Tuesday 29 March 2011

Why teaching 'social skills' doesn't work in autism

This is quite a long post, about the equivalent of 2.5 sides of A4 so you might want to get a cup of tea............

I have an article published in the UK’s SEN Magazine (issue 51) entitled ‘Adapt and Thrive’ where I put the case for prioritising the development of flexible, adaptive thinking in children with autism.  In it I share something that was shared with me recently by an older adult with autism – that his biggest challenge in life has been responding adaptively to the myriad of interpersonal challenges related to navigating the world on a daily basis.
Janine Collins from the University of Maine recently wrote a paper called ‘Socially skilled or socially adaptive – there is a difference.’  She asks a question about the transferability of ‘social skills’ that are taught as a discrete set of rules of behaviour and highlights that people without autism are able to learn and then apply rule-based ‘social skills’ because they ‘acquire ‘social capacity’ incidentally as part of growing up’.
The ‘social capacity’ that she is referring to is, of course, the dynamic intelligence that is developed in the early years via the interpersonal engagement between child and caregiver.
So – when we try to ‘teach’ social skills to people with autism, often they are able to learn the rules but then they fail to put them into practice….they don’t generalise the skills.  It would seem that learned rules of behaviour in isolation from the ability to adapt the response to the changing needs of a social situation, just don’t cut the mustard.
It’s not possible to learn alternative rules for every single variation that could occur in a social encounter – it’s probably not even possible to predict the nature of the many possible variations that could occur.  Collins tellingly states ‘It seems to be assumed that the application and adaptation will simply happen so long as the skill has been learned’.

Temple Grandin makes a similar point in her book ‘Unwritten rules of social relationships: Decoding social mysteries through the unique perspectives of autism’.  In her discussion of interventions for autism, she says ‘many programmes with a social or behavioural basis teach good/bad behaviour and expect behaviour conditioning to produce social understanding’.

And therein, for me, lies the crunch.  We know that autism is classed as a developmental disorder.  Surely the definition of a developmental disorder is that development is disordered??  If so, what would happen if we re-ordered it to facilitate the development of social understanding?  It never ceases to amaze (and frustrate) me that our approach to supporting people with autism doesn’t take account of the developmental steps that have been missed.

Over the past couple of years, I’ve noticed that there has been much more emphasis on autism research that looks at developing joint attention in children with autism.  That is definitely a good thing and a step in the right direction, but still misses out all the developmental steps that are the foundations for joint attention.

You’ll remember we looked at joint attention in a previous blogpost entitled ‘Why we need guided participation in autism education’ (11 Jan 2011).  Joint attention involves the child looking at an external object (e.g. a toy) and then looking to the partner to share their reaction to the toy.

I have a theory that the Pre-School Autism Communication Trial (PACT) (the largest ever randomised controlled autism research trial in the UK to date) didn’t achieve the outcomes that were anticipated because it looked at joint attention in isolation from all the preceding developmental steps.  Dr Gutstein once gave a good analogy about this ‘don’t run before you can walk’ approach – we can’t expect anyone to be able to solve a calculus problem without first having taught them to add and subtract.

The foundations that underpin joint attention include social referencing, role co-ordination, co-regulation, experience-sharing – all competencies (rather than ‘skills’ – I really don’t like that description) that are developed during interpersonal engagement in the early years.  In order for these competencies to be developed, the child needs to be in the right framework – the guided participation relationship (GPR).   We know (from studying the interaction of children with autism) that if the right framework isn’t in place, the interpersonal engagement can’t take place and the competencies do not develop.

That’s not to say that parents of children with autism don’t try to put the GPR in place - in autism, the child is unable to give the parents the feedback that they need to make the GPR work. When the framework that facilitates the interpersonal engagement leading to the development of flexible thinking and social understanding breaks down, it leads to a kind of domino effect where subsequent developmental steps are also then missed.

Generally speaking, humans start to talk around the age of 2 years.  However, what has preceded the development of language is thousands of hours of non-verbal communication – working on reciprocity, social understanding and paving the way for the development of perspective-taking.

Here’s a great clip of twin brothers who have taken part in a GPR, having a non-verbal ‘conversation’ (with thanks to Laura who brought this clip to my attention via facebook).

Some children with autism might babble as toddlers, but it’s more than likely that they babble to themselves, rather than babbling in a reciprocal way with a partner.  What’s great about this clip is that whilst the toddlers aren’t talking, they are communicating really well.   Toddler A babbles to toddler B, who is entranced by the babble and looks intently at his twin.  Toddler A uses intonation to emphasise different parts of his ‘conversation’.  He also uses body proximity, gesture and, I’m guessing  - although we can’t see it as his back is turned away from the camera - facial expression.

Toddler B waits for toddler A to get to the end of his babble and then does a mighty chuckle.  He also responds to toddler A’s babble with his own babble (including intonation for emphasis), gestures and facial expression. 

You can almost feel what’s happening between these two – it’s as if one of them shares something profoundly amusing and the other responds by acknowledging the hysterical nature of what has been shared and then takes it, builds on it and shares it right back with his twin to magnify their shared experience.  The sum of what they have created together is much more powerful than what they contribute singly.

These toddlers have not been ‘taught’ to respond to each other in this beautiful reciprocal way.  They have been taking part in a ‘communicative dance’ since they were born, initially with their parents.  Now they are at the stage where they can begin to communicate reciprocally with each other and have a really meaningful exchange without ever saying a word.

It’s the reciprocity and co-creation that stand out for me in this clip. 

Clearly, neither of these toddlers is consciously applying a set of rules to govern or guide their behaviour or responses.  They have developed the competence to adapt to (and build on) their partner’s social overtures.

We have come full circle back to where we started with Janine Collins.  She states ‘Social encounters are dynamic occurrences that require spontaneity, flexibility, adaptation’.

Research that has taken place in the school setting also reveals that being successful in school requires a combination of social, emotional, and academic competencies. A new analysis of more than 200 school-based social and emotional learning programs has found that such programs improve students' attitudes and behaviours, and in some cases, even boost academic performance.
"The findings highlight the value of incorporating well-designed and carefully conducted social and emotional learning programs into standard educational practice," according to Joseph A. Durlak, emeritus professor of psychology at Loyola University Chicago, the study's lead author. "Such programs do not detract from but can enhance academic achievement, while providing students with stronger skills in areas that are important to their daily lives and future functioning."
A meta-analysis of 55 published research studies reveals programs designed to teach social skills to children with autism are failing to meet their goals. The study, conducted at Indiana University, found that outcomes for social skills training were poor overall, but programs held in normal classroom settings were more likely to result in positive changes than programs held in other environments.
In terms of interventions/care programmes/support for our children and adults with autism, the way forward must surely be to re-create the conditions that enable them to become socially adaptive. This is what we (my family) are doing with our use of the intervention Relationship Development Intervention (RDI - see footage and text in previous blogposts) - helping our son, Philip to have greater flexibility in his thinking (and therefore, in his behaviour) and helping him to improve his social understanding and reciprocal communication.   

I think most of us would want to enable our kids with autism to be able both to share experience and to co-create experiences like the twins in this clip.  Without that, our emotional landscape would be pretty grey.

To learn more about RDI, please visit http://www.rdiconnect.com/

Wednesday 16 March 2011

Folding towels

Hello again - I seem to have been ridiculously busy...have been neglecting my blog but now have a short window to catch us up a bit!

With our current objective, Philip has to compare his actions to mine, to make sure that the accuracy and care of his actions matches mine. 

If you think about what it takes to be part of a team – let’s say, at work – you know that each member of the team has to take an equal responsibility for keeping the activity/interaction/project on track.  If team members don’t all take an equal responsibility, there is likely to be either project/activity breakdown and/or generation of resentment.  If someone doesn’t pull their weight, you don’t want to work with them again.  If you’re an employer, you might be having second thoughts about having employed them.

In this clip, we are folding towels and my objective is to see whether Philip folds his towels carefully and neatly.  If I have done my job in practicing this objective in different settings with different activities, Philip will complete the towel-folding with care, referencing me along the way to make sure that his actions are matching the accuracy of my actions.  If he doesn’t complete the job with care, I will gently spotlight this for him so that he can repair his action. 

Our folding of towels is kind of a metaphor for teamwork – taking joint and equal responsibility to get to a common goal.

In the event, I don’t need to do any spotlighting as he is taking total responsibility for the care and accuracy of his part of the joint task J J That’s my boy!! 

In the past, we have done earlier prototypes of this objective, which focus more intensely on getting the co-regulation of our interaction firmly in place.  Now that we have got co-regulation firmly underpinning everything we are doing, we can elaborate the prototype to include a focus on care and attention.

The other thing that happens in this clip that I think must’ve been happening for a little while, is that Philip is beginning to spotlight key moments for himself.  You don’t really notice these small moments in everyday interaction – it’s only when you’ve filmed something and you play it back that you can really concentrate on your child’s responses to what is happening in an interaction. 

Here we see Philip spotlighting his own mistakes and actually laughing at himself.  Now that sort of thing is run of the mill for people without autism, but for people with autism who struggle to cope when something unexpected happens – something that wasn’t in the script or in the picture that they had of themselves in their head….it feels to me like a huge leap forwards. It means Philip is internalising a process (spotlighting) that we (parents) have previously had to do for him.  You'll remember from a previous post that spotlighting supports the capture of episodic memories - the memories of competently resolving something that lead eventually to the development of resilience.

We all need to be able to laugh off mistakes in order not to be overwhelmed by feelings of incompetence when something goes wrong.  Otherwise, why would we ever have another go at something?

Here is what happened:

P checks in (references me) to make sure he is doing what I am doing at 0.17; 0.24; 0.30; 0.48; 0.55; 0.58.

With the second set of towels, P references at 1.57; 1.59; 2.06 and then whilst I am shaking a crease out, he gets confused with his folding but doesn’t let this bother him.

 In fact, @ 2.24 he makes a great joke out of his mistake, laughingly saying that he has created a ‘nappy’ ('diaper' for our US cousins).  At 2.33 he is not at all bothered about starting again – he just takes it in his stride.  Previously, this mishap (the folding not being perfect first time) would have thrown him off kilter completely, possibly precipitating a withdrawal from the activity.

He references @ 2.39; 2.43 and then at 2.45 he is struggling a bit with where to pick up the fold so I non-verbally model how to grasp the middle of the towel by exaggerating bringing my arm around.

At 2.46 there is a fleeting smile of recognition on P’s face as he realises how he should have done it. Our Consultant pointed out to me that this is another self-spotlight. Yay!

At 2.47 I spotlight his competence.

You can see how carefully he folded the towels without me having to ask or prompt him to do so e.g. 2.56 – 3.00.

Remember Philip's response to the collapse of the pizza base in previous blog footage?  Now we also have self-spotlighting.  You are watching the development of resilience.  How fabulous is that?