Boys painting at school

This article was originally written in the spring of 2011 for HaYidion, the journal of RAVASK, an organization of Jewish Day Schools. While it refers specifically to the inclusion of children on the autism spectrum in a Jewish Day School environment, nearly all the information here applies to other mainstream school environments as well.

A wide range of abilities and impairments

Children with autism are so varied that an ordinary person meeting two or more of them might be puzzled that their conditions fall under the same name. This is why child mental health professionals have settled on the term "autism spectrum disorders," or "ASDs," to describe this heterogeneous group.

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 tragically never acquire the ability to speak, to the "little professors" who show advanced verbal ability but have difficulty using language and nonverbal communication in socially typical ways.  

Social impairments likewise range from being 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.

The importance of the right evaluations

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. 

What kind of classroom?

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 the 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, and incentives for achieving goals are delivered at school or 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.

Additional assessments and therapies

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, and often with medications, prescribed by a child psychiatrist.

Children may also receive speech/language therapy for conversational and perspective taking skills (see www.socialthinking.com in Resource List), occupational therapy as described above, and physical therapy to treat gross motor delays.

The importance of working together

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.

Summary

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.

When inclusion isn't an option

While many children with special needs are successfully educated in general education settings with supports, some children require a more specialized setting for either a particular phase of their educational career or its entirety. Children with significant cognitive impairment who struggle with basic abstract reasoning have difficulty participating in a mainstream curriculum.  Children who are of average intelligence but have a learning disability, such as dyslexia, that is severe in degree, cannot keep up with academic demands and require a specialized placement in order to make progress. Children with medical conditions, for example, poorly controlled epilepsy, or a physical disability that prevents them from writing or using a keyboard, and children who have not acquired the ability to speak need to be placed in specialized settings.   Children with severe psychiatric illness who are a danger to themselves, aggressive to others, or who show impairment in reality testing need a specialized placement until they have recovered and can return.   

There are various public and private options for children who cannot succeed in general education settings. In the public schools, children can be placed in collaborative team-taught (CTT) or "inclusion" classrooms taught by two instructors, and offered a package of services such as therapies, an aide, social skills training, and guidance counseling. Public schools also have self-contained, small classroom settings of anywhere from 6 to 12 children that are often tailored to specific populations. There are also many out-of-district specialized schools, which parents can seek privately or petition their school districts to pay for.    

Parents should not automatically assume that a placement outside a Jewish day school is "forever." Many children who are provided with an appropriate, individualized program of support make progress such that they are able to successfully transition or return to a general education placement. It is also important for parents and educators to be guided above all by what a child needs in the moment. We stress to parents that plans should be conceptualized for a one-to-two year time frame and that planning too far ahead is not helpful.     

Selected resources

Asperger Syndrome and Difficult Moments: Practical Solutions for Tantrums, Rage, and Meltdowns – Revised and Expanded Edition by Brenda Smith Myles & Jack Southwick

Asperger Syndrome and Adolescence: Practical Solutions for School Success by Brenda Smith Myles & Diane Adreon

The Complete Guide to Asperger Syndrome by Tony Atwood

Understanding Asperger Syndrome and High-Functioning Autism by Gary Mesibov

Online Resources

NYU Child Study Center: www.aboutourkids.org

Social Thinking:  www.socialthinking.com
 
AAPC Publishing: www.aapcpublishing.net

Autism Society of America: www.autism-society.org

504 Accommodations Checklist provided by the Nebraska Dept of Education: www.come-over.to/FAS/IDEA504.htm

Information concerning learning disabilities: www.ldonline.org

Wilson Reading Program: www.wilsonreading.org

Lindamood Bell Learning Process: www.lindamoodbell.com

Jessica Kingsley Publishers: www.jkp.com

"Gateways: Access to Jewish Education": www.jgateways.org

Matan: www.matankids.org