Updated: Sep 10, 2020
Autism rates continue to climb throughout the United States with 1 in 54 children being diagnosed. In the state of New Jersey, this number is even higher, with 1 in 35 children diagnosed with Autism Spectrum Disorder (ASD) by age 4. Because of these staggering statistics virtually all school-based occupational therapists will come into contact with autistic children. When working with this population you will likely notice that autistic kids are often anxious. Research bears this out. A recent meta-analysis (van Steensel, F. J., & Heeman, E. J, 2017) found that approximately 40% of autistic children have enough symptomatology that could warrant a comorbid diagnosis of anxiety. This number does not even take into account the many autistic children who have subclinical levels of stress and worry that impact their daily ability to function.
Are you focusing on anxiety with your autistic clients?
I find many school based therapists believe that there are other school professionals who are better able to deal with mental health challenges. Yet, in my now decades of work, I often see that when a child has an ASD diagnosis counselors are rarely involved and the school psychologists and social workers tend to case manage or evaluate, not work on the emotional needs of autistic children. As OT’s we have many tools to help but we first have to recognize anxiety and subsequently own the skills that we already possess to help.
Connecting to the Body
One of the hypotheses about anxiety and autism is that it is related to differences in sensory processing. Many occupational therapists are experts in sensory integration and we are comfortable in our approach to remediating sensory challenges. Within educational settings, which are largely using behavioral approaches, there has long been the notion that sensory integration treatment is not based on research. Fortunately there is now some solid evidence to support sensory integration in autism services. One recent meta-analysis found that Ayres Sensory Integration Therapy can be considered an evidence based practice for autistic children (Schoen et al, 2019). The question for school based therapists then becomes can we as truly deliver Ayres sensory intervention, with fidelity, in the schools? For most school based therapists this is highly unlikely as within this approach, children are seen individually, there needs to be a variety of equipment, adequate space, and usually sessions are an hour in length. This criteria cannot be met by the average school OT. I offer an alternative to traditional sensory integration therapy that starts with a adopting a different mindset :
We may be working from an incorrect assumption that fosters the medical model of “fixing” the child and removing the problem?
Instead we can think about sensory differences as a part of ASD that may never be completely remediated to some “normal” level. Then we could help our autistic clients to manage sensory challenges. We could educate school staff and create awareness that the environments around autistic children may need an upgrade. Are we scanning classrooms and suggesting that we have less clutter on the walls and more defined spaces? Are there clear visuals of the schedule and the rules as many autistic individuals thrive when there is visual order. Are there spaces where children can move and/ or rest when necessary for their state of regulation? How about the volume in the classroom? Often people use a loud voice when talking to children who have language processing challenges. When a child demonstrates hypersensitivity to noise, voice volume matters. We can play with using less language, a more modulated pitch and perhaps being careful to not use clapping and cheering as our means of stating our approval. At a recent conference I attended (see note) there were many autistic adults present and we used hand waving to demonstrate our excitement. They also turned down lighting and had a separate space for people to escape to if they needed to decompress. Lastly we had name badges on that clearly stated our comfort level with being approached. These modifications were easily put into place and demonstrated respect for the participants of the conference. Environmental changes can go a long way in helping our autistic students and do not require that we remove children from the classroom for a sensory integration session.
Autistic adolescents have been found to be much more likely to be sedentary than their neurotypical peers. As exercise has been found to be an effective treatment for anxiety this is a troubling fact. Knowing the benefits of exercise and actually doing it are two very different things. Preschoolers love to move and rarely need our encouragement so the inactivity likely begins in the elementary school years. Of course many autistic children have delays in gross motor skills and motor planning challenges. They may also have had negative experiences in physical education class because they felt that they cannot compete. Occupational therapists often go straight to skill development to help their autistic clients but there is another way.
Habit Creation instead of IEP Goals for our Autistic Students
Successful long term exercisers find joy in movement. If we want our students to exercise then they must help them to find exercise that makes them feel good. As adults we must model this for students, but of course this only works if we believe it for ourselves. Anything can be exercise! We must take the competition out of exercise and help children to connect the feelings in their bodies when they move instead of focusing on learning skills. Exercise increases endorphins, enhances executive functioning and gets us out of our thinking mind and into our body. This is essential for people who struggle with anxiety.
A very simple method can be to incorporate a period of exercise into each OT session. When I have done this I then announce how I feel after we are finished. I encourage therapists to try this outside of the therapy space first to notice how they feel after you have completed a movement activity. Any movement that you enjoy, such as dancing, jumping on a trampoline, running after toddlers or going for a swim, counts. When we start to connect movement and joy we will not have to exercise, we get to exercise and we will feel grateful for it. When we have that grateful energy, it is contagious to those around us. Creating the exercise habit can be done with your clients. Yes, you can exercise at work, while getting paid, and also help your students to create this habit for themselves. I have seen even the most sedentary students thrive under this approach. When we help our students to create habits, we move beyond our discrete IEP goals, that no one remembers, and actually have an impact on the entirety of their lives.
Mindfulness practices have become mainstream and have been found to be great tools to deal with stress and anxiety. There are now several studies that have found that autistic children and adults can benefit from mindfulness practices. One study found that even for autistic adolescents who were aggressive and non-speaking that mindfulness can be taught and practiced to reduce incidents of aggression (Sing et al, 2011). As mindfulness is becoming more accepted in schools, it is again vitally important to teach mindfulness by modeling it. There are now many apps and videos that present mindfulness to children. I see teachers sitting at their desks, working on their paperwork while the video plays. What is this teaching the students? One, it is a clear message that these practices are for the children and not for the adults. There is also the message that it is not that important; it is just a time filler so the adults can get work done.
Working in the schools is stressful. Studies show that teaching rates as one of the most stressful occupations in America. Stressed teachers create stressed students. One study looked at burnout, teaching and cortisol (the hormone released during stress). The students, in the classrooms with the teachers who had the highest levels of burnout (a measure of high stress), were found to have the highest cortisol levels.This study demonstrated that stressful classrooms impact students on a physiological level.
As school based occupational therapists we are impacted by the stressful environments around us so we need tools to manage or we can inadvertently pass this on to those that we are trying to help. For our autistic students this cannot be overstated. Autistic adults often talk about their high level of attunement to the energy of the people around them. We may even think of autistic individuals as stress antennas and so if we want to be effective we should be very attuned to our own nervous system. When I got very clear on this fact, and my own mindfulness practices became a habit, my work with autistic children was transformed. There are many studies now that show when a parent of an autistic child uses mindfulness practices they report that their children’s behavior improves just by the parent working on their own stress levels and not because there was any change in their child’s programming. We can, and should, teach mindfulness practices to children but we must start with ourselves. This does not have to take time away from your day. It can start as a simple minute to close your eyes and notice your breath between therapy sessions as a way to clear out what just happened and help reorient you to your next student. We can then incorporate small moments of mindfulness working alongside our students. I often take very noticeable, visual breaths such as bringing my arms up on an audible inhale and then down on an audible exhale. After I do it, if feeling genuinely different, I let my students know that the breath changed me in some way. If practiced regularly, and if teachers also have buy in, even my preschool students start practicing these techniques without prompting.
Anxiety is a complex issue and there are many tools at our disposal as occupational therapists. These two body-based interventions are just part of what we can do to help our autistic students to manage stress and create resilience. If you would like to hear more please subscribe to my list at www.weinsteadofme.com.
Note: The conference that was referenced was NestCon 2020 in NYC. The NestCon brings in leaders on autism and inclusive education every 2 years and is highly recommended for autistic people and for those who love working with them.
Oberle, E., & Schonert-Reichl, K. A. (2016). Stress contagion in the classroom? The link between classroom teacher burnout and morning cortisol in elementary school students. Social Science & Medicine, 159, 30-37.
Schoen, S. A., Lane, S. J., Mailloux, Z., May‐Benson, T., Parham, L. D., Smith Roley, S., & Schaaf, R. C. (2019). A systematic review of ayres sensory integration intervention for children with autism. Autism Research, 12(1), 6-19.
Singh, N. N., Lancioni, G. E., Manikam, R., Winton, A. S., Singh, A. N., Singh, J., & Singh, A. D. (2011). A mindfulness-based strategy for self-management of aggressive behavior in adolescents with autism. Research in Autism Spectrum Disorders, 5(3), 1153-1158.
van Steensel, F. J., & Heeman, E. J. (2017). Anxiety levels in children with autism spectrum disorder: a meta-analysis. Journal of Child and Family Studies, 26(7), 1753-1767.