Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate, and Think (Book Review)

Author:  Greenspan, Stanley I., and Serena Wieder
Publisher:  Da Capo Press
Reviewed By:  Karen Zelan, PhD, Vol. 26 (3), 63-65

Stanley Greenspan and Serena Wieder’s comprehensive book on Autistic Spectrum Disorder (ASD), Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate, and Think, describes in detail how their “engagement” model is radically different from past and present methods of assisting autistic youth. Asserting that for sixty years “treatments for ASD have focused on the symptoms” (p. 2), an emphasis that the authors find unnecessarily limiting, they stress instead how a predilection for specific autistic behaviors arises from the processes underlying the condition. Their core thesis is that the “floortime” method creates a context in which a parent, teacher, or other professional can profitably engage the child in socializing and communicating. The triple-pronged approach, identified in the book’s subtitle, replaces thinking for playing in the usual cluster of socializing, communicating, and playing as target areas in a therapeutic program. The authors expand the theory behind their approach and counsel those working and living with autistic children on the benefits of the “developmental, individual-difference, relationship-based,” or the “DIR/Floortime” model. The book seems primarily aimed at parents or other caretakers, although there are chapters toward the end dealing with schools and learning.

Psychologists will recognize echoes of the child development literature in the authors’ analyses of typical development, autistic development, and their methods of assisting children on the spectrum. The works of Daniel Stern (“the earliest sense of self,” p. 47), Erik Erikson (“the wisdom of the ages,” p. 53), and Jean Piaget (“conservation of space,” p. 139) come to mind as having had an impact on the elaboration and application of their “DIR” theory (Stern, 1985; Erikson, 1964; Piaget, 1969). Stern, however, theorizes that an early sense of self, “the core self,” emerges at two to three months, much before the child is one to two years, as Greenspan and Wieder assert.

Though the senior author has written amply referenced works on child developmental theory and its applications, in this new book the references consist mainly of those dealing with medical, diagnostic, and technical aspects of autistic spectrum disorder, such as neurological dysfunctions in ASD youth, the capacity for theory of mind understanding, and the ways in which behavioral treatment methods differ from the authors’ own. Absent are reports from ASD individuals themselves or from parents who’ve written testimonials on their successes and failures with such youth. Also missing is a discussion of, or reference to, recently published works that share essential commonalities with the authors’ major theses (Sacks, 1995; Siegel, 1996; Ozonoff, Dawson, and McPartland, 2002; Zelan, 2003).

The authors confirm once more that there is no single cause of autism. Though most experts researching the condition believe autism is multiply caused, the ways in which specific neurological etiologies are interrelated and manifested in individual children are still a mystery. Likewise, the apparent increase in autism’s incidence is poorly understood—the current estimate is 5.5 out of 1,000 (Schieve, 2006). The increase surely reflects a greater public awareness of autism and its typical symptoms. Some experts, as well as parents, argue that such environmental factors as pollution may trigger a predisposition to the condition. Another plausible reason for its rise is that children must often be diagnosed with autistic spectrum disorder before they can receive mainstream or special educational services.

Greenspan and Wieder identify the core symptoms of ASD and stress that the diagnosis is dynamic, not static. Their underlying premise is that all three components of their treatment efforts, a capacity for intimacy, an ability to communicate expressively, and the capacity for meaningful speech, underdeveloped or missing in ASD youth, require an emotional engagement with other people. A dynamic view offers hope to parents, many of whom have given up on their withdrawn, often recalcitrant kids, believing a diagnosed child will always be “autistic.”

The authors relegate the sensory sensitivities of autistic people to secondary status. Perhaps this is because some autistic children appear to have underdeveloped sensory sensitivities. Yet, if one posits that sensory sensitivities are present at birth, possibly even in the womb, a case can be made that heightened sensitivity, in itself, causes very young autistic children to protect themselves from excessive stimulation, including and especially that emanating from other people. Such children ordinarily turn away from sound, touch, bold colorful patterns, strong tastes and aromas, and interpersonal intimacy. The authors themselves describe the intensity of emotion often suffered by autistic children: “…studies are showing that many children with autism can be very emotional but become so overwhelmed by their feelings that they avoid contact…” (p. 14). A twelve-year-old boy with whom I met in psychotherapy meetings finally found emotional expression palatable as he enacted his loving feelings for his mother by hiding his favorite marble in a doll he dubbed “Mom” (Zelan, 2003). Youngsters like this boy shut down a potential ability for expressive action and meaningful language as they deal with the daily onslaught of the sensory world and the chaos of their inner world (Zelan, 2003; Prince-Hughes, 2004; Williams, 1996; Grandin, 1995; Sacks, 1995). But they can be persuaded to join the people world when they feel understood and protected.

Early in the book the authors lay out their developmental approach toward autistic spectrum disorder. Many chapters are introduced by “case studies” that are vignettes only several lines in length. Since this is a parent education book, parents might want to know, for example, how the authors diagnosed “a receptive speech delay” in a one-and-a-half year old, which is better explained in an actual case study. The authors emphasize the importance of getting treatment started early, beginning with the current developmental level of the autistic child, whether developmentally on target in some areas, or significantly delayed. Gearing the treatment program to a child’s developmental level reassures parents that their child can begin anew, at the point he or she is on the stage scale, to progress in a promising, even liberating way. Sensitizing parents to typical developmental stages, and the ways in which parents and professionals can foster the attainment of later developmental milestones in ASD kids, is a theme permeating the entire book and represents a proactive approach.

Later chapters lead the reader step by step through the stage process inherent in helping these youth attain not only skills in relating, communicating, and thinking, but in integrating the three functions so as to bring order out of autistic confusion. Since playing is intimately related to thinking, the child’s parent or therapist can aid an organic stage-related development from the thought behind an autistic child’s enhanced ability to play freely to his increased ability to think inventively (Zelan, 2003, 2006).

Greenspan and Wieder cite the potential for developing the full range of higher intellectual functions in these youth. This has enormous implications for the development of theory of mind acuity. The authors happily conclude that these are within the developmental range of older autistic children if they are supported properly in their attempts to reach for skills they have not shown before. Parents and professionals are helped by the premise, geared to children’s individual strengths and talents, that they, like other children, can be the best they can be.

The authors devote several chapters explaining to parents how the “floortime” model works. Much of what the authors describe represents informed, effective play psychotherapy. What’s more, the model was devised so that parents could apply its principles in the home. Parents should follow their children’s lead and learn to share their interests with the aim of expanding their psychological and behavioral repertoires. Parents and professionals can best reach the child by letting the interaction evolve gradually, with the child an active participant, sometimes leading the way, sometimes following an inventive adult who varies their joint activities. Emotional engagement is at the heart of the method whereby children come not only to value human interaction but to actually take pleasure in it.

Greenspan and Wieder fortunately do not subscribe to the notion that ASD youngsters are incapable of pretend play. In building up a child’s use of words, concepts, and symbols, they stress the importance of pretend play in engaging the emotions. They also recommend “interactive drama” as a therapeutic tool. Citing the multi-modal appeal of attempts to help children think abstractly, the authors assert, “Teach not just with words but also with images, actions, and drama” (p. 124). A three-year-old boy with whom I worked experienced an emotional breakthrough as he dismissed his “bad boys” drama, a story that never ended happily, to join his mother in enacting what police officers actually do to protect families with little kids (Zelan, 2006).

“Once children, with or without ASD, learn the fun of interacting with another human being,” enthuse Greenspan and Wieder, “it feels so glorious and natural to them that they begin seeking it out more and more” (p. 77). And it’s never too late, write the authors, to achieve an authentic emotional engagement with even an older autistic youth. I once worked with a fourteen-year-old autistic girl who learned to re-engage emotionally by hugging me, then by jumping into my arms to be carried about. A caretaker’s pleasure in renewed contact with an autistic child doubtless fosters future emotional engagement between them; I was overjoyed that the girl who had grimly avoided personal contact now could not get enough of it (Zelan, 2003).

Another chapter on the “floortime” approach advocates an application of its therapeutic methods not only to families, but also to schools and classrooms, and to the communities in which the families live. The authors recommend that ASD children be mainstreamed in regular schools with an aide assigned to the needy child. The “floortime” method, write Greenspan and Wieder, ought to be incorporated into the curriculum to provide ASD kids with round-the-clock exposure to its benefits.

However laudatory the authors’ educational aim for these youth, it is difficult to imagine contemporary classrooms integrating what is essentially a psychotherapeutic program into their structured curricula that are often focused almost entirely on “the basics.” It would be better to advise parents using the “floortime” plan to collaborate with their children’s teachers, by informing them of their children’s sensitivities and predilections, and supporting the teachers in their efforts to teach the fundamental skills and nuances of literacy and numeracy. Team efforts among parents and teachers, when parents serve their children well in ways appropriate to parenting, and teachers in ways necessary for educating, have proven remarkably successful in rehabilitating ASD youth (Zelan, 2003).

Similarly, the “thinking curriculum” the authors envisage would require a revamping of today’s public education. The authors qualify their educational vision by writing, “These [advanced thinking] abilities are developed best in a school that has a thinking-based philosophy of learning” (p. 292). There are public schools with “critical thinking” curricula (see Zelan, 2003 for a description of one such public school). Currently, they are probably not numerous enough to make a nationwide difference in the quality of educational services provided to ASD youth.

Toward the end of their book, Greenspan and Wieder present a case study of a mute young adult who received community services that developed his abilities in a way that not only helped him but also his family. The authors point out that community assistance need not arise from a residential setting. As the story of thirty-two-year-old “Robert” attests, a “learning community can be built around the individual” (p. 238). Even a mute person in his thirties can learn to relate to his mother who, guided by the authors, encouraged Robert to communicate nonverbally. He learned to speak single words and, because of his interest in music, became involved in an arts program for people with special needs.

Similarly, a recent book showing how college communities foster the learning and development of ASD youth includes their interesting, personal student stories (Prince-Hughes, 2002). Another volume, delineating a “team approach” to working and living with youth with Asperger’s syndrome, describes how schools, colleges, clinics, and communities can coordinate their efforts, sometimes with remarkable success (Baker and Welkowitz, 2005). Parents and professionals alike are doubtless heartened by such team efforts, knowing that they are not struggling alone in their attempts to connect with their often wayward youth.

Greenspan and Wieder’s Engaging Autism confirms the worth, feasibility, and the necessity of comprehensive programs for youth with autistic spectrum disorder. They, among others who have written on the topic, demonstrate the promise inherent in the lifelong learning these individuals need to fulfill their often considerable potential.

Karen Zelan

References

Baker, L. and L. Welkowitz (2005). Asperger’s Syndrome: Intervening in schools, clinics, and communities. Mahwah, NJ: Erlbaum.
Erikson, E. (1964), Insight and responsibility. New York: Norton.
Grandin, T. (1995). Thinking in pictures and other reports from my life with autism. New York: Doubleday.
Ozonoff, S., G. Dawson, and J. McPartland (2002). A parent’s guide to Asperger Syndrome and high-functioning autism. New York: Guilford Press.
Piaget, J. (1969). The psychology of the child. New York: Basic Books.
Prince-Hughes, D. (2002). Aquamarine blue: Personal stories of college students with autism. Athens, Ohio: Swallow Press.
Prince-Hughes, D. (2004). Songs of the gorilla nation: My journey through autism. New York: Harmony Books.
Sacks, O. (1995). An anthropologist on Mars: Seven paradoxical tales. New York: Knopf.
Schieve, L. (2006). “Parental Report of Diagnosed Autism in Children Aged 4-17
Years, United States, 2003-2004,” Study by the Centers for Disease Control, reported in the New York Times, May 4, 2006.
Siegel, B. (1996). The world of the autistic child: Understanding and treating autistic spectrum disorders. New York: Oxford University Press.
Stern, D. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic Books.
Williams, D. (1996). Like color to the blind: Soul searching and soul finding. New York: Times Books.
Zelan, K. (2003). Between their world and ours: Breakthroughs with autistic children. New York: St. Martin’s Press.
Zelan, K. (2006). The scientist in the office (unpublished manuscript).

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