Interoception gives us the sense that “this is me; this is my body; this is how I feel” (Mahler 2016)
Interoception is an internal sensory system that gives an individual physical and emotional information about themselves. An individual can be aware or unaware of the information provided.
The insula cortex is the interoception area of the brain (Mahler 2017). Evidence has shown that poor interoceptive awareness is linked with less grey matter in the right anterior insula and less activity in the insula (Critchley et al 2004). Interoception allows us to self-manage, which facilitates self-care. It also allows self-regulation; the ability to express ourselves and have socio-emotional interactions in ways that are helpful to ourselves and others
What is autism?
Autism is a neurodevelopmental disorder that affects how people communicate and interact with the world. More than 1 in 100 are on the autism spectrum and there are around 700,000 autistic adults and children in the UK (National autistic society UK). The reason for autism is not fully understood, however it is likely that there are a number of candidate genes involved, along with environmental factors, that result in the condition.
Autism is a spectrum condition that affects people in different ways, from needing 24/7 support to just needing clearer communication and help with some aspects of daily living. It affects how people communicate, learn, and behave. Symptoms of autism can include under or over sensitivity to light, touch, taste, and sound. There may be difficulty with verbal and non-verbal communication, including difficulty recognising emotions in themselves and others, feeling overwhelmed in social situations, and restricted and repetitive behaviours. It is important to note that when you have met one person with autism, you have met one person with autism.
Interoception and autism
Decreased functioning of the insula is associated with a number of neurodivergent conditions such as, autism and ADHD, as well as some psychological conditions such as, OCD, schizophrenia, PTSD, anxiety, and depression. The focus here, given the word constraints of this article, will be in relation to autism, albeit the information will apply to other neurodivergent individuals and neurotypicals to a lesser or greater degree. (Goodall 2022) states that interoception awareness may be halted or reduced in those with autism.
People on the autism spectrum may find it a challenge to self-manage; or to recognise that they are hungry or thirsty for example. They may have difficulties self-regulating, knowing when they are becoming sensory overloaded until they have a meltdown. If those on the autism spectrum can develop skills, with support, to recognise these interoceptive cues, they can be appropriately responded to before any meltdown occurs. This would increase their physical and mental wellbeing.
As we know, in life-threatening situations, such as bumping into a polar bear, our sympathetic system is activated, and we are prepared nicely to fight or flee. We don’t consciously notice this, we just react. It is an inbuilt adaptive survival mechanism.
(Goodall 2022)) suggests that, in non-life-threatening situations, being able to recognise our internal signals of feelings and emotions affords us the opportunity to respond appropriately. However, autistic individuals can misinterpret situations and events as life-threatening and therefore the adaptive survival mechanism is often activated. If interoceptive awareness is reduced in people with autism along with a misinterpretation of situations, then, as emotions escalate, it becomes more challenging to down regulate them. So, on a scale of 1-10 with 10 being the peak of an emotion such as anxiety and 1 being least anxious, if the individual is at a 6, it is easier to down escalate from that point than when they are at a 9. Poor interoceptive awareness means that individuals may not recognise the need to self-regulate until they are in panic mode. You are more able to carry out anxiety reducing behaviours, for example with autistics behaviours such as stimming (repetitive or unusual body movement or noises), breathing techniques, and reframing stressful thoughts, when you are lower on the scale. (Goodall 2022) has developed a number of techniques that may help those on the spectrum to manage the interoceptive cues successfully. As stated, carrying out anxiety-reducing behaviour for those with autism will differ depending on their individual experiences of autism. For some, taking a break from a noisy social environment may be needed, or having 10-minute breaks away from the workstation, or walking, or stimming, or reframing thoughts to relieve anxiety – each is unique to the individual, as it is with neurotypicals. Stimming can often be seen in those with autism. One belief is that it is an attempt to reduce sensory input. Focusing on it reduces the impact of loud noisy environments, particularly in social situations. You should not try to intervene to stop it, unless it is unsafe in some way, for example scratching, then support to modify the behaviour would be needed. Many autistic people report that stimming and repetitive behaviours are fundamental to their wellbeing.
When I first started to investigate interoception, I was interested in how an understanding of it may benefit my autistic adult son. My son is an amazing young man, kind, caring and highly intelligent and currently studying for his masters in mathematics. It was during his recent exam period that I put into play what I had learned about interoception. He can quickly become exhausted due to sensory overload, particularly whilst revising and completing projects. He will hide away in his room for hours on end, only taking breaks to eat the food and drink that I quietly slip into his peripheral vision. He can get to autistic burnout before any signs have been seen. He is not aware of his interoceptive signals, so he hits the red zone with no warning, and then has little opportunity to manage it. However, any advice on this from me has been met with increased anxiety and further withdrawal. If you always do what you've always done, you'll always get what you've always got.
A new approach was needed. So, I mentioned during one of my food deliveries that I was reading some interesting articles on interoception and autism. His ears pricked up, as I said he is highly intelligent, and also a seeker of information that may benefit him in managing his autism. I planted the seed. A few hours later he popped downstairs, fortunately I was on my laptop looking at an article on the subject. He started to read over my shoulder and asked me to explain what interoception was, so I did just that. I then explained about the scaling, as I’ve outlined above, and he was in agreement that that made sense to him, he could relate to it. We then discussed how taking a break and focusing in on how he felt could allow him time to notice interoceptive messages. So, we tried it, at his request. I asked him to just take a moment to become aware of how he felt. He relaxed back and after about a minute said that he was thirsty and felt anxious and on a scale of 1-10 his anxiety was at a 6. I asked him what he could do to help him bring that down a step. He said I need to remind myself that LaTex (a maths programme, like word but for numbers!), isn’t as hard as I thought it was, I’m coping with the write up and I am using my time well. I need to take regular breaks though and continue with my morning walks before studying. He was clearly reading his interoceptive messages, both of self-management and self-regulation, and importantly responding to them! I must add here that my son has had, in the past, solution focused therapy with me, so he is well aware of the process, and so this focus on interoception was not too far removed from what he knows, which probably made it easier for him, compared to someone who is completely new to finding solutions. The recognising of interoceptive information and responding with positive actions is congruent with solution focused therapy, specifically the miracle question, where clients tell you what they want to change, whilst affording them the reflective space to work out how they are going to do it.
Support to help those with autism develop interoceptive skills is therefore essential for their self-management and self-regulation. And because it is a skill, it can be developed and improved upon due to brain plasticity. This is congruent with solution focused therapy and the importance we give to plasticity in changing and reframing cognition. Goodall (2022) has some extremely useful resources for carers and teachers to use with autistic individuals, as well as neurotypicals. Notably she has a wonderful hand model of the brain (which can be found on her YouTube link below), which younger children can readily relate to.
Interoceptive awareness also allows us to have a concept of self and therefore gives us a blueprint to understand others, so developing interoception with autistic individuals will benefit them in their interactions with others, which can often be a challenging time for them.
Furthermore, Goodall (2022) has carried out research into the effectiveness of interoception training in schools in south Australia, demonstrating the real benefits for students’ self-management and self-regulation. This has resulted in children, both neurodivergent and neurotypical being able to increase engagement in learning and reduce the need for staff to intervene in behaviour management. This is possible with a focus on interoception training only two to three times a day for 5 minutes!
After researching the area, one take-home is that, if you have a child or young person, neurodivergent or neurotypical, unable to manage emotions, be mindful that this is not a behaviour of choice but rather due to poor interoception. This changes how we respond to them – they are not naughty but rather in survival mode (Goodall 2023).
Critchley, D (2004) Neural systems supporting interoceptive awareness. Available from Neural systems supporting interoceptive awareness - PubMed (nih.gov)
Goodall, E (2021) Facilitating interoceptive awareness as a self-management and self-regulation tool to increase engagement in learning and education. Available from Emma GOODALL thesis final.pdf (usq.edu.au)
Goodall, E & Brownlow, C (2022) Interoception and regulation: Teaching skills of body awareness and supporting connection with others. Jessica Kingsley Publishers
Goodall, E (2021) Available from Understanding Autistic Thinking and Interoception for Greater Inclusion and Well-Being - YouTube
Goodall, E (2020) Available from Interoception and Body Awareness - Dr Emma Goodall - Autism Explained Online Summit 2020 - YouTube
Mahler, K (2022) Available from What is Interoception? - Kelly Mahler (kelly-mahler.com)
Mahler, K (2016) Interoception: The eighth sensory system. AAPC publishing
National Autistic society Interoception and mental wellbeing in autistic people (autism.org.uk)
Examples of internal support and activities Healthy Possibilities - YouTube