I used to have this burning question when I starting working with young autistic clients—

How do I get an interaction going when this little human clearly wants nothing to do with me? Sound familiar? Let’s face it, young children on the spectrum are a tough crowd, and that old uninvited friend, the imposter syndrome, returns.

 The saying “You can lead a horse to water but you can’t make him drink,” applies here—you can set up a great therapy session but you can’t make them interact or attend. So what can you do?

 The great news is, we can get interactions going and we can engage them. This episode discusses how to use the simplest tools for optimal engagement using bubbles, balloons, balls, and bodies.

— Useful Links —

Hanen More Than Words Overview 

Opportunity Cost 

First Speak Their Language 

Simple Tools Balloons

Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Denise: Welcome to the Speech Umbrella, the show that explores simple but powerful therapy techniques for optimal outcomes. I’m Denise Stratton, a pediatric speech language pathologist of 30 plus years. I’m closer to the end of my career than the beginning, and along the way, I’ve worked long and hard to become a better therapist. Join me as we explore the many topics that fall under our umbrellas as SLPs. I want to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness.

Hello, friends. Welcome to episode 83 of the Speech Umbrella podcast. The title of today’s episode is Simple Play for Optimal Outcomes With the Four Bs. And the four Bs are bubbles, balloons, balls, and bodies. Since April is Autism Awareness Month, that’s been my focus. In the last episode, I talked about making movies to foster inferencing and perspective-taking, which is certainly on the more advanced end of the work we do with our clients with ASD. Well, today I’m going all the way to the other end and talking about the preschoolers or even toddlers that we work with, the ones that aren’t really interacting with others, and maybe they’ve just been diagnosed with autism. Maybe you’re their first therapist they’ve seen, maybe not, but chances are they aren’t going to be great at interacting with you. And that used to be a source of great frustration for me, but not any more.

Before I go any further, I want to make it clear that while I believe this podcast has real substantial value for SLPs, it’s not going to cover the spectrum of how to treat autism with these kiddos. This is just a slice of the treatment pie, so to speak, and I have many other slices of treatment pie on other podcasts, which I’ll link in the show notes.

Long ago, when starting to work with a very young client with autism, my burning question used to be, how do I get an interaction going when this little human clearly wants nothing to do with me? In fact, is this child even aware I’m here in the room? How do I foster interest in other people? The saying, you can lead a horse to water, but you can’t make him drink applies here. You can set up a great therapy session, but you can’t make them interact or attend. So what can you do? The best way I have found is to keep things simple using the four Bs: bubbles, balloons, balls, and bodies. Today I’m going to talk about why the four Bs are so great, and share some examples of how to get creative with them.

First I’ll cover, what does this child’s communication look like? And by the way, this will likely correlate to their play skills. What’s your goal? Why are the four Bs so great? Some therapy tips and some real life stories of how this plays out in a session. I know it almost goes without saying, what does their communication look like? But I say almost because talking this through helps quantify it for parents, and sometimes for us too. Parents can become really, really focused on speech output without realizing all that goes into communication. Looking at how the Hanen More Than Words program describes the stages of communication is really helpful here. And I have a whole podcast on Hanen, and so I won’t go into detail here, but suffice it to say, Hanen does a fantastic job of breaking down advancing levels of communication on the autism spectrum. The clients I’m talking about today will likely be in either what they call the own agenda or requester stages.

Children in the own agenda stage, don’t send intentional messages to people. They generally play alone, are not interested in other people, and they look at or reach for what they want, but without the intent to communicate to someone. And their interactions are very brief. If they’re in the requester stage, they are just realizing their actions can affect someone, and so they will pull you or lead you to what they want and communicate mainly when they want or need something.

And children in this stage likely have very simple play skills, and that’s important to remember when you plan therapy, they are going to have the most rewarding time of play that is at their level. And even after all these years, I still have to remind myself to keep the play at their level and not to advance too fast.

So what is your goal with these children? Being aware of what their communication stage looks like is going to guide your goals. It will help parents realize why speech output is not the focus of therapy at this point. For a child at the own agenda stage, sending intentional messages and playing together and extending interactions is the focus.

And for a child in the requester stage, the main focus is to replace them pulling and leading you with gestures, sounds, pictures, and word attempts. And all of this is in the context of play and everyday interactions, and also you might still be working on some of that intentional communication, intentional messages.

Here’s the goal wording I use for a child at the own agenda stage. I really love how this defines the object of the session and the flexibility of the ways that they can send messages. Within six months, given play routines, the client will send messages to others through body movements, eye contact, smiles, and sounds in at least five different routines.

Now, this goal is a hundred times better than the goals I used to write for these kiddos. It’s doable and measurable and quantifies real progress, which is all that a goal should be. Imagine being in an IEP meeting and actually describing progress to parents that sounds something like this, she sends me intentional messages when we blow bubbles by moving her body closer to me. She returns to me when she wants more bubbles and makes eye contact. She’s just starting to send me these kinds of messages when we play with balloons, and she hasn’t shown an interest in balls yet, but I’m confident we’ll get there. I’ve sat in many an IEP meeting where nothing this concrete was communicated and a lot of vague wordage was thrown around.

In these situations, after the meeting, parents wander out, dazed thinking, what did we just talk about? And the next time the SLP looks at their goals for this child, they also wonder just what in fact am I measuring? I know because I’ve been that slp, and there’s no shame in it when you’re doing the best that you know how.

But as a profession, it’s time to move away from that. When we know better, we do better, and that’s what this podcast is all about. So how do we move away from the old way of doing things? Well with bubbles, balloons, balls, and bodies. Why are these tools so great? Because they’re people toys. A people toy is a toy that requires your help to play with it. Bubbles and balloons are 100% people toys. They really can’t make those work without you. While balls and bodies are pretty easy to make so, and these toys are simple. My mantra is keep it simple. Keep it simple. Keep it simple. Simple play, because they don’t comprehend complex play at this point. They probably aren’t even playing in a way that requires two steps.

Be careful of toys that will fascinate them to the point that they are going to exclude you completely. If you give them like a light up flashing toy, they may just engage with that to the exclusion of all else. And if you try to get their attention or share their attention with them, it’s not gonna be pretty.

Imagine I gave you the world’s best chocolate bar and you love chocolate and you’ve just taken your first heavenly bite and you’re savoring it, all this sensation. And then I reach out and I take it back from you and I say oh, I just want to eat some of this too, and I start eating it and I’ll give it back to you in a minute.

Well, how would you feel? That’s how they feel if they have that too-fascinating toy that’s not a people toy, that they can just make work by themselves and you try to engage with them. So that’s why people toys are the best at this stage. By the way, electronics fit into the category of too-fascinating toys for them to share their attention. So if you’re looking for a way to explain to someone why screen time is not great, maybe the chocolate bar analogy will help you. Heaven save us from the pandemic of screen time.

When you start to see progress in their communication, what might it look like? Well, it might look like increased eye contact. Maybe you’re looking at the same object together. Maybe they look from the object to you and back to the object. Maybe they reached for the object of joint attention. Maybe they turn their body towards you, or maybe they’re staying in a group with you or returning back to you. Maybe they talk back and forth with you. Maybe they’re not using real words, but you’re vocalizing back and forth. Perhaps they’re showing interest in a new way to play with a toy. While I’m nurturing all these skills, I’m constantly thinking about slowing down the interaction. Because as we slow down the interaction, they have time to think, they have time to plan, they have time to communicate better.

And my all time favorite thing that happens is when we look at each other for no other reason than just the reward of looking at each other. They’re not asking for anything from me. They’re just looking at me, and I have this feeling that new neural pathways are connecting in their brain just as we look at each other and what was a fleeting glance becomes seconds of just enjoying looking at each other, it’s fantastic. One of my highs as an SLP, I mean, who needs drugs if you can do that, seriously.

Well, here I am deep into this podcast and I haven’t actually talked specifically about the four Bs. Okay, let’s start at the very beginning, which is a very good place to start. I always start with bubbles. Bubbles are magical. There is no better word for them. Just blowing bubbles brings a sense of calm and the slowing down that is so critical to extending interactions is naturally built into bubbles as they slowly float around the room. The child who is orbiting the room will often move towards the bubbles and towards you and will stay close to you if you send more bubbles their way after the previous batch has popped.

And then after you have had this interaction going successfully for quite a few turns, you can gradually increase the length of it by taking a little bit longer to blow the next batch. Talking, not too much but a little bit, about the bubbles popping and popping a few yourself or seeing if you can establish eye contact longer, bubbles draw children towards you. And even if they do turn away or start orbiting again, many times they’ll come back. I tell you, the Pied Piper had nothing on bubbles. Recently I had a client who was really engaged with the bubbles. He was making eye contact and coming back towards me for more bubbles. And he had been doing this in multiple sessions, but one day some amazing things happened.

So if you think that bubbles is a very simple activity, yes it is. But here’s an example of how it just builds more complexity. One day he sat down right in front of me and he was so locked in and he was imitating, cursing his lips and blowing. And every time he moved away from me, his body was still oriented towards me.

And then this is so fantastic, he laid down on his stomach and he put his chin in his hands and he looked back over his shoulder at me blowing bubbles. Such a casual, relaxed, but at the same time, alert pose. If you had been a fly on the wall at that moment, I don’t think you would’ve known that he struggled with pragmatic communication, and so within that one session, he advanced a whole lot in just the way he was communicating with me without words.

Okay. Moving on to balloons. My favorite way to play with balloons is with a balloon pump. This $6 tool is worth every penny. I have a box of brightly colored balloons, and they choose one, and we put it on the pump to inflate it, and then I twist the top a little bit so the air doesn’t escape and let it go and show them how it zooms around the room like a mini rocket and the kiddos adore it. They run to get it, and when they figure out they can’t blow it up themselves, they bring it back to me. And after I’ve shown them how to release the balloon, I’ll hand it to them and let them let it go. So at first they’re quite impatient to have the balloon fly and they want me to take it off the pump before it really has much air.

But they gradually learn that the bigger the balloon is, the better it flies, and so they learn to delay their gratification. It’s just another way of slowing things down. I have a simple tools video showing the balloon activity, so head on over to thespeechumbrella.com/blog/simple-tools-balloons to see it.

But you can also see it on my YouTube channel and on Instagram. You should follow me because I have lots of cool things there. Now let’s talk about balls, which can be a harder sell than bubbles and balloons. At first, a lot of my clients aren’t really interested in them and they just don’t know what to do with them. But balls are so fantastic once they get interested because you can do so many things with a ball. So here’s a few different ways that I introduce ball play. I have a really big exercise ball, and some kids love to sit on top of it and have me bounce them. And when I stop, they’ll send me the message that they want more bouncing, and so we start bouncing again. Or they can lie on their stomachs facing you and you sit in front of them and you roll them towards you until their hands, almost touch the floor, and then you roll them back. And this is so great for eye contact because it puts them right at your eye level as you roll them back and forth.

I also have a collection of smaller balls, and I put them in a bag with the bubbles and the balloons. So often as they’re reaching for either the bubbles or the balloons, they will pause and look at the balls. And then in a later session, maybe they’ll pick one up and drop it and I’ll roll it back to them and they still might not be interested. This goes on from session to session as they slowly figure out that balls are fun, and once you can engage them in rolling or throwing a ball back and forth, the sky is the limit. Sometimes when I tie off an inflated balloon and throw it like a ball, that introduces them to an actual ball, and they’ll start playing with an actual ball, kind of like they played with the balloon.

Slow and steady is the key for ball play. Be the tortoise and not the hare and it’ll pay off. Finally, bodies, what kind of people games can you play with your bodies that will engage them? The exercise ball play that I just described, that’s a combination of body and ball play. It will depends on what, on what their sensory profile is. So do they avoid or seek movement? Do they like touch or do they pull away from it? So do you have a place that they can safely jump down from, like a small box? Think of simple games like catching their toes with your hands or beating on a table with your hands in unison, or hopping over things, or jumping on and off a blanket or in and out of a hula hoop or maybe moving to music. And they will either love this or hate it, depending on their sensory profile and your choice of music.

Once I was doing a home visit with one of these kiddos and I put a hat on my head and then leaned forward until it fell off, the child thought this was hilarious. I mean, it sent him into gales of laughter. He was super engaged in this hat game for 15 to 20 minutes. I kid you not just laughing his head off. It takes some exploration to find their favorite body game that they will do it with you. But again, it is so worth it. To wrap this up, I just have to warn you, be prepared for inconsistent behavior and preferences. Because what they love one day, they may have no interest in the next day. They may totally refuse it. So it’s important to realize that while you know what to do, you don’t always know what materials will work on any given day, and that’s okay because if autism were easy to treat, we wouldn’t be talking so much about how to treat it.

From day one, imitate any and all vocalizations they make. Impart meaning to them, start having conversations with them right away, they love it when you speak their language. As much as possible, you want to clear the room of distractions. Now I normally have a toy box in the corner of my room that holds my go-to materials, and I take that out of the room for these clients. It’s way too distracting and it distresses them if they can’t open and close the box or climb in it or take everything out of it and throw it around. In fact, I hide my phone and I hide my iPad and I turn off my monitor. I put the materials that we will be using that day in my bag, and I make myself and the bag the most interesting things in the room.

Finally, be prepared to pivot when things go sideways, as they will. One session I recently did, did not go as I expected. My client loved the balloon game and we had played it a lot. He was really good at it, had great eye contact, and coming back to me with the balloons, and so I thought, well, perhaps he’s ready to see if he can play with a balloon like a ball. Well, he really liked the inflated balloon that was tied up. He liked it so much, in fact that he would do nothing else but just hold that balloon. Uh-oh, I just gave him a too-fascinating toy and then he squeezed himself into a corner by a cabinet, I think because he was trying to get away from this annoying SLP who kept trying to play with him. Well, I sat down beside him and said, oh, you want to play choo-choo? And I boomed my arms and I was saying, choo-choo and singing the choo-choo song, and amazingly, somehow still very attached to the balloon. He imitated my arm movements and said, choo-choo several times while he looked right at me. And this was a first for him, imitating an actual word and a symbolic movement together. So cool. That session went sideways, but it ended up in a really good outcome. And he also said choo-choo in the waiting room too, when his mom was there.

We all had those sessions where things don’t go as we expect, but usually when something goes sideway, something also goes right. Focus on those bright shining moments. Those are your breadcrumbs. That’s your trail to follow, to move your clients to more advanced communication stages. I have seen so much more progress with my little clients on the autism spectrum now that I have arrived at this way of doing therapy, and I believe you can too if this has been an area that’s been frustrating you.

I don’t feel the imposter syndrome anymore. I don’t feel the need to apologize to parents for lack of progress because I can explain what I’m doing and why I’m doing it, and parents can see progress. They really do progress in fundamental ways. Well, that’s it for today, remember to check out that Simple Tools video on balloon play. Plus, I’ve linked several other podcasts and videos on this topic. I’m finally making the leap into social media because I want to be in the places that you frequent, so you can find me on Instagram, on Facebook, on YouTube. I want to be in places where I can discuss things with other SLPs, so check me out in those places.

You can find me on Instagram at dstrattonslp, or on Facebook and YouTube at the Speech Umbrella, and give me a like and subscribe. But even more importantly, let’s have a conversation about simple tools for optimal outcomes.

Thanks for listening to the speech umbrella. We invite you to sign up for the free resource library at thespeechumbrella.com. You’ll get access to some of Denise’s best tracking tools, mindfulness activities, and other great resources to take your therapy to the next level. All this is for free at thespeechumbrella.com. If you’ve enjoyed this podcast, subscribe and please leave us a review on Apple Podcasts and other podcast directories.