Low arousal approach

A low arousal approach deals with how staff handles patients who are aroused. These approaches aim to make staff avoid confrontational situations and to, instead, go for the path of least resistance".

Philosophy
The philosophy of low arousal approaches is one of non-confrontation. In high risk situations, responses that reduce arousal are adopted by carers and staff, especially when confronted by distressed individuals. These approaches became popular in services for people with intellectual disabilities in the UK in the mid-1990s. This humanistic and person-centred approach to crisis management was developed in response to the use of restrictive responses to crises such as restraint, seclusion, and chemical restraint. The avoidance of sanctions- and of consequence-based punishment strategies became an implicit part of the approach.

Strategies
A number of different strategies are employed in healthcare settings for the management of challenging behaviour. A theoretical rationale for a collection of short-term non-aversive behaviour management strategies described as low arousal approaches is to avoid the use of punishing consequences to behaviour.

The approach acknowledges the potential role of cognitive behavioural frameworks in shaping staff behaviour.

Components
There are four key components considered central to low arousal approaches, and those include both cognitive and behavioural elements:
 * 1) Decreasing staff demands and requests to reduce potential points of conflict around an individual
 * 2) Avoiding potentially arousing triggers, such as direct eye contact, touch, and removal of sspectators to the incident
 * 3) Avoidance of non-verbal behaviours that may lead to conflict, such as aggressive postures and stances
 * 4) Challenging staff beliefs about the short-term management of challenging behaviours

Evidence
Few studies have been published that directly examine the application of these approaches. In a case study, there was a significant reduction in verbal and physical aggression following the application of low arousal approaches with an adult with an intellectual disability in a hospital setting.

Autism and arousal
Arousal is not a new construct and was originally proposed as an explanatory theory for autistic spectrum disorders. Two implications of this theory are that children and adults with an autism spectrum disorder (ASD) would be more reactive to sensory stimuli than the normal population, and they may be slower to habituate to stimuli. There is some laboratory evidence of differences in physiological responses of individuals with ASD compared to non-autistic controls.

There have been studies comparing autistic children to non-autistic controls, one studying the baseline heart rates of each, and another comparing their baseline skin conductance responses. These differences require replication using larger samples, although there is an intriguing possibility that there may be considerable variation in physiological reactivity of both autistic children and adults.

Hyper- or hypo-arousal?
Hyper-arousal is not universally accepted by all researchers. A recent review of sensory difficulties in autism concluded that the experimental evidence or hyper-arousal was at best mixed. There are a number of problems with this view. First, ASD is a heterogeneous condition and the assumption that hyper-arousal should be a general explanatory theory of autism was too broad. Second, sensitivity to arousing stimuli may be intermittently presenting in individuals with ASD. Third, the stimuli employed in habituation paradigms cannot easily mimic real life non-laboratory-based events. Animal research on arousal has attempted to link deficiencies to conditions such as attention-deficit hyperactivity disorder, Alzheimer's disease, and autism.

Historically, under-arousal in people with an ASD has also been proposed as a factor to specific stimuli, although with limited laboratory evidence. Repetitive movements may serve a dearousing function. Unusual sensory experiences have been reported in autobiographical accounts of people with an ASD. Sensory over-activity has been explained as a possible response to over-arousal. An understanding of arousal and sensory experiences may have great explanatory significance for some forms of challenging behaviours.

Stress and arousal
Stress and anxiety has been proposed as a factor in challenging behaviours of people with ASD. There is a transactional model of stress that emphasizes the interaction between an individual and his or her environment. In this model, stress occurs when the demands of stressors outweigh coping responses. There is a clear interaction between environmental and physiological events. Implicit in this model is the cognitive appraisal of threat. Some individuals with an ASD have difficulties in regulating their emotional responses and even communicating this to carers. To help account for challenging behaviours, such as aggression and self-injury, arousal may mediate stress. There is a strong association between arousal and sensory experiences of people with ASD.

Arousal curve and information processing
The majority of individuals spend time in a state of arousal. In the case of people with an ASD, two distinct arousal groupings have an effect on behaviour. A group of individuals will be hyperaroused and highly reactive to environmental sensory stimuli. At the opposite end of the distribution, a proportion of people are hypoaroused. A number of people with ASD, who present with challenging behaviours, may experience either constant or intermittent states of hyperarousal.

Resources

 * Althaus, M., van Roon, A.M., Mulder, L.J.M., Mulder, G., Aarnoudse, C.C., and Minderaa, R.B. (2000). Autonomic Response Patterns Observed during the Performance of an attention Demanding Task in two groups of Children with Autistic-Type Difficulties in Social Adjustment. Psychophysiology, 41, 893-904.
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 * Goodwin, M.S., Groden, J., Velicer, W.F., Lipsitt, L.P., Grace Baron, M., Hofmann, S.G., and Groden, G. (2006). Cardiovascular Arousal in Individuals With Autism. Focus on Autism and Other Developmental Disabilities, 21, 100-123.
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 * McDonnell, A.A. Waters, T. and Jones D. (2002). Low Arousal Approaches in the Management of Challenging Behaviours. In D. Allen (Ed) Ethical approaches to physical interventions: Responding to Challenging behaviours in people with Intellectual Disabilities. Plymouth: BILD, pp. 104 – 113.
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 * McDonnell, A.A., Reeves, S., Johnson, A., and Lane, A. (1998). Management Challenging Behaviours in an Adult with Learning Disabilities: the Use of Low Arousal. Behavioural and Cognitive Psychotherapy, 26, 163 – 171.
 * O’Neill, M. & Jones, R. S. P. (1997). Sensory Perceptual Abnormalities in Autism:  A Case for More Research.  Journal of Autism and Developmental Disorders, 27(3), 283-293.
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 * Shore S. (2003). Beyond the Wall: Personal Experiences with Autism and Asperger Syndrome: Autism Asperger publishing company.
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