Teaching A child to Enjoy the World
Considering the many debilitating symptoms of Autism Spectrum Disorders, building this foundation can be a formidable task. Many parents find themselves at a complete loss when trying to decide where to start. Let us examine some of the challenges one may face.
First, Children with autism often have difficulty with new environments. This difficulty may show up as unwillingness to try new foods, temper tantrums in new places or anxiety reactions when exposed to unfamiliar people. Many well meaning parents and caregivers attempt to establish environmental acceptance with the child with ASD, not taking into consideration the necessary processes required based on the needs of the child with ASD. The first goal is to understand the child and their unique sensory issues and to adjust the environment to create comfort and security for the child. Hypo- and hypersensitivities have been documented in children with autism (Ornitz and Ritvo, 1968b). Sensory issues include auditory, visual, tactile, olfactory, gustatory, and proprioceptive/vestibular hypo and hypersensitivities.
Auditory – Many children with ASD are overly sensitive to normal everyday sounds. You may find them running away or leaving a room or just covering their ears and screaming when you flush the toilet or turn on the vacuum cleaner.
Visual – A child with visual sensitivities may hide under a table at school or the doctor’s office as a result of their sensitivity to fluorescent light.
Tactile – A child with tactile sensitivities may frequently strip out of clothing in public places or may be very picky about the type of clothes they wear.
Olfactory – A child olfactory sensitivities may be preoccupied with smelling people or inedible objects.
Gustatory – A child with gustatory sensitivities may continue to mouth inedible objects when most typically developing children have moved on to exploring objects mostly visually.
Proprioceptive/vestibular – A child with proprioceptive/vestibular sensitivities may spend hours alone rocking in a chair or may need to jump on a trampoline many hours of the day.
As we gain an understanding of the child’s sensory issues and sensitivities, as well as strategies to soothe and calm the child, we gain information about how environmental factors can be paired with new experiences to reduce discomfort in new situations. The child starts to develop trust and feelings of security that someone is capable of competently meeting his/her needs. This is a crucial step that will be returned to throughout therapy. The focus always has to be on providing a fun and content experience for the child roughly 90-95% of the time. The more comfortable and content the child is, the more we can use that comfort and security to progress them through their developmental challenges.
Creating a fun and exciting playful experience for the child throughout therapy will provide the therapist and parents with an initial stance from which they will be able to meaningfully impact the child’s life in positive, fulfilling directions. Creating such an environment requires skill and practice but the payoff is immense once mastered. Basically what this stance does is provide the therapist and parents with a wealth of information about how to help the child control the environment and instills in the child a trust that the therapists and parents can be looked toward as allies in navigating the world. Much the same way that an infant learns trust through having needs met after crying.
After the therapist has gained trust and understanding of the child and the ability to soothe and comfort the child, they can begin to address environmental expansion. As a general strategy, sensitivities or negative reactions to environmental events should be recorded, and a plan should be developed to address the difficulties.
Throughout therapy, document any aversive reactions and follow through with a systematic plan to expose the child with autism to new people, places, objects and sensory stimuli using systematic desensitization procedures. The child should be exposed gradually to the feared situations while in the presence of people or objects that comfort the child. The comfort from the parent, blanket, food or whatever the child is attached to will become associated with the unfamiliar situation and decrease the aversive nature of the new experience. After repeated exposure to the uncomfortable situation while in the presence of comforting people, objects or food, the new frightening situation becomes less frightening. You must be careful here not to reward fearful behavior at this point. The presence of the comfort person or item should be present at all times but should not increase after inappropriate or fearful behavior.
This sounds like a fairly simple and straightforward procedure for moving children beyond their preferences into the world of enjoying a vast amount of experiences, but actually accomplishing this task can seem unattainable for many parents. Many parents and families of children with autism gravitate to leading very restricted and patterned lives in an attempt to avoid the distress caused by new situations. Let me tell you the story of Jimmy. Jimmy had a very strong tendency to hoard objects. Any attempt to restrict the number of items Jimmy would carry would be met with extreme tantrums and aggression. In an attempt to comfort Jimmy, the parents continued to allow the hoarding behavior rather than place Jimmy through the discomfort of tantrums. After all, what is the harm in allowing Jimmy to carry around a few objects? The problem is that by not addressing the behavior, the behavior became gradually more encompassing and more debilitating to both the family and child. This particular situation ended up with the child stuffing an outfitter-sized pack full of items. When the pack became too big for Jimmy to carry himself, he expected others to carry it for him. The tantrums and aggression occurred when others refused or were unable to carry the pack. The restrictions this placed on Jimmy and the family were significant. Trips to the store, trips to restaurants, going to school, playing outside, and countless other opportunities were lost to the all encompassing need to hoard objects.
The problem with avoiding difficult situations is that life becomes more and more controlled by random environmental events. The immediate relief of getting out of the situations and the resulting decrease in distressing behavior on the part of the child is understandable. In the long run, life becomes patterned and many activities, people, foods, and places that could have been experienced with great joy are never experienced.
In general, all people, not just children with autism, need multiple exposures to new situations before they start to enjoy and crave them. Think about how many times you have to hear a new song before you begin to like it and look forward to hearing it. Think of the experience of hearing a song on the radio that brings back good memories and finding yourself really enjoying the song only to remember later that you always hated that song. What has happened is that the good memories and experiences from the time in your life that the song was played have been associated with the song. A song that was once hated is now loved. Most people can also think of a personal example with a food they once hated but now love.
If it is a natural human process to need to be exposed to things to begin to enjoy them, why do families of children with autism gravitate away from the strategy of exposing the child to new situations? The obvious answer is that the extreme reaction many children with autism have to new experiences makes pursuing exposure extremely unrewarding for the parent. Children with autism can be very persistent with their preferences and vocal when their preferences are not followed – to the point where it seems almost unnatural or counterproductive to expose the child to such distress, even if it is in the child’s best interest.
Theories of sensory sensitivities may correctly lead parents to the conclusion that the child can’t tolerate certain sensory stimulation. The only logical solution from that perspective is to decrease that sensory stimulation. As discussed earlier, there is a time and place to follow through with this strategy. The problem is that avoiding the situation leads to living a more and more restricted life. This phenomenon manifests itself in many ways. Common restrictions include avoiding restaurants, avoiding church, avoiding going to stores, avoiding family activities in the community etc. Restrictions can grow very gradually and the process is not always apparent until the restrictions have reached a very extreme state. For example, one family restricted their travel past all Wal-Mart stores when their child with ASD was in the car. This was done to avoid dealing with extreme tantrums the child demonstrated when seeing a Wal-Mart store. The tantrums originated from a very negative experience the child had at the store related to sensitivity. The part that is often missing is a plan to recognize that there is a sensitivity and then to develop a plan to desensitize the child to that experience.
Why would we want to tackle sensitivity at the cost of placing the child through discomfort resulting in tantrum? First, it is important to understand that such sensitivities can be overcome with a proper plan. The tantrums are only a temporary response when dealt with properly. Second, the payoff is enormous for both the child and the caregiver. Tackling sensitivities expands the child’s life and builds more enjoyable experiences into the natural environment. Instead of moving in the direction of restriction, we move in the direction of expanding options. Instead of moving in the direction of rigidity, we are moving the child in the direction of flexibility. If you only like Cheerios, the only option for happiness is Cheerios. If you are restricted to only Cheerios, what happens when Cheerios are not available? When you have learned to love Froot Loops, Lucky Charms, and Captain Crunch you have more options. When Cheerios are not available, you now have the option of enjoying Fruit Loops. Every time a child does not like something, you have the option to teach the child about one more thing that can be loved.
The field of Applied Behavior Analysis (ABA) provides a systematic way of approaching situations like this and removing obstacles to behavior change. Breaking problem situations down into smaller, more specific components are hallmarks of ABA. Such methods yield great benefits in children with ASD, among them is intervention planning that is manageable, efficient, and individualized to the child’s specific needs. Let us examine how an ABA approach might address the issue of environmental acceptance and expansion.
The first thing to consider is that behavior change cannot occur until one is fully aware of the behavior that is occurring. So, from an ABA approach, we first need to gather objective information about what is really happening in the environment. Gathering information is accomplished by learning to observe and record the reactions of the child to the different environmental stimuli he encounters. What stimuli do we make note of? Everything is possibly important. We are scientists making objective observations, throwing out any preconceived notions. Generally speaking, environmental stimuli are anything that the child can experience through the senses. Further, environmental stimuli need to be considered at many levels. Some examples include color, size, groups of people, or rooms. As we first begin our observations, we don’t know exactly what the child is reacting to in the environment. We begin to make sense of what we are observing by recording data about the context during the aversive reaction. The observation and recording procedures will eventually allow us to identify trends and narrow down the possible causes of the aversive reaction.
For example, suppose a child with autism is in a carpeted room with yellow walls that has ten people and a dog in it with music playing. The child begins to scream at the top of her lungs and tries to leave the room. Without recording information about the room or context of the reaction, we don’t know what the child is reacting to. The child could be reacting to the number of people, the dog, the color of the room, the music or type of music or the fact that the room was carpeted.
The first step is to record data (information) about the context in which the reaction occurred. After recording data for a set period of time over multiple occasions when the adverse reaction occurs, the information patterns of responding may become evident. With such patterns you now can begin to narrow down the possible causes of the adverse reaction. For instance, in the room described above, observations of the adverse reaction could be made that don’t involve people in the room, dogs, carpet, or color; however, each instance always involved music. Based on this information we can hypothesize that this child’s adverse reaction was related to the music playing. Taking data allows us to more objectively examine events and to specifically narrow down the environmental stimuli that the child may be sensitive to. This provides us with a very clear idea of the stimuli that needs to be targeted for desensitization.
Now that we have identified the target to work on (sound sensitivity), our attention can turn to intervention planning (in this case desensitization) that will be used to remediate the target problem. This is where most caregivers begin to feel overwhelmed and ineffective. Where and how do you begin to change this behavior from a very uncooperative child? Our answer to that is to step back from the problem and begin to break the issue down into manageable components. In the current example, the next step in intervention development is to develop a hierarchy of similar stimuli that cause the negative reaction. Assuming that the music is being targeted for desensitization, the stimuli are ordered from music that causes no reaction to music that causes a severe reaction. This process is called probing.
We now have information on the challenging stimuli (Sensitivity to music) and a hierarchy of offending music. Now what? The next step in the intervention process is to gather information about stimuli that the child finds pleasurable and comforting. Such items can include items, foods, places, and objects. At this stage, the plan is to expose the child to the least aversive music while the child engages in pleasurable activities such as playing, snuggling, or eating a favorite food. The general principle here is that the aversive event becomes predictive of a positive event, and the good feeling related to the positive event is being transferred to the negative event. The end result is that the child becomes comfortable with the previously aversive event. You then move up the list of aversive stimuli. As the child learns to overcome their sensitivity to music, and other challenges, he or she learns to enjoy and tolerate more human experiences, and these experiences can also be used in the future to desensitize the child to other stimuli.
In learning to tolerate and enjoy a vast array of experiences, the child is also learning mastery over the environment. Not only has the child become used to the formerly aversive event, the child has also learned that he/she has the capability to control preferences. The child has learned that, at least in this one circumstance, what was distasteful is now enjoyable. This internalized control of preference, knowing that you have a choice about how you interpret the environment, has vast ramifications for interactions with the environment in the future. You are no longer at the mercy of the environment. Free will and a sense of self develop out of learning to control and manipulate the environment. One experience will not result in this change, but thousands will. With each step the child becomes freer to experience the joys of the world and more competent in dealing with the world.
Although this is the first step in therapy, this is something that is focused on throughout the lifespan. Giving the child the strategy of facing situations that are distressing and learning how to control them as well as learning to control how he/she experiences the environment, increases the child's ability to cope in an ever-changing world. Through the process of therapy, the therapist working with the child and parents needs to be constantly vigilant. They always need to be watching for situations that can be targeted. If the child has a negative reaction to something, you have the option of developing a program of experiences to address the sensitivity or deciding that it is not a priority at this time.
On a cautionary note, we never want to overwhelm the child with too much change at any one time. We always go back to the initial stance of wanting the child to be comfortable and secure 90-95% of the time. We could spend all day long exposing children to things they fear. If this is done too extensively or in the wrong predictive direction (good-bad), the positives being paired with the negatives will lose their value. The negative situation will color the child’s view of what used to be a positive experience and undermine the child’s confidence and trust in the therapist/parent. This is where priorities must be set. Not everything can be worked on at the same time, and many goals will need to be abandoned all together to maintain an experience that is positive and enjoyable 90-95% of the time. Thoughtful consideration of the value of working on an issue must always be weighed against other priorities in the therapy process.
Throughout the course of therapy, there will be times when strategies and priorities need to be reevaluated to maintain the 90-95% rule. There will be times when the therapist or parent needs to reprioritize and wait to address an issue at a later date. Although the therapeutic process of intensive therapy begins with environmental acceptance, this will be an ongoing endeavor throughout therapy and throughout life.
Brad was a bright but extremely oppositional child with Aspergers Syndrome. Brad’s behaviors were a huge stressor on the family and were literally tearing the family apart. Brad’s parents frequently came to us frantic with concerns about how to manage his unruly behavior. Upon observation of the behaviors and how they were being handled by the family, we found this family doing what many do in such situations. That is trying to work on a little bit of everything all at once, without a clear plan. The problem with this is that it comes across to the child as a piecemeal approach and ultimately lacks consistency. When we examined the situation further, we helped the family prioritize goals and develop consistent plans for each goal that they agreed they could follow through with. In this instance, the child was aggressive toward others and used disrespectful language. Managing aggressive behaviors became the first phase of the intervention. Many other targets existed, however, they were left for another day while all “intervention energy” went toward following the plan to reduce aggressive behavior. Once aggression decreased and compliance increased, we could then begin to target other skills.
Of course, every child is different. As with any group of people, personalities range from very bold to very timid. Learning to observe the child’s behavior provides a vast amount of information about the child. One way to address environmental acceptance is to begin the session by not initiating interaction with the child at all. Just observe them doing whatever it is they are doing in the environment. This procedure won’t interfere with a child who is bold but will provide a more cautious child the time he/she needs to adapt to a new environment. As you observe the child in an environment ask yourself: Do they appear confident, bursting into the room and attacking the toys or more laid back and clinging to familiar people? If the child is interacting confidently with the room and people present, then environmental acceptance at this time is not much of an issue. If the child is anxious or uncomfortable with the room or new people they may avoid eye contact, cling to parents or sit quietly distant from the therapist. Sitting back and observing will give the child a chance to become acclimated to the room and you. With this child, continue to observe as he/she explores the room.
Once the child has had an opportunity to acclimate somewhat to the environment, we can turn our attention toward interaction. One way of initiating interaction, is to startle slightly and act slightly timid or afraid if the child should look at you. This is usually funny to children, and the action will increase their interest in you and their confidence in exploring. As they look at you, look away quickly as if you don’t want the confrontation. These behaviors are designed to strengthen the child’s confidence and increase feelings of security. The worst thing that will happen from using these strategies is that the child will think you are a little odd.
These behaviors are also drawing the child into interaction where they feel in control and empowered. The child will often begin to play with the control he/she has over you and become energized and bold. If you try to approach the child, approach in a casual non-threatening way. If they seem nervous back off slowly and act timid. You can even turn this into a game where they control your behavior by glancing at you and you back off with every glance they make.
As the child becomes more comfortable, you have the opportunity to see the child in their typical state. Observe the toys the child gravitates to and the movements the child prefers. When you approach the child, do so with the intent of helping the child pursue some goal you have determined he/she has. For example, if the child is stacking blocks, help the child by handing them more blocks or by keeping the tower of blocks from falling over. It is vital that you be ever conscious of the child’s reaction toward your efforts to interact because this will determine how you proceed. If the child gets anxious about your presence, step back and move more slowly. Remember that the child has no experience with you, and the child will need your presence to be predictive of positive interactions and enjoyment before you will be experienced as an enjoyable part of the child’s environment. As you slowly join the child’s activities with the goal of providing assistance, the child will start to feel comfortable around you. When they are comfortable, you can use all of the information you have accumulated through observation to join the child in games. Your observations of the child’s preferred movements may suggest to you that the child might like to swing or rock. Join with the child’s activities offering the preferred movements. Within no time, you will find that you have established yourself as a person who the child enjoys being around and the child has become comfortable with a new person and environment. Essentially you have expanded the child’s options in the world.
We recently had an initial appointment with a three-year-old child. The report from his pediatrician stated that his extreme shyness made it difficult to determine if he met the full diagnostic criteria for autism. The child smiled when I met him in the lobby as he ducked behind his parent. During the beginning of the initial session I spoke to the parents as I watched him play with toys. He explored the toy box and pulled out a number of toys. He interacted with his parents, bringing the toys to them.
When I tried to interact with the child he virtually crawled behind the couch as I approached. I sat back down and I tried the above techniques to draw him into interaction. As the session continued, the child began to look at me more often. Each time he did, I looked down at my paperwork, affectively demonstrating mild fear and that I was intimidated. With these strategies the child started to become bolder. He began to get off the couch and leave his mother to get me to react. Each time, I affectively showed a fear reaction and flinched. Within fifteen minutes, the child was running over and slapping my leg to get me to flinch. By the end of the session we were chasing each other back and forth in the room, and he was able to tolerate me picking him up and swinging him around. The positive result of this example required that I apply the rules of environmental acceptance that have been detailed in this chapter:
Making objective observations; the child was fearful and not comfortable with the environment and the examiner.
Recording observations; observations of the child and his reaction to me were recorded as the session went on.
Breaking targets down into manageable components; I determined from observations that the child was fearful of the room and examiner and decided I needed to decrease his fear before I could get an accurate sample of his autistic symptoms.
Creating a plan that fits the child’s current preferences and ability level; I determined as the session went on that the child enjoyed the control he had over my behavior. The child became bold and I took his lead in the chase game that we played.
Applying the plan patiently and consistently; In this case I worked on the first issue that significantly interfered with the task at hand. I needed an accurate representation of the child’s behavior. His fear was interfering with my ability to get an accurate sample of his behavior. So I worked on first things first. As he got over his fear his symptoms of autism were more clearly visible.
The case described above demonstrates a very good outcome from these procedures. I have also had children that would not interact with me during the two hour screening session. Ideally what I have done, however, is build a base of confidence that can be built on in upcoming sessions.
The above description of an initial session with an anxious child with autism highlights the use of behavioral strategies to develop security with the environment and people. Once security is developed and the child views the therapist as someone fun to interact with, the therapist can use him/her self as a comforting agent when introducing a child to a new environment. The more positive, enjoyable feelings the child has toward the therapist, the more power the therapist has to positively impact the child’s life. Systematic procedures can be used to develop positive feelings and behaviors toward places, people, foods, and interactions. Again the general strategy is to help the child build positive feelings with as many people, objects, and places as possible so that these can be used to further expand the child’s choices and opportunities in life.
When providing treatment to a new child, we like the major interactions to be around the establishment of environmental acceptance, helping the child to self-regulate through finding comfort in the environment and interactions, and creating as many positive and comfortable feelings as possible through emotional engagement. This should be the major focus of therapy for the first month or two as more demand-related and discrimination-related programs are added slowly. The time spent on establishing comfort and security, as well as a playful and exciting environment, will be well worth the time spent in the long run. The child will learn faster, have better attention and enjoy therapy more.
Play with a child at this level will often focus on getting the child used to the environment, toys, and people using the principals described above. We will often observe a child’s play at this level and join the child in their favorite activities. The main goal is to help the child feel comfortable in the environment and comfortable with the toys and people they will be interacting with. Very minimal intrusion into the child’s play will be attempted at this level aside from joining the child with the goal of helping them achieve some goal you have determined they have.