Therapist seeks your help and advice for patient with severe ASD


Jennifer Posts:

DEAR ERI COMMUNITY: Hi everyone. I’m having a hard time with a patient I’m working with and would like some advice/tips please. I’m working with a 12 y/o female dx with severe ASD. She is almost completely nonverbal with the exception of “yes”, “go”, and basic animals. She is a very tall and strong girl that can easily over power me. The problem is she becomes very aggressive, increasing verbal stims, and begins hitting herself and others. She is very difficult to calm. I have identified many of the cues she gives before becoming aggressive and have identified some causes including bright lights we now work in a dimly lit treatment room with minimal natural light, and have changed the tx time to the early afternoon at a less busy time in the clinic. We have tried vestibular, deep pressure, vibration, etc. Do you have any other calming techniques that I haven’t tried yet? Thank you!

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30 Responses to Therapist seeks your help and advice for patient with severe ASD

  1. Teri Deal says:

    Did vestibular therapy cover eye movement disorder exam and treatment? Not being able to focus visually can lead to much brain distress. I am not speaking of “focus” that eye glasses can correct.

    • Kristina Altieri says:

      Is she on any medication? One of my therapists had a silimiar patient recently that was getting increasingly aggressive. She had been on a medication to prevent/slow puberty for a few years, as well as a medication for either aggression or attention (I can not remember which one). Regardless, when it came to a point that she was about to be kicked out if her school we had recommended stopping all medications, letting her body cleanse, and basically starting over with a clean slate. To our amazement, within a few days of stopping her meds she was back to being more calm, less hand flapping and aggressive, and more responsive to others!

  2. Denise DesJardins says:

    Have you tried music? With some of my more involved ASD students playing classical or lullaby music seems to help set the tone. Also sometimes just singing silly songs and making silly faces seems to help as well.

  3. Stephen Bigler, COTA says:

    You could try using lavendar essential oil for calming, as well at the Theraputic pressure protocal with brushing/compressions, and have mom do epsom salt baths with her, to aid with overall calming, and sensory re-orgranization.

  4. Janice Buckwalter says:

    Google Irlen Syndrome. There is a questionairre for autism and a light activity that I have used and has been very successful. An Irlen diagnostician can provide glasses that are colored filtered. The Irlen website gives other suggestions in colored overlays,paper color, using a visor etc.

  5. Maureen says:

    Try slow gentle, rhythmic rocking with soft calming sounds/music and a weighted blanket if indicated.

  6. Julie A. Becker says:

    In my experience treating children with ASD, I have incorporated the use of lavender scent and the brushing protocol along with decreased visual stimulation which it sounds like you are already doing. Working with children large enough to overpower you is very difficult, good luck I hope this is helpful.

  7. Liz says:

    consider referral to psychiatry for evaluation of possible mood disorder. sometimes it doesn’t matter what sensory strategies you put in place–if the behavior/mood issues are brain-based, only mood stabilizing drugs will work. i work at a large hospital where we are in constant contact with out diagnostic teams, including psych and other MD’s. so if our approach is not working, the diagnostic team to refer to other resources.

  8. Deanna says:

    Have you tried a body sock? Playing a metronome may also help. You can download free IPAD calming apps, including a metronome sound. Also have her do as many activities in prone with weighted blanket on top, as you can for natural deep pressure through her body.

  9. Gina Maren OTR/L says:

    I have used Mozart for Modulation CD (and other classical pieces) playing softly in the therapy room. Chances are, that she would not allow “ear buds”, so playing it softly in the room may help.

    Also, taking “deep cleansing breaths” BEFORE you start to treat her to calm yourself. She can pick up on your anxiety.

    Good luck.

  10. Pat says:

    I would be proactive instead of looking for signs of approaching aggression. Schedule in regular calming breaks throughout your session time.
    I would also try to remember that your student is already under stress for things we would not notice.
    That being said, have you listened to her environment? Some ASD kids are hyper sensitive to certain noises, and volume, in particular. Ear phones may help. I like to use pressure to the palms, alternating. It has been very helpful with some of my kids. I hope this helps.
    Pat

  11. jill says:

    Have you tried pressure garments? shirts, vest or body sock for continual pressure? Is she trying to communicate and getting frustrated? Board maker for picture word board? Heavy work ? We also use a weighted animal in lap for cue to stay seated. Strong smells can be a signal for behavior, do you carry the lavender or other scent for use before the behavior and when you start seeing aggression?

  12. Janet Castriotta says:

    Try starting with very little demands and focus on simple yoga poses and deep breathing. Once you have established a routine that is familiar to her you can add some of the therapy you had planned for her. When she exhibits any signs of distress revert to the simple yoga poses. This will give her the comfort of knowing what is expected.

  13. Hi – I read the 5 previous posts and i agree with the suggestions. As you know 12 yo with violent malt downs are difficult…i have had success looking at the visual system: focal and ambient. Evaluating the status of fixation, tracking and joint attention play…using improved function as the calming agent. Due to her age- the tinted glasses are the way to start- many children do not accept glass wear, i start with plain black glasses like the movie theatre 3D glasses. Take the lenses out so you have just the thick black frames. The glasses will allow her eyes to orient to space and time through the ambient system. Once you have this orientation, the visual system will calm the vestibular and auditory systems just by orientation. Then you can play with a preferred item to increase joint attention or take a walk or do stair work…weighted ball handing or reaching. I also use even a large piece of oak tag paper and shine a light from the back to have the student follow the light (even colored lights) with their hand or finger to start fix and track..you can build this from sitting to standing, then give the student the flashlight to follow tape lines that you may have along the wall at eye level or on the floor… Just a start. I learned the most around the visual system and effective therapy (seriously almost 100%) at http://www.cliniciansview.com. The anatomy of the visual system by Dr Moor and the functional vision courses by Dr Padula and Raquel Benebib really helped most with the ASD population where early in my career i thought the visual system was largely in tact. Looking at the visual system as 80 % of all the incoming sensory information and 80 % of that being ambient which is spatial and served by the motor system-this program made sense. As soon as i can truct my students to hold visual fix and gaze, i start them with TAAP: Treadmill for students with Autism and Apraxia Protocol– then i have the sensorymotorsensory integrative piece. The visual tract of eyes through to cerebellum and back to cortex them limbic system is critical for function where the cerebellum is the grader of direction, force, effort, time and tone and precursor to those same things in thought patterns. Tapping the cerebellum is impossible (for me!!- tell me how you do it) without the treadmill especially with big aggressive students…some of my students will hand onto the black glasses as the black vertical and horizontal lines in the ambient are very organizing initially and they become attached….. This information are only ideas from my practice…

  14. Mandy says:

    Response from Barbara:
    IN response to some other calming activities that I have used and do work with some students, especially with ASD
    if you access to a pool, often just the water, itself with calm some children, using a wet suit to offer that extra pressure will at times, be helpful
    I often then do a variation on Watsu(shiatsu in the water along with some Bad Ragaz)

    if you’re limited to land, sometimes, treadmill walking will be helpful-we sometimes use an i pad with a favorite movie, show, etc to help calm with the continuous movements seem to help many students, especially the non verbal students.

    These, of late, have truly been my most successful and more positive approaches. i also work with my aggressive students(biting,hitting, kicking, etc) and these truly have been helpful.

    I hope the bloggers help you and find the best match for you and your student.
    Barbara

  15. Nancy Renner says:

    Working with this population within the school system we have found that frequent sensory breaks are helpful. For most of the students calming activities–quiet room with lights out–soft music as tolerated, weighted blanket,soft fuzzy pillows is helpful. For others hand/arm massage with lavender lotion, deep pressure/squeezes at joints–including TMJ and ‘head squeezes’. For others repetitive movement or functional activities (work boxes) seems to work. Some of the most involved students start the day with yoga and will ‘request’ the yoga childrens DVD’s …it sometimes took a few weeks for them to attend but gradually they have worked up to the full 30 minutes.

  16. Marie says:

    Have you tried finding out what she likes and is motivating to her? Maybe a certain TV character, a song, a toy? I made little “books” for one of my students with preferred characters (Disney princesses, dogs, Elvis). I let her look at the books for a break in between activities.

  17. Andrea says:

    I found by happy accident some children with Autism respond better to the scent of peach and vanilla. If the child tolerates I put a small amount on there hand so the child can smell it continually, it also provides a nice opportunity for deep pressure input. Another great deep pressure activity is an unpopped popcorn bin (you can place manipulatives in there for your student to find or hunt for items neede to complete a task).
    I agree that you may want to be a detective and find a preferred activity then consider a first (work) then (reward) token board or a token board with I am working for (reward) and do 1,2,3 etc. tasks to get the reward.

  18. Bala Pillai says:

    It looks like you have a lot of responses to your question, so I guess you now have a lot of suggestions.
    You mentioned that you tried vestibular, proprioceptive etc in yr clinic. Are all the adults in this child’s life also aware of these strategies and are they providing it to her on a consistent basis?
    Does coming to your clinic involve a lot of traffic time, how does she tolerate travelling? Is a visual schedule being used with her? How are people communicating their expectations from her and does she know what is expected from her? Giving her a sense of control about what is coming next goes a long way too in decreasing her anxiety.
    The aids to help her get organised/calm could be music, compression garments, compression/traction routines. Making arrival and dismissal times very predictable and easy and rewarding instrinsically and throwing in the therapist imposed challenging tasks in between has helped me.
    Also analysing why she has the outbursts…is it the task that is too boring /challenging. It looks like you have assessed the environmental barriers ( light etc). I don’t know how big yr clinic is…but letting her run around for a couple of minutes every now and then has also worked for me. Scaffolding on her likes/preferences is also a strategy that has been mentioned and works beautifully for me.
    Hope you find this helpful. Feel free to call me at 908 227 2139. ALl the best!
    Bala

  19. EMMANUEL says:

    you seems to hav tried every necessary protocol.
    The Pt will love to interact with familiar environment such as playing with her toys from Home.
    Her toys will help as cue.. Good Luck.

  20. Carolyn Hoover says:

    In addition to all the sensory strategies people have suggested, have you had a chance to talk to her school speech therapist and teachers regarding the nonverbal communication system and behavior strategies they use for her at school? Using a picture schedule which shows her the sequence of activities during OT time and which she can move the pictures to the ” all done” side once finished is very helpful. We use this with our most severely involved students. Also, a simple token system or high frequency reward system using preferred items is usually pretty helpful as well as ignoring the aggression the best you can. This may take additional staff. She is trying to communicate with you, but not in the way that you want. Good luck!

  21. Alicia says:

    We OTs always seem to jump straight to sensory as the “cure” for everything, but there are many factors that affect behavior. This sounds like it’s more behavior than sensory, and in theory some of the suggestions made here sound like great ideas, but I can’t imagine they will be all that practical if this kid can’t do much direction-following. She’s not likely getting aggressive because she’s seeking some sensory stimulation she doesn’t have. I’m guessing that it might be that you’re wanting her to do something she doesn’t want to do (i.e., a therapeutic activity), and her only way to communicate her dislike is to have aggressive behaviors. It sounds like you’re in a clinic, so it may not be an option to co-treat with an SLP, but if you can consult with one and have some kind of communication system in place that may go a long way. Even for the “low” ASD kids a checklist works amazingly well. Sometimes a picture schedule is a lot of effort to make, and I’ve found that just writing down the expectations in simple language (even if they can’t read) will keep them doing what you want with behavior much improved. (I do try to draw something with each step, but I don’t think my pathetic drawings really mean anything, it’s really the checklist.) I usually draw a box by each step and have them check it off so they get invested in it. I always put the last step as “your choice”, though I do manipulate it to provide options that are still therapeutic. Sometimes we have to move outside of our “fix everything with sensory” brains to find our solutions, and I think non-sensory approaches may work best for you. Good luck!

  22. Kristine says:

    She is 12 years old so hormones maybe a factor so ask mom about that. What happens when she gets aggressive. i have found that most people working with people who get aggressive physical back down or give in and thus the person learns to bully to get own way. i do family living with a 43 year old gentleman who is diagnosis with ASD and bipolar disorder. I met him in group home where he was violent and took two people to restrain him. He was none verbal except for repeating names and hi ya. He was on 1800mg of lithium and 900 mg of sequol a day. and still had outburst with some of staff. I have known him for 13 1/2 years i have had no outburst. He has lost weight and speaks in sentences and works. I started with his interest and brushing program, gave him fidgets to help in new situation and limited time doing things that stressed him. told him to say go if need to leave and used time so he know when time was up. ex going into store- light and crowd. We need to get …..(something he liked and in front of store set time for 2 min. told him if he wanted to leave sooner had to say go, he had fidget in hand or held mine to get pressure from me. We did this serval times then changed settings and increased time as he showed us how he was handling things. Consistancy and trust with one person are key. My husband has experience out burst with him x2 in last 13 years, everyone has been pain/medically related as he doesn’t understand or communicate when he isn’t feeling well. I have to look for signs, increase relestness, wrinkeled forehead, increase OCD. eating slow or not wanting 2nd.then question him, does this hurt and go thru body parts. We just started using therapeutic listening and have seen even more changes from that. We have always used played and used music. If mom or you would like to email me feel free. Krisinmt@aol.com. just type ASD in subject line so I know to open in case it goes to spam

  23. Kristine says:

    Oh I forgot to mention. I don’t believe he has mood disorder because we have reduced his lithium to 600 mg a day and taken away the seroquel all together and again I have had no outburst in 13 years and my husband has had 2 which where medically linked. so there is something to this”sensory thing” as doctor like to call what we do. good luck.

  24. Wendy Sweeney says:

    I have used yoga but it was with a kindergartener at the time. However, still it seems to have an organizing and soothing affect as a 5th grader. I start with a side stretch while sitting pretzel style and go into trunk twist. I count slowly and softly to 10 for each movement. Will she apply deep pressure while rolling a nobby ball on her arms and legs? We also used the “squish machine” allowing students to stay between the rollers while counting slowly to 10. To encourage this we did a demo and then had to hold the rollers up so the space between didn’t seem so scary. Then we eventually allowed the rollers to touch her back keeping the tension on the bands as loose as possible. Within a month she was able to go through the machine independently without the accommodations we made when first starting.

  25. Mandy says:

    Post from Mary Ann
    Good morning! It sounds like you’re working with the kind of child who keeps our jobs interesting and challenging which is a good thing! In the past, I’ve used some of the strategies you mentioned but used them simultaneously. Combining vestibular (prone on bolster swing), proprioceptive (weighted blanket) and auditory (Therapeutic Listening) has sometimes (not always) been successful. I was fortunate to hear Dr. Temple Grandin speak a couple of times and, as far as sensory interference from lights, she recommended cheap, dollar-store tinted glasses. Hopefully, your child will tolerate wearing them.
    Good luck to you and your challenge.
    Mary Ann

  26. Mandy says:

    Post from Renee
    You might try providing her with an activity that she is able to perform independently when you sense that she is beginning to lose control, with a distinct beginning and end (like a puzzle or sequencing activity), using a flashlight directed on the activity to give her additional visual support. Have you used music or a metronome?

  27. Janice Ling, says:

    Does she like music with a strong beat? Dancing with her incorportating proproiceptive input like stomping and large body movement might help her modulate and have fun at the same time. Dancing with her and having some fun together might help build a postive bond?

  28. Jane Allen says:

    Great responses.
    (Someone may also have mentioned)-
    What is the prep for her arrival like?
    Could there be a noxious stimulus before getting to the clinic? Mom/caregiver can make the transition there as peaceful and low key as possible.

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