Management Techniques, Obsessive, Compulsive and Self-Injurious Behaviour

Problem: Parents are currently asking for management techniques for 'autistic' behaviours that their children with autism display.

Definitions:

Management techniques

According to the Oxford dictionary (1969) to manage something or someone means to be able to "have effective control of, bend to one's will, cajole... bring about, secure, deal with or handle with skill..." This could be interpreted to mean that any strategy that can be used to successfully enable a situation or behaviour to be 'controlled, managed, used profitably and/or contained, to produce desired response, results or profit, for the owner of such management, might be useful. However, for the purpose of this paper the term 'handle with skill' will be used. This implies appropriate management that both respects the client, having their needs uppermost in mind, and fosters an atmosphere of cooperation leading to desired outcomes.

Autistic behaviours

According to Wing (1992) autistic behaviours, as earlier defined by Kanner (1942), consists of: aloofness, indifference towards others, obsessive and compulsive behaviours, resistance to change, repetitive behaviours, lack of expressive language, and of 'pretend' play.

Specific behaviours that parents find 'difficult' appear to be connected to the compulsive, repetitive and obsessive behaviors that are anti social, and/or embarrassing and/or a danger to self or others (Asperger Parents Support Group, 1996).

Wing (1992) suggests that positive reinforcement of any small move in the direction desired is very rewarding. She likens it to the child's game of Hot and Cold and says that "ultimate success is assured with this step-by-step reinforcement. Wing does, however, suggest that reinforcement is not the same as rewarding desired behaviour with an offered 'bribe' for change. Rather it is offering 'encouragement' for any sign of behaviour that is desired. The example given relates to one parent's story of reinforcement for her son through complementing him on his table behaviour "you know, Barry, you talk much less at the table than you used to. And sometimes you listen to what others say and follow the dinner conversation." Apparently this statement brought a marked change in Barry's tendency to monopolise the conversation at dinner time. Wing points out that such statements or compliments need to be repeated often and follow-up compliments would enhance the learning.

Another 'strategy' for behaviour management is making sure that all instructions are precise and concrete. Keep all instructions simple - set up schedules of importance i.e. Brush hair, brush teeth, etc. (Wing, 1992)

Teachers at a school for autistic children on the southern region of Victoria have noted certain strategies for one child's aggressive and/or anti-social behaviours. They are as follows:

For hitting, either adults or children, the following steps are outlined:
a. maintain arms length where possible
b. verbally "hands down" - conversational tone
c. physically direct arms down
d. re-direct to task

Kicking
Adults strategy - endeavor to be at side during all activities (not in front of child). Ignore, and then re-direct to current activity.

Stripping off
a. Retrieve clothes.
b. Give clothes to child to dress themselves with supervision.

Throwing self onto floor
Ignore for 30 seconds - say nothing during this period "stand up" and then re-direct

Headbutting
Always work form the side. Ignore, move away, work with child. Return to finish task later.

Trashing room
Verbal reprimand instantly "No..." (define what it is) repeat twice. Protect other students. Say "leave table please." Ignore, invite back to group if child says "No" leave, repeat after 60 seconds.

The above strategies are directed at behaviour only and do not attempt to understand 'why' the child does what they do. However, it is important to recognize that behaviour must be challenged in order to protect the child and those around them. When the child's behaviour is appropriately reinforced then the child is being given alternative communication skills, hopefully, and is being taught that to scream, hit, bash, strip off, throw oneself onto the ground or trash a room, is not the way to express 'discomfort, unhappiness, insecurity, or fear. The child, therefore, needs to be encouraged to express their unhappiness differently.

If the child is non-verbal, the use of pictures, colours and actions, demonstrated by the parent, teacher or professional, can be most helpful. However, this needs to be done when the child is cooperative and willing. Even when a child is verbal, colours, symbols, signs and actions will need to be used. This is so because even though the autistic child will 'feel' unhappy, they may not have the skills or comprehension to know what the feeling is.

According to Mohr and Sharpley (1985) self-injurious behaviour (SIB) needs to be treated with immediate and effective intervention. Apparently SIB can be catorigised into three types: medical, psychodynamic and behavioural, (Mohr and Sharpley, 1985). Medical intervention is commonly used for SIB, with developmentally delayed individuals. However, studies show that this method is rarely successful (Picker, Poling and Parker,1979); Ross and Mckay, 1979 cited in Mohr and Sharpley, 1985).

Apparently, one report concluded that "medical treatment may be neither necessary nor sufficient" (Pawell, 1982:534 cited in Mohr and Sharpley, 1985). However, in a direct comparison psychoanalysis with behavioural intervention results showed that "providing comfort and reassurance, treatment was successful (Lovas, Freitag, Gold and Kassorla 1965 cited in Mohr and Sharpley, 1985).

Mohr and Sharpley suggest that mild punishment, overcorrection and reinforcement can be successful in the reduction and elimination of SIB. Verbal reprimands such as 'NO' and short phrases to tell the autistic person what to do i.e. "hand still, hand down" at the same time as placing hand down onto table, knee or lap, were first resources. Encouragement and reinforcement took the form of "good boy, lovely still hand etc. frequently expressed, i.e. - per 10 seconds of appropriate behaviour delivered intermittently.

The Escaper

Kate Rankin (1992) reveals in the story concerning her son that escaping from the house was "... one of Gabriel's strongest aims in life..." Kate goes on to say that absolutely nothing could deter her son from escaping. This appears to be the case for so many children with autism (Parents Support Group, 1996). The only kinds of management appear to be those directed at implementing the child's safety. For example "..extreme vigilance, the locking of all doors and windows, knowing the whereabouts of the child at all times and even resulting to the wearing of a bell or alarm if the child should stray beyond a certain point" (Rankin, 1992 cited in Communication Vol 26). Kate even suggests (for those who could afford it!) closed circuit TV, buzzers on doors, windows and gates, and a permanently manned watch-tower in the garden!!

On a more serious note (although Kate does have a point) Attwood (1992) suggests that some 'autistic' behaviours are signs of stress and expressions for 'help'. For example: a child may bite their hand when they have failed to complete a task and need help. Attwood suggests the following:
1. Identify any signals which indicate increased levels of stress
2. Organize some distracting activity
3. Encourage relaxation or vigorous physical activities to reduce the stress level
4. Impose verbal control
5. Leave well alone

It is usual that each autistic child will have a pattern of communicating stress. It may be certain sounds, movements or phrases that they associate with the situation, even if the words they use are reintroduced from some previous time (Attwood, 1992). Once signals are understood distraction may help. If this does not occur then relaxation with soothing music or other calming remedies may help. Some children need to 'burn off' their energy before they can calm down. If seclusion is necessary for the person to feel safe and separated from what was upsetting them then make sure that the area is comfortable.

Sometimes relaxation can involve breathing calmly and deeply in a controlled manner. Children can be taught a breathing technique but it takes persistence and patience (Attwood, 1992). At other times verbal control is vital for the child to know that even if they feel out of control YOU are not! Being assertive and 'applying the brakes' is just another way of setting boundaries. Should none of the above management skills be affective then maybe the child needs to be left alone for a short period of time in a safe place. This may not mean removing oneself too far from the person but far enough so that the individual feels that they have space and privacy to work things out.

Powell and Jordan (1992) suggest that individuals with autism can have their thinking remediated. According to Powell and Jordan, autistic individuals can only concentrate on one thing at a time. So rather than filter out all other stimuli which may interfere with the learning of a procedure or command, a way has to be found to help maintain the persons focus so that they learn how to not be influenced by distracting stimuli. This can happen by:
a. facilitating an appropriate learning medium that takes into account any other social/affective stimuli that may be occurring simultaneously. It is not sensible to try and teach something when other things are happening.
b. attending to meaning or selective attention is profitable to the learning process.
c. visual mediation such as photographs, plans or outlines can help a person with autism make appropriate decisions and interpretations. It must be taken into account that for the person with autism to make a simple choice is most difficult. They need choices to be limited and not over powering.

Abnormal Posture

Kohen-Raz, Volkmar and Cohen (1992) suggest that some of the abnormal postures of autistic persons may be connected to 'stress' or to hypersensitivity to vestibular irritation. They also state that the pattern of lateral sway in low-functioning autistic children may be the result of general postural imaturity. If this is the case then exercises for motor control, similar to those practiced in kinder and primary school, could be helpful. Some research shows that when regular exercise is undertaken learning is also enhanced in academic ways (Sharpe and Ross, 1987:184-192).

Koegel, Koegel and Surratt (1992) found that incorporating parameters of natural language interactions and motivational techniques, in autistic children with severe disabilities, reduced the number of disrupted behaviours. They suggest that results were higher when persons were naturally reinforced during ordinary conversation as they made attempts at communication. The traditional analog clinical format was not so successful during teaching sessions and more disrupted behaviours were noted. This, therefore, suggests that even non-verbal autistic children can respond better to learning situations, when they are part of natural two way communication with motivational reinforcement.

Bladder control

Richdale and Prior (1992) noted that in high functioning children with autism, poor bladder control during the day, for children integrated into the normal school system, was related to 'stress'. They found that the high functioning autistic children in their sample had no evidence of abnormal urinary cortisol circadium rhythm but were subject to greater 'stress' reaction than non-autistic children.

This problem therefore, needs to be managed with 'stress' relief and should be explored on an individual basis.

Wainwright-Sharp and Bryson (1993) found that autistic persons have problems with registering, processing and responding to external stimuli. Their research supports previous research that noted "attentional dysfunction underlies autistic symptomatology" (e.g., Bryson, Wainwright-Sharp, & Smith 1990; Dawson & Lewy, 1989a, 1989b). This would suggest that the giving of information, instructions or relating conversationally needs to be done simply, repetitively and in small bursts. Otherwise the person with autism may be left at the gate while the other has crossed the road.

Tantam, Holmes and Cordess (1993) also noted that attention deficit was evidenced in persons with autism. They suggest that social attention deficits are a result of neurophysiological abnormality.

Conclusion

This paper has only scanned the literature and is by no means conclusive. However, it is apparent that children and adults with autism respond more cooperatively when they feel valued, respected, motivated and encouraged.

Learning material, whether in the form of management techniques or new information, appears to be handled more positively by the autistic person when it is presented clearly, concisely and in small chunks.

Motivators and reinforcers seem to work well and early intervention is known to improve outcomes.

REFERENCES

Asperger Syndrome Parents Group (1996) 53 Bowmore Rd, Noble Park Vic. Australia.

Attwood T., (1992) Professionals section 'managing the unusual behaviour of children and adults with autism' Communication Vol 26 (2) Australia.

Koegel R.L., Koegel L.K. and Surratt A., (1992) 'Language intervention and disruptive behaviour in preschool children with autism' Journal of Autism and Developmental Disorders, Vol 22 (3).

Mentone Autistic School, (1996) Blackwood Ave, Mentone Vic. Australia.

Mohr C., and Sharpley C.F., (1985) 'elimination of self-injurious behaviour in an autistic child by use of overcorrection' Behaviour Change Vol 2 (2) Publication of the Australian Behaviour Modification Association.

Powell S.D. and Jordan R.R., Remediating the thinking of pupils with autism: Principles into practice. Journal of Autism and Developmental Disorders Vol 22 (3).

Rankin K., (1992) Family section escaper. Communication Vol 26 (2) Australia.

Richdale A.L. and Prior M.R., (1992) Urinary cortisol circadian rhythm in a group of high-functioning children with autism. Journal of Autism and Developmental Disorders, Vol 22 (3).

Sharpe P. and Ross S., (1987) Living psychology. Brunswick Vic: Scribe Publications Pty. Ltd.

Tantam D., Holmes D. and Cordess C., (1993) 'Nonverbal expression in autism of Asperger Type' Journal of Autism and Developmental Disorders, Vol 23 (1).

Wainwright-Sharp J.A., and Bryson S.E., (1993) 'Visual Orienting deficits in high-functioning people with autism' Journal of Autism and Developmental Disorders, Vol 23 (1).

Wing L., (1992) Autism and Asperger Syndrome. (Ed. Uta Frith). London: Cambridge University Press.