Possible Reasons for Restricted Patterns of Behaviors, Interests

Restricted Patterns of Behavior, Interests, & Activities
Overview
As a mother of a child with autism, author Clara Claiborne Park
describes what restricted patterns of behavior, interests, and
activities look like in her book The Siege: A Family's Journey into
the World of an Autistic Child (1967):
We start with an image-a tiny, golden child on hands and knees, circling round and
round a spot on the floor in mysterious, self-absorbed delight. She does not look up,
though she is smiling and laughing; she does not call our attention to the mysterious
object of her pleasure. She does not see us at all. She and the spot are all there is, and
though she is eighteen months old, an age for touching, tasting, pointing, pushing,
exploring, she is doing none of these. She does not walk, or crawl up stairs, or pull
herself to her feet to reach for objects. She doesn't want any objects. Instead, she
circles her spot. Or she sits, a long chain in her hand, snaking it up and down, up and
down, watching it coil and uncoil, for twenty minutes, half an hour-until someone comes,
moves her or feeds her or gives her another toy, or perhaps a book. (p. 3)
Park gives testimony to the power that restricted patterns of interest can have over a
person with autism. One of the primary characteristics of autism spectrum disorder
(ASD) is restricted and repetitive behaviors, interests, and activities. The behaviors
occur more often and for longer periods of time in children with ASD than in typically
developing children. The behaviors can range from looking at a spot on the floor, to
flapping hands, to repeating favorite phrases, to lining up cars, to talking about
bathroom scales. They can include wanting routines to remain the same, needing
people to behave the way they did the last time they were in a given situation, or only
wanting to play with the wheels on a truck positioned upside down.
Why do we need to know about this characteristic? Restricted patterns of behavior,
interests, and activities serve a purpose for persons on the autism spectrum; we need to
try to understand why they do what they do and how we can help them make changes
to allow learning and growth to happen.
Definition
Autism is determined by looking at a triad of characteristics: impairment in social
interaction, impairment in communication, and presence of restricted, repetitive, and
stereotyped patterns of behavior, interests, and activities. Each characteristic has traits
listed in the handbook mental health professionals use to diagnose disabilities called the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, 1994).
To be diagnosed with ASD, one must show at least one trait from the area of restricted
patterns of behavior, interests, and activities listed below (see http://www.autismpdd.net/checklist.html#299.00 for other areas):
o
o
o
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encompassing preoccupation with one or more stereotyped and restricted patterns
of interest that is abnormal either in intensity or focus
apparently inflexible adherence to specific, nonfunctional routines or rituals
stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or
twisting, or complex whole-body movements)
persistent preoccupation with parts of objects
The next sections will examine each area and describe what the traits look like in a
person with ASD.
Stereotyped/Restricted Interest Area
Case Study: Carlos
Carlos is sitting at the lunch table in the school cafeteria. He is with several
other boys from third grade. Carlos begins talking about caves. He tells
about some local caves he has visited, about stalagmites and stalactites,
and then about underwater caves. Carlos was so absorbed in talking about
caves that he did not realize his classmates stopped listening. His classmates have
heard Carlos talk about caves often and are tired of it; they roll their eyes and move
away from him, but he just keeps talking. Carlos cannot believe everyone is not
interested in caves!
Carlos' story demonstrates how an interest can become an obsession and interfere with
the ability to have friends and talk to other people. Special interests may involve objects,
such as vacuum cleaners or trains; it may involve places, like caves, oceans, or Italy; or
it may involve a subject, such as geography, racing, or music. What sets these special
interests apart is the amount of time and energy spent learning about it, the time spent
sharing with others, the vast amount of information gathered, or the refusal to talk, read,
or write about anything other than the special interest. Or, the interest may be odd for
the person's age or may just be unusual. The person with ASD may love High School
Musical, but is 27 years old, or may know everything about Beethoven and his music
when she is in first grade. Sometimes the interest is in a strange topic, such as electrical
cords, yarn, beetles, or fire alarms.
Case Study: Tyler
Mr. Ace was getting a new student named Tyler in his preschool multiple-disabilities
class. Tyler arrived on the bus carrying a spoon. The bus driver told Mr. Ace that Tyler's
mom said he does not go anywhere without that spoon and that it is important not to
lose it and to make sure it comes home with Tyler. Mr. Ace thought he would observe
Tyler for a while, talk to his mom, and maybe his previous instructor before figuring out
a plan to ease Tyler into activities without his spoon.
Case Study: Gina
Gina's sophomore English class is writing a paper about a book they just finished
reading. They are to write about one of the characters and how the character changed
in the story. Gina chose the main character and wrote about how he decided to become
a paleontologist and study dinosaurs. She turned in a 10-page paper about her
character. The teacher was upset about Gina's paper, because there was no mention of
dinosaurs in the book. The teacher tried to talk to Gina about her paper, but all Gina
could talk about was dinosaurs and how everything she had written was true. The
teacher ended the conversation and decided to talk to the guidance counselor about
how to help Gina write about something besides dinosaurs.
Aspy and Grossman (2007) note that symptoms in the areas of communication and
social interaction usually become "less severe over time" (p. 247) while the area of
interests can become more challenging. Especially for persons with highfunctioningautism or Asperger Syndrome, the ability to research a subject and gain
more academic skills gets easier. As adolescents, persons on the spectrum may want
to develop friendships, so they talk about topics that are comfortable for them.
Unfortunately, their abilities to interact socially may make it tough to share their interest
in a way that helps them make friends.
Special Talent
Some persons with ASD can develop a special talent or savant skill that becomes a
special interest. They may excel at playing or singing songs by ear, or maybe they know
the make, model, and car of every teacher in their school. Some individuals can tell you
which day of the week any date, past or future, occurs on.
Case Study: Rich
Rich, a 35-year-old man with Asperger Syndrome, was out with his coworkers one night
for dinner. Terry, a coworker, told the waiter to ask Rich any question about baseball.
The waiter asked him what Babe Ruth's batting average was, and Rich knew. Then he
asked a couple of questions about Sabathia's pitching, and again Rich knew the
answers. The waiter brought the owner of the restaurant to the table to ask more
questions, and Rich still answered every one correctly. Rich remembered every fact and
stat he had ever read or heard about baseball. As the conversation turned to other
topics, Rich sat quietly and ate his dinner, not sure how to join in.
Many times, these special interests interfere with learning and socializing. Later in the
module, we will talk about why these interests may exist and how to use them in a
positive way. Next, we will discuss routines and rituals.
Routines and Rituals
Case Study: Phil
Phil loves to drop items that make noise. He will grab anything from anywhere and drop
it on the floor to hear the sound. Phil's teacher would like to make his ritual serve a
purpose. She has had difficulty with Phil completing his assembly work tasks
independently, so she decides to add a new task to his session. She makes a task
using a large metal coffee can and several objects that will make noise when dropped
into the can. Next, she teaches Phil how the task works by demonstrating it and having
him practice. Using Phil's work system (see AIM: Structured Work Systems and Activity
Organization), the teacher puts the newly acquired task at the end of his independent
work. The first time, Phil tries to do the new task first, but he is reminded of how his
shape match work system operates. The next time, Phil completes his independent
work correctly and then does the new task with great enthusiasm. As illustrated, the
teacher used his interest in noise and his work routine to help make a ritual a reinforcer.
Rituals are a pattern of behavior regularly performed in a specific sequence with no
obvious function. People with ASD can be very rigid and always want to do things the
same way at the same time. Since life tends to include change, expecting things to
remain the same can cause trouble for the person with autism and those around him or
her. One of the reasons persons with ASD like to watch videos or DVDs so much is that
they are the same every time; same people, same actions, same voices, same order;
nothing changes. They are predictable. Persons with ASD wish their lives were like a
video: same people, same actions, same voices, same order, with nothing changing.
This would allow them to move calmly through their life by not having to learn anything
new, which can be upsetting for them.
Case Study: Ginger
Ginger, a 13-year-old on the spectrum, is waking up at home on a weekday morning.
She looks at her morning routine picture schedule and gets started. First, she gets up;
next, she goes to the bathroom; then she gets dressed; and lastly she heads for the
kitchen to have breakfast. After she has eaten, she brushes her teeth and gets her
backpack. Now she gets to watch television for 20 minutes until the school bus comes.
Twenty minutes passed and Ginger's show is over. Where is the bus? Five minutes
later, Ginger is feeling anxious. Ginger's mom is starting to feel a little anxious, too.
Ginger's mom suggests watching a little more television until the bus comes, as it must
be a little late today. Ginger starts humming and rocking forward and back; she does not
like that her routine has changed. Then mom and Ginger both hear the bus turn the
corner. Ginger approaches the bus and gets on. She is ready to move on with her day.
Case Study: Kaleb
Four-year-old Kaleb is on a walk down the hall with his preschool class. He is closing
every open classroom door on the way. As the paraprofessional notices his behavior,
she decides to stop him at the next open door. As Kaleb reaches for the door, the
paraprofessional tells him "door open" and blocks his hand. Kaleb reaches for the door
again-with the same result. He then drops to the floor in a full tantrum. The
paraprofessional waits for him to calm and then reminds him it is almost lunch time.
Kaleb is distracted by the thought of lunch and gets back in line with his class. He
makes it to the room without touching a door, but he does look at every open door.
Rituals can be very strong for people on the spectrum. If the ritual cannot be carried out,
anxiety and anger may set in very quickly. A nonfunctional ritual may
include touching the same spot on the wall on the way to the
bathroom every time, opening and closing a lunchbox five times
before eating, or eating a bite of foam soap before washing hands.
Some rituals build over time while others are part of the repertoire
from the very first time they happen. Being aware of the person with ASD, watching for
rituals, and helping build change into his life is important. Learning about change can
reduce anxiety and stress. More on that later in this module.
Case Study: Lee
Lee is an 18-year-old young man with autism. He is on a community trip with the
Special Olympics track team at the local high school track. Practice is almost over, and
Lee hears the bus coming to pick up the team. Lee has been practicing for the one-mile
race, which is four times around the track. He has only finished two laps. His coach is
watching Lee and sees him start to go around the track again. The coach calls to Lee,
but he keeps on running. As Lee comes around, he tells the coach, "One more lap and
then I can leave." The coach waves him on to finish and knows that next time he will
need a strategy so Lee will interrupt his routine and leave when the bus comes.
Learning a positive routine, such as the order of events in the school day, is a good skill
to achieve until the order has to change. When there is an all-school assembly, a fire
drill, or a speaker in class, most students embrace it as a welcome change to their
"boring" day. However, the student with ASD sees this as a threat to her routine and
has difficulty transitioning to the unexpected activity. Building in a way to let the person
know when a change is coming can help her cope with the change. Supporting the
verbal notice with visuals can be especially helpful (see AIM on Visual Supports).
Repetitive Motor Behaviors
Repetitive behaviors may include motor movements, also referred to as self-stimulation,
or verbal repetitions, such as words, phrases, or lines from songs. These behaviors can
happen in any situation at any time. The purposes they may serve will be addressed in
the next section of the module.
Self-Stimulation Behaviors
Self-stimulation can involve any of the senses and also movement (Leaf & McEachin,
1999). Some of the motor movements persons with ASD may show include:
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arm flapping
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pacing
jumping
repeatedly making faces
hand flapping
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o
o
o
o
o
finger flicking
clapping
twirling
blinking
mouthing
o
o
o
o
o
feeling a surface, especially with a texture
staring at moving objects
unusual postures
rocking
banging a surface
Some persons with autism are very creative in combining several of the motor
movements into complex routines. Another area of motor movements involves selfinjury. Sometimes, persons on the spectrum engage in motor movements such as biting
the wrist, head banging, or hitting themselves repeatedly. If a person on the spectrum is
engaging in self-injurious behaviors, enlist the help of professionals to individualize a
treatment plan. Check with your school, counselor, therapist, or doctor to find someone
to help.
Motor Movements
Repetitive movement may include the use of objects. Turning on water to play in,
spinning the wheels on a toy car, or tearing paper or magazines are some of the
movements you might observe. These behaviors may focus only on a part of an object,
such as continually looking at a reflection in the window of a toy truck or pressing the
same button over and over on an electronic toy.
Case Study: Ronny
If there were a string, a rope, a ribbon, or anything else that you could twirl, Ronny
would find it. Ronny, a 9-year-old with ASD, loves to twirl things. He is quite talented
and uses items others would never believe would spin. For example, he would pull a
border from a bulletin board or grab the paper cover from a straw to spin. Once Ronny
jerked a scarf from a man's neck when he was at the grocery store with his dad so he
could snake it around and around. Twirling is a problem for Ronny.
Case Study: Carleesha
Carleesha is a 4-year-old with ASD. Her mom, Janet, called a friend, who also had a
daughter with autism, to ask if she had any ideas for helping Carleesha learn how to
play with toys. Janet told her Carleesha would occupy herself in their recreation room
for hours, but all she did was set up the blocks in a row by colors, put all of the cars and
trucks in a line front to back, and place all of the people figures on a shelf from shortest
to tallest. When Janet tried to pretend play with the cars or figures, Carleesha grabbed
them from her and put them back in order. Janet's friend told her about a book she had
about teaching play skills and loaned it to her so she could try some ideas with
Carleesha.
Verbal Repetitions
Some motor movements involve verbal repetitions. People with ASD may repeat a
sound, a word, or a phrase with no consideration for meaning. Sometimes they get
hooked on singing a line from a song or a jingle from a commercial or a theme song
from a television show. They may also ask the same question over and over or repeat
information, such as telephone numbers, important dates, or the weather forecast
(Fouse & Wheeler, 1997).
Case Study: Sonny
Sonny, a 6-year-old boy with autism, often quietly said a word over and over. At school
he recently started saying, "Eli." When his teacher wrote home about the new word,
Mom explained Sonny had seen his Uncle Eli two weeks before. On another occasion,
Mom asked the school about a word Sonny kept saying that sounded like "mostanist,"
but no one could figure out what it was or where it came from. When Sonny started
repeatedly saying, "blow," his brother figured out it was from his favorite video that had
a blowfish in it.
So why do these restricted patterns of behaviors, interests, and activities occur? We will
examine that in the next section.
Possible Reasons for Restricted Patterns of
Behaviors, Interests, and Activities
As one of the main characteristics of autism, restricted patterns of behaviors, interests,
and activities can cause major difficulties for the persons with ASD. Their need for
sameness is hard to overcome. The verbalistic behaviors can interfere with time spent
learning and sometimes make a person totally tune out the world around her. Restricted
behaviors and interests may develop from attempts to overcome difficulties with
communication and social interaction.
Two things to remember are that individuals with autism have no control over their
interests any more than a non-autistic individual does and that the interests and
behaviors are one of the main characteristics of autism, so they are not choosing to
behave in this manner. "It is a symptom of their disorder" (Twatchman-Cullen, 2000, p.
25).
It is also possible that persons with ASD are trying to relieve anxiety and stress by using
the behaviors and interests as a coping mechanism. Persons not on the spectrum,
sometimes called neurotypicals, also have ways to calm themselves, like chewing gum,
twisting a strand of hair, or tapping a crossed leg. Neurotypicals are generally aware of
the socially acceptable ways to calm down, so even though rocking back and forth or
spinning might work to quiet them down they won't do those activities in front of other
people. Persons with autism may use these activities to calm themselves or to block out
something that is bothering them (Leaf & McEachin, 1999). For some people with ASD,
the movements are exciting. In some cases, their sensory systems are
underresponsive, so they themselves need a high degree of movement and input to
wake up their bodies and minds.
Another possibility is that individuals with ASD get tired of working hard and resort to
behaviors and interests that provide an escape from demands, allowing them to relax
and find pleasure in their selection. It also could be that "people with autism often do not
find people or the environment interesting" (Leaf & McEachin, 1999, p. 71). In this case,
the behaviors or interests allow them to occupy themselves with something they enjoy.
It is important for those who live and work with people with ASD to understand the
possible reasons for their interests and behaviors. Being able to examine a situation
and decide whether the individual is anxious, bored, overworked, or understimulated
can assist you in problem solving with the person on the spectrum. The next section of
this module suggests ideas for how to use interests and behaviors for positive change.
Ideas for Using Restricted Patterns to Make
Positive Change
The first step towards positive change in the area of restricted patterns of behaviors,
interests, and activities is to decide if a given behavior is harmful or not.
Case Study: Robert
Robert, a 3-year-old boy with autism, has a habit of smelling things. His most recent
interest is smelling people's hair. Robert's parents and preschool teacher discuss his
smelling habit and develop a plan to stop him from smelling hair. Socially and for safety
reasons, Robert cannot approach people and smell their hair. They decide to try to
replace the behavior by helping him find smells he enjoys and giving him a place and
time to smell them.
Case Study: Georgia
Georgia, an 8-year-old girl with Asperger Syndrome, is very interested in the history of
motorcycles. She is starting to spend a lot of time at home researching and reading
about motorcycles. Her parents want to encourage her interest but also want her to
socialize and do other activities. They talk with Georgia and come up with a plan that
uses motorcycle time as a reward after she goes to soccer practice, does her
homework, and has a friend over one time a week. They also agree Georgia can earn a
motorcycle model for remembering her homework materials a set number of days for
the next month.
Behaviors and interests need to be safe and helpful, and not make a person with ASD
less acceptable socially. Once these issues have been considered, you can plan how to
use the interest or behavior.
Setting up a structure for an interest or behavior uses the individual's strength for
routine by defining a time, place, and duration for it. At home, maybe Jeff can spin his
tops for 15 minutes in his bedroom when he gets back from school or an activity. It has
been observed that this helps him calm and transition. At school, Tomas can use the
computer for 20 minutes to look up information about nuclear submarines after he
finishes his math assignment. This helps him stay focused on math, which is a difficult
subject for him. When Violet is at work, she can go to her car at break time to listen to
punk rock music and to read her magazines and articles about punk rock, making sure
to return to work on time. This break allows her to calm her sensory system because
her work environment is bright and active.
Interests in the Classroom
Using the interest as a reward has great potential. Finding something that is reinforcing
to an individual with autism can be difficult, so making use of what the person already
likes can be effective. Choosing the interest or behavior that fits with the person and
activity is crucial. If the interest or behavior takes too long or is so strong that it cannot
be interrupted, try a different one. Make sure there is a plan for the reward and that
everyone is using it consistently. If a student likes car racing, use car stickers on his
papers or reward systems, use phrases like, "Rev up your engines, it's time for reading,"
and find a way to use car racing for math problems or history.
Case Study: Evan
Evan loves dinosaurs! He has a huge collection of dinosaur figures,
books, DVDs, and puzzles. Evan was having problems in his
freshman physical education class. His P.E. teacher identified four
specific things Evan had to do in class. If Evan completed the four
things written on a checklist, he got to go to the computer lab for 30 minutes to look up
information on dinosaurs on the computer, since playing with his collection at school
could open him up for teasing by classmates. At home, Evan was allowed to play with
his collection each night for an hour after his homework was done and his room was
straightened up.
When dealing with a behavior or interest that appears to be associated with anxiety or
stress, each situation needs to be analyzed. If the difficulty seems to stem from
frustration with a task, try changing or eliminating the task to see if the behavior
decreases. If the behavior or interest is linked to an inability to communicate, provide a
way to share needed information. Maybe the person with ASD needs to learn how to
calm her body through relaxation practices, like deep breathing or yoga, or perhaps
some physical exercise built into the day will help relieve the stress.
Interests in Leisure and Vocational Areas
Sometimes an interest or behavior can be used to introduce a new pursuit. Joey loves
to jump up and down and spin around. His mom took him to a gym for lessons on a
trampoline. Since Joey also loves to swim, next they are trying diving classes. Susie
has an interest in horses, so her dad takes her riding at a local stable. He hopes she
can get a summer job at the stable helping care for the horses. Myles and Adreon
(2001) emphasize using special interests to lead to a vocation. In particular, they
discuss using an interest that the person can transition in and out of easily and one the
individual will not lose interest in. Making the connection from the interest to a future job
may take input and support from all those involved in the person's life. For instance,
Terrell loves putting items in order by the alphabet or by numbers. Those involved in his
life could help him learn filing so he will be able to work in an office or learn how to
shelve books to work in a library.
Henry and Myles (2007) suggest using special interests for social practice. The person
with ASD or someone in his life can find an environment where the interest is valued
and explored. Look for a club, group, or organization that will help the individual
increase his knowledge and give him a comfortable environment for discussing what he
loves. If someone loves magic, find a magic club she can attend. Maybe she really likes
poetry, so look for poetry readings where she can listen to, read, and discuss poetry. If
she is interested in flowers, find a flower club. In Beyond the Wall: Personal
Experiences with Autism and Asperger Syndrome(2003), Stephen Shore talks about
using his interests in music and bicycles to get to know people: "Building a relationship
with a person via an activity as the catalyst proved helpful. While this may hold true for
most people, it is especially so for those on the autistic spectrum. Having an activity as
the focus of the interactions reduces the reliance on being able to detect, accurately
encode, and respond appropriately to nonverbal social cues" (p. 86). Offer the supports
the individual with autism needs to be successful in the experience and help others
learn about and be sensitive to the needs of the individual, if appropriate.
Summary
The need for sameness can be both an obstacle or a benefit. Following rituals can help
at school, at home, or at work as schedules and routines are developed and taught, with
the ability to handle change built into the systems. Accepting repetition, even desiring it,
helps in teaching new skills as resistance is lessened by the recurrence. Being able to
turn an obsessive interest into a job or lifetime leisure activity lessens the oddity.
Remember, restrictive patterns of behavior, interests, and activities are one of the triad
characteristics of autism, along with communication and social interaction problems.
When displaying such behaviors or activities, the individual with autism is not
purposefully misbehaving, but is probably anxious or trying to communicate. Taking this
perspective helps see the person in a different light and allows us to develop supports.
If you want to change a behavior, replace it with one that is more acceptable and useful.
Look for the autism in a situation to help figure out a solution from the perspective of the
person with autism.
Discussion Questions
[ Export PDF with Answers | Export PDF without Answers ]
1. How can special interests negatively affect persons with
ASD?
Answers may include: Special interests can take time away from learning and
may interfere with social interactions. Repetitive behaviors can take time away
from learning and from being aware of the environment. Also, some people
may avoid being around someone who is stimming because they don't
understand what it is.
2. Explain what NEED FOR SAMENESS means to a person
with autism.
Answers may include: Persons with ASD like predictability in their schedule
and routines. It helps them reduce anxiety. They don't have to deal with
change, which may involve learning something new.
3. Why is transition difficult for people with autism?
Answers may include: Transition involves change of activity and body
position. It usually means leaving one area and going to another area that
may have different lighting, smells, noises, and people. It may mean leaving
an activity the individual was enjoying and maybe had not finished yet. It may
also require using communication skills to understand where the individual is
to go and having to interact with others to make the transition.
4. List five possible repetitive motor movements.
Answers may include:
o
o
o
o
o
o
o
o
o
Arm flapping
Pacing
Jumping
Making faces repeatedly
Hand flapping
Finger flicking
Clapping
Twirling
Blinking
o
o
o
o
o
o
Mouthing
Feeling a surface, especially with a texture
Staring at moving objects
Unusual postures
Rocking
Banging a surface
5. List three possible verbal repetitions.
Answers may include:
o
o
o
o
o
o
o
o
Sound
Word
Phrase
Line from a movie or television show
Line from a song
Jingle from a commercial
Ask the same question
Say information over and over (e.g., weather)
6. List two possible reasons for restricted patterns of
behaviors, interests, and activities.
Answers may include:
o
o
o
o
o
o
o
o
Boredom
Escape
Avoidance
Anxiety
Stress
Lack of communication skills to explain how individual is feeling
Sensory needs
Tired of demands
Activities
Activities on this page of the AIM site are provided at both the introductory and
advanced level allowing the user to target specific needs. Activities can be copied and
used within an existing platform such as Blackboard or WebCT. In addition, a general
email link has been provided. Participants can send their activity response directly to
another person (such as a professor or staff developer) by clicking the "Respond" link
below.
Introductory Activities
1. Special Interests Discussion
Discuss the differences between a person with autism who has a special
interest, like football or a certain kind of music, and a neurotypical person who
has the same special interest.
2. Role Play Activity
Choose a special interest topic and role play how it can interfere with a social
interaction with others in the group.
3. Video Clip Search and Share
Search and locate videos on the internet showing repetitive motor
movements. Share the clips with colleagues.
4. Special Interests and Vocational Skills Discussion
Discuss interests that can lead to vocational skills and jobs in the future.
Advanced Activities
1. Nonfunctional Rituals
Share some nonfunctional rituals you have observed in persons with ASD.
Decide if they are harmful based on safety and being socially acceptable.
2. Research Activity
Read articles about the latest research on repetitive movements and
diagnosis of autism. Share the information with your colleagues.
3. Lists Activity
Make two lists, one listing appropriate ways to calm stress and relieve anxiety
and one listing inappropriate ways.