“I Used to Be Good With Kids.” Encounters Between Speech-Language Pathology Students and Children With Pervasive Developmental Disorders (PDD)
Program in Communication Disorders
University of Texas at Dallas
Callier Center for Communication Disorders
INTRODUCTION
“I used to be good with kids” was a comment made by a graduate speech-language pathology student contrasting her prior experiences with children and her first assignment to provide therapy to a child with pervasive developmental disorders (PDD). The phrase effectively captures the bewilderment induced by children whose social and communicative behaviors are unfamiliar and incongruent with accepted notions about the ways young children interact. The following study explored the impact of the atypical interpersonal behaviors of children with PDD on students preparing for careers in speech-language pathology. It describes how behaviors that violate expectations lead to difficulties in establishing interpersonal relationships and can color one’s personal and professional views. The study offers insight into difficulties experienced by speech-language pathologists in training and why, as professionals, speech-language pathologists may avoid some clients or be less effective with some clients than with others. Beyond these practical implications, the study also suggests that knowledge of the impressions children with PDD make and the images students construct of them may help explain why some developmental differences are ultimately more perplexing and challenging than others.
Pervasive developmental disorders is an umbrella term for several impairments, including autism, which are perhaps the most puzzling and intractable disorders of development. PDD is defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994), as “… severe and pervasive impairment in several areas of development: reciprocal social interaction skills, communication skills, or the presence of stereotyped behavior, interests, and activities. The qualitative impairments that define these conditions are distinctly deviant relative to the individual’s developmental level or mental age” (p. 65). Although autistic disorder is the most familiar form of PDD, the classification of PDD also includes pervasive developmental disorder not otherwise specified (PDD-NOS). This particular diagnostic category includes children who exhibit impaired social and communicative skills and stereotyped behaviors, but who do not meet the full range of criteria necessary for a diagnosis of autistic disorder. In common usage, PDD usually refers to PDD-NOS (e.g., Grandin, 1995; Greenspan, 1992) and is used this way by participants in the study. Children diagnosed with PDD-NOS behave in ways that are qualitatively different from children with other developmental disabilities, but they show a broad range of abilities in communicating and establishing interpersonal relationships. In recent years, PDD-NOS has become a label of convenience for children exhibiting a variety of impairments in the social, communicative, and cognitive domains (Greenspan, 1992) and for children who are too young to accurately determine if they meet the criteria for a diagnosis of autistic disorder.
Research on autism and PDD has tended to focus on factors perceived to be internal to the individual. Thus, considerable effort has been devoted to the search for specific cognitive, social, and communicative deficits (e.g., Baron-Cohen, Leslie, & Frith, 1985; Fein, Pennington, Markowitz, Braverman, & Waterhouse, 1986; Mundy, Sigman, Ungerer, & Sherman, 1986; Wetherby & Prutting, 1984) or demonstrable organic pathologies (Courchesne, Townsend, & Saitoh, 1994; Dawson, 1994) associated with PDD. Despite this work, the source of the disorder remains unknown and PDD continues to be defined as an aggregate of observable behaviors each of which is perceived to be atypical or maladaptive. The reliance on behavioral characteristics in defining PDD raises the issue of the degree to which the disabilities associated with PDD are affected by an inadequate understanding of the communicative and social/affective behavior of these children. Frankel (1982) pointed out that in the typical interaction with a child with autism, true intersubjectivity or “mutual sense-making” does not exist. When the common code of language is missing or the language of one partner is clearly atypical (as in echolalia), the usual means of achieving intersubjectivity are lost. Without this common frame of reference, the adult often makes incorrect assumptions about the meaning of the child’s behaviors (Frankel, 1982). This may precipitate significant misunderstandings that affect the course of their interactions. A prerequisite to effective interaction with children with PDD may be the ability to interpret accurately the meaning and intent of the child’s nonlinguistic, echolalic, and social/affective signals. Because most people are not attuned to these forms of communication, nor do they consistently interpret them correctly, mutual understanding may be difficult to attain (Frankel, 1982).
Students entering the field of speech-language pathology are attracted to it in large measure because they perceive it as a “helping” profession. They tend to be motivated by a desire to assist others in overcoming obstacles and place a high value on interpersonal relationships. In fact, the American Speech-Language-Hearing Association (ASHA), the national professional organization of speech-language pathologists, stated in a recent recruiting manual: “To enter this career, one must have a sincere interest in helping people, … and the sensitivity, personal warmth, and perspective to be able to interact with the person who has a communication problem” (Chabon, Cole, Culatta, Lorendo, & Terry, 1990, p. A-6). The students in this study typically indicated in their graduate admission applications that a primary motivation for entering the field was to help others. They wrote of their desire to ameliorate or eliminate communication disorders, often sharing poignant stories of friends, relatives, or acquaintances who had been helped by speech-language pathologists. By placing students in a practicum with children who have PDD, the stage was set for some intriguing encounters between students who prize interpersonal relationships and wish to help, and children who may not welcome or appreciate their overtures.
METHODS
Participants were 36 speech-language pathology students enrolled in their first or second semester of graduate study. They were women, most of them in their twenties and with no children of their own. About half indicated a preference for future employment in positions serving children. All participants were enrolled in a clinical practicum (supervised practical experience in assessment of and interventions for persons with communicative disorders) and were assigned to a university based classroom program for preschool children with PDD. The program immersed students in all aspects of service delivery including assessment, preparation and implementation of treatment plans, and counseling of families. Students were assigned to, and served as the primary therapist for, one child for the entire semester. At the start of the semester, students participated in a 1-week inservice program where they were given general information about children with PDD and specific information about the children enrolled that semester. The inservice included observation of videotapes of the children and instruction in child-centered therapy. Students were taught ways to maximize communicative interactions in a variety of contexts and were instructed to use and respond to nonverbal as well as verbal communications.
Students spent four mornings a week mostly in one-on-one interactions with the child to whom they were assigned. There was no prepared curriculum for the program. Thus, students had considerable freedom but substantial responsibility for designing and implementing daily activities, and developing long-term intervention goals for the child to whom they were assigned. The intervention focus was on enhancing the children’s communicative skills, and students were encouraged to select activities and contexts where productive communicative interactions were likely to occur. To better understand the communicative abilities of the children and to monitor progress, students conducted five or six standardized communication and language assessments over the course of the semester.
Students were videotaped once a week in an activity with their child. Each week, the students, under the guidance of a practicum supervisor, analyzed their videotaped interactions using a microanalytic coding system (Stillman & Williams, 1990). The coding system served as a framework for the students to identify the verbal and nonverbal behaviors they used to convey information and the communicative intention underlying each of their expressive acts. The students also coded the verbal and nonverbal expressions of the children. The purpose of the videotape coding was to assist students in understanding how and why they communicated with the children, and the “match” between their own expressions and the communicative abilities of the child.
Children in the program ranged in age from 18 months to 5 years, but were mainly in the 2- to 4-year range. The children were a distinctly heterogeneous group with regard to language, social, and cognitive skills. However, all had serious communicative impairments and all showed atypical social interactive skills. Most of the children had a prior diagnosis of PDD, although this was not required for admission to the program. In some cases, no formal diagnosis was available. However, a preadmission assessment confirmed that all children were appropriate for placement in a program for children with PDD.
The data for this study were collected through individual interviews and small group discussions. In addition, weekly videotapes of students interacting with the children were viewed by the researchers, sometimes in the company of the participating students. Interviews were conducted by peers employed as research assistants. Interviewers were instructed in nondirective interviewing techniques and in the use of probes to encourage expansions and clarifications. Most interviews lasted about 45 minutes, although some were much longer. Interviews were conducted in the first and last months of the semester and consisted of both open-ended questions (e.g., “Tell me about Joey?”; “What do you do with Joey?”) and questions designed to elicit comments on specific topics (e.g., “How does Joey communicate?”; “What traits distinguish clinicians who are effective or ineffective with these children?”). Usually, 20 to 25 questions were asked. As themes emerged, additional questions were inserted in subsequent interviews in an effort to confirm or refute our evolving interpretations of the students’ comments; and some questions were dropped when they appeared confusing to participants or yielded redundant responses. The participants were uniformly willing, in fact eager, to share their views and seemed candid in sharing their disappointments as well as their successes.
All interviews were audiorecorded and transcribed into a computer-based filing program. Informal group discussions including 2 or 3 students and the first author of this chapter were used to clarify, confirm, or reinterpret information emerging from analysis of the interview transcripts. Handwritten notes were taken during these conversations. Additional information was gathered during discussions with student clinicians as they viewed and described their videotaped interactions with the children, and in informal, unplanned conversations with the students. Videotaped viewing sessions were audiotaped and written notes were taken during or after other discussions and conversations. Interview transcripts and notes from the other discussions were analyzed for general themes and specific topics. Because the study was concerned with the students’ thoughts and perceptions rather than their actual interactive behaviors, no effort was made in this study to match or confirm the students’ comments with the videotaped observations of the students and children.
Coding of the transcripts was carried out by the authors of this chapter, who read the transcribed responses to each interview question and attached summary phrases to each response. The coders’ summary phrases were either descriptive (eye contact, interaction with peers, lack of appropriate social feedback) or interpretive (social skills without language are better than language without social skills; feeling rejected by the child; being social makes you look better to others). The coding was sometimes carried out jointly, with several coders viewing and discussing portions of the transcripts displayed on a computer monitor. This was done primarily at the start of the coding phase in order to arrive at agreement in application of the coding categories and to generate new categories. However, it was not feasible to group-review all of the transcripts. Most transcripts were passed among the coders and serially evaluated. Each coder could then review, comment on, or add to the findings of the previous coder. Areas of disagreement were marked on the transcript and discussed at a later time. Where disagreements between coders could not be readily resolved, the particular segment of discourse was marked “ambiguous” and omitted from the results. When coding of the responses was complete, the codes were listed and sorted to reveal general themes and the topics that comprised the general themes. Specific instances, called “clippings,” were then taken from the transcripts and notes and sorted under the theme and topic headings, using several large bulletin boards. A review of the clippings allowed us to confirm or modify the themes and topics extracted, using the initial code-sort.
RESULTS
The immense quantity of data and the broad range of issues that arise both in serving and learning to serve children with PDD and their families makes this very much a work in progress. But three general themes that have emerged are: “Normal Development Is the Standard,” “Clinician Confidence,” and “Relationships.” In this chapter, we emphasize the results on the first and third themes, Normal Development Is the Standard and Relationships. The issue of Clinician Confidence, although clearly an issue in many of the students’ comments, will be described more fully in future work. Examples of data from which the themes were derived are presented in this chapter as verbatim student comments. Their comments are interspersed with explanatory and interpretive statements. However, the clarity and cogency of most of the students’ statements allow them to stand alone.
It is not surprising that the students selected normal development as the standard for judging children PDD. Most students had had considerable exposure to young children from babysitting and other paid and volunteer child-care work. As a result of their experiences, the students had acquired familiarity with and expectations for the social, play, and conversational abilities of young children; and they had developed a repertoire of skills in capturing children’s attention, managing their behavior, and comforting or consoling them. Because the students’ familiar role was mainly to keep the children entertained, happy, and safe, they usually enjoyed success in their interactions. Many, in fact, claimed a “knack” with children probably emanating from mutual affection, a feeling of being in control in interactions with children who were generally responsive and compliant, and the infrequent necessity to impose unwanted tasks or restraints. Some students, of course, had had prior experience with children with communicative impairments. But these were mostly children with relatively mild delays and disorders in the domains of expressive speech and language. Few students were prepared for the social interaction difficulties they were to encounter with children with PDD. It was not unexpected, then, as one student put it, that her first experience with these children “rocked my world.”
Okay, this is how it is. This is the situation. It is not you just babysitting a normal kid like you used to, this is like … like M———‘s different.
I worked in a day-care center, but those were all pretty normal kids. But it was a whole different thing because you could get them to attend and you could tell them things without their flying off the handle. … This is completely new for me, and baffling. But I think, on the other hand, I don’t really know what’s normal for kids. I mean, I do. I know what’s textbook normal for kids, but some of these behaviors they don’t talk about in textbooks.
I used to be good with kids. I expect to be good with kids. I assume children will be social and want to interact with me and be responsive to me. When it didn’t happen, I felt like a failure.
Kids have always responded well to me, and I’ve always worked well with them. But the kids I’ve had exposure to have been normally developing children, so I have a feeling there could be a problem there. I may be expecting the same kind of reaction. And especially with these kids, you know, they don’t look to other people for affection or stimulation or whatever.
I guess I expected a more reciprocal type thing, but I guess that’s because that’s what I’ve had with children, reciprocal type relationships. It was really frustrating and hard for me because he wasn’t like any other child I’d spent time with. I mean, usually I can find something that the kid enjoys doing, but he was hard to engage.
I really thought “I don’t know what I’m going to get from him” because he really wouldn’t look at anyone, and he didn’t want you to touch him. He didn’t want you to pick him up so I really didn’t know if I would get much of anything from him.
I think that overall it’s going to be hard to relate to them, because there’s going to be something there that’s going to make it more difficult, whether you want to call it their disorder, or whatever it is, it’s a barrier. And it seems like with the other kids I’ve worked with, there’s always just this ease of—you know, you sit down and you play with them enough and they get to where they really like you, and it’s real easy. You’re friends. And especially if your goal is to make them happy, then they really like you.
The aforementioned comments relate the students’ observations of differences between children with PDD and typically developing children, and the students’ concern that their familiar ways of interacting with children will be unsuccessful. But the students’ comments are clearly flavored by their impressions of whether the children like them or even care if they are around. This mingling of objective observation, clinical knowledge, and emotional reaction characterizes their comments throughout. The students know that children with PDD are different and that differences in the social-communicative domain are a defining feature of PDD. Nonetheless, they remain puzzled and disturbed by the children’s apparent disinterest in or unwillingness to engage in reciprocal social interactions with them.
Among the factors that seemed most important in shaping the students’ perceptions of the children were eye contact, focus on objects, and the extent to which the children’s behaviors were atypical and unpredictable. All of these, of course, contribute to a diagnosis of PDD, but appeared to affect the students in a personal way. In particular, the presence and absence of eye contact was discussed extensively by all students. Eye gaze and gaze aversion are well-known and powerful social signals, having a multitude of culturally specific uses and meanings in adult-adult and adult–child interpersonal interactions (e.g., Brooks, Church, & Fraser, 1986; Grumet, 1983; Kleinke, 1986). In addition, eye gaze is reported to be a significant aspect of early communicative development. Thus eye gaze is considered one of the child’s earliest and most potent means of regulating the behavior of others and contributes to the pacing of mother–infant interactions (Fogel, 1977; Kaye, 1982). Furthermore, with toddlers, the pairing of eye contact with nonverbal acts distinguishes intentional communication from other nonverbal behaviors (Bates, 1979).
For the students, the presence or absence of eye contact by the children seemed to play multiple social-communicative roles. For example, the absence of eye contact contributed to the students’ sense that a child was avoiding you or “looking through you.” It was an immediate indicator that there was “something wrong with the child.” Eye contact was also a measure of a child’s interest and attention, and whether the students were “getting through” to the child. Most importantly, eye contact indicated a child’s interest in the student and was, perhaps, the students’ most valued form of social feedback. Eye contact was typically described by students in all-or-none terms (“He makes good eye contact”; “He never makes eye contact”) and contributed to the students’ impressions of a child as sociable or nonsociable and influenced their view of the overall functioning level of the child. Students believed that the children could learn to make eye contact, and identified the acquisition of eye contact as an instructional goal. Eye contact, when observed in some children, was considered an indicator of emerging sociability and attachment by the child. In the following comments, eye contact (or its absence) is viewed as: defining autism, an index of functioning level, a measure of the effectiveness of interactions, a measure of progress of intervention, an essential nonverbal component of communication, and an indicator of sociability.
D——— is pretty classically autistic. He averts eye contact.
I would say that he is higher functioning than the other children in that he attends to you. His eye contact is great. There’s no problem with the eye contact.
Someone in there had him one day and always thought he was higher level and she was like, “I didn’t realize how he really doesn’t make eye contact, and how much he does just take off, and not stay on task.”
I would say he’s probably the lowest functioning. For example, J———, he might look like he’s lower functioning just because he’s younger and he won’t sit still during music, and he’s running around on his tippy-toes, and he has some really strange behaviors, but he looks at you more. He makes eye contact.
He interacts very well with me. He has great eye contact. He doesn’t try to avoid you.
I really enjoyed working with her. She really enjoyed being there. You know, she would look at me. And that was just the nicest thing, to actually have eye contact.
(How do you know when you are being effective?) When I’ve got him to look at me, and not just at my hands, but at my eyes or at my face. Whenever I get eye contact. I mean, I don’t care what we’re doing, if we’re playing patty-cake, if we’re playing hide-and-go-seek, if we’re reading books. I mean anytime he looks at me and includes me in his activity.
He’s expressing himself a lot more and using a lot more eye contact with me. I think he’s doing pretty good.
If he has eye contact with me for five seconds during an activity and the next time we do it, he has it for ten seconds, that is progress.…
Another factor shaping the students’ perceptions of the children was their concern about the children’s attraction to certain objects and their perseverative actions and vocalizations, which seemed to render the students invisible. Students described the children as isolated and inaccessible, “in their own little world,” and felt themselves excluded. It was as though their presence, at times, was of little consequence to the children. Students were also puzzled by the children’s failure to respond to apparently salient environmental stimuli and noted the children’s failure to “hear” verbal efforts to gain their attention.
His attention is pretty good to an activity. It’s not to an individual.
If there is an object such as a ball or a toy, she interacts with the object, so then it’s like I’m no longer there.
He can be right in front of me, and we’re sitting at the table, but he’s in his own world. He is just not hearing me.
When he’s perseverating on something, when he goes off into his own little world, sometimes he’ll just kind of stare off or he’ll be having just kind of a gibberish conversation with himself, has his back turned, and puts himself in the corner or something so that he doesn’t want to talk to anybody.
And a lot of time, like on the tricycles and stuff outside, he doesn’t talk on them. And there’s certain things where I know it doesn’t work, and so we just don’t even go on them anymore. Because it’s like I’m not even there. He just kind of turns inward into his own little world.
He jargons a lot. He’s in his own world at those points. He really is. And he’ll jargon and jargon. He’s absolutely not even hearing me, I don’t think. My impression is that he does not hear me until at some point I get through and then he hears me.
… [he’s] just kind of fixating on the wall or on a person, and even if I use gentle touch on his face or keep saying “C———, C———” right in his face, it’s like I’m not even there.
He becomes fixated on a person or on an object or on just anything on the wall, and it’s, I mean, you could knock-knock on his head and you cannot get through to him.
The students’ impressions of the children were also shaped by the inconsistencies in the children’s interests, moods, and behaviors. In some cases, the inconsistencies were viewed as puzzling or inexplicable. But in cases where there was a risk or history of violent or aggressive behavior, the students seemed to sense both a distance and a danger in the children and saw the children as driven by incomprehensible forces. The students expressed a sense of their own helplessness, as though whatever they did had no predictable or lasting effect.
You cannot predict what he is going to do, be it whether he’s going to love doing something, or he’s going to throw himself on the floor and have a fit for ten minutes.
He can be real responsive, real interactive, and then in the middle of it, just wander and go off into space, either actually physically walking and wandering off or he’ll just look off and get stuck on something else.
Sometimes he’ll just cry and I won’t even know. I mean, out of the blue he’ll be laughing and then he’ll cry. And he laughs out of the blue sometimes, too. He’s done that quite a few times where he’ll have almost a wicked laugh and nothing is funny. Nothing has happened. I have no idea what’s going on in his head.
It depends really on the kind of day he’s having, because there’s some days that he’s in his own world, and doing self-stimulatory behavior, and running around, and I try everything every day to get him to pay attention to me, and there’s some days that he will after a while, and there’s some days that he won’t.
And he has really good times and he does stuff where you’re just like, “Wow, that’s really great that he does that,” and then he turns around three seconds later and he does something where you’re just like, “Weird, what are you doing?”
I was kind of scared of him at first because he is so unpredictable, inconsistent, just his behavior is so bizarre. I was scared of what he was going to do next.
Some days he’s really agreeable and some days he’s really, really aggressive. Like he’s been really aggressive lately with scratching and biting, and that scares me. Because I don’t think I have the tools to deal with that.
… he seemed to have a few more violent tendencies than some of the others, and just has this look in his eye that he would just kind of, you know, hit you to death if he could.
One of the most striking aspects of the students’ comments was the significance they placed on establishing relationships with the children. The students’ statements regarding eye contact, object focus, and inconsistent behavior seemed overlaid by a general concern about their relationships with the children. The students wanted to be accepted and liked by the children and were disappointed, frustrated, or hurt when the children’s attention or affection was not forthcoming. A strong positive relationship was regarded as a motivating force for both student and child in interacting and in joint participation in activities. Furthermore, a strong positive relationship was viewed as a hedge against public confrontations with the child or at least gave the student confidence that such confrontations would be short-lived. For these reasons, students seemed particularly eager for the children’s appropriate displays of attention, friendship, responsiveness, and initiative. Students working with more social children described them in terms that suggest they noted the contrast between their children and others in the classroom. They emphasized their positive relationships with the children, discussed the children in warm and affectionate terms, and noted that the children liked and cared about them. These students described feeling included rather than excluded by the children and commented on appropriate displays of affection, such as hugging, and on the children’s willingness to participate in an exchange of greetings and other conventional social routines. These students were aware of and sympathetic to students working with children who displayed less affection or did not establish positive relationships.
I wasn’t expecting such a friendly kid. We hit it off instantly. It was just so neat. We are so close, it is just so funny. And it’s nice to have that relationship, seeing that the other clinicians—not that they don’t have it, it’s just that the kids aren’t willing or aren’t able to maintain a relationship like that. So he’s really cute. I just love him to death.
I have a real good relationship with him and he’s real playful and real loving and real affectionate toward me, and friendly. So that’s fun.
Every morning he would come in and he would come to me to give him a hug. He had a lot of the social responses that are favorable, unlike a lot of the other children who are just like, “OK, I don’t care if you’re there.” And he did care, for the most part. He really did. And that was kind of nice because you knew that he wanted you, so he wanted you to be part of whatever he was doing.
I was really pleased with the way ht. responded to me and he would always come to me in the mornings and that was really fun, for him to be excited. And he would always say “Bye-bye, K———” and things like that. in the afternoon. And I think he learned who I was. So I guess the relationship was the best.
And just in the last couple of weeks, he’s started hugging me sometimes. I’ve seen him hug his parents, and I thought it was wonderful, and that it would never happen [to me].… But he will look at me and hug me sometimes, and that’s been recent. And I feel like that’s all good signs of how he’s responding to me.
In contrast, students whose children were perceived as less social and who did not feel they had achieved a warm and affectionate relationship tended to attribute to the children a willful and selective disinterest in them. They interpreted the children’s behavior, not as a global disinterest in social interactions, but as a personal rejection. They seemed to feel that despite their best efforts, they were excluded and rebuffed by children with whom they had anticipated affiliating and interacting.
I’ve dealt with W———, and he just looked straight through me the whole time. I don’t think he knew I was there.
The minute he comes in, he’ll just try to get into the closets and open objects, or get these little objects, and he’ll have a little truck and he’ll just look at the tire and just stuff like that.…I know there’s gonna be absolutely no way that he’ll include me. He just doesn’t act like I’m there.
Most of the time he’ll just throw me away like I didn’t even exist.
He just looks like he doesn’t really like you, he doesn’t want to be there, and he doesn’t want to do anything with you.
For the most part of the day, he’s not responsive to me and he doesn’t listen to me, and he doesn’t want me around, and he doesn’t want to interact with me no matter how hard I try.
He’ll never have eye contact with me or really care that I’m there. He’ll never interact with me, basically. I’ve got to either hold him or do this or that. It’s hard. It’s just so hard.
The child’s willingness to initiate contact with the student was judged to be very important. When asked to identify “transition signals,” or indicators of the onset of a positive relationship, students cited child-initiated behaviors such as seeking out the student, voluntarily taking the student’s hand, choosing that particular student when other adults were available, making eye contact, saying the student’s name, showing the student something, and requesting that the student initiate or join in some activity that only they do together. Child responses to student-initiated interactions were considered less satisfactory indexes of a relationship than child-initiated behaviors directed toward the student, because initiations were interpreted as indicating the child’s choice to be interactive. Responses by the child to the student were perceived as more obligatory and thus less indicative of the child’s interest in the student. Students also alluded to a lack of feedback from the children, which appeared to be due to the absence of overt and consistent child displays of initiation, friendship, affection, and acceptance. Without these social features, which characterize typically developing children’s relationships with familiar adults, the students seemed to acquire a negative view of the children and even expressed disinterest in serving them in a professional capacity.
Maybe it’s just autistic children in general, but to me it’s difficult to work with this type of child because you don’t get that response back. You know with a normal child, especially just that hugging, just that emotional stuff—You don’t get that reinforcement and it makes it difficult to work with him day in and day out.
I think probably anyone would say the higher-functioning kids are easier to work with, because you get more feedback.
… we’re not getting anything from the kids. We’re not getting any kind of reinforcement.
S———could care less whether it’s me or somebody else with him. I mean, he knows who I am, but I would guess I would rather have more of the personal attention. But that’s not real common in these kids.
I think it’s easier to work with the kids who are more responsive. I mean, that’s the whole problem with some of these kids, is they’re not responsive. Like M———. A lot of the time she’s in her own little world. And it’s just easier if they are responding. I think it takes a special person to work with a kid that’s not paying attention to you. And at this point, I don’t feel like I could do that.
In the following statements, students expressed a desire for the children to be more interested in establishing friendships with them. They seemed to see this as a responsibility of the child, as though the child were capable of establishing a relationship but chose not to engage or be responsive to the student. The students seemed to feel they were outsiders and wanted the children to feel closer to them.
I guess I’d like to have him engage more, I guess maybe socially. That means looking at me more, or responding in some way to what I’m saying or what he’s doing. Maybe try to involve me in some sort of activity that he’s doing.
I guess I would like him to become more comfortable with me, and eventually like me, maybe, and look forward to playing or whatever it is we do.
I would expect the child to be able to interact with me more easily, more comfortably. For us to get to know each other and for us to bond, just one-on-one.
The importance of the child’s interest in the student was observed also when the students described the children’s verbalizations. The children’s verbal efforts to seek the student when needing assistance or to engage in conventional verbal exchanges were seen as indicators of the child’s progress and of reciprocity in the relationship with the child.
He just doesn’t communicate very well. You know, he doesn’t ask for things or tell you if he’s hurt or anything like that.
It was really refreshing to have him talk, say things back to me, and communicate with me, and ask me how am I doing; or what am I doing, and you can really interact so much more.
We’ll be walking and all of a sudden I’ll feel his hand in my hand. I’m not really reaching for him, but he’s making that attempt. Or he’ll ask me questions now, instead of before, when he needed help, he wouldn’t ask me unless prompted. He would just try to do it himself and get frustrated. And now, after maybe two or three tries, he’ll make eye contact and say, “G———, help?”
I think he uses my name a lot because he knows how excited I’ll get.
At the end of the semester, students were asked to identify children in the program with whom they would most and least like to work. The following are key words and phrases used by students to describe the particular children they would select or avoid:
| Select | |
| Word | Phrase |
| affectionate | enjoys being there |
| social | provides feedback |
| expresses emotion | communicates |
| has personality | verbal |
| fun | normal behavior |
| cute | can see progress |
| compliant | rewarding |
| easygoing | higher-functioning |
| participates with group | interesting |
| interacts with peers | older |
| shows interest in student | |
| Avoid | |
| Word | Phrase |
| tantrums | looks through you |
| lack of expression of emotion | difficult |
| not lovable | self-stimulatory behaviors |
| strange | severe impairments |
| aggressive | remote |
| violent | doesn’t attend |
| no eye contact | extremely nonsocial |
Based on the above lists, it appears that students would choose to work with children who participate in typical preschool activities, are sociable, expressive, and exhibit behaviors expected of children their age. They would avoid children who do not afford them feedback and with whom it might be difficult to establish a relationship. Thus, sociability, responsiveness, and the presence of typical interests and behaviors seem most important in the students’ selection of children with whom they prefer to work.
DISCUSSION
Children with PDD are, by definition, impaired in reciprocal interaction abilities and communication skills, and may exhibit a variety of stereotyped interests and behaviors (DSM–IV). PDD, therefore, is a disorder in which both the ability to interact socially and to act in a socially appropriate manner are problematic. Graduate speech-language pathology students in their first clinical experience with children with PDD are greatly influenced and affected by the behavioral and interpersonal characteristics that define the disorder. Two factors seem responsible for the effect these children have on the students. First, students entering the field of speech-language pathology have a desire to help others and may assume that their clients wish to be helped. Perceived rejection of their efforts by the children may affect the idealistic view students hold of the profession and the confidence they have in their ability to effect positive change in their clients. Second, students enter the field with preconceptions about young children derived from previous successful experiences in interacting with children. The students’ efforts to generalize this knowledge to children with PDD frequently eventuates in misunderstandings and frustrations similar to those reported by Frankel (1982). The assumption that kindness and affection should immediately yield a like response from the children reflects an apparent misunderstanding on the part of the students of the nature of PDD and the steps necessary to engender the children’s trust.
One may be critical of the students’ apparent naivete in expecting to be able to establish immediate rapport with the children or in anticipating positive feedback from them. Yet even Sacks (1995), in discussing his own encounter with a person with autism reveals a similar desire to be accepted and liked:
I wanted to be liked by Stephen, or at least seen as a distinct person—but, there was something, not unfriendly, but de-differentiating in his attitude, even in his indifferent, automatic good manners and good humor. I had wanted some interaction; instead I got a slight sense, perhaps, of how parents of autistic children must feel when they find themselves faced with a virtually unresponsive child. I had still, in some sense, been expecting a relatively normal person, with certain gifts and certain problems—now I had a sense of a radically different, almost alien mode of mind and being, proceeding in its own way, not to be defined by any of my own norms. (p. 221)
The students’ desire to establish interpersonal relationships with the children and to see the children as accessible and interested in them was a striking finding. Although it was not expected that students would approach children with PDD dispassionately, their feelings of rejection were greater than anticipated. It is tempting to conclude that what the students sought most from the children were behaviors the children, because of the nature of their disorder, were least able to provide. For example, eye contact was an issue of major concern. The students seemed to consider eye contact to be an essential social-communicative signal, and its absence was viewed as an expression of disinterest or rejection. Furthermore, children with unconventional eye contact were viewed more negatively than children whose frequency and timing of eye contact more closely approximated the students’ expectations. The negative connotation attached to the failure to make eye contact is well recognized and has led some well-known behavior modification programs, which seek to “normalize” the behavior of individuals with autism, to focus on training eye contact as an initial intervention step (Lovaas, 1981).
Current research, however, has tended to show that the failure of children with PDD to show typical gaze behaviors is not volitional, but instead reflects cognitive or neurological problems underlying or co-occurring with PDD. For example, several lines of research suggest that children with PDD have difficulty coordinating eye gaze with other social, communicative, and object behaviors (Dawson, Hill, Spencer, Galpert, & Watson, 1990; Mundy, Sigman, Ungerer, & Sherman, 1986). Anecdotal evidence presented by Grandin (1995) supports the notion that simultaneous attention to several sensory channels is difficult for persons with autism. Furthermore, neuroanatomical abnormalities in the cerebellum (Courchesne, Townsend, & Saitoh, 1994) or the frontal lobe (Dawson, 1994) identified in persons with autism suggest a possible substrate for difficulties in a variety of domains that underlie social behavior, including eye contact, object/person coordination, and the ability to visually acquire information on others’ emotional states. Although the students were not necessarily well versed in research regarding neurological correlates of PDD, they were certainly aware of neurologically based hypotheses regarding autism. Nonetheless, their own emotional reactions to the children’s interpersonal behavior seemed to override their classroom-based knowledge regarding the disorder. For them, the lack of eye contact was a signal, if not a symbol, of the child’s rejection of social interaction and disinterest in establishing an interpersonal relationship. In reverse, children who showed appropriate and consistent eye contact were viewed as friendlier, more responsive, and even more competent. Typical eye gaze behavior seemed to serve as a trigger for positive feelings from the students and served as a criterion for selecting children with whom they would prefer to work. It also influenced their evaluation of the children’s prognosis.
It is the negative effects of atypical eye gaze, however, that are most troubling. Children who were perceived as failing to make eye contact were seen as less likely to progress and, if given a choice, students indicated that they would be less likely to select them for therapy. Some students even felt unable to work effectively with children who did not provide them feedback via eye contact. This suggests that students (and perhaps practicing speech-language pathologists as well) should examine their feelings and biases regarding eye contact. From the results obtained here, it appears that this particular deviation from typical child behavior has a disproportionate effect on the feelings of others and potentially a very real effect on the quality of therapy the children receive.
The other primary concerns of the students were the tendency for children to focus on objects in preference to, or to the exclusion of, people, and the children’s atypical and unpredictable behaviors. Again, students tended to take these behaviors as personally directed and saw them as efforts by the children to exclude the students from their “world.” Students were probably familiar with alternative explanations for the children’s interest in objects—for example, Schuler’s (1995) suggestion that this reflects one pole of an object-oriented versus person-oriented mode of thinking. They probably also recognized that the child for whom regulating the object world or regulating sensory input takes precedence over interacting with other people, is unlikely to develop relationships rapidly despite the students’ best efforts and intentions. The students were probably also aware of the hypothesis that many atypical and apparently inconsistent behaviors of children with PDD reflect developmental discontinuities within and across the domains of communication, cognition, and social/emotional abilities (Schuler, 1995). However, for these students, prior knowledge of the causes and characteristics of autism seemed to be secondary to the emotional impact of the children on them. As one student put it, “No amount of preparation can prepare you for the first day the child walks through the door.”
The premium students placed on positive interpersonal relationships and the preponderance of “isolating” compared to “engaging” behaviors among the children may have consequences for services to children with PDD. Students who were most pleased with their relationships with the children were those assigned to children who would most readily be described among this population as “social.” Students assigned to children whose behaviors were more typical of autism tended to express greater frustration at their inability to get through to the child or to receive from the child the type of interest and affection they sought.
When asked to describe the characteristics that would lead them to seek or avoid a particular child, sociability factors predominated. This suggests that many students, if given a choice, would serve children whose social interaction abilities approximate those of typically developing children. Of course, the students were interviewed and observed very early in their graduate education, and some student attitudes and concerns may be attributed to immaturity and inexperience. However, previous work suggests that even experienced teachers and therapists are also deeply affected by a child’s sociability and strive to elicit positive affect, teacher-directed behaviors, and indications of personal recognition by the children, even when these elicitations are counterproductive within the activity (Stillman, Williams, & Majors, 1991). Schuler (1995), too, has argued that clinicians serving persons with autism must “… examine their own levels of discomfort when common behavioral expectations and norms are violated” (p. 30). Thus there is the prospect that the attitudes, expectations, and feelings expressed by the students may be carried forward into their professional career.
CONCLUSIONS
This study has shown that students preparing for careers in speech-language pathology hold strong views regarding child sociability and would prefer to provide therapy to children who show typical social/affective behaviors. Thus child sociability may be a prime factor in attracting clinicians in training to particular clients. Students rely greatly on their interpretation of specific nonverbal acts, such as eye gaze behavior, object play, and unusual interests and attentional foci, in estimating the child’s sociability. Some nonverbal behaviors, such as eye gaze, are imbued with intention and meaning that may not be warranted and may lead to generalizations that are counterproductive to effective therapy. The role of nonverbal behavior in therapy is often described only in terms of the identification and response to particular communicative acts (e.g., Siegel-Causey & Guess, 1989). However, for these students, some nonverbal behaviors seemed to elicit feelings of acceptance and rejection rather than communicate particular information. For student clinicians at this stage of their careers (and perhaps for others more experienced, too), the study shows that it is no easy task to overcome feelings of rejection caused by the children’s impaired and atypical social interaction abilities, nor is it easy to accept the children’s behaviors as indicators of a disorder rather than indicators of personal preference.
ACKNOWLEDGMENTS
We wish to acknowledge the contributions of Katherine Stanland, Fereshteh Kunkel, and Lara Baker to this study. We also thank Angela Linam, Allison Cook, and Amanada Owen for their assistance in editing and revising the chapter. Some of the data were presented at the annual meeting of the American Speech-Language-Hearing Association, in Orlando, FL, in November 1995.
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