4 Take Home Strategies-Final Post

1. Encourage facilitation of visually scanning the entire face. Take particular attention in having children look at the eyes of another person. It is important that this skill is not forced. You could encourage the child to look at the color of another person’s eyes. Encourage eye contact through the concept of anticipation. Have the child look to you during a game in order to obtain eye contact in anticipation of the next step and next answer. Give time so the child can look at you to receive the next step of the game or obstacle course (Amy Lynch Power Point, 2009).

Rationale: According to the Deruelle article children with ASD scan the bottom of the face, using a local processing strategy. Typically developing children look at the eyes and interpret the whole picture.

2. Emotional expression and intonation is important during communication and interaction. Without these skills, children can be viewed as disinterested. Have a child practice expression of intonation related to feelings. For example, practice “I am excited!”, “That is fun!”, or “I prefer not to play now.” Have the child work toward emphasizing emotions. Encourage this to be incorporated at home. In addition, have the child interpret other’s feelings. A group setting or bringing a friend to therapy can facilitate this skill.

Rationale: Children with ASD tend to learn social skills cognitively. They often have problems interpreting social exchanges. These skills need to be addressed because the children are not aware of their deficits or how to fix them independently (Miller-Kuhanceck).

3. Social modeling can be used to improve social interaction skills. Try using a videotape of the child interacting with another child. Friends can be videotaped in order for it to be more personalized. I have used videotaping with success with other skills. It appears effective since the local processing skills are so superior and children are often intrinsically motivated to watch a video. Then these skills should be practiced in a natural environment.

Rational: Children with language impairments have difficulty establishing and maintaining relationships. Some students may not do well in a social setting and general programs may not meet the specific needs of that child. The video clips can give a child an opportunity to look at different emotional expressions and spend time discussing these in order to work toward mastery on interpretation (Brinton, 2004).


4. Using social thinking is a strategy that incorporates the understanding of the why in social interactions skills. It helps children realize that others have separate thoughts. Encourage the child to consider other’s emotions in a social setting. This mindset is different than social skill training and is found to have better generalization. Social thinking encourages children to “think with your eyes” and that equals thinking.” This helps emergence of social growth.

Rational: According to the Crooke article, by teaching children with ASD and HFA to consider the why it promotes the core principles of social learning. The use of this strategy promotes generalization of these concepts into various social situations. Overall, this may be an effective technique to increase positive social behaviors.

Also, inspired by the Brinton article, it is clear that social issues take time and dedication to improve social interaction. Factors that led to successes were the adolescent’s motivation, family support, and the child’s ability to learn another person’s perspective. I hope this will help to incorporate social goals, activities for emotion and face processing, and the awareness of the importance of these issues. By addressing these issues it can lead to increased self-worth and success in a person’s life.

Take Home Activities

1. Help Child Identify Emotions with more ease

Look through a magazine and cut out pictures of faces and label emotions appropriately.

Hang the handout in an area that can be viewed and referenced easily.

Have the child practice identifying emotions. The child can identify them on family members, tv shows, or in the community. Give the child encouragement by repeating emotion when he/she is successful. You may have to begin with over emphasizing emotions initially such as laughing loud or frowning intensely. Try to have the child identify emotions at least 1x a day. This will be easy to incorporate into the daily routine.

2. Role Playing Practice

Have the child practice 1 role-playing activity 1x a day. Try to make this a fun activity. It can even be incorporated into a game.

Some examples are as follows.

· Ask a friend to play a game.
· Ask someone for help to find a lost object (ball, quarter, pencil)
· Tell a person you like his/her hair, clothes, hat, backpack, etc.
· Tell a person that he/she hurt your feelings
· Thank a friend for playing with you.
· Greet a person in the morning
· Ask a teacher for help on a question

Encourage the child to make eye contact. Gentle reminders are nice but should not be forced. Instead, delay response to the child so eye contact is made before continuing conversation. Explain the purpose of eye contact is the listener knows that you are talking to him and it tells the listener you are interested in him.


I have found that simple home programs are completed more consistently. If I give the family too much to do the child and parents can become overwhelmed and don’t engage as willingly in the activities. According to the Ginsburg article over scheduling may lead to emotionally unbalanced children. I try to keep in mind of all of the demands the children have including school, therapy, counseling, play groups, etc. If I have a family that has challenges staying organized I make a list of the weekdays as follows.

Home Program (Role Playing or Emotion Game) Schedule
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Beside each day I place a box and have the child check off each day the home program is completed. I ask them to aim for 5 checks in a week. If the checklist comes back successfully completed a small reward is given, such as a sticker, cookie, lollipop, or choice of a new activity.

Listed are the 3 strategies to compensate for the challenges listed in the last posting.

1) Adam and writing.
* I will use priming with Adam prior to entrance into the room to prepare
for the activity.
* I will try to use some of Adam’s occupations more thoughtfully. I could
incorporate his love for sports as a calming mechanism in order to gain his attention and be able to calm prior to the writing activity. This way he will be able to “hear me” when I explain the change in the situation.
* I could use a picture system in which he is involved in removing cards so he
feels more in control (Miller-Kuhanceck).

2) Camden and mini-interviews.
* I could ask Camden to bring a peer so peer-mediated intervention
could be used to facilitate better generalization.
* I could have him generate the questions that he was interested in learning
about others instead of me generating the questions to be asked. This should
tap into intrinsic motivation.
* Teach social thinking skills in order to explain other’s intentions. This also
teaches the why in social thinking. It is involves more than memorization of
social skills, but incorporates reasoning behind thinking. Teaching social
thinking to children with HFA has been found effective for increased positive
social behaviors (Crooke, Hendrix, Rachman, 2008).

3) Dan agitated in the waiting room.
* Next time I will try a therapy ball in the waiting room to help him become
modulated prior to entrance to the clinic. Then I will work toward increased
focus in order to prevent a meltdown (Miller-Kuhaneck).
* Dan is functioning at a lower level and cannot understand concepts of how
others feel so modulation needs to be addressed initially to prevent an emotional meltdown. He reacts upon an emotion and escalates with environmental complexity issues.
* Once Dan is modulated, priming can be used in order to establish a general
sequence of events for therapy session. He will be able to understand to the
best of his ability that I am not angry. Eye contact can be incorporated to
increase his interaction with facial emotions.
* Encourage Dan to push a weighted shopping cart back to the sensory
room, providing proprioceptive input and more appropriate outlet of his
energy. Eventually, Dan can work toward identifying emotions on picture
cards as skills develop.

The following are 3 examples of clinical situations in which your treatment approach is challenged by a child’s reduced or unavailability to process emotion or facial features.

1. When working with Adam on writing, he can become very frustrated. This particular day I set up the activity prior to entrance into the room. He was having difficulty transitioning from the previous activity and when he entered the room he had a melt down consisting of verbally refusing and attempts to leave the room. After his difficulty initially in the sensory room, I had decided we should wait for writing or avoid it all together. As we entered the room, I attempted to explain but he was unable to “hear” me or look at my expression to explain that the planned activity would be altered.

2. When working with Camden I had him practice completing mini-interviews of 1-2 questions of the staff. He is an intelligent boy and would always extrapolate correct information. He would obtain the answers but would never respond to their expressions. He did not understand about others emotions and feelings and how to respond appropriately. As I look back I don’t feel it benefited him, because he wasn’t able to generalize this information to a new or different situation or change the way he responded week to week.

3. Dan was highly agitated in the waiting room and Mom was holding him down. He becomes excited to come back to therapy. As soon as he was released to come back to therapy he ran full force so I had to chase him. I know that he was glad to attend therapy, but as I ran after him to protect himself and others he lay down on the floor and started sobbing. It appeared to be a culmination of prior events plus misinterpreting my running as anger.

Research

There is research available detailing the impairments in facial and emotional processing and resulting neurological differences are explained. (Pierce, 2001) found weak or no activation in the fusiform gyrus as well as significantly reduced activation in the amygdala, inferior occipital gyrus, and superior temporal sucus during a face perception task. (Durelle, 2004) revealed facial identities are determined in a different way in children with ASD versus typically developing children. Children with autism used high spatial frequency and the right inferior temporal gyrus which supports the weak central coherence theory of a feature based, local processing style. Typically developing children and adults use configural information which is a low spatial frequency processing. The authors concluded that children with autism processed faces like objects. They use a feature-based strategy instead of a global processing strategy. Finally, research indicates a specific deficit in the dorsal pathway of children since they are using the high spatial frequency processing.

(George and Conty, 2008) concluded that direct gaze perception is associated with increased fusiform, N170, and M170 responses in seen faces. Additionally, (Sasson, 2006) reported evidence of abnormalities in the amygdala, which is a brain region involved with assessing the emotional significance of a situation. Children with autism have enlarged amygdalas. The amygdala activates less for children with ASD when making judgments about facial affect. (Dawashima and Sugiura, 1999) found the left amygdala plays a role in interpretation of eye gaze and the right amygdala activation increases when another person's gaze is directed toward him. This supports the belief that the amygdala is involved in interpreting social signals from the face. Overall, these findings indicate that research has identified problems with facial and emotional processing and clear neurological differences are revealed during these processing tasks.

Durelle, C., Rondan, C., Gepner, B., Tardif, C. (2004). Spatial Frequency and Face Processing in Children with Autism and Asperger Syndrome. Journal of Autism and Developmental Disorders, (34)2, 199-210.

George, N., Conty, L. (2008) Facing the gaze of others. Clinical Neurophysiology, 38, 197-207.

Kuwashima, R., Sugiura, M., Kato, T., Nakamura, A., Hatano, K., Ito, K., et al. The human amygdala plays an important role in gaze monitoring. Brain, (1999), 122, 779-783.

Pierce, K., Muller, R.-A., Ambrose, J., Allen, G., Courchesne, E. Face processing occurs outside the fusiform 'face area' in autism: evidence from functional MRI. Brain, (2001), 124, 2059-2073.

Sasson, N. (2006). The Development of Face Processing in Autism. Journal of Autism and Developmental Disorders, (2006), (36)3, 381-394.

Daily Function

Emotion and face processing impacts daily function dramatically. Both of these components are key in every person to person interaction. Each time a social interaction occurs verbal gestures, eye contact, non verbal gestures, prediction of emotion and more exist in a transaction. According to the Encyclopedia of Childhood and Adolescense, social referencing is the first step to be able to recognize emotions. Social referencing is built upon in order to develop positive, mature social skills.

In many of the child's occupations including playmate, friend, sibiling, son/daughter, student, grandchild, and employee it is imperative to process facial information and emotions in order to build the relatationship. If a child has continual negative social interactions due to impairments with face processing and emotion, it can be a cyclic event. Failed attempts as a child could lead to low self-esteem, poor confidence, and uneasiness as a teenager and an adult. A child has more considerations and assistance than a teenager or adult has available. However, the demands are greater in high school, college, and with employement. (Miller-Kuhaneck) Specifically, an employee who does not make eye contact with his/her superior could be viewed as disrespectful and treated negatively. The severity of ignorning this domain in childhood impairs the overall success in adulthood.

Challenges in Emotion Understanding

The challenges our children with ASD have with emotional understanding are that they don't understand rules of social interaction, challenges with generalizing information and predicting social behavior. This process can be confusing and unsuccessful and can lead to teasing or bullying from peers. Social acceptance is a basic desire. A child with ASD displays deficits in understanding how their behavior effects others. Unfortunately, all these negative experiences can create loneliness and some of these children show an increased risk for developing clinical depression in adulthood. (Miller-Kuhaneck)

Children with ASD also have impairments with facial processing. Children with autism exhibit impairments with a variety of facial processing tasks including visual scanning, memory of faces, and affect recognition. It is believed that individuals with autism process facial information differently than the typical population. Keller and Zach, 1993 revealed that lack of early eye contact, even in the 1st month of infancy, can lead to maladaptive relationships. Gaze direction signals interest and provides essential information about other's emotional states. (George, Conty, 2008)

Facial processing and emotional processing are inter-related because a child receives visual information from the face and body in order to appropriately process emotional information. For example, if a typically developing child was smiling but told his friend (child with ASD) to get away the child with ASD could easily misinterpret the information if he was unable to process facial information. He may perceive this as a mean comment and react on that feeling. In turn, this could create tension in a peer relationship. Due to the poor interpretation of social signals a child is challenged to respond appropriately.

Overview of Emotion and Face Processing

Children with autism exhibit a chronic impairment in the processing of social and emotional information including abnormalities with eye gaze and in expression and comprehension of facial emotions (Sasson, 2006). Face processing is the ability to correctly interpret visual information about other people in our environment and is an emergent and developing skill. Emotion processing is the ability to anticipate, predict, and read behaviors of others. (Sasson, 2006)

The theory of weak central coherence describes a cognitive style based on local processing, focusing on details and individuals have problems integrating the whole (Frith,1989). This would account for a child's ability to recognize parts of faces and not take into account the entire face, or the global picture (Duruelle, Rondan, 2004). Additionally, the "experience expectant" model of visual development (Nelson, 2001) explains that humans enter the world prepared to deal with human faces but only through exposure to faces does perceptual and cortical specialization occur (Sasson, 2006). The impaired ability to interact with others is often explained by the theory of mind which is understanding that other peole have thoughts, beliefs, and feelings separate from oneself (Miller-Kuhaneck).

After reviewing the research it is clear that facial and emotional processing are complicated, having many factors to consider. This is an enormous issue related to children with autism. Learning about this subject revealed to me the role OTs and SLPs (tell me if I am overstating my bounds regarding SLPs) can have in addressing the occupation of social interaction with peers. A goal of this project is to enhance learning for myself as well as alerting and educating classmates to the need to address these issues. This appears to be an area under addressed by clinicians.

Sasson, N. (2006). The Devolpment of Face Processing in Autism. Journal of Autism and Developmental Disorders, 36, 381-394.