Autism and Managing Anxiety

Transcription

1 Autism and Managing Anxiety 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 Setting the Scene What is anxiety? When is anxiety useful? When does it become a disorder? 1

2 Autism and Anxiety (White et al, 2009) Prevalence rates from 11% to 84%; consensus is about 50% Compare with typical children - prevalence is % More anxious than clinically anxious typically developing children. Autism Differences and Anxiety Dyad of impairments - social demands; difficulty making sense of the world In typical development children use multiple sources of information to derive meaning In autism children may get confused when they try to understand abstract concepts and language Delayed processing of language Learning style thinking in pictures ; visual, literal Continued Unusual responses to sensory stimuli Cognitive Theories Theory of mind Central coherence Executive function Poor problem solving and flexibility 2

3 Starting Point Daily challenges Need for routine Unexpected changes Social demands Difficulties with communication Exposure to anxiety provoking situations Tension 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 3

4 The Girl with the Curly Hair Alis Rowe 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 4

5 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 5

6 Sensory Processing and autism 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 inmy 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 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 Sensory Processing and autism The Girl with the Curly Hair Alis Rowe 6

7 The Girl with the Curly Hair Alis Rowe 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 7

8 Strategies Stress Kit Sensory Toys Ear Phones/MP3 Manage sensory environment e.g. noise, temperature, lighting access to an identified calm area Deep pressure techniques and strategies Learn to identify sensory related behaviours e.g. sensory training Stress Kit A stress kit can be used to re-direct your child s attention towards a more positive experience in order to help avoid meltdowns. Items in this box could include: Sensory toys: stress balls, chew sticks, blu-tac Bubble wrap Ear-plugs Small box of raisins Calming music Books Special interest Photo album Stress Kit 8

9 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 Communicating Anxiety 9

10 Strategies: Relaxation Create a consistent quiet relaxation space Gentle lighting Calming music Sensory toys for reducing stress Special interests Space to lie down and relax Relaxation routines Social story 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 Breathing Exercises Often it is too abstract to talk about fast breathing and slow breathing for children and young people with autism. It is better to make such concepts visual and more tangible, for example, show children what it looks like to have slow breathing by blowing paint on a page, blowing out candles on a cake or by blowing up balloons. 10

11 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 Progressive Muscle Relaxation Progressive muscle relaxation provides a framework for individuals to go through all the main muscle groups in their body and systematically tense and relax them whilst breathing slowly. This allows individuals to be able to compare what a tense body feel like in comparison to a relaxed body. 11

12 Relaxation Games The Gorilla Game The conveyer belt Washing day What is Emotional Regulation? The ability to self monitor physiological arousal and emotional states 12

13 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 and Learning 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 Continuum of emotional states 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 13

14 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 baffling incomprehensible mayhem, which terrifies me. Ros Blackburn, 2005 My primary emotion is and has always been fear. Temple Grandin, 2006 Emotional Regulation Critical Capabilities in Typical Development 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 14

15 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) Do not use decontextualised materials. Start from context. Link facial expressions and emotions always to context. 15

16 Teaching Emotions Angry Punchbag Angry Home School Punchbag Tell mum Ask for quiet time 16

17 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 17

18 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 Stress What does Stress feel like? Feeling sick Red face butterflies? Shortness of breath Want to run away Faint 18

19 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? 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 Anger Shouting and yelling Using bad words Throwing things Breaking things Hitting, kicking fighting Wanting to hurt yourself 19

20 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! 20

21 Communicating Anxiety Feelings Thermometer Emotion Thermometers 21

22 Resources Podcast / websites: Inner Health Studio Mental Health Foundation 101 Relaxation Games for Kids Allison Bartl TeenHealth Anxiety BC 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 What are Cognitive Strategies? There is neither good nor bad but thinking makes it so Hamlet Act II Scene II 22

23 Thinking Errors Thinking Errors Thinking Errors 23

24 Thinking Errors Thinking Errors Thinking Errors 24

25 Emotional Toolkit CBT designed for children and young people with autism Designing a tool-box to fix the feeling 25

26 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? 26

27 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? Anxiety A Personal Perspective DfCcandindex=15andlist=PL0t2dRFWj648bfg 1aVONrjioeb05GD8fm 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. 27