Helping Less Verbal Youth with ASD Manage Strong Emotions

Learning Objectives:

Participants will recognize how the biological features of ASD make coping (or self-regulation) very challenging, especially when a person doesn’t have easy access to language.
Participants will increase awareness of the behavioral signs of escalating anxiety in youth with ASD.
Participants will learn about a variety of strategies and resources that can be used to assist a youth with ASD who doesn’t use language readily to cope more effectively in real-life settings.

I. Development of Self-Regulation (Good Coping)

1. A healthy nervous system is well-integrated, leading to a coherent experience of physical perceptions, cognitions, and emotions.

2. Fears, anxieties and worries impact our bodies, our thoughts and our actions.

3. The ability to maintain psychological “balance” in the face of physical challenges, distressing thoughts and strong feelings is called “Self-regulation”.

4. Self-regulation is the result of a person’s reactivity (or strength of response to stimuli) and how well it is modulated by their attentional skills (or what some theorists call “effortful control”).

5. Self-regulation skills are usually learned through social learning, which is facilitated by: facial recognition, emotional contagion, joint attention, imitation, play, exploration of novelty, theory of mind/perspective-taking, attention monitoring, and cognitive flexibility.

II. How Is This Relevant For Understanding People With Autism?

1. Autism spectrum disorders are now thought to be “disconnectedness syndromes” — or conditions marked by inefficient integration or connectivity of the nervous system

2. Each individual experiences varying degrees of connectedness across different brain areas, which helps to explain how people with ASD can be so very different from one another while still sharing a common behavioral profile of social, communication and exploratory behaviors.

3. Without a well-integrated nervous system, a person with ASD has a difficult time integrating physical perceptions, cognitions and emotions, often resulting in chaotic or confusing behaviors. It is possible that a person with ASD is biologically primed to be at risk for self-regulation difficulties.

4. Compounding this biological propensity: each individual with ASD also shows varying degrees of openness to social learning. A person’s ability to self-regulate depends, in part, on a person’s profile of social learning skills (e.g., facial recognition, emotional contagion, joint attention, executive function, etc.) — all developmental capacities that tend to be impaired in persons with ASD of various functioning levels.

III. How Can We Help a Person Develop Better Self-Regulation Skills?

1. We need to conduct an assessment, so that we can learn about

a. the Individual — how does this particular person experiences bodily sensations, link those sensations to thoughts and feelings, and then link those thoughts and feelings to specific behavioral responses? How does this person communicate about those experiences?

b. the family — How has the family handled these “disconnects” in the past? What is the family’s learning history with regard to these challenges? How do different family members think about these self-regulation problems?

c. the school team — How have school teams handled these “disconnects” in the past? What is the school team’s learning history with regard to these challenges? How do different members of the school team think about these self-regulation problems?

2. We pick and choose strategies from different interventions, depending upon the person’s profile. We may choose from:

Strategies designed to promote awareness and tolerance of physical sensations; provide appropriate physical outlets for challenging feelings:SEE Body Work
Techniques focused on improving openness to social learning by enhancing core social relatedness, social communication and executive functioning:SEESocial Learning
Interventions designed to promote helpful thoughts/reduce negative self-talk: SEE Thinking
Supports to promote calm behavior in stressful situations:SEE Positive Behavioral Supports

We will discuss each of these intervention approaches, in the hopes that you can consider an appropriate integration of the strategies to best fit the needs of your child/student/family member.

IV. Body Work

Strategies designed to promote awareness and tolerance of physical sensations; provide appropriate physical outlets for challenging feelings

Exercise. Given that many persons with ASD have a limited set of interests, and may be more likely to self-select passive activities, such as playing video games or watching movies (Nally, Houlton & Ralph, 2000), intervention may be necessary to support the person to engage in additional leisure activities that require physical effort. Helping to broaden a person’s leisure interests and activities is important for developing a flexible repertoire of self-calming and intrinsically motivating activities, which may stimulate pleasure, decrease arousal, and provide the opportunity to respond in an adaptive manner to regulatory challenges (Hawkins, 1982). Positive outcomes reported in studies of the impact of physical exercise on child behaviors include improvements in social engagement (Orsmond, Krauss, & Seltzer, 2004; Pan, 2010), decrease in repetitive behaviors (Sigafoos et al, 2009), increase in academic engagement (Nicholson, 2008), and improvements in endurance (Pitetti, Rendoff, Grover, & Beets, 2007).

Aerobic exercise has been shown to improve the efficiency of the prefrontal cortex – which is the part of the brain primarily involved in planning, shifting attention, and generating new solutions to problems (Hillman, Erickson & Kramer, 2008)

Martial arts and “exercise with character education” have been shown to improve inhibition, motor planning, initiation and self-calming in school-aged children with behavioral and learning disabilities in several studies (see Diamond & Lee, 2011).

Expand leisure interests & provide predictable, non-contingent opportunities to do favorite activities. Helping to broaden a person’s leisure interests and activities is important for developing a flexible repertoire of self-calming and intrinsically motivating activities, which may stimulate pleasure, decrease arousal, and provide the opportunity to respond in an adaptive manner to regulatory challenges (Hawkins, 1982). Regular leisure time on a daily basis has been associated with fewer problem behaviors in kids with ASD (Gerber et al, 2008).

Healthy sleep is critical for supporting self-regulation (Anders, Goodlin-Jones & Sadeh, 2000), particularly for persons with ASD who may be at risk for disrupted sleep-wake cycles (Allik, Larsson, & Smedje, 2006).

Nutritional intake is also recognized as influencing a person’s ability to regulate affect, attention and behavior (Burdge & Lillypop, 2010). Persons with ASD are at risk for nutritional inadequacies and restricted diets which adversely affect their health (Coury, 2010).

Relaxation Training (Baron, Groden, Groden, & Lipsett, 2006; Cautela & Groden, 1978)

Sensory Diet Approach (Fenech & Barber, 2008). Developed by occupational therapists, this approach is based on the idea of planning a schedule of activities for a person that incorporates the “just right” amount of movement, arousal and stimulation to maintain appropriate behavior and affect. The activities chosen are useful experiences for the person to have on a daily basis and fit into the natural social context. For example, involving a study in the “heavy work” activity of pushing the school mail cart could provide some functional motoric input within the natural school routine.

Biofeedback. Scientists are developing and studying the usefulness of wear-able personal monitors that can provide readings of psychophysiological responses in real time and thus signal increasing reactivity for caregivers and help to teach the connection between feelings and bodily reactions for persons with ASD (Goodwin, 2010; Picard, 2011).

V. Social Learning

Techniques focused on improving openness to social learning by enhancing core social relatedness, social perception, social motivation and social communication.

Relationship-based Interventions (such as the Early Start Denver Model (Rogers & Dawson, 2010), DIR^®/Floortime^™ (Greenspan & Wieder, 1997; Wieder & Greenspan, 2003), Responsive Teaching (Mahoney & Perales, 2003), and other approaches that prioritize actively engaging the child in opportunities to become “in sync” with others (Landa & Garrett-Mayer, 2006; Wetherby et al, 1998) could help to develop improved self-regulation.

Mirroring: Recent work suggests improved social responsiveness in young children with autism when an adult “mirrors” the child’s behaviors (i.e., imitating the child without adding any novel actions to the social interaction) (Katagiri, Inada, & Kamio, 2010). Observing and matching the rhythm of a child’s movements may help to establish a trusting relationship, which can provide a foundation for learning how to self-soothe (Maurer, 1993: Baron et al, 2006).

Instruction in joint attention, imitation and play. Interventions designed to improve a child’s capacity to share attention with others, imitate the actions of others, generate novel actions with toys and explore his or her environment could all improve a child’s openness to social learning.

Curricula that are (or will soon be) available for parents and therapists are:

Early Start Denver Model (Rogers & Dawson, 2010). For a link to an online course on the model: http://extension.ucdavis.edu/unit/education/course/listing/?unit=EDU&prg…

Joint Attention & Symbolic Play (JASPer): Kasari, Gulsrud, Wong, Kwon, & Locke, 2010. See www. www.autismspeaks.org/science/science-news/do-you-see-what-i-see

Supportive/Exploratory Parenting: Conveying confidence in the child’s ability to cope is an important aspect of encouraging independent self-regulation. Unfortunately, it may be the instinct of a responsive parent to protect his or her child from feeling any distress, and well-meaning parents sometimes work tirelessly to anticipate and control the environment so that their children are not overwhelmed by challenges to cope (Dadds & Roth, 2001; Reaven & Hepburn, 2006). Adopting a style of overprotection is likely to result in providing less practice managing small stressors for the child, leading to an overly dependent or fearful behavioral style and a lack of foundational skills for regulation (Dadds & Roth, 2001).

Video Modeling. For some youth – especially those who are visual learners – seeing how a new situation plays out on film is very helpful for reducing anticipatory anxiety. For an extensive video modelling curricula developed for special educators: http://www.stanfield.com/products/social-life-skills/lifesmart-curriculum/

Instruction in Social-Communication (Pragmatics). Communication regulates the behaviors of others, as well as enabling an individual to appropriately assert preferences, desires, and needs, which, if not able to be expressed appropriately are likely to be expressed through inappropriate or dysregulated behaviors. For ideas on how to use pragmatic interventions to improve self-regulation, see: Prizant, B.M., Wetherby, A.M., Rubin, E., Laurent, A.C., & Rydell, P.J. (2006).

Pivotal Response Training (PRT; (Koegel, Koegel, Harrower, & Carter, 1999; Schreibman & Pierce, 1993) is a comprehensive intervention approach that explicitly incorporates teaching self-regulation within social interactions and communicative exchanges.

Computer Games

Frame–It is a computer game that uses a puzzle format to teach children to decode nonverbal cues by focusing their attention on the eyes. An initial treatment study suggests skill acquisition for school-aged children with ASD (Eckhardt, Goodwin & Picard, 2010). Frame It is one of the projects being pursued by the Affective Computing group at MIT. For more information on their work: www.media.mit.edu/research/groups/affective-computing

FaceSay is a computer game focused on improving emotional recognition and interpretation of nonverbal emotional cues. Designed for children with high-functioning ASD, the program has been shown to improve emotion recognition in the game. Generalized benefits have been noted in playground observations (Wimsatt, 2010).

To order the game/more information: www.facesay.com/

VI. Thinking

As children progress across elementary and middle school, explicitly teaching social skills in real-life settings can be helpful. This is referred to by Brenda Smith-Myles as the “Hidden Curriculum”. Parents and teachers can capitalize on natural learning opportunities and direct instruction to teach social nuances, rules and conventions, which can prevent some of the social confusion and overarousal a child with ASD may experience within a puzzling social scenario (Smith Myles, Trautman, & Schelvan, 2004).

Narrative Interventions, such as the use of social stories, video modeling, and other techniques that employ scripts and explicit models in an effort to teach adaptive responses can be helpful in promoting self-regulation (Cullain, 2002; Gray, 1993; Smith-Myles et al, 2004).

Computer Games

The Secret Agent Society (Beaumont & Sofronoff, 2010) is a computer game designed to teach social problem-solving skills for children 7-11 with high functioning ASD. Research suggests children enjoy the game and demonstrate improvement in social cognition, specifically perspective-taking, interpretation of nonverbal social cues, and choice of appropriate behavioral responses within social challenges. To order the game or to learn more: www.sst-institute.net/

Cognitive-Behavioral Therapy (CBT). (Attwood, 2005; Chalfant, Rapee, & Carroll, 2007; Reaven, 2009; Wood, Fujii & Renno, 2011). Cognitive-behavioral strategies are thought to be a good fit for the cognitive style of many individuals with high-functioning ASD (Greig & MacKay, 2005). As with other aspects of social competence, self-regulation may need to be explicitly and directly taught to persons with ASD, and cannot be assumed to be learned naturally through experience (Konstantareas & Stewart, 2001; Laurent & Rubin, 2004).

For a small group coping skills program designed for families of children with ASD and co-occurring anxiety, see: “Facing Your Fears” (Reaven, Blakeley-Smith, Nichols & Hepburn, 2010). This is our manualized CBT program that we have been studying for about ten years at University of Colorado. Brookes Publishing sells a 3-manual set – one for facilitators, one for parents and a workbook for the child. The program has been studied with promising results in children with ASD, 8-14 years old, who are verbally fluent. The most effective format has been for two clinicians to conduct 14 small-group sessions with 4 parent/child pairs. We are now piloting a version designed for school teams. For more information: www.jfkpartners.org or: www.brookespublishing.com/store/books/reaven-71783/index.htm

CBT: Self-Monitoring. Researchers are studying the use of personal digital assistants (PDAs) to provide reminders of coping strategies and promote self-monitoring (Blakeley-Smith et al, 2010; McLeod & Lucci, 2010).

Executive Function Interventions. There is evidence from the therapeutic literature on children without ASD that effortful control can be taught to children with regulatory difficulties. Existing programs that have been developed for youth with executive dysfunction may be therapeutic for youth with ASD, although more research is needed to evaluate the impact of these programs in this population.

CogMed (Pearson Education, Saddle River, NJ) is a cognitive training program designed for children 9-13 years. There is empirical support for improvement in working memory both within the games and in real-life situations; however, there is less empirical support for the inhibition games in the current version. (Diamond & Lee, 2011)

VII. Positive Behavioral Supports

Clinicians who work in developing positive behavioral supports (PBS) provide a wealth of evidence for the power of teaching functional communication skills as appropriate alternatives to inappropriate behavior (O’Neill, Horner, Albin, Storey, & Sprague, 1990). As communication improves and the person has appropriate ways to regulate the behaviors of others and change features of the context that pose coping challenges, self-regulation may be less overwhelming to achieve (Janzen, Baron, & Groden, 2006).

Approach self-regulation difficulties as skill deficits and respond with instruction and antecedent-focused interventions instead of consequence-focused interventions. For example:

(a) Sending a student with dysregulated behaviors to “Time Out” without providing instruction at other times on how to cope is not likely to sufficiently improve regulation.

(b) Actively ignoring a specific problem behavior may not be effective, particularly if the behavior is not motivated by social attention, but serves a self-regulatory function. By ignoring the behavior in this situation, the individual’s inappropriate behaviors may be inadvertently reinforced, since engaging in the inappropriate behavior without interruption may result in a decrease of the unpleasant arousal the person was feeling in the first place. Instead, it may be a better strategy to firmly and quickly redirect the person to do a particular action, such as sitting in a particular place associated with calming down or engaging in a physical task that is safe, easy, and distracting.

Instruction is more likely to be effective when the person is calm. Strategies learned in calm moments can be prompted to be practiced when the person is upset, but only if they have been adequately taught under optimal conditions.

Try to calmly and quietly redirect problem behaviors.

Do not try to reason with the person during a behavioral episode.

Do not provide too many choices.

Relying on natural consequences (i.e., allowing things to happen so that if a person tries to use a coping strategy, good things happen and if a person doesn’t employ a coping strategy, nothing good happens) can be more effective than using artificial rewards. For example, if a child enjoys playing video games, but throws his controller when he loses, a parent may respond by requiring the child to take a 5-minute break from the game. Conversely, when the parent observes the child tolerating losing without throwing the controller, the parent can provide the child additional time to play the game.

BIBLIOGRAPHY & SUGGESTED READINGS/RESOURCES

SECTION I: DEVELOPMENT OF SELF-REGULATION

Cicchetti, D., & Tucker, D. (1994). Development and self-regulatory structures of the mind. Development and Psychopathology, 6, 533-549.

Hilgetag, C.C., & Barbas, H. (2009). Sculpting the brain. Scientific American, 66-71.

Kopp, C.B. (1982). Antecedents of self-regulation: A developmental perspective. Developmental Psychology, 18(2), 199-214.

Siegel, D. (2007). The mindful brain: Reflection and attunement in the cultivation of well-being. New York: W.W. Norton.

SECTION II. HOW IS THIS RELEVANT FOR UNDERSTANDING PEOPLE WITH AUTISM?

Bachevalier, J., & Loveland, K.A. (2006). The orbitofrontal-amygdala circuit and self-regulation of social-emotional behavior in autism. Neuroscience and Biobehavioral Reviews, 30(1), 97-117.

Courchesne, E. & Pierce, K. (2005). Why the frontal cortex in autism might be talkingonly to itself: Local over-connectivity but long-distance disconnection. Current Opinion in Neurobiology, 15(2), 225–230.

Geschwind, D.H. & Levitt, P. (2007). Autism spectrum disorders: Developmental disconnection syndromes. Current Opinions in Neurobiology, 17, 103-111.

Minshew, N.J. & Williams, D.L. (2007). The new neurobiology of autism: Cortex, connectivity, and neuronal organization. Archives of Neurology, 64, 945-950.

Mundy, P.C., Henderson, H.A., Inge, A.P., & Coman, D.C. (2007). The modifier model of autism and social development in higher functioning children. Research and Practice for Persons with Severe Disabilities, 32, 124-139.

Ozonoff, S. (1998). Components of executive function in autism and other disorders. In J. Russell (ed.), Autism as an executive disorder, (179-211). New York: Oxford University Press.

SECTION III: HOW CAN WE HELP A PERSON TO SELF-REGULATE BETTER?

Dadds, M.R., & Barrett, P.M. (2001). Practitioner review: Psychological management of anxiety disorders in childhood. Journal of Child Psychology and Psychiatry, 42(8), 999-1011.

King, N.J.& Ollendick, T.H. (1989). Children’s anxiety and phobic disorders in school settings: Classification, assessment, and intervention issues. Review of Educational Research, 59(4), 431-470.

SECTION IV: BODY WORK

Baron, M.G.; Groden, J.; Groden, G.; & Lipsitt, L.P. (2006). Stress and coping in autism. Oxford, England: Oxford University Press.

Cautela, J.P. & Groden, J. (1978). Relaxation: A comprehensive manual for adults and children with special needs. Champaign, IL: Research Press.

Coury, D. (2010). Medical treatment of autism spectrum disorders. Current Opinion in Neurology, 23, 131–136. Fenech & Barber, 2008

Goodwin, M.S. (2010). Developing innovative ways to measure and communicate autonomic arousal in autism spectrum disorders. International Meeting for Autism Research (May, Philadelphia, PA).

Pan, C. (2010). Effects of water exercise swimming program on aquatic skills and social behaviors in children with autism spectrum disorders. Autism, 14(1), 9-28.

Picard, R. (2011). Future affective technology for autism and emotion communication. Philosophical Transactions of the Royal Society of Biological Sciences, 364, 1535, 3575-3584. doi: 10.1098/rstb.2009.0143.

Pitetti, K.H., Rendoff, A.D., Grover, T., & Beets, M.W. (2007). The efficacy of a 9-month treadmill walking program on the exercise capacity and weight reduction for adolescents with severe autism. Journal of Autism and Developmental Disorders, 37(6), 997-1006.

Rosenthal-Malek & Mitchell (1992). Brief report: The effects of exercise on the self-stimulating behaviors and positive responding of adolescents with autism. Journal of Autism and Developmental Disorders, 27(2), 193-202.

SECTION V: SOCIAL LEARNING

Greenspan, S.I. & Weider, S. (1997). An integrated developmental approach to interventions for young children with severe difficulties in relating and communicating. Zero to Three, 17, 5-18.

Mahoney, G., & Perales, F. (2003). Using relationship-focused intervention to enhance the social-emotional functioning of young children with autism spectrum disorder. Topics in Early Childhood Special Education, 23, 77-89.

Rogers, S.J. & Dawson, G. (2010). Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement. New York: Guilford Publications.

Instruction in Social-Communication (Pragmatics):

Prizant, B.M., Wetherby, A.M., Rubin, E., Laurent, A.C., & Rydell, P.J. (2006). The SCERTS Model: A comprehensive educational approach for children with autism spectrum disorders. Baltimore: Brookes.

Executive Function curricula designed specifically for youth with ASD:

Kaufman, C. (2010). Executive Function in the Classroom: Practical Strategies for Improving Performance and Enhancing Skills for All Students. Baltimore, MD: Brookes Publishing.To order: www.brookespublishing.com/store/books/kaufman-70946/index.htm

Promising executive function curricula with some research support for their effectiveness with school age kids and adolescents (not specifically for kids with ASD):

Brainology. www.brainology.us/educator/programDescription.aspxbrainology.com. This is a software program designed for middle schoolers in particular, with the goal of improving metacognition (i.e., helping students to reflect on their own thoughts and attitudes) and developing motivation and resilience in the face of learning challenges. The interactive website may be particularly engaging for science-minded kids. For research on the effectiveness of this program, see:

Maricle, D.E.; Johnson, W.; & Avirett, E. (2010). Assessing and intervening in children with executive function disorders. In D.C. Miller (Ed.), Best practices in school psychology: Guidelines for effective practice, assessment, and evidence-based intervention (599-640). Hoboken, NJ: John Wiley and Sons.

Meltzer, L. (2007). Executive function in education: From theory to practice. New York: Guilford Press.

SECTION VI: THINKING

Attwood, T. (2005). Cognitive behavioral therapy for children and adults with Asperger’s syndrome. Behavior Change, 21, 147-161.

Gray, C. (1993) The Original Social Story Book. Arlington, Texas: Future Education.

Smith Myles, B.; Trautman, M.L.; & Schelvan, R.L. (2004). The hidden curriculum: Practical solutions for understanding unstated rules in social situations. St. Louis, MO: Autism/Asperger Publishing Company.

Greig, A., & MacKay, T. (2005). Asperger’s syndrome and cognitive behaviour therapy: New applications for educational psychologists. Educational and Child Psychology, 22, 4-15.

Reaven, J., Blakeley-Smith, A., Nichols, S., & Hepburn, S. (2011). Facing Your Fears: Group Therapy for Managing Anxiety in Children with High-Functioning Autism Spectrum Disorders. Baltimore, MD: Brookes Publishing. To order: http://www.brookespublishing.com/store/books/reaven-71783/index.htm

SECTION VII: POSITIVE BEHAVIORAL SUPPORTS

Carr, E.G.; Horner, R.H.; Turnbull, A.P.; Marquis, J.G.; McLaughlin, D. M.; McAtee, M. L; Smith, C. E.; Ryan, K. A.; Ruef, M. B.; Doolabh, A.; Braddock, D [Ed].(1999). Positive behavior support for people with developmental disabilities: A research synthesis. xvi, 108 pp. Washington, DC, US: American Association on Mental Retardation; US.

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