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Planned Self-Care: Why "As Needed" Doesn't Cut It in Autism

Updated: Jun 6, 2020

Photo by Gian Cescon on Unsplash

"She can take a break when she needs to."

"But he wanted to go to the carnival!"

"Let me know if you anything?"

One well-meaning but often inadequate approach to supporting the autistic individual is to offer breaks or other accommodations "as needed."

Why would something so considerate be ineffective?

1. Deficits in Self-Monitoring

Individuals with autism often struggle to identify both their internal physical and emotional states efficiently.

In the area of the physical, sensory processing challenges may include deficits in interoception. In other words, the individual may not clearly understand whether he is hungry, tired, in pain, or cold.

Those on the spectrum also struggle to identify and understand their emotional states. As noted by Mazefsky et al., "...research suggests that youth with ASD... experience the physiological consequences of emotion with limited cognitive insight. Children with high-functioning ASD tend to rely on overt cues to describe their emotion (e.g., I was sad because I was crying) and provide nonspecific accounts of their emotional experiences....research suggests that individuals with ASD generally lack the emotional insight needed for effective ER [emotional regulation]."

Without a strong sense of what is happening physically and emotionally, the ASD individual struggles to understand her own needs, perhaps until she reaches a crisis point (e.g., panic attack, severe pain). She is less likely than her neurotypical peers to feel internal states "coming on" gradually. This struggle means that self-care "as needed" may not be enough to keep a steady internal state.

2. Impairment in Social Approach and Social Communication

The diagnostic manual (DSM-5) outlines several aspects of communication difficulty that are core to the spectrum.

Even when the ASD individual understands what he needs in a given moment, the inherent demand for approaching someone to request a break is often itself overwhelming and avoided.

3. Problems Predicting Likely Outcomes.

The autistic individual is likely to struggle to predict likely outcomes of her decisions. The ability to anticipate what her needs may be in certain situations is often problematic.

The individual may have a genuine interest in an event (e.g., like a pep rally) and a desire to avoid the attention of others (Why is she leaving the pep rally?). One of the pieces of improved self-awareness is to help the autistic individual predict what is likely to happen (e.g., You have had two panic attacks today. You're worried about your mother in the hospital. The last time you attended a pep rally, the noise was very upsetting. Do you think going to the pep rally might be too much for your system today?).

4. Need for Predictability and Routine

For some on the spectrum, there is anticipatory anxiety that leads to escape and/or avoidance of situations like school, work, or family activities (e.g., "in case I can't handle it"). In these situations, the prediction of possible anxiety may lead to an extreme number of breaks (e.g., the student with school refusal or leaving class ten times a day).

One strategy I've found helpful is to offer scheduled breaks (rather than as needed). In the context of planned breaks, the autistic individual knows he can rely on this predictable routine. He can then think, "I feel like leaving the class, but I know I have a break in ten minutes. I can last that long." The reliability of the break schedule often leads to fewer breaks than the "as needed" approach.

Mazefsky CA, Herrington J, Siegel M, et al. The role of emotion regulation in autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2013;52(7):679–688. doi:10.1016/j.jaac.2013.05.006

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