Understanding special needs

15th February 2011

Introduction

ASD or PDD First identified in 1943 – Leo Kanner They are a range of complex, lifelong

developmental disabilities which vary in severity

Includes autism, Asperger’s syndrome, Rett syndrome, atypical autism and childhood disintegrative disorder

Introduction Exact number of children with autism is

unknown - ? 6 in every 1000 If one child has autism, more likely that sibling

will develop autism Rise in recognition of the condition Unproven link with MMR Effects all social and racial groups Boys more affected than girls About 75% of children with autism also have a

learning disability No cure, but there are effective management

strategies and educational programmes

What happens

A child will demonstrate difficulties in 3 areas (Wing and Gould 1979)

Impairment of social interaction Impairment of social communication Impairment of social imagination

Key features of autism

Social interaction Cannot make sense of people Relates better to objects than people Will only tolerate being approached or

approaching people that they know really well

May only see people as a means to an end Is usually unaware of simple rules and

conventions

Key features of autism

Social communication Slow to develop speech or no speech at all Uses words out of context or without

communicative intent Echolalia May use words and then lose them Poor eye contact Rarely understands or uses gestures May use pointing to indicate need rather

than to share an experience

Key features of autism Social imagination and flexibility of though

Finds it hard to make sense of a sequence of activity Loves routine Stereotypical body movements Often resists new experiences Poor symbolic play Often pays attention to particular details May be hypersensitive to sound

Every child’s profile is different

Associated features and disorders Intellectual disability – moderate range Behavioural difficulties e.g. hyperactivity,

short attention span, impulsiveness, aggressiveness and tendency to self injury

Odd responses to sensory stimuli High threshold for pain Hypersensitivity to sounds or touch Exaggerated response to light or smells Fascination to certain stimuli

Associated features etc. Abnormalities in eating e.g. limiting diet

to a few foods or pica Abnormalities of mood e.g. giggling or

weeping for no reason No sense of danger Excessive fearfulness to harmless

objects Adolescents may become depressed Seizures develop in about 25% of

children usually in adolescence

Diagnosis

‘a signpost, not a label’ Exley No simple test Multi-disciplinary team over a period of

time and in several settings Must show signs in all 3 areas Early diagnosis preferable but difficult to

be accurate under 18 months Hearing test often undertaken to exclude

deafness

DSM IV – Diagnostic criteria 3 sections – A.B and C Must display a total of six items from A,

B and C with at least 2 from A and one each from B and C

Must be delays or abnormal functioning in at least one of the triad areas with onset prior to 3 years of age

The difficulties are nor caused by Rett’s syndrome of childhood disintegrative disorder

Asperger’s syndrome – diagnostic features Severe and sustained impairment in

social interaction Restricted, repetitive patterns of

behaviour interests and activities No significant delays in language No significant delays in cognitive

development Must not be any other type of autism or

schizophrenia

Asperger’s

Later onset than autism Motor delays or motor clumsiness may

be noted in preschool years difficulties in social interaction may not

be noted until child is at school It is then that ‘odd’ interests may be

noted e.g. fascination with train timetables

Asperger’s

Adults may have problems with empathy and appropriate social interaction

Usually lifelong Increased frequency of Asperger’s

among family members of individuals who have the disorder

Childhood disintegrative disorder

Rare condition Normal development until 2 yrs and then

rapid regression i.e. later regression than autism

Loss of previously acquired communication, play, social abilities, cognitive and motor skills

Rett syndrome

Development disorder affecting girls Normal development in first 12 months followed

by period of rapid regression Loss of purposeful hand movements – replaced

by stereotypical hand movements such as hand wringing and clapping

Poor trunk or gait co-ordination Loss of social engagement Cognitive skills, receptive and expressive

language skills are severely impaired

Atypical autism

Diagnosis by exclusion of other ASD Symptoms of autism may only be

partially present in number or degree or where the age of onset was over 36 months

Very similar behaviour patterns to typical autism

Intervention approaches

Many different approaches each stemming from a particular belief e.g. biological versus behavioural

No one approach works for all children Elizabeth Newson 1979 believes it is

important to address ‘the whole nature of autism’

Very important to check evidence base

TEACCH – treatment and education of autistic and related communication handicapped children

Whole life approach – began in 1966 in North Carolina

Requires that adaptations must happen in 3 areas of a child’s life – home, school, and community

Based on structured teaching Physical structure Schedules Work systems Visual clarity

Musical interaction

Aim is to engage each child in the process of interaction

Based on the way parents naturally play with children

Emphasis is on helping the child develop communicative intent

Focuses on what the child can do and builds on this

Non - invasive

PECS – picture exchange communication system

Developed in the USA in 1985 Aim is for children to acquire key

communication skills especially initiating communication in a social exchange

6 distinct phases of teaching Combines knowledge from ABA and SLT

PECS continued

Initially 2 adults needed using a strong motivator for the child

Children can go on to develop spontaneous speech

Increase in communicating leads to a decrease in frustration

Can be used from 14 months and can be used with adults

Can be used with other disabilities also

The Earlybird project Set up by the National Autistic Society in

Barnsley Early intervention key Working through parents vital Aims to put parents in control, empower

parents, support parents and assist parents in establishing good practice in managing their child at an early age

6 families at a time for a 6 week programme – 3 hour sessions

Day time training sessions plus home visits

Applied behavioural analysis – ABA, (Lovaas) Should start before child is 42 months Intensive interaction for up to 40 hours a week Delivered by all significant people who work

with the child Periodic and objective assessment,

reinforcement, skilled staff Most of research done by Lovaas himself Much criticised for having too narrow a focus

and for being inappropriate but parents seem to like it

Other approaches

Intensive interaction SPELL Son-rise program (option approach) Daily life therapy (Higashi) Auditory integration training Diet (Opiod Excess Theory) Secretin Irlen

Choosing an approach – questions to ask On which theory of autism is the approach

based How long has the approach been used Was the approach specifically designed for

children with autism What does it involve Who is involved in delivering the approach How is the approach introduced to the child Is it invasive to the child

Questions to ask

What skills does the approach aim to develop in the child

Has the approach been evaluated Can the approach be used with other

approached To what extent will it effect the family lifestyle How much does it cost Home based? School based? Or both? How will you know it is successful What happens if it doesn’t work

General guidelines for the management of ASD- communication Speak clearly and directly using simple words

and language Try not to use metaphorical speech or

exaggeration – remember the child will take your words literally

Use songs and rhymes, especially those to which the child has previously shown a response. Encouraging clapping and beating a rhythm.

Inanimate v animate object confusion

Management – social interaction

Encourage the child to meet other children regularly

Encourage child-adult interaction and then child – child interaction

Repeat games that the child enjoys Music in a group

Management – safety and physical issues A child with ASD has a lack of natural caution –

vulnerability Be vigilant e.g. hot and cold water and food Remember the child may display inappropriate

behaviour in public such as approaching strangers and wandering off

Use the child's preference for routine to improve skills such as toilet training, dressing etc.

A firm, caring, consistent approach is important

Implications for the future

A child will continue to need considerable support through out school

The condition can be managed and the effects minimised but not cured – ASD is for life

More research!

Case study

Adam

What other signs might have indicated Adam’s ASD earlier?

How could you help Adam begin to control his ritualistic behaviour?

Including a child with ASD in the pre-school or classroom

Suggestions?

Fragile X syndrome (FRAX)

Introduction

Relatively recently discovered condition of genetic origin

Most common inherited cause of learning disability

May also be some physical characteristics Occurs in approx. 1 in 3600 males and 1 in

4000 to 6000 females Features of disability less in females Blood tests available but only after a child has

failed to develop in a ‘typical’ way Term ‘fragile’ does not mean that the child is

sickly or ill

What happens to cause FRAX?

Passed on by the X chromosome (boys XY, Girls XX) If a girl has a fragile X, she will also have an undamaged

X which is why the condition is less severe in girls A damaged or fragile X looks different under a

microscope – abnormality at the tip and appearing partially separated

Condition can be passed by unaffected male and female carriers

Development difficulties – learning difficulties

Usually present in both boys and girls, with boys being more severely affected

Severity ranges from mild educational delay to severe difficulties

Some features similar to autism

Speech and language difficulties Usually present in all children with the condition Language delay may be the first sign of a

problem Particular features are;

Word and phrase repetition, accompanied by up and down swings of pitch

Echolalia Poor control of the rhythm on speech and

inappropriate use of pauses Comprehension difficulties

Behaviour and attention

Tantrums continuing after the expected development stage

Excessive response to stimulation Overactivity/hyperactivity Impulsive Concentration problems Anxiety – avoiding eye contact

Behaviour and attention

Short term memory problems but long term memory can be quite good

Mimicry – especially specific words Ritualistic behaviour – likes routine and is

distressed by changes Repetitive behaviour – finger flicking, hand

flapping, and hand biting can occurThe severity can lessen as the child grows The older undiagnosed child may be noticed as

‘badly behaved’, just lacking in concentration or appearing unco-operative at times

Physical characteristics and health implications

These physical features may not be present in all children and may not be noticeable until a child is older Laxity of joints and muscles- late sitting and

walking Recurrent middle ear infections A long narrow face with a prominent jaw

bone Epilepsy – 20% of children Large testes in adult males

General care

Team-based, early intervention recommended

Emphasis on early speech and language therapy

Development will follow a similar pattern to any child but be slower

A child with FRAX can be routine dependant so a flexible and realistic care plan should be developed

Health problems are the same as any child

General care continued

May be strain on family if child is getting little sleep

Because child will tend to mimic – use a positive role model particularly for safety practices

The child needs to learn to be part of a group Help the child to moderate behaviour with

verbal reinforcement, praise and encouragement

General care continued

Remember the child's cognitive stage of development – do not expect him to take turns if he has not learned to share yet

Help the development of concentration by breaking down games/activities into small, achievable units

Sign systems may help e.g. Makaton

Ongoing management

Provide a distraction free area and keep noise levels low to allow for concentration

Ensure a calm, reassuring environment Keep the child close to you but alongside

you rather than facing you as eye contact can be threatening

Make sessions short – 10-15 minutes Alternate quiet and energetic sessions Use ‘time out’ as necessary

Ongoing management

Be consistent, clear and realistic Tell the child what behaviour is

unacceptable and reward positive behaviour

Be prepared to repeat instructions and check that the child understands

Use a visual approach to story telling

Ongoing management

Build the child’s self esteem with praise and encouragement for effort

Work to the child’s strengths All staff should follow similar

management approaches Maintain good home liaison Number work can be difficult but use of

computers can be valuable

Case study

Jason