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RSA (Respiratory-sinus-arrhythmia) biofeedback and stress reduction in adolescents with autism

Updated: Feb 12, 2023

During the online LAVA reading session on May 19th, 2021, PhD Anoushka Thoen (KUL) explained her research protocol and received valuable feedback from the members of LAVA vzw. More about the promising research and discussion can be found in the report below.


In recent years, research in autism has demonstrated a relationship between the different functioning of the autonomic nervous system (ANS) (a central component of the physiological stress system) and the presence of psychiatric disorders. The current project will further explore whether and how this different functioning of the ANS is related to social and psychological problems in adolescents with autism (13-18 years). In addition, the effectiveness of a biofeedback intervention for normalizing the autonomic nervous system is investigated. This form of biofeedback aims to increase respiratory sinus arrhythmia (RSA) which is controlled only by the parasympathetic 'restorative' system of the autonomic nervous system. RSA is a component of hart rate variability, which is present in a healthy heart through the cooperation between the sympathetic or accelerating system and the parasympathetic or decelerating system (with respect to heart rate). RSA is named after the phenomenon whereby the heart rate increases during inhalation and decreases during exhalation. The application of this RSA biofeedback to promote the self-regulation of physiological stress has already demonstrated positive results in other populations. Furthermore, it is highly relevant within a population with autism since other frequently used stress-regulating interventions (mindfulness, yoga, etc.) are often associated with a figurative language, which can often lead to problems in people with autism. In addition, these techniques rely on the ability of interoception and body awareness, which is frequently limited in most people with autism. Finally, this phase will also investigate whether this intervention is valid and feasible when applied within the home context (using biofeedback applications).


In summary, the first part of this study will determine autism-specific changes in autonomic nervous system functioning in adolescents with and without autism by using online questionnaires for parents and adolescents and a stress test involving physiological and cortisol (stress hormone) measurements. In doing so, the following research objectives will be tackled: (1) Determine the differences in parasympathetic modulation of heart rate between adolescents with and without autism; (2) Determine the differences between adolescents with and without autism based on physiological, behavioral and cortisol data.


The second part of the study will determine the effectiveness of a biofeedback intervention in adolescents with autism during a supervised and an unsupervised intervention period. The following research objectives will be investigated during this part: (1) Determine the change in parasympathetic modulation of heart rate resulting from RSA biofeedback compared to baseline measurements; (2) Determine the changes on behavioral outcome measures resulting from the RSA biofeedback intervention compared to baseline measurements; (3) Determine the influence of the baseline behavioral outcome measures on the effectiveness of the intervention.


This project was discussed at a reading session of LAVA vzw on May 19th, 2021 where members could express their opinions and offer advice to the researchers associated with this study.


The following discussion points were addressed:


- During the intervention, a certain breathing frequency is determined individually. This can change during the intervention so, during each supervised moment, it can be adjusted when necessary. Other forms of interventions such as yoga and mindfulness also rely on slowing down the breathing frequency. However, adolescents with autism frequently experience difficulties during these interventions due to their difficulties with interpreting figurative language and the rather abstract nature of mindfulness. During the biofeedback intervention, there is no presence of suggestion but a very concrete focus on the way of breathing and how it can be slowed down so that the parasympathetic nervous system can be trained.


- Cortisol measurements were included in the testing protocol to assess, in addition to measurements of the autonomic nervous system, the influence on the hormonal system. However, possible depletion of cortisol levels in young people with autism was taken into account. Due to long-term exposure to stress, it is possible that cortisol levels will no longer rise as a result of stress in young people with autism. The researchers will be able to clarify this by comparison with the cortisol levels of adolescents without autism who went through the exact same stress-inducing test.


- It was determined not to include adolescents without autism in the intervention groups because one of the hypotheses states that adolescents with autism would have more "growth margin" to increase their parasympathetic influence on heart rate compared to adolescents without autism.


- The goal of the intervention is not to obtain moment-specific reduction of stress but to increase the general threshold where one obtains stress. In other words, it might make the proverbial “bucket” less likely to overflow.


- The intervention certainly does not aim to wipe out autism traits but to teach young people how to cope better with their autism. There was no concrete discussion about it but the following hypothesis supports this goal: increasing the parasympathetic influence on the heart rate will bring them more to rest throughout the day so they are less easily/often over-stimulated. This will free up more space in their minds to work on social skills, to build and expand relationships. In addition, a lower parasympathetic influence was linked to more severe stereotypic behavior. The reverse reasoning then states that an increase in parasympathetic activity may have a positive impact on behavior.


The researchers thank the members of LAVA vzw for their productive and inspiring feedback.




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