Final Question on Repetitive Play Patterns, Perseveration and Self-injurious Behaviors

What are four key take home treatment strategies that SLP’s and OT’s can apply given the literature and discussion provided? What is the rationale for each of the take home strategies? 

Blog questions 1 and 2 examined and defined Repetitive Play Patterns, Perseveration, and Self-injurious Behaviors, how they manifest, and what their impacts are.

In developing treatment strategies in this area it is important to consider each child individually. Researching the topic would indicate that there is no single intervention can universally reduce or eliminate repetitive behaviors, perseveration and self-injury. However it is important to look at the behaviors, consider what might be the cause, motivator or reward, and look at how and to what degree they impact that individual’s life. OT and SLP working together can bring additional perspective and angle to treatment strategies. Co-treating can achieve the joint benefit of reinforcing each others' goals which can help consolidate new skills and assist with generalization.

Repetitive behaviors primarily impact individuals in three areas: socialization, communication and learning. (ref Blog question) Some of the reasons or causes of repetitive behaviors include:

• Stress and/or anxiety: Repetitive behaviors can assist the individual in self-calming, and sometimes provide sense of structure and comfort. Self-injury can cause endorphin release in brain. 

• Attention seeking or avoidance of demands or attention.

• Physiological Causes: self-injurious behavior may be caused by pain that isn't being addressed, illness or infections, tic disorders (Clements and Zarkowska, 2000), sub-clinical seizure activity.  

• Communication: to convey frustration or other emotions when more effective forms of communication are not possible. 

• Environmental Causes: It is possible that arousal levels and sensory issues may lead to repetitious and self-injurious behavior.
  
• Poor Executive Functioning and lack of imagination can lead to restricted repetitive play which in turn can impact learning, communication and social skills (ref Blog Q.2.)

Treatment Strategies

If it is considered that the behaviors are adversely impacting the individual’s life, the treatment strategies will directly relate to the both the probable causes and the areas of life negatively impacted.

1)Communication and social skills: Research has shown that individuals with an ASD who are actively involved in communication social programs are less likely to engage in repetitive behaviors. Studies have also shown that social isolation can cause an increase in repetitive and self-injurious behavior. (for more information refer to Ann K’s Blog on Behavioral and Social Engagement Intervention, Deepali’s blog on Communication, and Jen's on Emotion and Face Processing)  Module 2. Q.1   Mod 6 Q1 &2  Mod 7 Q1   Mod 5 Q 4  Mod. 4 Q3

2) Environmental causes: Look at the individual’s ability to deal with sensory stimulation and look at the environments. Do specific stimuli cause over arousal? Is he/she using repetitive behavior or self-injury to cope with sensory sensitivity?  Or the opposite, is he/she seeking out sensory input in response to under arousal or boredom?  Activities such as biting hands may be a way to let off steam in an environment that is too loud or complex. For those with low levels of arousal, inducing pain may be a way to provide stimulation.  Treating self-injurious behavior may be as simple as reducing or increasing the stimulation levels in the environment. For some an environment that includes toys, a lack of demands, and reinforcement for non self-injurious behaviors and redirection seems to work the best. (Iwata et al, 1994) Mod 3 Q 2

Other sensory based strategies that can be explored include deep pressure or proprioceptive input activities such as rope climbing, wheel barrow, jumping on a trampoline or pushing and pulling heavy toys. This type of play will activate receptors in the muscles and joints which can have the effect of calming the nervous system and bringing the child into a more optimum level of arousal where they are more receptive to learning new skills and communication.

Strategies for dealing with other sensory sensitivities include trying earplugs or earphones for auditory sensitivity, Irlen glasses or sun glasses to cope with changes in lighting, for tactile sensitivity look at clothing that isn’t restrictive or have rough tags. For some children simple, uncluttered environments can reduce repetitive or self-injurious behavior. (ref Blog Q.5) Mod 3 Q2

Providing safe space and limited times for stimming might allow children to release stress caused by their environment. For some it is very helpful to teach the child how to seek help when they are feeling overwhelmed or frustrated. Programs like the Alert System (how does your engine run) or Stik kids work by helping the child identify specific strategies to use when they feel over stimulated.

(ref. Blog Q.5)

3) Self-injurious behaviors:  First look at and eliminate possible health issues which may be causing pain or discomfort.  (refer to Audra’s blog on GI Issues and Diane’s on Alternative Medicines)

Strategies to prevent the child from causing themselves actual bodily harm ideally should be short term and should not draw negative attention to the child. For head banging a helmet can help reduce injury. In blog question 3 one mother used padded sports gear in an effort to protect her son from doing actual bodily harm. She also felt the sports gear might look less restrictive or medical. Sometimes providing a ‘chewy’ can reduce hand biting. (ref.Blog Q.3)

4) Executive functioning/Play skills: working on the child’s ability to play constructively and creatively. The lack of imagination and the difficulty forming a play plan can lead to repetitive restrictive play patterns. Research suggests that without the ability to regulate behaviors or to inhibit repetitive behaviors, the child with ASD may become “locked in” to certain behaviors. (Turner, 1999) (ref. Blog Q.4 &2)  Mod.5 Q.1     Mod.3 Q.3

A treatment approach that encompasses the child’s interests and then encourages and expands their play repertoire through ‘chaining’ can be helpful. A child who is simply spinning the wheels on a car can be shown how to roll it along the floor or to a peer or sibling. Creating the just-right challenge in play is important, meet the child where they are at and widen their world of play. Ensuring the approach is both fun and playful is important. Including TD peers or siblings in play both at home and in pre-school or school can model creative play and social skills for the child with an ASD. (ref. Blog Q.3)