What therapists need to know to work effectively with autistic individuals

Therapists such as occupational therapists, speech language pathologists, physiotherapists, psychologists and other specialists can be a big part of an autistic individual’s life.  In order for sessions to work well, the therapist has to build a trusting, respectful relationship with the person and understand who they are. Because each person is an individual, one strategy won’t fit all nor will it work every time. It can also take time for a goal to be achieved so you may not see the fruits of your labor right away, but your work is building a foundation. Success is often seen in small increments with developmental plateaus.

Let’s look at what we need to know to best support autistic individuals in a therapy session.

Understand Autistic Neurology/Thinking

Monotropism

Autistic minds have a processing style that tends to be monotropic. Monotropism, a term first coined by autistics Dinah Murray and Dr. Wenn Lawson, has the following definition:

“Monotropic minds tend to have their attention pulled more strongly towards a smaller number of interests at any given time, leaving fewer resources for other processes. We argue that this can explain nearly all of the features commonly associated with autism, directly or indirectly. However, you do not need to accept it as a general theory of autism in order for it to be a useful description of common autistic experiences and how to work with them.”

Dinah’s autistic son Fergus Murray says, ““In a nutshell, monotropism is the tendency for our interests to pull us in more strongly than most people. It rests on a model of the mind as an ‘interest system’: we are all interested in many things, and our interests help direct our attention. Different interests are salient at different times. In a monotropic mind, fewer interests tend to be aroused at any time, and they attract more of our processing resources, making it harder to deal with things outside of our current attention tunnel.”

Monotropism affects sensory processing. It’s easier to process one thing at a time rather than having to distribute one’s attention in multiple areas which can cause sensory overload. Monotropic thinking focuses the resources all in one place, rather than on other things that may be occurring at the same time.

In social situations, autistic people need more processing time which can make social situations difficult because of multiple input through speech, body language, and eye contact (this also relates to movement differences). Conversation involves back and forth exchanges and pulling in all kinds of information both internally and externally. Monotropic thinking expects one thing to follow from another directly, but conversation tends not to work that way.

Restricted or repetitive interests is one of the autism diagnostic criteria in the DSM-V. What is really happening is there is an intense focus on an interest. Use a person’s interests to support engagement and create a flow state, a mental state of operation where a person is fully immersed in an activity, characterized by a feeling of energized focus, full involvement, and enjoyment in the process of the activity. Look at this as a great way of being!

The Need for Sameness

Mirko Uljarević, clinical assistant professor of psychiatry and behavioral sciences at Stanford University in California, completed a study of 1,892 autistic children that found the insistence on sameness is comprised of three distinct types of behavior: routines, rituals, and insistence on sameness in others’ behavior.

The 3 subdomains from this study are:

Ritualistic – the need for objects in one’s environment to be arranged in a particular or “correct” manner, according to the person. For example, food must be arranged in a certain way or the person asks the same questions and needs specific answers.
Routines –  behaviors that are performed in the same order each time, typically to achieve a goal such as always going to bed or taking a bath in exactly the same way.
Sameness – insisting that other people follow specific routines or rituals. This third subdomain is less commonly seen outside of autism. Ex. At bedtime, my son needs me to say 3 specific sentences before he can go to sleep.

Therapists need to be aware of these 3 differences about sameness in order to understand an autistic person’s needs and plan accordingly. To ignore this could increase anxiety and stress and lead to behaviors of concern.

Movement Differences

In 1996, researchers Martha Leary and David Hill defined movement differences as “a difference, interference, or shift in efficient and effective use of movement. A disruption in the organization and regulation of perception, action, posture, language, speech and emotions.”

Movement differences may affect speech, thoughts, perceptions, memories, and emotions. They profoundly affect early experiences. They may impair learning about oneself, learning about textures, tastes, temperatures; learning about size, learning about orientation of the body in space, the development of perceptual skills and independence from others. Movement differences cause problems with starting, stopping, combining, executing, continuing and switching movements.

All communication requires movement. Even emotions, thoughts and memories may require “movement” on a smaller neurological level. Autistic individuals perceive the world differently. Every person will need accommodations such as contrived strategies, gestures, touch, rhythm, visualizations, music, and perhaps a specific support person during a session. Accommodations will be different for every person and can change with time and situations.

Autistic inertia which is the tendency that autistic people have to want to remain in a constant state, is also is a movement difference. It is difficulty with starting or stopping tasks. It can also look like extreme demand avoidance, which may be linked to high levels of anxiety. This can be perceived by those observing as laziness or a lack of motivation.

Effective Accommodations and Supports

All accommodations and supports have to keep this premise in mind – providing predictability. An autistic individual needs predictability to:

• lesson anxiety
• reduce fear over change
• help with transitions
• give a clear beginning, middle and end to an activity
• support autonomy
• support communication

Predictability is created by:

• a structured environment/activities
• visual supports
• having a session schedule
• routines
• visually breaking down a task into manageable steps 

Know the Sensory Profile

Sensory processing involves 8 systems: tactile, vestibular, proprioception, visual, auditory, gustatory, olfactory, and interoception.  Individuals will either under-reactive or over-reactive to stimuli and will not be one way all the time. Processing problems with any of these systems will look difference in each person. Sensory overload happens when there is more input coming in from the senses than the brain can sort and process. Autistic people tend to be more hypersensitive to sensory input, making sensory overload more likely.

Recognize the signs of sensory overload then make adjustments to the pace, requests, or provide a break.

• difficulty focusing due to competing sensory input
• extreme irritability
• restlessness and discomfort
• urge to cover ears or shield eyes from sensory input
• feeling overly excited or “wound up”
• stress, fear, or anxiety about the surroundings
• rapid breathing
• self-harming behaviors

Ask if an individual has a sensory diet in place and what sensory activities their plan has. Use sensory tools and activities that help with regulation. Make sure you are using co-regulation responses with the person you are supporting.

Recognize Arousal States and De-Escalate

It’s important to recognize arousal states before they escalate into difficult behavior. The behavior we observe is just like the tip of an iceberg; below the surface of the waterline lies the cause of behavior. These are the common indicators of an increase in the state of arousal:

• changes to the face – expression, coloring, pallor, or ruddiness
• changes to breathing rate
• apparent increase in energy levels, leading to movements not usually seen in the individual when they are calmer
• increase in body tension – hands, arms, shoulders, face look ‘tense’
• changes in communication – rate, volume and rhythm of speech or vocalizations

When there is an increase in arousal level, consider:

• reducing demands
• not talking
• providing personal space
• having an escape plan for the individual
• offering quiet time
• employing exercise when anxiety levels are spiking

Attempt to distract or redirect an individual who is building towards crisis by:

• offering tangibles – food, drink, toys or favorite objects
• offering non-tangibles – talking about favorite topics, interests, or do preferred activities
• do something funny or surprising – it’s very difficult to stay angry if you’re laughing! If we can do something that makes the person laugh, or that shocks them (in a good way), this might be enough to break the escalation of their arousal. Sing, dance, tell your favorite (clean) joke!

The most important thing to remember is autism is the way people are rather than a thing people have. We can’t change who a person is, but we can develop a deeper understanding of an individual’s unique needs. We must adapt, support, and accommodate accordingly.