Severe/Extreme Head Banging/Slapping

[blueemerald]

I wonder if anyone out there can help me help one of my students?

She is 11 years old, severely autistic, pre-verbal, very hyper/manic, obsessed with people/faces and dropping plastic or metal things repeatedly (forks or spoons for example). She also claps almost continuously (at any given time she is either eating, dropping, clapping or touching someone's face) and clicks her tongue or vibrates her lips together. She is disinterested in/annoyed by music/lights.

We have made great progress in getting her to communicate with PECs and gestures and she can now follow most verbal instructions and sit at her own desk for about 10 mins at a time to work.

Our biggest problem at the moment is head banging. When she starts to get annoyed or frustrated (can be as a result of not getting what she wants 80% of the time or seemingly come from nowhere 20% of the time) she will at first bang the back of fingers on one hand against the palm of the other (sort of like punching her hand into her palm) and then fly into a rage slapping her head but slapping does not do justice to what she does, she will beat herself in the head for 10-15 mins at a time; today she slapped her head so hard she gouged out a chunk of skin from her forehead.

We have tried massaging or rubbing her head when angry and when calm but she will push you away or move away from you. We tried to put a padded helmet on her but that made her even angerier.

Part of me thinks it is a learnt response as she wants her own way??

Does anyone have any other suggestions??
Sorry for the long post but I wanted to give you an overview of what she is like in case any of it links together.

DS1 does it. I ignore it on the whole or say 'hands down' in a cross voice.

The other thing is that he went through a patch when it was REALLY bad, by which I mean dropping to concrete and whacking his head on concrete bad. He had big bruises all along his forehead as he was doing this about 15 times a day - we still have holes in our walls from that time. In that case it was bizarrely linked to food. His diet was extremely limited at the time and he had just added peanuts to it. (which I was overjoyed with as he ate no meat, fish or dairy so I was pleased about the protein). I removed the peanuts for a trial and within 4 days all the ridiculous headbanging had ceased. He was still headbanging but not with the intensity he had on peanuts.

What sort of school are you in? I think this is really common - certainly amongst many of the severely autistic kids I know. Does it occur at home and school? What strategies do parents/carers use.

Thanks for your reply. I work in a special needs secondary school.

It's difficult to ignore it when she is deemed 'a risk to herself or others' we (teacher and TAs) are expected to intervene. We tried ignoring it and she started occasionally escalating to attacking adults (pulling hair, biting etc) but sometimes she would stop and look slightly confused (at not getting the expected response?). We've tried restraining her and that works sometimes.

Our most common/effective response seems to be 'supportive waiting' (I sit in the room with her and tell her I'm happy to wait for her (not in a sarcastic way!), what would she like, does her head hurt, would she like some squeezes etc talking slowly and softly, trying to be a calm, receptive presence)

Her diet is limited (she loves white carbs- bread, pasta, chips, crisps, rice cakes/ snack a jacks, biscuits- and cheese.) We've noticed she is very sensitive to sugar highs/lows so have tried to cut down the starchy stuff and give her slow release carbs and cheese.

She has been banging her head since she started with us (in September) but from her behaviour (looking confused when not given what she wants for example) I think it is an established response.

Her mother is rather secretive and doesn't share very much with the school so I don't know if she does this at home or what the response it. She is an only child with several adults at home so it is possible her needs are always quickly met so her meltdowns don't happen there.

is it worth getting advice from a specialist ASD unit / school? I have no direct experience of it but there must be an established way of dealing with this as i have heard it is quite common amongst very severely autistic children. maybe try ringing NAS school. I have done this myself for advice once!

We are a specialist ASD with M/SLD school but, to be fair, this student is years behind any of the other pupils. Most of the students are verbal etc so these types of behaviours are hardly seen. She is by far and away the most severely autistic pupil in the school.

Is she unusual for the school in terms of ability/profile- it's certainly a common behaviour in ds1's school, or some sort of variation of self injurous behaviour (biting for example).

Do you have padded areas? DS1's school now has a safespace which I would imagine could be used for this sort of behavioural issue (although it might be difficult to transport there).

Have you had a team teach course or something similar? I'm going on one shortly (not team teach but same idea) - they apparently talk mainly about strategies that avoid getting to the need for restraint, which should be a last resort of course (although granted at times it will be needed).

Can you get strategies from the previous school? Or clinical psych in? Also check out the Challenging Behaviour Foundation they have lots of factsheets and advice there.

What would she do if you tell her to stop. Ds1 sort of ignores me if I say 'hands down' but it does slow him down and bit and can break the impulse.

Oh okay - you answered my question.

TBH it sounds like an inappropriate placement. Is she likely to stay with you?

I worry about inappropriate placements btw as I think it puts staff and students in a really difficult and vulnerable position.

THis might be a good place to start

www.thecbf.org.uk/chall-behaviour/self-inj.htm

There's a DVD as well - although it's quite pricey

Bollards!
www.thecbf.org.uk/chall-behaviour/self-inj.htm

I want to point out that we have these outbursts maybe once a week, it's not a daily occurance. She fits in well in her class of 8, they are all around the same P levels etc but the other students are quite a bit calmer (there is one boy who has terrible temper tantrums but these are purely behavioural). Our class does stand out as being of lower ability than the rest of the school though.

Biting (both self and others), kicking, scratching and pinching are more common throughout the school.
Our Sensory Room is well padded and she loves it in there (as long as there are no 'interesting' lights or music on)

In terms of moving her I think that would be nearly impossible. Mum wanted her in a single sex religious special needs school (which doesn't exist) and after 4 years at the school's primary site is just starting to come round the idea of her daughter being at our school.

If you tell her to stop (with a makaton sign too) or that the head banging has finished (with the makaton symbol) she will normally respond but it is mostly only a brief pause. 'Hands down' and then giving a desirable object if she complies (to drop with) might be worth a try. She's not one for throwing things around.

I've been doing some googling and found mentions of a link between a drop in head banging/slapping and a cf/gf free diet. This girl lives on mostly bread and cheese. Would it be worth trying to replace these foods?

Possibly but you would need her mum to be involved.

DS1 was gf for years as it had an effect on his behaviour. (He's fine now but his guts are also fine and they weren't in the early years).

I would get the Clinical Psychologist in to do a full assessment and give everyone working with the girl an appropriate plan for how to respond.

They would likely recognise the need for urgency in assessing her, due to the risk of her harming herself, and because self-harm can be an extremely difficult cycle to stop, if it gets the chance to become established.

Been thinking about this - agree about the clinical psych (I mentioned above in passing but the more I think it's probably the best way to tackle this unless there's a specific behaviour team in your area). Has there been functional assessment?

I agree, we have a really amazing clinical psychologist who comes to the school regularly. He has assessed this student before but didn't see any of her outbursts (this is a big problem) so he mainly dealt with her lack of communication and her non verbal communication is now great and her PECS skills are really coming along.

To be honest I think the cycle is in full swing, 9 times out of 10 this behaviour is in response to not getting her own way. Sometimes if you turn your back on her during on outburst she will stop and come and peer round at you as if she is confused.

She was back in school today and had a really calm, smiley day and the OT was really pleased with the progress she's made since her visit last week.

Can you video the outbursts? I use video a lot (not sure whether you would need parental permission) to highlight problems AND good things. I quite often drag my computer along to the annual review

If it is in response to not getting her own way it sounds as if you are doing the right sort of things. At home I tend to just ignore. I think in school they have found a 'red spot' on a chair quite helpful with ds1. So if for example he was kicking off in circle time he had to sit on the red spot until he had calmed down when he was allowed back to his normal chair. I think this helped him identify his behaviour as inappropriate and he apparently started to take himself to the red spot when he kicked off. I don't think he does kick off anymore.

They also used some sort of traffic light system next to the board to feeback about behaviour but I'm not sure exactly how that works.

Mum has refused permission for photos and videos apart from one to go on her coat peg and PECS book. I wonder if we could use annual review as a reason to film an outburst? Seems to be at school that ARs are intended to really focus on the positives though (understandably) so SLT might be reluctant.

"Thinking chairs" and football style yellow and red cards are used with the higher ability children but when this behaviour gets going she is beyond physical control (it took 4 people to carry her out of the road to a safe place when she kicked off getting on the bus home) so it just wouldn't work with her.

I can understand AR's focussing on the positive (having sat through ones where ds1 was treated as if he was an animal in mainstream) but I think if there are issues they have to be raised. Saying that as a parent. I'd hate to have a positive annual review if there were aspects of ds1's behaviour that were troubling staff. Can it be framed in a positive way? ie 'we need some advice on how to deal with this behaviour, or why it might be happening'.

DS1 isn't high ability (he's non verbal aged 12, in the 'severely autistic' class of an SLD/PMLD school, currently has to be marched through the door of respite with 2 men either side hooking arms under him as he won't go in - he is fine once he's in, had done this with various doorways over the years...), so I would imagine the cards took a while to work/be understood but they seem to work pretty well now.

That's encouraging. Maybe we just need to put her on a thinking chair as soon as she starts to create. Do you then take the "supernanny" approach and keep putting her back if she gets up?

I don't know exactly what school do. I might know more after his annual review next week. I don't think they've had such an issue recently.

When ds1 was younger that had break buttons. So if the task was too much he was taught to use a break button. He would sit out but had to return to the activity after a short break (few minutes initially I woukd guess). He was about 6 when they started that - at that age he couldn't imitate, receptive language was about zero etc etc

If you got the clinical psych in to observe she might be able to help set up these sort of strategies.

Ds1 gets a lot of symbol social stories as well. They started using those daily when he was infant aged. But they gradually became interactive. So initially he was passive but as his understanding increased he was more involved in running through it (selecting the colour day it was etc)

The break button is a great idea. We could also use a 'change symbol' as most of her outbursts occur when she wants/doesn't want to leave the room (she currently spends 70% of her time working 1 to 1 out of the classroom).

Thank you so much for helping me (and hopefully this student too) saintlyjimjams. She was in school again today (her attendance is patchy) and had an even better day than yesterday and we got footage of some items on her P level sheet show she is making progress!

Egg timer or countdown buttons as well to warn of the transition?

Countdown buttons work well with ds1. 3 buttons on a pecs strip then '3 waits and finished' after however long take off one button '2 waits then fiished' etc. You can adjust how long each button lasts as well. It would be used for transitions as well or to keep him at an activity. He doesn't need them so much now but they still have a place in school.

Hope you begin to fnd strategies that work. And do get the clinical push in if you can - good ones can have really great ideas.

I will push to get the clincial psych in to her see her (I'm not the class teacher but a TA).

The big difficulty is that she is so obsessed with faces that she will rarely look at objects, pictures, symbols etc when a person holds them and if you put them down and/or don't look at her she will run off. She's lucky she's adorable ;)

In ds1's first class they used screens a lot. So if a child wasn't paying attention a screen was quickly pulled around them and the teacher/TA while they went through whatever it was that needed to be done and then quickly removed again. It seemed to really help focus attention where it needed to be. They were light plastic and fabric stand alone screens.....