notes from the table 14.11.11

Class was rather routine today, though I did observe some small successes from recently strategies we’ve implemented.

W is prone to repeating phrases over and over. This is common amongst those with ASD-type conditions and can serve different functions, 4 of which are:

* Avoidance: by repeating a phrase or question any task which W wants to avoid is delayed. The task might not be linked to what is being said at all so it is important to understand what apprehension W may have with the job at hand.

* Anxiety: everyone likes to hear that ‘everything is going to be ok’. A basic need for re-assurance in a world which seems uncertain and full of surprises is understandable. Add to that the impairment in social interaction in those with ASD and this removes the barrier that tells us that it is not alright to continually repeat yourself. So, for W, the more he repeats himself, the more reassurance he gets, so why not?

* Conversation starting: Linked to anxiety and compounded by the lack of verbal inventiveness and impairment of social communication skills symptomatic of those with ASD. By having a certain phrase that gets a response W can ensure he always has a way of breaking any silence. It is also a way of allowing him to break the ice socially and whilst it is socially inappropriate, it can work. I have worked with a boy who would ask anyone he met if they had been to his respite centre and if they had met one of his former classmates. Obviously he received unanimous negative answers to both questions, but as they at least got the conversation underway he stuck by these phrases.

* Ritual fulfillment: most common in those towards the more severe end of the spectrum, sometime the individual needs to use a repetitive phrase in order to fulfill a ritual. The phrase may be repeated until the ‘right’ answer is given, thus completing the ritual. This is distinct from the above reason as there is no desire to engage socially – the recipient of the phrase is merely asked to play a role for the satisfaction of the individual.

With the myriad of reasons behind the repetition in mind we decided to address one of the underlying difficulties that allows for it to take place: the lack of internal restraint against repetition. In other words, we had to make repetition a bad thing.

It was important to tread carefully here, if the deterent was too strong it could create more anxiety in W which would either lead to an increased desire to repeat himself or to break down communication altogether. He has come on leaps and bounds recently when it comes to conversation so we didn’t want to undo this.

Our tactic was to write any phrase repeated without meaning* on a whiteboard beside the desk used for class. That W does not like anything ‘new’ or any alteration to his environment made this enough of a deterent. Any instance in which the phrase was repeated after it was written up and the therapist would simply motion towards the board.  If he continued to repeat the phrase the therapist then discussed it and highlighted it on the board.

W’s brother goes on a bike ride whilst W is in class and he has become – ostensibly – very concerned about when is brother is leaving or is back. This has been the key question we have looked to stop W repeating ‘when is X’s bike ride?’ and in the last week he has only been asking once or twice each class -  a great achievement considering whole hours could be spent discussing this question only two months ago! Whether or not having the question written up will now become an obsession, or if he can go both without the asking and the board, is yet to be seen; this is the next step, but for now at least we’re stepping in the right direction.

The important things to note when undertaking something like this:

- Ensure the answer is known to the pupil – don’t condemn them for asking a genuine question.

- Make the point that it is repetition that is wrong, not communication.

- Understand the function of the repetition, whether one of the four noted above or an idiosyncratic function. The behaviour can only be address if its function is first understood as this will determine why it is happening.

- Be unerring in your silence: if the response is already known to the pupil, or otherwise redundant, do not engage in any way, don’t chastise, don’t explain, just silently acknowledge and move on.

- – -

* There is a great explanation of words without meaning by someone that I can’t remember right now – I’ve just done a twelve hour day! – that goes along the lines of…

 

Think of the phenomenon by which if you say a word over and over it seems to loss its meaning. Potato potato potato potato… you get the idea. The reason this happens is because with the repetition you are not saying the word but the phoneme – the sound that word makes. You do not mean potato, in fact, it doesn’t matter what a potato is here, you are just making the same sound over and overl A word is not the sound of the word, but the sound linked to a signified – something that sound is supposed to represent, to draw to mind. In order for speech to be ‘words’ it is not enough for the sounds to be right – a cough can sound like a word, a cat can sound like it is talking and everyone knows of a parent that is convinced their baby just said ‘geography’! – but the sounds must be attatched to a meaning, one which is agreed upon by the social contract that is language. So, if you are deciding whether a pupil’s repeated question is really a question or fulfilling another function ask yourself whether the words themselves matter or if they are just pronouncing the phoneme -  what is more important: the words said or that words are said? The former, the issue is understanding and an explanation will help; the latter and you’ve got to look deeper.

notes from the table 9.11.11

The Difficult Capriciousness of “Being”

Today W was on great form and we managed to stretch out one task for almost the entire class. The task involved having W create simple subject-verb-object sentences by describing what was happening in a series of pictures; the focus being upon getting him to use the correct pronoun and appropriate form of ‘to be’. As I have noted before he tends to omit the subject in any sentence and go straight to the verb, so to act as a prompt I had post-its lain on the table with ‘I am, you are, they are…’ and whilst this was helpful for him it highlighted a difficultly he has in choosing the correct copula: whilst he was confident using ‘you are’, he almost invariably used ‘they is’.

This is, in a way, a follow-on from the difficulty with personal pronouns common amongst  individuals with ASDs and described in my previous entry, yet it is not simply an extension of this but a multiplication of the traps already faced in these types of sentences – now, as well as facing the slipperiness of reference that is a pronoun, there are now a bunch of, seemingly arbitrary combinations to be remembered! I would be very interested to hear from others how those they know with ASD cope with this minefield.

	Present indicative	Past indicative	Present subjunctive	Past subjunctive
First-person singular (I)	am	was	be	were
Second-person singular (you)	are	were	be	were
Third-person singular (he, she, it)	is	was	be	were

As W was taking to this task so well I used it as the basis for addressing another of his targets – typing. W can type reasonably well, however is so easily distracted and so put-out by any mistakes- typing one letter wrong is perceived as either a great failure or a hilarious joke – that he rarely types independently. To encourage him I got rid of as much clutter as I possibly could with the word processor, so that the screen essentially looked like a terminal. He happily typed out ten of our sentences independently until – bing! – the dreaded pop-up. Anti-virus update. Right, enough interruptions, this was closed, I explained what happened and got W back on task. Just as I returned to my seat – bing! – another message, another distraction, another two minutes lost.

he world at your fingertips, but it won’t leave you alone!

I have experienced this countless times with pupils in ICT lessons in school and would readily welcome a ‘gaming mode’ setting as found on anti-virus software that stops any pop-ups,  messages or interruptions coming from anywhere at all! Whilst the computer is a great tool for education it is also very demanding, you are constantly asked to interact and for those that don’t respond well to surprises this is a nightmare. Any programmers out there – a ‘Leave Me Alone’ mode would be an asset to anyone using computers in education so get on it!

***

After having W format the text – making the subject of the sentence blue, verb green and object red; something which he picked up immediately and revelled in doing and doing at great speed! – we were ready for the next test: inverting the sentence to an object-verb-subject order. This proved to be very tasking but a worthwhile exercise as, in forcing W to treat language in this plastic way he did not ellide any words and made his best effort to understand the action of the sentence -  what was happening to what. The colour-coding means that the basic structure is already there, leaving W to focus on the other challenges: the change in to the objective form of the pronoun, the altered verb and the extra carrier phrases needed. We didn’t get far in to this before W had ‘had enough’ and we moved on.

This raised another issue in my mind. W is now at the stage that he can stick to task for a long time. Previously each class would include a dozen exercises in rapid succession, now we can work on one thing, with me amending it ever so slightly to use the same base material to hit different targets. Obviously, this is a sign of maturity and a great boon to his abilities. It also means that the therapists don’t have to conjure up as much teaching material for each class. By persuing one task it runs the risk of turning stale, but by having many tasks – no matter how superficial the differences between them are – there is an introduction required for each and an accompanying excitement/anxiety on W’s behalf.

My quandary was: would W have completed this element of the task if it was introduced as a new exercise – using different sentences, using paper instead of the computer, given a different name (superficial changes)? I think it is easy to be pleased to have a student stick to their task – not only does it show their own skills it also alleviates the need for the tutor to produce new material (this said it requires that they have the ability to covertly alter the task or morph it in to another, something I believe to be one of the most important skills) – but one must also know the value of the superficial changes that can be made in order to present an exercise as something new. The saying a change is as good as a rest comes to mind, and while I knew that the exercise had changed, it hadn’t be flagged up that it had changed, which, perhaps, could have saved it from being sent to the realm of ‘had enough’.

***

My final note for today is about typing programs. I have tried out a number of ‘learning to type’ programs with pupils with ASDs and have yet to find one with which I’m truly happy. Sunsoft’s Type to Learn – the early 90s version only! – is good, however it costs and the recent versions are filled with flash graphics that I have found to be too distracting.

Run-down of the free online programs:

• The BBC’s typing program is criminally bad, with a terrible interface, awkward feel to it and a Scouse goat as your tutor.
• Visibone Typing Tutor has a clean feel to it but it is not always clear what you are to do, they’ve gone for ‘unique’ ways of indicating which key you are to press, this just slowed me down and at times out-right confused me.
• TypeOnline had a nice basic appearance, no flash or java, no graphics and simple instructions. However it is perhaps too simple, there is not enough feedback to the user and I was left trying to get to the end of each exercise as quickly as possible just so that I could find out if I had done it properly.
• The best yet: Sense-Lang.org. Very simple interface but with a good amount of feedback and various options and games available. But still room for improvement.

I’ll report on further free typing-tutors til I find one that ticks all the boxes. If you’ve any recommendations I’d be glad to hear them.

notes from the table 31.10.11

Today a new therapist (henceforth NT) sat in on the class. When you are used to working in the intimate, one-to-one environment which is the mainstay of such therapy, having someone look over your shoulder is the most disconcerting experience and, as I have found through discussing this with others, one of the most hated aspects of the job. There are so many things that you do intuitively, so many things in the way you conduct yourself that you consider important that you have to draw attention to and in doing so it is very difficult to not sound patronising or overly didactic. Yet at the same time it is exciting – there’s the excitement of welcoming on-board a new member of staff, looking at your own work through another’s eyes and having a chance to see those you work with through another’s eyes. So I was torn when I began class today: eager to get it over and done with, but at the same time aware that these opportunities are both rare and valuable.

NT sat in on the staff meeting a couple of days ago so I ensured that the activities were more ostenstibly target-oriented than usual. I also made use of any opportunity to encourage W to interact with NT. Another of the worries of these observed classes is that W relies so heavily upon the usual therapist that the new one is left out or alienated by his refusal to engage with them. Another is that the presence of a new therapist is likely to influence W to change his behaviour. Both mean that the newbie gets a skewed picture of the classes and W himself. Luckily neither were the case today.

We began with the ‘I did/I am going to task…’ during which I had W describe NT‘s day to me after he had questioned her on what she’d been doing. To help with this I laid out post-its with ‘wh’ words which W had to tick-off each time he used them. This encouraged him to vary his questioning, and although he relied heavily on ‘what’ they did help him ask better questions. The challenge I have here is moving him away from ‘what’ and on to more succinct, natural sounding questioning: when? as oppposed to what was the day?; where? as opposed to what place did you stay?

One of the big targets set for W in the coming months is to ensure he includes the subject in the sentence. When he does use sentences in speech they most often start with the verb: ‘go to the shops’, ‘riding the bike’. Whilst part of this can be attributed to his inherent difficulties with language another part has to do with what I have found is one of the biggest problems in language for those with an ASD: personal pronouns.

For many with ASDs the concept of ‘I’ and ‘you’ are very difficult. Those words have a great fluidity of reference, changing what they refer to dependent on the speaker. They are at the heart of one of the main defects in autism: theory of mind.

autism-help.com defines theory of mind as “the ability to attribute mental states—beliefs, intents, desires, pretending, knowledge, etc.—to oneself and others and to understand that others have beliefs, desires and intentions that are different from one’s own.” It is the understanding that the behaviour or yourself and others finds its motivation in thoughts or feelings that are specific to the person thinking or feeling. Simon Baron-Cohen (yes he is related to the Borat creator) was one of the first to devise the concept of theory of mind and suggested that individuals with autism lack a theory of mind. This explains difficulties in communication – why is communication necessary if everyone thinks the same, if there are no other minds but the individuals? – and social interaction – people should know that an autistic individual is unhappy or anxious because they don’t have an independent mind; everything is shared and everything is obvious to those with autism.

Imagine the mind as a locked box – everyone has one but you only have the key to your own. The only way to find out what is in the box of others is for them to display it in some way – this is communication, be it facial expression, body language, speech. This is the way of things. Now, imagine that you were told only you had a box. Your box contains everything. There is nothing outside your box and – in fact – your box is open, with its contents on show to everyone else. Why should you have to display what is in your box when you believe that your box is open? This is the way for someone with autism and this conflict forms the base point from which to understand many of the problems faced by those with an ASD, particularly with regards to communication.

With I and you being such difficult concepts to grasp for W he was used to using names – they are concrete and un-changing: he is always W, I am always G. So his sentences would sound ‘W is happy today’, ‘it’s W’s turn’… In the interests of encouraging typical speech over the years, we as therapists have clamped down on this but through our correcting, prompting and discouraging of this way of speaking we have caused W to become unsure of his speech and to opt for the safest bet: getting rid of the subject altogether.

The task conjured up to address this involved W sorting pictures in to the categories: I, WE, HE, SHE, THEY and NAME. This he could do easily. I then modelled a sentence “pronoun is action” which he then had to say for each photo. The pronoun was given, giving him the confidence he lacked, which I believe is partially to blame for the ellision of the subject, so he could focusing on identifying the action; something with which he is fairly confident. The task worked very well and allowed W a degree of independence so he could relax and interact with NT.

In the second half we worked on a time-task – matching numbers – multiples of 5 – with others to make 60. This was played as a game of pairs and used to help W in learning ‘… to …’ times. I let NT  take over for this and notwithstanding a couple of calls over from W to “look” and some instances in which he refused to let NT help, he worked well with her.

For the most part I dodged the double-barreled assault of the observed class. One bullet causes me to get pent up, make the class too formal and structured and become self-critical to such a degree that I’m not thinking about the important person in the class – W. The other makes me too excited about the novel experience, so much so that I explain every utterance, bombard the new therapist with ideas and information and generally ramble like a caffeinated evangelist. Still, lets hope that NT stays with us long enough that I don’t have to train up any more therapists for a long while!

I would be interested in hearing from anyone on teaching personal pronouns to those with an ASD. If you have any ideas or know of any articles on the matter please get in touch.

Further reading on theory of mind:

- Autism Help: http://www.autism-help.org/points-theory-of-mind-research.htm

- Simon Baron-Cohen et al. (1985) “Does the autistic child have a ‘theory of mind’?”

- Alan M. Leslie (1987). “Pretense and Representation: The Origin of ‘Theory of Mind’”.

- The Sally-Anne Test: an experiment used to test whether an individual possesses a typical theory of mind.

whose therapy?

I began writing this blog with zeal and a commitment to get myself in to the routine of examining my work and sharing it on a regular basis, yet it has now been almost four weeks since my last post. The reason being that my world was ripped from under me just over three weeks ago. Pulled out from underneath me in one swift movement, like a tablecloth from under a tower of champagne glasses. But there is no magic here. No sleight of hand. Unlike the glasses in the trick I was not left standing tall in the same spot, but shattered in to pieces on the floor.

This all happened on a Saturday, by Monday I wasn’t ready to return to work so had to call in to both the school and to cancel the class I had scheduled that night. Tuesday: still couldn’t face the world. I was due to have a class on the Wednesday and whilst I was far from recovered I decided not to cancel. I stayed off from my job at school during the day to sort out some personal issues before braving the outside world to head to class. On the walk there I felt as if I was back on my feet, ready to work and regain a semblance of normality in my life, however once I arrived at W’s his mother asked do you want to speak about it? – my quivering no, I can’t in response caught me off-guard and I began to doubt whether this was really a good idea; throwing myself back in to a job in which I have to be upbeat, energetic and – in a sense – infallible in order to inspire W to do his best. Could I really expect him to give his best if I was incapable of doing so?

Yet despite this apprehension the class went well. I stuck with well-known tasks and games for the first half, but after spending my break planning further activities I attacked the second half of the class with renewed vigor and forgot myself and my situation enough to break a smile for the first time that week.

As I left class I was walking on air, stomping my way down the street with that familiar lightness and sense of assurance I usually feel after working with W. Of all the things I had tried that week in order to elevate me from out of my depression getting back to work was what helped most. This led me to consider the therapeutic value of the classes – not for the pupil but for the therapist. Behavioural therapy is work in which the therapist cannot consider themselves for too long. I can’t think about myself as in order to work I have to be fully concerned with W: assessing his mood and well-being, analysizing his behaviour, planning the next task. Me as a self is almost removed as a division – or rather a manipulation, a duplication – of myself must occur: I have to be the therapist with whom W interacts, light-hearted, in-control, enthusiastic and clear in my expression and intention – as well as the therapist hover above the class like an observant spectre – one which is continually examing the interaction, assessing the success of tasks or the language used by the light-hearted therapist. In this excess of activity I have found that I become my most passive with regards to my own worries.

Following this initial buzz, the immediate high of engaging in work and leaving myself behind came a secondary buzz, one which I felt once I had shed the therapist mask. This buzz was characterised by one intense feeling: gratitude. I was thankful to have work like this, in which I can leave myself behind – the self that is bogged down with worries and anxieties, with the weight of the world on my shoulders and a heart-stopping fear of the future. Working as a behavioural therapist – in a demanding environment, one-on-one with another person that consumes all of your attention – forces you to live in the present. You plan, you have a to-do list, but it extends three-hours ahead at most. In class I am in my own zen bubble.

With this in mind I resolved to throw myself in work in order to get through the coming weeks. This has been the reason I have been late in posting. It is also the reason I have managed to gather together the pieces and slowly, gradually put myself back together again.

 

- Les moments de crise produisent un redoublement de vie chez les hommes. (Moments of crisis produce a redoubled vitality in men).

          François-René de Chateaubriand

notes from the table 6.10.11

Today is national poetry day. Events, themed classes, special occasions are all futile with W but today I tried and it worked. I have been using rhyme as a way to encourage W’s sentence use and ability to connect ideas – I’ll post the exercise in full shortly – so thought I would jump at the chance to involve W in an event.

W arrived in class a little anxious and pre-occupied – he attends a day centre and there was an incident today in which he got in trouble – but he settled quickly. We started with a recap/plan activity I did/I am going to do…  I was apprehensive about having him recap on his today, being as it were that it included some stress, but he did so very well – sequencing is perfect and he is gaining confidence in using the prepositions written on the post-it notes on the table, although it will be some time before he can go without these prompts. I introduced a new element to the exercise today which worked well: I placed a bunch of post-its on the table, each bearing a questioning phrase and as W gave his account of his day I would ask questions beginning with the written phrases. Once I’ve asked the question W can take the post-it from the table. This did a number of things:

• brought W’s narrative in to the realm of a conversation
• encouraged W to listen to ensure he took off the correct post-it
• made W accept questions – one he’s in ‘game mode’ he does not like interjections.
• illustrated what aspects would be appropriate to share, where to elaborate beyond a time-line of events.

I will be continuing to use this tactic in the exercise and reckon it’ll be of use throughout others – for W scrunching up a post-it and throwing it in the bin is a reward in itself so the reinforcer is inherent. Come to think of it, I reckon most folk enjoy getting to bin a post-it – they’re desk-zits, you want them gone and gone fast.

W was beginning to get edgy – I was implored to ‘work’,  line the deskclock up properly, told to get the next game ready whilst it was sitting a foot away from the table – but after some steering back on track we finished the task. It was poetry time.

As with most individuals with ASD W has a restricted range of interests but what he is in to, he is really in to. One of these – started in the classes – is countries. We use this often in class and I employed it here, with the aid of a pack of very retro cards, for the poetry task. The cards each had a picture with a rhyming couplet as a caption, with a handful of the cards labelled ‘Holland’, ‘Austria’ and ‘The Alps’. I had W read each of the cards and identify the rhyming words then suggest more rhymes for each. I then seized upon the country cards and suggested he write a similar couplet – ‘poem’ – for other countries. Using something finite and known as a framework appeals to W and the idea of the task being a ‘countries’ one immediately sparked his enthusiasm. He named three countries from each area of Europe – categorisation is a big thing for W so we’ve broken Europe in to different areas – and wrote each on a separate index card, then it was time for break.

Often these breaks also mean a total break in interest, meaning that W’s disinclined to resume a task, but not today. It was on. Poetry here we come. On his return we set about written the poems. W has little verbal creativity, dislikes free-reign and relies upon default association* so for the first line of the couplet he was to take something from his stores of knowledge of the country – what’s the capital, associations of food, its size – meaning that it was an easy start. The second line was the challenge, but thanks to using  end-rhyme we narrowed the field of play. I had W work out a couple of words that would rhyme with the last word of the first rhyme, he then chose one and made a sentence for the second line. He’s not task creatively as the fields of play are narrowed and he has the freedom to write as he pleases. The goal of the task is to get away from the default associations and see if W can make a second line which follows logically from the first. If he can work in a context.

W was very pre-occupied during the task – I was ordered to re-allign the clock and CD player, ‘work’, close and open the drawers all dozens of times – but we finished. It wasn’t the smoothest class, he was agitated and his OCD really came out, but it was testament to him that he kept on with the same exercise for most of the lesson; time was the paper would ripped to confetti and hair out in clumps. Those days are nearly gone, or at least few and far between. W’s anxiety today made me up my game, not as a preventative things-might-go-mental way but so that I could keep him focused on the task and get not only more work from him and from the results I reckon there’s potential in his ability to link ideas and get things in context.

Here are a selection of the poems – we were also looking at people’s names in different countries so this makes some of the second lines appear more apt! The last two are golden.

In London Sarah uses the train

fly on a plane

-

The people are called Slovak

Pavel’s t-shirt is black

-

Serbia is a country that is Balkan

in the summer get a tan

-

Russia is big

oink oink says a pig

-

The Pope wears white

in the Italian night

-

In Scotland we eat mince and tatties

food makes us fatties