Perseveration in Autistic Spectrum Disorder

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Recently, I read an article sent by a colleague that had a catalytic effect on my thinking. The paper is entitled, “The need for a broader approach to emotion regulation research in autism” (Mazefsky, Palfrey, & Dahl, 2012).

This paper focuses on emotional reactivity and regulation in children on the autistic spectrum. The authors note that a more typical approach to studying emotion in ASD individuals is to explore their reaction to emotion in others or their difficulty recognizing their own emotions. However, those who have an ASD individual in their family or who work with ASD individuals know that emotional regulation is a major challenge. Often, frustration escalates, as a rigid imperative of expressed desire or need is repeated over and over in a pattern of perseveration. A child, such as one of my little patients, may plead, “choo choo train!” again and again, despite parental explanations that it isn’t possible to ride the choo choo train at that moment. Frequently, the perseveration ends in a meltdown.

The authors point out another crucial fact known to all families of ASD individuals. Too much negative emotion can adversely affect personal relationships, cognitive abilities such as attention and problem solving, and communication (p. 1). They suggest that individuals with ASD may have an exaggerated amygdala (part of the brain central to the stress response system) response when experiencing negative emotion, and a dampened response when perceiving or judging emotions in others (p. 2). Perseverating behavior is behavior in which the individual focuses intently and excessively on one thing and is unable to adaptively shift his focus of attention. Research on the perceptual processes in perseveration has shown that children with ASD can shift their attention perfectly well in a task involving continuous shifting of attention, but when they are allowed to get involved in an activity, they have difficulty shifting their attention to something else. The paper hypothesizes that increased and sustained amygdala reactivity in individuals with ASD interferes with their cognitive control. This sustained amygdala reactivity may be caused by decreased inhibition of the amygdala by the prefrontal cortex, the part of the brain that exercises judgment, among other things (p. 3).

Studies have shown that negative emotion can interfere with a child’s ability to control his behavior, particularly when his attention is focused on a salient emotional cue or when the motivational significance of the cue is enhanced (p, 4, citing Mischel & Baker, 1975; Prencipe & Zelazo, 2005); (Beck et al, 2011). Since the choo choo trains are motivationally significant to the child in my example, his cognitive flexibility is impaired and it is difficult for him to stop pleading for “choo choo train” and accept the alternatives his parents offer him.

The paper proposes a model called the Iterative Reprocessing Model to explain how strong emotional salience may interfere with executive functioning and cause emotional dysregulation (p. 4). According to this model, there is a bidirectional flow of information from a neural network beginning in the midbrain in the thalamus and amygdala and interacting with many areas of the prefrontal cortex (Zelazo & Cunningham, 2007). When this information reprocessing system works well, it supports regulation by amplifying or suppressing attention to certain stimuli. Negative emotion can affect this reprocessing, but in typically developing children the prefrontal cortex improves in its ability to function in this reprocessing system over time, even in emotionally salient situations (p. 4, citing Zelazo et al, 2010). Current theories of underdeveloped connectivity with the frontal cortex in ASD are consistent with the idea of this reprocessing activity being disrupted (p. 4, citing Schipul, Keller, and Just, 2011). In the case of the child with the perseveration on choo choo trains, we would hypothesize that his initial love of choo choo trains (their “emotional salience” for him) would have caused his amygdala to overreact, and the failure of inhibitory processes due to ineffective connectivity to the prefrontal cortex would sustain the negative affect state and indeed allow it to escalate.

Considering some of the clinical implications of this model, the article suggests that treatment of emotional responses in children with ASD could be improved by learning more about the neurobiological mechanisms involved. Current methods of treating these problematic emotional responses are often nonspecific, involving multiple psychotropic drugs, or have not been shown to generalize to long-term emotional stability (p. 5).

After reading this article, I wondered if joining the child in the emotional aspect of his perseverating behavior – even exaggerating that emotion in a pretend mode – might be an effective approach. In the dyadic work I am doing with an autistic child and his mother, she and I began to experiment with joining him in his plaintive cries for choo choo train. This was a change from our previous empathic remarks about how sad it was for him to not be able to have a ride of the train right now. Instead, assuming that we didn’t really know the exact meaning “choo choo train” had for him in that moment, we joined him in lamenting not having it, as if it were a legitimate and urgent desire. We were as repetitive and insistent as he in crying for a choo choo train, though we always waited for him to initiate the call.

My rationale, in addition to the hypotheses about the neurobiology of ASD proposed by the article, was informed by the principles of dynamic systems theory. A greater number of component parts of the system (now composed of the child, his mother, and I) in interaction had a better chance of finding a moment of meeting and disorganizing the current rigid organization of the system – his perseverating on choo choo trains. If that happened, there was a chance of a new, more complex organization to emerge. In fact, at one point, he murmured “airplane” instead of choo choo train. Picking up on the cue, his mother began to alternate cries for choo choo train with airplane, and a new pattern – slightly more complex – was created. Indeed, there was no meltdown in the session. Instead, there were moments of pleasure shared by all of us, and – though we do not know what next week will bring – even a feeling of hopefulness about change.

Mazefsky CA, Pelfrey KA, Dahl RE (2012). The need for  a broader approach to emotion regulation research in autism, Child dev Prospect, 6(1):92-97.

1. Beck DM, Schaefer C, Pang K, Carlson SK, Executive function in preschool children: Test-retest reliability, J Cogn Dev. 2011 Jan 1; 12(2): 169–193.
2. Mischel W, Baker N. (1975). Cognitive appraisals and transformations in delay behavior. Journal of Personality and Social Psychology. 1975; 31:254–261.
3. Prencipe A, Zelazo PD. Development of affective decision-making for self and other: Evidence for the integration of first- and third-person perspectives. Psychological Science. 2005; 16:501–505.
4. Zelazo, PD.; Cunningham, W (2007). Executive function: Mechanisms underlying emotion regulation. In: Gross, J., editor. Handbook of emotion regulation. Guilford; New York: 2007. p. 135-158.
5. Zelazo, PD.; Qu, L.; Kesek, AC. Hot executive function: Emotion and the development of cognitive control. In: Calkins, SD.; Bell, MA., editors. Child development at the intersection of emotion and cognition. American Psychological Association; Washington, DC: 2010. p. 97-111.

3 thoughts on “Perseveration in Autistic Spectrum Disorder

  1. Ruth Setlak

    Check out Stanley Greenspan’s work on children with autism. This is the approach his model employs to build strength at lower levels of development. It’s very powerful.

  2. Alexandra Harrison Post author

    Thank you for your comment! As you probably know from other blog postings, I am very familiar with Greenspan’s work and admire it a great deal. However, I actually think that this is rather different. Of course, it focuses on regulation, but I think that in a more psychodynamic model like this one the regulation process is enriched by bringing together multiple simultaneous levels of meaning, including symbolization at least in the mind of the adults, in a nonlinear process. I find Greenspan’s hierarchy of levels rather constraining.

  3. Ed Tronick

    Alex:
    I think your clinical thinking about this issue is quite insightful and leads to an important principle or intervention. You say that neither you or the mother do not know the meaning of choo-choo to this little boy. Yet you know that it does have meaning for him. Your choice to join him, rather that use a ‘cookie cutter’ empathetic response is well… brilliant. It allows you to join with him in the making of shared meaning and holds the potential for forming a dyadic state of consciousness with him. Moreover, it does not demand that he now make meaning of your empathetic response, which might be very challenging for him and therefore fail and add to his dysregualtion. In addition, through the repetitions you a new meaning is generated by him – airplane – which follows systems principles about repetition and indeed it is more complex. Last, while the brain model may help it is more important to recognize that it is your understanding of behavior and meaning making that actually moves the exchange forward.

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