Author: Emily Rastall, PhD

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.

Ask Dr. Emily- Sensory Sensitivity and Ritualized Behaviors

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 here, on the last Friday of each month, 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 4 year old grandson, who is diagnosed with autism. He comes to stay with me every other week, and I am learning a lot about him. Ever since he learned to walk, he has a fighting fit when his diaper or pants are taken off him. I’m worried about the diaper rash that he gets as a result. He doesn’t like when anyone tries to wash or wipe him. What is going on?

A: Because you mentioned a rash, the first thing to do is to have your pediatrician assess the area and give treatment recommendations. While I can’t say specifically what might be happening in your case, I can speak to one thing that could be playing a part. Specifically, it is not uncommon for children with autism to present with sensitivities to certain sensory input. In fact, one of the diagnostic criteria for autism spectrum disorder (ASD) is what we call “sensory sensitivities.” We call the sensitivities having to do with touch, “tactile sensitivities.” Children with tactile sensitivities could be sensitive to certain types or textures of clothing, may not like water on their skin or heads, might resist clothes being put on or taken off, may dislike haircuts or teeth brushing, and/or may dislike certain textures of food in the mouth. We can think of sensory sensitivities as the “senses on steroids;” everything feels stronger and more intense than you or I might feel it. Occupational therapy can be one way of helping children with ASD learn to tolerate sensory input more effectively. Like I mentioned earlier, the first step when there is a medical concern (like a rash) is to visit your pediatrician, who can make a referrals or recommendations based on their assessment of the issue.

 

Q: My 3-year-old daughter has autism, and I’m learning more and more about her every day. I’m curious as to why she walks around objects in certain ways. For example, she will walk around a table that is pushed up against a wall or will sometimes even walk around her younger brother’s toys that are on the floor. Sometimes I try to move things so that she doesn’t have to walk around them, but then she gets upset. What’s going on here?

A: One of the diagnostic criteria for autism spectrum disorder (ASD) is what is called “ritualized behavior.” This means repetitive patterns of behavior that may or may not appear to serve a purpose. A lot of the time these patterns of behavior don’t make a lot sense to us, but they make complete sense to our kids with ASD. Other examples of rituals might include stacking papers before bedtime, eating foods or doing tasks in one order (and one order only), requiring that parents take the same route home each day, or requiring that others say things in a certain order or certain way. It’s not uncommon for kids to become upset if they are not able to complete the ritual in the way they think it should be performed. The good news is that many times, these rituals are fairly benign. However, if you are finding that rituals are taking a great deal of time and interfering significantly with daily life, talk to your pediatrician about a possible treatment options and/or referrals.

Ask Dr. Emily- Movement and Sensory Overload

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 here, on the last Friday of each month, 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 two neighbors and a nephew with autism. Something I see all three of them do is walk—A LOT. For example, they might pace or go for walks up and down the driveway, hallway, around the block, etc. Does walking help self-regulate or is it because they are bored?

A: Individuals with autism spectrum disorder (ASD) often have a need to move their bodies. This “need to move” could be explained by a number of things. First, the “autism brain” is often, by nature, an active one. As a result, you might see squirmy, fidgety, and/or restless behaviors. Second, individuals with autism may present with what are called “stereotyped motor patterns,” or more simply put, repetitive body movements. This might look like pacing, rocking, flapping hands, jumping, spinning. Given the “autism brain’s” tendency toward movement, walking or pacing can be soothing to the system. We might think of it as “releasing steam.”

Q: My 3 year old son has autism and he just started school. As soon as we get there he covers his ears and sometimes hums also while covering his ears. He has also started to resist getting his diaper changed. I am wondering why he does these things and if this has anything to do with him starting school about 3 weeks ago.

A: It is not uncommon for kids (typically developing or otherwise) to present with new behaviors (or old behaviors that have disappeared, but come back) when going through significant transitions, such as starting school. They might have a hard time with things that have previously been easy. Kids going through large transitions may also be more tired, so tolerating even the simplest things (like diaper changes) can be challenging. During large transitions, kids can benefit from  sticking to routines at home, getting plenty of rest, and getting extra  child-directed play time with their parents or caretakers.

Specific to kids diagnosed with autism spectrum disorder, new environments can present as overwhelming to the senses. For example, the background noises of the classroom may be loud enough that it prompts kids to cover their ears. Humming may be working to drown out those noises even further. Kids with auditory sensitivities often benefit from noise reducing efforts, such as headphones or a quiet place to rest or recuperate.

Ask Dr. Emily- Asperger’s and Screen Time Questions

Welcome to the April 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 here, on the last Friday of each month, 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 16-year-old son was diagnosed with Asperger’s when he was very young. My friends and other people have told me that “Asperger’s” is no longer the term used to describe his level of functioning. What is the correct term to use when talking about him to teachers and other parents so they understand?

A: A new version of the Diagnostic Statistics Manual-5th Edition (DSM-5) was released in 2013. The previous version of the DSM (DSM-IV-TR) described three diagnoses: Autistic disorder, Asperger’s disorder, and pervasive developmental disorder, not otherwise specified [PDD, NOS]. All three of these disorders were considered “autism spectrum disorders.” The current DSM-5 discontinued the use of the three specific diagnoses and, at present, provides only one diagnosis: Autism spectrum disorder (ASD). The way we now describe “functioning” is to qualify whether an individual presents with intellectual impairment and/or language impairment.

Many individuals historically diagnosed with Asperger’s could be described by today’s DSM-5 standards as “autism spectrum disorder without intellectual impairment and without language impairment.” Because the term “Asperger’s” was used for so long, and so many understand it well, it is not uncommon for individuals, families, and providers to continue using the term in conversation to describe presentation and/or functioning. Bottom line: Keep using the term, if it helps you communicate with educators and others, but know that there are new official terms out there.

 

Q: What is the thinking about the impact of screens on kids with autism?  I know that limiting screen time for typical kids can impact their brain and social development.  Screen time seems to be a form of comfort for my autistic teenager after a long day at school, etc…   Texting has provided a great way for her to socialize with her friends but more on her own terms.  And texting seems to be a great tool for she and I to have a difficult conversation – it seems to be less charged and conflictual that way.   Is there any research and/or guidance for the healthy way to reap these benefits without affecting brain development in a negative way?

A: This is such a great question and one that I hear often. Research tells us that screen use (i.e., T.V., video games, computer games) in typically developing children is correlated with several negative effects on development. Specifically, increased screen use in typically developing children is correlated with delays in language development, reduced social interaction, less sleep, poorer school performance, higher rates of obesity, social skills challenges, impulse control challenges, and inattention/lack of focus. Earlier start age has been correlated with language delays and executive functioning delays (like attending, planning, and resisting impulses). These results make sense, right? Time spent on media is time NOT spent interacting with and being active participants in the world and people around them.

Research regarding media use in individuals with autism spectrum disorder (ASD) tells us that children with ASD spend more time using screens on a daily basis compared to their typically developing counterparts. Bottom line, kids with ASD are getting more exposure, which puts them at potentially higher risk for experiencing the deleterious effects of media mentioned above.

Regarding recommendations, the American Academy of Pediatrics (AAP) offered their recommendations in 2011 regarding recreational screen time use. Specifically, the AAP recommends that children under age two not engage in screen time at all. Between the ages of 2 and 18, the recommendation is between 1-2 hours, with no more than two hours per day. Yes, children these days are more and more engaging in screens as a way of staying socially connected. And many kids with ASD, specifically, endorse media/screen time as their most preferred activity. Thankfully, nothing out there is saying that we cannot use screens, however, moderation is the key. Thus, setting limits, creating balance, and providing alternative activities can teach kids how to set healthy boundaries for themselves as they grow into adulthood.