Strings From the Heart

 

As a Speech-Language Pathologist and DIR/ Floortime professional specializing in children with autism spectrum disorders, I’m constantly searching for creative ways to “open windows” for the delightful children and families with whom I work. Many of these children with autism present unique differences in their sensory processing, in terms of hypo-responsiveness or hyper-responsiveness. I’ve found incorporating a wide variety of artistic experiences can be incredibly beneficial. It strengthens the sensory processing and communication of the children, while meeting them at their individual developmental levels and incorporating their preferences. The rich affectual, emotional components to art experiences are invaluable in bringing about that “light in their eyes,” engagement, and reciprocal communication.

Recently, I had the opportunity to be part of an “art” experience with one of my little ones that was life-changing and life-giving for many in Little Rock, Arkansas.

As a fundraiser for Autism Speaks and A-Camp (our camp for children with autism and their peers here in Little Rock), a local art gallery, M2 Gallery, hosted an art showing and auction. Brilliant artists from the state and country donated art for display and sale. The gallery owners also invited several of my young patients to create pieces.

As I thought of children on my caseload who had recently shown great responsiveness to art within our therapy sessions, my mind immediately went to 6-year-old Elijah. This precious young man had just begun enjoying expression with finger paint on huge strips of suspended paper. As he explored the sensations, engagement, delight, and a myriad of spontaneous, meaningful, reciprocal utterances emerged.

As I discussed what might be most representative of Elijah with his mother, she and I both thought of strings. For Elijah, strings of all shapes, sizes, and textures bring great joy, comfort, rhythmicity, and synchrony. We decided to let him express himself with strings on the canvas for sale. As he squeezed the first drops of paint on the canvas and pulled the strings through the paint to create his work of art, we held our breath, wondering what his feelings might be about altering many of his beloved strings. What delightful surprise it was to us all as he pulled string after string through the paint for 45 minutes, leaving many of them glued behind on the canvas. His mother and I named the piece “Strings from the Heart.”

What we thought might just be a minimal contribution to a very gracious fundraiser became Elijah’s fun “trip to fame” in the next several weeks. As publicity grew about the fundraiser for A-Camp, time and again the works of amazing artists were focused. Each time, Strings from the Heart was right there! Newscasters interviewed and conveyed the value of reaching children like Elijah with the emotion and sensory experiences of art.

No price could be placed on the joy and pride Elijah’s family members experienced. No doubt, his puzzle piece would’ve taken top price at the auction, but not a soul was willing to outbid his loving grandfather who stood beaming by the piece. What a great reminder it has been to me as a therapist to continually search for and incorporate whatever means might reach a child with autism and help him continually grow in a shared world of engagement and communication!

 

Rachel Morse, CCC-SLP, is an SLP in private practice in Little Rock, who has owned Building Bridges – Pediatric Therapy Services for over 25 years. She loves providing relationship-based, family-centered therapy for children with neurological differences. In the summers she also helps lead A-Camp, a 6-week therapeutic day camp for children with autism spectrum disorders.

Autism Awareness Month

As April- Autism Awareness Month- draws to a close, I wanted to share a presentation I made this weekend in Florida at NOVA Southeastern University, sponsored by the Florida DOE and the Center for Autism and Related Disabilities (CARD). The focus of the presentation was technology resources (web-based and iOS) that are dedicated to or can be “re-purposed” for use with the population of students with autism at various levels of functioning.  One goal of the presentation was to place technology resources in context of intervention programs helpful for this population. Along with Dr. Robin Parker and Dr. Marlene Sotelo, we also ran an informal “App Smackdown” in which participants shared apps that they have found helpful for students with autism.  The presentation is embedded below, and a link to a supporting weblist is here, and the apps shared during the smackdown here.  I hope you find it helpful!

(Google Reader and Email subscribers, please click through on the link to the post in order to see the presentation on the blog):

 

(This post originally appeared on SpeechTechie)

Sean J. Sweeney, M.S., M.Ed., CCC-SLP, an SLP, instructional technology specialist and consultant, works in private practice at The Ely Center in Newton, Massachusetts. He is the author of the blog SpeechTechie, a contributor to the ASHA Leader, and recently took on a role as Product Development Manager for Smarty Ears Apps.


The ABCs of ABA in the SLP World

Literacy Stations: ABC Order

Photo by Chrissy Johnson1

We speech-language therapists have a lot of acronyms in our little speechy world. We are SLPs (speech-language pathologists) who have our CCCs (Certificates of Clinical Competence) from ASHA (the American Speech-Language and Hearing Association). When I graduated with my M.S. (okay, you all know that one) in speech-language pathology, I was pretty sure I’d mastered the alphabet soup of our profession.

Until I fell in love with kids with autism, that is. That’s when I was introduced to the world of ABA. If you’ve loved a child with autism, you’ve no doubt run smack into this term, too, and probably very early along the journey you took. Despite the fact that this word swirls around the autism world with great furiosity, it is often misused and a bit misunderstood. Some people love it with a passion; others hate it with the same intensity. Me? I think it both extremely valuable and sometimes overused.

But I’m getting ahead of myself. My goal today is to begin to define the term for those who don’t know it well. Later, when I’ve laid the groundwork just a bit, we’ll delve into the true complexities that exist with what appears, at first glance, to be a very simple concept.

ABA stands for Applied Behavioral Analysis.  It’s based on the work of B.F. Skinner, a psychologist who focused on operant conditioning, or the study of observable behaviors and the events that cause and reinforce those behaviors. The applied part of ABA means that we take this system of looking at the way behaviors are shaped and apply it to everyday life; we use it to shape behaviors that are important to the lives we lead. When we peer at the world through the eyes of ABA, we find ourselves looking at three main things.

The Antecedent: What happened in the environment before the behavior occurred?

The Behavior: This part involves describing the overt behavior that you see or want to see. Not the motives, not the intent, not the feelings behind the behavior. Simply the behavior as you can observe it in front of you. Those who study and use the principles of ABA believe in describing the behavior as clearly and objectively as possible. For example, instead of saying “Sally got mad,” a behavior analyst would say “Sally screamed and hit the door with her fist.”

Consequence: What happens after the behavior? Does this thing that occurs after the behavior (the consequence) increase the chances the behavior will occur again, making it a reinforcement? Or does it decrease the chances the behavior will occur again, making it a punishment?

To help explain, let me share a couple examples.

Say you are teaching a child to say “cookie.” The steps behind teaching the word might go a little something like this:

Antecedent:  You hold up a cookie and say, “cookie”
Behavior: The child imitates “cookie”
Consequence: You give the child the cookie. (This would be positive reinforcement, assuming that giving the child the cookie increases the chances he will say the word again in the presence of the the cookie. Or, in plain English, assuming the child actually wants the cookie–although behavior analysts would probably shy away from describing it this way, as it reflects the child’s internal state, rather than his behavior).

Or, perhaps you are teaching your child to walk. 

Antecedent: You hold out your hands and say “come here!”
Behavior: Your child takes his first step toward you.
Consequence: You cheer and throw your child in the air as he giggles. (Again, this is only reinforcement if it actually increases the chances your child will take a step toward you the next time you hold out your hands and say, “come here!” It wouldn’t be a reinforcement if he hated being thrown in the air- in this case, it might decrease the chances that he’d come to you and would, then, become a  punishment*. Consequences are different for different people- the exact same action that is a reinforcement for one person can be a punishment for another).

These three things- the antecedent, behavior and consequence (Or ABCs of ABA, if you will…yes, another acronym), make up the core of ABA. Those who live in the world of ABA focus very carefully on the ABCs behind any and all behaviors. They graph and chart and study these elements of life and plan interactions around them.

ABA is much more complex than this, of course; I took four full graduate level classes about ABA when I completed my graduate certificate in Behavioral Intervention in Autism.  There are those that study ABA all their life and still don’t have all the answers, and there are entire, complex, and well-graphed treatments for autism that are based the concepts behind ABA.  It is not nearly as simple as I am making it at the moment. And yet, if you understand the ABCs behind ABA, you can begin to understand the world through the eyes of an applied behavior analyst.

How, then, does ABA fit into the world of SLP? As an experienced applied behavior analyst once told me, we all (parents, teachers, speech-therapists, all of us) use ABA in one form or another.  SLPs are no exception. We use the principles of ABA to teach children first words (Antecedent: “Say, Ball!” Child’s Behavior: “Ball!”  Consequence: Child is rolled the ball). We use ABA methods to teach children how to behave and understand language (Antecedent: “Sit down please.” Child’s behavior: sits down. Consequence: “Here’s your snack.”).  We call on ABA to help us figure why children behave in certain ways, so that we might help them find a better response and eliminate challenging behavior. For example, we might look at what comes just before a child hits another child (the antecedent), discover that it happens whenever another child obstructs the way, and then give the  child a new behavior (saying, “move please”) by teaching and reinforcing this new behavior.

So yes, we all use the concepts behind ABA, intuitively and frequently, to teach, motivate, and shape our children’s behaviors. And yet, controversy behind these methods exists. Why so? Because there are significant differences in how and when we apply these methods, in how stringently we define the behaviors we expect, in how we select and apply consequences, and in how strongly we believe that the ABA lens is the only one through which we can view the world.

That’s a post for a different day though.  For now, we’ll just be happy that we’ve learned our ABCs.

 (This post originally appeared on Child Talk)

 

Becca Jarzynski, M.S., CCC-SLP is a pediatric speech-language pathologist in Wisconsin. Her blog, Child Talk, can be found at www.talkingkids.org and on facebook at facebook.com/ChildTalk.

Thoughts on ‘Apps for Autism’

iPad on Tanmay's jeans


Photo by Chirantan Patnaik

First a disclaimer: I don’t work with patients with autism, in fact I haven’t done so since grad school, and even then I only worked with the population sparingly. iPads on the other hand, are awesome, and I use mine daily (much to my wife’s chagrin) for nearly everything (including this post) besides treatment (unless you count documentation, for which I use an iPod Touch), and that’s only because it doesn’t make much sense for my setting, not yet anyways (this is the point where I stop making parenthetical statements). But I am a speech pathologist and I do know a thing or two about communication, and that’s why I watched last Sunday’s 60 Minute segment, Apps for Autism, with much anticipation and excitement. I generally have respect for the show, but at the end, I just felt ‘meh’ about the whole piece. And let me tell you why.

When you watched the segment, did you notice the peeps with autism struggling and ultimately failing to use paper letter boards to communicate, which was immediately followed by the same person using the iPad exceptionally well to convey their message? This scenario was shown a few times throughout the piece and it felt like an As Seen On TV infomercial. Besides that, it completely ignored the decades worth of research and development that has been done in the field of Augmentative and Alternative Communication (AAC). It’s as if the Lightwriter, Dynavox, Prentke Romich, Tobii-along with a host of other companies-devices have never existed. That the idea of using technology to help people communicate is one that is original to the iPad. And that, of course, is rubbish.

It also seemed to prescribe the iPad as a panacea for autism treatment, you know, just give the kid an iPad and he’ll be on his way to communicating and that it’ll unlock an new and undiscovered portal into their minds that we never knew existed. Forget the fact that the successful use of AAC devices require training, especially for those with cognitive deficits, and forget that speech pathologists and special education teachers are needed to foster language development and literacy skills in order for the iPad to even be a viable option. A Twitter friend, @JohnduBois, said it right: “I felt it ignored the point that AAC is a tool and requires proficient users and teachers-too much “Apple magic”. Indeed sir, indeed.

And what was with that lady doing hand-over-hand assistance with the kid who had no apparent interest in the task? It was way too reminiscent of facilitated communication, and we evidence-based practitioners do no want to go there. Most likely, and hopefully, she was simply providing cues and trying to engage the kid in activity, but I cringe at even the slightest hint of FC.

For all of 60 Minute’s shortcomings, it must be said that the iPad is most definitely an inspiring piece of technology, and it is capable of capturing the attention of of children and adults alike with its boundless applications. But we need to be mindful that when teaching social skills to children, we teach them to use turn-taking skills, theory mind and what have you with people and not machines. If a child is captivated by the iPad and is able to direct their attention to something purposeful and meaningful, that’s great, but its all for naught if those skills do not generalize to the world at large.

The iPad is a wonderful and powerful tool, and has numerous applications for autism treatment, and the broader speech pathology and special education fields as well. But let’s place our focus on the end goal and not the bright and shiny gadgets that serve to facilitate such goals, lest we become victims of the latest fad and fail to view the iPad for what it is: a tool.

(This post originally appeared on slowdog)

 

Adam Slota M.A., CCC-SLP is a speech pathologist working in long term care and long term acute care settings, primarily with tracheostomy and ventilator dependent patients. He is also the author of the blog slowdog where he writes about various topics in speech pathology and beer, among other frisky and/or mundane missives.

 

 

Moving Therapy to the Gym: The Benefits of Gymnastics for Children with Autism

Rings for gymnastics(つり輪)


Photo by kawanet

The sport of gymnastics can provide children with Autism Spectrum Disorder (ASD) access to a differentiated approach, which potentially can create a model program to meet each child’s individual needs in a unique and effective manner. Gymnastics is a sport that provides an enriching environment filled with opportunities for sharpening the mind by stimulating the brain, fostering social skills, and strengthening gross and fine motor skills, while providing children with ASD an alternative method for learning and developing new skills.

Concentration or focus is required in each skill that is executed in the sport of gymnastics. Learning to focus in the gym can allow for increased attention to tasks outside of the sport of gymnastics. Children with ASD have the opportunity to develop the vestibular system and increase spatial awareness through various connections that the brain is building when performing routines on different apparatus that involve using various gymnastic skills.   The sport of gymnastics provides a highly structured and organized environment in which a child with ASD is able to learn at his/her own pace.  In addition to skills that initiate brain development, it is important to nurture and reinforce positive mental qualities.   Some of the ways that this can be performed is through modeling gymnastics elements, taking advantage of teachable moments, and providing positive reinforcement aligned with instruction.

As children with ASD continue to develop their social skills, they transition from home to school settings and other environments (e.g. gym) where they begin to experience a wide range of opportunities to communicate.   All of these interactions will have a substantial impact on the language and speech development of each child with ASD.  Interaction with other teammates and coaches allows for increased appropriate use of paralinguistic behaviors such as taking turns, listening and following directions, making verbal requests, and making eye contact with peers.

The sport of gymnastics provides a sensory-rich environment while simultaneously using physical exercise to develop fine and gross motor skills in children with ASD.  Gross motor skills (i.e. running, climbing, jumping) and fine motor skills (i.e. manipulating a hula hoop) are developed through gymnastics skills such as running and jumping on the springboard into the foam pit, climbing a rope, and other related activities.

Gymnastics also provides a learning environment for children with ASD by providing creative approaches for teaching each child new skills. Gymnastics instructors can organize and shape each learning opportunity to correlate with each child’s targeted learning goal(s) while allowing for additional exploratory time. In gymnastics, it is important to allow children time to feel comfortable with the skill before they attempt to execute it (i.e., one child may approach the end of the beam and jump cautiously, where another child may take quick steps with no hesitation when jumping).  Each child is provided with a tailor-made learning environment which allows the instructor to adapt and modify the program based on the child’s individual needs.

Gymnastics programs can potentially aid in providing a functional and invaluable learning environment for children with ASD.  Therefore, it is advantageous for parents and professionals to collaborate in defining, planning, and implementing participation in recreational activities (Potvin, Prelock & Snider, 2008).   Gymnastics gives children with ASD an opportunity to experience the joys of success through their individual achievements, or from the success of their teammates. Moving therapy to the gym could provide immeasurable opportunities for children with ASD, and promote generalization of learned skills to his/her natural environment.

References

Potvin, M.C., Prelock, P.A. & Snider, L. (2008).  Collaborating to support meaningful participation in recreational activities of children with autism spectrum disorder.  Topics in Language Disorders, 28(4), 365-374.  Retrieved from:  http://www.uvm.edu/~pprelock/articles/Potvin%20Prelock%20Snider%20Collab%20Support%20Recreational%20Activities%20Children%20ASD.pdf

 

 

Jourdan Saunders, M.S, CF-SLP, received her Master’s degree at Loyola University in Maryland. She is currently completing her Clinicial Fellowship year in the Miami Dade County Public School System in Florida.  She is the creator of the website, Futureslps.com and has a blog that is linked to her website.  She created the website to provide resources, inspiration and motivation for individuals who have chosen to major in the field of Speech Language Pathology.  Futureslps.com is directed towards students, but anyone can benefit from the resources provided on the site.  Jourdan has a gymnastics background of 23 years, she is looking forward to developing gymnastics programs for children with special needs.

Should You Buy an iPad Now?

(This post originally appeared on SpeechTechie)

Probably, yes.

We have all been witness to the flurry of blog posts, tweets, Facebook updates, and news stories on the potential of the iPad for teaching and learning. Though I was initially a bit delayed in drinking this particular flavor of Kool-aid, I am definitely a convert to this device’s portability, versatility, interactivity, and the instantaneous student engagement that results whenever it is pulled out (see Heidi Hanks’ post for a second on this, and Barbara Fernandes’ for a third). My one reservation is in the “versatility” area- the iPad still has its limitations with regards to producing work, especially written work, and though it contains a web browser, it cannot access many of the wonderful educational interactives out there that are Flash-based (and therefore should not be thought of as a replacement for a laptop). However, all that said, the iPad and the cornucopia of apps available for it have proved an essential addition to my therapeutic toolkit since I bought it last Fall (and keep in mind that I say that as a part-time SLP currently- if I had a more diverse caseload I think I would be even more enthusiastic about the iPad).

Why now? I have had a number of inquiries in the past months about the iPad, and my response has been that waiting for the arrival of iPad 2 would be wise. iPad 2 was just announced this week for release on March 11, and as expected it is faster, thinner, and equipped with dual cameras for FaceTime, PhotoBooth, and video creation. The pricing structure remains the same, with the 16G WiFi model (my recommended starting option as long as you know your district will let you put the device on their network- ask!!!) at $499. Now is also a good time to consider whether you would be happy with a first-generation iPad at a greatly reduced price, as many fanboys (probably me too) will be selling theirs and Apple is offering refurbished models for pretty cheap.

So, I’d say go for it. Before the buzz around iPad 3 starts (probably in 2012) and kills our buzz.

Check out this snippit from the video used at the iPad 2 announcement on Tues, featuring Howard Shane’s (of the Children’s Hospital, Boston- Communication Enhancement Center) thoughts on it being a “game-changer” for kids with autism). It actually made me a little verklempt.

Sean J. Sweeney, MS, MEd, CCC-SLP is a speech-language pathologist and instructional technology specialist working in the public school and in private practice at The Ely Center in Newton, Massachusetts. He has presented on the topic of technology integration in speech and language at the ASHA convention and is the author of the blog SpeechTechie: Looking at Technology Through a Language Lens.

Meeting the Extreme Makeover Challenge Part 2

This post is the second part of The Extreme Makeover Challenge Room Re-Design

Before and after images of student workstation

Link Visual Strategies To Support Expressive Communication with Alternative-Augmentative Communication ( AAC )

As consultants, we meet these extreme makeover challenges every day by assisting caregivers and professionals to physically re-structure living and learning environments, and by implementing and linking tailored visual strategies to support expressive communication with Alternative-Augmentative Communication ( AAC ).

We define AAC as the use of materials, techniques and equipment to compensate for expressive communication limitations individuals may exhibit, and to provide varied methods that allow for success in the communication process. AAC methods are tailored for individuals based on cognitive level, physical abilities, academic needs and communication settings, and include the following most common methods:

  • Speech Generating Devices (SGD)– SGDs are electronic equipment with speech output capabilities, that may be programmed,
    and offer the individual with increased communication opportunities. In Rising, we discuss various uses of SGDs such as in this device which allows children to communicate information between school and home. Other applications include communicating messages to answer questions, participate in academic lessons, offer social greetings, relay information, exchange thoughts, and interact with significant members in their lives at home, school, and in the community.\
  • Picture Exchange Communication System ( PECS )– PECS is an augmentative communication system designed to facilitate quick, effective, functional communication. It is a concrete visual-based program that encourages communication. Although speech emerges with some individuals and verbal speech is indirectly encouraged, PECS is not specifically designed to teach speech. Its primary objective is to establish an understanding about the purpose and method of communication exchanges, and to facilitate communication by providing the opportunity to relay messages through pictures. We have found a number of our students have been very successful communicating via PECS.S
  • Symbolic Language System–We define symbolic language systems as any method of communication that utilizes
    an action or material, assigns specific messages to it, and relies upon it consistently to relay meaning to the listener. A symbolic language system provides a consistent and easy-to-interpret method of relaying messages when a verbal message cannot be presented intelligibly. Pictures of items or places, labels of products, objects, gestures, and vocalizations are most commonly used to depict representations of desired messages. Rising illustrates many types of symbolic language systems to relay messages for many communication situations such as communication boards, eye gaze charts, and communication binders.

These are some of the elements required to meet the challenge of a successful re-design. We have observed children with autism, other PDDs, and AAC , achieve organization and success, improved behavior, social skills, and communication success when adults implement the strategies we’ve shared.

Carol L. Spears and Dr. Vicki L. Turner are Speech Language Pathologists, Assistive Technologists, and Alternative/Augmentative Communication Specialists. They utilize extensive professional experience, continuing education, and personal perspectives when working with students with autism and other pervasive developmental disorders to provide evidence based interventions. They are co-authors of the book, Rising to new heights of communication and learning for children autism. They are partners in the private consultation practice, Communication by Design Specialists, LLC (CoDeS). CoDeS, located in Northeast Ohio, provide caregivers and professionals with compassionate support and training in homes, educational institutions, and workshop settings. You can follow then on Twitter at @autismplus and find them on Facebook at Communication-by-Design-Specialists-LLC.

The Extreme Makeover Challenge Room Re-Design Part 1

As discussed in our book, Rising to New Heights of Communication and Learning for Children with Autism, we have observed that disruptive behaviors displayed by a child with autism or other PDDs may occur when they don’t know the answers to the following questions:

  • Where do I need to be?
  • What do I need to do?
  • How much do I need to do?
  • What comes next?

In our work, we have found that physically re-structuring the living and/or learning environment is a strategy which effectively increases the likelihood that appropriate behaviors will increase and inappropriate behaviors will dissipate – assuming the setting is designed effectively.

Whether at school or at home, a well-designed space has designated areas with defined borders for particular tasks. Materials are easily accessible, and the location where they are to be used is clearly identified. All individuals have their own workstations, desks, cubbies/lockers, or places informing where they are to be and what they are to do. By engineering the physical environment, parents, teachers, Speech Language Pathologists, and others may assist children with exceptional needs by enhancing their learning and functional experiences.

As discussed in Rising, when re-designing spaces for children with autism or other PDDs, visual supports are key because they provide information and tools allowing individuals to:

  • comprehend the instructions and communication of others.
  • understand and follow directions.
  • follow schedules, learn routines, negotiate transitions, accept changes.
  • support and improve a child’s receptive language, ultimately improving expressive language, learning, behavior problems, and social skills.
  • enhance involvement, participation, and socialization of individuals with autism, the tools may be equally successful for those with other diagnoses.
  • complete work independently and work or play appropriately during groups activities.

Whatever visual supports you use – objects, symbols, schedules, choice boards, social stories, or
task organizers – being able to see the support will increase comprehension, particularly when
auditory difficulties exist.

Before and after images of student workstation

Look for part 2, Meeting the Extreme Makeover Challenge, next week on ASHAsphere.

Carol L. Spears and Dr. Vicki L. Turner are Speech Language Pathologists, Assistive Technologists, and Alternative/Augmentative Communication Specialists. They utilize extensive professional experience, continuing education, and personal perspectives when working with students with autism and other pervasive developmental disorders to provide evidence based interventions. They are co-authors of the book, Rising to new heights of
communication and learning for children autism. They are partners in the private consultation practice, Communication by Design Specialists, LLC (CoDeS). CoDeS, located in Northeast Ohio, provide caregivers and professionals with compassionate support and training in homes, educational institutions, and workshop settings. You can follow then on Twitter at @autismplus and find them on Facebook at Communication-by-Design-Specialists-LLC.

Autism Spectrum Disorders…Labels, Categories, and Confusion: Part 2

Cartoon conversation about Aspergers

(This post and this photo originally appeared on www.ocslp.org)

In my last post, I introduced Gabriel and Vera, two young kiddos who both fall into the category of having “moderate-severe autism” but who are very different in terms of how their autism spectrum disorder is manifested. I wrote about the heterogeneity of autism, and stated that this “spectrum” of neurodevelopmental disorders is anything but clear-cut in terms of categories and labels, which makes it especially difficult for parents, professionals, and individuals to explain this condition to others and treat clinically.

To add to the confusion over categories and labels, the American Psychiatric Association (APA) has proposed changes to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which eliminate the terms “Aspergers’ Syndrome (AS)” and “Pervasive Developmental Disorder-NOS (PDD-NOS)” entirely from the diagnostic codes used by psychologists and medical practitioners. Individuals with a former diagnosis of these conditions would now be considered to demonstrate an Autistic Disorder (Autistic Spectrum Disorder). The specific criteria for an Autistic Disorder would include:

  1. Clinically significant, persistent deficits in social communication and interactions, as manifest by all of the following:
    • Marked deficits in nonverbal and verbal communication used for social interaction:
    • Lack of social reciprocity;
    • Failure to develop and maintain peer relationships appropriate to developmental level
  2. Restricted, repetitive patterns of behavior, interests, and activities, as manifested by at least TWO of the following:
    • Stereotyped motor or verbal behaviors, or unusual sensory behaviors
    • Excessive adherence to routines and ritualized patterns of behavior
    • Restricted, fixated interests
  3. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

These proposed changes have stirred up a whole lot of controversy. Folks applauding these changes argue that the current diagnostic categories, labels, and criteria do not necessarily describe the actual symptoms present in individuals with autism spectrum disorders, so that diagnosis is made in terms of overall severity or based on a single area of development, such as whether the individual demonstrated a language disorder early on. It’s suggested that by eliminating AS and PDD-NOS, as well as collapsing the two social and communication criteria into one (i.e., “Social communication”), diagnosis would be based on the presence and severity of symptoms, which would result in greater accuracy and ease in making a diagnosis. Some parents of higher functioning kiddos have even commented that the single “autistic disorder” category might make it easier to access services and resources that were formerly denied their children due to the less severe nature of their symptoms.

Opponents to these changes argue that collapsing these categories into one autistic disorder further masks the heterogeneity of autistic spectrum disorders. In addition, individuals with Aspergers’ Syndrome (some referring to themselves as “Aspies”) may take pride in their differences and of the fact that many brilliant individuals (Einstein, Isaac Newton, and Thomas Jefferson to name a few) are thought to have had AS. As a result, these folks may be reluctant to refer to themselves as “autistic” or include themselves in the same category with individuals who have significant functional impairments.

As an SLP who has worked in the schools, a single diagnostic category is not altogether foreign to me. Public schools have been using “autistic-like” as a category to qualify kiddos for special education services for some time. Further, the terms “autism spectrum” and “the spectrum” are commonly used to describe individuals at all levels of functioning and with a myriad of symptoms that stem from a neurodevelopmental disorder.

My concern is that the variegated nature of autistic spectrum disorders may be overlooked. Special educators may attest that many ”autism programs” are unsuccessful because individuals with autism spectrum disorders are so different from one another. The same can be said for clinical treament models. Autism intervention and programming seem destined to fail when they lack the flexibility to address the whole child with his or her unique pattern of strengths and weaknesses. But flexibile and individualized programming equates to greater costs, and there’s the rub, especially in states teetering toward bankruptcy.

There is no easy or even clear solution to the confusion surrounding this perplexing spectrum of disorders we call “autism,” but I do have a few thoughts and observations which might be helpful.

  1. The unique set of symptoms and special needs of kiddos with an autism spectrum disorder require the development of a PROFILE by a TEAM OF PROFESSIONALS, which clearly articulates the child’s STRENGTHS and WEAKNESSES in all DEVELOPMENT DOMAINS. This, of course, is what IEP teams are intended to do, but many times they fall short due to a myriad of financial or organizational issues. In particular, public schools often lack the personnel to manage the social and emotional difficulties that present in kiddos with autism spectrum disorders, especially those who are higher functioning.
  2. GOALS AND SERVICES that are BASED ON this PROFILE are far more likely to succeed than those based solely on the diagnosis of “autism.” This is that flexibility I was talking about earlier.
  3. the PARTICIPATION of ALL PROFESSIONALS working with a child with an autism spectrum disorder is critical to the successful planning and implementation of an IEP. For example, the input of an SLP is important throughout the entire IEP meeting because the kiddo’s communication needs are present throughout the day. Further, much of “behavior” is actually communication-related. On the other hand, I’ve found it extremely helpful and necessary to be present when the OT is going over sensory issues. I’ve had many successful sessions after implementing some sensory activities prior to starting speech/language tasks. In short, the child benefits when the whole IEP team is present throughout the entire meeting.
  4. Last, ON-GOING COMMUNICATION among all members of the team (including parents, of course) is a key component to flexible and effective treatment and programming. This seems obvious, but is so difficult to actually implement. Large class sizes and caseloads make regular correspondence an insurmountable task.

I wish I could say that I’m less confused about autism spectrum disorders after organizing my thoughts to write a couple of blog posts. I really do. I adore the kiddos I work with and feel so frustrated when I can’t do more to help them. But I can’t blame it entirely on the caseload size, available time, limited resources, or additional training I myself may require. Autism, the very nature of it, is like an insidious tangle of holiday lights. Just when you think that you’ve managed to loosen a knot, another tightens elsewhere. But here’s the thing…the light itself is beautiful no matter the knots. And sometimes just standing back and admiring it’s delicate mid-tangle glow gives you the energy and patience you need to resume your challenging task.

Web References:

APA DSM-V Proposed Changes

APA “Report of the DSM-V Neurodevelopmental Disorders Work Group”

National Public Radio ”Aspergers Officially Placed Inside Autistic Spectrum”

Debra L. Brunner, M.A., CCC-SLP works as a private speech-language pathologist in Orange County, California and a part-time clinician at The Prentice School, a non-profit day school for children with language learning differences. Ms. Brunner’s blog, as well as information regarding her private practice, can be found at www.ocslp.org.

Autism Spectrum Disorders…Labels, Categories, and Confusion: Part 1

Organizational bins

(This post and this photo originally appeared on www.ocslp.org)

Gabriel could be one of Raphael’s angels with his curly locks and sweet full-lipped smile. Sitting at his TEACCH station, Gabriel whizzes through his sorting task with otherworldly speed. His classmate Vera, on the other hand, throws her work on the floor in frustration and begins a perfect recitation of the opening narrative from “Beauty and the Beast” while twirling her long red hair around each finger on her right hand. This reciting and twirling will not end without a tantrum until the entire repertoire has been repeated exactly four times.

I often think about Gabriel and his sorting. There’s comfort in sorting a mess into convenient containers, whether that mess is an overturned drawer, an in-box spilling it’s contents onto a nearby file-cabinet, or a mental tornado of “to do” items whirling in one’s consciousness at 2:00 a.m.

Sorting implies categories which imply labels which are mental constructs of anything and everything “out there” and “in here.” Categories arise when there are too many labels to manage. It’s a whole lot easier to ask your kiddo to “fold the clothes” instead of listing each and every item in the laundry basket.

Let’s get back to Gabriel and Vera for a moment. Gabriel has not uttered a word since he was 19 months, even though he had babbled delightful syllables containing a variety of sounds as an infant and could even say “ma” “da” and “no” on his first birthday. Gabriel independently communicates his needs/wants using PECS. Vera is highly intelligible and started reading at 2 1/2 but does not use language to communicate her basic needs unless she is prompted. Gabriel has “moderate-severe autism.” So does Vera.

These are two kiddos who share the same category of “autistic spectrum disorder” and the same sub-category of “moderate-severe.” Gabriel is also considered “non-verbal,” while Vera is considered “verbal.” Both kiddos have “sensory integration dysfunction” (another category), but Gabriel is “sensory seeking” and Vera is “sensory avoiding.” Vera is considered to have “mental retardation” (I really hope this label soon lands in the great big dumpster of offensive words). Gabriel, on the other hand, WAS thought to have MR, but his IEP team isn’t so sure about that anymore. Both have “behaviors” that interfere with their adaptive functioning.

Are you confused? Overwhelmed even? Yeah, me too.

To bend your mind a bit further, consider that these two kiddos are not the most severe, nor are they “mildly autistic” or “high functioning.” What happens when we include labels such as “Aspergers Syndrome,” “Pervasive Developmental Disorder, NOS,” and “Non-Verbal Language Disorder” (which by the way is NOT an autistic spectrum disorder and does NOT mean that an individual is non-verbal)? Confusion, confusion, and more confusion.

And now the American Psychiatric Association (APA) is proposing to scrap several of these labels altogether in exchange for “Autistic Disorder/Autism Spectrum Disorder” in the DSM-5 (more on that in my next post).

It’s no wonder that individuals, parents, families, and professionals find understanding, explaining, and treating autism so difficult. This “spectrum” of neurodevelopmental disorders (more on this too in my next post) is anything BUT clear-cut and defies convenient labels and categories.

As the saying goes, “You’ve met one person with autism, you’ve met one person with autism.” After working with at least 100 kiddos with an autism spectrum disorder and knowing at least 100 more, I have to wholeheartedly agree with this.

Debra L. Brunner, M.A., CCC-SLP works as a private speech-language
pathologist in Orange County, California and a part-time clinician at The
Prentice School, a non-profit day school for children with language
learning differences. Ms. Brunner’s blog, as well as information
regarding her private practice, can be found at www.ocslp.org.