WHAT IS DIR/FLOORTIME?
DIR/Floortime (Developmental Individual processing Relationship differences) was founded in the early 1980’s by the late Stanley Greenspan, M.D. (Child Psychiatrist and former director NIMH Mental Health Study Center and the Clinical Infant Development Program; clinical professor of Psychiatry, Behavioral Science and Pediatrics at George Washington University Medical School and Chairman, of the Interdisciplinary Council on Developmental and Learning Disorders) and Serena Wider, Ph.D. (Clinical Psychologist) in collaboration with Terry Berry Brazelton (Pediatrician), Julius Richmond, M.D. (Surgeon General), Selma Fraiberg (Psychiatrist) and others at the Clinical Infant Development Program at the National Institute of Mental Health.
DIR/Floortime is a biological-social-psychological framework for understanding how children in their processing of relationship interactions with primary caregivers develop in the first three years of life and how this begins to set the necessary foundations for all functional emotional and developmental growth throughout the lifespan. It is based upon the six primary core functional-emotional developmental capacities or milestones that directly involve child/primary caregiver social emotional relating/engaging, thinking and communicating and that are typically mastered by each child during the first three years of life. This includes the ability for each child to achieve
1) Self-Regulation and Taking Interest in the World
2) Engagement and Relating (Falling in Love)
3) Purposeful Two-Way Communication
4) Complex Communication and Problem Solving
5) Using Symbols and Creating Emotional Ideas
6) Logical Thinking and Building Bridge between Ideas (1)
DIR/Floortime is a highly affectively structured peer-reviewed evidenced based treatment model for children with autism spectrum disorder and related developmental based challenges. It is a child-centered, parent guided approach. The therapeutic focus is not as in traditional behavioral approaches (applied behavioral analysis) concerned with adults changing the child’s “surface behaviors” but rather clinicians respectfully and consistently guiding primary caregivers to learn how to slow down, understand, listen and go directly to their child’s world in order to emotionally and developmentally engage their child’s natural affect or emotions. Emotional engagement rather than a focus on managing or changing "surface behaviors" is an integral part of executive functioning (e.g., child/parent engaged in back and forth co-regulated emotional signaling with facial affect, prosody of voice; bodily gestures, sequencing of ideas and social-pragmatic language).
Clinicians gently and systematically guide primary caregivers to Developmentally understand (functionally-emotionally and empathically) their child's processing differences and to go where their child currently is for the purposes of deepening reciprocal attachment, attunement and emotional engagement around their child’s perspective. Unlike traditional behavioral-based approaches, the child’s behaviors (the external or symbolic manifestation of each child's underlying processing differences) are not simplistically labeled and targeted (i.e. “appropriate vs. inappropriate”) but behaviors are addressed as an integral part of the child’s whole biological, social and psychological dynamic. Thus, the child's “selective behaviors" are not isolated, targeted and analyzed for modification but progressively change in the course of guiding primary caregivers to warm and pleasurable engagement and simple to increasingly complex back and forth patterns of reciprocal-child/primary caregiver emotional problem solving scenarios during simple to complex symbolic play and throughout all daily living activities. (2)
The primary focus in DIR/Floortime is on encouraging the primary caregivers with the child to build and sustain deepening reciprocal attachment, attunement and bodily based healthy emotional-social communicative relationships, the foundations for ALL developmental growth, engagement and leaning . Therefore, from a Developmental evidenced-based practice, the child's Functional Emotional Developmental milestones and his/her sensory-affect-motor processing differences (e.g., proprioceptive, vestibular, auditory-prosodic, tactile-gestural and visual-facial) never proceeds by clinicians labeling, managing and training the child for increased "surface compliant behaviors" for less "surface compliant behaviors" but rather on encouraging the purposeful and meaningful use of each child's [deeper] integrated executive functioning.
Executive functioning (major function of the prefrontal cortex which occupies the largest part of the brain) is responsible for each child’s capacity to spontaneously integrate, coordinate, plan, sequence and communicate gestures, ideas and social or pragmatic language during simple to increasingly complex everyday back and forth two-way emotional problem solving with primary caregivers and peers. Importantly, what is required by special educators and other therapists with respect to the above is an in-depth Developmental biological-and-psychosocial understanding of the underlying affect-regulation foundations which constitute each child’s Functional-Emotional Developmental milestones and individual sensory-affect-motor processing differences that make sustained engagement and communicating challenging for both the child and primary caregivers. The child/primary caregiver relationship is the central core component or foundation for functional-emotional developmental milestone advancement and integration.
Thus, by clinicians developmentally engaging the whole child's individual nuanced biological-psychological and social-emotional development (e.g., where s/he is in all relationship activities and addressing his/her unique sensory-affect-motor processing strengths and challenges, under-responsive, over-responsive and mixed responsivities across all sense and processing domains, auditory-prosodic, tactile-gestural, visual-facial processing, gustatory; proprioceptive, vestibular and intereoceptive ) clinicians are in effect guiding primary caregivers to meaningfully deepen reciprocal attachment, spontaneous joint back and forth attention; increased ideation, language and most importantly, the desire on part of their child to want to engage.
A comprehensive Developmental evidenced based practice such as DIR/Floortime is in direct contrast to traditional behavioral based methodologies (e.g., Applied Behavioral Analysis). ABA is a data driven model that attempts to show great success in managing the child’s “surface behaviors." For example, the child is trained to comply to simple to increasingly complex demands by the clinician to complete rote memorized academic-and-behavioral tasks on a checklist . When the child successfully complies with the demands of the task the child is reinforced by an external reward (e.g., a cookie, favorite cartoon or a toy, or a vapid, repetitive, ad nauseam, "Good Job"). What the behavior(s) symbolically represents, that is, communicating beneath the surface (e.g.,, at a biopsychosocial level) or how they are being interpreted by the child (i.e., his/her autonomic nervous system and sensory processing differences) is not considered especially relevant.
The central focus in DIR/Floortime is to guide each child-with-primary caregivers and with peers to form pleasurable, engaging sustainable and meaningful emotional-social communicative relationships. The success of the latter is borne out by peer reviewed evidenced-based practice combined with decades of exhaustive research in Developmental affect neuroscience, infant and early childhood mental health, developmental psychotherapy, psychoanalysis, Polyvagal theory, somatic therapy and other related biopsychosocial sciences (see Research Section).
By clinicians and primary caregivers fully supporting the child's natural emerging sense-of-self through warm , pleasurable and challenging relationships with others this aids in fully supporting and strengthening each child’s underlying core Developmental capacities as each child hierarchically moves up the neurodevelopmental ladder (e.g., the six basic primary functional emotional developmental milestones noted above) with increasingly fully intact and integrated peer competent skill sets (i.e., age appropriate receptive/ expressive language, sensory, social-emotional and cognitive/academic milestones) (3)
(1) The six-basic functional-emotional developmental capacities or milestones that are typically successively acquired from birth to three. There are ten additional milestones throughout the lifespan. Each milestone represents a greater developmental capacity for deeper or more expansive social-emotional relating, thinking and engaging. For a more detailed explanation see, http://www.icdl.com/dir/fedcs
For a brief but wonderful video documentary on DIR/Floortiime see, Playtime: A DIR/Floortime short documentary https://www.youtube.com/watch?v=wuF3ZveRWpg
The following is a longer and wonderful overview of the DIR/Floortime methodology not only in the early years, addressing the basic six functional-emotional developmental milestones, but as the child progresses and we begin to target greater and higher developmental levels (e.g., comparative thinking, grey area thinking, reflective thinking) see, Floortime Strategies: Using the DIR Model with older children and teens: https://www.youtube.com/watch?v=LcjhFST4GTw
(2) From a comprehensive biological-psychological-social and developmental perspective we do not dissect, target or analyze "behaviors” (i.e., surface symptoms) but rather we address the whole child. We address the child's underlying core Functional Emotional Developmental constitutional capacities (e.g., what is behind the behaviors or what the behaviors symbolically represents and is communicating with respect to the child's underlying emotional-sensory modulation, processing and motor planning differences - how s/he is navigating placing together and interpreting the world as a whole).
Therefore, with respect to what constitutes healthy functional-emotional child/primary caregiver and child peer relationships, we avoid reductionist narratives (e.g., ABA methodologies) as behavioral clinicians often naively and simplistically label each child's enormously complex heterogeneous sensory-affect-modulation and motor processing differences and functional emotional-developmental challenges as "off-task," "interfering", "inappropriate” or "non-compliant behaviors." Rather we proceed to address the whole child in a fully integrated manner and always in the context of family relationship patterns, of healthy child/primary caregiver secure based attachment, attunement and increasingly complex two-way reciprocal social-emotional engagement and thus helping families build their child’s core foundations leading toward their child’s expanded ideation (e.g., simple to complex perspective taking of others/Theory of Mind) and social-pragmatic language.
* For an absolute essential must watch 45 minute comprehensive video introduction to the DIR/Floortime methodology by Stanley Greenspan, M.D,. and Serena Wieder, Ph.D., see https://www.youtube.com/watch?v=OjJ-moe4BpQ For an excellent up to date DIR/Floortime resource site for research, discussion, presentations, audio talks and materials, see, http://circlestretch.com/
For a parent friendly introduction as well as a comprehensive overview on sensory processing disorders, which includes over-responsive, under-responsive or mixed responsivities in one or more sensory-affect-motor areas (i.e., vestibular, proprioceptive, tactile, auditory, olfactory, gustatory, visual-spatial processing and interoception)see www.spdfoundation.net www.spdstar.org/basic/your-8-senses
(3) From an evidence-based Developmental perspective when skills are embedded in the context of social-emotional relationships (i.e., around your child’s natural feelings-and-emerging “sense of self”) they become integrated, spontaneous and meaningful. However, when skills are addressed in a robotic or isolated manner as typically done in traditional behavioral methodologies (Applied Behavioral Analysis) and thus targeted apart from the child's pleasurable and affect challenging dynamics of social-emotional relating and engaging then those "selectively targeted" cognitive performance-behavioral skills become compartmentalized (i.e., splintered and mechanical and remain disassociated) from the child’s natural developing and integrated “sense of self."
For example, the clinician performs a functional behavioral assessment or if necessary a more detailed functional behavioral analysis to simplistically and reductionistically determine what “function the child’s behavior is serving” (e.g., desire for attention, desire for highly preferred item, escape/avoidance; or automatic function/self-stimulation) S/he then subsequently designs a behavioral treatment plan with different schedules of reinforcement around the child's list of so-called, "challenging behaviors” and a new selective laundry checklist of skills. The goal is to have the child replace "undesirable behaviors" with more "desirable behaviors" (i.e., essentially, an aquired rote memorized checklist of performance-behavioral tasks and discrete skills) that can be behaviorally-mechanically regurgitated on cue for test-taking purposes. Moreover, this is often conveyed to parents as indispensable under the egregious admonition of necessary peer competent "preschool readiness” or ‘school readiness skills. "
However, what we should be asking from a comprehensive neuroscientific developmental perspective is instead why this emphasis? on modifying, replacing and/or extinguishing behaviors since this antiquated focus of everything as being essentially, “behavior on the brain” has no scientific basis whatsoever with what we now know from the mid 1990’s with respect to an evidenced based biopsychosocial understanding. This includes the core foundations of social-emotional intelligence and the associated core Functional-Emotional Developmental undertaking of addressing and engaging the child where s/he is in the present moment( i.e., biopsychosocially with regards to social-emotional -cognitive relational functioning; sensory processing differences; autonomic nervous system regulation and arousal). Instead, what is emphasized is developing behavioral treatment plans to environmentally re-condition [surface] deemed "undesirable behaviors" in exchange for more [surface] deemed "desirable behaviors."
Engaging the child where/she is in terms of his/her functional-emotional milestones, sensory processing differences and child/caregiver relationship patterns is not done to target, reduce, fade out or extinguish "A" ("bad behavior") and replace it with "B" ("good behavior") but as an integral part of child/primary caregiver two-way reciprocal developmental social-emotional problem solving skills around the child's natural emotional curiosity and interests and affect-sensory modulation processing challenges The latter addresses not the surface based responses (i.e., "replacement behaviors") or new declarative memorized or compartmentalized tasks (e.g., "Child upon testing can point to or say ‘X ‘upon cue" - as we can all train all children to perform endless lists of memorized tasks) but rather addresses the underlying primary core relationship based challenges associated with ASD. This includes implicit procedural memory, which is an integral part of not part of trained tasks produced ion command but part of the broader landscape of spontaneous Emotional-Social Thinking, Relating and Communicating. (The latter is part of a biopsychosocial approach, irrespective of typical or atypical development, and supported by three decades of neuroscience and Interpersonal Neurobiology, see Research Section).
By addressing the whole child creates the necessary foundations for all meaningful integrated skill acquisition. Meaningful skill acquisition (e.g., social-emotional-cognitive, linguistic) is completely dependent upon cultivating these underlying core Functional-Emotional Developmental Relationship foundations (i.e., what is happening beneath the surface of the apparent acting out or withdrawn “externalizing behaviors" of the child). Failure to understand this and implement Developmental treatment accordingly directly results in children often acquiring a compartmentalized set of new performance-behavioral tasks but significantly not able to link and utilize those “skills” in any meaningful or sustainable manner, that is, in a safe, secure/comfortable and continuous flow of dynamic emotional interactions (i.e., social communicative relationships) with others. It should be noted, however, that it is precisely the ability to increasingly maintain back and forth internally regulated/co-regulated social-emotional engagement with others (e.g., a hierarchical and integrated biopsychosocial understanding) where we begin to see new subcortical and cortical connections made, that is re-wired in a much healthy developmental and integrated fashion). https://www.youtube.com/watch?v=4TRL1TMwsuA&t=11s
Therefore, it is not at all surprising what we commonly see when reductionist applied behavioral based methodologies are used with very rare exception (even when behavioral-natural environment approaches are utilized) is that the child’s newly acquired (inventory/itemized "surface trained") tasks and non-verbal and verbal language skills tend from the onset to become highly rigid or mechanical and contextually restrictive memorized responses, unsurprisingly as it consistently mirrors the compartmentalized flat affect of the practitioner, essentially an adaptation of new and improved functionally scripted responses (e.g.,, child behaviorally conditioned/reinforced to think/respond, “I touch, say or do ‘X’ when ‘X’ happens”).
This is in marked contrast to the child successfully gently, intuitively and emotionally guided by the attuned therapist and parent to spontaneously learn to use his/her greater back and forth social-emotional-problem solving capacities not simply to mechanically provide the "correct answer" - or sets of newly trained functional scripted responses on cue (e.g., "I want_____" or "Give me ____" as new learned behaviors or declarative rote memorization of responses more or less with the same unvarying or flat affect across different situations or person to person encounters) but rather the child (as a core part of executive functioning) beginning to spontaneously emotionally-cognitively register, assess, attune and respond to each person or encounter in increasingly novel ways (i.e., a part of implicit-procedural memory). This is quite different than a focus on changing surface tasks or surface cognitive-behavioral responses.! Instead, this is a focus on cultivating the child's (deeper) social-emotional relationship based interactions. In other words, the child (or older) spontaneously beginning to converse from a more internally secure, affective co-regulated and integrated manner and thus functionally being able to more fully receptively process, understand and proactively respond to what is actually being both non-verbally and verbally communicated by others.
One of the primary points that needs to be emphasized here is that all this points to the child’s earlier and extremely crucial core Functional Emotional Developmental foundations. This critically involves clinicians beginning to more adequately address core executive functioning. This entails an understanding of what typically occurs in infant/toddler/primary caregiver development and thus a deeper understanding of the integration of cortical and subcortical functioning and associated autonomic nervous system functioning (i.e., parasympathetic sympathetic and immobilization responses). For example, we see in healthy organized attachment, calm, regulation/co-regulation with primary caregivers then when breaks in engagement occur, fight/flight or immobilzation responses then, the beginning of a "co-repairing" or re-regulation to healthy restoration (re-establishing warm emotional dyadic connection -and increased oxytocin, dopamine, serotonin, endorphins, etc.) by the reassurance of the primary caregiver's facial, bodily gestural and vocal affective engagement. The co-repairing or re-regulation of deepening reciprocal attachment and attunement with the child (or older) results in greater internal [self] regulation, ideation and nuanced engagement (for one of the earliest and vivid illustrations of this in typical development see, Ed Tronick, "The Still Face Paradigm." https://www.youtube.com/watch?v=bG89Qxw30BM ). Allen Schore, 2017: The First 1000 daty of Life: A Critical Period For Shaping Our emotional Selves And Social Brains. https://www.youtube.com/watch?v=bhjPfCwTHPs&t=2181s
However, when we turn to atypical development (e..g., bio-genetic, immune vulnerabilities, exposure to neurotoxins, etc.) resulting in an entirely different trajectory or additional impacts of psychic trauma in two-way emotional problems with respect to establishing and maintaining optimal arousal and engagement, we quite similarly (but adjusting ourselves to the child’s core processing differences) through back and forth social-emotional based attunement and engagement help strengthen (literally neurophsyiologically re-construct) for the child (or older) these vital underlying emotional-developmental foundations (in conjunction with addressing as viable any other comorbidity factors, biomedical needs, nutritional and so forth), which begin to allow for the child (or older) an optimal state of arousal and a healthy spontaneous affective and assertive "sense of self " with primary caregivers and others during simple to increasingly complex and nuanced back and forth social-emotional engagement.
Clearly, we have different set of causal factors in utero resulting in moderate to severe challenges in social-emotional reciprocity in autism spectrum disorders (e.g., genetic-biological, endocrine and immunological based factors) resulting in an affective diathesis or disruptions in the child able to establish and maintain engagement . Although there are often present much more moderate to extreme accompanied high levels of anxiety and associated traumatic based responses around social-emotional engagement due to in utero biological genetic factors, this is often dramatically improved towards greater biopsychosocial integration by the skilled therapist guiding primary caregivers to slow down, attune, emotionally engage and thus increasingly help maintain and/or restore spontaneous back and forth reciprocal social-emotional engagement and social-pragmatic language. Therefore, this developmental biopsychosocial understanding and evidenced-based treatment approach absolutely necessitates that special educators as well as all other therapists,
(A) Understand what are the biological-psychological-social emotional underpinnings in healthy nurturance based practices (healthy attachment, attunement and co-regulation) that constitute healthy infant mental health and early childhood development with respect to simple to increasingly complex back and forth circles of social-emotional engagement leading to more complex ideation and social-pragmatic language. (see Allan Schore, 2017, The First 1000 Days of Life: A Critical Period For Shaping Our Emotional Selves and Brains: https://www.youtube.com/watch?v=lY7XOu0yi-E&t=6s )
(B) Understand what are the biological-psychological-social emotional underpinnings with a foundational understanding that includes sensory-affect-motor challenges in the context of dyadic engagement that constitute a diathesis or affective dysregulation in simple to increasingly complex back and forth engagement associated with ASD and related developmental challenges resulting often in All or Nothing responses; inhibited or reduced ideation and delayed social-pragmatic non-verbal and verbal language.
(C) Accordingly, target NOT the child’s surface behaviors (e.g.," non-compliant responses" and re-direct, them into "compliant responses") but take the time to guide primary caregivers and others to engage the child's earlier deeper primary core executive challenges (i.e., connecting and embodying each child's feelings during emotional-social back and forth engagement in a completely respectful and integrated manner - one which attaches, aligns and joins with the child’s earlier, subcortical, processing and autonomic regulation challenges ) which then increasingly leads to reduced anxiety, increased secure-based reciprocal attachment, increased pleasurable, meaningful and sustained engagement and the emergence of spontaneous social pragmatic language/communication. (see Research Section)
Emphasis with respect to the above will tend to lay less emphasis on what is generally evaluated during standard diagnosis and targeted for treatment , for example, the child’s superficial ability to identify, label, match and imitate (i.e., looking, pointing or utterance upon rote memorization or command). The latter are fine with respect to “surface based tasks”, but are essentially an artifice of a screening evaluative rote checklist to satisfy a standardized testing protocol which often results in misdiagnosis, over-diagnosis as well as under-diagnosis in ASD and related developmental-pragmatic relationship based challenges. Rather, what is indispensable and critical are clinicians guiding primary caregivers to emotionally engage/understand, listen attune and guide their child to proactively initiate, play with affect/emotion and communicate with other(s) in back and forth novel rather than in scripted manners (i.e., the child’s perspective) from his/her emerging core “sense of self” in relationship to the world-and-others.
While new selectively targeted skills acquired by the child using various schedules of reinforcement (i.e., trained memorized rote academic/behavioral tasks on a laundry checklist of skills largely for satisfying a certain proven checklist state guideline measurement of performance - and pardon my cynicism with respect to appeasing parents, school boards'streamline efficiency and funding) may naturally appear to be a "remarkable achievement", whereas formerly, the child, for example, demonstrated little if any task/skill development, they, nonetheless, significantly pale in contrast to what many children diagnosed with ASD and/or other biopsychosocial developmental challenges are fully capable of achieving and, furthermore, much earlier on!
In other words, what the child is fully capable of achieving in a comprehensive manner much earlier on when those targeted "discrete tasks to generalized skills” are not looked upon the surface and thus robotically and blindly implemented, as is commonly done by special educators and other professionals (e.g., adult directed tasks or selectively targeted behaviors apart from the child’s natural intent or affective "sense of self " and underlying processing challenges under the pandemic willfully ignorant enormously profitable and misguided belief of the “the only scientifically proven methodology for children with ASD, applied behavioral analysis" ).
Rather, from the perspective of voluminous research data in developmental affect neuroscience, translated into evidenced-based treatment, all "skills" must be fully embedded and addressed throughout the day, that is, in the moment to moment context of guided reciprocal emotional-social engagement around the child’s developing sense-of-self, his/her natural intent and sensory-affect motor processing differences that make engaging and relating with others challenging. Thus, from a comprehensive Developmental perspective, the focus is not to train the child on a laundry checklist of specific targeted behaviors or "broken down tasks" (so the child can comply with the demands of the evalulator's rote testing) but rather as the evidenced based neurodevelopmental facts clearly demonstrate and demand on core executive functioning or praxis.
Again, this necessitates every clinician guiding primary caregivers to an understanding of each child’s natural affective ability to spontaneously use his/her emotion-cognition-language and senses as a whole, that is, to regulate and coordinate not newly trained “memorized responses”, such as arbitrarily labeling as special educators and other clinicians insist and train the child to do (e.g.,"big, small, red, sad, happy", etc.), but rather from day one, during play and throughout all activities learning - through adult guided co-coordinated/co-regulated social engagement around the child’s affect - in order to pleasurably/affectively register, assimilate and cognitively assess the multitudinous non-verbal-and-verbal cues/communication of other co-communicators.
This is also commonly known in the field as, "Theory of Mind." Essentially, the latter is each child's core ability to be able to read other people’s emotions or affect (i.e., facial expression and bodily posturing, intent; rhythm, stress, pause, tone, inflexion of voice, etc. - the prosodic elements of [nonverbal] language that comprises 95% of expressive language) and, thereby, learning developmentally to socially relate and engage (i.e., increasingly co-coordinate or co-regulate/regulate and assess) each new situation differently, that is, in greater integration or seamless accord to what is actually being communicated non-verbally-and-verbally by others in any given situation or moment. It is precisely the latter which represent the core challenges in ASD but once properly addressed enables each child (or older) to move up the functional-emotional developmental ladder with respect to nonverbal and expressive language, social and cognitive skills.
WHAT IS APPLIED BEHAVIORAL ANALYSIS (ABA)?
Behaviorism is the theory that human and animal behavior can be explained in terms of conditioning, without appeal to thoughts or feelings, and that bio-psychological disorders are best treated by altering behavior patterns through applied behavioral analysis or a combination of applied behavioral analysis and psychotropics as needed.
Applied Behavioral Analysis( ABA) is based upon the behavioral theory of B.F. Skinner who believed that higher organisms largely learn through environmental conditioned-responses and that their current [learned] behaviors can be modified by applying what has been traditionally referred to as, “operant- conditioning” (i.e., clinicians modifying either the “antecedent”, that which precipitates a current behavior and/or the “consequences”, which reinforces a current behavior). It has been well established that animals can be taught or “re-conditioned” to obtain or acquire new behaviors in response to their environment, such as the classical illustration of rats or pigeons pushing levers in novel ways to obtain food pellets. Applied behavioral analysis, popularized by the clinical psychologist Ovar I. Lovaas in the 1970’s, who worked with severely behaviorally challenged older children and adults, utilizes operant conditioning and applies it to changing "problematic human behaviors" with targeted and more adaptive replacement behaviors and new skill acquisition. (1)
For example: The clinician initially conducts a functional behavioral assessment of the child's current skill sets through direct observations (e.g., at home, school, etc) and indirect observation (i.e., parent report). If the functional behavioral assessment cannot adequately account for orr determine the function of a specific behavior, the clinician begins a functional behavioral analysis to analyze to a much greater extent the antecedents or motivating operations (i.e., the factors, such as place, time, frequency, occurrence, duration, etc., that precipitate the “child’s behaviors”) and the accompanied consequences that reinforces any given behavior or patterns of behaviors (i.e., how the primary caregivers are responding or other environmental cues/factors as well as any automatic function or “perseverative behaviors” which reinforces the child’s so-called, “interfering behaviors” and that negatively impacts "learning”).
Once the functional behavioral assessment and/or functional behavioral analysis is completed, the clinician proceeds to devise a behavioral treatment plan(s). The treatment plan will first establish a baseline for a particular testing condition such as where, when and how frequently the behavior occurs with respect to the function the so-called, “problem behavior” is serving (e.g., child seeking social attention, desire for highly preferred object; escape from the demands of the task). What are considered successful targeted outcomes is an emphasis on alternative or replacement strategies to the child’s presented “problem behaviors.” This is done over time through the methodical implementation of "schedules of reinforcement" to produce more “positive behaviors. “
The overarching goal (in any treatment plan) is to systematically re-condition the way the child is “inappropriately responding” to his/her environment, which is said to be reinforcing his/her (perceived) antisocial, off-task or “undesirable behaviors. “ The primary goal in ABA is to re-train (i.e., diminish/fade out, extinguish and replace), the child’s so-called, “inappropriate behaviors” with more adult deemed “appropriate or compliant behaviors” as well as in general to target all new academic learning/skill acquisition by implementing various methodologies through top-down behavioral reinforcement.
ABA is all about changing the child’s behavioral responses. It is primarily an adult-directed child approach. It is not a child-centered adult guided approach around the child's functional-emotional developmental stages of dynamic relational "sense-of-self", arousal, autonomic regulation and individual sensory modulation and processing differences. Instead, it is a top-down approach, as its proponents adhere to the principle that only "behaviors" - that which can be empirically or objectively observed and measured - should constitute for the therapist the primary focus and through behavior data collection, "the only proven scientific basis of treatment for children with autism spectrum challenges" as well as other related behavioral based challenges (e.g., ADHD, ODD, etc). Essentially, its advocates hold the belief that the antecedents and consequences of any "problem behavior" once properly understood and analyzed can be step by step systematically re-directed or shaped with the proper implementations of alternative or replacement behaviors (and psychotropic medications as required =hence, a well-established long time collaboration between Phramaceutical industry and behavioral thertpay) through systematic schedules of reinforcement.
"Behaviors" as a rule are not generally considered, for example, as in infant and childhood mental health, developmental neuroscience, psychoanalysis and developmental play based therapy in terms of their deeper affective or social-emotional components. For example, it is well-established in fields of infant through adult mental health the symbolic or external manifestation of what is constitutionally occurring beneath the surface and embodied in terms of the child's neurophysiology. Thus the latter includes a strong emphasis on the child's interpretative feelings (interopception), sensations and correspondingly autonomic nervous system responses/regulation through interpersonal social-emotional interactions (e.g. social-emotional calm and regulation or high levels of stress and anxiety in dyadic interaction with primary caregivers and others).
In fact, for ABA clinicians the use of the phrase. "Beneath the surface of the external manifestation of behavior” is largely and summarily regarded as superstitious myth or possessing little meaning (e.g., depicted as the bygone era of earlier psychoanalysis that has little scientific evidence behind it). Applied Behavioral Analysis understanding of the transformation in the fields of neuoanatomy, neurophysiology, infant child mental health and Interpersonal Neurobiology (see Reserach section) as translated in practice is limited at best. It is only that which can be objectively observed and measured by establishing behavioral baselines and behavioral targeted treatment outcomes, that is, backed by the data driven analysis with respect to the occurrence, duration, frequency of "the challenging behaviors" and their targeted outcomes toward more adaptive or "typical replacement behaviors" (and replicated in well-designed clinical trials that focus on surface performance behaviors) that is deemed worthy by the field of any viable treatment or worthwhile, "scientific analysis."
Therefore, it is not surprising ABA clinicians attribute very little if any importance to the child's unique individual differences and rich internal world (e.g., each child's emotional-sensory modulation processing differences) and how infant and toddlers brains grow and develop in accordance to Developmental Affect Neuroscience and the field of Interpersonal Neurobiology which at each and every single moment helps shed light on forming and informing the language of the child's externalized social-emotional behaviors. The latter in fact is borne out by decades of developmental neuroscientific anatomical research and imaging studies and corresponding comprehensive developmental biopsychosocial evidenced-based treatment perspective. (see Research Section)
Thus, in ABA methodologies the child's intereoceptive and rich internal world and emerging "sense of self " with others (i.e., how s/he is biologically-socially-psychologically registering and processing the world - with respect to the subcortical, limbic hypothalamus, pituitary adrenal axis which is connected to autonomic nervous system sympathetic and parasympathetic regulation) is given little if any significance. For example, Does the child feel overwhelmed ? Underwhelmed? Excessively stressful and therefore avoidant or anxiety ridden and/or shut down (immobilized) with regard to how his/her world is being modulated, registered and interpreted during back and forth social interactions? While comorbidity factors (e.g., previous exposure to nerotoxins and other environmental insults) are taken into consideration, the question of the child's emerging self-concept, that his his/her registered affective "sense of self" with others during moment-to-moment back and forth interactions are not. The latter have very little if any place in the overall treatment protocol or at best addressed as a tertiary or minor concern.
In this sense, ABA methodologies unfortunately under-emphasize or in many cases as colleagues and I have seen inexcusably and entirely overlook or circumvent the child’s earlier Functional-Emotional Developmental milestones. The latter most notably includes clinicians re-addressing due to underlying biological psychological social constitutional based challenges leading to pervasive development disorder earlier parent/child deepening reciprocal attachment, attunement and two-way social-emotional problem solving around the child’s feelings or natural intent, arousal states and autonomic nervous system regulation (i.e. fight, flight, freeze or immbolization responses).
When the foregoing not theoretically but in practice is properly addressed by clinicians guiding primary caregivers it sets the foundations for the child's spontaneous social-emotional initiations and desire to stay in back and forth engagement and social-pragmatic language. However, ABA often circumvents this crucial underlying deepening reciprocal attachment and attunment (which is a part of implicit procedural memory not just declarative memory) and the evidence based developmental neuroscience which supports it. It does not consider the infant/toddler or older child’s emerging “sense of self”- an integral part of infant mental health and early childhood development - a significant factor for clinical emphases (arguably, the child's emotions adjoined with emerging sense-of-self even an “objective reality” apart from or derived solely from the child’s external produced behaviors on command or that which can be subjected to immediate observable and analyzable behaviors - its sole clinical emphasis for measuring progress and change).
The primary focus in ABA methodologies is on the objective manifestation (i.e., data collection and analysis) of what "behaviors" the child is producing and not what the child is actually seeing, feeling and experiencing (e.g., "selective challenging behaviors" targeted for change in contrast to the qualitative - critical developmental capacity - of each child's ability for nuanced emotional-social relating with others). This includes what can be systematically broken down, analyzed and presented in terms of data-driven analyses of newly produced "replacement behaviors" or "positive performance tasks" and not the deeper arousal states, autonomic nervous system regulation and thus the underlying or core aspects of Development (e.g., child's individual, unique and more complex heterogeneous underlying processing differences) that make social-emotional engagement and social/pragmatic conmunication skills problematic.
The latter in contrast to the former places central emphases on nuanced "social emotional connecting and relating with others" which neurophsyiologically integrate skills in a meaningful (i.e., biopsychosocial constitutional) manner. For example, how the child or older is not just evincing new "skills" satisfying the evaluator's demands of checklist criteria but how s/he is actually registering and navigating his/her senses/emotions and processing, regulating and co-regulating pragmatic social-emotional relationships with others (which is an implicit part of procedural memory and underlying processing).
It is in fact emotional-social processing challenges (core executive functioning) and the clinicians both developmentally and intuitively knowing how to attune with and engage the child's heterogeneous sensory modulation and processing differences in the context of family/caregiver relationship patterns, which in turn then helps provide the framework for more sustained regulation/co-regulation needed to help move the child up the Developmental ladder. The latter, from a comprehensive neuroscientific perspective, represents the core challenges associated with ASD and other related functional-emotional developmental and social-pragmatic communication based disorders. (2)
Thus, ABA methodologies do not generally consider “scientifically valid” - or at best tends to minimize the factors that constitute the uniquely complex individual profile of each child’s biological based constitutional and sensory-affect-motor processing strengths and challenges that contributes to and comprises in part the child’s sense of underlying security, well being and infant/toddler emerging personality. Instead, these challenges are primarily viewed as poorly learned, acclimated or maladaptive behaviors that can be re-shaped with properly implemented schedules of reinforcement that target the excessive or disruptive behaviors.
The following is a common example. Typically, children with ASD and other Developmental based challenges have over-responsive, under-responsive or mixed responsivities in one or more areas of their social-sensory-affect-motor system (i.e., proprioceptive, vestibular tactile, auditory, gustatory, olfactory, visual spatial processing areas). (3) From a comprehensive developmental evidence-based perspective, sensory-affect modulation and motor processing differences are viewed as deeply rooted or core aspects of every child’s constitutional differences,. In developmentally competent practice, they need to be focused upon not just per specific (or compartmentalized)targeted processing area but rather guided by all clinicians throughout the day and in the context of warm, pleasurable engagement, that is, as an integral part of the child’s unique differences and emerging “sense of self” and relationship to others.
Nonetheless, in practice from an ABA perspective the child’s sensory-affect-motor processing challenges (e.g., flapping hands, spinning objects and continuous or repetitive movements such as rocking, etc.) are at best addressed in a highly compartmentalized fashion and discouraged during “instructional-task time" (e.g., relegated to two hours or more per week pull out time with an occupational therapist to address motor-function first and sensory input second). In general, they are regarded by the teacher and other clinicians as child "avoidance of task" or “interfering behaviors”, which disrupts receptive comprehension and joint-attention to the "instructional demands of the task" and that should be as soon as possible replaced with more “appropriate replacement behaviors."
Thus the child’s underlying biological sensory-affect modulation processing challenges are primarily regarded as “inappropriately learned responses” (e.g., poorly learned compensating coping mechanisms to the immediate demands of the task) and viewed as aberrant behaviors to be "re-directed by systematically replacing them with more adult deemed appropriate behaviors" rather than empathically, that is,-biopsychosocially understood by each clinician and addressed as core part of the child’s underlying constitutional differences.and an integral part of the child’s emerging “sense-of self.” (I will put aside for the moment both the appeal and the politics of the teacher desiring to maintain classroom homogeneity and control, which then drives or lends itself to the perception - and necessity - to re-direct the child's "off-task behaviors.")
Despite criticisms expressed here, this is not to imply that children receiving ABA do not learn. ABA is an evidenced-based highly data driven behavioral based approach. It is not an evidenced-based data driven neuroscientific Developmental approach. Many children do indeed learn new itemized checklist of “performance-task behaviors and skills” (e.g., greater compliance to a set of memorized-tasks and thus school-skill readiness) through appropriate clinician re-directed behavioral-task reinforcement.
However, from a comprehensive and evidenced-based Developmental perspective they are not acquiring (biopsychosocially speaking) the core Functional Emotional Developmental foundations of social-emotional cognitive and pragmatic language skills nor having sufficiently understood, respected and addressed by the clinician the child's underlying emotional-sensory modulation and sensory processing differences. For example, not just the child's ability to implement or "memorize" new itemized behavioral routine tasks and responses on cue (essentially more adaptive or"functional scripting") but rather, and more crucially, the ability for each child to securely and spontaneously regulate/co-regulate and maintain a meaningful and continuous flow or back and forth spontaneous affective-nonverbal gestural and social/pragmatic language communication with others in entirely new or novel social contexts . (4)
(1) In 1945 B.F. Skinner established the experimental analysis of behavior, otherwise know as "radical behaviorism" to study the effects of behavioral conditioning in both non-humans and human using the core principles of applied behavioral analysis known as operant conditioning. The applied behavioral analysis approach to Child Development was formally proposed as a legitimate field for study in academia by psychologists Dr. Sidney Bijou and Dr. Donald Baer in the late 1950's/early 1960's (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2859799/). It later became greatly popularized in the mainstream public by Dr. O.I , Lovaas in the mid 1960's early 1970's with his work in early intensive behavioral intervention with children with autism, as well as considered at the time other "aberrant behaviors", e.g., pathologies of gender misidentification in young children. See, O. Ivar Lovaas' seminal published paper, Behavioral Treatment and Normal Educational And Intellectual Functioning In Young Autistic Children, 1987 http://www.beca-aba.com/articles-and-forms/lovaas-1987.pdf .; O. Ivar Lovaas and George A Rekers , Behavioral Treatment of Deviant Sex-Role Behaviors In A Male Child, 1974 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1311956/)
ABA is a teacher or adult led methodology and not child led/adult guided around the child’s emotions or sense of self. Its emphasis is on the targeting and changing what it deems, "the child (or older) aberrant or excessive and disruptive challenging behaviors" in accordance to a a predetermined set of societal norms vis-a-vis operant conditioning. This sharply contrasts with a comprehensive functional-emotional developmental perspective (e.g., DIR/Floortime) that addresses the child's core underlying functional emotional social developmental capacities and unique or individual sensory-affect-motor processing differences and child/primary caregiver affect relationship patterns. The latter is deeply rooted in Developmental affect neuroscience, infant and childhood mental health; developmental psychotherapy, psychoanalysis and developmental play therapy. The therapeutic intervention revolves around the child’s natural affect or intent (i.e., the child's range of emotion connected to his/her healthy emerging “sense of self” in spontaneous social regulation/co-regulation with others) creating the necessary foundations for healthy social-emotional cognitive growth and language development. It's biopsychosocial therapeutic framework/lens applies equally to both typical and non-typical development from infancy through adulthood.
In biopsychosocial developmental evidenced based treatment approaches such as DIR/Floortime, “behaviors" are always seen as the symbolic or external manifestation of underlying events. They incidentally and meaningfully begin to change in the course of deepening affect secure reciprocal attachment (e.g., family child/caregiver relationship/engagement patterns) and understanding and addressing the child’s high levels of anxiety and individual underlying sensory modulation differences Specifically, they begin to change as developmental patterns of emotional-social interaction and engagement begin to become more securely, internally regulated, deepened and integrated through the nurturance of co-regulation (see Research Section). This occurs not as primary caregivers or practitioners re-direct the child"to "appropriately perform" on [surface memorized] adult directed object cognitive or language tasks" but rather - internally and in an integrated fashion - as a part of implicit or procedural memory - as we begin to [emotionally] engage the child where s/he and thus begin to Functionally-Developmentally begin address the deeper roots of his/her emotional intelligence. The above is connected to and with the rebuilding of meaningful and sustained social-emotional interactions around the child’s natural affect or emerging relational "sense-of-self" with-others in any given situation or interaction. What should be noted is that this is a typical part of psychobiological development and an integral part of affect neuroscience known as “Interpersonal Neurobiology, see Research Section. (Italics mine.)
(Note: even though arguably the ABA methodology of pivotal response training (PRT) and the Early Start Denver Model does to a much greater extent revolve around the child's interests, the focus is still not on systemic process (i.e., the comprehensive core foundations that Developmentally constitute affective or moment to moment emotional relating and engaging). The latter, such as DIR/Floortime, include, for example, joint co-created/co-narrative moment to moment meaning-making around each child's emerging core emotional-relational and symbolic "sense-of-self with-other" (thus quite different than addressing and targeting "surface behaviors" or a behavioral data-driven model.)
DIR/Floortime addresses as a seamless and integral core part of the child's each and every interaction (rather than attempts to minimize or eliminate as a part of "overall disruptive behavioral patterns that needs to be managed") each child's underlying sensory modulation and processing strengths and challenges (and, at the same moment, family caregiver affective relationship patterns, e.g., clinicians guiding or synchronizing the primary caregivers' affect with an understanding and thus in accord to the child sensory-affect modulation differences) that initially disrupts or makes sustained engagement and further functional-emotional developmental advance problematic. Pivotal response training (PRT ) while centered around the child's interests is much more discretely (individually) rather than interpersonally or co-affecttively-structured (e.g., it is generally taught in a specific a priori sequence of four pivotal learning variables. This includes, motivation, responding to specific cues, self-management and self-initiations and is geared towards a checklist of the specific measurement of the product(s) or outcome(s) of selectively targeted cognitive tasks and behaviors.)
From a neurodevelopmental perspective, it is the child’s natural intent or affective "sense-of-self" (his/her feelings) that is the primary coordination or dyadic regulation factor (we call it the "affective glue") between the child’s sensory-affect-motor processing and the execution and sequencing of social ideas with others (executive functioning). When there are disruptions due to genetic-environmental or biological constitutional challenges between affect and motor planning, as, for example, we see with children with ASD (or non-bio constitutional challenges, as in other social-emotional psychological factors such as early trauma, e.g., avoidant-ambivalent or disorganized attachment patterns, etc.) then there is what becomes known as an affect-diathesis. The following is extraordinarily important reading on these factors and the basis of a major seminal paper by Stanley Greenspan, M.D., "Developmental Pathways To and From Autism: The Role of Emotions in the Core Deficit in Autistic Spectrum Disorders-- The Affect Diathesis Hypothesis." https://drive.google.com/file/d/0B4eYdf4hpBzyRi12eWp5OWx5NE0/view
Moreover, all the above must be considered in the immediate and larger social context, e.g., first and foremost the child/primary caregiver affective relationship dynamics and all others who interact with the child (which is more than a set or a series of labeled behaviors that can be targeted, analyzed and extracted). All of these are organic crucial integral (interpersonal and intrapersonal) aspects that need be both Developmentally theoretically understood and emotionally-pragmatically addressed in a unified fashion by all special educators and other clinicians in each and every session and interaction. Unfortunately, this is generally not the case.
(2) ABA is based upon the theory that all learning is environmental or behavioral conditioned responses and that any internalization or conceptualization of a child’s “sense of self “, that is, apart from the child’s environmentally conditioned behaviors that can be “objectively observed and measured” must, therefore, be regarded as irrelevant or non-pertinent data ( purely extraneous information). In that sense, it regards (relegates more or less to the subjective garbage bin) Infant Mental Health, dyadic developmental psychotherapy and the field of psychology in general apart from behavioral learning theory (i.e., applied behavioral analysis and cognitive behavioral therapies) as non-scientific and fiction [on the basis that] since any conception (i.e., internalized associated feelings) of the toddler’s emerging “sense of self” (or later, the adult’s more mature subjective self) cannot be “objectively observed.”
What can be objectively observed and accounted for is the “data analysis” of the person’s actions (i.e., the antecedents that precipitate a desired behavior or the consequences that reinforce a desired behavior). A simple example, the child has a tantrum the mother responds and give the child her toy, etc. The pedagogy here is, “You cannot observe or engage a child’s affect or feelings you can only observe and measure a child’s actions” (i.e., the concrete action/duration of the precipitating behavior and the consequential actions that reinforces that behavior). It is upon this “scientific” or rather pseudo-scientific ideological position that behavioral analysts make no attempt to look at the child’s emotions or feelings from the child’s perspective, as the child’s natural intent, feelings or affect (i.e., the child’s sensory-affect-motor connections) is not something that can be subjected to the rigors of “scientific measurement” (i.e., "behavioral data collection and analysis”). It must, therefore, be “objectively” cast or placed aside in the evanescent black hole of “subjective interpretation.” (even though decades of anatomical research and infinitely improved fMRI shows precisely what does occur prenatally on.)
Therefore, what developmental therapists/educators refer to as the child’s emotional or executive functioning (praxis) and his/her emerging “sense of self “ (and the substantive neurophysiological data that demonstrates what occurs in neurotypical or non-neuroypical development through the Developmental stages) as the child's healthy affective sense-of-self is properly/improperly engaged, see Research Section) is not given by behaviorists any consideration as part of any "sound scientific basis" with children (or older) with ASD to address cognitive, language and social challenges/deficits but only the child's immediate observable behaviors (i.e., a schematized checklist of agreed upon behaviors) as subjective “emotions or feelings” cannot be objectively observed only the child's external actions modified by operant conditioning; and measured through data analysis to verify their targeted and achieved [behavioral] outcomes.
Thus, it is upon this premise that ABA clinicians generally never attempt to form an emotional bond or relationship with the child, that is to say, from the child’s perspective and thus attribute purpose and meaning to the child’s natural intent (affect) and thereby begin to embark upon “real-shared perspective taking” and participation with the child’s expanding inter-subjective “sense of self”, which includes spontaneous curiosity and interest in the world (or guide and encourage parents to do likewise) but exclusively look at the child’s "targeted and reinforced memorized responses" and thus "appropriate behavioral-task achieved outcomes”, as these are the only “real things” (i.e.,data-taking over bonding) that stand up to the snuff test of “objective scientific measurement” or “real science” (i.e., applied behavioral analysis) in contrast to the nebulous or phantasmagoric pursuit of engaging a child’s feelings or emotions (i.e., inter-subjectivity or “pseudo-science”).
This is not to say that behavioral clinicians are disembodied bots. They do systematically proceed in treatment to form a happy and engaging “relationship with the child” (i.e., during performance-tasks at table or on the floor in play) but based solely upon the child’s compliance to the specific targeted outcomes in the child’s individual behavioral treatment plan as the child begins to acquire discrete to more general memorized performance based routines/skills on a checklist.
(3) Sensory-affect-motor processing challenges should never be viewed as the child's (or older) inappropriate sets of poorly learned (or poorly gauged) default behaviors/mechanisms that need to be replaced with more "appropriate behaviors" in order for the child to complete the "demands of the task" (even the term, "demands of the task" is problematic as it is accompanied by a misunderstanding or simply a neglect to look at the arousal necessary to attend or interferes in attending , e.g., the hypervigilance , anxieties stressors and other constitutional, social and psychological factors which I will address elsewhere), nor for that matter should it ever be addressed in isolation (e.g., as it often is compartmentalized by the OT whereby the child receives occupational therapy X times weekly). Instead, it must be fully respected, understood and addressed by all clinicians and primary caregivers as a part of the child’s biological constitutional differences and developing emerging sense-of-self throughout the day in all activities.* (For a detailed overview presentation by eminent DIR/Floortime OT, Rosemary White , https://www.fresnostate.edu/chhs/ccci/documents/06.19.15%20Slides.pdf
*The following article was published by TIME Magazine in 2006 but is still highly pertinent and gives a brief insight and overview with respect to the two different approaches, ABA and DIR/Floortime in an actual school setting. https://www.celebratethechildren.org/uploads/1/8/3/9/18392315/a_tale_of_two_schools_--_printout_--_time.pdf
4) " No study has found evidence that ABA increases spontaneity, initiation of conversations or social and emotional reciprocity—core deficits of Autism." Spreckley M., Boyd R. (2009) Efficacy of Applied Behavioral Intervention in Preschool Children with Autism for Improving Cognitive, Language and Adaptive Behavior: A Systematic Review and Meta-analysis. The Journal of Pediatrics, 154 (3); 338-344.
The following is an extremely important link for all primary caregivers and clinicians with respect to advocacy for their children, intervention guidance, ,public policy, insurance coverage and the adjoining supportive research evidence for a comprehensive Developmental Relationship based approach such as DIR/Floortime, included as well are answers to common questions from families on ABA which is distortedly presented as the only evidenced-based treatment approach for children with ASD and related challenges.
I am devastated! My child just turned 26 months and just began early intervention. He just received today a diagnosis by our developmental pediatrician of moderate autism with global delays. In order for my child to be able to develop cognitive and language skills, such as understanding and using simple gestures and words to get his needs met doesn't he first need to learn how not be self-directed and instead learn how to follow simple adult commands? This is clearly told to me by my child's evaluation team and then written on my child's IFSP (early intervention plan) as one of the primary goals we should be working on!
No! Although seemingly commonsense, as it is taken for granted by many special educators and other clinicians in the field, it is developmentally speaking quite misguided. What is often left entirely unaddressed due to lack of education are the underlying core milestones prior to your child learning to follow simple commands or adult directions. These milestones include first and foremost your child's ability to be comfortable in his body and environment and his/her natural desire to want form and maintain simple and meaningful back and forth social-emotional engagement.
It is absolutely critical that your child first begins to maintain spontaneous simple back and forth social-emotional engagement with you rather than following simple adult directions on command. When your child begins to relate and engage s/he is beginning to expand his/her receptive understanding. For example, your child begins the DEVELOPMENTAL critical process of reading and processing your facial and bodily gestures; rhythm, tone and inflexion in your voice.
S/he begins to make more consistent eye contact with you not because s/he is being commanded or trained to do so (i.e., "Look at me" and consequently receives a reinforcer or "reward" such as a cookie or an ad nauseam, verbal, 'Good job'") but rather because it becomes increasingly pleasurable to spontaneously maintain back and forth co-regulated attunement and engagement with you (i.e., critically internally registered by your child's emerging "sense-of-self "as secure, safe and desirable to do so). Your child following simple to more complex directions should never be thought of in the common dumb down, developmentally inaccurate conveyed advice of, "Compliance vs. non-compliance to the demands of the task." Rather more humanely, empathetically and in keeping with a neurodevelopmental perspective, it simply a matter of your child being able to securely and comfortably process his/her social-emotional environment.
What must be first absolutely and clearly understood by everyone (e.g., parents, clinicians, schools, daycare providers, et al) is that there is a basic and fundamental core Developmental understanding and difference between your "Child Wanting to Engage because s/he feels Comfortable and is Enjoyable To Do So" and your "Child Engaging because s/he has been Trained To Follow Commands." In the first instance your child is being encourage to naturally [spontaneously] engage because s/he is learning how to slowly (and calmly with respect to his/her autonomic system) co-regulate with others his/her own internal processes (which includes constitutional differences in how your child is registering, interpreting and modulating his/her sensory processing differences) and use of ideas to bring "the process of engagement online" in accordance to his/her natural pleasurable emotions (affect) or intent. This process involves the clinicians slowly and systematically guiding you how to follow your child's lead and to join in with your child's natural interests or emotions in order to convey to your child a deeper sense of safety, well-being, trust, curiosity, excitement and interest.
We can call the latter, however, "unscientific" it may sound but is extraordinarily so, "a wooing process" (see our Research section) rather than as is done in traditional behavioral based methodologies (ABA) a trained behaviorally reinforced or monkey see as I do or "command you to do" process, where your child in accordance to schedules of behavioral reinforcement receives a verbal or concrete token/reinforcer after properly complying with the demands of the task (e.g., a cookie, toy, robotic "Good Job", etc). Following your child's lead and wooing him/her into wanting to engage begins to cultivate authentic and spontaneously meaningful back and forth social engagement and begins to neurophysiologically establish the functional-emotional developmental foundations for simple to increasingly complex symbolic ideas and meaningful (social-pragmatic) expressive language.
This necessitates the necessary arousal, security and integration of your child's senses-emotions-and motor planning/coordination (executive functioning) on a simple back-and-forth neurophysiological social-emotional interactive level. We call this the opening and closing of simple circles of social-emotional communication. This begins from infancy, mommy smiles to baby, a smile begets a smile, a frown a frown and so forth, It is extraordinarily useful if not critical to begin to think not in terms of your child's "non-compliant vs compliant behaviors" but more accurately, expansively and respectfully with what we refer to from a comprehensive evidenced based bio psycho social developmental perspective as your child's unique individual processing differences or "sensory-affect-motor connections."
This involves at a minimum a basic practical knowledge from the clinician with respect to the ability of your child to obtain/exert the necessary arousal to initially sustain back and forth attention/interaction, depending upon his individual sensory profile (e.g., calm or excitement) in order to integrate and co-regulate/co-communicate with others simple to complex two-way back and forth social-emotional engagement. Moderate disruptions in your child's sensory-affect-motor connections (i.e., under-responsivity, over-responsivity or mixed responsivities in or across one or more sensory-affect motor domains, vestibular, tactile, proprioceptive, visual spatial, interoceptive, etc) creates mild to severe challenges in establishing and maintaining basic core social engagement and communication. So it is never a question (as much as it is often regrettably presented by special educators and other clinicians, ad nauseam) of your child learning to be compliant to the task or follow on command more "appropriate behavioral responses" (and all too often as egregiously done as a "sensory reward", i.e., give him 5 minutes on bouncing up and down on a large ball, trampoline or on a swing) but rather you beginning to learn how to woo, soothe and co-regulate with your child across many different instances and throughout the day to make engagement desirable pleasurable and sustainable!
Can you elaborate a bit more on what you mean by sensory-affect-motor connections?
Your child's senses includes how he is registering, acclimating and interpreting the world around him through all his senses, as we all do (for example, touch, sound, movement, taste, smell and visual-spatial processing and the overall sense of the internal state of the body; typically referred to by clinicians as tactile, auditory gustatory, proprioceptive, vestibular and interoceptive. Affect is your child's natural intent(or range of emotion) which is connected to and an essential core part of his emerging "sense of self" during all back and forth interactions. For example, Is what your child seeing, touching and hearing pleasurable or overwhelming and aversive to him? Motor planning; How does your child transition between seeing and desiring a particular desired object to executing his ideas (what we call praxis) to obtain that desired object or make his needs known to you? How does he move his body, turn, reach for and take what he desires - that is, specifically in accordance to his natural intent and integration or synchronization with how he is receiving, interpreting and thus avoiding or proactively responding to his environment?
Now, this naturally varies greatly from child to child. For example: Auditory processing: certain foreground or background sounds a little too loud or not stimulating enough. Tactile processing: a little touch too overwhelming or underwhelming and therefore your child might seek out less or more touch, and so forth. Visual-spatial processing , too many objects or people (or an internal flood of ideas around each object or person) in my surrounding space confusing and overwhelming or simply needing the visual constant reminder of mommy physically present rather than in the adjacent room lest s/he panics, etc.
Again, we refer to this as your child's sensory-affect motor connections (one child can be hypoactive, hyperactive or have mixed responsivities across one or more sensory domains). In typical development, this is a more or less "smoothly coordinated" and thus well-regulated integrated sensory-affect-motor patterns are in place and which are necessary for simple to increasingly complex spontaneous reciprocal back and forth social-emotional engagement with you and others, see, https://www.spdstar.org/basic/understanding-sensory-processing-disorder (Also, the following is a brief clip from an early Stanley Greenspan, M.D. talk on a case history of a 17 month old heading into the autistic spectrum but through proper identification and address of sensory regulatory challenges was averted https://www.youtube.com/watch?v=3IfKs5nTgq8 )
However, to simply label (as is too often done by clinicians in the home or in the schools) how your child is poorly coordinating the demands of arousal needed for attention and registration of sensory input in coordination with his motor planning and guided by his executive functioning (emerging "sense of self") as your child's cognitively or behaviorally challenged "non-compliant and inappropriate behaviors" we would argue from a Developmental perspective is inaccurate and grossly simplistic with respect to a deeper more complex understanding of your child either typically or with challenges.
Now, this might be true if we decide to turn a blind eye and decidedly blindly paint with such a broad brush as to smooth over (blithely ignore) your child's actual Functional Emotional Developmental milestones and underlying sensory processing differences. In other words, if we decidedly turn a blind eye and just look just at and condition your child on the surface to become "compliant" (i.e., to fit a certain test measure and once compliant check it off as completed on a checklist) and egregiously not look at the language behind your child's behaviors or what his/her behaviors are actually communicating and, in fact, disrupting his/her ability to maintain simple to more complex engagement.
From an evidenced-based neurodevelopmental perspective, the traditional behavioral interpretation of your child adversely genetically and environmentally conditioned (e.g., either due to prenatal bio-genetic constitutional differences or environmental parental reinforcement) and consequently engaging in "non-compliant or inappropriate behaviors" which need to be "re-trained" not only often demonstrates a profound lack of Developmental understanding but can significantly leave unaddressed the core challenges associated with ASD (i.e., spontaneous social relating, thinking and engaging) and in many instances can significantly hold back your child's developmental functional-emotional milestone advance.
What is presented to parents as a-friendly dumb-down test assessment/protocol checklist of compartmentalized reductionist inappropriate or non-compliant behaviors vs appropriate or compliant behaviors magnificently often fails to A) Take the time to comprehensively Developmentally and empathically understand and appreciate your child's unique differences (strengths and challenges) and self-perspective and B) Begin to meaningfully address your child's not surface behaviors ("non-compliant vs. compliant) but his/her actual underlying emotional-sensory modulation and processing challenges that in fact make back and forth engaging challenging. and C) Subsequently, begin to systematically guide you and others to attribute both purpose and meaning to where your child actually is in order to make engagement possible, enjoyable, sustainable and expansive with respect to affective ideation and social-pragmatic language.
Again, it is not about training your child on more "appropriate replacement behaviors" (a profoundly misguided and simplistic phrase conveyed to parents). Rather, it is about you, as well as other clinicians, beginning to learn how to understand how to understand the functional emotional developmental capacities, unique processing dynamics and complexity of your child and effectively begin woo your child into back-and-forth relating and engaging (that is, as an integral part of understanding, engaging your child's functional-emotional, sensory modulation and sensory processing differences) in order to effectuate not rote [memorized] responses on command (blindly, dutifully and conveniently marked + or - by the therapist on a checklist) but rather sustained spontaneous meaningful and integrated functional-emotional developmental engagement which will meaningfully and sustainably move your child up the Developmental ladder.
Your child's spontaneous reciprocal back and forth desire to not only initiate but to stay in engagement and relate with you and others is in fact a biopsychosocial process. It is in fact the most basic and primary core challenges of children with mild to severe autism spectrum challenges. Thus, we can state rule number one: Purposeful and meaningful engagement does not and cannot ever come from children trained and prompted to follow behaviors' on command (otherwise more popularly known as "more appropriate replacement behaviors"). Rather in order to be developmentally clinically significant and meaningful it must come from your child's core executive functioning - that is, his/her internal or integrated and spontaneous "sense of self" in relationship to you and others. Your child's social "sense-of-self "or range of affect is also what happens to occupy the largest part of the brain and is referred to as"executive functioning. " For example,
From the perspective of your child your child thinks: "I see it, I want it, How am I going to get it (cookie, toy, ball. etc.)?" Well, this entails a most basic and necessary integration of his emotional-sensory and motor functioning guided by his executive functioning (i.e., his emerging comfortable, pleasurable, regulated sense of self with other) . The latter is a fundamental part of nuanced back and forth social communication (i.e., maintained regulated/co-regulated co-affective emotional signaling between you and your child that each and every clinician should understand and be implementing ). In other words, an authentic, spontaneous and integral part of all fundamental social communication rather than a focus on grooming or training your child' to respond in a mechanical fashion ("compliant behaviors") in order to "prepare him for preschool readiness skills" , which absolutely has nothing to do with addressing the underlying core functional-emotional developmental capacities.
There is often an erroneous and egregiously false assumption made by many special educators and other clinicians that your child simply doesn't receptively/cognitively "understand"so s/he needs to be defacto repetitively tasked- to death ("trained") on a series of "targeted behaviors" to perform what is expected. From an evidenced-based and comprehensive developmental perspective, it is in fact your child's executive functioning ("sense of self") that developmentally and meaningfully guides your child's own decision making process-and-spontaneous joy to want to maintain social engagement with others! Without all educators and other therapists understanding and adequately addressing this, they are training your child to mechanically perform thousands of series of robotic or performance on command behaviors. This is clearly what we do not want!
However, let us go back for a moment and entertain the traditionally more popular folk wisdom, "Your child must be trained to follow simple to more complex commands." What is being conveyed to your child is that once s/he performs the "demands of the task", however disassociated or unconnected from his natural desire or intent, such as "Look at me", Touch nose" or "Point to blue," s/he will get an external reward for performing on command (i.e., "Cookie", Ipad, etc ). Now, what may be understandably confusing to parents is that it may look like the same thing or may seem to later lead to purposeful engagement (i.e., after all, you might ask, "Isn't my child now following commands and by definition 'purposefully engaging?''). However, the answer is a resounding NO!
The latter is a behavioral and non-developmental piecemeal by piecemeal. adult-led external-behavioral reinforcement of your child performing a hierarchy of [memorized[ selectively compliant or "surface responses on cue" (and not internally driven by your child's motivation coming from his/her sense of self in relationship to his environment and others). Thus, the so-called, "behavioral-scientific methodology" (with tomes of evidentiary support) proceeds on the basis of instituting specific "schedules of reinforcement" in order to cultivate and present precise analyzable steps of selective targeted behavior(s) achieved by the child. For example, first s/he demonstrates those performance behavioral tasks n isolation then generalization of those tasks that are then "objectively" marked off an evaluative protocol (checklist) as achieved. However, unfortunately the prefrontal cortex (i.e., core executive functioning) and the associated affective(emotional) engagement of your child (which do not consist of nor are they reducible to a series of "trained behaviors") are not taken into consideration as part of your child's quite necessary Functional-Emotional Developmental and therapeutic process.
Thus, the daily focus and goal when your child is "commanded to perform" and be in compliance to the demands of the task (and rote memorization of those tasks in general activities) is the exact opposite of your child's absolute and non-negotiable spontaneous back and forth social-emotional relating (again, the core critical factor with children with ASD ). It is your child's natural intent or emotions (which is not some vague or insubstantial term but rather the central navigation or coordinating emotional glue) which specifically guides and helps coordinate (implement/regulate) your child's sensory-affect motor functioning and integrally connected to his/her overall executive functioning). His/her ability to engage not from memorized routines (functional memorized scripts) but in a novel and spontaneous fashion (i.e. executive core functioning) , spontaneously opening and closing circles of communication with social-pragmatic language in back and forth social-emotional engagement. Critically, the first traditional prescription often found on most IFSP's as an early goal: "Johnny will learn to follow a series of adult led tasks or commands" is thus neither child initiated nor driven by your child's primary and necessary executive functioning or internal desire to want to spontaneously maintain social reciprocal engagement with you simply for the joy, curiosity and desire to do so and with no extrinsic or concretely proffered reward or robotic reinforcement, except for the "reward" of the joy and desire of the engagement itself. We cannot emphasize this enough: The former does not lead to the latter!
Furthermore, there is another often egregiously false assumption made with regards to your child's cognitive delays. Your child not knowing how to feel comfortable in engaging or relating with others is often neither a cognitive deficit nor a cognitive deficit that constitutes a series of steps that need to be broken down and repetitively reinforced , nonetheless it is almost universally proceeded as is and must be broken down as such for purposes of his/her comprehension. The reality is, when your child's executive functioning begins to come "online", his whole body, his whole self is part and parcel of that social-reciprocal engagement or nuanced back and forth interactions with you and others. However, when back and forth reciprocal engagement around your child's natural intent is not cultivated but is from the get-go dumb-down , e.g., as is traditionally done mechanically taught or incidentally taught as a "series of commands", a series of broken down steps that your child has to learn one by one and performed "on cue" it is not! "Compliance" neither can ever be reduced to nor is it equal to authentic engagement. It must come from your child's executive functioning (whole self) otherwise the "engagement" itself invariably tends to be splintered, disassociated, scripted and mechanical!
Simply, when the internal motivation of the child is the primary focus, the joie d' vivre is the engagement itself! (This should be the focus of early intervention from day one). The latter then leads your child to come back for more! How about that, it is actually pleasurable to engage and not because s/he is being spoon-fed/reinforced by an external concrete or verbal reward for compliance! So, again, the following needs to be thoroughly understood: Compliance is not engagement! Nor does compliance lead to social-relatedness that is required. There is an enormous difference between having your child's hippocampus (memory) trained by you and/or clinician taking an interaction for your child to perform and breaking it down into "simple and manageable steps" (i.e., "First we do A, then B then C", which can appear convincing and reasonable but it is not) and not having those steps taught, broken down and robotically reinforced at all!
Core executive functioning: As your child begins to spontaneously engage and thus understand the nature of the interaction, the formerly adult piecemeal , broken down artificially and mechanically taught steps" (i.e. first we do A, then B, then C) become no longer necessary. Why? Because the language of the interactions, the critical language of social-emotional engagement is implicitly understood and along with that so are intuitively the steps involved in many directions or the "following of tasks."
Again, this extremely important to understand. What is typically not recognized by the vast majority of special educators and other clinicians in the field is that once the child's "social-emotional engagement comes online" the receptive understanding begin to not only follow but in fact with many children does so exponentially! In other words, as the "emotional-social engagement" (spontaneous back and forth co-emotional signaling) becomes more pleasurable, comfortable, enjoyable, spontaneous and reciprocal for the child so then follows what had formerly (in many instances unquestionably) "appeared to have been deficits in receptive language and cognitive functioning begins instead to become spontaneously demonstrated by the child. In a vast and understated majority of cases those apparent initially diagnosed are in fact actually core challenges in comfortability and fluidity of maintaining social-emotional engagement compounded by underlying over, under or mixed responsivities in sensory modulation and sensory processing domains.!
Genuine engagement (e.g., functional-emotional developmental differences and and underlying processing challenges) is much, much more complex than "child compliance to the demands of the task." The contrast between addressing core executive functioning (i.e., wanting, curious desiring to engage coming from your child's internal or core affective sense-of self) and child compliance to the demand of the task should never be confused! The child led by the special educators and other clinicians through various positive behavioral supports and applied behavioral analysis to "complete the demands of the task" is sadly (and I am potentially risking the ire of many by asserting so) deceptively passed off under the auspices of a "the only or most proven scientific methodologyto address child with ASD." Yes, indeed, the child (albeit quite mechanically) is taught to comply and complete a series of specific to generalized tasks on a checklist (the status quo or soup de jour in early intervention and traditional behavioral based methodology). Tragically, this is a horrible caricature from an evidenced-based neurodevelopmental perspective what purposeful, meaningful and significant engagement is and thus falls far short, as we blindly (often from day one) fail to adequately and meaningfully address the core challenges with children with ASDand other developmental communicative challenges We do not want a child who is engaging because s/he has been repetitively trained to engage and memorize many task-performance based routines. We want a child who is utilizing and integrating his/her core emotional-developmental capacities to warmly, spontaneously engage with curiosity and simple to deeper levels of reflection in each and every newly presented encounter!