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Triad of Impairments
And now we come to the Triad of Impairments.   You can't have autism without the triad.   It's the headings under which people are diagnosed with autism.   It was originally devised in 1979 by Lorna Wing and Judy Gould, who described children with autism as having impairments of social relationships, social communication and imagination.   You can find out more about the triad in books or on the web, the National Autistic Society have some good information sheets and one of my favourite sites is Awares.org.  

I've taken the information in the triad in the bluish boxes below mainly from the Awares website, they've done a really good job and there's no point reinventing the wheel.
Triad Slider 
Autism, that's how we roll here!

Before we start, its important to get things into perspective.   The autism (and the triad) is only a part of all the stuff that makes up your child.   There's also their own unique personality, much of which they probably got from you!   Ask someone who knew you as a child what you were like, I'm guessing that a lot of the personality traits you see in your child were evident in you when you were that age, and you've probably still got a lot of them now!   Its just that, for your child, their personality has an autistic accent.

Its also important to remember that, like any trait, disability, skill or symptom, your child will experience the different sections of the triad to a greater or lesser degree.   If you think of someone with cerebral palsy, the way their disorder affects them can range from totally and profoundly disabled, to living independently, married with kids and working full time!   The same goes for singing, some people are dreadful, some are OK, and some are good enough to make a living out of it.

If it helps, try thinking about it using the sliders from the Wonga.com TV adverts.   There's a saying plastered all over the internet, I believe it originally came from Lorna Wing herself.   It goes "once you have met one person with autism, you have met one person with autism".

With that out of the way, lets move on to the triad.
 
Social Interaction
Social interaction involves lots of very subtle and complex rules that differ from situation to situation, culture to culture, generation to generation and person to person.   It seems people with autism have trouble picking up on these the way neuro-typical people do.   We're not born knowing them, we learn them through trial and error, and they change as we get older.   Unfortunately no one has written a comprehensive manual yet.

Social interaction can be divided into four groups.   It is important to remember that most children won't fit 100% into each group, they're children, they wouldn't want to make it easy for us!   Just remember the sliders.
 

1. The aloof group This is the most common type of social impairment. Behaviour may include:

  • Behaving as if other people do not exist.
  • Little or no eye contact made.
  • No response when spoken to.
  • Faces empty of expression except with extreme joy, anger or distress.
  • No response to cuddling.
  • If something is wanted, carers' hands may be pulled towards the object.
  • May respond to rough and tumble play well, but when this stops return to aloof pattern.
  • Seem to 'be in a world of their own'.

2. The passive group Least common group, features may include:

  • The child accepts social approaches.
  • May meet the gaze of others.
  • May become involved as a passive part of a game.

3. The active but odd group Children of this group make active approaches to others but make that contact in strange ways, including:

  • Paying no attention to the other party.
  • Poor eye contact although sometimes may stare too long.
  • May hug or shake hands too hard.

4. The over-formal, stilted group Seen in later life, this behaviour is common in the most able person with autism. The following characteristics may displayed:

  • Excessively polite and formal.
  • Usually has a good level of language.
  • Tries very hard to stick to the rules of social interaction without really understanding them.
 
IgnoreUs humans tend to be remarkably offended when people don't stick to the social rules, it makes us very uncomfortable.   We also hate anything strange or different.   Sometimes we find it funny, but usually only when someone else is on the receiving end.   Watch a few episodes of Borat.

When you're aware there are social rules to follow, but you're not sure what they are, you can feel very uncomfortable.   This is a situation many people with Asperger Syndrome (AS) or High Functioning Autism (HFA) often find themselves in.   We'll come back to this when we visit Afghanistan later on to look at anxiety.   It can often lead to people with avoiding social situations altogether.

One area of social interaction difficulties where visual and other supports can help is around helping to child to recognise, label, express and, at least partially, understand emotions in themselves and others.   We can also help with the etiquette of social greetings, who you can and can't talk to, hug, kiss, and how the rules can change depending on the situation.   Watch out for "the targetty thing" in The What section later.

Next time you're out and someone is being a little odd, maybe flapping their arms, making funny noises or doing the ministry of silly walks, just stop and think who are they actually harming?   Who really has the problem, the person being odd or the people being offended by it?
 
Social Communication
Children with autism often have great difficulty using and understanding language, especially spoken language.   They may simply repeat words and sentences, use phrases without understanding the words that make them up, or be unable to process sentences, picking out only the key words.

They particularly struggle with the non-verbal aspects of communication.   Body language, tone of voice, word emphasis, even the unsaid and the implied.   All these are integral parts of human conversation and communication, and they really affect what we think of people (just look as accents) and well as enhance the information being conveyed or even change it entirely.

Problems with communication can be divided up as follows.

1. Using speech Common speech problems include:

  • Repeating words spoken to them (echolalia).
  • Asking for things by repeating a phrase they associate with the action e.g. 'Do you want a cup of tea' instead of 'I want a cup of tea'.
  • Missing linking words out of sentences such as 'in' 'on' 'because' 'under.' So, for example a child may say 'go car shop' missing out the joining words.
  • Explaining in greater detail than is necessary.
  • Long replies to questions spoken as if learnt from a book.

2. Understanding speech Difficulties arise in a number of situations:

  • When objects have more than one name such as a bowl (washing up or eating from?).
  • Confusion between the sound of a word e.g. meet and meat.
  • Literal interpretation can be problematic. Imagine if you took phrases like 'it's raining cats and dogs' or 'have you lost your tongue' literally.
  • Humour, especially that which relates to verbal ambiguity can be difficult for a person with autism.

3. Intonation and voice control These include:

  • Problems with volume, sometimes too loud; often too quiet.
  • The voice may sound mechanical or monotonous.
  • Enunciation of words can be over-emphasised.

4. Using and understanding non-verbal communication

  • Speech is only one of a variety of ways in which people communicate, all sorts of gestures accompany speech including subtle eye movements, arm and hand movements and posture changes. People who are not autistic but have an impairment in, say, speech, are able to use other ways of communicating. However people with autism have a fundamental impairment in communication, which goes beyond just speech.   This is why some children, although taught to use PECS or sign-language, still need prompting to use them, or will only use them in specific settings.
 
JokeAs mentioned above people with autism may struggle with some types of jokes, while others may appeal to them more.   Sarcasm is usually one of the worst, people with autism often have a very literal understanding of language and here we have a form of humour where you say the exact opposite of what you mean and use your tone of voice and body language to convey that fact!

So think carefully when communicating with your child, especially verbally.   Use clear, consistent language and give them time to process.   And use their name!   Some people with autism report that, unless you put their name at the beginning of the conversation, they don't know you're speaking to them, and if you don't put any names in, they're not sure if you're speaking to them or not which can make them quite anxious (ever had that thing you think a stranger is talking or waving to you when actually its someone behind you? How did you feel?).

Social communication is something that's worked on a lot in early years settings, things like turn taking and PECS (Picture Exchange Communication System).

Once again, when you look at it closely, often its not only the people with autism who have the problem in this area, its also us who never say quite what we mean, and insist on communicating with funny body movements and voices while getting offended when people with autism do their own funny movements and voices.
 
Social Imagination
Also known as flexibility of thought, this is the big one.   This is where dependence on routines, hating change, narrow interests or obsessions and no awareness of danger all come from.   Its proper meltdown territory.   Its not settling to sleep on your own, not learning to use the toilet, resistive eating, spinning objects, lining them up, "light on, light off", ministry of silly walks and debilitating anxiety.

First of all, lets do a little exercise to understand imagination and it's purpose.   It has a very important function in our ability to keep ourselves safe.   I want you to pick up your mobile phone, and throw it hard against the floor or wall...actually I don't want you to throw it, I just want you to think about what would happen to it if you did throw it.   It would probably break.

How do you know it would probably break?   Have you ever thrown that phone sitting in your hand hard against the wall or floor before?   Have you ever seen someone else throw that phone?   Actually, a parent of a child with autism may have seen their phone thrown but I hope you get my point.   You used your imagination to apply knowledge and learning from one situation to another, you generalised.   We have all dropped or seen other people drop objects similar to your phone, and experienced the results.   We may have seen it in real life, or on the telly, or just heard about it.

Ancestor UggIf you think about our ancestors, hunter-gatherers twenty thousand years ago, imagination was vital.   Say Ugg came across a lion, how would he know to run away?   Maybe he's seen Uncle Ogg being eaten by a sabre-toothed tiger.   He may not have seen a lion before, but he'd be able to use his imagination to see the similarities and make an informed decision.

In the description below, they appear to be describing children with a severe impairment of imagination.   Once again, remember the sliders!   I do know children with autism who engage in a degree of imaginative play.   Often you do have to look closely at this, as they may be acting out scenes from TV shows or copying imaginative games that they have learned from other children or adults, but I have seen genuine, imaginative play.

Sometimes they may play well with, say, their Thomas The Tank Engine train set and their Peppa Pig toys, but not think to join the two together, such as making Peppa ride in Annie or Clarabel the way a neuro-typical child may.
 

One of the characteristics of autism is the inability to play or engage in imaginative activities. So a toy truck becomes a play thing only in as much as the spinning of a wheel provides stimulation. Some more able people with autism develop a sequence of events which appear to be play but close observation shows the sequence is often repeated over and over again.

The lack of imaginative play leads on to limited or no understanding of other people's emotions so people with autism find difficulty in sharing happiness or sorrow with others.

Many people with autism find their pleasure in special interests.

Repetitive stereotyped activities Many people with autism display stereotyped activities. These range from the simple, such as:

  • Tasting, smelling, feeling or tapping different surfaces.
  • Listening to mechanical noises such as washing machines.
  • Switching lights on and off.
  • Spinning objects.
  • Head banging.

These simple stereotypies may last until adulthood. More complex stereotyped behaviours include:

  • A complex sequence of bodily movements.
  • Placing objects in long lines that cannot be moved.
  • Extensive bedtime routines.
  • The family sitting in exactly the same places at mealtimes.
  • Attachment to strange objects such as pieces of string or leaves.
  • Collecting strange objects such as tins of polish.
  • In more able people with autism, fascination with the weather, timetables, train numbers, etc., etc. may be found.

Many of the above do not extend into adulthood. However, fascination with numbers and sequences can often continue.

 
I often find that children who enjoy lining toys up when young progress on to data (i.e. lists) as they get older.   They may start with lists of who likes to eat what or organise their classmates by hair colour, before moving onto more complex data such as train timetables or makes of tank over the last hundred years as they gain maturity.

A child may enjoy being shown how to use a computer for these activities, Microsoft Excel (assuming your child goes to school, they will be entitled to the Home and Student version) or one of the free alternatives such as Open Office are excellent for organising data and take up a lot less room than endless pieces of paper!   Its worth using an online backup system such as Microsoft's Sky Drive or Box.com to avoid the devastation of losing years of lists should the computer go wrong!