Presentation on theme: ""SOLVING THE PUZZLE OF AUTISM: PRACTICAL STRATEGIES FOR SUCCESS""— Presentation transcript:
1 "SOLVING THE PUZZLE OF AUTISM: PRACTICAL STRATEGIES FOR SUCCESS" Asperger Syndrome 101"SOLVING THE PUZZLE OF AUTISM: PRACTICAL STRATEGIES FOR SUCCESS"June 2012San Angelo, Texas
2 DSM-IV Classification Pervasive Developmental Disorders AutismPDD-NOS(not otherwisespecified)Asperger’sSyndromeRett’sSyndromeChildhoodDisintegrativeDisorderThe DSM-IV or the Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and in the United States is the primary criteria used to classify and diagnose mental disorders. Asperger Syndrome is considered part of the classification under Pervasive Developmental Disorders and includes an array of related disorders including Autism, Asperger’s Syndrome, PDD-NOS (Pervasive Developmental Disorders Not Otherwise Specified), Rett’s Syndrome, and Childhood Disintegrative Disorder.In reading and hearing about Autism, you hear terms like High Functioning Autism or HFA in addition to the official categories in the DSM-IV TR, however there is little clear distinction between Autism, PDD-NOS and Asperger’s Syndrome except as a continuum of symptoms often viewed as ranging from more pervasive and severe with Autism to milder and less profound with Asperger’s Syndrome.There is a wide range in severity of symptoms from profound disability (Autism) to milder forms (Asperger’s Syndrome)
3 History of Asperger Syndrome Neurobiological disorder affecting the systems of both brain and bodyFirst described in 1944 by Hans AspergerOfficially recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in 1994Asperger Syndrome or (Asperger's Syndrome) is a neurobiological disorder effecting the systems of both brain and body. The term neurobiological was coined to describe the effects that autism has on the neurological systems as well as the physical systems of people.Named for the Viennese physician, Hans Asperger, who first described the specific pattern of behaviors unique to this disorder in Although Hans Asperger’s paper was published in 1944 it wasn’t until 1994 that Asperger Syndrome was added to the Diagnostic and Statistical Manual of Mental Disorders.
4 Prevalence of ASD 1 in 88* children in the U.S. Male to Female ratio 4:1More prevalent in pediatric population than:CancerDiabetesDown SyndromePrevalence rates of Autism Spectrum Disorders, to include Asperger Syndrome, have increased dramatically over the last 10 years but whether the current rates of identification actually reflect an increase in the disorder or improved diagnostics is widely debated.* Centers for Disease Control and Prevention (CDC); 2012
5 Cause of Asperger Syndrome? Genetic influences (dozens of genes linked to ASD)Possible Environmental FactorsVaccines reactions (Thimerosal?)Biological Factorsabnormal tissue in gutfood allergiesinflamed tissue in the brainDo we want to address this – OR – just omit….?? Lots of controversy – especially in the Austin area..Autism does NOT result from:Poor parentingDifferences in culture or language
6 Asperger’s Syndrome: DSM-IV Diagnostic Criteria (2000) A. Qualitative impairment in social interaction.B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities.C. The disturbance causes clinically significant impairment in social, occupational or other important areas of functioning.D. There is no clinically significant delay in language (e.g., single words by age 2 years, communicative phrases used by age 3 years).E. There is no clinically significant delay in cognitive development, self help skills, adaptive behavior (other than social), and curiosity about the environment in childhood.F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.
7 DSM-IV Criteria Briefly summarized: Impairment in social interaction Restricted, repetitive and stereotyped patterns of behavior, interests and activitiesClinical impairment in social, occupational, or other important areas of functioningNo significant language delayNo significant cognitive delayThe DSM-IV TR does separate the criteria for Asperger’s Syndrome with specific requirements including an impairment in social interaction, restricted patterns of interest and activities, significant (or clinical) impairment in social, occupational or other areas of functioning and eliminates significant delays in language and cognitive ability.
8 Disagreement with DSM-IV Some professionals in the field, disagree with current DSM-IV criteria for Asperger SyndromeIdentical social and repetitive behavior criteria as AutismIndication of no communication differences in Asperger SyndromeAgree that Asperger Syndrome is a “triad” of symptomsSocial differences considered to be the defining characteristicCommunication DifferencesSocial DifferencesRepetitive BehaviorsMany experts in the field believe that the DSM-IV criteria for Asperger Syndrome is not accurate in that it describes the social and repetitive behaviors for Autism and Asperger Syndrome identically. The manual also indicates that significant communication differences are absent in Asperger Syndrome. Professionals do agree that Asperger Syndrome is defined by a triad of symptoms including repetitive behaviors, social and communication differences. Professionals also agree that social differences are considered to be the defining characteristic of Asperger Syndrome.
9 Features of Asperger Syndrome Challenges withReciprocal Social Interaction
10 Reciprocal Social Interaction Lack of skills to establish friendshipsDifficulty initiating or maintaining conversationsDifficulty joining in an activityIs naïve and easily taken advantage of or bulliedDifficulty discerning appropriateness of topicPersonal space violationsMinimal, intense or unnatural eye-contactInappropriate affective expression or responseLack of appropriate body languageInability to read body language and facial expressionsLacks tact or appears rudePassivity / AggressivenessLack of awareness or disinterest in popular fads and trendsDifficulty in perspective taking (theory of mind deficits)There is a misunderstanding that people with Asperger Syndrome do not care about social relationships and do not want friends. The fact is people with Asperger Syndrome want to make friends and establish relationships just as much a people without Asperger Syndrome, but simply lack the skills and knowledge necessary to connect with others and build relationships. Persons with Asperger Syndrome have difficulty interpreting and understanding the unwritten social code or as Brenda Smith Myles has coined it the “Hidden Curriculum” that sets the expectations for our behaviors and social interactions in given environnments and situations. Their behaviors are often misinterpreted as rude or tactless – particularly when they are clearly bright and talented in other areas – as it appears their social differences are by choice not lack of skill.
11 Features of Asperger Syndrome Challenges withUse of LanguageIt is important to note that the majority of language problems experienced by persons with Asperger Syndrome are pragmatic in nature; meaning the use of language to interact socially. You may recall that one of the defining criteria of Asperger Syndrome is no significant delay in language; however acquisition and use of words to impart information is not the same as using language to share information in the give and take pattern of conversation.
12 Use of Language (Pragmatics) Repeats certain words or sounds repeatedly, “well, actually”Interprets words or conversations literallyDifficulty with the rules of conversationDoesn’t initiate or respond to social greetingsDifficulty using gestures and facial expressions appropriate to the situationTalks incessantly or minimal talking (selectively mute)Advanced vocabularyMakes seemingly irrelevant commentsDifficulty talking about others’ interestsSpeaks in an overly formal way; often sounds like a “little professor”Unnatural rhythm or rate of speech (sing song voice or unusual tone)Reduced ability to communicate and comprehend verbal language when frustrated or anxiousExpressive skills may mask significant receptive issues – especially socially mediated informationThe limited ability of persons with Asperger Syndrome to interpret the non-verbal language and social language used by typically developing people can have a significant, negative impact on daily interactions. Many persons with Asperger Syndrome have an advanced vocabulary for their age as children and sound like “little professors” as they impart the knowledge they have gained on topics (usually just one or two) of interest. The impairment comes in their inability to read the cues others are sending them and may continue talking long after the other person has become disinterested.
13 Features of Asperger Syndrome Restricted Interests, Insistence on Sameness, and Difficulty with ChangePersons with Asperger Syndrome have a strong need for sameness. They are often rigid in both their thinking and their actions – responding to minor changes or unexpected events with extreme reactions or even “meltdowns”.
14 Restricted Interests, Insistence on Sameness, Resistance to Change Has intense interest in a specific topicResists change; difficulty with unexpected events or changes between activitiesSeems unmotivated by typical rewards for ageDifficulty stopping a task before it is completedAsks repetitive questionsAppears ‘stubborn’ or ‘oppositional’Fixates on rules and moral rightsStudents with Asperger Syndrome often have great difficulty stopping tasks when they are not finished, transitioning from one activity to another or accepting an unexpected change in routine – even if it is for something viewed as positive like getting out of school early. It is theorized that this rigidity in thinking and action stems from high levels of anxiety and difficulty with flexibility. Teaching flexibility in our thinking and actions is one of the most important skills we can give our students with Asperger Syndrome.
15 Features of Asperger Syndrome Motor FunctioningandMotor Planning
16 Motor Functioning / Planning Balance difficultiesPoor coordinationResists or refuses handwriting tasksDysgraphia (inability to write legibly)Delayed timing, imitating and execution of movementsAccident proneDifficulty with snaps, buttons, fastenersWalks with an awkward or unusual gaitUnusual body postures and/or facial expressionsDifficulty starting or completing actions (may rely on prompting by others)Difficulty with athletic activities including riding a bike, catching a ballOften display hypotonia (general muscle weakness)Motor planning and functioning in persons with Asperger Syndrome is a much-overlooked, but very significant challenge. Motor planning and action challenges effect not only the physical activities but the academic ones as well – especially in the area of written expression. The range of impairment is vast from minimal impairment like a poor pencil grasp to complete Dysgraphia, the inability to write legibly. It is the rare person with Asperger Syndrome who has strong athletic skills – the compounded challenges of impaired motor functioning and social skills interpretation …. (etc.)
17 Features of Asperger Syndrome Differences inCognitive Processing
18 Cognitive Differences Poor problem solving skillsDifficulty with planning and organizing (materials, projects)Difficulty applying learned skills in new settings (generalization)Attention problemsImpulsiveVery logical learnersRigidity in thinking and routineDifficulty perceiving dangerDifficulty processing multimodal information simultaneouslyDifficulty retrieving experiential memoriesDifficulty generalizing knowledge to applicationDifficulty discerning between fiction and realityDifficulty discerning between relevant and irrelevant informationDisplays weakness in reading comprehension despite strong word recognition abilityVery literal understanding of conceptsPoor self-reflection; Difficulty understanding the connection between behavior and consequences
19 Cognitive Processing Theory of Mind (ToM) Perspective taking Making social judgementsLack of skills creates easy targets for bulliesPoor inferencing and predicting skills (reading comprehension)Written expression may be affected by fine motor issuesfMRI studies clearly show some with AS that process info using different parts of the brainYale studies showing individuals with AS focused on different parts of dramatic videoTheory of Mind reflects how a student with ASD makes social judgments (may include sizing up a situation, making inferences, and predictions.).In a 2001 research paper, Simon Baron-Cohen describes Theory of Mind as "...being able to infer the full range of mental states (beliefs, desires, intentions, imagination, emotions, etc.) that cause action. In brief, having a theory of mind is to be able to reflect on the contents of one's own and other's minds.“Theory of Mind has a direct link to both cognitive performance in the classroom especially in the areas of reading comprehension and advanced cultures or history classes where students make judgments of societies based on historical data and being able to take the perspective of people living in those times.Differences in Theory of Mind also lead to misunderstandings in social situations when the student with Asperger Syndrome is challenged to interpret the social meaning and intent of others’ actions. This can lead to bullying and victimization for the student.
20 Features of Asperger Syndrome Sensory DifferencesSome surveys indicate up to 90% of parents reports children with ASD have sensory issues
21 Sensory Differences May be hypo (under) or hyper (over) responsive to: Touch – tactile defensivenessSounds or frequencies – auditory defensivenessLightPainSmellsTextures or tastes of foods.May be emerging evidence of Sensory Processing Disorder in DSM-VStudents with Asperger Syndrome often have extreme sensory differences meaning their senses over or under respond to stimuli in comparison with the systems of a typically developing person. In fact, a person with Asperger Syndrome can be both hyper and hypo sensitive within the same context. For example, they may be hyper sensitive to a light touch on the arm (responds as though in pain) and hypo sensitive to deep pressure on the same arm (a tight squeeze that may cause you and I discomfort feels comforting and relaxing). Person’s with Asperger Syndrome may be overly bothered or distracted by the humming noise created by fluorescent lighting common in many classrooms – but may not respond at all to someone yelling their name while near them. Many children are often assessed for hearing impairment prior to a diagnosis of Autism or Asperger Syndrome.Lights may over stimulate the sensory systems of people with Asperger Syndrome by causing their senses to become heightened or over-aroused. This simple trigger can often lead to increased activity levels or distractibility in the classroom.Some children with Asperger Syndrome do not react to pain in the same context as a typically developing person. They may over-respond to a simple pat or walk around on a broken leg for days without realizing it.Smells can be very upsetting to or very calming to persons with Asperger Syndrome. Candles and other room scents that we find calming and pleasurable may be intolerable and upsetting. Smells of certain foods can trigger illness or nausea just as they sometimes do in early stages of pregnancy for women.Textures and tastes of food are frequently an area of sensory difference. Many children with Asperger Syndrome are described as “picky eaters”. Some may limit their food intake to only a few foods due to their low tolerance for a broad continuum of textures and tastes.Sensory issues often play themselves out in the classroom as fatigue, increased anxiety, motivation, or outbursts of explosive emotion. Working to find a balance in meeting the sensory challenges faced by the individual child with Asperger Syndrome can be a challenge but is important in helping to teach the child self-regulation, calming and coping strategies for managing their sensory differences.
22 Features of Asperger Syndrome Emotional Vulnerability
23 Emotional Vulnerability Low frustration toleranceNegative self-talkDifficulty tolerating mistakesSelf-injuryAppears sad, depressed or anxiousMakes suicidal comments or gesturesHas difficulty managing stress and/or anxietyWorries obsessivelyAnxiety and depression are probably the most frequently observed coexisting conditions with Asperger Syndrome. Difficulty with interpreting the emotions of others combined with the stressors created by difficulties with sensory processing, cognitive processing, motor planning and other neurologically based challenges of Asperger Syndrome create a world based in stress and put children with Asperger Syndrome at greater risk for the rages or tantrums referred to as “neurological storms” or “mountains of emotion” by Brenda Smith Myles and Jill Hudson in their publications on Asperger Syndrome.Common emotional differences seen in persons with Asperger Syndrome include obsessive worrying, low frustration tolerance, negative self-talk, difficulty tolerating mistakes, self-injury, appears sad, depressed or anxious, makes suicidal comments or gestures, and difficulty managing stress and anxiety, and worries obsessively.
24 Features of Asperger Syndrome The Gifts of Asperger SyndromeMany adults with Asperger Syndrome consider their own unique way of thinking and processing a gift that they would not reverse given the opportunity. Temple Grandin, a well-known adult with autism who received a Ph.D. in Animal Science and is considered a world expert on both autism and animal sciences
25 The Gifts Honest Determined An Expert Notices sounds others do not hearKindForthright (speak their mind)Enjoy solitude (important for emotional restoration)PerfectionistReliable, loyal friendGood at art (or other creative outlets)Observant of details others do not seeExceptional at remembering things other people have forgottenHumorous in a unique wayAdvanced knowledge in mathematicsLiked by adultsThe Gifts
26 Neurological Differences Research is now showing us that people with Asperger Syndrome use their brains in unusual ways: they memorize alphabet characters in a part of the brain that ordinarily processes shapes. They tend to use the visual centers in the back of the brain for tasks usually handled by the prefrontal cortex. They often look at the mouth instead of the eyes of someone who is speaking – missing the social context so important to interpretation and understanding of the message being sent.Wallis, Claudia – Time Magazine. May 15, “Inside the Autistic Mind”
27 Neurological Differences Frontal Lobeshome to higher reasoninggreatly enlarged due to excess white matter (brain’s connector cables)Impaired higher reasoning influences student’s ability to easily learn abstract concepts.
28 Neurological Differences Corpus CollosumUndersizedLinks left and right hemispheres of the brainActivity across diverse regions of brain is poorly coordinatedLeft to Right brain connectivity is slowedEffects many areas of learning – creative writing for exampleInsert color – word test here to illustrate coordination and cross-over between left and right brain.
29 Activity: Left – Right Brain Test Look at the chart and say the COLOR, not the word. Your right brain will try to say the color while your left brain will read the word! Can you do it in less than a minute?ALSO video on you tube -
30 Neurological Differences Hippocampusabout 10% larger than normalvital to memorypossibility is that this structure becomes enlarged because autistic children rely on memory to interpret situations that most people process elsewhere.Tendency to hyperfocus on detail and miss the big pictureRote memory is a strength (making connections between new material is not)Learn in “scripts” or routines – will often respond in ways that have been witnessed in movies / tv even if situation is somewhat different
31 Neurological Differences Cerebellumoverloaded with white matterFine tunes motor activity, balance, body movements, coordination and the muscles used in speakingMay also play a significant role in the ability to shift attention from one stimulus to anotherMay be “clumsy” or uncoordinatedDifficulty anticipating events / action of others in contextMiss information due to slow attention shift
32 Neurological Differences Distribution of white matter – the nerve fibers that link diverse parts of the brain is abnormal.Local areas tend to be over-connected with more limited connectivity between more distant areas of the brain. Right and left hemispheres of the brain are also poorly connected.As if there are too many competing local phone services but no long distance. Students with ASD have difficulty bringing different cognitive functions together in an integrated wayThought processes often result in unexpected answers or ideas – typically connect to a previous experience / learned or memorized response to an eventProcessing is often delayedNeurological Differences
33 Moving from knowledge to intervention Identification and implementation of appropriate supports and strategies across all environments, activities and persons is crucial to aiding students in achieving successMoving from Knowledge to ActionLooking at the individualBuilding relationshipKey areas firstSocialEmotional vulnerabilityHow do we know whatinterventions to put in place?
34 Areas of Instructional Need – Other Than Grade Level Academic Instructional Needs (to address features)Social SkillsLink to reading comprehension skill developmentDirect InstructionEmotional VulnerabilityOrganizationAdaptiveMotor planningSelf-helpAs we have reviewed the features, or characteristics that define Asperger Syndrome, it is important to note that the delays, impairments and challenges noted do not have to be permanent features of the persons life. Through quality, evidence and research based instruction, these skill deficits and challenges in skill acquisition can be remediated. Just as the average person with a typically developing brain would not learn algebra without specific instruction in the skills and application of the math process, persons with Asperger Syndrome need direct instruction in the areas of learning their brains do not naturally acquire. Specific areas of instruction to address include; social and pragmatic language skills, organization skills and for many students specific adaptive or self-help skills based on their personal development.
35 Social & Pragmatic Language Skills “Normal children acquire the necessary social habits without being consciously aware of them, they learn instinctively. It is these instinctive relations that are disturbed in autistic children. Social adaptation has to proceed via the intellect” – Hans Asperger
36 Why are Social Skills Important? Value society places on social abilityGood social skills promote acceptance of students by peersBuild lifelong social and emotional growthImproved social competence reduces problem behaviorsCan be successful without high cognition, but impaired social skills will hurt in the long runWhy are social skills important to our society? First, our society places a value on people who have good social skills. People who are awkward, geeky or lack tact in social situations are not sought out as friends as business partners as a general rule. We are drawn to the well-spoken, outgoing, people who seem to get along easily with everyone. Good social skills help us connect with each other and friendships and close relationships are proven by research to build lifelong social and emotional growth. Social relationships help us stay physically and mentally healthy.
37 Social and Pragmatic Language Skills to TeachInitiation of play –early, tween, teen, adultConversational SkillsReading emotions / non-verbal cues (self and others)FlexibilitySelf-regulation / anxiety managementThe array of skills we use in our everyday social interactions is vast and can best be comprehended by a study of the curricula recommended. Key areas of need that seem consistent across students with Asperger Syndrome include initiation of play from a very young age, the give and take of conversational skills including turn taking, asking questions, maintaining a topic and showing interest in the topics of other people. Understanding the emotions of themselves and other people is the first bridge into perspective taking also known as theory of mind and is also closely linked to learning self-regulation and anxiety management skills. After all you must understand how you feel and why before you can begin to recognize the signs of stress and anxiety and begin to cope with them in a thoughtful way.
38 Social / Emotional Needs Directed, specific, cognitive-based, instruction in play, social thinking and friendship is essentialSocial ThinkingVideo modelingDrama / Role PlayingSocial Stories / Comic Strip Conversations / Power CardsRating ScalesCognitive Behavior TherapyEmotional Toolbox
39 Social and Pragmatic Language Social NarrativesSocial Stories™Social ArticlesPower Cards
40 Social and Pragmatic Language Instructional Practices and CurriculaIntegrated Play Groups – (Wolfberg)Think Social (Winner) - Cognitive Behavioral TherapyBellini’s Building FriendshipsThe Hidden CurriculumPLAY (Ric Solomon)Skill Streaming
41 Emotional Vulnerability “Autistic children are often tormented and rejected by their classmates simply because they are different and stand out from the crowd. Thus, in the playground or on the way to school one can often see the autistic child at the center of a jeering horde of little urchins. The child himself may be hitting out in a blind fury or crying helplessly. In either case he is defenseless”- Hans Asperger
42 Teasing & BullyingUse a team approach and include the target, school administration, teachers, parents, psychologist, other children and the child engaging in bullyingProvide staff trainingEnsure justice is equitable based on motivation, knowledge and factsUse positive peer pressureTeach target skills to handle bulliesDon’t be aloneAssertive and honest responseSelf-protection courses
43 KEY to Solving Behavior Problems… You must findthe realantecedent!!!!!
44 Common Mistakes in Managing Behavior Thinking that a student can learn when under extreme stress and anxietyThinking that the behavior is on “purpose” or under the student’s controlRaising voice when a student misbehavesDenying a student request before hearing it outFocusing on what the student does wrong,(look for antecedents)
45 Mistakes Cont. Talking about the student as if he/she is not there Disagreeing with another professional about discipline in front of the studentRepeating instructions too often rather than checking to see whether the student understood, or had time to processFocusing on too many behaviors with the student
46 Finding the Antecedent What was going on just before the incident? -(antecedent)Include info such as:TimeActivity the student participating inEnvironmental factors
47 Finding the Antecedent – cont. Formulate a hypothesis for the behavior?Put on your detective hat and really think…Remember the Autism perspective (consider the difference in thinking).
48 BehaviorRemember that behavior serves a purpose for the individual and that our job is to figure out that purposeSensory Defensiveness / DysregulationMisinterpretation of the environmentMisinterpretation of teacher expectationsSocial misunderstandings with peers
49 Behavior Conditions likely to increase unwanted behaviors Anxiety / biological issuesSchedule / staff changesMedication changeIrregular sleep patternsIllness / pending illnessSkill deficitsLack of communication system
50 BehaviorTeaching an alternative response (alternative behavior) should be an integral part of the behavior response planFocus on self-control / not outside (adult) controlSelf-monitoring / self-awarenessChoice makingRelaxation trainingCommunicationSocial SkillsIf we are only rewarding / punishing behavior then we are not teaching what is wanted (appropriate behavior)
51 Behavior All behavior communicates Remember – when anxiety and frustration go up / abiltiy to use and comprehend verbal language goes down..Receptive and Expressive Language (ability to communicate)AnxietyAndFrustration
52 Behavior A few key points to remember… Teaching must occur before learning can occurShowing a student a visual – is not teachingHave a crisis plan for anticipated behaviors – but realize that crisis management is a short-term solution and does not equal long-term behavior change
53 Support Strategies Restricted Interests “Don’t treat the special interest as a toxin to be purged, but as a trait to be managed”Jennifer McIlwee Myers inan to Tony AttwoodUse restricted interests and activities to your advantage and topics for writing, reinforcers and social bridges.
54 Support Strategies Restricted Interests Limit time with interest (‘special time’)Work “with” the interest rather than againstSupport interests that could become long-term employmentUse to facilitate friendships/peer interaction
55 Support Strategies Cognitive Difficulties in this area may include transitions, impulsivity, inflexibility and distractibility.STRATEGIES:Transition strategies: visual supportsAttention to task strategies: may be maintain by selecting activities to task; positive reinforcements, frequent breaksSelf monitoring strategies: behavior sheet, social stories, schedule boards, etc.Planning and organizing strategies: agenda/planner for recording assignments, Franklin Homework Whiz, and mind mapping software.A student may have difficulties being on time, have problems getting from class to class, may forget materials, or carry the overloaded back pack everywhere. These can all be related to anxieties related to directionality, inability to make subtle adjustments when something unexpected occurs, and difficulties with organization.
56 Support Strategies Motor Physical SupportsFrequent BreaksAssistive TechnologyA student may have difficulties being on time, have problems getting from class to class, may forget materials, or carry the overloaded back pack everywhere. These can all be related to anxieties related to directionality, inability to make subtle adjustments when something unexpected occurs, and difficulties with organization.
57 RESOURCES OASIS OAR Social Thinking National Professional Development Center on AutismTexas Autism Resource Guide for Effective TeachingBrenda Smith Myles, Tony Attwood, Michelle Garcia Winner,