Meeting the Needs of Students with Aspergers Disorder

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Clinical Assistant Professor of Pediatrics The
Ohio State University ____________________ Nationw
ide Childrens Hospital ____________________ Child
Development Center

• Meeting the Needs of Students with Aspergers
  Disorder
• David Michalec, PhD

david.michalec_at_nationwidechildrens.org
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A bit about me

• David Michalec, PhD
• Clinical Child Psychologist
• Child Development Center
• Nationwide Childrens Hospital
• A graduate of Columbus Diocesan Elementary and
  High Schools
• Much thanks to colleague C. Murphy for sharing
  some slides
• __________________________________________________
  ___

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Understanding Aspergers Syndrome

• When I learned that I had Asperger's, I thought
  that
• I was going to get a cheese burger made out
• of a cows butt!
• -- Tommy, 10 years old, when asked about his
  understanding of Aspergers Disorder

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What is Autism/Aspergers?

• complex different terminology
• genetic
• neuropsychiatric
• neurodevelopmental
• Disorder
• life-long

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Autism Spectrum Disorders

• Autistic Disorder
• Aspergers Disorder
• Pervasive Developmental Disorder, Not Otherwise
  Specified (PDD-NOS)
• Childhood Disintegrative Disorder
• Retts Syndrome

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Pervasive Developmental Disorders
Childhood Disintegrative Disorder Retts Disorder
Autistic Disorder Aspergers Disorder
PDD-NOS Pervasive Developmental Disorder Not
Otherwise Specified
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The Triad of Impairments . . . . The Autism
Spectrum
More Severe
Less Severe
Communication
Social Interaction
Repetitive Behaviors
Co-occurring Problems
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Autism Spectrum Disorders

• Core symptoms
• 1) Communication Impairment
• 2) Social Interaction Impairment
• 3) Repetitive, Ritualistic and Restricted
  Behaviors
• Except Aspergers.we technically should only
  have 2 of 3

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Aspergers Disorder
Thing 1 and Thing 2
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Aspergers Disorder

• Core symptom 1
• Social Interaction Impairment
• - Lack of social/emotional reciprocity
• - Poor peer relationships appropriate to
  Developmental Level
• - Lack of spontaneous seeking to share
  enjoyment, interests, or activities (not
  bringing, showing, or pointing)

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Aspergers Disorder

• Core symptom 1continued
• Social Interaction Impairment
• - Impairment in Nonverbal Behaviors
• Poor eye-to-eye gaze
• Flat or blunted facial expressions
• Inappropriate Use of Body Postures
• Poor use of gestures to regulate social
  interaction

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Autism Spectrum Disorders

• Core symptom 2
• Repetitive, Ritualistic Restricted Behaviors
• - Preoccupation with parts of objects
• - Repetitive motor mannerisms (hand flapping)
• - Inflexible adherence to specific,
  nonfunctional routines or rituals
• - Preoccupation with a restricted pattern of
  interest or particular topic that is abnormal in
  intensity

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Aspergers Disorder

• Core symptom 3
• Communication Impairment
• - Delay or lack of spoken language
• - Trouble with sustaining or initiating a
  reciprocal conversation (one sided)
• - Repetitive use of language (scripting)
• - Lack of varied, imaginative, imitative play
• THIS IS TECHNICALLY NOT PART OF THE DIAGNOSIS

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Aspergers Disorder

• Core symptom 3
• Communication Impairment
• While technically true, some communication
  symptoms do overlap
• One-sided Speech
• Overly Pedantic speech, poor prosody, monotone
• Little Einstein type of speech
• Verbosity of speech

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Aspergers Disorder

• Children with Aspergers have cognitive skills in
  the average (or above) range
• No delay in the development of age-appropriate
  self-help skills and curiosity about the
  environment (besides social delays)

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Aspergers Disorder

• Symptoms That hang out with Aspergers but are
  NOT diagnostic.
• Difficulty with mechanics of hand writing
• Unusual gait patterns (toe walking), posture
• Auditory, tactile, visual sensitivity
• Sensitivity to taste and texture of food
• Inattention, hyperactivity, poor organizational
  skills

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Aspergers Disorder

• Symptoms That hang out with Aspergers but are
  NOT diagnostic.
• Motor clumsiness
• Uncoordinated in gross motor area, gym class and
  team sports
• Delay in acquisition of some self help skills
• Cant do versus wont do

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How do we diagnose Aspergers?
I oftentimes refer to the differential diagnosis
of ASD as a TREE.
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How do we diagnose Asperger's?

• Unfortunately, we dont have one simple test
• It is a behavioral diagnosis based on seeing the
  core behavioral symptoms in a child
• The best is a team approach to evaluate all areas
  of a childs functioning
• Psychology
• Medicine (neurology, Developmental Pediatrics)
• Speech Therapists
• Occupational Therapists

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Why is diagnosis so difficult?
ASPERGERS
Social Interaction Deficits Repetitive Behaviors
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Why is diagnosis so difficult?
Social Interaction Deficits Repetitive Behavior
ASPERGERS
??????????????????????????????????????????????????
??????????????????????????????????????????????????
????????
Social Interaction Deficits
This thing we call . . . ASPERGERS
Repetitive Behavior
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Differential Diagnosis of Aspergers

• For example
• Poor social skills
• could be anxiety, language delay, low cognitive
  abilities, mental retardation, family stress,
  hearing difficulties, depression
• Repetitive behaviors
• Tic disorder, tourettes, Anxiety (Obsessive
  Compulsive Disorder), low cognitive abilities,
  gross/fine motor delays

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Complexity of Diagnosing Aspergers

• In some cases, there are disturbing
  characteristics
• Incomplete understanding of these disorders
• Uneven distribution of professionals with
  relevant knowledge
• Considerable Overlap with other conditions

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Common Misdiagnoses of Aspergers

• ADHD
• Hearing Impairment
• Learning Disability
• Mental Retardation
• Nonverbal Learning Disability
• Obsessive-Compulsive Disorder
• Depression

• Reactive Attachment Disorder
• Schizoid Personality Disorder
• Schizophrenia
• Selective Mutism
• Social Anxiety Disorder
• Language Disorders
• Tourette Syndrome

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Strengths of Aspergers

• Advanced verbal skills
• Good memory
• Often a good verbal memory (A young thespian?)
• Often want to be part of the group
• Will follow rules
• Can be very pleasant with staff and faculty
• Preoccupations can become shaped into passions
• Some preoccupations can be employable and very
  useful

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• Interventions for Aspergers in the school
  setting

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Available Recommended Interventions

• Intensive Behavioral Intervention
• Behavioral Management (as needed)
• Speech Therapy pragmatics of speech
• Occupational Therapy (as needed) - handwriting
• Physical Therapy (as needed) - coordination
• Inclusion / Mainstreaming (as indicated)
• Psychological Counseling (as needed) - anxiety
• Medicines (as needed) inattention/emotional
  dysregulation

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Treating Aspergers at School

• Education for staff
• Social skill development
• The Use of Visual Supports
• Helping with Transitions
• Managing Frustration
• A safe place or person
• Seatwork strategies
• Using Reinforcement
• These should all overlap

Always remember try play to/utilize their
Strengths!
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1. Education for Staff

• Educate ALL staff who work with the child
• Teachers Paraprofessionals Lunch Room
  volunteers Bus Drivers - Custodians
• Aspergers behavior is not necessarily a sign of
  defiance/disrespect
• Poor eye contact
• Repetitive behaviors
• Odd posturing
• Parent involvement (of course) is vital for
  success

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2. Social Skill Development

• This is a CORE symptom
• If your school as a counselor/social worker doing
  a social skills group, sign them up
• Identify peers to pair the AS student with
• Create a small lunch bunch with structured
  topics (Conversation cardsA good movie I saw
  recently was..)
• Give a competent peer a preferred item that the
  AS student wants
• Spiderman magazine

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2. Social Skill Development

• This is a CORE symptom
• Create groups centered around the AS students
  preferred activity
• Yu-Gi-Oh! LEGO group during indoor recess
• This will help motivate the AS student to be with
  peers
• Assign the AS student some questions to ask
  another student
• Did you win your soccer game?
• Do you want to see my new Star Wars LEGO?
• I like your new coat. When did you get it?

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2. Social Skill Development

• This is a CORE symptom

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2. Social Skill Development

• This is a CORE symptom
• Help explain jargon, sarcasm, or idioms of speech
• Youre just pulling my leg!
• Quiet down and zip it up!
• Try to avoid, if at all possible

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2. Social Skill Development

• This is a CORE symptom
• Help make Skill Cards
• For example How to introduce myself
• 1. Say Hi and get their attention
• 2. Say My name is David while looking at their
  eyes
• 3. Extend your hand and shake theirs
• 4. Say I noticed your book on UFOs, do you like
  to read?
• 5. Listen to what they say
• Look at Social Stories by Carol Grey
• Pictoral representations of what to do in a
  social stiuation

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(No Transcript)
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3. The Use of Visual Supports

• Providing the AS student with a Visual cue
  about
• The routine
• Their assignments
• Their feelings
• Consequences
• Reinforcement

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3. The Use of Visual Supports

• With routines
• You could also add times of
• Day or partners with whom to
• work, etc.
• Try and make these (and
• all visual supports) subtle

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3. The Use of Visual Supports

• Keeping them subtle
• Taped to their desk
• Inside their locker
• On their folders
• On the outside of their
• notebooks
• On a small business card

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4. Helping with Transitions

• Obviously, s 1,2, and 3 will help
• Again, use Visual reminders or cues
• ______________________________________

Davids Change in Routine Card NOTICE Music
class WILL BE CHANGED ON Monday, November 7th
BECAUSE Mrs. Tambourine is sick and not in
class today THE NEW SCHEDULE IS we are not going
to Music. We will review our spelling words and
will read our Social Studies lesson
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4. Helping with Transitions

• With transitions
• Activities are PLANNED not GUARANTEED
• Emphasize that activities can be changed,
  cancelled, or rescheduled.
• We are planning on going to an assembly tomorrow
  by a guest jazz band. Be prepared for music and
  the whole school. The music may be loud and you
  can wear earplugs. If so, you can sit with Mrs.
  Patience in the back. However, the band may not
  come. If this happens, we will have reading as
  usual. Remember our plan is to go see the
  jazz band.

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5. Managing Frustration

• Remember, because of all the deficits with AS,
  the student is prone to frustration
• Be aware!...dont let their frustration lead to
  task avoidance!
• 1 you present work
• 2 he blows up
• 3 you remove work to stop the distraction and
  allow him to play on computer
• The blow up will surely occur next time you
  present work!

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5. Managing Frustration

• Can you avoid the situation that leads to
  frustration? Maybe
• Change the environment?
• Sit away from distractions
• Allow small ear plugs to reduce loud noise
• Warn when you know a fire alarm is happening
• Provide a place for relaxation
• Providing visual cues
• And, there are also times when you cannot change
  or avoid the situation

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5. Managing Frustration

• Try to head off at the pass when frustration
  will occur
• Learn the childs cues when they are going to
  get frustrated
• Red faced, hands shaking, breaks pencil, starts
  to get loud, becomes jittery
• Intervene HERE before it explodes into a full
  blown rage!
• The Incredible 5-Point Scale by Kari Dunn Mitzi
  Curtis

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5. Managing Frustration
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5. Managing Frustration
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5. Managing Frustration
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5. Managing Frustration

• Remember, if the students explodes and disrupts
  the class, you still need to discipline
• Aspergers is NOT an excuse for disruptive
  behavior
• Re-group and look for Teachable Moments next
  time, so as not to repeat the previous explosion

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6. A Safe Place or Person

• Is there a person or place at school the AS
  student can go to prior to an explosion?
• Nurse
• School Counselor
• Quiet corner
• Take a lap turn paper over, get a drink, walk
  to end of hall, come back, finish assignment

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6. A Safe Place or Person

• If the student with AS can tell you (either
  intended best scenario or not) that they need
  their safe place..
• It has worked!

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7. Seatwork Strategies

• Attention span
• Preferential seating
• Be sure you have their attention
• A small tap or sign
• Handwriting difficulties
• Can they use a PDA instead of notebook?
• Typing? (at higher grades)
• Consult with your Occupational Therapist
• Handwriting without Tears program

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7. Seatwork Strategies

• Provide incremental reminders when time is up
• www.timetimer.com
• Can child dictate into a
• tape recorder?
• Twice as much time, half as much work
• Allow fidgets

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8. Using Reinforcement
A Behavior that you want to see more
of

Reinforcement

MORE of that same, good, positive behavior!
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8. Using Reinforcement

• The standards
• Stickers, little toys, rewards
• You may have to be more subtle
• Time with preferred objects
• Within a specified time period
• The more visual, the better
• The LEGO example
• Be patient and reassuring!

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Aspergers Resources

• The New Social Story Book (2000) by Carol Gray
• Aspergers Syndrome A Guide for Parents and
  Professionals (1998) by Tony Atwood.
• Simple Strategies that Work! (2006) by Brenda
  Myles et all
• The Incredible 5-Point Scale (2003) by Kari Buron
  Mitzi Curtis
• Asperger Syndrome Difficult Moments (2005) by
  Brenda Myles Jack Southwick

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Aspergers Resources

• Life Journey Though Autism An Educators Guide
  to Asperger Syndrome (2005) by the Organization
  for Autism Research www.researchautism.org
• www.asatonline.org
• www.behavior.org
• Online Asperger Syndrome Information Support
  (OASIS) www.udel.edu/bkirby/asperger
• Tony Attwood Home Page www.tonyattwood.com.au
• Yale Child Study Center DD Clinic www.autism.fm
• www.autismspeaks.org They will give you the
  School Tool Kit

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State Support Teams

• State Support Team
• Consultation, assistive technology, workshops,
  school training, lending library
• Region 11 Columbus area
• www.cosptid.org/franklin
• Region 12 East Central Ohio
• www.sstregion12.org
• Region 15 Southern Ohio (Portsmouth, Waverly)
• www.rpesd.org
• All sites can be found www.ode.state.oh.us

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OCALI

• The Ohio Center for Autism and Low Incidence
• www.ocali.org
• 5220 High Street
• Columbus OH 43214
• [phone]
• Pediatrics Journal Article
• www.pediatrics.org