The first year I was working as a Behavior Therapist, I had a client named David*- a five year old boy with autism, who was my first case as a newly-promoted supervising Senior Therapist. My boss and I met the entire family at their home on an initial fact-gathering mission, in preparation for the beginning of an intensive 35 hr/week home therapy program. We asked David's mom the typical questions- age of onset of symptoms, verbal ability, what types of perseverative behaviors he had, etc.
David had Hyperlexia; they figured he probably began reading at about 18 months of age, but had developed very little communicative language. He had almost no eye contact, and no real social skills to speak of. He also had an extremely limited diet that included roughly three different food items, which had to be prepared and presented in a very specific way. He would drink only white milk- no water, no juice. He developed patterns and routines after seeing two consecutive occurrences of behavior: you come to the front door two days in a row, and now you must always come to the front door. Show up at the back door, and there will be a complete behavioral meltdown, fire and brimstone, mass hysteria. Control issues you say? Oh, yeah.
As I listened to his mother describe her concerns for his lack of interest in connecting with others on a social level, I was taking notes and watching him. He wandered around the living room, seemingly oblivious to what any of us were doing or saying. He was preoccupied with a tiny instruction manual to a toy, obviously a favorite item, considering the worn and tattered state of that little booklet.
His mother was telling us that she could stand in front of him and call his name, and he would make no eye contact, as if she weren't even there. All attempts to engage him in play that involved anything except toys or objects with letters was futile. She told us the story about how she first discovered he could read.
His older sister had a Speak and Spell (electronic toy with the letters of the alphabet, that recited the letter when you pushed it), one of the few toys David seemed interested in exploring. One day, in an act of desperation to get him to connect with her, his mom sat next to David with the Speak and Spell, pushing the letters H-I, wanting him to reciprocate this attempt at a social greeting. He had no interest in this activity- he was too focused on the little Trident gum wrapper he was holding and inspecting.
H-I... "Hi"... H-I..."Hi"... H-I..."Hi"... H-I... "Hi." She would repeat this over and over again, pressing the letters to spell "Hi", then saying "Hi" to him. Just at the point when she was about to give up and walk away, David turned to her and reached for the Speak and Spell. "He is going to press the letters H-I!" she thought, excitedly. He looked at her briefly and pressed the letters S-T-O-P, then resumed his examination of the gum wrapper. She saw this as a break-through, for that was the first reciprocal interaction they ever had! He was not yet four years old.
As she is telling us this story, I asked her if she had considered using words and letters as a means to try and get his eye contact or to interact with her in other ways. She seemed unsure of what I was getting at, so I reached into my handbag and pulled out a few blank index cards** and wrote down the words, "Look at me". I then went up to David, stood in front of him, and held the card in front of him, while saying, "David, look at me". He glanced at the card and immediately looked right into my eyes. Everyone cheered, which he found somewhat amusing. He started walking away, and again I held the card out to him, saying "David, look at me." Again, he looked right into my eyes.
I decided to see how far I could take his willingness to follow written directions. I took out another card and wrote, "Take a drink of water" and held a glass of water out to him. He took a sip, albeit with a grimace. That was the first drink of water he had taken for as long as his mom could remember, and quite possibly ever. And he did it on the first request, no protesting, which was just short of a miracle, considering the tight control he kept over his environment.
And so that began his treatment.
David was obsessed with letters and words, and tuned out verbal language. I explained to his mom that because he learned in an atypical way, he needed to be taught in an atypical manner. We had to sort of toss out the window Piaget's rules about what a child learns first, second, and so on. David was different; he learned things out of order. We just had to carefully assess what he did know and what needed to be taught, and go from there- no set sequence of skill teaching-order.
If he was reading, but not speaking, he could be taught to speak by reading instructions on how to communicate. Instead of taking the approach as some would think appropriate, which is to restrict his access to letters and words in order to force him to interact by other means, we did the opposite. We used MORE written language as a tool to help him learn verbal communication, and how to tune-in to the rest of the world around him.
Here's the bonus: because I wrote everything down for him when I gave instructions or taught him skills, he was motivated to learn. He wanted to interact with me, often giving me blank cards, waiting for me to write something down. He went from a child who seemed completely unmotivated to learn or participate in therapy, to a child who eagerly awaited the times when therapists would come to his home to play with him. We had bonded over index cards.
The amount of progress he made in the years to follow was unbelievable, even to me. The relationship we built with him meant everything to his amazing progress. Had we not developed that rapport, I am confident in saying that he would not have made as much progress or as quickly as he did. In four years time, he had "graduated" out of the intensive program; he was in a regular classroom, had birthday parties, friends, and was a complete chatterbox, with a wicked sense of humor.***
So the question is, what steps do you need to take in order to establish this working rapport- in order to get the highest rate of learning, participation, and cooperation with each individual child? Each kid is different, and if you have any experience at all with autism, you know this full well. The method I used with David may not work with another child with autism, or even one with Hyperlexia, but it worked for him. The key is to follow some basic guidelines that help you to tailor custom teaching to each child's specific needs. Some of these concepts apply to parents, some to teachers and therapists, and most of them to both. The important thing is to be flexible, and be prepared to modify teaching methods constantly, especially when beginning treatment.
Watch. Listen. Learn.
One of the biggest rookie errors a therapist with a new client makes is jumping right into hardcore teaching- setting ground rules, establishing a hierarchy of "You student, me teacher. Me boss, you listen" all in the first session. So you may be asking yourself, "What? Shouldn't I try
and take charge right away?" No, you shouldn't. And there are very good reasons why.
The very first thing you need to do is establish rapport. Until you do that, no matter how many ground rules you make, or how high or often you wield your sword, he will tune you out like you are not even there. And a child with autism can do this very easily. First you need to watch him- don't get into his face right away- you need to understand who you are approaching before you do. Leaping in front of a child with hypersensitivity to high-pitched noises with a gleeful, "HEY THERE!!!" will likely get you a tantrum and/or a dust cloud as they run from you in terror.
I always spend at least the first 10 minutes just quietly watching and taking notes of my observations; noting behaviors, reactions to stimuli, and his repetitive patterns. What does he play with? What are his perseverative topics? How does he respond to humor? Is he attracted to visual stimuli, music, tactile objects, movement and horseplay, or silliness? Learn these things, and you learn how to reinforce skills and motivate him to participate in his learning. M&Ms or other edibles are not always reinforcing for every child. Sometimes the best motivator can be something as natural as misspelling a word, and acting as if you have no clue what the problem is. In fact, the idea of reinforcement should and likely will be a topic for an entirely different article in the future.
Bottom line: Pay attention to the specific child- what he likes, dislikes, what annoys him, and what motivates him. Don't rely too much on what the books tell you to see- he is unique. Use your own eyes and ears.
Use their strengths to teach to their weaknesses
Whatever the child's high-interest subject is, use it to help teach him the skills he needs to learn. It may seem logical to assert that if a child is obsessed with, let's say trains, then you should try and stop him from playing with trains, talking about trains, thinking about trains, in order to get him to attend to more "appropriate" things and topics. The rationale for this approach is to get him to widen his repertoire of interest items, instead of continuing to hyper-focus on one topic. However, that high-interest topic is so darn interesting to the child, that he could care less about much else.
You need to be able to reach him in some way in order to teach necessary skills, so why not use the "easy in"? If he needs to learn math, teach math concepts in the context of trains. You are holding the Golden Ticket of Motivation. You already know he is going to pay attention, because it is about trains. It doesn't matter what benign symbols you use, as long as it teaches mathematical concepts.
Example: The departure time for Train A is 4:00. They just announced that they are experiencing delays, and the Train will be departing at 4:20. How long is the delay?
Example: The cost of a Charlie Ticket is $10 for 10 rides on the T. A single ride on the T costs $2. How much money will you save if you buy a Charlie Ticket instead of paying for 10 single rides on the T?
Example: You need to make some repairs on your disabled train. New paint costs $50. Oiling the wheels costs $75. New seat cushions are $10 each, and you need three of them. How much money will you need to make all of the repairs before you can start service to passengers?
The goal here, in this specific task, is to teach math skills. So teach the skills using their perseverative topic. Teaching flexibility and diversity of interests is a target for a different program. Generalization comes later. One thing at a time.
The best advice EVER in rapport building: Get to know his world. Understand it. Love it. Get him to invite you in willingly.
If you think about building rapport like building a relationship, it is much easier to see why certain teaching methods work and some don't, especially regarding behaviors. Instead of trying to yank a child out of his perfect little world that he has carefully created, join his instead (changing his world comes later). But you can't force your way in- you must be invited.
Many children with autism have strong problematic behaviors that are centered around control. If you always keep that in mind, and run every therapeutic decision through that filter, you've won half the battle. They spend a lot of time and energy trying to preserve and control their world, and the last thing you want is to be perceived as the big jerk who is shredding their life apart at the seams. If you are smart about your approach, you can shred their life apart without much protesting, and they may even help you do it.
When I started working with David, it was all letters and words, all day, all night. He wanted to obsess over a Trident gum wrapper? Well, fine then- I got giddy over it as well. In fact, I pulled out of my bag a different gum wrapper with tiny print and was like, "Whoa... have you seen this one? WAY cool." It was like I gave him a new video game. He loved that I loved his "things". I got him, and he appreciated that. ****
He would run to me and tell me things like, "I think I want a glass of pilk," purposely using a P instead of an M, waiting for me to find this incredibly funny and clever. Then I would say something equally ridiculous, "Ok David, I am going to get you a mass of glilk." I would laugh hysterically right along with him, as if I was a friend of his on the playground. Once he saw me as a peer, geeking out over gum wrappers and writing or saying nonsense words as jokes, he would seek out my attention, trying to draw me in, instead of the other way around.
I like to call this the "moving in together" phase. He was beginning to invite me into his world. When this starts happening, you know you have him hooked. And this is when you make your move to really start shaping his behavior.
Once you are living together, gradually begin changing things.
This next phase of rapport is the "roommate phase". I think of it as the two of you becoming metaphorical roommates: Once he trusts you enough to ask you to move in with him (the previous "moving in together" phase), he is basically saying to you, "Ok, I trust you around my stuff, and have faith that whatever choices you make are for the 'good of the household'."
You move in, get comfortable in your new digs (his very eclectically designed apartment-world), then once things are harmonious and calm, you make a little change. Buy a new couch. Change the picture on the wall. Toss out that old chair. He may not like that you threw out his chair, and tell you so much with a tantrum, but he trusts you, and may decide the new chair isn't that bad after all.
Had you not gotten this far in your trusting relationship, any small diversion from his routine would be interpreted as hostile, and met with a fierce defense. However, now you are roommates. When you make an unexpected move, he is more likely to think, "Huh. Didn't expect that, but I trust that she has a good reason for doing it."
At this time, there is less resistance, and you have an opportunity to make tiny changes, bit by bit, similar to a systematic desensitization method of modifying inflexible behaviors. There may be some distress (ok, there will probably be a lot distress and protesting initially), but it will be shorter lived and less intense, because he trusts that you are not trying to hurt him or his world. After all, you live in his world, too, and you wouldn't try and set fire to your own apartment, right? He may think, there must be a good reason for this change, even if I don't like it.
Not to mention, even after he has a violent hour-long tantrum, tells you "You're fired!" (true story), and kicks you out of the metaphorical apartment for the day because you wouldn't let him gain access to the bathroom to play in the water, he will go right back to trusting you again once he calms down, and you pick up right where you left off.
Even the most rigid, controlling, defiant children have made huge strides towards flexibility, once they trust you and invite you into their world. When the changes are gradual enough, after a while, when you take a step back, you are both in a whole new apartment, one that you both created- a more functional, social, inclusive environment. But because he had a hand in creating that environment, it is not frightening, and he might even want to invite friends over at times. You are on your way to helping him build social relationships.
Now, this is not a perfect metaphor, and not meant to be taken literally, but the level of trust and rapport built through this method is real, and has proven successful for me in the many years I have been a therapist. And really, most of these concepts are common sense if you think about how we learn and trust.
If you want to teach a child with autism, first you need to figure out what their world is like, on every level. Once you understand it, get them to invite you in. Once you are let in, start making gradual changes to their environment. This is when you start pushing more compliance and set higher standards of behavior and change. At that point, progress is high, and so is motivation. If you can do these things, the limits for progress are practically boundless.
I have found that investing more time in the beginning, establishing a solid, trusting, relationship with a child with autism will put him in a position to not only learn more, but want to learn more. You may think that the initial phase of this rapport-building is making you look like a pushover, but on the contrary- you are on an information-gathering mission, and doing an investigative study on how that child ticks. Once you understand him, you are in a position to lay down the rules, set boundaries, and demand compliance. The thing is, by the time you start gradually doing that, they are already complying with your rules, following your directions, changing their behavior- because they genuinely want to please you. You can start doing this after only a few sessions, if you are pretty savvy on picking up on what motivates that child. Once you've really bonded, you can push them beyond their comfort zone, and they know that if the world crashes down around them, you will be there, and you will rebuild it together.
Final note: If any parents, teachers, or therapists have any specific questions, or would like more information about anything I mentioned in this article, please feel free to email me via Scientific Blogging, and I will respond as promptly as possible.
* The names of those involved in this narrative have been changed to preserve privacy.
** Tip: Always carry blank index cards. I cannot tell you how many times they have been unbelievably useful, for all types of kids and ability levels. Trust me on this one.
*** Here in Boston, wicked means really good, or excessive.
**** Tip: Always load your bag with items that he loves to obsess over, but only gets access to when you are with him, during therapy time. This makes the objects more desirable, and you increase your own reinforcement value as well.
If you're interested in reading additional articles on autism, ScientificBlogging's Autism Awareness page provides a listing of all the articles on our site that touch on the subject.
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