Given the challenges kids and teens with autism often face regarding sensory sensitivities and changes in routine, the exposure activities for a plan of action targeting these fears may need to be more gradual. You will likely need to get creative with these exposure activities in order for them to represent the full range of the anxiety intensity scale (0 to 10).
Maybe your child is like George and avoids public restrooms. If your child rates any variation of entering a public restroom (even with headphones on) an 8 or above on the anxiety intensity scale, you will need to find an easier activity to start with that your child rates lower on the scale. Your child could start out by listening to an audio recording of toilets flushing and sinks running while at home.
If your child is like Sophia and has anxiety about their schedule changing, you might try using visual symbols on their calendar to let them know ahead of time that a schedule change is coming up. This symbol can be anything your child likes, such as a shape, a sticker, or a color- as long as they know what the symbol means! Using visual symbols can be a way to help lower your child’s anxiety at the start of their plan of action by warning them in advance that a change is coming.
Getting creative and using audio clips and videos (animated and real) is also a good way to ensure there are enough opportunities to practice exposure activities. For example, if your child is afraid of fireworks, you can use videos of fireworks instead of waiting for the Fourth of July or New Year’s Eve to complete an exposure activity. Try to experiment with a few options and create a plan of action with activities that are gradual enough for your child.
Making a plan of action for fears that overlap with traits of autism can be trickier than usual, so don’t get discouraged if you and your child have a hard time at first. Just keep adjusting the activities until you figure out what works best!
Plan of Action Related to Sensory Sensitivities
As you saw earlier, George’s fear of public bathrooms is an example of how sensory sensitivities can overlap with anxieties and fears.
George gets easily overwhelmed by sounds. In the past, George has gotten overstimulated by all the loud noises in public restrooms (like hand-dryers and toilets flushing). George is also scared of germs and worries about all the germs he might touch if he goes into a public restroom.
Let's look at the plan of action George will use to tackle his fear of public restrooms. His plan will make sure to address his sensory sensitivity to sound. (View a PDF version or look at his plan below.)
George's Plan of Action!
- What anxiety or fear is this plan of action for: Fear of using/being in public restrooms
- What is your goal: Be able to use the busy public restroom at school
| Exposure Activity | Anxiety level (0-10) |
|---|---|
| Listen to the sound of my own toilet at home flushing without running away or covering my ears | 2 |
| In the bathroom at home, listen to an audio recording of toilets flushing, hand dryers turning on, and sinks running | 3 |
| Go inside a single person public restroom and stay in there for at least 5 minutes | 4 |
| Wearing noise cancelling headphones, go inside a single person public restroom and wash/dry my hands with the hand dryer | 5 |
| Wearing noise cancelling headphones, use a single person public restroom, flush, and wash/dry my hands with the hand dryer | 6 |
| Wearing noise cancelling headphones, go inside an empty public restroom and stay there for at least 5 minutes | 7 |
| Wearing noise cancelling headphones, go inside a public restroom while there are people there and stay for at least 5 minutes | 8 |
| Wearing noise cancelling headphones, go inside a public restroom while there are people in there and wash/dry my hands with the hand dryer | 9 |
| Goal Activity: Wearing noise cancelling headphones, use a busy public restroom, flush, and wash/dry my hands with the hand dryer | 10 |
Note: George could repeat the second step at increasing volumes if it's too difficult for him to move to the next step. For the third and fourth steps, he could try out the activities first while his dad is with him and then by himself. He also plans on going to a few different restrooms so he knows that he can complete these activities in any public restroom, not just certain ones.
George’s overall goal is to use the public restroom at school while other people are in there. This is a busy restroom with a lot of stalls and loud hand dryers. Because George is very sensitive to sounds, he will wear his noise cancelling headphones while doing this. Remember, his goal is to get over his fear of public restrooms, not to try and change the way his brain works!
Plan of Action Related to Insistence on Sameness
Sophia’s fear of change is an example of how a natural attachment to routines can overlap with anxiety. Like many other autistic teens, Sophia relies on schedules and routines a lot. Her routines help her navigate and make sense of the world around her. They also help her stay organized and prepared.
But Sophia gets very anxious if her schedule suddenly changes or if she has to do something she did not expect to do. If there is a change, Sophia repeatedly asks her parents questions about the new plan. She insists on knowing every detail so that she can feel less anxious.
Let’s look at the plan of action Sophia will use to overcome her fear of change. (View a PDF version or look at her plan below).
Sophia's Plan of Action!
- What anxiety or fear is this plan of action for: Fear of changes in my routine
- What is your goal: Be comfortable (anxiety intensity level < 2) with detours, delays, and stops on my way home after school
| Exposure Activity | Anxiety level (0-10) |
|---|---|
| With mom’s early notice in the morning, we make a quick stop somewhere I like on the way home from school | 2 |
| With mom’s early notice in the morning, we take a different route on the way home from school that adds 8 minutes | 3 |
| With mom’s early notice in the morning, we make a quick stop somewhere I like on the way home from school- but this time, she does not tell me where | 4 |
| With mom’s early notice in the morning, we run a quick errand on the way home from school that adds 15 minutes | 5 |
| With mom’s early notice in the morning, she picks me up 10 minutes later than usual | 6 |
| Without notice, we make a stop somewhere I like on the way home after school | 7 |
| Without notice, we take a different route home from school that adds 10 minutes | 8 |
| Without notice, mom picks me up 10 minutes later than usual | 9 |
| Goal Activity: Without notice, I run errands with mom or make an unplanned stop on my way home after school | 10 |
Now, take a look at how Sophia and George adapt their plans to face these fears:
Autistic people experience the world differently compared to people without autism. Many autistic people are more sensitive to sensory information, such as noises, lights, smells, or textures, and many also have a very strong preference for routines and for things to be predictable. These are just two examples of ways that autistic people’s brains might work a little bit differently- Here’s one way you can think about this difference:
Everyone’s brain sorts out or processes information. If you are autistic, your brain uses a different system to make sense of things than most other brains do. Some autistic people are very attached to routines and schedules, and this is because of the way their brains work! Having structure and routine can be very important for autistic people.
As you can see, sensory sensitivity and attachment to routine are both traits of autism. On their own, these traits are different from anxiety. But if they cause problems, then they can start leading to fears and worries.
You have seen George working on his fear of germs so he can reach his goal of using public restrooms. However, germs are not the only reason he is fearful of public restrooms. George gets overwhelmed by all the unpredictable loud noises, like toilets flushing and hand dryers blowing. George creates a new plan of action for his fear of public restrooms, but this time, he thinks about his sensitivity to sound.
For this plan, George makes the activities more gradual and starts with one he feels ready to do right away. He also repeats some of the activities in his plan before moving on to the next ones. For example, he listens to different audio recordings of toilets flushing and sinks running a couple of times before moving on to activities that take place inside public restrooms.
George wears noise cancelling headphones during many of his exposure activities. His headphones help him manage his sensitivity to sound as he takes steps toward his goal. While he is still challenging his fear of public restrooms, George may use his headphones fairly often. But George also wants to be flexible when it comes to wearing his headphones. Eventually, George will practice going into public bathrooms without his headphones since he knows he may not always have them. He has also been thinking about some other flexible strategies he can use, like covering his ears or using deep breathing to help him feel more confident and relaxed in public restrooms.
Even after George has conquered his fear, he knows there will still be days when he is more sensitive to sound than others, and it’s ok for him to use his headphones whenever he is feeling overstimulated. But for now, his headphones are helping him feel more confident being in crowded and busy public restrooms. George’s headphones are a flexible tool that help him reach his goals and are not a “quick fix” because they help him face his fears, instead of avoiding them.
Preference for routines is another autistic trait that can sometimes lead to anxiety. Sophia enjoys and relies on her routines. But she gets very anxious when something unexpected happens or when she needs to change her schedule. Sophia and her mom create a plan of action to help Sophia face her fear of routine changes. Like George, Sophia makes her activities more gradual. Her goal is to get comfortable with changes such as stops and delays on her route home after school. For many of Sophia’s activities, her mom lets her know ahead of time that a change is coming up by marking the upcoming change on Sophia’s calendar.
In LUNA, our goal is not to get rid of your sensory sensitivity, your preference for routine, or any other traits that make you, you. Our goal is to help you reduce your anxiety around these things, so they do not stop you from doing what is important to you. We want you to have confidence in yourself and the ability to face your fears in a way that works for you!
Your Turn to Practice
After your child has read their version of this module, take some time to talk with them and decide if you should make a new plan of action for fears related to sensory sensitives or routine changes. If so, use the My Plan of Action Worksheet to make a new plan of action, and make sure to use the tips we talked about in this module.
Regardless of your child’s age or independence level, when making plans for anxiety that's related to autism, it's very important to incorporate your child's input. Ask them what they think is doable, what they would need, and what makes sense for them in their life.