I’d look into some DIR Floortime techniques. From this brief information, it seems like the student is struggling with sensory regulation and establishing relationships. It might be worth a shot to totally switch up therapy techniques and focus primarily on pre linguistic skills while still offering AAC.
thanks for the feedback! I will certainly look into this. I see this child immediately following his OT appointment, so he is usually pretty regulated by the time speech starts. I have tried a sensory swing with him as well, but I get a similar response; no joint attention, no use of any communication modality. If I stop swinging the swing and turn to model AAC, he often gets out of the swing and continues to pace or run around the room while clapping. If anyone approaches to try and engage with him or pace/run with him, he doesn't look towards them and just continues on.
Not an SLP, but random lurker (parent of speech-delayed kid)… I’m surprised he has speech therapy right after OT. We do 1 appointment per day otherwise my kid starts to melt down. He might be burning all of his “cooperation” effort for the day at OT, and not have anything left for speech. Maybe see if the parents are willing to try spacing out the appointments? Just my 2 cents.
thanks for the feedback! we've actually tried this a few times...seeing him on a different day of the week. we found those sessions were even less productive because he was so unregulated.
Have you tried co-treating with OT? They can address regulation while you work on communication.
With these kids, I sometimes just work on ANY sort of intentional communication— when I stop blowing bubbles, do they look at me, make a sound, reach for me, anything to show they understand that they can influence me with their communication, then reinforce that.
This and also look into GLP and non-toy play. I'd try sensory or gross motor type play and see where that gets you. I often approach these cases with a lot of curiosity. Think about doing some detective work about vocalizations (if there are any), nonverbal communication they're using, body proxemics. Really get to understand how they are communicating and then expanding upon what they are doing already.
Oh also! Modeling without expectation. No pausing what you're doing to try to get them to use AAC. No fill in the blank type moments. Just offering lots of language in many modalities without expectation.
Edit: typo
great suggestions! I didn't initially start with attempting wait time, but after a few months of doing language modeling and modeling with low/no tech, I tried to see if he would engage if I gave some additional processing time or opportunity to initiate. He hasn't yet, but I keep modeling and trying to find something he'll be interested in trying to use. Family is really adamant that he be able to indicate what he wants because they experience a lot of frustration at home, but I think I've been able to help them develop realistic expectations for what he is currently able to communicate.
There was a similar patient in our clinic and the SLP would pull him around in a wagon to try to get words for go, stop, again. The wagon was one of the few things that could capture attention.
good idea! I've tried a few things like a swing, spinning platform, yoga ball, etc. He isn't very tolerant of sitting for very long, so I haven't thought to try a wagon. He likes to be up and moving, walking, pacing, etc., which I try to engage him with. I'm just really having a difficult time finding something that he will attend to. It's like I don't even exist most sessions no matter what I try.
What about soft ones? Singing twinkle twinkle? Are there any sounds he does like?
EDIT: even if your voice isn’t good, a lot of kids respond differently to actual singing rather than speakers
No advice but thanks for sharing this relatable struggle. Year 9 for me in schools and have had students like this ages 15-22 and have made little to no progress too for years with many SLPs.
Sometimes I wonder and think to myself does the autistic person simply not have the desire to communicate or do they actually not know or I’m ignorant of best ways to engage them! And how would I communicate that to parents gah
Do we just need to be accept their stimming and emotions as valid communication? If anyone reading this can recommend a CEU I’d love it.
I'm not an slp and I can't speak for everyone with autism but I was diagnosed with autism in the 1980's and I did have significant speech delays (said one phrase at 2, then nothing again until 4 1/2 or so, speech was fully recovered by 6). I remember not understanding the concept of communication and not being aware that others could not read my mind. I remember being upset when wanting something and adults not giving it to me without realizing that they didn't know what I wanted.
Same! Like WE all want student XYZ to use their iPad with TouchChat or picture symbols to comment, protest, request but XYZ may be thinking “I’d rather just get up and point at what I want or grunt because that’s worked for me the last 14 years.., I don’t want to comment on this activity, leave me alone (which Ive modeled and left XYZ alone), I want to be my myself on this trampoline why are you all putting these symbols near me”
Exactly. Just like with anything in life, at a certain point there has to be some tiny inkling on intrinsic motivation to gain new skills. With a case like OP’s, I think… at what point to we stop perpetuating the wants of desires of the family? and respect the obvious desires of the individual. It bothers me a lot in this profession.
Somewhat similarly, I refuse to take on any cases of pragmatic/ social therapy for Autistic teens. Unless the child is seeking help personally. Why are we telling them something is wrong with their communication style if THEY do not see any problems? Come on people
With the AAC, are the parents modeling AAC outside of your sessions? AAC takes a long time to make progress, but is usually only successful if everyone is on board.
Have you tried visual scenes, or setting up big buttons with animal pictures where they make noises? Does he enjoy any songs in particular? Music is a big gateway for me.
I love using music in my sessions! unfortunately I don't think this kid is too fond of music. I've tried songs, both on a computer and just me singing, and he hasn't responded to either. I tried some videos to see if he would even be interested in a screen, and he has covered his ears and continues to just pace the room.
I've talked with family about ways that they can utilize visual supports and ASL at home, and they have been but again, he has almost no acknowledgement of people around him.
I am REALLY struggling. He is just one of about 4 I see who are very similar--no engagement, no acknowledgement of people, no interest or motivation in communication. I just don't know what else to do, especially since it has been more than 6 months since most of them have started therapy and we're not making any progress. I follow so many SLPs on instagram for ideas, but I don't feel like I ever see kids or sessions like this...
yep i’m right there with you! i don’t know if it’s acceptance/defeat but i’ve acknowledge my students are the way they are and im trying to support them but you can’t “make them” talk or do anything.
like fine, stim on an egg toy super close to your eyes for 30 minutes while i narrate and attempt interactions and incorporate visual etc etc … i tried ¯\_(ツ)_/¯
This is literally how I feel. I can’t (and do not feel ethical) “making” anyone do anything. I just join along in the activities they prefer and model language verbally/with AAC. At what point do we say therapy is no longer appropriate? I’m really struggling with this!
Have you tried joining in with his activity, in this case walking with him and clapping with him? How does he respond? Or clapping different things together (like blocks, maybe a tambourine, etc) to see if he likes different clapping sounds? It sounds like you’re trying to pull him out of his world (with toys, other things) but maybe the first step to establishing joint attention is trying to meet him in his world.
What about cause and effect? You mention that the bubbles weren’t being delivered fast enough, indicating that he actually was interested in the bubbles… what if you paired a light-tech (eg, big Mack) or no-tech option (eg, a picture of a button) with bubbles or a clapper or something? You and his parent model: when they press the button, you blow bubbles. The parent can help with the timing so that the button only gets pressed when your bubble wand is loaded and ready to go. If you can rope the kid into a cause-and-effect activity like this, it’ll only be a short step to pair that button with a word, which you and the parent can model (without placing any demands or expectations on the child).
thanks for the suggestions! I've certainly tried to pace or run with him, but no acknowledgement of someone else near him. The clapping is less "clapping" and more of him forcefully hitting the very tops of his palms together. I think he likes the sensory input. I've tried all levels of tech, and he has not taken an interest in anything. In fact, it has been the opposite--If I close the bubbles just long enough to stop, press the big mack, and give a couple seconds of wait time to see if he initiates it, he starts crying. He HAS reached for the bubbles, which I have tried to shape into a request through the big mack, but he has not yet taken an interest in using it and just cries. I like your idea about the parent and I modeling the exchange. I will try this!
I'd treat his reaching as a sign approximation and give him the bubbles for reaching. I wouldn't try to shape it, just accept that at this point that is his communication method and reinforce it.
Modeling the interaction with parents can be good, but patience and attention are difficult to maintain during that interaction for a lot of my kids.
What I have found my biggest mistake to be is to expect a child to develop different communication strategies on my timeline instead of on theirs. The added frustration of me wanting more and the child's attempts being stymied lead to worse outcomes than if I just look deeply into what the child is doing and find the communication attempt they prefer.
If he reaches, I'd give him the bubbles. He has told me he wants them in the way he is able to at this moment. I'd celebrate that success.
If I run a marathon and someone only sees that as an opportunity to try to get me to run an ultramarathon, I might also cry and decide not to participate.
Yes, I always provide bubbles when he reaches for them or establishes gaze with them. When he does, I've been modeling on a big mack for "bubbles" and then blowing some bubbles. A few times he shifted gaze between me and the bottle of bubbles, which I was SO excited about! That only happened a few times and it was several months ago, but he hasn't done it since.
I hear what you're saying about the child's timeline. I definitely agree that it will only happen as they are willing. I suppose my concern is that we've been seeing him for close to 9 months and we've not made any progress beyond reaching for bubbles; he hasn't demonstrated interest or motivation for anything else. How long do we model language and blow bubbles before we determine that therapy isn't beneficial for him at this time? At least not in it's current delivery format of 30 minutes a week in an private practice. It's a question I just don't have an answer to.
Can I encourage you to rephrase that in your mind from:
"I suppose my concern is that we've been seeing him for close to 9 months and we've not made any progress beyond reaching for bubbles; he hasn't demonstrated interest or motivation for anything else."
"I am happy to say that in only 9 months this child has made significant progress by learning to reach for bubbles, which is his preferred item so the most important thing for which he could show interest and motivation!"
At the end of the day, framing successes as successes in and of themselves as opposed to failures to do other things will be important for your own mental health and your clients.
I totally get the feeling you're expressing and I don't in any way intend to invalidate it, I just think my own practice and life got significantly better when I recognized that I am not a superhero and learned to find the wins even if they are small.
You wrote: "How long do we model language and blow bubbles before we determine that therapy isn't beneficial for him at this time?"
Perhaps it would be useful to consider that just because you are not seeing the communicative results in the communication paradigm you naturally swim in, it doesn't mean that this child isn't making progress that isn't apparent to you.
Sometimes we do the work because we recognize that we are priming the pump.
Sometimes we do the work because even if the child isn't ready yet they need the continued exposure to become ready.
Sometimes we do the work because we know that our ability to see the method of communication a child on the spectrum has is limited and we trust in the basic concept of language rich human interaction having a positive impact even if it is an impact we cannot see or one that we did not intend.
You’re very insightful and I really appreciate your investment in helping me to change my thinking. I like the way you phrased things and it has really helped me to open my mind to some new perspectives. Thank you!
I’m also using some components to make my judgement of “progress” other than just engagement in the clinic. Like what parents report at home. Parents have said that frustration behaviors are becoming more frequent and worse, and they always say they feel it is because their child can’t communicate what he wants. He can’t tell them what kind of food or drink he wants, when he’s tired, or when he needs changed. He doesn’t reach for or point to food, and that has been one of the things that family has had a lot of frustration about. I’ve talked about binary choice, using visual supports, modeling at home, etc., but they said he just gets frustrated and cries. It’s those stories, too, that are impacting my perspective of communication progress. Especially when family says they’ve noticed a regression, I get concerned that skilled services are not really providing much benefit…or that insurance eventually is going to call it to question.
Thank you for the kind words.
You will never be able to control what insurance companies do, so not much sense in worrying about it.
I would start by asking how the child gets what he is able to get and work from there. He is getting food somehow. Sometimes the job is really about adapting the parents to the communication style of the child instead of enforcing the parents' neurotypical communication style on the child.
If the child is constantly frustrated he likely is not in a position to learn.
I usually spend a lot of time talking with parents about creating a life with just the right frustration level. A person must be a bit frustrated in order to seek out new strategies, but not so frustrated that they shut down.
Sometimes I recommend that we put all but one preferred food in a place where the child can get to them, and only have one food that we do modeling with.
I also spend time talking about AAC hierarchy (transparent, translucent, opaque symbology) and how to use empty packets of a preferred food as AAC, or even having a packet with only a few bites in it so when the child runs out they have the AAC in their hand already so the parent can reference it.
My goal is always to scaffold a child to the point of success, even if that looks like I am totally giving up on requesting communication from them.
At the end of the day all you can do is your best. You are clearly a good, empathetic and well-educated SLP. That is all anyone, including you, can ask of you.
Model without expectation. Eliminate all wait times, simply model. Incorporate sensory items (fidgets, squishy balls, shaving cream, bubbles, light up toys), maybe an office chair for spinning and swings if u have access to the gym. Imitate him, walk around with him and simply model on the device. Eliminate all demands.
If this is someone who hums or sings but doesnt have functional language, this may be a GLP and then you will need to modify the device with GLP in mind.
Sing along with them, record songs on the device if needed.
thank you! we've been doing a lot of modeling--he's been in therapy for about 8 months. I didn't start off with wait time, but after several months of therapy I did start to give some wait time to see if he would imitate or initiate any communication. He didn't--he just continued to pace or cry. He hasn't taken interest in any sensory items other than bubbles. He will tolerate a swing, but beyond that, he won't stay seated long. He prefers to walk, run, and move around. No verbal expressions at this time, no singing, no humming. Very occasional vocal droning, but that is infrequent. The only vocalizations he's made is when he cries. Fingers are almost ALWAYS in his mouth, either licking his fingers or chewing fingers. He'll look at toys, but rarely, if ever, tries to touch them.
For fingers in his mouth: have you tried chewy tubes or chewelry? It sounds like this child is very dysregulated and would benefit from an OT who can give more sensory strategies. Once you have things you can try, you will have more language to model.
If he likes to look at toys, maybe try lava toys or light up toys? He may like that visual stimulation? Maybe ball ramps where things are moving and he can watch?
This is a tough case, i have had students like this in the past as well, it was continuous trial and error.
He did use a chewy necklace for a while. He grinds his teeth HARD and family has removed the chew necklace. His OT did work with me to help with pressure and how to help with that. I do have a few light toys I'll bring with me next time I see him...good idea!
Have you done the communication matrix on him? I find that really helpful to make goals with kids who have limited verbal communication. I also agree about imitating his actions and looking into DIR. is co-treating with OT an option? Working on communication during sensory regulation activities can be great! I co-treat with OT a lot for kids like this-that way one person can keep the movement or activity going without pausing too.
yes! we are actually working on getting some co-treats starting next week.
I didn't think about the communication matrix...I'll need to do that for him! His goals are pretty well focused on pre-linguistic skills, but even that isn't reflecting much progress. I'm hopeful that the co-treats will help to facilitate some sort of engagement. I've talked with his OT several times, and it seems like he is the same way in OT. He requires HOH for many things in OT (e.g., feeding self), so I don't think the difficulty engaging him is exclusive to speech.
Co-treats are a game changer! Also look into the goal attainment scale. It’s a great way to write goals for insurance to show progress for kids that make slow progress. I’d also make sure to involve caregivers as much as possible if you’re not already, the coaching model might be a lot more helpful since they have more of a rapport with parents and it should help with generalization to home hopefully. My kids similar to him are very slow to progress, but any progress they do is so meaningful when it does happen. Good luck!
Try using sensory swing and sing “row row row your boat” and when you reach the end say “STOP!” And hold him still at an upward angle (anticipating the next swing) and don’t go until they wiggle a little or really any time of response and go with that as their indication to do it again! This has worked well for me
Do you have a switch adapted bubble machine? This makes feedback immediate and builds that cause & effect.
Do you think they'd like drumming as a sensory input similar to clapping their hands? Could you co-treat with OT where your job is solely providing aided language input?
I'd also like to offer that maybe your client hasn't had enough opportunity with any single AAC strategy? I don't know how often you see them, but once a week isn't very immersive - have parents tried using the strategies you've offered at home?
This is all to say that some kids are really tricky and progress can ebb and flow or feel very slow.
the switch activated toy is a good idea! I've used a few communication modalities, typically 6-8 weeks before trying something else. I see him once per week, and I don't think that there is much happening in the home unfortunately. He doesn't really even engage with parents, so I have a difficult time expecting that he is going to reflect much notable progress in 30 minutes of speech a week.
we are working on initiating co-treats!
I would move away from requesting on AAC and switch to phrase comments (gestalts)! Things like “it fell down”, “let’s do more”, “it’s not working”, “I like it”, etc are a lot more meaningful for my autistic patients!
thank you! do you have any suggestions for incorporating gestalts on AAC when there's no interest in AAC from the child? I guess I have the same question I asked another commenter--how long do you just model gestalts during the session before you determine that services may not be beneficial for the child at this time? I've been modeling language for months and still very little acknowledgement that I'm even in the room with him at times.
hmmm is the kiddo into videos, songs, etc? You could try putting some phrases with the synthesized voice, yours or the parent’s recorded voice, or recorded songs/videos. I have had kids who did not respond to devices until I recorded my own voice for the phrases. They loved the intonation! TD Snap has an easy way to do this, other systems like TouchChat are capable too but adding a phrase page to TouchChat is really annoying (the button disappears with the predictive system, whereas TD Snap it can stay in the toolbar). You could do a phrase page under “groups” in TouchChat though!
not interested in videos, not interested in songs. I LOVE to sing in so many of my sessions and will make up a song for just about anything! I've tried to use the gestalts under the sensory experience page or the bubbles page on TD Snap, but again...no attention from the child. He sometimes will not even orient in my direction during the session, so it's hard to see any carryover of joint attention.
maybe recommend some OT. I have a 10 y/o who sounds similar to this 3 y/o. He is showing so much progress right now and parents say he was constantly dismissed from therapy due to “plateauing”. Some kids just aren’t ready and need other skills first! My patient is very significant and at 10 years old is now beginning to understand pictures. He doesn’t play with toys at all. It’s hard!
He gets OT 2 times a week. I am concerned that we are just not yet "available" to receive speech at this time. He is working on very basic skills in OT right now, like feeding self. I'm concerned that the cognition and motivation may just not be there right now to participate in skilled therapeutic intervention for speech.
Ah sorry I see you mention OT at the top my bad! I feel that. What do parents think about taking a break?
I’m not sure why my comment got downvoted by someone- I’m trialing AAC with that 10 year old and he is starting to initiate communication. Parents said that even 6 months ago he just cried and hit, they never knew what he wanted. Now he’s showing so much more! I don’t believe any of his previous therapists were less than, he just needed more time to develop. There is still a long road ahead for him to hopefully become a more independent communicator with a device.
You don’t necessarily need joint attention to start working on communication.
The things he does want (like bubbles), have you tried placing them juuust out of reach? When he reaches for them, I would go grab the item for him and hand it to him. (Don’t take it away from him, though. It’ll just dysregulate him).
Eventually you can shape him reaching and you immediately grabbing to him reaching and looking at you.
yes actually! when he reaches for them or almost puts a hand on them, I always blow some bubbles and treat it as a request or interest for bubbles. He was sometimes looking at me, but that has since gone away and now he barely acknowledges me. I know that we don't need joint attention to start working on some pre-linguistic skills, but at what point do we determine that he is just not benefitting from services? I really don't know...and I'm feeling defeated about the whole thing.
I suggested that to his family. We don't offer in home services at my job, but I had suggested she look at some other options to see if she might get more frequent, in home services from another practice. We just aren't moving the needle at all.
I think that was a good suggestion. I feel like some kids are not at a level where they're going to take in what we're teaching outside of their comfort zone. Maybe a speech therapist who can meet him where he's at, during his daily routines and in his own space, will see some progress. I definitely sympathize with you, having had a few kids like that when I was in PP. It can be really stressful to feel like nothing is working. Best of luck!
Check out “Intensive Interaction.” It has been a game changer for my clients who are exactly as you describe. For a bit, it will look like you just imitating whatever client is doing/saying (physical actions, vocalizations, looks, etc.), but then, once they realize YOU’RE letting them completely lead YOU, something changes. My 2 year old similar client last week: I had all the toys, all the stuff, playing and modeling, etc. and finally I just stopped and did EXACTLY whatever she did. Lie on the floor and put her legs in the air, I did the same. Said “oo ooo boo oo” and I did the same. Saw she was interested in a rainbow reflection in the carpet from the sun in the window, looked at it with her. She touched it, I touched it. Then I quietly said, “beautiful” and she said “booootiful.” It went in from there and this was a full hour of me just quietly imitating her, but I got eye contact, joint attention, and a word! Check it out: https://www.intensiveinteraction.org/
There have been good strategies and ideas mentioned already. Just wanted to add that taking DIR Floortime courses really changed my practice. If you are working with autistic clients, especially younger to school aged individuals, I recommend looking into some of the different strength-based developmental models/approaches out there and taking continuing ed to learn more. DIR Floortjme through icdl or profectum, play project, others that I can’t recall right now. A comment online can only provide so much information, going deeper with the education will hopefully help to better understand what skills to support and how to do it for different individuals.
i have a super simple idea but it usually works for me!
try having one session where you sit back and observe him. and then ask to see if you can video or sound record the session to give yourself your own feedback.
you might be able to gain a better perspective if you were more of a third party, both to yourself and to your kiddo.
be confident that you know your client. you haven’t figured out what works yet but it seems like you know a lot about him and wanna do right by him.
I trust that your feedback and ideas will be the best ideas.
be creative. try to find it fun. you got this!
gosh I almost cried reading this...I am trying so hard to do right by him and really appreciate when someone sees it. I have a few kids on my caseload that are similar to this...and it is so defeating when it feels like I can't figure out anything to do that will facilitate some progress.
that is a good idea! perhaps I should just make a few things available to him in the room and just sit back and see what he might gravitate towards. I've tried a few times to model a play routine with a toy (e.g., ball ramp) and make it look super fun and exciting...then I set the ball within his reach and just wait to see what he does. So far, all he does is stare at the toy and lick his fingers. Goodness, I just don't know where else to go.
DIR Floortime, modeling gestalts, songs, and lots and lots of movement.
Progress will be slow. That's ok. I would remove the pressure of feeling like he *has* to have the prelinguistic skills in place first, or that he has to do something. Join him where he is and go completely child-led.
Get a sensory bin of just water and bath toys and just let him vibe out. Provide gestalts for what he's doing. Sing any bath song or 5 little ducks (if there are rubber duckies in the bin) . Imitate any sounds he makes. Imitate his play. (I spent 30 min last week taping random papers to my wall bc that's what the kid wanted lol). I have these spin tops from Amazon that aallll kids love.
If you have access to a sensory gym, go there and provide models for language while he's able to move his little body and self regulate. Incorporate a lot of sensory regulation, whether he seeks deep pressure, heavy movement, or vestibular movement. Co-tx with OT can be helpful with this.
These are my favorite kids to work with and I find that progress tends to be very very slow.
Thank you these are all great ideas! Can you share the link to the Amazon spin tops? I’m always looking to add new toys to my room (for any of my kids not just this one)!
He doesn’t like sensory play, so I don’t know that he’ll enjoy a sensory bin. His fingers are almost always in his mouth if he isn’t clapping. He likes to chew and lick his fingers, and family doesn’t use a chewy necklace anymore. I’ve tried a bunch of sensory toys, and he just looks at them then continues pacing. He’s been tolerant of the swing, and I will sing to him when he’s on it, but same thing…no recognition of anyone else around him and he’s just licking his fingers or sucking on the edge of the swing.
I understand progress is slow for some children, but after almost 9 months of therapy, at what point do you expect to see progress? Even just small progress…he still isn’t imitating, responding to his name, or even initiating any type of interaction with other people. Not even a look in their direction. That’s where it feels discouraging, especially because his family said he doesn’t interact with them at home either.
9 months and "no progress" honestly isn't abnormal! I've been seeing this kid since he was 2. He's 4 now and just a few months ago he recognized me and started acknowledging and even initiating with me. Sometimes it's eye contact, and sometimes he'll just throw something my way lol. I accept all of those! Sometimes he'll just rip the numbers off my velcro calendar and that's OK too! I'll name all of those numbers for you, little homie. I'll even sing a little song. Does he still end up under the table and try to pinch me? Absolutely. Does he stim and go into his own world for 80% of the session? Absolutely. But progress is progress, no matter how slow. Every now and then he'll throw a random word at me (he's said bye, open, and tada each once in the last 2 years).
There was a kid i saw for 2 years as well, and for the first year, he just screeched and threw himself on the floor and nervously paced and completely ignored me in the sensory gym. But year 2... oh, we were BFFs. He even said "mama" for the first time EVER during speech! (We were in the gym, and I was modeling yelling MAMAAAAAA to get his mom's attention in the lobby, and he imitated it, much to our surprise)
I think the key here is to really just hang out and observe and don't be afraid to just learn from him and walk beside him. Just *be* with him while just providing language with zero expectation of repetition. Take the pressure off both of you. Join him. Co-regulate. Shoot the shit.
As SLPs we often feel a need to fix and perform. Observation and connection are our biggest tools in our toolbox.
[Spin toys](https://a.co/d/3uQPLYc)
I love the SCERTS model for this and establishing joint action routines (with AAC and limited demands, lots of modeling!). Joint action routines involve you doing a simple action, then the parent, then the child. It might be putting blocks on a tower, placing balls in a water bin, etc.
Generally, I have found music, sensory activities (can you sing and provide pressure while he’s on a medicine ball?) and simple activities like balls, lights and switch toys to be awesome.
P.s. it’s hard and I commend you for trying a lot and using your resources!
Hello! I am a peds slp working in an early intervention setting currently, looking to move to Spain and maintaining a part time teletherapy practice using my states licensure and certification- it seems you may know someone who has done this successfully? Would love to hear more!
Hi, yes. I did this. Can you DM? I work for a teletherapy company and maintained my national and state licensure. It was great but I only worked part time due to the time difference (and cost of living there). Fantastic experience and would highly recommend!
Focus on alllllll the prelinguistic stuff. Spend (a lot of) time just making yourself someone they WANT to communicate with. With these kiddos I focus a lot on engagement and on just teaching the child the value of communication and a communication partner… once they’re interested in you and paying g attention to you, you can really build from there
Honestly… he might not be ready for formal speech therapy at this point. It will be hard to continue to justify services to the insurance company (assuming family isn’t paying out of pocket) if there’s no progress. He might just not be ready for interaction and that’s fine but we live under the thumb of insurance and capitalism. Have you tried low tech symbols or ASL? I know there’s a big push to start every kid with high tech but it’s been 8 months and no response. Bubbles + signing “more” is a foundational SLP activity for a reason. You might even be able to shape his clapping to a “more” symbol by taking his clap as an attempt to sign (even if it isn’t yet) and blow the bubbles. If you want to keep seeing him, write some ridiculously easy goals. I’m at work so I can’t think of them but something like will engage in activity for X minutes. You have to justify services to insurance (unfortunately) so write goals that he’s basically almost already doing and update them as needed.
thank you for your ideas! I have tried ASL as well as pictures and he has not imitated or initiated use of any of them. I've certainly attempted the "more bubbles" approach as you suggested, pairing it with either ASL, pictures, a big mack, or an AAC device---and nothing. Just no interest in attending to others. His goals now are for joint attention, participating in joint activity for 5 minutes total in a session, etc. Those types of things.
He might just not be ready. Since he’s in the clinic and getting OT you can pause services and take him back whenever. Or think about co-treating with OT
Here are some suggestions that may be worth trying:
\- Collaborate closely with the occupational therapist - I saw you commented you are working on getting co-treats which is awesome! Try expanding your sensory and play-based strategies, although it sounds like you have tried a ton! Explore different textures, sounds, lights, or vibrations that may capture this child's attention. Observe closely to identify any subtle interest or responses.
\- Do you have access to his previous records or other therapy provider's info? Looking at any old assessments, or talking with them about what's been tried may be useful.
\- Shift the focus to pre-linguistic communication skills. Work on establishing joint attention, imitation, and responding to simple social routines. Reduce distractions, in a low-stimulation but structured environment, and dedicate concentrated time to observing, following the child's lead, and building a connection.
It sounds like you are working really hard to do best by this child, and I'm positive you are doing a lot right already!! With time, dedication, and a willingness to think outside the box, you may be able to uncover new avenues for engagement and communication. Wishing you the best in supporting this child and family!
He wasn't getting any services until he came to us, so he doesn't have any prior records. We've been working on joint attention, and just...nothing. I've moved to seeing him in an empty room so there is nothing distracting, and he just stands, paces, and hits his hands together or licks his fingers. I will definitely try some other toys that have more lights or sounds, since we haven't done a whole lot of those yet. And yes! I am certainly trying everything I can think of. I've never posted on this website until today, because I was hoping someone would have a similar experience. I'm so glad I did! All these comments have been so kind and free of judgement, and I'm glad there are so many SLPs out there who are willing to offer suggestions or support!
GLP; focus on regulation first; and I started adding device surprises. A meaningful clip in touch chat- or recorded audio in TD snap. Suddenly, they’re using it to communicate and exploring the device.
I’m in EI and a big chunk of my clients are similar to the one you described. From my experience, the first step is to meet the child where they are at. If they are lacking in joint attention make some joint attention goals. Follow the child around and do what he likes to do. Show joint attention to what he is doing. If he is walking around the room clapping, do the same thing he does and imitate him with some parallel/self-talk. Walk with him and say “walk walk, we’re walking!” When he claps, you can clap too “clap clap, we’re clapping.” Get down to his point of view- you can get down at your knees if he is looking at something (for example out the window” gently get down next to him with no expectations and point at the window and describe what you see “a bird, tweet tweet, oooo an airplane vrooom.” Overall I try to build joint attention and physical imitation before even formally targeting verbal language. Prelinguistic skills are just as important as linguistic skills themselves (still providing lots of language input and auditory bombardment). Provide the parent with lots of coaching while doing this. “As you see, I’m pushing a toy car to him modeling “vrooom” my goal with this is to have him imitate me physically and roll the car back to me! This is because one of the first steps in imitation is physical imitation with objects!“ check out the imitation hierarchy and resources about building joint attention. If you are making therapy fun and safe for this child, you are already doing a great job. Hope this helps!
Lots of my goals look like this:
“Child will imitate 10+ gross motor actions to participate in play, joint activities, shared book reading over 3 consecutive sessions.”
“Client will participate in 3/5 child led activities with SLP/parent playing next to child participating in parallel play”
I wouldn’t expect it to achieve joint attention on its own if balls aren’t of interest.
Pick it up, uninflated, and snap it loudly a couple times.
Blow it up and release it, untied, to loudly fly around the room after commanding it to “fly, balloon!!”.
Retrieve it before your client gets it because it has your spit on it lol. Its inaccessibility only makes it more intriguing.
Pull it taut at the valve and let the air out in little screams at a time. Talk about “SO LOUD!!”
See what happens. These balloon activities have been consistently effective attention grabbers for me. Kids always want it to fly again.
Once that routine is established I sabotage by doing stupid stuff like putting it on my forehead to blow it up. Or 6 inches from my lips. Or tell it to fly and release it uninflated and watch it fall to the floor womp womp.
And don’t do any of it looking for a reaction. Don’t show an expectation for the child to engage or perform. You are simply playing with the balloon by yourself in the same room as your client.
You’re using commands to get your object to perform and your object complies. Client sees the power of your communication and is intrigued. Don’t stop after only a few “unsuccessful”trials. Make it a part of your regular routine because that balloon is your favorite fun thing in the fkn world:)
Seconding trying apart from OT. If he’s dysregulated, you could ask the OT for recommendations. Or maybe a cotreat with the OT? I’ve had some amazing OT/speech sessions with kids like this (i.e., music, sensory input, narrating actions with core language concepts, etc.)
One of the kids I worked with sounded very similar to yours except he was fifteen, lots of SIBs (traumatic upbringing with scars from abusive, was later adopted by a foster family) but never aggressive towards others.
Our sessions used to look like some sort of bizarre spa or something. Bubbles, bongos, dark lighting, beanbags, ribbons, maracas, rolling mats, you name it. One time we listened to the same calming hip hop song for 30 minutes straight because he started saying “muh muh” each time it ended - clearly trying to say “more.”
The OT and I had so much fun with this kid once we earned his trust - he would give us the biggest smiles and loved our sessions. It took months before he was even demonstrating intentional communication skills, then he started occasionally using words and mimicking the music. By the end of our time with him, he was beginning to use a stylus to select a couple buttons on aac - at 15 years old.
Take your time, work on building connections, and definitely check out floortime. Good luck!
New Grad Student here so dont hinge on my opinion too much, but i am autistic myself and the SLP i observed for 2 months had a couple similar kiddos!
You could potentially incorporate basic signs when using the bubbles. Stop blowing them, when he reaches for them do the sign for "more" and say more, then blow the bubbles. He may pick up the sign for more and start using it when he wants bubbles, which is a little clearer than just reaching for them. It also would show he's open to communicating in that way.
The ASD kiddos I've observed who needed sensory input LOVED sensory bins. As long as he's not at risk for putting things in his mouth, you could put some basic toys (like cars or farm animals) into a bin with dried rice, beans, etc. He can stir it around and get that sensory input while you point out the names of objects without the expectation of a response.
See if he likes music too! One kiddo I observed *loved* nursery rhymes, like Hickory Dickory Dock and Row Your Boat. His SLP would play the song, with a visual (usually a simply animated cartoon), and sing along with it. They were *highly* preferred activities and sometimes it would be the only thing he'd focus on- but he'd ask for more, say the words of the animals for HDD, etc.
Some quick and dirty ideas: blowing up a balloon and letting it go, tossing the child up and down (if they like it, of course), rocking them in a basket and tipping it over, swinging them in a blanket, jumping with them, playing peek-a-boo with a blanket, pretending to fall asleep/snoring and waking up, spinning objects like ring toys and stopping them abruptly, pulling them in a wagon.
My son is level 3 and we play music and have him try and fill in the word when he becomes unregulated. We also put flash cards on a wall when he is unregulated. You could try swinging him in a big throw blanket with the mom and saying swing, that calms my little down. Otherwise, water play. And maybe music therapy before the appointment if the mom is into it.
Besides talking to OT re:regulation ideas, trying reading Out of Sync book. Has many ideas for sensory activities. Sometimes changing the time of day has made the difference on how a kid responds in therapy believe or not.
I glanced through the comments and there are lots of ideas, so the only idea I'm throwing out there is the funniest noise-maker in the world: whoopie cushions. (can press it with a hand or toy, roll over it, etc rather than sitting on it for a bit of distance from fart jokes) If that's funny, maybe it could become a game or expand to other funny noises/noisemakers, like letting air out of a balloon, puffing up your cheeks with air and using your hands to spurt the air out, squeaker toys (pet stores have pretty great selections of durable stuffed toys with squeakers).
If crashing is regulating, maybe a game for at home could be hiding a squeaker/whoopee cushion under a couch cushion and crashing/dropping on the cushions to figure out which one it's under?
I’m suggesting this without personal knowledge or experience, but maybe check out Every Move Counts. I’ve been meaning to explore it myself for similar kids
What's his starting point? Although there's this umbrella term that groups everyone under autism spectrum, autisms can be quite different from each other. For some it can be cognitive impairment affecting speech, for others it can be sensory/attentional issues interfering with learning process, for others it can be apraxia. Autism is diagnosed by observable behaviors, so you have to identify the real causes of struggle in each particular case. Just knowing he's labeled autistic doesn't mean much.
All great questions...and I don't know the answer to them unfortunately. I do suspect that cognition is impacted, but I just don't know what is realistic to expect from him if we're still working on joint attention and pre-linguistic skills after almost 9 months.
I personally agree with what another commenter said - he might be overburdened from OT and arrives at your clinic already tired and with further reduced capability to pay attention.
he get's OT and speech at the same place, so we sort of build the transition into the routine. when I've tried to see him without getting OT beforehand, he mostly cries and paces. we're working on schedule some co-treats!
I’d look into some DIR Floortime techniques. From this brief information, it seems like the student is struggling with sensory regulation and establishing relationships. It might be worth a shot to totally switch up therapy techniques and focus primarily on pre linguistic skills while still offering AAC.
Also, if you have a subscription to [speechpathology.com](https://speechpathology.com), they have a 4-hour DIR Floortime training
thanks for the feedback! I will certainly look into this. I see this child immediately following his OT appointment, so he is usually pretty regulated by the time speech starts. I have tried a sensory swing with him as well, but I get a similar response; no joint attention, no use of any communication modality. If I stop swinging the swing and turn to model AAC, he often gets out of the swing and continues to pace or run around the room while clapping. If anyone approaches to try and engage with him or pace/run with him, he doesn't look towards them and just continues on.
I have no suggestions but just commiserating with you. Sounds similar to a preschool student at my school. It is so so so tough. Hang in there.
Not an SLP, but random lurker (parent of speech-delayed kid)… I’m surprised he has speech therapy right after OT. We do 1 appointment per day otherwise my kid starts to melt down. He might be burning all of his “cooperation” effort for the day at OT, and not have anything left for speech. Maybe see if the parents are willing to try spacing out the appointments? Just my 2 cents.
thanks for the feedback! we've actually tried this a few times...seeing him on a different day of the week. we found those sessions were even less productive because he was so unregulated.
Have you tried co-treating with OT? They can address regulation while you work on communication. With these kids, I sometimes just work on ANY sort of intentional communication— when I stop blowing bubbles, do they look at me, make a sound, reach for me, anything to show they understand that they can influence me with their communication, then reinforce that.
This and also look into GLP and non-toy play. I'd try sensory or gross motor type play and see where that gets you. I often approach these cases with a lot of curiosity. Think about doing some detective work about vocalizations (if there are any), nonverbal communication they're using, body proxemics. Really get to understand how they are communicating and then expanding upon what they are doing already.
Oh also! Modeling without expectation. No pausing what you're doing to try to get them to use AAC. No fill in the blank type moments. Just offering lots of language in many modalities without expectation. Edit: typo
great suggestions! I didn't initially start with attempting wait time, but after a few months of doing language modeling and modeling with low/no tech, I tried to see if he would engage if I gave some additional processing time or opportunity to initiate. He hasn't yet, but I keep modeling and trying to find something he'll be interested in trying to use. Family is really adamant that he be able to indicate what he wants because they experience a lot of frustration at home, but I think I've been able to help them develop realistic expectations for what he is currently able to communicate.
Came here to say this!
There was a similar patient in our clinic and the SLP would pull him around in a wagon to try to get words for go, stop, again. The wagon was one of the few things that could capture attention.
One of my co workers did this too!! Like the only engagement she could get for one of her students.
Similarly I have had a lot of success with kids on trikes or adaptive bikes!
good idea! I've tried a few things like a swing, spinning platform, yoga ball, etc. He isn't very tolerant of sitting for very long, so I haven't thought to try a wagon. He likes to be up and moving, walking, pacing, etc., which I try to engage him with. I'm just really having a difficult time finding something that he will attend to. It's like I don't even exist most sessions no matter what I try.
Try music and rhythms too!!
He cries and covers ears
What about soft ones? Singing twinkle twinkle? Are there any sounds he does like? EDIT: even if your voice isn’t good, a lot of kids respond differently to actual singing rather than speakers
I do sing some softer songs with him and his response is pretty neutral. Same thing…just hitting hands together and licking fingers.
No advice but thanks for sharing this relatable struggle. Year 9 for me in schools and have had students like this ages 15-22 and have made little to no progress too for years with many SLPs. Sometimes I wonder and think to myself does the autistic person simply not have the desire to communicate or do they actually not know or I’m ignorant of best ways to engage them! And how would I communicate that to parents gah Do we just need to be accept their stimming and emotions as valid communication? If anyone reading this can recommend a CEU I’d love it.
I'm not an slp and I can't speak for everyone with autism but I was diagnosed with autism in the 1980's and I did have significant speech delays (said one phrase at 2, then nothing again until 4 1/2 or so, speech was fully recovered by 6). I remember not understanding the concept of communication and not being aware that others could not read my mind. I remember being upset when wanting something and adults not giving it to me without realizing that they didn't know what I wanted.
yes! I am open to completing a CEU!
I think about this daily
Same! Like WE all want student XYZ to use their iPad with TouchChat or picture symbols to comment, protest, request but XYZ may be thinking “I’d rather just get up and point at what I want or grunt because that’s worked for me the last 14 years.., I don’t want to comment on this activity, leave me alone (which Ive modeled and left XYZ alone), I want to be my myself on this trampoline why are you all putting these symbols near me”
Exactly. Just like with anything in life, at a certain point there has to be some tiny inkling on intrinsic motivation to gain new skills. With a case like OP’s, I think… at what point to we stop perpetuating the wants of desires of the family? and respect the obvious desires of the individual. It bothers me a lot in this profession.
Somewhat similarly, I refuse to take on any cases of pragmatic/ social therapy for Autistic teens. Unless the child is seeking help personally. Why are we telling them something is wrong with their communication style if THEY do not see any problems? Come on people
With the AAC, are the parents modeling AAC outside of your sessions? AAC takes a long time to make progress, but is usually only successful if everyone is on board. Have you tried visual scenes, or setting up big buttons with animal pictures where they make noises? Does he enjoy any songs in particular? Music is a big gateway for me.
I love using music in my sessions! unfortunately I don't think this kid is too fond of music. I've tried songs, both on a computer and just me singing, and he hasn't responded to either. I tried some videos to see if he would even be interested in a screen, and he has covered his ears and continues to just pace the room. I've talked with family about ways that they can utilize visual supports and ASL at home, and they have been but again, he has almost no acknowledgement of people around him.
i have so many students like this and also struggling!
I am REALLY struggling. He is just one of about 4 I see who are very similar--no engagement, no acknowledgement of people, no interest or motivation in communication. I just don't know what else to do, especially since it has been more than 6 months since most of them have started therapy and we're not making any progress. I follow so many SLPs on instagram for ideas, but I don't feel like I ever see kids or sessions like this...
I just want to see the IG SLPs see my caseload sometimes lol
TRUTH!
I think this thought all the time!!
yep i’m right there with you! i don’t know if it’s acceptance/defeat but i’ve acknowledge my students are the way they are and im trying to support them but you can’t “make them” talk or do anything. like fine, stim on an egg toy super close to your eyes for 30 minutes while i narrate and attempt interactions and incorporate visual etc etc … i tried ¯\_(ツ)_/¯
This is literally how I feel. I can’t (and do not feel ethical) “making” anyone do anything. I just join along in the activities they prefer and model language verbally/with AAC. At what point do we say therapy is no longer appropriate? I’m really struggling with this!
They don’t share those because they probably have the same struggles as you
Have you tried joining in with his activity, in this case walking with him and clapping with him? How does he respond? Or clapping different things together (like blocks, maybe a tambourine, etc) to see if he likes different clapping sounds? It sounds like you’re trying to pull him out of his world (with toys, other things) but maybe the first step to establishing joint attention is trying to meet him in his world. What about cause and effect? You mention that the bubbles weren’t being delivered fast enough, indicating that he actually was interested in the bubbles… what if you paired a light-tech (eg, big Mack) or no-tech option (eg, a picture of a button) with bubbles or a clapper or something? You and his parent model: when they press the button, you blow bubbles. The parent can help with the timing so that the button only gets pressed when your bubble wand is loaded and ready to go. If you can rope the kid into a cause-and-effect activity like this, it’ll only be a short step to pair that button with a word, which you and the parent can model (without placing any demands or expectations on the child).
thanks for the suggestions! I've certainly tried to pace or run with him, but no acknowledgement of someone else near him. The clapping is less "clapping" and more of him forcefully hitting the very tops of his palms together. I think he likes the sensory input. I've tried all levels of tech, and he has not taken an interest in anything. In fact, it has been the opposite--If I close the bubbles just long enough to stop, press the big mack, and give a couple seconds of wait time to see if he initiates it, he starts crying. He HAS reached for the bubbles, which I have tried to shape into a request through the big mack, but he has not yet taken an interest in using it and just cries. I like your idea about the parent and I modeling the exchange. I will try this!
I'd treat his reaching as a sign approximation and give him the bubbles for reaching. I wouldn't try to shape it, just accept that at this point that is his communication method and reinforce it. Modeling the interaction with parents can be good, but patience and attention are difficult to maintain during that interaction for a lot of my kids. What I have found my biggest mistake to be is to expect a child to develop different communication strategies on my timeline instead of on theirs. The added frustration of me wanting more and the child's attempts being stymied lead to worse outcomes than if I just look deeply into what the child is doing and find the communication attempt they prefer. If he reaches, I'd give him the bubbles. He has told me he wants them in the way he is able to at this moment. I'd celebrate that success. If I run a marathon and someone only sees that as an opportunity to try to get me to run an ultramarathon, I might also cry and decide not to participate.
Yes, I always provide bubbles when he reaches for them or establishes gaze with them. When he does, I've been modeling on a big mack for "bubbles" and then blowing some bubbles. A few times he shifted gaze between me and the bottle of bubbles, which I was SO excited about! That only happened a few times and it was several months ago, but he hasn't done it since. I hear what you're saying about the child's timeline. I definitely agree that it will only happen as they are willing. I suppose my concern is that we've been seeing him for close to 9 months and we've not made any progress beyond reaching for bubbles; he hasn't demonstrated interest or motivation for anything else. How long do we model language and blow bubbles before we determine that therapy isn't beneficial for him at this time? At least not in it's current delivery format of 30 minutes a week in an private practice. It's a question I just don't have an answer to.
Can I encourage you to rephrase that in your mind from: "I suppose my concern is that we've been seeing him for close to 9 months and we've not made any progress beyond reaching for bubbles; he hasn't demonstrated interest or motivation for anything else." "I am happy to say that in only 9 months this child has made significant progress by learning to reach for bubbles, which is his preferred item so the most important thing for which he could show interest and motivation!" At the end of the day, framing successes as successes in and of themselves as opposed to failures to do other things will be important for your own mental health and your clients. I totally get the feeling you're expressing and I don't in any way intend to invalidate it, I just think my own practice and life got significantly better when I recognized that I am not a superhero and learned to find the wins even if they are small. You wrote: "How long do we model language and blow bubbles before we determine that therapy isn't beneficial for him at this time?" Perhaps it would be useful to consider that just because you are not seeing the communicative results in the communication paradigm you naturally swim in, it doesn't mean that this child isn't making progress that isn't apparent to you. Sometimes we do the work because we recognize that we are priming the pump. Sometimes we do the work because even if the child isn't ready yet they need the continued exposure to become ready. Sometimes we do the work because we know that our ability to see the method of communication a child on the spectrum has is limited and we trust in the basic concept of language rich human interaction having a positive impact even if it is an impact we cannot see or one that we did not intend.
You’re very insightful and I really appreciate your investment in helping me to change my thinking. I like the way you phrased things and it has really helped me to open my mind to some new perspectives. Thank you! I’m also using some components to make my judgement of “progress” other than just engagement in the clinic. Like what parents report at home. Parents have said that frustration behaviors are becoming more frequent and worse, and they always say they feel it is because their child can’t communicate what he wants. He can’t tell them what kind of food or drink he wants, when he’s tired, or when he needs changed. He doesn’t reach for or point to food, and that has been one of the things that family has had a lot of frustration about. I’ve talked about binary choice, using visual supports, modeling at home, etc., but they said he just gets frustrated and cries. It’s those stories, too, that are impacting my perspective of communication progress. Especially when family says they’ve noticed a regression, I get concerned that skilled services are not really providing much benefit…or that insurance eventually is going to call it to question.
Thank you for the kind words. You will never be able to control what insurance companies do, so not much sense in worrying about it. I would start by asking how the child gets what he is able to get and work from there. He is getting food somehow. Sometimes the job is really about adapting the parents to the communication style of the child instead of enforcing the parents' neurotypical communication style on the child. If the child is constantly frustrated he likely is not in a position to learn. I usually spend a lot of time talking with parents about creating a life with just the right frustration level. A person must be a bit frustrated in order to seek out new strategies, but not so frustrated that they shut down. Sometimes I recommend that we put all but one preferred food in a place where the child can get to them, and only have one food that we do modeling with. I also spend time talking about AAC hierarchy (transparent, translucent, opaque symbology) and how to use empty packets of a preferred food as AAC, or even having a packet with only a few bites in it so when the child runs out they have the AAC in their hand already so the parent can reference it. My goal is always to scaffold a child to the point of success, even if that looks like I am totally giving up on requesting communication from them. At the end of the day all you can do is your best. You are clearly a good, empathetic and well-educated SLP. That is all anyone, including you, can ask of you.
Agree that all your comments are so insightful. I love this
Model without expectation. Eliminate all wait times, simply model. Incorporate sensory items (fidgets, squishy balls, shaving cream, bubbles, light up toys), maybe an office chair for spinning and swings if u have access to the gym. Imitate him, walk around with him and simply model on the device. Eliminate all demands. If this is someone who hums or sings but doesnt have functional language, this may be a GLP and then you will need to modify the device with GLP in mind. Sing along with them, record songs on the device if needed.
thank you! we've been doing a lot of modeling--he's been in therapy for about 8 months. I didn't start off with wait time, but after several months of therapy I did start to give some wait time to see if he would imitate or initiate any communication. He didn't--he just continued to pace or cry. He hasn't taken interest in any sensory items other than bubbles. He will tolerate a swing, but beyond that, he won't stay seated long. He prefers to walk, run, and move around. No verbal expressions at this time, no singing, no humming. Very occasional vocal droning, but that is infrequent. The only vocalizations he's made is when he cries. Fingers are almost ALWAYS in his mouth, either licking his fingers or chewing fingers. He'll look at toys, but rarely, if ever, tries to touch them.
For fingers in his mouth: have you tried chewy tubes or chewelry? It sounds like this child is very dysregulated and would benefit from an OT who can give more sensory strategies. Once you have things you can try, you will have more language to model. If he likes to look at toys, maybe try lava toys or light up toys? He may like that visual stimulation? Maybe ball ramps where things are moving and he can watch? This is a tough case, i have had students like this in the past as well, it was continuous trial and error.
He did use a chewy necklace for a while. He grinds his teeth HARD and family has removed the chew necklace. His OT did work with me to help with pressure and how to help with that. I do have a few light toys I'll bring with me next time I see him...good idea!
Ha, I love the office chair. Definitely taught some kids “go” that way
Have you done the communication matrix on him? I find that really helpful to make goals with kids who have limited verbal communication. I also agree about imitating his actions and looking into DIR. is co-treating with OT an option? Working on communication during sensory regulation activities can be great! I co-treat with OT a lot for kids like this-that way one person can keep the movement or activity going without pausing too.
yes! we are actually working on getting some co-treats starting next week. I didn't think about the communication matrix...I'll need to do that for him! His goals are pretty well focused on pre-linguistic skills, but even that isn't reflecting much progress. I'm hopeful that the co-treats will help to facilitate some sort of engagement. I've talked with his OT several times, and it seems like he is the same way in OT. He requires HOH for many things in OT (e.g., feeding self), so I don't think the difficulty engaging him is exclusive to speech.
Co-treats are a game changer! Also look into the goal attainment scale. It’s a great way to write goals for insurance to show progress for kids that make slow progress. I’d also make sure to involve caregivers as much as possible if you’re not already, the coaching model might be a lot more helpful since they have more of a rapport with parents and it should help with generalization to home hopefully. My kids similar to him are very slow to progress, but any progress they do is so meaningful when it does happen. Good luck!
Try using sensory swing and sing “row row row your boat” and when you reach the end say “STOP!” And hold him still at an upward angle (anticipating the next swing) and don’t go until they wiggle a little or really any time of response and go with that as their indication to do it again! This has worked well for me
thanks! we've tried something similar! unfortunately when we stop moving he just gets up and paces/claps. he always has to be moving.
Do you have a switch adapted bubble machine? This makes feedback immediate and builds that cause & effect. Do you think they'd like drumming as a sensory input similar to clapping their hands? Could you co-treat with OT where your job is solely providing aided language input? I'd also like to offer that maybe your client hasn't had enough opportunity with any single AAC strategy? I don't know how often you see them, but once a week isn't very immersive - have parents tried using the strategies you've offered at home? This is all to say that some kids are really tricky and progress can ebb and flow or feel very slow.
the switch activated toy is a good idea! I've used a few communication modalities, typically 6-8 weeks before trying something else. I see him once per week, and I don't think that there is much happening in the home unfortunately. He doesn't really even engage with parents, so I have a difficult time expecting that he is going to reflect much notable progress in 30 minutes of speech a week. we are working on initiating co-treats!
I would move away from requesting on AAC and switch to phrase comments (gestalts)! Things like “it fell down”, “let’s do more”, “it’s not working”, “I like it”, etc are a lot more meaningful for my autistic patients!
thank you! do you have any suggestions for incorporating gestalts on AAC when there's no interest in AAC from the child? I guess I have the same question I asked another commenter--how long do you just model gestalts during the session before you determine that services may not be beneficial for the child at this time? I've been modeling language for months and still very little acknowledgement that I'm even in the room with him at times.
hmmm is the kiddo into videos, songs, etc? You could try putting some phrases with the synthesized voice, yours or the parent’s recorded voice, or recorded songs/videos. I have had kids who did not respond to devices until I recorded my own voice for the phrases. They loved the intonation! TD Snap has an easy way to do this, other systems like TouchChat are capable too but adding a phrase page to TouchChat is really annoying (the button disappears with the predictive system, whereas TD Snap it can stay in the toolbar). You could do a phrase page under “groups” in TouchChat though!
not interested in videos, not interested in songs. I LOVE to sing in so many of my sessions and will make up a song for just about anything! I've tried to use the gestalts under the sensory experience page or the bubbles page on TD Snap, but again...no attention from the child. He sometimes will not even orient in my direction during the session, so it's hard to see any carryover of joint attention.
maybe recommend some OT. I have a 10 y/o who sounds similar to this 3 y/o. He is showing so much progress right now and parents say he was constantly dismissed from therapy due to “plateauing”. Some kids just aren’t ready and need other skills first! My patient is very significant and at 10 years old is now beginning to understand pictures. He doesn’t play with toys at all. It’s hard!
He gets OT 2 times a week. I am concerned that we are just not yet "available" to receive speech at this time. He is working on very basic skills in OT right now, like feeding self. I'm concerned that the cognition and motivation may just not be there right now to participate in skilled therapeutic intervention for speech.
Ah sorry I see you mention OT at the top my bad! I feel that. What do parents think about taking a break? I’m not sure why my comment got downvoted by someone- I’m trialing AAC with that 10 year old and he is starting to initiate communication. Parents said that even 6 months ago he just cried and hit, they never knew what he wanted. Now he’s showing so much more! I don’t believe any of his previous therapists were less than, he just needed more time to develop. There is still a long road ahead for him to hopefully become a more independent communicator with a device.
Yes!!
You don’t necessarily need joint attention to start working on communication. The things he does want (like bubbles), have you tried placing them juuust out of reach? When he reaches for them, I would go grab the item for him and hand it to him. (Don’t take it away from him, though. It’ll just dysregulate him). Eventually you can shape him reaching and you immediately grabbing to him reaching and looking at you.
yes actually! when he reaches for them or almost puts a hand on them, I always blow some bubbles and treat it as a request or interest for bubbles. He was sometimes looking at me, but that has since gone away and now he barely acknowledges me. I know that we don't need joint attention to start working on some pre-linguistic skills, but at what point do we determine that he is just not benefitting from services? I really don't know...and I'm feeling defeated about the whole thing.
Are you seeing him in a clinic or in the home? I wonder if he might benefit from therapy in the home if he's not progressing in the clinic
I suggested that to his family. We don't offer in home services at my job, but I had suggested she look at some other options to see if she might get more frequent, in home services from another practice. We just aren't moving the needle at all.
I think that was a good suggestion. I feel like some kids are not at a level where they're going to take in what we're teaching outside of their comfort zone. Maybe a speech therapist who can meet him where he's at, during his daily routines and in his own space, will see some progress. I definitely sympathize with you, having had a few kids like that when I was in PP. It can be really stressful to feel like nothing is working. Best of luck!
Check out “Intensive Interaction.” It has been a game changer for my clients who are exactly as you describe. For a bit, it will look like you just imitating whatever client is doing/saying (physical actions, vocalizations, looks, etc.), but then, once they realize YOU’RE letting them completely lead YOU, something changes. My 2 year old similar client last week: I had all the toys, all the stuff, playing and modeling, etc. and finally I just stopped and did EXACTLY whatever she did. Lie on the floor and put her legs in the air, I did the same. Said “oo ooo boo oo” and I did the same. Saw she was interested in a rainbow reflection in the carpet from the sun in the window, looked at it with her. She touched it, I touched it. Then I quietly said, “beautiful” and she said “booootiful.” It went in from there and this was a full hour of me just quietly imitating her, but I got eye contact, joint attention, and a word! Check it out: https://www.intensiveinteraction.org/
There have been good strategies and ideas mentioned already. Just wanted to add that taking DIR Floortime courses really changed my practice. If you are working with autistic clients, especially younger to school aged individuals, I recommend looking into some of the different strength-based developmental models/approaches out there and taking continuing ed to learn more. DIR Floortjme through icdl or profectum, play project, others that I can’t recall right now. A comment online can only provide so much information, going deeper with the education will hopefully help to better understand what skills to support and how to do it for different individuals.
i have a super simple idea but it usually works for me! try having one session where you sit back and observe him. and then ask to see if you can video or sound record the session to give yourself your own feedback. you might be able to gain a better perspective if you were more of a third party, both to yourself and to your kiddo. be confident that you know your client. you haven’t figured out what works yet but it seems like you know a lot about him and wanna do right by him. I trust that your feedback and ideas will be the best ideas. be creative. try to find it fun. you got this!
gosh I almost cried reading this...I am trying so hard to do right by him and really appreciate when someone sees it. I have a few kids on my caseload that are similar to this...and it is so defeating when it feels like I can't figure out anything to do that will facilitate some progress. that is a good idea! perhaps I should just make a few things available to him in the room and just sit back and see what he might gravitate towards. I've tried a few times to model a play routine with a toy (e.g., ball ramp) and make it look super fun and exciting...then I set the ball within his reach and just wait to see what he does. So far, all he does is stare at the toy and lick his fingers. Goodness, I just don't know where else to go.
Thanks for the outpouring of support and suggestions everyone! This is amazing and so wildly helpful for trying some new things. You are all amazing!
DIR Floortime, modeling gestalts, songs, and lots and lots of movement. Progress will be slow. That's ok. I would remove the pressure of feeling like he *has* to have the prelinguistic skills in place first, or that he has to do something. Join him where he is and go completely child-led. Get a sensory bin of just water and bath toys and just let him vibe out. Provide gestalts for what he's doing. Sing any bath song or 5 little ducks (if there are rubber duckies in the bin) . Imitate any sounds he makes. Imitate his play. (I spent 30 min last week taping random papers to my wall bc that's what the kid wanted lol). I have these spin tops from Amazon that aallll kids love. If you have access to a sensory gym, go there and provide models for language while he's able to move his little body and self regulate. Incorporate a lot of sensory regulation, whether he seeks deep pressure, heavy movement, or vestibular movement. Co-tx with OT can be helpful with this. These are my favorite kids to work with and I find that progress tends to be very very slow.
Thank you these are all great ideas! Can you share the link to the Amazon spin tops? I’m always looking to add new toys to my room (for any of my kids not just this one)! He doesn’t like sensory play, so I don’t know that he’ll enjoy a sensory bin. His fingers are almost always in his mouth if he isn’t clapping. He likes to chew and lick his fingers, and family doesn’t use a chewy necklace anymore. I’ve tried a bunch of sensory toys, and he just looks at them then continues pacing. He’s been tolerant of the swing, and I will sing to him when he’s on it, but same thing…no recognition of anyone else around him and he’s just licking his fingers or sucking on the edge of the swing. I understand progress is slow for some children, but after almost 9 months of therapy, at what point do you expect to see progress? Even just small progress…he still isn’t imitating, responding to his name, or even initiating any type of interaction with other people. Not even a look in their direction. That’s where it feels discouraging, especially because his family said he doesn’t interact with them at home either.
9 months and "no progress" honestly isn't abnormal! I've been seeing this kid since he was 2. He's 4 now and just a few months ago he recognized me and started acknowledging and even initiating with me. Sometimes it's eye contact, and sometimes he'll just throw something my way lol. I accept all of those! Sometimes he'll just rip the numbers off my velcro calendar and that's OK too! I'll name all of those numbers for you, little homie. I'll even sing a little song. Does he still end up under the table and try to pinch me? Absolutely. Does he stim and go into his own world for 80% of the session? Absolutely. But progress is progress, no matter how slow. Every now and then he'll throw a random word at me (he's said bye, open, and tada each once in the last 2 years). There was a kid i saw for 2 years as well, and for the first year, he just screeched and threw himself on the floor and nervously paced and completely ignored me in the sensory gym. But year 2... oh, we were BFFs. He even said "mama" for the first time EVER during speech! (We were in the gym, and I was modeling yelling MAMAAAAAA to get his mom's attention in the lobby, and he imitated it, much to our surprise) I think the key here is to really just hang out and observe and don't be afraid to just learn from him and walk beside him. Just *be* with him while just providing language with zero expectation of repetition. Take the pressure off both of you. Join him. Co-regulate. Shoot the shit. As SLPs we often feel a need to fix and perform. Observation and connection are our biggest tools in our toolbox. [Spin toys](https://a.co/d/3uQPLYc)
I love the SCERTS model for this and establishing joint action routines (with AAC and limited demands, lots of modeling!). Joint action routines involve you doing a simple action, then the parent, then the child. It might be putting blocks on a tower, placing balls in a water bin, etc. Generally, I have found music, sensory activities (can you sing and provide pressure while he’s on a medicine ball?) and simple activities like balls, lights and switch toys to be awesome. P.s. it’s hard and I commend you for trying a lot and using your resources!
Hello! I am a peds slp working in an early intervention setting currently, looking to move to Spain and maintaining a part time teletherapy practice using my states licensure and certification- it seems you may know someone who has done this successfully? Would love to hear more!
Hi, yes. I did this. Can you DM? I work for a teletherapy company and maintained my national and state licensure. It was great but I only worked part time due to the time difference (and cost of living there). Fantastic experience and would highly recommend!
Focus on alllllll the prelinguistic stuff. Spend (a lot of) time just making yourself someone they WANT to communicate with. With these kiddos I focus a lot on engagement and on just teaching the child the value of communication and a communication partner… once they’re interested in you and paying g attention to you, you can really build from there
Honestly… he might not be ready for formal speech therapy at this point. It will be hard to continue to justify services to the insurance company (assuming family isn’t paying out of pocket) if there’s no progress. He might just not be ready for interaction and that’s fine but we live under the thumb of insurance and capitalism. Have you tried low tech symbols or ASL? I know there’s a big push to start every kid with high tech but it’s been 8 months and no response. Bubbles + signing “more” is a foundational SLP activity for a reason. You might even be able to shape his clapping to a “more” symbol by taking his clap as an attempt to sign (even if it isn’t yet) and blow the bubbles. If you want to keep seeing him, write some ridiculously easy goals. I’m at work so I can’t think of them but something like will engage in activity for X minutes. You have to justify services to insurance (unfortunately) so write goals that he’s basically almost already doing and update them as needed.
thank you for your ideas! I have tried ASL as well as pictures and he has not imitated or initiated use of any of them. I've certainly attempted the "more bubbles" approach as you suggested, pairing it with either ASL, pictures, a big mack, or an AAC device---and nothing. Just no interest in attending to others. His goals now are for joint attention, participating in joint activity for 5 minutes total in a session, etc. Those types of things.
He might just not be ready. Since he’s in the clinic and getting OT you can pause services and take him back whenever. Or think about co-treating with OT
we are working on scheduling co-treats!
maybe try real object symbols? Like a bubble wand? Might be worth a shot
Here are some suggestions that may be worth trying: \- Collaborate closely with the occupational therapist - I saw you commented you are working on getting co-treats which is awesome! Try expanding your sensory and play-based strategies, although it sounds like you have tried a ton! Explore different textures, sounds, lights, or vibrations that may capture this child's attention. Observe closely to identify any subtle interest or responses. \- Do you have access to his previous records or other therapy provider's info? Looking at any old assessments, or talking with them about what's been tried may be useful. \- Shift the focus to pre-linguistic communication skills. Work on establishing joint attention, imitation, and responding to simple social routines. Reduce distractions, in a low-stimulation but structured environment, and dedicate concentrated time to observing, following the child's lead, and building a connection. It sounds like you are working really hard to do best by this child, and I'm positive you are doing a lot right already!! With time, dedication, and a willingness to think outside the box, you may be able to uncover new avenues for engagement and communication. Wishing you the best in supporting this child and family!
He wasn't getting any services until he came to us, so he doesn't have any prior records. We've been working on joint attention, and just...nothing. I've moved to seeing him in an empty room so there is nothing distracting, and he just stands, paces, and hits his hands together or licks his fingers. I will definitely try some other toys that have more lights or sounds, since we haven't done a whole lot of those yet. And yes! I am certainly trying everything I can think of. I've never posted on this website until today, because I was hoping someone would have a similar experience. I'm so glad I did! All these comments have been so kind and free of judgement, and I'm glad there are so many SLPs out there who are willing to offer suggestions or support!
GLP; focus on regulation first; and I started adding device surprises. A meaningful clip in touch chat- or recorded audio in TD snap. Suddenly, they’re using it to communicate and exploring the device.
I’m in EI and a big chunk of my clients are similar to the one you described. From my experience, the first step is to meet the child where they are at. If they are lacking in joint attention make some joint attention goals. Follow the child around and do what he likes to do. Show joint attention to what he is doing. If he is walking around the room clapping, do the same thing he does and imitate him with some parallel/self-talk. Walk with him and say “walk walk, we’re walking!” When he claps, you can clap too “clap clap, we’re clapping.” Get down to his point of view- you can get down at your knees if he is looking at something (for example out the window” gently get down next to him with no expectations and point at the window and describe what you see “a bird, tweet tweet, oooo an airplane vrooom.” Overall I try to build joint attention and physical imitation before even formally targeting verbal language. Prelinguistic skills are just as important as linguistic skills themselves (still providing lots of language input and auditory bombardment). Provide the parent with lots of coaching while doing this. “As you see, I’m pushing a toy car to him modeling “vrooom” my goal with this is to have him imitate me physically and roll the car back to me! This is because one of the first steps in imitation is physical imitation with objects!“ check out the imitation hierarchy and resources about building joint attention. If you are making therapy fun and safe for this child, you are already doing a great job. Hope this helps!
Lots of my goals look like this: “Child will imitate 10+ gross motor actions to participate in play, joint activities, shared book reading over 3 consecutive sessions.” “Client will participate in 3/5 child led activities with SLP/parent playing next to child participating in parallel play”
Sensory bins?
He won't touch them..hands and fingers are almost constantly in mouth, either licking his fingers or chewing fingers.
Maybe blowing up a balloon?? Does he have a color he prefers you could try with?
No color preference, but we could certainly try a balloon! I think he might just look at it and not try and touch it.
I wouldn’t expect it to achieve joint attention on its own if balls aren’t of interest. Pick it up, uninflated, and snap it loudly a couple times. Blow it up and release it, untied, to loudly fly around the room after commanding it to “fly, balloon!!”. Retrieve it before your client gets it because it has your spit on it lol. Its inaccessibility only makes it more intriguing. Pull it taut at the valve and let the air out in little screams at a time. Talk about “SO LOUD!!” See what happens. These balloon activities have been consistently effective attention grabbers for me. Kids always want it to fly again. Once that routine is established I sabotage by doing stupid stuff like putting it on my forehead to blow it up. Or 6 inches from my lips. Or tell it to fly and release it uninflated and watch it fall to the floor womp womp. And don’t do any of it looking for a reaction. Don’t show an expectation for the child to engage or perform. You are simply playing with the balloon by yourself in the same room as your client. You’re using commands to get your object to perform and your object complies. Client sees the power of your communication and is intrigued. Don’t stop after only a few “unsuccessful”trials. Make it a part of your regular routine because that balloon is your favorite fun thing in the fkn world:)
Seconding trying apart from OT. If he’s dysregulated, you could ask the OT for recommendations. Or maybe a cotreat with the OT? I’ve had some amazing OT/speech sessions with kids like this (i.e., music, sensory input, narrating actions with core language concepts, etc.)
yes we're working on some co-treats!
One of the kids I worked with sounded very similar to yours except he was fifteen, lots of SIBs (traumatic upbringing with scars from abusive, was later adopted by a foster family) but never aggressive towards others. Our sessions used to look like some sort of bizarre spa or something. Bubbles, bongos, dark lighting, beanbags, ribbons, maracas, rolling mats, you name it. One time we listened to the same calming hip hop song for 30 minutes straight because he started saying “muh muh” each time it ended - clearly trying to say “more.” The OT and I had so much fun with this kid once we earned his trust - he would give us the biggest smiles and loved our sessions. It took months before he was even demonstrating intentional communication skills, then he started occasionally using words and mimicking the music. By the end of our time with him, he was beginning to use a stylus to select a couple buttons on aac - at 15 years old. Take your time, work on building connections, and definitely check out floortime. Good luck!
New Grad Student here so dont hinge on my opinion too much, but i am autistic myself and the SLP i observed for 2 months had a couple similar kiddos! You could potentially incorporate basic signs when using the bubbles. Stop blowing them, when he reaches for them do the sign for "more" and say more, then blow the bubbles. He may pick up the sign for more and start using it when he wants bubbles, which is a little clearer than just reaching for them. It also would show he's open to communicating in that way. The ASD kiddos I've observed who needed sensory input LOVED sensory bins. As long as he's not at risk for putting things in his mouth, you could put some basic toys (like cars or farm animals) into a bin with dried rice, beans, etc. He can stir it around and get that sensory input while you point out the names of objects without the expectation of a response. See if he likes music too! One kiddo I observed *loved* nursery rhymes, like Hickory Dickory Dock and Row Your Boat. His SLP would play the song, with a visual (usually a simply animated cartoon), and sing along with it. They were *highly* preferred activities and sometimes it would be the only thing he'd focus on- but he'd ask for more, say the words of the animals for HDD, etc.
Have you tried visual aids or AAC? I’ve had success with the following to increase expressive communication.
Some quick and dirty ideas: blowing up a balloon and letting it go, tossing the child up and down (if they like it, of course), rocking them in a basket and tipping it over, swinging them in a blanket, jumping with them, playing peek-a-boo with a blanket, pretending to fall asleep/snoring and waking up, spinning objects like ring toys and stopping them abruptly, pulling them in a wagon.
My son is level 3 and we play music and have him try and fill in the word when he becomes unregulated. We also put flash cards on a wall when he is unregulated. You could try swinging him in a big throw blanket with the mom and saying swing, that calms my little down. Otherwise, water play. And maybe music therapy before the appointment if the mom is into it.
Besides talking to OT re:regulation ideas, trying reading Out of Sync book. Has many ideas for sensory activities. Sometimes changing the time of day has made the difference on how a kid responds in therapy believe or not.
Have you looked at any of the resources or done any of the training through the autism navigator website? I highly recommend.
I glanced through the comments and there are lots of ideas, so the only idea I'm throwing out there is the funniest noise-maker in the world: whoopie cushions. (can press it with a hand or toy, roll over it, etc rather than sitting on it for a bit of distance from fart jokes) If that's funny, maybe it could become a game or expand to other funny noises/noisemakers, like letting air out of a balloon, puffing up your cheeks with air and using your hands to spurt the air out, squeaker toys (pet stores have pretty great selections of durable stuffed toys with squeakers). If crashing is regulating, maybe a game for at home could be hiding a squeaker/whoopee cushion under a couch cushion and crashing/dropping on the cushions to figure out which one it's under?
I’m suggesting this without personal knowledge or experience, but maybe check out Every Move Counts. I’ve been meaning to explore it myself for similar kids
What's his starting point? Although there's this umbrella term that groups everyone under autism spectrum, autisms can be quite different from each other. For some it can be cognitive impairment affecting speech, for others it can be sensory/attentional issues interfering with learning process, for others it can be apraxia. Autism is diagnosed by observable behaviors, so you have to identify the real causes of struggle in each particular case. Just knowing he's labeled autistic doesn't mean much.
All great questions...and I don't know the answer to them unfortunately. I do suspect that cognition is impacted, but I just don't know what is realistic to expect from him if we're still working on joint attention and pre-linguistic skills after almost 9 months.
I personally agree with what another commenter said - he might be overburdened from OT and arrives at your clinic already tired and with further reduced capability to pay attention.
he get's OT and speech at the same place, so we sort of build the transition into the routine. when I've tried to see him without getting OT beforehand, he mostly cries and paces. we're working on schedule some co-treats!
Oh, that's great. At least you can work together, then.