There is a clear consensus that children with disabilities are the most vulnerable to both short- and long-term effects of COVID-19 (United Nations, 2020). This is particularly true for children with Autism Spectrum Disorder (here forward autism) for whom the sudden disruptions in educational and therapeutic services have negatively impacted behavior and emotional health (Espinosa et al., 2020; Spark Foundation, 2020). Concurrently, parents have faced the difficulties of being their child’s direct care and education providers while also managing their careers (Espinosa et al., 2020). Many parents report inflexible behavior, difficulty with transitions, trouble independently completing tasks, and low frustration tolerance. Here, we briefly summarize strategies to help families support their children.
Behavioral science principles are the most commonly used to decrease challenging and disruptive behaviors (Bearss et al., 2015; Beavers et al. 2013). These evidenced-based interventions establish that, to improve behavior, one first identifies a specific problem behavior and looks at what happens before (antecedent) and right after its occurrence (consequences). This will allow to identify the possible function(s) of that particular behavior. Behavior generally has one of four functions: 1) obtain attention, 2) access a tangible object or activities, 3) escape or avoid a task, or 4) seek or avoid sensory stimuli. Once the antecedents, consequences, and function(s) of a behavior are established, a behavioral plan is developed to promote the desired behavior.
Also called stimulus control or environmental modification, antecedent-based strategies address the environment/events prior to a behavior occurrence with the goal of reducing the likelihood that the behavior will occur again (Odom, et al., 2010). One way to modify the environment is to enhance and/or develop a schedule of activities and tasks. Visual schedules facilitate independence, increase on-tasks behaviors, and improve transitions (Banda & Grimmett, 2008; Knight et al., 2014) by making it clear to the child what is coming next. For children with autism, not knowing what to expect can increase disruptive behaviors and trigger emotional dysregulation. Therefore, visual schedules using pictures and/or text to illustrate a sequence of daily activities can prompt appropriate behavior(s) by setting clear expectations (Dettmer et al., 2000). Early reports from areas where strict social distancing responses to COVID-19 were in place have shown that using detailed schedules were effective, even for children who did not require them before (Espinosa et al., 2020).
In constructing a visual schedule, the order of tasks should be individualized to reflect the child’s age and abilities. Common strategies for implementing a visual schedule include placing it in a visible central location and reviewing it with the child using both nonverbal and verbal methods such as showing pictures or reviewing the schedule out loud. Using a timer and methods to track activity progress, such as check boxes, moving a picture from a “to do” to a “done” section, and crossing something off, are also helpful practices. In conjunction with the visual schedule the physical environment should also be adjusted to increase attention by removing and/or limiting access to distractions (e.g., storing preferred items away out of sight and reach). Using software applications that limit, monitor, and restrict screen time may also be necessary when media use is excessively distracting.
Addressing consequences of behaviors, such as positively reinforcing a desired behavior, is another important step. Positive reinforcement can be tangible (rewards) or intangible (labeled praise). Rewarding desired behavior increases the likelihood that behavior will occur again. Using a response-contingent model (in that a child has to do a desired behavior to earn a reward) is most helpful. To use strategies from this model effectively, the parent must first identify two things: 1) a desired, alternative or replacement behavior and, 2) a positive reinforcer. Then, a parent only provides the identified reinforcer if and when the desired behavior occurs. It is also helpful to identify a proactive plan for what to do when the child exhibits the undesired or “problem” behavior.
Planned ignoring is one example of an effective strategy for behaviors that have the function of gaining attention or avoiding/escaping a demand or activity. To implement planned ignoring, parents can actively remove attention from the undesired behavior, and only attend to appropriate, desired behaviors. For instance, if “whining and complaining about schoolwork” is an undesired behavior, when the child complains about schoolwork, the parent remains silent and does not change their facial expressions or demeanor. When the child engages in schoolwork without complaints, the parent positively reinforces by using labeled praise. Labeled praise is when the parent explicitly describes what they like about what the child is doing. A parent might say, “Awesome job moving on to the next row of math problems!” to use labeled praise as positive reinforcement during schoolwork.
When implementing a behavioral management plan, parents should expect extinction bursts. An extinction burst is when a behavior occurs more frequently and intensely because the reinforcers for that behavior are removed. It is essential that these behaviors are not inadvertently reinforced when a burst occurs. Parents may often think it means the behavior plan is not working when it means the opposite. If the behavior is not mistakenly reinforced, extinction bursts ultimately end with extinction of that behavior (Wong et al., 2015).
If using antecedent and consequence/reinforcement-based strategies do not help to improve your child’s behavior, then consider consulting a professional for additional intervention. More broadly, behavioral specialists can help in guiding parents to develop, monitor, and adjust an individualized plan based on the child’s response over time. A number of telehealth approaches have been developed for this purpose (The Council of Autism Service Providers, 2020) and are available in centers across the United States, including ours. Although implementing behavioral strategies can be effective in reducing challenging behaviors, in situations in which safety is at-risk, parents should always reach out for professional and/or emergency support. In these instances crisis lines (Text HOME to 741741), as well as autism specific, personalized information is available (Autism Response Team by Autism Speaks).
During this COVID-19 crisis, parents have reported that professional support related to their child’s special needs has been helpful (Toseeb et al., 2020). Autism treatment programs aimed at increasing social communication and daily living skills have been adapted into telehealth formats (Bearss et al., 2018; Ferguson et al., 2019; Ingersoll et al., 2016; Sutherland et al., 2018). In response to COVID-19 broader implementations of telehealth interventions are increasingly more accessible (Autism Response Team or Child Mind Institute).
While effective strategies for supporting children are important, parents’ own management of stress and incorporation of self-care is essential. Especially in these difficult and unprecedented times, finding ways to help oneself so that one can help their child has never been more important. Social support, and engagement in solution-focused strategies, mindfulness-based programs, keeping healthy diet, sleep, and exercise routines (Cachia et al., 2015; Pottie et al., 2009; Saha & Agarwal, 2016; Zaidman-Zait et al., 2016; World Health Organization, 2020) are all evidenced-based ways to help parents cope with these inherent stressors. Other strategies for parents include maintaining frequent and regular contact with a child’s teachers, special educators, and treatment providers. Staying in touch with friends and family and asking for help when needed (e.g., having friends deliver groceries or other necessities) is also recommended.
Although the COVID-19 crisis has brought stress and challenges for all families, many also underscored that more family time is an incredibly rare and valued benefit of this unprecedented time. We hope the suggestions discussed above can help families to take advantage of this opportunity and improve the quality of their time together.
Bethany A. Vibert, PsyD, Cynthia Martin, PsyD, and Margaret Dyson, PhD, are Clinical Psychologists, and Adriana Di Martino, MD, is Research Director at the Autism Center at the Child Mind Institute.
To learn more about the Autism Center at the Child Mind Institute, visit www.childmind.org/center/autism-clinical-center.
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