Laurence Irwin Sugarman M.D.

On and Off the Spectrum

ART in ASD, Part One

Could autonomic regulation training help kids with autism spectrum disorder?

Posted Jun 23, 2015

The most common, unifying feature of autism spectrum disorder (ASD) is that everyone wears the label differently. We cannot pigeonhole the huge range of intellectual abilities, social talents, language skills and senses of humor in this wonderfully diverse group of people who are affected with ASD.

Many clinicians and researchers seek a unifying hypothesis that explains ASD and its heterogeneity, and so leads to meaningful and practical therapeutic strategies. At the Center for Applied Psychophysiology and Self-regulation (CAPS) at Rochester Institute of Technology, we think we are onto something promising: an autonomic dysregulation hypothesis of ASD.

This post introduces that hypothesis. My next installment will show how the hypothesis translates into helping young people with ASD and their families. The third post in the series will explore origins of ASD that are consistent with this premise.

Part 1:  Autonomic dysregulation hypothesis of ASD

The latest edition of the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-5) holds that, to meet criteria for ASD, a person has core impairments in two areas of daily functioning:

  • Social communication—language, reading nonverbal cues, understanding facial expression, the emotions of others.
  • Cognitive and behavioral flexibility—adapting to new situations, making transitions from one thing to another, thinking about new things.

These two core impairments are reflected in people who can be socially awkward or even unaware of others and who have restricted and narrowed interests and repetitive behaviors (for example, rocking or hand-flapping). The variation is in how these impairments manifest and change over time, but are two of the reasons that there is such a wide range of kinds of people with ASD. Intellectual ability is another, by the way.

Even with their individual diversity, people with ASD share one thing in common—a lot of anxiety. Their “fight or flight” response is set on high, leading them to feel nervous, tense and hypersensitive, and to anticipate bad things to happen, for example. In some symptom surveys of people who have ASD, anxiety is more prevalent and problematic than the ASD characteristics themselves.

Many presume this increased frequency of anxiety is “emergent”—meaning that it stems from having to cope with ASD itself. If that were the case, then the machinery of the “fight or flight” response—the sympathetic nervous system—ought to turn down when people with ASD are left alone with their routines and do not have to cope with novel situations or unfamiliar people. That doesn’t happen in the few studies that have tested this premise. Even when people with ASD are in a comfortable and familiar environment, their sympathetic nervous systems idle high

Repetitive behaviors = Stress relief, self-comfort

There also seems to be a connection between stress, anxiety, and repetitive behaviors. Many animals display repetitive, stereotypical behaviors when negatively stressed. Picture the leopard pacing back and forth at the zoo, the parakeet moving back and forth on her perch and the person waiting in line behind you who is tapping his foot. Sixty years ago, a zoologist named Hinde called these patterns “displacement behaviors.” He was the first of many to note that they serve to lower sympathetic nervous system arousal. In other words, repetitive behaviors and restricted areas of interests are often self-regulatory efforts to ease stress and find comfort.

Searching for clues in the vagal system

The vagus nerve—or vagal system—functions as an integrative conduit for both somatic processes (gastrointestinal, cardiovascular and respiratory) and a “social engagement system” (eye-contact, listening, speech production, emotional regulation and empathy). It acts as a counter-balance to the sympathetic system. In fact, all of the areas influenced by the vagus nerve are typically impaired in ASD.

So, could something happen before or in the weeks after birth to the vagal system that leads to the development of ASD? Could ASD be an alteration in autonomic balance? Could symptoms such as restricted areas of interest and repetitive behaviors be symptoms of coping?

Since our research center focuses on how people self-regulate for health, we began to focus on these questions. In our paper ”Symptoms as Solutions: Hypnosis and Biofeedback for Autonomic Regulation in Autism Spectrum Disorder,” Kelsey Williford, Brian Garrison and I asked, “What if the restrictive and repetitive behaviors of ASD were an effort to self-regulate, and cope with autonomic imbalance that favors sympathetic arousal?” We built on the arguments made previously by Stephen Porges, Marcel Kinsbourne and others to propose that ASD fundamentally rests on too much sympathetic tone and not enough parasympathetic or vagal tone.

Some questions from this premise have to do with etiology, or the origins of ASD. What kind developmental trouble would alter the development of the vagal system and increase the likelihood of ASD? Would that process also help explain the growth in ASD prevalence? Would it favor boys over girls as ASD does? Would it help explain ASD’s broad heterogeneity?

A bold, new approach: autonomic regulation training (ART)

And there are implications for treatment. Could teaching affected children and their parents how to increase their vagal tone and lower their sympathetic tone change symptoms of ASD? Could using biofeedback for autonomic regulation be as potent as social skills training or other commonly used therapies? Could it reduce reliance on medication for behavioral control? Could it decrease restrictive and repetitive behaviors by decreasing sympathetic tone? Could autonomic regulation training (ART) be a key to helping people with ASD be more comfortable and in control? We are very interested in finding the role of ART in ASD.

Next up: Biofeedback, hypnosis and meditation

We have started looking at questions about cause and effect. In July, I will post the second installment in this series and explore how we have begun to use biofeedback, hypnosis and meditative approaches with kids with ASD and their families to improve their autonomic regulation. In the fall, I will share some ideas about processes that may change autonomic, especially vagal, development and lead to ASD.

Autonomic regulation training is exciting, promising and hopeful work. It focuses on helping young people help themselves. It invests in what they can do, rather than what they cannot. Stay tuned.


American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, D.C.: Author.

Sugarman, L. I., Garrison, B. L., & Williford, K. L. (2013). Symptoms as solutions: Hypnosis and biofeedback for autonomic regulation in autism spectrum disorders. American Journal of Clinical Hypnosis, 56, 152–173.

Porges, S. W. (2011) The Polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York, NY: W.W. Norton & Company, Inc.