Sunday, February 13, 2011

Social Interventions and other tools

There are a number of ways to increase social interaction with ASD children. As mentioned in other blogs, children with ASD do not automatically learn social skills through observation. These social skills have to be specifically taught. ASD children lack 'Theory of Mind' so cannot understand that people have separate thoughts to them. We have to accept that with ASD children, social interaction will be on a rote/learnt basis and any empathic skills you may observe is a due to the child remembering the rules and not specifically because of they have managed to "understand" what the other person is thinking and feeling. We also have to remember that a child with ASD has problems generalising a skill learnt in a specific environment or situation. Social skills are very general and there is no way of being able to teach what a verbal cue will be in a situation.

SOCIAL INTERVENTIONS

Social Stories - Recent information has come to light regarding the usefulness of 'social stories' in teaching social skills. (Don't ask me to point to it, because it was mentioned in the conversational part of the lecture and it wasn't referenced as such. Remember this is a blog not an educational work, so I am allowed that lapse).

It has been seen that "social stories" are actually not very good at showing un-defined social skills, i.e. be nice to the kids in school because they will be sad, but is VERY good at teaching specific behaviour, i.e. in class we are quiet, we sit still and we listen to the teacher. When you think of the lack of ToM in ASD children, it makes sense that social-stories will of course not teach how your actions will make people will feel, because this is a concept that is out of the reach of them.

Social stories are best when they are read before you want the desired behaviour, but are not good for teaching desired behaviour after an incident. Social stories are also very good for teaching social behaviour and rules to Neuro-typical children.

"The New Social Story Book" by Carol Gray is written by one of the leading proponants of "social stories"

Floor time - This was developed by Stanley Greenspan. It encourages the caregiver to get to floor level with the child and see/participate what the child is experiencing and expand on that interest with social and verbal skills.

Turn taking games - Turn taking games specifically requires a back-and-fro reciprocal setup. My turn, your turn scenario shows that sometimes you have to sit back and let the other person participate. This initially will have to be aided by visual cues to show who's turn it is, (It's the persons turn when they have the cue card, beanbag etc). This back and forth is important for building conversational skills.

Facilitate Peer interaction - Social skills taught by peers is essential. In a social group at the school you can shape the peers to cue the child with ASD in the correct behaviour. Getting the peers to prompt the child is one of the best ways of teaching social skills to a child with ASD.

Circles program - Nicolas Watkins. This is good for teaching social distances to ASD children. It shows visually what social behaviour is acceptable to (and from) different groups of people. i.e. that hugs and kisses are okay for parents, but not okay to the store clerk. There are some links to the program here.

Video modelling - "Model me Kids program" by Scott Belamy. Short videos that show the targeted behaviour in various situations. Apparently very successful.

Social Thinking - Michelle Garcia Winner. This is a program that shows in a discrete way how people think about you and how you can think about them. She has created the "super-flex" cartoon series which shows expected and unexpected behaviour and how other people react to that. (watched a video showing her practising it - very good).

OTHER TOOLS

Preference Profile sheet - Although not a tool in teaching desired behaviour it is important in showing to a floating SEA/teacher the likes/dislikes and other comments relating to a child with ASD. This is invaluable in showing quickly the triggers and re-inforcers you can use in a child that is not known to you. See link below for a clean example of a "preference profile sheet"

PREMACK system - This is a way of altering a child's schedule so that a preferred activity follows an non-preferred activity. Using a visual schedule or a "Now/Then" chart, you can ensure non-preferred activities are achieved by showing a "preferred" activity will follow. Many ASD children have no concept of time and therefore may feel that during a non-preferred activity they will "never have any fun EVER!". By showing a preferred activity will be coming, you can re-direct avoidance behaviour.

Token Economy - To most parent's this is the token board. A child earns preferred items/scheduling by earning tokens for achieving desired behaviour for a period of time. You have to ensure that when choosing a desired behaviour you are very discrete. A reward for "being good" won't work as the term "being good" is too general. You should define the behaviour through a contract between the child on series of tasks over a specific period of time. Before you create a token economy you need to "base-line" the level of non-preferred behaviour. It is unfair to expect a child who hits 10 times an hour to go 2 hours before earning a token. Initially you may need to reward a child who achieves the desired behaviour EVERY time he performs it. You then increase the time between each token, or increase the number of tokens to be earned before a re-inforcer is given. Increasing the number of tokens to be earned only works on ASD children that have learnt to delay gratification for a re-inforcer. The size of the re-inforcer should be small enough that the child does not become bored of the re-inforcer, i.e don't give a whole bag of candy as a reward, maybe just one. :)

Prompting - Occassionally prompts are required to help a child perform a task. The idea behind prompting is that you should move to reduce the invasiveness of the prompt as quickly as possible. Generally prompting goes through the following levels:
Physical - * Hand-on-hand prompting (moving a child's hand to perform task)
* Physical Tap, or physical reminder to perform task
Gestural - * Showing in a gesture what the action/task should like when you are
performing it. You look as if you are brushing teeth
* Pointing to area or item to show that the task should be done. i.e. pointing
to teeth
Verbal - * Giving full verbal prompt and what should be done. i.e. put toothpaste
on your brush and brush your teeth
* Partial verbal prompt to what should be done. Teeth
You should attempt to move as promptly from Physical to Verbal as you can, however, this
should be directed by the child. If the child is failing to understand a prompt then go back a few steps.

Task Analysis - Most children with ASD become overwhelmed when they envision a task is too big. This will lead to avoidance behaviour. Sometimes it is necessary to split a task into it's individual components and have the child complete the larger task one "sub-task" at a time. When completing a series of sub-tasks, an adult can help the child at the beginning of the set or at the end. Forward chaining is when the child performs the first parts of the task, but the adult completes the rest, (the child puts on his shoes, but the adult ties them up) . Backward chaining is when the adult performs the first steps but the child completes the last (the adult puts the toes in the sock, but the child pulls the sock up).

Discrete Trial Format - Most ABA programs are based on this. There are five stages of Discrete Trial Format.
Ready - if the child is stimming (flapping/moving for stimulus) then manual move hand to a ready position
Stage 1 - Discriminative Stimulus. This is the request... "give me", "match"
Stage 2 - Student response. The child's answer
Stage 3 - Consequence. If the child has the answer wrong, then the child is asked to perform the task again. If the response is correct then a re-inforcer is given.
Stage 4 - Inter-trial interval. Usually the period it takes for the BI to mark the answer before the next repetion of the task.
Stage 5 - Pause for Data collection. The time spent between each series of trials.

Errorless-learning. This is a way of always encouraging the child to the right response either through manipulating the environment (pushing the correct object forward) or a physical prompt. When a intervention is made for the correct answer then a reward is still given. Remember we are trying to encourage the correct response via positive re-inforcement.

Break and relaxation options
Children with ASD may very well become overwhelmed with their environment and therefore it is useful to have a way of allowing a student to have periods where they can relax. This should be done through both Scheduled breaks throughout the day but also through a setup where the student can ask for breaks. (D uses a break card he can hand to the teacher when he needs to calm down). When these breaks occur there are a number of ways to relax. The concrete ways are, books, toys, body pressure, or "hard-work" activities. Abstract ways are, progressing muscle relaxation, deep breathing, visualisation and imagery.


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