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 [email protected].

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.