This post is an excerpt from William Dikel’s book, Student Mental Health: A Guide For Teachers, School and District Leaders, School Psychologists and Nurses, Social Workers, Counselors, and Parents (W. W. Norton).
ASD, or autism spectrum disorder, is a uniquely challenging disorder for children both inside and outside the classroom that is often misdiagnosed and misunderstood—often to the extreme detriment of the child. Here, in recognition of National Autism Awareness Month, we share an excerpt from William Dikel’s book Student Mental Health (Norton 2019) that guides teachers in recognizing ASD in their students.
The types and severity of symptoms of ASD (autism spectrum disorder) in children vary widely, from mild and not obvious to severe. Some of the most challenging students are those who have ASD in the more moderate range of severity, but who also have multiple other psychiatric disorders such as depression, bipolar mood disorder, ADHD, obsessive-compulsive disorder, panic disorder, and so on. Given the dramatic symptoms of these other problems, their ASD may not be obvious. However, it is important to recognize that this disorder has unique characteristics that can interfere with a student’s educational progress and social-emotional functioning in ways that other mental health disorders do not.
Individuals diagnosed with ASD have persistent deficits in social communication and social interaction. They have deficits in social-emotional reciprocity, with problems such as difficulty maintaining conversations, lack of emotional sharing, and a failure to initiate or respond to social interactions. They have nonverbal communication deficits with problems such as poor eye contact, difficulty reading nonverbal communications, and lack of gestures. They have significant problems in developing, maintaining, and understanding relationships such as a lack of sharing imaginative play, an absence of interest in peers, and difficulty adjusting their behavior to the social situation.
Additionally, they have restricted, repetitive patterns of behavior, interests, or activities, with at least two characteristics in that category. The first group of characteristics includes stereotyped or repetitive motor movements, use of objects, or speech. The second group includes the insistence on sameness with inflexible adherence to routines. Next are highly restricted, fixated interests that are abnormal in intensity and focus. The last item is hyper- or hyporeactivity to sensory inputs (sights, sounds, smells, touches) or unusual interest in sensory aspects of the environment. Symptoms must have been present in the early developmental period and cause significant impairment in functioning.
Manifestations of ASD in the Classroom
Symptoms of severe ASD are easily recognizable in the classroom setting, as students who have this level of disability tend to have severe difficulties with language use, interpersonal relationships, unusual behaviors (e.g., repetitive rocking), and, often, significant cognitive difficulties.
As this disorder occurs along a spectrum, there are many students who have milder forms that are not always obvious, and, in fact, are often not diagnosed at all by medical or mental health professionals. These students tend to have difficulty with social skills and have difficulty making and keeping friends. If they have poor eye contact and restricted gestures, they may be seen by peers as being different, strange, or weird. They tend to not fit into social groups and may prefer solitary activities, leading them to be teased, bullied, or shunned by their peers. They may have difficulty reading nonverbal communication such as gestures or facial expressions, and may not understand or may misinterpret others’ emotions.
Often, students who have ASD have significant difficulty dealing with changes in routine. This could manifest in the classroom in the form of anxiety, and the student could respond to alterations in a previously fixed daily schedule with near panic. These students need to be prepared for major changes, often days or even weeks in advance, and they respond best to gradual rather than sudden routine changes.
Unusual movements or mannerisms are common, and may take the form of tiptoe walking, hand flapping, or rocking back and forth. Students who have ASD may have significant oversensitivity to touch, sound, or light. Touch sensitivity, known as tactile defensiveness, can be observed if a student cringes or becomes agitated when someone attempts to shake hands, pat him or her on the back, and so on. Sounds that are barely perceptible to other students (e.g., the background hum of machinery in the school building) may be very distracting to these students. Loud noises may trigger severe anxiety. Many students who have ASD are very sensitive to fluorescent lighting, especially the type with the wider bulbs that have magnetic rather than electronic ballasts. Magnetic ballast fluorescent lighting has a flicker that is generally imperceptible to nondisabled individuals, but that can be very disturbing to students with ASD. Changing lighting to incandescent or, even better, daylight can result in significant reduction in anxiety levels and a reduction in behavioral difficulties as well.
These students may be very concrete in their thinking and may have difficulty with abstract concepts. Their speech may appear stilted, and their significant difficulties in initiating and maintaining a conversation may keep them from engaging in classroom discussions. Younger children, in classrooms where storytelling and make believe play is encouraged, may have significant difficulty engaging in imaginative activities.
A common feature of ASD that tends to manifest in the classroom is the excessive preoccupation with a topic of interest. The student will continue to refer to that topic and have great difficulty transitioning to another subject. The topic may be anything that may interest the student, such as a video game, cartoon character, weather patterns, airplanes, and so on. The student may have amassed a huge amount of information on the topic, and may want to talk about it with the teacher or classmates without recognizing others’ lack of interest. This tends to alienate others and can lead to ostracism. Many high-functioning autism spectrum individuals have followed career paths along the lines of their excessive interests (e.g., computer science) and have been quite successful as a result. The challenge for the classroom teacher is to encourage topic exploration on the one hand while also encouraging a broader focus of study for a student who may be resistant to getting off the hyperfocused topic.
Susan is a 6-year-old student who has been demonstrating socialization difficulties since kindergarten. She avoids eye contact, has difficulty maintaining conversations with others, and has problems interpreting her peers’ nonverbal communication (e.g., gestures, facial expressions). She has some hypersensitivity to noises, lighting (especially fluorescent lighting), and the texture of her clothing. She has some unusual movements including flapping her hands when excited and tiptoe walking on occasion. Her grades are good, but her teacher is concerned about Susan’s social difficulties, as she is at risk for teasing and ridicule by peers. A special education evaluation was done to see if she qualified for the Autism Spectrum Disorder (ASD) category, but her problems were not severe enough.
What do you think the next steps should be to address her at-risk status? Who should be involved in the discussions? What interventions would assist her in overcoming her difficulties? What would be her teacher’s role in this process?
William Dikel, MD, is a child and adolescent psychiatrist who consults with educators nationwide, in settings varying from general education classrooms to self-contained special education programs for severely emotionally disturbed students.