© David Sponder, L.E.P., BCBA, Floortime C3c
Executive Director, Sponderworks Children’s Services

Child-Led Developmental Therapy (C-LDT) Checklist

First, there a few things that apply to C-LDT that are in important in any intervention that calls for the Guide to follow the child’s lead.  These would include ABA methods of Pivotal Response Therapy and Verbal Behavior, and Relationship-based Intervention (R-BI).  Regardless of the specific method you’re using, you must understand a few things before going on:

There have to be Real, Measurable and Observable Outcome Goals

This is not just play.  The casual observer of the teaching must be able to tell readily what you’re working on.   Child-lead methods are just as goal oriented as Adult-lead and Clinician-lead methods.  There are skills and responses you promote actively through the medium of play or other routines the child prefers.  Goals should be part of a developmental-scaled based plan (a hierarchy of skills reflective of normal pathways of development – especially emotional development).  The responsibility of the Senior Therapist or Consultant is to provide ongoing assessment of the child’s skills and to help you devise a C-LDT plan.

The list of skills a child needs to learn could be very long, but it is counterproductive to work on too many things at once.  It is best to keep one or two in mind at a time and work until the child can use the skills fluidly.  If you are a beginner yourself, it is wise to focus on one or two of the teaching skills listed in this document and perhaps not worry about the child’s skills until you feel comfortable.  Since child-led therapies are very improvisational, it is common for beginners to feel “at sea” at first.  It is also common for experienced therapists to feel this way with children they don’t know or children that are shy or have difficulties trusting others.  A good idea is to simply watch your child play and then when your alone, think of ways to incorporate yourself into the child’s play.  It can be difficult for the beginner to think of things while working with the child.  Each of the headings below represent teaching tools that you can focus on one at a time.

Emotion-Sharing

Face-to-face emotion-sharing is the ultimate goal of R-BI.  This occurs when one partner feels something and turns to their partner to share the emotion.  The reason a person turns to their partner is to see if the partner feels the same way (congruency) or not (incongruity).

This is much more than “eye-contact,” a much overused and useless term.  There must be a reason why you want to look into someone’s eyes (e.g., to see if they see the same thing you do [passive joint-attention]; to see if they feel the same way or not [emotion-sharing/ congruence]; to get some form of information [instrumental referencing, as when you look at someone to see if what you’re doing is correct]; etc.).

I just described several forms of social-referencing.  Emotion-sharing is what makes a person less autistic.  It is very rewarding once learned and bonds people into intimate relationships.  It is the most important form of social reference.  I cannot underemphasize this.  Emotion-sharing has several characteristics:

Affective Attunement

Partners become highly interested in each other’s emotional state (affect[1]) at the moment.  It is a moment to moment thing; constantly changing.  To be attuned is to constantly look at the partner to “read” their partner’s emotion states as reflected on their face.

Throughout childhood, adults do most of the work of attuning to their child.  That is, adults tend to do more reading of their children’s emotion states and make more adjustments to their needs, and children do less reading of and adapting to adults needs.  This is as it should be.  This balance is distorted of course in the case of attachment disorders (caregivers fail to attune for reasons having to with themselves) and autism (the child’s signals are distorted and difficult to read or adjust to).

The outcome of attunement is that one feels their partner understands their feelings empathically.  They “feel felt.”  For there to be true affective attunement, it is not enough for one person to have empathy for another.  The other person must feel the interest and somehow know in a deep, emotional way that their internal state is either understood, or that their partner is trying to understand.  Affective attunement is the act of trying and communicating that to the partner.  Most of it is nonverbal, as words are too inarticulate for emotions.  Children with attachment disorders or autism have difficulty feeling felt, and attuning to others.

Mirroring

Partners in attuned relationships tend to mirror each others’ facial affects.  Neurotypicals in intimate relationships do this in an automatic, subconscious way.  It is an almost reflexive process managed by subconscious, emotional/motor parts of the brain (mirror neurons).  Mirroring starts in infancy.  The caregiver starts by responding to all of the baby’s actions, whether intentional or not.  This is a C-LDT techniques (responding to unintentional acts on the part of the child and treating them as intentional).

Babies don’t have social smiles (an organized affective signal) from birth.[2]  However, caregivers respond to babies from birth.  When they burp, sneeze, or whatever, the caregiver responds with some form of action.  The social smile is a sign that the baby is beginning to understand this emotional cause-effect relationship (I do something, she does something).[3]

In C-LDT, the adult initially does the vast majority of the work.  I want to point out that the adult must reflect the child’s state, and not try to get the child to feel something she isn’t feeling at the moment.  Yes, your ultimate goal is mutual and reciprocal emotion-sharing, but you cannot manufacture emotions in the child simply by acting excited or joyful.  This is a common mistake for beginners.  They try to be real giddy around the child in order to get joyful interactions going, often to find that the child rejects them.  This is not following the child’s lead.  The adult instead tries to be a mirror for the child’s emotions, reflecting the child’s emotion of the moment on their own face.  They do not try to get the child to mirror their expression.  This has to come naturally, and may not occur for a while.[4]

Congruence

Congruence has to do with whether our partner actually feels the same way we do.  So for instance, we could watch something happen together.  I might think it’s funny and turn to my partner to share my emotion and check to see whether she feels the same.  When I look, I see that she doesn’t think it’s funny.  If I’m attuned, my face will reflexively go from a joyful affect to one that mirrors hers – at least for a moment.  In this instance, the incongruence is meaningful, as well as my dynamic adjustment to the change in our mutual affect states.

Synchrony (see Tronick’s “Mutual Regulation Model”)

Synchrony is the hallmark of successful social interaction.  People send social volleys back and forth, giving each other room to respond.  If one person goes on too long without looking for a response from the other, the relationship feels out-of-sync.  The same is true when one partner does not respond when a response is expected.  Asynchronous moments such as these are signs to partners that repair of the moment is needed, and socially adept individuals are adept at making these repairs.

Since the children who receive C-LDT are either emotionally delayed or emotionally disturbed, I recommend several rules of thumb:

  • Focus on 1 for 1, action-response cycles.  That is, if you do an action, look for a response from the child before doing something else.If you do too many actions at once or your actions are too complex, you run the risk of boring, alienating, or merely entertaining the child.  Bored or alienated children disengage.  Entertaining a child has no learning value, although the child may love it.  Getting a child to laugh or making him excited is not beneficial alone.  The child has to somehow respond to your response (see Circles of Communication below.  For a further description of Circles of Communication, refer to the page: Circles of Communication).  This is a matter of inserting a therapeutic pause (waiting) so that the child can formulate a response.
  • If you allow the child to go on and on without her looking for a response from you, you are also out of sync.  The child is simply going on in her own world without you.This is a trickier problem.  The key is somehow making yourself needed in the activity.  For instance, if a child likes to play with blocks, you put yourself in the position of handing the blocks to the child.  This sets up that 1 for 1 relationship and allows you to add variations to this pattern.   Another example might be a child who jumps up and down on the couch.  Here you might turn it into a game where you catch him every third time by chanting “jump, jump, catch.”  There are endless ways to do this.  Some of these patterns are difficult to enter, so if you’re stuck, contact the Senior Therapist or Consultant for help.Synchrony also has to do with matching the emotional tone of the child, the complexity of his actions and other things.  A typical mistake is trying to respond to a simple behavior with a complex one.  So for instance, a child might be simply opening or closing a door, simply for the pleasure of this simple action.  The adult might respond by encouraging the child to put things inside and take things out.  This is too complex, and the child stops enjoying the activity.  A better move might be to place your finger in the door and playfully yell “ouch” each time he closes the door.  This adds a simple-enough variation to the activity that many kids would enjoy, and you can build on this.  The child now begins to look to see if you will put your finger there – so now you’re in!
  • Another mistake is to try to enter a quiet activity with a lot of manufactured excitement.  Floortimers are trained to find that optimal arousal state, and experienced ones know that first you must enter at a state congruent with the child’s.  You can gradually bring a hypo-aroused child “up” with increasing the movement of the activity or by putting materials out that attract the child to movement (e.g. therapy ball).  You can gradually “down-regulate” a hyper and disorganized child by being a beat or two slower or adding resistance (e.g. tug of war; pressure hugs or rhythmic movements), music that changes the child’s gear, or water or sand play.  Here again, if you’re stuck, contact the Senior Therapist or Consultant for help.

Joint Attention

Joint attention (JA) is a phenomenon that exists on hierarchical levels, where the upper levels require more ability to understand other people’s attention-states and at the lower levels – the person simply understands that his or her behaviors cause some kind of contingent response in others (this isn’t really considered true “joint attention” because it doesn’t require knowledge that someone else is using their attention). 

Simple JA requires that both people refer to the same thing or the “referent.”  This is sometimes called, “shared attention.” 

True JA however requires that partner’s have knowledge of their partner’s attention state (knowing what they are attending to, where they are attending, whether they are attending, etc.), as well as partner’s making attempts to direct or manage the other person’s attention state.  This also requires checking the other person’s attentional state to make sure they are attending to the correct referent.

The actions we take to get someone to look, listen, understand, etc. are called “joint attention bids.”  They actively attempt to draw the other person’s attention to the referent.  Examples include pointing; words like “listen,” “look,” etc.; presenting objects, and any other means of getting someone else to attend to a referent.  In fact, the understanding of any word requires a shared referent.  If I say the word “car” to someone and they understand what I mean, then we are sharing a common referent. 

But joint attention bids are different.  They are acts that manage other people’s attention.

In C-LDT, there must at least be shared attention.  The adult actively tries to focus on the same thing the child does, resulting in a shared attentional referent.  The adult joins the child by acting on the referent with the child (the adult who sticks her finger in the door in the example above shares the child’s attention on the door). 

Emotionally and communicatively more impacted children don’t make overt, active (expressive) joint attention bids.  Many cannot understand the joint attention bids of others (receptive JA).  They can only be passive participants in shared referents, and the more capable person is doing all the work.  If they do develop communicative intent at the early levels, they might use devices like hand-leading or presenting objects to others, but there is little understanding of the adult’s attention state.

It is important that you know the basic elements of JA

The Basic Elements of Shared or “Joint attention”

Visual Domain

Most of early JA is visual, and visual JA is pervasive in social interaction that takes place when people are physically in the same area.  Also, language stimulates others to think, and when they think, they visualize.  Visual memory deficit is a major reason for problems with perspective-taking and episodic memory:

Gaze Detection

This is a simple awareness that another person is looking at something.  This is an important first step in perspective taking because we generally assume that what someone is looking at is what they are attending to, or in other words, what is on their mind and what they are thinking about.

Most higher mammals know when you are looking at them.  Knowing whether someone is looking or not looking at you is a very basic element of JA.  Understanding in a cognitive way that because someone looks at you they can see you is not something mammals can really do.  They tend to go on instinctual responses to eye-contact.

Gaze Following

This has to do with the ability to follow someone else’s eyes in order to determine what they are looking at.  As mentioned, we are conditioned to assume that what someone is looking at is what they are thinking about.

We learn a lot from following other people’s gaze, learning it early in development and doing it for the rest of the lifespan.  First, we get an idea of what a person can see or not see, which eventually leads to an understanding of what others know or don’t know (Theory of Mind or ToM).

We also learn what other people think is important, which helps us develop a value system for learning what relevant versus irrelevant stimuli are all about.

Gaze Monitoring

This has to do with watching another person’s eyes to see whether or not they share the same referent, after one makes a joint attention bid.  You see evidence of this when someone points to something and then looks to see if you are looking in the right place.

Gaze Directing

Gaze directing is the active part of directing another person’s attention.  The skill requires all of the skills above.  Attempts to manage another person’s attention are called JA bids.

Auditory Domain

When we listen to each other talk, we actively share referents.  These referents are often ideas that we actually visualize in order to understand, so it comes back to vision anyway.  Also, the ways we determine whether someone is listening are mostly visual, although we have devices to detect whether others share referents through auditory forms of communication.

There isn’t much written about this, but it seems to fairly common sense that there is such a thing as Auditory Joint Attention (AJA).  We ask people to listen, and we have ways of determining whether they are listening and whether they share the same referent.  To analyze AJA, I’ll use the same heuristic as VJA:

Auditory Detection

How do we tell if someone hears us?  There are signs we look for (e.g., they interrupt their action for a moment; they orient to the sound; they respond somehow to what we said, etc.).

Auditory Following

If we can tell someone is listening to something, we might make attempts to listen to what they are listening to.

Auditory Monitoring

If we are talking or singing or making noise, we look for the signs that the other has heard us.

Auditory Directing

We speak louder, make attention-orienting sounds, or say words like, “Listen.”

Shared Attention in the Proximal Senses of Touch, Proprioception, Balance, Smell and Taste

What about the other senses?  Do we not know whether someone smells something that we smell?  If I sneak a cigarette – would others know that I was smoking (the cigarette smell being the shared referent)?  Don’t we have an idea that when we burn incense that others will smell it and can’t we tell if they do or not (smell detection)?  Don’t we monitor (“Can you smell that?  Do you smell apple pie?”)?  Don’t we direct others (“Take a whiff.”)?

What about taste?  If I sneak salt into your coffee, wouldn’t I expect you to detect that?  Wouldn’t I look to or listen determine if you detected the salt?  You get the point.

When doing C-LDT, you follow the child’s attention assiduously.  In a stricter format such as Floortime, you would follow this anywhere (with a lower functioning child at least), including toward the child’s circular behaviors (stims).  In Floortime, you join circular behaviors as you would any other of the child’s interest, although in SCS C-LDT, this becomes a decision made by the team whether to do this or not.

But in every C-LDT, the adult strives to form JA frameworks or “JA Frames.”  A JA frame exists when the both partners know they share the same referent (it isn’t necessarily a JA frame when the child is unaware of your presence or does not engage with you in circles of communication).

To do this, the adult tries to position herself in the easiest position for the child to see her.  The adult should never be behind the child.  Objects should be held close to the adult’s face if possible.  One of the reasons Floortime is called Floortime is because the adult gets down there on the floor with the child – in order to establish shared attention frames.

C-LDT No-nos

This list may not conform to rules of other C-LDTs, but they do with SCS C-LDT:

  • Don’t ask a bunch of questions.  Use simple declarative phrases, ones that are simple enough for the child to understand fully, and one’s that you hope to hear the child repeat at some time.
  • Don’t go overboard on “narration.”  This is when the adult labels the things the child attends to.  Since children with ASD become captured by their own actions, they may not be able to process your words and their actions at once.

Remember, C-LDT might be used to teach any skill, including language, but its primary intent is to teach emotion-based relationship skills.  Circles of communication can consist of simple looks and facial expressions that go back and forth.  Language instruction is not the primary goal.

  • Don’t talk or do anything when the child isn’t focusing on you.  Don’t talk to the back of their head or to a child that is walking away from you.You have to wait for the child’s mindful attention.  Hopefully your actions are simple and interesting enough for the child to want to engage with you.  And by incorporating yourself into the child’s actions, you establish shared frames.
  • Don’t use words to manage the child’s attention.  Avoid imperative JA bids such as “look at this” or WORSE,  “Look at me.”  The reason?  You are no longer following, you’re leading.A frequent mistake is to think you have something important for the child to see, but he’s interested in something else – perhaps not as important as you think it should be.  For instance, you walk by a flower and want to share the experience with the child, and the child is more interested in the dirt beneath the flower – share the dirt and don’t try to direct the child’s attention to the flower.You can do actions that you know are interesting to the child conspicuously in front of her.  I call these “declarative actions.”  They can be accompanied by declarative statements (e.g., “I’m making a house!”  “Ooh cookies!”  “Here comes the tickle finger.”).  If they don’t work however, that doesn’t mean you should switch to imperatives (“Look at my house”).

Two excellent books of ideas to use to give you good ideas for C-LDT situations

Giggle Time – Establishing the Social Connection: A Program to Develop the Communication Skills of Children With Autism, Asperger Syndrome and Pdd

By Susan Sonders (Jessica Kingsley Publishers; January 2003).
Playing, Laughing and Learning With Children on the Autism Spectrum: A Practical Resource of Play Ideas for Parents and Carers

By Julia Moor (Jessica Kingsley Publishers; January 2002).

 

 

 

 

 

 


Checklist

 

  • How are you managing the child’s arousal?

 

  • Is your child maintaining an optimal state of alertness for learning throughout the session?

 

  • What things does your child require in order to maintain the optimal level of alertness?

 

  • Do you recognize when the child’s arousal state has become a problem?
  • How do you help your child adjust states of hypo-arousal or hyper-arousal?

 

 

  • How responsive are you to your child’s signals?

Are your responses engaging the child effectively?

 

  • Are you following the child’s actual focus of attention and shifting when he does?
  • Are you close enough to be sure you are that both you and the child can maintain a joint attention triangle?

o    What is your zone of connection?

§  Are you keeping a tight triangle?

§  Do you look for gaze-shifting?

ú   Do you use approved techniques designed to elicit gaze-shifting?

§  Are you allowing the child enough time to respond?

§  Are you waiting for the child to reference you before moving on to the next response?

  • Are you mirroring the child’s affect?  Behavioral rhythm and pace?  Level of intensity?
  • How well do you match the child’s true level of development when joining him or her?  Are you staying in the child’s true “Zone of Proximal Development?”

o    Are your initiations too complex?

o    Are you expecting responses that are too far above the child’s ability?

o    Do you find yourself prompting or falling back into imperative prompting or coaxing?

 

  • When the child disengages, do you know why?
  • Do you respond to unintentional communications as intentional?
  • Are you maintaining an emphasis on declarative and experience sharing types of communication rather than on merely requesting or answering questions?
  • How are you managing your materials and your environment?
    • Are you sure the use of objects in play is advised at this time?  Have you considered using dyadic “baby games” if your child becomes too absorbed in objects?
    • Do the objects you choose provide both interest to the child and communication temptations?
    • How well are you controlling access to materials?  Does your level of control match the child’s ability to organize his or her intentional behavior to request, comment, etc.?
    • How well are you controlling space?  Is wandering a problem?
    • How does your positioning of materials affect the child’s attention shifting from the object to you?
    • Does your choice of materials reflect your knowledge of the child’s language objectives?

o    Do the activities bring new sources of vocabulary?

o    Do they help maintain vocabulary already acquired?

 

  • How well are you teaching nonverbal and verbal communication?
  • Are you having success engaging the child in long-chain emotional and communicative interactions?
  • Are you using intensive language input as a scaffold for verbal communication?

o    Are you using a repetitive but specific vocabulary to input?

§  Are you using declarative language to stimulate responding (as opposed to imperatives like questions)

§  Is it consistent with the child’s language objectives?

§  Is it slow enough for the child to comprehend?

§  Do you wait for the child to have a specific reference (you [preferably] or the object of interest) before inputting?

o    Are you speaking clearly enough?

§  Slowing down?

§  Separating your words so that the child can hear where each word begins and ends?

§  Using a normal inflection rather than making everything sound like a question?

o    Do you have an expectation that the child communicate rather than just listen?

§  Do you create a moment or space for the child to formulate her response?  Do you give her enough time?

§  Do you respond immediately to the child’s communications?

√      Do you treat unintentional communication as an opportunity to respond?

√      Do you respond to communication attempts?

 

  • Use of Language Expansion Techniques

o    Do you incorporate the child’s utterances into your response?

o    Do you add a developmentally appropriate expansion?

o    Do you wait for the child to respond (either with a novel utterance or echolalia)?

 

  • How well do you deal with static or circular (repetitive, self stimulatory) behavior?
  • Can you find a way to join the child when he or she is involved in circular behavior?
  • Do you continually introduce peripheral variations in order to reshape circular play or interactive patterns?
  • Do you control access to materials that promote avoidant, circular behaviors?

Session Tips

 

  • Know what you want to accomplish with the child that session.  Your goals will either be: getting to know a new child – with no particular goals for developing skills at the moment (the goal is merely to get acquainted and to feel comfortable with each other), or;skills that we have targeted during the last clinic meeting.
  • Try to work within a reasonably confined area.  This is especially important for disorganized children who wander aimlessly.  You can work in corners or move furniture to set up rough boundaries.
  • Clean up the clutter.  We have found that leaving a bunch of toys out encourages flitting from one thing to another aimlessly.  Less is more.

o    Leave out objects or toys that you think will appeal to the child, but that won’t be too absorbing.  Use communicative temptations.

o    Therapists may not want to use toys at all.  They can be more of a problem than a help.  Watch the child to see if he gravitates to anything – anything.  You can do C-LDT watching ants climb a pole, with a garden hose, with leaves, throwing sand in the air – anything that holds the child’s interest.

 

 

When Starting with a New Child

 

  • The main goal at first is for the child to get comfortable with you and then to enjoy being with you.  Really – that’s all.Believe it or not, some children with ASD are very easy to engage.  They have naturally gregarious personalities that make them trust and enjoy people.  All they need is someone to play with them, and to accept and be able to join them in the way they play.The Anxious/Avoidant Child

    Others can be very mistrusting.  When you approach them they move away to avoid you or they get hostile.Don’t be discouraged.  Just don’t try to accomplish as much at first.  We’ve never seen a kid stay that way.

 

For some very touchy children, I recommend what I call the “Jane Goodall” approach.  Jane Goodall was an anthropologist that did famous studies on wild chimpanzees in Tanzania.  Initially, the chimps were very wary of her and treated her as a potential threat.   Her approach was to just sit there – month after month, just so the chimps could get used to her smell.  She barely moved and didn’t speak.  She made notes in her note pad, but that was about it.  The first sign of progress was that the chimps started going about their business, showing that they were less anxious around her.

Then they started to approach her.  She didn’t do anything to coax them or to rush the process.  She didn’t want anything from them.  To make a long story short, they eventually became very comfortable with her and they interacted regularly.

For our human kids, this has never taken months.  Corey few weeks sometimes, but they always warm up.

 

 

Dont take this approach with every child.  Do it only when nothing else works.  Generally, this approach is the result of a decision made by the whole clinical team (Therapist, Parent, Supervisor, me).  Corey problem with this approach could be that the parent doesn’t understand what you’re doing and they will naturally question how long will it go on.  Parents are desperate for progress, and it looks like you aren’t doing anything.  This is why you want to bring me in on the decision early.  I can help you explain this to the parent and get them on board with it.

 

Here are some general tips:

 

√      Allow free access to trusted figures.  Allow access to the parent or sibling whom the child trusts.  Allow access to transitional objects such as pacifiers, blankets, teddy bears, etc.  Allow whatever the child currently uses to manage anxiety.

√      Engage the trusted figures without the child.  Try doing something the child enjoys with the parent/sibling.  For instance, you might engage the kid’s mother and his sister in “Ring Around the Rosy.”  This is a perennial favorite.  Or you can take turns with the parent blowing bubbles.  Parents know what attracts their child – so use those things.

 

√      Allow distance.  You can play alone, only smiling when the child looks at you.  You can play songs on a boombox.  The child might signal from across the room what song she wants.  You can imitate her movements to the song from there.  Don’t do too much to coax the child to approach you – take your time.

 

√      Whisper.  Speak very slowly with few words and hushed tones.  Use smiles and open body language more than words.  The reason a lot of children are avoidant is because they have very sensitive nervous systems without filters, and loud noises and sudden moves wig them out.

 

√      Move slowly.  Reduce your movement in general, and when you do move – move slowly.  Sudden moves can cause the child to recoil and fear that you’re unpredictable.   What these kids want is to be able to predict what you will and won’t do.  This is why after long histories with familiar people, they can be comfortable.

 

The Fussy/Temperamental Child

 

First, never assume that the child is “spoiled.”  While it may be the case that the child has discovered that their more annoying and punishing behaviors have been the most effective, these kids have the same problem as the avoidant children – they feel they do not have enough control.

 

We will approach this situation differently when we are doing C-LDT, RDI, or ABA.  In Clinician-led therapies, we choose very careful challenges, control sensory and input conditions, guide and support actions, etc., and allow the child to fuss and self-regulate.

 

In C-LDT, we might also wait for the child to calm down and perform an action to regulate the interaction (e.g., communicate, initiate a step, do something to avoid, etc.).  Whatever caused the child to fuss is considered the variation that occurred, and that calls for the child to initiate a regulatory repair action (that is, to do something to communicate or regulate the interaction somehow).

We will set goals for children to be able to tolerate specific sensory input (by increasing sensory input gradually and incrementally, and pairing unpleasant with pleasurable stimuli such as rocking or music).  But in C-LDT we don’t direct their actions very much.

 

So here are some tips:

 

√      Look at the sensory environment.  Make sure the child is not overwhelmed.

√      On really bad days – pick less demanding things to do.

√      Don’t be afraid of the child’s moods and negative feelings.  We expect this type of child to have more difficulty than others – sometimes much more.

√      View the child’s difficult moments as opportunities.  These episodes are really opportunities for the child to learn to cope and get through difficult moments while in the presence of adults who care about her.

√      Wait.  Don’t do anything proactive to get tantrums or negative behaviors to stop more quickly.  Allow the child plenty of time to cope with his feelings.  There’s very little you can or want to do to make bad feelings go away.

Remember, it is the child’s task to deal with negative feelings, and we want him to understand that his feelings are normal and survivable.  Doing too much to spare the child negative feelings deprives him of an opportunity to learn to deal with them, or worse – it communicates implicitly that “this is bad as you think it is.”

√      When the child is fussing and it goes on for a long time, stop waiting and staring at the child.  Go on to other fun things in his presence, but don’t coax or invite him to do it with you.  Here, you are implicitly communicating, “life goes on” and “[I’m not worried, so that means that…] you’re going to be OK.”

Once the child has recovered and re-enters the play, don’t bring up what just happened – unless the child broke a serious rule and needs reminders of the rules before reentering play.

 

The Aimless Wanderer

 

First, it is important to understand this child.

 

  • This child is very likely to have very severe perceptual and motor planning problems, and therefore lacks skills to explore the environment.
  • This child usually lacks visual perceptual skills: poor depth perception; poor understanding of how parts relate to a whole; poor ability to discriminate one object from another in a busy array – or – zeroes in on something of particular but irrelevant interest such as threads from carpet, beads or marbles, or some other object in which the interest appears compulsive.
  • This child has difficulty seeing patterns in anythingThe biggest challenge when working with this child is to try to establish patterns in what seems to be random behavior.They have difficulty noticing patterns such as shapes, direction of movement, sequences of actions (seeing steps as part of goal-oriented actions).
  • Working memory is severely impaired.  WM is dependent upon well established sensory processing systems now functioning as sources of memory.  Goal oriented and stepwise behavior requires keeping ideas in mind while executing steps.
  • Procedural memory is usually impaired.  These kids have so much difficulty managing their perception, or working around distortions of perception, that they have trouble developing “automatic” behaviors such as walking, balancing, reaching, manipulating, etc., that they have to actively think about them.  This preoccupies them and leaves little attention or memory left to focus on events in the here and now.
  • Encounters with things and people are very short.

o    Encounters with people tend to be very limited in their function.  They may not communicate intentionally, but will stand by the door or refrigerator until someone helps them.

o    They may tolerate or even enjoy the presence of very familiar people in very predictable routines.

o    Encounters with things tend to be of a very immature nature – usually mouthing, holding and dropping, “dumping and chucking,” or some other form of 1. single-step and circular, and 2. sensory-based behaviors.  They get bored with things very quickly because they do not really explore what they do.

o    They may give up very easily because they don’t understand step-wise behavior.  For instance, they might reach for something, but if a chair is in the way, it won’t occur to them that they should move it.  So they simply walk away.

 

Therefore, working with this child is about establishing patterns that you can add variation, whereas with others, you take existing patterns and vary them.

 

Your major task is to help this child establish rhythms and patterns that:

 

1.   he notices and can recognize, and that
2.   because he can recognize the pattern, he can also recognize variations in the pattern, and;

3.   because he recognizes the variation, he performs an action to adjust or stay coordinated.

 

Pattern, Variation, and Adaptation: Spontaneous social interaction follows an ongoing and complex pattern where people initiate actions and patterns, add variations and new information, and react to the new information.

 

  • Gutstein has called this the ‘Regulated Pattern,’ ‘Change,’ ‘Repair or Re-adaptation’ of the pattern (RCR) as part of a cycle.  Since RDI usually starts with the adult in the lead, I will use an adult-led scenario to illustrate:

 

a.     The adult establishes a pattern (steps or actions in a behavioral sequence – called a “regulated pattern”).

The child shows recognition of the pattern by showing evidence that she anticipates the next step.
b.    The adult varies the pattern in some way (variation).

c.     The child responds to the variation in some way (adaptation).

 

Example:

 

¼      (Regulated Pattern) Franco wanders around the room.  The adult takes his hand and walks with him, establishing a regulated pattern (holding hands and walking together).  If Franco fusses, the adult waits until Franco accepts the demand.  He doesn’t let Franco go anywhere without holding hands (regulation).

(Variation1) The adult adds a variation, walking a few feet and saying “stop.”  To help the child understand the pattern, the adult says rhythmically as they’re walking, “We’re walk-ing, we’re walk-ing, we’re walk-ing, stop.  We’re walk-ing, we’re walk-ing, we’re walk-ing, stop.”

(Adaptation) The child notices the pattern and begins to anticipate stopping.

(Regulated Pattern) They keep walking and stopping (the new regulated pattern).

  • Greenspan has called this Circles of Communication.  This is also a cycle of action, variation, reaction.  Since Floortime is a C-LDT, I will use a child-led scenario to illustrate:

 

a.     The child does something.  It might be something with a purpose (intentional) or random or accidental (like a sneeze, or walking around the perimeter of the room).  This is called the “opening” of a “circle of communication.”

b.    The adult does something in response to what the child did.  The child notices that what the adult did was in reaction to what she did (variation).

c.     The child “closes the circle” by doing something in response to the adult’s response.

Example:

 

¼      (Opening1) Tyisha is bouncing on a ball.  She does this all the time.  She simply bounces up and down for a while and then gets up and wanders away.

The Therapist treats this as an opening of a circle of communication.

(Variation1) The Therapist sits in front of her and says rhythmically and song-like, “bounce-bounce-bounce, “bounce-bounce-bounce, bounce-bounce-bounce…”

(Closing) Tyisha continues bouncing.  This is not only the close of the first circle, it is the opening of the next one (Opening2)

(Variation2) The Therapist adds another variation,  “bounce-bounce-bounce, bounce-bounce-tickle.”   Tyisha enjoys this, but out of habit, she wanders away.

(Closing, Reopening) The Therapist waits for a second or two – and Tyisha returns to the ball and looks at the Therapist (perhaps a sign of anticipation).

(Re-opening) The Therapist continues “bounce-bounce-bounce, bounce-bounce-tickle.”[5]

The circles get opened and closed in a very repetitive way for a while so that Tyisha can get comfortable, but then, the Therapist adds something new (variation3): “bounce-bounce-bounce, bounce-bounce- [funny noise].”

 

In order to establish patterns in kids that have real difficulty with them, the patterns have to be very simple and very repetitive.  Think of the kind of “peek-a-boo” games played with babies.  Always allow enough repetition for the child to show anticipation of steps – to notice the pattern and to be a participant.

 

Add only very simple variations.   Allow the child time to formulate responses.

 

The Therapeutic Pause: The therapeutic pause is used to:

 

√      allow the child time to process and absorb what just happened (think)

 

√      allow the child the time to formulate a response (motor plan)

 

√      provide an opportunity for the child to communicate or demonstrate knowledge or skill

 

The therapeutic pause is simply a moment of time (a waiting period) that you insert in order to see if the child will do something.  The communication temptations/incentives listed below include examples of using waiting to elicit responses.

 

Inserting pauses to allow or provide incentive for the child to initiate or respond is often what we mean by SLOWING DOWN.[6]  New Therapists and other anxious adults often put pressure on the child to respond more quickly, or they just keep inputting without waiting to see if the child has absorbed anything.

 

 

Compensation v. Remediation

 

When doing any therapy, we have to keep in mind whether we are teaching the child to do things for herself, or compensating for her weaknesses.

 

Compensations are things you do to help a child do something she cannot do.  We have the goal of withdrawing any compensations we’re making – if we can, and if it is the right time.

 

Examples might include:

 

¼      using a picture schedule to compensate for a child’s poor ability to remember sequences or to talk about things from the past or future.

¼      helping a child perform a step that is difficult

¼      talking for the child

¼      making things too easy for the child

¼      trying to make a child happy when he’s upset

 

As you can see, compensation can be a problem.  It inhibits growth.

 

Generally if you’re talking too much and doing too much for a child, you’re probably compensating too much.  The questions to ask are always:

 

Am I doing this for her when she really should try to do it herself?  Why?

 

Is there some skill he should learn so this compensation wouldn’t be necessary?

 

Is compensation such as this available in typical environments? 
COMMUNICATION INCENTIVES
Adapted from Susan Boswell: Division TEACCH

Children with autism are more likely to be successful communicators in environments that are designed to encourage and support their efforts. In order for the child to initiate effective communication, two conditions should be met.

 

  • The child must see a reason to communicate (WHY)This is encouraged by the use of motivating materials/activities and by creating
    situations in which he must communicate to make something happen.

 

  • The child must have a means to communicate (HOW).The child needs to be taught the communicative behavior needed, and visual supports for that communication will need to be available.

Listed below is a collection of suggestions for setting up communicative enticements that are meaningful and motivating to the child. Many involve play. Some involve problem-solving situations. All involve good timing, especially “waiting”, on the part of the adult who sets up the situation and responds to the child’s communicative attempts.

  • Engage in a FUN play routine several times, then pause and wait for the child to re-initiate the routine. If the play routine involves motor movements, simple language, and a particular object, then the child has several options for HOW to re-start the pleasurable routine.

 

Examples: blowing bubbles / balloons
pillow games
physical interactions such as tickles or swings
motor games / songs
rolling / spinning object

 

 

  • Set up obstacles to desired objects or activities.

 

Examples: things that are out of reach but in view
stand in front of doorway/destination
containers that child cannot open independently
toys with mechanism the child cannot operate independently

 

 

  • Set up problem-solving situations.
Examples: leave out pieces of a puzzle or other motivating toy / game
put in extra pieces that do not go with an activity
give Dad’s shoes instead of own
put block on plate at snack time
leave out needed tool / object, such as spoon when eating
spill something

 


  • Be observant for situations that the child dislikes.Before negative behaviors become a problem, teach the child to communicate “finished” or “stop” or “take a break”, then respect this communication.
Examples: offer disliked foods and teach acceptable way of rejecting
teach “take a break” in middle of stressful situation, such as a haircut,
but then go back to it after a break is given.

 

  • Offer choices, making them visual, whenever possible, throughout the day.

 

Examples: foods and drinks
toys / videos / songs
places to go
clothes to wear

 

  • Be observant for situations that the child dislikes.

    Practice turn-taking during motivating activities, using a visual cue along with verbal cues for whose turn.

 

Examples of visual cues: hand held out palm first toward person whose turn it is
pass object back and forth to signal turn (game pieces, microphone)
name card or picture signals turn
special button or hat signals turn

 

 

Key Points to Remember

 

 

  • We are teaching the child both HOW to communicate (a system) and WHY to communicate (sharing experience; regulation of the environment).
  • Multi-modal communication (combining gesture, pictures, words, objects) is GOOD and helps the child learn both HOW and WHY more rapidly. Respond to the child’s communicative intent whenever possible, whether he uses a spoken word, a gesture, a picture, an object, etc.
  • To help your child understand you and also develop his own expressive language:

√      Use statements, observations, rather questions (declarative language)

√      Limit your own language to words he knows, and try to use the same words each time in the same situation.

√      Use short, simple sentences or phrases.

√      Speak slowly and clearly, and WAIT.

√      Exaggerate your tone of voice and facial expression.

√      Use gestures or other visuals (pictures, objects, print words) paired with your verbal language.

√      When the child is stressed or upset, reduce your verbal language and increase use of visual supports.

√      Imitate what your child says, and expand on it slightly.

√      When you notice your child engaged in something that interests him, use simple language to describe what he is doing. Pairing words with actions makes them more meaningful.

 

More Examples of Communicative Temptations

 

1.     Eat a desired food in front of the child without offering any to the child.

 

2.     Activate a wind-up toy, let it deactivate, then hand it to the child.

 

3.     Give the four blocks to drop in a box, one at a time (or use some other action the child will repeat, such as stacking the blocks or dropping them on the floor); then immediately give the child a small animal figure to drop in the box.

 

4.     Look through a few books or magazines with the child.

 

5.     Open a jar of bubbles, blow bubbles, and then close the jar tightly and give the closed jar to the child.

 

6.     Initiate a familiar social game with the child until the child expresses pleasure, then stop the game suddenly and wait.

 

7.     Ready-Set-Go:  Once the child becomes familiar with the game – leave out “Go” and let the child say it before continuing.

 

8.     Offer the child a food item or a toy that he or she dislikes.

 

9.     Place a desired item in a clear container and place it in front of the child, then wait.

 

10.  Place the child’s hands in a cold, wet, or sticky substance, such as Jell-O, pudding, or paste.

 

11.  Roll a ball to the child.  After the child returns the ball C times, immediately roll a different toy to the child.

 

12.  Engage the child in putting together a puzzle.  After the child has put in several pieces, offer him one that doesn’t fit.

 

13.  Engage the child in an activity with a substance that can be easily spilled (or dropped, broken, torn, etc.); suddenly spill some of the substance on the table and wait.

 

14.  Put an object in an opaque container and shake the bag; hold up the container and wait.  This can be used to teach the Pivotal Response of asking, “What’s that?”

 

15.  Give the child materials for an activity of interest that necessitates the use of an instrument for completion (e.g. a piece of paper to draw on or cut; a bowl of pudding or soup); hold the instrument out of the child’s reach.

 

16.  Give the child materials for an activity of interest that necessitates the use of an instrument for completion (e.g. crayon, scissors, wand for blowing bubbles, spoon); have a third person come over and take the instrument, go sit on a distant side of the room while holding the instrument within the child’s sight, then wait.

 

17.  Wave and say, “Bye” to an object before removing it from the play area (or placing it back in a box).  Repeat this for a second and third situation, then do nothing for the fourth object and wait.

 

18.  Hide a stuffed animal under the table.  Knock, then bring out the animal.   Have the animal greet the child the first time.  Repeat this for second and third time, then do nothing when bringing out the animal a fourth time.

 


C-LDT Checklist Explained

 

We are not purists about C-LDT.  We will do what is necessary to make sure that sessions go well and the child is learning as much as possible – including making the decision that this is not the right time for C-LDT or C-LDT is not the best approach for this child.

 

We will control the child’s access to toys if necessary, and we will not follow a child as he wanders all over the house or back yard.  We won’t join kids in video games (most of the time) or other things that prevent attention shifting.

We won’t work in cluttered and noisy environments that constantly overwhelm the child.  We analyze the child’s defensive behaviors and exercise environmental control until we can figure out how to help the child build more effective ways to manage the environment for herself.

 

No Therapist allows children to hurt themselves or others or engage in potentially dangerous behaviors (this is not allowed by C-LDT purists either).  When this happens we will step in, or ask the parent to.  The checklist below details what we think is important from C-LDT and what we recommend that you do in various situations.  Make a habit of reviewing this on a regular basis.

It would be helpful at this time to review some of the important elements of social interaction:

 

Affect: This has to do with having an idea of what you want – your intention.  Your intention is based on something you feel.  This feeling is reflected in facial expression, body language, tone of voice, and in other ways.  Every purposeful action begins with an affect, and both partners should be continuously formulating and acting upon their affects, and their affects should be affecting the affect of their partners in an ongoing way.

 

Referencing: A reference is simply a source of information – like a dictionary, encyclopedia, or phonebook.  When you “reference,” you seek a source for information.

 

One of the most important contributors to autistic delays in social, emotional, communication, and overall learning is that children with ASD – by definition – are either unaware of or have trouble understanding information around them.  Therefore, they don’t watch carefully the many goings-on of daily life as typically developing children do.  They don’t keep track of what happened before and learn from discoveries of sameness and difference.  Therefore, they have difficulty learning from their own actions and they have even less ability to learn by watching others.

 

 

Most of what children know is learned indirectly.  That is, most of what children know is the result of watching or listening to others – and not being directly shown or taught anything.  Children learn most of their words not by talking directly with others – but by overhearing other people’s conversations.  This is because there are far more new words available from overhearing the conversations of others than in the child’s own direct conversational experience.

Children also discover most of the patterns, rhythms, and routines of the environment without these patterns being pointed out to them.  The ability to do this is from referencing the actions and communication of others from very early on.  From this, they learn to anticipate things, and they derive a sense of control in their lives that comes from understanding what goes on around them.

 

 

Instead of referencing information around them, kids with ASD tend to watch their own actions.  They are “absorbed” or “captured” by something.

 

Usually, the absorption is due to some problem managing incoming information (sensation, perception, understanding), attention, memory, or; with outputinformation (coordinating actions and thinking).  These processes can take so much conscious effort on the part of the child, that he cannot afford to pay attention to the outside world.

 

Therefore – they can retain a sensory-motor style of being in the world that prevents them from being fully aware of their environment – even after many other aspects of their development may be relatively advanced.

 

 

Think of the last time you learned something difficult, such as learning a musical instrument, riding a bike, a stick-shifted car, finding your way to the office, etc.

 

At first, you had to concentrate a lot on what you were doing.  You were very focused on what you saw, heard, what you were told, the actions and sensations of your body, etc.  You couldn’t really do or think of anything else at the time because it was what you were doing was so new, and you had to think about everything you did.

 

In other words – you were very focused on your sensory and motor experience – and you weren’t too much tuned in to the background.  Your awareness and attention to your sensory and motor experience was ‘explicit’ and absorbed most of your mental resources.

 

Sensorimotor huh?

 

Then after initial experience, you start to be able to do basic things more easily.  Basic moves are starting to be controlled without a lot of thinking about them (“implicit”).  But you still have to think hard to manage the more difficult aspects (e.g., learning to drive a stick-shifter, and then driving the car on the freeway).  Instead of focusing on explicit perception or action, you are now focused on the carrying out of operations (e.g. getting to the office).

This is concrete operations.

 

With continued experience, you are doing so much automatically that you are able to do several things at once (driving while talking on a cell phone and thinking about where you were going).  Most of your basic actions are now running automatically (implicit), so consciousness (explicit awareness; thinking about) can now be available for focusing on the world.

 

Formal operations.

 

 

So the “sensory-motor style” that I’m referring to has to do with how the child’s moment to moment experience is absorbed by the work he has to do to make sense of things and to coordinate his actions.  This child doesn’t really want to take his attention off of what he is doing because taking in any more information will overload his already slow system.  He is unlikely to make those frequent shifts of attention between his perceptions and actions, and what’s going on around him.

 

 

 

In a normal environment, information is available from multiple sources:

 

ú   basic visual, auditory, touch, spatial information (sensation; perception);

ú   patterns, rhythms, timing, sequence and other characteristics of other people’s behavior and language;

ú   symbols: symbols help us ‘refer’ to objects, actions, ideas, and events so that others can ‘refer’ to the same thing.  Symbols are often put to use in joint-attention frames where two or more people share their observations, experiences, memories, ideas, etc. about a common point of focus.

ú   hidden structure such as history, context, shared-meaning;

ú   ongoing communication (spontaneous experience-sharing communicated through body language, emotional gestures, words, ideas, etc.).

 

So even a simple 1:1 interaction is full of layers of information that guide each partner’s constant adjustments to the other.  In spontaneous interaction, partners give each other a constant stream of social information: body language, symbols, etc.  Partners also use this stream of information to guide their own actions from moment to moment.  This requires the brain to manage both input (perception) with output (actions) at the same time – flexibly.

 

Other people’s faces are sources of information that we check for many reasons.  We look at each other every few seconds or so in normally brief glances.  We scan our social environment constantly.  We do this to keep track of the quickly evolving and largely unpredictable information involved in fluid social interactions.

The difference between “referencing” and “eye-contact” is that when you’re referencing, you really do want to know what the other person is thinking, feeling, paying attention to, etc.  On the other hand, “eye-contact” is just a matter of focusing one’s eyes on a target.  Eye-contact is one of the many different types of things people do to keep track and remain coordinated in social interaction, but it is only referencing when the reason one looks is because he actually wants to know something.

 

Too often, “eye-contact” is taught like other actions children can be taught.  The child learns to perform the action by responding to prompts such as “look at me” and being “reinforced” with something from the Therapist that could be feedback, incentives, praise, access, and so on. This way, looking functions mainly as a learned behavior that requires recognizing some sort of stimulus to know when to do it.

 

Therefore, a child can be taught to look – but she may not know what she’s looking at, and she may not care.  Referencing has to do with why a person looks.

The main reason for referencing is to resolve uncertainty.  We reference because we want to know something.  We need to be able to do that to keep up with fluid and spontaneous interaction.  We don’t want to miss what we need to know, so no one has to motivate us or provide cues or prompts for us to look.

For example, I might say something to you, but I cannot know if you paid attention, understood, agreed or disagreed, etc. without looking for your reaction.  So I look briefly at your face to resolve my uncertainty.

Instrumental v. Emotional Referencing: There are two main categories of functions of referencing: instrumental and “experience-” or “emotion-sharing.”  “Social referencing” typically involves a balance between instrumental and experience-sharing reference actions.

 

Instrumental references seek information to remain coordinated in a goal-oriented activity – mainly for the purpose of getting something done or getting an answer.  Instrumental situations involve giving or following directions, asking or giving information, performing role actions in routines, etc.  Instrumental purposes for referencing include resolving uncertainties related to these situations such as:

 

Are you paying attention to me?  Do you know what I want?  Are you getting it for me?

Did I do this right?

Are we referring to the same thing?

Is this the one?

Where is it? (looking for the direction of the other person’s eyes, or “eye-pointing”)

Is this safe?

Are you telling me the truth?

Am I walking alongside you?

 

During the course of experience-sharing social interaction, each person “references” the other to see if they feel the same or not, on the order of every few seconds or so.  This is called “referencing for emotion-sharing.”  “Experience-sharing” or “emotion-sharing” references might include:

 

“Did you see that?”  “Are you as excited as I am about that?”
“Do you like what I did?”
“Did you think that was funny too?”

“Do you see how angry I am?”

“I’m scared – are you scared too?”

 

 

Children with ASD will reference for instrumental purposes more readily than they will for emotion-sharing.  Therefore, we are always striving to shift the balance towards more emotional referencing than instrumental referencing.

 

If you are simply using communication temptations such as placing objects out of reach in order to get a child to request your help, asking them what they want, etc. – you are likely to be stuck in the realm of instrumental referencing.  This may be the only thing possible in the beginning, but it is not the main object of C-LDT.

 

 

When referencing for emotion-sharing, we are looking for congruence v. non-congruence.  Either you feel the same way I do (congruent), or you feel differently (incongruent).  If I make a joke and you laugh we’re congruent.  If I make a joke and you look disgusted – we’re incongruent.  When we are congruent – I’m encouraged to keep going.  When I see you feel differently, I should adapt somehow.

Joint Attention (JA): Joint attention has to do with two people sharing a common focus of attention.  During normal social, emotional interaction, partners not only share their attention on a common subject, object, or idea (i.e. “referent”), they also do things to keep track of and coordinate each others’ attention.

 

There are three points to a basic “Joint Attention Triangle (JAT):” YouA + MeB + whatever we’re referring toC.

 

Other versions might include:

 

MomA, babyB, and the bottle they both see.C

 

Or DadA, his little girlB, and the bike she wants for her birthday [idea] .C

 

Or maybe, ‘a woman A describing her date last nightB to a friend.C’  These are examples of triads.

 

Triads get more complex as the child learns to handle more information, to remember more, to relate more.  Triads can go on to include You A + Me B  + what we both know another person knows.

 

-       How about, Nina A, Papa B, and the lie Nina told C about SarahD hitting AshleyE first.

In other words, they go can go on to include ever increasing complexity, abstraction, and variation.  Starting in infancy, JATs typically go on to include multiple, coordinated interactions with a growing circle of other people about many other things.

 

One example could be:

 

¼      Who knows

¼      whatA about

¼      what the others knowB that

¼      Franco saidC to

¼      MichaelD about your friend

¼      SamanthaE in

¼      Math ClassF
and

 

¼      we both rememberF that

¼      Michael said G

¼      (thought: did he lie? H + memory of C, D, E)?) to you

¼      last weekI (concept)

¼      the exact oppositeJ of

¼      what he said then (memory of C, D, E).

You get the point.  We can appreciate that social interactions beyond infancy go on to require tracking multiple sources of information, practically simultaneously.  References go on to include JA states that travel freely in time from the past, current, and future.  Memory is toggled in and out from long term, intermediate term, short-term, and our ‘here and now’ consciousness (working memory[7]).

I’d also like you to appreciate how much mental ability and flexibility this requires.

 

First of all, complex tracking depends a great deal on the child’s frontal lobe development.  It is in the frontal, executive areas that the brain tunes in and out sources of information from current perceptions, actions, memory, etc.  It’s your mental “desktop.”  In neurotypical development, we don’t expect this to happen seriously before 18 months of age, more or less.

Second, the brain can’t manage the present very well if it has to think about everything.  There’s a lot of stuff that it has to do without your having to think about it.   If you’re sitting upright while reading this, your brain is sending thousands of messages to your muscles to keep you upright.  It’s monitoring your body states.  Importantly, it’s managing your attention.

 

It is constantly shifting your attention between sources of information both internal and external, as well as now, then, and in the future – without your having to think about it.  One way to think about it is to compare it to the desktop on your computer.  You can open and close files, make them appear and disappear as windows on the screen.  And by clicking on any window, it will come to the forefront, and the rest of the windows will be rearranged in the background.

 

The coordinate points in JA transactions go on to require managing and tracking multiple reference points that include people, experiences, concepts, etc. as the circles of social interaction get larger.  To do it in real time, the brain has to mange this information very flexibly and spontaneously, staying in an ongoing rhythm and pattern with the mental states and behaviors of others.  Most scientists will tell you that it is the demands of tracking the information involved in the socially complex world of humans, is the reason why human brains grew to get so big.  Another way to say that is that our brains evolved to meet demands for social intelligence.  They might also tell you that as complexity grows, breakdowns are more likely to occur.

 

 

Autism means that the child has difficulty with managing multiple sources of information rapidly.  He wants to slow the world down and make sure it doesn’t change.  He doesn’t like new things, and he does poorly in spontaneous social settings.

 

Behaviors such as pointing, getting others to look, listen, do, or “think about” are called joint attention behaviors.

But joint attention behavior has to do with all of the devices we currently use to manage other people’s attention and knowledge.  In an ongoing manner, we look at [reference] them frequently, follow their eyes to things, communicate, [8] create images in mind about what is in others’ minds, think to ourselves, etc., all while we are doing other things like walking or working together at the moment.  JA is not the same thing as “eye-contact” or “pointing,” if when doing so, you’re not really aware of what others are aware of.  If you’re not thinking about the other persons attention and having some understanding of what they see, hear, or know – you’re just performing a script.  JA usually includes these elements, but pointing and making eye-contact alone are not evidence of JA.

 

 

 

 


 

  • How are you managing the child’s arousal?

 

  • Is your child maintaining an optimal state of alertness for learning throughout the session?

    C-LDT strives for a mentally “optimal state” for learning.  This state is characterized by high interest, alert and focused attention, and low anxiety.The best way to get this is to try to follow the child’s natural interests.  Corey rule of thumb is that whatever the child is looking at or trying to engage with – is the most likely time that a child will be interested.  This is why the main strategy in C-LDT is to “follow the child’s lead.”Conversely, it can be difficult to “manufacture” interest in the child by directing her to look at things that you think should be interesting,or to overwhelm the child with your own exaggerated excitement.Having said all that, we know that that the nervous systems of kids with ASD make them prone to hyperarousal (hyperstimulated, overwhelmed, distractible), to hypoarousal (underarousal, spacey, unresponsive).  These states are not optimal, and you should take measures to correct it.  When a child is either hyper- or hypoaroused, it is much less likely that they will be able to benefit from therapy.

 

o    What things does your child require in order to maintain the optimal level of alertness?

 

o    Do you recognize when the child’s arousal state has become a problem?

 

o    How do you help your child adjust states of hypo-arousal or hyper-arousal?

 

Generally, overstimulated kids require that your actions have the effect of calming their nervous systems down.  Think of this state as a “gear” the child is in, and you have to downshift.  You do this by…

 

¼      dealing with any source of anxiety – if that’s what is causing hyperarousal

¼      slowing down

¼      talking less or at least talking softly

¼      moving more slowly and reducing your movements in general

¼      changing the scenery – move to a quieter place

¼      putting in some music that will have the effect of changing the child’s “gear” – this is often very effective

 

Underaroused kids require some kind of input that wakes up their nervous system.  This can be done by increasing the “value” or intensity of sensory input, but this is never as effective as finding something interesting and putting in out there to “seduce” (not to direct or manage) the child’s attention.  You do this by…

 

¼      knowing what typically interests your child, so you can bring it out at the right time 

¼      rotating your materials and activities so that you can keep interest fresh

¼      going for changes in scenery when little else is working

 

Corey good portion of kids have difficulty getting interested in objects.  These kids tend to have visual perception problems and subsequent fine and gross motor coordination problems (since vision guides movement), so they do little to explore the world of objects.  When this happens, we will develop a curriculum of activities designed to increase visual exploration skills, but in the meantime, it is actually preferable to work without them.

Keep in mind that because a child doesn’t get interested in objects, it doesn’t mean that they’re not interested in anything.  Corey lot of kids are actually more interested in people – although their interactions with people can be one-way streets, or limited in variety and true reciprocality.

 

Corey lot of other kids go for basic sensory stimulation.  They jump repeatedly, stare at sprinklers or shimmering leaves, play in water or sand, wander around walking on their tiptoes, or perform other circular behaviors (i.e. there’s no beginning or end) in a totally self-absorbed manner.

 

When those kids engage in these circular behaviors, they tend to go into an almost opiate, trance-like state.  The state is pleasurable most of the time.  At other times, children do these things to calm their anxiety (by withdrawing into the trance-like state), or to stimulate themselves out of boredom.

 

How do you intervene?  You do this by…

 

¼      making yourself a part of the circular behavior.  For instance, if the child is staring at leaves, throw some leaves in the air.  Use the garden hose to create patterns and spray – you’ll get a ton of mileage out of a garden hose.  Bubbles work for most kids.

 

¼      adding variations that you hope the child will incorporate into the behavior cycle.  For instance, if the child is running her fingers through sand or water, get a spoon and bucket and show her different things she can do

 

¼      imitating the child.  This will often get you noticed, and begin a turn-taking protoconversation.  Add variations to this, and wait expectantly for the child to try to imitate you.

 

 

  • How responsive are you to your child’s signals?

Are your responses engaging the child effectively?

The point of all relationship-based therapies is to teach children how to engage in reciprocal, experience-sharing interaction.  In a very important way, the success of C-LDT is measured in terms of the child’s ability to engage in long chains of reciprocal emotional interactions.  By “emotional,” we mean that the child’s actions are purposeful (representing an idea and an “intention” on the child’s part).  In fact, Greenspan maintains that what autism really represents is a child’s difficulties forming intent, and then formulating flexible action (motor-) plans (which typically involve signaling and communication between partners to remain coordinated) towards their goals.[9]

 

Another important measure of good C-LDT is whether or not the child looks at you (“references” you) for the purpose of knowing your knowledge, attentional and feeling states.

 

In the beginning of therapy, expect that your child will engage in precious little referencing towards you.  You almost always begin by being highly responsive to the child’s intentionally and unintentionally communicative signals.  By doing this, the child learns that what he does affects another person, and hopefully, begins to anticipate and look for your reactions to what he does.

 

C-LDT is intimacy to the extreme – as a mother does with her very young infant.  She spends long periods gazing into the infant’s eyes and responding to every cough, sneeze, smile, yawn and fart.  This is how mothers teach their children communication.  In C-LDT, you will recreate this paradigm – responding to everything in some way or another.

 

  • Are you following the child’s actual focus of attention and shifting when he does?

    Follow the child’s eyes all the time.  Try to move close enough to the object of interest so that a slight shift in the child’s glance will see you.

 

Avoid prompting or cueing the child’s attention.  If you are successful at prompting the child to look at something else, you are less likely to create real interest.  You may of course surreptitiously place something interesting in the child’s line of site as “bait,” but if she doesn’t take it – get rid of it.

 

It is not unusual, especially with a less organized, less emotionally mature child, for the child to flit from one thing to another.  This is why you limit the number of objects in your space.  However, when the child shifts attention, shift along with the child.[10]

  • Are you close enough to be sure you are that both you and the child can maintain a joint attention triangle?

o    What is your zone of connection (ZOC)[11]?

This refers to the closeness required for the child to respond to you.  Generally, the more self-absorbed the child – the closer you have to be.  Remember – the original ZOC for neurotypical children at the earliest stages of emotional development is about AB inches – the distance between Mother’s eyes and her breast.  And during breastfeeding or any other form of early engagement – the child is always positioned so that the main attraction is Mother’s face.

Your child is likely to be at a very early stage of emotional development – so being between AB and B4 inches away is a typical ZOC.

If the child is not initiating actions with you in mind – you’re too far away.  If the child is no longer responding to your initiations, or fails to notice what you do – you’re too far away.

One of the requirements of C-LDT is that the therapy is “intense.”  There should be continuous responding back and forth between Therapist and child.

This usually cannot be done by remaining stationary and hoping to stay in contact with the child by talking.  You need the sharing of facial expressions, so you must be close enough that the child looks to you frequently.

§  Are you keeping a tight triangle?

There are C points in the JA triangle: your face (especially your eyes), the child’s eyes, and the object of interest (what you are both referring to – the ‘referent’).  The point of keeping a ‘tight-enough’ triangle is to insure that you are continuing to share attentional states with the child and that the child knows it.  You maximize the tightness of your triangle by…

 

¼      keeping your face close to the object of interest

¼      controlling the object so that you allow a brief glance and then quickly make the object disappear behind your back so that your face is now ‘substituted’ for the object.

§  Do you look for gaze-shifting?

Does the child ever look back at you?  Do you take steps to elicit gaze shifting towards your face?  You have to care about this a lot and find ways to increase referencing for JA to normal levels.

ú   Do you use approved techniques designed to elicit gaze-shifting?

Prompting to “look at me” is not an approved technique.  Devices such as making noises or clearing your throat function mainly as cues and then become prompts – so avoid relying on these.  Approved techniques include but are not limited to:

 

¼      waiting.  By building up a pattern of back and forth actions, you insert a pause and wait until the child looks to see why you stopped.

¼      allowing a brief glance at the object of interest and then quickly making it disappear behind your back, as described above

¼      touching the child – putting your hand on his forearm or shoulder and waiting until he looks

¼      making conspicuous, large movements in the periphery of the child’s vision – this can spark a reflexive glance

¼      making a noise with an object

 

§  Are you allowing the child enough time and space to respond?

One of the most common mistakes Therapists make is to talk too much and do too much for the child.  Slow Down!  We go for quality over quantity of interactions.

The Therapist has to leave a lot of open spaces between actions to give the child a chance to respond meaningfully.  So when you initiate an interaction or take an interactive turn, wait until the child does something before you go on.

Ideally, for each interactive turn you take, the child initiates one of her own – directed towards you (as a communicative gesture or step of a mutual, interactive activity).

 

 

It can take up to 45 seconds or longer for a child to formulate a response (motor action plan) – whether it is a movement, a communicative gesture or word, the next step of a sequence, etc.

 

This doesn’t always happen.  A lot of the time, the child’s next move is either unintentional or unorganized (wanders, picks up the first thing she sees, stims, etc.).  Or, the child goes on playing without you.  In this case, you respond to what the child does in limited ways so that you can establish a pattern.

§  Are you waiting for the child to reference you before moving on to the next response?

Kids with ASD will tend to participate in ongoing interaction without looking at others to keep track of what they’re doing.  They tend to watch their own actions – even when they don’t need to or shouldn’t.

The goal is to have the child glance over at you every few seconds or so in a normal way.

How do I get my child to look at/reference me?

 

As mentioned, we have approved ways of doing this.  Prompting a child tolook at me,” asking a lot of questions, and other ways of pushing a child to look/reference are not recommended.

 

Remember, the main reason for referencing someone is to resolve some sort of uncertainty.  Therefore, what you want to do is to have a certain unpredictability so that the child has more reason to “keep track” of your actions.

 

The following things work:

 

√      Keep a tight triangle or Zone of Connection

 

√      Establish a pattern, add a variation, and then wait.

 

√      Use therapeutic pauses.

 

√      Wait for the child to look before responding to the child’s initiation, answering questions, etc.

 

√      Use larger movements in the child’s visual periphery

 

√      Put the child in a position where he needs to track where you are, or where he has to look to you for information.

 

√      Use communicative temptations

 

 

  • Are you mirroring the child’s affect?  Behavioral rhythm and pace?  Level of intensity?As a Therapist, you will decide whether you want to match the child’s tone and intensity, or to purposefully do something to slow the child down or energize him up.In general, starting by matching the child’s tone is a good idea – even when you want to change it eventually.  The child’s tone is noted by these elements among others:

 

¼      how fast or slow he moves or talks

¼      the urgency in which she takes actions or communicates

¼      how loud or soft she talks

¼      how much energy he expends, how much he tries to do

¼      how often she switches from one thing to another

¼      how strongly he feels and shows his feelings (affect)

¼      how much is going on (business)

¼      how interested or apathetic she is about what’s happening

¼      how close he prefers to be to someone else

¼      how much frustration or challenge he can handle

Matching tone is a good way of joining a child.  You may not think that what the child is doing at the moment is productive (it often isn’t), but in order to get involved you should match the child’s tone at first.

 

Sometimes the child’s tone and intensity are a problem.  They can be either hyperstimulated – going so fast and taking so little time to explore anything that they’re not learning from their experience, or; can be so static, repetitive, or otherwise uninterested in their world that they also don’t learn anything.

What we are looking for is a sense of calm alertness and interest.  So you may have to do things to adjust the child’s tone.

 

So join first, and then if you want to speed up a child:

 

√      gradually add more movement and excitement to your own actions

√      add more stimulation to the environment or activity: make it more movement oriented, use music, rhythm

√      select activities known to be of interest and that are exciting.

 

If you want to slow the child down, join first, and then:

 

√      gradually reduce movement and slow down your own actions

√      reduce stimulation to the environment or activity: make it more sedate

√      use music, rhythm

√      select activities known to be of interest that have the effect of promoting more focused and calm behavior

 

  • How well do you match the child’s true level of development when joining him or her?Are you staying in the child’s true “Zone of Proximal Development?”

    You have to start with a good understanding of the child’s true level of development, as evidenced by her most common behaviors, as well as ones she can do on good days.Abilities, possibilities, and limitations of the child’s development are defined in the assessment we do up front, and by the bimonthly updating we do in the course of therapy.In general, if your responses are too difficult for the child to understand or too foreign to him – he will disengage.  Therefore, what you’re looking for is not necessarily what is the most interesting thing you can offer – but what the child can readily absorb and incorporate into their own behavior.

o    Are your initiations too complex?

Here are some helpful rules of thumb:

 

√      do things that the child can associate with the simple, ongoing pattern

avoid things that change the pattern too abruptly or that are not recognizable to the child as part of the pattern

√      try to do things the child can imitate without practicing

√      say things the child can imitate without practicing

 

o    Are you expecting responses that are too far above the child’s ability?

This can be very easy to do.  Some children get all the pleasure they want or need from some very simple and repetitive patterns that they prefer to do alone – or sometimes with people.  This defines their autistic pattern of development and we want to change this style of interaction or play.

But we first have to meet a child where she is at.

 

For instance, you see a little boy opening and closing doors on a toy barn.  He’s doing it over and over again.

The Therapist “joins” by putting toy animals in the barn.  She says, “Can I go inside?” for the animal as he opens the door.  The boy walks away (disengages).

This was too complex.  He was simply enjoying the repetitive motion of opening and closing the door.  Her response by required him to understand the animal as a representation of a real (talking?) animal entering a real barn – way too complex.

The next time, she joins him by saying “open, close, open, close…” as he does it.   He notices, but doesn’t really include her in what he’s doing.  That’s OK, she’s not asking him to do anything.  He keeps going until he gets used to her talking.

She then sticks her finger in the door as he closes it and says “Ouch!” (Variation).  He laughs, looks at her.  He goes back to opening and closing, she announces “open, close, open, close, [finger in] Ouch!”  He now recognizes the pattern, and if the Therapist decides to wait before sticking her finger in the door – he vocalizes to get her to do it again.

 

o    Do you find yourself prompting or falling back into imperative prompting or coaxing?

This is wrong for many reasons.  First, prompting or questioning is usually a compensation for a child that is not really offering much in the way of verbal communication.  Adults want the child to talk – so they give him scripted or routinized things to say and prompt when to say them.  That means that the majority of the skill in conversation remains in the adults’ heads.

When prompting or asking questions imperatively you are compensating for the child’s lack of referencing or initiation.   Most importantly, you are compensating for the child’s poor ability to share his experience.  But when prompting, you are teaching a child that referencing and speaking are something someone does in response to something someone else did – so you now have even less of a chance that the child will spontaneously offer her opinion.

 

Initiation and referencing have to be voluntary and spontaneous (volitional) behaviors.  Volitional behaviors are executed differently in the brain than responses are.  That is because they start with an affect – a feeling, and an intention.

When you prompt – you turn the child’s behavior into responses, not volitions.  We want the child to formulate a new action – not simply execute a response learned from training.

 

Prompting and asking questions – or “going imperative” is a sign that what you’re doing isn’t working.  If this is the case, you have to go back to the drawing board and figure out how to get interaction and referencing going without prompting.[12]

 

  • When the child disengages, do you know why?

    Try not to view disengagement as failure.  Take it seriously however.  Analyzing whatever happened that led to the breakdown as part of your ongoing assessment.Think of it this way: Social interaction is expected to be messy.  It is expected to come with minor but multiple misunderstandings and clarifications, changes of interest and topic, context.  People reference each other to maintain a current “read” on their social partners and they make constant corrective adjustments to their own behavior.Breakdown and repairis normal and expected in all interactions.In the beginning, the Therapist may make the majority of the adjustments.  She references the child more than the child references her actions.  She is aware of much more about him than he is of her.  She is extremely sensitive to his signals – even though his signals may not make sense to other people. She controls the level of input and demand in a sensitive way so that the child can trust her.But whenever she can, she holds back, slows down, waits, providing only context and room for a child to think of what to do next.   Her goal is for him to do more and more of the work of social interaction.
  • Do you respond to unintentional communications as intentional?

    This is a technique you use when a child does not yet have the concept of two-way communication.  It is not always necessary.Well before a child begins to use speech to communicate with others, she understands that her behavior is noticed by others and that it causes others to respond.  Some children with ASD have not made this basic discovery, and make few spontaneous attempts to communicate directly with others.  This technique is useful then to create a situation where you can help them make this discovery with your responses.One way of looking at this is that you are trying to create a cause and effect relationship between the child’s actions (cause) and some sort of reaction from the environment (effect).  And, you’re trying to get the child to notice the relationship between cause and effect.   Here are some tips:

o    Respond to anything the child does – even if the act was not intended as a communication.  Therefore, you can respond to coughs, sneezes, burps, farts, dropped toys, self-stimulatory behavior…  …anything.

o    Respond quickly after the child does it.  The closer in time between his doing something and your reaction, the more easily the connection is understood.

o    Exaggerate your responses – you’re trying to be noticed.  Wait for the child to look at you.

  • Are you maintaining an emphasis on declarative and experience sharing types of communication rather than on merely requesting or answering questions?

    Always emphasize declarative v. imperative functions of communication.  The balance of utterances and other communications from either partner should favor declaratives.  This is where partners share their observations, thoughts, ideas, etc., rather than simply request things, make choices, or answer questions.It is actually preferable for you to say “I” a lot in reference to yourself.  “I see an airplane.”  “I’m coloring!”  It’s really good to tell the child what you see and what you’re doing, as well as to make comments about what the child is doing “You made a circle.”When you say “I see this….” Or “I’m doing that…” and then you wait expectantly, you actually invite a child to share hisobservations.  This is better than asking “What do you see?”If the child trusts you and wants to be with you – it is better to announce what you’re going to do next without asking.  “I think I’ll go on the swings (and then look expectantly at the child)” rather than, “Do you want to go on the swings?”Tips for using declaratives:

o    Speak about what you see, hear, are doing.

o    Use short statements.

o    Wait after you say something and look expectantly at the child.

o    Make sure you have a tight enough triangle so that you can maintain a common reference.


  • How are you managing your materials and your environment?

o    Are you sure the use of objects in play is advised at this time?

I do not want to make a set rule on play objects in therapy.  We will make collective decisions on the right thing to do for individual children.

Some toys or objects can turn out to be a fatal disaster to C-LDT.  Some objects have become obsessions where it is very difficult for the child to shift his attention off of them.  Allowing access or trying to join through C-LDT may waste a lot of valuable time.

Stim Objects: Sometimes, a child might associate certain objects with blocking the rest of the world out.  Remember, these children deal with so much more anxiety than everyone else does.  The world is too often not predictable to them, so they can live in constant states of low level anxiety and fear that are punctuated (sometimes frequently) with moments of intense fear and displeasure.  This is exhausting to the child, so she might look for respite in repetitive behaviors that allow them to block everything out.

Repetitive behaviors are known to activate neurotransmitter systems associated with pleasure and calmness (dopamine, serotonin, and opiate systems).  The behaviors can provide a pleasurable and necessary escape, albeit that they are often bizarre and socially stigmatizing.  BUT THEY DO HAVE A VALID FUNCTION.  And we respect that.

In general, the C-LDT approach liberally accepts these behaviors, but tries to turn them into something interactive.  We endorse this as well – when we’re doing C-LDT.   The therapist finds some way to become a part of the behavior, introducing variations regularly until the behavior is no longer recognizable.

However, we also recognize that behaviors that produce changes in dopamine and opiate systems can be addictive.  Literally addictive, because addictions involve these neurotransmitters and the child may come to need them, just as addicts need their drugs and behaviors.  Food, sex, and gambling activities don’t ingest substances that change their neurotransmitters, but the behaviors involved produce either a “high,” or at least temporary respite form otherwise crappy feelings.

So we might want to control access to these eventually.

For some, the object has to go away immediately and there’s no access during a session (e.g., the TV will have to be off).

Generally avoid electronics.  They do way too much for the child, absorb his attention,  and permit so little interaction:

o    TV/Videos

o    Computer games of any kind

o    Electronic toys

 

For others, certain objects have come to represent a form of security blanket that you might not want to take away at first.  You may choose to try to join the child in the enjoyment of the object and try to turn solitary play into interaction.

For others, you may allow the child to see the object but not play with it until you give permission.  This is perfectly alright, although you may have to spend some time with the child helping her as she works out her feelings and adjusts to the new rule.

 

Have you considered using dyadic “baby games” if your child becomes too absorbed in objects?

In general – we want most of the joy the child derives to come from expressions on your face – not from what objects do.  And for some children, the use of objects is simply counterproductive.

 

√      A lot of kids will do better with active games such as jumping, tickling, chasing, going on the swings, etc.

√      Others will do really well with baby games and songs that are done very closely and intimately.

√      Some will be very engaged in mutual sensory activities such as playing in water, sand, cornmeal, rice, lotions, play dough, finger-paint, etc.

  • Do the objects you choose provide both interest to the child and communication temptations?

o    The Standard Therapist Kit

√      Bubbles

√      Musical instruments, flutophones, noise-makers

√      Play Dough and/or “Floam”

√      Finger-paint

√      Blocks, Legos, Bristle blocks

√      Spinners

  • How well are you controlling access to materials?  Does your level of control match the child’s ability to organize his or her intentional behavior to request, comment, etc.?

    Ultimately, objects have to give you some advantage, or else don’t use them.  But let this be our decision.  A child’s access to toys in our C-LDT is not a given, and when we do use them – it is at the adult’s discretion.Some children are very impulsive and grabby around objects.  Therefore, you have to be careful about how you allow access to them.In general, keep objects behind you, and do not allow the child to reach around you to grab things.  Introduce what you think the child can handle.  Again, the object must have some sort of facilitating effect on developmental therapy and the child’s specific learning objectives.
  • How well are you controlling space?  Is wandering a problem?

    There are techniques that can be used to shape aimless wandering into productive interaction.

o    You can turn it into a game of chase and tickle or something similar.  Playfully announce, “I’m gonna tickle you” and move towards the child in an exaggerated way.  Be careful, as this can scare some children.

o    You can use what Greenspan calls “playful obstruction.”  You do things like lay down in front of the child and make him walk around you; open your legs and let her walk through them; let him bump into you and fall over in a comical way.

Greenspan calls for adding some sort of problem solving for the child in this situation.

When the child wanders, she may very well go into a brain-wave state that relatively inactive – a sort of fog.  There’s very little thinking about anything – just relaxing and predictable.   Not really demanding.

Greenspan maintains that by using devices like playful obstruction, turning wandering into a game, etc. you are getting the child to focus attention on the here and now.  This is very valuable in itself, because the brainwave state that I’m describing is destructive in that it becomes a very likely default state.  That is, the more time the child spends in a certain brainwave state, the more easily the brain falls into such a state.

Conversely, the more time the child spends focused on the here and now (an entirely different brainwave state), the more likely he will be to be able to maintain a calm and interested focus on the world.

o    A lot of the time the child isn’t really wanderingshe’s avoiding.  She finds you  too complicated, unpredictable, scary…  and every time you approach she moves away or cries.

Remember, the Jane Goodall approach is always available, and we may make the collective decision to use that technique.

o    And then some of the time, you find yourself following a child that is avoiding you and who has wide open spaces and access to a lot of other things, and C-LDT isn’t working.  In this case:

√      Limit the space that you’re both working in by moving furniture to become barriers or, work in corners.  Allow the child enough space to avoid you, but not a whole lot.  A 10 ft. by 10 ft. area is more than enough room.

√      The child is not allowed to leave the area without being taken.  He has free access to objects of comfort (including Mother) while inside, and there is not pressure placed on him to approach you. 

 

  • How does your positioning of materials affect the child’s attention shifting from the object to you?

    Think about the position of your body and of the toys you’re using and whether they make it easier or harder for the child to reference you.

o    Try to work either in front of the child or at an angle in front of the child.  Never work from behind the child.  Keep a tight triangle between your face, his face, and the focus of your mutual attention.

  • Does your choice of materials reflect your knowledge of the child’s language objectives?We rarely work from vocabulary lists.  We may or may not have objectives for target (specific) vocabulary words.  Most of the time, we are most concerned with the reasons why the child communicates, what he wants to communicate, and perhaps some particular language functions or forms.

 

o    Do the activities bring new sources of vocabulary?

Instead we like the variation of activities to provide us with fresh things to talk about.  Think of activities you set up, toys you select, etc., as sources of vocabulary.  If you have enough variety, you don’t have to worry about vocabulary lists.

o    Do they help maintain vocabulary already acquired?

Therapy should have a balance between opportunities to practice vocabulary already learned and new things you introduce.  For slower progressing children, you will want to spend more time on the same thing, allowing for more repetition.  For children who pick up words quickly, variety is the way to go.

 

  • How well are you teaching nonverbal and verbal communication?

o    Are you having success engaging the child in long-chain emotional and communicative interactions?

Circles of Communication: As mentioned, a Circle of Communication is defined as (a) the child initiating an action – (b) your responding – and (c) the child responding to your response.

A lot of the time, both the actions and responses that make up circles of communication are facial expressions, gestures, references (looks) or other non-verbal turns.  This is good.  Don’t overemphasize speech by making talking a requirement for every interactive turn.

Circles break down due to some sort of mismatch between what the child is expected to do and what she truly is able to do.  This is why we pay close attention to her arousal and interest, her mood, her ability to understand and imitate you, etc.  Again, don’t treat disengagements as failures.  Analyze them.

  • Are you using intensive language inp ut as a scaffold for verbal communication?

    When we are sure the child is listening, we will provide rich input in a declarative way.  The Therapist will put words to what the child sees or hears or what he is doing.   This rich input consists of using a limited amount of words repetitively.  Everything spoken by the therapist should be something the child can absorb, understand, and imitate.While we don’t prompt a child to talk or imitate our speech, we will provide pauses and expectant looks to elicit the child’s communication attempts.  We will provide temptations and opportunities to communicate.But we don’t talk just to be talking.  Be careful of becoming an ignored part of the background.  It’s not input unless it’s going in.  The child must attend to your speech, so speak when you feel like the child will not only try to listen, but also be able to make the connection between your words and what you’re talking about.

o    Are you using a repetitive but specific vocabulary to input?

Fewer words repeated more often are better than a simple preponderance of talking.  Speak slowly and clearly.  Let him hear the separations between words.
Give the child many opportunities to hear and think about what you’ve said before pausing and waiting for communication from the child.

√      Is it consistent with the child’s language objectives?

Whatever language you input should be developmentally appropriate.  We are always working within the child’s Zone of Proximal Development or ZPD.[13]

We define the ZPD during assessment and then between once and twice per month thereafter – so you should always know what it is.  Language input should come from the child’s ZPD.

√      Is it slow enough for the child to comprehend?

Most Therapists talk too fast out of habit.  There isn’t much separation between their words and it can be difficult for some children to make out all of the sounds.

Really, really, slow down.

√      Do you wait for the child to have a specific reference (you [preferably] or the object of interest) before inputting?

DO NOT ADDRESS (talk to) CHILDREN THAT ARE NOT PAYING ATTENTION.  Be careful to make sure the child is in an attentive state and is actually ready to take in the information before inputting language.

Sometimes, when a child is wandering or engaging in highly circular self-stimulatory behaviors, their brains have entered an almost trancelike state.  They cannot benefit from language input at that time.

A lot of the time, the child is engrossed in what he’s doing and is not really taking in much else.  There is a chance to talk about what he’s doing and that he’ll pay attention to what you say – and then maybe not.  If not – stop inputting.

o    Are you speaking clearly enough?

√      Slowing down?

√      Separating your words so that the child can hear where each word begins and ends?

√      Using a normal inflection rather than making everything sound like a question?

Keep in mind that the children will learn a lot of their language from imitating you – directly (echolalically).  So when you ask the child a question, you can expect the child to repeat the statement back – as a question.

But this isn’t how it works in real conversation.  A person might ask a question – using the characteristic upwards pitch at the end that we use when asking questions.  But the responder doesn’t use that higher pitch.  The responder sounds like he’s answering the question rather than asking the question.

 

 

To prevent mistaken inflection, you input language in a way that gives the child a chance to “try it on.”  You speak as if you are speaking for the child.  You speak in the child’s first person point of view (“I saw…”  “I did…”  “I want…”).[14]

 

o    Do you have an expectation that the child communicate rather than just listen?

√      Do you create a moment or space for the child to formulate her response?  Do you give her enough time?

√      Do you respond immediately to the child’s communications?

√      Do you treat unintentional communication as an opportunity to respond?

√      Do you respond to communication attempts?

It is the attempt at communication that we want to encourage.  Initially, it is best to accept just about any attempt a child makes as a means of showing him the power of communication.  You can accept opaque[15] signals such as grunts or when the child stands in front of something she wants and looks at you, or looks in your direction for the next tickle, etc.

Once the child is making regular and deliberate attempts to communicate, you can begin to “hold back” a little and make the child work harder to make herself clearer.

This is called “behavioral shaping.”  You begin to respond differently to the child’s attempts.
Specifically, you hold back until the child comes up with something more clear – closer to what is ‘correct.’  How do you “hold back?:”

 

¼      You act as if you don’t understand until she comes up with a better pronunciation of the word:

 

Child:          “Mm Mmm.”

Therapist:    Huh?  Milk?

Child:          “Mm…” “Mmm.”

Therapist:    “Sounds like you ‘want milk.’  You ‘want milk’ don’t you?”[16]

Child:          “Mik.  Mik.”

Therapist:    Oh, you want milk!

 

 

¼      You act as if you can’t see something unless she references you.

 

Therapist:    (places books on the floor)  “Which one?”

Child:          (excited: looks directly at the books) “Clifford” “Clifford”

Therapist:    (waits)

Child:          “Clifford” “Clifford”

Therapist:    (waits)

Child:          “I want Clifford.”

Therapist:    (waits)

Child:          “I want Clifford.” (looks at Therapist)

Therapist:    (smiles – shares excitement) “Lets read Clifford.”

 

In other words, you raise the bar a little and don’t respond as the child expects you will.  Now, you tend to wait for the most improved response you can get.

Shaping better responses works best in situations when a child is very motivated to communicate something with you.  She is more likely to be persistent when she really has something she wants to get across to you.

You also have to think about the size of the steps you’re asking the child to make.  If you’re asking for some kind of a response that is too difficult, not adequately understood or whatever, then you are setting the both of you up for too much frustration.  The child will likely end up discouraged and make fewer attempts to communicate.

Then on the other hand, if you don’t challenge, and yes, frustrate the child enough… you don’t get growth.

¼      Give the child the benefit of the doubt when you can.  Respond positively when she makes good attempts and let her be successful a lot – especially at first.

¼      Make sure there are adequate foundations established for the improved response you’re looking for.

¼      Be sure that you have thought about what is reasonable to expect in terms of the new shape of the response.

¼      Provide a little help when you think it is necessary.

§  You can use a language input approach: somehow modeling the response for her and giving her a chance to imitate you)

§  You can say some or part of the words for her, and let her “fill in the blank”

§  You can show her or point to something that would remind her of what she should do

 

 

  • Use of Language Expansion TechniquesLanguage response expansion techniques build on what the child can already say.  This technique is most useful with children that are spontaneous imitators.  The adult repeats what the child says, and then adds something to the phrase to make it more complete.  Here are some examples:

 

Child:    “Butterfly”

Adult:   “I see. I see a butterfly.”

Child:    “See a butterfly.”

Adult:   “I see a butterfly over there.”

Child:    “See a butterfly.  Over there.”

Child:    “Juice.”

Adult:   “you want juice.”

Child:    “want juice.”

Adult:   “Oh, you want juice.  Here’s some juice.

 

Child:    “Daddy go”

Adult:  “Daddy’s going in the car.”

Child:    “Going in the car.”

Adult:   “Yes.  Daddy’s going in the car.”

Child:    “Daddy.  Go in the car.”

 

As you can see in the examples, the child hears the expansion and tries to imitate.  This technique then helps you build length and complexity into the child’s utterances.

 

o    Do you incorporate the child’s utterances into your response?

The language response expansion technique involves incorporating all or part of the child’s original phrase.  The adult interprets the meaning of the phrase for the child and adds words that will make the child’s utterances more complete.

o    Do you add a developmentally appropriate expansion?

Again, the rule of thumb is that anything that you model for a child should be something the child can imitate and master.

Think of stretching – not making quantum leaps.  So if a child is using one word sentences mostly, it wouldn’t help to respond with a 6 word expansion.

o    Do you wait for the child to respond (either with a novel utterance or echolalia)?

While we don’t want to pressure a child to respond, we do allow time and space for the child to try to imitate what we model.  Also, if we’re pretty confident that the child will be able to successfully imitate, we can “hold back” (as described above) until we get the best response possible.

 

  • How well do you deal with static or circular (repetitive, self stimulatory) behavior?We will make decisions during assessments and clinic sessions on exactly how we will intervene with circular behaviors.  There are some general guidelines we use:

o    It is likely to be allowed during C-LDT as opposed to direct teaching or adult-led situations.  In C-LDT, we are allowed to join the child.

o    If and when we do join the child in circular behaviors:

 

¼      We try to make it interactive by creating turns  (e.g. you do it, I do it)

¼      We add variations, hoping the child will incorporate them into the previously static circle.

¼      We want to add variations until the pattern is no longer recognizable from its original form.

¼      We want to add variations so that the child begins to add new variations.  At that point, we are no longer going in a circle.

 

When we are teaching or leading directly – we generally don’t allow (or at least – don’t join) self-stimulatory behavior.  This applies most of the time when we are doing adult-led teaching.

This is because self-stimulatory behaviors interfere with the child’s attention to us and to what she should be paying attention to when we are teaching.

Won’t this confuse the child?

Perhaps, initially.  This is why we are careful about making the decision whether to join it or not.  Most of the time, we can assume that through experience, the child will learn whether or not the adult will join them.

We can set up situations that let the child know that circular behavior is allowed.  For instance, we may use only the child’s bedroom for C-LDT, or a specified play area, or a special portion of the session the child comes to understand as “playtime.”

Or, we can rely on the child referencing you for the information.  That is, the only way she will know it’s OK is to look at you.  This is like any other situation where things are sometimes OK and sometimes not.  Children look to adults for permission (they reference for approval).  If you shake your head “No,” the child should eventually understand.

 

  • Can you find a way to join the child when he or she is involved in circular behavior?

¼      One way to do this is by conspicuously imitating the child until he notices what you are doing.  This is a form of exaggerated parallel play, where you play the same way he does in parallel – but you do it in a big enough way to get him to notice that you’re doing what he’s doing.  He has to be able to recognize that what you’re doing is the same as what he’s doing (he recognizes it as imitation).  Not all kids are at that level when you start.

If the next time he does it – he looks to see what you will do – then you have joined successfully.  He will do some of the behavior, stop, and wait for you to do it too.  Now you’re taking turns and it’s like a protoconversation.  You’re now joined in an interactive activity that wasn’t interactive before.

¼      Another way to do this is to become a part of the activity as a helper or go-between.  So if a child lines up trucks and cars in a static way, you can make sure you have the basket of trains and hand them to him.

If a child bangs the table over and over with her hand, put your hands underneath hers to create a sort of pat-a-cake thing.

  • Do you continually introduce peripheral variations in order to reshape circular play or interactive patterns?

    Peripheral variations are those that don’t really change the goal of the play.  Throwing sand up in the air over and over may not be very goal oriented, but it must do somethingfor the child.  So you can say that whatever she gets out of throwing sand in the air is what she intends to get from throwing the sand in the air.  It’s obviously very satisfying to her.A peripheral change to throwing the sand in the air would not change what she currently gets out of that behavior.  It would be a variation that preserves the satisfying result, such as your throwing sand alongside her.Gutstein calls them “just noticeable changes.”  These describe the types of variations you typically add to circular behaviors.  They are small changes – enough to notice, but not so radical that the child doesn’t recognize them as part of her pattern and disengages.If she stops what she’s doing for a moment to look at you, you have added a peripheral variation on the original pattern.  If she accepts your doing this, and then does something to continue the pattern – you have successfully added a variation.   You might turn it into a turn-taking thing, which is another variation, but one that doesn’t change her original “goal” of having fun throwing sand.  And then you might say “Ready-Set-Go” and throw the sand at the same time.  That’s another peripheral variation.  And so on.But would adding a pale and shovel be too much – too fundamental of a change?  Perhaps.  You can try it, and if she rejects the variation or doesn’t join, it probably was too fundamental.  It does change the nature of the activity, as sand is no longer flying through the air, but she may accept it.

Let’s use the example of a child lining up trains.  He may line trains up for hours and get very excited looking at them.  He sets them up each time with very little variation.  He may get upset if anyone disturbs them in any way.

Trying to get him to roll the trains on a track might be too radical.  He may not accept that as what he does with trains.  Therefore, he doesn’t see what you did as a variation on what he did.  In fact, he may actually see it as something completely unrelated to what he’s doing.

Remember, in this type of play, the child doesn’t relate to objects in a normal way.  He probably lines the trains up because he likes to see the edges or the rows of wheels.  He doesn’t really see them as trains (representations of real trains) per se, rather, they are simply a visual array that he enjoys.

By trying to put the trains on tracks, you assume the child wants to play with the trains as trains.  But to him, they’re not representations of real trains as they would be to most children his age – they’re a pleasing visual array.  But he might tolerate or appreciate you handing him the trains, or introducing a new train.  He might even tolerate you building a bridge and rolling the trains underneath (this doesn’t attempt to turn the trains into ‘representations’ of real trains – something you understand but he doesn’t).  Sending the trains underneath a bridge is visually interesting.

Here are some other ways of adding variations:

ú   Make it a turn taking thing

ú   Speed up or slow down

ú   Do it in rhythm

ú   Add “Ready-Set-Go”

ú   Add chanting, or a song, or counting to it

ú   Build up a pattern of back and forth, and then insert a therapeutic pause to build excitement and anticipation

  • Do you control access to materials that promote avoidant, circular behaviors?

    And sometimes, we might decide that joining self-stimulatory behavior is not the best therapeutic choice.  Doing so is a strategy that we prize mostly for it’s use in establishing a trusting relationship with a child.  You can also teach a lot of new play and communication behaviors once you and the child are in the habit of imitating each other.  Therefore, we often set aside a portion of the session where will follow the child’s lead.As Therapists, we recognize that some toys, some behaviors, are just too absorbing to the child for us to get anything done.  We usually choose to redirect, ignore, or interrupt circular behaviors for most of the session.  In this case, you want to get any toy or object that promotes the behavior out of sight until the session is over.

Final Thoughts

 

A lot of people feel very uncomfortable, especially at first, when attempting C-LDT.  They feel lost and foolish, and they can get discouraged when the child disengages or avoids.  You worry that you won’t know what to do next.

 

This is normal – it was for me.  I felt “at sea” for a while before I got comfortable with it.

 

Go slowly, and be easy on yourself.  We usually explain to parents why we didn’t initially start by coercing their child to the table for “lessons.”  We’re clear that the goal is relationship-building, so we might not try to get much out of the session other than having the child trust you.

 

Gentle persistence will win the day.  Focus less on the variations and the teaching objectives at first, adding them as trust has been built.



[1]     Affect refers to the outward expression of internal emotion states, usually via facial expression.  Other forms of body language, emotional vocal inflection, and other behaviors reveal our internal states to others as well.  The totality of these emotion signals is called “affective expression.”  Non-verbal affective expression is usually a more reliable indicator of internal states than words.

[2]     The social smile usually emerges by 6 to ten weeks in neurotypical infants, along with cooing and other signals of pleasure.

[3]     Stanley Greenspan points out that the emergence of this cause-effect understanding far precedes evidence of [physical] object-based cause-effect understanding, which requires the baby to understand patterns of physical motion on objects.  This may change as new methods of infant testing are revealing remarkable, inborn understandings that babies have of the physical world.  In fact, the social cause-effect relationship described above may have evolved by using the same neural equipment that tracks cause-effect sequences.  Either way, we now know that Piaget’s belief that such understanding emerges at around 1 year was an underestimation.  His observation of cause and effect was based on the baby’s actual motor acts on objects, which require visual and motor coordination as well as understanding.

[4]     I have found that adult-lead R-BIs like RDI (Relationship Development Intervention) or SCS A-LDT actually bring this about sooner, since the adult makes demands on the child and responds with approval or correction in an affectively attuned way.  The child begins to reference for approval and other signs of the adult’s emotion states.

This is not to imply that A-LDT is somehow superior to C-LDT.  It’s just that they tend to emphasize different things.  For a lengthy comparison of the advantages and weaknesses of various therapies, please refer to the page: Summary of Developmental Therapies Used at SCS.

[5]     You can say that when Tyisha returned to the ball so that the Therapist could bounce and tickle her again – she closed the first circle and at the same time opened the next one.

 

[6]     Slowing down not only refers to allowing children time to think and respond, it also refers to: slowing down your speech rhythm, speaking less, using more repetition in your words; presenting slower or simpler actions for the child to respond to; introducing variations only after the child has absorbed previous ones; overall focusing on intensity, quality, and intimacy over quantity of activities.

[7]     Working memory holds what you have in mind when your doing something.  WM is what you have in mind now.  It calls up and manages information from all types of memory and combines that information with what is going on in the here and now.   Perceptions, memories, actions (including a lot of stuff you do automatically without thinking (called Implicit or Procedural Memories), and feelings make up most of your current mental awareness or WM.

[8]     Using words alone is not evidence of JA.  Children with ASD can be taught to use words to make requests or give information – but they may have no idea of what is going on in the mind (knowledge state or attentional state) of the other person.

For a determination of JA, there has to be evidence that the child uses words with the understanding that they have to make the other person aware of something.  This is why when a person is misunderstood they will try another way (“communication repair”) to get that person to understand.  Children who use language without true JA do not engage in communication repair – they simply will repeat what they were taught in the same manner and get frustrated.

[9]     As he puts it “connecting affect to motor planning.”

[10]    This is an appropriate strategy for early stages of C-LDT – designed to teach the child the pleasure of engagement.  Later on, we might use different strategies to encourage longer, more stepwise approaches to play.  This decision depends on the development of “exploration skills,” which are targeted separately.

[11]    This is Gutstein’s term.  Piaget called it the “Zone of Efficacious Intent.”

[12]    Here again, we may very well make a decision that C-LDT is not the best approach for the moment.  The deciding factor will have to do with child characteristics rather than the Therapist’s skills however.

[13]    This is a term coined by Developmental Psychologist Lev Vygotsky.  The ZPD is the set of skills that come from the next higher stage of development that the child can do some of the time, under favorable conditions, and/or with help.  It is often called the “Teaching Range.”

[14]    It is important to note here that this is a compensation for the child’s poor understanding of speaker and listener points of view.  As the child references more and gains experience in joint-attention frameworks (verbal and non-verbal), she will come to understand and adopt the way the tone changes when someone changes from speaker to listener, asker to responder, and so on.  This will later on allow her to use pronoun reversal (“I” “You” “Me”) correctly as well.

[15]    The term “opaque” is used in the sense that what the child is doing is difficult to understand, unclear to many, idiosyncratic.  This manner of communication is what you would expect from younger infants.

[16]    Some words are printed smaller here to illustrate how you should use – but not emphasize less essential parts of the sentence.  You want to sound natural – so you don’t use unnatural abbreviations of sentences such as “put in box.”  You use the natural articles and conjunctions in speech such as “the” and “it,” but you say the more meaningful words slightly louder and with more emphasis.


 [DS1]This is its own page

 [DS2]Link to page: Dynamic Intelligence; Heading: Dynamic Adjustment

 [DS3]Link to page: Circles of Communication

 [DS4]Link to page: Joint Attention

 [DS5]Link to page: Forms of Memory