Supporting the Caregiver in Creating a Connection with a Hard to Reach Child

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I had the pleasure of observing a preschool teacher, Lisa, with an almost 4-year old boy with autistic spectrum disorder, Max, in the classroom last week.  What became clear is that what is necessary with children like Max is a shift in perspective to the essentials of learning. Instead of a focus on teaching him academic and concrete skills, one could instead emphasize above all social relationships and the communication of emotions. (This is not new; Stanley Greenspan and his DIR followers to a refined degree have developed these ideas in the technique of “Floor Time”.) In the list of priorities after social relationships and the communication of emotions, is regulation – because regulation is critical but it can’t be supported outside an affectively attuned relationship. Next, it is important to place Max’s initiative in the center of the relationship; helping him make decisions, feel like an active agent in the world. Finally, you want to help Max make links between his internal states (emotional and physiological arousal states, such as calm or revved up) and his behavior. You also would like to help him make these links between other people’s feelings and their behaviors. 

So, let me address my observations. I want to mention up front that these thoughts consist of my elaborations of the consultation I had with Debbie Bausch, my friend and colleague who is a DIR (“Floor Time”) O.T. and sensory perceptual specialist. 

First of all, I was very appreciative that the school had gotten a swing. Regulatory breaks are so important and the swing can be a resource for many children. In the swing, Max can experience calm. Once he is calm, he can make use of person-to-person interaction, with the aim of creating reciprocity. One can ask him, “Max, shall we go faster or slower?” He can be part of the decision about how to swing – back and forth, fast and slow. That is scaffolding his initiative. When I saw him in the swing, he was calm, and he looked at me and smiled, demonstrating that he was ready for an interaction. That is a good swing for him. 

The swing break was called to a close by the entrance of other children. Lisa was gentle and patient with Max in helping him make the transition out of the swing. The slow pace she used consistently during her time with Max was perfect for him. Slowing things down makes them easier to understand. That is especially true for a child with processing problems, as most children with developmental disabilities have. When Lisa and Max were putting away the swing, Max was trying hard to hold himself together. There was a lot going on for him – the stimulation of the other kids coming in and the challenge of going through the motoric, physiological, sensori-perceptual, and affective transition from the swing to standing upright and leaving the room to return to class. He used his hands in his mouth as a self-regulating behavior here and at other times during the morning. Debbie mentioned that a special hard plastic bracelet could be used for this kind of oral stimulation. 

If Max were calm enough, this would be a good time to give him some more information, such as, “Max, look! The other children are coming in! We have to get out of the swing because the other children have activity time!” In general, it is good to narrate all these small, ordinary events, because first of all it is not clear that he perceives them (due to processing and attentional problems) and also because it gives you a chance, using your adult competencies, to scaffold his meaning making of the world. Of course, you always have to “read” his state to see if he is well regulated enough to take in that information. Also of course, you can never be right all the time about this. It is a messy, sloppy, business – reading someone else’s state. Yet I would bet that most preschool teachers are particularly good at reading non-verbal cues, and you will get to know Max’s cues, such as putting his hands in his mouth, squiggling around in his seat, etc., better and better. 

In general, once he is calm enough to communicate, it is good to direct him into a back and forth communication. “What should we do, should we swing faster or slower?” with the swing, or, “Shall we walk or hop?” when you are walking down the hall. This could be described as a “sensory-emotional break” (Debbie Bausch). 

After that, it is time to prepare him for what is coming next. What will be expected of him in the next period of time? It is good to think ahead and help him get ready. Lisa repeatedly talked to Max about what they were going to do. She bent down to his level and spoke slowly to him about going back to his classroom. She asked him what he would like to do and when he did not answer she suggested the block corner. If Max had been in a state of better regulation, he might have been able to participate in the decision that Lisa tried to engage him in, but the stress of making the transition may have gotten in the way.  Debbie suggested giving him a whistle to blow to exercise his oral senses, and some heavy beanbags to throw, or to carry when he walks down the hall as an aid to regulation. Sometimes maneuvering so that you are in his line of vision (not intruding into his “space bubble”, but right there if he looks up) can help engage him in exercising his initiative. Experiment a little; it may take him longer to look at a face. Other times, slowing things down even further can help. Another thought is to back up and talk to him when he is still in the swing, calm and attentive, before moving down the noisy hall.  If he is still sitting in the swing when you are talking to him about what is going to happen next, you can have ready some alternative ways of communicating to him about the next step. For example, you can have cards with pictures of the activities, in case he doesn’t respond to the words. 

The main point here is that Max’s teachers will need to learn to imagine what is going on in Max’s mind. All these things going on around him during the day do not connect for him; the world is chaotic. Even inside of him it is often chaotic.  His teachers will have to find answers for the question of when is he at his best, and how can they make school easier for him.  

Walking into the classroom, Lisa saw that the blocks corner was occupied. She was right on target when she explained to Max that there were already “four friends” in the block corner, so that they would have to make another choice. She helped him choose a book. This was my favorite part of the observation. In the book corner, Lisa found many opportunities to teach Max about himself and his world while he was calm and regulated. As they were sitting down, Max picked up a wooden board on the bookshelf, and remarked, “Art Activity!” Lisa responded positively to his communication. I thought this demonstrated a real strength on Max’s part. I would like to think that I would have been able to join him there and say something like, “Oh, Max, yes! Art Activity! I remember when you made X or did Y in Art Activity!” But I do not know for sure if I would think of it. That is why it takes practice to “imagine Max’s mind”. Once you get better at it, you more naturally think of joining him in those moments and expanding a little on what he has started. In those cases you are helping him make more sense of his world than he could do by himself, using your adult competencies to scaffold his meaning making, and simultaneously supporting his agency by recognizing what he has done and taking it a step further.

Then, Janie came over, holding a book. This might be an opportunity for teaching about relationships and about the rest of the world in that context. For example, “Oh, look! Janie is coming over!  Look what she has! Shall we ask her if she wants to read a book with us?” Or one could do it an even easier way for Max: “Janie, Max and I are going to read a book. I am going to ask Max if he would like you to read a book with us. Max, would you like Janie to read a book with us?” The difference is that by addressing Max first you are taking the social pressure off him and also previewing the central point of the social communication – does he want another child to join. It is also a good example of the way I work with Gil Kliman’s “Reflective Network Therapy”, making use of the classroom to help Max make sense of his experience of himself with a peer. 

Another thought is that when Max is asked to choose a book, the choice may overwhelm him. That is when you can make it easier for him by taking two books out and asking him to choose between the two. By limiting the choices but emphasizing his choosing, you scaffold the processing task he needs to use his initiative. 

When Max reads the book, he is calm and totally engrossed. He has chosen a book with pictures of his class. He recognizes each classmate by name and points to him or her. This, again, is a significant strength. One of the hallmarks of his disorder though, his lack of looking at Lisa’s eyes, interferes with his taking in other crucial information. He looks only at the book. That is a less challenging way for him to take in information than by looking at the constantly changing facial expression of a person. It would be good to gently but persistently try to get him to look at your eyes. There is a wonderful point in the book reading when Max points to the eyes of the child in the book and then at the eyes on the figure on his shirt, and Lisa says, “Does Max have eyes?” pointing to Max’s eyes, and then, “Does Lisa have eyes?” At that moment, probably the best moment in the observation, he looks directly into her eyes and sees her smiling at him. This of course is what he misses when he doesn’t look at the other person’s face. That was truly what I call a magic moment. One would like to repeat that magic moment. One way you could do it is by pausing now and then and making a big expression with face and voice say, “Oh, yes! That’s Jacob! I remember you playing ball with Jacob!” or something like that. If you look at his face, you will see lots of little facial expressions that you can comment on, again enhancing his awareness of his own inner feelings, such as, “Oh, Max. I can see that you like that picture!” or “Max, I think you do not like that picture!” In the observation, Lisa uses Max’s pointing to pace their activity, a great way to support his initiative. 

Then little Janie barges in and sits in between them. Interestingly, Max does not seem to notice that she is there for quite a while. Is this because he cannot attend to these two things at once? Is it because he cannot easily scan the periphery and return his gaze to the page of the book? I don’t know, but one could help him take in the information with words: “Max, Janie is coming to sit with us. Is it OK that she sits in between Max and Lisa?” When Max notices Janie, he gives her a direct gaze and a smile; then, he leans over against her, and she squeals in annoyance. It appears that Max really desires a connection with Janie but doesn’t know how to do it. This is the time, Debbie says, when the teacher could put a little weighted lap pad or pillow on his lap to give him some of the sensory input that he seems to need to regulate himself. One could also talk to him about it, “Oh, Max. You want to sit next to Janie! It makes you excited to sit next to Janie! Let’s use your pillow to help you keep calm while you sit next to Janie.” In fact, Lisa does recognize what is going on and gives him information about what he might do – “You could say, ‘Hi’.” She also gives him some pressure with her hand to help him regulate himself. Then Lisa directs Max back to the book, and in a nice attention shift, he joins her. 

The next step might be to engage Janie in reading the same book. You can say, “Oh, Janie, Max knows the names of all the kids!” or “Max, Janie is wearing the same necklace in the book that she is wearing now. Look at her necklace!” then point back to the book. Not only is that working on his relationships and using the neuro-typical peer as a co-teacher, but it is also working on his ability to flexibly move his body and his attention from one point to another. 

During the rest of the observation, Lisa was able to get Max to use his matching board, though he clearly was having a hard time staying regulated, and even to get him to help her pick up the cards that he dumped behind the bench (in an expression of protest). I was left thinking that this was a child with real potential growth and a teacher with real talent. On the other hand, I was also left with the clear imperative to give the teachers the recognition and support that they deserve and need with this wonderful but very challenging little boy.

 

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