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By the end of this post, you will have a better understanding of what stress is and how the stress response works. You will be able to describe factors which influence responses to stress by individuals with ASD, identify challenges related to stress, and identify types of interventions and support that may be available for teaching coping skills.

What Is Stress?

Well, put simply, it is any demand on the body. Bayer, Lispon, and Goodridge in 2006 stated that stress originated from the Latin noun strictus meaning “tight” or “narrow.” The term stress is used in medicine to denote when the state of health and stability in an individual is challenged or pressured.

Everybody experiences stress. Things occur around us and inside ourselves that contribute to stress every day. Not all experiences that contribute to stress are necessarily negative like a parking ticket, divorce, or death of a loved one would be. Positive experiences like a wedding, a new job, and the birth of a child are also stressors. Think about your own life experiences at a time when you experienced stress – notice that some of these experiences were negative and some were positive. Stress also impacts the body differently depending on its intensity. Mild stress can prime the system to motivate the individual to operate at peak performance levels while severe stress can be debilitating for both the individual and his or her performance.

Stress affects individuals on the autism spectrum in ways that could be highly problematic for their cognitive physiological and behavioural functioning. This is evident as shown by the higher rates of co-morbidity for this population. Co-morbidity means that two or more disorders co-occur in the same individual – such as someone being diagnosed with autism as well as OCD, attention deficit disorder, depression, or another combination. Researchers have shown that children and teens on the autism spectrum are at a 40% higher risk than typical children or teens to develop affective or mood disorders. Results from a study conducted by Tony Attwood in 2007 indicate that approximately 65% of teens with Asperger’s have co-morbid affective or mood disorders. Researchers are continuing to investigate stress in ASD, but in this 30-minute presentation, we will only be able to briefly touch on the topic. I highly recommend that you access the most recent comprehensive resource on this topic, which was published in 2006. It is called “Stress and coping in autism,” and edited by Baron, Groden and Lipset from the Groden centre. Now, let’s learn more about stress.

Regardless of the stressor, how an individual’s body responds to stress varies greatly. Body responses are influenced by the nature of stress, personal characteristics and temperament, and environmental factors. Let’s consider an example where you are stuck in an elevator. The nature of the stressor is that you are stuck in the elevator; tolerance to confined spaces and coping and problem-solving skills would be part of those characteristics and temperament. The time of day that you are stuck in the elevator and what you have with you could be related to the environmental factors, such as being stuck in an elevator with a cell phone during business hours so you can easily contact people for help. Being stuck in an elevator in the middle of the night with no means of contacting others could be a very different situation and your response to those stressors would vary greatly. Different models are used that rank stressful events based on a relative arbitrary value. For example, you might rank the death of a spouse near the top, whereas receiving a speeding ticket may be ranked lower. Depending on the individual, the responses will vary greatly, as already mentioned.

Now, how does this relate to autism spectrum disorder? Morgan, in 2006, said that “to the degree that autism reduces the resources that one has available to cope with challenges and homeostasis, the view of a given potential stressor is likely to be much different for someone with autism than for someone who does not have autism.”

So, what does stress feel like when you have an autism spectrum disorder? Morgan, in 2006, provides us with this illustration: “Imagine you are suddenly whisked away by a party of aliens. They surround you, gesturing with their bodies and making sounds out of what appears to be a mouth, but you cannot understand any of their gestures or the sounds they make. As you fail to respond to them, they grow more and more agitated, and the pitch and loudness of their sounds increases until it is quite painful. At the same time, they reach out to touch you, but their touch is accompanied by a feeling not unlike electric shock; it is simply excruciating.” Morgan continues to share how many persons with high-functioning autism have described experiences just like this, arising from interactions with well-meaning family members or friends.

Before helping somebody learn strategies to better deal with stress, we first need to understand how stress works. This model was adapted from Judd Barker in 2005 in his book “Preparing for Life.” When something happens that increases your stress, the event is called a trigger. There are two types of triggers: Internal triggers, such as lack of sleep or pain, and external triggers, such as making a mistake or not getting what you want. Automatic thoughts occur as a way to try and understand what happened. For example, if someone bumps into you and you think it is on purpose, this would lead to more anger, as opposed to thinking it was an accident, which would not arouse as much anger. And then we have our feelings about the situation – you might feel angry, sad, scared, happy, calm, or any other variety of emotions. Your feelings create a cycle which causes automatic reactions and reinforces the behaviour, as you can see in the model.

What Are Stressors?

Stressors are environmental triggers contributing to stress. An individual’s response to stressors can consist of physiological, emotional, cognitive, and behavioural changes. An individual’s response may not be what you expect. You may expect quick service when in an empty restaurant; but in many cases, peak performance may occur when stressors are present, such as quick service in a busy restaurant vs. an empty restaurant. Mild stress motivates staff to move quickly and stay on top of their game. There is a fine line between stress that can cause peak performance and stress that is debilitating. Individuals with ASD have some neurological compromises and unique challenges which thin that line further. For example, compromises in the physiological arousal mechanism can result in chronic states of under-arousal or over-arousal. Under-arousal requires a relatively high degree of stimulation in order to respond optimally or even to evoke a desired response. In over-arousal, the system is already in a state of distress, making any amount of stimulation a stressful event.

What Triggers Stress?

Some possible triggers or stressors include difficult tasks or demands, unfamiliar environments, social situations such as hanging out in the hallway, or group work. Sensory processing differences might be evident in noisy or crowded environments and places where there is a lack of structure. The individual may feel tired or sick, or experience motor-planning difficulties. What else triggers your students?

As mentioned earlier, everyone responds to stress differently. This means that each person may display different behaviours when he or she is feeling stressed. We must first learn to recognize the signs of stress in our students before intervening.

Some common behavioural indicators of stress could be asking multiple questions over and over again, low activity levels, avoiding interactions, passive involvement or not asking many questions, and increased self-stimulation such as finger or body twitching, tapping, or humming. The individual may also increase voice volume, and exclaim escape-related phrases such as “leave me alone!” “get me out of here!” “I don’t want to do this!”, swearing and verbal threats, physical aggression, and throwing objects. These are just a few examples of indicators of stress. What other indicators have you noticed in yourself or your students?

Problematic behaviours generally begin with small, subtle behavioural indicators of stress. Individuals often exhibit a fairly consistent sequence of observable behaviour and response to stress. As said earlier, everyone responds to stressors differently, both in type and intensity. Some escalate slowly through several levels of intensity while others can escalate quickly to a crisis level. The intensity of behavioural indications of stress increases as stress increases. At the peak of intensity or crisis level, we see reflexive panic-like responses with potentially dangerous behaviours resulting from fright, triggering flight-or-fight behaviour.

The profile of stress is one model of understanding the escalation of the stress response. Jansen and Jansen in 1996 provided us with this example: “Stage 1: this is when escalation is occurring – there is an increase in agitation and the individual is showing more behavioural indicators of stress at this time. Stage 2 – the curve is reaching the crisis level – you are seeing out-of-control behaviour at this time, such as aggression and self injury or complete shutdown. Stage 3 – this is when de-escalation is occurring; the individual is becoming calmer and a decrease in energy might be observed. In stage 4, they have reached equilibrium; they are stable and under control. Some children may become more withdrawn as stress increases, as in a flight-or-fight response. Emphasis needs to be placed on teaching coping strategies and reinforcing acceptable responses to stress so that the curve does not need to reach the peak shown here in order for de-escalation to occur.

Let’s consider the impact of sensory hypersensitivity on the nervous system. Behavioural responses to stress can include shut down such as a flight response, or a meltdown explosion such as a fight response. Here, the student starts the day highly aroused and certain events, whether sensory experiences, changes in routine, or frustration, can create explosive responses. The student can respond with a dramatic reaction and maintain a high level of arousal or move into shutdown where they do not appear to be responding to sensory input at all. Another example of this is when children and adults commonly get fatigued in highly stimulating settings, such as a birthday party. This is also evident in some babies who may actually fall asleep in similar settings where highly stimulating events cause fatigue.

Stress is any demand placed on the body or mind that causes a cascade of chemical responses in our system. Our stress response, which is based on individual experiences and perceptions, unravels a series of events that take place in the brain. Information comes through our senses, enters a part of the brain called the thalamus, and then travels to the amygdala. The thalamus helps to regulate arousal, and the amygdala serves the purpose of helping us perceive whether something is potentially threatening or not. It is also important for regulating emotional tone and social interaction. If the event is perceived as a threat, a chain of hormonal events takes place to prepare for the fear – flight-or-fight response. This prepares the body with extra energy so that it can respond appropriately.

Studies indicate that those with autism spectrum disorder do indeed experience heightened responses to stress. This is understandable considering the following studies. Brain imaging studies show variations in the volume of the amygdala – which is responsible for perceiving threats and regulating emotions. Levels of endorphins and ACT which trigger production of cortisol have been found to be higher in individuals with ASD compared to neurotypical peers and even peers with intellectual disabilities.

In addition – higher levels of cortisol have been found during times when novel events are presented, and also in integrated settings. When someone has an overly responsive system, this can lead to anxiety. Based on this information and reports from individuals and family members, stress and ASD appear to go hand in hand. Rebecca Little and Terry Todd in 2009 said that stress and ASD appeared to be inseparable, but this inseparability does not mean that they are unmanageable. Next, I will introduce some tools and strategies to help students with autism spectrum disorder to manage their stress effectively.

An intensity scale can be a very useful tool to help identify each phase or stage of stress. This allows us to identify the earliest behavioural signals of stress, intervene, and provide appropriate support to either the person themselves or to others who are supporting them and de-escalate stress before it reaches the crisis point.

This also allows us to facilitate a more rapid return to a state of equilibrium, which returns the person to the optimal level of alertness and stress to be productive. Having this scale also allows teachers and support staff to maximize teaching self control and coping skills. When you are teaching self-control and coping skills, as in any other lesson, it is best to teach when the student is at equilibrium.

Here is an example of an intensity scale that is commonly used. It is called The Incredible 5 Point Scale developed by Kerry, Dunn, Burn, and Mitsey Curtis.

Think of students’ stress on a scale of 1-5. For each level, identify the behaviours you would observe; these are things you see or hear for that emotion. 1 is optimal behaviour for equilibrium and 5 is a “too late” behaviour or out-of-control behaviour. One of the benefits of a scale like this is that it is a visual tool to teach awareness and make the abstract concept of stress more concrete for your students.

While sufficient research on the incredible 5 point scale itself is not available yet to say that it is effective, it can be a useful tool in your intervention program. As with any intervention that has not yet been fully researched, one must use data collection to monitor progress and make sure that what you are doing is actually working. When using the 5 point scale, you must adjust according to each individual. For some children it may be a five point scale, while for others, it may be a 3,7, or 10 point scale. The objective is to clearly define each stage of stress for the individual so that they know what level they are at and at what time based on those behavioural indicators of stress.

There are many variations of behavioural scales to visually display your students’ stress levels or emotions. Keep in mind that these are used to teach awareness; they are not intervention tools by themselves. The key is to individualize the plan based on your students’ needs.

Regardless of the type of scale used, the behaviour scale is not only a tool that helps your student to recognize his or her emotions, it is also a tool for you and others to provide support at each level of stress. By using clearly defined and observable behaviours, this ensures consistency of support. Also, it allows you to look at earlier signs of stress to intervene well before the level of stress gets so high that you are in a crisis level.

Evidence-Based Practices for Managing Stress and Autism

Now let’s switch gears and talk about evidence-based practices for a moment. Individuals have the right to effective treatment. Scientific research is needed to determine whether an intervention is beneficial or not. Evidence-based practice refers to an intervention model and strategies that are grounded in research. When designing intervention plans, one should first look into those intervention strategies that are repeatedly shown to be effective through well controlled studies, though sometimes research is emerging and not yet published. This does not mean that an intervention is not effective. This means that we need to be our own critic and monitor effectiveness of interventions as best practice.

So, what do we know about research on stress and coping with ASD? As we just said, evidence-based practice is research that is used to determine if an intervention is effective and beneficial to an individual. Susan White and colleagues in 2009 conducted a review of the research which revealed the following about the current state of research on interventions for anxiety and poor stress management of children with autism. Intervention studies for anxiety in ASD can be grouped into three categories based on Susan White and colleagues:

  • psychopharmacological,
  • psychosocial, and

White and colleagues found no empirically-supported treatments for autism spectrum disorder and anxiety-related concerns in the review. However, they did find some preliminary evidence for pharmacological and cognitive behavioural therapy interventions. Studies on medications such as SSRIs were done, but these studies were not well controlled and used small sample sizes.

Cognitive behavioral therapy studies have been done which show great promise. However, most of these have been done with those who are on the higher-functioning end of autism or are older using modifications to the standard way of conducting cognitive behavioural therapy in groups and interventions. Those with autism spectrum disorder have shown great promise with this intervention.

However, there are not enough studies completed at this point to consider it as an empirically-supported treatment. Other alternative interventions have been published but do not yet have enough evidence to draw conclusions on their effectiveness with autism spectrum disorder – either they have not included those with autism spectrum disorder in their research and these studies have been done with just typically developing individuals, or their measures of anxiety are so varied that it is difficult to compare the effects of these studies. Additionally, some studies have used such a small number of participants that it is difficult to draw conclusions, or the studies have not been well controlled.

White and colleagues recommend treating anxiety in those with autism spectrum disorder using a multimodal approach; collaborating with a multidisciplinary team is essential. The key, however, is to identify if the challenges are a true co-morbid condition or are a result of the challenges related to the characteristics of autism spectrum disorder in the individuals themselves. This can help direct you to treatment options that are better suited to the individual. As I said already – collaborating in a multidisciplinary team is essential – this includes using applied behavioural analysis to increase skills and decrease challenging behaviours. I will talk more now about how that can be applied to addressing stress and coping skills in individuals with ASD.

Cookie cutter strategies such as a one-size-fits-all approach or trial and error may not work and can even make things worse. These should not be used. We must individualize support strategies, choosing those that have the best chance of working for the individual. We choose these based on evidence. Evidence can come from research or our own use of best practice in collecting data and monitoring progress – every individual is unique. Using ABC data collection in your assessment to understand why the behaviour is happening in the first place is essential.

A wise teacher always accesses the team that is available to them to develop a sound ABA support plan. Always allow for an adequate amount of time to work and collect data. Make sure to collect data at baseline before you start the intervention to compare any changes and ensure that what you are doing is actually worth the effort. There is so much more to learn about applied behavioural analysis than can be shared in this brief presentation. Feel free to watch the “what is ABA” and “what is an FBA” modules to find out more about how ABA can improve the quality of life of your students through teaching skills and decreasing challenging behaviour.

Developing a Behavioral Support Plan

One of the things to consider when developing your behavioural support plan is what your current responses are to the stress of your students. What are you currently doing in response to your students’ stress-related behaviours at each stage of intensity? Think about this for a minute. Do you give them time and space to calm down? Do you offer them help? Do you offer comfort?

It’s okay if you are not really sure what you do. ABC data will help you identify your responses as well. You will record what is happening before the stress-related behaviours, and what is happening after – include your responses to what you are recording to help identify how you are responding to stress. This can give you a clue as to what stress behaviours are functioning for. Are they helping the student access your help or time away? These are all important things to consider.

It is important to remember what the teacher’s main role is. The goal of a teacher and education assistant is to maximize learning by the students. When a student is experiencing stress and engaged in stress-related behaviours, how well can they learn the lesson you are presenting? Teaching coping skills in how to manage stress better is one of the roles that a teacher and educational assistant may need to take on. Only then will it be possible to teach new skills.

You can do this by first understanding the students’ perspective. How are they perceiving the situation which is presented to them? It is also helpful to try and interpret situations triggered by stress for the student. It is important not to shame the student, and to help them understand the triggering situation in neutral terms. You can do this by structuring conversations around things such as the anger record developed by Jed Baker in 2005 in his book “Preparing for life”, or “Social Stories” by Carol Gray. Effective support will help your students reach their potential.

Providing effective support also means being that trusted and reliable person your students can go to. A study by Skufulsky in 1994 showed that the presence of a trusted friend in a social support network helps decrease the stress response, and allows the individual to function more effectively. So, while you learn strategies to better teach your students skills to manage their stress, also work on building rapport and establishing that social support network that is much needed for any student. The ultimate goal is for the student to learn the skills necessary to cope with stress and to transition out of the school environment into the home and community and workplace settings.

What are your students already doing to cope with their stress? They are already using their own coping strategies, whether they are inappropriate or unconventional, and they still may be functioning to help manage their stress. Some may be crying or running away or shutting down and not responding to you at all. What do you think the result of this is for your student when they are engaging in these coping strategies? Does it allow him or her to escape or avoid a situation that is a source of stress? Think for a moment about what your students are currently using as coping tools or strategies – whether they are unconventional or not. This can be great information to help give you some hints about what types of alternative strategies you can offer them to expand on what they are already doing, or to offer alternative skills that they can learn to use instead.

The Relationship Between Behaviour and Environment

The functional relationship between behaviour and the environment follows this 3-term contingency we call the ABCs of behaviour to best support your students. You need to understand what is actually happening that is triggering the stress and what happens as a result of the coping strategy that they are currently using.

When examining the ABCs of behaviour, the antecedent, or the A, is the trigger of the stress, the B, or the behaviour, is the coping strategy used, and the C, or the consequence, is what happens as a result of using that strategy. The result may be that the coping strategy effectively decreased the stress with a delay, avoidance, or stopping of the trigger that is causing the stress to begin with, receiving comfort or support from a trusted person, or a sensory feedback that helps to regulate the equilibrium.

In order to teach your students more adaptive ways to cope with stress, it is essential to identify those antecedents, behaviours, and consequences. For example, let’s take a situation where you present a math worksheet to a student and he effectively rips it up and then gets sent to the office. What is the trigger here? The trigger is the math worksheet being presented.

This increases the student’s stress, and his current way of coping with that behaviour is to rip up the math worksheet. The outcome is that the math worksheet is now gone and he gets to take a break from the classroom and leave the area. Perhaps he also gets to have some time to chat with somebody and receive some comfort. By using your ABCs, you are able to identify what the trigger is.

With some more careful assessment, you can look at what it is about the math worksheet or that situation that is causing the stress and why that student is ripping up the paper to begin with. Once you can understand that, you can understand what it is that the student is effectively doing by ripping up the worksheet. You can then look closely at what those more adaptive ways of coping with the stress are. Is it that the math worksheet is too difficult and the student is not understanding what the instructions are? Maybe he needs to learn how to ask for help.

Perhaps accommodations are necessary to deal with more difficult work and to chunk the work or to alternate between easy and difficult tasks. But for these to be most effective, you need to identify what the actual triggers are, and the consequences of the student’s response to the stress. You can use ABC data collection to identify these factors that are influencing the behaviour. Let’s look at the different types of behaviour more closely in the next slide.

There are triggers that can elicit a stress response immediately. These are called “fast triggers” and or the antecedents. These occur immediately before the behaviour. There are also things called setting events or slow triggers that do not occur immediately before the behaviour but still affect whether the behaviour occurs or not. Setting events are things such as fatigue, hunger, or something that has occurred hours or days before. Setting events can also be the person’s perceptions of the situation, including the thoughts that they are having about what is happening and how they understand the trigger. Imagine your stress is like a soda pop can. A trigger is something that shakes the can. Setting events are slow triggers that are little shakes to your pop can. Just one little shake on its own won’t explode the can, but over time – lots of little shakes could build up to cause you to be overloaded and explode. A fast trigger, or an antecedent, would be something that occurs immediately before the behaviour – this could be that last shake to the can over a long period of time, or one really large vigorous shake that explodes your pop can.

Setting events, or slow triggers, do build up over time and cause overload. Overload stressors are challenging because you don’t actually see them coming. When the person does have a stress response, it can seem disproportionately large compared to the trigger that you observed immediately before. Let’s look at an example:

A Case Study

In this example, the student did not sleep well last night and the lights in the classroom are too bright: these are the setting events. The antecedent, or the trigger, is difficult work. The student may respond with a fright – flight – fight response. The fight response could be to scream and hit, the fright response no response at all, or flight response to run away.

The consequence, or what happens after the behaviour, could be that the teacher removes the work, talks with the student about it, and then the student puts his head down on the desk to avoid the lights. Now let’s see what happens with the teacher’s ABCs. The teacher has a setting event as well – the teacher has a headache. The behaviour of the student actually acts as the trigger for the teacher’s behaviour. The teacher then removes the student’s work, then talks to the student in response to the student’s screaming, freezing, or running away. This effectively stops the student’s undesirable behaviour.

The student’s behaviour in this example allows him/her to escape from the demand – whereas the teacher’s behaviour allows him/her to escape from the student’s undesirable behaviour. Now in this situation, the behaviour worked for both the student and the teacher – it has been reinforced. Once a behaviour has been reinforced, it increases the likelihood of repeating the same behaviour again under the same situation. What other factors could be included in this diagram that could help us understand what’s contributing to the stress for the teacher or the student?

The ABCs of Behavior

The ABCs of behaviour will help us to understand the triggers and consequences of the student’s response and to develop strategies to prevent the likelihood of those responses in the future. They can also help us to identify replacement skills that serve the same function or have the same end result, as well as help us to identify when to intervene and with what strategies once the target behaviour occurs. Using this example, you can see where the points of intervention are.

A preventative approach could be used to modify or eliminate setting events and antecedents, such as getting a better night’s sleep and making accommodations for the difficult work. At this stage, the teacher may also prime the student – warning them that they are handing out difficult work and to remind them of the strategies that they can use, such as requesting a break.

Preparing the student by recommending that they engage in some relaxation to decrease their stress even lower before starting the difficult work may also be helpful. The strategies that you suggest to the student would be individualized to what works for him/her. Teaching the student replacement and coping skills to use instead of the behaviours that we want to see decrease would be effective as well. The student could be taught to ask for a break or to ask for help.

Lastly, we learn how to intervene at the consequence stage. The teacher would effectively intervene by prompting and reinforcing replacement and coping skills. Based on the individualized behavioural support plan, the teacher would be trained to prompt the student to use one of those replacement skills once the stress starts to increase, such as asking for a break, and the teacher would reinforce the use of that coping skill by actually allowing the break and removing the work for a period of time.

Stress Support Plan Components

Here are some of the key support plan components and tips. For preventative and proactive strategies – try to modify or eliminate the triggers (setting events and antecedents). This prevents or reduces the magnitude of the stress response in your student. You can do this by providing frequent breaks, decreasing demands, providing warnings, or education about potentially stressful events, embedding calming sensory input within the existing routine.

For situations where the stress triggers cannot be changed or modified – skill promotion strategies are a great area to focus on. In this strategy, you would teach and promote replacement skills that serve the same function as the target behaviour – such as in our previous example. Teaching coping skills such as how to handle conflicts and solve problems would also be an area of skills to promote. Teaching self-regulation skills to maintain the right level of alertness, such as a sensory tool kit, would also be useful.

Intervention strategies are the strategies that you use when you are reacting after the stress response has already occurred. For these strategies, you want to focus on how to respond to the behaviour: ensure the individual’s safety and reinforce replacement skills to increase the likelihood that they will use those again in the future. Be mindful of your student’s motor planning skills when teaching motor-based skills and use your multidisciplinary team, such as an occupational therapist, to look at the best way to address those sensory challenges.

To Conclude

Stress and anxiety affect everyone; however, neuorotypical people have more strategies at their disposal to deal with the stress. In contrast, individuals with ASD are at a distinct disadvantage when it comes to dealing with stress and anxiety. Given their psychological make up and the cognitive and social factors that predispose them to stress and anxiety, remember that providing effective support will help your students reach their potential. By working collaboratively with a multidisciplinary team, including the students themselves, you can work together to fully understand how stress affects your students and develop an effective behaviour support plan.