Covering autism and other developmental disorders, “The Child With Special Needs,” offers a new understanding into the nature of these challenges and specific ways to help children extend their intellectual and emotional potential through Stanley Greenspan’s “floor time” approach. Dr. Greenspan, clinical professor and practicing child psychiatrist, was invited on the “Today” show to discuss the book and its theories. Here's an excerpt:
Floor time, a systematic way of working with a child to help him climb the developmental ladder, is the heart of what we call the developmental approach to therapy. It takes a child back to the very first milestone he may have missed and begins the developmental progress anew. By working intensively with parents and therapists, the child can climb the ladder of milestones, one rung at a time, to begin to acquire the skills he is missing.
Most children with special needs are involved with therapists and educators who are helping them master developmental challenges. But to climb the developmental ladder, a child needs intensive, one-on-one work. Even daily speech or occupational therapy often does not provide enough practice. After all, a child may have 12 or more waking hours, during which she is learning something. The question is, what? Is she learning about TV (one-way communication)? Is he learning about staring out a window or repetitively opening and closing a door or lining up toys? Is she learning the pleasure of engaging with others and the satisfaction of taking initiative, making her wishes and needs known, and getting responses? Is he learning to have long dialogues, first without words and later with them, and eventually to imagine and think? Floor time creates opportunities for a child to learn these critical developmental lessons. It can be implemented, both as a procedure and as a philosophy, at home, in school, and as a part of a child's different therapies. First, we describe floor times as an intensive, one-on-one experience; then we discuss the overall therapeutic team and educational approach.
The developmental approach to therapy consists of three parts.
1. Parents do floor time with their child, creating the kinds of experiences that promote mastery of the milestones.
2. Speech, occupational, and physical therapists, educators, and/or psychotherapists work with the child using specialized techniques informed by floor time principles to deal with the child's specific challenges and facilitate development.
3. Parents work on their own responses and styles of relating with regard to the different milestones in order to maximize their interactions with their child and create a family pattern that supports emotional and intellectual growth in all family members.
While all three of these processes are important, floor time is the hub around which the other two revolve because it is primarily through floor time that your child will learn to interact in a way that fosters growth. As his specific needs are met with therapy, he will bring his new abilities to floor time interactions. As you learn how your own responses influence your child, you will put that learning to use in floor time. In the interactions and free play of floor time, you can help your child build interpersonal, emotional, and intellectual skills.
Floor time is precisely that: a 20-to-30-minute period when you get down on the floor with your child and interact and play. How can playful interactions help your child master the milestones? The answer has to do with the nature of the interactions. Certain types of interactions with other people promote a child's growth. In the chapters that follow, we describe these specific types. First, though, we want to explore the importance of human relationships.
Human relationships are critical to a child's development. Human beings seem to be created to learn and grow in the context of relating to other humans; the brain and mind simply don't develop without being nurtured by human relationships. Without relationships, self-esteem, initiative, and creativity do not grow either. Even the more intellectual functions of the brain — logic, judgment, abstract thought — don't develop without a constant source of relating.
Much of our best early learning happens through our relating to other people. An infant learns about cause and effect in part by dropping her spoon and watching it hit the floor. But she learns far more, and far earlier and more solidly, by smiling and getting a smile back. Later she learns by reaching out her arms and having Mommy pick her up. The pleasure that results from this learning is far more intense; the subtleties in Mommy's response far more varied. This kind of rich and intense response, which becomes deeply etched in the child's emotions, is possible only in human interactions. The child then applies this emotional lesson in causality ("I can make something happen") to the physical world. That the emotional lesson comes first and is the basis for the cognitive lesson is opposite to the traditional view of cognition and learning. This insight is essential for mobilizing intellectual and emotional growth in children with special needs.
Through interactions, you can mobilize your child's emotions in the service of his learning. As explained in the previous chapter, emotions make all learning possible.
By interacting with your child in ways that capitalize on his emotions by following his interests and motivations, you can help him climb the developmental ladder. You can help him want to learn how to attend to you; you can help him want to learn how to engage in a dialogue; you can inspire him to take initiative, to learn about causality and logic, to act to solve problems even before he speaks and move into the world of ideas. As together you open and close many circles of communication in a row, you can help him connect his emotions and his intent with his behavior (such as pointing for a toy) and eventually with his words and ideas ("Give me that!"). In helping him link his emotions to his behavior and his words in a purposeful way, instead of learning by rote, you enable your child to begin to relate to you and the world more meaningfully, spontaneously, flexibly, and warmly. He gains a firmer foundation for advanced cognitive skills.
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Children with special needs require a tremendous amount of practice in linking their intent or emotions to their behavior and then to their words. Like a right-handed person learning to throw a curve ball with her left hand, they need to practice the skill over and over to master it. Floor time is your child's practice time. Each time you get down on the floor and interact spontaneously, joyfully, following your child's interests and motivations, you help him build that link between emotion and behavior, and eventually words, and in doing so move forward on his journey up the developmental ladder.
The Nuts and Bolts of Floor Time
Floor time is like ordinary interaction and play in that it is spontaneous and fun. It is unlike ordinary play in that you have a developmental role. That role is to be your child's very active play partner. Your job is to follow your child's lead and play at whatever captures her interest, but to do it in a way that encourages your child to interact with you. That means if she wants to roll cars, you roll cars with her, offering her a faster car or a competitive race or, if necessary, crashing her car with yours — doing whatever it takes to create an interaction. If she wants to build with blocks, you build with her, adding blocks to her tower, even knocking a block off her tower with an "oops" again, doing whatever it takes to create an interaction. Your role is to be a constructive helper and, when necessary, provocateur by doing whatever it takes to turn her activity into a two-person interaction.
Following a child's lead means building on the child's natural inclinations and interests. It does not necessarily mean going along with what a child wants to do. Many parents and professionals frequently follow a child's lead passively, without generating a lot of opening and closing of circles. Active following of the child's lead means building on what the child does in a way that literally compels the child to want to open and close more circles of communication. Sometimes the child will readily build on your attempts to expand his interactions. Other times you will need to be much more compelling, but always in the context of his areas of interest. For example, when the child is focused entirely on a toy horse and avoids your overture to have your horsey talk to his horsey and begins wandering toward the door, having you and your horsey block the door challenges the child to negotiate with gestures and/or words, and in so doing, open and close a number of circles. You are following his lead in an active and challenging way because you're dealing with his interest in horsies and his interest in going out the door. You are not going along with him, but you are building on what he's doing.
Initially this won't be easy. Some children with challenges fight tooth and nail to be left alone. You may have to be playfully obstructive — literally get in your child's way — to create an interaction. But with time, he may come to anticipate your initiatives and even to like them. Once that happens you can work on extending your interactions, prodding him through play to close multiple circles of communication. As his joy in engaging, emotional expressions and gestural communication grows, you can introduce the world of ideas. By putting a puppet on your hand or a doll in the car he is rolling, you can woo your child into complex imitation and pretend play; by being a character in his dramas, you can continue to foster interaction while introducing words. As his dramas become more complex and his language ability grows, you can help him begin to verbalize his feelings rather than act them out.
You can encourage him to close verbal circles, just as he closed gestural ones. In this way, you may gradually entice him into the world of ideas and logical thinking.
Earlier we described the emotional milestones as six discrete skills that a child must master in order to communicate, think, and form a sense of self. Your floor time goals will not be pegged exactly to the six milestones, because several of these milestones naturally overlap as your child learns. You will work on four goals in floor time.
Goal 1: Encouraging attention and intimacy. As your child learns to remain calm while exploring her world, she will also be developing an interest in you because you are the most important person in her world. You both will work on maintaining mutual attention and engagement. Your goal is to help your child tune in to you and enjoy your presence. (This goal contributes to milestones 1 and 2.)
Goal 2: Two-way communication. Next you will help your child learn to open and close circles of communication, at first with subtle facial expressions and a gleam in the eye, a dialogue without words. By creating a gestural dialogue, you build interaction, logic, and problem solving. Your task is to encourage a dialogue, to help your child use his affects or emotions, hands, face, and body to communicate wishes, needs, and intentions. Over time, you try to help your child open and close many circles of communication in a complex, problem-solving dialogue. (This achievement correlates with milestones 3 and 4.)
Goal 3: Encouraging the expression and use of feelings and ideas. Your child can now begin learning to express her feelings or intentions in words and pretend play. Your goal is to encourage dramas and make-believe, through which your child can express her needs, wishes, and feelings, and gradually to help her express these in words. (This goal corresponds with milestone 5.)
Goal 4: Logical thought. Finally, you can help your child link his ideas and feelings to come to a logical understanding of the world. Your goal is to encourage him to connect his thoughts in logical ways. (This ability corresponds to milestone 6.)
Where to Begin?
The purpose of floor time is to help your child master the emotional milestones one by one, in sequential order, starting with the earliest one that he hasn't mastered. For many children with special needs, this means beginning with the ability to feel calm, focused, and intimate. It's hard to start working on so basic a skill when your child is two, three, or even older. It's tempting to work instead on language skills, color recognition, or some other age-appropriate behavior; but such an approach is not effective. Each milestone lays a foundation for the ones that follow. If your child has serious behavior problems — banging his head, throwing tantrums, repetitively opening and closing doors — it's equally tempting to begin work on those. You need to deal with such behavior to keep your child safe, but it is important to keep the primary goal in mind. Once the basic skills are in place, you will find it easier to work with problem behavior because you will be dealing with an interactive, communicating child. It's often possible to work on your child's most basic needs in the context of a more advanced skill, such as using imitation games to foster calm, joyful, focused relating.
A milestone is fully mastered when a child can exhibit that skill even at times of high emotion; she should be able to be intimate with her caregiver shortly after being angry, to sustain two-way communication even while upset, to express feelings through words or play shortly after frustration, and to connect ideas logically even when she is disappointed. Most children learn the milestones at times of emotional equilibrium; it takes a lot of practice to sustain them under stress. But when children can do so, all subsequent learning will be on a firmer foundation.
Children don't naturally master the milestones in neat sequential order. It's common for children to be somewhat verbal but still become avoidant when stressed, or to have episodes of pretend play but still be inconsistent at gestural communication. For that reason, you'll find yourself working on several milestones at once. But your primary job is to broaden and stabilize the earliest milestone your child has not fully mastered.
You may already have an intuitive sense of where you need to begin. To confirm your ideas, conduct the following simple exercise. Ask yourself these questions and consider how you would answer if your child were stressed and how you would answer if he were content.
Any observations you made of your child based on Chapter 3 should also help you determine in what areas he needs work and in what areas he is strong.
The next chapters address tailoring floor time to each of the goals, but certain guidelines apply regardless of the skills you are trying to build.
• Pick a time when you know you can give your child an uninterrupted 20 to 30 minutes. Your child needs your undivided attention. Even the busiest parents can find 20 to 30 minutes to give undiluted attention to their child. Many children will require many 20 to 30 minute sessions.
• Try to stay patient and relaxed. If you're feeling pressured, distracted, or nervous, you won't be able to help your child tune in and stay calm. Whether they are four months or four years old, children know when an adult has time and patience for them.
• Empathize with your child's emotional tone. If your child is troubled or tired, let him know you see and understand. To a verbal child you might say, "Gee, I see you're feeling tired today," using a warm and understanding voice. To a preverbal child you can gesture, perhaps by tilting your head or making a pillow of your hands while looking at him warmly. Doing this makes the child feel understood and helps build rapport between you. As you interact with your child, show him you understand his mood by the way you engage in floor time. For an overloaded, tired child, floor time might involve lying on the floor together and letting your child show you or tell you where he likes his back, arms, fingers, or toes rubbed. For an energetic runner, floor time may involve pretend play with lots of action. By empathizing, you can make floor time a pleasurable, meaningful, and developmentally facilitating experience regardless of your child's mood.
• Be aware of your own feelings because they will affect how you relate to your child. If you're on a different emotional wavelength, you'll have a harder time tuning in to hers. So before you begin floor time, take stock of how you're feeling. For instance, feeling irritable or angry may make you brusque and demanding. In particular, be aware of depression. Sometimes when parents are depressed, their interactions slow down to half speed; there are lengthy pauses between their sentences and between their child's actions and their own. They may speak and gesture without joy. It is very difficult to respond to this kind of behavior, especially for a child who needs to be drawn out. Occasional depression is common in parents of children with significant challenges. Choose a time for floor time when you are feeling more cheerful, or seek help yourself if the despondent mood does not lift.
• Monitor your tone of voice and gestures. You want to be and sound warm, enticing, and supportive — not impatient, angry, or demanding — even when your child is not responding as you would like. Remember that your child is doing his best. He's not thwarting you on purpose; he's doing what his abilities and stage of development permit. Your goal is to encourage him to play with you, and you'll only do that by sounding like someone he might want to play with. Would you want to play with someone who was stern, accusatory, or impatient?
• Follow your child's lead and interact! Look for ways to turn all your child's actions or seeming nonactions into interactions. Treat all her behavior as purposeful and as an opportunity to build two-way communication.
- If she is moving a car, move your car near hers. See if she will create an interaction; if not, offer a race or playfully block her car.
- If she wants to read, read together. Challenge her to point to the pictures; discuss what you see or read; turn reading into an interactive game. If your child is preverbal, hold the book upside down or turn the pages backward, challenging her to interact with you by fixing the problem. Simply reading to your child without discussion, without letting your child finish the story or point to a favorite picture — although great for other times — is not appropriate for floor time because it doesn't involve enough interaction.
- If your child wants to build a block tower and wants you to assemble the blocks, make sure he directs the activity. If you respond to his directions, you're interacting. If you build the tower for him, you're not.
- If he wants to do nothing but look out the window, look out the window with him and comment on what you see; see if he will point or vocalize to show you something. Point excitedly to birds. Laugh at dogs trotting by. Imitate the sound of cars roaring past. Use gestures, noises, and facial expressions to turn looking into a joint activity in which your child can take some initiative rather than simply listen to or ignore you. If it is difficult to attend together to something outside, put family pictures or colorful stick-on pictures of Sesame Street or Disney characters on the windows to look at. If your child objects and takes them off, interactions begin.
- If your child runs to the other side of the room each time you come near, turn her dodging into a game by saying, "Ready, set, go!" and switching sides yourself. Keep up the game as long as your child does.
- If she turns away each time you come near, turn her avoidance into an interaction. Say playfully, "You can't get away from me!" or "I'll get to your spot first!" or "I'm the cat and I'm chasing you, the mouse!" Even if your child does not understand your words, your actions will help you keep up interactive dialogues. Try not to feel rejected, but instead to see her avoidance as an opportunity for interaction.
• Tune in to your child's multiple developmental levels. Foster attention, engagement, the exchange of gestures — including long sequences if possible — and, as your child becomes ready, the shared use of ideas in pretend play and discussions.
• No hitting, breaking, or hurting. For your child this is the only floor time rule. Anything your child wants to play at is fine, as long as it respects this basic tenet. If he becomes overexcited, soothe and calm him. If he responds violently, you may have to hold him firmly, helping him organize himself while you are making clear this is not allowed.
Children with special needs often need many sessions of floor time a day. Many family members, as well as friends, other caregivers, or students, can be a part of your floor time team. Because you need to remain calm, energetic, and joyful, it is unwise to go beyond your own capacity, but many parents do find that their capacity enlarges with practice. You should try to have floor time sessions as often as possible, depending on your schedule, the number of people who can assist you, and the nature of your child's challenges. For many children, especially for those with severe challenges, in addition to a floor time philosophy during all waking hours, six to ten 20-to-30-minute floor time sessions a day is optimal. One to two sessions a day is often not enough.
Try to establish routine times for your sessions and then set up a schedule. Otherwise, other needs, phone calls, or sheer avoidance may take over. Floor time can occur before or after school or work, before or after meals, and before or after bath time.
At times, your whole family can do floor time together. Being involved in floor time will help your other children relate constructively and positively to their sibling with special needs and will help them feel that they're getting your attention as well. Each child might be the floor time leader for 15 to 20 minutes with the other(s) in a support role. You take your cues from the leader, but all the children are drawn into the interaction.
Try to sit down or have a conference call weekly with all the people who are interacting with your child to discuss what went well and what was difficult, to share tricks and ideas, to discuss frustrations and concerns, and to reset goals. These team meetings will support everyone's efforts.
Most important, you can use the floor-time principles even when you're not engaged in a floor time session. Interactions during dinner, while getting dressed, while driving in the car, while negotiating bedtime all can be geared toward enhancing interactions that promote your child's development. Remember, the keys are to (1) harness your child's natural affect or intent, when necessary, creating circumstances to mobilize emotions, joyful interactions, and more purposeful, intentional behavior; (2) build on these intentional behaviors and open and close many circles in a row; and (3) move your child up the developmental ladder from attention, engagement, and two-way gestural and behavioral interaction to complex imitation, pretend play, and discussions that use ideas, logical dialogues, and patterns of thinking. The following four chapters describe how to mobilize your child's development through your interactions with her.
Excerpted from “The Child With Special Needs: Encouraging Intellectual and Emotional Growth,” by Stanley Greenspan, Serena Wieder, and Robin Simons. Copyright © 1998 by Stanley Greenspan, Serena Wieder, and Robin Simons. Published by Da Capo Press, a division of Perseus Books. All rights reserved. No part of this excerpt can be used without permission of the publisher.