clddv 173: autism: overview and treatment dir floortime …laffranchinid.faculty.mjc.edu/173 six...
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CLDDV 173: AUTISM: OVERVIEW AND TREATMENT
DIR FLOORTIME CONCEPTSPrepared by Debbie Laffranchini, Professor
Taken from Engaging Autism, by Stanley Greenspan and
Serena Wieder
Six Levels of Engagement
■ Stage 1:
– Shared attention and regulation
■ Stage 2:
– Engagement and relating
■ Stage 3:
– Two-way communication, purposeful emotional interactions
■ Stage 4:
– Complex two-way communication, shared problem-solving
■ Stage 5:
– Shared meanings, symbolic play, creating ideas
■ Stage 6:
– Emotional, logical thinking
Stage 1: Shared Attention and Self-Regulation
■ Adult does 100% initiation to
sustain shared attention as child
develops
■ Adult does almost all of the work –
to get attention and looks –
modulating pace of play for
regulation
Stage 1: Shared Attention and Engagement: Techniques to Bring the Child Into
Your World■ Get the child to look at you because
they WANT to look at you
■ Slow down your movements
■ Provide sensory support
– Pay attention to their sensory profile
■ Swinging
■ Bouncing
■ Follow the child’s lead
■ Playful obstruction
Stage 1: Shared Attention and Engagement: Expanding the Child’s Interest in the
World■ Meet the child at their level of ability
■ Move from one-step actions to two-
step actions
– Child indicates they want
something (first step)
– Child indicates a further action
(second step)
■ Complete “circles of
communication”
■ Support them to discover the
pleasure of engagement
■ Don’t entertain; interact
Stage 2: Engagement
■ Adult still does most of initiation to
WOO the child into engaging
– Child will sustain engagement in reciprocal social interactions
■ WOO, THEN WAIT
■ WAIT EXPECTANTLY
■ Adult feels like they are doing a lot of work “entertaining” to get laughter, smiles, affect and engagement
Stage 3: Two-way Communication
■ Child begins to initiate purposeful
interactions around desires
– OPEN CIRCLES
– CLOSE CIRCLES
■ Child engages in back and forth
interaction, gestures
– PING PONG
■ Adult feels some sharing of work
Stage 3: Encouraging Two-Way Communication and Social Problem-Solving
■ Preverbal communication
– Verbal skills children need
begin here
■ Facial expressions and tone of voice
– Communicate warmth,
acceptance, and love
■ Gestural communication
– Builds cognition and
intelligence
Stage 3: Encouraging Two-Way Communication and Social Problem-Solving (cont)
■ Communication delays:
– Motor planning delays
– Challenges in sequencing
– Challenges with auditory
processing
– Challenges of visual-spatial
processing
– Challenges modulating
sensory input
Stage 3: Encouraging Two-Way Communication and Social Problem-Solving (cont)
■ Encouraging communication
– Follow the child’s lead
– Tune into child’s interests, emotions, and goals
– Incorporate child’s favored object or activity into your interaction
– Use exaggeration
– Encourage multiple circles of communication
– Use playful obstruction
– Peek-a-boo
– Hide and seek
– Rhythmic coordinated activities
– *Key: get child motivated
Getting Communication Going■ Are you following the child’s lead?
■ Are you enticing the child to take the initiative?
– Don’t do all of the work!
■ Do your voice, gestures, and posture show expectation?
■ Are you tailoring the interactions to the child’s nervous system?
– Low muscle tone, underreact: energize them
– Be aware of sense used to learn
■ Are you involving as many senses as possible?
– Sight, sound, touch, movement
■ Put the loved object in plain sight, out of reach
– So they initiate
■ Increase complexity of behavior
■ Use times of high motivation
Playful Obstruction
■ Beat the child to the spot
■ Gently block their escape route
■ Blanket, become child’s blanket if
they are lying down
■ Veil or scarf, cover the window the
child is staring through, attention
getter
■ The tub
Stage 4: Complex Two-Way Communication
■ Child can work up to a continuous
flow of 20 to 30 + back and forth
circles, large, small, and micro-
circles
■ 50/50 adult and child doing the
effort
■ Child is responsible for half of the
relationship
■ Adult waits for problem solving
Stage 4: Complex Two-Way Communication: Symbols, Ideas, and Words
■ First words
– Repeat key words, over and over
■ May need to say 10,000 times
■ Do you want to go OUT? OUT? OUT? Let’s go OUT. OUT. We came OUT!
– Nouns easiest to learn
– Give choice
■ Juice or milk? Juice? Milk? Repeat, repeat, repeat
– Use real situations to teach language
– Don’t ask abstract question, stay concrete
■ Say, “Do you want to eat?” Instead of “Are you hungry?”
Stage 4: Complex Two-Way Communication: Symbols, Ideas, and Words (cont)
■ Imaginative play
– Demonstrates intelligence
– Demonstrates cognition
– Use daily routines to begin with, things the child knows a lot about
– Use repetitive language
– Build in emotion
■ The baby likes the water
■ The baby likes the duckie
– VERY FEW PROPS to begin with
■ Keep it simple!!
– Do not take the lead
– You can become the object or a character
■ The baby
Stage 4: Complex Two-Way Communication: Symbols, Ideas, and Words (cont)
■ Engage with the child’s interests
– Some may find it difficult to help the child come up with ideas to what the baby would say, etc.
– Sometimes children run away when they don’t know what to do next or the play is too complicated
– Be a bit demanding
– Introduce a conflict or challenge (the plot thickens!)
– Don’t give the child what they want right away…wait!
■ Don’t be the “too-good adult”
– Explore feelings
Stage 4: Complex Two-Way Communication: Symbols, Ideas, and Words (cont)
■ Signal with gestures
■ Get many circles of communication in a row
■ Create emotionally meaningful situations
■ Associate a word (open) with an emotional goal
■ Use ideas logically
■ Ask questions, then expect
■ Wait
■ Wait expectantly
■ Taffy pulling
Stage 5: Shared Meaning, Symbolic Play, Problem Solving
■ Use of ideas (words) to convey feelings and intentions
■ Adult works at expanding child’s pretend play
■ Adult asks “wh” questions
– Who
– What
– Where
– When
– Why
– How
Stage 5: Shared Meaning, Symbolic Play, Problem Solving
■ Looking for long chains of back-and-forth emotional signaling and shared problem-solving
■ Stretch dialogues
■ Ask open-ended questions
■ Combine action and words
■ Avoid parallel conversations
■ Use conflict and challenge to promote logical circle closing
■ Form bridges between ideas
■ Create multifaceted characters in play
State 6: Emotional Thinking
■ Child is challenged to connect ideas
together by:
– seeking their opinion
– enjoying their debates
– negotiating for things they
want using logical reasons
■ Adult works at negotiating with child
■ Adult challenges child to think,
understand, and open to others’
perspectives
Stage 6: Emotional Thinking, Creating Ideas, Logical Thinking in the Real World, Complex Communication■ Limited logical thinking
■ Fully logical thinking
■ Early steps of logical thinking
– Begins first three or four months of life
■ Step one: requires accurate information
■ Step two: engaging the world in an emotionally meaningful way
■ Step three: purposeful interaction with the world (reaching for rattle)
■ Step four: combining series of purposeful actions (get help to get an item out of the way)
■ Step five: use of ideas (search for hidden object)
Additional Intervention Guidelines to Increase Interaction
■ Follow the leader
■ Treat whatever the child is doing as intentional and purposeful
■ Extend the child’s desire and sometimes play dumb
■ Differentiate your actions from theirs (when a child uses an adult hand as an extension of their own body)
– Position yourself in front of the child
– Work in front of a mirror
– Put your hand over theirs rather than their hand over yours
Additional Intervention Guidelines to Increase Interaction (cont)
■ Help them do what they want to do
– Hand them the next object when they are lining up objects
– Put an object in the same place they would
– Put an object in a wrong place
– Put the object in several different places
■ Have sensory toys, wind up toys, and simple cause and effect toys available to get their attention
Additional Intervention Guidelines to Increase Interaction (cont)
■ Give the child a problem to solve
– Gentle obstruction
■ Surprise the child, do novel things
■ Don’t take no for an answer
– Undoing what you did is a response!
■ Encourage exploration and the child’s choices
– Children with severe motor planning difficulties may need hand over hand to help them start to use the object or toy
– Keep a variety of toys out
Additional Intervention Guidelines to Increase Interaction (cont)
■ Give old behaviors new meanings
– If child is running back and forth, begin “Ready, Set, GO!”
– Child is laying down, engage in dramatic play sleeping routine
■ Simple to complex
■ Join children in ways they enjoy but do not back away from anger
– Anger precedes their ability to express pleasure
– Anger is a response
Additional Intervention Guidelines to Increase Interaction (cont)
■ Open the door to symbolic play
– Motor sequencing is difficult
– If they want to leave, offer them keys
■ See if they turn out the lights and ask for help to open the stuck door
– They are using symbolic gestures like climbing on the couch
■ Work on multiple levels at once and be very persistent
■ This requires HOURS of practice
■ Goal: four to eight 20-minute sessions a day
Additional Intervention Guidelines to Increase Interaction (cont)
■ Provide destinations for actions
– Child taps, bring “drum”
– Child throws, provide basket
■ Create problems to solve, require
multiple steps
– Object in box to open, untie,
remove tape or rubber band
– Objects to fix using tools, tape,
rubber bands, band-aids
– Put socks on hands
Additional Intervention Guidelines to Increase Interaction (cont)
■ Change environment frequently to encourage flexibility, create problems, and expand discussion
– Move expected objects
– Create problems with furniture
■ Chair upside down
■ Deal with consequences of actions symbolically
– Baby doll falls: Uh oh! He’s crying. Are you hurt? Get a bandage, go to the doctor, call an ambulance…
– Car crashes: Oh no, it’s broken! Can you fix it mechanic?
■ Plan your idea, discuss what child will need for their idea
– Get props
Additional Intervention Guidelines to Increase Interaction (cont)
■ Play interactive song-hand games
– One potato, two potato
■ Play treasure hunt and use maps
■ Play games
■ Encourage athletic activities
Why follow a child’s lead? “That’s our ultimate goal for entering their shared world – to help them become empathetic, creative, logical, reflective individuals.
~Dr. Stanley Greenspan