Housing Adaptations for Children
with Challenging Behaviour
Elaine Doherty
Senior Paediatric Occupational Therapist
Dublin South East
May 2012
Overview
•Introduction
•Autism
Definition
• Causes
• Aims for
adaptations
•Epilepsy
• Definition
• Seizure types
• Aims for
adaptations
Questions
•
Autism criteria -DSM IV
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Autism Spectrum Disorder Must meet criteria A, B, C,
and D:
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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
Deficits in nonverbal communicative behaviours
used for social interaction; ranging from poorly
integrated- verbal and nonverbal communication,
through abnormalities in eye contact and bodylanguage, 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
2.
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’
Autism
 PDD not otherwise specified
 Asperger’s syndrome
 Rhett’s syndrome
 Childhood 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
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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:
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Digital keypad and handle latches
Mechanical keypad deadlocks and handle latches
Card-swipe systems
Proximity systems
Biometric systems (finger print detection)
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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
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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
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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
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Organisation
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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
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Media
www.familysafemedia.com
 Visual schedules
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Other
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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
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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
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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
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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
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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.
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Tonic-clonic
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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-tonicclonic seizures! This type is what most people
think of when they hear the word "seizure." An
older term for them is "grand mal."
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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:
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Epilepsy Syndromes
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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.
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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 independence
 Safety
 Planning for future needs particularly if a
epilepsy syndrome or if seizures are
refractory to treatment.
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Questions to Ask
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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 prognosis
 Assess all behaviours and decide
whether it is sensory based or a learned
response. Is the behaviour to obtain or to
avoid?
 Remember safety first
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Questions?
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Thank you