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From the Townsend Letter
October 2009

Book Review:
Entering the World: A Paradigm Shift for Treating Autism
review by Adrianne Harun

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Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate, and Think
by Stanley I. Greenspan, MD, and Serena Wieder, PhD
Da Capo Lifelong Books, Perseus Books Group,
Paperback; 2009;  $18.00; 434 pp.

For years, a diagnosis of autism was tantamount to a door slamming shut. The best parents could hope for was that their child's behavior eventually could be modified toward a more conventional norm. The prognosis was a steely one with virtually no promise of recovery and little hope even of real learning progress. Treatment plans consequently dealt with easing the symptoms of Autism Spectrum Disorder (ASD). Teachers, caregivers, and therapists focused on altering socially unacceptable behavior (like aggression or non-compliance) and on teaching simple cognitive skills that relied primarily on repetition, since that seemed to be a hallmark of ASD behavior. Within this model, children on the autistic spectrum could evince some changes that would allow them to enter into more mainstreamed educational environments, but they remained, for the most part, separate from that environment in fundamental modes of interaction.

Then along came Stanley Greenspan, MD, and Serena Wieder, PhD, with an altogether different approach called the Developmental, Individual-Difference, Relationship-Based (DIR) approach. DIR upends not only the idea of autism as an irreversible condition that follows a predictable course, but also moves beyond standard treatment models, applied broadly across the spectrum, to address the individual needs of each child on his or her own terms. In essence, this is a fundamental shift from a emphasis on symptom reduction to a focus on the individual child, and it offers real hope for children once given a rigid and irremediable prognosis.

DIR is often referred to as the Floortime model, for reasons that will soon become apparent. First and foremost, the program works to engage the child. Drs. Greenspan and Wieder begin by making the case that emotions guide learning. That first exchange of smiles between baby and parent spurs thought as a baby learns one response begets another and then figures out how to use that back-and-forth process in other circumstances to get what she wants. Gradually, thought processes grow more sophisticated with babies and toddlers interpreting more complex, emotionally based interactions to forge new thoughts and ideas. To instigate new cognitive development, therefore, the authors argue, one first needs to engage a child and make the emotional connections that instigate thinking. This engagement involves entering the child's world on her own terms – e.g., getting down on the floor with her.

As you read through this comprehensive, if somewhat repetitive, guide to DIR/Floortime, it's clear that an energetic flexibility is key, as is a unfailing responsiveness. DIR is not a single solution applied broadly, but a dynamic and continually reflective, playful approach that works from the premise that each child and family is unique and so must be approached in individualized ways.

Engaging Autism opens by defining autism and ASD, identifying the early signs, and also debunking some modes of diagnosis. The section on misdiagnosis is particularly enlightening and should be read by every parent about to embark upon testing with her child. Also in Part I, the authors offer an overview of developmental stages and discuss goals for working with children in each stage.

In Part II, they illustrate how families can advance relating, communicating, and thinking in specific ways. Part III goes into Floortime itself, which has two principle aims: "to follow the child's lead" and "to bring the child into a shared world." In these chapters, the specifics of the Floortime technique, utilizing objects, siblings, friends, and different settings (including school) are discussed. The authors don't bypass the difficulties but do continually stress the advantages of creating challenges and building interactions and logical thinking by following the child's lead. Part III also wades into working with older children, adolescents, and even adults, setting out principles for a learning community that include determining long-range goals, valuing cognitive growth over learned "living skills," understanding unique personalities while working toward more individual flexibility, and creating group identities through shared activities.

Part IV delves further into assessment and educational plans and stresses the need for a comprehensive overall plan for ASD interventions that envelopes home, school, and other social environments. While taking into account the ever-present theme of flexibility and individual needs, the authors present a precise model here for daily activity that covers the fundamentals – Floortime, plus specific areas of processing (language, visual-spatial, regulatory-sensory) and appropriate academic work (reading, writing, math, science, etc.).

Part V addresses a few specific, often challenging symptoms, ranging from scripting and echolalia to avoidant behavior, as well as potentially difficult everyday situations like toilet training, mealtime, and the seemingly inevitable meltdowns.

Finally, the authors provide three appendices that provide further overview and support for the DIR model.

Inspiring stories pepper Engaging Autism, and it's more than heartening to read about children diagnosed on the autistic spectrum who have made enormous gains in cognitive skills and, perhaps more importantly, in connecting emotionally. Drs. Greenspan and Wieder have flung open that closed-door diagnosis and created a credible route to widened possibilities, even recovery. Indeed, the DIR theory has introduced the very real expectation that a young child, diagnosed as autistic, can avoid the onset of fully realized autistic state and even reverse the condition dramatically. The one caveat I'd offer after reading Engaging Autism is that DIR/Floortime is, without a doubt, a hugely time-intensive, "takes a village" endeavor, and not all parents or caregivers will be able to devote the enormous amounts of time and energy that are required to create these dramatic changes. Nor will they necessarily find supportive school systems or the financial resources to employ appropriate therapists. That said, it's clear that this approach can yield extraordinarily positive results and that the more parents are educated in these methods, employing them as often as possible for them, the more likely they will find greater engagement with their child and the promise of true progress.

When Floortime Seems Too Difficult
"…Don't pressure yourself to do so much. Whenever you feel stuck, take a step back, relax, and observe what the child is doing. The child may not seem to be doing much; she may just be playing with her own fingers. But that is something. A child is always doing something. Ask yourself how you can build on it. Joining one of your fingers with hers, or any other strategy that helps your child relate to you, could work. For children who are extremely challenging, sometimes the best way to start a relationship is through simple, sensory-based play, such as lying on the floor together, rolling over each other, and making funny noises, or simple holding and rhythmic rocking. There's no substitute for warm joyful relatedness."


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