Playing With Fear: Treating Phobias in Children with Autism

Here is an example of a method for treating phobias in children with Autism or other Developmental Disabilities (DDs), using the approach we developed, Replays, (e.g. Levine and Chedd, 2007), or Affective Behavioral Play Therapy (ABPT) as we call it for professional consumption.  In this approach, as in traditional paradigms for treating phobias, we use gradual exposure combined with pleasurable activity, but, in contrast to traditional treatment approaches for children with Autism or other DDs (see my Blog Treating the Child under the Behavior), the focus is on the child’s affective experience, played out in an affectively rich interactive context.

My little patient, 5 year old Jonah*, who has mild Autism and massive Anxiety, pretends to flush a tiny plastic toy dollhouse toilet.  He himself is terrified of the real toilet flushing noise, screaming in fear if he hears one accidentally, and refusing to go in to public bathrooms in case they have automatic flushers. 

As he pushes down the pretend plastic flusher I make loud goofy gurgly flushing sounds. “Kshhpfsshhkshk” I say loudly, moving my mouth and eyebrows all around in a funny exaggerated expression, giving him my all out best impression of a flushing toilet.  I’ve practiced this a lot over the years, as this is a common phobia, and I do a pretty good flush by now.  I cover my ears at the same time.  “TOO LOUD!” I say in a playfully exaggerated pretend upset, scolding voice pointing to the offending pretend toilet.  Jonah looks up at me, giggles and pretends to flush it again, pushing down carefully where the little plastic toilet would have a flusher if it did, then looking up at me expectantly.  I do my crazy flushing noises again, then cover my ears. “STOP THAT FLUSHING, YOU NOISY TOILET!”, I order, pointing my finger again scolding the imaginary evil handle. By now he is shrieking with laughter, pretending to flush again and again, watching for my reaction each time, taking great pleasure in torturing me, clearly knowing I’m not REALLY scared.

He doesn’t have much language, and doesn’t pretend on his own, but he clearly recognizes this familiar sequence of events and emotions, and the playful spin we are putting to it, together. 

Each time he pretends to flush, causing me to pretend to be scared he laughs so hard he can barely catch his breath.  Soon we “graduate” to the next step:  Now when he pretends to flush, I still make my own crazy flushing sounds, but more quietly, while I simultaneously play a recording of a real toilet flushing that I have on my phone, a little louder each time.  “BE QUIET YOU NOISY TOILET”, I reprimand the little toy after he “flushes” it again.  As long as he’s still laughing we’re OK and I can shift the volume up a little bit.  If he starts to look serious or scared I turn it off for a round of just my sounds to gain his happy interest again.

Eventually after all this hilarity, Jonah needs to pee for real, and he pulls his mother into the building’s hallway bathroom, uses the toilet and then, unbelievably, he flushes it!  “It’s amazing”, his mother says when they return. “He’s never done that before! He wouldn’t have even gone IN to a bathroom like that before.”

Why do these phobias often lift with this kind of play?  I don’t know exactly, and clearly it doesn’t always work, although it often does, but even when it doesn’t fix the problem, the process is usually incredibly fun for all involved, and provides a “language” through which to communicate about the child’s scary affective experiences.

In this approach, the child experiences control, in play, of the thing that scares them, and of pretending to make the adult feel a play version of their own fear.  Simultaneously the child gains exposure to increasing manageable amounts of the scary event, and to their fear associated with it, but now paired with a shared playful experience with a trusted adult. While most children with Autism don’t use pretend play in this way independently, when the adult facilitates and scaffolds their participation, many recognize the scenarios as representing affective experiences that are so familiar and emotionally meaningful to them.  The scary flusher, the terrifying blood pressure cuff, lose their toxicity, and become associated with interactive fun play.

Typically developing children generally use play naturally in this way to process their life’s more scary events, often together with each other and adults, pretending to be the doctor and giving parents “100 shots” or pretending to be the adult putting the child in Time Out “forever” etc.  Children with limited social, cognitive or language skills don’t spontaneously use interactive play to master fearful events.

This and other affect and relationship-based approaches (e.g. Floor Time) are clearly not experienced as coercive, are largely pleasurable, promote a child’s growth in understanding of their affective experiences, and foster co-regulation with others to help with difficult affective states.  There is a small but growing family of treatments for children with Autism or other DDs that recognizes and supports the Child under the behaviors.

* Name and details have been changed to protect patient privacy.