Greg Fritz, MD (Host 1): Today on Mindcast, we're talking about transitions, more specifically, transitions for children with autism spectrum disorder. Transitions are by definition, and the way we're using them here today in our podcast, are the act of moving or changing from one activity to another or from one setting to another. Children and adolescents, and actually adults as well, transition repeatedly throughout the day at home, at school, at work, and at various places in the community.

Transitions actually make up a large portion of any day. Studies have shown that up to 25% of a school day maybe is spent engaged in transition activities. So, it seems important to spend some time on how we can support kids during transitions and help them to move through their day. And here to give us more information, tips, and strategies to set kids up for success is licensed clinical social worker, Gina Marini. Gina has extensive experience working with children and adolescents on the autism spectrum and works at Bradley Hospital's Verrecchia Clinic for Children with Autism and Developmental Disabilities. Thank you for being here, Gina.

Anne Walters, PhD (Host 2): Welcome, Gina.

Gina Marini, MA: It's great to be here. Thanks for having me.

Host 1 : And this is Mindcast: Healthy Mind, Healthy Child, a podcast from the mental health experts at Bradley Hospital, leaders in Mental health care for children. I'm Dr. Greg Fritz with my colleague Dr. Anne Walters.

Host 2: Gina, as Greg shared in the opening, up to 25% of the school day includes transitional activities for a child with autism spectrum disorder or other developmental disabilities, these pose even greater challenges. Can you talk a little bit about why transitions are more difficult for kids with autism?

Gina Marini, MA: So, children with autism spectrum disorder and other developmental disabilities often have a need for sameness and predictability. Children with autism struggle to cope with changes in their routine leading to greater difficulties transitioning or shifting flexibly from one task, activity or location to another. Children with autism may also experience difficulty when a pattern of behavior is disrupted or experience difficulty understanding what activity will be coming next, difficulty sequencing information and recognizing how steps of an activity connect can further impact their ability to transition.

Additionally, children with autism may not recognize subtle cues, signaling an upcoming transition, leaving them unprepared to transition. And some children with autism take longer to process directions and may not comprehend all of the visual information being presented to them. Lastly, research shows that children with autism spectrum disorder often experience anxiety, which can impact behavior during times of change or transition.

Host 1 : So, keeping in mind that it's important to consider the unique needs of each child and to adapt transition strategies to meet their needs, what are some of the reasons you would recommend having a plan in place?

Gina Marini, MA: I would say without a plan in place, children with and without autism sometimes experience negative feelings in response to transitions. So, some children may be confused by unclear expectations during transitions or frustrated when prompted to stop a preferred activity. For other children, waiting to move to or begin the next activity results in restlessness and stress. Challenging behaviors often emerge in the context of transitions and are more likely to occur when there are too many transitions, when transitions are prolonged and children have little or nothing to do, when there are unclear expectations or no clear warning or advanced notice of the transition. So, research has shown that planning for and supporting transitions between activities is beneficial to children. A number of transition strategies have been found effective for children with autism spectrum disorder. These strategies are intended to prepare children with autism before a transition and to lend support to the child during the transition. Transition strategies increase predictability for children with autism spectrum disorder and create positive routines around transitions.

Host 1 : Where do you find these strategies to be most helpful?

Gina Marini, MA: I would say transition strategies are helpful in all settings. As mentioned earlier, transitions make up a large portion of any day, no matter the setting. At school, teachers often rely on transition strategies to support their students in navigating multiple transitions throughout the school day. Teachers use a multitude of strategies including verbal cues and reminders, auditory cues and written or visual schedules to facilitate those transitions.

For consistency, parents and caregivers can use similar transition strategies to support their children in navigating transitions in the home or in the community. Common transitions in the home include shifting from home to school, transitioning from homework time to dinner, shifting off of screens and electronic devices, and transitioning from dinner to a nighttime routine, which may involve personal hygiene tasks. Common transitions in the community include entering new locations, such as grocery stores or retail stores, or entering novel activities, So during the summer, families often visit the beach or go to their local pool, or children may be going to summer camp. Later on, I'll discuss some specific strategies that parents and caregivers can use in the home and community settings.

Host 2: So even with the best of intentions and strategies in place, if you don't have time to carry out the strategies, the child might not be successful. Can you expand on the importance of planning and time, especially when developing routines?

Gina Marini, MA: So, research has also shown that transitions do take time, but that parents and caregivers tend not to plan for that transition time when arranging their schedules. Transitions should be structured and predictable with goals to promote communication, learning and interaction. While planning for transitions and implementing these strategies may be time-consuming for parents and care caregivers especially at first, what we know is that when transition strategies are used and routines are developed, children with autism spectrum experience a reduction in the amount of time it takes to transition, increase appropriate behavior during transitions, thus decreasing any challenging or problematic behavior that could occur during transitions. There's also less reliance on adult direction and further development of independent skills. And perhaps, most importantly, transition strategies allow children with autism spectrum disorder to meaningfully and successfully participate in various outings.

Host 2: And sometimes we'll talk about the fact that you can put the time in preparing to be successful or you're going to put the time in dealing with the sort of aftermath of having a transition that goes awry.

Gina Marini, MA: Exactly.

Host 1 : Pay now or pay later.

Host 2: Yeah, pretty much.

Host 1 : Let's talk about how these different strategies work in a real life setting. So, can you give us some examples of strategies and how they could put it into action?

Gina Marini, MA: Certainly. So, there are many strategies to support smooth transitions between activities, which can be used across settings. So first and foremost, there's verbal cues or reminders, which can be used to signal or warn of an upcoming transition. So, common example might be five more minutes before dinner or five more minutes on the tablet, and then counting down until the time is finished. While verbal cues and reminders are helpful for most children, verbal cues or reminders might actually not be the most effective way to signal a transition to children with autism spectrum disorder, as they may experience delayed processing and difficulties comprehending verbal information. Additionally, providing the cue just before the transition is set to occur might not be enough time for children with autism spectrum disorder to shift from one task to another. So, it's important to give children with autism time to prepare for the transition and more noticeable cues to refer to as they're getting ready to transition.

Other strategies to support smooth transitions include non-verbal cues, that might be ringing a bell or using a timer, playing music when it's time to stop an activity or even showing pictures of the next activity. And that brings us to visual cues or representations, which assist children in understanding expectations, anticipating the transition and knowing what to do.

Research also shows that children with autism spectrum disorder demonstrates strength in visual learning. So, visual supports or cues result in independent task completion, less reliance on parents and caregivers, faster learning, lower levels of frustration, anxiety or aggression related to task completion and greater adjustment to changes in their environment.

So, some examples of visual cues or representations include visual timers. Visual timers display a section of red indicating the allotted time, which disappears as the allotted time runs out. So, common examples of that on the market might be a Time Timer, maybe an online stopwatch or even an egg timer.

Another sort of similar strategy that's low tech might be a visual countdown, which allows children to see how much time is remaining in the activity, but which gives parents and caregivers greater flexibility in manipulating the time. So, a way to implement a visual countdown might be taking a dry eraseboard, writing 5, 4, 3, 2, 1 in a column or in a row, and then erasing each number as the time passes to help the child see the passage of time.

There are also picture cues, which we've mentioned a little bit earlier in terms of showing pictures of the next activity. Picture cues are another low tech strategy that presents one piece of visual information at a time during transitions. So, picture cues can be presented to children to represent the location or activity that they will be transitioning to. Picture cues allow children to see where they're expected to go or what they're expected to do, thus infusing additional predictability into their day and reducing any kind of anticipatory anxiety during transitions.

Host 1 : I just have one question as you're talking about these cues. Is it the cue itself or is it the combination of the cue being presented by the same person at most of the time? In other words, if a kid is used to a certain cue and babysitters there, can they use the cue advantageously, even if the child doesn't know the babysitter too well?

Gina Marini, MA: I would say yes, right? The hope is that the picture cue becomes generalized no matter who's presenting it to them. and the picture cue is something that they can hold onto as they're making the transition so it carries more meaning. So, a parent or a caregiver or a sitter or a teacher could use these strategies across settings. And so, it sort of develops that routine too around picture cues. So say if a sitter was in the home, a child would know that if the sitter hands them a picture cue of food, it indicates the transition to mealtime, right? So then, the child also then has a routine. They then walk to the dinner table and they might have a designated area to place that picture cue, maybe in an all-done bin or a finished box and that signals to them that they've completed that transition and that it's time for dinner.

There's also first-then sequences. Another low tech strategy that presents two pieces of visual information at a time during transitions, which allow children to see what activity they're currently engaged in or completing and what activity will follow. And with first-then sequences, typically a non-preferred activity is followed by a preferred activity to help foster the child's motivation to complete that non-preferred activity. So, that could be, you know, first homework, then game or first shower, then bedtime. A first-then sequence should be portable and move with the child, as he or she is transitioning. So, you might have a laminated first-then board, or again, maybe you're using a small dry erase board and writing first-then on it, and erasing it as the child completes that transition.

 There are also visual schedules, another low tech strategy that presents a longer sequence of visual information. Visual schedules list daily activities, and help children understand and learn the order of activities across the day. They help as well in terms of preparing for what's going to happen next and anticipating transitions between activities. And visual daily schedules can be particularly helpful during the summertime when there are large chunks of unstructured time. Depending on the children's skills, visual schedules can be made up of photographs, icons or words. And when creating the schedule, I'd recommend trying to minimize transitions where possible.

Host 1 : Yeah, that's the best thing. Avoid them entirely.

Gina Marini, MA: Omitting unnecessary transitions and really trying to maximize the time that the children are engaged in meaningful activities. With visual schedules, it's important to also, again, place reinforcing activities such as preferred activities after those non-preferred activities. And when implementing a visual schedule, having it posted in a central location in the home or the classroom can be quite helpful, again, in terms of helping the child to develop a routine around their schedule and their transitions and providing cues to the child to check their schedule throughout the day. In similar fashion to the picture cues, it's also a good idea to, to have a designated location, maybe a finished box or an all-done folder or envelope where the child then places the completed task or activity. And visual schedules should be used consistently to aid in successful transitions, and again to develop those positive routines.

And then lastly, priming is another strategy to support smooth transitions. Priming involves previewing an activity or event before it occurs to increase predictability. Priming has been shown to be effective in helping children with autism spectrum disorder during times of transition. So prior to transitioning to a new location or novel activity, prepare children for what they can expect. And one way to do that is by using video priming. And that's where we're videotaping a specific transition, whether that's going to a new location in the community or transitioning maybe to an activity that's hard for them. When taping, an actor should model the steps required during the transition. And after taping, the parent or caregiver can watch the clip with their child repeatedly over several days and review the steps within that transition.

Host 2: Gina, these are such great suggestions. And I know the idea of creating something called a Social Story is a tactic you've discussed in the past. In fact, I think you developed one for your patients that visit the clinic. Could you tell us what a social story is and how you might use it?

Gina Marini, MA: Sure. So, Social Stories were first created by Carol Gray. Sometimes they're referred to as social narratives or story-based interventions. And these are written stories that prepare children with autism spectrum disorder for transitions to novel events. Social Stories present concepts and situations in a visual format to enhance the reader's comprehension. Social Stories can be used to explain what is happening or what is expected across different settings.

As you mentioned, our clinic has a Social Story available on our website for new patients and families. The Social Story features pictures of our building, our front office, our waiting room. It reviews activities that children can do while they're waiting for their therapist. Essentially, it sort of orients them to our clinic and prepares them for the first visit. Parents and caregivers and teachers as well can create social stories across settings to prepare children for various transitions. So if your child is going to summer camp, a parent or caregiver can create a social story to orient the child to this new setting and camp activities.

For example, it might be, you know, "In summer, I go to camp. I'll take a bus to camp each day. When I arrive at camp, I'll greet or say hi to my camp counselor. I will follow my camp counselor to our cabin. And each day, I'll try new camp activities like paddle boating or swimming. And when the camp day ends, I will take the bus home." So, social stories can be short and brief with pictures to enhance comprehension. And just sort of a tip would be, with social stories, it's very important to use developmentally appropriate language, positive language, again to incorporate pictures or photos and to read the story to the child multiple times ahead of the transition or novel activity.

Host 2: So, it's almost like communicating ahead of time that this is gonna go well, and everyone's going to be so proud.

Gina Marini, MA: Exactly. Yes. Yes.

Host 2: Excellent. Gina, thank you so much for being here. Developing predictable and consistent transition routines are key factors for success. And you've done a wonderful job outlining the research and very actionable strategies to support parents, teachers and caregivers as they support their children. It's important for the team to continually assess how transitions impact individuals on the autism spectrum. Depending on the activity environment and the specific needs and strengths of the individual, a variety of strategies may be appropriate.

We thank you all the audience for being here. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library at bradleyhospital.org/podcast.

This is Mindcast: Healthy Mind, Healthy Child, a podcast from the experts on children's mental health at Bradley Hospital. I am Dr. Anne Walters with my colleague and friend, Dr. Greg Fritz. Thanks for listening.