Transcript TEACCH - LADSE

Social Implications for
Students with Autism
Spectrum Disorders
Presented by
Marrea Winnega, Ph.D.
Licensed Clinical Psychologist
Consultant on Autism Spectrum Disorders
February 22, 2011
Why are people with Autism or
Asperger’s Disorder different?
• Brain is wired differently
• Object area of brain is more developed than
people area
• Not wired to be social
How?
• Genetic/starts in utero before born
• Likely to be a genetic/environment interaction
• NOT caused by bad parenting
2
Different Perspectives
Wicked
The 3 Pigs from the Wolf’s perspective
Slumdog Millionaire
Breakfast Club, Grease, High School Musical,
etc.
3
Different points of view
Car accidents
Sister has Columbus Day off
– She works 2 half days per week
– Should she get the day off?
Perspective of vacation – secretaries vs.
educational staff
Asking, “How are you?”
4
Evidence-based Interventions
Use the National Standards as your guide
Note: The results support behavioral
interventions – because that is where the
research is
National Standards
www.nationalautismcenter.org
The National Autism Center is a nonprofit
organization dedicated to supporting
effective, evidence-based treatment
approaches for Autism Spectrum Disorders
(ASD) and to providing direction to families,
practitioners, organizations, policy-makers,
and funders.
6
Treatment Divisions
• 11 “Established” Treatments: treatments
that produce beneficial outcomes and are
known to be effective for individuals on the
autism spectrum. The overwhelming
majority of these interventions were
developed in the behavioral literature (e.g.,
applied behavior analysis, behavioral
psychology, and positive behavior support).
7
Treatment Divisions
• 22 “Emerging” Treatments: treatments that
have some evidence of effectiveness, but
not enough for us to be confident that they
are truly effective. Need more research
• 5 “Unestablished” Treatments: treatments
for which there is no sound evidence of
effectiveness. There is no way to rule out
the possibility these treatments are
ineffective or harmful.
8
Examples of Methods
Communication – Speech production; Picture
Exchange Communication System; Sign
Language; Assistive Technology (All 3 are
Emerging Treatments) – therefore find the one
the student prefers
Social Stories/Social Skills/Peer training (All
Established)
– Circle of Friends and Integrated Play Groups
Joint Attention/Self-management – Established
Pragmatic Language - Emerging
9
Methods
Relationship Development Intervention/Floor
Time or DIR (home based vs. school based) –
both are Emerging
Music Therapy – Emerging
Exercise – Emerging
Sensory Integration is Unestablished
10
Autism Spectrum Disorders
• Also known as the Pervasive Developmental
Disorders
• Under this umbrella are:
– Autistic Disorder
– Asperger’s Disorder
– Pervasive Developmental Disorder Not Otherwise
Specified
• Girls fly under the radar
Educationally: All of these
fall under Autism
Autism Defies Generalization
Aloof
Active but
Odd
Severe
Gifted
Social
Interaction
Measured
IQ
Non-Verbal
Highly Verbal
Communication
Gross
Awkward
Agile
Motor Skills
Fine
Uncoordinated
Coordinated
Sensory
Hyposensitive
Hypersensitive
12
The Iceberg:
Understanding Autism
Behavior - Tip
Below the water line:
Reciprocal Social Interactions
Communication and Play
Restricted Repetitive Behaviors/
Need for Sameness
Sensory Processing
Learning Style
www.teacch.com
13
Impairments in Reciprocal Social
Interactions
• Marked impairment in the use of multiple
nonverbal behaviors to regulate social
interactions
– Eye contact, gestures, facial expressions (social
smile/range), body posture; joint attention
• Failure to develop peer relationships
appropriate to developmental level
– Response; interest; imaginative play; group play;
Age 10 and over – friendships
Impairments in Reciprocal Social
Interactions
• Marked impairment in spontaneous seeking to
share enjoyment, interests or achievements
– Showing/directing attention; offering to share;
sharing one’s enjoyment
• Lack of social or emotional reciprocity
– Comfort; inappropriate facial expressions; quality
of social response and overtures; socially
awkward; social perspective taking
Impairments in Communication
• Delay or lack of development of spoken
language
• Marked impairment in ability to initiate or
sustain a conversation
• Stereotyped or repetitive use of language
• Lack of varied, spontaneous make-believe play
or social imitative play
Note: Impact of
Communication Impairments
• Sequencing information
– Difficulties retelling a story
• Describing routine events
– Brushing teeth, washing hands
• Describing nonroutine events
– A trip to Great America or a recent vacation
Restricted, Repetitive Behaviors
• Encompassing preoccupations
– Circumscribed interests
• Nonfunctional routines and rituals
• Preoccupation with parts of objects
• Repetitive motor mannerisms
Theory of Mind Deficits
• Inability to perceive feelings and thoughts
of others
• Insensitivity to other people's feelings
• Do not appear embarrassed
• Inability to read intentions of others
• Inability to read listener's level of interest in
one's speech
• Not knowing what the listener needs to
know
Theory of Mind
An Aspie Perspective
Jean-Paul Bovee
• All communication takes two people.
• We have our own things that embarrass us.
• Odd or repetitive behaviors, etc. have a
reason for existing.
• “There is not a shared understanding of
how the world works.”
• There are not shared beliefs.
A Reinterpretation of
Theory of Mind
• We have our own perspective.
• Not every person thinks alike.
• It is not the fault of the individual with ASD
– both parties have a problem.
• “We are people and we are different.”
Perspective Taking
From Social Skills Solutions
• Level 1:
Labels emotions in pictures, other people, on
self; looks for and finds hidden objects
• Level 2:
Cause for emotions; respects personal space
• Level 3:
Interprets body language; identifies nice vs.
mean vs. teasing
Who knows what?
From Carol Gray
First page:
My name is _______. Sometimes, I like to think about
_______, _______, or _______. I think about other
things, too.
Second page:
(My mom, dad, grandparent, teacher, sibling, friend)
thinks, too.
S/he sometimes likes to think about _______,
_______, or ________. S/he thinks about other
things, too.
Illustrate each page.
Think about:
• A lack of social understanding is not
misbehavior
• A lack of social understanding makes students
on the autism spectrum vulnerable to being
set up by peers
Social Pitfalls
• Not socially aware – varies from nonverbal to
verbal students
• Social misperceptions
– “They are laughing at ME!”
• Not knowing social norms or the “hidden
curriculum”
– How to act in different social situations
– Which way do you stand when you ride an
elevator? Why?
• Not knowing what is “cool”
Laughing
(Social Story)
People like to laugh.
The kids and teachers in my class laugh a lot.
Sometimes I don’t know why they are laughing.
I will try to stay calm and ask them why they are
laughing.
Then I can laugh, too.
Social Pitfalls
• Asking inappropriate questions
– Why do you color your hair?
• Making inappropriate comments
– It smells in here!
• Speaking their minds or not knowing about
little white lies
– You smell…well, then, your cologne smells.
• Teasing and Bullying
• Fabricating stories
Socially
Inappropriate Comments
• “Your idea is crap.”
– Tell soccer coaches and other players what
they are doing wrong (days later told a student
he was awesome at the game).
• I am the smartest
– Yet cannot tolerate getting a math problem
wrong and throws a tantrum if does
– Knows peers will not do this when they get one
wrong
Story of Matt
• Identified with Asperger’s about 3 years
ago; now a 4th grader
• Very verbal and bright
• Excellent gross motor skills and good at
soccer
• Very competitive
• Swears on the soccer field – only one who
does
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Processing
Real
Drama
• I’m not (might not)
play this.
• I’m never going to play
soccer again
• This is a big
disappointment
• I suck at soccer
• I hope I get to play
next year
• It’s my mom’s fault I’m
not playing soccer
Difficulty Disclosing
Child brought legos home from school:
T: Did you take something home?
C: Is that bright green or yellow?
T: Tell me something. Did you take something
home?
C: Yes (showed legos)
T: Cannot take without asking. What happens
if adults take something?
C: Call Police. And so this color is bright green
or yellow.
Discussion
Do these points make sense? Do you agree?
• A lack of social understanding is not
misbehavior
• A lack of social understanding makes
students on the autism spectrum
vulnerable to being set up by peers
The Iceberg:
Understanding Autism
Behavior - Tip
Below the water line:
Reciprocal Social Interactions
Communication and Play
Restricted Repetitive Behaviors/
Need for Sameness
Sensory Processing
Learning Style
www.teacch.com
33
Does not follow
classroom directions
Below the water line:
Does not process language in groups or
subtleties of language
Social – does not know that she
is part of “everyone”
Possible interventions:
Teach that she is included in group directions
Ask indirectly
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Thinks everyone
is laughing at him
Below the water line:
Limited social reciprocity/Limited understanding
of the perceptions of others
Limited peer relationships
Possible interventions:
Teach concept of humor and different ideas that
students think are funny (e.g. slapstick vs.
puns vs. play on words
35
Social Misperceptions
Below the water line:
Lack of social reciprocity
Limited peer relationships
Poor communication skills
Possible interventions:
Teach other perspectives on the situation; teach
purposeful behavior vs. accidents (being
bumped into)
36
Argumentative Student
Below the water line:
Lack of social emotional reciprocity
esp. social perspective
Need for sameness (certain pair of shoes)
Concrete/logical
Possible interventions: Don’t argue – once starts, we
have lost; pause and think about student’s
request and how to modify your request; ask
indirect questions (could you take your seat
please?)
37
Will not do homework at home
Below the water line:
Lack of social emotional reciprocity – bound to
rules; concrete thinker: “Homework is school
work. I do it at school. I have other work to do at
home.”
At school, socially overwhelmed/senses are
overwhelmed – exhausted when arrives home
Possible interventions:
Complete during day/study halls
Shorten assignments
Also give frequent movement breaks or breaks from
sensory and social input.
38
Manipulative*
Below the water line:
Lack of social emotional reciprocity
Does not understand instructions
Poor expressive communication skills
(has concerns)
Possible interventions:
Help express concerns and problem solve
*True manipulation takes forethought and
planning (team going to 31 Flavors vs. Dairy
Queen)
39
Disruptive Student –
too talkative vs. makes sounds
Below the water line:
Lack of social emotional reciprocity
Poor expressive communication skills
Lack of awareness of social situations
Possible interventions:
If blurts out or interrupts: Teach when can talk;
use Social Stories to understand this
If makes sounds, try to teach when can make
sounds; give alternatives such as lollipops
40
Will not do what you want him/her to do
when you want
Below the water line:
More interested in what s/he wants to do
May not understand first this then that
Does not understand what you want
him/her to do
Does not know when it will end
Interventions:
Build additional motivation into the task;
Clarify how much work (perhaps visually)
41
Aggressive – hits, slaps
Below the water line:
Lack of social emotional reciprocity
Limited social skills
Poor expressive communication skills
Functions: Escape, attention, tangible
Possible interventions:
What is the cause of the aggression? When is
it occurring?
Teach to ask for a break
Give student frequent motor breaks
42
Visuals for Understanding
•
•
•
•
•
•
•
•
Sit
Walk
Quiet
Work
Stand up
Clean up
Classroom rules
Stop/Think/Make a Choice
Problem Behavior/Speech Issues
and using visuals
• Visuals* can be distracting (power struggles)
• Requests are key
• Write a sentence and have student read = “Use
your words”:
I want a Reese’s cup
• Lack of spontaneous speech:
– Expand the sentence: write “May I have a cookie?”
*Objects, photographs, Boardmaker drawings,
written words, etc.
State/Teach the
Behavior You Want
• Do directions > don’t do/no’s
• Tell your student what you want him/her to
do:
– Sit down
– Walk with me
– Open the door
– Hold the door
– Hands on knees
– Hands on desk/table
45
Social Thinking
Michelle Garcia Winner
www.socialthinking.com
• Social Thinking is required before social
skills; aka Social Cognition
• “Successful social thinkers consider the
points of view, emotions, thoughts, beliefs,
prior knowledge and intentions of others
(this is often called perspective-taking considering the perspectives of others).”
46
Social Thinking –
Core Philosophies
1. We “think with our eyes” to figure out other people’s
thoughts, intentions, emotions, plans, etc.
2. Our thoughts and emotions are strongly connected.
How we think affects how we feel, how we behave
affects how others think and feel.
3. We think about people all the time, even when we
have no plans to interact with them. We adjust our
own behavior based on what we think the people
around us are thinking. (This is how we drive our
cars!).
47
Social Thinking –
Core Philosophies
4. As part of our humanity, each of us is on a daily quest
to avoid each other’s “weird thoughts.” We … adjust
our behavior to help people have “normal thoughts
about us.”
5. Most of the core social thinking lessons operate
BELOW the level of cultures, meaning that all people
engage in these thoughts and social behavioral
adjustments.
6. How we adapt our behavior changes as we age and
are in different situations and cultures. The nuance
and sophistication of our behaviors is constantly
evolving.
48
Social Thinking –
Core Philosophies
7. Social thinking is something all of us do every day, all
day, even when we are alone in our homes. To
understand a TV drama/sitcom/novel one has to think
about the character’s emotions, thoughts, reactions.
8. Social thinking, therefore, plays into our academic
world, requiring us to think about the motives and
intentions of people we read about in literature and
history.
9. Social thinking affects us in adulthood. To hold a job,
most of us have to adapt our own social behavior
based on the perceived thoughts of the people we
work and live with.
49
Social Thinking Interventions
• Four Steps of Perspective Taking
• Four Steps of Communication
• I LAUGH
50
Four Steps of
Perspective Taking
Imagine you are in an elevator:
Step One: When you come into my space, I have a little
thought about you and you have a little thought about me.
Step Two: I wonder “why are you near me?,” “what is your
purpose for being near me?” “Is it because you are just
sharing the space, do you intend to talk to me or do you
intend to harm me?” I have to consider all these things in
order to keep me safe around people as well as to predict
what will happen next.
51
Four Steps of
Perspective Taking
Step Three: Since we have thoughts about each
other, I wonder what you are thinking about me.
Step Four: To keep you thinking about me the way I
would like you to think about me, I monitor and
possibly modify my behavior to keep you thinking
about me the way I want you to think about me.
52
Four Steps of Communication
Step 1: Thinking about others and what they
are thinking about us
Step 2: Establishing a physical presence
Step 3: "Thinking with our eyes"
Step 4: Using language to relate to others
• It is not all about talking!
53
I LAUGH Model
I: Initiation of Communication
L: Listening with Eyes and Brain
A: Abstract and Inferential
Language/Communication
U: Understanding Perspective
G: Gestalt Processing/Getting the Big Picture
H: Humor and Human Relatedness
54
Worksheets! for Teaching Social Thinking
and Related Skills*
1.
2.
3.
4.
5.
6.
Learning about our own behavior
Self-Monitoring and Rating Sheets
Friendships
Being part of a group
Exploring language concepts
Developing effective communication
Worksheets! for Teaching Social Thinking
and Related Skills
7. Understanding and interpreting emotions
8. Perspective taking
9. Making plans to be with others
10.Problem solving and dealing with
responsibilities
11.Poster handouts
Strategies for Organization
• Daily individual
schedule
• Monthly or long-term
schedule
• Individual work system
• Schedules within
schedules
• Lists
• Color coding – folders,
books, spiral notebooks
– Containers for
colored hanging files
– Expanding file folders
• Physical structure of
building
57
Strategies for Organization
• Assignment books
– Teach what is most
important to do
– Teach how to
manage deadlines
– Who writes in it?
• Erasable highlighters;
highlighting tape
• Adjust the level of
spoken language
• Use shorter sentences
for directions
• Enhance oral
directions with
written information
• Teach length of time –
use stopwatches and
timers
58
Fundamental Social Interventions
• Instruct them on how to interact socially (changes
every year)
• Teach in small groups (one or two other students)
• Facilitate social interactions on the playground, in the
lunchroom or gym, etc.
• Teach feelings and how to read the facial expressions
and body language of others
• Cultivate social awareness - of self and others
Foundation Social Skills
• Joint Attention
• Requesting
• Speaking in 2 to 3 word meaningful phrases
with 1 word being a verb
• Tolerating the close proximity of peers
60
Joint Attention
From Social Skills Solutions
•
•
•
Level 1: Follows eye gaze, point or gesture
by others; looks/orients/responds to
objects presented; passes item to peers
Level 2: Orients toward person when
speaking/listening; shows others objects
with intent to share; follows other’s eye
gaze to objects; follows basic nonverbal
commands (stop, point-look, come here)
Level 3: Uses gestures to communicate
61
Social Language
• Greetings
– Hi, Bye
•
•
•
•
Saying, “Please” and “Thank you”
Giving Compliments
Responding
Initiating
62
Motivation
• Is there a peer the student with an autism
spectrum disorder gravitates towards?
• Give peer something the student with autism
wants
• Teach the names of his/her classmates
63
Teaching to say “Hi”
• Written on a strip: Hi <person’s name>
• Modeling/Verbal cuing
• Social Story
64
Saying Hi to My Friends
(Social Story)
Sometimes other students talk to me.
This may mean they want to be my friend.
I will try to say “Hi” when another student says
hi to me.
Maybe students will talk to me more if I talk to
them.
65
Task Analysis of a Conversation
• Response to peers greeting or questions
• Initiate greetings, social interactions, or
topics
• Maintain a conversation:
– Make comments
– Listen and ask questions/make comments
– Stay on topic
– Let peer make a comment or ask a question
• End graciously (e.g., talk to you later)
66
Conversation
• Start with area of interest and teach skills
• Teach concept of a topic
• Teach alternative topics – what are peers’
interests?
• Try using a topic chart
67
Shoebox Sample Questions
•
•
•
•
•
•
•
•
What is your favorite movie?
Where do you like to eat?
What is your favorite food?
What is your favorite TV show?
What is your favorite video game?
What did you do over winter break?
What do you like to think about?
What should you say when you meet
someone for the first time?
68
Social Interaction Schedule
1.
Say, “Hi <therapist>” (Check box or draw line through the
activity)
2. Review schedule.
3. Ask <therapist>, “What did you have for dinner last night?”
4. Listen to the response.
5. Listen to <therapist’s> question.
6. Answer.
7. Select a game to play.
8. Play game.
9. Say “Goodbye, <therapist>”
10. Go back to class.
Levels of Social Comfort
•
•
•
•
•
•
•
Proximity
Looking
Parallel Play
Sharing
Associative Play
Turn Taking  Cooperative Play
Following Rules
70
Basic Social Skills
• Tolerate peers
• Appropriate
touching
• Appropriate social
distance
• Making choices
• Sharing
• Eye contact
• Turn taking
– Relinquishing one’s
turn
• Losing graciously
• Participating in class
group activities
71
Interventions with Peers
Circle of Friends
Peer buddies
Peer mentor (Student on the autism spectrum
teaches about his interest)
72
Strategies
• Model
• Prompt
• Provide picture or
written cues
• Coach
• Facilitate
• Orchestrate
• Task Analysis –
break skill down
and teach each
part
• Create a list of the
steps of the skill or
use a schedule
(next slide)
73
Social Skills Solutions
• Uses ABA
• Checklist:
– 3 Levels
– 9 Modules
Social Skills Checklist
MODULES:
• Joint Attention/
Attending
• Greetings
• Social Play
• Ability to Calm Self
• Conversations
•
•
•
•
•
Perspective Taking
Problem Solving
Advanced Language
Friendships
Community/Home
Joint Attention
From Social Skills Solutions
•
•
•
Level 1:
Follows eye gaze, point or gesture by others;
looks/orients/responds to objects presented
Level 2:
Can sit and listen to group stories; shows others
objects with intent to share
Level 3:
Repeats and performs 4-5 step directions; follows
and completes large group instructions
Perspective Taking
From Social Skills Solutions
• Level 1:
Labels emotions in pictures, other people, on
self; looks for and finds hidden objects
• Level 2:
Cause for emotions; respects personal space
• Level 3:
Interprets body language; identifies nice vs.
mean vs. teasing
Critical Thinking Skills (Level 1)
Problem Solving (Levels 2 & 3)
From Social Skills Solutions
•
•
•
Level 1:
Ability to follow a schedule; understands
first/then; can sequence 4 pictures
Level 2:
Retells events of that day/yesterday; retells
short stories without visuals
Level 3:
Asks for clarification; makes predictions;
interprets idioms
Friendships
From Social Skills Solutions
• Level 1:
Sits next to same peer consistently; shares
with peer
• Level 2:
Gives others compliments; helps others when
asked; apologizes
• Level 3:
Introduces self to others; invites friends over;
beginning sexuality - privacy
Video Modeling
Scott Bellini & Jennifer Akullian – MetaAnalysis of 16 single subject design studies
(49 participants) in Council for Exceptional
Children, 2007:
• Promotes skill acquisition
• Skills acquired are maintained over time
• Skills transferred across persons and setting
• Meets criteria for evidence-based practice
Video Modeling
Possible Skills to Teach
•
•
•
•
•
•
•
•
•
Motor behaviors
Social skills (e.g., initiations, responses, play)*
Communication (e.g., conversation)*
Self-monitoring
Functional skills (e.g., purchasing, hygiene)*
Vocational skills
Athletic performance
Emotional regulation
Behavioral functioning (e.g., decreased problem
behaviors, off-task/on-task behaviors)*
*All part of Bellini & Akullian meta-analysis
Video Modeling
•
•
•
•
•
Choose 1 skill
Models are similar to the child
Model is successful
Model is reinforced
Scripted
***Make sure there are no extraneous details***
Adapted Games
• Matching games
• Modified Candyland
• Card games – start with Disney and transfer to
“Bicycle” playing cards. Then teach a new
card game with the Disney cards.
Social Story Dictionary
Define terms related to thoughts
•
•
•
•
•
•
•
•
Know
Guess
Learn
Decide
Topic
Idea
Wonder
Understand
•
•
•
•
•
•
•
•
Suppose
Confuse
Expect
Hope
Anticipate
Opinion
Forget
Believe
Group Skills
 Observe group activity from a distance
 Stay during a short activity then to the completion
of an activity (10 min)
 Participate in circle-time songs or games by
– Listening and watching
– Imitation
 Participate in group time by
– Looking at/listening to a book
– Making choices of activities
– Discussing the topic
Layered Groups
 Everyone – lively songs with music
– Routine actions
– Counting
– Concrete – objects to hold
 Smaller Group
– Calendar or Weather
with visual supports
 Smallest Group
– Language
– Social Skills
– Current Events
Working in Groups
Provide explicit group instructions – roles for
each student in the group/who is responsible
for what aspect of the project
 Some students with ASD control the group; others
do not attempt to be part of it; others do both
depending on the group
Teaching how to use
a relaxation system:
 Select a picture cue
 Teach and Practice while calm
and with the picture present
 Practice in one setting
 Generalize to other settings
***This becomes a new routine***
Relaxation Visual System: www.littlefriendsinc.org
88
Resources
The TEACCH Approach to Autism Spectrum Disorders
(www.autismsociety-nc.org)
Teach Me Language (www.autismbooks.com)
Social Skills Solutions; A Work in Progress; The Verbal
Behavior Approach (www.difflearn.com)
Educate Toward Recovery (www.amazon.com)
Peer play and the autism spectrum: The art of guiding
children’s socialization and imagination (Integrated Play
Groups Field Manual) by Pamela Wolfberg
(www.asperger.net)
Wolfberg website:
http://coe.sfsu.edu/coe/faculty/moreinfo/wolfberg.php
Michelle Garcia Winner: www.socialthinking.com
Resources
From www.asperger.net :
Super Skills: A Social Skills Group Program for Children
with Asperger Syndrome, High-Functioning Autism
and Related Challenges
The Hidden Curriculum by Brenda Smith Myles
Power Cards, Incredible 5 point Scale
Navigating the Social World by Jeanette McAfee
Social Skills Training; Social Skills Picture Book by Jed
Baker
Exploring Feelings: Cognitive Behavior Therapy to
Manage Anger by Tony Attwood
Exploring Feelings: Cognitive Behavior Therapy to
Manage Anxiety by Tony Attwood