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photo by Shayne Lynn

Social Studies
Patricia Prelock works seven days a week creating innovative
interventionsthat are helping children with autism play, share, and connect
by Lee Ann Cox

Six-year-old Matthew Reynolds is playing with his friend Takshal on a Saturday afternoon when he darkens and knits his brow. He sees a large Lego in the set of smaller ones and it puts him on edge for a second, then he pulls it out and his cheerful face returns. Patricia Prelock is watching.

“You were so flexible there Matthew; I’m proud of you,” she tells him, because another day not so long ago, the incident might have gone otherwise. But what’s remarkable about this story is not that this talkative little boy has a room full of toys carefully stored away in their designated bins, it’s that Matthew Reynolds is playing with his friend Takshal. Matthew has autism spectrum disorder, or ASD, a neurological condition that can make forming the most natural interpersonal connections — such as playing — a painful, baffling prospect.

Children with ASD, even verbal ones like Matthew, struggle with social interaction and communication, says Prelock, professor and chair of communication sciences and a 2004 University Scholar. They may have difficulty making eye contact, finding appropriate words, and may exhibit odd, inflexible, or repetitive behaviors. For a child with autism, seeing another person’s perspective (like, say, wanting a turn with a toy or to try another game) is simply not part of their wiring, nor are abstractions like pretend play. Trains, blocks, maps, these are predictable and controllable and therefore more comfortable than people.

And yet, the need for human connection, for friendship, is as real for those with ASD as for anyone else. “Kids who have successful social relationships have better long-term outcomes in terms of being satisfied and successful,” says Prelock, whose aim is to give autistic children the normal stuff of childhood, complete with birthday party invitations, playdates, and sleepovers. How to make that possible is a challenge that keeps her working seven-day, 70-hour weeks.

PLAY 101
Prelock has designed an innovative intervention study she terms “peer play,” in which pairs of children — one with autism and the other not — are given specific strategies for interacting. While one graduate student videotapes, another facilitates the session, modeling the soundtrack of successful play: “I have an idea, let’s play ball,” “Oh, I like your picture; I wonder what you’re drawing,” or simply, “Your turn!”

What’s most unusual about this research is that it takes place in the home of the autistic child. Similar projects have been done in school settings, but Prelock believes that by working in a child’s home, within his comfort zone and with his own toys, they are maximizing the chances of success, defined, in carefully coded analysis, by the ways the kids interact and the amount of time they spend mutually engaged. It’s also unique to train both the child with the disorder and the typically developing peer. Other research has focused exclusively on one or the other.

Prelock’s study takes place over 15 weekly playdates, with follow-ups after three and six months. The first three sessions are the hardest, for the children, the interventionists, and particularly the parents. During this baseline phase, the kids are videotaped with no coaching to see how they interact on their own and the results can be heartbreaking. Often the children play in separate rooms or act as if no one else is there.

“That’s hard for the parents to see,” says Prelock, “that their children didn’t really have a way to connect.”

The kids then get ten weeks of coaching, with the intervention removed after five sessions, and then again after the tenth, so Prelock and her team can assess the progress. Are the children initiating play? Are they responding to their names? Are they taking turns? Not surprisingly, the social behavior dips after the first few weeks of intervention. But after ten weeks, the work is showing results.

“If you saw the videotapes, it’s dramatic,” says Prelock. “I think that’s what blows people away. You can actually see this dramatic change in the kids’ ability to communicate with each other.”

Take Matthew and Takshal, who were one of Prelock’s earliest pairs. In the beginning, she says, Matthew was reserved and echolaliac, parroting back people’s speech.

“His play was very limited,” Prelock says. “He didn’t know how to use objects and only wanted to do repetitive things.” As Takshal played pirate ship, walking a small figure up a rope, Matthew would sit and watch, and look to the interventionist. But with coaching, he gradually began to get it. Two years later, on the day of the Lego incident, the pair shared a pretend game of doctor and patient and Matthew was well versed in the language of taking turns, speaking, at times, more like therapist than child.

“They were given the words to use,” says Giovanna Reynolds, Matthew’s mom. “They learned to share; they learned to wait; they learned to ask; they learned to help each other. It was concrete and it got through to him on his level.”

As Prelock had hoped, the social behaviors have extended beyond the home setting and with children other than the trained peer. “He’s more confident,” reports Reynolds. “Before I had to drag him to playgroups and now he asks to go. He asks kids to come over.”

And he’s been to those all-important birthday parties. “Matthew wants to do everything every other kid does,” Reynolds continues. “This way, I think he learned how to be a friend. Not what a normal kid would do or be, but he’s a lot better than he was.”

The study is limited to children between the ages of four and six who have language skills at least at a 30-month level. Within those guidelines, there is a range in the severity of autism cases. Matthew is a highly verbal child with high cognitive function and he was diagnosed early, an important factor in his favor. But Prelock has had successful outcomes with children whose disorder is much more severe. In fact, the personality of the typical peer may be a better indicator of success.

Prelock has completed five dyads and she started three more in January. It’s a demanding process, involving extensive travel, painstaking data analysis (each half-hour play session takes four to seven hours to code) and enormous sensitivity in dealing with vulnerable families. But it’s gratifying work. Prelock regularly gets calls and emails from grateful families like the Reynolds who credit her with their child’s progress.

But Prelock also adds a note of caution. Because she makes the needs of the children and their families paramount, this is not a strictly controlled study. “I can’t tell families they can’t have any other interventions,” Prelock says. “That’s just not appropriate.” And she won’t withhold the intervention either, so there’s no control group. But by consistently replicating her results with these single-subject designs, Prelock says it’s possible to draw some powerful conclusions about the efficacy of the intervention.

For all his progress, Matthew’s problems haven’t vanished. He talks and talks, but rarely stops to listen. He’s so resistant to change that he rejected the idea of turning six. Most painfully, now that he can ask kids to play, he lacks the perspective to judge body language and other cues that might help him avoid rejection. So Reynolds hooks him up with Prelock and her students whenever she can. She eagerly enrolled him in a new study led by Prelock that studies the effectiveness of using social stories to change or encourage behaviors in autistic children, as well as to help them assume another person’s perspective.

The technique, developed by autism educator Carol Gray, uses a short narrative to describe a social event (like greeting somebody), offer a child cues as to how others feel (if you spit on them — that’s bad) and what to do when he’s in a similar situation (say hello). The stories are individualized depending on the issues a child — and his family — are struggling with. The hope, Prelock says, is that this simple change can help children overcome some of the obstacles that prevent them from making valuable human connections.

“I want Matthew to be independent, to have what everyone has, a family and friends around,” Giovanna Reynolds says. “I want him to find work that he’s comfortable with and to show empathy for others, to be there and help people out, not just me, me, me all the time.”

Prelock wants to help kids like Matthew get as far towards those ends as their unique situations will allow, but she also wants the world to meet them halfway.

“I’ve always been intrigued by the unique way children with autism approach their world,” Prelock says, noting that many people who are uncomfortable or afraid believe that people with this disorder don’t know how to communicate. Yes they do, she says, and we need to do a better job of understanding them.

If that means trading fluorescent lights for lamps in schoolrooms, organizing the day with a schedule and visual supports so a child with autism knows what’s going to happen next, if it means taking sensory breaks for the whole class so a child who needs to spin around won’t look weird, then, Prelock says, it’s worth it, and it might just help other kids too.

For Prelock, her work is the chance to build a small bridge between two worlds that seem so foreign to each other, the languages of which she knows by heart. For the families caught in between, it’s a lift out into the light.

“I don’t expect miracles,” Reynolds says, “but even the tiniest change just gives us hope and more strength to
carry on.”