Fight, Fright, or Freeze; the adverse effects of continuous anxiety and environmental modifications that can assist children with Autism Spectrum Disorder.
Think back to a time you felt truly terrified. Your hands clam up, your heart rate increases. The hair on the back of your neck stands up as your adrenaline pumps and breath shortens. We’ve all experienced the sensation of fear and anxiety. This feeling neurologically elicits a Fight, Flight or Freeze (FFF) response in order to cope with the threatening stimuli for that moment. Imagine you felt that way all day; every day and had no way of intrinsically rationalizing how to cope. Now, imagine that threat was your own body and your own neurological dysfunction that you were not able to make cognitive sense of. Through clinical observations and analysis of physical symptoms, I theorize that this is how some children with Autism Spectrum Disorder (ASD) feel as they are attempting to navigate throughout their environment. Throughout the article I will touch on fight, fright, or freeze, its impact on children with ASD, and environmental modifications that are detrimental to decreasing the adverse effects.
Fight, flight, and freeze are rooted from the Autonomic Nervous system (ANS) and the intricate relationship between the Parasympathetic Nervous System (PNS) and the Sympathetic Nervous System (SNS). Each subsystem of the ANS work synergistically in order to shut down and increase certain organ functions in times of distress. When we perceive a situation to be dangerous, our body begins to shutdown non-vital organs such as the gastrointestinal organs and increases blood flow to essential organs such as the heart and brain.
Sensory modulation is an incredibly complex and fascinating subject. The ANS is a vital component of the modulation and regulation of sensory information. Children that have been diagnosed with Autism Spectrum Disorder (ASD) typically have some type of sensory modulation difficulty. Children with ASD consistently perceive their internal and external environment as noxious. This continuous bombardment of noxious stimulation creates a feeling of anxiety and fear. As neurotypical individuals we are able to use reason and use abstract thought to create rational outcomes and decrease our fear and anxieties. When we have continuous anxieties that plague our day to day we are also able to participate in recreational activities that counteract these feelings. Children with ASD have multifaceted obstacles that does not allow for them to make those choices for themselves and need the expertise and clinical judgments of occupational therapists to manipulate the environment and create adaptations to allow them to have these experiences.
Anxiety and FFF are important concepts to discuss when it comes to working with children with ASD. There are a number of physiological and behavioral factors that are apparent when an individual is in fight, fright, or freeze. Examples of these factors are as follows but are not limited to, raised shoulder girdle, decreased gastrointestinal production, shallow breath, rapid heartbeat, frequent colds or other bacterial/ viral infections, teeth grinding, inability to focus, fidgeting, and pacing. Through clinical observations there are common threads that link behavioral concerns of children with ASD and the physiological symptoms of Fight, Fright, and Freeze.
So, what do we do with this information and how do we help our kids? First, determine which behaviors the child is exhibiting, in order to assess what their response is and to what they perceive as noxious and fearful. This can be done through clinical observation and assessments such as the Sensory Processing Measure (SPM). The internal neurological systems of children with ASD do not modulate sensory information as we interpret information. Commonly, there are multiple systems affected which can create complexity when treating. One of the more common and easier physiological components to target is looking at their breath and shoulder girdle.
Many of the children, whether in Fight; Flight; or Freeze, have a raised and tense shoulder girdle as well as a shallow breath. In order to allow yourself to empathize with how this feels, shrug your shoulders and attempt to take a deep breath in. It is increasingly more difficult to conduct diaphragmatic breathing when the shoulder girdle is tense. Now let go of your shoulders and take another deep breath in. This will feel very different than in the first example. Now imagine not having the ability to take that deep breath in and exhale out when you are experiencing a stressful and anxiety provoking situation. Chances are this will increase your anxiety and stress even further.
Physiologically, children with a raised shoulder girdle cannot even begin to take a deep breath because their anatomical structure will not allow it. To begin to rectify this situation there are a number of therapeutic handling tactics that can be elicited. Before therapeutic handling occurs, crucial environmental adaptations need to occur to create a soothing and calm space. Through clinical reflection, I have found the ideal environment is one with low and calming music, lower or natural lighting, and use of a lavender scented diffuser.
Studies have shown the importance and the neurological effect music has on our mood and temperament (Novotney, 2013). Music is a force that drives my disposition daily and has just as much of an effect, if not more, on children with ASD. There are physiological effects of listening such as, vasodilation in the cheeks, pupillary dilation, cessation of motor activity, and breath changes to increase depth (Frick and Young, 2012). Utilizing slow, rhythmic, and relaxing tones or music can add external support in order to decrease neurological chaos and dysfunction that may be occurring within the child’s system. If an individual has auditory defensiveness, utilizing tones with no vocals and less changes in frequency, pitch, and tone has a soothing effect.
Creating a space with low light or natural light couples the implementation of soothing music to the environmental adaptation. As clinicians, we work in a myriad of spaces, which can sometimes create obstacles to a therapeutic and soothing environment. This is where our creativity and intelligence can shine. The biggest obstacle for most spaces is fluorescent lighting. This is not only visually noxious but also auditorily noxious. In order to decrease the visual component many adaptations and tools can create a calming space such as, blue or green colored window film or Cozy Shades.
An increased interest in holistic medicine has caused an increase in research on the neurological and physiological effects of the inhalation of Lavender. Koulivand, Gadiri, and Gorgi (2013) state that it decreases anxiety, increases neuromuscular activity, increases social interaction, and decreases aggressive behavior. This olfactory component becomes another layer in which to help the ANS begin to relax. Using a diffuser with essential lavender oils, I have found, to be the best tactic. With these environmental modifications as well as a reflection and modification to therapeutic use of self, even in the most crowded sensory gyms there will be a neurologically automatic calming response.
Bubble Mountain
Children engaging in bubble mountain pre and post obstacle course to increase core awareness.
It is important to consider and target environmental factors and physiological structure before we expect the child to sit and participate in any gross, fine motor, or cognitive task. When we have created a serene environment we can then start to engage the core. Engagement and awareness of the core are an important step in increasing breath depth. This is extremely beneficial in order to elicit a counteractive reaction to their internal anxiety. There are a number of techniques that wonderful occupational therapy (OT) minds, such as Patricia Oetter and Sheila Frick, teach for example, Belly Ball and utilizing blowing activities such as balloons, whistles, or bubble mountain (Oetter, Richter, and Frick, 2010). Another technique that I have found to be successful is what I call, Belly Bounce. Belly Bounce gives gentle compressions to the abdominal muscles while also giving proprioceptive input to the lower extremities. There is a component of visual attention that automatically occurs which starts the ability for the child to acknowledge outside presence in an unregulated state. Belly ball and blowing activities can then be attempted when the therapeutic rapport has been established.
All of these components are important preparatory modifications needed in order to facilitate a relaxing environment to decrease the fight, flight, or fright response. It is important to eliminate this response so that they are able to participate and interact with their environment. We continuously follow the proximal to distal mentality when planning our therapy sessions, the new proximal should be viewed as internal neural components. Reactions to fight, flight, or fright can have damaging effects on behavior, overall health, and our neurological structure.
All in all, children with ASD have a tremendous amount of obstacles that they are internalizing and attempting to make sense of on a daily basis. Their obstacles are difficult to process because of their abstract nature. However, by beginning to recognize the correlation between disruptive behaviors and their current state of alert and fear we can begin to create environments that decrease their anxiety levels in order to increase their ability to participate and interact with others.
Resources:
Chang, M. C., Parham, L. D., Blanche, E. I., Schell, A., Chou, C., Dawson, M., & Clark, F. (2012). Autonomic and Behavioral Responses of Children With Autism to Auditory Stimuli. American Journal of Occupational Therapy, 66(5), 567-576. doi:10.5014/ajot.2012.004242
Grapel, J. N., Cicchetti, D., & Volmar, F. (2015). Sensory Features as Diagnostic Criteria for Autism: Sensory Features in Autism. Yale Journal of Biology and Medicine, 88(1), 69-71. Retrieved February 7, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4345540/.
Koulivand, P. H., Ghadiri, M. K., & Gorji, A. (2013). Lavender and the Nervous System. Evidence-Based Complementary and Alternative Medicine, 2013, 1-10. doi:10.1155/2013/681304
Novotney, A. (2013). Music as Medicine. American Psychological Association, 44(10), 46. Retrieved February 7, 2017, from http://www.apa.org/monitor/2013/11/music.aspx