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The next area, that I want to talk about, is difficulties with social-emotional reciprocity,
and what I mean by that is the back and forth nature
of communication interactions and play interactions
with other individuals. In children, who have an autism
spectrum disorder, who are hearing, what this might
look like is difficulty approaching other children,
difficulty having back-and-forth conversations.
We often talk about children, who have autism,
who have difficulty with the social chitchat,
like they don't understand the intention
of communicating for an entirely social purpose,
rather than just trying to gather facts.
Sometimes, you'll see difficulty in play, reciprocal play,
being able to take turns in play, being flexible
about shifting who's changing the play,
and who's making the rules in play. Those are all ways
that we can see difficulties with social-emotional reciprocity. For typically developing children,
who are deaf and hard of hearing, we usually see those
early social communicative behaviors that indicate
reciprocity come in line as we would expect,
so that social smile that you see with your infant
when you smile at them. We would expect a typically
developing deaf and hard of hearing child to smile back
at you. Typically developing children, who are deaf
and hard of hearing, also use things like eye contact
and holding things up to show or giving things
to other people, before they have formal language
to be able to try to engage other people
in a back-and-forth interaction. We usually see
those children being able to imitate what other people
are doing, which is an early skill that's necessary
for building those back-and-forth interactions,
imitating for infants, those facial expressions
and silly mouth movements that you make
with your baby like [Gibberish][Laugh].
That one's particularly complex, but [ Laugh] the idea is
that they're trying to imitate. We also expect children,
who are typically developing, who are deaf
and hard of hearing, to be able to engage in something
we call joint attention, which is the ability to join
with somebody else in sharing interests
in a particular activity or toy.
We know that joint attention, itself, can look
and be established in different ways with children,
who are deaf and hard of hearing.
Whereas, with hearing children what joint attention
looks like is that idea of pointing to the object
and looking back to the person, that you're trying
to communicate. That can be established
for deaf children of deaf adults
in slightly different ways.
They might sign between themselves and their parents
and the object, reflecting an understanding that if I sign
here, then my parent is understanding that I'm talking
about the object that's in the same visual signing space.
The ways that deaf parents of deaf children
versus others might engage their child in joint attention
might be different, because we have to navigate
how you direct communication and object play
to mediate being able to have that
shared interaction. But regardless,
typically we see that the purpose of joint attention is there, that they're able to establish that shared
referencing and shared enjoyment with an object or an activity.
For children, who are deaf and hard of hearing,
who have autism, joint attention is difficult.
They have again, we talked about the examples
that they might point to something and not look back
at the person that they're referencing or they might have
difficulty shifting their eye contact between the objects
and the people that they're trying to interact with.
Children, who are deaf and hard of hearing, are generally
very interested in interacting with others
in their social environments, but autism can sometimes
interfere with that. They sometimes tend to look like
they're more focused and more interested in the objects,
that are around than the people.
That's a key distinction for distinguishing autism
for children, who are deaf and hard of hearing,
versus typical development.
Some of the ways that these difficulties with reciprocity might appear later on in development might be
difficulty having social conversations, engaging back and forth. Oftentimes, for children, who have autism,
we might see them engaging in a monologue,
that's a one-sided discussion, where they're
communicating a lot, they're saying a lot,
often about a very specific interest, but they're not
leaving much room for people to join that conversation
or have back and forth interactions.
One of the things, that we have to consider in making
a differential diagnosis of autism among children,
who are deaf and hard of hearing, is what the language
environment looks like. Do they have good access
to others, who are able to communicate with them
in their chosen communication modality?
Because we don't want to make an assumption that,
because a child, who's deaf who uses
sign language, is having difficulty engaging
with hearing peers, who don't use sign language,
that might reflect a mismatch between the child's
communication and the environment, rather than
a symptom of an autism spectrum disorder.
We want to make sure that we're considering whether
the communication environment is accessible
for the child, who's deaf and hard of hearing.
The next criteria has to do with difficulties developing and maintaining appropriate relationships.
Again, I want to emphasize that this is relationships that are appropriate to the child's developmental age.
You might have a nine-year-old,
who developmentally is more like a two-year-old.
Our expectations of what their social relationships
would look like, would be based on understanding
of how we expect that to look for a two-year-old
rather than a nine-year-old. Roughly speaking.
For children with autism this can look like difficulty
building relationships appropriate for their
developmental level, whether that's being able
to engage in parallel play at two, versus being able
to have truly back and forth interaction with peers
using objects, that they're sharing and developing
elaborate play schemes together when they're older.
It can reflect difficulty adjusting their behavior
to the social context. Children, who have difficulty
recognizing that their role is not to correct all the peers
in class, who are not following the rules. [Laugh]
Sometimes, this is something, that we see
in children with autism.
Sometimes, it has to do with children, because autism
is a continuum. You might have children, who show
very limited social interest, and who are socially
withdrawing in situations, where there are peers around,
and communication is accessible, versus all the way up
to children, who seem socially motivated, and they have
some social interests, but they just don't know how
to make it work. They don't know how to join
other peers play. They don't know how to establish
friendships that are really reciprocal with their peers,
even when the communication access is not an issue.
In typically developing children, who are deaf
and hard of hearing, when they're provided
with environments, where communication is accessible
and their play follows a somewhat typical
developmental course commiserate with
their developmental abilities and their language abilities,
we expect children, who are deaf and hard of hearing,
when they have the established communication
to be able to be flexible in their play.
Sometimes, you see as children, who are deaf
and hard of hearing, are acquiring language,
you might see some rigidity in their play interactions or
difficulty following conversations, if there's a mismatch
between their language ability and their peers ability.
But again generally speaking, if we make
the communication environment accessible
to them through sign or through other interventions
to make it accessible to children, who use an auditory
oral approach we expect them to be able to show
reciprocity in their play interactions.
For children, who are deaf and hard of hearing who have autism, in addition to the things that we've already
talked about, you might see less of that early social enjoyment that showing and giving behavior.
You often see a gap between their developmental
abilities and their play skills. Children, who are deaf
and hard of hearing who have autism, might show
delays in the acquisition of pretend play skills.
They're not consistent with their communication skills
and their cognitive abilities. They often have difficulty
making and sustaining friendships
even when communication is accessible.
Sometimes there are situations where especially
in early childhood, where parents or adults are doing
a lot to mediate peer interactions and sometimes these
difficulties are not really readily apparent to other
individuals until we see that child struggling to make friends independent of other people
mediating their interactions.
Another thing to look for are social behaviors
that are unusual, that might be more consistent
with autism than hearing loss.
An example would be children, who back into their
parents laps rather than establishing eye contact
to make that affectionate gesture or to seek comfort
from their parents. Children, who use unusual or
negative social overtures too excessively
frequently across several different contexts.
Grunting at peers, rather than trying to communicate
first, or hitting with peers to try to initiate play,
rather than seeing how other peers are initiating play, and following suit.
Another unusual social overture, that you might sometimes see is something
called hand as tool use. This is specifically the behavior
of using another adults hands to manipulate an object.
Taking their hand and putting it over their parents hand
to get the parents to open a door or to activate a toy.
This is a behavior that is not commonly seen either
among typically developing hearing children or children,
who are deaf and hard of hearing.
If you do see it, it's usually the communicative behavior of last resort, so they've tried everything else
to get their parents attention first, and when they're unsuccessful with that, they just get frustrated
and try to get their parent to do it. But otherwise you really wouldn't expect to see that kind of behavior.
The next cluster of symptoms, that we talk about in the DSM-5, are repetitive behaviors or restricted interests.
This can vary and the DSM-5 changed this criteria
a little bit to include what we call stereotyped language
or repetitive speech. That can range from those earlier
symptoms, that we talked about, the echolalia or
the repeating signs or phrases, that they've seen
somewhere else, in a way that doesn't quite fit
the context. It can also be children, who have
verbal rituals or in the case of sign, signed rituals,
where they want somebody to say something
always, exactly, the very same way.
This can also include repetitive motor movements
and repetitive use of objects. The repetitive motor
movements that I'm referring to, might be
repetitive movements with their hands or stereotyped
movements with their hands or bodies,
could be rocking, pacing, spinning excessively,
There are lots of other hand and body movements that
might fall into this cluster. Having said that, repetitive
motor movements can be present in a variety
of developmental disabilities in the absence
of an autism spectrum disorder. One thing that's
important to emphasize is that, even if a child has
a repetitive motor mannerism, that in and of itself
doesn't necessarily mean that they have
an autism spectrum disorder. It's only when those
behaviors are present with the additional criteria
that we've already talked about.
Another way that you might see this,
repetitive nature of behavior might be repetitive use
of objects. Repetitively playing with toys in a way
that seems non-functional, lining up toys.
It could be repetitively spinning something,
and being very focused on the spinning or the part
of the object, rather than playing with the object
as it's intended to be used.
Another area that you might see is difficulties
with transitions. Difficulty transitioning from one activity
to another, from a preferred activity to a non-preferred
activity. In typically developing children, who are deaf
and hard of hearing, we don't typically expect to see
this repetitive language, that we've talked about already,
especially once their communication system is well
established. Again, echolalia can be part of a typical
developmental pattern, but it should be for a brief time
and should dissipate by the time, that the child
has flexible use of phrase language,
combining two or more words or signs.
The repetitive motor movements are not typically
associated with children, who are deaf
and hard of hearing, in the absence of another
developmental explanation for that.
In terms of difficulties with transitions,
difficulties with transitions can reflect difficulty
understanding what's happening for the child,
and if there is a mismatch between the child and
their communicative environment, that is not enough
about what's about to happen is being communicated
to the child, you might see that child have
difficulty with transitions, or until they have the language
to understand what is happening in their environment.
Typically for children, who are just deaf and
hard of hearing, who don't have autism, if you intervene
to teach them, either visually what's about to happen,
or by increasing their access to communication
in their environment, you would see that difficulty
with transitions subside and dissipate.
But difficulties with transition that children with autism often have are also sometimes related to just being
fixated on what it is that they were engaged with or having a compulsive need to complete what
they were previously working on before transitioning.
Similarly, one of the repetitive patterns of behavior
that you might see is excessive adherence to routines.
We talked before that this could look like
a verbal ritual, something that the child insists that you
sign or say, always the same way, every time
in that particular circumstance. It can also
be an excessive resistance to change, not liking to drive
a different way to school, getting upset if something
happens out of order in their schedule, children
who meltdown when there's a substitute teacher
in the class. These are all common ways that this might
manifest for children with an autism spectrum disorder.
Again, for children, who are typically developing,
who are deaf and hard of hearing, as long as we
provide communication access for their understanding
about those changes in their routine,
you'll generally see less resistance.
Some children, who have autism also get excessively
and intensely focused on either an unusual interest
or one that might be usual, but seems unusual
for the child's developmental age.
An example of that might be a tendency again
for a child to get preoccupied with a particular part
of an object. Sometimes you'll see children also,
who fixate on using other senses to explore objects
in unusual ways, who might have what we call
close visual inspection of toys, where they might get
down and look at the wheels of the train engines
as they roll them towards them, or they might hold
things up and look at them in unusual ways.
Again, in the absence of an additional vision difference,
we wouldn't expect this in typically developing children,
who are deaf and hard of hearing.
Sometimes, this looks like an intense interest
in a particular object or topic. Kids, who get very fixated
and interested on Thomas the Tank Engine
or Pokemon or Transformers or whatever it may be,
and what sets this apart as being different than typical
development is that the preoccupation is intense,
and it interferes. It might be that they are interested
in that topic to the exclusion of playing with other types
of toys, or that when they're fixated on that topic,
or that object it's not social in nature, that is they're not
allowing other people to enter that play or that interest.
It could also be that they have difficulty transitioning
away from that to a marked degree that causes
significant upset. For children, who are typically
developing, who are deaf and hard of hearing, you might
see that they talk about specific interests that are within
their access to communication, that is that they have
the vocabulary around, but you won't typically see
the intensity around that or the upset around it,
when it's removed. It's more about this is what I'm able
to communicate to you, and it has a social function
of that behavior. This is an important point in general,
in considering the symptoms. The same symptom, the same behavior may be part of typical development
for one child, but might be considered a symptom of autism for another child, and what sets those apart
is often, whether it's consistent with what we would expect for where they are developmentally,
and what the function of that behavior is. A child, who is consistently trying to communicate with you by bringing
you a particular toy, that could be a very functional and social skill for that child, who is a limited repertoire
of vocabulary in their communication modality. But for another child, who has broader language skills
than that and more ability than that, that could look like a symptom of autism, if they have skills to be able
to communicate about other things, but are choosing to only consistently communicate about that one topic.
One of the newer changes in the DSM-5 criteria
is this idea of children, who are either under-reactive
or over-reactive, hyper- or hypo- reactive,
to sensory input, or who have unusual sensory interests
in their environment. We've already talked a little bit
about that idea of visual inspection, but unusual
sensory interest can also look like smelling objects
that you wouldn't typically smell. The child, who has
to smell everything before they engage with it.
It could also look like a fascination with other visual
aspects, watching the blinds go up and down
or the TV credits rolling down repeatedly,
or children who have tactile interests,
who might press their chins against you,
or who might seek a lot of tactile input.
Sometimes in children, who have autism, we see that
they are the reverse. They're under sensitive.
They don't react in situations where you would typically
expect them to indicate to you that they were
experiencing pain or heat or cold.
For children, who are typically developing, who are deaf and hard of hearing, we sometimes do see
sensory differences compared to a hearing population. There's limited research about this, but what
that literature does suggest, is that there are difficulties that might be more commonly seen among children,
who are deaf and hard of hearing, such as differences
with vestibular processing. Those are related to balance
and movement, but you're less likely in the absence
of a vision impairment or a visual difference to see
visual inspection or that persistent olfactory
or tactile exploration of objects in unusual ways.
One of the other ways, that we might see these symptoms present in children, who are deaf
and hard of hearing who have autism,
is sensitivity to wearing their assistive technology.
Children, who are resistant to wearing their hearing aids
or cochlear implants beyond what we see
at the developmental age where it's common
for children to take off their hearing aids
or their implants immediately when they're toddlers.
But children, who are excessively resistant
to those types of interventions around that.
And of course in those situations, you want to have
consultation with their audiologist, but we also need
to be sensitive to the fact that their resistance to it
might be a part of symptom associated
with these sensory differences for children with autism,
and then we would intervene differently knowing
that the child might have an autism spectrum disorder.