Australian Occupational Therapy Journal

Australian Occupational Therapy Journal (2011) 58, 145–154

doi: 10.1111/j.1440-1630.2010.00896.x

Research Article

Dinnertime and bedtime routines and rituals in families with a young child with an autism spectrum disorder
Kylie Marquenie,1 Sylvia Rodger,1 Kim Mangohig1 and Anne Cronin1,2
of Occupational Therapy, School of Health Sciences, The University of Queensland, Brisbane, Queensland, Australia, and 2Division of Occupational Therapy, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
1Division

Background ⁄ aim: Routines are thought to be critical in laying the foundation for ritual development, and in turn rituals are considered important for forming a strong and healthy family unit. This article provides a description of the experiences of dinnertime and bedtime routines and rituals in Australian families with a young child with an Autism Spectrum Disorder (ASD), as well as common challenges experienced. Methods: Fourteen Australian mothers with a young child with an ASD between the ages of two and five years were interviewed about their performance of dinnertime and bedtime routines and rituals and their perceptions of both occupations. Descriptive qualitative interviews were audio taped and transcribed. Transcripts were analysed using thematic content analysis. Results: Two overarching themes emerged, including ‘centred on ASD’ and ‘ASD alters meaning’. Mothers’ descriptions revealed that families with a young child with an ASD experienced unstructured and chaotic routines at dinnertime. In contrast, bedtime involved the performance of more structured, and at times, non-functional routines. Moreover, dinnertime was bereft of meaningful interactions and rituals, whereas bedtime contained some positive meaningful interactions and rituals.

Conclusions: Occupational therapists need to consider supporting mothers and the child with an ASD in enhancing their participation within all aspects of family life, by encouraging them to develop structured and more predictable dinnertime and bedtime routines inclusive of all family members. In doing so, this action will support mothers to develop a strong and cohesive family unit. KEY WORDS ASD, early intervention, qualitative research, rituals, routines.

Introduction
As paediatric occupational therapy practice has shifted from being child-centred to family-centred, research has emerged analysing how families construct their daily lives and function as a family unit (Larson, 2006; Werner DeGrace, 2004). A family’s daily life largely consists of routines that follow a sequence of steps to achieve meeting an instrumental goal, and are repeated at similar times each day (Boyce, Jensen, James, & Peacock, 1983; Segal, 2004). Embedded within these routines can be rituals or meaningful interactions that create a sense of identity and belonging (Boyce et al., 1983; Imber-Black & Roberts, 1992; Segal, 2004). Importantly, Segal (2004) identified that routines are critical in laying the foundation for ritual development, and in turn rituals are important for sustaining participation and positive interactions between family members. Other research also suggests that rituals are important for forming a strong and healthy family unit by creating a sense of belonging, family cohesion, and acting as a protective factor against stress (Cheal, 1988; Imber-Black & Roberts, 1992; Schuck & Bucy, 1997; Wolin & Bennett, 1984). Previous research depicts families with a child with an Autism Spectrum Disorder (ASD) as experiencing greater stress, poor adjustment and decreased family cohesion, reflecting poor routine and ritual development (Gray, 1997; Higgins, Bailey & Pearce, 2005; Sanders & Morgan, 1997). To date, two American studies (Larson, 2006; Werner DeGrace, 2004) have attempted to explore

Kylie Marquenie MOccThySt, BAppSc (Biochemistry); Masters student. Sylvia Rodger PhD, MEdSt, BOccThy; Professor and Head. Kim Mangohig MOccThySt, BMus; Masters student. Anne Cronin PhD, OTR ⁄ L, BCP; Associate Professor. Correspondence: Kylie Marquenie c ⁄ o Professor Sylvia Rodger, School of Health and Rehabilitation Sciences, Division of Occupational Therapy, The University of Queensland, St Lucia, Brisbane, Qld, Australia 4072. Email: kmarquenie.ot@gmail.com Accepted for publication 21 July 2010.
2011 The Authors C
C Australian Occupational Therapy Journal 2011 Australian Association of Occupational Therapists

146 routines and rituals in families with a child with an ASD, both demonstrating that the child with an ASD impacted negatively on the performance of daily routines and rituals. Although both studies provided an overview of routines and rituals in families with a child with an ASD, they lack an in-depth analysis of how routines and rituals within specific occupations are performed. Further investigation may not only provide insight into possible reasons why families with a child with an ASD experience greater stress and disrupted functioning as a family unit, but may also identify specific challenges and areas in need of intervention. Children with an ASD are commonly recognised to experience challenges surrounding food and sleep and understanding the routine and rituals of these occupations for children with ASD may indicate areas for intervention. The studies conducted by Werner DeGrace (2004) and Larson (2006) contained only a small number of American families with children with an ASD aged between 6 and 10 years, beyond the expected age for the early establishment of family routines. However, it is in the first five years of life that children learn to be independent in most aspects of self-care, and begin to contribute to the development of family routines and rituals (Fiese, Hooker, Kotary, & Schwagler, 1993). Thus, an in-depth understanding of the performance of family routines during the first five years is critical to understanding the process leading to the establishment of the child-centred and non-meaningful routines that have been identified in families of children with an ASD. In light of the preceding literature, this study aims to provide occupational therapists with a description of the individual and collective experiences of dinnertime and bedtime routines and rituals in Australian families with a child with an ASD aged less than six years. It also aims to depict common challenges experienced by these families. Subsequently, recommendations will be made as to possible objectives for occupational therapy intervention to support family-centred practice and strengthen the functioning of family units.

K. MARQUENIE ET AL.

services to families with a child with an ASD); and (iii) autism parent support groups, was used to recruit mothers to this study. Mothers were eligible if they had a child between the ages of two and five years, were not attending formal full-time schooling, lived in Queensland, Australia, and had a formal diagnosis or early signs of an ASD identified by a paediatrician according to the DSM-IV criteria (American Psychiatric Association, 2000). Upon conclusion of the Growing Stronger Families with Autism Program (Rodger et al., 2004), from which most participants were recruited from, all children had a verified diagnosis of an ASD. Mothers who responded to a letter of invitation and accompanying information, met the inclusion criteria and provided informed written consent were recruited to the study. Although 21 expressed an interest in participating, only 14 mothers completed the study. Reasons for non-participation included recent relocation from interstate, rural residence, unreliable phone access and consent received after the data collection deadline. Saturation of data was reached by the tenth interview. Participant information is detailed in Table 1.

Instruments
The semi structured, open ended interview schedule used in this study was adapted from the schedule used by Werner DeGrace (2004). The interview schedule was adapted and expanded to include questions prompting the description of how dinnertime and bedtime occupations were structured and mothers’ experiences of each, as well as mothers’ perceptions of the moments when they most felt like a family. Interview questions are outlined in Table 2. As the interview schedule had been used previously by Werner DeGrace (2004), it was not pilot tested.

Procedure
Prior to the interview, demographic questionnaires as well as the interview questions were mailed to participants. For participants who resided in a metropolitan area (n = 10), the interviews took place within the family home. For the remainder (n = 4), phone interviews were arranged. Interviews ranged from 40 to 90 minutes and were conducted by the first and third authors. These were tape recorded and transcribed verbatim by the first and third authors. Brief interview notes were taken by the first and third authors and referred to latter in the study analysis. Although four interviews were conducted over the phone, which was a potential limitation of this study, all individual interview summaries were mailed to each participant for member checking of analysis of interpretation. Seventy-one percent of summaries were returned and signed for confirmation of accuracy of interpretation.

Method
Design
A descriptive qualitative research design guided interviews with 14 mothers of children with an ASD to explore dinnertime and bedtime routines and rituals. Ethical clearance was gained from the Behavioural and Social Science Ethics Committee at The University of Queensland.

Participants
Purposive sampling (Patton, 2002) from: (i) participants in the Growing Stronger Families with Autism Program (Rodger, Braithwaite, & Keen, 2004); (ii) Autism Queensland (a non-government organisation providing support

Analysis
Thematic analysis of content (Patton, 2002) as described below was utilised in this study. Descriptions of dinner 2011 The Authors C 2011 Australian Association of Occupational Therapists

Australian Occupational Therapy Journal

C

C

TABLE 1: Demographic information about participating families (N = 14)

Participants Blended House with yard, BMA House with yard, BMA 26–30 (M) 36–40 (F) 40–45 (M) 36–40 (F) Medium Tertiary undergraduate (M & F) Year 12 (M & F) Medium Year 10 (M & F)

Name & Age of Child with ASD Family Structure Parental Occupation

Number of Siblings & Age

Parental Age (years)

Approximate Family Income bracket† Parental Highest Level of Education Home Residence & Location Family & Community Supports

Fleur

Frances (3 years) Nuclear

2 (1 years, & 10 years)

2011 The Authors Australian Occupational Therapy Journal Home duties (M) Sheet metal 2nd class (F) Customer service (M) Consultant (F) House with yard, BMA Nuclear 31–35 (M & F) Low Single 26–30 (M) 31–35 (F) Medium Tertiary undergraduate (M & F) Family business manager (M) Self-employed handyman (F) Student and home duties (M) Civil Engineer (F) House with yard, BMA Single 26–30 (M) 26–30 (F) Medium Year 12 (M & F) Home duties (M) Surf-Board manufacturer (F) Architect (M) Chef (F) Apartment ⁄ Unit, BMA Single 31–35 (M) 36–40 (F) 26–30 (M) 31–35 (F) 31–35 (M) 36–40 (F) Medium Low Apartment ⁄ Unit, BMA House with yard, Regional High Office administration (M) Retail manager (F) Home Duties (M) Airline Pilot (F) House on acreage, Regional Grandparents, Growing Stronger Program’ Aunties, church, grandparents, Growing Stronger Program, SEDU Aunties, grandparents, Growing Stronger Program, uncles Aunty, Autism Queensland, Autism support group, cousin, DSQ, grandparents, SEDU, Growing Stronger Program, uncle Child care, DSQ, FECS, occupational therapist, SEDU, speech pathologist Baby sitter, child care, SEDU Single Nuclear Tertiary postgraduate (M) TAFE (F) Tertiary undergraduate (M & F) TAFE (M) Other (F) Community health, day care, Growing Stronger Program Growing Stronger Program, kindergarten, nanny, SEDU

Donna

Sean (3 years)

2 (1 years, & 4 years)

DINNERTIME AND BEDTIME IN FAMILIES WITH ASD

C

Elizabeth

Leigh (4 years)

1 (7 years)

Molly

Brandon (3 years)

0

Anna

Shane (3 years)

0

2011 Australian Association of Occupational Therapists

Joy

John (4 years)

0

Cheryl

Jason (3 years)

2 (5 years & 7 years)

Natalie

David (3 years)

3 (8 months, 1 year, 6 years)

147

148

TABLE 1: (Continued)

Participants Nuclear 31–35 (M) 36–40 (F) Medium Tertiary postgraduate (M) TAFE (F) Early childhood teacher (M) Electrical technician (F) Secondary teacher (M & F) House with yard, BMA House with yard, BMA

Name & Age of Child with ASD Family Structure Parental Occupation

Number of Siblings & Age

Parental Age (years)

Approximate Family Income bracket† Parental Highest Level of Education Home Residence & Location Family & Community Supports

Sophie

Lesley (4 years)

1 (2 years)

Kate

James (4 years) Nuclear Nuclear High Medium

1 (6 years)

Nuclear

40–45 (M) >45 (F)

Medium

Joanne

1 (7 months)

Aspergers Services Australia, child care, grandparents, Growing Stronger Program AEIOU, aunty, Autism Queensland, grandparents Kindergarten, SEDU House with yard, Regional House on acreage, Regional

Australian Occupational Therapy Journal 36–40 40–45 31–35 36–40 (M) (F) (M) (F) Tertiary postgraduate (M & F) Year 10 (M) TAFE (F) Year 10 (M) TAFE (F) Home duties (M) Book keeper (F) Home duties (M) Diesel Fitter (F) Nuclear 36–40 (M) 36–40 (F) High Paramedic educator (M) Paramedic (F) Home duties (M) Associate pastor (F) House with yard, BMA Nuclear 31–35 (M & F) Medium Tertiary postgraduate (M) Tertiary undergraduate (F) Tertiary undergraduate (M) Tertiary postgraduate (F) House with yard, BMA

Helen

Gabrielle (3 years) Heath (3 years)

0

Janelle

Bob (4 years)

1 (6 years)

C

Bella

Tom (4 years)

1 (3 years)

Autism Queensland, Autism Support Network, day care, SEDU Aunty, child care, grandparents, Growing Stronger Program, SEDU baby sitter, church, Disability Services Family Team, Growing Stronger Program, kindergarten, play group, respite care, SEDU

2011 The Authors C 2011 Australian Association of Occupational Therapists

K. MARQUENIE ET AL.

†Income brackets were based on the Australian Taxation Office: Individual income tax rates for 2006–2007 (2006) Low = 0–500, Medium = 500–1500, High = 1500 + (dollars per week). M, Mother; F, Father; SEDU, Specialist Education Developmental Unit; TAFE, Technical Education; DSQ, Disability Services Queensland; AEIOU, Autism Early Intervention Outcomes Unit; FECS, Family and Early Childhood Services; BMA, Brisbane Metropolitan Area; Growing Stronger Program, early intervention home based program.

DINNERTIME AND BEDTIME IN FAMILIES WITH ASD

149 content from the transcripts, which reflected the thematic labels developed for each occupation. One week following initial coding, the first and third authors independently recoded clean transcripts according to the established themes ensuring that prominent statements were captured and consistently identified under each theme by both authors. Eighty percent of transcripts were independently coded by the fourth author based on discussions among all authors regarding the emerging themes. As it was not possible to gather all the participants together and because of the time limitations related to this project, only two randomly selected participants were involved in a final member-checking exercise via a teleconference call with the first and third author. These participants suggested minor alterations to elaborate and confirmed the accuracy of the authors’ interpretation.

TABLE 2: Interview questions used in this study 1. Can you describe for me a typical week day? 2. Can you describe for me a typical weekend day? 3. Routines are events that occur at about the same time, in the same order or in the same way every time. For example, some families have routines related to meal times. What routines does your family have? 4. We have found that families typically have routines around meal times, bath times, and bed times, as well as having family times. Can you describe for me how meal times happen in your family? Start from when the meal preparation begins for dinner? 5. Can you describe what bed time looks like in your family? 6. What types of things do you typically do together as a family, what fun things do you do together? 7. What is important for you to do together as a family? 8. Describe how your family participates in traditions and celebrations? 9. Describe those moments when you feel most like a family?

Rigour
Rigour was ensured during data collection and analysis through adherence to strategies of credibility, transferability, dependability and confirmability (Krefting, 1991). Details of these strategies and respective methods are outlined in Table 3.

time and bedtime activities were extracted from interview transcriptions into two separate word processing documents respectively labelled dinnertime and bedtime. The first and third authors independently read and identified common themes for both dinnertime and bedtime. These were discussed, and through consensus between all authors, labels for themes emerging within each occupation were established. The first and third authors independently colour-coded statements and
TABLE 3: Strategies utilised to establish rigour (Krefting, 1991) Data collection — 4

Results
From mothers’ in-depth descriptions, it became clear that the child with an ASD profoundly impacted the development and performance of routines and rituals and the functioning of the family unit. The initial analysis revealed eight themes capturing mothers’ experiences with a young child with an ASD. When discussing these themes, it became apparent that they collectively described how both dinnertime and bedtime centred on

Strategy Credibility

Methods Triangulation Member checking

Data analysis 4 4

Comment All authors were involved in the analysis of data Interview summaries were provided to all participants during data collection. A summary of emerging themes was presented to two participants during data analysis All authors dissussed the analysis of data A demographic questionnaire was provided to all participants A detailed description of the methods is provided for study replication As above As above The first and third authors recoded one week following initial coding As above

Transferability Dependability

Peer examination Rich description of participants Dense description of research methods Triangulation Peer examination Code-recode procedure Triangulation

— 4 4 — — — —

4 — 4 4 4 4 4

Confirmability

C

2011 The Authors Australian Occupational Therapy Journal

C

2011 Australian Association of Occupational Therapists

150

K. MARQUENIE ET AL.

Centred on ASD

ASD alters meaning

Dinnertime Focus on the child ASD: the exception to the rule Caught up in the child’s idiosyncrasies

Bedtime No problem as long as things happen

Dinnertime Dinnertime is horrible Holding on

Bedtime Bedtime all the colours of the rainbow Trapped in routines

FIGURE 1: The Collation of the Initial Eight Themes into Two Overarching Themes. 1Those themes italicised reflect direct quotes from mothers.

…with Charlie [sibling] it was all pretty well easy and now, since we’ve had Frances and realised all the things, it’s totally different to what it used to be. What we eat has even changed because there’s so many foods that she [Frances] won’t eat… Most of the time what you put on the plate will end up in the dog’s dish. If you dish up say meat, potato, peas, corn she will only eat the meat. If any of its touching it gets shoved off onto the floor.

the child with an ASD, and how meaningful interactions within these occupations were altered by the child with an ASD. Thus, the initial eight themes were synthesised into two overarching themes titled ‘Centred on ASD’ and ‘ASD alters meaning’, depicted in Figure 1. This synthesis enabled a richer description of mothers’ perceptions of each occupation and similarities and differences between each occupation to be identified.

Approximately 82% (n = 14) of mothers reported behavioural challenges when these idiosyncrasies were challenged or not accommodated, often demanding family member’s attention. The most common challenging behaviours surrounded food, which is captured by Cheryl:
Jason will come through [into the kitchen] and ask for bread or toast and I will try and say no we are going to have dinner. If I just ignore him he will punch me in the back. I do dish his food up and put him up at the table to eat with us but generally half the time he either throws it on the floor or says don’t want it, don’t want it.

Centred on ASD
Mothers reported constantly accommodating the demands of the child with an ASD during dinnertime and bedtime. This commonly involved restructuring the occupation and the way in which it was performed that gave the impression that the child with an ASD directed both dinnertime and bedtime occupations. During the analysis, clear similarities and differences between dinnertime and bedtime routines and the level of participation of the child with an ASD in each occupation became apparent.

Dinnertime
Mothers described a sequence of routines during dinnertime that was similar for all families. These routines were notably centred around the child with an ASD and often involved the following sequence; preparing a meal, setting the table, sitting down at the table, eating the meal, leaving the table and clearing up. Although the child with an ASD was not always present during each routine, mothers spent significant time detailing the child’s idiosyncrasies and challenging behaviours impacting the development and performance of each routine. These mothers appeared to have become so caught up in the child’s idiosyncrasies and challenging behaviours that they were no longer focusing on the actual occupation of dinnertime. Common dinnertime idiosyncrasies included food selectivities, use of favourite cutlery, crockery and demanding the same chair and position at the table. Approximately 65% (n = 14) of mothers reported idiosyncratic food selectivities of the child with an ASD were a major focus encompassing the whole occupation and limiting other family member’s choices. This is captured by Fleur:

Other food related behavioural responses included gagging, ‘meltdowns’ (Kate), refusing to feed self and walking away from the meal. Helen described a ‘battle of wills’ when she tried to get her son to eat food outside his selective repertoire. Similarly, Joy described ‘picking her battles’ when choosing whether to challenge her child’s idiosyncrasies and challenging behaviours as ‘at the end of the day, it’s just not worth it’. Approximately 92% (n = 14) of mothers reported that their child with an ASD did not easily participate in the dinnertime routines they were trying to create as a family and were often exempt from rules and acceptable behaviour that governed participation for the rest of the family. The child with an ASD was often excused from eating served meals and sitting down at the table with the rest of the family, disrupting the performance of dinnertime routines. This was captured by Molly who described herself as a ‘Mexican Jumping Bean’ having to chase her son around the kitchen to get him to sit long enough to eat his meal. Similarly, Sophie spoke of allowing her son to follow his own agenda during dinnertime routines:
He will sit in his chair … but he’s not still, he’ll jump up and carry on. But then after that he’ll completely lose it and be off…, there’s no point trying to keep him there … all he will do is end up disrupting Martin [sibling].

Mothers detailed descriptions of these idiosyncratic demands and challenging behaviours portrayed a sense of chaos with no clear structure or predictability to dinnertime. Moreover, with this occupation rarely being inclusive of all family members and with a sense of chaos

Australian Occupational Therapy Journal

C

2011 The Authors C 2011 Australian Association of Occupational Therapists

DINNERTIME AND BEDTIME IN FAMILIES WITH ASD

151 times of their day evidenced by phrases such as ‘worst time of the day’ (Cheryl), ‘hell on earth’ (Fleur) and ‘absolutely chaotic’ (Sophie).These mothers never reported this occupation to contain rituals or meaningful positive interactions. In comparison, bedtime was reported to involve both challenging as well as pleasant meaningful interactions and rituals. Joy described bedtimes feeling like ‘all the colours of the rainbow’ with elements of both ‘frustration’ juxtaposed against ‘special times’, hence the sense of a spectrum of colours ⁄ experiences.

permeating throughout this routine, the instrumental goal of meal consumption was not always achieved.

Bedtime
At bedtime, the sequence of routines tended to involve: bathing, teeth cleaning, toileting, dressing in pyjamas; then play ⁄ television or story reading; good night hugs ⁄ kiss, having a drink, getting a comfort toy, followed by lights out and lying down in bed with the child to assist transition to sleep. During bedtime, mothers’ focus also centred on the child with an ASD to achieve the instrumental goal of getting the child to sleep. Similar to dinnertime, bedtime involved the accommodation of idiosyncrasies demanded by the child with an ASD, including the need for specific objects (e.g. bottle or pacifier), conditions (e.g. lighting or bedding) and sequences (e.g. mother needing to stand in particular position and kiss the child in a special way). However, unlike dinnertime, these idiosyncrasies demanded the specific performance of certain bedtime routines, thus creating structure and a sense of predictability within this occupation. Moreover, there was more variety in the child’s idiosyncratic demands and they were often specific to one routine not permeating throughout the entire bedtime occupation. Janelle depicted the inflexible and very specific settling to sleep routine demanded by of her son Bob:
He [Bob] has a particular round pillow, and then he has another pillow, and then he has his blankets up and I put the pillow over the top. But before he snuggles in, I have to have a drink of water ready to go because if I don’t he screams out for water when I am gone. So he has the smallest sip of water… and then he lies down and if I don’t have the pillow there he screams for that too.

Dinnertime
The ‘pressures’ (Anna) of dinnertime appeared to surround the child’s food idiosyncrasies and their demanding and unpredictable behaviours in response to meal consumption and participation. Commonly, the mother’s description of dinnertime indicated that food had become a symbol of ‘stress’ for themselves and their child with an ASD. Fleur described this stress and her resulting perception of dinnertime:
Oh yeah it gets hell on earth some days with her. Dinner is horrible, I hate dinnertime. I hate deciding what to have for dinner because it’s so hard. There are so few things that she [Frances] will eat.

The ‘stress’ of this occupation also appeared to be exacerbated by mothers not only worrying about the nutrition of their child with an ASD, but they also expressed concern about how their food idiosyncrasies restricted the food choices of other family members:
I cook an adult meal, nine times out of ten that Mark [sibling] will eat but Lesley won’t. In saying that, if Lesley has something different than Mark, Mark wants that and he won’t eat what we [mom and dad] are eating. Originally, because Lesley is fussy, Paul [dad] and I would just virtually not have an adult meal, and it was ridiculous that we weren’t getting to eat anything we wanted purely because of Lesley (Sophie).

Approximately 45% (n = 14) of mothers reported behavioural challenges such as screaming and tantrums if they deviated from the previously mentioned demanded special sequences, conditions, and specific object choices. However, these idiosyncratic demands and behavioural challenges did not appear to be as frequent or as disruptive for the family as they were at dinnertime with mothers spending less time discussing these challenges during the interviews.

ASD alters meaning
The second theme ‘ASD alters meanings’ illustrates mothers’ perceptions of both occupations and how the development of meaningful interactions and rituals was impacted by the everyday performance of dinnertime and bedtime routines and the many challenges experienced within both. Approximately 92% (n = 14) of mothers described dinnertime as one of the most stressful

Approximately 65% (n = 14) of mothers reported cooking multiple meals, giving a sense of trying to be more inclusive and accommodating of other family member’s food desires and nutritional needs. However, this was reported to increase meal preparation time, and sometimes created conflicts between siblings who did not want to be eating different foods to the child with an ASD. Some mothers reported trying to incorporate pleasant or meaningful interactions into this occupation (e.g. talking about each family member’s day); but, continual redirection of family members’ attention by the child with an ASD limited possible opportunities. Thus, the mother’s description of dinnertime was absent of any

C

2011 The Authors Australian Occupational Therapy Journal

C

2011 Australian Association of Occupational Therapists

152 indicators of meaningful family enjoyment and rituals. In the few occasions where mothers described attempting to construct rituals around positive family interactions, the child with an ASD was not part of the family’s dinnertime experience:
Most of the time James will sit and eat until he is full, and if we haven’t finished and James has we generally put the TV on for James to watch so we can finish and talk, cause we generally do a lot of our talking. So then he is occupied and we can continue to relax as a family. If we don’t do that he can be whining, he will keep getting up from the table, he might want help with something else, then he drags you away from the table to help him do stuff, so the video helps (Kate).

K. MARQUENIE ET AL.

mothers described story reading to be pleasant because this was a time when the child with an ASD was calm and may display affection or appreciation. Similarly, others described lying down with their child as they settled to sleep as a pleasurable ritual for the same reasons.

Discussion
The purpose of this study was to identify experiences of dinnertime and bedtime routines and rituals in Australian families with a young child with an ASD, as well as common challenges experienced. The interpretation of the mother’s detailed descriptions of both occupations suggests that dinnertime and bedtime centred on the child with an ASD, and the presence of the child with an ASD impacted negatively on the development of meaningful interactions and rituals. These findings support those of Larson (2006) and Werner DeGrace (2004) who identified that the pervasive nature of ASD was responsible for inflexible and child-centred routines, and positive social and emotional family experiences within daily occupations were fleeting. This study identified both dinnertime and bedtime to be directed by the idiosyncrasies of the child with an ASD, which appeared to be an attempt by the child to create some control and certainty within both occupations. This supports other studies that suggest children with an ASD need structure and predictability to support task performance and participation (Larson, 2006; Wing, 1997; Wing & Attwood, 1987; Wong & Hughes, 2000). However, the presence of other family members at dinnertime and mothers’ concerns for all members’ nutritional needs meant that these idiosyncrasies could not consistently be accommodated during this family occupation creating challenging behaviours and chaotic routines. This appeared to reduce participation from the child with an ASD. This was in contrast with bedtime where the child with an ASD and mother were frequently the only participants, making it easier for mothers to incorporate the child’s idiosyncratic demands into this occupation. As a result, bedtime compiled structured, predictable, and at times non-functional routines that appeared to reduce the frequency of behavioural challenges and also enabled the child with an ASD to be more of an active participant compared with dinnertime. Similar to Segal’s (2004) findings, this study also demonstrates the importance of developing structured routines to not only support participation, but create opportunities for ritual development. With dinnertime being chaotic and absence of structured routines, opportunities for meaningful interactions were rare, which appeared to contribute to the absence of rituals at dinnertime. In contrast, the structured and functional routines at bedtime appeared to create opportunities for meaningful interactions between the mother and the child with an ASD resulting in bedtime containing some rituals. These findings were in contrast with a study by Evans and
2011 The Authors C 2011 Australian Association of Occupational Therapists

Bedtime
Unlike dinnertime, bedtime was reported to have moments of meaningful interactions and rituals amidst an often rigid and sometimes non-functional sequence of activities. Both bathtime and getting their child to settle to sleep were the most commonly reported ‘stressful’ bedtime experiences. Anna described her distress when her son Shane was having difficulty settling to sleep:
If Shane is awake and wants to let me know, he will bang his head, and bang and kick and bang and bang, which keeps him enough stimulated that it will keep him awake. So if it is a night where that is happening it can be quite awful because I am very tired…if he doesn’t go to sleep then it snowballs out of control.

Approximately 74% (n = 14) of mothers reported being ‘trapped’ in performing some bedtime routines causing frustration and detracting from a potentially positive interactive and meaningful bedtime experiences. This was illustrated by Cheryl when describing Jason’s bathtime routine:
We had a situation a couple of months ago where the drains were blocked and I had to use a plunger to get the water down. Now, every time when he [Jason] has finished his bath I have to get the plunger and plunge the water down, every single time… It’s incredibly frustrating.

Approximately 37% (n = 14) of mothers also reported feeling ‘pressured’ when one or more siblings were involved in the bedtime routine as this often required shared attention from the parent ⁄ s, as well as other siblings having to accommodate the child’s inflexibility and idiosyncratic demands. Although there were no specific routines that all mothers reported to be pleasant, approximately 74% (n = 14) described some bedtime routines to contain meaningful interactions and rituals. Some

Australian Occupational Therapy Journal

C

DINNERTIME AND BEDTIME IN FAMILIES WITH ASD

153 ticipants in the latter check may not provide a true representation of all families interviewed. In addition, one interview with each participant may have been insufficient to understand these families’ occupations. Moreover, lack of prolonged engagement with these families may not have provided sufficient rapport influencing the mother’s level of disclosure. It is recommended that future studies explore the impact of ASD on other family occupations. Observations of the performance of occupations, including dinnertime and bedtime routines and rituals would further enhance rigour and confirm interview findings. A longitudinal study design could also be conducted to identify if families with a child with an ASD ever develop routines and rituals if the foundations are not established in the early stages of family life. Analysis of the presence of one or both parents during the performance of specific routines may also provide further insights into how these family occupations are supported by parental presence.

Rodger (2008), which found both dinnertime and bedtime for families with a young typically developing child to be imbued with meaningful rituals, positive emotions and a special connectedness. In accordance with previous research (Cheal, 1988; Imber-Black & Roberts; Schuck & Bucy, 1997; Wolin & Bennett, 1984) this study also highlighted how rituals may aid in reducing stress and increasing family cohesion. The current study depicted dinnertime lacking rituals with the majority of mothers reporting this occupation to be one of the most stressful parts of their day. Moreover, dinnertime routines rarely contained moments of meaningful interactions between all family members. This was in contrast with bedtime, which illustrated how having moments of meaningful interaction and rituals embedded into this occupation reduced mothers’ perceptions of stress from approximately 92% (n = 14) at dinnertime to approximately 72% (n = 14) at bedtime, which was mainly attributed to performing non-functional routines.

Clinical implications
This study identified a number of important factors for occupational therapists to consider when offering a family-centred early intervention service to families with a young child with an ASD. In particular, it highlights the importance of supporting mothers in developing structured and more predictable dinnertime and bedtime routines inclusive of all family members. This will enable mothers and the child with an ASD to understand better and address their idiosyncrasies and related challenging behaviours. Children may also become more flexible with the performance of some bedtime and dinnertime routines thus reducing the non-functional components of these occupations. This in turn will not only develop opportunities for meaningful interactions and the development of family rituals to evolve within dinnertime and bedtime, but will also build the foundation for a stronger and healthier, more cohesive family unit.

Conclusion
The exploration of dinnertime and bedtime occupations with a young child with an ASD provided in-depth insight into the performance of routines and rituals, and mothers’ perceptions of both occupations. This study depicted that families with a young child with an ASD experienced structured bedtime routines with some meaningful interactions and rituals embedded. This is in contrast with dinnertime routines, which were often unpredictable, chaotic and bereft of meaningful interactions and rituals. This study also illustrated how stressful dinnertime and parts of bedtime were for mothers. With the lack of positive meaningful family experiences and rituals during these daily occupations, the findings of the current study and those of previous research suggest that these families are at risk of increased stress, and reduced family cohesion (Cheal, 1988; Imber-Black & Roberts; Schuck & Bucy, 1997; Wolin & Bennett, 1984). Thus, occupational therapists providing early intervention services for families with a young child with an ASD need to consider supporting mothers and the child with an ASD in enhancing their participation within all aspects of family life, and developing shared and meaningful family occupations and rituals. In doing so, occupational therapists will be supporting the devolvement of a strong and cohesive family unit.

Limitations and future research
In contrast with previous studies (Larson, 2006; Werner DeGrace, 2004), this study included a larger sample size (n = 14). However, this sample may not be representative of all families with young children with an ASD as the majority of parents had additional qualifications post-secondary school, were middle-to-high income earners, and were accessing multiple autism specific intervention services for their child. These characteristics may have influenced the performance of dinnertime and bedtime routines and rituals and their perceptions of both occupations. The reported perceptions of dinnertime and bedtime may have also been further been limited due to interviews only being conducted with mothers and not fathers or siblings. Although member checking was incorporated during both data collection and analysis, access to only two par C

References
American Psychiatric Association (APA) (2000). Diagnostic and statistical manual of mental disorders (DSM-IV-TR) (4th ed.). Text Revision. Washington, DC: Author. Boyce, W., Jensen, E., James, S. & Peacock, J. (1983). The Family Routines Inventory: Theoretical origins. Social Science and Medicine, 17, 193–200.

2011 The Authors Australian Occupational Therapy Journal

C

2011 Australian Association of Occupational Therapists

154
Cheal, D. (1988). The ritualization of family ties. American Behavioral Scientist, 31, 632–643. Evans, J. & Rodger, S. (2008). Routines or rituals: Mealtimes and bedtimes as key family occupations. Journal of Occupational Science, 15, 98–104. Fiese, B., Hooker, K., Kotary, L. & Schwagler, J. (1993). Family rituals in the early stages of parenthood. Journal of Marriage and the Family, 55, 633–642. Gray, D. (1997). High functioning Autistic children and the construction of ‘‘normal family life’’. Social Science and Medicine, 44, 1097–1106. Higgins, D., Bailey, S. & Pearce, J. (2005). Factors associated with functioning style and coping strategies of families with a child with an Autism Spectrum Disorder. Autism, 9, 125–137. Imber-Black, E. & Roberts, J. (1992). Rituals for our times: Celebrating, healing, and changing our lives and our relationships. New York: Harper Collins. Krefting, L. (1991). Rigor in qualitative research: The assessment of trustworthiness. The American Journal of Occupational Therapy, 45, 214–222. Larson, E. (2006). Caregiving and Autism: How does children’s propensity for routinization influence participation in family activities? The Occupational Therapy Journal of Research: Occupation, Participation and Health, 26, 69–79. Patton, M. (2002). Qualitative research and evaluation methods. California: Sage Publications. Pierce, D. (2000). Maternal management of the home as a developmental play space for infants and toddlers. American Journal of Occupational Therapy, 54, 290–299.

K. MARQUENIE ET AL.

Rodger, S., Braithwaite, M. & Keen, D. (2004). Early intervention of children with Autism: Parental Priorities. Australian Journal of Early Intervention, 29, 34–41. Sanders, J. & Morgan, S. (1997). Family stress and adjustment as perceived by parents of children with Autism or Down Syndrome: Implications for intervention. Child & Family Behavior Therapy, 19, 15–32. Schuck, L. & Bucy, J. (1997). Family rituals: Implications for early intervention. Topics in Early Childhood Special Education, 17, 477–493. Segal, R. (2004). Family routines and rituals: A context for occupational therapy interventions. The American Journal of Occupational Therapy, 58, 499–508. Werner DeGrace, B. (2004). The everyday occupations of families with children with Autism. The American Journal of Occupational Therapy, 58, 543–550. Wing, L. (1997). The autistic spectrum. London: Constable and Company Ltd. Wing, L. & Attwood, A. (1987). Syndromes of autism and atypical development. Handbook of autism and pervasive developmental disorders. New York: John Wiley and Sons. Wolin, S. & Bennett, L. (1984). Family rituals. Family Process, 23, 401–420. Wong, V. & Hughes, S. (2000). Autistic Spectrum Disorder in Children. Medical Progress, 8–15. Individual income tax rates for residence, 2006-07 recommended by Australian Taxation Office, Australian Government. (Accessed 2006, June 30). Retrieved October 28, 2006 from http://www.ato.gov.au/individuals/content.asp? doc=/content/12333.htm

Australian Occupational Therapy Journal

C

2011 The Authors C 2011 Australian Association of Occupational Therapists