Understanding that individuals on the autistic spectrum, or with cognitive difficulty, may possibly be interpreting their environment in an entirely different way to those supporting them, is an important first step in responding to the challenging behaviour. Accepting that, for these individuals, the levels of anxiety caused by sensory regulation issues is a major trigger. Then managing the triggers and consequences of such challenging behaviour becomes the keystone in supporting individuals with such a seemingly deep seated behaviour pattern. How does this knowledge help us in working with individuals who present with this form of challenging behaviour? Essentially, if we can predict the causes, we can plan to reduce them and we can help the individual develop the skills necessary to manage their situation themselves.
In this article we will consider understanding the needs of the individuals, assessing their strengths and the elements that they struggle with. We will look at how we can improve their environment to reduce sensory impact. We will examine strategies that are thought to help in regulating responses to environmental stimuli. We will look at how we can train life skills such as focusing, relaxation and also help individuals to communicate their needs.
Planning has to include assessment – we need to know what the triggers are to an outburst. Noisy environments? Close proximity of other individuals? Smells? Touch? The list is extensive. Don’t forget too that we may constantly be placing demands upon individuals that are not matched to their abilities. Accepting challenge and the frustration that goes along with not meeting your target is part of life’s learning process. Working with those that we support means finding ways to help them meet challenges and deal with frustration without increasing anxiety.
Where do we start first – the individual or the environment? Well, I would always start with the easiest first, look at the environment. In school, in a residential setting or in someone’s private home there will always be a clash of needs and a demand for a compromise. Good classrooms are meant to be bright and stimulating displaying examples of student’s work. They also need to meet a range of needs and abilities. The first thing to do is to assess that environment. Film it on video – video captures all sound without discrimination. We can hear just how noisy that environment maybe. We can look at the surroundings with a detached view. Are there shiny surfaces reflecting light? Do the displays create a lack a focus? A crucial point here is that we must not use this assessment to simply strip away stimuli from the environment. Consider whether you can alter the room in any other way. Can we provide distraction free zones or can we provide temporary covers for displays? Think about dark curtaining over wall displays which can be pulled back when we use the displays. Consider the surroundings. Whilst the shrubs outside may look beautiful in summer, in winter the low sunlight through the tracery of branches causes disturbing flickering light. Roller blinds can be used so that at that point of the day, when the sun just shines through that window we can reduce the impact. Then when the sun has moved we can reveal the shrubs and branches again. Noise from other students working can be distracting or confusing. Maybe we could place the individual in a safe zone, a corner say, so they can locate most of the sources of sensory input. Knowing where sensory input is coming from is the first step in understanding that there is nothing to fear from it. There is a very natural and deep seated need to have your back protected. It may be possible to wear ear protectors or headphones with some single source of sound or it may be enough to place sound deadening screens against the walls. Remember that, at the end of the day, we are teaching those we support to cope with the real world and we cannot achieve that by taking away all sensory stimuli that causes stress. We must teach the individual to manage their fears and we do that by facing one fear at a time, not all at once.
Having completed an environmental assessment, we also need an assessment of the individual. There are many of these around, in journals, books and online, but for me the real starting point is, getting to know the individual you are supporting. Talk to carers and family about their likes, dislikes, strengths and weaknesses. If you are in a school situation, indulge in sensory play, lots of it, and observe and record the individual’s responses. These days, if you have an iPad or similar tablet available, you can record the sessions, pick out the highlights and delete for the next session. Or, using a voice recorder, add comments during an activity. If at home or in a residential setting, observe and record the day to day activities. Use your mobile phone to record your comments if you are out and about in town. It is less obtrusive than a video recorder and easier than a note pad and pen. All of this information will build up a picture that will help your planning. Be aware that what is a trigger one day may not the next day, try and work out why. Is it different times of the day or different people around? The permutations are as endless as the subtle shades of light and sound that we experience, but they will start to add to a picture of the individual’s strengths and needs. All this play, activities and interaction helps us build up a picture of how and where the individual functions best. What they are happiest with? What experiences we can consistently introduce without the person we are supporting experiencing a melt down? This process will also provide a picture of those stimuli that individuals are not at peace with, however, don’t just remove them. Remember our role is to help individuals manage their fears and anxieties. Introduce them in safe spaces or at safe times. Give the individual clear escape routes from sensory experiences and, most importantly, provide them with the opportunities to communicate, “I don’t like that” or “I do like that and want more of it”.
As we all know, communication is an essential element of dealing with challenging behaviour. We may know what we are intending to do, we may know the daily routine is about to change, but how do the individuals we are supporting know this? Because we tell them? Even if we could nail down our routine so tightly that it never changes, does that mean we should? Remember we are trying to teach those we support how to manage in the real world, not to cocoon them from it, and things change regularly in the real world.
Environmental adaptations and protection for the individual can only take us so far. Part of the planning needs to consider how to respond if the individual becomes agitated. Once the body chemicals discussed earlier have reached the point where fight or flight becomes the overpowering response point, any physical intervention will simply worsen the situation, leading eventually to the need for restraint. For the individual to return to a calm state, it is necessary for the adrenalin to dissipate from the body. This occurs either by using up the energy made available or by having time and space to calm down. In real life situations, the first generally occurs when the individual has gone on a rampage destroying property, furniture, wall displays or when the individual fights against being restrained by a stronger force, often a group of adults. The boosting of the body’s physical abilities has a finite limit. Or it occurs without risk to individuals, property, increased stress levels, when the individual is provided with space to calm down. If safe space and time is given, the adrenaline will eventually dissipate. The time this takes will vary for all individuals but as a general guide we should be providing a calm down period of forty minutes plus, not just five minutes in a quiet room. Planning then can identify appropriate safe spaces and training can ensure that staff supporting can assist the individual in getting to that safe place speedily and safely.
Provide opportunities for lots of movement, both when there seems no imminent prospect of a meltdown and especially when a meltdown is imminent. Our understanding of sensory integration techniques indicates the neural pathways of the brain function best when the body is in movement. Yet teachers particularly, especially in mainstream settings, remain prone to restricting children’s movement. In my experience, in adult settings a lot of the individual’s time is spent sat down often in very expensive purpose built chairs and seating that, whilst very comfortable, restricts movement. We have always attempted to stop those who rock, spin, hand flap from doing so, yet we now know these individuals are better off and less anxious when on the move. Soft play areas are ideal and not just for youngsters. Sensory rooms that promote movement and exploration are ideal. In fact, many sensory rooms are now being designed without the large areas of soft matting that restricted movement, allowing proprioceptive activities. Have outside areas that promote movement, which have interesting stimuli to encourage exploration. When designing sensory gardens look to encourage movement. Not just a simple linear route, but paths that crisscross, are of different heights encouraging stepping up and down and looking up and down.
Training for the individual is essential, but unlike the old days of behaviour modification approaches, we need to be focusing upon life skills including self management of anxiety. I realise that those we support are communicating their needs to us through their behaviour, but we need to teach them to both recognise their own triggers and to communicate their anxiety to us in a way we understand that doesn’t harm them or others.
We need to train and encourage relaxation skills. Ultimately, relaxation stems from deep breathing. Work in an area that the individual feels safe and comfortable and encourage long deep breaths, getting them to hold it for a count of two and then exhale. Where there is resistance, or the individual’s level of cognitive ability, makes it difficult to get them to follow an instruction to breathe deeply, get them involved in any activity that makes them have to blow out. Blowing bubbles, blowing paint through straws, using a sound to light device are good options. There are hundreds of activities. The essential point is that blowing out long and hard means you have to breathe in harder. It is very hard for many of the people we support to understand visualisations that encourage relaxation, so projected images are helpful. Liquid wheels in a rotary projector, abstract projected images, an IOS app called ‘Serenity’ is perfect. https://itunes.apple.com/gb/app/serenity-the-relaxation-app/id482497082?mt=8 The autistic child who loves watching Thomas the Tank Engine has become a has cliché, but if it promotes calm for a period of time is it that wrong?!
The issue of sensory regulation is key to understanding some of the anxieties experienced by those we support. Lack of sensory regulation and sensory processing difficulties lie at the heart of many meltdowns because of the anxiety it causes. One aspect that may be beneficial is teaching the individual to develop what may be called mono-focussing skills – developing the ability to zone in to something and begin to disregard the surrounding stimuli. Bubble tubes are a great resource for this, because of their near universal appeal. The powerful visual, auditory, tactile and sound experience attracts many individuals and we can begin practicing, ‘Just Looking’. Start with a black sheet behind the bubble tube getting rid of the mirrors and all other visual distractions. No music, keep the lights down low and positively reinforce the notion that it is good to just be looking, or feeling or listening to one thing. Aim to slowly introduce other stimuli without overloading the senses.
An area that is gaining some ground in supporting individuals with challenging behaviour, is the notion of deep pressure. When we get anxious or worried quite often a hug is all that is needed to help us begin to calm, if no one is around we may even hug ourselves, wrapping our arms around ourselves. Temple Grandin in her autobiography ‘Emergence Labeled Autistic,’ describes how she overcomes panic attacks through the use of her ‘squeeze box’. Weighted blankets are in common use now. Also available are jackets with pockets for weights and straps to tighten around the body giving a ‘virtual hug’. Patricia Wilbarger developed a treatment for sensory processing issues that involves brushing and joint compression techniques, now known as the Wilbarger Protocol. Following this approach will require appropriate training, particularly in the case of joint compression. However, many children and adults enjoy, and are comforted by, the sensation of being brushed. Many more of those we support enjoy the sensation of joint compression that occurs though their own movements, such as tip toe walking. Families can be encouraged to look for occasions when they can introduce such activities without becoming too invasive. This depends upon that individual assessment. Knowing what and when the individual likes. When we study those that we are supporting, it may become evident that they are in fact practicing their own forms of self-medication to deal with their sensory issues. The autistic community discuss the notion of ‘stimming’ in many online blogs. Stimming involves constantly repeated self stimulatory moves, such as flicking the fingers in front of the eyes, rocking, flicking objects and even head banging. Temple Grandin says she does it because it feels good. In many cases, the behaviour intensity and repetition blocks out competing sensory stimulation by allowing the individual to focus on their chosen activity. In the past, much time and effort was devoted to developing modification plans to remove these behaviours!
To sum up these comments on supporting individuals with challenging behaviour?The first step is to really get to know the individual and how they react to their environment and activities. Try and understand why they are repeatedly doing what they do. Encourage movement and activity, the harder and more intense the better. Plan for meltdowns, they will occur and have a safe haven where adrenalin can be allowed to dispel. Ensure the communication is there in a way that can be understood when the individual’s anxiety level is increasing. Train relaxation and encourage self supporting practices, even when they seem to be at odds with your expectations. Finally, remember that none of the people we support wants to be in such a state of anxiety.
Hear more from Clive on ‘Sensory Approaches for Challenging Behaviour’ in London on 12 February 2016.
237 Heysham Road,