As part of comprehensive ASD treatment, the overarching goal that must be kept in sight for all learners is a healthy quality of life. This approach to intervention begins at the moment of diagnosis or before, and continues far into late adulthood, the frontiers of which we currently know little about. As such, the question that should always be asked is whether a particular intervention, experience, or learning situation will ultimately play a role in improving a child’s quality of life, either in the moment or further down the road. Renowned early intervention (EI) programs that follow an evidence-based model, are typically rooted in applied behavior analysis (ABA) as it is broadly defined. This includes such approaches as Pivotal Response Training (PRT), Positive Behavior Support (PBS), and Discrete Trial Teaching (DTT).
To achieve the overall goal of improved quality of life, each of these programs include focused intervention and skill building that varies according to many factors including the child’s age, cognitive and language abilities, family goals, readiness and motivation, and the target person of the intervention (e.g., the child, parent, teacher, peer). What many of the programs have in common is the desire to build specific skills in general areas. If you were asked, “What are the most common, global, and important targets for intervention for young children with ASD?”, you would probably easily be able to generate a list of domains that the intervention programs focus on. This list would likely include cognitive development, communication, social skills, behavior (appropriateness), pre-academic s, adaptive skills, gross and fine motor abilities, and play and leisure.
While we strongly believe in the importance of each of these target areas, we routinely see youth in our practice who, despite have participated in intensive early intervention, are missing some very important skills, contributing to the difficulties for which their parents are seeking therapy. The general domain under which these skills fall is “emotional abilities.” Each of the comprehensive intervention programs incorporates some focus on emotions, however it is typically limited to identifying emotions in self and others by looking at photo cards of faces, or perhaps identifying situations that would cause someone to feel a particular way. A true emotions curriculum is extensive in both its breadth and depth, and is as important as each of the other target areas for intervention. At our clinic, we conduct an emotions assessment with each of our clients as part of beginning therapy. These assessments are very enlightening and provide us with a baseline of where to start therapy. For example:
Hilary (a composite case example) came to ASPIRE Center at age 7 because she was having daily meltdowns at home that were getting worse – more severe and lasting longer. She was also starting to break down at school. Hilary is a very bright young girl with an Asperger’s diagnosis who had participated in a highly reputable EI program and was in general doing quite well. She loves safari animals, and has a best friend from school. We learned that Hilary had been seeing a therapist for over a year to help with her outbursts, with reportedly no noticeable improvement. What was most surprising was that her emotional vocabulary was limited to “feeling good” and “feeling upset;” she was unaware what she did when she was feeling upset, or of how it felt in her body. When asked, she could not make an angry face unless she could look at herself in the mirror. Ultimately essential for being able to regulate one’s emotions and behavior, Hilary was unable to communicate what situations made her angry, which is essential for being able to regulate one’s emotions and behavior. We now had many initial goals to work on while we started therapy.
Hilary’s situation is not uncommon. In fact, we have teen and adult clients with whom we work who have a highly limited emotional skills set, even starting with matching emotions in pictures. And yet, much of the published research on emotions and ASDs has been limited to emotion recognition in facial expressions. What about the rest of an emotions skill set? Mayer and Salovey (1997) argue that there are four components to a fully developed emotions skill set. These include:
- Perceiving Emotions – detecting and deciphering emotions of both self and others across a wide range of stimuli (e.g., pictures, voices, sculpture). Perception is the foundation on which emotional intelligence is built, and is therefore a key skill to learn in early intervention.
- Using Emotions – being able to harness our emotions to facilitate cognitive activities such as thinking and problem solving.
- Understanding Emotions – comprehend an emotional vocabulary and understand the complex relationships amongst emotions (e.g., a girl going to her first day of camp is feeling both nervous and excited).
- Managing Emotions – this facilitates emotion regulation in ourselves.
Emotional skills are an essential target of intervention as they are highly connected to communication abilities, behavior, self-awareness and self-monitoring, social skills, well-being, mental health, and self-esteem. Data has shown that girls with ASDs as young as 2 years of age present with more sleep difficulties and depressive and anxious affect. By adolescence, many youth have full-blown depression and anxiety, and present with internalizing symptoms. Youth with ASDs, like Hilary, generally have difficulty regulating their emotions, and they frequently have a limited repertoire of coping skills. If emotional skills are a target of intervention during the EI years, it is possible that we may be able to prevent some of the challenges that emerge during childhood, and continue on into adulthood. A comprehensive EI emotions program would incorporate the following skills:
- Labeling primary (happy, mad, sad, scared) and secondary (surprised, disgusted, embarrassed) emotions across a wide range of stimuli to incorporate multisensory learning (e.g., puppets, music, drawing, acting, mirrors)
- Identifying a range of emotions (e.g., happy——ecstatic)
- Identifying what causes emotions in favorite characters in books or on television or in movies (e.g., why is Sponge Bob crying?)
- Identifying whether a display of emotion matches the severity of a situation (e.g., having a meltdown because a video game has to be put down at dinner time)
- Identifying the causes of their own emotions
- Beginning to identify their own emotion-based behavior in certain situations (e.g., runs away when angry)
- Being able to identify what goes on in their body when they feel a certain emotion (e.g., jittery stomach when anxious)
From here, you can begin to work on self-monitoring and the development of simple, concrete coping skills (e.g., breathing, counting, visualization, mantras), in addition to the more sophisticated skill of identifying thoughts, and linking those thoughts to feelings, situations, and behavior (early stages of cognitive behavioral therapy).
A recent study demonstrated that many youth and teens with ASDs (approximately 70%) develop a co-occurring psychiatric disorder, such as an anxiety disorder, or depression. Other youth present with sub-threshold symptoms, and difficulties with “life management” (poor coping skills, low frustration tolerance, self-regulatory difficulties, anger, poor problem-solving skills, and deficits in executive function: Gjevik et al., 2011).
If we are able to incorporate substantive skill-building in the area of emotions when kids are young, we are essentially facilitating strong emotion regulation skills as kids get older. Both external and internal supports are available in teaching emotion regulation. Early learners typically start with having external support (e.g., consistency in routine, scheduled breaks, clear calm communication, visuals, choice and control). As skills are taught, internal supports develop and more independence emerges (e.g., social skills, asking for help, problem-solving skills, relaxation and coping skills, being able to engage in cognitive restructuring).
The basics of identifying emotions creates the first step in the ladder towards independent self-regulation. Youth can’t self-regulate if they don’t know what they are feeling, if they don’t know what they do and how their body experiences a particular feeling, and if they don’t know what situations cause them to feel certain ways. By incorporating emotion skills as an essential component of a comprehensive EI treatment plan, providers are building the stage for self-esteem and self-efficacy, the ability to self-monitor, and ultimately the ability to regulate behavior and emotions. Youth as young as five years old have come to our clinic for emotion assessments and interventions in order to get ready to participate in cognitive behavioral therapy. Remember, it all starts with feelings.