By Megan Romanczyk, CCC-SLP
Note: This article uses identity first language (i.e., the autistic individual vs. the individual with autism). For more information about this choice of language, please refer to What is Neurodiversity?
How do you provide neurodiversity affirming and anti-ableist speech and language therapy to children? The first step is to learn from autistic individuals. This blog pulls from the insights of autistic speech-language pathologists¹²³⁴⁵, autistic researchers⁶, and autistic children and adults⁸ who have shared what self-determined, authentic communication means to them. The following is a list of ways in which we strive to provide affirming, personalized, and effective therapy to our clients based on what we have learned from the autistic community.
1. Build trust
The first step to building trust is to show genuine interest in a child’s enthusiasms. If a child comes into the therapy room and is interested in spinning objects, we seek to understand what it is about the spinning that is interesting. Is it the visual properties of different objects? Is it the challenge of figuring out the physics of how to make different objects spin faster and for longer on different types of surfaces? If a teen could talk for hours about Roblox, we take the time to learn why they love it so much. Trust is the foundation for a strong therapeutic relationship. To support a child in their development, it is imperative that they know we see them, we value them, and we seek to understand their perspective. Only through a trusting relationship can meaningful growth take place.
2. Focus on the ‘Why’
In “Uniquely Human” Dr. Barry Prizant, PhD, CCC-SLP writes about the power of asking “why” a child behaves the way they do⁷. Traditional behavioral approaches to treating communication disorders focus on first managing or extinguishing a child’s behavior, whether that be throwing objects, yelling, or attempting to sprint away every time they enter a therapy room. As Dr. Prizant writes, this approach is problematic as “it fails to show respect for the individual and ignores the person’s perspective and experience. It neglects the importance of listening, paying close attention to what the person is trying to tell us.” A neurodiversity affirming approach emphasizes asking ‘why’ the child is behaving the way they are, seeking to understand, and responding with empathy and support. What we find when we look closely is that a behavior is often an adaptive response to emotional dysregulation, or feelings of discomfort, anxiety, or confusion attributed to emotional and physiological challenges. If a child runs away every time they enter the therapy room, we don’t give them a star chart to reward them for remaining in their seat. We seek to understand the cause of this behavior. Are they feeling uncomfortable being in a small space? We can try providing therapy in the gym. Are they anxious in an unfamiliar environment? We can write a social story so they know what to expect. Are the lights too bright? We can dim them. Is the carpet uncomfortable on their bare feet? We can bring in a mat or a blanket. When we focus on the ‘why’, we are not only creating a more positive therapeutic experience for the child, but we are also validating their experiences and helping them build trust in others.
3. Engage in two-way perspective taking
In 2012, an autistic researcher named Dr. Damian Milton introduced the world to what he termed “The Double Empathy Problem.” Milton hypothesized that “when people with very different experiences of the world interact with one another and struggle to empathize with each other”, communication breakdowns occur due to differences in lived experiences, not due to one individual’s cognitive system. In other words, when an autistic individual struggles with social communication, it is not that the individual’s communication style is inherently disordered, but rather that the individual is communicating in a world in which the neurotypical majority does not share their perspective. This theory was supported by a 2020 study, which found that communication breakdowns occurred when autistic and non-autistic adults relayed information to one another, but not when autistic individuals communicated amongst themselves⁸. Imagine you’re an artist in a sports bar or an engineer at a teaching conference. If you struggle to connect with others there, it is not because you are incapable of communicating successfully, but rather that you don’t share the same experiences, perspective, and lingo. This theory suggests that to support autistic individuals in fostering meaningful relationships in their self-determined communities, we should engage in two-way perspective taking. This means simultaneously supporting an autistic individual’s understanding of the neurotypical communication norms and expectations while seeking to better understand the autistic individual’s perspective and communication preferences. Just as we support our children in navigating neurotypical conversational expectations, we as therapists are responsible for educating ourselves on autistic culture and communication styles.
4. Emphasize capacity over compliance
Traditional social communication intervention for autistic children has emphasized the use of “expected” social behaviors and social scripts. Progress is judged based on a child’s ability to engage in non-preferred conversation topics with non-preferred peers, consistently respond to greetings and questions with socially appropriate language, ask a certain number of follow up questions, and reduce the amount of time they talk about their interests in conversation. The issue with these goals is that they measure communication behavior without addressing the underlying capacity (i.e., two-way perspective taking, understanding hidden conversational rules, understanding communication style differences among communication partners). Further, this style of intervention reduces self-determination in communication. It asks individuals to disregard their communication preferences and mask their authentic selves. As adults, we don’t always ask 3-5 follow up questions, stay on topic for 10 minutes, or chat with our “non-preferred” peers. Every individual’s communication style and preferences are different, and therefore communication intervention should always be tailored to the individual. Here are some examples of how, with the guidance of autistic speech-language pathologists, we have rewritten social communication goals to promote social understanding over social compliance¹²³⁴⁵. These goals are intended for older autistic individuals who have identified an interest in better understanding allistic (non-autistic) communication styles. It is important that these supports be used in conjunction with supporting neurotypical peers to understand autistic communication styles.
Behavioral Goal | Neurodiversity Affirming Goal |
“The child will consistently respond to greetings and use socially appropriate communication (i.e., please, thank you, excuse me).” | “The child will develop an understanding of the rationale for various social phrases by stating the reason when asked (i.e., Why do some people say excuse me?)”³ |
“The child will interact with peers in an appropriate manner through maintaining personal space and a respectful voice.” | "The child will a) independently explain 'why' an unexpected behavior (getting too close, touching a peer, grabbing a peer, etc.) may make someone express a negative emotion, and b) state what they could do instead to communicate their message to that person (I care, I like you, I feel bad that you are upset, etc.) |
“During unstructured free time or during electives, the child will initiate and begin a back and forth conversational exchange on a topic of a peer’s choosing (for example, greeting and asking previously rehearsed questions learned during role-play) for 5 minutes.” | "After watching a video or listening to a passage, the child will demonstrate perspective-taking skills by indicating which pragmatic action (such as speaking over someone else, or interrupting, or answering for someone else) might be expected to produce: a) negative feedback b) positive feedback from a communication partner" ³ |
“The child will cooperate with group decisions in which the child is not in agreement.” | "The child will demonstrate measurable progress with self-advocacy and expressive language by a) asking for help when she is struggling with materials or lectures b) requesting modifications and accommodations to which she is entitled (using self-determined language)"² |
An important distinction between behavioral focused goals and neurodiversity affirming goals is how progress is measured. With a behavioral therapeutic approach, progress is measured by a child’s ability to demonstrate a pre-taught behavior. The therapist dictates who the child will talk to and what they will talk about to determine success. With a neurodiversity affirming approach, progress is measured by a child’s ability to demonstrate growth in understanding the nuances of social communication. Neurodiversity affirming therapists emphasize that communication must be self-determined to be authentic and meaningful. Conversations, social experiences, and friendships should be intrinsically motivating, and therefore the role of the SLP is to support the child in successfully navigating relationships without determining the terms of the social interactions.
5. Incorporate enthusiasms into therapy
Therapeutic sessions should always be meaningful to the child. Rather than using a child’s interests as a reward for demonstrating a skill, we help a child develop their communication skills in the context of what is motivating to them. This may look like targeting sequencing in the context of sensory based science experiments with preferred colors and textures, targeting action words in the context of gross motor play in the gym, or targeting prepositions by going on a scavenger hunt with a child’s favorite objects. Enthusiasms come in all forms (birds, the color green, ocean animals, the alphabet, famous wrestlers, racecars), and with some creativity, there are always ways to incorporate a child’s interests into therapy.
6. Write goals that are meaningful to the child
When working with emerging communicators, we work with the family to determine what goals will be most impactful. We focus first on what is the most immediately achievable way for a child to meet their wants and needs, whether that be through the introduction of gestures, signs, robust AAC systems, spoken communication, or a combination of these. For children with more advanced communication skills, we collaborate with them in the goal writing process. For a child who is having a difficult time with interpreting non-literal language, we may ask if they want to work on slang and sarcasm in peer conversation or figurative language in the context of written texts. For a child who stutters, we may ask if they want to begin by learning fluency shaping strategies or work on developing self-advocacy skills to better navigate challenging speaking situations. While speech-language pathologists are experts in communication, we are not experts in the communication context of each individual we serve. Only through collaboration with the individual can we determine which therapeutic targets will be the most impactful.
7. Seek out opportunities for continued learning
At the BAC, we are continuously re-evaluating past practices and reflecting on how we can better serve our community. While we continue to expand our list of books, articles, podcasts, Instagram pages, Facebook pages, and blogs which share the perspectives of autistic individuals, we would love to hear from you! Do you have a favorite resource that has opened your eyes to autistic culture and communication? Let us know in the comments below!
References:
1. Randall, K. (n.d.). An Autistic SLP’s Experiences with Social Communication [web log]. https://therapistndc.org/an-autistic-slps-experiences-with-social-communication/.
2. Roberts, J. (n.d.). On Writing Masking Goals for Middle School Girls - Stop It! [web log]. https://therapistndc.org/masking-goals-autistic-middle-school-girls/.
3. Roberts, J. (n.d.). Why Perspective-Taking and Neurodiversity Acceptance? [web log]. https://therapistndc.org/why-teach-perspective-taking-neurodiversity-acceptance/.
4. The Dilemma of Social Skills Therapy Part 1: The Dilemma of Social Skills Therapy Part 1: The Young Child — Rachel Dorsey: Autistic SLP, LLC (dorseyslp.com)
5. The Dilemma of Social Skills Therapy Part 2: The Dilemma of Social Skills Therapy Part 2: Adolescence — Rachel Dorsey: Autistic SLP, LLC (dorseyslp.com)
6. Damian E.M. Milton (2012) On the ontological status of autism: the ‘double empathy problem’, Disability & Society, 27:6, 883-887, DOI:
7. Prizant, B., & Fields-Meyer, T. (2015). Uniquely human. Souvenir Press.
8. Crompton C.J., Ropar D, Evans-Williams CV, Flynn EG, Fletcher-Watson S. Autistic peer-to-peer information transfer is highly effective. Autism. 2020;24(7):1704-1712. doi:10.1177/1362361320919286
Further Reading:
Non-ableist Pragmatic Language Therapy: Non-ableist Pragmatic Language Therapy | Therapist Neurodiversity Collective (therapistndc.org)
Social Skills Training: Social Skills Training | Therapist Neurodiversity Collective (therapistndc.org)
Why Perspective-Taking and Neurodiversity Acceptance? Why Perspective-Taking and Neurodiversity Acceptance? (Part 2 of “Training” Social Skills is Dehumanizing: The One with the Therapy Goals) | Therapist Neurodiversity Collective (therapistndc.org)
A Letter from an SLP to a Parent A Letter from an SLP to a Parent, Immediately After an Autism Diagnosis for a 5-Year-Old | Therapist Neurodiversity Collective (therapistndc.org)
Nothing about Social Skills Training is Neurodivergence-Affirming https://therapistndc.org/nothing-about-social-skills-training-is-neurodivergence-affirming/
The Double Empathy Problem The double empathy problem (autism.org.uk)
Social Camouflaging in Autism Social camouflaging in autism: Is it time to lose the mask? - Will Mandy, 2019 (sagepub.com)
