Ask Dr. Emily

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: I have a second cousin who is 19-years-old and has been diagnosed with autism. He is verbal, and his IQ is 92. What I can’t understand is that he is very manipulative. Is it possible that he could be misdiagnosed? He has anger issues and screams and acts like a “child” when he does not get his way. He can cook, wash clothes, and make his bed, but he only does these things when he wants to. My 73-year-old cousin, who he lives with, has had enough. He doesn’t want to move out or go to a group home, and even if he wanted to, I’m not sure he’d be accepted due to his anger issues and outbursts. What can be done for him?

A: Thank you for writing in. It sounds like there are two questions to answer here. First, you’re wondering if the diagnosis of autism spectrum disorder (ASD) is appropriate for your cousin because you observe his behavior as “manipulative” in some ways, correct?

Rather than think about behavior as purposeful or “manipulative,” it might be helpful to think about behavior in terms of its function. Behavior for all humans always serves one (or more) of the four purposes: Get something, get attention, avoid something, or is automatically reinforced.

Behavior therapy, like applied behavior analysis (ABA), works to determine the function of behavior and can help an individual learn to get their needs met with new, more effective behaviors.

The second question I hear you asking relates to housing resources for adults with ASD. It is possible that with behavior services, your cousin will be better able to control his outbursts and function more independently in his current living situation. However, given the age of your 73-year-old cousin he lives with, it might be a good idea to look into options for the future. Each state is different in how it handles housing for those with developmental disabilities, but keep in mind that many clients have behavioral challenges so this wouldn’t necessarily keep your cousin from being served. In Washington State, the Developmental Disabilities Administration (DDA), which is part of the Department of Social and Health Services (DSHS), is the housing authority for persons with developmental disabilities.

Q: Hello. I’ve been following this site for a while now, and I have a major concern. I’m in a relationship with my girlfriend and she has a 7 yr. old daughter. We’ve been together for four years. I strongly believe that her daughter has some type of ASD. I have a son the same age as her daughter and the stress level for him when we’re all together is very high due to her abnormal behavior. Of course my son has his moments being a 7 yr. old, but it’s easily handled. Here are some of the things that are challenging: Transitions, sleeping, public meltdowns, interrupting, attention seeking, safety issues (like darting into the street without looking and talking to strangers), noncompliance, difficulty playing alone, and hyperactivity and fidgeting. It’s like she’s being driven by a motor that doesn’t shut off. I apologize for such a long list of issues. I need help in trying to talk to her mom about it. When the issues have been brought up (by her daughter’s father), my girlfriend has shut the idea down. I really love this woman, but I would not be able to move in with her if things stayed as they are now. Please help. Thank you so much.

A: Thank you for reading our blog, and I’m glad you wrote in. This sounds like a really hard situation for you, as you’re torn between a loved one and setting boundaries for yourself and your children. I can completely understand your hesitation to take that next step (moving in), especially given the stress your 7-year-old may experience. I also understand your hesitation to speak with your girlfriend about your concerns, as it sounds like her reaction to others bringing this up in the past has been (perhaps understandably) less-than-collaborative. However, as is the case in any important relationship, communication with absolute transparency, especially about the hard stuff, is key. You might start with talking about your feelings and about how hard this is for you to talk with her about. You might also share how this issue is impacting your ability to move forward in the relationship (a hard dose of reality, but reality nonetheless). Finally, you might consider approaching this as a “let’s partner on this” issue, so that your girlfriend feels supported (rather than defensive). Best of luck to you as you work to align with your partner on this tough issue.

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 son is 23, currently lives at home and has been aware of his diagnosis of Asperger’s for many years. He is a pretty accomplished guy, but struggles constantly with anxiety, confidence, and independence. Nevertheless, he chose to spend a year away from home in a residential living skills vocation program, which he really enjoyed. He has nearly completed his Bachelor of Commerce degree, and has also, albeit reluctantly, obtained his driver’s license.

My question revolves around driving. He’s got his license, but it’s been like pulling teeth to persuade him to keep practicing the skills he’s learned. His great reluctance to drive by himself has led me to try following or leading him in our extra car while he learns to drive longer and longer distances. My hope was to have him feel confident enough to drive himself to places he can’t get to by walking or by bus. He grows in skill but negates any progress he makes. I am at my wit’s end and wonder if this is a losing battle. Any thoughts?

A: A losing battle? No. However, it does sound like, despite your son’s driving skills improving, anxiety is playing a large part in his resistance to driving independently. In general, skills can take longer and require more repetition for the autism brain to master (and let’s face it, driving is a VERY complex skill with a lot of variables to learn). If you are worried about anxiety impacting this and other parts of your son’s life, your son’s primary care provider may be able to make a recommendation for a mental health evaluation, which will provide you with diagnostic clarification and a treatment plan. It is also important to think about the stick with which we measure success. In the end, not everyone is a driver. More and more folks these days choose to walk and take public transportation, which may be what your son opts to do. Ultimately, I hear you saying that independence is the goal, and this can likely be achieved, driving or not.

Q: I recently read that kids with Autism convert sensory input into picture or video memory. Is this true? If so, is singing to my child a good thing or should I be having my child watch videos instead? Do videos harm him? What kind of limits should I place on singing songs or watching videos?

A: Thank you for writing in. Generally speaking, given the “autism brain’s” varying challenges with language (which is an abstract process), the use of pictures (which are more concrete than the spoken word) can aid in understanding and communication. That doesn’t mean, however, that singing to your child or listening to songs is harmful or not worth doing. Speaking to and singing to (any) child increases the vocabulary that they are exposed to, which is good for any child’s language development. One could argue that increased language exposure for a child with language challenges is especially important. You might add to the singing experience by showing your child pictures, using hand gestures, or using puppets or props that coincide with the song lyrics. Reading and simply talking to your child can also be helpful.

Videos are another way of providing visuals to your child, and children with ASD tend to focus more heavily on video content than even the same actions happening live in front of them. Unlike reading, talking or singing though, there is a guideline that limits 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 learning, observing, exploring, interacting, and playing—all things that help promote development in any child.

In sum, sing and read and talk to your child to your heart’s content; do modify how much you use screens. Happy playing!

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.

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.

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.