Daily Excerpt: Choice and Structure for Children with Autism (McNeil): Comprehension and Communication
excerpt from Choice and Structure for Children with Autism
COMPREHENSION AND COMMUNICATION
Children with autism need clear and predictable cues to help
them know what to do, when to do things, where to go, or what to get. Basically,
they need cues to assist their comprehension of your requests. You may or may
not be aware of it, but you are already using predictable cues with your
children to let them know what expectations you have. A cue is anything that is
done, said, shown, or positioned to signal an expectation to act, refrain from
acting, or indicate that there will be upcoming information. A cue can be as
obvious as standing in front of your child with a ball and asking, “Do you want
to play basketball?” A cue can also be as subtle as raising an eyebrow and taking
a deep breath before answering a request for another chocolate bar. With this
breath, most children already know the answer is, “No.” Children with autism,
by nature of the diagnosis, do not pick up on subtle cues. They will stand
waiting in anticipation for your answer until it is clearly and determinately given.
The answer is spoken, “No,” and the candy is put on the top shelf of the
cupboard. Using clear, obvious cues that support the child’s developmental, social
and communication skills is extremely important for children with autism. Cues
may be delivered through a variety of senses including auditory, physical/tactile,
visual, and environmental means.
·
An auditory cue is anything that can be heard. It
includes simple sounds such as the beep of the microwave, ringing of the phone,
or the sound of the timer alarm. Spoken words are also auditory cues. In the
common language of autism practitioners, talking is referred to as verbal cues
or verbal prompts. Auditory cues are considered fleeting pieces of information
because as soon as the sound ends the information is no longer available. Children
with autism do well with simple auditory cues like a timer to help them know
when it is time to clean up. Verbal cues which hold more complex information
are far more difficult for children with autism to process. Verbal cues need to
be used very deliberately with limited specific wording.
·
Physical/tactile cues are those that engage
touch. A tap on the arm to gain a child’s attention or slight press on their
back to help them know when it is time to walk forward are simple physical
cues. Physical cues are good supports for autistic children when teaching new
skills. Gently tapping a child on the arm to remind him to complete an action
is a typical physical cue. Physical cues can also be disruptive in some
situations. A good example is when you are trying to leave the park and you
place your hand on your child’s back to let him know to begin walking to the
car. If your child wants to protest leaving, this touch may ignite a tantrum.
·
Environmental cues include, space, walls and
objects around the area. A closed door indicates that the bathroom is not
currently accessible. Mom placing a pillow on the floor in front of the TV
indicates a comfy place to sit while watching cartoons. Environmental cues are
very strong supports for children with autism.
·
Visual cues are anything that can be seen. Many
visual cues used with autistic children include the real objects, real
pictures, line drawings, gestures, pantomime and written words. With the
abundant use of electronic devices such as smart phones and tablets many
families are using pictures on these devices to aide in providing visual cues. For
instance, if you are asking your son to get in the car you could have a picture
of the car or the car-seat on your phone to show as a visual cue to help him
understand the request. Printed visual cues including electronic pictures, are
the most successfully used cues for children with autism. A printed visual cue
is static and continuous. The information remains available to process for as
long as the child can look at it. Unlike auditory cues or fleeting visual cues such
as gestures and pantomime, a printed visual cue can be continuously
re-referenced to aide in remembering the information across time and location. Pictured
visual cues can be used in the absence of objects, and travel far easier than
objects. Pictured visual cues, especially electronic versions are our autism
super stars! I strongly suggest the use of pictured visual cues to support
children with autism.
Visual Supports:
Visual supports are the most important receptive and
expressive communication aides for a child with autism. A visual support is
anything that can be seen that helps children with autism understand and
communicate. Visual supports include both the visual cues and the environmental
cues discussed above. A child can see a closed door and pillow as well as the
gestures, objects, pictures and words. Autistic children are known to process
information better through vision than through hearing. They are visual
learners. They are also visual communicators.
Visual supports can be of a fleeting nature or a static
nature. Fleeting visual supports include gestures and pantomime. If Dad waves
to his son to come toward him and then puts his hand down, the wave gesture disappears.
It is no longer available information for the son to see. Similarly, if Mom
indicates her daughter should wash her hands before eating lunch by rubbing
them together, that information disappears when Mom stops. It is only
accessible to the girl while Mom is acting out the movements.
Static visual supports are those things that remain
available to be seen across time. Objects, pictures and positions of furniture
in the room remain available for referencing long after the initial
presentation. This static nature is very helpful to children with autism. The
permanent nature allows autistic children time to process information. Static
visual supports also allow the flexibility to return attention to the
information again and again for as long as it is in sight.
Visual supports are essential to the positive engagement of
children with autism. For most children, printed visual supports raise the strength
of assistance greatly. For the benefit of this discussion, I include any
electronic illustration such as pictures and words on smart phones and tablets
as a printed visual support. The power of printed visual supports lies in their
stay-ability across time and their portability across environments. It is far
easier to indicate to your daughter that she is to sit in the swing by showing
her a picture of the swing and by taking it with her as she exits the house. After
she breaches the threshold of the door onto the patio, she may see a ball and
begin to run toward it. At this time, you can remind her she is meant to go to
the swing by reengaging her visual attention toward the picture. Printed visual
supports travel easily. Electronic devices travel well and can quickly be used
to add new pictures on a moment’s notice. The ability to quickly add a picture
to your collection is extremely helpful.
Pictured visual supports are magic aides for children with
autism. I encourage parents to become familiar with using them in as many
interactions as possible. Visual supports that are used as cues help children
receive information and tell the children what is expected of them. This is
known as receptive communication. The same materials are available for children
to express their wants and needs to their families. This is known as expressive
communication. Children with autism who struggle with spoken communication, can
use static visual supports to express their wants and needs. Many children can
learn how to utilize these supports to independently approach others and make
requests. In this book I have focused on using them when helping children through
the offer of choices. No matter the reason, all forms of visual support are indispensably
beneficial for children with autism.
STORY
An Evening with Jinho
“Time to eat Jinho,” Mom calls out from the kitchen. Jinho
is deeply engrossed in his game on his tablet and does not respond to his
mother. “Jinho,” she calls out again. Still no response. Bringing a plate with
her, Mom approaches Jinho. Running her hand down the length of his arm, she
gently breaks his trance. As he looks her way, Mom holds up the plate
repeating, “Time to eat.”
Hungry from a long day of playing and with the smell of
dinner cooking, Jinho quickly puts down his tablet and heads toward the dining
table. Placing her hand on his shoulder Mom stops Jinho. When he turns to see
why she stopped him, Mom pantomimes hand washing and requests “Wash your hands,
please.” Jinho knows this predictable routine well and willingly complies.
Returning to the table to be with his family, Jinho sits and
happily awaits his food. The family pauses to give thanks for their meal before
eating. Jinho begins gesturing toward the bowl in front of him, and his dad
taps his hand lightly, then makes an overexaggerated motion of placing his own
hands together in a position of prayer. Jinho imitates his father and waits
patiently for his sister to complete her recital. The family then enjoys a
delightful meal.
After dinner, his sister goes outside and gets the
basketball. Showing it to Jinho, she inquires, “Want to play?” Showing his
agreement, Jinho flaps his hands with excitement and begins to move toward his
sister. Mom stops the two, “Hold on a minute. Jinho you need to use the
restroom first.” Holding her phone with a picture of the bathroom in front of
his sister’s ball, she says purposefully, “first bathroom, then basketball.”
Jinho agreeably runs toward the restroom but finds the door
closed. He stops and looks back at Mom. Realizing that Dad is using the
restroom, Mom approaches Jinho and places his hand on the wall, saying, “Wait.”
Jinho is well practiced at this direction and stands with
his hand on the wall for the next minute while Dad finishes-up. As soon as Dad
opens the door, Jinho rushes past, uses the restroom, and washes his hands. While
Jinho was in the restroom, his sister was instructed to get a light sweater
because it was getting cool outside.
Mom also picked three options for Jinho. As he exited the
bathroom, Mom greeted Jinho with the sweaters and said, “Pick one.” Jinho grabbed
his black sweater and then responding to his sister’s wave to come, ran
outside.
While he and his sister were enjoying their basketball game,
Dad came outside. Whistling to get the kids, attention Dad holds his hands out
in a catching motion encouraging Jinho to pass him the ball. Jinho includes his
father in the game, and the three take turns shooting at the basket. After a
while, Dad wanted to practice Jinho’s A.P.E. goal to play as a team. Dad began
instructing Jinho and his sister to pass the ball around before shooting into
the basket. To help Jinho understand, Dad arranged four pictures together on
his smart phone. One picture of Sister, one picture of Dad, one picture of the basket,
and one with all three choices. When Jinho had the basketball, Dad would show
him a picture indicating where to throw the ball: Dad, Sister, basket. Sometimes,
Dad would show Jinho the screen with all three pictures, allowing him to choose
for himself. Jinho always chose to shoot the ball. Dad and the kids had fun
playing basketball.
As the evening wound down, the three of them made their way
back indoors. Jinho wandered back to the couch where he had been playing on his
tablet before dinner. When he was unable to find his tablet, he pulled his mom
by the hand and asked for help. Mom showed Jinho that she had put it away in
the locked cabinet. Jinho expressed his disappointment, and Mom reclosed and
locked the door to indicate her decision was final. Offering him three pictures
of other activities Mom redirects Jinho to play with something else. Knowing he
is unable to influence his mother once she locks the door, Jinho accepts the
offer and plays with his cars in the living room.
When bath time arrives, Dad shows Jinho a picture of the
shower. Jinho puts his toys away and walks to the bathroom. Once in the
bathroom, Jinho disrobes, dropping his clothes on the floor.
“Jinho, those go into the hamper.”
Flapping his hands and bouncing around the bathroom, Jinho
ignores his father’s instructions. Shaking the hamper and opening the lid, Dad
repeats, “Jinho! Hamper!” The ruckus of the hamper shaking catches Jinho’s
attention, and his dad’s opening the lid spurs Jinho’s response. Jinho picks up
his dirty clothes and places them in the hamper.
After his shower Jinho relaxes in his room by spinning his
favorite toy before falling asleep.
DISCUSSION
Adding a variety of cues and visual supports to
communication facilitates understanding for children with autism. Good
understanding increases the speed with which the child is able to respond. Making
communication easy through the use of cues and visual supports helps children
with autism to cooperate and engage positively with their families. When using
visual supports to assist in choice it is highly recommended to use the most naturally
occurring supports available or the highest level of visual support the child
can understand consistently.
You will see throughout Jinho’s evening that his family
fluidly utilizes a large variety of cues and visual supports.
Naturally occurring cues and visual supports are often the
most accessible and make the most practical options. A good example in Jinho’s
story is when Mom uses a tactile cue by gently rubbing Jinho’s arm to gain his
attention as he played on his tablet. Further ,she brings a dinner plate with
her to let Jinho know it is time to eat. Mom didn’t need to find a picture of
the dinner table because the plate was right there, naturally available to be
used as a cue. Jinho’s sister used the basketball to ask him to play with her,
and Dad used the hamper as a natural cue for Jinho to clean up his clothes.
Gestural cues that Jinho knows well were quick and easy
supports his family used effortlessly. Mom rubbed her hands together when
requesting Jinho wash his hands before dinner. His sister beckoned him outside
with a “come here” wave. And, Dad requested to be passed the basketball by
moving his hands in a catching motion.
Other cues displayed in Jinho’s tale included the auditory
cues of Dad whistling to gain his attention on the basketball court, and
shaking the hamper in the bathroom. Environmental cues of closed doors let
Jinho know he could not access the location or item of his interest. Further
Mom used a tactile and environmental cue together when asking Jinho to wait
near the bathroom door. She placed his hand on the wall indicating he stand
where he was, touching the wall.
When making requests or offering items that are not immediately
available, using the highest level of visual supports the child can
consistently understand will be beneficial. Jinho is able to understand
pictures on electronic devices. Both his Mom and Dad effectively use these when
providing instructions and choices. If Jinho were able to read, then simply
writing the words down on a paper or showing words on the phone would be fast
and show respect for his skill level.
Here I offer you an example of how to walk through offering
a 3-item choice using naturally occurring items.
·
Present the item while speaking your offer: When
asking a child to choose from three items such as milk, juice and water, if
possible, hold or place all three items at equal distance apart.
·
Ask, “Would you like milk (gesture toward or
push forward the milk), juice (gesture to or push forward the juice) or water
(gesture toward or push forward the water)?”. Repeat the offer a second time,
only speaking the item name and repeating the indication of the item. “Milk (gesture),
juice (gesture), water (gesture)?”
·
It is important to pause and wait for the
child’s response for at least 10 seconds.
·
If no response, repeat the offer again.
·
Allow the child to make his/her preference
through whatever means is most independent.
·
Immediately give the child the chosen
item/activity!
·
Voilà! You are done. See? Quick, easy, and
empowering!
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