Expert: James Michael Roan - 10/29/2006

Question
I am sorry to keep asking questions but i want to be sure i understand everything.  below you mentioned that steriotypies increase with age and stimulation...i thought that the old you get, the more cognitive you become and can sort of change or hold off on some things.  sometimes when my 6 year old realizes that someone is looking at him, he will excuse himself and go to the bathroom to "stim" or whatever you call it.  will what he is doing with his hands, being above his head change into something less obvious on it's own?  he used to only push under his chin when stressed, then it became the hands, but closer to his mouth, now for the longest period, it's above his head.  is this a natural/typical progression? will he be able to control it on his own at some point?  where can i find more info on these.  we saw dr. singer at john's hopkins who was supposed to be the expert on this, but $850.00 later, he still couldn't direct us other then to say what it was.  can you offer ideas?  thank you so much again!!!! I can't tell you how refreshing it is to finally have someone know what i am talking about.
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Thank you for answering my question.  I am curious about medication for anxiety that doesn't have any BSE's(behavioral side effects), like paxil/lovox? As far as school, he is in an inclusion class with 20 kids, 2 teachers, 2 assistants and 1 aide.  enough to give anyone anxiety. To get through the day to day things with less anxiety overall, and knowing how he reacted to prozac and zoloft, would you think that another ssri may be the ticket?  i am not looking for a quick fix, i am looking for him to "not get teased" with his hand movements and hyperactivity.  he is only in 1st grade and we are trying to avoid the brutality that is potential coming.  if he didn't have these movements and hyperactivity, no one would think he has any issues out of the norm.  he doesn't talk above people or mechanical, and fits in in other ways, but kids are starting to say things to him about his hands.  thanx so much for your help!!!!  
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My son has an aspergers diagnosis (actually high functioning autism) and he seems to get fixated on one thing at a time.  right now it is mario brothers.  he often will act out various scenes at inappropriate times like leaving school.  my question is...his teachers said they think he is hyperactive, impulsive and having trouble starting and stopping various things like lunch, writing etc.  they think he is all over the place.  when i did a school visit, it was clear to me that he was thinking about mario brothers and was uninterested in what they were doing because mario was "more fun to think about". i could see him laugh to himself etc.  he also has hand movements called steretypies (not flapping-more of a steady movement w/ hands above head and facial grimmacing) and will often escape things by thinking of mario while doing his unusual hand movements.  when we thought he had anxiety, his dr. put him on prozac which helped his hands and his mario obsession, but it made him incredibly hyper.  we then tried zoloft which did the same and finally agreed to try strattera which made him cry day and night and he became angry and agressive.  how do we know which to focus on? is this sounding like a typical aspergers thing or more of an obsessive ocd thing or hyperactivity?
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Hi Lisa;

This is definitely Asperger's related behavior. The attention problems, initiating/terminating, and impulsivity is due to an "executive dysfunction" issue, which is typical of Asperger's Syndrome (AS). It is very, very frequently misdiagnosed as ADHD. The stereotypies, which are also a main component of AS are a good index of anxiety levels. Reduce anxiety and the stereotypies will diminish also. The anxiety comes from over social-stimulation. He probably needs a quiet place to escape from them at school. The OCD, like stereotypies are a way to modulate and attenuate over stimulation and anxiety.

My advice, if possible, is to reduce his anxiety and arousal states by working with his school and developing a plan where he has a pre-established retreat from over stimulation.

Kind Regards,
James
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Hi Lisa;

I cannot comment on the medication since I am not a licensed physician.

I suggest you have the teacher conduct a functional behavioral assessment (FBA) in order to discover the function of the behavior. Generally, the finger movements are part of autism, but you should be able to find a substitute for them. Most stereotypies increase with age and stimulation. Reduce the stress and the stereotypies diminish.

The occupational therapist at school can complete a Sensory Profile. Some behaviors are driven by sensation avoidance while others are sensation seeking. Information from both instruments can guide your decision making.

Kind Regards,
James

Answer
Hi Lisa;

You are welcome to ask as many questions as you like. I'm sorry I confused you with my poorly constructed sentence. What I had meant to say was, as you observed with the fingers above the eyes, stereotypies become more elaborated over time because of a developmental increase in cognition results in an increase in anxiety. The anxiety comes from multiple sources: sensory defensiveness, social anxiety, and a sense that they are different from others. You and I would do just about the same thing under those circumstances except for one HUGE difference: we have appropriate social cognition/thinking. We have developed "theory of mind skills" (see Simon Baron-Cohen. That is we are always thinking about what others are thinking about us (see Michelle Garcia-Winner). We filter what we do because we don't want to be socially inappropriate. Most children on the autism spectrum are very poor at this. What others think is not an issue with them, either because they are delayed socially and/or because they are unable. Logic and reason works very well with children who have Asperger's Syndrome (AS)due to their concrete thinking style. Use rules. Use "social stories" or "comic book conversations" by Carol Gray to explain what others think about his actions and how they may misinterpret them. Then work to find other ways to help him mediate the stress, such as take a walk to the office and back or have the teacher give him some heavy books to carry somewhere. The exercise will help attenuate the stress.

Please let me know if you have any more questions.

Kind Regards,
James