Mythily Chari M.Ed., Ed. S (Special Education)
Director
IRIS

Introduction
Early detection, intervention and integration of toddlers with autism/Asperger’s syndrome have been the primary focus of IRIS.
For the past two years we have been integrating children with autism in regular play schools where children without special needs attend. The dilemma that we face is to decide whether to tell or not tell about the child’s condition and the special needs. Some schools admit the children if we inform them that the child’s developmental milestones are delayed, and s/he may be hyperactive. Some teachers once informed that the child has autism either shirk the responsibility of addressing the child’s special needs thinking it is a specialist’s job, or magnify every misbehaviour and attribute to the child’s autism. A director conveyed to us that she was ready with a Transfer Certificate to hand over, if the child became too difficult to handle!

Staff handling the child with autism need to have basic training in anticipating the problems and are prepared so that the child mainstreamed is programmed for success.

Each child’s and family’s needs determine the choice of school, it is my observation that even in less than perfect situation the child progresses in the company of other children and not so much due to direct intervention. However if the teachers handling the child are knowledgeable then the learning potential for the child can be maximized. The adaptation or accomodation one has to make while interacting with children with autism is very minimal, one need not invest in costly equipments or adapted furniture, the basic attribute a (very special) teacher should have is flexibility of mind; an attitude of why not and what if- to try innovative ideas. Lack of resources is no hurdle, a resourceful teacher can overcome any problem with ingenuity. I out line a play school set up and ways to create a prosthetic environment to include a child with autism/Asperger’s syndrome.

Play Behaviour
How do children with autism play?
Though children with autism do not play pretend and imaginatively like their age peers they can be trained in this area. First the child should be aware of the objects and their usage; cup to drink, spoon to scoop etc. At the presymbolic level you teach the child to extend the action from self to others; drink from the empty cup, make the teddy bear drink, make the doll drink make mummy drink etc. The you may add on the pretend element by using miniature empty cups and add to the scheme by making tea, pouring etc.

Children with autism do not use substitution (a skill displayed by three year olds) very well. For example I asked a child how will the baby doll sleep, since there was no pillow,instead of substituting he went inside and got his pillow! However role playing skill can very easily taught to children with autism.

Children with autism very often take the tree to the woods! They play with a part rather than the whole toy. A typical free play area where children are left to themselves to self direct and stimulate works differently with children with autism. Because s/he likes the wheel of a car, or a bead that has come undone, or sticker that s/he has peeled off from a toy s/he engages in spinning the wheel, sucking at the bead, or rubbing the sticker and is self stimulated but the net result is not what the teacher intended. Or the very boistorous nature of free play session creates a sensory overload and the child with autism retires to a quiet corner. Unattended the child will not be able to interact with other children or respond to the give and take of parallel play.

How to modify play area to include children with autism?
Organization of space and material
It will be helpful to have a visual demarkation by using screens, furniture or carpet/durries to show that the children are expected to sit down or stand up or be seated on chairs. Ideally the children should have floor sitting time alternated with chair sitting.
Typically toys, books and puzzles are kept in low shelves so that children can help themselves to them. Toys and puzzles should be kept in boxes or in shelves where the children should not have ready access. This not only helps to avoid the clutter and mess, it also facilitates communication. The child with autism will have to seek someone’s help to get a toy. Have a “FINISHED”box to put away a toy after being done with it.

Planning transition activity to reduce wait period and disengagement
Transition activities have to be thought about also, this gives something to do while there is an overlap and also the extra processing time required to switch gears. The Montessori school where two of the children are integrated offers an excellent activity which is rolling up or unrolling of individual mats to indicate the closing and starting activity providing visual auditory and kinesthetic sensory involvement. Another teacher found that playing music for five minutes helped children calm before a lunch activity. I found that the children knew roughly what 4 minutes were; the duration of the song! Children with autism do not usually internalise time. When an activity is going to finish they need a reminder that “FIVE MINUTES” later the activity will finish. It need not be real time. Some visual indicator to show that an activity is over, what succeeds it will be very helpful. Either photographs or line drawings can be made as cue cards and kept on a stand, they can be flipped over or a cloth over put on top to show the finishing of an activity. This orients the child to her/his daily planner. I have found that using a flip chart with velcro buttons helps to change the daily time table at will and the child accepts change easily if represented visually.

Using peers as “co-therapists”
We can choose a child as a mediator after careful observation, choose a child with high “Emotional Quotient (EQ)”. While I was showing a clapping joker which is a wind up toy, every child wanted to have a turn, one boy grabbed the joker and bit his pinocchio nose, when I cried in a child’s tone, he laughed and bit the nose once more. Every other child clamoured for a turn at windingthe toy. One little girl brought a friend of hers; a quiet boy and told me ” He did not get a turn”. She exhibited a higher level of EQ. She would be my choice for a cotherapist. I would teach her to play interactively with the child with special needs.

Integrate in Skill Area
Children with autism are good at puzzles, building /stacking blocks and assmebling toys in a train. They shoud be integrated in an area that is their strong point, the goals for children without special needs should be helping and not completion of a puzzle. Give some puzzle pieces to the “cotherapist” child and instruct her that when A requests “please give” she should help him by giving a piece. Thus the children learn to play together. Later we could train her to turn her whole body away from him and /or to delay giving. Endless possibilities of the same scenario can be worked out.

The inborn nature of the child with autism is that of curiosity and engagement. It is here that I feel Montessori set up which is activity rather than teacher oriented is preferable. Keeping the hands busy lessens frustration. A higher level of play can be modeled for the child by a more settled ‘senior’. The shift in the expectations from the children – that they use material properly without hurting the peers and the facilitative style lessens the child’s stress level.

To cite an incidence while I observed the class the children where engaged in a variety of activities, one child approached the teacher and asked whether she would sing for him, she replied that he should then put away the material and bring mats and arrange them in a circle. Except two children everyone brought their mats. Teacher kept asking what they wanted to sing, children where taught to appreciate everyone’s choice, taking turn and waiting for their turns. The choice option is narrowed to two for the child with autism.

Social Behaviour
Schooling is all about socilisation and learning socially appropriate behaviours by modifying oneself. Play school is a wonderful arena to observe the transformation of the shy child blossoming out and the class bully softening up, they all regress to the mean, to borrow a statistical expression! What ever a peer’s special needs the children accept them and include them in play but the child with autism is usually ignored or sidelined. What is it that makes the child with autism antisocial? During lunch hour and play time he grabs the tiffin or the toy, instead of saying please give, he never waits for his turn, and is usually quick to hit out. When some one shares a toy or an orange he does not smile, make eye contact or say thank you. Thus even if children are admitted in play schools it is not sufficient by itself. We have to actively facilitate inclusion.

Communicative Behaviour
Children with autism learn to communicate and speak in a different way and not in a simple delayed manner. They communicate instrumentally, ie to get needs met, and have no use for socialisation. Whereas even a child of 11 months will bring an object to caregiver to initiate a conversation. Children develop the triadic communication using eye gaze, gestures and the object even before they learn to talk. Children when they learn to talk, use language as first choice to communicate whereas children with autism use gestures to communicate and use language as a last resort! The following vignette will elicit my point, further.

Minal is a three year old child who speaks Punjabi. She attends a school where other kids speak Tamil or English. She wanted an adult to scratch her back because she had prickly heat. First she said in Punjabi ” It is biting me” the adult who did not understand asked her “what is it?” Minal then made exaggerated chewing movements, the adult responded by checking her frock for ants! The girl then grabbed the adult’s hand and put on her back and simulated scratching movements. The adult understood then that the child had prickly heat blisters.

The child used language, and tried to repair the communication breakdown, only as a last resort did she use the grabbing gesture. Whereas it is justthe reverse for children with auitsm. I have trained parents to maintain the high level of motivation of the child while requesting milk or biscuit, and frustrate him just long enough for him to use language as a last resort. We use naturally developing situations to teach language, and not necessarily in a flash card format, as the children with autism learn only within context, they do not generalise readily to other situations.

Break time is an ideal situation to teach social and communicative skills. We can teach sharing, taking and giving in a socially appropriate manner. We teach the children that just because some one asked you politely, you need not share if you really do not want to, or you have shared enough. Mealtime can be utilised differently if the school provides refreshments and drink. Using other talking kids we can ask the question ” who wants juice/cookie/milk?” When the children provide an answer that child will be given the refreshment, this strategy known as “priming” provides the child with autism a model to echo,within context thus we can utilise echolalia. Always give a little less so that child has to ask for more, one more or somemore.

General guidelines to tempting children with autism to communciate
Dr Prizant and Whetherby after extensive research on autistic language have provided very simple guidelines to Communicative Temptations. Engage the child in a preferred activity, try to get him/her to make eye contact, once you are within the visual field smile a lot and use very animated facial expression and voice like one would in ‘parentese’. When the child communicates to you that he is having fun, you stop the activity. The child will try to initiate the activity. You supply the word. For example you may spin him and then stop, then teach him the words “more spin”. Eat a desired item (of the child’s) in front of the child without offering any wait for his response and give him the word. We teach phrases which are generic in nature “gimmejump, gimmegrapes, gimmebubble” as one word. Do not give up if he does not say these words immediately, he will after some time. Children with autism display echolalia and echopraxia ie. They echo an expression or phrase or action a later instant, they require more processing time.

Use descriptors
Describing words are rarely used by caregivers. They use a profusion of questions, so that the children do not have words to describe the inner state or attributes.

It is hot, very hot, I am happy, angry, miss you, like it, this is nice, hurts, feeling sick, feeling good, yummy, oops, look at that etc.

Use of a Communication Dictionary
When children are nonverbal many tantrums can be avoided if all caregivers respond to the child appropriately, this can be achieved by creating a communication dictionary. Parents can for example write “If Raju runs around pulling at his pants it means he has to go to the toilet”. Underlying communicative intent of non verbal gestures need to be deciphered accurately too. When a couple had come for consultation with
their daughter, she got restless after an hour or so. Seeing that we kept on talking she started throwing the chairs on the floor, parents reacted to her action negatively, I explained to them that she may have told instead(if she could talk) “let us go home”.

Conclusion
When a child is nonverbal or cannot express well, caregivers assume that s/he has nothing to say. The child gets forced or led into situations that s/he has no option or choice. A good way to judge would be to see how much freedom a child (of same age ) without autism has and proceed from there. The more decision making options a child has s/he will tantrum less.