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The Incredible 5-Point Scale
Kari Dunn Buron
Patricia Howlin, a researcher from the UK,
once said that having autism must be like falling through
Alice’s looking glass (from Alice in Wonderland),
everything is chaotic and confusing. Nothing seems to
make sense, not even our natural social order. A child
on the autism spectrum may not understand that the teacher
is the boss and he is not, and so be terribly frustrated
that he does not get to make up any of the school rules.
Such social confusion can easily lead to social stress,
anxiety, and even aggressive behavior.
We have learned that individuals with autism
tend to work best when taught within visual and predictable
routines. Simon Baron Cohen (in press) suggests that if
individuals with ASD possess good systematizing skills,
it may be possible to use those skills to compensate for
difficulties in empathizing skills. This would imply that
students with ASD may learn best using visual and predictable
“systems”. Dr. Tony Attwood (2006) says that
the more someone with ASD understands his or her emotions,
the more able that person is to express them appropriately.
The Incredible 5-point Scale (Buron &
Curtis. 2003) introduces the use of a scale to teach social
and emotional concepts to individuals who have difficulty
learning such concepts, but who have a relative strength
in learning systems. An example of learning a concept
with a scale can be illustrated by a student who often
talks too loud for the situation. Telling that person
to “be quiet” or “use an inside voice”
hasn’t changed the behavior. Using a scale to further
break down the expectations might be helpful (figure one).
The first step is to decide how you want to break down
the concept. In this case, we broke volume down to illustrate
silence all the way to screaming. Once you have created
your scale, you can write a story for the student to explain
the scale. You can then post the scale near the student’s
desk or personal space. I recommend you review the schedule
often when the student is calm and ready to learn. Do
not wait until the person is upset or in the midst of
screaming to teach.
Once
the student learns about the volume scale and has studied
it repetitively, the parent or teacher can begin practicing
its use in different environments. One way to do this
is to use a small 5 point scale (some teachers wear these
on their ID tags) as a visual prompt. When the student
in this case is talking loudly in the library, the teacher
can get the student’s attention, point to the 4 on
the small scale and pull her finger down to a 2. This
provides a non-confrontational, systematic and visual
way for prompting the student.
Individuals with autism tend to have unusually
high levels of stress (Smith Myles, 2002). Children and
adolescents with ASD tend to have multiple problems related
to stress and anxiety issues. Stress can be caused from
such things as social confusion, changes in the schedule
or environment, miscommunication, or a sense of loss of
control. These problems can include external symptoms
such as tantrums, screaming, aggression towards others,
self-aggression, destruction of property, or social withdrawal.
These behaviors may appear to ‘come out of nowhere’
to the parent or teacher who is not aware that the student
is under stress. It is important to remember that behavior
happens for a reason and that stress and anxiety can play
a significant role in triggering unwanted behavior.
If we know that most children with ASD have
problems with high levels of stress and anxiety, and if
we know that varied forms of stress reduction can release
physical tension caused by stress and anxiety thereby
increasing physical control, then it seems logical that
we should attempt to teach the person with ASD to relax
when they encounter frustrating situations. The Groden
Center has had success in teaching relaxation routines
to children with ASD (Groden, et al. 1994) and such routines
have been used as part of a successful behavior management
program to reduce aggressive behavior (Gerdtz, J. 2000).
The 5-point scale can be used to help teach
the person with ASD to recognize different levels of stress
and anxiety. The scale visually breaks down a person’s
responses to stress by labeling each level with what the
behavior looks like, what the level feels like, and what
stress reduction exercise or routines can be used to reduce
the stress level. The person with ASD and his caregiver
can begin to think in terms of ‘being at’ a
level 1, 2, 3, 4, or 5 using the scale as a visual prompt.
After much practice and patience, the person can be prompted
to bring their stress level down from a 4 to a 2 using
the scale as a guide. The 5-point scale is a cognitive
behavioral method of teaching that attempts to teach the
student how to recognize their own internal emotional
states and then to practice successful responses to those
emotions. We now have published case studies and objective
scientific evidence that CBT does significantly reduce
mood disorders in children and adults with Asperger’s
Syndrome (Attwood. In press).
Consider the case of Johnny, age 10, who
has problems with explosive behavior at school. His teacher
used the 5-Point scale as a worksheet (figure 2) to help
Johnny focus on the different levels of stressful behavior
he exhibited during class. The teacher helped Johnny determine
how each level of frustration might feel, then what situation
might make him feel that way and finally how he typically
reacts at that level.
Johnny’s
teacher had her own small scale that she wore around her
neck with her ID tag. When Johnny exhibited level 2 behaviors,
she would get his attention and point to the 2 on her
scale to prompt him to get out his relaxation photo album.
If Johnny exhibited level 4 behaviors, she would point
to the 4 on her scale and pull her finger down to a 2,
visually illustrating (without words) that she wanted
him to pull his level down to a 2.
Another way of using the 5-point scale is
to give a student input on her own Functional Behavior
Assessment (FBA). Sue had demonstrated several confusing
bouts of explosive behavior. Her educational team decided
to conduct an FBA. To involve Sue in her own evaluation,
I used an activity designed to teach her the use of a
5-point scale while she gave me feedback about her own
stressors. The activity was made from a file folder, marker,
index cards and library pockets (Figure 3). There were
5 pockets labeled with: This never bothers me (1), this
sometimes bothers me (2), this can make me really nervous
(3), this can make me really mad (4) and this can make
me lose control! (5). I had about a dozen or so typical
school situations written on the index cards and after
explaining each pocket, asked her to put each card in
the pocket that fit how it made her feel.
(figure 3)
I then transferred Sue’s answers to
a chart (figure 4) and included it in the FBA report.
(figure 4)
The 5-Point scale has also been successfully
used with nonverbal students with ASD who are not as able
to contribute to the formation of a chart. Karen, who
is 12 years old, would often scream during group time.
Her teacher developed a voice level scale using pictures
to illustrate a closed mouth, a talking mouth with a little
talking bubble, a talking mouth with a bigger talking
bubble, and large mouth with a talking bubble with big
words, and a screaming mouth with an exploded talking
bubble. She taught Karen about the scale in a very direct
and fun way by pointing to the closed mouth picture, pointing
to her own closed mouth and having Karen close her mouth
while looking in the mirror. Karen was rewarded with praise
for modeling the closed mouth. The teacher taught the
talking mouth by using a low hooting sound (which Karen
was able to make), pointing to the picture and again encouraging
Karen to model the sound in the mirror. The teacher then
opened her mouth wide and made a modified screaming sound
while pointing to the screaming picture. Karen enjoyed
screaming and easily modeled the teacher’s scream.
During the group, the teacher had the scale ready and
prompted a classroom assistant to work with Karen, showing
her the scale and pointing to the closed mouth. When Karen
would scream, the assistant showed her the scale pointing
to the scream and pulling her finger down the scale to
the closed mouth. Within days, Karen began to respond
to the visual prompt to stop screaming and within a month,
Karen sat in group with a prompt card with the number
1 on it as a reminder to remain silent. The teacher used
a #2 card to interact with Karen from time to time during
the group and allowing her to verbally participate.
It is important to recognize early symptoms
of social stress and anxiety, such as repetitive movement,
perseverative talking, swearing, oppositional behavior,
inattention or escape behavior. Stress reduction strategies
can then be introduced on the person’s schedule prior
to any predictably stressful situation. A helpful strategy
for teaching relaxation is the use of a calming sequence.
A calming sequence is a short series of relaxation strategies
taught in a visual and repetitive way. I typically use
the 5-point scale to illustrate “coming down”
from anxious to calm while repeating the calming sequence
5 times (figure 5). A typical calming sequence might involve
squeezing hands, rubbing your head, rubbing your legs,
slow breathing or stretching your arms. Some students
may inject their own flavor into the sequence which is
fine, as long as the action is actually relaxing for that
person. The actions should also be ones the person can
do themselves (now or eventually) so that the sequence
does not rely on another person.
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Buron,
Manns, Schultz, and Thomas, figure 5
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The calming sequence should be available
visually and should be practiced repetitively several
times every day. The more the routine is practiced, the
more accessible it should be when high levels of anxiety
set in. If your child has a tantrum whenever there is
an unexpected TV schedule change, then a calming sequence
can be done prior to looking at the TV guide as a way
of preparing for the possible change or disappointment.
When My Autism Gets Too Big! (Buron. 2003) is an
example of using a book to help teach a calming sequence
to children with ASD. In the book, I included deep breathing,
visualization and slow rhythmic breathing as a part of
the sequence.
Any successful program includes adequate
staff training. One method of teaching the 5-point scale
concept as it relates to explosive behavior, is to use
the anxiety curve model (figure 6). This model visually
illustrates the escalation of anxiety, point of explosion
and the de-escalation phase.
(figure 6)
I explain to parents and educators that
teaching takes place when everybody is calm (at a 1).
Levels 2 and 3 indicate heightened anxiety and it is here
that redirection or refocusing needs to take place. I
often hear that the explosion came out of nowhere, however,
when such a situation is examined carefully we can usually
begin to identify subtle symptoms of anxiety that later
can lead to less tolerance, greater frustration and possibly
explosion. For example, Eric is a 5th grader who has been
known to explode, seemingly out of nowhere. Eric’s
educational team began to look closer and noticed that
tantrums happened more often when Eric arrived at school
with a grumpy face. His teacher began to ease up on her
demands when Eric’s face looked this way, assuming
he might have less tolerance for demands on his “grumpy
days”. The team also realized that if they talked
to Eric when he was at a 4 (typically characterized by
swearing or yelling at others), it increased the chances
he would escalate to a 5 (aggressive and destructive behavior).
After an explosive event, Eric needed about
10-15 minutes of silence before he had regained enough
emotional control to handle verbal input from his teacher
or parent. Using the anxiety curve model helped Eric’s
team to visualize the symptoms of his stress as well as
become very planful about their own responses.
It is the recommendation of this author
that all children who engage in destructive, aggressive
or explosive behavior have goals and objectives on their
educational plans that address relaxation. Such goals
and objectives can be addressed in a variety of ways,
one of which is with an incredible 5-point scale.
References:
Attwood, Tony. (2006). The Complete Guide
to Asperger’s Syndrome. Jessica Kingsley Publishing.
Baron-Cohen, Simon and Golan, Ofer. (in press). Systemizing
Emotions: Teaching people on the autism spectrum to recognize
emotions using interactive multimedia. Chapter in text
edited by Kari Dunn Buron and Pamela Wolfberg. Due out
in 2007.
Buron, K.D. 2007. A 5 is Against the Law! Autism Asperger
Publishing Co.
Buron, K.D. 2007. A 5 Could Make Me Lose Control! Autism
Asperger Publishing Co.
Buron, K.D. 2003. When My Autism Gets Too Big! Autism
Asperger Publishing Co.
Buron, K.D. & Curtis, M. 2003. The Incredible 5-Point
Scale. Autism Asperger Publishing Co.
Buron, K.D. 2003. Relaxation Module. ICAN online curriculum
project. www.autismnetwork.org.
Cautela, J. and Groden, J. 1978. Relaxation: A Comprehensive
Manual for Adults, Children, and Children with Special
Needs. Research Press Company.
Gerdtz, John. 2000. Evaluating Behavioral Treatment of
Disruptive classroom Behaviors of an Adolescent with Autism.
Research on Social Work Practice. Vol. 10, #1. Sage Publications,
Inc.
Groden, June, et al. 1999. The Stress survey Schedule
for Individuals with Autism and Other Pervasive Developmental
Disabilities. The Groden Center, Inc.
Groden, J, Cautela, J, Prince, S, Berryman, J. 1994. The
Impact of Stress and Anxiety on Individuals with Autism
and Developmental Disabilities. Behavioral Issues in Autism,
edited by Eric Schopler and Gary Mesibov. Plenum Press,
New York.
Kim JA, Szatmari P, Bryson SE, Streiner DL, Wilson FJ.
2000. The Prevalence of Anxiety and Mood Problems among
Children with Autism and Asperger Syndrome. Autism. Vol.
4.
Smith Myles, B. 2002. Behavioral Forms of Stress Management
for Individuals with Asperger Syndrome. Child Adolescent
Psychiatric Clinics North America.
