Interoception as a building block for wellbeing – both physical & mental health require self-connectedness

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Dr Emma Goodall, Senior Autism Advisor, Disability Policy & Programs, Department for Education and Child Development, South Australia emma.goodall@sa.gov.au

Contents

What is interoception?How does interoception link to wellbeing: physical and mental health?Constipation, interoception and autismSelf & co-regulation success with interoceptionMental health and autism

SensoryThere are now known to be EIGHT sensory modalities:

6. Proprioception

7. Vestibular

8.

InteroceptionInteroceptive awareness (IA) can be broadly defined as the conscious perception of internal bodily cues such as heartbeat and breathing and is related to emotional experiences. Awareness of both biological and emotional internal body cues are affected in individuals on the autism spectrum (Schauder, Mash, Bryant, & Cascio, 2015, Mahler, 2016).

Implication – a lack of awareness or understanding of physical internal bodily cues for students may be a core factor in emotional overload, shutdowns, meltdowns and challenging behaviours as well as lead to decrease in wellbeing

External behaviours reflect internal states of being;

Communication – expresses needs/wants that arise from internal states of being

Actions, such as eating or drinking – fulfil internal needs/wants

The amygdala responds faster (than the conscious brain)

when driving survival behaviour.

Those decisions can be rational if emotions are balanced with logic orThey can be guided by our amygdala and be instinctual: This looks like survival behaviour

The ability to self regulate requires connection to self and wellbeing requires a positive connection to others

Wellbeing requires a positive connection to selfConnection to self requires interoception

Physical health

• Students/children/adults are not able to identify the physiological changes that signal mood changes or bodily self-regulation needs

• They do not know when they are starting to feel something –they just react when the electro/chemical bodily changes reach the biological imperative to act – fight, flight or freeze, void bladder/bowels, this damages relationships with others and feeds into the downward spiral of poor mental health.

Without good interoception…

Emotional intelligence as foundation to social-emotional skills

• Goleman (1995) suggested that labelling feelings is the first step in developing social-emotional skills

• However, without interoceptive awareness, it is not possible to notice the biological signals that indicate emotional state, and therefore not possible to label those feelings

• Perhaps low interoception is responsible for autistics difficulties in social-emotional skills

The Nest Project (GAWLER EAST)Is combining the explicit teaching of interoception to improve:• The awareness of students of their own emotions• The ability of students to monitor and respond to their emotions• The engagement of students in learning

With strategies from the UK that have been found to be the most effective strategies to promote inclusion in schools – flexible withdrawal spaces open to ALL students, whenever they need them.

The Nest – a flexible withdrawal space• Students who have yet to develop good interoception require

guidance and support to know when to go to the nest.

• Students MUST access the nest BEFORE they are ‘a 4 or 5 on the incredible 5 point scale’ – before the sympathetic nervous system cascade into fight/flight/freeze

• Students NEED to take their work with them, as the nest provides activities to connect to themselves (interoception or mindful body awareness) AND a space to engage with their work

How it works most effectively:• All students do the interoception activities for a few minutes at a time, as

part of their regular class on a regular basis – ie on arrival and before/after recess/lunch

• They learn the associated vocabulary (provided in the activities section of the Interoception 101 pack) and use it regularly

• Staff model the activities • Children/students are encouraged to reflect on what they are learning and

use it in new contexts (follow on activities are provided in the activities booklet)

• It is combined with a flexible interoception/work space to maximise effective inclusion

What happens:

• Classes visit Nest once as term as a class to revisit process

• Students do interoception activities as whole class activities daily (as decided by each site)

• Students can request or be given a ‘Nest pass’, which they take to the Nest, with their work

• Student arrives in the Nest and takes an interoception activity card to do (or is guided to do an interoception activity) and does this in the quiet end of the rom

• Once ready to work, student does their work at the classroom end – adult support as needed

• Students can ask or are prompted to return to class when they have completed their work. If they choose to remain they do additional interoception activities around feelings (with photos)

Managing stress fight or flight video clip

Activity

Have a go at one of the activities:

Feeling – hand musclesFeeling – muscles (hands)

Sitting down, just rest your hands on the top of your thighs (demonstrate)

Now stretch your fingers as wide apart as possible and hold them tense like that for 30

seconds

Rest them back again, now they should be relaxed

Where could you feel your muscles when your hands were stretched?

Image – hand relaxed, resting on thighs Image - hand stretched out

Image – hand relaxed, resting on thighs

Image - hands stretched out with big question

mark

What was the point of that?Children/students who are yet to or still developing their sense of interoception may not know how to feel the difference between relaxed and tense muscles. This can lead to difficulties in writing for example when the pen/pencil is gripped to hard resulting in pain &/or tiredness whenever the child/student writes which can lead to work refusal.

What are the implications for children of:

Poor interoceptive awareness of muscle state?

How could this impact on low muscle tone?

Why do so many autistic children have low muscle strength in their core muscles?

What about hyper awareness of muscle tension or pain?

Memecenter.com

The parasympathetic (calming down) and sympathetic (fight/flight/freeze) systems cannot be active at the same time. The sympathetic system is activated by the excitatory neurotransmitter noradrenaline in the brain, whilst the parasympathetic system is activated by the inhibitory neurotransmitter acetylcholine.

Constipation – the scourge of autism

• How do you know you (or your child) are constipated?

• What if they have poor interoception and/or severe anxiety?

What are the implications of chronic constipation?

• On wellbeing?

• On ability to develop optimally?

• On levels of attention?

• On behaviour?

Activity – finding a pulse• Your pulse can be found physically or using technology

• Children/students/adults can learn about the variations in pulse signalling different states.

• Please find you pulse and note it down. Then please engage in vigorous activity for 1 minute and retake your pulse. Note this down….

What was the point of that?

Children/students who are yet to or still developing their sense of interoception may not know how to feel their pulse or heart rate. If they can learn to do so, they can monitor it and use it as a guide for some of their emotions. For example, they may find that when their heart rate is up and they have not exercised, it is a signal to engage in an interoception activity and this may prevent rage from building uncontrollably.

Benefits of learning interoceptionWhat students say:

• Doing interoception helps me feel better

• I can do my work more

• It helps me calm down then I can go back to class

• When my pulse is fast I know I need to slow it down. I can learn better when my pulse is slower.

• My head is tight when I am angry, now I know how to relax it again

Benefits of teaching interoceptionWhat teachers say:

• The students get back to work quicker.• There are less disruptions in class.• I am more aware of why things happen.• It is easy to teach and the kids love it. • It has freed up time for me to focus on things other than

behaviour.• Now I know why the 5 point scale didn’t work, … just had no idea

how he felt until it was too intense to manage.• It teaches kids to get to know when they are getting angry, so

they can start to learn how to control their anger

We have to know we are getting angry in order to be in control of our anger…

Anger.wmv

Why should we teach interoception?• To help children/students connect to and learn to

understand their own bodies and emotions

• Because it is a pre-requisite skills for self-regulation, it provides children/students with the tools to know when they are developing emotional reactions and the skills to be in control of those reactions

• Without interoception social skills are just the application of rules and not a meaningful way of interacting – it enables students to develop a sense of belonging

• Classrooms where it is being taught have decreasing behavioural challenges and those where it is not have static or increasing behavioural challenges (school wide behaviour reporting analysis)

1 2 3 4 5 6 7 8 9 10 11

Term 1 47 0 73 53 100 53 47 67 0 33 60

Term 2 75 73 93 67 100 100 87 100 0 6 81

Term 3 0 0 53 100 100 100 87 0 87 73 81

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)Levels of Engagement per student - Interoception Trial Gawler East

Primary School

Term 1 Term 2 Term 3

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Term 1 Term 2 Term 3Nu

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Levels of interoception

None Some Good

• n.b. 3 students transferred prior to term 3 data being collected.

• No student decreased levels of interoception – measured using

• Qualitative interviews and the DECD Interoception tracking sheet.

Where the stress levels increased in term 2 this was due to a significant increase in self-awareness of challenges in managing self and interacting with peers.For student 6, this increase in awareness took place in term 3 when he re-engaged with his class as in term 2 he refused to stay in class.

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MEDSAS incident reporting - Interoception Trial Gawler East Priamry School

for 6 students with a history of complexity enrolled durign term 2.

Term 2 Term 3

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INTEROCEPTION LEVELS IN TERM 2

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INTEROCEPTION LEVELS IN TERM 3

NONE SOME GOOD

Types of behaviour Increase or decrease AFTER 8 weeks

(quantitative)

Increase or decrease AFTER 2 terms

– qualitative evidence

Sustained off task

behaviour

50% DECREASE Continued decrease

Major disruption of class

learning

80% DECREASE – across school Continued decrease EXCEPT in the 3

classes not teaching interoception.

Students request interoception in

order to facilitate learning

Yard incidents reported 51% DECREASE Continued decrease and increase in

kind and pro-social behaviours

Time to settle down to

work after recess

60% DECREASE In all classes that use interoception

after recess, work is able to commence

immediately after interoception

activity

On task/engaged in

learning

Individual variations, but all significantly

increased

Student requiring 1:1 no longer

requires 1:1, all other students

increased on task/engagement in

learning

SUMMARY OF CHANGES IN BEHAVIOURS OVER TERMS 1 & 2 & 3 Interoception trial at Gawler East Primary School

Mental illness/health – a continuum

• There is a much higher incidence of mental illness amongst children/young people/adults on the autism spectrum

• Contributing factors are: low levels of self awareness/connection (poor interoception), lack of a sense of belonging, feelings of alienation, fixated thinking, perfectionism, lack of sleep, increased incidences of bullying, sensory overload…. (Purkis, Goodall, Nugent, 2016)

Implications• Children and students on the autism

spectrum are vulnerable to mental health difficulties (Humphries, 2015)

• Any extra negative stress increases the likelihood of short and long term issues

• Eating disorders are more prevalent among this group

• Gender and sexuality are more diverse within this group than in society at large (Goodall, 2016)

• Transgender and gender fluid and non-heterosexual high school students are more at risk of bullying and mental illness (Berlan et al. 2010)

Medication and talk therapy reactions tend to be atypical for those on the autism spectrum

• Much lower or much higher doses of medications are often required (as with patients with ID)

• Literal interpretation of language and sensory issues can make talk therapy problematic

AHMED, Z., FRASER, W., KERR, M.P., KIERNAN, C., EMERSON, E., ROBERTSON, J., FELCE, D., ALLEN,

D., BAXTER H., & THOMAS, J., (2000) Reducing antipsychotic medication in people with a learning disability,

BJP , 176:42-46.

What works?• Learning not to overthink repeatedly – ie to be in the moment

• ACT (not the place) – to accept non-judgementally

• To learn to connect to self – interoception

• To gain a positive sense of self – join the autistic community, make and keep friends, gain a sense of value

• To learn practical self care strategies – being nice and kind to self, eating well, staying hydrated.

http://www.unh.edu/health-services/ohep/emotional-wellness

ReferencesAHMED, Z., FRASER, W., KERR, M.P., KIERNAN, C., EMERSON, E., ROBERTSON, J., FELCE, D., ALLEN, D., BAXTER H., & THOMAS, J., (2000) Reducing antipsychotic medication in people with a learning disability, BJP , 176:42-46.Clarke, T-K Lupton, M K Fernandez-Pujals, A M Starr, JDavies, G Cox, S Pattie, A Liewald, D C Hall, L S , MacIntyre, D J Smith, B H Hocking, L J Padmanabhan, S Thomson, P A Hayward, C Hansell, N K Montgomery, G W Medland, S E Martin, N G Wright, M J Porteous, D J Deary, I J McIntosh. A M Common polygenic risk for autism spectrum disorder (ASD) is associated with cognitive ability in the general population. Molecular Psychiatry, 2015; DOI: 10.1038/mp.2015.12Goodall, E., (2013) Understanding and facilitating the achievement of autistic potential, Create Space, SC.Grandin, T. (2015) Autism & My Sensory Based World –presentation at Irabina, MelbourneGunn, K. C., & Delafield-Butt, J. T. (2015). Teaching Children With Autism Spectrum Disorder With Restricted Interests. A Review of Evidence for Best Practice. Review of Educational Research, 0034654315604027.Humphrey, N., Bond, C., Hebron, J., Symes, W. & Morewood, G. Autism and education. London: Sage, 2015. eScholarID:270565Mahler, K. (2016) Practical Solutions for Improving Self-Regulation, Self-Awareness and Social Understanding of Individuals With Autism Spectrum and Related Disorders, AAPC Publishing, KansasPurkis, J., Goodall, E. & Nugent, J., (2016) The Guide to Good Mental Health on the Autism Spectrum, Jessica Kingsley Publishing, London.Schauder, K.B., Mash, L.E., Bryant, L.K., Cascio, C.J., Interoceptive ability and body awareness in autism spectrum disorder, Journal of Experimental Child Psychology, Volume 131, March 2015, Pages 193- 200, ISSN 0022-0965, http://dx.doi.org/10.1016/j.jecp.2014.11.002.