Expert: Dr. Sharon A. Mitchell - 5/26/2009

Question
My 5 year old grandson will hit and kick when he is told not to do that. when he is not getting his way, He will pee and or poop his pants on purpose. He does this on a very frequent bases . His speech is difficult to understand and he does not listen and talks over the top of me or his parents. What can we do ?

Answer
You don't mention if your grandson has a diagnosis of something on the autism spectrum. But since you're searching for answers on the autism site, then I'll assume that either this little boy has a diagnosis of autism or you feel he shows some of the characteristics.

No matter what the diagnosis, the hitting, kicking and soiling are disconcerting for all concerned. Yes, even for your grandson.

Let's start first with his speech. You may have heard the saying, "All behavior is communication". This may apply in this circumstance. Often when kids have difficulty making their wants and needs known, they revert to behaviors to try to control their environment - often behaviors we don't like. Of course, speech is the easiest way to explain what we want but for some kids, this form of communication does not come easily.

How is his hearing? Sometimes we assume that a child hears just fine but in fact may have some degree of hearing loss. This possibility is even stronger if the boy has a history of ear infections. An audiologist or speech language therapist can check his hearing more thoroughly than the routine screening done by public health nurses.

Even small degrees of hearing loss can have a big impact. If he can't hear well, then it's hard for a child to pick up the nuances of our language, let alone be able to mimic the range of sounds required to speak so that others readily understand. I'd strongly recommend that this child see a speech language therapist if he does not already.

Then there's the issue of auditory processing. Even if he can hear just fine, he may be showing difficulties with auditory processing.

Most people with autism have strong visual skills but weak auditory. This means that they take in information better that they see as opposed to what they hear. In fact auditory processing is a serious weakness for people with ASD (autism spectrum disorders). While their hearing might be OK, making sense of what they hear, and knowing how to act on what has been said to them is a problem. And this problem greatly increases in times of stress and when there is background noise in the environment. This is part of the reason why attempts to coax the child out from beneath the table may result in increased screaming rather than cooperation and why the psychologist advised to not yell at him.

When upset, most of us talk. For a child with autism, even a child who can speak and understand words well at other times, when upset his ability to process what he hears will go way down. Talking to him at these times will add to his distress, not alleviate it.  
Instead of talking, letting him calm down alone, directing him to a safe hide away, using pressure and swaddling would likely be more productive than your words. The other tactic I would try is to use visuals. This just means to use a picture of what it is you want him to do rather than telling him in words. If you've built him a tent, take a picture of it to show him. There's a great website at www.do2learn.com that has free pictures you can print off. The site also explains why visuals work and how to use them.

You might also consider implementing a visual schedule (more about this at www.do2learn.com). The schedule would let him know what's going to occur that day.

Another strategy to consider is to use a social story. Here's a site that gives you lots of examples http://www.autisminspiration.com/public/department47.cfm

I am not condoning his behaviors and I know how unnerving it is for all around him, including the child. But all behavior is a form of communication. and when at his wits end, this little boy may not feel he has options to let people know of his distress.

When most small children are upset, a light, gentle touch is soothing. But a child with tactile sensitivities, that light touch may seem like fingernails on a blackboard. Rather than a light touch, if you touch him use a firm stroke. Approach him from the front so you don't startle him with your touch, but stroke his arm with more pressure than you would ever think you'd use for a toddler.

Pressure and weight can have a calming influence. Try cocooning him tightly in a blanket or large towel. Teach him to wrap himself in it and pull it tightly across his shoulders. Some kids try to crawl under sofa cushions trying to give themselves the feel of weight and pressure to help calm themselves. The darkness of a box or tent helps weed out some of the distracting, overwhelming sensations that are coming at them. If you can get hold an an old fur coat, they work well. The weight and the feel are comforting to some kids.

These things naturally work better when used preventatively, before the child gets into the highly aroused state where he screams and screams.

But like every child, a child with autism requires discipline so that he knows his boundaries and feels secure.

Hitting may seem to some to be not that big a deal when the child is only three. After all, how hard can he really hit? But kids with autism easily fall into patterns. What may be cute at 3 is less cute at age 8 and by 16 can have serious physical, social and legal repercussions. If this little guy is going to be accepted by others he'll need to learn that hitting is not appropriate or allowed. Getting this lesson through may take longer than with a typical three year old but it's possible and in my opinion, crucial.

Again, talking is likely not the best way. Take a look through the social stories at the link I gave you above. You may find some helpful stories there. A simple visual you can use is to have a picture of an arm hitting then draw a thick diagonal line across the picture.  
Show this to him when you tell him, "No hitting". There's a child's book called, "Hands are Not for Hitting" that you may like.

I would not spend time lecturing him on why he should not hit or kick; I think it would frustrate him and you. Instead, a short phrase would be better. Do not give him attention if he hits. Turn your back; walk away; pay attention to another child, etc. Nor is it helpful to let him believe that hitting is a way to get people to leave him alone. He may need to be alone but show him other ways to ask for that time.

Sensory issues play a large role in the behavior of kids with autism. Try to think of what he may be getting out of hitting. He may like the firm sensation in his hand and arm  or foot when he lashes. If so, then given him appropriate ways of getting these feelings. He could punch or kick a pillow, swing a plastic bat outside, play with play dough, stretch tubing, etc.

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It's my guess that when your grandson hits, kicks or shows inappropriate bathroom behavior, he may be in sensory overload. The sensory system  of kids with autism is unusual and creates greatly to the difficulties such kids have in dealing with the world. His sensory system will be either over or undersensitive and each sensory system may react differently and to varying degrees. The sensory systems I'm talking about are:

   * tactile (touch)
   * olfactory (smell)
   * visual
   * auditory (what he hears)
   * vestibular (balance located in middle ear)
   * gustatory (taste or to do with the oral-motor functions of the mouth)
•   proprioceptive (sensors in the large muscles of the body that alone with the  vestibular system give you a sense of where your body is in space).

Although he may lash out or scream as if he's in a rage, anger may not be the predominant emotion he's  feeling. He may be completely overwhelmed by sensory issues. He might be out of his routine with  extra people around or he's in an environment different that his home. There will be many people talking, sometimes at once. There will be more noise and confusion. He may be expected to be around people. Meal times may vary. People may not sit in their usual spots around the table when there's company. Although these things are all a normal part of life and most kids handle with aplomb, for a child with autism, these are  big deals.

He may be hiding under the table, seeking a quiet, dark place to ward off the sensory onslaught he's feeling. You could provide a better option for him. Here's a few suggestions:

   * department stores sell small kids' tents that are meant to be set up indoors on a bed or on the floor - this would make a cosy retreat for him
   * build him a tent by draping a blanket of a table, coffee table, between two chairs, etc.
   * large cardboard boxes make great hide-outs. Appliance boxes work well. You can make the box comfortable by stashing a blanket, pillow, book, favorite cuddly toy, music, crayons, etc. inside. Chances are, any siblings will also want to make use of this tent

Of course, since he's only 5, he may not figure out on his own that this tent is a safe,  comforting place to go. You may have to show it to him, crawl in with him, explain that he can do here when he wants to be quiet. Alternatively, he may calm done well in his own bedroom but may not realize that it's OK to escape to there when he feels the need.

Peeing and pooping publicly is certainly a way to get people to either back off and leave him alone, get them to pay attention to him or get him away from whatever is going on. Think about the function of the behavior and what he could possibly be getting out of it. It is attention? A method of escape?

Preventative measures are the most ideal. Try to record when he does these behaviors. Where is he? Who is around? What is going on? When he does this, what is the repercussion? How is he afterwards? It can help to start a book with notes for such observations. Divide the page into three lengthwise. Label the first column with a large A (standing for antecedent - what was happening before the behavior). The second column is labelled B (for Behavior) where you'll describe what he did. The third column's label is C (for Consequence). Keep track over a number of weeks and see if you can discover a pattern. That might help you get at the root cause and take preventative action.

Again along the preventative lines, let's go back to the concepts of weight and pressure, some kids are calmer when wearing a pressure vest or a weighted vest. Ankle weights can work well too (the kind with velcro you might put around your ankle or wrist when exercising). Here's a suggestion for making a weighted toy http://www.autisminspiration.com/public/258.cfm

If his parents have access to an Occupational Therapist, OT's are often great  sources of wisdom about these things.

There a couple books that I think might help your family:

- Solving Behavior Problems in Autism (http://tinyurl.com/q34g9m)

- Asperger Syndrome and Sensory Issues (Asperger's is a form of autism) (http://tinyurl.com/http-www-amazon-com-Asperger)

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

- The Social Skills Picture Book Teaching Play, Emotion, and Communication to Children with Autism (http://tinyurl.com/qnkg8j)

- My Social Stories Book (http://tinyurl.com/osv4l4)

Libraries or local autism organizations may have these books available for borrowing although you may find them worth the investment of buying.

There are most definitely lots of things his family can do to make life more enjoyable for all concerned and to help this little guy feel more comfortable.


Sharon A. Mitchell
www.autismsite.ca