Expert: Dr. Sharon A. Mitchell - 1/11/2011

Question
QUESTION: I'm a working Mom. My Son diagnosed ASD. He is going to a play school, and my son is being taken care of my servant who was with me for last 10 yrs and she is like afamily member. 2 months ago, started giving speach therapy and occupational therapy by a teacher comming home. At time its frustrating when I hear that my son does not respond and some days he never wants to do anything. My servant is being given instructions and taught how to assist my son. Me & My husband is also given instructions on this and after we reach home, start doing activities with him Mostly I feel he does not give attention much. His play school teacher says, he is good in school and listen to the teacher. My son understands our emotions very well. Only thing is does not have proper speach, does not follow instructions very often. In his vocabulary has about 15+ words. Quiting my job cannot be done at this time, since it will create verry difficult financial situations, such as selling our house etc. Since my husband's salary is to cover the housingloan.and I run the child/home requirements.Can you advise me with few tips to control my son and get his attention to do what is good for him. He sings, he can understand, he is very loving, and not harmful at all. By crying he is trying to get his things done for his favours, but now what we asked him to do. When teacher come at times he slowly go to the bed and sleep, and ignore on several occasions.

ANSWER: Hello Neesha,

It sounds like your son is a lucky child - two involved parents, a nanny, a speech and occupational therapy teacher,as well as experiences at play school. You are already doing a lot.

Since he's in play school, I'm assuming that your child is about three or four years old. While he has a diagnosis of an ASD, he's still a little boy. There are times when a child does not wish to do what the adult in charge wishes - even kids without ASD. So, some of his refusal to cooperative with the home teacher may be just a function of his age and a preference to go play.

There are many approaches to helping a little child with ASD. Some therapists will prefer to sit across a table from the child to conduct therapy. Others prefer a play-based model, while still working at a table. Still others follow the child's lead while playing on the floor (such as Floortime and Relationship Development Intervention). Neither method is right or wrong. No two children with ASDs are alike and the therapeutic approach should be one that fits the needs of the child and the family, while still working towards specific, practical goals.

It's good to hear that the therapist is giving the three adults in the households suggestions on how to interact with your son. You three, after all, are the ones who spend the most time with him and have the closest bonds.

It's encouraging that his play school teacher says he listens and follows along at school. That is indeed encouraging news because this will make his introduction to kindergarten and grade school that much smoother. Life is a group affair and in school, unlike at home, a child must follow along with the group.

Another positive is that you say your little guy understands your emotions. Reading facial expressions and body language are often difficult the people with ASD. That your son can already do some of this is a good sign.

It sounds like your main concerns center around the language areas - his listening (receptive language) and talking (expressive language). There's a nice definition at the following link on just what the terms "speech" and "language" mean: http://www.asha.org/public/speech/development/language_speech.htm.

This next link talks about language skills usually shown by three to four year olds. At the bottom of the page are suggestions about things you can do to encourage your child's language skills: http://www.asha.org/public/speech/development/34.htm.

Language plays a large role in our social lives. Kids with ASD often have difficulty with pragmatics, the social niceties of how we use language. Here is an explanation of pragmatics.

You ask for suggestions on controlling your son, gaining his attention and compliance. Again, some of his refusals or ignoring may simply be a factor of being a kid. But there are definitely things you can do to help.

When he does not listen, it may not be that he is deliberately choosing to ignore you. Kids with ASD may have the ability to almost hyper focus - concentrate intently on what is interesting them so much so that the rest of the world just fades away. He may honestly not have heard you. Breaking his concentration may be difficult. You could try walking directly up to him, rather than saying directions from another room, assuming he would hear you. Touch him to get his attention. You may need to direct his face away from what he's doing so he looks at you.

Sensory sensitivities are prevalent in people with ASD, as the occupational therapist has likely explained. Your son could be over sensitive or under sensitive to some senses. It is possible that it takes a lot of auditory (hearing) sensation for it to register with him.

It sometimes helps to think of autism as a processing disorder where the person has difficulty  processing more than one piece of incoming information at a time. Think about our modern households. There is often a lot going on. The television may be playing, the dishwasher may be running, adults may be talking, your son's toy may make noise. To a child with ASD, all these sounds make come at him with the same intensity. It would then be confusing to know which sound to pay attention to. Most of us have good central coherence, meaning we know which stimuli in the environment to pay attention to and which to let recede into the background. This skill is not automatic for many kids with ASD and can be part of the reason they become overwhelmed and may respond with a melt down.

Even though your son's hearing may be just fine, he may have difficulty processing what he hears. He may hear the words you speak but have trouble deriving their meaning. Many kids require a wait time - when you make a request, don't expect an immediate response but allow him say half a minute to make sense of what you said. While you wait, don't interrupt, don't repeat or rephrase what you said.

I gather that the difficult behaviors are not displayed all the time. Do you have any idea what sets off the defiance and aggression? Is there a pattern?

You could try charting when these negative actions occur. Divide a piece of paper lengthwise into three columns. Label the columns A, B and C. A stands for antecedent or what happened before you noticed the negative behavior. B stands for behavior and is where you'd describe what you are observing when your boy displays the behavior you don't want. C stands for consequence. What type of consequence did you impose after the behavior and how effective was your consequence. If you keep track for a few days or a week, you may begin to detect a pattern of when your son acts out. And how successful your consequences are at deterring these behaviors.

Thomas Phelan has written an easy-to-follow book called 1-2-3 Magic: Effective Discipline for Children 2-12. It shows you a calm, planned, not-reactive way to help your child learn cause and effect as he learns to control his behavior. I like it because the rules are clear-cut, taking the guess work and emotionality out of the situations. When you're dealing with a difficult child, anything that helps you remain calm is a boon. You can find this book here: http://www.amazon.com/1-2-3-Magic-Effective-Discipline-Children/dp/1889140163/re

Kids with autism have difficulty making sense of their world. Adults with autism, such as Temple Grandin (http://www.amazon.com/Thinking-Pictures-Expanded-Life-Autism/dp/0307275655/ref=p) and Donna Williams (http://www.amazon.com/Somebody-Somewhere-Donna-Williams/dp/1853027197/ref=pd_bbs) talk about how this feels and how it affects the way they cope with their lives. These are intelligent, articulate women who have thought about and learned about what works for them. A three or four year old boy would not have the knowledge or experience to figure out such strategies on his own. As a parents, you can learn a lot of listening to and reading what successful adults with autism spectrum disorders have to say.

If you have trouble making connections and therefore making sense of your world, think how you would react. When you felt you had a handle on something, you'd resent anyone trying to change you or make you stop what was giving you comfort or pleasure. But in our lives, we don't get to do just what we want, even when you're three. So, when your son is enjoying his play, and you ask him to come to the table for dinner or get ready for bed, there may be an explosion. You've interrupted him. Many three years olds find this annoying but most learn to go along with what is asked of them (at least much of the time).

The child with autism may have even greater difficulties with such interruptions. You're asking him to end his play but on top of this, he may not know what you're asking of him or what will happen next.

Most kids fall into the pattern of the household and grow to anticipate what comes next and the order in which the family does things. But kids with autism may well not make such connections and even though you follow the same routine with him each evening, he still may not have picked up on the sequence of steps you always go through in getting him ready for bed.

Conversely, he may have internalized some of those patterns and woe is you if you deviate from the regular pattern.

If from your charting, you find that these types of situations are causing your son trouble, there are several things you can try.

Before I describe some of these ideas, I'll give a bit of background information. It's common among people with autism to have strong visual skills and weaker auditory processing. That means that such people find it easier to take in information that they see rather than what they hear.

We talk to our kids a lot. That's a good thing most of the time. But when upset, a person with weak auditory processing skills will experience a further reduction in his ability to understand what is said to him. Unfortunately, as parents and as teachers, when we're frustrated we tend to talk even more to kids and maybe even with a raised or frustrated voice. This in turn, can upset the child more, and further hinder his ability to understand our words.

So, rather than talking in such situations, be quiet. Speak less. Speak calmly and most important, use pictures. Show the child what you mean. Visuals can be actual objects, photographs, line drawings or even hastily drawn stick figures.

While you wait for his speech to develop, you could introduce signs or pictures. For some children, pictures are ideal as they closely represent the real object so that they catch on to the idea that showing this picture of a glass of juice actually makes someone give me a glass of juice. There are free pictures available at such websites as www.do2learn.com. There you'll also find an good explanation of why using pictures or visuals works and find assistance in getting started. Another site to browse is http://www.bellaonline.com/subjects/8561.asp.

Or you might consider teaching him baby sign language. An advantage of signing is that you always have your hands with you while you may not have the correct picture handy. Here's a website with some information on teaching a young child signs: http://www.lifeprint.com/asl101/pages-layout/concepts.htm

Think back again to the difficulty many kids with autism have making sense of their world. If you were in a similar situation, or on whirlwind trip through Europe, I'd imagine that you'd be please to have a map and itinerary to let you know what was coming next.

Kids with autism disorders often respond amazingly well to schedules. You can post one on the fridge each day that will let your son know what will be happening that day. Again, pictures are available free on www.do2learn and the site also gives you suggestions on how to make your schedule.

Sometimes we nag kids. This is especially bad if a child has trouble understand what you're saying to him. Remember those Charlie Brown cartoons where the teacher's voice drones, "Waaa wa wa wa wa"? If you find yourself nagging your son to get ready in the morning, try putting a chart in his room that tells him how to get dressed. The first thing on the chart could be his underclothes, then his socks next, then a picture of his pants, etc.

The same thing could work in the kitchen for getting his cereal. Or for cleaning up his toys.

Here are a couple books I really like for their clear, simple suggestions that are doable in the home:

Visual Strategies for Improving Communication : Practical Supports for School & Home by Linda Hodgdons http://www.amazon.com/dp/0961678615?tag=autismhelpf0e-20&camp=14573&creative=327

Asperger's Syndrome and Difficult Moments: Practical Solutions for Rages, Meltdowns and Tantrums. (Don't worry about the word "Asperger's" in the title. Asperger's Syndrome falls within the autism spectrum. It's the strategies that matter for your child, not the label.) http://www.amazon.com/Asperger-Syndrome-Difficult-Moments-Practical/dp/193128270

You might also consider trying social stories. They are brief explanations of what is going to happen. It sounds simple, but using them is a surprisingly effective strategy that can decrease negative behaviors. For instance, a social story about going for a walk might help. Carol Gray, who started the term social stories, has written a number of books such as this: http://www.amazon.com/dp/188547766X?tag=autismhelpf0e-20&camp=14573&creative=327

You can find examples of social stories at sites like :

http://www.polyxo.com/socialstories/

http://www.frsd.k12.nj.us/autistic/Social%20Stories/1social_stories.htm

http://www.adders.org/socialstories.htm

http://www.autismnetwork.org/modules/social/sstory/index.html

I hope that through charting and trying some of these ideas you may begin to find out when your son's negative behaviors are occurring and can make connections to what is happening around him. Then you'll be in a better position to focus in of the strategies that are most helpful to him.

Best wishes,

Dr. Sharon A. Mitchell
www.autismsite.ca


---------- FOLLOW-UP ----------

QUESTION: Hi Dr. Sharon - Thank you so much for the tips you have given.My son will be 4 years on 25th Jan. I cannot say he is aggressive, but show difficulties in cope up with situations such, as this he does not wish to do, or sometimes he is lazy and not allowing what he wants to do. And the other thing is he tries to idolise him self.Example- family gathering at a hotel, he wants to be in swimming pool and does not want to come out of it. No limits, he cries hard and try his thee best to go back and show unpleasantness. Earlier around 2 months ago, he never wanted to go to a dr, and cries hard enough to show his dislike, but jus few weeks ago, he is out of this, and when Dr. is checking him, he is rather ok, but need quick finishes. even at shopping malls, when he saw the elevator, he wants to go on this and cries hard enough to get about and turns the place upside down, and people around show unpleasantness as well. Do not want to stay sit down in church at the sermon, is this normal, or does he need to be descipline. The teached who comes home given the task by the diagnosed Dr, to prepare him for his schooling, on focusing on getting attentions, and getting what we need from him, and so on and many more. In Sri Lanka for Autism is a very unpleasant thing, but other european countries have lot of facilities and have special focus on these , so due to this reason sofar, we believe yo migrate to europe, which would be a better place for my son's living. do you think this is a good idea, in order to help my son.  I will follow the tips you said. and shall give you a

ANSWER: Hello, again Neesha,

I think you are already receiving good service. I cannot comment on what might be available in the European country you are thinking about. Services vary widely, even within the same country.

There are some pluses to remaining where you are. It's familiar to both your child and to you. You have a home. Both you and your spouse have good jobs already. You have a loyal servant. Medical people have recognized your son's difficulties and given a diagnosis at a young age. You've been provided with a home teacher. His speech and occupational therapy needs are being taken into consideration. He attends a preschool where he can interact with other children. You seem to have a good relationship with his teacher. The professionals are working to help prepare your son for school. There are many Europeans and North Americans who would envy your situation.

Some of the behaviours you describe seem typical for a four year old. The question is to what degree he displays these things. Most four years prefer to have their own way, want what they want when they want it, do not wish to stop swimming when told and are not good at sitting through church services.

In your position, I would concentrate on running my home according to a routine and having a picture schedule depict what is going to happen each day. When the daily plan includes something unusual, such as visiting a doctor, going to a mall, etc. I would show the child the picture depicting that activity.

I would also write a social story to explain about that trip. Over time, you can accumulate a whole binder full of social stories that your son may refer to, such as one for going to the doctor's office, one for the grocery store, one for the park, etc.

A visual schedule and the use of social stories are strategies that can continue when he is in school as well as at home.

I think your son is off to a good start.

Dr. Sharon Mitchell

---------- FOLLOW-UP ----------

QUESTION: Dear Dr. Sharon. I am getting complaints from the teacher who commies home for my son, saying he just crying and ignore what she is trying to do, not at all can be taken him to her side. Teacher is trying her level best to get his attention and slowly to get his attention, but she fails to do so. I'm having feares that my son go back to square one again. What can I say to teacher to do to get his attention. Dr. he just fuss over, by grumbling, never show an interest at it. No cooperation at all. Will this continue this way or will he come out of it, by continuously teacher comming for him. How can teacher get over it.

Answer
Neesha, there are many approaches that the teacher (and you) could take. One that may be appropriate to this situation is Floortime. If you go to this link, you can learn about it and watch some demonstrations: http://www.youtube.com/dirfloortime

Think about this from your son's point of view. What's in it for him? He's a four year old who likes to play and do his own thing - understandable. He'll see the teacher as interfering in his life and a nuisance. You know that what the teacher is attempting is for his own good, but he will not know that.

Again, this is a place to use a visual schedule. If there is something you absolutely need him to do show him in pictures First_________, Then__________ with the Then being something he wants to do. Initially make the First part of it easy and short so that he gets his reward of his preferred activity.

I'd suggest that start where he is. Become involved in what he likes. Rather than trying to make him do what you want him to do, follow his lead. If he plays with a toy, try to become involved with him. Entice him into your world. Four year olds play, so play with him. This is a way to get eye contact, joint attention, shared enjoyment and language going.