|I am concerned about a three-year-old in my class who seems uninterested in relating to other people. He is fairly verbal, but he definitely prefers relative social isolation to interaction. I have tried various approaches to integrating him into group activities, but after a few minutes he always ends up alone. Do you think he might have PDD? What are some strategies for handling this situation?|
Many children with this kind of problem have been labeled with terms like Pervasive Developmental Disorder (PDD), Autism, or Asperger's Syndrome. We need to ask what is going on with the child instead of labeling him, and we need to try a number of interventions that meet his needs for a substantial amount of time. Labels tend to carry needlessly pessimistic implications that cause some families and teachers to feel hopeless about the possibility of growth and change. But hopelessness is not warranted. In fact, when we identify the child who has trouble relating relatively early in his life, we can intervene and often effect great change.
Teachers and parents are understandably concerned about children who seem to not be interested in relating to others. Some of these children have little-- if any-language, while others are quite verbal. However, all children with this problem will tend to avoid two-way communication.
Parents often report first noticing an indifference to other people when their children are between 18 months and three years old-the period when we expect to see rapidly developing language. If the language doesn't come in as expected, parents suspect that something is wrong. Many wonder if it is a hearing problem, but when tests reveal no hearing loss, concern grows about the language delay and the limited efforts the children make to communicate and relate.
When further discussing their child's earlier development, parents may recall that the child hadn't communicated in typical preverbal ways either. Then, as he became a little older, instead of making progress in communicating or relating, the child slipped more and more into his own world, behaving in an aimless, self-absorbed manner and avoiding contact with others, even other children.
All children seek out adults for comfort when they are hurt or in need. A child with a problem relating may do so too, but the difference is that he will indicate a concrete wish, such as for a door to be opened, but will not be interested in having any sort of complex two-way conversation, either verbally or with gestures.
A child with a problem relating may enter preschool talking, but the talk is mechanical rather than meaningful and not designed to enhance interaction. He may know the words to many songs and rhymes and be able to recite the alphabet and name numbers, but he will not put this information in any particularly relevant context. When another person, child or adult, tries to converse, this child may turn away. Occasionally, the child may use a word or two purposefully, like "juice," but more often what he says doesn't make sense to others, fit the context, or have any social purpose.
Roots of the Behavior
If we look back at the beginning of the child's second year, a time when, ordinarily, children are learning to become complex preverbal problem solvers, we find the roots of this kind of behavior. While, typically, children of this age will guide an adult to a toy area and point to the toy they want or gesture at the refrigerator to communicate a desire for a particular food, these children do not. In order to do those things, a child has to have a wish that is based on a feeling, which directs the action. She needs to know what she wants before she can communicate it, and she then has to be able to connect her feelings with motor planning and other functions of the nervous system. For some as-yet-unknown reason (probably a biological one), children who are not relating and communicating find it very difficult to make these connections.
In some instances, the child's core problem is with motor planning, auditory or visual processing, and/or with connecting any or all of these with feelings and wishes. If he can't plan his movements, he's going to wander aimlessly and line up his toys rather than use them for purposeful play. If he has problems with short-term auditory memory or can't easily give meaning to the things he hears, he is going to be silent, self-absorbed, or recite meaningless syllables or irrelevant words.
Overcoming all of this requires an urgent motivating force: feelings and desires. That's why it's of no value to try to change such a child by having him simply memorize social scripts (for example, learning when to say "hello" or "goodbye" or "good morning"). This won't solve the real problem. If you can get a feeling going, however, the child is very likely to begin interacting with others in a genuinely purposeful way.
Of course, every child's potential is different, and some children who have trouble relating do beautifully with the interventions we recommend; others may take more time. It's difficult to predict what the rate of progress will be, but the sooner we start working with the child, the better. At four months, if a child is not enjoying shared attention and intimacy and seems indifferent to others, or if by eight months, he is not purposeful and intentional, there may be a problem. Typically, though, it isn't clear until the early part of the child's second year that something should be done.
The first task is to heighten affect by creating challenges that matter to the particular child. Let's say a child has a favorite toy. The child's parent or teacher might put the toy on her own head or in her mouth. The child gets intrigued and reaches for the toy. The adult sweetly teases the child until he tries to get the toy. Or the adult may take a cookie, put it in her mouth, and tempt the child to take it out. In the simple act of the child reaching for the cookie, there is a feeling: "I want that cookie!" And motor planning is required too: "I'm going to get that cookie." If the adult hides the treat in her sleeve, the child must use visual-spatial thinking in order to retrieve it. An interaction between adult and child is then underway.
To help most effectively, follow these principles:
- Develop an ambitious individualized program for each child based on his problems with language, motor planning, sequencing, and so on. Remember: A child who can't understand what's being said, organize what he's seeing, or sequence his own behavior may feel lost and behave in a self-absorbed and avoidant way. But if we work with him, we can strengthen his processing abilities and enable him to relate and communicate.
In most communities, early-evaluation and -intervention services are available. Experts working with a team approach would include a speech therapist, an occupational therapist, a developmental pediatrician, a special educator, as well as a child psychiatrist or child psychologist, and sometimes a pediatric neurologist or other specialist. The team will do a complete evaluation and plan their intervention with the help of both the parent and the teacher.
- Whether at home or at school, the child should not be allowed to spend his time passively, playing alone repetitively with the same toy, or working on rote skills. Instead, the time should be spent in communication with family members, peers, and teachers. Plans for enticing these children into such activity should be individualized-geared to each child's level of development and personal desires. One member of the expert team, often a child psychiatrist or psychologist, might coach the family.
- Always attempt to engage the child with what you know interests him. In the educational setting as well as the home, everyone should be capitalizing on the child's known wishes (as in the cookie game). Or try this: Place yourself as an obstacle until you can't be ignored. Let's say the child is moving a truck back and forth aimlessly. If you say, "What a nice truck. Where is it going?" the behavior will simply continue. Instead, take a doll or a stuffed animal and, speaking for it, say, "I want to go for a ride in your truck." If the child ignores this, put the doll in front of the truck and say, "I am going to stand in front of your truck unless you give me a ride." The child must choose between moving the truck to avoid knocking the doll over or taking the doll out of the way.
(If this doesn't work the first time-if the child stops playing or walks away-don't give up. Working with a child with this problem is often very difficult, and you may need lots of help and support and time.)
The idea is to build up the child's interest and create more and more interaction. Daily play with peers is also critical; other children will challenge the child with the kinds of speedy interactions that adults can't do. You might start off with a peer who won't be too competitive or aggressive.
- Use the child's strengths. If he is reading and writing but can't speak well, have him write out what he wants to say. Always connect the skills to the child's intentions. That means following his lead and capitalizing on his wishes. Motivation, after all, is the important missing piece when there are problems in relating. A wish or intent leads to relating and later to abstract thinking.
Most children with this problem are at first capable of only limited back-and-- forth communications. Eventually, you'll want to get 60 or 70 circles of communication-back and forth with emotional signaling-going on. If the child is already verbal and capable of doing some imaginative play, you'll want to broaden it. If the child is capable of logical thinking, answering the "W" questions-Who, What, Why, Where, and When-you'll want to move him toward discussions.
But your goal is not to get the child to answer questions with facts. Because facts are concrete and rigid and don't enhance relating, they are the enemy. Instead of piling on rote skills and facts, increase the child's emotional range by challenging her with new emotions. For example, you shouldn't be trying to teach a child to name colors; instead, you want her to answer questions such as, "Which color do you like better and why?"
Remember that the child's rigidity and inability to relate have two origins: uneven development in processing ability and the anxieties and fears this creates. I am suggesting working on these problems by encouraging a stronger and broader range of feelings.
If interventions are tailored to the individual child's existing developmental capacities, rather than to a pre-designed skill or rewards program, many children learn to relate to teachers, parents, and peers with warmth and intimacy and eventually go on to have rich interpersonal lives.