Enhancing Movement in the Lives of Children with Autism David Sugden University of Leeds

1. Enhancing Movement in the Lives of Children with AutismDavid SugdenUniversity of Leeds Exploring Autism from Movement, Health and Wellbeing Perspectives 14th April 2018 Mardyke Arena Cork

2. Initial Thoughts on Improving Movement Skills Movement takes place in a context and therefore context is always considered Movement often involves others and therefore different individuals play different roles Movement involves learning specific skills and those that involve generalization Movement involves being able to participate and being able to learn Movement is the only way we have of interacting with both other persons and the environment Thus movement involves the total ecology of the child’s daily life Travel Broadens the Mind (Campos et al)

3. Key Features of Any Intervention Intervention outcomes are a function of the interaction of the child’s resources, the environmental context and the manner of presentation of tasks to be taught. Or put another way Any difficulties do not solely reside in the child!

4. Child Movement Outcomes Involve Three Major Constraints/Variables Child resources-MOTOR, social, cognitive, language, emotional, etc. OUTCOMES School, home, community, health Mode of delivery and type of tasks

5. Implementing Intervention Through Participation and LearningEcological Intervention (Sugden, Henderson & Barnett 2007) Ecological Intervention is not an add on but built into the fabric of the child’s daily life involving • Increasing participation through engineering and changing the environmental context • Successful learning through good teaching/therapy and manner of presentation • Leading to: • Enhancement of child’s resources • More favourable overall outcomes

6. Participation and Learning Participation-Learning OUTCOMES

7. PARTICIPATIONQuality of life in children with general developmental disorders and participation in leisure activities: Active participation is important for physical well being. Participation is associated with increased self esteem, self competence and respect from others. Participation leads to greater happiness and enjoyment of life Participation is important for developing friendships

8. Increasing Participation Through Changing/Engineering the Environment Participation is a prerequisite for learning. We know from other fields (reading) that time spent on appropriate practice is a hugely influential variable for learning. Time spent on practice to a large extent depends upon enabling participation In order for children to participate the environment has to be accommodating and inviting

9. Participation and Children with Autism and Movement Difficulties Children with Autism and MD participate less than their TDP, thus widening skill gap. This gap widens over time. Children with Autism MD enjoy participation less and parents are less satisfied with outcomes. There are spin off deficits such as poorer peer relations, lower self concept, and self worth. In spite of the above, much can be remedied by altering the participation variables.

10. Participation The child needs to find it easy to be involved Movement has to have meaning to the child’s life The context needs to be appropriate to the child’s needs One of the twin concepts with ‘learning’, participation is crucial in the lives of children with autism . It is not a unitary concept:

11. In practical terms what does the environmental context involve? Actively build meaningful Movement into daily life Reasonable adjustments; more promotion & encouragement of movement, in first principles of school policy Linking of health and education and parents Art, culture, leisure, recreation ‘seek and find’ rather than benign acceptance

12. In practical terms what does the environmental context involve? Family and home -build activities into daily life of family not just special sessions, so food preparation and clearing, gardening as well as family walks, cycles and other pursuits. School setting-reasonable adjustments; more encouragement, promotion; built into first principles of school policy-labs, PE etc. Health services -how to use professional expertise to link with, and support education and empower parents. Different practices and scheduling according to client needs-group work for example. Professionals MUST cascade skills to those who see child on a daily basis. Community support -sports centres to actively seek rather than passive policy

13. The ‘Accumulation of Marginal Gains’ or lots of small changes result in big changes overall. By modifying the environment in different ways we accumulate small yet significant increases in participation. Thus by increasing enjoyable participation we have a child on task for more time actively being involved in more appropriate practice. We then look to making small changes in the learning process from many different angles.

14. Structuring the Learning Programme Recognising a difficulty Collecting information to plan the programme Planning the Programme Implementing the programme

15. Collecting Information on the Resources of the child Standardised tests-language, cognitive, social, motor and others that are appropriate Dynamic assessment-observation by skilled therapist/teacher Criterion referenced tests-various checklists for therapists/teachers, parents and others Interviews, child, teachers, parents, therapists/others School reports Co-occurring characteristics-attention, personal and social, cognitive, other.

16. Collecting Information on the resources of the child • POP • Profile-strengths and needs • Objectives-negotiated with child, parent others. • Priorities-immediate need, quick wins, lead to others.

17. Evidence for Intervention Theoretical and Empirical Evidence: Motor learning models; IPS models; Dynamic system models Specific Empirical evidence: RCTs and meta analyses and reviews Professional/Personal evidence-experiences of those working in a practical situation-Health, education, parents and families.

18. General Guidelines from Established Motor Learning Literature Amount and Type of Practice Distribution of Practice Variability of Practice Practice and Specificity Stages of Learning Instructions and Feedback Learning v performance Theory and Practice Mental Practice Meaningful and Enjoyable Goal setting Expert Scaffolding Problem Solving Strategies Knowing and Doing Group and individual (Schmidt and Lee; Magill Two books that provide detail on the above.)

19. Child Movement Outcomes involves Three Major Constraints/Variables Child resources-MOTOR, social, cognitive, language, emotional, etc. OUTCOMES School, home, community, health Mode of delivery and type of tasks

20. Dynamical systems The child is never the unit of analysis Movement outcomes are a function of the three variables. Context is crucial. Learning & development are non linear: intervention same Emphasis on function not form/technique Variability (flexibility) of outcomes not just consistency (rigidity)to be celebrated. Solutions are temporarily assembled (“softly”) cf language generation to address context. Usually done in a self organising fashion to meet contextual demand. Changing context invites (affords) different movements (eg Peas; cubes; baby catching) Inner Game

21. Non-Linear Pedagogy Movement is a product of Task-Child-Context transactions. ‘WE’ can alter constraints (influences) in each of these. Constraints are temporary and emerge or decay according to circumstances. We are facilitators, organising tasks and learning environment circumstances to create optimal context for child solutions. Nurturing variability/flexibility according to context.

22. A Self Organising System to a degree The NLP to a degree is a self organising system. Utilising constraints of Child-Task-Context Not a totally free system but steered within certain limits through classes of communication events. The teacher/therapist/parent steers but not totally directive and the leader may change to be the pupils who dynamically modify the changing ecological circumstances. (Think weather systems, flock of birds, termite hills, growth of cities and, other dynamical system in the natural world, +cycling pelotons!). Naturally occurring situations driven in context by teacher/therapist/parent and individuals.

23. Variability of ResponseVariety is the spice of life!Especially in Autism Usual literature notes high intra individual variability in some populations. But not the total picture with good and bad variability according to context. High variability can be seen as bad as the child cannot produce a consistent response. Low variability often seen as good. But low variability can equal rigidity of response locked into a routine when we need high variability to show flexibility and adaptability of response to meet the prevailing changing contextual demands. Context will determine what is required but in general we are looking for variability of response to environmental circumstances.

24. Dynamic Movement

25. Organising the context • Data on: • Child, targets s/he has set • Targets others see as important • Support systems and possibilities • Individuals and their roles • Meeting and firm commitment • Scheduling and practice • Communication and timetabling for action

26. Working in a meaningful context Functional tasks Realistic and relevant Everyday activities-formal and informal Active movements

27. Teaching specific skills through task analysis, task adaptation and expert scaffolding Analysing Adapting Strengths –weaknesses Expert scaffolding Bike riding and tennis examples In most cases specific skills need to be generalised

28. Learning to Move-Moving to Learn Continuum Movement activities divide into two categories, not separate but helpful for planning. Most movement activities involve learning to move, whereby movement activities are taught and learned; this is a traditional way involving control of basic fundamental movements such as posture, balance, locomotion and manual activities and those involve planning, strategies and complex responses to varying environmental contexts such as responding to moving others. Movement activities are also helpful in moving to learn, where movement activities are used to acquire other attributes such as emotions, planning, cooperation, language, cognitions, and social competencies. In partner work the child is learning about cooperation; turn taking, consideration of others, moving slowly to accommodate others, assessing one’s own and others capabilities; in slow movements the child is learning about sustained attention and freedom from distraction. Good for children with autism. Any intervention and movement programme will involve both with the balance and ratio depending upon the resources and needs of the child.

29. Choice of tasks Functional activities-from assessment, objectives and priorities. Very strong research evidence for this. Group tasks for generalisationeg same cognitive processes, similar demands but vary the detail. Helps ‘solving a problem’. Specific tasks according to need.

30. Task adaptation and task Analysis Task adaptationgood for participation. Task analysisgood for learning Togetherthey interact and achieve both participation and learning.

31. Task Analysis • Break down the task into components • Each component has to be: • achievable • a whole in itself-for motivation • easy to build into the overall task

32. Task Adaptation Changethe context/environment- modify the task. Modify instructions, feedback. Adapt the assignment.

33. Teaching specific skills is not enough: broadening the experience through generalisation • Prior learning affecting new learning • Taking information, skills, knowledge learned in one context and using them in another • Performing new skills in a slightly different manner to ones learned

34. Generalisation • What is required to generalise? • The acquired knowledge, strategies, dispositions, abilities, information for a particular task • A recognition, automatically or consciously/cognitively, that the new context requires the above. The second bullet point is the one that often proves to be very problematic and particularly resistant to improvement in children with atypical development

35. Generalisation • So we focus on: • Tasks Type and range • Learners Cognitivists and learner’s perception of similarity • Contexts Sociocultural perspectives and social interactions in context

36. Facilitation of Transfer/Generalisation Clinical/educational/home settings and practices • Variability of examples/practice in class of actions (Task) • Importance of explicit task analysis (Learner) • Cognitive strategies-explaining to each other, teaching of self regulation, monitoring (Learner) • Expert scaffolding (Context) • Practice in context (Context)

37. Example of handling the learning process Instructions and practice • Understanding the skill • Short and simple, move straight into task; pick out 1 or 2 major points the child needs to understand. Feedback the same. Cognitive awareness • Acquiring and refining the skill • Gradual progression to looking at errors and how to correct. Cognitive awareness • Automating and generalising • Dual tasks and different contexts/cognitive awareness

38. Monitoring and Evaluation • Ongoing monitoring • Check with child-enjoyable-progress • Check with others-carryon? Adjustments? • Realign targets and priorities? • Evaluating the whole programme • Childs view • Meeting of original targets-view of the team • Test data • Other data

39. Examples-Appendix 1 • Let the child choose a task-or in most cases choose from a range that is offered. • Ensure that the task is most relevant to daily life and presenting most difficulties. • Choose task that are functional. Interest is in whether the child can adequately perform tasks in daily living and in many cases without an emphasis on technique and form. Functional activitieswith meaningful outcomes relevant to the child’s life are more important than form, technique and style. • Move from the easy to more difficult. Make sure the child can actually perform the first task they are given. • Make the tasks meaningful and enjoyable-crucial for motivation and staying on task • Adapt and analyse the tasks to match the ability and interest of the child. • Present quick win tasks-it is good for the child’s self esteem and motivation to choose a task that they can accomplish rapidly.

40. Appendix 1 Continued. • Give a variety of tasks that are similar. For example, if manual skills are thought to be necessary, present a number of tasks that are alike thus providing a schema or class of events the child can master. In manipulation for example, present press studs, zippers, laces, peg turning-and others from a list. • It is advisable to ask the child how they are going to approach a task; how they will do it; problem solving activities moving the responsibility from the adult to the child. The child with a planning and organisation problem may be helped by asking what they know and what they need to do • Any formal sessions such as in direct teaching should be little and often: around 20-30 minutes and if possible 4-5 times a week. • Experience should be used to enhance participation. • Experience to be built into the daily life of the child as much as possible with little disruption and with as much possible help from numerous individuals. • All activities to be in a problem solving environment with the context inviting and the child seeking solutions in this environment.

41. Examples Appendix 2 Attention • Slow-Fast-Normal pace.These involve actions that are fast, slow or at normal pace such as the following; • Walk a curved path, about 10 metres marked out. • Roll a large ball along the path • Draw a line like the path on the paper-this can be traced or draw between lines • Winding in a fishing reel-around 3 metres long. • Relaxation Training. • This may help her consciously relax. It is based on the premise that she may not know the actions she is doing but just ‘does them’. • Lie down on a mat on back, knees slightly bent maybe with a roll underneath and a small pillow under the head. • Ask her to tighten and then relax various parts of the body. • Linda “can you make your body stiff like a piece of wood/metal; now can you make it like jelly” “Can you make your arm stiff, now like jelly; can you make one stiff and one like jelly”. stiff-relax-stiff-relax. What we are doing here is trying to get Linda to know more about her body and what it is doing; • Try to get her to relax and tighten her jaw and face muscles-often a source of tension. • Other instructions to include some imagery like “can you make your body be heavy”? “or light”. “ can you you’re your body sink into the mat” “can you make it float”. • Other techniques-ask her to touch her opposite leg with her/his arm; if appropriate use left and right instructions.

42. Appendix 2 Continued • Prolonging Activities • This involves performing a movement for a longer duration that may transfer to other activities. • Walking lines of increasing length in a ‘normal’ controlled manner is an obvious on • Placing a tennis ball on a square piece of wood (about18” square or equivalent ) and ask her to walk around with the ball on the board. • Drawing in between lines on paper with the track increasing in difficulty and complexity will help her with her drawing.  • Impulse Control. • Walking as slow as possible-on a line • How slowly can she get up from lying down; sitting down with crossed legs. • Use of white/blackboard with ‘tracks’ on it and how slowly can she ‘drive’ the car through on the ‘road’. Use of music.  • Passing object-medicine ball as slowly as possible in a group circle

43. Appendix 3 Ball Skills example • The following tennis games and practices are tailored to Adam’s unique profile and features. The are progressive moving from easy to complex and from individuals to partner and group settings: • On his own to practice daily for 10-15 minutes/ He needs a racket, a ball and a wall. • First he just bounces the ball up and down on his racket. He can do this while walking around as a progression. No instructions are given, he explores all possibilities. • The same but keeps flipping racket back and forth to do it both sides of the racket. A quick feedback on grip may be helpful here. But again, exploration should dominate. • Next he bounces ball on the floor with the racket again followed by walking around while doing this. • If there is a marked and obvious problem in technique leading to an impoverished outcome, one may ask him to modify grip but few technique instructions are given. • A progression is to hit the ball against a wall. Start close to the wall and hit the ball direct to the wall letting it bounce once before hitting it again. Count as a challenge. The object is functional strokes hitting the wall continuously. Very few instructions or feedback are provided, leaving Adam to problem solve himself. • A starting point for any feedback is to look at his body positioning. All one needs to say is “stay away from the ball”. All this means is don’t get too close and it automatically allowing him room to swing at the ball. It also encourages the all-important movement of feet. • There is no predetermined outcome save repeatedly hitting the ball against the wall. Adam is exploring all of the possibilities himself and he will self organise to discover optimum solutions. It is not just repetition but being flexible enough to deal with an unpredictable return of the ball. Adam will start to adjust accordingley. • All accomplished at different distances from the wall and with an added complexity such as keeping the ball against the wall by a volley rather than letting it bounce. automatically encouraging nimble footwork that in turn provides room for an appropriate swing. • As soon as possible it is advantageous for Adam to work with a partner/friend. In this situation, the same practices but taking it in turn to hit the ball. This brings in another variable. It is now Adam having to adjust r to the unpredictability of his friend. encouraging the appropriate use of feet to be in the best position. • Using cooperation also helps him learn through movement. If the return is easy for his friend they can build up cooperation to help each other and eventually competition as a pair to try for the highest number of returns each time.

44. Appendix 3 Continued • Move from wall to tennis court. With his friend, he now moves to the local tennis court. A small group would be advantageous if this step is manageable. • Start with each facing each other either side of the net on the service box line thus making it a shortened court. The net can be lowered as much as necessary. Again, a cooperative game involves how many times they can hit the ball to each other with one bounce. • The only technique given is to move the feet to provide room to strike the ball. • This can be changed by lifting up the net and/or moving into a competitive game where each is trying to win a point. Again, in the shortened half court • From these modified games go back to helping each other by taking a step back for a few shots until they are at the baseline. The context is being simplified to accommodate the changing ability of Adam and friend. • These can be organized into short sessions by Adam or suggestions by friends and family. A summary of these practices include: • First Adam is learning tennis skills in particular and ball skills in general. He is learning about moving to hit a ball using space. • He is learning about an unpredictable situation and adjusting to it. Each time he hits the ball, his responses involve obtaining variability of practice and response so that he can flexibly adapt to a constantly changing moving situation.

45. Appendix 3 Continued • Who is the partner? In the first instance, it can be a friend. It could be a parent of sibling but a friend is probably better. • Being part of a small group performing these practices would be helpful. The next biggest step is to mix with others in this kind of situation. Again, choosing who to play with and when is all important. •  All of these can be done during personal recreation time away from school, in school or at home with family. • Short sessions on individual skills at regular intervals. 20-30 minutes a day. • Have a friend help after initial individual skills. Build into friendship and fun time. Enjoyment ! • Concentrate on function not technique-get the ball over the net; in the goal; though the basket; kick to a partner. • Being a problem solver with the mover constantly changing the action to meet the prevailing changing contextual demands. A never-ending flexibility of responses • All of this facilitates and encourages both participation and learning which in turn allows more time on task thus improving the motor skills and so on in this reciprocal learning –participation transaction.

46. Final Words • We can make a difference; different individuals combining to produce optimistic results in an every day ecological setting • Both specialist and non specialist support and combining • Engineer the environment and tailor the learning process to meet the child’s needs • Huge apologies for not being present. Use the power points if you wish noting where they arose. • I am happy to answer queries through email: d.a.sugden@leeds.ac.uk • David Sugden April 2018