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Understanding empathy and autism

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Empathy

We know that there are three forms of empathy, cognitive, affective, and behavioural and that the expression of each is underpinned by similar and different neurological structures in the prefrontal cortex. Cognitive empathy is the ability to determine what someone is feeling or thinking by ‘reading’ their facial expressions, gestures, vocal tone, and social context. An autistic person may need to use intellect rather than intuitive abilities to identify and process nonverbal communication that they see and hear. Affective or emotional empathy is the ability to ‘feel’ the emotions of others. A recurring theme from our clinical experience of talking to autistic teenagers and adults and reading autobiographies is an over-sensitivity to the negative feelings of other people. Behavioural empathy is knowing how to respond to someone’s feelings. Autism is associated with uncertainty in identifying what is expected to be said or done to alleviate or respond to someone’s feelings.

Emotional empathy

A central characteristic of autism is difficulty knowing how to read and respond to the emotions of others (Schwenck et al 2012). However, clinical experience indicates that there is a hypersensitivity to feeling another person’s negative emotions such as disappointment, anxiety or agitation. Autistic individuals have a remarkable capacity to mirror, or amplify within themselves, how another person feels (Fletcher-Watson and Bird 2020). As one of the participants in that study said, “We express empathy differently.” This capacity has been described as empathy over-arousal (Smith 2009) and occurs in both autistic males and females (Schwenck et al 2012).

We have yet to determine how this capacity is achieved but quotations from autistic adults may provide some indication.

I am able to distinguish very subtle cues that others would not see, or it might be a feeling I pick up from them.

There’s a kind of instant subconscious reaction to the emotional states of other people that I have understood better in myself over the years.

Emotional empathy can occur with all expressions of autism. Robert Hughes (2003) wrote about his non-speaking autistic son, Walker whom he described as being a “supersensitive emotional barometer who registered the true emotional pressure in the air, no matter how hard we tried to mask it”.

Exteroception

We have long recognized that a characteristic of autism is an extraordinary perception of sensory experiences from the external world which we describe as exteroception sensitivity. This can be a heightened sensitivity to sounds, light intensity, tactile experiences, aromas, and tastes. We speculate that exteroception may include a sensitivity to the emotions of other people. An extraordinary ‘sixth’ sense can be a response to being with someone who is experiencing negative emotions, but also responding to suffering on television news and in documentaries far more than is typical.

In contrast to heightened exteroception, an autistic person can have difficulty with interoception, that is perceiving their own internal sensory experiences, such as not being consciously aware of increasing heart rate and breathing that indicate rising anxiety or agitation. In his autobiography, Aaron Wahl (2019) wrote “I perceived the feelings of others often overly clear but could not find access to my own”.

Negative and positive emotions

Our clinical experience indicates that there is an extraordinary perception and sensitivity to another person’s negative emotions, as in the comment If someone approaches me for a conversation and they are full of worry, fear or anger, I find myself suddenly in the same state of emotion. Negative emotions in others are ‘infectious’ to an autistic person. One of our clients’ said Emotions are contagious for me. Emotional empathy may be one of the reasons why autistic individuals avoid crowds due to the risk of proximity to someone who is experiencing a negative mood and being ‘infected’ by that mood.

As psychologists, we often try to determine why an autistic person experiences a negative emotion, and one of the reasons may not be due to a specific event or thought but being ‘infected’ by someone’s negative feelings. This may also contribute to a characteristic of autism of avoiding eye contact since the eyes convey feelings (Smith 2009).

Social withdrawal for an autistic person is not exclusively due to social expectations and sensitivity to auditory, visual, and tactile experiences. Lilian said We don’t have emotional skin for protection. We are exposed, and that is why we hide. The sensitivity to the negative mood of others can lead to wanting everyone to be happy.

While we have found that someone’s negative mood can be contagious for an autistic person, they may not be equally ‘infected’ by someone’s positive mood. They can seem impervious to someone trying to ‘jolly them up’. Happy and exuberant positive emotions in others may sometimes cause an autistic person to be confused and uncomfortable and not know how to respond or resonate with others, for example, at a family celebration or reunion or when someone receives exciting news.

There seems to be a preference for a middle to a neutral range of emotions in others, both negative and positive emotions. If there is any greater intensity, the autistic person may become confused, overwhelmed and unsure of what they are expected to do or say.

Strategies for coping with empathic over-arousal

As clinicians, we help the person create a mental barrier using the metaphor of protection by putting on armour and using a shield or putting up an umbrella for protection from a downpour of emotions. We also use advice from autistic adults who share the same emotional empathy such as an autistic mother who said: We have lots and lots of empathy, but if it’s too much to deal with you have to just shut it off because it’s so overwhelming (Dugdale et al 2021).

We also advise family members and teachers to be aware of how their negative mood can be contagious to an autistic person and we teach strategies to stay calm and neutral to assist their loved one through difficult emotions. Sometimes parents and partners may try to temporarily suppress their feelings, although an autistic person may be able to sense the emotions behind their mask of neutrality.

We encourage autistic people to explain their sensitivity to someone’s mood and that the reason for their temporary withdrawal or avoidance of them is a coping mechanism due to emotional empathy and not a rejection of them as a person.

When an autistic person has difficulties with behavioural empathy, that is knowing how they are expected to respond to the distress of another person, they may need clear guidance and encouragement on what to do or say. This could be to suggest that the autistic person gives you a hug that is within their zone of tolerance or makes a reassuring comment.

We now have programmes to help autistic adults read nonverbal communication (cognitive empathy) and develop verbal empathic comments (behavioural empathy) (e.g., Koegel et al 2016).

We also recognize that increased emotional empathy may be an advantage when being with autistic children and adults by being aware of an autistic person’s tolerance of emotional states in others and adjusting their interactions accordingly. We know of many autistic individuals who thrive in the helping professions due to their high levels of emotional empathy.

References

Dugdale et al (2021) Autism 25, 1973-1984

Fletcher-Watson and Bird (2020) Autism 24 3-6

Hughes R (2003) Running with Walker Jessica Kingsley Publishers

Koegel et al (2016) Improving Verbal Empathetic Communication for Adults with Autism Spectrum Disorder Journal of Autism and Developmental Disorders 46, 921-933

Schwenck et al 2012 Jr Child Psychology and Psychiatry 53:6

Smith, A. (2009) The Psychological Record 59 489-510

Wahl A. (2019) Ein tor zu eurer welt KNAUR

How to create an autism-friendly home

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How to create and autism-friendly home

Introduction

As parents get to know the profile of abilities and daily challenges of their autistic child, they make accommodations at home to create an autism-friendly environment. The central characteristics of autism include sensory sensitivity, need for times of solitude, social communication difficulties, engagement in a special interest and difficulty coping with change. Parents know that situations that are enjoyable for typical children can be stressful for an autistic child, such as having visitors to the home and making spontaneous decisions about activities for the day. There is also the likelihood of an autistic child having high levels of anxiety and being sensitive to the ‘emotional atmosphere at home. We will explore each of these characteristics of autism to affirm why the home of an autistic child may at times be different to the home of a non-autistic child.

Sensory sensitivity

Some sensory experiences are perceived as excruciatingly painful by autistic children. This can include sudden or ‘sharp’ noises such as a dog barking, the sound of electrical appliances, the type and intensity of natural and artificial lighting, tactile experiences such as seems and labels in clothing, the taste of some foods and the smell of cleaning products. Parents soon know which sensory experiences are aversive and recognise that for example, if their autistic child cannot tolerate the sound of a vacuum cleaner, to do the vacuuming when the child is at school or out of the house. They may also become aware of how auditory experiences during the night can cause an autistic child to wake up and adjust the child’s meals to accommodate sensory sensitivity associated with food. An occupational therapist may be able to provide advice on sensory sensitivity and adjustments that are needed at home.

Social experiences

Autistic children can enjoy social experiences, but social engagement is achieved through intellectual rather than intuitive abilities. Consequently, socialising with family members and visitors to the home can be mentally and emotionally exhausting. Parents may recognise when their autistic child needs to recover in solitude emotionally and cognitively, perhaps spending time alone in their bedroom or the garden. An autistic child may need guidance in reading social cues and knowing social conventions such as the different types of greetings according to the position of the visitor within the family and cultural expectations. For many autistic children, ‘two are company, three a crowd’ so there may need to be adjustments regarding the number of people in the room or home. Large family gatherings and sibling parties may need careful preparation and monitoring according to the ability and stress level of an autistic child. Parents will need to explain their autistic child’s challenges in social situations to those visiting the home.

Special interest

One of the characteristics of autism is an interest that is unusual in intensity or focus. The interest has many functions including a sense of emotional and intellectual enjoyment, a thought blocker for anxious or sad thoughts, an energiser when energy is depleted, such as when returning home from school and a means of making friends with those who share the same interest. The difficulty for parents is determining what is a reasonable amount of time to engage in the interest. There will need to be a compromise and an autistic child knowing and accepting when and for how long they can engage in their special interest.

Coping with change

Autistic children feel calmer when they experience routines and predictability in the daily schedule of experiences and expectations at home. There can be extreme distress when there are even small changes to their expectations. They have a ‘plan for the day’ and can have difficulty conceptualizing an alternative plan. It is inevitable that there will be unexpected changes in daily routines at home and parents will need to provide advanced information on what will change and why and help the child create a ‘plan B’.  Having too many changes in the day will increase stress levels which could result in an emotional meltdown. Parents tend to manage by planning fewer activities, using visual schedules, and giving advance notice of upcoming changes.

Coping with anxiety

Autism is associated with high levels of anxiety. Unfortunately, due to difficulties with interoception (perceiving internal body signals such as breathing and heart rate) and alexithymia (describing thoughts and feelings in words) an increase in anxiety levels may not be recognised and communicated by an autistic child. However, parents may gradually determine the signs and situations associated with anxiety. In the home environment, they will need to be aware of situations likely to increase anxiety such as specific sensory experiences, change and the unexpected, social expectations and fear of making a mistake. They recognise the child’s fight, flight or freeze reactions to high levels of anxiety and the tendency to refuse to comply with requests when anxious or needing reassurance and the completion of routines and rituals to alleviate their anxiety.

Parents will become aware of strategies to reduce their autistic child’s anxiety by providing reassurance, and information and being calm themselves. They may need advice from a psychologist and paediatrician on the range of activities and treatments available for anxious autistic children. This can include Cognitive Behaviour Therapy which may include meditation, mindfulness, and yoga that can be conducted at home. A paediatrician may consider medication to treat high levels of anxiety.

Managing a meltdown

Sensory, social, and emotional experiences can increase to a level where there is an emotional meltdown. Parents may have experienced an autistic child’s propensity for meltdowns since they were toddlers. There are two types of meltdowns that can occur at home, an explosion of emotional energy that is fuelled by frustration and anger or an implosion of emotional energy that is an expression of intense despair and the potential for self-harm. Parents will learn that during a meltdown they need to inhibit their own distress and be calm and reassuring, affirming, and validating the child’s intensity of emotions and explaining that the intense feelings will eventually go away.

It is also important not to ‘interrogate’ their autistic child as to why they are so angry or distressed.  In such an emotional state they will have difficulty giving a coherent and sequential explanation of why they are agitated. As an autistic child said: When I’m upset, the last thing I want to do is talk to someone. Parents will also learn that a focus on punishment and consequences during a meltdown will not be effective as explained by an autistic child who said: I can hear but my brain can’t process what people say.  After the meltdown parents can explore with the child what happened to create such intense distress and create with the child, a plan to manage similar situations in the future.

Experiencing and expressing affection

An emotion repair mechanism that is very effective for typical children is affection, but affection may not be as effective for autistic children. As an autistic adolescent said: Human comfort has always been a mystery. Parents soon learn to adjust their level of affection as an expression of love and reassurance to a level that is comforting and enjoyable for an autistic child. The level would probably be perceived as insufficient for a typical child but just right for an autistic child. Parents also come to accept that the autistic child’s own expression of love for them may not be at the level of expression they would like to experience. This is due to being autistic not an absence of feelings of love for a parent.

Emotional empathy and sensitivity

A characteristic of autism that we are increasingly recognising is an ability to perceive, absorb and amplify within themselves, negative emotions in others and a difficulty resonating with euphoria being experienced by other family members. A parent may be feeling anxious, agitated, or distressed (perhaps for reasons that have nothing to do with their autistic child) and try to suppress and inhibit their feelings. However, an autistic child can have a ‘sixth sense’ ability to recognise such feelings in others and be distressed themselves and not know either how to separate their own feelings from their parent’s feelings or what to do to repair their parent’s feelings. When parents are aware that this is happening, it is important to suggest to their autistic child what to do practically or emotionally (such as a quick hug) to make a parent feel better.

When there is a joyful family celebration, an autistic child may not be able to resonate with the euphoria of others and seek solitude or everyone return to a subdued emotional state. While parents may be aware of this characteristic of autism, it may need to be explained to visiting family members or family friends.

Social debriefing

Making and keeping friends can be difficult for autistic children and they are vulnerable to bullying, teasing and rejection by their peers. One of the roles of the parent of an autistic child is to provide an opportunity for a social and emotional debrief after school and to explain the intentions of peers and the development of a friendship network.

Coordinating support services

Parents of autistic children often benefit from a multi-disciplinary support team that provides advice on improving abilities and emotion and behaviour management at home and at school. Parents will need to coordinate information and strategies between their support team, teachers, and extended family. This will require the allocation of time for this role.

Daily living skills

Due to difficulties with motor coordination, attention, and planning, the parent of an autistic child will need to allocate more time than for a typical child to encourage daily living skills from learning to tie shoelaces to domestic chores. An autistic child is typically very dependent on external prompts as reminders to complete certain tasks. They also struggle to see “the point” of why they should engage in certain activities, such as household chores or tasks to attend to personal hygiene, because they personally do not care if their room is dirty, or they smell. Reasons for why we engage in these tasks need to be presented with calm and logic.

Summary

Creating an autism-friendly home will require adjustments to family routines and expectations and for parents to spend more time on a range of activities than would be expected with a typical child.  Making changes to both our expectations and the home environment, such as those changes described above, will ultimately decrease the background stress for your autistic child, and thus for the whole family.