Introduction
These reports describe our success in implementing
a comprehensive in-home program for a boy diagnosed as Asperger’s (PDD).
The program was designed from the start to meet Sam's unique needs, difficulties
and learning styles. Sam has been described as a very complex child with
numerous presenting problems and diagnoses and a history of hospitalization.
His school experience has been very difficult, and it was the school system's
failure to find an appropriate placement for him that led to his mother's
decision to home-school and ask for our assistance.
From September 1999, we provided Sam
with an in-home program using a highly structured behavioral format. We
also provided him with a nutritional program based on our work with lutein-free
diets in autism. Based on a careful functional behavioral analysis we performed
in 10/99 his program was designed to include specific components which are
said to be essential for optimal performance and include:
- A structured and consistent school schedule from 8:00 -
2:30, six days per week;
- A reinforcement system which is clearly understood by Sam
and administered consistently;
- Regularly scheduled breaks for physical activity based
on indices of Sam’s need;
- Consistent modification of the length and difficulty level
of tasks based on Sam’s tolerance for frustration;
- Computer instruction;
- Maximization of auditory instructional materials (e.g.,
books on tape, reading to him);
- Minimal levels of stress and extraneous stimulation;
- Continuous modification of the teaching setting according
to Sam’s variable sensory status and tolerance for stimulation.
Initial emphasis was placed on promoting behavioral self control and later,
as behaviors improved, work on academics was begun.
Setting the child up for success - Symptom
or behavior?
Setting unrealistic goals leads to the experience
of failure. A goal that may be easily attainable in a typical child may
be unattainable in an autistic child, especially when what is holding the
child back is not a behavior but a symptom of autism, such as under-functioning
fine-motor control, or distorted visual perception. Choosing activities
as goals which the child already practices regularly and naturally with
success to use as the basis of a schedule makes the transition to using
effective tools much easier for the teacher, parent or caregiver.
But if ‘spinning objects’ was targeted
as a ‘problem behavior’ and the reward system focused on overcoming this
as a primary goal then it is unlikely the teacher or Sam would have a feeling
of success or accomplishment.
Breaking down behavioral complexes
The detailed functional behavioral analysis
that we use provides us with the insight we need to break apart a behavioral
complex - a group of behaviors which work together to make intervention
difficult and make it easier for the parent or teacher to give in. These
complexes are part of a coping strategy that the child develops and include
power struggle techniques, disruption of everyone’s schedule, creating chaos,
etc. They are used very effectively by autists and attachment disordered
children. We use a functional behavioral analysis to identify and target
the behaviors which are most interfering with Sam’s ability to develop new
skills and show us what he can do.
Meeting the child’s needs
Maslow’s hierarchy of needs says that the
child must first feel safe, comfortable and fed (satisfied). Sam wants to
know that he is not in danger, that he can be successful and that foods he
likes and tolerates will be available.
In April, Sam’s progress was again reviewed:
April 26, 2000: Sam does need frequent breaks
and stimulating activities. Once Sam enters the classroom he is eager to
begin work and complete an activity session which can last up to 45 minutes
i.e. computer art, keyboarding and math games. Between activity sets which
generally last 10 to 20 minutes Sam gets up to retrieve his motivator i.e.
beverage, treat, coins and then returns to the computer for the next set.
After a full activity period (3 sets) Sam needs movement and a free time
period outside the classroom if possible - during inclement weather alternatives
such as swimming at local sports center or indoor electronic darts may be
used for movement activities.
Sam returns to the classroom and again
is available to attend to the activity session i.e. hands on art, block
building, crafts. Sam will work on a large time consuming project or up
to 3 smaller projects both independently (with the preparation and adaptation
provided) and 1:1 for more difficult projects. This session is followed
by a free time activity and may be outside or inside. Inside games which
allow Sam to move about such as electronic darts or Mattel tic-tac-toss
may need to be accomplished outside the classroom in the P.E. setting.
Sam’s third activity period is often
reading, phonics and word recognition with short breaks between sets. After
the third activity period Sam sometimes requires a short rest period, possibly
associated with midday medications.
The fourth activity period usually
includes science, social and therapeutic recreation which result in the need
for less motivators when hands on tasks are included which Sam enjoys i.e.
gardening, counting coins, playing board games. One to two days per week,
usually Saturday and Wednesday afternoon peer activities are included in
Sam’s program i.e. simple crafts such as sand art, swimming, board games
with direct supervision and 1:1 support for Sam and peer(s).
Sam is eager to produce stories to
go along with his hand-drawn pictures and ‘make a masterpiece’ computer creations.
Sam’s fine motor deficits make it difficult for him to select keys on the
regular keyboard, so Adaptive Technology equipment ‘Intellikeys’ has allowed
Sam to create story boards to go along with his pictures. Sam enjoys playing
educational interactive games and as soon as he understands the steps he
is eager to say “I can do it myself”; he is particularly eager to start the
programs himself and hear the jingles which accompany many programs i.e.
‘Blues clues’ and ‘Dino-spell’. Audio materials, particularly Auditory Integration
Therapy (AIT) CD’s have decreased his auditory sensitivity and resulted in
the opportunity for additional materials to be added to Sam’s program i.e.
‘Books on tape’. A formal ‘Assistive Technology’ evaluation is scheduled
for April 2000. It is anticipated that recommendations for additional adaptive
equipment may result from this evaluation.
By April 2000, Sam could: work on a computer
using several different interactive programs; designed and constructed his
own picture book wall collage using computer-assisted artwork; recognized
and could spell up to 100 words; understood basic math principles (addition,
multiplication etc.), participated in craft activities including making
gifts, birthday cards, etc. gardening, cooking, housework, shopping, apologized
for stepping on someone’s toe, was interacting with his ‘typical’ younger
sister in a peer relationship, was fun and entertaining, making jokes and
telling stories.
Sam's mother reported:
“A night and day difference” in Sam’s behavior
since beginning the home-based program and eliminating lutein from his diet.
He is far less aggressive toward and harassing of his siblings. He is less
likely to run away. He is significantly more compliant with verbal directives
and with his home-school routine. His level of motivation to participate
in academic tasks has increased and he earns his maximum reward most of the
time.
Attending abilities have improved as
well. He is better able to focus and can do so for a longer period of time.
He is reportedly less distractible and less hyperactive. His rate of task
completion has improved.
Emotionally Sam is happier and, having
had a greater number of success experiences, more confident in his skills
and proud of his accomplishments. Sam’s adaptive behavior skills have also
improved. He is able to prepare simple lunches for himself and perform routine
hygiene tasks more competently with little or no assistance. He is able
to occupy himself independently and productively for increasingly longer
periods of time. Social skills have improved as well.
