John Scott

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Scott, John

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Logopedija, 5, 1, 2015, 31-33     31 John Scott SLP, private practice, Nanaimo, BC, Canada    Review:  SCERTS, the prologue to Prizant’s “Uniquely Human”  Book review       UDK: 616.895    Dr. Barry Prizant’s new book, “Uniquely Human: A different way of seeing autism”, will be published in August 2015. His model for autism intervention (Social Communication, Emotional Regulation and Transactional Support; SCERTS) (Prizant et al., 2006), is reviewed below to provide some clinical background to his new book. Barry Prizant, PhD,  (www.barryprizant.com) a prominent Speech-Language Pathologist in North America, is co-author of many Autism Spectrum Disorder (ASD) studies in professional journals and texts. This time in “Uniquely human”(Prizant, 2015), he has decided to write for the general public: this can also help if English is not your native language. General books on ASD can be empty seashells, full of noise. Knowing Prizant’s previous works, I believe this one will be very readable, affordable, compassionate, parent and grandparent-friendly and teacher-friendly and yes, still professionally correct and accurate: Prizant and his SLP colleagues have focused on autism for 40 years. “Uniquely Human” has one 5-star review by Temple Grandin: I love his approach for understanding problems with sensory overload, anxiety and discomfort. He provides common sense, practical advice based on 40 years working in the trenches with parents and teachers. This review is 1 of 13 positive ASD expert reviews on Simon & Schuster’s website; one expert  even called it ‘the first book to read and the last book to read’.  As the cover notes, This book argues that ASD is not a tragic disability but a uniquely human way of being. Dr. Prizant suggests a major shift in understanding autism: instead of classifying ‘autistic behaviors’ as signs of pathology, he sees them as part of a range of strategies to cope with a world that feels chaotic and overwhelming… better to enhance abilities, build on strengths and offer supports that will naturally lead to more desirable behavior and better quality of life. This echoes a famous line by Temple Grandin: My primary emotion is, and always has been, fear. Ros Blackburn, UK ASD adult, says: You would all react as I do, if you were pushed as far as I am.  The last major SLP therapy publication by Prizant’s team was: “The SCERTS Model: A Comprehensive Educational Approach for Children with Autism Spectrum Disorders” (Prizant et al., 2006).  This two-part manual for diagnosed ASD children calls itself  “an innovative integration of research and clinical practice published by us since the mid-70s”.  In 1993 Prizant and Wetherby co-authored “CSBS –Communication and Symbolic Behavior Scales” used worldwide: a  norm-referenced, standardized observation method for infants, toddlers & preschoolers at risk of communication development delays. CSBS research led to similar but simpler, criterion-referenced ‘Partner Levels’ used in the 2006 SCERTS Manual, which lists most works by Wetherby, Prizant and others in its References: pp. 245-249.  In her presentation in January 2015 (Introduction to SCERTS assessment and therapy - workshop in Vancouver, Canada), Emily Rubin, MS, CCC-SLP, youngest co-author of SCERTS, reviewed its format and application around the world. Past member of ASHA’s Ad Hoc ASD Committee, past Yale lecturer, present clinical SLP, Rubin began by reviewing neurological findings in autism, including: ASD  processes faces in the brain region designed for objects, so no oxytocin ‘social high’ is triggered by seeing a human face, as in neurotypical infants. Taking her own personal experience of high anxiety (a fear of flying, but a career that means flying worldwide) Rubin shared her elaborate coping strategies: she  researches each specific plane’s ‘safe seat’ in view of the emergency exit. In two days together, she modeled other ways to reduce anxiety: ‘pre boarding’ emails; predictable schedules,  and visuals.  We watched  ‘introduction to SCERTS assessment and therapy’. She used Time Timer App for her and us. It helped us take, enjoy, and return on time from each mini-break, and to finish on time for flights and ferries home. ‘Visual supports’ = Universal Design. We all need coping strategies; ASD children need them every second. As I write, Vancouver Engineer Andrea Palmer is developing ‘Reveal’, a ‘smart shirt’ with ‘imperceptible’ bio-sensors to signal to parents’ phones if a nonverbal ASD child’s anxiety level ‘goes critical’. SCERTS stands for ‘Social Communication, Emotional  Regulation and Transactional Support’.  At 720 pages, “SCERTS” is definitely ‘comprehensive’ but also well structured, into two volumes, one on Assessment and one on Program    Planning    and    Intervention.    Purchasers    are Correspondence: John Scott, Nanaimo, British Columbia, Canada, vivaldi-one@shaw.ca   Scott: SCERTS, the prologue to Prizant’s “Uniquely Human” 32     specifically permitted to copy 53 pages of forms “for clinical or educational use from an original book” , so, no additional costs or ordering problems for extra assessment and planning forms. On opening SCERTS, the Introduction tells you how to read it, what it is and is not, etc. Vol. 1 even devotes 6 pages to ‘glossary of terms’.  Any of the first 3 chapters - Social Communication, Emotional Regulation, Transactional Supports - would help university and staff inservice education on ASD. Chapter 6, “Continuum of current intervention approaches and the SCERTS model” reviews ‘ASD best practices’ and how SCERTS fits into them. In an age of arguments, it is factual and fair. Co-written by five experienced specialists in calm tones, SCERTS’ open ‘framework’ was designed to help any proven method, any agency, clinician, region or country-wide ASD program work smarter, in the best interests of the unique children and families. One may ask just how Prizant’s new book, or SCERTS, is even relevant to clinicians or families living with ASD in Croatia, or children still undiagnosed, waiting for autism services? It was once like that in Canada, and in many areas it still is. However, CSBS scales already in use in Zagreb have helped analyze child - parent interaction  and symbolic communication; Wetherby & Prizant’s  many earlier books found their way onto shelves of Croatian  SLP and psychology professionals; SCERTS can also offer future Croatian ASD programs ‘practical guidance and meaningful activities’. Quality Indicator Forms on the final pages list Quality Assurance (QA) components needed to evaluate any ASD program. They could just as well help to start one. If any expert group or centre is writing guidelines or policy for ASD programs, SCERTS has all the right QA questions and many of the current answers, arranged stepwise in one comprehensive document.      In another way, “Uniquely Human” could help students, parents, professionals, anyone who reads English, to better understand ASD. Let’s ask for a Croatian translation; someone call Simon & Schuster. It will also interest ‘professional learning groups’ in education/ health, as well as book clubs and study groups. Copies donated to school or public libraries could move us from ‘awareness’ to ‘understanding’. Why? Because Prizant argues that each unique person on the autism spectrum needs us to learn and change just as much, to change and modify our unpredictable, overwhelming environments that trigger or escalate the ‘autistic behaviors’ in the first place. We have as much work to do as the child with autism spectrum disorder. How? Through social communication, emotional regulation and transactional supports. Rubin said that too many intervention plans for ASD children still start with long lists of ‘inappropriate behaviors to  stop’  before, or instead of, any goals related to:  Social Communication (SC), the core disability in autism;  Emotional Regulation (ER), the second missing competency;   Transactional Support (TS),  the third leg of the tripod.   The Transactional Support domain of  SCERTS recognizes that we are all in it together and must form a partnership in the complex task of supporting children with ASD and families. Tactfully entitled “Support to families and support among professionals”, chapter 3 in volume two shows how professionals and families can all work together as a team to provide supports needed. After the child’s goals, each TS intervention goal states what a partner does or will do. All goals start with ”Partner uses…” or “Partner arranges”.  Just like Peter Limbrick’s Team Around the Child (TAC) model (Limbrick, 2012), SCERTS builds teams around a child, including siblings and family. It asks what they expect (“family expectations for service and helpful supports form”, p.48) and makes plans (“family support planning form, part 1, educational support and part 2, emotional support”, pp.77/78). These plan out what adults need to do for a child and for their own well-being. Transactional support is a kind and humane addition to ASD early intervention literature, especially the section regarding the urgent need for ongoing support among professionals on pp.79-81. Sample activities for ‘educational’ and ‘emotional’ support are given. SCERTS comes in two large print/format books. Thanks to:    ‘Snapshots’ of real children at one point in time;   ‘Spotlight on..’ showing a child’s complete intervention story;  ‘Question and answer’ pages  One page summaries - ‘Summary of goals, desired outcomes and related objectives of emotional support to families’  it almost lives up to its intention to be “user-friendly, accessible to professionals, paraprofessionals and parents” . The authors do add,  “…we believe the reader must make an investment in understanding the rich theoretical and research foundations of the model to apply it effectively”.  (Chapter one, page one). Four experienced SLPs and an occupational therapist did not ‘re-invent the wheel’ 720 times. Their ‘next generation framework’ model aims to make any evidence-based ASD intervention method more productive, efficient and, vitally, more cost-effective. Today, the USA’s daily cost of autism intervention is 3 times the cost of regular education and rising (Rubin, personal communication). All countries show rising ASD incidence. So New Zealand has adopted SCERTS as the ‘national framework’ for all autism services. This is progress. From Canada to Hong Kong to London, ASD teams are using SCERTS’ approach in whole or in part. Respecting the continuum of existing therapies (from ABA to PECS to Social Thinking) it just asks ‘what’, ‘when’ and ‘how long for each day’ and ‘is this goal based on research or a waste of time and money?’ Yes, truth hurts sometimes. For example, 2 hours matching objects 100% is not ‘better’ than 30 minutes matching face photos to printed names of all children in ‘my class’.  Asking ‘why do this?’ is step one. SCERTS helps ask hard questions. Since we only determine functional goals by assessment, SCERTS asks what skill ‘level’ the child has reached. Are they at a: 1)  Social partner level 2)  Language partner level  3)  Conversation partner level? Logopedija, 5, 1, 2015, 31-33 33     By using these 3 criterion-referenced levels, we will not move too fast and miss basic skills that have not been mastered, such as this one: ‘protests/refuses undesired objects or activities ’. All checklist items for the levels are evidence-based, in neurodevelopmental sequence. This simple but not simplistic, efficient, three-level grouping clears the mind and works well with SC, ER, TS, to create a ‘teachable system’.  This supports our multidisciplinary, whole team intervention; the fact SCERTS is now in fourth printing, June 2014, speaks to its success. To mention one SCERTS area which Prizant and Rydell have both contributed to since the 1980s, let’s look at the 4 major forms of  ‘unconventional verbal behavior’  (Prizant et al., 2006; table 4.2, page 81):   Immediate echolalia  Delayed echolalia  Perseverative speech  Incessant (repetitive) questioning.  Prizant helped ‘decode’ autism by recognizing that echolalia ‘may serve a variety of communicative and cognitive functions. In other words, it sounds unconventional, but may still be communication. Progress. Just as Prizant was the first to demonstrate how ‘meaningless echolalia’ might ‘mean something’, Emily Rubin suggested ‘language regression’ reported by parents, when any speech stops, may not be regression, but functional: unsuccessful speech acts stop, but are replaced by successful physical acts – using parents’ hands as ‘tools’ to open containers, a ‘next stage’ of ASD communication attempts. Children use our hands because it works.  Why is it relevant to learn how differently each ASD brain sees the world, how uniquely  autistic children experience ‘reality’ with their unique sensory-sensitive systems? Because then we will understand:   the child in an overcrowded Hong Kong daycare with nowhere to run, who bends his head back at right-angles to stare at the ceiling all day, because it is the only place to escape, to turn off the ‘visual noise’, the only piece of empty sky left (Emily Rubin talk).  the child in a busy all-inclusive Canadian classroom who stares  out the window all day, her only face-free zone, self-regulating, or audio filtering her loud verbal peers, mutually regulating.  The Australian ASD adult Ph.D. who says ‘bright lights off!’ in a studio and wants questions in a script, to read and write replies on, in advance, not ‘live chat’.  When we recognize each child with autism as ‘uniquely human’  we will study that one child, family and social setting, and develop a way to teach that one child, respecting individual, intense anxiety. Since ‘ASD escape behavior is 90% functional’ (Emily Rubin talk), we will offer ‘break cards’, an open door, ‘emergency exit’, a ‘way out’ in full view.  Researcher Stephen Scherer`s team in the largest-ever autism genome study  ‘Toronto Autism Genome Study’ has found 85+ different ‘autism genomes’ so far (Yuen et al., 2015); how can we expect every ASD child to respond to any one method? Unique snowflakes, they melt under the unbearable heat of our far too intense world. If we fail to include new insights, we may not offer autism therapy that works, or, worse, offer one kind of therapy for too long. Rubin reported how stressed ASD children often experience a ‘cortisol spike’  of stress hormones between 1pm and 6pm, falling to ‘normal’ only by midnight. What happens at 2pm? Meltdowns. Later, how can an ASD child go to sleep, after a cortisol level as high as a car-crash?  One solution: pre-plan afternoons for low-stress, low ‘people time’ activities, outside the class, even out of doors at the school. In short, ‘Please be kind to my ASD mind’ (John Scott). The human brain is designed to remember stories on page or screen; data give us knowledge but stories give us insight and empathy. “Uniquely Human” holds data and stories. You may want to take this book to the coast for summer reading, and Lisa Genova’s fine novel “Love Anthony”. Parents love and want to accept their ASD child, but it takes a whole village to raise any child. ‘Uniquely Human’ has news for the village that may save an ASD child from unintended harm, to live out a rich, unique and different life. Please read it, enjoy it, and pass it on.   REFERENCES________________________________   1) Limbrick, P. (2012) Horizontal Teamwork in a vertical world: Exploring interagency collaboration and people empowerment.  Clifford: Interconnections.  2) Prizant, B., Wetherby, A., Rubin, E., Laurent, A., Rydell, P., (2006). The SCERTS Model – a comprehensive educational approach for children with autism spectrum disorders. Baltimore: Paul H. Brookes. 3) Prizant, B. (August 2015). Uniquely Human: a different way of  seeing autism. New York: Simon and Schuster.  4) Yuen, R.K.C., Thiruvahindrapuram, B., Merico, D., Walker, S., Tamminies, K., Hoang, N., Chrysler, C., Nalpathamkalam, T., Pellecchia, G., Liu, Y., Gazzellone, M.J., D'Abate, L., Deneault E., Howe, J.L., Liu, R.S.C., Thompson, A., Zarrei, M., Uddin, M., Marshall, C.R., Ring, R.H., Zwaigenbaum, L., Ray, P.N., Weksber, R., Carter, M.T., Fernandez, B.A., Roberts, W., Szatmari, P., Scherer, S.W. (2015) Whole-genome sequencing of quartet families with autism spectrum disorder. Nature Medicine, 21, 185-191.                  

Review: SCERTS, the prologue to Prizant’s “Uniquely Human”

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