Tag: ASD

Introduction

Autism, Asperger’s syndrome, and Pervasive Developmental Disorders (PDD) are most likely related neurological disorders that fall along the same spectrum. They involve disturbances in a number of areas, including an impairment in verbal and nonverbal communication skills, impairment in reciprocal social relationships, severe sensory integration problems, and a limited repertoire of activities and interests connected with repetitive or stereotyped movements (Frith, 2003). Autism is at the lower functioning end of the spectrum while Asperger’s syndrome is at the higher functioning end. PDD fits in somewhere in between and includes delayed language and a mix of symptoms and functioning levels.

Drama therapy can be one of the best interventions to help individuals who have autism spectrum disorders (ASD) learn social skills and come to understand the unwritten rules of social relationships that baffle them. In fact, drama was one of the very first techniques used in treatment. Hans Asperger the German doctor who first described the condition in 1944, created an educational program for the boys he was treating which involved speech therapy, drama, and physical education (Attwood, 1998). Unfortunately, Sister Viktorine, the director of the program, was killed as the ward on which she was working was destroyed in an allied bombing attack in World War II, so no record of exactly how she used drama survives (Attwood, 1998). At the very least, this early use of drama indicates an appreciation for the strengths it offers as an intervention.

Theoretical Reasons for the Use of Drama Therapy

The Mirror Neuron System Theory

For many years, the causes of ASD were a mystery. A recent theory suggests that ASD may be caused at least in part by impairment in the mirror neuron system (Gallese, Eagle, & Migone, 2005; Iacoboni & Dapretto, 2006; Oberman & Ramachandran, 2007; Ramachandran & Oberman, 2006.). Mirror neurons were discovered in the early 1990’s by a team of neuroscientists in Parma, Italy who were mapping individual neurons in the motor cortex of monkeys to see which neuron connected to which muscles/movements (Iacoboni, Molnar-Szakacs, Gallese, Buccino, Mazziotta, & Rizzolatti, 2005). The mirror neuron theory is important to look at in detail because the mirror neuron system is also theorized to be the origin of empathy, social understanding, and imitative learning (Goleman, 2006; Iacoboni, 2008), all abilities in which people on the autism spectrum are limited and all abilities which can be developed through drama therapy.

In the pre-motor cortex of the brain, where body movement is planned and initiated, there are “regular” motor neurons which fire only when an organism makes a purposeful movement, and there are mirror neurons which fire when the organism makes a purposeful movement and when it sees, hears, or in some way senses, the same action done by another organism (Gallese, Eagle, & Migone, 2005). (I say “organism” because mirror neurons have been found in mammals and other living creatures, not just human beings.)Essentially, this means that we “understand” the actions of others by simulating them in our own brains as if we were taking the action ourselves. For example, if you see a friend licking a strawberry ice cream cone on a hot summer day, you will understand the experience he is having on many different levels, because even though at that moment you do not have an ice cream cone in your hand and are not licking and tasting a cold, strawberry flavored treat, you have done a similar action in the past and the mirror neurons of your pre-motor cortex that are connected to your hand, wrist, lips, tongue, and mouth are all activated as you watch your friend in action.

In addition to helping us understand the actions of others, mirror neurons make it possible for us to understand what other people are feeling, in part, because emotions are expressed through actions: facial expressions, breathing, movement, body positions, etc. (Bloch, 1990; Ekman, 2003; Oberman, Winkielman, & Ramachandran, 2007). For instance, when a person smiles, mirror neurons are activated in the pre-motor cortex of whoever sees the smile, just as when a person cries, mirror neurons are activated in whoever sees or hears the crying (Goleman, 2006). However, mirror neurons have also been discovered in other areas of the brain, specifically in the cingulate and insular cortices, where emotions are processed (Ramachandran & Oberman, 2006). Experiments have shown that “certain neurons that typically fire in response to pain [in the anterior cingulate] also fired when the person saw someone else in pain” (Ramachandran & Oberman, 2006, p. 65).

Empathic connection is believed to be the result. We are able to understand what another person is feeling or thinking or doing – because our brain is mirroring virtually, what the other person’s brain (and body) is doing actually. In this way we are able to literally “put ourselves into the other person’s shoes” and see situations from the perspective of the other. Vittorio Gallese, one of the neuroscientists who discovered mirror neurons, calls this “a direct form of ‘experiential understanding’ of others” (Gallese, 2006, p. 1). He terms this modeling mechanism “embodied simulation” and believes it leads to “intentional attunement” or the ability to understand the motivations and intentions behind other peoples’ actions (Gallese, 2006). Gallese talks repeatedly about the “as if” experience that mirror neurons provide, in a manner reminiscent of the “as if” experience that master acting teacher Constantin Stanislavski spoke of as crucial for an actor to have in order to reproduce life-like and true emotions in the character he is portraying on stage (Stanislavski, 1961).

Another important ability that theoretically stems from mirror neurons is the ability to learn through imitation. This innate learning mechanism can be observed even in newborns who will automatically imitate the facial expressions of adults who engage their attention (Blakemore & Frith, 2005). At 12 months, typically-developing infants can predict the action goals of other people and imitate facial and hand gestures (Iacoboni & Depretto, 2006). Later our predisposition to imitate becomes crucial in our ability to learn to speak. Ramachandran and Oberman (2006) point out that language development in childhood requires the child to mirror and imitate the parents’ speech actions in order to transform the auditory signals of speech into words that can be spoken using lips, tongue, mouth, and breath. Social behaviors, sports, games, and physical skills are all learned by typically-developing children through imitation rather than through verbal description (Blakemore & Frith, 2005). In fact, dramatic play which typically-developing children automatically begin to engage in at about the age of 3 is a universal form of imitative learning (Bailey, 1993; Ginsburg & Opper, 1969).

Marco Iacoboni (2008) suggests that deficits in the mirror neuron system might be the cause of the inability to relate to and understand emotions of others in individuals who are diagnosed with ASD. He reports that as measured in fMRI (functional magnetic resonance imaging) brain scans, “children with autism had much lower activity in mirror neuron areas compared with typically developing children. Moreover, Mirella [the neuroscientist who ran the tests] found a clear correlation between activity in mirror neuron areas and severity of disease: the more severe the impairment, the lower the activity in mirror neuron areas” (p.176).

Ramachandran and Oberman (2006) of the Center for Brain and Cognition at the University of California, San Diego agree, noting that:

Mirror neurons appear to be performing precisely the same functions that seems to be disrupted in autism. If the mirror neuron system is indeed involved in the interpretation of complex intentions, then a breakdown of this neural circuitry could explain the most striking deficit in people with autism, the lack of social skills. The other cardinal signs of the disorder – absence of empathy, language deficits, poor imitation and so on – are also the kinds of thing you would expect to see if mirror neurons were dysfunctional. (p. 65).

Neuroscientists who subscribe to this theory do not believe that people with ASD have no mirror neurons; they believe that they either have less mirror neurons or the mirror neurons that they do have do not work correctly (Iacoboni & Dapretto, 2006; Ramachandran & Oberman, 2006).

If Mirror Neurons, Then Drama Therapy

Drama therapy actively engages mirror neurons because clients’ bodies are actively, physically engaged in the therapy process. As clients participate in and watch drama games and improvisations, they are often literally putting themselves “in another person’s shoes” by taking on the role of another character. If a client is acting out something that actually happened to him, his experiences are shared with the others in the group through the intentional attunement that occurs when his purposeful actions are observed by others. Through action, clients can generate new states of mind and experiment with new behaviors, reinforcing new brain connections, new social connections, and new understandings of themselves and others. A participant in The Spotlight Program, one of many dramatic arts programs springing up around the country for students with ASD, attests to this when he says, “I’ve gained friendships and learned new games, how to be more mature and how to interact with others” (North Shore ARC, 2008, p. 1). Another says, “I’ve learned to recognize myself in others” (North Shore ARC, 2008, p. 2).

If a dysfunction in the mirror neuron system is a cause or contributing factor to ASD, then drama therapy might be a perfect intervention precisely because it does use embodied, imitative learning, and allows for repeated rehearsal of skills in an enjoyable, playful way. One of the most important discoveries about the brain in the last 20 years is the plasticity of the brain: its ability to grow, change, and re-wire itself (Blakemore & Frith, 2005). The brain changes through use (or lack thereof); just as muscles change through exercise (or lack of exercise). This suggests that activities that encourage the use of mirror neurons which people with ASD possibly under-use would strengthen the mirror neurons they already possess and, perhaps, encourage the growth of new ones.

Temple Grandin (Grandin & Scardino, 1986; Grandin,1995), an expert in animal science and autism who is herself a highly functioning person with ASD, is a firm believer from her own experience that people who have ASD will not naturally develop social functioning and emotional relatedness, and, therefore, must be taught – the earlier the better. She credits her success in life to her mother’s patient and unrelenting training during her childhood and adolescence. She stresses in one her chapters of Unwritten Rules of Social Relationships, co-written with Sean Barron (2005), that “children with ASDs need live interaction in order for social skills to become ‘hard-wired’ in their brains. They learn by doing, through direct experience, much more than they learn by watching and listening” (p. 51).

The Theory of Low Connectivity between Brain Areas

Another theory focuses on the possibility of low connectivity or disconnections between areas within the perceptual, executive, and emotional centers of the brain (Baron-Cohen, 1997; Spice, 2004). These are areas that must work together to help us make social interconnections and understand each other in subtle, empathetic ways. Neuroscientists who espouse this theory believe that many of the behaviors seen in ASD may relate to poor connections between areas of the brain like the superior temporal sulcus, the orbito-frontal cortex and the amygdala where important information is processed and integrated with information flowing in from other areas of the brain (Baron-Cohen, 1997; Spice, 2004). The more serious/low functioning the person’s ASD, the more blocked or dysfunctional the connections between two or more areas (Spice, 2004).

Temple Grandin (Grandin & Baron, 2005) reports that her brain scan “shows that some emotional circuits between the frontal cortex and the amygdala just aren’t hooked up” (p. 40).She believes that “autism involves an atypical development of the midbrain and basal ganglia reward systems” (p. 41) which contributes to the disconnection in interpersonal relationships as well as repetitive thoughts and movements that are symptoms of many persons with ASD.

If Low Connectivity, Then Drama Therapy

If the issue is low connectivity between crucial brain areas, why use drama therapy as opposed to a different intervention? Whether the issue is mirror neurons or low connectivity, drama therapy works because it provides participants with numerous opportunities to rehearse and replay skills until the skill is learned and integrated into behavior. Through drama, this rehearsal is done in an enjoyable way and clients are positively engaged in the repetition as the connections and/or mirror neurons are strengthened.

Just because a disconnection exists between two or more areas in the brain does not mean a connection cannot be healed or another created somewhere else: that is the beauty of plasticity. Our brains grow from the time we are forming in the womb until our early 20’s with various periods of growth spurts and pruning (or cutting back) of the number of neurons and the kinds of neuron connections. Our brain continues to grow, albeit at a slower rate, throughout our adulthood, and often will grow and change at any age in response to an injury. All of these changes happen primarily in response to how our brain is used (Blakemore & Frith, 2005). A new skill becomes mastered and remembered only after long-lasting, sustained practice in small doses over time, usually past the point of overlearning (Willingham, 2004). “Practice, therefore, requires concentration and requires feedback about whether or not progress is being made” (Willingham, 2004, p.5).

Memories are formed when neurons in the brain form connections or networks that are used often enough that they become “wired together” or create a pattern which can easily be reactivated. The strength of a memory and the ease with which it can be accessed depends on how many times the original stimulus has been experienced (Levitin, 2006). More practice means stronger connections between the neurons in the brain and a stronger representation of that specific memory, be it of a fact, skill, behavioral response, understanding, or some other kind of learning. If people with ASD have difficulty creating connections between different brain areas or between neurons that need to form a pattern in order to be able to understand something (say, understanding the meaning behind tone of voice), then they will have to practice even harder and longer for the connections to form or for different connections to be constructed.

Neuroscientists looking at the arts and the brain have discovered that the arts are motivating to children because they create conditions in which attention can be sustained over longer periods of time compared with children involved in activities not found to be motivating (Posner, Rothbart, Sheese, & Kieras in Ashbury & Rich, 2008). With sustained attention, knowledge and skills can be practiced, learned, and remembered for future use. No matter how “good” a teaching method might potentially be, if students are bored by it, they will not pay attention long enough to learn from it. An additional benefit of the arts, particularly drama, is that participants receive feedback in the process of enacting a scene from the other actors and from the audience, as well as afterwards when the group discusses the scene and/or when they replay the scene with corrections (Jensen & Dabney, 2000; Posner et al, 2008).

Learning is more apt to “take” if it is associated with an emotional component, preferably a pleasant one, which arouses the attention (Jensen & Dabney, 2000; Levitin, 2006). Learning is shut down by distress because cortisol, a hormone created when we experience anxiety or trauma, interferes with memory formation in the hippocampus, a part of the brain that is primarily involved in memory creation (Zull, 2002). Drama is enjoyed by many clients on the ASD spectrum, so they engage in dramatic activities with enthusiasm.

Practical Applications of Drama Therapy

Adapting Drama Techniques for Clients who have ASD

Because of the socio-emotional and sensory integration issues involved with ASD, the drama therapist needs to be aware of how to make appropriate adaptations and accommodations for her clients. These adaptations are necessary no matter which drama therapy techniques or methods are used. Use of concrete activities and visual and kinesthetic media engage attention while a mono-channel approach to information will lessen sensory overload. Routine and ritual ensure predictability and the feeling of safety for participants.

The most important concept to keep in mind is that clients with ASD need to use concrete, rather than abstract activities (Bailey, 1993). Concrete games use actual objects, rather than imaginary ones, so there is something real to focus on and manipulate. This means working memory does not have to hold onto an invisible image while also thinking of something to do with it; the visual object can be focused on and related to directly. An example of the difference between a concrete and an abstract form of the same game can be found in the appendix at the end of this chapter.

Related to this, people with ASD tend to use concrete symbols rather than abstract ones for meaning making (Grandin & Scardino, 1986; Grandin, 1995). A visual image or another type of sensory image can come to represent a concept if it is associated with a related experience. Temple Grandin (1995) reports that she can understand the concept of the “give-and-take” of personal relationships only when she imagines the visual symbol of doors and windows. An example of how a concrete symbol might be used in a dramatic enactment could be using pillows to represent stresses that are building up in a character who is not communicating his feelings clearly to others in a scene. Each time the character is not clear or honest or each time he avoids expressing his feelings with words, a pillow could be added to his load until he cannot see the other actors or move easily around the space.Whenever he expresses himself appropriately and the situation begins to be worked out because communication is clear, a pillow could be taken off the pile, making his load lighter and easier to handle.

Temple Grandin (1995) believes that most people with ASD are visual rather than verbal thinkers. She says she thinks first in pictures and then must translate the pictures into words. This makes her manner of processing the world very different from those of us who transfer our thoughts into language as our major symbolic mode. Lev Vygotsky, the Russian developmental psychologist and educator, believed that language and thought (which is internalized language) develop originally from social communication with others about objects and experiences into egocentric speech (when a child talks to herself out loud) and finally into inner speech, the soundless thought processes inside our heads (as cited in Dixon-Krauss,1996). At some point in this transition, probably between the ages of five and ten, the brain switches from relying primarily on visual processing to verbal processing. In 1988, Graham Hitch did a study on visual working memory in typically-developing children and discovered that five-year-olds used mental images more often to remember information than ten-year olds, who relied primarily on words (as cited in Robertson, 2002). Perhaps the difficulty with speech that many people with ASD experience is caused in part by their inability to move from that early social language to egocentric speech and then to internal verbal thought. They may stay with the original visual and visceral thinking we all naturally used as infants.

In any case, people with ASD seem to be “right-brain thinkers.” That is, they tend to score high in fluid intelligence and in nonverbal thinking skills (visual, spatial, and pattern-making) (Grandin, 1995). Often, they are visual and kinesthetic learners. Some are adept at creating with their hands, but others have motor planning difficulties (Grandin & Scariano, 1986). Pantomime and movement activities, therefore, might be a good starting point for a new group because they will access communication strengths and, after group members feel accepted and comfortable, new skills using verbal techniques can be built.

Sherry Haar (2005, personal communication), a professor of apparel and textiles at Kansas State University, has created a line of therapeutic costumes to promote sensory integration, motor development, and cognitive skills. The thematic designs of the costumes (bug and butterfly) allow the child to use his imagination while practicing developmental skills. The costumes include a variety of textures, resistance bands, and weights important for the tactile and proprioceptive senses. Fine motor skills are encouraged through the manipulation of closures (i.e., zippers, buttons, snaps, and lacing) and objects (i.e., antennae and eyes on the helmet). Shapes in a variety of colors and sizes aid in cognitive development. The cape part of the costume encourages the child to “fly,” thus promoting balance and other gross motor skills.

Most drama therapists have costumes, scarves, props, parachutes, and other manipulative objects that they incorporate into dramatic scenes. These can serve the same purpose as Haar’s therapeutic costumes by engaging clients visually and kinesthetically in their characters and by serving as set pieces or visual/kinesthetic symbols to enhance meaning. By the same token, puppets and sandtray figures can be used to play out the drama visually at a distance from the clients, making them feel more in control of the drama.

Puppets provide safety, distance, and a sense of personal control that can be missing in dramatic activities which are fully embodied. I had an actor with ASD in one of my performing companies who actually learned to talk as a child using a puppet. Other than echolalic repetitions of other words people said to him, he did not speak on his own and never initiated communication with others until one day when he was ten years old. His mother had taken him shopping in the mall and they happened to pass a kiosk in which there were marionettes on sale. He walked right up to one of them and started a full-fledged conversation. His mother realized immediately that something out of the ordinary was happening and bought him the puppet. When they took it home, he continued talking to it so she bought him more! He conversed with them as well. Through several years of talking with these inanimate theatrical beings, who did not push him to communicate, but just patiently listened to him, he learned how to initiate speech and then began to talk to people. When I met him, he was a senior in high school. He was so fluent and comfortable with speech that I would never have suspected his late start with language, if his mother had not told me their story.

While typically-developing people can be intimidating with their insistence that children with ASD comply with their mysterious customs of communication and relationships in the neurotypical world, puppets are not. Most of them are on a smaller scale than a living person so interacting with your own or another’s puppet is not threatening. A puppet on the hand of a client is clearly visible and under his control. When it comes to performing, being hidden behind a puppet stage can take the pressure off performers, as they know the audience can only see the puppet, not the puppeteer.

People who have ASD tend to be over-sensitive to sights, sounds, smells, and touch. Loud or sudden noises can be painful to their ears and certain smells are perceived as very offensive (Grandin, 1995; Grandin & Scariano,1986). When in a state of sensory overload, they may need what Donna Williams calls the “mono-channel approach” – to block out all but one type of sensory input in order to pay attention (Grandin,1995). While many typically developing people do better with multisensory teaching, this may be too confusing for someone with ASD. Simplify your presentation. Use one mode of delivery at a time: speak or demonstrate or show a diagram; do not do all three at the same time.

Because individuals with ASD are easily over-stimulated and prefer routine, the variety of activities and the amount of sensory stimulation in a drama therapy group can be overwhelming. Check out how much sensory stimulation is in your therapy space. If there are lots of toys, props, or odds and ends lying around, clean them up or cover them up. Simplify the visual design of the room so it is not distracting. Limit the distracting sounds inside and outside the room, if you can. Avoid drama games that incorporate sudden, loud noises, or busy physical gestures which would over-stimulate.

As much as possible, follow a similar routine in your lesson plan from week to week. Begin with an opening ritual that stays the same: raising the drama curtain or bringing down the curtain of silence or singing a song of welcome. If the group has a favorite drama game, it could be played at the same point in the session each week. Have clients sit in the same location in the circle. Keep the arrangement of the room the same. Always place the audience and performance areas in the same place. In addition to ending with a closing ritual, the last part of a session might be used to review what was accomplished and to plan for the next one so group members are prepared for what will be happening when they meet again.

Clients with ASD need to feel in control of the amount and type of stimulation they are getting. Provide a quiet, safe place in the room where there are few visual or auditory distractions where an over-stimulated individual can go to get away from the group, if necessary. Warmth and deep pressure tend to lessen arousal and create relaxation. You could provide a mat or heavy quilt for the client to wrap himself up in or some big pillows or bean bag chairs he could burrow under. If he needs to spin, allow him to spin in an area where he will not bump into anything and where the floor is not slippery.

Understanding and exploring body boundaries can be another area that needs work for clients. Often people with ASD are not sure where their body ends and the chair they are sitting in begins (Grandin, 1995). Movement exercises can help work through this confusion. Movement, in fact, can be another calming/focusing technique. Scarves, coopera-bands (also called buddy bands), parachutes, and body sox can be useful tools for exploring movement and body boundaries in creative ways. They can be used on their own or incorporated into role plays.

The only way to learn how to use clear, expressive communication is to have a clear model and to be encouraged to practice. The drama therapist must take the lead and be the role model for expressiveness. Play drama games that will enhance vocal, facial, and body expressiveness. Practice gestures and sounds that will communicate emotions and ideas. Provide a place to learn give and take between the clients.

Many times, people with ASD feel those of us who are “neurotypical” are very strange beings. How we think and relate to each other does not make any sense to them. Temple Grandin (2002) says growing up she viewed many cultural customs, behaviors, and fashions as ISPs – Interesting Sociological Phenomenons. This theme is echoed by Chris Banner, a K-State music faculty member who has Asperger’s syndrome. He says,

The ordinary person probably has no real idea of what it is like to be autistic and to have to live by rules of social interaction that they have been explicitly taught because they cannot figure it out and understand it by themselves.  The ordinary person does not understand how it is to live with people trying to force them to be something they inherently are not and then punishing them for being different.  The ordinary person does not know what it is like to live with no theory of mind, as the term is, and to live in constant fear of doing some simple little thing wrong or being different in some way, and then to live in constant fear of having to suffer terribly for it.  It is living with the constant fear of being hurt for no apparent reason that is so hard to take. (Personal communication, 2009).

Role play can be the perfect way for people with ASD to come to a better understanding of the neurotypical world’s ISPs. Practice putting themselves in another person’s or character’s shoes can become the first steps toward understanding how the rest of the world feels, thinks, and relates, a way to begin developing and testing out a theory of mind. Grady Bolding (2007), a K-State drama major who has ASD, says this about his experience with theatre, “Only recently did I figure that the world of theater helped bring me out of my shell, since I got free crash courses in interpersonal communications with every script. Today, I speak like anybody else, but I still come across a roadblock here or there, like trying to find the difference between ‘joking around’ and ‘being rude’ – that’s a doosey.” (Bolding, 2007, p. 3).

By the same token, the drama therapist needs to better understand the ASD experience in order to maintain our patience and respect toward them when they seem inflexible and rigid. Since those of us who are typically-developing have normal mirror neuron systems, we have the ability to put ourselves in their shoes so that we can understand how confusing and threatening the world is to them. Two fiction books which beautifully and richly capture the thought processes and emotions of the ASD world are Mark Haddon’s The Curious Incident of the Dog in the Night-time and Elizabeth Moon’s The Speed of Dark. I highly recommend both.

References

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Bolding, G. (2007, November 9) Student overcomes autism with acting. The Kansas State Collegian, p. 3.

Dixon-Krauss, L. (1996). Vygotsky in the classroom: Mediated literacy instruction and assessment. White Plains, New York: Longman Publishers.

Ekman, P. (2003). Emotions revealed. New York: Holt.

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Iacoboni, M., Molnar-Szakacs, I., Gallese, V., Buccino, G. Mazziotta, J.C., & Rizzolatti, G. (2005). Grasping the intentions of others with one’s own mirror neuron system. PLoS Biology, 3 (3) 79e downloaded January 23, 2006 from www.plosbiology.org.

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Moon, E. (2002). The speed of dark. New York: Ballantine Books.

North Shore ARC brochure: The Spotlight Program: Innovative drama-based social pragmatics for students ages 6-22 downloaded January 11, 2009 from http://spotlightprogram.com/Documents/Spotlight%20Brochure.pdf

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Ramachandran, V.S. & Oberman, L.M. (2006). Broken mirrors: A theory of autism. Scientific American, November, 63-69.

Rizzolatti, G. & Sinigaglia, C. (2006). Mirrors in the brain: How our minds share actions and emotions. London: Oxford University Press.

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Spice, B. (2004, November 30). Autism findings focus on how areas of the brain communicate. Pittsburgh Post-Gazette, p. A14.

Stanislavski, C. (1961). Creating a role. New York: Theatre Arts Books.

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Zull, J.E. (2002). The art of changing the brain: Enriching the practice of teaching by exploring the biology of learning. Sterling, VA: Stylus Publishing.