Category Archives: motor planning

Summer term

First days are always difficult. Henry has spent the whole of the Easter holidays doing more or less what he likes and any sense of routine has been pretty well absent. But this first day has been made much easier by the arrival of a visitor we haven’t seen much of recently – the sun. Being trapped inside by rain, wind and cold for much of the last five months has been depressing, but it has also deprived Henry of one of his most important sensory activities: trampolining. Of course it’s possible to trampoline in winter, but he hates the dead leaves, the dirt, the pools of water that collect under the surround and ambush your feet as you jump. He’s a fair weather bouncer and so this weekend has been the first time he’s been on in months. Today we spent a long time on the trampoline together and I remembered why I love it. Henry managed to imitate a sequence of actions (clap, touch knees, turn around, seat drop) that he would find difficult on ‘dry land’. He’s been struggling with the speech therapy pronunication exercises we’ve been given – consonant blends with ‘s’ and three syllabled words – but ‘sneeze’, ‘snow’ and ‘snore’ came out perfectly while bouncing and saying ‘tram-po-line’ with a jump on each syllable seems to help his articulation too, as well as being a lot more fun than simply repeating it. Eye contact and engagement were great and we had lots of spontaneous speech as well as the ‘drills’ – ‘Mummy sit’, ‘jump high’, ‘lie down’ (I needed that one) and ‘get out’ (when the cat had the temerity to try to join in).

The sensory feedback Henry gets from this type of activity is described by occupational therapists as ‘proprioceptive’ and ‘vestibular’. Proprioception governs motor control and posture and works with the vestibular system, which keeps the body balanced. Together they provide a sense of where the body is in space, an orientation of oneself in relation to the world. Trampolining, which requires constant adjustments of balance, posture and muscular effort in order to stay upright and bounce rhythmically, is a brilliant way to get these systems working in harmony, enabling my son, who cannot jump off a chair, climb a ladder or balance on a beam without support, to do the most effortless and graceful seat drops. As I’ve written before (Hammock, November 2012) being physically regulated also seems to help organise his brain, including the speech centres. And it also makes him very happy and calm. We went into town in the afternoon and he queued patiently behind two people in Next, managed to walk out of a charity shop without melting down because they didn’t have any DVDs he wanted and, having pointed at a Twirl bar in Smiths that was well within grab-unwrap-and-stuff-into-mouth-in-seconds range, accepted without complaint that he couldn’t have it ( I’m not mean; he’s allergic to dairy). Summer, I love you. Please don’t go away.

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iPad lad (with thanks to B’s Dad)

Henry brings me the iPad to show me a thumbnail photo of his brother watching television.”TV, TV” he says. I’m busy in the kitchen and say “Yes, Ned watching TV” in speech-therapy-approved-extending-the-phrase style but this isn’t what he wants. What he is pointing at in the photo, increasingly insistently, is a miniscule rectangle of green balanced on the top of a heap of similar tiny rectangles piled on the table beneath the TV. Helpfully, he grabs the iPad back, selects the photo, enlarges it with finger and thumb and shoves it under my nose again. If I squint, I can just about make out a video. Rosie and Jim:Trees. Of course, this, according to the Law of Things One is Asked When in the Middle of Cooking Dinner, is the one video that is no longer in the pile. We have Rosie and Jim:Puppets, Rosie and Jim:Hats and Rosie and Jim:Gingerbread Man, but none of these will do. I spend many, many minutes looking behind sofas and under beds and many, many more trying to explain that Rosie and Jim:Trees has disappeared, is gone, lost, not here, while Henry grows increasingly frustrated. It’s in the photo, therefore it should be here.

Despite the hair-tearing, this incident got me thinking about Henry’s use of IT and my thoughts were further stretched by a post entitled ‘The IT Kid’ on the blog ‘Life with an Autistic Son’ (http://autisticson.wordpress.com) in which the writer, ‘B’s Dad’, discusses his son’s obsession with computers. I hope he won’t mind me taking the theme and running with it for a while. Although our sons are at the opposite ends of the spectrum, much of what he writes hits me with a thud of recognition.

Henry adores his iPad. It is the first thing he asks for in the morning and he would happily use it all day if we let him. Before the iPad, it was our PC and before that, a portable DVD player, but neither had the ease of use and sense of control that the iPad seems to provide. He doesn’t play games, but has built up a vast library of bookmarked Youtube clips around which he scoots with dizzying speed. Each clip brings up a menu of alternative links, and he is able to navigate between these, sometimes jumping between six or seven screens before finally arriving at the clip he wants. There must be part of his brain that resembles a London Underground map, telling him that to get to Truly Scrumptious he has to travel via Trumpton and Tots TV, changing at Toyland and Fun Song Factory and finally alighting at Chitty Chitty Bang Bang. Each clip is also studied in minute detail, so that he knows exactly where to move the play bar in order to get to the moment when Thomas sneezes or the judge tells Toad he is sentenced to ‘another year for being green’. He’s also interested in the photo library, though not to anything like the same extent, tending to focus on pictures of himself eating chips and the aforementioned TV photo, but other than that, it’s YouTube all the way.

We have rules for iPad use – he only has it during the school day at lunchtime and isn’t allowed it after dinner in the evening. We’ve also introduced ‘iPad sharing time’ in the morning, whereby he engages with a speech therapy, colours or drawing app in return for a turn on YouTube, which we then watch with him. But there are still a huge number of hours a week when he’s glued to a screen. Like many parents, this makes me feel guilty, but there is perhaps more anxiety attached to the issue when you have a child with autism and speech delay, and particularly one who responds so well to therapies like Intensive Interaction. Every minute that he spends communing with YouTube is one less minute spent interacting with another person, one less minute learning about two-way communication, one less minute exploring the real world (and who am I kidding typing ‘minute’ when I mean ‘hour’?). Another worry is the fact that iPad use seems to increase stims, in particular a repeated, drawn out ‘ Eee-eeee’ sound which, not to put too fine a point on it, just makes him sound more autistic.

And yet and yet – it’s the only thing he can do independently with any degree of skill. His fine motor skills, so delayed in other areas, are precise and delicate when he’s navigating on screen. Listening closely to the clips he chooses reminds me of something I’ve always known – that he loves the sounds and rhythms of words as much as music – and that is something we can use in II sessions. It gives us time to do other, necessary, domestic stuff. It saves the TV remote from imploding. Apart from the fact that he still favours CBeebies and Hit Factory, his skills are more age=appropriate than in any other area of his life. And above all, what his use of the iPad demonstrates is his enjoyment of having something he can control, absolutely and completely, in a world where not much else is easily controlled.

Of course we’ve considered cashing in on Ipad-love to try using the device as a communication aid, but Henry absolutely refuses to have anything to do with Proloquo2Go or any of the other talker apps we’ve tried. It’s the old story – anything he wants, he learns to say or finds a way to show us, as the ‘Rosie and Jim’ incident demonstrates. It’s not something we’ve ruled out though and although we’re following the speech therapist’s advice to concentrate on developing his spoken language at the moment, it’s something we’ll revisit. Unfortunately, I think we’ll need another device – one without Youtube!

Hammock

I haven’t written much about sensory integration therapy on here as yet, but it’s certainly something that benefits Henry hugely. He seems to crave swinging at the moment, in particular swinging on the hammock in our garden. The clip below shows how this seems to helpĀ enable his speech. Occupational therapists would explain this by saying that the vestibular feedback he gets from the movement helps to regulate his sensory system and organise his brain, including the speech centres. Others might say that he’s simply having fun and that this is motivating him to speak. Whatever the reason, he’s certainly having a good time ordering me around!

Progress

Five weeks into home schooling and the main focus is still on Intensive Interaction. I’m aware, however, that our version of II may offend the purists. We tend to start the day with pure II, simply mirroring Henry’s body language and sounds, in order to engage him. But then, as the day goes on and his engagement increases we begin to introduce more demands, while still allowing him to lead the play. Most of these demands involve the prompting of speech. Henry is good at using language to get what he wants, but he has always used single words. He has been able to do this since he was four and in the six years since, although his vocabulary has widened, he hasn’t really moved on, apart from learning the phrase ‘ I want X please’ by rote, which he will gabble, often with the words in the wrong order, if pressed.

Although some of this is autistic pragmatism – why use four words when you can get what you want with one – much of it is bound up with Henry’s difficulties with sequencing. He has always had huge problems with motor planning, or executive function as it is sometimes called: the ability to organise actions or speech into logical order to achieve a desired end. It affects every area of his life, from playing with a train set to articulating a sentence. Using a prompting method, something we learnt when following an ABA programme, seems to help. In brief, you start with a full prompt (ie. helping him to do an action hand-over-hand) and then gradually fade the prompt, giving less and less help until he is able to accomplish the task independently. With speech, the full word or phrase is given, then gradually faded to an initial sound, a sign, a raised eyebrow and eventually, just a pause.

So, what we have ended up doing in some sessions is a kind of ABA-meets-Intensive Interaction hybrid, which will no doubt horrify some of the proponents of both approaches. How much of each approach we use in a session depends on how engaged and relaxed Henry is. There is no doubt that pure II gets him ‘in the right place’ for speech. But I feel that he also needs the prompting structure to help him to organise and articulate what he wants to say.

The short clip below shows Ellie, Henry’s new tutor, using this approach. It seems to be working, in that Henry is trying to string words together in a way he has never done before. Best of all, a number of people who’ve met him over the last week or so have commented that they find him easier to understand. I feel hopeful about his speech in a way I haven’t done for years. Exciting times.