This current set of summaries begins with a survey of the views and experiences of a sample of parents and professionals, in the context of the emphasis upon mainstream inclusion, concerning the process of school admission and what makes for positive outcomes.
The next section refers to imitative abilities in children with ASD and the means of fostering such skills.
There follows a description of an initiative where alternative seating (therapy balls) was tried as a means of enhancing engagement, with positive outcomes reported.
The use of video interactive guidance with mothers and ASD children is described as a further means of achieving positive changes in attunement.
The final section draws implications from an interview with Temple Grandin concerning expectations, goals, and methods in ASD.
M.J.Connor February 2005
A survey completed through the use of focus groups by Waddington (2005) has investigated what factors are perceived as critical in the success or failure of inclusion of children with ASD according to parents or to professionals directly involved.
Waddington begins her report by referring to the political and philosophical background to this whole issue describing, firstly, the “Rights’ Agenda” (Gallagher 2001) which holds that inclusion should be assumed as an automatic entitlement and a human right in any half-decent society.
This is contrasted with that philosophy which looks to a more cautious form of inclusion such that individual needs are matched by the best available educational provision in whatever setting that is.
Meanwhile, the Code of Practice and the DfEE Programme of Action (1998) have asserted the right of pupils with special educational needs to be educated in mainstream schools wherever practicable, in accordance with parental wishes, and when appropriate support can be provided. This carries the implication that inclusion within mainstream will not necessarily be the most suitable arrangement for all children with SENs.
Current governmental targets fall short of total inclusion and one of the major issues is that of determining how best to provide for children with social, emotional, and behavioural difficulties including those identified with autistic spectrum disorders.
The debate seems to have reached the point where the principle of inclusion is generally accepted as a desirable aspiration but the current organisation of schools and existing pressures are such that the practice and available provisions to match the wide spectrum of needs may fall short of what is required.
Further, some critics argue that some children may always require highly specialist provision, and fear that the case for inclusion is a kind of crusade driven by ideology, translated too quickly and uncritically into practice. A compromise view has it that there is an ever-continuing need to determine for any given child where and how (s)he is likely to learn best.
Waddington’s study is based upon the observation that there has been little empirical evidence published about how best to provide inclusively for children with ASD, but also upon the commonly expressed view that a significant element will be located within the opinions and experiences of parents/carers and of professionals closely involved in the decision-making process.
Seven groups of parents (N=23) and LEA staff (N=20) were recruited from three LEAs in the South East of England, with each group organised by a trained moderator.
The discussions were taped and transcribed for content analysis in order that key themes could be identified and information categorised.
The first topic was that of who decided that the child was ready for inclusion within a mainstream school, and professionals and parents were in agreement that the parents had the major say in the decision.
A common view among a significant minority of parents was that the mainstream school was where the child should be and no other place should be considered. A small group of parents felt it was a joint decision; but the second most common response from parents was that they did not realise there was a problem and would not have thought of anything but a mainstream place. A further group held that there was no choice given the lack of alternatives to the mainstream place such that it may have been largely or wholly their decision, but a forced decision.
The following topic concerned the basis for the decision to go for a mainstream place, and there was a consensus among professionals and parents that the most important factor was the lack of alternative provision for the child. Reference was made by one professional to the apparent irreconcilability of an emphasis upon value for money with specialist provision.
The next most important factor also agreed by both groups was the observed capacity of the school to meet the needs of the child.
The parents also argued for the importance of facilitating the socialisation of the child and the taking into account of his/her academic levels, although these factors were not mentioned by the professionals who, instead, argued for the significance of the location of the school.
Positive influences upon inclusion were seen by parents to be largely concerned with LEA factors such as funding and access to training for the teaching staff. Professionals held that in-school factors such as a commitment to inclusion and to meeting the needs of the child, alongside good communication between school and parents, were the most important factors. Also agreed by both groups to be important were peer awareness of ASD needs and the nature of peer relationships; and the level of the child’s needs and disabilities and of social skills was seen to play a part in determining the extent of the success of inclusion.
Negative influences were perceived by around half of the parents to be related to the school’s or the individual teachers’ (limited) commitment and to the level of the specialist training completed. The professionals shared this view but also referred to the significance of overt behavioural problems in the children as an inhibitor to inclusion.
When it came to improvements, the shared view highlighted the need for a willingness to at least consider alternatives other than mainstream. Parents also made frequent reference to the need for more training, along with more resources and peer awareness-raising.
The professionals commonly argued for some means of determining the components of the most appropriate placement, and agreed with the implications concerning the availability of increased resources.
Parents and professionals were more divided when it came to discussing the perceived advantages of a mainstream place over a specialist place. Many parents believed that the main benefit was the enhancement of the child’s leading a normal life; professionals emphasised the importance of social skills alongside the benefits for normally-developing peers in terms of their awareness of diversity. Some parents felt that the advantages would vary according to individual child need and family circumstances.
When it came to the matter of help or information from the LEA, the majority of parents described having no help or information from the LEA; and what information had been available to a minority of parents was given at the time of diagnosis.
The parents showed considerable agreement in holding that advice, support, and information should all be available at the time of diagnosis; and professionals noted the importance of advice and information about arrangements for (inclusive) schooling at least two terms before admission. Reference was made by around a third of all respondents to the need for ongoing information.
The author recognises some weaknesses of this study associated with the small sample size and the possible lack of representativeness (and one would have liked some indication of the roles of the professionals who participated), but it is noted that two of the major outcomes - that parents see resources and teacher training as critical, and that professionals emphasise the commitment of the school staff and the sharing of information – are closely in accord with the findings of a previous study (Burack et al 1997) which examined attitudes towards inclusion.
Also in accordance with existing literature is the call by both parents and professionals for a more flexible inclusive movement since parents see themselves and are seen currently as under some pressure to place their child in a mainstream school.
The paper by Beadle-Brown (2004) starts with a description of the way in which, ever since Kanner’s initial description of autism, attempts have been continuing to identify the primary deficits which contribute to the observable behaviours (the triad of impairments).
One view (Rogers and Pennington 1991) held that an early deficit in imitation might be primary and provide a significant basis for the weaknesses in emotion-sharing and mind-reading. However, this view has been criticised in terms of uncertainty over the age at which the beginnings of imitation would be anticipated among children with autism, and the failure to take into account the possible range of outcomes when encouraging the child to imitate different types of action.
In particular, it has been held that actions with some symbolic significance are likely to produce different outcomes in the way of imitation compared to actions without any symbolic significance. There might also be effects from the level of complexity of the actions required and the amount of visual feedback available to the child.
In respect of the apparent consistency of the weaknesses in imitative skills in autism, a number of hypotheses have been proposed.
Baron-Cohen (1988) held that impairments in imitation, in common with other autistic deficits, area function of an inability to understand the perspective or mental state of other people.
An alternative hypothesis proposed by a number of authors (eg Ozonoff et al 1991) holds that weaknesses in imitation are a direct reflection of limited executive functioning, including poor planning or recognising sequences of events.
Some support has been found for the propositions that, if a symbolic deficit is the issue, the autistic individuals would have problems with meaningful rather than non-meaningful actions; and that executive function deficits would result in problems with sequential tasks. However, evidence has been inconsistent; and a further possibility is that the problem could be a matter of visual or visuo-motor weaknesses.
There remains also some question over the child’s performance when the task to be imitated involves pretence, the use of objects, the use of both hands rather than one hand, and symmetrical rather than asymmetrical actions.
As a preface to the current study, Beadle-Brown (op.cit) summarises existing data to the effect that individuals with autism did not have significantly greater problems than controls on a number of imitation tasks, although certain actions seemed a little more difficult for the autistic children compared to controls in the younger age groups.
The implication drawn was that imitation is impaired early in development and that there could be a general inhibition of various developmental processes as a result.
Her own study set out further to explore the nature of delay or deficit in autism, and how they relate to different types of action …. facial actions, manual actions, symbolic or non-symbolic actions, using objects, etc..
The participants included school-age children and adults with autism, and controls included pre-school and 5-6 year old normally-developing children, and children with mild to moderate learning difficulties attending specialist units in primary and secondary schools.
The outcomes discussed by the author indicated that there were only a small number of actions where the children with autism seemed to be delayed in their imitative skills, and it was argued that poor or partial imitation was a matter of the degree of accuracy rather than of an “absolute” deficit in imitation. However, some of the younger non-autistic children showed similar errors, as did some adults before self- correcting.
The types of task that did discriminate the autistic sample to some extent included those two-handed actions, symbolic actions with objects, and meaningful actions miming some familiar task such as brushing teeth.
The conclusion suggested a developmentally normal pattern of imitation with difficulties observed among the younger children, but only the very young children with autism performed significantly more poorly than the other groups.
In other words, the children with autism do not seem to be more impaired in imitation than in other skills, and the ability to imitate and greater accuracy of imitation emerge with age, perhaps more slowly than what is typical but largely consistent with mental age.
Meanwhile, the pattern of findings suggests support for the mind reading deficit as significant, but not for the executive function deficit.
What matters is the further evidence that children with autism can imitate, and encouraging the child to imitate, alongside imitating the child’s own actions, may be instrumental in increasing the child’s responsiveness and ability to engage in interaction.
It is recognised by Schilling and Schwartz (2004) that most interventions seeking to increase engagement and attention among children with ASD have followed traditional lines, but they hold that the very particular style of such children, including underlying sensory issues, have been insufficiently noted.
Sensory processing theories concerned with the brain’s handling of sensory input for the purpose of preparing for engagement in some action would suggest that normally-developing individuals have the ability to modulate sensory information as necessary in adapting to the setting and demands of the situation.
However, there is converging evidence (eg Dunn 2001) that children with ASD respond differently to sensory stimuli. Efforts to regulate the input may include perseverative behaviours or stereotyped responses; and there may, anyway, be processing deficits which inhibit attention or social engagement and interactions.
The implication is that modulation of arousal is a necessary precursor to optimal engagement, attention, and learning; and the authors have been exploring the use of therapy balls for seating with young children with ASD as a means of maintaining a good level of arousal.
The “dynamic” nature of the therapy ball gives the child the opportunity to move around and to maintain a positive level of arousal (and, therefore, of attention) while also maintaining a good and safe posture.
Existing evidence reviewed by the current authors is acknowledged to be anecdotal but there are consistent claims for not just good posture but also for improvements in the quality and span of attention and of school performance. The children are described as less likely to become bored and being able to focus better; noise is reduced, and those children who appear to need to move around can do so without disturbing peers so that the whole class is calmer.
The current study was organised to extend existing experience by examining the use of therapy balls for seating as a specific intervention for children with a diagnosis of ASD.
Four children were the participants, ranging in age from 3-11 to 4-2, each with a formal diagnosis of ASD and selected on the basis of preschool staff’s reports of poor attention and problems with any activity requiring in-seat behaviour.
Baseline measures were taken as a means of determining any effects on behaviour from the use of therapy balls fitted to the child to ensure comfortable and secure seating. The focus of the measures was upon engagement, defined as orientation to the appropriate activity and materials, plus interaction with those materials, while responding to the teacher, and sharing eye contact with the teacher, as required. Measures of oppositional behaviour were also made.
The outcomes reported included
“substantial” improvements in in-seat behaviour and engagement in all four
children when seated on therapy balls (whenever in-seat behaviour was required)
over a period of 2 weeks. Both the boys
themselves and their teachers expressed a consistent preference for the use of
therapy balls over any other form of seating for the children.
The benefits were demonstrable across varying ability levels, and, even if there were individual differences in the way the children responded (notably in the degree of movement) to the therapy balls, there was a consistent improvement in engagement.
Teachers’ reports referred to improved and more compliant behaviours.
The authors acknowledged that, despite the empirical data available from this study, there needs to be caution about seeking to generalise results. A longer term period of investigation is required, and a wider sample of participants given the range of levels and types of need among children all identified as having ASD. This might provide pointers about which children are likely to gain most benefits from the use of therapy balls …. and it is acknowledged that no single intervention has yet been identified as appropriate for all children with ASD.
Nevertheless, the conclusion suggested that the use of therapy balls can be an effective intervention for improving in-seat behaviour and engagement even if it is not possible to specify why the benefits are achievable, and if it is also remembered that the use of this kind of seating is one strategy to use alongside and not instead of other strategies.
McMillan (2005) describes video interactive guidance as a means of establishing more accurate attunement within interactions. The goal is that of helping individuals
(usually a teacher or parent/carer) to gain greater awareness of what aspects of their actions are most associated with positive responses in a given child.
The intervention involves video-recording of interactions which can, with editing as required, be played back to the parents or teachers to observe for themselves the handling style or stimuli most likely to gain adaptive responses, and to establish “ contact principles ”.
The use of VIG has been adopted to improve attunement between two children with ASD and their mothers in McMillan’s study.
The reported outcomes included positive changes in the children’s behaviours following the identification of the contact principles in terms both of the quality and the extent of interaction, with both mothers describing themselves as more able to “tune in” to their child.
McMillan holds that the benefits gained may be at least partially a function of the collaborative system rather than external prescription in that the parents themselves are determining the effective actions on the basis of their own observations of what appears to be working.
An interview with Temple Grandin (Medscape 2005) who was diagnosed with autism as a young child, and who achieved academic success despite the difficulties, has highlighted or reinforced a number of issues.
Firstly, in discussing the use of a child’s fixations instead of seeking to stamp them out, Grandin’s insight has suggested that fixations or obsessions can be great sources of motivation. High achievement might even be dependent upon a significant degree of fixation.
The underlying principle could be described as that of accommodating, at least to some extent, to the individual style of the child or adult with autism, and not demanding that the accommodation should be wholly in the other direction whereby the autistic is expected to fit to more “typical” behavioural styles and expectations.
The example is given of those people who make scientific breakthroughs as a result of persisting with or fixating upon some specific and narrow area of interest, when that persistent and fixated style might have been seen as maladaptive and undesirable at a younger age.
Similarly, there is some question whether social conformity is an appropriate goal given that social difficulty is a core characteristic of autism, and when the better target is that of developing the practical and functional skills that the child does have.
While it may be legitimate directly to teach “survival” social skills (such as not telling people they are stupid !) common work tasks and goals and methods, as well as shared interests and skills, could ultimately provide the means of increasing social interaction.
Further, Grandin stresses the need to examine the reasons underlying what appears to be non-compliant behaviour. There is a need for a kind of functional assessment by which to determine what the behaviour is seeking to achieve. It may well prove to be linked to the source of anxiety or stress when the child lacks the communicative skills by which to express his or her feelings, or even to a situation when stress is felt but the child does not realise the source.
There is a further reminder of the concept of a spectrum disorder such that one needs to assess/observe any given individual in order to determine his or her profile of skills and weaknesses and to set down legitimate targets. The ASD label indicates the likely and general nature of the difficulties, but not their precise form or level.
Improved communication, by whatever medium, is seen as a major goal for children with autism …. or, at least. greater skill among parents, carers, or teachers in interpreting the child’s communicative attempts. Grandin holds that the inability to communicate is a major frustration in itself, and there can be a critical handicap in terms of enabling other people to appreciate what (s)he finds distressing (such as a sensory sensitivity which leads to stressful experiences in noisy settings or where there are flickering fluorescent lights).
A linking theme is that of anxiety. The individual with ASD experiences anxiety in a range of situations which might not be recognised by typically-developing others as a potential source of stress.
The associated principle is that of seeking to see things from the point of view of the person with ASD, to anticipate what could be stressful, and to recognise the significance of even minor changes of routine.
Grandin’s final point is a plea to avoid advice to the effect that a child validly diagnosed with autism will grow out of the condition. The symptoms may moderate, and family members, teachers, and colleagues may gain experience in reducing sources of stress alongside capitalising on the individual’s strengths and interests, but the underlying autism will remain.
* * * * * *
Baron-Cohen S. 1988 Social and pragmatic deficits in autism : cognitive or affective ? British Journal of Developmental Psychology 5 139-148
Beadle-Brown J. 2004 Elicited imitation in children and adults with autism. Journal of Applied Research in Intellectual Disabilities 17 37-48
Burack J., Root R., and Zigler E. 1997 Inclusive education for students with autism. In Cohen D. and Volkmar F. (Eds) Handbook of Autism and Developmental Disorders. Chichester : Wiley
Dunn W. 2001 The sensations of everyday life. American Journal of Occupational Therapy 55 608-620
Medscape (Medscape Psychiatry and Mental Health) 10(1) 2005 Autism first-hand : an expert interview with Temple Grandin. 3rd. February 2005
McMillan A. 2005 The use of video interactive guidance to increase the attunement between children on the autistic spectrum and their mothers. Proceedings of The British Psychological Society : February 2005 13(1) p 5
Ozonoff S., Pennington B., and Rogers S. 1991 Executive function deficits in high-functioning autistic individuals relative to theory of mind. Journal of Child Psychology and Psychiatry 32 1081-1105
Rogers S. and Pennington B. 1991 A theoretical approach to the deficits in infantile autism. Development and Psychopathology 3 137-162
Schilling D. and Schwartz 2004 Alternative seating for young children with autistic spectrum disorder. Journal of Autism and Developmental Disorders 34(4) 423-432
Waddington E. 2005 Perceptions of parents and LEA officers of the factors affecting the success of inclusion of pupils with ASD. Unpublished research report : Department of Psychology, University of Wales (Swansea)
© Mike Connor 2005.
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