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READ THIS IF YOU WANT PRACTICAL IDEAS FOR GROUP WORK STUDENTS TO LEARN BY DOING TO FACILITATE TRANSITIONS

CHILDREN AND YOUNG PEOPLE WITH HIGH LEVEL AUTISM AND ASPERGERS SYNDROME ARE CHALLENGED BY SITUATIONS DEMANDING SOCIAL COMMUNICATION SKILLS. EVEN WHEN THEY ARE PERFECTLY ABLE TO CARRY OUT TASKS ASSOCIATED WITH SCHOOL, LEISURE ACTIVITIES AND THE WORKPLACE, THEY CAN FACE SERIOUS PROBLEMS COPING WITH ASPECTS INVOLVING INTERACTION WITH OTHER PEOPLE. THIS CAN LEAD TO OR EXACERBATE SOCIAL EXCLUSION AND MENTAL HEALTH ISSUES. OUR TWO CONTRIBUTIONS FOCUS ON THE VERY SPECIFIC ROLE A SPEECH AND LANGUAGE THERAPIST CAN PLAY IN HELPING CHILDREN AND YOUNG PEOPLE WITH ASPERGERS SYNDROME UNDERSTAND THEMSELVES AND OTHERS THROUGH BRINGING TOGETHER THE RIGHT PEOPLE AT THE RIGHT TIME IN THE RIGHT WAY. SOCIAL COMMUNICATION GROUPS (1) STRUCTURE, STRENGTHS AND STRATEGIES SOCIAL COMMUNICATION GROUPS (2) A WICKED COURSE

Structure, strengths and strategies

JANE BAKER EXPLAINS HOW THE MANTRA STRUCTURE, STRENGTHS, STRATEGIES INFLUENCES THE CONTENT AND FORMAT OF SOCIAL COMMUNICATION GROUPS FOR CHILDREN FROM 31/2 YEARS TO ADULTHOOD IN SOUTH DEVON. TOGETHER WITH GILL ROGERS, SHE ALSO SHARES RESOURCE IDEAS.
In Baker (2005) I discussed the 4 us Model of the South Devon Aspergers Group. This includes four components: a support group for parents, a youth group, a sibling group and social communication groups. Preparing children with Aspergers Syndrome for a social life requires us to use structure, build on strengths and develop strategies. I therefore thought it would be useful to discuss the social communication groups in more detail. There are four different age groups running at any time. The Own Agenda group is for children from 31/2-5 years. We have two Social Communication Skills groups for primary school aged children (5-8 years and 9-11+ years) and one for secondary school aged children (11+ -19 years). games, to begin to tolerate other childrens agendas, and ultimately to begin to remember another childs preferences. We play games such as:
Name game Each child chooses another child they want to roll the ball to. They have to look at that child, say their name, then roll the ball to them. The receiving child then gets the next turn. The therapist assists by giving forced alternatives and reminders if necessary. Change can be introduced by using different balls or soft toys, or even an invisible ball. Collecting game Using cards with different sets of pictures (like snap cards), each child chooses one or two to be the ones they collect. All children lay their chosen cards faceup so the others can see them. The children take it in turns to pick a card from the remaining pile, then identify the collector by name and give the card to them. The recipient thanks the giver by name.

HOW I (1):

1) OWN AGENDA GROUP

The Own Agenda Group is designed for children suspected of having higher functioning autism / Aspergers Syndrome. It includes pre-schoolers presenting as own agenda children but not necessarily having an autistic spectrum diagnosis. This group runs for half an hour weekly at Kingsteignton Medical Practice with a maximum of six children. Parents are encouraged to chat and exchange information in the waiting room, and are given photocopied sheets of group games to play at home. Here are two abridged examples:
Bricks game Take turns piling up bricks until they fall over. Use phrases like my turn; your turn; daddys turn. Once your child is tolerating the involvement of others in the game, you can ask, Whose turn now? Whats in the pillow case? Put lots of different toys / unusual items in a pillow case. Take turns to take an object out use suspense and make it exciting (no peeking!) Encourage your child to notice everyones turn. When the object comes out, model appreciative noises (wow!; thats interesting!) Talk about whose turn next? and the process of passing on the bag, offer praise (good passing!) and work to keep their interest up.

We keep a simple rating scale (1 = poor / 2 = variable / 3 = good) for willingness to participate, eye contact, turn taking, response to / interest in others and listening. One of the most useful outcomes is the friendships that develop between parents and the children, who often meet up independently and continue to support each other.

SOCIAL COMMUNICATION GROUPS - PRIMARY

We run two groups for primary school age children as part of the South Devon Aspergers Group Asperations. Both have a similar structure and a maximum of eight children. Gill Rogers runs the 5-8 year old group while I take the 9-11+. Each member of the group has a credit card sized membership card with the rules of the group in symbol form on both sides (figure 1). These are: Be part of the group Take your turn to talk, share turns Listen to others Ask questions Be kind to others Learn to change your attitude No interrupting No violence No shouting No swearing or name-calling Dont be boring Keep to your own space.

The group aims are to switch the children on to each other, to notice each other, to share turns with each other, to listen to requests from each other and respond appropriately, to be part of the group and play the group

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OMMUNICATION GROUPS
In addition to having their own membership card, the rules are reinforced visually by the therapist showing the relevant rule card (for example, change your attitude) as a reminder. We have a zero-tolerance policy towards violence to keep everyone feeling safe. We have a system of yellow cards. If a child hits / hurts another child they are given a yellow card and have to leave immediately with their parent / carer. They are banned for one meeting. They have two chances; if they are given three yellow cards during their membership they are asked to leave permanently. This permanent exclusion has never had to be enforced. While both groups run to a similar structure, the similarities and differences are explained in more detail below.

Figure 1 Membership card

2) 5-8 YEARS
Gill Rogers says: For this age group the focus is to introduce each concept through games. I find the games in figure 2 particularly useful. As many of the concepts are abstract, they are introduced at a concrete level and then graduated to the abstract level. For example, news is introduced by playing a game saying whether an item is old or new (concrete) and then getting them to identify what is old or new information about themselves (abstract) that the group doesnt already know. This of course leads to a lot of discussion and is core to the difficulties they are encountering due to theory of mind. It is also reinforced through the debate as to whether someone has asked a relevant question - thumbs up - or an irrelevant question - thumbs down - to maintain a topic or build friendship skills. Similarly, feelings are introduced starting with what the child likes; either food or what they like playing with (concrete). Then a drawing is made of what they look like when they are playing with that item and then the language to describe how they are feeling at that time is taught (abstract). The focus on playing games is core in order to create and explore the dynamics of interaction as it happens, in much the same way as conversational analysis. It has the effect of pacing the interaction so we can isolate breakdowns in communication and work on them. A games environment is extremely difficult for this population as it highlights the same difficulties they are experiencing in social interaction and society. Each game has its own set of rules, just like each social situation. These have to be learnt and adhered to for success, but many are not explicit and are context specific. Many of the children do not want to play games due to previous failure and lack of understanding of what went wrong. For example, they may understand the object of a game is to come first and, if this doesnt happen, perceive they have failed. Giving them confidence just to participate by talking through all these issues is vital - in particular, How to lose gracefully, even though you may be angry! I

Figure 2 Games for 5-8 years group GAME MANUFACTURER News UNO Blink Murder Pass the Gesture Fruit Salad (animals) The Socially Speaking Game Whose Voice? LDA (Alison Shroeder) Mattel

SKILLS As 9-11+ group Change, game play, consequences Looking Turn-taking, looking, being part of a group Listening, turn-taking, looking Variety of social skills

Social communication skills pack, Listening awareness Fowler & Baber (2002), East Kent Coastal Teaching Primary Care Trust Awareness of self and others Early Learning Centre Team building working towards balancing all the monkeys as a team Identifying significant information, asking questions, extension MB Games LDA cards Awareness of facial features and differences Problem-solving Using question forms Self-esteem When, how, how much and where Indicating levels of anger, happiness etc. I am happy when I am good at Self-esteem MB Games The Puppet Company Turn-taking, team play, winning and losing Emotions the child selects appropriate response to a situation Looking, listening, team play Tomy Turn-taking, anticipation, winning and losing Sharing experiences, strategies to try

Drawing selves and partner Monkey Business 20 questions Guess Who? What Would You Do? Question dice Giving and receiving compliments Commenting Making visual graded chart Sentence completion Jenga Feelings glove (Emotions faces on each fingers) Pass the Ball Pop Up Pirate Problem-solving as a group Discussing what is teasing, bullying, name-calling Describing an object, identifying its main features Self-assessment What is a friendship? Change Tokens Why? Because Jane Baker (Unpublished) LDA cards

What do others need to know? (function, shape, size, where would you use it?) Insight

Motivating children to make changes and understand change Picking out relevant information to predict

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have recently introduced complimenting the winner verbally or shaking hands so they can focus on an appropriate action response rather than reacting to their own feelings. And of course games are what children play. They enable friendships to develop through a common focus (Attwood, 2003).

3) 9-11+ YEARS
Before the group begins, each child is given a job or target. This is a specific skill that needs practising by that particular child as ascertained by the child themselves, the therapist and sometimes by a consensus of the group members. This gives valuable feedback and can include a functional skill (giving & receiving crticism; assertiveness), conversation skills (repair strategies; ending), awareness skills (self awareness; group awareness) or non-verbal communication (proximity; facial expression). The job / target is written / symbol drawn on a highly coloured post-it note along with the childs name. Points are awarded throughout the session when the child shows evidence for that target behaviour. Targets are used in both the primary aged groups, but these older children are encouraged to choose their own target.

I present the problem to the children and ask them to give me their ideas on how to solve it. I then feed back the results at the next meeting.
Typically the group runs for an hour (the younger group is slightly shorter). We start with news. This is information sharing with the other members who are expected to listen in order to ask a relevant question about that childs news. We explain why this is an important skill to learn for making friends. In telling news, children are learning that the experiences of their lives are not necessarily already known about or understood by others, and that they need to take time to explain (theory of mind). They need to learn the amount of detail to tell; not too much or it may prove to be boring to the others, but not too little either. They need to learn that news is new information, or extra information on previously given topics. They also need to learn what topics might interest the others. They then get to choose who will ask them a question (remembering who has already asked a question and who still needs to ask). This means paying attention to the other members in the group and trying to remember their names. If they have forgotten someones name, they learn how to ask them politely. They need to listen to the chosen persons question and reply relevantly to them. They need to learn to respond without annoyance if the person hasnt quite understood them, and how to clarify, or correct misunderstandings. In this older group we have a target called extension to try and continue the conversation for as long as possible. This might include giving anecdotes or compliments.

Everyone has to ask a relevant question. (If one member is finding this difficult we encourage others to help them out by suggesting questions they might like to ask.) The news giver chooses someone who hasnt yet told their news. Again, this encourages attention to the other members. News telling can take up at least half the time available - and be a lively forum for discussion and debate. After news, we spend time on a particular skill, such as compliments, and role-play its use. Sometimes we have a problem-solving exercise. I bring a real problem I have at home (usually to do with my cat!) I present the problem to the children and ask them to give me their ideas on how to solve it. I then feed back the results at the next meeting. I encourage the children to bring their own problems to the group and get suggestions from themselves and the others on different ways to solve them. This often leads the children to ask if they can have a job / target outside of the group in their home or school lives, and ask their parent to give them points for achieving it (for example, stop beating up my younger brother). They go armed with suggestions and solutions. This helps generalise what they have learnt in the group to their everyday lives. Often we work with strength cards, an exercise designed to help children see and appreciate the strengths they do have. Encouraging good self-esteem is a major target for us. We finish with a game of some sort. This could be UNO, which is a great favourite. Not only is it a good turn-sharing game, but the order of play can change at any moment so everyone has to pay attention to everyone elses turn to play the game. UNO is also a great way of teaching children to change their attitude when they get fed up / disappointed / angry, and also a good way of pointing out cool behaviour. The children learn so much from each other. We also like the hat game. Each group member gets 5 chocolate buttons but is not allowed to eat them until the end of the game. They take turns to speak, perhaps to a topic. The person wearing the hat is the only one allowed to speak. If anyone else speaks or makes silly noises they have to give a chocolate button to the speaker who can eat or save it. (Parents can model losing a button!) This game teaches children to hold on to what they want to say until it is their turn, and also the pleasure of being listened to without interruption. Parents can extend this into everyday life; if the child interrupts while they are on the phone, they can say the phone has the hat. Or, if they have two children vying for attention, they can point to one and say hat. An excellent board game is Friendship Island (Incentive Plus) where the children have to answer questions on friendship skills and are rewarded for recognising useful strategies for making friends. We also give tokens for politeness, passing the dice and saying thank you. Other useful board games are Socially Speaking (LDA) and Say and Do Positive Pragmatic Gameboards (Gill & De Ninno, available from Taskmaster).

expectation that everyone contributes and everyone tells their news for the week. We usually expand the discussion from whatever is brought up. If bullying or any problem is an issue, we discuss it and investigate it with a solution focused approach. We always have felttips and plain paper handy for doodling as this seems to help loosen up the conversation. The young people who attend the Asperations 11+ group do not have to come to the Social Communication group; it is entirely voluntary. If they prefer to play pool with another young person that is entirely appropriate and fulfilling our purpose. However, if they do choose to come to the group, they are expected to stay for the hour. One of the main purposes of this group is to provide the young people with a regular meeting where they are accepted, a place where they feel safe enough to explore all those teenage concerns (Who am I? Why am I like I am? How am I different? Is it OK to be different? Why cant I make friends? How can I get a girl/boy friend?) as well as learning social communication skills. The group is a place where its OK to make mistakes and where the participants get very straightforward feedback on solutions from their peers.

We always have felttips and plain paper handy for doodling as this seems to help loosen up the conversation.
Parents have recently asked for an anger management course for both parents and children, which we have started on alternate weeks. The 11+ group is extended in the holidays by the Holiday Play scheme run by our Play Worker. This includes trips to the cinema, swimming pool, zoo and other attractions, as well as themed events in the Youth Club. We also have parties and celebrations to mark key anniversaries. The children are all sent birthday cards from the group. One of the parents takes responsibility for sending them out (with permission from the childs parent / carer). Gill and I run training workshops for people wanting to set up Social Communication Groups in their setting based on the East Kent Social Communication Workbook, and using the Training CD ROM kindly permitted by Fiona Fowler and Caroline Baber. Do get in touch if you would be interested in finding out more. Jane Baker (e-mail jane.baker@nhs.net) and Gill Rogers are speech and language therapists with South Devon Healthcare Trust.

References
4) SOCIAL COMMUNICATION SKILLS 11 + GROUP
The 11+ group is much less structured, and follows more the lines of a conversation based very loosely on the Attwood, T. (2003) Aspergers Syndrome. [DVD] London: Jessica Kingsley. Baker, J. (2005) Asperations 4 U, Speech & Language Therapy in Practice Winter, pp. 27-28.

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