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Text Transcript: Anxiety in Individuals with Autism Spectrum Disorder (Part 2)

- In the presence of a threatening stimulus, like for example when I came up on the stage.

Or when Barbara Streisand is in front of the audience, or when Bette Midler is in front of the audience, something automatically happens.

Or when I'm on the trail hiking and I come around the bend and there's some bear scat in the middle of the trail.

Something automatically happens, it's biochemical in nature on the front end.

Some chemicals are released into the system.

Cortisol, epinephrine, adrenaline.

And once those come into the system, they recruit something from the body called glucose.

They recruit glucose from the muscles and from the liver.

Glucose for the body is what gasoline is to a car.

But just like a car, where the gasoline has to be burned in order to provide the energy for the car, the glucose has to so-called be burned by the body in order to provide energy for the body.

Except in the body it's not burning it's called oxidization, so it needs to be oxidized.

So breathing rate changes when those chemicals come into the body.

So there's oxygen in the system to metabolize the glucose and then that turns into fuel.

But it needs to be distributed throughout the body so blood pressure and heart rate go up.

And so now the engine is running.

Like there's a little brick on the gas peddle, (makes car noises) and the central system that's managing all this only gives the person two options on the front end, I already told you what they were.

Attack and kill or get the heck out of there.

And if you can execute one of those actions, everybody goes home in a limousine except for the person you attacked and killed.

But if you can't, you can't execute the actions and you still have the energy, now what?

What do you do with that energy?

I mean I'm doing it now, I'm distributing my energy this way but what if you don't have an option?

Act this out, let's say you're 16 year old daughter successfully argued for a midnight curfew on Friday and ordinarily her curfew is like 10:30 but she argued you into a midnight curfew.

And she was going with some kids you weren't certain of and now it's 12:15 and she isn't home yet and she hasn't texted, she hasn't called.

And you can't call her for whatever reason.

So you can't leave the house because you wanna be at command central.

You can't get in touch with her, there's nobody to call, there's nothing you can do but sit there and wait.

Now what?

'Cause that threat based stress response would have been activated, so this would not be unusual.

None of that's gonna bring her back, but we're using that energy.

You've gotta use it for something.

If it just sits there, it'll be like just leaving the brick on the gas pedal in a car, it'll just burn the car out.

So a lot of that stuff that doesn't make too much sense in the behavior of persons on the spectrum is that.

Sometimes it's just self stim, sometimes it's using energy that was generated by a threat.

Sometimes that nonsensical repetition that they engage in is just what I'm talking about.

They've been activated by something in their environment they find aversive.

You've taught them not to attack it, you've taught them not to run away, but you haven't necessarily what to do when they feel that way because we don't even know they're feeling that way.

And that's where we see it.

So, the Navy SEALs are regularly in the presence of threat.

They are human beings, just like you and I, just like person on the spectrum.

Their threat based stress response occurs just like ours does, just like persons on the spectrum does, only they are trained to do something in the presence of that kind of an experience.

'Cause they have to aim their weapon and fire it at people who are aiming their weapons and firing at them.

And believe me, they are activated.

But they're trained to calm themselves down, they have a method.

It's something, there's variations on this theme, what they call it is the four by four by four by four method.

They draw in breath through their nose for a count of four.

They hold for a count of four, and then they release the breath through their nose or mouth for a count of four, and they do that for four minutes.

And that calms the system down and takes the brick off the gas pedal.

It lowers heart rate, lowers blood pressure, and diminishes that chemistry that's occurred in the body.

There are ways to do this.

You know if the Navy SEALs do this it works, 'cause they don't do anything that doesn't work.

So there's a huge prevalence of anxiety, I mean anxiety is the number one mental health condition affecting mankind.

And the prevalence rating in the United States is 29%, that's anxiety disorders.

Not the experience of anxiety, but actual clinical anxiety, 29%.

But in the autism spectrum population, it's above 40%.

That almost makes it normal in that population.

Anything that achieves 50% is normal in the population where it occurs, statistically normal.

So why is that, what's going on here?

Requires that I talk a little bit about how anxiety occurs in this population.

It could be genetically transmitted, and I think there is a genetic basis to anxious people, clinically anxious people.

When I am working with an anxious kid, I feel safe enough to ask him or her which one of their parents is anxious, because usually there's one of them.

But the genetics wouldn't account for this, I don't think.

Maybe it's part of the syndrome itself, but nobody's ever identified that.

Maybe they have more trauma in their life, but I haven't seen statistics reporting that.

So I tend to want to be more parsimonious and look at their development.

And I think there may be an answer in their development.

So there's developmental milestones that kids need to go through in order to have a successful transition through their childhood years into adult years, and it starts with attachment.

This has been studied abundantly in what researchers like Mary Ainsworth for example have shown is that if an infant or a toddler is very securely attached to its caregiver, then it'll venture out further and stay longer in strange situations.

They'll even get out of visual range of the mother.

It's as if the securely attached infant or toddler is bringing the security of that attachment out into the world with them, experiencing the world as if it were secure as sort of an extension of the security they feel around their caregiver.

But an insecurely attached infant or toddler will not venture out very far into strange situations and will not stay very long, and will not leave the visual range of the mother.

It's as if the insecurely attached infant or toddler is bringing the insecurity of their attachment into the world with them.

And for them, the world is a strange and terrible place.

Now we're just talking about their house.

We're just talking about them toddling or crawling away from mom in the sitting room around the corner into the dining room.

So we're not talking about anything that's really dangerous.

They're not crawling out the front door and going down to the local bar.

We're just talking about going from room to room in the house.

So we're talking about anxiety.

Now how securely attached are kids on the spectrum in the early parts of their lives?

See I think one of the complaints that a lot of parents have is that it was difficult to establish any kind of attachment because there wasn't much reciprocity.

So we have maybe an increase in insecurely attached infants and toddlers, and that would set the stage for an anxious response to the world.

Then in another developmental stage, and developmental necessity is interactive play.

See early on, children interact with each other playing using objects that we call toys.

That's the medium of exchange.

So they create all the relationship with these objects that we call toys and they keep doing that until they become sophisticated enough with language that they can create their relationships with new objects that we call words.

And then they start playing inside of conversations rather than playing inside of toy based recreational activities.

But the foundational predicate for the conversational interaction is the toy based interaction which requires interactive play.

So how much interactive play do you see in young autistic children?

They prefer isolated play.

And we'll talk about that a little later.

So for them then, the conversations that ultimately are gonna be necessary have a very shaky predicate because they didn't do much interactive play, so they don't know much about the interactions necessary, the give and take, the listening and speaking that goes on in a conversation, because they got no give and take experience when they were using toys.

So their experience socially becomes anxious.

And then boundaries.

They don't learn necessarily interpersonal boundaries because the only way you learn them is by interacting with other persons and making the mistake of violating their boundaries.

You want to see this happen, just go to a day care or a preschool and watch what these kids do as they're teaching each other boundaries.

What do you think all that biting is about, and screaming, and bonking, and crying out to the caregiver?

You watch the kids and they wanna lift themselves up, they put their hand on the other kid's face and push up that way.

And then they get bit or they take toys from the other kids or they grab other kids and they're teaching each other get out of my air space basically, and over time they learn to give a little sway.

And ultimately, that progresses into the language based world where boundaries also occur.

And so they learn not to be too intrusive with their conversations, they learn not to be too blunt.

They learn how to establish reasonable boundaries in accord with the relationships that they're in.

But if you don't have much interaction early on, then you don't learn those boundary based rules, and as a result, interactions subsequently become really unpleasant on an ongoing basis.

There's a, a researcher, a marriage researcher, his name is John Gotman, he studies what are called interactional ratios in marriage.

And what he's shown is that if a couple has an interactional ratio between pleasant and unpleasant interactions that ranges around five to one or higher.

Five pleasant interaction for every unpleasant interaction.

That their marriage is immune from all the known causes of divorce including infidelity.

But if the interaction ratio falls down to one to one or lower, that the probability of emotional divorce is 100% and the probability of legal divorce is very very high.

People will divorce themselves from people with whom they're having a relationship if the ratio of the interaction becomes too unpleasant.

I'm thinking these ASD kids who have no boundary based rules to occupy themselves and guide them as they interact with people, are ongoingly having really unpleasant interactions with people around them, and thus they're starting to divorce that world and stay closer to home.

Give you an example, that's why I had this picture up here of a boundary based set of rules that you and I are really good at.

So we'll do something that no other mammal would ever ever ever ever ever consider doing, ever.

Is we'll get into a small receptacle that will rise to great heights when it's full of other flesh eating mammals that we don't know.

We'll get into an elevator that is gonna rise to great heights and is full of flesh eating mammals that we don't know, and we do that without even thinking about it.

Now how is that possible?

Because we know the boundary based rules of the elevator.

And the rules are, enter elevator, do not make eye contact, do not comment to anybody in the elevator, swiftly turn around, press the button for your floor, stare at the numbers above the door as if the secrets of the universe are contained there somewhere until the ding for your floor rises, exit the elevator, do not turn around, go to your room.

We know these rules.

But what if you didn't know the rules of the elevator?

Then you got on that elevator, so you don't even know to turn around.

Then you don't know not to touch people and you don't know not to look at people, and you don't know not to talk to people.

And you don't even know you're supposed to leave the elevator when your room arises.

How pleasant would that elevator experience be?

It would be horrible.

And my thought is, these autistic kids, for them the world is that elevator.

And then unlearned social roles and social rules, which is related to boundary based rules.

You and I know this set of rules.

We might not know them so well that we can teach somebody what they are, but I'm willing to bet dollars to donuts that most of the people in this room could go to a cocktail party conducted on behalf of their spouse or significant other where they don't know anybody.

You wouldn't want to go, and the only reason you're going is because you're married to you know who or you're in a relationship with you know who and so you feel obligated to go.

And you could go and survive 'cause you kinda know how to handle yourself.

You're not gonna know anybody, you don't have enough jokes, you don't know how to talk about your husband's work or your wife's work or your significant other's work, but you know enough about please and thank you, you know how to listen, you know where you can go and get something to eat.

You know to stand in line.

You might introduce yourself to a few people.

You know the rules, you can survive this.

It's something that makes us uncomfortable, but it doesn't terrify us so much that we have to go and shut ourselves and lock the door in the bedroom.

But the important part is we kind of inherently know the rules.

What if you didn't?

Here's a metaphorical example.

Every day, you know I do something that's really dangerous, really dangerous, incredibly dangerous.

We get into these vehicles that we have.

They weigh two, three, four, five, six, seven, eight tons and we drive them at 10, 20, 30, 40, 50, 60, 70, 80, 90 kilometers an hour, where there's hundreds or thousands of other people doing the same thing in their vehicles all around us.

That's pretty dangerous.

Do we respond to it as if it's dangerous?

No, we don't even think about it.

Putting on our makeup in the mirror.

We're eating a sandwich, we're talking on a cell phone, we're texting, we even got DVDs implanted in the dash.

We're thinking about our day, we're thinking about our weekend, we're thinking about the argument that we had last night, we're thinking about anything other than driving.

It doesn't even occur, unless something out of the ordinary happens we're not even paying attention.

So is it scary?

Not at all, even though it's dangerous.

But, what if there were no rules?

'Cause we follow the rules, that's why it's safe.

We stay in our lane for the most part, we stop at the red, go at the green, we stop at the stop sign, we don't go the wrong way in a one way, we signal our turns.

Generally we follow all these rules, we know the rules so well we don't even have to think about them.

And that makes it all pretty safe, or seems safe.

What if there were no rules, none?

You were allowed to get in your car and go from point A to point B, dog eat dog rules, first one to get there wins.

You don't have to stop, you don't have to yield, you don't have to do anything you don't wanna do.

How safe would you feel driving around?

Like if I asked you to go across town to get me a six pack, what are the chances you'd do that for me?

In other words, will you risk your life so that I can have a couple of beers?

I don't think so.

My thought is that that road way that we would be on with no rules is kind of like what life seems to the person on the spectrum 'cause they don't know the rules.

They know there are rules, as far as they're concerned nobody is following them.

'Cause they have their own set.

And the rules that we're going by, they don't know what they are.

And so the world for them is an unsafe place, and so what you find is that they don't wanna go out, they wanna stay home.

'Cause the ratio that I talked about, pleasant to unpleasant, that's usually pretty good at home.

Not so good at school, definitely not good on the street, not good in the workplace, but very very good at home, so why not just stick at home and divorce the world?

So that's my thought about how the increase in anxiety might occur in this population.

'Cause we've sort of got a bunch of these developmental processes.

So what are some signs of anxiety in play?

Well excessive is the key again.

And yeah, kids order their toys and kids move their objects around and kids move their bodies around, kids repeat what's been said to them, kids do that.

And they have little emotional reactions, but we're looking at is excessive moving around, excessive ordering, excessive echoing.

And what you're looking for is maybe there's something other than play going on here.

Maybe they're not really playing.

Maybe what they're doing is trying to manage that arousal that we talked about.

'Cause I mentioned when you put the brick on the gas pedal you get that threat based stress response.

The engine is now running and that energy has to be dissipated somehow, and you'll see it in their play sometimes.

If you watch it carefully enough, it really isn't about play.

It's about dissipating that internal unpleasant energy that's been generated by the experience they're having in that particular moment.

So you tell a typically developing kid hey honey, go pick up your toys.

And the kid goes, pick up my toys?

Well that's echolalia.

But you tell the ASD kid, hey honey go pick up your toys.

And they're like, pick up my toys, pick up my toys, pick up my toys, pick up my toys, pick up my toys, pick up my toys, pick up my toys.

That's different.

They're trying to manage the experience that they had when they were told to disrupt their play and pick up their toys, and they're doing it with echolalia, that's echolalia with a different function.

And when they start ramming everything around, they're not necessarily just playing, they may be distributing that energy.

So we look for that sign of anxiety in their play.

You see signs of anxiety in their social interactions?

Well yeah, remember control is the deal.

Like anxious people tend to be controlling people and controlling people tend to be anxious.

And so ASD kids generally are a little on the bossy side, or can be, because they want things to go their way.

If the things don't go their way, they don't feel very good about that, they're distressed by that.

In order to avoid the distress, they try and direct the play, they script it.

And they get very very frustrated and beyond frustrated, maybe even a little worked up, maybe a little stressed when there's a shift in play they didn't anticipate or direct.

They interrupt the play of others when it's not going the way they want it to go because they don't feel too good about it when it's going that way, they want it to go this way.

This way makes them feel okay, that way is uncertain.

This is all sort of anxiety based.

And ultimately, avoiding playing with others altogether 'cause it just isn't going to work out the way I want it to work out.

And similar here with signs of anxiety in elementary school.

You get the need for control, the correcting, the bargaining, the arguing, just trying to manage the play, just trying to make the game go the way they want it to go, the way they're comfortable with.

What they really have here, and remember I mentioned this on the front end.

The most successful members of our species are people that are the most tolerant of their own discomfort.

The least successful members of our species are the least tolerant of their own discomfort.

And what we have in the ASD population are human beings that are very intolerant of their own discomfort.

And that discomfort is generated by situations where there is any element of unknown, where there's any element of unpredictability, and that occurs a lot in the play of young kids.

So if they can't get it to go the way they want it to go, they're not gonna do it, they're gonna avoid, and then they have outsized emotional reactions if they're forced to do it.

And then adolescence.

I mean, it's bad enough as it is.

Who wants to go back and do your four years of high school all over again.

And I don't mean knowing what you know now.

I mean exactly the way you did it the first time around.

I mean if you're a quarterback, you got a 36 on the ACT, you're a head cheerleader, well sure you'd go back, you hit it out of the park every time you took a swing.

The rest of us, more on the normal end of the spectrum, it was pretty unpleasant and it was a pretty anxious period of life where being included was really key, being accepted was really key, and being included and accepted was always in doubt.

And trying to find an identity that would work, and trying out methods without being called a phony.

I mean there were so many different ways to err in high school when you're typically developing, and you throw the ASD kid in there and it's just fraught with peril for them.

And I've got a paper on my desk, it's really good research.

Some day you guys should get Jonathan Tarbox to come here and speak to you.

He works specifically with adults and kids on the spectrum.

And one area that he's interested in is executive functions.

But another area he's interested in is teaching adolescent kids how to use and respond to sarcasm.

And where we learn that is in high school 'cause it's central to our high school relationships.

But you know and I know that autistic kids tend to be pretty literal, and if you're literal, then sarcasm sounds like a real insult instead of an opportunity for a funny exchange.

And teaching them the nuances of that exchange would be very valuable for them to learn.

It's not something I work on, but something he works on.

But that's my thought.

Bantering, teasing, sarcasm, it's kind of part and parcel of high school life, and how good are these autism kids at that?

Let's say you've got your autistic kid, he's a junior and he's in a little conversation with three typical development kids, Tom, Dick, and Harry.

And they're teasing each other.

So Tom teases Harry, all four of them laugh, Harry teases Tom, all four laugh.

Dick teases Harry, everybody laughs.

And then the autistic kid says exactly what Tom said to Harry, nobody laughs, and all three of them walk away.

It's like, he didn't know what's going on, he just did what they did.

But the key for sarcasm and teasing, for joking in general, is timing and delivery.

And who's gonna teach them timing and delivery?

If you don't time it well, and you don't deliver it well, it's not a joke any more.

Let me try one.

Horse walks into a bar, bartender says hey fellow, why the long face?

See there's no timing and delivery there.

Let me turn it into something, it's not a great joke, but it's a joke.

A horse walks into a bar.

Bartender says hey fella, why the long face?

The timing and delivery changes those words into something different, and they don't have a good sense of timing, they don't have a good sense of delivery.

The kid goes home and tells his mom, I was talking to Tom, Dick, and Harry and they were saying this stuff to each other and they were all laughing and then I said it and they all walked away.

Well she can say, well honey they probably thought you meant it, which is what she's probably thinking, 'cause when he talks it sounds like it means everything he says and that's not gonna work for teasing, that's not gonna work for sarcasm, that's not gonna work for bantering, 'cause in your delivery, you have to make it sound like you don't mean it, and if you can't put that tone in there and that timing in there, then you're not gonna make friends.

In an attempt to make friends, you're gonna make enemies.

So they end up with low distress tolerance, easily frustrated and overwhelmed by their experiences in school.

More prone to acting out in class because of what happened in the hallway.

Maybe they get little depressed about the whole thing and they depend on adults, not a good sign.

It's a good sign for toddlers and preschoolers and kindergartners and elementary schoolers and even some middle schoolers to be dependent on adults and want to hang with adults.

It is not a good sign when adolescents wanna do that.

They should be out there forging their own identities and their own groups, and if they start hanging around too much with the adults, one, adults are too accepting, so they don't learn the breadth of personalities they're gonna need to negotiate the social landscape when the adults are not there, they're not gonna make friends, and the adults aren't gonna be there forever to make sure everything's okay.

So now we've got the parent and caretaker anxiety, which is also a factor here.

You've got the helicoptering, the kind of hovering.

Checking, making sure, but in doing so there's an inherent communication.

It's not spoken, but it is delivered nonetheless.

If you have to check on a kid a lot, then the message to the kid is they're not okay.

'Cause if they're okay, then why are you checking on them?

Why do you keep coming in there and making sure everything's okay?

The implicit message is things aren't okay, or things are okay but the kid's not okay, and that message can end up being a self-fulfilling prophecy.

So if you get an ongoing message, even though it's not spoken, but nonetheless it's communicated, from the most important person in your life, the person that's been foundational as far as your identity is concerned that you're not okay, then not okayness can bleed into that identity and the person doesn't feel okay.

I'm gonna talk a little bit about this this afternoon, I'm gonna mention it now.

I'll make two more points and I think there's food in the back and I'll let you have a break.

So I mentioned that behavior is a function of its circumstances.

What I didn't mention is that we're always of the circumstances, you can't escape them.

This is not a moving we're watching, this is a movie we're staring in.

We're always in the movie.

It seems like we're watching the movie when we're watching life, we're not, we're affecting it.

You can stare at your TV all day and you won't affect it.

But you stare at people, even for a little while, and you affect them.

So if you're trying to change something in somebody, you're really efforting at getting them to change, you're trying stuff to get them to change, doesn't matter who it is, could be a kid you're working with, could be your significant other, could be a neighbor or friend, could be your colleague, could be your boss.

And they're not changing, you're a part of the maintenance system, and that's hard to grasp.

'Cause we're putting it on them for not changing.

But we're trying to get them to change so we are a circumstance in their life and they're not changing, something is maintaining that behavior and we are part of that something.

That's hard to grasp.

And the helicoptering cocooning parent is part of the circumstances that are causing the need for helicoptering and cocooning.

So the very attempt to protect the child can generate circumstances that require the child to be protected.

Am I making sense here, it's a tricky point to make.

So, I'll end on this point here.

I have on here low distress tolerance.

I am not talking about the parent's distress, per se, I'm talking about their tolerance for their child's distress.

That's what I'm talking about.

And I frequently find they don't have a lot of it.

And what we need is a lot of it.

We need a lot of tolerance for that child's distress.

It is not possible to learn behavior change without some distress, because you're changing.

You're changing from what worked to something that doesn't work, to something that will work better.

In that transition, discomfort is a natural part of the process.

And believe me, in anxiety, treatment, there is always gonna be discomfort.

And the more discomfort present in the steps in an anxiety treatment program, the more learning occurs, it's just hard to be present to.

I'll give you a couple of examples.

One involves my wife.

God bless her, she loves to help.

Help.

And I love her for it, but what it really boils down to, and I really, I shouldn't be saying this 'cause they're filming it.

Who knows where that film's gonna end up.

I guess I better say some really nice stuff right now.

Have I mentioned my wife is a fantastic person?

It's just that she's kind hearted and she wants to help.

And frequently that is exactly what the doctor ordered.

But sometimes it's not, and when it's not, it involves our television set, because I've got this entertainment center that I need a NASA engineer to come to my house to show me how it all works.

So I don't even know why I spent the money on it.

But I've got like five remotes, you know?

And so I'm trying to get something to come on and I'm a little perplexed, but she's sitting right there, I can't show here that I'm perplexed.

I'm on stimulus overload already, and so I've gotta act like I've got it under control and I'm cool, calm, and collected even though I'm not.

Inside I'm like, what the?

But outside I'm like oh, this is going well.

Because if she sees distress, she will come over and help me.

I'm already on stimulus overload, so her attempt to help has me sort of have to reset the whole plan and start from scratch because I couldn't keep enough in my head to solve that problem.

The point is she has limited tolerance for my distress, and so she comes over, in the guise of helping, she is actually trying to create her own comfort.

You see what I'm saying here?

It's a tricky point.

I used to do these developmental assessments for very very young kids, kids four weeks of age.

So they can't walk in, sit down, and take the test, they've got to sit on mom's lap.

And we're trying to get a developmental level.

When you're doing these kinds of tests, you're trying to determine very early on if there's a developmental disability, because you can tell fairly early on.

And the earlier you know, the faster you can get the programs going.

And so you've got the infant sitting on mom's lap, and I do these tests, like for example, here's the test.

You hold a block, a red block and show it to them, if they look at it, they pass.

Then you put it down on the table, if they look at it they pass.

And then if they attempt to grab it, they pass, and then if they actually grab it, they pass.

So now they've got the block, I have another block.

I put it down.

If it occupies their attention they pass, if they attempt to grab it they pass, if they grab it they pass, and now they've got two blocks.

So now they have two block grabbers that are completely occupied, and I have a third block.

You follow what I'm saying here?

So this is a real problem.

I put that block down and they're looking at it.

They have no idea what to do next.

And what you're seeing is cognition developing in real time.

This is real problem solving.

And so sometimes they'll put one down, pick up the third block, and like ah, I'm right back where I started from.

This is all cool for me, I'm watching it like an anthropologist.

But the kid is distressed.

What I've got to worry about is that mother, she can't take it.

And I know she can pick up blocks.

I'm absolutely certain this woman is, she can probably pick up 20 blocks so I'm not testing her, I'm testing her infant, but she contaminates my test by nudging the kid.

I'm like wait, hey hey hey, hey.

We're trying to figure out something here.

It's her distress tolerance I've got to worry about.

Or like the patron saint of distress tolerance in the world of children is the mother of 12.

Absolutely.

So like a mother of one, a little sniffle, off to the ER we go.

Mother of 12, you break your arm, it's not a compound fracture, splint it yourself.

She knows when to hold them, when to fold them.

She knows when to intervene and when not to intervene.

She's only got so much energy for those 12 kids, and so she distributes it very beautifully and she's learned how to do that along the way.

And she's perfect for what I'm talking about.

And with that, let's take a break and there's snacks in the back.