Ask Amanda - About Tourette syndrome awareness

What might a strategy be in order to educate a class where there is present a boy with Tourette syndrome? Ho might we address this situation with respect to the students as well as the class? The boy has blinking as well as some verbal ticks wich at times can be distracting to his learning ability as well as the rest of the class. ... Facebook Friend

When helping build awareness about a child's disability the most important rules to adhere to are:

1. Make sure the process is controlled by the parent and/or the child.
2. Promote empathy rather than sympathy

Make sure the process is controlled by the parent/child

Talk to the parent and the child. Get their ideas. What do they want to share?

If they do not want to talk about the child's disability specifically, then you need to address the issue in general terms. I will talk more about this below. This is often the most effective approach as it decreases the chances of the child being stereotyped by their "label" or disability.

Secondly, if the child does want to talk about their disability, it should be done in the context of all students talking about themselves. This sets up an environment of respect and empathy, rather than pity and isolating the student as "different" or with nothing in common with their peers.

For example, use "get-to-know-you" games. These could include sitting in a circle and throwing a ball. The person who catches a ball has to say something about themselves. It is best to have some guidelines about what they share, and also have some rules about responding respectfully. To find out more about rules go here.

And that brings me to another point - before you do anything, you need to set up a culture of respect by establishing these class rules. You also need to model the attitudes you want, such as including the child and praising the child, relating to them in the same way you would with any other student in your classroom.

Promote empathy rather than sympathy

If you want to discuss the issue with the class, make sure you do it in a way that helps them relate to the child rather than feel sorry for or fear them.

For example, don't talk about Tourettes syndrome. Talk about the things that the children see and hear (the blinking and verbal tics). But do this indirectly. An example of how you might do this is below. You will need to adapt this according to the age of the children and so on.

The way we act and what we say is effected by a lot of different things. But one of the most important things that effects how our body moves and what we say is the messages our brain sends to our body.

It is like each person is run by electricity and the brain is the power station. The "wires" that carry the electricity to "run" our body and our speech can be effected by different things. Tiredness, being sick and sometimes just the way our bodies are made. These things may mean it is hard to turn the power on or off. It may mean that one part of our body gets too much power, while another part doesn't get enough.

If we can't turn the power off when we want to we might call out when we don't mean to, or our body might move even when we don't want it to move.

Whether you personalise it or not will depend on whether the child/parent wants this. But just remember - if your students ask you "Is that what is wrong with ...", don't avoid the issue like it is taboo or a bad thing. Just calmly and briefly answer the question (or give the child with tourettes syndrome the opportunity to respond) without making a big deal of it.

This approach will help the children understand and relate to the child, rather than trying to teach them about a "label" or a syndrome - to which they won't be able to relate. Labelling can also increase the chances of bullying.

I hope that helps. If you want to know more about the syndrome and what you can do in the classroom to support students with tourettes, you might want to visit http://www.tourettesyndrome.net/education.htm

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Ask Amanda - response to Paula

I work with a 4th grader who has Down Syndrome. She often sees other children, who are close friends, hugging or pushing each other in joking ways. Since she is not at age level with social skills, she applies this same behavior to other children she doesn't know. She will go up to children in the lunchroom or on the playground and grab or hug them. Most children do not like this. I don't know how to explain the social do's and don'ts to her. Paula D.

Thanks for asking, Paula.

Helping your student understand complex and changeable rules can be difficult, especially if they struggle to understand abstract concepts. One of the best ways to make it more concrete is through visuals.

In this case, you may find that the best way to teach your student about appropriate hugging and touching may be through a picture.

The illustration on below is based on the colours of a traffic light - it could be presented as three separate circles as well. The idea is that the student can write names of people, or illustrate or collect pictures of specific people or types of people (eg teachers) to stick into each circle according to how she should relate to that person.

You can also write (or use symbols) in the circles to clarify under what circumstances and how you might touch a person (eg. shake hands when saying hello).


This process could be used for other social rules, but it is best to focus on one at a time so as not to be too confusing or complex for the child.

I hope that helps a little... Again, if anyone else has any suggestions, please feel free to add your ideas as a comment.

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Ask Amanda - Kim's Question

Hi Amanda, this is Kim from facebook. I have a question, or a suggestion depending.. Have you made a book, or social story about biting? Or other behaviors like kicking, hitting, spitting, banging head. Any "sterotypical" autistic behaviors that need intervention? I think showing visuals would help with these since the child doesn't understand that it hurts others, or can really hurt themselves. Thanks

Thanks for your comment, Kim.

I have only just begun writing books that can be used for children of all abilities to learn social skills. Dave is Brave, the first of these books, does look at rough behaviour, but it does not directly address the behaviours you have highlighted. It is something I will consider in the future.

Having said that, there are some great visuals that have been developed by others. You might want to check out http://www.do2learn.com/subscription/product_details/pdf_social.php or search for Boardmaker products. I am not sure about other countries, but many schools and early intervention centres in Australia use Boardmaker so you may find that your child's school already has a product available that may help.

Another thing to consider about these behaviours is the reason why they are occuring. If it is not due to the social difficulties discussed in previous posts, it may be due to sensory integration difficulties. This document, Sensory integration and Sensory integration dysfunction, discusses this well.

So, for example, if a child is biting themselves or banging their head in order to "feel" something, it may be important to find an alternative that provides that stimulation without hurting the child rather than trying to use pictures to communicate why they shouldn't bite themselves. Massage beads, stress balls and other toys may be usefull in helping change the child's behaviour. Giving the child an object such as this every time they start to display self-harming behaviour will help them replace the behaviour, eliminating it, whilst still gaining the stimulation needed to cope with difficult situations.

If there is anyone reading this blog who has some other suggestions, please feel free to share.

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Modelling and rewards

Chris is sitting eating lunch with her peers. They are chatting away. Suddenly, without warning, Chris gets up and leaves. Her peers look very surprised and a little offended.

Applied behaviour Analysis

Pictures and social stories are often used in the process of Applied Behaviour Analysis (ABA). This approach is about analysing what we can see, breaking down behaviour into small steps, and changing it through encouraging, modelling, prompting, and praising changed behaviour

Using ABA for Chris

If we applied this approach to Chris’ situation, we would have to start by looking at what is actually happening. We might start with writing a more detailed observation of what is happening.

Antecedent:
Before Chris walked away, she had been intermittently involved in a discussion with her peers. They were talking about their favourite foods.
Jenny looks at her sandwich then smiles at her two buddies: I love vegemite sandwiches! They are great.
Chris continues looking at and eating her sandwich. Tom smiles back at Jenny: Yeah, I like them, too. But I like cheese better.
Chris (still looking at her sandwich, which is almost finished): I like cheese.
Tom smiles at Chris: Mmmm. It is so good, especially with some tomato. Have you ever had it with tomato?

Behaviour:
Chris has finished her sandwich and walks away.

Consequence:
Chris puts her rubbish in the bin and puts her lunchbox away in her bag.
Tom looks surprised and a little offended.
Jenny looks at Tom: Maybe she didn’t hear you.
Tom and Jenny sit silently until they finish their sandwiches, then quietly pack up.

So what next?

This observation gives some ideas about what is going on. For example, while Chris was listening to Tom and Jenny, she was not paying attention to them. That is, she is not making eye contact. This meant that she missed the body language, facial expressions and social rules that would have told her about whether the conversation was finished or not.

Modelling, prompting, praising

To start teaching Chris the skill of eye contact we may need to draw attention to the importance of eye contact.

For example, when Chris wants something we might wait until she responds to the prompt, “Chris, look at me” before we respond to her. We may also use a physical cue like putting our hand into the line of her gaze, then bringing the hand to our cheek or chin.

Any attempt to make eye contact should be praised. This can be a combination of specific praise (eg. “Thanks for looking at me” said with a beaming smile) and giving Chris what she wants.

And all the time we are doing this, we need to be modelling good eye contact.


Functional behaviour analysis, or behaviour support

Another way of looking at this behaviour is to ask why Chris walked away in the first place. What was the function, or purpose of her behaviour?

Why did Chris walk away?

It wasn’t just that Chris wasn’t paying attention, it was that she was paying attention to something else.

The observation suggests that she was following a routine, and she was focused on this. She had finished eating. And, according to routine, when you finish eating you put your rubbish in the bin and put your lunchbox away.

So what next?

We need to help Chris to balance the routine with her friendships. So, first, we need to help her make eye contact with her peers. We need to help her apply what she has learnt with an adult prompt (“Look at me, Chris”) to her discussions with her peers.
So we may teach her peers to say, “Chris” and wait for Chris to look at them before speaking.

Then we need to teach Chris to use a signal to let her peers know she is going to leave the conversation. So we could teach Chris to say, “I am going to…. now.” before she walks away.

Modelling, prompting, praising

To start with, we might have to practice this skill in the classroom. Or a teacher may need to sit alongside Chris and her peers in the playground.

In the beginning, the teacher may need to encourage Tom and Jenny to say Chris’ name and wait until she looks at them before speaking. The teacher may need to give some immediate praise to encourage Chris to use eye contact. The teacher may also need to use a picture, social story or modelling the sentence “I am going to…. now.” to prompt Chris to use this sentence.

To make sure that this is making a difference, we would need to keep a record of Chris’ successes.

But the end product should go something like this:

Antecedent:
Chris is chatting with Tom and Jenny. They were talking about their favourite foods.
Jenny looks at her sandwich then smiles at her two buddies: I love vegemite sandwiches! They are great. Aren’t they, Chris.
Chris continues looking at and eating her sandwich. Jenny waits for a moment, then says: Chris?
Chris looks at Jenny.
Jenny: Do you like vegemite sandwiches?
Chris shakes her head.
Tom smiles at Jenny and Chris: I like vegemite sandwiches. But I like cheese better.
Chris (still looking at Jenny): I like cheese sandwiches. See! (she holds out her cheese sandwich.)
Tom smiles at Chris: Mmmm. It is so good, especially with some tomato. Have you ever had it with tomato?
Chris has finished her sandwich and is packing up her rubbish.

Behaviour:
Tom: Chris?
Chris looks at Tom.
Tom: Do you like tomato?
Chris: No. (short pause) I am going to put my rubbish in the bin now.

Consequence:
Chris puts her rubbish in the bin and puts her lunchbox away in her bag.
Tom and Jenny continue talking until they finish their lunch. Then they put their rubbish away and join Chris. They all go and play together.


If you want to know more:

Conway, R. (2008). Encouraging Positive Interactions. In Forman, P. (Ed) Inclusion in Action, p198. Thomson: Australia

Moyes, R.A. (2002). Addressing the Challenging Beahviour of Children with High-Functioning Autism/Aspereger Syndrome in the Classroom: A Guide for Teachers and Parents. Jessica Kingsley Publishers: London.

Repp, A.C, and Horner, R.H. (1999). Functional Analysis of Problem Behavior: From effective assessment to effective support. Wadsworth: Canada

Weiss, M.J, Harris, S.L. (2001). Reaching out, Joining in: Teaching Social Skills to Young Children with Autism. Woodbine House: Bethesda


You may also want to visit these links:

http://www.autismsa.org.au/html/strategies/therapies/aba.html

http://www.learningplace.com.au/deliver/content.asp?pid=7498

http://www.txautism.net/docs/Guide/Interventions/ABA.pdf

http://www.usu.edu/teachall/text/behavior/LRBIpdfs/Functional.pdf

At the end of every month I want to anwer any questions you might have relevant to the topics discussed in this blog. If you have any questions, post them here as a comment. I will answer them next week....

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Ask Amanda

At the end of every month I want to anwer any questions you might have relevant to the topics discussed in this blog. If you have any questions, post them here as a comment. I will answer them next week....

But in the meantime, I want to talk about another way to teach pragmatics... I'll get back to you with this shortly.

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Using pictures

Are you Angry or Not?

(pictures from www.learn2bebuddies.com.au)

Tommy asks Jenny if he can play with the truck she is using. She says, calmly and politely, “No. I am playing with it. There’s another one over there.”

Tommy begins to cry and comes rushing up to you. “Jenny won’t let me use the truck! She is being mean! Waaaaa!”

How do you explain that Jenny wasn’t being mean, or angry? She just wanted to play uninterrupted. There are other toys she wanted to share with you...


Using pictures to teach pragmatics (following on from the previous posts)

Tom needs to learn the difference between the facial expression and body language that makes the word “No” represent bullying or “meanness” as opposed to the pragmatics that reflect a reasonable refusal. This is a complex concept for all young children to learn.

For some children you may be able to talk to them and use words to help them understand this. But talking about it assumes several important things. Firstly, if you reason with Tom you are expecting that he is able to hear the words and understand what they mean. If he has a hearing impairment, developmental delay or a language disorder, this may be a difficulty for him.

Second, you are expecting that he can imagine and relate to the actions and emotions reflected in the words you are using. Again, children with developmental delays, Autism, Aspergers Syndrome and other social or behaviour difficulties may struggle with this process.

So what can we do?

One way to approach the issue is to use pictures. There are a number of benefits to using visuals (Bondy & Frost, 2002; MacKay, 2000; Marion, 2007).

1 - They can attract attention
For example, children with autism will find it hard to make eye-contact with others. It may be difficult for them to process sights, sounds and movement all at once. Making eye contact may mean they struggle to actually “hear” what the speaker is saying. Other children may have difficulties concentrating, paying attention or directing their gaze to something when asked.

When you use a picture, you can help a child focus on a representation of the facial expressions and body language without having to process movement and sound as well. The child can also be given the picture to hold, or it can be held in their eye-line.

2 - They are permanent
You can allow the child to study the picture for as long as needed. The expression won’t disappear in a moment as it would from another child’s face.

3 - They can be carried around
You can use the picture in a range of situations. You can get the child to use it to communicate their own emotions. Or you can point to the picture to communicate what another child may be feeling. By doing this you are helping the child generalise the information, or apply it to different situations and different people. This, in turn, will help them develop empathy.

4 - They are concrete
You don’t have to use language and imagination. The picture is a concrete representation of an abstract concept. You are providing them with the “image” for their imagination. This is especially important if the child thinks in pictures rather than in words.

5 - They can be adapted to any age
You can use photos, pictures or line drawings. You can adapt the pictures to any age and to any child’s interest.


So, in Tom’s case, you may use two pictures such as those seen below (free download from http://www.do2learn.com/).

You may get him to chose which one he thinks reflects Jenny’s response. Then you may get Jenny to choose the one that reflects what she really meant. Then you help correct the miscommunication in a very concrete way.

Don’t expect immediate results. You may have to use this process many times depending on the child’s difficulty. The first step may be just getting the child to look at the picture.

But with repetition, patience, praise and reinforcement (such as getting the truck after he has played with another toy for a short while), Tom will learn the difference between a calm and friendly, “No.” and an angry, mean “NO!”

References:

Bondy, A., Frost, L. (2002). A Picture’s Worth: PECS and Other Visual Communication Strategies in Autism. Woodbine House: USA

MacKay, G. (2000). Primary-age Pupils with Pragmatic Difficulties. In R. MacKay and C. Anderson (Eds), Teaching Children with Pragmatic Difficulties of Communication, pp55-71. David Fulton Publishes: London.

Marion, K. (2007). Visual Supports for People with Autism: A Guide for Parents and Professionals. The Canadian Journal of Occupational Therapy, 75(5) p281.

Line drawings retrieved from:

http://www.do2learn.com/picturecards/printcards/2inch/imagegridsnowords/emotionsnoword.htm

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Teaching pragmatics using Social Stories

(Following on from previous post)
A Social Story: When I want to play with blocks

I like to build with blocks. But sometimes other children are playing with the blocks.

I won’t get mad. I will just ask to play.

I will look at the child who is playing with blocks. I will try to smile. I will say their name.

When they are looking at me, I will ask, “Can I play?”

Sometimes they say, “Yes.” This makes me happy. I will take turns with the blocks. I will share the blocks with my friends.

Sometimes they say, “No.” I will try to stay calm and not get angry. If they say it in a rough voice and tell me to go away, I will go to the teacher and ask for help.

But they are not always being nasty. If they say it in a softer voice, or if they say “Not now” the children might be building something special and I will wait until they are finished.

Sometimes there are too many children playing blocks already. I will stay calm and wait until it is my turn.

While I am waiting I will play on the computer or do some drawing.

Images are from the children's book, Dave is Brave, written by Amanda Gray and illustrated by Daniel East.

Copyright Amanda Gray and Daniel East 2008 http://www.learn2bebuddies.com.au/

Social stories

Social stories were first introduced by Carol Gray (1994). Social stories are a way of helping children, especially those with Autism, learn social skills. They can be used to teach children to recognise facial expressions, body language and other social skills necessary for interacting with their peers.

Social stories aim to give children a concrete description for the very abstract things that occur in social interactions. Wherever possible, they should be accompanied by relevant pictures. They are written specifically for a child and a situation that the child may be finding difficult.

For children who may have a very literal and concrete way of understanding their world, these stories can be very useful. If you want to read more about social stories, you may want to find some of the following books and websites:

Education Queensland Disability Support Services (2006) Social Stories. Retrieved 16/04/2009 at: http://www.learningplace.com.au/deliver/content.asp?pid=33083

Gray, C. (1994) The New Social Story Book, Future Horisons: Arlingon.

Latrobe University. (2009). Social Stories. Retrieved 16/04/2009 from: http://www.latrobe.edu.au/hcs/projects/autism/social_stories.htm

Smith, C. (2003). Writing and Developing Social Stories: Practical Interventions in Autism. Speechmark: Oxon


Some other great sites include:

The originator of social stories – find her list of publications and more information at
http://www.thegraycenter.org/

For Aussies, Carol Gray’s My Social Stories Book is easily purchased at:
http://www.spectronicsinoz.com/product/my-social-stories-book

Autism Spectrum Australia at http://www.aspect.org.au/default.asp#logo

The Online Asperger Syndrome Information and Support website at
http://www.udel.edu/bkirby/asperger/

Tony Attwood’s website. Here’s a link to his list of useful publications on socialisation:
http://www.tonyattwood.com.au/social.html

Or Sue Larkey’s website at http://www.suelarkey.com/index.php?pr=Home_Page

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Facial Expressions, Body Language and Empathy

Billy was building a road out of blocks.

“Hey, Billy! Can I play?” Tim said eagerly.
Billy smiled, “Sure, you can play!”
“What can I do?” Tim asked.
Billy pointed to the end of the road, giving Billy a toy car. “Just sit over there.”
“Okay!” Tim said as he sat in the indicated space and started running his car along the block road.

Billy was building a road out of blocks.
“Hey, Billy! Can I play?” Tim asked shyly.
“Sure you can play!” Billy replied sarcastically, looking at Tim with a sneer.
“What can I do?” Tim asked falteringly.
“Just sit over there.” Billy pointed to the very edge of the mat, out of reach of the road and any blocks.
“Okay.” Tim sat in the indicated spot and watched as Billy turned away to continue building the block road.

(Image copyright Daniel East 2008. Illustration is part of the children's book, Dave is Brave, written by Amanda Gray. Visit www.learn2bebuddies.com.au for more information.)

Body Language, Facial Expressions and Empathy

These two vignettes illustrate how the same words, used in different ways, can hold very different meaning. That’s because communication isn’t just about the words we use. It is about how we use them.

The same words can have a very different meaning depending on what facial expressions, tone of voice and body language we use. These things let others know what we really mean, or the intent of our words.

There are also many unspoken rules we need to follow when we are communicating to get our message across successfully. For example, we speak differently to a friend that we would to our boss. We also need to take turns, keep to the topic of conversation and use conventions like “I have to go now” to end our conversations.

These things all combine to give us the social context of language and are referred to as pragmatics (Scott Lue, 2001, MacKay, 2000). If a child has difficulty with pragmatics their success in interacting with others will be affected. Not only will they misunderstand others’ communication efforts, but they may struggle to get their message across without misunderstandings, hurt and frustration.

For example, as we speak to and interact with others we use their facial expressions and body language to help interpret how they are feeling or reacting to us. As we empathise we adapt our behaviour (McKay, 2000). So pragmatics helps us tell when someone is not interested in what we are saying, and we stop talking. Or it helps us realise if our actions or words are hurtful. It can also help us recognise jokes, sarcasm or bullying.

But not all children learn these skills in the same way.

Children who may struggle to learn pragmatics

To learn the pragmatics of language you need to be able to see, hear and concentrate. You need to be able to analyse, remember and adapt what you have learnt to new situations. You need literacy skills such as knowledge of words, grammar and how context changes a word’s meaning. And you need to be able to guess at other people’s attitudes and recognise someone else’s point of view (Anderson, 2000).

Children who have vision impairments can miss body language and facial expressions (Scott Lue, 2001). Taking turns in conversations may be hard as their ability to use eye-contact may be limited. They may need to develop other signals to help their friends know they are listening.

For children with hearing impairments, developmental delays and language disorders learning new words and concepts may be difficult. They may struggle with finding the right words to match their body language and gestures so they can get their message across (Anderson, 2000).

Children with attention deficit disorders may find it hard to keep eye-contact and pay attention when interacting. They may miss important facial expressions and body language, thus missing how their words and actions may be affecting another person (Sinzig, Morsch & Lehmkuhl, 2008).

Children with developmental delays, such as children with Down Syndrome, may struggle with the complex process of analysing, remembering and adapting what they have learnt in one situation to be used in new situations (Buckley, Bird & Sacks, 2002; NSW Council for Intellectual Disability, 2006). So they may find it hard to interpret body language and facial expressions they are not familiar with.

But the children we read about most often as struggling with pragmatics are children with autistic spectrum disorders (ASD) (Scott, Clark & Brady, 2000).

Autism Spectrum Disorders

Children with Autism may have difficulties learning to speak. Children with Aspergers Syndrome may have a big vocabulary and speak well, but struggle with the pragmatics of language. But in both cases, their key difficulties will include:

• making eye contact
• recognising and responding to facial expressions, tone of voice and body language
• taking turns and
• empathising (Scott, Clark & Brady, 2000).

For example, a child with autism spectrum disorders may keep bringing the conversation back to their area of interest even if it is not relevant to the conversation. They may not show interest in what the other person is saying. They may echo or imitate a question they have been asked rather than respond to it.

Teaching pragmatics

We usually develop our knowledge about the rules of communication and socialisation by observing, practising and applying past experiences to our interactions (Scott Lue, 2001; MacKay, 2000). We start learning these skills as a baby when we first make eye contact with our parents. But, as previously mentioned, children with a range of different difficulties will not learn these skills in the same way. For these children it is about explicit teaching.

We can do this in many different ways. I won’t discuss this now as I think I can sense from your body language that you may be losing interest :-). But in the coming weeks I will blog about how modelling, prompts, rewards, pictures and social stories can help children with a range of disabilities learn to recognise, interpret and develop body language, facial expressions and empathy.


References

Anderson, C. (2000). Pragmatic Communication Difficulties. In G. MacKay and C. Anderson (Eds), Teaching Children with Pragmatic Difficulties of Communication, pp24-38.

Buckley, SJ., Bird, G., and Sacks, B. (2002) Social Development of Individuals with Down Syndrome – An Overview. Retrieved 10th April 2009 from http://www.down-syndrome.org/information/social/overview/

MacKay, G. (2000). Actions and interactions: the roots of pragmatic communication. In G. MacKay and C. Anderson (Eds), Teaching Children with Pragmatic Difficulties of Communication, pp6-23.

NSW Council for Intellectual Disability (2006). What is Intellectual Disability? Retrieved 10th April 2009 from http://www.nswcid.org.au/standard-english/se-pages/fact-sheets.html

Scott, J., Clark, C. and Brady, M. (2000). Students with Autism: Characteristics and Instruction Programming. Singular Publishing group: California.

Scott Lue, M. (2001) A survey of Communication Disorders for the Classroom Teacher. Allyn and Bacon: Boston.

Sinzig, J., Morsch, D. and Lehmkuhl, G. (2008) Do hyperactivity, impulsivity and inattention have an impact on the ability of facial affect recognition in children with autism and ADHD? European Child & Adolescent Psychiatry, 17(2) pp 63-72.

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