Saturday, 21 May 2016

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.

Here are some of the practical OT tips and sensory strategies which may be beneficial for anxious adolescents and young children.Parents, teachers or caregivers are advised to make any changes in following strategies according to child's needs and priorities.

#Maintain a Log record: 

Keeping and maintaining a log record of child’s anxiety or noting possible triggers,
location, and child’s behaviour patterns during and after anxiety. Identifying patterns and understanding behaviour can provide us opportunities to modify it inappropriate manner. 

A log sheet determines child’s challenging behaviour that needs to be tracked and rectified.Here's is a download link.

Sometimes, a particular subject, place or days of a week are difficult to manage for a child.  I had one child at the workplace who used to display extreme anxiety on Mondays especially, as coping after a weekend (change of routine) was a big challenge for him. To reduce anxiety, he was provided with quiet space area and proprioceptive sensory input before registration which supported him to cope well during the day.

Another girl stopped attending school on Thursdays al of a sudden and parents informed staff that she had stomach-ache. Having the stomach ache on every Thursday did not sound right to school staff. On digging  details of her absence, it was found that she used to get anxious seeing new art teacher of school who joined recently and her art lessons were timetabled on the same day.

So, in conclusion, the log record is a helpful resource providing the detailed analysis of child’s challenging behaviour as well as clues that can be trigger anxiety.

#Deep Pressure: Weighted Blanket & Vests:

Weighted items are provided to provide proprioceptive input which in turn improves body awareness or body scheme, attention span, reduce hyperactivity
, impulsiveness and fidgety. 

Sensory seeking behaviour or stemming such as hand flapping, nail biting, spinning objects, mouthing things can be due to anxiety as mentioned above in causes. The deep pressure received from a weighted blanket or weighted vests helps the child to calm down as it causes the brain to release neurotransmitters (dopamine and serotonin) which induce a soothing effect. 

Moreover, it improves sensory seeking behaviour such as excessive running, jumping, distraction disorganisation of work, exhibiting aggressive behaviour, or not being able to sit still at the home or school. 

When anxiety is due to sensory stimulation then SI focuses on improving child’s ability to modulate, organise, and integrate information. 
Deep pressure activities such as joint compression, traction, wall pushes and chair pushes, vibrators, burritos (wrapping and rolling child in the weighted blanket or sensory snug), vibrators can be helpful.

#Create child-friendly Environment: 

For children with Autism, Sensory Processing Disorder and ADHD it is incredibly hard to make sense of the world. They are mostly isolated due to lack of social communication and imagination skills. Due to sensory sensitivities, a child may over- respond under-respond or seek for stimulation within his environment.
A child’s senses can be over-developed (over-responsive) or under-developed (under-responsive). In both the cases, a child will face challenges or difficulties to cope with the environment.

Structure & Routines: In-cooperating structure and routines in child’s daily life will support him to predict and organise events better thus reducing anxiety to a great extent. For example, giving visual timetable reduces anxiety as this enables him to know which lessons he will be receiving throughout the day. Similarly, creating a visual sequence of morning activities, before leaving for school can support the child to organise better and stay calm.

Calm Environment: Children having different sensitivities may easily get anxious with minor changes and disruptions. Fluorescent or bright lights can be disturbing for children with visual sensitivities. Construction work noise or vehicle noise occurring outside the classroom can be disruptive for the child with auditory sensitivities. To reduce noise carpet or soft flooring is better than laminated flooring. Better sleeping can be enforced in a calm environment.
Classroom Tips & Routines: Regular opportunities of quiet space should be there. Comfortable pillows and quiet space areas. You may find more tips on my post 25 Tips for making Sensory Smart Classroom. Calming music and natural sounds in quiet space area can be helpful and soothing. Some of the basic considerations can be as follows: 
  • Child’s desk and surrounding should be decluttered.
  •  Availability of fidgets in the classroom.
  • Weighted items for deep pressure and proprioceptive input (weighted vests, lap weights, ankle weights). 
  •  Allow an anxious child to sit away in the quieter place away from entrance, noise, hallway or water fountain.
  •  Keep all the classroom decorations, charts, pictures on the back wall to avoid visual distraction. 
  •  Keep white board clear to avoid visual distraction. 
  •   Define personal space by masking a tape outline on the floor.
  •  Use headphones to reduce auditory stimulation. 


#Visual Support System

Many children with ASD, SPD respond very positively to charts, sign posters, pie charts, and other visual strategies. This form of information presentation encourages them to communicate appropriately and helps to develop language and process information. Thus, it helps them to be more independent and self-confident to verbalise or make other understand their own feelings.
Visual strategies can be purposeful for expressing and understanding feelings and emotions, while going through transitions or changes, visiting a new place or meeting a new person.
It can be in the form of timetables, behavioural sheets, safety charts, activity sequencing for self-care skills (example-tooth brushing) or independent living skills (driving, sex education), emotion’s chart, social skills, instructions or reminders.

#Sensory Rich and Healthy Diet:

  • Fresh fruits: Children with anxiety should be given food for oral stimulation that will lead to healthy eating and hormonal functioning. Our body needs carbohydrates and sugar, therefore, fruits like apples, grapes, blueberries or peaches, slices of dried mango, carrot sticks may be advantageous.
  • Water: Dehydration always leads o anxiety. Keep child as much hydrated as much possible. Water bottles or sipper should be in close proximity of child for easy access.
  • Omega-3 Fatty Acids: Foods like fish, flax seed, and water squash are rich in Omega-3 fatty acids and play an important role in reducing anxiety, stress and depression.
  • Coffee: Coffee acts as anxiety stimulant. It also increases heart beat and pulse rate. This may be hazardous for children with anxiety or people who get panic attacks.
  • Dairy Products & Sugars: Excessive intake of dairy products, sugars, preservatives, and dyes leads to hyperactivity and raised levels of adrenaline which can lead to anxiety.

#Safety:


Children with hypo-responsive behaviour lack danger awareness, therefore maintaining safety should be a high priority.
  • Special precautions should be taken with daily electrical appliances such as radiators, electrical sockets, blowers, fan and cookers.
  • Install plug locks to prevent a child from putting fingers in plug sockets.
  • All medicines, inflammable items, sharp objects such as a knife, razors, a fork should be either locked up or kept away from the reach of the child.
  • Child’s identification card should be always available in child’s bag with emergency details.