Autism Spectrum Disorders Interdisciplinary Teaming in Schools Features
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Features  |   April 01, 2003
Autism Spectrum Disorders
Author Notes
  • Margaret Ervin, is a contributing writer to The ASHA Leader.
    Margaret Ervin, is a contributing writer to The ASHA Leader.×
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Special Populations / Autism Spectrum / School-Based Settings / Features
Features   |   April 01, 2003
Autism Spectrum Disorders
The ASHA Leader, April 2003, Vol. 8, 4-15. doi:10.1044/leader.FTR2.08072003.4
The ASHA Leader, April 2003, Vol. 8, 4-15. doi:10.1044/leader.FTR2.08072003.4
Alex is very interested in school. He loves the unit on dinosaurs that his fourth-grade teacher is presenting. He knows more dinosaur facts than anyone else in the class. He can tell you when Triceratops roamed the earth (65 million years ago), what they ate (small trees, saplings, and bushes), the meaning of their name (tree-horned head), and when and by whom the first fossil specimen was found (in 1888 by John Bell Hatcher). But despite his prodigious thirst for knowledge and his remarkable memory, Alex is one of his teacher’s most challenging students.
The teacher asks the class what Triceratops ate. Emily, who sits near Alex, moves closer to get a look at his detailed dinosaur report and answers the teacher’s question, “Triceratops ate plants.” Alex responds in a loud inappropriate voice, “Small trees, saplings, and bushes. Small trees, saplings, and bushes. Small trees, saplings, and bushes.”
Alex finds it very difficult to have anyone physically close to him in the classroom. When he feels crowded or when someone touches him he may react the way he did to Emily, and his behavior can easily escalate from perseverating or argumentative language to shouting and hand flapping. Yet his behavior has purpose. When Alex raises his voice and starts to argue with his classmates or the teacher, he is communicating that he feels uncomfortable. And by asserting his mastery over the facts, he is attempting to regain control of his world.
His teacher and the teacher’s aide have learned to recognize Alex’s discomfort before his behavior gets the best of him. Thanks to an integrated team approach involving the classroom teacher, a teacher’s aide, and a speech-language pathologist, Alex has people to help him step back from stressful situations before he acts out. He has a place to go outside the classroom when he needs a break. He has a speech-language pathology group outside the class where he works on pragmatic language skills. His classroom teacher, SLP, and parents all work together to provide a consistent approach with minimal pull-outs, which they have learned works best for him now that he is in fourth grade.
Alex has a diagnosis of autism, and, like many children with autism, he needs the intellectual stimulation and integration of the classroom and wants to be like his peers, even though being in the classroom sometimes presents social challenges that he is unable to handle on his own.
Children like the fictional Alex present both a challenge and an opportunity for clinicians. SLPs are uniquely equipped to address the needs of children with autism, since many of these children’s needs center around pragmatic language, the use of language in its social context. At present, SLPs receive general background in pragmatics but little formal training in working with children with autism. An SLP’s first encounter with a child with autism is often on the job, and, given the recent increase in the prevalence of the disorder, there is now plenty of opportunity for on-the-job training. Because autism specialists are increasingly being hired either on staff or as consultants, SLPs are gearing up as leaders on the integrated teams of professionals that serve children on the autism spectrum.
Though the causes of the increase in autism have yet to be determined, initial investigations indicate that it stems from a combination of improved diagnosis and a real increase in incidence, the latter perhaps the result of environmental factors. While scientists work to get to the bottom of the mystery, some school districts have experienced as much as a fourfold increase in their autism spectrum caseload. The challenge of such an increase can feel staggering on a day-to-day basis, but SLPs are often the heroes in this story, providing solutions and structure to support families and to help children with autism move toward independence, appropriate language use, and social connection.
The Necessity for Teams
One of the issues in working with children on the autism spectrum, as the term “spectrum” implies, is the wide range of cognitive, communication, and social abilities represented by children with a range of diagnoses from autism to Asperger syndrome. Alex represents a relatively high-functioning child, but some children with autism have more severe cognitive, communication, and social disabilities.
“There is no typical child with autism,” says Pamela Martins, an SLP who works in the Newton, MA, public schools. This means diagnosis is not a prescription for language and pragmatics treatment, but a guide. The balance of information about the child’s treatment needs is going to come from multiple sets of eyes.
Barry Prizant, a former professor of communication sciences and disorders at Brown University and now a private practitioner specializing in autism, echoes Martins’ observation. He says, “Each child with autism will have needs that may be as different from another child with autism as they are from the needs of a child who is developing normally.” The approach for each child must both take into account known treatment strategies and be flexible enough to adapt those approaches to a specific situation. To get to an effective treatment, the SLP has to listen to everyone who knows what is going on with the child.
In addition to the challenge of finding what works for the individual child, children on the autism spectrum generally have a high need for consistency. This further necessitates teaming. Though the nature of the approach varies from child to child and over time, the common denominator is that children with autism make the most progress when the adults in their lives are on the same page. Says Elsa Abele, a professor at Boston University who consults in schools on high-functioning children on the autism spectrum, “Sometimes the parents use a journal to communicate back and forth with the teacher. Other times it is a tape recorder. And, of course, the team meets on a regular basis, but usually it is the classroom teacher who is the primary contact with the parents.”
The SLP’s Role on the Team
In terms of the dynamics of the interdisciplinary team—parents, teacher, SLP, occupational therapist (OT), and others—Abele says, “It becomes clear who is working well with the child, and other people are then willing to let that person take the lead. The thing that keeps turf wars from happening is ironing things out in meetings, not on the back of the child.” But Abele notes that conflicts on teams over who is the lead, whether SLP or OT, are rare in her experience. She observes, “People are grateful to have someone else take the lead, far from seeing that person as encroaching on their territory.”
In Abele’s consulting work with children diagnosed with Asperger syndrome—a disorder characterized by behaviors similar to autism, deficiencies in social and communication skills, but normal intelligence and language development—she sees one of the roles of the SLP as changing the way general educators think. She maintains, “Rather than narrowly defining educational success as helping someone be a successful learner, we need to focus also on how children handle the social aspect of schooling. What do you do with a child who gets high academic scores but has trouble socially?”
As a school SLP, Martins works with a wide range of children on the autism spectrum. She describes her role on the team as “fitting the puzzle together for each kid and acting as facilitator.” In the fall, before school starts, she provides an inservice for the other team members. “Knowledge being a powerful thing,” she says with a chuckle, “I give them some research articles to read. I also give them information about what worked with certain kids from the year before. Then once school starts I can model some of the techniques for the teacher. Modeling always works better than telling. Show, don’t tell.”
Sharon Basten, autism specialist for the Palatine Community Consolidated School District 15 in Palatine, IL, works in a district that has experienced a radical increase in the incidence of autism—400% in five years. Initially after the increase, SLPs did a lot of training with other team members on visual systems as a form of language. Now teachers understand and are used to incorporating visual language in their classroom teaching.
Another way Basten and her colleagues lead the team is in setting up a system of data collection. Basten says, “Certain areas of growth are targeted, and every member of the team is responsible for collection.” Data collection is good practice in any event, but in working with children with autism, it is vital. Because children with autism are very different from one another and because their needs change over time, it’s important to adjust their treatment plan according to new developments. Data collection—recording observations of specific behaviors—helps keep track of changes. It also provides a way to keep the whole team focused.
Another area in which the SLP functions as educator for the team is in championing an understanding of behavior, even inappropriate behavior, as an attempt at communication. Even hand flapping can be communication. Current best practice for speech-language pathology stresses that inappropriate behavior occurs when a child does not have the ability to communicate appropriately. An older behavior modification approach focused on a set of desired behavior and sought to drill children until they behaved in the desired manner. Current interventions start from the assumption that the child wants to communicate and assume that the SLP’s role is to help remove obstacles to communication and provide tools for communication.
Classroom Inclusion and Peer Groups
Gail Richard, SLP and professor of communication sciences and disorders at Eastern Illinois University, says she has seen a huge leap forward in the past 10–15 years in terms of humane treatment methods for children with autism. Her interest lies in the neurobiological directions in research on autism spectrum disorders, and she demonstrates in her research that children on the autism spectrum have a high need for exercise. Incorporating exercise in children’s daily routine increases their ability to perform other tasks and decreases inappropriate behavior. She also gives children something to occupy themselves physically (e.g., a simple squishy ball) to help them focus while the teacher reads a story.
Abele works with interdisciplinary teams in the Newton, MA, public schools to help develop IEPs for children on the autism spectrum who have Aspergers or autism with high-functioning cognitive abilities. She helps guide and support the process SLPs and other professionals go through in order to adjust to children’s evolving needs. Abele suggests that children with autism can be provided with a safe space, outside the classroom if necessary. For some children it works well to have a safe space in a corner inside the classroom. In addition, children may do explicit work on speech production in a separate treatment room with the SLP also visiting the class at least once a week so that she can check on language use and comprehension.
“By fourth grade,” says Abele, “it’s often important to have a client manager so the child isn’t being pulled out too much.” It’s the children who give the cues that they don’t want to be pulled out. In fourth grade they are becoming more interested in fitting in with their peer group.
“The client manager, often a speech-language pathologist or occupational therapist, implements the pull-out services that the team agrees are needed,” Abele says. This requires good communication on the team and consensus as to the child’s goals.
And there are other ways to meet a child’s growing need to fit in. Martins describes children with autism as possessing “a depressed understanding and desire to be social combined with a cognitive desire to be like their peers.” This is where peer groups come into play. Rather than running a pull-out peer group that removes children with disabilities from the classroom, Martins runs a lunch-time peer group that meets in her office. This way the group blends into the schedule. She opens the invitation to the whole class, calling it “boys group.” Each group meets for six weeks. The incentive is having lunch outside the lunchroom with boys only. Her current lunch group consists of three boys, one of whom—let’s call him Sam— has autism, while the other two are normally developing.
At age 11, Sam has a strong desire to have friends. He looks around and sees that other boys have friends, and he wants some too. Martins says that when they started meeting, Sam sat with his back to everyone and ate his sandwich. Now, with some minimal prompting from Martins, he faces the group and talks about topics of common interest. “That isn’t hard to find,” says Martin. “Computer games. All the boys are interested in computer games, but kids on the autism spectrum are just a little more interested.” Sam is learning how to initiate conversations with help from Martins, and all this is happening in an organic fashion in the context of a peer group.
Celebrating Day-to-Day Success
Very rarely does a person recover from autism. Very unusual are the people with Aspergers or autism who have genius IQs. But those are the stories that play in the media. On television and in newspapers we get either news stories about the increase in autism or human interest stories depicting unusual treatment methods that effect miraculous cures. SLPs in schools who work daily with children on the autism spectrum don’t see their work reflected in those stories. Real day-to-day successes are found in small communication breakthroughs or in gradual improvements that take place over the course of years.
Reflecting on success, Basten says, “We have a student who rarely uses appropriate pragmatic language. Then the other day someone came into the class to observe, and this child said ‘Hi,’ and then, as if that wasn’t surprising enough, he introduced the guest to the rest of the class.”
Martins remembers helping some parents through a hard time. “The parents met with me and they were wondering and worried about the diagnosis and why their child is this way. I spent some time engaging them in that philosophical discussion, but then I turned the topic to how we could help their child have a friend. They aren’t ready to let go of asking ‘why,’ but now they feel some relief because we are working on their child’s welfare today.”
Katherine Elias, a private practitioner in Watertown, MA, tells a story of one moment and her wry take on turning it into a success story. “I was giving the group their snack, and a little girl who really never uses language appropriately said, ‘Kathy, I really like the snack.’ I guess that is success. At the end of the day, I know that I have contributed to someone’s life. I’m glad I don’t sell TVs. I get to go home and say, ‘I gave someone a nice snack.’”
Another practitioner summed it up by saying, “I don’t think success can be measured by any fireworks. Day in, day out, there are small successes, and you have to celebrate each and every one.”
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April 2003
Volume 8, Issue 7