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Behavioral and Daily Challenges in Children with !Autism! By: Cara Koscinski, OTD, MOT, OTR/L The Pocket Occupational Therapist

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Cara Koscinski, OTD, OTR/L Cara Koscinski, OTD, OTR/L, author of the award-winning Pocket Occupational Therapist Book Series, is a pediatric occupational therapist. She specializes in trauma-informed care, behavior, interoception, and autism. As an educational speaker, Cara incorporates her expertise as a mother of two children with autism. She has published six books and has over 98,000 followers on her blog and social media channels. Cara is also a children’s YOGA instructor. In addition to her books, Dr. Koscinski regularly blogs and creates fun products for those who work with children who have special needs. She serves on the Advisory Board of Autism Asperger’s Digest Magazine. Cara is an instructor for the University of Saint Augustine's Occupational Therapy Program.

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§  Presenter Disclosure: Cara Koscinski has received an honorarium for presenting this course. Non-financial: Cara Koscinski has no relevant non-financial relationships to disclose.

§  Content Disclosure: This learning event does not focus exclusively on any specific product or service.

§  Sponsor Disclosure: This course is presented by OccupationalTherapy.com.

Mother to two children with autism Advisor for OT and contributing author for Autism Asperger’s Digest Magazine & Autism Parent Speaker across the US for Universities, Future Horizons, state and local organizations Founder of The Pocket Occupational Therapist Teach at the University of St. Augustine’s OTD & MOT Programs

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Learning Outcomes

§ Recognize behavioral challenges as a form of communication in children with autism

§  Identify potential behavioral meltdowns during occupational performance prior to their occurrence

§ Recognize tools/behavior techniques-including visual, interoceptive, multisensory, and mindfulness to assist students prior to and during difficult times

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Why BEHAVIOR? §  All behavior has a function.

§  When we look through the sensory processing lens, we find many children struggle with effective processing of information around them.

§  Optimal function of our bodies occurs when our sensory and motor

systems are strong and able to adapt to the demands of the environment.

§  When our body’s systems are not integrated to form a strong

foundation, difficulties in many areas occur.

Q1 8

§  deficits in social communication and social interaction across multiple contexts

§  deficits in social-emotional reciprocity §  deficits in nonverbal communicative behaviors

used for social interaction incl. poorly integrated verbal and nonverbal communication

§  deficits in developing, maintaining, and

understanding relationships

DSM V (2013), Autism (299.00) diagnostic criteria:

White_ribbon.svg: MesserWolandJigsaw_Puzzle.svg: Psyonderivative work: Melesse / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

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§ Autism ‘Fruit Salad’ Model

Personality

Genetics

Environment

LearningStyle

Adapted from Donna Williams The Jumbled Jigsaw, 2005 10

Occupation is the ‘job of living.’ Children learn through playing: -Cause and Effect -Natural Consequences -Fine and Gross Motor Skills -Sensory Development

EVERY Person Wants to Succeed!

Q2 11

§  Watching and imitating others §  Trying and succeeding vs. trying and

failing §  Use of senses and exploration

Guess what’s difficult for our kids with special needs?

How Do Kids Learn?

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1.CognitiveRehabilitationofAdaptiveBehaviorinChildrenwithNeurodevelopmentalDisorders:AMeta-Analysis

Ahn,S.Hwang,S.(2018)

OccupationalTherapyInternational

Developmental,cognitive,andneurologicaldelayscanaffectsocialfunctionandcorrelatetonegativebehavior.ThearticlecontributestothegrowingbodyofevidencethatOTclinicianscanincorporatecognitivetechniquesintoourtreatmentsessionstohelpfacilitatepositive/adaptivebehaviortechniques.

2.Promotingprosocialbehaviorandself-regulatoryskillsinpreschoolchildrenthroughamindfulness-basedkindnesscurriculum.

Flook.L.Goldberg,S.B.Pinger,LDavidson,R.J.(2015)

DevelopmentalPsychology

Considerationofcognitive-basedtechniquessuchasmindfulness,emotionalawarenessteaching,andinterventionsthatareproactivecanimproveperformanceinplayskillsaswellassocialinteractions.

3.Autismspectrumdisorderandinteroception:Abnormalitiesinglobalintegration?

Hatfield,T.R.Brown,R.F.Giummarra,M.J.Lenggenhager,B(2019)

Autism Whenlookingatbehaviorandexperiencesofindividualswithautism,considerationofinteroceptiveawarenessisimportant.Addingtechniquestohelpimprovebodyawareness,listentointernalandphysiologicalsignsofstress,andidentifyingemotionsmaybeincludedintraditionalOTsessionstoimproveoccupationalperformance.

13

4.Gastrointestinalandpsychiatricsymptomsamongchildrenandadolescentswithautismspectrumdisorder

Neuhaus,E.Bernier,R.A.Tham,S.W.Webb,S.J.(2018)

FrontiersinPsychiatry

Considerationofco-morbiditiesasacauseforcomplexbehaviorsinchildrenwithautismshouldbeofprimaryinvestigation.Occupationaltherapistsneedtorefertomedicalsourcesandconsiderpsychologicalandphysicaletiologiesofbehaviorotherthansimplelookingatsensoryorbehaviouraloutburstsinisolation.

5.Cognitivebehaviourtherapyforsocialanxietyinautismspectrumdisorder:asystematicreview.

Spain,D.Sin,J.Harwood,L.AndreinaMendez,A.Happe,F.(2017)

AdvancesinAutism Integrationofinteroceptiveawareness,traditionalcognitivebehavioraltherapy,socialskillstrainingintoOTtreatmentsessionscanhelpimproveanxiety.

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Why is this baby crying? •  Before babies learn to

speak or gesture, we read their BEHAVIORS

•  Meltdowns/responses are

beyond the person’s control

•  Some behavioral

responses are simply reflexes

Beth / CC BY (https://creativecommons.org/licenses/by/2.0)

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Relation to Autism •  Autism is likely to cause difficulty with

communication socially, for wants, for needs, for expressions of feelings and emotions.

•  It’s common for parents to forget that behaviors in

older children still indicate issues such as hunger, fear, fatigue, health/illness, etc.

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Upstairs vs Downstairs Brain Tantrum: §  Conscious choice §  Strategic and manipulative §  Can reason, make choices §  Emotions under conscious control §  STOP when demands are met

Sensory: §  Flood of hormones §  Over-ride conscious choice §  Loss of body control §  Can NOT be reasoned with §  Not capable of choices

Q3 19

Adapted from Dr. Daniel Siegel Dr. Tina Payne Bryson The Whole Brain Child 20

Basic Brain Functions: §  Brain will do what it takes to SURVIVE – energy efficient

§  When a child has a stressed system, he is ‘dysregulated.’ §  Dysregulated child cannot focus on higher level brain

functions because he’s CONSTANTLY looking for potential threats in the environment.

§  Moro reflex = startle

Q4 21

Learning by using many senses

§  Auditory §  Vision §  Taste §  Olfactory (smell) §  Touch §  Vestibular §  Proprioceptive §  Interoception

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Interoception § Receptors internally that detect INTERNAL

responses § Organs, muscles, skin, bones, smooth muscle § Toileting, sexual drive, hunger, thirst, fatigue, heart

rate, deep breathing § May significantly affect our external responses § Chemically controlled § Higher level functions & emotions

Dolly Diaphragm

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Interoception

§  Intuition §  Perspective-Taking §  Self-Awareness §  We feel nervous prior to

reading aloud in class and our body responds.

§  Teach children to ‘control’ their internal body such as breathing, relaxation, visualization.

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Allows us to ‘feel’ our skin & body SUBJECTIVE

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Higher Abstract Concrete Thought Affiliation Attachment Sexual Behavior Emotional Reactivity Motor Regulation Arousal Appetite/Satiety Sleep Blood Pressure Heart Rate

Pyramid of Learning: https://www.yourkidsot.com/blog/the-importance-of-the-pyramid-of-learning

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§  Extreme effort required to screen out background noise and visual distractions

§  Needs frequent breaks to prevent sensory overload

§  Focuses on one thing at a time/perseveration

§  Body awareness and boundary difficulties

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Behavioral Responses • Tense, Jaw Clenched • Anger, Rage

Fight

• Conflict Avoidant • Fear, Anxiety • Run away from stimulus/situation

Flight

• Over-compliance • Shut Down • ‘Checking out’ of situation

Freeze

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Physical Signs of STRESS in children: § Stomach and headaches § Sleeping issues § Anger or aggression toward others § Dilated pupils § Sweating §  Flushing of cheeks § Wide “deer in headlights” eyes

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Mind-Blindness !(Simon Baron Cohen) §  Person’s ability to predict relationships between an internal

and an external state. §  Seems un-aware that someone else may have a different

viewpoint. §  Views the world as ‘black and white.’ §  Does not realize that the other person has his/her own

thoughts and feelings about a situation. §  Facial recognition, body language, social rules.

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§  Tourette Syndrome §  Food Intolerances/Allergies §  Sensory Processing Disorder §  GI Disorders §  Other genetic disorders §  Sleep disturbances §  Puberty/hormones §  Depression/Anxiety §  Apraxia, Dyspraxia in speech and motor §  Processing delays

Autism does NOT cause challenging behaviors.

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When Students Become Overwhelmed By BIG EMOTIONS

it is our job to SHARE OUR CALM

not to JOIN THEIR CHAOS

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Quick Tips For OTs

§  Come down to their level §  Lower the tone of your voice

Means you’re in control

§  You have done ________ which has broken our rules. We know that when you break rules, you have two choices…..

§  Two choices YOU as the adult chooses

§  Ignore (unless they are harming)

Q5 33

Overall Tips for Behavior Management §  Set expectations and allow children to earn privileges that they choose. §  Transition warnings §  Use empathetic statements §  Avoid using ‘DON’T’ but instead use can you stop doing

______________. §  Give choices §  Do not negotiate with children. §  Arguing back and forth should be avoided §  Use natural consequences (teachable moments)

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Tantrums MeltdownsGoalOriented NodemandsarebeingmadeWatchesforreactions–dependingonreactiontheintensityoftantrummayincreaseordecrease

Nointerestinreactionofthosearoundhim

Avoidsgettinghurt MayhurthimselfActingonprimallevel!

Endsquickly Slowtoendasit’sdrivenbysympatheticnervoussystemandstresschemicals

Individualisincontrol NOTincontrolInbasicsurvivalmodeandactinginstinctively

Warningsigns:RequestssomethingDesiresacertainoutcomeBelievesoutcomecanbeachieved

WarningSigns:Physiologicalsignsofrednessofface,quickbreathing,overwhelmedbysensoryinput,spacingoutordistancingfromthesituation.Medicalissuesmaybelinked 35

Rage Cycle Model § The rage cycle model

visualized www.saraidesign.com

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Prioritize Behavior

High Priority Low Priority

Eliminate Problem Causing Behavior AND Quickly Intervene to Ensure Safety and STOP Behavior Destructive Disruptive Distracting Socially Inappropriate Required to Self-Stimulate/Calm

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BAC

Proactive Intervention

Reactive Intervention

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Proactive Interventions

§  Come BEFORE the behavior……….this is where your planning pays off!

§  Setting up the area/environment for success

§  I Need a BREAK card §  Visual cues, schedules §  Calm-down areas §  Reinforcement of desired behavior

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Reactive Interventions

§  Come AFTER the behavior occurs §  Goal is SAFETY §  Keep voice calm §  Do NOT match the child’s level of

excitement §  Visual supports §  Remove from dangerous situation

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BAC

ProactiveIntervention

ReactiveIntervention

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Changing Behavior

What is the reason?

What can we replace the behavior with?

How do we teach and reinforce a replacement/new behavior?

What was the level of the behavior?

Who can best teach behavior?

WhatistheroleoftheOccupationalTherapistinBehaviorPlanning&Intervention?

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Planning Interventions:

§  ABC Chart §  What coping strategies have been

successful? Examples: deep breathing, drawing or writing when frustrated, driving, sensory

§  Use distraction and re-direction. §  Stress Pass/Brain Breaks

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Sensory Ideas To Help With ANXIETY

& WORRY

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8 Senses to Calm §  Return to Flexion, Linear Swinging,

Vestibular §  Music §  Smells (vanilla, lavender) §  Use crunchy snacks, dehydrated

fruit, jerky §  Lower lighting/floor lamps §  Decrease Environmental Stimulus §  Proprioceptive Input PUSH, PULL,

LIFT, CARRY

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Consistency Between ALL Settings

Discuss natural consequences (consequential learning) such as: refusing to eat=hunger; not bringing homework to school=poor grade; not bathing=stinky body; not grooming=dirty appearance.

You MUST follow through with the consequences every time. So, do not make a consequence that you cannot follow.

**EVERYONE needs to be consistent when intervening** if not, interventions can be confusing to the child

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Tune In and Focus on Mindfulness §  Focus in on and feel breath. §  Mind jar: shaken up represents our

chaotic thoughts. §  Deep breath = settling of our thoughts §  Breath is the anchor (touch backs to

connect) §  Focus on who each student is and

slow breath and mind down §  When in pose, think about connection

to body.

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The Incredible 5-Point Scale

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Used with permission from Kari Dunn Buron

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Case Study Review

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Contact Cara www.PocketOT.com

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Additional Resources: 1)  Parent’s guide to Functional Behavior Assessments. http://

pages.uoregon.edu/ttobin/Tobin-par-3.pdf 2)  Functional Behavioral Assessment and Positive Interventions: What

Parents Need to Know www.wrightslaw.com/info/discipl.fba.jordan.pdf 3)  Appendix 2 Common "problem" behaviors and speculations about their

causes by Ruth Myers, MD, James Salbenblatt, MD, Melodie Blackridge, MD www.autismspeaks.org/sites/default/files/section_4.pdf

4)  Howlin, Baron-Cohen and Hadwin (1999) Teaching Children with Autism to Mind-Read: A Practical Guide. The Guide provides information on how to teach theory of mind skills to individuals across the autism spectrum while taking into consideration the developmental stages of theory of mind acquisition.

5)  Behavioral Consequence Chart www.specialconnections.ku.edu/?q=behavior_plans/functional_behavior_assessment/teacher_tools/antecedent_behavior_consequence_chart

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Additional Resources: 6)  The Incredible 5 Point Scale and Anxiety Curve information, downloads,

purchase information is available at: www.5pointscale.com 7)  Downloadable for student questionnaires, bullying, and feelings units available

at www.pocketoccupationaltherapist.com 8)  Donna Williams fruit salad model

https://www.youtube.com/watch?v=Hy70PAHFNx4

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1.CognitiveRehabilitationofAdaptiveBehaviorinChildrenwithNeurodevelopmentalDisorders:AMeta-Analysis

Ahn,S.Hwang,S.(2018)

OccupationalTherapyInternational

Developmental,cognitive,andneurologicaldelayscanaffectsocialfunctionandcorrelatetonegativebehavior.ThearticlecontributestothegrowingbodyofevidencethatOTclinicianscanincorporatecognitivetechniquesintoourtreatmentsessionstohelpfacilitatepositive/adaptivebehaviortechniques.

2.Promotingprosocialbehaviorandself-regulatoryskillsinpreschoolchildrenthroughamindfulness-basedkindnesscurriculum.

Flook.L.Goldberg,S.B.Pinger,LDavidson,R.J.(2015)

DevelopmentalPsychology

Considerationofcognitive-basedtechniquessuchasmindfulness,emotionalawarenessteaching,andinterventionsthatareproactivecanimproveperformanceinplayskillsaswellassocialinteractions.

3.Autismspectrumdisorderandinteroception:Abnormalitiesinglobalintegration?

Hatfield,T.R.Brown,R.F.Giummarra,M.J.Lenggenhager,B(2019)

Autism Whenlookingatbehaviorandexperiencesofindividualswithautism,considerationofinteroceptiveawarenessisimportant.Addingtechniquestohelpimprovebodyawareness,listentointernalandphysiologicalsignsofstress,andidentifyingemotionsmaybeincludedintraditionalOTsessionstoimproveoccupationalperformance.

54

4.Gastrointestinalandpsychiatricsymptomsamongchildrenandadolescentswithautismspectrumdisorder

Neuhaus,E.Bernier,R.A.Tham,S.W.Webb,S.J.(2018)

FrontiersinPsychiatry

Considerationofco-morbiditiesasacauseforcomplexbehaviorsinchildrenwithautismshouldbeofprimaryinvestigation.Occupationaltherapistsneedtorefertomedicalsourcesandconsiderpsychologicalandphysicaletiologiesofbehaviorotherthansimplelookingatsensoryorbehaviouraloutburstsinisolation.

5.Cognitivebehaviourtherapyforsocialanxietyinautismspectrumdisorder:asystematicreview.

Spain,D.Sin,J.Harwood,L.AndreinaMendez,A.Happe,F.(2017)

AdvancesinAutism Integrationofinteroceptiveawareness,traditionalcognitivebehavioraltherapy,socialskillstrainingintoOTtreatmentsessionscanhelpimproveanxiety.

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Additional References §  American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.).

§  Conson, M., Mazzarella, E., Esposito, D., Grossi, D., Marino, N., Massagli, A. and Frolli, A. (2015). Put myself into your place: Embodied simulation and perspective taking in autism spectrum disorders. Autism Research 8(4), 454-466.

§  Marinan, J.J. (2015). Mindblindness Theory: Touchstone for Interdisciplinarity. PsyArt Journal. 19, 85–102.

§  Mazefsky, C. A.., Herrington, J., Siegel, M., Scarpa, A., Maddox, B. B., Scahill, L., & White, S. W. (2013). The Role of Emotion Regulation in Autism Spectrum Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 52(7), 679-688.

§  White, S. W., Mazefsky, C. A., Dichtercd, G. S., Chiue, P. H., Thomas, A. R., & Ollendicka, T. H. (2014). Social-cognitive, physiological, and neural mechanisms underlying emotion regulation impairments: understanding anxiety in autism spectrum disorder. International Journal of Developmental neuroscience, 39, 22-36.

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Web Resources & Clip Art Credit §  Bruce D. Perry, M.D., Ph.D.

www.ChildTrauma.org Body Temperature

§  Kari Dunn Buron www.autismawaresscentre.com §  Dr. Dan Siegel

www.drdansiegel.com

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Best Books to Read About !Autism & Sensory Difficulties!

How Can I Talk if my Lips Don’t Move by Tito Rajarish Muhopadhyay*

Carly’s Voice by Arthur Fleischmann with Carly Fleischmann*

The Reason I Jump by Yoshida and David Mitchell

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