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DIR FLOORTIME

STANELY GREENPAN’S MODEL

TRADITIONAL APPROACH (DDT) VS DEVELOPMENTAL APPROACH (FLOORTIME)

The "D"  D = Development: A child’s developmental profile is not solely about milestones, but rather how the "I" works together with the child’s "R" to shape development.  I = Individual: Children have unique physiological, neurological, psychological, communication, motor, and sensory processing differences. Together these influence the child's trajectory.  R = Relationship: Parent/caretaker relationships in a child’s life play a vital role in shaping development, social and emotional growth.

FEDL's • The DIR® Functional Emotional Developmental Levels (FEDL) represent nine essential developmental capacities necessary in building the core foundation every child needs for optimum growth and development. • By contrast, typical chronological measures often miss the interplay between developmental systems at work in the emerging growth of a child, and how interdependent they are. Weaknesses in one will influence the advancement of others. • These nine core functional offer an integrative perspective on vital developmental domains, including health and well being, social emotional, communication and language, regulation, sensory-motor, visual-spatial and ultimately cognitive functioning. • Assessment and treatment is multi-disciplinary and highly collaborative.

• The developmental systems at work include: Regulation, sensory-motor, visual-spatial, social-emotional, communication and language, cognition, health and well being.

A Comprehensive DIR Program Includes in Floortime

• Starts with frequent sessions (6-8, 20-30 min.)

• Talktime Semistructured Activities

• Social, Work, Groups

 Sensory-Motor activities

• Movement, sports, gym

 Family Supports Other Interventions Education, special education, hybrid Therapies

• Language, OT & PT. Visual Spatial,

• Psychotherapy

• Creative Arts Peer Play Dates

• Social Thinking Bio-medical interventions DIR at LISCA | 2

EMOTIONAL SCALE:

1. Self regulation and interest in the world (3 months) 2. Forms relationship, attachment and intimacy (8 months) 3. Intentional 2 way communication (9 months) 4. Complex sense of self (12-18 months) 5. Emotional Ideas (24-36 months) 6. Emotional thinking (36-48 months) 7. Multi-casual and Triangular Thinking 8. Comparative and Gray Area Thinking 9. Reflective Thinking/Growing Sense of Self/Stable 10. Structural and Thematic Characteristics of Greenspan's FEAS Developmental Stages

Stages of Development and Organizing Fantasies and Themes

1) Regulation and Interest in the World= Omnipotent control; being overwhelmed; falling apart 2) Engagement and Relating= Isolation; emptiness; inanimate objects; unconditional love 3) Intentional Communication= Part object pleasures or fears; chaotic, fragmented interactions 4) Complex sense of self= Narcissistic self-absorption; grandiosity; suspiciousness; somatization; global self deprecation 5) Emotional Ideas= Neediness, being taken care of and/or fear of separation and/or danger 6) Emotional Thinking= Power; being admired; respected; shame; humiliation; loss of love; injury or harm to self or others

Capacity 1: Self Regulation & Interest in the World Discovering Your Child's Sensory and Motor Profile After nine months in darkness, a baby is born. Suddenly he is plunged into a world of light and sound, movement and touch, taste and smell. A sensory extravaganza! All this information is exciting and stimulating to the baby, but at the same time he has to learn not to be overwhelmed. His very first challenge is to take in this sensory panorama while regulating his response and remaining calm.

Gradually he finds things that focus his interests and at the same time can be used to calm himself—Mother’s face, Father’s voice, the soft texture of a blanket next to his skin. Little by little the infant learns to balance growing awareness of sensations with the ability to remain calm. This pair of skills is the most basic building block of emotional, social, and intellectual health. Without it we can’t learn, we can’t develop relationships with others, we can’t survive in our highly stimulating world. How an infant modulates and processes sensations is an important contributor to this first milestone.

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From his earliest days, Peter was an irritable baby. He slept little and cried constantly, and nothing seemed to console him. When his parents sang him songs or rocked him in his cradle, he flailed his arms and legs unhappily. When they picked him up and held him he arched his back and screamed. His parents were despondent. Their baby was miserable and hard to live with, and all their efforts to help him only made him worse. Gradually, feeling frustrated, exhausted, and saddened, they simply stopped trying so hard. They left Peter alone for longer and longer periods of time, and after a while he would cry himself to sleep. By six months of age, he was sleeping or looking self-absorbed much of the time. He had already failed to master the first emotional milestone. The next step, intimacy, would not be possible until he mastered this step. Peter’s parents sought help from their pediatrician. A thorough examination determined that Peter was hypersensitive to touch, sound, and movement. This information enabled his parents to make Peter’s world a more comfortable place. They stopped rocking him so briskly and tickling him. Instead, they held him gently but tightly and substituted a gentle rocking rhythm. They softened their voices and facial gestures when they talked to him and spoke very slowly. Soon Peter could look at them for several moments at a time. They used their soft voices to attract his attention and keep him calm. With a little experimentation they found that lower tones were particularly soothing. They could then begin some simple movement-pattern exercises to enhance Peter’s pleasure in moving. They placed Peter on the floor and slowly moved his arms and legs. They massaged his arms and legs with deep pressure. Gradually, his tolerance for movement and touch increased, and Peter allowed his parents to carry him. Bit by bit, with patient help from his parents, Peter found the world a more hospitable place. And bit by bit, he learned to calm himself down without going to sleep. By the time he was a year old, by working with and around Peter’s individual sensitivities, his parents had helped him master this first emotional milestone.

Unlike Peter, Angie appeared to be a lazy baby. No matter how much her parents talked to her or smiled at her, she seemed uninterested. She rarely made eye contact, didn’t brighten when they looked at her, and didn’t turn toward them when they approached. She was equally uninterested in their gestures. When they picked her up or tickled her, she flopped in their arms. Since her parents couldn’t grasp her attention and she seemed happy, or at least quiet, on her own, they began to leaver her alone for longer and longer periods. Angie had no trouble calming herself down. Her problem was the reverse: she had no interest in the world. Nothing drew her out of her quiet shell. She, too, had failed to master the first emotional milestone.

Angie’s grandparents recognized that something was wrong and convinced her parents to seek treatment. An assessment revealed that Angie was underreactive to sensations, especially to sound, touch, and movement. In consultation with a therapist, Angie’s parents found other ways to attract their daughter’s attention. She turned out to be responsive to visual stimuli, so her parents grabbed her attention by using animated expressions. They also raised their voices and used brisk movements. Angie liked their silly faces and soon began laughing when they talked to her using higher-pitched voices. She also responded to brightly colored objects or pictures held in front of her, and as her parents waved the objects back and forth, Angie would break into a smile. They found that she liked being moved quickly in the air and swung briskly in their secure arms. She would kick her feet and tense her muscles, counteracting her normally weak muscle control. Gradually, by using visual stimuli and vigorous movement, and lots of finger and toe games to compensate for her underreactivity, Angie’s parents were able to get her to show an interest in the world.

They also began experimenting with noises. They tried quick and slow rhythms to see what would cause Angie to react. They found that very energetic vocal tones in the middle range helped her tune back in to auditory information. Processing sound continued to be challenging, but by the time Angie was six months old, she seemed to find the world a delightful, stimulating place. With patient help from her parents, she had mastered the first emotional milestone and was ready to master the following ones. DIR at LISCA | 4

From Theory to Practice: Tips on how to help your child master stage 1

Stage 1: Self-Regulation and Interest in the World

 Discovering your Child's Sensory and Motor Profile o Entering your child's world involves more than simply intuiting what gives your child pleasure; it's a systematic process. You must first learn how your child's nervous system works, by understanding his or her unique style of hearing, seeing, touching, smelling, and moving. To help your child feel comfortable in the world you must first carefully observe which sensations help your child become calm and regulated, which ones overwhelm him or her, and which don't pull him or her in enough. - Source: Greenspan & Wieder (2006). Engaging Autism. Chapter 6.

Goal: Becoming calm, attentive, and interested in the world.

You can help your child improve in this stage by helping him or her to look, listen, begin to move, and calm down. Her sense of security and awareness will help her understand more complex thoughts, help her brain develop, and lay the foundation for future learning. Consider the following, and tailor your interactions toward your child’s unique preferences to allow her to relax and learn. If the activity is not enjoyable for your child, he or she may withdraw or shut down.

 What sights, sounds, touches, and movements bring her pleasure?  Which senses keep him calm and get his attention? Does he like firm or soft touch?  Does he like soft or loud sounds? High or low voices? Slow or fast rhythms?  Does he enjoy energetic, animated facial expressions and sounds or calm, soothing interactions?

At this stage, if your child becomes upset, your continuing relationship with him and the familiar sight of your face, the comforting sound of your voice, and your gentle touch and movements will provide him with a reassuring sense of security that helps him calm down and explore his world. Stage 1: Dos and Don’ts

 Do interact with your child, without distractions, for short stretches of time (20-30 minutes), several times per day. This is called “Floortime” and will help your child ’s brain develop.  Do find enjoyable ways to involve your child’s senses and movement at the same time  Do interact with your child, do not just stimulate him with exciting toys.  Don’t leave him to gaze at the world on his own for very long stretches of time. You cannot spoil your child by spending too much time with her.

Games to help your child master Stage 1:

 The Look and Listen Game: Lean in close to your child and talk about his or her sparkly eyes, round cheeks, or big smile. Keep your face animated and your voice lively as you slowly move to the right or left, trying to capture your child ’s attention for a few seconds.

 The “Soothe Me” Game: Soothingly touch your child, stroking her arms, legs, tummy, back, feet, and hands to help the child relax. The back and forth rhythm of the rocking chair can be especially soothing. DIR at LISCA | 5

Try to gently wiggle his or her little fingers and toes in a “This Little Piggy” type of game. This game can also be played during diaper changing time.

Capacity 2: Engaging & Relating

Along with interest in the world comes a special love for the world of human relationships. But not just any relationships! The infant wants her primary caregivers or parents. She has singled them out as the most important aspect of her world, and she lets them know they’re special. When they enter her field of vision, she brightens, she looks them in the eye, she smiles. And in those moments of shared smiles and joy, parents and baby continue to fall in love. Together they discover and deepen their intimacy. The ability to be intimate forms the basis of all future relationships. It teaches a baby that warmth and love are possible, that relationships with people can be joyful. A child who has learned this with her parents has built a foundation for continuing to learn about loving relationships throughout her life.

Mastery of this milestone also cements motor, cognitive, and language skills. The infant learns to use her body to seek out the face and touch of the parent, whether through eye contact or snuggling. She learns to scan her world for familiar objects and faces and to pay attention to them for 30 seconds or more. She learns to recognize the sound and source of speech, especially the speech of her parents. All these skills provide a foundation for her later capacity to move, think, and talk.

From birth, Jenny was oversensitive to sound and touch. (Doctors later found that she also had a severe auditory-processing problem.) A ringing phone, a barking dog, her brother’s cry would set her off. Even her mother’s soothing voice irritated her. When her parents picked her up, stroked her, or sang to her, hoping to calm her down, the combination of auditory and tactile stimulation would cause Jenny to become more confused or to lose control completely. Jenny’s parents didn’t know what to do. Their first child had been so easy; he’d cooed and laughed and smiled with little prodding from them. What was wrong with this baby? What was wrong with them? Feeling terribly rejected, they gradually began spending more time with their older child and less with “angry Jenny.” They didn’t mean to ignore their daughter; they just didn’t know what else to do. More than anything they wanted her to look at them and smile, but that was the one thing she seemed incapable of doing. At seven months, well past the point when most children fall in love with their parents, Jenny still wouldn’t easily smile or be joyful.

Jenny’s grandmother lived close by, a remarkably patient woman who was willing to spend long hours with the fussy baby. She would put Jenny in an infant seat, set her on a table, and play little “I see you” games in which she would come into Jenny’s world from the left or right, from below, from behind a napkin. She showed Jenny toys or picture books while humming softly. She sometimes put the infant seat on the floor and rocked it gently with her foot as she sat on the couch and knitted. While doing so, she’d gaze down at Jenny with loving eyes and make happy, silly faces at her. Jenny responded to these gestures. She was calmed by the gentle motion of the infant seat; she liked her grandmother’s silly faces and brightly colored pictures. Her grandmother intuitively used simple vocal rhythms, repeating simple sounds, such as “bababa,” rather than more complex sounds of songs. As time went by, Jenny began to look her grandmother in the eye for longer and longer periods, and soon she began to smile. By stimulating Jenny’s stronger senses and avoiding her hypersensitive ones, her grandmother wooed Jenny into intimacy. She had instinctively found ways to work around Jenny’s sensory difficulties to help her master the second emotional milestone. Watching Jenny respond encouraged her parents to persist in similar efforts, modeling their approach after that of Jenny’s grandmother. DIR at LISCA | 6

It is not only babies who have to learn intimacy. Many older children fail to master this skill because processing difficulties have made loving contact with their caregivers confusing, scary, or painful. Regardless of a child’s age, patient work by caregivers can help woo a child into closeness.

At age two and a half, Jay seemed to love playing with trucks—as long as he could play alone and repetitively. He wasn’t talking yet, and his parents were understandably worried. Whenever Jay’s father tried to join him, Jay grabbed the trucks from his father’s hand and defiantly turned his back. Jay’s dad, understandably upset, reacted by forcing his way into the game. He’d build bridges and tunnels for Jay’s trucks to negotiate, or he’d issue directions such as “Drive it here!” from the sidelines. Jay rebuffed his father’s advances. The harder his father tried, the more Jay closed him out. Eventually Jay began avoiding his father altogether. At an initial evaluation, he was diagnosed as having pervasive developmental disorder.

Part of the evaluation included trying to figure out why Jay was so avoidant and defensive. Careful observation revealed that Jay was extremely sensitive to touch and had motor-planning difficulties and mild auditory-processing difficulties. He was trying desperately to remain organized and to keep himself from being overwhelmed by controlling and avoiding interactions. Various interventions were suggested to help Jay and his dad begin relating.

Rather than force an interaction, Jay’s dad need to make it safe for Jay to approach him. First, Jay’s dad had to learn to watch quietly on the sidelines while Jay played with his trucks. He could make an enthusiastic comment or two and gesture with his own car, but he was not to issue directives or take over. He was to woo and entice. Jay’s father learned that it was best to help Jay do what he wanted to do by anticipating what objects Jay would need and handing them to him. After a few weeks, Jay began facing his dad some of the time while he played. Then his dad used a truck to encourage interaction. He played with it himself, imitated Jay’s movements, or made nonintrusive comments such as “Can my car go along with yours?” Jay looked over at him from time to time but continued to play mostly by himself. Slowly, however, Jay moved his car nearer his dad’s or let his father’s car follow his own. Then one day Jay sat near his father as played. Toward the middle of the play session he leaned on his father for a few moments. Jay’s father was thrilled, but instead of reaching out and touching Jay, which would have caused him to retreat, he merely smiled and said, “Hi.” Over the next few weeks Jay continued to lean on his dad sometimes, and he occasionally showed his dad where to move his trucks. Then one day Jay suddenly took his own truck and banged it into his father’s. An invitation! His father took his truck and banged it into Jay’s. Jay laughed. Then his father did something unexpected. He rolled his truck toward Jay’s, but at the last minute pulled it back. Jay laughed again. He liked that surprise. After a few months of playing this way many times each day, Jay tried to surprise his father; he rolled his truck and stopped it, hid it behind his back, then pulled it out. Several months later, Jay’s father held a truck out to Jay and to his surprise, instead of taking the truck from his hand, Jay climbed into his lap to look at the truck. As they sat together examining the toy they experienced their first real moment of intimacy. By being patient (painfully so at times!) and by following Jay’s lead, his father had made it safe for Jay to come to him. By working around the boy’s reluctance, he had helped his son experience the second emotional milestone. Jay had other challenges. He required speech therapy to help him with is language difficulties and occupational therapy to help him with his motor planning. Helping him become more regulated was a critical first step in mastering his developmental challenges and sensory-modulation challenges.

From Theory to Practice: Tips to Help Your Child Master Stage 2 DIR at LISCA | 7

Stage 2: Engagement & Falling in Love

 Following your child's lead, regardless of where his or her interest lies o Why? Because your child's interests are the window to his or her emotional and intellectual life! Through observing your child's interests and natural desires, you will understand of what he or she finds enjoyable, what motivates her. Your child has real feelings, real desires, and real wishes. Your child will feel closer to you if he or she can see that you can respect and participate in what interests him or her. o But what if my child's interests are unusual or peculiar or are not things we want to encourage? This should not be a concern at this point, because the only way you can engage your child at the beginning is by joining his or her interests, regardless of how unusual they are. Assume that whatever your child is doing is bringing him or her some pleasure, and then see if you can deepen and widen that pleasure and make it part of a human relationship. o Following your child's lead does not limit you to doing only what your child does! After joining him on his or her interests, after doing the same thing next to him or her,and entering into his or her world, you can entice him or her into an interaction. The key to expanding your child's ability to be secure, calm, and regulated in the shared world is to meet him or her first at the level of his or her ability, and then gradually expand out from that base of security. Anytime your child becomes withdrawn or overexcited and irritable, you need to go back to the baseline and expand more slowly, and have FUN together! o You will know when your child is fully engaged with you when you see the gleam in his eyes!

Goal: Falling in love with each other

Throughout this stage your child becomes more and more focused on you and other persons and things outside herself. Your delightful task during this stage will be to promote pleasurable feelings between you and your child. Emotional engagement and attachment is important because as your child relates to you and expresses loving feelings, various motor, sensory, language, and cognitive achievements are also often taking place. The milestone of falling in love usually gives purpose to these skills. For example, when your child is physically capable of reaching out and grasping something, she will more often attempt to reach for something that she is interested in and takes delight in. There’s nothing more interesting in her world than you, and her love for you will continue to spur her on as she learns to reach, grasp, and eventually come toward you, the object of her affection. How you know your child is falling in love with you:

 Responding to your smiles with a big one of his own  Making sounds and or moving her mouth, arms, legs, or body in rhythm with you as you move in rhythm with her  Relaxing or acting comforted when you hold her or rock him  Cooing when he is held, touched, looked at or spoken to  Anticipating with curiosity and excitement the reappearance of your face and voice  Looking uneasy or sad when you withdraw in the midst of playing with her

There are many ways to fall in love. Sometimes it takes a while for love to blossom, sometimes there are lots of bumps along the way. What’s important is that your shared intimacy is gradually growing. You have plenty of time to cement a loving relationship with your child, as long as you stay emotionally involved. DIR at LISCA | 8

Your child may have individual preferences regarding what is pleasurable to her, and radiate excitement when you amplify her pleasure by:

 Talking to him, using a variety of high and low pitches and soft to loud tones  Offering him a range of different facial expressions while talking  Touching or massaging her, using gentle touch while telling her what you are doing  Gently moving her arms and legs while talking to her and looking at her  Moving him horizontally or vertically fast and slow, through space while beaming at him with big smiles accompanied by lots of sounds and words

Games to help your child master Stage 2:

 The Smiling Game

Enjoy using words and/or funny faces to entice your child into breaking into a big smile or producing other pleased facial expressions such as sparkling or widened eyes. You can chatter about the spoon you’ve stuck in your mouth, or the rattle you’ve placed on your head, or simply about how “bee-you-ti- ful” her hair is!

 The “Dance with Me” Sound and Movement Game

Try to inspire your child to make sounds and/or move his arms, legs, or torso in rhythm with your voice and head movements. You might say, “Are you going to dance with me, sweetheart?” Oh, I bet you can – I know you can!” while looking for a gleam of delight in his eyes.

Capacity 3: Purposeful Two-way Communication Opening and Closing Circles of Communication

When a baby falls in love with his parents, an interesting thing happens. He realizes he can have an impact on them.

When he smiles at Mommy, she smiles back. When he reaches out to Daddy, Daddy reaches back.

The baby expresses a feeling or an intention, and his caregiver responds. This is the beginning of communication;

the baby and his grown-ups are having a dialogue.

We like to think of these dialogues as opening and closing circles of communication. When a child reaches out—with a look, for example—he opens the circle. When the parent responds—by looking back—he builds on the child’s action. When the child in turn responds to the parent—by smiling, vocalizing, reaching, or even turning away—he is closing the circle. When the parent responds to the child’s response—by holding out a toy, by saying, “Don’t you want to play?”, by echoing the child’s vocalization—and the child responds with another gesture (a look, a smile, or hand movement) they have opened and closed another circle.

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Fairly quickly the baby extrapolates from this experience; not only can he cause Mommy and Daddy to react, but he can cause other reactions, too. He bangs a toy, and the toy makes a sound! He drops a block; it falls to the floor. He has an impact on the world, and for the first time the baby becomes a person of volition, someone who can actively choose to do things, knowing that his actions will cause a result. He is learning fundamental emotional, cognitive, and motor lessons.

Two-way communication is essential for all human interaction. It also allows children to learn about

themselves and about the world. The older child hugs a teacher and the teacher hugs back; she learns

that she is appreciated. She pushes another child, and that child begins to cry; she learns that her actions can move someone to tears. Without these essential experiences in two-way communication, children can’t

form a basic sense of intentionality, which means they can’t begin to form a true sense of who they are or see that the world is logical.

From his very difficult birth Scott seemed hard to engage. Many of his senses were underreactive, his muscle tone

was low, and his motor development delayed. His left side was weaker than his right. At eight months of age his

parents were told that he had cerebral palsy and would need physical and occupational therapy to learn to coordinate and build strength in his arms and legs. Even with therapy he showed little interest in the world and

initiated few activities. When his mother smiled and cooed at him and tried to get him to smile back, he turned

away, closed his eyes, or stared past her. After working on gaining his interest and building intimacy (using the approaches described earlier), his mother began to help Scott master the third critical skill, two-way communication. It was no longer enough to get Scott to pay attention to Mom and Dad; he now needed to be challenged to respond to their gestures with gestures of his own.

Scott’s parents began showing him the power of his gestures. Whenever Scott made the slightest noise or movement, his parents oohed and aahed or responded in an exaggerated way. They were careful to build on motor gestures that Scott could do easily, such as looking or moving his tongue or head. Soon he caught on that his gesture produced a reaction in them. He had an impact on his world! Gradually Scott’s parents turned these gestures into dialogues. Each time Scott moved his arms, however slightly or seemingly unintentionally, Daddy waved his arms; then Scott would move his arms again. He had closed a circle of communication.

As Scott came to appreciate his power to make things happen, he began to take initiative. He would knock a toy off his high chair. Plunk! Now his parents could use toys to lure him into further communication. They would get down on the floor with him, face to face, and hold a toy he was looking at to see if Scott would reach for it. Or they would put a toy he was touching just outside his reach and challenge him to slither toward it. When he succeeded, they congratulated him heartily: he had closed a circle of communication. DIR at LISCA | 10

In this way, by using Scott’s natural interests and existing motor capacities, they restarted the developmental progression. They helped him begin to master the third functional emotional milestone. With their work at home, his physical and occupational therapists also reported more progress.

From Theory to Practice; Tips on how to help your child master stage 3 Stage 3: Opening and Closing Circles of Communication

 Encouraging two-way communication o Communication builds on intentionality, the goal is to help your child take the initiative. o Your child's interest and purpose is the first step in meaningful communication. o Your child will OPEN the circle of communication by his own purpose or intention, by o doing what he wants to do o You can then build on this intention by helping your child achieve his goal. o Your child will CLOSE the circle of communication when he takes advantage of what you o offered and gestures back to you o Getting to a continous back-and-forth communication is the goal of this stage.

Goal: Becoming a two-way communicator.

How you know your child is communicating: Your child may open up gestural dialogues with you by doing the following:

 Reaching out to you to be picked up, or hugging you back when you hug him  Smiling, vocalizing, putting a finger in your mouth, taking a rattle from his mouth and putting it in your own, or touching or exploring your hair  Pushing undesired food off a high-chair tray with an accompanying angry look, screaming when a desired toy isn’t fetched quickly enough, or wiggling out of your arms when he has no interest in getting dressed (His angry face, shouts, and squirmy body clearly communicate his sense of protest or anger).  Looking for the toy that fell to the ground or (toward the end of this stage) looking in your hand for a hidden, desired rattle.  Showing caution or fear by turning away, clinging to your leg, or looking scared when a stranger approaches too quickly.  Follow your child ’s lead and challenge him to exchange gestures and emotional signals with you about his interests.

Do’s and Don’ts as your baby learns to communicate

 Do simultaneously exercise as many of the sesing, smelling, hearing, touching and moving elements of your child’s nervous system as you can while the two of you interact.  Don’t be a ringmaster and direct the way your play unfolds. Follow your child ’s lead and help him use his interests to give direction and organization to his new abilities.  Do play lots of emotionally pleasurable games for longer times. The more interactive playtimes you share, the more fun you’ll have. DIR at LISCA | 11

 Do seek out the magic moments.

Becoming a Communicator Take note of the things your child is naturally interested in (your funny nose, or the rattle you’ve placed in your mouth, for example) and then challenge him to express himself with feelings and actions in a purposeful way. In this way you will help him become a two-way communicator!

Games to help your child master Stage 3:

 The Funny Sound, Face, and Feeling Game

Notice the sounds and facial expressions your child naturally uses when he’s expressing joy, annoyance, surprise, or any other feeling, and mirror these sounds and facial expressions back to him in a playful way. See if you can get a back-and-forth going.

 The Circle of Communication Game

Try to see how many back-and-forths you can get going each time your child touches a tiny red ball or pats your nose and you make a funny squeel or squawk in response. Or see how many times he will try to open your hand when you’ve hidden an intriguing object inside. Each time your child follows his interests and takes your bait, he is closing a circle of communication.

Capacity 4: Complex Communication & Shared Problem Solving Did you practice capacity 1, 2, and 3? Don't run into capacity 4 until you have mastered, at least partially, capacities 1, 2, and 3

 Observe Your Child: Complete this chart to help understand where your child is developmentally  Expanding the Circles of communications to Solve Social/Relational Problems  Once a child has mastered the basics of two-way communication, the number of circles she can open and close grows rapidly. And with their number, so grows their complexity. When earlier she responded to things with a single gesture, now she can link gestures into complicated responses. When she sees her mother after an absence, she can run up to her, put up her arms, and squeal with delight, a series of gestures that were impossible at an earlier stage.

 For the first time the child has a vocabulary for expressing her wishes. It is a vocabulary of gestures, not of words, but by linking them together she can communicate fairly complicated thoughts. For instance, when she is hungry, she no longer needs to wait for Daddy to offer food; she can take him by the hand, lead him to the refrigerator, and point to what she wants. When she is angry at her brother for stealing her toy, she can hit and kick and try to grab the toy instead of merely crying. She can also go look for it in his room and bring it back to her own play area. When she is happy with her parents, she can run over, flirt with them, and hug and kiss them, rather than simply smile. When she is disappointed, she can give them longing looks and then punish them with a period of unforgiving coldness.

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 Her growing gestural vocabulary offers her more complex ways to express herself, and along with this expressiveness she becomes creative. She no longer has to do things exactly the way her parents do; she can now add her own elements to a game of chase or mimic her mother’s gesture while adding a flourish of her own. Her new gestural and communication skills provide a myriad of ways for her to express her individuality. The child’s personality emerges. At the same time, her sense of self is becoming far more complex. She now understands that 20 or 30 behaviors—a pattern of behaviors— are involved in being close to, or angry at, someone. She has a wide range of feelings and a varied behavioral vocabulary with which to express them.

 As she uses her growing gestural vocabulary to express her many feelings and intentions, and as she responds to the growing complexity of her parents’ gestures, she and her parents engage in lengthy gestural conversations. Twenty, thirty, forty circles are closed, and each circle builds the child’s sense of self. She understands that “I” is built of patterns of intentional behavior, not simply of isolated responses.  Meanwhile, the child begins to comprehend the patterns of others. She can figure out from her parents’ gestures whether she is safe or in danger, approved of or disapproved of, accepted or rejected, respected or humiliated. Before she used words to any degree, she and her parents hold dialogues on life’s major themes. She forms character patterns, expectations of others, and a sense of self. Patterns of helplessness or assertiveness and expectations for love and respect or harm or insult also emerge.

 These growing dialogues are the prelude to speech. Through her extensive experience with communication the child builds the foundation for speech. During this stage, the child may begin to imitate the sounds of her parents’ words. Communication difficulties are often first revealed by a child’s difficulty in mastering this stage, long before the more obvious lack of speech is evident. If between 12 and 20 months of age your child is not making complex gestures, such as taking your hand and leading you to the door in order to play outside or pulling you along to help her find a toy, a full evaluation is probably indicated. Often when a child is not using words, parents and professionals are caught up trying to decide whether to wait and see or to implement a full evaluation. Even if a child is not talking, if she shows complex problem solving, such as taking you to the door or toy corner often, you can wait and see. If she does not engage in such preverbal patterns, however, waiting is unwise.

 The ability to express herself through complex gestural conversations builds a child’s motor and motor- planning skills. To convey her wishes and intentions she must first organize her behavior into logical sequences and she must learn to read the sequenced behavior of others. As her ability to use and enjoy the world grows, so grows her ability to grasp the world cognitively. Now she knows that when Daddy is hiding behind the curtain, Daddy hasn’t disappeared. Now she can pull the curtain aside and find him.

 At three years old, Andrew was an aimless child. He would pick up a toy then drop it, go over to another, look at it, then run to the window and clamor to go outside. If his mother refused to let him go outside, he would dissolve in bitter, inconsolable tears. This kind of random, piecemeal activity characterized his behavior. But most disturbing to his parents was Andrew’s seeming lack of sustained interest in them. He would come over to them for a fleeting hug, but wouldn’t stay for more than a few seconds. In that time he would close two or three circles of communication—perhaps meeting his father’s eye, or respond to his mother’s gestures by putting his head in her lap to be stroked, or taking a proffered toy—but before they could do more Andrew would run off and resume his aimless wandering. Three minutes later he might return, but only for several seconds. Andrew’s parents were also troubled because his vocabulary was limited and he seemed clumsy to them—poorly coordinated and physically insecure. DIR at LISCA | 13

 An evaluation revealed that Andrew had fragile X syndrome. He had auditory-processing difficulties that made it hard for him to interpret sounds. His parents’ words were lost on him, and even their enthusiastic hurrays, their soothing murmurs, their sounds of warning were difficult for him to comprehend. He also had motor-planning problems, which made it hard for him to negotiate sequences. Not only did Andrew face challenges coordinating sequences of movement, but interpreting sequences of sound or movement was equally challenging for him. When his parents used a series of gestures accompanied by sounds he couldn’t understand to tell him to come downstairs for dinner or put away his toys, Andrew literally did not understand them. Their communication was confusing intrusion. He loved his parents and craved their affection, hence his advances to them. Yet no sooner did he advance, than they began making these confusing (and slightly overwhelming) sounds and gestures, and he felt the need to retreat.

 After his evaluation, one of Andrew’s therapists showed his parents how to work around his challenges to help him gradually extend the length of contact. The therapist instructed them to keep their gestures going, but not to overload Andrew. When he came over for a hug, they should smile warmly and hug him back. When he broke away, they should keep smiling and say simply, “More hug,” then offer another or go over to Andrew and gently use hands, sounds, and facial expressions to offer an embrace.

 Andrew’s parents practiced these instructions, and during the next few months Andrew began coming for a hug, running away, then coming quickly back. “More hug” had become a game, one that Andrew could control and clearly enjoyed. By giving his parents a cocky a little smile he could get them to open their arms and say, “More hug”; then he would run into their arms.

 The therapist then suggested extending the game. “Try to go from three circles of communication to ten. After Andrew hugs you, say, ‘Leg hug,’ and point to your leg. See if he will want to give your leg a hug. When he’s comfortable with that, perhaps your arms will want a hug. See how long you can keep the communication going. Perhaps he will point to his leg for a hug, or smile and say, ‘No!’ Either way, circles are being opened and closed.”

 Over the next few months Andrew and his parents extended the “more hug” game to arms and legs, knees and feet. They were closing eight, nine, ten circles at one time. All the while, Andrew’s parents were working together to keep their vocalizations and gestures energetic and clear. Instead of saying, “Andrew, come downstairs for dinner, please,” they said, “Andrew, let’s eat!” Instead of saying, “Do you want cheese on your sandwich?” they pointed to the cheese and said, “Oh boy, look, cheese!” They also tried to keep the backup to their words—facial expressions and gestures—as animated as possible.

 Andrew responded readily to his parents’ new vocabulary. Over the next six months he initiated more contact with them, sat in their laps for quiet hugging games, and respond to their simple gestures with gestures of his own. He was routinely closing 10 or 12 circles in a row with deeper engagement, more pleasure, and longer chains of gestures. He also began to imitate more of his parents’ sounds, using more variety. Not only was Andrew moving toward complex gestural communication, but he was also developing the skills that would lead toward richer speech.  Lucy, at three, was a far more difficult child than was Andrew. Willful and energetic, she was hard for her parents to control. She, too, ran aimlessly from object to object, but instead of quietly examining things, she tore into them with a frenzy, often leaving a trail of broken items. Lacking speech, she made loud sounds as she ran, ignoring her parents’ entreaties to come and cuddle. Lucy could engage in limited communication with her parents. She would take object from their hand; she would point to DIR at LISCA | 14

things she wanted; she would pound the door or television set or refrigerator to indicate her desires. But once she had what she wanted she would be off again, a whirlwind of agitated movement.  Lucy was diagnosed as having attention deficit disorder and a language disorder. An occupational therapist who focused on Lucy’s individual differences explained to Lucy’s parents that their daughter’s continual movement in part stemmed from an underreactivity to sensory input. Because her body craved stimulation, she was on a continual mission to find it. Running, touching, squeezing, and fondling were all ways of satisfying her body’s need for tactile and proprioceptive stimulation. The therapist suggested that Lucy’s parents build these kinds of sensations into their interactions by playing games that involved jumping, running, touching, wrestling, and moving in space. This approach would help Lucy experience appropriate levels of sensation

 The therapist also encouraged Lucy’s parents to try and lengthen Lucy’s contacts with them. “When she bangs on the door to go outside, don’t just open the door,” said the therapist, “pretend you don’t understand so that she has to show you more of what she wants. Try to stretch the communication from three circles to ten.”

 So each time Lucy banged on the door to go outside, her parents played dumb. They looked at her as if to say, “Huh? What do you want?” She would bang the door again, and they would push on the door as if that was what she wanted. She would bang even harder. Still her parents feigned ignorance. Finally, Lucy would take their hands and place them on the doorknob. “Oh,” her parents would say, “you want me to open the door?” Lucy would jump up and down, but still her parents would delay her, perhaps fiddling with the latch until once more Lucy would move their hands to the knob and try to turn them in the right direction.

 At first these exercises were intensely frustrating for everyone. Lucy seemed ready to lose control, and her parents hated making her so uncomfortable. But they could see that the strategy was working; each time they did it Lucy closed eight or ten circles in a row. They began applying the strategy to other encounters. When Lucy wanted a particular toy or a particular cookie, they pretended not to understand, offering her the wrong one or pretending not to know how to open the box, until Lucy had closed seven, or eight, or nine circles in communicating her desire. Her parents were always warm and supportive and had a gleam in their eye while negotiating with her. And they made their communications very animated. They communicated their love for Lucy while pushing her to work a little harder.

 Several months later, Lucy was routinely communicating with her parents in these lengthier conversations. At the same time, her parents were continually chatting with her about the activity at hand. “You want a cookie? Okay. Oh, not that cookie? Which cookie? Oh, the chocolate chip cookie…” Occasionally Lucy imitated the sounds she heard her parents making. “Ooh-ooh,” she might say, replicating the sound of “cookie.” By giving Lucy so much interreactive emotional experience with communication, her parents were laying the groundwork for speech. Their persistence in stretching circles of communication was helping her master the forth milestone and also become more focused and attentive.

From Theory to Practice: Tips on how to help your child master stage 4 Tips to Practice Stage 4:

Goal: Using a series of interactive emotional signals or gestures to communicate.

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Stage 4 Do’s and Dont’s

 Do engage in long chains of interaction around all your child ’s interests  Do make a point of exploring a range of feelings: pleasure, excitement, curiosity, closeness, anger, defiance, and limit setting.  Do challenge your child to experience different feelings in the same play session so she can make various feelings part of who she is.  Do let your child know what you expect in terms of behavior, much as a corner policeman directs traffic. Use expressive facial expressions, body postures and vocal tones.  Do challenge your child to solve more and more complex problems, like finding you in a hide-and-seek game.  Do challenge your child to use her gestures to show you what she wants.  Don’t label your child as good or bad.  Don’t focus only on playing with blocks, puzzles, or cause-and-effect toys.  Don’t become preoccupied with teaching your child about discipline and controlling her behavior.

Learning How to Solve Problems Challenge your child to interact with you to solve problems- not only those that she wants to figure out on her own, but also those that you present to her. Exchange many gestures as the two of you problem-solve, including sounds or words and actions such as puling each other in various directions.

Games to help your child master Stage 4:

 The Working-Together Game

Note your child ’s natural interest in various toys, such as dolls, stuffed animals, trucks, balls, etc., and create a problem involving a favorite toy that she needs your help to solve. For example, you might have a favorite teddy bear “run away” and “climb” to a high shelf. Your child will have to raise her arms to reach, and gesture for you to pick her up to extend her reach, and you will gladly comply. Such a simple game will involve opening and closing many circles of communication while solving a problem at the same time.

 Copycat Game

Copy your child ’s sounds and gestures, and see if you can entice her to mirror all of your funny faces, sounds, movements and dance steps. Eventually, add words to the game and then use the words in a purposeful manner to help her meet a need, for example, by saying “Juice” or “Open!” Is stage 4 hard for you and your child? Go back and practice more stages 1, 2, and 3. The better you get at stages 1, 2, and 3, the easier it will be to move up the developmental ladder to stage 4!

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Capacity 5: Using Symbols and Creating Emotional Ideas Creating Emotional Ideas

The child’s ability to form ideas develops first in play. The child uses toys to weave stories, and through these stories he experiments with the range of intentions and wishes that he feels. Baby dolls are fed by Mommy dolls. People inside a house are threatened by giant bears. Cars crash into other cars. Along with this idea-laden play comes expanded use of words. At first the child merely labels the important elements of his world—the people on whom he depends, his favorite foods and toys—or commands imperiously, “That!” to indicate a desired object. In time, he adds dialogues to his play. Later, with help from his parents, he puts names to his range of intentions, wishes, and feelings.

Through idea-laden play and expanded use of words the child is learning that symbols stand for things. The empty box in which he bathes his doll is a symbol for a bathtub. The word bath is a symbol for his activity in the tub. The word mad is a symbol for that bursting feeling he had inside. Each symbol is an idea, an abstraction of the concrete thing, activity, or emotion with which the child is concerned. As he experiments more and more with pretend play and words, he becomes increasingly fluent in the world of ideas.

Eventually he is able to manipulate ideas, to use them in ways that meet his needs. For instance, he can see, hear, and feel Mommy when Mommy isn’t there. Now when he wakes at night, instead of simply crying, he can call for her. Sometimes just picturing and thinking around his mother is enough to comfort him. When he is thirsty, he can thing about juice and say, “Mommy, juice,” instead of hoping she will know what he wants. With this new ability to manipulate a world of symbols, he has made the leap to a much higher level of communication and awareness.

Ryan had had numerous medical problems and surgeries as an infant, and although he was healthy at age two and a half, he had difficult, disruptive behaviors. He never slept for more than three hours at a time; he rejected most food and was significantly underweight; and he was active and irritable. The preliminary evaluation showed that Ryan has mastered the earliest milestone. He evinced an eager interest in the toys in the office and was able to keep himself calm. But his skills at intimacy and two-way communication were intermittent. He often turned his parents out, refusing to interact and ignoring their words and gestures, but when motivated, he could string numerous gestures together to express his wishes. For instance, he pointed avidly at a dollhouse on a shelf until it was placed on the floor and then he methodically opened and closed all its doors and windows; but he showed little inclination to use the house to play out any ideas. When offered some dolls, he mechanically put them inside, but he didn’t create a story. His use of words was limited also. He used some single words, such as door, but didn’t use words to interact with others that occasionally to say “no” or “out.” It seemed that Ryan had not fully mastered the earlier milestones, and hence his ability to tack milestone 5 was impaired.

Observations of Ryan at play brought to light something else about him: his range of emotions appeared constricted. When things went wrong, he didn’t get angry; when they went smoothly, he didn’t smile. He was interested in the toys in the office but exhibited little curiosity. And when his parents tried to hug or encourage him, he showed no evidence of warmth or pleasure. His mother had described him as “always negative,” and it was easy to see how this sullen little boy could seem so.

As part of the evaluation an occupational therapist discovered that Ryan was tactilely oversensitive in and around the mouth, which accounted for some of his pickiness about food. He was also posturally insecure, that DIR at LISCA | 17 is, not comfortable with how his body felt as it moved through space. A foot’s moving off the ground made him feel uncertain and unbalanced.

Observations of Ryan and his parents playing together revealed that Ryan’s sensory difficulties were only partly responsible for his problems. The way his parents played with him contributed also. In their efforts to engage Ryan, his parents were a little too quick to offer ideas; as a result, they hampered Ryan’s ability to develop his own ideas. For instance, Ryan’s mother handed him a doll. “What’s this?” she asked. When he didn’t answer immediately she said, “That’s the boy doll. What’s this?” Again he didn’t answer immediately. “That’s the girl doll,” she filled in. “What do they want to do together?” Once more she supplied the answer. Ryan responded by turning away. His mother then put a puppet on her hand and said, “What are you going to say to the puppet?” When he didn’t respond she said, “Say hi to the puppet. Say hi.” Ryan turned away, then he took a block, put it on another block, and toppled them over. Ryan’s father behaved similarly with his son. If anything, he was more directive, and Ryan’s gestures and responses were even more limited.

Ryan’s parents gave him so little room to move that turning away and making negative gestures had become his only way to assert himself! This emotional tendency was enhanced by his sensory patterns. His postural insecurity made him inclined to be passively negative—to turn away rather than to hit or kick—and his sensitivity around the mouth predisposed him to be negative when it came to food. Perhaps his inability to sleep was just one more way to assert himself with his parents. By tuning his parents out he gained some space for himself, but in the process he limited his chance to develop his own ideas.

The treatment program, in addition to working on Ryan’s oral oversensitivity and muscular control, worked with both parents on their interactions with their son. They had to learn to give Ryan time to respond before offering a response or their own. They had to give him room to initiate play. Gradually both parents learned to be very engaged with them. As they did so, Ryan became more engaged with them. He also began to show some leadership. In one session several months later, he put a whale puppet on his hand and held its mouth open. Instead of directing the action as she would have in the past, his mother put a puppet on her hand and had her puppet say, “What do you want, Mr. Whale?” Then she waited patiently for Ryan’s answer. Ryan said the whale was hungry. Instead of feeding the whale herself, his mother asked, “What does he want to eat?” Ryan, taking a great deal of verbal initiative, generated a list of foods the whale wanted. As simple as this little interaction was, it was a major improvement in the family dynamic. Rather than telling Ryan what to do at each juncture, his mother had let him direct the play and inspired his initiative by joining him in his drama. She became a player in the drama; but he was the director.

Some weeks later, Mom and Ryan played with the whale puppet again. This time, the whale spit out its food. “How does the whale feel when it spits out his food?” Ryan’s mother asked. Ryan didn’t answer. “What does the whale want to do?” she asked. Ryan then had the whale bite everything in the room. When the whale finished biting, he knocked down some toys. Ryan’s mother watched. When he was through she said, “Is the whale mad or happy?” “Mad,” said Ryan. Then he smiled. This was the first time Ryan had expressed anger in the form of ideas. Ryan’s father made similar strides. Around the same time, in a session with his father, Ryan noticed a flashlight. “What’s this?” he asked. Instead of grabbing it, his father responded, “Let’s see if we can figure it out.” He pointed to the switch. Ryan began pressing the switch, and after a couple of times the flashlight turned on. Ryan giggled. Then he shone it at his father, and his father made funny faces. Then they switched— Ryan’s dad shone the light at Ryan, and Ryan made funny faces. Through this little exchange both Ryan and his father laughed. Their exchange was warm and intimate, and for the first time, clearly pleasurable for Ryan.

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Suddenly Ryan got an idea. He said to his father, “Me,” pointing to the flashlight. When his father shone the light on him, Ryan stood in the spotlight and pretended to be onstage. With everyone watching, Ryan pranced and preened. When his audience applauded, he performed some more. This was an enormous step. For the first time, Ryan initiated a complex drama in which his parents and therapist were importantly involved. With help from his parents he was opening up to the world of emotional ideas, strengthening his skills at intimacy and communication. He was cementing his hold on the earlier milestones, and he was making good progress on milestone 5.

From Theory to Practice; Tips on how to help your child master stage 5

Goal – Using symbols or ideas to convey intentions or feelings.

Now is the time to help your child tell you what he wants or thinks, and to become a partner in his emerging make-believe play. You can pretend to be a puppy, or talk for a puppy puppet, and ask your child for a hug or a kiss or a dog bone, for example. You can also open up conversations with him about his desires and wishes, and ask, “What do you want to drink, milk or juice?” His reply of “juice” could be met by your eager head nod and response of, “Let’s go and get it! Show me where to go.” As he answers, “There, Mommy,” while pointing toward the refrigerator, he’ll know that he can get his needs met by interacting with you.

Stage 5 Do’s and Don’t

 Don’t rely on puzzles, books, structured games, DVDs, or TV to spark your child’s use of ideas.  Do get down on the floor and become a character-such as a bear or wizard-in a pretend drama of your child’s own choosing. Ham it up! Interact, talk, and emote through your character.  Do hold long conversations about anything that interests your child, from a new toy to his favorite or most despised food. Use games, TV, and videos as a basis for long back-and-forth conversations rather than as ends in their own right.

Games to help your child master Stage 5:

 Let’s Chitchat

Using your child’s natural interests, see how many back-and-forth circles of communication you can get going using words, phrases, or short sentences. You can even turn your child’s single-word response into a long chat. For instance, when your child points to the door and says, “Open,” you might reply, “Who should open it?” He is likely to say “Mommy do it,” and you could shake your head from side to side and say, “Mommy can’t now. Who else?” He’ll probably turn his head to his father and ask, “Daddy do it?” Daddy might reply, “Do what?” When your child once again points to the door and says “Open, open!” Daddy can walk toward him saying, “Okay, can you help me push the door open?” With his eager head nod, your little boy will be closing this long sequence of back-and-forth words and gestures.

Let’s Pretend Become a dog or cat or superhero in a drama of your child’s own choosing. Ham it up and see how long you can keep it going.

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Capacity 6: Logical Thinking and Building Bridges between Ideas

In the previous stage, the child’s expressions of emotion are like little unconnected islands. Play moves from a happy, nurturing tea party to an angry crashing of cars to a monster threatening to tear down a house all within a few minutes, as the child uses whatever caught her eye to play out emotional themes. In this sixth stage, the child builds bridges between those islands. Ideas are linked together into logical sequences and play, and imagination is also more logically connected. Whereas in stage 5 a child might dress up a doll, then, seeing a crayon, scribble, then, seeing a drum, pretend to be a drummer, a child at the stage of emotional thinking connects the pieces together. For example, she might have the drummer play for the dressed-up little girl and use the crayon to make invitations for the performance; or, the doll might have a tea party, call friends to invite them, prepare refreshments, set the table, and determine the seating pattern.

At this stage the child is able to express a wide range of emotions in her play, and through experimentation she begins to recognize more and more what makes “me.” She can even predict some of her feelings—“if Mommy leaves I will be scared”—and she begins to see that her feelings and behavior have an impact on others: “if I get angry and hit, Daddy will get mad”.

She also begins to understand emerging concepts of space and time in a personal, emotional way: Mommy is in another city, which is different from another room; if I hit Tommy today, he may hit me back tomorrow. The ability to conceptualize space and time and to link actions and feelings enables the child to develop a sense of self that has logical bridges between different perceptions, ideas, and emotions. She is also able to connect ideas in terms of spatial and verbal problem solving; instead of seeing separate block towers as isolated structures, she can link them together to make a big house. She can answer what, when, and why questions, enjoy debates, logically articulate an opinion, and begin the long journey to higher and higher levels of abstract thinking. Both verbal and spatial problem-solving abilities rest on emotional problem-solving skills. As with the earlier stages, emotional interactions create the thinking strategies that are then applied to the more impersonal world.

During this stage the child becomes more fully verbal. She still resorts to gestures to express her feelings— especially negative feelings such as anger and aggression—but she is now comfortable in the realm of words and understands that ideas and feelings can be communicated verbally.

At first we see children master islands of emotional thinking. Over time these islands coalesce into continents and the child’s view becomes more cohesive, integrating more experiences into a sense of self and problem- solving ability. Higher levels of thinking build on this foundation.

When Robbie was one year old, he was diagnosed as having cerebral palsy with low muscle tone and right-side weakness. He made good progress, however. At four and a half he was an engaging little boy, with the jagged walk and unintentional arm movements of a child with motor difficulties. But he had a warm smile and he made good eye contact—intermittently. His mother described him as “mysterious” because he was not always easy to understand, or “realistic.” His speech was immature for his age; he understood simple words but not concepts or abstract phrases, and he often gave silly, illogical answers to questions. Asked what he had for lunch he was apt to say, “The moon is green” or mutter illogical phrases to himself. But sometimes, such as when asked for a toy, he would be logical and connected to reality. His parents worried because he didn’t play with his peers and he so often seemed “lost in make-believe.” DIR at LISCA | 20

Robbie had achieved most of the early emotional milestones, although none appeared to be fully mastered. They fall apart when he was stressed. For instance, he was eager to play with the toys and objects in the therapist’s office and remained calm while he examined them, but when his mother tried to pry a toy away from him, he screamed in rage for 15 minutes. Sometimes he turned inward, babbling to himself as if only his inner thoughts could comfort him. Much of the time he was connected to his parents. He would look them in the eye and answer their questions, although he rarely smiled. Then suddenly, with no apparent provocation, he would turn away and willfully ignore them. He was clearly capable of two-way communication, both with gestures and with words. His word comprehension and use of ideas was sometimes quite sophisticated. But again, with no apparent provocation, he would suddenly stop closing circles and instead respond with silly, illogical phrases. His play was mechanical; he enjoyed putting dolls down the slide of the dollhouse rather than acting out a drama, and when he did begin a little drama, what emerged were bits of unconnected action rather than a unified story. His range of emotion was narrow. In general, Robbie seemed unable to sustain an idea, a conversation, or a feeling more than a few seconds. After that he needed to retreat to the comfort of his inner world. His incomplete mastery of the earlier milestones had undermined his ability to work on Level Six.

Further evaluations revealed a number of factors contributing to Robbie’s problems. He had an auditory- processing and word-retrieval problem, which mean that he often couldn’t understand what was said to him and couldn’t think of the word he wanted. It was easy to see how this might discourage him from closing circles. He had made great strides in his physical therapy, but he still had significant gross- and fine-motor deficits. His posture and balance was insecure, and it was hard for him to plan and execute his movements. This difficulty accounted for his jagged walk, unintentional arm movements, and general lack of coordination. To tackle these impairments, his treatment program included speech and occupational therapy along with his physical therapy.

Equally important to treatment was the program developed for Robbie’s parents. It was clear from observing them play with Robbie that they could help him become more layered and integrated. His mother, rather than steer his conversations back to reality, often got lost with him in his self-absorbed elaborations of ideas. She called his fragmented ideas “his poems,” but she didn’t try to understand them. “Only he needs to know,” she explained. Robbie’s father was relatively uninvolved with him and avoided family activities. Untethered to reality, Robbie was moving further and further into his own world. In time, if the situation didn’t change, he would relate less and less well with others.

As part of the treatment program, Robbie’s parents were to play on the floor with him, encouraging him to close his circles of communication. Their goal was to prevent Robbie from withdrawing into himself and tuning them out. Each time he made a silly comment, they were to link that comment to reality by joining him in his play. By helping him close verbal circles, they would help him share his world with them and they would help him share their world rather than continue to live in his own. For instance, when Robbie slid a doll down the slide of the dollhouse and announced, “The doll is jumping out of the moon,” his parents might say, “Where is the moon?” If he didn’t answer they might say, “Is the slide the moon?” or “How do we get to the moon? as a means of joining his play. The slide might then turn into a spaceship and off they would go. Each time they joined him they tried to help him tie his ideas to their ideas so that there would be a logical bridge between what he created and what someone outside him created.

Robbie’s parents also practiced reality-based conversations. They might ask what Robbie did at preschool that day. If he said something silly, such as “The chimney has water in it,” they made a transition to something realistic. They might respond, “Did something happen with a chimney or with water?” and continue patiently until he was able to give them a logical reply. Robbie’s teachers were similarly encouraged to help him close his verbal circles. DIR at LISCA | 21

Robbie’s parents were helped to set limits when Robbie had temper tantrums. In the past they had let him flail around or had given in to his demands. Now they held him tightly to help him calm down and then gradually helped him talk about the problem. After a few weeks they also used exercises from Robbie’s occupational therapy to help him calm down.

Over time, Robbie made slow but steady progress. By a few months into therapy he was able to maintain two- way communication for a longer period of time and was having few tantrums at home. With a lot of cuing from his parents to compensate for his word-retrieval problem, he was doing a better job of describing his day at school.

A few months later, his pretend play took on a whole new emotional level. He began to develop elaborate dramas in which good guys were constantly being overwhelmed by bad guys and having to defend themselves. Occasionally he would blurt out while playing that he was mad at his sister or at a child at school because “they wreck my things.” These comments began to provide a sense of Robbie’s inner feelings. Apparently he often felt overwhelmed by other people, felt angry at them for hurting him, and fantasized about counterattacking. He had begun forming bridges between ideas, between the real world and his play.

A year and a half later, Robbie had made tremendous progress. He could hold a conversation for as long as his partner wanted. His tantrums had virtually disappeared, and he had become quite capable of regulating his moods. He was able to express a wide range of emotions—from happiness to sadness, dependency to aggressiveness—in play as well as in life. And when earlier he had tuned out and closeted himself in his inner world, he was now rooted in reality. In the past Robbie had used his creativity and cleverness to escape into fantasy, in part because processing other people’s ideas and finding words was difficult and in part because of the conflicts over certain feelings. Now he used his creativity to stay involved in two-way communication, to build logical bridges between ideas, and to work out his problems with auditory processing and word retrieval. He still has some of these problems, and his parents continue to work with him on that. But overall Robbie’s progress has been excellent. He is now functioning at an age-appropriate level in all basic areas. With his parents’ patient help he has mastered all six emotional and intellectual milestones.

Children achieve these milestones at different ages—there is wide variation even among children without challenges. What is important is not so much the age at which a child masters each skill, but that each one is mastered, for each skill forms a foundation for the next.

Once a child has mastered all six milestones, he has critical basic tools for communicating, thinking, and emotional coping. He has a positive sense of self. He is capable of warm and loving relationships. He is able to relate logically to the outside world. He can express in words a wide range of emotions (including love, happiness, anger, frustration, fear, anxiety, jealous, and others) and is able to recover from strong emotions without losing control. He can use his imagination to create new ideas. He is flexible in his dealings with people and situations, able to tolerate changes and even some disappointments and bounce back. Obviously not all children do all these things equally well, but a child who has mastered the milestones will have important foundations for loving and learning.

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From Theory to Practice: Tips on how to help your child master stage 6

Goal: Building bridges between ideas. Challenge your child to connect her ideas together by seeking her opinion, enjoying her debates, and enlarging her pretend dramas.

Learning to Think Help your child learn to think by holding long conversations with her in which you seek her opinions rather than simply trade pieces of information. For instances, when she expresses a desire to “Go out now!” you can ask her what she wants to do once she’s outside. When she replies, “Play on the slide!” she’ll be linking her wishes with your thoughts and ideas. Try and pose open-ended questions to get her thinking, such as “Why do you like this color so much?” rather than “Which is your favorite color?” Enjoy debates about everything from bedtime to ice cream flavors! When your child clamors to stay up later, and you ask, “Why should you be allowed to stay up so late?” she’s likely to give you a lawyerly response of “Because you let (big sister) stay up late and I’m almost as old!” Also, as you continue to be a pretend partner, try and come up with new plot twists. You might explor the dolls’ feelings or let her be a mommy while you are the child.

Stage 6 Do’s and Don’ts

 Do rely on jointly creating elaborate pretend dramas that have logical plots. For example, tea parties and school scenes and trips to Grandma’s can be woven together.  Do rely on enjoyable debates about everything from food and clothes choices to sharing toys.  Don’t simply tell your child what to do; explain why you want to do something. Discuss the pros and cons, and give your child plenty of time to argue her viewpoint. A good rule of thumb is that if your child’s answers don’t frequently surprise you, or if you have a single correct answer in mind, you are probably over-scripting.  Do rely on reflective discussions. When your child wants something, don’t simply say yes or no. Instead, ask “What/when/why/how…?” In this way, you’ll help your child give an opinion and reflect on her own wishes – the foundation for abstract thinking.  Do carry out these activities in peer, sibling, and small play groups. Children can debate each other or make funny pictures.  Don’t solve problems for your child; let her solve them herself. Your role is to help her brainstorm or to offer any needed encouragement.  Do create experiences involving quantity, time, and space concepts that engage your child’s strong feelings of the moment.  Do expose your child to a rich range of activities and encourage her natural interests and abilities. All these experiences will strengthen her ability to think abstractly.  Do enjoy stories, reading, puzzles, and other traditional activities as part of a vibrant back-and-forth discussion  Do enjoy helping your child use words to describe all the different feelings of life, from anger to closeness, Discuss feelings during both pretend play and reality-based conversations.

Games to help your child master Stage 6:

 The Director Game

See how many plot shifts or new story lines your child can initiate as the two of you lay make-believe games together. After the tea party play becomes a little repetitive or lacks direction, you can subtly DIR at LISCA | 23

challenge your child to thicken the plot by announcing something like “I’m so full of tea my tummy’s sloshing! What can we do next?”

 “Why Should I?” Game

When you child wants you to do things for her, gently tease her with a response of “Why should I?” and see how many reasons she can give you. Then, offer a compromise, such as “Let’s do it together,” when she wants you to get her riding toy out of the garage, or pick out a new outfit to wear, etc.

For older children, Dr. Greenspan added three additional levels.

Capacity 7: Multiple Perspectives – In this stage, children move beyond simple causes for reasoning and move to multi-causal thinking. (Maybe Alex doesn’t want to play with me because he doesn’t like me, or because he’s already playing with Breanna, or because he’s afraid I’ll break his tower.) This capacity allows the child to compare and contrast two things. Also, if one friend can’t play, he can ask another to play. To learn mufti- causal thinking, children must be able to invest emotion into more than one possibility. At this stage, children can understand family dynamics in terms of relationships among different people, rather than just in terms of whether they get their own needs met. The child or pre-adolescent is able to: • explore multiple reasons behind ideas • compare feelings • understand triadic interactions among feeling states (“I feel left out when Susie likes Janet better”). The child or pre-adolescent becomes more interested in how he or she fits into the larger world which now has much more meaning to him. Understanding the three person system the child becomes interested in all facets of their world: sex, death, where did I come from?, etc.. It is common for some children to experience fear and anxiety dealing with this.

CORE ACTION Multi-Causal Thinking • The child has a more sophisticated emotional problem solving capacity and can invest emotionally in more than one possibility • He or she can move beyond black and white thinking and demonstrate the ability to think of 3 or more possible solutions to the same problem • This flexible thinking allows the child to regulate mood and impulses Triangular Thinking • The child or pre-adolescent is able to find an indirect road to problem solve, (e.g.: John wants to be Sarah’s friend. He sees that Tom is Sarah’s friend, so John becomes Tom’s friend). This type of thinking is more expansive and even a little manipulative. He learns to “work the crowd” to satisfy his social needs. • Go to Mom if Dad says no because Dad is softer than Mom (the child can make comparisons) • The child is able to understand the dynamics of relationships beyond their immediate needs and desires

Levels of Functioning: • Initially the child was reacting purely from her perspective. She was not able to connect ideas logically and access the emotional context of the experience. • With scaffolding, she was able to think about other reasons/motives for the incident rather than just seeing it from her own perspective. • She was able to make emotional connections to the motives behind the interaction • She had the emerging ability to think about how this new understanding may support her emotional regulation in the future. DIR at LISCA | 24

Levels of Functioning: • The students were working at multiple levels at a time • Students were being challenged to come up with multiple reasons to support an idea • They were required to take another person's perspective

• Challenges in flexible thinking prohibited some students from creating a logical argument

Capacity 8: Gray Area Thinking – This kind of thinking enables children to begin understanding varying degrees or relative influence of things. This is important for school since children often must weigh factors and relative influences. This is also helpful with peers, as this kind of thinking offers new ways to solve problems and children can now compromise. Gray-area Thinking: The child or pre-adolescent moves beyond black and white thinking and is able to understand shades and gradations among differentiated feeling states (e.g., is able to describe degrees of feelings about anger, love, excitement, disappointment, for example, “I’m a little mad, very mad, etc.”) As the adolescent is able to see the “shades of gray” this allows them to be more flexible and more successful problem solvers. He or she can also see consequences of behavior. Comparative Thinking: He or she can make comparisons between objects, their feelings, events, character traits of self and others, etc. He or she also develops the capacity to rank people, situations and events in order of preference or importance, (e.g., “Jo is the best, I'm the second best, and John is the worst.”). With these new capacities the adolescent begins to know where they fall on the social ladder. He or she begins to define himself by how he is accepted by his peer group CORE ACTION Gray-area Thinking • The child or pre-adolescent expresses his or her emotions in degrees (how happy or sad they are: "forgetting my lunch makes me a little angry, being yelled at makes me very angry, being touched when I don’t want to be touched makes me furious") • He or she can determine the degrees that two people are similar or different, ("I am the same as Billy in that we both enjoy video games and dislike sports, but we are different in that he learns well by listening and I don’t") Comparative Thinking/Rank Order • The child or pre-adolescent an make comparison between things in degrees/rank order ("the most significant causes of wars in order are #1 land, #2 resources, and #3 religion") Social Hierarchy

• Can understand their relative standing in various social hierarchies ("I’m the best of the group at

Capacity 9: Reflective Thinking and an Internal Standard of Self - By puberty and early adolescence, more complex emotional interactions help children progress to thinking in relationship to an internal standard and a growing sense of self. Children can now judge experience and they can say things like “Boy, I was really mad – more than usual.” Or, they can look at a peer’s behavior and say, “That is OK for them, but not OK for me. ” Children can now make inferences and can think in more than one frame of reference at a time. They can create new ideas from existing ones, they can consider both the past and the future. This allows for a higher level of intelligence and more mature thinking.

He or she can reflect on feelings in a relationship to an internalized sense of self (“It’s not like me to feel so angry” or “I shouldn’t feel this jealous”). The teenager becomes self reflective and can evaluate his or her own ideas, actions, behavior and feelings/Judge their own experiences. He or she is able to see beyond the DIR at LISCA | 25 immediate situation and think in more than one frame of reference at a time. The teenager begins to internalize values and develops a greater sense of self that can’t be broken down by lack of acceptance by peer group, e.g., "Sally was mean to me because she was having a bad day, but I’m still a good person." The abilities at this level allow the teen to think about the past, consider the present and dream about the future

CORE ACTION • The teen can reflect upon their personal strengths and weaknesses ("It is really hard for me to spell and listen to directions but I’m great at helping the younger children and writing creative stories") • He or she can objectively evaluate their own performance and work, objectively summarize their work ("I feel that while I had lots of details and backed up my opinion, my overall presentation lacked three of the required components"). • The teen can establish and their own personal opinions on issues ("I feel that the war is sometimes just and necessary"). • The teen can differentiate between how they feel in the moment and their more stable character traits, feelings, etc. (e.g., "I was mean to Kathy today, but I'm not a bad person, I am just feeling bad because I failed my math quiz") • The teen can consider the past as a factor in the present ("I didn’t accept the extra help I really needed in writing last year and now it is causing me to feel I am behind my classmates").

• Has an ability to reflect on their own future ("I would like to have a career that allows me to spend time with my family as well as earn a good living")

After the ninth level is reached, people continue to develop throughout life. There are as many as seven more stages. Human development doesn’t stop, even for those on the autism spectrum. Those later stages include:

 An expanded sense of self that includes family and community relationships: *The ability to reflect on one’s future *A stable, separate sense of self (which allows young adults to remain secure when separating from their nuclear families) *Intimacy and commitment (including long-term commitments such as marriage, home ownership and a career) *Parenthood and other nurturing roles *Broadening perspectives on time, space, the life cycle and the larger world *A sense of responsibility to the environment and future generations, along with a sense of perspective on ones’ place in the grand scheme of things.

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Use the following chart to help you identify which milestones your child has mastered and which still need work.

Capacity 1: Self-Regulation and Always Sometimes Never Not Interest in the World under stress Shows interest in different sensations for 3+ seconds Remains calm and focused for 2+ minutes with your help Recovers from distress within 20 minutes Shows interest in you (i.e. not only in inanimate objects) Need to work more on the capacities of this level? Click here Capacity 2: Engaging & Relating Always Sometimes Never Not Under Stress Responds to your overtures (with a smile, frown, reach, vocalization, or other intentional behavior) Responds to your overtures with obvious pleasure Responds to your overtures with curiosity and assertive interest (e.g. by studying your face) Anticipates an object that was shown then removed (e.g. smiles or babbles to show interest) Becomes displeased when you are unresponsive during play Protests and grows angry when frustrated Recovers from distress with 15 minutes with your help Need to work more on the capacities of this level? Click Here Capacity 3: Purposeful Two-Way Always Sometimes Never Not Communication Under Stress Responds to your gestures with intentional gestures (e.g. reaches out in a response to your DIR at LISCA | 27

outstretched arms, returns your vocalizing or look) Initiates interactions with you (e.g. reaching for your nose or hair or for a toy, raises arms to be picked up) Demonstrate the following emotions:  Closeness (e.g. by hugging back when hugged, reaching out to be picked up)

 Pleasure & Excitement (e.g. by smiling joyfully while putting finger in your point or while taking a toy from your mouth and putting it in own)

 Assertive curiosity (e.g. by touching and exploring hair)

 Protest or anger (e.g. by pushing food off the table or screaming when desired toy not bought)

 Fear (e.g. by turning away, looking scared, or crying when a stranger approaches too quickly)

Recovers from distress within 10 minutes by being involved in social interactions Need to work more on the capacities of this level? Click Here Capacity 4: Complex Always Sometimes Never Not Communication & Shared Problem Under Solving Stress Closes 10 or more circles of communication in a row (e.g. takes you by the hand, walks you to the refrigerator, points, vocalizes, DIR at LISCA | 28

responds to your question with more noises and gestures, and continues gestural exchange until you open the door and get what he wants) Imitates your behavior in an intentional way (e.g. puts on Daddy's hat, then parades around the house waiting for admiration) Closes 10 or more circles using:  vocalizations or words

 facial expressions

 reciprocal touching or holding

 movement in space (e.g. rough-housing)

 large motor activity (e.g. chase games, climbing games)

 communication through space (e.g. can close 10 circles with you from across the room)

Closes 3 or more circles in a row while feeling the following emotions:  closeness (e.g. uses facial expressions, gestures, and vocalizations to reach out for a hug, kiss, or cuddle, or uses imitation such as talking on toy phone while you are on the real phone)

 pleasure and excitement (uses looks and vocalizations to invite DIR at LISCA | 29

another person to share excitement over something: shares "jokes" with other children or adults by laughing together at some provocation)

 assertive curiosity (explores independently; uses ability to communicate across space to feel close to you while exploring or playing on her own)

 fear (tells you how to be protective, e.g., says "No!" and runs behind you)

 anger (deliberately hits, pinches, yells, bangs, screams, or lies on the floor to demonstrate anger; occasionally uses cold or angry looks instead)

 limit setting (understands and responds to your limits whether expressed through words - "No, stop that!" - or gestures - shaking finger, angry face)

Uses imitation to deal with and recover from distress (e.g. bangs on floor and yells after being yelled at) Need to work more on the capacities of this level? Click Here Capacity 5: Using Symbols & Always Sometimes Never Not Creating Emotional Ideas Under Stress Creates pretend dramas with two or more ideas (e.g. trucks crash then pick up rocks, dolls hug then have a tea party). Child does not need to explain relationship between ideas DIR at LISCA | 30

Uses words, pictures, gestures to convey two or more ideas at a time (e.g. "No sleep..., play!").Child does not need to explain relationship between ideas Communicates wishes, intentions, and feelings using:  words

 multiple gestures in a row

 touch (e.g. lots of hugging or rough-housing)

Plays simple motor games with rules (e.g. taking turns throwing ball) Uses pretend play or words to communicate the following emotions while expressing two or more ideas:  pleasure and excitement (e.g. makes funny words then laughs)

 assertive curiosity (e.g. makes pretend airplane zoom around room, then says it's going to the moon)

 fear (e.g. stages drama in which doll is afraid of loud noises and then call for mother)

 anger (e.g. has soldiers shoot guns at one another then fall down)

 limit setting (e.g. has dolls follow rules at tea party) DIR at LISCA | 31

Uses pretend play to recover from and deal with distress (e.g. plays out eating the cookie she couldn't really have) Need to work more on the capacities of this level? Click Here Capacity 6: Logical Thinking and Building Bridges Between Ideas Always Sometimes Never Not Under Stress Bridges Ideas (Builds bridges between emotional ideas) Elaborates and can reflect on actions Aware of time and space Child invents things such as a new game Can play games with rules Reflects on his/her own feelings Asks and answers "Wh" questions (who, what , when , where, why, and how) Gives opinions and reasons for his/her feelings and actions Uses logic and abstract thinking Debates, negotiates, and expresses choices Holds a sustained sense of self and others Expresses a full range of emotional themes such as conflict, loneliness, aggression, frustration, and morality. Need to work more on the capacities of this level? Click here

**Not under Stress: Children sometimes do not show some of the above abilities when under stress (e.g. hunger, anger, fatigue). In these stress situations it is better to help them to self-regulate (capacity 1) before helping them to move up the developmental ladder (move into the next stages)

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GOALS:

1. Engagement: encourage, attention & intimacy 2. 2 way communication: create verbal/non verbal communication 3. Shared meaning: allow child to explain in symbolic (pretend) way 4. Emotional thinking: child connects ideas and feelings to the world.

STRENGTHEN DEVELOPMENT:

1. Motor 2. Sensory 3. Language 4. Cognitive

DESIRED GOAL BEHAVIOR

1. Alert and Aware: notice something is different discriminating visual, auditory and other sensory information recognizing that they are facing an obstacle identifying the problem, etc. 2. Taking Initiative: encourage to be less passive in environment do not allow process to proceed in more or less automatic way assist child to become more critical and ready to take action to help self it is critical to "wait" to give child chance to recognize problem and realize they must be ones to start doing something about it 3. Flexibility: create small changes and problems to help child notice, initiate and tolerate changes help child to learn to cope with by solving problems and taking in more information 4. Longer Sequencing: Have experiences which require taking as many steps as possible to solve the problem at hand and to communicate: who wants the problem solved what they want solved when they want it solved where they want it solved why they want it solved how it can be solved through actions, gestures and words 5. Problem Solving: guide child through the process of solving problems do not tell or show how to do a skill (e.g., Where should we look?, Did you check all the sides? Is there a tab? Let's try pulling. Does it work? Is it stuck? Do you need a tool?

STEPS: Five Steps in Floor Time 1. Observe 2. Open circle 3. Follow child’s lead 4. Extend and expand the play 5. Child closes the circle

Step One: OBSERVATION Both listening to and watching a child are essential for effective observation. Facial expressions, tone of voice, gestures, body posture, and word (or lack of words) are all important clues that help you determine how to approach the child, e.g.: is a child's behavior relaxed or outgoing? withdrawn or uncommunicative? bubbling with excitement? is child a real go-getter. DIR at LISCA | 33

Step Two: APPROACH - OPEN CIRCLES OF COMMUNICATION Once a child's mood and style have been assessed, you can approach the child with the appropriate words and gestures. You can open the circle of communication with a child by acknowledging the child's emotional tone, then elaborating and building on whatever interests the child at the moment.

Step Three: FOLLOW THE CHILD'S LEAD After your initial approach, following a child's lead simply means being a supportive play partner who is an "assistant" to the child and allows the child to set the tone, direct the action, and create personal dramas. This enhances the child's self-esteem and ability to be assertive, and gives child a feeling that "I can have an impact on the world." As you support the child's play, the child benefits from experiencing a sense of warmth, connectedness and being understood.

Step Four: EXTEND AND EXPAND PLAY As you follow the child's lead, extending and expanding a child's play themes involves making supportive comments about the child's play without being intrusive. This helps the child express own ideas and defines the direction of the drama. Next, asking questions to stimulate creative thinking can keep the drama going, while helping the child clarify the emotional themes involved, e.g.: suppose a child is crashing a car: Rather than ask critically, Why are those cars crashing? You may respond empathetically, Those cars have so much energy and are moving fast. Are they trying to get somewhere?

Step Five: CHILD CLOSES THE CIRCLE OF COMMUNICATION As you open the circle of communication when you approach the child, the child closes the circle when the child builds on your comments and gestures with comments and gestures of own. One circle flows into another, and many circles may be opened and closed in quick succession as you interact with the child. By building on each other's ideas and gestures, the child begins to appreciate and understand the value of two way communication.

BEHAVIORS

1. Mimic child rhythm 2. Get into his themes 3. Observe child 4. Respect child 5. Empathy for child’s feelings 6. Understand his needs

Strategies for Floor Time Intervention

Follow child's lead and join them - it does not matter what they do as long as they initiate the move persist in your pursuit treat what child does as intentional and purposeful - give new meanings help child do what they want to do position self in front of the child invest in whatever child initiates or imitates join perseverative play 4 do not treat avoidance or "no"as rejection expand, expand, expand - keep going, play dumb, do wrong moves, do as told, interfere etc. do not interrupt or change the subject as long as it is interactive insist on a response do not turn the session into a learning or teaching experience.

Opening the Symbolic Door get engaged at any level get intentional - build on any intent, problem solving, corner or undoing heighten affect - at every level, all emotions are equal 10. Follow the Child's Lead have symbolic toys available recognize and create opportunities cue or model symbolic actions be meaningful make it easy persist through - affect cues - affect pacing-wait/speed up personalize be a player - join in expand and keep going do not change the subject 11. Creating and Expanding Ideas treat object or action as an idea! you do not need permission to play do not "read" or just describe talk to child in role - as actor or with figure take on a role DIR at LISCA | 34 and talk through the role build on real experiences - bridge to what would happen next wait for child to make the next move - then give choices or model next step resist the temptation to take over "Appreciate" child's need for control try to build bridges between ideas give reasons for your or child's actions problem solve and assist in the finding of a solution make ideas more complex and more elaborate

QUESTIONS:

1. Who 2. What 3. Where 4. When 5. Why 6. How

Questions to Ask Yourself if You Are a Good Floor Timer

Do I use a calm voice? Do I give gentle looks? Is my body posture supportive? Arm my actions non-intrusive? Do I use encouraging gestures? Do I demonstrate calm and supportive listening? Am I aware of the child's rhythms and gestures? Am I able to help the child identify play themes? Do I expand and extend the child's drama by staying involved with the play theme and help to elaborate the details? Am I able to help the child extend the drama by summarizing main ideas of play themes? Do I observe the behavior, language, and gestures of the child? Do I observe the child's style of relating? Do I approach the child slowly, with respect and thoughtfulness? How often do I allow the child to take the lead? Do I follow that lead? Do I let the child know through gesture, facial expressions, emotional tone, and supportive body posture that I am there for the child? Do I know when to be verbally responsive, and when it is better to quietly share a child's emotion? Do I work to understand the emotional needs of the child?

PLAY DUMB:

CONSTRUCTIVE OBSTRUCTION to Extend Problem Solving:

The child will be surprised, amused or frustrated when faced with the changes and obstacles you create for them. Approach child with a supportive attitude, sharing surprise, Oh no what happened?, What's the matter? Help child solve the problem, but wait for child to recognize the problem first and then encourage the process. 7 Stretch the problem as long as possible by playing dumb Offering wrong solutions so child can check out several alternatives Asking questions and opinions about what they want, etc. Remember: goal is not to frustrate child but to mobilize child's thinking and acting in face of something which matters personally to the child.

DIR=

 D=Developmental Capacities:

This is critical point. Here we plan to see where the child fits in one of the 6 developmental level.

 I= Individualized Processing Differences (affect diathesis model): DIR at LISCA | 35

The ‘I’ describes the unique biologically based ways each child takes in, regulates, responds to, and comprehends senstions. sound, touch and the planning and sequencing of actions or ideas are areas where ‘I’ can be observed. Hyper responsive or under reactive to touch or sound, seek or avoid environment richness.

 R=Relationship Based: . it is affect based interaction depending on child’s ‘I’ and ‘D’. The relationships enable progress in the child’s overall functional and emotional development.

Learning relation with people with whom interaction is done

In autism child should learn:

1. Relating to others 2. Communicating 3. Achieving developmental milestones 4. Respecting child’s individual needs and challenges 5. Building relationship with caregivers

TECNHIQUES:

1. Joint Attention Triangle 2. Radical Lead Following 3. Radical Following of Interest and Intention 4. Radical Following of Developmental level of Play.

Technique: Developing and Maintaining the ‘Joint Attention Triangle’ In Floortime, we always want to be part of the child’s attention. We want to become an integral part of the child’s moment to moment reference point. Instead of the child just focusing on herself or on some action or object (one or two points of reference), we want three points of reference: the child, you, and some shared reference. We give you tips on what Joint Attention (JA) is and how it works, as well as how to facilitate your remaining a part of the child’s attention in other articles on this site. Getting and keeping a joint attention triangle going is challenging with children with disorders of relating and communicating (autism spectrum or attachment disorders). They can have difficulties with every level of perspective taking. Remediation involves increasing the individual’s ability to share attention, thinking, and experience with others. This is very different than a singular focus on teaching a child how to get their functional needs met. We can do both – but this is extremely important and is overlooked by interventions that are not developmentally informed. The full measure of joint attention is demonstrated by one partner’s awareness of another person’s attention, as demonstrated by taking active steps (joint attention bids) to manage the other person’s attention. In a “joint attention frame,” I would notice or think of something and want to share that with you. My attention is on what I notice or what I’m thinking about. I now want to share my attention with yours, and yours with mine. So I point it out to you in some way (I could point or gesture; I could say, “Hey look…” or “Listen to…” [In other articles, we talk about reference points and how reference points and attention can involve any of our senses, and even our ideas - not just what we see]). That wouldn’t be quite enough. I have to be sure that we’re sharing what I intend for us to share. So I check to see if you’re sharing: “Do you see that?” “Do you smell that garlic?” I would probably look at you (gaze monitoring), or, if we were on the phone or not looking at each other – there are other ways: Phone conversation… DIR at LISCA | 36

Me: “Do you know Joe from the hardware store?” Partner: “Joe with the red hair?” Me: “No, Joe with the gray hair. He’s very tall.” In that transaction, I took an extra step to insure that we were referring to the real shared reference – not red- haired Joe, but tall, gray-haired Joe. I might also check further by waiting or adding… Me: “Joe – the Manager.” Partner: “Oh yeah. Joe Jones.” Me: “Right, that’s him.” Now we have a completely and accurately shared reference. Sharing attention and building the foundations for the individual’s motivation to share their experience with the rest of us should be a major goal if not the major goal of intervention. This is a defining characteristic of relationship-based therapies. Other types of therapy may claim that relationships are important, but they have not studied or developed techniques to build the real foundations. Being warm and playful is good, but that doesn’t make a method “relationship- based.” Relationship-based methods focus on the foundations for intersubjectivity. It is easy to do intervention without focusing on intersubjectivity, joint attention or true reciprocity much at all. We can choose to focus on teaching a child to request things, or to speak in ever longer sentences, but if we are to make the person less autistic, we have to focus on the shared experience, and the capacities the child has and needs to be able to share their experience with others. The examples below give some idea of how to help someone share experiences with others more fully. Technique: Radical Lead Following In Floortime, following the child’s lead means much more than simply using materials or subject matter the child is interested in in order to tap into the child’s motivation. You seek to find the child’s current reference point and join in it assiduously. More accurately, this involves joining the child in pursuit of her intentions and facilitating her accomplishing them. This is in contrast with therapies such as Pivotal Response Therapy, or PRT, where the child-lead is a way of getting a child to make specific responses (e.g., utter vocabulary words; answer questions; imitate a response and/or other imperative demands). Having said that, there is a great deal of overlap between Floortime and Pivotal Response. Floortime, like other relationship-based therapies is a dynamical systems approach, where any type of response that continues the interaction is rewarded, whereas therapies in the behaviorist tradition of ABA are more likely to focus on getting the child to produce specific responses (e.g., to label something; to request an item). Back to Floortime. Good questions to ask at this point might be: How do I increase my child’s skills? How do I teach her to communicate better? How do I teach him self-help skills? There are a couple of basic answers to those questions. One is that you enter and then gradually expand the child’s current “system” (the system or frame that contains the child’s actions and intentions, and whatever objects or people that are also included). Once you successfully enter the system, you want the child to welcome you in, rather than to resist you or to withdraw. Therefore, you have to take a very calibrated step that will not destroy the system – but expand the system. Another thing that you might do is introduce a problem for the child to solve on the way to attaining her goals. You employ declarative techniques – comments, statements and observations, as well as actions that the child responds to, rather than getting them to follow directions, answer questions or respond in specific ways to a demand that you make (imperative techniques). You playfully get in the child’s way, or act as if you don’t know and therefore she has to find a way to get you to do something she wants, or you do something new that she might want to continue. If you are attuned to the child’s intentions and staying within her developmental capacities – the child tries very hard to keep you engaged and to solve problems with you. We’ll talk about what these “problems to solve” might look like in various ways and forms. DIR at LISCA | 37

Finally, because of the need to develop specific skills that are needed right away – especially communication skills, there is a variation of Floortime developed by the ICDL called “Applied Floortime” that is almost indistinguishable from PRT. (This just reiterates the point we make throughout this site and that is – it’s all ABA and eventually the autism wars will end and there will be more understanding and more rapprochement).

Technique: Radical Following of Interest and Intention You always have to follow the child’s true intention, at least at the early stages (later on you might challenge the child and engage in the kind of co-regulatory tension expected in typical interaction outside of Floortime). So if you pass a rose bush, you might think the most important thing is to talk about the color, the smell, the thorns or the other aspects of a rose that seem most relevant – to you. But as you pass the rose bush, your child starts playing with the sand and the leaves around the bush. You bend a rose over and you ask him to smell it – and he simply moves away and looks for more sand and leaves. You ask him to look at the rose. You exclaim about its beautiful red color. He doesn’t even look. Obviously, you and your child are operating in parallel universes. It is doubtful he’s giving you the quality of attention and engagement required for learning, what Greenspan called “optimal engagement.” Optimal engagement is powerful and you know it when you see it. There’s a gleam in the child’s eye and he is very responsive and full of initiation. You say to yourself, “The rose is not doing it.” So you get down there in the sand and the leaves. He’s picking up clumps of sand and pouring them through his fingers. You start to comment, “Ooh, sand, leaves…” No response. You still haven’t successfully become a part of the play. There’s no meaningful ‘back and forth.’ Your stuck (this is a normal feeling when you get started). If you continue to comment, you see that he not only doesn’t listen or respond, he might continue to backpedal and move away from you. You’re annoying him. Finally, you cup your hands underneath his, so that when the sand pours from between his fingers, it falls into your hands. He smiles. You do it again. You move to another position, but keep doing the same thing. He moves to follow you – he wants to continue this new expanded system that now includes you in it. You’re reciprocating – on a very basic level – but it is ongoing and dynamic. You add something more: you begin to take your sand and pour it into his hand. He squeals with delight. You keep doing it – moving around, letting him pour the sand into your hands and pouring the sand back into his. You notice that he’s now anticipating, by putting his hands out and waiting for you to do your part. Once you’ve built up some momentum, you introduce a change that will spark some attention to you. He pours the sand into yours and you just stop and wait. You say, “Uh oh!” He looks up at you – as if wondering – ‘what’s wrong, we had something good going?‘ You take that opportunity – where he’s looking at your face, to show excitement – and you throw the sand. Now he’s cracking up – he loves it. He brings you more sand. You throw it. He wants you to do this again and again. You’re now engaging in those long chains of warm, emotional interaction they talk so much about in DIR, and there’s that gleam in his eye. Now you scoop some sand and give it to him. You can see that he’s stuck for a minute. You can almost see the gears turning. He’s thinking. He’s still engaged, but he’s stuck. You gave him a problem to solve. He’s in a moment of uncertainty. He doesn’t quite know what to do. Then he throws it. He repaired the system. Now you can go on this way. You give him enough repetition so that each variation and reiteration of the system becomes comfortable before moving on. He trusts and likes you in a new way now. No one could ever join him in play the way he knows how. Everyone just tells him what to do, but he never feels like this. He’s never really wanted anyone – or more correctly, never experienced the unique joy that comes from sharing in this way. DIR at LISCA | 38

Technique: Radical Following of Developmental Level of Play Many readers may not know a child like this, or they may not see the real benefit behind it. How does this help him talk? He’s 4-years old already. Who’s going to play with him like this? Well, if you want to build one of the most important elements of social interaction – the desire to share an experience on a deep level with someone else – you will take the trouble. Steven Gutstein of RDI calls these the “why bother?” skills. Why bother? Because otherwise, you take the risk of creating only the most rotely expressed, uninterested, reluctant and prompted forms of interaction. You could still have success clowning and entertaining him, but he won’t be involved in any thinking or problem solving. Granted, some children on the spectrum start high, and they’ve mastered higher levels of relatedness. But they are always missing some elements from the lower stages that preclude them from developing abstract and flexible thinking and perspective-taking. They have trouble making inferences and drawing conclusions from different elements of a story. We don’t go back to pouring sand with these children, but we recover these skills in more age-appropriate and meaningful ways that fit the child we have. Once you build an intense desire to want to interact with others, you often see a ‘snowball’ effect. More desire brings more interactions. More interactions mean more variations, problems to solve, and more mental flexibility. You see desire and persistence in the face of problems, whereas before, you had stagnation, withdrawal and avoidance of people. Most importantly, you see a growing interest in others and more learning by watching others. This leads to a lot of learning outside of therapy. This is what Vygotsky referred to as acquiring the tools of learning, or what Robert and Lynn Koegel of Pivotal Response call “pivotal responses.” When working with a DIR professional – you talk about where you can take this – because the point is to elicit as much problem solving as you can in a session. This develops new skills, and you want to grow in complexity. Eventually, you will be able to spot opportunities to do this in the course of everyday routines – you’re no longer completely reliant upon taking time out of your schedule to do Floortime sessions. I realize that this is an example that many might not be able to relate to, because their child might be further along the developmental ladder – well beyond simple sensory play. So let’s introduce DINOSAUR-LEGO-POKEMAN KID!!! Most of us professionals have met him – several dozen times. He’s pretty smart. He can tell you everything you never wanted to know about his favorite subjects, yet he has little or no interest in anything anyone else is interested in. You can easily engage with him in conversations about his favorite subject(s). But despite his adequate verbal abilities and his probably above-average ability to remember facts, he still has real trouble truly relating to others, and as he gets older, he’s at risk for more punishing forms of social isolation, teasing and maybe bullying. Different methods have different ways of dealing with this. RDI would not want to feed this beast, so they would encourage more active engagement in the here-and-now of the current context; what the Guide or partner is doing, or what they could do together that is new and different. After all, a serious problem is that there is no real reciprocity going on. The kid isn’t really interested in your contributions,. It’s a one-way street. There are traditional ABA methods that would also ‘put this on extinction’ – in other words – stop encouraging it – stop responding to it. But here, we’re talking about how a Floortime partner might deal with this. A Floortime partner would use the same principles – joining, getting chains going, expanding the system and introducing problems to solve. So here’s the dialogue: DIR at LISCA | 39

Kid: “A T-Rex could probably crush a car in his mouth.” Apropos of nothing, he brings up his favorite subject. The Floortime partner takes the opportunity. FP: “You think so?” (This is a question, but it isn’t as imperative as other questions could be, like “What kind of car?” When on their favorite subjects though, verbal, less impacted kids can tolerate more imperatives – but you don’t want your half of the conversation being exclusively questions – that’s not really joining). Kid: “Yeah!” (He’s encouraged to keep going with the mild imperative – it didn’t throw him off as imperatives often do). “Even big cars.” FP: “Even giant animals!” Pivots on “bigness.” Joins and adds a variation, joins on the emotional level of excitement, but gently steers him towards the possibility of talking about things relevant today. Kid: “Yeah. He ate mostly other dinosaurs.” Back to dinosaurs. FP: “And people!” A problem – because people don’t factor into his encyclopedic conversation about dinosaurs and dinosaur movies. But it’s productive uncertainty because it isn’t that far out of his ‘box.’ Kid: “There were no people back then. Dinosaurs are animals, but there were no human beings. It was 65 million years ago, so there were no people then.” FP: “I think Dad was there.” Playful, still steering towards the here and now. Kid: “He’s not that old.” Note that we’re now talking about Dad. FP: “Dad’s only about 2 million years old.” Joking, playful productive uncertainty. Kid: [Laughs] “No he’s not! He’s like 60 or something.” (He’s 32). FP: “He’s older than me.” Joking, playful productive uncertainty. Kid: “No he’s not. You have gray hair and my Dad has black hair.” We have now bridged into a conversation about us. We’re fully in the here and now and there’s no more dinosaurs. This could launch aq new system – curiosity about people’s ages. This has the potential for being annoying for sure – but it is a focus on people – real people. FP: “Oh you know how to tell. I’ll bet you know how old everyone is.” This may seem daunting – for the Floortime partner to have so much skill exercised so flexibly. But if we remove the commentary, the conversation goes like this… Kid: “A T-Rex could probably crush a car in his mouth.” FP: “You think so? Kid: “Yeah!” FP: “Even giant animals!” Kid: “Yeah. He ate mostly other dinosaurs.” FP: “And people!” Kid: “There were no people back then. Dinosaurs are animals, but there were no human beings. It was 65 million years ago, so there were no people then.” FP: “I think Dad was there.” Kid: “He’s not that old.” FP: “Dad’s only about 2 million years old.” Kid: [Laughs] “No he’s not! He’s like 60 or something.” (He’s 32). DIR at LISCA | 40

FP: “He’s older than me.” Kid: “No he’s not. You have gray hair and my Dad has black hair.” FP: “Oh you know how to tell. I’ll bet you know how old everyone is.” We don’t need to go further with this example, but we’ve had so many conversations like this that we know that we can keep circles going for a very long time – all with very impressive levels of engagement, thinking, warmth and humor, puzzlement (productive uncertainty) and bridging from topic to topic. Also note in both of the examples above, that at first you follow the child’s klead, but before long – the lead exchanges more normally. You’re neither exclusively following or leading. The main point here is that you have to enter at the child’s level of interest, thinking, and capacity. Too far outside this zone and you will end up with the kid not wanting to continue talking to you (withdrawal), or a rigid responding, where everything you try to say or do snaps back to dinosaurs. That isn’t useful either.

WHAT IS A CIRCLE OF COMMUNICATION: It is a 2 way communication.

Opportunities for Doing Floor Time with Child To assist child to solve problems and handle changes identify opportunities in the child's daily life which present a "stage" for problem solving and change accepting "dramas" Brainstorm how you could utilize the following opportunities: all thing you routinely do for child all the things child expects or waits for you to do all the things child already expects to do for self all the things child desires or expects to have or go to daily challenges

1. Home Based Opportunities for Floor Time dressing and undressing: giving child choices about what to wear or not or what to take off first, is following the child's lead. mealtime: chose one meal a time with enough time - talk may focus around food preparation, different foods being served, which foods are particularly enjoyable or any topic relating to the child's life. car time: engage child in a relaxed conversation in which child takes the lead, or sing-along for which child chooses songs coming and going time: plan to have at least a little time to get child settled on arrival to a classroom or in switching and transitioning from one activity to another by reading a short story, visit pet in classroom or at home, or look at special toy in classroom or at home. Show child support through your interest and warm clear good-bye if leaving in classroom. On picking child up from classroom give the child a chance to tell you something important about the day while you are still in the school setting. bath time: Bath toys are wonderful props as they float, get dunked, and come into contact with each other. The water is a great opportunity for play. The child will naturally relax in the water. book time: Read the book with the child on your lap or next to you on a chair or bed. As you read, be aware of responses and questions that you can extend. (If the child is totally absorbed, however, it is best to continue reading and simply enjoy the sense of shared interest) bedtime: Bedtime is often accompanied by a ritual, but is also a moment to feel close and loving. Children sometimes share important thoughts and feelings during the last moments before falling asleep. Although you will not want to revup the child up prior to sleeping, you can respond with empathy and stay close until the child is calm and feels safe enough to sleep.

2. Turning Every Day Activity into Problem Solving for Child: chair not close to table, in the child's spot, when meal time arrives bottle not open when you are trying to pour juice bathtub empty of water when you tell child it is time to take a bath shoes hidden from usual resting place 8 changing the shelf locations of favorite books, DIR at LISCA | 41 tapes etc. putting two socks on same foot putting shirt on feet give child adult shoes instead of their own use rubber band to hold together a spoon and fork when giving child tool for eating being sure cup is upside down when offering child a drink put markers in a new container which child has not yet learned to open mix puzzle pieces of two or three puzzles together

3. Strategies for Engagement and Two-way Communication: Give child seemingly random actions new meanings by responding to them as if they were purposeful. Use sensory-motor play -- bouncing, tickling, swinging, and so on -- to elicit pleasure. Use sensory toys in cause-and-effect ways: hide a toy, then make it magically reappear; drop a belled toy so that child will hear the jingle; bring a tickle feather closer, closer, closer until finally you tickle child with it. Play infant games, such as peekaboo, I'm going to get you, and patty cake. Play verbal Ping Pong with child, responding to every sound or word the child makes and continue the ping pong match to expand the number of circles closed. Pursue pleasure over other behaviors and do not interrupt any pleasurable experience. Use gestures, tone of voice, and body language to accentuate the emotion in what you say and do. Try to be as accepting of child's anger and protests as you are of child's more positive emotions. Help child deal with anxiety (separation, getting hurt, aggression, loss, fear, and so on) by using gestures and problem solving.

4. Strategies for Helping Child Build Symbolic World: Identify real-life experiences child knows and enjoys and have toys and props available to play out those experiences Respond to child's real desires through pretend actions Allow child to discover what is real and what is a toy (e.g., if child tries to go down a toy slide, encourage child to go on; if child tries to put on doll's clothes, do not tell it doesn't fit; if child puts foot in pretend pool, ask if is cold) If child is thirsty, offer an empty cup or invite to tea party If child is hungry, open cardboard-box refrigerator and offer some food, pretend to cook, or ask if the child will got to the pretend market with you to get things. If child want to leave, give pretend keys or a toy car If child lies down on floor or couch, get a blanket or pillow, turn off the lights, and sing a lullaby Encourage role playing with dress-up props, use puppets - child may prefer to be the actor before using symbolic figures Use specific set of figures/dolls to represent family members and identify other figures with familiar names Give symbolic meaning to objects as you play:

When child climbs to top of the sofa, pretend child is climbing a tall mountain When child slides down the slide at the playground, pretend the child is sliding into the ocean and watch out for the fish Substitute one object for another when props are needed. Pretend that the ball is a cake or the spoon is a birthday candle. Resume use of gestures for props along with toy objects and substitutes As you play, help child elaborate on personal intentions. Ask who is driving the car, where the car is going, whether child has enough money, did child remember the keys to the car, why is child going there, why not somewhere else, etc. Expand as long as you can. (Use all of the Who, What, Where, Why, When questions, and keep them open ended) Make use of breakdowns. When a problem crops up during play, create symbolic solutions. Get the doctor kit when the doll falls so child can help the hurt doll, tool kit for broken car etc.

Acknowledge child's disappointment and encourage empathy. Get involved in the drama. Be a player and take on a role with your figure. Talk directly to the dolls rather than questioning child about what is happening or narrating Both help the child and be your own player. Talk as an ally (perhaps whispering), but also have your figure oppose or challenge child's ideas. Insert obstacles into the play. (e.g.: make your bus block the road. Then speaking as a character, challenge child to respond. If necessary, get increasingly urgent (whispering to child to encourage to deal with the problem, offer help if needed by becoming an ally). Use symbolic figures child knows and loves, such as Barney, Disney or Sesame Street characters, to generate symbolic play. Reenact familiar scenes or songs, create new ideas, and notice characters and themes child may be avoiding or fear. Use play to help child understand and master ideas/themes which may have been frightening. Work on fantasy and reality. DIR at LISCA | 42

Let child be the director. Child's play need not be realistic (child may still be a magical thinker) but encourage logical thinking. Focus on process as you play; which character to be, what props are needed when ideas have changed, what the problem is, when to end the idea, etc. Identify the beginning, middle and end. As you play, match your tone of voice to the situation. Pretend to cry when character is hurt, cheer loudly when your character is happy, speak in rough or spooky tones when you are playing the bad guy. Remember, drama, drama, drama to give child affect cues.

Reflect on the ideas and feelings in the story both while playing and later on as you would with other real life experiences, Discuss child's abstract themes such as good guy/bad guy, separation/loss, and various emotions such as closeness, fear, jealousy, anger, bossy, competition, etc. Remember symbolic play and conversation is the safe way to practice, reenact, understand and master the full range of emotional ideas and experiences.

5. Strategies to Develop Abstract Thinking: Follow child's lead, build on child's ideas Challenge child to create new ideas in pretend play Heighten affect and engagement Practice and expand rapid back and forth interactions and conversations (gesturally and verbally) Carry on logical conversations all the time (e.g.: while driving, at meals, during baths etc.) Content does not have to be realistic Encourage understanding of fantasy- reality: child will use toys as real objects for self as if real (e.g.: puts feet in play pool, tries to go down toy slide, tries on doll clothes, etc.) child may prefer to start with role play and puppets child will use toys in pretend fashion child will use symbolic solutions for problems and fears child will find safety to experiment with themes of aggression and power Recognize fears and avoidance of certain feelings, themes and characters. During play and conversations get beginning, middle and end of story or idea - identify problem to be solved, motives and feelings - accept all feelings and encourage empathy Select books to read that have themes, motives and problems to solve - discuss alternative outcomes, feelings Encourage abstract thinking: ask why questions ask for opinions compare and contrast different points of view reflect on feelings - come back to experiences again later don't ask questions you know the answer to don't tell child which dimensions to use Use visualization - picture yourself avoid rote, fragmented, academic questions Be creative if child puts foot in pretend pool, ask if it's cold. if child is thirsty, offer an empty cup if child lies down on the floor or couch, get a blanket or pillow, turn off the lights, and sing a lullaby. Encourage role playing with dress-up props, use puppets - child may prefer to be the actor before the child uses symbolic figures. Use a specific set of figures/dolls to represent family members and identify other figures with familiar names. Get involved in the drama. Be a player and take on a role with your own figure. Talk directly to the dolls rather than questioning child about what is happening or narrating.

6. Strategies to Develop Motor Planning Abilities Encourage "undoing" move object in line cover desired object put puzzle piece in wrong place bury desired object(s) under other toys and very different objects hide desired object from the place where child last put it etc. Provide destinations for actions - treat as intentional and symbolic child throws - catch it in basket child holds figure (little person, animal) -bring over toy slide, school bus, food (if child does not use spontaneously, ask if the figure would like to... give choices if needed...ask figure directly...try not to direct) child taps - bring over drums (can be plate, plastic toy, sticks etc) child rolls car - bring over garage, crash into it, block with figure child reaches for hand - play give me five, variations, dance Create problems to solve - require multiple steps put desired objects in boxes to open, untie, remove tape or rubber band pretend object needs to be fixed using tools, tape, rubber bands, Band-Aids (symbolic) create obstacles to child getting around or more or restore to correct position hold book to read upside down and/or backwards offer pens/markers which do not work sit in child's special place get to where the child is running first hide object child desires in one hand or the other so that the child can choose when child seeks your hand instead of using own hand, put your hands on your head or in your pocket put socks on child's hands instead of feet give child your shoes to put on make desired toy/object a moving target (move from place to place) Change DIR at LISCA | 43 environment frequently to encourage flexibility, create problems and expand discussion Be playful and supportive as you encourage and expand these interaction. move expected objects (change drawer content, change content in baskets) rearrange furniture and create problems (child find chair upside down, or is told to sit down when chair is across the room)

Hang up pictures from magazines at eye level and change frequently Encourage child to initiate/continue action Ready, set, Go! put toy which child was using back in child's hand. (Oh, you dropped, forgot) provide cues - uh oh, knock, knock, help use indirect prompts (call the figures to come, where are you?) bring over next step (puppet to eat pretend food, mirror to see the hat etc.) trade objects, positions etc. Deal with consequences of actions symbolically baby doll fall (is dropped) - Uh oh! He's crying. Are you hurt? Get a bandage. Go to the doctor. Call an ambulance... car crashes - Oh no, it's broken! Can you fix it mechanic? Plan your idea - discuss what child will need for their idea get toys/props child will need identify setting and destinations while playing identify problems and sequence of solutions identify beginning, middle and end challenge, reason, negotiate Play interactive song-hand games Itsy bitsy spider one potato two potato slap my hand sailor went to sea, sea, sea etc. Play Treasure Hunt and use maps (use visual and verbal cues) Play games social playground/party games board games (cognitively challenging) cooking drama arts and craft activities Encourage athletic activities individual sports e.g. tennis, roller skating, shooting baskets, ice skating etc group sports e.g. soccer, baseball, basketball etc gymnastics Tae Kwon Do

INDIVIDUAL DIFFERENCES

Motor plan analysis : Development is not automatic, is very uneven, and presents with core deficits in relating and communicating §It is a disorder of neural connectivity between different regions of the brain • Auditory Processing and Language: the way in which we receive information, comprehend it, and express it. • Motor Planning and Sequencing: how we act on our ideas or on what we hear and see. • Visual-Spatial Processing: the ability to make sense of and understand what we are seeing. • Sensory Modulation: the ability to modulate or regulate sensation as it is coming in.

At SCS, we have a strong emphasis on something called “motor planning.” A motor plan is the pathway from “ideation” (the formation of an intention or a response to stimuli) to “praxis” (Greek for “movement”). Motor planning is basically thinking and moving and involves the following elements in a Motor Plan Analysis:  A source of idea or intention (ideation)  Attention changes from one thing to another  This can be a novel, spontaneous or creative idea or intention  This can be a response to a stimulus inside the body (e.g., hunger, pain, restlessness, the desire to seek or continue a pleasurable state, etc.), or something that occurs outside the body – an event that the person notices  This can be a response to a stimulus that a person may or may not be aware of, but that somehow triggers an idea from memory  Attention focuses on the new stimulus or change in stimulus and sensory perceptual mechanisms tune in or prepare for input (tuning). If tuning does not prepare prior to the switching of attention, reflexive or unprepared or haphazard responding is probable, possibly even begun by a startle. This is why carefully monitoring your own speed is an important way of facilitating full benefit in any method DIR at LISCA | 44

you use.In ongoing, truly engaged interaction, where there are no overwhelming surprises, this can run quite smoothly. But this attention switch is very difficult to achieve when the person is doing something else that is not engaged with you.  Attention and Memory interchange. This is very technical, but the evidence shows that attention and memory are versions of the same thing. Memories aren’t stored anywhere. Memory is how attention reignites neural pathways that represent prior experience. Conscious awareness is the process of activating these circuits in the moment (current experience), whereas memory is the process of activating the same circuits at a later time. Very often, a cue in the environment activates a memory and turns into an idea that requires attention to the moment.  Perception (Input) and Movement (Output) happen simultaneously (the Perception/Action cycle) when the brain is working well and is “in sync.” They constantly update each other for smooth functioning:  Perception (this has to do with the process of initial uptake of sensory information to appraisal of the meaning of it). Here, we want to assess how the child:  Evidence of how he or she experiences the sensation or basic sensory awareness of the internal and external world. We may not be able to observe the brain’s function directly, but there are characteristic behaviors that demonstrate how a child compensates [or fails to compensate] for difficulties in input processing. We also are able to interpret the results of psychological and sensory testing better than others because of our depth in developmental and educational psychology.  Some children under-register sensory stimuli. They are less sensitive or impervious to sources of sensation that others would normally notice or feel. We can see their compensations as sensory-seeking behaviors. That is, they seek to intensify their experience by behaving in ways that increase their ability to feel or experience sensation.  Other children tend to “over-register” sensory information. They tend to engage in sensory avoiding behaviors such as covering their ears when they hear an intense sound.  Evidence of changes in arousal before and after changes in the environment or in ideation. Arousal has to do not only with the ability to sense and perceive information, but also to become interested and emotionally engaged enough to focus their attention on a stimulus.  Under-aroused children have trouble getting interested in the world and staying focused enough to learn. They form few reference points at all. They have a passive posture towards the world and can be apathetic. They can be daydreamers.  Over-aroused children can be disorganized and scattered and can ‘go too fast’ to really discover meaningful reference points. They can be impulsive and distractible, or  they can become hyperfocused and operate like ballistic missiles once they form an intention (trying to stop them or change their course can enrage them or further increase their rigidity).  Evidence of comprehension. Comprehension has to to do with how the mind makes meaningof the hundreds and thousands of data points surrounding the individual within and outside the body. Sensation doesn’t always lead to perception, and perception doesn’t always lead to conception or comprehension.A lizard feels something and reacts. That’s going from mere sensation to action. Perception is the awarenessof the source and type of sensation. It is a mental representation that can be remembered.Comprehension has to do with the ability to make meaning of patterns and regularities and change in the world. In this respect, we look at:  Whether the person is able to understand the meaning of spatial arrangementsof objects or people. Does the child comprehend that there is a line forming at the slide, or does he walk right up to the front? Can he tell from watching a basketball game who is on which side, DIR at LISCA | 45

even though they are constantly moving around? Can he tell from how close or far apart people are standing, or the postures they take – what the mood of the group is?  Whether the person is able to understand the meaning of sequences of events or actions and the like in order to form a “gestalt” (an appreciation that the whole is greater than the sum of its parts). The importance of gestalt thinking is too deep of a subject to go into fully here, but it is integral in understanding the difficulties with abstract thinking that many with learning and developmental disorders such as autism experience.This is especially true when it comes to behavioral gestalts. These have to do with how steps are tied together into a singular action melody. A child has to learn that the behavioral gestalt or action melody of “Mom getting me a drink” involves a series of steps. Mom doesn’t just produce the drink like a magician. She doesn’t even approach you at first. She first goes to the refrigerator, gets the pitcher, goes to the cabinet, gets a cup, pours, etc. All of these are connected into a singular behavior gestalt or behavior melody of “getting me a drink.”Understanding behavioral gestalts helps us understand other people’s intentions are – the directionality of their actions. And that makes us feel safer because we can see the orderliness and direction of the actions and plan our movements in anticipation. The ability to understand such patterns helps us see the regularities of the environment in what otherwise might seem chaotic. The difficulties with this are manifest in the lack of tracking (continuous monitoring and focusing on changes and progressions of actions) that we see in autistic disorders. We can readily observe the absence of tracking behaviors. An we can correlate, as has been done empirically many times, the the compensatory behaviors: resistance to change; insistence on a static and predictable world – a preference for sameness.  Attention: Attention is motor action seeking input. We can see a person’s eyes move as a sign of shifting attention. But every sensory apparatus moves or “tunes” in a physical way, usually involving some form of movement. The mechanisms inside the ear move like little radar dishes. The head and/or body turns; nostrils open; saliva readies for taste, etc. We look at the following aspects of attention that are necessary for motor planning and coninuous, smooth perception and action:  Attention release: this has to do with how smoothly and easily the individual releases their attention from the current focus.  Attention search: this has to do with scanning the environment for reference point, or the memory of relevant reference points  Attention focus: this has to do with finding, selecting and settling attention on reference points  Attention maintenance: this has to do with keeping the mind on the same reference point long enough  Attention following: this has to do with “tracking” and “monitoring” changes in reference points in order to find patterns, anticipate, and discover the directionality or intentions of other people’s behavior or the behavior of an object  Movement: This is fairly straightforward – or so it seems. Movement involves how the brain coordinates physical action and thought. We can see obvious overt signs of clumsiness and difficulties with coordinating physical action. In most cases of developmental disorder, there is some awkwardness or dyscoordination of movement. But this isn’t always obvious or always the case (it is rare though: almost all cases of developmental or attachment disorders, bipolar disorders and schizophrenia in children show concomitant dysfunctions of praxis). We judge the quality of movement by its flexibility and ability to adapt quickly to changes in input.  Movement is dependent on constant updating from perception. As we move through the world, our position in relevance to the things around us changes. This is how we avoid obstacles and adapt our movement as the position of our body changes vis-a-vis the objects we hold or DIR at LISCA | 46

encounter. We make adjustments as to the weight and feel of objects. We make adjustments to the movement patterns of objects. Movement should be a two way street.  Autism is a severe learning disability when it comes to the processing point of analysis. All learning disabilities involve some issues with the smooth coherence between different brain circuitry that control the multicomponent and multivariate aspects of perception, attention/memory, and movement at all levels.  Autism is considered the outward behavioral and developmental manifestation of an underlying disorder of central coherence. Connectivity between the interdependent circuitry of the mind is affected, causing bottlenecks in the flow of information. This results in the characteristic:  looping behaviors (repetitive and circular behaviors such as hand-flapping or pacing; looping of thoughts such as perseverative interests and difficulties getting their minds off of things);  interruptions in train of thought (getting lost in the middle of trying to carry out steps and forgetting what one was doing), or  the opposite, not being able to stop what one intends to do or to be able to change course in the face of changing circumstances (what we call a “ballistic motor plan“). This accounts with the so-called high co-incidence with OCD or Obsessive Compulsive Disorder. OCD involves an obsession or fear (e.g., of germs) that can only be assuaged temporarily with a specific repetitive behavior tied to it (e.g., washing hands). Personally, unless there is a clear and distinct difference fear (obsession) tied with the repetitive behaviors, I consider it to be looping and not OCD. But it is not our place to argue with a diagnosis from a competent Neurologist or Psychiatrist. We’re interventionists. We don’t really focus on diagnosis. We look at development and behavior independent of diagnosis.  Thought is movement without overt action. Thought is internalized movement. Whenever you think inside your head, your mental representations are almost always visual clips. Think of going to the grocery store. What do you “see” inside your head? You see yourself moving through the store, scanning the environment, doing things. You don’t just see a static picture, and, while you might hear language inside your head, the language merely narrates the image-ination going on inside your head. These are just some of the individual differences that DIR considers. Therapy would then focus on recruiting stronger channels and circuits to help repair or exercise weaker ones and help them learn. In our initial Functional Analysis of Behavior, we do a “motor plan analysis” where we look at behavior in terms of affect diathesis, taking it apart via the individual differences we can readily observe above. We look at the patterns of relating, communicating and problem solving, and how the individual goes about it. In traditional Functional Analysis of Behavior, we look at the consequences that behavior produces. But the consequence a behavior produces may not be intentional – it may not be the intention of the person behaving. Besides the consequences, we want to look at the very important antecedent conditions that involve individual differences in neurological processing.

TECHNIQUES:

1. Attunement 2. Scaffolding DIR at LISCA | 47

3. Slowing Down in communication and movement 4. Simplifying 5. Intensifying 6. Intensive responding 7. Language Technique: a. Focused vocabulary b. Abundant gestures and visual cueing c. Intensive Language Input d. Communicative temptations e. Sabotage, delay and interruptive techniques

8. Maintaining and improving responses

i) Shaping responses ii) Reinforcing responses : discrete trials

9. Set yourself up for success

I. Freedom to explore II. Eliminate the competition III. Electronics IV. Pepper the area V. Brother and sisters are capable players

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FLOORTIME TECHNIQUES ASSOCIATED WITH ‘R’ OR ‘DIR’

TECHNIQUES: Intention facilitation: Figure ‘how to fit in’ GOALS: 1. Going for the gleam in the eye 2. Evidence: Circles of interaction 3. Technique: Enticing instead of leading 4. Having fun without entertaining 5. Be playful: I. Challenge child II. Unintentional child III. What to do with wanderers IV. What to do with observers V. What to do with loopers VI. Expand the system VII. Switch objects=looping FOCUS ON AROUSAL: 1. Functioning Equivalent Sensory Replacement 2. Mutual Interaction 3. Declarative Action 4. Expanding the system

 THE RIGID INFLEXIBLE CHILD

 THE VISUAL TABLEAU CHILD =Tronick’s Mutual Regulation Model

 PROBLEM WITH PART TO WHOLE PERCEPTION o Baby Steps o Same Way Sadie o Social Stories o Video Modeling-dynamic Intelligence o Functional Scripting o Scripting as play THE AVOIDERS: Jane Goodall approach Setting Limits and dealing with Oppositional Behavior

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Technique: 1. Attunement Attunement is the process of trying to assess the subjective state of another person on a deep level. Babies and people with disorders of relating and communicating cannot share in an effective way what they feel or think. They have difficulty comprehending or appreciating what we feel or think. The Floortime partner is highly attuned. They constantly assess the child’s moment-to-moment intentions, feelings and actions. Granted, these are mental states and the process of attunement is fraught with error. But attunement, is what makes us human, and it is a characteristic of our genetic endowment to be able to learn how to do this. Furthermore, we learned because someone else was able to teach us. In other sections on this site, we refer to Tronick’s Mutual Regulation Model, and how the process moves from synchronous relating (when partners are in tune with each other and interaction flows smoothly), to the inevitable breakdown (there is some misunderstanding or disagreement were some new information that is not yet understood by one or both partners) and the all-important efforts to repair the system (what partners do to get back “in sync” and continue the interaction). Tronick’s Mutual Regulation Model sequence:  Synchronous relating  Inevitable breakdown (minor to major)  Repair All of which lead to increased…  Competence in relating and repairing, and subsequent…  Resilience From this perspective, “breakdown” is considered necessary for interaction to be dynamic, spontaneous, and interesting. In a Floortime interaction, naturally the Floortime partner is more capable and takes more responsibility for making the repairs of the breakdowns. However, breakdowns produce moments of uncertainty that are opportunities for learning. So it is better for the Floortime partner to assume only enough responsibility and to allow or even introduce therapeutic breakdowns so that there is this uncertainty, and the child has to “try things” in order to resolve the uncertainty. This promotes the child to look for relevant reference points into invent behaviors or call upon previously learned ones in order to resolve the uncertainty and bring the interaction back in sync. Tronick’s Mutual Regulation Model, which comes from the field of Infant Mental Health, has made an important and seminal contribution to our understanding of how we learn social skills. The role of the more capable Guide or Floortime partner then, is to make sure – by being attuned, that these moments of uncertainty are not overwhelming and remain “productive” in the sense that the child can resolve the uncertainty with reasonable effort. This is why it is so important to understand the child’s true capacities – developmentally, and from moment to moment. Attunement may seem inconsistent with the principles and philosophy of behaviorism and ABA. However, we make assessments based solely on patterns of overt behavior. That is the only way that anyone can do it – be attuned. 2. Scaffolding Scaffolding means supporting the individual in some form of Guided Participation teaching. The word was coined by a disciple of Lev Vygotsky named Jerome Bruner and is the developmental discipline’s version of behavioral techniques of modeling, shaping responses, prompting and fading. But there is an an important nuancal difference. DIR at LISCA | 50

Scaffolding bypasses a lot of time spent in developing readiness skills. for instance, there would be no point in teaching a child to sit at a table and learn the labels of “grass” “lawnmower” “handle” to learn how to mow a lawn. Instead, in a Guided Participation teaching frame the Guide and the individual would simply go out and mow the lawn. The Guide would assign appropriate roles to himself and to the Learner. Along with these roles come designated role actions that but Guide assigns. Naturally, the Guide would reserve the more complex role and role actions for himself and give portions of the task that are within the Learner’s current capability and zone of proximal development (that set of skills that the Learner can perform either with help or with more practice). As the Learner becomes more adept, the Guide “transfers responsibility” gradually to the Learner. The “help” that the Guide gives along the way changes dynamically along with the growth of the Learner’s skills. Guided Participation teaching is sometimes referred to as the, “Master/Apprentice Relationship.” All of the above comes from Vygotsky’s model of learning, which like Greenspan and Gutstein, emphasizes the social and emotional relationship between the or capable partner and the Learner. The term “scaffolding,” comes from the Vygotskian tradition, but it is equally applicable to Floortime. “Scaffolding” is an apt term, because just as the painter does not lower the building in order to paint the top of it, neither does the Guide or the Floortime partner lower the bar for learning. Instead, the painter builds a scaffold so that he can reach the top. When the top is painted, he lowers the scaffold so that he can move downward and finish painting the building. The analogy here is that the more capable partner provides support during a meaningful and context-based activity with an authentic product. There is no decontextualized teaching. There is no wasted time developing unrelated “readiness” skills. In the terms of the ABA, natural environment teaching uses scaffolding but they may use a different jargon. In a Guided Participation teaching approach, the initial phase may involve explicit modeling and teaching and gradual lowering of the scaffold, which in ABA terms would include strategies of “modeling;” “most-to-least prompting” and; “prompt fading.” Once the Learner begins to perform the skill, the Teacher would exercise a “least-to-most” prompting strategy – providing help only when needed and providing as little help as possible so that the Learner demonstrates maximal levels of independence. Now there are many differences that we can identify between techniques used in Guided Participation teaching or a traditional behaviorist teaching format – none of which I want to go into here. But there are a lot of essentials that are the same. In Floortime of course, we are following the child’s lead. The “meaning” and “authentic product” that we work with is the child’s intention. Nevertheless, the Floortime partner, being the more capable one, provides scaffolding in order to help the child achieve her intention. In addition, as in Guided Participation teaching, the Floortime partner provides a good deal of scaffolding so that the individual with deficits in communicating and relating can engage in reciprocity and put to use their full potential Functional Emotional Developmental capacities. The following is a compendium of scaffolding techniques that can be appropriate for use in Floortime: 3. Slowing Down The first technique involves giving the child plenty of time and space to respond. This is one form of slowing down. We always keep in mind the central coherence disorder that is the neurological deficit causing the autistic symptoms and the problems with motor planning, so we have to be slow in the way we pour in the “input” and patient in how we wait for the child to formulate a response (output). Now we have talked about the child that is perhaps chronically underaroused and subsequently needs the Floortime partner to quicken the pace in order to “energize up” the child, but this does not mean an absence of slowing down. In this particular case, slowing down would involve limiting the differences in the variations in the type of inputs we present to the child. We keep in mind that this type of child has difficulty forming systems and DIR at LISCA | 51 discovering patterns, so we simplify patterns so that he may join us, or more correctly, we turn what he does into something that we can do together. Apart from the above example, slowing down is more straightforward. Here we will give a non-exhaustive list of examples of slowing down that can be used in Floortime:  Slow down your communication. Slow down your speaking and provide more than adequate space between your words. We might take for granted that the typical infant has an innate ability to find within a string of syllables the beginnings and endings of words. But when we think of our experience listening to a language that we are not familiar with, we cannot do this. So especially in the case where the individual differences include auditory processing issues and language delays, speaking slowly and providing a lot of space between words becomes an especially important plank in the scaffold;  Over-articulate your words to emphasize the component phonemes. This is also an important plank in the scaffold that helps the Learner with auditory processing issues to more fully comprehend speech.  Slow down your movement. You want to move at a speed that maintains interest and fun, but you do not want to move so fast that the patterns of your movement become isolated from each other and the child cannot infer continuity between your actions (i.e., a behavioral gestalt). If you are moving all over the place, the child cannot detect a pattern and cannot anticipate your actions. Move deliberately.  Slow down your affective expression. The human face is a very complicated stimulus because it is almost always moving. If the Learner has difficulty understanding the different configurations of facial muscles involved in affective, emotional displays, then he will have even more difficulty if you are rapidly changing your expressions. You want to hold your expressions a little bit longer so that the Learner can appreciate them before moving on. 4. Simplifying Taking care of the individual differences of the Learner means relating at a proper level of complexity so that absorption and comprehension are maximized. You certainly don’t want to do too much too fast and overwhelm the Learner. Here is another non-exhaustive list of ways that you can reduce complexity:  Use controlled levels of structure and stimuli  Choice of Materials: The choice of materials that you leave in the play area will often determine where the child’s interest and attention goes. This is why “baiting” the area with toys you want him to explore is a good idea.  Limiting access to too many toys or distractions will help the child remain organized and focused and allow for more repetition.  Set up areas where certain types of activities take place (e.g., blocks; representative toys; sensory materials, etc.) and bins with similar types of materials in them. “Areas” carry with them certain expectations that help the Learner “shift mental set.” That is how our minds work to anticipate and prepare responses so that we can be more quick and flexible. Within each area, there are characteristic materials and expectations for behavior. The Learner experiences a lower level of anxiety because in a given area he or she can anticipate what will happen more easily. It is Less effective to use one part of the room to do everything. In clinical or classroom settings, it is not uncommon to use the same floor space for physical play, play with representational toys, play with construction type toys, art activities, eating, and everything else. This makes the Learner more dependent on prompting and can be confusing. Contrast this with the way a home works: people usually eat in a certain area, play in another, work in another, etc. (granted, these lines are often blurred in modern life – but neurotypical children don’t have the same kinds of problems shifting mental sets that children with system forming disorders have). DIR at LISCA | 52

 Use Bins as a source of controlled vocabulary and content. Bins really help you keep yourself and the child organized. Bins help with shifting mental sets because the bin provides for some homogeneity and boundaries for activities. Just as an area that contains certain types of materials and has a tradition of certain types of play and behaviors associated with it, a bin can provide some or a similar level of scaffold for categorization and pattern recognition. Also, when you load the bin, you know what’s in it and you know what vocabulary is possible. This will help you with data keeping.  Stay within the Learner’s zone of proximal development. This means controlling the level and type of variations that you introduce. You have to be very careful with us and learn to appreciate the child’s true intentions as described above. 5. Intensifying Individuals with autism have difficulty noticing and tracking what goes on around them. They can remain captured by their own actions and ideas and be somewhat or totally oblivious to what’s going on around them. Floortime is a method of getting into that world and enhancing and growing it. But you can hardly be effective if the child does not notice you. You want to become an important part of the play, not just a mere facilitator. A mere facilitator is like a coin-operated machine. While it may be useful to observe the child lining up trains and then become a part of the play by handing the child the next train – this is a beginning step. Before long, you want to take noticeable actions so that you challenge the child – you intentionally break the synchrony as in the Mutual Regulation Model, so that the child has to develop a new skill in order to repair the system. Here is an example: The child is currently engaging in a well-worn activity of lining up trains in exactly the same way. You sat and watched this for a while and learned the pattern. The next time, you get between the trains and the child and you become “the Giver.” This can be a very important demonstration to the child that you not only understand what he’s doing, but that you appreciated and you have no intention of taking over or taking it away from him. Granted, the play is monotonous and stagnant and you eventually seek to change that, but this is your starting point. Eventually you want to do something noticeable and to break the system. So perhaps you hand him the right train, and then another right train, and then another right train, and you keep going in this manner, and then you hand him the wrong train intentionally. You have an intense little moment here of uncertainty. You play dumb. Now the child has to work in order to get you to give him the right train. He wants to fix the system badly. You don’t allow the child to simply reach across you. To make it easier, you hold up the right train and the wrong train, but you keep them both out of reach. He reaches for the train that he wants, and you treat that as if he pointed to the train. In later iterations of this pattern, reaching can beget a prototypical point gesture, which can be get tapping, which can be get pointing and so on. 6. Intensive Responding Respond to Non-communicative Acts as if they are Communicative As in the example given above you respond to non-communicative acts (i.e. burps, sneezes, actions, etc.) as if they are communicative. In the example above the child attempt to reach was “shaped” into a more articulate pointing gesture.Some individuals that are functioning at Stage II or below (the child with the trains appears to be functioning at about this level), may not understand basic “contingency.” That is, they may have difficulty understanding the effect their behavior has on others and/or what others expect them to do when they direct an action towards them. Now the child with the trains in the example above may be able to function in many ways contingently in familiar situations where he has experienced them by rote and has learned what to do and what is expected. But his parents might tell you that when it comes to new situations, they almost always are difficult and they feel like they are starting from scratch.By responding to unintentional communication and using those behaviors to “shape” more intentional behavior, you are teaching contingency and setting the foundations for truly reciprocal “two-way communication.” DIR at LISCA | 53

Narrate and Comment, But be Careful Comment on things (“Bubbles!”) with limited vocabulary and repetition (below). This refers to the use of declarative language and declarative actions as a means of enticing the child to interact with you without pressuring her to perform specific responses. In other articles on this site, we talk about declarative forms of stimulating responding. What we will say here is that by slowing down and waiting for the moment when you have the child’s mindful attention, that may be a good time to associate a word with an object or an action. It is “intense” when the Floortime partner carefully waits for that moment and assiduously takes opportunities. This particular point needs more attention. Talking while your child is doing something can be distracting and even annoying and ultimately ineffective or counterproductive. There is no point in talking when your child is not listening. You want to wait for that moment when you really feel that your child can take in what you say. Verbose commentary is absolutely out of the question. Keep in mind that processing multiple streams of information is one of the secondary deficit of the central coherence disorder that causes autism. While on the one hand you want to be able to help your child form associations between words and objects and actions, on the other hand, you want to make sure that your child understands the connection. There is always this potential for “mis-mapping” your words to the wrong object or action, so you have to be careful. For instance, while observing your child drink juice, you can say “juice” or “drinking juice,” but the atypically developing language learner can easily misunderstand what you are referring to. As you say “juice,” the child may not understand whether you are referring to the liquid, the cup, the act of drinking, or the fact that you were sitting there talking. This is not a problem with typically developing children because they have developed a system for observing and figuring this all out. This is why they don’t go through a very long period where they confuse the words “I,” “You” and “Me.” Typically developing children learn most of the words that they know from overhearing conversations between other people and connecting that to the directions of people’s eyes, attention, and subsequent actions. Children with language delays and disorders of relating and communicating have not learned to learn this way, so there is great potential for confusion when you are sitting there narrating. Intensively share the child’s space Get down to the child’s level, physically and euphemistically. Get on the floor if that makes sense. In another article on, we talk about zones of “connection;” “efficacious intent;” and other references to the proper distance and proximity required to get consistent responding and ongoing circles of interaction. We talk about how the zones are dynamic (how they change according to the child’s interest and engagement from moment to moment and; how in one instance you may be too close and crowding and in another instance too far away and outside of the child’s field of attention). The space is right when you feel an intense sense of connectedness with the child. Adults turn children off by  Giving too many directions  Asking too many questions  Placing too much emphasis on responding, following directions, finishing, cleaning up, etc. In other words, too much emphasis on performance – or the child’s ability or willingness to please you. This is being too “imperative.”  Insisting that there is a right way of doing things. Now perhaps joining the child in chewing on the furniture is a little bit too “radical following of the child’s lead.” That could be turned into a game of “do it again,” where you dare the child to chew on the furniture [do it] again and each time he tries to do it you tickle him. This ends up with very little chewing on the furniture and a lot of reciprocal back and forth play.But there are a lot of things that children on the spectrum do that are odd or even inappropriate. The four- year-old who get pleasure out of dumping over the toy box is certainly in need of improvement, but you have to start there. Perhaps you can gather up the materials once she dumps them onto the floor and fill DIR at LISCA | 54

up the box with just a few things and then hand the box back to her so that she can dump it again. But then, you can take the empty box and pretend that it’s a hat. She might want to imitate that, and once she begins to use the box as an item of apparel, it now has more than one use and we have the very rudimentary foundations of abstract thinking. We can build quite a bit on this humble start.  Directing the child’s attention to what you think is important. You will often lose the child in the process and end up directing and correcting, which is what every conventional teacher does. Floortime, can be very useful when such approaches have not been effective or that have created a defensive and anxious child when around adults. We gave examples of that with the child and the rosebush and DINOSAUR- LEGO-POKEMAN KID above.

7. Language Techniques 1. Use a focused vocabulary (preferably a pivotal response – below) that is repeated very frequently. 2. Use abundant gestures and visual cueing. 3. Intensive Language Input 4. Communicative Temptations 5. Sabotage, Delay and Interruption techniques

8. Maintaining and Improving Responses Shaping Responses/Reinforcing Responses: The Discreet Trial in Floortime This is an interesting comparison. But as you can see in the examples we’ve given, Floortime interaction is a series of contingencies and contingent responses. Each one of them can be mapped out as a trial where one of the partners provides a stimulus or cue for the other partner, that partner responds with an action, and the partner that opened the circle (provided the stimulus) responds in a way that provides for another circle of interaction. Just like in an ABA discreet trial, there is a chance for failure and breakdown and corrective feedback. It’s done a little differently in floor time, but there are the same kinds of contingent responding that include the intensity and the basis in behavioral shaping that constitute the evidence basis for the use of the technique. As I have mentioned in other articles here, the evidence basis for a lot of the newer ABA packages do not come from full-blown randomized controlled trials, but from the use of very well tested techniques of behavioral shaping used in Floortime.

Know What Truly Reinforces a Behavior

The brain as a self-regulatory apparatus: Positive feelings are the true reinforcers – these are the experiences the brain in programmed to seek out and repeat. All of the techniques that we think are effective and evidence- based utilized some manner of associating stimuli that is already reinforcing with more enduring forms of motivation such as the feelings of satisfaction that come from mastering something (Tronick’s “resilience;” the feelings that come from finally understanding and knowing how to fit into a pattern that lead to feelings and desires for increased confidence and self-efficacy). Mastery is the reinforcer. If we can engineer environments and relationships so that we can arrange for mastery experiences associated with us, then the Learner will give us increasing license to introduce new things and new patterns and new experiences more frequently. We find that this type of therapeutic experience generalizes a lot faster than anything we might seek to produce by putting a child in the position to perform for artificial reinforcers. Further, children that form such rigid systems and that may be quite intelligent at the same time can be extremely perfectionistic as part of their profile of autism, so conventional “social reinforcers” can actually be counterproductive. Instead, it is better for the child to develop an ability to derive feelings of satisfaction based DIR at LISCA | 55 on self appraisal and not become dependent on the praise and appraisal of others in order to know whether or not something is good or to continue. 9. Set Yourself Up for Success You want to set up the environment so that you both can be successful. You want things available that are interesting but that are not isolating or difficult to share. Freedom from worry – freedom to explore The first thing you want to do is to set up a safe area that is somewhat constricted in terms of space. On the one hand, you want the child to be free to explore and to be able to touch anything – you don’t want to be saying, “No” very much. So it is not a very good idea to play around delicate things in your living room, audiovisual equipment and wires, sharp things, etc. This will help you be more relaxed as well. Too much space can be a problem, especially for the child that has difficulty forming intentions and wanders around a lot, or for the child that backpedals and avoids. If you are working in a very large space you might consider rearranging furniture so that you can set up barriers and make it smaller. These barriers can also be sources of fun, for instance, when the child tries to climb over the couch or under a table – you can join us and make chasing or tickling games out of it, and in the meantime you are slowing the child down and making it not quite so easy to escape the demands of relating. Eliminate the Competition One of the secrets in Floortime or Guided Participation teaching or any other relationship-based technique is for you to become the most interesting thing in the room. Ideally, your face should be the most interesting thing in the room from the most commonly referenced source of information. You want to keep in mind that there are certain objects and certain types of toys, that because of the individual differences a person might have, have not only become favorites or preferences, they have become almost exclusive sources of entertainment. Things like spinning wheels, electronic toys that can be managed simply with the push of a button, puzzles, etc., are simply too easy and can be extremely attractive and compete for your attention. Advice to control this competition may seem contradictory to advice to follow the child’s lead. We just know that there are certain types of toys and competition that interfere with any method that you might use it if you can get rid of them or do without them, you are probably better off.

Electronics: Electronics are notorious for being difficult to share. So in your Floortime area, you might want to get rid of hand-held video games, computers, or even push-button toys because there isn’t a whole lot that you can really do with them. Turn off the television. We put this little bit of advice in the “Individual Differences” section because people on the spectrum are particularly vulnerable to becoming “captured” by these types of toys or activities and they have even more difficulty sharing them. The more captured that they become, not only is it more difficult to share, it is more difficult to get them to make a transition away from the toy – so you’re better off without them.

Pepper the Area On the other hand, you want to cover the area with objects that you know your child finds interesting. This can be a tricky value judgment on your part. On the one hand, you might think that materials like sand or leaves or a piece of string that your child likes to twirl might be a bad idea because it has been so difficult to share that with her in the past. But then on the other hand, she might really appreciate you sharing this with her and by doing so, she can “feel felt,” that is, someone finally comes along and instead of taking it away from her and treating it DIR at LISCA | 56 as a stupid activity, her play partner becomes one of the first people to finally “get it.” We recommend that you use these objects, although they can be difficult to share. Construction materials (Legos, Blocks, Lincoln Logs, Tinker Toys, Magnetix, etc.) might also seem difficult to share, but they are among the best types of materials.The value judgment that you made here has to do with how static the goal of the play is. Nowadays, too many toys come in kits where there is only one way to complete the project. Back in the day for instance, like those used to come as a collection of assorted pieces that you can make anything with. Now it’s hard to find just the blocks – everything is part of a kit to make a “Star Wars” fighter or an aircraft carrier or whatever, and now, the intention comes not from the child’s imagination but from the picture on the box and the instructions. Such a toy can be useful at the earlier stages of DIR, when you simply seek to join an activity and you are not that worried about working on imagination. But when you are working on imagination you want to have neutral materials that can be used in dynamic ways. Then there is always the ubiquitous train set, in particular “Thomas the Tank Engine” and his friends. The “Thomas Stage” has almost become a stage of development, particularly for boys – lots of children really glom onto this toy. “Thomas” has become an industry of its own, replete with videos, movies, all kinds of connected characters, placemats, underwear, and I’m not kidding – Thomas the Tank chopsticks! For a child prone to develop excessive interests, Thomas can be a perfect fit and a ready supplier. All joking aside, Thomas is fine. If you are wondering why kids with autism seem to be particularly attracted to Thomas, you might want to look at one of his videos. Thomas’s face is pretty static – it changes once per scene. And the characters are pretty wooden – they don’t move very much. This eliminates a lot of the challenge of pattern discovery, motion tracking and other aspects of behavioral gestalt thinking that are so challenging for children on the spectrum. Some girls can be into dolls, but girls on the spectrum often play with dolls statically. That is, they dress the dolls which is like completing a puzzle. They tend to do it in the same way every time. Once the doll is complete, they are satisfied and they don’t do anything else with it. These too are fine. Neutral objects such as balls, Frisbees, or sports equipment that “pull” for interaction would be great – if only your child were interested in using them with someone else. If that is the case by all means put some of those in the area as well. There are books out there that can tell you how to set up a play room, but those lists work really well with neurotypical children or clinics that see a lot of different kinds of children. You don’t need all that. All you need is what you know your child is interested in and to try to keep out the stuff that just pushes you away like electronics. If your kid likes to twirl leaves, put leaves in the area. Remember, you put things out there that your child can easily find interesting and will give you a lead, not what you want your child to play with and that he won’t touch without you taking the lead. Brothers and Sisters and other more capable Players Sometimes that more capable brother or sister can be an asset, and sometimes they can be too dominant and interfere. Think about it – here you are giving your child exclusive attention and having a lot of fun, while your other more capable child is supposed to sit on the sidelines and understand why you’re doing this. Most of you out there will not need me to explain to you why this can be a problem. First of all, every child wants their own personal clown! Secondly, typically developing children always want to show you how good they are at things. If you are involved child has difficulty making a block tower, his brother or sister will want to show you how they can make one all the way to the ceiling. And they will talk, talk, talk, and be very busy and fast and possibly overwhelming to their brother or sister on the spectrum. DIR at LISCA | 57

Do we shun this child? Do we expect a three or four or five-year-old sibling to somehow understand why you can’t pay any attention to her right now? Good luck with that. There are a few things you can do depending on your situation. While it is hard to get a younger sibling to slow down in order to be comprehensible to your child on the spectrum, you can try by giving him or her some specific role to play. The role allows him to show you what they can do without barging in on your attempts to slow down for your impacted child. If you have help, especially from your spouse, that might make an excellent time for them to spend some “Special Time” with the siblings so that you can focus on a much more simple dyad. It is hard enough for a child who is just beginning to learn to relate and to discover the patterns of other people’s behavior in a slowed down and simplified dyadic interaction with a very attuned Floortime player. Siblings over the age of 18 months or so are remarkably complex if they are developing typically and they can be overwhelming to your child on the spectrum. You cannot expect them to sit on the sidelines for very long – they are going to want to join. You can give them privileges that they normally would not enjoy – such as extra time with electronics or videos, but you may be uncomfortable with doing that. Special Time can be just what the doctor ordered (see the article on “Special Time” and how to make that work really well).

10. Intention Facilitation Intention facilitation is a key technique, especially when establishing a new relationship with a child, or when dealing with a defensive or very sensitive child. A major Floortime mistake is to be overly intrusive and take over the intentionality of the interaction. The assumption here is that children that are fully prepared to co- regulate at age expected levels don’t really need an intensive intervention like DIR. Individuals with serious processing differences and challenges have difficulty with flexible adaptation to new information or change. They have difficulty forming motor plans and staying on them. They compensate for this difficulty by giving up easily and withdrawing, or reacting defensively and in a controlling way and trying to coerce the world into remaining the same or following along with the child’s own rigid motor plan. These children will need some kind of specialized intervention. Here we are talking about DIR, and the way to help them with Floortime. Intention Facilitation works like this:  The Floortime partner watches the child in action for a while, before attempting to do anything or to enter the child’s play. He or she will notice two broad types of individuals:  Individuals that have difficulty forming intentions in the first place. These children appear to be aimless and apathetic. They wander and they don’t really form any systems of interaction between themselves and objects or other people. They often engage in looped and repetitive behaviors focused on their own bodies, or very repetitive actions on objects that are characterized by an extreme lack of variation. These children often interact with objects in a purely sensory way – not really using them in the way the object is intended to to be used (e.g., shaking and banging a toy truck were putting it in her mouth or throwing it; repeatedly emptying drawers and spilling the contents on the floor; knocking things off shelves, etc.). Arnold Miller, developer of the systems based “Miller Method” refers to these children as having a “system-forming disorder.”  Individuals that tend to form closed systems. As Miller states, “… [they are] so preoccupied with one or more objects that they totally ignore people, and have difficulty with transitions. Left of themselves, such children may spend hours lining up blocks or twin animals were flushing toilets, or opening and closing doors. Some become very distressed of the usual way of going from one place to another is altered.” (Miller, 2007) At the lower or “more impacted” end of this spectrum, are the children that create the simple tableaux and that can become very disturbed by your efforts to introduce variation. At the upper and or “no less impacted” end of the spectrum, are those individuals DIR at LISCA | 58

that may be involved in many different kinds of systems including social ones, but that have difficulty incorporating new information coming from people. They may be able to have conversations – such as the “dinosaur kid” mentioned above, but they can go on and on without really “taking up” the perspectives and contributions and variations coming from others.  The Floortime partner then figures out how to fit in. With the aimless child that has a “system forming disorder,” the Floortime partner tries to turn the absence of the system into a system that the child can comprehend. A key part of this would be becoming part of that system and sharing reference points with the child. Specific techniques about dealing with this type of child are outlined below. With the more rigid type – the one that Arnold Miller might refer to as having a “closed system disorder,” the Floortime partner observes the tableau or the directionality of the child’s intention and seeks to be a useful helper at first. This is the only way that such a child might let you in. She will not let you in by simply taking over, making suggestions, or adding variations – sometimes even in the smallest degree. Specific techniques about dealing with this type of child are also outlined below.

11. Goal: “Going for the Gleam in the Eye” Stanley Greenspan talked a lot about the types of arousal that represent ‘optimal states for learning.’ He base this on findings from neuroscientific research and common sense if you will, that people focus more productive attention on things that they are interested in. When things are interesting to them, it is not hard for them to focus on them, and it is not hard for them to maintain their focus and persistence. It is also a neuroscientific fact, that the quality of the attention that comes from interest is most suited for learning. Contrast this with attention that is “coerced” by offering incentives or threats on objects or subjects that would normally be an interesting to the child. Unfortunately, the motivation for children to pay attention and to “demonstrate learning,” is to merely get adults to leave them alone. This is compounded by the offering of rewards that are enjoyed alone (e.g., the awarding of break time where the child spends it in solitary play, time on the computer, or worse, “time to stim.” If you have been lucky enough to have engaged a child in a highly intensive, emotional (hopefully joyful, but this may also include intensive negative feelings focused on you), you know that “gleam in the eye” when you see it. This type of interaction involves frequent incidences of “positive anticipation,” those moments where the child continues to focus on you as he or she waits excitedly for you to continue. A very easy example would be a tickle game, where the adult tickles the child and then pauses for a moment, and you can see that the child is strictly focused on the adult and excited about what is going to happen next. This is a very obvious moment of “positive anticipation.” Another obvious example might be when a child expects a surprise that the adult holds behind her back. You might see that the child squeals and jumps up and down and is completely and totally involved emotionally. Contrast this with other activities where the child seems to be merely complying and going through actions perfunctorily in order to obtain an unrelated reward. 12. Evidence: Circles of Interaction As mentioned many times throughout this article, DIR focuses on increasing the individual’s ability to engage in long chains of ongoing, continuously reciprocal, spontaneous and warm social interaction. Greenspan came up with a way of measuring this – not in simple terms of duration, but in the number and type and quality of back and forth actions, especially those on the part of the child. A “circle of interaction” is really more like a triangle. It starts with one member of the interaction “opening the circle” by engaging in an action intentionally directed at the social interaction partner. This action could be as simple as a gesture such as a look in that person’s direction, a smile directed at the person, handing the person something, saying something, etc. To qualify as an opening of the circle (or for that matter any aspect or part of a circle of interaction), the action must have some sort of communicative intent directed at the partner. We will DIR at LISCA | 59 talk about how to get that to happen with a technique of ‘responding to unintentional behaviors as if they were intentional communications.’ The next part of the circle involves the other partner responding to that opening with a congruent and equally intentional response. Here again, the response could consist of any of the forms mentioned above, more or less, with the qualification remaining that it has to be an intentional act related to the prior action of the partner. The circle is closed when the “opening partner” responds to the response. That is, the opening partner responds in a congruent way to the partner’s response to their opening response. One of the primary goals of the a Floortime session is to engage the child in interactions of as many consecutive circles as possible. A good metaphor for this would be a game of volleyball, where reciprocity represents continuous bouncing of the ball back and forth from one team to the other, where no one drops the ball. The experienced Floortimer learns from the dropped balls. They are inevitable. One reason for this inevitability is that it is human to experience breaks in interaction. But a more relevant reason is that we are dealing with individuals whose primary presentation and reason for referral has to do with their difficulty in engaging in ongoing spontaneous social interaction. 13. Technique: Enticing instead of Leading It is comparatively easy to tell a child what to say or do, or to rehearse “scripts” and responses that the child learns to emit given a certain cue. The problem with this is that in dynamic and spontaneous social interaction is almost impossible to anticipate every possible cue. Not only that, we’ve all had the experience of trying to rehearse a conversation to ourselves and to anticipate what our partner might say or do. We inevitably find out that within a minute or two, we are off the script and on our own. One of the distinguishing characteristics of good Floortime is the almost complete absence of the adult directing or prompting the child to do anything. The emphasis is almost completely on child volition. The Floortime partner is a very excepting person indeed. He or she is prepared to respond to almost any type of action the child might make. There are no incorrect responses. There are only responses to shape into reciprocal interaction. This could include joining a child that is engaged in totally self-focused actions that have no intentional communicative meaning for others. In many cases, the circular and repetitive behaviors don’t even really represent “play.” They may simply represent efforts on the part of the child to achieve or maintain some sort of neurological homeostasis. In some cases – perhaps many, such circular, repetitive or looped behaviors produce opiates and induce very pleasurable “trance-like” states. Any attempt on our part can represent a serious “buzz-kill” for the child. He or she does not want to stop. He or she is not in distress and is not stuck. He or she is having a really good time and does not need other people. It can be very difficult indeed to try to enter this sort of a system. One must use creative ways in order to enter such a system, but there are ways in Floortime technique that emanate from the principles of DIR, and some earlier research on the social induction effects of imitating the child’s behavior rather than the other way around. 14. Goal: Having Fun without Entertaining It can also be comparatively easy to entertain a child. Novice Floortime partners can be fooled to thinking that a ‘gleam in the child’s eye’ is leading to some form of learning. Here, we have a very strong connection to the “behavioral” aspect of ABA. That is, learning can only be demonstrated by an overt demonstration of a skill by the Learner. It is simply not enough for a child to enjoy watching you. It is not enough for the child to enjoy being a passive recipient of your actions. The child must be an active responder. As in ABA, Floortime works from a system of goals and objectives that operationally defined the behaviors that represent learning. ABA allows for the child or the Learner to demonstrate any number of behaviors that belong to a class of appropriate responses. There is no necessity to evoke a very specific response. What we are looking DIR at LISCA | 60 for is a congruent response that represents intentional behavior on the part of the child and that serves to facilitate continued interaction. The goals and objectives set forth by the Floortime partner will come from a DIR assessment and follow the conceptually systematic hierarchy or epistemology of the DIR method. This epistemology is based on thousands of studies that demonstrate typical courses of development and the need for foundational skills to be mastered before higher skills can be demonstrated convincingly. There is no provision in any ABA manifesto that the order noted in typical child development cannot serve as a curriculum basis – although in reality, many of the curricula that you see in practice in ABA does not appear to be informed by neurobiological development and neurotypical epistemology. 15. Technique: Be Playful This has become a given in almost all aspects of early intervention. We realize that a young child’s primary mode of learning is through play. Didactic forms of learning are not ethologically natural for our species, and this is especially true for children. Modern humanity has been around for at least 1500 centuries, where as didactic teaching has only been around for a few centuries. Schools and school settings such as classrooms teachers up in the front teaching and children sitting at their desks receiving instruction is very new on this timescale. It has proven effective in many ways, but there are perhaps more ways in which it is ineffective. If such a manner of teaching were effective for children with disorders of relating and communicating, we certainly wouldn’t be having this discussion. Play is one of the “developmental tasks” to master in childhood – to be elaborated upon further throughout the lifespan. In other words, we play throughout our life in one way or another and we continue to learn about play each time we do it. One of the best things you can do is to watch the child for a while and see how the child plays. There are several broad categories that are relevant: how the child plays alone with or without objects; how the child plays around people or with people; how the child handles boredom, and; what makes the child laugh or enjoy things? After all, you are looking for a “handle” that you can grab so that you can enter the child’s play in the joyful and reinforcing way. One of the bigger challenges is the child that doesn’t seem to really play. They may engage in wandering or jumping, but there doesn’t seem to be any point or any room for another person in the play. These children are obviously having difficulty forming systems, and the Floortime player would some how try to make a system out of apparently “system-less” play. In general, tickling, jumping, and sometimes run and chase games are available to young children and the “emotional young” child, but not every child likes to be touched. This type of “puppy like” play usually works with young children. Sometimes, the aimless wanderer can be gathered up in a game of “I’m gonna get you.” An excellent source of ideas for ways to be playful – even for the avoidant or disinterested wanderer can be found in a book called “Giggle Time” by Susan Aud Sonders, which we list in our bibliography. Another possibility is to try to engage the child in very simple games that you play with babies. These might be as simple as touching the child’s nose playfully and making a sound effect, playing pat-a-cake, or peekaboo. You can also turn unintentional behaviors into big, playful effects. If the child bumps into you can fall over playfully. She might turn around and want to do that again. If she is sitting on the couch, you can take her feet in your hands, and naturally she will push a little bit, in which case you can fall over backwards to make a big deal out of it. When she then raises her feet, you are now getting circles going. Floortime can be used in the context of ordinary routines where it doesn’t really seem to make sense that the child would be in the lead, such as when dressing or bathing or cleaning up. Playful surprise is a key technique that you can use here. For instance, as you are rolling up the sock and he’s putting out his foot, you can then put it on his hand. You can turn bath time into a game of peekaboo by getting down on the floor and pop in your head up over the rim, or, you can play games of “bombs away” by dropping different things into the tub. DIR at LISCA | 61

Questions that we are often asked have to do with whether or not a parent should always have to be playful; whether there is a danger in creating an expectation of playfulness and every routine, or; how will the child know when it is time to be serious? The answer has to do with making the changes in your behavior noticeable enough, for instance, your playful tone and your matter of fact tone should be able to show a clear changing of gear. But not every child is sensitive to that, and once lured into the pleasures of playing, children are wont to give it up. In such a case there are other options available. You can use what we call, “gear changers.” Popping in a short song (or singing a song), allowing a short video, serving a snack, and similar things can really settle a hyper-excited child down in a minute. Sometimes, the problem is the opposite – the child is two under-aroused and turns out to be a rather limp play partner. These children have difficulty waking up their nervous systems and need little bit of help. Sometimes they appreciate a little bit of deep massage first or some bouncing on a ball or a bed, or some tickling. This is what they call in Floortime, “energizing the child up.” The point we’re making here is that arousal has a lot to do with play – and so does trust. Challenge the Child It’s clear by now the floor time is not near play – it is a teaching technique. It is meant to foster development and it works according to clear goals and objectives for growth. Therefore it is necessary to provide challenges for the child during the Floortime play. Let’s go back for a moment and look at the basic problem – affect diathesis. The person has difficulty forming an intention and/or bringing the necessary perceptual, conceptual, social, emotional and physical skills to bear in order to accomplish it. For the child that has difficulty forming intentions in the first place, what Arnold Miller refers to as a “Systems Forming Disorder,” the challenge is to learn to form an intention. So let’s say that the child wanders around the room aimlessly moving from one corner to another or from one object to another without really doing anything with it, or engages in endlessly looping behaviors such as hand flapping or jumping. In such a case, you challenge the child by taking essentially what is unintentional and turning it into an intention. We go into this a little bit further below, but basically, you have to provide some sort of “playful obstruction.” In the spirit of treating unintentional behavior as if it were intentional, by getting in the way of someone who is pacing, they now have a problem to solve of getting around you or over you. In other words, they have to form an intention to get around you. We will repeat this particular caution many times: you want to do this in as playful a manner as possible and your goal is not to continuously frustrate the child or make yourself annoying. We are trying to attract rather than repel. The Unintentional Child The easiest child to work with is one who is alert and oriented to the present, and is able to focus his attention on something for at least a minute or two. However, child’s willingness to play, or her ability to engage in optimal play learning can be quite variable, especially if a lack of play skill is the main problem. Some kids wander aimlessly much of the time. They simply are not always interested in toys or people. Some kids can become interested if given something to do, or if invited or tempted by something interesting. And with some kids, their stage of play development is still infantile and largely self-stimulatory, and their wandering may simply be the only way they know how to explore their environment. Pacing and wandering maybe just ways to dissipate energy and pass the time. Others do it mainly when they feel stressed or bored. The first thing you have to do is to get the child to notice you. You have to do something that the child must form a response to. The point is that you are challenging the child to do something different. It is not within the scope of this article to tell you everything that you can do (we don’t even know and never will – the possibilities are endless), but in general they tend to include variations of: DIR at LISCA | 62

What to do with Wanderers  Use temptations (declarative actions with or without toys [e.g., funny noises; falling down; throwing a blanket over his head...] that usually spark interest) and seductions (e.g., singing a song, or doing something in front of the child that might draw him in such as blowing up a balloon).  Limit the playroom to only a few things that are likely to be very interesting. Don’t try to compete with toys or activities that promote aimless behavior (i.e. TV).  Use interruption techniques (last resort) such as putting obstacles in the way, “stop games,” piggyback rides, throwing a blanket over her and playing “peek-a-boo,” etc. These games can be frustrating and off- putting to a child, so be careful and sensitive.  “Playful obstruction” (e.g., if the child is crawling you get in his way and he crawls over you and you wrap them up in roll him over and then let him go; getting in front of her and gently guiding her through your legs and becoming a playful “spanking” machine… So what you are really doing is you are now turning the wandering into kind of a steeplechase);  “Hyper- or Intensive Responding” (as in the example of the child bumping into you and you fall over backwards; which introduces a contingency or a cause and effect into what was before behavior without much of a cause);  Turning wandering into a game of chase or ‘hide and seek’ (e.g., playfully “chasing” the child and turning it into a game of “I’m gonna get you” and tickling him or pulling him to the floor for a game of roly-poly when you catch him; getting in front of her and popping out from behind furniture – this could now create a level of vigilance which is a more active state of arousal and problem-solving than you had before, etc.);  Mutual Imitation: Some children respond to your imitating them. If he notices it, stops and looks for a moment, and then the next time he does it he looks at you, you are starting to see him do the behavior on purpose. Now the “intention” is to get you to imitate him, or at least observed the effect for his cause. In a lot of cases, you can then turn the tables and start adding variations that the child imitates. When that happens you really have the potential for a lot of circles of communication going back and forth.

What to do with Observers

Observers like to sit and watch. They’re either very shy, environmentally sensitive, or slow to warm up. They also may have difficulties with rapid motor planning and imitation.  “My Turn, Your Turn.” Do something interesting and very easy like bounce on a ball or knock a block tower over and then invite the child to do it by saying “My Turn” when you do it and then motioning for the child to come over and say, “Your Turn” and then, gently encouraging participation. If the child still shows reluctance, don’t push. Sometimes a child make take a long time to really process what she sees. There will be many times where you’ll do something one day and you won’t see the child try to imitate or participate, and then when the child is on her own time – you might see her doing it! This is especially true for children who have difficulty with motor processing. They have way more difficulty figuring out how to make their body move than you might think. So it can take up to a day for them to figure out how to “motor it out.” Sometimes, the neural integration can only occur during sleep.  Insert your face between the child and the object of interest. Work on gaze shifting and attention sharing by looking into the child’s eyes, then to the object, and back and forth. This is a matter of tightening up the “Joint Attention Triangle.”Most of the time, children are short and grown-ups are tall – in comparison. Grown-ups’ eyes are up here, and childrens’ eyes are down there. And people in general would rather look DIR at LISCA | 63

slightly downward than upward – which is why we experience eyestrain when we work at the computer for too long.So it is a good idea to position yourself in general slightly below the child’s eyes. You do this by getting on the floor or getting on a knee. This is true even and especially when the child is seated in a chair. The best position when a child is sitting in a chair is to be at a 45° angle and slightly below the child’s eyes. Maybe it is because Floortime players get down so low all the time (as do Preschool Teachers that know what they’re doing) that that is the reason it is called Floortime. Oh, as a matter of fact, that is the reason it is called Floortime.

What to do with “Loopers”

More than likely, a “loop” is just a very short motor plan that consists of one step that is repeated over and over. At around the age of eight months, as a child learns to “imitate herself,” so you see children repeating very simple actions on objects such as reaching and putting them in their mouths, and more relevant to the discussion here, shaking and banging objects. This often goes with the delightful behavior of pushing things off surfaces like highchairs and watching them fall to the floor, which they can do over and over with endless delight (beginning cause and effect). Some children on the spectrum do things like turn the light switch on and off over and over again or open and close doors repeatedly or they do some of the exact things that you see a nine-month-old babies do like bang a spoon the table. They often do the same thing with many different objects or all objects. These children are showing you the stage (Developmental) or cusp (Behaviorist) of exploration they are currently in. Let’s call it a “style” or a “means of exploration” that your child uses as primary. Whatever the explanation is, when the behavior seems to be a form of play, here are some things that you can do:

 Expand the System: Let’s say that the child turns the light on and off. This might be the progression that you introduce:Child turns on the light Child turns off the light Child turns on the light You hold your hand out for “high five” Child high-fives you Child turns off the light Do that several timesChild turns on the light Child high-fives you You turn around as if you’re doing the Hokey-Pokey and then hold out your hand for another high-five Child high-fives you You turn around again and then hold out your hand for another high-fives and you hope that this time the child can do the turning around part too And so forth and so on until the child forgets about the light and you are off doing other things  Switch Objects: Capitalize on the child’s means of exploration and delight in repeating a behavior by rotating the objects in which she does this.So what you can do is to fill a basket with the kinds of objects that you know he likes to shake and bang or spin or twirl or whatever, and as he gets ready to do it again give him another one of the objects. So you become kind of like a jukebox. You can add some excitement to this by working with the objects in a concealed container and revealing them ever so slowly to note that excitement and positive anticipation. This kid is going to want to continue doing Floortime with you because he knows that you know what’s really cool, and you’ve got a stuff. By slowing down and “milking it” to maximize that positive anticipation, you are no longer a coin-operated jukebox, but a fun human being.Keep doing this for a while, taking one really cool object out of the bag after another, and then take DIR at LISCA | 64

something out of the bag that you know he doesn’t want. At that moment you were creating this little moment of uncertainty where he is likely to look at you, and then you can in an exaggerated manner shake your head and say, “Nooooo.” Now cast it aside, and then motion as if you’re asking whether or not you should reach in the bag again. Wait for that “look,” of approval or anticipation and then keep going, randomly interspersing good and bad objects. This will keep his attention on both you and what comes out of the bag rather than just on the bag.

Looping as a Means of Inducing a Trance-like State

Looping behaviors can produce a very pleasurable state the child does not want to give up. In any case you want to become a part of this “system.” These children can actually produce a “trance-like” high by engaging in repetitive behavior. We know this because there have been studies that show that repetitive behaviors produce pleasant neurochemicals such as serotonin, dopamine and oxytocin; we see that people under extreme stress resort to primitive self soothing behaviors such as rocking back and forth, and; we also see that monks and other people that intentionally induce themselves into altered states of mind use repetitive chanting or thoughts. If this is your child, other people and even professionals will disagree on whether your child “needs to do it” or that “he needs to stop it.” The answer to that question can be different for every child, which is why we call it an individual difference. I would try to settle the question by asking us to agree that if we could somehow or another rewire the brain through teaching (all teaching and subsequent learning rewires the brain to one extent or another), we would want to help the individual “not need to do it;” to have something equally pleasurable and useful to replace it. In Floortime, we want the child to behave voluntarily. This might involve switching from the behavior to something else, or varying the behavior and varying it more and more until the original behavior is no longer recognizable. Because these repetitive behaviors often travel dopamine pathways, there is an addictive quality to them. They are hard to give up. They are pleasurable. Our intrusion into them can be experienced as an extreme “buzz kill,” or like asking the alcoholic to put down the bottle. If this is the case we want to tread carefully here – again, we want any behavior change to the volitional or voluntary. That motor plan has to be connected to an idea that comes from inside the child’s mind and not ours. Here are some things you can do:  Focus on Arousal: Since this appears to be an arousal issue, then it makes sense to focus on meeting her needs for arousal with an equally pleasurable type of interaction.  Functionally Equivalent Sensory Replacement: Look for things that you can do that belong to the same “sensory channel.” Most of the time these behaviors are in the proprioceptive channel. So encouraging activities such as climbing and jumping and bouncing on the other things can meet the same need.Also consider that children who have poor vestibular development can be preoccupied with behaviors directed at their own bodies such as jumping or patting their chest, so engaging them in movement, especially climbing where there are challenges such as in ladders and going under and over things can not only be therapeutic, but also the source of interaction by playing follow the leader. You want to include lots of belly crawling, somersaults, climbing up the slide and things like that as challenges to their vestibular and motor systems.  Massage: Deep pressure can be relaxing and stimulating at the same time, and this might almost be able to compete with the buzz they get from trance-inducing.  Mutual Imitation, as described above;  Declarative Actions, as described above. This may not work because it is really hard to compete with “getting high.” DIR at LISCA | 65

 Expanding the System, as described above.

The Rigid, Inflexible Child There are so many ways for a child to be inflexible that it would be impossible to cover them all here. But there are a few common types and we can give you some suggestions for them: The Visual Tableau Child This is the child of lines things up; it sets a very rigid visual tableaux of objects that if you try to move or alter them will spark rage or something just short of it. They will line up or place their objects in a very particular way and go on that way for months before you ever see any sort of variation, and if you do see variation, it has to be their idea. They can leave the room and if you move one of the objects ever so slightly, it will be the first thing that he notices when he walks back in and he will fix it. This is what Arnold Miller describes as the child with a “Closed-System Disorder.” In systems theory, a closed system resists new information entering the system. This is exactly what you have here. “Repair” to this child means returning the system to exactly the way it was, not something new (as the way “Repair” works in Tronick’s Mutual Regulation Model, which is all about “open” or dynamical systems).

Entering the Visual Tableau: When beginning to do floor time with this type of a child, the last thing you want to do is barge in and change a lot of things. In fact, you’re better off not really changing anything except who gives her the next piece. The silver lining in this is that regularity. What you do, is you sit by and watch the creation of this tableau and you make note of which order and which part goes next. Once you have the “assembly instructions” memorized, you can think about entering. First, you might have to wait until the child puts it away or takes a break, because you want the materials to be on your side behind you. If she can simply reach over and grab materials there is no need for you and you might as well not be there. So the first thing you do is you get between the materials and the child and her tableau. She’s going to think you’re pretty cool if you seem to know what goes next. This is the move least likely to upset her. Just as in the “switching objects” scheme described above, you go along with the regularity of the system, handing her the objects that she expects, and then eventually, perhaps after some trust has been built, you start playfully handing her the wrong ones. Now watch out! Don’t do this too soon. She would rather you not be there because she was doing just fine before you tried to enter her play. Take your time. You probably have seen additions to this tableau periodically, but it may be next to impossible to figure out how she decides what to add. Usually, she notices some other object lying around and takes an interest in it or she sees something on television or whatever and then she spontaneously just decides to add it. Problems with Parts-to-Whole Perception: It is key that you understand the individual difference(s) going on here. First of all, it is very likely that this child has difficulty discriminating parts from the whole. If you change one little part, then she may actually have trouble recognizing the whole. This is because her focus tends to be either too much on the individual parts without seeing the whole, or on the whole without seeing the parts. This child’s mind takes photographs that resist Photoshopping. She’s not going to let you switch anything or substitute one part for another, that simply won’t work.

“Baby Steps” is the key. Whatever you add should not be radically different, such as putting animals on top of the the trains or rearranging the dolls in different positions. You might try just adding something similar to the end. So if you have a line of trains you might consider adding another train at the end, or you you have a child that just dresses the doll in the same way, you might consider adding an accessory. DIR at LISCA | 66

This might seem like it would take forever to bring about any kind of change. But actually, what you are working on as a functional emotional developmental capacity is tolerance for change, and as you build up a track record of change, then more changes become easier and larger steps possible. Same-way Sadie Same-way Sadie has to do everything the same way every single time. Once she experiences something, it appears that she has an internal belief that it cannot change – so routines get set in concrete very quickly. If you go to a new store, then she is going to want to go the same way every single time. If you read her three stories, she is going to want you to read them in the same order in the same way every single time. Same-way Sadie has very much in common with the child described directly above, for the same reasons. She has difficulty with part-to-whole or “gestalt” thinking. One of the most important functions of the prefrontal cortex is to be able to hold things in memory buffers, sort of as a mental chalkboard, so that we can rearrange things inside our head before we have to actually do them. This skill helps us anticipate the consequences of making changes before we do them. This child has difficulty doing that and tends to use other parts of the brain that are better at memorizing for long-term memory – to function in the here and now. The problem with that is that the here and now is a dynamical system and long-term memory is somewhat of a closed system. They don’t match, so this child comes off as rigid when she tries to operate almost exclusively from long-term memory. In other words, if we take a trip to the store, on an emotional level, we understand that it is just a way to get there and that there are other ways that might even be better. The emotional part of this is that we accept that. But we have to be able to do the prefrontal thinking in order to get to that emotional stance. It is almost a chicken and egg thing. You have to have the prefrontal wiring, and you can’t get the prefrontal wiring without exposing yourself to change. This child needs change more than anything in the world, but it is likely that she has developed defensive behaviors or even aggressive behaviors to keep people from trying to change things on her. It is a vicious cycle. Baby steps is one way of dealing with this – small changes. But I think it’s important to point out here that this will cause some discomfort and that is okay. As long as you’re not trying to change every system at once. One thing to do, is to start out with systems that she doesn’t seem to be very emotionally invested in if you can find them. There may be some things that she actually doesn’t care all that much about and you can start by changing those regularly. And you progress towards changing systems where she cares more – in baby steps. Social Stories: Social Stories are short stories that you compose to help the child expect change. They are the ultimate in static thinking, but they can be useful as a bridge towards change – a temporary, but beneficial compensation if you will, but definitely not a tool that you want to use for all manner of changes that you might introduce. You don’t want to use any sort of visual schedule or visual support or Social Story as a primary means of learning to deal with change, because this merely reinforces the child’s worldview that the world has to match the picture. Sure, many people; many professionals will argue that with the use of visual supports you can change the parts by adding changes to the schedule regularly. That may be a useful trick, but it is still very static and it doesn’t really teach dynamic thinking. The world is a movie not a picture. The world is an ever-changing story, not a printed text. When you over rely on these static interventions, you teach the wrong reference points. The reference points should be the changes that are actually going on in the environment, which include how people feel from moment to moment. That is impossible to depict in a Social Story or any other form of artificial reference point. Ultimately we want to teach the child to switch attention, track and monitor, rather than consult prefixed instructions or schedules. With that caution in mind, you can go ahead and use Social Stories as temporary bridges. Video Modeling: This is a variation on the visual support theme, but with moving parts. You take video clips of behaviors or situations that you want the child to enter, and the changes they are to expect are depicted on the video. I have the same criticism of this, although it is better, because it is also pretty static in nature and does DIR at LISCA | 67 not teach real tools of dynamic thinking. It does however give the child more time to sit with the new situation and to have some control over it and to change his emotional threshold. But don’t confuse Social Stories and Video Modeling with learning how to cope with ongoing, spontaneous, long chain social interaction in a dynamical system. It is better to work in the here and now and to take baby steps and to go very slowly so that the child uses you as a reference point and later on, the rest of the objects in the outside world as reference points. A big problem with Social Stories and Video Modeling is that we are again bringing the dynamic world in a static form on a silver platter to a person that really needs to learn the tools of dynamic intelligence.

The “Scripter” Scripting can have different functions or uses for the child. The same child can use scripts for different reasons, and use just a few scripts for many reasons. Scripting shares a lot with visual tableaux. Scripting represents difficulties with part-to-whole thinking and flexible interchanging of the parts to make new wholes. We hardly ever say things the same way each time. That is because we use parts of our brain that specialize in recombining elements to perform novel actions and word combinations. When one uses, or over relies on long-term memory, what you get are chunks of memory that are not interchangeable and that are projected as indivisible wholes. Functional Scripting: This child uses a “best match” strategy to find something he has learned and committed to long term memory for the situation in the here and now. The scripts that he uses sound pretty close, but they are inflexible in that they are usually worded in exactly the same way every single time (they are not grammatically recursive as natural language), but they are pretty close to the context at hand. Functional Scripters want to have conversations, but they make errors and they sound repetitive because they rely on their long-term memory rather than on the parts of the brain that are meant to recombine smaller pieces. These are two distinctly different pathways in the brain, and what they need is more experience using the dynamic pathways. With Functional Scripters, you do a version of system expansion by adding to the script or recasting the script with slightly different words. It is very important that you do not shut these scripts down because this is all the child has to carry on a conversation and really wants to be included. When a parent shuts a child down by saying “No Movie talk,” she may be shutting down the child’s ability to contribute anything at all. This is what the child has, and if you shut it down you have nothing to build upon. If you shut it down and try to replace it with something unrelated or a brand-new sentence, it is going to go to long-term memory and it’s going to come back to you as another script. Simply compiling more scripts will not make the person any more fluid or any less autistic. Everything will still sound rote, taught, and well, scripted.

Scripting as Play: Notice that I do not use the term “self-stimulatory” in these articles. That is because we all stimulate ourselves through play and other things that we do alone, it is just the low rate of variance that gives it the term “self-stimulatory” in our field. If I read a book or listen to an opera I am self-stimulating. If I read the same book over and over or listen to the same opera over and over, some might label that as “self-stimulatory.” The repetitiveness makes it no less “self-stimulatory” than anything that I might do that has variation and novelty to it. Behaviorists have come up with a better term, perhaps for this reason and it is called “automatic reinforcement.” These are the things we do to make ourselves happy by ourselves. We would do them whether or not anyone else was with us – but most of us tend to do these things when we are by ourselves. When we do them in the presence of other people without seeming to acknowledge that fact, then it is a behavior that stigmatizes us and is in need of change. DIR at LISCA | 68

Some people like to utter things as a way of entertaining themselves. This has a different function but we don’t call it “functional scripting,” I guess because it has no real intention for communication. Speaking should have some intention for communication, even if it is just for ourselves (e.g., such as when we think aloud). When scripts are used as play, the person does not direct the speech at anyone else and is just as likely to do it when by himself as he is when around other people. So in this way the script resembles the visual tableau, and can be I think rightly referred to as and auditory tableau. Therefore, the intervention would be the same. You would take the same steps that you would when dealing with a visual tableau. That is, you would enter gently and start expanding the system using the language technique of recasting. I keep trying to link you to the article on recasting, because it is a very useful technique used by a lot of different language interventionists, and for our purposes here let’s just suffice to say that it is a way of expanding a verbal utterance. It is a means of systems expansion that you can use for both the Functional Scripter and the Scripter that uses scripts as personal entertainment.

The Avoider The Avoider avoids for a reason. Often this reason is because so much in the life of an individual with autism is misunderstood. What we may see as unusual or inappropriate behavior may be very important to the child nonetheless. It is interesting to note here that one of the fundamental contributions of Behavioral Science, is the Law of Determinism, which posits that all behavior happens for a reason. Just because we do not understand the reason at the moment, does not mean that it is purposeless or not adaptive. One of the most beautiful things about Floortime, is that it is unequaled in its ability to show a person respect. So much of what we do is intrusive. We look at that odd behavior and we seek to change it. We look at that visual tableau as malfunction in play, and we often discount it or try to take over. We recognize that fitting into the world means following other people’s lead and doing things that are consistent with what typical people do. Indeed, it is hard to argue with all of the above. Floortime is about change. But, Floortime looks at the behavior and tries to figure out what it means to the person. Floortime recognizes that what seems useless, “non-functional” or whatever pejorative we care to place on what this individual does – is this person’s way of being in the world. That line of trains, those spinning objects, that peculiar pattern of actions strung together in that odd way – well it just may make no bit of sense to us, but to that person it can be their Mona Lisa. In this way, the Floortime partner can establish the type of intimacy that the individual may never have experienced before. The key to dealing with a backpedaler is to be “attuned.” Attunement recognizes that change is necessary, but at the same time recognizes that individuals do not seek to be changed. It is so easy to dismiss the odd behaviors as unnecessary and to simply take over. Professionals may find it easy to just toss out the advice, “just throw out the dinosaurs.” Sometimes I wish I could empower the individual to counter, “OK, you go first. Throw out your wedding pictures and your license and the deed to your house, and then I will consider throwing out my dinosaurs!” On the other hand I think it is a gross misunderstanding of DIR to assume that stringent following of the child’s lead is anything but a place to start. Soon enough, regular challenge will be an integral part of the sessions. At the end of the session, both parties should be spent. The Floortime partner is exhausted from the intense level of attunement and responsiveness, and the individual will be exhausted from having to do so much thinking and problem solving to continue the fun. It is understandable that a child can be somewhat “fried” after a session and need some downtime. That is a sign of a good session. DIR at LISCA | 69

The Floortime partner shows attunement by backing off and being responsive to the child’s back off signals. But the Floortime partner doesn’t respond to failures and breakdowns by going away. The Floortime partner is persistent. The Floortime partner studies his mistakes and learns from them. Yes, breakdowns will occur – the child will abandon play or backpedal or complain or try to isolate – these are indeed signs of some type of failure. But this is no reason to go away. Friends don’t go away and neither do loved ones over simple failures. There is breakdown and repair. Sometimes it might take a while and sometimes it might be a struggle. The Jane Goodall Approach: You may recall the famous Primatologist, Jane Goodall. She is famous for being accepted into a band of wild chimpanzees and becoming a part of their family. A very crucial part of the story is that her initial efforts were seriously rebuffed. Even when she tried to offer them food, they reacted fearfully, hostilely, and sometimes with defensive and anxious aggression towards her. But she was very attuned. She responded exquisitely to their back off signals and they learned not to fear her. She had to sit and watch them almost motionless for almost a year before they made their initial approach toward her. She allow them to take the lead. She had to. Chimpanzees are so physically strong that they’re capable of tearing a human being apart. But they never hurt her. That is because she never pushed them too fast or too hard. But eventually, she had become so well accepted into the chimpanzee family that she was allowed to handle the infants and to assert herself quite a bit. They allowed her to take the lead just like any other member of the family. It can take quite a bit of confidence in the process for a professional who is being paid to take their time and to not start by trying to “hit the ground running.” It can take quite a bit of patience on the part of a parent to wait when they think about all of the developmental time that has already been lost. But pushing too hard will create more defensiveness, more anxiety, and more barriers to progress when Floortime is the right prescription for the child (as with any of the methodologies mentioned on this site – I do not maintain that any methodology or therapy is right for everyone). Floortime is often the best prescription for children that have tremendous anxiety around people or that have lost their trust in others. Once you make the decision to use Floortime because you think it is the best approach for this individual, then you have made the decision to be exquisitely attuned and to try to join that person on a very deep level. This means unconditional acceptance of their behavior – with the only exceptions being those behaviors that are injurious or otherwise harmful to the person or others or that are unnecessarily destructive (see below). Particularly important are the admonitions to slow down, to listen and watch extensively before you do anything; to be exquisitely attuned and responsive; to be playful without being intrusive; to use declarative actions without being unnecessarily distracting or expecting too much; to follow the child’s lead radically at first – all that goes double for the avoidant individual Setting Limits and Dealing with Oppositional Behavior  Gently contain aggressive behavior and try to calm and soothe the child first.  Show or tell the child you understand what she’s feeling or trying to say, or at least that you are trying to.  Once the child is calm, use problem-solving techniques (i.e. “What’s wrong?” Helping).  Biting or pinching or hitting – if the child’s intentions are playful in nature (i.e. to get attention or start an interaction), you should respond warmly. Make a game or a joke about it, and then model other games to take its place, such as a special greeting, or “High Five,” or use a dinosaur to bite back, etc.

Functional Developmental Evaluation

 Developmental history DIR at LISCA | 70

 Observation of family patterns  Biomedical assessment  Review of current functioning  Observations of child-caregiver interactions  Reviews and/or observation of educational program and peer interactions  Assessment of auditory processing and functional language skills  Assessment of motor and perceptual-motor functioning  Assessment of sensory modulation  Assessment of sensory processing

Tecnhique 1: Speaking to the child in ways that maximize communication

Adults are not always aware of a child’s true capacities for understanding their language, which can lead to conflict. Without knowing it, adults use words that refer to concepts the child does not yet have. This leads to miscommunication when children do not really grasp the concepts the way adults may think they do. Children act on the information in the way they understand it – if they understand it. This can lead to frustration on both sides. Adults may assume that children understand, but choose not to listen or to cooperate. And children may form expectations based on their immature understanding of what adults say. For example, adults often give instructions to children with references to:  When: Communicating about “when” is probably the most frequent source of confusion, especially since concepts related to time, sequence and duration emerge later in development. A little girl asks repeatedly to go to McDonalds. Her mother tells her, “Sure, honey. We’re going to McDonalds after we go buy some shoes.” Everything seems fine until they drive past a McDonalds and her daughter starts screaming. “We’re not going to McDonalds first. We’re buying shoes first, and after we buy shoes, then we go to McDonalds. Mom tries to be clear. She tries to give her daughter the information. But what her daughter seemed to hear was “McDonalds” and maybe “first.” All of that further explanation served only to aggravate her as she did not understand it, but was smart enough to know that it meant – No. Children may easily misunderstand references to…  time (“In a few minutes…” “In 5 minutes…” “In a minute“)  day (“Today” “Tonight” “tomorrow” “on Friday” “next Thursday” “in February“)  sequence (“first” “next,” “then” “before,” “after” “when we…”” after we…,”)  context dependent such as, “soon,” “later” or “in a while“  amount (more; less; one; one more; a lot; too much” big, bigger, biggest/small, smaller, smallest)  spatial/location (“over there” when the child has difficulty following pointing; prepositional terms; left/right, etc.  “Logic:” Adults understand the difference for instance, between “cookies orcake” and “cookies and cake.  “Perspective, Agreement/Disagreement” (He sees/hears/knows; Can Mommy be a daughter at the same time? Can Daddy like chocolate better than strawberry and Mommy like strawberry better. Which one is better?)  “Inclusion/Exclusion” (something “will” or “will not/won’t…” “does” or “does not/doesn’t” “can” or “cannot/can’t,” etc.) DIR at LISCA | 71

These are just a few examples. Children begin to understand language concepts related to what they can see and touch (things and actions). Their language reflects their thinking. Tests on young children show that they don’t use or understand these terms because they don’t have the mental concepts to understand them either. “Concrete thinking” refers to understanding only what one can see or experience, and usually relates to real objects and known actions and experiences. At the most concrete level, the child can only make specific associations between a word and an object or an action. The child may understand “bottle” to mean only his personal milk bottle, and recognize no connection between that and any other bottle. As children’s thinking matures, they draw more connections to form concepts and can understand references to categories (fruit; clothes), generalities instead of specifics (go to “the store” without any specific store in mind), and references to events that occur in other places or at other times. “Abstract thinking” requires “inferring” and hypothesizing and thinking about things that perhaps cannot be seen directly, such as concepts of “fairness” what is “good” or “better” etc. Our cautions against speaking over children’s developmental heads notwithstanding, we also note that there are lower levels of abstract thinking that many children can understand. So what we’ve done is to provide a developmental ladder from very concrete to what we call, “Lower Level Abstractions” that a given child may or may not understand. Matching a Child’s Developmental Language Level “Matching developmental language level” refers to a therapeutic manner of speaking to your child that is at a level [of abstraction]that he or she can actually understand. It also requires knowing the [next] level of language in which to teach (called the “zone of proximal development”). In general, this will consist of references to “labels” of things (tangible items), actions (observable events), and easily identifiable feelings (observable changes in facial expressions, body language and tone). Elements of matching developmental language:  Adults discriminate concrete [tangible] labels vs. concepts. Concretions: singular and tangible items such as a cup, TV, Mommy, banana. Concepts: things that have common attributes such as color, shape, function, class, etc, i.e. red things, big things, square [shaped things]; animals, etc. For instance, a banana is a concretion whereas fruit is a concept. A penny is a concretion whereas money is a concept.  Adults discriminate concretions and concepts from “Lower Level Abstractions” (i.e. good/bad, nighttime/daytime; directions such as up/down; prepositions, pronouns, etc.). For instance, a bed is a concretion, bedtime is a concept, and sleepy is a LLA. A bowl of cereal is a concretion, breakfast is a concept, and delicious is a LLA.

Technique 2: Rephrasing what the child says : Language Recasting or the Language Recast

You can use “Language Recasting” to increase and elaborate your child’s utterances. The way you respond in turn to your child’s utterances contains their words and ideas, but in a more correct form. Adult reflections – or recasts, echo the child’s intentions or sentiments in correct form, without having to correct the child overtly. This keeps the communication flowing, and instead of feeling corrected, the child continues to feel heard. This is how children learn to refine their grammar and learn multiple meanings for words – they hear more competent speakers say the same things – only better. The typical language learner somehow recognizes that the adult’s version is more correct, imitates it, and it then begins to use it in their own. As they begin to use it elsewhere, they are able to learn from the feedback they get whether or not their usage is correct. Studies that compared rates of language learning in groups of children whose parents recasted used language more frequently and initiated more often, as opposed to children whose parents used more overt or direct ways of teaching such as correcting or teaching specific language lessons or scripts. This was true for typical language learners, as well as those with autism and other disorders of communication. DIR at LISCA | 72

One of the best advantages of the language recasting technique is that no matter who the learner is, it doesn’t discourage or shame the child by pointing out “the problem” with her language. The adult’s emphasis remains on the child’s ideas. Repeating what the child says, albeit in more correct form, shows the child that her message is indeed important, no matter how she communicates it. When a child’s verbal expressions are too short, grammatically incorrect, incomplete or poorly articulated, instead of overtly correcting the statement (e.g., “Say it right;”) or telling the child that what they’re saying it wrong (“…that’s not how you say it – how do you say it?”), the adult rephrases withoutcorrecting. This is so the child can hear the correct form, without risking feeling ashamed or embarrassed about how they say things. The more a parent overtly criticizes the way a child says something – the more [well-meaning] corrective feedback and emphasis on form, the less motivating conversing will be for the child. Language recasting is a way of providing corrective feedback in a non-offensive way. Finally, it provides a more correct model for the child to imitate. Recasting is something that adults do for typical language learners – without being aware of it. Here are some examples: Child’s original utterance Adult recast Child imitates “Let’s go to the “…go to the “Go store” store” store” “I want to get “Want up” up” “…want get up” “I don’t want “…don’t want “No cereal.” cereal” cereal” “Mine” “That’s mine” “…dat’s mine” “Oh look – a “…look, kitty “Kitty cat” kitty cat.” cat.” Important Cautions on the Differences between Language Learners that understand “Points of View” and Those that Don’t Note how the adult uses phrases that use the child’s first-person perspective, as if the adult were speaking from inside the child’s body. This isn’t needed with typical language learners, but may be a necessary scaffold for children with expressive language disorders or full blown disorders or relating and communicating. Adults have to be cautious and aware that children that have disorders with both relating and communicating require careful modeling of perspective. Learners that do not yet know how to learn from overhearing other people talk to each other (called, eavesdropping) can be expected to have difficulty understanding the idea of changing voice-perspectives. The reason why children with autism often experience difficulty learning by eavesdropping” is that they simply do not observe, or do not know how to observe in that way in the first place, so they can’t follow the conversation well-enough to see the way the patterns are supposed to work. Think of what a remarkable phenomenon it is to master pronoun reversal in the English language (and most other languages). Imagine that an alien from another planet watches vide of a conversation between you and me. The alien might wonder because… I call myself, “Me.” You also call yourself. “Me.” (Do we both have the same name?) I call you, “You.” You also call me, “You.” (How can both of our names be “Me” and “You” at the same time? This is really getting confusing) Children that learn typically, actually learn this by observing others speak. This makes sense, because if the two parties above were trying to figure it out simply from talking to each other, the pattern would be very difficult indeed. This process is called a “deixis,” (another lesson – too involved to describe completely here). Suffice to say that in lieu of specific instruction in deixis and teaching children with ASD to learn by eavesdropping, we have to be careful to use recasts that they can imitate directly. For instance, when asked, “How are you doing?” it is not uncommon for language learners that don’t learn typically to respond incorrectly, “You’re fine.” DIR at LISCA | 73

Note that there are several techniques that have been developed to teach language pronoun deixis directly. They may involve clever devices such as the use of mirrors and handing objects between partners. But these are unnatural techniques compared to the logical way in which typical language learners acquire the pattern. To me, this reinforces the notion that teaching the child the correct points of reference is a better approach, as opposed to teaching with direct methods (teaching the child what to say or rules about what to say). Mirrors and transition objects can be successful methods of teaching correct pronoun use between two interfacing individuals, but they can run into serious limitations or distortions when used among multiple partners. Technique 3: HELPING Remember words : Intensive Language Input

This describes a therapeutic way of talking to your child that gives your child repeated experience hearing a word, before he or she is expected to use it. This technique is more natural and less restricting or impinging than massed trials, and therefore allows teaching to occur without your child becoming defensive or confused about how language is really used. We find this technique to be very effective in building vocabulary and basic grammatical development. Elements of ILL include:  Using words from a focused range of vocabulary or grammatical targets – instead of a rigidly established “vocabulary list.” For your child, this means intensifying the use and emphasis on concretions for now, then expanding to concepts and LLAs.  Repeating these words intensively but naturally– without prompting your child to respond. You may look at the child expectantly and include a pause, but do not pressure or request the child to respond. Responding will come, but perhaps not for several weeks. We ask that parents try to be patient, although it is natural for them to want to see immediate results.We have found this technique to be much more effective in facilitating truly spontaneous and “in-context” language than more direct methods. In most cases, we do advocate that this technique be used along with direct-teaching methods (response oriented), such as the incidental methods described below. For example: (The adult places a cookie in a conspicuous place, but still out of reach for the child [see “Sabotage” technique below]) “Oh I see a COOKIE. How about a COOKIE. Would you like a COOKIE? OK. Here’s a COOKIE (the adult breaks up the COOKIE into small pieces and gives the child one). Mmmm. That looks good. I like COOKIES too. Want more COOKIE? Here’s some more COOKIE. Wow, you really like that COOKIE. (Musically) COOKIE, COOKIE, COOKIE, COOKIE, COOKIE, COOKIE, COOKIE. I LOOOOVE COOKIES and you love COOKIES too. I think this is a chocolate COOKIE, or maybe an Oreo COOKIE. Want more COOKIE…?” 17 repetitions so far with 1 cookie, all while talking to your child naturally, and without losing his interest. This technique can be used whenever the adult is truly following his interest. Technique 4: making your words POP

In the above example, the adult should add a little more emphasis on “cookie” than the other words in the sentence. This can be done by slowing down and putting clear stress on the word, “over-articulating” (speaking slowly and enunciating with maximum clarity, sometimes called, “over-enunciating;” using visual cues [pointing to the mouth, tongue, throat, etc.]; using creative or dramatic pauses, singing the word or using it rhythmically, using various voices or inflections in a funny way, etc.). This is to avoid the use of telegraphic or “choppy” or “robotic” language to the child under the false belief that by removing the connecting words (articles and conjunctive words such as “it” “and” “the” etc.), that somehow you are lightening the process load (Fey, Long, & Finestack, 2003). You can shorten a sentence without really shortening it. Yes, perhaps the child can only process certain parts of a sentence. For example, it may be a while before the child understands the difference between “Open the door,” “Close the door” and “There is a door.” (Prizant, 1983) Instead of removing the DIR at LISCA | 74 words, you can remove the emphasis on the connectors and make the salient words pop out. Here are some examples: Do you want some juice? Here’s your juice. That’s an airplane Put it on the table.

TECHNIQUE 5: Incidental Engineered Opportunities

There are five kinds of incidental-engineered opportunities: incidental teaching (Halle, Alpert, & Anderson, Natural environment language assessment and intervention with serverely impaired preschoolers, 1984), the mand-model technique (Goetz & Sailor, New directions: Communication development in persons with severe disabilities., 1988), the delay procedure (Halle, Alpert, & Anderson, Natural environment language assessment and intervention with serverely impaired preschoolers, 1984), chain interruption (Goetz, Gee, & Sailor, Using a behavior chain interruption strategy to teach communication skills to students with severe disabilities, 1985), and the cloze procedure (Ingersoll & Dvortcsak, Including Parent Training in the Early Childhood Special Education Curriculum with Autism Spectrum Disorders, 2006). These can be used when teaching within natural routine tasks and other activities. Incidental Teaching Teaching becomes a matter of “‘making’ or ‘taking’ opportunities” for challenging, teaching and learning in the course of regular daily life. Here, a parent waits for or sets up a challenge to encourage a particular response. For example, a parent may encouraging more requesting by placing objects the child wants in plain sight, but out of reach. If the child speaks unclearly, or needs to work to discover a way to communicate in a given situation, the parent might “act dumb” by pretending to understand. This can encourage the child to try other ways to communicate, or it might provide an opportunity for modeling and imitation of a new way to communicate. Communicative Temptations “Communicative Temptations or “Communication Temptations” are examples of how, by tweaking routine activities in certain ways, the parent can harness a child’s natural (read: emotional) motivation to communicate, and avoid naked prompting of the child to speak. I believe the term was coined by Barry Prizant and Amy Weatherby, and various versions can be found all over the web. (The same techniques are also called “establishing operations” in Applied Behavior Analysis [ABA]. These make things [reinforcers] more desirable, making us want more than we now have. Here are a few examples:  Eat in front of the child without offering any to the child  Start a toy, let it deactivate, then hand it to the child  Give the four blocks to drop in a box, one at a time (or use some other action the child will repeat, such as stacking the blocks or dropping them on the floor); then immediately give the child a small animal figure to drop in the box  Look through a few books or magazines with the child  Open a jar of bubbles, blow bubbles, and then close the jar tightly and give the closed jar to the child  Initiate a familiar social game with the child until the child expresses pleasure, then stop the game suddenly and wait  Ready-Set-Go: Once the child becomes familiar with the game – leave out “Go” and let the child say it before continuing  Offer the child a food item or a toy that he or she dislikes  Place a desired item in a clear container and place it in front of the child, then wait  Place the child’s hands in a cold, wet, or sticky substance, such as Jell-O, pudding, or paste DIR at LISCA | 75

 Roll a ball to the child. After the child returns the ball 3 times, immediately roll a different toy to the child  Engage the child in putting together a puzzle. After the child has put in several pieces, offer him one that doesn’t fit  Engage the child in an activity with a substance that can be easily spilled (or dropped, broken, torn, etc.); suddenly spill some of the substance on the table and wait.  Put an object in an opaque container and shake the bag; hold up the container and wait. This can be used to teach the Pivotal Response of asking, “What’s that?  Give the child materials for an activity of interest that necessitates the use of an instrument for completion (e.g. a piece of paper to draw on or cut; a bowl of pudding or soup); hold the instrument out of the child’s reach  Give the child materials for an activity of interest that necessitates the use of an instrument for completion (e.g. crayon, scissors, wand for blowing bubbles, spoon); have a third person come over and take the instrument, go sit on a distant side of the room while holding the instrument within the child’s sight, then wait.  Wave and say, “Bye” to an object before removing it from the play area (or placing it back in a box). Repeat this for a second and third situation, then do nothing for the fourth object and wait  Hide a stuffed animal under the table. Knock, then bring out the animal. Have the animal greet the child the first time. Repeat this for second and third time, then do nothing when bringing out the animal a fourth time. The Mand-model Technique Here, a parent inserts a request into a child’s ongoing activity, and then prompts and/or reinforces the child’s response (Goetz and Sailor 1988). For example, while a child is playing with toy cars, his mother asks what he is doing, or asks your child to show her a red car. This, brings the child into contact with possibly unnoticed events, and helps your child generalize into the play setting behaviors he acquired elsewhere (e.g., color naming and the question-answer format). In contrast to incidental teaching, the mand-model technique involves more initiation by a parent. The Delay/Sabotage Procedure In a delay or sabotage procedure, a parent identifies spots in a task or interaction where a child could make a request (Halle, Baer, and Spradlin 1981). The parent participates in the interaction as usual, but at the pre- selected spot interrupts the flow for a few seconds, and waits for the child’s request. If a request is not forthcoming, the parent models one. For instance, the parent gets the juice from the refrigerator, approaches the table, looks expectantly at the child, but waits. Your child is expecting the parent to pour the juice, but there is now a “pregnant pause” which creates therapeutic tension. Here the parent can simply wait for the child to speak up, or use a mand as described above.  Chain Interruption: In chain interruption, a parent interrupts the child engaged in a sequence, and makes a request requiring the child to insert another behavior into the sequence, thus enriching it (Hunt and Goetz 1988). This is very similar if not the same in many instances as a Delay. The difference is that your child must direct a parent action.For instance, while your child is watching a video, the parent can stand in front of your child, blocking his view. Naturally, the child becomes a little (“therapeutically” of course) – upset. Playing dumb and using the ILL technique, the parent wonders aloud, “Do you want me to MOVE? MOVE? You want me to MOVE? OK. I’ll MOVE.”Of course, this blockhead parent never learns and does it again 5 minutes later.This time she uses the mand technique “Do you want me to MOVE? MOVE? You want me to MOVE? OK. [Say] MOVE MOMMY.” The child echoes, “MOVE MOMMY.” Mom says, “OK, I’ll MOVE.” DIR at LISCA | 76

 Cloze Procedure:This can be thought of a “fill in the blank” type procedure. It is primarily used to teach vocabulary. Using phrases he has heard over and over, the adult says the sentence, leaving the target word out. For instance, when getting in the car and grasping the seatbelt, the parent says, “OK, time to put on your ______” and waits for the child to say, “Seatbelt.”

Props Needed for Floor Time Food:

Plastic vegetables and fruits etc. plastic foods: chicken, hot dogs, eggs, bacon, french fries etc. plastic dishes, cups, forks, knives and spoons plastic or paper soup cans and boxes of foods plastic cooking utensils, pots, mixer, toaster etc. play kitchen with table and chairs

Transportation: minimum of 12 match box size cars, trucks etc tool kit to fix cars, e.g.: screwdriver, wrench, pliers, etc. garage road signs, play road road construction equipment other forms of public transportation: airplane, boat, bus, train

Empathy and Nurturing of others: minimum of two dolls, one boy and one girl minimum of two bottles plastic figures of a family whose sex and number of members matches the child=s family plastic figures of helpers in the community: doctor, nurse, fireman, construction person, police doctors kit to help dolls tool kit to fix objects owned by dolls doll house for plastic family blankets and clothes for dolls play bath equipment for dolls play crib or bed for dolls

Fantasy Play: plastic animals from the jungle, zoo, water and farm plastic dinosaurs Fisher Price or Play School: farm, pirate ship, airport, school, store etc.

Communications: set of two telephones chalk or white board on easel

Reading: books on a variety of topics which are age appropriate word signs around the room display of letters of alphabet and numbers 1 to 10 in room school desk for dolls or child to go to school

Aggression Fantasy: toy soldier set with military transportation (e.g.: tanks, helicopter, boat, and armored trucks) guns, tents, etc. cowboy and Indian set with horses, tents, wagons, guns, bows and arrows etc

Construction Play: wooden block set plastic block set tool kit for construction e.g.: saw, hammer, screwdriver etc. Lincoln log set construction equipment: truck, earth mover, etc.

Art Play: crayons and paper watercolor tempera paints, brush and paper finger paints and finger paint paper clay or Play Dough for sculpting

Outdoor Play: sand box, pails, shovels and other sand containers water play table gym set with slide, swings and ladder rubber football and/or baseballs to throw and catch rubber soccer ball and/or basketball to kick

Constructive Obstruction Props: soap bubbles to be blown on child while playing with other props to create need to be flexible and attend to distraction in a coping way balloon or light ball to bounce on the drama which is occurring to create crisis blanket to hide the desired objects under rubber bands, to fix or bind things together tape, to fix or bind things together bunch of nerf balls to throw to create obstacle which needs to be attended to, DIR at LISCA | 77

Prop Storage: keep theme related props in "shoe box" size transparent plastic containers with covers so child can see inside and select theme to play with. This will make it easier to keep play room orderly and neat when floor time is ended. Enlist child to assist you in putting props in their respective containers.

Home Based Opportunities for Floor Time dressing and undressing: giving child choices about what to wear or not or what to take off first, is following the child's lead.

mealtime: chose one meal a time with enough time - talk may focus around food preparation, different foods being served, which foods are particularly enjoyable or any topic relating to the child's life. car time: engage child in a relaxed conversation in which child takes the lead, or sing-along for which child chooses songs coming and going time: plan to have at least a little time to get child settled on arrival to a classroom or in switching and transitioning from one activity to another by reading a short story, visit pet in classroom or at home, or look at special toy in classroom or at home. Show child support through your interest and warm clear good-bye if leaving in classroom. On picking child up from classroom give the child a chance to tell you something important about the day while you are still in the school setting. bath time: Bath toys are wonderful props as they float, get dunked, and come into contact with each other. The water is a great opportunity for play. The child will naturally relax in the water. book time: Read the book with the child on your lap or next to you on a chair or bed. As you read, be aware of responses and questions that you can extend. (If the child is totally absorbed, however, it is best to continue reading and simply enjoy the sense of shared interest) bedtime: Bedtime is often accompanied by a ritual, but is also a moment to feel close and loving. Children sometimes share important thoughts and feelings during the last moments before falling asleep. Although you will not want to revup the child up prior to sleeping, you can respond with empathy and stay close until the child is calm and feels safe enough to sleep

Turning Every Day Activity into Problem Solving for Child chair not close to table, in the child's spot, when meal time arrives bottle not open when you are trying to pour juice

bathtub empty of water when you tell child it is time to take a bath shoes hidden from usual resting place

changing the shelf locations of favorite books, tapes etc. putting two socks on same foot putting shirt on feet give child adult shoes instead of their own DIR at LISCA | 78

use rubber band to hold together a spoon and fork when giving child tool for eating being sure cup is upside down when offering child a drink put markers in a new container which child has not yet learned to open

mix puzzle pieces of two or three puzzles together

Strategies for Engagement and Two-way Communication

Give child seemingly random actions new meanings by responding to them as if they were purposeful.

Use sensory-motor play -- bouncing, tickling, swinging, and so on -- to elicit pleasure.

Use sensory toys in cause-and-effect ways: hide a toy, then make it magically reappear; drop a belled toy so that child will hear the jingle; bring a tickle feather closer, closer, closer until finally you tickle child with it.

Play infant games, such as peekaboo, I'm going to get you, and patty cake.

Play verbal Ping Pong with child, responding to every sound or word the child makes and continue the ping pong match to expand the number of circles closed.

Pursue pleasure over other behaviors and do not interrupt any pleasurable experience.

Use gestures, tone of voice, and body language to accentuate the emotion in what you say and do.

Try to be as accepting of child's anger and protests as you are of child's more positive emotions.

Help child deal with anxiety (separation, getting hurt, aggression, loss, fear, and so on) by using gestures and problem solving.

Strategies for Helping Child Build Symbolic World

Identify real-life experiences child knows and enjoys and have toys and props available to play out those experiences

Respond to child's real desires through pretend actions

Allow child to discover what is real and what is a toy (e.g., if child tries to go down a toy slide, encourage child to go on; if child tries to put on doll's clothes, do not tell it doesn't fit; if child puts foot in pretend pool, ask if is cold)

If child is thirsty, offer an empty cup or invite to tea party

If child is hungry, open cardboard-box refrigerator and offer some food, pretend to cook, or ask if the child will got to the pretend market with you to get things.

If child want to leave, give pretend keys or a toy car

If child lies down on floor or couch, get a blanket or pillow, turn off the lights, and sing a lullaby

Encourage role playing with dress-up props, use puppets - child may prefer to be the actor before using symbolic figures DIR at LISCA | 79

Use specific set of figures/dolls to represent family members and identify other figures with familiar names

Give symbolic meaning to objects as you play:

When child climbs to top of the sofa, pretend child is climbing a tall mountain

When child slides down the slide at the playground, pretend the child is sliding into the ocean and watch out for the fish

Substitute one object for another when props are needed. Pretend that the ball is a cake or the spoon is a birthday candle.

Resume use of gestures for props along with toy objects and substitutes

As you play, help child elaborate on personal intentions.

Ask who is driving the car,

where the car is going, whether child has enough money, did child remember the keys to the car,

why is child going there, why not somewhere else, etc.

Expand as long as you can. (Use all of the Who, What, Where, Why, When questions, and keep them open ended)

Make use of breakdowns.

When a problem crops up during play, create symbolic solutions.

Get the doctor kit when the doll falls so child can help the hurt doll, tool kit for broken car etc.

Acknowledge child's disappointment and encourage empathy.

Get involved in the drama.

Be a player and take on a role with your figure.

Talk directly to the dolls rather than questioning child about what is happening or narrating

Both help the child and be your own player.

Talk as an ally (perhaps whispering), but also have your figure oppose or challenge child's ideas.

Insert obstacles into the play. (e.g.: make your bus block the road. Then speaking as a character, challenge child to respond. If necessary, get increasingly urgent (whispering to child to encourage to deal with the problem, offer help if needed by becoming an ally). DIR at LISCA | 80

Use symbolic figures child knows and loves, such as Barney, Disney or Sesame Street characters, to generate symbolic play. Reenact familiar scenes or songs, create new ideas, and notice characters and themes child may be avoiding or fear.

Use play to help child understand and master ideas/themes which may have been frightening. Work on fantasy and reality.

Let child be the director. Child's play need not be realistic (child may still be a magical thinker) but encourage logical thinking.

Focus on process as you play; which character to be, what props are needed when ideas have changed, what the problem is, when to end the idea, etc. Identify the beginning, middle and end.

As you play, match your tone of voice to the situation. Pretend to cry when character is hurt, cheer loudly when your character is happy, speak in rough or spooky tones when you are playing the bad guy. Remember, drama, drama, drama to give child affect cues.

Reflect on the ideas and feelings in the story both while playing and later on as you would with other real life experiences

Discuss child's abstract themes such as good guy/bad guy, separation/loss, and various emotions such as closeness, fear, jealousy, anger, bossy, competition, etc.

Remember symbolic play and conversation is the safe way to practice, reenact, understand and master the full range of emotional ideas and experiences.

Strategies to Develop Abstract Thinking

Follow child's lead, build on child's ideas

Challenge child to create new ideas in pretend play

Heighten affect and engagement

Practice and expand rapid back and forth interactions and conversations (gesturally and verbally)

Carry on logical conversations all the time (e.g.: while driving, at meals, during baths etc.) Content does not have to be realistic

Encourage understanding of fantasy-reality: child will use toys as real objects for self as if real (e.g.: puts feet in play pool, tries to go down toy slide, tries on doll clothes, etc.) child may prefer to start with role play and puppets child will use toys in pretend fashion child will use symbolic solutions for problems and fears child will find safety to experiment with themes of aggression and power

Recognize fears and avoidance of certain feelings, themes and characters. DIR at LISCA | 81

During play and conversations get beginning, middle and end of story or idea - identify problem to be solved, motives and feelings - accept all feelings and encourage empathy

Select books to read that have themes, motives and problems to solve - discuss alternative outcomes, feelings

Encourage abstract thinking: ask why questions ask for opinions compare and contrast different points of view

reflect on feelings - come back to experiences again later

don't ask questions you know the answer to don't tell child which dimensions to use

Use visualization - picture yourself avoid rote, fragmented, academic questions

Be creative

if child puts foot in pretend pool, ask if it's cold. if child is thirsty, offer an empty cup or invite child to a tea party

if child is hungry, open toy refrigerator and offer some food, pretend to cook, or ask if child will go to pretend market with you to get things to eat.

if child want to leave, give pretend keys or a toy car if child lies down on the floor or couch, get a blanket or pillow, turn off the lights, and sing a lullaby.

Encourage role playing with dress-up props, use puppets - child may prefer to be the actor before the child uses symbolic figures.

Use a specific set of figures/dolls to represent family members and identify other figures with familiar names.

Get involved in the drama. Be a player and take on a role with your own figure.

Talk directly to the dolls rather than questioning child about what is happening or narrating.

Strategies to Develop Motor Planning Abilities

Encourage "undoing"

move object in line cover desired object

put puzzle piece in wrong place bury desired object(s) under other toys and very different objects hide desired object from the place where child last put it etc. DIR at LISCA | 82

Provide destinations for actions - treat as intentional and symbolic child throws - catch it in basket

child holds figure (little person, animal) -bring over toy slide, school bus, food (if child does not use spontaneously, ask if the figure would like to... give choices if needed...ask figure directly...try not to direct) child taps - bring over drums (can be plate, plastic toy, sticks etc) child rolls car - bring over garage, crash into it, block with figure child reaches for hand - play give me five, variations, dance

Create problems to solve - require multiple steps put desired objects in boxes to open, untie, remove tape or rubber band pretend object needs to be fixed using tools, tape, rubber bands, Band-Aids (symbolic) create obstacles to child getting around or more or restore to correct position hold book to read upside down and/or backwards offer pens/markers which do not work sit in child's special place get to where the child is running first hide object child desires in one hand or the other so that the child can choose when child seeks your hand instead of using own hand, put your hands on your head or in your pocket put socks on child's hands instead of feet give child your shoes to put on make desired toy/object a moving target (move from place to place)

Change environment frequently to encourage flexibility, create problems and expand discussion

Be playful and supportive as you encourage and expand these interaction. move expected objects (change drawer content, change content in baskets)

rearrange furniture and create problems (child find chair upside down, or is told to sit down when chair is across the room) hang up pictures from magazines at eye level and change frequently

Encourage child to initiate/continue action Ready, set, Go,! Put toy which child was using back in child's hand. (Oh, you dropped, forgot), Provide cues - uh oh, knock, knock, Help, Use indirect prompts (call the figures to come, where are you?), Bring over next step (puppet to eat pretend food, mirror to see the hat etc.), Trade objects, positions etc., Deal with consequences of actions symbolically, Baby doll fall (is dropped) - Uh oh! He's crying. Are you hurt? Get a bandage. Go to the doctor. Call an ambulance..., Car crashes - Oh no, it's broken! Can you fix it mechanic?, Plan your idea - discuss what child will need for their idea, Get toys/props child will need, Identify setting and destinations, While playing identify problems and sequence of solutions, Identify DIR at LISCA | 83 beginning, middle and end, Challenge, reason, negotiate, Play interactive song-hand games, Itsy bitsy spider, one potato two potato, slap my hand, Sailor went to sea, sea, sea etc., Play Treasure Hunt and use maps (use visual and verbal cues), Play games: social playground/party games, board games (cognitively challenging) cooking, drama, arts and craft activities, Encourage athletic activities: individual sports e.g. tennis, roller skating, shooting baskets, ice skating etc, Group sports e.g. soccer, baseball, basketball etc, Gymnastics, Tae Kwon Do.

Understanding and Teaching Students with Autistic Spectrum Disorders and Reducing the Problems in the Classroom

Terry R. McCauley

Virginia Polytechnic Institute and State University

Abstract

This paper explores research on how teachers can better understand and teach children with autistic spectrum disorders (ASD). A brief discussion of the causes of autism is a good jumping off point. One of the most important parts that follow is the behaviors or symptoms exhibited by a person with ASD. By having a better understanding of the symptoms and behaviors exhibited by students with autism, the research also explores methods used by teachers to reduce problems in the classroom and build a better learning environment for all children. Since this is the main focus of the paper, diagnosis and early intervention before education begins will not be covered.

Once we begin the move into the classroom, the behaviors and symptoms of ASD will become autistic learning disabilities (ALD). Research has shown that the following methods can reduce behavioral problems caused by autism. Autism cannot be cured in the classroom and there is not enough research to suggest that it does. The idea of inclusion will be discussed briefly as this relates to the debate of classroom instruction methods that reduce behavioral problems.

Keywords: autism, autistic spectrum disorders (ASD), autistic learning disabilities

(ALD), and inclusion

DIR at LISCA | 84

Teaching Autistic Students and the Reducing the Problems

Education is the single most important thing in society and everyone has the right of access to one including people with disabilities, especially people with autistic spectrum disorders. Scientists are not entirely sure what causes the development of ASD, but one thing is certain. Autism cannot be cured and there is not enough research to support this idea. But there are theories as to what may cause it. After discussing those potential causes it is important to address behaviors that are typical in people with ASD. Moving on from the symptoms and behaviors we move into the field of education as children with ASD join their peers in the classroom.

The focus will primarily involve cases where children with mild to moderate ASD can join the mainstream schools and regular classrooms. Research suggests that through specific teaching methods and practices, teachers can reduce the symptoms of ASD, allowing the student to succeed not only in the classroom, but in life as well. By reducing the symptoms we simply mean understanding the specific needs of the child and focusing on teaching practices that help meet the needs of that child and help create a better learning environment for them in the regular classroom setting. By meeting those needs through creative practices you may avoid the frustration and anxiety the child may feel when faced with challenging situations. The behaviors associated with autism may be reduced and become less apparent, thus producing more positive outcomes. This not only builds a better learning environment for the autistic child, but it also builds a better learning environment for all students involved and allows the teacher to focus more on teaching the class instead of putting too much of their focus on one student.

Creating a more stable learning environment for the child with ASD in the regular classroom brings the debate of inclusion to the frontline. While it may not be possible for children with more severe cases of ASD to spend time in a regular classroom, the autistic children with more mild cases could be more fully included in regular classroom instruction if certain methods are explored by the teacher as to what helps that child learn best. More inclusion could lead to a better understanding of ASD by other students and parents. People fear what they don’t understand, but hopefully this research will lead to a greater understanding and tolerance of people with not only ASD, but other disabilities as well. DIR at LISCA | 85

As expressed earlier, the causes of autism are not fully certain or understood. Many theories exist but some hold more weight than others. Every child is born with a different potential for development (Siegel, 2003). Just as people are unique and different from one another, so are our brains. All of our brains develop, grow, and mature differently. Research suggests that specific genes can cause autism, but some of these genes do not always cause it.

They sometimes need to be “activated” by other things. This can include events during the pregnancy, the birth, and other environmental factors that could make ASD more likely. It does not seem likely that autism is caused by any traumas, illnesses, injuries, or accidents (Siegel,

2003).

The strongest case for the causes of autism appears to be a combination of genetics and other outside factors that seem to activate it. People are products of their environments. We are molded and shaped by our experiences in life. So too are our brains. Our brains possess the potential to be molded and reshaped from experiences. Transfer of function is an important part of this process. Transfer of function is the idea that certain parts of the brain perform certain functions. With ASD, some parts of the brain are at a disadvantage. Transfer of function means early intervention to provide stimulation to transfer those functions in the disadvantaged region to another region of the brain (Siegel, 2003). This is the beginning of developing instructional methods to suit the needs of the child. Autistic children may have difficulty with auditory processing (hearing), so the teacher may include images or objects in the lesson. Not all children with autism experience auditory issues, however, as the symptoms and behaviors vary widely across the spectrum.

With the title autistic spectrum disorders the key word is spectrum. Every individual is unique as is every case of autism. Children with autism fall all over the spectrum and just as individual people have specific needs, so each individual with ASD has individual needs to be met. Those individual needs also vary depending on the severity of the autism. There are of course mild, moderate, and severe cases, and everything in between those three categories. Kate

Wall groups the behaviors of autism into three broad categories: social interaction, social communication, and imagination (2004). Bryna Siegel highlights some general characteristics and behaviors of people with ASD (once we move into the classroom these characteristics will DIR at LISCA | 86 be referred to as autistic learning disabilities): lack of awareness of others, lack of social and emotional reciprocity, lack of social imitation, difficulty in understanding body language and facial expression, difficulty in expressive body language and facial expressiveness, understanding spoken language, using spoken language, lack of imagination in play, and finally stereotyped and repetitive interests (2003).

Before moving into the classroom we must understand and expand those behaviors and symptoms of children with ASD highlighted by Wall and Siegel. Of course each of these behaviors and the degree to which they occur vary from child to child. The characteristics when discussing social interaction include but are not limited to avoiding eye contact, lack of desire to play with others, lack of desire to establish relationships or friendships, and being unable to interpret people’s feelings and emotions. Social communication involves but is not limited to lack of useful language, lack of desire to communicate with others, inability to understand non verbal communication such as facial expressions, inability to process conversations, and delayed or unusual patterns of speech. Imagination behaviors may include lack of imaginative play, stereotypical and repetitive play, resistance to play in imaginative scenarios, repetitive or obsessive behaviors, and difficulties in dealing with routine changes (Wall, 2004). In addition to these behaviors a child with ASD may also exhibit other behaviors such as repetitive movements of the body, non-typical responses to stimuli, unusual responses in “normal” situations, self harming or inappropriate behavior, or the child may excel at a specific skill. These children are called “autistic savants” (Wall, 2004).

Once we begin to understand the causes and the behaviors and symptoms of ASD, we can begin to explore the topic of education. Mainstreaming is the main focus of this paper. By mainstreaming I mean placing the student with ALD in a regular school with children that do not have disabilities and having them participate in some regular education classes. According to

Berkell, the ultimate goal of education is to prepare individuals to become participating members of society (1999). When discussing education and autism, that goal should not change. Education can be used to develop or correct to a certain degree the negative behaviors associated with autism to the point where the individual can become a fully participating and integrated member of society. There are four general goals outlined by Christy Magnusen when dealing with autism DIR at LISCA | 87 and education. These goals are: (1) to reach a state of independence (2) to develop spontaneous communication in social situations (3) to be capable of self-advocacy and decision making and

(4) to apply academic knowledge in a functional way (Magnusen, 2005). A large part of autism involves the idea that they don’t perceive the world as we do. They do not understand social interaction and communication the way we do. They are unable to communicate effectively and understand the feelings, emotions, and expressions of “normal” people. It is their lack of understanding of social rules and expectations (Magnusen, 2005).

When it comes to educating children with ALD, the earlier you start the better and specialist input is an essential part of the process. A special pre-school is an excellent start to help the child cope with the adjustment to a mainstream school setting. One simple benefit includes identifying and developing the basic social and communication skills that will help the child in the future (Jordan and Powell, 1995). You should identify the objectives beforehand and they should be measurable and observable skills and behaviors that affect a child’s behavior in the education setting (Brock, 2006).

The discussion of educating children with ALD must start with the teacher. The teacher is the authority figure, the facilitator of learning, the leader in the classroom, and the role model. It is not necessarily the methods, practices, and strategies that will help the child with ALD succeed. They play an important role but more importantly it is how the teacher creatively uses them (Magnusen, 2005). Rita Jordan and Stuart Powell argue that for progress to be made and as a necessary prerequisite, the teacher needs to make him or herself as knowledgeable as possible about autism (1995). Not understanding autism could be detrimental to all those involved and may cause feelings of anxiety and frustration in the classroom for the teacher, the autistic child, the parents, and the rest of the students. It could lead to miscommunication and a misunderstanding of the child’s behavior. Teachers can start with the physical structure of their classroom. Physically arranging the classroom in a specific manner to suit individual needs includes arranging the classroom in a way that is conducive to the learning styles and needs of the child with ALD. Setting aside quiet areas where they may go from time to time when the classroom can become overbearing is an important step. Another method the teacher can use is clearly marking and arranging the materials in the classroom. (Mesibov and Howley, 2003). DIR at LISCA | 88

Children with ALD are interested in pleasing themselves more than others and it does not mean they are disobeying any instructions given to them. Mesibov and Howley also claim a student with ALD can become easily distracted so the teacher should place them in the least stimulating section of the classroom (2003). The success or failure of the child can depend on this factor.

Another important factor in building a more stable classroom environment involves schedules. Children with ALD enjoy predictability, organization, clarity, and routines. A sudden change in routine without the knowledge of the child could result in a meltdown. By offering students with autism a schedule, teachers can ensure calmer and more cooperative behavior because the student understands exactly what they need to do. When they do not understand something is when they can experience feelings of frustration and anxiety which results in resistance to the curriculum. Scheduling reduces this feeling of anxiety by allowing the child to organize and anticipate their activities (Mesibov & Howley, 2003).

Stacey and Dion Betts and Lisa Gerber-Eckard recently published a book in 2007 about strategies teachers can use when dealing with a student who has Asperger Syndrome. Asperger syndrome is a highly functioning form of autism and the reason I include some of their strategies here is because they also prove useful in reducing the symptoms of autism in the inclusive classroom. An important strategy worth mentioning is peer helping. Teachers may choose to pick one or a few students from the class, give them some informal training and facts about people with autism, and assign those students to help their classmate. Transition periods can be difficult for children with ALD. The peer helper may do things like walk their fellow classmate to their next class or help them get to lunch. Traveling through the chaos of hallways can cause confusion for the student with ALD and the peer helper can be particularly useful there. The peer helper can also help the student organize their materials and write down important assignments.

This is a wonderful idea in creating respect, understanding, and tolerance of people with ALD not only for the classroom and the other students, but also for the community as a whole. (Betts,

Betts, & Gerber-Eckard, 2007).

There are many important factors that teachers should consider before employing the strategy of peer helpers however. Here are some basic tips or questions you should ask according to Betts, Betts, and Gerber-Eckard. Waiting a few weeks to see if your student with ALD forms a DIR at LISCA | 89 natural relationship with a fellow student is a good idea, choose a responsible and mature student that will not view their role as “babysitting”, ask the peer helper and their parents for permission, ask the permission of the parents of the child with ALD and make sure they are comfortable with it, and of course provide some training to the peer helper so they may better understand their peer with ALD (Betts et al., 2007).

Other strategies teachers can employ involve allowing time before and after instruction for the student to organize their materials and write down any assignments, write the assignments in a similar section of the board every day, give plenty of verbal and written notice of any special events taking place, give the student a tour of the school and important places they will need to know, take pictures of those places to give to the student, and give the student a written schedule of the day and let them practice if needed (Betts et. al., 2007).

Effective educational programs for students with autism involve six major components:

(1) time given to complete a task is maximized (2) the student is programmed for success (3) educators are involved in the teaching and learning process (4) teaching is based on direct instruction (5) educators listen and respond to students, and (6) teachers establish and maintain high expectations for their students (Berkell, 1999). It is important to note, however, that students with autism still from time to time do require individual attention (Berkell, 1999).

Having high expectations for all your students is an important part of being a teacher. You do not necessarily want to treat an individual student in your regular class different from all the others.

The strategies and practices outlined above should not be viewed as treating your student with autism differently from everyone else. It should be viewed as specific ways you as the teacher can build a more effective learning environment for everyone involved and make it an enjoyable place to be to facilitate learning. These tasks are designed to enhance the educational experience of the student with autism, making their path through life smoother with clarity, organization, and routine. Education can provide them with and enhance the skills they may be lacking.

Teachers can also apply what is known as antecedent strategies in the classroom to help their student with autism. A large part of the difficulties people experience with autism is with language and communication. Speaking slowly and clearly will help eliminate some of the language confusion an autistic student might experience. Eliminate extra language and avoid DIR at LISCA | 90 multiple commands. When given multiple commands the student might miss what he or she was supposed to do for the assignment and not completing the task might appear to be laziness or outright disobedience of instruction by the inexperienced teacher. Since students with autism experience difficulty with verbal and non-verbal communication, pictures are an excellent asset.

You may use pictures to supplement the material. When going over class rules and expectations you might ask the students to act out the behavior while you take pictures and post them in a clearly labeled area where everyone can see them. Allow the student an appropriate amount of time, around 10 seconds for example, to respond to your question. Ask the child to repeat back to you the instructions you have given them. Children with autism have the tendency to take things literal so you may also want to avoid sarcasm, figures of speech, and idioms (Moyes, 2002).

Students with autism as previously discussed enjoy structure, routine, and sameness.

Consistency is very important when dealing with behavior. Teamwork between teachers and teachers and parents is very important. If certain behaviors are handled differently at home than at school, the autistic child will experience a lot of stress (Moyes, 2002). The student must be taught in a way they understand what will happen if they misbehave. Punishments do not work as well because they do not teach the child, or any child for that matter, what the accepted behavior is. Rewards and motivators can also be useful tools, but the rewards must be something that is important and pleasurable to the child (Moyes, 2002). A few strategies that may work include having the student write an apology and an explanation of what he or she did wrong, making the student explain what they did wrong or drawing a picture of it, and have them review the rules again so they understand what they did (Moyes, 2002).

The topics of mainstreaming students with ALD, placing them in regular classrooms, and developing creative techniques, practices, and strategies to reduce behavior problems associated with autism and help that child become a more important, understood, and participating member of the classroom and society, brings into discussion the idea of inclusion. Inclusion is not for everyone. But those with only mild or moderate cases of autism that are deemed able to be in a regular classroom for at least part of the day should be. One theory is that since some autistic children learn behaviors by imitating others, they will imitate and learn the more appropriate behaviors from their peers. Also, these types of students typically have professional teaching aids DIR at LISCA | 91 in the classroom that help them in their daily activities. This frees the teacher from focusing too much of their attention on one individual, but at the same time allows them to alter their methods and delivery of instruction to suit the needs of the student with ALD to build a better learning environment for all. Another part of inclusion is providing a resource room. This is a place students with ALD can go which serves as a homeroom for those that can’t handle a group setting for those six to seven hours of the day (Siegel, 2003). Another component of inclusion is adapting the curriculum to fit the needs of the student with ALD. A study done by Wang and

Birch showed “that students with disabilities who are fully mainstreamed in regular education classes demonstrated increased academic skills, improved classroom behavior, and better generalization of classroom behavior compared to their partially mainstreamed peers”

(Kellegrew, 1995). Inclusion as stated above is not for everyone, but for those students with mild enough forms of autism that can handle the environment should be included as much as possible.

People with disabilities are often feared and ignored by society because they are misunderstood. It is often said that they do not have the mental capacity to learn and therefore cannot join mainstream society as an active participating member. We need to change these false attitudes about people with disabilities, especially autism. The way we do that is through education. The research and material presented has shown that if we take the time and patience to understand autism and include those who are able to join a mainstream school and a regular education classroom, then we can more fully accept them by employing specific strategies and practices that help reduce the common behavioral problems associated with autism. These teaching methods also might provide students without disabilities with the idea of tolerance.

Education, understanding, and the building of tolerance and acceptance will hopefully help create a happier and brighter future for everyone.