Housing Adaptations for Children with Challenging Behaviour

Elaine DohertySenior Paediatric Occupational TherapistDublin South East

May 2012

Overview

•Introduction•Autism

• Definition• Causes• Aims for

adaptations•Epilepsy

• Definition• Seizure types• Aims for

adaptationsQuestions

Autism criteria -DSM IV

Autism Spectrum Disorder Must meet criteria A, B, C, and D: 

A.    Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:

1.     Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction,

Autism criteria -DSM IV

2.     Deficits in nonverbal communicative behaviours used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.3.     Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behaviour to suit different social contexts through difficulties in sharing imaginative play and  in making friends  to an apparent absence of interest in people

Autism contd. B.    Restricted, repetitive patterns of behaviour,

interests, or activities as manifested by at least two of  the following:

1.     Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).

2.     Excessive adherence to routines, ritualized patterns of verbal or nonverbal behaviour, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).

3.     Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests)4.     Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).

C.  Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

D.  Symptoms together limit and impair everyday functioning.

DSM-IV categories

Several autism-related disorders are grouped under the broad category of ‘Pervasive Developmental Disorder or PDD’

AutismPDD not otherwise specifiedAsperger’s syndromeRhett’s syndromeChildhood disintegrative disorder

Hypotheses

Genetic links Viral causes Abnormalities in CNS structure Abnormalities in serotonin levels Seizure disorders Immune mediated responses

Autistic people use their brains differently

Their visual centres in the back of their brain are used for tasks usually handled by the prefrontal cortex

Over connectivity in localised areas

Poor interconnections between more distant brain structures

Other disorders with autistic-like bahaviours

Mobius syndrome Sotos syndrome Tourette syndrome William’s syndrome Angelman’s syndrome Childhood schizophrenia Fragile X syndrome Rett Syndrome Landau-Kleffner syndrome

Autism: Aims for adaptations

Shape the environment in a way that the child will be more successful and can help calm, stimulate and provide order for the child

Assist the family to regain control

Allow the child to experience more choice, control and independence

Home Safety

Kitchen Keeping children out of the fridge to prevent over eating or

eating raw or partially cooked foods. Secure dangerous chemicals, knives, matches, lighters,

scissors etc PICA Most efficient way is to put all non perishable food is in one

area that can be secured Locking the fridge depends on the model. Side by side doors

can use bicycle locks. For side opening doors a two piece latch system can be fitted and secured with a padlock

Securing cabinets. Drill a small hole and fit a drawer lock. Alternatively a security lock that is opened by a magnetic key can be fitted and this is not visible from the outside

Elopement

The type of lock will depend on the child’s ability. Locks will stall the child

Hook and eye bolts and slide bolts are the most common. Consider a spring loaded catch which makes it more complicated.

Dead bolts are good but it involves carrying another key and they can be a risk in case of fire.

Keyless locks: Digital keypad and handle latches Mechanical keypad deadlocks and handle latches Card-swipe systems Proximity systems Biometric systems (finger print detection)

Side by side fridge doors

Side opening fridge

Alarms

Some systems will allow you to set for the doors only There are inexpensive alarms that can be attached to

doors and windows. They are useful for doors that aren’t used very often. The models that can be shut off by a key are the most useful

Motion alarms for the child’s bedroom and hall. The sound can be set to different frequencies and can alert a parent that the child is wandering around at night.

The child can also wear an alarm but this can be dependent on their tactile sensitivity.

Stuffing toilets/sinks

There are alarms that are attached to the intake pipes of a toilet or sink. When it senses a leak or overflow it will automatically shut the water off

Cool-down room

Not always suitable to use the child’s bedroom as they may associate it with behaviours and bad feelings and may not want to use it for leisure, relaxation or sleeping

There should be a minimal number of objects to throw or break Objects in the room should be soft: bean bag, soft mats, big

cushions and pillows Secure furniture to floor or walls to prevent it being tipped over Use curtains instead of blinds. These can be hung with velcro if

necessary. You may need to consider different glass for safety (tempered glass)

Sensory items for calming: music, dimmer switch for lights, fiber optic lights, lava lamps etc

Lights

Children with ASD are often bothered by fluorescent lights

Replace with incandescent lights. Recessed lights cannot be as easily broken

For children with sensitivity to light consider the colours and tones of the colours that are used in rooms. Avoid yellows, reds and bright white.

Avoid paint sheens that reflect a lot of light such as semi-gloss and high gloss opt for flat or egg shell

Bathroom

Water play. Sensory diet & behaviour modification

Under floor heating to dry floor more quickly

Floor drain

Organisation

Need for sense of order and structure Having things off tables and counter tops will

prevent them being thrown Organise functional items in see through

plastic boxes with visual labels Place items within reach Video games and films that are locked away

should have a picture catalogue allowing the child to choose

Home work

Set time to establish structure and predictability

Have a specific area away from distractions such as TV, toys

Consider temperature & lighting

Media

www.familysafemedia.comVisual schedules

Other

If the child has a tendency to put holes in walls consider panelling

Children can find the odours of certain foods aversive so consider ventilation

Tactile sensitivity: carpet maybe better than hard wood. Commercial grade vinyl may also be appropriate.

Adjust the water temperature so that the child cannot burn him/herself

Social stories and sensory stories

Epilepsy

Epilepsy is a brain disorder in which a person has repeated seizures (convulsions) over time. Seizures are episodes of disturbed brain activity that cause changes in attention or behaviour.

Epilepsy

It occurs when permanent changes in brain tissue cause the brain to be too excitable or jumpy.

The brain sends out abnormal signals. This results in repeated, unpredictable seizures

A single seizure that does not happen again is not epilepsy.

Epilepsy may be due to a medical condition or injury that affects the brain, or the cause may be unknown (idiopathic).

Common causes of epilepsy

•Stroke or transient ischemic attack (TIA)•Dementia, such as Alzheimer's disease•Traumatic brain injury•Infections, including brain abscess, meningitis, encephalitis, and AIDS•Brain problems that are present at birth (congenital brain defect)•Brain injury that occurs during or near birth•Metabolism disorders that a child may be born with (such as phenylketonuria PKU)•Brain tumor•Abnormal blood vessels in the brain•Other illness that damage or destroy brain tissue

Epilepsy- types of seizures

Primary generalized seizures begin with a widespread electrical discharge that involves both sides of the brain at once.

Partial seizures begin with an electrical discharge in one limited area of the brain.

Absence seizures

Absence seizures are brief episodes of staring (petit mal). During the seizure, awareness and responsiveness are impaired. People who have them usually don't realize when they've had one. There is no warning before a seizure, and the person is completely alert immediately afterward.

Simple absence seizures are just stares. Many absence seizures are considered complex absence seizures, which means that they include a change in muscle activity. The most common movements are eye blinks. Other movements include slight tasting movements of the mouth, hand movements such as rubbing the fingers together, and contraction or relaxation of the muscles. Complex absence seizures are often more than 10 seconds long.

Tonic seizure

In a "tonic" seizure, the tone is greatly increased and the body, arms, or legs make sudden stiffening movements.

Consciousness is usually preserved. Tonic seizures most often occur during

sleep and usually involve all or most of the brain, affecting both sides of the body. If the person is standing when the seizure starts, he/she will often fall.

Tonic-clonic

The tonic phase comes first: All the muscles stiffen. Air being forced past the vocal cords causes a cry or groan. The person loses consciousness and falls to the floor. The tongue or cheek may be bitten, so bloody saliva may come from the mouth. The person may turn a bit blue in the face.

After the tonic phase comes the clonic phase: The arms and usually the legs begin to jerk rapidly and rhythmically, bending and relaxing at the elbows, hips, and knees. After a few minutes, the jerking slows and stops. Bladder or bowel control sometimes is lost as the body relaxes. Consciousness returns slowly, and the person may be drowsy, confused, agitated, or depressed.

Tonic-clonic seizure

"Clonus” means rapidly alternating contraction and relaxation of a muscle - in other words, repeated jerking. The movements cannot be stopped by restraining or repositioning the arms or legs. Clonic seizures are rare.

tonic-clonic seizures, in which the jerking is preceded by stiffening (the "tonic" part). Sometimes tonic-clonic seizures start with jerking alone. These are called clonic-tonic-clonic seizures! This type is what most people think of when they hear the word "seizure." An older term for them is "grand mal."

Myoclonus

Myoclonic (MY-o-KLON-ik) seizures are brief, shock-like jerks of a muscle or a group of muscles.

In epilepsy, myoclonic seizures usually cause abnormal movements on both sides of the body at the same time. They occur in a variety of epilepsy syndromes that have different characteristics:

Epilepsy Syndromes

Juvenile myoclonic epilepsy: The seizures usually involve the neck, shoulders, and upper arms. In many patients the seizures most often occur soon after waking up. They usually begin around puberty or sometimes in early adulthood in people with a normal range of intelligence. In most cases, these seizures can be well controlled with medication but it must be continued throughout life.

Lennox-Gastaut syndrome: This is an uncommon syndrome that usually includes other types of seizures as well. It begins in early childhood. The myoclonic seizures usually involve the neck, shoulders, upper arms, and often the face. They may be quite strong and are difficult to control.

Progressive myoclonic epilepsy: The rare syndromes in this category feature a combination of myoclonic seizures and tonic-clonic seizures. Treatment is usually not successful for very long, as the patient deteriorates over time.

Drop attacks

Muscle "tone" is the muscle's normal tension. "Atonic" means "without tone," so in an atonic seizure, muscles suddenly lose strength. The eyelids may droop, the head may nod, and the person may drop things and often falls to the ground. These seizures are also called "drop attacks" or "drop seizures." The person usually remains conscious.Another name for this type of seizure is "akinetic", which means "without movement."

Aims for adaptations

Maximise independenceSafetyPlanning for future needs particularly if a

epilepsy syndrome or if seizures are refractory to treatment.

Questions to Ask

How frequent are the episodes? In what situations do they occur? Do they begin abruptly? Can they be interrupted? How long do they last? Does the person do anything during the

episode? What is the person like immediately after the

episode?

Consider

Consideration of an engaged/vacant sign in bathroom may provide increased privacy without compromising on safety Rubber or cushioned vinyl would be preferable to tiles as they reduce the risk for head injury during a seizure.Consider under floor heating by removing radiators from the room a falls hazard is removed. Shower controls that do not protrude again reduce the risk of injury.Hoist

Caution

Many people who have seizures during bathing experience serious burns as they adjust the temperature when then fall resulting in scalds.

Other considerations

If you are not the primary therapist discuss the case with the primary therapist.

Research the diagnosis and prognosisAssess all behaviours and decide

whether it is sensory based or a learned response. Is the behaviour to obtain or to avoid?

Remember safety first

Questions?

Thank you