Question 5.

Describe the role of stress upon repetition, perseveration, and self-injury. Be sure to present both physiological changes in the body during a stressful situation, as well as psychological. (can find information in animal literature, as well, for example: stress in transportation animals, etc.) ________________________________________________________

Many studies have illustrated that stress can cause an increase in repetitive, perseverative, and self-injurious behaviors. 

Individuals with ASDs have sensory processing deficits which can lead to  over stimulation, stress or in some instances extreme fear. Temple Grandin mentions that her teen years were fraught with constant fear; while the squeeze box she invented helped to calm her, it wasn’t until she started taking antidepressants that life began to feel bearable to her. 

When the body senses a stressor or a source of danger, a cascading series of events floods the body with hormones that prepare the body to meet whatever threat is perceived. When a threat is perceived, cells in the hypothalamus excrete two hormones that signal cells in the adrenal medulla and pons to put out a global alarm system. The autonomic nervous system kicks in very rapidly causing the fight or flight response, engaging the sympathetic nervous system and muting the parasympathetic nervous system. This elevates the heart rate and blood pressure, encourages the liver to release sugars into the blood stream to provide extra energy, shuts down the digestive system, preparing the body for any action necessary to avert the danger that the mind detects.Breathing becomes more rapid. Blood is shunted away from extremities causing the skin to sweat.

Children with ASDs have been found to have less activity in the amygdala, well known for its association with the emotion of fear. Social anxiety and the isolation it brings adds to stress levels.

Many children with an ASD find human touch to be uncomfortable and human interaction to be stressful because of language and perception issues. Unfortunately, this can increase stress levels further; long-term isolation is known to cause stress and repetitive behaviors in captive animals. (Mckinney, 1974) Schultz (2005) suggested that the social isolation caused by the effects of autism might cause enough stress to lead to an increase of repetitive, perseverative, and self-injurious behavior, and that this behavior might become part of a compulsory coping mechanism as the child with ASD matures.

Although people with an ASD can find human contact to be overwhelming, they still on some level crave the benefit of human contact. Deep tissue stimulation is extremely relaxing to people with ADHD, ASD, and sensory disorders. Temple Grandin, having observed the way cattle in a restraint system relaxed, created what she called a “squeeze box” that triggers a relaxed state. (Grandin, 1992)

 

Because ASDs are a complex spectrum of disorders, no single intervention can universally ease the stress causing repetitive behaviors. For children who find sensory stimulation to be too intense, earplugs, changes in lighting, clothing that isn’t restrictive or noisy, and simple, uncluttered environments may reduce repetitive or self-injurious behavior. Some studies have indicated that adaptive methods such as Irlen glasses might be beneficial.

For children with high levels of arousal, sensory stimulation/activities such as deep pressure stimulation with massage, joint pressure, weighted vests or blankets, or rolling the child up tightly in a blanket can help to bring down the arousal level.

Providing safe space and limited times for stimming might allow children to release stress caused by their environment. For some, teaching the child how to seek help when they are feeling overwhelmed by demands placed on them might limit tantrums. Exercise is extremely helpful; it provides good proprioceptive feedback as well as a healthy stress release.

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References:

Grandin, T. (1992). Calming effects of deep touch pressure in patients with autistic disorder, college students, and animals. Journal of Child and Adolescent Psychopharmacology.

Mckinney, W. T. (1974). Primate Social Isolation: psychiatric implications. Archives of General Psychiatry, 422-426.

Schultz, R. T. (2005). Developmental deficits in social perception: the role of the amygdala and fusiform face area. International Journal of Developmental Neuroscience, 125-141.

Question 4.

Summarize articles that discuss executive function and decision-making skills as they may contribute to repetitive behaviors.

As we have discussed in previous weeks, executive function disorders are a common feature shown by people with an ASD. One may assume that weak central coherence and deficits in executive function may contribute to repetitive behaviors. One study found that repetitive actions are a result of executive function as opposed to weak central coherence. (South, Ozonoff, & Mcmahon, 2007)

Executive functions control our ability to initiate and to stop actions, as well as to plan future actions. Executive function helps us to monitor what we are doing, to form abstract ideas, and to bring information together in novel ways. People with EF issues may experience poor impulse control, which may lead to verbalizing in bizarre or inappropriate ways to other people. Executive function encourages flexible thought and the ability to change topics or activities. Routine or repetitive tasks may make fewer demands upon executive functioning. (Kuhaneck & Watling, 2010)

When compared to children with ADHD, also a disorder that features problems with executive function, children with ASD exhibit more issues with planning and flexibility, while children with ADHD have more difficulty with impulse control. It has been noted that as many as half of children with an ASD seem to have ADHD symptoms as well. Is it possible, then, that the rigidity of ASD in combination with the lack of impulse control of comorbid ADHD can contribute to repetitive behavior?

(Sinzig, Morsch, Bruning, Schmidt, & Lehmkuhl, 2008)

 

Research suggests that without the ability to regulate behaviors or to inhibit repetitive behaviors, the child with ASD may become “locked in” to certain behaviors. (Turner, 1999) With a diminished system in place to enable one’s ability to self-regulate behaviors, assimilate new routines, and to remain flexible in new environments, it is easy to understand that children with an ASD engage in repetitive behaviors, especially when faced with new and stressful situations.

An EMT friend of mine relayed a story about a patient with high-functioning ASD she transported recently. He was very ill and needed surgery immediately, but he had tickets to an art exhibit the next day. He was so locked into the idea of going to the exhibit he repeatedly demanded that the doctor release him right away. She noticed that he also had a fascination with addresses, so she distracted him with the addresses of all the hospitals in the area, which kept him calm enough for transport. Fortunately, the gentleman was conserved and could not refuse the surgery that saved his life. This patient's inability to take in the information that he was critically ill and his unwillingness to cancel his trip to an art show are perfect examples of how problems with executive function and the lack of flexibility associated with ASD can impact decision making.

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References:

Kuhaneck, H. M., & Watling, R. (Eds.). (2010). Autism, A Comprehensive Occupational Therapy Approach (3rd ed.). Bethesda, MD: AOTA Press.

Sinzig, J., Morsch, D., Bruning, N., Schmidt, M. H., & Lehmkuhl, G. (2008). Inhibition, flexibility, working memory, and planning in autism spectrum disorders with and without comorbid ADHD symptoms. Child and Adolescent Psychiatry and Mental Health.

South, M., Ozonoff, S., & Mcmahon, W. M. (2007). The relationship between executive functioning, central coherence, and repetitive behaviors on the high functioning autism spectrum. Autism, 437-451.

Turner, M. (1999). Annotation: Repetitive Behaviour in Autism: A Review. Journal of Child Psychology and Psychiatry, 839-849.

Question 3.

Summarize at least 3 articles which explore play patterns, perseveration, and self-injurious behaviors. 

Play Patterns

Miller & Kuhaneck carried out a study in 2008 entitled Children’s Perceptions of Play Experiences and Play Preferences: A Qualitative Study. The study investigated the perceptions of play and rational for play preferences for ten typically developing children aged 7 to 11 years. The importance of play as being a child’s primary means to develop socially, emotionally, cognitively and physically is emphasized. How children play is often more important than what they play with. However what children select and prefer to play with is also looked at in this study.

Play choice can be influenced by many factors. In typically developing children research has shown that gender impacts play choices significantly, with girls preferring dyadic play and social interaction and boys tending to be drawn to more physical outdoor play. Another major factor impacting play is age. Typically developing children as they develop new motor and cognitive skills move towards more complex play. They use play to explore the world around them; relational play is followed by symbolic or pretend and social play.

In the study children were asked what were their favorite toys and why. They were asked how they felt when they played and how they chose what to play with. Questions also included where they played and what their favorite places to play were.

The results of the Miller & Kuhaneck study indicated that play choices for the typically developing children were primarily influenced by the ‘fun’ factor.

Fun was described by most of the children as the opposite to being bored. They talked about play being something you can do with your friends and how play made them feel happy.

The children in the study selected play activities that were perceived as ‘fun’  The primary activities chosen were  activities that incorporated a challenge,  that were seen as not too hard or too easy. They chose activities that involved  teamwork, playing with peers and bonding play with others.

The study concluded “When viewed in this manner, it becomes clear that therapists need to pay particular attention to creating the just-right challenge, being fun and playful in approach, and using peers and others in therapy.”

(Miller, E., & Kuhaneck, H. (2008). Children’s perceptions of play experiences and the development of play preferences: A qualitative study. American Journal of Occupational Therapy, 62, 407–415.)

When looking at the play patterns and choices of children with an ASD we see a very different picture.

Children with an ASD do not follow typical developmental patterns of play. Due to poor executive functioning they have difficulty initiating and carrying out play ideas. The skills inherent in executive function require that the child build a fund of knowledge about their environment and the objects in it. This fund of knowledge is built and developed through play exploration and interaction with their environment. Without these cognitive functions the child lacks the ability to generate an idea, think imaginatively, and make a plan to play.

Typically developing children appear to be intrinsically motivated to play and explore by their perception of fun. By contrast children with an ASD often appear to be motivated more by sensory needs which can result in play that is restrictive and repetitious.

The lack of constructive play patterns in children with an ASD reduces learning opportunities. The difficulties in engaging in peer or team play impacts socialization and social skills.  And restrictive repetitive play patterns means that the child misses out on exploration, as well as social and learning opportunities and the ability to have fun.

Perseveration

Perseveration refers to a set of repetitive behaviors frequently seen in individuals with an ASD. They include verbal, physical or gestural behaviors. A child who perseverates repeats a meaningless action over and over again, even though the initial stimulus is no longer present. For example, a child may perseverate by repeating a word or a question over and over again, or repeat a gesture or action repeatedly without any apparent meaning. Perseveration is one of the key diagnostic criteria in autism.  

A study was carried out by the UC Center for Research on Special Education, Disabilities and Developmental Risk to look at the various types of perseverative behaviors and document the frequency of the different types of behaviors that the children with autism displayed.

Perseveration is not specific to children with an ASD. It is also present in children with other disorders such as trisomy 21 and fragile X syndrome. 

Perseverative behaviors impact individuals in three areas: 

• socialization
• communication 
• restrictive play or interests

The study included 37 children between the ages of 29 to 73 months. All children had an autism diagnosis. The Timed Stereotypies Rating Scale, revised (Luce, 2003) was used. This rating scale was developed to ascertain the frequency of perseverative behaviors in individuals with an ASD. It looks at a diverse range of behaviors including:

• teeth grinding
• tiptoe walking
• spinning objects
• hand flapping
• biting
• covering ears or eyes
• body rocking

The results showed that the most prevalent perseverative behavior was verbal perseverative and the most infrequent behavior recorded was perseverative actions.

In summary the article stated that perseveration persists in individuals with an ASD into adulthood and these behaviors take up a large portion of the individual’s time. It suggested that further research into perseverative behaviors is imperative to improve our understanding of this phenomenon in children with autism. It is hoped this would assist in the development of appropriate interventions to address these behaviors. (Arora, 2008)



Self-Injurious Behaviors

Perhaps one of the most frightening and difficult aspects of ASD, self-injurious behaviors, result from a number of causes and may consist of the following:

• hitting or punching
• head banging or forceful shaking
• gouging the eyes 
• biting hands or fingers 
• picking at, scratching, or pinching skin
• pulling hair

Because so many people with an ASD are nonverbal it is difficult to determine exactly what triggers these behaviors. Some possible causes include:

• Physiological Causes, Self-injurious behavior may be caused by pain that isn't being addressed, illness or infections, tic disorders (Clements and Zarkowska, 2000), sub-clinical seizure activity, endorphin release,  high serotonin levels, and perhaps dopamine imbalances. 

• Social Causes Self-injurious behavior brings a great deal of attention very quickly. This behavior may be an effective way to avoid demands placed on a person with an ASD. Also, behaviors like head slapping may be a way to convey frustration or other emotions when more effective forms of communication are not possible.

• Environmental Causes It is possible that arousal levels and sensory issues may lead to self-injurious behavior. Activities such as biting hands may be a way to let off steam in an environment that is too loud or complex. For those with low levels of arousal, inducing pain may be a way to provide stimulation. 

• Perseverative Behavior Self-injurious behavior may be a part of ritualistic, repetitive behavior that is so common in ASDs.

Because such a wide array of issues may lead to these types of behaviors, it is important to rule out medical issues as well as to observe the social and environmental milieu as self-injurious behaviors are happening. Finding the cause of this behavior can be challenging and time-consuming. Caregivers have found some creative and effective ways to protect their charges from self-harm:

Treating self-injurious behavior may be as simple as reducing or increasing the stimulation levels in the environment. For some groups an environment that includes toys, a lack of demands, and reinforcement for non self-injurious behaviors and redirection seems to work the best. (Iwata et al, 1994) Future blog entries will explore the uses of drug therapies and sensory integration strategies. 

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References:

Aurora, T. (2008). Perseveration in Autism. UC Center for Research on Special Education, Disabilities, and Developmental Risk. Santa Barbara.


Clements, John, & Zarkowska, Ewa. (2000) Behavioural Concerns and Autistic Spectrum Disorders: Explanations and Strategies for Change. Philadelphia: Jessica Kingsley Publishers.


Iwata, Brian A.; Dorsey, Michael F.; Slifer, Keith J.; Bauman, Kenneth E.; Richman, Gina S. (1994) Toward a Functional Analysis of Sef-Injury. Journal of Applied Behavior and Analysis, 27, 197-209.


Miller, E., & Kuhaneck, H. (2008). Children’s perceptions of play experiences and the development of play preferences: A qualitative study. American Journal of Occupational Therapy, 62, 407–415.