BY ROBERT J. BERNSTEIN
Progress comes with an individualized approach – in my case, a cognitive one – and must take into account the many contexts in which children must learn to function.
Jordan, a verbal 12-year-old with high functioning autism, was brought to my office by his mother, who was having tremendous difficulty dealing with his frequent tantrums in school. She was being called (at work) to take him out of school at least twice a week. Jordan was a fairly heavy teddy bear of a child, which was endearing until there was an issue in school. Jordan hit peers and staff when he felt provoked. Restraining or removing him from a situation was complicated by his size. His mom told me he also often had tantrums at home.
As an educational therapist who has worked with kids on the autism spectrum for more than 30 years, I know that no single approach suits them all. Progress comes with an individualized approach – in my case, a cognitive one—and must take into account the many contexts in which children must learn to function, whether on the playground, in the classroom, in family settings, and in public arenas. In my practice I use real-life interactions or I design opportunities in real-life settings, to enable my clients to gain developmental milestones.
When I evaluated Jordan I was struck by his lack of: understanding other people’s needs and desires, self-awareness, and patience to wait for something he wanted. He seemed to refuse to understand the concept of “later.” He had limited ability to follow directions or concentrate on a task that was not of his choosing. He was impulsive, and became physically aggressive when frustrated. He was functioning in those areas at the developmental level of a 16-month to two-year-old child.
I worked with Jordan in and out of the office, so that he could develop like any other child, in a variety of contexts. We ate out, went for drives, played sports, went for walks, went shopping, and attended local community events. The immediate goal was to decrease the frequency of Jordan’s tantrums. The long-term goal was to enable Jordan to develop the mindset and behaviors of his typical age-level peers. I also had a specific goal of enabling Jordan to make a genuine friend. (This is often an unstated goal of parents, who think it is too unrealistic to even voice.) I used real-life situations as treatment sessions. I also purposefully designed or staged situations to promote Jordan’s growth. I engaged Jordan’s mother, school staff, therapists, camp personnel, religious leaders, family friends, and neighbors, so that all would be using the methods with Jordan that I saw promoted progress.
First I needed to determine the reasons Jordan tantrumed. Jordan’s mom had shared the most recent episode that had caused the school to have her pick him up in the middle of her workday: Jordan had called a girl in his class “fat.” She did not respond negatively, but their teacher immediately chastised Jordan in front of the class. The teacher then reiterated the five things she had told the class previously, part of her “class rules,” that they were never to discuss, which included people’s physical appearance. Although he couldn’t grasp her meaning, the teacher’s tone told Jordan he had done something wrong, and he began to yell out, “I’m sorry.” He knew that was the right thing to say, but couldn’t control how he said it. The teacher persisted in admonishing him, and his loud apologizing became perseverative. The teacher called the assistant principal for help. When Jordan didn’t follow his instruction to calm down, the assistant principal began to physically remove Jordan from the classroom. Jordan, completely out of control now, kicked him. That’s when his mother was called.
It was clear to Jordan’s mother and to me that Jordan had no malicious intent in using the word “fat.” He was simply being his honest, unfiltered self. I met with his school staff and explained the teacher’s “class rules,” were meaningless to him at that point in his development. It was impossible for him to understand that he had done anything wrong, since he was unable to see things from someone else’s perspective. Reacting to his behavior as if he were a typical 12 year old set him into a downward behavioral spiral. I suggested that in the future, they might prevent tantrums by assessing the specific situation rather than going by a general “rule.” For example, the girl in question had not been bothered, but the teacher chastised Jordan anyway. Another option was speaking privately to Jordan, with a more “teaching” rather than an “accusatory” tone; e.g., explaining to Jordan that while this girl was not offended by being called “fat,” other people might be.
In order to help Jordan develop more typical age-level thinking and behaviors, which would help reduce his tantrum, I and the other adults in his life needed to help him to continue to become more flexible, see situations from other people’s viewpoints, follow directions, concentrate on tasks, speak at a reasonable volume, be reflective and thoughtful, and be less reactive, perseverative, and anxious.
When I first met Jordan he was terribly inflexible. He wanted to do what he wanted when he wanted it, and when he didn’t get his way, or get it soon enough, he whined, cried and screamed. A real-life situation I used to enable him to become more flexible was to ask him what he wanted, and then immediately suggest another option, which I knew he also liked. I always presented the other option by saying it was what I wanted. Initially he insisted on having his first choice; e.g., chips not popcorn. I would continue to campaign for popcorn, saying I wanted him to have it so I could have some of it too. He would become somewhat upset. The first few times, I needed to say he could have chips, but only if we had popcorn first. My goal was to get him to switch gears. Once he was able to agree to my idea, I talked it through with him, making sure he was okay with the new plan and having him feel that he was making a reasoned decision. This is an important step in “negotiations” with kids on the spectrum – deescalating, so the child feels in control in a new positive way about the outcome; not that he’s won a battle as he has in the past.
I designed a situation to help Jordan understand another person’s viewpoint by asking my assistant, Elaine, to delay her regular arrival time. Jordan arrived and she wasn’t there. He said, “Let’s go skating.” I reminded him that Elaine was supposed to come, and asked what we should do. Jordan said, “Go without her,” a reflexive response typical of a child with high functioning autism. I said I was concerned. I asked what would happen if she arrived after we left, and what he thought we could do. He thought for a minute and said, “We should call her.” My purpose in this was to give Jordan the responsibility of making a considered and considerate decision, not automatically reacting in his usual egocentric way. I identified the dilemma in the situation for him, he reassessed it and was able to think more flexibly and consider Elaine’s point of view. A critically important element of this kind of exercise is to make the situation the point of conflict in the child’s mind, not the person who is in the situation with the child. I was careful not to present it as a “fight” between Jordan and me; I made the “conflict” inherent in the situation.
The next designed situation I used to help Jordan develop more flexible, less egocentric thinking, and awareness and respect for other people, was to have his mother join us the next time we went out. We played a game of air hockey and I purposely won to see if he could deal with losing. He seemed fine, which indicated to me that, just as with his tantrums improving, he was beginning to accept not always getting his way. I suggested that his mother might like to play. Jordan said he would play with her.
I then created a dilemma. I said I wanted to play too. He now had to find a flexible-thinking, creative solution to accommodate both his mother and me. And he did: he suggested that whenever his mother or I scored a goal on him, we would switch places, thus giving us both an opportunity to play. This acceptance of two other people’s wishes and thinking creatively were beyond anything he had ever done before. I then created a more sophisticated dilemma. “The whole purpose was for your mother to play. I already played. She hasn’t played yet. Why should she have to sit down half the time?“ In the past, pushed this far, Jordan would have exploded, “Forget it! Let’s do something else.” Now he thought and came up with another creative solution; to enable his mother to get full playing time, he and I would switch off after one of us scored a goal. Remarkably, that his solution meant he limited his own playing time. I asked him to explain the “rules” he’d come up with, in order for him to reflect on what he’d established and solidify it in his mind. The next thing to do was play, not as a “reward” but because it was the next natural thing to happen. As we played, I never said anything like, “Okay, now it’s my turn.” I left it up to Jordan to remind us when to switch.
By taking ownership of the system he created, which accommodated three peoples’ needs, and included sacrificing some of his own desires, Jordan was able to feel the satisfaction that typical people find frequently, in social situations to make other people happy. This was an enormous step for him in shedding typical autistic modes of thought and behavior and gaining typical ones. And it made me believe Jordan was ready to make a genuine friend. Like many children with autism, Jordan had never had a true friend. By “true” friendship I mean one where there is healthy give and take, and mutual respect. A friend’s child, Casey, one year older and also with high functioning autism, seemed to me a good match for Jordan. I had them meet in my presence in order to facilitate positive communication. They didn’t connect at first. As their communication broke down, I intervened. Jordan told me later that he liked that. He was so often misunderstood by other people and did not yet have the ability to see what another person might not understand. Having me do it for him felt like a great relief to him. Both boys seemed to enjoy their exchange of ideas. I continued to have them meet in my office once a week for six weeks. By week four they took control over choosing the shared activity. By the last session, they were interacting entirely independently of me. After that they began to visit each other, and went bowling and to the movies together.
Casey and I were invited to a celebration for Jordan. With a house full of people, Jordan’s mother found him in his room. She asked for my help. Jordan was playing a video game. I told him that Casey was in the living room, not talking to anyone. I asked Jordan what we should do about it. He didn’t answer. I continued to press the issue, so that Jordan would recognize Casey’s point of view; he had traveled to be with Jordan, he didn’t know anyone at the party, and Jordan had disappeared. Jordan got it, and went out to Casey. They spent the rest of the afternoon together enjoying this people-filled social situation, quite a remarkable feat for both.
Jordan responded more favorably to Casey than his mother when it came to learning to control his behavior. His mother told me that when she told Jordan not to grab a piece of chicken at dinner, he ignored her. But when Casey said, “You should ask first,” Jordan asked politely thereafter. The boys’ friendship continued to grow. Jordan’s self-esteem began to soar, knowing that there was a peer who genuinely liked him. In Casey’s presence, he controlled the negative behaviors he still displayed to some extent at home and at school. I pointed this out to Jordan, that having a friend he trusted and related to enabled him to control his behavior more than he had ever done before. Jordan acknowledged this, and I was then able to use it to show him that if he was able to exhibit control with Casey, it meant he had control, and could choose to exercise it in other situations for which we had identified triggers.
With a real friend in his life, Jordan’s happiness and behavior changed dramatically. For example, in order to make plans with Casey, he called him on the phone and often Casey’s mother would answer. Jordan then had to talk to Casey’s mother, speaking respectfully, answering her questions, etc. Making plans at all was a new behavior – it requires a level of executive functioning that people with autism often have difficulty engaging. Put in simplest terms, friendship takes the “aut” – self-involvement– out of autism, as it requires concern for the well-being of another person, consideration of another’s needs and ideas, and full-on engagement with someone else.
By the sixth month of our work together, Jordan’s tantrums were few and far between, and his overall functioning was roughly at a 10-year-oid level (and higher when interacting with his first real friend). By educating the adults in his world to meet Jordan at his developmental level, and by helping him develop more flexible thinking, problem solving, and communication skills, the tantrums, which were symptoms of tremendous frustration, were almost gone, and his newly developed abilities brought him to a point of the greatest social change – making a real friend.
ABOUT THE AUTHOR:
Rob Bernstein’s methodology encompasses understanding the systems and cognitive processes that underlie outward behaviors in order to create fundamental and lasting change. To learn more about Rob’s approach go to www.autismspeech.com. You can also reach him at 914-330-3393.
