Introduction to Autism Spectrum Disorders

Editor’s note: This text is an edited transcript of the webinar, Introduction to Autism Spectrum Disorders, presented by Tara Warwick, MS, OTR/L.

Learning Outcomes

At the conclusion of this course, participants will be able to:

• Identify two core features of autism spectrum disorders
• Describe impact of autism spectrum disorders on daily living skills
• Identify tools for screening and evaluating individuals for autism spectrum disorders

Introduction and Overview

Thank you for having me. My specialty is working with children who have autism and those who have challenging behaviors. I'm excited to present this introductory information today. I will also be presenting upcoming courses on challenging behavior, as well as on communicating with teens that you can find in the course library on continued.com/early-childhood-education.

What is Autism?

Autism is a spectrum disorder. In other words, it is a continuum, ranging from mild to severe. Individuals with autism may exhibit varying degrees of severity across many different skills and abilities. 

Autism is a brain based disorder. Individuals with autism process information differently than those without autism. Their brains simply work differently. It's not a mental health disorder, it's not an emotional disorder. It is a brain-based developmental disorder.

Autism is lifelong -- there is no cure for autism. People don't outgrow autism. That's not to say that people with autism can't learn. They can be very successful and lead fulfilling lives, although the characteristic of autism will impact them throughout their life.

Autism is evident during the first three years of life. The earlier we can identify individuals with autism, the better the prognosis. The earlier we can work on those skills, when the brain is still malleable, the better the outcome.

Autism symptoms range from mild to severe. One individual may have an excellent vocabulary and talks non-stop, whereas another individual may be nonberbal, using no words to communicate. Then, there are those who fall in the middle of those two extremes.

Autism Prevalence

According to the Center for Disease Control and Prevention, one in six children have a developmental disability (ranging from speech impairment to serious developmental disability). As of 2016, one in 68 children have a diagnosis of autism. In 2007, the prevalence was one in 150 children, and there has been a 172% increase in autism diagnoses since the 1990s. Autism is distributed throughout the world. It affects all races, nationalities and social classes. Autism knows no borders or boundaries. Autism is more common than pediatric cancer, diabetes and AIDS combined. If you are participating in this course, it is likely that you are interacting or working with an individual with autism, either in your personal life or your professional life. If not, sooner or later you will invariably encounter an individual with autism. 

Risk Factors

The following conditions are risk factors for autism:

• Twins are at higher risk for autism (36-95% of identical twins; non-identical 0-31%). 
• Children whose parents have autism are at a 2-18% higher risk of having autism.
• People with Down syndrome, fragile X, tuberous sclerosis, or other chromosomal disorders are more likely to have autism.
• Parents who conceive children at an older age are more likely to have children with autistic traits.
• Children with a low birth weight are more likely to have autism. 

Diagnosis

Diagnosis at age two can be reliable if you're using the right tools. As early childhood educators, as you're helping families who are concerned about autism, I encourage you to go to reliable sources for a diagnosis. The earlier they can get diagnosed the better. Most cases of autism are diagnosed after age four, but if we can get a reliable diagnosis at two or three, they will be better off in the long run. Most parents notice developmental problems before their child's first birthday. Currently, research is being conducted that is looking at videos of first birthdays, to see if there are signs of autism at age one. Additionally, researchers are looking at newborn brain scans to see if there are any noticible differences between the brains of children with autism and those without autism.

Why do we have more autism diagnoses now than 10 or 20 years ago? Why does it keep increasing? First of all, there is an increased awareness of autism. More people know about and aware of autism. Additionally, there are more screening tools. Physicians now are supposed to be doing regular developmental screenings for autism. There have also been changes in how autism is defined. With all the changes in the DSM, the definition of autism was changed to broaden the scope. However, all of these factors combined still do not account for the increase. 

What does this tell us? It tells us that we are more likely now to encounter an individual with autism now, than we were 10 years ago. I would bet that the majority participants in attendance at this webinar have encountered autism on a personal level. I know I have. A decade or so ago, I would never have thought I'd have a friend who had a child with autism, and now I have several of them. We all need to understand how to best support individuals with autism and their families. It takes a village -- we all have to work together.

Red Flags

When you're working with children and families, these are some red flag signs of autism to keep in mind from the Centers for Disease Control (CDC):

• Not responding to name by 12 months: Initially, many families think that it is a hearing issue and will bring their children to have their hearing checked.  
• Not pointing: One of the first things we work on with young children with autism is how to point. Pointing is a social mechanism to indicate to another person that we want something. 
• Avoiding eye contact
• Delayed speech
• Upset by minor changes
• Obsessive interests (above and beyond just liking something)
• Flapping hands, or other sterotypical motor movements
• Unusual reactions to sensory (e.g., a child who hates to have his hair cut or take a bath)

The American Academy of Pediatrics recommends that physicians screen young children for autism at 18 and 24 months of age, to make sure that they are meeting those milestones.

Identification of Autism

There are no biological markers that we can use to identify autism. In other words, children with autism don't physically look any different than children without autism. The diagnosis is based on behavior and history, and consists of a parent interview, play-based and conversation-based assessment, and input from other people familiar with the child. Any assessment tool that we use to diagnose autism should tap social and communication delays. One tool that is considered a "gold standard" for diagnosing autism is the Autism Diagnostic Observation Schedule (ADOS). The ADOS is an assessment based on interaction. 

Screening Tools

Early childhood providers and physicians can use several types of screening tools, including those that are developmental and some which are autism specific. 

Some developmental screening tools that are not specific to autism, but can be helpful in making the diagnosis, include Ages and Stages (ASQ), Communications and Symbolic Behavior Scale (CSBS) and the Parents Evaluation of Developmental Status (PEDS). Screening tools that are specific to autism include the Modified Checklist for Autism in Toddlers (MCHAT), and the Screening Tool for Autism in Toddlers and Young Children (STAT). The MCHAT is one that you can access online for free. You can print it and go through that screening tool with your families, if they have concerns about autism.

Diagnostic Tools

As far as diagnostic tools for autism, the gold standard is based on observation of the child's behaviors and history. The Autism Diagnostic Interview - Revised (ADI-R) is a great tool for interviewing families to find out about the child's developmental history. The Autism Diagnostic Observation Scale - Generic (ADOS-G) looks at how the interaction is occurring. You may have heard of the Childhood Autism Rating Scale (CARS) or the Guilliam Autism Rating Scale - Second Edition (GARS-2). Although they are not as reliable as the first two diagnostic tools, I do see the CARS and the GARS-2 used a lot in schools.

Two Systems to Identify Autism

There are two systems used to identify autism: clinical (diagnosis) and educational (categorical label).

Clinical diagnosis. A clinical diagnosis of autism is based on the DSM-5: the Diagnostic and Statistical Manual of Mental Disorders. Essentially, the DSM-5 includes any disorder that you can't diagnose using a blood test. It includes all of the criteria for meeting the diagnosis of autism. This diagnosis must be made by a licensed professional, such as a clinical psychologist or a physician.

Educational diagnosis. The educational diagnosis is a categorical label that makes students eligible for services. It's based on the Individuals with Disabilities Education Act (IDEA). Students do not have to have a clinical diagnosis to qualify for an educational diagnosis. This can be a misconception in the schools: children can still be put on an IEP under the category of autism, without having an official clinical diagnosis. Children can qualify for an IEP based on how they're doing in school, according to the criteria for that category.

Characteristics of ASD

The main characteristics of autism spectrum disorder that we will discuss today fall under three categories: reciprocal social interactions, language and communication, and restrictive, repetitive, sterotyped behavior.

Reciprocal social interaction. One of the core characteristics of autism is the lack of reciprocal social interaction. How is their eye contact? They might have poor eye contact. They may not look at you at all, or they might stare at you. They will likely have a limited range of facial expressions. This past summer, I worked with some boys whose facial expressions never changed. It didn't matter if they were having the time of their lives, or if they were bored out of their minds. Their facial expressions remained the same. It was difficult for me to discern when they were having fun. Another characteristic of autism is a failure to develop peer relationships. Individuals with autism may fail to share enjoyment with other people. This is something we look at when children are young, for example if they have a toy that they like. Will they try to share that toy with other people, or do they just sit there and enjoy it by themselves? Finally, in their interactions with others, people with autism lack the ability for social reciprocity. In social relationships, there is a certain amount of give-and-take that is lacking in individuals with autism.

Language and communication characteristics. A child with autism might have a delayed language, where they don't begin to talk until much later than other children. Or, they might exhibit atypical language. One of my friends has a child with autism. When her child was around 18 months or two years old, she told me that her child could spell the names of all the planets, whereas a normally developing two-year-old would not be able to do that yet. However, this child didn't know how ask mom when they need a drink. They excelled in certain areas, but were lacking in others. Children with autism may have difficulty initiating or sustaining conversation. You might see children whose conversation is like a monologue instead of a dialogue. They think of conversation as telling you everything that they want to tell you. They never reciprocate; they don't ask you questions. We have to teach them that conversation is a dialogue that should go back and forth, or they won't have any friends. Other children won't stick around, because they get tired of listening to them talk all the time. Another characteristic of autism is what we call echolalia. This means that they use the same phrase over and over again. I used to work with a little girl who would just start saying "backpack, backpack" which meant that she liked Dora the Explorer. Whenever she needed something, she didn't know how to ask for help, but she would just say "backpack, backpack." Her mom knew then that she needed something, because Dora could go to always go to her backpack and get what she needed. Finally, children with autism exhibit a lack of pretend play. They don't how to make-believe, or play dress-up and other types of creative, pretend play. Instead, they may play with structured toys, or put all of their toys in a line, things like that.

Restrictive, repetitive, sterotyped behavior. Often, when we think about autism, we picture someone with repetitive mannerisms, or circumscribed interests. In other words, they are so interested in something, they can't focus on anything else. Topics of interest vary widely, including astronomy, tropical fish, and even watching a washing machine spin. Some people with autism exhibit rigid adherence to routines and rituals, and not in a way that is efficient. I'm working with a man right now who's 25. Right now, we are working on ritual busting, because he has so many rituals, it is consuming his life. It has gotten to the point where he feels compelled to turn everything a certain way, and to touch everything a certain way. Some individuals with autism have a preoccupation with parts and objects. For example, children will spin the wheels of a toy car over and over again, instead of playing with the cars the way they were intended to be played with. 

What do These Behaviors Look Like?

In the school or in the home setting, you might see individuals that have difficulty with change and transitions. I work with a student who has extreme difficulty with any kind of transition. Even if he is going to his favorite environment, dealing with any kind of change is hard for him. People with ASD have limited or inconsistent interaction with others. They are easily frustrated. If things don't turn out exactly how they're supposed to, they have a meltdown because they don't know how to problem-solve through things. Individuals with autism often insist on doing things a specific way. One of the strengths of individuals with autism can be memorizing details, memorizing routines. Spend time teaching them routines the way you want them to do the routine, or else they're going to find their own way to do it, and they will insist on doing it their way. Another common behavior is having trouble imitating others and learning by observation. When we're working with young children, one of the first things we start with is pointing and imitating, and teaching them how to watch other people and do what they're doing. Children learn by watching and doing. If you have an individual who can't watch and imitate, they're going to have trouble learning.

Impact on Daily Function

Autism can have an impact on concrete and literal thinking. Those with autism can have trouble with gray areas -- they are black and white thinkers. They tend to struggle with attentional issues. Focusing on the right things might be hard for them. They also experience discrepancies in learning. For example, I work with a lot of students who have very high math scores and low language scores. We're going to have to teach them language at one level, and math at a different level. People with ASD have difficulty generalizing. This is a big issue when you're talking about home environment versus school environment. Sometimes children exhibit behaviors at home that they never do at school, or vice versa. I have worked with children who will talk at home, but when they get to school, they don't say a word. They might learn in one environment, but that doesn't mean they can generalize that to another environment. Many times, we're going to have to teach them across different environments.

Common Strengths

It is important to focus on the common strengths of individuals with autism. We don't want to get so bogged down in what they can't do. We want to think about using their strengths to teach them skills.

One common strength of these individuals is rote memory. A lot of individuals I work with have excellent memories. They can memorize long routines. They memorize things in different ways than you or I might memorize things. Additionally, they learn best through routine and practice. We're going to have to practice things with them over and over again.

They can be straightforward, honest and objective. I always say, if you want to know how you look in a pair of jeans, ask an individual with autism and they will tell you honestly. It can be very endearing.

Use something that they are interested in to motivate them. They might not be motivated socially, but find what they're interested and use that. I worked with a child who was interested in Swiffer WetJets, and so we had to figure out how to use Swiffer WetJets to teach him how to read.

Use visual processing to aid learning. Language can go in one ear and out the other. We need to look how we can make things more visual. Even if a child is highly verbal, we still need to put visuals in place to reinforce learning. I'm going to give you some examples of those coming up.

Ten Things Every Individual with Autism Wishes You Knew

As we get into the next section, I wanted to share the following quote from the National Research Council (NRC) Guidelines (2001): "There is no single behavior that is always typical of autism, and no behavior that would automatically exclude an individual child from a diagnosis of autism.” In other words, a diagnosis of autism takes many characteristics into consideration, and looks at the quality of a child's different skills. If a child lines up all of her dolls, that single behavior does not mean that the child has autism. We have to look at the whole picture.

In addition, the NRC goes on to state that "education, both directly of children and of parents and teachers, is currently the primary form of treatment for autism spectrum disorders." There is no magic pill. There are no magic oils. There is no magic diet. Education is the primary form of treatment for ASD. To further our education, I will now be sharing with you ten things that every individual with autism wants us to know.

1) Every Student with Autism is Unique

Just like any child, each student with autism has their own strengths, as well as areas where they need more support. As Temple Grandin says, "See the person, not the label." When you're working with a child who has autism, we have to learn about that individual child. What do they like? What are they good at? What things are difficult for them? Every child with autism is unique.

As stated earlier, there is a spectrum of ability within autism spectrum disorders. A child can range from severe to mild in the following areas:

• Language/Communication
• Social/Emotional
• Cognitive/Intellectual Ability
• Perception/Sensory Regulation
• Attention: Orienting, Shifting, Joint
• Motor Planning

2) Individuals with Autism Often Have an Area of Special Interest

You have to find what drives each child. If you're just starting to work with a child with autism, or if you're currently struggling with a child with autism, take a step back. Don't get caught up in what you're trying to teach them. Instead, put time into thinking about what they like. If you don't know what they like, you need to find something they like, because you cannot teach unless you have reinforcers.

Many of the reinforcements that we commonly use in the schools are social based. For example, some children try to do well in school to impress their teacher or their parents. Or, some students are motivated by competition, and they want to do better than the student sitting next to them. Those are social motivators. However, autism is a social disorder. Those with autism might not be driven by social expectations. As such, we're going to have to find something else that they like. It's critical use things that motivate the child. Importantly, we do not decide what motivates them: they decide. If you only have stickers, and they don't like stickers, that will not be a successful reinforcer. 

Use the child's special interests and reinforcers to teach them to build skills and behaviors. If a child likes to play on an iPad, use that iPad to motivate them to do some work. You're going to build that into their day. Gradually, we will fade the use of the iPad, but at the beginning, we might have to use it more often.

Structure and plan the process for using their special interests. I'll often hear people say that they would use a particular favorite item, but they would never be able to get it away from the child. One person hid the iPad up in the closet, which resulted in the child banging on the closet door. That tells me that the iPad is really motivating to them. If we want to teach them something, we need to use it, but we also need to teach them how to transition away from it. That would be my first thing to work on: teaching the child to transition away from something that they like.

Use their special interests to teach some other things they might enjoy. If you have a student who only likes iPad, I would use that iPad to teach him how to play with other things. A while back, I was working with a young boy who was very motivated by candy and fruit snacks. We thought that if we could teach him how to play Nintendo, that would be another motivator for him. We thought he would like it, but he wouldn't even try it. We had to use candy to teach him how to play Nintendo. When he played Super Mario Brothers, every time he'd jump over the little mushroom, he'd get a candy. Gradually, he started liking Nintendo. We then had another reinforcer to use that was more age-appropriate.

Positive reinforcement. Positive reinforcement is a process. It is a presentation of a reinforcer after an individual performs a skill. When you give them something they like after they do a certain skill, that's positive reinforcement. It can be tangible (e.g., candy, iPad). It could be social (e.g., a high-five, a pat on the back). It could be a combination of both tangible items and social reinforcement.

There is a difference between bribery and positive reinforcement. It's all about the timing. Bribery is when we use a reinforcer or preferred item to stop a behavior from happening. Think of the following scenario: A student is working at their desk, and they get up out of their seat and fall on the floor. The teacher tells the student that if they go back to their desk, they can have the iPad. That is bribery; the reinforcer was given to stop a behavior. The student will learn that if they want the iPad again, they should throw themselves on the floor. Now, here is a positive reinforcement scenario: A student is working at their desk. The teacher gives the student the iPad, and tells the student they are working nicely. We're reinforcing the behaviors we want to see, versus using the preferred item to stop an undesired behavior.

Positive reinforcement tips. The following tips will help you implement positive reinforcement appropriately and effectively:

1. The reinforcer needs to be age-appropriate. If the student is in high school, don't reward them a Dora the Explorer video. Make sure the age matches the reinforcer. I work with a 25-year-old who loves the old Disney movies (e.g., Little Mermaid, Lion King). We've stopped giving him those movies as a reinforcer. However, we discovered that he really likes the music on them. Now, we use the music instead of the video. He can listen to the music on his headphones. No one knows he's listening to it, and he still enjoys it, but he's not watching the movies.
2. Be specific about the target behavior that you are addressing.
3. Set clear expectations. We cannot tell a child, "If you're good all day, you get the iPad at the end of the day." That's not specific enough. What does "good all day" mean? Can any of us be good all day? Break the day down into smaller, more realistic increments.
4. Positive reinforcements should be given immediately after the target behavior. This is especially important when you're first starting, because it helps children learn to associate the reinforcement with the desired behavior.
5. The more reinforcements you have in your arsenal, the better. Variation is key! If you're working with a child who only has one or two things that they like, your goal should be to increase the number of reinforcers that they have. So many children these days love the iPad. We'll use iPads to teach them how to play at the ball toys, teach them how to color, teach them how to play with Play-Doh, in hopes that those things will then become reinforcers.
6. Fade the reinforcements. Make sure you don't get in a habit where the student does the activity and automatically puts his hand out, expecting the reinforcer. If that is the case, we didn't fade it quickly enough.
7. Use the 50% rule. Many times, people will ask how often they are supposed to give the reinforcement. I tell them to look at the amount time between behaviors. Let's use an example of a student who runs around during circle time. This student runs around every 60 seconds. We need to divide that time in half, which would put us at 30 seconds, and that's how often they need positive reinforcement. It might be in the form of an item; it might be social. Use whatever works, but they need to have the reinforcer every 30 seconds. Otherwise, if you wait too long, you risk bribing them instead of positively reinforcing them.
8. Use visuals to show when they gain access (e.g., a reward board or a token board, example to follow shortly). 
9. Be consistent across the team. We need to make sure that we're all consistently providing positive reinforcement in the same manner, as much as we can.
10. When in doubt, over-reinforce rather than under-reinforce. If you under-reinforce, you run the risk of getting into a bribery situation. It's better to give more reinforcers, especially in the beginning, and especially if they're having a lot of challenging behavior. I've been on consults recently, where teachers have told me about children who have had horrible days, and they hadn't earned any of their reinforcers. Horrible days are the days children need to earn more reinforcers, to turn their horrible day around. Don't wait until they start changing their behavior. Give it to the child to help change their behavior. 

Token reward system. A token reward system is a visual to show a student when they will gain access to their reinforcement (Figure 1). It shows the child when they earn this many tokens, they get access to reinforcement. Not only does it help the child see when they will receive their reward, it also keeps us accountable, so we don't get into the habit of telling children they can have that later. We have a visual that indicates what "later" means (e.g., after two more stars). A token reward system helps with transitioning the child away from the reinforcer.

Figure 1. Example of token reward system.

In Figure 1, on the center of the chart, you would place a picture of the reward that the child is working toward (e.g., iPad time, candy, games, etc.). Begin with no stars on the chart. Each time the child exhibits the desired behavior (e.g., if they sit for 30 seconds), they earn a star. If the child had two stars left to earn, you could show them that after two more stars, they gain access to their reward. The biggest mistake I see with token reward systems is that people don't give stars frequently enough, or they remove them. I would not recommend that you remove stars, especially in the beginning, because once you take them all away, you have no more leverage.

3) Individuals with Autism Often Have Difficulty Communicating Wants and Needs

When we are working with young children, we begin by assessing their functional communication skills. Most of the challenging behavior that you see in children with autism centers around their inability to communicate. First, we need to determine if they can accurately communicate their wants and needs. If so, are they communicating verbally, or through the use of gestures, pictures or devices? Is a lack of communication causing challenging behavior? We have to focus on this communication across the student's day. It should not just happen during speech therapy sessions. You might be targeting new skills during speech, but those skills need to be practiced throughout the day. If a child uses pictures to communicate during their speech therapy, they need access to those pictures all the time. In order to generalize, we're going to have to teach the child across different environments.

Figure 2 shows a chart that lists an undesired behavior, and a corresponding functional communication skill that will help the child to better communicate. We need to think about what the child is trying to tell us with their behavior, and how we can teach them a better way to communicate their needs. The first behavior is that the child tears up a worksheet when it gets difficult. A functional communication skill would be to teach the child how to give you a help card, or how to raise their hand for help. Another behavior could be that when a child wants to play with another student, he takes the toy from the student and runs around the room. We need to teach him how to tap the student on the shoulder and wait for the other student. When a child needs a break from the classroom, he throws himself down on the floor until someone takes him into the hallway. We need to teach that child how to ask for a break. We have to replace those behaviors with functional communication.

Figure 2. Behavior versus functional communication.

4) Individuals with Autism Need Us to Understand the "Why" Behind Challenging Behavior

Anytime you see challenging behavior happening, you need to stop and think why. What is the child trying to tell me with this behavior? They're not doing it just to make you mad. They have a reason. They're trying to tell you something.

Behind every behavior is a positive need. The behavior might not seem very positive. The key is not to take it personally, and try to think about what is the need. What are they trying to tell you with these behaviors? Are they trying to get away from something? Are they trying to get attention? Are they trying to get an item? Are they trying to get away from attention? Once we determine what the child needs, we need to figure out another way for them to communicate this need, like we discussed earlier when we talked about functional communication. How else can that need be met? Also, we can see if modifying the environment might have an impact. The majority of the time, when I see a lot of behavior happening, it's around the work. How can we modify the work, make it a little easier, to prevent that behavior from happening?

I like to use the analogy of an iceberg. These observable behaviors (e.g., hitting, kicking, spitting) are at the tip of the iceberg. The big piece that we have to be concerned about is what is going on under the water (i.e., the unobservable skill deficits). What are those deficits that are impacting the child's behavior?

It is useful to find out what occurs during the time surrounding the behavior. What happens before the behavior? What happened afterwards? What stops the behavior? What makes it worse? When does the child not have challenging behavior? If you see a common thread, an environmental modification may be necessary, in addition to teaching some replacement skills.

5) Individuals with Autism Need Structure and Predictability

All people benefit from structure and predictability, but especially individuals with autism. If you're working in a school system, students with autism need schedules, routines and procedures.

Schedules. Since they have difficulty observing and imitating, a visual schedule will help children with autism stay on track so they know what comes next and where to go. It can teach them independence. Instead of relying on a paraprofessional or a teacher to tell them what to do, they can now refer to their schedule.

Schedules decrease anxiety. If you have a student who's constantly asking when activities will occur, or they have their schedule memorized, those are the children who need that predictive structure. They need the schedule written down in a visual.

Schedules help with transitions. Even if children have memorized their schedule, those are the children that need it the most. We have schedules to represent when things are different. When we have a doctor's appointment, our schedule needs to be altered. We have to to write that down. Most of us don't have schedules for our daily activities. We need to provide schedules for children so they know when events are going to occur that are different from their daily activities, so that they have a reference for those different activities.

The schedule can take different forms. It can include objects, photos, or symbols of daily activities. You might make a list of all of the day's activities, with pictures next to each activity as a visual. Dry erase boards work great for written schedules. If the child can't read, draw a picture off to the side. First/Then boards are useful. For example, "first math, then iPad." Even if the child is highly verbal, you can still use something simple like this. Just break it down into small steps. Older students or students who have good reading skills might do well with a Monday, Tuesday, Wednesday, Thursday, Friday type of written schedule, and each day might be different. They can see it at a glance, and they can cross it off when they're done.

Routines and procedures. If you're working in early childhood classrooms, make sure that you have routines and procedures. A procedure is how the teacher wants things done in the classroom. Routines are what students do without prompting or supervision. We must teach these routines and procedures, similar to academic content. For individuals with autism, they need to practice routines over and over again. The majority of challenging behavior is going to happen during wait times, and during times when the routines and procedures are not clear. Analyze when those times occur, and how can you break down and teach them those routines.

Use visuals, and break down the routine into small teachable steps. Many individuals with autism get overwhelmed with all the steps of activities. Think about how many steps are involved in hand-washing. There are more than five. How can we break those down and teach them step by step. The entire team needs to be consistent in how we're teaching the steps, and then we need to reinforce them for doing those steps.

Break time. Teach children about break time. In your classrooms, or even in home environments, have a designated break area. Taking breaks helps with self-regulation and stress. Things that happen during break should be calming, but not rewarding. You want to make sure that it doesn't lead to any other difficulty in the classroom. They are taking a break, versus getting a reward. It could just be a chair in a corner of the classroom where we let the student chill out. Teach it and practice it before they need it. Have them walk through what it means to take a break, and what you do when you're in a break. Teach them how to communicate when they need a break, by using a picture, or maybe some kind of signal to represent that they need a break.

6) Individuals with Autism Can Have Difficulty Understanding Verbal Instructions

It is important to pay attention how you give verbal instructions to a person with autism. Add visuals whenever you can, because your instructions can go in one ear and out the other unless you have it written down. Give them choices. If you're having a lot of power struggles, you can give choices, such as "Do you want to go to the bathroom now, or after I count to five?" or "Do you want to turn off the computer, or do you want me to turn off the computer?"

Provide simple instructions with one to two steps. Avoid giving an overwhelming long strand of instructions. Avoid "can" and "will" instructions. When you begin a sentence with "can" or "will," it is just like asking a yes or no question. "Can you do this?" or "Will you please sit down?" Instead, tell them exactly what you want them to do, or give them some choices.

There is a distinct difference between instruction and feedback. Instruction is when you tell the child what you want or what you expect. Feedback is what you provide after the behavior occurs. Instruction should be brief and concise (e.g., "Sit down"). Feedback can be more elaborate (e.g., "I like how you're sitting nicely in the circle"). Figure 3 shows some examples of providing verbal instructions.

Figure 3. Examples of verbal instructions.

7) Individuals with Autism Have Difficulty with Social Skills and Relationships

Two concepts that are essential for effective social communication are theory of mind and executive functioning. Theory of mind involves putting yourself in someone else's shoes. It is the ability to understand that other people have their own thoughts, ideas and opinions. Individuals with autism often are unable to understand things from another person's perspective. When you can understand things from someone else's perspective, you can make inferences regarding other's behavior. If you can't do that, it's hard to make a guess as to what people are going to be doing, or what they're thinking or feeling.

Executive functioning is the ability to do all it takes to keep your mind on what you're doing in order to accomplish a task. For example, taking notes in class, knowing what information to pay attention to during a lecture, organizing materials, planning your day. If you're in a meeting, and you're thinking about the groceries you need to buy later for a dinner party, you're not paying attention to the speaker. Many children with autism have trouble with executive functioning, as do many children with ADHD. 

The first question we need to ask regarding social skills is whether the child has a skill deficit, or if it is lack of motivation. If it's a deficit, we have to teach those skills. Maybe they don't know how to ask someone to play. Maybe they don't know how to ask people questions. We're going to break it down into small steps and practice it. We can start off in a one-on-one setting, and then we're going to move to a natural setting. We're going to incorporate peers and visuals. We're going to focus on teaching them the skill.

If the child has a lack of motivation, we're going to reinforce them when they're using the social skill. They might know how to do it, but it's so hard that they aren't motivated to use the skill. We're going to incorporate reinforcement, to get them to use those social skills (e.g., a token reward system). Perhaps give the child a higher reinforcement when they initiate on their own in natural environments. Eventually, as those students are more successful, that social piece will become rewarding in-and-of itself, and you won't have to use reinforcement anymore.

8) Simplify Difficult Activities and Help with Organization

We can modify activities by breaking them into small teachable steps. Again, using visuals is always helpful for individuals with autism. I also like to use what we call no-fail learning. When you're working on any kind of task, make sure that you're helping the child get it right from the beginning and then fade your help, versus letting them continue to make errors. For example, if I'm going to teach a student how to write the word "dog", I'm going to help them write it correctly the first time, maybe hand over hand. The next time, I'm just going to help them write the letter "D," and after that, I'm only going to help them with the "O." Gradually, I will fade my help, but I'm going to teach them how to do it the right way from the beginning with success.

9) Individuals with Autism Need to be Around Their Peers

To reiterate, the core deficit in a person with autism is social skills. That being said, we need to make sure children with autism are around their peers, because that's where they're going to learn social skills. Inclusion means offering the same activities to everyone, while providing support and services to accommodate people's differences. We're going welcome everyone in the classroom. We all have a seat in the general classroom, although some children might need different levels of support. Inclusion promotes a welcoming environment, where differences are valued and learning opportunities are accessible to all, in every classroom. This is not just valuable for individuals with autism. It is valuable for all students, because all of our students are learning how to work with each other's differences.

Here are some useful tips to promote inclusion:

• Educate everyone!
  • Administrators
  • Teachers
  • Assistants
  • All staff in school
  • Peers
  • Parents
  • Community
• Be prepared
• Have a plan that includes the entire team
• Better, shorter and successful, instead of pushing to failure
• High reinforcement!
• Get peers involved

I'll see some schools that claim they promote inclusion, but then they ultimately push the students into failure. Their attitude is, "We tried it and it didn't work." It may have failed because they tried to keep students with autism in the general ed classroom all the time, and maybe that wasn't the appropriate course of action. If they failed, we didn't give them the right support.

My advice is that if you're just getting started including children with autism in the classroom, begin with five minutes versus 30 minutes. Don't wait until they have a meltdown to remove them from the classroom. What that does is teach children that when they have a meltdown, they get out of this classroom. I'd rather it be a positive experience. End on a positive note so that the child enjoys being in there, and build on that.

10) Individuals with Autism and Their Families Need to be Supported by the Community

Think about community inclusion. It takes a village to raise a child with autism. The most recent statistic is that one in 68 children have autism. This is an epidemic. We need to think about community and helping these families, because they are struggling. One friend that I work with has a little boy with autism, and he's a safety concern. They have alarms in their house, and they have GPS monitors, and locks on the doors, but he is smart enough that if he has something on his mind, he will figure out how to get out the house. This is why we have to educate our neighbors, and make sure that we are all supporting this family and this child. 

There is a great resource through the National Autism Association called The Big Red Safety Box. If you go to their website (www.nationalautismassociation.org), they have different versions of The Big Red Safety Box (e.g., one for schools, one for families). They discuss preventative strategies, such as measures you can put in place to prevent things from happening (e.g., safety locks, monitors). They talk about the skills we need to teach individuals with autism. For instance, we can have them memorize their address and phone number, or their parent's name, and teach them how to ask for a break instead of running away. Awareness is another key piece when dealing with individuals with autism. We need to make everyone in the community aware of signs to look for and what to do if they think they encounter an individual with autism. I would strongly encourage families to go to the National Autism Association website and request a a free Big Red Safety Box packet of information. They will also send information to teachers.

Summary and Conclusion

In summary, there is an increased prevalence of autism. One in 68 individuals are diagnosed with autism. We all have to know about autism.  Remember that every student is unique. Autism does not define a person. What defines them are their individual characteristics: things that they're interested in, things that they are good at, things they like, things they don't like. Make it a priority to include students with autism. They might require more one-on-one attention in certain environments than others, but what they really need is to develop social skills by being around their peers. Additionally, peers can learn a lot from being around students with autism. It is critical to our society that we are teaching everyone how to work with each other's differences. It truly does take a village: when we look at safety and community, we all have to know about autism, and we all have to know what to do in order to support families and to keep children safe. Thank you for joining me today.