On the AER listserve, several folks requested assistance regarding writing appropriate (e.g., measurable) IEP goals in the area of social skills for children with visual impairments who also presented with Aspergers Syndrome. As many of you know, Aspergers Syndrome and other autistic spectrum disorders have a cluster of behaviors that define them diagnostically, all of which interact and contribute to what we see in children and adults. What follows is my effort to provide some direction to Brandi as well as "food for thought" (e.g., broader perspective, going beyond the observable behaviors to suggest some underlying causes) to parents and professionals in a timely (though incomplete) fashion. It is based on my training and clinical experience with children and adults who fall within the autistic spectrum disorder, with children with visual impairments, and now with the dually diagnosed.
Terese Pawletko, Ph.D.
Licensed Psychologist (former vision teacher)
You're not alone in your questions/concerns re: children who are VI and within the autistic spectrum. Several other TVIs and a parent emailed me directly about diagnostic issues, strategies for social skills, etc. I have to ask you to bear with my long response - I've opted to review some of the diagnostic features since not everyone on this listserve may be familiar with them; I'm also "long winded" because not seeing your student, not being able to ask questions, review records, etc. makes it more difficult.
You mentioned that your student is a 7th grader, who has some vision (in the legally blind range). That is very helpful to know because, as you so aptly pointed out, vision is not your student's main problem - rather, her communication and social impairment is likely to drive her program (and that is where input from an LD teacher or speech/language pathologist or autism specialist may be helpful) with her visual impairment being taken into account and vision used maximally. You (and she) have an advantage here as most programs for children who fall within the autistic spectrum rely very heavily on visual supports (e.g., picture systems; visual structure and organization). With the students I have been involved with who are autistic and visually impaired, they will use any vision that they have given the auditory/language world can be pretty unreliable for them.
Re: her diagnosis not being 'official' as your student's doctor did not feel comfortable diagnosing her as a child with Asperger's syndrome given she has a visual impairment - this is not the first time I've encountered this either - caution is good as one runs the risk of over diagnosis (e.g., we've heard comments like "he flaps his hands when he's excited, it is something autistic children do, therefore he must be autistic"), yet being overly cautious may result in under-diagnosis and lead to inappropriate interventions. Autistic spectrum disorders are a CLUSTER of symptoms that involve impairments in language/communication and social relatedness; results in restricted interests, and need for sameness, not defined by the appearance of just one behavior (e.g., stereotypies).
Children with Aspergers specifically have the following areas of deficit:
- Social interaction (poor social skills, inability to read social cues, inability to take the perspective of another, shift attention, maintain topic in conversation, etc.); have most difficulty in less structured settings; difficulty recognizing relevant from irrelevant information.
Communication (both verbal and non-verbal). Their own body language and facial expressions can be odd or stiff; they have difficulty reading the body language of others, so would not pick up cues such as 'boredom'. Spoken language is often not entirely understood (so kept simple and concrete). Their own language can be pedantic (e.g., uncharacteristic for a child that age), used inflexibly (e.g., use phrases they've memorized); have unusual qualities (e.g., too loud, too soft, variable inflection); they may have word retrieval and sequencing and organizational deficits; difficulty maintaining or shifting topics (e.g., they may know a lot on their interest, but almost nothing on topics of interest to peers, nor on a topic under discussion in a lecture - esp. given the rapid rate at which spoken oral language moves). Often because they are so verbal, people assume that their understanding (and visual/spatial, organizational, motor skills) are at the same level - not so. The intersection of these two areas of deficit results in the children with Asperger's talking "at" rather than "to" you, giving information rather that holding proper, give-and-take conversations. The youngster you describe as "seeking attention" from the teacher may, in fact, be filling time that the teacher has given as "time to start homework" (unstructured time being difficult for children within the spectrum) or as her way of participating in class (since she cannot keep up with the rate of discussion, knows she is to participate, but it is on her terms/her topic - not in an effort to be difficult, but given egocentricity, and difficulty accessing/keeping up with a topic under someone else's control, it is what one may see). If she is to participate in a class "discussion" it may be important to have the question asked be factual vs. abstract (since these children are literal), and even take the form of a multiple choice to help jump start her. For instance, a young man, I'll call Scott, LOVES to talk about history and politics (and that was before the election). He is in a Health class and they are discussing something about athletes and cardiac fitness. He loves being part of a class, interacting, but is not able to just jump in (and under these circumstances if he did it sure wouldn't be about fitness, though he is a runner). The teacher's job here, knowing Scott has his hand up and is likely to be off topic, is to help Scott join the discussion by giving him a multiple choice - "Scott, let me ask you - if you were trying to maintain good fitness, would you choose running, swimming, or skiing?" Then, the teacher could guide him from there. It provides him with the necessary information and facilitates the shift. Now, why did I go through this? It is hard to know why your student is "off topic" - likely it is dependent on the situation (e.g., time of day, level of abstractness, level of anxiety, level of or lack of structure - all of which require different fixes/interventions). So, in answer to your question re: "what IEP goals should I write?" -- that depends on the reason your student is engaging in the behavior, it will likely require that the staff tailor the class time to meet her needs for increased structure - then in the IEP, you and the other staff would be looking at your student's ability to implement/follow the strategies after a period of instruction, implementation within the various settings, etc., etc., etc.). One other thing - somewhere in your email you mentioned that you are only there at the end of the day, with your primary responsibility being help with homework. Friday being the social skills session - thus, you were not there to prompt her. It is a good thing that you're not there to prompt her, because she would then she would only do it when prompted, likely only prompted "by you." You are not there 24 hours a day. You see, all the staff need to be on the "same page" in working with her.Now I am going to say something heretical. She needs social skills work. But, it sounds to me like you are all still in the assessment phase of this (informal assessment/observation). So you may not be ready to define goals and objectives. Does that mean it cannot be worked on? No, but I could come up with LOTS of goals/suggestions, but totally miss the mark and not have the goals tailored appropriately to your situation. I'm not trying to be difficult - just cautious - and encouraging your IEP team to work with your district autism specialist because your student's is not driving these behaviors and confusions. Let me elaborate - you wrote: "I can think of plenty to work on, but I am not there all day to observe her and prompt her, take data, etc. – She asks questions that are irrelevant in class - I want to decrease this behavior, but I am not there with her in her classes to take data and work on this." The "WHY" she is asking questions irrelevant in class could be because:
- the material is too abstract or being presented too rapidly, therefore she has no idea what is being asked/is in a world of her own and wants an answer to whatever is currently her topic of focus;
- she is distressed and may know the answer, but one coping strategy that she may be using is to "ground herself in the familiar" (e.g., her topic; for lower functioning children you may see stereotypies or other fixations pop up);
- she wants to participate in the social interaction and the only way she knows how to "join in" is on her topic (and it may be used for every social interaction);
- she wants to interact (and middle school has little free time, and social interactions are challenging for children who are "intact") and the classroom is the only time that the noise levels and other sensory stimuli are under relative control, and thus she is "settled" and her egocentric view says "other folks are asking and answering questions" and she is not apt to see the difference and no one has defined/structured in/built in a time for me to do this - this is as good a time as any" and so on and so on.
- Narrow interests and preoccupation
- Repetitive routines and/or rituals, inflexibility (which contributes to difficulties shifting attention, leads to an individual doing the same activity the same way, or demanding that the same person be present when he/she is doing that activity. They may have strong rote memory but learn without understanding (and don't necessarily understand what they can repeat in toto). And trying to reason with them/provide rationales may prove ineffective (because of the difficulties with language, the fact that this demands the ability to take the perspective of another, etc.). As noted above I think the thing that is deceiving with children with Asperger's is that they are assumed to have higher overall ability (e.g., expected to handle visual/spatial, organizational, mathematical/sequencing /time management tasks, social situations at a level commensurate with their verbal skills) because of their verbal facility. Yet Scott, the history and political buff (almost professorial in demeanor) routinely lost money, his books, coats (pretty much everything he put down). Thus frustrating staff because "he should know better" (this was before I gave him the diagnosis of Aspergers). He is very, very learning disabled in the visual/perceptual/motor, language, and social areas (hallmark features of Aspergers). What saved him? The adults in his environment took charge of developing individualized organizational tools, tangible schedules, and anticipating all the breaking points/glitches before turning them over to him.
So, where should you begin? In light of these features (any/all of which could be things she has difficulty with...see the partial report that I attached at the end - Note: I do not expect that you'll do this level of detail, but it gives you a sense of the scope of the learning problems that can be encountered in this population)
- Pick one area of ADLs. Think about where she is experiencing "breakdown." Look for ways to implement stable organizations and routines - even using a checklist that is posted.
Request an assessment of her social/communication skills (if it hasn't been done already), as she has impairments in both, above and beyond what we would expect given her visual impairment. The results will guide where the whole staff should focus (since it needs to be across the board, not once a day outside the setting where she needs to apply the skills and structures). The team then has the opportunity to develop "within situation structures" in conjunction with her teachers. For instance: I had a young man who was autistic and mild-MR (not visually impaired) who loved to talk about his topics. He would engage ANYONE on them in any location. He also did not understand when/how social interactions ended or what the appropriate level of intimacy was for a given situation (e.g., might ask very personal questions of or hug a complete stranger); and each one has different defining features - e.g., leaving the library, going to the barber, to a party. I am ever amazed at the complexity of the social world and the level of detail/concreteness that these individuals need in light of their literalness and inflexibility given brain function. With this young man, we had scripts/rules for each situation that were reviewed with him before going to the situation. He had a copy to read in the car. He reviewed it before getting out of the car. He had a list guiding him back to the car, and what he was to do when he arrived
e.g., library - "just one more book" would be his request, but there is always "one more book". So we wrote a sequence of events, including "10 minute warning, then 5 minute warning
- if not pick book at 5 minute mark, no more chances until the next time visit;
- if tantrummed, would have to remain at the group home when the group went the next time because he did not follow the rules"
- e.g., library - "just one more book" would be his request, but there is always "one more book". So we wrote a sequence of events, including "10 minute warning, then 5 minute warning
Folks need to structure the day and even provide structure/guidelines for "unstructured time." With your student, perhaps she needs a defined "personal talk time" (where if class has 5 minutes left, she can ask the teacher 1 question of topic of interest to her at the teacher's desk). Left to her own devices, she'll do what she thinks is OK. Unstructured time (or less structured), social, or free time can be 'lethal' for children within the autistic spectrum. It can be anxiety provoking in some cases, at which point one may see children engage in stereotypies (e.g. repetitive monologues or questions that they already know the answer to). The TEACCH staff have a great phrase: "Work is play, and play is work for children within the autistic spectrum disorder."
You asked for sample recommendations. I pulled some snippets from an evaluation I did (shorthanded it here as it was 12 pages) on Scott (17 year old at the time) in which I gave him the diagnosis of Asperger's. He had been diagnosed as ADHD, OCD, Organic Brain Syndrome, LD in reading and written language, etc. etc. etc. - about 10 labels, some of which no longer exist. As he had all the characteristics, I want to illustrate some of what is beneath the surface with these students, as well as, share recommendations for one student.
"Scott is a deceivingly complex young man with a tremendous scatter of skills and abilities. On first encounter, Scott appears extremely verbal, conversing quite passionately and articulately about difficult subjects (e.g., political history) not typically of interest to adolescents. He is socially interested and attentive to personal details, remembering many specifics over long periods of time. Yet, his ability to deal with abstract concepts, or keep track of the money he just had in his hand or the book he took out of his backpack in an effort to locate something at the bottom of it. Scott is polite and empathic and yet can be brusque and at times rude to those people who are trying to help him, intolerant of peers who do not follow prescribed daily routines (e.g., tooth brushing); and have extreme reactions to events that many would let slide (e.g., staff being a few minutes late for a lesson). He wants friends, but can become overwhelmed and frustrated by the social situations.
Scott's social and learning behaviors are the result of the "goodness of fit" between his skills and abilities and the expectations and demands of the environment. When he is "not performing as one would expect" it is easy to assume "he isn't working hard enough," or "he needs more practice or to learn problem solving skills" or "more time in the setting," "it's just his attention deficit disorder". This is far from the case. He is trying to do his best, wants to succeed and be "like the other students," wants to please the adult, etc. but without the adults in his environment taking his deficits into account, there is little chance for success, and high probability of anxiety, agitation, and anger (Scott's and the adult's).
While not defining features of Asperger's, other features warrant a comment as they impact on his ability to process information:
Scott has a documented visual impairment (as well as visual-perceptual-motor deficits) which results in limitations in distance vision as well as depth perception, figure ground, picking out essential details (visual-perceptual-motor tasks), etc. However, many other sensory systems are involved in daily functioning. Scott has hypersensitive hearing - hearing many extraneous environmental sounds (e.g., phone ringing, hum of a fan; NYC noise) and easily overhears conversations of others, both of which can be intrusive and compete for his attention. Note, that in the case of his overhearing conversations, it is not that he is "being nosey," but that he cannot adequately screen out these noises. The result is that Scott cannot focus on what he has to attend to (e.g., directions given orally, doing tasks that require much concentration). Scott's tactile and olfactory systems do not seem to be affected.
As noted above, Scott is a very pleasant and cooperative young man. But for those familiar with him, he can also present as a very anxious young man. This is suggested by his rocking back and forth, either seated or standing; his picking at or posturing his fingers, facial expressions (e.g., gritting his teeth), and his tone of voice (also present when he becomes angry or agitated).
To those working with Scott, his emotional reactions to situations can be extreme. Why? One does not see the drip by drip' filling of his stressor bucket; nor have the history re: how he packages events and interactions with individuals and how these are then used by him to predict what will happen in the upcoming encounter. For instance, when the family was going to Buffalo for the holidays, Scott become somewhat obsessed at the prospect of visiting a particular relative. When I spoke to Mrs. Pullman she expressed surprise as it had been years since they had seen that individual; however, it turned out that this individual had picked on Scott. Because of his rigid, concrete, and somewhat packaged' view of the world every trip to Buffalo could cause these images and worries to resurface.
Scott has a great deal of difficulty coping with change. This is true for major changes and minor changes. Important to keep in mind with Scott is the fact that what we perceive as an inconvenience (e.g., construction on the Pullman back porch), may be seen as a major change and significant stressor for him, completely disrupting and redefining the world as he sees it (e.g., has to change his route and routine, shift the definition of porch,' can't problem solve or use self-talk spontaneously to settle himself). This level of distress results from several factors (e.g., slow processing time; difficulties shifting sets and accommodating related to the way his brain is wired;' inability to determine the correct sequence/adjustment to make in his day (can't even sequence changing fishbowl water). It is not that he does not want to do something, he is overwhelmed/has been derailed.
Scott is a very social young man, who politely greets everyone he encounters. He is very well liked by staff. Of concern, however, is his circumscribed understanding of social relationships lumping almost all relationships into the common category of "best friends." To his credit, Scott always leads in with a statement like "I don't know if you care to discuss this, but" While some may perceive it as endearing, it is clear that he needs rules and concrete supports and teaching as he could be at risk for abuse and being taken advantage of by strangers.
By report, Scott has a history of problems with peer interactions and the social skills necessary to initiate and sustain them. When one stops to think about it, this is not surprising as social interactions and relationships are fairly complex. For instance, one needs to know how to join a group interaction (e.g., pay attention to what peers are discussing, whether there is an opening and way to share in/be curious about the discussion or activity, read non-verbal cues re: acceptance, be flexible, take turns, be interested in the interests of others); appropriate verbal (e.g., flexibility in topic) and non-verbal behaviors (e.g., using an appropriate tone of voice, not rocking). Furthermore, his circumscribed interests (e.g., history, politics) are not ones most adolescents follow. Scott does participate successfully in the adult structured group activities (e.g., track, chorus, games night)
SUMMARY AND RECOMMENDATIONS
Asperger's is not a disease, but rather descriptive in nature and defined by a cluster of behaviors that is multi-determined rather than resulting from a single etiology. It shares some things in common with autism (e.g., cerebellar involvement, rigidity, circumscribed interests), but also has some significant differences (e.g., some average abilities in the verbal domain, socially interested, visual-perceptual-motor deficits).
Scott is delightful, earnest in his desire to do his best and please himself and others, as well as to learn new skills and participate in the planning and carry-through of his program and learning. He is also teaching us where he has problems:
- no problems with enthusiasm, cooperation
- does better with simple, concrete, specific language rather than long and/or abstract utterances
- deficits re: knowing how to execute things, problem solving, sequencing, applying the correct strategy at the right time and evaluating whether it is working; following a schedule (can recite it, but moving about - other things to distract him); motor planning problems; no time or money concepts; functioning "up in space;" weaknesses in math (e.g., number, time, amount, time management, money), visual-perceptual motor skills, reading and word recognition, efficient scanning, recognizing what the key features are, what to do when something goes awry
- complicate it by the fact that he has to move within and across environments and you've essentially lost him
In light of the results of this evaluation, the following recommendations and considerations are offered.
ACROSS SETTING CONSIDERATIONS:
- Use Scott's strengths and interests to develop his program
- Keep in mind that he is going to rely on adults to build in organizational strategies - left to his own devices, Scott will have difficulty identifying where to begin and end a task; how to organize it; how to recognize when he is having trouble and needs to get help
- Scott does better when the skills are developed in the context in which they will be used (or when he is applying already acquired skills to a new context).
- Staff need to realize that just because Scott can demonstrate a skill in one environment, with one set of structures and be successful, does not mean that either he can apply those skills to another setting or another activity. This will need to be taken into account and taught/structured into new environments.
- As with all visually handicapped children, one must assume that without deliberate teaching and demonstration that Scott will not know what the key features of an activity (or picture, or context) are, will not pick up concepts/information incidentally, etc.
- Scott needs all adults in his environment to have the same script, use the same terminology, with the same directions, teach and reinforce the same skills in the same fashion.
- Scott's current functioning in the area of daily living skills need to be examined and priorities developed such that we maximize his opportunities to learn these with the appropriate structures.
Scott does better if things are stable, attached, are left in a consistent place for use in that place, and do not require transporting:
- wallet, ID card, etc. to be placed on a ring that is then placed on a chain and attached via semi-permanent means to the inside of his fanny pack
- have him leave notebooks/folders with important instructions in a specific place
- use photos and/or templates on the actual surfaces to help Scott know where to place things
- consider using "Tri-wall" cutouts to maintain organization of Scott's desk, dresser surface, etc.
- recognize that once Scott is "up in space" (e.g., moving around the room, room to room, across the campus) any number of things can happen - he is unable to perform the skill demonstrated consistently while sitting or standing in one place; may forget where he is going and/or what he is to do; may stop to talk and/or set something down and lose track of it; may lose orientation, sequence, track of time, etc. etc. etc.
- Consider developing stable activity sequences (e.g., object or picture sequence that remains Velcroed in the laundry room so that Scott can do his laundry; a sequence for changing his fishbowl water) - these will be important to develop in consultation with appropriate service providers, test out with Scott, etc.
Questions staff should ask when considering an activity:
- What specific activity am asking him to do in this environment?
- Have I conducted a thorough task analysis?
- What are the skills demanded in this activity?
- Does Scott consistently and independently perform the skills in a familiar setting?
- Does the task require any movement place to place?
- Does the task require any reading? Motor skills? Sequencing? Math? Etc.
- Have I had him do a dry run of the activity in a familiar setting? With any difficulties noted during the dry run, did I seek the input of other service providers/consultants (e.g., O.T., speech)? Does the activity need modifications (e.g., increased structure, decrease length of directions, a jig to remind Scott of the steps, materials stabilized)?
- Have I introduced him to the new setting prior to having him work/apply those skills?
- If a system or structure works it should remain in place - Scott gets some success, wants to try it on his own' figuring he's got the skills, but does not understand that the success is the result of his consistently using the structure. Scott can get overconfident and stops using the strategy (e.g., giving money to staff member) and is back to "the old ways." It may be very helpful to outline the specific goal with Scott (e.g., keeping track of his money), define the supports (e.g., wallet attached to fanny pack, check written to dorm staff, withdraw money' on as needed basis, keep bills flat in wallet, loose change in ___, etc.) and to have all parties concerned sign the contract, the frequency with which his progress will be reviewed (nightly checks of wallet, if criteria reached fade to spot checks, etc.), and the only conditions under which it will change (e.g., Scott has reached criteria and maintained behavior for ___ period of time, may fade to spot checks at least ___ per week, etc.).
- In new situations, Scott may do better if the number of choices he has is pared down. Also, if one really wants to know what Scott is interested in, how he feels about something, etc. use an inventory or some structured list to make the inquiries rather than asking open ended questions such as "what do you like to do for work?" Open ended questions make heavy demands on word retrieval, organization, memory, etc. as well as assume a student knows all the possibilities available, etc.
- If Scott is to get adult assistance, for instance, because he has a problem with computer and he did not comply it would be easy to get mad and yet, in some ways it was not totally his fault - why? He needs deliberate training on help-seeking' and following through on directions that involve moving to another space in the room and/or across settings. Being "up in space" and having to make executive decisions is hard for children with Asperger's and other neuropsychological difficulties. Scott even needs practice following directions that require that he go to an adult' to get help if he needs it; stop what he does before making another move. This needs to be done using deliberate practice and having the adult in close proximity, gradually moving further away from him with his repeated success at the current distance. A picture or large word cue saying "get dad" on the computer and over the shut off switch may also serve as a reminder. Make sure he has lots of practice doing it in your presence first...then gradually increase the distance (and do periodic booster sessions)
- Scott has been evaluated a number of times over the years and many recommendations offered. They should not be used without evaluating them in light of the findings of the current evaluation. For instance, in the past it was suggested that Scott be provided with a tape recorded copy of any book as well as being expected to "take notes via tape recorder." These are very complex skills - there are the listening skills demands (e.g., being able to hold in memory a significant amount of material, know how to pick out the key information, know what to do with the key information and how it relates to prior knowledge, etc.); the how to access the medium' (e.g., finding the correct tape, knowing how to operate the tape recorder but more importantly the set up of the books on tape - finding the correct page, recognizing whether you're on the right one, stopping the machine in time, etc.); then there are the organizational demands (e.g., bringing the right tape with you, keeping track of the recorder, keeping track of the tapes, having the recorder charged), etc. etc. etc. As anyone working with Scott can see, this is an overwhelming task and is not going to be one he'll benefit from using. Any suggestion/recommendation/ change in strategy needs to be examined in light of his skills and deficits; then tried in a familiar setting, debugged, and structured for maximum success and independence; put into place with close supervision, spot checks to maintain it, etc. prior to assigning it to Scott independently.
Organization of clothes:
- Within dresser - use slat dividers for drawers - consider an enlarged word label at the bottom of and/or on the outside of the drawer to help him know where to find things (would need to decide whether one would also want to use the outside of the drawer to keep track of how many' through a Velcro/picture system - might be better given it is at the site vs. on a board across the room).
- Have set laundry routine with object/picture sequence defined (recognize that it is more likely to be followed to its entirety if not competing with a preferred activity or started early enough in the evening to succeed).
- Identify a way to keep track of the clothes he has and where the breakdown is (e.g., are things not getting out of the dryer? Is he leaving any at the pool? Are any in his locker? What is he packing to take home and what is returning?) One strategy might be to have a visual inventory' of all the clothes that he brings in with him (almost like a Velcro paper doll clothing system). Staff would have to help him use it, debug it, etc. For instance, Scott starts the year with four polo shirts (so in picture representation, Velcro on back, 4 are on the inventory board'). He wears one, moves the shirt into the laundry basket' when it is dirty. He does laundry and as he removes the dried laundry from the basket, puts each pictured garment' back up. If he took two polo shirts home, the picture representation would be moved into the suitcase' and if they returned on Sunday with him, go back onto the inventory board. Yes, it would take adult monitoring, but be part of the sequence.
- Develop an afternoon/evening schedule for the dorm using pictures to examine if that helps him sequence the evening, remember to do things that do not- staff will have to role play it with Scott
- Scott needs to have his wallet firmly secured/attached to the inside of his fanny pack. The Pullmans may want to consider writing a check to the primary dorm person who would cash it and have a bank account' for Scott. Prior to his going to bed, Scott could withdraw' from the bank' what, if any money, he would need for the next day. Staff would observe Scott putting it immediately into his wallet, fanny pack securely shut before he walks off. He is not to borrow from staff or classmates. All staff should be given the script of Scott's money handling program as it is developed; data can be collected, with spot checks re: whether all is accounted for, whether it is in clothes, flat in his wallet or folded and stuffed wherever, etc. After this is successful for at least 3 months, then look where to add independence. Should periodic spot checks reveal that Scott has started slipping' re: the money handling program, then the program would be reinstated.
Books on Tape:
- The IEP team discussed a program whereby Scott can order books on tape, but they would come to the classroom teacher. Since several books often arrive at one time the teacher would record what was received and give Scott the option of whichever book he wanted to take and listen to. It would be Scott's responsibility to listen to the book on tape, rewind all the tapes when completed, and return it to the teacher in rewound condition at which point he could be issued another book on tape. No more than two books on tape should be in his possession at any time.
- Scott will benefit from specific work in the area of social skills. This is better done in a social rules format' and maybe a skill of the month/skill of the week' that many could reinforce if alerted to what he is concentrating on. Making sure that all adults have copies of the rules that he is being taught to use, the script used to cue him, etc. A brief assessment of his baseline social skills using a criterion referenced type checklist available in many social skills curricula would be helpful.
- We need to go beyond the verbal, explaining mode with him and be very specific. Saying he has problems with boundaries is not enough. Boundaries are defined by: appropriateness of physical distance, physical contact, topics of conversation that are within and off limits, etc. Define what is OK and not OK for him to do.
- Recognize that social situations, particularly with peers, are difficult and have not been successful in the past. Adults will have to identify what Scott is comfortable with as well as what within that setting or social interaction works; and what/where things are difficult (e.g., YMCA, church youth group). Scott likes computer games - is that a place to begin? Would having someone over for a Star Trek marathon and sharing pizza or other snack food be a starting point (e.g., low social interaction demand, shared time)?
- Before taking Scott into new social situations, be sure to provide him with information about the setting, the types of behavior that is acceptable, what he can do if he gets distressed, rehearsals/dry runs re: skills he may have to use.
- Scott takes the feedback well, and often responds with an apology, but would also benefit from social rules that all involved with him reinforce ('rule of the month').
- Consider using situations that are difficult for Scott, develop a script, repeated chances to practice before having to implement the skill in public, etc. The Orientation and Mobility staff of MSB has done a wonderful job using this approach with Scott and has even identified ways to help keep track of the materials used.
- Help Scott learn (in vivo) that there are different levels of relationships and skills and behaviors associated with them.
- Recognize that Scott can become overwhelmed by any change (and experience them with the same level of distress be it a staff member was minutes late for an appointment, the fact that someone mentions placement change' which we can defer thinking about but he cannot, to the loss of a loved one). Try to alert him in advance of changes in his schedule.
- Minimize the number of transitions (within and across settings) that Scott has.
- Scott does not like surprises' - when meetings will involve hot topics (or an outing or trip may be stressful either because of lack of prior experience or because of past associations or experiences) it helps to do a preliminary meeting with him to review what will be discussed so he has ample time to process, can get his initial questions addressed in private (without having multiple adults and other sensory distractions interfere). Similarly, outlining what to expect on a trip or outing, identify ways to cope, etc. is helpful. If available, a videotape will concretize what he might expect.
- Should Scott be "surprised" by something or very distressed as indicated by his agitated state or limited ability to focus, find out what has upset him and tell him you can answer one question now and the rest he can get answered at _____ today (or whenever). Even if he feels he has "too many questions and not enough time" when asked to pick his "top three" only 1-2 may come up and he regains his composure, is relieved and is now free to attend to instruction. Additionally, adults can help him restructure his day and get back 'on track.'
- Recognize that Scott bases future encounters with the same setting or person on his past experiences, successes, stressors, etc.
- Discuss with Dr. B whether it is worth a trial of an anti-anxiety medication (much will depend on whether or not Scott is experiencing seizures at this time)
- This recommendation cuts across ALL domains: When trying to motivate Scott to participate in something that is hard for him, use his peak interests and apply them in realistic situations. Children are more likely to attempt, understand and retain skills if they are attached/integrated into key interests. Scott loves star trek, horseback riding, history, etc.
- Scott would benefit from developing coping skills as well as having staff address a situation that derails him. For instance, on a number of occasions during the testing and between sessions, he appeared at my door upset about something. Asking about his 'top most concern,' addressing it and helping him restructure his day was all that was needed. For more recurrent issues consider using social stories that are developed/written specifically for Scott (see Social Stories book by Carol Gray).
- Keep it simple, keep it specific, keep it short - give directions within his memory capacities, pause to allow him to process the information.
- Avoid open ended questions.
- Consider using advanced organizers' so he can anticipate what the class, book on tape, etc. will be about and gear his listening/attention accordingly (e.g., "there are three important.;" "this chapter is about___ and the four reasons why").
- Encourage Scott's using the talking calculator so he gets auditory feedback
- Encourage his using the Reading Edge and other technologies that are reinforcing, help him access his information in both meaningful and independent ways, and are built into his schedule/are prompted by his schedule. Why build them in if he knows how to use them? Folks with executive functioning deficits do not know when to apply what they know, how to apply them to a new situation, what parts to apply, etc.
- Keep environmental distractions to a minimum
- Role play (e.g., phone skills, greetings)
- Letter writing and functional life skills - how to address what he needs to function in community? Scott can read his own writing and short passages: what is reasonable to expect of him? How will the team accommodate to the fact that he cannot read well?
- Examine what computer programs he can use most effectively to access email, access the Web; how he can write letters (e.g., voice recognition?), etc. Recognize that while he may know the programs, he needs staff to deliberately put them into his routine, provide structures that enable him to use them when and where he needs to use them.
- Preferential seating, away from distractions
- Access to the Reading Edge if given free time in class
- Alternative projects (roving reporter')
- Use his interests to work on his skills
- Use advanced organizers, simplify language, allow time for Scott to process
- Begin with skills that you already knows he hasor in settings that you already know he is familiar with
- Unless absolutely necessary do not have Scott transport things he does not need to transport - If he is not using books, can they be left in the classroom vs. his locker?
- Test out whether Scott can benefit/learn skills/increase understanding through the use of videotapes? From parent report, he was able to glean a lot from a nature program on a national park, moreso than actually being at the park. Why? It was viewed in the safety of a familiar environment, provided key information in a multimedia format, no reading/writing required; the park - new environment, not an interest of Scott's (like history is), hard to pick out what the attend to (given visual handicap as well as visual perceptual motor and organizational demands)
Examine the goodness of fit between the demands of an activity and Scott's skills (e.g., vocabulary, things learned via videotape program format; stationary, simple one to two step repetitive non-verbal activities which do not his moving across a room/across settings) and deficits (e.g., problems sequencing, knowing where to begin and end; right/left confusion; number/time/amount; no ability to independently organize his space or activity; problem solving; motor planning; auditory distractibility). This is accomplished by doing a thorough assessment of the skills required and demands of the task (conduct thorough task analysis) and the setting; then structuring the activity so that it is foolproof and that Scott already has the skills or can be taught the skills within a familiar setting before applying them to a new environment, then re-evaluating and restructuring as needed. Using the current work situation - it is not that he's had enough time at Blockbuster and that is why things are going better, but rather that instead of him multi-tasking, moving around the store (visually and spatially confusing even for the non-learning disabled; and auditorally distracting with videos running) he is stationary and doing repetitive/one or two step tasks (e.g., labels on, in the same spot, and put tape in box).
Below are some sample resources (not exhaustive by any means, mostly focused on Asperger's vs. autism)
http://www.tsbvi.edu - If you go to the multi-handicapped section you can access handouts we used at our AER talks in June, 2000.
http://www.unc.edu/depts/teacch/teacch.htm - There is a tremendous amount of information on the TEACCH website “ the Aspergers' specific material is listed below. In addition, you might want to look at the Yale Child Development website as Ami Klin and Fred Volkmar have some downloadable handouts as well. TEACCH's downloadable related information is listed below.
- Recommendations For Students with High Functioning Autism by Kerry Hogan
- Tips For Teaching High Functioning People With Autism by Susan Moreno and Carol O'Neal
- Understanding the Student With Asperger's Syndrome: Guidelines for Teachers by Karen Williams
http://www.udel.edu/bkirby/asperger/index.html - another good source for information on Aspergers
http://www.asperger.org/ - good articles; current conference listings
Sample Reading List:
Gray, C. Social Stories. note: there are several volumes available.
Smith-Myles, B. & Simpson, R.L. (1998). Asperger Syndrome: A Guide for Educators and Parents