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Neurodivergent-Affirming SLT

Supporting autistic children's speech, language and communication needs through compassionate approaches

3D icon of a star, beige coloured with dots in an outline of the star, with a smaller star above it

Examples of Neurodiversity-Affirming goals

Assessment

ASSESSMENT

ASSESSMENT TOOLS

  • Talking Mats
  • Environmental assessment of home, classroom, communication partners
  • Observations in a variety of contexts e.g. lunch, break, play
  • Blank Levels (Levels 1-4)
  • Key word level instructions
  • Observing language in specific functions e.g. requesting, asking for help
  • Describing composite pictures
  • Rating scales - keep them simple and avoid 0-10
  • Self-rating questionnaires individual to the person's needs / topics
  • Parent / carer / teacher interviews

Behaviour does NOT always = communication

Is the communication difficulty causing them / other people distress?
Are they not able to communicate that they need the toilet? Are they neglecting their basic needs because they don't know how to express these? Are they having frequent communication breakdowns? Do they know what to do when people don't understand them? Are they using explicit language that is genuinely upsetting others?​​
"Non-verbal"...
NonVerbal – a. being other than verbal; b. involving minimal use of language; c. ranking low in verbal skill.
Verbal – a. of relating to or consisting with words; of relating to or involving words; spoken rather than written. 

Is the child actually non-verbal?  Nonspeakers do not like to be called non-verbal because it is interpreted as "oh, they don't understand any language at all" and can be treated worse as a result - people make assumptions that they don't have the capacity to understand what is going on around them.  A child who does not speak / use mouth words is mistakingly regarded as non-verbal when in fact they can communicate in other ways - and they quite possible can UNDERSTAND language. So, nonverbal discounts the child's understanding of language.

Are there any ADDITIONAL factors contributing?

  • Selective Mutism
  • Expressive / receptive communication difficulties
  • Speech sound / phonology difficulties
  • Bilingualism / multilingualism
  • Mental health, trauma
  • Sensory needs, dysregulation
  • Fluency (stammering)
  • Fatigue
  • Autistic burnout
  • Voice
  • ADHD
  • Dyspraxia / apraxia
  • Insomnia
  • Masking, social trauma

Supports

We want to create a maximally enabling environment. The world isn't set up for autistic children which is why we need to focus on removing barriers in their natural environment and create environmental adaptations. We want to create a Total Communication environment. So we don't change the person, we change the environment. Autistic people have difficulties generalising skills to new situations (so applying a skill learnt in a 1:1 session outside the room to a range of contexts).
  • Everyone in the child's environment are responsible for providing 'intervention'
     
  • The people in the environment ARE the communication environment, meaning professionals have a duty to adapt their communication and interaction styles to support autistic children.
     
  • Strategies are embedded all day, every day, through the day, by everyone.
     
  • Adults provide regular opportunities for children to use, develop, and practise communication skills
     
  • Therapeutic input is embedded in the natural environment e.g. in the classroom, at lunch, in lessons
     
  • Skills are taught / developed in regular daily activities - not just with the Speech and Language Therapist in a 1:1 session 1x a day or week.
     
  • Adults teaching language through modelling in natural contexts - Aided Language Stimulation
     
  • Not using ABA or behavioural interventions such as PECS in order to develop language - see here for why
Total Communication logo - 5 coloured circles representing an eye, ear, nose, mouth, finger

Total Communication: an approach that uses all methods of communication to create a maximally enabling environment

Communication strategies

  • Slow down your rate of speech. Talk slower. This supports the students' language processing and executive functioning difficulties
     
  • Reduce the amount of speech / spoken language you are using 
     
  • Don't rush the person or give off the vibe that you are wanting them to finish what they're saying. This creates more anxiety which further impacts their ability to communicate their message
     
  • Give PLENTY of processing time. It might feel awkward for you, but it won't for the autistic person. Find out what that person's individual processing time needs are; some will need longer - some shorter
     
  • Pause between sentences, give them time to digest and process your message especially when explaining something or giving instructions.
     
  • Avoid multi-part questions. Ask 1 at a time and wait for a response. 
     
  • Be as specific as you can. Say what you mean. There are many interpretations to things people say.
     
  • If the person asks follow-up questions to your questions, they are simply seeking more information because something hasn't been explained sufficiently.
     
  • Explain or check understanding of non-literal language (metaphors, symbolism, idioms, words and sentences with double meanings or with lots of different interpretations)
     
  • Explain technical language / jargon e.g. if explaining the law and using words like 'offence', 'breach', 'custody'.
     
  • Break down instructions. Say one thing at a time.
     
  • Repeat instructions / information
     
  • Say their name to gain their attention before you start talking to them

Pathological Demand Avoidance

The drive for autonomy

Any sense the child may lose control will trigger them to resist any form of demand. They can be in survival mode which means they will be needing to protect themselves by denying adults' demands. The 'behaviours' are a result of unmet needs. 
Why do they need to protect themselves? What makes them feel unsafe? What things in the environment cause them to become dysregulated?

Find out the things that make them feel unsafe: events, activities, situations at school.

Find out the things that make them feel safe: events, activities, situations at school.

Tap into their interests and inspire them rather than instruct, demand, or direct them. If they do this task, what will they get out of it?

Image of Pathological Demand Avoidance infographic of communication strategies

Free Download of PDA Language Strategies

"This is how my neurobiology navigates it’s way through the internalised resistance"

- Kristy Forbes

SELF-ADVOCACY:

Helping students develop autonomy, confidence, self-esteem. Self-advocacy skills are vital for autistic children / teens and will have life long benefits on their self-esteem, their autistic identity and their autonomy.

Examples of skills to develop:
 

  • requesting an item or activity

  • communicating a need

  • requesting help

  • making a choice

  • problem-solving

  • expressing opinions

  • describing their boundaries

  • asserting themselves

Five children facing away with their backs facing the camera. All wearing different coloured capes

How do we teach self-advocacy?

Understand that the behaviour might present as 'challenging' but the child might just be trying to communicate a need and self-advocate. Respond to any attempts they make to communicate their needs, verbally or nonverbally. Don't insist on "use your words" or "say that more politely" - they may not have language, vocabulary, cognitive or sensory capacity in that moment. They might be dysregulated or shut down. Encourage them to ask for what they need. Create lots of means, reasons, opportunities for through the day e.g. offer choices, model how to express needs. Provide visual schedules, symbols, break / help cards, first / then visual, labels in the classroom. If the student struggles to self-advocate verbally start off by helping them do this via other methods e.g. writing their needs down, gesturing, pointing, nodding or shaking their head to closed questions. 

SELF-ADVOCACY DOESN'T ALWAYS LOOK POLITE

5 self-disclosure badges and self-advocacy badges e.g. "I'm autistic", "Please don't touch me"

More practical strategies to empower autistic children:

Respect when the child refuses something or says no

Acknowledge the child's attempts of self-advocacy - "I liked how you advocated for yourself there!"

Ask the child to list some of their personal qualities, talents, strengths

Ask the child "do you need anything from me?"

Write affirmations on little cards for them to carry around e.g. "it's OK to ask for what I need"

Write affirming messages and reminders on post-its and put them on the child's desk e.g. "I can take my time and don't have to rush"

Disclosure badges as a visual aide to communicate needs to people - "I'm autistic", "I need time to process your words" etc.

www.etsy.com/uk/shop/PawsitivePins

SOURCES

LANGUAGE / PRAGMATICS

rather than working on 'social skills'

A group of teenage boys and girls sat with their backs against blue lockers laughing and chatting
Educate autistic students about The Double Empathy Problem and how misunderstandings aren't solely down to their communication style, but it being due to a relational difficulty between Autistics and neurotypicals.

Teach them about neurotypical communication and the breakdowns in communication they will likely to encounter in the community. Prepare them and teach them how to repair a misunderstanding when it happens. Model how to repair misunderstandings and ruptures in the relationship when they happen between you.

Focus on having real interactions with the student, not assessments and interventions disguised as activities and games that are really to test their communication skills. Actually build the relationship. Ask them about their special interests / passions / favourite topics. 

SOURCES:
How to teach pragmatic language without being ableist [blog post]. Available from: www.deepcontemplationblog.wordpress.com

Non-ableist Pragmatic Language Therapy - The Therapist Neurodiversity Collective - https://therapistndc.org/therapy/non-ableist-pragmatic-language-therapy/

EXPLICIT LANGUAGE

  • Try not to judge or assume. Try to unpick what's going on behind the language / behaviour.
     

  • Consider diagnostic overshadowing - are they in pain?
     

  • Check-in with people at home to explore anything that might be contributing.
     

  • Build their understanding / explore how people might react to them (perspective-taking)
     

  • Use Social Stories & Comic Strip conversations (without imposing how they 'should' act - don't dictate to them!)
     

  • Use Talking Mats to identify their feelings about various topics e.g. how they feel about school, friends, hobbies etc
     

  • Consider any mental health needs / underlying trauma and refer on to counselling/psychology/psychotherapy
     

  • Explore sensory needs / encourage and increase regulation strategies through the day e.g. movement breaks
     

  • Is it PDA? Are they trying to seek control as a way of managing overwhelming anxiety?
     

  • Are they just trying to initiate a conversation but don't really know how?
     

  • Do they enjoy the reaction they get from people around them e.g. do people laugh?
     

  • Is it immediate or delayed echolalia? Do they understand what they are saying?
     

  • Are they dysregulated / outside their window of tolerance? Sensory overload?
     

  • Are there any underlying language difficulties contributing? E.g. do they have the vocabulary to identify and describe their emotions? Consider ALEXITHYMIA

PERSPECTIVE-TAKING:

Building understanding of themselves and other people

QUESTIONS TO PROMPT PERSPECTIVE-TAKING

  • What emotions do you feel?

  • Why did you say / do that?

  • Why does that make you feel X?

  • Why do you think / feel that?

  • What's your perception of what happened?

  • Why might they feel that way?

  • Why do you think they did that?

  • What might they be thinking / feeling?

  • What do you think they'll do next?

  • What do you think their interpretation is?

A note on perspective-taking...

When attempting to explore other people's perspectives with your autistic client, there's a time and a place for this. When they bring a situation to you whereby they are dysregulated, upset, angry, anxious in response to something distressing e.g. an argument, a time they've felt misunderstood, ALWAYS validate their perspective first.

 

Remember, most autistic people have experienced relational trauma whereby they've been told their whole lives that they're the ones who think/feel/act is wrong. By jumping straight to exploring other people's perspectives you are repeating a trauma for that person whereby they've had their feelings and experiences invalidated again.

Read about autism and trauma here.

Provide social commentary - think out loud

Explain your process out loud, narrate what you're thinking, comment on social issues e.g. racism, sexism if they come up in lessons or in conversations. This can really help develop understanding as students get a MODEL of perspective-taking / exploring social issues.

SOCIAL STORIES

Carol Gray's Social Stories are a great way to support understanding, reduce anxiety about situations and to build perspective-taking. Unfortunately many Social Stories are written in a way to compel compliance in autistic children, so that adults can get them to do what they want. This approach encourages masking, discounts the child's needs and perceptions, and attempts to just control a behaviour e.g. "I should not interrupt", "I will be quiet". Carol Gray's approach is to 1) Abandon all assumptions 2) Recognise social difficulties are shared by both sets of people and 3) Both perspectives are equally as valid. Social Stories should be individualised for the child with language and images pitched at the right level. They should describe more than they direct, answer WH-questions, use reassuring language and not contain judgmental language.

COMIC STRIP CONVERSATIONS

Comic strip conversations are a helpful tool when exploring both people's perspectives and feelings of situations e.g. disagreements, misunderstandings, conflict. Explanation here.

SOURCES

EMOTIONS

The belief that autistic people lack empathy is a myth. Autistic people can feel emotions so intensely that it is overwhelming. Since we are significantly more likely to experience mental health problems than the general population, it's really important that professionals and services pay attention to unmet emotional / sensory / physical needs, and consider the impact of repeated trauma on autistic individuals. Our behaviour is frequently misunderstood and pathologized e.g. obsessive, rigid, challenging, inappropriate, selfish.
Infographic of 'alexithymia'. 4 coloured boxes representing different aspects to alexithymia

ALEXITHYMIA

Alexithymia is a psychology term for "without words for feelings". It is characterised by difficulties identifying feelings, matching physical sensations in the body with various emotional states, difficulties verbally expressing feelings and describing how the person feels. Alexithymia is common in autistic people. 
Logo of Neuroclastic website. Black background with red wing, with "neuroclastic" in white letters

Here's what Neuroclastic have to say about Alexithymia: 
https://neuroclastic.com/2019/05/13/alexithymia-and-autism-what-its-like-to-not-know-how-you-feel/

A child wearing headphones watching a tablet screen

Using AAC to talk about emotions

Assistiveware
https://www.assistiveware.com/blog/using-aac-to-talk-about-emotions

PrAACtical AAC
Dealing with Feelings: 5 Ways to Encourage Emotion-related Expression by AAC Learners : PrAACtical AAC

SUPPORTIVE STRATEGIES

  • Create REGULAR opportunities through the day for the young person to identify how they're feeling. Use Emotion Thermometers and Zones of Regulation with caution: there are many reasons why these tools may not work for autistic children; The problem is that on a lot of emotion thermometers you have a long list of emotions which are actually really hard to differentiate between.So what’s the difference between surprised and excited? Due to Alexithymia, many autistic people struggle to identify and describe emotions, which is linked to muted interoception and so matching body sensations with emotions is hard. This can be similar with Zones of Regulation because if the child doesn’t know when they're in the green, blue, red zone, then how are they going to know when, why, and how to use the strategies. In addition, some autistic people find the colour red triggering/distressing so it can inadvertently cause a distressed reaction. What we suggest instead is tapping into energy states.

    'Autism Level Up' are the leaders in this area and have created a fantastic tool called The Energy Meter: https://autismlevelup.com/energy-meter/
     
  • Model how to express emotions and what vocabulary to use e.g. "I'm feeling tired this morning - my body feels really heavy", "I'm feeling happy today - I have lots of energy and want to jump around"
     
  • Ask them WHY they might be feeling a particular emotion. 
     
  • Identify the person's self-regulation strategies and help them access them when they are dysregulated. Make a list and put it on their desk e.g. "when I feel angry I can X"
     
  • Ask them to identify some physical sensations that might be associated with an emotion e.g. "how do you know when you are angry? How does it feel in your body?"
     
  • Joint work with Occupational Therapy / Clinical Psychology
     
  • Visual tools:
Emotion Thermometer with green to red colours to represent emotions
A photo vignette of a selection of emojis
A photo of coloured pencils on a mood tracker piece of paper

Emotion Thermometer

Use emojis to identify emotions!

Mood trackers

Intervention
Pragmatics
PDA strategies
alexihymia
Communicatin strategies
Self-advocacy
perspective-taking
emotios
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