The #1 Reason OTs Feel Ineffective with Kids On the Autism Spectrum
Most OTs 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 kids on the autism spectrum, I felt immense pressure to really help the families I was seeing. The parents were exhausted, confused, and out of other options. 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 come out of school ready to be successful with kids on the spectrum. 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 we begin to feel that we don’t really know how to be effective with our autistic kids.
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).
We eventually 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 clients on the autism spectrum.
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 clients on the autism spectrum. When we begin to deeply understand autism learning styles, 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 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 kids on the autism spectrum have social differences. And somehow we wind up teaching new, rigid routines that don’t help our kids at all. We try to teach our kids to play, and they won’t imitate us. So we just keep trying, feeling ineffective once again.
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 do behavior problem solving, we continually write, “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 autism learning styles, you have the opportunity to do something different. You can become a more skilled therapist and begin creating interventions that really speak to your clients. You can clarify your therapy process from start to finish so that you show up knowing exactly where to start each day with your clients on the autism spectrum. And you can rekindle your excitement about your work and your confidence in yourself knowing that you are truly an expert with deep knowledge of autism that guides your work.
Using Autism Learning Styles to Guide Your Work
When I work with OTs in one-on-one consultation or in my continuing education courses and workshops, I start with a deep and thorough exploration of how kids on the autism spectrum think and learn. Then, we practice going through each part of the autism learning style and using it to problem solve a behavior and develop an intervention plan.
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:
He may not pay attention to how others play and therefore does not imitate others.
His peers’ social play may not capture his attention, so he doesn’t look around and join in with the other kids.
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:
Teach him imitation in a way he understands, using naturalistic strategies to capture his attention.
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:
He may have a very strong interest in how toys look when they are falling.
He may have a very limited set of play interests, and the toys present during free play may not capture his attention.
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:
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.
Provide him with appropriate play activities that involve watching things fall.
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.
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:
He may have difficulty understanding how he “should” play because of his challenges with receptive language.
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.
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.
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:
Explicit instruction in how to play, using a blend of naturalistic strategies and structure.
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).
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.
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 kids on the autism spectrum 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.