S.C., Bond W.B., Barnes-Holmes D. & Austin J. (2007). Acceptance and Mindfulness at Work. New York: Haworth Press


SELF REPORT MEASURES

• AAQII (Psychological Flexibility)

• VLQ (Valued Living)

• BDI-2 (Depression)

• SCL-90 (Psychological Symptons)

MEASUREMENT AT BASELINE, T1, T3

02468

101214161820

T0Baseline

T1 T3 *p>0,05

BDI 2

0

10

20

30

40

50

60

70

AAQII T0 T1 T3

s1

s2

s3

s4

s5

s6

s7

s8

s9

s10

s11

0102030405060708090

VLQI VLQC

T0

T1T3


Groups Pre-Sch N 544-6

Sch N 317-11

Adol N 1712-18

Basic Course: 6 session 3 h

1.ASD and interventions2. Play and learning3. Language and communication4. Contexts and generalization5.Challenging behavior and emotional impact6. Autonomy

1.ASD and interventions2. Social Skills and Play3.Comunicazione e linguaggio 4.Contexts and generalization 5. Challenging behavior and emotional impact 6.Autonomy and self determination

1. ASD and community resources2.language and Communication 3.Social skills and social autonomy 4.Affect and sexuality 5.Challenging behavior and emotional impact 6.Adaptation and integration. And the futures?

N 39 N 18 N 14

Advanced Course: 3 sessions 3 h

Challenging behaviors Social skills Affectivity and sexuality

T0 N 160T1 N 102 (3 of 6)T3 N 71 (2 of 3) 2) PT in groups ACT facilitated

Groups Pre-Sch N 544-6

Sch N 317-11

Adol N 1712-18

Basic Course: 6 session 3 h

1.ASD and interventions2. Play and learning3. Language and communication4. Contexts and generalization5.Challenging behavior and emotional impact6. Autonomy

1.ASD and interventions2. Social Skills and Play3.Comunicazione e linguaggio 4.Contexts and generalization 5. Challenging behavior and emotional impact 6.Autonomy and self determination

1. ASD and community resources2.language and Communication 3.Social skills and social autonomy 4.Affect and sexuality 5.Challenging behavior and emotional impact 6.Adaptation and integration. And the futures?

N 39 N 18 N 14

Advanced Course: 3 sessions 3 h

Challenging behaviors Social skills Affectivity and sexuality

T0 N 160T1 N 102 (3 of 6)T3 N 71 (2 of 3) 2) PT in groups ACT facilitated

Example of session 2) PT in groups ACT facilitated

Session 1 3h

- 45' Large Group (30):

Autism (characteristics and interventions), Pairing, Reinforcement and Play

- 15' Break

- 60' Small Group (4-6 split couples): present your child

- 15' Large Group: info on video recording

“if you chose to describe (the difficulties of) your child

to a person you care about”

notice the function of this (defusion)

(noticing listener evoked fn)

Session 2 3h

- Large Group (30):

Language and Communication

- Break

- Small Group (4-6): self video modeling

- Large Group: introducing next session


Session 2 3h

- Large Group (30):

Language and Communication

- Break

- Small Group (4-6): video

- Large Group: introducing next session

Able to track for contingencies (appetititves) in their and their child behavior


SELF-AS-CONTEXTI as distinct from other

(you/he/she/it/they/ someone else/something else etc.)

here as distinct from there now as distinct from then

DEFUSIONI, here, now notice thoughts - and recognise them as nothing more or less than words and pictures

ACCEPTANCEI, here, now notice thoughts and feelings and make peace with them

CONTACTING THE PRESENTI, here, now notice something else (something else = anything that I, here, now can think, feel, see, hear, touch, taste, smell, or do)

COMPASSIONI, here, now notice other beings suffering - and respond with kindness

SELF-COMPASSIONI, here, now notice painful feelings – and respond with kindness

THEORY OF MINDI, here, now imagine what someone else is thinking & feeling etc,

EMPATHYI, here, now feel what someone else is feeling

INNER CHILDI, here, now imagine being kind to my past self, then and there

FUTURE SELFI, here, now imagine my future self, then and there coming back to advise me here and now

TRANSCENDENT/OBSERVING SELFI, here, now am the awareness of everything else. (everything else = body, thoughts, feelings, and the external world)And I, here, now am the same as I, there, then

DEFUSION FROM SELF-AS-CONTENTI, here, now notice thoughts about who I am - and recognise them as nothing more or less than words and pictures


Risultati QSG

9,99,0

11,2

13,5

9,010,4

12,6

9,0

0

2

4

6

8

10

12

14

16

carico fisico senso di inefficacia sostegno sociale carico emotivo

T0 T1

*

Covati, Giuberti, Miselli, Pellegri, Santelli e Gallo, 2012

Fattore CF

0

1

2

3

4

1 2 3 4 5 6 7 8

Pre-test

Post-test

I padri danno, in generale, punteggi significativamente più bassi rispetto alle madri.

(1.85 vs 1.32, p<0.05)

Tra pre- e post- test i punteggi subiscono una generale riduzione.

1,0

1,2

1,4

1,6

1,8

2,0

PRE POST

Carico Fisico


Fattore EF

0

1

2

3

4

1 2 3 4 5 6 7 8

Pre-test

Post-test

1,0

1,2

1,4

1,6

1,8

2,0

PRE POST


(1.15 vs 1.48, p<0.05)

Tra pre- e post- test i punteggi subiscono una generale riduzione (p<0.05).

*

Senso di Inefficacia


Fattore SO

0

1

2

3

4

1 2 3 4 5 6 7 8 9

Pre-test

Post-test

0,0

0,2

0,4

0,6

0,8

1,0

1,2

PRE POST


(0.77 vs 1.2, p<0.05)

Tra pre- e post- test i punteggi non variano significativamente.

Sostegno Sociale


Fattore EM

0

1

2

3

4

1 2 3 4 5 6 7 8 9

Pre-test

Post-test

0,0

0,2

0,4

0,6

0,8

1,0

1,2

PRE POST


(0.73 vs 1.3, p<0.01)

Tra pre- e post- test i punteggi subiscono una generale riduzione.

Carico Emotivo


pre basic post basic pre adv post adv25

30

35

40

45

50

1 ACT PT sch

PT sch

2 ACT PT sc

ACT vs PTQSG score

pre post0

10

20

30

40

50

60

70

80

90

100

AAQ II

PSI

vlq

Psycological FlexibilityN 37

p>0,05 AAQ and VLQ

THANK YOU!

[email protected]

Giovanni Miselli PhDIESCUM, AUSL RE

Documents

ACT and Parent Training for Autsim and PDD: Creating a Context to Move Toward What is Important Giovanni Miselli, PhD IESCUM, ACT-Italia, AUSL RE