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Thursday, December 5, 2013
Stopping Mouthing/Chewing in A Child with Autism
I am a one-on-one teacher for kids with autism. One of them is an autistic nonverbal boy age 6. He is just learning the PECs system of communication and is having some success, though his self-initiated communication is still sporadic at best. He knows how to communicate what he wants by using PECs, but he prefers to grab items himself or simply scream to get what he wants instead of going through the process of PECs.
I am very concerned right now because he has some pretty severe chewing and mouthing behaviors. If he does not have his chewy toy with him (provided by his OT), he will put anything and everything into his mouth. If he finds a squishy item, he will chew it. If he finds a hard item, he will suck on it. If he finds chalk or playdough, he will eat it. He will also pull the strings off of Koosh balls and eat them, as well as suck on craft pom-poms or rubber balls. This is all very distressing because of the obvious choking and hygiene hazards, as well as behavioral concerns.
When he has his chewy, he will rarely put anything else in his mouth. Our problem now, though, is that his chewy seems to have become an obsession with him, despite our constant efforts to keep it as a reinforcer for tasks, etc. Now it seems that when he DOES have the chewy toy, he becomes more tense and more aggressive. This is opposite to what use to happen...the chewy toy used to calm him down and help him focus a little better. Lately we have noticed a drastic increase in aggressions to staff, other students, and himself WHILE he is chewing his chewy toy.
We have tried using different chew toys, and using them as reinforcers and not things he`s just allowed to have all day long, because the longer he chews them the more aggressive he gets.
So now we are in a position where our instinct is to phase out the chewy toys to decrease the aggressions and tension we see when he`s chewing them...but that puts us right back to square one where he eats/chews/sucks on everything he can find. And now we find that when he does not have his chewy toy, he will tantrum and be aggressive as much as when he DOES have it.
I have also been trying pressure on his face and head, which he seems to really crave. He will ask for it by placing my hands on his head or cheeks and pushing on them with his own hands. The head pressure does seem to calm him down at times, but it doesn`t seem to help with the chewing.
This is very distressing because I worry about his safety when he puts things in his mouth. I also worry about the dramatic increase in aggressions and physical tension I see in him when he is chewing now. It is obvious that the chewing has a purpose for him...either sensory (pressure-related) or as stress-relief, or both. I would like to redirect him to some more appropriate activities for the sake of reducing the new tension and aggressions, but his lack of communication/eye contact and the severity of his stereotypical and perseverating behaviors make it very complicated.
I care for my student very much, and I am very concerned for him. His progress in other areas has decreased as the chewing obsession has increased. Do you have any suggestions? I would be very grateful for any ideas you can offer.
Keep working on developing this child's communication skills. It is very important to develop his alternative communication system (e.g. PECS) to include a large vocabulary, independent use, and self-initiation. Do not accept any negative behaviors as communication, and insist on him using PECS, signs, or verbalizations. Do not respond to negative, destructive or tantrum behaviors in any way that reinforces him. Initiate and maintain parent training with PECS and support the parents to use this alternative communication setting at home and in the community.
Some instructors move through the PECS training phases too quickly or too slowly. It is important that you spend sufficient time in phase one working through the fully assisted exchange and fading your assistance to the open hand cue. When a child is responding 95-100% of the time to the open hand cue, then and only then should you move on to phase 2 and work through the 3 steps designed to increase spontaneity. Be aware that children become dependent upon your assistance (e.g. prompt dependent) during phase 1; if you fade your assistance or prompts, even just a bit on every PECS exchange, you'll avoid prompt dependency. As an aside, some children who are successful with PECS but who do not develop vocal speech are good candidates for an electronic communication device.
Your student's chewing problem, also called PICA, is a very disturbing and dangerous behavior. You are right to be concerned about this. The interventions for this are varied and complicated, and work to varying degrees depending on the child. My first recommendation is that you work with a behavioral psychologist to complete a behavioral assessment and to develop a comprehensive plan to address this. You have tried a common "replacement behavior" intervention by offering a chewy toy, but it sounds like you don't think it is working. And, in fact, in many cases the intervention you described (e.g. providing a chewy toy) does not work as well as people would hope.
The range of interventions available for treating PICA are too complicated to describe here, but one option for your team is to consult with an outside behavior specialist. You could contact our Developmental Assessment Program at Nationwide Children's Hospital (NCH) in Columbus, Ohio at 614-355-8315 or Dr. Kimberly Brown at the psychology department at NCH (6141-722-4700) to seek consultation. There are also some private practitioners you could seek, and if you call NCH we could give you additional referrals.
But, follow your data. If the aggression has increased, then you know that whatever intervention you have designed to decrease aggression is not working. Of course, the chewy toy may not necessarily be related to the increase in aggression, but a behavioral assessment would help determine that.
Eric Butter, PhD
Clinical Associate Professor of Pediatricsl
Adjunct Assistant Professor of Psychology
College of Medicine
The Ohio State University