# data[].attributes.attachment_link.authors[].name
Emma Young (Author), John Devolle (Illustrator)

# data[].attributes.attachment_link.title
Your SENSE-ational Human Body: A Sensational Guide to Your 32 Senses

# data[].attributes.attachment_link.description
Your SENSE-ational Human Body: A Sensational Guide to Your 32 Senses [Young, Emma, Devolle, John] on Amazon.com. *FREE* shipping on qualifying offers. Your SENSE-ational Human Body: A Sensational Guide to Your 32 Senses

# data[].attributes.headline
From Understanding to Action: Unlocking Access for Children with DB

# data[].attributes.subject
From Understanding to Action: Unlocking Access for Children with DB

# data[].attributes.body
Dual Sensory Impairments

# data[].attributes.attachment_link.title
Reading handwriting with assistive technology

# data[].attributes.attachment_link.description
How to read handwriting, handwritten notes and cards using technology.

# data[].attributes.attachment_link.title
DbI Review – Deafblind International DbI

# data[].attributes.attachment_link.description
Deafblind International DbI is THE point of connection in deafblindness worldwide

# data[].attributes.attachment_link.readable_text
Bilateral coordination activities are essential for coordinated and fluid movements that require both sides of the body. Also called bilateral integration, the movements of both hands together in activities requires processing and integration of both hemispheres of the brain to enable both hands working together at the same time, or bilateral movements. Without bilateral coordination, a child might appear to be clumsy or drop items, use primarily one hand in activities, or switch hands during tasks that require a dominant hand and a helper hand. Development of bilateral coordination skills is powerful in functional skills like self-feeding, handwriting, self-dressing, grooming, and more.

Bilateral Coordination Activities

First, let's talk a little more about bilateral coordination. What is bilateral coordination, and how do bilateral movements impact learning, functional tasks, and play in child development?

Activities that support development of bilateral coordination skills integrate several areas of development:

Visual motor

Core strength and stability

Attention and focus

Sensory processing: vestibular, proprioceptive, and visual sensory systems

Balance and coordination

Body awareness

Development of a dominant side of the body

Each of the areas listed above are both needed for participation in tasks requiring bilateral skills and developed, or strengthened through participation. Play is a powerful tool to support these areas.

Check out these bilateral coordination toys to help kids build skills through play and games.

Why is bilateral coordination important?

Bilateral coordination is important for a variety of skills.

When bilateral coordination or bilateral integration is intact and progressing appropriately through development, it is an indicator that both sides of the brain are communicating effectively and sharing information during functional tasks.

Younger toddlers and babies can be observed using both hands in play as they pick up objects in their line of sight. However, they typically will pick up items with the hand that is closest to the object or toy.

As toddlers progress in development, they will begin to establish a dominant hand and crossing midline. Read more about this in our resource on cross crawl exercises.

This ability to utilize a dominant hand and a non-dominant hand in activities indicates a maturation of the brain and lateralization in functional tasks, which is very important for motor planning, directionality, and visual motor skills.

When a child is challenged in development of bilateral coordination skills, there can be resulting difficulties.

In fact, impaired bilateral coordination skills can lead to difficulty in the classroom. Science tells us that problems with bilateral coordination can have an impact on academic performance, with slowness and disinterest in schoolwork.

In the school setting there are many areas that can be a challenge as a result of bilateral coordination struggles:

performance in school tasks that require coordination

using scissors

writing- including holding the paper and erasing

tracing

using tools such as rulers

managing clothing- buttons, zippers, snaps

managing lunch containers

putting on and taking off a backpack

turning pages in books

managing and organization skills in folders and backpacks

Development of bilateral coordination in self-feeding depends greatly on the child's developmental level. The baby who is learning to place dry cereal in their mouth will be vastly different level than the child who is scooping soup or cutting a piece of chicken. Development of fine motor skills and visual motor skills have an impact on coordination of the hands in self-feeding.

What makes up bilateral coordination?

In fact, there are three components of bilateral coordination:

Symmetrical movements

Alternating movements

Dominant hand/supporting hand movements

types of bilateral coordination:

There are three different types of bilateral coordination. Let's break these down.

1.) Symmetrical movements - Both hands do the same thing at the same time. An example of this would be pulling up pants or socks. Other activities that can work on this skill include

Holding a squeeze bottle with both hands at the midline to paint.

Jumping rope

Jumping Jacks

Catching a ball with two hands

Holding onto a swing as it moves back and forth

Holding onto a rope in tug of war

Pushing oneself against an object to propel oneself forward or backward against a stable object

Pushing oneself forward or backward against an unstable object

2.) Alternating Movements - Using the two extremities in alternating motions. You will see alternating bilateral coordination with swimming or climbing a ladder. Activities to work on this skill include:

Riding a bike

Marching

Holding onto a swing, slide, or other object while using the other hand to move and manipulate toys or objects

Alternating movements with the arms or legs

3.) Dominant hand/Non-dominant hand - Using one hand to perform a task while the other assists is needed for many fine motor skills. This type of bilateral coordination is needed for writing, and cutting with scissors. Activities to work on this skill include:

This occupational therapy tool is Easter-themed but it builds the skills needed for kids to cut with scissors while refining and building accuracy with scissor skills.

Bilateral Coordination and the Vestibular System

Bilateral coordination is closely related to the vestibular system. When our body registers movement and gravity it allows us to respond with appropriate movement, balance, and posture. The vestibular system and our body's ability to register information and integrate it into movements enables bilateral coordination and body awareness of the upper and lower body. Below, you will find all of our activities that build and develop bilateral coordination. Try these activities to work on many skills like visual motor integration and fine motor skills while encouraging bilateral coordination. Be sure to stop back, because this page will be updated often!

Related: Need some indoor bilateral coordination activities like this one? Try our list of Winter Bilateral Coordination Activities that kids will love!
Bilateral Coordination ideas for kids: Development of Bilateral Coordination in Self-Feeding Winter Bilateral Coordination Activities Bilateral Coordination Shamrock Crossing Mid-line Gross Motor March Bilateral Coordination with Pop Tubes Bilateral Coordination Lacing Plate Fine Motor Burlap Feather Lacing
In-hand Manipulation Letter Puzzles Jumbo Fine Motor Skills Threading Activity Intrinsic Muscle Strength with an Egg Carton Magnetic Spoons and Handwriting Game Pencil Grasp Trick Thumb IP Flexion Thumb Opposition Fine Motor Play Dough Intrinsic Muscle Strength Rainbow Hundreds Chart
Neat Pincer Grasp Fine Motor Activity Benefits of Stickers in Occupational Therapy Buttoning Tips and Tricks Hand Dominance and Fine Motor with Scooping and Pouring Homemade Pegboard Activities The Benefits of Coloring Clothes Pin Exercises and Pinch Grasp Types Creative Scissor Skills Practice Precision in Grasp and Release of Fine Motor Skills Chain Link Counters Color Sort Hand-Eye Coordination Heart Math Handwriting Warm Up Exercises Homemade Lacing Cards Motor Planning Fine Motor Maze Hand Strengthening Building Activity Fall Leaves Craft Alphabet Discovery Bottle Scarecrow Math Craft Pencil Control Exercises
Pre-Writing Handwriting Lines Rainbow color sort
In-Hand Manipulation with Coins
Extended Wrist Fine Motor Activity

Crayon shaving art
Mini Rhythm Sticks
Shape building

Dyed lollipop sticks

Foam Workout

Water Bead Sensory Box

Handwriting With Cookie Cutters

Cursive Lines Fizzy Dough

Push Pin Can Letters
Handwriting with Foam Strips
Marble Run Water Table

Empathy Beads

Butterfly Craft
Fine Motor Tripod Grasp with Cereal

Handwriting on Resistive Foam Trays

Snap Block Light Sabers
Cherry Blossom Trees
Fine Motor Pincer Grasp Color Match

Finger Dexterity Exercise

Fine Motor Play With Crafting Pom Poms
Feather Beading
Sparkle Collage Art

Visual-Motor Letter Match

Bunny Scissor Tongs
Play Dough and Rocks
Fine Motor And Auditory Fireworks

In Hand Manipulation Ideas for Kids
Brain Building with Balls in a Muffin Tin Using Pipe Cleaners for Fine Motor Skills
Color Matching with Play Dough
Fine Motor Play with Tissue Paper Golf Tee Hammering Fine Motor Table Top Play with Tape
Fireworks Art

Color Sort Scissor Activity

Fine Motor Grow a Garden
Sunflower Craft
Fine Motor with Keys

Hand-Eye Coordination Cookies

Crayon Play Dough
Threading Lids Creative Scissor Skills Practice Scissor Skills Crash Course Improving Scissor Skills with Play Dough Cutting Foam Beads Finger-painting Fireworks for Scissor Use
Rainbow Bracelets

Pipe Cleaner Fine Motor Fun

Icicle Scissor Skills

Fine Motor with Keys

Straw Fine Motor Sort

Easy Scissor Practice

Bilateral Coordination Problems

We covered a lot here about activities to support the development of bilateral coordination. But what if there are challenges that impact coordinated movement of the two sides of the body?

There are several areas to explore when it comes to bilateral coordination:

Praxis-

Modulation- Challenges with sensory defensiveness, gravitational insecurity, and aversive responses to movement can also manifest as a result of modulation problems.

Sensory integration dysfunction- This includes visual, proprioceptive input, and vestibular input that are not registered or are not processing.

Balance and core strength

bilateral coordination activities occupational therapy

The following are some occupational therapy interventions to use in developing strengthening bilateral coordination skills. These bilateral coordination exercises may not be appropriate for every individual.

1. Child prone on floor scooter as the child moves the scooter with their hands on the floor to propel through an obstacle course

2. Child prone on a sensory swing to push away from the OT using a dowel rod or ball

3. Pulling on ropes against the resistance of the OT while sitting on a floor scooter, therapy ball, or sensory swing

4. Child sitting on a therapy ball, scooter, platform swing and pulling a hula hoop against the resistance of the therapy provider

5. Child prone in a therapy net and using ropes to push and pull rhythmically against the therapy provider's resistance.

6. Kicking a ball or toy suspended from the ceiling with both feet

7. Catching a ball while on a stabile base of support or an unstable base (on a wobble disk, sitting on a platform swing, or standing on a therapy mat)

8. Sitting or laying on a platform swing and throwing bean bags into targets with both hands

9. Sitting on a ring swing or inner tube swing with ropes to pull from side to side

10. Climbing activities: climbing a slide or on overhead monkey bar equiptment

11. Swinging on a traditional swing and tossing objects into a target

12. Hand clapping games

13. Opening a jar, food containers

14. Zippering, snapping, buttoning clothing

15. Tying shoes

16. Typing on a keyboard

17. Cutting with scissors

18. Writing and holding the paper on a table surface

19. Putting on pants, shoes, and socks

20. Finger painting with both hands

21. Sign language

All of the bilateral coordination strategies listed above can be modified to include discrete or sequenced bilateral movements. They can also include symmetrical or alternating bilateral movements.

These exercises and therapy activities, combined with the bilateral coordination activities listed in the links above can provide a great collection of ideas to support development.

# data[].attributes.attachment_link.title
The Best Bilateral Coordination Activities for Kids - The OT Toolbox

# data[].attributes.attachment_link.description
These bilateral coordination activities are bilateral movement strategies to help kids demonstrate bimanual coordination skills.

# data[].attributes.attachment_link.readable_text
Bilateral Integration is an area that kids need for so many tasks...but it's not a developmental milestone that stands out unless a problem is necessarily noticed unless there is a problem. What we do notice in as our kids grow and develop are the motor skills that impact functioning. We notice use of both hands, fluid and efficient movements in tasks like playing, getting dressed, and interacting with peers. Let's take a look at bilateral integration and dissect how to support this essential sensory motor skill.

Another resource that supports this information is our blog post on bilateral coordination. You'll find many bilateral integration activities in that blog post.

Bilateral Integration

From writing and holding the paper, to holding a art project and cutting with scissors, to zippering a jacket, coordinating both sides of the body in an efficient manner is a skill that is necessary for almost everything we do.

Bilateral coordination develops from a very young age. When babies begin to bring both hands together at their mouth, you are seeing coordinated efforts begin. When the infant pushes up on both arms while lying in a tummy time position, the integrated movements of both hands and legs occurs along with strength and control.

Research tells us that motor tasks like jumping, jumping jacks, riding a bike, hopping, etc. become easier and more fluid with age as children develop. It's through play, sensory input, motor skill experience, and activities that these skills are developed.

Below, you will find bilateral integration activities that can be incorporated at various ages. Use these bilateral coordination activities to promote coordinated and efficient movements in meaningful activities.

What is Bilateral integration?

Bilateral integration refers to the ability of both sides of the brain to work together in a coordinated manner. We see this ability when the skills associated with the left side of the brain are done in conjunction with skills associated with the right side of the brain.
Skills associated with the left side of the brain: Skills associated with the right side of the brain:

Creativity and imagination

Creative thinking

Spatial skills

Intuition

Art, drawing, and creative artistic skills

Musical skills

Then, when other aspects of functional performance are added to the mix and the individual is still able to complete the task, this is bilateral integration in action.
Those other considerations include:

Attention and focus

Proprioceptive input

Vestibular input

Visual information

Motor targets achieved, or motor control shown by fluid movements

Praxis- movements thought about and completed in coordinated manner

When both sides of the body work together in a coordinated manner so that the individual can manipulate objects such as cutlery with various amounts of force modulation, taking in sensory stimuli such as sights, sounds, tastes, and proprioceptive and vestibular input, and managing posture, coordination, and body awareness, bilateral integration is visible.

When bilateral coordination or bilateral integration is intact and progressing appropriately through development, it is an indicator that both sides of the brain are communicating effectively and sharing information during functional tasks.

Tasks that require bilateral integration

Knowing what we covered above, it is easy to see how some daily tasks are impacted by coordinated and integrated motor skills requiring both sides of the body. Each of these skills requires and has input from other sensory systems and cognitive systems as well, such as proprioceptive input, executive functioning, attention, and even creative thinking and problem solving.

Writing and holding the paper in a stable position

Cutting and holding the paper steady and at an appropriate height

Putting on a coat while holding a backpack (or other item)

Tying shoes

Pulling up pants and not losing balance

Putting socks on

Jumping jacks with coordinated movements

Turning a page and writing or copying work

Typing

Squeezing toothpaste and brushing teeth

Flossing teeth

Playing an instrument

Using a knife and fork

Pouring water from a pitcher into a cup

Cooking skills: chopping, cutting, slicing, peeling, taking food out of packages, putting food into the microwave or stove, taking food out of the fridge

Reaching for objects

Stabilizing an object with one hand while manipulating another object with the other

Jumping rope

Catching a ball

Riding a bike

Swimming

Many more tasks!

Bilateral Integration Activities

Amazon affiliate links are included in this post.

First, let's talk about some ways that coordinated use of the arms and legs are needed for coordinated movements. These are skills and tasks that can easily be performed by some children. Others, who struggle with motor planning, core strength, posture needs, left-right discrimination, visual motor skills, or many other areas can struggle. It's easy to see that simply addressing some areas won't fix the issue when an underlying concern is present.
To promote the skills needed for these tasks, try some of the activities listed below to promote bilateral integration:
Related Read: Here are are some additional bilateral coordination activities with a winter theme.

Bilateral Integration Activities for Babies

Bilateral movements are part of everyday life for baby! From turning, creeping on the floor, rolling, sitting, crawling, cruising on furniture, and taking first steps, babies are developing bilateral integration skills from birth.

Read here about the types of crawling, all of which integrate bilateral coordination and motor planning.
Encourage these bilateral integration activities with babies:
There are ways to support child developmen t at this stage through age-appropriate play that will support the child's progression at later stages, too.

Provide various toys and objects appropriate for young babies. Include bold colored objects including black, white, and red items or contrasting colors, toys, or pictures on a blanket or play mat during tummy time. This black and white board book (affiliate link) can be propped up or used while on an adult's lap.

Provide gentle infant massage during and after bath time, and on all extremities. Here is a resource book on infant massage. (affiliate link)

Provide toys and age-appropriate objects for reach and grasp. This banana toothbrush teether (affiliate link) has molded handles that make it a great teething item for little ones.

Provide teething toys as baby brings hands together at their mouth.

Provide toys that are appropriate for mouthing that can be held in both hands.

Provide hand-held toys while the child is seated in a high chair. This one (affiliate link) has a suction cup base to keep it stable, but has a black and white ring at the base that babies can grasp with one hand while manipulating with the other hand.

Provide toys of various weights when seated upright to provide resistance against gravity and to promote strengthening of the upper extremities. Blocks, rings, sorting toys, or something like this quality teething toy (affiliate link) made of heavier materials can be useful to provide variances in weight, while still allowing the baby to manipulate the item.

Provide toys available on a high chair or table surface at various distances to provide opportunities for depth of perception when reaching for toys and bringing them to the mouth.

Continue tummy time while playing in prone to promote strength and stability in upper extremities.

Use the ideas in our baby play library for more ideas.

Bilateral Integration Activities for Toddlers

Provide toys requiring one hand to stabilize a base while the other hands manipulates an object. Shape sorters are great for this.

Other toys include:

Peg Boards (affiliate link)

Blocks- These press and stay sensory blocks are perfect for encouraging one hand to use as a stabilizer and one hand as a

Play Dough

Drawing/coloring- Here is more information on the benefits of coloring.

Use these crayons for toddlers to support bilateral coordination skills during coloring.

Bilateral Integration Activities for Preschool

Preschool is a time for building hand strength, coordination, eye-hand coordination, and improving motor skills needed for the upcoming years. You can find many preschool activities here on our website, but some specific ways to support bilateral integration include:

Encourage kids to participate in cooking activities.

Use play dough to cut with scissors and roll out play dough snakes or balls of play dough.

Age-appropriate crafts and craft sets are great for this age.

Play with stickers of various sizes.

Make "snow angels" on a carpet or fluffy blanket

Simon Says is a great game for encouraging novel and varied motor combinations. Use these Simon Says Commands to get started.

Play various song and movement games such as the Hokey Pokey, Farmer in the Dell, etc. Here are movement and song activities that can be used in circle time, warm-ups, centers, or in group activities. All of these move and dance songs promote core strength and stability.

Climb on outdoor play areas at playgrounds and in low trees.

Add sensory! Try this table top bilateral coordination activity to draw shapes.

Draw with both hands! This four leaf clover activity is a powerful one as it covers a variety of skills.

Bilateral Coordination Activities for School-Aged Kids

In schools, development of bilateral integration is important for tasks like putting on a coat or jacket and backpack, holding a paper with the supporting hand and writing, and using scissors. There are many other bilateral integration tasks that happen throughout the day.

Some ways you can support development of these skills include:

Last thoughts on encouraging bilateral integration

The best way to encourage and promote integration of both sides of the body? Movement and play! Get the kids active, moving, and experiencing various planes against resistance and with exposure to all types of sensory experiences.

The combination of proprioceptive input into a play experience that promotes strengthening in a fun way provides all of the benefits kids need to improve bilateral coordination skills. Add personal interests as the child grows. And finally, have fun!

# data[].attributes.attachment_link.description
Bilateral integration information and ideas to build bilateral coordination skills in kids. These occupational therapy activities are so fun!

# data[].attributes.attachment_link.readable_text
When you're the parent of a child with special needs, every aspect of parenting is magnified. Playdates become complex projects requiring diplomacy, support, and vast quantities of time and patience. Trips to the doctor are frequent, expensive, difficult, and fraught with worry. Ordinary shopping excursions are strewn with potential disasters and pitfalls.

With so much more to think about, worry about, plan for, and manage, special needs parents really do have... special needs.

11 Needs of Special-Needs Parents

Here's a partial list that may sound familiar to moms and dads who are coping with the ups and downs of life with a child who, for whatever reason, is considered to be "special." While these are the top 11, they're in no particular order.

Between PTO meetings and work deadlines, it can be hard for any parent to find "me" time. Magnify that 10 times for parents of children with special needs who must also add IEP meetings, therapy appointments, and multiple doctor visits into the mix.

Add challenges such as driving 50 miles to get to the only dentist who will work with your child, only to learn that you'll need to come back next week to fill that cavity... and then driving 60 miles in the other direction because your kid wants to take ballet and there's a special needs ballet class on the other side of the county.

And let's not get started on time for yourself, your partner, your other children, your extended family.

Energy Reserves

Not only is it time-consuming to be a special needs parent, but it's also exhausting. Add up all the energy required to raise a typical child, and then add hours a day for driving to out of town appointments, filling out paperwork, doing more research, managing your child's meltdowns, cooking special foods for your child because of allergies, intolerances, or feeding issues.

Toss in the energy required to cope with strangers' stares, teachers' "concerns," and grandparents' worries, and it all adds up to very few hours between the sheets.

Money for Critical Expenses

Two parents working full-time should, in most cases, be able to earn enough money for a family to live comfortably. But when you're the parent of a child with special needs the costs increase.

Special equipment, medicine, therapists, extra gas to drive to all those specialists-it all adds up. And many mothers of kids with special needs wind up cutting back their work hours to be available for their child, thus decreasing their income when they need it most.

Adult Friendships

When you're the parent of a special needs child, it seems that every interaction outside of work involves some aspect of special needs parenting. Even your social get-togethers wind up including mostly parents of other special needs kids, with conversations focused on "the best therapist for x" or "how rotten the resource room teacher is."

A Sitter for Date Night

Parents of typical kids hire a babysitter and go out for the evening. For parents of special needs kids, it's not always that easy.

Some special needs require sitters with special abilities that can range from medical training to autism expertise. Not only are such babysitters hard to find, but (naturally) they charge double or triple the going rate.

Reassurance

If your child has special needs, chances are you've spent an unreasonable amount of time agonizing over whether you somehow caused her problems, whether you've chosen the right medical or therapeutic options, whether you're doing enough (or too much) to improve her chances in life.

An Emotional Outlet

Your partner has heard it all 50 times. Your parents have either heard it or don't care. Your friends aren't interested in hearing about your latest frustrating IEP meeting, nor are your coworkers. You can't vent to your kids.

So who's left? By holding it in, parents of special needs kids may only make matters worse, but what are their options?

Support groups can be helpful, but to get to them you need to find the right group, clear time on your calendar, drive to the meeting, and hope the members will have the time and energy to respond to your concerns.

Exercise and Nutrition

This may sound like a minor issue, but for many parents of special needs kids, there simply aren't enough hours in the day for self-care. Exercise is, for many people, a huge stress reliever. It can also be a chance to socialize with friends.

Just as importantly, a lack of exercise can lead to serious health issues. The same, of course, is true of nutrition: too many fast-food meals can wreak havoc with your digestion, weight, and wellness.

Compassionate Family and Friends

It's amazing how often even well-meaning family and friends become anxious and short-tempered when exposed to a child with even mild special needs. An autistic child doesn't want to play touch football, or a child with sensory challenges puts his hands over his ears, and everyone in the room seems to respond with judgmental surprise.

While the child himself may not be aware of the raised eyebrows and exchanged glances, parents certainly are. And while it's difficult to cope with judgments from strangers, it's much harder to let close friends' judgments roll off your back.

Schools, doctors, therapists, and agencies are all set up to help families support their children with special needs. Why is it, then, that none of these entities seem eager to actually tell families what's available, what they're entitled to, and how to get what they need?

Most parents of special needs children will tell you that you already need to know special needs law, understand the ins and outs of agency options and policies, and have a full grasp of all available therapies before stepping foot in a planning meeting for their child.

None of us go through life more than once, so all of us are novices when it comes to parenting. But there are people who make a profession out of helping parents of children with special needs to navigate the options and pitfalls.

Most parents would be thrilled to have the help of such a coach who could tell them "ask for this, not that," or "fill in this form and you'll have access to better services for your child."

How You Can Help

If you're the friend, sibling, mom, or dad of a parent of a child with special needs you may be wondering "What can I do to help?" The good news is, there are many ways you can make a difference without changing your life or overwhelming yourself and your family.

Here are some suggestions:

Avoid pity. While it's sometimes hard to imagine the challenges of special needs parenting, pity doesn't help. In fact, pity can reinforce the frustrations and feelings of isolation.

Be supportive and positive. It's all too easy to get into negative talk when discussing a child with special needs. Instead of spiraling downward, though, do your best to accentuate the positive. Tell your friend or loved one that they're doing a great job, and point to some of the very real positive outcomes they're almost certainly seeing.

Get a clue. Don't be that sister, cousin, or parent who stares blankly at a child with special needs and wonders how to engage with them. Instead, read a book, watch a video, attend a class, or ask questions so that you can jump right in during family events.

Give siblings a special treat. Many people with special needs kids have typical children who also need attention. When you can, consider taking the siblings of a special needs child out for a treat, or even chauffeuring them to their sports events and cheering them on. It's a great way to build a relationship while giving Mom and Dad a little time to themselves.

Listen. It won't cost you a nickel to be a listening ear and a shoulder to cry on.

Offer to babysit. If it's within your comfort and ability zone, give your friends a break by looking after their special needs child for an hour, an evening, or even a weekend. This is called respite care, and it's an extraordinary gift.

Pick up the tab. Loans are probably a bad idea for many reasons, but when you can it's great to pick up the tab for a lunch, a beer, or even a dinner out.

Set an example of inclusion. Find ways to include your friend's special needs child in ordinary activities and accommodate challenges. For example, if a child with special needs has difficulty climbing to the top of a slide, give them a hand. If they're not quite understanding the rules of a game, simplify the game so everyone can join in.

Take a walk. Give the parent of a special needs child a chance to get outside in the fresh air and get a little exercise with a friend or loved one.

# data[].attributes.attachment_link.title
11 Things Special Needs Parents Need to Survive and Thrive

# data[].attributes.attachment_link.description
When you're the parent of a child with special needs, every aspect of parenting is magnified. Playdates become complex projects requiring diplomacy, support, and vast quantities of time and patience. Trips to the doctor are frequent, expensive, difficult, and fraught with worry. Ordinary shopping excursions are strewn with potential disasters and pitfalls.

# data[].attributes.attachment_link.readable_text
Special needs parenting comes with a whole host of emotions that can be difficult to deal with. One of the most difficult for so many of us is the isolation we feel. When our children are diagnosed, we tend to pour ourselves into the diagnosis. We research, talk to experts, doctors, therapists, special education professionals, all in an effort to help our kids have the best life possible.

In all the preparation and planning we do to help our children, we fail to prepare ourselves for the journey. We don't realize just how life altering having a special needs child will be. We might find ourselves going through a period of denial, then we go through the grieving cycle.

Unless you're one of the lucky few, the isolation can almost become an even bigger battle than the diagnosis.

The Early Years

When our special needs children are still toddlers the isolation doesn't really set it yet. Play dates are still relatively easy because our children are still at an age where the mommies and the babies are all on the floor together participating. Depending on the diagnosis our children has, there might not be a huge developmental gap between our kids and our friend's kids.

During this time we still have our friendships. We can still visit each other's houses without much thought for accommodating our child's needs. Sitting on the floor chatting with other moms while our children play together with a little guidance is still a reality.

The early signs of isolation do start to present itself during the first few years, but we usually don't see it. We spend a considerable amount of time traveling for doctors, specialists, throwing ourselves into therapy interventions. We can't go on as many play dates, meet at the park as often, or join in on a walk with the neighbors because our schedules revolve around all of these appointments.

When the Isolation Escalates

Then it happens. Our kids start getting older, but they're not meeting milestones. Not only that, but the gap between our special needs child's abilities and that of their peers grows. What was once a small dip we could easily step over has suddenly become as wide as the grand canyon.

Suddenly, we can't do play dates. On the rare occasion we're still invited for a play date we find ourselves facing hard choices. While other kids are now free to run and play, our child isn't capable. For special needs moms, this means we have to choose. We stay with our child and help them participate with the other kids as much as possible; or, we sit and socialize with the other moms (making our child sit with us).

No one wins in this scenario. Either we as moms miss out on conversation with other moms, or our child misses out on being with her peers. This of course is happening at a time when these relationships are crucial to us. The worst part is, those on the outside of special needs parenting don't see it.

I can't tell you how many times I have chosen to be by Ladybug's side, excluding myself from the circle of moms and no one stopped to think of coming along side of me or joining us. No one realizes that if my kids are with, I can't participate. While it's easy to say that it's only for an hour or two. The emotional toll of this isolation escalates when it happens every. single. time.
Watch video for personal stories of conversations with friends that contributed to isolation
Isolated at Home

Of course the big part of isolation comes from the fact that it takes a LOT of work go to places with our special needs kids. Most people assume that this special needs mom gig gets easier with time, but that simply isn't true. While we have accepted their diagnosis and our new reality, their level of care increases with time. Meaning many things actually become more difficult.

So many places are not as accessible as the non-disabled community would like to believe. Adequate bathroom facilities are becoming a bigger problem as our children grow. The ability to contain an autistic meltdown gets much more difficult as their bodies get bigger and stronger. We need to consider things like wheelchair accessibility, and the amount of sensory stimulation our kids will be exposed to before going anywhere.

Many times it's just easier to stay home.

The Isolation is a Natural Progression

The worst part of the isolation reality special needs families face is that it's no one's fault. There is a natural progression to it. As our kids get older we don't participate in the same activities. While our lives revolve around doctors, procedures, and therapies everyone else is pouring their time into sports practice, dance lessons, gymnastics, boy/girl scouts and every other "normal" activity kids participate in.

Our paths no longer cross. We no longer relate to each other. It's hard and it takes an effort to be friends with a special needs mom. I don't say that to sound harsh, but it's the truth. It is much easier to maintain friendships with other moms you can relate to. It's a fact. Yes, it's a sad fact, but it's still fact.

Babysitters are Hard to Come By

This is a fact that many don't even think of. When we look for a babysitter we need to consider things like the person's ability to lift our child who is completely dependent on us for transfers. Are they comfortable with the fact that it's possible our child will have a seizure? Can they recognize when our child is overstimulated and about to have a meltdown if they don't intervene?

I'll be honest, most people are freaked out by the idea of babysitting our special needs children. I get it, really. I mean this is like foreign territory if it's not your everyday life. It's intimidating, I acknowledge that. I'm not placing blame or trying to guilt anyone who would be uncomfortable babysitting for us. I'm simply stating that this is another hard reality keeping us isolated from the outside world.

We Spend All Our Money on Medical Needs

Our lives are filled with medical appointments, procedures, equipment, home modifications, therapies, adaptive devices, time missed at work (assuming we even CAN work outside of taking care of our children).

Needless to say we simply can't go out to eat, grab drinks, or buy tickets to events. When the group goes out, we need to stay home. What was once just a normal Friday night activity, is now a luxury.

The worst part of this reality is that when it comes to kids with disabilities, this reality doesn't end. Our kids will always have these expenses.

The worst part of this reality is that when it comes to #kidswithdisabilities, this reality doesn't end. #specialneedsmom Click To Tweet

We Get In Our Own Way

Sometimes the isolation of raising special needs kids comes from ourselves too. There are times we simply don't have the energy.

I have a saying: If I'm awake, I'm tired. This special needs mom gig is exhausting, and it never lets up. So, on the rare occasion we have the chance to get out with friends we're probably too tired to really enjoy it.

Then of course there is the emotional energy it takes. Like I mentioned above, it's hard for us to relate to others. Conversations are difficult. They're difficult because it's hard to talk about our situation. If we are honest and share our struggles it's perceived as if we're complaining and we don't love our kids (which is why I added the disclosure to the top of this post). So, we feel the need to put on this mask and pretend that everything is all sunshine and rainbows. Why? Because the last thing we want is further isolation because of the negative perceptions that tend to come when we are honest and vulnerable.

Sometimes it feels like I live frozen in time. I can look around and see the world moving around me. I see other families growing, laughing, and enjoying life while we're standing still. That's what isolation feels like.

What Can We Do?

Isolation is real, I know I'm not the only special needs mom who struggles with this. If you're a special needs parent like me, try to find time for self care. Make sure you're working on your marriage. Get professional help if the isolation is consuming you and bringing on depression. Of course, remember all the blessings your special needs children bring to your life.

If you're not a special needs mom, I simply ask that you don't forget about us. I know it's easy because we don't run into each other at the kid's activities; but, we're still here. We need your friendship now more than ever.

# data[].attributes.attachment_link.title
The Isolation of Special Needs Parents ~ Raising the Extraordinary

# data[].attributes.attachment_link.description
Special needs parenting comes with a whole host of emotions that can be difficult to deal with. One of the most difficult for so many of us is the isolation we feel. When our children are diagnosed, we tend to pour ourselves into the diagnosis.

# data[].attributes.attachment_link.readable_text
J Autism Dev Disord. Author manuscript; available in PMC 2011 Apr 1.

Published in final edited form as:

Abstract

Using daily diary methods, mothers of adolescents and adults with ASD (n = 86) were contrasted with a nationally representative comparison group of mothers of similarly-aged unaffected children (n = 171) with respect to the diurnal rhythm of cortisol. Mothers of adolescents and adults with ASD were found to have significantly lower levels of cortisol throughout the day. Within the ASD sample, the son or daughter's history of behavior problems interacted with daily behavior problems to predict the morning rise of the mother's cortisol. A history of elevated behavior problems moderated the effect of behavior problems the day before on maternal cortisol level. Implications for interventions for both the mother and the individual with ASD are suggested.

Keywords: stress, cortisol, parenting, behavior problems, adolescents, adults

Parents of children with autism spectrum disorders (ASD) often report higher levels of stress and poorer psychological well-being than parents of children with other types of developmental disabilities ( Abbeduto et al., 2004; Blacher & McIntyre, 2006; Eisenhower, Baker, & Blacher, 2005). Past research has examined various child-related factors that might explain this elevated level of psychological distress among parents of children with ASD, with findings consistently indicating that child behavior problems are significant sources of stress ( Hastings et al., 2005; Herring et al., 2006; Lounds, Seltzer, Greenberg, & Shattuck, 2007). It is not known, however, whether this level of stress disturbs the physiology and health of these parents, highlighting a need for research on the biological markers of stress in families of individuals with ASD. The present study sought to address this gap by examining the associations between behavior problems in adolescents or adults with ASD and maternal salivary cortisol, a hormone secreted from the adrenal gland, in a sample of mothers and their adolescent or adult children with ASD.

Biological Markers of Stress

Cortisol is a hormonal marker of stress which has received considerable attention in studies of psychological and physical health. During exposure to an acute stressful event, the hypothalamic-pituitary-adrenal (HPA) axis is activated and releases cortisol from the adrenal cortex into the bloodstream. Cortisol, in turn, acts on a variety of adaptive responses including protein synthesis and glucose regulation, immune function, and mental activity ( Flinn, 2006). In the short term, these changes enable the body to respond to the immediate challenge (i.e., extending the "fight or flight" response induced by adrenaline); however, chronic stress and persistent activation of the HPA axis can have detrimental impacts on health and well-being, such as a suppression of bone growth and certain immune responses, as well as poorer cognitive performance ( McEwen, 1998; Segerstrom & Miller, 2004).

A major methodological breakthrough for psychological research was achieved when it was shown that salivary cortisol level reliably reflected circulating hormone levels ( Kirschbaum & Hellhammer, 1994), which enabled assessment of adrenal activity across the day in a noninvasive manner. The present study measured cortisol levels in mothers of individuals with ASD via saliva samples collected at four times during the day over a four-day period. Cortisol typically follows a clear daily rhythm, with peak values seen shortly after waking up in the morning and declines occurring throughout the day until bedtime. By collecting daily measures of subjective stress and daily salivary specimens, we were able to extend prior research on the impact of familial stress to mothers whose son or daughter has ASD, a group for which cortisol regulation had not previously been investigated. By focusing on mothers of adolescents and adults with ASDs (as opposed to mothers of young children on the autism spectrum), we were able to investigate the effects of chronic as well as daily parenting stress.

Psychological Stress and Cortisol Response

In past research on individuals experiencing chronic stress, it was initially expected that heightened cortisol levels would be the pattern associated with sustained demand and challenge. However, in a review by Gunnar and Vazquez (2001), it was observed that chronic stress is in fact associated with reduced cortisol levels in multiple populations. For instance, in comparison to parents of healthy children, parents of children with cancer showed flatter diurnal slopes due to a reduction in cortisol at one hour after awakening ( Miller, Cohen, & Ritchey, 2002). Blunted cortisol responses have likewise been seen among combat soldiers, Holocaust survivors, and individuals suffering from post-traumatic stress disorder ( Heim, Ehlert, & Hellhammer, 2000; Yehuda, Boisoneau, Lowy, & Giller, 1995; Yehuda, Kahana, et al., 1995). There also appears to be an association between the severity of stress and the impact on the HPA-axis. For example, in a study of employees with clinical burnout, more severe burnout symptoms were associated with lower cortisol awakening response ( Sonnenschein et al., 2007). Taken together, these findings highlight the fact that the hormonal response to chronic stress is quite different than the immediate elevation of cortisol seen after acute challenges.

To our knowledge, no prior studies have examined cortisol levels in families of children with ASD, although past research has investigated the cortisol rhythms of parents of children with other types of disabilities. Seltzer, Almeida, Greenberg, Savla, Stawski, Hong, and Taylor (2009) compared parents of adolescents and adults with developmental disorders and mental health problems with parents of similarly-aged children who did not have disabilities or chronic health conditions. Disabilities in children in the Seltzer et al. (2009) study included attention deficit hyperactivity disorder (15.9%), bipolar disorder (12.2%), schizophrenia (9.8%), depression (7.3%), Down syndrome (6.1%), and others. The findings indicated that parents of a son or daughter with a disability had a normative daily rise of salivary cortisol but a significantly less pronounced daily decline of cortisol when compared to parents of children without disabilities, a pattern that was most pronounced on days when the parents spent more time with their children ( Seltzer et al., 2009). These findings provide some indication of a dysregulated pattern of cortisol activity. However, the heterogeneous range of disabilities in the children may have obscured diagnostic-specific patterns.

Present Study

The present study extended these findings not only by focusing on mothers of individuals with ASD, but also by investigating the role of child-related stress, specifically behavior problems, in predicting cortisol levels within the ASD group. We examined daily behavior problems in predicting daily maternal cortisol response as well as how the child's behavior problem history conditioned the mother's response to the behavior problems manifested by her child on a given day. Past longitudinal studies (e.g., Lounds et al., 2007) have shown that behavior problems manifested by a child with ASD have a long-term effect on maternal well-being. Thus, it may be valuable to determine how a mother's response to acute behavior problems interacts with her son or daughter's history of behavior problems in producing the maternal cortisol response.

The present study had four aims. First, in order to profile the diurnal pattern of cortisol activity characteristic of mothers of adolescents and adults with ASD, we investigated whether these mothers differed from a comparison group of mothers of similarly-aged children without disabilities on measures of salivary cortisol collected at four points across the day: awakening, 30 minutes after awakening, before lunch, and before bedtime. Second, within the ASD group, in order to elucidate how chronic stress may affect cortisol levels, we examined the impact of history of child behavior problems by comparing the cortisol levels of mothers of adolescent and adult children with a history of clinically-significant levels of behavior problems to mothers whose son or daughter had a history of below-clinical levels of behavior problems.

Third, in order to investigate how acute stress may simultaneously affect cortisol levels, we examined the impact of daily behavior problems on the diurnal rhythm of cortisol among mothers of a son or daughter with ASD, using multilevel modeling. Finally, also using multilevel models, we estimated the interaction of daily behavior problems with behavior problem history in predicting maternal cortisol levels, in order to explore whether chronic stress moderates daily stress.

Consistent with prior studies of parents with stressful caregiving experiences ( Miller et al., 2002), we hypothesized that mothers of adolescents and adults with ASD would have significantly lower levels of daily cortisol secretion throughout the day than mothers of unaffected, similarly-aged children. We also expected that mothers of children with ASD who had a history of clinically-significant levels of behavior problems would have lower cortisol levels than mothers of children with a history of below-clinical levels of behavior problems, reflective of the effects of chronic stress.

Based on past research findings indicating a strong association between child behavior problems and parental psychological stress ( Hastings et al., 2005; Herring et al., 2006; Lounds et al., 2007) and studies showing that day-to-day experiences can affect subsequent daily variations in cortisol secretion ( Adam, Hawkley, Kudielka, & Cacioppo, 2006; Eller, Netterstrom, & Hansen, 2006), we hypothesized that when adolescents and adults with ASD had multiple behavior problems on a given day, their mothers would show a more pronounced cortisol response to awakening the next day than mothers whose son or daughter with ASD had fewer behavior problems the day before. Finally, we explored whether the behavior problem history of the adolescent or adult with ASD would moderate the effects of daily behavior problems on maternal cortisol. Specifically, we explored whether the impact of frequent daily behavior problems would be less pronounced for mothers whose adolescent or adult child had a history of elevated levels of behavior problems than for mothers whose child had a history of low levels of behavior problems. Mothers who are exposed chronically to high levels of behavior problems may be less reactive to daily behavior problems than mothers from whom this degree of stress is unusual.

Method

Participants

Participants were drawn from two longitudinal studies. The target group of mothers was obtained from an ongoing longitudinal study of adolescents and adults with ASD (the AAA study; Lounds et al., 2007; Seltzer et al., 2003; Shattuck et al., 2007). The comparison group of mothers was obtained from a nationally representative study of individuals in the National Survey of Midlife in the United States (the MIDUS Study; Brim, Ryff, & Kessler, 2004; Gruenewald, Mroczek, Ryff, & Singer, 2008, described below).

AAA Study

Mothers in the AAA study were recruited via service agencies, schools, diagnostic clinics, and media announcements. At entry into the study, families met three criteria: (a) the family included a child 10 years of age or older; (b) the child had received a diagnosis of ASD from a medical, psychological, or educational professional, as reported by parents; and (c) scores on the Autism Diagnostic Interview-Revised (ADI-R; Lord, Rutter, & Le Couteur, 1994; Rutter, Le Couteur, & Lord, 2003), administered by research staff, were consistent with the parental report of an ASD. Nearly all (94.6%) of the sample members met the ADI-R lifetime criteria for a diagnosis of Autistic Disorder. Case-by-case review of the other sample members (5.4%) determined that their ADI-R profile was consistent with their autism spectrum diagnosis (i.e., meeting the cutoffs for reciprocal social interaction and repetitive behaviors for Asperger's Disorder, and meeting the cutoff for reciprocal social interaction and the cutoff for either impaired communication or repetitive behaviors for PDD-NOS).

Initially, 406 mothers of individuals with ASD participated in the AAA study, which began in 1998. Between 1998 and 2005, data were collected from mothers at four points in time, about once every 18 months, spanning about a 4.5 year period for each mother. During 2006-2007, the AAA Daily Diary Study was conducted (described more fully below), providing daily data over an 8-day period. The Daily Diary protocol, which was modeled after the Daily Diary Study of MIDUS ( Almeida, Wethington, & Kessler, 2002), consisted of short telephone interviews conducted with the mother at the end of each of eight consecutive days, with cortisol measured four times a day on Days 2 through 5.

An additional criterion for participation in the AAA Daily Diary Study was that the son or daughter with ASD lived at home with the mother. When the AAA study began in 1998, the full sample was comprised of 264 individuals with ASD who lived with their families and 142 who lived away from home. An increasing proportion of individuals moved away from the family home at each subsequent point of data collection, such that by the time of the AAA Daily Diary Study, only 136 individuals with ASD remained co-resident with their parents.

Of the 136 mothers who were potential participants in the AAA Daily Dairy Study, 6 could not be reached and 34 declined participation in this component of the AAA study, resulting in 96 mothers who participated in the AAA Daily Diary Study. Of these, 3 mothers declined to participate in the cortisol collection, and 7 mothers did not provide complete data on daily medication use, which was needed for the present analysis. Thus, AAA participants in the present set of analyses consisted of a sub-sample of 86 mothers. The adolescents and adults with ASD in this subsample ranged in age from 18 to 53 years of age ( M = 24.7 years, SD = 7.24). The majority of the sample members were male (79.1%).

Just over half (57%) of the sample members had an intellectual disability (ID). ID status was determined using a variety of sources. Standardized IQ was obtained by administering the Wide Range Intelligence Test (WRIT; Glutting, Adams, & Sheslow, 2000) and adaptive behavior was assessed by the Vineland Screener (Sparrow, Carter, & Cicchetti, 1993). Individuals with standard scores of 70 or below on both measures were classified as having ID, consistent with diagnostic guidelines (Luckasson et al., 2002). For cases where the individual with ASD scored above 70 on either measure, or for whom either of the measures was missing, a review of records by three psychologists, combined with a clinical consensus procedure, was used to determine ID status.

MIDUS Comparison Group

A comparison sample of 171 mothers of co-residing sons and daughters without disabilities was drawn from the National Study of Daily Experience (NSDE), one of the projects comprising the National Survey of Midlife in the United States (MIDUS). MIDUS is a nationally-representative study of English-speaking, non-institutionalized adults who were aged 25 to 74 in 1994 (MIDUS I; Brim et al., 2004; Gruenewald, Mroczek, Ryff, & Singer, 2008). Data used in the present analysis were collected from 2003 to 2005 as part of a second wave of data collection (MIDUS II). There were 1265 individuals in the MIDUS II sample who participated in the NSDE (David Almeida, PI), referred to here as the MIDUS II Daily Diary Study.

For our comparison sample, we excluded 558 of the 1265 cases in which the respondent was male (as the AAA study consisted exclusively of mothers) and 66 cases where the respondent was female but had a child with a developmental disability or mental health condition. Additionally, 421 female respondents were excluded because they did not have any children living in their home, resulting in a potential comparison group of 230 mothers of co-residing, similarly-aged children without disabilities. Of the 230 mothers, 59 were excluded from the analysis because they did not provide complete information about medication use. The remaining 171 sample members constituted the comparison group for this analysis.

AAA versus the comparison group

The two groups of mothers were similar in terms of educational attainment, household income, marital status, and number of children (see Table 1 ). However, the mothers in the AAA sample were more likely to take medications during the study period, χ ² = 4.68 df = 1, p < .05, and therefore this variable was controlled in the between-group analysis (described below). In addition, the mothers in the AAA sample were significantly older than those in the comparison sample, t = 2.82, df = 255, p < .01; therefore, maternal age was controlled in the between-group analyses.

Table 1

AAA vs. Comparison

N

Mean

SD

Marital status (0 = not married/1 = married)

0 Comparison
1 AAA

171
86

.743
.791

.44
.41

Number of children

0 Comparison
1 AAA

171
86

2.63
2.74

1.38
1.28

% sons among co-residing children
% sons among target children

0 Comparison
1 AAA

171
86

49.4%
79.1%

As noted earlier, consistent with ASD prevalence data (APA, 2000), the majority of the children in the AAA sample were sons (79%). Because the MIDUS study was not originally designed as an investigation focusing particularly on parenting, mothers in the MIDUS sample did not designate a target child, precluding controlling for child gender in the current analyses. However, for descriptive purposes, we calculated the proportion of coresiding children of the comparison group who were sons versus daughters, which we expected to be equal. As expected, in the comparison sample, the proportion of co-residing sons was 49.7%.

Among both the AAA and the comparison groups, there were no significant differences in mothers' socio-demographic characteristics (i.e., maternal education, income, marital status, age) between sample members included in the analysis and those excluded.

Procedure

For the AAA study, mothers participated in four in-home interviews, each spaced 18 months apart, that typically lasted two to three hours, and they completed standardized self-administered measures. The present analysis used measures of behavior problems (described below) obtained in the Time 1, Time 2, Time 3, and Time 4 interviews.

For both the MIDUS and the AAA studies, the Daily Diary protocol involved telephone interviews with mothers each evening for a period of 8 days. The daily telephone interview, which lasted approximately 15-25 minutes, included questions about daily experiences in the previous 24 hours. Data about medications taken each day were also used in the present analysis for control purposes. Daily Diary interviews for both groups were conducted by the Survey Research Center at The Pennsylvania State University. This ensured that the procedures for interviewing mothers in the AAA and MIDUS studies were identical. Several additional questions were included in the telephone interviews for the AAA sample, including the daily measures of behavior problems. The Daily Diary protocol is described in detail in Almeida et al. (2002) and its use with our sample of mothers of adolescents and adults with ASD is described in Smith, Hong, Seltzer, Greenberg, Almeida, and Bishop (2009).

For the cortisol analyses, mothers provided four saliva samples each day on Days 2 through 5 of the 8-day Diary Study period to be assayed for cortisol: one upon awakening, a second 30 minutes after awakening, a third before lunch, and a final sample at bedtime. Respondents received a Home Saliva Collection Kit one week prior to their initial phone call. Saliva was obtained using Sarstedt salivette collection devices. Sixteen numbered and color-coded salivettes were included in the collection kit, each containing a small absorbent cotton pad, about 3/4 of an inch long, as well a detailed instruction sheet. In addition to written instructions, study staff reviewed the collection procedures and answered any questions. Mothers were instructed to collect their first saliva sample before eating, drinking or brushing their teeth. They were also asked not to consume any caffeinated products (coffee, tea, soda, chocolate, etc.) before taking their subsequent samples throughout the day.

Data on the exact time respondents provided each saliva sample were obtained from the nightly telephone interviews and on a paper-pencil log sent with the collection kit. In addition, approximately 25% of the MIDUS respondents received a "smart box" in which to store their salivettes. These boxes contained a computer chip that recorded the time respondents opened and closed the box. The correlations between self-reported times and the times obtained from the "smart box" were high: .93 for the wake-up collection time, .95 for the collection 30 minutes after awakening, .83 for the lunchtime collection, and .75 for the evening occasion.

Measures

Cortisol

Two types of cortisol measures were used as dependent variables. First, we measured the level of cortisol at each of the four collection points. Second, we computed the awakening response. The awakening response, or "morning rise," is defined as the increment between the cortisol value obtained upon awakening and the value 30 minutes later. Cortisol data was log transformed because typically, raw cortisol levels have positively skewed distributions. Therefore, we used the natural log of cortisol to adjust the skewness in the multilevel models (described below). However, raw cortisol levels were used in Figures 1 - 2 to facilitate interpretability of data. To minimize the influence of extreme outliers, salivary cortisol values higher than 60 nmol/l were recoded as 61, before the log transformation, following the statistical approach recommended by Winsor ( Dixson & Yuen, 1974; Wainer, 1976). Only a small percentage of sample members were extreme outliers (n = 4, 4.7% of cases for the AAA sample and n = 19, 11.1% of cases for the MIDUS comparison group). An outlier was identified if at least one collection, out of a maximum of 16, had a cortisol value higher than 60.

Behavior Problems

For the within-group AAA analyses, two measures of behavior problems were used. One reflected the manifestation of behavior problems on each day during the AAA Diary Study (referred to as daily behavior problems), while the other was based on the behavior problems manifested during the Time 1 through Time 4 points of data collection in the AAA study (referred to as the history of behavior problems). Both measures of behavior problems were based on the Scales of Independent Behavior-Revised (SIB-R; Bruininks, Woodcock, Weatherman, & Hill, 1996). The SIB-R scales assess eight types of behavior problems: behaviors that are hurtful to self, unusual or repetitive, withdrawn or inattentive, socially offensive, uncooperative, hurtful to others, destructive to property, and disruptive. The SIB-R is a measure of behavior problems developed for the broad population with developmental disabilities. Some of the types of behavior problems are inherent to autism (e.g., unusual or repetitive behaviors), while others are more common across developmental disabilities of a variety of etiologies (e.g., uncooperative behavior).

For the history of behavior problems measure, at Time 1 to Time 4, mothers were asked to indicate if their son or daughter with ASD had manifested each of the eight behavior problems during the previous 6 months and, if so, to rate the frequency of each behavior problem (ranging from 1 = less than once a month to 5 = one or more times an hour) and its severity (1 = not serious to 5 = extremely serious). Using standardized algorithms ( Bruininks et al., 1996), frequency and severity scores were translated into a summary score at each time point. The reliability and validity of the SIB-R has previously been shown to be excellent ( Bruininks et al., 1996). Higher scores on the SIB-R reflect more severe behavior problems.

For the history of behavior problems measure, the mean value of the four SIB-R measures obtained at the Time 1 to Time 4 points of data collection was calculated and used in the multilevel models. There was a high level of stability of SIB-R scores from Time 1 to Time 4; intercorrelations of the four scores across this time period averaged .67. Further, for descriptive purposes and to graph the interaction findings, the sample was divided into two groups those above and below a score of 110, which is the cut-off point between clinical and non-clinical behavior problems ( Bruininks et al., 1996). The sample was evenly divided between those above clinical levels of behavior problems (n = 44, 51.2%) and those below clinical levels (n = 42, 48.8%).

The daily behavior problems measure reflected a count of the number of behavior problems mothers reported their son or daughter with ASD had on a given day, which was a modification of the standard approach to administering the SIB-R. During the Daily Diary interview, mothers indicated if their child manifested each type of behavior problem that day (each coded 1 if yes and 0 if no), and the total number of "yes" responses was computed for each day. Due to a clerical error, the "disruptive behavior" item was omitted from the Diary Study, and thus the total number of daily behavior problems ranged from 0 to 7. Although the SIB-R was scored differently for the history and daily measure, the correlation between the two measures was .63.

Control Variables

For the between-group analyses, control variables included maternal age and whether the mother took prescription medications during the Diary Study (0 = no, 1 = yes), which are the two variables on which the AAA and comparison groups differed significantly. We also included saliva collection time at each of the four collection points, as a method of controlling the chronobiology of cortisol ( Keenan, Licinio, & Veldhuis, 2001).

For the within-group analyses, control variables included characteristics of the mother and the son or daughter with ASD. Characteristics of the mother included age, education, marital status, the number of children in the family, medication status, and awakening saliva collection time ( Keenan et al., 2001). Maternal education was measured using an ordinal scale (1 = less than high school, 2 = high school graduate, 3 = some college, 4 = college graduate). Marital status was a dichotomous variable (1 = married, 0 = not married). The number of children in the family included all children, living in the home or elsewhere, and medication status indicated whether the mother took any prescription medications. We also controlled whether or not the son or daughter with ASD also had intellectual disability (1 = yes, 0 = no) and child gender (1 = male, 0 = female).

Data Analysis Plan

First, for the between-group analyses, mothers who had a son or daughter with ASD were compared to mothers of similarly-aged children without disabilities with respect to cortisol levels at each collection point. We used repeated measures MANOVA and multilevel models using Hierarchical Linear Modeling (HLM) software ( Raudenbush & Bryk, 2002) to examine the extent to which mothers who had a son or daughter with ASD differed from the comparison group in daily cortisol levels at each of the four time points (awakening, 30 minutes after awakening, before lunch, and before bedtime). In the multilevel models, covariates included maternal age, whether the mother was taking prescription medications during the Diary Study, and the time that cortisol was collected at each time point.

Next, the AAA sample was divided into two groups (i.e., mothers of those with a clinically significant history of behavior problems and mothers of those with a history of below-clinical levels of behavior problems, divided at the SIB-R score of 110) and their cortisol levels were compared.

Finally, for the AAA group, we examined how behavior problems manifested by the son or daughter with ASD the previous day were related to maternal cortisol activity, using multilevel models predicting the cortisol awakening response. We focused on the awakening response parameter (from awakening to 30 minutes after awakening) because we expected that the morning rise would be more sensitive to behavior problems manifested by the son or daughter on the prior day than would cortisol collected later in the day. By asking whether behavior problems have a lagged (i.e., next day) effect, rather than examining a simultaneous (i.e., same day) effect, we will be able to more confidently interpret the direction of effects as extending from behavior problems to cortisol response.

For these analyses, both the history and the daily measures of behavior problems were used to assess between- and within-person associations. History of behavior problems (a person-level predictor) was used to assess whether mothers whose son or daughter had higher levels of behavior problems differed in cortisol activity compared to mothers whose child had lower levels of behavior problems. The daily measure of problem behavior (a day-level predictor) was used to reveal within-person associations. We first estimated the main effects of the history and daily behavior problem measures (Models 1 and 2, respectively). Next, we estimated a model testing the interaction effect between the history and daily measures (Model 3). In these models, the covariates included maternal education, age, marital status, number of children in the family, whether the mother was taking prescription medication during the Diary Study, awakening collection time, whether the child had an intellectual disability, and the gender of the son or daughter with ASD. Note that in the within-group multilevel models, the history of behavior problems variable was a continuous measure, but the dichotomized measure was used to graph the interaction in Figure 2 .

Findings

Between Group Analysis of Cortisol Activity

We first sought to determine whether the diurnal rhythm of cortisol in mothers of individuals with ASD differed from the comparison group. To do so, we conducted a multivariate ANOVA (MANOVA) with four measures of cortisol levels (using log transformed scores, averaged across the four days) as the dependent variables, and group (the AAA group versus the MIDUS comparison group) as the factor. Follow-up univariate ANOVAS were used as post-hoc assessments of between-group differences at each time point.

The overall multivariate test was significant [F (4, 249) = 11.197, p < .001], suggesting that the two groups differed significantly in cortisol levels. Follow up t-tests revealed that mothers of individuals with ASD had significantly lower levels at first three time points (p < .001), but the two groups did not differ at bedtime (see Table 2 and Figure 1 ). Note that, to aid in interpretability, Figure 1 is based on raw scores.

Table 2

Cortisol Variables

AAA vs Comparison

N

Mean

SD

Next, we used multilevel models to analyze log transformed cortisol levels at these four time points in the AAA and MIDUS samples, controlling for maternal age, whether the mother was taking prescription medications during the Diary Study, and for the collection time of each of the four saliva samples, all of which are factors that can affect cortisol levels. As shown in Table 3 , the significant coefficient for group (AAA vs. comparison) indicated that even with these factors controlled, mothers of individuals with ASD had significantly lower cortisol at all four time points than mothers in the comparison group, providing support for our first hypothesis.

Table 3

Awakening

30 min. after awakening

Before lunch

At bedtime

Fixed Effects

Intercept

2.742 (0.040)***

3.093 (0.046)***

1.958 (0.044)***

1.187 (0.053)***

Person-level predictors

Group (AAA = 1)

−0.276 (0.056)***

−0.310 (0.063)***

−0.338 (0.057)***

−0.181 (0.077)*

Mother's age

0.003 (0.003)

0.003 (0.003)

0.007 (0.003)*

0.010 (0.003)**

Taking medication (yes = 1)

−0.091 (0.053)⁺

−0.067 (0.060)

−0.051 (0.093)

−0.006 (0.068)

Day-level predictor

Collection time

−0.056 (0.024)*

−0.115 (0.020)***

−0.028 (0.019)

0.145 (0.030)***

Random Effects (Variance Component)

Between-Person: Intercept

Between-Person: Collection time

0.026 (d.f. = 227)
X ² = 253.2

Within-Person

0.161

0.146

0.151

0.246

History of Behavior Problems

Next, within the AAA group, we examined whether mothers' cortisol level differed by their son or daughter's history of behavior problems as measured by four assessments of behavior problems across the 4.5 years between Time 1 and Time 4. The average history of behavior problems score for the current sample was 112.9 ( SD = 9.1), ranging from 99 to 136.

Mothers whose son or daughter with ASD had clinically-significant levels of behavior problems (scores greater than 110; n = 44) were compared to mothers of individuals with below-clinical levels of behavior problems (scores less than or equal to 110; n = 42). For this comparison, we used analysis of covariance, run separately for each point of cortisol collection; covariates included maternal education, age, marital status, number of children, whether the mother was taking medications during the diary study, and wake-up collection time. We also controlled for whether the son or daughter with ASD also had intellectual disability and child gender. Although mothers whose son or daughter had a history of clinically-significant behavior problems had lower cortisol levels, the differences were not significant at any time point, and thus our second hypothesis was not supported.

Daily Behavior Problems

Table 4 presents descriptive data on daily behavior problems manifested during the 8-day Diary Study. As shown in Table 4 , repetitive behaviors were the most frequently reported behavior problem (on 52% of days). Fully 80% of mothers reported repetitive behavior on at least one day of the study period. Withdrawn behavior occurred on 28% of days, with 58% of mothers reporting withdrawn behavior on at least one day of the 8-day study period. Mothers reported uncooperative behavior and socially offensive behavior on 25% of days. Additionally, 62% of mothers reported uncooperative behavior and 46% of mothers reported socially offensive behavior on at least one day of the 8-day study period.

Table 4

Mean

SD

Behavior Problem on at Least One Day

Destructive behaviors were less frequent: mothers reported behaviors that were hurtful to property and hurtful to others on 7% of days. However, 20% and 18% of mothers reported at least one day during the 8-day study period in which their son or daughter exhibited behavior that was hurtful to property or hurtful to others, respectively. Self-injurious behaviors were reported on 6% of days, with 24% of mothers reporting that their son or daughter displayed self-injurious behavior at some point during the 8-day study.

We also calculated the number of days mothers experienced at least one behavior problem manifested by their son or daughter with ASD. As shown in the bottom row of Table 4 , on average, mothers reported that their son or daughter exhibited at least one behavior problem on 65% of days. Only 6% of mothers did not report any behavior problems during the Daily Diary Study. Not shown in Table 4 is the finding that 35% of mothers reported at least one behavior problem on all 8 days.

Behavior Problems and the Diurnal Rhythm of Cortisol

Table 5 presents multilevel models in which the effects of both history and daily behavior problems on the cortisol awakening response were evaluated. Specifically, the effects of behavior problems from Time 1 through Time 4, the effects of the number of daily behavior problems the day before cortisol collection, and the interaction between the history and daily measure of behavior problems were used to predict the morning rise of cortisol (i.e., the cortisol awakening response).

Table 5

Model 1

Model 2

Model 3

Fixed Effect
4.779 (2.413)+

4.396 (2.395)+

4.400 (2.394)+

Intercept

Person-level predictors

History of BP

−0.020 (0.085)

−0.022 (0.085)

−0.022 (0.085)

Day-level predictors

Awakening collection time

−1.257 (0.450)**

−1.417 (0.481)**

−1.368 (0.452)**

Daily BP-previous day

--

0.617 (0.647)

1.521 (0.715)*

Cross-level Interaction Effects

Daily BP x History of BP

--

--

−0.201 (0.067)**

Random Effect (Variance Component)

Between-Person Intercept (Level 2)

As shown in Table 5 , in Model 1, the history of behavior problems did not predict the morning rise of cortisol (consistent with the MANOVA results described earlier). Model 2 portrays the effects of the daily measure of behavior problems (i.e., the number of behavior problems the day before), which also was not a significant predictor of the morning rise, thus not supportive of our third hypothesis.

However, the interaction between the history and daily behavior problem measures was a significant predictor of the morning cortisol rise (see Model 3). This interaction effect is graphed in Figure 2 . (Raw scores are graphed to aid in interpretability.) The significant interaction effect indicates that, as hypothesized, mothers whose son or daughter had a history of clinically-significant levels of behavior problems had a less pronounced morning rise of cortisol the morning after a day when the child had more behavior problems, as compared with mothers whose son or daughter had a history of below-clinical levels of behavior problems. In contrast, on days when the son or daughter with ASD manifested fewer behavior problems, there was much less of a difference in the mother's awakening response based on her son or daughter's history of behavior problems. Thus, a history of clinically-significant levels of behavior problems reduces the mother's response associated with the "bad prior day" effect (yielding an attenuated reaction after rousing). In contrast, mothers of adolescents or adults who had a history of below-clinical levels of behavior problems showed a heightened response to the prior day's events, which is a more typical cortisol rise at awakening following stress.

Discussion

As a group, mothers of adolescents and adults with ASD evidenced a profile of HPA hypoactivity as compared with normative patterns manifested by mothers whose similarly-aged children do not have disabilities. This cortisol profile may initially seem counterintuitive given the endocrine response to acute stressors, but it is similar to findings on other groups experiencing chronic stress, including parents of children with cancer, combat soldiers, Holocaust survivors, and individuals suffering from PTSD ( Heim et al., 2000; Miller et al., 2002; Yehuda, Boisoneau et al., 1995; Yehuda, Kahana, et al., 1995). Past research on mothers of individuals with ASD has documented their high level of psychological stress ( Abbeduto et al., 2004; Seltzer, Krauss, Orsmond, & Vestal, 2000). The present study extends those findings by demonstrating that these mothers also present with the physiological profile characteristic of individuals experiencing chronic stress. The possible adaptive benefits of this down-regulation of hormone activity have been debated, but it may have some undesirable consequences, such as contributing to fatigue and attentional problems. Indeed, a previous study of the present sample suggested elevated levels of daily fatigue in these mothers of adolescents and adults with ASD ( Smith et al., 2009).

Furthermore, the present study provides evidence to link the subjective experience of stress and cortisol levels over time. The longitudinal and daily designs were particularly helpful in sorting out the temporal order and direction of effects. The history of behavior problems in adolescents and adults with ASD was assessed four times over a 4.5 year period, with a several-year gap between the last measure and the Daily Diary Study when cortisol was assessed. In addition, the measure of daily behavior problems was obtained the day before the cortisol awakening response was measured.

Importantly, the findings showed the benefits of considering the influence of both types of stress on cortisol level. Neither the history nor the daily measure of behavior problems predicted cortisol level independently. Rather, it was the interaction between the two indicators of stress that significantly predicted a mother's daily cortisol level. The global pattern of behavior problems experienced by mothers over a multi-year period established the context in which daily behavior problems had their effects. Specifically, for mothers whose son or daughter had a history of below-clinical levels of behavior problems, a day when their child manifested multiple behavior problems was experienced as aberrant, and the mother reacted on the following morning with a larger and more abrupt rise in cortisol. In contrast, mothers whose son or daughter historically had clinically-significant levels of behavior problems experienced a "bad day" yesterday (i.e., a day when their child had multiple behavior problems) as consistent with the past, and they showed a blunted cortisol response. Thus, it is when a mother's individual history of stress is taken into account that her response to daily stress can best be interpreted.

The descriptive data provided by the present study reveal an alarmingly high level of behavior problems manifested by adolescents and adults with ASD. During the eight-day diary study, virtually all (94%) mothers experienced at least one episode of child behavior problems, and one-third (35%) of the mothers experienced behavior problems on all eight days. Of particular concern, 24% of the mothers indicated that their adolescent or adult child displayed some type of self-injurious behavior on at least one day of the diary study. In addition to daily exposure, the average behavior problems score for this sample was in the clinically significant range over the 4.5 year study period, indicating both a high history of behavior problems measured globally and a high level of current behavior problems measured daily. Together this high exposure, which likely extended over the child's entire life, helps explain lower cortisol levels in the mother. This is the "biological signature" that has been associated with the feeling of job burnout in high stress occupations as well as the arousal, depression, and anxiety found in individuals with PTSD after traumatic events ( Fries et al., 2005; Sonnenschein et al., 2007). In this regard, it would be important in future studies to more specifically and acutely examine the mother's immediate response to her son or daughter's problematic behavior, because people who have PTSD often are highly sensitized to arousing stimuli associated with the trauma experience in spite of manifesting an attenuated daily cortisol rhythm. It is this combination of arousal, along with the intrusive thoughts, numbing, emotional distancing, fatigue, and attentional problems, that contributes to their psychological distress and abnormal physiological states associated with chronic stress ( Fries, Hess, Hellhammer, & Hellhammer, 2005).

An alternative explanation for the between-group differences that we found when contrasting mothers of individuals with ASD and the mothers in the comparison group is that there may be a pre-existing tendency for lower cortisol levels in mothers who have a child with ASD. In other words, the hypoactivation of HPA may be the result of a pre-existing status rather than reflective of the reactive effects of the parenting a child with autism. Recent studies have reported that children with ASD also manifest lower cortisol levels ( Brosnan, Turner-Cobb, Munro-Naan, & Jessop, 2009; Corbett, Schupp, Levine, & Mendoza, 2009). Autism is believed to be a complex genetic disorder, which would suggest that some close relatives may share milder versions of characteristics with those who have the full disorder, including potentially a tendency toward hypoactivation of cortisol. Future research should examine cortisol levels in mothers of children whose developmental disabilities are known not to be inherited (i.e., in sporadic genetic conditions) in order to better separate the influence of difficult parenting from biological propensity to downregulate the HPA axis. Similar issues have been raised with respect to the risk factors for developing PTSD on the basis of twin studies that suggested that a smaller hippocampal volume might contribute to vulnerability ( Gilbertson et al., 2007).

There are several other important questions that emerge from this research that should be pursued in future studies. It would be valuable to assess cortisol patterns in mothers of young children with ASD who have had a shorter period of stress exposure than the mothers in the present sample. It has been suggested that hypocortisolism follows prolonged hyperactivity of the HPA axis ( Fries et al., 2005). Thus, it is possible that the cortisol profile in mothers of young children with ASD might be one of hyperactivation, reflecting reaction to pressures of the newly-challenging parenting situation. Examination of the pattern of cortisol in young mothers is particularly important because studies in the general population suggest a decline in HPA resiliency associated with age ( Seeman & Robbins, 2006).

It will also be important to examine prospectively if cortisol dysregulation is associated with an increased vulnerability to hormone-related health problems in mothers of individuals with ASD, as might be expected based on past research on other groups experiencing chronic stress ( Heim et al., 2000; Miller et al., 2002). Alternatively, it is possible that hypoactivation is a protective response that reduces the individual's risk of health problems, as was suggested by Fries et al. (2005). The longitudinal design of the present study, which is ongoing, will make these determinations possible in the future, with data on maternal health problems collected prospectively. Finally, it would be valuable to examine those factors that might increase vulnerability to and/or that buffer parents against these types of familial and life stressors and to consider the types of interventions, including psychoeducation interventions and cognitive behavior therapies, which could ameliorate the cortisol dysregulation. As mothers of individuals with ASD have increased risks of psychiatric comorbidity ( Piven & Palmer, 1999), this is a particularly important set of investigations to carry out.

The present research had a number of methodological limitations and thus the results warrant cautious interpretation and replication in future studies. The mothers in the AAA study were primarily Caucasian, all volunteered to participate, and all those who were included in the present analysis co-resided with their adolescent or adult child with ASD. Thus, the extent to which they were representative of the diverse population of families with a member with ASD is unknown. In addition, it is possible that the higher proportion of sons in the autism sample than the comparison sample contributed to the between-group differences. We explored this possibility by restricting the samples to son-only families to determine if any of the results changed. This approach did not result in any change in the findings. Juxtaposed against these limitations are the unique strengths of this research, including the longitudinal study period extending over an average of seven years, a nationally representative normative comparison group, and a previously validated protocol for daily cortisol collection (Almeida, McGonagle, & King, under review).

In conclusion, the present study indicated that mothers experience both acute and chronic stress associated with the behavior problems of their adolescent or adult children and that the degree of their cortisol dysregulation is linked with their child's behavioral profile. Interventions that reduce behavior problems would enhance the health and quality of life of both mothers and the individuals with ASD, and thus should be a high priority for service provision. Although behavior problems are implicated in this study, they are linked in complex ways to autism symptoms and cognitive functioning, and thus are just one aspect of a much broader challenge.

Acknowledgments

This research was supported by grants from the National Institute on Aging to support longitudinal research on families of adolescents and adults with autism (R01 AG08768, M. Seltzer, PI) and to conduct a longitudinal follow-up of the MIDUS (Midlife in the US) investigation (P01 AG020166, C. Ryff, PI, and R01AG019239, D. Almeida, PI). The original MIDUS study was supported by the John D. and Catherine T. MacArthur Foundation Research Network on Successful Midlife Development. Support was also obtained from the National Institute of Child Health and Human Development for P30 HD03352 to the Waisman Center at the UW-Madison.

References

Brosnan M, Turner-Cobb J, Munro-Naan Z, Jessop D. Absence of a normal Cortisol Awakening Response (CAR) in adolescent males with Asperger Syndrome (AS) Psychoneuroendocrinology 2009 [[PubMed] Google Scholar]

Dixson WJ, Yuen KK. Trimming and winsorization: A review. Statistical Papers. 1974;15:157-170. [Google Scholar]

Flinn MW. Evolution and ontogeny of stress response to social challenges in the human child. Developmental Review. 2006;26:138-174. [Google Scholar]

Smith LE, Hong J, Seltzer MM, Greenberg JS, Almeida DM, Bishop S. Daily experiences among mothers of adolescents and adults with ASD. Submitted to Journal of Autism and Developmental Disorders 2009 [[PMC free article] [PubMed] Google Scholar]

Wainer H. Robust statistics: A survey and some prescriptions. Journal of Educational Statistics. 1976;1:285-312. [Google Scholar]

# data[].attributes.attachment_link.title
Maternal Cortisol Levels and Behavior Problems in Adolescents and Adults with ASD

# data[].attributes.attachment_link.description
Using daily diary methods, mothers of adolescents and adults with ASD (n = 86) were contrasted with a nationally representative comparison group of mothers of similarly-aged unaffected children (n = 171) with respect to the diurnal rhythm of cortisol. ...

# data[].attributes.attachment_link.readable_text
Number one New York Times best seller

In her latest book, Brené Brown writes, "If we want to find the way back to ourselves and one another, we need language and the grounded confidence to both tell our stories and to be stewards of the stories that we hear. This is the framework for meaningful connection."

In Atlas of the Heart , Brown takes us on a journey through 87 of the emotions and experiences that define what it means to be human. As she maps the necessary skills and an actionable framework for meaningful connection, she gives us the language and tools to access a universe of new choices and second chances - a universe where we can share and steward the stories of our bravest and most heartbreaking moments with one another in a way that builds connection.

Over the past two decades, Brown's extensive research into the experiences that make us who we are has shaped the cultural conversation and helped define what it means to be courageous with our lives. Atlas of the Heart draws on this research, as well as on Brown's singular skills as a storyteller, to show us how accurately naming an experience doesn't give the experience more power, it gives us the power of understanding, meaning, and choice.

Brown shares, "I want this book to be an atlas for all of us, because I believe that, with an adventurous heart and the right maps, we can travel anywhere and never fear losing ourselves."

Includes a downloadable PDF of illustrations from the book

PLEASE NOTE: When you purchase this title, the accompanying PDF will be available in your Audible Library along with the audio.

# data[].attributes.attachment_link.title
Atlas of the Heart: Mapping Meaningful Connection and the Language of Human Experience

# data[].attributes.attachment_link.description
Amazon.com: Atlas of the Heart: Mapping Meaningful Connection and the Language of Human Experience (Audible Audio Edition): Brené Brown, Brené Brown, Random House Audio: Audible Books & Originals

# data[].attributes.attachment_link.readable_text
Our clients are best able to cope with stressors and triggers when they're operating within their window of tolerance.

But a traumatic experience can narrow our clients' window of tolerance, leading to states of either hyper- or hypo-arousal.

So we created this infographic as a tool you can share with your clients. It can help you explain what's going on when they're feeling dysregulated. Plus, this will help to support the exercises and work you do together as an important part of healing.

Click the image to enlarge

If you'd like to print a copy for yourself, just click here: Color or Print-friendly

(Please be sure to include the copyright information. We put a lot of work into creating these resources for you. Thanks!)
For more strategies you can use to help clients who've experienced trauma, be sure to check out the Treating Trauma Master Series.
You'll get insights from Bessel van der Kolk, MD; Dan Siegel, MD; Pat Ogden, PhD; Stephen Porges, PhD; Peter Levine, PhD; Allan Schore, PhD; and Ruth Lanius, MD, PhD.

Now we'd like to hear from you. How could this help you in your work? Please leave a comment below.

# data[].attributes.attachment_link.title
How to Help Your Clients Understand Their Window of Tolerance

# data[].attributes.attachment_link.description
Our clients are best able to cope with stressors and triggers when they're operating within their window of tolerance. But a traumatic experience can narrow our clients' window of tolerance, leading to states of either hyper- or hypo-arousal. So we created this infographic as a tool you can share with your clients.

# data[].attributes.attachment_link.description
The usual challenges of parenting are compounded for parents and primary caregivers of children with special needs.

# data[].attributes.attachment_link.title
Improving services, results, and quality of life for children and youth who are deaf-blind

# data[].attributes.attachment_link.description
NCDB is part of a network of projects for children and youth with deaf-blindness (birth through 21) that includes state deaf-blind projects in every state, as well as Puerto Rico, the District of Columbia, the Pacific Basin, and the Virgin Islands. We are funded by the U.S. Department of Education.

# data[].attributes.attachment_link.provider_name
Professional Development for Teachers of the Visually Impaired

# data[].attributes.attachment_link.title
Professional Development for Teachers of the Visually Impaired

# data[].attributes.attachment_link.description
Resources & professional development opportunities for teachers of students who are blind or visually impaired, including additional disabilities.

# data[].attributes.attachment_link.title
HKNC: Helen Keller National Center for DeafBlind Youths & Adults (HKNC)

# data[].attributes.attachment_link.title
David Brown - Idaho Project for Children and Youth with Deaf-Blindness

# data[].attributes.body
Understanding the importance of Family Dynamics is Important.

# data[].attributes.attachment_link.description
Family dynamics are the patterns of relating, or interactions, between family members. Each family system and its dynamics are unique, although there are some common patterns. All families have some helpful and some unhelpful dynamics. Even where there is little or no present contact with family, a young person will have been influenced by dynamics in earlier years.

# data[].attributes.attachment_link.readable_text
Mirror neurons. Imitation has always been a powerful learning tool. The human brain is enabled with different mechanisms that allow us to imitate actions. Babies are capable of reproducing facial expressions, and as adults, we imitate basic behavior. Laughter can be spread, we can cry while watching a sad movie... It seems like we have the capacity to feel what others feel, empathize with them and understand their feelings. What happens in the brain for this to happen? The answer is mirror neurons. In this article, we will explain everything you need to know about mirror neurons. What are they? How do they intervene in education and empathy? Why is emotion contagious?
What are Mirror Neurons?

In humans and primate species there are neurons called Mirror Neurons. These brain cells activate when we see someone doing something. For example, when a chimpanzee sees its mother opening a nut with a rock and then tries to imitate her with another nut. Mirror neurons are related with empathic, social and imitations behavior. They are a fundamental tool for learning.

"We are social beings. Our survival depends on our understanding the actions, intentions, and emotions of others. Mirror neurons allow us to understand other people's mind, not only through conceptual reasoning but through imitation. Feeling, not thinking."- G.Rizzolatti.

In the 90's a group of neuroscientists, directed by Giacomo Rizzolatti from the University of Parma (Italy), discovered something surprising. A hundred group of neurons in the brain in primates were activated not only when the monkey was doing something but also when the monkey saw another one doing that same action.
Mirror neurons can be defined as a group of neurons that activate when we perform an action or when we see an action being performed.
Mirror neurons are essential for imitation which is key in the learning process. From birth these group of neurons are active and it allows us to learn to eat, dress, speak... Mirror neurons are also important in planning our actions as well as understanding intentions behind actions.

In the next video, Ramachandran a neuroscientist, explains what are mirror neurons and why they are important.

Mirror Neurons and Education

Mirror neurons allow us to learn through imitation. They enable us to reflect body language, facial expressions, and emotions. Mirror neurons play an essential part in our social life. They are key for the child development, as well as relationships and education.

Humans are social beings programmed to learn from others. We all reach our goals working as a group than individually. Seeing a parent, professor or student show a cognitive skill or any other skill, gives us a tangible experience rather than learning from explanation.

How do mirror neurons intervene in our daily lives?

Mirror neurons are responsible for yawning when we see someone else yawn.

These neurons also act when we see someone sad or crying and in turn feel sad.

The same thing happens with smiling or laughing. The way laughter can be contagious.

Studies suggest that there is an activation of the anterior insula when we see someone expressing disgust.

Another study shows that the somatosensory cortex is activated when we see someone touching another person the same way it activates when we are the ones being touched.

8 tips: How do mirror neurons influence education?

Thanks to mirror neurons the emotions we portray have a direct influence on others. This is why teachers have to make the effort to control their emotions, avoid teacher burnout, in order to use mirror neurons as an asset.

1. Show happiness and optimism and that way you will transmit that to your students and children.

2. Control and avoid negative emotions. We all have bad days but teachers have to be sure this doesn't reflect on the children. However, the tricky part is that this doesn't mean children should repress these emotions. As a teacher be sure to detect what emotion the child is feeling and help them learn to identify and manage them accordingly.

3. Use visual signs and imitation any chance you get. Make examples practical with physical demonstrations so that children can imitate you.

4. Encourage group interactions. This will maximize the use of mirror neurons and therefore the child's social relationships and empathy.

5. Use imitation in any activity that you want the children to learn (washing teeth, cleaning up after themselves...)

6. Run from violence. Children learn what they see. If a child is educated in a hostile environment, his mirror neurons will activate and he might repeat these violent behaviors.

7. Teach children the importance of how we listen, particularly body language. That way when someone has to share something or needs help the mirror neurons will activate and empathy will be reinforced.

8. Teach children about emotional intelligence so that they can be able to identify their own and other people's emotions.

Mirror Neurons and Emotional Contagion

Do you feel happy when people around you are happy? Do you get sad or depressed around negative and pessimistic people? This is due to the emotional contagion produced by the mirror neurons.

Emotional Contagion is a process through which a person or group influence the emotions and emotional behavior of another person or group. This can be done through emotional induction conscious or unconscious.

When people communicate they have the tendency to imitate gestures and facial expressions and in many cases feel what others are feeling. It has been proven the high impact emotional contagion has in our personal and work relationships. We are still not conscious of the influential ability we have in other people's emotional state and in turn other people on our own emotional state.

Mirror neurons allow us to literally feel what others are feeling and "live" their emotions. Mirror neurons are based on empathy.

Empathy is the ability to share someone else's feelings or experiences by imagining what it would be like to be in that person's situation.

This is proof that we are social beings. Empathy has been essential to our species survival and shows how without attachments and protection we wouldn't have survived.

How can we take advantage of emotional contagion?

The fact that we can interconnect to each other and understand each other's feelings can work to our advantage.

Happiness is more contagious than sadness, so try to surround yourself with happy people. However, don't avoid people who are sad, we all need support sometimes and giving them love might help them recover faster.

Imitate happy and positive people, do what they do. Practice sports and smile more (even if you don't feel like it, you will later feel better). Keep a healthy self-esteem and stop thinking negatively.

Think before acting or saying anything, especially if its negative. Try to say it politely, educated and as calmly as possible since your emotional state can be contagious.

Check out how laughter can be contagious with this video.

https://www.youtube.com/watch?v=fM45JMTpkBU

Mirror Neurons and Culture

Does culture influence our brain? The answer seems to be yes. According to an investigation from the University of California, mirror neurons respond differently if the person in front of us shares our same culture or not.

Researchers used two actors, one American and another Nicaraguan to show a group of American participants a series of gestures (some American, others Nicaraguan and others without cultural meaning).

With Tr ansc rani al magnetic stimulation (T MS) they investigated mirror neuron activities. They found that participants showed more activity when they saw the American do the gestures in comparison to the Nicaraguan. When the Nicaraguan showed American gestures to the group, the mirror neurons decreased their activity drastically.

It's possible to conclude that mirror neurons are influenced by culture and in turn have an influence on our behavior. The results from this study show us that we are more prepared to understand and empathize with members of our own culture and ethnicity than those who are not. This also explains why we connect faster and easier with members of our own culture.

Mirror Neurons, empathy, and psychopathy

Psychopathy is a personality disorder distinguished by a superficial charm, pathological lies, and low empathy.

It's common for psychopaths to lead a criminal life, however, not all become, serial killers or murderers. Some can actually lead a normal life.

If these psychopaths are not capable of empathizing, does that mean their mirror neurons are not working? A recent study answered this question.

Researchers observed the brain activity of two groups (18 psychopaths and 26 healthy people) while they watched short videos. The videos showed images of hands touching, gently, painfully, socially, rejecting each other and neutrally. They were instructed to watch the video and then to try to feel what the people were feeling. The next part of the study the participants were hit with a ruler to register their pain area in the brain.

Scientists found that only when psychopaths were asked to feel something did they actually feel something, mirror neurons even activated the same way as in the other group. However, when no instruction was given, the psychopath's group showed less activation of the mirror neurons and pain receptors of the brain.

It's not that psychopaths don't have empathy, it's that it's a switch that can be activated and deactivated, and by default, it is always deactivated.

Mirror Neurons and Autism

Symptoms of autism include a delay in language and strained emotional recognition. They are not capable of perceiving different emotions, including their own.

Scientists, therefore, studied the mirror neurons in people with autism to check if they were "broken". They found that the system has a developmental delay, where the activity is slower, weaker and less activated than in others. Nonetheless, the activity increases with age and by age 30 it becomes normal and then unusually elevated.

Other studies have discovered that not all people with autism have a delay in these neurons. They can be activated normally by familiar faces.

Hope you found this article interesting. Please leave a comment below!

References

Molnar-Szakacs, I., Wu, A. D., Robles, F. J., & Iacoboni, M. (2007). Do you see what I mean? Corticospinal excitability during observation of culture-specific gestures. PLoS One, 2(7), e626.

Meffert, H., Gazzola, V., den Boer, J. A., Bartels, A. A., & Keysers, C. (2013). Reduced spontaneous but relatively normal deliberate vicarious representations in psychopathy. Brain, 136(8), 2550-2562.

This article is originally in Spanish written by Andrea García Cerdán, translated by Alejandra Salazar.

# data[].attributes.attachment_link.title
Mirror neurons: The most powerful learning tool

# data[].attributes.attachment_link.description
Mirror neurons. Imitation has always been a powerful learning tool. The human brain is enabled with different mechanisms that allow us to imitate actions. Babies are capable of reproducing facial expressions, and as adults, we imitate basic behavior. Laughter can be spread, we can cry while watching a sad movie...

# data[].attributes.attachment_link.description
Interview with Dr. Suzanne Zeedyk, founder, Connected Baby. Click the Attachment button to download a transcript, audio file, and/or handout.

# data[].attributes.attachment_link.description
This video segment, adapted from NOVA scienceNow, introduces the latest research on a system of neurons that plays a part in how people relate to each other.