Monthly Archives: April 2021

Latest research on camouflaging

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Latest research on camouflaging

Children who have autism will know at quite a young age that they are different to their peers with regard to the ability to read facial expressions, body language and social cues, and are different to their peers in the ability to make and keep friends. How does the child with autism cope with this knowledge?

One way of coping is to avidly observe other children and adults and to analyze their social behavior, looking for patterns or social ‘systems’ and copying or imitating what you see and hear. This coping mechanism of acquiring social skills by observation and imitation is an intellectual rather than intuitive activity. The child or adolescent subsequently creates a social ‘mask’ and artificial persona, gradually acquiring social scripts in terms of dialogue, facial expressions, and gestures that they have observed, analyzed, and imitated. This coping mechanism is known by clinicians and academics as camouflaging and was first recognized as a consistent theme in the autobiographies of women who have autism, such as in Liane Holiday Willey’s seminal autobiography Pretending to be Normal. (Holliday Willey 1999). Clinicians specializing in autism also became more aware of camouflaging when observing girls and women in social situations at school and work and during a diagnostic assessment or therapy session. Recent research has confirmed that camouflaging is not an exclusively female phenomenon and occurs with males who have autism (Cage and Troxell-Whitman 2019; Hull et al 2020; Lai et al. 2017). We now know that 70% of adults who have autism consistently use camouflaging in social situations (Cage and Troxell-Whitman 2019).

The motivations for camouflaging are varied and include a means of protection from ostracism, humiliation, and bullying and facilitating being accepted and included by peers at school and colleagues at work. Camouflaging can also contribute to gaining and maintaining friendships and relationships. A husband who has autism explained one of his reasons for camouflaging was that “…it makes my wife less embarrassed to be seen with me” (Cage and Troxell-Whitman 2019). Camouflaging becomes a social survival mechanism, being an obligation rather than a choice (Mandy 2019).

We now have a questionnaire to explore whether a person engages in camouflaging in social situations and the degree of camouflaging (Hull et al. 2019). The Camouflaging Autistic Traits Questionnaire (CAT-Q) was developed from discussing aspects of camouflaging with adults who have autism describing their social experiences and abilities. A recent study using the CAT-Q found that females who have autism had higher total camouflaging scores on the questionnaire than males who have autism. While camouflaging is not an exclusively female phenomenon, in general females are better at camouflaging and more likely to use camouflaging in a wider range of social situations (Hull et al 2020).

Camouflaging can also delay the diagnosis of autism, eliciting comments such as, ‘You’re too social to have autism’. This will delay and inhibit self-understanding and self-acceptance (Bargiela, Steward and Mandy 2016). A delay in confirming the diagnosis will also delay access to appropriate support networks and services, and understanding by family and friends.

We recognise that social acceptance and success through camouflaging will have been achieved at some psychological cost. There can be performance anxiety in social situations, as though the person is continually ‘on stage’ and at the end of the day, ruminating on their social ‘performance’ and the perceived judgement of friends and colleagues. As social inclusion is achieved intellectually rather than intuitively, camouflaging is mentally exhausting. Like Cinderella at the ball, the person can maintain the social pretence for a while, but then becomes totally drained of mental energy and must return home to recover in solitude. The unrelenting mental exhaustion of camouflaging can lead to prolonged stress, anxiety, and depression, and may be one of the reasons for self-harm and suicidal ideation. Thus, camouflaging can contribute to the development of a deep and prolonged depression.

The psychological consequences of camouflaging can also include a lack of knowledge and expression of the inner and true self, with many adults who are successful at camouflaging saying, ‘I don’t know who I am’, and ‘I never reveal the real me’. This creates a lack of self-identity, low self-esteem, and prolonged self-analysis. The person recognizes that friendships and relationships are based on deceit, with the presentation of a ‘false’ identity leading to feelings of deep inner loneliness. The person yearns to find, and be able to be, an authentic self, but is aware that when the true self is revealed, they may be rejected and despised.

In psychotherapy we recognise that there are times when camouflaging or ‘acting’ is necessary, as in the phrase ‘when in Rome, do as Romans do’. However, we also encourage the person to restrict the duration of camouflaging during their day to a level that is not detrimental to mental health. In other words, be true to the real self and to learn ways of explaining social difficulties and seeking sympathy and support rather than playing the exhausting and false role of a neurotypical.

References

Bargiela, Steward and Mandy (2016) Journal of Autism and Developmental Disorders 46, 3281-3294

Cage and Troxell-Whitman (2019) Jr. Autism and Developmental Disorders 49 1899-1911

Holliday Willey (1999) Pretending to be Normal: Living with Asperger’s syndrome. Jessica Kingsley Publishers

Hull et al (2019) Jr. Autism and Developmental Disorders 49 819-833

Hull et al (2020) Autism 24, 352-363

Lai et al. (2017) Autism 21, 690-702.

Mandy (2019) Autism 23 1879-1881

“I’m bored”: a translation

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“I’m bored” – a translation

The comment “I’m bored” is often said by teenagers at high school, but those students who have autism may use this phrase to express a range of thoughts and feelings. A translation of “I’m bored” for those who have autism can be:

I do not have the energy to do this

At high school Students who have autism consume mental energy to process not only the academic curriculum but also the social curriculum as well as manage anxiety and sensory sensitivity. A typical day at high school is mentally exhausting, hence the comment “I’m bored” means “I have no mental energy to process this activity”.

This activity is pointless and irrelevant

Components of the high school curriculum may not have relevance to modern life or the future of the student who has autism. Typical students recognize that the activity is futile but will persevere to comply with the school’s expectations, maintain peer engagement and to pass exams. The student who has autism may not follow such conventions and if the activity is perceived as irrelevant, it may well be boring, and the student with autism may repeatedly express their opinion to the teacher.

This activity is too easy for me

The cognitive profile associated with autism can include abilities in advance of same age peers. The teacher usually presents the activity based on the average abilities of the students in the class. Thus, the student with autism may have completed the activity in advance of his or her peers and now has nothing to do and is bored.

The teacher is uninspiring

The style of teaching or personality of the teacher may be uninspiring, or the teacher may be depressed. The lesson is then boring for all students.

I am being treated as an idiot

Adolescents who have autism may not be successful socially or in school sports. Academic success then becomes important to achieve respect and for self-esteem. Thus, the student with autism often wants to demonstrate intellectual abilities. To say, “I’m bored” may translate to “I cannot demonstrate how smart I am”.

It makes me sound ‘cool’

One way of achieving social acceptance and inclusion is to imitate peers, especially the ‘cool’ students, who may often say “I’m bored”.

My imagination is more exciting

In the early grades of school, the child who has autism may recognize that he or she is different to their peers, and often excluded socially. One of the adjustment strategies is to escape into imagination, perhaps as a super hero who has special and valued powers or an alternative world such as Hogwarts or being with animals. The imaginary world is exciting and with achievements that are elusive in reality. There is a huge contrast between the social and academic classroom and an imaginary world, hence the lesson is boring in comparison to enjoying a vivid imagination.

I cannot understand what the teacher is saying

Autism can be associated with specific language and learning difficulties, such that the teacher may be talking too fast or using complex language structures for the adolescent to cognitively and linguistically process the information. There may also be difficulty discriminating the teacher’s voice from the voices of nearby children quietly talking to each other, or the teacher may be using idioms and sarcasm that are confusing.

I am feeling depressed

There is a high level of depression in teenagers who have autism. One of the characteristics of depression is anhedonia, an inability to experience pleasure or interest in a formerly pleasurable activity. Favourite subjects such as mathematics, information technology, art or drama are no longer enjoyable due to feeling depressed.

Thus, parents and teachers may need to translate the phrase “I’m bored” as an expression that has many meanings.

Autism in couples

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Autism in couples

There are many qualities associated with autism that are appealing to a prospective partner. The person can be attentive, knowledgeable, creative, kind, endearingly immature, physically attractive, quiet, and inexperienced in romantic relationships. There can be compassion for their naive social abilities and having been teased and bullied at school. The prospective autistic partner is often appreciated for being predictable, honest, and confident in their opinions, perhaps with shared interests and an admired career. They may have similar characteristics to one of the parents of the neurotypical partner, such that they are easily fluent in the language and culture of autism. In the early stages of the relationship, the characteristics of autism may be suppressed such that the neurotypical partner is not be aware of their partner’s autism, anticipating a conventional and fulfilling relationship. If autism is recognised or disclosed, there may be the assumption that love will provide the mutual understanding and accommodations within the relationship.

Clinical experience and research have identified that both autistic males and females may develop a compensatory mechanism of camouflaging social and interpersonal difficulties in the early, romantic stage of the relationship.  They may have acquired what appears to be expertise in being an ideal partner from watching romantic films which have provided a script and a role that can be acted, and successful in captivating their partner. This ability to act neurotypical, to camouflage autism and use a variety of scripts and roles can also be used successfully at work and social settings with friends, becoming a ‘chameleon’, but in the privacy of home, their partner gradually experiences living with the real person behind the mask.

The autistic person may be attracted to someone who has exceptional social expertise and empathy for their social difficulties, understanding their confusion and sometimes being overwhelmed in social situations and the subsequent exhaustion and need for solitude.  The autistic partner may recognise that they need and actively seek a relationship partner who can be a social mentor and ‘translator’ of the autistic perspective to friends and family and does not criticise their partner for being social naïve or ‘clumsy’. They continue many of the social and emotional support functions previously provided by a parent.

After several years of living together, the couple may find that the relationship may not be developing as they originally expected. There may be a sense of grieving for the elusive conventional reciprocal relationship they once hoped for. For the neurotypical partner, autistic characteristics that were endearing at the start of the relationship, such as an being an avid collector of model trains, subsequently becomes a source of conflict regarding the amount of time and money devoted to the interest. The initial optimism that their partner will gradually change and become more emotionally supportive and socially skilled can dissolve into despair; social skills appear to be static due to limited motivation to be more sociable, or require constant prompting from their partner.

The autistic partner needs periods of social isolation at home to recover from the social aspects of work, and joint social contact with friends and family can slowly diminish. Gradually, the neurotypical partner reluctantly agrees to reduce the frequency and duration of social contact for the sake of their partner, and slowly absorbs the characteristics of autism into their own personality and lifestyle.

A significant problem for the neurotypical partner is a sense of loneliness within the relationship. In contrast, the autistic partner can be content with their own company for long periods of time – alone, but not lonely. Conversations from the perspective of the neurotypical partner can be infrequent and superficial, but from the perspective of the autistic partner, are satisfying, and primarily an exchange of information, rather than an enjoyment of each other’s company and sharing experiences.

There is an expectation in a relationship of regular expressions of love, affection, and emotional support. What may be missing in the autistic/neurotypical relationship are those daily words and gestures of affection and compassion and emotional support and compliments. The absence of these aspects of a relationship can be a contributory factor to low self-esteem and clinical depression for the neurotypical partner who feels caged within the relationship. Due to having autism, the autistic partner may not be able to recognise and know intuitively how to respond to the subtle non-verbal communication of emotional and practical needs, and can feel that whatever they say or do is never enough to make their partner feel happy. They unintentionally keep getting it wrong and feel excessively and unjustifiably criticized and rejected.

The ability to read subtle, non-verbal communication and contextual cues to determine what someone is thinking and feeling, Theory of Mind, is impaired for autistic children and adults. However, the neurotypical partner can have an impaired Theory of an Autistic Mind. That is,  they have difficulty perceiving or determining what the autistic person is thinking and feeling by reading their facial expression and body language; this is because autistic adults often have a limited ‘vocabulary’ of facial expressions, gestures, and prosody. Another characteristic of autism is alexithymia, that is, having considerable difficulty converting thoughts and emotions into conversational speech, which inhibits the disclosure of thoughts and feelings in a conversation. Thus, there is a breakdown in communicating and understanding each other’s thoughts and feelings for both partners.

The dynamics and stress within the relationship will inevitably change with the arrival of children, presenting new responsibilities and sources of conflict, such as different parenting styles. The relationship may reach breaking point. The autistic partner will have less access to their stress management strategies, such as solitude or their special interest, which is a source of pleasure, relaxation, and an effective thought blocker.  The relationship could be deteriorating, with expressions of despair and anger for both partners who are unaware of what to do to support and repair the relationship.

Over several decades Michelle Garnett and Tony Attwood have provided therapy for couples where one or both partners have the characteristics of autism. On the 20th of February 2021 we presented a whole day web cast on strategies to strengthen the relationship with modules on the:

Qualities of the relationship in the early stages

Signs that the relationship is not as anticipated for both partners

Expressions of love within the relationship

The communication of thoughts and emotions

Managing stress, anxiety, and anger

Verbal, emotional, and physical intimacy

Working as a team and family responsibilities

The future together

The webcast will also include a description of ‘The Relationship Minefield’ programme designed and used by Michelle, Tony and colleagues. For further information to download the web cast, please go to www.attwoodandgarnettevents.com

Managing an autistic meltdown

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Managing an autistic meltdown

Why do meltdowns occur?

Autistic people often have a different way of:

sensing internal and external stimuli

problem-solving

learning and organizing information

understanding and relating to

The daily challenges inherent in these differences can lead to the buildup of stress which can eventually be released as a meltdown.

To avoid and manage a meltdown, we need to determine:

the causes and triggers for stress and mental and/or physical tension

accommodations and modifications to the causes and triggers where possible

the signs of an imminent meltdown at the early and middle stages

best ways to support a person through a meltdown

activities for the person to safely release tension and stress

ways to facilitate emotional recovery for all those involved

The causes of a meltdown

The primary causes of a meltdown are stress from sensory sensitivity, cognitive overload, and aspects of social engagement.

Sensory sensitivity

One of the diagnostic characteristics of autism is hyper- or hypo-reactivity to sensory input. Clinical experience, autobiographies and research has confirmed that autism is associated with a different profile of exteroception and interoception. Exteroception is the perception of the external sensory world and interoception is the perception of the internal sensory world. We know that autistic individuals often have extreme sensitivity to external sensory experiences within the auditory, tactile, visual, and olfactory sensory systems.  The sensitivity is much greater than with typical individuals, and sensory experiences that are often not noticed and easily accommodated by non-autistic people, are extremely intense and distressing, if not actually painful, for an autistic person. We are also recognizing that autistic people may have an extraordinary sensitivity to negative emotions in other people. This can be someone’s agitation, disappointment, and anxiety. Negative emotions can be acutely and accurately perceived and ‘infect’ the autistic person, becoming a contributary factor for increased stress and a potential trigger for a meltdown.

While an autistic person may have a sensory system that is overly sensitive to external sensory and emotional experiences, there can also be a lack of perception of their internal sensory world, that is, a difficulty with interoception. This can include not being aware of the internal signals of hunger or needing to go to the toilet, body temperature, injury or imminent vomiting. Difficulties with interoception in autism can include difficulty perceiving and being consciously aware of increasing stress, especially emotional distress. There can be a mind and body detachment, and the internal signals of impending meltdown may not be recognized. Non-autistic individuals can perceive low level indicators of physiological and psychological stress and can also easily communicate and moderate their internal emotional state. An autistic person, on the other hand, may have alexithymia, that is, a difficulty explaining thoughts and feelings in words to communicate to someone that they are reaching breaking point. Eventually the level of distress is so intense that it is recognized, but at an intensity that is too great to be effectively controlled by the autistic person, or by those trying to moderate the degree of distress.

Cognitive overload

Autism is associated with a distinct profile of cognitive abilities that can contribute to increasing stress and frustration, leading to agitation and a meltdown. The cognitive profile includes less mental flexibility, or a ‘one track mind’. This means not knowing what else to do to solve a problem, quickly becoming frustrated and ‘hitting the panic button’. There can also be a difficulty mentally adjusting to change and transitions especially to a novel situation without a ‘script’ of what will happen, how to behave or what to do and say. Another cognitive cause of overload is having to cope with unclear instructions or expectations, and a need for prolonged processing time for information. This leads to a difficulty working at speed and coping with time pressure. Another cognitive characteristic of autism is stress from having to choose from multiple options, with a fear of making a mistake and being judged. There is also the potential of increasing stress due to ruminations over past slights, injustice, social rejection and bullying.

Social engagement

A core aspect of autism is a difficulty understanding people. Stress can be due to simply being with too many people, especially in crowded situations such as a shopping centre, station, or playground. There can be stress due to being in the presence of people who are not perceived as ‘autism friendly’. There is also stress from people making broken promises, such as saying, “I’ll be back in two minutes” and then not returning for four minutes and thirty seconds.

In social situations, there is an expectation that people are able to read facial expressions, tone of voice, gestures and social cues, while an autistic person may be able to intellectually process and ‘read’ this social information, it is exhausting for them. There is the potential to be confused by mixed messages, as in sarcasm, and determining the more subtle thoughts and intentions of others. There will be limited capacity for the duration of social engagement, and once that capacity has been reached, there is a risk of further social experiences being intolerable, which could contribute to a meltdown.

Social situations can also be associated with many aversive sensory experiences, such as being accidentally touched, the noise of shouting or applause, and the smell of perfumes and deodorants.

Signs of an imminent meltdown

Each autistic person will have a signature pattern of thoughts, behaviors and actions that indicate an imminent meltdown. The early warning signs may include knowledge that the person has probably come to the end of their ability to tolerate aspects of their sensory, cognitive, and social experiences. Signs of a more imminent meltdown can be a determination to escape the situation, engage in certain routines and rituals that serve to reduce anxiety and agitation, and avidly seeking access to a special interest as a thought blocker and energy restorative. Other signs can be increasing the volume of speech, and the use of obscenities, agitated gestures, refusing help or needing excessive reassurance. Talking about a specific topic or past injustice, or fragmented and incoherent thoughts and speech can also be signs of the level of agitation that precedes a meltdown.

Due to problems with interoception and alexithymia there may be few, if any warning signs perceived by the autistic person themselves or observed by others. A series of events may increase stress levels, lowering the threshold for a meltdown, and it may be one superficially trivial event that becomes the breaking point for the release of a build-up of stress over many hours or days.

A meltdown will be heralded by an increasing heart rate; a sports watch can be used to measure a person’s heart rate to indicate a meltdown is imminent. Another early warning system can be an Autism Assistance Dog or even the family dog. Animals may be able to perceive that a meltdown is about to happen sometime before the autistic person and their family members. The dog may seek the autistic person’s attention and become a distraction or engage in behaviour known to sooth the autistic person, thus reducing the likelihood of a meltdown.

How to manage a meltdown

There are two types of meltdown: one is outwardly directed, an explosion of emotional energy that is destructive, with feelings of rage and actions of destruction; the other is an implosion, with energy that is inwardly directed and expressed as intense despair, self-harm and suicidal thoughts. There is a potential third meltdown, or ‘shut down’. This is behaviour that acts as a means of self-protection. The person is physically immobilized, or ‘frozen’, and may even fall asleep as a means of ‘switching off.’

A meltdown is a psychological crisis, and there are recommendations regarding what to do and what not to do when a meltdown occurs. The following suggestions can help to minimize the depth and duration of a meltdown. The following suggestions are strategies to use in an outwardly directed explosion, or rage attack.

What to do in a meltdown

One person should take control of the situation.

The support person must remain calm, reassuring, and confident.

Affirm and validate the depth of emotion and explain that the feeling will eventually go.

Use calm, slow body language.

Use minimal speech.

Try to minimize eye contact for both of you.

If possible, be alongside the person rather than facing each other.

Keep other people away or encourage the person to take a position where other people are not visible to them.

Suggest a calming or distracting activity, such as an iPad, looking at information related to a special interest; or a mesmerizing activity, such as spinning and twiddling toys.

Accept restless behaviour, as this is a constructive means of discharging the energy inherent in a meltdown.

Praise compliance and calmness.

Suggest something to look forward to, or an enjoyable memory.

Suggest going to a quiet retreat area or separate room, or perhaps go outside in nature if possible.

An alternative option is to engage in a physical activity that constructively releases emotional energy, such as star jumps or press ups, or crushing items from the recycling bin.

Remember the meltdown can have a constructive function in releasing compressed stress and re-setting the emotion regulation system.

Wait patiently until the emotional storm has passed.

What not to do in a meltdown

Try not to:

Talk about punishment, consequences, damage, and cost.

Use reason when the person is too emotional to be reasonable.

Interrogate, that is ask for an explanation as to why the person is so agitated or distressed.

Encroach on personal space.

Turn the situation into a lesson.

Make sudden movements.

Correct agitated behaviours.

Match the person’s mood with your speech.

Criticise the person for being overly dramatic or selfish.

Use physical restraint.

Make critical, demeaning, or patronizing comments.

Facilitating emotional recovery

Eventually, the despair and agitation will subside. The autistic person may subsequently experience remorse or embarrassment and engage in self-criticism. In extreme cases, the person may have no memory of what happened, being confused and in a state of denial when a ‘post-mortem’ is conducted on their behaviour.

It will help to suggest a practical way of restitution and repairing feelings, for example, by asking the autistic person to clear up any mess or complete a household chore as a means of recompense.

When calm, the person may be able to give a coherent and logical description of why the meltdown occurred, preferably without fear of incrimination or increased consequences, which would inhibit an objective evaluation. There may need to be penalties that are mutually agreeable, and a focus on appropriate rewards for self-control in future situations when a meltdown may occur. It will also be important for everyone to learn from the experience, and to draw up a plan for preventing and managing a future meltdown. The plan will include more effective ways of perceiving, communicating, and expressing stress in the future.

The support person will also need to emotionally ‘debrief’ and express their thoughts and feelings in a non-judgemental conversation with someone who can express compassion. The conversation needs to focus on how well they managed the situation, and any new information that has been discovered that may reduce the frequency and intensity of meltdowns.

Recommended reading: From Anxiety to Meltdown (2011) by Deborah Lipsky, London, Jessica Kingsley Publishers.

Understanding challenging behaviour in classic autism

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Understanding challenging behaviour in classic autism

Classic autism is a term we use to describe our original conception of autism. A child or adult who has significant and conspicuous social, language, learning and behavioural impairments. We now use the term Autism Spectrum Disorder Level 2 or 3 to describe this expression of autism. Challenging behaviour can occur due to difficulties with communication, a distinct profile of cognitive and social abilities, sensory sensitivity and difficulty regulating emotions. There can also be movement disorders and medical factors that affect the behaviour of those who have classic autism.

Communication

One of the primary causes of challenging behaviour is frustration from not being able to effectively communicate thoughts and feelings. There is usually extremely limited speech which has not been replaced with a complex gestural communication system as occurs with deaf children. We are exploring the origins of the lack of speech which may be an expression of apraxia, that is a difficulty getting the brain into gear with the mouth and body. New therapies such as PROMT are designed to encourage speech by the specially trained speech pathologist using their hand to encourage jaw, lips, and tongue movement. There are also Apps to encourage vocalization and speech as well as advances in communication from Music Therapy and alternative and augmentative communication systems. It is important to remember that lack of speech does not automatically imply a lack of intelligence, and that for some classically autistic children, they learn to read before learning to speak.

When there is extremely limited speech, the signature mannerisms of autism are an effective means of communication. Parents and teachers often ‘translate’ the behaviour as thoughts such as “I can’t cope” or “I need help” or feelings such as jumping for joy or ‘in a flap’. These mannerisms can also be used as an early warning system of signs of distress and agitation.

Cognitive abilities

The cognitive profile associated with classic autism includes a range of characteristics that can affect behaviour. There can be a fear of making a mistake and a lack of cognitive flexibility such as not knowing what else to do. The overriding priority is to solve a problem rather than satisfy the social or emotional needs of others, with self-esteem from intellectual achievements. The learning style can be a ‘visualizer’ with a preference for a silent demonstration of what to do, and learning cognitive abilities and language from a computer or television screen. There can also be a talent and interest in identifying patterns and sequences and enjoying symmetry. However, there can be a very limited tolerance of frustration, with a tendency to quickly ‘hit the panic button’, having an intense aversive emotional reaction and giving up quickly to end the ‘pain’.

Social abilities

One of the central diagnostic criteria for autism is a deficit in social-emotional reciprocity, reading non-verbal communication and making and maintaining friendships. The social context can cause confusion, stress and feeling overwhelmed for autistic children and adults, leading to avoidance and escape behaviour. There are several relevant social dimensions such as the number of people in a room, intrusive peers and adults, and the duration of socializing. For an autistic person, socializing is emotionally and energy draining, rather than refreshing and enjoyable. There is a need for regular ‘oases’ of solitude, with a preference for solitude as an emotional restorative and for learning.

A characteristic of autism is to be extraordinarily sensitive to another person’s negative mood such as disappointment, anxiety, or agitation. There can be an avoidance of some social situations and specific people due to a perception of ‘negative vibes’ and quickly determining if someone is ‘autism friendly’. Some parents, teachers and therapists have an intuitive understanding of autism and facilitate social engagement rather than withdrawal.

We now have a range of programmes to encourage social abilities and confidence such as Social Stories developed by Carol Gray and ensuring social engagement, especially in a learning situation, that can be fun together.

Sensory sensitivity

Another diagnostic criterion for autism is sensory sensitivity. Specific sensory experiences are aversive and often painful. Repeated exposure does not automatically reduce the degree of sensitivity, but we can encourage endurance and develop avoidance and barrier strategies, such as vacuum cleaning the house when the child is at school, or using ear plugs or noise reducing headphones in the classroom or playground. The sensory profile associated with autism is complex including being overly sensitive to external sensory experiences such as sounds, lighting, touch, and smell, but lacking sensitivity to internal sensory experiences such as needing to use the toilet, hunger, and body temperature. Occupational Therapists have developed sensory assessment questionnaires for parents and teachers and strategies to moderate sensory sensitivity such as Sensory Integration and Processing Therapy.

An autistic child or adult lives in a world of terrifying sensory experiences and may have discovered a coping mechanism of being mesmerised by a repetitive action or sensation that ‘blocks’ the aversive sensory experience. Temple Grandin described how: “Intensely preoccupied with the movement of the spinning coin or lid, I saw nothing or heard nothing. People around me were transparent and no sound intruded on my fixation. It was as if I was deaf. Even a sudden loud noise didn’t startle me from my world. But when I was in the world of people, I was extremely sensitive to noise.”

The sensory profile associated with autism can also include craving specific sensory experiences, often avidly mouthing, touching, sniffing, or spinning objects.  The experience is perceived as enjoyable but can be distracting and disruptive in a school or community setting. Sensory Integration and Processing Therapy may also help with this type of challenging behaviour.

Regulating emotions

From early infancy, an autistic child or adult may be notorious for having intense anxiety, anger, or sadness, that seems to be an ‘on/off light switch of brilliant light rather than a gradually increasing dimmer switch. When extremely distressed the autistic child or adult is not responsive to reason, distraction, or compassion. There can be a meltdown that is outwardly directed and an energy explosion, or inwardly directed implosion. We are developing strategies for a meltdown that include a parent, teacher or caregiver not interrogating the autistic person as to why they are distressed, nor becoming emotional -especially expressing anger or affection and focusing on punishment and consequences to end the meltdown. It is important to affirm and validate the emotion, confirm the feeling will eventually go, to keep other people away, and perhaps using a special interest as an ‘off switch’.

Nearly all autistic individuals have high levels of anxiety throughout their day and intense anxiety associated with specific situations. This includes anxiety created by change, transitions and the unexpected, as well as the anticipation of aversive sensory experiences and abandonment (separation anxiety). To cope with anxiety an autistic child or adult may become very controlling of others and events in their daily lives, being oppositional and not complying with simple requests. Another coping mechanism is developing routines and rituals as a calming mechanism or engaging in a favourite activity as a thought blocker. An alternative effective coping mechanism is an explosion or melt down to discharge the emotional energy and to reset emotion regulation. There are strategies for each type of coping mechanism that becomes a challenging behaviour due to anxiety that includes the concept of an ‘Emotional Toolbox’ with a range of tools to regulate emotions and emotional energy. This can include regular physical activities, encouraging relaxation and self-awareness using mindfulness, mediation, and Yoga. There are additional tools in terms of medication for anxiety and depression.

Movement disorders and medical factors

Autism is associated with dyspraxia, a range of involuntary tics and akathisia or motor restlessness. These movement disorders will affect daily living skills and motor coordination and potentially cause frustration, stress, and distress. Advice may be sought from an Occupational Therapist or Physiotherapist. There are also medical factors that may affect behaviour and abilities, such as epilepsy, auto-immune disorders and poor quality and duration of sleep. Thus, the management of challenging behaviour in classic autism requires a multi-disciplinary approach, an understanding of autism and the function of specific behaviours.