The #1 Reason Therapists Feel Ineffective in their Work with Autistic Kids
Most OTs, SLPs, and mental health therapists want so badly to make a real impact in the lives of the people we work with. We want to feel like what we are doing matters for our kids and their families, that it is effective, and that our time has been well spent.
When I first started out as an OT in early intervention working with autistic kids, I felt immense pressure to really help the families I was seeing. The parents were exhausted, confused, and running short on people who could truly help them support their Autistic kids, who were often in burnout. They were counting on me to help. I did the best I could, but every day I felt awful. I felt ineffective, confused, and terribly stressed. I worked all the time and felt like I accomplished nothing.
The thing is, we don’t truly learn in school how to understand the needs and experience of our neurodivergent clients. Sure, there are a few lectures on autism in our pediatrics classes. And we get some experience on fieldwork. But when we really dive into the work, whether we are new therapists or have been doing this for years, eventually, there is a moment that we question if our work is really making an impact.
The insecurities creep in. We may start to think, “Do I know what I’m doing?” We may feel like imposters and dread going to work. We stay up late trying to look at research (even though we no longer have a research database logins, so we are reading abstracts and clicking on links that won’t actually load).
For many of us (trust me, I’ve been there), we settle in and start to do the same uninspired interventions over and over again. They don’t really feel individualized or effective. They often don’t even feel like skilled interventions. But we really don’t know what else to do, so we keep plugging along and try not to think about it.
We take continuing education courses, and they feed us more theory and superficial ideas. We are taught to consider the environment, to use a new theoretical framework, or to use more visuals. But we still don’t really know what that means or how to do it in a way that will really make a difference for our young autistic clients.
Have You Been There?
It’s easy to get caught in an uninspired rut, and to feel like no continuing education could get you out of it. However it’s not so complicated to become a truly effective therapist for your Autistic clients. When we begin to listen to the Autistic community and think deeply about our clients’ needs, it’s entirely possible to feel skilled, competent, successful, and inspired in our work once again.
Doing Something Different
If we never deeply learn about how Autistic kids think and learn, we try to get by on what we think we know. We use clipart in our instructions because, “They’re visual learners, right?” The clipart picture schedules and visual instructions often get ripped up, ignored, and thrown on the floor. We aren’t sure what we are doing wrong, but we keep plugging along, spending hours putting pictures onto pages.
We try to teach social skills, because we know that neurodivergent kids have social differences. And somehow we wind up teaching new, rigid routines that don’t help our kids at all. We teach fine motor activities, even though we aren’t sure that it will ever make any real difference in daily activities. And we teach tons of handwriting, because after all of this time we’ve gotten good at teaching handwriting, while we still feel uncertain working on other daily routines and activities.
When we think through routines that the child is having a hard time with, we may write hypotheses like “The purpose of the behavior is to gain attention or to get out of something” even though this generic hypothesis isn’t really helping us generate effective interventions for our Autistic kids.
Working like this eats away at our confidence. It leaves us numb or even dreading our work, and it makes us question our abilities as therapists.
If you are dragging yourself along in your therapy without a true, deep understanding of the experiences and needs of Autistic people, you have the opportunity to do something different. You can become a more skilled therapist and begin creating interventions that really support your clients. You can clarify your therapy process from start to finish so that you show up knowing exactly how to align your work with your values. And you can rekindle your excitement about your work and your confidence in yourself knowing that your work is truly on track.
Using Autistic Learning Styles to Guide Your Work
In our flagship courses, we always start with diving deep into the Autistic learning profile. Then, we become curious about the child’s strengths and learning needs and use these to guide our support plans.
Here’s an example of how this process took one therapist from stuck to totally rocking it.
The therapist’s client, Kyle was an Autistic five year old who dumped out all of the toys during free play. Kyle’s behaviorist hypothesized that this behavior was to gain attention. But the OT wasn’t so sure. She suspected that the behavior related to poor play skills. But she didn’t know how to make the leap from her suspicion to a full intervention plan.
After working together to problem solve using autism learning styles, here is what we came up with.
Our first hypothesis was that Kyle’s dumping toys may be related to his difficulty with social relationships and social communication. We hypothesized:
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He may not pay attention to how others play and therefore does not imitate others.
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His peers’ social play may not capture his attention, so he doesn’t look around and join in with the other kids.
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He is not motivated by his parents’ and teacher’s social responses to how he does or doesn’t play, so traditional behavioral strategies like praising desired behaviors and ignoring challenging behaviors aren’t effective.
To address this, we decide we may need to:
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Teach him imitation in a way he understands, using naturalistic strategies to capture his attention.
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Consider that behavioral strategies requiring perspective taking (e.g. “Kyle I don’t like it when you throw blocks!”) are unlikely to be effective since Kyle has difficulty with taking others’ perspectives.
Our second hypothesis was that Kyle’s throwing blocks may be related to his restricted and repetitive behaviors. We hypothesized:
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He may have a very strong interest in how toys look when they are falling.
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He may have a very limited set of play interests, and the toys present during free play may not capture his attention.
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Throwing and dumping toys may be a rigid play routine, and routines are very difficult for him to change once established.
To address this hypothesis, we determined that we may need to:
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Teach Kyle how to play with the available toys in a one-on-one setting using clear, visual instructions, autism-specific teaching strategies, and structure.
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Provide him with appropriate play activities that involve watching things fall.
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Bring in new toys that we have taught him how to use rather than trying to teach him to stop dumping the current toys, since breaking the current strong routine of dumping toys will be difficult.
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Incorporate his strong interests into the available play activities.
Our third hypothesis was that Kyle’s dumping toys may be related to his learning profile and executive function. We hypothesized:
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He may have difficulty understanding how he “should” play because of his challenges with receptive language.
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He may not know how to play with new toys because implicit learning is not a strength for him, and he has never been taught to play in a way he understands.
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He may have trouble seeing where the play activities start and where they finish, so he can’t pick up a toy and know how to get started with a play routine.
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Dumping toys does not have a clear end point, so once he starts he continues dumping everything.
To address this, we realized that Kyle likely needs the following:
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Explicit instruction in how to play, using a blend of naturalistic strategies and structure.
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His play activities in free play should have a clear beginning and end (e.g. start with the puzzle pieces in a container next to the puzzle for him to put into the puzzle, so he can get started right away and also see that he’s finished when the container is empty).
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A visual to-do list of play activities that he can do during free time. If he doesn’t understand pictures, his visual to-do list will need to be at the object level.
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If we create an activity that involves appropriate dumping, we’ll need to make sure it has a very clear and concrete end point.
What a Difference it Makes!
What a difference it made when we applied autism learning styles to this therapist’s behavior problem solving process! This OT certainly didn’t need all of these interventions, but she was finally able to approach her team confidently with a relevant list of hypotheses and interventions that related directly to how this child thinks and learns. From there, together they could figure out where exactly to start. She went from “Maybe it’s his play skills?” to this rich, relevant, concrete list of behavioral hypotheses and interventions.
From Confused to Confident
Being an OT can leave you feeling totally alone and confused. But becoming a competent and confident therapist for autistic kids is totally possible. When you commit to deeply understanding autism learning styles and applying this to your practice, you can reinvigorate your work and rediscover that hopefulness that you felt when you first decided to work with kids with disabilities.
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