On Restraint…and How it is Used Incorrectly

A Theoretical Aside

 


TW/CW for the below sections: Abuse, Restraint, Injury, Language


 

Well, we are back to this again. Some local school districts have approved more invasive manual restraint and forced physical guidance techniques for use on K-12 students. Since this will disproportionally apply to students in special education, and more particularly to autistic students, I feel a need to cash in my two cents.

My assumtions underlying this post are as follows:

  • I assume that all teachers mean the best but often act improperly due to lack of training in how to respond correctly in fearful or dangerous situations (link)
  • I assume that adults will use all the tools they have at hand to control a highly disruptive student – all the tools, even the ones we should not have given them (link).
  • I assume 99.9% of students act out to get their needs met and have a history of communication failing them
  • I assume that restraint is 100% ineffective for any purpose other than to maintain bodily safety in extreme situations, and even then it is never the optimal solution

I feel I needed to give these assumptions so it is understood I do not believe that teachers crack their knuckles and prepare to brawl it out with a tough kid when they come to school each day. I do honestly believe that virtually all teachers mean the best and are not trying to hurt or ostracize a student. That might be the effect of their interventions, but it was not their intent.

I have previously written on the misuse of restraint as a de-escalation measure and refer the reader to that post as preliminary reading to this one.

What do I mean by restraint?

When I talk about restraint, I mean: any means by which an individual is forecefully immobilized or has their movement restricted in such a way their freedom of movement is impaired. This is similar to policies spelled out by the US Federal government.

Specifically, I am going to pictorally show different restraints and I will then give describe how these restraints are used in the next section. For the below images, I ask that you imagine you are a typical 8-12 year old with a full-grown 24 year old woman or man performing these restraints.

restraints-960.gif

There are more, but these are the ones I am going to address. Some school districts still authorize carries, but I can say that is NEVER necessary in a school setting to carry a student unless it is being done by police officers or paramedics.


TW/CW for the below sections: Abuse, Restraint, Injury, Language


Restraint Abuse and How I Intervened

These nonexamples are going to be described as they happened. I personally watched them happen or had to deal with the immediate aftermath as part of my position as a behavioral specialist. In no cases should anyone use restraint the way these teachers did. In none of these cases was restraint used ethically, even though the use was described as justified and necessssary.

In this section where students use fowl or obscene language I quote it. I do this to be clear why teachers in Utah may respond dramatically given the language and context in which it was used.

Example 1: Basket hold as a consequence

For this example, a student was walking out of class and into every other class in the school causing trouble. The student was calling little islamic kindergarteners and first graders “skanky fucking cunt” or “whores” and asking them if they would “…suck my big dick you little slut”. These were refugee students whose parents were very concerned about the treatment of their girls by Americans that do not understand their Islamic culture. So teachers were very reactive to these types of comments and responded dramatically, usually by physically grabbing the student and forcefully dragging him away from the situation.

This student had a tendency to run and hide in the school and generally be a problem. He would try to get in the kitchen to get knives. He would try to rip the blade off the large paper cutter to make a sword. He sharpened sticks on asphalt at recess to stab peers. Generally not safe behavior. One day he even  learned how to give other students paper cuts with a sheet of card stock.  The consequence for all of these behaviors was the teacher would yell/scream at him and he would be restrained and forcefully guided to the copy room where he could be isolated. And the behaviors were only escalating in frequency and intensity.

These interactions where the intervention results in increased behavior is a positive feedback loop as diagrammed below.

restorative-justice-an-old-idea-whose-time-has-come-positive-feedback-loop-definition-violence-biology-example-examples-system-a-mechanism-oxytocin-promotions-differs-from-negative
This is an example of a positive feedback loop for societal violence. This is still 100% applicable to a student situation, just replace the word “policing” with “enforcing” or “discipline”. The step that the teacher and administrator can address to break the cycle is “tighter legislation”

Given the above behaviors, it is not surprising this student was restrained, a lot. Almost daily. By everyone except the principal.

The principal was amazingly patient. She would get the student to go into the copy room and close the door. She would literally calmly and stone-facedly watch the student destroy this room over and over until he was out of energy and then he would start to clean up for lack of anything else to do. Then the principal would engage in dialogue – after the behavioral outburst was done. When the principal was not around, well, this kid was in basket-lock heaven.

The student would spit on adults because they would repulse and gag. The student would to urinate and defecate on themself and hug the adult to get a response. He would attack the adult and inflict bodily harm. If something could be used as a weapon, all the better. This was not a good situation.

As stated above, restraint had become a positive feedback situation.

So I came in.

The student hated me from day 1. Our first encounter was him telling me (loudly), “you wear faggot shoes, faggot. You take it in the ass”. The only response he got was a bemused look from me (a calculated one to confuse him) but no accompanying alteration to my behavior. He would run outside and I would stand by the door to keep other students from opening the door to let him back in. Rather than pay attention to the student and the behavior as he wanted, I set an arbitrary (and harmless) rule that if he had to run outside, he had to enter the school from the front door because the side doors were locked. I occasionally reminded him how to get back to class and walked away, ignoring his obscene tirades.

I was spit on. He tried to urinate and defecate on me. I was called a “faggot” and “gayboy”. I was called a, “bitch asshole fuck you” and kicked/punched at. Weapons were fashioned for use against me. I did not respond other than by blocking direct punches or casually stepping away.

This student was aggressive and violent and put on a great show of being dangerous, but he was not very good at it. He had no idea how to react when there was not an aggressive overture from an adult toward his behavior. He could come at me with anything he could muster, and I would simply gauge the threat as nominal, steop out of the way, and then I would act appropriately.

When this student pulled scissors on me or tried to cut other students, I had to restrain him or use forceful physical guidance to isolate him until I could disarm him. I did not have a choice because no one gets to physically assault the students in the school and I really did not want to call the police to detain this student for assault. But I never chased, never raised an eyebrow, never raised my voice, and never reacted to spit or other bodily fluids.

Fast forward two months. This student has by now learned my schedule and only misbehaved when I was not around. So, much to his chagrin, I changed my schedule. The first day I did this, I was sitting on the floor in the hall when he charged out of class screaming and swearing. I coughed and they student stopped in his tracks and stared at me. I pointed to the wall across from me in the hall and he sat down.

Conversation happened because I had confused him by my presence. He felt momentarily disarmed. I learned a lot about his motivations, family, and the troubling amount of physical, sexual, and emotional abuse he had received from his biological and step fathers. It was clear he was a tough kid with a tough past and a hard life that had no idea how to process that trauma and how to act in society. I said nothing. I just listened. I figured I was not going to be any help other than as a passive therapist.

We made a plan for how to succeed in the future. It felt like we had made great progress, at least until later that day he tried to sneak-attack me with a stapler… But he did apologize for it when he regained control of himself.

Three days later, the family moved to another district and we got this student placed in an appropriate classroom to help him learn the social and emotional regulation skills they need to not end up in prison.


Example 2: Basket hold / Supine hold

This was a student with behavioral and emotional control issues. They were diagnosed as autism, but I did not see autism as the problem. This student was placed in an academic unit classroom because of their behavior in a kindergarten in a school for autistic kids. This was not a wise move.

This student was bored with the curriculum and angry at classmates because they were academically far below this student’s level. So the student acted out. Bit teachers. Attacked teachers. Kicked them. Punched them. Spit at them. Threw chairs at peers. Ran around the classroom sweeping materials onto the floor while giggling and swearing. Climbed bookshelves. The student ran outside the door and screamed, “fuck you bitch asshole” as loud as possible into the school – paticularly at the kindergarteners.

So, what did the teachers do. They put the student in a basket hold on the ground or in a chair and started talking and trying to reason with the student. Trying to calm the student down. Big mistake. One could see the smile on this student’s face as the interaction unfolded. The student would feign calmness, and as soon as the teacher would relax, the student would break the hold and run away to destroy more property. This was a cycle leading to the student being restrained greater than 60 minutes a day.

At this point I was called in.

I was unhappy with this assignment because I actually had to begin by using restraint on this student in order to fade restraint out as an option. Early on in my interventions I started to receive death threats from the student. I usually do not pay these any mind as a first grader has a very hard time hurting me, but the student stripped a pair of scissors apart and tried to stab me. They also tried to staple my head (though I admit it was harder to not laugh than it was to gain control of the stapler). Then the student turned on themself. They tried to hurt themself these same ways but their heart was never in it, especially when I would simply respond by asking, “Who is that going to hurt, exactly?”

The student was not getting away with behavior. They were not having fun. They were not in control. They had escalated and started trying to actually hurt others with sharp objects and swinging sticks, so I had to use restraint until I could get the classroom cleared or move the student out of the presence of others prior to my intervention. Because I do not show emotion and I know how to place my body to not allow contact from the student — they did not contact reinforcement from this interaction. Sadly, in a way, it broke them because it took away their control. I still feel bad because no student deserves that.

I spent a month working with this student to rebuld their self esteem. They still ran away. They still attacked me. They still screamed “fuck” at the kindergarteners and visising parents. But less. This kid had previously learned their behavior led to a direct power struggle with the teacher, and they enjoyed the intimacy of a direct and close interaction with the adult. When I intervened, I demanded age-appropriate interactions. The student was to speak appropriately and I would respond. I did not accept anything other than appropriate vocalization as a communication behavior. It took a month of kicking against me and my lessons on social communication (literally), but the student learned to communicate correctly. By the end we had a pretty good little teacher-student relationship going.

That was, until I left. Within a week the student  had been restrained by the teachers and was slipping back into old behaviors. When I probed into why the restraint happened, it was because the student threw a pencil when a math problem was hard. It was not aimed at anyone. It was just a mistake. A simple mistake made by first graders everywhere. But this mistake was turned into a big deal by the teacher who restrained the student. This very quickly turned into a positive feedback situation wherein the student was spending more and more time being restrained each day.

The end result of this was the student relapsed and regressed to using aggressive and anti-social behavior rather than verbal as a primary means communication. They were Transferred to a social and emotional learning unit classroom.

The video below is a fairly similar example to how this student was treated. Particularly how the basket hold was reinforcing to the student and got them a LOT of attention. Moreso when the second adult was requred to come and help escort him out of the room.

Anytime a kid can spit on you, flail back and hit you, or generally effectively fight the restraint, they have won. You might as well just ascede to their wishes. They are enjoying the restraint every bit as much as you are not.


Example 3: PRT hold as a consequence

In my first classroom, I had a student that would randomly misbehave and be naughty. By no means and by an orer of magnitude was this student not my toughest student in the class. The student was not particularly dangerous unless they were trying to climb the baseball backstops out at recess. Occasionally they would use thumbtacks or anything sharp to self-mutilate the tips of their fingers. They would mouth off to paraeducators and then talk about violent things and then spend the rest of the day drawing pictures of death and blood. This always got a rise out of the paraeducators. So they would restrain him until he was “under control”.

Early in the school year, based upon what the previous teacher had put into the classroom plan, these naughty episodes were met with PRT restraints (see below for how this is done correctly, noting that what was being done on my student was much more aggressive than this). This was under the guise that the behaviors I decribed above were precursor to more dangrous outbursts or increasingly anti-social behavior (climbing over stalls in bathrooms, running around the school screaming, patting student’s buttocks, etc).

I dug more into this, as I was suprised to see this restraint procedure was in the informal plan. Furthermore, the paraeducator was a carry over from past years and came in prepared for battle with this kid. Well, this paraeducator was not trained in any de-escalation of restraing method. The notes said, “They know how to do it”. My concern was that this restraint was straight out a form of abuse and the student had grown accustomed to being a supplicant to adult aggression.

This had to stop. immediately.

I needed data in order to change the plan. So I very overtly took notes on student and adult behavior whenever manual restraint was used. What I observed first was that the student was enjoying the restraint. They would act out and fight the paraeducator like mad. Then they would relax. But once the offer was made to be quiet and still for 5 minutes and they could go back to class, the student would wait 2-3 minutes and then spazz out afresh and flail their head backward to hit the paraeducator. This student was effectively getting out of half a day’s lessons by being naughty and prolonging the punishment. They were also getting what amounted to an hour long, uninterrupted hug from an adult.

Smart kid.

I got rid of this protocol on the premise that we would never touch kids in my classroom. I decreed that if there was going to be any restraint of any students in the class for any reason I was to be the one to do it as I was the only one formally trained.

This kid tried their darnedest to get me to restrain them. They climbed. They tried to swear (they were a naughty innocent kid so their swearing was almost always made up words that sounded like swears), they climbed stalls in the bathroom. They threatened to hurt themself.

I met their efforts with patience and a soft voice.  They slowly stopped behaving and started asking me if they could get their needs met. It was simply easier that way.

When it was noisy and chaotic they asked to walk to the end of the hall to fill their water cup instead of use the in-class sink. They started to ask if they could climb…and accepted when I said no. They tried to discuss death and violence with me. I let them draw whatever they wanted as long as they would have a discussion with me about what they were thinking and why they were making those drawings and how they felt emotionally.

The student was able to progress, once we removed restraint and abuse from the list of options we had available to us. By the end of the year misbehaviors were rare from this student. They paid attention and did their work. They had some mental health struggles for sure, but they wer no longer volitionally naughty and taunting the teachers to use restraint.


Example 4: Isolation/Time-out booth

I was working for a few days in a social and emotional learning unit classroom with students that were classified as having a behavioral / emotional distorder. My goal was to help keep one of the students safe as they had fled the school 3 times in that past week and had attacked a teacher with a sharpened pencil the day before. I was there to keep them in school and everyone safe.

The day was going well until one of the paraeducators started picking on this student. I was clearly there helping them (I was less than 3 feet away from the student and discussing their work), but the para decided they needed to come and comment on how work was “intentionally” not being completed fast enough. At this point I had to bolt to a door faster than the student because they had decided that they were done with school. Since I was standing in front of the door (I am between 6’5″ and 6’6″ tall and broadly built), the student could not escape and started to punch me in the chest and stomach. Hard. I chose not to react to this and they gave up after less than 5 seconds and stomped back toward their desk.

The paraeducator that precipitated this whole thing and the classroom teacher grabbed the student by the arm and drug them to the time-out booth and pushed them in. The student was told they were to stay in there until they wer eunder control and that they had committed “a physical”. Below are approximate methods used.

At this point I almost lost it. A situation was mostly under control (I was in control until the teachers had intervened because the student had given up hitting me and was walking angily back to their desk to continue their work). Now I was in front of a time-out booth with a swearing, spitting, kicking child that was not at all interested in de-escalating.

Lovely.

I got the student out of the booth as fast as possible and the student asked if we could take a walk just me and them. I knew this was a trick for them to escape–but I reward communication as a rule. So we walked. The student tried to escape by walking a long way in front of me. I let them. They left the front of the school. I let them. I was not going to physically block or intervene at all. I stood at the door and asked them in a curious voice what they should be doing. The answer was, “sitting in class doing my work” and they came inside. This was a surprise to me. I was expecting a fight, but the student came in and walked to class.

Story done, right? Nope. The instant the student got to class, the teacher and paraeducator corraled them and forced them to the time-out booth again. They said it was because the student was looking at another student and they were worried an attack was imminent. So, once again. I am in front of a time-out booth lisening to increasingly florid and creative swearing and threats to urinate and defecate in the booth.

I was furious at the teachers at this point.

The instant the student was not banging against the door , I opened it and I took the kid out of the booth. We went to the social worker’s office. We sat and worked the rest of the day without problems. There was still yelling and swearing about having to do work, but the student was worked up from that morning so I let them vent. But there was no voilence or even precursors to violent behavior. We even went and had a pleasant lunch where we talked about this student’s family and their previous school. It was nice.

The student was given a 3-day suspension the next day for trying to escape the school after they had a confrontation with the teacher and paraeducator and were thrown into the time out booth.

So How Do We Maintain Safety if not by Force?

The critical part of maintaining safety is prevention. In fact, that is the one thing all the programs I mentioned above agree upon. If we can proactively play defense and keep the students active, engaged, and learning in class without feeling overwhelmed – they will be able to self regulate.

I have said for a long time that the best way to keep a student from acting out and having a crisis/meltdown is to keep their mind engaged and body active.


I will end with some specifics on how to use this chart of the excalation/crisis cycle to mitigate the necessity of using restraint in a classroom setting:

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  • Choose to believe the least dangerous assumption: the student is struggling but they will be able to overcome any challenge if provided the right tools
  • Don’t escalate the kid to the point of no return (the Escalation phase above)
  • Anticipate the student’s needs based on behavior and past experience and provide options regarding how they can appropriately get those needs met
    • These are not ultimatums but legitimate choices and options
    • If the student makes the choice, immediately support their decision
  • Talk to the kid during baseline and stimulation phase
    • This makes it so the students does not perceive interation as aversive or a sign they are in trouble
    • Let students lead conversations so much as possible
  • Walk away before the Escalation Phase.
    • No, Really. Walk away.
  • Walk away during the De-Escalation Phase as well.
    • Pressuring kids and making demands on them at this stage leads to Crisis all over again.
    • Offer them a chance to cool off in a safe and private-ish place
  • Have a thorough and comprehensive debrief that the student can lead during stabilization and Post-crisis phases.

Note: If at any point on this cycle you touch a student aggressively to restrain, they will immediately go into Crisis. When in crisis, humans engage in aggressive/survival behaviors and are not capable of thinking rationally. 

Why am I so against restraints?

Restraining a student has only two functions in my opinion. One, it makes the teacher or other authority feel like they are in control. And two, as they are commonly performed, restraints serve to reward the kid for their behavior. Finally, in the very rare instances restraint is appropriate, it is extremely difficult to do right and I have met only a handful of educators in my life sufficiently trained to do it well.

I will unpack these points below.

Restraint Gives Adults the Illusion of Control

If there is on thing I have learned from studying behavior, it is that the second you touch a child, you have lost. They are now fully in control of the situation and can prolong or end the confrontation whenever they like. At their whim,

When we restrain, it feels like we have are terminating a behavior or else interrupting a behavioral pattern. I can understand that. It also feels like we are being effective because we are doing something rather than standing idly by taking notes while a student is engaged in some very inappropriate or borderline dangerous behavior. However, we should be standing idly by taking data.

Making the choice to stand back and think rather than impulsively act is what gives us control. Rash decisions lead to mistakes. And we cannot be accidentally in control. We can only be accidentally out of control.

Kids know this.

Restraint Rewards Behavior

What do I mean? I mean it how it sounds. If there is any interaction among the student and the teacher during a restraint, the adult is reinforcing or rewarding whatever behavior led to the restraint.

Looking at the video I linked above with the student spitting on and hitting the teacher using a basket hole on him. Does it ook like the kid is getting under control at all? Does it look like he is unhappy with the situation? Or does it look like there is some kind of weird pleasure in the fighting. I assert the latter.

This student gets physical contact and intense 1:1 attention during the restraint. Even the teacher nagging about sitting still for 5 minutes is rewarding. The bouncing and standing. Rewarding. The other students coming in to spit on the teacher and interact. Rewarding.


To avoid this reward, there is a simple trick. And it is very hard to do. When restraint begins, emotion is turned off. Voices are turned off. Reaction to stimuli are turned off. The only communication is a clear directive at the beginning and every 2-3 minutes (or whenever law/policy requires a temporary release of the hold) stating the condition of release. The body has to be placed such that the student cannot touch you. Cannot spit on you. Cannot bounce against you. Cannot loosen by struggling.

This is hard. And requires a lot of training.

So How do I Restrain When it is Absolutely Necessary?

Honestly? You don’t. Avoid it if at all possible. You can go an entire career without restraining students.

Aspire to that.

If you forsee you are going to be in situations requiring restraining students, here is what to do:

  1. Sign up for a district or state run training that involves de-escalation and restraint methods. Even if your district doesn’t advertise these trainings, they have one available. Behavioral specialists in the district office lead the trainings and your colleagues in special education (and sometimes your administrators) have taken these classes.  Here are some examples. My preference is for the last three on the list.
    1. MANDT
    2. SafetyCare
    3. ASPEN
    4. TCI
    5. CPI
  2. Verify your district has school or district-level behavioral specialists that are willing to work on plans and interventions with you. Get to know them. Be open about concerns regarding restraint.
  3. Attempt ALL de-escalation and calming strategies available to you prior to considering restraint
  4. If possible, clear the classroom or isolate the student rather than restrain
  5. Call in help prior to moving toward using restraint
  6. If time, notify law enforcement or paramedics for assistance with students in crisis

Here is the guidance from Chapter 10 of the MANDT manual (Chapter on Restraint Methods). Note how carefully they explain restraints are not maintained until the person is calm. Only until the immediate danger or threat of harm is mitigated.

Conclusions

Overall, it is always best to avoid physically confronting students. Restraint creates distrust and harms the self esteem of the indiviual being restrained. Restraint leads to injury and in some cases has led to deaths.

If it is necessary to hold a student for the safety of others, make sure you are trained and that you have another responsible, trained individual with you as a safety monitor. After the crisis is over, it is critical that the student be allowed to have a thorough de-brief where they can express themselves freely, not just telling the teacher how they are going to do better next time.

 

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Most of What We Call Autism-Behaviors Really Are Not Unique to Autism

An Educational Aside

In my working with teachers and school psychologists, I have noticed there is a trend toward attributing a wide array of maladaptive and challenging behaviors to autism.  Poor social skills are called “autistic traits.” Whenever there is a profound sensory need autism is assumed, even though sensory processing issues are present in a wide array of developmental disorders. Poor communication is regarded as autistic. Idiosyncratic toy usage…  Stimming…  And so on and so on.

These assertions are just wrong and they kind of get on my nerves because I regularly have to say, “he is not autistic” and “that is not autism.” But then I realize most people do not know any better, and they think labeling a behavior with a disorder is helpful somehow.

Illustrative example: 22q11.2 deletion syndrome

My example from research is from Tony Simon’s lab. He found that kids with the 22q11.2 deletion syndrome are often given an autism diagnosis. He and the team of pediatricians in the 22q clinic he works with were annoyed by this trend. They saw 22q and concomitant anxiety disorders, not autism. So they studied whether 22q is actually associated with autism.

The study is: Social Impairments in Chromosome 22q11.2 Deletion Syndrome (22q11.2DS): Autism Spectrum Disorder or a Different Endophenotype?

What they did was to take all the children with 22q11.2 DS that came through their clinic and used two gold-standard autism questionnaires. The ADOS-II and the SCQ. The UC Davis MIND institute had decided previously that their autism diagnostics were based on agreement across these two measures. This reduces false positive diagnoses (diagnosis of autism in a child that is not autistic), but only slightly increases false negatives (an autistic child does not qualify for an autism diagnosis) when compared with the parent responses to the ADI-R. The effect of this choice was that the researchers at the MIND Institute were confident that when a child was labeled autistic, they were.

When the kids with 22q were assessed in the clinic, they were found resoundingly not autistic. Not even close. Zero kids with 22q11.2DS met the criteria for an autism diagnosis using the combined ADOS-II and SCQ.

What the researchers found was that 22q has a unique pattern of abnormal social skills and other functional deficits that could be interpreted as autism if the clinician did not conscientiously take 22q into account. Basically, despite overlapping behaviors, 22q and autism are unique. The paper suggests clinicians refrain from labeling 22q as autism because the help and interventions available for autism are not always appropriate for kids with 22q.

Their conclusion paragraph (emphasis mine):

In conclusion, based on best practice assessment, ASD is not as common as previously reported in 22q11.2DS and highlights the importance of integrating multiple sources of information when considering an ASD diagnosis. Elevated scores on single measures are not sufficient for a clinical diagnosis of ASD, and this study is the first to use the ADOS in addition to parent report, in the evaluation of ASD symptoms in 22q11.2DS. All children with 22q11.2DS had strengths in social interaction and weaknesses in imagination and insight on the ADOS. Children with elevated ADOS scores tended to have relative weaknesses in communication. Further investigation is warranted to explain how the social impairments, difficulty with communication, and repetitive behaviors in children with 22q11.2DS are similar and different from ASD. Comorbid conditions such as anxiety and cognitive impairments likely contribute to false elevations on individual ASD measures, and future research should proceed with both components to ascertain accurate levels of ASD in 22q11.DS populations. This would directly impact treatment recommendations and patient care procedures

My two cents about labeling rather than describing behaviors

One concept I learned from Tony Simon when I was collaborating with him as a graduate student and postdoc was the idea of a neurocognitive endophenotype. That is just a fancy word for patterns of deficits unique to populations with genetic disorders. This has helped me to see that no single or small subset of behaviors are sufficient to accurately diagnose any disorder. We need to look at the whole child and all of their behaviors. Only then can we have confidence in our diagnostics. Some links to my writings on this are here, here, and here.

I often forget that most clinicians and all educators are not trained to think this way. So they do not see the error of their ways in armchair diagnosing based on 2-3 behaviors. As stated above, they believe they are being helpful by attributing behavior to a diagnosis.


My contribution to this discussion

Instead of ranting about behaviors and dangers of kids being mislabeled, I am going to educate. I feel like the best contribution I can make is to provide knowledge that can be acted upon.

I am going to list a bunch of “autism behaviors” I hear a lot on one side of a table. I went on the internet and searched “autism behaviors” and cut/pasted the items from the list into the table as well. On the other side of the table, I will list other disorders that show the same behaviors.

I hope that you will be able to see that these are not very useful behavioral criteria for a differential diagnosis, but they are the traits most commonly labeled as behaviors caused by autism.

For this table, I will leave it to the reader to surmise examples of these behaviors in neurotypical folks as well. I will volunteer one: one can claim a version of echolalia is that one friend that communicates exclusively using Big Lebowski quotes, regardless of the applicability to the present conversation or evident annoyance of people around them.

Another example is pen twiddling or hair twirling during meetings. We all do it, but these are clearly defined as stimming behaviors when done by an autistic.


For this table, I am going to use the following neurodevelopmental and psychological disorders as examples. There are many others I can use, but I chose these. I have experience with all of these disorders and can say confidently based on clinical research and experience that kids with these disorders are not autistic.

FXS = Fragile X Syndrome; DS = Down Syndrome; CDD = Childhood Disintegrative Disorder; ID = Intellectual Disability; WS = William’s Syndrome; TS = Tourette’s Syndrome; 22q = 22q11.2 deletion syndrome (also called DiGeorge or velocardiofacial Syndrome); OCD = Obsessive Compulsive Disorder; ADHD = Attention Deficit Hyperactivity Disorder; KF = XXY, XXYY, or other Kleinfelter’s/Sex Chromosome Aneuploidy karyotypes; AS = Angelman’s Syndrome.

 

BEHAVIOR DEVELOPMENTAL DISORDERS
Communication Deficits
No Speech FXS, DS, CDD, ID, AS, KF
Severe Language Delay FXS, DS, CDD, ID, WS, 22Q, AS, KF
Abnormal Speech Patterns FXS, DS, CDD, ID, WS, TS, 22Q, ADHD, KF, AS
Echolalia FXS, ID, TS, KF
Do not Initiate or Engage in Reciprocal Conversation FXS, DS, CDD, ID, 22Q, ADHD, KF, AS
Do Not Respond to Name FXS, DS, CDD, ID, TS
Do Not Point of Gesture to Items of Interest FXS, DS, CDD, ID, AS
Unrelated Answers to Conversational Questions FXS, CDD, ID, TS, 22Q, OCD, ADHD, KF
Pronoun Reversal FXS, ID, KD, AS
Avoid Eye Contact FXS, DS, CDD, ID, 22Q, OCD, ADHD, AS
Do Not Imitate FXS, CDD, ID, TS, AS, KF
 Restrictive Interests
Insist on Sameness FXS, DS, ID, WS, TS, 22Q, OCD, ADHD. AS
Insist on Routine FXS, DS, ID, WS, TS, 22Q, OCD, ADHD, AS
Obsessive Interests FXS, DS, ID, WS, TS, 22Q, OCD, ADHD, KF, AS
Restricted Interests FXS, DS, ID, WS, TS, 22Q, OCD, KF
Stereotypical Play with Toys FXS, DS, ID, WS, TS, 22Q, OCD, ADHD
 Repetitive Behaviors
Spin Objects FXS, ID, TS, AS
Flap Hands, Rock Body, Spin FXS, DS, ID, WS, TS, AS
Line Up Objects FXS, DS, ID, 22Q, OCD, KF
 Social Skills Impairments
Poor Imaginative/Pretend Play FXS, DS, ID, OCD, ADHD, KF, AS
Social Skills Impairments FXS, DS, CDD, ID, WS, TS, 22Q, OCD, ADHD, KF, AS
Poor Theory of Mind FXS, DS, CDD, ID, TS, 22Q, OCD, ADHD, KF, AS
Heightened or Elevated/Reduced Fear/Danger Awareness FXS, DS, CDD, ID, WS, TS, 22Q, OCD, ADHD, KF, AS
Unusual Interests/Behaviors FXS, DS, CDD, ID, WS, TS, 22Q, OCD, ADHD, KF, AS
Desire for Isolation/Alone FXS, ID, OCD, KF
 Sensory Dysfunction
Over or Under Sensitivity to Senses FXS, DS, CDD, ID, WS, TS, 22Q, OCD, ADHD, KF, AS
Resistant to Physical Contact FXS, DS, ID, KF
Self-Injury FXS, DS, CDD, ID, WS, TS, OCD, ADHD, KF, AS
Rocking FXS, DS, CDD, ID, TS, OCD, AS
Executive Function Deficits
Unusual Mood or  Reactions to Stimuli FXS, CDD, ID, WS, TS, 22Q, OCD, ADHD, KF, AS
Aggression FXS, CDD, ID, TS, OCD, ADHD, KF
Hyper or Hypo activity FXS, DS, ID, TS, OCD, ADHD, KF, AS
Impulsivity FXS, DS, CDD, ID, TS, 22Q, OCD, ADHD, KF, AS
Low Attention Span FXS, DS, ID, TS, OCD, ADHD, KF, AS
Impaired Social Attention FXS, DS, CDD, ID, TS, 22Q, OCD, ADHD, KF, AS
Inconsistent Sleep Habits FXS, DS, CDD, ID, WS, TS, 22Q, ADHD, KF
Meltdowns FXS, DS, CDD, ID, WS, TS, 22Q, OCD, ADHD, KF, AS
Nonspecific Phobias FXS, CDD ID, OCD, KF

I sincerely hope we can all agree not to call these “autistic” behaviors anymore. They are by no means unique to autism. 

Implications / Conclusion

I think we need to all just take a step back when working with kids and be extremely careful with labels – especially medical/diagnostic labels. It is far too easy to make an uninformed diagnosis without access to the full medical and family history. And…most of us are unqualified regardless.

Sometimes I feel like we are part of the Monty Python Psychiatrist Milkman sketch, making hasty diagnoses without data.

The solution is simple.

We do not give behaviors labels. We describe the behavior.

We stop attributing certain behaviors to a given disorder. We just describe the behavior carefully and develop interventions without consideration to any particular underlying disorder unless diagnosed by a neuropsychologist and addressed in the student’s educational records.