Ask Dr. Emily

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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.

Ask Dr. Emily- Flu Shot Tips

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: I had to bring my 10 year-old autistic son twice to the doctor’s office for a flu shot. First time they couldn’t do it. Second time they gave him some medicine to calm him down which didn’t help. We ended up holding him down and doing it. It took 4 adults this time. I have no idea what we are going to do next time. My son is growing and I don’t think holding him down will work much longer. What can I do?

A: This is a great question and one that comes up every year around this time. There is a lot of work that can be done to prepare for events like these. These kinds of procedures can be scary for any child, but may be especially anxiety-provoking for children with limited language, cognitive, and/or emotion regulation skills. First, it is important that we are honest with kids about what to expect with shots; rather than telling kids that “shots don’t hurt,” we want to message that shots pinch at first, but that the pain is finite and only lasts a few seconds.

In preparation for the procedure, the use of social stories can help children understand what is going to happen and how. Additionally, frequent rehearsal at home using pictures and other visuals (like a toy doctor’s kit) can also help kids understand what to expect and can work to desensitize kids to the procedure and tools used.

You will also want to teach basic coping strategies within those social stories and rehearsals. For example, teaching deep breathing strategies (“smell the flower, blow out the candles”), positive scripts (like “I’m going to be okay. It only hurts for a second.”), or self-distraction strategies (like counting or singing out loud while getting the shot or procedure).

 

Ask Dr. Emily- Sensory Sensitivities and Where to get Information on Autism

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: How can I deal with a child who is hyper sensitive to sounds when we are in a mall or supermarket? My child has tantrums when they are overstimulated.

A: Settings that have a lot going on can definitely be overwhelming to the senses for children with sensory sensitivities. One way to reduce sensory input would be to provide headphones (either with music or not). Another suggestion might be distraction; offering a preferred object (like iPad, book, or musical toy) may help distract children from the things going on around them. Also, offering frequent rewards (like stickers, small food items [like goldfish, raisins, or M&M’s], or tokens) for calm behavior in these settings might help. Finally, working to reduce exposure to these settings (when possible, of course) may also take the pressure off of everyone (parent and child alike); for example, using online shopping services or phone apps or leaving kids at home with a sitter (again, when/if possible), might help to ease everyone’s pain.

Q: I’m a parent of two wonderful girls (9 and 3-years old). I am also recently (last 6-2 months) a step-parent to a beautiful young 3-year-old boy with autism; he fills my heart with joy. We only have him every two weeks, but already we have a connection. He reaches for me, and he likes it when I sing him nursery rhymes. Some of the things he does (like spinning objects) are confusing to me. What can I do as a step-parent to learn more and to help him as he grows?

A: Well, already you are doing it…by that I mean reaching out and working to gather as much information as you can. Subscribing to blogs, attending seminars (like Seattle Children’s Hospital’s Autism 101 and Autism 200 series), joining list serves, and talking to other parents will broaden your understanding and introduce you to parents who may have similar experiences. Additionally, websites like Autism Speaks and FEAT Washington are excellent resources. In addition, it will be important to be involved in your step-child’s treatment; attending treatment sessions, doctor’s visits, and engaging the “homework” assignments that your child’s treatment providers assign will help you learn about your step-child and will give you opportunities to ask the professionals questions that come up. Finally, collaborating, observing, asking questions in a non-judgmental manner, and joining forces with your spouse, who has been at this longer, will strengthen your bond with your spouse and will help you learn about your step-child and what strategies work best for him.

Ask Dr. Emily- Dealing with Major Life Changes and Predicting Outcome

Welcome to the August 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: While this is an absolutely wonderful article for daily activities, I am wondering if there is an article of the same level of information for major life changes. My son is 18 and is high-functioning autistic, OCD, anxiety disorder as well as ADHD. We recently moved into a new house, school ended (he is homeschooled), his brother and sister-in-law moved into our home with our grandson, and he just had another surgery that resulted in a pulmonary embolism and a 6-Day Hospital stay. Needless to say, he is very upset and exhibiting aggression as well as temper tantrums and wild mood swings. I have tried spending extra time with him and validating his jealousy as well as his anxiety. He has a tendency to go nonverbal when his stress becomes too much, He not only has done this but has started his tics again. Please help if you have any ideas on what we could do for him.

A: Let me start by acknowledging how much you and your family have been through recently.  As we know, humans, in general, like to know what is coming—what is next. Children, in general, respond to change and/or major life events (like loss, moves, change in school) in various ways; responses can include irritability, despondence or withdrawal, challenging behaviors (such as noncompliance and/or aggression), and/or emotional lability (e.g., tearfulness, outbursts). Children with ASD, specifically, may also demonstrate increased repetitive behaviors, increased sensitivity to the environment, outbursts, or aggression.

So how can we help kids (and children with ASD, in particular) through some of these major life changes? Many of the strategies recommended for day-to-day activities (mentioned in a prior blog) can also be helpful for big life events. I am encouraged to hear you mention more one-on-one time and validation as strategies you have tried; these are great relationship builders and can lead to positive outcomes. In addition, if you have time to prepare for life events, using social stories, pictures, practice, and preparatory exposure can be helpful. In addition, allowing extra time (if possible) for adjustment can be beneficial. We also want to provide as much structure as is possible (e.g., checklists, visual schedules, breaks). In addition, it can be helpful to keep as many things the same as is possible. For example, if changing schools, keep the same backpack, lunch items, and/or morning routine. If staying overnight in the hospital, having blankets/pillows/stuffed animals/foods from home can help to ease discomfort.

Ultimately, even when you go to great lengths to ease difficult situations, change in routine and major life events are difficult to cope with–period. A little understanding (and reframing our negative thoughts to more tolerant ones) can go a long way. Parents, don’t be afraid to ask for what you need in terms of support, too. In the end, children look to us for feedback about how to feel about situations. The more support we can get to cope with our own emotions, the better off everyone will be.

Q: I have a 5-year-old daughter on the ASD spectrum. She can repeat what you say (though not clearly) and has mastered some questions. She will also answer when asked a question (like, “What’s your name?” or “How old are you?”). Do you think she will speak spontaneously (i.e., communicate on her own) someday?

A: While I cannot predict outcomes, there are some good indicators out there that are associated with improvements in language functioning. First, we know that early evidence-based intervention (like speech therapy, behavioral intervention) often leads to more positive outcomes in language and overall functioning later in development. Second, we know that language skills build on one another. So mastery of early language fundamentals (like babbling, word approximations and single words) can lead to more sophisticated language skill development (like phrase speech, sentence speech, and spontaneous language more broadly). Finally, we know that using visuals (like pictures) to assist individuals in communicating can lead to improved communication outcome.  Bottom line, continue providing therapeutic  support for language growth, and she will show us what she can do.

 

Ask Dr. Emily- Ritualized Patterns of Non-Verbal Behavior and Sensory Seeking

Welcome to the July edition of Ask Dr. Emily! This month we celebrate the one year anniversary of our Ask Dr. Emily series! Thanks to Dr. Emily for her helpful advice and to our readers for sending questions we can all learn from. Here’s to another great year! 

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 always turns his stuffed animals to face the wall when he’s playing. I’m curious about whether other kids do this and, if so, why?

A: One of the diagnostic criteria for autism spectrum disorder is something called “ritualized patterns of non-verbal behavior.” Often, children with autism dislike when these rituals are disrupted. Your son’s insistence on turning his toys a certain way may be one of these rituals. We don’t know why children with autism choose the rituals they do. It might also be difficult for us adults to understand what purpose these rituals may serve. We might guess that these behaviors bring order to an otherwise chaotic world, and thus, may serve to soothe an underlying unsettledness.

Q: My son was diagnosed with Autism Spectrum Disorder in August of 2015. He is almost four years old. He rubs his head across the floor when he is upset or even just randomly sometimes. Why does he do that? Is there a term for that? Also, he can be aggressive when upset. Are there ways to slow his aggression?

A: Often, repetitive behaviors (like the rubbing you described) can be the result of what is called “sensory seeking.” Sensory seeking is one of the diagnostic criteria for autism spectrum disorder. Children who are under-sensitive to tactile (skin) sensations, may seek it out for the purpose of calming, or simply for pleasure. It’s a little like the pleasure we might get from a back scratch or a foot rub; but their bodies want more of it more of the time.

With regard to your question about aggression, it is not uncommon for children, autism or not, to hit, kick, throw, and/or push, when upset. First, the reasoning part of the brain (frontal lobe) that helps us humans think through consequences and resist the urge to lash out (and we all feel it sometimes, right?) is very under-developed in young children. In fact, the frontal lobe is not fully developed in typically developing individuals until they reach 25 years old! In addition, when upset, stress hormones in the brain cause the frontal lobe to stop working as well. Children with autism spectrum disorder commonly have frontal lobes that are even less developed than their same-age peers. They also tend to feel things (like emotions) more intensely than their typically developing peers (or feel things equally, but understand them less, making the experience overwhelming and confusing). Time for brain development to occur, in addition to behavioral interventions (like applied behavioral analysis) can promote the development of self control in children with autism.