Common Behavioural Concerns Associate With Autism Lorraine Ringland & Dr Clare Bailey Lorraine...
Transcript of Common Behavioural Concerns Associate With Autism Lorraine Ringland & Dr Clare Bailey Lorraine...
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