5 insights into the behavior of children with autism

Autism Behavior Intervention Strategies

Behavior challenges are very common among children with autism spectrum disorder (ASD). As with any child, the causes of their behavior—and the best ways to respond—may not always be what they seem.

Dr. Casey Clay, director of the Behavior Program at the Thompson Autism Center at CHOC, explains five of the most common misunderstandings about autism and behavior. You’ll learn healthy autism behavior intervention strategies for challenging behavior.

Dr. Casey Clay, director of the Behavior Program at the Thompson Autism Center at CHOC
Dr. Casey Clay, director of the Behavior Program at the Thompson Autism Center at CHOC

1. Children with autism don’t often “misbehave.”

At first glance, behaviors in a child on the autism spectrum might appear to be discipline problems, such as:

  • Yelling
  • Running from the room
  • Hitting others or themselves
  • Refusing to listen or sit still

“When a child with autism shows what we call maladaptive behavior, in the majority of those cases, the child is doing that to communicate something,” Dr. Clay says. “They’re really not having their needs met, so they have to engage in behaviors because that is going to get them what they need.”

2. Behavior is changeable.

Another myth about behavior is that it is part of a child’s personality and diagnosis, and therefore can’t be changed. As with any person, children with autism can adapt their behavior, with the right help.

Applied Behavior Analysis (ABA) is one of the most effective interventions to change behavior, and it is backed by evidence-based research. Through ABA, therapists can determine a child’s preferred items, activities and ways of communicating, as well as the unique triggers and consequences that are influencing a child’s behavior.

For example, if a child wants to be left alone but can’t express it vocally, they might be able to select a card that says “alone” or touch an icon on a tablet that says “alone” instead.

“The goal is to stop the behavior it before it happens,” Dr. Clay says. “We can change the environment so it addresses their needs and sets them up for success. ABA is highly individualized and in doing that, we respect the individual and their needs and preferences.”

3. Punishment is not the answer.

Researchers have shown that positive reinforcement and rewards are more effective for overall better behavioral outcomes than punishment alone, for all people, not just children with autism.

Try to look for examples of your child showing appropriate behavior and praise them when you catch them doing something well. For example, tell them, “I love how you shared that toy, I love how you waited your turn or I love how you asked me very nicely.” You can also practice a desired behavior by role-playing and reward your child for putting in the effort.

4. Children with autism are not always averse to social interaction.

If interacting with a child with autism causes them to behave inappropriately, the assumption may be that they don’t like interaction. In fact, they may just prefer a different type of interaction.

“Although those challenges exist, some social interactions are really rewarding for them,” Dr. Clay says. “It’s a matter of seeing what they prefer and approaching them or communicating with them in that way. They may not like physical touch, but instead they might like to talk about a preferred topic like baseball cards. If they like a thumbs up or a high five, those things might be better than a hug.”

5. Parents, it’s not your fault.

Parents and caregivers often come to Dr. Clay feeling guilty about their child’s behavior. While changing behavior does require a lot of parent involvement, there is nothing they’ve done to cause a diagnosis of autism.

“We are here to help families, and that starts with understanding why and when challenging behavior is happening, and how to move forward,” Dr. Clay says. “Your child can adapt, as we all can, and reach their goals in life. It starts through small steps, but usually leads to large improvements.”

Learn more about the Thompson Autism Center at CHOC.

5 strategies to help children with autism and feeding difficulties

By Amanda Regan, CHOC clinical dietitian

Picky eating is something often seen in children as they grow and explore new foods, but research shows that children with Autism Spectrum Disorder (ASD) can be five times more likely to develop feeding difficulties. This is often caused by sensory processing difficulties, which can cause a child to be sensitive to different tastes, textures, smells, appearances and even temperatures of food. Many children with ASD also tend to prefer foods that are processed and high in carbohydrates, rather than fruits and vegetables. Kids with ASD may also have a hard time focusing during mealtimes, causing them to consume inadequate amounts of calories and nutrients.

Managing these types of feeding difficulties can feel overwhelming for any parent. However, it is important to stay calm and make sure mealtimes don’t turn into a battle ground. If you have a child or loved one with ASD, here are some strategies that you can use.

Rule out medical problems

Sometimes children may refuse foods because they’re struggling with another condition, such as food allergies or constipation. If your child has extreme food selectivity, it is important to seek advice from your pediatrician to rule out any other medical conditions. Your pediatrician can also help refer you to any other services your child may need, such as feeding therapy, a GI specialist, or a dietitian.

Take small steps

Taking baby steps to introducing new foods can make a huge difference. You can start this by familiarizing your child with new foods even outside the kitchen. Try teaching your child about the new food or go to the grocery store together to buy it. Later, you can start to ask your child to take small steps to eating it by smelling, licking, touching and finally tasting the food.

Expose and repeat

Remember, sometimes it can take 15 to 20 times before any child accepts a new food. If your child consistently refuses a new food, try to serve it in a different way. It’s also important to remember that sometimes kids just simply don’t like a certain food. If your child continues to reject a food after 15 to 20 exposure times, don’t be discouraged, and move on to offering a new food.

Something old and something new

When introducing new foods, pair them with other foods your child already enjoys. This can help your child to feel more comfortable during the meal. Your child may also want some sense of control when it comes to choosing foods. Try to allow some options, such as letting them pick which veggie they want to try, or which preferred food they want to pair with the new food.

Minimize pressure

Adding pressure to eating or force feeding can make mealtimes even more stressful for you and your child. Try to maintain a positive atmosphere during meals. Children with ASD may need extra time to expand their diet variety. This means it is important to be patient and allow your child to take bites of new foods at their own pace.

Explore autism resources at CHOC.

A day in the life of a pediatric psychologist who supports children with autism

As a pediatric psychologist, Dr. Jina Jang spends her work days supporting children who are receiving care at the Thompson Autism Center at CHOC, a centralized place for children to receive early diagnosis, advanced therapy and the possibility to reach their full potential.

Dr. Jina Jang, CHOC pediatric psychologist

Follow along for a day in the life of Dr. Jang

6:45 a.m. – If my alarm goes off before my 2-year-old wakes me up, it’s a lucky day. I get ready, feed my dog, and ensure my kid’s bag is ready for daycare. I go over my daily schedule with my mother, who helps with daycare drop-offs. If I have time, I usually stop by a coffee shop to pick up some much-needed caffeine.

8:15 a.m. – I arrive at the Thompson Autism Center at CHOC before my first patient is scheduled and quickly check messages and emails. On days that I arrive a little earlier, I will usually sit for a few minutes to admire the beautiful artwork throughout the center. A bubble theme is woven throughout the center’s artwork, and CHOC’s mascot, Choco Bear, is even hiding in a few of the bubble images. This artwork was among the many special considerations made when the center was being built. The center is designed throughout to ensure sensory experiences and transitions, lighting, stimulation spaces, signage and artwork are best suited for people with autism spectrum disorder (ASD).

Dr. Jang enjoys admiring the artwork in the Thompson Autism Center at CHOC, which was designed throughout to ensure sensory experiences and transitions, lighting, stimulation spaces, signage and artwork are best suited for people with autism. | Photo taken before COVID-19.

8:30 a.m. – My first patient arrives for an in-person evaluation. Today, we have a patient who was referred by their pediatrician for an ASD evaluation. We had an intake session via telehealth yesterday. This is a new hybrid appointment model designed to help limit in-person contact as much as possible during the COVID-19 crisis, but ensure we still see patients who need in-person testing. This morning, we will conduct testing to assess the child’s overall developmental functioning. We will also assess for symptoms of ASD using standardized observation and interaction.

10:30 a.m. – I have a phone consultation with one of my patients’ applied behavior analysis (ABA) therapists. Children with ASD often have many different care providers and it is important for us to work closely with them to ensure collaborative care with continuity and compassion.

11:30 a.m. – I conduct a therapy session via telehealth with a patient as part of the center’s co-occurring conditions program.  Children with ASD often have other medical conditions as well, and this program helps patients get all the care they need in one visit.  I am co-treating this patient with Dr. Jonathan Megerian, a pediatric neurologist and the Center’s medical director. Having all providers at one visit not only reduces the amount of stress and other barriers for our patients,  but it also allows us providers to map out the best treatment plan for our patients.

At the Thompson Autism Center at CHOC, children with co-occurring conditions may be seen by pediatric specialists and psychologists to help treat their ASD and other underlying conditions. Seeing all providers at one visit can not only reduce the amount of stress on the family, but it also allows providers to talk together and map out the best treatment plan for a child. | Photo taken before COVID-19.

12:30 p.m. – Time for lunch! Before the pandemic, I would go out to lunch with my colleagues or pick up takeout for us to eat together. These days, I usually just eat alone in my office. Dr. Megerian is usually my lunch buddy. He is not only a great mentor but a fun friend. He has guided our team every step of the way, providing invaluable guidance and advice. I feel truly blessed to have such an amazing work family. Although we can’t share a meal in the same room due to physical distancing precautions, we still try to get lunch together. Today, he picked us up chicken sandwiches from a restaurant next door.

1 p.m. – When I have some time between appointments, I catch up on notes and review reports from my psychology trainees to provide feedback. The trainees are pursuing post-doctoral fellowships and honing their training and education to work with children with ASD in the future.

1:30 p.m. – I have a meeting with the team. Today, we evaluated our current assessment flow with the entire team, including our wonderful medical assistants, nurses, resource specialists and social workers. As a new center, it is important for us to continuously evaluate our clinic flows and assess what is working and what needs to change. Also, I am in communication with the entire team, which also includes other psychologists and financial coordinators, all throughout the day.

The Thompson Autism Center at CHOC’s highly trained clinical team includes pediatric neurologists, psychiatrists, psychologists, developmental behavior pediatricians, occupational therapists, speech language pathologists, applied behavior analysis (ABA) therapists, child life specialists, social workers, nurses and more. | Photo taken before COVID-19.

2 p.m. – Now I’m meeting with our assessment team about the young patient I met with earlier today. After meeting with the psychology team, this patient and family also met with one of our developmental behavioral pediatricians and also had speech and occupational therapy evaluations. Our amazing child life specialist helped ease any fear or anxiety the child and family may have felt throughout their appointment. The purpose of this team meeting is to discuss test results and diagnostic impressions, and make recommendations as a multidisciplinary team.

2:30 p.m. – Next, we meet with the patient’s family to provide feedback. As a team, we typically provide feedback on the same day as assessment. This child received a diagnosis of autism and global developmental delay. It is never easy to be the first ones to tell a parent that their child has developmental delays. However, our goal is to provide families with comprehensive testing results and treatment recommendations without a delay. We understand that this new diagnosis may be overwhelming and stressful for our families. After a diagnosis, they get connected with our social workers and personal service coordinator to continue support with additional resources.

The Thompson Autism Center at CHOC offers a true family-centered approach. Support groups for parents, grandparents and siblings offer a place for families to support one another and learn everyday tips on how to juggle doctors, school, work and family life. | Photo taken before COVID-19.

3 p.m. – On to another therapy session.  Now, it’s a patient with ASD, attention deficit hyperactivity disorder, and sleep difficulties. For this patient, we created some tools and systems to help.

Many of our patients and families have experienced disruptions to their daily routines due to the COVID-19 pandemic. It’s crucial that we help families and children cope with disrupted routines; establish “new” routines; teach “new” norms like wearing masks and keeping distance; and teach families strategies to manage any increased challenging behaviors.

4 p.m. – My last session is a follow-up meeting with a patient with ASD who is also experiencing separation anxiety. We have been working on exposing the child to small, controlled moments of separation with hopes that will reduce anxiety over time.

4:30 p.m. – I have a one-on-one meeting with Matthew Lazari, the center’s executive director. My check-in meetings with Matt usually involve picking his innovative and smart brain to address any challenges we might have. Today, we talk about screening candidates for a new psychologist position.

5 p.m. – I send messages to patients through CHOC Link, a portal for CHOC patients and families to communicate with caregivers. I also check emails and check my schedule for tomorrow. With that, I say goodbye to my colleagues and head home to my family.

Tips to foster a happy holiday season for children with autism

Amid stay-at-home orders, remote learning and other changes caused by the COVID-19 pandemic, many families are faced with finding different ways to celebrate the holiday season than they’ve done in years past. The holiday season can still be a joyful time of the year. For families with a child who has autism spectrum disorder (ASD), following a few tips from the Thompson Autism Center at CHOC can help ensure everyone enjoys the festivities in their own way.

Activities

Holiday breaks often mean big changes in schedules and routines, which results in things becoming much less predictable. This can often result in the child being more anxious, less able to tolerate frustration, changes in eating/sleeping patterns, as well as impacting a variety of other triggers that may result in challenging behaviors.

To help your child, provide a visual schedule of each day, with start times and end times. Use visual timer apps, “First This Then This” schedules and personalized “social stories” to help prepare for activities. Try to maintain your child’s standard bedtime and mealtime routines.

Decorations

Instead of decorating your entire home all at once, decorate gradually. Look at pictures from previous years to help your child prepare for the change. Avoid overly bright or blinking decorations and strong scented candles. Create a holiday-free zone — such as your child’s room —for your child to come back and use as a “safe place” when necessary.

Gifts

Children with ASD can especially benefit from toys that involve social interaction, encourage turn-taking and build language skills. Give other family members a list of gifts your child might like.

Some children on the spectrum tend to repetitively talk about a gift that they want. To help set boundaries, offer your child three tokens that they can redeem each day to talk about the gift they want.

Opening gifts can be overwhelming for those on the autism spectrum. Video modeling is an evidence-based way to teach your child what to expect and how to behave. Take a video of family members opening presents, taking turns and saying, “Thank you,” and watch the video several times in advance. Also consider wrapping something familiar if your child does not enjoy opening new presents.

Traditions

Choose a tradition that is important for you and your family. Try not to get caught up with keeping old traditions. Create your own family traditions that follow COVID-19 safety precautions and are easy and fun for everyone, like decorating the house or tree using your child’s preferred items and participating in sensory-friendly programs.

“There are many ways to help your child cope with the hustle and bustle of the holiday season,” says Dr. Jina Jang, pediatric psychologist at the Thompson Autism Center at CHOC. “The most important thing to remember is that your child will enjoy the holidays in their own way, even if it’s different from how others enjoy them.”

Tips for involving your child with ASD in the kitchen

Cooking as a family this Thanksgiving can be an enjoyable experience for all parents and children, including those with challenges related to autism spectrum disorder (ASD) such as food aversions or sensory issues. With a bit of planning, the experience can be fun, and help strengthen important skills. The Thompson Autism Center at CHOC offers these tips for involving children with ASD in the kitchen.

Safety first

Talk to your child about the importance of food safety and hygiene. Take the time to explain the danger of sharp knives and hot stoves. Demonstrate hand-washing and have your child practice good hand-washing side-by-side with you before handling any food.

Prepare in advance

Before the cooking begins, spend some time explaining new or unfamiliar words that may be used in the kitchen, like the ingredients and tools you’ll be using. Understanding the vocabulary can make the cooking experience more enjoyable for your child.

Avoid sensory overload

Cooking engages all the senses, which may be overwhelming for children with ASD. Try to avoid using noisy appliances or cooking with strong-smelling ingredients. Allow your child to wear food-safe gloves if they are uncomfortable touching foods with different textures. Try to expose your child to one new physical texture, such as gooey pie dough, and make a game of it.

Choose a favorite dish

Children with ASD are more likely to have food aversions. Involving your child in the kitchen is one step toward tasting new foods. Start by cooking something your child loves to eat. This could be as simple as a sandwich or pizza. If your child wants to eat what they are cooking, they are more likely to be engaged in the preparation.

Keep it simple

Try a recipe that is on the simpler side without a lot of steps. If visual supports are helpful for your child, — like they are for many children with ASD, — use pictures to show the steps of the recipe. Avoid too many activities with complex steps or motor tasks if those are challenging areas for your child. Chopping is a simple activity to try, and it’s a good way to improve fine motor skills. To help your child chop, put your hand over your child’s hand to help them maneuver items.

Complementary tasks

Give your child tasks that complement their strengths. For example, if your child is good at measuring, have them start by measuring ingredients. By mastering the easier skills and gaining confidence, accomplishing the harder task will be a much more enjoyable process.

“Cooking is a skill that can help a child with ASD gain independence as they get older,” says Dr. Tom Megerian, pediatric neurologist and medical director of the Thompson Autism Center. “It offers a chance for social interaction, lets children feel pride in their work and also may help broaden the range of foods they are willing to eat, as they taste their work. But even more, it is a way for you and your child to connect.”