Autism and Managing Anxiety

Transcription

1 Theory and Practice 1. Theory why do children and young people with autism experience high levels of anxiety? Autism and Managing Anxiety Lorna Fitzpatrick Centre for Autism 2. Emotional Regulation 3. On the spot strategies 4. Long term management strategies Starting Point Social Difficulties Daily challenges Need for routine Unexpected changes Social demands Difficulties with communication Exposure to anxiety provoking situations Tension 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 Trigger Anxiety Increased preoccupations Fight / Flight 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 1

2 Anxiety Increasing 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 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 What Do We See? Anger and aggression outburst Self harming behaviours Regression Absconding Physiological reactions to anxiety e.g. Incontinence 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 Sensory Processing and autism 1. Identify and remove trigger 2. Manage sensory input (will be addressed) 3. Relaxation techniques 4. Redirect 5. Negotiated time-out...certain sounds frightened me- dogs barking, mopeds, tractors and cars, engines of various kinds. They would explode inside me and make me lose all sense of the way my body related to my surroundings. It was like being flung out into space- whoosh- quite without warning. Sometimes I screamed and covered my ears...some sounds around me I hardly reacted to at all... (Gerland G, 1999) 2

3 Sensory Processing and autism Sensory Processing one thing I don t like is crowds. For example, I just hated the classroom. The noise annoyed me. At the time, the sound of children s chatter 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 Most children and young people with autism have unusual perceptions of sensory input Some individuals have difficulty in filtering sensory stimuli 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 of food 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 Sensory Toys Ear Phones/MP3 Manage sensory environment e.g. noise, temperature, lighting Deep pressure techniques and strategies Learn to identify sensory related behaviours e.g. sensory training Communicating Anxiety Stress Kit 3

4 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 Take Ten 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 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 4

5 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 short periods 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,

6 Emotional Regulation Critical Capabilities in Typical Development Long Term Management Strategies Self Regulation The ability to independently attain an optimal level of arousal. Mutual Regulation The ability to solicit and secure assistance from others in regulating one s arousal 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) 6

7 Teaching Emotions Angry Angry Home Punchbag Tell mum Punchbag School Ask for quiet time What are Cognitive Strategies? There is neither good nor bad but thinking makes it so Hamlet Act II Scene II 7

8 Affective Education Teaching children what it feels like to be Angry Stressed Unhappy 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 Unhappy 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? How does my mum look when she is stressed? How does my dad look when he is stressed? 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 8

9 Anger Practice Identifying Emotions Shouting and yelling Using bad words Throwing things Breaking things Hitting, kicking fighting Wanting to hurt yourself Emotions Bingo! Facial recognitions Modelling Role play Over to You Knowing what it feels like Describe happy Describe irritated Describe relaxed / calm What ways could you illustrate these to a child? Angry pictures? Sports, cartoons? 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 9

10 Thinking Errors Thinking Errors Thinking Errors Thinking Errors Thinking Errors 10

11 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? 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? How might you do this work 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? 11

12 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. 12