Ask Dr. Emily

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 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: My twins are 8 years old have ADHD and have learning difficulties. They are in 3^rd grade, but are testing at a 1^st grade level. They have difficulty playing in groups of children and sometimes become very upset and angry in these situations. They both have a compulsion for water playing and often flood the bathroom at home (not intentionally, I don’t think). They refuse to wear certain clothes and refuse to eat certain foods. One of my twins is very anxious and continually coughs; we have been to the doctor to get medical treatment for the cough, but it has not worked. He still coughs for hours on end. I’m wondering if this is this just ADHD, or is it something more? I am waiting on a pediatrician to see them. I could go on, but ultimately, I need an answer.

A: It sounds like you are on the right track with asking your pediatrician. Ultimately, it sounds like you may be concerned about autism, so you will want to ask your pediatrician for a referral for an autism-specific evaluation. While sensory sensitivities, social challenges, emotion dysregulation, and repetitive behaviors are diagnostic features of autism, these can also be present in other diagnoses, such as ADHD. Ultimately, you (as the parent) are an expert regarding your children, so don’t be afraid to advocate for what you think they need, evaluation-wise. Good luck to you and continue listening to your parenting instinct.

Q: I need advice and have a question I’d like answered. First, I’d like to say I’m greatly disappointed that I’ve looked all over on Google for the viewpoint of those with autism and advice/help that can be given in certain situations and all I ever get is information on how to help parents of autistic children. I was diagnosed with high functioning autism when I was 20. I’m 22 now. I live with my parents because I have no basic life skills, but I want to get out of here because my step dad and I can’t stand each other. Since I’m autistic, still learning life skills, and only recently got my first job, I really have no way to leave this house, so I’ve tried to put on a smile and work things out with my step dad. He’s only known me for a year and has never had experience with ANYONE who’s had disabilities, not just Autism. He doesn’t know how to approach me, how to talk to me, or even how to treat me. I’d tolerate just being left alone with occasional “Hello’s” and many smiles, but he, wanting to be dad, wants to be involved in every second of my life whether he’s physically there or not. As I’m autistic, I will say, I am VERY introverted and feel like my work and house life are separate and what I do in my spare alone time should be kept private, unless I completely trust the person and find them easy to talk to, such as my mom, my sister, my best friend, or my boyfriend…my stepdad, not understanding me at all, has gotten into heated arguments with me, sometimes insulting my way of thinking, and we just don’t usually get along, so how can I trust him and talk to him easily? I feel like I’m walking on eggshells around him and I’m sure he feels the same with me.

So here are my two questions:

1.) Is it an autistic trait for me to want to open up freely and immediately about activities I’ve done to only trusted people, but close up to those who actually ask or am I just an extra kind of special? (I suppose, I feel that the people I trust and spend the most time with don’t need to ask because in my desire to talk with them, I’ll just tell them regardless, but if someone had to ask, I wonder “Why? If I haven’t said anything, then it was either a very ordinary day or I really don’t want to talk about it and if you really knew me, you’d know this about me,” and then it gets awkward because I’m silent and nervous).

2.) How do I solve these issues? I don’t know if I can keep living like this.

A: Thank you for writing in. I think most people would agree that they have a trusted circle of people with whom they can be themselves and share their experiences, emotions, and thoughts.  So really, it sounds to me like you are like most humans—you want to feel you trust someone before you’ll spill your beans. For some folks, trust is easily earned and networks of trusted others are wide. For others, those circles are smaller and trust is harder earned. How much we trust someone significantly impacts how we perceive their actions.  It sounds to me like your step-dad is trying his best to connect with you, but because your level of trust in him is not as high, his actions get interpreted as “nosy” and “boundary pushing.” Those who know you best are the most trusted and are more likely to be given the benefit of the doubt.

You’re also in this awkward in-between phase where you are working toward “individuating” from your parental units. Like a lot of young adults (autism or not), you want to be on your own and making your own rules, but still need to acquire some skills, means, or opportunity to be on your own. Parents and young adults do their best to connect and communicate during this period, but often end up butting heads. While it may not come across this way, both parties have the best intentions—parents to connect and be there for their kids and young adults to set boundaries for themselves and do things independently. This transitional period can be frustrating and challenging to navigate, and as a psychologist, I often provide therapeutic support for young adults (and parents, for that matter!) during this period. A therapist or counselor can act as a non-biased third party and is a person with whom you can vent, process, and problem solve during this time. Folks who see me during this time discuss things like self-advocacy, social problem solving, effective communication, emotion regulation, interpersonal effectiveness, goal setting, and life planning.

Good luck to you as you begin your journey toward individuation and thank you again for sharing your perspective.

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 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: I have a 16-year-old with autism who is “high functioning.” As a parent, how do you get a teen to realize they are going to be on their own? How do you help them see that the things that you try to teach them at home are going to be things they will need for the rest of their lives?

A: I think you’ve asked the ultimate parenting question when it comes to raising teens. This is something most parents of teens struggle with, so I know you’re not alone. Add autism into the mix, and it can be a real challenge to prepare a teen for the “real world.” Listen, all teens (and especially those with ASD) have challenges with executive functioning; that’s the thing that happens in your frontal lobe when you plan ahead, think of the future, think critically and logically. Science tells us that the frontal lobes of adolescents are going through a lot of changes, which causes them to function at a sub-optimal level. In fact the frontal lobe does not fully develop until the age of 25! We also know that autism can affect how quickly parts of the brain (the frontal lobe included) develop over time. Your child with ASD may need more time for parts of their brain to fully develop. Translation: Your child with autism may need more time to become fully independent.

What can parents do to support their child’s independence while the brain is developing? The answer–we (the parents) will have to act as their frontal lobes while theirs are “offline.” For example, we set expectations and limits around things like screens, social media, sleep, nutrition, freedom, driving, hygiene, chores. We assist kids with time management; we help them make and execute a plan, provide visuals to help them see their progress, and offer rewards for task completion. Ultimately, teens don’t like the limits and “meddling,” but it’s one of those necessary evils to help them develop good habits for the future. Over time, we slowly offer more and more freedom and take away some of the supports. By the time your child’s brain is fully developed, they will have the skills and habits you have helped them form and they will have a fully developed brain to help them use these skills effectively. At this point, we won’t expect them to understand WHY we put those boundaries in place or to appreciate the life skills we are teaching them. That comes later…much, much later.

Q: Our son graduated college in Aug 2016. He is living at home working part time, lacking a social group, anxious, and stressed, which I’m sure we are adding to. He does not know that he has autism. I believe we’ve been trying to fit a square peg into a round hole for years. How do I tell him he’s on the spectrum?

A: It sounds like you know it’s time to have this challenging, but important, conversation with your son. My guess is that he has wondered (or is currently wondering) why things that seem easy for others are harder for him. In my opinion, honesty, along with love and empathy and compassion and support, is the best policy here. You might let him know that you have something important you’d like to talk to him about and then check in with him about a time that is generally a good time for him to talk. I would also go into this conversation with as little expectation about the outcome as possible and with resolve to remain calm and compassionate no matter what his reaction is. We can’t begin predict how this will feel for him. He may be relieved to finally have an answer. He may not agree with the diagnosis and ultimately reject it. He may feel a number of things. The important thing to convey is that you love and accept him no matter what and want to help him however you can. Good luck to you and your family as you navigate this transition into “knowing.”

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 [email protected].

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!

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 [email protected].

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.

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 [email protected].

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!