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Developmental Approach to Problems in Relating and Communicating in Autistic Spectrum Disorders and Related Syndromes Stanley I. Greenspan, M.D. Principles of Intervention The Developmental, Individual-Difference, Relationship-Based model (D.I.R.) mobilizes the child's emerging developmental capacities and is based on the thesis that affective interaction can harness cognitive and emotional growth [Greenspan, 1979a & b, 1989, 1997a; Feuerstein, et al., 1979; Feuerstein, et al., 1981; Carew, 1980; Klein, et al., 1987]. The following principles guide caregiver-child interactions so that they are developmentally appropriate in the fullest sense. These principles also guide the work of the therapeutic team so that the speech and occupational therapy work,and in addition to its traditional goals, mobilize fundamental developmental processes. The primary goal of the D.I.R.-based intervention is to enable children to form a sense of themselves as intentional, interactive individuals and help them develop cognitive language and social capacities from this basic sense of intentionality. Children with severe problems in relating and communicating often lack the most basic foundation for interpersonal experiences. They are often not interactive in the purposeful way that ordinary eight-month-olds are. Therefore, much of the experience that they might use to abstract a sense of their own personhood is not available to them. For these children, the earliest therapeutic goals often must be geared to the first steps in the developmental progression. These goals should foster focus and concentration (shared attention), engagement with the human world, and two-way intentional communication (and then symbolic levels) in order to create the interactive experiences the child can use to abstract a sense of self and form higher-level cognitive and social capacities. Mobilizing these basic developmental processes is especially important. Our observations suggest that children at risk for autistic spectrum disorder may have a unique type of biologically based processing deficit involving the connection of affect or intent to motor planning and sequencing capacities and auditory processing and language capacities [Greenspan & Wieder, 1997]. A child uses his "intent" or affects to provide direction for his actions and meaning to his words. Typically, during the second year of life, we observe the ascendancy of a complex intentional problem-solving behavior. Later on, we see meaningful use of language based, in part, on the child's ability to connect "intent" to his motor sequencing and emerging capacity to form symbols [Greenspan, 1997]. Our hypothesis is that when these critical connections are not formed, the child is vulnerable to aimless or repetitive use of behavior and/or words rather than intentional behavior and/or words. The level of functioning in many of the components of the central nervous system (that in this circumstance are not under intentional control), such as auditory memory, may, in part, determine the presence and severity of different symptoms and the presence or absence of splinter skills (e.g., rote recall of entire books). Therefore, the initial goal is to harness the child's affect or intent and foster attention and engagement. To do this, one must pay attention to the child's regulatory profile, as described earlier. For example, if he is over-reactive to sound, talking to him in a normal loud voice may lead him to become more aimless and more withdrawn. If he is over-reactive to sights, bright lights and even very animated facial expressions may be overwhelming for him. On the other hand, if he is under-reactive to sensations of sound and visual/spatial input, talking in a strong voice and using animated facial expressions in a well-lit room may help him attend. Similarly, in terms of his receptive language skills, if he is already at the point where he can decode a complex rhythm, making interesting sounds in complex patterns may be helpful. On the other hand, if he can only decode very simple, two-sequence rhythms, and perhaps understands a single word here and there, using single words (not as symbolic communication, but as gestural communication) and using simple patterns of sound may help him engage. One may find that he remains relatively better focused in motion, such as being swung. Certain movement rhythms may be more effective than others. For some children, fast rhythms, such as one swing per second, may be ideal. For others, slow rhythms, similar to the breathing rate (one swing every four or five or six seconds) may be better. Different kinds of tactile input may foster concentration and focus, such as firm pressure on the back or the arms or legs. Large motor movement and joint compressing may also foster attending (e.g., jumping on the bed or any trampoline-like motion). Each child is unique. It is especially difficult to foster a sense of intimacy. As one helps a child attend and engage, it is critically important to take advantage of a child's own natural interests. It is most helpful to follow the child's lead and look for opportunities for that visceral sense of pleasure and intimacy that leads a child to want to relate to the human world. Intimacy is further supported as one works on forming simple, and then, more complex, gestural communications. For example, the father of a very withdrawn child was only verbalizing to his child. The therapist suggested trying simple gestural interactions first. The father very gently put his hand on a toy car as his son was exploring it and pointed to a particular part, as though to say, "What's that?" But, in pointing, the father actually moved the car, so the son felt the car moving in his hands and noticed, without upset, his father's involvement. The son took the car back, but looked at where the father had touched with his fingers. This more physical, gestural communication seemed to get at least a faint circle of communication-the son's interest in the car and the father's pointing to a spot on the car and moving it a little-opened a circle of communication. The son's looking at that particular spot and taking the car back closed a circle of communication. The opening and closing circles of communication creates a foundation for subsequent communication. After getting this minimal interaction going, and as the son was moving the car back and forth, the father got another car and started moving it back and forth next to his son. The father and his car moved toward his son's car, but did not crash into it. The son initially pulled his car out of the way but then moved his car fast, as his father had, toward his father's car. Now three or four circles were closed in a row, and a real interaction was beginning. After gestural interaction becomes complex with, for example, the father hiding his son's car and his son pointing, searching, and vocalizing to find it, one fosters the movement from gestures to symbols. As father and son were using the car for simple and complex gestures, the father started to say, "fast" and "slow," to describe his own action. When he moved the car fast, he said, "fast," and when he moved it slow, he said, "slow." After four or five repetitions, the boy boomed his car into his father's car and said the word fast although not pronouncing it quite clearly. The father beamed. He was amazed that his son could learn a new word and use it appropriately so quickly. While in this case symbols came in quickly, in many cases, it is a long and slow process, with lots of work occurring first at the presymbolic levels. Regardless of the length of time needed, words and symbols are more easily learned, however, if they are related to the child's actual experiences and built on the child's affective gestures. Words in isolation, or as imposed labels, have little meaning for the child. A major challenge is a child's tendency to perseverate. One child would only open and close a door. Another would only bang blocks together. The key is to transform the perseveration to an interaction. We use the child's intense motivation to his advantage to get gestural circles of communication opened and closed. For example, we get stuck in his door or our hands caught between his blocks. We are gentle and playful as he tries to get us out of his way (like a cat and mouse game). As gestural interactions occur, behavior becomes purposeful and affective. We modulate his feelings of annoyance and help soothe and comfort as well, though often a child finds our "playful obstruction" amusing. As the child becomes more purposeful, he can imitate gestures and sounds more readily and can copy feeding a doll or kissing a bear. With continuing challenges to be intentional, he copies complex patterns and imitates sounds and words, often gradually beginning to use words and "pretend" on his own. Another challenge, as one moves toward more representational or symbolic elaboration, is to help the child differentiate his experience. The child needs to learn cause-and-effect communication at the level of ideas and to make connections between various representations or ideas. Since most children with pervasive developmental problems have difficulty with receptive language (that is, auditory processing), and some have difficulty with visual/spatial processing, it is much easier for them to pay attention to their own ideas rather than the ideas of others. The way the child categorizes his experiences at the level of symbols or representations, however, is through feedback. The parent becomes the representative of what is outside the child and the foundation for reality. The clinician's or parent's ability to enter the child's symbolic world becomes the critical vehicle for fostering emotional differentiation and higher levels of abstract and logical thinking. When during pretend play the child ignores the therapist's inquiry about who sits where at the tea party, the therapist brings the child back to the comment or question until the child closes the symbolic circle. The adult might "play dumb" (a little like the TV character Columbo) and bring the child back to the point of confusion. For example, when the child has the puppet biting the head off the cat, the parent may say, "Ouch, you hurt me." Then, if the child looks at the tree outside, the parent might ask, "I see the tree you are looking at, but what about the cat? What about his ouch?" If the child then says, "I'll give another ouch," and bites the cat with the puppet, the child has closed the symbolic circle of communication. If the parent then says, as the child goes back to the tree, "Do you want to talk about the tree or the cat?" and the child says, "Let's look at the tree," the child has closed yet another circle and has also created a logical bridge from one set of ideas to the other. As the parent or therapist helps the child create such bridges, always following the child's lead, the child becomes more representationally differentiated. If the parent either lets the child become fragmented or becomes too rigid and controlling, differentiation may become compromised. Relating to the child when he is feeling strong affects is critical. He is connecting his words to underlying affects, which give them purpose and meaning. When a child is motivated, for example, in trying to negotiate to get a certain kind of food or to go outside, there is often an opportunity to open and close many symbolic circles. The child who is trying to open the door because he wants to go outside and is angry that he cannot, may, in the midst of his annoyance, open and close twenty circles of communication if the adult soothingly tries to find out what he wants to do outside, etc. Children with pervasive developmental disorders often find it especially difficult to shift from concrete modes of thinking to more abstract ones, partiallyart because they do not easily generalize from a specific experience to other similar experiences. There is a temptation to teach the child answers and repeat the same question by scripting the dialogue. The child can only learn to abstract and generalize through active, emotionally meaningful experience. Most helpful are long conversations with debates or the child giving his opinions (e.g., "I like juice because it tastes good.") rather than memorized elaborations of facts. |
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