Learning Outcomes
- The participant will be able to identify at least 4-5 critical skills to teach children with autism.
- The participant will be able to describe at least three ways to perform a task analysis on at least 2-3 critical skills for children with autism.
- When presented with a case study of a child with autism, the participant will be able to list at least three of the appropriate strategies to teach a new skill.
Introduction and Overview
Today's training is centered on the skills that are critical and necessary when working with individuals who have autism. Also, I will share with you how to teach these skills. All these are evidence-based practices and strategies for teaching children with autism critical skills.
When I was in college about 20 years ago, before I attended OT school, I was working as a one-on-one assistant for a 16-year-old young man with autism. He was exhibiting significantly challenging behaviors, and no one knew how to help him. I was the one getting hit and bit and scratched by him. An OT came in and provided me some helpful strategies. At that moment, I thought, "This is what I want to do. I want to help families, help schools and most importantly, help children learn better strategies to reduce their challenging behavior." Everything I've done since then has been geared toward getting more education on how to better support families, communities, and schools who have children with autism.
Right now, I own a therapy company, but I also see children with autism. I do a lot of trainings and I go to a lot of schools. Just this morning, I was at a school looking at a first grader with autism who is struggling with a lot of behaviors. The strategies that I'm going to share with you today, I use them on a daily basis, and they work. They work well and they work quickly. I want you to be able to walk away from this training and know what to do to teach a child or an adult with autism. These skills work for all ages. I am working with a young man right now who is 25. I'll be referring to him throughout this webinar because we work with him a lot with his job, his volunteer work, and many other functional activities.
Agenda
Today, we're going learn about critical skills. We will then perform a task analysis, and learn how to create a plan for how to teach the skill. We're using evidence-based practice. We're going to use a model called the AFIRM model, and we're going to go through that with a lot of different types of skills. An upcoming two-part webinar that I will be presenting is called "Understanding Challenging Behaviors." In that webinar, we will learn how to break down and understand the behaviors of individuals with autism, and then learn what strategies to put in place. The skills I'm going to talk about today also will help you with challenging behaviors.
Common Problems
One of the most common problems that I often see when teaching children new skills is getting too caught up in the challenging behavior, and not focusing on the replacement skills. They'll say, "I just want him to stop biting. I just want him to stop hitting." I'll say, "Okay, I do too, but tell me what you want them to do instead." We have to think of behavior as serving a function; we can't simply eliminate the behavior without giving them another skill to do. We have to look at those replacement skills. Thinking about the boy I saw this morning, whenever someone would give him work that was either too hard for him or he didn't want to do it, he would scream. He didn't know how to tell the teacher that he needed help. Instead of raising his hand asking for help, he would scream, start throwing things and hit others. It doesn't matter how you address the screaming and the hitting: if you don't teach him how to ask for help and how to ask for a break, those behaviors aren't going to change until he gets that need met.
Another common issue involves spending too much time on skills that are not critical. According to the DSM-V, the critical skills to address in people with autism fall into two categories: social skills and repetitive behaviors. Communication falls within social skills. We need to make sure that we are spending time teaching children social skills, teaching them how to communicate, teaching them how to play: all those things that will significantly reduce their behaviors and increase their time in the classroom. Instead of worrying so much about things such as handwriting, for example, we have to look at those skills that will interfere with their behavior and their performance in the school system.
An additional problem that often occurs when teaching children with autism is not breaking down the skill into small enough steps. This can cause a lot of frustration for children with autism. When I'm working with a child on a task, even as simple as sitting on the rug, I have to break it down step by step and teach one step at a time. When instructing a child to complete a worksheet or do a cut and paste activity, we need to break it down into small steps until they're successful and teach them those steps consistently. The number of steps will depend on the child's current emotional or physical state, the time of day, the type of activity and other extraneous factors.
Another issue that I often see is using motivators, or things that children like, as bribes instead of positive reinforcement. In other words, the child is told, "You need to stop throwing a fit or you will not be going to the computer lab." That's bribery. We're telling them that if they stop the behavior, then they will get something they want. Instead, we should reword our request, such as, "I want you to do your work. When your work is completed, you get computer lab." It's all about the timing and trying to increase the good behavior versus stopping the challenging behavior.
Why is it Different for Individuals with ASD?
These strategies can work with any individual, however, they are critical for those with autism. People with ASD have difficulty in several areas, including:
Learning through Imitation. People with autism have difficulty learning through imitation, or by watching other people. That's how children learn: by watching their teacher do something, or by observing their friends' actions and behaviors. For so many individuals with autism, this is extremely hard for them. Imitation begins in infancy: babies as young as 4-6 weeks can imitate behavior. When a child doesn't know how to imitate, it's going to be difficult for them to learn. That's why for individuals with autism, we're going to have to do things a little bit differently and break things down into smaller steps because this imitation is a big piece.
Difficulty Understanding the Most Important Details of an Activity. It is challenging for an individual with autism to ascertain what they need to pay attention to and what they don't. For example, I'm currently working with a very high functioning freshman in high school. He's in all general ed classes, and he doesn't have a para. However, we found that when he is listening to a teacher give a lecture in class, among all of the information she is providing to the students, he can't pick out that an assignment was given, or that he has a quiz in a couple days. He's listening to all these things, but he can't pick out what is important about what she's saying. What we're going to do with this particular student is to start recording the lecture, and help him highlight what is important, and what is not as important in these lectures.
Difficulty Picking up on Cues from Another Person. Individuals with ASD have a hard time understanding nonverbal language. In other words, observing someone else and knowing how to respond or what to do based on the person's body language or facial expressions. Picking up on those nonverbal cues is difficult for individuals with autism.
Difficulty Following Directions. This is related to imitation. For example, a teacher gives the students a direction and then they watch each other and learn how to follow the directions. This is something we work on with children who are young: listening to a one-step instruction and following through with that instruction. How we give instructions is also an important part of this process. I was working with a teacher who gave the following instruction: "It's time to do your worksheet. I need you to come sit over here. After you do your worksheet you can come to the computer. I know you like to do the worksheets. I know you like to play on the computer." That teacher just said in five sentences what she should have said in one. Every time she gave him another instruction, he had to process again what she was telling him. Keep instructions short and simple and direct, to help them learn how to follow direction.
Difficulty Learning New, Complex Skills. Some of you may be familiar with the term discrete trial training. It's similar to what we're doing now with a task analysis. Discrete trial training involves breaking skills down into small steps and teaching those steps systemically. Because our individuals with autism they have trouble doing that on their own, we're going to have to break those skills down for them and help them through the steps.
Case Studies
I wanted to provide you with a few case studies of individuals in different age groups. Think about these case studies as we're going through the strategies in today's presentation.
Carly
Carly is a third grader in Mrs. Smith's class. Carly loves stickers and enjoys participating in Social Studies class, PE, lunch, and recess. Mrs. Smith reports that Carly is having a hard time during math class. When given a math worksheet to complete, she will tear it up and throw it on the floor. After this occurs, her teacher makes Carly pick up the mess and throw it away. By the time Carly is done picking up her mess, it is time to go to the PE class again.
Troy
Troy is a 21-year old working at a local hotel. One of his job duties includes watering all the outdoor and indoor plants. The goal of his employer is to get him to be independent in his work duties. Currently, Troy will water only one plant. He will water this same plant for about five minutes and skip the other 19 plants he's responsible for watering. After watering the one plant, he will set the watering can down and wait for further instruction from his employer. Troy is needing a lot of help to go from plant to plant.
Logan
Logan is an 11-year old boy that enjoys music, eating Cheerios, and being with his grandma. At both home and school, Logan always forgets to close the door when he uses the bathroom. After using the bathroom with the door open, he goes straight back to what he was doing before his bathroom break, without stopping to wash his hands. His grandmother would like him to start closing the door during bathroom breaks and wash his hands immediately after the bathroom.
Luke
Luke is a four-year-old who attends Toy Story Preschool. Luke enjoys playing with blocks and building towers with other classmates. During free playtime, Luke will run to other children in his class and shake them or pinch them on each arm. This causes the other children to cry and tell Mrs. Pumpkin that Luke hurt them. In response, Mrs. Pumpkin places Luke in time out for hurting his classmates.
What Should I Spend Time On?
What is interfering with the individual participating in daily routines? What can't they do that they need to be doing? The student I was with earlier today is having a huge problem participating in the general ed classroom activities whenever any kind of expectation is placed on him. It was not even just when he was given a worksheet -- anytime someone approached him with any kind of instruction, he would have a meltdown. What's interfering with his routine is that he doesn't know how to handle any kind of expectations. We're going to have to teach him that. We're going to have to change our expectations a little bit. We're going to have to make it a little clearer. We're going to have to put some more supports in place in order to teach him how to handle expectations. Because in the schools, as in life, there are expectations all the time. The school started to take the attitude of, "Let's pull him out of general ed. Let's reduce his day. Let's put him in the special ed class." Our response was, "Absolutely not. If we do that, we are reinforcing that behavior." Instead, we need to teach replacement skills. We need to teach him what he needs to do instead of letting those behaviors dictate what's happening.
What is keeping the family and child out of the community? I see so many families who are isolated. They have no village. They've exhausted their family members. They haven't been able to build a village for their child and their family. We have to go back to what is important to this family and what can we do to help them get back out in the community again? Is it the behaviors? Is it accessing environments? What is it that's keeping them out of the community, and how can we as therapists make that a priority in what we're doing with the plan? How can we help them with community access and help them build a bigger village for their children?
What is keeping the child away from friends? Why are they not able to play with peers their age? Especially for the younger children, they often don't have the play skills. They don't know how to play with things that their friends are playing with. We then have to look at teaching them play skills, so at least they are playing in the vicinity of children their age. They might not even start by interacting with them, but they're at least playing alongside them. In our preschool program, there is a huge emphasis on teaching them play skills. Many times, we get resistance, because a lot of children with autism don't like change. We have to employ task analysis and positive reinforcement to teach them to play with things that they wouldn't play with on their own. We've used art projects, Play-Doh, Legos and all kinds of things. Our thinking is that if they can at least play with those things, that increases the chances that they're going to be playing with peers.
What is keeping the child from being more independent? We have to look at what is holding them back. Thinking about Troy, our 21-year-old case study, why is he still relying on us for what he needs? What is it that's keeping him from doing things on his own? As a therapist, or as a consultant, how can we work on teaching the child the skills where our services are not needed anymore so that we can build their independence? We have to always be thinking about the long-term goal and doing it in such a way that the child will be more independent over time.
Critical Skill Deficits in Children with Autism
There are several skill deficits common in children with autism that can significantly impact behavior; deficits which may need to be addressed before you can work on more specific therapy goals. These deficits include:
Asking for and Taking a Break. Many times, we have to start off by just giving them a break, because they don't yet have the skills to ask for a break. They don't know when they're at a point that they need a break until it's too late. Not only do we have to teach them how to ask for a break, but also how to take a break. The 25-year-old gentleman that I work with doesn't know how to chill out and take a break. We've had to use reinforcers to teach him how to relax because he doesn't know how to slow down, let alone ask for a break.
- Asking for Help. Inability to ask for help relates to the individual's theory of mind. Theory of mind is the ability to attribute mental states (i.e., beliefs, intents, desires, pretending, knowledge, etc.) to oneself and others, and to understand that others have beliefs, desires, intentions, and perspectives that are different from one's own. Perception of other people's thoughts and feelings can be challenging for individuals with autism. That is why asking for help is difficult for them: in their mind, they think if they don't know the answers, no one else will know the answers either. I've also had children who feel that if they don't know the answers, and if they need to ask for help, that they are a failure. We have to work with them on being aware that everyone needs help sometimes. They need to know that there are a lot of different ways that a person might need help. Sometimes they may need help with the whole activity; sometimes, assistance may be needed for just one piece of the activity. We have to try and make them understand that it is not always black and white.
- Emotional Regulation. Children with autism have a difficult time monitoring their emotions. I have been on many consults with teachers who have commented that one of their students "goes from happy to having a meltdown in two seconds." That's because the child doesn't know those in between stages; they don't know what to do when they are escalating. We have to work on that emotional regulation, and on teaching children when to take a break, how to ask for a break. Think about a five-point scale, where a five is a child having a tantrum or going off the deep end, and a one is a very happy child. We need to enable these children to evaluate their situation and think about what they need to do when they are at a three or four so they don't get to a five. That ability to regulate emotion is extremely hard for some children.
- Initiating Interaction with Another Person.
- Transitioning. For individuals with autism, moving from one activity to another can be extremely difficult, as was the case for the young man I worked with today. Leaving an activity and transitioning to another -- even going from something that he didn't like to something that he liked -- was a struggle. We had to break down the transition for him, and we had to reinforce that transition. We have to think about that as a learning opportunity. Instead of simply avoiding transitioning, we had to think about teaching him how to transition. We needed to teach him how to go from something that he likes to something he doesn't like, and vice versa because school and life are full of transitions.
- Giving up a Preferred Item. Often, what I see happening is that an individual likes something (e.g., an iPad), but they don't know how to give it up. What happens then is teachers, parents, therapists will say, "We don't use the iPad anymore because he won't give it back to us." My response is that we need to teach him how to give up something that he likes. Because when we can do that, it gives us more leverage. We need leverage to teach them skills. We have to teach them how to give up a preferred item by breaking it up into small steps.
- Dealing with Losing. I have several children who don't know how to handle situations where they lose or when things don't go their way. I had to work with a young boy on this, and we had to break it down by starting with games that have a short duration. I couldn't begin with a long game like Monopoly for example, where you play for an hour or more; if the child lost after that long period of time, he would have been too emotionally wrapped up. We had to start with a card game called War, where each person gets one card and the highest card wins. I had to reinforce him for that because the world is full of situations where sometimes you're going to win and sometimes you're going to lose. You have to know how to deal with it.
- Occupying Time (Waiting and Down Time). The student I saw today transitioned very well into the room this morning. However, he went to his little area and there wasn't an activity there for him. He didn't know what he was supposed to do. All the other children were waiting until the next activity was going to happen. This child started roaming around the classroom. Before too long, his behavior had escalated, and he started getting in a little trouble because he didn't know what to do during downtime. He didn't know how to wait. We're going to have to teach him how to wait and how to occupy himself during downtime.
- Motor Skills. Do they know how to use their motor skills during PE? Do they know how to use their motor skills when they're out at recess, and how to play with others? Do they know how to do imitation?
Tools for Assessing Critical Skills
These are tools that you may be familiar with. They don't specifically pertain to physical therapy, but I think it's useful to know them. As I said earlier, these critical skill deficits might be the reason why you're not able to progress further in your physical therapy sessions.
Functional Communication Checklist (Figure 1). This checklist can be used to get an idea of the individual's communication skills. This can be completed by either the teacher or the parent. Even with higher functioning children, the majority of behavior occurs because they have trouble communicating their needs. Again, the boy I was with today is very high functioning, but he couldn't tell someone when he needed help; he couldn't tell someone when he needed a different activity. If we review this checklist, we can see where the child falls and what they need help with.
