I've responded to a lot of questions across the Internet about my work with my own son Graham and with other families. Although the answers to the questions I've posted here are not structured in any particular way, they may help to provide a more complete understanding of floor-time play. Keep in mind that I am an experienced parent, have been working with other families for some time, and am working on a degree in counseling, but I do not claim to be an unqualified expert.
One of the challenges in comparing different approaches to intervention is that the goals and measures of success can be quite different. The goal of floor-time is not (primarily) to create appropriate behaviors in a child, nor is it to get a child mainstreamed. Instead, the primary goal is to create sustained two-way communication, which will then lead a child up the developmental ladder. As the child becomes better able to interact with others, he or she will begin to understand the common context for relating that most of use share. This developing motivation and understanding will help the child take his or her part in the community, which ultimately will mean being in a mainstream school setting.
Consequently, when I engage in therapy with a child, I am just as interested
in helping the child be as highly functional as possible. I currently believe
that many children have the potential to recover completely, or nearly so. I do
not, however, see my job as mainstreaming a child. There are plenty of people
who are mainstreamed who are not recovered. It makes no sense to me to work
hard to get a child to comply with instructions from an adult if they don't
have the social understanding to thrive in a community environment. I want to
develop a child's fundamental skills
first--responsiveness, social awareness, contingent behavior--before I worry
about whether or not he or she will sit still long enough for me to tell him or
her something. If children don't understand why they are sitting there, why
another person might be talking to them, why they should care about doing what
other people say, and so on--then there is no value to mainstreaming them.
Mainstreaming is a benefit of a recovered child; it is not a goal in and of
itself, and it is certainly not a strategy to recovery. (I define mainstreaming
here as being in a typical life situation, like school, without benefit of any
atypical support, like a facilitator.)
I will first say that when you are talking about very young children, the idea of making them sit in a chair to receive therapy is probably developmentally inappropriate. All children learn though play! It is our adult perspective that leads us to believe that the best way to teach a child is to sit them down so they can pay attention to our adult delivery. Children learn by exploring, experimenting, playing. Just because children with autism explore a narrower range of things, or explore in an unusual way, that doesn't mean that they don't learn by exploring and playing. Therefore, a child-centered therapist sets about the task of creating awareness in the child of the therapist. The therapist tries to find the developmental level and interest level at which the child can relate. By finding this, the therapist will then help the child to become aware of the therapist, begin to look at and wonder what the therapist is doing, respond to the therapist, engage in contingent behaviors, and so on.
If a child is lying on the floor kicking the wall, she may be doing it because it feels good, because the sound is rewarding, because she is disorganized and needs the organizing feel of the kicking--there are many other possible reasons. If a therapist moves the child up out of the kicking, he is indicating to the child that the behavior is inappropriate; for that child, that behavior may be the only way she has to express her particular need. Instead, a therapist might choose to lie on the floor and kick with the child. This achieves a couple of things:
If a child is not sitting in a chair and is not paying attention to a therapist, I do not see these things as pre-conditions to effective therapy. I see them as some of the manifestations of the disorder that indicate a need for therapy! Sitting in a chair and paying attention to people (and understanding why paying attention is a fun and useful thing) are the goals of therapy, especially with a young and hard-to-reach child.
It may be that some people assume a greater level of basic social understanding on the part of children than I do. I see autism as the apparent inability to understand and engage in human social interaction, probably caused by a variety of factors. The core issues may be related to processing, motor planning, or other events or challenges. The core issue is not compliance, and it's not lack of ability to identify objects, and it's not lack of ability to speak. These are all serious parts of autism, and I am not suggesting that they are not important. I believe, however, that many of those problems occur because of the lack of reciprocal social interaction.
Many people seem to see "social issues" as one subset of autism issues. I really see it as something that underlies autism.
Don't forget that language is not really a prerequisite for social interaction. There are plenty of people in the world who can't talk who are social. I have worked with a number of children who were highly verbal, but not social. These children frequently use language to self-stimulate and withdraw.
In addition, I would say that "appropriate play" is not really the goal. The goal is consistent engagement and two-way communication, which ultimately leads to typical, or "appropriate," play.
First, child-centered therapy does not reinforce inappropriate play behaviors in the sense that it encourages and tries to develop them. It is not the goal to develop the skill of kicking the wall. The goal is to develop social interaction (which ultimately means "appropriate play behaviors"). A therapist does not try to extinguish inappropriate behaviors as a first approach. Rather, he creates connection from those behaviors before then moving towards more typical activity.
I believe we have been able to help him in those areas. The thrust of our home program was almost entirely on social and emotional understanding, expression, and communication. Graham's cognitive abilities have always been fairly evident (in relative terms), and we decided early on with the help of a good developmental psychologist that we would much rather have a happy, social child who needed extra help in cognitive abilities than a splinter-skilled child who could not relate to anyone else.
In our work/life/play with Graham, we spend a lot of time commenting on our own feelings and expressions, those of others, and his. We write a lot of books with him (or sometimes ourselves that we then read to him) that explore social interaction and emotional expression ideas. The "book" might be as simple as "Graham hit his head. He cried. Later, he felt better." Often, that alone will spur some discussion or clarification from him. Sometimes we can encourage him to draw the pictures--you always learn so much (and I think he does too) about him.
One thing Graham used to do: when he would bump his head on the wall, he would get upset and say, "Daddy, why didn't you move that wall! You didn't help me!" He really seemed to think that we knew in advance what was going to happen, or that we could control things. One technique (if you want to call it that) that has helped Graham develop a better ability to understand how he feels is the praise and celebration we have always tried to provide for any expression of emotion. When he tantrummed, cried, laughed, whatever, we would spend a lot of time telling him that we knew what he was feeling when he did that (or that we didn't know and could he tell us). Rarely have we chastised him for getting angry or distressed. I like to think that the freedom he has had to express whatever he was feeling has given him the opportunity to really explore what those feelings feel like, and to come up with useful and appropriate ways to express those feelings.
Much of our work in the play room with Graham has focused on the fundamental social interaction elements--helping Graham to become motivated to look at us, respond to us, share with us, take turns, etc. We don't set out to "teach" those skills (no drilling), but we do put a tremendous amount of effort into creating an environment that will motivate Graham to do them, and when they happen, they get recognized with great excitement.
We had been struggling with Graham for his first three years, wondering why parenting was so unsatisfying, yet not being confident enough to go to a doctor and say, "something's wrong here." Actually, our pediatrician kept reassuring us that things were fine, even though raising Graham was a remarkably awkward thing to do--he was distant, unhappy, uncommunicative (not totally, but enough to make us feel weird).
We felt like nothing that we had heard about or had read about parenting really applied. We went out and bought child-proofing stuff for our house, and we never needed it. He just never explored things that way. He had very limited, non-dangerous interests, and we just convinced ourselves he was a beautifully behaved little boy. No matter that he sat and watched the ceiling fan for hours at a time.
The whole issue of guidance, discipline, correction, teaching, whatever you want to call it, just never really came up. He was so hard, but so easy too. As long as you didn't cross him, everything was smooth and easy. We simply did not develop any kind of give and take relationship with him. In fact, we didn't realize exactly how much we had shaped our lives to accommodate his unusual needs and behavior until our younger son David was born. Suddenly, everyone's life was thrown into chaos, and we became aware of what we had been doing to make it seem like things were "normal."
Yes, pretty much. As I understand that time period now, Graham was reacting to the incredible stress of a disrupted schedule, of unpredictability. He must have had no clue what was going on. I remember that, when David was born and brought home, Graham stopped sleeping. He would get up over and over and over, coming out of his room like a zombie. We progressed from cuddly returns-to-bed to firm, consistent march-back-to-bed to putting a gate on the door and letting him cry for 5 minutes, then 10 minutes, then 15 minutes. After about a week, we were trying things like blocking him into the bottom bunk of the bed, and he was climbing out like Houdini. Now I would call it an obsessive-compulsive ritual kind of behavior, but at the time it was just creepy and rebellious, we thought. We finally put a lock on his door and suffered through horrible crying, screaming for several hours, for many nights. Eventually he calmed down, but by then he had gotten so sick that we were attributing everything to the ear infections.
Anyway, I do feel like David's arrival probably turned Graham's very limited, protected, predictable world into a mess, and he responded by getting sick and by really becoming outwardly autistic.
Graham has never been truly self-injurious, although I have seen behaviors in him that, taken to an extreme, probably would be. He sometimes gets so "disorganized," laughing, silly, unresponsive, that his tolerance for pain skyrockets--like he's a drunk falling down in the street and not knowing that his face is bleeding. I think a lot of SIB stuff is probably experienced as something other than pain as we understand it in these kids (and I am definitely not an expert here--this is just from what I know about sensory integration). I do believe that the best way to treat much of this behavior is to try to respond to the underlying sensory integration dysfunction, to try to normalize the child's response to sensory input. Some kids bite themselves or pinch themselves or bang their heads (I believe) because the stimulation, the input, gives them something that they crave. I do not think you can control it by extinguishing it. A lot of people struggle to stop their kids from hurting themselves, and I don't have a good perspective as a parent on that struggle. As a general rule, I would say that you want to create an environment for every child that is safe, protected, and enables him to meet as many of his needs as possible (while you work with them to help them find alternative ways to meet those needs). I am not one to try to extinguish behavior, certainly not without understanding the underlying cause.
One example of a child I have worked with recently may be useful. This child, who is six years old, has a history of pulling his sibling's hair, pinching or hitting his parents, and sometimes biting himself. In an early training session with the mother and child, she was driving a toy car gently over his body. When the car reached his arms, he reacted suddenly, as if in pain. He quickly reached over to pinch his mother, and subsequently also bit his own arm. As we explored this situation further, it became clear that the child enjoyed the car game very much, as he directed the mother to drive on his back, his head, and his legs. Every time she made a gentle motion to drive on his arms, however, his reaction was aggressive.
Imagine how this child might react in a school setting when unexpectedly grabbed or touched on the arm, and imagine what the response might be from an adult who has no awareness of the tactile sensitivity this child clearly experienced.
Perhaps a better way to phrase this is to say that you are going to put all of your effort and energy into "motivating" him to respond. You aren't just wanting it to happen--you are going to do a lot of creative interacting in order to tap into his motivation. He won't ever have to respond, but you want to focus so intently on his interests and behaviors that you find the motivational keys--even if a lot of what you do is act "playfully obstructive."
Wow, that's a big question, and I've added a whole year of experience (as a facilitator for my own son and as a supervisor for the woman who helps me) since I posted that web site material. In brief, here's what I suggest:
1. Aim for the most flexible school environment possible. You want to focus on reciprocal social interaction—your child’s connection with other kids and with the sense of community overall. You don't want to get hung up trying to force him to conform to lots of rigid schedules, behaviors, curricula, and so on. Spend as much time as you can helping the teachers understand what you're trying to achieve and how they can help. You don't need them to do a lot of extra work, but they need to understand how to support your facilitator, and how to support your child’s goals.
2. Find a facilitator who is comfortable in a room full of kids, and who is equally comfortable playing with them or directing them. This is a tall order, but you want someone who has total confidence maneuvering the kids around him/her. The facilitator must be sensitive to the demands and norms of the class and the teachers, but also savvy enough to work around them and take advantage of them (and I don't mean that in a dishonest way). The facilitator must be able to remain focused on your social/emotional goals for your child, and not get hung up on the behavioral goals that will distract from the important stuff. Remember, if the social/emotional piece comes into place, the behavioral stuff will follow.
3. Observe as much as you can, give the facilitator lots of support, and especially make sure the facilitator has time with your child outside of school. As the structural demands rise for him, you must also increase the floor-time, and the facilitator needs to have this kind of relationship with him.
4. Just because you begin sending him to school, don't get fooled into thinking you have to do it all day every day. To the extent that the school allows, have him there only when it is helpful to him. don't sacrifice the valuable stuff you do in other contexts just to have him at school all the time. In my view, school is much less "therapy" and much more "testing grounds." Don't replace all of your most efficient therapy with stressful, testing environments. Add it in a little at a time.
What is your opinion on
Greenspan's floor time vs. Lovaas/Behavior Modification?
I have a strong opinion on this, as you probably already know. The Lovaas approach does not account for how children develop. It is a "method" based on fairly limited techniques of behavior modification, and the drill-oriented intervention that I have seen does little to actually support the child's development. Behavior modification techniques have their place, but they do not constitute an effective way to mobilize a child's development, and I would argue that a Lovaas approach actually overlooks the most critical areas for these kinds of kids. People who see "success" with Lovaas see a certain kind of positive growth that is focused on too much on isolated skills and obedience. Even if you ultimately work with a Lovaas approach, reading and understanding Greenspan's work on developmental stages will enhance whatever you do.
I just came back from
visiting with my sister. She has begun
the A.B.A. program. She is working
through Rutgers. Already she sees an
unbelievable improvement. I'm very
curious as to the reasons you are not so sure about this program.
Basically, I think ABA is reductionist in focus. By that I mean that its techniques, while useful in some situations, don't address the underlying issues that these kids face. Whatever "causes" autism, and it is certainly different for different kids, the common factor is that these kids have not received the tremendous number of interactive experiences that typically developing kids seek out and receive from infancy on. To try to drill appropriate behaviors into a child whose emotional development (led by basic back-and-forth interaction with others) is impaired is not going to lead to long-term improvement in the real deficits (i.e., reciprocity, emotional expressiveness and flexibility, interactivity). ABA may appear to facilitate development, but I believe that in most cases it leads to apparently appropriate behavior in children who still need much more attention at a lower developmental level. ABA will not reduce a child's "need" to tantrum or to stim or to become obsessive-compulsive. It may reduce that child's manifestations, but ABA does not address the underlying developmental problems.
I have spent most of the
last year confused and depressed. I am
not sure if my child's problem is the result of bad mothering. I have felt very alone in this situation,
like there is nobody else in the world with a child like this. I could not relate to the other parents in my
child's classes, because their children had different developmental issues than
him. I'm not sure what to do at this juncture.
There doesn't seem to be much hope or help.
Before I say anything else, let me tell you right now that “bad mothering” is not what you want or need to be thinking about. You did not create your child’s issues, and the wonderful news is that you are, in fact, the best person to help him through his issues. There is hope and there is help, and I encourage you (as best as e-mail allows) to believe that both of those things are available to you. First, don’t hesitate to call Dr. Stanley Greenspan in Bethesda, Maryland to make an appointment. He will provide you with excellent counsel and a wonderful way to begin to understand (and work with) your child. You can also check the Multidisciplinary Directory at http://www.saveachild.com/ for professionals who live in your area who have been exposed to Greenspan’s work. Greenspan is an MD, and his initial evaluation should be covered by insurance.
I also highly recommend Greenspan’s book The Child With Special Needs, as well as a book by Carol Kranowitz called The Out of Sync Child: Recognizing and Coping With Sensory Integration Dysfunction. You should find in these sources a nice way to understand your child without having to pigeonhole him into an inappropriate label.
There are plenty of kids in the world like yours, and plenty of parents who have gone through (and come through) what you are going through. Do not despair. Look at your child as a human being that you don’t fully understand--go to his level to communicate with him. Interpret what he says and does without judgment or condemnation. Through this process you can begin to foster a real dialogue with him (mostly nonverbal, perhaps), and help him to grow. Resist the temptation to fight him. Instead, join him, stretch him, enjoy him. I know that all sounds too simple and easy, and I know from experience that it is not always easy. But you can have hope and you can help him yourself, as well as find help for him.
As I have read through Greenspan's writing, I am beginning to understand the opening/closing of circles of communication pretty well, but am having a hard time getting a clear picture on how this works with a non-verbal, non-motivated child. I am trying to figure out how to teach others about opening and closing circles with my child and I don't get it myself. The facilitator at school then tends to drop back to a completion of task orientation because she can't see how to facilitate anything with the other children. My child is already starting to resist going to school. Any thoughts/suggestions would be greatly appreciated.
One of the most important things to understand about how humans develop communication is that gestural (non-verbal) communication comes first. Typically developing infants open and close many, many circles at the gestural level--smiling, pointing, touching, reaching, etc. etc. Although I understand your tremendous desire to help your child to develop words, you can actually help her to do this most effectively by focusing on the gestural level. Your attempts at opening and closing circles of communication must focus on gestures--exaggerated facial expressions, body movements, pointing, tone of voice (as opposed to the words themselves), and so on. You must foster an interaction based on affect--use your own emotion and energy to arouse your child's affect.
Depending on the sensory profile of the child, you may find that very simple chase games or tickle monster games work to generate this gestural level of communication. Alternatively, for a sensitive, over-reactive child, quieter, more cautious approaches might work better. You have got to engage her at a level that she finds motivating. Her apparent lack of motivation to engage with you is because you may be trying to engage her at a level that is too complex (perhaps too word-oriented?).
With respect to the school situation, her attempts to engage with peers will be shallow and hard to sustain until a more solid gestural level of communication exists. To the extent possible, however, her aide should work to arouse your child's affect. Tell her to be flirtatious, irreverent, and not at all focused on task completion. Your child’s ability to complete tasks is not the critical problem here. The aide should coach the other kids to include your child whenever possible, rather than prompting her to do things. ("Hey, you guys are building a store? Well, maybe [name] could be your checkout person. Why don't you ask her?"--then the aide can shift back to your child’s team to help her respond in some way.)
If you are struggling to open and close circles, think simple, think non-verbal, and think affect. Find the level of stimulation that arouses her to a point where she anticipates you, reaches for you, engages with you.
I do not believe that it
is at all possible to engage in an ABA type program in a non-judgmental
way. The ABA methodology is all about
what people are SUPPOSED to be like, not about who they really are. Essentially, people who engage in these
programs do not accept their children the way that they really are, but wait to
be happy with their children when they are who they (the parents) want them to
be. In order to do an ABA program, one
must first decide what is "normal" and what is not, taking out of
account the marvelous new ideas and perceptions of the world that little (or
big) person offers. Would you agree?
Don't we all interact with kids, not just to share and appreciate their world, but to help them begin to understand and relate in "our" world? In other words, I engage kids with the hope of kick-starting their developmental growth. I happen to believe that this growth is a normal and appropriate direction for all people. I certainly differ with a lot of behaviorists with respect to what is "normal and appropriate," but aren't we all striving to create healthy children?
To me, the difference between Greenspan and Lovaas is that Greenspan views the process of interaction as inherently developmental. Lovaas views it as a prerequisite to therapy. I'm not completely sure how The Option Institute approach falls in this scheme. Option certainly regards an attitude of non-judgment as a prerequisite for effective interaction, and I would agree with that. Nevertheless, a nonjudgmental attitude does not mean that we don't challenge kids to develop in healthy directions (regardless of where they are, and regardless of how much we love and accept them for who they are). I think Option would agree with that also.
A behaviorist also tries to move a child in a healthy direction, but because the child is regarded as a collection of behaviors, issues of personhood (i.e., acceptance) and relationship (i.e., interaction) never become central.
It seems to me that you could, in theory, practice ABA in a nonjudgmental way, although you'd want to eliminate negative correction ("No. Try again.") and similar techniques. I suspect that a nonjudgmental ABA practitioner would still be missing the boat, because as long as one believes that humanity exists within the behaviors themselves, then a key focus will never materialize, which is interaction between humans.
I've been reading a lot about behavioral therapy recently, which has led me to this common discussion (the one above, I mean). It strikes me, though, that without autistic disorders, it is much easier to believe in behaviorism, because most other disorders occur in situations where more developed interactive capability exists. Autistic spectrum disorders are lacking in interaction, which means that autistic behaviors take on a different depth of meaning than non-autistic behaviors. In other words, if you have other communication channels available to you, then a modification of your behavior might, in fact, easily lead you to access those alternative channels. I f behavior is your only means of communicating, however, then it will probably be less likely that it can be modified effectively (or with meaning) until other communication channels are developed.
Well, in so many ways, the
Option/Greenspan techniques are very behavioral in nature-- behaviors we want
to perpetuate, such as eye contact and playing with others are nurtured, others
get no real response, or a response of "go ahead if you need to, but I
don't have to get involved with this emotionally because I'm separate from
you".
Actually, I see something of a difference in Greenspan and Option. Let me qualify that by saying I see a difference in what I remember learning at Option (and what we did with Graham for 2+ years) and what I understand Greenspan to be saying. While both would argue that the emotions of the therapist can inhibit the interaction, Option always seemed to be saying that an idealized state would be to never feel or express negative emotions. Practically, this puts a lot of pressure on people to act ways they don't always feel, and developmentally puts the cart before the horse (i.e., changing your thoughts and behaviors can then change your emotional response--which is actually a behavioral understanding of the world). Greenspan is much more comfortable with people having and expressing the full range of emotions--in fact, he would argue that healthy development requires that individuals develop the ability to feel, understand, and express functionally all feeling states.
The way to do this (and to help others do it) is to engage with them interactively--to create back-and-forth communication, and through that interactive process (laden with affect) foster emotional development. So, for example, if Graham gets angry in the play room, the Option and Greenspan responses are not radically different. Both would suggest that the therapist should engage around that affect, probe it, play with it, not take it personally, and so on. Option's reasoning for this response, however, would focus on the importance of the therapist not accepting the burden of Graham's anger, and would focus on Graham understanding the effects of his behavior (tantrumming won't get you an irate, exciting response, it won't get you the juice, and so on).
Greenspan's reasoning for this response would focus on the need to keep the interaction going solely to give Graham more time to access those feelings--to make the connections between his sensory/somatic feelings and his emotional ones. In other words, Greenspan sees interaction as the path to Graham developing from a behavioral state (stimulus=response) to a representational state (stimulus=thought, or representative, symbolic idea=chosen response).
Ahh, I think I've just cracked a code I've been struggling with. A Lovaas approach doesn't really acknowledge that people are (or can be) representational in their thinking (that's a big Greenspan word). People simply function as responders to given stimuli. In many ways, Option seems to operate from the same philosophy, only they are dealing with feelings as behavioral responses to stimuli (which is what cognitive behaviorists do).
ABA/DTT discounts for the
most part where the client is in all of this-- the client's needs are basically
forgotten in favor of the more concrete, scientific, and attractive goal,
regardless of who the child really is. In
working with the AS population, children are discouraged or redirected from
stimming, though they may need this.
I would agree with this, especially the idea that the fact that the approach is apparently concrete and scientific (i.e., measurable) is a large part of what makes it attractive. It's a lot like the guy who lost his contact lens in the grass but decided to look for it under the lamppost in the street because the light was better. However, it’s difficult to generalize about what “all Lovaas practitioners do”; I actually believe that when Lovaas programs create success, it is primarily a function of the affect-laden interactions that a particular therapist generates in the midst of the drills. Any time you have a caring, emotionally aware person trying to communicate with your child in loving ways, this has got to be a positive.
As a therapist, I see big
differences when I work with a child who I truly love and accept, no matter
what, and catch myself when working with children who I want to change or
fix. The children become objects in a
way when they need "fixing" and who am I to tell them that they need
to be fixed? What is important is that
they are happy and realizing their potential through the guidance of others who
nurture them and lead them in a world that does not make as much sense to them
as it does to us.
I agree with this to a large degree, but as people who have climbed the developmental ladder relatively successfully, we are in a good position to help others up that ladder. You may not be telling someone that they need to be fixed, but you can tell whether or not they are engaging with the world in a way that fosters their own development to the best of their ability. You can create an environment and a way of interacting with someone that does something more than just show them love and acceptance and nurturing. You can create a world that actually enables them to develop more effectively. I know you know this, but as a therapist, one does have the opportunity to help people make specific steps up the developmental ladder.
I've always looked at The
Option approach as encouraging that people have a choice to how things
"make" them feel-- an empowering thought, really. Needing things from people can cause lots of
misplaced emotions. I never really
understood from Option that a range of emotions is inappropriate, but that we
do choose how we feel about everything, and that there is always another side
to every emotion. If I want to be angry
in an Option world, it would be okay, but the other person would not HAVE to respond
to that in the form of granting a request.
Same in the Greenspan world, right?
Things are sad in our world, just as things are exciting. I have come to recognize that we choose this
response as well. We also tend to
express our needs in a fashion that gets us the most response. Isn’t that behavioral?
The thing is, I'm not convinced that people do have a choice about how they feel--at least not in the sense of being able to make a conscious decision about it. Our feelings are a function of our early (and ongoing) sensory perceptions and our interactive experiences. When we are in emotional states (e.g., high stress, such as someone cutting in front of us on the highway), we are not choosing how we feel. We can, in many cases, choose how we act, but the feeling (both physiological and mental) is more automatic. I'm not suggesting that these processes can't be changed--they definitely can--but they can't be changed just by deciding to feel differently. The only way to change your feelings at that level is to engage in supportive interactive experiences (in environments that foster growth) that help you to better sense and understand those feeling states, and to begin to make concrete connections between those feeling states and your common resulting behaviors.
When we feel emotionally constricted, we act behaviorally instead of representationally. We may, for example, automatically flip the bird at the guy who cut us off, never really making a conscious decision to do so. In calm times, we may even say to ourselves, "gee, I shouldn't do that," but in the heat of the moment, our representational thinking deserts us (that is, our ability to abstract our feeling state and generate behavioral alternatives--I could do this or that when I feel this way).
Back to Option: to suggest that we can choose our emotional response to a given situation is only partially true, in my opinion. We cannot control our feeling states to any great degree (at least not the vast majority of us); we can choose our behavioral reactions, but only if we are able to operate from a representational mode--that is, being able to picture ourselves in our head having a certain feeling that leads us to want to act in a certain way, but then making a choice to act in another way.
How is the tantrum viewed
in the Greenspan world of opening and closing circles of communication? Is it an opener or a closer, or is it
dependent on the child or the interaction?
A tantrum is the mode of communication that a child has available to him at a given moment to express how he feels. Your best response to it is to tease out the feelings behind the tantrum. You don't want or need to stop the tantrum, nor do you need to ignore it or let it play itself out without response. Instead, you want to be empathetic and supportive, and at the same time moving in to engage the child around their feeling. For some kids this may simply mean holding them supportively; for others, it might mean beginning to engage in some simple dialogue--wow, you look like you want to hit me! Where do you want to hit me? How many times? Hard or soft? What you are doing here is helping the child to more fully articulate how they feel. As I mentioned earlier, you may take the approach of drawing out some connections between body and feeling. Do you feel it in your head or your stomach? Is it a squeezing or a punching feeling?
You may ultimately give the child what he wants or not--that decision would be based on your previously defined limits, but would really be incidental to the "therapy" of the situation. The trick is to tease out the child as long as possible while keeping them engaged in a series of circles of communication.
In situations that we
cannot anticipate, we also use a learned response, but it is a tried and true
response, and it is probably not an appropriate time (though not impossible) to
decide to feel another way. Maybe it's
because I personally work at this, so it’s like riding a bike--it's hard to
think of a time when I couldn't do it-- but I must be one of those few that can
change a response even mid-response if I am aware. If I am tired, I go with the default response-- the one that I
have used before, not always the best one.
Well, I think we are talking about feelings at a different level. As an adult and as a professional at what you do, I believe that you can control and adjust many of your responses to both anticipated and unanticipated situations. But you are still having an initial visceral reaction (a feeling) to each situation. Your body has a reaction--a tightening of the gut, a nauseous feeling, a jumpy, nervous twitch, whatever--to every situation in your life. These visceral feelings can change over time, especially as your awareness of them increases.
But when you are talking about helping a child to develop appropriate behavior, it is critical to recognize that their behavior is derived from those visceral feelings (those psycho-physiological reactions to stimuli), and that to try to change the behavior, or to teach a child how to "choose" to feel differently, is to not aim low enough. A therapist must help any child tease out his own awareness of and understanding of those feelings and their connection to higher level symbols (such as the words sadness, anger, and so on). This teasing out process occurs through the interactions themselves, not through the cognitive level teaching that we all do with kids.
Take Graham for an example. When David comes home and Graham is already there, Graham frequently these days begins a taunting routine--"I'm gonna give David a little kissy because I love him so much." I know, sounds ok in an e-mail, but trust me that it's an odious, inflammatory behavior. Graham cannot (most times) "choose" another behavior--even if a logical consequence is attached to the behavior (such as not being able to play with David, or getting hit with a baseball bat by David--true story). When David comes home, Graham is being bombarded with an affect surge that he cannot control or understand (and is mostly not aware of). Until he can become much more concretely aware of the physical/somatic reactions he has to David coming home and their corresponding emotional causes (David will get more attention, I'll have to fight for my toys, it will be noisier, etc. etc.), Graham will not be in a position to choose anything. The feelings Graham has are probably jealousy, fear of not being loved, and many others all rolled up, and the most effective way to help him access those is through floor-time--pretend play, stretching his emotional thinking, flexibility, and awareness. We also have more direct conversations and role-plays and other sorts of things around all of these issues, and we also engage in some behavioral strategies, but all of these things occur within the context of Graham's struggling emotional development.
I opted to put my child in
a private special education school that does reverse mainstreaming. The school provides speech and occupational therapy
and the student teacher ratio is 2:1. So
at that school I know she gets a lot of attention. She is however one of the highest functioning children which is
what Dr. Greenspan does not want. He
wants these kids around typical children.
If your daughter is getting a lot of personalized attention and is getting some opportunity during the day to interact with peers of any sort, then you're in great shape, especially since you provide her with some other typical opportunities. The most important thing she can get right now is one-on-one floor-time anyway; the peer component is less important, especially if she is resistant to it at this point. Once her engagement and communication capacities are more fully in place, this component can become more important.
The private schools I
called do not want the liability of a child like mine for fear she will not
progress. Also she is not potty trained
so they will not accept her. I am happy
with the special school however am worried that she is not in a mainstreamed
class. She does attend a regular
Gymboree class on Saturday and goes to Sunday school weekly where I help her
play with children. (Not easy she avoids children.)
You are giving her plenty of opportunities to be around typical kids. If she is avoidant, then focus on developing her more fundamental capacities (i.e., mutual engagement and intentional communication). As you mentioned, she may be overwhelmed from a sensory standpoint or for some other reason, and you really need to play to her strengths.
My advice is not to lament the fact that she is not mainstreamed. She is just 3 ½, and you don't need to be thinking about school for her anyway (except perhaps to give yourself a bit of a break). You should focus intensively on providing her with as much warm, empathetic, challenging floor-time. Really help her develop her desire and capacity to stay related and communicative.
I cannot emphasize enough, both from my personal and professional experience, that your child will see the most progress from a lot of floor-time style intervention. The special class is fine, and the ST and the OT, but don't skimp on the one-on-one time.