PARKVIEW CLINIC

REGIONAL CHILD & ADOLESCENT UNIT

(formerly Heathlands (Charles Burns Clinc)

60 Queensbridge Road

Moseley

BIRMINGHAM B13 8QE

Tel: (0121) 243 2000

Fax: (0121) 243 2010

HELPING *- ADVICE TO CARERS

* has a pragmatic language disorder. This is a cognitive impairment which improves with age and help. It does however have a specific affect on * 's sociability, language, play and academic achievement.

THE COGNITIVE DIFFICULTY

Children like * have difficulty in extracting a meaningful whole from what they see and hear. The more complex the environment, the more difficulty they have in extracting vital information. An inability to separate what is meaningful from what is redundant results in :

1. A need to remember everything and to develop a good memory for details.

2. An ability to observe difference and detail rather than to extract similarities.

3. An inability to recognise similarities in new situations.

4. A context bound learning without the ability to generalise.

5. An inability to predict future events.

6. A need to create ones own predictability by keeping events the same. Anxiety therefore surrounding change.

7. A tendency to miss the most abstract information particularly what other people are thinking - mind blind.

8. An inability to understand the world from other peoples points of view or outside ones own experience i.e. self centred. Children are often only motivated to learn what they have experienced or have a special interest in.

9. A difficulty in understanding intentionality.

Suggestions

Learning should therefore :

(A) Take advantage of special interests, memory skills and logical reasoning skills.

(B) Help recognise the same information in different contexts

(C) Enable * to gain a meaningful understanding of a task rather than to simply learn by rote.

Build * 's understanding, particularly of more abstract concepts, through direct learning in a range of meaningful contexts. Teach via a concrete multi sensory learning approach and help to generalise new knowledge into a range of different situations. Hence develop skills through concrete "hands on" as opposed to abstract learning.

NB It is more how one teaches rather than what is taught.

SOCIABILITY

Children like * usually want to be sociable but often go about this the wrong way. They often appear rude or shy. They are children who are often egged on by more streetwise children. What starts off as 'rough and tumble' becomes bullying or out of control aggression. Children with Autistic Spectrum hardly ever make a connection between the 'aggression' they inflict on others and that directed at them. They can be very distressed for example when hurt or ignored and often have no idea about how they are sending out the wrong signals for friendships to develop.

Some have few verbal strategies to engage children. Some stand and watch other children play and have to be drawn in. Others prefer to draw attention to themselves negatively. The constant reminder of failing both academically and socially does have a gradual impact on self esteem. Being told one is 'naughty' or 'silly' coupled with an acute sense of what is right and wrong can compound an already fragile sense of self.

NB Many programmes designed to help children with behaviour problems assume these children 'know' how to behave appropriately and simply require sanctions when they break the rules. In the case of children with autistic Spectrum difficulties, this assumption is not valid. A behaviour modification programme which attempts to 'punish' only, tells the child how not to behave and since he isn't sure of an abstract concept like being good or being polite anyway, he is only certain of what not to do.

He may know, for example, that it is wrong to shout out in class but he only sees this in the same context as for example taking an extra biscuit or forgetting to put his tie straight. If this lack of understanding of the seriousness of a misdemeanour is coupled with the idea that by doing something very 'minor' and drawing attention - to oneself he will make friends then he is likely to break a rule to cury favour as he sees it.

Many parents report that after saying things like "if you are good this week I will take you to Blackpool on Saturday", produces instant 'bad' behaviour. We suggested that any 'programme' which attempts to change behaviours does so by:-

1. Taking account of the child's specific cognitive impairment e.g. he cannot be normalised all of the time. He needs to be told specifically what good behaviours are and how to achieve them.

2. Is conditioned around praising specific good behaviours e.g. putting hand up before speaking, finishing work etc.

3. Is free of negative judgements.

4. Allows the child dignity.

5. Takes account of the child's wish to be like everyone else - even though he cannot all of the time i.e. any changes in school activities e.g. small games clubs, homework books are done discretely and seen to be organised for a group rather than for him.

6. Individual support within class is deployed with discretion and creativity. e.g. It is not always helpful to have an adult sitting next to you who only points out when you have made mistakes.

Children often prefer, if able, to work in a small group with their individual support worker. Alternatively, the classroom support can be used to help another group of children and therefore release the teachers to give more individual support for the child with specific learning difficulties.

7. Allows weekly counselling on an individual basis and in a small group with other children who have the same or similar diagnosis.

8. Children are brought to counselling/club sessions rather than expected to rely on their own ability to get there.

9. Regular family appointments e.g. 1 x monthly to discuss with staff and * all the good things he has achieved as well as the difficult. * may not tell you how he is feeling unless mum is there to facilitate this.

Solutions

A. Raising Self Esteem

B. Helping interactions and appropriate behaviours.

C. Predicting future events and completing tasks.

Suggestions

After consultation with parents it would be helpful to:

Please make sure that all the teachers and dinner ladies know about * 's difficulties.

1. After consultation with parents, inform the rest of the class of * 's difficulties so children are more sensitive to his particular needs. This could be via a topic of helping people e.g. some people cannot see, what do they need?. * does not always know what to do, how can we help him?

2. Give * clear rules about what he can or cannot do in the classroom and the playground or at home. Avoid making judgements such as 'naughty' and 'silly'.

NB It is better to say 'the rule is' rather than 'I want you to'.

3 NNB It is also better sometimes if you acknowledge what the child wants first, and not question, and give a specific time when his preferred activity is possible.

E.g. avoid saying "now what do you want" or "no you cannot" as openers to conversation.

4. Distract rather than draw attention to inappropriate behaviours.

Try to give more individual attention when * is behaving appropriately. Many children like * would rather behave negatively than be ignored.

5. Provide 1:1 adult support where possible particularly during the more unstructured moments of the day like in the playground or at dinner time. In the playground for example, provide equipment such as a bat or ball to enable *to more easily become involved in play with others.

6. Provide respite at lunchtimes perhaps through a games club. This could centre around a specific area of interest to him that he can participate in with one or two others. E.g board games, (reading factual and quiz books) computers and chess.

7. Provide * with a job to do on his own and one with one other child on a regular basis, with the aim of developing his confidence and self-esteem. Choose jobs which are not open ended, are rewarding in themselves and do not involve peer relationships e.g. watering plants or working in the library.

8. Encourage development of a special skill so that * has the opportunity to succeed amongst his peers and to feel more equal in the class. Others may then realise his strengths and be more tolerant towards his difficulties. This skill may also give him the opportunity of using language to help others.

With the help of 1:1 support record all incidents in the playground which involve * . These provide concrete examples for counselling sessions in which teasing, bullying, intentionality and accidently can be discussed in terms of what people are thinking when they behave in particular ways.

9. Help * sociability by enabling him to work co-operatively in small groups or in pairs. This is particularly important in practical lessons like Art and Science.

10. During counselling sessions help * to think about other people's minds. For example, social situations could be discussed either individually or within a small group to consider how other people may think or choose to behave and what their feelings could be in certain settings.

11. As part of *'s humanity studies, provide small group opportunities for * to investigate what the other children do, like, think, surrounding certain topics through asking specific questions.

12 Encourage * and his parents to invite children home from his class to play. Help parents choose good role models. Make the sessions short and structured.

13. Provide predictability through sequencing a series of pictures or photographs to indicate the sequence of the day's main activities e.g. writing, playtime, maths etc. These pictures could be placed on the wall or photo copied and kept in a special folder so that he can take them home and share with parents.

14. Avoid large noisy informal groups which have no clear structure.

15 Where appropriate, encourage *to work in small quiet groups.

16 * will feel less anxious about changes in his routine if he is prepared for them first. Therefore make sure that he is aware in advance of any known changes such as school being closed for the day or swimming being cancelled, e.g. the day can be circled in advance and marked off on a calender. Make an advent calender for school holidays.

17. Use visual indicators to enable * to know what he should be doing. For example, if he needs to change tables for an activity, place a picture on the table where he needs to be.

18. Help his organisational skills by providing parents with a 'wall chart', school timetable which indicates when special equipment needs to be taken to school and when home work needs to be handed in.

LANGUAGE

Although children like * often talk a lot, they often have specific difficulty in acquiring abstract meanings-particularly words associated with 'time' and peoples intentions. They have problems using language as a social tool so that whilst they may be able to talk at people or butt in on conversations, they fail to share social chit-chat or give important information about how they feel or about past events.

They often make very literal interpretations of other peoples conversations and can over react to comments. They can be distressed by other peoples teasing and sarcasm, although they may learn to use it themselves. Autistic Spectrum children rarely make a connection between the harm they inflict on others and that directed at them.

They are often impulsive saying things that other people only dare think. They may sound unintentionally rude or arrogant. Because they acquire language through memory rather than meaning they tend to convey messages obliquely. Their intentions are sometimes misunderstood by well intended adults.

Suggestions

1. Be aware of sarcasm - Explain it when you do. E.g. "I was only pretending, what I meant was ......"

2. Attempt to reduce the length and the complexity of the sentences which you use.

3. When giving general classroom instructions always address *

by name, to ensure his attention. Make sure he is looking at you. You may need to touch him first.

4. Use a weekend diary with both pictures and words so that parents and teachers have shared knowledge surround * 's day. This knowledge will provide a basis for conversational exchange. The diary should contain information about events and not behaviour. Class teacher or assistant could fill in what * has done on Friday. On Sunday, parents could draw a picture in the book and write a few words about what * has done that day.

5. If possible, record all trips and events with a camera and make a photo album for *which can be used as a reference point for understanding conversation about past and future events.

6. Provide parents with information about topic work to be covered in all subjects for the following half term. Parents will then be in a position to support learning at home by providing extra 'hands on' experience.

7. Where possible provide adult support in the classroom particularly for those more difficult subjects which require, abstract understanding. e.g. Science and Technology, History and English.

8. Help * build up clear semantic links between similar but nevertheless different words by for example working on:

(A) opposites e.g. floating/sinking, above/below - particularly giving other children specific instructions.

(B) sorting objects according to their similarities and differences - semantic grouping and explaining why they go together.

(C) guessing games geared towards enabling him to both give enough specific information to other children, and also to develop retrieval strategies for himself (ie help word finding difficulties). Always use vocabulary surrounding topic work so other children can be included in the activities.

Eg A child takes a picture or word card out of a box. The child gives clues

as follows to the rest of the group

e.g. (I) by their function " you eat it".

(ii) description - "it's round"

(iii) phonological - "it begins with"

e.g.2 Make a town map on a large sheet of card with specific buildings drawn like school, police station, etc included allowing for discussions of what these buildings would be used for etc. Find some toy cars etc. Make cards on which the buildings are drawn. A child takes a card without showing it to the next child. He must direct him to the building.

9. Help to develop his listening and real language skills through always commenting on things as opposed to questioning him in front of the class, e.g. reflect what you think he means by what he says e.g. "I don't have to do my homework" for example could mean "I haven't done it because no one was free to help me" or "I did not understand what you wanted me to do".

NB Behaviours and verbal scripts, however unacceptable, nearly always serve a communication function. Make sure you give him appropriate verbal strategies if you wish to change a behaviour or modify his choice of words.

10. Always give *individual support for new tasks. It is often best to see to him first.

11. Pair him sometimes with more able children who will enjoy helping him and also provide good role models.

12. Check that he understands the implications of written questions or commands. This is particularly important when given open ended tasks and course work e.g. write about y. You will need to add more explicit instructions particularly for homework. Encourage him to ask.

13. Help to generalise the same concept embedded in a more abstract form by the addition of visual props.

14. Help him to translate simple mathematical problems into mathematical formula by using props, drawings and his own symbols before adopting the recognised ones.

15. When introducing new activities always try to help him to tune in or to understand through the addition of visual props.

16. Acknowledge *'s individual style of learning and where possible teach new concepts through a more personal or "hands on" approach. If he walks away this usual signals that the task, as it is presented has no meaning for him.

17. Allow * to use any special skills to give information to other children.

18. Encourage * to seek help when he does not understand by reflecting his need to ask, rather than allowing him to comment, sit passively or leave the table. E.g. * needs help or * says I don't understand.

19. Encourage * to develop questioning strategies for shared conversational skills by setting tasks in which he needs to ask children for specific information about what they have done etc. E.g. Ask Sam where he went etc. Picture diaries would be a helpful focus.

20. Support the development of creative skills through the use of pictures and by drawing on real life experiences or other peoples stories. For example, tell him a story and ask * to predict the end of the story and write about it.

If * is having difficulty writing a creative story encourage * to write in the first person.

21. Help * to realise that he needs to give adequate information in order to be understood through games and activities which encourage him to give clear verbal instructions. PE and cookery are often a useful focus.

22. Help * to understand that words do not always mean what they say through explaining teasing, lying and jokes to him. Also develop understanding of idioms used in context e.g. "pull your socks up". Make him aware when you know he is 'lying'. Try framing it positively e.g. 'you're pretending'.

23. Help *to read time. Have a clock with numbers in the classroom as well as in the kitchen at home. Teach * the time systematically, signal changes in his routine by referring to the clock.

24. Help * understand 'time' labels like 'yesterday', 'tomorrow' and 'next week'. Make a cardboard 'week' clock. Divide into 7 segments, colour the last 2 in a different colour. Label from 1 to 7 with days of the week. Draw a picture with the day's main event in each segment. Allow * to move the clock everyday.

25. When reading stories, plays or poems in class, please spell out non literal use of language as well as explain peoples motives.

26. Allow * to present his finished work on a word processor. This will allow him to write in rough and self correct for :-

a. Correct sequence of events

b. Punctuation and spelling

c. Use of more complex sentence structures, particularly joining words like 'so' and 'because' and modifying clauses starting with 'if' 'when' 'while', 'after', 'before' 'during' etc.

d. The information * is giving is clearly understandable to the reader without having shared the topic work.

e. He has understood the implications of the question and answered correctly.

f. He has written enough

27. In Maths again check at the beginning of class he understands the implications of questions or instructions. Encourage him to ask for help.

28. If he is distractible or day dreaming in lessons. Insist that he must sit at the front or at the end of a row. Alternatively sit him between mature sensible children who will allow him to get on with his work without encouraging him to talk. * will not be able to switch from social chit-chat to working in class, like other children. He does not have that flexibility of thinking.

29. Avoid shouting at * or other children in class. This could distress him.

30. Create situations or games in which * 's use of language has an impact on other children. This could be by giving verbal or non verbal instructions to other children in PE, or it could be games based on first recalling 'how to make say a sandwich' having just done it and then with the help of a sequence of pictures, give these instructions to another child.

PLAY AND PRETENCE

Children like * often have good problem solving ability. They can be creative in the physical work but have problems with the more social aspects of play. As small children, they enjoy exploration particularly physical play and sound making. They understand that toys represent real objects but often have problems with more abstract substitutions or omissions. They often perform the appropriate action on objects e.g. making cups of tea, for example, but because they cannot easily put themselves in the shoes of others, they find it difficult to pretend. When they do learn to pretend they find it difficult to share with other children without adults support.

As they mature, they find unstructured social play situations difficult to handle, hence the need for protection in the playground. Most bright adolescents for example with Autistic Spectrum difficulties prefer special interest groups like computers, model making and chess rather than youth clubs etc.

Suggestions

1. Encourage * to explore new textures, sounds and smells through different forms of sensory play.

2. Encourage * to develop more creative play through drama and role play. Play should aim to :

(A) use real objects first e.g. saucepans, packets of food.

(B) occur in the absence of objects e.g. pouring tea from a toy cup without actual liquid or taking a bite out of an imaginary apple by gesture.

(C) substitute props in place of real objects e.g. use a toy brick as though it were a biscuit or pretend that a banana represents a telephone or make different food items out of playdoh.

(D) accept adults in different situations or states e.g. an adult pretends to be cross, surprised, upset or asleep.

(E) encourage * to watch, copy and share pretence with other children and to carry out a negotiating role e.g. prompt him to pretend to be somebody and to carry out an activity within that role.

(F) using small toys, e.g. play people to develop or recreate a storyline. In some situations try to follow, as opposed to direct * play activities and encourage him to expand and sequence his play ideas.

(G) Always develop pretence based on real experience e.g. a visit to the shops or park etc.

NB Avoid fantasy characters.

3. Support the development of rule based games with other children via games in the soft play area or PE, pushing a car along or rolling a ball back and forth.

4. During play take a less directive approach and try to follow the lead of the child and to expand his ideas instead of directing his activities. Prompt *

to become involved in games which require joint attention and anticipation e.g. ready, steady, go.

5. Encourage * to participate in activities which require the use of models and small toys to develop themes and original plots.

6. Encourage * to take part in simple mime e.g. of everyday activities and then to expand into role play e.g. via dressing up. Encourage him to watch and follow the lead of other children involved in pretence, as in drama or in free play situations.

7. Through role play based on previous real life experience help * to develop strategies for coping with different social dilemmas, e.g. "what would you do if?"

8. In Art and Technology, when building models out of clay or wood etc. it may be necessary to show him the finished model first.

9. During Art lessons show him examples of artists work where they have used 'impressions' rather than 'detail' to convey meaning. Give him specific projects based on this concept.

READING, SPELLING AND WRITING

Many children with pragmatic difficulties learn to read well but not always with understanding. That is they are unable to follow complex plots.

Some have specific problems with fine motor control and sound discrimination tasks so they have specific spelling difficulties too. Most find creative writing difficult. Some memorise bits of stories they have read and regurgitate these. Others find it easier to write about themselves.

1 Games which help * understand the sounds which * 's letter land characters make, eg a stepping stone game - Large cards with a sound on each one. Using only 4 sounds at a time place cards on floor. Can * move or jump to the sound * hears.

Contrast 4 different sounds, eg m, s, p, n moving to sounds which are more closely related like t and k or s and sh.

NB Can * tell another child where to jump.

2 Rhyming pairs games - rhyme detection and rhyme generation.

Using visual pairs matching games. At the end of the game sort cards into rhyming pairs eg pea/sea and car/bar.

Use word chunks too like eat words (seat, meat) and 'in' words bin, tin etc.

3 I spy.

3 objects on the table, eg pen, car and dog - "something beginning with P" etc. Followed by how many more words can you think of beginning with P.

4. Board game which involves reading and identifying first or last sounds in words. Using minimal contrasts for example depending on how * 's spelling rules contrast with the adult model. Make flash cards eg sip/slip or sheep/ship. Make a race tract divided into squares each one contains the symbol of the sounds to be contrasted, eg ee/i or s/sl etc. The adult first picks up a flash card which the child is not allowed to see. She says the word eg 'sip' what sound does it begin with did I say 's' for sip or 'sh' for ship etc.

It is then the child's turn to pick up a flash card and attempt to read so the game becomes visual as well as auditory. This game can be used to contrast any sound discrimination and spelling problems.

5. Use good visual memory skills to learn new sight vocabulary.

E.g. Make a pairs game for each new word.

E.g. 'Had' - put this word into a meaningful context. i.e. "I had a biscuit". Draw two pictures of the child with a biscuit and write 'had' underneath.

6. Specific practice in sequencing picture stories surrounding every day activities. Please emphasise words which reflect peoples motives, needs and beliefs, e.g. "Wanted to", "needed to", "didn't know", "surprised" and "embarrassed" etc.

7. Encourage the development of keyboard skills and allow * to present his finished work on a word processor. This will allow him to self correct for :-

a. Correct sequence of events

b. Punctuation and spelling

c. Use of more complex sentence structures, particularly joining words like 'so' and 'because' and modifying clauses starting with 'if' 'when' 'while', 'after', 'before' 'during' etc.

d. The information * is giving is clearly understandable to the reader without having shared the topic work.

e. He has understood the implications of the questioner and answered it correctly.

f. He has written enough

ACADEMIC PROGRESS

Progress through schools tends to be affected by :

1. Size of group

Children like * concentrate best in small groups.

2. Adults on hand to explain

The intentions of spoken and written questions

Openended tasks.

Facilitate interactions in the playground and in practical lessons.

Keep an eye on bullying and teasing..

3. Attitude of staff

The ability of staff to adapt their teaching and to accept the child as an equal member of the form. Negative judgements by staff unfortunately give other children permission to dislike the child with difficulties.

4. Routine and Structure

Children like * need to know what to expect on a daily basis if anxiety is to reduce to allow learning to proceed.

5. Close contact with parents

Children like * need more experience outside school.

Parents need to share on a regular basis what is being taught. What homework has to be done for when etc. Vital information should always be sent by post.

6. The egocentricity of the child.

Children like * will always work best in topics which have a special interest for then. Their patch performance reflects real learning difficulties and not laziness.

7. Context and attitude to learning

Many children associate school with work and home with play. They need to be encouraged to do work of interest to them at home as early as possible.

They need the experience of seeing children in class outside the classroom too.

8. Other learning difficulties

Brighter children obviously have the best chance of solving problems.

Many bright children with Autistic Spectrum difficulties do have specific reading, writing and spelling problems associated with Dyslexia, Many need to be screened for dyslexia from about 6 years of age.

9. Abstract elements of the curriculum

Children often have most difficulty with writing stories, history and religious studies.

10. Team Sports

Some children like * can appear well co-ordinated for individual actions but appear a little clumsy when involved in reciprocal activities which require anticipation and learning rules.

Many children like * do well if they are allowed to pursue individual sports like running, swimming, horse riding, golf and ski-ing in particular.

11. Supervision

Children have most difficulties in the unstructured moments of the day. Teasing and bullying should be taken seriously even if the child appears to bring it on themselves. The best strategy to avoid problems seems to be protection rather than exposure.

LU/aw/sjw/May 1995