What can we do if repetitive play patterns are dangerous?

There is a misconception that we should never intervene with Autistic play. 

Honouring Autistic play and neurodiversity ...... and intervention are not mutally exclusive. 

We can be respectful and neuro-affirming, yet help our Autistic children by exposing them to new experiences, encouraging skills rather than forcing them, taking their lead with interests and motivations, addressing their sensory needs and supporting their development. 

In my last article, I explored the "why" underlying repetitive play patterns.  If you have not read that article, pause here and go back to the article HERE.  The article also encouraged us to consider on what the child finds beneficial about their play with reflective questions. You may also be interested to read about strategies when a child says "no" in this BLOG ARTICLE. 

One challenging area is when this repetitive play is dangerous and unsafe for the child or others. In this article, we will explore a real case study. 

Background Information:
Let's call my 3 year old friend, Ben (not his real name).  He lives with his parents and older sister in an apartment complex. Ben has a developmental delay and no other diagnosis (at time of referral).  He selectively speaks but this is infrequent. 

One of Ben's favourite activities is to go onto the balcony and throw items off the balcony onto the street below. The balcony was located situated off the open plan living room and kitchen. The family did not have air conditioning in their apartment and opened the door to allow for air flow.  They lived 6 stories above street level and the balcony had a metal balustrade (with openings about a hand space).  Ben was indiscriminate with what he threw from the balcony from toys to any other object that he could squeeze through the balustrade.  He had not yet learnt how to climb up to the hand rail to throw over the railing, however his parents were worried that he would learn to do this.   Throwing occurred daily, often when his parents were busy (eg. cooking). 

Ben's parents were concerned about his safety and whether he would eventually climb onto furniture to throw items. They were concerned about the falling items on people passing by underneath.  Fortunately they lived on a quiet street so there were not a lot of people regularly walking under the apartment.  Ben's parents were also starting to resent needing to go down to the street to retrieve the items thrown.

Ben was enjoying the "game" of his parents shouting when they saw him rush onto the balcony, sometimes trying to physically grab him to stop him and then taking the elevator (lift) down stairs to retrieve the items. He laughed and wanted to do it again.

Intervention:
* Environmental - It was recommended that a fly screen (security) door could be added to the balcony to allow for secure air flow.  Ben's parents were renting and needed to seek permission for this to occur. 
* Environmental - It was recommended that the balcony door be shut when Ben's parents could not provide supervision. 
* Environmental - It was recommended that furniture be removed from the balcony so that Ben did not learn to climb onto the furniture on the balcony. 

When considering Ben's desire to throw things, we introduced a range of activities with this action while providing varying targets too. These were not forced, but gradually introduced (one or two per session) to show him options. 
* Throwing items included balls, bean bags, soft toys, scarves, plastic rings, small plastic animals, juggling balls, fidget toys, cushions, plastic fruit, pipe cleaners, pop tubes, oven mitts, hats, stress balls, splat toys.
* Targets to throw towards included buckets/containers (from large to small sizes), onto sensory gel tiles, onto the sofa, onto a table, under a table, onto a bath mat, onto a towel, onto the wall (for sticky objects), through a hoola hoop, between someone's legs, under a chair, towards another person.

When considering Ben's enjoyment of being above and seeing things land... we changed his physical environment providing opportunities to climb indoors and lean over (eg. lying over the sofa or therapy ball to play with items on the floor), standing on a stool to place things onto a vertical surface, throwing items from a chair that had a string or a magnet (such as a fishing rod) attached to retrieve item.  Standing on a balance cushion or a bilibo also provided sensory input. 

When considering Ben's enjoyment of connection and engagement with his parents.  We worked on shared enjoyment opportunities where his parents could provide lots of laughs, squeals and joy! One of our favourite games was throwing scarves at each other like snow balls.  We also played parachute games, tugging pop tubes, pull along games on lycra sheets, peek-a-boo type games with scarves/blankets. Ben's parents were encouraged to reduce their response if he threw things from the balcony and become more expressive at other times. 

Conclusion:
Over time, Ben found enjoyment in some of the repetitive play patterns which were introduced to him. He received sensory input (tactile, visual, proprioception, auditory) as well as the desired interaction with his parents.  We introduced sensory proprioceptive activities such as a lycra tunnel, animal walks, pushing and pulling items.  Oral motor activities were also introduced to encourage deep breathing and assist with regulation.  Multisensory activities such as shaving cream and kinetic sand were also enjoyed by Ben.

Gradually as Ben developed rapport with OT, he participated in multiple step activities and we could increase the play routines. We tried other repetitive play routines (eg. play with a teddy, muscial instruments, cars). We developed a relationship where routines could be modelled and copied if he wanted to try it out. 

Ben was given opportunities to continue with repetitive play routines that he found comforting, while expanding the repertoire he could choose from. He was less interested in throwing things from the balcony, however there were occasions where he continued to do this. 

Ben's attention to alternative tasks also increased with a desire to try new things.  We tried other activities that have an underlying (throw/put into something) but the activities also became more skilful using tools such as hammers, golf sticks, pencils and scissors.  Smaller and more directed actions such as shape sorters, button snakes, posting objects were also achieved over time.  Ben also began learning how to catch thrown items. ​

What else would you have tried with Ben? Do you work with someone who also enjoys throwing things from a balcony.  Did you gain some ideas from my case study? 

This month I have been promoting the FULL SPECTRUM OF PLAY conference which is about to start (March 17-20 - northern hemisphere dates which tend to be almost 12 hours behind us here in Sydney)! This FREE 4-day event is designed to help you confidently use neurodiversity-affirming, play-based therapy strategies to support autistic kids in ways that truly matter.  15 expert speakers share actionable strategies on integrating play into therapy with many many case studies.  

The FREE TICKET will give you 24 hour access to each day's program (March 17-20). You can also upgrade your ticket for VIP Access ($US).  VIP access allows you to listen or watch the talks anytime (starting as soon as you purchase the ticket) with life time access (so you can tak your time too).  You will also receive an extensive workbook with summaries of each talk, podcast access, additional information from each speaker and there are 17 accredited learning hours with AOTA and other organisations, once you complete an assessment. 

Parents, you will also benefit from this conference, however it is catered mainly for a professional audience. 

For those of you who have already registered for the PLAY Conference, let me know what you are looking forward to the most!  If you also have questions, you can find the FAQ page HERE or also please feel free to contact me [email protected]. I would also love to hear from you if you like reading case studies (as I haven't shared in this way before). 

Until next time,

Cindy is a registered occupational therapist practising in Sydney, Australia.  She has two growing children who are a constant source of inspiration and learning.  Cindy loves working creatively to help children to reach their potential, finding opportunities in everyday living and making learning fun. She is also addicted to making printables (even when they take a long time to complete).  Cindy is the author of the Occupational Therapy blog Your Kids OT.  Read more articles from Your Kids OT at https://www.yourkidsot.com/blog

Cindy is a contributing author of the Functional Skills for Kids Therapy Team.  They have together published THE HANDWRITING BOOK, THE SCISSORS SKILLS BOOK and THE TOILETING BOOK.

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