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Sometimes the difficulties of autism can lead to behaviors that are quite challenging to understand and address. Most individuals with autism will display challenging behaviors of some sort at some point in their lives. Autism Speaks offers the following resources to help.Challenging Behaviors Tool Kit
Autism dilemma: Why is teen chewing on clothes, swallowing objects?
Autism dilemma: Why is teen chewing on clothes, swallowing objects?Our 17-year-old son has a diagnosis of autism and developmental delay. Lately, he’s been chewing on his shirt collars as well as chewing and sometimes swallowing things like pen caps, erasers and all sorts of paper. I also find objects around the house with teeth marks on them. Why is this happening?
This week’s “Food for Thought” post is by occupational therapist Moira Pena, of Toronto’s Holland Bloorview Kids Rehabilitation Hospital. The hospital is one of 14 centers in the Autism Speaks Autism Treatment Network (ATN).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.
Thank you for your question. Your family is far from alone in grappling with this problem. Chewing on things can be a form of repetitive behavior. The habit of swallowing non-food items is called pica. Both are very common among people who have autism.
I’m glad to share some of my insights as an occupational therapist who frequently works with families whose children have this dangerous tendency. But my overview and general strategies are no substitute for working with a behavioral and/or occupational therapist to develop a personalized intervention program for your son.
In addition to my tips below, I also highly recommend two Autism Speaks Autism Treatment Network guidebooks – Pica: A Guide for Parents and Pica: A Guide for Professionals. The ATN developed these tool kits as part of its role as the federal funded Autism Intervention Research Network for Physical Health (AIR-P).
Ruling out medical issues
On rare occasions, pica results from nutritional deficiencies. Pica can also produce serious medical problems such as lead poisoning. So it’s important for you to alert your son’s doctor to his pica and have him appropriately evaluated.
Figuring out “why”
Any plan to address a problem behavior should begin with some detective work to figure out what’s driving it. So let’s consider your son’s new habit from three possible angles: emotional coping, sensory stimulation and attention seeking.
Is it anxiety?
We know that anxiety is particularly common among children and teens who have autism. Some research suggests that around 40 percent of children with autism have an anxiety disorder.
In my practice, I often see children and teens who begin chewing non-food items because they are having trouble managing anxiety or frustration. Here are some issues to explore – ideally with the guidance of a child psychologist familiar with autism:
Does your son tends to chew on his shirt or other non-food items during situations or times of day he finds stressful? For example, when it's time to leave the house for school or to do his homework?
Does he seem upset when he starts chewing on things?
Have there have been changes in your son’s life that may have increased his overall anxiety or frustration levels?
Is it sensory stimulation?
Sensory issues are likewise very common among both children and adults on the autism spectrum. Sometimes this involves seeking out sensory experiences such as chewing on objects or clothing.
Signs that your son may be such a “sensory seeker” may include:
* having difficulty keeping his hands to himself
* having difficulty holding still (hyperactivity)
* being attracted to strong smells
* seeking constant visual stimulation (signs can include becoming excited at stimulating sights such as merry-go rounds, whirring fans and bright lights)
Another clue that his pica may be a sensory seeking would be your son’s mood when he engages in pica. Does he seem happy versus anxious when he’s chewing on his shirt? If so, the chewing may be something he does to calm himself.
Is it attention seeking?
I recall working with a family of a teen with autism who had started swallowing double AA batteries. After tracking the behavior, it became apparent that it occurred only on school day mornings. When I discussed this with the teen, he admitted that he swallowed batteries to avoid school and instead spend a day at the hospital with his parents close by his side.
While all of us engage in attention-seeking behavior, it’s important to remember that such behaviors can become a means of expressing needs for those who have trouble communicating – a core symptom of autism.
Now what? Strategies for curbing pica and inappropriate chewing
I am not a behavior therapist, but as an occupational therapist I’ve found the following general strategies helpful when working with families dealing with a child’s who is chewing on and/or swallowing inappropriate objects:
Track when it happens
It helps to identify when your child is most likely to engage in chewing and/or swallowing objects. This gives you opportunities to prevent the behavior by redirection.
Chart by teamupforfamilies.comI encourage parents to keep a log, or diary, noting when and where it happens. Here’s a download link for the example behavioral log shown at right.You can likewise use the log to note possible triggers – such as being told to get ready for school or when you notice he is tired.
Identifying patterns gives us opportunities to alter them for the better. For example, if your son tends to chew on his clothing or objects while he’s waiting to leave for school, see if you can prevent the behavior by engaging him with some favorite music or a game. Distraction can be a powerful tool for breaking unhelpful habits and other problem behaviors.
Change the environment
Does your son look for chewing objects in a particular place – say, a specific drawer? Lock it. Or better yet, move its contents somewhere out of sight and out of reach.
If you sense he starts chewing on things when bored, try livening up the environment. Turn on some background music or add some colorful posters or other visuals to a room. Conversely, some people on the autism spectrum get anxious if a room is “too busy.” If that seems to be the case with your soon, try creating a quieter, more visually subdued environment.
In fact, I find that small changes in the environment are often enough to draw attention and so reduce the impulse to engage in problem habits. Experiment to see what works for your child.
Helping your child communicate
What if you suspect that your son’s behavior is a way of getting your attention? In the case I described above – with the teen swallowing batteries – we created a visual weekly schedule. He and his parents used it to schedule “together time” when they could block out time to play games, go on walks and do other activities together.
Try using a picture of a traffic light as a visual support to help your child signal growing unease (yellow light) or an anxious urge to chew or swallow things (red).We also gave the boy and his parents a visual support – a picture of a traffic light – and showed him how to use it to communicate his needs to his parents in a constructive way. He learned to point to the red light when he felt the urge to find and swallow batteries. That was a signal for his parents to take a few minutes to engage him in one of the activities that he found calming. (Trampoline jumping was a favorite.)
Even better, the boy could point to the yellow light to signal that he was starting to feel unsettled. That gave his parents an earlier opportunity to steer him toward a favorite activity or other distraction.
An emerging option for getting ahead of problematic, stress-triggered behaviors involves using a wearable stress monitor that picks up on increased heartbeat and other physiological signs of stress. These range from free apps for mobile phones to devices that cost several hundred dollars. But getting a child or teen to wear one can be challenging.
It can also help to introduce a reward system for not engaging in the problem behavior. In working with the boy who was swallowing batteries, his parents began by giving him a daily reward. Then we began stretching out the positive reinforcement over increasingly longer periods of time.
Addressing sensory needs
Occupational therapists such as myself are trained to work with children on sensory processing issues – including sensory-related chewing and pica. Again, a personalized approach is best, but some general strategies might include the following:
High sensory foods
Offer your son a variety of sensory-rich snacks and foods high in crunch and chewiness. Examples include carrot sticks, dried mango slices, chewy granola bars and licorice.
For another sensory-rich oral experience: Invite him to drink thick semi-liquids through a straw. Options include applesauce, yogurt, milk shakes, icy smoothies, etc.
Even better, the boy could point to the yellow light to signal that he was starting to feel unsettled. That gave his parents an earlier opportunity to steer him toward a favorite activity or other distraction.
An emerging option for getting ahead of problematic, stress-triggered behaviors involves using a wearable stress monitor that picks up on increased heartbeat and other physiological signs of stress. These range from free apps for mobile phones to devices that cost several hundred dollars. But getting a child or teen to wear one can be challenging.
It can also help to introduce a reward system for not engaging in the problem behavior. In working with the boy who was swallowing batteries, his parents began by giving him a daily reward. Then we began stretching out the positive reinforcement over increasingly longer periods of time.
Addressing sensory needs
Occupational therapists such as myself are trained to work with children on sensory processing issues – including sensory-related chewing and pica. Again, a personalized approach is best, but some general strategies might include the following:
High sensory foods
Offer your son a variety of sensory-rich snacks and foods high in crunch and chewiness. Examples include carrot sticks, dried mango slices, chewy granola bars and licorice.
For another sensory-rich oral experience: Invite him to drink thick semi-liquids through a straw. Options include applesauce, yogurt, milk shakes, icy smoothies, etc.
Chewy tubes; image courtesy chewytubes.comSensory chew toys
Sensory chewies are yet another option. Examples include chewy tubes, chew sticks and chewlery. Most of these tools are designed to be hard to swallow. Still, I recommend supervision when using them. Also, I recommend ordering them from manufacturers based in the U.S. or Canada, as some countries may use unsafe materials or unsanitary manufacturing methods.
The “sensory diet” approach
Just as we all need a variety of foods in our daily diet, a “sensory seeker” may benefit from having two or three substantial “sensory meals” and as well as some “sensory snacks” throughout the day. We call this a “sensory diet.” It involves a variety sensory-based activities to balance mood and alertness.
Options can include making mud pies, finger painting, using modeling clay, jumping, running and so on. Find out what your child enjoys. Learn more about sensory diet activities here.
Add deep pressure to sensory diet activities
Research has shown that the occupational therapy technique of deep pressure input (proprioception) has a calming effect on the body and mind. If your son’s chewing is associated with anxiety, he may be calmed by engaging in some deep pressure activities throughout the day.
Some options include:
* jumping on a trampoline (with safety barriers in place)
* brushing the inside of his cheeks with an electric toothbrush
* pushing, pulling and lifting activities like engaging in a game of a tug of war or playful arm wrestle.
Over a few weeks, use your son’s behavioral log to see if any of strategies help decrease his tendency to chew on things.
Keep in mind that both behavioral and sensory issues may contribute to the behavior. So ideally, you’ll want to work with both a behavioral and an occupational therapist to develop a multidisciplinary approach to address his needs.
Thanks again for your question. Please let us know how you and your son are doing with a comment below or by emailing us again at gotquestions@autismspeaks.org.[
Readers: Got Questions for our behavioral and medical experts? Send them to GotQuestions@AutismSpeaks.org.Check back Fridays for new posts here, or subscribe to a daily feed of Autism Speaks blogs, including our Friday advice series here.
Help! Our 4-year old has autism and won't stop pinching
A behavioral therapist in the ATN offers tips to parents that include exploring possible reasons for the behavior, communication strategies, prevention and rewards, and how to respond in the moment. Read More
Help! Our 4-year-old has autism and won’t stop pinching
My son is 4 years old and has autism. Several months ago, he started pinching people. It could be anybody – adult, child or baby. He’ll just run over, pinch the person and run away. We’ll give him time outs for this, and he’ll say “sorry” the minute he does it. Can you recommend any solution? It's getting quite embarrassing when we go to playgrounds or people's houses.
This week’s “Got Questions?” response is by psychologist Kenneth Shamlian, director of the behavioral treatment program at the University of Rochester Medical Center. The University of Rochester is among the 13 sites in the Autism Speaks Autism Treatment Network (ATN).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.
This is a great question. Many times, the behaviors of children with autism don’t make sense on the surface. There’s likely some detective work to be done before determining a good solution for this problem.
If possible, I encourage working with a trained behavioral therapist to determine why your son is pinching and finding a replacement behavior that doesn’t hurt anyone.
I also recommend reading the Autism Speaks Challenging Behaviors Tool Kit for additional strategies and resources. You can download it free of charge from the Autism Speaks website. (Follow the title link above to learn more and download the free tool kit.)Meanwhile, let’s explore why your son may be pinching. As you may know, many children – and adults – on the autism spectrum have difficulty understanding and/or expressing why they do something. So let’s start with the most common reasons people do anything. They include:
* To get attention (positive or negative)
* To escape an uncomfortable situation or unwelcome task
* To get something – be it a desired activity or object
* To increase or decrease sensory input – for example, to escape an uncomfortable sound, sight or other sensation or to get more of an enjoyable one (As you may know, sensory aversions and stimulating repetitive behaviors are particularly common among people with autism.)
Of course, there’s nothing inherently wrong with pursuing these things – so long as we act in ways that don’t hurt others.
Your description of your son’s behavior suggests to me that he may be doing this for attention. That is, he may like getting a reaction from others. My inference is no substitute for an in-person behavioral evaluation, but you may notice some clues to whether he’s looking for a reaction. For example, does he start to smile or give you or others a fleeting glance before he pinches or when he runs away? Though it may seem counterintuitive, even a negative reaction such as scolding can reinforce attention-seeking behaviors.
If this is the case, I would start by teaching him appropriate ways for getting attention.
Teach a new way to communicate
Ideally, you want to teach him how to ask directly – verbally or nonverbally – for the attention he wants. This can have the added benefit of teaching better play skills.
Spoken communication. For example, if your son has some spoken words, you can teach him to ask to play a game. Let’s take the game of “tag” for an example. Remember many children on the spectrum need even simple steps demonstrated. So show him how to play by gently tagging him as you say “tag” and then jump away to invite him to tag you. You might need to ask a third person to join in the game to help demonstrate.
Once he is enjoying the game, stop the play using clear body language. Then prompt him to say, “Play with me,” if he wants to play more. As soon as he says the phrase, begin playing with him again. Praise him warmly for communicating nicely.
Repeat this playful exercise, until he begins asking when he wants to play without your prompting.
Nonverbal communication. If your son lacks strong verbal skills, create a picture card that he can hold up, touch or give to someone when he wants to play. You can teach this approach by asking and/or showing him how to touch the card or hand it to you to signal he wants to start playing. Then encourage him to do the same. As soon as he either touches or hands you the card, begin playing again.
For more on picture cards and other visual cues, see Visual Supports and Autism Spectrum Disorders, a free tool kit by the Autism Speaks Autism Treatment Network.(Click on the title link to learn more and download.)
You can teach these approaches to communication and play at home. Eventually you want your son to try them with new people and in different places.
Prevention and reward
While your son is learning these new, more-appropriate behaviors, consider going out of your way to give him extra attention – and so decrease the likelihood that he’ll pinch to get a reaction.
Understandably, you can’t always give your son attention when he wants it. So it’s important to:
1. Provide him with enjoyable ways to occupy himself
2. Have a way to remind him that pinching is not okay before he pinches.
Perhaps you already have a sense for the kind of situations that tempt your son to pinch. Perhaps it involves social gatherings when he’s not the center of attention. Or maybe it’s when he’s feeling tired and/or frustrated. It can help to keep a diary – perhaps in a small notebook – where you jot notes about when and where your son pinches.
Next, be sure communicate your expectations to your son before you enter one of these potentially problematic situations. Then be ready to reinforce the expectations with a signal should you sense he’s tempted to pinch. If he responds to spoken words, you can use a simple phrase such as “Gentle hands; no pinching.” If he responds better to visual prompts, you can draw or print out a visual cue. (A web search on “no pinching visual prompts” brings up some nice examples.)
As mentioned above, it can also help to give your son something to occupy himself – particularly his hands. Some good options include a small bendable toy, play dough, a palm-sized sensory ball or a hand fidget. (See examples at right.)In our practice, we’re big fans of catching kids being good and immediately praising and/or rewarding them. So praise your son when he refrains from pinching by saying something along the lines of “nice hands.” Consider rewarding him with a sticker, small toy or a token on a reward board. The Visual Supports and Autism Spectrum Disorder tool kit (link above) has an example of a visual reward board you can copy.
So right before walking into a social situation, show your son something he would like to have. It could be that sticker, an actual object such as a small toy, or a picture of a favorite activity such as going to the playground. Explain what he needs to do to get it. For example, “If you want to play video games, use nice hands. No pinching.”
Catch him being good as often as you can by praising his “nice play.” Frequently remind him of his reward for good behavior.
When he pinches
Admittedly, there will probably be times when your son pinches. Here’s an example of an approach we use to discourage unwanted behavior after it happens. Keep in mind that you want to minimize the reward of “attention.” First, calmly approach him. Do notlook him in the eye. Don’t say anything except for restating the rule “Use nice hands, no pinching.” Then immediately place him somewhere he can take a break from others. Make sure it’s boring and in no way the center of attention. Explain that after he calms down, you will invite him to rejoin you.
After a short period – perhaps a minute – restate the no-pinching rule and how to ask for attention in an appropriate way. What really counts is being immediate and consistent with this consequence for pinching.
For a more complete discussion on how to use “time outs,” also see the Autism Speaks ATN/AIR-P Parent's Guide to Applied Behavior Analysis. (Follow the title link for more information and free download.)Thanks again for your question. I hope these tips help you and your family and that enjoyable play soon takes over the pinch.
* Learn more about the Autism Speaks Autism Treatment Network here.* Find the ATN center nearest you here.
* Explore our archive of ATN expert-advice blogs and news stories here.
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