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The emotion repair toolbox

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The emotion repair toolbox

Autistic children and adults usually have a limited range of emotion repair mechanisms and are less likely to use the more effective strategies used by typical children and adults, such as putting the event in perspective, reappraising the situation, considering alternative responses, acceptance, or being able to disclose feelings to another person, thus seeking, and benefiting from compassion, validation and affection from a family member or friend. However, autistic children and adults can learn new emotion repair strategies, and these can be conceptualised as acquiring more emotion repair tools.

From a very early age, children will know a toolbox contains a variety of different tools to repair a machine or fix a household problem. The strategy is to identify different types of ‘tools’ to fix the problems associated with negative emotions, especially anxiety. The emotion repair for autistic children and adults can be conceptualised as a problem with ‘energy management’, namely, an excessive amount of emotional energy and difficulty controlling and releasing the energy constructively. Autistic individuals appear less able to slowly release emotional energy by relaxation and reflection, and usually prefer to fix or release the feeling by an energetic, potentially destructive action or thought and emotion blocking action.

The range of tools can be divided into those that quickly and constructively release, or slowly reduce, emotional energy, and those that improve thinking or reduce sensory responsiveness, as well as taking out of the toolbox those tools that can make the emotions or consequences worse such as self-harm.

Physical tools

A hammer can represent tools or actions that physically release emotional energy through a constructive and acceptable activity. For young autistic children, this can include bouncing on the trampoline, going on a swing or using playground equipment. Although these facilities may be available at a school, they may not be used by an autistic child due to the number of children using the same equipment, and the autistic child’s need to achieve solitude and avoid social interactions during break times. They may have special dispensation to use such equipment when the other children are in class. At home, it is easier to encourage such physical activities as an emotional repair mechanism.

For older children and adolescents, going for a run, or dancing alone in a bedroom may be used to ‘let off steam’ or release supressed or increasing emotional energy. An autistic adult described how, ‘running keeps anxiety away.’ Other activities may include cycling, swimming or playing the drums, tennis practice or horse riding, and going to a fitness centre.

Unfortunately, autistic children and adults often feel, and indeed may be, clumsy and poorly coordinated, and have often been teased in the past by peers for not being good at team sports and ball games. While research has confirmed that physical exercise decreases repetitive behaviour, aggression, inattentiveness and escape behaviours in autistic children (Lang et al., 2010), there may be limited motivation and low self-confidence with physical activities. A personal trainer may be able to assess the child or adult’s body type and personality and design a specific programme of realistic and achievable physical activities that can be completed in solitude, and do not involve activities in a social context where there is a risk of ridicule. We recognize that regular exercise is excellent for mental and physical health, but also to improve clarity of thought and problem-solving abilities. ‘Exercise will make you smarter’ is a concept we explain to autistic children and adults who often value and seek to demonstrate their intellectual ability.

Some autistic children and adults have identified that destruction is a physical tool that can be a very effective ‘quick fix’ to end unpleasant feelings of suppressed or increasing anxiety, depression and anger. At home, there are some household activities that provide a satisfying and constructive release of potentially destructive energy, without causing damage that may require expensive repairs.  For example, empty cans, water bottles or packaging can be crushed for recycling, or old clothes torn up to make rags. This ‘creative destruction’ might be the repair mechanism of first choice at home, and especially when returning home from school or work.

Relaxation tools

Typical children and adults usually know intuitively how to relax, and it is a state of mind that they will have often experienced. This may not be the case with an autistic person. Our extensive clinical experience has indicated that there is often a difficulty in achieving a state of relaxation, and confusion as to what to do when someone says, ‘Just relax.’

Relaxation tools help the person lower their heart rate and gradually release and reduce emotional energy. Perhaps a picture of a paintbrush or spirit level could be used to illustrate this category of tools for emotional repair. Relaxation tools or activities could include drawing, reading and especially listening to calming music to slowly unwind negative thoughts and fears. Routine chores or activities can result in a sense of accomplishment, satisfaction and relaxation when complete.

A characteristic of autism is find that solitude, in the sense of being alone rather than lonely, is a very effective means of relaxing. Being away from people, and from certain sensory experiences – perhaps retreating to a quiet, secluded sanctuary – is an effective way of reducing anxiety and stress, and achieving relaxation and emotional repair. The autistic person will need islands of tranquillity and solitude both at school or work and at home.  It may be possible for the autistic child or their parent to talk to a teacher about accessing somewhere secluded at school during break times or recess, for example, the library. Such solitude can be emotionally refreshing and a means of true and deep relaxation. A further source of relaxation can come from being in nature, walking or camping in a natural environment, with few social encounters and only natural sensory experiences and engaging with the wildlife.

Cue-controlled relaxation is also a useful emotion repair tool. The strategy is for the person to have an object, perhaps hidden in his or her pocket, that, through association, symbolizes and engenders feelings of being calm and relaxed. For example, an autistic child may feel relaxed when on holiday and going fishing: thus, a fishing float in a pocket can be retrieved and looked at to recreate the feelings, images and sensations of relaxation and enjoyment when fishing.

Meditation tools

In Western cultures, there is a growing awareness and appreciation of the value of activities such as yoga in encouraging a general sense of well-being and providing an antidote to anxiety. We now have yoga activities specifically developed for autistic children to use at school and home (Betts & Betts, 2006; Bolls & Sewell, 2013; Mitchell 2014; Hardy, 2015), and some teachers are now using classroom and individual meditation activities to encourage relaxation and enhanced attention for the whole class. Mindfulness is also being used to regulate attention toward the present moment, to let an emotion pass and encouraging an attitude of openness and acceptance using imagery, meditation and yoga (De Bruin et al., 2015).

A meta-analysis of 123 studies of the effects of meditation of the brain found that eight regions of the brain were consistently enhanced in meditators (Fox et al. 2014). All eight brain areas are associated with autism. Thus, meditation can be perceived as a form of therapy for autism.

Social tools

This tool is to be with someone, or an animal, that can help repair the mood. These tools could be represented by a sponge to soak up the emotional distress. The social experience will need to be enjoyable and without the stress that can sometimes be associated with socialising, especially when the interaction involves more than one other person. For an autistic person, two are company, three a crowd. There are social experiences that reduce anxiety, for example, being with someone who has the ability to be like an emotional ‘sponge’, soaking up worries and anxious thoughts; a particular family member, teacher or colleague who accurately ‘reads’ the autistic person’s emotional state and intuitively knows what to say or do to be reassuring and calming. Another social tool, in the broadest sense, is spending time with pets that are non-judgemental listeners and more forgiving and accepting than humans. Sometimes, even just looking at photographs of favourite people and pets on a mobile phone or iPad can significantly decrease anxiety, despair, and agitation.  Someone emotionally close to an autistic child or adolescent could make an audio recording of soothing comments on their mobile phone to help them cope with extremely anxious or distressing moments.

Helping others

Another tool is the act of helping someone and being needed – an altruistic act. Autistic individuals can change their mood from self-criticism and pessimism to a feeling of self-worth and resilience when they experience opportunities to help and be of value to others. This can include activities such as helping someone who has difficulties in an area of the autistic person’s talents or expertise: for example, helping a teacher or sibling fix a problem with a computer. Being needed and appreciated is a significant emotional repair mechanism for all of us, including autistic individuals.

Internet activities

Internet support groups and conversations between subscribers or multi-player games participants can be an effective emotional repair mechanism. Autistic individuals often have greater eloquence and insight disclosing their inner thoughts and feelings by typing rather than talking; they don’t need skills with eye contact, or to be able to read a face or understand changes in vocal tone or body language when engaged in a ‘conversation’ on the Internet. The chat line or Internet conversation can include other autistic people who have genuine empathy and may offer constructive suggestions to repair a mood or situation.

Thinking tools

Another type of implement, such as a screwdriver or wrench, or a repair manual, can be used to represent a category of tools that can be used to change thinking or provide knowledge. The autistic person is encouraged to use his or her intellectual abilities to control feelings such as anxiety by using a variety of techniques such as self-talk or an internal dialogue such as, ‘I can control my feelings’, ‘I can stay calm’, or, ‘be a mirror, not a magnifying glass’. By using words and thoughts that are reassuring and encourage self-confidence and emotional resilience, the autistic person is encouraged to create a ‘force field,’ ‘suit of armour’ or ‘umbrella’ for emotional protection.

A thinking strategy is the creation of ‘antidotes to poisonous thoughts. The procedure is to think of a comment that neutralizes or is an antidote to negative (poisonous) thoughts. For example, the negative thought, ‘I can’t do it’ (poisonous thought) can be neutralized by the antidote, ‘If I stay calm, I will be quicker at finding the solution’; or ‘I’m a loser’ can be neutralized by the antidote, ‘but I’m a winner at Minecraft.’ A list is created of the person’s negative or poisonous thoughts, and the parent or teacher helps create a personalized antidote to each thought. Cognitive Behaviour Therapy (CBT) focuses on discouraging maladaptive thinking and encouraging adaptive thinking and CBT has been adapted to accommodate the characteristics of autism (Scarpa, Williams White and Attwood 2013). The maladaptive thinking associated with autism is a tendency to catastrophise (meltdown) or supress (engage in a special interest) and CBT encourages adaptive thinking such as self-soothing, perceiving alternative perspectives and the disclosure of feelings to others.

Academic or intellectual achievement

A tool that can be used with autistic children and adults to reduce anxiety and improve mood and resilience, is the achievement of academic success or acquiring knowledge on the Internet. When an autistic child is anxious or agitated in class, the teacher may instruct the child to complete an academic activity that he or she enjoys, and for which the child has a natural talent, such as solving mathematic problems, spelling, playing an instrument or drawing. This is in contrast to typical children, who would probably try to avoid academic tasks when stressed. Adults may reduce stress and improve their mood and self-esteem by seeking knowledge via the Internet or reading.

Additional tools: Sensory sensitivity, nutrition and sleep

The exploration and analysis of the causes of anxiety may include sensory sensitivity (Green & Ben-Sasson 2010). Experience has indicated that repeated exposure to the sensory experience does not easily lead to habituation and a reduction in sensitivity. Sensory sensitivity appears to be a life-long characteristic of autism, with adults creating life circumstances to avoid some sensory experiences or, with maturity, learning to consciously endure and tolerate such experiences, even though they may be just as aversive as they were during childhood. An occupational therapist may be able to provide advice on strategies to reduce or tolerate sensory sensitivity. For example, auditory sensitivity can be for both sounds of a particular pitch or volume, or general noise levels, and can include difficulty filtering out background sounds to focus on a teacher’s or line manager’s voice. Anxiety can occur due to the possibility of not being able to hear important instructions. Specific sounds can be avoided, or encountered less frequently, such as someone shouting; or being prepared and supported for particular events, such as fire alarm testing. A Sensory Integration Programme created and conducted by an occupational therapist may reduce sensory sensitivity.

Clinical experience and advice from mature autistic adults suggest that physical and emotional well-being can be improved by reducing the amount of junk food consumed and having a good diet with nutritious food (Attwood, et al., 2014). While junk food is popular, well-advertised and easy to acquire, and can provide some comfort in the short term, the problems, which range from unstable mood to weight gain, outweigh the perceived benefits. Healthy food does contribute to a healthy mind.

We recognize that autism is associated with a range of sleep disorders (Chen et al 2021; Kotagal, & Broomall, 2012;). Sleep has many functions, one of which is to refresh mind and body. The sleep cycle associated with autism can be unusual, for example, taking some time to actually fall asleep (especially if worried about events of the day, or fearfully anticipating the next day), with a tendency for there to be a disturbance of the depth and quality of sleep subsequently. While attention to, and modification of, sleep routines, and medications such as Melatonin, can all help establish a reasonable sleep cycle, if problems persist, a referral to a sleep clinic may be needed. Having restful and deep, uninterrupted sleep can lead to an improvement in the ability to manage emotions such as anxiety.

Summary for the emotional toolbox

We recognise that autistic children and adults will have difficulties managing and expressing feelings which become increasingly significant throughout childhood, and especially in the adult years. Autistic adults often rate problems with anxiety and depression as having a far greater effect on their daily lives than making and keeping friends and getting and keeping a job (Attwood, et al., 2014). Thus, we need to recognize the importance of emotion repair at home, school and at work.

References

Attwood, T. Evans C. & Lesko A. (2014). Been There. Done That. Try This!: An Aspie’s Guide to Life on Earth. London: Jessica Kingsley Publishers.

Betts, D. E., & Betts, S. W. (2006). Yoga for children with autism spectrum disorders: a step-by-step guide for parents and caregivers. London, Jessica Kingsley Publishers.

Bolls, U. D., & Sewell, R. (2013). Meditation for Aspies: Everyday Techniques to Help People with Asperger Syndrome Take Control and Improve Their Lives. London: Jessica Kingsley Publishers.

Chen et al (2021) Sleep problems in children with Autism Spectrum Disorder: A multicenter survey. BMC Psychiatry 21:406

De Bruin, E. I., Blom, R., Smit, F. M., Van Steensel, F. J., & Bögels, S. M. (2015). MYmind: Mindfulness training for Youngsters with autism spectrum disorders and their parents. Autism, 19(8), 906-914.

Fox et al 2014, Neuroscience & Biobehavioural Review, (Apr), 20140409.

Green, S. A., & Ben-Sasson, A. (2010). Anxiety disorders and sensory over-responsivity in children with autism spectrum disorders: is there a causal relationship?. Journal of Autism & Developmental Disorders, 40(12), 1495-1504.

Hardy, S. T. (2014). Asanas for Autism and Special Needs: Yoga to Help Children with their Emotions, Self-Regulation and Body Awareness. London.  Jessica Kingsley Publishers.

Kotagal, S., & Broomall, E. (2012). Sleep in children with autism spectrum disorder. Pediatric Neurology, 47(4), 242-251.

Lang, R., Regester, A., Lauderdale, S., Ashbaugh, K., & Haring, A. (2010). Treatment of anxiety in autism spectrum disorders using cognitive behaviour therapy: A systematic review. Developmental Neurorehabilitation, 13(1), 53-63.

Mitchell, C. (2013). Mindful Living with Asperger’s Syndrome: Everyday Mindfulness Practices to Help You Tune in to the Present Moment. London. Jessica Kingsley Publishers.

Scarpa, A., Williams White, S. and Attwood T. (Eds) (2013) CBT for Children and Adolescents with High Functioning Autism Spectrum Disorders. New York, The Guilford Press

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.