The following story is a detailed account of my daughter Beth's history and challenges with imitation. During the process of teaching my daughter patty-cake, I observed that imitation is easier for Beth when both of us are facing the same direction. If you have any experience with this issue, I would appreciate hearing from you within a post I started on my Facebook page (http://www.facebook.com/pages/Fumbling-Thru-Autism/102482513246303).
It is early October, 2012, and I wake up mentally sorting through things I want to do with my daughter Beth. We are finally able to work together, after a tough transition (for background see Going it Alone, http://wp.me/p2OomI-3, and I Need a Miracle worker, http://wp.me/p2OomI-2S).
My mind wanders to imitation. Neurotypical children learn social interaction and how to do new things by imitating others, and imitation is arguably a core deficit for children with autism (1). For my daughter, imitation is definitely an deficit, and recently she has taken a downturn in imitation after removal of an edible reward (more on that below).
So I decide we will work on the basics of imitation, with a simple game I played with her as an infant. I look at Beth, who is now 4.5 years old, and say, "Today, we will do patty-cake." Easier said than done. Beth's problems with motor planning (the ability to plan and execute new tasks) ( 2) make this a very difficult game for Beth.
But I am motivated to help Beth play patty-cake today, both because it will help Beth develop and because it will help me heal. Autism took patty-cake and many other milestones from us, and I have let many dreams go, but this loss makes me angry. We almost had it, and then we lost it. I can't let it go.
Before Autism Took Hold: Beth Playing Patty-Cake
Beth got close to playing patty-cake when she was just under 2.5 years old, although she only did the patting (i.e. two high fives) part. In a remarkable display of coordination and verbal ability, she even sang and did the patting on a goat one time at the zoo (3):
Shortly after this video was made, she never sang a whole song or simultaneously sang while coordinating hand movements again. We started her in preschool, and her anxiety shot through the roof, her language and interaction went down, and her unusual behaviors and sensory issues increased. Beth was diagnosed with autism just before 3 years of age and I quit work to stay home with her.
Playing games like patty-cake took a back seat to managing Beth's anxiety and tantrums, and trying to help Beth progress with her speech, physical, and fine motor goals. But I had hope that Beth would still play games like patty-cake one day, because the therapists had a plan to help her with imitation.
Prior Therapy: Imitation Training
Beth went through about a year of imitation training at home and in classes with therapists who were trained in ABA (4). The therapists used rewards to encourage behaviors, employed methods that had the backing of research, and took data to track progress.
The therapists practiced simple one and two-step imitation moves with Beth at home. They would demonstrate the imitation (e.g., clap, jump, etc.) and verbally state it as well. It didn't seem too hard for her.
While her ability to do simple imitation was encouraging, imitation during songs, especially songs in group settings, was much more difficult for Beth. So, during songs in music class or preschool, the therapist sat behind Beth and used a powerful reward Beth loved, a vegetable extract called glycerin (5), to encourage Beth to imitate others. After Beth attempted to imitate others a few times, the therapist would give Beth a drop of glycerin on her hand, and she would lick the glycerin from her hand. It may sound strange, but it worked wonders to get her to attempt imitation. But I was concerned that Beth seemed to only care about the reward, and did not seem connected with those she was imitating. In fact, I tried playing games like patty-cake with Beth towards the end of her ABA therapy, and she couldn't do it at all. We were not going to get to genuine imitation by the path we were taking.
We stopped the ABA therapy, and I took away the glycerin reward because I thought it might be causing Beth's GI issues. Also, since I was going to use a Floortime (6) philosophy instead of ABA, using an external reward was not part of the new plan. To my disappointment, when the reward was removed, she hardly imitated others at home or in music class. For months, I tried to prime her at home for the songs and movements in class, but she seemed unable to pay attention and do the movements.
I had often wondered why both the ABA and the Floortime approaches both failed to help Beth learn to play simple games like patty-cake. By dedicating a day to teaching Beth how to play patty-cake, I was about to answer those questions.
Teaching Beth to Play Patty-Cake
I start by sitting across from Beth and trying to play patty-cake with her. I figure out quickly that we have two big problems: 1. Beth is not paying attention to what I am doing and 2. When Beth tries to do the high fives or claps, her hands are positioned reverse of what they should be.
When the previous therapists used the glycerin reward, it seemed to magically increase Beth's attention to imitation. Of course she liked the taste, but there was more to it. Figuring out why Beth's attention increased with the glycerin reward was the key to getting her to pay attention without the glycerin reward.
When Beth was with the therapist during a song in the group setting, she spent a lot of time looking behind her and down at the reward in the therapist's hand. In fact, she often only imitated WHILE looking back at the reward. I believe the glycerin helped her focus, because by looking down at it, it limited the visual information she had to integrate in order to imitate. Since she was limiting the visual information, I theorized that Beth mostly relied on verbal cues (clap your hands, etc) from the songs and therapist. This theory explains why imitating at home, when the therapist gave the verbal cue while demonstrating the action, worked so well.
Which brings me to why she didn't know how to pay attention to me during patty-cake. Since I wasn't singing "clap then pat, clap then pat" the verbal cues of song didn't help her. And since she didn't have a lot of practice looking for non-verbal cues during imitation, she didn't know where she was supposed to look. So, this time I try verbal instructions such as "Look at me!" and "Watch me!" integrated every so often into the song, but it did no good. Then I tell her exactly where to look. "Look at my hands." That works. Finally, she knows where to look and she is attempting my movements.
We are one step closer. But her hands are backwards.
2. Reverse Hands Issue
During patty-cake, whenever Beth tries to imitate two hands going away from her body (i.e., double high five move) or clapping, she reverses her hands, gets frustrated, and gives up.
I try verbal coaching (saying "hands this way" etc.) and positioning her hands correctly, but these approaches fail. On impulse, I turn around so that our bodies are facing the same way, with my body in front of hers and off to the side so that she can see my hands. Then I do a double high five into the air or a clap and she immediately reverses her hands and does the motion correctly. This is best explained by video clips that show Beth's hand reversal and then the correction of the hand position when I turn so that we are facing the same direction. Here are videos of me doing another song from music class (7), where Beth must do the double high five move into the air and the clap move.
So, we practice with our bodies facing in the same direction. First, as demonstrated in the videos above, we do many repetitions of high-fives into the air and claps, with me standing in front of her and off to the side.
Then we practice side by side, with cut-outs of our own hands on a wall.
Then we practice side by side, Beth with herself in a mirror, and me with the cut-outs of my hands on a wall.
After all of this, I turn around to face Beth to try patty-cake again. She is doing the high-fives now, and more consistently claps with her hands pointing in the correct direction. We only do the high fives and claps at first, we are going very slowly, and I say "look at my hands" to get her attention a lot, but we are doing it.
Patty-Cake Milestone Achieved!
As it gets easier for Beth, she really starts to enjoy herself. We practice more and we get a little faster. We add in the roll and the toss. And just like that, at long last, we are playing patty-cake:
1. Vanvuchelen, M., et. al. (2011). Do Imitation Problems Reflect a Core Characteristic in Autism? Evidence from a Literature Review. Research in Autism Spectrum Disorders, 5 (1), 89-95.
3. This is the version of the song we taught Beth: "Patty cake, patty cake, baker's man. Bake me a cake as fast as you can. Roll it up, roll it up. And toss it in the pan! Yay, Beth!" (With the goat, at the beginning she added "Here we go, patty cake!" and she substituted "Yay Beth!" with "Yay, goat!")
5. At first, Beth liked to rub lotion on her hands, so we used that as a reward. Then she started licking the lotion, so I looked for something like lotion that was edible and found glycerin in the cake decorating aisle at a craft store. It is a vegetable extract used in foods and other products. I researched it, and, in small amounts, decided that it safe to use.