Assessment of a Child with Mood, Anxiety, and Aggressive Behaviors

Adam is an 8-year-old referred primarily for tantrum behaviors and aggression. He was assessed using the Wechsler Intelligence Scales for Children, 4th Edition (WISC-IV), Clinical Evaluation of Language Fundamentals, 4th Edition (CELF-4), Vineland Adaptive Behavior Scale—Parent/Caregiver Rating Form (VABS-II), Test of Variables of Attention (TOVA), Sensory Profile, Behavior Assessment Scales for Children, 2nd Edition (BASC-II), Parent and Teacher Reports, Social Communication Questionnaire (SCQ), Autism Diagnostic Observation Schedule, Module 3 (ADOS) Children’s Depression Inventory, 2nd Edition (CDI 2), Revised Children’s Manifest Anxiety Scale, 2nd Edition (RCMAS-II), Sentence Completion for Children (Table 12.1).

Adam’s parents reported that he was noncompliant toward directions, had mood swings and frequent violent tantrums, and had excessive fears of thunderstorms and flushing toilets. He was reportedly aggressive toward his parent and siblings. Modifications were required to complete testing, such as sitting on the floor, receiving back scratches and back-rubs as a reward, eating small snacks, and having frequent breaks. Adam frequently cried and screamed and often asked his parents or the examiners to help him lower his hand from his face. This behavior seemed to be related to context and appeared to occur more frequently during questions that either were challenging or were emotional in nature. School and home observations indicated this behavior to be consistent across environments. Adam presented with impaired social interaction and social communication as well as a restricted interest in the planets. Everything in his room and all books he read were related to outer space.

His profile was found to be consistent with a diagnosis of an Autism Spectrum Disorder with significant problem behaviors and Generalized Anxiety. Adam was diagnosed with ASD and an anxiety disorder and then referred for behavioral therapy at Emerge, psychotherapy, and services in his school. His school was unable to provide the appropriate services, and he eventually received an out-of-district placement at a school specializing in the treatment of ASD. Adam received significant school and home-based treatment. Adam’s violent behaviors have been reduced significantly; he demonstrates better compliance with requests, has less anxiety, and his family reports a significant improvement in quality of life.

Research indicates that mood and anxiety disorders are commonly prevalent comorbid psychological diagnoses among those with ASD (Trammell, Wilczynski, Dale, & McIntosh, 2013); further, outcomes research indicates that individuals with such comorbidities struggle more to achieve positive outcomes than those with ASD alone. Measures used to assess psychopathology like the MMPI-2, Beck Depression Inventory, and other valid measures often do not include individuals with ASDs in the standardization sample resulting in poor discriminant and predictive validity (Trammell et al., 2013). Trammell et al. (2013) describe that the lack of instruments intended to assess mood and anxiety in individuals with ASD poses a challenge for clinicians. Individuals with ASDs often lack insight into their emotions and/or internal thought processes. These challenges may be considered associated with theory of mind and related to thinking about one’s own thoughts and feelings. Individuals with ASD tend to use more dichotomous adjectives like “always” or “never” to describe thought processes.

As has been shown throughout this book, it may be the case that emotional concerns are discovered during the initial consult or in administration of measures in the Core Areas (cognitive, language, social, and sensory). In this case, clinicians should look more closely at the Associated Area of Emotions/Mood in order to be comprehensive. Self-report measures must be used and interpreted with caution in this population (Deprey & Ozonoff, 2009). Even with those cautions considered, self-report measures provide helpful data for any diagnostic assessment. Self-report instruments that might be utilized to assess emotions include the BAI, BASC-2 self-report, BDI, CDI, MMPI-2, and RCMAS. These are just a few among many self-report measures available. The RCMAS contains a scale to assess an individual’s response to dichotomous items like “I like everyone I meet.” and “I never tell a lie.” Often children with ASD have very elevated scores on this scale and lower self-reported symptoms of anxiety. Patterns of absolute thinking cause elevation on this defensiveness scale. While these measures, including the RCMAS , must be interpreted with caution, this pattern of elevated defensiveness may be an area for clinical attention. What is termed by Helena Huckabee, Ph.D. as a “frozen profile” may also be of clinical consideration. A frozen profile refers to a self-report profile of symptoms that is flat in nature and consistently much lower than the 50th percentile across a mood and anxiety scales. Generally, everyone experiences symptoms of worry or sadness at some point. Scores that are too low indicate either defensiveness or a limited ability to interpret one’s own emotions.

Some individuals with ASD have difficulty offering perspective on how they generally feel, but they can provide information in the moment in response to what is currently happening in the environment. This could lead to a frozen profile as the individual feels “fine right now” and cannot reflect on past instances. A scale with extreme elevation may indicate that an individual is in emotional pain right now and so he or she is unable to reflect on times that things went well. Comparing self-report scales to parent and teacher scales can be helpful because it is noteworthy if other reporters see huge emotional and behavioral challenges while the individual reports nothing or vice versa. If parents and teachers paint a rosy picture but the individual reports elevated symptoms, it is likely that there are symptoms there in need of treatment; but it may also be that the individual is reporting elevation based on something happening presently. For example, often children with ASD are teased. If a child is reporting to the evaluator his history of being teased and bullied, and then completes a self-report scale, he might rate his emotions as elevated. If the same child has just finished reporting about a new module on Minecraft, he may rate a different emotional profile. This phenomenon is also likely related to local versus global processing of information, also known as, Central-Coherence theory.

Researchers looked at the association between ASD, anxiety, and a construct called Alexithymia or challenges identifying one’s own emotions. They found that anxiety and Alexithymia are related to ASD as individuals have challenges identifying feelings. Research indicates that 40–50 % of individuals with ASDs have significant anxiety. Early face and emotion processing is delayed in ASD, but it does improve over time (Burner et al., 2014). Many individuals with autism have a breakdown in understanding the causes of the emotions they experience. These individuals better report physiological symptoms and specific phobias responding to a checklist of concrete fears instead of reporting worry or feelings independently. Researchers note that it can be counterintuitive to ask individuals who have difficulty identifying and speaking about their own emotions to do so (Gaigg, Bird, & Bowler, 2014). Indeed, these authors find that certain instruments, particularly projective tests (like the Roberts-II and the TAT) may not be practical to administer for individuals with severe difficulties identifying their own emotions. However, when there is some degree of emotional understanding present, certain self-report emotional measures can provide useful data.