Why do ASD kids get Anxious ? 6 Core Strategies

                                                      

14-year old Jack diagnosed with Asperger’s Syndrome came to attend Occupational Therapy (OT)  session in school's OT room. Jack loves OT as he feels that he doesn’t have to study in this lesson and he can learn and do fun activities. However, this time, when he came to attend a lesson, he was seen worried and unfocused while carrying out tasks. On being asked,the reason of consistent worry, it was found that he has to come to school by public transport (bus) whole next week along with his class friend, as his father has gone on an official tour and mother doesn't know driving.

A thought of travelling in the bus made Jack extremely anxious because of which he couldn’t focus even on tasks he like. Waiting for the bus, getting on it, asking for a ticket from bus driver (new person), standing along with new unknown people, being touched by people which creates defensiveness while bus is moving, hearing different sounds (people talking, vehicles on road, baby crying, music), smell of various deodorants, are some of challenges which made Jack so nervous! 

Above mentioned experiences are just so normal for anyone of us and do not affect any typically growing adolescent, however, for a child like Jack they are big reasons of worry!

Children with or without autism display anxiety during the day to day situations. Getting separated from the parents (separation anxiety) is most common cause of nervousness among typically and atypically developing children. Recent research at the University of Amsterdam suggests that 40% of children and adolescents with ASD have anxiety issues.

Every day most of us face situations that can cause anxiety or nervousness such as getting late for school or office, getting stuck in traffic jam, before examination or interview or even not being able to understand a simple joke that others find funny. 
We simply know how to cope with such situations, either by informing office staff that we are running late or ignoring joke that we do not understand. However, for autistic or learning disabled adult and child coping with stress, anxiety or frustration can be a great challenge.

“My 5-year old son with Autism gets nervous easily in school and public places. He often starts crying in malls and I feel embarrassed. Is there anything I can do to help him?"

This is a common question heard from parents of children diagnosed with Autism Spectrum Disorder (ASD), Sensory Processing Disorder (SPD), Learning Disabled (LD) and ADHD. Anxiety is not uncommon to anyone of us, however, atypically developing children display extreme nervousness in ordinary situations too.
As per anecdote reports, many children with autism will receive the another diagnosis at some point of development. The additional diagnosis is mostly related to (Simonoff, et al). 

So what triggers anxiety in children?             Dr Chuck Edington (2010) suggested common triggers of anxiety at home and school setting are, Unstructured Timing, Academic situations, sensory issues, social situations and Routines. Other factors of anxiety can be homework, examination, meeting a new person, fear of rejection from peers, or health concerns. 

Children with autism commonly display self-stimulatory behaviours (stemming) such as hand flapping, finger flicking (hand mannerisms), chewing and mouthing things, watching spinning objects, rocking body back and forth while sitting, nail biting or hand biting which, if not stopped can be self-injurious in nature.
Stemming helps them to calm down and reduce anxiety. Children having under-responsiveness (hypo-sensitivity) towards touch or hearing lack danger awareness which can lead to self-harming behaviour. 

For highly anxious children sensory stimulation (stimming) as a way of shutting down their thoughts, anxiety and related stress. It works as a medium of shifting one's own attention to physical stimulatory behaviour that is more engaging.

There is no causal relationship between anxiety and over-responsiveness (hyper-sensitivity) established through researchers, however, it is commonly observed, that children with over-sensitivity often react negatively to noisy and visually complex environments. 

Shutting their ears in public places, displaying temper tantrums, meltdowns during recess, trying to avoid hair cutting or dental check-ups by any means, being avoidant to bathing or tooth-brushing are some of the behavioural patterns of ASD child with anxiety.

To resolve the problem, parents need to be carried out some ‘detective’ work to find out possible reasons for anxiety.

Strategies for Tactile Defensiveness!

                                                     

Touch is the first sensation that starts developing in the womb at five weeks. Some children react adversely, negatively or display  escape-like behaviour on being touched, hugged or kissed since they have difficulties in processing sensory information due to the poor tactile system. This behaviour is referred as Tactile Defensiveness.

Due to the inaccurate functioning of touch mechanism and neural system, these children are often in the state of 'red alert'. They may react by clinging or complaining (fright) to someone, or lashing out (fight) and running away (flight).

Often children displaying tactile defensiveness may also have self-stimulating behaviour. Repeated movements such as hand flapping, body rocking, hand gazing, spinning have been found prevalent in children with developmental disabilities and Autism.

Research done by Feig et al (2012), concludes that there is a significant relationship between Tactile defensiveness and Self-stimulatory behaviours.They both are problematic as they appear and interfere in child's day-to-day activities. For example, a child who engages in hand flapping may not be able to do any other activity such as washing herself or eating on her own. Likewise, due to tactile defensiveness doing teeth-brushing or other self-care activities will be difficult.


Here are some of the suggestions for tactile defensiveness which may or may not be helpful, as each child is different, however making appropriate changes within child’s environment or strategies according to his needs and priorities can support him to live better and stay calmer.

A) Understand your child: (Address child's issues seriously= Trustworthy relationship + better behaved child)

Most importantly, it is parent’s responsibility to understand their child and her problems. Giving labels such as she has "bad behaviour" or "poor "attitude will not solve the issue. 

If she says “something always hurts me” or gets irritated due to scratching herself all the time, do not think she is pretending to gain empathy or purposefully trying to seek attention. 

There must be something unusual happening causing her to behave in this manner. 

Developing trust and developing an understanding of child's difficulties are essential parts of combating any problem. 

It will be great if parent and child both stay on the same team as good team players to resolve the issue rather than opponents where parents label the child for being anti-social frequently, and child reacts impulsively and aggressively on hearing those words over and again. 

B) Deep Pressure: (Leads to release of Dopamine or "happy neurotransmitter"= Calm brain & relaxed body)

Firm massage or deep pressure with pillows, cushions or rolling in a weighted blanket is very calming. Parents should understand signals when these strategies are needed. Children having sensitivities are overloaded with touch or noise in crowded places or parties. Parents should be aware of these situations and intervention should be provided before emotional or anger outbursts happens.Children get sleep disturbances caused due to sensory issues.Using techniques like Wilbarger Brushing Protocol  has been found to be an effective way of calming child for better sleep.
This should be under the supervision of Occupational Therapist or consult child's OT before trying Brushing Technique.

C) Weighted Items: (Stimulates body joints & muscles = Improves self-regulation,modulation,stress and anxiety)

Wearing weighted blankets, vests, backpacks or hats can have the calming effect in the classroom as well as at home. Great range of weighted items is available on Amazon such as ankle weights, lap weights shoulder and neck weights. They help to calm down a child in the classroom as well as any other environment leading her to focus on the task and reduce distraction. Weighted blankets are very helpful in calming the child’s distractibility, emotional liability, and hyper activeness. Another very good resource is TFH, South Paw. 
T-Jackets have been found to be a good resource of calming down a child. They have been scientifically customised for providing deep pressure and calming effects. 

D) Safety: (Prevention is better than cure so TAKE-CARE of child!)

Children who are hypo-responsive or sensory seeking towards touch are unaware of bruises and injuries. They do not get pain sensation messages from brain centers due to which they are prone to injuries. They may display self-stimulating or self-injurious behaviours along with tactile defensiveness.The stereotyped behaviours are common among Autistic children. Most common form is motor patterns are hand flapping, body gazing or object manipulation. Temple (1992) in her study Calming Effects of Deep Touch Pressure in Patients with Autistic Disorder, College Students, and Animals has suggested that Tactile Defensiveness co-exists with Stereotypical behaviour in Autism .Sensory Modulation and regulation is an important function which does not work well in both hyper and hyposensitivity of touch.It is important to follow some hands-on strategies such as:

• Use of sensory experiences :Such as trampoline jumping,obstacle course, running
• Follow Routines and maintain structure: e.g., planning a week ahead
• Communication: Understanding child's behaviour in anticipation, environment, emotional liability.
• Visual Support: Emotion's chart, use of PECS.
• Talk to GP about Medication.
• Use Barriers such as using cushions or pillows if the child does head banging,or tie the cloth on his hand to reduce self-biting.
• Use soft furniture.
• Keep rooms safe, the child should not be able to lock himself in a room, windows should not be wide-open.
• Keep sharp objects like knife, fork, scissors, razors out of reach of the child.

F) Fabrics: (Removal of unpleasant sensory input = Relief & physical comfort)

Pay attention to the different fabrics. Following tips may be helpful related to fabrics:-

• Give preference to child's fabric or texture.Some children like to wear cotton and avoid woolens, synthetics or any other texture that might irritate them. 
• Wearing skin fit clothing is preferable than loose clothing. 
• Stick to seamless clothing. 
• Liners and tags are always irritable making child impulsive and distracted easily. Removing or cutting tags is the simple solution for this. 
• As far as footwear is concerned, it should be comfortable and slip on type. Fasteners are also the good option if he finds tying laces complicated.
• Long sleeves are preferable than short arm sleeves. 
• Do not force him to wear belts, waistbands if he doesn’t feel good about it.

H) Active Involvement: (Child knows himself better than anyone else)

Self-directed tactile experiences are more calming then done by anyone else. Therefore, encourage the child to perform activities himself rather than done passively, by anyone else for him, however, assistance or supervision may be needed for completing tasks. After bath let him rub himself or put lotion independently since he can judge well how much deep firm pressure will be calming for self. Make your own Play-Doh at home.

I) Classroom Strategies: (Favourable IEP = Better provisions = Better behaved child + raised self-esteem)

Let the child stand last in a row in school. Let him

sit alone if he gets distracted by other pupil’s touch. Talk to teachers and school management to create awareness about your child’s difficulties. Teachers should know what child is going through and why is he distracted multiple times or scratches himself during the lessons. They should allow the child to do wall pushes or chair pushes if he feels calming during break times. The child should also get movement breaks if the teacher allows.  This should be included in his IEP. http://www.additudemag.com/adhd/article/5894.html

J) Inform before touching: (Respect child's integrity)

Hugs, kisses or any other type of touch should be done with consent. Ask or inform him before touching the child. This reduces anxiety levels and arousal too.Touching without consent can create disruptive behaviour. To know more about cause and neuroscience of tactile defensiveness click here.

K) Heavy Work Activities (Proprioceptive Input): (Tactile + proprioceptive input = calming effects,reduced anxiety,disruptive behaviour)

Pushing and pulling heavy objects such as barrels, carts, large bean bags,
the pile of chairs or pushing another child on the swing. All this 
gives proprioceptive input!

These activities provide deep pressure to muscles, joints, ligaments and key points of the body (Shoulders, Pelvis, Hips) to a tactile defensive child. 
Moreover, giving movement breaks will support a child to concentrate better in studies, such as sending him to an office to handover papers or asking him to distribute assignments in the classroom. See Classroom strategies for more information.

Deep Pressure: Magic of Weighted Blanket!

                                                     

                                                  

John diagnosed Autistic at age of 6 years got admission in special needs school for progressive future. His parents did not inform school staff much about his maladaptive behaviours except being picky eater, impulsive and having tactile defensiveness. On first day to his school, he was introduced to classmates and support assistant (Ms. Johnson) by his class teacher (Ms. Winslet). As the day progressed, John seemed calm and settling within the classroom surrounded by some new friends.

During the lunch-time, Ms. Winslet told him about rules of eating in classroom and ensured that he is doing fine.  John without making any eye contact heard everything and absorbed all in (taking in too much information from new environment,resulting in sensory overloading) while eating his sandwich and nodded head.
All of a sudden, after fraction of seconds, everyone heard John shouting, being physically aggressive on child sitting next to him and crying without listening to anyone. He also bitten the support assistant who tried to stop him from hitting. Due to extreme kicking, hitting, pushing and biting behaviour (physical violence) he was restrained by two male staff members.

School OT intervened and he was taken to therapy room where she wrapped John in a weighted blanket (deep firm pressure) and rolled on floor until he calmed down.

Later, this little man mentioned that he got angry because child sitting next to him was eating crisps and making noise, that John didn’t like!!

Phew!! so, now we know why John behaved in such a manner.

Well, but what happened when he was wrapped in a weighted blanket? How so much angry young man (who needed male staff for restraining) calmed down so easily? Why didn’t he resist to weighted blanket?

This happened due to MAGIC of DEEP PRESSURE!!

Tactile Defensiveness Vs Tactile Discrimination

Protective System (Dysfunction causes Tactile Defensiveness) 

Skin has an important function - protection. It acts as a physical barrier between us and the world. Our skin can feel too hot and cold sensations’ and respond accordingly, for example, on being pricked by a needle we are hurt and brain perceives pain sensation. For detailed description of Tactile Defensiveness click here

This system helps us in identifying light touch, crude touch, pain and

temperature which are protective in nature. When a needle is inserted in baby's buttocks for vaccination he feels uneasy and painful due to which he may cry aloud, this pain sensation happens due to protective touch system. Touch is the first sensation that starts developing in womb at five weeks. Protective system works phenomenally in a newborn, which helps him to react towards changes in temperature, come in contact with his or her mother and feel secure in her arms. It helps in sucking mother’s nipple to take the feed and feel her body’s warmth and cosiness. Due to this, children clasp fingers and toes when being touched.

When child tries to stand on his own feet however falls back due to lack of balance and postural control, he feels distressed and cries, since he feels pain in his buttocks or legs. The protective system supports child to sense the pain and discomfort. Similarly, dirty diapers make child uneasy and, colic pain (prominent from 0-6 Months) can cause too much of discomfort and distress.

SUMMARY SHEET

Neuroscience Background:

According to A. Jean Ayres (1972), tactile defensiveness is the response that occurs, when Dorsal Column-Medial Lemniscus (DCML) Pathway fails to exert inhibitory influence over Anterolateral (AL) Pathway.This means that DCML system does not work properly and hence AL system predominates on it due to which child reacts adversely, negatively on being touched, hugged or kissed.

The child has difficulties in hair washing, tooth brushing and nail cutting or avoids being touched reflecting Tactile Defensiveness. Child shows dislike towards parents or caregiver’s hugs, kisses or arm around the shoulder by either pushing or asking not to touch him.They don't like being messy or touching objects like glue, paints, shaving form or cream, shampoo, bubble bath.

Treatment Strategies:

Weighted Items: Wearing weighted vests, backpacks or hats can have calming effect in school. Great range of weighted items are available on Amazon such as ankle weights, lap weights shoulder and neck weights.

Heavy Work/Resistive activities: These activities have calming effect on brain. The muscles and ligaments work against the gravity proving deep-firm pressure to the body.

Brushing: Sensations received from clothes or their tags can be disrupting in nature. An Occupational Therapist (OT) may guide parents in administering the Wilbarger Brushing Protocol which reduces tactile defensiveness.It is designed a particular fashion to reduce tactile defenesivemess.The brushing is done in specific sequence at specific intervals throughout the day.  

Vibration: Vibrators can be useful around arms and legs however should be applied under supervision of Occupational Therapist who is Sensory Integration trained. It is another form of deep pressure that activates proprioceptors (receptors in muscles and ligaments). The adverse effects which will be immediately visible are dizziness, headache or nausea.

  

Tactile Discrimination System (Dysfunction causes Tactile Discrimination difficulties)

This system is fast, efficient and its development is essential for dextrous tasks and In-Hand-Manipulation. Discriminative system is associated with function of discrimination, such as exploring the world and differentiate between different types of touches such as type of texture, and size of object. For example, consider how easily we can differentiating between different size coins in our pocket without looking at them. Opening or closing the lid of jar or doing small buttons without actually looking at shirt are examples of Tactile Discrimination and in hand Manipulation. He might not react at all towards injuries, may have lack of body awareness. 

This system also responds to vibration, touch pressure and deep pressure

information. As the child achieves developmental milestones they also develop a sense of touch discrimination. As the child grows older his abilities of discriminating tools objects and toys improve gradually. 

In a normal developmental process, as the child grows and he develops fine motor skills ability to discriminate different fabrics (soft blanket or stuff toy and wooden surface), sizes (small and large Lego pieces) develop. They enjoy jumping on soft mattress bed rather than playing on the wooden floor with carpet. 

So if the child’s cluster of behaviours such as being accident prone, dropping things from hand, difficulties in managing buttons, zippers, laces and ties, difficulties in handwriting it may be considered that these activities are linked to dysfunction in tactile discrimination.

Neuroscience Background:

Discriminative system is associated with function of tactile discrimination such as detection of size, form, texture as well as movement across the skin as evidenced by Fisher and Bundy (1991). The dorsal column medial leminiscus (DCML) pathway and associated receptors are responsible to respond to stimuli transmitting vibratory, touch pressure, discriminatory and deep pressure information meaning for appropriate functioning of Discriminative system DCML system is responsible.

When there is damage in DCML pathway, the sensory feedback to higher brain centres (cortex) is interrupted leading to deterioration of coordinated fine motor abilities of child.  This can be evidenced with empirical research work done by Cohen (1999), who concluded that injury to DCML can lead to decreased sensory feedback to the cortex causing uncoordinated fine motor skills. Therefore, child has difficulties in carrying out fine motor activities such as doing laces, buttons, fastening zippers.

                                                             

7 ways to control Angry child!

            

            Parent’s voice of tone µ Child's Aggression

The above equation says it all, higher is the voice tone of an adult while dealing with the angry toddler or young child, greater will be his aggression. Calmness, patience and nonviolent environment are essential components to improve child’s behaviour. In simple terms,child's behaviour is (directly proportional) very much affected by parent's behaviour!

If the parent and child shout together then situation remains, the same without any enhancements. It will be like beating around the bush which has no outcome ever. Moreover, it affects child’s trustworthiness and emotional security (parent-child bonding) in the long term. 

It is important to understand that a child under the age of four or five years does not have any intention to harm anyone around him. He wants to explore the world through different body senses such as touching different textures (Examples-carpet, power plug points, keys of laptop, smartphone), observing contrasting colours and images to explore visuals (snatching phone or I-pad to see images or photos) and shouting as they enjoy their own voice but hitting, kicking or pinching parents or caregivers is not their agenda fundamentally. Even shouting or getting angry is not their first choice, it happens only when they have no other option to get their things done!

Biting usually happens due to tethering factor.

At this developmental stage attention seeking behaviour is prevalent which is misinterpreted as aggressive behaviour of toddlers or young ones. Study done by Auruhn Dhal in University of California also suggests, that the use of aggression by toddlers  or young ones is unprovoked. 

Children involve into explorative force to seek attention. Unprovoked acts presumably become less frequent from 18 months onwards as toddlers learn that their aggression harms' others or they become sensitive towards other’s distress. 
So it should be understood that children are not hitting, biting, pinching or kicking intentionally to upset parents, siblings or others but because of their own newness in the world. Children belonging to age group of 36 month or more, are likely to get aggressive.
If child is having frequent aggression issues and hits people around revengefully which   reflects in his temperament, then following strategies can be explored: -

A. Act quickly but Calmly: Child’s Anger + Violence = Address problem calmly + Quickly:

When the child is aggressive it is important that, parents should demonstrate patience, calmness and normal voice of tone. Screaming, yelling or shouting will not resolve the issue instead will aggravate the aggression within child. Moreover, there will be mirroring of parent’s actions. Plus, stomping foot, slamming doors will aggravate the behaviour and cause emotional meltdown and mistrust.  
If parent resolves the issue in soft, non-violent way, child will probably follow the same example. He should be spoken about the issue softly but immediately. Parents must not waste time or follow "Let it go" approach considering that this is his first time or he is too young to understand. For example:The child hits his younger sibling without any reason, for the first time, so it should be addressed immediately. He needs to apologise and take time-out of 3 to 5 minutes to calm down and think about his mistake, Later, parents can discuss with him making him realise what wrong he has done. He should be aware of his actions and their consequences.

Keynote: Setting rules for actions and related consequences is important

B. Appreciate your child (good for 3-year-old or more): Leads to better Behaviour + raised Self-esteem: 

Praising plays an important role. Explain to him how much “Grown up” he is acting whenever he behaves in a desirable manner (communicating without being aggressive) instead of shouting, kicking, pinching or biting. It will be good to give him one or two smileys or thumbs-up on the behavioural chart for good deed or kindness act such as opening doors for others if the child is 5 years or older than that.
Hugs and kisses are good to calm down an angry child. According to Sensory Integration, hugs provide deep pressure to body which is a great way of relaxing the child.Use of weighted blankets or vests can also be helpful for ADHD,Sensory Processing Disorders, Autism Spectrum Disorder.Most of the times anger are co-morbid with these conditions.

25 Tips for Sensory Smart Classrooms!

                                

                                   

    Classrooms need to be Multisensory for better learning!!

         

A.  Instructions should be simple, clear and short for the child to follow easily.

B.   Be precise and slow while giving instructions. One step at a time since brain’s information processing is slow.

Fidgets 

C.   Encourage the child to learn and practice the task. Practice! Practice! Practice makes a lot of difference.

D.  Keep Fidgets handy! They reduce anxiety levels in different environments and facilitate attention on a task in hand. Use of different magnetic balls, paper clips, blue tac, or mechanical pencils can work well too. Other common fidgets can be giant nut and bolt, key chains, fidgeting fleece bags, finger squeezers, tactile balls (koosh ball): Resource: 

E.   Let child do heavy work activities such as jumping, chair push-ups, wall push-ups, clearing cluttered desk,carrying the heavy bag.

F.   Give verbal instructions with visual demonstrations where ever possible. Showing child how to do activity is better than telling him about it. Demonstrate how to do the obstacle course and then let him perform.

Carrying heavy books has to calm effect

G.   Give extra time in the classroom to complete written work. Teachers need to have patience and calm!

H.  Remove visual distractions from the classroom. All wall decorations, notices should go on the back wall. Whiteboard should be clear (except when teaching!) with a date in the corner.

I.   Use colourful marker pens for teaching particular topic or concept.

J.   Child should sit near to teacher’s desk and in front of a classroom.

K.   Organise child’s desk, textbooks, supplies. Label different folders. This makes a lot of difference.

Supplies should be adequate

L.   Keep the supplies and textbooks in the good amount within a classroom.

M. Introduce and encourage calming music.

N.  Let child submit written assignments rather than hand written since handwriting can be illegible or messy.

O.  Labelling and Categorisation: Use sticky tags for labelling folders such as work done, work to be done, notices, to be read and other labels can be made according to requirements and relevance. It supports the child to distinguish and different folders and binders as well as subjects.

Sticky Notes for Organisation & Labelling

P.    Lighting: Use of Halogen lighting system is considered better than fluorescent lighting system in classrooms.

Q. Homework Print Outs: It is better to post homework on school website so it is easier for parents and kids to understand the given assignments.

R.   Visual Reminders: These can be in the form of picture posters, sticky notes, widgets or coloured writing on the board.

S.  Sensory Diet: A sensory diet is a carefully designed, personalised activity plan that provides sensory input to a person needs to stay focused and organised throughout the day (Occupational Therapist Patricia Wilbarger). It is developed by an Occupational Therapist specifically according to person’s sensory needs and abilities

Credit

T.   Movement Breaks: A child should be given a break for 2-3 minutes’ maximum. This for stress release and reassure that child can re-focus well on topic again. Doing deep Breathing or Stretching exercises can be beneficial. Going to an office to hand over paperwork is one example of movement break.

U.  Pencil Grips: Children respond well to pencil grips as it improves handwriting, legible and provides tactile-proprioceptive feedback. Resource: 

V.   Wobble Cushions: Good for ADHD kids especially. Keeps good posture and maintains focus.Resource:

W.                Ergonomics for Seating:

a.    While sitting on chair hips, knees, and ankle should be perpendicular to each other.

b.   Back should be straight and ninety-degree angle should form at an elbow.

c.    Wrists should be in resting position.

d.   Table and chair should have appropriate height.

e.   The seat back should be angled at 15 degrees.

f.    The child should lean forward with body weight supported by the floor with feet on the ground.

g.   Provide slanting desk or tilt table desktop for achieving ideal reading and writing angles for vision and spine.

h.   Elbow rests prevent straining of shoulders and neck muscles.

i.     Reading angle should be about 60 degrees from horizontal.

j.     Writing angle should be about 10-20 degrees.

X.  Introduce Theraband Stretching exercises or Deep Breathing as a part of Daily morning routine to concentrate well in a classroom.

Y.   Weighted Items: Use of appropriately weighted items should be done within the classroom on discussion with Occupational Therapist. Shoulder, Shoulder and neck weights, lap weights, wrist, ankle weights, snakey weights, weighted scarfs are weighted products for Calming down, reducing impulsivity, hyperactivity, and aggression. Resource