Managing self stimulating behaviours associated with individuals diagnosed with autism.
Stereotypy or self-stimulatory behaviour is a repetitive body movements or repetitive movement of objects that self-stimulates one or more senses in a regulated manner (Miller, Jones and Walsh, 1996, p. 9). They are a normal developmental phenomenon, important as a part of child’s exploration and development (Murdoch, 1997). However, in people without developmental disabilities these self stimulatory behaviours usually decline over time or become hardly noticeable and socially acceptable.
Self stimulation is a common behaviour for individuals with developmental disabilities, however, it appears that it is more often reported as a behaviour associated with those who have been diagnosed with autism. In fact, if a person with another developmental disability exhibits a form of self-stimulatory behaviour, often that person is also labelled as having autistic characteristics.
Stereotypy can involve any one or all of the senses. The table below shows common examples, for each of the senses, of behaviours exhibited by people with ASD. The sixth sense of Vestibular awareness is also included (Edelson, 2008).
Sense - Self-stimulatory behaviours
• Visual - Flapping hands, blinking and / or moving fingers in front of eyes; staring repetitively at a light, rolling eyeballs
• Auditory - Making vocal sounds; snapping fingers, tapping ears
• Tactile - Scratching; rubbing the skin with one's hands or with an external object
• Vestibular - Moving body in rhythmic motion; rocking front and back or side-to-side
• Taste - Licking body parts; licking an object, placing body parts or objects in one's mouth
• Smell - Smelling objects or hands; sniffing people
These stereotyped behaviours could be thought of as a product of the person’s autism, however, Jordan (2001) points that there is no such thing as autistic behaviour. There are things that those diagnosed with autism really enjoy doing and are important for them. For those individuals who are hypersensitive or hyposensitive it can provide them with sensory stimulation and internal pleasure. There are also things that those diagnosed with autism do when they are under stress (Clements & Zarkowska, 2000). It is important for parents, careers, teachers and others who deal with these people to remember that being under constant stress is an inseparable element of their condition (Imray, 2008). Permanent anxiety can come from problems with communication, social interaction, transition, unexpected changes as well as panic, fears and phobias (Imray, 2008). For those diagnosed with autism it can led to a range of self-stimulatory behaviours as sometimes it is the only way known to them to reduce stress and bring the control of their world back (Jordan & Powell, 1995).
The range of anxiety can also come from some form of sensory sensitivity people with autism experience. A person's senses are either intensified (hypersensitive) or under-sensitive (hypo-sensitive), for example, a person with autism may find certain background sounds, which other people ignore or block out, unbearably loud or distracting. This can cause not only anxiety but sometimes even physical pain. People who are hypo-sensitive may not feel pain or extremes of temperature. Some may rock, spin or flap their hands to stimulate sensation, to help with balance and posture or to deal with stress.
If this is the way people with autism cope with the world around them, why do we want to change it or even eliminate it?
Some self-stimulatory behaviours may be health damaging and a danger to the wellbeing of the person with ASD and for that reason these behaviours need to be managed or even eliminated (Jordan & Powell, 1995). Others, sometimes not dangerous in themselves, may seriously interfere with the learning process, restrict access to important experiences or cause stress (Whitaker, 2001). Sometimes they can be highly reinforcing to the child and make other more adaptive behaviours less appealing and block further development. Some of those behaviours are not acceptable in our society and could be stigmatizing for the individual (Clements, 2005).
To better illustrate the subject discussed in this paper I will use a case study drawn from my own classroom. The name of the child has been changed to protect his anonymity.
Philip is 8 years old. He has autism and severe learning difficulties. He is developmentally quiet low functioning with very limited spoken language. Philip presents a very wide range of stereotyped behaviours associated with his diagnose. He very often engages in self stimulating activities such as rocking, hand flapping, wringing the hands whilst scratching his inner palms and making odd noises as well as head banging. Philip tends to take his shoes and socks off and then tickles his feet and/or smells them. He also likes to spin objects.
All these behaviours appear frequently and interfere with his ability to concentrate and learn. Some of these behaviours are also dangers for his health and are not socially appropriate.
When starting to think about the elimination or reduction of a particular behaviour it is important to ask whether the behaviour itself poses a real problem or is it just that we think that the behaviour is inappropriate and makes no sense and should stop (Clements & Zarkowska, 2000). We have to think very carefully whether to leave the behaviour alone or whether it is really to the person's advantage for limits to be set and the behaviours curtailed (Whitaker, 2001).
Having decided to deal with the behaviour one would like to reduce or eliminate, one should come up with strategies in the same way in which any other challenging behaviour is dealt with. To start with it is necessary to build up a picture of all the aspects of the environment in which the behaviour usually occurs. There is also a need to look for triggers which seem to spark the problem. It may be that the person is reacting to an unpleasant incident, sensory experience, unexpected change or transition and engaging in self stimulation brings him/her relief from the tension (Mason & Newson, 1990). This hypothesis is supported by accounts from individuals with autism, such as Donna Williams (1994). Although it maybe thought more likely that there is simply nothing really more interesting for the child to be engaged with (Nind and Kellett, 2002). It could also be the way of communicating a desire or need for attention, asking for reinforcement, for escape, or for sensory stimulation, an expression of frustration or happiness. This theory is supported by studies showing that stereotyped behaviours increase with increased demands on the person and decrease when alternative ways of communicating are taught (Carr and Durand, 1985).
Observing Philip in the school environment and talking to his parents and staff working with him led the team to come up with the most probable triggers which may cause Philip’s self-stimulating behaviours.
o Hand flapping and wringing the hands whilst scratching his inner palms emerge when Philip becomes excited
o Making odd noises, rocking and head banging appear when Philip is anxious, frustrated, doesn’t understand instructions, cannot communicate his needs, likes and dislikes, when he is asked to do things he doesn’t like or placed in a crowded/noisy environment overloaded by sensory experiences or when he does not know what is going to happen next or when his routine is disturbed
o Taking his shoes and socks off and then tickling his feet and/or smelling them as well as spinning things emerge when Philip is not engage in any structured activity. He takes real pleasure from doing this.
Once the team working with the individual “make sense” of his/her behaviour and answer the question “Why does this behaviour appear?” then an individualized plan that specifies the behaviours that are to be targeted for limitation and the process by which this is to be achieved should be devised. The answer should not only be to eliminate or reduce challenging behaviours discussed in this paper. In the long term, the plan should lead to a reduction in stress and to show to the individual better ways of occupying himself or herself and ways of dealing with anxiety (Whitaker, 2001). It is important to start with only one behaviour and not to try to change all of them at the same time. It can be highly confusing for the child and bring even more stress to his/her life. Self stimulating behaviours which can affect the child’s safety and wellbeing should be prioritised and dealt with at the very beginning.
When it is clear why the behaviour appears it is time to implement the methods that will be used to reduce or eliminate the targeted self stimulating behaviour.
There are different approaches to dealing with self-stimulatory behaviours; however, there are some general issues which have to be addressed in relation to beneficial support around all repetitive behaviours. It is important to begin with reassurances that the child lives, learns and plays within the environment which meets his/her needs and ability. It has to be certain that the method and the level of communication provided is understandable and accessible for the child (visual cues, objects of references) (Imray, 2008). It has to be as clear as possible that a child knows what is going to happen during his/her day to predict the stress which is very often caused by the lack of this information. That the goal can be reached by using schedules and timetables as well as other visual cues (Schopler & Mesibov, 1994). It could be also very helpful to decrease the level of stimulation and stress triggers. When creating a behaviour management plan all the individual’s needs and ability have to be addressed. It is important to plan it well and individualize.
Another essential part of the management strategy plan described above should be to make sure that
it is very clear what the person would be doing instead of presenting the challenging behaviour and it has to ensure that access to alternative behaviour is well structured (Imray, 2008). When it comes to working with autistic children punishment never works (Bogdashina, 2006). A lack of social imagination, communicative and interactive skills make it difficult for them to change by themselves. Finding and showing alternative behaviours is crucial as those diagnosed with autism find it very difficult to engage themselves in non- structured activity (Jordan & Powell, 1995). It is likely that the program will be unsuccessful if the person doesn’t know how to fill his/her time if he/she is unable to engage in self-stimulatory behaviours.
Knowing that people with autism struggle with a lot of anxiety and as a result they often engage themselves in self stimulatory behaviours it seems logical to start with teaching these individuals other ways of managing his/her stress. It is good to be aware that each person whether he/she has autism or not has his/her unique method of dealing with pressure and by taking it away and not teaching at the same time other ways of dealing with stress can be devastating (Notbohm, 2005). Stress in all people comes in the form of repetitive behaviour, however, repetitive behaviours presented by those diagnosed with autism are often considered socially inappropriate. These mechanisms of reducing stress can be reduced or even eliminated by providing an individual with ways of managing his/her anxiety. Teaching self calming strategies can be very beneficial and significantly change the quality of life for all people, not only for those diagnosed with autism (Clements, 2005).
The aim of self calming is not to let anxiety build up to its highest possible level where it can hardly be dealt with, but to provide the individual with some strategy/method of how to handle it before there is an outburst (Hewett, 1998). Self-calming strategies may include physical exercises such as breathing exercises or hand exercises.
When Philip became tense he was shown a symbol of “Break” by a member of staff and taken to bounce on a physio ball in another room. Having learnt the link between being anxious and having a break he has begun to use the symbol with only occasional prompts. Modelling his communication was the crucial factor.
Another method which can help in managing self-stimulatory behaviours is to find an indirect outlet for the behaviour which does not deliver the same experience as a current one but delivers something close to it (Whitaker, 2001).
To reduce the time Philip engages in tickling his feet and/or smelling them, school provided an aqua food massage machine which is available for Philip during non-structured activities. When Philip took his shoes and socks off, a member of staff would show a picture of the machine and Philip was encouraged to use it. He really likes it and recently he spontaneously started to ask for it. It significantly decreased the time when Philip was engage in this type of self-stimulatory behaviour.
The method, mentioned above, can be a good way to reduce those repetitive behaviours which are not socially acceptable and can become very stigmatizing for the child. Providing an individual with an alternative, more socially appropriate one can be beneficial for his social development (Clements & Zarkowska, 2000).
In order to reduce Philip’s hand flapping and wringing of hands whilst scratching his inner palms when he became excited the adults at school modelled a more socially appropriate behaviour. Every time when this kind of behaviour emerged and it correlated to Philip being excited, hand clapping was modelled by a member of staff. At the very beginning this was done with a small amount of physical support but very soon with only verbal encouragement and lots of praise. This resulted in hand wringing disappearing from his list of self-stimulating behaviours.
Philip still flaps his hands when excited but only for a very short period of time, followed by a smooth transition into clapping.
Even though we replaced an awkward behaviour with a more socially acceptable one there is still a need to set some limits on the time and the place the child can engage in it (Whitaker, 2001). If the behaviour is accruing most of the time then the aim should be not the immediate elimination but short period of respite. Once sensitive boundaries are in place we can gradually increase them until the level of the behaviour becomes acceptable.
Philip likes to spin things. He doesn't have a particular favourite toy which he likes to spin. The first goal was to determine the objects that were acceptable for him to spin. If he became engage in spinning an unacceptable object it was immediately replaced with an acceptable object.
These chosen objects was selected after observing Philip and kept in the box which was easily accessible by him.
Once the habit of using only these toys to spin was in place, a time frame of when it was acceptable to spin was also introduced using schedules with pictures.
Having set limits the behaviour itself might become a very powerful reward (Moor, 2002). Allowing self-stimulation as rewards helps to diminish the number of times in which the child engages in this type of activity but at the same time allows the child the comfort to be who he/she is.
When the person engages in stereotyped behaviour which is associated with one particular object it can be a good idea not only to find a replacement for a current behaviour but to expand the interest of the individual. Introducing new toys and developing social skills can really have a big impact on reducing self stimulating behaviours. Using social stories (Gray, 2000), modelling social interactions using schedules such as TEACCH (Schopler & Mesibov, 1994) or through role play can help to achieve these goals. Intensive Interaction is an alternative approach for working with individuals with complex difficulties that responds positively to the individual and their stereotyped behaviours, sometimes using these as a point of connection. Intensive Interaction sets out to develop social and communicative skills and not to reduce stereotyped behaviours, however, findings from research projects, shows some reduction in stereotyped behaviours (Nind & Kellett, 2002; Jones & Williams, 1998).
Another powerful tool in managing self-stimulatory behaviours is channeling attention to something else. However, we have to be extra careful to avoid reinforcing the behaviour we are trying to reduce by offering the child’s favourite objects (Whitaker, 2001). In this case it seems to make sense to redirect the child’s attention to the activity he should be doing at this particular time by reminding him/her to check his/her timetable or simply showing the picture, symbol or object of references (Schopler & Mesibov, 1994). To be able to do it we have to provide a high level of structure and a habit of using schedules. Many people with autism function better when activities are individualized, well planned, structured, communicated and delivered consistently. It is more likely that when there is unstructured, undirected time the individual will engage in self stimulatory behaviours.
In order to help an individual to manage his/her stereotypic behaviours we have to make sure that everyone involved is doing exactly the same thing. We have to be certain that there is consistency in what we are doing and what we want to achieve (Imray, 2008). The perfect situation is when all the organisations (home, school, respite centre) which deal with the individual are fully aware of the strategy and are able to implement it. However it is not always possible and sometimes we can only make sure that the consistency takes place within the school.
To summarise this paper I would like to point out the main factors of managing self stimulating behaviours. To start with it is necessary to establish why the behaviour appears. To do so it is crucial to have a good knowledge about the individual we are working with and his/her difficulties related to autism. We have to make sure that the environment where the person with autism functions is tailored to his/her ability and needs. The key to success is to provide the person with a new behaviour which can replace the one we would like to reduce or in some cases eliminate.
As per the case study shown in this paper it is achievable to succeed by complying with general rules when working with self-stimulating behaviours and individualising an approach towards any child’s ability and needs.
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