Tri-Therapy(Body, Mind, Soul)
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A document prepared for a course on Education of the Exceptional Student By Shamai Currim November 8, 2001 Introduction Over 10 years ago North Carolina began closing their mental institutions. The state legislature had UNC develop a program for the young autistic people who would have no place to go. This process began before the special education law was passed. The result was TEACCH. At the time, people were very excited about the TEACCH programs. Today there are many new approaches to working with students with autism, or autistic spectrum disorders. Autism is sometimes seen as a medical-neurological condition. In Taber's Encyclopedic Medical Dictionary, Fifteenth Edition, 1986, autism is considered to be a mental introversion in which the attention or interest is fastened upon the patient's own ego-a self-centered mental state from which reality tends to be excluded. Infantile autism is a syndrome appearing in childhood with symptoms of self-absorption, inaccessibility, aloneness, inability to relate, highly repetitive play and rage reactions if interrupted, predilection for rhythmical movements, and many language disturbances. The word autism is taken from the Greek autos, meaning "self", and refers to the extreme sense of isolation and detachment from the world which characterizes the autistic individual. Symptoms of autism emerge before the age of 2 ½, with few diagnosed after age 5. Autism is seen as one of the most seriously disruptive of all childhood disabilities, resulting in varying degrees of deficiencies in language, interpersonal skills, emotional or affective behavior, and intellectual functioning. Autism is thought to have been described as early as the 1800's, began to appear in the research literature in the first half of the 20th century, and became a recognized disability category in 1990. "The federal regulations for IDEA(Individuals with Disabilities Education Act) employ the following definition of autism: Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects educational performance. Characteristics of autism include irregularities and impairments in communication, engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. (U.S. Department of Education, 1991,p.41,271" (Hardman, Drew, Egan, Pg. 355). Autistic students present significant educational challenges, and have a tendency to perseverate on specific items learned, find maintaining attention difficult, need support with psycho-social skills, show uneven abilities, respond impulsively, find processing information and abstract ideas difficult, may fail to understand the general concept, and yet may possess qualities, such as their need for routine, which can form helpful focus for instruction. Long term memory skills for factual information are usually strong. Each individual child must be seen as such, a student who possesses both limitations and strengths, and must be individually assessed when considering educational programming. The IDEA assures that all handicapped children have available to them a free appropriate public education which emphasizes special education and related services designed to meet their unique needs, to assure that the rights of handicapped children and their parents or guardians are protected, to assist States and localities to provide for the education of all handicapped children, and to assess and assure the effectiveness of efforts to educate handicapped children. The term "free appropriate public education" means special education and related services that 1. Have been provided at public expense, under public supervision and direction, and without charge, 2. Meet the standards of the State educational agency, 3. Include an appropriate preschool, elementary, or secondary school education in the State involved, and, 4. Are provided in conformity with the individualized education program required under section 1414(a)(5) of this title; "related services," services that support the provision of special education, including transportation and those developmental, corrective, and other supportive services determined by a local placement committee to be required for an eligible child to benefit from special education. IEP's are written which include the present level of educational performance, annual goals and short term objectives, a statement of the specific educational services to be provided, the extent to which the child will be able to participate in regular educational programs, the needed transitional services, the projected date for initiation and anticipated duration of such services, and the appropriate criteria and evaluation procedures and schedules for determining whether instructional objectives are being achieved. A wide variety of instructional options are required to effectively educate children with autism. Alternatives range from specialized individual programs to integrated placement accompanied by support services. Current studies emphasize the benefits of integration for educational purposes to the maximum degree possible. Autistic students IEP's usually focus on developing functional communication skills, social skills, and the maximum amount of independence possible. Programs increasingly use technological enhancements, such as virtual reality and multimedia. Creative, innovative, and positive teachers are particularly important in providing effective education for students with autism. Parental participation in preparing children with autism for school and other segments of life can be of great assistance. New treatments are always being developed to improve the prognosis for these children. New programs continue to evolve, just as new treatments evolve for other medical conditions. It is a mistake for people to become emotionally wedded to one program if this blinds them to the possibility that new treatments and improvements will be made over time. In 1997 the NIH launched research programs at several university medical centers around the country with objectives to sift through the claims being made , to identify the most appropriate ways to treat children with this diagnosis, how to diagnose more accurately, etc. Psychodynamic-based therapies , medically based treatments, behavioral enhancement, and educational interventions are just some of the current approaches. Many teachers use a mixture of these, preferring an eclectic/pragmatic approach. TEACCH, Higashi, Lovaas, Option, and more recently SPELL have all come to the forefront. This paper takes an overall view of these teaching interventions, and how we can use some of these ideas in an ordinary mainstream classroom. TEACCH TEACCH is an approach that looks towards independence in the community for individuals with autism, with a concentration on the development of vocational skills. This is introduced progressively with vocational skill development becoming enhanced as the student gets older and preparing to leave school. Working from strength, rather than from deficits, students go right from the start into such pre-vocational skills as sorting, rather than progressing through a developmental model , which would not fit in with their scattered pattern of development. A truly independent existence beyond school is what the program is striving to attain. In the mainstream classroom teachers using the TEACCH program are really referring to Structured Teaching. It is believed that children with autism need the teacher to avoid verbal instruction, necessitating the use of visual or concrete strategies. In reality, these pupils may not understand, or may be distressed by its use. Container organization is used to develop the routine of working from left to right. Material is prepared in advance with pupils starting work in the left hand box, and putting it in the right hand box when complete. Students become less teacher, and more self, reliant. At the pre-school level, the students are referred by professionals or parents, based on a diagnosis or autism or related communication disorder. The classroom is developed and run by the lead teacher, with approximately five students between the ages of 2 ½ and 5 years. The professional educator, who has extensive experience in autism, in early childhood, and in working closely with families, is helped by an assistant teacher, who is also well trained in autism and TEACCH interventions. Program consultation, as well as parent liaison support, is also provided. Classes run 4 days a week, 3 hours a day. Families receive weekly home visits from a member of the TEACCH staff. Students continue to receive services by participating in the TEACCH Summer Training Program. The curriculum includes a comprehensive education program with an emphasis on developing both motivation and skills in a wide range of curriculum areas: "learn how to learn" through the use of Structured Teaching, expressive and receptive communication, focusing on initiation, intent and effective communication, social interest and skills, play skills, cognitive and functional academic skills, fine and gross motor skills, self-care. Improving child motivation and skills while adjusting the environment to compensate for the child's weaker skill areas, becomes an individualized, development appropriate plan for each student. Daily opportunities for one-on-one instruction, group teaching and independent practice is managed in curriculum areas. Students are constantly being assessed for their strengths, weaknesses, and emerging skills both in class and at home. Parents and teachers are in active collaboration with weekly in-home training and consultation assisting with implementing affective and functional home programs. Community outings foster generalization of learning across settings. Bi-weekly integrated play groups foster generalization of learning to larger group settings. TEACCH in the Mainstream TEACCH is a school-based program. The basic model places several children in small self-contained classes, usually with one teacher and one aide. TEACCH provides the child's family with education and support. The parents are not blamed for their child's autism. The goal of TEACCH was to permit the autistic child to remain in the community, albeit in highly supervised, structured living and employment environments. For many years, TEACCH was adopted widely by public school systems throughout the country as the model of special education for autistic individuals. The TEACCH desk organization and use of screening can be utilized in a mainstream school for pupils who have difficulty with attention, personal organization, and sensory sensitivities. The positive aspect achieved is the sense of 'personal space'. Ownership gives students a sense of safety and security where they have a degree of control and where there are known rules and routines. During times of stress and anxiety, this 'owned' space provides security in an ever changing world. At the elementary level, where students remain for the whole day, it is easier to set up, or create, a "little office' within the classroom. In middle or secondary schools, where there is far more movement, a specific desk can be set aside in each classroom, with the student needing only carry his/her personal boxes. A desk set up outside of the classroom can be used for quiet time or one-to-one tuition, or when the student just needs to work alone. Those students who have difficulty with personal organization , and more specifically, when to start and end tasks which are set, will require a visual timetable, which allows for flexibility as well as the inevitable changes which might cause stress and anxiety. An obvious visual representation of the passing of time, helps. Many students are particularly sensitive to noisy areas, to both a physical sensitivity and the inability to block out unwanted noise. Fluorescent lights are another environmental factor that affects sensitive children. Setting up a desk in a quiet area, using acoustic screens as area dividers, can really help these oversensitive students. OPTIONS What most people refer to as the Option approach or "Options" is more accurately named the Son-Rise Program develop by Samahria and Barry Neil Kaufman. Based on their own particular philosophy of total love and acceptance, which transformed their own son, diagnosed as incurably autistic with an IQ under 30, he now is a near genius IQ graduate with no trace of his original condition. The program is home based and parent delivered , although parents are encouraged to develop and train a group of helpers. Work takes place in a specially constructed 'playroom' and the highly intensive interaction is designed to "build a bridge into our child's universe, allowing us to help him find the road back to us" (Sun-Rise start up program introductory letter from Bears and Samahria Kaurman). A loving and accepting attitude, which challenges the more traditional ways we think of disability, is the most powerful resource . The child is the teacher. Behavior is not labeled good or bad. IEP's are not written. All judgement is dropped. Everything the child does is seen as the best they can do at the time. If they could do better, they would. The relationship and intense interaction developed in the playroom is so loving and so exiting "that perhaps the young person will want to know more, get more and learn more from us" (as above). Options builds on the three E's, excitement, enthusiasm, and energy, when working with children with autism. The teacher is usually very demanding of the child, sustaining the demands for social contact in an enclosed environment, and always looking for eye contact. OPTIONS in the Mainstream Translating the Son-Rise program into the mainstream setting has obvious difficulties but the thinking upon which the program is based deserves consideration by any teacher. LOVAAS Lovaas is known as a Discrete Trials Method. Behavior modification or positive reinforcement is usually used when dealing with problem or challenging behavior. The main Lovaas/ABA debate came from school districts placing two and three year old autistic children in 'class based' programs for 9-12 hours a week. In these group programs, these very young children made little or not progress. Many actually lost skills. Dr. Lovaas has been criticized for using 'aversives'. Over the years changes and fine-tuning have taken place, with aversions being no sharper than a 'no' from the parent or therapist. Lovaas videos show small children being rewarded for tasks and utterances with sweets and jam on spoons. Few people toady, and no teachers in schools or specialist settings, claim to use a Lovaas approach, which would be difficult to defend today. Today's home based Lovaas programs are very similar to the Options approach, using the same kind of highly animated praise and 'in your face' contact as the Options approach. LOVAAS in the Mainstream The principles and practice of behavioral approaches, and the kind of intensive behavioral intervention advocated by Lovaas supporters, will probably not find its way into mainstream settings. PEACH There is a parent run support group advocating early and intensive behavioral intervention for children with special needs known as PEACH. Parents for the Early Intervention of Autism in Children use behavioral intervention which emphasizes:
The PEACH web site claims that according to available scientific research and empirical data, behavioral intervention can have numerous benefits for children with autism. These include increases in communication, social, self-help and academic skills, increased IQ levels, increased self management due to reduced aggression, self injury, lethargy and avoidance. Increased motivation based on repeated success, increased generalization by teaching in multiple environments, increased opportunities for full inclusion, reduced risk of institutionalization, involvement of parents as effective teachers, less stress for families and the community. PEACH in the Mainstream Mainstreaming in regular schools once basic "attending" social skills re learned. SPELL The acronym for a framework which emphasizes that all interventions should be individually determined and that no two individuals are the same, is SPELL"
SPELL is the common thread running through all of the specialist services provided by the National Autistic Society (NAS). SPELL training provides the overview of the autistic spectrum and an introduction of the basic principles. At it's first level, it is designed for people with limited knowledge and/or no formal training in autism. In the second phase practitioners seeking to further develop their understanding and application will take part. Other SPELL modules are currently under development. SPELL incorporates explanations for understanding and responding to autism relevant to the interests of both parents and professionals. It is believed that all interventions should be individually determined and that no two individuals are the same. SPELL in the Mainstream Endorsed by the NAS, SPELL is a framework that ensures that as far as possible opportunities for learning and life are maximized by reducing the disabling effects of autism. The framework emphasizes the individual, with an overlapping of shared, similar experiences. SPELL underpins all areas of Practice, Environment, Teaching and Learning, Organization, Training and Problem Solving. DAILY LIFE THERAPY/HIGASHI "Within every child exists its most bond of self identity, to search this out and foster it with loving care; is the essence of education of the autistic child". (Dr. Kiyo Kitahara-founder) Dr. Kitahara's approach to group dynamics incorporates physical education, art, music, academics, the acquisition and development of communication and daily living skills to promote social independence. The primary focus is to establish stability of emotions gained through the pursuit of independent living and development of self esteem. Through the mastery of self help skills (dressing, eating, independent bathroom use) students develop self confidence and gain initiative to attempt other adaptive skills. Extensive physical exercise establishes a rhythm of life and provides benefits related to release of endorphines, which inhibit anxiety. Students gain control over their bodies and, consequently, over their behavior. Physical education is seen as a bridge to social development. Language and communication skills focus on the whole language approach and age appropriate curriculum and materials to maximize modeling are used. Painting, drawing, and musical performance are the premise for developing creativity. Daily Life Therapy is not a set of discrete techniques of interventions to change or eliminate behaviors. It s a holistic approach based upon a bonding between child and teacher. The major tenet of Daily Life Therapy is that education should be conducted in an environment of normality. DAILY LIFE THERAPY in the Mainstream If we look at the major tenet of Daily Life Therapy, then mainstream is where this should take place. Each student, in his/her own unique way, will fit into this holistic approach. Other than the self help skills, which should already be in place for the regular learner, this model is already part of the general classroom curriculum. HIGH AND LOW INTRUSION Dr. Richer talks about approaching children with autism in three particular ways (holding, animated baby play, quiet socially unintrusive object play). He writes about factors that increase a child's avoidant behavior, typical of autistic children. This intensifies when the situation or activity is frustrating, uncertain, difficult, and is less in clear simple or well structured settings or activities. Ordinary, friendly communicative behavior tends to promote avoidance, least when the adult is relatively undemanding or intrusive in their social behavior, or when the adult is demanding and sustains the demands. The three interactive distinctions are called :
What we see as friendly, everyday interaction is actually full of social and interpersonal demands that a child may not be equipped to deal with. The one thing that can bring the most distress and anxiety is the approach most often used by people meeting a child with autism for the first time. Individuals with autism do not understand or deal with the hidden messages-eye contact, body language, intonation of the spoken words, easily. If distressed and anxious to begin with, approach with a low intrusion mode. Be quiet, calm, and slow in movement. Make little eye contact, placing yourself behind or beside the pupil. Maintain a neutral body posture and a 'dead pan' face. Speak quietly with an even tone of voice and always remember to keep language as literal and simple as possible. High intrusion brings the best results when trying to engage a reluctant student in an activity. Sweeping him/her along in your enthusiasm and desire for him to have a good time usually works well, along with praise and excitement about success. Sitting down to chat with these pupils brings out the most challenging behavior. HIGH AND LOW INTRUSION in the Mainstream Even with the common students in the general classroom setting, it is important to be sensitive to their style of interaction. We are dealing with students from many different walks of life, many different nationalities and societal differences. Moving in with low intrusion, focusing into middle, and adding in the high intrusion when trying to catch their attention, fluctuating in and out of each mode, can work well. It makes the teacher aware of her teaching style, and the interaction with students. One does not have to be like the overly-sensitive autistic child to understand and experience the effect of different levels of communication. We all have a style that best suite our needs, in different situation. Again, like with most models, flexibility, and sensitivity to individual needs, is paramount. THEORY OF MIND A relatively new hypothesis in the field of autism refers to the notion that autistic individuals do not understand that other people have their own plans, thoughts, and points of view. It appears that they have difficulty understanding other people's beliefs, attitudes, and emotions. Theory of mind, appearing uniquely in autistic individuals, appears in Asperger's syndrome to a lesser degree, and not in the average, or mentally retarded individual. Social and communicative skills are hampered by this inability to anticipate what others will say or do. They appear to be self-centered, eccentric, or uncaring. Carol Gray has come out with 'social stories', short stories which describe different scenarios which allow autistic individuals to understand themselves and others better. We all have the ability to think about other peoples thinking, what they might think about our thinking, and what underlies much of our interaction with others. Know what other people are thinking helps us make sense of others behavior, influences the way we react to others, and gives us the ability to appreciate that others have mental states, intentions, needs, desires, and beliefs that may be different to our own. The effects of this impairment is subtle, pervasive, and specific. It leads to fear and avoidance of others, an inability to read the intention, emotions and behavior of others, and how it affects how we and others think or feel, leading to a lack of conscience and of motivation to please. Pedantic or incomprehensible language follows, with an inability to read and react, anticipate, deceive and understand deception. Lack of understanding of social interaction leads to difficulties with turn taking, prior topic maintenance, inappropriate eye contact, and a poor understanding of what differentiates fact from fiction. THEORY OF MIND in the Mainstream Knowing and understanding this lack of communicative ability will help when mainstreaming the autistic individual. It is at the very essence of the IEP, and IDEA ruling that all must be treated as both individuals, and as equals. It helps us to see within the makings of the autistic characteristics that make up the individual. Compensations, and sensitivity can be build into every interaction . All students need be dealt with at their individual level, and knowing that only autistic individuals have no sense of other, helps to put things into perspective. WHOLE SCHOOL APPROACH: Managing Social Behavior There is a high correlation between ongoing teach training and the achievement of pupils. The key to unlocking the full potential of any pupil in school lies in the expertise of the teacher. A whole school approach is dependent on identification, assessment, and planning that will in turn be the basis for the promotion of social development, positive behavior, and preparation for adulthood. Pupils with communication and interaction difficulties display immature behaviors which restrict their social and emotional development. These may be the primary features of their disorder, and are also influenced by social environment and the effects of medication. These characteristics include inattentiveness, lack of perseverance, low self-esteem, and difficulty in sustaining positive relationships with adults and peers. The whole school approach concentrates on considering more carefully the origins of behavior and on developing knowledge, understanding, and skills to meet the challenges of problematic (or just different) social behavior. A whole school approach encourages teachers to:
WHOLE SCHOOL APPROACH in the Mainstream The whole school approach appears to be formulated specifically for mainstream schooling. Once we have an understanding of the nature of autistic thinking and behavioral difficulties, and how it effects access to the curriculum, we will have gained strategies based upon identification, assessment, and planning, supporting all students and aiding them to become the best they can possibly be. Understanding that some of the autistic students strengths may be:
The corresponding weaknesses:
CONCLUSION Autism is considered to be a mental introversion in which the attention or interest is fastened upon the patient's own ego-a self-centered mental state from which reality tends to be excluded. Symptoms usually include self-absorption, inaccessibility, aloneness, inability to relate, highly repetitive play and rage reactions if interrupted, predilection for rhythmical movements, and many language disturbances. Symptoms usually emerge before the age of 2 ½, with few diagnosed after age 5. Autism is seen as one of the most seriously disruptive of all childhood disabilities, resulting in varying degrees of deficiencies in language, interpersonal skills, emotional or affective behavior, and intellectual functioning. Current teaching methods being used for the autistic population include TEACCH, Options, Lovaas, PEACH, SPELL, Daily Life Therapy, High and Low Intrusion, Theory of Mind, and Whole School Approach, all of which can be mainstreamed into regular classrooms. Psychodynamic-based therapies, medically based treatments, behavioral enhancement, and educational interventions are just some of the current approaches. Many teachers use a mixture of these, preferring an eclectic/pragmatic approach. Autistic students IEP's usually focus on developing functional communication skills, social skills, and the maximum amount of independence possible. Programs increasingly use technological enhancements, such as virtual reality and multimedia. Creative, innovative, and positive teachers are particularly important in providing effective education for students with autism. Parental participation in preparing children with autism for school and other segments of life can be of great assistance. Bibliography Hardman, Michael L.; Drew, Clifford J.; Egan, M. Winston.; Human Exceptionality: Society, School, and Family, Viacom Co., MA, 1999.
Web sites used to gather information:
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