I have a client who picks and scratches her skin until she bleeds. It is a behavior that is being addressed by other members of her team. It comes and goes. This week it came.
She is non-verbal, autistic, and has significant sensory issues and challenging behaviors.
Soon after she arrived for therapy this week, she scratched her hand and quickly had a bleeding wound that needed to be addressed (I did not want to deal with blood all over my office and materials). A bandage would not be tolerated. So we spent much of the session attempting to apply pressure to stop the bleeding. Unfortunately, my client had great difficulty tolerating this. I calmly told her (repeatedly) that it was not safe for her to be bleeding. Repeatedly, I asked for her hand, which she would give and then a few seconds later rip away. Repeatedly, I would explain what I was doing and why I was doing it. When the active bleeding had mostly stopped and she was at her limit of tolerating my holding her hand and applying pressure, I switched to providing sensory input to help her calm. She LOVES a vibrating massager, so I whipped that out.
As I was massaging her head and back, she suddenly thrusts her wounded hand at me. She wanted me to apply more pressure! Suddenly, all the pieces came together. She needed three vastly important pieces to successfully tolerate tending to her wound: control, communication, and sensory input. We have been working on 'more' and 'all done', so every time she thrust her hand at me, her dad and I encouraged her to communicate 'more'. Every time she pulled her hand away, we encouraged her to communicate 'all done'. And in between, I applied sensory input.
Her dad commented, "I never would have thought of this as a motivating activity." Being able to advocate for yourself and your health/medical needs is an empowering skill. And one that needs to be taught in the moment.
I try to find/create motivating activities for therapy to entice communication. I realized that my therapy sessions can leave a parent feeling like elaborate, planned activities are needed to provide opportunities for their child to communicate. Especially for emerging communicators. Many times though, the most powerful opportunities are present in the little, every day moments of life.