Mod 8-Transition to Adulthood

We might consider Jonny as being far from his transition into adult life. However, as we have heard and seen in many commercials "Life comes at you fast."

Even though we are helping Jonny's family manage his transition into a school- age kindergarten program, we need to be aware of all the skills that we can teach him as a preschooler or as early elementary student that will help him be successful as an adult. Helping Jonny manage his environment by placing supports initially but removing them as he is successful will help him be less prompt dependent as an adult, minimizing the 'learned helplessness' that is alluded to by Miller-Kuhaneck. Continued development of Jonny's social skills in small group setting will allow him to become more successful as he attempts to interact with peers in school and in other social situations. We can both expect and hope that the many years of practice will only allow Jonny the chance to enjoy a happy adult life that includes productive employment and fun with friends!!

Week 7: Family: Living with autism

As review from the first post, Jonny lives with his parents and older brother. Both parents work and he spends long hours between his specialized classroom and daycare before going home around 5:30 each weekday. There is little consistency between program's although program staff are assigned to the daycare to teach them strategies that are used in his classroom. Because of the parent's work schedule , the communication book sent home from the classroom does not have much information on how tings are going at home and requests to ask for information may go unanswered for several days.

Jonny 's emotional state is very variable. he can be smiling one minute an become very 'whiny' and upset the next. Although he is not a physical or aggressive child, this behavior can be very upsetting for parents as they try to move through a normal routine after having a long day at work, especially since they do not see their child for very much during the weekday.

Obviously these parents are very overwhelmed with their home responsibilities and raising 2 children, 1 with autism. It appears that beyond environmental complexity and processing for Jonny, as stated in previous posts, that some of his behaviors are learned in order to attain what he wants to do in the easiest way possible over 3 very different settings. The best suggestion is to get all parties working with Jonny at the table again and discuss a plan that is very consistent with all 3 environments. Jonny is going to the school age program in the fall, so really 4 programs should be involved. It has been very difficult for parents to be able to attend meetings, so the chances of this happening are not great, but Jonny's greatest chance of success for next year will be to at least gather the groups that will be involved with him as he starts in the fall.

Module 6: Social Skills and Perspective taking, mental flexibility

Jonny has many challenges in independent participation in his preschool setting, even when provided with antecedent supports such as social stories and review of the rules for play during free time. Jonny’s difficulties lie in the areas of perspective taking and social referencing ( attention, eye gaze and joint attention).

Jonny has many special interests that he enjoys engaging in during free play time. One of them is dressing up in a cowboy costume and walking around the room. He enjoys other children and tries to get some of them to participate in the dress up routine, but he attempts to specify the costume the other child should use. His lack of perspective taking makes it difficult for him to understand it when the child protests using the particular costume and decides to play something else. In addition, if a child does decide to play, he becomes so consumed in walking around with his costume he forgets the other child is also playing with him.

Social referencing is also an area that affects Jonny’s interactions with others in the classroom. He has difficulty in maintaining attention during circle and often needs to be called personally to respond while many others have answered chorally. He needs more specific and repeated attempts by staff to get his attention in order to get him to follow a point or a gaze toward the area that has the item of interest that the teacher is discussing. When Jonny tries to express himself, he is often turned away from his peers and is not able to modulate his voice to be sure that he is heard and understood. In addition , unless an adult tells him, he will continue repeating the same message over and over, not realizing that he needs to modify his delivery and not sure how to go about doing it when he does. The lack of response to his requests results in Jonny getting very ‘whiny’ and upset, and he sometimes drops to the floor and refuses to participate further.

Module 5 - Motor Control and Motor Learning

Jonny demonstrates poor precision in his grasp and uses the ulnar fingers of his hands rather than his thumb, middle and index finger to do activities such stabilizing a bead before stringing it. Other manipulation tasks are also affected by this poor precision. He uses 2 hands together to throw any size ball.

Jonny is right hand dominant for tasks and can cross mid-line, although he tends to use either hand for tasks. Jonny has difficulty in processing the sensory information to the point that it affects his posture and muscle tone. Due to this, he has poor endurance, leans on others for support and often needs to use his other non-dominant hand for support rather than to help in completing a bi-manual task. He tends to avoid activities that are physical in nature, using inappropriate behaviors such as crying, whining, or emotional outbursts. This is exacerbated in his preschool, where there are an increased number of children, more unstructured time and less consistent follow-through in using the strategies that are set up for him.

Motor programming may be an additional factor for Jonny. In addition to his fine motor precision, as he needs additional time to complete tasks that have sequences of activities, such as bead stringing and just making snips on a piece of paper. He has difficulty with self-help tasks such as opening and closing fasteners and independently undressing or dressing without cues and prompting, even though he can complete most individual steps independently.

The strategies that are built into Jonny’ program are to use backward chaining to complete self-help activities, with multiple practice opportunities and well as visual supports that provide a more permanent picture of the motor plan that is being addressed. Jonny participates in sensory activities to reduce arousal and to calm him before going to the motor room for activities with the large group. Social stories or a visual schedule are used to prepare him for the activities that are coming. Prior to fine motor tasks, weight-bearing activities ask or manipulating small toys is encouraged to strengthen arm, shoulder, hand and finger movements. The OT consults with Jonny’s teacher in the daycare to carry over the strategies.

From what I have learned in the recent module, I would try to use play to increase Jonny’s motor planning skills. Play is a goal for Jonny already, but I would adjust strategies by observing his play without supports at this time given the information I have on Jonny and motor planning. I will incorporate strategies that will begin at the level of functioning he is at without support, adding strategies such as imitation, using motivating toys (which is already a strategy), and visual play schemes created with his help ( ideation) . I would gradually increase the complexity and encourage flexibility to expand play to help increase motor planning for Jonny. I would encourage the staff that supports Jonny in his daycare to make the daycare staff aware of Jonny’s motor planning difficulties and consider adding additional strategies there as they become successful for him in his specialized preschool.

Miller-Kuhaneck, Heather. Autism: A Comprehensive Occupational Therapy Approach 2nd Edition. Bethesda: The American Occupational Therapy Association, Inc., 2004.

Week 4- Cognition/Action//Perception/Modulation

When Jonny was referred to our program, he received a comprehensive multi-disciplinary evaluation. A service consultant completed the Battelle Inventory of Basic Skills and found that Jonny had difficulty in areas of pre-math, pre-literacy, and imitation of block designs. Attention was fleeting to most tasks. The speech-language pathologist evaluated Jonnny’s pragmatic language/social communication aspects of language. Jonny had difficulties in volume (he does not use appropriate volume level to direct his speech to the person he is talking to), prosody (intonation too varied, somewhat ‘sing-song quality), voice (pitch can sometimes be too high), rate (at times too rapid). He was unable to answer questions without visual cues, indicating language processing deficits. The psychologist assessed behavioral and social areas using the Vineland Social Emotional Early Childhood Scales and the Social Skills Rating Scales along with observation to asses play with peers. Concerns were many, but in the areas of modulation, Jonny was found to initiate with peers, but due to the inability to modulate his volume and maintain an appropriate proximity to the person he is interacting with, his is not able to maintain interaction with peers. The occupational therapist assessed Jonny’s fine motor skills and gathered information regarding his sensory processing through observation and parent and teacher completion of sensory profiles. Jonny had typical vestibular processing and visual processing with difficulties in touch, oral sensory and auditory processing. An observation was completed in Jonny’s daycare. Jonny has difficulty in sustaining interactions with peers and having his needs met in a classroom setting that has more students and less supports than his specialized preschool environment. The difficulties that inhibit him are more pronounced there and result in inappropriate behaviors such as meltdowns, and arguments with peers.

Jonny uses a variety of sensory strategies that are incorporated into his specialized preschool. He has been taught to ask for a break, request a sensory strategy using a picture board ‘menu’ of strategies to reduce his high arousal state, and has visual strategies to help him monitor his time for each activity. Social stories and role playing and modeling are used to demonstrate and practice appropriate volume, proximity and how to direct his voice to a listener. Jonny is paired for activities with peers that are more likely to be able to maintain the interaction to help make conversation and interactions more successful. These strategies are taught to his daycare staff through consultants, although follow through is inconsistent, partially due to a much higher teacher-child ratio in that setting.

Week 3-Environmental complexity and novelty

When Jonny initially began his classroom placement, he had significant difficulty in handling any new situations. One specific example was his need to use the exact same bathroom stall each time he entered the bathroom. He would tantrum if someone went into that stall before he got there, and this behavior would continue when back in the classroom. The strategy that was used with Jonny was a combination of sensory input and a social story. Upon arrival, the speech therapist would read a social story to Jonny while he sat near the table on a large therapy ball. The story contained the explanation for flexibility in using any stall in the restroom. The strategy was very successful and was eventually faded entirely. From the readings in this module as well as previous modules, it appears that Jonny’s difficulty in processing environmental complexity is his inability to visually process the entire environment and all the activities that are simultaneously happening. Additionally, Jonny attends 2 programs that are structured (or not structured) very differently, and he needs to shift his knowledge of each environment twice each day. Jonny is aided by visual schedules for transitions and has consultation to his daycare to provide visuals and strategies that attempt to give consistency between programs.

Hodgdon, Linda. Visual Strategies for Improving Communication. Troy: Quirk Roberts Publishing, 2000.

Week 2: Behavior and Communication

Jonny enjoys going to school. He manages many transitions well in his specialized classroom, although this depends on his emotional state at the time. He sits and attends to stories but has difficulty with participation at circle time. Motor tasks are difficult for Jonny, and he often shuts down or whimpers and cries and refuses to participate. He had difficulty when there is a change in routine that he is not previously aware of it. Social stories have been helpful with Jonny in changing behaviors if used consistently.
At Jonny's daycare setting, he has more difficulty transitioning. They report whining, crying and a lack of focus and attention. A therapeutic support specialist had been going to daycare with him, although daycare staff felt that this hindered his learning and there was an increase in behaviors (not defined by his daycare). Jonny usually attends both programs every day, and each of these program are run very differently with different expectations and supports. Jonny is supported by special education staff on a consultative basis at his daycare. Jonny’s special education program recommended considering the use of therapeutic support staff again to help him in understanding and managing the transition between programs for him to better succeed in both settings.
In the area of communication, Jonny can follow 1 and 2 step directions best when his attention is gained prior to giving the direction. He has had difficulty in understanding questions, and some improvement has been noted. He still has some difficulty in answering questions when visuals are not present.
Jonny uses verbalizations as his mode of communication, although he does resort to behaviors as listed above when conventional communication methods are not successful for him. Jonny can uses sentences to ask for items, protest, greet and to comment, prompting is needed at times. Some scripted language is noted during favorite play activities, such as during dress-up. The content of his language notes reduced vocabulary or word retrieval and syntax (grammatical errors) are prevalent. Jonny does not connect thoughts by using connected sentences. He can turn take with facilitation and prompts to 2 turns. Jonny has difficulty in directing his message to a listener, which is a significant factor leading to him using the behaviors of crying and whining. Even in his specialized classroom of about 8 children and 3 staff, Jonny will verbalize why he is upset, but will not be around an adult to hear him. By that time an adult realizes it, he has already begun to use the behaviors noted. His reduced attention and focus causes him to move around the room and verbalize wherever he is. Jonny does best when an adult is at his side. The adult uses proximity prompts and directs directions or explanations to him, as following these cues within a group are difficult. Jonny’s articulation has notable errors, although when he directs his speech they do not impact intelligibility. He uses a widely varying pitch, easiest described as ‘sing-song quality” when responding. His volume ranges from adequate to low, which impacts his communication when speech is not directed. Jonny will verbalize to peers in his classroom , but often does not wait for a response from them. He does respond to directions or comments from them at times.

Linder, Toni. Transdiscilplinary Play-Based Assesment 2. Baltimore: Brookes Publishing, 2008.

Case Study Introduction - Jonny

I would like to introduce you to the student I chose for this case study blog. His name is Jonny. Jonny was referred to our program by his pediatrician with concerns about his slow speech and language development as well as a developmental delay. Initial screening by the evaluation team using the M-CHAT determined that further assessment for the presence of an autism spectrum disorder was warranted. Jonny’s initial diagnosis of developmental delay, given at the age of 3 years, 6 months, was changed to autism after further evaluations were conducted. Jonny attends an Early Childhood Special Education Classroom 4 mornings a week. He receives services in Speech Therapy, Occupational Therapy and Physical Therapy which are integrated into his classroom program. Consultative services from an Educational Consultant and an Occupational Therapist are also provided to his daycare.

Jonny demonstrates strengths in some basic pre-academic skills, such as rote counting and identifying letters of the alphabet. His sustained attention and attention to task continues to interfere with his participation in preschool and daycare activities. He is inconsistent with handling transitions in the classroom depending on his overall emotional state. He follows simple directions best when there are no other distractions or when visuals are present. He verbalizes using short sentences and asks questions, although many of his utterances are scripted or out of context. Jonny has difficulty using verbalizations to request, asking and answering questions, attending to a speaker, as well as directing verbalizations to a speaker. He has difficulty in taking turns during an activity. He often seems unaware of the actions of others around him and does not take cues from peers.

Jonny lives at home with his parents and his older brother. English is spoken in the home. The family participates in many activities together including camping and watching movies. Jonny is in daycare for the entire day that he does not attend his specialist classroom and for half-days on the four other days. The family consults with a behavior specialist. There are many challenges for Jonny in his preschool, including transition difficulties and behaviors that interfere with learning. He appears to spend only a few waking hours at the end of the day before getting ready for bed in his home on weekdays.

Week One: Case Study Description

I thank my colleague Christina for her initial blog entry on the description of our program and eligibility requirements. I am looking forward to the opportunity to share information about the child that I am following as a part of this child study blog. Because of my position at the present time, the children that are directly on my caseload are there only during the evaluation process. However, I provide support to our program staff as needed and presently have several children that I am involved with that have a diagnosis of an autism spectrum disorder. It is from that group that I chose the student that I will follow as a part of this assignment. I hope that with everyone's input the knowledge I gain will help not only this child but many children in our program in the future!