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Thursday, July 22, 2010

Play in Autism To improve social interaction and comprehension.

Advance for Speech and Language
By Jason Mosheim
Posted on: July 19, 2010

Restricted play skills are one of the hallmarks of autism. Among the handful of reasons that children on the spectrum have trouble branching out in their play is that many lack ideation, which is necessary for understanding how to interact with new objects.

"Many kids with autism reject novelty," said Lisa Audet, PhD, CCC-SLP, assistant professor in the Department of Speech Pathology and Audiology at Kent State University in Kent, OH. "When something is new and they don't have a mental template or schema in their heads for how to engage with the object, they reject it." They prefer to play with only a handful of predictable items.

"Limited ideation results in them doing 'same old'-playing with the same thing all the time," she told ADVANCE. Comfortably stuck in one mode, they don't accumulate a well-rounded knowledge of basic concepts over time.

Many children with autism have motor planning deficits. They have difficulty using their hands to operate and explore toys in a way that most parents expect.

One boy who lacked fine motor skills and had difficulty using his fingers to operate cause-and-effect toys, like a See 'n Say®, only wanted to dump and throw objects, Dr. Audet recalled. His play skills did not evolve much beyond those motions because he didn't have good hand use. "As he got older, it looked more aberrant because you have a 10-year-old who's dumping and throwing like a 2-year-old," she said.

Older children with autism often display play skills that are similar to those of much younger, typically developing children. For example, 18-month-olds often derive great pleasure from filling containers or rolling a ball. Older children whose play skills closely match this age group may have language skills at about the same level.

Restrictive play also could be caused by anxiety. Children with autism often feel uneasy when they are presented with novel objects because they are forced out of their comfort zone. "They play with particular objects as a way of calming themselves, to self-regulate," Dr. Audet said. "Kids with limited ideation don't move to pretend play, where it becomes symbolic, and that parallels the absence of language, which is also a symbolic act."

Many children with autism also have trouble with turn-taking. The two types of reciprocal interactions to be on the look-out for are dyadic, between two people, and triadic, which involve two people and an object. Adults can teach dyadic interactions by singing a song that contains gaps for the child to fill with lyrics or sounds.

"We use strategic wait time and a lot of rhythmic information and melodic intonation to create predictability, which can be helpful in getting reciprocity around something dyadic," said Dr. Audet.

When children are engaged in sensorimotor activities that provide them with movement, such as bouncing or swinging, speech-language pathologists can seize the opportunity to assist them in maintaining the dyadic interaction and reinforce the predictability of a routine.

Only when a child is able to engage in one-on-one joint interactions can clinicians begin to facilitate triadic interactions. Unfortunately, many clinicians start with the triadic events when attempting to increase joint attention and reciprocity. "The triadic interaction can be difficult for kids with autism," she said, "yet so often we start there, especially if the child is older, and doesn't yet understand reciprocity."

To qualify for kindergarten, children need to be able to occupy themselves with a solitary, adaptive activity for at least seven minutes. When working with a child prior to school enrollment, speech-language pathologists and parents must keep this in mind in addition to other social aspects of play, including parallel play, trading and sharing, and cooperative play.

"If we're working on parallel play, we know that imitation is difficult for kids with autism," said Dr. Audet. One way to facilitate imitation is to imitate a child's natural play behavior. For example, a speech-language pathologist can join a child in the activity of filling and dumping when trying to introduce a new tool.

"If a child is putting corn in a bucket and then dumping it, we begin to model so he knows he has a partner," she explained. "In addition to imitating, we work on parallel play by modeling with our own shovel. We then offer the shovel to the child and wait expectantly. The child may pick up the shovel and imitate us. If they don't, we continue to present an exaggerated model of the behavior and continue to present the shovel to the child."

The speech-language pathologist is building on the natural play of filling and dumping and modeling the next level of play.

The first cooperative play skill to teach is sharing. The child has to relinquish control of an object, probably a highly preferred one.

Most children learn to trade before they learn to share. This is important to keep in mind when working with children with autism because they must never be left without anything to keep them occupied as they wait for their play partner to return a toy. Otherwise, they are likely to succumb to frustration and act out.

Clinicians can teach trading by having children play with cause-and-effect toys such as cars or tops. "Give the kids different ones so they trade," she said. "They will get something similar but not exactly the same. Trading becomes important as a steppingstone to learning how to share."

Speech-language pathologists should be supportive so children will request help when needed. Nonverbal cues are a good place to start in providing children with the means to ask for help. Don't rush in to provide assistance whenever a problem arises, however. "Provide a mechanism for them to ask for help, whether it's a picture icon, a voice-output device, a hand-over-hand movement or signing," she said. "We let them know before they get too frustrated with an event that we're there to help. It's really important to read the nonverbal cues that are really subtle."

To spark spontaneous language in children with autism, speech-language pathologists can tap into their knowledge of normal childhood development. For example, typically developing children begin to speak in two-word combinations when they have approximately 75 words in their repertoire. Before attempting to elicit spontaneous speech and to get a sense of what expectations to set, clinicians need to ask themselves how many words are in the child's repertoire, if they are spontaneous words, and whether the words are approximations, imitative or echolalic.

Clinicians often advance too far ahead in treatment. "If children have 25 words in their repertoire and are echolalic, using a five-word sentence like 'I want more cookie, please' is a big jump if we expect that utterance to have true linguistic meaning," said Dr. Audet.

After determining the level of spontaneous language, speech-language pathologists can start building single-word vocabulary to help children reach the 75-word mark. "Begin to work on semantic relations, then reinforce those two-word combinations. When the child says, 'My cookie,' we say, 'Yes, Jimmy's cookie,' versus 'Tell me, 'I want more cookie, please,' and jumping to that rote utterance, which the child is going to comply with if he is echolalic," she said. "We sabotage ourselves if we reinforce echolalia vs. spontaneous language."

A child may need some echolalic chunks to ask for help, protest, or engage in adaptive behaviors, but that's only one prong, Dr. Audet said. The other prong is building up spontaneous vocabulary by reinforcing the use of single words and two-word combinations without making the child produce a complete sentence. "That's like a three-year developmental leap for a child who has a disability," she said. "We wouldn't expect that from a typically developing child."

For More Information

Lisa Audet, PhD, laudet@kent.edu

Jason Mosheim is a Senior Associate Editor for ADVANCE. He can be contacted at jmosheim@advanceweb.com.