Focus on Strategies for Anxiety at Annual Conference

 

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The Autism Society of North Carolina held its annual conference March 24-25 in Charlotte. We will be sharing information from conference presentations in upcoming blog posts.

Holly Blanc Moses, a Board Certified Behavior Analyst, Licensed Professional Counselor, and Licensed Psychological Associate, gave a presentation titled “Autism and Anxiety: Strategies that Work” on the second day of the conference. Ms. Moses began by reminding her audience that everyone experiences anxiety at some point in their lives and listed several indicators: rigidity, oppositional behavior, unresponsiveness to reason, excessive emotional reaction, resistance to transition, excessive avoidance of harmless events/objects, excessive need to control others or the environment, confusion, frustration, and frequent question-asking. Anxiety can even manifest in physical symptoms including shortness of breath, rapid heart rate, muscle tension, headaches, and stomach pain.

It is estimated that up to 40 percent of individuals with autism may have a co-diagnosis of anxiety that can worsen their social challenges, increase their challenging behaviors, and generally reduce the scope of the world in which the person with autism interacts. Individuals with autism will usually have difficulty communicating their anxiety. As a result, their caregivers will often misinterpret their anxiety as bad behavior, applying labels such as “defiance” or “aggression.” Attempts to discipline the “bad behavior” will likely lead to one of three unproductive responses: avoidance or escape, fighting back, or shutting down.

The triggers for anxiety in individuals with autism are what Ms. Moses labels “heavy stuff”: expectations to tolerate difficult moments, to be social, to do homework, to please teachers and parents, to maintain self-care and complete chores; as well as unexpected changes. A patient of hers described his reaction to the heavy stuff as “I feel like I’m on fire,” and another noted “People like us don’t know how we fit in this world.” The focus of her therapy when working with these individuals is to find ways to lighten the load of the heavy stuff.

Ms. Moses explained that she tries not to minimize what her patients say; she dislikes common counselor questions such as “Is that a big problem or a little problem?” since it all feels “heavy” to these patients. She gave her audience a brief quiz by tossing out simple words and having the audience quickly respond “good” or “bad” to label each word; most found it very easy to identify words such as “happy” as being “good” versus “sad” which is “bad.” But Ms. Moses explained that her patients with autism and anxiety may struggle to apply such simple labels. She tries to work on their terms by keeping two small balls nearby; one is lightweight, soft, and fuzzy; the other is heavy, hard, and wooden. Patients can select a ball to respond to a word she gives by indicating how that word makes them feel, rather than by giving it a good or bad label.

Ms. Moses likes to use the phrase “My brain is telling me a story that…” and encourage patients to finish the sentence. Often the patient chooses a heavy or “stuck” thought such as “everyone hates me” or “I don’t do anything right” or “I stay in my room so I don’t have to monitor so many people” (these are actual responses gleaned from young patients, male and female). Ms. Moses then works to help the patient lighten the load of these heavy thoughts and getting them “unstuck” by helping the patient to interpret their brain story in a more positive way.

Ms. Moses then outlined two cases, beginning with Jack, a 10-year-old with ASD and anxiety who had an intense fear of mascots. Ironically, he loved the concept of mascots and had memorized the mascots associated with major league teams around the country and even talked about becoming one. But his fear meant that his family avoided fun outings such as ball games and had had to constantly surveil stores and restaurants for mascots before taking Jack inside. Jack also avoided social interaction with his peers and a schoolwide reward program. Her plan for Jack was based on social-skills training in session and during lunch and recess at school, systematic exposure to mascots (she emphasized that this type of exposure must be directed by a professional), and a system of rewards (reinforced at home) for school participation. The social-skills training involved four phases beginning with a group of a dozen or so students whom Jack pre-approved; no students knew that Jack was the target of the sessions. Conversation topics were also identified in advance, and students were encouraged to answer questions with short one- to two-word responses. In the second phase, Ms. Moses added some students that Jack didn’t pre-approve and encouraged full-sentence answers. In the third phase, the ratio of known to unknown students was about 50:50, and longer conversations were encouraged (three exchanges per question). Finally, the 50:50 ratio was maintained but the topics were pre-identified only for the first two exchanges; students were instructed to both ask questions and make comments. She tracked Jack’s contribution to each session, which rose from 3% to 70%. Best of all, when the sessions ended, Jack hugged a mascot and attended a sports event with his family that included a mascot.

Dave was a 13-year-old with ASD and anxiety; he dealt with his anxiety by running from the room and had engaged in self-injurious behavior severe enough to lead to multiple hospitalizations. He also had not-so-cool ways to try to engage his peers, such as breaking into a rap song in the middle of class. Ms. Moses’ plan for Dave included trying to make room for what he called his “brain trains” (the “heavy stuff”) by understanding that they will arrive whether we want them or not, and encouraging him to jot down his brain trains to discuss in sessions. She also developed a school behavior plan to include a signal to the teacher requesting a break in the hallway for up to five minutes and two to three daily check-ins with the school counselor. Ms. Moses worked to further educate both the teacher and Dave’s parents about autism; this included training his mother to give more effective instructions, especially for transitions. And finally, Ms. Moses added social-skills training, which encouraged Dave to engage with students with similar interests and helped him learn to be more effective at giving compliments. Over time, Dave made friends, acquired his first girlfriend, and engaged in school activities including Math Olympics, bowling team, football team manager, and theater.

Ms. Moses concluded her presentation with some quick tips, beginning with “Make Time Visual.” Time can be very hard for those with autism to conceptualize leading to complaints such as “This is gonna take forever!” or “Whatta you mean it’s time to quit?” Keep a colorful timer nearby. Another tip is “Make Life Visual” with pictorial (or text as the child ages) schedules, homework goals, reward systems, etc. Praise successes, especially if you notice more calmness with your child in challenging situations. Gradually expose him/her to feared events or objects. Use clear one- or two-step instructions, and always be sure the goals you’ve set are genuinely reachable.

Holly Blanc Moses, MS, BCBA, LPC, LPA, of Crossvine Clinical Group, PLLC, in Raleigh, has more than 19 years of experience in working with individuals with autism and developing strategies to assist them.

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Managing Frustration and Anxiety

 

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Dr. Jed Baker, noted autism expert and author, shared some of his expertise with parents and professionals last week at a one-day conference in Raleigh. His presentation was titled “Managing Frustration and Anxiety and Teaching Social Skills” and provided strategies for individuals with Autism Spectrum Disorder, ADHD, anxiety, mood disorders, and learning challenges.

For those who could not attend, we are sharing highlights of the portion of Dr. Baker’s presentation on managing frustration and anxiety. You can also learn more with his award-winning books, available in the ASNC Bookstore at www.autismbookstore.com.

Keep Your Cool

Dr. Baker’s first tip was that caregivers must learn to control their own emotions. “If you can be cool, you can get someone else cool,” he said. Reacting to someone having a meltdown by either giving them what they want or forcing their compliance is not effective, he said. Giving in doesn’t last; it feels good in the moment but has disastrous long-term consequences. Getting angry comes from not feeling respected. Caregivers can use fear and unpredictability to scare individuals into complying, but in the long run, the individuals don’t trust you anymore, they don’t want to be in your home or class, and they will not like you, he said.

“90 percent of teaching and parenting is tolerance,” Dr. Baker said. Caregivers must tolerate their own discomfort long enough to think about what to do and not give in or get angry.

So how do caregivers control their own emotions? Number one, by having hope! Tthink of challenges as a temporary issue that can be fixed, not a character flaw. Know that things will get better eventually as long as you stick to strategies. Studies have shown that parents who are optimistic stick to strategies and therefore bad behaviors lessen over time.

Two other things to keep in mind when attempting to control your own reactions: Realize that the individual’s behavior is not intended to challenge your authority but is rather a reflection of their lack of coping skills. Also, do not worry about what other people think. Most observers understand that a child having a meltdown in public is not a reflection of your competence, and they do not blame you. You can gain respect by controlling yourself, not the child.

Lastly, be sure to take care of yourself and maintain balance in your life. What are you doing to make yourself happy? Dr. Baker suggested trying yoga, meditation, and exercise as great ways to reduce your own stress and enable yourself to maintain control of your emotions in the face of meltdowns.

Build a Positive Relationship

The first step to managing an individual’s behavior is to build a positive relationship, Dr. Baker said. It is very important for children to know that adults around them actually do care about them; show warmth and caring.

Ensure that the individuals know what is expected of them by using structure, visual supports, and differentiated instruction. Fair is giving everyone what they need, not teaching everyone at the same level, Dr. Baker explained.

You can also build confidence through the 80/20 rule. Enable individuals to succeed by starting with tasks or lessons they already grasp, then move on to new or more difficult material for the last 20 percent. If you start with the difficult material, they will feel defeated, Dr. Baker said. If you don’t let them make a mistake or fail the first eight times, they will believe they can succeed.

And finally, avoid power struggles. For example on homework, allowing breaks or limiting the amount of time they spend on it is not giving in, it is managing the work. You could also try doing the work with them or doing the first problem for them.

Manage Crises

When an argument, meltdown, or crisis does come up, first be willing to take some time to manage it. Listen to their side of the situation, agree, and apologize when necessary. Show some sympathy; there is always a kernel of truth in why they are acting out. Then collaborate and ask them “what do you want? Let’s find the right way to get that.”

If the individual is too distraught to use logic or reason, try to distract them and change their mood or focus with novel items, special interests, or sensory activities. Dr. Baker said that when he is working with individuals on the spectrum, he always keeps his pockets full of things he can use to distract them. Distraction is not rewarding the behavior as long as you don’t give them what they were having a tantrum over. If the individual is trying to avoid a task, distraction helps them avoid it, so give them a legitimate way such as taking a short break or breaking the task into pieces.

Once the crisis is over, make a plan for next time.

Work on Repeat Behavior Problems

If the individual is repeating unwanted behavior, explore why it happens. Observe and keep a journal so that you know what happened before, during, and after the behavior. The difficulty is that causes for the behavior come before the behavior, when you might not be paying attention. But with practice and time, you should be able to discover the trigger for the behavior.

Some of the typical triggers Dr. Baker listed were:

  1. Internal issues – hunger, exhaustion, illness
  2. Sensory issues – noise light, touch, overstimulation, boredom
  3. Lack of structure – not enough visual supports to give expectations
  4. Challenging or new work, feared situations
  5. Having to wait, not getting what one wants, disappointments
  6. Threats to self-esteem such as losing, mistakes, criticism
  7. Unmet wishes for attention – being ignored, wanting others to laugh

Once you have data on the trigger(s), you can develop a prevention plan. Dr. Baker mentioned his No More Meltdowns app that will help caregivers keep track of behaviors. The app allows you to upload to www.symtrend.com/nmm, which will analyze data and give you a prevention plan.

A good behavior plan will change or remove the triggers as much as possible, teach the individual skills to deal with the triggers, and reward new skills. If the individual is not already frustrated, you can also use a loss system when they do not use new skills to deal with the triggers.

Demands for Work

When an individual is frustrated by demands for work, there are several ways you can change that trigger. First, model and prompt rather than test. This goes along with the 80/20 rule mentioned previously. “Teach” them something they already know first, so they succeed. You also can give them a choice of which work they do, or use their special interests to make the work more appealing. Visual supports, such as instructions, outlines, and labels are helpful for many individuals. Finally, try reducing the length of time and using a timer so they can see how long they must keep doing the task.

To help individuals deal with demands for work, teach “trying when it’s hard,” Dr. Baker said. For some individuals, the fear of the work is the trigger, and this can be overcome with gradual exposure. Get them to try a small portion of the work. Teach them to ask to watch first or to ask for help. Tell them that they may take a break for a certain amount of time and then come back to try again. Finally, be willing to negotiate how much they do (unless you know you are working with an individual who will keep negotiating, which Dr. Baker referred to as a “congenital attorney,” much to the audience’s amusement).

Dealing with Fear

Some individuals fear situations that can just be avoided, but many must face their fears because situations cannot be avoided. Start by persuading these individuals that they must deal with their fears. Talk about their strengths and their optimistic future, and then bring up that they should deal with their fears so that the challenge is not in their way anymore. It can be a relief for them to learn that they do not have to change fundamentally, they just have to make it so that the challenge does not stand in the way of their success, Dr. Baker explained.

Then explain anxiety and true vs. false alarms. Being anxious means that the brain lies to you and makes you afraid all the time, rather than just keeping you out of true danger, he said. Help them to think like a scientist and do research on their fears. For example, if they wash their hands constantly because they are afraid of germs, they should research the likelihood of contracting a disease. Let them convince themselves through logic that their anxiety is overblown.

You can also try gradual exposure to their fear. A visual aid of a fear ladder with rungs of exposure can allow for rewards as they reach each rung.

To reduce individuals’ overall anxiety, add exercise, mindfulness meditation, and relaxation techniques. Dr. Baker recommended the resource www.fragrantheart.com. Focusing on the moment means they are not worrying, and it recharges and re-energizes, he said. The best time for many is at night, because they are less occupied, and so that’s when all the worries come out.

Finally, if anxiety is debilitating and other methods are not working, Dr. Baker said neurofeedback and medication can be useful options.

Waiting, Accepting No, Stopping Fun

Dr. Baker offered several strategies for individuals who have meltdowns because they are unable to wait, accept no for an answer, or transition away from preferred activities. A visual timer can help them understand how long they will have to wait or when they must start a new activity. A visual schedule also helps with transitions. “Prime ahead” by discussing what they will gain by waiting or accepting no, and talk about disappointments that might occur during an upcoming period.

Help them accept no by providing what they want or something else that they want at a later time. Use a reward system such as a “disappointment poster” and give them points for waiting, accepting no, and stopping fun.

Self-esteem: Mistakes, Losing, Teasing

For individuals who are upset by losing or mistakes, again the 80/20 rule is useful, Dr. Baker said. Let individuals win or succeed 80 percent of the time to build up goodwill. You also can talk ahead of time about mistakes that might occur but remind them that mistakes help us learn and grow; if you are not making mistakes, you are not trying new things or learning.

For teasing, first protect the individual as much as possible by surrounding them with supportive peers. Peer buddy programs have been shown to be a very effective method of building children up and preventing teasing. When teasing does occur, help them to check it out first to make sure they understood correctly. Perhaps it was not meant to be teasing. Teach them that when they are teased, they should calmly ask the person to stop, showing that the teaser did not get to them and does not control them. If the person does not stop, they should report the behavior.

Unmet Needs for Attention

Some individuals act out to gain attention. To change this trigger, you can schedule attention or special time for the individual so they know they will get it. In the classroom, for example, you could use a timer to count down to when they may speak with the teacher rather than calling out in class. Dr. Baker also recommended looking for appropriate outlets for the individual, such as theater or standup comedy.

Also, teach the individual about positive ways to get attention, stressing that they want to be liked, not just gain attention. Teach them about public vs. private topics, and if in a classroom or other group setting, try to get peers in on it — if the peers laugh when the student says something inappropriate, that is a reinforcement of the negative behavior. Teach the individual the “rules of comedy”: Don’t make fun of vulnerable people. Use slapstick, random thoughts, and self-deprecation.

Sensory Needs

For individuals who engage in self-stimulation such as drumming, flapping, or chewing for sensory needs, you can try to change the triggers by avoiding boredom such as waits or group activities in which they are not engaged, or by modifying frustrating work.

Skills you can teach them include alternative ways and times to self-stimulate and how to be a self-advocate for a better environment, Dr. Baker said. Individuals need to know to ask for what they need, such as less noise or more interaction. On the other hand, they need to know they have a right to the environment that works for them but can’t impose it on everyone else. If they need it quieter, they can ask people nicely, and if they don’t get it, the individual should ask to leave and take a break.

Self-Calming

Dr. Baker also discussed ways to prepare for unexpected triggers. Collaborate with the individual on ways to distract and soothe themselves in the case of upsets. Have them compile a folder of relaxation techniques. Establish safe people whom they can turn to when they need support. Teach them this self-talk: “All problems can be solved if you can wait and talk to the right person.”

Jed Baker, Ph.D. is the director of the Social Skills Training Project, an organization serving individuals with autism and social communication problems. He is on the professional advisory board of Autism Today, ASPEN, ANSWER, YAI, the Kelberman Center and several other autism organizations. In addition, Dr. Baker writes, lectures, and provides training internationally on the topic of social skills training and managing challenging behaviors; he was the keynote speaker at ASNC’s 2015 annual conference.