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 intervention focus is not, as in traditional behavioral approaches (applied behavioral analysis) concerned with adults changing the child’s “surface behaviors” but rather clinicians respectfully, slowly and consistently guiding primary caregivers to learn how to understand, listen and go directly to their child’s world to functionally 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 back and forth co-regulated emotional signaling with facial and bodily gestures, sequencing of ideas and expressive language).
Clinicians gently and systematically guide primary caregivers to developmentally, functionally-emotionally and empathically, understand their child's processing differences and to go where their child currently is for the purposes of deepening reciprocal affective 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 "behaviors" are not isolated, targeted and analyzed for modification but progressively and positively change in the course of guiding primary caregivers to warm and pleasurable engagement and simple to increasingly complex back and forth reciprocal-emotional problem solving scenarios during 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 social communicative relationships, the foundation for ALL developmental growth, engagement and leaning. Therefore, from a Developmental evidenced-based practice, the child's Functional Emotional Developmental milestones and sensory-affect-motor processing differences (i.e., proprioceptive, vestibular, auditory, tactile, visual-spatial) never proceeds by clinicians labeling, managing and training 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 (i.e., 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 two-way emotional problem solving with primary caregivers and peers. Importantly, with respect to the latter what is required by special educators and clinicians is an in-depth developmental psychological-emotional understanding of each child’s Functional-Emotional Developmental milestones and unique 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.
By clinicians engaging the whole child's nuanced biological-psychological and social development (e.g., where s/he 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, tactile, visual-spatial processing, gustatory; proprioceptive, vestibular, etc.) clinicians are in effect guiding primary caregivers to meaningfully deepen 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 approach such as DIR/Floortime is in direct contrast to traditional behavioral based methodologies that target, analyze and manage the child’s “surface behaviors” where, for example, the child is trained to comply on command to the clinician to complete individual or generalized "itemized checklist tasks" and is subsequently reinforced by an external reward (i.e., a cookie, favorite cartoon or a toy, or a vapid, repetitive, ad nauseam, "Good Job" by the clinician) upon performance.
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. By clinicians and primary caregivers doing the latter, this aids in fully supporting and strengthening the child’s underlying core Developmental capacities or milestones and as an integral part of this process, the child's healthy emerging “sense-of-self” as each child hierarchically moves up the neurodevelopmental ladder (i.e., 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 milestones) (3)
(1) The six-basic functional-emotional developmental capacities or milestones that are typically successively acquired from birth and 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
For 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 as we target greater or 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 target and analyze "behaviors” but rather we address the whole child (e.g., what is behind the behavior or what the behavior symbolically represents and is communicating with respect to the child's underlying emotional-sensory modulation, processing and motor planning differences). Therefore, with respect to what constitutes healthy developing minds-and-bodies we do not (as is commonly the case in ABA) simplistically label either a child's underlying sensory-affect-motor processing differences or developmental challenges as "inappropriately learned" or "non-compliant behaviors" but rather address the whole child in a fully integrated manner and always in the context of emerging relationship patterns of child/parent attachment, attunement and simple to complex reciprocal social-emotional engagement. * 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 the child’s natural feelings or emerging “sense of self”) they become integrated, spontaneous and meaningful. However, when tasks or “behaviors” are addressed in an isolated manner or targeted apart from the child's pleasurable dynamics of social-emotional relating and engaging then those targeted "performance-behavioral skills" become splintered, mechanical and disassociated from the child’s natural developing and integrated spontaneous “sense of self" (e.g., the clinician directs child to complete a series of performance behavioral-cognitive checklist tasks - often under the guise of "necessary preschool/school readiness skills" rather than a focus on the more functional- emotional Developmental undertaking of engaging the child where s/he is, that is as an integral and core part of two-way reciprocal social-emotional problem solving around the child's affective interests).
Therefore, it ought not at all be surprising what we commonly see when behavioral based (ABA) methodologies are used with very rare exception is that the child’s "trained verbal and non-verbal language" tend to become highly mechanical or contextually restrictive memorized responses, essentially, an adaptation of new and improved functional scripted responses (e.g.,, child behaviorally conditioned/trained to think/respond, “I touch, say or do ‘X’ when ‘X’ happens”). This is in marked contrast to the child successfully [functionally emotionally-developmentally] guided to spontaneously learn to use his/her greater "social-emotional-problem solving capacities" (i.e., core executive functioning) not to simply [mechanically] provide a set of newly memorized responses on cue (e.g., with the same unvarying or flat affect across different situations or person to person encounters) but rather to spontaneously emotionally-cognitively register, assess, attune and respond to each person or encounter in increasingly novel ways. In other words, the child (or older) communicating from a more internally secure, co-regulated and integrated affective manner and thus functionally able to more fully receptively process, understand and proactively respond to what is actually being both non-verbally and verbally communicated by others.
The primary point that I want to emphasize here is that these typical earlier and extremely critical Functional Emotional Developmental foundations (i.e., addressing the child's earlier internal regulation/co-regulation and thus emotive or affective developing "sense of self " with primary caregivers and others during back and forth social engagement) absolutely necessitates that special educators and other clinicians need to (A) Understand what are the typical foundations of infant mental health and early childhood development, (B) Understand what are the core challenges associated with ASD. (C) Accordingly, address not the child’s surface [behavioral]non-compliant responses and turn or re-direct, them into "compliant responses" but the child's deeper primary earlier core executive challenges (in a completely respectful and integrated manner) which then leads to reduced anxiety, increased pleasurable, meaningful and sustained engagement.
For example, not the child’s ability to identify, label, match and imitate (i.e., looking, pointing or utterance upon rote memorization or command) but much more importantly clinicians guiding primary caregivers to understand, listen attune and guide their child to proactively initiate, play with affect/emotion and communicate with other(s) in novel rather than in scripted manners, that is, from the child’s perspective (i.e., his/her emerging core “sense of self” in relationship to others).
While new selectively targeted skills acquired by the child using various schedules of reinforcement (i.e., trained memorized behavioral/tasks on a laundry checklist of skills largely for satisfying a certain proven rote state guideline measurement of performance - and pardon my cynicism with respect to appeasing parents, school boards and funding) may naturally appear to be a "remarkable achievement", whereas formerly, for example, the child 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, when those targeted "discrete tasks or skills” are not robotically or 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 or misguided belief of the “the only scientifically proven methodology for children with ASD, applied behavioral analysis" ) but rather 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 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" but rather as the evidenced based neurodevelopmental facts clearly demonstrate and demand on core executive functioning or praxis.
Again, this necessitates on part of every clinician and primary caregiver 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 - 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" (the Developmental Social Pragmatics of engagement). 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 to meaningfully 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 accordance to what is actually being communicated non-verbally-and-verbally by others in any given situation or moment. It is precisely the latter which enables each child (or older) from a comprehensive Developmental perspective to move up the developmental ladder with respect to nonverbal and expressive language, social and cognitive skills.
WHAT IS APPLIED BEHAVIORAL ANALYSIS (ABA)?
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 I.O. Lovaas in the 1970’s, who worked with severely behaviorally challenged older children and adults, utilizes operant conditioning and applies it to changing human behavior or new targeted skills acquisition. (1)
For example: The clinician initially conducts a functional behavioral assessment of the child's current skill sets. Following the functional behavioral assessment the clinician proceeds to conduct a functional behavioral analysis to determine more precisely how the child’s behaviors are reinforced (i.e., what consequence or reward the child is deriving from the adult deemed “undesired or inappropriate behaviors”). A functional behavioral analysis analyses 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 consequences that reinforces any given behavior or patterns of behaviors (i.e., how the primary caregivers are responding or other environmental cues/factors that reinforces the child’s “interfering behaviors” that negatively impacts learning).
Once the initial analysis is completed, the clinician proceeds to devise a behavioral treatment plan(s). This is a focus on detailed "schedules of reinforcement" to re-condition the way the child is inappropriately responding to his/her environment. The primary goal in ABA is to systematically re-train or replace the child’s “inappropriate or aberrant behaviors” with more adult deemed “appropriate or compliant behaviors” as well as in general to target all new learning skills acquisition by implementing various methodologies of behavioral reinforcement.
ABA is all about changing the child’s behavioral responses. It is primarily an adult-directed approach, not a child-centered adult guided approach. 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 the sole "scientific" basis of treatment for children with autism spectrum challenges and other "behavioral based challenges." It believes that the antecedents and consequences of "any behavior" once properly understood and analyzed can be systematically re-directed or shaped with the proper implementation of reinforcement. Thus, in practice, it attributes very little if any importance to the child's internal world (e.g.., sensory modulation and sensory-motor processing differences) associated with the child's external behaviors. Thus the child's emerging "sense of self" or view of the world (e.g.., how s/he is biopsychosocially taking in, registering and processing his/her world) has very little if any place in the treatment process).
ABA methodologies generally do not address the child’s earlier Functional-Emotional Developmental capacities or milestones, specifically the significance of earlier parent/child deepening reciprocal attachment, attunement and two-way social-emotional problem solving around the child’s feelings or natural intent or for that matter even considers 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 (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 behaviors or that which can be subjected to immediate, empirical, observable, and analyzable behaviors - its sole emphasis for measuring progress and change).
Thus the primary emphasis is on what "behaviors" the child is producing (i.e., what can be systematically broken down, analyzed and presented in terms of newly "successfully produced" child performance-behavioral tasks) and not the deeper core aspects of Development: the child's unique and more complex heterogeneous underlying processing differences (i.e., how the child or older is registering and navigating his/her senses/emotions and processing, regulating and co-regulating social-relationships with others). It is in fact the core emotive social processing challenges (executive functioning) and the clinician knowing how to attune with and developmentally engage the child's heterogeneous sensory modulation and processing differences in the context of family/caregiver relationship patterns which co-regulate and help the child up the Developmental ladder (i.e., in contrast to changing the child's targeted surface behaviors or newly trained memorized responses) which represent the core challenges connected with ASD and other related developmental and 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 are primarily viewed as poorly learned, acclimated or maladaptive 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 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 [delimited 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 frequent movements such as rocking, etc.) are at best addressed in a delimited or 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 - and the child be anxious and overwhelmed or underwhelmed not at all). 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 (vis a vis behavioral schedules of reinforcement) with more “appropriate behaviors.”
Thus the child’s underlying individual sensory-affect motor processing challenges are primarily regarded as “inappropriately learned responses” (e.g., poorly learned compensating coping mechanisms to the 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, developmentally and systematically understood 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 of the child's "off-task behaviors.")
All what I have said here is not to imply that children receiving ABA do not learn. ABA is an evidenced-based behavioral approach. It is not an evidenced-based developmental approach. Many children do indeed learn new itemized “performance-task behaviors and skills” (e.g., greater compliance to a set of tasks and school-skill readiness) through appropriate clinician re-directed behavioral-task reinforcement. However, from a comprehensive and evidenced-based Developmental perspective they are not acquiring (neurophysiologically) 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 sensory modulation and sensory processing differences. For example, not just the child's ability to memorize new itemized behavioral routine tasks and responses but critically each child spontaneously regulating/co-regulating and maintaining a back and forth continuous flow of spontaneous affective-nonverbal gestural and social/pragmatic language communication with others in entirely new or novel social contexts . (4)
(1) Applied behavioral analysis (ABA) is a teacher or adult led methodology and not child led/adult guided around the child’s sense of self, i.e., the child’s functional emotional developmental levels, which include the child’s unique affective or emotional dynamics that comprises the child’s natural intent (his/her healthy emerging “sense of self”) and constitutional differences.
(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 relating and engaging). The latter, comprehensive developmental approaches such as DIR/Floortime, includes, for example, joint co-created/co-narrative meaning-making centered around the child's emerging core affective relational and symbolic "sense-of-self with-other" and at the same moment, addressed as an integral core part of the child's each and every interaction his/her underlying sensory modulation and processing challenges (and family caregiver affective relationship patterms) that make sustained engagement and further functional-emotional developmental advance problematic. Instead the former are geared towards the specific measurement of the product(s) or outcome(s) of the selective cognitive tasks or behaviors targeted.)
It is the child’s natural intent or affective "sense-of-self" that is the primary coordination or regulation factor between the child’s sensory-affect-motor processing and the execution and sequencing of social ideas (executive functioning). When there are disruptions due to 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/ambivalent or disorganized attachment, 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 crucial integral organic (interpersonal and intrapersonal) components 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.
(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.”
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 ronly 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” 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 receive occupational therapy X times weekly) but 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.*
*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 greatly alarmed! My child just turned two and just began early intervention. We just received 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 gestures and putting words together doesn't he first need to learn how to follow simple adult commands? This is clearly stated on my child's IFSP (early intervention plan) as one of the primary goals!
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 egregiously left entirely unaddressed 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 engagement.
It is absolutely critical that your child first begins to maintain spontaneous simple back and forth social 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 important 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 (importantly, 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 dumb down, developmentally inaccurate and polarized terms of "compliance vs. non-compliance." It is a matter of your child being able to securely and comfortably process his/her social environment.
What must be first absolutely and clearly understood by everyone (from parents, clinicians, schools, daycare providers, etc.) is that there is a basic and fundamental core Developmental difference between your "Child Wanting to Engage" and your "Child Engaging because s/he has been Trained To Follow Commands." In the first instance your child is being encourage to naturally engage because s/he is learning how to slowly 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, trust, curiosity and interest.
We can call the latter, "a wooing process" rather than as is done in traditional behavioral based methodologies (ABA) a behaviorally reinforced or monkey see and do" or "command you to do" process, where your child in accordance to schedules of behavioral reinforcement receives a verbal or concrete token/reinforcer for complying (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 set the foundations for simple to increasingly complex symbolic ideas and expressive language. This necessitates basic arousal, security and integration in your child's senses, emotions and motor coordination on a simple level, for example, simple opening and closing circles of communication. Thus, it is particularly 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 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 social engagement and communication. So it is never a question (as much as it is 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" 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 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; typically referred to by clinicians as tactile, auditory gustatory, proprioceptive, vestibular, interoceptive); Affect is your child's natural intent or range of emotion which is 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 (as is too often done by clinicians in the home and in the schools) to simply as well as simplistically label 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 challenged or "non-compliant and inappropriate behaviors" we would argue from a Developmental perspective is both inaccurate and grossly simplistic with respect to a deeper more complex understanding of your child. This might indeed be "true" if we 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 conditioned (either due to constitutional differences or parental reinforcement) and 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 as a bifurcated or polarized insistence on a parent-friendly and test protocol easy 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 and 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 receptive and expressive language.
Again, it is not about training your child on more appropriate "replacement behaviors. Rather, it is about you, as well as other clinicians, beginning to learn how to understand the functional 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 (conveniently marked + or -by the clinician on a checklist) but rather sustained spontaneous meaningful and integrated functional-emotional developmental engagement which will meaningfullyand 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 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., 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."
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 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 a series of behaviors. This is clearly what we do not want!
However, let us go back for a moment and entertain this, 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 targeted behavior(s) achieved by the child that are then "objectively" marked off an evaluative protocol (checklist). However, unfortunately the prefrontal cortex (i.e., core executive functioning) and the internal feelings (or affect) 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 is the exact opposite of your child's absolute and non-negotiable spontaneous back and forth social 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 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). 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 . The problem is that it is almost always perceived as such. 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!