Strategies: Communication and Behaviour By Guest Blogger Rachel McNamara

Strategies: Communication and Behaviour

By Guest Blogger Rachel McNamara

I started this blog 6 months ago. Over that time the way I write has changed. I decided to look though my earlier blog posts after reading the PACLA magazine on acceptance to see if I wrote anything offensive to people with autism. Yes, I have autism too but that doesn’t proof me against being discriminatory and yes, I was writing like I was an authority on autism (cringe) and I used discriminatory rhetoric (cringe).

With regard to two of my earlier posts, I felt they needed a total re-write. So I have deleted my posts on ‘challenging behaviours‘ (cringe) and joined them to form one very long one post here called ‘teaching my children how to communicate better and/or a general guide for addressing behaviours of concern in children‘. This post won’t be perfect but hopefully it will be a bit better and on the topic of perfection neither am I. A day doesn’t go by when I don’t do something imperfectly as a parent but it doesn’t stop me trying to be the best I can be in a balanced and conscious way.

Everything in this post may also be relevant for children without autism.

Unfortunately, I still sound a bit instructive in it sometimes; I can’t seem to shake that completely. However, it is important to me that you understand that I consider myself to always be learning and I just want to share the strategies that helped my young boys communicate and cope better with others and their environment.

What works for my boys may not work for everyone, what is most important when you develop effective strategies that work for you and your children is that you maintain consistency with them. The world is a chaotic place for some of us and consistency helps to reduce that. I don’t mean don’t [not to] change anything [ever], especially if it’s not working, but don’t change too much too quickly and gradually expose and explain what you are doing and why to your children.

Communication and behaviour

With a few exceptions, behaviour is communication and although each child with autism is different, the one thing that can be said for children with autism is they have difficulties with social communication. Those difficulties vary greater from child to child, but given that behaviour is usually considered a form communication then you would expect that their behaviour would show that (sometimes more obviously than others).

Communication difficulties can sometimes be to the extent of not being able to communicate verbally at all. Fortunately, there are communication methods available for children with or without autism that enable them to communicate their needs. My children are not non-verbal but I thought it was important to include information on facilitated and augmented communication so I have copied a link explaining these forms of communication here.

[Portia wants to emphasize this:] Definition of a meltdown: Complete loss of control over one’s actions due to a fully engaged flight or fight response (this is caused by over-stimulation of the sympathetic nervous system).

My children rarely experience meltdowns (complete loss of control over their actions due a fully engaged flight or fight response) but once again because I am writing about communication and behaviour here I felt the need to refer to this behaviour because it cannot be addressed with many of the strategies that I write about in this post. Please refer to the following link for more information about meltdowns here.

The next point that I need to make is that some behaviours that we see in children are a response to sensory overload or under-stimulation rather than a form of communication. Sensory processing difficulties and differences are very common among children with autism [1, 2].

Studies have shown that there are three to four subtypes of sensory processing domains in children with autism, which represent a combination of differences in auditory filtering (sound), movement sensitivity (vestibular and or proprioceptive), tactile sensitivity (touch), taste/ smell sensitivity and low energy/weak (posture and static body position) characteristics [1, 3]. Within each of these domains children may be either under sensitive or over sensitive or exhibit both extremes [3, 5]. In addition those sensory processing differences are shown to be related to communication and behaviour [1].

Some behaviours that children may have may concern people when actually the behaviour serves an important purpose of the child. In some cases the behaviour acts as a sensory modulator (rather than a form of communication) for the child and may not necessarily cause harm. Stimming is one such behaviour.

Jeremy fidgets constantly, chews his nails, chews his clothes or flicks his ears or other less common movements. To prevent damage to his clothes I have encouraged him to take fiddle toys and chewy pencil toppers to school. Sometimes the toys etc. help to reduce his chewing of clothes and sometimes they don’t, so I have taken to not purchasing clothes that are easily damaged such as studded jackets (he chews studs of the jackets). Chewing and fidgeting repetitively fits the definition of stimming. Most forms of stimming have a sensory function and can help children to cope with their environment. Stimming is quite common among children with autism and even among children without autism. Refer here for more information on stimming.

Maslow’s hierarchy of needs‘ as it relates to motivation and reaching one’s full potential suggest that basic needs such as physiological and safety needs have to be met first [4].

In general, what I like about his theory is the general premise that basic needs have to be me before more specific and complex goals can be achieved. If you have an onslaught of sensory stimuli or are under responsive to sensory stimuli you are hardly going to be in a great position to sit still and actively listen to a teacher. Similarly, if you are very hungry or tired and do not recognize it or are unable to communicate your need for food or sleep you are not going to be in a good position to learn something new or interact effectively with others and that may be a familiar situation for children without autism too. These are examples of basic physiological need that take precedence over other behaviours.

An Occupational Therapist is the health expert to consult about concerns of a sensory nature. In particular, always look for a health professional with expertise in autism and one that comes highly recommended by other families in the autism community.

In general, children with autism have more daily challenges than those without autism, in particular many sensory challenges and difficulties recognizing and then communicating their needs to meet those needs. So then, it is not surprising that behaviour that may seem to be ‘bad’ behaviour by unaware people such as ‘refusal to comply’ or ‘running away’ or ‘not sitting still’ may be more common among children with autism. With this in mind it is important to understand all behaviour properly and not making a quick judgement of the reason for or function of the behaviour.

The use of a behaviour recording chart is usually recommended to observe and analyse any behaviours of concern displayed by children with or without autism.

Jeremy’s child psychologist first alerted us to this method and it helped her to understand Jeremy’s behaviour better before providing me with advice. Behaviour recording charts often include sections for writing descriptions of the behaviour including frequency and intensity, what happens before the behaviour, what happens after the behaviour, what factors may have led up to the behaviour or triggered the behaviour. Functional behavioural analysis as it is otherwise known is an important part of addressing behaviours[5]. You can find out more about behaviour recording charts and how to use them from the following link.

It is important to realise that rather than eliminating the behaviour of concern such that only the challenge is left, a replacement behaviour should be taught (and/or the environment modified where helpful) rather than leaving the child with no means of communicating their needs, coping with their challenges or achieving their goals.

In general, with regard to addressing the needs of our children, we need to make sure that the basic needs of the child with autism are being met such as through use of communication aides, sensory therapies, relaxation techniques, daily schedules and routines and modifications to their environments (for example by modifying or removing sensory stimuli). We may also need to communicate with them in a way that they can better understand by using visual means, by providing extra cues and unambiguous language and by explicitly teaching them how to communicate their needs more effectively to us.

Testing the boundaries

There are several general strategies* I use a for addressing behaviours of concern with my boys when the motivation for their behaviour is to ‘test the boundaries’.

1. Incentives/rewards

It is important to note that we rarely do anything for free unless it is something that we find personally rewarding and we need to believe that what we are doing is making a worthwhile difference.

We believe that we are making a difference when we can perceive the good we are doing and see the follow on effects of our efforts and notice how our lives are enriched by our choices. Children with or without autism may not always be able to see the bigger picture with respect to the good that their actions can have. Children with or without autism may not always be able to easily see the full extent that their actions, words or lack thereof can impact others or make an overall positive outcome for themselves.

Both social and monetary rewards have been shown to be useful for improving task performance [6, 7]. It has been shown that social reward has less effect in improving task performance than monetary rewards for children with autism compared to a child without autism [6, 7]. No value judgement needs to be made about this. It is just a difference that should be accounted for and provides an even greater argument for utilizing incentives with children with autism rather than relying completely on learning from social feedback.

Pairing social teaching with incentives in the form of positive reinforcement of behaviour performance has been shown to be effective for teaching social skills to children with autism. The explicit teaching of social skills to children with autism is very helful and includes the use of such methods as Social StoriesTM, Teaching Interactions [8], Video Self-modelling and Cognitive Behaviour Therapy (this can also be very helpful for managing anxiety in children with autism). The premise is to teach children more effective ways for getting their needs met. Social teaching really deserves a post of it’s own so I’d urge you to click on the links for more information.

I find incentives to be a very effective strategy for motivating my boys to display a newly learned skill that I have taught them. The more they practise the skill the easier the skills usually get. The incentive should be something that personally appeals to your child like a lolly or a small toy or time to pursue a special interest. Your child should be aware that they will only receive the incentive if they perform the desired behaviour such as a greeting. The desired behaviour should be achievable and be explained in such a way that your child understands what they need to do properly before facing the situation.

For example, the explanations like these were usually successful for my sons “Damian, if you say ‘hello’ to the kindergarten teacher when we walk into the room and look at her eyes when you say it, I will give you a blue jellybean. Remember you will only get the jellybean if you have said ‘hello’ and looked at her eyes at the same time” (I know some kids find making eye contact difficult or even painful but Damian can do it without discomfort -I’ve asked him- he just needs to be reminded, so the request is reasonable for Damian).

It is important that you stick to the agreement; so that you give them the incentive as close as possible to after they have demonstrated the behaviour and that you do not give them the incentive if they do not perform the behaviour to make sure that the strategy is effective in the future.

My children are usually highly motivated to display a desired behaviour when offered a food treat like a doughnut or chocolate. Obviously, I do not use this strategy every day, given that this treats are not very nutritious. I have completed a Masters of Nutrition and Dietetics many years ago and my children have a generally well-balanced diet so the occasional treat is of no concern to us. Although, I must admit it was a little embarrassing (and a little amusing), when I offered a promised lollypop to my boys in front of a disapproving dental nurse, after they behaved exceptionally well at their first dentist visit.

Where possible I gradually phase out incentives when a desirable behaviour has become part of their everyday repertoire. For example, after a few weeks, I was able to stop offering the lolly to greet his kindergarten teacher and just use praise and finally I was able to phase out even the praise. These days I reserve praise for times when Damian voluntarily and spontaneously says ‘hello’ to his school mates. I’m so impressed that he has come so far with greetings.

2. Token Reward Systems

I have found the token reward chart to be highly effective for encouraging behaviours and tasks that the boys do not enjoy but need to do regularly, like homework.

Token systems, such as token reward charts, are often referred to generally as “Token Economy’ [9]. Token economy is considered to be a very effective form of encouraging specific behaviours in children generally but appears to have reduced in popularity due to changing social trends and the introduction of new approaches to teaching behaviours for children with autism [9]. Preliminary evidence suggests that token economies are effective for changing behaviours in children with autism [9,10].

Token Economy has been given more attention in recent times with regard to children with autism, with the realisation that involving special interests as tokens and rewards may have much greater value for learning tasks and behaviour change than traditional or social rewards and tokens for children with autism [10,11,12,13].

My token reward system involves placing tokens earned for displaying specific desirable behaviours on a board until a prize is earned. My boys receive ‘small prizes’ at specific intervals (after receiving 6 tokens) until their chart is full (4 lines of 6 tokens). When their chart is full they receive a ‘big prize’. They can choose from a variety of prizes although they usually pick the same things. Damian prefers lollies for a small prize and action figure of recent interest for the big prize. Jeremy prefers time (30 min) playing games on the iPad for his small prize and an iPad game app of his choice for his big prize (plus 30 min playing time). It’s important to get the ratio of number of tokens to prizes right to maximise your child’s motivation.

I use images from the internet that appeal to my boys such as dinosaurs and superheroes to use as tokens. I print off smaller versions of these pictures (right token size), laminate them and apply velcro so that they can be used as tokens instead of stars, smiley faces or other generic tokens which have less appeal for my boys. As a three-year old, Jeremy once insisted on throwing away the ‘smiley face’ tiles in a board game, in preference for playing with the number tiles only and Damian often refuses generic stickers offered by therapists as a reward for behaviour if they do not interest him.

My children get a pre-determined number of tokens for activities that they have reduced motivation to complete (as well as using other strategies such as social teaching where relevant and praise). Such activities include:

  • School readers
  • Other school homework
  • Speech therapy
  • Vision Therapy
  • Leaving the school playground after school when asked and without complaining excessively
  • Following two or three basic rules for when on play dates
  • Practicing skills that they find challenging such as bike riding

Finally, when using token economies it is usually recommended that you do not remove tokens as a punishment because they were hard-earned. It is best to use another unrelated system for applying negative consequences.

A Facebook friend recently shared a post on a parenting style that is popular among some parents. It involved avoiding applying any “unnatural” consequences, claiming that unnatural consequences are not only unnecessary but damaging to the child and the parent -child relationship. ‘Natural‘ consequences were allowed, such as pointing out how your child make another child unhappy as a result of his/her actions. The idea is that you child would then alter their behaviour in the future as a result of taught empathy. I consider this an extreme parenting style and I do not recommend it. You may recall that I suggested that some children may not respond as well to only social feedback so you can see how it may not work effectively alone with those children.

In general, parenting needs to be a flexible process, all children are different, all situations are different and I don’t believe that anything is ‘unnatural‘ (anything that happens is natural) much less providing consequences besides just social feedback and explanations.

I’m all for teaching my children how their behaviour affects others and I do, but at this stage in their lives I know it’s not going to be enough for them to give up a toy they really like that they snatched off another child (for example).

In the event of a ‘snatched toy’ in a public situation, I am more likely to apply strategies such as distraction (to a better toy or game) and/or apply the concept of ‘taking turns’ (using my phone alarm to indicate 5 minute turns) and I insist that they first give the ‘snatched toy’ back. This is in addition to explaining that they have made the child upset and it is not a friendly thing to do. If these methods have not been successful, I will apply a consequence such as saying firmly “If you don’t give that toy back within the count of three you will not be allowed to play the iPad today“. On top of that I also make sure they hand it over nicely, if they throw it, I’ll get them to pick it back up and pass it to the other child “nicely“. I did however have a problem on my hands the day a child bought a golden coloured ‘Thomas the Tank Engine’ toy train to PlayConnect playgroup when ‘Thomas the Tank Engine’ was a special interest and the colour gold was a favourite colour of my boys. I had to ask the mum to hide it and fortunately she understood.

There is another less popular form of consequence that I apply sometimes with my boys….

3. Time Out

Time Out involves the child having to leave a room or activity as a consequence for specific behaviours. Time Out also offers an opportunity for the child and the parent to calm down if upset.

I use Time Out to manage situations where my children have intentionally physically hurt one another or have refused to follow repeated routine requests (that I know they are capable of carrying out). In the case of physically hurting each other they get sent straight to their room immediately with no warning. However, for all other behaviours I give a warning that the next repeat of that behaviour will result in them being sent to their room or alternatively “If you do not do as I ask in the ‘count of three’ then you will be sent to your room for Time Out!” These warnings give them the opportunity to reconsider their actions. The ‘count of three’ warning when followed through with properly works very well with my boys.

Jeremy and Damian have a timer in their room that I set to the allotted time, which is almost always the number of minutes that equals their age in years. For example, 6 minutes for a 6 year old. The time does not start until they are quiet. If they start repeatedly yelling at me during Time Out then I start the timer again. After they have been quiet for the allotted time, I do find that their anger (and mine) has subsided and they are willing to do as I have asked.

What do you do if they refuse to go to their room for time out or leave their room during time out? I found an effective and simple method manage this. I simply say “If you do not go to your room in the ‘count of three’ then I will add one minute to your time out” If they have not gone to their room, after the count down, I confirm the new time and say “If you do not go to your room in the count of three then I will add another minute to your time out” and so on. This works without fail for me (the longest time I ever had to allocate was 20 minutes once). If it doesn’t for you then you can also consider taking away a privilege of some sort. I don’t recommend physical force to get them to participate in Time Out or keep them in the room during Time Out because it usually just makes them a lot angrier and encourages aggression.

When Time Out has been completed, the idea is to go about the days usual activities as if nothing has happened. I received most of my Time Out strategies from a very helpful child psychologist and she made it clear to me that she did not think it was necessary for Jeremy to apologize after Time Out because having to say ‘sorry’ may escalate the behaviour more. This works well for us. Click here for more information on Time Out.

Alternative behaviours to those that resulted in them being sent to their room, can be taught and encouraged separately to Time Out. It is best to teach behaviours in a positive way when your child is in a good mood using strategies like Social StoriesTM or role play rather than immediately after Time Out when your child may still be vulnerable to getting upset.

Recently, when attending a workshop for parents on managing challenging behaviour in children with autism, one of the parents asked the facilitator “When do we instruct our child to say sorry?” The facilitator replied “Our model is a ‘no discipline’ model”. The room was mostly silent in response to that, most of us probably thinking that doesn’t fit with our current parenting styles. The facilitator effectively implied that it was not recommended to punish our children ever.

Broadly speaking, punishment refers to applying negative consequence for the behaviour.

Punishment can involve taking away something that the person wants or likes and  even includes something as benign as not receiving the usual reward or token when an activity is not performed as requested. Punishment also includes instances where something undesirable is given in response to the behaviour, such as being given an extra household chore to complete. Time Out also acts as a form of punishment in that the child may be removed from activities or attention that they enjoy.

Punishment is increasingly becoming taboo in our society and yet many of us actually do punish our children sometimes for displaying behaviour that we do not like, in addition to using non-punishment strategies. Some researchers suggest that functional analysis of behaviour, followed by altering reinforcements of the behaviour and substitution with replacement behaviour eliminates the need for punishment [14].

However, according to an article by Vollmer (2002), regardless of changing social expectations and the availability of non-punishment options for managing challenging behaviour, punishment still happens, either unplanned or planned, whether socially mediated or not socially mediated [14]. Vollmer argues that to ignore what seems to be an inherent process of human evolution or existence is not perfect logic but how punishment can be applied to maximise the effectiveness of interventions within an ethical framework is yet to be fully appreciated and requires more research [14].

In particular, there is greater pressure from health professionals not to punish your child when they have a diagnosis characterised by communication or sensory challenges [15] because their behaviour is more often related to communication difficulties or sensory processing and  they may be punished for behaviours outside of their control at the time. That is why I wouldn’t apply Time Out to an autistic meltdown.

Unfortunately, researchers are failing to recognise when comparing the use of punishment between children with or without autism, is that behaviours in children without autism may also have the same function in a child with autism such as a communication challenge (remember from my first blog that the traits of autism are distributed in a continuous gradient across the whole population). In addition, a child with autism is not defined completely by autism and their behaviour may have similar functions to those children without autism on occasions also such as ‘testing the boundaries’ or ‘seeing what they can get away with’, so why wouldn’t we use punishment for those circumstances where the motivation for the behaviour is the same.

The fact of the matter is that punishment has been shown to be effective for changing behaviour and is especially useful when the participation in the behaviour itself is reinforcing for the child to continue with it such that it cannot be controlled satisfactorily in the short or long term [15]. Of course, I also use other strategies for my boys as well as punishment as my preferred methods for encouraging behaviour that communicates their needs better and modifying their environments to be more supportive.

I’m not sure if it is actually possible for a parent to raise a child who exhibits a large number of behaviours of concern with no punishment at all, ever.  Perhaps it is possible, but I can assure you that almost all of us apply punishment at some form or another when raising our children.

4. Positive to negative ratio of interactions and praise

I propose a theory on punishment frequency (and I am not referring to abusive punishments here but to punishments such as Time Out and withholding of rewards) whereby non-punishment strategies with positive reinforcement (praise and incentives) versus punishment should ideally reflect a ratio of 5:1 (or more) in application, approximating the ratio of praise/compliments to criticism for ideal performance/relationships that has been shown for working and romantic relationships [16, 17].

You don’t have to follow the ratio exactly; it’s just a theory very loosely based on only two articles that I read. The general idea is to have an overall heavy positive influence in our children’s lives.

Children with autism or communication difficulties or sensory processing difficulties often get so much criticism sometimes that it is likely to have negative effects on their self-esteem and relationships with significant others unless countered with even more praise for the things they do well.

I often find when my children and I are getting grumpy that a few hugs, a few games that they enjoy, a few compliments can set us on a course to a brighter day.

Click here for more information on the general benefits of praise and how to make your praise more effective.

One thing is for sure, researchers have not determined the ‘right’ way to raise a child yet and all children are different.

It is unlikely that our children will be severely psychologically damaged by loving parents who use primarily non-punishment strategies (such as teaching and positive reinforcement) but sometimes also use consistent non-abusive punishments (such as Time Out and withholding of rewards) that act as fair and reasonable consequences for specific behaviours that are based on ‘testing the boundaries’.

Keep in mind that a behaviour record chart can help identify the cause or function for/of the behaviour, and may reveal important triggers for the behaviour, which can also be avoided or minimized in the future.

Note: It is possible that these strategies may not be suitable for children with severe intellectual disability. Parents should use their knowledge of their child, to decide if their child is able to understand the concept of these strategies and benefit from them.

References:
1. Lane, A.E. Young, R.L. Baker, A.E.Z. Angley, M.T. Sensory processing subtypes in autism: Association with adaptive behavior. Journal of Autism and Developmental Disorders 2010; 40:112-122
2. Ben-Sasson, A. Hen, L. Fluss, R. Cermak, S.A. Engel-Yeger, B. Gal, E. A meta-analysis of   sensory modulation symptoms in individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders 2009; 39: 1-11
3. Lane, A.E. Dennis, S.J. Geraghty, M.E. Brief report: Further evidence of sensory subtypes in autism. Journal of Autism and Developmental Disorders 2011; 41:826-831
4. Koltko-Rivera, Mark. E. Rediscovering the later version of Maslow’s heirarchy of needs: Self-transcendence and opportunities for theory, research, and unification. Review of General Psychology 2006; 10(4): 302-317
5. Myers, S.M and Plauche Johnson, C. Management of children with autism spectrum disorders. Pediatrics 2007; 120: 1162-1182
6. Delmonte, S. Balsters, J. H. McGrath, J. Fitzgerald, J. Brennan, S. Fagan, A.J. Gallagher, L. Social and monetary reward processing in autism spectrum disorders. Molecular Autism 2012; 3(7): 1-13
7. Lin, A. Rangel, A. Adolphs, R. Impaired learning of social compared to monetary rewards in autism. Frontiers in Neuroscience 2012; 6: 1-7
8. Leaf, J.B. Oppenheim-Leaf, M.L. Call, N.A. Sheldon, J.B. Sherman, J.A. Taubman, M. McEachin, J. Leaf, R. Comparing the teaching interaction procedure to social stories for people with autism. Journal of Applied Behavioral Analysis 2012; 45(2):281-98
9. Matson, J. L and Boisjoli, J. A. The token economy for children with intellectual disability and/or autism: A review. Research in Developmental Disabilities 2009; 30:240-248
10. Charlop-Christy, M.H. and Haymes, L.K. Using objects of obsession as token reinforcers for children with autism. Journal of Autism and Developmental Disorders 1998; 28(3):189-198
11. Charlop-Christy, M.H and Haymes, L.K. Using obsessions as reinforcers with and without mild reductive procedures to decrease inappropriate behaviors of children with autism. Journal of Autism and Developmental Disorders 1996; 26(5):527-546
12. Boyd, B.A. Conroy, M.A. Mancil, G.R. Nakao, T. Alter, P.J. Effects of circumscribed interests on the social behaviors of children with autism spectrum disorders. Journal of Autism and     Developmental Disorders 2007; 37:1550-1561
13. Koegel, R. Kim, S. Koegel, L. Schwartzman, B. Improving socialization for high school students with ASD by using their preferred interests. Journal of Autism and Developmental Disorders 2013; 43(9):2121-2134
14. Vollmer, T.R. 2002. Punishment happens: Some comments on Lerman and Vorndran’s review. Journal of Applied Behavioral Analysis 2002; 35(4):469-473
15. Lerman, D.C. and Vorndran, C.M. 2002. On the status of knowledge for using punishment: Implications for treating behaviour disorders. Journal of Applied Behavior Analysis 2002; 35(4): 431-464
16. Gottman, J. M. (1994). What predicts divorce: The relationship between marital processes and marital outcomes. New York: Lawrence Erlbaum.
17. Losada, M. & Heaphy, E. The role of positivity and connectivity in the performance of business teams: A nonlinear dynamics model. American Behavioral Scientist 2004; 47(6):740–765.
http://endautismstigma.wordpress.com/2014/04/21/teaching-my-children-how-to-communicate-better-andor-a-general-guide-for-addressing-behaviours-of-concern-in-children/

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