Autism Conversations: Structuring a Sensory-Based Student Interview. IASP Workshop Session Amsterdam July 23, 2016

Transcription

1 1 FAMILY THERAPY AND THE AUTISM SPECTRUM Autism Conversations in Narrative Practice MARILYN J. MONTEIRO Autism Conversations: Structuring a Sensory-Based Student Interview IASP Workshop Session Amsterdam July 23, All rights reserved. These handouts are for the express use of the ISPA Conference participants on July 22, Copying and distribution of these handouts is not authorized. The material is copyrighted and posting on your website is an unauthorized reproduction infringement.

2 2 The Visual Framework for Autism-Spectrum Disorders: The Descriptive Triangle This framework helps you: Understand the Autism Worldview Take the Perspective of the Child Describe Behavior Patterns Instead of Using Labels Start with Strengths and Then Describe Differences Link the Student s Autism Behavior Profile to Practical Interventions and Educational Supports Language and Communication Differences in Brain Style Sensory Use and Interests Social Relationships and Emotional Responses ; 2010; 2016 All rights reserved. Adapted from her books Autism Conversations: Evaluating Children on the Autism Spectrum through Authentic Conversations (2010: Western Psychological Services, publisher) and Family Therapy and the Autism Spectrum; Autism Conversations in Narrative Practice (2016; Routledge Publications).

3 DSM 5 Autism Spectrum Disorder Levels of Support: Using the Autism Conversations Descriptive Triangle to Individualize the Diagnosis 2013, 2015 All rights reserved 3 Level 1: Requiring Support Level 2: Requiring Substantial Support Level 3: Requiring Very Substantial Support DSM 5 Criteria A Social Communication and Language: (Social Communication) Language skills well developed Usually has developed one or more areas of passionate interest Conversation with others focuses on conveying facts and details about preferred topics Sensory-driven speech (the person appears to repeat details for his or her benefit rather than sharing information for social interaction) Ability to organize and use language diminishes when responding to others in social situations, and when discussing emotions Some demonstrated use of nonverbal communication function but inconsistent in the ability to interpret and use common cues Language skills typically less developed than in children at Level 1 Use of language is prompt-dependent on adults May have developed one or more areas of passionate interest but has difficulty communicating details with others May initiate conversation but notable difficulties with reciprocal conversation Inflexible and limited in ability to participate in an extended conversation Use of repetitive questions and phrases is commonly seen Use of nonverbal communication cues inconsistent and infrequent May be functionally nonverbal Rarely uses nonverbal communication functions (eye gaze, gestures, joint attention) When verbal skills are present: Vocabulary is organized around labeling Use of language is rote and self-directed with frequent use of scripted language Comments rarely directed towards a listener Expressive language more developed than receptive language in everyday situations Receptive language most organized when verbal requests are paired with visual contextual cues DSM 5 Criteria A Social Interaction and emotional pattern of differences: (Social Communication) Usually initiates and extends social exchanges but does so on his or her own agenda Most comfortable with adults or younger children even though a desire for peer relationships is generally present Peer relationships are often a sour of anxiety and are experienced as perplexing May have difficulty regulating emotional states as evidenced by inflexibility, explosive outbursts, behavior escalation Prompt-dependent on adults to structure social exchanges and may be able to initiate and extend as long as structure is present Lacks flexibility in play routines May become anxious and agitated during loosely structured language and social interactions Access to language significantly decreases as emotional distress increases Becomes anxious with social exchanges and does not generally initiate or sustain social interactions; Tends to remove self from social exchanges Most comfortable with others when sharing sensory interests and limited language is used Easily distressed by unexpected changes in routine Responds best when distressed when language use is limited an visual prompts are provided

4 4 DSM 5 Criteria B Sensory Use and Interests: (Restricted Interests and Repetitive Behaviors) Has developed one or more areas of passionate interests that may be age-appropriate in content but unusual in the individual s focus and intense interest Sensory-driven quality to their narrative when sharing information with others about preferred topics Sensory triggers (noises, textures, changes in routine, perceived unfairness ) leads to decrease in access to language and the individual reverts to the use of inflexible, immature, or unusual behaviors Unusual body movements are subtle but repetitive Displays some drive to establish sensory-driven play but can be redirected by adults During social play, tends to create rigid and inflexible play routines Infrequent display of unusual body movements and mannerisms may be noted during times of stress or during solitary play times Tends to focus intently on the sensory aspects of toys and materials; Seeks out manipulative materials with visual and tactile features; Creates repetitive sensory routines as a means to self-regulate anxiety; Frequently displays distinctive unusual body movements and mannerisms Level 1: Requiring Support Level 2: Requiring Substantial Support Level 3: Requiring Very Substantial Support DSM 5 Autism Spectrum Disorder Levels of Support: Using the Autism Conversations Descriptive Triangle to Individualize the Diagnosis 2013, 2015 All rights reserved

5 5 Autism Conversations: Structuring a Sensory-Based Student Interview Understand the importance of having an initial neuro-atypical conversation: Recognize the value of experience sharing: Goal is to experience a mutual sharing of the child s interior world Sensory toys and sensory topics allow you to gain a detailed understanding of the child s unique worldview Sharing this worldview creates a bond between you and the child Understanding this worldview provides you with information you need to develop individualized supports for social and emotional skills development Discussing social and emotional topics: Social and emotional discussions work best when done after the neuro-atypical bond has been established Helps answer the following questions: Does the child have an understanding of social and emotional concepts? Does the child have the necessary vocabulary to discuss those topics? Can the child access social and emotional skills in the natural setting? Learn to use: Visual prompts for conversation starters Dealing with Feelings cards Telling jokes Using common figures of speech Physical activity: Playing catch lets you know if physical activity is organizing or dysregulating for that particular child. Does the child access language best when given frequent physical breaks, such as standing or walking? Does the child spontaneously engage in physical movement routines or body use? 2011, 2016 All rights reserved.

6 6 MIGDAS Diagnostic Student Interview: Ten Tips for School Psychologists 1. Follow the 3-step flow: Sensory toys and topics; social relationships and emotions; physical movement 2. Remember the goals of the interview: Experience sharing; taking the perspective of the child; Limit social talking at the start of the session 3. Familiarize yourself with the child s areas of interest ahead of time if possible; if not, scaffold your questions and comments on the information the child provides; use visual prompts 4. Decide which sensory toys and materials are appropriate to use; probe for the sensory entry point to the establish the shared conversation 5. If using a multidisciplinary team, determine which team member will take the role of the lead interviewer; include comments and social probes from all team members 6. Understand that the conversation begins when you escort the child to the interview room; look for visual cues in the child s clothing or objects brought to the session 7. Ask comparison questions and make factual statements; mirror the child 8. Let things go in an unexpected direction with the child as your guide 9. Remember to include probes for jokes, idioms, and questions about 3 facts about self and 3 wishes 10. Ask the child if he or she has any questions for the group 2011,

7 7 Autism Conversations: Structuring a Sensory-Based Student Interview Toy Categories and How to Use Them 1. Visual cause-and-effect toys Hand held water games Light-up toys with buttons and switches 2. Noisemakers Thunder tube Squawk tubes Cartoon Sound Machine 3. Science Toys Ball of Whacks Kinetic flashlight 4. Tactile objects 5. Artwork Sensory stress balls Hoberman mini-sphere Acquired before or during the interview 6. Playing catch Switch pitch Velcro ball and mitt 2008 All rights reserved.

8 8 Autism Conversations: Structuring a Sensory-Based Student Interview Diagnostic Student Interview 3. Prosody: intonation and inflection Prompts: MIGDAS Sample Page Language and Communication topic -Listen carefully to the student s intonation, inflection, cadence, and voice volume -Reflect a subtle version of the student s style back to him or her when you speak -Find opportunities to interrupt the student s narrative flow by asking questions when the student is speaking -Match the student s voice volume and intensity when discussing a preferred Observations: Does the student -Speak with unusual cadence, pitch, or tone? -Have a speaking style that is formal or scripted? -Have a pronounced nasal intonation? -Speak with a lilting, stilted, or exclamatory cadence? -Speak consistently in a loud or soft-spoken way? -Modulate his or her voice volume in a natural way? -Show an increase in voice volume when his or her narrative is interrupted by the examiner s questions or comments? Notes: 2008 Western Psychological Services.

9 9 Autism Conversations: Structuring a Sensory-Based Student Interview MIGDAS Sample Page Social Relationships and Emotional Responses Diagnostic Student Interview 5. Sensory sensitivities: response to manipulative materials Prompts: -Place sensory toys and materials on the table in front of the student throughout the interview session. -Initiate play with the range of sensory toys and materials. -Start with the water toys or sensory stress balls put items away periodically as you introduce new items. -Have enough light-up toys for all team members so they can participate. -As the student manipulates toys, participate by following the student s lead. -Encourage the student to draw pictures if art is a preferred activity. -If the student is reluctant to touch the materials, manipulate the objects first and then offer them to the student. -Ask the student which objects he or she prefers. Observations: Notes: -Pay attention to the type of sensory input that is sought by the student and which sensory items are preferred. -Does the student -become captured visually or otherwise by the sensory items? -select one or two preferred items and manipulate them throughout the interview? -place any objects close to his or her eyes? -seek out or recoil from auditory input? -apply deep pressure to some materials? -resist touching the sensory toys? -smell objects or press any objects to his or her face repeatedly? 2008 Western Psychological Services.

10 10 Autism Conversations: Structuring a Sensory-Based Student Interview Diagnostic Student Interview MIGDAS Sample Page Sensory Use 5. Sensory sensitivities: response to manipulative materials Prompts: -Place sensory toys and materials on the table in front of the student throughout the interview session. -Initiate play with the range of sensory toys and materials. -Start with the water toys or sensory stress balls put items away periodically as you introduce new items. -Have enough light-up toys for all team members so they can participate. -As the student manipulates toys, participate by following the student s lead. -Encourage the student to draw pictures if art is a preferred activity. -If the student is reluctant to touch the materials, manipulate the objects first and then offer them to the student. -Ask the student which objects he or she prefers. Observations: Notes: -Pay attention to the type of sensory input that is sought by the student and which sensory items are preferred. -Does the student -become captured visually or otherwise by the sensory items? -select one or two preferred items and manipulate them throughout the interview? -place any objects close to his or her eyes? -seek out or recoil from auditory input? -apply deep pressure to some materials? -resist touching the sensory toys? -smell objects or press any objects to his or her face repeatedly? 2008 Western Psychological Services.

11 11 MIGDAS-2 Diagnostic Student Interview Verbally Fluent Language and Communication 1. Intonation and inflection Prompts: Listen carefully to the student s intonation, inflection, cadence and voice volume. Reflect a subtle version of the student s style as you speak. Match the student s voice volume and intensity. Periodically interrupt the student s narrative flow by asking questions or making comments when the student is speaking. Observations: Speaks with an unusual cadence that is distinctive and unvarying throughout the interview: Lilting Exclamatory High-pitched Nasal Stilted Monotone Exaggerated or overemphasized Halting flow Uses a speaking style that is formal or sounds scripted Consistently loud or soft spoken without modulating voice volume to fit the conversation Voice volume increases in a pronounced way when the student s narrative is interrupted Distinctive differences in speech patterns become more pronounced as the session progresses Varies his or her cadence to match the flow and content of the conversation Speaks in a style consistent with range used by typically-developing peers Modulates voice volume as a natural part of the conversation Responds to interruptions without increasing voice volume Intonation, inflection, cadence and voice volume remain consistent throughout the session Notes: 2013 Western Psychological Services.

12 12 MIGDAS-2 Diagnostic Student Interview Verbally Fluent Sensory Use and Interests 4. Introduction of preferred topics Prompts: Introduce the student s areas of preferred interest by making a statement or asking a question. Use visual prompts as needed. Refer to the manual for suggested strategies. Observations: Displays a notable increase in alertness and engagement when preferred topic is introduced Narrows focus to adult introducing preferred topics, to the exclusion of other adults Increases spontaneous initiation of language with preferred topics Emphasis on citing facts or details about specific topics Number of initiated utterances greater with preferred topics Length and complexity of utterances greater with preferred topics Grammatical structure of utterances greater with preferred topics Organizes language best when provided with visual contextual cues regarding areas of preferred interest Responds to a wide range of introduced topics; no pronounced alertness to any one topic Includes a range of adults in conversational topics Uses an equivalent amount of language regardless of topics References social information during conversation with the examiners Number of initiated utterances consistent across topics Length and complexity of utterances consistent across topics Grammatical structure of utterances consistent across topics Language output is consistent with or without visual contextual cues Notes: 2013 Western Psychological Services.

13 13 MIGDAS-2 Diagnostic Student Interview Verbally Fluent Language and Communication 2. Content of preferred topics Prompts: Introduce one or more of the student s preferred topics of interest. Refer to the manual for specific strategies to structure the conversation. Observations: Speaks in a narrative that has a sensory, selfdirected quality to it (focused on details of his or her narrative to the exclusion of the participation of a conversational partner) Uses the words well, actually or other recurring phrases to regain control of the conversation Conversation focuses on conveying information to the conversational partner Acknowledges conversational partner by responding to the examiner s statements with joint attention comments, eye contact, head nods or other social communication gestures Moves with ease from one topic to the next Repeatedly interrupts and overrides the comments made by the adults Repeatedly corrects the examiner s comments Displays equal interest and engagement in the and statements conversation regardless of the topic Repetitively manipulates one or more of the Content of conversation includes social sensory items throughout the conversation information and details Uses unusual phrases and advanced vocabulary Uses a similar level of vocabulary and detail when discussing a range of topics Displays a rote, rehearsed, or scripted quality to The quality of the student s narrative is his or her narrative consistent with the level of detail and flow of Emphasizes facts and details, omitting or minimizing social and relationship information Uses questions or a recurring phrase as a way to direct the conversation to a preferred topic Responds to the content of the examiner s questions and comments seemingly without an awareness of the unusual nature of an adult discussing the area of interest in this random and detailed way Notes: information experienced with same-age peers Emphasizes both the social and the factual aspects of the topics discussed Engages in a reciprocal exchange of information with the examiners regarding the topic of discussion Responds to the examiner s questions and comments but directly asks or otherwise indicates curiosity about the purpose of this seemingly random content of conversation 2013 Western Psychological Services.

14 14 Autism Conversations: Structuring a Sensory-Based Student Interview Best Practice Autism Evaluation Quick Reference Make sure your evaluations are focused on obtaining the behavioral sample and profile of the individual student Remember: singular presentation of a global disorder This means expanding the scope of your diagnostic tools beyond the ADOS-2 And using an organizing framework to highlight areas of strength and differences (The Descriptive Triangle) Are you routinely: Completing a detailed parent interview and carefully considering parent report? Using a range of best practice checklists, including the CARS-2, ASRS, SRS-2, BASC-2, PLSI, CCC-2, TTAP? Including a behavior sample using less structured prompts while providing sensory materials and/or preferred interests at the start or end of your evaluation session? For students who at an ADOS-2 Module 3 level do you routinely include or use the MIGDAS Diagnostic Student Interview? Holding off on your diagnostic conclusions until after you ve completed a thorough and systematic discussion and organization of the student s behavioral profile, taking all sources of data into account? 2014