Students With Autism Spectrum Disorder 9 Pre-Test: 1. Autism spectrum disorder (ASD) is a relatively new disability category. T/F 2. Students with ASD must exhibit two of the following: difficulty with communication, social skills, or repetitive behavior. T/F 3. Vaccines have been disproven as a cause for ASD. T/F 4. Students are typically diagnosed with ASD in elementary school. T/F 5. Students with ASD require instruction in a selfcontained classroom or specialized school. T/F Answers can be found at the end of the chapter. Jodi Cobb/National Geographic/SuperStock Learning Objectives After reading this chapter, you should be able to: 1. Define autism spectrum disorder. 2. List and explain the disorders that fall on the autism spectrum. 3. Explain how researchers determined ASD was a separate disorder from ID. 4. Describe the characteristics of students with ASD. 5. Describe potential causes of ASD. 6. Explain the evaluation procedure for ASD. 7. Explain when an ASD diagnosis takes place. 8. Detail classroom strategies that are helpful for teaching students with ASD. 311 pow85736_09_c09_311-354.indd 311 5/7/13 8:17 AM CHAPTER 9 Introduction Introduction A utism spectrum disorder (ASD) has probably received more media attention in the last 10 years than any other disability. Most of this publicity has involved the idea that childhood vaccines may be a cause of ASD. Another reason is that the number of students identified with ASD has increased substantially over the last few decades. Some people even call ASD an “epidemic.” That increase may be partially attributed to the fact that autism only became a separate disability category in 1990, but that change does not fully explain such an increase in students with ASD. Because many aspects of ASD are puzzling, and because there are many different components to this disorder, the community of children, adults, researchers, families, and others who are supportive of people with autism often visually represent the disorder with puzzle imagery. Like students with ID, students with ASD can greatly benefit from therapy and instruction, and outcomes can improve with early and intensive intervention. As adults, many people with ASD will be able to live on their own and have successful careers and relationships. Some individuals, however, may need to live with family members or in special communities where they can receive special attention. Thus, it is vital that IEP teams consider post-secondary opportunities for students with ASD, just as for students with other disabilities, and begin transition planning early in the student’s schooling. iStockphoto/Thinkstock Because the causes of ASD are perplexing, the ASD community uses puzzle pieces as a visual metaphor for the disability. The colorful pieces of the puzzle represent the differences among students with ASD—a rainbow of characteristics. pow85736_09_c09_311-354.indd 312 This chapter describes the IDEA 2004 category of autism and discusses the prevalence of ASD. It also highlights changes to types of ASD listed in the upcoming DSM-5. Later sections focus on characteristics of students with ASD and possible causes for ASD; the chapter concludes with a discussion of teaching strategies for students with ASD. 5/7/13 8:17 AM Section 9.1  What Is Autism Spectrum Disorder? CHAPTER 9 9.1  What Is Autism Spectrum Disorder? S tudents with autism spectrum disorder (ASD) experience difficulty with communication, social skills, and repetitive behavior (Goldstein, Naglieri, Rzepa, & Williams, 2012). These students often struggle with changes to their routines or environment. They may have unusual sensory responses, such as sensitivity to loud noises, picky eating, or a dislike of getting dressed or grooming (Tomcheck & Dunn, 2007). Many students with ASD have difficulty making eye contact, recognizing faces, and understanding emotions (Kirchner, Hatri, Heekeren, & Dziobek, 2011). Over half of students with ASD exhibit average to above-average intelligence (Whitby, Travers, & Harnik, 2009). ASD is another term for pervasive developmental disorder (PDD). A student with PDD exhibits delays in communication and social skills, and these delays are often first recognizable during the developmental period from ages 2 to 4. Several disorders have been included in ASD, including autistic disorder (i.e., autism), Asperger’s disorder, pervasive developmental disorder not otherwise specified (PDD-NOS), Rett’s disorder, and childhood disintegrative disorder (CDD). The next section of this chapter describes these in detail; the recent changes to the names of the disorders and how they are categorized will also be outlined. Students with ASD are often described as high-functioning or low-functioning. High-functioning students with ASD exhibit the hallmark characteristics of ASD, but these characteristics do not prohibit the student from participating in regular activities. Students are typically verbal, and their ASD is less severe than low-functioning students. Low-functioning students with ASD often have below-average intellectual functioning, and they exhibit severe difficulties due to ASD. Many low-functioning students may be nonverbal. Defining ASD The Diagnostic and Statistical Manual (DSM) defines disorders and disabilities to help professionals diagnose their patients. The fifth version, DSM-5, published in 2013 by the American Psychiatric Association, places the diagnostic labels of autistic disorder, Asperger’s disorder, PDD-NOS, and CDD under the umbrella term ASD. Individuals with ASD are categorized into levels—Level 1, Level 2, or Level 3—based on their challenges with communication, social skills, and repetitive behaviors. Because this categorization system is new and the old labels will still be used for a while, this discussion begins with a description of the older labels for these disorders so you can understand some of the differences between those and the newly described levels of ASD. Figure 9.1 shows the categories under the previous edition of the DSM-IV, which you will probably encounter for several years to come. Note that in the past, Rett’s disorder was classified under ASD; however, it is now not mentioned in conjunction with ASD. In DSM-5, Rett’s is considered a separate disorder from ASD (although some students with Rett’s will still qualify for services if their behavioral characteristics indicate an autism diagnosis, as well). pow85736_09_c09_311-354.indd 313 5/7/13 8:17 AM CHAPTER 9 Section 9.1  What Is Autism Spectrum Disorder? Figure 9.1: ASD Under DSM-IV Under the DSM-IV, five disorders fall under the umbrella category of ASD. The disorders are listed from the more severe (on the left) to the less severe (on the right). Many in the ASD community describe students with ASD on a spectrum like the one here, sometimes adding the descriptors “low-functioning” or “high-functioning.” The proposed three levels of the DSM-5 will describe low-functioning as “Level 3,” high-functioning as “Level 1,” and a middle range as “Level 2.” Autism Spectrum Disorders (Pervasive Developmental Disorders) Rett’s Disorder Childhood Disintegrative Disorder Autistic Disorder PDD - Not Otherwise Specified Asperger’s Disorder Source: Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (Copyright 2000). American Psychiatric Association. Autistic disorder, also called autism, is a category that describes students who have severe difficulty with communication and social skills. Most individuals with autism avoid eye contact and have difficulty recognizing faces and reading emotions. They often have below-average intellectual skills, which may appear similar to an intellectual disability. Some students have limited or nonexistent verbal skills. Students with autism may be preoccupied with one or two topics (Willis, 2012). They may also exhibit rituals or behavioral routines (e.g., placing toys in order) that border on compulsive. Most students with autism display repetitive, stereotypic behaviors, such as hand flapping or finger popping (Willis, 2012). Many have or will develop seizures during their lifetime. Students with Asperger’s disorder typically have average to above-average intelligence. They exhibit typical characteristics of autism (i.e., lack of eye contact, not responding to the calling of their name) when they are toddlers and in preschool, but they gain social and communication skills as they age (Willis, 2012). Students with Asperger’s, however, still continue to exhibit some atypical communication and social skills throughout life. One of the hallmarks of Asperger’s is an exceptional or obsessive interest in one area. For example, a student may have an unusual fascination with trains or outer space. Students typically have difficulty with social skills, and they can be clumsy and uncoordinated. Many people describe Asperger’s as a high-functioning version of autism. Pervasive developmental disorder not otherwise specified (PDD-NOS) falls between Asperger’s and autistic disorder in severity and is typically diagnosed later than either one. Students exhibit characteristics of autistic disorder (e.g., atypical communication and social skills), but they do not qualify as autistic because they do not exhibit repetitive behaviors as severe as students with autistic disorder (Willis, 2012). Because PDD-NOS is a gray area, professionals use this catch-all category to categorize students who do not qualify under Asperger’s disorder or autistic disorder (Chlebowski, Green, Barton, & Fein, 2010). Rett’s disorder is a very rare degenerative syndrome that affects girls exclusively (Willis, 2012). They usually exhibit typical development until pow85736_09_c09_311-354.indd 314 5/7/13 8:18 AM Section 9.1  What Is Autism Spectrum Disorder? CHAPTER 9 6–18 months of age. At that time, communication and social skills decrease, and the girls have problems with coordination. Many experience seizures. Therapy can help them recover some of their communication and motor skills. Childhood disintegrative disorder (CDD), or Heller’s syndrome, is very uncommon (Willis, 2012). Like girls with Rett’s, children with CDD develop normally at first. When they are 2–4 years old, their communication and social skills decrease, as does intellectual functioning. Students become severely impaired, and therapy cannot help them recover. CDD develops more often in boys than in girls. Andy Cross/Contributor/Denver Post/Denver Post via Getty Images In the DSM-5, Rett’s disorder is not associated with ASD. While the characteristics of Rett’s disorder are similar to ASD, researchers believe that it is a neurological disorder that does not classify for inclusion in a psychological manual. ASD and IDEA Autism became an IDEA disability category with the reauthorization of IDEA in 1990. IDEA 2004 defines autism as a developmental disability in which a child has problems communicating, verbally and nonverbally, to a degree that affects academic performance. It states that these communicative and social difficulties usually arise before the age of 3 years, and are often accompanied by repetitive movements or behaviors, resistance to change, and atypical responses to sensory experiences. The IDEA definition specifically excludes those children whose performance in school is hindered primarily by an emotional disorder, though it does allow for an autism diagnosis to be made in children older than 3 years. Thus, the IDEA 2004 definition uses the term autism to describe the full spectrum of autism disorders, which the DSM-IV and DSM-5 (and this chapter) refer to as ASD. It remains to be seen to what degree girls with Rett’s disorder will be eligible for IDEA 2004 services, and how their disability will be categorized, once the DSM-5 becomes the predominant diagnostic guideline. Prevalence of ASD Approximately 1% of school-age students are diagnosed with ASD; approximately 45% of those have autistic disorder, 45% have PDD-NOS, and 10% have Asperger’s disorder. CDD and Rett’s are extremely rare (Autism and Developmental Disabilities Monitoring Network, 2012). Boys are identified about five times more often than girls, but identification of ASD occurs equally in all racial and socioeconomic groups (Goldstein et al., 2012). Currently, about 1 in every 54 boys is diagnosed with ASD; for girls, it is 1 in 252 (Autism and Developmental Disabilities Monitoring Network, 2012). pow85736_09_c09_311-354.indd 315 5/7/13 8:18 AM Section 9.2  How Has the ASD Field Evolved? CHAPTER 9 The rate of students identified with ASD has increased over the last few decades (Kopetz & Endowed, 2012). One reason is that with the reauthorization of IDEA in 1990, autism gained its own disability category. Before then, many students with ASD were categorized as having an intellectual disability (ID). Medical and school professionals, as well as parents and guardians, are also more aware of ASD and may be better equipped to refer students for evaluation. Assessments have also been refined to better identify students with ASD. From My Perspective: Working With Students With ASD Hi! I’m Lauren, and working with students with autism is the most exciting, creative, rewarding, and thought-provoking job I’ve ever had. Every day is different, yet I try to keep things the same so there is consistency and routine. I have quickly learned that it’s important to be able to consider the ways in which a child’s sensory, cognitive, behavior, communication, and social needs interact simultaneously. And so begins the dance. The dance requires careful planning and always being one step ahead. At first, your timing may be off or you feel clumsy and slow. Soon, you get into the routine and you know the steps. The music might change, but you change along with it. The secret to dancing is Top Photo Group/Thinkstock to let go and have fun. Through repetitions and modeling, students start to develop meaningful communication. With reinforcement and shaping, their behavior improves. Through structured teaching and opportunities to interact with their peers, they begin to recognize others and make social connections. Your ability to dance has a meaningful and lasting impact on your students, as well as their families and the community. 9.2  How Has the ASD Field Evolved? P aul Eugen Bleuler first coined the term autism in 1910, from the Greek word for “self,” to describe a disorder exhibited by his patients, who had been diagnosed with schizophrenia, who had atypical social and communication skills (Crespi, 2010). His patients with autism isolated themselves from others and had interests that bordered on obsessive. Bleuler himself felt he had many characteristics of his autistic patients. Over the new few decades, other professionals used autism to describe the disorder of students with atypical social and communication skills. Hans Asperger, a doctor in Austria, wrote about his patients who had “autistic psychopathy.” These boys lacked feelings for others, had difficulty forming friendships, and exhibited intense interests in one topic area—characteristics of what is now called Asperger’s disorder. Dr. Asperger described these boys as “little professors” because they could talk forever and in great detail about their special topic area. pow85736_09_c09_311-354.indd 316 5/7/13 8:18 AM Section 9.3  What Are the Characteristics of Students With ASD? CHAPTER 9 Another Austrian doctor, Leo Kanner, studied children who exhibited characteristics related to autism at Johns Hopkins Hospital in Baltimore, Maryland. He described children who wanted things in their lives to be consistent and unchanging and who had difficulty fitting in with other children. His 1943 Autistic Disturbances of Affective Contact laid the groundwork for the modern study of ASD. In this paper, Kanner described 11 students who demonstrated repetitive behaviors and atypical social skills. The condition that Kanner described was different from that of students with ID. Autism was not recognized as a distinct condition until the middle of the 20th century, when researchers recognized autism was distinct from other disabilities. Until then, it was typically described as an intellectual disability or as schizophrenia. Largely because of the writings of Kanner and psychologist Bruno Bettelheim, autism was blamed on parents—especially mothers—who were distant and cold. That idea, which has been proven incorrect, persisted through the 1960s and 1970s in the public view about autism. Copyright Bettmann/Corbis/AP Images Dr. Bleuler, a psychiatrist in Switzerland in the late 1800s and early 1900s, coined the term autism to describe patients who exhibited unusual social and communication behaviors. Students with autism have undergone some controversial techniques to “fix” their autism over the years. In the 1960s and 1970s, some professionals used shock treatments or LSD to try to alter behavior. During the 1980s and 1990s, applied behavioral analysis became the standard method for treating and working with students with autism. Section 9.7 of this chapter discusses this behavior therapy. As researchers gained understanding of how autism manifested differently from child to child, the “spectrum” of autism was developed in the 1990s to describe students with a range of difficulties in communication, social skills, and repetitive behaviors—what is now called ASD. 9.3  What Are the Characteristics of Students With ASD? N o two students with ASD exhibit the exact same characteristics. In addition to the hallmark symptoms that determine their diagnosis, students may also exhibit characteristics related to academic skill in the classroom, physical appearance, or actions. And as with almost all disabilities, students with ASD may experience comorbid disabilities that cause additional issues. pow85736_09_c09_311-354.indd 317 5/7/13 8:18 AM Section 9.3  What Are the Characteristics of Students With ASD? CHAPTER 9 Hallmark Characteristics Although the characteristics of ASD vary from individual to individual, there are three hallmarks—necessary characteristics—of ASD: (1) difficulties with communication, (2) difficulties with social skills, and (3) repetitive or obsessive behaviors. Many of these characteristics appear at a very early age. For example, parents may say that their babies avoided eye contact or focused on one object for an extraordinary amount of time. Keep in mind that no child exhibits every one of the following characteristics, however (Arora, 2012; Kirchner et al., 2011; Moruzzi, Ogliari, Ronald, Happé, & Battaglia, 2011). Difficulties With Communication Students with ASD must exhibit some characteristics related to communication, as outlined in Table 9.1. Often, students understand what they want to communicate, but the means of communication are atypical. Many of the communication difficulties are typical for young children learning to speak and communicate, but when these difficulties persist past 3–4 years of age, parents or teachers may want to refer the student for a formal evaluation. Table 9.1 Difficulties with Communication Behavior Example Makes verbal sounds when listening. “um” Misuses Pronouns. “me like dogs” instead of “I like dogs” Repeats words or phrases. “Red balloon! Red balloon! Red balloon!” Speaks in short sentences. “Want pizza.” Speaks with unusual pitch or rhythm to voice. Speaks in a robot voice. Struggles to whisper. Speaks loudly into someone’s ear. Struggles with understanding directional items. Mistakes “top” for “bottom.” Talks too loudly or quietly. Uses normal voice when in movie theatre. Uses a person’s name excessively. “Ms. Ellis, I need a pencil. Ms. Ellis. Ms. Ellis.” Sources: Bölte, Westerwald, Holtmann, Freitag, & Poustka, 2011; Bolton, Golding, Emond, & Steer, 2012; Chiang & Carter, 2008. Difficulties With Social Skills Students must also demonstrate difficulty with social skills to be diagnosed with ASD. Many of the characteristics related to social skills as highlighted in Table 9.2 cause the student to appear aloof or immature for their age, while some (e.g., intense interest in one topic) make the student appear well. pow85736_09_c09_311-354.indd 318 5/7/13 8:18 AM Section 9.3  What Are the Characteristics of Students With ASD? CHAPTER 9 Table 9.2: Social Skills Characteristics Behavior Example Avoids answering questions about themselves. Parent: “Rob, do you like your new shirt?” Student: “When do we get to play outside?” Blurts out. “I want that!” Cannot understand the feelings of others/lacks empathy. Hits girl and doesn’t understand why she is crying. Displays a lack of personal space. Gets very close to person’s face when talking. Does not start social interaction. Plays alone, without engaging other students. Failure to respond when name is called. Parent: “Maya, will you come brush your teeth? Maya? Maya?” Student: Does not look in the parent’s direction. Maintains little or no eye contact. Looks down or around when talking to someone. Makes honest observations that are inappropriate. “Your hair looks messy.” “You smell.” Resistance to holding or touching. Does not like hugs. Struggles with interpreting facial expressions. Does not understand that a frown means unhappy. Struggles with understanding jokes or sarcasm. “This story will have you rolling on the floor with laughter!” Talks a lot about one topic. “Tornadoes are dangerous and can kill people. I just read a book about tornadoes. There was an EF-4 in Oklahoma last spring. Have you seen a tornado before?” Trusts others too much. Interacts with strangers when inappropriate. Sources: DeMatteo, Arter, Sworen-Parise, Faseiana, & Paulhamus, 2012; Lyons; Cappadocia, Weiss, 2011. Repetitive or Stereotypic Behaviors Students with ASD must also exhibit some characteristics related to repetitive or stereotypic behaviors (Table 9.3). Stereotypic behaviors are those behaviors that are repetitive and interfere with normal activity (Cunningham & Schreibman, 2008; Ghanizadeh, 2010; Goldman et al., 2008; Lanovaz & Sladeczek, 2012). Students may constantly rock back and forth or repeat a word or phrase. Some behaviors are harmless, but others can be dangerous to the student. A few of these characteristics may be similar to characteristics of ID (e.g., difficulty with motor skills) or EBD (e.g., obsessive behavior), but the characteristics may be due to ASD when the student also has difficulty with communication and social skills. pow85736_09_c09_311-354.indd 319 5/7/13 8:18 AM Section 9.3  What Are the Characteristics of Students With ASD? CHAPTER 9 Table 9.3: Repetitive or Stereotypic Behaviors Behavior Example Clumsy. Trips. Walks into things. Collects things. Picks up every orange leaf on the playground and at the park. Difficulty with gross- and fine-motor skills. Struggles to catch ball. Has hard time gripping pencil. Forms strange attachments to things. “I can’t go to school without my rabbit foot!” Has a ritual or compulsive behavior (stereotypy). Opens and closes mouth. Licks. Hums. Flaps arms. Rocks back and forth. Sucks. Rubs. Sniffs. Twirls. Jumps. Covers ears. Arches back. Injures self. Bites arm. Cuts skin. Bangs head against wall. Quotes movies, games, or books. “You shall not pass! You shall not pass!” Participates in repetitive play. Rolls a car around on the floor hundreds of times. Sources: Cunningham & Schreibman, 2008; Ghanizadeh, 2010; Goldman et al., 2008; Lanovaz & Sladeczek, 2012. Academic Characteristics Some students with ASD perform well in academic subjects, whereas others struggle in school (Oliveras-Rentas, Kenworthy, Roberson, Martin, & Wallace, 2012). Typically, students with high-functioning ASD perform better with academic tasks than students with low-functioning ASD, but almost all students with ASD require accommodations or modifications in the classroom (Estes, Rivera, Bryan, Cali, & Dawson, 2011). Researchers believe students with ASD may experience difficulty because they have weak theory of mind, weak central coherence, or impaired executive function (Constable, Grossi, Moniz, & Ryan, 2013; Harris et al., 2008). Students who have weak theory of mind have difficulty understanding the feelings and thoughts of others. When central coherence is weak, students process information in small pieces instead of understanding the bigger picture. If students have impaired executive functioning, then planning and paying attention, as well as accessing information from working memory, may be difficult. All three of these types of difficulties may contribute to obstacles with learning in the classroom. Some students demonstrate exceptional ability in music or art, and others need help with fine-motor skills, such as coloring a picture and cutting with scissors (Vital, Ronald, Wallace, & Happe, 2009). Some students with ASD demonstrate exceptional skill with remembering dates or being able to compute large numbers (Iavarone, Patruno, Galeone, Chieffi, & Carlomagno, 2007). This exceptional talent, however, is very rare in students with ASD, even though this skill has been highlighted in popular media. pow85736_09_c09_311-354.indd 320 5/7/13 8:18 AM Section 9.4  What Are the Causes of ASD? CHAPTER 9 Most students with ASD have trouble dealing with changes in the school routine. For example, if a student knows that Wednesday is the day for physical education and suddenly the class is attending an assembly instead, the student may struggle with the change by refusing to participate or throwing a tantrum. Similarly, students with ASD tend to have difficulty with transitions from one activity or class to another. Physical Characteristics Many students with ASD exhibit atypical physical movement. They may have unusual posture, walk on their toes, or experience clumsiness. They may not swing their arms normally when walking; they may often walk or run into stationary objects or other people. Students with ASD often have bowel and bladder difficulties. They may have abnormal amounts of burping and passing gas, and they may also have food allergies or sensitivities. In addition, they may have difficulty sleeping. Comorbidity With Other Disabilities Students with ASD may also have other conditions, such as Fragile X syndrome, ID, ADHD, bipolar disorder, OCD, or Tourette syndrome (Grzadzinski et al., 2011; Leyfer et al., 2006). They may have seizures; approximately 30% of students with ASD develop epilepsy by adulthood. Students may have visual impairments as well. 9.4  What Are the Causes of ASD? T here is no one cause for ASD. Researchers believe heredity and environmental factors contribute (Dietert, Dietert, & Dewitt, 2011), but many risk factors remain unidentified. The Role of Heredity Researchers have discovered specific genes associated with ASD (Walsh, Elsabbagh, Bolton, & Singh, 2011). No one gene can be said to cause ASD, but there are studies that support the role of heredity. In sets of identical twins, up to 90% of twins both struggle with ASD if one twin does (Rutter, 2011). If a non-twin sibling has ASD, there is a 5–7% chance that another sibling will have ASD (Dodds et al., 2011). pow85736_09_c09_311-354.indd 321 5/7/13 8:18 AM CHAPTER 9 Section 9.4  What Are the Causes of ASD? The Role of the Brain Blend Images/SuperStock Studies comparing the brain characteristics and functions of students with and without ASD point to differences between the groups, but more research is needed to help understand how these brain differences contribute to ASD. As researchers learn more about the brain, teachers and medical professionals may also discover more effective ways to treat and teach students with ASD. also differs, with students with ASD having a thicker cortex Keshavan, Minshew, & Hardan, 2012). Students with ASD also demonstrate characteristic brain differences compared to students without ASD (Gotts et al., 2012; Mak-Fan, Taylor, Roberts, & Lerch, 2012). Often, students with ASD have larger heads and larger brains than average (Zielinski et al., 2012), and their brains are different in other ways, as well. For example, Jou et al. (2011) determined that students with ASD may have neural passages that do not connect in a typical manner. McAlonan et al., (2008) demonstrated that students with ASD have atypical grey matter areas compared to students without ASD. Grey matter is the area in the brain where neurons that control information are located. The thickness of the brain’s cortex than students without ASD (Frazier, The Role of the Environment A wide variety of environmental factors have been suggested as possible causes of ASD, but none of them has been verified (Dodds et al., 2011). A mother’s infection or complications before or during birth may contribute to ASD. Some medications taken by pregnant women may also contribute. Siblings who are born less than a year apart have a greater chance of having ASD. Some researchers have pointed out that both mothers and fathers who have children at a later age tend to have more children with ASD (Eriksson, Westerlund, Anderlid, Gillberg, & Fernell, 2012). Mothers who take prenatal vitamins, specifically vitamins with folic acid, before getting pregnant have a lower chance of having a child with ASD (Surén et al., 2013). In addition, students with ASD typically show different vitamin levels (especially vitamin D) than students without ASD (Adams et al., 2011), and the severity of ASD is related to these vitamin levels in the body (Mostafa & Al-Ayadhi, 2012). Other environmental factors may include exposure to pesticides, other chemicals, and some plastics (Shelton, Hertz-Picciotto, & Pessah, 2012). Over the last decade or so, various other environmental causes of ASD, including diets and vaccinations, have garnered extensive media attention. Some parents believe food allergies to gluten or casein trigger or enhance some of the behaviors associated with ASD. Thus, they may put their children on gluten-free and/or casein-free diets. (Gluten is found in wheat and barley products, pow85736_09_c09_311-354.indd 322 5/7/13 8:19 AM CHAPTER 9 Section 9.5  How Are Students Diagnosed With ASD? and casein is found in dairy products.) While parents may claim that they see improvement when their children are on these diets, research has not determined whether the diets are effective (Mulloy et al., 2010). Many parents of children with ASD believe that their children were developing normally until they received vaccinations at about 2 years of age. The argument that vaccines, specifically the measles-mumps-rubella (MMR) vaccine, were a cause of ASD gained international attention in 1998 when Dr. Andrew Wakefield and colleagues published a paper claiming a link between the MMR vaccine and ASD (Wakefield et al., 1998). This paper has now been discredited because of Wakefield’s falsification of study results. Parents tried to use the court system to sue vaccine makers for causing ASD, but no lawsuits were successful (Keelan & Wilson, 2011; Kirkland, 2012). By 2001, vaccine makers had removed thimerosal, a preservative containing mercury, from all vaccines, but thimerosal has never been proven as a cause for ASD either (Miller & Reynolds, 2009). Research has shown no direct link between vaccinations and ASD (DeStefano, Bhasin, Thompson, Yeargin-Allsopp, & Boyle, 2004; Hornig et al., 2008; Price et al., 2010). iStockphoto/Thinkstock Many parents have worried about the possibility of vaccines causing ASD, and some elected to not vaccinate their children in the 1990s and 2000s. The decrease in vaccinated children led to a slight increase in children with diseases, such as measles, that had almost been eradicated. 9.5  How Are Students Diagnosed With ASD? T he diagnosis of ASD is typically made when a child is between 2 and 4 years of age, before beginning school (Chlebowski, Green, Barton, & Fein, 2010). Often parents notice unusual behaviors or developmental patterns in their child and talk to their medical doctor. Physicians, psychiatrists, or other trained medical personnel make the diagnosis for ASD, but schools will evaluate students to determine whether they qualify for services under IDEA 2004. Some early indicators of ASD are listed in Table 9.4. Table 9.4: Early Indicators of ASD Early Indicators of ASD (ages 1–3) Later Indicators of ASD (ages 4–8) No babbling or pointing by age 1. Inability to make friends. No single words by 16 months. Impaired ability to start or sustain a conversation. No two-word phrases by age 2. Absence of, or impairment in, play. No response to name. Stereotyped or repetitive use of language. (continued) pow85736_09_c09_311-354.indd 323 5/7/13 8:19 AM CHAPTER 9 Section 9.5  How Are Students Diagnosed With ASD? Table 9.4: Early Indicators of ASD (continued) Early Indicators of ASD (ages 1–3) Later Indicators of ASD (ages 4–8) Loss of language or social skills. Restricted patterns of interest. Poor eye contact. Preoccupation with certain objects or subjects. Excessive lining up of toys or objects. Inflexibility with routines and rituals. No smiling. Source: National Institute of Neurological Disorders and Stroke, 2009. If parents, caregivers, or teachers notice some of these characteristics on a consistent basis, the student should be referred for an initial evaluation to a professional, such as a pediatrician or family physician. Many places also have clinics specializing in the identification and treatment of students with ASD. Parents may be referred to these clinics for evaluation. It is important to note that a medical diagnosis of ASD may differ from a school diagnosis of ASD. Although uncommon, it is possible for a school to not recognize a student as ASD if the student does not fulfill the criteria for autism under IDEA 2004 guidelines. If a student’s educational performance is not affected by ASD, then a school may not be able to diagnose the student as such. A survey or screening instrument is used to evaluate the child (Bölte et al., 2011; Chlebowski et al., 2010; Flose, Plotts, Kozeneski, & Skinner-Foster, 2011; Mayes et al., 2009). Some examples of instruments include: • • • • • • • • • • Ages and Stages Questionnaire (ASQ) Childhood Autism Rating Scale (CARS) Autism Diagnostic Observation Schedule (ADOS) Communication and Symbolic Behavior Scales (CSBS) (shown in Figure 9.2) Gilliam Autism Rating Scale (GARS) Parents’ Evaluation of Developmental Status (PEDS) Modified Checklist for Autism in Toddlers (MCHAT) Social and Communication Disorders Checklist (SCDC) Social Responsiveness Scale (SRS) Screening Tool for Autism in Toddlers and Young Children (STAT) A comprehensive evaluation should include information from parents, teachers (if possible), and a medical professional (Bölte et al., 2011). Others who might help with the evaluation include a psychiatrist, psychologist, speech therapist, occupational therapist, ASD specialist, or neurologist. pow85736_09_c09_311-354.indd 324 5/7/13 8:19 AM CHAPTER 9 Section 9.5  How Are Students Diagnosed With ASD? Figure 9.2: ASD Checklist The Communication and Symbolic Behavior Scales (CSBS) checklist is used to assess communication skills and social skills of young students (ages 2–4) who are suspected of having ASD. If the parent answers “not yet” to many of the questions, the child should undergo a formal evaluation for ASD. CSBS DP Infant-Toddler Checklist Child’s name: Was birth premature? Filled out by: Date of birth: If yes, how many weeks premature? Relationship to child: Date filled out: Instructions for caregivers: This Checklist is designed to identify different aspects of development in infants and toddlers. Many behaviors that develop before children talk may indicate whether or not a child will have difficulty learning to talk. This Checklist should be completed by a caregiver when the child is between 6 and 24 months of age to determine whether a referral for an evaluation is needed. The caregiver may be either a parent or another person who nurtures the child daily. Please check all the choices that best describe your child’s behavior. If you are not sure, please choose the closest response based on your experience. Children at your child’s age are not necessarily expected to use all the behaviors listed. Emotion and Eye Gaze 1. Do you know when your child is happy and when your child is upset? Not Yet Sometimes Often 2. When your child plays with toys, does he/she look at you to see if you are watching? Not Yet Sometimes Often 3. Does your child smile or laugh while looking at you? Not Yet Sometimes Often 4. When you look at and point to a toy across the room, does your child look at it? Not Yet Sometimes Often Communication 5. Does your child let you know that he/she needs help or wants an object out of reach? Not Yet Sometimes Often 6. When you are not paying attention to your child, does he/she try to get your attention? Not Yet Sometimes Often 7. Does your child do things just to get you to laugh? Not Yet Sometimes Often 8. Does your child try to get you to notice interesting objects—just to get you to look Not Yet Sometimes Often at the objects, not to get you to do anything with them? Gestures 9. Does your child pick up objects and give them to you? Not Yet Sometimes Often 10. Does your child show objects to you without giving you the object? Not Yet Sometimes Often 11. Does your child wave to greet people? Not Yet Sometimes Often 12. Does your child point to objects? Not Yet Sometimes Often Not Yet Sometimes Often 13. Does your child nod his/her head to indicate yes? Sounds 14. Does your child use sounds or words to get attention or help? Not Yet Sometimes Often 15. Does your child string sounds together, such as uh oh, mama, gaga, bye bye, bada? Not Yet Sometimes Often 16. About how many of the following consonant sounds does your child use: ma, na, ba, da, ga, wa, la, ya, sa, sha? None 1–2 3–4 5–8 Over 8 Words 17. About how many different words does your child use meaningfully that you recognize (such as baba for bottle; gaggie for doggie)? None 1–2 3–4 5–8 Over 8 18. Does your child put two words together (for example, more cookie, bye bye Daddy)? Not Yet Sometimes Often Understanding 19. When you call your child’s name, does he/she respond by looking or turning toward you? Not Yet Sometimes Often 20. About how many different words or phrases does your child understand without gestures? For example, if you say “where’s your tummy,” “where’s Daddy,” “give me the ball,” or “come here,” without showing or pointing, your child will respond appropriately. None 1–2 3–4 5–8 Over 8 Object Use 21. Does your child show interest in playing with a variety of objects? Not Yet Sometimes Often 22. About how many of the following objects does your child use appropriately: cup, bottle, bowl, spoon, comb or brush, toothbrush, washcloth, ball, toy vehicle, toy telephone? None 1–2 3–4 5–8 Over 8 23. About how many blocks (or rings) does your child stack? Stacks: None 2 blocks 3–4 blocks 5 or more 24. Does your child pretend to play with toys (for example, feed a stuffed animal, put a doll to sleep, put an animal figure in a vehicle)? Not Yet Sometimes Often Do you have any concerns about your child’s development? Yes No If yes, please describe on back Source: Amy M. Wetherby & Barry M. Prizant © 2002 by Paul H. Brookes Publishing Co., Inc. All rights reserved. For ordering information on all components of the CSBS DP, visit http://www.brookespublishing.com/resource-center/screening-and-assessment/csbs/csbs-dp/csbs-dp-itc/. Reprinted by permission of Paul H. Brookes Publishing Co., Inc. pow85736_09_c09_311-354.indd 325 5/7/13 8:19 AM Section 9.6  How Does ASD Differ Across Grade Levels? CHAPTER 9 9.6  How Does ASD Differ Across Grade Levels? W hen students with ASD receive early and intensive intervention, outcomes are greatly improved. To keep up the positive gains, schools should work on developing programs and appropriate teacher training at all levels for students with ASD. In this section, you will learn how students with ASD receive services throughout early childhood, elementary, and secondary school settings. Early Childhood Once an ASD diagnosis is made, it is important that a plan be put in place so the student can receive important services. This will be an Individualized Family Service Plan (IFSP) if the child is younger than 3 years and covered under Part C of IDEA 2004. If the student has turned 3 (and is not yet 22 years old), an Individualized Education Plan (IEP) is created under Part B. Because students with ASD struggle with communication and language, early special education services and academic/social interventions should be employed to help improve these skills as soon as possible. Early childhood services focus heavily on developmental skills, such as language and social interactions. Students may receive services either from certified behavior analysts or speech therapists, or from general school-ready providers, such as Head Start. Involving families and parents in interventions improves outcomes for the students (Wong & Kwan, 2010). Sometimes early intervention takes place in a school setting. Families who do not live in an area with a school option, however, may have to take their children to clinics or hospitals to meet with speech therapists or ASD specialists. Preschool and early intervention programs focus on teaching communication and social skills. Teachers provide a good deal of instruction and practice on relating to, and working with, other students and adults. Teachers also work with young students to help them understand what schedules are and how to follow them. Classrooms should be structured and organized, and students with ASD should learn to work within the classroom schedule. . Gaetano/CORBIS Many parents notice atypical characteristics in their child, but preschool teachers need to also be aware of students with difficulties with communication, social skills, or repetitive behaviors. Students who have difficulty interacting with other students and adults and those who cannot communicate their thoughts and ideas may need to be referred for evaluation. pow85736_09_c09_311-354.indd 326 Working on basic academic skills, such as writing letters and learning numbers, should be a goal of preschool programs if it is appropriate for the student. Behavior therapy led by certified behavior analysts might also be appropriate for young students with ASD (see the feature box in Section 9.7 for a discussion of this type of therapy). Above all, teachers should create an inviting classroom environment where the student feels like a classroom member. 5/7/13 8:19 AM Section 9.6  How Does ASD Differ Across Grade Levels? CHAPTER 9 As will be discussed later in the chapter, technology can help young students with ASD communicate. Some students with ASD do not talk, but they can share their wants and needs with technology that “speaks” for them. In one computer application, the student can press a picture and the computer voices the desire. For example, when students need a drink of water, they can press a picture of a water fountain to let the teacher know their need. Such communication can make meltdowns or tantrums less frequent. Students, teachers, and parents need to receive appropriate training with these, as with all, technologies. Elementary School Many of the preschool skills (i.e. taking turns, asking for help, talking to peers) taught to students with ASD should continue into elementary school. When schools know that a student with ASD is starting kindergarten, they should ensure that school staff and parents work together to develop an IEP for the student before the school year begins to ensure that the student receives appropriate services from the start of formal schooling. Many of the accommodations and modifications listed in Chapter 2 are common for students with ASD. Districts should ensure that teachers and others who work with students with ASD receive proper training on teaching academics and behavior to students with ASD. If a student has not attended school before kindergarten, teachers will have to work more on social skills, especially skills in relating to other students and adults. In fact, schools may evaluate all students in terms of behavior and social skills to develop the best individualized program for each student. A good elementary classroom for students with ASD is organized and structured. Depending on the students’ IEPs and school settings, students with ASD may receive instruction in a self-contained special education classroom, the general education classroom, or a combination of both. Regardless of setting, teachers should create a meaningful curriculum for the entire class and tailor activities for students with ASD. Teachers must develop cohesive behavior management plans for the classroom. Many teachers consult with behavior specialists or special education teachers to work on eliminating or reducing problem behaviors in the classroom. An important part of any behavior plan involves communication. Young students with ASD need to have a system of communication with their teachers, so that they can express themselves and understand teacher instructions at all times—including when they are upset. Picture cards and sign language are two good communication options, as are technologies like a DynaVox or an iPad. These tools can also be helpful in teaching academics and social skills, in addition to behavior. Secondary School Secondary school students with ASD often spend much of their time in a general education classroom, as other placement options may not exist. Explicit instruction in academic and social skills, as mentioned in the elementary section, is appropriate for secondary students. Specific teaching pow85736_09_c09_311-354.indd 327 5/7/13 8:19 AM Section 9.7  How Do I Teach Students With ASD? CHAPTER 9 strategies are covered in Section 9.7. Many secondary students have difficulty making and maintaining friendships, so working on communication between peers can benefit students with ASD. For secondary students, it is vital that the IEP team and the student begin to think about transition and post-secondary options (Schall & McDonough, 2010). Transition Some students with ASD plan to go to college or into the workplace after secondary school. Others may move to a community/group home for individuals with disabilities or live with relatives who can provide necessary care. Regardless of the post-secondary choice, transition plans need to be in place by age 15. Continued work on social skills will help students develop appropriate competencies in college or the work environment (DeMatteo et al., 2012). Social skills instruction and practice should occur in the projected setting whenever possible (i.e. on the college campus, at a workplace). For example, students with ASD may need help in learning how to live with roommates or how to call a supervisor if they are too sick to report to work. 9.7  How Do I Teach Students With ASD? B ased on the severity of their disability, students with ASD spend varying amounts of time in the general classroom (Figure 9.3). Approximately half of students with Asperger’s disorder spend their entire school day in the general classroom. They may have appropriate accommodations (e.g., use of picture schedule, breaking activities and assignments into smaller chunks) and modifications (e.g., allowing student to write an essay about their favorite topic instead of an assigned topic), but their school day is spent with peers without disabilities. A small percentage of students with Asperger’s spend their entire school day in a self-contained setting. About one-quarter of students with PDD-NOS and only 15% of students with autism spend their entire school day in the general classroom. One of the major reasons the DSM-5 renames the ASD categories is to describe student needs in terms of levels (i.e., Level 1, Level 2, and Level 3) that can help teachers and schools provide appropriate placements for students. Schools are not using this level system yet, but they may be switching over in the next few years. Level 1 students with ASD require support but will likely spend most of the school day in the general classroom. Level 2 students need substantial support, and these students may spend some time in the general classroom. Level 3 students require extensive support, which means these students will likely spend most of their time in specialized classrooms or schools. As with all disability decisions, the IEP team will make placement decisions based on the individual student’s needs and not based on a disability category or level number. pow85736_09_c09_311-354.indd 328 5/7/13 8:19 AM CHAPTER 9 Section 9.7  How Do I Teach Students With ASD? Figure 9.3: Placement Decisions for Students With ASD Students with high-functioning ASD are more likely to be placed in the general classroom than students with more severe ASD. High-functioning students possess better communication skills and social skills that enable these students to participate in activities alongside peers without ASD. Autism PDD-NOS Asperger 10% 14% 25% 31% 47% 45% 43% 41% 44% All regular education All special education Mixed regular/special education According to LRE policy, students with ASD should receive the majority of their academic and behavioral instruction in naturalistic settings as close to the general classroom setting as possible (Wolery & Hemmeter, 2011). In fact, most of the court cases involving schools, students, and families with ASD, as well as disagreements about IDEA, have involved disagreements about the placements of students (Hill, Martin, & Nelson-Head, 2011). Some school districts have developed separate ASD classrooms or schools that specialize in helping those students. These specialized programs, however, may not be inclusive because only students with ASD attend (Marks, 2007). In addition, the programs are less common for older than younger children (Figure 9.4). Many schools do not have the resources to best provide services to students with ASD, and many families and students experience challenges in accessing appropriate educational and behavioral services (Tincani, 2007). This is especially the case in more rural areas of the United States (Murphy & Ruble, 2012). All students with ASD should have highly qualified teachers who use evidence-based practices (Lerman, Vorndan, Addison, & Kuhn, 2004). Many of the teaching suggestions presented in previous chapters may benefit students with ASD. For students with high-functioning ASD, many of the strategies for students with SLD may prove helpful (Donaldson & Zager, 2010). For students with more severe ASD, teachers may want to adopt the teaching strategies for students with ID and EBD. Educators need to individualize instruction for all students with ASD, as for any disability, and detailed plans about instruction and the learning environment need to be written into the student’s IFSP or IEP (Guldberg, 2010). pow85736_09_c09_311-354.indd 329 5/7/13 8:19 AM CHAPTER 9 Section 9.7  How Do I Teach Students With ASD? Figure 9.4: Inclusion of Students With ASD at Various Grade Levels Students with ASD spend differing amounts of time in various settings based on grade level. Many schools have put preschool programs in place for young students with ASD. It is less likely that elementary and secondary schools have ASD programs, so students spend more time in the general classroom at those grade levels. PreK/K Elementary 19% 22% 26% Middle School 24% 29% High School 28% 31% 48% 33% 51% 47% 41% All regular education All special education Mixed regular/special education The following discussion covers both general teaching strategies for students with ASD and strategies for teaching academics and behavior in particular. General Teaching Strategies Teachers need to carefully choose the language and vocabulary they use in talking to students with ASD. They should communicate directions and expectations in language that is simple, unambiguous, and easy to understand, and avoid sarcasm, metaphors, and idioms, as these kinds of indirect expressions can confuse students with ASD. For example, the command “Zip your lips! Pretzel time!” is often used to get students to close their mouths, not talk, and sit cross-legged on the floor. Such word choice can be confusing to students with ASD, who often take the meanings of words literally. A teacher would be much better off saying, “Time to listen. No talking. Sit with your legs crossed.” As much as possible, the teacher should tightly organize and structure the classroom environment and schedule, which benefits not only students with ASD, but all students. Written or visual prompts (Figure 9.5) and reminders are important to help students understand the steps required to complete an assignment or the daily schedule of activities (Cuhadar & Diken, 2011). The teacher should try to provide as much warning as possible about an upcoming schedule change. For example, most schools participate in fire drills periodically. Teachers usually know when these drills are going to take place and can prepare students for the interruption. pow85736_09_c09_311-354.indd 330 5/7/13 8:20 AM Section 9.7  How Do I Teach Students With ASD? CHAPTER 9 Figure 9.5: Clean Desk Reminder Students with ASD may benefit from visual representations of concepts—in this case, a picture of a clean desk and workspace accompanied by. written reminders help students understand the expectations for an organized desk. Some students with ASD would do fine with the written reminders, while others need the ideas presented with pictures. 1. Books and notebooks under desk. 2. Pencil caddy under desk. 3. Scissors and glue under desk. 4. Name tag left alone. 5. Chair on top of desk. 6. No trash on the floor. Many students—especially students with ASD—have problems with the concept of time. A teacher’s request to “finish up your work in the next 2 minutes” can be confusing because a student may not understand whether 2 minutes is about the length of a snap, a commercial, or a movie. Setting a timer and placing it where the student can track the amount of time left before the teacher moves on to the next activity can help prepare the student and help with the transition to the next activity. Teachers should verify that students with ASD understand directions and assignments. Instead of asking, “Do you understand?” teachers should ask a student to repeat directions back to them to make sure the student understands. When students are working in the classroom, the teacher should frequently monitor student progress and provide appropriate feedback. Many students need help understanding what it means to finish or complete an activity or assignment. For example, students may wonder what a “finished” art project looks like: Is it only creating a dragon or does the background of the paper need to be colored in, too? Teachers can provide a picture of a finished project or a cleaned workspace so the student can use the picture for comparison. pow85736_09_c09_311-354.indd 331 5/7/13 8:20 AM Section 9.7  How Do I Teach Students With ASD? CHAPTER 9 Teachers often allow students to make choices about what they will read or how they will go about completing an assignment. For students with ASD, it is often best to whittle down choices to one or two viable options. For example, instead of asking a student to pick a book from the reading corner, the teacher could provide the student with two books and ask them to choose one. Choices for students with ASD may also extend to nonparticipation in activities. Within reason, teachers should decide when it is appropriate for a student to opt out of a certain activity. For example, a student with ASD may not enjoy playing a game in physical education that involves throwing balls. The teacher may create an alternative activity for that student. Music can help students understand mathematical concepts (such as fractions) and learn letters and states (e.g., “The ABC Song” and “The State Song”). For example, students can learn concepts of numerator and denominator by clapping to the first beat (out of 4) to demonstrate 1/4. Music can also improve the communication and speech skills of students with ASD by helping students become more comfortable with talking/singing with others (Reschke-Hernández, 2011). Students who have difficulty with speaking may find music an easier outlet for communicating ideas. pow85736_09_c09_311-354.indd 332 iStockphoto/Thinkstock Teachers can use sand timers to help students understand how much time is left before moving on to another activity or having all materials ready or put away. For students who have difficulty with math, sand timers eliminate the need for calculating how many minutes or seconds are left until the end of an activity. 5/7/13 8:20 AM Section 9.7  How Do I Teach Students With ASD? CHAPTER 9 Teaching Academics Many strategies can help students with ASD excel in the classroom. Often, activities need to be broken into smaller, more manageable steps for learning and practicing. Technology can be used to teach students new skills, and one use of it, video modeling, shows great potential in helping students with ASD. Task Analysis Breaking down tasks into steps, or task analysis, was discussed in Chapter 8 in the context of teaching students with ID. This strategy is useful in teaching both behaviors and academic tasks to students with ASD. A task analysis can be used to teach students how to add suffixes to words, how to water a plant, how to prepare their materials for the school day, or how to walk to the lunchroom. . Tony Kurdzuk/Star Ledger/Corbis Augmentative and alternative communication (AAC) devices help students with ASD communicate their wants and needs. This student is using his AAC to make a choice about what he wants to eat for lunch. After completing a task analysis by writing out the task step by step, the teacher needs to explicitly teach the student how to follow the steps to complete a task. For students with ASD, teachers may want to break a project into smaller chunks (e.g., complete the first three steps on Monday and the last three steps on Tuesday) to ensure that the student achieves success with the project. Teachers may provide students with a written or pictorial list of steps when appropriate. Technology Technology can greatly enhance the classroom experience and participation of students with ASD. If they have difficulty with handwriting because they have problems with fine motor skills, the use of computers or voice-activation software can help them with written responses. Students with ASD who are nonverbal or have limited verbal communication can use Augmentative and alternative communication (AAC) that provide answer choices or help students put together sentences using pictures. pow85736_09_c09_311-354.indd 333 5/7/13 8:21 AM Section 9.7  How Do I Teach Students With ASD? CHAPTER 9 Using Interest Areas Many students with ASD have an exceptional interest in one or two topic areas. The teacher can use this characteristic to advantage in teaching. For example, the teacher might present choices related to a student’s area of interest for activities like writing a persuasive essay or reading a book. A student who is fascinated by trains might write an essay about establishing a train museum or read a book about train engines. The teacher could include a few problems about train cargo when that student is solving multiplication word problems. While it is important that students with ASD not focus all of their time learning about their primary area of interest in school, teachers can play into these interest areas to engage these individuals and make academic work meaningful. Teaching Reading Many students with ASD struggle with the reading skills of decoding (i.e., understanding the connections between letter sounds and words), vocabulary, and comprehension (i.e., understanding the meaning of text) (Huemer & Mann, 2010; Saunders, Page, & Wood, 2011). Explicit instruction is the key to helping students improve reading skills (Chiang & Lin, 2007; Ganz & Flores, 2009). To provide explicit instruction, teachers model and provide many opportunities for practicing a skill. It is also important to use different types of media (e.g., computers, books, songs) to help students understand the connections between letters, sounds, words, and text. Students should be taught sight words as well (Spector, 2011). Sight words are words that appear frequently within text that students should know without decoding (e.g., the, because, always, and). To improve comprehension, teachers can use graphic organizers and instruction about the structure of text and stories. Teachers can show students how to find important information within the text and how to reread for understanding (Randi, Newman, & Grigorenko, 2010). For example, teachers may teach students how to identify the topic sentence in a paragraph and how to answer who, what, when, and where questions as the student reads or rereads. Computer programs can help improve speed of letter and sight-word recognition (Coleman-Martin, Heller, Cihak, & Irvine, 2005; Travers et al., 2011) and help with understanding of vocabulary (Moore & Calvert, 2000). One computer program to improve vocabulary is called an E-word wall (Narkon, Wells, & Segal, 2011). Using this program, students can read and hear a word, see a picture, and then read and hear a sentence using the vocabulary word that relates to the picture (Figure 9.6). The multiple ways of hearing and seeing the word help students with ASD ascribe meaning to the vocabulary and text. pow85736_09_c09_311-354.indd 334 5/7/13 8:21 AM CHAPTER 9 Section 9.7  How Do I Teach Students With ASD? Figure 9.6: E-word Wall In an e-word wall program, students learn words beginning with the letter C. Students can listen to the word, see a picture of the word, and see and hear the word used within a sentence. All these examples help provide concrete examples of the word and its meaning. c cat The cat is brown. c cut I cut the ribbon with scissors. c car My car is blue. c candy The boy is eating candy. c candle The candle is burning. c cup pow85736_09_c09_311-354.indd 335 Coffee is in the cup. 5/7/13 8:21 AM Section 9.7  How Do I Teach Students With ASD? CHAPTER 9 Explicit instruction in higher-order skills of reading comprehension is also effective. For example, the teacher can break down the steps for how to sequence a story, providing sentence starters for students to use when retelling—”in the beginning,” “then,” “at the end,”—and explaining how to use them. Then the teacher models the steps to read and retell a story the students find interesting. Throughout the story, the teacher gradually asks students for more input on the beginning, middle, and end, so that students will be ready to practice this skill on their own. The teacher provides appropriate and immediate feedback as students respond, and provides opportunities for students to practice the skill with gradually increasing independence. Teaching Writing Many students with ASD have difficulty with handwriting because they have problems with coordination. Additionally, some students have sensory difficulties that make the student resistant to touching or gripping objects like a pencil. Teachers can practice writing words, such as a student’s name, with the teacher’s hand guiding the student’s hand. Teachers can also prepare tracing activities for students to practice writing letters and words (as shown in Figure 9.7). Figure 9.7: Tracing Letters A student can practice writing letters by tracing the dots. Often, it is best to have students work on tracing one or two letters instead of the entire alphabet. For some students, teachers may not want to push handwriting with a traditional writing instrument. Instead, teachers can be creative and offer students writing instruction in a variety of mediums. Teachers may let students paint on an easel, use chalk on the sidewalk or chalkboard, or write with fat or skinny markers. Teachers may let students roll play dough into letters, write letters with shaving cream or pudding, or pick out magnetic letters. To improve higher order writing skills, such as writing a sentence or a paragraph, teachers should also use explicit instruction. To do this, teachers can demonstrate how to write a sentence with a subject and verb that agree or model learn how to write a paragraph with a topic sentence, three supporting sentences, and a concluding sentence. Self-regulation, which was discussed in Chapter 3, is a good strategy to use with students with ASD (and most other students). To self-regulate, pow85736_09_c09_311-354.indd 336 5/7/13 8:21 AM Section 9.7  How Do I Teach Students With ASD? CHAPTER 9 students learn a strategy for writing, and they also learn how to monitor their progress when working through the strategy. Students with ASD can also practice writing by using computer programs. One such program provides key words that students are to use to write their sentences or paragraphs (Pennington, Stenhoff, Gibson, & Ballou, 2012). Teaching Mathematics Teachers should use explicit instruction to teach important mathematics concepts and procedures (Donaldson & Zager, 2010). Teachers can provide multiple demonstrations for solving a mathematics problem, give the student multiple opportunities to practice with the teacher, and then allow the student to practice problems independently with teacher support. Using the concrete-representational-abstract (CRA) sequence can help students with ASD see the connections between concepts and procedures (Donaldson & Zager, 2010). At the concrete stage, students use manipulatives, such as Base-10 blocks, fraction tiles, or bear counters, to practice mathematical concepts (Cihak & Foust, 2008). At the representational stage, students solve problems with pictures of manipulatives or objects drawn on their paper. At the abstract stage, students solve a problem with numbers and symbols. The following is an example of CRA in action: • C: Student starts with 3 red bears. Student adds 4 blue bears. Student counts all bears: “1, 2, 3, 4, 5, 6, 7. 7 bears. 3 plus 4 equals 7.” • R: Student works on a worksheet with 3 bear pictures on one side of the paper and 4 bear pictures on the other side. Student is able to touch and count each bear: “1, 2, 3, 4, 5, 6, 7. 7 bears. 3 plus 4 equals 7.” • A: Student solves an equation written on paper: “3 + 4 = __.” Music can be used to help students remember number sequences or answers to basic facts. For example, students can learn a song to help them remember how to count from 1 to 20. Songs make remembering numbers and facts easier, just as the alphabet song does for letters. Mnemonics can help students remember how to regroup a multi-digit addition problem or how to divide fractions. For example, when dividing fractions, students learn to “copy, change, change”: copy the first fraction, change the sign from division to multiplication, change the original fraction to its inverse. Some teachers teach students to use numbers with dots that represent their amounts. (See TouchMath in Chapter 8.) By using the dots on each number, students can quickly add and subtract (Cihak & Foust, 2008). Teaching Behavioral Skills Many of the hallmark characteristics of ASD contribute to behavioral problems in the classroom. To address these, teachers can create lessons on relating to peers that are designed for all students in a class, including those with ASD; use video modeling to teach adaptive behavior; train all students, including those with ASD, to pair up for effective peer tutoring; or use computer-assisted instruction programs to help students learn to recognize faces and emotional cues that they do not usually notice, which can ease social strain and improve behavior. General and special education classrooms can also incorporate the assistance of applied behavior analysis specialists or occupational therapists to facilitate behavioral change and to avoid situations that trigger problem behaviors. pow85736_09_c09_311-354.indd 337 5/7/13 8:21 AM CHAPTER 9 Section 9.7  How Do I Teach Students With ASD? From My Perspective: Occupational Therapy and ASD I’m Cate, and I’m an occupational therapist. Students with autism spectrum disorders are often eligible for occupational therapy services to maximize their participation and learning potential in the school setting. Justin is a 9-year-old nonverbal student with autism who has difficulty with transitions, managing his sensory needs, and relating to his peers. When overstimulated or frustrated, Justin reacts by becoming loud, exhibiting abusive behaviors towards himself or others, bolting from the classroom, or shutting down completely. The occupational therapist (OT) works with students like Justin and the educational team every day to develop strategies to manage sensory experiences for optimal receptivity and availability for learning. Jupiterimages/Creatas/Thinkstock Justin receives direct occupational therapy services three times per week, either as part of a group in which his goals are to improve his social skills—sharing, cooperation, and communication with peers—or during an individual session where specific sensory, motor, or cognitive challenges are the focus. I accompanied Justin’s class on a recent field trip to an apple orchard where the goal was to help Justin manage his behavior in what can easily become an overwhelming situation. Justin needed frequent quiet breaks away from the crowd to calm his overactive sensory system before he became overstimulated. As an OT, I am trained to gauge the “just right” amount of challenge and sensory input for Justin to learn, and I plan strategies to avert negative outbursts. Once we were back in the classroom, Justin worked in a small group to prepare the apples for an easy microwave apple dessert. With picture cues to direct him and OT intervention to guide him, Justin was able to respond to simple directions, work as a team member, and challenge his hypersensitive tactile system by touching mildly offensive slimy apple slices. Justin was able to contribute and succeed in an age-appropriate, meaningful, and intellectually stimulating school project. Relating to Peers and Others Many students with ASD have difficulty relating to peers; they have trouble understanding social cues and how to act in social situations (Whitby, Ogilvie, & Mancil, 2012). General education students, in turn, may need some help learning to understand and work with students with ASD in their classrooms. Teachers may work with both the student with ASD and the entire class on certain types of social skills (Campbell & Barger, 2011). pow85736_09_c09_311-354.indd 338 5/7/13 8:21 AM Section 9.7  How Do I Teach Students With ASD? CHAPTER 9 For example, if a student with ASD has trouble playing a game in which the students take turns or compete, the general education or physical education teacher may engage the class in a lesson focused on taking turns and cooperation (Obrusnikova & Dillon, 2011). It is important that these lessons be aimed at the entire class rather than the student with ASD so that all students learn how to work with each other. Video modeling can help improve conversational skills, playing, and When a classroom uses video modeling, students have a visual other social skills of students with and auditory presentation for completing a task. Students usually ASD (Biederman & Freedman, watch the video several times and then practice components of 2007; Kagohara, 2010; Ganz, the video with the teacher. Instruction before, during, and after Earles-Vollrath, & Cook, 2011). the video is necessary. Students watch a video of a task to learn how to act in a specific situation or how to do something. Students often watch videos multiple times, and teachers use scaffolding to remove the video from use. For example, students may watch a video of students playing a board game to better understand taking turns and moving game pieces. Students then play a game and practice the strategies outlined in the video. Students can view the video multiple times and then practice the skills repeatedly (Ganz et al., 2011). iStockphoto/Thinkstock Teachers can create their own videos for students after identifying a target skill, gathering materials, and filming the video. Special Education: Your Profession Current Practices in Special Education One method for helping improve the behavior of students with ASD is applied behavior analysis (ABA). ABA specialists identify problem or atypical behaviors and use interventions to improve such behaviors. ABA also helps teach students skills that they may not learn inherently (Axelrod, McElrath, & Wine, 2012). Interventions are implemented by ABA-certified teachers, staff, or clinicians in school and clinic settings. ABA identifies student behavior in certain situations, quantifies student behavior by gathering data on instances of the behavior, and measures the relationship between the intervention and behavioral outcomes (Kauffman, Bruce, & Lloyd, 2012). Each intervention is tailored to the relationship between a student’s behavior and the student’s environment (Ringdahl & Falcomata, 2009). (continued) pow85736_09_c09_311-354.indd 339 5/7/13 8:21 AM Section 9.7  How Do I Teach Students With ASD? CHAPTER 9 Special Education: Your Profession Current Practices in Special Education (continued) ABA therapists use a variety of techniques to improve behavior. Therapists may provide prompts or cues for students, model and scaffold instruction, or use various types of reinforcement to improve behavior (Ogletree & Oren, 2001). ABA therapy typically takes a lot of time, with some students participating in therapy 20–40 hours each week until behaviors improve. The targeted “behaviors” may be academic (e.g., reading a story, completing a math problem), communication-based (e.g., asking for help), or related to social skills (e.g., not hitting when losing a game). ABA can also be used to reduce or eliminate injurious or stereotypic behavior. If you are interested in becoming a Board Certified Behavior Analyst (BCBA), you must take specific classes at recognized institutions, and you must pass specific examinations. For more information, visit http://www.bacb.com. Peer tutoring can be an effective strategy for students with ASD to improve communication and social skills (Sperry, Neitzel, & Engelhardt-Wells, 2010; Su, Lai, & Rivera, 2012; Trottier, Kamp, & Mirenda, 2011). Teachers, however, must provide proper training and structure the activities. Merely letting students choose partners and begin working together is not effective for either student in the pair. Teachers should assign roles in the pair (i.e., coach and player; leader and doer) and make sure that students understand those roles. Teachers also need to teach strategies for getting along with partners. For example, some students need to learn a little patience and understanding, while other students need to learn how to praise their partner and help if the partner makes a mistake. Video modeling can help students with ASD and their partners see how to work together (Silton & Fogel, 2012). Some students with ASD have difficulty recognizing and discriminating among people’s faces, as well as interpreting others’ emotions visually (Hopkins et al., 2011). Computer-assisted instruction (CAI) programs can increase students’ recognition of faces and understanding of emotion cues (Tanaka et al., 2010). These programs show different faces and emotions, and students learn how to recognize and interpret them. Making Decisions Students may need instruction on how to make decisions in and outside of the classroom. Providing students with pictures as options is helpful for students with ASD. For example, to help a student decide what to eat at lunch, the teacher could display pictures of chicken, salad, and a sandwich. Students could also choose a picture to decide which task to complete first: read a story or finish math homework. Students can also learn to use Social Stories to make decisions (Kokina & Kern, 2010). Students can read a Social Story or an adult can read it for them, and the story helps the student think through a situation. Stories can be in words or pictures. For example, students may use Social Stories to work through how to cross the street at a stoplight, raise their hand to go to the bathroom, or ride the school bus. To teach street crossing, the story might be: “When I’m walking down the street and I see a stoplight, I need to stop at the street corner. If I don’t stop, I could get hurt. After I stop, I push the button and wait. When the walking man flashes on, I start to cross the street. I keep walking until I’m all the way across the street.” pow85736_09_c09_311-354.indd 340 5/7/13 8:21 AM Section 9.7  How Do I Teach Students With ASD? CHAPTER 9 From My Perspective: Raising a Son With Autism I’m Melissa, and I am the mother of a 22-year-old who is an “Exceptional Learner.” He has autism. The truth is, however, that he is not just an “Exceptional Learner,” but an exceptional teacher as well. He has taught me about life, love, compassion, disappointment, spirituality, and acceptance. He has done the same for the rest of his family and his community. When Bruce was diagnosed with autism in 1994, there was little information available and even less understanding of autism. I was scared about what life would be like for Bruce and what life would be like for our family. I knew that there Jupiterimages/Creatas/Thinkstock were going to be many challenges ahead for us all. I wanted to wave a magic wand and be able to see into the future. Would he be able to go to school? Would he be able to read? Would he be able to communicate? Would he have a job? Would he have friends? The list of questions in my mind would roll like an unending script. Where was that crystal ball when I needed it? Now, some 18 years later, as I type this and think back on that time, I am able to remember the many fears and recognize the many blessings that have occurred. School was one of my biggest fears for Bruce, and it turned out to be one of the experiences where he was richly blessed. Most years he was blessed with a teacher who may not have known very much about autism, but who had a tremendous heart for exceptional learners and worked very hard to see that he was successful. Case Study: Applying Teaching Strategies for Adaptive Behavior and Academics for a Student With ASD Alex is a second-grade student with autism spectrum disorder. He attends his neighborhood public elementary school, and receives the majority of instruction in your general education classroom. Alex is a very bright young boy whose IEP goals are primarily focused on behavior. He has two IEP goals aimed at increasing his reading fluency and comprehension level. Alex is new to the school this year, and his parents were very unhappy with his previous placement. Last year, Alex was in a self-contained setting that did not provide an adequate focus on academics. Additionally, the school staff called his mother several times a week to pick Alex up early because his “behavior was out of control.” After moving to the new neighborhood, Alex’s parents were adamant about Alex receiving instruction in the general education classroom with inclusion support. At his current school, Alex has a full-time teaching assistant to help with his behavior plan. He also has a special education teacher who manages his IEP. The first few weeks of school were difficult for Alex, and his behavior frequently escalated. During this period, Alex began running out of the classroom, hoping teachers would chase him. Since then Alex’s behavior has improved, in part because of a consistent schedule and behavior plan. Alex is making great progress in all academic areas, except reading. While his behavior is improving, Alex still has a tendency to run out of the classroom when he wants to avoid work. He has made limited progress in peer interactions, and often gets upset during recess and classroom activities that involve group work. (continued) pow85736_09_c09_311-354.indd 341 5/7/13 8:21 AM Post-Test CHAPTER 9 Case Study: Applying Teaching Strategies for Adaptive Behavior and Academics for a Student With ASD (continued) Questions to Consider: 1. What are some strategies you would use with Alex during reading instruction? 2. What are some strategies you would use to teach adaptive behavior with Alex? 3. How would you structure peer interactions for Alex? 4. How would you communicate with the teaching assistant and special education teacher about his behavioral and academic progress? 5. How would you communicate with Alex’s family about his behavioral and academic progress? Wrap-Up • Students with ASD represent about 1% of students in schools. To be eligible under the category of autism under IDEA 2004, students must exhibit characteristics in three hallmark areas (communication, social skills, and repetitive behavior) and demonstrate that the ASD leads to adverse educational outcomes. • ASD is a relatively new disability category. It was first recognized by IDEA in 1990. Before 1990, students with ASD were often categorized under intellectual disability (ID). • Students with ASD must demonstrate difficulty with communication, social skills, and repetitive or stereotypic behavior. Characteristics vary considerably based on the student and the severity of the disorder. • Research has revealed several causal factors for ASD: genetics, brain differences, and environmental causes. No single cause has been identified at this time. Vaccines do not cause ASD. • The diagnosis of ASD is conducted by a trained professional. Schools evaluate students with ASD for eligibility under IDEA 2004, but schools do not diagnose students with ASD. • Most students with ASD are identified during the preschool years, although students can be identified throughout their school career. Early intervention, to help students with communication and social skills, greatly improves the outcomes for students with ASD. • Students with high-functioning ASD may spend some or all of their school day in a general classroom. Students may require support with academics, with behavior, or with both. Post-Test 1. How does ASD change in DSM-5? a. PDD-NOS becomes a separate category. b. Autism becomes the catch-all category. c. Asperger’s disorder becomes a separate category. d. Students are categorized by levels of severity. 2. When did autism become a separate category under IDEA? a. 1975 b. 1990 c. 2001 d. 2004 pow85736_09_c09_311-354.indd 342 5/7/13 8:21 AM Post-Test CHAPTER 9 3. Which researcher described students with ASD characteristics for the first time? a. Paul E. Bleuler b. Hans Asperger c. Leo Kanner d. Bruno Bettelheim 4. Which is not a hallmark of ASD? a. Repetitive behavior b. Deficits in intelligence c. Deficits in social skills d. Deficits in communication 5. What is the main cause of ASD? a. It is not known b. Genetics c. Pesticides d. Vitamin deficiencies 6. Which is not typically used for diagnosis of ASD? a. Checklist b. Observation c. Blood test d. Parental interview 7. When are students usually diagnosed with ASD? a. At birth b. 2–4 years old c. When starting kindergarten d. 6–8 years old 8. What should teachers use with students? a. Idioms b. Metaphors c. Similes d. Clear and concise language 9. Which strategy helps students with ASD with academics and behavior? a. Video modeling b. CRA sequence c. Manipulatives d. Transition services 10. Who delivers ABA services? a. General education teacher b. BCBA c. Special education teacher d. OT Answers: 1 (d); 2 (b); 3 (a); 4 (b); 5 (a); 6 (c); 7 (b); 8 (d); 9 (a); 10 (b) pow85736_09_c09_311-354.indd 343 5/7/13 8:21 AM CHAPTER 9 Acronyms Used in Chapter 9 Discussion Questions 1. How do you explain the rise in numbers of students with ASD over the past 20 years? 2. What’s the difference between the DSM-IV and DSM-5 criteria for ASD? Why did the DSM-5 change the criteria? 3. As a member of an IEP team, how would you decide which accommodations and modifications would be appropriate for a student with ASD? Answers and Rejoinders to Pre-Test 1. True. Autism became a disability under IDEA in 1990. 2. False. Students with ASD must exhibit difficulty with communication, social skills, and repetitive behavior. 3. True. Vaccines have been disproven as a cause for ASD. 4. False. Students are typically diagnosed with ASD between the ages of 2 and 4. 5. False. Many students with ASD spend some of the school day in a general classroom. Additional Resources • Autism Speaks is one of the largest research and advocacy organizations for students with ASD. The site provides great resources for parents and teachers. www.autismspeaks.org • This site helps parents understand the early signs of ASD. www.firstsigns.org • The Autism Society has a myriad of resources for parents and teachers. www.autism-society.org • This site has resources for families of students with ASD. www.autismaction.org • This site provides background information on Asperger’s disorder. www.aspergers.com Acronyms Used in Chapter 9 Acronym Description AAC Augmentative and Alternative Communication ABA Applied Behavior Analysis ADHD Attention-Deficit/Hyperactivity Disorder ADOS Autism Diagnostic Observation Schedule ASD Autism Spectrum Disorder ASQ Ages and Stages Questionnaire BCBA Board Certified Behavior Analyst CAI Computer-Assisted Instruction CARS Childhood Autism Rating Scale (continued) pow85736_09_c09_311-354.indd 344 5/7/13 8:21 AM CHAPTER 9 Key Terms Acronyms Used in Chapter 9 (continued) Acronym Description CDD Childhood Disintegrative Disorder CRA Concrete-Representational-Abstract CSBS Communication and Symbolic Behavior Scale DSM Diagnostic and Statistical Manual DSM-5 Diagnostic and Statistical Manual, Fifth edition DSM-IV Diagnostic and Statistical Manual, Fourth edition EBD Emotional and Behavioral Disorder FAPE Free Appropriate Public Education GARS Gilliam Autism Rating Scale ID Intellectual Disability IDEA 2004 Individuals with Disabilities Education Act IEP Individualized Education Plan IFSP Individualized Family Service Plan MCHAT Modified Checklist for Autism in Toddlers MMR Measles-Mumps-Rubella OCD Obsessive-Compulsive Disorder OT Occupational Therapist PDD Pervasive Developmental Disorder PDD-NOS Pervasive Developmental Disorder Not Otherwise Specified PEDS Parents’ Evaluation of Developmental Status SCDC Social and Communication Disorders Checklist SLD Specific Learning Disability SRS Social Responsiveness Scale STAT Screening Tool for Autism in Toddlers and Young Children Key Terms applied behavioral analysis  An approach to improving behavioral outcomes for students by focusing on positive reinforcement. pow85736_09_c09_311-354.indd 345 Asperger’s syndrome  A disorder in which students experience difficulties with communication and social skills, and typically exhibit average- to above-average intelligence. 5/7/13 8:21 AM References autism  Another word for autistic disorder. (May also sometimes be used to refer to the larger category of ASD under IDEA 2004.) autism spectrum disorder (ASD)  A disorder related to difficulty with communication, social skills, and repetitive behavior. autistic disorder  A disorder in which students have severe difficulty with communication and social skills. CHAPTER 9 low-functioning  Description of students with ASD who exhibit more severe characteristics. Students may be nonverbal and have a lot of difficulty participating in general school activities. pervasive developmental disorder (PDD) A disorder that causes delays in the communication and social skill development of young children. This is an older term to describe the disorders of ASD. childhood disintegrative disorder (CDD) A rare disorder in which students experience typical development and then experience a decrease in communication, social skills, and intellectual functioning. pervasive developmental disorder not otherwise specified (PDD-NOS)  A disorder in which students have difficulty with communication and social skills. PDD-NOS falls between autistic syndrome and Asperger’s syndrome in terms of severity. high-functioning  Description of students with ASD who exhibit less severe characteristics. Students can often participate in school activities with little to some difficulty. Rett’s disorder  A rare disorder that affects girls, in which they experience typical development for the first 1 to 2 years and then experience a decrease in communication and social skills. stereotypic behavior  A behavior that is repeated and interferes with normal activity. References Adams, J. 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Diffusion tensor imaging in autism sp...
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