The role of physiological arousal in the management of challenging ...

Running head: LOW AROUSAL APPROACHES 1

The Role of Physiological Arousal in the Management of Challenging Behaviours in

Individuals with Autistic Spectrum Disorders.

Andrew McDonnell, Ph.D. Clinical Psychologist,

Studio3 Training Systems, Alcester, UK

Michael McCreadie, Health Psychologist,

Studio3 Training Systems, Alcester, UK

Richard Mills, Director of Research,

The National Autistic Society,

UK

Regine Anker, Assistant Psychologist,

Studio3 Clinical Services, Bath, UK

Judy Hayden, Assistant Psychologist,

Gheel Autism Services, Dublin, Ireland

Address for Correspondence: Andrew McDonnell, Clinical Psychologist, Studio3 Training

Systems, Minerva Mill, Alcester UK, B49 5ET [email protected]

LOW AROUSAL APPROACHES 2

Abstract

Challenging behaviors restrict opportunities and choices for people with autistic spectrum

disorders (ASD) and frequently lead to inappropriate and costly service interventions.

Managing challenging behaviors of people with autism is an important area of research.

This paper examines some of the evidence for the role of physiological arousal influencing

these behaviours. Evidence from the emerging literature about sensory differences is

examined. It is proposed that sensory reactivity is associated with hyperarousal; catatonic

type behaviors are associated with low levels of reactivity (hypoarousal). A low arousal

approach is proposed as a generalised strategy to managing challenging behaviors with ASD.

The use of non-contingent reinforcement and antecedent control strategies are recommended

for use with challenging behaviors which have a sensory component. Examples are provided

to illustrate the approach. The implications of arousal and the use of physical interventions

are discussed. It is proposed that arousal is a construct which has significant heuristic value

for researchers and practitioners.

Keywords: Autism, Challenging Behavior, Low Arousal, Physiological, Arousal, Sensory


The Role of Physiological Arousal in the Management of Challenging Behaviors in

Individuals with Autistic Spectrum Disorders.

People with autistic spectrum disorders (ASD) can present behaviors that challenge

and a recent survey of the behavioral intervention literature identified a diagnosis of autism as

a risk marker for physical aggression (McClintock, Hall, & Oliver, 2003). A large number of

behavioral intervention studies have tended to focus on long term interventions for physical

aggression (Horner, Carr, Strain, Todd, & Reed, 2000) with short term management receiving

less attention (McDonnell, 2010).

This paper will examine the low arousal approach to managing challenging behaviors

in people with ASD (McDonnell, Waters, & Jones, 2002). This approach has become

popular with autism services in the UK and Europe. The low arousal approach emphasises a

range of behavior management strategies that focus on the reduction of physiological arousal

and manipulation of antecedent triggers to prevent aggression and crisis strategies which

avoid punitive consequences and seek low intensity solutions. The approach seeks to

understand the role of sensory factors in the onset and maintenance of challenging behaviors

in people with ASD. It will be argued that such an approach can greatly enhance crisis

management strategies, functional assessment, and positive behavior support strategies. The

implications for the application of physical interventions will also be discussed.

1.1 Arousal and Emotion

Arousal is a construct which has proved difficult to define with researchers adopting

views that it is either a unitary or multifaceted construct; recent research in neurobiology


indicates that there is a generalised arousal mechanism in the brain which feeds cortical

functions (Pfaff, 2005). “Generalised arousal is higher in an animal or human being who is;

(S) more alert to sensory stimuli of all sorts, and (M) more motorically active, and (E) more

reactive emotionally” (Pfaff, 2005, p. 5). This relatively simple definition relates arousal to

information processing; novel, unpredictable stimuli will lead to an increased arousal

response. The link between arousal and information processing was originally described by

Yerkes and Dodson (1908). The law maintains that performance and arousal are linked in a

classic inverted U shape; the Yerkes Dodson law proposes that high levels of arousal lead to

decreases in human performance. The original study examined the performance of mice in a

learning task where electric shocks were delivered for incorrect responses and has been used

as an analogy to show arousal reducing information processing has an optimum level

(Easterbrook, 1959). Critics of the Yerkes Dodson law often cite the case that high levels of

arousal have survival value (Zajonc, 1980) and, in some circumstances, may increase

performance (Hanoch & Vitouch, 2004). Despite these criticisms, the construct of arousal is

considered useful in understanding the regulation of emotion (Pfaff, 2005) and both arousal

and stress are considered to be important in the moderation of emotions (Reich & Zautra,

2002). To summarise there would appear to be a consensus that high states of arousal can

have a negative effect on human performance.

1.2 The Link between Arousal and Autism.

Physiological arousal is not a new construct and has long been implicated in autistic

spectrum disorders (Hutt, Hutt, Lee, & Ounsted, 1964). Two implications of this are that

children and adults with ASD would be more reactive to sensory stimuli than the normal

population and that they maybe slower to habituate to stimuli. There is some laboratory

evidence of differences in physiological responses of individuals with ASD compared to non


autistic controls (Althaus et al., 2000; Hirstein, Iversen, & Ramachandran 2001; Van

Engeland, Roelofs, Verbaten, & Slangen, 1991).

There is mixed evidence across the spectrum for increased and decreased arousal in

response to predicted stressors. Jansen et al. (2006) compared adults with ASD with non

ASD adults in their response to public speaking and found that individuals with ASD showed

decreased heart rate, but normal cortisol responses. Goodwin et al. (2006) compared children

and reported higher baseline heart rates of ASD participants. Hirstein et al. (2001) reported

unusually high and unusually low baseline skin conductance responses in autistic children

compared to non autistic controls. These differences require replication using larger samples

but there is an intriguing possibility that there may be considerable variation in physiological

reactivity of both autistic children and adults.

Jennett, Hagopian, and Beaulieu (2011) investigated the relation between self-injury

and arousal in an individual with autism under different conditions of restraint. When some

form of restraint was used the heart rate of the individual remained close to the resting heart

rate although, when this restraint was removed or signalled to be removed, the individual‟s

heart rate increased dramatically within a short time period.

There are three prominent theories of autism: theory of mind (Baron-Cohen, 1995),

weak central coherence (Frith, 1989; Frith, 2003; Happe, 1996), and executive dysfunction

(Geurts, Verte, Oosterlaan, Roeyers, & Sargeant, 2004; Hill, 2004; Ozonoff, Strayer,

McMahon, & Filouz, 1994) but all have difficulties accounting for sensory processing

difficulties. A major criticism of all of these theories is that they attempt to provide a

universal explanation of autism rather than viewing it as a collection of multiple deficits

(Rajendran & Mitchell, 2007).

The role of physiological arousal is not explicitly clear in either the theory of mind or

weak central coherence theories. The executive dysfunction theory does use the construct of


arousal in the form of inhibitory control. Inhibitory control limits a person‟s ability to

suppress the activation, processing, or expression of information. Some laboratory studies

have reported evidence for inhibitory control (Geurts et al., 2004; Ozonoff et al., 1994)

although mixed findings have also been reported (Christ, Holt, White, & Green, 2007). An

alternative suggestion redefines executive functions (EF) in terms of hot and cool aspects

(Zelazo & Muller, 2002); hot EF is needed to solve problems that have an affective

component, whereas cool EF is elicited by abstract or decontextualised problems. Zelazo and

Muller (2002) argued that autism may be a consequence of impaired hot EF. This link

between emotion and perception is useful to consider in terms of physiological arousal.

Laboratory based problem solving tasks are often used to examine hypothesised

cognitive processes. It is possible that physiological arousal may have a mediating effect on

the behaviour of some people with ASD. Johnson, Yechiam, Murphy, Queller, and Stout

(2006) investigated autonomic arousal using skin conductance in 15 people with Aspergers

syndrome in a gambling task and reported differences in skin conductance between this group

and the non autistic controls.

Hyperarousal is not universally accepted by all researchers and a recent review of

sensory difficulties in autism concluded that the experimental evidence for hyperarousal was

at best mixed (Rogers & Ozonoff, 2005). There are a number of problems with this view.

First, ASD is a heterogeneous condition and the assumption that hyperarousal should be a

general explanatory theory of autism was too broad. Second, sensitivity to arousing stimuli

may be intermittently presenting in individuals with ASD. Third, the stimuli employed in

habituation paradigms cannot easily mimic real life non laboratory based events; animal

research on arousal has attempted to link deficiencies to conditions such as ADHD,

Alzheimer‟s disease, and autism (Garey et al., 2003).

Historically under arousal has also been proposed to specific stimuli (DesLauriers &


Carlson, 1969; Rimland, 1964) although with limited laboratory evidence (Rogers &

Ozonoff, 2005). Repetitive movements may serve a de-arousing function (Kinsbourne,

1980). Unusual sensory experiences have been reported in autobiographical accounts of

people with ASD (Grandin & Scariano, 1986; Jones, 1997; Mukhopaday, 2003; Shore, 2003).

Sensory over activity has been explained as a possible response to over arousal (Liss,

Saulnier, Fein, & Kinsbourne, 2006). An understanding of physiological arousal and sensory

experiences may have great explanatory significance for some forms of challenging

behaviors. Recently Schoen et al. (2009) compared the physiological differences in sensory

processing in children with ASD and sensory modulation disorder (SMD) and noted a

significantly lower physiological arousal level in the ASD group at baseline compared to the

children with SMD and also controls. In contrast to the SMD group, a strong association

between arousal level and reactivity was found in the ASD and control groups, with groups

who had higher arousal tending to have higher reactivity, while those with lower arousal

tended to have lower reactivity.

1.3 Sensory Differences in People with ASD

Relating sensory experiences to everyday behaviour is not a new phenomenon. Leo

Kanner (1943) in his seminal paper that defined the term autism using 11 case examples

described sensory issues; he reported the case of Herbert B: “He was tremendously frightened

by running water, gas burners and many other things” (p. 231). Similarly, Frederick W had a

fear of certain objects and the sensation of movement or confinement:

He is afraid of mechanical things; he runs from them. He used to be afraid of my egg

beater, is perfectly petrified of my vacuum cleaner. Elevators are simply a terrifying

experience for him. He is afraid of spinning tops. (p. 223)

In the 63 years since this paper the knowledge of information processing deficits in


autism has greatly increased (Frith, 2003). Damasio and Maurer (1978) produced a

neurological model for childhood autism implicating the temporal lobe and mesolimbic

systems. Lathe (2006) attempted to identify the limbic system as implicated in sensory

differences and Ornitz (1988) argued that sensory inputs may have had a causal role.

Gillberg (1992) refers to sensory differences as characteristic of autism symptomology but

not necessary diagnostic criterion. Given the complexity of autism it is unlikely that one

factor will have a clear causal role.

Dunn (2001) introduced sensory differences as being a continuum with sensory

sensitivity and low response at the two extremes with a need to regulate or achieve

equilibrium as a driver for much behaviour, particularly in the vestibular and proprioceptive

systems. This is of particular relevance to our understanding of the symptoms of autism.

Dunn (2001) identified a strong relationship based on fluctuating thresholds between

sensory information processing and behaviour and distinguished four sensory categories of

sensory perception (low and high registration) and overt behavioral responses (sensation

seeking and sensation avoiding). Developing literature appears to show that these constructs

may have some face validity with sensory sensitive and sensation avoiding groups being

more responsive than low registration and sensation seeking groups (Brown, Tollefson,

Dunn, Cromwell, & Fillion, 2001).

Sensory differences in individuals with ASD are increasingly being reported by

researchers. Kern et al. (2006) used the sensory profile (Dunn, 1997) and found that there

were differences in auditory, visual, touch, and oral sensory processing between participants

with autism matched with a control group of persons without ASD. Baranek, David, Poe,

Stone, and Watson (2006) and Cheung and Siu (2009) identified that children with autism

have different responses to sensory stimuli and identified they can be hypersensitive to sound.


More recently Wiggins, Robins, Bakeman, and Adamson (2009) used the sensory profile and

found that children with ASD show more auditory filtering difficulties and also more tactile

and taste/smell sensitivities compared to other children with developmental delays. It was

suggested that these sensory abnormalities may be a distinguishing symptom of ASD and

Wiggins et al. propose the notion of incorporating sensory abnormalities into the diagnostic

assessment of younger individuals. The significant abnormalities in sensory processing in

children with autism found in a study by O‟Brien et al. (2009) also led to the conclusion that,

with further research, sensory processing may again be included in the diagnostic criterion for

ASD.

A recent study by Lane, Young, Baker, and Angley (2010) proposes three distinct

sensory processing subtypes in autism differing in taste and smell sensitivity and movement

related sensory behavior.

There is emerging literature suggesting that there are abnormalities across multiple

domains (Baranek et al., 2006; Leekam, Nieto, Libby, Wing, & Gould, 2007; Provost,

Crowe, Aeree, Osbourn, & McClain, 2009; Rogers, Hepburn, & Wehner, 2003). A recent

meta-analysis by Ben-Sasson et al. (2009) found significant evidence for sensory differences

between individuals with ASD and both individuals without ASD and individuals with

developmental delays and, in particular, noted that the magnitude of these differences was

moderated by age. There is a current lack of research into the sensory differences in adult

and adolescent individuals with ASD (Ben-Sasson et al., 2009).

The sensory measures developed by Dunn (2001, 1997) have also been used to

compare children with a diagnosis of Aspergers syndrome and non learning disabled controls

(Dunn, Myles, & Orr, 2002). The Aspergers sample reported both hyposensitivity and

hypersensitive responses. There are however difficulties in interpreting questionnaire studies

as they do not directly report behavioural measures of sensory difficulties and the use of


measures such as galvanic skin responses (Brown, et al. 2001) may be an appropriate way

forward for practitioners.

Gomez and Danuser (2004) reported that sound can affect physiological responses; in

general high arousal noises increased physiological responses and lower pleasant noises

showed a decrease. Hypersensitivity to smells has also been reported where some odours

decrease the heart rate and skin conductance (Campenni, Crawley, & Meier, 2004). Pernon,

Pry, and Baghdadli (2007) reported differences in experiences to tactile stimuli and further

behavioral assessments may help to identify the experiences of individuals more accurately

than interview based methods.

Some evidence for sensory differences has been reported based on personal accounts

of people with ASD (Grandin, 1992a, 1996; Grandin & Scariano, 1986; O‟Neil & Jones,

1997; Mukhopaday, 2003). O‟Neil and Jones (1997) identified sensory-perceptual

abnormalities in people with autism, these included: hyper – and hyposensitivity, sensory

distortion, overload, multi-channel receptivity, and processing difficulties. Grandin reported

that sudden loud noises hurt her ears, likening the experience to a dentist's drill hitting a nerve

(1992a); she also argued that her fear of a noise was a factor for her challenging behaviour

(Grandin, 1996).

In summary the sensory profile of individuals across the autism spectrum suggests a

significant difference to those of the general population. However useful they are, the

personal accounts of people with ASD do not constitute strong empirical data for a

population as a whole (Iarocci & MacDonald, 2006; O‟Neill & Jones, 1997). To date there

are only a limited number of studies which primarily use checklist based measures (Brown et

al., 2001; Kern et al., 2006) and more emphasis is required on empirical studies using direct

behavioural observation.


1.4 A Low Arousal Model of Challenging Behavior in People with ASD

Sensory experiences may account for a significant proportion of challenging

behaviors in people with ASD. Unpredictable sensory experiences (Pfaff, 2006) may

increase stress and elevate physiological arousal. If an individual cannot easily avoid or

escape from these stressful stimuli or communicate distress appropriately, and effectively,

they may develop a functional means of escape (Goodwin et al., 2006).

Stress and anxiety have been proposed as factors in challenging behaviors of people

with ASD (Howlin, 1998; Groden, Cautela, Prince & Berryman, 1994). Lazarus and

Folkman (1984) described a transactional model of stress emphasising interaction between an

individual and his/her environment. Stress occurs when the demands of stressors outweigh

coping responses and there is a clear interaction between environmental and physiological

events. Implicit in this model is the cognitive appraisal of threat as some individuals with

ASD have difficulties in regulating their emotional responses and communicating them

(Frith, 2003). There does appear to be a strong association between physiological arousal and

sensory experiences of people with ASD (Liss et al., 2006). To help account for challenging

behaviors such as aggression and self injurious behaviours we propose that physiological

arousal may mediate stress.

A model of arousal which mediates certain forms of challenging behaviors could

provide a useful explanatory framework. A central premise is that an individual‟s internal

physiological state of arousal influences cognitive processing of environmental sensory

stimuli. Extending this view we would contend that the regulation of arousal mediates

behavioral responses to environmental stressors. Individuals seek a state of arousal

equilibrium; that is the optimum individual arousal level required for an individual to


function in an environment; this is similar to the bodily state of homeostasis. We propose

that arousal can be thought of in three distinct areas of a Gaussian curve; the majority of

individuals spend time in a state of arousal equilibrium. In the case of people with ASD two

distinct arousal groupings will have an effect on behavior; both appear in the tail end of the

arousal curve. Individuals will be hyperaroused and highly reactive to environmental

sensory stimuli (Liss et al., 2006) or hypoaroused and exhibit low responses to sensory

stimuli.

A number of people with ASD who present with challenging behaviors may

experience either constant or intermittent states of hyperarousal. Dunn (2001) argued that

people often experience modulation of sensory input. The mixed results of empirical studies

on hyperarousal may be accounted for by individuals whose arousal level may fluctuate on a

regular basis. This model suggests that there is a transaction between the person‟s internal

state of arousal and interaction with environmental stressors. The reduction of environmental

arousal should decrease stress and anxiety and therefore reduce the frequency and intensity of

challenging behaviors. Correspondingly, techniques to reduce internal arousal such as

behavioural relaxation training (Groden et al., 1994), cognitive behavioral therapy (Attwood,

2010), or multisensory environments (Lancioni, Cuvo, & O‟Reilly, 2002; Stephenson, 2002)

may also increase an individual‟s ability to tolerate sensory stimuli.

Extreme levels of hyperarousal may lead to a person becoming less responsive to

environmental stimuli and literally appearing to “shut down”. Goodwin et al. (2006) reported

lower sensitivity to environmental stimulation in five individuals with ASD compared to their

controls; these individuals also had higher baseline heart rates than their controls. It is

possible that higher levels of internal arousal may make some individuals less responsive to


environmental stimuli. In this instance the internal arousal state becomes more dominant;

this may provide an explanatory framework for some forms of catatonic type behaviors

observed in some individuals with autism. Other forms of catatonia may be a result of low

levels of physiological arousal which has an effect on movement. A recent case study

reported positive outcomes for the use of electroconvulsive (Ghazuiddin, Quinlin &

Ghazuiddin, 2005). The altering of physiological arousal states may be an important

mechanism in developing interventions for catatonia.

There are several testable hypotheses that can be extrapolated from this low arousal

model of challenging behaviours in individuals with ASD.First, basal physiological arousal

measures should be able to identify groups of individuals with high and low responsivity in

measures such as heart rate and skin conductance (See Goodwin et al., 2006; Hirstein et al.,

2001). Second, reducing generalised physiological arousal should reduce challenging

behaviors. Third, the more unpredictable sensory stimuli there are the greater the levels of

arousal should be experienced, which should lead to increases in challenging behaviors.

Fourth, extreme forms of hyperarousal may lead to reduced attention to external stimuli.

Finally, people with ASD who present with frequent challenging behaviors and show high

sensory reactivity, should also show higher or extremely fluctuating levels of physiological

arousal.

1.5 Low Arousal approaches to Crisis Management

Positive behaviour support strategies are used with people with ASD (Becker-Cottrill,

MacFarland & Anderson, 2003) with positive outcomes in the published literature (Horner et

al., 2000). A common theme of these interventions is that the approach does require

considerable time and staff resources. Behavior management strategies are often required by


carers to manage behaviors in the short term.

The short-term management of aggressive behaviors has been acknowledged to be

important (Carr et al., 1994; LaVigna & Willis, 2002; McDonnell & Sturmey, 1993); the

expression “crisis procedures” has been adopted by some authors (LaVigna & Donnellan,

1986). A distinction has been made between behavior management and behavioural

treatment goals (Gardner & Cole, 1987). The objective of behavior treatment is to produce

“enduring behavior change that will persist across time and situations” (Gardner & Moffatt,

1990, p. 93).

A recent survey of 625 service users with learning disabilities in Canada reported that

only 26.9% of service users had some form of crisis intervention plan (Feldman, Atkinson,

Foti-Gervais, & Condillac, 2004). Crisis interventions are a critical component of community

supports for people with a learning disability who present with aggressive behaviors (Hanson

& Weiseler, 2002; Lakin & Larson, 2002). The development of more effective behavior

management technologies would significantly benefit researchers and practitioners (Allen,

2002)

If some challenging behaviors are mediated by a heightened state of physiological

arousal, the reduction of this physiological arousal state should reduce challenging behaviors

at least in the short term. Low arousal approaches are strategies used to manage these crisis

situations. McDonnell (2012) defined four key components of low arousal approaches . First,

decreasing staff demands and requests to reduce potential points of conflict around an

individual. Second, avoidance of potentially arousing triggers, e.g. direct eye contact, touch

and removal of spectators to the incident. Third, the avoidance of non verbal behaviors that

may lead to conflict, e.g. aggressive postures and stances. Fourth, challenging staff beliefs


about short term management of challenging behaviors.

In a reformulated cognitive behavioral framework the four key areas of the approach

are (a) the reduction of staff demands and requests in a crisis; (b) the adoption of verbal and

non verbal strategies that avoids potentially arousing triggers (direct eye contact, touch,

avoidance of non-verbal behaviors that may lead to conflict, aggressive postures, and

stances); (c) the exploration of staff beliefs about the short-term management of challenging

behaviors; (d) the provision of emotional support to staff working with challenging

individuals. A cognitive formulation of this model emphasises the role of staff behavior in

the maintenance of aggressive behavior which has some support from the literature (Hastings,

2002; Hastings & Brown, 2000; Hastings & Remington, 1994ab; Taylor & Carr, 1992).

The reduction of staff demands and requests in a crisis is a key component of a low

arousal approach (McDonnell et al., 2002; McDonnell, Reeves, Johnson, & Lane, 1998) as a

reduction in staff demands can lead to reductions in aggressive behavior (Taylor & Carr,

1992). A possible negative effect on staff is to reinforce an avoidance model (Hastings,

1997). Whilst an avoidance model should not be seen as a long term strategy to crises

approaches it may well be the most effective staff response. Task demands are a component

of many interventions that adopt positive behavioral supports (Carr et al., 1999). Terms such

as “strategic capitulation” (LaVigna & Willis, 2002) have been used to describe demand

reduction in crisis situations. Reducing demands should decrease the level of processing

required by individuals and therefore decrease hyperarousal.

The evidence for the efficacy of low arousal approaches is emerging but scarce.

Whilst the construct may have face validity, to date there is little empirical data for approach.

In addition reducing arousal may not always be the strategy of choice for some individuals


with ASD. The sensory model proposed by Dunn (2001) would imply strongly that there

may be times where individuals actively seek sensations. It is here that more formal

assessments of sensory profiles coupled with changes to the environment and programme are

particularly helpful and relevant; in circumstances where it is necessary to increase

physiological arousal as part of the individual‟s programme. This is supported by anecdotal

reports of the use of bespoke „squeeze machines‟ (Grandin, 1992).

1.6 Arousal Reduction Intervention Strategies

Identifying sensory factors within individuals with ASD using functional assessment

methods is an important practice. It has been argued that sensory processing difficulties may

be lifelong (Dunn, 2001), although the processes may become less intense with age (Kern et

al., 2006). The literature at present strongly indicates modest effects of auditory and sensory

integration approaches with regard to altering such processes (Baranek, 2002). Dunn (2001)

argued cogently that: “Sensory processing patterns are a reflection of who we are: These

patterns are not a pathology that needs fixing” (p. 617). The implication is that not all

sensory related behaviors require modification and managing arousal mechanisms may be a

more achievable goal for clinicians.

1.6.1 Relaxation Techniques.

Relaxation techniques to reduce physiological arousal are a significant tool in

alleviating sensory processing difficulties and positive results of training individuals in

relaxation techniques have been reported in the literature (Groden et al., 1994). Training in

techniques based on CBT has also been advocated for people with intellectual disabilities

(Dagnan & Jahoda, 2006) as well as anxiety management techniques (Attwood, 2007;

Sofronoff, Attwood & Hinton, 2005; Sofronoff & Attwood, 2003). In a recent study, Singh


et al. (2011) demonstrated that adolescents with autism are able to learn and utilise a

mindfulness based strategy for self-management of aggressive behavior.

1.6.2 Sensory Environments.

Positive effects of multi-sensory environments appear to indicate that increased

relaxation and reduced overt signs of anxiety can be achieved (Lancioni et al., 2002;

Stephenson, 2002). A 10 week observational study which compared the effect of Snoezelen

(controlled multisensory stimulation), skills training and vocational skills training reported

lower levels of aggressive behavior and self-injurious behavior (Singh et al., 2004).

Sensory rooms may reduce anxiety levels which may have an impact on behavior;

there are a limited number of studies that imply that lower levels of physiological arousal

may be accompanied by reduced frequencies of challenging behaviors. Shapiro, Parush,

Green, and Roth (1997) reported lower heart rate levels and fewer stereotyped behaviors

during Snoezelen sessions. Dunn (2001) identified the association between physiological

arousal and sensory input; people who have a profile of avoiding sensory stimuli may benefit

from strategies which aim to reduce sensory stimulation by the regulation of their

physiological arousal. Strategies which aim to reduce arousal should, in our view, be a

primary intervention strategy.

1.6.3 Physical Exercise.

There are obvious benefits of regular exercise in reducing anxiety (Petruzello,

Landers, Hatfield, Kubitz & Salazar, 1991). Studies have demonstrated reductions in

stereotyped behaviors of people with ASD (Allison, Basile & MacDonald, 1991; Kern,

Koegel & Dunlap, 1984; Rosenthal-Malek & Mitchell, 1997). In this model repetitive

behaviors may be a by-product of irregularities in physiological arousal and serve a de-

arousing function (Kinsbourne, 1980).


The role of physical exercise in managing aggressive behavior is less well understood.

McGimsey and Favell (1988) found that when severely aggressive and hyperactive clients

were exposed to two daily periods of jogging and strenuous activities there was a systematic

reduction in problem behavior for 8 of the 10 participants to levels considered not a

problem or only an occasional problem . They argued that physical exercise may offer

promise as an effective, benign, and practical adjunct to other treatment and management

techniques. Physical exercise may have positive effects on reducing physiological arousal.

1.6.4 Reinforcement Based Methods.

Sensory reinforcement may in some individuals be automatic in nature that is the

behaviour itself has reinforcing properties that are not related to the social environment

(Vollmer, 1994). If behaviour is maintained by individuals seeking sensory reinforcement, it

may be possible to adopt strategies using differential reinforcement of alternative behavior

(DRA). This approach requires that alternative access to sensory reinforcers be provided and

the responses of staff to the challenging behaviors are maintained. In this instance sensory

reinforcers are provided in the absence of challenging behaviors. Extinction based strategies

could potentially cause high levels of distress to individuals and, as such, should be avoided.

A second approach would be to apply sensory reinforcement in a non contingent

manner where the reinforcer is provided on a regular schedule regardless of the presence or

absence of the target behavior (Vollmer, 1994). This is similar to the approach of a sensory

diet where sensory experiences are made an integral part of an individual‟s life (Bogadashina,

2003). There is some evidence for the effectiveness of non-contingent reinforcement

strategies for reducing difficult behaviors (Carr et al., 2000). Recent evidence has reported

some reductions in self injurious behavior using such approaches (Lindberg, Iwata, Roscoe,

Worsdell & Hanley, 2003). The advantages to this approach are that the individual receives a


reinforcing stimulus in other contexts and times and extinction bursts are avoided. A third

behavioural strategy involves antecedent control; these methods are used in other areas of

applied behavior analysis (Luiselli, 1998). The association between sensory experiences and

challenging behaviors would strongly suggest that removal of some of the stimulus

characteristics may be a useful form of behavior management, creating environments to avoid

sensory stimuli that may elicit challenging behaviors (specific noises, sounds, smells). The

design of houses specifically with regard to low arousal strategies is a newly developing area

but there is good anecdotal evidence from individuals with ASD that certain environments

create significant difficulties for them. For the most part, the literature refers to problems

associated with light and sound frequency but there is a relative dearth of good empirical

evidence and, in practice, there seems to be little accommodation.

Teaching self control strategies through the use of noise cancelling headphones, ear

plugs or wearing of walkmans for individuals who are sensitive to sounds may be a beneficial

area of research. The wearing of sunglasses or specialist filters (often referred to as „Irlen‟

lenses) are often recommended for individuals who are sensitive to light. Even the types of

clothing material worn by people may be important as a trigger of challenging behaviors and

may relate to acceptance of a novel sensation or habituation to certain fibres.

1.7 Physical Interventions

Physical interventions are used to manage individuals who may be hyperaroused and

overtly distressed and agitated. The physical contact required may in many cases increase

physiological arousal at least initially. A central tenet of the low arousal approach is to create

environments where the need for physical interventions will be significantly reduced. The

authors accept that this may not be achievable in all care environments. Given, this caveat


this remaining section will examine the application of low arousal philosophy to use of

physical interventions with people with ASD.

Physical interventions are described as “any methods of responding to challenging

behavior which involves some degree of physical force to limit or restrict movement of

mobility” (Harris et al., 1996). There are categories of physical interventions, the two most

common are breakaway skills and physical restraint. Breakaway skills can be defined as

“physical strategies which assists a person to break free of an aggressor, where actual

physical contact has taken place” (McDonnell, 2010). Physical restraint has been defined as

“actions or procedures which are designed to suppress movement or mobility” (Harris, 1996,

p100).

UK guidance specifies that the use of physical interventions should be a last resort

(British Institute of Learning Disabilities [BILD], 2002). There are several good arguments

to avoiding physical interventions altogether. In evaluating physical intervention methods it

is useful to consider three dimensions of safety, effectiveness, and social validity. First,

people with intellectual disabilities may be vulnerable to abuse (Baker, 2002). Second,

physical restraint can lead to both staff and service user injuries (Baker & Allen, 2001; Lee et

al., 2003). Third, there is the possibility that physical interventions may become positively

reinforcing as in the case of some mechanical restraints (Favell, McGimsey, & Jones, 1978).

Fourth, restraint methods such as prone holds may be associated with fatalities (Allen, 2008).

Some experts have called for a ban on all prone restraint holds in care (McDonnell, 2010);

other academics refute the claims that these postures are strongly associated with sudden

deaths (Paterson, 2006). Incorrect application of methods is associated with some childhood

deaths in care in the United States (Nunno, Holden & Tollar, 2006).


Dunn‟s (1997, 2001) model identifies four clear profiles all of which have

implications for people with ASD who may be physically restrained. People who are

identified as “low registration” may be particularly vulnerable to injury as they lack

sensitivity to tactile and other stimuli. In these circumstances care staff may apply restraint

methods too robustly as the individual does not appear to show overt signs of distress.

Conversely, individuals with hypersensitivity to touch may feel extreme pain at minimal

levels of contact or restraint (Harris, Cornick, Jefferson, & Mills 2008). Dunn (2001) also

describes individuals who do not show signs of distress to sensory stimuli at least initially

but, who are sensitive and do experience considerable internal distress. A good example

involves the teaching of physical restraint skills which can include the hyperflexion of joints.

From an ethical viewpoint the deliberate infliction of pain to suppress behaviour raises major

ethical concerns; Leadbetter (2002) used the expression “High tariff techniques” to describe

these types of methods. There are good practical reasons why these methods should be

avoided with service users with ASD.

Applying a hold which involves the abnormal rotation of the wrists has additional

risks. An individual with low registration may not appear to respond to the painful stimulus

in the way that is intended. There is considerable evidence from the sensory literature that

indicates that some people may respond to painful stimuli with a limited behavioural

response. Bromley, Hare, Davison, and Emerson‟s (2004) survey of parents reported that

45% of children were hyposensitive to pain. Some cases of infantile ASD and self injury

reported a lack of response to painful stimuli (Tordjman et al., 1999). Seven out of 18 cases

of infantile autism clearly stated that the child either ignores or appears to be insensitive to

pain (Hauser, DeLong & Rosman, 1975). In conclusion physical intervention methods which

involve the infliction of pain would need to be applied so robustly to some people with ASD

who have low registration difficulties that they would be unethical and unacceptable by


reason of the increased risk of harm.

Individuals who avoid specific sensory stimuli may attempt to escape from situations

where the stimuli are present. Bromley et al.‟s (2004) survey of parents reported that 23% of

their children were hypersensitive to pain and some people with ASD are sensitive to

particular types of light physical contact. A Swedish woman with a diagnosis of ASD,

Gunila Gerland (1997), described touch as making her nervous system “whimper”. Touch

may also elicit extreme arousal in individuals with ASD who are hypersensitive.

Hypersensitivity to touch was reported identified by parents in 52% of 75 children (Bromley

et al., 2004). Holds which restrict movement could potentially increase physiological

arousal. It is also possible that people with ASD who are hypersensitive to touch may be

more at risk of sudden deaths. The authors acknowledge that this comment is speculative and

would require data.

The application of physical restraint methods by definition involves touch and

immobilisation of limbs which may have paradoxical effects particularly among people with

autism (O‟Neill & Jones, 1997). Occupational therapists have observed how light touch

seems to alert the nervous system but deep pressure is relaxing and calming (Grandin,

1992b). Dunn (2001) described individuals as sensory seeking. Some individuals with

autism seek out sensory stimulation, as their senses are „hyposensitive‟. Grandin (1992b)

reported how deep pressure seemed to have calming affects on individuals and that

“relaxation was physically evident”. There is some limited empirical evidence for so called

squeeze machines. It is possible to speculate that touch using deep pressure may serve a

function for some individuals.

The recent evidence for differences in processing of vestibular stimulation (Kern et

al., 2007) has major relevance for the application of physical interventions. It is possible to


speculate that some individuals may find restraint procedures which require movement more

effective than immobilisation holds. Intermittent physical contact may represent a safer

alternative. We would argue that if physical restraint is required to keep an individual with

autism safe there are some guiding principles based on low arousal philosophy. It would be

practical to keep the duration of any hold to a minimum. If an individual has a need for deep

pressure contact, then this could be applied by the use of tight fitting garments or by the use

of staff holding a person in a seated position. Holds that require immobilisation on the

ground either in prone or supine positions should be avoided. A technique which involves

teaching multiple movements known as the „walkaround method‟ can be used with people

with ASD (McDonnell, 2012). The use of unexpected movements may operate by

overloading the person‟s sensory system, or by increasing vestibular stimulation. Further

work to evaluate the usefulness of this approach is indicated.

It may be useful to consider allowing service users to experience physical touch or

restraint non-contingently but the ethical basis of this approach will need careful

consideration. This may allow graded exposure to the methods and lead to less distress when

the methods are applied in more aroused situations. This approach is similar to stress

inoculation training (Meichenbaum, 1996). Importantly such rehearsal trials may also reduce

staff anxiety created by physical interventions. Services users may find the method less

aversive (Blackburn, 2006).

The use of physical interventions to manage crisis situations is regarded as a taboo

subject (Leadbetter, 2002). Whilst the authors strongly support the reduction of physical

intervention methods in general, we would make a strong case that sensory factors makes

their use on people with ASD particularly problematic.


1.8 Implications for Research

Theories of autism such as executive dysfunction (Ozonoff et al., 1994), theory of

mind (Baron-Cohen, 1995), and weak central coherence (Frith, 2003) need to account for

physiological arousal and sensory processing differences in the ASD population. The

concept of hot and cool processes (Zelazo & Muller, 2002) clearly fits with the arousal

mechanism described in this paper. Problem solving tasks should have affective components

combined with physiological measures and the level of physiological arousal should be

positively associated with performance. In addition, the use of standardised sensory

screening tools (Dunn, 1999) and correlating these profiles with cognitive performance would

identify individuals who are hypo or hyper aroused.

Behavioral (Groden et al., 1994) and cognitive based anxiety management methods

(Attwood, 2007; Dagnan & Jahoda, 2006) may be especially important for individuals who

are hyperaroused or experience fluctuations and identifying high risk individuals using

baseline heart rate may be beneficial. Sensory rooms (Stephenson et al., 2002) may be

beneficial for individuals experiencing regular states of hyperarousal. Individualised

assessments of sensory experiences may improve the efficiency of these methods.

Studies investigating the effects of arousal should contain physiological measures

(Althaus et al., 2004; Hirstein et al., 2001; Johnson et al., 2006; Van Engeland et al., 1991)

although some may be too intrusive for individuals who are tactile defensive. Heart rate

monitors have been used by researchers (Goodwin et al., 2006) and may be a useful method

to use in care environments.

The assessment of sensory differences is a complex task. Several studies (Brown et

al., 2001; Dunn, 1997; Kern et al., 2006) have used an assessment tool developed by Dunn


(1999) which appears to have both face validity and reasonable reliability (Liss et al., 2006).

Brief and psychometrically robust measures would be of great benefit for researchers in this

area (Harrison & Hare, 2004). Measures based on behavioral approach avoidance tests

would appear to be lacking in the area although they are becoming more commonplace

(Pernon & Rattaz, 2003) and provide a template for researchers.

Functional assessment techniques are based on good environmental analysis (Mace,

Page, Ivancic, & O‟Brien, 1986; Toogood & Timlin, 1996). Using Dunn‟s (2001, 1997)

definitions of sensory differences, it is possible to construct a speculative assessment

framework for employing sensory approaches. Interventions based on sensory reinforcer

assessments using strategies such as non contingent reinforcement are testable. The arousal

model described in this article would also imply that many challenging behaviors may not

necessarily be under the control of the individual.

The individual variation in responses to sensory stimuli single case designs would be

of great benefit as currently only one case study has formally evaluated the implementation of

low arousal approaches (McDonnell et al., 1998) and there is a paucity of direct research

(Allen, 2001; McDonnell, 2010).

Investigating arousal states and physical interventions in relation to the apparent

presence of sensory differences in this population (Kern et al., 2006; Brown et al., 2001;

Dunn, 2001) would suggest a need for empirical investigations of specific physical

interventions. Identifying individuals who seek out physical holding for positive

reinforcement and individuals who are tactile defensive should help determine the merits of

specific physical interventions. Currently the effectiveness of intermittent holding and

training of individuals with ASD about physical intervention using cognitive and behavioral


strategies (Meichenbaum, 1996) requires empirical investigation. Using feedback from

individuals with autism about experiences of physical interventions (Blackburn, 2006) may

represent a useful methodology as consumer based methods have been used successfully by

researchers in this field (Fish & Culshaw, 2005; Cunningham, McDonnell, Easton, &

Sturmey 2002).

2. Conclusion

This paper has proposed that physiological arousal is an important mediator variable

in challenging behaviors. An individual‟s internal state of arousal works in a transactional

manner with their experiences of the world. Low arousal approaches (McDonnell et al.,

2002; McDonnell et al., 1998) in the management of challenging behaviors in adults with

ASD do appear to have face validity.

Systematic research of environmental and programmatic features in relation to sensory

differences is overdue and would help to answer questions around maximising access and

reducing problematic behaviors. Anecdotal accounts provide a good starting point for this

work but larger scale studies are needed. Apart from one case study (McDonnell et al.,

1998) the majority of evidence for this approach would appear to be predominantly

anecdotal. Recent research which examines the sensory experiences of people with ASD

would appear to provide further support for the approach however more research is required

in this area.


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