Ask Dr. Emily

All Articles in the Category ‘Ask Dr. Emily’

Ask Dr. Emily – Coping with Change and Understanding Social Norms

Welcome to the March 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 6 year old with ASD has all of a sudden started to ask for the sun to go away, she is saying Autumn is not over and tell the sun to go away. My daughter never had an issue with the sun in fact she loves it and would often sit with the sun on her face. I know it could be an event coming up she relates with Spring or it could be a number of things. They are teaching them the change in Seasons in school at present. Help would be much appreciated with this.

 A: Any way you look at it, change is hard. Change is especially hard for the autism brain, which relishes in structure, the predictable, and the known. The world, however, is in constant motion, so my guess is (and this is only a guess) that your daughter may be reacting to the conflict between what her brain likes (consistency) and the lack of that in the universe.  Your first step may be to simply validate what your child is feeling. You might say something like, “It sounds like you’re feeling ___ about change. Change is hard, isn’t it?” You might then offer your support  by saying, “You know I’m here to help if you need me. I have lots of ideas about how to feel better when things are hard.” Finally, you might offer some ideas about how to cope; deep breaths, distraction, and visualization of a “happy place” are some basic coping strategies you might model and describe (e.g., “I’m going to take a deep breath to feel better.” Or “Sometimes when I feel stressed, I like to do something fun to take my mind off of things.”), in an effort to expand  your daughter’s coping repertoire.

 

 Q: Hi…I went to work at a preschool and it was my first day. A child came up to me and just held my hand and wouldn’t stop. I didn’t know her, but later I found out that she has autism. So, what does it mean if a child with autism holds your hand and they don’t even know you?

 A: One of the diagnostic criteria of autism spectrum disorder (ASD) describes challenges making social initiations. Another criterion describes difficulty understanding social norms. My interpretation of this behavior (which could be correct or not) is that this child was attempting to connect with you or attempting to feel grounded in an environment of constant change (or both?). Either way, she’s not fully aware that this behavior is incongruent with the social environment and behavior of her peers. Through coaching (from you and other therapy providers), she will learn how to initiate effectively and will learn other (more socially appropriate) strategies for feeling safe and grounded. All of this aside, she chose you to feel safe with. What a special first day!

 

 

 

Ask Dr. Emily – Behaviors and Co-occurring Conditions

Welcome to the February 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 12 year grandson with autism is having trouble with portion size on everything, like how much shampoo to use, soap, using butter, mayo, just everything! He fixates on eating one thing at a time and is getting very picky about not liking foods he use to like. He is also getting very OCD. Does this go along with having autism?

A: It is not uncommon for individuals with autism spectrum disorder (ASD) to present with executive functioning challenges. That means that things like thinking ahead, planning, weighing consequences, resisting impulses, and stopping yourself when it’s time to stop, are difficult to do. Portion control is another one of those things that is processed in the executive functioning center of the brain (i.e., the frontal lobe), so it makes sense that this is something that is challenging for your grandson to do.

With regard to “OCD” symptoms, one of the diagnostic criteria for ASD involves “repetitive patterns of behavior or interest.” This can include “ritualized patterns of verbal or non-verbal behaviors” (e.g., eating foods one at a time in the same order, repeating words a specific number of times, closing every door in the house), “insistence on sameness” (e.g., needing the same green plastic cup for dinner) or “inflexible adherence to routines” (e.g., insisting that you drive home the same way every day). Often sensory sensitivities (another diagnostic criteria for ASD) play into food preferences (or lack there of) too. While many of these symptoms can mimic OCD (or obsessive compulsive disorder), much of the time these are expected behaviors to see with an ASD diagnosis. In conclusion, while OCD can occur with ASD, most individuals with ASD do not have “true” OCD.

 

Q: I have 13 year old fraternal twin boys, one was diagnosed with autism when he was 7-years-old, and the other with Tourette’s when he was 10. Now I am being told that my son with Tourette’s is showing signs of autism and my son with autism is showing signs of Tourette’s. How can this be happening at different ages and times? I need help to understand this.

A: While autism spectrum disorder (ASD) presents early in development, symptoms may not become notably impactful until later in an individual’s life. This might lead to a diagnosis that occurs later in life. Conversely, ASD symptoms that develop early in life may present as significantly impactful right away, which would lead to earlier diagnosis. With regard to Tourette’s, this can develop at different times for different children; one may develop it in elementary school while another’s symptoms may present around puberty. Tourette’s and ASD have been known to co-occur more often than would be expected by coincidence. For more information, you may be interested in the following book: Kids in the Syndrome Mix of ADHD, LD, Autism Spectrum, Tourette’s, Anxiety and More! By M Kutscher and T Attwood

 

Q: When puberty hit our 16-year-old Trey, OCD hit his high functioning autism really hard. He went from mildly medicated and in all mainstreamed classes to highly medicated (and yet unaffected) to moved into several special education classes. His anxiety has the entire family in tears at this point. We don’t know how to help him. Lights on and off, clothes on and off, food in and out, it is never ending. It doesn’t help that he is 6’6 and 400 pounds. We really need help. Any advice?

A: It is not uncommon for mental health challenges (anxiety, depression) to present with onset during puberty. I suggest you consult with your primary care provider and ask for a referral for a mental health evaluation. You will want this to occur with a psychiatric provider who has training in assessing, diagnosing, and treating obsessive compulsive disorder (OCD) and who also understands autism spectrum disorder (ASD). That provider, based on the diagnostic conclusions, will be able to provide treatment recommendations from there.

 

 

Ask Dr. Emily- Is This Lying?

Welcome to the January 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 3-year-old son just got a provisional autism diagnosis. I think he is able to “lie” to me. For example, after I put him in his crib he told me he needed to use the bathroom. So I brought him to the bathroom, but he refused to go. All the while, he was smiling and singing and excited to be out of the crib. Another time, he pretended to cough (while smiling) so that I would give him cough syrup (he loves the taste). Is this “lying?” Is it premeditated? What is going on here?

A: This sounds like pretty typical “kid” behavior. Most kids will try about anything to get what they want and/or like. Sometimes that means saying things that aren’t true to get their needs met. They are not meaning to deceive, but rather, they have learned that a certain behavior offers a certain result. Thus, they try the behavior again to see if it will pay off. Let’s say a child in the crib really does need to use the bathroom one night, and while doing so realizes, “Hey, I’m out of my crib!” They are more likely to ask to use the bathroom the next night as a way to get out of the crib.

Here’s another example: A child gets a fever and receives medicine and extra attention, gets to stay home from school, and gets to watch cartoons all day. They may try to convince you later that they are sick in hopes that they might get the same attention and privileges they received before. Who can blame them? I think we can all agree, this is less premeditative than simply reinforced, or learned behavior.

The best thing you can do in these situations is to give as little attention to the behavior as possible. You’ll want to do your own fact-checking and then respond as needed. Redirect and distract to move on to the next thing as soon as possible. Good luck, detective!

 

Ask Dr. Emily – Suggestions for Pica Treatment

Welcome to the December 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 child engages in Pica and I had him tested for iron & other deficiencies which came back clear. He does it when he is stressed, over excited and has even done it whilst he appears relaxed. Unsure where to go from here as have tried chewing gum, sensory chew items and scented play doh? Unsure where to go from here.  Any suggestions?

A: “Pica” (pronounced “pie-cuh”) is described as an individual “eating non-food items,” such as dirt, hair, paint/glue, rocks, lint, or paperclips. Pica is not uncommon in children with developmental disabilities, such as autism, but the precise prevalence is not known. The function of pica varies from individual to individual; the literature tells us that the most common explanation for pica is that it serves a sensory purpose—simply put, it feels and/or tastes good. Pica can also be a self-soothing strategy (like when stressed) or can be driven by social reinforcers (like attention from parents/teachers/peers). 

Regarding treatment, the literature tells us that interventions using applied behavioral analysis (ABA) techniques are most effective for treating pica. However, before you start behavioral treatment, it’s important to consult with your pediatrician to rule out any nutritional deficiencies as the root cause. The next step (and the first step in creating an effective behavioral treatment plan) will be to determine the reason the pica behavior is occurring; the behavioral treatment will vary based on the purpose of the behavior for your child. Thus, a functional analysis (FA) needs to be conducted by a trained behavioral expert (such as a BCBA). 

Subsequent treatment plans may include things like behavioral replacement (like chewing gum or “chewies”) which it sounds like you’ve tried, environmental enrichment (offering the child other items or activities and reducing the availability of non-food items in the environment), and/or reinforcement (rewarding the child when they engage in OTHER, more appropriate behaviors). Something to note: If a child or individual has received medical attention (e.g., trip the emergency room) or has health issues potentially due to pica, more immediate assessment and treatment will be called for.

If you’re waiting to see an ABA provider, there are some preventative strategies you can use to minimize harm. For example, you can remove preferred non-food items from the home. Educate all of the people your child interacts with (teachers, child care providers, extended family members) so that they can help supervise and prevent items from being ingested that might cause harm. Finally, minimize your emotional reaction (but do attend to it) to your child’s pica to decrease the chance that pica is reinforced by your attention. The Pica Toolkit for Parents and Professionals (brought to you by Autism Speaks) is also a nice resource.

 

 

Ask Dr. Emily – The Function of Stealing and Cognitive Rigidity

Welcome to the November 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 name is Chris, and I work in a high school with our ASD student population (high functioning). This past week I’ve dealt with two separate students involved in theft (a teacher’s laptop and the master school key). I was wondering if you could comment on the typical function of stealing for people on the spectrum? Is it common? Neither student was able to express why they had stolen their respective items, and both were aware of the negative consequences associated with getting caught. I’m finding it difficult to come up with a contingency plan with them when I can’t identify the function of the behavior we’re trying to replace. Any resources you think might help would also be very appreciated!

A: Thank you for your question. I’m not sure there is a universal “typical function” of this behavior for individuals with ASD. However, there are some special considerations to make when looking at the function of this behavior in children with ASD. For example, executive functioning skills in kids with ASD are often less developed than their typical peers, so they have a more difficult time thinking about consequences and/or resisting impulses. Though they may know the consequences, in that moment when they see something they want, their brains aren’t thinking about those consequences and aren’t able to resist the impulse to take.

In addition, we know that kids with ASD often have a hard time considering the perspective of others, so they are less likely to think about how taking an item will affect others. Also, items may be increasingly appealing if they fit within the restricted interests of a child with ASD.  Finally, kids with ASD may have a harder time communicating their needs, so taking items is a quick and easy way of “bypassing the ask.”

No matter the purpose, it’s not uncommon for kids to have a hard time explaining why it was that they took a particular item; I often hear, “I don’t know.” or “I just wanted it.” The truth is, they may not actually know or they may not have the words to describe it.

Regarding behavior planning, a functional behavior analysis (with someone who knows ASD well) is probably where you want to start. As far as intervention, broadly, just like for all humans, behavior changes are made via reinforcement of “the right” behaviors. Thus, we might start by praising and rewarding impulse control behaviors, like raising a hand in class (“I could tell you really wanted to speak out, but you raised your hand instead.”) and/or asking for desired items/privileges (“I appreciate you asking to use my pencil before taking it from my desk.”).

Another option might be to reward the absence of stealing behaviors. We might also teach scripts for how to ask for things and/or how to negotiate politely and effectively; when scripts are used, praise and rewards are given to promote continued use. For more resources about behavior management in the classroom, the following books might be helpful:

Positive Behavior Support in the Classroom (Jackson and Panyan)

A Work in Progress:  Behavior Management Strategies and Curriculum for Intensive Behavioral Treatment of Autism (Leaf and McEachin)

Coaching Students with Executive Functioning Deficits (Dawson and Guare)

 

Q: Thank you for your informative blog. It has answered so many questions. I was wondering if a friend’s fixation or obsession and competiveness are common in high functioning autism. My 11-year-old son has a mate with Asperger’s/autism (many titles here in Oz), that has a real fixation with being with my son constantly and having to have whatever he has and do whatever he does. It was fine when they were toddlers, but lately my son has found it tiresome and wants to form other friendships. As a mum I’ve suggested not catching up as often and both adding new friends, but as they attend the same school and sporting activities, this can be a challenge.

A: Thank you for your question. One of the primary diagnostic criteria for ASD is what we call “cognitive rigidity.” This might manifest as “getting stuck,” having a hard time making changes, or becoming overly focused on items, ideas, and/or people. As the social expectations increase throughout development, it is not uncommon for kids with ASD to have a hard time “keeping up with” the changes that need to occur to maintain friendships. I also want to mention, though, that it’s not uncommon for all kids to go through changes in their friendships, the root of which could be any number of things: Changes in location or school, changes in interests, family changes, personality preference changes.

It sounds like your son may be experiencing what is a normal part of growing up—shifting and changing of friend groups and interests. Luckily, this is a life lesson in kindness, tolerance, and inclusion. We want to teach kids that it is okay to outgrow friends, but never to become unkind or purposefully exclude others. While your son and his friend may move on to different friend groups, we want to encourage continued care, tolerance, and empathy for one another (they will continue seeing a lot of each other at school and extracurriculars, after all).

Bottom line: We want to help your son branch out, but also to continue showing kindness and compassion for a longtime friend. In order to improve variety and also remain inclusive, you might encourage your son to invite other peers to play with him and his friend on the playground or during play dates.

In the spirit of setting boundaries, your suggestion to support your son in kindly asking for some space is a good one. You might encourage your son to pursue other extracurricular activities that may open the door to a wider variety of potential friends, with whom play dates can occur. Play dates that do occur with your son’s friend, could include other peers or could be less frequent, shorter, and/or activity-focused (pumpkin carving or cookie making). It may be that, with your son less available, your son’s friend finds other peers that he likes to spend time with too.

This is not an easy transition, but one that most, or all, kids go through at least once. Your continued support and coaching will help your son make this transition kindly and empathically.