Let's talk about REPETITIVE ACTIONS in autism.
Like OPENING and CLOSING doors.
Like looking through a book OVER and OVER and OVER again.
I recently gathered my thoughts on a challenge that a speech therapist shared with me. The situation involved an autistic boy who spends the bulk of their sessions engaged in repetitive behaviors. These actions are always the same, as I mentioned above: opening and closing doors to a dollhouse and flipping through the same book over and over.
This therapist felt at a loss for what to do.
As an autistic OT, I have a few thoughts. Before I say anything more though, I want to start by addressing the very start of her interaction with me.
She mentioned "sensory differences" twice, and because she did, I assumed she felt that the opening and closing of doors, or the reading and re-reading of that certain book was based on "sensory differences", but I would not immediately characterize these actions this way.
Just to clarify, sensory differences refer to either of the following:
1- sensory modulation differences in which a child is either over- or under-responsive to sensory input (so a child with tactile modulation differences, for example, may have a defensive reaction to messy tactile media or may crave touching a variety of different textures),
2- sensory discrimination (when a child struggles to "make sense" of tactile input to their fingers let's say, as when a child cannot fasten buttons without looking at them).
This child was leaving a therapeutic situation and engaging in actions, and there may have been some sensory aspect to why they enjoyed the actions they engaged in, but I don't feel these actions were necessarily "driven" by sensory processing differences. (That said, the child may have been experimenting with sensory discrimination, and perhaps slightly varying the force with which they open and close the doors, or trying to turn the pages themself with different touch pressure.) But, I will share my initial thinking.
First, we don't know what we don't know - a great starting point, I believe, for when an adult is baffled by a neurodivergent child's actions. So, I suggest fully accepting that a given motor activity a child engages in holds meaning for that child.
That is not to say that the child necessarily wants to do the same activity over and over (they might or they might not - we don't know). But when any person engages in a certain task, it enables them to have control over a situation to some extent.
In an ideal world, and if this child was at home, or was feeling completely self-regulated, perhaps there is another action that they would prefer to engage in. But in this therapeutic environment, perhaps the one activity that they can access, that they know can feel regulating, may be to open and close doors of a dollhouse, or repetitively read the same book.
WHAT I WONDER here is about what demands are put on this child when they enter the therapy space. I am specifically thinking about the environmental sensory demands (lights, other children - they can be loud, unpredictable, and very dysregulating, is it a speech room with shelves that are not covered and with clutter that is visually overwhelming?).
I am thinking about the social demands (is this a group? is a sibling there who keeps trying to join in the therapy?)
What about communication demands (are communication exchanges with the SLP organic, child-led, scaffolded? Or are they difficult and demanding?)
What about interoception (does the SLP see this child at the end of the school day? are they hungry? tired? do they need to go to the bathroom after school and do they typically withhold their poop until they get home?)
I ask these questions about demands on a child because I have found that a dysregulated, stressed child seeks regulation. Repetitive actions that a child controls can provide some degree of regulation. And this is great. And it may or may not feel good to the child in the therapy session - again, we don't know.
But as neurodiversity-affirming practitioners, it is not our job to stop a given action. Rather, our job is to support the quality of life of autistic children, to accommodate environments and modify tasks, so that they are able to engage in activities that are meaningful to them, so they can master skills that they want to learn.
So, bigger questions I would ask?
1- Can I set up the environment so the child is as regulated as can be from the start of therapy? (You could ask the parent or the child's OT to provide input on what sensory input is dysregulating to the child and what sensory input is regulating (like swinging, being pulled on a crash pad, playing with slime)
2- Could I do an even better job of eliminating demands from me right from the start of the session and follow the child's lead?
3- If a child does gravitate to the house or the book, can I honor the child's multi-modal communication to enable this child feel respected, safe, and even entertained and happy WITH the SLP (does the therapist stop when they push their hand away, engage when they pull their hand toward them for help, do they laugh when you make the dog jump on the house, do they groan or frown when they try to open a door yourself)? Why not follow the child’s lead and springboard their speech therapy using this activity?
To be honest, I am so curious about what her speech goals are with this child - and I didn't get there. But I think, for me, cultivating trust, and regulation, and felt safety are crucial.
What do you agree with in this post?
What would you add???
More from Dr. Lisa Marnell and Kids Master Skills . . .
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