Patty-Cake

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-6z, 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 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.

1.  Attention

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.

Hand Cut-Outs on Wall

Side by Side Patty-Cake: Hand Cut-Outs on 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.

Mirror (for Beth) and Hand Cut-Outs on Wall

Side By Side Patty Cake: Mirror (for Beth) and        Hand Cut-Outs on Wall (for Me)

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. 

2.  http://medical-dictionary.thefreedictionary.com/motor+planning

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!”)

4. http://en.wikipedia.org/wiki/Applied_behavior_analysis

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.

6. http://www.icdl.com/dirFloortime/overview/index.shtml

7. The Maxi chant was provided by Little Hands (http://www.littlehands.com/).  The song was used by agreement in my daughter’s music class (http://www.milestonesinmusic.com/).

Applying Floortime to Technology: How My Child with Autism Learned to Use the iPad

In this post, I will share how our daughter Beth learned to work the iPad (i.e. learned to poke and drag, the key to using all apps).  I will narrate our process during videos of my daughter demonstrating the apps, and then generalize the lessons I learned at the end of this post. Since we are using Floortime (1) for play therapy, I took a play-based child-centered approach to helping Beth use the iPad.  I realize that all kids are different and this approach may not work for all children, but I am hoping that by describing the process we used to help Beth succeed, our experiences will help another family.

Fumbling with the iPad

We got the iPad almost 2 years ago, when my daughter Beth was about 3 years old. My husband and I downloaded several fun apps that we thought would motivate Beth. But because of Beth’s fine motor, motor planning, and communication delays, she became easily frustrated.  I tried hand over hand (using my hand to guide hers) to help her progress on the iPad, but she resisted this method of teaching.  She managed to poke at a few things within apps, but helping Beth progress on the iPad fell to the bottom of a long priority list and we let it go for awhile.

When Beth was about 4.5 years old, I decided to put more time into teaching her how to use the iPad, because I hoped the device could help her with her fine motor development and, eventually, preschool learning.  To teach Beth, I primarily used a Floortime approach (following her lead and interests, sitting beside her and demonstrating the apps with my own hand, highlighting items on the iPad with simple and excited language, using no additional rewards other than the app itself). With a lot of patience, careful thought, and trial and error with many apps, Beth has made astounding progress over the last 3 months.

But Beth’s road to progress started with a lot of poking, so that is where I will begin…

Beginning Poking

We had tried to get Beth to use her pointer finger for years (popping soap bubbles, putting holes in play-doh, popping cookies dough out of cutters, pointing to things she likes, etc), so it was hard to imagine her working the iPad touch screen with her finger.  But for Beth, using her pointer finger on the iPad was easier than using it in the real world, because her movements were confined to a two-dimensional screen. In fact, beyond finding motivating apps, I did not have to help Beth with this step.

We started with a simple free Balloon Pops (2) app and she quickly got the hang of it:

A bubble pop app (Beautiful Bubbles, 3) is also available from the same seller.  There are many other similar apps available if these do not work for your child.  Try these key words in iTunes and browse under the entertainment category: pop, bubble, balloon.

Advanced Poking

Next we used a few apps to help Beth refine her targeting (i.e. the targets she had to poke were more spaced out).  Refined targeting required more motivation, so I looked for apps that emphasized her natural love of real-looking bubbles (Bugs and Bubbles, 4) and her favorite song (Itsy Bitsy Spider, 5).  To encourage Beth to expand her exploration of the Itsy Bitsy Spider app, I sat beside her and poked non-preferred items and excitedly labeled the items and their actions.

To find apps that work for your child, try entering keywords of your child’s favorite toys, songs, or objects into iTunes, and, if necessary, limit by the entertainment or education categories.  Find apps (or parts of apps) that are controlled by poking only.  The best targeting apps have objects that are significantly separated and/or moving, and require poking over entire iPad screen.

From Poking to Dragging

Controlled dragging of objects with her index finger was a big challenge for Beth.  There was a single vertical dragging item on the Itsy Bitsy Spider (5) app mentioned above, so we started there.  Then we used the app called Wheels on the Bus (6), which is made by the same company as Itsy Bitsy Spider, and has both horizontal and vertical dragging.  Wheels on the Bus was a perfect next step for Beth, because she loves the song and the app used the same singer and some of the same graphics as Itsy Bitsy Spider.  To encourage her to try dragging, I sat beside her and dragged my finger across non-preferred items and excitedly labeled the items and their actions.

If your child has trouble learning to drag, I suggest finding apps (or parts of apps) that are very motivating to your child and have a lot of poking and very minimal dragging.  After mastering the minimal dragging apps, slowly increase to apps with more dragging.  This may take a lot of key word searches and some trial and error (i.e. purchasing several apps that don’t work out), but it is worth it.

Advanced Dragging

Next I had to find an app with lots of dragging.  Because Beth loves letters, I looked for a spelling app, and I found one that had spinning items as a reward (First Words, 7).  I think I demonstrated the app 1 time and she immediately started using it.

There is a free version of First Words (7) if you would like to try it out. If your child is good with sorting, you can try the sorting section of Bugs and Bubbles (4) or the Candy Count (8) sorting app.  Many preschool apps contain a sorting section, drag and drop puzzles, and drag to match sections.  Again it may take some creative keyword searching,  browsing in iTunes, and purchasing some apps that do not work out, but it is well worth it.

General Lessons Learned

  • I use my child’s interest (favorite toys, objects, songs, etc.) when selecting apps.
  • I find apps that have the right amount of challenge for my child.  If she is having trouble, I try to break the goal into smaller parts (i.e. find easier apps, use easy parts of preschool apps, or look for easy options within apps).
  • If I the app itself is not very motivating (i.e. spelling), I find apps with rewards my child likes (spinning, firework visuals, applause, etc.).
  • If I see my child stimming (hand flapping, jumping up and down, etc.) while using an app, I take it as a good sign that I have found the right app!  It means that she is excited.
  • If my child becomes fixated on a part of an app, I try to slowly expand her use of new parts by sitting beside her, demonstrating the new parts on the iPad with my own hand, and highlighting the new parts with simple expressive language she understands.
  • I try free apps first, but I do not hesitate to spend money to find the most motivating apps for my child.
  • It pays to take time to browse iTunes to find the most motivating apps for my child.
  • I use creative keyword searching in iTunes to find apps, then filter by category (entertainment, education, etc) if the hits are too large.
  1. http://www.icdl.com/dirFloortime/overview/index.shtml
  2. Joe Scrivens (2012). Balloon Pops (Version 1.1) [iPad application software], https://itunes.apple.com/us/app/balloon-pops/id436692552?mt=8
  3. Joe Scrivens (2011).  Beautiful Bubbles (Version 1.0)  [iPad application software], https://itunes.apple.com/us/app/beautiful-bubbles/id447038145?mt=8
  4. Little Bit Studio, LLC. (2012). Bugs and Bubbles (Version 1.1)  [iPad application software], https://itunes.apple.com/us/app/bugs-and-bubbles/id500195730?mt=8
  5. Duck, Duck, Moose, Inc. (2012).  Itsy Bitsy Spider (Version 1.1) [iPad application software], https://itunes.apple.com/us/app/itsy-bitsy-spider-by-duck/id331863487?mt=8
  6. Duck, Duck, Moose, Inc. (2012).  Wheels on the Bus (Version 1.1) [iPad application software], https://itunes.apple.com/us/app/wheels-on-the-bus/id303076295?mt=8
  7. Clozure Associates (2012). First Words Sampler (Version 4.4) [iPad application software] https://itunes.apple.com/us/app/first-words-sampler/id312571156?mt=8
  8. Camigo Media LLC (2012). Candy Count (Version 1.3) [iPad application software], https://itunes.apple.com/us/app/candy-count-learn-colors-numbers/id454950461?mt=8