Mental FlexibilityAn important part of developing coping skills is being able to adapt one's thinking to meet the demands of a situation.  When the behavior, thought or rationale you were using to address a situation is not working then the behavior or thought needs to change in order for coping to take place.  This can be difficult for people with ASD as many people with ASD can only think of one idea or engage in one behavior at a time.  Also, the person may become so invested in that thought or behavior that they cannot conceive of another possibility.  Even when an alternative is introduced, the alternative is often denied or dismissed despite compelling evidence.  Fortunately, the ability to recognize alternatives (referred to as mental flexibility) can be achieved, but it is typically a slow an gradual process.

From a Positive Behavior Support point of view, mental flexibility can be achieved by first establishing a consistent routine/schedule then changing one (and only one) aspect of that schedule each day.  Prior warning/review of any schedule changes should occur before the changes take place to give the person ample time to process the alteration and give them opportunities to find out more information.  There should also be a clear explanation for the change so the person can see the benefit of doing so.  While there may be initial resistance to the daily changes, if they are done consistently then the person will eventually come to expect to minor changes in routine and be more accepting when they occur.           

Another way to achieve mental flexibility is to offer choices.  Choices allow the person with ASD to see that there are multiple options available.  Start with two options as too many options may be overwhelming.  Be sure to make the options ones that can be carried out and would not cause distress for the person with ASD or the parent, caregiver, or educator.  Choices can be simple such as what type of snack the person wants or more something complicated like choosing chore assignments.  Choices can also be given when a preferred item or activity is not available, informing the person of what they can do or have instead.  

For individuals with more language, once the person becomes comfortable with making choices, the next step would be for the person to generate their own options for choice.  This can be achieved by asking the person to think of alternatives.  This is typically a foreign activity for many people with ASD so it could be helpful to start this activity by using an area of interest or expertise.  For example if the person's interest is sports, after watching a specific play during the game, you could ask them, what else could the player or coach done in that situation?  If they suggest an alternative you could follow up by asking how that idea cold work better or what could go wrong with that plan.  This ensures a logical thought process to the alternative.  If the person cannot come up wit an alternative, options could be suggested and the person can discuss why or why not they would work.  The important aspect of this is to help the realiz          

What to Do after Calming

While previous posts have concentrated on how to help someone with ASD become calm once they are upset, this next series of post will discuss what to do once calming is achieved.  The upsetting situation does not go away just because the person has become calm and often times redirection to another thought or activity is only a temporary fix.  What has led to the person becoming upset will eventually resurface and needs to be dealt with an appropriate coping response. 

When an upsetting situation occurs there are typically a few ways to respond.  The first is acting on impulse or first thought.  This type of response can be helpful if the person has a broad range of experience with the situation and has a strong knowledge base of how to proceed in these situations.  Unfortunately, many people with ASD have limited experience in the social and life situations that are most upsetting for them and would have few appropriate responses to draw upon.  Therefore reacting on impulse often leads responses that are either random or designed for immediate emotional relief without long term benefit.  This type of approach should be discouraged for people with ASD, unless it is a situation where the person has a great deal of familiarity, like a special interest or regularly occurring activity.

When an immediate response may not be helpful.  The next option would be to think of multiple possible responses then, after weighing the pros and cons of each, decide on the approach that you think will work best.  This may also be difficult for people with ASD because of difficulty processing multiple thoughts simultaneously.  For this approach to be successful for a person with ASD, they would likely have to think of a single response and evaluate its potential outcome.  If the potential outcome was not pleasant then other responses could be generated until a response with a beneficial outcome was found.  Some people with ASD may be able to perform this process independently, but others may need a visual outline to guide them along a decision tree.   Still others may need to be verbally prompted to think of alternative responses and potential consequences.  If the person is unable to think of alternatives and consequences, those can be suggested by others.  the important aspects for the person with ASD to remember is that there is always a consequence for an action and there is always more than one way to solve a problem. 

Finally, there are sometimes when the person cannot think of a reasonable response to a situation.  In that case the person needs to talk to someone else about the situation.  When with the other person, they can either ask for help in a situation or at least relate their feelings about what is upsetting them.  Often just telling someone how you feel can lead to getting assistance, if not emotional support.  Asking for help and discussing feelings are also difficult for people with ASD.  People with ASD can be encouraged to discuss feelings by providing them a simple and direct way of doing so such as using 'I feel' statements.  An example would be " I feel sad when I have to stop playing my favorite game."  For those with less verbal skills, pointing to pictures depicting different emotions and situations may be helpful.  The idea is to help the person with ASD connect a feeling word to the upsetting situation and thus be in a position to elicit emotional support and help.  To encourage asking for help, explain how everyone needs help with some things and that it is ok to do so when needed.  You may need to model asking for assistance by asking the person with ASD for help in an area of their expertise. 

Hopefully these strategies will help.  I often use the following cue words with clients to help with remembering:  Slow down, Stop, Calm, Think, Talk.

Steven C. Altabet, Ph.D.               

Stop versus Slow Down

I was working with a client with ASD during one of my sessions on the physical calming techniques discussed in my previous post.  He commented that when he became upset that he was unable to 'stop' what he was doing because his body wanted him to 'keep going.'  We tried several role play exercises where would become physically excited then try to stop.  We even tried the game 'red light-green light' to help reinforce the notion of stop versus go.  Unfortunately even when he was able to get his body to stop moving, his mental excitement continued.  It seemed as though requesting him to stop being excited was too abrupt a process and not effective for him. 

As we were discussing alternative approaches, we realized that you wouldn't ask a person running full speed to suddenly stop.   Doing so would either cause the person to fall or get hurt.  When sprinters cross the finish line, they typically take several gradually slower steps before coming to a complete stop.  We then came to the conclusion that if his brain was going 'full speed' that it would not be fair to ask him to suddenly stop what he was doing and try to redirect his thoughts or feelings.  People with ASD typically need more time for transition.  Therefore, we included a prompt to slow down prior to stopping.  That way he could reduce his excitement gradually before stopping and have more time to stop the negative thoughts and emotions and transition them to more positive thoughts and calming activities.  He indicated that he believed that this would work better for him and he was looking forward to trying this out at home. 

The message for me as a therapist was 'listen to your clients."  The broader meaning in terms of this post, however, I believe is that for many children and adults with ASD, we are doing people a disservice by asking them to stop without warning, particularly when there is excitement or strong interest involved.  Stopping suddenly may not be feasible.  We give people with ASD time to transition from one activity to another, why not give that same transition when changing behavior, switching thoughts or trying to implement calming/coping procedures.  Stopping may still be the ultimate goal, but perhaps we educators, therapists, parents, caregivers etc. should be asking the people we serve to slow down first. 

Steven C. Altabet, Ph.D.               

Physical Calming

Turing times of distress there is typically physical as well as cognitive (thought process) hyper-arousal.  When trying to calm it usually very difficult to calm the mind without calming the body first.   People who try to think calming thought  when hyper-aroused often find it difficult because the brain will typically operate in 'survival mode' when distressed.  What I mean by that is when highly aroused, the brain diverts emphasis from frontal lobe functions (complex thought) to parts of the brain more involvedwith alertness and quick decision amking.  There usually is not much time for slowly developing complex thoghts during emergenices and when people are distressed that is what the brain perceives the situation to be.  Therefore in order to restore the frontal lobe and allow for well thought out decision, the brain has to come out of this emergency state.  Physical calming activities are able to slow the body enough to allow the brain to return to it's typical functioning.   

For many people the easiest way to slow the body is through slow deep breathing.  Breathing slowly and deeply serves the dual purpose of slowing arousal while supplying more oxygen to the brain.  However, for breathing to be effective in calming, it has to be  deep, slow, and most importantly soft.  When I try to teach deep breathing to many of my clients (especially children), they respond by taking and hard deep breath and blowing out the air forcefully. They typically know how to breathe deeply but not softly or slowly.  This type of breathing increases arousal and is counterproductive to calming.  People with autism often need a concrete way of gauging the speed of their breathing.  I will often ask my clients to count to 5 in their head for each breath in and each breath out.  If visual guidance is needed the person can count with their fingers or follow a digital counter.  Breathing softly is often the more difficulty concept to teach, but I can usually get the point across with a simple analogy.  Have the person imagine they are blowing bubbles.  For young children they can actually blow bubbles which makes it more enjoyable. and gives the child visual feedback.  The idea is to imagine or actually try to blow a large bubble     
because a softer controlled breath is needed in order to blow a large intact bubble.  Once the breaths become soft and slow, initial calming can usually be achieved in 5-10 breaths, although some people may need longer depending upon their excitement level. 

For those who have difficulty with deep breathing, physical calming can still be achieved through sensory integration techniques.   In addition ot removing the stimulation frothe environment or the person from the stimulation, certain types of stimulation can actually enhance calming.  In particular, anything that applies deep pressure to the joints can have a calming effect.  Examples include draping with a heavy blanket, a firm hand the shoulder, squeezing a ball or pillow and exercise.  Deep massage could also be helpful, although that may be difficult to administer during times of distress. Also, activities where the person can tense their muscles then relax them can have the same effect.  These types of activities take  about 15 minutes before the person becomes visibly calmer.  Once physical calming occurs, then it is easier for the person either to think more clearly of a solution for themselves or be guided through problem solving and coping statements by others.  The cognitive elements of sutiational be explored during the next post.

Stopping the Escalation of Emotional Distress

Because people with Autism tend to have sensitive nervous systems, emotional reactions tend to come much more quickly and are stronger than those who are more typically developing.  As a result, when a person with ASD becomes upset, the nervous sytem goes into almost immediate overload which make any type of rational thought virtually impossible.  It makes absolutely no sense to try to problem solve with a person when they are in this state.  Therefore, before any real coping can take place the person much first be able to recognize when the person is experiencing stress and STOP the escalation.  Typically this involves stopping the current activity and going to a quiet place for calming.  This could be as simple as going to the restroom, getting a drink of water, or taking a short walk.  Once in the quiet area, the low stimulation will help slow the person's arousal and put them in a state where they can begin physical calming activities.   

The first step in this process is recognizing when one is in distress.  When teaching someone to recognize signs of distress in oneself, be aware of the physical signs.  These include increased heart beat and breathing, muscle stiffness or pain, and stomach upset.  Also, thoughts may be moving too quickly which makes decisions and activities that are normally done easily more difficult. When a person starts to feel this way they should immediately stop what they are doing, find a quiet place (perhaps excusing oneself to the restroom of water fountain) and engage in some type of calming procedure until typical physical and mental functioning is returned. 

When recognizing distress in others, look for behavior that is atypical for that person or any sudden changes in behavior.  General signs to look for include increased motor activity, restlessness, or agitation.  This could include pacing, fidgetiness, and hyperactivity.  The person may seem unusually stiff or tense, and not move as fluidly as they typically do. Also, their speech may get louder or, in contrast, they can become more quiet/withdrawn than usual.  The person's need for routine and sensory functioning may additionally be more sensitive during these times.  There may also be more talk about preferred interests, repetitive speech,obsessive thought, or stereotyped behavior.  A change in sleep patterns or appetite may also be noticed, along with the mentioning of events previously associated with distress.  In fact, many people with Autism will recall a distressing past or association in order to communicate current distress.  If the distress is recognized early, the person can be prompted or redirected away from the distressing activity (temporarily) and engaged in calming activity without major incident. 

The next post will review specific calming activities. 

Steven C. Altabet, Ph.D. 

                        Using Sensory Regulation to Lessen Stereotyped Behavior & Anxiety

One of the hallmark features of Autism Spectrum Disorder (ASD) is the demonstration of stereotyped behavior.  Within the realm of Autism, stereotyped behavior typically refers to actions that are either repetitive, odd (not related to situation), or overly ritualistic/routined.  This can apply to both movement and speech and can be very disruptive for both the person with ASD as well as the other people involved in the interaction.  Some people refer to these as self stimulatory behaviorn or 'stimming' for short.  What is unique about this behavior is that it difficult to find an external stimulus (trigger) for the behavior and even more difficult to stop or re-direct the behavior once it starts.  Applied Behavior Analysis (ABA) teaches us that all behavior serves a function or purpose.  Spech/Language Pathologists (SLP's) similarly assert that all behavior is a form of communication.  If that is the case then what is the purpose or message behind sterotyped behavior?

The answer to this question may lie in another aspect of ASD, which is now included in the diagnostic criteria for Autism Spectrum Disorder in DSM 5.  Sensory regulation refers to the body's ability to organize and filter all of the information we receive through our senses.  This includes everything that we see, hear, feel, smell, and taste, along with our ability to process our movement and relation of our bodies to the physical environment.  People with ASD are often overly sensitive or not sensitive enough to these stimuli. Examples include:

Vision - May have a sharp eye for visual detail, but may become overly excited in places where there is a lot of visual stimulation (e.g. crowds and larger department stores).  There may also be a startle effect in situations where there is sudden and unpreditable movement, such as sporting events.

Hearing - The person may have very sensitive to hearing.  You might notice someone with ASD being able to hear a train or plane well before anyone else notices it and there may be a strong affinity or talent for music as well.  On the other hand, loud noise may become overwhelming and excessively high or low pitched tones can become quite irritating.  I've heard many individuals with ASD complain about the hum from flourescent lights or even the clicking of a computer keyboard or high heel shoes.    

Touch - With this sense, individuals with ASD are typically overly sensitive to light and unexpected forms of touch like tapping on the shoulder, light rubbing, and certain types of clothing.  Conversely, this same person may be under sensitive to hard forms of touch and pain .  Some individuals intentionally try to create a pain response because it feels good to them.

Taste/Smell - Some people may be overly picky eaters or have an excessive aversion to cleaning fluids or other strong smells.  The picky eating can also be related to the texture or feel of the food.  

Movement - Proprioception refers to a person's ability to perceive themself and their movement in relation to others and the space around them.  A disturbance in this area can affect balance and the ability to move quickly and efficiently.  It can also affect social skills such as personal space and playing interactively.  

The basic relation of sensory dysfunction to stereotyped behavior is that the odd behavior typically comes when the person is either overstimulated or understimulated.  Therefore, if the amount of stimulation can be regulated, then there will be less sterotyped behavior.  Sensory regulation can be achieved in two ways: Through modifying the immediate environment around then person and by applying sensory regulation techniques to the person.  The person can also do both the environmental modification and senosry regulation themselves if able.
        
Environmental modifications to reduce sensory stimulation include avoiding places of high stimulation such as crowded restaurants, parties, or department stores.  When playing music, be sure sure it is not too loud, high pitched, or have an excessive bass tone.  When out in public always look for the quieter less crowded areas.  Sometimes you can't help being in a highly stimulating environment.  When that is the case, plan periodic breaks to a quieter area to allow for relief from the stimulus overload.  Also, when you see someone becoming more restless or irritable, this would be a good time for a break thus preventing a potential meltdown.

There are also several simple techniques people can use to promote sensory calming during times of distress.  Psychologists often recommend taking several slow deep breaths.   The increase in oxygen provides the energy needed for impulse control and the slow rhythm of the breath activates the parasympathetic nervous system which slows the body down.  Additionally, Occupational Therapists recommend applying deep pressure to the joints as a way of releasing endorphins and providing physical stress relief.  Deep pressure can be achieved in several simple ways including chewing, squeezing a small ball, exercise, running, jumping, and swimming.  Swimming is especially good because it combines exercise with water which is heavy and applies further pressure.  Firm pressure and weight can also be gained through wearing heavy clothing or deep massage.  If a person with ASD allows a hug, it is typically a deep hug.      

Conversely, stereotyped behavior can also occur as a function of seeking stimulation.  This often happens when there is a lack of interaction or direct activity.  Sometimes the answer can be as simple as directing the person to a structured activity of interest.  The activity should be specific and within the person's skill set or they may revert back to the stereotyped behavior because it is more stimulating or less difficult than the activity that is planned for them.  In addition, many of the deep pressure activities that promote calming such as chewing and squeezing a ball can also provide a mild stimulating effect, which can be helpful when the person has to pay attention and concentrate.  

Therefore, I recommend that sensory regulation be part of every behavior treatment plan for people with ASD.  Once sensory regulation can be achieved, the the person's extra sensitive senses can be used as a strength and not a weakness.  Sensory regulation will also help the person with ASD be in a better physical and emotional state to receive education  and training in new skills and adaptive behavior.             

                                                        Slow and Steady Wins the Race

                                                    The Use of Routines in Skill Building 

One of the hallmark features of people with Autism Spectrum Disorders is a strong preference for routine behavior.  The routines can appear nonsensical and interfering for outside viewers, but may hold significant importance for the person with ASD.   Routines frequently allow the person with ASD to engage in established behavior patterns without having to integrate much new information, which can be potentially overwhelming.  From what I've observed over the years, I believe that the need for routine is so strong for people with ASD that it cannot and should not be extinguished.  Instead, the need for routine can be used as a strength in skill building, independent behavior, and eventually employment.    

One of the easiest ways to incorporate routines in a positive way is with the establishment of morning and bed-time routines.  Building on the last post about task analysis, set up a stepwise procedure for getting ready in the morning for school or work and for getting ready in the evening for bed.  The steps should be consistent with the person's abilities and preferences so the individual will be able to complete the procedure with little to no resistance.  Help can be provided when needed until the person feels more comfortable completing the steps independently.  A routine is established when these procedures are repeated daily.  The repetition over time will allow the person to have comfort and familiarity with what is expected, typically resulting in less resistance and more independence.  Routines can be used for a multitude of behaviors including self-care, homework, and work related tasks.  

Some care must be used in establishing routines, however, as once a routine is established it is very difficult to break or modify.   Make sure that the routine is set up in a way that it can be carried out consistently.  For example, if the morning routine takes a specific amount of time then it is imperative that the necessary amount of time is available in the person's schedule for completion of the routine.  Consistency of routines needs to be across settings and people as well as time.  A new job coach or supervisor needs to allow the employee with Autism to work within their regular routine.  The same with a new teacher or caregiver.  

That does not mean that routines are unchangeable.  Sometimes routines need to be altered for legitimate reasons.  For altering the timing of a routine, show the person with ASD the proposed time change on their calendar and explain and reasons and logistics of the change.  For example, if a morning routine needs to start earlier in the day, the person may need some assistance in resetting their alarm or be shown on a clock the new time for the routine.  If the steps of the routine need to be altered, review the new task analysis (list of steps) and show the person with ASD how it is different.  Some practice sessions may be needed with the new routine before it is formally adopted.    

There are many jobs and activities in society that require repetition and routine for success.    Since people with Autism have a natural tendency for this type of behavior,  using routines for developing skills and independence can not only be helpful for the person with Autism individually, but can help the people with Autism get more opportunities to make greater contributions to society in general.    

Steven C. Altabet, Ph.D.

                                                Task Analysis - Breaking it Down

Many people with Autism have deficits in Executive Function (EF).  EF refers tot he brain's ability to organize information and regulate your thoughts and actions.  Some people refer to EF as the 'brain's secretary.'  Without a well developed EF, people are unable to organize all of the information they receive and thus have difficulty planning out and completing even the most activities without becoming overwhelmed.  This can lead to individuals resisting activities even when there is positive incentive for completion.  for people with a poorly developed EF, the effort and emotional stress associated with doing activities requiring organization and planning exceeds and positive consequence they may receive for completion.  This avoidance is often more powerful and negative consequences for incompletion as well.

Fortunately, there is a method helping people with poorly developed EF to complete activities and develop skills.  Applied Behavior Analysis (ABA) therapist call this a Task Analysis.  A task analysis refers to breaking an activity down into a series of short discreet steps.  These steps are then put on a picture or word list for the person to use as a reference.  This allows the person with an EF deficit to only have to think about one small step at a time.  Organizing thoughts or keeping track of multiple steps is not required saving the individual from being overwhelmed and making them more likely to attempt and complete the activity.  For example if one wanted to make a task analysis for washing your hands, it look like this:

1. Turn on cold water 1/2 turn 
2. Turn on hot water 1/2 turn
3. Place both hands under faucet.
4. Squirt soap on hands.
5. Rub hands with soap.
6. Place hands under faucet again.
7.  When soap is off, dry hands with towel.
8. Turn off water.

This can be modified to meet the person's needs.  Some may need pictures or less words, but this type of approach can be used for not only simple tasks like this, but for more complicated tasks as well (.e.g. school assignments, chores, work activities, finances, etc.).  In general if a person with EF deficits is resisting a task it is likely because they perceive the task as either too larger or too difficult.  Often times a task analysis can make the activity seem less daunting.

The other key aspect of the task analysis is the list itself.  Having the reference list with the individual steps is highly important.  It allows the person to see the steps so they do not have to think about them.  It also helps because the person realizes that if they forget a step they can refer to the list.  This further creates a sense of independence because if the person has access to the list (and understands it) they do not have to rely on others to tell them what to do.  If a person can complete a task independently that they were once not able to do, the sense of accomplishment is often greater than any reward or incentive that is given.

Steven C. Altabet, Ph.D.         

                                                            Positive Use of Routines

The strong need for routine by most people with Autism can often lead to distress and challenging behavior whenever a routine is interrupted, postponed or changed in some way.  However, this same need for routine can also be used to  help people with Autism learn new skills and increase their independence.  Many people use routines in their everyday lives to help get ready in the morning for work or school and in the evening to get ready for bed or the next days activities.