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The cluster of impairments of social interaction, communication and imagination and the consequent repetitive pattern of behaviour is the common thread connecting all autistic disorders, whatever other conditions may be present. Teachers with training and experience in the field are developing methods of helping children to compensate for these disabilities and a range of books and papers is available. Here, the aim is to give some simple ideas that parents can use in everyday situations.

Social interaction
This is the aspect of autistic conditions that causes parents the most heartache and feelings of inadequacy and guilt that are totally undeserved.

Developing social contact
The young child with typical autism of the kind described by Kanner appears aloof and indifferent to others and happy in his or her own world unless someone interferes. One of the barriers to making contact with such a child can be dislike of being touched. This can make washing and dressing a nightmare and cause the child to resist being help by the hand when out walking. Paradoxically, the children usually enjoy rough-and- tumble play and this can be used to give them the feeling that contact with other people can be enjoyable. The play sessions can begin with more active play and then gradually become quieter and more gentle. This type of contact can be associated with other experiences that enjoyed, such as a mid-morning drink or biscuit. If the child likes music, as so many of them do, they may be happy to sit on a parent’s lap and be rocked while listening to a favourite tune. They may be more receptive to this after some physical activity or after a bath. It may be necessary to start with a few seconds of contact only and then gradually to increase the time.

Some aspects of appropriate social behaviour can be taught, even though they are used in a mechanical way. Eye contact does tend to improve with increasing age but it can be encouraged. Providing this does not cause distress, the child’s head can be gently held to attract their visual attention when talking to them. Some will make eye contact if the adult pulls funny faces, or sings a favourite song. One game that a little girl enjoyed was touching noses with her mother who then twisted her head to create a funny visual effect. The child happily made eye contact to ask for this game and then used it for other requests.

Positive signs of affection within the family can also be taught. Instead of allowing the child to accept a hug and a kiss passively, their own arms can be guided to return the hug. It is best for the child to learn this as a response to affection from others rather than encouraging them to imitate the contact, in case they assume that is the way to greet everyone.

A child can be taught to shake hands if their hand is guided correctly whenever a visitor offers hand first. Again, it is better to teach this as a response to a proffered hand rather than encouraging the child to make the first move, since they will not understand when it is correct to do this and when not. With the children who can speak, teaching polite behaviour, such as saying please and thank you, is worthwhile. They have no idea why people do this but helps to make them more socially acceptable.

Although they lack the inbuilt social instinct, the children do, in the course of time, become attached in their own way to the people who care for them. This is partly due to the fact that their parents or others cares become familiar to them and partly because they provide the things the child wants. This is “cupboard love” to start with but it does grow into something deeper over the years. It is never the same as instinctive feelings but it is no less genuine. The attachment grows most easily if parents are calm and consistent in their approach, provide a clear framework of rules that apply to all the family and give the child some pleasant experiences to make up for the fact that ordinary life tends to be a constant source of anxiety and confusion for them. Sisters and brothers, especially if they are of an age at which they are willing and eager to play, also become important to a child with an autistic disorder. Often, the sibling leads the child with an autistic disorder into all kinds of activities in which they would not otherwise engage. The fact that child is mostly or always a passive partner does not matter. The experience of play is of benefit.

Even if they relate well to siblings, it is easier for the children to relate to adults than to children outside the family, especially those of the same age. This is probably because adults are able to adapt themselves to the child, whereas other children, unless they also have siblings who are autistic, do not have the necessary insight and not modify their behaviour. Most children with autistic disorders with moderate or severe handicaps will always need supervision and guidance whenever they are with a group of same age children. They must be protected from bullying and teasing. Children with autistic disorders cannot defend themselves and do not learn to do so through experience. They have neither the verbal wit nor the physical skills to hold their own among their peers. The situation must never be allowed to degenerate so that the autistic child reacts with random aggression, or else withdraws and wanders away on his own.

So far I have concentrated upon ways of encouraging social mixing. The other side of the picture can be seen in some children who make good progress. They may become over-friendly and sociable in an immature way and fail to discriminate between people they know and complete strangers. One girl of 10 would rush up to strangers with a joyful greeting, to their amazement. Her parents had to restrain her and explain many times over that she must not talk to people in the street unless her parents made the first move. She was most upset at first, but the phase passed after a few months. There is no easy answer, since parents do not want to discourage a spontaneous friendliness that they have spent so long in encouraging. However, I have not met any children who have become withdrawn again because their over-friendliness has had to be curbed.

Expeditions, Holidays and Social Occasions
Trips out with parents, brothers and sisters are a part of family social life. Young children with autistic disorders often find crowds and bustle confusing and frightening. At this stage, family expeditions should be carefully planned. They should be kept fairly short and not too far from home, so that it is easy to remove the child if the situation proves too distressing. Different kinds of outings can be tried. If one is not success, then it is best to leave it for a while and try again later. A visit to the zoo, with lively, noisy, smelly animals, may terrify a young child but be enjoyed when the child is older. When the child is able to understand, they can be prepared in advance by explaining in words and pictures where they are going, what will happen there, how long it will last and, very important, that they will, in the end, return home. Details, such as when and where they will eat and whether there are toilets and, if not, how they will cope, have to be included in the story.

Most young children with autistic disorders do not understand the point of birthday parties and do not participate if parents invite other children and there is no point in trying to make them take part. Older and more able children may like to go to parties although they may join in very little. One boy who liked sitting and watching the other children at parties was sad when his sisters were invited without him. The hosts had not realized that, in his own quiet way, he was enjoying himself. Parents, who so often have to stand between the world and their child, need to overcome any diffidence they feel and explain to friends and relations, so that the child has as much social life as possible. When the family entertains, the child with an autistic disorder may enjoy having a special role, such as handing round dishes of nuts or sweets, or clearing the table after the meal. This has to be practised in advance and the guests primed to express praise and appreciation, if this pleases the child.

Although some children with autistic disorders are afraid of trains or buses, many love travelling in any way of transport and may be calmer and happier when on the move than in any other situation. However, apart from the actual journey, holidays away from home may be difficult. A young child may be bewildered by new surroundings and may never settle during the whole period away from home. Many families do not take a vacation, or else try arrange temporary residential care for the child while the rest of the family goes away. The problems often lessen as the child grows older. A short break should be tried first. A self-catering holiday away from other people has obvious advantages.

As always, advantage preparation of the child using pictures to explain exactly what will happen makes all the difference to the child who can understand. Some of the child’s favourite possessions should be taken and the activities planned so that the child is kept amused and happy as much as possible. The aim is to associate going away on holiday with happy occasions so that eventually trips become easier to organize. The effort is worthwhile because new experiences that the child enjoys help to build confidence in place of fear. One child found it difficult to tolerate a long journey to a holiday destination the first time this was tried. She had no idea how long the journey would take and what would happen at the end, despite the parents’ attempts to explain. She was able to recognize and match written words so, on the next long journey, she was given a list of all the towns and villages on the route. The signs with the names on were pointed out and she crossed them off her list as they were passed. This proved an enjoyable occupation and showed her, in visual terms, the length of the journey.

Communication
In the first edition of this book, I included a description of a method intended to teach children with autistic disorders to speak, used by psychologists who advocated the “operant conditioning” approach. Briefly, the technique was gradually to “shape” the sounds made by the child by rewarding nearer and nearer approximations to words. Even then, there was considerable doubt as to the effectiveness of this system. Now it is clear that the language impairments in autistic disorders are primarily due to the lack of the normally innate drive to communicate with others. There may or may not be developmental language disorders in addition to this fundamental impairment but the communication problems cannot be overcome simply by teaching the children to speak, even if that were possible.

Within the people autistic spectrum, including those who are most able, the majority of children do develop speech sooner or later and most do so without any specialist help. The problem is that this speech is based on a vocabulary that is learnt by rote, although those who make progress do become very fluent with a large store of words. The best way for parents to try to encourage the communicative is to give the child as wide a range as possible of social and other experiences.

Preparing in advance with words and pictures and retelling events afterwards with more words and pictures provide the opportunity for the child to make connections between events and to learn that words have meanings in the real world. If a video camera is available, video-tapes of special occasions are useful for gaining the attention of some children. Even if videos can be made, still photographs have their advantages as well because they capture one single moment in time. The ordinary events of everyday life as well as special trips and treats provide plenty of material for these sessions. This type of interaction with parents and siblings helps the children to develop some awareness that talking to others can be interesting and rewarding.

About the abnormalities of speech that are characteristic of autistic disorders, it is not helpful to correct these odd ways of speaking. It is more important to encourage the child to communicate in whatever way they can. Where appropriate, rephrasing the child’s utterances when replying, without criticizing, is more useful.

In contrast to the children who speak very little, there are some who talk repetitively and far too much. Their speech is not used for two-way communication. The same ideas for enlarging experiences and using them to develop understanding are just as relevant for these children.

For children with no or very limited speech, the signs the child does use, such as indicating by touching or pointing, should be encouraged. If a child has no other means of expressing their needs, it is preferable for them to lead someone by the arm to show what is wanted than to scream. At this stage, the parent can teach the child, by repetition, to respond to the words “Show me” while putting out a hand to be taken. Every opportunity should be taken to reward more appropriate methods of communicating but any method is better than nothing. Teaching a manual sign language, such as the Makaton system, can be tried although, almost always, the same limitations and abnormalities are found in signed as in spoken speech. Just occasionally a child learns to use the signs much better than speech. Presumably this occurs when child has an additional developmental disorder affecting expressive speech but has sufficient inner language to allow them to express more in signs. For this reason, it is always worth trying to teach a sign language but the child should not be pressurized to use it if there is little or no progress.

Imagination
Pretend play is the earliest indicator of the development of imagination. Like speech, it is either conspicuous by its absence or repetitive if presents. Some children will learn a sequence of actions, such as preparing, pouring out and offering a pretend cup pf tea, but true creativity in play, especially that shared with other children, cannot be taught. Sometimes sisters or brothers involve the children in pretend games, assigning them a role they can carry out as directed.

The children, who have repetitive “pretend” play, including acting out scenes from videos or other sources, do have a way of occupying themselves, which can be a relief for parents. If the child becomes so invaded in one activity that it takes over from all other activities, then limiting the time spent on such play is necessary. This does involve parents in the task of finding other activities to replace the repetitive play.

The value of true imagination and creativity is in associating past and present experiences and making plans for the future, ranging from the mundane what to do tomorrow to the grand plans for the whole of life. The impairment of this aspect of development in people with autistic disorders is a constantly repeated theme throughout this book because is has such wide and deep implications for their lives.

Resistance to change and repetitive activities
This type of behaviour ranks high on the list of problems that cause parents the most worry and despair. If not handled properly, a child’s insistence on routine can come to dominate the life of the whole family.

The behaviour is the child’s attempt to introduce order into their chaotic world and this has to be remembered when working out the best way of managing the problem. It is necessary to arrange the child’s life so that it has order and pattern. Some kind of repetitive behaviour is inevitably present in a child with an autistic disorder and this has to be accepted. A firm line needs to be drawn when the routine or resistance to change reaches the point where it interferes with the life of the rest of the family and prevents the child from moving forward to more constructive activities.

The solution depends upon the nature of the routine. If the child insists on holding an object in their hand that is large and attracts adverse attention in public, or prevents other activities in which the hand would be used, or leads to other difficulties, the system of gradual reduction may be successful. One small girl insisted on holding a piece of photographic negative in her hand. Whenever the negative became creased or torn, which inevitably happened sooner or later, she screamed loud and long until a new piece was provided. Her parents decided to make the negatives a tiny bit smaller each day. She did not bother about this gradual change. Eventually the stage was reached when the piece of negative was about one centimetre square. At this point a new problem emerged. The little girl held this in the centre of the palm of her right hand with the tip of her middle finger. As soon as it became damp with perspiration, which occurred very frequently, she had a temper tantrum, though she did not release her grip on the fragment of negative. Eventually, her parents decided not to give her any more pieces and to ignore the screams. After a difficult day or two, the child lost the last fragment and the routine disappeared.

Some objects cannot be cut down in size. One strategy that can be used is to allow the child to have the objects at certain times and not at others. If, for any reason, the times when the object is to be allowed has to be reduced, this should be done gradually. Much determination is needed to start the process of time restriction but, once established, it becomes part of the child’s routine. One girl, at 10 years of age, wanted to carry a large dustpan and brush with her all the time. Her parents insisted that she left it al home whenever she left the house. After a few protests she accepted the new routine of putting the dustpan and brush in one particular place and saying, “All ready for come back” when she went out.

There are other kinds of collecting that cannot be tackled by these methods. The case of the boy who wanted to hold empty detergent packets has already been mentioned in a previous chapter. He could find the packets in any house he was taken to visit and would run into a stranger’s house if the door was open. If he found a packet with powder in, he would empty it in the sink or on the floor. The only way his parents could deal with this was to prevent it altogether. They hid their own detergent packets, visited only friends and relations who understood and would do the same and kept a tight hold on the child’s hand when out walking. They did not take him into any shop that sold detergents. After a few weeks, he had lost interest in this pursuit. If it is decided that some behaviour of this kind has to be stopped and it cannot be done gradually, the policy of total prevention is the most likely to succeed, if it is possible to put this into effect.

Some children involve other people in their routines. One child insisted that everyone in the family sat on the same chair at each meal. His temper tantrums if the pattern was disturbed made it impossible for the family to have guests for a meal. To overcome the problem, the rest of the family decided to change their places at every meal, regardless of the tantrums. The child’s protests became louder and longer for several days, then diminished over a few days and finally stopped completely.

Bedtime routines present particular problems. The children who have them may not settle to sleep until a complex sequence of actions involving the parents has been completed without error. It may be possible to diminish the routines by missing out a tiny step every few nights. Refusal to allow the routine al all is likely to lead to tantrums and refusal to settle to sleep for some time. It is not possible to predict how long the protest might last. If the routine is not too taxing to carry out it is easiest to accept it, especially if the child then sleeps peacefully. It is worth taking a stand only if it is very long and complicated or it seems to be growing in length and complexity.

Often, parents who have had the courage to tackle a particular routine have found that, once the problem has been overcome, the child confidence in their ability to help their child and the child finds that giving up a routine dos not make the world fall to pieces. He or she has been helped to take a small step forward and all the family gain from the experience.

It is one of the basic facts of autistic disorders that, if one routine disappears, another comes along to take its place. However, if one is overcome successfully by the parents, those that follow tend to present less of a problem. In theory it should be possible to deal with each routine as it occurs. In practice, most parents find that a compromise works well. Some of the habits comfort the child but do not cause any problems and these can be left alone. For example, it does not matter if a child likes to carry a particular small object in a pocket, as long there is no tantrum if it is lost. Effort should be saved for tackling routines that do have adverse effects on the child or the family.

Once parents have made up their minds to discourage the unacceptable routines, it is helpful to deal with a new one that might be troublesome as soon as it appears. The task is easier in the early stages than it is once the routine is well established. A number of mothers take deliberate steps to vary household practices just a little every day so that the children become used to the idea of a certain amount of change. This may seem to contradict the rule that autistic children need order in their lives. The aim is to find a balance between too much rigidity on the one hand and too little structure on the other. How this is worked out depends on the individual child and the family concerned.        

Lorna Wing (1996) - The Autistic Spectrum, a Guide for Parents and Professionals. London: Constable