By Dr. Jeanette McAfee

Planning programs for school-aged children and teens with Asperger's Syndrome (AS) and high-functioning autism (HFA) can be an overwhelming experience for parents and school staff alike. Although some professionals are very knowledgeable and can help guide parents, many speech therapists, psychologists, teachers, and physicians have little training in issues facing children on the higher functioning end of the spectrum. The goals of this article are to provide an overview of the types of programs and services that might be looked at for a child with AS or HFA and to encourage the reader to consider alternative ways of delivering services to this population of children.

 

In spite of individual differences between children with AS/HFA, there are certain areas of need that are common to many or most of these children. Each child should be carefully evaluated for deficits in the following areas and should be provided with appropriate interventions as needed. These areas are as follows:

 

 

The child with AS/HFA typically lives each day with a burden of stress that is difficult to imagine. Children with AS/HFA have core deficits in pragmatic communication (the social use of language) and in understanding social cues. In addition they are faced with often-severe problems understanding the thoughts, feelings and intentions of other people. Because of their social difficulties, their sometimes-odd speech and language, and other differences, children with AS/HFA are all too often teased and bullied unmercifully. Although some of these children are not interested in peer relationships, a large percentage of them do desperately want to have friends and to be included and accepted by other children. For the latter group of children, being exposed to frequent teasing and bullying is particularly devastating and is itself a major source of stress. Problems with focusing and attention are nearly universal in this group of children, and learning disabilities are common. Sensory integration problems may cause the child to be painfully sensitive to light, touch, certain odors, specific sounds, or loud noises. In addition, coexisting diagnoses such as obsessive-compulsive disorder, depression, anxiety, or full-fledged attention deficit disorder add to the stress load of many children with AS/HFA.

 

As is the case with anyone, a child with AS/HFA will not be able to learn effectively if he is trying to cope with a high level of stress at the same time. Because daily life contains so many stressors for these children, one of the top priorities in planning programs for them is to assess their stressors and stress levels, and to treat significant stress before asking them to tackle stress-inducing academic or social tasks that may drive them "over the edge". To neglect this crucial point may lead to problem behaviors, poor self-esteem and depression.

a) Graded exposure programs: One approach to teaching stress management is a graded exposure program in which tasks that cause stress in the child are ranked on a hierarchy from the least stress-inducing to the most stress-inducing. The child then chooses and practices a set of relaxation techniques when not stressed. Next, the child uses his techniques to relax while tackling the tasks on his hierarchy, in order from least to most stressful in several practice sessions. Finally, he practices using his relaxation techniques in real-life situations. Providing the child with meaningful reinforcers for completing each step encourages his participation and cooperation.

 

b) Quiet place: Provide the student with quiet places at school and home where he can go when beginning to feel stressed. Allow him to do self-stimulating behaviors in his quiet place when possible if this helps him relax.

 

c) Frequent Breaks: Give the student frequent breaks between tasks to minimize stress and maximize efficiency.

 

d) Environmental Controls: Modify the classroom and home environment to diminish the effect of environmental stressors. For example, look for and address sensory stressors such as exposure to uncomfortable or painful lighting or sounds, and keep surroundings as non-stimulating as possible.

 

e) Bullying Intervention: Routinely monitor for teasing and bullying. Avoid telling the victim to "just ignore it". Involve the whole peer group in a bullying intervention program.

 

f) Decrease or Eliminate Homework: A child with AS/HFA may have used up all of his energy just "holding it together" at school, and he may fall apart the minute he gets home. In such cases, consider reducing his homework load or eliminating homework altogether. Also consider providing study hall time at school as an elective to allow him to work on homework assignments.

Many children with AS/HFA are innately resistant to developing new skills and to learning about subjects outside of their special areas of interest. This resistance is what I term primary non-compliance. In other cases, a child with AS/HFA may develop avoidance behaviors after repeatedly failing at specific tasks that he was initially willing to attempt. I call this secondary non-compliance. In the latter case, it is critical to look for and treat any learning disabilities, attention difficulties, stress factors, illnesses, organizational deficits, or other problems that may be interfering with the child's ability to work. Not to do so will guarantee failure in trying to help him. In treating compliance problems, using a graded exposure program similar to the stress management program mentioned above can be very helpful. In this type of program the teacher or parent works with the student to create a list of tasks that are at or below his ability level, but which have caused compliance problems in the past, starting with the least challenging and progressing to the most challenging. The child then completes the tasks on his hierarchy in practice sessions over the course of weeks or months. As above, the teacher or parent provides reinforcers that are motivating to the child after each task. Finally, the child receives reinforcement for complying with these and similar demands as they occur in real life.

Because of often-severe problems in understanding and using appropriate social-emotional skills and pragmatic language, each child with a diagnosis of AS/HFA needs to be carefully evaluated for his or her relative strengths and weaknesses in these areas. A strong social-emotional skills and pragmatics program should be a regular part of the curriculum for these students, and in most cases it should be treated as equally important as the child's academic curriculum. In planning a social and pragmatics skills program, consider programs that a) provide individual work with the child to introduce and teach target skills and to allow for practice with a non-judgmental adult, and b) provide social skills work in small group settings in the home, school, and community to encourage generalization of skills. Using tools such as Carol Gray's social stories and comic strip conversations to address specific problem situations can be very helpful. Also a cognitive behavioral therapy (CBT) approach to teaching a child how to understand and cope with emotions is essential for these children. Finally, drama and role-play are invaluable tools in teaching social-emotional and pragmatic skills, and recruiting staff members with backgrounds in this area can add immeasurably to the overall program.

 

It is important to recognize that social-emotional and pragmatics needs in children with AS/HFA are very different from, and much more complex than those of non-autistic children. It follows that effective programs for teaching these skills to this group of children will be different from, and significantly more involved than traditional social skills programs designed for neurotypical children. It is therefore critical that the person delivering this type of program has in-depth training and past experience in the area of teaching social-emotional and pragmatic skills specifically to individuals with AS/HFA.

Many children with AS/HFA have trouble with organizing their work, schedules and activities of daily living. Providing these students with written assignments, visual reminders and organizers can help immensely. In addition, some students may be greatly helped by a classroom aide who checks to make sure that their work is turned in and that their daily assignments and supplies are ready to take home at the end of the day.

Students with AS/HFA vary greatly in their academic strengths and weaknesses: some have one or more learning disabilities, while others sail through all of their academic courses with little effort. It is important to screen children with AS/HFA for learning disabilities at a young age (preferably by kindergarten or first grade) and to start intervention programs early. This approach will help prevent the additional burden of repeated failure to their already high stress load. Children with AS/HFA often are very concrete thinkers. Abstract concepts and "getting the big picture" can be very difficult for them. "Chunking" (breaking down) teaching material into small steps, using concrete examples whenever possible and employing inductive teaching techniques, can help immensely. Regardless of their learning profile, most children with AS/HFA have easily identifiable special interests. These special interests can be a great help to the teacher, since the student will naturally concentrate better when they are used. Include them in the curriculum as often as possible.

Many, if not most, of these children suffer from neurologically-based problems with focusing attention. Some are hyperactive as well. For these children, care needs to be taken to give frequent, brief breaks coupled with physical activity as often as possible. Also, this group of students will nearly always benefit from help with organizational skills. (See #4 above.) Note that if problems with attention or hyperactivity interfere with the child's ability to work, a medical evaluation should be sought for these problems from a developmental pediatrician, child psychiatrist, or primary care physician who is experienced in this field.

Because many children with AS/HFA have such intense interests, it often is possible to identify future career paths at a much earlier age. When feasible, it is helpful to begin career planning as early as sixth or seventh grade. When possible, set the child up with a mentor at the school or in the community, or find an "apprenticeship" in their field on interest.

Modifications to teaching techniques and learning environment may be necessary for some students with AS/HFA. As mentioned above, many of these students need to have teaching materials, assignments, and schedules in a readily accessible, visual format. The student's curriculum also may need to be modified to present material using an inductive approach (i.e. the student first learns discrete facts and then is helped to derive the general rule or concept from those facts) rather than the more traditional method of presenting the rule first and facts second. The physical environment may need to be modified to minimize distractions and sensory overload. Other provisions, such as the use of a laptop word processor or increased time to complete tests, can be helpful depending on the needs of the individual student.

In addition to the program components listed above, here are a few additional services that students with AS/HFA might require*: Occupational therapy (for sensory integration and fine motor problems), Adaptive PE, and Central auditory processing therapy. (There is a trend toward treating central auditory processing deficits using computerized programs such as the Fast ForWord program.) *This list is a sample of a variety of additional services that may needed, and is not intended to be all-inclusive.

Because AS and HFA are complex disorders that affect several different areas of the child's development, treatment programs must be delivered by well-trained and experienced staff (often from several different disciplines) working closely together as a team. Clear and frequent communication between staff members is a must to insure consistency in program delivery and sharing of new information. Training of both staff and parents should be practical, and hands-on when possible, with frequent updates as new methodologies are discovered. In particular, well-trained and well-supervised classroom aides can provide the intensive services many of these children need in a more cost-effective way.

In deciding how to deliver services to children with AS/HFA, there are several placement models to consider. These include:

 

-- Self-contained classrooms specifically for students with AS/HFA. (Note: Classrooms for children with severe emotional disabilities, oppositional defiant disorder, or conduct disorder are inappropriate placements for children with AS/HFA and should be avoided.) Some school districts have started to place classrooms specifically for students with AS/HFA on mainstream campuses. This has the advantage of providing specialized programs and experienced staff, with potential access to mainstream activities.

 

-- Mainstream with "pull-out" sessions for stress management, social-emotional skills, organizational skills, compliance training and academic support as needed. This model can work well for higher functioning students, particularly those that do well in most academic subjects. The trick is to provide pull-out programs that are appropriate for this group of students. (Refer to Program Components section above.)

 

-- Private school placement. Private schools that are geared to children with AS/HFA and that provide training in stress management, social-emotional skills, organizational skills, and compliance can be excellent. However, cost is often an issue and there may be little or no access to peer support from neurotypical students.

 

-- Home school. More and more families are pulling their children with AS/HFA out of public schools and are home schooling them successfully. This model can be particularly effective for those students who are emotionally fragile and at risk for significant depression. In addition, some families feel that they are better equipped at home to provide the intensive, one-on-one help that their child may need. On the other hand, finding neurotypical peer helpers may be a challenge, and there may be less access to specialized services. Home schooling can be an effective and valuable option, but it represents a significant commitment and should be undertaken with particular care.

 

-- Magnet schools. In this model a school district or a group of neighboring districts designates a general education community school site as a magnet school for students with AS/HFA (or autism spectrum disorders in general). Enrollment at the magnet school site is voluntary. Intensive social-emotional, organizational, compliance, and stress management skills training is provided to the AS/HFA students (and optionally to other students). Staff and parents receive on-going training in how to help students with these diagnoses. Students with AS/HFA attend either mainstream classes, the campus learning center, or a combination of both. One of the greatest benefits of an AS/HFA magnet school model is that a district is able to concentrate resources in order to provide specialized facilities and a core of highly trained staff at that site. This is much more efficient and cost-effective than attempting to train the staff at multiple school sites within a district in the complex and challenging subject of autism. As the staff at the magnet site gains expertise, they can provide consulting services at other school sites. Equally important is that each student with AS/HFA has access both to mainstream classes and to a learning center attended by peers with a variety of strengths and weaknesses. In the long term, magnet schools can serve as prototypes for similar schools in other districts.