Quote of The Day

“During any moment of any given day, I’m either obsessed with what I’m doing or bored with what I’m doing.”

–Student with Asperger’s explaining the difficulty navigating everyday activities.

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“Cats Are Autistic Dogs” Part II: Notes on Asperger’s

The response in my office and on the web has been so positive to my previous posting on Asperger’s features, that I thought I would share some more thoughts.  I would also like to thank the people over at CafeMom.com for adding my blog to their impressive Autism/Asperger’s/PDD awareness group.

• Aspies are usually the offspring of Asperger’s fathers who are socially shy and usually have careers in engineering, computers, accounting, or the math/science fields.  The moms of Aspies tend to be teachers, social worker types who are very outgoing, social, and often Type A or ‘organized’ personalities.
• Siblings of Aspies tend to be gifted/talented, have ADHD or OCD features, or even have anorexia diagnoses (there is a perfection element somewhere in the gene pool).
• Group projects in school are one of the biggest difficulties because of the social element.  This is the same reason why Aspies do so well in solitary occupations like computer programming but then begin to struggle when they are promoted to management.  Aspies do not manage people and social interactions well.
• We don’t give Aspies enough credit for how hard they work during the school day.  They keep it together during school and then ‘fall apart’ or are completely exhausted when they return home.  They work at least three times as hard to keep up with the social environment inherent in the school setting.  REMEMBER: Aspies need to learn both academics and social skills in school while neurotypicals only need to learn academics (the social aspect comes naturally).  Imagine the energy differences between the two groups after the same school day!
• Aspies in history were found in monasteries or were carpenters, jewelery/watch makers, and explorers.
• Young Aspies may look like children but they act like adults.  Their social difficulties attract bullies as well as female peers who are the ‘caregiver’ type.
• We usually make the error of telling Aspies, “I shouldn’t have to tell you…” when in fact we have to instruct them every step of the way when it comes to social interactions.  Remember to use logic, not punishment.
• Aspies value intelligence more than anything.
• When trying to get an Aspie to stop a behavior, use their desire for intellect to your advantage.  For example, if your child has difficulty sharing, try telling him, “Smart people share.”  Sometimes Aspies will hear foul language and repeat it without knowing the meaning behind it.  Telling the child, “Smart people don’t use those words” will usually do the trick.  The other technique is to exaggerate your response to the word such as holding your hands over your ears if your child repeats something inappropriate and yelling “Ouch!  That hurts my ears!”
• Aspies often tune out during class lectures or social situations because their thought is, “If this is not one of my strong interests then why should I involve myself with it?”
• The rigidity in thinking inherent among Aspies also creates difficulty converting thoughts and emotions into speech (communicating feelings) as well as getting thoughts from one’s head onto paper for a report in school, for example.
• As the chronological age of the Aspie increases, the emotional, maturational, and social development stays at a younger level.  Younger neurotypical siblings will eventually surpass their older sibs in social and emotional development.
• Aspies look at the action, not at the motives of the action.  So when they are ‘hit’ by a peer who was giving them a joking tap on the shoulder, they tend to retaliate because their thinking says, “He hit me, I ‘m going to hit him back!”  Guess who ends up in the principal’s office?
• The nature and severity of Aspie symptoms vary dramatically from day-to-day.  This is a ‘swiss-cheese’ developmental presentation with no clear, consistent pattern.  This not only complicates the diagnosis, but schools often try to argue that a child does not have Asperger’s because of having ‘good’ days at times.  They also say things like ‘he is so smart’ or ‘he makes good eye contact.’  Parents often know that a particular day is a ‘good one’ versus a full-on ‘Aspie day’.  Also, full moons actually seem to have an effect on severity of symptoms!
• Aspies misinterpret behaviors.  An adult may raise their voice to be heard in a crowded room or to make a point.  An Aspie will always see shouting as anger and thus the reasons for raising one’s voice must be explored in depth.
• If your Aspie child is upset, consider the following:

• People are confusing to Aspies.  Thus, you want to eliminate the social context when the child is upset.  This is not the time for a face-to-face chat…face the wall if you need to!  (Dr. Mark sits to the side of the child and speaks in the same direction the child is looking..don’t worry about eye contact at this moment!).
• Tell the child, “I don’t need to know what happened right now.”
• Keep emotionally calm yourself.  Adding your own emotion at this time is like pouring gas on a fire.  Be sure to tell the child, “I’m not upset with you.”
• Begin helping the child to calm down by suggesting closing their eyes, deep breathing, and other relaxation strategies.
• Compliment the child and give them something to look forward to.  “I think you handled this situation with intelligence and I know that the next time you are upset you will do another good job.  What do you say we go look at your book of the planets?!”

• Children with Asperger’s should be allowed to complete a project on emotions/social skills at least one hour each week while in school beginning in Kindergarten through 12 years of age.  Schools need to do a better job of teaching these children the Hidden Curriculum.
• For every hour an Aspie is social, they need about an hour to unwind and decompress.  Thus, there is not enough time to unwind after a full school day.  Ever wonder why the stress level is so high during the school week?  How about the trouble getting homework completed?

Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

“Cats are Autistic Dogs”: Notes on Asperger’s

The title of this posting is taken from Dr. Tony Attwood’s discussion on Asperger’s last week.   As indicated in a previous posting, I had the opportunity, or shall I say privilege, to spend an entire day hearing Tony speak his thoughts on Autism and more specifically Asperger’s Syndrome.  I thought I would share some talking points as they relate to Asperger’s for those of you who were unable to attend.  Please note that the term ‘Aspie’ is not derogatory and is instead embraced by many individuals with Asperger’s when describing themselves.

• Aspies use intellect, not intuition.  Only logic works when trying to discipline…punishment does not work!
• Handwriting is a huge problem for Aspies, but handwriting is a 19th Century skill.  Teach kids to type!
• Aspies may tune out because if it is not one of their key interests, then why learn it?
• Preoccupation with specific topics of interest produces euphoria and enjoyment that Aspies cannot obtain otherwise.
• Girls are able to hide their symptoms so well that diagnosis may be missed or delayed as much as 10 years.  Girls will often escape into imagination, fantasy, and fiction and “pretend to be normal.”
• Asperger’s includes all neurotypical characteristics magnified to the most extreme degree.
• There is a compulsion to complete tasks that Aspies experience which makes transitions difficult.
• Aspies generally DON’T learn from mistakes..and they don’t naturally know what else to do when faced with a challenging social situation.
• Anxiety begins to be expressed in the form of avoidant or controlling behaviors as a means of coping with uncomfortable feelings.
• When emotions run high, there are three ways Aspies try to repair them: 1) Aggression/Rage, 2) Isolation, and 3) Avoidance via heightened special interests (e.g., video games).
• Sadness and anxiety are expressed by Aspies in the form of anger, especially in school when Aspies are not allowed to use one of the above three ways of coping/repairing heightened emotions.
• For Aspies, anger is the ‘acceptable’ way to express sadness.  It also allows the individual to get the uncomfortable rise in emotional feelings over with by exploding and then feeling better quickly as if nothing ever happened.
• Top three trigger words guaranteed to get a rise out of Aspies: 1) No, 2) Wait, and 3) Change
• An Aspies’ need for affection can fit inside a cup.  A neurotypical’s need for affection can fit inside a bucket.
• Aspies generally have an intense dislike for public praise.
• ‘Cats are Autistic Dogs’ is an observation by Attwood meant to illustrate the differences in social abilities/interests of the two animals.
• For More on this Topic, view Part II of this post here.

Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

Autism and OCD in Children

Autism Spectrum Disorders (ASDs) and Obsessive-Compulsive Disorder (OCD) can and do occur at the same time.  OCD is a specific diagnosis under a larger umbrella of anxiety.  Children with OCD experience unwanted and intrusive thoughts that they can’t seem to get out of their heads (obsessions), often compelling them to repeatedly perform ritualistic behaviors and routines (compulsions) to try and ease their anxiety.  Children with ASD generally have repetitive, perseverative thoughts that are intense in nature, much like children with purely OCD symptoms.  The big difference is that children with OCD do not like the experience of having repetitive thoughts and would do anything to get rid of the thoughts (such as washing one’s hands 25 times).  Children with Autism Spectrum diagnoses are not bothered by their repetitive behaviors and thoughts, and instead are usually comforted by them (such as playing with a train in a repetitive fashion for hours at a time).

Anxiety is highly prevalent among children with Autism Spectrum diagnoses (greater than 35% of children experience both).  This is due to a combination of genetics, brain development, and higher levels of stress.  The error that many schools and therapists often make is attributing a child’s anxiety symptoms to his or her Autism diagnosis (i.e., “The only way to really reduce  anxiety and aggression is to treat the Autism.”)  For example, many children are referred into social skills groups when what they really need is help with anxiety that is interfering with their social functioning.  Highly anxious children with OCD may begin to act out behaviorally in school prompting teachers to encourage (some might say ‘coerce’ or ‘force’) parents to begin medicating the behavior.  The concerns here is twofold: 1) the behavior is numbed with medication and the root anxiety is never truly addressed (i.e., stop the medication and everything returns to the way it was), and 2) the school may begin to implement safety nets such as increased para support to keep the behaviors from occurring while again failing to adequately address the underlying anxiety symptoms.

The question often asked is, “Can you really treat a child who has both an autism spectrum diagnosis and OCD?”  The answer is “yes” and new research is beginning to show that there are some exciting recent behavioral treatments out there for these children.  Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for anxiety that has been established by the American Psychological Association as effective for children.  A recent study of CBT for neurotypical children with anxiety (Wood et al., found):

• Childrens’ school performance improved & they attended school more regularly
• Children had more friends & better quality friendships
• Children got along better with family members
• Children had higher self-esteem

The authors of that study have adapted the neurotypical CBT protocol for children with autism spectrum and are finding some promising results.   In general the results suggest that the authors’ adaptations of the pre-existing CBT manual can be effective for treating anxiety such as OCD in children with autism (research article link).  This treatment manual is available to practitioners and families, a sample of which can be viewed here.   Thus, there is hope for effective anxiety treatment for your child who also has an autism spectrum diagnosis.  It is highly recommended that you seek out services from a pediatric specialist who has training and experience treating children with co-occurring anxiety and autism spectrum diagnoses.

On a personal note and aside, I will be spending tomorrow with noted Asperger’s guru Dr. Tony Attwood  so stay tuned for a blog later this week where I hope to share some new ‘nuggets’ of information.

Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

© 2009 Mark Bowers, Ph.D.

Scripting and The Autistic ‘Veil’

The nature of Autism is the brain’s desire to keep the world the same.  This is why one of the hallmark diagnostic features of Autism is repetitive, perseverative, and stereotypical behaviors.  One of the most common is scripting in which the child takes dialogue that he or she heard someone else say (usually a favorite cartoon or television character) and applies it in a repetitive and often nonfunctional fashion.   Scripting is often referred to as a Comfort Zone behavior.  This posting attempts to provide some strategies for how to deal with scripting as well as some reflections on the nature of Comfort Zone behaviors.

For children with Autism, the Comfort Zone is what the child will do when you let them do whatever they want to do.  Examples include: playing with/lining up cars, watching portions of the same video, flipping through familiar books, scripting, opening/closing doors/drawers, visually stimulating on an object (e.g., spinning), and staring off in the distance as if in a trance or daydream.  By the way, ever wonder why the fascination with trains?  The answer is that there is not likely anything much more linear and repetitive than a train going from one place to another and then back again.  I digress, so in this comfort zone, children are not connected or engaged with the world.  In fact, by the time kindergarten starts, one measure of school readiness is that the children are connected with the social environment most of the time and turn consistently to their names.  You probably notice that your child does not turn to his or her name being called consistently if they are absorbed in a particular activity.  If your child is ‘stuck’ inside their comfort zone and not paying attention to the environment, not easily engaged, not able to interact in a back-and-forth fashion; then they are going to need help leaving this comfort behavior for longer periods of time (i.e., you will need to engage them more and not allow them to be off on their own in a perseverative or repetitive behavior).  The key to remember here is that as engagement with others increases, perseverative/repetitive behaviors such as scripting decreases.  Thus, we must be aware of when the child is in his or her comfort zone and not allow them to remain there for too long.

I do want to take a moment to acknowledge, however, how it must feel for a parent to see the Autistic ‘veil’ drop in front of the child’s eyes as they check out from the real world for a moment and become absorbed in a repetitive behavior.  Especially for parents who have been working with their child for a number of months or years and have begun to see progress; the child’s return into scripting and other stereotypical behaviors is a glaring reminder that the child has Autism.  It also serves as a reminder to the world that something is not quite connecting in the child’s brain.  I often conceptualize this as a neurological tug-of-war that is taking place inside the child’s brain.  The hardwiring of the Autistic brain is determined to keep the world simple and the same, with little (if any) interest in relationships or social connections.   However, as the child makes progress and begins to learn how much fun can be had with others and the value of having play partners, another part of the brain begins to compete for dominance.

I see a similar phenomenon take place among children with OCD that I treat.  They experience what I refer to as “brain hiccups” that play tricks in one’s mind, often convincing the child that unless he washes his hands 15 times in a specific fashion, for example, something awful will certainly happen.  This thought will not go away (hence the ‘hiccup’) until the child engages in the ritual of the brain’s liking.  What these children describe to me, however, is the rational part of their brain telling them that they don’t really want to have to wash their hands that many times (or at all for that matter) to make the thoughts go away.  There are often strong similarities between the brains of children with OCD and brains of children with Autism.  However, one critical difference is that the OCD brain ultimately wants the repetitive thought to go away while the Autistic brain is comforted by the repetitive and familiar nature of the thought.

Remember:

• The child in their comfort zone seems like they don’t want to be part of our world.  However, this is not regression or a lack of progress.  In fact…
• Perseverative and stereotypical behaviors are not ‘bad’.  These behaviors help child regulate a chaotic world.
• However, these behaviors may become habits & keep the child isolated.  These are potentially addictive for the child and need to be monitored.
• ‘Joining’ in these behaviors helps our engagement with the child.
• As our engagement with the child increases, the perseverative and repetitive behaviors naturally decrease!

For more information on this topic, visit the work of Dr. Rick Solomon and the PLAY Project.

Dr. Mark Bowers is a Licensed Pediatric Psychologist at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.

Mark Bowers, Ph.D. © 2009

Video Game Addiction

Many of the families I see at The Ann Arbor Center for Developmental and Behavioral Pediatrics have at least one child who occupies most of their time with a video game system.  While many ‘tweens’ and adolescents enjoy video games, I see many children who have diagnoses of Asperger’s Syndrome and Pervasive Developmental Delay-Not Otherwise Specified (PDD-NOS) whose interest in this electronic media stretches beyond simple enjoyment.  Especially during the junior high and teen years when children are feeling more socially isolated or have preexisting social skills difficulties that make interpersonal interactions uncomfortable; video games provide an escape.

The American Academy of Pediatrics (AAP) guidelines recommend that parents limit a child’s “screen time” (includes video games, computer, television) to one to two hours per day at most.  An alternative that I often recommend to my families is to limit screen time to one hour on school nights and two to three hours a day on weekends and holidays.  My intention is not to make the child’s life miserable (which they often accuse me of trying to do!) but rather to open up opportunities for relationships.  Notice I recommend that parents limit, not eliminate video games.  Video games are not interactive between people.  Even if your child plays with a friend in the same room or online, this is not a spontaneous and reciprocal social interaction.  Indeed, if you turned off the video game and asked the two kids in the room to get a conversation going for more than a few minutes, they would inevitably become uncomfortable and want to discuss or return to playing the video game.

In the world of autism spectrum, professionals like myself are always concerned about Comfort Zone activities.   An autistic child’s Comfort Zone is his neuropsychological sense of comfort that occurs when he is doing what he wants and likes to do, especially when he is repeating activities.  The comfort zone is based on the child’s atypical neurological system that makes the child want to keep the world the same.  Thus, Comfort Zone activities for the young child may begin as lining up toys, progress to obsession with trains, and then morph into video game addiction during the teen years.

Although the strategies for how to wean a child from excessive video game usage vary from family to family, a few bits of advice may provide a good start:

• Make conversation a priority in you home.

• Read to your children.

• Don’t use video games as a reward or punishment.

• Encourage active recreation.

• Get the TV sets and video game systems out of your children’s bedrooms.

Children who excessively play video games tend to do so for a reason.   Whether it is loneliness, social skills difficulties, feelings of isolation, anxiety, or depression; the use of video games becomes self-medicating and a means to quickly pass the time.  The strategies mentioned above are only a drop in the bucket if your child is experiencing difficulties in any of the areas just mentioned.  If you are fortunate enough to be reading this article while your child is still young, the best form of intervention is prevention.  So start early and set those limits now while encouraging more appropriate use of your child’s time.  Get them involved in fun activities out of the home to keep them interested and active.  If your child is already hooked into the video games for an excessive amount of time, it may be worthwhile to seek a professional consultation to begin breaking the so-called video game “addiction.”

To Spank or Not To Spank…

A paper presented at the International Conference on Violence, Abuse and Trauma on Sept. 25 by sociologist  Murray Straus has caught my attention this week.  Straus and his colleague Mallie Paschall followed children over the course of four years and determined that those who were spanked had up to a 5-point lower IQ than their peers who were not spanked.  Further, the more the children were spanked, the lower their IQs.

This debate is not new.  In fact, I find myself in this debate at least a few times each month with some of the families I see.  The age old question is whether or not spanking is an effective form of discipline.  My professional stance (in conjunction with the science that supports it) is that spanking is actually punishment (not discipline) and is only effective in the short-term.  Try telling that to the ‘old school’ father who swears, “It worked on me when my father spanked me!”  With a little more investigation in my office, I am often able to reveal that while it may have garnered attention in the short-term, it fueled resentment toward the parent over the long-term.

I truly believe that the majority of spanking occurs in the form of a parental temper tantrum in which the parent has lost control and is at a loss for an effective discipline strategy.  There are a number of problems with punishment that I encourage parents to consider when deciding if they really want to employ spanking as a method of punishment.

• Spanking focuses anger on the parent doing the spanking.  When we resort to punishment it gives children someone else to be mad at or something else (the spanking) to blame.
• Spanking causes the behavior to stop quickly, but in the absence of spanking, the negative behavior returns.
• Spanking does not teach accountability. The “punisher” (parent) is responsible to see that the child’s behavior changes.   The child learns nothing on their own as a result of the spanking.
• Punishment denies a child the right to experience the real consequence of their actions.  If your child hurts someone else, for example, the other child may not want to play with your child anymore.  Your child quickly forgets this possibility when spanking is introduced.
• A big error comes when we think that the punishment has taught the child what to do the next time a similar situation occurs. It has taught the child NOT to do something… but it has not taught them what they should do!

In case those reasons were not enough, we also know that spanking makes children anxious (especially toward the parent using this method) and spanking can lower self-esteem.  A report endorsed by the American Academy of Pediatrics in 2008 looked at 100 years of research and concluded, “There is substantial research evidence that physical punishment makes it more, not less, likely that children will be defiant and aggressive in the future.”

The full report can be read at www.phoenixchildrens.com/discipline