The Dilemma of Social Skills Therapy Part 1: The Young Child
TW: suicide, mental illness
This series is going to make SLPs, related providers, and parents feel uncomfortable. It is incredibly painful to hear that your well-intentioned, compassionate, and dedicated therapy plans targeting pragmatic language are likely hurting the very population you serve. It is uncomfortable to hear criticism from the minority you possibly got into this career to help. However, autistic voices on this matter urgently needs to be listened to and appreciated. And this is not just criticism for criticim’s sake—there is an actual solution. Current social skills curriculums are not working—but there are meaningful ways forward to truly help autistic kids navigate, socially. Not just autistic kids, but all kids. In fact, that’s the key.
Research is just starting to come out saying what the autistic community has said all along—autistic communication is just as effective as neurotypical communication. The breakdown only occurs when autistics communicate with neurotypicals and vice versa (Crompton, C. J., Fletcher-Watson, S., & Ropar, D., 2019). That being said…
There are the autistic kids who end up in social skills therapy, usually led by an SLP but sometimes a BCBA or school counselor, and there are the autistic kids who don’t end up in social skills therapy, or any speech-language therapy at all. The first kids more obviously don’t know how to fit in with their peers, may not have friends, or are disruptive in class—the second kids may have some friends, but are the cling-on in groups, and might occasionally be kind of awkward in class, but not enough for it to be problematic for the teacher. The first kids don’t really know how to navigate neurotypical social skills without guidance—the second kids are able to observe and study peers, Youtubers, and television shows and movies to find neurotypical patterns of behavior to copy and roughly fit to real-life situations. The first kids are being explicitly taught “masking”—the second kids figure out “masking” on their own. Both types of kids are significantly more likely than their neurotypical peers to grow up to an adulthood suffering from depression, anxiety, and obsessive-compulsive disorder. Both types are significantly more likely to engage in suicidal idealization in adulthood—in fact 35% of autistic adults have planned or attempted suicide. Both types of kids are directly more likely to have these outcomes as adults as a result of prolonged autistic masking (Cassidy, S., Bradley, L., Shaw, R., & Baron-Cohen, S., 2018; Hirvikoski, T., et al., 2016; Nimmo-Smith, V., et al., 2020). These statistics need to be repeated. Again and again. Until something is done.
Autistic masking is the conscious and/or subconscious suppression of autistic traits and tendencies in favor of acting more neurotypical….
and it is killing us.
My first social memory is being in preschool as a 3-year-old. I had a favorite peer, as many autistic kids do. I remember following her around the class, copying every action she did. I was studying her, imitating her, and hoping, as a result, she would like me. My first social memory is one of me navigating the logistics of successful autistic masking. I somehow knew, from that young age, that hiding my authentic self in favor of imitating my peer would result in more social success. I was 3.
When I was 6 my peers started calling me “short.” Objectively, I was a short child. However, I knew that society favored taller people, so I thought that others’ telling me I was short was a personal attack about how they viewed me as “lesser,” just like society views shorter people as “lesser.” Plus, being short made me stick out from my peers, and I was socially aware enough to know that’s not good. That’s why I gotta copy actions from the people I like. So my classmates would call me short, and I would cry, and I would not be able to stop crying no matter how much I tried. One time a classmate called me short, and my teacher made me and her sit in the corner of the classroom until we could resolve the issue. She sat in silence as I cried and couldn’t make it stop. This is one example of my NOT being able to mask my true feelings.
As mentioned previously, some autistic kids don’t naturally figure out that they need to suppress their true feelings and copy others to be socially accepted. And so there are entire preschool social skill curriculums for those kids! They learn things like following along to the whole group instead of having fun alone with your own unique idea. Look at the group to see what they are doing! Watch them with your eyes, listen with your ears, keep that mouth silent, turn your body toward that speaker, keep those body parts still or else you’ll miss the subtleties of how to act JUST like your peers. Listen to their words. WOW! That’s important stuff—way more important than your ideas. Stop talking so much! Let her have a turn going first in the game. I can see you are getting upset, but everybody needs a turn going first. Your brain is getting “stuck” like we talked about yesterday. Don’t let it win! Hey, that boy wants to help you build your Lego tower. No, no, he won’t mess it up. Oh…the base of the Lego tower isn’t very strong now—he is stacking bricks as opposed to alternating the bricks for maximum support. No, no, he didn’t ruin it. No, it’s fine. Everybody has valid ideas and should be allowed to show them off. Hey! We don’t kick our toys when we are mad! It’s okay to be mad, but we don’t kick. Hey, let’s go to another table. You are feeling some very big emotions right now—let’s see how big that problem is. See, your reaction is are right here, in the “red zone”. Your friend wanted to do build the tower a different way—how big do you think that problem is? Oh, you think it is a big problem, also in the “red zone”? Hm, remember what we talked about last week? Big problems, “red zone” problems, are really really big! Like you are lost and can’t find your mom! Uh-huh, yeah, this problem right now is a small problem, in the “green zone.” Can you think of some ways to problem solve this problem? No? You want to build the tower by yourself? Aw look, look at your friend’s face….he is looking down and frowning…he must feel bad about his idea. Your brain seems pretty “stuck” right now. Don’t let it win! Let’s brainstorm together all sorts of ways to solve this problem. Why does he now think his idea is bad? What could you say to make him feel better?
Although there is a lot to unpack here, I am going to focus on the aspects that teach autistic children to ignore thoughts and feelings. This is a major part of autistic masking, and clearly, it starts young.
Let’s say I was diagnosed as a child, given an IEP, and put in social skills therapy as a 6 year old with this same curriculum. My reaction to being called short would be in the “red zone.” And since my peers weren’t actually being “mean” to me by calling me short, I’d be told the size of the problem would be in the “green zone.” But I still thought my peers were being mean—I interpreted their words as truly being mean and causing intense anxiety and torment, given my knowledge that I need to fit society standards. Now I am being inflexible and rigid, because I truly KNOW that being called short is offensive. Can’t let that inflexible brain win, so that will be something to work on. In this social skills therapy, I would have learned that my feelings were wrong. But, hopefully, with time, I would use my brain to see that my emotional reaction does not match the true situation. However, I would say that that my large reaction revealed a perfectly valid, insightful, and, ironically, mature understanding of the world around me. As a child, I couldn’t express it verbally. But as an adult, I can say that my reaction revealed an understanding of the unequality and injustice in this world that is all too often ignored and invalidated by adults. Short stature is socially inferior. You adults are telling me it isn’t. But the subtle clues society is giving me say otherwise. Not only is it upsetting that people are treated unequally because of things they cannot control, but you adults are turning your backs to it, making it seem like I am the one who doesn’t understand the social world!
Similarly, in the hypothetical example above, the child’s method of building a Lego tower was clearly structurally superior. Superficially, it appears he is upset because he is inflexible and wanted to just build the tower his way. However, his large reaction is compounded by his frustration that the adults are saying that all ideas are valid when, clearly, his engineering abilities are far superior. And the adults are turning their backs to it! The child shows signs of building anxiety early on and being pushed to include a peer in his project, only for the peer to not do it the right way was enough to make him incredibly upset.
We tell small kids that everybody is equal as far as their worth, which is absolutely true. Given this truth, everybody should be treated equally, always. But others can be treated differently based on their age, gender, race, and appearance. And we can treat others differently based on the situation itself, emotions, sickness, fatigue, etc. Not only is it incredibly confusing, especially for a young child, but it is incredibly unfair. But furthermore, we tell them everybody’s ideas are valid and good and valuable. But this isn’t true. This isn’t true in the real world. Some people have better ideas than others on certain subjects or topics. And some people really struggle more than others with certain subjects and topics. Autistic kids often have an unrelenting sense of honesty, equality, and justice and it is being constantly misinterpreted.
We tell small kids that their feelings are valid. But inflexibility or rigidity seems to exist in this vacuum of being unable to be explained by any neurotypical person, ever. Autistic people are inflexible because they are stuck because they are rigid because they want things a certain way because they can’t figure out another way because they don’t understand others’ perspectives because its in the DSM V. Let me be clear: inflexibility stems from anxiety. What if I mess it up this new way of playing the game? What if this new food makes me gag? I don’t know this different route to McDonalds…What if we get lost or get there late? I don’t know the buildings and trees and neighborhoods on this route. I am anxious. I feel floaty. Get me out of this car. AH! Meltdown!
Keeping everything the same is the way of controlling a chaotic, logically inconsistent, and sensory overwhelming environment. The potential benefits of the new thing are heavily outweighed by the possibility it will be horrible. It is risk-aversion.
Here are some hypothetical examples outlining how the combination of a strong sense of honesty and equality along with anxiety presenting as inflexibility and rigidity can present as poor social skills in young autistic children. And then common therapeutic attempts at helping the child, socially:
Johnny drew a picture of a car during art time. The teacher has every students’ drawing in her hand and shows some to the entire class. Johnny is very proud of his drawing but becomes very upset, pounding his fists and whining, when his teacher doesn’t show it to the class. Over time and with his therapist, working to be more “flexible,” Johnny sees sometimes his drawing is shown and sometimes it isn’t. To his teachers and therapists, it appears he learned that he can’t always have a turn. Johnny actually learned to hide the intense disappointment of his drawing not being shown most times, and sometimes he doesn’t even want to draw now. Masking.
Bella is playing a turn-taking game with the therapist and a peer. Bella wants to play the game the same exact way each time, but the therapist wants to try a new way because she needs to learn to try new things. Bella insists no because she just got really good at the same way, and changing it causes anxiety due to the executive functioning challenges of learning a new multi-step routine and possibly looking dumb. The game gets changed anyway, and Bella loses the game, causing her to cry and remain silent the rest of the day. Eventually she gets used to hiding the anxiety of a new way of playing games. Masking.
Grace’s therapist is working on her turn-taking skills during a conversation. The therapist starts a conversation with a question, “What did you do this weekend, Grace?” and Grace responds with what she did. There is a pause, and the therapist prompts her to ask the same question back. Grace says “I don’t really care what you did” and the therapist says that hurts her feelings. Grace is startled by this and asks what her therapist did this weekend but doesn’t wait to hear the answer, instead walking away to color in a coloring book. Grace was just being sincere and honest, why would that hurt anybody’s feelings (?), and would much rather do her coloring anyway than talk about weekend plans. But the therapist starts working into every session how Grace needs to repeat questions back to the partner, even if she doesn’t really care. Masking.
Learning to mask yourself or by being in social skills therapy is reinforcing from the youngest of ages that autistics should follow along with the crowd and push away our thoughts and feelings.
It creates the foundation of a lifetime of inauthenticity and shame around our true selves.
So, then what? The current way things are set up, we either teach the kid how to mask, leading to potentially some social acceptance and school success at the expense of their true sense of identity, or we do nothing, causing the child to be socially rejected and possibly a distraction in class.
The answer: Completely shifting the framework of what it means to communicate and be “social” , starting at the youngest age possible by discussing neurodiversity and neurotypicality. With ALL kids.
No whole body listening—we each are able to pay attention with different bodily presentations. No using logic to convince ourselves our emotions aren’t justified—by learning about our brains, our bodily responses, and what they mean, we learn what we feel and how to regulate. No being stuck vs being flexible—just different ways of interpreting situations, consistent with the ways our different brains work. We need to break the deadly cycle of teaching and encouraging autistic masking.
Got an autistic young child as a client or your own kid? Do they know they are autistic? No? Start there. Got a neurotypical young child as a client or your own kid? Do they know about autism and ADHD and dyslexia? No? Start there.
The Dilemma of Social Skills Therapy Part 2: Adolescence will be next in this blog series. This one will focus on perspective taking and problem-solving as is traditionally taught through social skills therapy.
References:
Cassidy, S., Bradley, L., Shaw, R., & Baron-Cohen, S. (2018). Risk markers for suicidality in autistic adults.
Crompton, C. J., Fletcher-Watson, S., & Ropar, D. (2019). Autistic peer to peer information transfer is highly effective. doi:10.31219/osf.io/j4knx
Nimmo-Smith, V., Heuvelman, H., Dalman, C., Lundberg, M., Idring, S., Carpenter, P., Magnusson, C., & Rai, D. (2020). Anxiety Disorders in Adults with Autism Spectrum Disorder: A Population-Based Study. Journal of autism and developmental disorders, 50(1), 308–318.
Hirvikoski, T., Mittendorfer-Rutz, E., Boman, M., Larsson, H., Lichtenstein, P., & Bölte, S. (2016). Premature mortality in autism spectrum disorder. The British journal of psychiatry: the journal of mental science, 208(3), 232–238. https://doi.org/10.1192/bjp.bp.114.160192
