AAC and ASD: Engineering Perspective-Taking and Emotional Regulation

1. AAC and ASD: Engineering Perspective-Taking and Emotional Regulation Marcia Weber-Olsen, Ph.D., CCC-SP Monterey County SELPA Verjene Kalashian, M.A., CCC-SP San Lorenzo Valley USD

2. THE BIGPICTURE…our vision for the future Engaging Learning Environments that promote communicative, social, and cognitive growth for learners with Social Learning Disabilities Strong receptive base to support comprehension Behavior management to support student engagement Frequent expressive AAC use to support social interactivecommunication Strong language and literacy training to support learning

3. Agenda • Social Cognitive Learning (SCL) Deficits • Perspective-taking and ‘mind blindness’ in SCLD • Different ‘pathways’ to SCLDs • Developmental prerequisites for perspective-taking • Social Communication, Executive functioning and Emotional Regulation Challenges in students with SCLDs • AAC as a framework to support perspective-taking, emotional regulation and social-communication

4. Agenda- continued Engineering AAC supports for: • Social Communication • Social Scripting & Partner Focused Questions • Small Talk • Sharing the Day/Visual Bridges (Hodgson) • Perspective-Taking • Social Stories • Comic Strip Conversations • Video Social Review • Emotional Regulation • Identifying/Recognizing Emotions • Grading of emotions • Cognitive Behavior Therapy: Behavior guides, Calming Strategies • Contingency Maps

5. Languagecomprehension & perspective-taking deficits ….at the root of social learning difficulties (Mirenda & Beukelman,2000) • Comprehension drives language sense-making • Perspective-taking drives our thoughts about others’ thoughts, beliefs, knowledge, intentions & desires • ‘Mindblindness’: Deficits in mentalizing about others (Baron-Cohen, 1995)

6. What Do We Mean By….”Perspective Taking”? • Perceptual perspective: ability to visualize what others can ‘see’ or ‘hear’ • Conceptual perspective: ability to know what others are thinking and keep track of what others know

7. PERSPECTIVE-TAKING: a range of complex social scenarios Source: Carol Gray.

8. “Theory of the Mind” ….a system for inferring and predicting a full range of mental states from another’s behavior” - Baron-Cohen, 1995 • ToM : a social executive function: “Understanding one’s own and others’ emotions, thoughts, beliefs, prior experiences, motives, and intentions …and inferring plausible causal factorsfor these states” (Rubin & Laurent,2001) • Inner language & executive functions assist perspective-taking • Without ToM: the world is an “unpredictable place”

9. “Mindblindness”: deficits in mentalizing about others(Baron-Cohen,1995) • Difficulty establishing shared knowledge for learner to process ongoing social interaction, or account for what others know • Difficulty understanding and predicting others’ intentions, actions or intended meanings… • Inability to understand misunderstandings • Difficulty anticipating what other’s think of one’s actions • Difficulty understanding deception, or being deceptive

10. Empathy & Perspective-taking • Difficulty reading other’s emotional states; comprehending other’s feelings • Insensitivity to others’ feelings

11. Pragmatic symptoms and Perspective-Taking Poor ability to share topics: obsessive, circumscribed interests, “sticky topics”: problems linking to new topics(R. Paul, 2008) Poor ability to infer what others already know & what they need to know in running conversation (pre-suppositional knowledge)

12. Different ‘Pathways’ to SCLDs Students with social-learning difficulties: • High Functioning Autism • Asperger Syndrome • PDD-Not Otherwise Specified: Atypical ‘Autism’

13. AUTISM SPECTRUM DISORDERS High functioning Asperger Syndrome Autism Pervasive Developmental Disorder-NOS Source: Wetherby & Prizant, 2000

14. Behavior &Social-Cognitive Characteristicsin Autism Spectrum Disorders • Inflexible learning style • Do not accommodate well to change or novelty • Strongly desire routine in their environment; respond best with ‘predictability’ and structure (Rubin & Lennon, 2004) • Sensory processing and behavioral ‘modulation’ difficulties (Wetherby & Prizant, 2001) • Unique perspective-taking: difficulty predicting or correctly inferring what others “feel” or “think” • Genuine inability to understand others’ beliefs and emotions (Baron-Cohen,’95) • May expect others to know their thoughts, experiences, opinions

15. Other groups ‘at risk’ for Social-Cognitive Learning challenges • Attention Deficit Disorder: both hyperactive and inattentive types • Traumatically Brain Injured • Emotionally Disabled • Schizotypal affective disorder • Bipolar disorder • Genetic syndromes: Fragile X Syndrome:~ 33% of children with this genetically inherited condition also have a co-morbid ASD and associated social-cognitive deficits(Hagerman, U.C.Davis M.I.N.D. Institute) • The ‘quirky kid’

16. Students with Social Cognitive Learning Challenges • Desire social contact, but have limited social & pragmatic skills to establish and maintain friendships • May appear indifferent to peer pressure • Unaware of “unwritten” social rules (hidden curriculum) • May lack intuitive empathy; insensitivity to other’s feelings • Often victims of bullying by middle school because of pronounced social learning problems • Significantly ‘at risk’ for mood disorders (Anxiety, depression) Sources: Twachtman-Cullen, 2000; Atwood, 2003)

17. Developmental Prerequisites: between 9-18 mos. • Joint Attention social communicative behavior in which two people share attentional focus on an object or event • Joint Attn: Child responds to another’s attentional “directive” or initiates shared attention with another • Most massive deficits in autism are evident in shared referencing/joint attention (Curcio,1975) • Eye gaze: three-way gaze shifts • Pointing gestures • Other declarative gestures (showing, or ’showing off’;inviting interaction from others)

18. Joint or Shared Attention in Autism • Initially ASD children use pointing/showing gestures to get what they want in an instrumental way, not to “share attention” with social partners • Discrepancy in use of early pragmatic functions: Requesting & Commenting functions (to share topics/ invite interaction) do not develop concurrently as in typically developing children - Wetherby et al., 1998 • Disrupted joint auditory attention: some ASD children speak too loudly, or too softly, or with little modulation (Frith, 1989)

19. Social Language features in Autism Spectrum Disorders(ASDs) Pragmatics & social communication are core areas of deficit • Conversational and pragmatic skills such as, • Staying topic-focused, turn-taking in conversation; establishing and following the conversational focus of their social partners; • Reading non-verbal cues • Social Communication Skills include: Pragmatic skills + Paralinguistics: prosody, gaze, gestures, proximity - R. Paul, 2008 • AND….Social Behaviors include: • Conventional gestures • Facial expression and body language • Avoiding socially unacceptable behaviors

20. Language Features in Asperger Syndrome • Grammatical & syntactic expression is on par with age: often ‘fluent’, syntactically mature utterances • Speech may be lengthy; say too much- • Intense and narrow restricted interests drive conversational topics • Overly ‘formal’ (pedantic) vocabulary • Caveat: “superficial verbal skills often mask cavernous weaknesses in comprehension”(Twachtman-Cullen, 2000) • Prosody shows high rates of impairment in ASDs • Atypical intonation: flat pitch contour, robotic • Poorly modulated volume: overly loud or too soft • Speech rate: ‘hyperverbal’ • Difficulty with figurative language; humor and/or abstract verbal concepts

21. The Invisible Disability…qualitatively assessing social pragmatic skills • SLP’s standardized assessments measure basic technical language skills…do not capture if student shows communicative competence in these skills. • For students with social pragmatic deficits, the optimal assessment is a qualitative one • Observe student across environments and contexts • Compare social functioning to the level of their peers • Incorporate pragmatic language samples into the assessment battery • No assessment of a student with AS can be valid if it is completely based on standardized tools (this is also true for all child-based assessments to include psychological and educational)

22. Social Cognitive Assessment • Emotional Intelligence Protocol. Source/author (VK) 2003, Thinking Publications • The Social Thinking Dynamic Assessment Protocol- Garcia Winner, M. in Thinking about you thinking about me. 2nd edition.2007

23. Behavioral & Social-Cognitive Characteristics in ASDs Difficulty with: • Emotional regulation:ability to self-regulate one’s arousal and emotional state, or seek assistance from others (mutual regulation) for availability and for social engagement(Rubin & Lennon, 2004) • ER is another CORE developmental challenge in all students with ASDs • Developmental progression from more basic physiological/biological need states (e.g., sucking thumb, averting gaze when stressed) to sophisticated behavioral strategies and the use of language & meta-cognition to self-regulate arousal levels • ASD learners demonstrate ‘idiosyncratic’ motor ‘strategies’ used to self-regulate(to increase or decrease their arousal level) (e.g. flapping, toe walking; crashing into someone) that are misinterpreted as socially ‘deviant’ behavior • Social partners often isolate themselves from such individuals

24. Supporting dysregulation in a Middle school student

25. Emotions & Stress Neurotypicals Mildly/moderately stressful situations activate frontal lobe functions; use cognitive rehearsal & language to verbally ‘mediate’/modulate their emotions Autistic Individuals Get “neurologically stuck” in an attempt to manage a rigid set of ‘expectations’ or to avoid novel& ambiguous events (Corbett,2003) • Sensory or processing overload, anxiety/fear, increased novelty (change) or ambiguity elicits unregulated emotional reactivity (Levine & Wiener,1989) • Frontal lobe activity shuts down; amygdala activates & ignites a cerebral “fire storm” • Explosive ‘meltdowns’ • Aggressive and/or ‘panic’ behaviors- flight/fight response • Escape behaviors • Withdrawal • Sensory shutting down (plugging ears, shutting eyes) • Significantly elevated stress circuits (limbic system-cortisol levels) compared to neurotypicals when stressed (Corbett,2004)

26. Structurally denser neurons in autistic brains: Medial temporal lobe Amygdala: almond-shaped structure • aggression & emotion • interpretation of facial recognition and non-verbal social cues Hippocampus: sea-horse shaped structure memory functions

27. Designing AAC Intervention Strategies

28. Range of Skills to become competent communicators- Light, J. & Bilger, C, 1998 • Linguistic Skills • Receptive and expressive skills • “Linguistic code” • Operational Skills • Form signs or gestures correctly • Social Skills • Skills to initiate, maintain, develop, and terminate interactions • Skills to develop positive relationships and interactions • Skills to express range of communication functions (e.g., comments,requests, protests,etc.) • Skills to develop perspective taking • Prerequisite:turn-taking skill • Strategic Skills • Compensatory strategies

29. GESTURES Natural Gestures Sign Systems Sign Language GRAPHICS Traditional Orthography Photographs Line Drawings Augmented OutputMay either supplement speech or act as a primary communication mode Augmented InputCan play an important role in producing and/or comprehending speech Visual Language Systems… successfully used for students with autism, etc. to visually augment language input and output

30. Core to all intervention strategies… …present a combination of visual and verbal cueing

31. Middle School SDC Program

32. AAC Visual Supports Enhance Receptive and Expressive Communication • Prompt joint attention • Enhance attention to, and understanding of social messages and behavior • Establish conversational referents • Promote memory recall • Increase comprehension of language concepts • Facilitate social initiation and communicative intent Johnston, S., Nelson, C., Evans, J., and Palasolo, K (2003).

33. Aided Language Stimulation • A legitimate ‘second language’ involving a paradigm shift…visual language is a real language and must be available as an essential aspect of each life activity • Infuses the environment with visual language to assist in the receptive and expressive processing for students with autism Goosens et al., 1992 and Cafiero, 1998

35. Pool of Response Options…a scaffold that aids the student’s… • Repeated exposure to input-comprehension • Initiation of communication • Expression • Retention/memory • Communicative functions beyond requesting • Expansion of syntax: words into complete sentences • Segmentation: breaking sentences into individual parts

37. How Many Symbols? • ALS is appropriate for students with autism who can process many picture symbols compared to those who are at the one-to-three symbol level. • Students with joint attention and able to point can handle up to 50 symbols on a language board. • Students not yet able to establish joint attention can use 2 to 6 symbol language boards • Because ALS is initially receptive language training, more symbols are used than student can verbalize or understand • Students with autism who are speakers also benefit from ALS as a means to stimulate more complex receptive and expressive language skills. Words can be used in place of symbols for those with literacy skills. Cafiero 1998

38. Engineering AAC supports for:Social Communication • Social Scripting: • Vocabulary for turn taking • Sequence of a social script • Partner focused questions • “Small Talk” • Sharing the Day: Visual Bridges (Hodgon,1998)

39. Vocabulary to Support Participation in Social Interactions …socialvocabulary can be used to take a turn in the conversation and participate more frequently. …focus on turns that are quick to produce …communicates to the partner that the AAC user is involved and interested in the conversation

40. Vocabulary to Facilitate Turn Taking

41. Turn Taking Turns include spoken messages, sign or gestures, messages on a communication board or speech-generating device. Obligatory turnsfollow a partner’s question “What are you doing?” Nonobligatory turnsfollow a partner’s comment or statement or they can be turns that extend or change a conversational topic “Cool! I have another idea”

42. Anatomy of a Sequenced Social Script • Attention Getters “ Hi there!” “ There’s Nancy!” • Starters “What’s up?” “ Did you see Lost last night?” • Maintainers, Holders and Interjections…add interest to story and prompts listener to make a comment. “It was awesome!” “I’ll give you a clue.” • Turn Transfers…(partner focused questions) “What did you see?” “How about you?” • Closing

43. PATHS to Starting a Conversation • P: Prepare ahead: keep “fact files” with important facts about people you know • Birth date…family members…favorite food, color, school subject…interests…reading computer games • Later on keep ‘invisible’ files • A: Ask your self what you are going to say and how you are going to day it before you day it • Conversation starters • T: Time is right • H: “Hello” • S: Signals - smile, gaze, body Source: J. McAffee, 2002

44. Social Coaching…Small Talk

45. Determine the Content of the Introduction Message • Attention-getting message “Excuse me.” • Greeting(s) “Hi, “hello” • The individual’s name Full name for formal situations Nickname for informal situations • The purpose of the interaction “I’d like to introduce myself.” “I’d like to place an order.”

46. Partner-Focused Questions Those questions an individual ask his or her communication partners about their thoughts, feelings, and experiences “How are you?” “What’s up?” “What’s new?” “What did you do this weekend?” “What do you think?” “How about you?” “What’s wrong?” “How’d you do?” Shows partners they are interested in them Fosters social closeness and enhances interaction

48. Social Scripts to Promote Social Interaction • Scripts used for joke-telling, sharing life stories and general conversations • Scripts help AAC users move beyond wants and needs • Support students in learning to claim, start, and maintain turns in a conversation • Pre-programmed turns on speech-generating devices (SGDs)

49. Sharing the day: Visual ‘bridges’ Hodgson,1998