Rules of Engagement for Praising a Child with Autism

Dear Melissa,
What is the best way to tell my son with Autism that he is doing a good job?

If you read any parenting book or blog, one overwhelming truth comes out: one of the best ways to encourage positive behavior is to praise a child when he is being good.  This is true for children with Autism, this is true for children without Autism and this is true for your spouse as well! But news flash, in most cases, you have to speak differently to the child with ASD than you do with most other children. For example, those often posted "101 Ways to Praise a Child” are NOT how you praise children with Autism! I have had the fortune of supervising many OT interns over the years. Here I have seen firsthand how traditional praising that works for most children can backfire for children on the Autism Spectrum. 

Children with Autism have difficulties processing language and social interaction. This is the hallmark of the diagnosis. However, not all children with ASD are alike, just as not all “neurotypical” children are alike. But there are some general truths I have learned from over a decade of working with children with Autism. 

Praising a child in a variety of different ways is confusing.  
Children with ASD already have difficulties interpreting social cues and expressive language. Praising a child with ASD in 101 different ways requires him to decode the different types of praise 101 different times. Exhausting! That does not sound like a reward at all!

Consistent, predictable praise works wonders.
Consistency, consistency, consistency! Kiddos on the Autism Spectrum often repeat the same phrases over and over and watch the same movies repeatedly. The child who enjoys all of this repetition also enjoys it from you as well! For example, when a child with ASD brushes his teeth, he may expect that you sing the same song over and over. When he puts the puzzle piece in, he wants the same “good job” each time. One child I work with will even say the “good job” for me if I forget to say it after he completes a task well. 

Want to be a little bit more creative?  
You can spice things up a little bit by having 2-3 different phrases, but too many can quickly become overwhelming and less effective for a child with ASD. I personally use “Good job!”, “Whoohoo!” and a “Good job (name)” song. If the kiddo can handle a bit more, you can always add a qualifier to the “good job”.  For example: “Good job coloring”, or “Good job cleaning up”.  

Avoid too many words.
Don't use too many words in your attempt to praise your child. For example, you would NOT say “Johnny, I am so proud of you for brushing your teeth so nicely. See how shiny they are? You are such a big boy!”  This would be fantastic praise for a neurotypical child, but generally not appropriate for a child on the Autism Spectrum. Unless a child can speak back to you in several sentences strung together with emotions and abstracts thrown in, this is too much!

Try to ignore misbehavior. 
Responding to misbehavior with a simple “no no” or “ehh!” can really backfire. Just as the child with ASD may be motivated by immediate, consistent praise, he may also crave immediate words of reprimand. When you see a child misbehaving...then waiting for you to give the same verbal reprimand you offered last time...that is when you know you have entered a negative dance. If at all possible, keep quiet, avoid eye contact, and gently/silently redirect the child to the correct action. This one is particularly hard, but you can do it!   

Parenting a child on the Autism Spectrum offers a whole new set of challenges. But with shoulders to lean on, some extra patience and a few tricks in your bag, you can do it! 

What do you find most difficult about parenting a child with Autism?  

What tricks have worked for you and your family?  Please share!

email: share@childrenstherapyteam.com

Resources:

Autism Spectrum Disorders, Parenting.com, accessed February 2015.

Behavior & Discipline Issues for Children with Autism Spectrum Disorders, Super Nanny (June 25, 2014), accessed February 2015.  
Helping Children with Autism, Helpguide.org, accessed February 2015. 
Tips for Parenting a child with Autism, WebMD, accessed February 2015. 

Potty Training Wisdom: Constipation

image credit: Envato

I have received many questions over the years concerning difficulties with helping children have bowel moments in the toilet. The concerns often sound something like this:

Melissa, 

Our son still refuses to have a bowel movement in the toilet. When we put him in underpants, he will either simply use the underpants for a bowel movement, or “hold it” and become horribly constipated.

Though I have seen issues surrounding bowel movements with many “typically” developing children, boys with Autism tend to have particular difficulty with this aspect of toilet training. A study published in Pediatrics (February 2014) found that children with ASD have four times more GI distress (constipation, diarrhea, & abdominal pain) than “neurotypical” children. No wonder it can be so tricky for these kiddos! It has been my experience that little boys will often find success with urinating in the toilet, but many of them have a whole new set of troubles when it comes to bowel movements including:

• Withholding bowel movements and becoming constipated.
• Requesting that the caregiver change him into a diaper so that he can have a bowel movement.
• Only having bowel movements at night when they are changed from underpants into a pull-up. 
• Not caring if they have a bowel movement “accident” in their underpants. 

This area of difficulty is SO common, and it seems that the reason for it is often multi-factorial including: 

• Fear of sitting on a standard toilet/potty seat.
• Fear of pain associated with previous bouts of constipation.
• Difficulty with wiping after bowel movements.
• Difficulty with managing clothing before and after bowel movements.
• Not wanting to take the additional time required to sit on the toilet.

So...with this many different factors playing into the problem, there are many different ways to address the issue. As with most problems with raising children, it is often best to attack this predicament from several different angles. Here are a few ideas:

Adjust your child's diet

Sometimes simply adding lots of water, juice, and fresh fruits is enough to prevent bouts of constipation.

Add fiber supplements or laxatives 

Work with your pediatrician to make sure that your child does not become constipated. This may include adding fiber supplements or laxatives.

Develop a strong association between the bathroom and bowel movements 

 Allow the child to be changed into a diaper for bowel movements if the child requests this.  However, encourage him to go into the bathroom to have the bowel movement in the diaper. This will help him associate that THIS is the room where people go potty. 

Normalize this aspect of everyday life 

Use social stories, books, and TV shows to help your child understand that “everybody poops”.  It's normal and not something to be scared of or ashamed of. In my house, after this particular developmental learning stage passed, we then firmly established a new set of ground rules revolving around one idea: “We only talk about poop in the bathroom!”

Reward every step

Take baby steps toward sitting on the toilet with rewards for every step of the way:

• Sit on toilet with clothes on (and even while holding a grown up's hand if this is still scary).
• Sit on toilet with underpants only.
• Sit on toilet with bare bottom.
• Sit on toilet using a timer for longer periods of time (start with a few seconds, then work up to a few minutes).
• Sit on toilet several times per day, particularly after meals, to help encourage accidental success.

 Learn More

Consider attending the March 26, 2015 talk:

Toilet Training Children with Autism at the University of Arkansas, Fayetteville. 

Resources:

Elizabeth Pantley's Potty Training Tips - Part 2: Poo Problems! (updated 2014). Super Nanny, retrieved February 2015 from supernanny.co.uk/.

Gastrointestinal Symptoms in Autism Spectrum Disorder: A Meta-analysis (2014). McElhanon, B., McCracken, C., Karpen, S., Sharp, W. Pediatrics, American Academy of Pediatrics, retrieved February 2015 from pediatrics.aappublications.org/ 

Gastro woes more common in kids with Autism: Review (2014). Brenda Goodman. Autism Spectrum Disorder Health Center, retrieved February 2015 from webmd.com.

Toilet Training Children with Special Needs (2014). American Academy of Pediatrics, retrieved February, 2015 from HealthyChildren.org.

Toilet Training. (2010). University of Michigan Resources on Child Development and Behavior Resources, compiled by Kyla Boyse and Kate Fitzgerald. Retrieved February 2014 from Med.umich.edu.

Did your child have difficulties with toilet training?  

What solutions do you have to share?  We would love to hear from you!

email: share@childrenstherapyteam.com

Potty Training Wisdom: 7 Day Challenge

image credit: Envato

Dear Melissa,

My 4-year-old daughter has Autism. She will sit in her potty chair several times a day when I take her, and she even occasionally uses the potty. I think we are ready to actually start potty training. Now what?

Congratulations on all of your hard work...now for the hard part! Again, potty training was my LEAST favorite part of being a mommy, so I have read many different books and sought lots of advice on this matter. I have listed three approaches below. The third, a modified version of the first two approaches, is a "Seven Day Challenge" and has been my go-to approach for my own children. 

The Gradual Approach

The gradual approach involves having the child wear pull-ups or training pants while you take her to the bathroom frequently throughout the day for several weeks. This approach has its benefits in that you don’t have to worry about your child having “accidents” either in your home or in public. The downside of this approach is that it often takes much longer for a child to become ready for big-kid underpants. In addition, pull-ups are so absorbent that children often can’t feel the difference when they do have an accident. 

The "All-In" Approach

For this method, you take the child to the store, ask her to pick out her favorite big-kid underpants (I suggest buying a lot!), and then she NEVER goes back into diapers/pull-ups. First, you start off by taking the child to the toilet every 20 minutes and gradually move to every hour over the next several days. If a child has an accident, you do NOT shame the child.  You are matter-of-fact about it being her accident (just as if she had spilled milk), and you ask her to clean it up. This approach means changing clothes and cleaning the floor if necessary. You can certainly help, but ultimately it is her responsibility.

The 7-Day Challenge Using an Adapted Approach 

Personally, I used the "all in" approach for my own children, largely because it was what their school required. However, I modified the approach a bit and allowed my kids to wear pull-ups at nap and bedtime, and they still turned out OK. I suggest using this technique for one week. Hang in there for the full 7 days! It is really awful the first few days. However, if you see NO improvement by day 7, the child may just not be ready yet. That’s OK. Go back to the readiness tips from last week’s blog and try again in a couple months

7 Tips to considers:

1. Don’t switch back and forth between diapers and pull-ups. This confuses the child and they can’t remember if they need to use a diaper or run to the toilet. 

2. Provide lots of positive role models. If everyone feels comfortable, allow older siblings to take the younger child to the bathroom, read books about “big kids” using the toilet, etc. 

3. Bribery works!  Keep lots of tiny treats on hand for success.  Think M&M’s, stickers, hand stamps, etc. Young children need immediate positive reinforcement rather than more extended behavior charts. However, they can save up their immediate rewards of stickers for larger prizes. 

4. Use easy clothing. Avoid buttons and zippers on pants during this time.  In addition, clothing that is slightly too big is even easier to manage. 

5. Do not reduce fluid intake. Rather encourage her to drink lots of water. This will create more opportunities for successful use of the toilet. 
6. Don’t hesitate to help.  Although the goal is independence, don’t hesitate to help your child when it comes to learning proper hygiene and proper cleanliness techniques. 
7. Praise, praise, praise! I know it often doesn't seem like it, but young children really DO want to please their parents! The more you praise small successes (even simply sitting on the potty), the more likely your child is to cooperate. 

As always, talk to your child’s therapists, pediatrician, and teachers to determine the best approach for YOUR child. In addition, your child’s speech therapist has the “magic fairy dust” of social stories. These fantastic stories help a child know what to expect with toilet training and make the whole process less intimidating. 

Learn More

Consider attending the March 26, 2015 talk:

Toilet Training Children with Autism at the University of Arkansas, Fayetteville. 

Resources:

Establishing Toileting Routines for Children. (2014). American Occupational Therapy Association, developed by Jay Doll, Bonnie Riley. Retrieved February, 2015 from AOTA.org.

Toilet Training Children with Special Needs (2014). American Academy of Pediatrics, retrieved February, 2015 from HealthyChildren.org.

Toilet Training. (2010). University of Michigan Resources on Child Development and Behavior Resources, compiled by Kyla Boyse and Kate Fitzgerald. Retrieved February 2014 from Med.umich.edu.

What has worked with toilet training your child? 

Did you use the gradual approach, or go cold turkey?  I would love to hear your ideas.

Please share! share@childrenstherapyteam.com

Potty Training Wisdom: Readiness

 credit: Envato Images

Dear Melissa,

My 3-year-old daughter, who has Autism, has recently been removing her diaper. Does this mean she is ready for potty training?

I will admit that toilet training was my least favorite part of being a mommy!  Some children are independent and literally tell you, the parent, when it is time to lose the diapers. Other children are more subtle. There are a wide variety of factors involved with determining when a child is ready for toilet training. In sharing my insight I reiterate my stance - you can’t force children to eat, sleep or potty. But, there is a lot you can do to support your child during their journey to becoming ready to toilet train. 

As parents, if we are unable to answer "yes" to a majority of the questions below, then toilet training will likely end up being a frustrating failure for both the parent and the child. Below I have listed five common readiness indicators that I recommend parents consider.

5 Common Readiness Indicators

1) Verbal skills: 

• Does the child have some way (either verbally or non-verbally) to tell you that she needs to use the bathroom?

2) Motor coordination skills: 

• Does the child have the ability to manage simple clothing, wipe after voiding, flush the toilet, and wash her hands independently? 
• Can the child control her sphincter muscles for voiding?  
• Can she climb onto the toilet/potty chair independently?

3)  Cognitive skills: 

• Does the child understand the cause and effect of voiding and soiled clothing?  
• Does the child have the capacity to sequence the steps of toileting?

4) Sensory processing skills: 

• Can the child tolerate the sounds of the flushing toilet, running water, and echoing bathroom?  
• Can the child feel the difference between wet/dry?  
• Is the child able to tolerate the sometimes scary sensation of sitting on a toilet (vs. a solid chair seat)?

5) Emotional skills: 

• Does the child have any desire to wear “big kid underpants”?  
• Is she in a phase where she is fighting you tooth and nail and saying “no” to everything you say? 

Again, regardless of your child’s chronological age, these are the precursor steps for toilet training. This is where many parents understandably despair. We often feel like toilet training is an all-or-nothing deal. BUT IT’S NOT! There are many, many actions you can take to encourage toilet training readiness and help set your child up for success.

Ways to Encourage Readiness

Change diapers in the bathroom. This encourages her to associate voiding with THIS room in the house, rather than elsewhere.

Wash hands in the bathroom. All toddlers need more practice washing their hands. I love them to pieces, but our toddlers can be like little Petri dishes!  Also, washing hands in the bathroom helps the child to integrate the sensory input piece of the process – stepping on a stool, splashing water, echoing bathroom, you get the idea. 

Practice dressing. Even if you are placing your hands over your child’s hands to help her pull her pants up and down, this begins the motor planning process. 

Establish routine. This will assist with the emotional/behavioral piece. If we are going into the bathroom at regular intervals in the day for diaper changes, then it will eventually become just as easy to use the toilet during these times. 

Sit on the potty. Listen to music, sing songs, read books, keep your clothes on, whatever.  Just help the child get used to sitting on the toilet or potty chair in a “no pressure” situation. 

Establish “potty time”. If your child is comfortable and ready, begin a routine of sitting (bare bottom) on the toilet several times a day. The times for best success are generally when first waking in the morning or after nap, after meals, and before bath time. 

Praise like crazy! If the child “accidentally” uses the potty correctly, then YES, singing and dancing are required. Party hats and confetti are strongly encouraged. 

Next week I'll dive into different techniques for toilet training once your child is developmentally ready. 

Learn More

Consider attending the March 26, 2015 talk:

Toilet Training Children with Autism, 

at the University of Arkansas, Fayetteville. 

Resources:
Establishing Toileting Routines for Children. (2014). American Occupational Therapy Association, developed by Jay Doll, Bonnie Riley. Retrieved February, 2015 from AOTA.org.

Toilet Training Children with Special Needs (2014). American Academy of Pediatrics, retrieved February, 2015 from HealthyChildren.org.

Toilet Training. (2010). University of Michigan Resources on Child Development and Behavior Resources, compiled by Kyla Boyse and Kate Fitzgerald. Retrieved February 2014 from Med.umich.edu.

Dentist's Tip: Keep helping kids brush!

credit: Envato

Dear Melissa,

I have a 4 year old son with a diagnosis of Autism. He has extreme defensiveness to touch, food textures and he gags easily. This oral sensitivity also makes brushing teeth a nightmare! He refuses to let me brush his teeth and refuses to brush them himself. I'm hoping that not brushing or flossing will be OK because he just has baby teeth. 

In responding to this question I have already addressed: 1) The importance of caring for baby teeth in the "Baby Teeth...Big Concern!" post; 2) The challenges of oral care in the "Help, my child refuses to brush!" post. Finally, 3) I address the all important topic of when and how children should begin to independently care for their own teeth at home. I'm again joining forces with Dr. Karen Green, a Board Certified Pediatric Dentist at Pediatric Dental Associates & Orthodontics. 

Melissa:  Until what age should the parent still help the child brush his/her teeth?

Dr. Green: A child should be allowed and encouraged to brush their teeth, but until the child is at least 8 years old (and often older depending on how effective brushing is) an adult should be helping the child brush.  

Melissa: I think some parents might be surprised by how much they need to still help a child who seemingly brushes independently?
Dr. Green: Think of it this way: Would you allow your 4 year old to wash your dishes and then expect that they have been thoroughly cleaned? The same goes for his/her teeth. At a young age, their manual dexterity is not sufficient to do a thorough job. 

Melissa: I just got a mental picture of my 4 year old daughter washing the dishes, and then the family eating dinner on them. Not pretty! I am officially helping her brush her teeth more! 
Dr. Green: If you start this practice early, the child will be more receptive. As soon as the first tooth cuts through the gums, the parent or guardian should be brushing the child's tooth/teeth twice a day. Even before the first tooth erupts, a baby's gums can be massaged with a baby toothbrush or a soft dampened washcloth.  

Melissa: For older kids a good compromise might be for the child to brush his teeth first, and then the parent provides a thorough, but gentle, scrubbing after the child is “finished”. How often should a child (and parent helper) brush his/her teeth?

Dr. Green: Brushing should be done at least twice a day, preferably after breakfast, and before bedtime. Flossing should be done once daily.

Melissa: Do all children need to floss?

Dr. Green: Most kids do need to floss. A toothbrush cannot reach between the teeth like floss can. If your child's teeth are crowded, flossing is really important. Look inside your child's mouth and if you can see space between all of their teeth, then flossing is not necessary at this point, but practicing and getting into the habit of daily flossing is always a good thing.

Thank you Dr. Green for your expert advice! Over the years I have helped many children with Autism and Sensory Processing Disorder learn to brush up their pearly whites. So, there is hope! I know it can be done. From my perspective as a Pediatric Occupational Therapist, here are just a few of the many components of brushing and flossing:

• overcoming sensory defensiveness, 
• developing body awareness,
• "fine tuning" fine motor skills, 
• working on sequencing skills, 
• focusing attention on the task.

If your child finds any of these components difficult, COMMUNICATE! Talk to your dentist, occupational therapist, or speech therapist. Oral care can become a painless and simply part of your daily routine, but developing the foundational skills to make that happen may require consultation with professionals. Do a bit of research to find out which dentist in your community works best with children who are orally defensive. In Northwest Arkansas, don't hesitate to reach out to the Pediatric Dental Associates. I think they do a wonderful job with children who have challenges with sensory defensiveness.  

A special thanks to Dr. Karen Green for participating in this week’s blog!

front office area at Pediatric Dental Associates and Orthodontics

What has worked with your little ones to create a healthy home oral care routine?  

I would love your tips!  Please share! share@childrenstherapyteam.com

References:

Pediatric Dental Associates & Orthodontics, Fayetteville, AR

"Dentist visits for kids with sensory defensiveness", Children's Therapy TEAM Dear Melissa Blog for Parents (February, 2015)

"Baby Teeth...Big Problem!", Children's Therapy TEAM Dear Melissa Blog for Parents (February, 2015)

"Help, my child refuses to brush his teeth!", Children's Therapy TEAM Dear Melissa Blog for Parents (February, 2015) 

American Academy of Pediatric Dentistry

American Academy of Pediatric Dentistry for Parents