Inclusion for Children with Autism Spectrum Disorders

Many children with autism spectrum disorders can be taught in mainstream, “inclusion” settings. Careful evaluation of each child, the availability of a range of supports, creativity, flexibility, and good communication with parents are critical ingredients to success.

ASDs are lifelong neurodevelopmental conditions, meaning they are caused by impairments in the growth and development of the brain and its neural pathways. ASDs are characterized by marked, enduring, qualitative impairments in the areas of communication, social interaction, play and imagination, and the presence of a restricted range of interests. Communication impairments in ASD range across the spectrum from children who never acquire the ability to speak, to those who show advanced verbal ability but have difficulty using language and nonverbal communication in socially typical ways.

Social impairments likewise range from profound, in the child who shows only basic attachment to his caretakers, to mild, in the child who desperately wants to make friends but lacks an instinctive understanding of how to go about it. Repetitive behaviors and restrictive interests range from the child who persists in simple water play or the shaking of a favorite object, to the bright child who displays unusually intense or odd interests, in gum disease, or the history of the carousel, for example.

Children with ASDs also differ greatly with respect to the presence and severity of associated symptoms, including cognitive impairment, fine and/or gross motor skills delays, inattention, hyperactivity, and executive dysfunction (which includes deficits in planning, organization, and decision-making skills and impulse control), deficits in academic skills, anxiety and obsessiveness, mood swings, hypersensitivity to light, noise and other sensory stimuli, and difficulty sleeping.

A neuropsychological evaluation, which entails detailed testing to pinpoint a child’s unique abilities and deficits in learning and communicating, is critical to identifying his or her educational and therapeutic needs. While some form of neuropsychological testing is sometimes available at public schools, neuropsychological evaluations obtained from practitioners in the community or at a university-based hospital often offer a more in-depth assessment. In addition to comprehensive testing, usually completed during a series of appointments, the evaluation process also includes taking a comprehensive history from the parents of behavior and symptoms since birth, as well as gathering data from teachers or even directly observing a child in the classroom. The results of this process yield important information concerning intellectual ability and strengths, language ability and language pragmatics (the ability to use language appropriately in social circumstances), attention, executive functioning (including organization and decision making), visual and perception skills, motor coordination, social knowledge, recognition of faces and facial expression, learning, and memory.

The experienced neuropsychologist also gathers important clinical observations during the testing process, such as the child’s interests and unique personality, and his or her responses to humor, social overtures, and frustration. These results form the backbone for a set of recommendations for the child’s education, and for further therapeutic and psychiatric evaluations and services, for the treatment of mood or behavior problems, for example. (It’s important to distinguish between a neuropsychological evaluation, which identifies learning and cognitive issues, with a psychiatric one, which diagnoses other symptoms of mental illness and is necessary in order to receive medication.) A good neuropsychological report flags a child’s strengths and offers specific prescriptions for the remediation of weaknesses. Parents may also seek out occupational, speech/language, or physical therapy evaluations. Evaluations can be obtained privately or through the school district.

Once a child has been evaluated and his doctors, parents and teachers have developed an educational plan, there is a range of academic supports available to children with ASDs. Classroom accommodations and modifications are often sufficient to meet the needs of less challenged students. These may include preferential seating in a teacher’s “target zone,” modifying homework and in-class assignments, providing extra time on tests and class assignments, or offering an extra set of books to children with organizational problems, to help ensure they have materials they need to complete assignments both at home and at school.

A mainstream inclusion classroom may offer the presence of an extra “push-in” teacher, often certified in special education, to help individual students or offer individualized instruction. Many private schools offer a resource room (referred to as a “pull-out”), where children can learn in small groups at their own pace with a teacher who has special education training. Professional development in the form of in-service training is another effective tool for increasing the ability of Jewish day schools to successfully include children with ASDs.

Teachers and their support staff can offer individualized help with executive functions such as initiating, persisting, and remaining focused on in-class activities. Sometimes a simple behavior modification plan—rewarding children for staying focused, completing tasks, or using good self-control—is helpful. Incentives for achieving goals can be delivered at school and at home.

Reading and writing disabilities often improve in response to evidence-based instructional methods such as the Wilson Reading program or other Orton-Gillingham-based methods. The Lindamood-Bell Program offers evidence-based instruction in reading, writing, and math. Handwriting problems can be addressed by providing extra time, occupational therapy, and for older children, keyboarding instruction. Some children may need a modified physical education program due to gross motor delays.

Therapeutic services and other more individualized school supports for children in Jewish day schools are accessed and delivered in a variety of ways. They can be obtained privately from trained professionals and tutors in the community, from the school district via an Individualized Educational Plan (IEP), or offered in-house by the child’s school. An emerging trend is the on-site delivery of therapeutic services to Jewish day schools by non-profit Jewish organizations. Gateways: Access to Jewish Education, based in Newton, Massachusetts, and Matan, located in White Plains, New York, are two examples. The location of service delivery can be the child’s home, a clinic, the local public school, or the child’s private school. For example, a school district may agree to provide a therapy or an individual aide (paraprofessional) who travels to the child’s private school, or a child may travel after school to his or her local public school to receive a therapy.

Psychiatric and psychological evaluations provide additional, critical information concerning a child’s emotional and behavioral profile and are crucial in the development of an appropriate intervention plan. For example, a more mildly affected child with ASD may need social understanding and skills instruction both at home and through individual therapy as well as the guidance of a classroom teacher to facilitate social interaction. However, if such a child also has an anxiety disorder, he or she will benefit from individual therapy targeting these symptoms, and possibly a referral to psychiatry as well.

Children with more complicated diagnostic profiles may also behave very differently at school in comparison to those diagnosed only with ASDs. For example, a child diagnosed with ASD may be noticeable in the classroom primarily due to social awkwardness and mild overreactions, while a child with an additional anxiety or mood diagnosis is apt to exhibit more challenging behaviors, such as refusing to join in a classroom presentation. Rarely, a child with significant associated symptoms may exhibit extremely dysregulated behavior, e.g., panicking, meltdown, or leaving the classroom. Children with significant associated symptoms of anxiety or depression that result in behavioral challenges at school and children with Attention Deficit Hyperactivity Disorder (ADHD) with symptoms of inattention, hyperactivity, or impulsivity, often benefit from having a paraprofessional in the classroom. Paraprofessionals can also be trained to facilitate and improve social interaction.

Children with ASD do best with an array of therapeutic supports within the school setting, in the community, or in combination. Mental health needs are addressed with cognitive behavioral therapy (CBT), in which the therapist helps the child change the way she thinks and responds in difficult situations. CBT is often accompanied by medications prescribed by a child psychiatrist.

Children may also receive speech/language therapy for conversational and perspective taking skills (see socialthinking.com), occupational therapy as described above, and physical therapy to treat gross motor delays. Ideally, school counselors and psychologists work closely with parents in sharing a daily or weekly journal that is passed back and forth among a child’s caregivers. Even basic status information jotted down quickly or emailed between parents and teachers can be invaluable, particularly if a child has had a rough day in school or a difficult morning at home.

Good working relationships between classroom teachers and the school counselor or outside psychologist are also crucial. Teachers can provide observational information to help the psychologist formulate and modify an effective behavior plan. For children with greater emotional regulation difficulties, school behavior plans, with step-by-step meltdown protocols, and a quiet room can offer safe ways to calm down. Staff training in the management of irritability, low frustration tolerance, and meltdowns is often important to a successful school placement.

Behavior plans can also be used for managing less disruptive behaviors such as asking repetitive questions, as well as to encourage positive social behaviors being taught in therapy, e.g., appropriate ways to initiate conversation. Rewards are an important component of behavior plans in order to reinforce increases in positive social behavior and decreases in problem behavior. Training peers to be social mentors in the classroom or at recess is a very forward-thinking model of encouraging positive social interaction that benefits children with social difficulties and gives typically developing children the opportunity to perform a mitzvah.

In summary, many children with ASDs can be accommodated in mainstream inclusion settings, particularly when recommendations provided through comprehensive neuropsychological and psychiatric reports are followed carefully by both schools and parents. Flexibility is key, as children’s needs evolve. A program becomes a living, dynamic process of support requiring continual attention and adjustment over time. These adjustments may require periodic updates of previous evaluations, or new evaluations and services.

Some services may also be discontinued as goals are reached or issues resolved. For example, while ASDs and ADHD are often lifelong diagnoses, anxiety and mood disorders can resolve or change across development. A child’s social awareness and self-management skills often improve over time as a result of intervention and brain maturation. The appropriate package of supports changes with each phase in development and needs regular, critical review particularly at transition points, for example at the end of middle school, junior high, and high school.

While working with the learning and emotional differences of children with autism can create challenges in any setting, accurate evaluations and appropriate supports can promote school success. Integrating children with ASDs and other differences creates an opportunity to teach the values of inclusivity, fairness, and acceptance. Jewish day schools have the opportunity to model to the Jewish community at large what is possible in teaching children both academics and shared values. ♦

Candice Baugh, MA, LMHC, a licensed mental health counselor who specializes in the treatment of ASDs, ADHD, and anxiety disorders, is the program coordinator of the Social Cognition Program and an instructor of child and adolescent psychiatry at the NYU Child Study Center. She can be reached at [email protected].

Elizabeth Roberts, PsyD, a clinical assistant professor of child and adolescent psychiatry at the NYU Child Study Center, is a neuropsychologist specializing in ASDs and other
neuropsychiatric disorders. She can be reached at [email protected].