1. LEEDS AUTISM SERVICES The Autistic Spectrum Trainer – Karen Worrell Mobile phones off / silent please!Breaks / Toilet etc. Health and Safety Introductions
2. Autism / Asperger SyndromeCourse Objectives:Myth bustingDevelop basic understanding of ASDUnderstanding the triad of impairments Sensory issues and autism Behaviour analysis General strategies
3. It’s just as though he’s not listening. He’s always ruining others’ activities! The only place she will eat her dinner, without screaming, is in the I told the him we were corridor. going to have a treat instead of the usual day and he starts shouting and screaming. She paces round and round the TV lounge. She doesn’t even watch it. He just won’t leave the lounge room door open – it If I get cross, she just gets absolutely roasting seems to think it’s funny – during summer! why won’t she listen?
4. AUTISM – MYTHS AND FACTS? result of emotional deprivation or emotional stress x a wish to avoid social contact x a developmental disorder involving a defect in brain function associated with unusual responses to sensory stimuli a life long disability often linked to genius abilities x
5. Biological Basis Genetic factors Pregnancy and Birth 100 complications 90 80 Viral infections 70 Other causes – trauma, 60 male hormonal imbalances 50 female Biological factors result in 40 30 The Triad of Impairment 20 Far more males are 10 affected than females: 0
6. Prevalence NAS Fact Sheet February 1997 Autism IQ below 70 20 per 10,000 Spectrum IQ above 70 71 per 10,000 Total Prevalence 91 per 10,000 Based on these figures Leeds would expect: 5100 adults with autistic spectrum disorders. 15% would have significant learning disabilities. At least 765 adults in Leeds requiring services.
7. Triad of Impairments (The Defining Characteristics of ASDs) Lorna Wing - 1978
8. The Triad Social understandingCommunication Imagination
9. THE TRIAD OF IMPAIRMENTS All three areas of impairment must be present for a diagnosis They will be present before 36 months The severity of each will vary between individuals and within individuals over time They will be out of keeping with their developmental level
10. Impairment of social understanding aloofness and indifference to other people passively accepts social contact Spontaneous but in an odd, inappropriate, or repetitive way with little or no attention to responses Interactions tend to be ‘one way traffic’ i.e. not reciprocal Lack of empathy (Theory of Mind)
11. Impairment of social understanding Expressions of emotion often inappropriate or extreme Expects other people to know their thoughts and feelings May appear withdrawn / introverted or over familiar Can make personal comments without understanding that this may cause offence
12. Theory of Mind... Theory of mind is the ability to...or knowing how to mind read! attribute mental states— beliefs, intents, desires, pretending, knowledge, etc.—to oneself and others and to understand that others have beliefs, desires and intentions that are different from ones own Eye contact Body language Facial expressions Tactile communication
13. Impairment of social communication difficulty making sense of and using all aspects of communication i.e. verbal and non verbal ranges from little or no spoken language to those who appear articulate lack understanding of body language e.g. tone of voice, facial expression literal, pedantic, concrete understanding and use of words, limited content of speech
14. ‘I’m on top of the world!’‘Youd better pull your socks up!’‘I laughed my head off!’‘Could you keep your eye out for dad’‘If you don’t stop doing that you’ll be in hot water!!‘It’s on the tip of my tongue’ ‘I’m tied up at the moment’ ‘Don’t forget to pull the door behind you’ ‘Now we are going to toast the bride and groom’
15. Communication – How Good Are You?Rules: You are not allowed to say the name of the objects in the drawing or use names of components of the picture You are not allowed to use the names of comparative objects You are not allowed to name the purpose or use of objects in the drawing i.e. – you may only use descriptive terms such as shapes and where they appear on the paper / in relation to each other The ‘artist’ is not allowed to talk!
16. Imaginationnounthe faculty or action of forming new ideas, or images or concepts of external objects not present to the senses:she’d never been blessed with a vivid imaginationher story captured the public’s imagination[mass noun] the ability of the mind to be creative or resourceful:she was set in her ways and lacked imaginationthe part of the mind that imagines things:a girl who existed only in my imagination - Oxford English Dictionary definition “Imagination is more important than knowledge. For knowledge is limited to all we now know and understand, while imagination embraces the entire world, and all there ever will be to know and understand.” - Albert Einstein
17. Impairment of imagination Difficulty with creative, open-ended activities, and more abstract ideas Rigidity and inflexibility in thinking and behaviour restricted range of interests and skills pursued in a repetitive manner Rituals and obsessions, and an insistence on sameness
18. George Orwell – Author; Albert Einstein – Physicist; One of His troubled life went along with social the greatest minds of the 20th interaction problems. Wrote a “Such, century. Reportedly couldn’t tie Such were the Joys” a bitter account of his days in boarding school in which he his own shoelaces describes many of the traits related to Asperger Syndrome. Nikola Tesla - Inventor Andy Warhol – Artist;Was able to mentally picture very detailed Credited with creating the pop-art mechanisms; spoke 8 languages; was never movement. Also reported to havemarried; was very sensitive to touch and had an had an obsessive personality, beacute sense of hearing and sight; was obsessed unable to adapt to different social with the number three; was disgusted by situations and frequently described jewelery and overweight people and also had by contemporaries as ‘odd’. several eating compulsions Dan Aykroyd - Actor / Comedian; Diagnosed with Asperger’s and Tourettes “Well, it was mostly physical tics, the classic Tourettes type syndrome, that type of thing. But by the time I was 14 it was allayed and I really havent had too much occurrence except on the Aspergers side, where I have a fascination with police, and I always have to have a badge with me. ... I have a fascination with law enforcement and the police. “
19. Why the obsession with rituals and routines?
20. How important is your routine?
21. Sensory Difficulties (The Fourth Characteristic)
22. Abnormal responses to environmental stimuli. An individual with autism may be: hyposensitive or hypersensitive All senses may be affected. Over stimulation can be a trigger for those “out of the blue” reactions.
23. ‘School was a nightmare! I was so easily caught away with lifes interruptions. It might have been a child coughing, a bus passing by on the road outside, a bird singing, or simply my own thinking trying to work out words from a previous conversation’. Wendy Lawson
24. SENSORY QUIZIFNOSPACESARELEFTBETWEENWORDSITSDIFFICULTT OSEEORIF TH EWO RDS BEG INA NDE NDI NPLA CEST HAT DON TMAK ESE NSE TEWO E O CE D H R S EM T N U AN OW DS DA P N
25. Who is this?
26. What everyday task are you being taught in the audio clip?
27. SENSORY QUIZ - ANSWERSIFNOSPACESARELEFTBETWEENWORDSITSDIFFICULTT OSEE If no spaces are left between words it’s difficult to seeORIF TH EWO RDS BEG INA NDE NDI NPLA CEST HAT DON TMAK ESE NSE...or if words begin and end in places that don’t make sense TEWO E O CE D H R S EM T N U AN OW DS DA P N The words seem to dance up and down
28. What everyday task are you being taught in the audio clip?
29. Who is this?
30. VisualHypersensitive Covers eyes / looks down Looks at minute particles / dust Frightened by flashes of light Dislikes dark / lightHyposensitive Stares at bright lights Moves fingers or objects in front of eyes Fascinated with reflections or bright coloured objects Runs hand round edge of objects
31. AuralHypersensitive Covers ears Makes repetitive noises Isolates self in areas such as toilet, store cupboards etc. Dislikes thunderstorms, crowds, having haircut etc.Hyposensitive Bangs doors / objects Seeks noises Makes loud vocalisations Delayed / no response to aural cues
32. TactileHypersensitive Resists touch Cannot tolerate new clothes / damages clothing Dislikes foods with certain textures Avoids peopleHyposensitive Seeks pressure Prefers tight clothing Prone to self injuries Little response to extremes of temprature
33. Olfactory (Smell)Hypersensitive Toileting problems Moves away from people Refusal to wear new clothes / frequent changing Avoidance of certain smellsHyposensitive Sniffs / smells objects or people Smears / plays with faeces Seeks out odours Bedwetting / urinary ‘incontinence’
34. Gustatory (Taste)Hypersensitive Very limited food repertoire Gags / vomits easily Poor eater Uses tip of tongue for tastingHyposensitive Regurgitates food / intentional vomiting Mouths / licks objects Eats inappropriate materials Mixes food e.g. Main course and desert
35. Interoceptive / vestibular / proprioceptiveHypersensitive Places body in strange positions Seeks pressure Unsteady on feet Extreme reactions to heat or coldHyposensitive Incontinence Appears ‘floppy’ / low muscle tone Constantly seeks food / drinks Rocking / spinning
36. “That tension that I have to live with every dang minute... I have to take naps through theQuotes - feelings day because I wear myself out just being...constantly startled is a good way to put it.” - Phil Wheeler “I experience life in themes. I have tremendous difficulty filtering out the essential from nonessential. I have trouble prioritizing the relevant pieces of information.” - Dena Gitlitz
37. Analysing Behaviour
38. poor concept of time changes in does not know / routine understand rules unsure what is anxious aboutgoing to happen failure STRESS difficulties with communication sensory difficulties literal interpretation of situation
39. AGGRESSION ICEBERG Pushing HittingSpecificBehaviours Spitting Throwing Shouting Swearing • unaware of social rules • unaware of others feelingsUnderlyingDeficits • over sensitive to noise • frustration through inability to communicate appropriately • inappropriate reaction to others
40. OVER PASSIVE ICEBERG Seems lazySpecific UnmotivatedBehaviours Waits for prompts Over dependent • Unaware of other peopleUnderlyingDeficits • Poor concept of time • Does not understand future rewards • Unmotivated by usual rewards • Does not understand expectations
41. Analysing Behaviour: The ABC Approach
42. ABC Recording Sheet
43. Addressing Challenging Behaviour Record the behaviour (actions) Analyse the underlying causes (setting and triggers) Analyse the consequences (results) Alter the triggers and / or results Analyse the function of the action and teach more appropriate responses
44. Behaviour Support Plans Identify behaviour/s of concern Known triggers Management strategies Reducing impact of incidents Response strategies at each stage Follow up / debrief Review / evaluate Agreements / multi-agency consistency
45. Practical Suggestions
46. Practical Suggestions• Incorporate a routine• Minimise unstructured time• Be aware of the environment• Use practical problem solving• Think about an individual in terms of their autism• Involve everyone• Ensure consistency Early intervention is key - Prevention is better than cure!!!
47. VISUAL CUESPeople with ASD are visual learners so visualways to facilitate communication areexplored: What I do is write everything I have to do down. That visual support is very useful for me. My to do list is like a ritual to me. Some people pray at night, I write a to do list.Dena Gitlitz
48. Visual Learning – What Are the Benefits?• Develops understanding•Aids retention• Provides alternative to social imagination• Provides reference point• May assist in developing ownership of agreedactions
49. VISUAL COMMUNICATION TEST Do you have a diary or calendar that you write things on to help you organize your life? Do you have a list of “things to do” on your fridge or at work? Have you ever pointed to a picture in an advertisement or a menu to show someone what you want? Do you write a shopping list before you go to the supermarket?
51. Work Systems A work system is a concrete, visual way to tell the person:1) What they have to do2) How much they have to do3) When they are finished4) What happens next
52. Setting up schedules/ timetables WHAT vertical gridsThe visuals go downthe side as seen in thismorning schedule.
53. Visual Structure
54. Social Stories Visual – symbols, photos, writing Fewest points possible Permanent - allow individual to revisit Simple language – whether written or spoken Based on knowledge of individual Explicit – do not make assumptions Factual – stick to known outcomes; consequences must be agreed and carried out Definite – avoid use of ‘maybes’
55. GENERAL STRATEGIESCommunication Limit language used – clear, precise and slow The ‘implicit’ should be made ‘explicit’ Be aware of the literal – explain idioms, don’t ask unless there is a genuine option Cannot assume understanding – check ensure / cue attention
56. GENERAL STRATEGIESSocial Interaction Social skills need to be ‘taught’ not ‘caught’ ‘Unwritten’ or ‘unspoken’ rules will need to be made explicit
57. GENERAL STRATEGIES Need to be aware of structure and routines -what’s now / what’s next Flexibility in thinking – the more inflexible the individual is, the more flexible the staff will need to be! Visual cues – easier to understand and also ‘permanent’ reminder ‘Free’ unstructured / transitional time may need planning Abstract or open ended activities may need to be made more concrete or specific
58. GENERAL STRATEGIESBehaviour and Obsessions Clear consistent guidelines and boundaries Ensure rules are understood Emphasis on what we want the individual to do rather than what we don’t want them to do ‘Desirable’ behaviour may need teaching – be patient Distract and divert Obsessions – cannot eliminate but limit or use as motivation
59. GENERAL STRATEGIESWorking Together Maintain a dialogue with parents and carers Ensure that all staff are fully informed Use written plans / scripts where appropriate Consider how other service users can understand the nature of the disability Think about unstructured times and transitions Limit choice so it is manageable to the individual
60. Golden Rules Know the individual Understand ASD Structure the environment Reduce your language Recognise anxiety / build up
61. It’s just as though he’s not listening. He’s always ruining others’ activities! The only place she will eat her dinner, without screaming, is in the I told the him we were corridor. going to have a treat instead of the usual day and he starts shouting and screaming. She paces round and round the TV lounge. She doesn’t even watch it. He just won’t leave the lounge room door open – it If I get cross, she just gets absolutely roasting seems to think it’s funny – during summer! why won’t she listen?
62. Further ResourcesUseful Websites• www.nas.org.uk• www.through-the-maze.org.uk• www.bild.org.uk• www.autismuk.comSuggested Reading• Autism and Asperger Syndrome – Simon Baron Cohen• A History of Autism – Adam Feinstein• The Curious Incident of the Dog in the Night-Time – Mark Haddon• Thinking in Pictures – Temple Grandin