Asperger Syndrome Article Review

The article The Social, Behavioral, and Academic Experiences of Children with Asperger Syndrome by Church, Alisanski and Amanullah (2000) is a descriptive study of children with Asperger Syndrome (AS). By conducting a retrospective chart review that is, examining comments, observations and reports from teachers, physicians and parents on the childrens past and present health care records the authors tracked the development of the childrens social skills, behaviour, language skills, sensory issues and academic skills from age 3 to 17. The use of a retrospective chart review has its disadvantages, including availability and accuracy of records, possible case selection bias and the fact that there is no control group to compare it to (Hess, 2004). The authors addressed the availability issue by ensuring that they only chose children who had health care, school and family data available or obtainable, and attempted to address the accuracy issue by seeking verification of information from the parents or children. The latter action, however, has its drawbacks given that parents and children may have been relying on recollections from previous years, thus casting doubt on the accuracy of some data. Additionally, the lack of a control group to compare findings prompts questions about how many of the identified characteristics are Asperger-specific or how their frequency or intensity differs to that of neurotypicals. Despite these criticisms, the article remains a useful resource for those working with children with AS, by identifying common characteristics as well as highlighting variability of these traits between children and over time. The first section of this review will examine the studys findings as they relate to children in the elementary years of schooling (ages 6-11) and discuss how these can be utilised to inform teaching practice. The second section will discuss the studys findings on social skill development over time and how these findings sit in relation to broader AS theory and research literature. ASPERGER SYNDROME IN THE ELEMENTARY YEARS Church et. al. (2000) synthesised data from the records of 39 elementary students aged 6-11, and categorised their results according to social skills, behaviour, language, sensory issues and academic skills. In doing so, they identified key elements that resonate strongly in the data. Findings of particular note in the elementary years included increased social and motor skill difficulties, a reduction of sensory integration problems and increased obsessive and orderly behaviours. However, their descriptive study also demonstrates the variation in how AS manifests itself from person to person, and echoes the sentiment that if you know one child with ASD you know one child with ASD. As such, it is paramount that the needs of each individual are assessed, addressed and monitored. To this end, Table 1 lists some assessment tools for each of the categories examined in the article that could be used by teachers to determine student need and monitor student progress. Academic assessment has been left out as students with AS should be able to access the same assessment items as their peers, albeit with appropriate accommodations and adjustments where necessary. Social Skills The study found that all students in the sample were experiencing significant social difficulties (Church et. al., 2000, p.14) by age 6 or 7. Although these difficulties presented themselves in various

ways, there were a number of common elements relating to lack of social reciprocity, inappropriate social interactions (in your face interaction or touching) and inability to read social cues. Given that the elementary years introduce children to the classroom and the schoolyard it stands to reason that, as noted by Church et. al., this uncharted territory is challenging for children with AS as they are exposed to novel and more complex social situations. Furthermore, these social skill deficits may become compounded by continued negative interactions, resulting in peer alienation. Practical Implications for Teachers The area of social skills emerged as the most prominent issue during the elementary years due to the impact of increasing social demands on students with AS. As such, a significant portion of this discussion will be dedicated to this area. Given that this period is essentially the childrens baptism of fire into the educational realm, teachers play a vital role in not only assisting students with AS to develop socially appropriate behaviours and pragmatic language skills, but also in creating an accepting and inclusive social environment. There are a number of ways in which teachers can achieve this, and some are detailed in Table 2. However, research shows that many of these social skill interventions will have little effect, maintenance or generalisation unless: (a) there is a sufficient dosage of the intervention (i.e. 30 hours of instruction over 10-12 weeks is insufficient); (b) the intervention is conducted in a contextualised environment; (c) the strategy matches the skill deficit; and (d) the intervention is implemented correctly (Gresham, Sugai & Horner, 2001). The upside is that many of these social skill interventions can be easily linked to syllabus outcomes in English, Drama and PDHPE, thus ensuring that teachers can integrate social skills training into their day-to-day teaching. For example, social stories can be linked with English (Reading), and role plays can be linked with Creative Arts (Drama), English (Talking and Listening) and PDHPE. These strategies are extremely useful for teaching students about overt social behaviours, however, teachers should also be conscious of bringing the hidden curriculum into awareness for students with AS. These unspoken, subtle social nuances provide particular challenges for students with AS (Myles & Simpson, 2001). Behaviour The study found that during the elementary years, behavioural hallmarks of the students in the sample were: a strong desire for routine, ritual and order; a need for strict adherence to rules; and an increasingly intense fixation on special interests. Additionally, although repetitive movements such as hand-flapping and spinning continued to occur during times of high anxiety, they began to decrease during this period, with self talk, humming, drumming and pacing the most frequently cited repetitive behaviours. Practical Implications for Teachers Teachers can address a students need for routine, ritual and order by utilising whole class and/or individual timetables as well as task sequence cards. Transitions whether they be vertical (from grade to grade) or horizontal (from lesson to lesson) should be clearly signalled and students should be well prepared for them. In terms of rule rigidity, basic good teaching practice of applying classroom rules fairly and consistently becomes paramount when working with a student with AS. However, at the same time

students need to be taught appropriate ways of dealing with rule breakage and cheating, and should also be taught that sometimes changes need to be made or flexibility. These can be tackled via some of the social skill strategies. As for the students special interest, a teacher can capitalise on this in a number of ways. To begin with, teachers can weave the students special interest into the curriculum, thus strengthening the learning process (Brownell & Walther Thomers, 2001; Safran, 2002). Additionally, a childs special interest can be used as a means of facilitating social interaction (e.g. photography club or games Safran, Safran & Ellis, 2003) or provide opportunities for social valorisation (e.g. trained to become the school tech expert Marks, Schrader, Levine, Hagie, Longaker, Morales & Peters, 1999). It can also be utilised as a motivator in reward activities (Safran et. al, 2003) or behaviour prompts such as Gagnons (2001) Power Card Strategy. However, it is important that the special interest is kept in check, lest it becomes all-absorbing and/or becomes a cause for peer ridicule (Safran, 2002). Language Closely linked with social skills, the students language skills in the elementary years indicated that pragmatic language was the key area of weakness in the sample, relating mainly to lack of reciprocity and a tendency to engage in long monologues on a single topic. Additionally, there were found to be problems with voice modulation and inflection as well as gestures. These deficits existed despite 96% of the sample receiving speech and language therapy to specifically address pragmatic and prosody skills. Practical Implications for Teachers As detailed in the assessment section, collaboration with a students speech therapist is an important part in the planning, programming and assessment process for students with AS. In terms of classroom implications, many of the pragmatic language issues can be addressed via the social skill interventions mentioned earlier, including turn taking, greeting, gestures and explicit instruction about the reciprocity of social interaction. As for vocal quality (voice modulation and inflection), teachers can utilise strategies such as The Incredible 5-Point Scale (Buron & Curtis, 2003) adapted to show a scale of voice volume from no talk to yelling. This scale can then be used to teach students appropriate levels of volume in various situations with a view to self regulation. Sensory Issues The study revealed some significant changes to students sensory needs during the elementary years. Firstly, although many of the children had sensory integration problems throughout the period, most of these were eradicated by age 11. Additionally, there was increased concern about motor skills, with the authors putting this down to an increase in the number of organised athletics events that the students would have been participating in at school. Interestingly, the study also noted that during this period, several of the fathers in the study were becoming frustrated at their sons preference to engage in indoor activities (TV, computer) rather than outdoor activities. This may indicate that students in this age group were also starting to become aware of their own motor deficits and were subsequently choosing to avoid related activities. Practical Implications for Teachers Although the study indicated a decrease in sensory integration issues, these still persisted to some extent. As a result, teachers need to be aware of the sensory needs of their students (via assessment or collaboration with the childs OT) and ensure that accommodations are made to reduce any sensory triggers. Additionally, teachers should undertake any appropriate desensitisation activities that have been suggested as a result of collaborative planning.

In terms of developing gross motor skills, teachers should differentiate the physical education curriculum to ensure that students with AS experience success. This can be enhanced by ensuring that physical activity is presented in terms of health and fitness rather than in a competitive way (Williams, 1995). It may also be useful to increase proprioceptive input by adding weight to the childs body or objects so that students will be more aware of their body parts (Dunn, Saiter & Rinner, 2002) Similarly, collaboration with an OT to establish a fine motor skills program may also be important. To complement this, accommodations may need to be made for the student including additional time to complete handwritten tasks, the use of a computer or personal notetaker (e.g. Alphasmart) for transcribing written work, or support during cutting/pasting tasks. Academic Skills For most children in the sample, their schooling experience was a positive one, and the authors attribute this to the confidence instilled by high grade achievement. In terms of this academic achievement, the study found that the children with AS possessed above average maths and computer skills. In literacy, the authors state that most of the children possessed above average reading skills, however this must only relate to decoding skills as they also state that comprehension skills were poor unless the text was factual. Reflecting similar deficits in gross motor skills, the childrens fine motor skills were of concern at this age as evidenced through reference to handwriting difficulties. These handwriting difficulties were compounded by their need for order as many students work habits were described as slow, meticulous and obsessive. Practical Implications for Teachers Any academic strength for any child should be celebrated, and this is no different for students with AS (whether they fit this studys maths/computer profile or not). However, celebration of these strengths is particularly relevant to students with AS as it may serve as a bridge to the social world(Safran et. al., 2003, p157). In literacy, whilst decoding skills are generally good, comprehension skills are conversely poor, particularly when dealing with fictional texts. These should be explicitly unravelled with the student, much in the same way a social autopsy is conducted. This can be supported by teaching the student to use scaffolds or prompts such as graphic organisers or mnemonics (Marks et. al. 2003). SENSORIMOTOR ISSUES IN STUDENTS WITH ASPERGER SYNDROME The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Test Revision (DSM-IVTR: American Psychiatric Association, 2000) states that people with Asperger Syndrome are characterised by: qualitative impairment in social interaction; qualitative impairments in communication; and restricted, repetitive and stereotyped patterns of behaviour, interests and activities. As such, the criteria make no mention of sensorimotor difficulties that is, a combination of symptoms resulting from aversive responses to nonharmful sensory stimuli (Wilbarger & Wilbarger, 1993, as cited in Huebner, 2000). However, it is commonly accepted that many students with AS experience sensorimotor difficulties and some researchers argue that sensory-motor issues are an underlying feature of AS (Attwood, 1998; Fling, 2000). Others, however, believe that it falls under the repetitive and stereotyped behaviours category (Dunn, Myles & Orr, 2002). Regardless of this semantic stoush, it is clearly evident that sensory-motor issues can present difficulties for students with AS. Church et. al.s (2002) study reveals some interesting things about sensory-motor issues. To begin with, they found a trend of sensory-motor issues reducing in severity from ages 3 through to 17. On one hand, it could be argued that this is a discrepancy given that there were 40 students in the preschool sample and a gradual trickle down to five students in the high school sample. Naturally, this would imply that there would be less data from which to draw from in the latter years. However, this is somewhat countered by the fact that reports, observations and commentary in the childrens health records specifically note a reduction in the severity of many of the sensory integration issues. A visual and textual representation of this decrease can be found in Chart 2.

It is difficult to determine whether this reduction is due to sensorimotor interventions or just a naturally occurring desensitisation and/or adaptation. The authors note that during the elementary years, 58% of the children were receiving occupational therapy to counter fine motor issues, while 33% were undergoing physical therapy to deal with gross motor issues. However, the authors do not note any overlap between these groups, nor do they provide any information that correlates the therapy with the reduction in sensorimotor difficulty. Research supports the efficacy of sensory integration therapy, and has had particularly positive effects with students with autism in the areas of self-care, play, attention, motor skills, language and psychosocial interaction (Huebner, 2001; Case-Smith & Miller, 1999), however there little evidence to gauge the degree to which it improved it. The study also revealed an interesting spread of difficulties across the various senses, as displayed in Table 3. Auditory and tactile sensory difficulties persevered throughout all age groups, which reflects the sensory observations made by Asperger (1944, as cited in Dunn, Myles & Orr, 2002) in his initial study. Aspergers also observed responses to taste stimuli in his case studies (who were aged 6-11) however in this sample, sensory issues pertaining to taste (gustatory system) were not mentioned beyond age 5. Additionally, it is interesting to note a lack of reference to sight or smell sensory issues. The former area is of interest given that students with AS are often considered to be visual learners and that visual processing is regularly a strength (Quill, 1995, 1997, 1998, as cited in Dunn, Myles and Orr, 2002). Church et al.s findings seem to support this idea, in that no concerns were raised about deficits relating to the visual sensory system. However, this sits in contrast with findings by Dunn, Myles and Orr (2002) who found that children with AS had significantly lower visual processing scores than students without AS and cite this as an area for further research. AN OVERVIEW Church et al.s (2002) article, The Social, Behavioral, and Academic Experiences of Children with Asperger Syndrome, presents a developmental timeline of children with AS. As a result, the reader can choose to pluck information from an age group that is relevant to them, or can trace the development of a particular AS trait over time. Both of these actions are useful for informing a teachers planning. Although some criticism can be levelled at the methodology (a retrospective chart review) and the thoroughness of the data could be challenged, it still gleans a number of important aspects from the data, and highlights key issues pertaining to social skills, behaviour, language, sensory needs and academic skills that can be used effectively by teachers. REFERENCES

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