Section 1What are Triple-A difficulties?

A note on how to use this resource

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Section 1

What are Triple-A difficulties?

Learning outcomes for Section 1

  • To understand what attention, arousal and anxiety are
  • To understand how Triple-A difficulties are relevant for teaching and learning in the classroom
  • To understand who experiences Triple-A difficulties

This section should take approximately 30-40 minutes to complete.

Introduction from the research team

What is important for learning to take place in school?

Before we begin to discuss Triple-A, it is really important to reflect on learning at school more generally.

Take a minute to think about what factors might be important in order for a child to learn and engage in the classroom. For example, you might think about reading ability or communication skills, or factors that are not about individual children.

Take a minute to list up to three factors in the box to the right (there are no right or wrong answers)

Factors that might impact learning at school

In truth, there are a wide variety of factors that are important for learning in school. For example, we might think about:

• Cognitive abilities
• Mood
• Motivation
• Feeling safe
• Mental Health
• Social Factors
• Communication abilities
• Classroom environment
• Socio-economic factors

Factors that might impact learning at school

You may have thought about these, or others. The point of the exercise is to get you to think about the complexities of learning at school and the fact that so many different things can have an influence. Some of these are specific to individual children, some are specific to particular schools, and some of these influences are much broader societal ones.

Different factors (cognitive ability, mental health) will be more or less important depending on the needs of the particular child. Research can help to guide us to what might be particularly important for groups of children that share certain characteristics.

In this resource, we will be thinking about the unique needs of neurodivergent children, and specifically autistic children. When thinking about this group of children there are a number of unique factors to think about, and we are going to hone in on three of these.

In this resource we will be focussing on…

Arousal (Sensory Processing)
Arousal (Sensory Processing)

Attention – what is it?

In school and in the classroom, paying attention is a really important skill. To read, write or count, we first need to pay attention to the task at hand. Of course, we simply cannot pay attention to everything at once, as our attention skills have a limited capacity. So, we have to focus our attention and our mental resources on some things, to the exclusion of other things in order to learn. This is what we mean when we say that attention acts as a kind of ‘gateway’ to learning.

Although we often refer to attention as one thing, it is in fact a set of related skills which are important at different times and depending on the task that is being done. Research evidence from psychology studies shows that there are 3 main attention skills – selective, sustained and executive attention. These are highly related to each other (if a person has good selective attention, they most likely have good sustained attention too), but they do have slightly different functions.

Attention – what is it?

Selective attention is about selecting the information that is relevant to what we are doing and ignoring the information that is not.

Sustained attention is about being able to maintain focus and concentrate for long periods of time, like keeping focused on a long lesson in class.

Executive attention is about attentional control and regulating our attention especially when there are conflicting demands or distractions.

Development of attention

Attention abilities change dramatically with age, especially over pre-school and early childhood years, and are typically well-developed by the time children are about 10 years of age [1].

Older children are much better able to filter out and ignore distractions and they have better control of their attention skills compared to younger children.

Development of attention

Why is it important to know about the development of attention skills? Because attention skills are so important for almost everything we do in school (and beyond), and because they can differ considerably from child to child.

Crucially, we cannot assume that all children of a particular age have good attention skills – for some children attention skills can take longer to develop and they may not be at the level expected for their age. Furthermore, understanding that there are different kinds of attention skills is important for supporting children with attentional difficulties.

For example, if a child struggles with sustained attention, then breaking up tasks in to smaller chunks can be helpful. For a child who struggles with selective attention, really clear instructions and guidance is important. Finally, for a child who struggles with executive attention, support with tasks that involve several demands at once (i.e. listening and writing at the same time) will be beneficial (e.g. visual prompts, scaffolds).

Well Done!

Continue on to the next slide

Attention for learning

What do attention difficulties look like in the classroom?

What is arousal?

Arousal, or sensory processing, refers to the way the central nervous system receives input from the senses and pulls this information together in order for us to respond to our environment. [4]. In other words, our body receives sensory input from the environment all of the time (e.g. loud bang) which we have to make sense of (was that a door closing?) and respond to (do I need to open the door, or leave it closed?).

Research has found that around 90% of autistic people experience sensory differences [5, 6].

It is important to think about what everyday sensory inputs might feel like for a person who experiences sensory differences, especially when these inputs are occurring constantly.

Please play the audio clip below, for further reflection on this:

What do sensory processing difficulties look like in the classroom?


Mollie (autistic young person) shares her experience of Triple-A at school

Anxiety – what is it?

Anxiety – what is it?

Anxiety is defined by NHS England as ‘a feeling of unease, such as worry or fear that can be mild or severe’ [7]. This is quite a broad definition, and actually anxiety can mean different things to different people.

Anxiety can also feel different to different people. Some people experience their heart pumping fast, sweating, having difficulties breathing, having panic attacks, or just the feeling of being worried and having racing thoughts that turn over and over again in one’s mind. Some anxiety in children is developmentally normal (e.g. anxiety when a child separates from their parent or caregiver would be expected at younger ages and to a certain degree). However, anxiety can become a problem and impact on daily life. Children can become anxious for a range of reasons, and research has suggested children with neurodevelopmental conditions are more likely to have difficulties with anxiety.

Anxiety – what is it?

Anxiety can be a significant problem for people with neurodevelopmental conditions, but particularly for autistic people.

Anxiety prevalence rates for individuals with ADHD (25%) [8], Williams Syndrome (48%) [9] and Fragile X Syndrome (51%) [10], all sit above the estimates for children without neurodevelopmental conditions (~15-20%) [11].


Anxiety and autism

Anxiety as a co-occurring diagnosis in autistic people is something that has been found in research studies many times. Several studies have shown that very high levels of anxiety are experienced by between 40-50% of autistic people. [10, 12]. It is important to understand how much of a problem this can be for autistic people, as it has a big impact on the ability to do everyday activities and it can be really distressing.

The anxiety that comes with the fear of getting things wrong can be debilitating. It can stop them trying something new, or difficult – my son has a lot of anxiety around writing, which is something he struggles with, and sometimes goes to extremes to avoid doing. His anxiety comes with a real fight/flight response.

Quote from parent of autistic son

If you have to perform [in a music lesson performance] and then you’ve been told earlier, you have stress leading up to that lesson, and then they’ll make you worry and you can’t really focus that well.

Quote from autistic adolescent

It [anxiety] has been described to me as like having a cup. A neurotypical person would most often start their school day with an empty cup.

Throughout the day as things happen and anxiety is experienced the cup may fill a little. The child may have the ability to empty the cup too (manage their anxiety and overcome feelings). A child on the autistic spectrum may have had to manage a number of anxieties before they even get to school (the act of going to school can in itself cause deep distress for some) so on arrival their cup could be filling up or even brimming. It then takes seemingly very little for the cup to be unable to hold any more water and it spills. We may see this as shutting down, becoming non-verbal, an increase in stimming or other self-soothing behaviors, a child displaying undesirable behaviours or a full meltdown. These children often lack the skills to ‘empty their cup’ and an extended rebound time involving support from trusted/skilled adult or often quiet and solitude to process feelings would be required before child is able to return to their learning.

Quote from parent of autistic son

What does anxiety look like at school?

Well Done!

Continue on to the next slide

‘Triple-A’ in the classroom

A multi-sensory classroom

The classroom is a very busy multi-sensory environment. There are lots of things that children have to filter out and ignore in order to pay attention and learn in the classroom.

Children need to use their attention skills for many different things, for example: to focus on learning tasks; to pay attention to the teacher at the right time; to remember what they’ve been told to do; to filter out noise from classmates, smells lights and colourful displays, all of which change day-to-day; and manage whatever they may be feeling inside, be that anxiety or something else.

Many children can actually do this relatively easily, but children who have difficulties with Triple-A can find the classroom a very demanding and challenging place to learn.

Social Relational Model of Disability

The Social Relational Model of Disability [13] provides a useful framework for understanding how and under what circumstances Triple-A difficulties can affect the day-to-day lives of pupils.

The Social Relational Model has been shown to increase inclusion of autistic individuals when embraced by educators.

Social Relational Model of Disability

In the Social Relational Model, a disability is seen to occur when there is a mismatch between an individual’s ability and their environment. As an example, a blind person, although impaired, only becomes disabled when the environment has not been adjusted to meet their needs. When thinking about arousal and sensory processing differences, a child with hypersensitivity may be able to manage these differences at home, but may experience a ‘disability’ when placed in a busy classroom with significant sensory inputs, such as bright lights and noisy classmates. Given that children spend the majority of the school day in a classroom, a mismatch between the environment and their sensory needs could be especially adverse. [14,15,16].

Therefore, understanding Triple-A issues in the context of our schools and classrooms is absolutely crucial in order to provide the best support (for further reading on the Social Relational Model of Disability, please see reference [13]).

Who experiences Triple-A difficulties?

Although Triple-A difficulties can act as barriers to learning for any neurodivergent child (including children with ADHD, Williams Syndrome, Developmental Co-ordination Disorder, and other diagnoses), they can be particularly problematic for autistic children. This is because autistic pupils often experience all three of these difficulties at the same time.

“as a pattern…if we’re talking about those three things happening at the same time, I think possibly you’re more likely to see that within a child who has an ASD diagnosis, but that’s not to say these are unique to children with autism at all”

Quote from an Educational Psychologist

Why focus on Triple-A and autism?

Academic outcomes for autistic children and young people are highly variable and large attainment gaps exist for autistic pupils compared to their non-autistic peers (e.g. in GCSE grade achievement) [17]. Other factors beyond IQ may also play an important role in academic outcomes for autistic pupils, such as Triple-A [e.g. 18].

Why focus on Triple-A and autism?

An All Parliamentary Party Group report (a government report produced in the UK in 2017) found that autistic children are 3 times more likely to be excluded from school compared to those children with no Special Educational Needs (SEN) [19]. This is an important statistic to think about when we consider that Triple-A may underlie some of the behaviours that would contribute to some of these exclusions.

Why is it important that teachers and educators understand Triple-A issues?

As well as the previous statistics about attainment gaps and school exclusions, pupils also suggested in the All Party Parliamentary Group survey that understanding was important to them. 60% of the autistic pupils that took part suggested that the key thing that would make school better is having a teacher that understands them [19].

He’s got the knowledge, he understands the concepts you know, you can ask him anything and he can tell you anything, he takes a hell of a lot on board, but those three key factors are what really impacts how well he does with it

Parent of autistic son


Emily (autistic adult with Sensory Processing Disorder) reflects back on her experience of Triple-A when at school

Summary of Section 1

In this section, we have given a broad overview of the rationale and some of the research that highlights how issues with attention, arousal and anxiety are really important to understand when supporting pupils in a classroom. This is especially true for neurodivergent pupils, and particularly autistic pupils. You should now have a better understanding of:

  • What attention, arousal and anxiety are
  • How Triple-A difficulties are relevant for learning in the classroom – because they provide unique barriers to learning and engagement
  • Who experiences Triple-A difficulties – autistic and neurodivergent pupils



Incorrect answers are shown in red, correct answers in green.

What is attention?

Which of the following is generally true when thinking about attention skills for neurotypical children?

Which of the following is true when thinking about attention in neurodivergent populations?

True or False - Research has shown that attention skills at age 4-5 are predictive of later academic achievement at age 11?

Research has suggested that what percentage of autistic people experience sensory differences?

Which of the following illustrates hypo-arousal?

Can the same person have hyper and hypo-arousal difficulties?

True or False: anxiety feels the same for everyone who experiences it?

Who experiences anxiety?

Questions continued

Incorrect answers are shown in red, correct answers in green.

True or False: Research suggests that anxiety prevalence rates are similar for neurotypical and neurodivergent groups?

Which of the following is true of the Nordic Relational Model of Disability?

Who experiences Triple-A difficulties?

According to research, autistic pupils are how much more likely to be excluded from school compared to pupils with no Special Education Needs?


[1] Gaspelin, N., Margett-Jordan, T. & Ruthruff, E. (2015). Susceptible to distraction: Children lack top-down control over spatial attention capture. Psychonomic bulletin & review22(2), 461-468. Doi: 10.3758/s13423-014-0708-0

[2] Merrell, C., Sayal, K., Tymms, P. & Kasim, A. (2017). A longitudinal study of the association between inattention, hyperactivity and impulsivity and children’s academic attainment at age 11. Learning and Individual Differences53, 156-161. Doi: 10.1016/j.lindif.2016.04.003

[3] Erickson, L. C., Thiessen, E. D., Godwin, K. E., Dickerson, J. P. & Fisher, A. V. (2015). Endogenously and exogenously driven selective sustained attention: Contributions to learning in kindergarten children. Journal of experimental child psychology138, 126-134. Doi: 10.1016/j.jecp.2015.04.011

[4] Dunn, W. (1997). The impact of sensory processing abilities on the daily lives of young children and their families: A conceptual model. Infants and young children9, 23-35.

[5] Leekam, S. R., Nieto, C., Libby, S. J., Wing, L., & Gould, J. (2007). Describing the sensory abnormalities of children and adults with autism. Journal of autism and developmental disorders37(5), 894-910.

[6] Tavassoli, T., Miller, L. J., Schoen, S. A., Nielsen, D. M., & Baron-Cohen, S. (2014). Sensory over-responsivity in adults with autism spectrum conditions. Autism18(4), 428-432. Doi: 10.1177/1362361313477246

[7] NHS, (2018, December 19). Overview – generalised anxiety disorder in adults. NHS. Retrieved from Overview – Generalised anxiety disorder in adults – NHS ( Aug 18 2021

References (cont.)

[8] Schatz, D. B., & Rostain, A. L. (2006). ADHD with comorbid anxiety: a review of the current literature. Journal of Attention disorders10(2), 141-149. Doi: 10.1177/1087054706286698

[9] Royston, R., Howlin, P., Waite, J., & Oliver, C. (2017). Anxiety disorders in Williams syndrome contrasted with intellectual disability and the general population: A systematic review and meta-analysis. Journal of Autism and Developmental Disorders47(12), 3765-3777. Doi: 10.1007/s10803-016-2909-z

[10] Ezell, J., Hogan, A., Fairchild, A., Hills, K., Klusek, J., Abbeduto, L., & Roberts, J. (2019). Prevalence and predictors of anxiety disorders in adolescent and adult males with autism spectrum disorder and fragile X syndrome. Journal of autism and developmental disorders49(3), 1131-1141. Doi: 10.1007/s10803-018-3804-6

[11] Hollocks, M. J., Lerh, J. W., Magiati, I., Meiser-Stedman, R., & Brugha, T. S. (2019). Anxiety and depression in adults with autism spectrum disorder: a systematic review and meta-analysis. Psychological medicine49(4), 559-572. Doi: 10.1017/S0033291718002283

[12] Van Steensel, F. J., Bögels, S. M., & Perrin, S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: a meta-analysis. Clinical child and family psychology review14(3), 302.

[13] Mackenzie, M., Cologon, K., & Fenech, M. (2016). ‘Embracing everybody’: Approaching the inclusive early childhood education of a child labelled with autism from a social relational understanding of disability. Australasian Journal of Early Childhood41(2), 4-12. Doi: 10.1177/183693911604100202

[14] Goodley, D., & Runswick-Cole, K. (2012). Reading Rosie: The postmodern disabled child. Educational and child psychology29(2), 53.

Well Done!

Continue on to the next slide

Section 1


Jayne Sayers

Advisory team member

Jayne is the parent of an autistic 8 yr old son, and has 22 years experience in the NHS as a nuclear medicine technologist, working with patients of all ages and capabilities.

Mollie Preece

Advisory team member

In her own words, Mollie describes herself as “12 years old and I’m different in a good way. Change is difficult but with the right support I can manage it. If I feel people understand me, I can work well with them and not shut down. A loud noisy environment is just not helpful. It really helps me to learn when I have a calm and productive environment in the classroom.”

Marie Preece

Advisory team member

Marie is the parent of an autistic daughter and was diagnosed as autistic herself at the age of 45. She runs a successful business and in her spare time she is involved in various projects which aim to bring awareness and understanding of the challenges of autism in girls and women.

Sharon Minikin

Advisory team member

Sharon has taught children with Autism for 18 years and is currently SENDCO and Provision Manager of a Local Authority commissioned Resource Base for children with social communication needs.

Prof Sue Leekam

Advisory team member

Sue is an Emeritus Professor in psychology at Cardiff University and holds a Leverhulme Trust Emeritus Fellowship. She is an expert in neurodevelopment and especially in the areas of attention, anxiety, sensory and social differences.She is also passionate about building strong research-community relations in areas of health and education. She serves on the NHS Wales Steering Committee for Neurodevelopmental Service Improvement, and was also an advisor to the Welsh Government’s Autism Strategy.  She has been invovled in the development of training tools to improve public and professional understanding of autism [See here for free training film for front line professions on the signs of autism: see ]

Charlie Hookway

Advisory team member

Charlie was diagnosed with autism in year 4 and he is now in his final couple of weeks of A levels. He loves photography and is due to start a degree at university in September

Amanda Hookway

Advisory team member

Amanda is a mum to 3 boys. Her eldest son is on the autistic spectrum. She has worked in schools supporting students who have additional needs and learning difficulties for many years. 

Emily @21andsensory

Advisory team member

Emily has Sensory Processing Disorder (diagnosed aged 8) and is Autistic (diagnosed aged 25). She is an Illustrator, Graphic Designer and Podcaster. She enjoys discussing and drawing about her life as a sensory-being across social media at @21andsensory. Emily hosts and runs the 21andsensory Podcast where she chats to neurodiverse people from all walks of life

Helen Sellars

Advisory Teacher, Commuication & Interactin Team

Helen is an Advisory Inclusion Teacher from the Communication and Interaction Team which is part of Specialist Inclusion Services at Durham County Council. Prior to working in SEND and Inclusion, Helen was an Assistant Head Teacher and SENDCo.

Elizabeth Mulholland

Team Leader, Communication & Interaction Team

Liz is the Team Leader for the Communication and Interaction Team which is part of the SEND and Inclusion Service at Durham County Council. Prior to this Liz worked as an Advisory Inclusion Teacher within the same service having spent several years previously as a senior leader and SENDCo in a primary school.

Dr Janet Crawford

Principal Educational Psychologist

Janet is the Strategic Manager for Specialist Inclusion Support and Principal Educational Psychologist in Durham with a long standing interest in autism and neurodiversity. Janet is the current Chair of County Durham Think Autism Strategy Steering group

Rosie Johnson

Research Assistant

Rosie is a Research Assistant on this Triple-A project. Prior to this Rosie has worked as an Assistant Psychologist, including previously working in CAMHS with children and young people who are neurodivergent.

Dr Liz Jones

Project Collaborator

Liz is a mixed-method researcher with an interest in understanding the experiences of children and young people with sensory differences at school. During her PhD she explored the impact of sensory processing differences on learning and school life for autistic pupils.

Dr Emily McDougal

Project Collaborator

Emily is a researcher with an interest in understanding neurodivergent children in the context of the primary school classroom. During her PhD, she investigated the role of attention in learning for autistic pupils.

Jessica Hirst

Lead Research Assistant

Jess is the lead research assistant on this Triple-A project, having worked on it from the beginning. Indeed, some of the research Jess completed for her Masters in Developmental Psychopathology has contributed to the evidence for this training. Jess is really interested in understanding and supporting engagement and learning at school for autistic and neurodivergent pupils, and having now begun a PhD, she is focusing on developing a holistic model for learning and engagement at school for autistic and neurodivegent pupils.