Expert: Dr. Sharon A. Mitchell - 4/11/2007

Question
QUESTION: Hi Stephen,
My son is 5 years old, and was diagnosed with high functioning ASD.  My question is in regards to his aggressive behavior.  My son is usually a pretty affectionate kid.  However, I have not found a discipline that works for him, and more disturbingly, I have not found an effective praise.  

As an example, he usually hates to have his teeth brushed.  One night, he was doing a wonderful job letting me brush, so I said "Wow- you are doing a great job brushing your teeth!  That makes me so happy!"  He quickly became angry, hit me in the forehead and said "you...not...happy!"

He tends to turn from happy to angry in a second, with no warning.  Sometimes all it takes is just saying "hi", or trying to ask him a question.

Please help me to understand what sets this behavior off.  I understand that there could be a lot of sensory things, but I honestly have not been able to pinpoint anything!

Thank you so much.
ANSWER: Melissa,

Your question was sent to the autism question pool rather than to just Stephen. Since I also have a son with high functioning ASD, I thought I'd give you an answer.

It can be distressing when an otherwise loving child does something aggressive. And naturally, you don't want a repeat of such incidents.

I agree with you that some of this might be sensory-based. It might also have to do with the processing difficulties inherent in autism.

Sensory sensitivities can really interfere with teeth brushing for kids with autism and related disorders. The mouth is a highly sensitive part of the body. Some kids are so sensitive that they dislike the feel of objects in their mouth. Some feel only able to tolerate certain textures or temperatures. This can create dietary nightmares for parents.

When you think about brushing your teeth, there are many things involved
- opening your mouth wide
- inserting bristles on a stick into your mouth
-insert the brush too far and you can invoke your gag reflux
- insert it not far enough and you can tickle your lips, a shivery sensation
- the bristles can feel so hard that they almost hurt
- it's one thing to brush teeth but another thing when that toothbrush touches the gums. Or the tongue
- standing with your mouth open can create extra saliva that can pool in places in the mouth
- saliva pooling near the back of the mouth can create a drowning sensation
- saliva pooling too near the front of the mouth may make you drool
- toothpaste can smell pleasant or horrid, depending on your sensitivities
- the taste of toothpaste can also be strong and unpleasant
- brushing with paste creates some froth which may feel awful
- after brushing, there's too choices - spit or swallow and neither option may appeal to your son

There are several things you could try:
- experiment with different toothpastes to see which one your son dislikes least
- health food stores will have a few toothpastes that your local grocery or drug store may not offer
- if he finds no toothpastes tolerable, you could try brushing his teeth with baking soda and water.
- try different kinds of brushes from soft to harder
- some kids prefer the battery-run spin brushes
- perhaps not as efficient, but better than nothing are the individual finger glove-type cleansers. A package holds several small paste-flavored pads you slip over a finger then run your finger over your teeth
- a brush with nothing on it but water would be better than nothing if toothpaste is the issue

Have you been able to talk to an Occupational Therapist about this? OT's can be helpful in designing a desensitization program you can do with your son to gradually accustom him to having something in his mouth. They may suggest oral motor exercises for his jaw, cheeks, mouth and tongue.

Speech/Language Pathologists can also be helpful with oral motor exercises that may decrease your son's sensitization. Some examples of oral motor exercises are at these sites:

http://www.speech-therapy-on-video.com/oralmotor.html

http://www.widesmiles.org/cleftlinks/WS-563.html

Sensory sensitivities could account for your son turning on you when your were brushing his teeth. But there could be some other things going on.

Independence can be a big issue for kids. Even though he would not do the job as well as you, is there a change he might be more cooperative if he brushed his own teeth rather than you doing it for (to) him? Sometimes unpleasant things are more tolerable if they are under your own control rather than someone doing it to you.

If he's sensitive around his mouth and was tolerating your brushing, that might be all he could handle at one time. Auditory processing is often a weak area for people with autism, meaning that while your son's hearing might be fine, his ability to take in what he hears, understand it and react appropriately may be weaker. And this skill would be under stress if he was concentrating on tolerating the brushing. Then when you talked to him, especially if you praised him in an effusive fashion, it might have all seemed too much and he lashed out.

Not that that's all right. He should not hit at all, but it can help if you understand the possible reasons behind his inappropriate reaction.

When under stress, a reaction can be instinctual. Rather than saying, "Stop" or "I've had enough", your boy might have reverted to younger child behavior and hit rather than using words to say what he wanted.

Perhaps if he dislikes his teeth being brushed and you said that you were happy during the process, he interpreted your words as being unsympathetic to his distress. In his mind, how could anyone be happy when such a thing was going on. Or if you were happy, how mean was that, when he was feeling badly?

Are you familiar with the term "Theory of Mind"? Temple Grandin refers to it as "universal mind". This is a feature of autism where the affected person feels that whatever is in his mind, whatever he's feeling is shared by other people. So, if your son was feeling miserable about having his teeth brushed and you said you were happy, that could seem most inappropriate to him.

This all sounds a lot like a guessing game, doesn't it? Sometimes that's what it feels like when you parent a child with autism.

Nevertheless, your son still needs to learn to react in more appropriate ways and ways that will enable him to get what he wants without aggression or uncalled for anger.

Take a look at this site for some ideas on where to begin:

http://www.autismcommunityconnection.com/files/autismcc_responds_agg_behavior.pd

How well does your son use language? Does he express his wants and needs in words? Does his anger erupt when he wants something but is unable to communicate that need to you as quickly or efficiently as he'd like?

Does he understand other people's facial expressions and body language? Can he decipher how he himself feels? Some kids understand happy and mad but none of the other varieties of emotions. Some kids equate hunger and fatigue with anger. There are a couple good games your could do with your son at the excellent Do2Learn website:

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

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

Do you use visuals with your son? Even for high functioning kids who speak well, visuals or pictures can greatly enhance how well they understand. So, rather than just talking him through the steps of teeth cleaning, having step-by-step pictures may involve less of a processing load for him, especially when under duress. Taking in the information visually may be easier for him than listening to your words. You can find free pictures to use for this at the Do2Learn website.

You might also wanV.try creating visual schedules using pictures to structure his day and the morning and before bed rituals. Then he'd know what is coming next, what you expect of him, etc.

Another thing to try is a social story. They're such a simple idea but can be truly effective with kids with autism spectrum disorders. Here's an example:

http://www.polyxo.com/socialstories/hygiene/brushingmyteeth.html

Here's a combination using visual and social story concepts to teach a child about anger:

http://www.autismcommunityconnection.com/files/autism_rage_tantrums.pdf

A book that is a favorite of mine is part of Linda Hodgin's visual strategies series, "Solving Behavior Problems in Autism" (http://www.amazon.com/Solving-Behavior-Problems-Autism-Strategies/dp/0961678623/). It goes well with her companion book, "Visual Strategies for Improving Communication : Practical Supports for School & Home" (http://www.amazon.com/dp/0961678615?tag=autismhelpf0e-20&camp=14573&creative=327).

While your son is a sweet little guy now, he's only going to get bigger and stronger. Hitting people is a habit you do not want him to get into. Taking into account possible sensory sensitivities, decreasing the amount you talk to him when he's upset and using visuals can help your son find different and better ways of responding to his frustrations and getting his needs met.

Sharon A. Mitchell
www.autismsite.ca






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

QUESTION: Wow- thank you so much, Sharon.  I don't know how the question got into Autism question pool, but I'm glad it did.

the toothbrushing was just an example of how his anger just pops off at any time.  He will now brush his own teeth, but he does not do an efficient job with it- he has just had some pretty extensive dental work for a 5 year old (multiple fillings and a crown), and he really does need to let me brush, which is the battle.  

Anyway, he does have language, but has expressive/receptive language disorder as well.  This does frustrate him at times, and he does get aggressive.  He is also hyperlexic, and tends to respond better to the written word rather than pictures.  It's all about if he's choosing to be receptive to what's being asked at the time or not.

My son's aggression is getting pretty bad lately.  I can't think of anything that has changed.  Every day, he targets my mom (who watches him and his 4 month old brother) while I'm at work.  He has hit, kicked, and bitten her on an almost daily basis.  One thing that I have noticed, is that his "rituals" are becoming more frequent.  It seems that he is making a ritual out of anything.  Example:  We were playing with blocks.  He wanted me to put the block in a certain way, and I wasn't understanding how he wanted me to arrange the block.  He got mad, said "now, I have to hit you".

His aggression has gotten to the point that it almost does seem that he believes he "needs" to hit, or lash out physically- no matter how I try to help him redirect his anger.  Often, he will use our "relaxation techniques" after the fact.  He will hit and then say that he needs to take a deep breath.  He'll kick and throw things at you, and then say that he needs a break and goes to his room.  

Sigh, it still is a big guessing game for us most of the time.  I do think that much of the frustration is due to the increased rituals though.  Any recommendations or advice about rituals?  :)

Answer
My apologies. I see that the latter part of my answer did not come through. We must have some sort of tech glitch. I'll paste it below, then get on to your current questions.
________________________________________________________
Taking in the information visually may be easier for him than listening to your words. You can find free pictures to use for this at the Do2Learn website.

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

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

Do you use visuals with your son? Even for high functioning kids who speak well, visuals or pictures can greatly enhance how well they understand. So, rather than just talking him through the steps of teeth cleaning, having step-by-step pictures may involve less of a processing load for him, especially when under duress. Taking in the information visually may be easier for him than listening to your words. You can find free pictures to use for this at the Do2Learn website.

You might also want to try creating visual schedules using pictures to structure his day and the morning and before bed rituals. Then he'd know what is coming next, what you expect of him, etc.

Another thing to try is a social story. They're such a simple idea but can be truly effective with kids with autism spectrum disorders. Here's an example:

http://www.polyxo.com/socialstories/hygiene/brushingmyteeth.html

Here's a combination using visual and social story concepts to teach a child about anger:

http://www.autismcommunityconnection.com/files/autism_rage_tantrums.pdf

A book that is a favorite of mine is part of Linda Hodgin's visual strategies series, "Solving Behavior Problems in Autism" (http://www.amazon.com/Solving-Behavior-Problems-Autism-Strategies/dp/0961678623/). It goes well with her companion book, "Visual Strategies for Improving Communication : Practical Supports for School & Home" (http://www.amazon.com/dp/0961678615?tag=autismhelpf0e-20&camp=14573&creative=327).

While your son is a sweet little guy now, he's only going to get bigger and stronger. Hitting people is a habit you do not want him to get into. Taking into account possible sensory sensitivities, decreasing the amount you talk to him when he's upset and using visuals can help your son find different and better ways of responding to his frustrations and getting his needs met.

Sharon A. Mitchell
www.autismsite.ca
___________________________________________________________

Now to reply to your April 11th email. I'll copy here what you wrote:

Wow- thank you so much, Sharon.  I don't know how the question got into Autism question pool, but I'm glad it did.

the toothbrushing was just an example of how his anger just pops off at any time.  He will now brush his own teeth, but he does not do an efficient job with it- he has just had some pretty extensive dental work for a 5 year old (multiple fillings and a crown), and he really does need to let me brush, which is the battle.  

Anyway, he does have language, but has expressive/receptive language disorder as well.  This does frustrate him at times, and he does get aggressive.  He is also hyperlexic, and tends to respond better to the written word rather than pictures.  It's all about if he's choosing to be receptive to what's being asked at the time or not.

My son's aggression is getting pretty bad lately.  I can't think of anything that has changed.  Every day, he targets my mom (who watches him and his 4 month old brother) while I'm at work.  He has hit, kicked, and bitten her on an almost daily basis.  One thing that I have noticed, is that his "rituals" are becoming more frequent.  It seems that he is making a ritual out of anything.  Example:  We were playing with blocks.  He wanted me to put the block in a certain way, and I wasn't understanding how he wanted me to arrange the block.  He got mad, said "now, I have to hit you".

His aggression has gotten to the point that it almost does seem that he believes he "needs" to hit, or lash out physically- no matter how I try to help him redirect his anger.  Often, he will use our "relaxation techniques" after the fact.  He will hit and then say that he needs to take a deep breath.  He'll kick and throw things at you, and then say that he needs a break and goes to his room.  

Sigh, it still is a big guessing game for us most of the time.  I do think that much of the frustration is due to the increased rituals though.  Any recommendations or advice about rituals?
_____________________________________________________
Rituals - it can help if you think of autism as a processing disorder, where it's difficult to process more than one piece of sensory information at a time. Also, people wiht autism tend to have difficulties generalizing information from one situation to the next. Even when they learn a skill in one situation, they'll have trouble realizing that the current situation is similar to the previous one and not know that the same skill might help them out this time. They may remember things but that information is almost over-compartmentalized in their memories. These two (the processing and generalizing) make the world a confusing place.

When we're confused or unsure, we cling to that which we know. When there aren't strict procedures in place, we make them up to help lend structure and predictability to our world. That's where some of the rituals may stem from and behaviour that resembles that of people with obsessive-compulsive disorder.

Unfortunately, some people with ASD become obsessed with their rituals and needing the sameness, making change or intrusions hard.

There are a couple things you might try. First, run your lives by a schedule. I know just how unappealing that thought is but when we tried it, it made our household much more livable for all concerned. Since your lad is hyperlexic, make it a written schedule and post it in various places throughout your home and that of your mom's. The schedule could be something like:
- 7:00 - wake up and go to bathroom
- 7:15 - eat breakfast
- 7:30 - get dressed
- 7:45 - gather backpack and get in car

In your bathroom you could have a schedule for what you expect him to do there in the mornings. A schedule on his bedroom wall could state the order in which he should get dressed. A schedule on the back door could have a checklist of what he needs to make sure is in his backpack.

Such schedules lend predictability. They also relieve you of the need to nag and make sure he's doing what he should. Plus, they work towards his independence - he can eventually follow his morning routine on his own without your constant supervision. There's no room for debate or arguing - it's clear what he is to do.

Sometimes kids who hit have a need for more proprioceptive information. Propriocceptors are nerve endings in the large muscles and give feedback to the body about force and pressure. Possibly your son receives needed body feedback when he hits or kicks.

You may be able to turn some of this around by supplying other ways for him to get this type of feedback. You could have him try things such as:
- punching a pillow
- squeezing a stress ball
- wearing a weighted vest
- wearing ankle or wrist weights (small ones)
- jumping on a rebounder or mini-trampoline
- doing wall push-ups
- swinging
-rocking in a rocking chair
- carrying heavy objects
- sitting on a therapy ball
- sandwiching him in between large pillows and applying some pressure

An Occupational Therapist can be a great ally in assessing your son's sensory needs and devising a plan whereby he receives frequent, regular bits of the sensory stimulation his body craves.

Here's a little book that I've found very useful, "Asperger Syndrome and Difficult Moments: Practical Solutions for Rages, Meltdowns and Tantrums: (http://www.amazon.com/Asperger-Syndrome-Difficult-Moments-Practical/dp/193128270).

Another one I like is "Asperger Syndrome and Sensory Issues: Practical Solutions for Making Sense of the World" (http://www.amazon.com/Asperger-Syndrome-Sensory-Issues-Practical/dp/0967251478/r).

Discipline can be difficult when a child with an ASD. Are you familiar with the program called, "One-Two-Three Magic"? It's simple, clear-cut and a non-equivocal way to have your child learn to manage his behavior. (http://www.amazon.com/1-2-3-Magic-Effective-Discipline-Children/dp/1889140163/re).

I think some of your other questions were answered in the part of my initial response that did not make it to you. Hopefully you are able to take a glance at it now.

Sharon Mitchell
www.autismsite.ca