Autism in the Visually Impaired Child

Autism in the Visually Impaired Autism in the Visually Impaired ChildChild

Terese Pawletko, Ph.D. & Lorraine Rocissano, Ph.D.Terese Pawletko, Ph.D. & Lorraine Rocissano, Ph.D.

Psychology DepartmentPsychology Department

Maryland School for the BlindMaryland School for the Blind

AER/DENVER, July 18, 2000AER/DENVER, July 18, 2000

Their behaviors (e.g., stereotypies, rituals; restrictions in play) Their behaviors (e.g., stereotypies, rituals; restrictions in play) seen as:seen as:

indicative of emotional disturbanceindicative of emotional disturbance

associated with sensory deprivation (e.g., turn inwardassociated with sensory deprivation (e.g., turn inwardfor stimulation)for stimulation)

related to mother-child attachment (e.g., inrelated to mother-child attachment (e.g., inincubators longer; lack of eye contact incubators longer; lack of eye contact

so hardso hard to read cues; maternal depression to read cues; maternal depression furtherfurther limiting her involvement with limiting her involvement with child)child)

Explanations for “Autistic-like” Behaviors in Blind ChildrenExplanations for “Autistic-like” Behaviors in Blind Children

T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000T. Pawletko, Ph.D. & L. Rocissano, Ph.D., July, 2000

NON-AUTISTIC AND AUTISTIC RUBELLA NON-AUTISTIC AND AUTISTIC RUBELLA CHILDREN - Distinctions noted by Chess et al.CHILDREN - Distinctions noted by Chess et al.

Non-autistic rubella children with sensory defects:Non-autistic rubella children with sensory defects: 1. Are very alert to their surroundings through their other senses1. Are very alert to their surroundings through their other senses 2. Exhibit appropriate responsiveness - “Some are shy, some slow to2. Exhibit appropriate responsiveness - “Some are shy, some slow to

warm up, some perhaps wary; but one is impressed by theirwarm up, some perhaps wary; but one is impressed by theirreadiness to respond to appropriately selected and carefully timedreadiness to respond to appropriately selected and carefully timedovertures.”overtures.”

Rubella children with autism and sensory defectsRubella children with autism and sensory defects 1. Do not explore with alternative senses1. Do not explore with alternative senses 2. Maintain distance from people that is not explained by the sensory2. Maintain distance from people that is not explained by the sensory

deficits nor by degree of retardation deficits nor by degree of retardation 3. Their affective behaviors do not resemble those of the same mental 3. Their affective behaviors do not resemble those of the same mental age. age.

From Chess et al. From Chess et al.

Caveats in DiagnosingCaveats in Diagnosing

1. Autism is a developmental disability, not parent1. Autism is a developmental disability, not parentinduced, not induced by blindnessinduced, not induced by blindness

2. It is a syndrome; no one symptom yields a diagnosis.2. It is a syndrome; no one symptom yields a diagnosis.

3. Autism is a spectrum disorder, with a wide range of3. Autism is a spectrum disorder, with a wide range offunctional levels, and behavioral presentations.functional levels, and behavioral presentations.

4. While symptoms show improvement over time, the 4. While symptoms show improvement over time, the individual remains autistic. Autism is a lifelongindividual remains autistic. Autism is a lifelongdisorder and for most individuals some level ofdisorder and for most individuals some level ofsupport may be required.support may be required.

Jim…as a point of explanation for Jim…as a point of explanation for you...the ‘icebergs that follow’ detail you...the ‘icebergs that follow’ detail the key diagnostic features of autism the key diagnostic features of autism using an iceberg approach - the using an iceberg approach - the behaviors one might observe on the behaviors one might observe on the surface, and the processing difficulties surface, and the processing difficulties that might account for them.that might account for them.

Fails to or has difficulty engaging in reciprocal interactions

Treats others as though they were objects

Seems uninterested in peers

Problems with SocializationProblems with Socialization

Problems shifting attention

Unable to process social information effectively

Difficulty processing complex stimuli due to difficultiestelling figure from ground, and problems makingvery rapid shifts of attention

Cannot process multiple sensory stimuli simultaneously


Implications for Parents and EducatorsImplications for Parents and Educators

1. Recognize that the social world is more complex and less1. Recognize that the social world is more complex and lesspredictable for an individual with autism, andpredictable for an individual with autism, andtherefore more stress producing.therefore more stress producing.

2. Do not assume that simple exposure to peers will result in2. Do not assume that simple exposure to peers will result inthe acquisition of social skills. the acquisition of social skills.

3. A child cannot be pushed to acquire social skills. Begin3. A child cannot be pushed to acquire social skills. Beginwith something short, structured, teacher directed, and with something short, structured, teacher directed, and success oriented.success oriented.

Seems very verbal but can’t followinstructions

Poor receptive language

Echolalia

Pronoun reversal

Non-verbal

Problems in LanguageProblems in Language

May use words expressively which they don’t really understand(receptive language lower than expressive)

Difficulties discriminating language sounds - poor central auditoryprocessing

Difficulties with sequencing phonemes and words

Can’t break the linguistic code


ImplicationsImplications

1. Check out whether child understands what he/she is saying1. Check out whether child understands what he/she is saying(e.g., “what does that mean?”)(e.g., “what does that mean?”)

2. Use controlled language (e.g., short, concrete phrases with 2. Use controlled language (e.g., short, concrete phrases with time between statements to allow for processing)time between statements to allow for processing)

3. If student has vision, try to provide some information3. If student has vision, try to provide some informationvisually; if not, provide information tactually.visually; if not, provide information tactually.

Perseverates on one topic

Shows no interest in other people’s topics

Too close or too far when talking

Says something unrelated to the conversation

May become angry when he hears certainwords

Problems in CommunicationProblems in Communication

Can’t apply rules in context

Problems with impulse control

Inability to take the perspective of another, as well asproblems shifting attention



1. Direct instruction in the actual setting is key.1. Direct instruction in the actual setting is key.

2. Identify clear, concrete rules that the child needs to follow 2. Identify clear, concrete rules that the child needs to follow in specific situations.in specific situations.

3. Social stories can be helpful in providing a child with a3. Social stories can be helpful in providing a child with ascript to follow.script to follow.

Need for sameness, predictability

Motor stereotypies

Focuses on parts of objects in play (e.g., wheels,spins everything, flips handle ofbasket repeatedly)

Age appropriate pretend play not observed

Restricted and perseverative interest (e.g.,elevators, Xerox machines, CD titles)

Perseverative or Narrowly Focused InterestsPerseverative or Narrowly Focused Interests

Difficulty getting meaning from environment due to all cognitiveprocessing deficits

Repetitive events are easier to understand and make sense of thanmultifaceted input

Repetitive behavior may be experienced as soothing



1. Recognize that the routines and self-stimulatory behavior 1. Recognize that the routines and self-stimulatory behavior are the things that the child understands best and mayare the things that the child understands best and mayserve as a “life-preserver” for the child. It is theserve as a “life-preserver” for the child. It is thechild’s retreat to his comfort zone.child’s retreat to his comfort zone.

2. The child’s reliance on such behaviors will tend to2. The child’s reliance on such behaviors will tend toincrease in times of stress and anxiety (e.g., transition,increase in times of stress and anxiety (e.g., transition,lack of clear expectation, challenges). Ask yourselflack of clear expectation, challenges). Ask yourself“why is the child engaging in this now?” “why is the child engaging in this now?”

3. Identify a time when the child can engage in his self-3. Identify a time when the child can engage in his self-stimulatory behavior; tighten up the structure,stimulatory behavior; tighten up the structure,schedule, routine to decrease anxiety and increase schedule, routine to decrease anxiety and increase non-verbal information.non-verbal information.

Over-reacts to certain noises (e.g., fire-alarms,vacuum cleaner, fan motor)

Finds certain tactile experiences aversive (e.g.,certain foods, texture of clothing, softfurry objects, being touched)

Often finds warm temperatures aversive

May not react to bumping head, falling down, etc.

Stops listening to instructions when asked to openbook

Hypo- and Hyper-Sensory SystemsHypo- and Hyper-Sensory Systems

Has poor regulation of auditory system (e.g., at times may findraindrops sounding like gunshots, other times not aproblem; visceral panic regulation to sudden loud soundslike fire alarm - heart and respiration rate do not returnto normal for several hours)

Can only process one sensory input at a time

Brains process temperature, texture, multi-sensory things differently



1. Be alert to how the sensory environment may be 1. Be alert to how the sensory environment may be impacting on your student.impacting on your student.

2. Try to keep the environment as low key as possible (e.g.,2. Try to keep the environment as low key as possible (e.g.,visually clear, sound absorbing materials, novisually clear, sound absorbing materials, noextraneous noise or conversation; balance lightingextraneous noise or conversation; balance lightingneeds for children’s visual impairment with those ofneeds for children’s visual impairment with those ofarousal).arousal).

3. Be aware of possible multi-sensory input issues and3. Be aware of possible multi-sensory input issues andadjust instruction accordingly.adjust instruction accordingly.

Autistic Spectrum Disorders and Autistic Spectrum Disorders and Cortical Visual Impairment: Two Cortical Visual Impairment: Two

Worlds on Parallel CoursesWorlds on Parallel Courses

Mary Morse, Ph.D.*, Terese Pawletko, Ph.D. & Lorraine Mary Morse, Ph.D.*, Terese Pawletko, Ph.D. & Lorraine Rocissano, Ph.D.**Rocissano, Ph.D.**

AER/DENVER, July 18, 2000 AER/DENVER, July 18, 2000

* Educational Consultant, N.H., ** Psychology Department, Maryland * Educational Consultant, N.H., ** Psychology Department, Maryland School for the BlindSchool for the Blind

Autism CVIGets fixated on certain activities Fixated on certain sensory stimuli (e.g., or sensory stimuli (e.g., certain certain colors, lights, finger or hand visual and auditory patterns) gazing, certain visual patterns)Insistence on things remaining Performance may be better w/some the same (e.g., sequence of types of visual stimuli than others events, placement of objects) (e.g., objects, faces, spatialPerformance may be better with orientation) and in familiar context – certain materials or in familiar may seem more impaired in new context – may seem more context impaired in new context

Pattern and PredictabilityPattern and Predictability

T. Pawletko, Ph.D., L. Rocissano, Ph.D., M. Morse, Ph.D., July, 2000T. Pawletko, Ph.D., L. Rocissano, Ph.D., M. Morse, Ph.D., July, 2000

Brain is looking for patterns it can recognize (e.g., visual, auditory; sequencing) in the environment - child may not recognizedifferent phonemes and their pattern and sequence, yetrecognize pattern in inflection or music and thus, more likely toattend to the latter

YOU YOU SEE:SEE:

AutismAutism CVICVICannot discriminate foreground Cannot discriminate foreground Difficulty discriminating what visualDifficulty discriminating what visual from background noise (e.g.,from background noise (e.g., stimuli is important to attend to stimuli is important to attend to seems to attend to conversationsseems to attend to conversations Does not see and/or show recognition Does not see and/or show recognition across the room whileacross the room while of some types of visual stimuli of some types of visual stimuli ignoring language directedignoring language directed toward him).toward him).Fiddles with string while Fiddles with string while ignoring toy the string isignoring toy the string is attached to.attached to.

Processing Problems: Figure-groundProcessing Problems: Figure-ground

T. Pawletko, Ph.D., L. Rocissano, Ph.D., M. Morse, Ph.D. July, 2000T. Pawletko, Ph.D., L. Rocissano, Ph.D., M. Morse, Ph.D. July, 2000

Brain is having difficulty sorting essential from non-Brain is having difficulty sorting essential from non-essential information, brain may perceive things asessential information, brain may perceive things asa whole for some individuals, or attend only toa whole for some individuals, or attend only tocertain details disregarding the gestalt.certain details disregarding the gestalt.

YOU YOU SEE:SEE:

Autism CVIStops listening when cat jumps Tends to look away when

reaching/touching on lapSensory overload can lead to Has more difficulty in using vision total or partial shutdown, or when managing other sensory over over-arousal or motor demands

Sensory overload can lead to total or

partial shutdown, or over over- arousal

Processing Problems: Multi-sensory Input


Brain is having difficulty regulating and processing informationcoming in (e.g., type, rate, amount, multiplicity)

Brain may only be able to process information from only onemodality at a time

Can suffer from cumulative effects of overstimulation

YOU YOU SEE:SEE:

Autism CVIMay understand scripted May recognize objects or people directives in context but not in familiar context but not in out of context unfamiliar context

NOTE: typical child can be taught and know “a cup is a cup” acrosssettings; autistic and CVI children are not able to apply oldlearning to new situations without specific instruction.

Do not Spontaneously Generalize LearningDo not Spontaneously Generalize Learning


Brain relies on the “total package” to comprehend the situation. The package may include a specific subset of the following kinds offeatures: the sequence of events, location, specific materials,specific person teaching, specific words, etc. etc. etc. to define“the event” or “the concept.” What feature the child uses as an

anchor is unique to the individual.

YOU YOU SEE:SEE:

Autism CVINo reaction to loud noise at one At one point in time seems to recognize one point in time, but may objects and/or persons, but at another have extreme reaction at time (even moments later) may not another time (may change recognize object or person moment to moment)

Seems to understand instructions one day, seems lost the next

MISLEADING BEHAVIORS: MISLEADING BEHAVIORS:

Instability of FunctionInstability of Function

T. Pawletko, Ph.D. & L. Rocissano, Ph.D., M. Morse, Ph.D., July, 2000T. Pawletko, Ph.D. & L. Rocissano, Ph.D., M. Morse, Ph.D., July, 2000

Parts of the brain that regulate sensory thresholds, efficiency of neurotransmission, and ability to access memory may all impact on the child’s functional ability at any point in time. This is also true for the child’s physical condition (e.g., illness, medication side effects, fatigue).

YOU YOU SEE:SEE:

Jim…to again provide you with some Jim…to again provide you with some explanations...the slides above were to explanations...the slides above were to begin to alert VI teachers to the some begin to alert VI teachers to the some potential similarities and distinctions potential similarities and distinctions between some children who are autistic and between some children who are autistic and other children with CVI [based on some of other children with CVI [based on some of the children we’ve seen at Md. School f/t the children we’ve seen at Md. School f/t Blind].Blind].

The next group of slides were to begin to The next group of slides were to begin to offer concrete suggestions for intervention offer concrete suggestions for intervention and make distinctions between what is used and make distinctions between what is used for non-autistic vs. autistic visually impaired for non-autistic vs. autistic visually impaired children; also to review the components of children; also to review the components of structured teaching that we use with our structured teaching that we use with our autistic-vi students across settings.autistic-vi students across settings.

Comparing Strategies for the Blind vs. Blind Autistic Comparing Strategies for the Blind vs. Blind Autistic StudentStudent

For a blind child:For a blind child:

Use a lot of language paired Use a lot of language paired simultaneously with object simultaneously with object exploration.exploration.

• Use a lot of vestibular input, Use a lot of vestibular input, tactual input.tactual input.

• Moderate levels of extraneous Moderate levels of extraneous noise generally will not cause noise generally will not cause distraction.distraction.

For an autistic blind child:For an autistic blind child:

• Use brief statements, Use brief statements, moderating the pace of speech; moderating the pace of speech; pace of exploration of object.pace of exploration of object.

• Control the amount & type of Control the amount & type of input so child is not over input so child is not over aroused, unable to attend.aroused, unable to attend.

• Be aware of impact of even Be aware of impact of even subtle noise on child’s stress subtle noise on child’s stress level and ability to attend.level and ability to attend.


Comparing Strategies for the Blind vs. Blind Autistic Comparing Strategies for the Blind vs. Blind Autistic StudentStudent (Continued)(Continued)

For a blind child:For a blind child:

• Provide lots of social stimulation. Provide lots of social stimulation. The child can be expected to enjoy The child can be expected to enjoy a variety of social contacts. a variety of social contacts.

• His sensitivity to social His sensitivity to social reinforcement, including reinforcement, including withdrawal of attention, means that withdrawal of attention, means that praise and “time out” will be praise and “time out” will be effective motivatorseffective motivators

For an autistic blind child:For an autistic blind child:

• Balance social time with alone Balance social time with alone time. Child may often find social time. Child may often find social experiences aversive rather than experiences aversive rather than reinforcing.reinforcing.

• Social experience is generally not Social experience is generally not important to child. Praise, “time important to child. Praise, “time out,” are typically not effect out,” are typically not effect motivators. motivators.


Components of Structured TeachingComponents of Structured Teaching

Physical StructurePhysical Structure

• What activity will occur in “X” location? What activity will occur in “X” location?

• What sensory sensitivities need to be addressed by the physical What sensory sensitivities need to be addressed by the physical structure?structure?

SchedulesSchedules

• What will we do?What will we do?

• In what order?In what order?

Individual Work SystemsIndividual Work Systems

• What am I going to do?What am I going to do?

• How much will I do/for how long?How much will I do/for how long?

• When will I be finished?When will I be finished?

• What comes next?What comes next? Adapted from TEACCH, July, 2000Adapted from TEACCH, July, 2000

Components of Structured TeachingComponents of Structured Teaching

PHYSICAL STRUCTUREPHYSICAL STRUCTURE

• What activity will occur in “X” location? What activity will occur in “X” location?

• What sensory sensitivities need to be addressed?What sensory sensitivities need to be addressed?

Ideally, Ideally, only one activityonly one activity occurs in one location (e.g., teacher table is occurs in one location (e.g., teacher table is sole place that 1:1 work occurs; independent work desk used only sole place that 1:1 work occurs; independent work desk used only when child works independently; independent play activities occur in when child works independently; independent play activities occur in one location; craft activities occur in a different location)one location; craft activities occur in a different location)

Processing and sensory needs:Processing and sensory needs: use controlled language, minimize use controlled language, minimize extraneous noise through use of sound absorbing materials (e.g., tennis extraneous noise through use of sound absorbing materials (e.g., tennis balls on bottom of chair feet, hang sound absorbing materials from balls on bottom of chair feet, hang sound absorbing materials from windows and walls, replacing faulty buzzing fluorescent bulbs, staff to windows and walls, replacing faulty buzzing fluorescent bulbs, staff to use conversational tones only); use barriers (e.g., book cases) to define use conversational tones only); use barriers (e.g., book cases) to define space, provide visually calm environmentspace, provide visually calm environment

Components of Structured TeachingComponents of Structured Teaching (con’t) (con’t)

SCHEDULESSCHEDULES

• What will we do?What will we do?

• In what order will we do them?In what order will we do them?

Minimizes demands on memory and attentionMinimizes demands on memory and attention

Decreases problems with time and attentionDecreases problems with time and attention

Compensates for problems with language comprehensionCompensates for problems with language comprehension

Aids motivation (e.g., “first work, then play”)Aids motivation (e.g., “first work, then play”)

Allows for greater independence in functioningAllows for greater independence in functioning


Components of Structured TeachingComponents of Structured Teaching (con’t) (con’t)

INDIVIDUAL WORK SYSTEMSINDIVIDUAL WORK SYSTEMS

• What am I going to do?What am I going to do?

• How much will I do/for how long?How much will I do/for how long?

• When will I be finished?When will I be finished?

• What comes next?What comes next?

Predictable, methodical, consistent approach to tasks - takes advantage of Predictable, methodical, consistent approach to tasks - takes advantage of autistic individual’s love of sameness - follows left to right, top to bottom autistic individual’s love of sameness - follows left to right, top to bottom formatformat

Modify work system based so child can be successful in independent Modify work system based so child can be successful in independent completion of task - if can’t be independent, back down and add more completion of task - if can’t be independent, back down and add more structurestructure


Autism in the Visually Impaired Child

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