Low arousal approaches

The philosophy of low arousal approaches is one of non confrontation. In high risk situations responses which reduce physiological arousal are adopted by carers and staff especially when confronted by distressed individuals. These approaches became popular in services for people with intellectual disabilities in the UK in the mid 1990’s. This humanistic and person centred approach to crisis management was developed in response to the use of restrictive responses to crises such as restraint, seclusion and chemical restraint. The avoidance of sanctions and of consequence based punishment strategies became an implicit part of the approach.

Definition

A number of different strategies are employed in healthcare settings for the management of challenging behaviour. McDonnell, McEvoy & Dearden, (1994) introduced a theoretical rationale for a collection of short-term non-aversive behaviour management strategies described as low arousal approaches. These avoid the use of punishing consequences to behaviour. A low arousal approach:

"“attempts to alter staff behaviour by avoiding confrontational situations and seeking the least line of resistance.”"(McDonnell, Reeves, Johnson & Lane, 1998, p164.)

The approach acknowledges the potential role of cognitive behavioural frameworks in shaping staff behaviour. There are four key components considered central to low arousal approaches, these include both cognitive and behavioural elements.

1.Decreasing staff demands and requests to reduce potential points of conflict around an individual.
2.Avoiding potentially arousing triggers e.g. direct eye contact, touch and removal of spectators to the incident.
3.Avoidance of non-verbal behaviours that may lead to conflict e.g. aggressive postures and stances.
4.Challenging staff beliefs about the short-term management of challenging behaviours.

Evidence

Few studies have been published which examine directly the application of these approaches. McDonnell, et al, 1998, reported a single case study following the application of low arousal approaches with an adult with an Intellectual Disability in a hospital setting. A significant reduction in verbal and physical aggression was reported.

The link between autism and physiological arousal.

Physiological arousal is not a new construct and was originally proposed as an explanatory theory for autistic spectrum disorders (Hutt, Hutt, Lee and Ounsted, 1964). Two implications of this theory is that children and adults with an ASD would be more reactive to sensory stimuli than the normal population and that they may be slower to habituate to stimuli. There is some laboratory evidence of differences in physiological responses of individuals with ASD compared to non autistic controls (Althaus, van Roon, Mulder, Mulder, Aarnoudse and Minderaa 2004; Hirstein Iversen and Ramachandran 2001; van Engeland, Roelofs, Verbaten and Slangen, 1991) Goodwin, Groden, Velicer, Lipsett, Grace Baron, Hoffman and Groden, (2006) reported higher baseline heart rates of five autistic children compared to non autistic controls. Hirstein Iversen and Ramachandran (2001) reported unusually high and unusually low baseline skin conductance responses in autistic children compared to non autistic controls. These differences require replication using larger samples, although there is an intriguing possibility that there may be considerable variation in physiological reactivity of both autistic children and adults.

Hyper or hypo-arousal?

Hyper-arousal is not universally accepted by all researchers. A recent review of sensory difficulties in autism concluded that the experimental evidence or hyper-arousal was at best mixed (Rogers and Ozonoff, 2005). There are a number of problems with this view. First, ASD is a heterogeneous condition and the assumption that hyper-arousal should be a general explanatory theory of autism was too broad. Second, sensitivity to arousing stimuli may be intermittently presenting in individuals with ASD. Third, the stimuli employed in habituation paradigms cannot easily mimic real life non laboratory based events. Animal research on arousal has attempted to link deficiencies to conditions such as ADHD, Alzheimer’s disease and autism (Garey, Goodwillie, Frohlich, Morgan, Gustafsson, Smithies, Korach, Ogawa and Pfaff, 2003)Historically under-arousal in people with an ASD has also been proposed as a factor to specific stimuli (Rimland, 1964; DesLauriers and Carlson, 1969) although with limited laboratory evidence (Rogers and Ozonoff, 2005). Repetitive movements may serve a dearousing function (Kinsbourne, 1980). Unusual sensory experiences have been reported in autobiographical accounts of people with an ASD (Shore, 2003; O’Neill and Jones, 1997). Sensory over-activity has been explained as a possible response to over-arousal (Liss, Saulnier, Fein and Kinsbourne, 2006). An understanding of physiological arousal and sensory experiences may have great explanatory significance for some forms of challenging behaviours.

tress and physiological arousal.

Stress and anxiety has been proposed as a factor in challenging behaviours of people with ASD (Howlin, 1998; Groden, Cautela, Prince and Berryman, 1994). Lazarus and Folkman (1984) described a transactional model of stress that emphasized the interaction between an individual and his/her environment. In this model stress occurs when the demands of stressors outweigh coping responses. There is a clear interaction between environmental and physiological events. Implicit in this model is the cognitive appraisal of threat. Some individuals with an ASD have difficulties in regulating their emotional responses and even communicating this to carers (Frith, 2003). To help account for challenging behaviours such as aggression and self injurious behaviours we propose that physiological arousal may mediate stress. There does appear to be a strong association between physiological arousal and sensory experiences of people with ASD (Liss et al. 2006). A model of arousal which mediates certain forms of challenging behaviours could provide a useful explanatory framework. A central premise of this model is that an individual’s internal physiological state of arousal influences cognitive processing of environmental sensory stimuli. Extending this view we would contend that the regulation of arousal mediates behavioural responses to environmental stressors. Individuals seek a state of arousal equilibrium; that is the optimum individual arousal level required for an individual to function in an environment; this is similar to the bodily state of homeostasis. We propose that arousal be thought of in three distinct areas of a Gaussian curve. (See Figure 1)

Figure 1: The Arousal Curve and Information Processing

The majority of individuals spend time in a state of arousal equilibrium. In the case of people with an ASD, two distinct arousal groupings will have an effect on behaviour, both appear in the tail end of the arousal curve.. A group of individuals will be hyperaroused and highly reactive to environmental sensory stimuli (Liss et al. 2006). At the opposite end of the distribution a proportion of people are hypoaroused. A number of people with ASD who present with challenging behaviours may experience either constant or intermittent states of hyperarousal.

External links

* [http://studio3.org/research/chapter8n.htm Research Article 1]
* [http://studio3.org/research/low_arousal_approaches.htm Research Article 2]
* [http://studio3.org/members/showthread.php?t=265 Workshop]

References

*Althaus, M., van Roon, A.M., Mulder, L.J.M., Mulder, G., Aarnoudse, C.C., and Minderaa, R.B. (2000). Autonomic Response Patterns Observed during the Performance of an attention Demanding Task in two groups of Children with Autistic-Type Difficulties in Social Adjustment. Psychophysiology, 41, 893-904.
*Deslauriers, A. M. & Carlson, C. F. (1969). Your child is asleep: Early infantile autism. Homewood, IL: Dorsey Press;
*Frith, U. (2003). Autism Explaining the Enigma. (2nd Edition Oxford: Blackwell.
*Garey, J., Goodwillie, A., Frohlich, J., Morgan, M.,Gustaffson, J.A., Smithies, O.,. Korach, K.S.,Ogawa, S., and Pfaff, D.W. (2003) Genetic Contributions to Generalized Arousal of Brain and Behavior. Proceedings of the National Academy of Sciences of the United States of America, 100, 11019-11022.
*Goodwin, M.S., Groden, J., Velicer, W.F., Lipsitt, L.P., Grace Baron, M., Hofmann, S.G., and Groden, G. (2006). Cardiovascular Arousal in Individuals With Autism. Focus on Autism and Other Developmental Disabilities, 21, 100-123.
*Groden, J., Cautela, J., Prince, S., and Berryman, J. (1994). The Impact of Stress and Anxiety on Individuals with Autism and other Developmental Disabilities. In E Schopler and G Mesibov (Eds.) Behavior Issues and Autism. New York, Plenum Publishing.
*Hirstein, W., Iversen, P and Ramachandran, V.S. (2001). Autonomic Responses of Autistic Children to People and Objects. Proceedings. Biological Sciences/ The Royal Society
*Howlin, P. (1998). Children with Autism and Aspergers Syndrome: A Guide for Practitioners and Carers. Chichester: Wiley.
*Hutt, C., Hutt, S.J., Lee, D., and Ounstead, C. (1964). Arousal and Childhood Autism. Nature, 204, 908-909.
*Kinsbourne, M. (1980). Do Repetitive Movement Patterns in Children and Animals Serve a Dearousing Function? Developmental and Behavioral Paediatrics, 1, 39-42.
*Lazurus, R. S., & Folkman, S. (1984). Stress, Appraisal, and Coping. New York: Springer.
*Liss, M., Saulnier, C., Fein, D, and Kinsbourne, M. (2006). Sensory and Attention Abnormalities in Autistic Spectrum disorders. Autism, 10, 155-172
*McDonnell, A.A. Waters, T. and Jones D. (2002). Low Arousal Approaches in the Management of Challenging Behaviours. In D. Allen (Ed) Ethical approaches to physical interventions: Responding to Challenging behaviours in people with Intellectual Disabilities. Plymouth: BILD, pp. 104 – 113.
*McDonnell, A. A., McEvoy, J and Dearden, R.L. (1994). Coping with Violent Situations in the Caring Environment. In T. Wykes (Ed) Violence and health care professionals. London : Chapman and Hall, pp. 189-206.
*McDonnell, A.A., Reeves, S., Johnson, A., and Lane, A. (1998). Management Challenging Behaviours in an Adult with Learning Disabilities: the Use of Low Arousal. Behavioural and Cognitive Psychotherapy, 26, 163 – 171.
*O’Neill, M. & Jones, R. S. P. (1997). Sensory Perceptual Abnormalities in Autism: A Case for More Research. Journal of Autism and Developmental Disorders, 27(3), 283-293.
*Rimland, B. (1964). Infantile autism, New York: Appleton Century Crofts.
*Rogers, S.J & Ozonoff, S. (2005). What Do We Know About Sensory Dysfunction in Autism? A Critical Review of the Empirical Evidence. Journal of Child Psychology and Psychiatry, 46, 1255-1268.
*Shore S. (2003). Beyond the Wall: Personal Experiences with Autism and Asperger Syndrome: Autism Asperger publishing company.
*Van Engeland, H., Roelofs, J.W., Verbaten, M.N., and Slangen, J.L (1991). Abnormal Electrodermal Reactivity to Novel Visual Stimuli in Autistic Children. Psychiatry Research, 38, 27-38.