Any family supporting a child with a diagnosis of autism spectrum disorder (ASD) is likely familiar with restricted/repetitive behaviors (RRBs). Disturbing or disrupting someone engaged in RRBs may cause immense anxiety and challenging behaviors. RRBs can significantly impair functioning and an adapted exposure therapy can be an effective form of treatment.
Anna O, a 7-year-old non-verbal communicator with a diagnosis of autism spectrum disorder, was referred to the Family Behavior Support and Advocacy program with Parent Network. At the time of admission, Anna’s parents reported a variety of challenging behaviors including RRBs. For Anna, there was intense focus on lining up objects in a particular manner. Anna was so fixated on how items were lined up that anyone attempting to engage with Anna amid the ritualized pattern would be met with a variety of challenging behavior that included screaming, aggression, self-injury, crying, and intense anxiety. From the moment I first met Anna it was obvious that Anna was “in charge”. Any attempt to intervene when Anna was engaged in RRBs meant that Anna would punch herself or others, bite their hands or arms, scream and cry. Why wouldn’t a parent ‘give in’ when the result may put their child (or others) in harm’s way? For Anna, RRBs are soothing and disturbances to RRBs are stressful. Only Anna knows how they want things lined up and in Anna’s mind, only they can perform the task. This meant that Anna experienced significant challenges with sharing, taking turns, and engaging in reciprocal play.
From the outset, it was important for Anna to know they were still “in charge”. Anna got to decide how much engagement and participation they were able to tolerate. This was a crucial step in building trust and rapport. The first few weeks of treatment were focused on getting Anna to tolerate my presence in the home and then when engaged in RRBs. As my presence was increasingly tolerated, I was able to observe Anna’s RRBs in closer proximity and eventually be seated right next to Anna. This adapted form of exposure therapy was being used as a form of behavior intervention to address Anna’s RRBs – and it appeared to be working! Within a month, Anna not only tolerated my proximity but sought it out. Anna would select items to line up and sit right next to me. The next step was to introduce mirroring. I brought items similar to Anna’s to her home during treatment sessions. Anna and I would sit side by side and each engage with our own objects. I would mirror (or copy) Anna’s RRBs. In less than two weeks Anna was “correcting” my mirroring errors. It was now time to introduce parallel play. During parallel play, I would use the same or similar items while engaging with the items in my preferred manner (as opposed to Anna’s preference). This step was met with some difficulty as Anna struggled with accepting that I would engage with items differently than Anna would prefer. So, we took a step back and introduced a ‘half-step’. We returned to mirroring, and introduced minor alterations that would be made one at a time (color, size, spacing between objects, etc). This helped Anna to gradually accept minor differences associated with RRBs. Anna and I stayed on this step for a few months prior to reintroducing parallel play. The second attempt at parallel play was met with less anxiety and increased tolerance. Another few months went by, with Anna and I playing next to one another during treatment sessions until one day when Anna offered me one of her items to place in line. This was a sign that Anna was ready for the next level of exposure – reciprocal play. Gradually, I introduced the concept of reciprocal play. During reciprocal play, there is interaction and engagement between two or more people with the same objects. First, Anna had to learn to tolerate sharing one set of items/objects with me during RRBs. I systematically added my items to Anna’s items so that there was eventually only one set to be lined up. Next, I would let Anna dictate when it was my turn and Anna would select the item that I was permitted to add to the line. Next, Anna would decide when it was my turn, and I would select the item. After this step I introduced a timer and would take a turn every one minute. Week by week, the duration of time between turns decreased by 5 seconds until successfully being able to take turns placing every other item in line.
Throughout the process, I worked with Anna’s family so that Anna’s parents and siblings would be able to effectively engage with Anna outside of treatment sessions while maintaining the level of exposure. After a year of treatment, Anna was able to share and take turns with siblings and parents with minimal verbal prompting and visual cues more than 90% of the time during RRBs. Positive behavioral change was observed in Anna’s interactions with classmates and neighborhood children. Anna experienced significant decreases in her self-injurious behaviors and anxiety associated with RRB’s. Anna developed coping/calming skills, socialization skills, improved her ability to self-regulate, improved her frustration tolerance, and increased her cognitive flexibility. Anna’s parents started receiving encouraging notes from the school. Anna engaged in reciprocal play with a neighbor!
The 3 keys to effectively implement adapted exposure therapy are to: let the child set the pace, break down RRBs into the smallest possible pieces, and increase the degree of exposure only after the current level of exposure is tolerated. With time and patience, RRBs can be successfully treated.
Written by: Debbie Schutt, MS, Behavior Intervention Coordinator
