Triad of Impairments Part One - Communication Impairment.

Earlier this year, I was asked to present at a professional development for early childhood educators. The presentation? All about Autism and Sensory Processing Difficulties.

The presentation was received so well that I thought that I would use part of my presentation on my blog as I'm often asked questions about Autism and O and L. So here goes!! Part One focusing on the Triad of Impairments.

Individuals who have been diagnosed with Autism commonly have difficulties in three main areas, known as the Triad of Impairments. These areas are ....

1. Communication Impairment

2. Impairment in Social Interaction

3. Restricted and Repetitive Behaviours, activities and interests.

Before we begin to discuss these three areas, keep in mind that many of these traits are present in typically developing children. The difference in those diagnosed with ASD, is the intensity in which these traits present. In a child with ASD, the traits are much, much more intense and they are ongoing. I’m going to refer to children with Autism but all of these traits may be present in Autistic adults as well.

Children who have been diagnosed with Autism have a unique profile of communication development. While different skill levels in communication are seen – from non-verbal right through to verbal – children with Autism, regardless of their skill level ALL have difficulty in a number of areas. Many remain significantly impaired throughout their lives in their ability to understand language and/or to communicate verbally. Those children who are considered to be high functioning will still have a communication deficit.

Those children who are non-verbal may understand more than they can speak. They may be highly intelligent and unable to verbalise their thoughts, needs and wants. Non-verbal also does not mean quiet. Often children who are non-verbal can be the loudest!

Children may talk at peers rather than talk with peers. They may want to exclusively talk about their favourite topic. This isn’t because they are eccentric or uncaring, they have major skill deficits in understanding the social use of language as well as being unable to understand Theory of Mind – they don’t understand that everyone doesn’t quite always think or feel the way that they do.

In children whose language does develop, their comprehension can often be very literal and as such they are very concrete thinkers. They may have difficulty in understanding abstract concepts or phrases such as “hold your horses” or “stop and smell the roses.” 

We have some very interesting conversations at home – “Your shoes are on the wrong feet! But I don’t have any other feet!” “Please put your shoes and socks on. Don’t you mean socks and then my shoes.” “We’re going to follow our noses! Why is your nose up in the air? I’m following it.” “Go and hop in the bath please.” That was a fun one to sort out! My children are bone fida smart alecs!

Often, a child’s thinking may be concrete, literal and detail focused, so that he or she may find it difficult to see the bigger picture. As an example, children with Autism may focus on a small ladybird on the corner of each page of a book, rather than the main pictures and the story.

Children whose language has developed may at times appear to be little encyclopedias in that they are able to talk your ear off about particular subjects. However in some cases, these children have better expressive language skills than receptive in that they can say more than they understand. Their comprehension of what they read or recite can be quite low. O's reading level is at a year 9 level (she's in grade 5!) however at times her comprehension of what she is reading is not quite up to that level yet.

Stay tuned for Part Two - Impairment in Social Interaction.

Theory of Mind and Autism

Over the past few years since we received L's and then O's ASD diagnosis, I have heard a lot about and have read a lot of articles that focus on the idea that individuals diagnosed with autism lack Theory of Mind.

I've very briefly touched on Theory of Mind in a previous post so I thought that it was time for a more detailed post on this subject.

Theory of Mind, or ToM as it is often written, can be briefly defined as having an understanding that the minds of others are different from our own. In particular the understanding that other individuals have different thoughts, feelings and perspectives than our own. Theory of Mind provides us with the ability to put ourselves in the place of others to try and figure out what or how they may be feeling or thinking at any particular moment in time.

Theory of Mind is crucial for us all as we navigate through social interactions. We use Theory of Mind when analyzing, judging, and making calls on the behaviour of others. We use Theory of Mind to predict the behaviours of others based on what we think that they might be thinking. For example Theory of Mind assists us when we are empathising with someone who is having a tough time, even though we may be having a great day.

Every time I hear or read about Theory of Mind, the same example is shown or spoken about. It is called the Sally-Anne task. In the Sally-Anne task, a child must determine what another child's response would be as to the location of an object. One of the examples that I have seen is that Sally places an object into a hiding spot and then leaves the room. Anne then moves the object to another hiding spot. When Sally returns to the room, the child (who is observing this) must indicate when Sally WILL look for the object.

If the child's Theory of Mind has developed, the child usually answers that Sally will look in the original hiding spot as she is not aware that the object was moved after she left the room. In terms of a developing Theory of Mind, this is the response that researchers are looking for.

If a child's Theory of Mind has not developed, the child will usually answer that Sally will look in the other hiding spot. That's the last spot that THEY spotted the object in so therefore they think that Sally will know that is where the object is hidden. 

In typically developing children, Theory of Mind usually begins to emerge between the ages of 4 and 5. During this period, children typically start to think about other children's thoughts and feelings. In the Sally-Anne task, researchers have shown that the responses of children under the age of four years, is inconsistent. Whereas the responses of children aged 4 to 5 years, become more consistent in that they understand that while they have seen where the object was moved to, Sally didn't.

Theory of Mind continues to further develop as a child grows older. For the next few years, they learn to predict that what one person feels/thinks about a topic is not necessarily the same as the next person. As Theory of Mind further develops, children begin to understand complex language that relies heavily on Theory of Mind such as lies, sarcasm and figurative language.

There is a train of thought that our Theory of Mind is constantly developing even as adults as we have more opportunities to experience life, and observe people and their behaviour. I tend to agree with this.

So how does Theory of Mind relate to Autism?

It is thought and has been shown that Theory of Mind doesn't develop fully in individuals diagnosed with ASD until much later in childhood. In some cases, Theory of Mind doesn't begin to fully develop until individuals reach adulthood.

The reason behind this thought is that most individuals who have been diagnosed with autism, lack the awareness that others can have different thoughts, beliefs, opinions and so on from themselves. Individuals diagnosed with autism need to work much harder to develop their own Theory of Mind.

Well, O and L are both examples of individuals whose Theory of Mind is still developing. Yes they are only 9 and 6, but compared to typically developing children O and L's Theory of Mind is still in the developmental stages.

At the age of 9 O is well aware that she thinks differently from others in that she thinks in pictures and sounds, but she struggles to put herself in others shoes in relation to the idea that not everyone thinks and feels the same as her. She is developing more skills in this but she also still struggles.

Both O and L struggle to interpret particular social cues especially the non-verbal cues that we all take for granted that are scattered throughout social interactions.

As a young child, L exhibited inappropriate reactions and responses to others emotions. He often would not respond to us or to O when we were sad or angry. He wouldn't respond when we were happy. And if he did respond, it would be a totally inappropriate response. He still occasionally struggles with his responses. The look on his face now is that he knows he should respond in some way, he just isn't sure how to respond.

For a time O also struggled with this. One example that I can recall vividly is when I took her to watch the movie "The Good Dinosaur" at the cinemas. All throughout the movie, particularly in scenes that I thought were quite sad, O was laughing her backside off. In fact she thought that the entire movie was quite hilarious. Meanwhile other movie goers were crying during different scenes in the movie. Although they did end up laughing due to how loud O was laughing!

O struggles in responding the social expected way when someone says hello, good morning or good afternoon to her. If you are in the place where you are meant to be, ie: at home, she often won't respond. You're where you are meant to be, in her mind, she shouldn't need to greet you. However if she spots you in a setting where she doesn't expect you to be, then you can expect a completely different response.

O struggles to understand why children her age say one thing and yet they mean another.

L still struggles to show empathy towards others. And yet O on the other hand can be over-empathetic at times. She lacks the understanding that at times there is such a thing as too much cuddles. I've lost count of the number of times when we've had to remind her that the child she is cuddling, really doesn't want to be cuddled anymore, which is why they are struggling to get away from her!

Both O and L regularly cause frustration in each other and in us when they say "Do you know where the thing is?" or "Did you see that?" What thing?????? At times they simply do not comprehend that we either didn't see something happen or that we haven't seen the toy/book/object that they're referring to. We constantly have to remind them that they need to describe said object or toy or movie scene that they're referring to so that we know what they are talking about! Although I have a feeling that this is all children in general but it does relate back to a child's Theory of Mind!

All of the above examples can be indicators that a childs's Theory of Mind is still developing.

So how can we assist a child's theory of mind to develop? How can we help a child to tune into the thoughts and feelings of others as well as tune into their own thoughts and feelings?

When talking with O and L, we talk about how we feel or what we are thinking in particular situations. This gives O and L a different perspective on what they might be feeling or thinking at that particular time. It begins to embed the idea that others DO think and feel differently than them.

When we see other people experiencing different emotions, we talk about why they might be feeling happy or sad. We provide O and L with the language that they may need to describe how they are feeling.

When we read books we talk about how and why the different characters in the story might be feeling or what the characters might be seeing in the story. Doing this helps my little superheroes to put themselves into the shoes of others. We'll then often relate how the characters are feeling back to a time that O and/or L were feeling that same way so that they begin to understand that other people have the same thoughts and feelings as they do.

We encourage both O and L to engage in role play games and if we are included in the game, we step out of the parent role and into the role that we're playing in the game. Role playing in itself assists in developing a child's Theory of Mind as it encourages the child to think and act out the role of the person that they are playing. They have to actively think like the other person.

Just simply talking with O and L about how we all feel and think provides the opportunity for them both to think deeper about their own thoughts and feelings. Talking embeds the idea that others have different thoughts and feelings from their own. It also begins to embed the idea that the way we all act is often based on what we think and feel.

All of these strategies assist in the development of O and L's Theory of Mind.

But one of the most important strategies that we keep in mind at all times is that the emotional perplexing behaviours that O and L often show are not done deliberately. They're done to communicate the difficulties that they are both having in understanding Theory of Mind.

Child's Play. Therapy at Home!

I have mentioned several times in various posts that I am able to turn almost any household chore or child's game into a therapy activity.

In my experience with working with children in early learning settings, through my previous jobs as an Education Officer and even with my own two little superheroes, I have found that children learn best when they are playing.

Children, including my two little superheroes, seem to be more willing to take part in an activity when the activity is fun and enjoyable. They seem to learn best when they think that they are just having fun! If only they knew the truth that, shock horror, they were actually learning and practising new skills!

When an activity is fun and it is purposeful, this can be a huge factor in determining how successful the activity will be and how long a child will willingly participate in the activity.

When L started in his early intervention therapy last year, we wanted to give him the best opportunity possible of succeeding with the new skills that he was being taught.

So Daddy superhero and I decided that we would attempt to turn everyday household activities and chores into therapy activities.

Home really is filled with endless opportunities to teach our children new skills and to allow them to practise new skills.

So here is my list of the how, and the why, to turn household chores into learning opportunities.

But, and there is always a but, before I go on ALL of the following activities are based on our families experience and should NOT be considered medical advice. If you feel that your child lacks in any of the areas that are included in this piece, please consult your GP or paediatrician.

Crossing the Mid-line.

First up, what is the mid-line?

The mid-line is an invisible line that runs down the centre of our body and divides the body into the left and right. The ability of being able to cross the mid-line is not something that babies are born with. Children develop the ability through "normal" childhood development. But it is an ability that babies and children practise every day through play - reaching for toys, playing with their toes, exploring objects with their hands and so on.

Being able to cross the mid-line is an important skill to develop - we use it when writing, reading a book, tying our show laces, sitting cross legged on the floor, doing puzzles, hitting a ball with a bat, catching a ball and the list goes on. Any time your right (or left hand) crosses over to the opposite side of your body, you are crossing your mid-line.

Some children struggle to cross the mid-line and L was one of these children. His lack of being able to cross his mid-line was evident when he was drawing or painting. When drawing or painting on a piece of paper, if he wanted to draw or paint on the left hand side of the page, he would turn the page on the table to get to the spot that he wanted to decorate. L was physically unable to put his hand across his body to the left hand side.

When L was in kindy he was desperate to be able to write his own name, but crossing the mid-line can be a pre-cursor to be being able to write from left to right on a page. Mmmm, what to do.

He was practising crossing his mid-line at the early intervention centre through play, and at home through the following activities.

• Drying dishes - One of L's favourite household chores is drying the dishes - one day, his future partner is going to love me! We have a small child's table that we use for various reasons in our house. I seat L at the table, put the dish towel in his right hand and the wet dishes on the left hand side of the table. Through the action of reaching across the table to the wet dishes he was crossing his mid-line each and every time. 
• Painting - I'd always put the paint on the opposite side of the table and ask L to try and reach the paint without moving his body. Again, every time he reached for the paint, he'd have to cross his mid-line.

• Car letters and numbers - We have created a game board for L to practise his letter and number recognition skills. I have put letter and number stickers on the top of toy cars and have laminated words that L wanted to learn how to spell. L sits directly in front of the board and we put the cars that he needs to his left. Again when he reaches for the cars that he needs, he has to cross his mid-line!

Every time we were assisting L to practise these skills, either myself or Daddy superhero would model to him how to do the skill. This helped tremendously in L being able to successfully complete the skill. And when he became frustrated, we'd offer him reassurance and encouragement!

Proprioception Input.

Earlier this year I published a post on Sensory Proprioception. Put simply, the sense of proprioception is little known but it is very important as it is responsible for our body awareness and position. The proprioception sense tells us where our body parts are in relation to each other, it gives us information on how much force we need to exert in certain activities, like when hugging someone.

Prior to L starting early intervention, I can honestly say that I had no idea what this little known sense was responsible for. When one of his therapists explained the sense, it was a "aha moment."

We then had to start incorporating activities into our day to day routines so that L's sensory proprioception input was increased which in turn assisted in further developing his sense of proprioception.

We did this by:

• Getting L to assist in carrying the shopping into the house from the car. By carrying bags of differing weights he was able to get a feel for what different weights felt like.
• We'd get L and O to help with "heavy work" activities around the house - helping to pack away toys in the house, helping to put the washing into and out of the washing machine, watering the vegetable garden with a full 3L bottle of water, moving child's furniture around the house. The possibilities are endless!
• We'd do some deep tissue massage by squeezing L's arms and legs when he was agitated.
• We'd encourage L and O to play with different fidget spinners, playdoh and other sensory toys so that they could work out what level of force they needed to manipulate the tools.
• We have an endless supply of different types of pillows and blankets that the little superheroes can stack, climb on and hide under.

The possibilities for increasing a child's proprioception input really are endless!

Fine Motor Control.

Fine motor control really is a no brainer - we need this skill every day to tie shoe laces, to do up buttons and zips, to write, to read and so on.

Fine motor control is defined as the coordination of our small muscles usually in synchronization with our hands, fingers and eyes.

There are many ways in which a child can practise these skills.

• L loves to help hang the washing out and take the washing in - in particular he just loves playing with the pegs! I'll put the peg basket down at his level and let him play with the pegs, but the deal is that he has to pass me pegs when I need them. We have a game going where he pegs them onto the side of the basket and I take them from there. When we first started playing this game, hanging the washing out dragged on and on as L struggled to clip the pegs onto the basket. He would usually end up needing to use both hands to manipulate the pegs. Now, he manipulates the pegs with one hand with ease.

• Prior to going on a family holiday to Queensland in 2016, I created a pencil case of different letter recognition games. L loved "playing" with each and every one of these games. From my point of view, every one of the games helped with his fine motor control - he had to use pegs to clip onto the correct number on some games, he had to pull velcro pieces on and off of other games and all of the games assisted with his number recognition skills.
• Drawing and painting - we'd encourage L to use the pencil grip to hold whatever he was using to draw or paint with.

• We have a puzzle board with various clips on it. L loves playing with this and as every clip on the board is different he uses varying degrees of fine motor control to open and close the clips and puzzle pieces.

Again the possibilities for fine motor control activities are endless around the house.

Emotional Regulation

Put simply emotional regulation is the ability to recognise and respond to our own emotions as well as the emotions of others.

Emotional regulation is an important skill for ALL children to learn as it assists them to not only recognise and respond appropriately to their own and others emotions, it can also assist with their overall behaviour. It is thought that emotional regulation is linked to how well children manage other tasks during childhood. Through successful emotional regulation, children are more able to manage difficult and stressful times that occur as part of life. And as a child learns how to self regulate their own emotions, their concentration ability, turn taking and sharing skills are also improved. 

L has always struggled with his own emotional regulation - it was one of the big tell tale signs of his autism from an early age. L rarely responded appropriately to the emotions of others.

We try to incorporate emotional regulation into our daily routine, especially when reading books with L and O.

While reading, we talk about how L and O think the characters are feeling during the story. We talk about why the characters might be feeling that way - what is happening in the story to make them feel that way. We talk about how the story makes O and L feel.

We read books on emotional regulation, such as The Monsters Inside, during which the story gives L and O ways in which they are able to self regulate their own emotions.

Talking about how different characters are feeling also assists in developing my little superheroes theory of mind skills - but that is another blog post!

When deciding on what area of therapy an activity or game would slot into, I think outside of the box. I take a good look at the how and why of an activity. 

Do you have any activities that you do regularly to assist your child's development? I'd love to hear all about your ideas.

*** Theory of Mind - You may have seen this written as ToM. Theory of Mind is the ability to attribute your own mental states (beliefs, intents, desires, emotions and so on) not only to yourself but also to others. It is the ability to place your self in the place of others to try and work out how they may be feeling at any particular moment in time. It is also the ability to understand that others may have different perspectives than your own. Quite often theory of mind has not fully developed in individuals who have autism and as such they will struggle to understand how others are feeling.