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11. Behavioral modification

Behavioral modification program for a child with PDD:

This behavioral modification program is based on training the child to behave in a more appropriate and socially accepted manner. This should consist of an immediate correction of any aberrant behavior, utilizing a special holding technique to overcome temper tantrums. Many of the most difficult behaviors, if dealt with early, may become controlled, or if neglected, may lead to a wild, impulsive, uncontrollable behavior that may require institutionalization. In many families of children with PDD, instead of the children being taught normal, socially accepted behavior, the entire family learns abnormal behaviors from the kids in the process of trying to accommodate them to prevent the temper tantrums. This is why controlling the tantrums is so important. Accommodating these kids by giving in to the abnormal behaviors only delays the tantrums and makes the abnormal behaviors the accepted standard for those children with PDD.

  1. A structured daily routine is important. The child will perform best under familiar conditions, including location and activities. Later, as the situation improves, the rigid routine may be gradually modified, as tolerated.

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  2. Temper tantrum control: Controlling temper tantrums is of extreme importance.
    The holding technique, as demonstrated during the office visit, requires a firm hold of the child, with the back to the parent's chest; the child's legs should be held between the parent's legs. During the holding time, the parent must try to communicate with the child, calm him/her, yet not give in to the behavior that led to the tantrum. This procedure is not a form of punishment. It is devised to protect the child and others from the erratic behaviors. It must be done gently, not to hurt the child, yet firmly to get a clear unequivocal message through. It definitely is not meant to be "fun" time and a firm approach is required. Communication must be short, clear, and firm, expressing the parent's appropriate emotional reaction to the behaviors that led to the tantrum. The reaction (firmness of communication) must be proportionate to the severity of the behavior. This will also teach a child whose ability to understand emotional responses are impaired, how one must react under different circumstances. The main objective of the holding and the behavioral modification program is to correct inappropriate behaviors, thus trying to normalize the child's routines and behavior, including all social interactions as much as possible.

    There are three priorities, when it comes to "insisting" with a child over behavioral issues.

    1. First priority: Temper tantrums and inappropriate behavior that if left unchanged may potentially become life threatening, such as hitting, throwing objects, jumping out of high places or windows, running into the street, or refusing to eat, must be attended to immediately, without compromise.

    2. Second priority: "Sitting skills." Behavior, that if left alone, will make it impossible for the child to sit in class and, therefore, impossible to attend school with his/her peers, regardless of his abilities or "baseline IQ." This consists of teaching sitting skills. This may be accomplished while sitting for dinner with the rest of the family, sitting in a restaurant or at any family or social gathering that require sitting skills.

    3. Third priority: Dealing with the "repetitive ritualistic habits. Unusual "bizarre" behaviors, that may result in social isolation or difficulties, if left unchanged. Such are inappropriate play habits, pervasive repetition of activities, self-stimulatory behavior, hand flapping, persevering into strict interests or production of unusual sounds. This may be done with a simple firm "stop!" command, and by directing the attention to more appropriate behaviors.

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    The holding technique is very important and constitutes the frame structure for the behavioral modification program. The holding should be done with compassion, not trying to hurt the child, but helping him/her to adjust to a difficult situation. This is not a form of punishment. Only one parent should communicate with a child while being held. One parent holding, while the other is smiling and trying to console the child, will cause confusion and the wrong message to come through.

    The behavioral modification trains the child to acquire more acceptable behavior, thus giving him/her a better starting point, to enter life's social requirements, compared to a child who still remains with all the attended social, behavioral difficulties associated with PDD.

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  3. Communication: Must be short, clear, loud (not yelling). Many children with PDD have auditory integration difficulties. Talking to them excessively will not be registered and may sound to them as gibberish. Therefore, communication must be very simple and to the point, leaving time between words to integrate the information. Eye contact must be worked on.

    Never smile or regard inappropriate behavior as cute or funny. Some behaviors as pulling a parent to different locations must be discouraged. Facial expressions by the parents must be appropriate and sometimes exaggerated to teach the socially appropriate way of expressing emotions. Proper attempts by the child to communicate must be encouraged and pursued.

  4. Individualization of care: The behaviors of individuals with PDD may differ in many aspects. Each child has his own strengths and weaknesses. A good behavioral modification must be customized to each child's specific needs. The principle of correcting inappropriate behavior, however, applies to all.

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  5. Placement and education: The most regular, highest functioning environment, including a regular educational system, should be attempted whenever possible. This, with independent supplementation of all the other needs, including speech therapy, occupational therapy, and physical therapy, if needed, will result in the most favorable outcome. When a regular educational system is unrealistic, each community may offer different options. The parents should individually and personally check these options. Once in the program, I do encourage parents to come in and observe first hand the quality of services provided, and how the child fits in. You have to give it some time, but remember, be a strong advocate for your child. There is no program that fits exactly the individual needs of every child with PDD, therefore sometimes you may have to use your creativity, based on the knowledge of your child, to obtain the best solution. Rarely you may have to actively pull your child out of a program if he/she does not fit and seems to regress, and find a better alternative.

  6. Emotional aspects: No one can clearly determine the final outcome of a child with PDD. Do not give in. Have realistic expectations yet try to push him/her as much as possible. Try to demand from your child to behave like any other regular child and regard them as such. Do not let the child "get away with things" because he/she is autistic. If your expectations are set too low, it may impair the final outcome. On the other hand, when it is clear that a child cannot perform a certain task, know where to stop. The right balance may be sometimes difficult to determine.
    The "A" word and the social stigma: The public and some professionals, unfortunately, lack education when it comes to PDD. Do not deny the problem, try to educate yourself and deal with the specific difficulties. On the other hand, keep the diagnosis private, if possible, to prevent low expectations from educators and the public in a way that may eventually affect your attitude and opinion as well.

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  7. Other treatment options: Different modalities are available. Some are controversial, some clearly ineffective. There are no studies that unequivocally demonstrate beneficial results from vitamin or diet therapy, but there are some anecdotal reports falsely supporting many modalities. Contrary to this, there are reports of improvement without any "therapeutic" intervention.

    Modalities that can be considered should be free of side effects. Auditory and sensory integration training, when done properly, benefits certain children with PDD. Other modalities are discussed in the PDD package. To receive a package, you may call 1.800.3AUTISM or link to the Autism Society of America website.

  8. Medical treatment: Medications should be directed at specific goals. Stimulants (Ritalin, Dexedrine, Adderall ). SSRI's (Prozac, Zoloft Paxil and Luvox). At times, neuroleptics are used (Mellaril, Risperidal, Zyprexa) or tricyclics (Tofranil) may be helpful. Other medication options can be discussed with an experienced physician as new treatments may become available.

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Other topics in the PDD/Autism section:
PDD Main Page
1. What is PDD or autism? | 2. How is PDD or autism diagnosed?
3. The DSMV IV criteria
4. Review of the different PDDs
5. How does a typical child with autism present?
6. The PDD assessment questionnaire
7. Who should be evaluated for PDD?
8. What are the causes? | 9. Lab testing, medical consensus guidelines
10. What is the best treatment?
11. Behavioral modification
12. Prognosis (long term outcome) of autism
13. Differential diagnosis for autism
14. Secretin and autism
15. PDD and the educational system
16. Associations related to PDD (Links)
[Print entire PDD section]



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