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Let's pretend that you're a kid again.
You're bored, so an adult hands you a toy to play with -- a pretend cash register. You like the noise that it makes when you hold the button on the scanner. There are lots of buttons, actually -- ones that make the digital screen light up with numbers, and one that makes the drawer sproing open. You press all of them. It's really satisfying.
Then that adult appears again.
The adult says: Let's play pretend. I'm the customer and you're the cashier. No, you can't open the money drawer, you have to scan my food first. Do it like this. Here, now take my money. Say, Have a nice day!
The adult hands you a printed checklist of all the steps you should be doing to play out this pretend scenario. They ask you, kindly, to stop pressing buttons repeatedly because that's not how you do it.
Now, if you were that kid...how would you feel? What would you do?
What Happened Next
Two years ago, I was That Adult.
I'd been seeing an autistic girl, 12 years old, for around nine months. Let's call her Amy. I wanted to help her connect with others, and one of the ways I pursued this goal was through play. I'd noticed that Amy had trouble engaging in cooperative and pretend play. So, thinking that I was helping her, I brought some pretend play sets to our sessions. I showed her how to ring up groceries on a pretend cash register; I modeled the steps to bake pretend cookies or cake. When she continued to have trouble, I thought a visual aid might help. I printed out a checklist.
And what did she do?
She ripped it up.
Now, I'd been a speech therapist for long enough that I wasn't offended or even surprised. I just thought to myself, Okay, that didn't work. Moving on.
But I kept coming back to that moment over the next few days, even years. There was so much more going on there than Amy not liking the checklist. So much more that I was doing wrong.
That day, Amy helped me learn something that would change my entire approach to treatment forever.
Honoring Neurodiversity
Have you heard of neurodiversity?
If you haven't, I strongly encourage you to check out the list of resources at the end of this blog post. There are many people who have dedicated their entire online presence to educating others about neurodiversity, and the best way to learn about it is directly from autistic and other neurodivergent voices. But I'll do my best to summarize here:
Neurodiversity
refers to the idea that the world is filled with people who look, think, and act differently. The word "neurodiversity" specifically describes how our world is filled with people whose brains work differently. Different, but not wrong or broken. The neurodiversity movement encourages us to acknowledge, respect, and accept these differences as something to celebrate rather than as something to correct.
Neurodivergent
refers to a person whose brain functions differently than how most people's brains work. Autistic people and people with ADHD, dyslexia, and stuttering are all considered neurodivergent.
Masking
refers to the process where neurodivergent people are pressured to hide their natural way of existing in the world through suppressing stims, forcing eye contact, staying in uncomfortable or even painful sensory situations, practicing facial expressions and body language, studying others and rehearsing conversations, and much more. In short, masking is when neurodivergent people are trained to comply with social rules by acting like neurotypical people, thus quashing their differences. Masking is often encouraged by well-meaning individuals, including family members and even trained therapists.
Now that we've reviewed all this, let me ask you this: when I introduced that pretend play checklist to Amy, was I honoring neurodiversity?
If you answered a big, giant, mega-phone amplified NO, then you're on the right track.
Why I Was Wrong
Like so many other adults in my position, my heart was in the right place. I wanted to help Amy communicate and connect with others. When I noticed that she had missed a whole bunch of developmental milestones surrounding play, I thought it made sense to go through and teach those play skills directly.
Pretend play in particular can be important for learning how to see through other people's perspectives, to make inferences, to problem solve, and much more.
My mistake was thinking that pretend play is the only way to learn these skills -- that Amy needed to act neurotypical and meet neurotypical developmental milestones in order to develop these skills.
Here's what I missed: Amy doesn't like pretend play.
It isn't important to her. It isn't fun for her. Asking her to pretend play was asking her to comply with my neurotypical rules. And, because of that, it most certainly wouldn't help her connect with other people. At best, it would help neurotypical children connect with her. Except they wouldn't really be connecting with Amy; they would be connecting with a mask.
Here's another thing I missed: Autistic children don't follow a typical developmental progression.
Amy was 12 years old and had never learned to pretend play. But she could put together a puzzle, google search her favorite images, and read fantasy books. She didn't quite miss the pretend play milestones; they just never applied to her.
Thank goodness Amy is a strong, stubborn girl who was willing to stand up for herself. Because the thing is, Amy didn't need to learn to play in a specific way -- she needed help communicating her wants and needs in a functional way, while not having to change any part of herself in the process.
And if that's what she really needs, at the end of the day, who gives a flip if she can pretend play with a cash register or not?
Changing Things Up
Not long after the Ripping Up incident, I started to realize that this approach with Amy...it just wasn't working.
Obviously, I had to change things up.
Initially, my brain ran through the classic list of Things to Work on with Autistic Kids. Seriously, we could have a-whole-nother post on common goals used when working with autistic kids and why they are wrong. I bet someone's already written it. To give you a clue, the list includes eye contact, maintaining joint attention, reducing stereotypies, conversational turn-taking, responding to your name, greeting, following two- and three-step directions, answering "wh" questions, etc. etc. etc.
Some of these goals would target developmental language skills that Amy was demonstrating inconsistently (following directions, answering wh questions).
Others of these goals would target social skills so that AmyAmy could better communicate with neurotypical people (maintaining joint attention, conversational turn-taking, responding to your name, greeting).
The rest would just be plain masking with no excuse (eye contact, reducing stereotypies).
All of them would be wrong.
I could go very deeply into why each of these are wrong, but like I said, that really could be its own post. Instead, I'll give you the bottom line: none of these things mattered and were functional to Amy herself. If we worked on these skills, I would be telling Amy she has to do them just because and I would be focusing on her compliance.
So, I started thinking...what does matter to Amy?
Focusing on Connection
I needed to take a step back and focus on my connection with Amy -- on what I knew about her and what motivated her. Rather than telling her what to do, I needed to let her lead and -- even if she did so indirectly -- tell me what to do for her.
Just like Amy tore up my pretend play checklist, I tore up my Things to Work on with Autistic Kids checklist and shifted into my new role as detective.
But...without my usual goals to fall back on, what the heck did I work on with Amy?
Well, Amy really liked food. One of the things she most looked forward to was going shopping for food at Target or ordering meatballs from her favorite restaurant. In fact, one of Amy's frequent verbal stims was to say "meat," or "beef." It's really easy to ignore these types of verbal stims, because they occur seemingly randomly and in an off-topic way...but what if I listened instead?
So we started going on outings together. (Luckily, Talk Time is an outpatient private practice and I have that kind of flexibility.) I would ask Amy where she wanted to go, sometimes giving her choices based on what I knew she liked. Then we would plan out our trip, including what we might need to communicate to people in order to buy the right things. Then we would go and, well, do it.
I cannot emphasize enough that this led to a massive shift in Amy's motivation and communication.
Remember those skills pretend play helps with? Learning how to see through other people's perspectives, to make inferences, to problem solve, and much more. Just think for a moment about how easily we can address all of these skills by going on real-world outings to buy or order food. And in such a more meaningful and functional way!
I was no longer asking Amy to do what I wanted. Instead, I was asking her how I could help her do what she wanted. And this changed everything.
Building Trust
Once I stopped caring about my preconceived notions about what Amy should do and started caring about Amy herself, our relationship changed. Amy started sharing more of her thoughts with me. We could relate better. Now it feels like we're a team, because I am there to support her, not to quash her or to put a mask on her.
And the thing is, I like learning what Amy likes. I like it so much more than forcing her to pretend play with me! Every session I get to know her better and, even if I can't completely relate to her, I appreciate the way she thinks.
I am no longer here for speech therapy - I am here for her.
I will always be indebted to this wonderful, stubborn autistic girl who ripped up my stupid checklist and rocked my world for good.
Resources
Rachel Dorsey is an autistic SLP. You should read all of her blog posts: https://dorseyslp.com
Hillary Crow is also an autistic SLP. She has more resources on her page and offers consultation services to autistic individuals, family members, and professionals: https://www.crowconsultingservices.com/
ASHA Leader article by Rachel Dorsey, Hillary Crow, and Caroline Gaddy: "Putting Autistic Voices at the Forefront of Care (2020):
For information on child-focused, neurodiversity affirming treatment, follow these accounts on Instagram:
@bohospeechie
@rdorseyslp
@meaningfulspeech
@speechdude
@play_spark
@creativeconnectionspeds