The use of low arousal approaches to manage challenging behaviours in individuals with ASD:A concept

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The use of low arousal approaches to manage
challenging behaviours in individuals with ASDA
conceptual framework

• Andrew McDonnell, PhD.
• Clinical psychologist,
• Studio3 training Systems,
• Email Andy_at_studio3.org

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Autism is a heterogeneous construct

• It is important to stress the complexity of ASD.
• There have been significant attempts to develop
  universal theories.
• Too much research has focussed on falsifying
  various cognitive theories.
• Some constructs may have an important mediating
  effects, especially, when considering challenging
  behaviours.
• Arousal is not an unknown or new construct.

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Arousal and autism

• Physiological hyper arousal has been associated
  by researchers with childhood autism (Hutt, Hutt,
  Lee and Ounsted, 1964).
• Sensory overeactivity has been explained as a
  possible response to overarousal (Liss, et al.
  2006).
• It has also been suggested that repetitive
  movements may serve a dearousing function
  (Kinsbourne, 1980).

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Sensory issues

• There is an increasing body of literature which
  identifies sensory issues.
• people have different thresholds for noticing,
  responding to and becoming irritated with
  sensations reflected in their mood, temperament
  and ways of organising their lives (Dunn, 2001,
  p609)

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Sensory issues

• In a survey of UK parents of 75 children with ASD
  71 appeared to be hypersensitive to sound, touch
  smell and taste (Bromley, Hare, Davison
  Emerson, (2001).
• Individuals show abnormalities across multiple
  domains (Rogers, Hepburn, Wehner 2003 Baranek,
  David, Poe, Stone Watson 2006).

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Sensory Environments

• There is limited information which claims better
  concentration is observed after multisensory
  sessions (Lindsay, Pitcaithly, Geelen, Buntin,
  Broxholme Ashby, 1997).
• A recent single case study of three adults with a
  diagnosis of ASD reported fewer prompts required
  in a preferred activity for 2 out of the three
  participants (Kaplan, Clopton, Kaplan, Messbauer
  McPherson, 2006).

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Sensory environments

• The effects of multi-sensory environments appears
  to indicate that increased relaxation and reduced
  overt signs anxiety can be achieved (Stephenson,
  2002 Lancioni, Cuvo OReilly, 2002).
• Reduction in the frequency of aggressive
  behaviour of two individuals with ASD and no
  effect on a third person has been reported
  (Kaplan, Clopton, Kaplan, Messbauer McPherson,
  2006).

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Definition of low arousal approaches

• A collection of behavior management strategies
  which focus on the avoidance of confrontation.
  This is primarily achieved by the reduction of
  triggers / cue behaviors which may arouse an
  individual who presents with challenging
  behaviours. McDonnell, Waters Jones (2002)

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Key Elements

• Demand reduction in crisis situations.
• Reduction in environmentally arousing stimuli.
• Awareness of non verbal communication.
• Diversionary tactics.
• Challenging staff assumptions about the
  individuals control of their behaviour.

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External (environmental) factors

• Crowding.
• Temperature.
• Noise.
• Use of stimulants (caffeine).
• Staff/service users behaviour.
• Level of exercise.
• Visual design of environments

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Internal factors

• Damasio and Maurer, (1978) produced a
  neurological model for childhood autism. They
  argued that areas of the temporal area and
  mesolimbic systems were implicated in autism.
• Studies have also attempted to identify
  structural areas of the brain implicated in
  sensory differences particularly the limbic
  system involving the hippocampus and the amygdala
  (Lathe, 2006).

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Internal factors

• There is laboratory research which demonstrates
  the relationship between an individuals levels of
  physiological arousal and performance in
  learning.
• Studies of human performance have documented the
  relationship between behavioural performance and
  anxiety.
• High levels of physiological arousal may impair
  cognitive processing in some individuals with
  ASD.

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Maintaining Equilibrium A central tenet.

• A balance between internal and external stimuli
  is required to maintain levels of arousal.

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Equilibrium/balance

• The human body has a sensitive self-monitoring
  and self-regulating system that is constantly
  working to maintain the body in homeostasis
  (balance).
• I would suggest that physiological arousal
  employs a similar mechanism. A balance is struck
  between internal and external sources of arousal.
  Let us call it arousal homeostasis.
• Each individual has an optimum performance
  threshold of arousal to functioning successfully.
• We are aiming for a state of arousal equilibrium.
• Regulation of arousal is problematic for some
  people with ASD.

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Maintaining equilibrium

• Stereotyped movements may help maintain
  equilibrium because they serve a de-arousing
  function.
• Rituals may occur more frequently when arousal
  levels increase.
• People avoid specific arousing stimuli.
• Other do individuals seek out arousing stimuli.

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Challenging behaviour and panic reactions

• Many people with ASD and challenging behaviours
  show signs of panic in specific situations.
• Behaviours may be interpreted as deliberate by
  carers in these situations
• Similarities have been drawn between the symptoms
  of post traumatic stress disorder and some
  individuals who present with challenging
  behaviours (Pitonyak, 2004).
• Panic reactions can often lead to people needing
  to escape from situations.
• Panic responses do not appear to habituate
  rapidly. This may be true of a specific subset
  of people with ASD.

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Physical Interventions

• Some individuals may try to avoid physical
  contact. These individuals are often
  hypersensitive to tactile stimuli.
• Any physical contact can have the potential to
  cause major distress in these circumstances.
• Some persons may even experience light touch as
  physically painful (See Grandin Scariano,
  2002).

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Physical Interventions

• I have worked with individuals who seek out forms
  of restraint such as spine and prone holds .
• Temple Grandin described the calming effect of
  deep pressure contact for her.
• Some individuals may be of increased risk of
  harm especially if they show low initial
  reactivity to painful stimuli.

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High arousal approaches?

• Some individuals may show very low reactivity to
  environmental stimuli.
• In these cases low arousal levels effect
  initiation and regulation of movement
• Catatonia/ profound movement differences are
  relatively rare.
• Clinically, some individuals appear to require
  increases in environmental arousal to help them
  move.

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Measurement of arousal

• Measuring physiological arousal can be difficult
  in people with ASD.
• Cortisol levels (MacCreadie, 2007).
• Variations in systolic and diastolic blood
  pressure.
• Heart rate monitoring in the presence of specific
  arousing sensory stimuli.
• Habituation responses to specific stimuli.
• Functional assessment of sensory processing
  modalities. Where ethically appropriate some
  limited behavioural testing should be adopted.

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Conclusions

• Sensitivity to arousal as a model of working has
  several implications.
• We are aiming to create arousal equilibrium for
  individuals.
• Assessment of individual arousal sensitivity
  should be a fundamental part of the approach.
• Pharmacological approaches may need to
  concentrate more on reducing or in some cases
  increasing physiological arousal.

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Conclusions

• Designing environments where arousal levels can
  be controlled (heat, light, colour, space,
  sounds).
• Developing more self control distraction
  strategies (wearing walkmans, use of mood music).
• Anxiety reduction strategies may help some
  individuals (see Attwood, 2006).
• Consider individual arousal responses when
  developing individualised activity plans.

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Conclusions

• The behaviour of staff has significant impact on
  the management of challenging behaviours.
• Staff may inadvertently trigger challenging
  behaviours (McDonnell, 2005)
• Training staff/families to recognise the initial
  signs of panic and sensitivity may have a
  significant effect.
• Short term demand reduction should be a major
  facet of crisis management for people with ASD.

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Presentation availability

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