Click headings to move down page to appropriate section.
What is Autism?
What are possible causes?
Medical conditions linked to ASD
Is autism on the increase?
How is this affecting school in the UK?
Diagnosing Autism - A brief history
-Leo Kanner
-Michael Rutter
-Wing & Gould
-Importance of input of major shareholders
-Simon Baron-Cohen, ARC, diagnostic tools
-Diagnostic criteria
How best to teach children with ASD in school
The importance of structure (TEACCH)
Picture Exchange Communication Systems (PECS)
Applied Behaviour Analysis (ABA)
Teaching ASD children in primary mainstream school
Case study - Luke
Planning, goals and learning outcomes
Teaching ASD children in SEN schools
Case study - Class 3S
Case study - Andy
Case study - Simon
References & Links
Autism is considered to be a neurobiological disorder that affects the development of social and communication skills and severely restricts the child’s ability to think and play imaginatively. Autism is complex. Language delay and low IQ are typical of classic autism. Yet no two children display the same disorders or the same severity of disorders, nor indeed the same number of disorders, although many share the same difficulties of communication, social interaction and limited flexibility of imagination already mentioned.
The term Autistic Spectrum Disorders (ASD) describes the range or continuum of difficulties that children, adolescents and adults are enduring.
At the higher end of the spectrum are people with Asperger's Syndrome (AS). They are characterised by average and sometimes above average IQ and with fewer learning and language problems are more able to communicate.
The underlying essence of autism is the problem of making sense of the world, and is summed up by Professor Uta Frith:
“ It is the inability to draw together information so as to derive coherent and meaningful ideas. There is a fault in the predisposition of the mind to make sense of the world” (Frith, 1989)
The causes of autism are not known. Although the hunt is on at many frontiers and the future looks optimistic. It is generally accepted that autism is a complex neurodevelopment disorder (MRC 2001) and the cause and or causes may be result of a combination of different factors. At The Autism Research Centre (ARC) in Cambridge, researchers from a range of specialities including genetics, neuroscience and cognitive & behavioural development are combining their resources and expertise to increase their understanding of the causes, diagnosis and treatment of ASD. The diversity across these frontiers is paying dividends and a visit to the website to read about the work and progress is a must.
ARC is also one of the collaborating partners within the International Molecular Genetic Study on Autism, whose aim is to find the gene that may create a susceptibility to autism. ARC and National Alliance for Autism Research (NAAR) are, independently, investigating genetic hereditary patterns and susceptibility in families where there is a history of autism or related disorders. Here too the hint of progress is in the air.
Research on the neurobiological frontier has shown that children with autism may develop different head and brain sizes compared to non-ASD children. This is the subject of further investigation. Another line of research is focusing on specific regions of the brain that are key areas in the functioning and development of language and social abilities.
As educationalists we are eager to hear about advances on the cognitive and behavioural frontier so that we can apply them in the classroom. ARC has pioneered a programme that is available on CD-ROM that teaches children with ASD the facial gestures and sounds that accompany emotions. For many ASD children who cannot interact with another’s emotional state this is a wonderful tool with which to help them recognise many emotional expressions.
There are some medical conditions that have been linked in a small number of cases to autism. They include Fragile X syndrome, tuberous sclerosis, congenital rubella syndrome, and untreated phenylketonuria (PKU). The MMR debate continues and although in the US the Institute of Medicine concluded that the” evidence favours rejection of a causal relationship… between MMR vaccines and ASD”, they did agree that they “could not rule out “ a possibility that the vaccine could contribute to ASD in a small number of children. (ASA 2003) The research and debate continues.
That children are born with autism and the potential to develop it is clear. The research mentioned here is a tiny sample of the current progressing worldwide work. Thankfully a far cry from the old myths that autism was the result of bad parenting and those children with autism were mentally ill.
NAAR reports that studies reveal a ten fold increase in children diagnosed with ASD compared with ten years ago. Estimates from the US are that ASD are occurring in one in every 250 births. ASA reports figures from Centre of Diseases Control and Prevention, which claims that 1.5 million Americans have disorders within their classification of the spectrum and conclude that autism is growing at a rate of 10-17% per year. According to the NAS in the UK the ratio of people, that’s children and adults with ASD and AS, in the population is 91:10,000. Aarons and Gittens point out that the figures may reflect a greater understanding and acceptance of the broadening of the spectrum or continuum rather than an increase of the incidence of Autism. The MRC’s research suggests 60 per 10,000 children under 8 years are affected by ASD and a ‘narrowly defined autism’ at 10 - 30 per 10,000 for the same age group. (MRC, 2001)
Studies from both sides of the Atlantic concur on the ratio of 3 / 4: 1 in favour of boys to girls.
That apart, ASD affects children from all races, social backgrounds and cultures.
In the sixties the NAS set up autism specialist schools specifically to meet the needs of children with autism. Many are going strong today and can be found on their highly informative website.
Local Education Authorities are expected, by virtue of the Education Acts, to take responsibility for ASD children. This may mean the placement of some ASD children in mainstream schools if they are deemed to be more able and at the higher end of the spectrum or continuum. Other alternatives are special units often attached to mainstream schools, or special needs schools. This presumes that sufficient funding; staff and expertise will follow the children. Steve Broach, Head of Policy and Campaigns at NAS, is concerned that with an estimated 90,000 children in the UK with ASD and only 7500 specialist places available, that mainstream schools will be under a lot pressure to deliver the specialist help that children with ASD need.
The Autism Working Group has been established to combine the efforts of the DfES and Department of Health and offers guidelines for educational frameworks, teacher and parent training programmes, family support programmes and help with early identification of ASD. (
Autism is complex. Much of we know today and how we diagnose and therefore treat autism is the result of the accumulation of knowledge and the work of many over the last 60 years . An understanding of the history of autism helps lessen the complexity:
In 1944 Dr Leo Kanner, an American, produced a paper defining ‘classic’ behaviours of autism. He listed nine behaviours , the most important of which included the impairment of child’s ability to interact socially; the inability and lack of motivation to communicate; the inability of the child to play and use his imagination; a resistance to change of environment and routine; out-of-context repetitive use of phrases that may have been heard in the child’s environment; and a remarkable ability to remember things. Confusion and frustration followed for many years since many children who showed some of the above behaviours also showed other behaviours that did not fit Kanner’s criteria.
Professor Michael Rutter, many years later, established that there were as many variations of IQ and intellectual ability in children with autism as they were in normal children. This meant that some children with autism could be more or less able than others with autism depending upon their IQ and intellect. Subsequently Rutter devised criteria that were broader based than Kanner’s and allowed for a greater span of abilities. Rutter’s work was further developed by Dr Newson at Nottingham University widening the criteria on communication to include facial expression and gesture.
Further progress was made by Drs Lorna Wing and Judith Gould who, when studying the characteristics of children with moderate to severe learning difficulties, including children with autism, found that children with learning disabilities could be sociable, whereas children with autism had significant obvious, observable social impairments. They classified these as ‘The Triad of Impairments of Social Interaction’. Simply they are:
The idea of a spectrum (or continuum) of disorders is now widely accepted and informs diagnosis. It is also widely accepted that there is no medical test for autism (although some medical tests are needed to help identify the causes of other disorders that ASD children may have) and that diagnosis needs to be based on observation or recognition of the child’s levels of communication, patterns of behaviour and their individual history of development. This means that input from the major stakeholders, parents and other care-workers, is essential for an accurate diagnosis. This point is enforced by the ASA and is practised in the UK at The Centre for Social and Communication Disorders in Bromley. In addition to tests, presented in a fun and informal setting, and observation of the child, the team will talk to parents or carers using ‘a semi structured interview schedule’ which is called The Diagnostic Interview for Social Disorders or DISCO. This has been developed by Wing and Gould and helps the team to piece together a comprehensive history of the child from time in the womb to date. The centre was established in 1991 by the NAS to provide diagnosis and assessment of children, adolescents and adults with ASD and other social and communication impairments, and to provide guidance and advice to families. In addition the Centre provides training for professionals and works closely with other organisations throughout the UK.
There is font of research, which shows that early recognition, and diagnosis can improve the chances of interventions having a more positive effect on the child. NAAR reports that ASD may be identifiable at around 18 months. In the UK in the early 90s Simon–Baron Cohen, who now heads ARC, developed a simple yet effective screening tool, called the Checklist for Autism in Toddlers (CHAT) that looked at the five areas of pretend play, joint attention, pointing, social interaction and social play. The screening tool comprises of a simple questionnaire set in two parts, one for parents and the other for health visitors, doctor or paediatrician. In the US, as a matter of course, doctors should be screening baby’s progress by looking at five areas that The National Institute of Child Health and Human Development (NICHD) has targeted. Further assessment will be called for if toddler:
Since the characteristics of autism spectrum disorders are complex and so varied, diagnosis continues to be a challenge. Nevertheless it is important to have some standard classifications in place to provide a term of reference internationally. This is currently provided by the World Health Organisation and is called International Classification of Diseases (ICD) and is updated every few years and is currently ICD-10. More well known and more referred to is the Diagnostic and Statistical Manual (DSM-IV) which is produced by the American Psychiatric Association which is difficult to follow but, in a nut shell, says that the child is has autism if the following criteria are observable:
Many children with ASD, given the right educational setting and patient teaching can learn and develop skills and go on to feel accomplished. There are several approaches used to treat or educate children with ASD. They include TEACCH, ABA, PECS, Social Stories, Speech and Language Therapy, Sensory Integration, Music Therapy, Art Therapy, Trampoline, Horse Riding, Dancing, Gymnastics and Yoga. Often used as a multi- disciplinary approach they provide a broad experiential base for the children and teachers.
Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) was developed in the early seventies in North Carolina and was the first programme focused on the education, treatment and support of children and their families to be adopted by the state. The TEACCH approach is accepted and used worldwide often as part of a programme of multi-disciplined approach to help children with ASD.
TEACCH is about focusing on the individual and building a programme around that person’s needs, which may mean modifying the environment to suit those needs. In this way practitioners are focusing on the whole person, understanding that their problems of behaviour can arise from inherent difficulties in comprehension, communication and social interaction. Practitioners are able to recognise and nurture “emerging skills”(NAS 1997) as well as the child’s strengths, interests and talents. For example some children with ASD have the ability to see great detail or have a powerful memory. Building on such abilities shows respect for the child’s “culture of autism”. (Gary B Mesibov 2003). Good teachers know building on the student’s personal interests creates relevance and can increase motivation to learn.
Teaching the whole child means recognising that education encompasses social, moral and personal development as well as academic skills and so helping the child to improve his communication, social and coping skills is central to the approach because in this way the child’s independence can be increased. Gary B Mesibov of TEACCH talks about the need to “understand people with autism as they are” and that “it simply requires starting where people are and helping them to develop as far as they can go”
( Gary B Mesibov 2003)
Structure in the teaching environment and structure and consistency within teaching approaches and methods are also central to TEACCH principles. For example some children with ASD are easily distracted so it would be necessary to limit possible distractions in the classroom. The same principle applies when teaching yoga to children with ASD as the story of Andy aptly demonstrates. Many students with ASD need the guidance and security that structure can provide, because, for example, they may not be able to understand instructions, or they may have difficulties of self-organisation and do not know what happens next. An environment that helps students through these difficulties and encourages independence is crucial to the learning process. The TEACCH approach is one of many endorsed by the NAS and is highly recognised throughout the world of professionals helping children with ASD (Aaron and Gittens)
PECS is another approach recognised by the NAS and professionals worldwide world. PECS was developed about twelve years ago at the Delaware Autistic Programme. It is particularly helpful to many ASD children who have limited communication abilities. The child is able to exchange a picture that represents his needs with his teacher. The benefits are:
a. The action is initiated by the child
b. It is a clear simple method of communication
c. The teacher can initiate her need by giving the picture or symbol to the child.
Sequencing the pictures and symbols can be a useful approach to building sentences and developing thinking and speaking skills.
ABA is about finding ways to encourage acceptable behaviours and eliminate undesirable behaviours . Praising and rewarding desirable behaviours and ignoring undesirable ones is common practice in the classroom in any lesson, but to make it work with ASD children requires a great deal of expertise and patience. Dr O Lovaas has pioneered the Lovaas approach , which uses the basic principles of ABA in addition to intense behaviour therapy and full family participation. It is mentioned because it is acknowledged, in most quarters, as a successful treatment for ASD children and while we are concerned with yoga and teaching in the school environment , Loovas is normally practised at designated centres and at home.
It is important to differentiate between the teaching approaches used in mainstream and special needs schools.
Primary Mainstream School: As already mentioned there are an increasing number of children with ASD in mainstream education. Generally they will be children at the upper end of the spectrum with less severe impairments, but not necessarily. Luke’s story exemplifies this.
Luke
Luke has been diagnosed as ASD. He attends his Year 4 primary mainstream class four days a week, spending Monday at a special needs school. Luke has a full time carer, Sophie, and is one of thirty children in his class. Before the very first yoga lesson I had discussed Luke’s impairments with the class teacher and Sophie, and we had set strategies in place to help Luke should the situation require it. This good practice applies from the very first lesson to the very last and is crucial for the well-being of the special needs child in the mainstream setting.
Some of the strategies entailed:
The key to successful teaching is to set clear goals and learning outcomes before you start the lesson. Here are some generic goals (or aims) that I apply whether teaching mainstream primary or special needs children. The aims are to:
a. Improve flexibility and fitness
b. Promote and encourage appropriate behaviour
c. Improve concentration
d. Enhance self-esteem
e. Increase independence.
In addition there will be specific learning outcomes. In the case of Luke they were:
One day I was teaching Luke’s class the Roaring Lion Posture, which involves the class roaring at the top of their lungs. I had forgotten that a typical characteristic of ASD children was highly sensitive hearing. Luke became very distressed by the noise - very few children hold back given the opportunity - resulting in Sophie taking him out to allow him to calm recover. An important lesson!
Classes are generally smaller than mainstream, ranging from four to ten children depending upon year grouping, ability and age. Often children with ASD will be with children of other special needs, which could include ADHD and /or EBD. And even if the class were only ASD children the spectrum of abilities in terms of communication and social skills can be vary widely.
Language, approach, pace, reward
Instructions are expressed simply and language kept to the minimum. Children are taught a variety of activities in whole class, pairs and small groups so as to practise social skills. A variety of teaching approaches can be used including story, games, and simple demonstration. Pace and voice changes and total involvement ensure the students’ attention throughout the session. Children are rewarded for appropriate behaviour, for their comparative ability to be still, for showing kindness to a peer or a member of staff, for their improving ability to concentrate, and showing self-discipline in the face of distraction. Lessons are assessed in terms of achievement of outcomes.
The Teaching methods that have I have evolved are an integration of many fine features of good practice and include aspects of some of the methods already mentioned. For example,
I use PECS to teach groups of children with ASD. The idea is that the children can see at a glance the sequence of postures or activities that they will be practising during the session. This works well since the children seem more relaxed and are, comparatively, more attentive knowing what is coming next. In addition the pictures inform adult staff of the lesson plan and help them anticipate problems.
Ability range is wide and levels of understanding varied. Often a child may need to be helped into the posture despite prompts from visual aids or demonstrations from teacher or other children. Strategies, therefore, need to be created at the planning stage, as do specific achievable targets, and criteria that determine whether the targets have been reached. However I am also prepared to accept that if the strategy is not working to try another way. Out of such situations come many great workable ideas.
I am often asked where do I start with a class of ASD children. The answer is found within the TEACCH principles, that is “it simply requires starting where people are and helping them to develop as far as they can go” (Mesibov 2003) No coincidence that this is also the touchstone of Yoga.
Early years ASD Children are particularly challenging to teach, and yet, can benefit greatly from the yoga. When I first enter the class I try to discover how I can communicate to the children. I observe the strategies employed by the class teacher and carer and observe how the child responds to them. I take advise from them too for the best approach and then the rest can be trial and error. It becomes obvious quickly if there are chances of teaching simple postures like stick , star or cat to at least some of the children. And often there is not. Be prepared.
The first task is always to put the children at ease and begin to establish structure and routine. The following case study illustrates this.
Class 3S
The class consisted of five ASD children. They were very young - the average age being five. Including the class teacher there were enough carers for each child. There were a variety of behaviours ranging from screaming to quiet work. We all gathered in a small circle on the carpet area. I produced five ladybird finger puppets and preceded to fly one through the air accompanied with humming sound and let it land on the toe of one of the carers. This was repeated many times with all the adults joining in the humming. Not only did it make a powerful resonance, but also the atmosphere became serene and this was reflected in the behaviour of some of the children. Towards the end of the session some of the carers would try landing their ladybird on the toe or fingertip of their child. In some cases the children were frightened by the ladybird, but the carers carefully persevered and soon some of the children were allowing it to land on their toes. We repeated this activity for a further six weeks and each week it we witnessed a growing acceptance of the ladybird by the children. Our goal was to encourage the children to lie down in relaxation and allow the carers to ‘land ‘ the ladybird on toe and fingertip.
Andy
I began to teach Andy about a year ago. Andy had been diagnosed as ASD. He was in a class of other special needs children who had a variety of needs, including three children with ASD. The school hall presented Andy with an endless area in which to run around and so many distractions that we switched to a medium sized room where the only distractions were the light switch and the pull down blinds in each of the two windows. Andy would switch off the light and pull down the blinds and defend his territory steadfastly against staff and children. For the first month Andy’s attention was focused on defending his beloved light switch and blinds or running around the room shouting or throwing shoes or hitting his classmates. The breakthrough came when I was teaching a sequence of postures called the Sun Salute Sequence (well known in yoga classes world wide.) As I demonstrated and called out each posture of the sequence Andy mimicked my words and each posture. We adults were amazed and burst into spontaneous applause much to the delight of Andy. I repeated the sequence twice more and so did Andy. Over the ensuing weeks Andy fully applied himself to the Sun Salute, often taking delight in correcting me when I made a mistake, as well as kindly helping his classmates who maybe did not have the same memory capacity as he.
Simon
The second big breakthrough came with the arrival of hand puppets. Relaxation is an important part of the YogaBuds lesson. Simon and his classmates found great difficulties in being still and quiet even for the shortest of time, until the ladybird (finger- puppet) flew into the room and landed gently on Simon’s big toe; then flew up and landed on his knee, thumb, shoulder, nose, other shoulder, other thumb, other knee, other toe and finally on Simon’s tummy, and all the time Simon was being kind to the ladybird by being still. Simon had been still and quiet for about three minutes and so had most of the other children. Simon grabbed the puppet from his tummy and said “Its Sam’s turn” and proceeded to take the ladybird on the same circuit tour that he had just experienced. Sam lay peacefully as this happened.
Often with remarkable accuracy of tone and inflection Simon will mimic my words and comments but prefixes the sentence with a negative. For example “well done Simon”, is repeated back as “Not well done Simon” Oftentimes I would ask him if he would like to show the posture to the class, whereupon he would typically reply “Simon not show the posture” and proceed to demonstrate the posture admirably.
This year Simon is in a class dedicated to autistic boys aged from 8 to 10 years. As the elder of the group he seems takes a more paternal role in the yoga lessons. The yoga is now in his classroom where he has no pre-occupation with lights or blinds. He always greets me by name; still enjoys practising Sun Salute, pouncing on my mistakes, and now his repertoire includes candle (shoulder- stand) and bridge posture; and he maintains his enthusiasm for relaxation. Recently the class were involved in Harvest Assembly, they did well but the sheer effort and unusual timetable upset their daily structure and routine and they were very high The majority of our yoga time that morning was spent being still and quiet. Don’t think for a moment that everybody was still and quiet all the time, but some of the time some of the children were. For most of the time Simon was.
Over the years I have come to adjust my expectations to match the child’s skills and abilities. Seemingly tiny steps of progress are actually giant steps for that child. I would encourage future children’s yoga teachers to practise the main doctrine of TEACCH – which is to keep chipping away to find that chink of light that represents the skills and abilities that Luke and others undoubtedly have. The job then is to nurture those skills and abilities through the yoga.
Aarons M & Gittens T - The Handbook of Autism 2nd Edition (Routledge 1996)
Broach, Steve - Educating children with autistic spectrum disorders (Special Educational Needs Oct 2003)
www.mrc.ac.uk
www.teachernet.gov.uk
www.teacch.com
www.nas.org.uk
www.autism-society.org
www.naar.org
www.londonearlyautism.com
www.lovaas.com
www.ninds.nih.gov/health
www.cureautismnow.org
www.affectivecognition.org.uk
www.thegraycenter.org
www.autismresearchcentre.com
www.geocities.com
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