Autism vs. Oppositional/Defiant
A question parents and educators often ask is "How can you tell whether a child with ASD's misbehavior is intentionally malicious or related to their condition?" That is a very complex question to answer.  All behavior responses (positive and negative) are influenced in some way by our nervous system, experiences, thoughts process, and preconceived attitudes.  Also, since our mind and body do not operate in a separate vacuum, each of these areas can influence the other.  Since nervous system differences can influence how people expeience of life events, think about those experiences, and form attitudes towards them, you can say that for a person with Autism that all of thier behavior is influenced by their condition in some way.  That does not mean that the behavior was unintentional.  Most behavior outisde of reflexes and certain bodily urges are intentional.  For people with ASD, what may not be intentional are the consequences of the behavior.

For example, someone with ASD might leave or withdraw from a party because the music was too loud or the room was too crowded.  The intention may have been to escape the overstimulation.  The unintended consequence, however, may be offending the others in the room.  A person with ASD might refuse an assignment becasue it is different, too large, or require too fast of a response.  The intention is avoidance of anxiety and frustration, but the consequence is the preception of rudeness or defiance.  A child with ASD may see someone on television make a rude comment or act aggressively and get laughs.  They associate the rude comment or action with being funny and try it on other people.  Even when a person's actions are intended to cause another frustration or harm, it is often because people with ASD believes that they have been wronged and they lack the communication skills, emotion regulation, and impulse control necessary to resolve conflict in a more diplomatic way.             

I believe that the hidden meaning behind that question is "When the child misbehaves, should I provide traditional discipline measures or should I refrain from providing consequences?" In my experience, the answer to that question is neither.  Everyone needs to understand the consequences of their behavior, even the unintended consequences.  On the other hand, traditional punishment based discipline techniques have proven to ineffective and detrimental for people with ASD.  The emotional pain form the negative consequence is often so great that it overrides any potential learning from the conequence. Also, many people with ASD may not see the relationship between their behavior and the negative consequence or understand why they should be punished for an unintentional consequence.

So what is a parent, educator, or employer to do?  Using the principles of Positive Behavior Support, providing a consequence based disciplinary approach for people with ASD comes down to four basic elements:

1. Preparation - Review appropriate versus inappropriate behavior with the person prior to the start of the day/activity including the consequences (positive and restitution) for the different actions.  Making a list the person can see will aid in remembering.  
2. Reinforcement - All appropriate behavior should be followed by some type of reinforcement.  It does not have to be expensive or elaborate, but the person has to find the reinforcer enjoyable and they have to understnad why they are receving the reinforcer.  Simple praise that identifies specific actions can be very effective.  "I like the way you're waiting your turn."  "Our customers like it when you look at them and smile." 
3. Restitution - When an undesired behavior is observed, explain to the person with ASD why the behavior is undesirable.  Then, as a consequence, instead of an unrelated punitive measure, have the person with ASD engage in an activity that helps improve the situation.  For example, if the misbehavior wasted another person's time, then the person with ASD would need to make up the wasted time in some way.  If the misbehavior led to hurt feelings, then the restitution should inlcude making that other person feel better.
4. Alternative Behavior - Sometimes the misbehavior occurs because the person with ASD does not know another way to respond.  Other times, the person may not know how to provide restitution.  Either way this can be remedied by demonstrating and having the person with ASD practice new behaviors that can help them achieve their intended consequences in more effective ways.  Examples inlcude teaching someone to request a break rather than leaving without communicating or giving someone the words to express their emotions verbally when they are upset or want to provide comfort.

In conclusion, people with ASD often look oppostional or defiant when they are not intending to be and even when this type of behavior is intentional, it is typically because the person does not know a better way of handling the situation.  By viewing this as an  opportunity for education and not for discipline, the chances of future misbehavior will be reduced signficantly.  That does not mean that poeple with ASD cannot beomc oppostional or even antisocial. They can.  Typically this comes as a result of ongoing negative experiences with little to no positive experiences, combined with limited perspective taking and difficulty seeing long term consequences.  Thus, the need for a positive consquence based approach becomes even more imperative.  

Steven C. Altabet, Ph.D. 

                        Using Sensory Regulation to Lessen Stereotyped Behavior & Anxiety

One of the hallmark features of Autism Spectrum Disorder (ASD) is the demonstration of stereotyped behavior.  Within the realm of Autism, stereotyped behavior typically refers to actions that are either repetitive, odd (not related to situation), or overly ritualistic/routined.  This can apply to both movement and speech and can be very disruptive for both the person with ASD as well as the other people involved in the interaction.  Some people refer to these as self stimulatory behaviorn or 'stimming' for short.  What is unique about this behavior is that it difficult to find an external stimulus (trigger) for the behavior and even more difficult to stop or re-direct the behavior once it starts.  Applied Behavior Analysis (ABA) teaches us that all behavior serves a function or purpose.  Spech/Language Pathologists (SLP's) similarly assert that all behavior is a form of communication.  If that is the case then what is the purpose or message behind sterotyped behavior?

The answer to this question may lie in another aspect of ASD, which is now included in the diagnostic criteria for Autism Spectrum Disorder in DSM 5.  Sensory regulation refers to the body's ability to organize and filter all of the information we receive through our senses.  This includes everything that we see, hear, feel, smell, and taste, along with our ability to process our movement and relation of our bodies to the physical environment.  People with ASD are often overly sensitive or not sensitive enough to these stimuli. Examples include:

Vision - May have a sharp eye for visual detail, but may become overly excited in places where there is a lot of visual stimulation (e.g. crowds and larger department stores).  There may also be a startle effect in situations where there is sudden and unpreditable movement, such as sporting events.

Hearing - The person may have very sensitive to hearing.  You might notice someone with ASD being able to hear a train or plane well before anyone else notices it and there may be a strong affinity or talent for music as well.  On the other hand, loud noise may become overwhelming and excessively high or low pitched tones can become quite irritating.  I've heard many individuals with ASD complain about the hum from flourescent lights or even the clicking of a computer keyboard or high heel shoes.    

Touch - With this sense, individuals with ASD are typically overly sensitive to light and unexpected forms of touch like tapping on the shoulder, light rubbing, and certain types of clothing.  Conversely, this same person may be under sensitive to hard forms of touch and pain .  Some individuals intentionally try to create a pain response because it feels good to them.

Taste/Smell - Some people may be overly picky eaters or have an excessive aversion to cleaning fluids or other strong smells.  The picky eating can also be related to the texture or feel of the food.  

Movement - Proprioception refers to a person's ability to perceive themself and their movement in relation to others and the space around them.  A disturbance in this area can affect balance and the ability to move quickly and efficiently.  It can also affect social skills such as personal space and playing interactively.  

The basic relation of sensory dysfunction to stereotyped behavior is that the odd behavior typically comes when the person is either overstimulated or understimulated.  Therefore, if the amount of stimulation can be regulated, then there will be less sterotyped behavior.  Sensory regulation can be achieved in two ways: Through modifying the immediate environment around then person and by applying sensory regulation techniques to the person.  The person can also do both the environmental modification and senosry regulation themselves if able.
        
Environmental modifications to reduce sensory stimulation include avoiding places of high stimulation such as crowded restaurants, parties, or department stores.  When playing music, be sure sure it is not too loud, high pitched, or have an excessive bass tone.  When out in public always look for the quieter less crowded areas.  Sometimes you can't help being in a highly stimulating environment.  When that is the case, plan periodic breaks to a quieter area to allow for relief from the stimulus overload.  Also, when you see someone becoming more restless or irritable, this would be a good time for a break thus preventing a potential meltdown.

There are also several simple techniques people can use to promote sensory calming during times of distress.  Psychologists often recommend taking several slow deep breaths.   The increase in oxygen provides the energy needed for impulse control and the slow rhythm of the breath activates the parasympathetic nervous system which slows the body down.  Additionally, Occupational Therapists recommend applying deep pressure to the joints as a way of releasing endorphins and providing physical stress relief.  Deep pressure can be achieved in several simple ways including chewing, squeezing a small ball, exercise, running, jumping, and swimming.  Swimming is especially good because it combines exercise with water which is heavy and applies further pressure.  Firm pressure and weight can also be gained through wearing heavy clothing or deep massage.  If a person with ASD allows a hug, it is typically a deep hug.      

Conversely, stereotyped behavior can also occur as a function of seeking stimulation.  This often happens when there is a lack of interaction or direct activity.  Sometimes the answer can be as simple as directing the person to a structured activity of interest.  The activity should be specific and within the person's skill set or they may revert back to the stereotyped behavior because it is more stimulating or less difficult than the activity that is planned for them.  In addition, many of the deep pressure activities that promote calming such as chewing and squeezing a ball can also provide a mild stimulating effect, which can be helpful when the person has to pay attention and concentrate.  

Therefore, I recommend that sensory regulation be part of every behavior treatment plan for people with ASD.  Once sensory regulation can be achieved, the the person's extra sensitive senses can be used as a strength and not a weakness.  Sensory regulation will also help the person with ASD be in a better physical and emotional state to receive education  and training in new skills and adaptive behavior.             

                                                            Spread the Wealth (Learning)
                                               Generalizing Skills across Multiple Situations

A hallmark feature of people with Autism has been difficulty with learning a behavior or skill and applying it across multiple settings or people.  If a skill is taught by a specific person, then the skill is only demonstrated toward that person.  If a socially accepted behavior or social skill is developed in a specific location, it only get demonstrated in that location.  This can be very frustrating for educators, families, and caregivers who work very hard, but do not see the expected results.  It can also be just as frustrating for the person with Autism who may not understand why they are not meeting expectations.  This relates to Executive Function (organizational processes of the brain) differences and a hyper-focus with learning.  

Since many people with Autism learn through visual imagery and association, the circumstances in which new learning takes place becomes connected to the demonstration of that learning.  In many cases, if the person with Autism does not see the visual cues associated with the learning, then they do not know that this is a situation to display the new behavior or skill.  There are a few techniques to remedy this situation.

The easiest way to ensure generalization of a skill or behavior is to conduct training across multiple locations with multiple people.  This will allow the person with ASD to see that this skill is to be used in many situations and can help them generalize the skill with less prompting.  Care must be taken, however, not to vary the people and settings at the same time.  This could cause confusion and become overwhelming.  Typically, the training starts with one person and one setting.  Once the skill or behavior becomes learned, then generalization can begin.  You can either have a new trainer in the same location or have the original trainer conduct the training in a new location.  Either way, it will be important to inform the person with ASD of the change.  Also, the person may need additional transition assistance such as having the original trainer accompany initial sessions with the new trainer or having the person with ASD bring an item from the familiar setting to the new location.  This will allow for a more gradual and smoother transition and is often referred to as scaffolding.  

Once initial generalization has been established, gains can be maintained and possibly increased by the use of cue control.  Cue control refers to using some type of prompt  or reminder to trigger the association of performing the skill or behavior.  In other words, it is a subtle reminder that this is an appropriate situation for the person to use what they have just learned.  For people with ASD, cue control is typically best when the cues are visual and short.  Cue cards with pictures, single words, or both are typically most effective in achieving this purpose.  Cue cards are often the size of index cards and can be attached to a key ring or other small carrying device.  The cards could be carried by a caregiver and shown to the person with Autism at the appropriate times.  If the person with ASD is more capable, they can carry the cards themselves in a place that is accessible and refer to the cards when needed.  For those who are more technology savvy, the cues can be programmed into a smart phone or tablet and can be accessed by tapping an icon or programmed to either appear automatically or respond to voice command. 

In general, learning is only truly mastered when it can be applied whenever and wherever it is needed.  Many highly skilled and well trained/educated individuals with ASD do not succeed as independent adults, in part, because there has been an assumption that the learning will automatically generalize across the various situations where it is needed.  This is not the case.  In order for individuals with ASD to be successful as adults the generalization needs to be a part of every educational experience.  Appropriate education is not just a school issue, but a home and community experience as well.  When the three areas are combined in training, then greater generalization and independence become much more likely.

Steven C. Altabet, PH.D.                      

                                                        Slow and Steady Wins the Race