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Autism and Managing AnxietyLorna FitzpatrickCentre for Autism

Theory and Practice

1. Theory – why do children and young people

with autism experience high levels of anxiety?

2. Emotional Regulation

3. ‘On the spot’ strategies

4. Long term management strategies

Starting Point

•Daily challenges Need for routineUnexpected changesSocial demandsDifficulties with communication

• Exposure to anxiety provoking situations

• Tension

Social Difficulties

•Not understanding information the same way as

others – difficulties with context

•Building on poorly understood information

•Not socially motivated e.g. social reinforcement not

always effective or even recognised

• Perceived lack of common sense

•Naivety in relationships e.g. Bullies are now ‘best

friends’

Anxiety Build Up / Warning Signs

Trigger

Anxiety

Increased preoccupations

Fight / Flight

Trigger

•An event e.g. Something unexpected / a change in routine

•Poorly managed transition

• Life stage e.g. Adolescence

•Unknown / highly personal

•Sensory issue

•Special interest

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Anxiety

•Development or elaboration of mannerisms

• Increase in repetitive behaviours

•Physical symptoms

• Increased sensory sensitivity

•Raised voice

•Aggression / irritability

•May present differently in passive children and also in girls who can present as more passive –may not see an observable build up

Increasing Anxiety

• Loss of attention and focus

•Building temper – anger outbursts ‘short fuse’

• Increased fear, hyper-arousal

•Extreme avoidance of people/places/situations

•Removing clothing

Fight or Flight

•Anger and aggression outburst

•Self harming behaviours

•Regression

•Absconding

•Physiological reactions to anxiety e.g. Incontinence

What Do We See?

• Additional levels of withdrawal

• Loud and disruptive actions

• Self harming behaviours

• Verbally challenging behaviours ‘button pressing’

• Anti-social acts e.g. stripping off

• Self stimulating behaviours

• Avoidance

• Absconding

• Refusal

On The Spot

1. Identify and remove trigger

2. Manage sensory input (will be addressed)

3. Relaxation techniques

4. Redirect

5. Negotiated time-out

Sensory Processing and autism

‘...certain sounds frightened me- dogs barking,mopeds, tractors and cars, engines of variouskinds. They would explode inside me and makeme lose all sense of the way my body related tomy surroundings. It was like being flung out intospace- whoosh- quite without warning.Sometimes I screamed and covered myears....some sounds around me I hardly reacted toat all...’ (Gerland G, 1999)

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Sensory Processing and autism

• ‘one thing I don’t like is crowds. For example, Ijust hated the classroom. The noise annoyedme. At the time, the sound of children’schatter was like dynamite going off in my ears’.(Hall K, 1988)

•Temple Grandin•Reported anxiety in response to sensory stimuli•Discovered that she felt calmed with deep pressure

input• ‘Hug machine’

Sensory Processing

•Most children and young people with autism haveunusual perceptions of sensory input

•Some individuals have difficulty in filtering sensorystimuli

•Their brains are overloaded with sensory input,placing them in a state of over-arousal and stress

•Some may also have specific sensory dislikes e.g.noise of a baby crying, light touch, the smell offood

Responses to Sensory Input

•Anxiety escalates in sensory-rich environments e.g. a noisy supermarket, playground, classroom

•Anxiety is also triggered when they receive specific input which they dislike e.g. a child crying, light touch, smells

•Responses include

• ‘Fight or flight’- (hits out or escapes from situation)

• Child appears to be distractible and ‘on edge’

• Emotional outbursts

Strategies

• ‘Stress Kit’

•Manage sensory environment e.g. noise,

temperature, lighting

•Deep pressure techniques and strategies

• Learn to identify sensory related behaviours e.g.

sensory training

Sensory ToysEar Phones/MP3

Communicating Anxiety Stress Kit

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Time-Out

•Use an individualised system to communicate growing anxiety e.g. traffic lights, volcano, kettle,

thermometer (linked to emotional literacy)

•Have access to a time out space – relaxation room,

quiet space

•Access to special interest if the child has one

•Negotiate access when the child is calm

Strategies: Relaxation

•Create a consistent quiet relaxation space

•Gentle lighting

•Calming music•Social story

•Sensory toys for reducing stress

•Special interests•Space to lie down and relax

•Relaxation routines •Repetitive calming tasks

Calming Social Story

When I am angry or upset there are three things I can try

Think before I do anything

Take time to relax and calm myself down

I can close my eyes and think of something nice like a bubbles or a strawberry

I can take a deep breath like I’m smelling a strawberry

I can breath out like I am blowing out bubbles

I can do this three times

This will help me feel calm

Then I can move away and think of something I like

“Take Ten”

• Emotional stress – anxiety, stress, anger cause changes in our heart rate

•An irregular, spiky beat is known as an ‘incoherent’ heart rhythm

•A regular balanced beat is known as a ‘coherent’ heart rhythm

• “Take Ten” aims to promote coherent i.e. steady and slow heart rhythms using visualisation, positive thinking and games

Relaxation and Guided Imagery

•Go to your relaxing place and use your relaxation

rhyme

• Look at the picture of your relaxing place

•Do your breathing exercises

•Feel your body relax

Relaxation Games

•The Gorilla Game

•The conveyer belt

•Washing day

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What is Emotional Regulation?

The ability to self monitor physiological arousal and emotional states

Emotional regulation is a life-long developmental process underlying

attention and social engagement, and is essential for optimal social, emotional and communication development and

the development of relationships for all children and adults

Emotional regulation may also be considered from

the perspective of changes that occur over shortperiods of time, even from moment to moment.When one is well-regulated emotionally, he or she is most available for learning and engaging.

In contrast, when one is emotionally dysregulated, he or she is less available for

learning and engaging.

Both positive and negative emotional states may vary along a continuum, as one may be mildly anxious or experience extreme panic attacks, or may be mildly content or giddy/ecstatic. Common terminology referring to extreme negative states includes “meltdown”, “out of control” or “shutdown”.

Potential Signs of Emotional Dysregulation

• Mouthing or chewing on objects or fingers.

• Holding or hording familiar and comforting.

• Toe walking and rocking.

• Hand flapping.

• Humming.

• Removing oneself from a stressful situation.

• Preoccupation with specific topics/areas of interest.

• Adherence to rigidly rules.

“To me, the outside world is a totally incomprehensible mayhem which

terrifies me.”Ros Blackburn, 2005

“My primary emotion is and has always been fear.”

• Temple Grandin, 2006

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Emotional RegulationCritical Capabilities in Typical Development

Self Regulation

The ability to independently attain

an optimal level of arousal.

Mutual RegulationThe ability to solicit

and secure assistance from

others in regulating one’s arousal

Long Term Management Strategies

• Increasing amount of research indicates that

cognitive approaches are useful in helping children

with autism manage their anxiety

•Cognitive strategies are those that change the

things that we believe about ourselves, how we

think and make the connections between how we,

think, feel and act

Why is emotional expression difficult for children with Autism?

• They may not have had as many positive emotional experiences as typically developing children

• They often don’t perceive others as a source of help, social engagement or emotional assistance

• They often feel vulnerable and stressed

• They become disinterested in people and show decreased initiations particularly for social functions.

What can we do to foster more conventional emotional expression(Prizant et al, 2006)?

• Tune into to the child’s emotion

• Model emotional expressions appropriate to the child’s developmental level (from gestures, to early word combinations to sentences)

• Use visual supports to remind children how to express emotion and to provide choices of coping strategies and to enhance regulation

Context and Social-Emotional Competence

The biggest problem in autism is not a lack of skills, rather, it is knowing when, where, when not and

where not to do something.

This requires context sensitivity.

(Peter Vermeulen, 2012)

Teaching About Emotions

•Do not use decontextualised materials.

•Start from context.

• Link facial expressions and emotions always to context.

Peter Vermeulen (2012)

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Teaching Emotions

Angry

Punchbag

Angry

Home

Punchbag

Tell mum

SchoolAsk for

quiet time

What are Cognitive Strategies?

There is neither good nor bad but thinking makes it so

Hamlet Act II Scene II

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Affective Education

•Teaching children what it feels like to be AngryStressedUnhappy

•The reason why we feel these ways e.g. fight or flight

What Feelings do I have?

• Learning to identify feelings is important as it will help you control them.

• Three of the most common unpleasant feelings that people have are:

• Stress• Unhappiness • Anger

Resources

•Podcast websites:• Inner Health Studio•Mental Health Foundation •101 Relaxation Games for Kids Allison Bartl

Stress

• What does Stress feel like?

• Feeling sick• Red face• ‘butterflies’?• Shortness of breath• Want to run away• Faint

Stress

What happens when I feel stressed?

What does my face look like when I am stressed?

How much of the time do I feel stress?

1 2 3 4 5 6 7 8 9 10

How does my mum look when she is stressed?

How does my dad look when he is stressed?

Unhappy

•Tearful

•Not being able to sleep

•Feeling very tired

• Can’t think straight

• Losing interest in things that you are usually interested in

•Not wanting to go out

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Anger

•Shouting and yelling

•Using bad words

•Throwing things

•Breaking things

•Hitting, kicking fighting

•Wanting to hurt yourself

Practice Identifying Emotions

•Emotions Bingo!

•Facial recognitions

•Modelling

•Role play

Over to You

• Describe happy

• Describe irritated

• Describe relaxed / calm

• What ways could you illustrate these to a child? Angry pictures?

Sports, cartoons?

Knowing what it feels like

1. Recognise the feeling

2. Name the feeling

3. How strong is the feeling

4. Have a strategy for dealing with the feeling other than throwing a chair or running away

5. Range of strategies for a range of feelings

6. Associate feelings with places/behaviours/being a detective!

Thinking Errors

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Thinking Errors Thinking Errors

Thinking Errors Thinking Errors

Thinking Errors

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Emotional Toolkit

• CBT designed for children and

young people with autism

• Designing a tool-box to “fix the

feeling”

Emotional Toolbox: Physical Tools

•Think of some physical tools that can help you feel less anxious

•Think of some relaxing tools that can help you feel

less anxious

•Discuss with the person beside you

•Can you borrow any of their tools?

•How might you do this work with a child?

Emotional Tools: Social Tools

•What are the social tools that you might use in

your tool box?

•Discuss with the person beside you

•How might you use these with a child?

Emotional Tool Box: Thinking Tools

•What kind of thoughts could you have to help you

cope better with anxiety?

•Make a list of antidotes to poisonous thoughts

•How might you encourage a child to use thinking

tools?

Destructive Tools

•What would be classified as a destructive tool?

•What tools would you take out of the tool kit?

•How would you do this?

•How would you do this with a child?

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Bibliography

The Pictures and charts in this presentation were

taken from:

• Stallard, P. (2002) Think Good Feel Good: A Cognitive

Behaviour Workbook for Children. Wiley-Blackwell.

An autism Specific Book

• Attwood, T. (2004). Exploring Feelings: Cognitive Behaviour

Therapy to Manage Anxiety. Future Horizons.