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Ask the Mental Health Expert Archives 2001-2004

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Autistic Tween

Q. I am working with a student who has autism (high functioning). He has an obsession (sexual in nature) with feet and shoulders. He is turned on by bare feet and bare shoulders or even perceived bare shoulders. For example, if a girl is wearing a tank top with a shirt over it, he will try to pull the shirt down to expose the shoulder.

This is a student who is not aggressive in nature. However, he is a large middle school student. In the past, this behavior has only been in the form of staring, but recently he has begun touching. I tried reasoning and he understands cognitively what is appropriate and what isn't. When told he couldn't just go touch someone, that he needed to ask permission, he did that literally--would ask the girl to take off her shirt.

I tried teaching him to put sunglasses on when he was tempted--so people wouldn't know he was staring and that maybe the action involved would break his thought up. That didn't work. I tried writing a list of do's and don't's so he could review them when the feelings came. That didn't work for long either.

I tried giving him objects that felt like skin to hold (such as stress balls, balloons filled with flour) but that lasted a short time. I'm at a loss. I am afraid that he will touch the wrong person and get arrested but not understand what he did wrong. Do you have any advice?

A. That certainly sounds like a tough case! Before making some suggestions, I would raise a few questions: first, can you identify any factors in this young man's life that could account for the change in his modus operandi? Why, specifically, did he move from staring mode to touching mode? Has he become more impulsive or disinhibited in other areas of his life? Could some precipitating factor, such as illicit drug use, account for this? Could he have an underlying psychotic disorder that may have worsened? Etc.

Second, are his actions ego-alien or ego-syntonic; e.g., does he believe it is OK for him to touch females in this way? Or does he feel bad about it, and express some regret? This may reflect the degree of true obsessionality (which, in classic terms, is an ego-alien preoccupation) versus a form of sociopathy or psychosis (which may require a different treatment approach).

Neuropsychiatric testing might be useful in this regard. You have certainly tried some creative approaches to helping this young man, but I did not hear about any attempts to set clear limits with appropriate negative consequences--is there a reason for this? I don't know what specific negative consequences you are in a position to arrange, but surely somebody in this young man's life can do so--for example, are his parents involved with the treatment? If he touches a girl at school, how is he disciplined? Do his parents revoke privileges, etc?

There may be some aversive conditioning methods that could also be of help--please understand, I'm not talking about electric shocks! I mean, for example, visualization exercises, in which you have the patient imagine himself touching somebody; being hauled in to the principal's office; being picked up by the police, etc. This sort of cognitive-behavioral approach has been used with some success in mildly-affected sexual offenders.

Progressive relaxation techniques (Mullins & Christian, Res Dev Disabil 2001 Nov-Dec;22(6):449-62) have also been used to reduce disruptive behaviors in autistic patients. Also see Reese et al, J Autism Dev Disord 1998 Apr;28(2):159-65). I don't know your professional background, but if you are not a behavioral psychologist, I would recommend getting a consultation with one. (That's not a criticism, by the way--I have found such consultation very helpful in my own practice).

I also wonder if a social skills group might be of at least limited help--e.g., in helping the patient learn appropriate from inappropriate ways of getting to know people. Finally, have you explored medication options with a psychiatrist experienced in the treatment of autism? There are several types of medication that could be of help, depending on the nature of these obsessional preoccupations; e.g., an SSRI (Prozac, Zoloft), a mood stabilizer such as valproate; a low dose atypical antipsychotic; or--though this is more controversial-- a testosterone-suppressing medication (see Realmuto & Ruble, J Autism Dev Disord 1999 Apr;29(2):121-7).

As I said, this is a tough case?but I hope these suggestions are of some help.

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August 2003

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