This article is a practice guidance paper by Stuart Daniel and colleagues. It is written by a predominately autistic team, synthesises existing research and brings an insiders’ perspective as well. The authors present practical guidance for therapists working with autistic children. Their aim was to develop clinical recommendations that align with a neuroaffirming approach.

Double empathy

The paper starts by exploring in the Double Empathy Problem, which posits that communication challenges in autistic and non-autistic pairings are bidirectional and not based on impairments isolated in the autistic partner. The authors assert that most non-autistic therapists approach interactions with implicit biases of their own neurotype regarding sensory experience, interactive experience, and coherence in internal experience. They note that autistic children struggle to grasp subtleties of neurotypical communicative gesture and flow and non-autistic adults struggle to discern nuances of autistic children’s communicative gestures. This means difficulties arise from interpersonal mismatch between neurotypes. They are not the first to explore double empathy and if you aren’t heard of the model I would definitely recommend you do a bit of reading and self-study on the topic.

Sensory portraits

Next the authors provide comprehensive background on sensory processing difficulties in autism, explaining the eight senses and how they’re impacted. They note that over 90% of autistic people experience sensory processing differences. They include three powerful “sense portraits”—first-person accounts from autistic authors describing sensory experiences and illustrating how sensory challenges impact their interactions throughout the day in different environments and contexts. These are one of the reasons I chose the article for the journal club, as the sense portraits are very powerful, but difficult to present on a podcast. I would recommend that you have a look at them, the link to the article is available in the episode notes at EBPOT.com.

Sensory Stability

The authors provide detailed guidance on minimising potential stressors in the environment. For auditory, keep ambient sound levels low, and avoid very low or high pitch registers when sepaking. For visual, keep spaces tidy and minimal, wear simple block colours, keep light levels low and warm. For touch, don’t initiate physical contact but be open when approached, using firmer rather than overly gentle touch. For smell, keep spaces odour-free and don’t wear scented products.

They also discussed the sensory elements of our interactions, including our body language and tone of voice, with autistic persons. They suggested to start with minimal interactions to give both therapist and child time to adjust, for example keeping body language non-threatening yet open, projecting minimal expectation, and keeping things simple and slow. Specific suggestions included adjusting posture to be on level with or below the child’s eye-line, playing with mirroring the child’s posture, or matching the child’s vitality—the energy and style of movement. Additionally, tips were given for talking style, such as using clear and simple phrases, i.e. less is more, maintaining low-volume levels and using musicality in voice autistic children may be more effectively engaged by song than speech.

Tailored Empathy

I also found their discussion on emotions very interesting. They suggested that emotion-labelling can be harmful, as it may not capture the autistic child’s actual experience. I saw an example of this recently with a speech therapist showing a child who to me looked very frustrated, as they were clenching their fists and making verbalisations to suggest they wanted something different, a sad picture and was describing their state as sad. I found it interesting that we shared very different opinions on the emotion the child was showing. The authors suggested that instead of using emotion-labels, as therapists we should use behavioural empathy whereby we describe the behaviours we are observing, such as actions, gestures, movements, and body positioning, rather than assuming a specific emotion. For example, “You’re walking, slow, heavy feet… your shoulders and head hanging down” instead of than assuming and stating the individual is feeling sad. They suggested that we can label our own emotions but should avoid labelling those of our autistic children. This section of the article is quite detailed and if you want to understand it more I’d suggest reading the article, which is open access.

Playful Mindfulness

The final thing they explored was playful mindfulness. This approach helps autistic children become aware of and make functional connections within their inner experiences. It’s a remodelling of Kelly Mahler’s Interoception Curriculum, Kelly was an author on the paper. The strategy involves evoking movement and body sensations through rich sensory experiences; inviting the child to notice one body part at a time; supporting alternative forms of expression; using curiosity and gentle questions; drawing awareness to sensations and valence states; and acknowledging all responses. The aim is helping autistic children understand that some feelings require actions and how and when to take those actions.

Practical Takeaways

So, what are the practical takeaways. I think this article gives an incredibly useful first-person perspective on autism. I think the sense portraits could be used as a model for working with older children, and teenagers that could access them to help them to describe their own experiences. I also think the discussions on ensuring sensory stability and observable behaviour labelling rather than emotions is incredibly important for us to consider in our own practice and interactions with our autistic client. It’s definitely an article I would suggest you read. The link is available in the episode notes at EBPOT.com.

This study by Kadlaskar and colleagues examined sensory reactivity in children referred for autism evaluation and its associations with autism symptoms and adaptive skills. The researcher used the sensory profile 2 to explore how different patterns of sensory reactivity relate to both core autism characteristics and children’s functional abilities in daily life. They found that sensory differences can predict adaptive function, whereby higher sensory needs linked to lower adaptive function not just in the autistic children, but also other groups. There were also differences in sensory profiles across different developmental conditions which has implications for differential diagnosis. 

This study by Ferreira de Oliveira and colleagues investigated the relationships between social communication, sensory processing, and daily living skills in autistic children aged 3-5 years old. They used the PEDI-CAT, the Autism Classification System of Functioning and the Sensory Profile (2). For those unfamiliar with the PEDI it measures functional skills across daily activities, mobility, social/cognitive, and responsibility domains. So, it is a reasonable measure of ADLs. The researcher found that most children had age expected scores on the PEDI-CAT, but that only 13% had typical scores on the SP2. The Autism Classification System scores, age and gender influenced PEDI-CAT scores. However, unlike the Kadlsakar study, there were no associations between sensory profile scores and the PEDI-CAT score.

This study by Alkas Karaca and colleagues explored caregiver burden in mothers of 73 autistic children aged 3-6 years, with particular attention to the role of children’s sensory profiles. Again, a large proportion of the group (77%) had difficulties on at least one sensory area on the sensory profile. The research found that children’s sensory processing patterns significantly contributed to maternal stress and caregiver burden. Understanding this relationship is important for therapists working with families, as it highlights the need to address sensory challenges not only to support the child but also to reduce family stress and improve overall family well-being.