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Note: Often when faced with and autistic child with some language, we notice that little of the language is used to communicate. Often the child has learned language to get needs met, talk to himself, and perform tasks, but not to really engage others in conversations. In these cases, we find that it is essential to "go back to the basics" as it were, and teach the parents and child to become playful interactive partners first. Nick, below, came to me with a lot of words but almost no effective communication with the words. It soon became clear that playful interactive habits were the first needed goals. Nick is now 11 years old with strong conversational relationships with both adults and peers.
At age three Nick came to me with his mother who was concerned that the boy was showing several evidences of autism. Among them were the following. He was still not talking to others--he had about 50 words but rather he used them in fast, unintelligible sounds mainly to talk to himself and accompany his play but rarely to communicate with others. He was usually quite agitated and insisted on things staying the same, resisting change with tantrums. Rarely did he respond when people talked to him. When he did it was with echolalia. He preferred to play alone, mostly in repetitive nonfunctional ways that often seemed bizarre to his parents.
When approached by people, Nick showed anxiety by jumping, avoiding and retreating into repetitive routines, such as hand flitting. While Nick often ignored people, he did show exaggerated emotional responses when his mother acted emotionally. He resisted eye contact and kept so busy that any interactions were too brief for learning to communicate.
Consequently, Nick's language delay, rapid and relatively purposeless actions, rigid patterns of repetitive behavior, and general lack of productive interactions provided many problems. The question was, where to begin?
Where I began was to watch Nick with both me and his mother, and to watch the kinds of contacts we made with him.
My first concern was that Nick needed to stay with people in order to learn to communicate. As it was, his contacts with people were momentary, infrequent and rarely showed a genuine connection with people.
Nick's mother was consistently warm and positive regardless of whether Nick's behavior was social or isolated, appropriate or not, and agitated or calm. She reported that she had taught Nick many things for school that he could but often didn't do. She felt he understood much of her speech, and she talked to him in full sentences, often many at a time. She had been told he needed a lot of language stimulation, consequently she talked much of the time and showed little expectation or pausing for him to participate. She knew he was intelligent at many tasks and so she focused on teaching him more things that would show his intelligence. However, he showed his competencies in response to questions and demands but rarely when he interacted with people socially. While his cognitive skills were apparent and could be retrieved, his emotional and social skills were severely limited.
Our treatment began with me learning how to keep Nick with me interacting in any back and forth ways. To do this I used three basic strategies--matching, waiting and keeping him for one more turn. I found that the more I acted like him (matching), the more he attended to me; and the more I waited silently, the more he responded to me and did something on his own. I found it necessary to gently keep him with me a little longer then let him be on his own. He learned that when he was with me he needed to stay doing anything that he could do. He saw that I was doing things he could do and that I was not making demands beyond his immediate abilities. He also learned that I was willing to do things to keep his attention; often I did things that adults might call silly, but that competed successfully with his distractions. My thinking was that I had to be more interesting than his distractions before I had a right to expect him to attend to me.
For several weeks, Nick's mother played with the boy several times a day with the singular goal of keeping him interacting with her. She learned to talk less, wait more and act animated. She learned to be more of a play partner than a teacher or regulator. At first she reported that it was hard not to question him to show how smart he was. Playing like him seemed embarrassing to her, but she continued when she saw Nick attending more to her and becoming more of a companion. Waiting and not telling him how to do something was difficult for her. But, she soon found that she got more from him when she gave him time to give something to her on his own.
Through several months, I taught Ann how to fine tune herself to Nick and to come to a deep conviction that staying with people was now more important than teaching new things or showing off what he knew. When Ann saw that Nick often stayed more with me, she wanted the same and began learning how to enter into Nick's world and require only that he stay with her back and forth. She reduced what had been an over stimulating action and communication style and gradually got into a habit of doing something he could do then waiting for him to give something back. At first, very simple games of exchange were the main activity. Nick and his mother would exchange anything, looks, pencils, shoes, etc. then make it into a playful game where the major goal was to keep the interaction going and make it fun for both. Ann had to learn not to feel a need for "right" answers, but to learn that every little interaction was a chance for him to learn to communicate. She learned that, contrary to her prior beliefs, language was not just going to come like growing hair and height. Rather she learned it was going to come from their interactions when she was doing things he could do. She also learned that doing for him was not as important as having him give something to her.
As Nick and Ann moved into a more playful relationship, Nick began imitating more of what she and I did. He also initiated more contact and often stayed interacting without being held.
Beyond teaching Ann to play interactively, I focused on teaching her the many things Nick needed to do before language would be a habit. She observed and recorded many behaviors that she had previously thought were unimportant for language. Some of these were turntaking, imitating, responding and communicating with movement and sounds. Ann was an eager student and came back with lists of both the old and new things he could do.
After a year, Nick began to use words to communicate to people as much as to talk to himself. He still tuned out often, talked inappropriately at times, and showed many nonfunctional signs of agitation and self-stimulation. Then, I noticed that while Ann was becoming more playful and interactive, she was also paying considerable attention to the many of his off topic and socially unacceptable behaviors. It was difficult for Ann to learn to ignore the strange behavior that she wanted to stop. I gradually showed her that our attention and words were strong reinforcement for Nick. Consequently, Nick would make his bizarre sounds and movements more when we attended to them. Ann then learned to ignore undesirable, immature or destructive behaviors. After some personal struggles with the idea "I shouldn't ignore my child" and fears that he would go back into his isolated world, she learned that the less she responded to his inappropriate, unattractive and nonproductive behaviors, the less he did them and the more he substituted them with more acceptable behaviors that she showed him.
Ann also learned to abandon her habit of teaching him things she wanted all the time, and to accept Nick's little behaviors as things to build. She did that by getting into the habit of responding to his little sounds and actions in supportive ways. Sometimes she would imitate him and other times she would translate his actions into a word, acting like a second language teacher. She learned to see all of Nick's behaviors as either bits of knowledge or potential communications. Then she capitalized on the moment and showed him the next communicative step to talk about it.
As Nick came to use more words, I noticed that when we asked fewer questions and simply made undemanding comments, he would talk more. We came to see that questions made more work for Nick and didn't encourage him to think on his own.
After a year and a half, Nick was beginning to talk back and forth, although still quite stilted and more imitative than creative. He had learned to stay interacting and to leave an interaction only after he contributed something to it.
Now at age eight, Nick is doing well academically in a regular school. He still appears somewhat naive, sensitive and awkward in some social situations. His father thinks he lacks some practical "street smarts." His mother sees him having some difficulty taking others’ points of view. But, by and large both his parents enjoy his companionship and see him becoming more social and conversational all the time. Recently, Nick’s mom told me that the most important and difficult thing she learned was to play in his world and to not push him too fast or act like a teacher.