Monday, October 23, 2017

8 Things You Need to Know When Working with a Student Who has Autism { #1 }

You may notice that my blogging was on hold all summer. That's because my brain was about explode from learning so much! This past June I had the pleasure of hearing Dr. Patrick Rydell, an SLP who owns The Rocky Mountain Center for Autism, speak for a whole day. WOW! He said everything that's been floating around my head (with regard to autism) but said it so much better than I could have. Then, at ASHA Connect in July, I planted myself in sessions by Michelle Garcia Winner.  She reiterated so much of what Dr. Rydell said and more! 

I've been pondering all of their juicy information and combined it with everything I have personally experienced while working with children with autism for over 2 decades. I've come up with what I believe are the 8 essential things you need to know about treating kids with ASD. 

I can't imagine that any school SLP or pediatric SLP would ever go their whole career without assessing or treating a child with autism at some point. I admit that I am in no way an expert on this topic. In fact, I never had formal instruction on this topic in grad school. It just wasn't commonplace in the 90s. When I started working as an SLP, autism was still a "low-incidence" disorder, and now it's a high incidence one! I vividly remember encountering the first child whom I suspected had autism. He was, in fact, diagnosed in the months after I met him. Prior to that, his parents had brought him to doctor after doctor and left all of their offices with no answer. I still stay in touch with that young man and his family, and he'll forever have a place in my heart (and he is a success story I'm happy to report). I even remember when "asperger's syndrome" became a "thing."
Now 1 in 68 children have ASD. I truly thought I'd never see that day.

While I'm not an expert, I've learned a thing or 2 over the past 23 years as an SLP. I've learned so much that I would really love a DO-OVER with many of my former students! From a caseload of my own to my current leadership position, traveling from school to school and observing our district's toughest students, here's what I think educators (and SLPs, of course) need to understand when working with kids with ASD.

Children cannot take in instruction without joint attention.  We all learn about the importance of joint attention for communication in grad school, but in a school system and world now focused on rigor and higher level learning, it's easy to forget how very crucial joint attention is. 

Ask yourself: Can this child share focus on an object? 
(such as both of you looked at or playing with the same item while he looks at it and back at you)

Joint attention is achieved with 1 person alerts another to an object by means of eye gazing, pointing or other verbal or nonverbal means. It's a prerequisite skill for effective communication. 

Check out this oldie but very goodie video titled "Joint Attention Test." Note how the different children focus on an object and share (or don't share) focus with the adult. 

Best video ever right? And still holds true today!

I'm sure by now all of you SLPs reading this have a particular child in you mind. 
If your student does not exhibit joint attention, it's important that you establish it before moving on. It involves the ability to gain, maintain and shift attention away from the object, person or event and then back to it. 

How can you build joint attention?
1) For students who are not put off by touch, use hand over hand teaching, taking the child's hand and helping him touch items in both of your sights (you and the child) or manipulate items that you are manipulating. Use items that are high interest but not ones the child is obsessed with. 
2) Use less words and more play. Follow the child's lead. Yep, this one is hard for us. 
3) Reinforce joint attention if it's not naturally reinforcing. 

Let's get more specific...
1) In a not-too-distracting setting (with limited or no access to toys), bring in toys that you think the child will like but cannot see or have access to. 
2) Standing or sitting away from the child, pull out ONE toy only and hold it in a way that the child can see it but not touch it. If it makes noise or lights up, activiate it to to spark his attention. Your activities MUST BE IRRESISTIBLE! Thanks to our only guy SLP who started the term #bedesireable, that's what we now say. You MUST #bedesirable! 
3) If the child doesn't attend to it, put it away and try another toy. If he comes toward the object, talk about the toy briefly, "Oh you like my toy." or "You see my Buzz Lightyear." and give it to the child when he approaches. You are reinforcing that behavior (approaching due to interest) by giving him the toy. 
4) After he's had some time enjoying it, say "my turn" and gently take it away from the child and walk away (but stay in the area). If the child approaches you quietly/appropriately, talk about the toy again and how he wants a turn and give it to him. If he cries or shows inappropriate behavior, tell him he can have it when he calms down. Wait the child out. 
5) Notice we are not yet expecting communication, we are only expecting shared attention. Continue this for as many sessions you need to until the child is sharing what you have, even if he's not playing with it or sharing play with you.  

Do you have kids who are not responsive to objects or cannot manipulate objects but enjoys actions (spinning, swinging, tickling)? In that case, perform an action and then walk away. For example, push the child on a swing or tickle a child and then walk or look away. If the child smiles, reaches or gestures, repeat the action! 

If these methods don't work, maybe (just maybe) you aren't enticing enough.  Check out this video using "attention buckets" - as recommended by Gina Davies.  Although there are no students in the video, the goal is to get the child focused on the same item that you are focusing on. 

Some great items to engage students and build joint attention are those spinning light toys you get at "Disney on Ice" or parades/carnivals, musical toys, vibrating toys, SPLAT balls, light-up/shaky balls, or sensory toys. Some of my kids even really enjoyed electric fans. THIS happens to be my favorite fan because it's safe for little fingers. 
Click HERE to watch another video with more about Joint Attention - in which the therapist is modeling following the child's lead 
A few years ago I had a young, challenging student with ASD. Here's a shocker...(insert sarcasm)...he didn't want to focus on anything teachers or paras wanted him to focus on (books, paper, instruction, them). His mom explained that he loved balloons and we all knew that he loved trash bags. He continually took the trash bags out of the classroom garbage cans. Lastly, he loved instruments.  I should mention, too, that he was becoming a bigger and bigger behavior problem each day (running away, aggression, tantrums and basically never ever complying with any request).

Soon I decided that the only therapy material I needed was 2 trash bags. Yes, I disobeyed my own advice of not using a child's obsession. It was desperate times. I would hand him a trash bag (if he was calm), and he would open it, filling it with air.  Then he would smush it to squeeze the air out of it. He could have done this all day.  So, I hushed my mouth and did the same thing he did. He started to look at me (previously he only looked at small objects sideways and certainly never faces). He watched me do what he did (neither of us saying anything). He started to watch me intently (sort of half freaked out and half amazed I was doing what he was doing). Sometimes he even smiled; many times he made incomprehensible faces. After a while I would put things in the trash bag. He would take it out and put it in his trash bag and I would take it back (he didn't like that). The point is, we were doing it - joint attention. 

Then I used balloons in therapy (much to everyone's horror of this possible choking hazard). We each had a balloon. He buried his face in the balloon. I buried my face. He bit the tie of the balloon (gasp, but these were desperate times) so I bit the tie of my balloon. He pounded it; I pounded it. He liked watching me pound it as much as he liked doing it himself. 
 I can't even tell you how many times I said a quick silent prayer that no administrator would come observe me doing this. No one would understand. I wasn't even sure it would work. It felt so wrong. I wasn't pushing him; I wasn't making him talk.
Next day trash bags, the next day balloons, etc. I didn't want him to get "locked in" which we will talk about on a future blog post. 
Finally I brought in the beloved instruments (especially the drum). We pounded the balloons, we buried our faces, and finally we drummed the drumsticks on the balloons. This little guy smiled at me.  He watched me drum; he drummed on his. He even let me drum on his. Soon we could put balloons in the same trash bags, drum on the bag, etc. etc. He looked with anticipation for me to drum. He handed me a drumstick to drum, he smiled when I did it.  
THEN we finally started talking. It was a long time coming and it felt about as productive as running through quicksand but the end result was worth it.  Within the year this student was engaging with books, albeit interactive books. In fact, if you've ever tried my interactive books, those were made just for him. He needed to move and have a way to show what he comprehended even though he couldn't express himself well. 
Without joint attention, these little guys can't process or take in what we are trying to teach them. 
Hang out at joint attention as long as it takes. Moving forward without it is futile. 

Once you've got it, expand it!
Once the child is sharing and/or actions with you, increase your expectations! 
1) Require him to either look between you and item (if nonverbal), use a word, sign or picture (AAC) to indicate he wants the item or action. Keep your language at his level. 
2) Expect him to maintain the joint attention longer and longer (require him to look at the item longer to obtain it or wait longer to obtain it). If you think the child will get upset about waiting, stall for time by talking about the item or take a fake phone call while holding your hand up. Want to know how to teach a child to wait?? It's not easy and it's not pretty but Check out this video.  
3) Vary the activities. Don't cause the child to get "locked in." We need to foster cognitive flexibility (yep, that's a future blog post). 

Once a child has firm, maintained joint attention, you can get on teaching bigger and fancier things. Now he can attend to instructional materials, people and their actions, and the list goes on! 
Easier said than done? YEP. 
Establishing joint attention takes a lot of patience on the part of the adult, and it's not a quick process. 
Reading this blog post- because you care to know more-  is a great the first step. 

Please share YOUR tips for joint attention- we all need all the tools we can gather! 

Come back soon to read about the 2nd thing you need to know when working with kids with ASD! 

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