Thursday, August 14, 2014

After Autism: Are individuals cured or reaching their potential?

Adelphi University has been working for years to raise awareness of and inspire discussion on autism-related issues on Long Island. Our faculty are internationally known experts in autism, and our events, initiatives, and services all reflect their expertise. The following experts offer their opinions in response to the New York Times Magazine article, ‘After Autism’ byRuth Padawer, August 3, 2014.

Stephen M. Shore., Clinical Assistant Professor of Education, Adelphi University

While it is great to read people with autism are doing well – they have not "beaten autism".  

The individuals mentioned in the article are described as having residual effects of autism – usually in the social areas.  The question is... have these individuals recovered from or eliminated characteristics of autism?  Or have they learned how to work with the strengths that come from being on the autism spectrum?  As a person on the autism spectrum, I believe we would be much better served if the focus remains on what can be done with the characteristics autism gives a person rather than having to deny or defeat it.  

Judith H. Cohen, Ph.D., J.D. Professor of Education, Adelphi University, author of “Succeeding with Autism—Hear My Voice

Responding to the recent NY Times article by Padawer,  the outlook about autism is changing dramatically due to the increase in knowledge about the spectrum disorder.  Documented case reports about individuals ‘recovering’ from autism have become more frequent providing greater hope for many families.  

We now know that individuals do change over time and core deficits can be reduced or modified.   There are still no early indicators in childhood behaviors that reliably predict later functioning.  However there are indicators that are associated with better outcomes: early diagnosis, early intervention, consistent and expert intervention, medication to address symptoms, language ability, desire to change, intelligence, and maturity.
I prefer to use the term ‘managing and succeeding’ with autism rather than recovering from autism.

Two, very high functioning adults that I know had severe and classic autistic attributes in early childhood and the recommendation was that both should have been institutionalized.  Instead, their needs were addressed in early childhood through public education and home support.   Today both are independent adults with professional careers and both are still on the autism spectrum. Have they ‘recovered’ or have they learned to manage their areas of deficits and modified aspects of behavior?

Pat Schissel, LMSW , Executive Director, Asperger Syndrome and High Functioning Autism Association(AHA)

These kids are not "beating" autism. Simply put they do not meet the diagnostic criteria at this point. So what.

So what indeed! They still have social issues. They have highly focused interests. They have the past experiences of ASD (bullying and poor self-esteem). Most likely, in my experience, they will need to be supported and encouraged to embrace who they are. Not who the diagnostician in their narrow frame sees. They can do well going forward - as adults when this is acknowledged. I am not a big believer in denial.

Mitch Nagler, MA ’06 Director of the Bridges to Adelphi Program for students on the Autism Spectrum or those who struggle with Social Anxiety or other non-verbal learning disorders

By saying someone is cured of Autism is misleading in my opinion. Two people can present the same at the age of diagnosis [as referenced in the New York Times article], they can be given the same therapies and services, but faced with different individual variables their reaction is bound to be different.

Autism is a developmental disorder, so it makes sense to me​ that as people​ mature, they grows into themselves at a different paces compared to others. As they develop, I have seen many students that have less characteristics of the disorder than when they started in the Bridges to Adelphi Program. We just never know how much someone will progress, or when it will happen. Our approach in the Bridges Program is to support each student’s strengths, with that comes a building of self-esteem and lesser attention on their weaknesses.

Wednesday, August 13, 2014

Endorsing abstinence to treat substance abuse addicts

In a striking example of polar viewpoints, 61% of 100 mental health professionals (psychiatrists, psychologists and social workers) in a national  survey conducted by Wakefield Research on behalf of Adelphi University Center for Health Innovation, endorsed the goal of abstinence in contrast to that of harm reduction for their substance dependent patients.   These very same clinicians believed that the opposite view held true for their patients; namely 61% of their patients would support a treatment goal of harm reduction as opposed to abstinence.  Within this schism lie perhaps the keys to understanding some of the more telling secondary findings of this study: 1) Outpatient treatment programs often fail and 2) a vast majority of mental health professionals (67%) prefer to recommend new approaches including cognitive behavioral therapy, motivational interviewing, self management tools such as SMART recovery (with its roots in CBT), and contingency management reinforcement (with its roots in heightening motivation for change) as opposed to traditional 12-step interventions.

One does not need to go further then to understand that the perception of treatment failure might be closely linked to the disagreement between the mental health professional and their patient with respect to desired treatment outcome.  This would be true for any helper-helpee relationship in which there was a lack of consensus with respect to course of treatment. In fact, our survey revealed that only 28% of mental health professionals think traditional outpatient programs are effective for a majority of their patients.  Often, these programs are driven by abstinence-based mission statements upon which utilization reviews of treatment outcome and funding sources (insurance included) are predicated.

Patients seeking treatment on an outpatient basis, particularly within younger populations such as adolescents and young adults, where the line between abuse and addictive disorder is less delineated, may not be seeking abstinence as an initial goal of treatment. Perhaps their drugs of abuse are alcohol and/or marijuana and they would like to begin an exploration of harm reduction.  In fact, they may not even be motivated for treatment at all, let alone seeking abstinence, instead having arrived at the doors of outpatient treatment through the leverage of others, courts, schools or parents. Naturally, treatment as measured by abstinence goals will fail, although if measured by reduction in use, or decrease in risk-taking behaviors, may be seen as successful outcomes. Implicit in the survey findings is the curious contradiction of these very same professionals to overwhelmingly “prefer” (67%) and be “open to” (93%) using newer approaches that often “begin where the patient is” (this does suggest tolerance of harm reduction) as opposed to traditional approaches such as that of the 12-Steps that foster spiritual surrender to goals of abstinence as the basis of recovery.

In the case where drug use shifts to that of opiates, methamphetamine, cocaine, alcohol dependence, or  when addictive disorder becomes life threatening, or marked by repeated failed attempts to curtail use,  then abstinence goals are certainly more appropriate. Our survey results reveal that 63% of mental health professionals think a person who has been treated for substance dependence cannot use that substance again responsibly.  Perhaps their patients might ultimately come to share this point of view.

Written by Audrey Freshman, PhD, LCSW. CASAC
Adelphi University School of Social Work
Director of Continuing Education and Professional Development
Director of Postgraduate Certificate Program in Addiction

Tuesday, August 5, 2014

Abstinence vs. Harm Reduction - What works for addicts?

It’s interesting to speculate about the Center for Health Innovation Poll result that a large majority of mental health professionals endorse the treatment goal of abstinence over harm reduction.   It is often the case that those addicts who end up seeking professional help are a particularly distressed and difficult to treat group.  How do we know that?  Ann Fletcher who wrote “Sober for Good,” learned from speaking with addicts themselves, that as many as 50% find their way to abstinence on their own, without ever seeking professional help, and without ever attending a 12-step program.   We also know that a small number of alcoholics can actually drink on occasion without lapsing into more problematic use.  This suggests that professionals in our survey may be reporting on their experiences with addicts who have not been able to help themselves, whose behavior is already more engrained and resistant to the tools and approaches at the disposal of our professionals, when compared with addicts who manage to get sober on their own.  Hence, the professionals surveyed might advocate a tougher and more demanding abstinence approach with the people they treat.

It’s also likely that when asked to choose between treatment goals of abstinence versus harm reduction, professionals in our survey understandably report the more conservative and consensually endorsed one, abstinence.  But in practice, the dichotomy may be somewhat misleading.  Many professionals will begin, quite correctly, where their patient is at, so to speak, working initially with an addict’s stated preference for harm reduction, knowing that, to abrogate a patient’s treatment goal right off the bat, can be a recipe for failure.  And for many addicts with years of use and a lifestyle to go with it, abstinence is an unfathomable leap.  Harm reduction offers a way forward, but one that is stepwise, and for many subjectively more manageable.  As a result, our wise and experienced professional might say, in effect, “Let’s try harm reduction and see how far we get.  If this approach to moderation of your substance use works, then great.  If not, we’ll reassess and go from there.”

The survey also provides hints about some very important principles in working with addictions.  For one, recovery should address an array of often co-occurring and related problems, some of which are as important in addictive disorders as the substance use itself.  Many addicts may have psychological problems underlying the addiction, including major depression, bi-polar disorder, anxiety, eating and personality disorders (lifelong maladaptive behavior patterns that interfere with work and relationships).  If these co-occurring problems are not addressed, then detox and short term outpatient treatment, no matter how intensive, may afford the patient only temporary relief from the addictive pattern.  That may be why, in their estimation, professionals feel that medical insurance to support treatment of addictions is less than adequate; the range of associated problems that may underlie the addictive disorder requires extensive rehabilitative resources.   For an addict to remain well, he/she will often need not only to stop using drugs, but also to forge a new life that offers a compelling alternative to drugs and requires resources that may never have been available before the addictive cycle dominated their lives.

And on this last point, the involvement of family and friends is critical.  An approach gaining in popularity, CRAFT (community reinforcement approach and family training), helps people learn to reduce the power of their addictions, and also equips family and friends with supportive techniques to encourage loved ones to begin and continue treatment.   The approach also implicitly acknowledges that just as one addict can negatively affect the lives of so many others, so may others positively affect the life of the addict.

Written by
Jonathan Jackson, Ph.D.
Director, Center for Psychological Services
Derner Institute
Adelphi University

Tuesday, July 29, 2014

CHI takes on the topic of substance addiction and treatment trends

Adelphi University’s Center for Health Innovation continues to tackle some of the toughest issues of today. In 2012, 1.2 million people age 12 and older on Long Island and our immediate surrounding area were classified as living with a substance use disorder according to the Substance Abuse Mental Health Services Administrations, National Survey on Drug Use and Health. For this reason, gaining insight into how mental health professionals understand and treat addiction is a critical health need for our community and the nation.

On July 29, Adelphi’s Center for Health Innovation (CHI) released the results of a poll on addiction and treatment trends. Adelphi has a long standing interest in how we can assist local communities in dealing with substance abuse and mental health. We were the first institute of higher education in New York State designated as a disposal site for National Take-Back Drug Day, a day designed to provide a responsible means of disposing of prescription drugs, while also providing education to the public about potential for the abuse of medication. Through such efforts Adelphi University is taking an active and leading role in bringing together communities and providing data about an often stigmatized, deliberating condition effecting patients, families and communities.

Utilizing the knowledge and expertise from faculty, students and alumni, CHI seeks to find innovative ways of creating a culture of health by providing insight and data focused on both our communities; our most pressing needs and our greatest strengths. CHI’s research and practice is focused on strengthening what works well in communities on a daily basis and addressing social, educational, physical, emotional and economic health. CHI’s mission is to provide a foundation for creating community partnerships and leadership—with the goal of meeting current and emergent healthcare needs. We seek to ask and answer questions that help us understand how we can contribute to a culture of health in our communities and across the nation, we hope this type of commitment to our families and communities can help move the conversation forward and find solutions.

Written by
Elizabeth Cohn, Ph.D., RN, Director
Center for Health Innovation
Adelphi University

Monday, July 28, 2014

Caring for children 0-3, what's a working family to do?

President Obama’s recent White House Summit on Working Families raises awareness of the fundamental inadequacy of U.S. child care policy.  However, the President needs to do more to ensure that the federal government develops and funds universal policies to address U.S. child care needs.   The most recent regulations from the Department of Health and Human Services which are designed to improve the quality of child care in agencies receiving federal dollars will, in the absence of greater resources, do little to address the needs of many of the families they are supposed to help.

Parents across the economic spectrum have trouble finding safe, affordable, stimulating child care that is provided during their work hours.   Most parents, be they single or two parent families,  are working and struggle with family care, particularly, child care.  Sixty one percent of women with children younger than three are in the paid workforce.  The average child spends approximately 27 hours a week in child care in the first 4 ½ years of his or her life.  Approximately half of all children under 3 spend at least 25 hours a week in care with someone other than their parents.  The President noted, paid leave and flexible work conditions can help parents to care for their children but history has shown us that corporate America will not provide these benefits to many workers, particularly non-professional workers, without the inducement of law.

At present, we have a patchwork of public child care policies, providing subsidies for only a minority of those who technically qualify for them and some limited tax benefits.  By addressing this as a universal problem, President Obama is taking a huge step in re-framing the public discourse around child care policy which, since Nixon’s 1971 veto of the Child Care Development Act, has been largely limited to providing more extensive funding for existing poverty based programs. 

Investing in early education reaps huge economic benefits to society, more than those designed for school age children, by reducing the likelihood that these children will be involved in the justice system or be involved with other social benefits programs.  There is currently limited state and federal funding for early childhood education leaving many of those who are supposedly eligible without actual benefits.  In addition, much "high quality" care is not available during the hours that are needed by parents who do shift work or work non-traditional hours.  Kindergarten and universal pre-K are often limited to half day programs which, though they may meet some children’s educational needs, do not address the care needs that their working parents have.

Policies addressing early childhood education have historically been separated from child care policies designed to meet the needs of working parents and parental leave has not been viewed as child care policy, despite the fact that parents who can take leave need not hire someone else to care for their children.   Given the number of working parents who need 8-10 hours of care for their children each day, the separation between policies designed to meet early education and care needs is no longer viable.  Both the needs of working parents and the educational needs of their children have a lasting impact on our society. 

I commend President Obama and his Summit on Working Families for re-framing child care from an isolated policy issue designed only to address the needs of the working poor to a broader universal issue that affects all working Americans and one that is intimately linked with paid leave, flexible work and early education.  We need to do more than say that this is a problem.  First, we need to develop universal policies to educate in-home caregivers so that they can improve the quality of care they provide.  We also need to develop a universal system of center and home based care that models what is already available in much of the industrialized world and use tax dollars to fund it.  Finally, we need paid parental leave and sick leave for all workers, not only those with high status professional jobs. Caring for our children well will provide the US with more than simply economic benefits; it is simply the right thing to do.

Submitted by Elizabeth Palley, an associate professor of social work at Adelphi University, is the author of In Our Hands: The Struggle for US Child Care Policy.

Wednesday, June 11, 2014

Aging Family Members and Hidden Mental Health Issues

Associate Professor of Social Work Richard Francoeur first became interested in hidden mental health issues early in his career, as a medical social worker at a Veteran’s Administration hospital in Pennsylvania. He went on to compare the financial strain-related coping processes of patients over 65 who were undergoing outpatient palliative radiation for cancer with those of younger patients undergoing similar treatment.

Dr. Francoeur’s study revealed that older patients were more concerned about not having enough resources for the future, while younger patients were more concerned with difficulty meeting their current obligations. “Most screening for financial vulnerability and stress focus on present issues [like] paying bills,” says Dr. Francoeur, “so clinicians can miss older patients who are struggling, but who frame the issue differently.”

Similarly, in research with epidemiological data from an inner-city outpatient population receiving palliative care, Dr. Francoeur has found that screens for depression often miss older minority men. “Older adults are less likely to say that they feel sad, and yet they very much may be depressed even though they don’t use those kinds of terms,” Dr. Francoeur explains.

As an outgrowth of his work on hidden mental health issues, Dr. Francoeur’s research has more recently turned to symptom clusters. In his latest study, the experience of pain predicts depressive affect more strongly when pain occurred with fatigue and weakness or with sleeping difficulties, but only in patients reporting fever. When pain and either of these symptoms manifest together, interventions to relieve fever could reduce pain sensitivity and sickness malaise, which are concerns to multidisciplinary healthcare teams and smoking cessation programs.

Dr. Francoeur’s recent work has also focused on methodological advancement, in particular statistical innovations in moderated regression that make detecting and analyzing symptom clusters easier. Using his new methods, he plans next to look at symptom clusters in nonmalignant conditions that are related to the abuse of prescription drugs.

This piece appeared in the Erudition 2013 edition.

Thursday, May 29, 2014

Substance Abuse, Internet Abuse and Family Intervention

Errol Rodriguez, Ph.D., Gordon F. Derner Institute of Advanced Psychological Studies assistant dean and director of the master’s program in general psychology and mental health counseling, has spent much of the last decade studying families who have been affected by addiction. “Somewhere between four and five significant others are affected by one person’s addiction,” explains Dr. Rodriguez. “We know that somewhere around 23 million people are substance abusers annually, so that’s about one-third of the country each year that’s affected.”

One way Dr. Rodriguez hopes to reach more of the people affected by substance abuse is through Community Reinforcement and Family Training (CRAFT) interventions. Rather than the traditional model of intervention, which involves a surprise confrontation with the addict, the CRAFT model is a strategically planned intervention where family members first discuss their role in enabling abuse and then determine what they can do so the using person begins to feel the consequences of his or her substance abuse.

“It’s a powerful behavioral therapy approach,” Dr. Rodriguez says. “With over 80 percent of the people who begin the CRAFT model, their significant other enters treatment.”

“That doesn’t mean they stop using,” Dr. Rodriguez clarifies, “but family members often feel a great sense of relief knowing that their loved one has started to get help.”

Dr. Rodriguez’s most recent research focuses on a new type of abuse: Internet addiction, particularly among adolescents.

“Some young adults are really glued to their phones, to the Internet, in a way that becomes problematic for their lives and their families,” Dr. Rodriguez says. “It’s different from other teenagers who enjoy their phones but don’t seem obsessed with them.”

Dr. Rodriguez is examining vulnerabilities to this type of compulsivity. “Is it similar to other addictions, like alcohol or marijuana?” Dr. Rodriguez wonders. “Are some of the same markers that put teens at risk for other behaviors, things like low self-esteem and eagerness to fit in, involved in compulsive Internet use?” In the coming year, he’ll begin to find out.

This piece appeared in the Erudition 2013 edition.