Dr Hazel Fernandez writes about how behaviours of concern in children with Autism may be understood in the context of five domains. These behaviours can overlap and vary on the spectrum of autism.
DOMAINS
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Social Communication Difficulties
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Restrictive Repetitive Behaviours & Interests (RRBIs)
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Sensory Issues
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Learning Difficulties
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Co-Occuring Mental Health Issues
Social Communication Difficulties
- Children with Autism have varying responses to their environment and difficulties in negotiating “social norms”
- The lack of ability to effectively communicate their needs can lead to those around them misconstruing their social interactions and/or the lack of/inadequate/inappropriate social overtures can add to an inappropriate/inadequate response from those in their immediate environment which can lead to further deterioration in behaviour
Restrictive Repetitive Behaviours & Interests (RRBIs)
- Repetitive actions
- Circumscribed interests, rituals, routines, obsessions
- Food preferences/restrictive eating/overeating
- Self injurious behaviours such as head banging, biting, skin picking
Sensory Issues
- Sensory seeking behaviours like “stimming” where the children seek the calm themselves through actions such as running their hands in front of their face although these behaviours may reduce as they develop
- Loud/particular noises
- Overstimulating/under stimulating environments
- Textures of food/clothing
- Change in environment
Learning Difficulties
- Delay in attainment of milestones like toilet training, daily self-care
- Exacerbation of autism symptoms
Co-occurring mental health issues
- Depressive illness
- Anxiety and other phobic disorders
- Obsessive Compulsive disorders
- Psychotic symptoms
Behavioural overlap exists between all these domains and in addition to the above, may also manifest as:
- Distress/meltdowns when faced with unfamiliar situations
- Stereotyped behaviours
- Aggressive behaviours towards others
- Sexually inappropriate behaviours by others and/or towards others
- Bullying by others towards children with autism
- Behaviours such as wandering off
- Mental health issues can lead to self-injurious behaviours, aggression towards others and suicidal ideation.
SOLUTIONS
Solutions should be undertaken with the aim of ensuring that the children with autism build on their strengths, cope with their difficulties, and not have to fake being “neurotypical” in society, because this may lead to adverse future outcomes.
Management of Social Communication Difficulties
- Speech and language therapy
- Parent training
- Special needs school
- Autism friendly environment
Management of Restrictive Repetitive Interests and Behaviours (RRBIs)
- Not all RRBIs are harmful and understanding the purpose of these RRBIs in those with autism helps reinforce those behaviours that are helpful and to offer therapeutic intervention when they are unhelpful through therapeutic interventions.
- Restrictive eating in autism can lead to nutritional deficiencies and need monitoring through either Primary care or a Paediatrician referral.
- Family meals can help introduce diet changes in fussy eaters.
Management of Sensory Issues
- Occupational therapy assessment and intervention
- Sensory environment changes e.g. sensory areas/rooms
In addition to the above, general principles of management of behaviours of concern include:
- Primary care developmental screening for Autism
- Change should be introduced gradually, a step at a time.
- Applied behavioural analysis and psychological intervention
- ABC (Antecedent, Behaviour, Consequences) analysis is helpful when addressing behaviours of concern in children with Autism.
- Treating co-occurring mental health diagnosis with Psychotherapeutic interventions and/or Pharmacotherapy.
Fuentes, J., Hervás, A., Howlin, P. et al. ESCAP practice guidance for autism: a summary of evidence-based recommendations for diagnosis and treatment. Eur Child Adolesc Psychiatry (2020). https://doi.org/10.1007/s00787-020-01587-4
- Pre-treatment assessment
- Each individual, each family is unique
- Focus on individual strengths, not just limitations
- Intervention should be based on a “functional analysis” of behaviour
- Focus on making the environment more “autism friendly”
- Effective treatment is not determined by a fixed number of hours or sessions of intervention
- Reassess the professionals’ role
- Provide access to full and effective participation and inclusion in society
- Respect individual rights
- Establish referral mechanisms and coordinate key agencies
ONGOING WORK IN AUTISM
- Autism Education, Research and Training for all professionals involved in the care of children with autism.
- Advocating for establishment of Autism friendly treatment facilities for children with Autism.
- Autism passports for those with Autism.
- Autism awareness campaigns in Government, Law enforcement, Schools, Primary care and the General Public.
With permission of the CWP NHS Foundation Trust
USEFUL RESOURCES
http://www.asdinfowales.co.uk/autismchildsigns
https://ncse.ie/wp-content/uploads/2016/07/6_Press_release_ASD.pdf
Assessing Behaviours Regarded as Problematic for People with Developmental Disorders by John Clements and Neil Martin
Challenging Behaviour and Autism by Philip Whittaker
REFERENCES
- Boulter, C., Freeston, M., South, M., & Rodgers, J. (2014). Intolerance of uncertainty as a framework for understanding anxiety in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 44(6),1391–1402
- Crane, L., Davidson, I., Prosser, R., & Pellicano, E. (2019). Understanding psychiatrists’ knowledge, attitudes and experiences in identifying and supporting their patients on the autism spectrum: online survey. British Journal of Psychiatry Open, 5(3)
- Eussen, M. L., Van Gool, A. R., Verheij, F., De Nijs, P. F.,Verhulst, F. C., & Greaves-Lord, K. (2013). The association of quality of social relations, symptom severity and intelligence with anxiety in children with autism spectrum disorders. Autism, 17(6), 723–735.
- Hollocks, M. J., Jones, C. R., Pickles, A., Baird, G., Happé, F.,Charman, T., & Simonoff, E. (2014). The association between social cognition and executive functioning and symptoms of anxiety and depression in adolescents with autism spectrum disorders. Autism Research, 7(2), 216–228.
- Joshi, G., Petty, C., Wozniak, J., Henin, A., Fried, R., Galdo, M., … & Biederman, J. (2010). The heavy burden of psychiatric comorbidity in youth with autism spectrum disorders: A large comparative study of a psychiatrically referred population. Journal of autism and developmental disorders, 40(11), 1361-1370.
- Nicolaidis, C., Raymaker, D. M., Ashkenazy, E., McDonald, K.E., Dern, S., Baggs, A. E. V., Kapp, S. K., Weiner, M., Boisclair, C. (2015). “Respect the way I need to communicate with you”: Healthcare experiences of adults on the autism spectrum. Autism, 19 (7) 824-831
- Wigham,S., Rodgers,J., South,M.,McConachie, H.,& Freeston, M. (2015). The interplay between sensory processing abnormalities, intolerance of uncertainty, anxiety and restricted and repetitive behaviours in autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(4), 943–952