CLDDV 173: AUTISM: OVERVIEW AND TREATMENT

DIR FLOORTIME CONCEPTSPrepared by Debbie Laffranchini, Professor

Taken from Engaging Autism, by Stanley Greenspan and

Serena Wieder

Six Levels of Engagement

■ Stage 1:

– Shared attention and regulation

■ Stage 2:

– Engagement and relating

■ Stage 3:

– Two-way communication, purposeful emotional interactions

■ Stage 4:

– Complex two-way communication, shared problem-solving

■ Stage 5:

– Shared meanings, symbolic play, creating ideas

■ Stage 6:

– Emotional, logical thinking

Stage 1: Shared Attention and Self-Regulation

■ Adult does 100% initiation to

sustain shared attention as child

develops

■ Adult does almost all of the work –

to get attention and looks –

modulating pace of play for

regulation

Stage 1: Shared Attention and Engagement: Techniques to Bring the Child Into

Your World■ Get the child to look at you because

they WANT to look at you

■ Slow down your movements

■ Provide sensory support

– Pay attention to their sensory profile

■ Swinging

■ Bouncing

■ Follow the child’s lead

■ Playful obstruction

Stage 1: Shared Attention and Engagement: Expanding the Child’s Interest in the

World■ Meet the child at their level of ability

■ Move from one-step actions to two-

step actions

– Child indicates they want

something (first step)

– Child indicates a further action

(second step)

■ Complete “circles of

communication”

■ Support them to discover the

pleasure of engagement

■ Don’t entertain; interact

Stage 2: Engagement

■ Adult still does most of initiation to

WOO the child into engaging

– Child will sustain engagement in reciprocal social interactions

■ WOO, THEN WAIT

■ WAIT EXPECTANTLY

■ Adult feels like they are doing a lot of work “entertaining” to get laughter, smiles, affect and engagement

Stage 3: Two-way Communication

■ Child begins to initiate purposeful

interactions around desires

– OPEN CIRCLES

– CLOSE CIRCLES

■ Child engages in back and forth

interaction, gestures

– PING PONG

■ Adult feels some sharing of work

Stage 3: Encouraging Two-Way Communication and Social Problem-Solving

■ Preverbal communication

– Verbal skills children need

begin here

■ Facial expressions and tone of voice

– Communicate warmth,

acceptance, and love

■ Gestural communication

– Builds cognition and

intelligence

Stage 3: Encouraging Two-Way Communication and Social Problem-Solving (cont)

■ Communication delays:

– Motor planning delays

– Challenges in sequencing

– Challenges with auditory

processing

– Challenges of visual-spatial

processing

– Challenges modulating

sensory input

Stage 3: Encouraging Two-Way Communication and Social Problem-Solving (cont)

■ Encouraging communication

– Follow the child’s lead

– Tune into child’s interests, emotions, and goals

– Incorporate child’s favored object or activity into your interaction

– Use exaggeration

– Encourage multiple circles of communication

– Use playful obstruction

– Peek-a-boo

– Hide and seek

– Rhythmic coordinated activities

– *Key: get child motivated

Getting Communication Going■ Are you following the child’s lead?

■ Are you enticing the child to take the initiative?

– Don’t do all of the work!

■ Do your voice, gestures, and posture show expectation?

■ Are you tailoring the interactions to the child’s nervous system?

– Low muscle tone, underreact: energize them

– Be aware of sense used to learn

■ Are you involving as many senses as possible?

– Sight, sound, touch, movement

■ Put the loved object in plain sight, out of reach

– So they initiate

■ Increase complexity of behavior

■ Use times of high motivation

Playful Obstruction

■ Beat the child to the spot

■ Gently block their escape route

■ Blanket, become child’s blanket if

they are lying down

■ Veil or scarf, cover the window the

child is staring through, attention

getter

■ The tub

Stage 4: Complex Two-Way Communication

■ Child can work up to a continuous

flow of 20 to 30 + back and forth

circles, large, small, and micro-

circles

■ 50/50 adult and child doing the

effort

■ Child is responsible for half of the

relationship

■ Adult waits for problem solving

Stage 4: Complex Two-Way Communication: Symbols, Ideas, and Words

■ First words

– Repeat key words, over and over

■ May need to say 10,000 times

■ Do you want to go OUT? OUT? OUT? Let’s go OUT. OUT. We came OUT!

– Nouns easiest to learn

– Give choice

■ Juice or milk? Juice? Milk? Repeat, repeat, repeat

– Use real situations to teach language

– Don’t ask abstract question, stay concrete

■ Say, “Do you want to eat?” Instead of “Are you hungry?”

Stage 4: Complex Two-Way Communication: Symbols, Ideas, and Words (cont)

■ Imaginative play

– Demonstrates intelligence

– Demonstrates cognition

– Use daily routines to begin with, things the child knows a lot about

– Use repetitive language

– Build in emotion

■ The baby likes the water

■ The baby likes the duckie

– VERY FEW PROPS to begin with

■ Keep it simple!!

– Do not take the lead

– You can become the object or a character

■ The baby

Stage 4: Complex Two-Way Communication: Symbols, Ideas, and Words (cont)

■ Engage with the child’s interests

– Some may find it difficult to help the child come up with ideas to what the baby would say, etc.

– Sometimes children run away when they don’t know what to do next or the play is too complicated

– Be a bit demanding

– Introduce a conflict or challenge (the plot thickens!)

– Don’t give the child what they want right away…wait!

■ Don’t be the “too-good adult”

– Explore feelings

Stage 4: Complex Two-Way Communication: Symbols, Ideas, and Words (cont)

■ Signal with gestures

■ Get many circles of communication in a row

■ Create emotionally meaningful situations

■ Associate a word (open) with an emotional goal

■ Use ideas logically

■ Ask questions, then expect

■ Wait

■ Wait expectantly

■ Taffy pulling

Stage 5: Shared Meaning, Symbolic Play, Problem Solving

■ Use of ideas (words) to convey feelings and intentions

■ Adult works at expanding child’s pretend play

■ Adult asks “wh” questions

– Who

– What

– Where

– When

– Why

– How

Stage 5: Shared Meaning, Symbolic Play, Problem Solving

■ Looking for long chains of back-and-forth emotional signaling and shared problem-solving

■ Stretch dialogues

■ Ask open-ended questions

■ Combine action and words

■ Avoid parallel conversations

■ Use conflict and challenge to promote logical circle closing

■ Form bridges between ideas

■ Create multifaceted characters in play

State 6: Emotional Thinking

■ Child is challenged to connect ideas

together by:

– seeking their opinion

– enjoying their debates

– negotiating for things they

want using logical reasons

■ Adult works at negotiating with child

■ Adult challenges child to think,

understand, and open to others’

perspectives

Stage 6: Emotional Thinking, Creating Ideas, Logical Thinking in the Real World, Complex Communication■ Limited logical thinking

■ Fully logical thinking

■ Early steps of logical thinking

– Begins first three or four months of life

■ Step one: requires accurate information

■ Step two: engaging the world in an emotionally meaningful way

■ Step three: purposeful interaction with the world (reaching for rattle)

■ Step four: combining series of purposeful actions (get help to get an item out of the way)

■ Step five: use of ideas (search for hidden object)

Additional Intervention Guidelines to Increase Interaction

■ Follow the leader

■ Treat whatever the child is doing as intentional and purposeful

■ Extend the child’s desire and sometimes play dumb

■ Differentiate your actions from theirs (when a child uses an adult hand as an extension of their own body)

– Position yourself in front of the child

– Work in front of a mirror

– Put your hand over theirs rather than their hand over yours

Additional Intervention Guidelines to Increase Interaction (cont)

■ Help them do what they want to do

– Hand them the next object when they are lining up objects

– Put an object in the same place they would

– Put an object in a wrong place

– Put the object in several different places

■ Have sensory toys, wind up toys, and simple cause and effect toys available to get their attention

Additional Intervention Guidelines to Increase Interaction (cont)

■ Give the child a problem to solve

– Gentle obstruction

■ Surprise the child, do novel things

■ Don’t take no for an answer

– Undoing what you did is a response!

■ Encourage exploration and the child’s choices

– Children with severe motor planning difficulties may need hand over hand to help them start to use the object or toy

– Keep a variety of toys out

Additional Intervention Guidelines to Increase Interaction (cont)

■ Give old behaviors new meanings

– If child is running back and forth, begin “Ready, Set, GO!”

– Child is laying down, engage in dramatic play sleeping routine

■ Simple to complex

■ Join children in ways they enjoy but do not back away from anger

– Anger precedes their ability to express pleasure

– Anger is a response

Additional Intervention Guidelines to Increase Interaction (cont)

■ Open the door to symbolic play

– Motor sequencing is difficult

– If they want to leave, offer them keys

■ See if they turn out the lights and ask for help to open the stuck door

– They are using symbolic gestures like climbing on the couch

■ Work on multiple levels at once and be very persistent

■ This requires HOURS of practice

■ Goal: four to eight 20-minute sessions a day

Additional Intervention Guidelines to Increase Interaction (cont)

■ Provide destinations for actions

– Child taps, bring “drum”

– Child throws, provide basket

■ Create problems to solve, require

multiple steps

– Object in box to open, untie,

remove tape or rubber band

– Objects to fix using tools, tape,

rubber bands, band-aids

– Put socks on hands

Additional Intervention Guidelines to Increase Interaction (cont)

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

– Move expected objects

– Create problems with furniture

■ Chair upside down

■ Deal with consequences of actions symbolically

– Baby doll falls: 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 props

Additional Intervention Guidelines to Increase Interaction (cont)

■ Play interactive song-hand games

– One potato, two potato

■ Play treasure hunt and use maps

■ Play games

■ Encourage athletic activities

Why follow a child’s lead? “That’s our ultimate goal for entering their shared world – to help them become empathetic, creative, logical, reflective individuals.

~Dr. Stanley Greenspan