Problematic Therapy Goals and Pursuing Neurodivergence-Affirming Therapies

Note: This is a re-post and edit of material authored by me and originally shared iand commented upon in the FB group Autism Inclusivity. You can find them here.


For all of our talk about neurodivergence-affirming therapy for autistic children, parents often find that techniques used by their child's therapist are actually deeply problematic. Conveniently, I often read your child's therapy records, and I can usually tell if there's a problem. So here's how I know.


Transparency

First, you absolutely have a right to read and adjust your child’s therapy goals before they are sent to your physician for signature. And you need to read what’s actually written because it will give you a lot of insight into the therapist’s approach before they start treating your child. If this is denied by the therapist, run away.


Keywords


Every language has nuance and unique meanings for seemingly ordinary words. These are some of the keywords that you should look for and their meanings:

  • “Social”, “pragmatic”, or a goal mentioning something like back-and-forth conversation means teaching a child to perform according to neurotypical-normative social norms.

  • Joint attention goals usually involve eye contact and neurotypical expectations of how we pay attention. These are not reflective of autistic attention and often actually prevent a child from paying attention.

  • Goals about waiting, turn-taking, or anything including the word “patience” may involve withholding belongings. See below for more on this.

  • Goals to reduce sensitivity, desensitize, or anything including the word “tolerance” or “tolerate” is likely exposure therapy. This may be sensory exposure but can also be distress exposure goals, like “tolerate transitions” which may involve provoking the child with needless transitions. I'll talk more about exposure therapy in a few weeks.

  • "Behavior" goals are an indicator of the intent to fix a child's responses, often without adequate consideration of the "why" behind the behavior. Without understanding why children behave as they do, therapists often resort to methods to just make the child "try harder." If you believe, as I do, that kids do well when they can, behavior goals set kids up for failure.

Methods


Ask about methods used for achieving goals. These won’t be written in the plan, but are things that you can address before therapy even starts. These are the things that you should tell your therapist that you will not allow:

  • Fine motor goals supported by nonconsensual hand-over-hand. Never allow anyone to touch your child without consent, regardless of their intentions.

  • Any speech goals that will be achieved by planned ignoring until the child vocalizes their needs. Communication in any form is valid and should be recognized. Demanding their response in a particular format ignores the "why" behind their refusal.

  • Emotional goals including the idea of interpreting others’ emotions have to be taught without neurotypical bias toward what is "normal" and should not frame autistic social skills as inadequate. No expectation to "read the room" should be sought, as this is often unattainable for autistic people and puts the entire responsibility for bridging the neurotype gap on the autistic person.

  • Physical therapy goals that include balance issues need to be done with sensitivity to sensory defensiveness. Kids should not push through sensory overwhelm unless you want to teach them that their body's signals don't matter. Strength goals should be mindful of any joint hypermobility, or it will cause pain.

  • Talk therapy for anxiety often relies on the fact that anxiety is based on fears that aren’t real. But for autistic people, the fears can be very real. Anticipated sensory overwhelm is a valid fear and is not to be ignored. Concerns about people's social perception of autistic people are real and have been proven to us time and time again. Don't let therapists gaslight your child.

  • No rewards should be used for compliance or participation. Personal items or items of interest should not be withheld either. The power dynamic behind this is unhealthy. Also, consider the overwhelming evidence that reward systems undermine self-motivation and decrease both creativity and performance quality. This is a very common way of engaging children but is completely out of touch with current understandings of human motivation.

  • You should never be forced to separate from your child. Separation signals that the therapist views you, the parent, as a barrier or part of the “problem”. Even if you're willing to separate from them, consider these questions. Does my child want to be alone with this person? Do I trust this person with my child enough to allow them free reign over the therapy session? Can my child tell me if something inappropriate happens? Will my child defy authority and run away or defend themselves if something inappropriate happens? If one or more of these answers is no, then separating parent and child is not okay.

A reminder: good therapists don’t need any of these methods to help your child. They are born of a lack of knowledge of how to engage children naturally. Usually, the therapist needs these methods because their activities are one-size-fits-all and they don’t have the knowledge to adapt to the individual child. Your child’s therapist works for you, not the other way around.


Note #2: If you are a therapist and you do any of these things, stop now. You can do better. Check in with the Therapist Neurodiversity Collective. They can help you find other, more supportive, neurodivergence-affirming ways of helping your patients.



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