Saturday, 25 January 2014

Triad of impairments in Duck.

The triad of impairments in Autism

As I said before, these are the three key areas in which a child is assessed for autism. To be diagnosed as autistic of any form a child needs to meet all three targets. These are;
Communication and language impairments
Social interaction
Flexibility of thought.

Combined they often include some sensory processing issues, SPD, which I will cover separately

Pathological Demand Avoidance is different to typical Autism, as is Aspergers so some of the triad are hard to see.

Lets start with Duck and Communication impairments.

Duck can communicate, almost too well. Her vocabulary is fantastic and she is able to understand and reply to a wide range of questions. However, speaking and understanding is not the be-all-and-end-all of Autism. In fact, the National Autistic Society describe communication abilities in PDA children as;

'Although people with PDA may have some language delays at an early age, there is often a striking and sudden degree of catch-up. Certain elements of communication are not as disordered as in autism or Asperger syndrome, with more fluent use of eye contact (other than when avoiding demands) and better conversational timing. Some language difficulties remain, such as taking things literally and misunderstanding sarcasm and teasing. As an extreme form of avoidance, some children become selectively mute in many situations, yet their parents know they can speak when they want to.'

There is much more to communication than being able to speak. Duck hits all of the other key features which form part of communication. These are;
Understanding jokes and sarcasm
Social use of language
Literal interpretation
Body language, facial expression and gesture.

Duck clearly struggles in all of these areas, this often causes issues as she can react badly to a joke or not realise she has upset or angered someone (unless they are crying or shouting)

These difficulties are obvious in Duck (In my opinion) and I have had other parents tell me she reacted to something badly, and was really 'rude' in the way she dealt with it. Duck will laugh at a joke often, but as I described before, if you ask further, she doesn't really understand the joke its self, just that the situation warranted a laugh...this is social mimicry. Again, common in PDA children.

Duck ticks that box.

Moving swiftly on to Social interaction.

NAS website says;

'People with PDA are often very sociable and can display degrees of empathy previously not thought to be consistent with autism. Sometimes it seems that they are able to understand other people at an intellectual level but not at an emotional one. However, despite their use of social niceties, their social interaction is very often flawed by their inability to see the bigger picture, their lack of boundaries and their desire to be in control of the situation. They often understand rules but dont feel they apply to themselves. As children, this can lead to playground peer group difficulties....When they are younger, children with PDA often engage in a level of pretend play that would be unexpected from children with autism or Asperger syndrome. People with PDA are very good at taking on the roles and styles of others.'

Oh yes! Welcome to the world of PDA. Duck loves to have attention and be in control. She despises school, I strongly believe this is because she cannot have control. As I described before, this control is anxiety driven. Duck cannot cope with loss of control. In the play ground, she has a group of friends, but her social side is very shallow. To give examples, Duck came home telling me she no longer had a best friend because she had played with someone else today. Duck is described by one friend as very bossy and when she doesn't get her own way, she gets stroppy. A teacher described her and much more into role play than 'normal' children of her age. She has written and acted shows, taking control of a large group of people who wanted to be involved. As I said before, she was happy to take a lead role in the church Nativity. Another friends mum described this 'When my daughter is with any other friends, they play all sorts of games, when Duck is here, they play with barbies and nothing else.' Totally in control and totally role play, because it hides the fact that Duck has poor social skills. She always takes dolls and teddies with her almost everywhere, because she cannot cope without them.

Duck ticks that box.

The final point of the triad is Flexibility of thought.

The main key points are;
Difficulty coping with change to routine

So I have mentioned how Duck likes change, yet the triad of impairments clearly state difficulty in coping with change to routine as a key point. Let me explain. PDA children like the novelty factor. So, for example, when school have a 'dress up' day or a 'class treat' day or any other event that's different, Duck always goes in much better. This is because the demands are reduces and it holds more excitement. However, coping with change to routine doesn't have to be just school routine. Duck cannot cope to the 'expected plan'. for example, if we have arranged to meet friends and they cant come, Duck cannot cope. Its and unexpected change.  If we are going out, even to the shops and we have to cancel at the last minute due to an unexpected event, Duck cannot cope. Whatever we have told Duck is going to happen, she expects to happen. I tend not to tell her she has a friend coming until I know they are on their way, because if they need to cancel, Duck cannot cope.  She can cope with change provided she has been warned. So, if we were due to go to the shops the following day and our plans needed to change, that could be explained and Duck would have time to absorb the new plan, so its manageable.

Empathy is a difficult area to cover. Duck tries, she really does to be empathetic. She can be empathetic, but its very shallow. If a friend fell and hurt themself, she would rush to help and look after them and appear really empathetic. But she just doesn't understand unless she is there and sees the accident. Her empathy will be a blank face staring at you trying to figure things out. When one of the gerbils died, Duck said 'Oh well, I hope the other one dies soon too' Regularly since, she has gone out and said 'Has it died yet?' (Its still going strong!) She didn't understand why brother was upset. She is shallow, its dead, its gone. Sorted.

Generalisation. Duck cant generalise. She has to be specific. 'In a minute' means in 60 seconds. 2pm means 2pm. Not 1.59 or 2.01pm. I often find myself saying 'It will be sometime around 2, not at 2 but sometime around then is that ok?' I get the usual 'Yes' in reply, then if its early, she is not happy and if it gets to 2pm the stress starts. 'You said 2', 'No, I said around 2, that could be 145-215'. 'Yes, but around 2 is 2 so its late'. We cant generalise. It doesn't help when friends are visiting and they are late, even by a few minutes. Duck cant get the 'general' idea. It has to be specific. School run in our house starts at 8.20am. Not before, and not after. Even if meltdowns make us late to school Duck then becomes more upset because she will be late and she is due in school 835-840. (She goes in early, before everybody to allow her time to settle)

So, the question raised is Does Duck meet the Triad of Impairments?
My reply is a clear Yes. However, due to the amazing abilities of PDA children, she is able to mask most of her difficulties which makes it harder for specialists to pick up on. The reason most PDA children are not correctly diagnosed.  The reason most PDA children are not given the support they so desperately need.  The reason we are fighting for better recognition and better diagnosis and understanding within the NHS.

Duck is autistic. She is just far too clever at hiding it.

I have an appointment through for her ADOS, autistic assessment. Its not long, 10th February, 3 weeks Monday. I just hope Duck isn't too clever at hiding it on that day.

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