Some say that if you have met one child with autism, then you have met only one child with autism. That is because every child who is on the spectrum has an entirely different diagnosis and therefore has a unique set of needs and strengths. Consequently, it's impossible to design a uniform teletherapy plan for the autistic child.

At the same time, there are three fundamental principles that can serve as a general framework and guide an effective treatment plan for the autistic child to whom you are delivering teletherapy.

1. Establish Communication That Is Spontaneous and Functional

You must deal with first things first. Your initial goal in the teletherapy session with an autistic child is to assure that her communication is both functional and spontaneous. In other words, the child must have the capacity to communicate her basic needs and desires to those surrounding her independently, without being prompted regularly.

AAC

Sometimes the child's speech is so dysfunctional that introducing some form of augmentative-alternative communication (AAC) is necessary until a more organic method can be found. And even here, you need to be flexible as different forms of AAC work more effectively for different children. Some of the options available are:

1. Voice-Output AAC Device: When the child hits a switch or pushes a button, the device delivers an auditory message. These devices are often straightforward, easy to use, and quite effective in allowing the child to communicate.

2. Picture Communication System: For some children, communicating through pictures or object exchange is more concrete, and are therefore the methods of choice. Another phase in the system is introducing a simple communication board and teaching the child to point to the picture that conveys what she wants. A next can be incorporating the board into a voice-output device as mentioned above.

3. Sign Language: For some autistic children, sign language has proven to be very useful. Using their body to communicate the message has another significant benefit as well. It has been shown that many of these children become verbal quicker than they would have without sign language.

The Importance of Helping Children become Spontaneous

Many autistic children suffer from the deficit of being unable to speak spontaneously. They won't initiate dialogue, even in expressing their own needs, but will merely respond to another's initiation.

This being the case, it is imperative to gradually fade cues that prompt the child to speak, and thereby cultivate the child's facility to speak independently. There are many ways to fade cues for the child. And it is often the synthesis of the particular child's challenges and the SLP's creativity that will yield the most effective approach.

Another approach that has been effective for some therapists is first to teach the autistic child basic requests for those things that will be the most motivating to the child. And then gradually move on to more abstract interactions such as greeting, or commenting. Sometimes just opening that verbal door will lead to unexpected results!

2. Weave Social Communications into Daily Life

Once the autistic child's communication has become both functional and spontaneous, it is time to move on to the social realm. In this area as well, autistic children require direct instruction; if for no other reason, but the fact that understanding someone else’s behavior is difficult for autistic children.

What most children pick up naturally in their social interactions beginning in playgroups or daycare, and continuing into Elementary School, doesn't often happen for autistic children. These children demonstrate poor understanding of how to behave or act appropriately in social situations. This deficit if not resolved will invariably carry beyond the social dimension of school and negatively impact learning.

Socially Acceptable Behaviors Require Direct Instruction

It is imperative to explicitly teach autistic children what is both appropriate and inappropriate in various social environments. This goes beyond instructing the child as to what can and what cannot be said, but includes how the child should listen and react to others as well.

Regarding younger children, the focus will be on necessary skills such as listening when the teacher is speaking, following directions and answering the teacher's questions. As the children become older, the lessons will focus on communicating with a friend and participating in group conversations.

Social instruction strategies that have proven effective for autistic children include:

1. Visual Supports: Strategically planting visual reminders in the classroom to assist the child in remembering expectations for different situations.

2. Social Stories by Carol Gray: Reading stories that will teach the child what behavior is expected in various situations.

3. Video Modeling: Showing the child videos that demonstrate expected behaviors.

3. Peer Interactions Need to be Targeted

While teaching autistic children the basics of social communication is necessary, it is in no way sufficient. Think about it, just learning what to say on the one hand will help the autistic child to be appropriate. On the other hand, it may leave the conversation with a peer stilted and lifeless. Much more needs to be done to help these children have healthy social interactions and relationships.

The more subtle art of communication can be taught to autistic children. However, it is critical to remember that the skills to impart must be developmentally appropriate.

Peer Interaction Skills for Younger Children

1. Play skills: Young children need to graduate from parallel play and be taught how to play with others, taking turns and getting along without fighting.

2. Responding to Name: Show these children how to react when someone says their name.

3. Developing Attention Skills: Help autistic children to become tuned in to other children's reactions and feelings.

Peer Interaction Skills for Older Children

1. Targeting Conversational: Observe the autistic child's conversations to determine which social skills are lacking in regular dialogues and interactions with other kids and adults. Focus on these specific skills in the session.

2. Learning How to See Other Perspectives: An autistic child is often “trapped” inside his world. Consequently, the notion that there is such a thing as another's perspective is entirely beyond his grasp. Therefore the concept of another perspective needs to be introduced and explained, so the autistic child begins to realize that there is an "other."

What are Boundary Challenges?

When you stop to think about it, it is surprising how often therapists are confronted with boundary issues in the rural communities they serve. And while one might think that this is only true for mental health therapists, the truth is that these challenges exist for occupational and speech therapists as well.

In rural communities across the country, many unanticipated interactions between therapists and their clients are unlikely to pose any significant threat. Take, for example, when therapists and clients encounter one another in the local grocery store. While this brief, unexpected meeting may be awkward, it won't negatively impact the therapy nor the client-therapist relationship.

But at other times, those encounters can be problematic both in the short and long term. So, the question is, "How does a therapist set clear, appropriate boundaries that will maximize the therapy without sacrificing a healthy therapist-client relationship?" The answer lies in understanding that boundaries are invisible lines of demarcation. While creating a sense of separateness, this separateness is an essential requirement of maximizing the therapy, empowering the client, and actually bringing the therapist and client closer together.

Are Boundary Challenges Unique to Rural Areas?

Therapists who provide their services in rural communities aren't the only ones who face the challenges of setting boundaries. As it happens, therapists who work with members of their religious or faith communities face similar problems as well. What happens when the client and therapist attend the same religious services week after week?

What’s more, any therapist could be faced with the dilemma of becoming friends or getting involved in a business deal with a former client. And what about attending social engagements where a current client will be present as well?

However, there are specific boundary issues that exist in rural communities which are unique and demand both sensitivity and skill to navigate successfully if both the client and therapist are to escape unscathed. In a small community, therapists live with the constant awareness and concern that they will be "bumping" into their clients or the client's parents regularly. Or that they will be engaged in an activity together totally unrelated to the therapy being provided.

Liabilities of Dual Relationships

Dual relationships are sometimes unavoidable in rural communities. Sometimes it’s nothing more than the lack of people around that fosters overlapping relationships in any number of ways. This could be the overlap of therapeutic and social relationships, business relationships or even other professional relationships.

Once the higher likelihood that a dual relationship will occur is recognized, it behooves the thinking therapist to anticipate one of these intersections and begin preparing for it. Where appropriate, therapists should speak with their clients or their clients' parents to plan as to how they deal for these potentially awkward situations.

On the other hand, if the therapist allows the practically inevitable to occur without a discussion beforehand, the client may be confused by the therapist's inconsistency.   Today the therapist is so friendly, and tomorrow she comes off as a cold professional keeping her distance.

Client Confidentiality

Perhaps the most crucial reason for the therapist to establish healthy boundaries is to protect the confidentiality of the client. While privacy is essential in any therapeutic relationship, due to the unique dynamics in a rural community, the importance and consequent challenge for the therapist is that much greater.

Assume you, the therapist, are dining in a local restaurant, and your young client approaches you. Others in the restaurant will interpret the approach itself as an indication that the child is one of your clients. Engaging the child will confirm it, while being standoffish may seriously impair your therapeutic relationship. Checkmate!

In a similar vein, given the size of the rural community, it is likely that some of your clients know each other. This means that even an unintended slip of sharing confidential information regarding one client with another could be damaging. While just an innocent mistake, if the client thinks that his trust has been betrayed, the therapeutic relationship with the client will be imperiled.

What Is The Answer?

In some cases, therapists and their clients can brainstorm together and come up with straightforward ways to solve these potentially thorny boundary issues. Take, for example, if the therapist's client works for the only plumber in town. An easy solution would be to have the client to ask his boss to send someone else to fix the therapist's clogged drain.

Suppose one of the local organizations is sponsoring a trip that needs chaperones. If the young client is attending, it would be advisable for the therapist to refrain from chaperoning the trip, to avoid a potentially uncomfortable boundary conflict.

On the other hand, there are boundary issues, be they actual or potential, that are much more challenging to manage. Take, for example, when the client's father owns the company where the therapist's wife works. This may pose an unavoidable conflict that is going to require loads of respect, sensitivity, and wisdom.

In such a circumstance, where the connection cannot be avoided or severed, it behooves the therapist to broach the boundary issues with the client or the client's parents as early in their relationship as possible. They need to discuss reasonable ways of handling potentially awkward circumstances comfortably and respectfully.

The short answer is that there is no single answer as to the appropriate response to these and other boundary questions. It is very important for therapists, especially in rural communities, to be aware of potential boundary issues. It is only then that they can craft strategies or consult with others who may be helpful in solving these issues.

Be Prepared To Maximize Your Opportunity

The opportunity to serve rural communities is exciting, fulfilling and,  at times, challenging. The same small and tightly-knit community that is at the core of some of these more difficult boundary issues is the reason that many therapists find their work so fulfilling and meaningful. Don't be intimidated by these boundary challenges. They can and will be solved!