“Our son is 19 with pretty severe autism. He enjoys going to amusement parks and swimming pools. However, he becomes so obsessed afterward, not wanting to leave, crying and throwing tantrums the whole way home. Then this obsession continues for weeks. He keeps asking to return, showing us photos of what he wants and refusing to engage in other activities. He can become quite aggressive to us and himself with head butting and the like. Should we refrain from taking him at all when it causes so much strife for him and us afterward? He’s already on quite a bit of behavioral medication, but it doesn’t seem to help.”
Today’s “Got Questions?” answer is by (clockwise from top left) psychiatrist Rachel Brown, psychologist SungWoo Kahng, neurologist David Beversdorf, and applied behavior analyst Janine Stichter, all of the University of Missouri’s Thompson Center for Autism and Neurodevelopmental Disorders. The Thompson Center is one of 14 sites in the Autism Speaks Autism Treatment Network.
Editor’s note: The following information is not meant to diagnose or treat and should not take the place of personal consultation, as appropriate, with a qualified healthcare professional and/or behavioral therapist.
Thanks for your question. You are facing a complex situation that calls for personalized strategies to help your son with transitions and ease his obsessions.
While we can give some general advice in this post, we all agree that it would be best that your plan of action include a personal assessment by a psychiatrist who has experience working with teens or adults severely affected by autism, or if one is not available, another physician with such experience. In addition, we recommend working with a behavioral analyst or other behavior therapist with similar autism experience.
The therapist can help with behavioral strategies to ease your son’s agitation and obsession. This can include teaching him when and how it is or isn't appropriate to talk about past events. You and the therapist might start by addressing your son’s behavior following a visit to one of his favorite places – perhaps the amusement park you mention.
Putting pictures to work
For example, you mention that your son shows you his desire to return to a favorite place with pictures. Visual supports can be very helpful in letting him know when the next trip is going to be. For example, you can create a visual calendar that will allow your son to mark off, or otherwise count down, the days before the next outing. You might mark the day of the outing with a picture of the favorite place.
You can attach Velcro to the calendar and the back of pictures that you snapped at these favorite places. When you return from the outing, have your son remove the picture from the calendar and give it to you to put away or move to the next outing date.
For more visual support options, we recommend the Autism Speaks ATN/AIR-P Visual Supports Tool Kit. It provides a step-by-step, easy-to-understand instructions on how to make and use visual supports. You can download it and all of Autism Speaks’ free tool kits here.
Another useful strategy is to create a scripted picture story of upcoming trips – starting with the steps involved in getting ready to leave to taking that photo off the calendar when you come home again.
The story can include pictures of the places you will visit and illustrations of the behaviors you expect each step of the way. The story might also include an illustration of the reward you son will receive for calm behavior on returning home.
Click here for a library of social story templates on the website of One Place for Special Needs.
Red light, green light on discussions
Another useful way to use visual supports could consist of handing your son a green card or a red card to signal when it is or isn’t a good time to focus on the amusement park.
You might start immediately after a visit to the park. Give your son a green card and invite a discussion about some of the things you and he enjoyed together. Explain that the red card signals when it’s time to move on to other subjects. Then calmly but firmly refuse to engage if he tries to bring it up again. Just hand him a red card.
Be sure to reward him with praise and perhaps a treat when he complies. For example, you might say “I really like the way we switched to talking about what’s for dinner tonight.”
Have patience. It may take many trials for him to learn when it’s appropriate and not appropriate to dwell on the visit.
In order to practice this, try to find times when he’s not agitated or engaging in problem behaviors to initiative a discussion by bringing out the green card. This may seem counter-intuitive as you want less discussion. But in the long run, it can help him understand that there are appropriate and inappropriate times to engage in these discussions.
We want to emphasize that all these strategies work best with the guidance of a behavior therapist and consultation with a psychiatrist who can discuss possible changes or additions to your son’s behavioral medicines.
You mention that your son’s current behavioral medicines don’t appear to help with his fixation on his favorite outings. While standard medicines for autism-related irritability can help with more general obsessions, they’re generally not as useful for the kind of highly focused and intense behaviors you describe. When meeting with a psychiatrist, you may want to discuss such alternatives as alpha-2 agonist category (clonidine or guanfacine) for impulsivity; or a beta-blocker (propranolol) as a less-sedating option for easing agitation.
Thank you again for reaching out. We’re sure that your situation is one shared by many families. Please let us know how you and your son are doing in the comment section below or by sending another email to firstname.lastname@example.org.