RCOT CYPF: Reviewing the Evidence on Interoception in Autism Spectrum Disorder

Gina Daly. Title reads RCOT CYPF: Reviewing the Evidence on Interoception in Autism Spectrum Disorder


Gina Daly is chief editor of the SensorNet SIE publication. She is a senior Occupational Therapist with over ten years’ clinical experience in paediatrics and is based in Ireland. She is an SIE Advanced Practitioner in sensory integration and has completed a Masters of Science degree in Sensory Integration. She is part of the Sensory Integration Education UK & Ireland postgraduate education team where she holds roles as a Clinical Mentor, module E-Mentor and subject matter specialist. She is currently undertaking a PhD at University College Cork, Ireland while working clinically. Here, Gina reports on RCOT CYPF: Reviewing the Evidence on Interoception in Autism Spectrum Disorder.

On February 26th, the Royal College of Occupational Therapist (RCOT) CYPF ASD OT forum hosted a continued professional development learning event on interoception in Autism Spectrum Disorder (ASD). This is a hot topic at the moment and it is getting more traction across a number of fields. This surge in interest is well placed as we are now more aware of its impact on physical health (Quadt et al., 2018), mental health (Khalsa et al., 2018) and well as emotional functioning in general (Critchley and Garfinkel, 2017).

There were approximately 46 therapists in attendance for the forum and it proved to be a very stimulating and interactive event. Be sure to check out their profile to follow along for updates.

Brief introduction to Interoception 

To open the forum event on interoception, the attendees were provided with a brief introduction on interoception via a pre-recorded Ted Talk available on YouTube by Dr. Sarah Garfinkel, Professor of Cognitive Neuroscience at the Institute of Cognitive Neuroscience in University College London. In this talk, Dr. Sarah Garfinkel shared her research on the topic and shared with us the miraculous things our bodies are capable of doing, to help us bond better with our communities. This helped to set the scene for the rest of the day’s learning, before we divided into our smaller groups for the breakout rooms. See the link to this talk for your own viewing (10 mins).

Dr. Garfinkel has been doing research into the area of interoception, anxiety and linking it with the autistic population. In her recent research, she has found increases in interoceptive accuracy, which is then having an impact on reducing anxiety in autistic individuals. Within the research she is currently working on, they are starting to see how links between interoceptive accuracy in one domain, eg cardiac awareness, can impact on other domains in interoception such as bladder control.

Interoception is closely linked with emotional regulation, anxiety and there is research on interoception and eating disorders also. Interoception is quite a widely studied area but for the focus of the forum, the research on autism was the primary focus and the interventions relating to this. 

Prior to the forum event, all registered attendees were sent a number of research articles on interoception (see reference list for articles included). Each attendee was allocated an article to read and critically appraise using the relevant CASP checklist. This was required in addition to reading and appraising a research article by Hample et al. (2020) who completed a pilot study on an Interoception-Based Intervention for Children with Autism Spectrum Disorder. 

The attendees were divided into break out groups, based on the article to which you had been allocated. The CASP checklist was used as a format to structure the discussion. Completing this focused activity as a group and sharing with one another, provided the opportunity for sharing of different perspectives and viewpoints and provided an excellent opportunity for us to practice our critical appraisal skills. We summarised our critical analysis of the research article within the CASP tool for case control studies, before returning to the larger group to present our summary and findings. 

For the larger group discussion, each group fed back on their critical analysis of the research article to which they were assigned. Taking the time to review and critique the evidence is such an important and valuable part of our practice, however it can often get pushed down on the list of priorities. It is essential to ensure that we are keeping abreast of the current evidence base and gaps within the research. This was an interesting and engaging way to do such a review of the evidence. 

For the second part of the event, the pilot study on an Interoception-Based Intervention for Children with Autism Spectrum Disorder (Hample, Kelly & Amspacher, 2020) was the chosen article and we were provided with the following questions to help frame the discussion. 

  • How does interoception impact on occupational engagement for the Autistic children & young people accessing your service? 
  • How do you identify interoceptive challenges? 
  • What are you currently doing in your service to support these issues? 
  • How do they impact on your clients’ occupational engagement?
  • What are the barriers to interventions? 
  • How could you overcome these?

Perhaps this is an exercise you could carry out for yourself now if you did not have an opportunity to attend this event. 

The general consensus after reviewing the research article by Hample, Kelly & Amspacher, (2020) in comparison to some of the other research articles which were reviewed at the beginning of the day, was that this study was much more user friendly, easy to understand and interpret. There were elements that we felt could be translated into practice for trial. We all acknowledged the limitations of the study and the need for more robust research into this area and this has been reported by Kelly Mahler herself. She has reported that there are many more research studies in the process of submission and we look forward to seeing them in due course. We all agreed that as occupational therapists we are very well placed to be leading in such research. Relating the findings to meaningful functional outcomes was a shared value and belief amongst the group and we all emphasised the need for more research to shine a focus on this. We want to be able to take away tangible information, use tools in practice that are accessible and ultimately address the issue of interoception effectively with our clients. 

Interoception curriculum 

  • A private practice therapist shared her positive experience of using the interoception curriculum in practice and spoke about the positive outcomes and overall success she is seeing from using the programme. This therapist spoke about how she incorporates the curriculum by incorporating between 2-5 units of the curriculum per therapy session and its usually not completed in its pure form but mixed in with other approaches. 
  • We spoke about using the principles of the programme as an energy conservation technique to acknowledge when an activity will take more energy and time - for example an exam day. 
  • Some therapists have been using the Kelly Mahler interoception curriculum as part of their practice following completion of the training. There was an acknowledgement that this is usually not completed in its pure form instead embedded into therapy alongside other approaches – such sensory motor or ASI depending on what the client needs are. 
  • We discussed some of the barriers to accessing the curriculum which included the challenges that may arise for pre-verbal clients accessing the interoceptive curriculum, who don’t have the cognitive understanding or ability to access the curriculum. Keeping the learning concrete for these individuals by focusing on concepts such as hot/cold, soft/hard which would be more accessible for these learners. 
  • Commissioning pathways – there was a discussion around how there is not a clear consistent robust evidence base to support implementation of this intervention as detailed in the pilot study by Hample, Kelly and Amspacher (2020). The group discussed possibly trialling the intervention in our own services and then reviewing the outcomes and detailing its effectiveness to management as a starting point. There may be more generalised areas of improvement which would be important to note also when reporting on the outcomes. 
  • All agreed that it is very important to have school staff and parents involved when engaging in this programme. Some therapists discussed the training they complete with teachers and school staff around this.
  • We spoke about having more general discussions with families around interception and the issues relating to this rather than using a standardised measure/questionnaire in the first instance. 
  • There is a wide variation in what therapists were doing in practice. Many were addressing interoception inadvertently by identifying symptoms through standardised assessment tools and background information questionnaires and interviews. Some therapists identified that while it was an issue that was presenting itself, it was not being addressed in practice due to lack of training and confidence on the topic. 
  • It was wonderful to see some SIE advanced practitioners in attendance at this event and I wish to thank the CYPF ASD OT forum for running such a valuable event for our learning. 
  • Please see some of the resources and references which were discussed as part of the session. 

Additional Information

  • The REAL™ Assessment Measure (The Roll Evaluation of Activities of Life) was discussed, which looks at activities of daily living in great detail. This tool breaks down a task into all of its component parts and can guide parents on what to work on within the task of dressing. This is useful for setting functional goals. 
  • An app known as MIGHTIER (being mightier than your emotions) was shared – in which the individual wears a device like a fitbit monitor to track their heart rate. There are child friendly games which evoke excitement and thrill. This concept is about getting the child and young person in tune with their heart rate and linking it to a real-life context when they might feel excited, angry or another real-life emotion. (Mightier Biofeedback games)

Tools and Resources shared


References: 

Craig, A. D. (2002). How do you feel? Interoception: the sense of the physiological condition of the body. Nature reviews neuroscience, 3(8), 655-666.

Critchley, H. D., and Garfinkel, S. N. (2017). Interoception and emotion. Curr. Opin. Psychol. 17, 7–14. doi: 10.1016/j.copsyc.2017.04.020

DuBois, D., Ameis, S. H., Lai, M. C., Casanova, M. F., & Desarkar, P. (2016). Interoception in autism spectrum disorder: A review. International Journal of Developmental Neuroscience, 52, 104-111.

Garfinkel, S. N., Tiley, C., O'Keeffe, S., Harrison, N. A., Seth, A. K., & Critchley, H. D. (2016). Discrepancies between dimensions of interoception in autism: Implications for emotion and anxiety. Biological psychology, 114, 117-126.

Garfinkel, S. N., & Critchley, H. D. (2013). Interoception, emotion and brain: new insights link internal physiology to social behaviour. Commentary on: “Anterior insular cortex mediates bodily sensibility and social anxiety” by Terasawa et al.(2012). Social cognitive and affective neuroscience, 8(3), 231-234.

Kerri Hample, Kelly Mahler & Adam Amspacher (2020) An Interoception-Based Intervention for Children with Autism Spectrum Disorder: A Pilot Study, Journal of Occupational Therapy, Schools, & Early Intervention, 13:4, 339-352, DOI:10.1080/19411243.2020.1743221

Khalsa, S. S., Adolphs, R., Cameron, O. G., Critchley, H. D., Davenport, P. W., Feinstein, J. S., et al. (2018). Interoception and mental health: a roadmap. Biol. Psychiatry Cogn. Neurosci. Neuroimag. 3, 501–513. doi: 10.1016/j.bpsc.2017.12.004

Jones, A., Silas, J., Todd, J., Stewart, A., Acree, M., Coulson, M., & Mehling, W. E. (2020). Exploring the Multidimensional Assessment of Interoceptive Awareness in youth aged 7–17 years. Journal of Clinical Psychology.

Ondobaka, S., Kilner, J., & Friston, K. (2017). The role of interoceptive inference in theory of mind. Brain and cognition, 112, 64-68.

Palser, E. R., Fotopoulou, A., Pellicano, E., & Kilner, J. M. (2018). The link between interoceptive processing and anxiety in children diagnosed with autism spectrum disorder: Extending adult findings into a developmental sample. Biological Psychology, 136, 13-21.

Quadt, L., Critchley, H. D., and Garfinkel, S. N. (2018). The neurobiology of interoception in health and disease: neuroscience of interoception. Ann. N. Y. Acad. Sci. 1428, 112–128. doi: 10.1111/nyas.13915

Schauder, K. B., Mash, L. E., Bryant, L. K., & Cascio, C. J. (2015). Interoceptive ability and body awareness in autism spectrum disorder. Journal of experimental child psychology, 131, 193-200.


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