Autism Awareness Campaign - Horticultural Therapy

Continuing with other non-traditional therapies being practiced for persons with autism, today I am touching upon Horticulture Therapy (HT).   

Horticulture therapy makes people engaging with nature to combat anxiety, promote sensory integration and build social skills.  The critical aspect of Horticultural therapy is “people-plant connection”.  It uses plants, gardens and natural landscape to improve cognitive, physical, social, emotional and spiritual well being.  Horticulture therapy can offer cognitive and physical benefits to people with autism.

Extensive research studies were conducted in early 2000s to monitor effects of HT on mental healing, cognitive re-organisation, and training of sensory motor function.  The Functional Independence Measure (FIM) and Self-rating Depression Scale (SDS) were performed before and after the therapy sessions to assess the patients’ physical activities of daily living (ADL) and to determine the patient’s mental changes in depressive states, respectively.  Functional MRI (fMRI) during recognition tasks was also measured before and after the therapy sessions. The ADL of all patients significantly improved after the therapy sessions.  However, the depressive states in all patients did not change remarkably after the sessions.  fMRI examinations showed that the visual area, the inferior temporal area, the supplementary motor area, the sensory area, and the cerebellum in the brain were activated after the therapy sessions. These findings suggest that HT can accelerate an improvement of activities in the “visual and colour processing areas” and the “association areas” as well as the “sensory-motor areas” of the brain in the patients with cerebrovascular disorders as well as autism.  Horticultural Therapy, therefore simulates parts of brain, that are not always evoked through routine physical rehabilitation.  Results of these studies indicate effectiveness of Horticultural Therapy in improving brain functions, leading to better cognition, motor control and social skills.

For past few years Horticultural Therapy is being seriously practiced in Kerala. Thanks to the College of Agriculture, under the Kerala Agricultural University, that is spearheading this initiative.  There are similar initiatives in other part of the country also.  

Before all these developments, in 2004, I was looking for a not so common and different vocational activity for my daughter.  What I stumbled upon was Hydroponics, i.e. soil-less gardening; gardening with water as medium.  Not much resources were available at that time, and I had to do everything from scratch.  Involved Pratibha in some of the activities of hydroponics gardening (on our window sills) and I found that she liked it.  I didn’t think of it as therapeutical activity at that time.  But, I did realise the plant-people connection and its positive effects.  Now planning to seriously take up “Horticultural Therapy with indoor gardens using Hydroponics” for therapeutic benefit to developmentally disabled persons. 

An integrated approach combining mainstream therapies such as Occupational Therapy, Speech Therapy, Physical Therapy, Special Education, Psychologic Counselling with non-traditional therapies such as Music Therapy, Horticultural Therapy, Pet Therapy, Aquatic Therapy etc. are to be used in a goal-oriented intervention to see fruitful improvements in cognitive, behavioural and social aspects of persons with autism. 

I will conclude this post with a quote “Never underestimate the healing power of a quiet moment in the garden”.

Autism Awareness Campaign - Music and Autism

Many different types of therapies have been tried out by many to address overall improvements and improvements in some specific aspects of autism individuals.  Some of them are Music Therapy, Horticultural therapy, Pet Therapy etc. etc.  I would like to touch upon “Music and Autism” in today’s poster.  I have not used the term “Music Therapy” intentionally.  Based on my experience of working with music for developmentally and intellectually disabled persons, I preferred to use “Music and Autism”. 

In traditional music therapy, patients listen to different kinds of music depending on their symptoms.  In my practice, I involve the beneficiaries to play / sing music and be part of the music.  Hence I used the terminology “Music and Autism”.  

Music has many aspects. I started with rhythm as first step, and tried to align their internal rhythm to group clapping.  A research work carried out in 2013 by Helen Allen-Williams appeared in British Journal of Music Therapy, established role of rhythm in organising the internal chaos (mental and emotional) experienced by patients of dementia.  It I speculated that such chaos is often expressed through agitated behaviours, and that rhythm can be used in such instances as a means to stimulate meaningful interaction.  Results of the study showed that the use of individualised rhythmic interventions was functional as therapists noted reduced agitation, more organised physical movement and other communications, meaningful interaction and emotional reassurance.

I took cue from the above, and devised a rhythm based approach and tried it first with Pratibha.  It worked wonders.  My focus was to set Pratibha’s rhythmic sense.  This is done by a very simple exercise.  Play a musical instrument / clap, aligning beats from a metronome set to 50, 100 and 200 beats per minute.  It took many months to reach 70 to 80% alignment.  I have found this to be very powerful therapeutic method that helps in considerably improving the fundamental parameters such as attention span, observation skill and responsiveness, leading to overall improvements in cognitive and quite a few behavioural development.  For this kind of “active music intervention” to be helpful, the person has to spend good amount of time (at least half an hour to one hour) every day for few months.  Tried to propagate with few parents.  As ‘finding time’ by parents to do this was difficult.  A therapist doing it for half to one hour a week will have only minimum impact.

I have also devised and tried many brain gym exercises through music (to play on instrument), where we force improved communication between the left and right sides of the brain leading to higher level reasoning such as critical thinking, problem solving, auditory organisation and more.  Have seen this working well. 

Traditional music therapy is “passive”, while what I have been attempting is “active”, where the ‘differently abled person’ becomes part of music by clapping to the rhythm, playing an instrument or singing.  I strongly believe that Music can “heal” developmental and intellectual disabilities.  That needs good investment of time and efforts from parents / therapists, on a daily basis.

Autism Awareness Campaign - Brain Gym

Many traditional therapies such as behavioural therapies, occupational therapies, speech therapies, special education etc. were being extensively used to address different aspects of an autistic individual.  People have tried some non-conventional approaches also, which continue to give surprising results.  One such approach is Brain Gym.  My today’s poster is on Brain Gym, as I think, it has a role to play in helping autistic persons in addressing some critical issues.

We have tried brain gym with Pratibha and found good improvements in some coordination, learning and behavioural aspects.

In Brain Gym programs, children repeat certain simple movements such as crawling, yawning, making symbols in the air / on the wall, and drinking water, which are intended to “integrate”, “repattern”, and increase blood flow to the brain.  One of the underlying ideas is that the exercises are meant to ‘balance’ the brain hemispheres so the two “sides” work together better; there is also a notion of integrating the “top” parts of the brain with the “lower” parts of the brain to integrate thought and emotion, as well as integrating visual, auditory and motor skills.  

Brain Gym concept was developed in 1970s by Paul and Gail Dennison, and it seems to be based on neuroscience.  They called their approach “educational kinesthesiology”.  It was not developed for developmentally or intellectually challenged children, but for general child development.  But, many educators, therapists and professionals found it to be very useful for persons with autism.

Pratibha was unable to copy and draw diagonals in a rectangle correctly.  Whenever she copies a “left-to-right” diagonal in a rectangle, she will invariably copy it as “right-to-left” (mirror image).  Such characteristics were seen in spelling patterns also.  This continued for many years.  After practicing Brain Gym for few months, we could see this changing and she was able to understand the orientation of diagonals and copy them correctly.  Also, her attention to details improved.  These could only be few visible indications.  Quite a few other changes must have come resulting in improvements in other faculties too.  I don’t think, we monitored each and every change, which is humanly impossible.  Yes, Brain Gym did help her. 

Remembering a quote by author Coelho, “Autism is part of my child, it’s not everything she is. My child is so much more than a diagnosis.”

Autism Awareness Campaign - Applied Behaviour Analysis (ABA) Therapy

After getting a glimpse of behaviour issues associated with autism, now let us explore the Behaviour Therapies available to address these.

The most common method is Applied Behaviour Analysis (ABA).  Today we will try to get an understanding of ABA.

ABA is a therapy based on the science of learning and behaviour.  Behaviour analysis helps us to understand (a) How behaviour works, (b) How behaviour is affected by the environment and (c) How learning takes place.

The objective is to increase behaviours that are helpful, and decrease behaviours that are harmful or affect learning.  ABA therapy programs are used to help (a) increase language and communication skills, (b) improve attention, focus, social skills, memory and academics (c) decrease problem behaviours.

The key concept of ABA known as A-B-C concept, helps us understand how ABA works. .

A for Antecedent - what occurs before the target behaviour, it can be a command or a request.

B for resulting Behaviour - This is the persons response or lack of response to the antecedent. It can be an action / verbal response / something else.

C for Consequence - This is what comes directly after behaviour. It can include a positive reinforcement for the desired behaviour, or no reaction for incorrect / inappropriate responses.

We have used ABA therapy techniques at home to help Pratibha improve / correct some of her behavioural issues.  For past many years Pratibha is making tea in the morning, and she is adamant that only she has to make the tea.  When she delays going to kitchen, we used to tell her that “look Pratibha, it is already 7 o’ clock now, please start making tea”.  Our telling this makes her aggressive and she starts throwing tantrums.  We analysed this behaviour.  Here the antecedent is, we telling her the time, and then asking her to go to kitchen and make tea.  We tried to modify the antecedent by telling her in couple of different ways the same.  When we did not use the “time component” in the request, she was perfectly ok and immediately listened to what we said.  We started telling her that “Look Pratibha, your grand parents are waiting for your tea, and your tea will make them very happy”.  She immediately would go to kitchen and make tea.  This is the resulting behaviour to the changed antecedent.  We have tested our assumption in few other situations also.  Whenever we specify time (like 7 o’clock, 9 o’clock etc.) she gets wild.  After getting to know this, we have changed our way of interacting with her in different situations without mentioning any ‘time’.  Understanding of ABA and applying it, has helped us reduce quite a few undesirable behaviours of Pratibha.  

I feel, there is mis-understanding of ABA with few parents of autistic persons.  Once one parent told me that, for his daughter they have completed ABA.  I asked again. “You completed ABA”?  He again said “YES”.   I have heard similar statement from a person who runs a special school, saying that they complete ABA in 2 years.  

My understanding of ABA therapy is that, it is an approach to analyse and bring changes in behaviours or help learning.  It can never ‘get completed’ for a person.  We have to continuously monitor and analyse the behaviours, and keep correcting them to whatever extent possible.  For this, parents have to get deeply involved.  Just depending on therapists alone may not yield desired results.

Autism Awareness Campaign - Routines & Resistance to Change

Continuing on behaviour issues of persons with autism, in today’s poster I am attempting to touch up on the issue “Routines and Resistance to Change”.  

One of the diagnostic criteria for autism is insistence on sameness and an inflexible adherence to routines.  Getting  down to minute details with things such as placement of toys, or type of food available at certain meals and the order in which they may be eaten etc.  This insistence of routine and sameness can be categorised into obsessive and compulsive.

Any deviation from any of these particulars, even one almost undetectable to a neurotypical individual, can result in enormous anxiety and tantrums from as autistic person.  Adherence to routine becomes obsessively important and any sort of change is a major cause of alarm.

The world can be very unpredictable and confusing place to autistic people, who often prefer to have daily routine so that they know what is going to happen every day.  They may want to always travel the same way to and from school or work, or eat exactly the same food for breakfast.

It may be difficult for an autistic person to take a different approach to something once they have been taught the ‘right’ way to do it.  Sometimes minor changes such as moving between two activities can be distressing; for others big events like holidays, starting or changing school, moving house or Diwali kind of festivals, which create change and upheaval, can cause anxiety. 

We are living with this situation each and every day of our life.  For past many years, we are having only Upma for breakfast on Mondays!  Evan a talk on change to any other item, or making Upma on any other day would trigger aggressive tantrums from Pratibha.  This is just one instance.  Many such situations we face every day with respect to ‘routines and resistance to change’.  Many of them are fairly harmless, but many are not easy to deal with. 

Some of the changes that irritates the persons with autism could be:

• leaving for school / work a bit early or a bit late, 
• having visitors at your house, 
• going somewhere new, 
• switching between toys, activities or tasks, 
• doing things in a different order - for example, having a bath at an unusual time, 
• eating new foods, 
• cancelling activities - for example, not going to the park because of bad weather… 

Unexpected changes are often most difficult to deal with.  People on the autism spectrum may not be comfortable with the idea of change, but may be able to cope better if we can prepare them for changes in advance.

If you are able to watch an 8 minutes long, short film ANNA, by Harriett Maire, you will understand “resistance to change” and its implications.  Anna is a young woman on the Autism Spectrum who enjoys living a life of rigorous routine. When someone unintentionally sits on her seat on her morning bus, her day is sent spinning out of control.  The movie has won Jury Choice award at Cannes. 

Here is the link to the trailer of the film..

https://youtu.be/hdwNKW9PWRA

Autism Awareness Campaign - Stimming

In today’s Autism Awareness poster, I am taking up another behavioural issue, “stimming”.  The word “stimming” refers to self-stimulating behaviours, usually involving repetitive movements and sounds.

Stimming in people with autism can get out of control and cause problems.  Stimming isn’t necessarily a bad thing that needs to be stifled.  But it should be addressed when it is disruptive to others and interfere with quality of life.

A young autistic adult wrote. “I quickly become overwhelmed [in social situations]. Is it surprising that I then feel like blocking the world out and literally putting my thoughts back in order? That I start to rock to tell myself which feelings are mine? That I start speaking to myself or groaning to block out other sounds and so that I know which thoughts are mine? I think anyone experiencing life this way would do the same.”

Stimming may include arm or hand flapping, finger flicking, rocking, jumping, spinning or twirling, head-banging and complex body movements.  We may also see the repetitive use of an object such as flicking a rubber band to twirling a piece of string, or repetitive activities involving the senses (such as repeatedly feeling a particular texture).  My daughter Pratibha does quite a bit of stimming.  She does hand flapping, finger flipping, and rocking..   

The reasons behind repetitive behaviour may be:

• an attempt to gain sensory input [eg. rocking may be a way to stimulate the balance system; hand flapping may provide visual stimulation]. 
• an attempt to reduce sensory input [eg. focussing on one particular sound may reduce the impact of a loud, distressing environment; mainly in social situations]
• to deal with stress and anxiety and to block out uncertainty
• to pass the time and provide enjoyment

If stimming causes social isolation or it becomes disruptive in school or it affects ability to learn, or it causes problems for other family members, or it becomes self injurious, then managing stemming through therapies becomes critical.

Concluding this post with a short poem by Leah Kelley, in Thirty Days of Autism.

“Ode to the Stim”

H stims…

I stim too…

bounce and wiggle

twist a lock

hold tight to that ‘calming rock’

fiddle and fold

squint and spin

squeeze

and then begin again

shoes too big so toes can move

wiggly legs that find their groove

Tom Sawyer pockets with fidgets galore

quiet hands are such a bore

Autism Awareness Campaign - Obsession

In next few posters I will be touching upon some of the behavioural issues associated with Autism. Many of these may not be known widely. From an awareness point of view, they are very important.  Managing behavioural issues is what the parents, care givers, doctors and psychologists are grappling with throughout the life of an autistic individual. 

A young person with Asperger’s Syndrome (which is also being considered within autism spectrum) wrote. “My mind was constantly whirring with thoughts, worries, and concerns.  The time spent with my obsession was the only time in which I had a clear mind - it gave me that much sought-after relaxation”.

Here “Obsession” seems to give the person the much needed relaxation.  The obsession is nothing but intense and highly-focussed interests seen in majority of the autistic persons.  It can be art, music, trains, computers, car registration numbers, bus or train time tables, postcodes, traffic lights, numbers, shapes of body parts such as feet or elbows.  Autistic people often report that the pursuit of such interests is fundamental to their well being and happiness.  It is the intensity and duration of a person’s interest in a particular topic or object that marks it out as an obsession.  

Don’t we the Neurotypical individuals also have obsessions? Yes, we do.  Then why it is considered to be a predominant behavioural issue in autistic persons? Such obsessions are known as Obsessive Compulsive Disorder (OCD).  OCD is seen in general population also, limited to about 2%, whereas in autistic population it is quite high.  

Symptoms of OCD are more or less the same in autistic and non-autistic persons.  But, the treatment approach is very different. A person with autism who is absorbed in rocking or hand flapping or who insists on playing with the same toy every day at the same time is generally doing so without consciously thinking about the behaviour.   Autism persons may hum obsessively, for example, in order to drown out subtle noises that Neurotypical individuals would never notice.  [My daughter Pratibha has quite a few obsessions, one of them being, keeps humming in different situations such as when she plays sitar, when she cooks, when she tries to concentrate on any activity.]  In contract, a non-autistic person with OCD exhibiting the same behaviours is doing so consciously.  Their thought process latches onto the behaviour as an obsession, and they perform it ritualistically out of a fear of bad things happening if they cannot complete the ritual.  Their disorder is based around their thoughts and the coping mechanisms that use to deal with those thoughts. 

Answers to the following questions would decide whether any help is needed to control the obsessions. 

1. Does the person distressed when engaging in the behaviour or trying to resist the behaviour? 
2. Is the person unable to stop the behaviour independently? 
3. Is the behaviour impacting on the person’s learning? 
4. Is the behaviour limiting the person’s social opportunities? 
5. Is the behaviour causing significant disruption to other people, e.g. parents, caregivers and family?

Applied Behavioural Analysis (ABA) based techniques seem to help in managing some of the obsessive behaviours.