Beth was diagnosed with autism at nearly 3 years old. ADHD was not mentioned anywhere on her evaluation report. Which made sense at the time, because her diagnosis was based on the DSM-IV manual, which did not allow for an additional diagnosis of ADHD if a diagnosis of autism was given. With the release of the DSM-V manual and a change to the ADHD criteria, a diagnosis of autism is no longer an exclusion for an additional ADHD diagnosis (http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf). To read more about this, see this great post by Autsim and Oughtisms – http://autismandoughtisms.wordpress.com/2012/10/29/change-in-the-relationship-between-adhd-and-autism-in-the-dsm-5/).
I recently had an “aha” moment. I think Beth has ADHD, and in many ways ADHD has a bigger impact than autism does when we homeschool. In this post I want to describe how I came to this ADHD realization through the example of Beth’s struggle with puzzles.
Remember my puzzle post (https://fumblingthruautism.wordpress.com/2013/01/21/from-the-ipad-to-the-real-world-puzzles/)? Converting iPad puzzles to real-world versions was a huge step, because Beth stopped hating puzzles and would do a puzzle with me without a complete meltdown.
The following is the good news about puzzles:
- Beth’s filtering of sights and noises in the home environment is much better. For example, she no longer stares at the light seeping through the mini blinds or fixates on motors and sounds around the house (refrigerator, freezer, and heater motors in the house, planes flying over the house, lawn mowers outside, etc.).
- I let Beth stand for a long time to do puzzles, until one day she decided on her own to sit. I put a weighted vest on her recently, and it seems to help her sit still. Now she can sit and do several puzzles.
- Beth’s fine motor skills have improved, so her puzzle piece manipulation is very good.
- Beth can follow my verbal instructions if she is having trouble (for example, if I say “turn the piece more” or “try another piece” she understands and takes the direction).
- I verbally guide Beth based on color when she gets stuck, so puzzles with more color variation work best.
- Taking a picture of a completed puzzle with the iPad and using the image for reference is becoming helpful to Beth.
- If Beth knows the picture very well and really likes it, she does the puzzle more independently.
The frustrating news is she still can’t do puzzles independently. Even simple 6-piece puzzles. We have been doing a couple puzzles each day (with lots of oral rewards, praise, and also in a Floortime cooperative style), but progress is slow.
“I Can’t Do It”
Last week we were working on a puzzle and Beth said in a matter of fact way, “I can’t do it.” Beth had used that statement one other time while doing fine motor work at an Occupational Therapy (OT) session a couple weeks ago. I honestly thought I heard her wrong at the OT session, but this time it was crystal clear. First of all, that type of verbal statement is complex for her. It surprised me that she used the pronoun correctly, a contraction, and made a complete sentence. No one ever said anything like to her, so it is truly remarkable. But it is also heartbreaking. Her confidence is low and she is well aware that I want her to do a puzzle, but she is not able to do it. I told her I know it is hard, but I she can do it, and I can help her through it. But inside I knew we had to make a change in our approach yet again. We were missing a piece to the puzzle problem.
Just Slow Down
What happens if I let Beth do a puzzle without any guidance? Well, she grabs one piece in one hand, one in the other, starts shoving pieces in the puzzle board in a frantic way. She doesn’t check for corners or edges, she doesn’t try find the next piece to build off of a piece that is already in the puzzle, she won’t reference the picture, and on and on. The underlying problem is that she is working without thinking. It is not that she doesn’t understand how to do it, she can do quite well with some relatively minor guidance. She just can’t slow down. And this is a problem that I keep running into with her. Here are a few more examples:
- I am teaching her to use Proloquo2Go on the iPad, a “talker” where she presses the buttons as a means of communication. Our biggest hurdle is that she impulsively presses the buttons without taking the time to examine the options, much as I described in this iPad app post long ago (https://fumblingthruautism.wordpress.com/2012/12/20/preschool-with-the-ipad-listen-think-poke/).
- While cutting along a line, she rushes as fast as possible. If I introduce a slight curve at the end of the line she blasts right by it and keeps cutting.
- The girl can’t sit still. She just can’t. Is that autism? Or is it ADHD?
Who Cares About Labels Anyway?
I know, we could argue about the traits of autism, the parts of the brain affected, executive function, and how that can explain the ADHD traits and blah, blah blah. I can see the logic in those arguments. So why should I care if she has ADHD or just autism?
I care because all this time I was thinking it was her autism that hindered her learning. I was thinking maybe she didn’t understand what I was trying to teach her or why she should care, or she misunderstood my words due to language delays, or she had fine motor barriers, or she had a sensory issue that interfered with her ability to concentrate and sit still. Yes, she had all those problems, but with homeschooling we have knocked out the sensory issues and now her fine motor, receptive language, and ability to follow directions has greatly improved. In our home, she can sit long enough to do a task now, the joint attention is manageable, and stimming is at a minimum. If I run down the list of ADHD traits, those are the characteristics that are our biggest hurdle. And if I think of the problem that way, my focus is different for homeschooling. Rewards, praise, and guidance is centered on trying to slow things down due to her impulsive nature. Which is much different giving rewards, praise, and guidance just to get her to complete the task. So, I am going to try this new way of thinking, work on helping Beth manage her impulsive tendencies, and see where it leads us.