Challenging Behaviour and Severe Autism

8 Dimensions

1. Social understanding2. Communication abilities3. Sensory sensitivity4. Anxiety5. Change6. Developmental level7. Learning profile8. Movement disturbance

1: Understanding People

Diagnostic Criteria for Autism

• Qualitative impairment in social interaction

• Qualitative impairments in communication

• Restricted, repetitive and stereotyped patterns of behaviour, interests and activities

The Continuum of AutismAloof

• Greatest confusion in understanding and relating to people, severest autism

• People are perceived as intrusive, aversive and best avoided.

• Child learns strategies to avoid social interaction, including finding a solitary sanctuary, non-compliance and being unpleasant (hitting)

Aloof: Strategies

• Quiet, gentle social approach.

• Avoid group situations• Avoid intrusive eye

contact, touch and specific sensory experiences (especially shouting!)

• Gratitude for compliance

Aloof: Strategies

• Activity is already prepared and completed quickly, then the child is free to find solitude

• Minimum speech from the adult• Social contact for enjoyable activities

such as rough and tumble play

Passive

• Approach others for assistance such as opening the door to the garden

• Passively accept social interaction• Prefer to be alone but will tolerate group

activities for a short while• The child finds something more interesting

than socializing

Passive: Strategies

• Socialising in a one on one or very small group activity

• Make the activity fun and successful (errorless learning)

• Sharing and turn taking activities e.g. using a swing or completing an inset board

• Imitation of each other and early social games such as chasing and hide and seek

• The child watches videos of his or her real life social experiences

• Asking the child for help• Encouragement for maintaining

the interaction

Passive: Strategies

• Adult beside the child provides prompts of what to do and say in a social situation

• Observe the natural play of peers and practice with an adult role playing a friend

Passive: Strategies

Social Issues

• Population density (social situations aversive)• Intrusive peers and adults (affection)• Care givers intuitive understanding of autism• Empathic attunement • Contaminated by the negative emotions of

others• Need for solitude

Laura Anderson

• “He’s in his own world today, and I’m not invited”

• Accidentally Beautiful

2: Communication• The mannerisms have a message• Communication of thoughts and emotions

• When behaviour is the only means of communication

• Thoughts such as ‘I can’t cope’ or ‘I need help’

• Feelings such as jumping for joy or ‘in a flap’

• Foreign phrase dictionary

Strategies

• Acquire an alternative means of communication using actions, gestures, vocalizations and speech

• Use the behaviour as an early warning system of agitation

• ‘Thermometer’

Communication Activity

• Identify a partner to work with.• Choose who will have a thought or

feeling to communicate• The other person needs to close his or

her eyes to not see the following thought or feeling

• The partner will then try to convey the message to you without using speech

• I want my green shoes

•Where is my hat?

•Where is my string?

•Will you be here tomorrow?

Spoken Instructions

• Anyone with a birthday today?

Frustration: Problems With Comprehension.

• Verbal complexity and length of utterance.• Clear, simple instructions.

Frustration: Problems With Comprehension.

• Demonstration.• Match the length of utterance to the child’s

level of comprehension and memory.• One instruction at a time.• Processing time

Frustration: Problems With Expression

• Value of alternative and augmentative communication(Gestures and pictures)

Repetitive Questions

• Social echolalia.• To maintain the interaction.

Repetitive Questions• Predict what you are going to say next: What

colour is your car?• Reassurance that you have not changed your

mind

3:Sensory Sensitivity.

• Acute auditory sensitivity to specific sounds (Hyperacusis)

• Sudden or ‘sharp’ noises, ( dog barking, coughing, click of a pen top)

• Small electric motors or a specific pitch

Temple Grandin

• “ Sudden loud noises hurt my ears like a dentist’s drill hitting a nerve. High pitched continuous noises such as hair dryers and other small motors are annoying. All the behaviour modification in the world is not going to stop an autistic child from screaming when a noise hurts his ears.”

Suggestions to Reduce Auditory Sensitivity

• Identify and avoid the sound• Barrier such as ear plugs• Camouflage the perception of the sound with music -

iPod• Social Story

Tactile Defensiveness

• Acute sensitivity to specific tactile experiences• Sensitivity to touch and texture on particular

parts of the body (scalp, upper arms, palms of hands and soles of feet)

Temple Grandin

• “I pulled away when people tried to hug me, because being touched sent an overwhelming tidal wave of stimulation through my body.”

• “Church was a nightmare because the petticoats and other Sunday clothes itched and scratched. Many behaviour problems in church could have been avoided by a few simple clothing modifications.”

Stephen Shore

• “Haircuts were always a major event. They hurt! To try to calm me, my parents would say that hair is dead and has no feeling. It was impossible for me to communicate that the pulling on the scalp was causing the discomfort.”

Tactile Defensiveness

• Gestures of affection perceived as too intense a sensation

• Aversion to certain fabrics• Strategies: ‘deep pressure’, sensory

integration therapy

Sensitivity to the Taste and Texture of Food

• Sensitivity to fibrous texture and multiple flavours

• Sensitivity to particular aromas• Problems at meal times that are not due to

having to sit still, talk, socialize or try unanticipated food

Sean Barron

• “I was supersensitive to the texture of food and I had to touch everything with my fingers to see how it felt before I could put it in my mouth. I really hated it when food had things mixed with it. I could never put any of it into my mouth. I knew if I did I would get violently sick.”

Strategies for Sensitivity to Taste and Texture

• Check diet• Avoid programs of starvation to encourage a wider

range of foods• Avoid programs of force feeding• Accept the unusual diet at mealtimes• Try new foods during programs of interesting sensory

experiences• Distraction, relaxation and rewards to encourage

increased tolerance

• Pain and temperature

A World Of Terrifying Sensory Experiences

• Hyper-vigilant and ‘shell shocked’• Need a coping or escape mechanism• Self hypnosis, being mesmerized by a

repetitive action or sensation

Temple Grandin

• “Intensely preoccupied with the movement of the spinning coin or lid, I saw nothing or heard nothing. People around me were transparent and no sound intruded on my fixation. It was as if I was deaf.”

Meltdown versus TantrumFrom Anxiety to Meltdown by Deborah Lipsky

Meltdown

• Overwhelmed by social, cognitive, linguistic and sensory experiences

• Catastrophic reaction• Involuntary response• Escape• Solitude, reassurance• Slow to recover• Voice and directions like a GPS

Tantrum

• Response to frustration• Emotional blackmail• Instant recovery• Non-negotiable• Assertive and calm

Crave Sensory Experience

• Hyperactive• ‘Affection’ seeking• Sensory diet

Other Sensory Systems

• Mind and body connection• Proprioceptive system (position and

movement of the body)• Running: “I had to get my body back from

pounding my feet”• Sense of smell (perfumes, cleaning products,

bathrooms)

4: Anxiety

Amygdala

Coping with Anxiety

Controlling your experiences• If you share you lose control• Passive aggressive• Emotional blackmail

Coping with Anxiety

• Oppositional and defiant (will not comply)• A ‘terrorist’ at home

Coping with Anxiety

• Parent becomes a ‘slave’, lack of respect and to be punished if you do not do what the master orders.

• Child intoxicated with his or her power.

Coping with Anxiety

• Be assertive, decision is non-negotiable, be impervious to the emotional blackmail

• Hostage negotiation: Never lie, never promise.

Coping with Anxiety

• Routines and rituals• Soothing and relaxing, to feel calm• Can become compulsions to alleviate feeling anxious• Become prolonged and more elaborate

Coping with Anxiety

• Rituals a ‘superstitious’ behaviour• The Curious Incident of the Dog in the Night

time(Red cars good)• Classical Conditioning(House plant)• An anticipated sequence• Change the context or cue for the sequence

(examples getting dressed and coming home)

Coping with Anxiety

• Thought blocker• Special interest• From a spinning coin to computer games• If denied access when anxious, frustration at

not being able to cope without the blocking activity turns to anger

• Need more strategies to manage anxiety• See Tool Box

Coping with Anxiety

• Explosion or melt-down• To cleanse the system or clear the air• “It’s a bit like wanting to vomit and knowing

you will feel ill until you actually throw up. You get it over and done with and feel better. Getting it out of your system”

Emotional Toolbox: To Fix The Feeling

Physical Activity Tools. Quick release of emotional energy

• Physical exercise, walk, run, trampoline.

• Sport. (Basket Ball, golf, weight lifting) or dancing.

• Personal trainer• Creative destruction

(recycling).

Relaxation Tools. Slow release of emotional energy

• Relaxation training.• Music. • Solitude.• Massage.• Repetitive action.• Sleep

Social Tools

• Time with a compassionate autism intuitive adult

• Being with a pet.

Social Tools: Affection

• Approval• Intensity• Duration

Special Interests

• A means of relaxation, pleasure.

• Keeps anxiety under control• A means of escape• Thought blocking.• Energizer

Special Interest

• Distraction during a meltdown. • The ‘off switch’

Sensory Tools

• Sounds. Ear plugs, headphones.

• Light. Irlen Lenses, hat, sun glasses.

• Aroma. deodorants, cleaning products.

• Tactile. Clothing.

Medication As a Tool

• Treatment of an anxiety disorder or a clinical depression. (SSRI).

• Impulsive. (Stimulants).• Mood cycles. (anti-

convulsants).• Sedation. (anti-psychotics)

5: Coping with change

Therese Jolliffe

• “Reality to an autistic person is a confusing, interacting mass of events, people, places, sounds and sights. There seems to be no clear boundaries, order or meaning to anything. A large part of my life is spent just trying to work out the pattern behind everything. Set routines, times, particular routes and rituals all help to get order into an unbearably chaotic life.”

Donna Williams

• “I loved to copy, create and order things. I loved our set of encyclopedias. They had letters and numbers on the side, and I was always checking to make sure they were in order or putting them that way. I was making order out of chaos.”

Sean Barron

• “I loved repetition. Every time I turned on a light I knew what would happen. When I flipped the switch, the light went on. It gave me a wonderful feeling of security, because it was exactly the same each time.”

Fascination with symmetry and order

• “The fun came from setting up and arranging things. Maybe this desire to organise things rather than play with things is the reason I never had any great interest in my peers.”

• Repetitive behaviours and routines to achieve sameness and predictability

• Watching the same video again and again

Preparation for Change

• Explanation, preparation and reassurance.• Social Stories.• Compulsion for completion.• Transfer to another school.

Organised and Structured

• Sequence of activities.• Boxes or pictures.• What to do,• Who with, • Duration (completed, music, clock)• What next.

Pictures to see the sequence of activities

6: Developmental level

Exploration Through Sensation

• The person’s developmental level in exploratory play• Exploring the world through taste, touch, aroma,

sound, colour and perspective• Prior stage to constructive and imaginative play

Exploration Through Sensation

• Introduce a wide range of sensory experiences

• Sensory integration therapy• Can be used as a reward• If the action is dangerous or socially

inappropriate, find an acceptable substitute

7:Learning Profile

Visualizers

• Engineers• Learning may be facilitated by silent

demonstration.• ‘A picture is worth a thousand words’

Curriculum on I-Pad

One Track Mind

• Train track.• One-track mind. • The last to know and seek help if they are on

the wrong track.• Lose train of thought if interrupted.

One Track Mind

• Continue using incorrect strategies and not learning from mistakes.

• Not listening to advice• Compulsion for completion (switch tracks)• Anxiety increases cognitive rigidity• Relaxation programs

Mistakes

Fear of Making a Mistake

• Don’t try, you don’t make a mistake.• Fear of appearing stupid and being ridiculed

by peers.

Perfectionism

Coping With Mistakes• Self-perception as an adult.• Cognitive style of noticing details and errors.• Limited ability to tolerate frustration.• Frustration volume control an on/off switch.

Strategies

• An adult’s ability is not perfect.• Model how to cope with frustration.

Weak Central Coherence

• Remarkably good at attending to detail but appear to have considerable difficulty perceiving and understanding the overall picture or gist.

• Rolled up paper.• What is relevant and redundant.• Deciphering the pattern or meaning.

Practical Example

• Room split into 2 groups• Group one to close their eyes, the other group

to see the following slide

Group 2 Eyes open

Group 1 open eyes, group 2 Close Eyes

Seen by Group 1

• What was the room?• What was the time?

Autism Friendly Classroom

• Quiet, well-structured classroom.• Avoid sensory overload. • Minimal changes in routines and staff.• Visible daily schedule of activities and

preparation for transitions.

Autism Friendly ClassroomMotivation

• Completion• Backward chaining• No errors• Special interest• Intellectual vanity• Typical children motivated by rewards,

children with autism motivated to avoid errors.

8: Movement Disturbance

Apraxia and Dyspraxia

• Planning the movement

Apraxia and Dyspraxia

• Problems with starting, stopping, continuing, combining and switching motor actions

• Some actions are to help start or switch motor actions

Apraxia and Dyspraxia

• Touch to initiate and rhythm to coordinate movements

• Advice from an Occupational Therapist and Music Therapist

• Rhythm

Tourette’s Disorder:Motor Tics

• Blinking• Grimacing• Nose twitching• Lip pouting• Shoulder shrugs• Arm and head jerking

Tourette’s Disorder:Vocal Tics

• Grunting• Barking• Animal noises• Coughing/sniffing

Tourette’s Disorder: Complex Motor or Behavioural and Emotional Tics

• Touching the mouth area• Clapping• Face and head slapping• Hopping• Touching objects• Licking objects• Emotion tics (injury to others, crying)

Other Dimensions

• Pain• Epilepsy• ADHD• Personality• “I needed excitement to feel alive”

8 Dimensions

1. Social understanding2. Communication abilities3. Sensory sensitivity4. Anxiety5. Change6. Developmental level7. Learning profile8. Movement disturbance