Environmental Complexity Issues in Autism

Environmental Complexity Issues:
Years of research has found supporting evidence that exposure to a complex environment enhances brain development and function. Some such enhancements found in laboratory animals include: improved spatial and nonspatial memory; decreased signs of aggressive behavior, decreased repetitive behavior; decreased stress reactivity; and decreased incidence of seizure activity (Lewis, 2004). In a 1990 study by Diamond, increased environmental complexity with the presense of toys and play experiences for animals, resulted in greater brain growth and a thicker somatosensory cortex. The toys in this experiment needed to be varied however for positive changes to occur within the brain, substantiating the need for novelty and complexity (Lin et al, 2005). In another 1990 study by Diamond, the researcher found that rats from environmentally complex environments demonstrated increased brain growth and peformed better on mazes. The rats that learned new complex motor coordination tasks, developed a greater number of synapses within the cerebellum than rats who experienced movement solely from a wheel or treadmill (Lin et al, 2005).

Contrary to the positive effects a complex environment provides, a sensory deprived environment can have detrimental effects on brain growth and development. In several studies of impoverished orphanages, findings suggested that the longer the length of stay (>6-8 mths.), the greater the degree the developmental delay (Morison et al, 1995; Sweeney et al, 1995), growth delays, eating problems, social behavioral problems (Ames, 1997; Marcovitch et al, 1995) and attention and activity level problems (Morison & Ellwood, 1997). (Lin et al, 2005). Shortened lengths of stay were found to have better developmental outcomes. In a 2005 study by Lin et al, the researchers found that children from Eastern Europe orphanages who were institutionalized for longer lengths of time, achieved atypical sensory discrimination, praxis, and sensory modulation scores on the Sensory Integration and Praxis Test (SIPT). The areas found to be most vulnerable to deprivation included: vestibulo-proprioceptive; tactile, visual; auditory; and praxis. In the research article by Missiuna et al, 1991, the author described how play deprivation in children with physical disabilities created secondary disabilities. Being unable to access and participate in play, increased children's reliance on others, decreased their motivation, created a lack of assertiveness, caused poorly developed social skills in unstructured environments, and lowered the child's self-esteem.

The benefits of a complex environment are almost always compromised for children with autism as their "odd" responses to sensory stimuli often cause them to avoid the very elements that help improve overall development (Minshew, et al, 1991). Avoidance behaviors additionally subject these children to the detrimental effects a sensory deprived environment creates. Some common differences in sensory processing demonstrated by persons with Autism Spectrum Disorder (ASD) include an oversensitivity to movement, smells, touch, tastes, textures, and sounds. Temple Grandin and Donna Williams have helped us learn through autobiographical accounts, how it feels for a person with autism to process information from the world. They described sounds to feel like a "hearing aid stuck on super loud", a hug like "a tidal wave of sensation", and smells as overwhelming (Minshew, et al, 2008). Conversely, underresponsiveness to sensory input from their environment, can cause this population to be extremely passive and appear as a deaf or visually impaired persons. "According to arousal modulation theories of autism, an anxious or agitated response characteristic of overarousal and passivity and lethargy, characteristic of underarousal can interfere in this population's ability to attend to, process, and interact with the environment and can result in the failure to learn normative behaviors and skills from other people" (Lord & McGee, 2001; Prizant, Wetherby, Rubin, & Laurent, 2003; Siegel, 2003) (Goodwin et al, 2006). Anxiety disorders are highly present in children with autism and thought to be related to "panic-like levels of discomfort in response to environmental changes" (Goodwin, et al, 2006). Physiological responses to stress include changes in heartrate, hormone production, brain activation in the areas of emotion and memory, as well as other autonomic nervous system responses (changes in pupils, respiration's, digestion, and muscle tautness). Prolonged exposure to stress can contribute to chronic headaches, depression, a decreased immune response, and several other health related ailments. Physiological stress has also been found to interfere in memory and learning as it reverts the brain back to a primitive survival state.

References:

Goodwin et al, 2006. Cardiovascular arousal in individuals with autism. 21(2): 100-123.

Lin et al, 2005. The relation between length of institutionalization and sensory integration in children adopted from eastern europe. American Journal of Occupational Therapy. 59. 139-147.

Lewis, M., 2004. Environmental complexity and central nervous system development and function. Mental Retardation and Developmental Disabilities Research Reviews. 10: 91-95(2004).

Minshew, et al, 2008. Sensory sensitivities and performance on sensory perceptual tasks in high-functioning individuals with autism. Journal of Autism and Developmental Disorders. 38:1485-1498.

Missiuna, et al, 1991. Play deprivation in children with physical disabilities: the role of occupational therapist in preventing secondary disability. American Journal of Occupational Therapy. 45(10) 882-8.

Anticipatory Skills in Children With Autism

Anticipatory Skills:
Children with autism have difficulty with predictability and anticipation. This lack of anticipation is influenced by several factors commonly associated with ASD.

1. Poor Theory of Mind (Tom): "refers to one's ability to understand that other people have thought, beliefs, and feelings that are seperate and different from one's own" (Miller-Kuhaneck, 2004). Poor Tom causes an individual with ASD to have difficulty understanding what other people know, want, feel, and believe. This creates a challenge for those with ASD to anticipate what others will do and say in a situation.


2. Weak Central Coherence: or a local to global processing tendency, causes this population to focus on the details of a stimuli instead of striving for the higher "gestalt" or meaning (Pellicano et al, 2004). Weak central coherence makes it difficult for one to integrate incoming information.


3. Deficits in Executive Function: Executive function looks at goal-directed abilities such as planning, sequencing, cognitive flexibility, working memory, and monitoring and ceasing inappropriate behaviors (Miller-Kuhaneck, 2004). Deficits in these areas have been associated with repetitive behaviors and inflexibility to novel situations (Pellicano, et al, 2004).


4. Sensory Processing Differences: This population has difficulty modulating sensory input, often demonstrating sensitivity to sound, touch, lights, and odors while demonstrating poor body awareness, underresponsiveness to pain, and underresponsiveness to other forms of sensory input.


5. Diminished Facial Processing and Poor Eye Contact: This population has been found to demonstrate a decreased preference for faces and a tendency to focus on the parts, primarily the mouth and not the eyes when engaged in conversation or play.


6. Decreased Response to Perception of Biological Motion: According to Frietag, et al, 2008, these children perceive motion effectively but take longer to respond to movement.


7. Decreased Anticipation for Motor Planning: Children with autism make postural adjustments in response to stimuli rather than in anticipation of the required movements (Schmitz, et al, 2003). Poor processing of sensory input to create needed "motor mapping" may cause the child to simply react to each motor activity as if it were new versus anticipating it and generalizing it from prior learned motor movements.



Lack of Anticipation's Impact of Function

Lack of anticipation influenced by poor theory of mind, weak central coherence, deficits in executive functions, sensory processing differences, facial processing, decreased eye contact, decreased response to perception of biological motion, and decreased anticipation for effective motor planning can negatively impact the child with autism's ability to communicate and function in daily occupations of work, play, and self-help development.

The following link is a good example of social interaction and bonding between babies and parents based on the child's anticipation to daddy's voice.


http://www.all4humor.com/videos/funny-videos/laughing-babies.html



Other examples of how decreased anticipation affect daily occupations include:

a) Failure to Respond to, Initiate, or Sustain Conversation: if one is unable to understand the perspective of others, it will be very challenging to anticipate what the other person is thinking in order to respond and sustain communication appropriately.


b) Stereotyped or Idiosyncratic Language: individuals with autism often demonstrate "stocked phrases", and echolalia with decreased spontaneity. According to Frith, the ability to use spontaneous communication requires the ability to guess and anticipate what the listener may wish to hear at that precise moment.


Individuals with autism may also use obscure words and phrases which may have meaning to them but not to the listener. For example, a child who says "french toast" may be indicating "happy". The autistic speaker is not taking into account the work required of the listener to make this inference.


c) Abnormal Tonal Quality: Individuals with autism often have a "sing song" or monotone quality to their voice. Normally, a speaker will place emphasis on specific words to convey meaning. Lacking insight into the listeners perspective, the autistic speaker may not realize the need to emphasize words to portray his/her meaning. Similarly, the child with ASD will not likely comprehend the speakers intent when emphasizing particular words. Instead, they may be attending to the loudness of the word and miss out on what was being said.


d) Nonverbal Communication: To realize one's own and other's state of mind, one needs to be able to effectively interpret expressive gestures and other nonverbal means of communication. This skill is difficult for those on the autism spectrum and again, interferes in the ASD child's anticipation of where the conversation is leading.

e) Reliance on Routines: This creates challenges for adapting to new environments and situations. Resistance to complexity, demonstrated by increased rigidity and an increase in stereotypical behaviors, is often apparent as a result of poor anticipatory skills. Without gradual, consistent introduction of novelty, these children will experience a high level of anxiety with transitions like moving from one grade to the next, going out into the community, and transitioning into adulthood roles.


f) Conforming to Social Behavior: If one is unable to read the nonverbal cues of others and interpret inferences, they will have difficulty anticipating and conforming to rules of social behavior. This will interfere in play skills with peers and siblings as well as relationships with parents, teachers, and employers.



g) Difficulty engaging in nonpreferred topics: because of their desire for sameness, the child with autism will have a difficult time participating in conversations outside their area of interest and undoubtedly have difficulty anticipating the thoughts and feelings of others as it relates to an unfamiliar topic. They will also have limited play skills which will hinder cognitive growth and social interactions with peers.


h) Difficulty feeling empathy toward another: Not only do these children have a difficult time understanding the feelings of others, they will have difficulty anticipating how their comments could potentially hurt someone's feelings. Decreased awareness of emotions will negatively influence relationships with peers and adults.



i) Decreased Perception to Biological Motion: An increase in response time to biological motion suggests that children with ASD will have a harder time anticipating and making inferences from rapid changes in eye gaze, gestures, etc. It also suggests that these kids would have a difficult time participating in games and sporting events that require well timed motor movements like those needed to catch a ball or to swing a bat to hit a ball.



j) Dyspraxia: Motor planning difficulties can hinder almost every aspect of life. Some examples include: effectively navigating the classroom, performing self-help skills like putting toothpaste on a toothbrush or dressing, and effectively participating in games or playing on the playground with peers.



k) Sensory Processing: The tendency to be overaroused by a complex environment while demonstrating signs of underarousal (poor eye contact, appearing not to hear, poor awareness of position in space, decreased body awareness, etc.) can hinder one's ability to see beyond their own bombardment of sensations to effectively interact and anticipate the actions of others as well as prepare for changes in routine.





Resources:

Frietag et al, (2008). Perception of biological motion in autism spectrum disorders. Nauropsycholgia, 46: 1480-1494.

Frith, A new look at language and communication in autism. British Journal of Disorders of Communication. 24. 123-150.


Frith & Leslie, 1990. Prospects for a cognitive neurophysiology of autism: hobson's choice. Psychological Review. 97(1) 122-131.


Miller-Kuhaneck, 2004. Autism a comprehensive occupational therapy approach, 2nd edition.

Pellicano, et al, 2004. Central coherence in typically developing preschoolers: does it cohere or does it relate to mind reading and executive control? Journal of child psychology and and psychiaty. 46(5) 533-547.

Research Articles: Anticipatory Skills and/or How Environmental Complexity Challenges Performance

1. Response to Environmental Stressors:
Cardiovascular Arousal in Individuals With Autism. Journal of Autism and Developmental Disorders (2008). 38:1485-1498.

Authors: Matthew S. Goodwin, June G. Groden, Wayne F. Velicer, Lewis P. Lipsitt, M. Grace Baron, Stefan G., Hofmann, and Gerald Groden

Purpose: To compare arousal responses to the presentation of potentially stressful situations in five persons with autism and five age and sex matched typically developing individuals using heart rate as a measure of sympathetic activity.

Hypothesis: Based on arousal modulation theories of autism and on co-morbid presence of anxiety in individuals with autism, it was hypothesized that this group would demonstrate increased cardiovascular responses to environmental stressors than the control group.

Results: Research data indicated findings that were opposite to the responses hypothesized. The individuals in the autism group showed significant responses to environmental stressors only 22% of the time while the control group showed significant responses 60% of the time. Although it appears that the individuals in the autism group demonstrated a decreased response comparatively, it is important to note that their basal heart rate was nearly 20 beats per minute higher than the control group during baseline readings and during stressful situations. This suggests that the autism group was either overly stimulated by the testing situation (although great lengths were taken to control arousal by the testing environment and by other variables like medications that can influence autonomic responses) or that they are in a general state of “autonomic defensiveness” to begin with.

Important Points to Consider: If individuals with autism are indeed, in a continual state of overarousal, it will be important to address this through stress reduction techniques and relaxation techniques as a preparatory measure before implementing behavioral and academic instructions.

2. Sensory Processing and Environment:
Sensory Processing and Classroom Emotional, Behavioral, and Educational Outcomes in Children With Autism Spectrum Disorder. American Journal of Occupational Therapy (2008). 62(5): 564-573.

Authors: Jill Ashburner, Jenny Ziviani, Sylvia Rodger

Purpose:
* To confirm previous research findings that children with ASD respond differently to sensory input than typically developing peers.
* To explore the relationship between sensory processing in children with and without ASD and their classroom emotional, behavioral, and educational outcomes.

Results:
A. Significant differences between groups on the Short Sensory Profile, with the exception of movement sensitivity, confirmed previous findings that children with ASD respond to sensory input differently than typically developing peers.
B. Factors related to classroom outcomes:
* Typically Developing Group: only association was between IQ and academic performance.
* ASD Group:
Underresponsiveness/Seeks sensation and auditory filtering negatively impacted academic performance and attention to cognitive tasks.
High levels of tactile sensitivity were associated with a range of attention difficulties, including inattention and hyperactivity.

Points to Consider: Due to auditory filtering difficulty effecting functional engagement in classroom, amplification of teacher voice and improvement to classroom acoustics should be investigated. Due to tactile sensitivity leading to inattentiveness and distractability in classroom, measures to decrease tactile input should be explored, like positioning these children further away from their classmates. Other suggestion indicated in the article include: enhancing instructions (i.e. visual strategies, voice amplification) while minimizing competing input; increasing the predictability of activities; and providing information at a reduced pace.

3. Interventions to Increase Anticipation:
Teaching On-Task and On-Schedule Behaviors to High Functioning Children With Autism Via Picture Activity Schedules. Journal of Autism and Developmental Disorders (2000). 30(6): 553-567.

Authors: Linley Bryan & David Gast

Purpose: To evaluate the effectiveness of a graduated guidance and visual activity schedule in teaching children with autism on-task and on-schedule behaviors and to determine if on-task and on-schedule behaviors generalize to novel activities.

Results: Findings support the use of a picture schedule with children who have high functioning autism. It supported previous research findings in that: students learned the mechanics of a picture schedule using graduated guidance which was easily faded; students learned high levels of independent on-task and on-structured behavior with the use of the picture book alone; high levels of on-task behavior with appropriate scheduled materials correlated with a decrease in nonscheduled behaviors: and generalization to novel activities was achieved with minimal or no extra training.

Points to Consider: The effective use of picture schedules throughout the day as well as their effectiveness in dealing with transitions/aiding in decreasing the stress of unpredictability should be examined.

4. Interventions to Decrease Anxiety and Arousal Commonly Associated with Environmental Stimulation
Behavioral and Physiological Effects of Deep Pressure on Children With Autism: A Pilot Study Evaluating the Efficacy of Grandin’s Hug Machine. American Journal of Occupational Therapy (1998). 53(2): 145-152.

Authors: Stephen M. Edelson, Meredyth Goldberg Edelson, David C. R. Kerr, Temple Grandin

Purpose: To investigate the effects of deep pressure on arousal and anxiety reduction in autism with Grandin’s Hug Machine, a device that allows self-administration of lateral body pressure.

Results: The children who received deep pressure demonstrated a significant decrease on the Tension scale and a marginally significant decrease on the more general Anxiety scale. The Galvanic Skin Response (GSR), which measured physiological changes, showed greater benefits in the children who had the highest initial levels of physiological arousal.

Points to Consider: Incorporating deep pressure activities into daily activities and offering deep pressure pictures to choose from as a means to calm the nervous system may be effective in promoting an homeostatic level of arousal for improved participation in social situations and learning.

Treatment Strategies to Promote Anticipation and Reduce Environmental Complexity

Strategies:
1. Adapt Internal and External Environments to Reduce Complexity and Stress:

A) External Environment:

a) Sounds: Eliminate or reduce environmental sounds: Place padding under computers and noisy machinery; place refrigerators, furnaces, and washing machines on special vibration mountings; dampen noise with carpets, upholstery, drapes, wall hangings, and acoustic panels and tile while removing sound reflecting materials like plaster, glass, concrete, and sheet plastic; provide "white noise" like fans or humidifiers; play soft, soothing background sounds like music, chimes, or running water. Wear ear plugs. Use vocal chanting like "om" and therapeutic listeningCD's.

b) Lights: Provide natural lighting or dim lighting; turn off flourescent lights; pull shades/blinds; provide visual stimuli that is soothing like aquariums or oil and water toys; "de-clutter" a busy environment; provide a harmonious space that is easy to navigate, with colors that are soothing, furniture that is comfortable and inviting, with simple wall hangings, and rounded plants.

c) Scents: Avoiod wearing strong perfumes; use essential oils, not artificial fresheners; reduce indoor toxins, i.e cigarette smoke, etc.

d) Tactile/Touch: Allow child to wear comfortable clothing; allow child to hold a blanket or other hand fidget while working; make sure the classroom/home is at a comfortable temperature; honor child's desire for space.

e) Multisensory: Allow child to leave for secondary classes early to avoid loud, crowded hallways. Divide classroom up into well defined work, play, and relaxation/calming centers.

*Once the environment is conducive for learning, it is essential to gradually increase complexity to enhance child's ability to learn and grow .

B. Internal Environment:

a) Teach "How Does Your Engine Run?" Self-Regulation Program (Williams and Shellenberger, 1996) to Students and Staff to Decrease the Stress Associated with Novelty and Complexity:

1. Teach child how to identify "engine" speeds.

2. Allow child opportunity to experiment and adjust engine speeds using a variety of alerting and calming sensory strategies.

3. Help child to identify when their engine speed is influencing their performance and allow them to choose picture cards with strategies on them to self-regulate.

4. Teach Alert Program to families and set-up a routine-based sensory diet for the family to implement into daily activities.

b) Hunger, Fatigue, and General Ill Health: Poor nutrition, poor sleep patterns, and general ill health can influence one's ability to process information effectively. Allergic reactions to foods and other environmental toxins (metal, etc) can also influence one's overall performance. It would beneficial to have a DAN doctor evaluate the child and make any changes to diet or supplementations deemed necessary. Strategies to improve poor sleeping may be beneficial (weighted blankets, a warm epson salt bath prior to bedtime, increased physical activity/heavy work throughout the day).

2. Increase Anticipatory Skills:
a) Picture Schedule: A visual schedule provides a list of sequential activities of the day's/session's events. It helps to reduce anxiety by providing anticipation and predictability while decreasing the demands for memory.

b) Social Stories: Social stories can help a child prepare and better anticipate unpredictable events. They can be used in advance to help prepare the child for an upcoming change in routine or to practice appropriate social interactions.

c) Identify Transitions Verbally and Visually: A picture signal coupled with a verbal cue "In a few minutes, we will go to math" and then, a picture signal coupled with "We are finished, it is time for math now" will help the child anticipate an upcoming change in routine and give them time to prepare for it.

Resources:

Heller, S (2002). Too loud too bright too fast too tight.

National Education Association (2006). The puzzle of autism. 1-44.

Miller-Kuhaneck,H. (2004). Autism, a comprehensive occupational therapy approach, 2nd edition.

Williams, M & Shellenberger, S. (1996). How Does Your Engine Run?" The Alert Program for Self-Regulation.

Tools To Assess Effectiveness of Strategies Across Treatment Sessions

1. Professional Observations
Improvement in skills may be observed by the therapist over time. Some observations may include a decrease in challenging behaviors, a decrease in reliance on others, an increase in spontaneous communication and interactions with others, and an increased or decreased reliance of aids (visual schedules, etc.).

2. Reports
Verbal or written reports of improved skills and decreased atypical and challenging behaviors by parents, teachers, and others indicate that the child is making gains and beginning to generalize learned skills into other situations.

3. Standardized Test Scores
Standardized test scores administered over time can be effective tools to measure the effectiveness of therapeutic strategies.

Take Home Treatment Strategies

Strategies to decrease anxiety and increase structure and predictability will inevitably increase anticipation and overall success. Some strategies may include:



1. Using consistent routines.

2. Providing visual instructions, rules, and schedules. Focusing on the visual strengths of children with ASD will aid in social and academic independence.

3. Sensory Processing and Environmental Complexity: Being alert to signs of sensory overload or too much complexity in environment and redirecting to a quiet area or aiding in self-calming as appropriate.

4. Providing a picture menu of acceptable behaviors and aiding child in utilizing menu when needed.

5. Providing frequent breaks to calm nervous system and aid in attending.

6. Understanding the need for transition time and planning for it.

7. Structuring the physical environment into work, play, and relaxation areas where rules and expected behaviors are clearly stated.

8. Aiding in inference making by identifying the purpose of tasks.

9. Aiding in the executive function by organizing materials via color coding and prioritizing workload and determining due dates using picture schedules.

10. Using the child's area of interest to introduce new topics, challenging topics, or using the child's preferred interests as a reinforcer.

11. Aiding in appropriate responses by designating peer buddies for modeling.

12. Developing a functional communication system.

13. Teaching appropriate social responses and etiquette.

14. Modifying worksheets and test taking requirements.

15. Pre-teaching new concepts.

16. Providing opportunities for motor learning through repetition.

17. Providing opportunities to work on perceptual response timing/reactions to biological movement.


Resources

National Education Association (2006). The puzzle of autism. 1-44.