Third Edition 2010, Volume 60 No 3
Get Out of the Office
Speech Therapy in Natural Environments
By Erin Weiner, M.S., CCC-SLP
Traditionally, speech-language pathologists have worked with people on the spectrum in office settings. For the client, office-based therapy is like a doctor’s visit. While this common method is effective in some cases, the problem is that many people on the spectrum face their most difficult challenges during social interactions in their everyday lives. For this reason, many people who are diagnosed with autism spectrum disorders are better served when speech-language pathologists work with them in their natural environments. Instead of asking clients to come into an office, this new approach calls for visiting clients in their homes, schools and work places. By doing so, the therapist is able to help clients deal with real-world situations as they occur.
To be sure, there are certain instances in which the traditional approach may still be best. The office setting can act like a pair of training wheels, allowing clients to practice skills that they can transfer to a natural environment. And older clients may be uncomfortable with a therapist visiting them in their workplaces and thus prefer the privacy of an office. While the natural environment approach is a relatively new method, and therefore not well researched, my experience in the field has convinced me that it is the preferable way to work with most people on the spectrum, regardless of age.
BENEFITS OF THE NATURAL ENVIRONMENT APPROACH
One defining characteristic of people on the autism spectrum of all age groups is that they have a difficult time with social interactions. Social skills cannot be taught like math. Asking clients to memorize scripts can be useful as a stepping stone, but it will not teach skills that are applicable in the real world. The only true way to make sure a skill is generalized is to teach it in a variety of settings, and then practice it over and over again. It is one thing to talk about a past incident, but it is far better to be there to intervene when something happens. At the same time, when speech therapists are in the natural environment, it also allows them to coordinate with the entire team of specialists who work with those on the spectrum, and involve the family, peers and community in the learning process.
Once liberated from an office, there is no limit to where therapy sessions can be conducted. Even a setting as ordinary as a grocery store can prove to be a useful environment for working with those on the spectrum. Some clients have no difficulty locating items, but what if they cannot find something? The therapist can use this situation as an opportunity to have the client try to locate a store employee for help. During the interaction, the therapist can assist the client with formulating a question and asking it at the proper volume level. The store is also a great opportunity to work on greeting others. For instance, when it is time to pay, the client can be reminded to say “thank you” to the cashier.
Beyond the general reasons why natural environment treatment is preferable, there are reasons why it works for specific populations.
NATURAL ENVIRONMENTS AND CHILDREN
Children visiting a speech pathologist’s office are often forced to sit at a table during the session; however, it is very difficult for a child with sensory processing disorder to sit for long periods of time. Working with such clients in their home or at a local playground is much less confining and helps put them at ease.
School gets more difficult as students get older, and the amount of homework kids are assigned these days can be overwhelming. Kids who need speech therapy often require other services, such as occupational therapy. Between all of these appointments and schoolwork, they do not have much time to be kids. By conducting therapy in a more natural setting, it can actually be fun, and it is easier to involve family, friends and neighbors–a crucial aspect of childhood development. During the sessions, the therapist can create situations to help the kids practice the skills they have just learned.
The therapist can organize activities, such as watching DVDs, playing on a Slip ‘n Slide or jumping on a trampoline, and invite other kids over. This helps establish the client as living in a “fun house” where other children enjoy hanging out. It is a wonderful opportunity for kids on the spectrum to learn how to interact with others.
Regular office visits can be especially taxing for the parents of children on the spectrum. Because speech therapy is just one aspect of coaching people on the spectrum, parents are pulled in many directions. Driving their kids to all of these appointments can mean hours on the road each week to see the best professionals in the field. Families often find themselves spending more time in the car then they do in their own backyards playing or cooking.
EASING THE BURDEN ON THE PARENTS
Parents of children on the spectrum are also under a tremendous amount of emotional and financial stress, and as a result, they can feel socially isolated. Often, the only people they meet are other mothers in the waiting room at the therapy center rather than neighbors at the local park or a kid’s soccer game. The demands of taking care of kids who need services on a regular basis overrides everything else in the parents’ life. The natural environment approach in which the speech therapists come to them is one way to help ease the burden.
I worked with one parent who was concerned that her five-year-old son was crying and experiencing meltdowns while being driven places. He was also having difficulty transitioning between activities and was expressing anxiety over unexpected changes to his schedule. Over the course of treating her son, I observed that while he was able to make comments, he had not yet developed the ability to ask questions. To address the problem, I gave her a series of cards to play a game with the child. On the front of a card, it said, “I’m going to do something,” and that triggered the child to read the back of the card, and ask, “What?” Another card had the words, “I’m going to go somewhere” on front, and “Where?” on back. At first, I trained her to practice these exchanges at home, while engaging in motivating activities with her child. Once he had mastered the skill at home, I instructed the mother to bring those cards with her in the car and to the different places they went. Sure enough, after a few weeks, the child began asking questions without the cards, and the questions evolved into fully formed sentences such as, “Where are we going?” and “What are we doing?” As a result, his anxiety and meltdowns subsided, and he was able to smoothly transition among the day’s activities without a fuss.
HOW TEENS CAN BENEFIT FROM GROUP SOCIAL OUTINGS
Currently, there is a lack of speech services for teens on the spectrum even though they need the same practice with social interactions as younger kids and adults. Most speech pathologists work with kids from birth until 10 years old and sometimes until they turn 12. A lot of teens do not want the stigma of going to an office and are tired of going to the same place year after year. Yet, teens still need to be receiving therapy. Thus, the natural environment method is especially helpful in these cases.
What teens really want is to get out and engage in activities that interest them. Some teens may have a difficult time making friends and have different interests from most of their peers. That is why group outings with a speech therapist are a great way to place teens with people who have a common interest while allowing the therapist to observe where any breakdowns in communication occur. A bowling alley, for instance, is a good place for a lesson on sportsmanship, teamwork and respecting others. This type of social group therapy is much more beneficial than the old-fashioned way of taking a group of kids on the spectrum and placing them in a room to talk about potential social situations they might encounter, based on scripts. It is also a good way to prevent teens on the spectrum from staying glued to their computers looking for friends on social networking sites, which is a common complaint among parents.
HOW ADULTS CAN BENEFIT FROM THE NATURAL ENVIRONMENT
As those on the spectrum move into adulthood, some may continue to encounter difficulty with social interactions requiring more intensive intervention. In these cases, adults would still benefit from supervised group events. Outings such as visits to the movies, Renaissance fairs and rock climbing trips can all facilitate social development based on common interests.
For those on the spectrum who are gainfully employed and successfully married with kids, yet still need simple refinements to their social skills, they may be more comfortable with the traditional office-based approach.
Speech-language pathologists still have a long way to go in identifying the goals and social skill sets they need to teach adults on the spectrum who can experience significant difficulty with marriage, dating and even making friends.
Over time, we have developed a more nuanced understanding of the challenges those on the spectrum face, both with pragmatics and social interactions. It is only fitting that our method of working with this population adapts to that new understanding, which is why speech-language pathologists should embrace the natural environment approach.
Erin Weiner, M.S., CCC-SLP, is a speech-language pathologist serving the Palm Beach County area in Florida. She is certified by the American Speech, Language and Hearing Association (ASHA) and licensed by the states of Maryland, Virginia and Florida. She can be reached at firstname.lastname@example.org