Understanding Autism and Positive Behaviour Support (focus on Tuberous Sclerosis)

Understanding Autism & Positive Behaviour Support Dr Tom Tutton Natalie Willis [email_address]

Content
Aspect
Autism Spectrum Disorders (ASD)
ASD & TSC
Positive Behaviour Support
Environmental modifications
Behaviour management
Antecedents
Consequences
Replacement behaviours
New Skills
Questions

ASPECT Board Aspect Adults & Behaviour Support CEO Accommodation Services Aspect Young Children & Families Aspect Education & Research Working Aspect Employment Services Community Participation CASS BIS Recipe for Success Central Coast School Hunter School Western Sydney School South Coast School South East Sydney School Vern Barnett School Research Far North Coast Centre for Autism Autism Information Line Building Blocks Early Intervention Diagnostic Assessment Service School Outreach Service Someone to Turn To Adult Outreach & Training

ASD: A ‘triad’ of impairments IMPAIRED COMMUNICATION 1 IMPAIRED SOCIAL RELATING 2 REPETITIVE BEHAVIOURS & RESTRICTED INTERESTS 3

1. Communication
Limited expressive language
Limited receptive language
Limited non-verbal communication skills
Use challenging behaviours to get wants/needs met Anxiety as unsure what is happening next or what to do and may look like non-compliance Miss and misinterpret non-verbal cues and hence may be seen as non-compliant or odd Social isolation, boredom, frustration Impairment Potential difficulty

2. Social Relating
Lack of interest in being social (socially aloof)
Difficulty developing / sustaining appropriate relationships
Difficulty understanding others’ thoughts and feelings and motivations
Lack of awareness of social rules / norms
Anxiety if forced to be in social setting Frustration, boredom, loneliness, depression Appearing insensitive and having difficulty reasoning or compromising, vulnerable Inappropriate behaviour

3. Restricted & Repetitive Behaviours & Interests
Inflexible adherence to non-specific routines and rituals
Attachments / interests that are unusual in their quality, intensity or focus
Stereotyped motor mannerisms
Difficulties coping if routines broken Behaviours occur if favourite object/interests are taken away or not available. Behaviours occur if stopped. Possible self harm

The Autism Spectrum Profound degree of impairment Mild degree of impairment Communication impairment Impaired social relating Repetitive behaviours and restricted interests

Associated Features
Hyper- & Hypo-
Sensory Sensitivities
Intellectual Impairment
Vulnerability to Anxiety / Depression
‘ Savant’ skills / Specific Learning difficulties
Seeking out or actively avoiding certain situations More difficulties understanding a task. May be seen to be non-compliant. Lack of motivation / actively avoiding situations Often perceived as being equally capable in all areas. Again may therefore be seen as non-compliant

What causes autism?
Autism Genome Project: 1168 families
Current hypothesis: roughly six major genes involved in autism, combination of mutations in any of these genes could contribute to the likelihood of being born with autism.
Evidence from twin studies
Environmental influences ?

Prevalence of Autism
1 in 160
3 year study commissioned by the Australian Advisory Board on Autism Spectrum Disorders concluded that 1 in 160 Australian children aged between 6 and 12 years have an autism spectrum disorder (ASD) - that is over 10,000 Australian children in that age group.
The report’s finding could be extrapolated to suggest that as many as 125,000 people may have some form of ASD in Australia. Given the difficulties faced by many families, then half a million Australians could be impacted by ASD.

ASD and TSC
Co-occurrence of ASD and TSC
“… features of ASD are seen in 25-50% of individuals with TSC ”
Wiznitzer M, (2004) J Child Neurol
“ The rate of TSC in a child diagnosed with ASD is about 1%”
Tuberous Sclerosis Alliance Fact sheet (2007)
Why?

Exercise Other Behaviour Social Communication

Underlying disabilities

Executive Function
Executive functioning is the ability to go about problem solving to reach a future goal
Abilities include: planning, organising, thinking of different options, not to be impulsive, being flexible in thinking and actions, monitoring progress, self regulation etc.
Evidence suggests that individuals with ASD typically have difficulties in this area
How might these difficulties increase the
likelihood of a challenging behaviour?

Different beliefs will result in a different way you approach and respond to a situation PERSON CAN’T DO V’s PERSON WON’T DO More likely to be constructive & positive More likely to use punishment Perception of the behaviour

Punishment
Punishment
Can be effective (only in the short term) ?
Can sometimes exacerbate / escalate the situation
Can have effects on the relationship between parent and child
Can influence the child’s self-esteem
Doesn’t teach a positive behaviour
Our definition: Reactive strategies that are aversive to the child

behaviour Before the behaviour After the behaviour 5 % of energy & expertise 95 % of energy & expertise POSITIVE BEHAVIOUR SUPPORT a proactive approach Behaviour may still occur but it will be weaker

 Visual Supports to:
Structure time
Structure activities
Structure environment
 Clear communication
 Sensory support
 Behaviour rules
Making environmental changes Schedules, routines & timetables Picture communication Choice Boards First -> Then Templates

What type of visual supports do I use?
Hierarchy of visual representation
Exercise – what types of representation of an object are there when communicating?
Exercise – put these in order from most to least concrete

Picture Written Structuring Time : Home First / Then board Timers Free Play Transitions ROUTINE

PHOTOGRAPHIC SEQUENCE FOR 2 MIN NOODLES Structuring activities : self help

Structure physical environment : templates

Reduce anxiety as the day is predictable
and understandable
Help prepare for change
Make non-preferred activities more acceptable
as preferred activities are scheduled too
Help increase independence and reduce
the need to be prompted frequently
How do visual schedules help prevent challenging behaviour?

 Rules can assist behaviour management  Rules should be supported visually  Rule following behaviour should be noticed and always be reinforced  Rules need to be limited in number, for everyone & worded in a positive way  Rules may help the person monitor their own behaviour Rules

DO use gestures, point, touching & printed visual supports
DO use simple familiar phrases & key words
DO express one idea at a time
DO give time to respond and expect a delay
DO wait 20 seconds if you need to repeat your message
DON’T talk without using visual supports
DON’T use complex language & long sentences
DON’T express more than one idea at a time
DON’T expect the person to respond immediately
DON’T repeat yourself too soon
Clear Communication

DO use simple, specific language “John, in the bus”
DO focus on WHAT TO DO
e.g. “Keep your hands and
feet to yourself”
DO redirect and engage the person in an alternate activity e.g. “Time for recess”
DO use consistent language
DO leave plenty of
silences & use pauses
DO say things in the order in which they will occur
DON’T use questions to give instructions e.g. “Are you
ready to go now?”
DON’T focus on what NOT TO DO
e.g. “No hitting walls”
DON’T overuse words like STOP, NO, WAIT, NOT NOW, SOON

DON’T change the way you say things
DON’T talk too much or too loudly
DON’T say ideas out of order

Alternative & Augmentative Communication
Makaton
AAC device e.g, Go Talk
PECS
Does not limit attempts at verbal communication

Picture communication Picture Exchange Communication System http://www.pecs.com/

Activity: Set the table
Person 1
Set the table according to the instructions given
Person 2
Set the table with the equipment given

OVER-SENSITIVITY (Hypersensitive)
An inability to block out unimportant sensory input, or too much processing of sensory input.
(Territory Health Services, 2000)
Sensory Sensitivity
Alter the environment to minimise exposure to the stimuli
UNDER-SENSITIVITY (Hyposensitivity)
“… the person receives too little information and therefore the event does not create an impression”. (Territory Health Services, 2000).
Sensory Seeking
Find appropriate replacement stimuli and build into daily routine
http:// www.otnsw.com.au/ot/ppdir.php Sensory support

behaviour After the behaviour Before the behaviour Antecedent Event = An event that occurs immediately before a challenging behaviour & “triggers” it. Step 1 : Antecedent events Specific Behaviour Management Strategies

behaviour Before the behaviour After the behaviour Behaviour may still occur but it will be weaker Consequence Step 2 : Identify Consequences Consequence = what happens after the behaviour that causes the behaviour to increase or reduce

Behaviour = communication
People communicate in the most effective and efficient manner available to them at the time
Some people have no way to communicate except through challenging behaviour
Some people have other ways to communicate, but no one listens to them unless they use challenging behaviours
Rocking / hand flapping Inattention Non-compliance Tantrum Self-injury Absconding I’m anxious I’m bored I don’t understand I want it now I can’t cope It’s all to hard This is nice I don’t get it I don’t like you Stop doing that Come over here Chase me!

Assessment of behaviour A ntecedent B ehaviour C onsequence Importance of collecting information

Step 3: Developing a replacement behaviour
Identify appropriate replacement behaviour or teach a new skill
Make the replacement behaviour / new skill
rewarding
efficient
easy
Build a positive rapport

Giving someone a ‘High 5’
is a replacement for
pushing them over
TARGETING ONE BEHAVIOUR OVER ANOTHER The objective of this strategy is to strengthen appropriate behaviours which “compete” with inappropriate behaviours.

Positive reinforcement : When something follows a behaviour that means the behaviour will happen more in the future because it is perceived positively  How to make the positive replacement behaviour more rewarding Mark goes to the toilet and is immediately given a chocolate teddy Sarah gets dressed for school in time and is given $2 for the school canteen Anthony finishes his high school homework & gets an extra 20 mins computer time at the end of the day + + +

Exercise: List your child’s top 5 reinforcers
Praise
Food
Toys
Entertainment
Quality time
Activities
Personal appearance
Sensory

Token Economies A token economy is a system in which an individual earns tokens for targeted behaviors. Once he has collected a predetermined number of tokens he can trade them for an item or activity that he desires. Advantages : delayed gratification, increased awareness of own behaviour, more natural way to reinforce behaviour Can be designed to be age appropriate

Teaching New skills
What skills?
Self-help
Social
Academic
Gross or fine motor
Play
Communication
Community

Teaching New skills: Self-Management 8:30 8:15 8:00 7:45 7:30      Joe Mum Joe’s the Boss in the morning 20c  Get into car 20c  Pack school bag  Brush teeth 20c  Have breakfast 20c  Get dressed

New skills: The Relaxation Game
Play the relaxation game. Try it with different muscle groups in your body:
ARMS : Be a “muscle man”! Then slowly let your arms go soft…
FACE : Make a funny face! Then slowly let your face
go droopy…
SHOULDERS & UPPER BODY : Give yourself a great big squeezy hug! Then slowly let your arms and shoulders go floppy…
LEGS : Lift your legs up off the floor (one at a time!). Then slowly lower them back to the ground and let them go floppy…

Questions Thank You

http://www.webicina.com	98
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http://inclusionstrategieswedmhw12.wikispaces.com	31
http://introsouw12.wikispaces.com	17
http://hfspbs.blogspot.com	12
http://www.atss.org.au	1
http://legalrn.blogspot.com	1
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Understanding Autism and Positive Behaviour Support (focus on Tuberous Sclerosis)

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Understanding Autism and Positive Behaviour Support (focus on Tuberous Sclerosis) — Presentation Transcript