Read the article, Beyond Me? in the Readings and Resources section.? The author describes how individuals with Autism Spect

Mind blindness, or difficulty seeing another person's perspective, underpins

much ofthe social difficulty of autisnn. Interventions that open children's eyes to

others' points of view show promise for improving their social functioning.

BY BRIDGET MURRAY LAW

40 APRIL 2014 | THE ASHA LEADER

FAST READ: How can we help children on the autism spectrum better connect with others? Researchers iiave wrestled with this question and identified strategies targeting understanding of pronouns, emotions and sociai si<iiis. But no one method wins out. What's clear is that each child needs ongoing assessment and tailored interventions tied to real- life struggles.

TAGS: AUTISM SPECTRUM DISORDER, THEORY OF MIND, SOCIAL SKILLS

IT'S AUTISM AWARENESS MONTH | BIT.LY/AUTISM-MONTH 41

Charlie* is not having a good day. At all. The puffy-faced 5-year-old, who bears a strong resemblance to little "Mikey" of Life cereal fame, didn't want to come to social skills group in the first place. But his mother made him. Even after he bawled, wailed and clearly made it known that he needed to finish watching his favorite movie, "Cars." Needed to not be dragged out on this cold, snowy February day.

But drag him out she did. Now here he is in this strange room with the two other kids he doesn't really know and the train set

he can play with only if he's allowed to by this nice-enough-but-kind-of-demanding lady-—this "Ms. Lauren," who insists that he say her name and look her in the eyes. And who now says he has to share all the trains he worked so hard to grab from the box before the others did.

Why would he ever do that?

We can't know for sure that this is what Charlie was thinking during speech-language pathologist Lauren Civiello's weekly social skills group. But it's a best approximation of his perspective on a group that's ultimately meant to help him learn to understand others' perspectives.

Seeing the world from another's point of view is hard enough for neurotypical children—let's face it, it's a struggle even for some neurotypical adults—but for a child on the autism spectrum it's possibly the toughest skill to grasp. It also underlies much of the social difficulties inherent in autism, as pioneering autism researcher Simon Baron-Cohen and his team showed in the 1980s in their "theory of mind" studies.

As a refresher, theory of mind refers to the ability to recognize what you know, believe and feel—and, very importantly—to understand that others' knowledge, beliefs and feelings differ from your own. What Baron-Cohen famously showed in a 1985 study, published in Cognition (bit.ly/ cohen-tom), is that children on the spectrum fail what's known as "the Sally-Anne" test at much higher rates than age-matched neurotypical peers and peers with Down syndrome. In this test, the doll Sally places a marble in a basket and leaves the room. The doll Anne then moves the marble from the basket to a box. Lxperimenters ask

children to guess where Sally will look for the marble when she returns to the scene.

The correct answer is in the basket, because Sally doesn't know that Anne moved it. But the vast majority of children with ASD say the box, because they're not thinking of the situation from Sally's point of view. For SLPs, who are obviously concerned with language and social pragmatics, developing these children's "other awareness" is key to treatment success, says Patricia Prelock, University of Vermont professor of communication sciences and disorders and 2013 ASHA president, whose research focuses on theory of mind (see sources online).

So how do you get a child like Charlie to see that hoarding the trains means denying enjoyment to his 5-year-old peers Eric* and James*? SLPs and other developmental experts have investigated that question over the past 30 years and identified a number of effective approaches to teaching perspective-taking. These approaches target understanding of pronouns, emotions and social skills (see sidebars).

But no one method trumps any other, notes Prelock, and there's no surefire way to convey this concept. What's critical, she says, is that the SLP assess the child's current theory-of-mind functioning, then tailor a set of interventions

Tackling the Pronoun Problem

Mastering pronouns—the basic language of self versus others—can be a steep climb for children on the autism spectrum. When confronted with a question that requires pronouns in the answer, some children fall back on echolalia, repeating the last several words they heard instead of responding conversationally. For example, say an adult poses the question.

"Whose coat is that? Is that your coat or my coat?" A child with poor pronoun understanding might echo back, "Your coat or my coat?"

Modeling by adults is one way to show children how pronouns work, says Hannah Dostal, an assistant professor of literacy education at the University of Connecticut She and Jessica Lester,

42 APRIL 2014 | THE ASHA LEADER

accordingly and periodically assess treatment effectiveness. And by effectiveness, she means how well children perform in real social situations.

"What the literature has struggled with is that kids can do well on these interventions and strategies in the clinical setting but then they struggle in real social situations because the skills don't generalize," says Prelock. "That's why, no matter what intervention we use, it should always be tied to a real situation the child is actually dealing with."

See beyond me For any treatment to work, it first needs to meet children where they are developmentally, Prelock

notes. There's no way a child can grasp the complexities of others' perspectives without first mastering joint attention—being able to look where another is pointing and directing others similarly— and mastering some language basics.

Typically developing children master joint attention by 12 to 18 months and have a solid handle on pronouns by age 3. Children with ASD follow the same general pattern, but it's significantly delayed by a year, two years or more, depending on the autism severity. Again, says Prelock, it comes back to assessment. If testing reveals that the child struggles with joint attention, that's the place to start treatment (see sources online).

an assistant professor of inquiry methodology at Indiana University, have worked with SLP Kellie Ellenbaum on crafting "Perspective Speak," a five-phase pronoun program for children with ASD that—at least in the beginning—involves two adults working with the child.

In phase one, which focuses on self, one adult might ask the child to choose a food.

The other adult stands behind the child and, pretending to be the child, answers: "I want applesauce." The child repeats this phrasing until he or she can use this modeled language.

The rest of the program's phases tackle other pronouns, including possessive pronouns, and the language of perspective shifting. "You don't need to

necessarily do this one phase at a time," says Ellenbaum of the method. "Ability to learn fluctuates day to day with these kids, and it's likely that they will go back and forth between phases quite a bit before they really get it. But it's a good guideline."

For more specifics on the approach, see Ellenbaum's Pediastaff blog post at bit.ly/ perspectivespeak.

IT'S AUTISM AWARENESS MONTH BIT.LY/AUTISM-MONTH 43

Next it's key to establish understanding and use of pronouns, says SLP Tracy Magee, a colleague of Lauren Civiello's at Spectrum Pediatrics in Alexandria, Va. There are countless pronoun- building approaches, ranging from highly structured programs like "Perspective Speak" (see sidebar on page 42) to simple, unstructured play. For example, Magee holds tea parties with her children with ASD because pouring and serving pretend tea and food requires heavy pronoun use: your cup, my cup, his plate, her plate and so forth.

Charlie turns the trains over and over in his hands, as Ms. Lauren waits for him to hand some of them to Eric and James. He balks, his face registering bewilderment, consternation.

"Eric will be sad if you don't share those trains," says Ms. Lauren. "And so will James."

"And you want them to be happy, don't you?"

Get happy Happy. It's so simple for most of us to define, if not to feel. But for children on the spectrum, recognizing and labeling this and other emotional states is far from easy. Due to what Baron-Cohen dubbed "mind blindness," they battle to discern their own emotions, let alone read those of others.

"I have a client who, if you ask him to show you happy, will show you a strange devilish look," says Bethesda, Md.-based SLP Laura Rubinoff, who specializes in teaching perspective-taking skills. "He just doesn't have the self-awareness to demonstrate the emotion."

Because it typically takes visuals to engage children on the spectrum, she uses videos and computer animations to help teach emotions. Baron-Cohen's computer-animated library of emotions (featuring "Harry Potter" actor Daniel Radcliffe, bit.Iy/ emotion-coach) is a good starting point, she says. And the music video of Pharrell Williams' exuberant, up-tempo "Happy" also tops her list of tools. In it, a diverse group of actors depict the sunny emotion in seemingly every nonverbal way possible—as Williams sings, "clap along if you know what happiness is to you," they spin, finger-snap, play air guitar, jump, skip, smile, laugh, boogie and fling their arms up to the skies (bit.ly/happy-video).

"After we watch the video, the children think of other words that convey a whole continuum of happy—glad, feeling fine, content, delighted, thrilled, elated, ecstatic, beaming," says Rubinoff. "We then rewind the video and study how the people in the video use their body and facial expressions to

express 'happy.'" From happy, Rubinoff moves on to "sad" and

"mad," covering the wide array of associated words and body language.

Selected cards and apps also work well for teaching emotions, says Magee. SLPs can use them to act out emotions and inject game-playing fun. For example, Magee uses "Alligator" apps targeting emotion identification (free for download at bit.ly/emotions- app)—the child guesses emotions shown on people's faces by clicking on a choice of words.

Depending on the child's ASD severity and verbal levels, Magee also uses language-boosting board games and simple narrative stories to teach the "who, what, when, where, why" of emotions. For example, in the book "Taking a Bath With the Dog and Other Things That Make Me Happy," the child will identify what the protagonist is feeling (blue), why she is feeling that way (wallowing in the blueness), and how she can feel better (think of things that make her happy).

Structured activities aside, Magee recommends turning everyday moments into teaching opportunities. "Like if the child bumps their knee, it's saying, 'Oh that must feel bad, you must feel sad.' And the same goes for parents: labeling those emotions and using those moments."

Ms. Lauren is still trying to convince Charlie to share his trains with Eric and James, both hard at work piecing together the tracks. They sit side by side as they place them, singing the same song in unison: chugga chugga choo choo, chugga chugga choo choo.

"How about if Eric and James ask you nicely to share the trains?" Ms. Lauren asks Charlie.

Charlie hunches over the trains, possessively. How come everyone always wants to take his stuff???

Eric turns to him, trying to make eye contact. "Charlie, may I please have one of your trains to put on the tracks?"

Long pause. Staring at the floor, Charlie reluctantly hands a

train to Eric, his bad day continuing

Make others happy The tension between Charlie and the others in the room couldn't be more obvious, but what's causing it? In short, Charlie lags behind the other two in understanding a key aspect of theory of mind, which is that "what I do (my behavior) affects the happiness of those around me."

Civiello keeps this behavior-emotion link in her

44 APRIL 2014 THE ASHA LEADER

back pocket: She uses it constantly. During snack time, she asks Eric how his mother will feel when she learns he tried peanut butter and celery for the first time. "Happy!" he proclaims. She smiles and claps her approval. "And I'm happy you tried it, too!" she says, prompting a squirmy smile in return.

But remember what happened when she tried the "make someone else happy" approach with Charlie? He was unaffected, holding his trains close until coerced to hand them over. Meanwhile, in stark contrast, Eric and James sang the "chugga chugga choo choo" song together and cooperatively built the track—with no help from Charlie.

In Civiello's view, the difference in their actions mostly comes down to this: Charlie doesn't realize that his behavior affects the happiness of others. Eric and James, though also on the autism spectrum, are making this realization.

"They get that it's not just about their own little bubbles," says Civiello of Eric and James. "I really see a difference in how they interact with other kids. They've come a long way in six months of social skills group."

Key to her success with them, she believes, is tailored social skills treatment and ongoing assessment, what Patty Prelock considers the staples of successful perspective-taking treatment. SLPs can choose from any number of tests to gauge a child's other awareness (for example. The Theory of Mind Inventory, www.theoryofmindinventory.com, or the Theory of Mind subscale of The Developmental Neuropsychological Assessment-II, bit.ly/nepsy-2).

In the case of Eric and James, it helps, also, that they attend social group sessions more regularly than Charlie does and have play dates together. This gives them more chances to interact in the real world, to really get into a rhythm with one another. A year ago, they never would have shared their trains and train track pieces so readily—they play together so much better now, Civiello says.

Train tracks laid, the three boys try tbem out, one at a time. "Go, Charlie! Co, Charlie! Co!!" Eric and James cheer. And go Charlie does. Because finally, finally his moment has arrived: the moment of train wheels hitting tracks, red train going round and round, up and down as he pushes it. But then Ms. Lauren calls for clean-up. She'd said before that this was the last round of turns, but Charlie wants to run his train again. When he sees the other boys dismantling the tracks, he loses it. He bursts into tears and hurls his trains into the toybox so hard that Ms. Lauren flinches. While the other boys high-five Ms. Lauren on the way out, Charlie leaves in tears.

Civiello admits that it's hard to see a child like Charlie have a bad day, to repeatedly suffer for not getting his way despite her best efforts to ease the bumps. (Just one example: She uses a picture schedule to help with transitions.) But she's optimistic because … well, because being upbeat is

Programs Tiiat Target Social Skills A deficit in social skills is one of the hallmarks of autism spectrum disorder—and also one that can be addressed through systematic treatment. Speech-language pathologists have been on the forefront of developing such programs, including these three well-known ones:

Social Thinking. Pioneered by SLP Michelle Garcia Winner, this program is geared for high-functioning children on the spectrum and, according to its website, targets how their own social minds work—why they and others react and respond the way they do; how their behaviors affect the way others perceive and respond to them; and how this affects their own emotions and relationships. Among the goals are for participants to recognize that they and others have different perceptions and abilities

to process social information and to become more socially adaptive. For more specifics, see www. socialthinicing.com. Sociai Stories. Initially conceptualized by educational consultant and former teacher Carol Gray as a way to teach children a script for appropriate behavior, the social story has since been widely adopted by SLPs and others as a behavior modification tool. Typically the story is an amalgam of pictures and words describing how the child can, say, handle unexpected.

unwelcome events or manage conflid with others. For more on social stories^ see on.asha.org/sociai-story and i bit.ly/gray-soclal. Sociai Communication/Emotionai Regulation/Transactionai Support. (SCERTS). Developed by SLPs Barry ' Prizant, Amy Wetherby and Emily Rubin, and occupational therapist ¡ Amy Laurent, this program addresses social communication and emotional regulation. Key components ofthe program include peer and adult | modeling, a supportive environment and child-initiated communication. For more specifics, see www.scerts.corni Sociai Skiiiograpiiy. SLP Laura ^ Rubinoff draws on Garcia Winner's Social Thinking approach and Albert.' Bandura's social learning theory by ' pairing SLPs with improvisational

46 APRIL 2014 THE ASHA LEADER

part of her job. She's confident that if Charlie comes to sessions more regularly, he'll work through the suffering and learn.

"Kids learn best from other kids, from the experiences they have with them," says Civiello. "So I really push them socially. Sometimes they leave here a little upset, and that's OK. That's life."

Because when she sees children like Eric and James demonstrate the skills she teaches, it makes all the bad days worth it.

"I hear them say things like, 'That hurts my feelings,' or 'Tattling on friends makes them feel bad,' and I feel so good. Because I know I've done my job." 9

Bridget Murray Law is managing editor of The ASHA Leader. •[email protected]

*T/?e names of the children in this story have been changed to protect their privacy.

Q Find sources for this article at leader.pubs.asha.org.

actors to model emotions and conversational skills for small groupsof elementary and middle school students. The children learn about—and practice—using eye gaze rules, taking turns, sharing topics and responding to facial expressions and body language. Rubinoff rounds out the acting demonstrations with "video modeling" of social skills using clips from TV shows such as "The Literals" and "Sesame Street" and movies such as "Frozen" and "Toy Story." Learn more at bit.ly/ social-skillography.

Editor's note: ASHA does not endorse particular programs, products or procedures related to the treatment of autism spectrum disorder.

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