Expert: Dr. Sharon A. Mitchell - 12/23/2009

Question
Hi,

My son was recently diagnosed with ADHD/ADD and highly probable for Asperger's Syndrome.  The child psychiatrist didn't give him a diagnosis of Asperger's because of his normal social function.  He is more ADD with some Asperger's traits.

One of those traits are fixations on activities or what I call the "obsession du jour."  This month he's into busses and/or cars.  He wants to re-create a car with realistic feel.  I allowed him to be in my car in the driveway (with no key, of course) for hours one rainy afternoon.  He was perfectly safe and unable to put the car into gear without the key.  He was able to play with all the levers, buttons and the steering wheel.  I thought if he was in there for ten minutes or so, he would get it out of his system, but he wound up there in excess of an hour and then returned to the car later in the afternoon.

I don't want him to make a habit of it, so I told him that was only a treat for that day and would not be a regular occurrence.  

He remains fixated and when the play or pretend cars that he creates out of construction paper and my couch don't live up to his expectations, he has a mini-melt down.  He refuses to be redirected to any other activity.  He does come out of these 'car only' moments from time to time and will play with his brother.  

My question to you is how do I deal with the melt-downs?  He won't be distracted or take suggestions on any other activity.  He becomes very agitated and unreasonable.  Sometimes I just go down the list of all the things he CAN do and/or create and walk away, but are is there another approach I can take?

Thanks so much!

Answer
Many kids first receive a diagnosis of ADHD/ADD then later, when that does not seem to explain all the observed symptoms, the diagnosis may be altered to include Asperger's. It can be hard to diagnose Asperger's in some children, especially if they have received good training that over time has helped to ameliorate some of the social difficulties.

The "obsession du jour" you mention is a common hallmark of Asperger's and other autism spectrum disorders. No matter what label the child may have, these fixations are not easy to deal with.

Let's look at the plus side first. And yes, there are some pluses that can come out of these fixations. Many of the advances in history have been made by people who are obsessed with one topic - learning more about it, experimenting with it, sharing their knowledge, etc. Out of this obsessive focus can come great discoveries.

Think about your son's fascination with cars. While it's annoying right now, think what might happen if he retains this intense interest into adulthood. What might he accomplish?

In an ideal world, there would be a way to turn an obsession into a productive job. With some obsessions such as counting ceiling tiles, you might have to be a bit more creative but if a young man is consumed by his interest in cars, he may be able to combine his interest with a useful profession. Dr. Temple Grandin has written a small book on this that you can view here: http://tinyurl.com/yg2gntj

But, your child is likely years away from entering the work force. So in the meantime, what to do?

Sometimes the obsession is so all-encompassing that it's hard to get the child to pay attention to anything else. This means that he'll be missing some of the learning time he needs to develop his other skills.

In my experience, it's very difficult, almost impossible to remove a child's obsession. If you absolutely forbid access to the obsession, the upset might be huge and last for a long time and your son might cling even more tenaciously to what he wants.

Rather, you may have better luck in limiting his access to his current fixation. You could employ the "First.....then....." strategy. First, he must complete this task, then he gets so many minutes of ______ time.

Or you could ration his time by clocks or timers. Every half hour, he gets five minutes of _____. You'd have to adjust the times to whatever is reasonable for your child. You could gradually increase the time intervals or the amount of work he must accomplish before he gets time for the activity of his choice.

Rather than attempting to remove his access to it totally, you could try to find a substitute. Just plain removing an obsession may not work, but finding a substitute may.

The substitute would need to fill some of the same purpose that your son finds in the cars now. This takes some detective work on your part. Does he like the sound? Is the appeal visual - he likes the way the vehicle looks? Feels? Smells? Is it the feel of the motion? The sense of power he imagines would come from driving?

Once you figure out what the appeal may be, then you can start to find appropriate substitutes. A word of caution though; whatever you substitute could then become his obsession. So, make sure the substitute is socially acceptable, age appropriate and something that could endure for several years.

If you have access to an Occupational Therapist, they're great at helping determine the possible sensory appeal some obsessions may have for your son and in coming up with acceptable substitutes. If there is no OT available, you can play detective yourself.

Sometimes, a child will cling more tenaciously to his obsession when he's upset or unsure. The more calm and sure he is of his routine, the more he may feel he can let the obsession go or at least spend less time on it.

Kids with autism and Asperger's relish routine. When you have trouble making sense of your world, it's hard to predict what may come next, how it might affect you and what other people will expect of you. That's why routines and schedules are so important. A visual schedule let's the child know what will happen next in his day. And a visual schedule, whether in words or in pictures is better then just telling the child. Besides, teaching a child to rely on a schedule rather than on an adult telling him what to do helps in his independence. You can find out how to use visual schedules and more on why they're so important at websites like:

www.do2learn.com

http://www.usevisualstrategies.com/information.html

Sometimes, when obsessions are very intense, and resistant to all efforts to curbing or changing, you may want to seek medical help. In these cases, the obsessions may be similar to those seen in medical conditions such as obsessive/compulsive disorder and be helped by medications. As a parent, medications for a small child are the last thing you want to try. But on occasion, when all else has been tried, they can have a positive effect on the behaviors of some children.

Weak executive functioning skills are common in kids with Asperger's, autism, ADHD and learning disabilities, despite average or even high intelligence levels. Picture yourself as the CEO of a large corporation. It's your job to figure out what needs to be done, prioritize these tasks, determine who should do what, when, etc. These are all executive functioning skills that make life hard for such kids. The difficulty and frustration can be compounded because the child realizes that he is smart, yet he has more trouble than others around him. He may have trouble:

- telling time

- understanding the passage of time (that internal clock most of us develop) so that he is often late or are startled when you tell them it's time to go or time to clean up

- it may be hard for him to find things because he has no organized storage system

- he may become fixated with minutiae rather than focus on the big picture

Memory may also be an issue. You may meet a child who can tell you all kinds of esoteric details about his special interest but be unable to tie his shoes or remember where he put his lunch bag. When a child finds it hard to make sense of his world, when he can't see the forest for the trees, life can be scary. It is not a predictable place where you can guess what's going to happen next. Most of us store things in our memory in organized groupings, making it easier to retrieve these memories when needed. Many people with autism store memories in an overly compartmentalized fashion, not relating one event to the other.

Donna Williams, an articulate woman with autism explains this well in her book, Somebody Somewhere (http://tinyurl.com/yczxvhr). When a child has this problem, he may learn a coping strategy in one situation but have difficulty or forget to apply it when a similar situation crops up.

The approach you're currently taking is wise. You're calmly presenting the positive side by listing what he CAN do. If he's not in a listening mode, then you're walking away. When in the throes of a melt-down I doubt he will be able to take in what you say.

Most kids with autism and Asperger's tend to be stronger visually than auditorally. That means that they take in information better that they see than what they hear. Unfortunately, many of us as parents and teachers are talkers. We talk to explain, we talk to connect. And when upset, we tend to talk even more.

A child with Asperger's, even one who is highly verbal, when under stress will have increasing difficulties understanding what it is you're saying. When he does not respond appropriately, likely you talk even more, which actually compounds his stress, rather than decreasing it.

In such situations it's better to talk less, far less than would be your want. In fact, ideally talk little if at all. During the upset stage, your words will do little rather than aggravate the situation. Instead, when you do speak, keep your sentences short and blunt - one word utterances would be best. Couple those words you do use with visuals or hand signals. Remember that your child will take in information better that he sees rather than what he hears.

But what would make you happiest is to never get into these situations in the first place, of course. He could wear out his welcome with friends, at school and even in your home. Those are extremes, but with increasing, uncontrolled aggression, it is possible that things to go to such lengths.

Because of the difficulties many ASD kids have making sense of the world, they often appreciate having rules and expectations set out clearly for them. They often respond well to, "The rule is..." Try it. It's amazing how well such a simple things can work.

Establish house rules. Make them clear and unequivocal. Post them in many, conspicuous places. It won't be good enough to tell your son the rules or discuss them - they have to be visual. You might consider doing the same thing with the consequences you've set up for rule infractions. When you feel an incident may be building, rather than issuing verbal warnings, tap on the posted rule.

Linda Hodgdon has written a couple helpful books on using visuals to help with behavioral issues:

- Solving Behavior Problems in Autism (http://tinyurl.com/yce3fp4)

- Visual Strategies for Improving Communication: Supports for School and Home (http://tinyurl.com/ycb32ve)

It might surprise you to learn just what a difficult time your son has in reading the emotional state of others. There are a couple free games you could try with him. You'll find them at:

http://www.do2learn.com/games/facialexpressions/index.htm

http://www.do2learn.com/games/feelingsgame/index.htm

There's a small book by Brenda Smith Myles you might find helpful:

- Asperger Syndrome And Difficult Moments: Practical Solutions For Tantrums, Rage And Meltdowns (http://tinyurl.com/ye3teev)

Are you familiar with the concept of social stories? They are a way of letting your son know what is going to happen and what is expected of him. Linguisystems has a whole series of ready-made social stories appropriate for young teens (http://www.linguisystems.com/searchResults.php?action=search&search_term=pdd).

Going along with social stories, Carol Gray has developed Comic Strip Conversations, a way to go over the situation that happened, analyse it visually and present more appropriate solutions for next time. (http://tinyurl.com/ydvnxhl).

Another book that's pertinent to your situation is Just Give Him The Whale!: 20 Ways to Use Fascinations, Areas of Expertise, and Strengths to Support Students with Autism.  (You can take a look at it here: http://tinyurl.com/ykc7tgl).

Best wishes,

Sharon A. Mitchell, B.A., B.Ed., M.A., PhD Candidate
www.autismsite.ca