Category Archives: Autism and Mental Health

AUTISTIC SOLUTIONS RELATED TO TAKING IN INFORMATION: Direct Instruction of Social Information

Autism and Mental Health, Autistic Mental Health, ,

This series of blogs and the release dates are as follows:

AUTISTIC SOLUTIONS RELATED TO TAKING IN INFORMATION
Part One: Using Words to Make Pictures (January 13, 2023)
Part Two: Using Words to Describe Pictures (February 10, 2023)
Part Three: When Feelings Are Too Big (March 10, 2023)
Part Four: Examples Using Paint Chip Visual Supports (April 7, 2023)
Part Five: Direct Instruction of Social Information (May 5, 2023)

I would like to tell you a story. It took awhile to sort it out. The support worked because it was in line with the neurology of this client I will call Shelby.

I once worked with a young lady who experiences intense feeling that come on quickly whenever her neurology is hit with a surprise. Remember, a neurological surprise is not necessarily a practical surprise.

This young lady, even though she knew she was soon to leave the house to come see me, when her mom said, “Time to leave. Let’s get in the car,” Shelby’s neurology was hit with this surprise because she hadn’t been tracking the time. This meant Shelby’s fight or flight survival instinct was triggered and she yelled, “No, I’m not going!” while throwing objects and crying. This often made her late to places she was going.

For Shelby, it made sense to teach her how to track time when she needed to leave the house. This prevented the intense feeling from happening. Since Shelby always carried her cell phone with her she received direct instruction along with deliberate practice on setting the timer to go off five minutes ahead of leaving time. When the timer went off she had a few minutes to stop her activity, gather her purse and get to the car.


There are undoubtedly more ways to manage big feelings than there are clients who struggle with them! Our own creativity as clinicians can shine here. I have had many clients who have come to manage their own intense feelings that, in turn, allow them more options in their lives. Some of them learn a few feeling labels along the way and for others the labels that go with their feelings still elude them. Please don’t get stuck on teaching your clients to label their feelings at the expense of helping them learn to manage their feelings.

Direct Instruction of Social Information

Just like autistics often need direct instruction and practice on how to make their own pictures in their heads when reading a book so that they can comprehend what they are reading, they also often need direct instruction and practice when it comes to learning social rules. Because of autistic brain function, no matter how many times an autistic is in a given situation where others would automatically learn the expected social skill, his brain will have great difficulty being able to identify the social skill and to then use it going forward.

For autistics the social information simply doesn’t get automatically uploaded into the brain as it does for neuromajority people. This social information that we expect one another to know is called the hidden curriculum. Most of the time it is the most important information when it comes to getting along in the world. The hidden curriculum social information often needs to be directly taught to individuals with autism.

This has nothing to do with cognitive ability, but instead it has to do with the brain’s inability to consistently pick up and apply social information in such a way that it becomes part of their very being as they go forward in life. For example, most very young children generally learn that if you want to have a friend to play with it is more likely to happen when you are friendly, share your toys, and take turns when playing a game. Autistic children often need direct instruction and many times of practice to learn these socially expected behaviors.

For one example using direct instruction to teach a client how to be a good loser when playing a game please refer to the blog Autism, Direct Instruction and Having Friends.

Selection from: Autistically Thriving: Reading Comprehension,
ConversationalEngagement, and Living a Self-Determined Life
Based on Autistic Neurology, pg. 144-145.

Note: The author is a mental health therapist and is also autistic. She intentionally uses identity-first language (rather than person-first language), and invites the reader, if interested, to do further research on the preference of most autistic adults to refer to themselves using identity-first language.

If you are a clinician and interested in learning more about therapy with the autistic client please join me along with two of my colleagues in an online course.
CLICK HERE for additional information about  Mental Health Therapy with the Autistic Client.

BY JUDY ENDOW

Endow, J. (2021). Executive Function Assessment. McFarland, WI: Judy Endow.

Endow, J. (2012). Learning the Hidden Curriculum: The Odyssey of One Autistic Adult. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2006).  Making Lemonade: Hints for Autism’s Helpers. Cambridge, WI: CBR Press.

Endow, J. (2013).  Painted Words: Aspects of Autism Translated. Cambridge, WI: CBR Press.

Endow, J. (2009b).  Paper Words: Discovering and Living With My Autism. Shawnee Mission, KS: AAPC Publishing.

Myles, B. S., Endow, J., & Mayfield, M. (2013).  The Hidden Curriculum of Getting and Keeping a Job: Navigating the Social Landscape of Employment. Shawnee Mission, KS: AAPC Publishing.

AUTISTIC SOLUTIONS RELATED TO TAKING IN INFORMATION: Examples Using Paint Chip Visual Supports

autism, Autism and Mental Health, ,

This series of blogs and the release dates are as follows:

AUTISTIC SOLUTIONS RELATED TO TAKING IN INFORMATION
Part One: Using Words to Make Pictures (January 13, 2023)
Part Two: Using Words to Describe Pictures (February 10, 2023)
Part Three: When Feelings Are Too Big (March 10, 2023)
Part Four: Examples Using Paint Chip Visual Supports (April 7, 2023)
Part Five: Direct Instruction of Social Information (May 5, 2023)

This blog continues from the previous blog When Feelings Are Too Big and, as promised, includes several clinical examples of using paint chip visual supports.

I use paint chip samples from the hardware store – the book marker looking samples that show intensity of the paint color you are contemplating painting your walls. Clients choose the color they want to use and it is stapled to a piece of paper.

I usually divide the strip into sections of three by drawing lines and labeling the sections small, medium, large. We start by writing down examples of things since the last appointment that cause the client’s feelings to be small, medium and large. These answers are written into the corresponding place on the visual we are creating. Besides being a way for me to learn about the client’s week, it gives my client’s a structure for their appointment times along with teaching the system of small-medium-large and how to use it to define/plot feelings.

General example of showing the visual system of small/medium/large with paint chips:

The following are specific examples with a variety of autistic clients across the life span. Remember these are just a few examples. Also, for each photo, there is a context of a specific client situation it fit into, i.e. these photos of examples are not random, but apply to specific client contexts. All in all, there are limitless ways to use paint chips to show size of feelings. Sometimes extra words are written on the page and sometimes there is no narrative, depending on what is helpful to the particular client. The examples here were chosen so that there is enough narrative that the reader can understand the use of the paint chip visual.

These sorts of visuals allow for exploring ways to get more intense feelings to become less intense. Sometimes my client can tell me things they did that were helpful in causing an intense feeling to become less intense, but most of the time they need direct instruction. I accomplish this in a variety of ways, matched to the particular client.

Some additional examples include:

    •  For one client who used mindfulness, teaching and implementing three different mindfulness practices, keeping data on their effect on bringing big feelings down was helpful.
    • Teaching and practicing sensory strategies. These strategies can then be implemented both on a regular basis (proactively) so as to keep the sensory sytem more regulated and in response to (reactive) experiencing a big feeling (Mahler, 2016, 2019).

    • Using The Interoception Curriculum: A Step-by-Step Guide to Developing Mindful Self-Regulation (Mahler, 2019) has been significant for a number of clients in supporting the body-emotion connection.

    • Expand the small, medium, large feelings to a 5-Point Scale (Dunn-Burron, 2012).

    • Use the activity A 5 Could Make Me Lose Control (Dunn Buron, 2007). This activity has several cards depicting a variety of situations. The client places the card in one of the pockets numbered 1-5 that replicate the numbered order of the 5-Point Scale. For example, if making a phone call is mildly anxiety provoking a client might put that card in the pocket labeled 1 or 2 and if it causes the most anxiety ever it would be placed in the pocket labeled 5. This activity provides information that allows a client to then be supported in thinking through what to do the next time the item on the card occurs – in this case, making a phone call.

    • Teach Kerry Mataya’s visual problem-solving method  (Mataya & Owens, 2012). This consists of a visual depicting the choices in ways to solve a problem along with protocol to teach and practice the problem-solving choices. Once the skills are learned the client can use the Problem-Solving visual each time feelings get big and keep data showing the number of the feeling on the 5-Point Scale when escalated, which problem-solving strategy was utilized and what number the feeling was on the 5-Point Scale after implementing the problem solving strategy.

The take away point here is that we can teach our clients to successfully manage their big feelings without needing to teach the labeling of these big feelings! Often I invent helpful solutions during client sessions that apply to that one individual.

Selection from: Autistically Thriving: Reading Comprehension,
ConversationalEngagement, and Living a Self-Determined Life
Based on Autistic Neurology, pg. 142-144.

(The next and last blog in this series, Direct Instruction of Social Information, will give yet another clinical example.)

Note: The author is a mental health therapist and is also autistic. She intentionally uses identity-first language (rather than person-first language), and invites the reader, if interested, to do further research on the preference of most autistic adults to refer to themselves using identity-first language.

If you are a clinician and interested in learning more about therapy with the autistic client please join me along with two of my colleagues in an online course.
CLICK HERE for additional information about  Mental Health Therapy with the Autistic Client.

BY JUDY ENDOW

Endow, J. (2021). Executive Function Assessment. McFarland, WI: Judy Endow.

Endow, J. (2012). Learning the Hidden Curriculum: The Odyssey of One Autistic Adult. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2006).  Making Lemonade: Hints for Autism’s Helpers. Cambridge, WI: CBR Press.

Endow, J. (2013).  Painted Words: Aspects of Autism Translated. Cambridge, WI: CBR Press.

Endow, J. (2009b).  Paper Words: Discovering and Living With My Autism. Shawnee Mission, KS: AAPC Publishing.

Myles, B. S., Endow, J., & Mayfield, M. (2013).  The Hidden Curriculum of Getting and Keeping a Job: Navigating the Social Landscape of Employment. Shawnee Mission, KS: AAPC Publishing.

REFERENCES

Dunn Buron, K. (2007). A 5 Could Make Me Lose Control! An activity-based method for evaluating and supporting highly anxious students. Shawnee Mission, KS: AAPC Publishing.

Mahler, K. (2019). The Interoception Curriculum: A step-by-step guide to developing mindful self-regulation. Lancaster, PA: Kelly Mahler.

Mahler, K. (2016). Interoception the Eighth Sensory System: Practical solutions for improving self-regulation, self-awareness and social understanding of individuals with autism spectrum and related disorders. Shawnee Mission, KS: AAPC Publishing.

Mataya, K. & Owens, P. (2010). Successful Problem-Solving for High-Functioning Students With Autism Spectrum Disorders. Shawnee Mission, KS: AAPC Publishing.

AUTISTIC SOLUTIONS RELATED TO TAKING IN INFORMATION: When Feelings Are Too Big

Autism and Mental Health, ,

This series of blogs and the release dates are as follows:

AUTISTIC SOLUTIONS RELATED TO TAKING IN INFORMATION
Part One: Using Words to Make Pictures (January 13, 2023)
Part Two: Using Words to Describe Pictures (February 10, 2023)
Part Three: When Feelings Are Too Big (March 10, 2023)
Part Four: Examples Using Paint Chip Visual Supports (April 7, 2023)
Part Five: Direct Instruction of Social Information (May 5, 2023)

Just like the sensory system information can come in too big for an autistic and then become difficult to manage, so to can emotional feelings get too big too fast, making them difficult to manage. Typically, in a therapy setting neuromajority individuals learn to identify and label their feelings. This knowledge then allows them a way to talk about their feelings and ultimately come to manage them over time.

When this approach is used with autistic clients it too often doesn’t go anywhere. Autistics tend to have difficulty when it comes to labeling feelings and are often left trying to guess the right answer. Additionally, while some autistics may find it helpful to talk about their feelings, it has been my experience that most talk about what another person said or did rather than their resulting feelings about the occurrence.

These concrete happenings are easy to know and repeat and are typically what carries the story line for autistics. Many times the feelings experienced by the autistic telling the literal and concrete aspects of the story are apparent to the listener by observing body language, but may not be apparent to the autistic.

Once the literal and concrete details of the story are in order, trying to understand the social ramifications of how another person acted is typically the next topic of conversation. Finally, once the story is sorted out logically and the understanding of the hidden social information is had, autistics might become aware of their own feelings and if so may want to talk about them. It has been my experience that autistics in therapy usually find it much easier to talk about their behavioral response to something another person said or did rather than their feelings around it.

There is no right or wrong way to talk about your own life stories. I merely outline this to show there are neurologically based differences in the way neuromajority and autistic people tell their stories.

Given all of this, I have learned that it is more helpful for most of my autistic clients, regardless of age, to learn about the size of their feelings rather than to struggle over labeling them. Since the purpose of labeling is to be able to talk about and manage feelings, we can cut to the chase of learning to manage feelings by teaching size of feelings.

The beauty of this is that It does not matter if the too big disregulating feeling is a positive feeling such as excitement over an upcoming event or a negative feeling such as sadness over cancellation of a favorite activity in that the too big feeling is managed in the same way regardless of the what the feeling might be.  Therefore, no assigning of feeling labels are necessary to learn how to manage feelings that are too big. Often, it is more important that a client learn to manage/regulate too-big feelings in a short time rather than spending months (often years) getting stuck on labeling the names of these too-big feelings!

Selection from: Autistically Thriving: Reading Comprehension,
ConversationalEngagement, and Living a Self-Determined Life
Based on Autistic Neurology, pg. 141-142.

(The next blog in this series, Examples Using Paint Chip Visual Supports, details clinical examples of a variety of uses of paint chips as visual supports for showing size of feelings.)

Note: The author is a mental health therapist and is also autistic. She intentionally uses identity-first language (rather than person-first language), and invites the reader, if interested, to do further research on the preference of most autistic adults to refer to themselves using identity-first language.

If you are a clinician and interested in learning more about therapy with the autistic client please join me along with two of my colleagues in an online course.
CLICK HERE for additional information about  Mental Health Therapy with the Autistic Client.

BY JUDY ENDOW

Endow, J. (2021). Executive Function Assessment. McFarland, WI: Judy Endow.

Endow, J. (2012). Learning the Hidden Curriculum: The Odyssey of One Autistic Adult. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2006).  Making Lemonade: Hints for Autism’s Helpers. Cambridge, WI: CBR Press.

Endow, J. (2013).  Painted Words: Aspects of Autism Translated. Cambridge, WI: CBR Press.

Endow, J. (2009b).  Paper Words: Discovering and Living With My Autism. Shawnee Mission, KS: AAPC Publishing.

Myles, B. S., Endow, J., & Mayfield, M. (2013).  The Hidden Curriculum of Getting and Keeping a Job: Navigating the Social Landscape of Employment. Shawnee Mission, KS: AAPC Publishing.

Mental Health Therapy and the Autistic Client: When Clinicians Don’t See the Autism (Can’t See the Forest for the Trees)

Autism and Mental Health,

Today, autistic people, just like the population at large, find their way to therapy when symptoms of depression, anxiety, OCD and other diagnoses become problematic to them in their daily lives.

As clinicians we need to understand the autistic operating system – in other words, to see the autism – if we are to be helpful to our autistic clients. When we do not have a strong grasp on this the results are that our clients are not served well. Clinicians without a good understanding of autism generally make one of two mistakes. Last blog discussed the phenomenon “It’s All the Autism” which means once the autism has been diagnosed every symptom from that point forward is attributed to the autism. Today we will discuss the other mistake frequently made by clinicians when they do not recognize the autism.

Can’t See the Forest for the Trees

Over time these clients tend to wind up with multiple psychiatric diagnoses for which none of the typical treatments have been effective in lessening symptoms. These clients’ individual symptoms are sometimes collectively better known as autism, but because one cluster of symptoms at a time presents each cluster winds up meeting the diagnostic criteria for something other than autism. Over time the client collects many diagnoses. However, regardless of how many labels are added, the client tends not to make much overall progress. Effective treatment for individual symptoms cannot be rendered because we have failed to see the autism. Autism means there is a different operating system and that the treatment of troubling symptoms must be delivered in a manner compatible with the autistic operating system.

Example: Ricardo is a 14 year old who’s parents sought out therapy for him because even though he had been near the top of his class academically during middle school, he was now failing some of his classes in high school. Additionally, he had gotten in trouble several times for shoving students. He didn’t have much to say except he was sorry and would try harder to do better.

Ricardo had received an array of services over time. When he was 5-7 years old he received Occupational Therapy for Sensory Processing Disorder. Ricardo did well academically until Fifth Grade when he began having difficulties with angry behavior. He was diagnosed with Intermittent Explosive Disorder and attended both individual therapy and an anger management group. In Sixth Grade he was diagnosed with both depression and anxiety and prescribed medication. Some days it seemed to be helpful, but other days it seemed the medication wasn’t doing anything to make Ricardo’s life better.

During the weeks in therapy several things were discovered. Ricardo was receiving poor grades due to incomplete assignments. It was learned that he had in fact done the science and history assignments, but had neglected to turn them in. He complained that he put everything in his locker, but then couldn’t find what he needed for his various classes. When his mom went to investigate she found most of the missing science and history assignments in his locker along with partially eaten lunches, some missing sweatshirts and a general mess.

Ricardo had difficulty with algebra. He said he couldn’t concentrate because the smell was so bad in that room. It was discovered the boy who sat behind him had stinky feet. Additionally, the boys had just come from gym class and they did not always take showers so the room smelled like a locker room three times a week. While these things were not noticed by most students Ricardo was totally distracted by it. He often missed the assignment when the teacher announced it. When he did hear the assignment he got it done during the classroom work time, turned it in and always got an A grade. He just had so many missing assignments that his overall class grade was a D. When asked what he did during the classroom work time when he was not working on the assignment he said he was just doing the usual – trying to put up with the smell of the room. It did not occur to him that even though the other students were doing the assignment that it meant he should be working on this same assignment.

Ricardo displayed aggression towards fellow students at school. It turned out that much of this aggression was in response to not understanding a social situation and/or in response to anxiety. Typically Ricardo would shove another student in the hallway. Sometimes it looked random in that there was no conversation immediately prior to the shoving. When asked about these incidents Ricardo could only say he didn’t know why he was shoving others, he knew it was wrong and would stop doing it. Then, he would shove someone again. Using cartooning, the shoving was drawn and then, once Ricardo saw it he could contribute more. Eventually it came to light that the shoving was tied to times where Ricardo misread social cues and had thought the student had somehow made fun of him. Then, later in the day, or sometimes even the next day, Ricardo would see the student, know the student was on his bad person list and shove him. The cartooning helped him discover how he knew the student was a bad person.

These were the first clues that Ricardo needed to be evaluated for possible Autism Spectrum Disorder, for which he did meet the criteria. This was important because treating Ricardo for each of the cluster of symptoms that earned him his other diagnoses had not been helpful in alleviating his struggles. ASD better explained the complexity and ushered forth the supports he needed to be successful.

Ricardo was given a check in person at school who assisted him with executive function tasks, developing a system for him to use his assignment notebook and to do and turn in assignments.

When he got the notion to shove another student, Ricardo knew that was something to draw out (cartoon) in therapy and that likely he was missing some social information that others knew (hidden curriculum).

A 5 Point Scale was put in place for Ricardo to manage his anxiety. Over time, with increased social understanding and decreased anxiety Ricardo no longer thinks about shoving others. He did so well that he was able to decrease and then go off his antianxiety medication.

Additionally, Ricardo’s parents started him with an OT who works on sensory regulation strategies. Ricardo now sits near the door in algebra, the location where he is not surrounded by the offensive smells.

As he was growing up the solutions to Ricardo’s difficulties had not been found even though he had received diagnoses at the time of each difficulty – a diagnosis he met the criteria for based on the cluster of presenting symptoms. Once it was determined that ASD better explained his situation than each of the individual diagnoses, the supports could be put in place that would help him be and do what he wanted in his life. It took some time, but once we could see the autism Ricardo could be supported.

Conclusion

When clinicians do not have a good understanding of the autistic operating system they tend to lean toward one of the two mistakes of either attributing everything to the autism or not seeing the autism at all. Neither is helpful in supporting therapeutic progress of autistic clients. The Autistic Operating System, Part Three will delve further into this topic. We will learn about the autistic operating system and how to deliver mental health therapy to clients who happen to be autistic.

(Note: In my practice I see clients who happen to be autistic. Their autism is usually not the reason they seek therapy, but it certainly affects how the therapy for their depression, anxiety or other presenting symptoms is delivered. When mental health therapy is delivered in a usual manner and not based upon the autistic operating system of the client it generally is not very effective.)

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BOOKS  BY JUDY ENDOW

Endow, J. (2019).  Autistically Thriving: Reading Comprehension, Conversational Engagement, and Living a Self-Determined Life Based on Autistic Neurology. Lancaster, PA: Judy Endow.

Endow, J. (2012). Learning the Hidden Curriculum: The Odyssey of One Autistic Adult. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2006).  Making Lemonade: Hints for Autism’s Helpers. Cambridge, WI: CBR Press.

Endow, J. (2013).  Painted Words: Aspects of Autism Translated. Cambridge, WI: CBR Press.

Endow, J. (2009).  Paper Words: Discovering and Living With My Autism. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2009).  Outsmarting Explosive Behavior: A Visual System of Support and Intervention for Individuals With Autism Spectrum Disorders. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2010).  Practical Solutions for Stabilizing Students With Classic Autism to Be Ready to Learn: Getting to Go. Shawnee Mission, KS: AAPC Publishing.

Myles, B. S., Endow, J., & Mayfield, M. (2013).  The Hidden Curriculum of Getting and Keeping a Job: Navigating the Social Landscape of Employment. Shawnee Mission, KS: AAPC Publishing.

Originally written for and published by Ollibean July 30, 2017
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Mental Health Therapy and the Autistic Client: When Clinician’s Don’t See the Autism (It’s All the Autism)

Autism and Mental Health

Today, autistic people, just like the population at large, find their way to therapy when symptoms of depression, anxiety, OCD and other diagnoses become problematic to them in their daily lives.

As clinicians we need to understand the autistic operating system – in other words, to see the autism – if we are to be helpful to our autistic clients. When we do not have a strong grasp on this the results are that our clients are not served well. Clinicians without a good understanding of autism generally make one of two mistakes. One mistake is not seeing the autism at all, but instead seeing individual characteristics of autism and matching them with a clinical diagnosis. (The next blog will explore this more.) The other mistake is, once the autism has been diagnosed every symptom from that point forward is attributed to the autism. Today we will look at an example of when clinicians think, “It’s all the autism.”

It’s All the Autism

 When a client has been previously diagnosed with ASD it is common for mental health clinicians to attribute all psychiatric symptomatology to the autism, which often results in autistics not being diagnosed or treated for comorbid mental illnesses when warranted.

Example: Elaina was a 9 year-old autistic girl who was in a fourth grade Special Ed classroom. She interacted with her visual schedule tracking her day, which included some General Ed classes along with Speech and OT. She had two friends she ate lunch with and played with at recess. At home, Elaina and her 8 year-old brother each did household chores, participated in dinner conversations about their day and attended church on the weekend.

Elaina started hitting. First she occasionally hit her teachers. Within a few weeks she was also hitting her peers at school and her parents and brother at home. Her family stopped going to church because Elaina could not attend children’s Sunday School class unless one of her parents attended with her to keep her from hitting other children. In fact, Elaina’s life became smaller and smaller as her parents stopped taking her out into the community.

Initially everyone in Elaina’s life attributed the hitting to her autism. The school team worked very hard trying to change this behavior, but to no avail. Elaina saw a psychiatrist who prescribed a psychotropic often used for children with uncontrollable behavior. Other than making Elaina drowsy for a few weeks, the medication did not change her hitting behavior. Whenever anyone asked Elaina why she was hitting Elaina would say, “Don’t hit!” and would say that she would not hit again. The psychiatrist referred Elaina to a therapist.

Over the course of several sessions it was discovered that Elaina suffered from anxiety. When her anxiety felt unbearable she would hit. The hitting ensured people would back off which gave time and space for anxiety to come down.

How was this discovered when Elaina could not tell why she was hitting?

From the first session the context was set using a visual timer and a visual written schedule for the session. Her schedule was the same each time – check in with mom, set timer, therapist’s choice and Elaina’s choice. Elaina had the last 10 minutes to participate in a pleasurable activity of her choice. The therapist provided three choices of activities Elaina enjoyed and that were easily accomplished in the allotted time.

During the therapist’s choice time the therapist would have Elaina recall a specific hitting incident and then cartoon that event. To start Elaina could tell about the act of hitting. Once it was drawn with stick figures and word bubbles, which Elaina was great at making accurate, she was then able to tell other pieces of the incident. These pieces were not told in chronological order so Elaina’s story didn’t often make sense. The therapist took to drawing each piece of the story on a sticky note so Elaina could see it and decide if this piece came before or after the hit. Thus, more and more pieces were elicited. Soon there were enough pieces to tell the story in chronological order so that it made sense.

When there were three such stories the therapist began noticing a pattern so was able to explore the story before the hitting story. Using the same cartooning context Elaina began revealing this story of what was happening for her before the hitting. These sticky notes were a different color and this story was visually placed ahead of the hitting story. Soon the three hitting stories each had a pre story in front of them.

It became apparent that Elaina was experiencing a high degree of anxiety for the half hour or so before the hitting occurred. Therapy then became focused on teaching Elaina and the adults around her the signs of her anxiety, which were subtle, along with teaching Elaina relaxation techniques geared toward bringing her anxiety down. An app was used that read Elaina’s heart rate so she could see it and then watch it come down as she employed one of her relaxation techniques.

Additionally, this app was used for Elaina to check periodically (it was right on her schedule) to see her heart rate. Elaina and her therapist developed a chart that showed which relaxation techniques to use for each heart rate range. Elaina was able to manage her anxiety this way for several months, the hitting lessened and then altogether stopped. She was discharged from therapy.

Three years later, as middle school student, Elaina returned to therapy. Her anxiety management needed some assistance. At that time she was started on a low dose antianxiety medication and her relaxation techniques were reviewed, some revised and some new ones added. The area of mindfulness was explored and added to Elaina’s daily routine. Additionally, new information on the eighth sensory system – interoception – was looked at, along with the interoception activities from the book Interoception: The Eighth Sensory System by Kelly Mahler.

In Elaina’s example it is easy to see that if her anxiety had never been diagnosed and addressed the hitting likely would not have stopped. Alternatively, if a behavioral program had been instituted to stop the hitting without ever having addressed the underlying anxiety, Elaina likely would have learned to replace the hitting with an alternate behavior to help her get people to back off.

(Note: It has been my experience when a behavior is extinguished without understanding and addressing it’s function individuals most often come up with a replacement behavior that is of increased intensity. It serves nobody’s best interest to simply extinguish a behavior, even though this can and is done to autistics quite frequently.)

Conclusion

When clinicians do not have a good understanding of the autistic operating system they tend to lean toward one of the two mistakes of either attributing everything to the autism or not seeing the autism at all. Neither is helpful in supporting therapeutic progress of autistic clients. The Autistic Operating System, Part Three will delve further into this topic.

Next week we will look at the other easily made clinical mistake with autistic clients – when we do not recognize the autism because we can’t see the forest for the trees! Over time these clients tend to wind up with multiple psychiatric diagnoses for which none of the typical treatments have been effective in lessening symptoms. These clients’ individual symptoms are sometimes collectively better known as autism, but because the autism hasn’t been recognized we miss the boat in rendering effective treatment.

Going forward we will delve into learning about autistic operating system and how to deliver mental health therapy to clients who happen to be autistic. Hope to see you back!

(Note: In my practice I see clients who happen to be autistic. Their autism is usually not the reason they seek therapy, but it certainly affects how the therapy for their depression, anxiety or other presenting symptoms is delivered. When mental health therapy is delivered in a usual manner and not based upon the autistic operating system of the client it generally is not very effective.)

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BOOKS  BY JUDY ENDOW

Endow, J. (2019).  Autistically Thriving: Reading Comprehension, Conversational Engagement, and Living a Self-Determined Life Based on Autistic Neurology. Lancaster, PA: Judy Endow.

Endow, J. (2012). Learning the Hidden Curriculum: The Odyssey of One Autistic Adult. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2006).  Making Lemonade: Hints for Autism’s Helpers. Cambridge, WI: CBR Press.

Endow, J. (2013).  Painted Words: Aspects of Autism Translated. Cambridge, WI: CBR Press.

Endow, J. (2009).  Paper Words: Discovering and Living With My Autism. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2009).  Outsmarting Explosive Behavior: A Visual System of Support and Intervention for Individuals With Autism Spectrum Disorders. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2010).  Practical Solutions for Stabilizing Students With Classic Autism to Be Ready to Learn: Getting to Go. Shawnee Mission, KS: AAPC Publishing.

Myles, B. S., Endow, J., & Mayfield, M. (2013).  The Hidden Curriculum of Getting and Keeping a Job: Navigating the Social Landscape of Employment. Shawnee Mission, KS: AAPC Publishing.

Originally written for and published by Ollibean on June 14, 2017
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