Transitions and Insisting on Sameness

Welcome to the September edition of Ask Dr. Emily! We often receive questions that we want to share with all our readers. To help with this, Dr. Emily Rastall, a clinical psychologist at Seattle Children’s Autism Center, will share insights here, on the last Friday of each month, in a question and answer format. We welcome you to send us your questions and Dr. Rastall will do her best to answer them each month. 

I am a nanny and have taken care of many children who are diagnosed with autism. My grandson also has a diagnosis of autism. At times, when I set a limit (like with portions of food), my grandson and some of the children I care for have a hard time accepting “no.” I try to stay calm and maintain the limit, but sometimes the situation escalates to yelling, hitting, or pushing. What is going on and is there something I can do to handle this better?

One of the diagnostic criteria for autism spectrum disorder is insistence on sameness and/or inflexibility. This often translates into “rigid thinking patterns” and means that transitions, changes in routine or plan, and/or hearing an answer that you weren’t expecting or wanting are hard to tolerate. One of the most important things that parents and caregivers can do is to remain calm, so keep up the hard work. Consistency and follow-through are also key, as human behaviorism says that if we push and get someone to “cave” once, we are likely to push again next time. Finally, distraction, re-direction, and resisting the impulse to respond to protests are nice ways of moving past the limit, once it has been set. If behavior continues to escalate, autism and behavioral professionals can provide behavior management strategies and/or recommend other intervention.

My son is going to be 7 years old next month. He has been diagnosed with ADHD and autism and he does not speak. Sometimes he just starts crying for what seems like no reason. Sometimes we will be driving in the car and we come to a red light and have to stop and that seems to make him cry. Or he’ll be in his swing and that will stop moving and that will make him cry. He can cry for a whole day. We have tried visiting his doctor to see if it was something with his stomach, but after looking into it, the doctors thought his stomach was perfectly normal. I should mention, where we live in India, people seem to have very limited knowledge about autism and there aren’t many resources. Do you have any recommendations for how I can help my son or figure out what is causing him to cry so often?

Due to the communication barrier, we have to just check things off of the list of things that could be causing him stress. One of the first things we want to asses for is whether an individual is having physical pain. Another thing that is important to assess for is potential sensory sensitivities (e.g., movement in the car feels good, but as soon as it stops, that good feeling goes away). We may also be talking about the “rigid thinking patterns” part of autism spectrum disorder, which means that transitions, changes in routine or plan, and things going differently from what is expected are hard to tolerate. Providers who specialize in autism may be able to guide families through this process of elimination.

The information contained in this blog should not be used to replace the relationship that exists between you and your healthcare provider. Please contact your healthcare provider for specific medical advice and/or treatment recommendations.