Susan Senator
All happy families are not alike...
All happy families are not alike...
Caring for and treating a child with an autism spectrum disorder (ASD) can challenge the most highly trained and well-intentioned people. Our understanding of the origins and prognoses of ASD, as well as our methodologies of treatment, are limited. Parents and professionals often are steered toward applied behavioral analysis (ABA) of one form or another, and school systems are likely to use elements of ABA in their approaches.
Although children with ASD can acquire many necessary skills, including daily living skills, classroom attention, following and creating schedules, basic math, puzzles and games using behavioral techniques, ABA has its limits. However effective these types of approaches may be, children with ASD may be getting shortchanged by an over-emphasis on behavior. Other approaches are less well known, but developed properly they may be even more successful, particularly in the area that is perhaps the most problematic and elusive aspect of ASD: social skills.
As children grow and become more complex in character, they require understanding that takes more of their personality, desires and emotional make-up into account. If students are given only external motivators as rewards, as is the case in ABA, rather than learning that the desired act in itself is rewarding, it is quite possible that they may never learn to enjoy social interaction on their own or to enjoy it for what it is.
The message learned by a child in the ABA approach is “After you perform this task, you will be rewarded.” The thinking behind ABA is that a child gradually generalizes and internalizes the task, building on his or her repertoire. However, what if children don’t make that leap on their own?
For example, what if a student continues to amass communication skills, learns to answer “wh” questions, and learns to make small conversation from a script—a favored ABA technique—but never connects these skills together or learns the joy of communicating? Children with ASD start out in life with social impairments; does it make sense to teach them fragmented social skills using external rewards as motivators?
The integration of information makes sense for any child, particularly one with ASD. Although children who carry the ASD diagnosis vary greatly in their strengths and weaknesses, it is often the case that they demonstrate a fragmented view of the world around them, making integration of the information they are gathering from the environment challenging. They have difficulty categorizing and generalizing. Instead, they seem to understand the world in disparate pieces.
By taking a “top-down” approach and targeting areas such as problem-solving and inferential reasoning, these children may be able to learn how to integrate information from their environment, leading to opportunities for incidental learning of specific vocabulary and concepts.
Additionally, by challenging children to solve functional problems, the therapist actually may facilitate internal motivation that results in them taking an active role in their environment, which is essential to moving toward more appropriate communicative interactions with others.
In treating children of all ages who carry a diagnosis of ASD, the therapist can employ numerous ideas from the work of Stanley Greenspan, MD, and his Floor Time or Developmental, Individualized, Relationships (DIR) approach.
In an article outlining his approach to treating children with disorders like ASD, Dr. Greenspan says, “An appropriate intervention program must, therefore, focus not on isolated skills but on the most essential functional developmental capacities. Specific skills are embedded in these functional developmental foundations. More and more studies are identifying these capacities for shared attention, intimate relating, affective reciprocity, and the emotionally meaningful use of actions and ideas as the building blocks for logical and abstract thinking, including higher levels of empathy and reflection.”
The use of many of his ideas is not uncommon with younger children who recently have received a diagnosis of ASD. However, older children with the same diagnosis often have not been exposed to this type of treatment approach due to the preponderance of ABA in educational programs. Yet these children could benefit tremendously from Dr. Greenspan’s integrated, developmentally-based approach.
For example, children with ASD often demonstrate reduced flexibility with their daily/weekly schedule and demonstrate stronger visual processing skills than auditory and language processing skills. In many programs caregivers immediately implement a visual schedule for the child, even before determining whether such a schedule is necessary or appropriate. This type of treatment of children with ASD seems to facilitate inflexibility rather than teach flexibility and automatically provides a visual crutch for the child to lean on rather than challenge the child to rely on auditory and language processing skills.
Although the use of aids and strategies can help the child feel a sense of success, caregivers are often too quick to limit children by assuming that the child won’t be able to overcome the presumed weaknesses that are stereotyped in the ASD diagnosis. If we challenge the weaknesses that the child demonstrates rather than feed into them, we are more likely to see positive overall results in a child’s performance in a variety of areas of communication.
With older children who have been in behaviorally-based treatment programs for years, it is a challenge for people in their life to determine how to retrain them to feel internally motivated and reinforced by the natural consequences of appropriate interactions with the environment and other people.
The treating therapist can set up situations that require problem-solving and inferential reasoning based on the child’s areas of interest and functional activities of daily living. For instance, have the pre-teenage child participate in a multi-step art project based on a topic of interest, e.g., creating a beach scene or assembling a picture of a fire truck.
You may need to take a few sessions to familiarize the child with the steps required to complete such a project before you purposefully “sabotage” the situation. Once the child is familiar with the general idea of the targeted project, provide some of the materials, such as a pattern and paper, but neglect to provide items such as writing utensils, scissors and glue. Guide the child through the steps of the project as needed with verbal prompts such as “What do you need to do first?” and nonverbal cues such as tapping the needed item.
Use cues only as needed based on the child’s level of performance. Remember to allow children time to process the problem they have encountered, such as needing to cut but not having scissors readily available, and time to formulate and produce an appropriate verbalization or action to solve the problem. Encourage them to use environmental cues and past experiences to infer the sequence of steps and allow them to make errors and correct these errors on their own.
Treating clinicians should encourage other caregivers to similarly sabotage familiar activities in the child’s home and school programs. Creating numerous situations where the child is responsible for problem-solving and inferential reasoning will provide multiple opportunities for practice and generalization of these skills across a variety of contexts.
Additionally, these situations will encourage frequent involvement between children and their environment and caregivers, facilitating children’s understanding of their relationship with and control over the world around them. Continue to consider increasing a child’s flexibility as caregivers implement these sabotage techniques and remember to constantly change the activities and nature of the sabotage, e.g., provide an empty glue bottle or incorrect pattern.
Using this type of top-down approach to treatment leads to a child taking responsibility for his or her interactions within the environment and with others. The child then begins to learn vocabulary and concepts incidentally and through the use of newly learned problem-solving and inferential reasoning skills.
Additionally, children appear to begin to attend to nonverbal communication cues as they become more aware of the actions of those in their environment, and this lends itself to improved social interaction skills. The most important part of this treatment approach is that children are expected to perform to the best of their abilities, to continually make progress toward their communication goals, and to rise to the occasion when new challenges are presented. Of course, when working with any child, it is important to remember that we should not address any skill in isolation of the whole child.
Recognizing that a child’s play skills, cognition, sensorimotor skills, physical development, etc. all have a significant impact on overall communication skills will allow caregivers to better address and achieve the goals set for that individual. Using a multidisciplinary approach involving speech-language pathology, occupational therapy and/or physical therapy will further assist in achieving each individual’s therapy targets.
Meeting children at their particular place in development, capturing their interest, and drawing them out from there so they learn is the best way to teach students in a way that really has an impact. Taking into account their strengths and interests should be at the heart of a child’s education, whether the individual is typical or autistic. Motivation ultimately must be self-derived in order to foster full independence, rather than being externally imposed. It has to start with the child and build in small increments.
Approaches like Floor Time or top-down therapy have the ability to integrate the information learned, and all in the same relationship environment. These methodologies are challenging, but they certainly are achievable. They may not be as well-known as ABA and other behavioral approaches, but they are well worth using with any child on the autism spectrum, regardless of age.
Caregivers and professionals have a responsibility to help children find internally motivating reasons and reinforcement to communicate with others and to participate in the environment around them instead of allowing them to become dependent on external motivation and reinforcement. The more professionals and families understand and access the full range of capabilities of the children with special needs in their lives, the better off those children will be.
Copyright 2002, Susan Senator