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Routines and Other Therapies... Why They Work... And Why They Don't Work! When it comes to behavior therapy and the autistic child, I simply can not even begin to count the many "therapies" out there! As such, this section will not be an attempt to review all therapy practices but rather a section to help parents understand why "some things work" and "others don't"! Perhaps one of the "most accepted" principles out there when it comes to the autistic child is that "routines work for these children". I would argue that, truly, this is simply NOT the case! In fact, in my opinion, it is just the opposite that is needed for the autistic child! I touched on "routines" in my section on Socialization. I encourage all parents to review that section as it relates to this discussion. In my opinion, "routines" provide a familiar environment or sequence of tasks and in doing so, the autistic child comes to understand the "parts" that make up "the whole" in terms of what "makes up" his physical environment (the people, things, etc.) and what "makes up" the parts or sequence of daily life. When things are constant, either physically or in terms of the sequence of one's daily tasks, it is much simpler to "decode" the parts that make up the whole in everything... and once decoded, frustration levels, obviously, are reduced for the autistic child. Does that, however mean that this is the "best practice" in terms of how these children should be handled? In my opinion, the answer to that question is a resounding: "No"! Although routines provide consistency, and hence a sense of control and predictability, in the autistic child's world, in my opinion, they keep the child in a "synthetic" world... one that is never changing and one that provides for very little in terms coping with "real life", opportunity for growth, and hence, the ability to actually leave behind the shackles of autism. It had not taken me a long time to realize that, for Zachary, his stress level came not with a new environment per se, but with a lack of understanding of what was in that "new environment". I had noticed that he experienced no particularly heightened sense of frustration or stress whether he was in my house or someone else's house. He experienced no particularly heightened sense of frustration or stress if I went to a new grocery store or the "old" grocery store. In no time, I came to realize that "these places" - in and of themselves - did not increase Zachary stress levels. Yet, so much in "accepted practices" had stated that "routines were key" for many of these children. For a long time, this had puzzled me. How could my experience have been so different for "accepted practices" in terms of "routines"? I had on so many occasions taken Zachary to the homes of persons I knew, persons who for Zachary were complete strangers. Their homes, also, were completely strange for Zachary. Yet, on so many occasions, I had seen him perfectly "at ease" in these "strange homes". Almost the second he "hit the door" and was inside, he would do as he did at our house... take off his shoes and start looking for something fun to play with. If routines were so critical to these children, why was it that Zachary experienced no heightened stress whatsoever in such situations? In reality, I found Zachary actually thrived the more "I broke his routine"! I made it a point to drive home taking "different roads", to go to new stores, to go to new places, to try new things, etc. - and through it all, Zachary strived more than ever! Why was it that my experiences with my son simply went so against "accepted teachings" in terms of "what works" for these children? As I came to understand Zachary more and more each day and to understand autism more and more each day, the answer soon came to me. All houses were pretty well the same in that they were all places where people lived and they all pretty well had the same "objects" in them... doors, floors, ceilings, dishwashers, refrigerators, stoves, bathrooms, bedrooms, kitchens, etc. The same was true for all grocery stores... they all "looked" pretty much alike and all had pretty much the "same stuff" in them. The same was true of all parks, all beaches, all schools, etc. Once the "parts" to something were understood, the whole, in terms of "where it was" or "when it was done" really did not matter at all! I soon came to understand that the key to everything, for Zachary, was not having consistency in "where he went" or "what he did" but rather in having consistency in the understanding of the "parts" that made up the "whole" in every place, every situation, etc. Once the parts to places and things had been labeled and those things were understood, it mattered not "where" they were encountered or "when" they were encountered. Labeling the "parts" was the key to it and once those parts had been labeled, Zachary could easily cope with them regardless of when or where he encountered them. As such, it is my firm belief that autistic children need to be brought out of their "routines" and into the "real world" as much as possible and that the key to doing so with minimal stress for the autistic child lies in labeling absolutely everything for that child from the moment he leaves his "familiar" environment. Only by doing so will the autistic child truly learn to cope with "the real world" and how things work in real life. To leave an autistic child in a "synthetic" environment where things and sequences do not change or change only slightly, is to give that child basically no coping skills for life - to let him live in a bubble that can not be burst! All bubbles do eventually burst, however. People move, family dynamics change, etc. And, as such, to keep an autistic child in a "bubble", in my opinion, is the worse thing you can do for that child... because the day will come when that bubble will burst! And, then, what will happen to that child if he has been provided no coping skills to adapt to a changing world? By taking the child out of his bubble and labeling everything in his world, helping him to "decode" life, in my opinion, you provide much more in terms of necessary coping skills for that child... and much more in terms of "growth" for that child! In working with Zachary, I always remembered the words of my mother... the mother of ten children... who so wisely always said: "Children need to be made part of life to thrive and grow". The words of a mother, indeed, can be so precious and so true. Although she had no degrees, she truly understood child psychology... and she knew that children simply can not live in a bubble and do well! Although my mother died prior to Zachary's birth, her words rang loudly in my heart and so greatly helped me in the recovery of a grandson she never knew. The "bubble" of a routine is, in my opinion, but one of the many false keys that have for so long been provided to parents of autistic children in terms of what is "needed" for these children. This, however, truly is a false key in that, in my opinion, it can never truly unlock the shackles of autism because it does nothing to address the root cause of the autistic child's enslavement! In examining the autistic child's inability to understand the whole without first understanding the parts that make up the whole, as I thought about various "therapies" I could easily understand why some would work better than others, when understood in term of how they help the autistic child to "break the code©". For example, picture and word associations (such as seen with PEC - Picture Exchange Communication) was simply a method of providing "labels" for children and hence, once that "connection" of pictures or words "represent" something was made, the child moved forward. The issue with word and picture associations, however, in my opinion, is that they truly are not the cornerstone building block... the cornerstone on which all other communication is built. That cornerstone is the alphabet. The alphabet, I believe, must be the first building block for all these children, for if that symbol/meaning association is not made, then, in my opinion, communication will never proceed as efficiently and effectively as it perhaps would were the first cornerstone properly laid! Do autistic children need picture/word associations? Absolutely! The key to almost everything in the autistic child's life lies in labels - in labeling all the parts to the whole to "break the code©". But, as everything else, the label itself must be defined! The autistic child needs to understand "where it comes from" and that can only come from an understanding of the alphabet - first and foremost! Once the alphabet is understood as symbols representing "something", and that these symbols can then be put together to represent something else, then the autistic child can easily generalize that "concept" of labels and use it for all associations - to completely decode his world! Hand-over-hand - Why this can be an excellent tool for the parent of the autistic child who knows how to "move on", or a crutch that needs to be let go! "Hand-over-hand" is a basic behavior therapy practice that parents of autistic children need to be aware of. Basically, with Zachary, I've always instinctively done this, but, I wanted to make sure all parents were aware of exactly what this is since many of you may be doing this without actually realizing that you are. Again, based on the fact that I found order, and specifically, partiality processing to be key in everything that was a problem for Zachary, that also became a "key" I could use in teaching basic life skills. If things had a "specific order", that meant, by definition, they had a beginning and an end. In working with Zachary, I found that if I helped him "do the first motion" for a task or process, he could go on and complete it himself. So, to a child who knows only an "all or nothing" world, simply doing the first motion for the "in between", makes it so that he sees "this task" must now be completed. The partial motion, the partial process triggers the desire to complete the whole! That's, in my opinion, why this technique works so well! This, I found to be true for teaching many life skills, such as getting dressed or undressed as well as things like writing, cleaning up, etc. For example, in teaching Zachary to put on his socks, I literally took his hands and showed him how to put his thumbs inside the socks and then told him to pull them up. The "action" of putting his hands on his socks helped him to "do the task" because that was the first "part" of "putting on socks" (I still get the socks out for him...so, I could work on that...and teach "getting the socks out" as the first "part" of the task...the first "motion" in the "critical path" to the process). The idea was basically to simply "get him started" with the task. If I kept talking to him and encouraging him as he completed the process, then, I found he was more open to doing it the next time...more independently. I think with many, many tasks, the key was simply a matter of "initiating" what you wanted the child to do and eventually, the child figured it out and could do it with minimal prompting (such as a simple, "put your socks on"... and later, a simple, "get dressed"). The technique of "hand-over-hand" is definitely something I think many parents "do" without realizing it is actually a "technique" that works well for autistic children. I know, recently, I was playing a game with Zachary and I used this technique and that was what reminded me to include the discussion on this topic of "hand-over-hand". I had taken a deck of cards and was on my back on the floor. As Zachary tried to zoom past me, I'd take the deck of cards and make all the cards go flying "at him". He thought that was absolutely hilarious. When the game was over, I picked up half the cards and placed them on the table. As I was busy picking up the other half, Zachary was busy throwing the first half back onto the floor (to him, all cards "went together). I took his hand and forced him to pick up the cards with me. Verbal prompting alone did not work. I had to literally take his hand and force him to pick the first one up. Once he touched the first one, and placed it on the table, he picked up all the others just fine too. So, as he helped me clean up, I simply kept saying, "good job helping mom pick up the cards", or "what a big boy...helping mom clean up...thank you!". Before I knew it, he had completed the task. So, although it was difficult to "initiate" the first move, to force him to pick up the first one by me actually taking his hand and making him do it, once the first card had been picked up Zachary understood what was expected, and he gladly completed the process/task. Sometimes, when you do something and get the results you wanted, you may not know why it is that "it worked"... and as such, I wanted to make sure parents understood this "technique", because I am sure many of you are doing this without realizing it and perhaps not identifying it for what it is...and the next time, because you did not make that association and perhaps did not understand exactly "what worked", you may not tackle the task the same way and hence wonder why you can not get the desired result. Therefore, I wanted to make sure parents were specifically aware of this valuable technique, known as "hand-over-hand". Hand-over-hand is a valuable technique indeed in that it can truly help teach the autistic child many many processes. However, as I have so often done, there is an almost inherent desire for the parent to continue to "do too much" for the child rather than move on to the next level of simply using verbal prompts. For example, when trying to go somewhere in a hurry, I will often still help Zachary to put on his socks - still help him with that first motion or the entire process. It takes a great deal of patience to simply "let him do it all by himself" when you are in a hurry. :o) But, in reality, that is what needs to be done. The time must be taken for the child to do the task on his own, so that you can move toward the simple use of "verbal prompts" such as "put your socks on" or "get dressed when you get up in the morning" and to eventually move to no prompting at all. :o) Auditory Therapy - why they work - and don't work! As with everything, the benefits of auditory therapy, in my opinion, can be traced back to how they work in terms of "parts to the whole". Music therapy, for example, by the very fact that "music starts and ends" provides for the autistic child "a whole" ... its parts all "fit together" beautifully to form this thing called "a song"... and the song keeps going until it is all done. Hence, music, in my opinion, provides for an excellent coping mechanism for these children - a non-stressful way to relax (non-stressful in that all the parts "come together" to form the whole). Although there are many sounds within music itself (in the form of various instruments, voices, etc.), it appears to me to be the case that, as with so many other "sounds of life", the overall music is simply viewed as that "background noise" that the child has learned to accept as everyday life. Loud, unexpected noises, within a musical selection, would, however, in my opinion, increase the autistic child's stress level, most likely causing him to put his hands over his ears because such "unexpected" noises bring a new "part" into the equation... a new part that must be integrated into the whole. I do believe, as with all senses, that there is more to auditory issues than simply the issue of how "things come together" to form a whole. I do strongly believe that there may be issues with actual sound frequencies and the actual physical inner workings of how the ear perceives sound, in all likelihood, perhaps even involving a degree of pain for the child as sound waves "hit the ear". I have noticed that in spite of labeling, Zachary still does have sensitivities to certain sounds. Enzymes have helped him tremendously with this issue. Pressure therapy - the physical "compartmentalization" of the child! There are various "pressure" therapies available for autistic children... some of them, rather expensive. These include pressure vests and pressure equipment of all types. Given the importance of the autistic child's need to "compartmentalize" everything, to understand how all the "parts" fit into the whole, to "organize his world", I can understand, why for some children, these therapies may appear to work. The very act of putting pressure on the child, in a sense, allows him to "compartmentalize himself" - physically. Undoubtedly, for a child who has frustration and who is unable to understand his world, this may indeed provide a great sense of security. In my opinion, however, the key still lies in helping the child to "break the code", in helping him to understand his world and in helping him to understand the sensory information he needs to process (i.e., the information he receives from his sense of touch, as it relates to his sense of "self" and his sense of "others" in terms of "where they begin and where he ends" - in terms of being able to understand "his parts", as opposed to the "parts" of others. For more on this issue, please read my section on: I Don't Like To Be Touched!/Issues With Touch In The Autistic Child). Once the "code is broken", stress and frustration, in my opinion, are greatly reduced and as such, a simple hug may be the only "pressure" the child needs. I have absolutely no doubt that the autistic child, like all children, is in constant need of reassurance and as such, constantly seeks those things that provide for him security. Zachary used to often watch the video: "The Very Hungry Caterpillar" based on the best selling book written by Eric Carle. One day, as Zachary experienced a heightened level of stress, I noticed he was wrapping himself in a blanket. When I asked him what he was doing, he responded: "cocoon". He was physically placing himself in a "cocoon", in a place of comfort and security - a blanket wrapped tightly around him. Pressure therapy, in my opinion, is no different than Zachary's "cocoon" - it is a physical way to obtain comfort and security in a world of frustration. :o) If this is indeed true, then the danger of pressure therapies lies again in the fact that they can provide a "coping mechanism" that may simply allow the child to "not deal" with the source of frustration - thus again, not getting at the root of the problem. I do believe that the sense of "physical security" is truly important for the autistic child, but, I also do believe that this physical security needs to move from "pressure therapies" to an understanding of that which causes the frustration in the first place - to understanding what made it necessary to seek "physical security" in the first place. Once that happens, in my opinion, the autistic child should no longer need more than a hug when it comes to "pressure therapy". :o) In closing, I simply want to ask parents to look at "why" certain things work and why others "don't work" and to always look for the pros and cons in all therapies... including their costs. Many "therapies" are outrageous in terms of "what they cost"... and that is in everything from behavior therapy to pressure therapy. As with everything in life, parents need to look at what works, what does not work, weigh that in terms of cost/benefit analysis... keep the good and throw out the rest! There are many things parents can do to help their children deal with issues of partiality without spending a fortune, as you will see in my section on Exercises I Do At Home. I'm not saying that current therapies simply do not work...what I am saying, however, is that parents need to be much more critical of what works and what does not work and to carefully weigh the costs and benefits of all intervention methods/pratices! As with so much in life, the simplest answer is often the best answer, and in my opinion, this is no different in terms of "best therapies" when it comes to what works best for the autistic child! Those therapies that work best are those that provide positive coping mechanism for the child in order to help him “break the code” and understand the world about him – a world he very much needs to be a part of! :o) |
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