Support communication and reduce anxiety; implementing small strategies to help children on the Autism Spectrum
I think about small strategies a lot of the time – probably more than I should – because I see so many families struggle to find ways to implement advice from professional services into the fabric of their lives. It’s hard. It is so easy to give the advice, but so much harder to put it into practice.
Making sense of strategies
Family life is rarely structured like a clinic session, and parents rarely have just one child to focus on. Advice can seem alien and it can be hard to work out how to follow it, when to follow it, where and even why to follow it. Even small strategies can be hard to make sense of. Not for us – they are second nature to speech and language therapists – but they can feel like a foreign language to families and can easily fall by the wayside.
I am a problem solver and that is why I spend so much of my life thinking about these little strategies and how I can make them easier to implement. As I drive up the M25 to work, I wonder how I can integrate visual support with a busy family life. As I push the trolley round Sainsbury’s, I ponder on how to help families reduce the amount of questions they ask their child. Running the bath for my son who is old enough to run his own bath, I think of charts and grids I want to make. I miss turnings, burn the dinner, make my son’s bath too hot, and I still have not found the perfect solution!
This blog post is another attempt to find viable solutions. I want to share my thoughts and ideas with you, and I would welcome any thoughts and suggestions.
The behaviour that strangers don’t understand
I work mainly with children who are on the spectrum, or have some similar difficulties, which can impact enormously on family life. I work with one family who sometimes spend up to 40 minutes trying to coax their child into the car. This can be so exhausting, that they sometimes give up and abandon what they had planned to do. I work with another family whose child has such high levels of anxiety that leaving the house is extremely difficult. The child screams and cries, he is so fearful of the unknown, which is equally distressing and worrying for the parents.
Many parents tell me stories of strangers criticising their parenting when they go out with their children. People interpret fear and distress as bad behaviour, and love and concern as weak parenting. Parents have told me that strangers have come up to them and said that they are not strict enough, that their child needs firm boundaries and they should not put up with such appalling behaviour. Parenting a child with this level of difficulty can make you feel inadequate and unconfident and the last thing you want to hear is a total stranger criticise and judge you.
What they see is the behaviour, the response to what the child is feeling, seeing, hearing – the response to his internal and external situation. What they can’t see is what is causing this, what is underneath the surface driving the behaviours.
Most children find unpredictable events hard to manage, can become very upset when they have to stop activities that they really enjoy, and find change and transitions very difficult. Difficulties with theory of mind (empathy, being able to put yourself in another person’s shoes), anxiety and strong emotions that are hard to regulate, sensory difficulties and a different thinking style can impact on this and exacerbate difficulties. To the unknowing eye, this can look like bad behaviour. But that is one thing it most definitely is not.
Love for your child softens the hardship. I have met so many amazing parents. Parents who have worked out strange and wonderful coping strategies and support for their children. Parents who will do anything if it helps. Sleep is often a casualty. A social life can become a distant memory – it can be so hard. I know. I remember many of the experiences parents tell me about. When I look back, I can see the support I put in place without realising what I was doing. I was problem-solving, finding what would alleviate suffering, reduce anxiety, soothe distress, help my child to enjoy life and reach their potential. It can be a long, rocky road.
The importance of early intervention
We have known for a long time that early intervention can help children on the autism spectrum, and recently research carried out by several universities and NHS Trusts found that working closely with parents and carers had positive outcomes for social communication and interactions. See http://research.bmh.manchester.ac.uk/pact/about/ Parents who took part in this research attended a two hour intervention/training session every fortnight for six months and then once a month for a further six months. Families had to commit to 30 minutes of home practice every day. http://www.autismsupportnetwork.com/news/preschool-communication-intervention-helps-child-parent-interaction-autism-22938871
One size does not fit all families
Many of the approaches used in PACT are used routinely by speech and language therapists, but the research suggests that this support is needed for at least a year. Short blocks with gaps in between might not get the same results. Understanding your child’s communication difficulties and adapting your own to enable them is not easy. It can take time to feel confident and comfortable using strategies with your child and to understand the point and value of them. One size most definitely does not fit all, and families need to find what works for them and their child. In my work as an independent therapist, I have found that it is hard to quantify how long families need speech and language therapy support because it is not just about the child, it is about helping the whole family. Some families feel able to implement support quickly and confidently, but others do not.
Simple strategies to develop communication skills
Below are some simple strategies that can be used in all settings, e.g. home, nursery and school, to develop early communication and interaction skills.
“I think in pictures. Words are like a second language to me…when somebody speaks to me, his words are instantly translated into pictures… One of the most profound mysteries of autism has been the remarkable ability of most autistic people to excel at visual spatial skills while performing so poorly at verbal skills.” (Grandin, 1995)
Visual support can help children manage daily routines and activities, transitions and change and it can help them follow adult direction. It can reduce anxiety and make life more predictable and manageable. There are many different forms of visual support. Here are some examples of early targets that can make a difference to children and their families.
i) Use a timer to stop a child doing something that he/she enjoys, e.g. playing on a tablet, watching a favourite DVD, playing outside.
Timers can be a Godsend! It can take time to introduce them, but once the child has got used to them, they are great. I work with families who take them out with them so that if there is a potentially difficult situation they can bring out the timer and use it to avoid a meltdown.
ii) Use a now and next board to:
- Do two things at home, e.g. DVD / bath. Teeth / Train.
- Do 2 things out of the house, e.g. car / supermarket. Buggy / park.
Some children need photos of activities/places/people, etc. because they need an exact likeness. Others can use symbols. Recent research indicates that not all children need to follow a hierarchy of types of pictures, e.g. objects, colour photos, black and white photos, colour drawings, black and white drawings, written word. The National Autistic Society recommends finding what works with the child and using that: “Visual supports are very personal and what works for one person may not work for another.” (NAS visual supports. June 2013). I have found that visual support works all the time for some children and not for others. One size does not fit all. You have to be flexible and resilient – don’t give up if this is the case.
Directing communication to others
There is much debate about eye contact. This is where I stand on it: Looking, even if it is fleeting, does the following:
- Directs communication to others so that they know we are talking to them
- Helps us learn about emotions
- Helps us to monitor how others are responding to us, e.g. does the listener understand, are they interested?
- Shows we are interested in what others are saying
Some people do not work on looking. I do if the child/young person can tolerate it. I do it in a natural context, I never force it or demand it and I accept any eye contact, however brief. I do this because the functions are important, and not being able to look at others at all has impacts on communication and interaction. I recently had an experience where a teacher looked past me and said, “Hello Lucy.” I was really confused and had a quick internal debate with myself, “Is she talking to me or is there someone behind me called Lucy and she is talking to them?” I had no idea and it was quite stressful because I did not want to respond in the wrong way. In the end, I decided there must be someone behind me called Lucy. I turned around to see a lady standing behind me. “I’m called Lucy, too!” I said. The teacher looked confused, “I’m saying hello to you,” she said.
I don’t tell children and young people to look at me. I try to give them a reason to do it. For example:
i) to look at you, even if it is a brief look, when he/she chooses what they want to eat from a choice of two things, e.g. “Apple or banana?”
ii) to look at you, even if it is a brief look, when he/she chooses a toy from a choice of two toys, e.g. “Dinosaur or shark?” “Big ball or little ball?”
Prompting to encourage eye contact when you offer a child a choice of two things
i) Hold the two objects up so that the child can see them easily.
ii) Use an interesting voice, make it go up and down, as this can help children listen.
iii) If they reach for the item they want, but don’t look at you, don’t give it to them but try to help them look at you by:
- Holding out the item they want, keeping it level with your eyes and saying something like, “Apple! You want apple! Yummy apple!” in an interesting voice. Sometimes this helps the child to look at you, then you can give them the apple, “There you are! Apple!” even if they look at you fleetingly.
- If they still don’t look at you, I repeat this, but if it is causing the child distress, I give them what they want or if I have done this a few times and they are not looking I give it to them. If that is the case, I try putting the item they want on my nose, and when they look at it, it is so close to my eyes that they often look at me by accident! Then I immediately give them what they want to re enforce the link between looking and getting the item.
I do this to help the child learn that when they look at me, no matter how briefly, they get what they want, and that looking is part of asking someone for things that we want and communicating successfully.