Autism Consult - NCSteven C Altabet, Ph.D

Facing Fears - Using Imaginary Exposure

3/27/2015

As mentioned in my two previous posts, exposing someone to an anxiety provoking stimulus using a series of graduated steps paired with relaxation can help a person slowly get over their fear of that object or situation. However, what happens when the anxiety provoking stimulus cannot be presented in a controlled stepwise manner? An example of this could be speaking in public. Unless you are part of a speaking group or class it may be difficult to predict or control when your next public speaking opportunities may be.  When opportunities to encounter the anxiety provoking stimulus are not predictable (as it was with the school bus) then an image of the stimulus can be paired with relaxation in the early steps of the hierarchy until an opportunity for the actual stimulus is available.
    Using the public speaking example, the person could first create an audience in their mind and imagine speaking to them while performing the relaxation. If the person cannot create an image in their mind then a picture of a audience could suffice. If there are specific worries related to the speech, like forgetting what to say, that can be worked into the scene. Once comfortable in that situation, the next step could be making the speech in front of one familiar person, then a small familiar group, gradually leading up to the actual speech.
     A couple of important tips to remember. For every specific worry there needs to be a counter thought or solution. If the worry is forgetting then a solution could be making small cue cards so the person can easily access a way to stimulate their memory. If answering questions is a worry, then help the person come up with specific answers to anticipated questions prior to the speech. If the anxiety is related to a lack of knowledge or skills then those need to be taught first. The other aspect to keep in mind is that desensitization is not a method for encouraging people to perform activities they find unpleasant. This is only to be used when the person wants to do an activity but experiences sensations of anxiety/duress when trying to do so. It is important to respect people's preferences and gain consent prior to starting any exposure procedure.

Steven C. Altabet, Ph.D.

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Facing Fears - Part 2

3/18/2015

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As I mentioned in my previous post, facing fears systematically (in small steps paired with relaxation exercises) can be more effective for people with neurological sensitivities than a more direct exposure approach. In this discussion I will give a specific example where Systematic Desensitization has been helpful. I use an example relating to a specific fear.
      One of my first jobs was as a school psychologist and there was young girl who was terrified of getting on the school bus. The first step was to teach her how to breathe deeply. Once this was accomplished, a task analysis/fear hierarchy was set up to get her to first see the bus from a distance (30 feet away) then, once comfortable, get closer and closer (5 foot increments) until she was able to board the bus and ride the bus home.  Once the hierarchy was set up it was time to implement the plan. It was arranged with the girl's mother to drop off and pick the girl up from school during this process. After that, at the end of the school day, I would escort the girl to the bus loading area. We walked toward the bus until we were 30 feet away.  The girl was then instructed to look at the bus and stay right where she was and breathe slowly until she felt calm. She was assured that she did not have to go any further, but had to stay where she was until she felt calm. The girl agreed and when she looked visibly calm (and stated so) we left the area and her mother took her home. The next day we walked up to 25 feet away and we continued at this rate until she got on the bus. After each session the girl was asked if anything bad had happened during the exposure. She always said no, but if it had we would have addressed her concern. Once she was able to get on the bus, I was prepared to ride the bus with her for support, but the girl wished to ride the bus alone (her mother was waiting for her at home). She reported being able to do the deep breathing while on the bus and made it home without fear. She continued to ride the bus home the rest of the year.
   This happened to be a fairly easy case because her fear was directly about the bus itself and not worrying about something bad happening while on the bus like the bus breaking down or getting off at the wrong stop. In cases like that, in addition to the deep breathing, we would developed a coping thought to address the worry. For example if the client was an adult who was fearful of the getting off at the wrong stop, a coping statement could be "the bus driver will call out when the stop approaches, but if I did miss the stop I could get on another bus to take me to that stop." The other easy aspect of this case was that the feared item was accessible almost daily allowing for a 'real life' exposure that was well controlled.  Exposure to other fears may be more complicated if the feared item is not consistently available or the fear is an imagined situation that may or not happen. Systematic Desensitization can be still be applied to these situations, but the exposure then needs to take place in the person's mind. I'll save that for my next post.

Steven C. Altabet, Ph.D.

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Facing Fears

3/14/2015

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When it comes to fear, the adage is that if you face you are afraid of you will get over your fear. In my years of work with people with Autism I have come to the opinion that this statement is incomplete. Facing a fear all at once without any coping tools or support will not make the fear go away, but typically make the fear stronger leading to an increased likelihood of avoidance or resistance. For people who are emotionally/neurologically sensitive, the physiological effects of the fear response are so intense that prolonged exposure to what you fear stimulus becomes unbearable. To help overcome fears I propose an old school behavior therapy technique.
    Systematic Desensitization is a highly structured stepwise exposure procedure that allows the person to face their fear a little at a time in small manageable steps. Additionally, the exposure is paired with relaxation exercises so the physical intensity of the fear response is lessened. Over time the feared situation is associated with a relaxed feeling rather than a tense one. Doing this involves combining some of the previous behavior training techniques that have been discussed in past posts.

1. Create a fear hierarchy - For those who are more familiar with Applied Behavior Analysis (ABA) this means creating a task analysis for the fear exposure. Break up the exposure in to a series of small steps starting with a nonthreatening exposure then VERY GRADUALLY increasing the threat until full exposure is achieved. These steps are written out on a list with only one step of the exposure performed each time. A person cannot proceed to the next step until they feel completely comfortable with their current step. If the person is able, have them identify the different aspects/steps of their fear and rate each step to make sure that the steps are being ordered in increasing intensity.

2. Develop a reliable relaxation response - The key is for the person to be physically calm as possible when facing their fear. Prior to any exposure, develop a relaxation response that lowers the person's arousal level and they feel comfortable using. Deep breathing is typically the easiest to learn. Just remember that the breaths need to be not just deep, but slow and soft as well. Timing is important, about 4 seconds in and out. Listening to a recording of ocean sounds can help a person time their breath to the rhythm of the waves.  To help control the force of breath, think of the breathing in like sipping through a straw and breathing out like trying to blow large bubbles or slowly turning a pinwheel. If relaxation cannot be achieved through deep breathing, relaxation may be gained passively by listening to soft music or nature sounds and turning down the lights. Relaxation can be accompanied by positive thoughts such as I am safe, I am comfortable, or even a specific coping strategy ("If I have a problem I can call for help").

3. Perform each step of the hierarchy paired with the relaxation response - Once the person feels comfortable with the relaxation response it is time for the exposure. Start with the easiest/least intense step. After discussing what the exposure plan is and getting the person's consent begin with the relaxation exercise. Once the person appears calm expose them to step 1 of the hierarchy. Exposure can be live (actually seeing what is feared), in the person's imagination (creating a mental picture or thought). Likely the person will feel anxiety symptoms upon initial exposure but should gradually calm as they continue to perform the relaxation. They key is for the person to stay in that step of the exposure until they are completely relaxed. Early escape will only reinforce the fear. Once complete relaxation with that step has been achieved, then the exposure can end. Sometimes you can proceed to the next step if the person wants to, but often a break is needed. If the person gets stuck at a step, that step may need to be broken down further or an additional coping strategy may be needed. I'll give some examples next post.

Steven C Altabet, Ph.D.

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Pleasure Seeking vs. Positive Emotion

3/8/2015

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The last couple of posts talked about increasing positive emotion including increasing opportunities for positive emotion.  typically these activities can fall into one of three categories:
1. Activities for pure pleasure seeking - These activities are typically solitary and while enjoyable do not lead to any personal growth or discovery. Examples include playing video games alone, reading about previously learned material, or engaging in a preferred routine behavior without any changes.

2. Activities for shared enjoyment - These can be any enjoyable activity, but are done with another person. The more physical proximity there is the more positive emotion is derived. For example more positive emotion would be experienced playing video games with a friend in person than would be experienced playing with that same friend online. the same would apply for discussing a topic of shared interest.

3. Activities for personal growth - These are enjoyable activities that involve learning something new or performing a new behavior. For example learning new information about a preferred topic would qualify for this category. Teaching or discussing that information with another interested person would then result in shared enjoyment.

The best way to conceptualize the different types of activities is to think of pleasure seeking activities as a method of coping with the stress of every day life. The other two types of activities are ways of mind expansion either intellectual or social-emotional.  Since mind expansion and coping are both very important activities, the key is to have a balance of both in your daily activity schedule. Two other important things to remember with regard to people with Autism Spectrum Disorder:

A. While pleasure seeking/coping activities are important, doing them for too long a time can make it extremely difficult to want to do other activities, which will inhibit development and result in increased isolation. Also, overuse of pleasurable activities can eventually make them less pleasurable and result in less coping power. While time limits for individual people may vary, a general rule of thumb daily use should fall between 20-40 minutes. If the activity can only be done weekly, then the time limit can increase to 1-2 hours depending on the person's tolerance for stimulation.

B. With mind expansion activities, people with Autism typically can only handle change or social interaction in small increments. While it would still be beneficial for these activities to occur daily, it would be best if they are done in small increments with breaks in between of quiet/solitary activity. For example, a person with Autism could be more productive if their work/school day contains several short breaks scheduled regularly at specific times during the day (typically following stimulating activity).

By striking a balance between pleasure seeking and mind expanding positive activities, you are ensuring the best chance for personal growth with the least amount of resistance. I'll addressed dealing with fear/resistance in my next post.

Steven C Altabet, Ph.D.

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Developing Positive Emotions

2/25/2015

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Last post I introduced the value of increasing positive emotions by increasing the awareness of people with ASD to the positive events and emotions the person is already experiencing.  While this is a helpful beginning, it is often not sufficient to convince an overly critical thinker to think more positively. Belief in new ways of thinking only change when experience changes in a way that backs up new beliefs. It's like with confidence. Confidence only comes when you have a history of previous success to draw upon during times of difficulty. In order to increase both confidence and belief in the value of positive thought, there needs to be an accumulation of positive experiences. For many people with Autism, I believe that the best way to do this is to actively include successes and activities that lead to positive emotions into the daily schedule.
       I would start by developing a list of activities that the person can perform successfully or helps the person feel good about themselves. This is not isolated pleasure seeking like playing video games alone, but an interactive and productive activity that the person enjoys and has some skill. The best activities are ones where there is not only success/proficiency, but also the opportunity of giving to/helping others. The opportunity to give support rather than merely receive it increases self worth and increases the enjoyment of the experience. Make sure the person having to do these actions is contributing to the list.
     Once the list is completed, designate a specific time each day when the positive activity is to be conducted. The person and caregiver can choose an activity from the list each day. As long as the activities are not too challenging or stress provoking there should be cooperation in doing these. Encourage the person to acknowledge their feelings during the activity. Statements such as "You've been a big help, you should feel proud of what you done" could spur the person to think of other positive emotions or at least help them identify a positive feeling that they may have had trouble putting into words. Once the activity is completed, there may need to be some down time to wind down and recover from the stimulation and interactive activity. Once daily practice of positive activity is begun, experiencing of positive emotions will begin to become real and not just a bunch of words without meaning.

Steven C. Altabet, Ph.D.

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Positive Thoughts

2/18/2015

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I've been taking a course on Positive Psychology for personal interest, but the more I learn the material, the more I think that this information could be of great benefit for people with Autism (ASD) if presented in a way that they could relate to. When I have tried to introduce more positive thinking to my higher functioning clients with ASD, many of them have resisted the idea calling my approach 'unrealistic' believing that people who are primarily happy are either fake, lack intelligence, or live in fantasy land.  I believe the reason for this is that a cognitive strength of many people with ASD is there ability to think analytically and to focus on small details. While this can be a great asset in situations where attention to detail is needed, it can also lead highly critical and negative thinking. Negative emotions in turn are experienced very strongly and become highly reinforcing leading to a spiral of negative thoughts and emotions. Negative emotions also lead to a restriction of thought which allows a person with ASD to remain in their comfort zone. Positive thoughts in contrast are experienced more subtlety, but lead to broader thinking and new ideas/experiences. So, in essence, by promoting positive thoughts, you are asking a person with ASD to go away from their cognitive strength and enter a place that is uncomfortable for them, except in areas of personal interest.
      Fortunately, Positive Psychology does not promote the elimination of negative thought or critical thinking.  These are important for us to keep safe and protected in environments that can be unpredictable. What is does do, however, is provide a framework to put these negative/protective thoughts into proper perspective. One of the main tenants of positive psychology is that while negative emotions are felt more strongly than positive emotions, most people experience much more positive events in their lives than negative ones and if a person is aware of the these positive events, the increased number of them 'off-sets' the high emotional charge of negative events leading to a balanced emotional state. This can be difficult for those who think in extremes or have trouble picking up on subtleties, but I believe that an acceptance of positive thought can be developed in the same graduated experiential way that many other adaptive, communication, and social skills are increased.
     In the beginning, let's start small. Have the person with ASD think of one positive experience each day and communicate it in the best way that they are able (speaking, writing, pictures, etc.).  The person may need some suggestions of positive events to get started or they can use their personal interest, although it would be helpful for the person to identify positive events outside of personal interests as well. Once the positive event is identified, have the person relate how it made them feel. Even if the response is just "good" that's an important place to start. Over time the number of daily positive events can be slowly expanded. Ideally, you'd like a ratio of at least 3 positive events/thoughts to 1 negative event/thought. Highly optimistic people have a ratio of about 5:1. Once the person begins to think more positively, then the opportunity for greater perspective regarding the negative emotions can be achieved.

Steven C. Altabet, Ph.D

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Keeping Your Finger on the Piece

1/25/2015

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     Ok, one last chess analogy. This one has to do with the idea that in chess a move is not official until you take your finger off the piece you are moving. It's the only game I know where you can make a move, say "wait, let me think about it," then decide "never mind I'm going to do something else."   It's not exactly a 'do-over' like kickball or a 'mulligan' in golf, but its pretty close and more applicable to real life.
     When we make mistakes in during our daily lives we can often atone for them, but we cannot erase them and make them disappear. The mistake, once made, never goes away which can be a very difficulty concept for many people with Autism to accept I'll address that issue another time). The beauty of putting your finger on the piece is you have a chance to realize your mistake before it happens and take measures to prevent it.
     Preventing actions that have potential negative outcomes can be difficult, but is achievable with practice and instruction, just like chess. When a thought or urge comes to mind, that is the initial move. It is usually a reaction to something else you experience and typically not preventable. However, just because that thought or urge is there does not mean you have to act upon it. While it may be easier to go ahead with the thought or urge, like the chess player, you can tell yourself "Stop" "Wait" "What might happen to me if I do this?" "Will it be good or bad?" "Is there something else I could do or say?"  These little messages can you save a lot of heartache. Even if you do decide to go ahead with the urge or thought, at least you know what you are getting into. Knowing what to expect is also very important for people with Autism.
     The final aspect of this approach that is needed to be successful is time. Time is needed to process these thoughts and make a decision. The person making the decision needs to allow themselves enough time to make the choice and others around that person need to provide that time as well. For the person with ASD, this means requesting the time you need to think things through. For the parents, caregivers, and educators that means allowing the person the time they need or asking the person with ASD "Do you need some time to think about it." Sometimes I find it help to provide visual cues. Single words such as Stop, Wait, and Think can often be good triggers for the process. They can be printed on index cards or saved on a phone or tablet. This approach can be especially helpful for people who more impulsive. While quick decisions may be better for simpler decisions, you will gain more benefit by keeping your finger on the piece before making a complex decision or important move.

Steven C. Altabet, Ph.D

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Increasing Awareness

1/18/2015

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Continuing with the chess theme from my last post, I'd like to discuss the concept of putting someone into 'Check.' When a player is about to capture someone's King and end the game, they first have to warn their opponent of the impending move by saying "Check." This alerts the opponent of the danger and forces them to move their King out of danger before they can make any other moves. In life, parents, educators, and other well meaning people try to warn other of potential dangers. Sometimes, especially with younger children, the person can be forced to avoid the hazard before doing anything else. However, many times, especially when the children get older, they cannot be forced to heed the 'check' and must make a conscious choice to take safety measures. Therefore, a key component of independence is being able to exercise caution when no one is there to provide the warning signal.
     While ther may be many reasons for this, in my practice I have noticed three main variables. The first is impulse control, which was discussed durng the previous post. The second is knowledge of potential dangers and their signals. While it is important not to assume that the individual knows the potential dangers and warning signs, this is knolwdge that can be taught and shared with amny people with ASD. The third, and perhaps the most innate variable to Autism is awareness. Awareness is essential not only for receiving information, but for making sense of it an acting upon it as well. People with overly sensitive nervous systems have difficulty with awareness because being fully aware can overwhelm the system, so lack of awareness is sort of a defense mechanism. However, just like with other behaviors and experiences, awareness can be gradually encouraged and increased through exposure and coaching.
     The easiest way to increase awareness is to begin with everyday routine activities, particularly ones that the person finds pleasurable. For example when taking a walk, instead of having a conversation or thinking of an unrelated thought, encourage the person to focus on what they see, hear, feel, or smell. At first you may only want to bring awareness to one sensory experience at a time and the total time of awareness may only be a few seconds or minutes. Additionally you may need to provide an incentive since the person may have to stop engaging in thoughts related to a person interest in order to become more aware. Once engaged in the awareness, have the person relate to you what they are experiencing. This will force the conscious mind to be more active and gradually strengthen neural connections that promote awareness. Awareness can also be increased by overtly talking about current activity, rather than just doing it silently and passively.   This can be done with a variety of sensory and active experiences.
     With continued practice over time, you will notice awareness gradually increase. With increased awareness, it becomes easier for information to taught, retained, and brought back into consciousness when needed.  While building awareness, it is important however to respect the person with ASD's need/desire to have time when they can lost conscious awareness and drift into their own thoughts. It allows their nervous system to recover from the increased awareness, but also allows them to generate the elaborate thought which makes their life fulfilling for them. The goal is not 100% awareness, but rather a situational awareness that can be turned on and off when needed. That will allow for greater independence and effectiveness in situations where caution is needed thus resulting in being to keep one's life out of 'check.'

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Chess and Autism

1/10/2015

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I listened to a comedian who was talking about how he was learning to play chess and certain things about the game struck him as odd. The first aspect that he brought up was the concept of Checkmate. "I haven't captured your king yet, but I will in three moves so I WIN!" "It's like the quarterback going up to the line and before he even stats the play saying TOUCHDOWN! THIS DOESN'T HAPPEN IN REAL LIFE" he exclaimed, but actually it does. It's called planning and anticipation. If we think about head of time what we want and how we are going to achieve it them we can anticipate a likely outcome. Many people with Autism whom I've worked with have difficulty with these concepts.
     When your life is primarily visually oriented, it is difficult to think about concepts you cannot physically see, like the future. If you cannot see the future or predict with 100% certainty what is going to happen, then why bother thinking about it? This thought process leads to having to frequently react to unexpected events, also very difficult for people with Autism.  There is hope, however. The first step is to help the person to a see their future. On a simple level, this could be showing basic cause and effect relationships through modeling, demonstration, pictures or diagrams. "If you only want to play the game by your rules, then other children are less likely to want to play with you." You can also develop more complex models. "Here are the steps needed to get into college, applying for a job, going on an interview etc.." Listing the steps on paper, poster, dry erase board etc... makes the future concept and steps to be planned out real for the person and because they see them, it makes the ideas be part of the person's awareness.
     Regarding anticipation, many of my clients with Autism do anticipate, but they typically anticipate negative outcomes and the negative outcomes are often exaggerated.   This is typically referred to as anticipatory anxiety. For those who anticipate the worst, there are a couple of ways to address their fears. The first is "Yes that could happen, but is it LIKELY to happen? If it isn't likely then what is likely to happen?" If the feared action is likely to happen then what can be done to help the situation. Another possibility is to ask what is the best thing that could happen? that will at least balance out the thinking and allow for the possibility if a more moderate response.
    With increased planning and positive anticipation, future events can be prepared for and the person with Autism can be on the giving end of the checkmate rather than the receiving end.

Steven C. Altabet, Ph.D.

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the Dialogue of Autism #25

12/27/2014

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Since it had been a while since my previous post, I published it again to help people become reacquainted with the material. I would like to follow up on that previous post by discussing how to teach the independent skills that were previously outlined. The basic elements of teaching independent skills in teens and young adults is not much different from teaching them to children. However, teaching independent skills to young adults requires greater willingness for community exposure. While skills can be initially taught through modeling, practice and repetition in more controlled settings such as home, school, or day treatment programs, it is only through allowing the person with ASD to use these skills in the community that allows independence.

To help with community exposure, the first thing for a parent, caregiver, or trainer to do is to establish some connections with the local stores, banks, and transportation agencies. By explaining the situation ahead of time, it allows the staff of that place to prepare for the encounter. Many shops will be willing to cooperate if they know what to expect with regard to specific behaviors or habits that are typical. If a community location does not feel comfortable with the situation it is good to know that so you can try something else. If a person with ASD has a bad early experience, it maybe difficult to get them to try again.

Once you've prepped the community location and they are on board, then you need to prep the person with ASD for the encounter. If the person with ASD is not familiar with the location, have them become familiar by taking them to that location in a non-training situation. Once the person has familiarity with the sights, sounds, and smells of the place, then a training run can be tried. Rehearse the desired independent behavior prior to going to the location and let the location know when you are coming so they can provide assistance if needed. The person with ASD my need a reminder of what to do once they arrive. This can be done with cue cards, pictures, or task lists. these can be put on a smart phone or tablet for greater discretion. This visual reminders will promote greater independence than verbal instructions so the visual reminders should be given first.. Allow the person to attempt the activity without help at first then provide the visual or verbal instruction as needed.

Multiple repetitions in the location will likely be needed before independence with this activity is achieved. It may be helpful to have a specific employee be the initial contact to help promote comfort when initial learning is taking place. Once familiarity is established other employees can be introduced by the familiar employee so trust and generalization are gained. As with any training patience and positive reinforcement are very important for ensuring continued cooperation and motivation for the person with ASD to keep trying. Any corrections taking place in the community should be brief and discreet as possible with greater elaboration, practice and retaining done on the home or training setting. If successful, the experience will not only provide a boost in self worth for the person with ASD, it typically provides a positive experience for the staff of the community location and will foster greater cooperation and tolerance from them in the future.

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<<Previous

Facing Fears - Using Imaginary Exposure

Facing Fears - Part 2

Facing Fears

Pleasure Seeking vs. Positive Emotion

Developing Positive Emotions

Positive Thoughts

Keeping Your Finger on the Piece

Increasing Awareness

Chess and Autism

the Dialogue of Autism #25

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