Autism in the Visually Impaired Child

1. Autism in the Visually Impaired Child Terese Pawletko, Ph.D. & Lorraine Rocissano, Ph.D. Psychology Department Maryland School for the Blind AER/DENVER, July 18, 2000

2. Explanations for “Autistic-like” Behaviors in Blind Children • Their behaviors (e.g., stereotypies, rituals; restrictions in play) seen as: • indicative of emotional disturbance • associated with sensory deprivation (e.g., turn inward for stimulation) • related to mother-child attachment (e.g., in incubators longer; lack of eye contact so hard to read cues; maternal depression further limiting her involvement with child) T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000

3. NON-AUTISTIC AND AUTISTIC RUBELLA CHILDREN - Distinctions noted by Chess et al. Non-autistic rubella children with sensory defects: 1. Are very alert to their surroundings through their other senses 2. Exhibit appropriate responsiveness - “Some are shy, some slow to warm up, some perhaps wary; but one is impressed by their readiness to respond to appropriately selected and carefully timed overtures.” Rubella children with autism and sensory defects 1. Do not explore with alternative senses 2. Maintain distance from people that is not explained by the sensory deficits nor by degree of retardation 3. Their affective behaviors do not resemble those of the same mental age. From Chess et al.

4. Caveats in Diagnosing 1. Autism is a developmental disability, not parent induced, not induced by blindness 2. It is a syndrome; no one symptom yields a diagnosis. 3. Autism is a spectrum disorder, with a wide range of functional levels, and behavioral presentations. 4. While symptoms show improvement over time, the individual remains autistic. Autism is a lifelong disorder and for most individuals some level of support may be required.

5. Jim…as a point of explanation for you...the ‘icebergs that follow’ detail the key diagnostic features of autism using an iceberg approach - the behaviors one might observe on the surface, and the processing difficulties that might account for them.

6. Problems with Socialization Fails to or has difficulty engaging in reciprocal interactions Treats others as though they were objects Seems uninterested in peers Problems shifting attention Unable to process social information effectively Difficulty processing complex stimuli due to difficulties telling figure from ground, and problems making very rapid shifts of attention Cannot process multiple sensory stimuli simultaneously T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000

7. Implications for Parents and Educators 1. Recognize that the social world is more complex and less predictable for an individual with autism, and therefore more stress producing. 2. Do not assume that simple exposure to peers will result in the acquisition of social skills. 3. A child cannot be pushed to acquire social skills. Begin with something short, structured, teacher directed, and success oriented.

8. Problems in Language Seems very verbal but can’t follow instructions Poor receptive language Echolalia Pronoun reversal Non-verbal May use words expressively which they don’t really understand (receptive language lower than expressive) Difficulties discriminating language sounds - poor central auditory processing Difficulties with sequencing phonemes and words Can’t break the linguistic code T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000

9. Implications 1. Check out whether child understands what he/she is saying (e.g., “what does that mean?”) 2. Use controlled language (e.g., short, concrete phrases with time between statements to allow for processing) 3. If student has vision, try to provide some information visually; if not, provide information tactually.

10. Problems in Communication Perseverates on one topic Shows no interest in other people’s topics Too close or too far when talking Says something unrelated to the conversation May become angry when he hears certain words Can’t apply rules in context Problems with impulse control Inability to take the perspective of another, as well as problems shifting attention T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000

11. Implications 1. Direct instruction in the actual setting is key. 2. Identify clear, concrete rules that the child needs to follow in specific situations. 3. Social stories can be helpful in providing a child with a script to follow.

12. Perseverative or Narrowly Focused Interests Need for sameness, predictability Motor stereotypies Focuses on parts of objects in play (e.g., wheels, spins everything, flips handle of basket repeatedly) Age appropriate pretend play not observed Restricted and perseverative interest (e.g., elevators, Xerox machines, CD titles) Difficulty getting meaning from environment due to all cognitive processing deficits Repetitive events are easier to understand and make sense of than multifaceted input Repetitive behavior may be experienced as soothing T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000

13. Implications 1. Recognize that the routines and self-stimulatory behavior are the things that the child understands best and may serve as a “life-preserver” for the child. It is the child’s retreat to his comfort zone. 2. The child’s reliance on such behaviors will tend to increase in times of stress and anxiety (e.g., transition, lack of clear expectation, challenges). Ask yourself “why is the child engaging in this now?” 3. Identify a time when the child can engage in his self- stimulatory behavior; tighten up the structure, schedule, routine to decrease anxiety and increase non-verbal information.

14. Hypo- and Hyper-Sensory Systems Over-reacts to certain noises (e.g., fire-alarms, vacuum cleaner, fan motor) Finds certain tactile experiences aversive (e.g., certain foods, texture of clothing, soft furry objects, being touched) Often finds warm temperatures aversive May not react to bumping head, falling down, etc. Stops listening to instructions when asked to open book Has poor regulation of auditory system (e.g., at times may find raindrops sounding like gunshots, other times not a problem; visceral panic regulation to sudden loud sounds like fire alarm - heart and respiration rate do not return to normal for several hours) Can only process one sensory input at a time Brains process temperature, texture, multi-sensory things differently T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000

15. Implications 1. Be alert to how the sensory environment may be impacting on your student. 2. Try to keep the environment as low key as possible (e.g., visually clear, sound absorbing materials, no extraneous noise or conversation; balance lighting needs for children’s visual impairment with those of arousal). 3. Be aware of possible multi-sensory input issues and adjust instruction accordingly.

16. Autistic Spectrum Disorders and Cortical Visual Impairment: Two Worlds on Parallel Courses Mary Morse, Ph.D.*, Terese Pawletko, Ph.D. & Lorraine Rocissano, Ph.D.** AER/DENVER, July 18, 2000 * Educational Consultant, N.H., ** Psychology Department, Maryland School for the Blind

17. Pattern and Predictability YOU SEE: • AutismCVI • Gets fixated on certain activities Fixated on certain sensory stimuli (e.g., • or sensory stimuli (e.g., certain certain colors, lights, finger or hand • visual and auditory patterns) gazing, certain visual patterns) • Insistence on things remaining Performance may be better w/some • the same (e.g., sequence of types of visual stimuli than others • events, placement of objects) (e.g., objects, faces, spatial • Performance may be better with orientation) and in familiar context – • certain materials or in familiar may seem more impaired in new • context – may seem more context • impaired in new context Brain is looking for patterns it can recognize (e.g., visual, auditory; sequencing) in the environment - child may not recognize different phonemes and their pattern and sequence, yet recognize pattern in inflection or music and thus, more likely to attend to the latter T. Pawletko, Ph.D., L. Rocissano, Ph.D., M. Morse, Ph.D., July, 2000

18. Processing Problems: Figure-ground YOU SEE: • AutismCVI • Cannot discriminate foreground Difficulty discriminating what visual • from background noise (e.g., stimuli is important to attend to • seems to attend to conversations Does not see and/or show recognition • across the room while of some types of visual stimuli • ignoring language directed • toward him). • Fiddles with string while • ignoring toy the string is • attached to. Brain is having difficulty sorting essential from non- essential information, brain may perceive things as a whole for some individuals, or attend only to certain details disregarding the gestalt. T. Pawletko, Ph.D., L. Rocissano, Ph.D., M. Morse, Ph.D. July, 2000

19. Processing Problems: Multi-sensory Input YOU SEE: • AutismCVI • Stops listening when cat jumps Tends to look away when reaching/touching on lap • Sensory overload can lead to Has more difficulty in using vision total or partial shutdown, or when managing other sensory • over over-arousal or motor demands • Sensory overload can lead to total or • partial shutdown, or over over- arousal Brain is having difficulty regulating and processing information coming in (e.g., type, rate, amount, multiplicity) Brain may only be able to process information from only one modality at a time Can suffer from cumulative effects of overstimulation T. Pawletko, Ph.D., L. Rocissano, Ph.D., M. Morse, Ph.D., July, 2000

20. Do not Spontaneously Generalize Learning YOU SEE: • AutismCVI • May understand scripted May recognize objects or people • directives in context but not in familiar context but not in • out of context unfamiliar context • NOTE: typical child can be taught and know “a cup is a cup” across settings; autistic and CVI children are not able to apply old learning to new situations without specific instruction. Brain relies on the “total package” to comprehend the situation. The package may include a specific subset of the following kinds of features: the sequence of events, location, specific materials, specific person teaching, specific words, etc. etc. etc. to define “the event” or “the concept.” What feature the child uses as an anchor is unique to the individual. T. Pawletko, Ph.D., L. Rocissano, Ph.D., M. Morse, Ph.D., July, 2000

21. MISLEADING BEHAVIORS: Instability of Function YOU SEE: • AutismCVI • No reaction to loud noise at one At one point in time seems to recognize • one point in time, but may objects and/or persons, but at another • have extreme reaction at time (even moments later) may not • another time (may change recognize object or person • moment to moment) • Seems to understand instructions • one day, seems lost the next Parts of the brain that regulate sensory thresholds, efficiency of neurotransmission, and ability to access memory may all impact on the child’s functional ability at any point in time. This is also true for the child’s physical condition (e.g., illness, medication side effects, fatigue). T. Pawletko, Ph.D. & L. Rocissano, Ph.D., M. Morse, Ph.D., July, 2000

22. Jim…to again provide you with some explanations...the slides above were to begin to alert VI teachers to the some potential similarities and distinctions between some children who are autistic and other children with CVI [based on some of the children we’ve seen at Md. School f/t Blind]. The next group of slides were to begin to offer concrete suggestions for intervention and make distinctions between what is used for non-autistic vs. autistic visually impaired children; also to review the components of structured teaching that we use with our autistic-vi students across settings.

23. For a blind child: Use a lot of language paired simultaneously with object exploration. Use a lot of vestibular input, tactual input. Moderate levels of extraneous noise generally will not cause distraction. For an autistic blind child: Use brief statements, moderating the pace of speech; pace of exploration of object. Control the amount & type of input so child is not over aroused, unable to attend. Be aware of impact of even subtle noise on child’s stress level and ability to attend. Comparing Strategies for the Blind vs. Blind Autistic Student T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000

24. For a blind child: Provide lots of social stimulation. The child can be expected to enjoy a variety of social contacts. His sensitivity to social reinforcement, including withdrawal of attention, means that praise and “time out” will be effective motivators For an autistic blind child: Balance social time with alone time. Child may often find social experiences aversive rather than reinforcing. Social experience is generally not important to child. Praise, “time out,” are typically not effect motivators. Comparing Strategies for the Blind vs. Blind Autistic Student(Continued) T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000

25. Components of Structured Teaching • Physical Structure • What activity will occur in “X” location? • What sensory sensitivities need to be addressed by the physical structure? • Schedules • What will we do? • In what order? • Individual Work Systems • What am I going to do? • How much will I do/for how long? • When will I be finished? • What comes next? Adapted from TEACCH, July, 2000

26. Components of Structured Teaching • PHYSICAL STRUCTURE • What activity will occur in “X” location? • What sensory sensitivities need to be addressed? Ideally, only one activity occurs in one location (e.g., teacher table is sole place that 1:1 work occurs; independent work desk used only when child works independently; independent play activities occur in one location; craft activities occur in a different location) Processing and sensory needs: use controlled language, minimize extraneous noise through use of sound absorbing materials (e.g., tennis balls on bottom of chair feet, hang sound absorbing materials from windows and walls, replacing faulty buzzing fluorescent bulbs, staff to use conversational tones only); use barriers (e.g., book cases) to define space, provide visually calm environment

27. Components of Structured Teaching (con’t) • SCHEDULES • What will we do? • In what order will we do them? Minimizes demands on memory and attention Decreases problems with time and attention Compensates for problems with language comprehension Aids motivation (e.g., “first work, then play”) Allows for greater independence in functioning T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000

28. Components of Structured Teaching (con’t) • INDIVIDUAL WORK SYSTEMS • What am I going to do? • How much will I do/for how long? • When will I be finished? • What comes next? Predictable, methodical, consistent approach to tasks - takes advantage of autistic individual’s love of sameness - follows left to right, top to bottom format Modify work system based so child can be successful in independent completion of task - if can’t be independent, back down and add more structure T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000