My son, 17, is rubbing his elbows rather harshly against the arms of chairs or the console in the car. Sometimes it is his knees that are “getting the treatment” and you don’t dare stop him or he will lose it and go into crisis. I am wondering how to help him with this sensorial issue. Or if it is something besides being sensorial.— J. Massie
Thank you so much for your question! You are absolutely right to wonder about why he is doing the elbow rubbing because this is one of the most important steps you can take to helping him in a meaningful way. When it comes to any challenging behavior, the first thing we should ask about is whether or not we even need to bother doing something about it. This is particularly true when it comes to a behavior that has a sensory component to it.
We all have sensory behavior (e.g., do you twirl your hair? or chew on your pens?), it is just a matter of determining if it interferes with quality of life or harms anyone. If it does, then the next step is to get to the bottom of why it is happening and develop a customized plan to support him. In your question you mentioned that if you dare interrupt the behavior, he will go into crisis. I am definitely making some assumptions here, but based on the information you provided, helping him with his elbow rubbing sounds like a good idea. So I am going to get right into doing just that!
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Tip #1 Rule out a medical condition
Once you have decided that yes, you want to do something about the challenging behavior, the next step is to rule out any other medical or biological condition. One of my professors in graduate school told me about a case of a young adult with autism who started to engage in a neck rubbing/scratching behavior that was so severe it resulted in her having a sore on her neck. Instead of immediately jumping into developing a behavior plan, a doctor was consulted and it was found that she had swallowed a pit that had lodged itself in her throat.
There was even tissue growing over it. The only way she could relieve the discomfort was by hurting herself. I always share this example with my students and budding behavior analysts as a reminder to always consider a medical or biological condition first but also to demonstrate the point that all behavior serves to fulfill a need. In this example it was reducing significant discomfort.
Since your son is focusing on his elbows and knees, find out if there is something with his joints that is bothering him. You may want to see if he has dry or irritated skin. Of course it may be irritated from the rubbing itself depending on how often and how intensely he does it. However, it would be a good idea to consult a physician to rule out any other biological, or medical reason for the behavior. In the case of dry skin, some lotion would be a great place to start.
Tip #2 Figure out why
The next step is to look for patterns. This behavior that you described may have a sensory component to it, but we can’t know that just by looking at what he is doing. Unfortunately, figuring out why it is happening can be a bit more complex than that. What we absolutely do know though, is that any challenging behavior such as the one you described, serves a purpose for the person doing it. It is his way of getting his needs met. Typically, a need can fall into two broad categories: 1. to get to something you desire (e.g., a feeling, a thing, or a person etc.) or 2. to get away from something uncomfortable (e.g., a feeling, a thing, or a person etc.).
This challenging behavior has worked for him up until now and so if we are going to help him then we must figure out why he is doing it before we do anything else. What we do if he is doing it to access a feeling or something else is very different from what I would do if he is trying to get away from something that he may find uncomfortable. Challenging behavior has patterns associated with it and the key is to decipher what they are. Contacting a Board Certified Behavior Analyst (BCBA) is your best bet in helping you figure this out. In the meantime, it is a good idea to start tracking the elbow rubbing. This means that every time he does it write down what he is doing, what happened right before and what happened after. Here is an example of what I mean:
|Before the behavior…
|After the behavior…
|He was sitting alone in the car
|Rubbing his elbows on the console
|He continued to rub his elbows when I got in the car. I did not attempt to interrupt it.
If he rubs his elbows when there is no other person around there is a good chance that he is doing it for sensory reasons. We should not just guess though, so a BCBA would be able to help you confirm that it is indeed a sensory behavior.
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Tip #3 Develop a customized plan
Once we know why it is happening then we can begin to help him. If we do identify that he is rubbing his elbows to get to a feeling, in other words, he enjoys the sensory component, then we would begin to teach him when it is appropriate to do so and when it is not. It is not always easy to figure out which sensory need is getting fulfilled. For example, we might assume it is the rubbing itself on the skin, or the pressure, however it could also be the sound that it makes, or movement it produces.
This is why a BCBA would be very helpful, because if we identify the sensory aspect that it is fulfilling, we may be able to give him the same benefit with a different means. For example, one of my clients used to engage in a high prosody of voice, essentially would speak with a high pitch voice. It was the sound that he was trying to access as opposed to anything else, such as the feeling of the vocal chords vibrating. Once we figured this out we could give him headphones with different recordings of high pitch voices to fulfill his need.
This helped reduce the high pitch talking that was making him vulnerable to bullies but he also got to access the sensory component he was looking for. Basically it was a win-win. We may be able to reduce the likelihood of the elbow rubbing or challenging behavior if we give him access to it before he needs to do it. This might mean giving him free time to do it before he goes to school or it might mean introducing new activities that have similar movement or sensory input. We definitely don’t want to create a situation where he is deprived of it because it is serving a purpose for him.
Tip #4 Teach flexibility and tolerance
This final tip is related to your comment about him going into crisis when you attempt to interrupt him. I have worked with many families that describe intense challenging behavior as a result of interrupting something that his/her child wanted to do. This can lead to lots of stress in the home because it limits when and where you can go, it may lead to more dangerous behavior directed at the person interrupting, and it may throw a wrench into your plans if it happens unexpectedly.
That is why I think teaching our kids and teenagers with autism to be flexible and tolerate delays to getting things our way is a really important skill. The good news is, it is never too late to start. Dr. Gregory Hanley developed a wonderful intervention where he teaches kids with autism to ask for “my way.” So if they ask for “elbow rubbing” time, they can have it some of the time and other times they won’t be able to. This is because in the real world sometimes they cannot have what they want when they want it.
They will learn to tolerate that sometimes I get my way and other times I have to accept that I cannot, at least not immediately. In the beginning it is important to make it as easy as possible and gradually increase the challenge. This means that you should start with him getting his way more often and for longer periods of time than he does not get his way. As he becomes more and more successful you can begin to challenge him. This is a skill that all kids should learn and is not always easy.
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I hope that some of these tips help! I would contact a local BCBA if you are concerned about this behavior and going into crisis on a regular basis. They will be able to help you!
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This article was featured in Issue 62 – Motherhood: An Enduring Love