Classic autism is a term we use to describe our original conception of autism. A child or adult who has significant and conspicuous social, language, learning and behavioural impairments. We now use the term Autism Spectrum Disorder Level 2 or 3 to describe this expression of autism. Challenging behaviour can occur due to difficulties with communication, a distinct profile of cognitive and social abilities, sensory sensitivity and difficulty regulating emotions. There can also be movement disorders and medical factors that affect the behaviour of those who have classic autism.
One of the primary causes of challenging behaviour is frustration from not being able to effectively communicate thoughts and feelings. There is usually extremely limited speech which has not been replaced with a complex gestural communication system as occurs with deaf children. We are exploring the origins of the lack of speech which may be an expression of apraxia, that is a difficulty getting the brain into gear with the mouth and body. New therapies such as PROMT are designed to encourage speech by the specially trained speech pathologist using their hand to encourage jaw, lips, and tongue movement. There are also Apps to encourage vocalization and speech as well as advances in communication from Music Therapy and alternative and augmentative communication systems. It is important to remember that lack of speech does not automatically imply a lack of intelligence, and that for some classically autistic children, they learn to read before learning to speak.
When there is extremely limited speech, the signature mannerisms of autism are an effective means of communication. Parents and teachers often ‘translate’ the behaviour as thoughts such as “I can’t cope” or “I need help” or feelings such as jumping for joy or ‘in a flap’. These mannerisms can also be used as an early warning system of signs of distress and agitation.
The cognitive profile associated with classic autism includes a range of characteristics that can affect behaviour. There can be a fear of making a mistake and a lack of cognitive flexibility such as not knowing what else to do. The overriding priority is to solve a problem rather than satisfy the social or emotional needs of others, with self-esteem from intellectual achievements. The learning style can be a ‘visualizer’ with a preference for a silent demonstration of what to do, and learning cognitive abilities and language from a computer or television screen. There can also be a talent and interest in identifying patterns and sequences and enjoying symmetry. However, there can be a very limited tolerance of frustration, with a tendency to quickly ‘hit the panic button’, having an intense aversive emotional reaction and giving up quickly to end the ‘pain’.
One of the central diagnostic criteria for autism is a deficit in social-emotional reciprocity, reading non-verbal communication and making and maintaining friendships. The social context can cause confusion, stress and feeling overwhelmed for autistic children and adults, leading to avoidance and escape behaviour. There are several relevant social dimensions such as the number of people in a room, intrusive peers and adults, and the duration of socializing. For an autistic person, socializing is emotionally and energy draining, rather than refreshing and enjoyable. There is a need for regular ‘oases’ of solitude, with a preference for solitude as an emotional restorative and for learning.
A characteristic of autism is to be extraordinarily sensitive to another person’s negative mood such as disappointment, anxiety, or agitation. There can be an avoidance of some social situations and specific people due to a perception of ‘negative vibes’ and quickly determining if someone is ‘autism friendly’. Some parents, teachers and therapists have an intuitive understanding of autism and facilitate social engagement rather than withdrawal.
We now have a range of programmes to encourage social abilities and confidence such as Social Stories developed by Carol Gray and ensuring social engagement, especially in a learning situation, that can be fun together.
Another diagnostic criterion for autism is sensory sensitivity. Specific sensory experiences are aversive and often painful. Repeated exposure does not automatically reduce the degree of sensitivity, but we can encourage endurance and develop avoidance and barrier strategies, such as vacuum cleaning the house when the child is at school, or using ear plugs or noise reducing headphones in the classroom or playground. The sensory profile associated with autism is complex including being overly sensitive to external sensory experiences such as sounds, lighting, touch, and smell, but lacking sensitivity to internal sensory experiences such as needing to use the toilet, hunger, and body temperature. Occupational Therapists have developed sensory assessment questionnaires for parents and teachers and strategies to moderate sensory sensitivity such as Sensory Integration and Processing Therapy.
An autistic child or adult lives in a world of terrifying sensory experiences and may have discovered a coping mechanism of being mesmerised by a repetitive action or sensation that ‘blocks’ the aversive sensory experience. Temple Grandin described how: “Intensely preoccupied with the movement of the spinning coin or lid, I saw nothing or heard nothing. People around me were transparent and no sound intruded on my fixation. It was as if I was deaf. Even a sudden loud noise didn’t startle me from my world. But when I was in the world of people, I was extremely sensitive to noise.”
The sensory profile associated with autism can also include craving specific sensory experiences, often avidly mouthing, touching, sniffing, or spinning objects. The experience is perceived as enjoyable but can be distracting and disruptive in a school or community setting. Sensory Integration and Processing Therapy may also help with this type of challenging behaviour.
From early infancy, an autistic child or adult may be notorious for having intense anxiety, anger, or sadness, that seems to be an ‘on/off light switch of brilliant light rather than a gradually increasing dimmer switch. When extremely distressed the autistic child or adult is not responsive to reason, distraction, or compassion. There can be a meltdown that is outwardly directed and an energy explosion, or inwardly directed implosion. We are developing strategies for a meltdown that include a parent, teacher or caregiver not interrogating the autistic person as to why they are distressed, nor becoming emotional -especially expressing anger or affection and focusing on punishment and consequences to end the meltdown. It is important to affirm and validate the emotion, confirm the feeling will eventually go, to keep other people away, and perhaps using a special interest as an ‘off switch’.
Nearly all autistic individuals have high levels of anxiety throughout their day and intense anxiety associated with specific situations. This includes anxiety created by change, transitions and the unexpected, as well as the anticipation of aversive sensory experiences and abandonment (separation anxiety). To cope with anxiety an autistic child or adult may become very controlling of others and events in their daily lives, being oppositional and not complying with simple requests. Another coping mechanism is developing routines and rituals as a calming mechanism or engaging in a favourite activity as a thought blocker. An alternative effective coping mechanism is an explosion or melt down to discharge the emotional energy and to reset emotion regulation. There are strategies for each type of coping mechanism that becomes a challenging behaviour due to anxiety that includes the concept of an ‘Emotional Toolbox’ with a range of tools to regulate emotions and emotional energy. This can include regular physical activities, encouraging relaxation and self-awareness using mindfulness, mediation, and Yoga. There are additional tools in terms of medication for anxiety and depression.
Autism is associated with dyspraxia, a range of involuntary tics and akathisia or motor restlessness. These movement disorders will affect daily living skills and motor coordination and potentially cause frustration, stress, and distress. Advice may be sought from an Occupational Therapist or Physiotherapist. There are also medical factors that may affect behaviour and abilities, such as epilepsy, auto-immune disorders and poor quality and duration of sleep. Thus, the management of challenging behaviour in classic autism requires a multi-disciplinary approach, an understanding of autism and the function of specific behaviours.