Arun

Arun is an 11 year-old boy with mild mental retardation. Both of his parents are deaf and mute, and his mother has mild mental retardation. Because his parents are unable to work, he lives with his grandfather. He has a younger brother who is typically developing. His parents live 30 minutes away, so they are able to visit and Arun will leave the school every other weekend to return home. Because of his parents' condition, Arun developed language skills at a significantly later stage than most typically developing infants. He has difficulty controlling the volume of his voice and has problems with the pronunciation of some sounds. Arun would also benefit greatly from working with a speech therapist.

I have prepared an Individualised Education Program (IEP) to help Arun with his English and math skills. He is very interested in learning English, and has strongly improved his vocabulary in the past months. His memory for words (their meaning and spelling) is very good, and he is able to use these words when trying to communicate with me outside of class. His English is probably the most advanced out of all the young students. His Math skills are well developed compared to the other students in his class. He has learned double-digit addition with carry-over, however he does not have a good grasp of meaningful counting. He is able to correctly answer 99+99, but he can only count to 12 in English. When asked to recite numbers he is able to do so quickly and correctly, however when I present him with one number symbol on its own he is unable to identify the number. He can only recall the numbers in sequence and is unable to recognise which names go with which symbols. We have been working on this together and so far he can identify the symbols from 1 to 5. Children with mild mental retardation can hope to reach the intellectual level of a 6th grade child.

Arun is a very warm and caring boy. It is not common for Indians to use 'please', 'thank you', and 'sorry' in everyday conversation, but Arun is always very polite. He tries his best to help me understand what the other children are saying by translating into English.

Arun prefers to play alone rather than with other children. He is very friendly, he gets along well with the other students, and all of the students like Arun, but he still prefers to play by himself or sit quietly. There are many times when Arun will play with me and the other children, but I must usually invite him to join. He is very outgoing and happy, but he will not usually seek out others to play with him. We play a game where Arun pretends to call me, and we chat on our pretend phones, but the minute he speaks to me in Malayalam I say "Malayalam arrila" (I don't know Malayalam) and I hang up. We get through the typical introductions such as "how are you?", "what is your name?", and then he has to think of other words and sentences he knows in order to keep me on the phone. It's a great way to practice his English and his social skills.

Last week, I read Arun's file that was completed when he was first admitted to the school in June 2009. I thought the files must have been switched, because the description of Arun's behaviour was nothing like what I had experienced when working with him. The Arun that I know is very calm, extremely polite and friendly, and gets along well with other although he prefers to play alone. Arun's file described his behaviour as aggressive and stated that he is easily distracted and becomes frustrated often. His IQ was assessed by a psychologist and found to be between 45-49, which would point to a diagnosis of moderate, not mild, mental retardation. After working with Arun for 2 months, it is clear to me that this is not the case. There are clear deficits in his learning ability, however he is able to grasp new, complex concepts. His ability exceeds that of someone with moderate mental retardation. I believe the assessment was compromised by Arun's behaviour (inattentiveness, frustration,...) and the results led to an inaccurate diagnosis. As in North America, many Indian teachers feel that the IQ test has certain flaws. First, it is not sensitive to the cultural differences that exist in India. For example, one criteria is that the child knows how to use eating utensils, but in India this is not necessary to determine mental or physical competency since it is not part of their culture. Also, as in Arun's case, it is not able to distinguish between a child's mental inability to answer a question and a child's unwillingness to answer...a correct answer receives a point and an incorrect or unanswered question does not. It is important, therefore, to conduct behavioural assessments such as the Behavioural Assessment Scale for Indian Children with Mental Retardation (BASIC-MR) in order to determine the extent that behaviour problems can contribute to learning difficulties. At Asadeepam, all children undergo an IQ test to be diagnosed before being admitted, however the teachers understand that the test can be unreliable and they treat the child based on the abilities that they witness personally.

John Aditya (Chachu)

John Aditya is a 9 year-old boy with severe autism. His nickname is Chachu, and it is used so often that he will only respond to this and will not respond when called John Aditya.

He is non-verbal and has many habits that make teaching a challenge. Chachu only walks on the tips of his toes, and often spins around in circles with his hands interlocked behind his neck. He will cup his ears with his hands and make a loud shrieking sound. He also licks his fingers and wipes them on tab

les, chairs, walls, and people. It is difficult for Chachu to sit in one place for an extended period of time. He enjoys running and jumping. When he is given teaching materials such as puzzles, the pieces end up either in his mouth, all over the floor, or he holds them in his index finger and thumb and flicks them against a hard surface making a loud tapping sound. He does this flicking behaviour with any new object he finds, especially clothing, sticks and strings.

He is usually good-tempered, however his mood can change suddenly and often without warning or an apparent reason. Children with autism have difficulty with social interactions. Chachu does not show interest in playing with others, and will often sit by himself with a piece of string. When he interacts with others, the other person is simply a climbing apparatus for Chachu, or Chachu needs the person to get him a glass of water or help him get dressed. He has inappropriate bursts of emotion, and will often start laughing or crying for no apparent reason.

Chachu is very comforted by routine. It is important for activities to occur in the same order and at the same time everyday. He becomes very agitated when the daily routine is changed, and he does not cope well with new environments. He is very anxious around new people or objects. When I was working in Chachu's class, I brought in a new chair and Chachu became very upset and refused to go near it, however within an hour he was playing with the chair. I was also helping Chachu control his hyperactivity and receive some stimulation in the school's ball pool. He was terrifed of the ball pool and refused to be anywhere near it. After an entire day in the room, he was able to pick up a ball from the top of the pool and play with it. If anyone tried to help him into the ball pool he began to scream and crouch down to the floor.

The other students at the school take very good care of Chachu. They will play with him, make sure he eats his meals, and take him from one activity to another. One feature of Asadeepam is that it integrates children with autism and children with mental retardation. Children with mental retardation love to have social interactions and play. Children with autism find this challenging, so the children with MR are able to help them socialise.

Last week, I attended a lecture series on sensory integration (the organisation of sensation by the brain for use in everyday life) and autism. It was organised by the pediatrics department at a local hospital. The guest speaker was a physiotherapist from Chennai. In psychology, we focus much more on the cognitive and behavioural aspects of autism, so it was very interesting to approach autism from this perspective. He explained autism as a sensory disorder, and described methods to improve conduct through stimulation of certain senses. Behaviour that seems to be for no apparent reason can actually be serving as sensory stimulation for a child with autism.

There are 7 senses: taste, touch, smell, hearing, sight, vestibular (sense of balance and spatial orientation) and proprioceptive (sense of relative position of body parts). Children with autism may be under or oversensitive to one or more of these senses and they will have their own preference for certain types of stimulation. They use these senses to regulate their "energy level", or level of excitation. When the child wants to be more alert, they will seek stimulation to raise their energy level. When the child is overstimulated, they will seek stimulation that will make them feel relaxed and calm. Alerting stimuli are fast, erratic, loud, and calming stimuli are deep touch, rhythmic, and slow, depending on the sense that is being targeted. These self-regulating strategies help to stabilize their energy level throughout different activities and situations.

Sensory-seeking behaviour can often be labelled as problem behaviour by caregivers. There are some signs that can help us identify sensory-seeking behaviour. First, the behaviour seems purposeless and does not seem to be done to achieve something (e.g., screaming in order to get a cookie, hitting the table to get attention). Sensory-seeking behaviour seemingly occurs at random times, whereas problem behaviour can usually be seen immediately before or after some kind of trigger. The difference that I find most important is whether the behaviour occurs alone or when others are present. Sensory-seeking behaviour will occur at any time, including when the child is alone. Problem behaviour, however, is much more frequent when others are around because the child is trying to achieve something and needs the attention of others to get what they want.

Children with autism know what type of stimulation they need, but they do not know when it is suitable to seek it or what method of stimulation is most appropriate. Through teaching, children can learn to satisfy their sensory needs in an acceptable manner.

When I returned to the school, I began to pay more attention to Chachu's behaviour from a sensory perspective. Chachu does not seem to have a preferred sense, and he frequently shows sensory-seeking behaviour. To stimulate his sense of taste, he will lick his hands and furniture, and put objects in his mouth. To stimulate his sense of touch, he will run his hands along walls and flick a piece of string against his palm. To stimulate his vestibular sense, he will spin around the room on his toes and hang upside down. I have not been able to distinguish which senses he uses to lower and raise his energy levels. I have found that sounds seem to overstimulate him and deep touch works to calm him.

I have been attempting to turn some of Chachu's sensory-seeking behaviour into teaching opportunities. Chachu loves to jump, so I hold him under his arms and on the count of three he jumps and I lift him up. He enjoys being able to jump even higher with my help. I don't expect Chachu to learn to count through this activity, but it is teaching him delayed gratification and how to inhibit his responses until the appropriate time. if he tries to jump at the count of 1 or 2, I do not lift him and I tell him "No". Counting 1,2,3 is often used at the school by teachers so I am also familiarising him with their sound and meaning.

The lecturer said that we should try to replace inappropriate self-regulating strategies with more acceptable ones. For example, if a child is rubbing saliva on their face they may enjoy the wetness they feel so splash their face with water before bed and do not dry it off. This seems acceptable, however there are situations where a problem behaviour is replaced with something the child finds rewarding. For example, if a child chews on objects, it is suggested that you give them something crunchy to eat so that they mimic this sensation in a more acceptable way. From a behaviourist perspoective, giving the child food following this problem behaviour could be interpreted by the child as positive reinforcement and increase the problem behaviour. The child learns that when they are caught chewing on objects, they are given food. In this case, a sensory-seeking behaviour has become a problem behaviour that is being reinforced. Perhaps if this is started at a young age, the problem behaviours are completely replaced or the caregiver is able to anticipate when stimulation is needed. I will need to learn more about this perspective on autism before I can fully understand how it is used to improve behaviour in children with autism.

Also, many forms of sensory intervention require a certain level of understanding from the child. The caregiver must often reason with the child about time limits and replacing inappropriate behaviours. This is more difficult with children like Chachu who are severely autistic and have difficulty with comprehension. It will take much more time and effort to replace Chachu's current, inappropriate sensory-seeking behaviour with more acceptable methods of stimulation.

The lecturer also gave some helpful tips for working with children with autism:

• Make sure activities are age and skill-appropriate.
• Don't undo work that the child has done (i.e., don't undo a puzzle and ask the child to complete the same puzzle again). They will think there is no end to this game and will lose interest. Instead, prolong an activity by changing it slightly and increasing the difficulty as you go along (e.g., start with all but one piece of te puzzle in place, so that the child can complete the puzzle and understand the ultimate goal. Next, undo the puzzle and complete all but two pieces. Continue this until the child is completing the puzzle by themselves.
• When a child is able to complete all the given tasks, start to give two tasks at once (e.g., sort blocks by colour AND size). This increases the difficulty and teaches the child to keep more than one concept in mind at a time.
• Try to find multiple uses for a teaching tool.
• Avoid monotony and try to give a child variety in their tasks. Extend games by introducing new items.
• Choose activities according to the child's sensory preference.
• Give time limits for activities. This will sustain their interest if it is a desired activity, and it will increase their tolerance if it is an undesirable activity.

Shinu

Shinu is a 15 year-old boy with Down's Syndrome and moderate mental retardation. Shinu started at Asadeepam during my second week, so I have gotten to know him along with the other staff at the school.

Shinu's speech is very unclear, and he has invented his own version of English that he uses to communicate with me. Unfortunately, neither myself nor any of the teachers can understand it. At first, the teachers had many difficulties understanding him, but now they have grown accustom to his way of speaking.

Shinu has a wonderful personality and spirit. I was teaching Shinu's class when he first arrived, and I was trying to assess his skill level in Math and English. He answered the Math problems I had given him (incorrectly) and began to write his own problems. They did not make sense but they followed a similar structure to the ones I had given him. He could also write the English alphabet until the letter "H". Shinu wears a Hello Kitty watch everyday, and he is always playing with it and showing it to others. Shinu cannot tell time, however, so he will always ask you to tell him the time. I noticed that his watch was set to the incorrect time, so I changed it for him. He immediately changed it back, saying that he didn't like the way it looked. After playing outside, the face of his watch broke so the glass and the hands were removed. He still wears it every day, and will still ask you to tell him the time.

Shinu likes to take care of the younger children and myself. Before every meal, he reminds me to wash my hands with soap and asks whether I have showered. When we play badminton outside, he coaches my serve from the sidelines. Shinu loves to sing and dance, and will spontaneously break into either of these activities, but he becomes embarrassed when he spots someone watching him. Shinu will often make a loud moaning sound while completing tasks. He will also often lick his palms.

Shinu can be very cheeky and will try all kinds of things to get what he wants. One evening, we were returning home from an event. Shinu asked the principal's husband to stop for ice cream, but the principal's husband refused. Shinu said that he would start to cry if they didn't stop the car for ice cream. The principal's husband, calling Shinu's bluff, told him to go ahead and cry. Shinu, realising that his plan wasn't working the way he had hoped, turned to another teacher and asked her to start crying instead.

Shinu loves TV, especially comedy films, and he himself has a great sense of humour, although it may not always be intentional. Another intern fell asleep in the car on the way to a dancing competition, and she was leaning against Shinu. He began to stroke her hair and sing her a Malayalam lullaby for small children. These moments, and many more, make working with Shinu a constant source of entertainment. Despite his intellectual and language deficits, Shinu is a very social person.