Health & Psychology

The most frequently asked question “How are you feeling?” is a difficult one to answer

Imagine you are driving towards work, suddenly you have a very itchy foot, and you want to scratch it, but you cannot. Your hands are glued to the steering wheel while your feet are on the pedals. Your whole body is stiff, and it is impossible to move and therefore to scratch. The more you think about it, the worse the itchy feeling gets. You arrive at work, still unable to scratch and at the same time someone is putting bright lights on you while the construction site next to you is making so much noise that you can barely hear what your boss is saying. Now, how would you feel? Some of us would say frustrated, uncomfortable, or angry. Because we are neurotypical adults, we have learned over the years what the triggers are for our feelings i.e., itch, light, and noise. We have also learned how to self-regulate those feelings by doing an activity that would make us feel better such as “having a cup of coffee first” or “venting to your colleagues about your awful morning”.  

Self-regulation is being able to control your own emotions according to the triggers provided from the environment or from within yourself. For most neurotypical children this process develops naturally during their childhood. Neurodiverse children may struggle to notice their own body signals. Their body feels uncomfortable, but they cannot tell you why. Now, think back on how you desperately wanted to scratch your foot when you could not. You would try to move heaven and Earth just to scratch your foot for 1 second because you know that this action will make your body feel more comfortable. 

Besides struggling to notice their own body signals, they also struggle to connect these signals to the right emotion(s). As parents, we can see when our children are getting too excited or getting frustrated, but they will not accept that we tell them so because they cannot relate to the word “excitement” or “frustration”. These words do not mean anything to them as they do not know how to match the word with the right body signal and therefore the feeling. When it all becomes too much, those children cannot self-regulate by doing something that makes them feel better. The consequence, well you can guess it right? A full-blown meltdown.  

How do we know when a child cannot self-regulate or is having just a tantrum?  

Sometimes this is very clear when a teacher touches the child to guide the child to its place and the child starts to scream and shout. The external trigger is the touch, the body signals are too big for the child, and gets overwhelmed. The child cannot use his/her/them words because he/she/they did not learn how to notice and connect this body signal to the right emotional state and the brain is taken over by anxiety. We need to be able to catch the anxiety before the child has a meltdown. This is done by teaching them how their body feels. 

When the triggers are external such as visuals, sounds, tastes, smells, and touch. We, as parents, can recognise those and can help co-regulate the child. Either by removing or reducing the external triggers or teaching the child how to connect body signals to emotions and to take action.  

But what about our itchy feeling? Those body signals such as hunger, thirst, full bladder, sickness, itch, etc… are internal body feelings and are not so easy to detect as a parent. Most parents can make an educated guess. For example, when you pick up your child from school and it is getting upset, we can “guess” that he/she/they might be hungry, so we give him/her/them a snack. We call this being HANGRY. I bet you heard this term before but maybe did not make the whole connection to why we called it that way.  

Children remain children, so both neurotypical and neurodiverse children can throw a tantrum. This is kicking and screaming to get attention from a parent that is busy at that time or to get that colourful candy at the cash register of the supermarket for example.   

Can you see how an “attention” tantrum or a meltdown due to internal body signals can seem similar to parents or caregivers? To be able to distinguish between the two, we need to investigate more about the body-emotion connection which we call interoceptive awareness (IA). 

What does science tell us about interoception? 

Children who struggle to self-regulate might struggle with interoceptive awareness. They need to be able to first NOTICE those body signals and then CONNECT them to the correct emotional state. If you ask those children “how do you feel?” they cannot reply accurately because they do not recognise or misinterpret the amplitude of these signals. There are three possible scenarios. 

First, they might be able to recognise a general feeling of comfort or discomfort but cannot relate it to a certain homeostatic emotion such as hunger, sickness, nausea, or constipation. 

Second, if they can recognise basic emotions such as jealousness or anger, they are unable to determine the intensity of those emotions.

Finally, they might be unable to recognise other emotions that go together with a basic emotion. For example, excitement and nervousness.

For those children, their body signals are either too big, too small, or distorted and we describe this as having an unclear interoceptive awareness or unclear body-emotion connection. 

When the body signals are too big, the feeling is so strong and overwhelming as too many signals are arriving all at once in the brain. When they are too small, those signals still arrive at the brain but go completely unnoticed. And last, when body signals are distorted, they can feel something but are unable to locate where that body signal comes from. Recognising the way our body feels by connecting the body signal to the emotion is what motivates purposeful self-regulation behaviours (Strigo and Craig, 2016; Fustos, et al., 2012; Jackson et al., 2011). 

Can we increase our interoceptive awareness? Yes! Currently, the only evidence-based method that can increasing IA is mindfulness, to be in the moment and to notice your breath, heartbeat, etc… 

Well here comes the problem, did you ever try mindfulness? 

For adults, this is a great way to relax our bodies, but it takes practise, and even when we are doing mindfulness every day, our minds might wander off again because we have so many things to do that day. When using mindfulness with children how do we know for certain that they are paying attention to their breath? Or is their mind in some alternative world fighting monsters? There is a mismatch between cognition and attention for children. Another problem with mindfulness is that it is thought implicit while most neurodiverse children need explicit instructions. 

Kelly Mahler, an occupational therapist from the US, has created the interoception curriculum which is derived from mindfulness strategies but adapted in such a way that it is visually and verbally presented, more concrete, playful, engaging and checks for understanding. The explicit instruction and systematic organisation into categories build into the bigger picture of the whole body and the emotional states. It serves as an antecedent-based intervention for modifying behaviour and focus a promoting positive feelings. For more information check her website: www.kelly-mahler.com. 

How is self-regulation done within the school setting? 

Unclear interoceptive awareness is commonly linked to several conditions and disorders such as Autism Spectrum Disorder (ASD), Attention Deficit (Hyperactivity) Disorder (ADHD), Obsessive Compulsory Disorder (OCD), Sensory Processing Disorder (SPD), anorexia, Post-Traumatic Stress Disorder (PTSD), anxiety, depression, etc…(Shah, 2016). 

Those persons are reliant on other people to help them regulate. Yes, parents this is where you are trying to talk your child down when it gets too much for them, but this is also where interoception comes in. It will close the gap between regulation by others and self-regulation. 

Now when we are looking at schools, how many strategies and IEP goals do we have for: 

  • Reduce challenging behaviours? 
  • Decrease anxiety and emotional dysregulations? 
  • Decrease sensory difficulties and rigid thoughts or compulsive behaviours? 

And how many strategies do we have for: 

  • Increase happiness in school? 
  • Increase the feeling of safety and accomplishments within the school? 

Teachers have been asked to observe and record when students have a verbal outburst, avoidance behaviour, physical aggression, etc… but how many have been asked to record whether the child is smiling or happy? Most of you can answer these questions. I think it is time to move on from fixing behaviours or decreasing certain behaviours by promoting positive feelings and emotions. When we focus on the positive, the unwanted behaviours will decrease over time as a by-product.  

Children with any given label in school such as ASD, ADHD, etc… will receive Emotion Recognition Training (ERT) and Theory of Mind (ToM) training to learn how to self-regulate and to be able to understand the emotional state of others. 

But what about their OWN theory of mind? Should the child not be thought to notice their OWN body signals and emotions before learning how to recognise other people’s emotions? Do not get me wrong, the ToM could be useful but not before the child is being taught how to notice its own body signals and connect them to the right emotion. Furthermore, we should place the child in real-life situations and not in an artificial training situation. Social groups and worksheets, how realistic are those? As a parent, when your children come home from school are you first going to fill in a worksheet to know how they are feeling? No, we observe their facial expressions and behaviours and relate them to our OWN experiences to know how they feel. When a child cannot implement what they have learned in the ERT, the problem is generalisation. Well, NO. The problem is not generalisation but the way ERT was taught. You just learned the child how to label words to pictures. Just look at these pictures, how many of you look like this: 

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Figure 1: Examples of the Ekman-Friesen Pictures of Facial Affect  

used in the computerized task (Ekman and Friesen, 1976). 

Support for neurodiverse children in school settings or at home. 

Interceptive awareness could be the right tool for schools to teach children how to notice their OWN body signals and connect them to the right emotional state before you start teaching TOM. This can be included in IEP goals or within the Special Education Needs plan. Once this body-emotion link is established, we can go over to ACTION. The word ACTION is used to describe the ability to use feel-good strategies that match the body-emotion connection or in other words to self-regulate independently.  

So next time your child starts to scream and shout, be on the lookout to see whether this is a tantrum or a meltdown. If it is a meltdown, try to see if there are any external triggers that might have caused this. If not, could it be an internal trigger? What time is it? Is it nearly dinner? The child might be hungry? Another example could be a full bladder. If the child had a pee accident during the meltdown this could indicate that he/she had a full bladder but could not notice it. If it is a tantrum, welcome to parenthood! 

Whatever the reason, be empathetic with your child. When the child has a meltdown, there is no reasoning with him or her. First, try to calm down the child, and only when the child is calmed down you can talk over what happened.  

If you need more guidance, I will be happy to guide parents or help your child to increase their interoceptive awareness. 

Author Bio

I am Samantha Bulens, an educational therapist, working at Auticoach in Geneva which provides psycho-educational services.

My expertise lies in educating children with neurodevelopmental disorders in particularly Autism Spectrum Disorders (ASD), Attention Deficit Hyperactivity Disorder (ADHD), and Sensory Processing Disorders (SPD) to increase their understanding of their OWN minds and bodies using evidence-based approaches that will increase their overall well-being and happiness.  

I am specialised in teaching the interoception curriculum which teaches the child how their body is feeling, connecting them to the right emotions, and act accordingly to self-regulate independently. Besides the interoception curriculum, I also teach life skills, independence training, and educational kinesiology whilst coaching parents and families.    

Furthermore, as a licensed H.A.P.P.Y coach I provide happy plans for the well-being and happiness of people with ASD. Being a mom of three neurodiverse children, I can personally relate when it comes to learning difficulties at school and the personal struggles at home.  

For more information about me, visit my website at www.auticoach.ch 

References 

Ekman, P., and Friesen, W. V. (1976). Pictures of Facial Affect. Palo Alto, CA: Consulting Psychologists Press. 

Füstös J, Gramann K, Herbert BM, Pollatos O. On the embodiment of emotion regulation: interoceptive awareness facilitates reappraisal. Soc Cogn Affect Neurosci. 2013;8(8):911-917. doi:10.1093/scan/nss089 

Jackson SR, Parkinson A, Kim SY, Schüermann M, Eickhoff SB. On the functional anatomy of the urge-for-action. Cogn Neurosci. 2011;2(3-4):227-243. doi:10.1080/17588928.2011.604717 

Shah, P. Interoception: The Eighth Sensory System: Practical Solutions for Improving Self-Regulation, Self-Awareness and Social Understanding of Individuals with Autism Spectrum and Related Disorders. J Autism Dev Disord46, 3193–3194 (2016). https://doi.org/10.1007/s10803-016-2848-8 

Strigo IA, Craig AD. Interoception, homeostatic emotions, and sympathovagal balance. Philos Trans R Soc Lond B Biol Sci. 2016 Nov 19;371(1708):20160010. doi: 10.1098/rstb.2016.0010. Epub 2016 Oct 10. PMID: 28080968; PMCID: PMC5062099. 

 

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