I was recently invited to chime in on a question about speech therapy goals around flexibility for a young child with a PDA* profile. Crafting social communication goals, such as those related to flexibility, is always a nuanced and thoughtful process for me, no matter the individual’s profile or age.

Social dynamics are ever changing and complex, and always have an element of uncertainty. For many individuals who experience anxiety and/or sensory processing differences, and especially those with a PDA profile where anxiety is high, uncertainty can be at the very least uncomfortable, and at the most incredibly scary.

This discomfort and fear around uncertainty is often labeled as the outward behavior observed: inflexibility. But, if we as clinicians want to support the development of flexibility, we must start at its origin: create feelings of safety and competence around uncertainty.

*PDA is an autistic profile and stands for Pathological Demand Avoidance, or Persistant Drive for Autonomy. You can learn more about PDA here and here!

Appreciating the small moments

At the heart of all social exchanges, is a mixture of predictability and unpredictability between two people. Often we have a general idea of how things might or could unfold, but we never know exactly what an exchange will look like because we are not pre-programmed robots! Each person brings their own personal communication style and ideas to a social exchange, which influence and change it in unforeseen and unique ways. This is ultimately a good thing because this authenticity makes interactions interesting, and leads to true relationship building.

So, before we move ahead too quickly, it is important for us to acknowledge and give credit where credit is due. Because uncertainty is ever-present within social exchanges, the mere act of engaging in any social interaction requires a person to be flexible. Even though the engagement at hand may not be the ‘big flexible moment’ we are hoping for, know that the child is probably working very hard just to be with us, in an exchange that they cannot fully predict.

And importantly…

… little moments of flexibility have the potential to build over time, when we take good care of each moment as we go.

Let’s start … slowly.

When supporting an individual who has a PDA profile, where anxiety is especially high, it is in everyone’s best interest to take our time. Our goal is not to quickly change the chid’s behavior so that it is more “flexible”, but rather to take the time needed to build trust and safety within moments of uncertainty.

We want build trust in a few different ways. We want the individual to:

trust in themselves, that they can manage the uncertainty (and with our help if needed).
trust their ability to advocate for what they need if they start to feel overwhelmed.
And
trust that their communication partners will be there in ways that are supportive to their overall self-regulation, especially if they start to feel worried or overwhelmed.

But, how do we build this foundation of trust?

First, invite autonomy.

As we enter engagements and offer the individual autonomy (e.g., give them space to make decisions or have choices about their role within each opportunity), it will never eliminate uncertainty all together, but it will decrease the uncertainty factor. This will then help establish an environment where the individual may feel a little more comfortable facing the unknown territory that will inevitably follow.

Next, slow down.

When uncertainty is introduced too quickly, or when an individual feels forced into dynamic moments that they have not had time to adequately process and understand, it can lead to overwhelm (and dysregulation, meltdown, or shutdown as a result). These hard moments can then perpetuate a fear of uncertainty.

In contrast, when we give the individual time to observe and process change (even moments that we think are small), and give them information that helps them understand it, they feel more equipped to handle it. This will then help increase the individual’s feelings of comfort and safety around uncertainty, and we are headed in the right direction!

(Note: Please check out my 4-part post: Cognitive Rigidity or Processing Time Needed? to read more about the importance of processing time … another really important area.)

Evidence of trust

Trust between two people will look different for everyone, but two ways I note that a child’s trust in me is likely growing include:

staying with me or near me, without me asking them to (when kids don’t yet trust a person or relationship, they may move away).
communicating openness towards me by turing their bodies toward me, visually referencing me or what I am doing with curiosity, or by communicating spontaneously with me (when kids don’t yet trust a person or relationship, they may orient their body in a different direction, look down or look away, and not initiate communication).

When I see these nonverbal cues, it tells me they trust they can be near me, without fear that I will overwhelm them.

It then becomes my priority to honor and protect that trust as we move forward together.

After trust, then “goals”

Only from a foundation of trust, can we develop meaningful goals as a team. I say team, because this is never soley about the child’s growth! We must grow and change too. Remember, social interactions are dynamic, and how we respond in each moment matters.

To follow are some example goals within play opportunities to reflect this shared growth. For each child goal, I will also list clinician goals, outlining what we need to do to foster and create space for that area to develop. (Note: these are general guidelines, and can be adapted for older kids and adults).

Here we go…

Long Term Goals

Child will feel increasingly comfortable and competent when faced with uncertainty or unexpected change, alongside a trusted communication partner.

Clinician will be patient, and not expect this to happen quickly or overnight.
Clinician will not focus on behavior change, but on the foundation of trust between themself and the child.
Clinician understands that uncertainty can be scary, and supports should always revolve around helping the child feel equipped and safe.
Clinician will also understand that a child’s response to uncertainty and unexpected change will ebb and flow based on the context, surrounding communication partners, and other physiological factors such as fatigue or hunger.

Child will communicate / advocate for what they need to support their own self-regulation amidst uncertainty or change.

Clinician will respond in a supportive and thoughtful way when the child self-advocates, further strengthening and sustaining the foundation of trust.

Then, Short Term Goals

Area 1: Sharing Space Together

While engaging in an activity of their choice, the child will feel comfortable and safe* as the clinician shares space near or alongside them.
- Clinician will sit quietly with the child, observe their play, notice their ideas, and listen to their verbal and nonverbal communicative bids.
- Clinician will become authentically interested in what the child is doing and what they are communicating.
- Clinician will respond with interest and curiosity using declarative statements and/or nonverbal communication about the experience being shared, and be mindful to not use communication that places demands such as imperatives, questions, or inferential declarative statements.

*If you are unsure how to determine if a child is feeling comfortable, I would ask their parents or caregivers! Specifically, ask what body language or verbal communication the child uses to indicate they are feeling comfortable and safe. I am sure they will know! Some may match the nonverbal cues I mentioned above related to trust.

Area 2: Sharing Ideas and Joining Play

While engaging in an activity of their choice, the child will feel comfortable as the clinician joins their play by assuming a role that complements their ongoing plan and play scheme.
- Clinician will explore roles that they could assume within the actiivty that are complementary to the child’s plan, and follow through with roles that the child invites.
  - Examples: Putting together a Lego set, the clinician offers to hand each Lego to the child, and the child says “okay”; coloring a picture of Thomas the Tank Engine together, the clinician offers to color his eyes while the child colors the wheels, and the child agrees.
The child will communicate openness to hearing clinician ideas that expand their play; the child may respond to ideas presented by agreeing with the idea, disagreeing with the idea, or expanding upon what the clinician has said to come up with a different but related idea.
Note: the child does not need to accept clinician ideas, they simply are open, curious, and regulated while hearing new ideas, and from this place further dialogue, discussion, or planning may develop.
- Clinician will comment to share ideas that move with/in the direction of the child’s existing plan, or expand upon the child’s ideas in a complementary way.
  - Example: a child is pretending to be a waiter. The clinician pretends to order food, or asks for the check, and the child responds in a way that is related; a child is playing with a Hot Wheels track and cars. The clinician shares an idea to make the track even longer, and the child agrees.
The child will communicate opennes to clinician support when working to meet a goal or solve a problem that is important to the child.
- Clinician will wait quietly for the child to discover and indicate (verbally or nonverbally) that they need help.
- Or, clinician will let the child know they are here to help with the problem if needed, but it is also okay if they’d rather figure it out on their own.

This is certainly not an exhaustive list of goals, but is simply meant to guide you on where to start. I could tease this out forever, so I hope this post has enough information to help you appreciate how to apporach goals related to flexibility, yet not so long that you did'n’t get to the end with me here - LOL!

Remember, flexibility builds over time, within the context of a trusting relationship, and the path becomes less hard for everyone when we take the time to build the foundation needed. Navigating bigger changes and moments of uncertainty may always feel uncomfortable for the child, but these will be more manageable for them alongside someone they trust, who gives them the time that they need.

Until next time … have a great week!

Let’s talk about “Flexibility” Goals!

More Direct!

Boston Area Workshop: Understanding and Supporting PDA Individuals