Episode 58: Strategies for Supporting Autistic Toddlers Part 1

Welcome to the SLP Talk Show. Real Talk with Carrie about stuff that really matters. Hey, it's Carrie, your fast-talking speech therapy loving host. While you are driving, cleaning, exercising, or whatever it is you do while listening to podcasts, I'm going to be chatting about pediatric speech therapy stuff. But I don't want our time together to feel like work, or be born. You already work enough, and you already have enough boring stuff to do in your life. So let's get going and have some fun. Hello, and welcome to episode 58 of the SLP Talk Show. I am Carrie, and I am here with my partner in crime, Jim. Howdy, howdy. Before we jump into our topic for today, we of course need to play a quick game of chump or champ. Okay, sounds good. And I'm excited. It's Tuesday as we're recording this. And so we're going to actually go to trivia tonight. Yeah, yeah. Pub trivia. This will be a warm-up. This will be a warm-up for tonight. That's right. We're going to have a champ so we can win some prizes tonight. Okay. Okay. All right, here we go. Four questions, four chances to be a champ. If you miss any, well, I'm going to jump. Chump. Chump, it is. Okay, you ready? Here we go. Question number one. What country is the sports apparel and accessories company Adidas from? Germany. Ding, ding, ding, ding. Number two, what does an alchemist try to create? An alchemist tries to create, like, I guess, drug. It's actually gold. Gold. I did not know that one. That was a tough one. You're smart, so I thought you'd know that. I didn't know that one. No. Okay, here we go. Number three. Gold, huh? Yeah. Wow. Isn't that something? Maybe I should have been an alchemist. Maybe. Maybe. Maybe you still have time left in life for a new career. I'm going to look into that. New career, alchemist. You're just manifest gold out of finair. I love it. Question number three. What is the only US state to end in the letter G? What is it? We have friends that live there. We do. Yeah, we do. What am I drawing a blank? It's west of here. Wow. This can be a rough night for trivia. They come visit us in the 4th of July every year. Oh, Wyoming. Oh, my gosh. I wasn't thinking I.N.G. I was thinking, "I.N.G. I'm going to be a real star." I'm going to be a real star. I'm going to be a real star. I was thinking, like, what is. Oh, okay. All a gogg or something. Okay, here's a give me, though. You get one. What's up? I got that one. What do you mean? You helped me. You didn't even come close. Just a little. I nailed it. What actor has played Vivian in the 1990 film Pretty Woman? That would be what's her name? Come on. I know her brother's name is Eric. We'll say his last name and that'll help you. We shouldn't go to trivia tonight. Obviously not. Oh no. So you're going to go one for four. Oh, Eric Robert. So it's Julia Robert. There you go. All right. 50%. Do I get a bonus point for knowing who her brother is, too? Well, you get. And then finding my way to her name through him. Yes. You did good. Okay. Sorry you're a chump. I know. Well, I mean, you knew that. I knew that when I married you just one years ago. You were like, "Oh, I'll give this guy a shot. We'll see what happens." All right. You actually made me tear up a little bit. You're gonna laugh so hard. Okay. Okay. So let's go ahead and get into our topic today. In case you don't know this, Jim of course knows this about me. But tiny humans are my favorite. Oh, yeah. I love. Give me a two or a three year old. I'll take a four year old. 18 month old. Like I just love human beings under the age of five. I like my favorite people on the planet. So as a speech language pathologist, I've worked in the field of early childhood for over two decades. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. And have always loved tiny humans even before I became a speech language pathologist. But today what I wanted to do was talk specifically about therapy strategies for supporting autistic toddlers and preschoolers. Okay. So lots of these strategies that we're going to cover not only in this episode. We're actually gonna do a five part series. Awesome. Yeah. So a lot of these strategies are going to be supported for older autistic kids too. Okay. But what we are going to do is kind of go through the book that I wrote on this topic. Okay. And I don't know that maybe most people know that I have written a book. It's called The Learning to Learn Program. Mm-hmm. And it is. It comes with an informal assessment. Right. And it is filled with therapy strategies for providers supporting autistic toddlers and preschoolers. Okay. And I wrote it. Of course, during the pandemic, when I was not able to travel and do my. Yeah. That whole time. You look back on it and you're like, wow. What was that? What was that? And how did we survive that? Yeah. That absolute chaos. Yeah. Because I just remember everything was cool. You know, we had just put an offer on a house. Yeah. He hadn't sold our other house yet. Nope. So, and then the whole country just shut down. Shut down. And I was like, oh, we're going to own two houses. Yeah. And that was. That was quite a time. Maybe an expelative or two came out of my mouth. Yeah. But. It all worked out though. Yes. And then you lost 26 speaking gigs. I think it was 26, 25 or 26 speaking gigs got canceled in 2020. In like two days. Yeah, everything canceled because the world shut down. Yeah. So because I was grounded, if you will, because I was. I will just say I took a sabbatical. Is that. A COVID induced sabbatical. And so I had the time to write the program that I had always wanted to write. And so it is available. It's available on our website, which is carryebert.com. And in case you don't know how to spell my name, I spell my first name kind of. Yeah, kind of funny. Yeah. It's C-A-R-I-E-B-E-R-T.com. And so all of the strategies that I'm going to share today come from my book. So if you like what you hear and you want to order your own copy. As a podcast listener, we wanted to give you a coupon code. Oh. Everybody loves coupons, right? A coupon. A coupon. Here's a coupon for you listeners. And the coupon is podcast five. Podcast five. Podcast five. No space. Just type podcast five. Yep. And you can save five dollars off the purchase of your own learning to learn program book. Nice. What do you think? I like it. You do? Okay. So in the learning to learn program, I provide strategies for five different foundational skills to address when supporting very young children who have social learning differences. And I really like that term, social learning differences because not all of the littles that we are supporting have a formal autism diagnosis yet. Okay. So there are kids where, especially if you work in an early intervention in the birth of three world, you may be working with a toddler who doesn't yet have a diagnosis. Sure. You're seeing a lot of autism traits and realizing, gosh, maybe I need to be approaching things differently. Sure. And so I really like that term, social learning differences. So the strategies that I'm going to talk to you about and the strategies that are outlined in the book are not designed to coerce compliance. Right. Or to teach missing skills identified on standardized tests. Okay. Right. We, as if you're an SLP like me or an OT or if you're a teacher, when we went to school, we kind of learned, oh, you got to give a standardized test, figure out what skills are missing. And then we teach to the test essentially. Sure. And gosh, doesn't always work very well or count very well for the child because we don't end up teaching meaningful skills in meaningful ways. Okay. So that's really my big thing. We want to figure out how to teach meaningful skills in meaningful ways. So today we are going to start with chapter one in my book. And the first foundation skill that I cover is nonverbal imitation. So over the next four episodes, I will address the other four foundational skills. Okay. So again, if you like what you hear, I'm going to go over five strategies for nonverbal imitation. And if you like what you hear, you can get your own coffee. And there's more in the book. Yeah, absolutely. And I think I counted them for you. So when we get to that part, I'll tell you exactly how many, because I went through the book and counted how many there are. Oh, nice. Awesome. All right. So let's talk a little bit about nonverbal imitation. I'm a Tation is the basis for modeling and modeling is a really important teaching strategy that every adult uses. And so that's why imitation is so important because modeling isn't very effective unless the child can imitate what they see you doing. So imitative learning is critical for supporting the development of social, play, motor, and language skills. And it really helps build the child's awareness of their environment. So you know one of my new favorite topics and one of my newest courses is about executive functions. Right. Right. And you and I, we spend a lot of time talking about EFs, if you will, executive functions. And, you know, how being smart isn't enough that you have to have executive function skills. Sure. Yep. You mean being smart like knowing things. Right. Like knowing things having concrete knowledge isn't always enough. Right. It's what you do with what you know. Like knowing your ABC. Right. Knowing letters, numbers, shapes, and colors. Right. You know, a lot of adults think, oh, that means the child is smart. And while that may mean the child can rot memorized and you know has some surface level knowledge, we want to make sure that they have the ability to translate that and use the information, you know, in meaningful ways. And so having executive function skills is really important because those EFs are really what allow children to be ready to learn things like focused attention and working memory and impulse control. Right. All of those are executive. - Yeah, those are important. - Those are very important, right? For learning, for self-regulation, you know, all of that. - Impulse control. - Ooh. - Big one, right? Big one, yeah. So, perception of the environment is something I just wanna talk briefly about because perception of the environment is actually an executive function skill. So when we say that nonverbal imitation helps build the child's awareness of the environment, the reason we need to focus on this is because it is very common for autistic young children to not attend to their environment. - Okay. - That's why you'll sometimes hear parents or caregivers describe their autistic child as something like this, she's in her own world. - Okay. - Right? Or he's difficult to engage, okay? And so what we're really saying is, gosh, this child is not really attending to events or to people in their environment. And so the way I usually word this in a written report is something like this. The child focuses intently on their own interests and thus often misses what is happening around them in their environment. So they're just kinda, they're like me sometimes when I'm-- - My football's on? - Yeah. And you tell me something. And I say, uh-huh. (laughing) And you say like a week later, okay, we're gonna go and I'm gonna be like, I don't know what your time is. - Yeah, yeah. Focusing on your environment, attending to your environment, it's a really important skill. Another way you could word it is the child focuses intently on their own interests and has difficulty shifting to the interests of others. Right? Or to has difficulty shifting. 'Cause, you know, a shifting attention is also an executive function skill. Not just paying attention, but shifting attention. And so it's really important that we understand that modeling isn't an effective strategy if the child doesn't attend to you. - Right. - Right, well good does it do to model all of these skills for the child if the child isn't attending stuff. - Well, it's kinda like you trying to tell me something when I'm watching football. - Yeah, exactly. - It's not gonna do you any good. - You're absolutely right. So addressing nonverbal imitation supports joint attention and joint attention is actually the topic of our next episode. But the reason when I wrote the book that I put nonverbal imitation as the first kind of skill to address is because when you work on nonverbal imitation, it supports and builds joint attention, which is the second foundational skill. - So they build on each other. - They do, they kind of build on each other. So in neurotypical development, children begin imitating early in life for two primary functions. One of the functions is to learn and develop new skills. So we'll call this the learning function. - Okay. - Okay, so that's one function of imitation. So let's say you have a 10 month old and you are clapping your hands and the baby watches you and starts clapping their hands. So they are learning the skill of clapping through imitation. - Right. - That is a learning function. But the other reason that children begin imitating is to engage in social and emotional exchanges with other people. So this is the social function. So the difference here would be if you're clapping and smiling and the baby starts imitating you and you are clapping because you're now playing patty cake. So see now it's actually a social exchange or you're clapping because somebody does something fun. - Well, and I can tell you from experience in watching you do this with babies at church or wherever, when you get that reaction, you automatically are like, oh, you know, I mean, you react. And then they see, oh, they get that feedback from you. - See, that's the social feedback. See, and they're like, oh, this is cool. Yeah, imitating is cool. - Yeah, right. - And it's this reciprocal back and forth. It's what I've always called relationship-based learning. There's another term that is really cool that Harvard Center on the Developing Child Uses, the American Academy of Pediatrics uses in it's called Servin Return. And I think I talked to you a little bit about that, whether it's tennis or badminton or pickleball, whatever, but Servin Return, back and forth reciprocity. So what is very interesting, and I talk about this in the Learning to Learn Program book, is the research that I outlined in the book shows that while autistic children often struggle with the development of imitation skills, their development is not uniformly different. So what the research has found is that autistic children seem to do better with imitation as a learning function. - Okay. - But they don't, they struggle more with imitation as a social function. - Okay. - And that just makes so much sense, right? So like, I think about our own autistic son. Like, he could learn some new skills through imitation, but what took a lot longer in life was for us to be able to get that back and forth, that reciprocity for, you know, imitating in a social context, as opposed to in a learning context. So just because a provider can elicit imitative behaviors in a highly structured, therapeutic setting, does not mean that child will spontaneously imitate new behaviors during naturally occurring social interactions. Okay, so all the data that is collected in these highly structured therapy sessions may have very limited to no carryover in real life social situations. - Okay. - Okay, and that's why so many of us who are neurodiversity affirming in our approach in therapy, we recognize now that our sessions have got to be child-led. They have to be about that. And so what I love is the technical term behind it. We have to be addressing the social function of imitation, right? And I have so many terms, but just relationship-based learning, right? That's always been my term. I'm like, oh, I love how this all just fits together. Okay, so it's not about can you get the child to do this, clap your hands, do this, touch your nose, do this, pet your head, do this, stomp your foot. Like that's great. And we know that through discrete trial training, autistic kids can be taught the learning function, the learning function of imitation, but, in the grand scheme of things. - It's just like commands. - Yeah, it's just, it's doing wrote kind of drill work, if you will. But the research shows it's not generalizing. - But it's one-sided. - Yeah, it's not serving the return. - Right. - It's not back and forth. There aren't those big social smiles. There isn't that ability to build joint attention there. So this is why I put this as the first foundation skill in the learning to learn books. So there's two ways for us to think about how to, and I don't even love to use the word teach, but I wasn't sure what other word to put there. But when you think about teaching nonverbal imitation, I think we maybe could rephrase it as building nonverbal imitation skills. You know what I mean? Because teaching kind of sounds like it should be very directive. And so there is one very directive way, and it's a structured behavioral approach called discrete trial training. - Okay. - Like that's what behavior therapy is based on. A lot of SLPs who are more medical model, use a lot of discrete trial training. And this is when imitation is taught in a highly controlled, adult directed context. Skills are broken down into discrete tasks. That's why it's called discrete trial training. And then drilled over and over and over until mastered. The big thing about using discrete trial training is that extrinsic reinforcers are used. So if you say do this, and you clap your hands and the child does it, yeah, I've said Skittle, you said Eminem, right? But you know, you pop something in the, you know, give them a treat or give them a tickle or give them a, you know, a reward or a reinforcer of some kind. So discrete trial is really about establishing compliance. And that is one of the reasons why neurodiversity affirming providers are shifting away from that. Because our training should never be compliance based, okay? - So the discrete trial doesn't necessarily, and maybe I'm wrong on this, you can correct me, but it doesn't necessarily speak to the social component. - It does not. It is only for the learning function. - Okay. - You nailed it. - Okay. - See? - I'm very married, you're brilliant. Yeah, yeah. So for the listeners, just so you know, I kind of write the post and Jim is never really made aware. - I have no idea what's happening. Well, that's normal for me. I have no idea what's happening. - That is the normal tip. - No idea what's going on. No, but we just decided that he could be, you're the color guy. Is that what they call it in sports? - Or let's see, what is it in comedy? I'm the straight man, I guess. - I know, I know it's called. - I have no idea what it's called. I have no idea. - Where I just like, you know, when Johnny Carson would say, like something like, and I'm aging myself, they're oh my gosh. - Yeah, yeah. - He'd say, you know, some joke and Ed would say back, well how tall was he? - Oh, gotcha. That's you. Yes, yes. So anyways, Jim, yes, you are absolutely right. So discrete trial training really addresses the learning function of imitation. Okay. So the second way that we can think about supporting, building, teaching, nonverbal imitation skills is a naturalistic approach. Okay, where imitation is addressed during naturally occurring socially interactive contexts, such as during play and during other routines. So this is a child directed, not an adult directed approach. And I feel like the reason therapists tend to really prefer more of the discrete trial drill work type thing is because it's easier. It's like, you can play in your day. - Yeah, it's systematic. It's organized. You have an agenda. You stick to it. - But when it's trial led, you're kind of, you know, just have to know what your goal's on. - Going back to, going back to Julia Roberts flying by the sea to your pants kind of gal. You know, you like that? - Yeah, good one. Good one. Absolutely. Absolutely. Yeah, one of Carrie's all time favorite movies. Why am I referring to myself in the third person? - I don't know. Yeah, I don't know. This one's aging us. - Yeah. episode is definitely aging us. Yes. Okay. I was a kid when Johnny Carson when I was on Bible work. Okay. Wasn't like an adult. No. We are supposedly adults now though. Yeah. Yeah. You know what else makes me feel old is I just saw Wheel of Fortune. You know pets. Is this name? Pants. They did that he retired and now. Right. Right. Ryan C. Crest is the new host. Right. And Vanna is still the lady turn in letters. Is it bad? Did I remember who was the guy before pet say Jack? Who was it? It was Chuck. Yeah. I was gonna say see we are old. All right. We better stop dating ourselves. All right. So I want to share with you a few strategies on how providers and caregivers can support nonverbal imitation skills. I'm gonna cover five strategies in the episode. But I counted in the book. There are 24 strategies. Okay. And a train. There's our train. Yes. Because we work in downtown. Okay. So here we go. Strategy number one. You ready Jim? Yep. I'm ready. Another one of my favorite one lineers. I have a lot of one lineers focus on connection over instruction. So it's really important that you avoid trying to teach imitation in a structured manner. If you do, then you're only teaching the learning function. You're never going to address the social function. Okay. So it's really important that you're interesting, playful and low key. Like I always say, autistic children, they can smell your agenda from a mile away. So if you come in with an agenda and you're gonna try to I think that goes for all kids. Yeah. Probably true. Very true. But it's really important that you don't use discrete trial training. We I want you to think naturalistic interactions think relationship based learning think child led. Okay. Okay. Okay. Nero diversity. A firm. Yes. Nero diversity affirming. So again, the goal is to focus on the social learning social through imitation. Okay. Not just teaching skill. All right. Strategy number two. Be quiet. Well, at least talk less. Now for someone like me, that that was that was a challenge. That is a challenge because I am quite verbose. And whenever I go into one of my professional development trainings, I jokingly say, if I got paid by the word, I'd be a millionaire by now. Right. So I mean, it's it's an awkward silence. It is. But people don't like people don't like silence, but here's what we know is auditory over responsivity is very common in the autistic neurotype. Okay. Which is one reason why a lot of times autistic kids put their hands over their ears. They walk away from certain situations. And it doesn't even have to be loud. If it's something if it's a sound they're not familiar with. Sure. Or if it's the tone of someone's voice. It's not always that it's loud. Okay. You know, I was thinking about that the other day. I was thinking about Aaron and I was thinking, how does it feel? You know, I was trying to put myself in issues and I was thinking, and maybe this is a good analogy for how autistic people have to what they have to deal with. It's that it's like your your senses, your senses are like volume on a stereo. Like ours is at like 10 and there's is at 50. Right. And so anything can be too much. You know, for us, yeah, we're it's not overwhelming for that kind of interaction or noise or anything. But if you're already at 50, it's like your senses are so so over responsive over sensitive. Yeah. You know, just heightened. Then yeah, those things are going to that's going to be painful to you. Well, and think about the stereo analogy back when I don't know if you know, they still do this, but the receivers, there's other buttons for bass and for, you know, what are the other but you're like you're teedering on the edge right now of not just for volume though, but think about the other components. It's not always and that's I guess what I'm getting. It's not always just volume. It's the other things. Was it is it a familiar sound or is it unexpected? So being low key means, you know, not taking that and I know like especially watching you, you get excited. I get very excited when when you get a reaction and you know, so it's hard to tamp that down sometimes. But sometimes you have to. So I love that you brought that up because one of the things that I had to figure out very early on as an SLP was I had to figure out what the child's sensory preferences and needs were. And so for some children, I can be like, I don't know, kind of over the top, I can be really animated. I can be a little explosive in my cheering and my clapping and my woohooing and I can use that high pitch voice and I can get excited. And so it's kind of like being like an amusement park. Like I can be, you know, like I'm at the amusement park. But for some kids, I need to be like the library. And as that makes sense, like I need to tone it down. I can't have big reactions with my face. I still can't even with our son, Eric. He sometimes will still say calm. What is it? Calm down, mom calm down. Calm down. Calm down. He says it at least once a day. And it's not that I'm like jumping up and down. But if I even get a little bit excited and my, I mean, he'll stop you before he get there. Just my facial expression. If I don't, and he'll go, mom, calm down. And so my son is helping me to really understand, oh my gosh. And he's 19, right? And I didn't know all this when he was little. And so I think how I have to, I'm the one who has to change neurodiversity of performing providers understand that we seek to understand the autistic child's behavior. And then we change what we do rather than saying, you're fine. It's not that loud. You're going to be okay. You're overreacting. Stop being so dramatic. Right? Those are the things that people say when they don't, as you said earlier, put them, put yourself in their shoes, right? And so we don't. I can't put myself in errands shoes because I'm not autistic. So I don't know. But I try to, I always try to remember that behavior is an indicator of what is happening in the nervous system. So when a child has an overreaction, that means they are having a stress response, right? So with some kids, you can be the amusement park with some kids. You need to be the library and you need to bring it down to town. Yeah. And it just, it makes me, whenever that happens, whenever he says calm down, mom, makes me understand or realize he's still dealing with everything he dealt with when he was too. He still has that. And he's, he can cope with it better now. Right. And he can communicate is, yeah, he can say, let's say this, he can self-advocate. Right. See, and that's what's so beautiful because we work so hard before it resulted in a meltdown or crying or whatever, because he could not deal with it. He just couldn't. And, and you know, it's hard to kind of think about that now, you know, think, okay, yeah, there was some trauma that he had to go through, right, you know, and before he could self-advocate, right, for his needs. And so that's why we want to be very aware of that. So yes, sometimes you have to either be quiet or we could say be quieter or at least talk less. Okay, the goal is not to talk all the time. And this is where I think SLPs get very concerned because we think that our job is to teach them how to communicate or how to talk. And so we think we have to be talking nonstop. So you need to make sure that you're writing goals for, you know, communication and for engaging in, you know, for connection, for engaging in positive social interactions, you know, with the child, so that you can actually address this using the strategies that are appropriate. That's why we shouldn't be writing talking goals, right? We shouldn't know that we should be writing communication goals and social interaction goals and things like that. So I really, it took me some time, but once I started talking less and allowing myself to be comfortable playing quietly alongside the child when it was indicated, everything started to change. I started to build authentic connections with autistic toddlers and preschoolers because I wasn't overwhelming their nervous system, right? It wasn't constantly blah, blah, blah, blah, blah, whoa, whoa, with all my sound effects and, you know, animated personality. So for me, it's always been finding that happy medium, right? Right. Right. And really reading the child's cues. What I think, one of the, one of the things in coaching, and I'll always go back to sports because that's kind of how I'm built. Sure. Is that the, when you're good coaches will find a way to motivate their players, some are motivated, they're motivated in different ways. Right. Absolutely. So I think that ties into what you're saying about, you know, are you the library or are you the circus? Yeah, exactly. The circus. That's good. That's better than amusement park. I was trying to think of something that's over the top, like, you know, kind of great circus is great. What a great analogy. Yeah, yeah, that's great. So for some autistic kids, the more you talk, the more dysregulated they become. Okay. So what, what I would encourage you to do is choose your words wisely. Early on, when you do open your mouth, try just pairing interesting sound effects with your actions. You just may need to not make them super loud and animated. So if, just remember this, the goal is to draw the child's attention to what you are doing, not to what you're saying to what you are doing. We are addressing nonverbal imitation right now. Okay. So if you are, let's say the child is playing with blocks. So I'm going to get my own blocks. I would never touch the child's blocks. I really always start with parallel play. That would be a great episode. Can I interrupt you first? I'm just always, I'm amazed by the mindfulness that you as speech pathologists and all of them out there that you have to have coming into this. I mean, you have to think about all of these things in order to accomplish what you want to accomplish. It is a lot. It's incredible. And that's why I think think people look at us and say, oh gosh, you know, all you do is just play. And that's what it looks like to people who are observing. But there really is a lot of, you know, mental capacity that you use to figure out. And so it's kind of like, you know, I use this analogy like the ebb and flow. Like we push push push, but we have to recognize when we're hitting, you know, doing something and we pull back and repair the relationship push push push. Oh gosh, I'm, I'm upsetting the child or I'm causing this recognition pull back and repair the relationship. So I always say in any therapy session, I always view myself as either addressing our goals or repairing the relationship, addressing our goals, repairing the relationship. But it's this back and forth. You can call it the dance if you want. It's the dance. It's the it's it's servant return. It's the ebb and flow. Like there's so many great analogies. Just figure out which one works for you. So I appreciate you acknowledging that because it is there's so much mindfulness that goes into being exactly who the child needs you to be in this exact moment in time and being neurodiversity affirming. Yeah, you know, that's that's absolutely critical. So let's say the example is the child's playing with their blocks. So I'm going to get my own blocks because I'm a big believer in parallel play. I'm not going to touch their toys that will disrupt their gestalt way of thinking and processing. They've got this whole idea in their head of how the, you know, the blocks are going to look. So if I touch one, I kind of mess up that that processing. So I'll get my own blocks and let's say I stack my blocks and I have a little toy dump truck. And so just in an effort to, you know, play alongside the child and to try to be a little bit interesting, I may take my dump truck and crash the blocks down. Right. So I build the tower. My blocks. Yeah. So gosh, I've never knocked the child's down. So I knocked my own block down. I go, oh, oh, man, or oh, no, boom. So I again may not do it in a really animated way, but I may just pair some kind of an interesting environmental sound with it instead of saying, oh, look, the truck knocked the blocks down, knock your blocks down. Here's a truck, knock your blocks down. Come on, buddy, you can do it. Oh, my gosh, like that's what has to stop. That's very directive. And so if you do talk, talk very little. And what I always, and I think I talk about this in, in both chapter one and two is it really allow the child to come to you instead of forcing yourself on the child. So you may spend one or two therapy sessions playing parallel. And the reason again, therapist dislike this approach of child led is because they're like, well, what do I document? What did we do? Well, if your goal is child will engage with, you know, the adult in, you know, shared social interactions, I mean, you're addressing the goal. Do you know what I mean? You're just starting with parallel play and you can't force this. You cannot force it. Okay. And so and again, that's the agenda that is the agenda in the autistic child will smell that agenda from a mile away. And what a lot of our son, what he would do is if he smelled your agenda, he would just stand up, turn around and walk away. Right. I mean, literally he leave the toys and everything. Like if he thought you were going to try to get him to do something. And that's that demand of avoidance that is part of the autistic neurotype. That could be another whole episode. Okay. So third strategy, contingent imitation. And that's just a fancy way of saying you start by imitating what the child does. See rather than, hey, watch me little child and do what I do. Instead, I am just going to imitate the child. So if the child hits the table, I hit the table. If the child knocks on the window, I knock on the window. If the child throws their little foam blocks in the air, I throw my little foam blocks. Does that make sense? It's called contingent imitation. Well, but you're also getting that back and forth. Well, and sort of, it's like you can read my mind because exactly that's how we introduce the concept of serve and return. So you let them serve. Yes, they serve I return. And then they are going to serve again, not because I did it, but because it's intrinsically motivating to them. And they're doing it because it brings them joy. So then they go, then I go, then they go, then I go, does you see how that's how we actually establish another sports analogy? Okay, forgive me, but you're good. Like, you know, kids back in the day, we would have this thing called a backstop. And it was just like this, you know, springy thing you threw a ball into and it came right back to you. And so you learn, you kind of play, you could play, if you didn't have anybody to play catch it, you threw it or you took a tennis ball and you threw it off the side of the house. Oh, I used to hit against the garage door with a tennis racket. So you can instead of being the server, you're the backstop. Yeah, be the backstop, right? Just allow it to come to you. Just send it right back, right? It comes to you, send it right back. I love it. So it's really about responsive interactions between the child and adult. That's what serve and return is. Responsive interaction. So while the child may may not yet be responsive to you, you are being responsive to them, right? So that is exactly how it's just so beautiful. So this is how we actually begin to address social skills and autistic children. We're addressing it through shared social interactions, positive shared social interactions. Like to me, those are the forwards, positive shared social interactions. Yeah, everything because they're probably smiling or having fun while you're well, you're not having a stress response. Even if they're not smiling, even if they're not laughing, even if it looks as though they are paying no attention to you at all, if they are not running away from you, you know what I mean? If they are remaining and tolerating you being in there, in their, in their area so that you're parallel playing alongside, you know, and you're building that relationship. And you know what that relationship is built on his trust. I am not going to withhold something from you. I'm not going to use hand over hand assistance and make you do this. You see, I'm removing all compliance based support because there's when you're directive, there is no trust there. You're just, you're just being dictated to. It's all about to this. And we, we know everybody knows that a real relationship is built on trust. Every relationship is, you better believe it. You better believe it. Absolutely. So yeah, third strategy, contingent imitation, child leads, I follow. Okay. Fourth strategy, teach imitation in the context of whatever the child is currently doing. If you come in with an agenda and say, oh, we're going to roll a ball back and forth. Like that's what we're going to do. And we're going to do this. If the child has no interest in playing ball, all you're going to do is create a stress response if you try to force this. So that's why you need to write your goals if you're a provider so that you can address it in any activity. See, don't write goals specific to activities. That doesn't make any sense. So, you know, you want to make sure that you're writing goals that support positive social interactions, right? That's really what this is about. So avoid having a lesson plan with expectations for the child to complete a certain number of specific activities. We are focusing on the social function, not the learning function. Right. Okay. Yes. Okay. And the fifth strategy, avoid using hand over hand assistance. This is a big no no. We are all taught to do it. And it is a huge part of discrete trial training on camera. But there's lots of issues. Isn't that the ultimate directive? Oh, it's well, what it is. Oh, it's it's it's it exerts you're basically you're not just telling them to do it. You're making them do it. Yeah. So it exerts a level of control over the child that is completely unnecessary. Okay. When we choose power and control, we are not neurodiversity for me. Let's make that crystal clear. Okay. If you are saying the child, you better do it or else you're going to lose recess. I'm taking your here it is. Here's Aaron's favorite his favorite his little plastic sorting bears. I still have them throughout our house still. But that's what providers used to do is say, Oh, you like that bear then give me that bear and you do this and then you can earn it back kind of a thing. Right. So, but hand over hand assistance creates let's talk about some of the issues. Number one, it creates prompt dependency. So oftentimes because autistic kids often don't have very good body awareness, they often don't know where their body is in space, which is one of the reasons why they often struggle with object imitation is because they don't really have a good body awareness. But if you start taking their hand and doing the action for them, how are they ever going to improve their body awareness? Right. Yeah, because you're doing it. You're doing it for no like one of the things that I you know learn from amazing OTs is you know doing things like heavy work or giving them a weighted object. So like I have a I think it's a I have a one pound a two pound and I may even have a three pound. I think they're called medicine balls using when you work out that they're filled with sand. And so with an autistic child, I remember one time I gave him the one pound. He's a toddler weighted ball because he would never throw a ball. His parents were like trying to play ball with him. And he just wasn't interested all gave him a little weighted ball. And all of a sudden he was like, wait a minute, I really like this thing. And he started tossing it because it was weighted. It gave more input to the receptors and his muscles ligaments joints and tendons. And so the way you see what I'm getting at. So this is why we want to always think about the whole child. So we're not going to create prompt dependency. We're going to find what remember what we do is neurodiversity affirming providers as we fix the environment. We don't fix the kid. We fix the environment. Okay. So hand over hand assistance creates prompt dependency. Oftentimes what we'll see is kids will come up and just hand you their arm like here, whatever you want me to do, just do it. Do you see that's a huge issue. Okay. That's prompt dependency. And it's kind of icky, isn't it? Right. And they're like here, just whatever you want to do with my hand. Here it is. No. So prompt dependency is not what we want. It also doesn't support motor learning. My other specialty area as a speech language pathologist is at praxia. And in the brain is what is the motor cortex. And what happens when you use hand over hand assistance is part of praxis is the first part of it. After you have ideation, I have to figure out what action I want to do. Then what you have to do is initiate the movement. [BLANK_AUDIO] is one of the first components of praxis, and that's done in the motor cortex and the brain. Well, if I take your hand and do the movement for you, your motor cortex never initiates the movement. So it actually does not support motor learning, it actually inhibits motor learning. Hand over hand assistance is not okay. But the third reason, and the primary reason why we do not use hand over hand assistance is that it is a violation of body autonomy. And what it teaches children, and it teaches the most vulnerable members of society, which is children with disabilities, teaches them that adults can touch you whenever they want, wherever they want. And I hope you understand where I'm going with this. But it is unacceptable. - I wondered about that when you were talking about, I'm just handing you their hand. Well, it's like, okay, then you're basically saying, you can do whatever you want with me. - Whatever you want. So see, this is the issue, is when we teach kids that compliance matters more than anything else. - Right. Oh no. - And what happens when an adult says, do this or do that, or, right? - No, that's not good. - No, we do not, the goal is not compliance. Now, there are exceptions to every rule. Are there times when compliance has to be the issue, like crossing a street safely? - Oh yeah, safety. - So if safety is involved, then yes, we will do, quote unquote, compliance training, if you will, for those instances where it's like for death. - Right, absolutely. - But to learn to clap your hands or to learn to touch your nose or whatever this skill is that you're trying to teach, we would never use handover hand assistance, okay? - Right, I mean, it's like, you would not let a child go wander around a pool that does not have a swim. - Right, exactly, right. - Exactly. - So. - Yeah. - So if the child needs physical support to complete the motor act, there are other options. You can use a less invasive physical prompt. If you are trying to trigger initiation in the motor cortex and the brain, you could tap the elbow to indicate, it's time to move that, you know, you could tap the wrist, you could tap the shoulder. What physical therapy, as I've seen them do, when they're working with a young child, who they're trying to teach them how to alternate, their feet going up the stairs. Because a lot of times when kids have weakness in one leg, they will always start, you know, put the right leg up first, for example. - Right, yeah. - And so when PT's are trying to get them to alternate, they just tap the leg they want them to lead with. So that's a, it's not invasive. It's not controlling, but it does provide some physical support. But then your motor, more their motor cortex. - Yeah, it can be, it is. - Motor cortex gets involved. - Yeah, you need to actually initiate in the motor. - Yeah, I'm not doing it for you, absolutely. - Okay. - You also, and if you are gonna touch them, I always say it's important to get permission first. Like if I'm gonna touch, you know, is it okay if I touch your arm? Is it okay if I touch your elbow? The other thing you can do is guide the movement by touching the object in their hand. So if they have a tool in their hand, like a fork and they're trying to stab a chicken nugget, for example, I could tug on the fork to initiate the movement. Rather than grabbing their hand and doing full hand over hand assistance. The other option is to offer hand under hand assistance. And that would be where I say, here's my hand, if you wanna put yours on top, I'll get you and your fork to the chicken nugget. So do you see how they willingly put their hand on top of mine? And I move my hand in the direction where they wanna go because the child can then remove their hand if they ever feel threatened or feel unsafe. So do you see hand under hand assistance isn't about power and control. It's actually about providing a physical support. - Is that kind of the last thing that you would try? - Yeah, usually hand under hand assistance is my last thing. I'll try those other things first, but we're not gonna use hand over hand assistance 'cause that's about power and control. We are done choosing power and control. Okay. So those were the five strategies I wanted to share with you. In the Learning to Learn program, there are some examples of goals, for each of these foundation skills. So I'll just share a few with you here. Maybe you'd write a goal, during child-led play, Sasha will imitate five new actions with familiar toys. They could do something like that. Or during daily routines such as playtime, meal time or bath time, Marco will engage in imitative, back and forth interactions with three different people. So that's how you're making it measurable. Is it doing with more than one person, right? So maybe it's with a parent, a caregiver, a nanny, a sibling, a therapist. So that's one way you can make things measurable. One more goal example, Mandy will imitate new actions to three different songs and finger plays during circle time and day care. So I'm just to give you some ideas of examples. But as a result of our supports, here are some of the skills we hope the child gains related to imitative learning. We hope that they visually attend to what other people are doing. Okay. And we hope that they seek out favorite people who are not in plain sight. We don't want it to be out of sight. Find out this year. Yeah, if I'm looking for someone I want to walk around the room or the house and find them, be socially motivated to imitate their favorite people. Socially motivated. Socially motivated. Not because I got a skittle. Not because I'm doing it to just learn a skill out of context, but because I'm socially motivated. To learn more naturally through social interactions with other people instead of having to be taught in a discrete way. And then to use imitation for both purposes, we're always going to use imitation to learn new skills. If you want to learn to crochet, you're going to have to be able to imitate. So we never stop using imitation for learning new skills. But we also want the child to use imitation to socially engage with other people. Alrighty? So we better wrap this up. I want to thank you so much for listening to another episode of the SLP talk show. If you're interested in learning more, head on over to carryebert.com to purchase the Learning to Learn program. And remember to use coupon code podcast five. No spaces, podcast five, okay? To save $5. And be sure to join us for the next episode. We will dive into chapter two of the Learning to Learn program, which is joint attention. Until we meet again, cheers. [MUSIC PLAYING]