Ask Dr. Emily

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Ask Dr. Emily – Challenging Behaviors and Encouraging Creativity

Welcome to the October edition of Ask Dr. Emily!

We often receive questions that we want to share with all our readers. To help with this, Dr. Emily Rastall, a clinical psychologist at Seattle Children’s Autism Center, will share insights in a question and answer format.

We welcome you to send us your questions and Dr. Rastall will do her best to answer them each month. Send your questions to theautismblog@seattlechildrens.org.

Q: Please help, I have an adult son with autism who is nonverbal and has a habit of urinating all over the floor and/or seat in our bathroom. As a consequence, I insist that he clean it up, I take things away, I follow him in and prompt him (which is hard to do in the middle of the night). I have tried ignoring the behavior and I have tried rewarding him when he uses the toilet effectively, but nothing seems to work. He is eager to please about other things, so I don’t understand why this issue is so hard for him.

A: Thank you for writing in. The first thing you will want to do is consult with your primary care doctor to rule out a medical condition that might explain this behavior. Next, as with any challenging behavior, you will want to start by determining the purpose/function of the behavior using a Functional Behavior Analysis (FBA); FBA’s are most accurate and helpful when performed by behavioral specialists who are trained to provide behavioral assessment and treatment. Based on the data obtained by the FBA, you will want to seek behavioral treatment, like applied behavioral analysis (ABA); preferably, this treatment would occur in the home, as this is where the behavior is occurring. Good luck to you as you work to remedy this challenging behavior.

Q: My 8-year-old daughter, who has autism, talks at us, but not with us. She is starting to ask little questions like, “Where are you going?” but this is a very recent development. She seems like she is more engaged, but she would still prefer to watch her iPad all day. Her play is a verbatim re-enactment of everything she just saw on YouTube. How do I help her be more creative and think for herself?

A: Research in the area of child development tells us that imitation is the first step to creating novel narratives; typically developing children first imitate play and actions observed in others (or on television) and then begin to build off of it. All of this to say, there is some element of imitation in all children’s play.

Children with autism spectrum disorder (ASD), however, tend to prefer routine and things that are concrete and “known.” Thus, they tend to be more rigid about their play and have a harder time working in the abstract, creative arena. While the “ASD brain” will always prefer routine and sameness, there are ways to encourage more creativity. First, it makes sense to limit screen time. The American Academy of Pediatrics has historically recommended limiting screen time for children ages 2-18 to two hours or less per day. If you think about it, less time spent on screens means more time for play, exploration, and creativity.

In addition, you’ll want to be sure to make time for unstructured play time, which fosters creativity. Neutral toys, such as blocks, Legos, or boxes, in addition to toys that promote make believe, such as dolls/action figures, kitchen items (like plates, forks, etc.), puppets, or dress up clothes, are important to have on hand. You may need to model the use of these toys and items, so that your child knows how to play with them. Research has shown that children with autism are more likely to imitate videos, so you might show your child videos of you or someone else engaging with the make-believe toys. Once they are imitating your pretend play, you can model expanding and ask open ended questions (like, “What do you think happens next?”). Praise creativity (“You have such creative ideas.”), and slowly you may begin seeing your child expand their play.

Ask Dr. Emily – Facial Behavior and Daydreaming

Welcome to the September edition of Ask Dr. Emily!

We often receive questions that we want to share with all our readers. To help with this, Dr. Emily Rastall, a clinical psychologist at Seattle Children’s Autism Center, will share insights in a question and answer format.

We welcome you to send us your questions and Dr. Rastall will do her best to answer them each month. Send your questions to theautismblog@seattlechildrens.org.

Q: My son is 7 years old, and he has autism spectrum disorder. When he watches television, he makes faces with his eyes closed and lips out. Is that part of autism?

 A: One of the diagnostic criterion for autism spectrum disorder is described as this facial behavior that you describe sounds to me like it fits the description of a “stereotyped or repetitive motor movement,” one of the diagnostic criteria for autism spectrum disorder. These behaviors can be present when one is excited, relaxed, and/or upset.   

Q: I am an individual with autism. I want to touch on daydreaming. When I was in school, my biggest hurdle was “zoning out.” If I didn’t understand a topic, I would “check out” until the instruction ended. This sounds awful, but my family sometimes has to snap at me to bring me back to reality. I “pass” as typical, but every day is an exhaustive process of trying to stay focused and “in touch” with what’s happening around me. Is this something that happens with autism spectrum disorder?

A: Thank you for writing in and for sharing your experiences. Executive functioning (like paying attention, planning, thinking ahead, switching attention or tasks) is often affected (to varying degrees, of course) for individuals with autism spectrum disorder. This can make it challenging to maintain attention, multi-task, and stay present, especially in overwhelming, chaotic environments. It can be even more challenging to stay focused on topics or people that we don’t find especially interesting or appealing.

 Q: My son is 12 and has high functioning autism. He has also been diagnosed with anxiety, skin picking, ADHD, and we recently discovered he has two genetic duplications as well. He has had some real challenges at school: Social challenges (cannot read social cues from others, oversteps boundaries with peers, had trouble fitting in), behavioral challenges (aggression towards peers, incontinence), and emotional challenges (verbal outbursts, threats of harm to self and property). He was expelled from public school last year; he now attends an alternative school, but things have not gotten better. What should we do?

 A: First, let me empathize with how hard this must be for you, your son, and your family. His profile appears complex with his recent genetic findings, mental health symptoms, behavioral issues and potentially a number of medical and mental health providers involved. Might his primary care provider be “the quarterback” of his care/education team, with a coordinated comprehensive evaluation and treatment plan? This would hopefully shed some light on the function of his behavioral challenges and inform treatment next steps.

 

Ask Dr. Emily – Understanding Behavior and Bilingual Children with Autism

Welcome to the July edition of Ask Dr. Emily!

We often receive questions that we want to share with all our readers. To help with this, Dr. Emily Rastall, a clinical psychologist at Seattle Children’s Autism Center, will share insights in a question and answer format.

We welcome you to send us your questions and Dr. Rastall will do her best to answer them each month. Send your questions to theautismblog@seattlechildrens.org.

Q: I am a student and I recently started interning at a child development center. We care for a child who is on the autism spectrum who deliberately burps during his tasks. I’m assuming that this is one of his repetitive, stereotypical behaviors. Is this correct? Would you suggest some ways to reduce or stop the behavior?

A: Thank you for your work and for your question. Before we call this behavior “deliberate,” we will want to determine the function that this behavior is serving. Behaviors can be categorized into serving one or more of the following three purposes: Getting something (like attention or the iPad), avoiding something (like an unpleasant task), and/or self-stimulation (a repetitive, non-functional behavior that serves to stimulate a sensory response). You will also want to consider whether the behavior is a safety risk and/or whether it significantly impacts an individual’s daily functioning. Your intervention (or lack thereof) will vary based on what function the behavior is serving and how impactful it is on the child’s life.

In summary, it sounds like a functional behavior assessment (FBA) is in order. An FBA can help you determine what purpose a behavior is serving, which will determine the intervention you will choose to use. You will want to consult with your team of supervisors regarding how best to go about scheduling an FBA with a trained professional.

Q: I am a father of a child with autism who just turned five. My child’s mother and I do not live in the same home. My daughter speaks only Spanish in her mother’s home. I speak only English with her in my home, and her educators and therapists speak English with her as well. Historically, I have been against her learning Spanish, as I was concerned that her language development would suffer as a result of being bilingual. Although my daughter’s language development has grown dramatically over the last year, I have heard mixed opinions about the impact of being bilingual on language development in children with autism. Given that she is bilingual (whether I like it or not), I wonder if I should make an effort to seek out a bilingual teacher and/or speech therapist. Should I be concerned that my child with autism is being raised bilingual?

A: Thank you for writing in. Rest assured, the research is telling us that there are no ill effects for kids with autism who are exposed to two languages. In fact, the research even points to benefits of being bilingual for children with ASD; for example, bilingual children with ASD have been observed to vocalize more and use gestures more frequently. Seeking out a bilingual speech therapist might help your daughter advance in both languages and could be helpful in coaching you and your daughter’s mother to foster her bilingual growth.

 

Ask Dr. Emily – Autism Treatment and Trust

Welcome to the June edition of Ask Dr. Emily!

We often receive questions that we want to share with all our readers. To help with this, Dr. Emily Rastall, a clinical psychologist at Seattle Children’s Autism Center, will share insights in a question and answer format.

We welcome you to send us your questions and Dr. Rastall will do her best to answer them each month. Send your questions to theautismblog@seattlechildrens.org.

Q: My twins are 8 years old have ADHD and have learning difficulties. They are in 3rd grade, but are testing at a 1st grade level. They have difficulty playing in groups of children and sometimes become very upset and angry in these situations. They both have a compulsion for water playing and often flood the bathroom at home (not intentionally, I don’t think). They refuse to wear certain clothes and refuse to eat certain foods. One of my twins is very anxious and continually coughs; we have been to the doctor to get medical treatment for the cough, but it has not worked. He still coughs for hours on end. I’m wondering if this is this just ADHD, or is it something more? I am waiting on a pediatrician to see them. I could go on, but ultimately, I need an answer.

A: It sounds like you are on the right track with asking your pediatrician. Ultimately, it sounds like you may be concerned about autism, so you will want to ask your pediatrician for a referral for an autism-specific evaluation. While sensory sensitivities, social challenges, emotion dysregulation, and repetitive behaviors are diagnostic features of autism, these can also be present in other diagnoses, such as ADHD. Ultimately, you (as the parent) are an expert regarding your children, so don’t be afraid to advocate for what you think they need, evaluation-wise. Good luck to you and continue listening to your parenting instinct.

Q: I need advice and have a question I’d like answered. First, I’d like to say I’m greatly disappointed that I’ve looked all over on Google for the viewpoint of those with autism and advice/help that can be given in certain situations and all I ever get is information on how to help parents of autistic children. I was diagnosed with high functioning autism when I was 20. I’m 22 now. I live with my parents because I have no basic life skills, but I want to get out of here because my step dad and I can’t stand each other. Since I’m autistic, still learning life skills, and only recently got my first job, I really have no way to leave this house, so I’ve tried to put on a smile and work things out with my step dad. He’s only known me for a year and has never had experience with ANYONE who’s had disabilities, not just Autism. He doesn’t know how to approach me, how to talk to me, or even how to treat me. I’d tolerate just being left alone with occasional “Hello’s” and many smiles, but he, wanting to be dad, wants to be involved in every second of my life whether he’s physically there or not. As I’m autistic, I will say, I am VERY introverted and feel like my work and house life are separate and what I do in my spare alone time should be kept private, unless I completely trust the person and find them easy to talk to, such as my mom, my sister, my best friend, or my boyfriend…my stepdad, not understanding me at all, has gotten into heated arguments with me, sometimes insulting my way of thinking, and we just don’t usually get along, so how can I trust him and talk to him easily? I feel like I’m walking on eggshells around him and I’m sure he feels the same with me.

So here are my two questions:

1.) Is it an autistic trait for me to want to open up freely and immediately about activities I’ve done to only trusted people, but close up to those who actually ask or am I just an extra kind of special? (I suppose, I feel that the people I trust and spend the most time with don’t need to ask because in my desire to talk with them, I’ll just tell them regardless, but if someone had to ask, I wonder “Why? If I haven’t said anything, then it was either a very ordinary day or I really don’t want to talk about it and if you really knew me, you’d know this about me,” and then it gets awkward because I’m silent and nervous).

2.) How do I solve these issues? I don’t know if I can keep living like this.

A: Thank you for writing in. I think most people would agree that they have a trusted circle of people with whom they can be themselves and share their experiences, emotions, and thoughts.  So really, it sounds to me like you are like most humans—you want to feel you trust someone before you’ll spill your beans. For some folks, trust is easily earned and networks of trusted others are wide. For others, those circles are smaller and trust is harder earned. How much we trust someone significantly impacts how we perceive their actions.  It sounds to me like your step-dad is trying his best to connect with you, but because your level of trust in him is not as high, his actions get interpreted as “nosy” and “boundary pushing.” Those who know you best are the most trusted and are more likely to be given the benefit of the doubt.

You’re also in this awkward in-between phase where you are working toward “individuating” from your parental units. Like a lot of young adults (autism or not), you want to be on your own and making your own rules, but still need to acquire some skills, means, or opportunity to be on your own. Parents and young adults do their best to connect and communicate during this period, but often end up butting heads. While it may not come across this way, both parties have the best intentions—parents to connect and be there for their kids and young adults to set boundaries for themselves and do things independently. This transitional period can be frustrating and challenging to navigate, and as a psychologist, I often provide therapeutic support for young adults (and parents, for that matter!) during this period. A therapist or counselor can act as a non-biased third party and is a person with whom you can vent, process, and problem solve during this time. Folks who see me during this time discuss things like self-advocacy, social problem solving, effective communication, emotion regulation, interpersonal effectiveness, goal setting, and life planning.

Good luck to you as you begin your journey toward individuation and thank you again for sharing your perspective.

 

 

 

Ask Dr. Emily – ASD and Adulthood

Welcome to the May edition of Ask Dr. Emily!

We often receive questions that we want to share with all our readers. To help with this, Dr. Emily Rastall, a clinical psychologist at Seattle Children’s Autism Center, will share insights in a question and answer format. We welcome you to send us your questions and Dr. Rastall will do her best to answer them each month. Send your questions to theautismblog@seattlechildrens.org.

Q: I have a 16-year-old with autism who is “high functioning.” As a parent, how do you get a teen to realize they are going to be on their own? How do you help them see that the things that you try to teach them at home are going to be things they will need for the rest of their lives?

A: I think you’ve asked the ultimate parenting question when it comes to raising teens. This is something most parents of teens struggle with, so I know you’re not alone. Add autism into the mix, and it can be a real challenge to prepare a teen for the “real world.” Listen, all teens (and especially those with ASD) have challenges with executive functioning; that’s the thing that happens in your frontal lobe when you plan ahead, think of the future, think critically and logically. Science tells us that the frontal lobes of adolescents are going through a lot of changes, which causes them to function at a sub-optimal level. In fact the frontal lobe does not fully develop until the age of 25! We also know that autism can affect how quickly parts of the brain (the frontal lobe included) develop over time. Your child with ASD may need more time for parts of their brain to fully develop. Translation: Your child with autism may need more time to become fully independent.

What can parents do to support their child’s independence while the brain is developing? The answer–we (the parents) will have to act as their frontal lobes while theirs are “offline.” For example, we set expectations and limits around things like screens, social media, sleep, nutrition, freedom, driving, hygiene, chores. We assist kids with time management; we help them make and execute a plan, provide visuals to help them see their progress, and offer rewards for task completion. Ultimately, teens don’t like the limits and “meddling,” but it’s one of those necessary evils to help them develop good habits for the future. Over time, we slowly offer more and more freedom and take away some of the supports. By the time your child’s brain is fully developed, they will have the skills and habits you have helped them form and they will have a fully developed brain to help them use these skills effectively. At this point, we won’t expect them to understand WHY we put those boundaries in place or to appreciate the life skills we are teaching them. That comes later…much, much later.

Q: Our son graduated college in Aug 2016. He is living at home working part time, lacking a social group, anxious, and stressed, which I’m sure we are adding to. He does not know that he has autism. I believe we’ve been trying to fit a square peg into a round hole for years. How do I tell him he’s on the spectrum?

A: It sounds like you know it’s time to have this challenging, but important, conversation with your son. My guess is that he has wondered (or is currently wondering) why things that seem easy for others are harder for him. In my opinion, honesty, along with love and empathy and compassion and support, is the best policy here. You might let him know that you have something important you’d like to talk to him about and then check in with him about a time that is generally a good time for him to talk. I would also go into this conversation with as little expectation about the outcome as possible and with resolve to remain calm and compassionate no matter what his reaction is. We can’t begin predict how this will feel for him. He may be relieved to finally have an answer. He may not agree with the diagnosis and ultimately reject it. He may feel a number of things. The important thing to convey is that you love and accept him no matter what and want to help him however you can. Good luck to you and your family as you navigate this transition into “knowing.”