Common Behavioural ConcernsAssociate With Autism

Lorraine Ringland

&

Dr Clare Bailey

Lorraine Ringland

&

Dr Clare Bailey

PurposePurpose

To analyse common behavioural concerns from ASD perspective

To provide some practical strategies as to how these can be addressed

To provide specific strategies for toileting, sleeping and eating

Discussed common scenarios which parents have raised in the past

To sign post to relevant resources and services

“He is such a picky eater! He

gags at the thought of some

foods!” “It takes so long for him to go to

sleep, then he is awake so early!”

Why can’t he just use the toilet like other children his age?

Why does he have to ‘go’ in his bedroom?”

“It takes her so long to get dressed in the morning, she

is so particular about how her

socks sit!”

“I don’t understand why he won’t sit on

the toilet!”

Who Parents Turn ToWho Parents Turn To

First contact with sign post to: Community Paediatric Medical Services,

Occupational Therapy services, Dietetics and/or Continence services.– Detailed history to consider:

Social Communication / Interaction Inflexibility / Routines Sensory Issues Medical Issues

Social Communication / InteractionSocial Communication / Interaction

Social awareness – unspoken ‘dos and don’ts’

Difficulty initiating Dependence on others

Examples of Deficits with Social Awareness Examples of Deficits with Social Awareness

8 year old girl sitting with skirt around their waist Child puts dry clothes over wet Failure to close door behind them in public toilets Child states to floor ‘I’m going to poo my pants’ Challenging someone older and much larger for

‘jumping the queue’

Social CommunicationSocial Communication

Can you? Would you? Where’s your…? ‘Do what I mean, not what I said’. Consider specifics of instructions, e.g.

duration, beginning & end Is there a need for the ‘Science bit?

Examples of difficulties based on communicationExamples of difficulties based on communication

The child only uses a nappy as they do not know the purpose of the toilet

‘Eat your dinner!’, does the child understand that ‘dinner’ involves different items each day?

‘Go to bed!’ – is this all you want them to do? Whose bed?

‘Go and get changed!’ – into what……

RoutinesRoutines

Logically illogical General purpose of routine

– security / feeling safe What does the routine mean for your child? Any changes to behaviour become part of a

new routine

Examples of Difficulties with RoutinesExamples of Difficulties with Routines

Placement of items in specific ways Bowel movements in the bedroom Travel to school by same route Routine of ‘peek a boo’ before a child can get

started Only being put to bed by one person Checking out toilets in unfamiliar places Unexpected events / visitors Related to special interests

Sensory IssuesSensory Issues

Behaviours may be related to – seeking out or – avoiding the sensory elements involved.

Some subtle sensations can be enough to affect a child’s performance,

Includes motor development

Examples of common Sensory issuesExamples of common Sensory issues

Poor balance and postural skills at toilet. Toilet seat feels uncomfortable / painful. Difficulties settling to sleep He/she will only eat dry food types. The lighting in the bathroom is to bright, the

smell of soaps are too strong.

Medical AspectMedical Aspect Acute health issues may manifest through

behavioural changes. Medical reasons may need to be explored

where there have been changes to:– Weight, appetite – Chewing or swallowing– Bladder control– Bowel habit– Sleep pattern– Levels of activity / unusual movements

Structure the activity Preparing the child for change Sensory considerations

General StrategiesGeneral Strategies

Establish behaviour at present– E.g. Keep a sleep, diet or toileting diary,

Consider what is right for your family:– Can dinner be eaten at the same time every

night?– Can bathtime occur at the same time each

night?– Is there a consistent bedtime?

Provide Visual InstructionProvide Visual Instruction

Support routines and instructions with visual cues. These can be written, drawn, downloaded or photographed. Have it available when expecting the child to complete the task

For Example: bedtime routine

Brush teeth Wash face PJ’s on Into bed

6.30pm: dinner

7.00pm: quiet time

7.15pm: Drink and night time snack

7.45pm: bath

8.25pm: clean teeth

8.30pm: bedtime/sleep

7.30am: getting up time

Evening Schedule

Dinner Choice Board

Toileting ScheduleToileting Schedule

Preparing the Child for ChangePreparing the Child for Change

Use Social Stories© Use photo books:

– A series of photos of your child engaged in the desired activity with words to explain.

– The book can be read each time the child is engaged in the activity.

Use of pictures / objects.

Sensory ConsiderationsSensory Considerations

Child’s position? Level of activity? Sensory elements?

– Auditory: eg fans, ticking clocks, need white noise, flushing toilet too loud

– Visual: too bright, too dark– Tactile:, temperature changes, textures of seat, food

bedclothes, water– Taste: craves bland or spicy foods – Smell: Seeks or avoids smells, e.g. air fresheners, food

cooking, fabric softeners, perfume.

Strategies with ToiletingStrategies with Toileting

Keep all toilet related activities to the bathroom.

Timing the visits to bathroom. Consider environment

– Remove distractions e.g. make up bottles, shampoo, mirrors etc.

– Noise

Resists Sitting on ToiletResists Sitting on Toilet

Sit without removing clothes (practice only) Sit with toilet covered (cardboard under the

seat, gradually cutting larger hole) Take turns sitting or using a doll as a model Sit with the child Add physical supports: step, hand rails or

straddle the toilet Specify duration (sing a song, length of one

song on tape, set timer)

Afraid of flushingAfraid of flushing

Don’t flush until there is something to flush Allow child to flush eg hand over hand / count 1-2-3

flush Start flush with child away from toilet, perhaps

standing at the door Visually support how many flushes are needed

Bad AimBad Aim

Supply a “target” in the water, such as a ‘Cheerio’, or commercial made flushable targets

Add food colouring in water to draw attention

In boys allow them to sit

Cleaning ThemselvesCleaning Themselves

Hand over handSoft paper / wet wipesEstablish how many squares of toilet roll

is needed (support visually)

Sleeping Strategies Sleeping Strategies

Where is this place called ‘sleep’? Avoid the fear of the unknown.

– Understanding the need for sleep – Duration of sleep.

Consider using social stories, photo books and / or flow charts.

Taken from ‘My social stories book’ by Carol GrayTaken from ‘My social stories book’ by Carol Gray

What does it mean when people say, ‘Time for bed’?

All people sleep. Most people sleep on Monday, Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday. They wake up each morning.

I sleep in a bed. Usually Mum or Dad says, ‘Time to go to bed’. This means it is time to go to bed and to sleep.

(Published by Jessica Kingsley Publisher, 2002)

Sleeping Strategies - GeneralSleeping Strategies - General

Introduce a relaxing bedtime routine. Allocate time to discuss worries daily. Try different bedding

– Heavier blankets or – Weighted blankets – Sheets and blankets– Sleeping bags

Sleeping Strategies - SensorySleeping Strategies - Sensory

Sensory activities:– Press down on shoulders holding arm at elbow

and hold for 3-4 seconds and repeat 10 times. – Press through wrist holding arm at elbow and

bending wrist slightly and hold for 3-4 seconds and repeat 10 times.

– Hold child’s knee and foot (with knee and foot bent at right angles) and press up into knee, hold for 3-4 seconds and repeat 10 times.

Sleeping Strategies – BehaviouralSleeping Strategies – Behavioural1. Lie next to the child on the

bed (3 nights)2. Lie on separate mattress

next to bed (3 nights)3. Move mattress closer to the

door every 3 nights.4. Sit on chair at door with door

open for 3 nights5. Sit outside door, still visible

for 3 nights6. Sit outside door, not visible

for 3 nights7. Sit outside room door closed

for 3 nights

Strategies to Assist with Feeding Strategies to Assist with Feeding

What level of social interaction is required at mealtimes?– Allowing to eat alone– Joining family for social interaction after food

has been eaten

Environmental AspectsEnvironmental Aspects Eat all meals and snacks at a consistent location Advance preparation

– Post meals schedules in several locations in the house– Use timers to let everyone know when the next meal will

occur Write out list of desired behaviour and post it near

the table– How much to eat– When child can leave table

Clear eating environment of all distractions Allow the child to participate in setting the table,

preparing and serving the food Avoid drawing attention to refusal of foods

Sensori-Motor AspectsSensori-Motor Aspects

At other times of the day provide ‘chewy toys’ to improve chewing skills

Ensure feet are on stable surface and child is positioned well

At other times in the day allow the child to play with and explore various food items

If the child appears agitated at meal times, use the sensory activities to help him/her calm

Introducing New FoodsIntroducing New Foods The ‘Science Bit’ Allow the child to assist with meal preparation Agree with the child the new food item to be eaten

– May be useful to have a good food list and a bad food list supported with visuals

Use manageable steps carried out over days/weeks:– Place new food item on the table– Then a small piece on the plate– Try to get the child to touch it– Try to get the child to lick it – Try to get the child to hold it in mouth (not chew or swallow)– Then ask the child to chew– Then ask the child to chew and swallow

Use known motivators with caution but always support and encourage

Impact on HealthImpact on Health

Restricted diet– Nutritional deficiencies– Weight loss– Dental hygiene

Mental Health Other conditions go un-noticed Everything blamed on ASD

Role of MedicationRole of Medication

Dietary supplements Melatonin for Sleep Clonidine for Sleep ADHD Other co-morbidities Stronger medications

RecapRecap

Consider environment Consider language used Are expectations realistic, shared and

mutually understood Support with age appropriate visuals Think about telling the child what to do

rather than ‘don’t do’

RememberRemember

Pick your battles – one at a time Remain consistent – Don’t give up! Reward and praise success Play to the child’s strengths – ‘The Science Bit’ /

special interests The problem may worsen before it gets better Unfortunately there are no quick fixes but others

can help……..

Who can help?Who can help?

Other Parents Health Visitor / GP Community Paediatric Medical Services Allied Health Professionals – OT, SLT Dietetics Continence Services Clinical Psychologists CAMHS Others

Useful websitesUseful websites

NAS: http://www.autism.org.uk/living-with-autism/understanding-behaviour.aspx Do to Learn: Printable visual prompts for each stage of the toileting routine

– http://www.dotolearn.com/picturecards/printcards/selfhelp_toileting.htm http://www.falkirk.gov.uk/services/social_work/children_and_family_services/

support_for_children_affected_by_disabil/support_for_children_affected_by_disabil.aspx– and click on the links for:

Asperger’s Syndrome Booklet Asperger’s Syndrome (Teenagers) Booklet Autism Spectrum Disorder Booklet Life Skills For Little Ones Making Sense of Sensory Behaviour

http://www.northumberlandcaretrust.nhs.uk/services/services-files/community-health-service-files/childrens-occupational-therapy/Microsoft%20Word%20-%20Toileting.pdf

Continence Foundation of Australia (Victoria) http://www.continencevictoria.org.au/node/102 Sandbox Learning

– www.sandbox-learning.com Visual Strategies

– www.usevisualstrategies.com