Ask Dr. Emily

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.

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.

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-5^th 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.

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 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: What happens to people who are diagnosed with autism after the educational system is over for them and their caretakers cannot take care of them?

A: This is a timely question as a large number of children with autism are coming of age into adulthood. It’s also a question that could take pages to address, but here is a short summary. For previous generations, parents were told at diagnosis, that placement in an institution was best. Things are much different today with early intervention, educational rights, behavioral therapy, and other services in place. However, issues remain in terms of access, quality, and efficacy of adult care. Frankly, today’s parents are expected to care for their child until adulthood.

While services for individuals with autism have improved, supports and services for their families are woefully inadequate. One major “missing piece” for parents is true respite, giving them regular quality relief from the stress of 24-7 caregiving. With overloaded waiting lists for state services, many families struggle, physically, emotionally, and financially, to hang on until age 18-21 when faced with major transitions, including aging out of the public educational system and pediatric services and out of home placement.

In the state of Washington, “supported living” is the most likely option available to young adults who qualify for Developmental Disability Administration (DDA) services. In this model, clients live in apartments or houses in the community with one or more housemates and receive supports and services from a contracted agency, including 24-7 caregivers.

As far as educational, vocational, and recreational opportunities, while there are some services out there, we have a long way to go in developing meaningful opportunities for our young adults. Parents typically band together to explore and develop such options. This was the case in the creation of Seattle Children’s Alyssa Burnett Center, where Barbara and Charlie Burnett developed a center for their daughter and others, where they can continue to learn and be part of a supportive community.

In summary, adult services and opportunities for those on the spectrum are lacking as they once were for children on the spectrum. It will be through the concerted effort of parents, providers, and the community at large that we catch up.

Q: Hi Dr. Emily. I really enjoyed reading the Theory of Mind blog. I’m wondering, are their resources for improving ToM in children with autism? Can ToM be learned if a child doesn’t develop it naturally? Do providers offer “ToM training” for parents?

A: Theory of Mind (ToM) is a skill that typically develops between three and five years of age. If it doesn’t develop naturally (as evidenced by clinical measure and clinician observation), there are ways to compensate. For example, if one does not naturally think about what others are thinking, they might learn to simply ask. Social stories, increased exposure to social situations and peer interactions, coaching regarding “thinking of others,” and teaching to “look for clues” that reflect how others may be feeling are just some of the strategies that might be helpful in compensating for ToM challenges. Social skills groups often focus on teaching these kinds of “thinking about others” skills. The key is practice, practice, practice, so the more coached social interactions kids with ASD have, the better the outcome.

The bottom line is that our focus shouldn’t be on teaching theory of mind just as our focus shouldn’t be on curing autism. What matters is assessing specifically what each child’s strengths and challenges are and tailoring treatment to teach skills that will help a child best navigate his or her world.

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 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.

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