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: My child engages in Pica and I had him tested for iron & other deficiencies which came back clear. He does it when he is stressed, over excited and has even done it whilst he appears relaxed. Unsure where to go from here as have tried chewing gum, sensory chew items and scented play doh? Unsure where to go from here.  Any suggestions?

A: “Pica” (pronounced “pie-cuh”) is described as an individual “eating non-food items,” such as dirt, hair, paint/glue, rocks, lint, or paperclips. Pica is not uncommon in children with developmental disabilities, such as autism, but the precise prevalence is not known. The function of pica varies from individual to individual; the literature tells us that the most common explanation for pica is that it serves a sensory purpose—simply put, it feels and/or tastes good. Pica can also be a self-soothing strategy (like when stressed) or can be driven by social reinforcers (like attention from parents/teachers/peers). 

Regarding treatment, the literature tells us that interventions using applied behavioral analysis (ABA) techniques are most effective for treating pica. However, before you start behavioral treatment, it’s important to consult with your pediatrician to rule out any nutritional deficiencies as the root cause. The next step (and the first step in creating an effective behavioral treatment plan) will be to determine the reason the pica behavior is occurring; the behavioral treatment will vary based on the purpose of the behavior for your child. Thus, a functional analysis (FA) needs to be conducted by a trained behavioral expert (such as a BCBA). 

Subsequent treatment plans may include things like behavioral replacement (like chewing gum or “chewies”) which it sounds like you’ve tried, environmental enrichment (offering the child other items or activities and reducing the availability of non-food items in the environment), and/or reinforcement (rewarding the child when they engage in OTHER, more appropriate behaviors). Something to note: If a child or individual has received medical attention (e.g., trip the emergency room) or has health issues potentially due to pica, more immediate assessment and treatment will be called for.

If you’re waiting to see an ABA provider, there are some preventative strategies you can use to minimize harm. For example, you can remove preferred non-food items from the home. Educate all of the people your child interacts with (teachers, child care providers, extended family members) so that they can help supervise and prevent items from being ingested that might cause harm. Finally, minimize your emotional reaction (but do attend to it) to your child’s pica to decrease the chance that pica is reinforced by your attention. The Pica Toolkit for Parents and Professionals (brought to you by Autism Speaks) is also a nice resource.

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.

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).

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.

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.