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November 2008Helping Children with Autism Spectrum Disorders in Early Care and Education Settings Barbara T. Doyle (M.S.)

I have been in the field of early care and education for over 30 years. I don’t recall children who exhibited the kinds of behaviors we now refer to as “autism spectrum disorder” until fairly recently. What explains the rapid increase in this condition among preschool-age children?

I entered the field of special education more than 30 years ago myself. I remember all of the children with whom I worked in our early intervention program back then. I agree that the children with autism were just not there. I can remember a few children then who would have been diagnosed with autism today, but only a few over the first 20 years of my career. The incidence of autism spectrum disorders (ASD) when I entered the workforce was thought to be 1 or 2 in 10,000 live births.

When people talk about the increase in autism disorders among children, they often say that it is not a “true” increase. They mention things such as the following:

• We have broadened the definition of autism disorders to include children with the features of ASD who test within the typical range of intelligence, gifted intelligence, and profound learning problems.
• We have broadened the definition of autism to include people who are less severely affected.
• We are identifying young children with autism disorders more consistently than we did in the past.
• We now recognize autism disorders in children with other issues such as Down syndrome and cerebral palsy.

Yes, I would have to agree that all of those things are true. However, even when all of these are factored in, statisticians cannot account for the numbers of very young children who have the features of autism—neither can the early intervention providers who watch this increase continue from year to year.

Why? The answer is that no one knows for sure at this point. Multiple causes are being studied, including the effects of metals and other substances on early development, immune system compromise, changes in our genetic patterns, environmental toxins, toxins in the products we use in our homes, and viruses. Every week I read new studies about the causes of autism. Yesterday, a news broadcast reported that the incidence of autism is higher in rainy places! They suggested that rainy environments cause children to be indoors more of the time, watching more TV and other “screen-time” activities, and being exposed to more indoor toxins.

Indoor environmental toxins may be contributing. Every year, thousands of new chemicals are introduced into our homes and outdoor areas in the form of various products. The vast majority of these chemicals are not tested on animals or people. Their toxic effects are discovered only over a long period, and it can take many years to prove a toxic effect well enough for a product to be taken off the market.

Some researchers are studying the effects of too much television, videos, and computer time on very young children. In simple developmental terms, it makes sense that when children are engaging with non-human visual input, they are NOT engaging with human beings. Early intervention providers have known for decades that human interaction in the early months and years of life is essential for human development. When children are sitting and watching a screen, they are also not moving. Research shows that movement in young children is similar across the globe (running, jumping, hanging upside down, spinning, rolling, walking, throwing, catching, etc.) Movement early in life helps to complete the brain/body connection.

We do not know what is causing all of these children to need our services. However, we must change the way we deliver early services to reflect the needs of the children and families with whom we are working today.

I have known preschool children with autism who were very high functioning and children who were very low functioning. What in your view determines whether a child with autism can be included successfully or not in an early childhood program? 

I wish there were a better way to describe the effects of the features of ASD on human beings. “High functioning” implies that this person is going to be more “like us” and have a life that is similar to a typical person’s life. It does not take into account the fact that children who may seem “high functioning” may still encounter severe issues related to social interaction and understanding others. The term “low functioning” implies that these children do not have gifts and talents. It implies that these children need “separate” programming and will live lives with less quality and richness than typical people will.

There is a wonderful book by Anne Donnellan, PhD, and Martha Leary, MA, CCC-SLP, called Movement Differences and Diversity in Autism/Mental Retardation: Appreciating and Accommodating People with Communication and Behavior Challenges. In this book, the authors describe how the concept of intelligence and measuring intelligence began. They describe how our interpretation of what children can do causes us to create a life path for a child that eventually becomes a self-fulfilling prophecy. For example, a child who is viewed as low functioning may be placed in an environment with others who are viewed as less capable. In this environment, the children may be exposed to fewer people, objects, events, and environments, causing them to have fewer opportunities to learn. They may be exposed only to children who cannot model new and better ways of interacting with the world. Over time, they may learn less because they were exposed to less, not because they were innately unable to learn.

Look at our literature today. People who were considered severely or profoundly disabled (low functioning) during their childhoods are now telling us that they were “always in there.” When given sufficient communication supports and skills, they are able to show us that what we measured as their capabilities was not accurate. Some of them are writing books and giving lectures using augmentative communication!

Thinking this way does not mean that every environment in which children with disabilities are grouped together is necessarily wrong or bad. One problem with inclusion is the “all or nothing” approach. Sometimes children need to learn specific skills in special environments from highly trained people. However, no child should be confined to an environment and have limited opportunities to be exposed to the richness of learning because of our perception of their level of functioning.

Now I can answer the question: “What in your view determines whether a child with autism can be included successfully or not in an early childhood program?” I think the successful inclusion of a child with autism is determined by how the child is viewed by the adults and children in the program and how much individualization is practiced, not just discussed. To successfully include any child with autism in any program, several things need to be in place:

• Recognizing that inclusion is not about the geography. Inclusion is not about where the child is educated or the name or type of program. Inclusion is the state of mind of the children and adults in the environment. Does everyone understand the child? Do they have all the help and support they need? Do they understand that their classmate is “different but belongs here,” and “different but can do things,” and “different but likes us even if he cannot speak to us?”
• Understanding that the included child does NOT have to do what the other children are doing at the same time and in the same way as the other children. Although the child does not have to do what the other children are doing, the child with autism needs to be emotionally and socially connected to children and adults in order to have good mental health.
• Talking with the more typically developing children about their peers with disabilities on a regular basis at the appropriate developmental and experiential level. I have had these talks with 3-year-olds who were able to accept and accommodate the children with autism and other disorders.
• Highlighting what the child CAN do in a way that their peers can see. It might be something as simple as handing another child the crayons, or helping to put the toys away. Finding and displaying competencies usually involves working within the areas of “liked activities” the child has.
• Focusing on safety. I think about the child with autism who cannot yet tolerate the noise and action of “centers” and who dis-regulates and becomes very upset during centers. This child is still in the classroom during centers every day, displaying behavior that is upsetting to the child and others. Why? Why not have a therapy session during that time. In therapy, the child with autism could learn the prerequisite skills needed to enjoy times in centers. Or perhaps they would never do “centers.” That’s ok! They can have a great life if they use safe behavior, can communicate, and belong to a community of other children.

What are some ideas to help children with ASD who have poor verbal skills participate in group activities?

Great question! First, let’s reconsider our definition of “participate.” For many of us, participation in educational activities is equated with talking, especially answering when someone speaks to you. I think we consider this the “best” way of participating since this is the way most of us were encouraged to participate in our own educational experiences, all the way through university!

Consider the many ways that anyone can participate. Here are a few: listen, observe, talk, write, draw, think, compare, read, make charts or lists, ask questions, find answers in printed materials, work alone or with someone else, write on flip chart pages, take notes, report, keep time for a group, make learning or memory aids...and on and on.

For our very young children with autism disorders who are not verbal, let’s think about what they could DO to participate. Children with autism and other developmental issues often have good understanding related to the use of objects. If we want children to DO something, prompt them to use objects. These prompts could result in more participation than trying to prompt them to SAY something or LOOK at something. If we prompt a child with developmental and learning issues to DO something, the other children can SEE them do it, helping to create a community of children that knows that everyone can do things, even if they do them differently. Therefore, for participation, our young children could:

• Point to something (Teach meaningful pointing in context. It is an essential skill in communication and often does not develop spontaneously in children with ASD.)
• Stand near something.
• Sit near something.
• Hold up their hands.
• Hold up an object, picture, or word card.
• Give something to someone else.
• Take something from someone else.
• Move something to another place.
• Find something.
• Match things.
• Put things in order.
• Put away things.
• Use a voice output device to give an answer or make a comment (a terrific strategy!), and so on….

In addition, we need to consider the example of partial participation. In order for young children to learn to participate willingly and fully, they may need to first participate only partially. If a child is forced to participate beyond what he can endure, he may learn to use physical resistance, running out of the room and other strategies to avoid feeling trapped or overwhelmed. This response could cause the other children to view him as being “bad” or make the other children afraid of him. The goal of all of our efforts is to help children learn to stay calm, safe, and in control of themselves so that they can learn and develop. I call this helping children to remain in a state of “self-regulation.” When children “dis-regulate,” they lose their ability to control themselves, resulting in situations that do not help everyone learn. When we force a child beyond her limit of endurance and peerscan see or hear her protests, we do not accomplish the goals of inclusion. Children may begin to see the child with autism as “different and not capable” and “different and does not belong with us.” Please reconsider any approach that uses physical force and physical intimidation to try to accomplish “learning and relationship.”

Using partial participation strategies, the child begins by participating only to the degree that he chooses and for the time that he feels comfortable. He is supported in the idea of moving away from something before it becomes intolerable. He is supported to participate more fully when he is able to. In this way, he learns that it is safe to approach, move away, and approach again. (When I say move away, I don’t mean go to Rhode Island! Just a few feet of freedom to move may give sufficient support so that the child can learn in an environment that feels safe.)

Let’s put these two ideas into an example in context. The teacher is reading a book to all of the children seated on the rug. Kirsten, our child with autism, has a carpet square. She can put that square anywhere nearby the other children or can choose to sit at a table or desk nearby during the story (partial participation). She has a book in her hands identical to the book the teacher is reading (using objects to participate). The story in the book is about a blue dog. Kirsten has a blue card near her, and she has a picture of a dog. She also has a word card that says “blue” and a word card that says “dog.” (Yes, start introducing whole words in print and in context to very young children who have or are suspected of having an autism disorder. This, of course, is a topic for another question if you are interested!)

At an appointed time, an adult (or an older mentor child) is near Kirsten. In a prearranged way, the teacher says, “Is this book about a dog or a bear?” While the other children say “DOG!” Kirsten is prompted to hold up her dog word card and/or picture of a dog. When the teacher asks the color of the dog, someone helps Kirsten select the blue color card or the blue word card and show it to her teacher and classmates. Later, the teacher could ask Kirsten whether there is a picture of a dog in the room. Kirsten can be physically shaped to point to the picture of the dog on the wall nearby or helped to go and stand next to the picture of the dog.

This example shows how well this strategy can work. Making this work often requires some planning and preparation. Over time, however, when you learn to think this way AND to train all staff in the room to teach this way, adults will be able to think of many things for the child with autism to DO to participate. After this practice has been modeled for some time, young peer mentors will begin to do the same. They will have learned that Kirsten is thinking and participating and showing us what she knows in her own way—yes, true inclusion.

A word on whether or not Kirsten is paying attention… There is really no way to know! Adults with ASD tell us that sometimes in order to listen and attend, they must NOT look at the person who is talking. They tell us that sometimes when they were drawing or doodling in school, or rocking in a rocking chair looking out the window, they were actually taking in the most information.

This does not mean that we do not teach attending skills of looking and orienting your body toward the speaker. We do need to teach these skills and may begin teaching them in private teaching and therapy sessions. At the same time, we want to discover what each child needs to do and have in order to learn how to listen and attend in a safe way in a group of peers.

Once this has been discovered, simple explanations to the children can be very helpful. “Why is Kirsten sitting over there?” is a question the teacher might hear. “Well, that is the way she learns the best! You learn the best sitting with me, and Kirsten learns the best at a chair.” Yes, you will get requests from the other children to sit wherever they want to. So from time to time, let them choose where they want to sit while the book is being read. It may have a less controlled feel to it while you are reading, but most children will learn quickly that they want to be back on the rug so they can see and hear the best. If some children persist in being away from you when you read, then take a more in-depth look at how that child learns!

Can a child with sleep deprivation be mistakenly diagnosed with autism or autism spectrum disorders? I have heard that this happens.

Sleep deprivation can definitely cause learning, growth, development, and behavioral issues. Sleep deprivation and frequent sleep interruption have sometimes been used as part of torture because the techniques render the person unable to think, learn, and perceive clearly. Sleep deprivation can cause a person to act in ways that the person might not otherwise act.

Lack of sleep is a serious medical and mental health issue. Remember that if a child does not sleep, then it is likely that the whole family is sleep deprived or at least one or both parents. Sleep deprivation has been associated with child and elder abuse, including recent cases in which parents actually killed their children with autism.

When I have initial interviews with the parents of very young children, I ask them multiple questions to find out who is sleeping and for how long. Many families resort to allowing the child to sleep wherever he wants to in the house or bringing the child to sleep with the parents just to ensure that the family can sleep. But I am careful not to judge parents when they take these measures to ensure that people in the household can sleep. We talk about the situation, explore options, and discuss how to make gradual, successful changes.

Sleep is affected by many factors, including worries and anxiety, nutrition, medical disorders, the physical environment, safety concerns, fear, sensory issues, past events that occurred during the night, weather, pain, and illness. Providers of early educational services need to help families find the medical, social, environmental, and psychological supports they need to ensure that everyone in the household is able to sleep. This is a very high priority for providers!

Sleep deprivation would be unlikely to cause the diagnostic features of autism spectrum disorders, even though it would affect the child’s development and behavior. Although lack of sleep would affect development, I think it would be unlikely to actually cause the syndrome of autism to develop.

Think about the essential features of ASD. The most predominant is that the child does not spontaneously develop the skills needed to create and sustain relationships. In very young children, the child with an autism disorder may not use and understand gestures well, may not seek information from the faces of others, may not develop language and speech in a typical manner and sequence, and may use objects in an unusual or repetitive way. (Be sure to look at one ofthe many checklists that describe the early features of ASD.) One more consideration: many children with autism disorders do not sleep well. It would be possible to assume that lack of sleep caused autism. I think it may be more likely that a child who has autism also has problems sleeping.

I work with a 4-year-old who has a diagnosis "on the autism spectrum.” Sometimes he does things that would be considered typical in a child of the same age with no diagnosis. For example, when two adults are talking, he will interrupt. So we're wondering how to differentiate between "behavior that shows a child's disorder" and "a child with a disorder who is displaying a behavior that's fairly typical of children his age."  

I have been asked this great question many times.

First, it is wonderful that you have recognized an essential element of working successfully with young children with autism disorders: They are children! As children, they may have issues similar to all young, developing children. I am glad that you know this. I have seen young children with disabilities held to a higher standard than their more typical peers!

In my answer to your question, I am going to use the example you provided of interrupting others so that I can take you through a process to discover causes and create effective interventions. However, I would like you and other readers to understand that what I am describing here would apply to almost ALL of the social communication issues experienced by very young children who have features of autism disorders.

Typical children learn most of their social skills by observation and interaction, with some trial and error and coaching. The experiences of their daily lives often cause them to learn new social skills. It seems like a miracle to me, but most children simply learn by adding up the sum total of their experiences. Very young children could miss social cues, but they learn to watch for and understand social exchanges when we clarify our expectations of their behavior. We know this is true when young children learn to use social communication skills in a classroom when they have not learned those skills in other environments.

Think about the very young child with the features of an autism disorder. His interaction skills are greatly affected by the features of autism, preventing him from automatically learning social skills simply by experiencing them. Adults may have spoken to him and told him not to interrupt. How can he know what that means and how to comply if he cannot yet identify when two people are having a social exchange? His observation skills may be very limited since he may have trouble attending to the important components of social interaction and social learning. He may not be able to recognize and interpret “observable” clues such as the facial expression and tone of voice of his communicative partner. He may miss cues that indicate that two people are actually talking to one another (how their bodies are oriented toward one another, how their speech is directed at a particular person, etc.).

Another complicating factor is that children with autism disorders often have a developmentally young concept of time and the passage of time. If we tell a 4-year-old boy with autism to “wait,” he may respond like a much younger child who has not learned what “wait” means.

I do not think that we can always distinguish whether a child is displaying a certain behavior because he is 4 or because he is 4 and has an autism disorder. A more important distinction may be: will the child with autism be as likely to LEARN the correct behavior in the same way that a typically developing child learns or will he have to be taught the skill another way?

Something to consider: talking to a child is not the same as teaching a child. If you have spoken to the child about the social skills that you would like him to demonstrate, such as not interrupting, and he has not learned to do it, then you have not yet TAUGHT him what to do. If talking were teaching, then all of the children with autism would have learned to do everything we wanted them to, since we have talked to them about it many times!

Teams could try these steps to teach new skills more effectively than just talking about them:

1. Identify the social skills that the child with autism needs to learn.
2. Prioritize the social skills so that you have a list with the most important skills that he needs to learn at the top of the list. For me, social priorities always have to do with safety and privacy for self and others. For example, I would prioritize as follows:

• closing the bathroom door when he uses the toilet,
• not leaving the room without communicating with an adult first,
• learning to ask someone to move or learning to walk around them rather than pushing them aside.
3. Decide to support and mediate less important social skills until the more important ones have been acquired. For the less important skills, continue to support the child and his peers so that no one is embarrassed, upset, or feels disrespected.
4. Identify the combination of learning elements that result in this child actually learning. Create a “learning profile” of this child that describes exactly how he learns so you can develop teaching methods that are the most likely to result in acquiring new social skills. Does he learn best with pictures, word cards, drawings, role-play, using puppets or dolls, watching videos, etc.?
5. Create a teaching strategy to teach the specific skills.
6. Decide who would be the best person to teach the new skill using the identified methods.
7. Decide where the initial instruction should take place.
8. Decide how to carry over the skill into multiple environments.

Thanks for your question. I hope this answer has been helpful to you.  

We are in the process of setting up a picture schedule for a child diagnosed with autism. We want to have a schedule of her day posted in the room that we can refer to with her and have some pictures on a ring to assist her with transitions. We currently do not have Boardmaker—should we take pictures of her engaging in the tasks or just the area? For example, when it's snack time, should the picture be her eating snack or a picture of a typical snack.

Using visual supports for children with autism is a great idea. I am glad that you are moving in that direction. Remember that the schedule you are developing can become a means to two-way communication and that an important objective is for this little girl to be able to both receive and send messages using the symbols you will introduce and teach. I also appreciate your reference to using the symbols in context, such as showing her the symbol for snack while she is having a snack. Children with autism learn the best in context, when things are meaningful and make sense. Good for you!

Some people may object to the visual schedule, saying that the child already knows what is going to happen each day at school and has memorized the schedule. Children with ASD are very good at memorizing the schedule. However, some children with ASD have significant problems with any changes from the memorized routine or coping with any unexpected events (an assembly, fire drill, the hallway being painted, the pool being closed, etc.). A visual schedule can help with these issues.

Schedules help people anticipate and be ready for changes from day to day. Therefore, do not make copies and give the child the same schedule every day. Instead, create daily schedules that reflect the small and subtle changes that occur from day to day such as indoor or outdoor play, a substitute teacher, a change in work responsibilities, a visitor coming to the classroom, what book will be read, etc. This approach supports the child in learning to flow more easily with any aspect of his or her day that is unexpected or unusual.

When a child uses a daily schedule, the actual schedule becomes an “object” with which to gain mental focus during a time of change or transition. The schedule becomes a focal point from which information can be gained about changes. The schedule can help the child remain calm, self-organized, and self-regulated when events suddenly or unexpectedly change. Over time, many people with ASD who use visual schedules learn to internalize the process of identifying changes and selecting alternatives without becoming upset.

Before you start, let’s talk about what kind of symbols to introduce. Many times, we assume that there is a “hierarchy” of understanding symbols. For example, most people believe that photographs are easier for children with autism to understand than line drawings and that printed words are harder for children with autism to understand than colored photographs. In my experience, I have learned NOT to make those assumptions.

When we are starting to use visual supports, one of the first things we need to do is to assess the child’s level of symbolic representation. That is, we want to assess what kinds of symbols this particular child seems to understand the most. We can do this by carefully observing and recording the types of symbols this child seems to attend to or understand the best. Then we introduce that type of symbol in meaningful contexts.

Here is an example. A friend of mine has a son, Jason, who is severely affected by autism. (I changed the name to protect confidentiality.) In school, Jason was exposed to Boardmaker symbols. Over the course of one year of school, Jason spontaneously used only four symbols. No one was satisfied with that result. We knew that the symbols were being used in meaningful contexts and that Jason was well supported by his school staff who taught consistently and were very responsive to him.

Like many children with autism, Jason experienced distress during any unexpected change in schedule. In addition, if something unexpected happened and the visual symbols changed, Jason still seemed to experience great distress. This made us think that although he might know what some of the symbols meant, the use of the symbols in his schedule did not help him maintain a sense of well-being when his schedule changed, and the use of symbols did not support him in making smooth transitions.

We decided to assess his level of symbolic representation. We began to observe any type of symbol to which he seemed to respond. We learned that Jason was able to find videos to watch by looking at the words and colors on the spine of the video container. He selected favorite books by looking at their covers (design, color, words). He was able to find the type of drink he wanted in the soda pop aisle of the grocery store. Again, we saw him respond to colors and words.

To assess further, we made a card without the color or design but that just had the name of his favorite drink. With only a couple of trials, he was able to select the drink he wanted by looking at the word card and handing the word card to us.

We started to watch the movements of his eyes when we showed him a child’s picture book. His eyes most frequently moved to the typed words at the bottom of the page.

Jason spoke very little. One day while driving down the street with Jason, his mother heard him say “K” very clearly. When she looked around, she saw that they had just passed K-Mart. Jason had seen the big, red “K” and had said the letter.

We realized that Jason might need print, not any other kind of symbol. We slowly and carefully transitioned him from Boardmaker symbols to printed symbols. (Never take away something that is working for a child! Make all changes gradually. If you want to try a different type of symbol, then use the new symbol to introduce a new concept.)

Within weeks, Jason had acquired (spontaneously used in context) over 40 words! We were all very happy about this as you may imagine and continued to use printed words to support Jason. His vocabulary grew rapidly and continues to grow. We added color-coding (such as yellow means free choice time, blue means outdoors, etc.) because we had noticed Jason responding to colors.

Boardmaker types of symbols are wonderful for the children who can see and interpret TWO different kinds of symbols at the same time. With Boardmaker symbols, the child needs to see and interpret the line drawing and/or see and interpret the word or both. They may not be able to recognize that the drawing and the word tell us the same message. If children are not developing the ability to use their Boardmaker symbols well, we might want to switch to just one type of symbol at a time.

What else could be going on when children use symbols such as photographs, pictures, and drawings? The child may be experiencing “stimulus over-selectivity.” Sometimes children with autism “over-select” to one detail in what they are shown, rather than see and interpret the “whole” stimulus. They may see just one part of the drawing or photograph.

So what could we do? We could begin by introducing words to very young children in their schedules, communication boards, and voice output devices. If we are unsure about the child’s level of symbolic representation, we could put the printed word on one side and a picture or drawing on the other. Over time, the child may “self-select” the symbol that has the most meaning.

Words are symbols that children with autism can see as a “whole.” Words require less symbolic interpretation, association, and generalization. Words “say” what they mean. For example, a picture or drawing of a spoon and bowl might mean: eat, spoon, bowl, table, napkin, kitchen, cereal, soup, etc. When a child sees the word “eat,” it can only mean one thing: EAT! The word cereal means only one thing: CEREAL! Words are easier to memorize, and memorization is a high skill area for many children with autism.

People tell me that 3- or 4-year-old children are “developmentally too young” for using word cards. I disagree. Children do not have to know all the sounds of all the letters to be able to learn that words have meaning and to use words to communicate and understand the world around them. And a good sight vocabulary improves reading fluency later on.

I am concerned because sometimes I meet children with autism in the eighth grade who are still using pictures because they are not “ready” for print. When will they be ready? When will someone try to teach them meaningful reading words with which they can have an expandable communication system? And sometimes when I see a child’s “picture” schedule, I cannot even figure out what those symbols mean! That could make it hard for people in other environments to use the symbols effectively.

Another benefit to creating a visual schedule with printed words is that it helps begin to teach the important lifetime skill of “read and do.” As each item on the schedule is “read,” we “do” it. In this way, children can gain more independence and competence in moving through their day.

A schedule should not be stigmatizing and should be put into a form similar to that used by same-age peers. Even in the very early grades, other children will recognize the competence of the child with autism, and that she is “reading” just as they are. Another advantage to using print from the beginning is that anyone can make a relevant visual cue in the moment and in context. Parents may use more symbols at home if they can print a word and have it ready to use in context.

If you use print, use only lowercase letters except where uppercase letters are required. Print in good “teacher” printing, clearly using lines, circles, and half circles.

Now back to the other part of your question. No matter what symbols you decide to use, use them only IN CONTEXT. Do not create drills where the child simply identifies or names the word associated with the symbol. Remember that children with autism disorders often actually learn what we actually teach. My reminder phrase is, “Be careful what you teach, because someone might learn it!” This means that if you want a child to see a symbol and think about the associated activity, and use the symbol to predict and understand what is going to happen, then in the initial stages of training, only present the symbol when the event occurs.

So here are a few steps:

• Make a list of all of the people, objects, events, and environments that you would like this child to know, anticipate, and predict.
• Create simple word cards or other symbols for the child for everything on the list. Have them available for the child to see and use in all environments, including home.
• Before teaching the use of the visual schedule, teach the use of the symbols that are going to be used in the schedule until the child shows you some anticipatory responses to the symbols. By this, I mean that if you show the child the word card for “outside,” the child moves toward the door or goes to get her coat. As you explained in your question, you would show the word or picture for “snack” during snack time. You would have the word or picture for story time only when you were sitting on the rug listening to a story. In essence, you are pre-teaching the vocabulary in context so that later, when the child sees the next three words or symbols in her schedule, she will KNOW what the next three people, objects, events, or environments are going to be.
• Study the child’s use of her vision. Can she cross her midline when she scans? If so, you may be able to use a visual schedule that is presented from left to right (horizontal presentation.) If your informal assessment shows that she cannot scan left to right, you may want to present the schedule from top to bottom (vertical presentation) instead.
• Assess the child to see if she has object permanence. Does she seem to know where things are even if she cannot see them? Can you send her to get something in another room or somewhere that is out of her sight? If she can remember that things exist even when she cannot see them, then your idea of a ring of cards might be helpful. I like the portable nature of the ring and the idea that needed symbols could be brought to various environments but that she would not have to carry ALL of her symbols with her all of the time (portability).
• Here is a great idea I learned from a teacher of young children: when the schedule includes going to another environment (the lunchroom, the speech therapist’s room, etc.), the symbol for that environment was placed on the wall at the child’s eye level in that environment. For example, the word card “speech” is used in the child’s schedule. In the speech room, the identical word card “speech” is on the wall. When the child arrives in the speech room, she can match her schedule symbol to the one on the wall, teaching her to check to be sure that she has reached the right destination. If the symbol in her schedule is “speech” and she goes to the music room, her symbol will not match the symbol on the music room wall. This will provide her with feedback about being in the wrong place.

Keep the daily schedule as a fluid and changing daily document that includes both what we expect to happen and what unexpected events or changes occurred. Send the daily schedule home with the child so that parents will know the events of the day as they actually happened and will be better able to converse with the child about the day.

Over time, children with autism can be given a schedule and be taught to follow it through the day.

They can learn to use these schedules as a way to self-monitor and self-correct. The ability to follow a list of scheduled activities can become a lifelong support strategy. For example, at work, an employer could give an employee (perhaps a person with ASD) a list of the day’s scheduled tasks and the employee would know how to read it and move through the list, accomplishing each task. Families can use daily schedules at home to help children and adults learn to organize themselves more independently.

What kinds of resources and training are available for educators in Illinois to help create environments and teaching methods to work with children with autism spectrum disorders in early childhood settings? 

We are lucky to have some very good resources in Illinois. Give the people at these resources a call or email them and tell them exactly what you are looking for. They will direct you to what you need:

• The Autism Program of Illinois
  5220 S. 6th Street Road, Suite 1700
  Springfield, IL 62703
  Telephone: 217-525-8332
  Email: theautismprogram@thehopeinstitute.us
  Internet: http://www.theautismprogram.org
• Illinois Autism/PDD Training and Technical Assistance Project
  1590 S. Fairfield Avenue
  Lombard, IL 60148
  Telephone: 630-620-9473
  Kathy Gould is the project director (gouldkl@comcast.net)
  Internet: http://www.illinoisautismproject.org/index.htm Editor's note: This url has changed:http://autism.pbisillinois.org/index.htm

Be sure to check out the TEACCH Web site at http://www.teacch.com, and check out their information about Structured Teaching at http://www.teacch.com/structureteach.html.Editor's note: This url has changed:http://teacch.com/educational-approaches/structured-teaching-teacch-staff

What type of information would you suggest that a child care provider be familiar with when considering caring for a child who falls under the Autism Spectrum Disorders?    

Thank you for your question. I am going to give you a long answer! Included in my answer are many ideas to help you understand, protect, and support any child with autism in your care.

First, remember that children with autism disorders are children! Everything you know about working with children will help you work with the child with autism. You are probably sensitive, kind, helpful, gentle, supportive, and fun to play with! These qualities will help you provide care for any child, including a child with autism. When providing care to the child with autism, the kindest, most helpful, and most caring response is likely to be a good choice.

In the answer, I refer to the “team.” The team is anyone who is involved in the life of the child, such as parents, teachers, therapists, and others. Talking to members of the child’s team is a very helpful way to support the child. However, you must obey the rules of confidentially. Be sure you always talk to the parents first and obtain their written permission before you speak to anyone else about their child.

“The Big Ten” of autism is a list that I compiled to help people include and support children with autism spectrum disorders. If you do not understand anything that I have written, be sure to ask for help. Not every item will apply to every child, so choose what seems the most relevant for your situation and the child with autism you are supporting.

Are there specific modifications that I, as a teacher, can make to the classroom environment to help a child with ASD be more successful?

Great question! I like how you are thinking about what CAN be done! Classroom adaptations that support children with autism often improve the teaching and learning environment for all of the children and help the adults as well. This makes these adaptations even more desirable! So here are a few things that come to mind when I think about creating an optimum learning classroom:

1. Get organized! Every item in the classroom has to have a particular place where it belongs. As soon as you find the right place for an item, label that place with a printed word or two, such as “puzzles,” “small blocks,” etc.
2. To store many small, related items, get boxes or bins. Label the outside with the words for those items.
3. Arrange items so that they make sense. For example, store the books near the reading corner; store the paints near the easels.
4. Associate particular classroom areas with certain activities. For example, have one area that is associated with working independently or one-to-one, an area that is used just for eating or preparing food, an area that is associated with listening as a group, and of course specific areas for physical movement and playing!
5. Share the day’s schedule with all of the children in the morning or when they first come to your room. Post the schedule for the day. Be sure to include what is different about this day as well as what elements of the routine are going to be the same as usual. Then provide individualized, portable, visual schedules to each child and help them reference the schedule throughout the day.
6. Use systematic instructional techniques. Be sure that every task has a clear beginning and ending. When you plan activities, be sure to first identify the academic and lifetime goals of the activity for each child so that all the adults in the classroom can work in a coordinated way.
7. Only one adult voice should be heard at a time in the classroom. If an adult is working with an individual child or a small group, only those children should be able to hear that adult’s voice. Avoid the “tower of Babel” effect, and do not allow adults to speak in loud voices that all of the children can hear. And remember that when speaking to children with autism, louder is not better. Sometimes a quiet voice is easier for children to process.
8. Meet with various members of the child’s team for short, targeted meetings, and share information about your student with autism. Ask for help quickly so that other team members can help you before the child develops the “habit” of responding unsafely or inappropriately.
9. Children with autism spectrum disorders grow up very quickly! Their entitlement to services is limited to their free, appropriate, public education. Be sure that each child’s day and activities result in the acquisition of new skills in every child in your care. Don’t waste time on things that are not going to be important across the lifetime of the child. Focus on safety, communication, social skills, and productive activities.
10. Visit the TEACCH Web site for more ideas: http://www.teacch.com/structureteach.htmlEditor's note: This url has changed:http://teacch.com/educational-approaches/structured-teaching-teacch-staff

How and where is TEACCH being implemented in Illinois, if at all? TEACCH stands for Treatment and Education of Autistic and Related Communication Handicapped Children, a program administered through the University of North Carolina at Chapel Hill.

Thank you for your question. I was unsure of the answer so I did a little research for you.

First, I contacted Linda Tortorelli from The Autism Program at the University of Illinois at Urbana-Champaign. Mrs. Tortorelli and The Autism Program are wonderful resources for all of us here in Illinois. She told me that structured teaching strategies are being used throughout Illinois in various places. Urbana has specific TEACCH classrooms at the elementary, middle, and high school levels. This is the third year or so for these classrooms. She thinks that the Rantoul schools also have a TEACCH classroom at the elementary level. Linda said that the Champaign schools utilize some TEACCH concepts with some of their students in their general resource rooms, but they do not have separate TEACCH classrooms. There are TEACCH classrooms throughout the Chicago area as well. TEACCH trainings are offered in Illinois annually. Locally, they are held in Rantoul during the summer months. These trainings are always full. Be sure to get the information and make your inquiries early.

Next, I contacted Marrea Winnega. Dr. Winnega is a licensed clinical psychologist and Assistant Professor of Clinical Psychology at the Institute for Juvenile Research in the Department of Psychiatry at the University of Illinois at Chicago. She is a wonderful autism specialist and a tremendous asset to our state! Dr. Winnega said that the A.E.R.O. Special Education Cooperative (offices in Burbank, Illinois) has some structured teaching classrooms (TEACCH prefers them to be called structured teaching classrooms because TEACCH is actually the name of their program in North Carolina). Dr. Winnega said that there are two structured teaching classrooms in the Chicago Public Schools as well. The North Suburban Special Education District (NSSED) has some structured teaching classrooms too. All of these classrooms may not be at the “model” level yet, but they are worth seeing.

Dr. Winnega said that The Autism Program is sponsoring the trainings, which they call “TAP 1” trainings. You can check out The Autism Program Web site for more information. I went to the site and found this page, which might be helpful:http://www.theautismprogram.org.

Be sure to contact them and ask to be included in training that is relevant to your work.

Hope this helps!

We have a 4.5-year- old boy in our preschool class who is being tested for autism. We have a problem getting him interested in other things besides building with fine motor objects. He becomes increasingly agitated when we try to bring him to other activities, although once we have him doing another activity, he appears to enjoy it. How can we make transitions smoother for him and his teachers? 

By definition, young children with autism disorders have restricted highly focused interests. Some other children with developmental issues appear to be “stuck” doing only one or two things that they seem to prefer to all other things. Sometimes it may be watching a segment of a video many times, lining up toys instead of playing in a typical way with the toys, or as in your case, building with manipulatives.

I am proud of you for not labeling his highly focused activity as an “obsession” or “perseveration.” Good for you! There is no need to label highly focused interests with psychiatric terminology (with only very rare exceptions). Therefore, you are off to the best start by viewing building with fine motor objects as “a highly focused interest.”

I have spoken with many adults with autism about their highly focused interests in childhood. They have given me several different explanations. Everyone is unique, but the thoughts of people with autism may guide us to understand our young learners. Here are a few of the responses, paraphrased:

• My interests were teaching me. I do not know why, but I could not move on until I had exhausted my interest in those items.
• My interests were teaching me about form, relationships among items, and how things are connected.
• My interests made sense to me. Other things that were going on around me did not make sense to me.
• My interests gave me a feeling of control, in a positive way, over some small element of my environment.
• My interests made me feel calmer and allowed me to cope with events that I otherwise found intolerable.
• I liked my interests, and they made me feel happy.
• My interest early in my childhood actually was the beginning of the career I have today.
• When I had my objects with me and could touch them, I could actually process what I was hearing better. Without the objects, my auditory processing “shut down.”

So let’s assume that the interest in building with small manipulatives has meaning and makes sense for your little boy and may be actually helping him! At the same time, we want to teach him foundational social communication skills like engagement and reciprocity. We can do it!

Children with autism are sometimes described as having “attention” problems. You have found that this little boy CAN pay attention, right? The problem is more in shifting his attention to something else at the lead of his communicative partner. In other words, it is hard for him to lift his attention from where it is (on the manipulatives) and move it to somewhere else because you wanted him to. Therefore, we cannot expect him to shift his attention automatically because you have asked him.

What to do? USE the interests! Here are a few suggestions for your consideration. Start implementing any idea that makes sense to you in your situation and with this particular child.

1. Engage his focus and attention in more topics by making the restricted, repetitive interest an element of those topics, rather than constantly trying to “make him stop focusing on it.” So find books, pictures, and activities that are about using small manipulatives or about building things from small pieces. Then when it is reading time, he can read about the items that he likes. For math or writing, involve small manipulatives to count, to write the name of the piece, to arrange for learning shapes, to group according to the initial sound, etc.
2. Engagement is a foundational communication skill. If he has not learned to “engage” with another person, you will not be able to help him shift his focus to another person, place, or object. So begin to seek engagement with him while he plays. Some of the ideas that follow will help you do this.
3. Move into his space to begin to teach. This little boy may be playing in a certain place in the room because that place is the best for him right now. He may have chosen a quieter spot, or a place with certain lighting, or a place with less movement from others. He may be the most comfortable there. Consider bringing objects and activities to him in his space, at least until you can engage him. Once engagement is happening, he will be better able to move with you.
4. Use the interest to teach simple turn taking, another foundational social communication skill. When you start to “insert” yourself into his work for a short turn, it may be hard for him, so make your initial turns very brief. It may take some time for him to know that when you are “playing” he can still do things that he wants to do and that you are going to add to his fun, not stop it.
5. Start having him use a certain base for his play. For example, teach him to play with the manipulatives on a certain portable rug square or on a sheet or cloth that he unfolds to use as a base for play. You could use a large piece of cardboard or any item that will become the “floor” of his play when he is building with manipulatives. Over time, and when he has learned the skills we are describing, he will learn that that “base” has to be available in order for him to play with the manipulatives.
6. Use the interests as reinforcers. In individual sessions with targeted communication goals, prompt short, correct responses and reinforce with manipulatives that he can use to build. Perhaps he can build a base first then “earn” additional manipulatives to add to his creation. Keep the trials short and targeted. We are teaching him to tolerate short interruptions to his building without becoming upset. Then, gradually, we will teach him to tolerate longer interruptions. That is the long-range goal: tolerate interruptions and shifts in focus without becoming upset.
7. Create a very simple visual schedule using objects. Give him an opportunity to use his manipulatives in between every other activity. In the beginning, make the “other” activities very short. Over time, he will remain calm enough that you can lengthen the time he is engaged in other activities.
8. Use his interest to show the other children that he is competent. Be sure to point out what he has built, how creative it is, and how much you admire it.
9. Give him a small bag or box and let him have some manipulatives “with” him even if he is engaging in something else, somewhere else. In this way, he will get the idea that no one is taking them away. Instead, they are nearby and handy. If he needs the objects to feel safe at this point in his life, he will be better able to learn if the objects are nearby.
10. Remember that he may be “paying attention” to what you are doing even if it does not look like typical paying attention. So while he plays, read to him, talk to him, and use communication symbols to tell him that you are taking a turn, adding more items, etc. Try allowing him to use manipulatives during story time, as long as he is quiet and out of the line of sight of the other children. If you do this, it is likely he will begin to transition better to story time. Once he learns to tolerate story time (or other activities,) he may no longer need the manipulatives to move smoothly from one activity to another.
11. Insert communication opportunities into his play with the manipulatives. For example, you can have some of the items in a box. He gives you a communication card with a numeral on it, and you give him that number of pieces. Or you have a particular piece, and he gives you a word card and you give him the piece. For example, if there is a round piece that he usually uses, you have it. Show him the word card for “round.” He hands that card to you, and you give him the round piece.
12. Allow him to start some other activities by bringing some manipulatives with him to the new activity place. As you have indicated, he will engage in other activities once he gets started. To make the transition easier, have an open box placed where you want him to do the next activity. Place a few of his favorite manipulatives in the box. When he comes to the table, he can add more. He may seem “distracted” by the presence of the manipulatives, but I think your data will show that when he has some of his favorite things nearby and can touch them sometimes, he will participate longer and more fully in other activities. Resist the urge to take those manipulatives out of the box once he has placed them there. It may take a little time for him to believe that those objects will not “disappear” the second he puts them down.
13. Maybe we can think about his manipulatives as we think about our purses or wallets. We always want to know where our purse or wallet is, but we do not always have to be touching it if we know it will be where we left it when we want it again.

There are two handouts on my Web site related to this topic. If you are interested, go to http://www.barbaradoyle.com. Click on Helpful Handouts. Read and share Object Schedules and Working with Restricted, Repetitive Interests.

Hope these ideas are helpful.

How does playing video games affect children with autism? 

As in most things, there seems to be both pros and cons when it comes to the use of video games with children with autism. Let me give you some points that I consider when making decisions about using video games with young children with autism.

1. When using video games, children are NOT engaged in learning social skills with other children or adults. Although some games may be designed to help children learn about social skills, by their nature, video games are NOT social. Everyone is interacting with the screen more than interacting with each other. Few video games require real collaboration with a partner beyond just simple turn taking.
2. Some people think that if a child shares a mouse or other device with another child during a video game, then social skills have been learned and applied. I do not agree. Simple turn taking may have a chance to be practiced, but the child with autism can learn to take turns with the mouse without actually interacting with another child. He may be interacting only with the mouse or game device.
3. In my personal experience, it is rare for a young child to learn a skill in a video game that the child then automatically applies to real-life situations.
4. Video games can be learned across an entire lifetime. This learning does not have to take place in the early years of life. The early years for children with autism should focus on the development of social interaction, communication skills, and being a safe member of a family and school group.
5. Video games are largely sedentary activities where the child simply sits. The author Carol Stock Kranowitz talks about the need for physical activity in young children in order to “complete” the brain-body connection and to help children learn.
6. Obesity is now epidemic among children. Children spend untold hours sitting and looking at screens of some kind: televisions, handheld games, movies, screens in cars, video games, etc. While they are looking at screens, they are not interacting with others and are NOT engaging in physical activity and play. Nor are they burning calories and developing muscle and bone strength.
7. Some new virtual reality video games do require standing and moving. I am interested to learn how children with autism react to them.
8. Many hours of staring at screens may have damaging effects on the eyes, since the child stares at the screen at a fixed distance from their eyes. Young children need to use their vision in more complex ways, quickly switching from near to far to middle fields of vision. Here are a couple of Web sites about the effects of computer screens on vision: http://www.aoa.org/x5374.xml and http://www.aoa.org/documents/EffectsComputerUse.pdf. This Web site—http://www.aoa.org/x5379.xml—discusses the effects of computer use in children and how to minimize damage.
9. If young children are going to spend time at the computer, I prefer it to be learning to use the computer as a communication tool and to learn to read or do math (Sesame Street types of programs).
10. Select video games carefully. Use the game yourself first and go through all of the levels before you allow the child with autism to use the game. Be sure that the content is appropriate and that the language used in the program is appropriate for the child to use anywhere.
11. There may be good reasons to teach young children to play some video games:
    
    
    • The child can be engaged in a positive and independent activity, especially so that parents have time for their responsibilities in the home and time for other family members.
    • Some video games now include movement, such as dancing and singing, or learning sign language.
    • Playing video games is one way for children with autism to play alongside siblings and their friends.
    • If the child with autism has skill in video games, it can help others view him as more competent and more like the other children.
    • The child can safely engage in playing video games when others are not available to interact with him.
    • The child may be relaxed and happy when he plays video games.

So as you can see, my bias is to keep children engaged with adults and other children in positive and collaborative ways—to create a sense of belonging and to develop communication and social skills. Although I do not think that video games will necessarily hurt young children with autism, I have seen them “take over” in the child’s life. The child may learn to prefer the video game to human interaction because the computer does not require the presence of social skills—an area of need in children with autism. Therefore, my advice is to be careful and moderate. I suggest that you monitor the amount of time the child spends using video games and keep it to a minimum, especially early in life.

Applied Behavior Analysis seems very extensive. What parts of it can a general education teacher implement or adapt to help students with autism in the general classroom?  

Applied behavior analysis (ABA) has many aspects. It includes analyzing behavior for its communicative function and designing behavioral interventions, creating and adapting environments to enhance learning, designing interventions to help people interact more successfully with others, developing individualized curricula, and discrete trial training (DTT). When most people think of ABA, they think of DTT. DTT includes designing and implementing an individualized lesson plan with a targeted teaching goal, planned prompts and reinforcement, and a data collection system. Many people think that DTT has to be done in a one-to-one session with the child seated at a table and with many repetitions of the same item. We have all seen DTT done this way, but it is NOT the only way that structured teaching can be accomplished.

Instead of thinking about how to apply ABA in the classroom, it might be more effective for you to think about how to apply the principles of ABA and systematic instruction in your classroom. Here are a few hints:

1. Note: Some people use the word "stimming" to refer to repetitive movements that a child might use such as flapping hands, rocking, or twirling an object. The actual behavioral term is "self-stimulation." Remember that all behavior that you observe has meaning. Strive to find that meaning for the child in your classroom. Do not think about behavior as meaningless or perseverative or “stimming.” Think about the reason why any child would do what you are observing. When you find the underlying cause, you CAN change behavior.
2. No one can read the mind of the child with disabilities. Do not let others tell you what the child thinks, feels, or wants. This can lead to the wrong interventions because no one really knows what any child is thinking unless the child can clearly convey his or her ideas to others.
3. Carefully read the child’s IEP. It is your roadmap and compass. It will direct you to what is important for this child to learn. Keep the child’s IEPs in a folder in your classroom where you can easily refer to it.
4. Everyone whose name appears on the front page of the IEP is YOUR team! They are there to help you. They are obliged by law and ethics to do so. Ask for help as soon as you need it. Do not wait for things to go very wrong before you ask for help.
5. Therapists and other team support staff for children can spend time in your room observing as part of their therapy. Ask them to observe periodically and make suggestions.
6. When you teach, be sure that you have a targeted goal in mind for the child with disabilities in your classroom. It does not have to be the same goal as the other children have. Goals should be related to what is targeted on the IEP. For example, the other children may be learning about the continents. While the child with disabilities is learning about the continents, the targeted goal as stated on the IEP might be to take turns in talking about the continents, to work cooperatively with another child, or to write a complete sentence.
7. Do not be afraid of data collection. Data can reveal what is happening in a way that our minds might not be able to conceptualize. Children are always responding to either an external stimulus (event) or an internal stimulus (event, perception, or feeling). By collecting data related to external events, we may uncover “patterns” and “trends” that help us find the underlying meaning of communication and behavior. Collect data only about the most important things that need to change.
8. Prioritize safety. Your primary job as a classroom teacher may be to be sure that all of us CAN be safely included in this world. When you have learned what the child’s issues are related to safety, convene the team and tell them. It may change the IEP in an important way. Being included anywhere in society dictates that a child use only safe behavior. Systematically address issues related to safety of the child and others.
9. When a child has any problematic behavior, think to yourself, “What do I wish that he would do instead?” This question will help you choose the replacement behavior that the team can focus on and teach.
10. Use as many visual supports as you can. You will find that visual supports assist over 80% of all of the children in your class.

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