Abstract
This chapter will provide several handouts for parents to help tailor Parent-Child Interaction Therapy (PCIT) skills to manage autism spectrum disorder (ASD)-related behaviors (e.g., repetitive play, sensory dysregulation, insistence on sameness, poor social skills). Handouts cover how to manage ASD-related behaviors within the context of PCIT’s two phases: Child-Directed Interaction (CDI) and Parent-Directed Interaction (PDI). The chapter will additionally provide strategies for clinicians to help parents generalize skill acquisition to the home (e.g., additional considerations for setting up Special Time practice) and community environments (e.g., using CDI skills throughout the day). This chapter and the accompanying parent handouts aim to provide information for clinicians to best support families of children with ASD in generalizing these skills to manage ASD-related behaviors.
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Appendix: Parent Handouts for Managing ASD-Related Behaviors
Appendix: Parent Handouts for Managing ASD-Related Behaviors
1.1 What Is Autism Spectrum Disorder?
Autism Spectrum Disorder , or ASD, can affect your child’s ability to interact and play. Children with ASD aren’t trying to be difficult, their brain works differently which means they see and understand the world in a different way than most people. This can be hard for many parents to understand because children with ASD have trouble with things that may come naturally to you. They may have problems communicating, being social, and playing with other people, especially other kids. They may also show certain behaviors that can seem “odd,” off-putting, or disruptive. Some parents find it helpful to learn more about their child’s ASD-related behaviors so they can respond with more patience, understanding, and compassion. While ASD tends to look pretty different from one child to the next, here is a list of behaviors you might notice.
1.2 ASD Symptoms and Challenges
1.2.1 Social Communication and Interaction Challenges
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Trouble with verbal (talking) and nonverbal (eye contact, gestures) communication.
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Not noticing social cues/rules, like interrupting when you are talking with someone else.
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Not offering to share or take turns in play or when talking.
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Trouble noticing how other people feel, or telling people about their own emotions.
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Not knowing how to play with toys, or may play with them the same way each time.
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Would rather play alone than with other people.
1.2.2 Restricted and Repetitive Behaviors
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Making unusual noises or saying the same thing over and over.
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Moving hands or body in unusual or repetitive ways.
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Becoming upset when moving from one activity to the next.
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Trouble with sudden changes in routines or schedule.
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Strong or “obsessive” interest in certain toys or topics.
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Getting easily overwhelmed by loud, new, or crowded situations (like shopping malls).
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Having strong, sometimes sudden emotional outbursts and trouble calming down.
Children with ASD live in a social world that may be confusing and overwhelming. This can lead to anxiety, acting out, or avoiding new situations. This may also make it difficult to engage, play with, and enjoy your child during Special Time and throughout the day. Even with these challenges, children with ASD often have unique strengths—attention to detail, excellent memory, logical and rule-oriented personality—all of which make PCIT a great treatment choice for you and your child! The strategies you learn in PCIT can help you make the world a little bit more predictable for your child and make it easier for you to feel connected to one another.
1.3 Special Time: Additional Tips for Parents of Children with ASD
Play is hard work for children with ASD. These “on the job” tips may help answer some of your questions and make it easier for your child to play and enjoy being together during Special Time.
1.3.1 Toy Selection
Finding the right toys to engage your child is very important. You will want to follow the guidelines explained by your PCIT therapist during the CDI Teach, but it is also helpful to give some extra thought about the specific toys you put out during Special Time. Picking toys that will catch your child’s attention can help make the play more fun for everyone. Put out one toy you know your child will really like, and then choose 1–2 more toys that might be interesting to him or her. It some cases, it might be a good idea to have the same toys every session so your child knows what to expect. Once your child gets used to playing with other types of toys, you can remove or replace his/her “preferred” toys with different ones.
Sometimes children get “stuck” on a specific toy. While playing with this toy, he/she may show more problem behaviors that make it harder to get his/her attention or interact. In this case, you may need to put this toy away during Special Time. Try to have other, similar toys available. For example, if your child really likes cars and enjoys watching the wheels spin, choose a different set of vehicles with similar features like a helicopter. Try to avoid toys with set instructions (like a Lego manual), or remove the instruction booklet , as children with ASD can become really focused on following the instructions.
1.3.2 Structuring the Environment
Putting in a little extra effort in setting up the area in your home used for Special Time can go a long way. Children with ASD can be more sensitive to specific “sensory” parts of their world. If your child gets upset by bright lights, choose a room with dim lighting. If he/she is distracted or startled by noise from the room next-door, set up a fan or white noise machine to soften those sounds. A smaller room with less clutter or distractions may also make it easier for your child to focus and sit still. It may help your child feel calmer to always use the same room for Special Time.
Children with ASD like to know what to expect. Practicing Special Time every day can give them something to look forward to in their schedule, which can help lower anxiety and outbursts. Build Special Time into your daily schedule. Choose the same time each day. It can even help to make a “visual schedule” to use with your child so it is even clearer when your child can expect to have Special Time. For example, write down a list of activities that your child does each day before or after school. Write in Special Time as one of the activities. Draw pictures or use clip art along with words in your schedule to make it very clear . Put your schedule up on the refrigerator or wall where your child can see it. Here is a sample visual schedule:
During transitions, such as starting school, during trips, or on holidays, it is even more important to keep Special Time as part of your daily routine. Children with ASD can become even more stressed by these changes in schedule. They may be more irritable or have more outbursts. The more regularly you have Special Time , the less stressed your child will be. Also, if you expect a change in your routine, be sure to give your child a warning first, and to show your child how the day will be different by making changes to your “visual schedule.”
1.3.3 Let’s Warm Up
For children with ASD, play is work—it might not come as naturally to them. Try to pay attention to how your child is acting during Special Time. Sometimes children with ASD need some “warm up” time or may take longer to enjoy play. Just an extra 1–2 minutes in the beginning of Special Time where you play alone, or side by side, with your child may help give him/her time to settle in and be more open to play time with you.
Notice how your child reacts when you try to use the PRIDE skills. Does he or she look up at you, smile, start to talk more, move closer to you?—Great! It’s working! Sometimes, though, children with ASD may not be used to getting so much attention and may be resistant at first. It’s normal for some children to turn away, get upset, or tell you to “stop talking!” Remember that children with ASD can get overstimulated more easily than other kids and all this parent attention may just be “too much” right now. That doesn’t mean you should stop though. If you seem to be getting some push back, take a breath, say something like, “Okay, it seems like you’re not ready yet,” and play on your own next to your child for a while. If your child uses words to tell you he/she doesn’t want to play (instead of hitting or crying), that’s a great opportunity to praise those communication skills! You could respond by saying something like, “Thank you for using your words to tell me you want to use the trains by yourself. I’ll play with these blocks for a while.”
During the “warm up,” keep an eye on your child and look out for signals or “clues” that he/she is ready for some of your attention again. If he/she starts using some of the toys you have in front of you, or says something to you about the toys, that might be a good clue that your child is ready to accept some PRIDE skills. It might be a good idea to keep your statements short at first (for example, “Nice sharing,” “Good building,” or “Thanks for telling me”).
When children react poorly to your efforts to interact , you might be tempted to try harder to get your child’s attention. It is important to resist this urge. Your child is trying to tell you that it is too much right now—that his/her brain needs time to process. Even though it is hard to hold back, it might help to wait quietly and patiently for your child to be ready. Taking deep breaths, telling yourself “he’ll play with me when he’s able,” and focusing on what you are doing can help you stay calm and resist the urge to jump in. Taking the time to warm up helps show your child that you are listening to their signals, and accepting how he/she is able to play right now.
As your child warms up to Special Time, you may notice more talking, sharing of toys, sitting more calmly, and interacting more with you. It may take some time to get to that point though. For some children, it could take only 1–2 minutes, for others, it may take a few weeks. By taking the time at the beginning—listening to your child’s cues, using a few PRIDE skills here and there, and being very consistent with Special Time practice—you will get there and it will be well worth the time and effort you put in!
1.4 Managing ASD-Related Behaviors with CDI Skills
How you respond to your child’s ASD-related behaviors can help him/her learn new ways of playing and talking with other people. Just because a skill is difficult for your child right now does not mean it has to stay that way! It just means we may need to work a little harder to help him/her learn things that may come more easily to other kids.
As you are learning in PCIT, your attention helps teach your child new skills! When you reward a behavior with your attention, you will see more of that behavior. So, we want to notice “positive opposites” of challenging behaviors. The positive opposites we want to pay extra special attention to are ones we may all “take for granted,” or expect to see. Little things like looking at you, talking with you, playing with you, using greetings, and saying “please” and “thank you” may come naturally to you, but chances are they are really hard for your child to do consistently. That is why they need a little extra encouragement and help from you to learn them.
1.5 Positive Opposites of ASD-Related Behaviors
• Using more than one type of toy (flexibility) | • Sharing |
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• Staying calm when things change | • Making eye contact |
• Using words to make needs known | • Taking turns |
• Trying something new | • Including you in play |
• Pointing or showing toys | • Being gentle with the toys |
• Using gestures or other ways to communicate | • Expressing frustration with words |
Sometimes adding an explanation to the end of a Labeled Praise can be a powerful teaching moment for your child. Tell your child WHY you like what he/she did, and why it is important. For example: “Thank you for looking at me [Labeled Praise]. That lets me know you are listening to me [Explanation]!” Or, “Great job for sharing the toy with me [Labeled Praise], it’s much more fun when we play together [Explanation].”
1.6 Meeting Your Child Where He/She Is at, and Slowly Expanding
Sometimes it can be hard to find something positive to praise, especially when it seems like your child does not really want to play with you. On the other hand, it can be pretty frustrating when he/she only likes doing the same thing over and over again. We can slowly help your child learn to play differently by meeting your child where he/she is at right now, and raising our expectations little by little, over time. This may take a while, but if you stick with it, your child will be able to learn these skills.
First, figure out the specific behaviors you want to work on. Start with just 1–2 behaviors at a time. So, if you want your child to notice and play with you instead of by him/herself, first you have to ask yourself, where is my child at now? What do I see my child doing on his/her own? Next, figure out what you are working towards. What do you want to see your child do? Finally, write down every single step in between. Give your child A LOT of attention when you see each little step (even if it was very quick or seemed accidental)—use Behavior Descriptions , Labeled Praises, and Enjoyment together! Here is how this might work:
Steps to a new behavior | How to respond with PRIDE skills |
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• Turning towards you | • “Thank you for turning around! I am happy I can see your face now” |
• Moving closer to you | • “You are sitting near me, thank you for coming closer!” |
• Looking in your direction | • “You’re looking over at me. Great noticing me” |
• Looking at the toy you are using | • “Thanks for showing interest in what I’m doing” |
• Looking up at you (even briefly!) | • “Thanks for looking at me. I like that we are playing here together” |
• Looking you in the eye | • “You’re looking right at my face! Nice job looking!” |
• Smiling at you | • “You’re so sweet to smile at me! When you smile it lets me know that you’re happy. I love playing with you too!” |
What if your child doesn’t seem to know what to do? Well, then you might have to SHOW him/her first. We call this “modeling.” You can demonstrate the positive behavior you want to see. This can work really well when trying to teach new skills like imaginative play and coping with strong emotions.
For example: Your child only likes playing with cars, and during Special Time repeatedly rolls the car down the ramp. You roll a car down the ramp in imitation once or twice. Then, you pick up a miniature person and push it down the ramp saying, “The man is going down the slide! Wheee!” Do this again a few times, then hand the man to your child, or place it at the top of the ramp. When your child pushes the man down the ramp, even if by accident, comment enthusiastically, “Now you are making the man go down the slide [Behavior Description]. I love that you are doing something new [Labeled Praise]! Great job playing with the people too [Labeled Praise]!”
1.7 Be Patient!
Behavior does not change overnight. It takes a lot of planning on your part to help your child learn new skills. Children with ASD often learn new skills at a slower pace and may take a while to show those skills consistently in different environments. Be patient . Try and take a step back and look at the “big picture.” It can be easy to focus on behavior from just one day, but try to think about what Special Time practice was like a week ago, or two weeks ago instead. Notice the “little victories.” Maybe today your child seemed pretty “stuck” on a certain way of playing, but he/she was so much calmer when things did not go his/her way. Sometimes it can be hard to catch positive changes in one behavior when your attention is focused on another.
Your child is so lucky to have you on his/her team, committed to a treatment that will help him/her learn. It may take your family some time but PCIT will help your child develop new play and social skills, and the rewards will be well worth the wait. Stick with it!
1.8 Having PRIDE Throughout the Day
Children with ASD need extra practice and reinforcement to learn social skills. As you get more practice with the PRIDE skills during Special Time, you may find that you start to use them naturally throughout the day. Using PRIDE skills (especially Labeled Praises for Positive Opposites) during different times of the day can help your child carry over the good behaviors you are starting to see during Special Time to other social situations. Unfortunately, though, generalization, or the “spreading” or “expansion” of skills is not automatic. And children with ASD tend to have an especially difficult time with generalization . Deliberately setting up opportunities for your child to practice social skills outside of Special Time can help your child generalize the good behaviors he/she learns with you in Special Time. This will help him/her better relate to and play with other people beyond parents.
Look for natural opportunities throughout the day to use PRIDE skills. Start by making a point to notice Positive Opposites in your child at home throughout the day. It may be easier to just pick one or two “target behaviors” to look out for during the day. If your child has a really hard time staying calm and using words to communicate needs or frustrations, you might try to notice these types of behaviors in situations that are especially challenging.
For example, when your child is struggling with homework and says, “This is too hard!” You could respond, “Thank you for telling me that this problem is hard for you [Labeled Praise]. I can help. Great staying calm [Labeled Praise].” Other real-life activities where you can catch your child using Positive Opposite behaviors at home throughout the day might include:
• Getting ready for school or bed | • Playing near or with siblings |
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• Dinner time | • Waiting for a turn |
• Homework | • Conversations with family members |
• Transitioning to a new activity or place | • Stopping a preferred activity |
• Bath time | • Daily chores (washing dishes, laundry) |
After you’ve become more comfortable noticing and praising Positive Opposites during Special Time and at home throughout the day, now try to “catch your child being good” outside of the house, in the community. There are many opportunities to practice. Start by choosing one or two specific situations to practice. Challenge yourself by praising Positive Opposites in more and more typical life situations. Here are a few ideas to get you started:
• Eating at a restaurant | • At a religious service |
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• At the playground | • At the library |
• At a friend’s house | • In the grocery store |
• On a car trip | • Walking down the street |
• When greeting others | • At school pickup |
It also can be helpful to deliberately plan “low-pressure” situations where you can point out and praise positive behaviors you see in your child. These are settings where he/she is most likely to show good social skills because they are the most familiar or the child has enough adult support. Maybe invite an older cousin or nice classmate over for a playdate, or go to a favorite park. Set up play activities you know will be fun for your child. Stay with or near your child so you can catch him/her using good social behaviors.
The most reliable way to generalize skills is to teach your child (through your praise and positive attention) with as many different examples as possible across people, settings, and behaviors. The more you notice and praise these good behaviors throughout your child’s daily life, the more meaningful and long lasting these positive changes will be for him/her and your family.
See Alternative CDI Homework Sheets: “Using CDI at Home Throughout the Day” and “At Home and in Typical Life Situations” to help guide your practice and keep track of your progress with using PRIDE skills throughout the day.
1.9 CDI Homework Sheet (Using CDI at Home Throughout the Day)
Child’s Name ___________________ Parent’s Name ___________________
Date___________ | SPECIAL TIME PRACTICE Did you spend 5 min in Special Time today? | CDI DURING HOME ACTIVITIES Did you practice using PRIDE skills at home outside of Special Time? | TARGET POSITIVE OPPOSITES LIST HERE: ______________ ______________ List examples of Labeled Praises. | What types of home activities? Any questions or problems? | ||
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Yes | No | Yes | No | |||
Monday ___________ | ||||||
Tuesday ___________ | ||||||
Wednesday ___________ | ||||||
Thursday ___________ | ||||||
Friday ___________ | ||||||
Saturday ___________ | ||||||
Sunday ___________ |
1.10 CDI Homework Sheet (Using CDI at Home and in Typical Life Situations)
Child’s Name ___________________ Parent’s Name ___________________
Date___________ | SPECIAL TIME PRACTICE Did you spend 5 min in Special Time today? | CDI DURING HOME ACTIVITIES Did you practice using PRIDE skills during other activities at home? | OTHER CDI PRACTICE Did you practice using PRIDE skills in typical life situations outside of the home? | What types of situations? List examples. Any questions or problems? | |||
---|---|---|---|---|---|---|---|
Yes | No | Yes | No | Yes | No | ||
Monday ___________ | |||||||
Tuesday ___________ | |||||||
Wednesday ___________ | |||||||
Thursday ___________ | |||||||
Friday ___________ | |||||||
Saturday ___________ | |||||||
Sunday ___________ |
1.11 Managing ASD-Related Problem Behavior with PDI: Hierarchy of Commands
Play Commands to Use During Special Time These types of commands can encourage prosocial behaviors in the context of play | ||
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“It’s your turn, please take the train” (child loves playing with trains) | “Please put the red car down the ramp.” (child enjoys this activity) | “It’s my turn to build. Please put the blue Lego in my hand” |
“Now it’s my turn, please put both hands on your lap, like this” | “I want to play with you, please sit next to me, here [point]” | “Oh no, the tower fell down. I want to build it again. Please put the blue piece here [point]” |
“I like the dinosaur you made (child’s special interest is dinosaurs). Now draw a tree” | (Child is lining up the cars) “Now put this animal next to the car” | “Please put the toy away gently, like this [demonstrate]” |
Real Life Commands to Use at Home Throughout the Day Real life commands can be used to teach daily living skills, encourage independence, and improve coping skills. It is important to know what your child is capable of doing already so you do not unfairly give a command for something he/she has not yet learned how to do | ||
“You are finished eating, please put your plate in the sink” | “Please use a quiet voice” | “It’s time to start your math homework, please write your first name here” |
“It’s time to leave now, please put on your shoes” | “It’s time to practice staying calm [parent takes a deep breath to demonstrate]. Take one deep breath” | “You have two choices [present options]. Please use your words to tell me what you want” |
“Please give your brother a turn at the game” | “Please share the toy train with your sister” | “It’s dinner time. Please turn off the tablet” (child has trouble transitioning) |
Public Behavior Commands to Use Outside the Home and in Social Situations Commands can also be used to promote safety and encourage polite, prosocial, and adaptive behavior in new, unfamiliar, or social settings | ||
“Please walk on the sidewalk” | “We need to cross the street now. Please hold my hand” | “We are walking in the office now. Please use your indoor voice” |
“Please tell the waiter what you want to drink” | “Please wave goodbye/say hello” | “You interrupted me while I was talking. Please say ‘sorry’” |
“Share the car with your friend” | “Please sit next to your sister” | “Please wait in line for your turn on the slide” |
1.12 Putting It All Together: Addressing ASD-Related Problem Behavior with CDI and PDI
Problem behavior | LP for positive opposite | DC for positive opposite | DC for incompatible behavior |
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Wandering around the room | “Thank you for standing next to me while we talk” | “Please stand still” | “Please sit down in the chair/next to me” |
Putting toys in mouth | “Great job keeping your hands and mouth to yourself” | “Please take the car out of your mouth” | “Please put the car down the ramp” |
Waving hands repetitively | “Nice quiet hands you have” | “Please put both hands on your lap, like this” | “Please put the crayons back in their box” |
Takes toys away from others | “Thank you so much sharing your crayons with me!” | “Please put the crayon back in my hand” | “Please sit in the chair over there to color” |
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Burrows, C.A., Parladé, M.V., Garcia, D., Jent, J.F. (2018). Helping Parents Generalize PCIT Skills to Manage ASD-Related Behaviors: Handouts and Clinical Applications. In: McNeil, C., Quetsch, L., Anderson, C. (eds) Handbook of Parent-Child Interaction Therapy for Children on the Autism Spectrum. Springer, Cham. https://doi.org/10.1007/978-3-030-03213-5_22
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