the minding anxiety project m a p - division of student … minding anxiety project laurence i....

Investing in Autonomic Balance for Students with Autism:

The Minding Anxiety Project

Laurence I. Sugarman MD FAAP ABMHDirector

Center for Applied Psychophysiology & Self-regulation (CAPS) Research Professor

College of Health Sciences & Technology Rochester Institute of Technology

Clinical Associate Professor in Pediatrics Department of Pediatrics, University of Rochester

Behavioral PediatricianEaster Seals Diagnostic and Treatment Center

M A P

• A bit about autonomic dysregulation, autism and biofeedback.

• Our initial experience with and plans for the Minding Anxiety Project.

• Your experiences, questions, ideas.

What are We Exploring Here?

General then focus

A funny thing happened on the way to the office

• Solo primary care practice 1986

• Struggling with “New Morbidities” 1990

• Integrating hypnosis and biofeedback as psychophysiological self-regulation strategies 1993

• Primary focus of clinical work since 2007

• CAPS @ RIT 2010

Driving innovation in health and care by helping

people help themselves.

Focus on Autism

• Emerging, growing prevalence and morbidity

• Gap between talents and expression

• Trance-like behavior coupled with attempts to self-regulate anxiety

• Compelling puzzle...that might respond really well to efforts to help them help themselves

• ...and validate these kinds of interventions.

N clickthird bullet...”the experience of being neurodiverse - having an autistic lens- ...

Social Attachment

QualitativeLanguage

CognitiveFlexibility

Anxiety

ProsodyCreativityFluencyNonverbal

ReciprocityShared attentionEmpathy“Theory of mind”

RRB Obessessions PerseverationNarrowed interests“Systemization”

Emergentor

Foundational?

Focus on Autism“Syndrome”

Social Motivation, Mirror

neurons

Executive functioning, Conectivity

Connectivity, Information processing

begs for a unifying theory...is anxiety a clue?

Focus on AutismAutonomic Dysregulation

Social Attachment

QualitativeLanguage

CognitiveFlexibility

Anxiety

ProsodyCreativityFluencyNonverbal

ReciprocityShared attentionEmpathy“Theory of mind”

RRB OCD PerseverationNarrowed interests“Systemization”

Autonomic Regulation

Anxiety

Foundational?Arousal or Autonomic

Dysregulation Theory

“Autonomic Balance”Animated Graphics by Megan Kushner, RIT IGM Student

Autonomic Dysregulation in AutismAnimated Graphics by Megan Kushner, RIT IGM Student

Evidence for “Autonomic Apraxia” in Autism

• Male predominance Dart, et al (2002). Gender, sex hormones and autonomic nervous control of the cardiovascular system. Cardiovascular Res, 53, 678-687.

• Elevated “resting” sympathetic tone Toichi, M & Kamio, Y. (2003). Paradoxical autonomic response to mental tasks in autism. Journal of

Autism and Developmental Disorders, 33, 417-426. Ming, X., Julu, P.O.O., Bromacombe, M. Connor, S. & Daniels, M.I. (2005). Reduced cardiac parasympathetic activity in children with autism. Brain and Development, 27, 509-516. Kennedy, D.P., Redcay, E. & Courchesne, E. (2006). Failing to deactivate: Resting functional abnormalities in autism. PNAS, 103, 8275-8280.

• Frequency of sensory sensitivity Kenet, T. (2011). Sensory functions in ASD. In D.A. Fein, (Ed.), Neuropsychology of Autism (pp. 215-224.). New

York: Oxford University Press.

• Pervasiveness of stress, anxiety and OC behaviors Romanczyk, K. & Gillis, J.M. (2006). Autism and the

phsyiology of stress and anxiety. In M.G. Baron, J. Groden, G. Groden, L.P. Lipsitt (Eds.), Stress and coping in autism (pp. 183-204). New York: Oxford University Press.

• RRB’s consistently lower sympathetic tone Kinsbourne, M. (1980). Do repetitve meovement patterns in children and

animals subserve a dearousing function? Journal of Developmental and Behavioral Pediatics, 1, 39-42.

• Dysfunctional deactivation of the “default network” Lombardo, M.V. et al (2009). Atypical neural self-

representation in autism. Brain: doi:10.1093/brain/awp306. Kennedy, D.P., Redcay, E. & Courchesne, E. (2006). Failing to deactivate: Resting functional abnormalities in autism. PNAS, 103, 8275-8280. Buckner, R. L., Andrews-Hanna J.R. Schacter, D. L. (2008). The Brain’s Default Network Anatomy, Function, And Relevance To Disease Ann. N.Y. Acad. Sci. 1124: 1–38 (2008).

• Polyvagal Theory: links autonomic balance to emotional/social development Porge, S.W.. (2011). The polyvagal theory. Neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York: W.W. Norton.

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Therapeutic Implications of Autonomic Dysregulation

Restrictive Repetitive Behaviors (RRB)

are “Trance”

Teaching Autonomic Regulation with BF

ought to help

Save this for a workshop on hypnosis.

Focus on this.

Click the lines

Effects of Self-Regulation TrainingAnimated Graphics by Megan Kushner, RIT IGM Student

Reasons to Treat “Autonomic Apraxia” with

computerized autonomic biofeedback

• Young people with autism relate to & learn best from computerized interactions- limited, structured role-playing- controlled pace of processing information- apply virtual models to real world

• Operant conditioning does not require social, cognitive interaction- can be used with no or limited verbal ability

• Builds rapport with common interest- hardware and software are the primary engagement- therapeutic rapport follows, but is not the focus

Tools forTreating “Autonomic Apraxia” with

computerized autonomic biofeedback• Systems

- MindMedia’s NeXus/Biotrace system - Heartmath’s emWave

• Inputs- skin conductance level- peripheral skin temperature- respiratory rate- LF range heart-rate variability

• Feedback- graphs- puzzles- games

Click each heading.

Limitations in Treating “Autonomic Apraxia” with

computerized autonomic biofeedback

• The autonomic proxies (sensor inputs) have to be valid, discernible and controllable by the user

• Operant conditioning has to be effective

• The user must be motivated to generalize it beyond the biofeedback lab.

RespHR

SCL

LF HRV

ControllingDiscerning

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The Minding Anxiety Project

MAP

The MAP TeamJohn Weas

Counseling Center DirectorAssistant to the VP for Student Affairs

Mark MilesDirector of Counseling

Brian GarrisonCAPS Research Coordinator

Anna Hope Intern

Bill DestlerPresident, Inspirateur

Initial Map Funding

The Golisano Foundation

The Douglas Flutie, Jr. Foundation for Autism

MAP The minding anxiety project

• A pilot service project through RIT’s Counseling Center

• Provide matriculating students with autism training in how to self-regulate autonomic balance.

• Aimed at increasing Heart Rate Variability in Low Frequency Range (LF-HRV) and achieving self-selected goals

• Track progress onward to Coops, Graduation, Work

MAPInitial Recruitment

• 75 identified students with ASDs through the Student Affairs office...probably less than 5% of RIT population affected

• Spectrum Program with food

• Presentations to Counseling Center Staff

• Ads in The Reporter, student run magazine

• March 2011-2012

20

MAPRecruitment Lessons

• It is really hard to get students with conditions that result in social withdrawal to participate...in anything!

• Those students who DO participate are ready for change

• We need to broaden the focus beyond ASDs

• Duh

MAPInterventions

• AMAS-C, TSCS:2, (ADOS)

• Introduction to the nature of anxiety, brain-body connections and self-regulation of both

• Exposure to SC, Resp, HRV monitoring and biofeedback (NeXus/Biotrace, EmWave)

• Practice with self-selected modalities - EmWave PSR for independent use

• Integrating hypnosis then self-hypnosis

• Integrating that experience proactively into daily life

MAPInterventions, continued

• Weekly visits

• Review progress, challenges, adaptations

• Self-monitor progress towards selected goals

• Practice and altere self-regulation exercise

• Repeat AMAS-CE, TSCS:2 every 4 visits

• Ongoing tracking

MAPPreliminary ResultsEarly Trends, Small N,

No Statistical Significance...yet.

Goals Selected

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101214161820

Self Sleep Eating Class Social Attn Work Other

Par

ticip

an

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ng

00.51.01.52.02.53.03.54.04.55.0

Self SleepEatingClassSocial Attn Work Other

Self R

ati

ng

(0

-7)

SELECTED GOALS: SUCCESS

Selected Goals: Success

0

1

2

3

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6

7

SessionFirst Most RecentA

ver

ag

e o

f S

elf-R

ati

ng

s (

0-7

)

TSCS2: Self Concept

50.00

54.75

59.50

64.25

69.00

Session 1 Session 5

To

tal S

elf C

on

cept

(Per

cen

tile)

Bef

ore

Afte

r

AMAS-C: Anxiety

50.00

54.75

59.50

64.25

69.00

Session 1 Session 5

To

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Per

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Afte

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Respiratory Rate

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.10 Hz

Heart Rate Variability (HRV)

Hz

ms2

Area is %

Peak is “Power”

HRV Power

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SessionFirst Most Recent

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s2

/Hz)

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-10

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Change in HRV LF%

Δ HRV LF% & Δ SC

-20

-10

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Ch

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Change in HRV LF%

MAPToday & Tomorrow

• Mental Health Counseling Intern

• Standardized recording procedure

• Testing a novel, auto-adjusting, dynamic feedback signal set (DyFSS)

• Refined & enlarged set of goals• Personal• Social• Academic

• Prevention• Focused effort to anchor skills with daily triggers

Big Next Steps• Further formulate the protocol so that it is exportable.

• Develop training program.

• Create collaboratives.

• Further research on effects of changing autonomic regulation on phenotype

• Make a bigger investment in these remarkable people.

Would you like to join us?

Ques-ons? Answers? Ideas?

lisdsp@rit.edu

thank you.

• “IMPs” represent idealized self and the RRB

• Played with the clinician

• Generates usable data, motivation and conditioning

MindGamers™

• Therapeutic, physiologically-controlled, customizable, role-playing videogame for young people with RRBs

• Dynamic Feedback Signal Set (DyFSS) creates an optimum physiological fit for the physiological controller

• Avatars represent the player