Posts Tagged ‘engagement’

Using humor, puppets in play therapy can enhance social, communication skills for kids with autism

July 28, 2010

Teaching humor to children with autism through imaginary play can encourage engagement, facilitate interaction, and promote the development of abstract thought. Studies have even shown that the ability to role-play in children with autism is related to communication abilities.

Traditional autism therapies have focused on the behavioral aspects of autism, but while structured skills taught at a desk have their place, many children with autism have trouble generalizing those skills into the real world.

Joking around with children with autism, especially using puppets for symbolic play, is an underused and underappreciated way of promoting creative, imaginative, and spontaneous thought.

To read the rest of my article on, click here.


Progress of Children with Autism

December 23, 2009

How much can children with autism learn?  It’s a question I get a lot, as a person who provides therapy to kids with autism to improve their academic, social, and athletic skills.  The answer is that all children with autism can learn.  Some make amazing progress; for others the progress is much slower.

I’m listing below a couple of examples of students who have made excellent progress in all areas.  They are an eight-year old boy and a seven-year old boy I worked with who both made amazing progress in a short period of time.  (The greatest example of improvement that I am aware of is a teenage boy who I have been working with for five years.  I’m going to compile a before and after list of skills and behaviors.  This kind of progress is truly inspiring for parents who have young children who are worried about what the future holds).

It’s always the child himself or herself who deserves the most credit for learning.  The parents, of course, also play a huge role.  Other than that, it’s a team effort, with teachers and home therapists making contributions to the child’s success.

Experience has shown that children learn best when subjects are integrated, rather than splitting them up into different areas.  I believe that in the future, a typical session will be run like this:  one-third academics and cognitive skills, one-third social skills and functional life skills, and one-third sports, exercise, and motor skills.

Each area builds on the others and makes all learning more effective so that the child can use skills in a natural environment.  Pathways in the brain are developed to work in conjunction with each other, not in separate areas.  Interventions should be meaningful to the child, rather than just memorizing information.  Kids aren’t robots and neither are the people who work with them.  It’s not the number of hours that are spent learning.  It’s how efficient those hours are.

Area Progress for a high functioning 8-year old boy with autism during a 7-month period
Math Improved ability in:

  • place value
  • addition, subtraction and early multiplication
    • addition:  he improved from mastering sums of 9 to sums of 14
    • subtraction:  he improved from mastering 5 –x to 12 – x
    • multiplication:  he improved from nothing to up to mastering 3 x 4
    • Expanded notation
    • Word problems – he was terrible at them at the start, and by June he had mastered several different types.  He learned to draw to find answers to problems.
    • Learned the basics of fractions
    • Addition carrying the one
    • Counting mixed coins
    • Skip counting
    • measuring
  • Learned how to do opposites
  • Improved reading comprehension (I had time to work on this with him 20 min. a week.  The other company had 20 hours a week.  He would have made more improvements with me with the same amount of time).
  • Improved on capitalization.
  • Improved on spelling.
Maps Improved ability to find spots on the map.  Learned directions better than before.  Learned most of the states, which he didn’t have before.
Time Improved ability to tell time by counting by 5’s on clock.
  • The neighborhood kids respect him a lot more now than before because he can play sports a lot better and can handle his emotions better.
  • He had major tantrums at the start but improved a lot.  Showed him how he looks through video, helping him see how others see him.
  • He became very competitive, really wanting to win.  At the start he didn’t care if he won.
  • He learned to play defense where his role was to stop the other team so he became less reliant on needing to score to be happy.
  • He understood the rules much better in soccer, hockey and basketball, than before and he improved in his knowledge of football and baseball though he still has a long way to go.
  • He became interested in local pro sports after reading about them on the web and going to the Freedom game.
  • Learned not to run into the street after the ball.
  • Ice skating – though he can’t glide, the first time he fell 100 times, the most recent time he fell less than 10 times.
  • We did exercises based in yoga, relaxation, and balance to help him focus.
  • Most of the sports we did happened from April through June – we accomplished most of this in three months.
  • He learned that mistakes help you learn.
  • He can self-regulate better by taking deep breaths, counting, exercising, or talking about it.  This is a very important skill to have.  One that many kids cannot master.
  • He knows he can’t sit in the lap of anyone except his parents.
  • He still has a long way to go but has learned that you can’t say hi to adults who you don’t know.
Pretend and Abstract Play Improved spontaneity, imagination, and creativity by using jokes and pretend stories.  He improved his ability to make up stories and use symbolic play.
Games Improved ability to sit down and play scrabble.  He had a terrible temper at first but now can play an entire game somewhat independently.  Improved spelling through scrabble.  Introduced other games.
Social skills
  • Improved social skills through play dates.
  • Talked about bullying
Overall He had his best session ever on 9/21.  We had a lot of momentum and things were only going to get better.

Area Progress for 7-year old boy with autism with severe developmental delays including language
Overall He has made a lot of progress.  I have only been working regularly with him doing two-hour sessions for 3 months.  Before then we did 1.5 hours sessions sporadically.
Books He is able to sit for 15 minutes at a time reading books with me and is interested in looking at books (colors, foods) by himself.  Before he would not sit still at all.  He can now read different books with help, looking at words instead of just pictures.  Once we read 7 books back to back.
Flashcards Here are words he has mastered from my flashcards or bean bags.  They were not on the Verbal Behavior Team’s list of words he’s mastered (I realize he may have known a few of these before, especially the foods) – desk, table, chair, TV, fridge, wall, door, sink, soap, mirror, stairs; crackers, chips, salsa, nuts, onion, goldfish, beans, taco, broccoli, cheese, carrots; triangle, rectangle, square, oval, circle; three, four, five, six, seven, eight, nine, ten; Mom, Dad, his name, his sister’s name; sleepy, (he hasn’t learned sad, mad, happy, or sick, but I’ve made those flashcards because they are very important).

I also reinforced many of the words from the VBA team’s list by having him review flashcards.

Though he can read the words “Mommy,” “Daddy,” etc., he’s having trouble associating them with the pics on the flashcards, showing how important it was to make those flashcards.

Typing He wouldn’t do it at all at the start.  Now he has no problem sitting for 15 min. The work paid off as he knows where the keys are now.  Typing has helped him read his name and understand that the answer to how old he is is 7.  It has helped him learn to read Mommy, Daddy, his sister’s name and his name.  He has taken my finger and guided me to the letters before, showing joint attention, which is crucial to learning. Typing is NOT meant as an alternative method of communication for him, but it will help him spell and read words, then phrases, then sentences, and will ultimately help him speak better because he will understand language more.  Typing is one way to help kids generalize language – to learn words in several different ways rather than just reading sight words.  It also helps with fine motor skills.
Intraverbals In Aug. he mastered saying his name and 7 in response to “What’s your name?” and “How old are you?” but he lost them because of confusion with what VBA program has done.
Soccer He can kick back and forth on the grass. He can dribble the length of the field and then kick it hard into the net.  He can kick it into the goal over and over.  During the last two sessions I had him kicking back and forth with his brother, which is a huge milestone socially.
Basketball He can now shoot from several feet away rather than just dunk.
Trampoline He can play catch while jumping, kick the ball back and forth while on the trampoline, and stop and do imitative exercises, which he could not do before.
Imaginative and Pretend play He has a much stronger interest in stuffed animals now.  At first he had no interest.  Then he would smile and laugh and say “frog” or “bug.”This is very important to learn how to play and think abstractly.
Oral Motor He learned to imitate by using his tongue and lips.  In June he was able to blow bubbles but before he couldn’t.
Handwriting He is getting better at tracing numbers and letters.  Before he couldn’t do it at all.  He can’t do it independently but he in some cases is doing part of it himself.  He shows more interest in it.
Math He is very interested in counting though he loses track/needs help after about 15.  He has started addition.  His attention span has increased during math.
Numbers and shapes He has completely mastered numbers 1-10 and shapes with beanbags.  Determined he may be partly color-blind.
Spelling Spellmaster – He has chosen the right tiles to spell certain words. Using different ways to read is helping generalize (flashcards, books, typing, spellmaster, etc.)
Other He has been very engaged, with lots of two way interaction.  The rapport we have is very important to learning because kids will learn more when they are motivated and having fun.  He shows a lot of joint attention: Joint attention refers to the propensity of a child to engage another’s attention to share enjoyment of objects or events. Children display joint attention skills by initiating bids to others to pay attention to what they are attending to and by following the line of visual regard and point gestures of a social partner (Mundy & Thorp). Thus, children both initiate and respond to joint attention bids.

Joint attention behaviors represent a critical area in typical development. Joint attention skills have been found to be concurrently related to receptive and expressive language skills among typically-developing children. In addition, research indicates that joint attention is important for the development of a host of other, later-emerging, skills, such as more complex expressive language, symbolic play, and theory of mind.

Initiating joint attention, shared engagement, two-way interaction, connecting on an emotional level is how kids learn – this isn’t just from Greenspan but this is well known – this is taught at Johns Hopkins – and the relationship a child has with the therapist is very important to learning.  His words are very emphatic after we do something he enjoys.  He shows a lot of enthusiasm, also helpful to learning.  He has the ability to go with the flow.  These are all elements of RDI that he has shown for the past four months.  We have been doing RDI type games in a natural environment already.  He has not cried significantly with me since 6/21.

Greenspan’s DIR Model for Autism: Part 1

September 20, 2009

For therapists and families to be effective in working with kids with autism, they should be able to do any methodology.

There is an alphabet soup of different methods to teach kids with autism – Applied Behavior Analysis (ABA); the Developmental, Individual Differences, Relationship-Based (DIR) Model; Relationship Development Intervention (RDI); Treatment and Education of Autistic and Communication – Handicapped Children (TEACCH), and others.

Regardless of which methodologies are used, programs need to have goals and targets and teach in such a way so that kids can generalize skills to apply what they have learned to a natural environment.  Teaching methods should also integrate academics and cognitive skills; emotional awareness and social skills; exercise, sports, and motor skills; along with spontaneous, imaginative, and creative play.  Skills should be taught in a meaningful way rather than a robotic, rote way.

Children need to develop a relationship with caregivers in order to learn.  The revolving door philosophy of bringing people in and out so that a child has had 100 caregivers by the time he is 10 does not work.  Stanley Greenspan says, “Emotion always come before behavior.  The child needs to enjoy relationships with parents, peers, and teachers in order to learn.”  Emotion is critical to brain development.  It’s more than “cute” when a child is engaged with a caregiver.  The child learns better.

I have been an advocate of Greenspan’s DIR method for the past few years.   The Interdisciplinary Council on Learning Disorders ( says this about DIR.

DIR is a comprehensive, interdisciplinary approach that focuses on the emotional development of the child. It takes into account the child’s feelings, relationships with caregivers, developmental level and individual differences in a child’s ability to process and respond to sensory information.  It focuses on the child’s skills in all developmental areas, including social-emotional functioning, communication, thinking and learning, motor skills, body awareness, and attention.

The goal of treatment is to help the child master the healthy emotional milestones that were missed in his early development and that are critical to learning.  Building these foundations helps children overcome their symptoms more effectively than simply trying to change the symptoms alone.

Then it says this about Floortime:

Floortime, a vital element of the DIR/Floortime model, is a treatment method as well as a philosophy for interacting with children (and adults as well). Floortime involves meeting a child at his current developmental level, and building upon his particular set of strengths.  Floortime harnesses the power of a child’s motivation; following his lead, wooing him with warm but persistent attempts to engage his attention and tuning in to his interests and desires in interactions. Through Floortime, parents, child care providers, teachers and therapists help children climb the developmental ladder.  By entering into a child’s world, we can help him or her learn to relate in meaningful, spontaneous, flexible and warm ways.

Floortime is a component of DIR but not the same.  In Floortime, you follow the lead of the child.  In DIR, once kids move past the initial stages of the developmental ladder, you create programs that revolve around the child’s interests, in which he is emotionally engaged, with meaningful two-way interaction, customized toward his individual differences.  The kids don’t tell you what to do; you just do things that are meaningful to them.  Again, Floortime is only a subset of DIR.  In the lower developmental levels of DIR (Floortime), you follow the child’s lead (but even then that means you follow and join what the child is interested in – the child doesn’t tell you what to do), and in the higher levels there are more structured, therapist or parent-led programs.

Two and a half years ago, I wrote on my website at (see #4) a little about DIR and Floortime, as well as a summary of Applied Behavior Analysis (ABA).

I combine elements of Applied Behavior Analysis (ABA) as well as the Developmental, Individual-Difference, Relationship (DIR) based method. I believe a combination of ABA and DIR methods is optimal because ABA provides step-by-step instruction while DIR focuses on relationships, emotions and interests. Children need both structure and meaning when they learn.

ABA is used to teach academic, communication, problem solving, behavioral, social, play, and other skills by breaking tasks down into small steps and practicing drills. ABA also uses positive reinforcement and just as much prompting as is necessary. Inappropriate behaviors may be phased out by redirecting to target activities rather than drawing more attention to those behaviors. Antecedents, behaviors, and consequences are tracked to try to determine the reasons behind behaviors and implement appropriate interventions. However, some behaviors may be accommodations children need to manage their body or sensory difficulties. Therefore, I focus on building skills more so than reducing behaviors.

The DIR method focuses on the emotional development of the child. It takes into account the child’s feelings, relationships and individual differences. DIR involves following the child’s lead and enables the child to learn by doing what he or she likes to do in a fun and meaningful way. According to, “DIR focuses on the child’s skills in all developmental areas, including social-emotional functioning, communication, thinking and learning, motor skills, body awareness and attention.” The DIR method can also help a child generalize skills initially learned through drills.

Part of the DIR model includes Floortime, which is based on working with a child at his or her current developmental level, and building upon strengths and interests in a way that is meaningful to the child, rather than just focusing on surface behaviors and drills that don’t always generalize into life skills. Floortime can be especially effective during periods when a child needs more play and less work.

5.     Which is better – ABA or the DIR model?

In my opinion, this question is kind of like asking, “Which is better in football – running the ball or passing the ball?” or “Which is better in basketball – a zone defense or man to man?” They’re both necessary in different situations, and a balance of both may be most effective. For example, you can do repetitive drills broken down into small steps based on the child’s individual differences, interests and relationships, making sure to incorporate social skills and emotions.

In doing so, children can learn valuable skills such as sequencing the steps needed to complete a task. Children with autism benefit from structure, but they will be more engaged if the drill involves something in which they are emotionally invested. The DIR model is harder to quantify than ABA, but DIR is built on relationships, spontaneity and interaction. Children are not robots, and drills can’t be done in a vacuum.

For example, you can teach a child who is obsessed with a particular toy communication and problem solving skills in the following way: Hide the toy in one of your hands and get the child to reach for it and choose which hand it is in. Then you can do the same thing by holding the toy behind your back, or placing it near your face to establish eye contact. Subsequent steps may include getting the child to make sounds or use speech if possible to request the toy. The toy is used as a reward. This example is based on one in Engaging Autism by Dr. Stanley Greenspan.

For the rest of the FAQs on my website, see

Lately, it seems that RDI has taken off as the method of choice.  I can’t really see how RDI is much different than DIR, except maybe that the order of the letters sounds a little bit more catchy.  If anything, RDI seems like an implementation of DIR.  However, this summary from Chicago Floortime Families points out some differences as well as many similarities.

According to (I went there because the RDI website at doesn’t do a good job of describing RDI), children can develop the following through RDI:

  • Dramatic improvement in meaningful communication,
  • Desire and skills to share their experiences with others,
  • Genuine curiosity and enthusiasm for other people,
  • Ability to adapt easily and “go with the flow,”
  • Amazing increase in the initiation of joint attention,
  • Powerful improvement in perspective taking and theory of mind,
  • Dramatically increased desire to seek out and interact with peers.

This looks a lot like DIR to me.  In any case, whether it’s DIR, RDI, or you want to create a new acronym such as IRD or IDR, the goals of each system are the same.

Greenspan’s DIR Model for Autism: Part 2

September 20, 2009

I decided to take some of the most important passages from “Engaging Autism” by Stanley Greenspan and Serena Wieder, with other quotes paraphrased.  These are the lines from the book that I underlined when I read the book three years ago.  I did the same for the John Gottman relationship books on a blog a while back.  Of course, like Rodney Dangerfield said in “Back to School,” the guy underlining the pages “could have been an idiot.”  So with that said, here goes:

Quotes from Stanley Greenspan’s “Engaging Autism” (I bold parts that I think are most important, and I divided the quotes into categories where I thought they fit best).

Developmental vs. Behavioral Approaches

  • Many programs that focus…on symptoms or behaviors rely on the troubling assumption that many children with ASD cannot ever acquire skills for truly intimate relating, empathy, and creative problem solving.  The DIR model focuses on the underlying deficits that lead to symptoms.

  • Schools tend to be very structured and to put a high priority on compliance and limit setting, rather than on engaging, interacting, problem-solving, and thinking creatively and logically.
  • The behavioral model led to modest educational gains and little or no social or emotional benefits.
  • The old way:  children could learn social behaviors in a scripted, memorized way, but not engage in spontaneous and creative social interactions and thinking.
  • With the new developmental approaches, we see it as a continuum on which all children can become warm and related and purposeful.
  • We now understand that the lines of early development are interrelated.  Rather than assessing language skills, motor skills, and social-emotional skills separately, we should look at how well these abilities are integrated, how they work together as a whole.
  • An example of a non-DIR approach:  isolated skills, such as matching shapes, rather than essential developmental building blocks.
  • The DIR model shows how to use a range of interventions in a truly integrated manner.

  • Parents and clinicians need not make a Solomon’s choice between relationships on one hand and cognitive and language skills on the other.  Cognition, language, and social-emotional development all stem from the same foundation.

  • DIR is organized by asking:  What are the problem behaviors?  How is the child doing on the fundamentals of relating, thinking, and communicating?  How is the child doing on her processing capacities, and what are the contributing factors (including biomedical challenges) affecting these capacities?  What experiences work and don’t work to help the child, and how capable is the family of doing the things that work?

Don’t have a Ceiling

  • Progress comes from getting the child to take the initiative.  The biggest mistake is telling the child what to do to provoke a set response, rather than challenging her to take the initiative or to solve a problem with you.

  • It’s just as important to work with children when they’re at peak performance as when they’re struggling, because then we help them advance developmentally and master higher levels all the time.
  • Never assume a ceiling on a child’s abilities.  Always assume you can get to one more level, and after that, one more level.
  • The child may have a disorder or a set of problems, but he is not the disorder.  He is a human being with real feelings, real desires, and real wishes.
  • The brain develops into the fifties and sixties, so it’s never too late.

Learning and Language through Emotions, Engagement, and Relationships

  • Mastery of the early stages of emotional interaction is associated with language and thinking skills.
  • Language, cognition, and mathematical and quantity concepts are all learned through emotionally significant interactive experiences and relationships.  Emotions enable us to learn.
  • Emotion is critical for many elements of language.
  • When engaged, children have a desire to communicate.
  • At the second level are the ongoing and consistent relationships that every child requires for emotional and cognitive competency.  Children with ASD need even more warm, consistent caregiving than do typically developing children.  Almost all human learning occurs in relationships, which must foster warmth, intimacy, and pleasure.
  • Use words meaningfully through emotions and pretend play rather than by rote.
  • The goal is to have all of the emotional experiences of life expressed through circles of emotional interaction.
  • Turn the activity into shared interaction.
  • The ability to love deeply is present in children with ASD, whether or not it can be easily expressed.
  • Children should be encouraged to express negative feelings.  Don’t take the child’s expressions of negative feelings personally, but respond sympathetically so he doesn’t get the idea that expressing his feelings is dangerous.
  • Emotion always come before behavior.  The child needs to enjoy relationships with parents, peers, and teachers in order to learn.

  • Many adults who had ASD and other special needs as children achieve a high level of empathy or enter the helping professions, because often they had to struggle more with challenges or feelings of disappointment than their peers did.  (My comment – this proves that kids with autism can learn empathy.)
  • We believe the primary problem in individuals with ASD is a biological difficulty in connecting emotion to motor actions and later to symbols.  Emotions link different types of mental functioning.

Other Language Skills

  • It’s better for children to use single words interactively with meaning than to recite whole sentences or paragraphs they have memorized.
  • Children with auditory processing challenges especially need to hear the rhythm of a voice.  Repeat what you say, and emphasize it.
  • Since John’s main form of communication related to getting fed, mother played a little dumb to extend those moments with John was negotiating for some of his favorite foods.
  • Help the child connect ideas by pretending you don’t understand.

  • Say something like, “I went to the zoo and I saw a _______.”  Have the child fill in the blank.  Or, “He has four legs and barks.  He is a ______.”
  • Ask a child what he enjoyed most at school, and why?  (Keep in mind many of these suggestions will have to be adapted for the level of the child.  This one wouldn’t work for a child unable to communicate that level yet.)
  • Listen to audiotapes of stories in the car.

Family Involvement

  • Not enough time is spent watching the child interact with a parent or other trusted caregiver.  In many evaluations, children are separated from parents and challenged to perform various types of developmental tests in a way that fails to take into account the child’s individual differences.  The child becomes stressed and confused.  To make a proper diagnosis, a practitioner also has to see children at their very best.
  • The clinician may see the child for a couple of hours, but parents see the child for hours and hours every single day for years.
  • However gifted a particular therapist is, what really counts is what is done every single day, for hours a day, with a child.
  • The key is to have fun together.
  • A child’s progress with a DIR/Floortime program requires parents who are emotionally very available.
  • If you don’t pull the sibling into the family challenge, the sibling feels excluded.
  • Siblings and peers can help a great deal.
  • In general, it’s most effective for the child’s therapeutic team – including parents, educators, coordinator, and specific therapists – to meet regularly to design goals for the program.

Floortime:  Following the Child’s Lead

  • Observe what kinds of interactions bring the child pleasure.
  • Follow the child’s lead, regardless of where his interests lie.  That give us a clue about what he finds important.
  • Often we look for a way to reach a child – the magic key that will unlock the hidden door – when all the while the child is showing what he needs by his actions and the way he’s processing what comes his way.  We need to observe what children are doing to help themselves in the moment and then figure out how to meet them there.
  • We build on the child’s interest to help him move up the ladder of shared attention, engagement, two-way communication, shared problem solving, and creative and logical use of ideas.  That requires not just following the child’s lead but also challenging him.  So we don’t mean simply copying or imitating the child.  We mean taking the child’s cue in order to build new interactions and experiences.
  • The idea is to go with the flow but without giving into the child’s agenda.
  • In Floortime, why do you follow the child’s lead?  A child’s interests are the window to her emotional and intellectual life.
  • Always challenge the child to initiate.

Oral-Motor Skills

  • Some children have oral-motor problems that make it hard for them to move their tongue and the muscles in their mouth in order to speak.  Some children with both oral-motor problems may appear to have cognitive disabilities and to lack social skills when in fact they are limited in expressing their abilities by their motor impairments.

  • The teacher can play little imitative games, starting with sounds the child can make, with the child and teacher looking in a mirror together so the child can imitate the way the teacher’s mouth moves.

Sensory-Motor Skills

  • Orienting kids in space can help them with postural control, which helps them organize their nervous system, which makes it easier to get interaction.  One example is walking on a balance beam.

  • To help children be comfortable, caregivers must learn which sensations help children become calm and regulated, which ones overwhelm them, and which don’t pull them in enough.
  • The level of a child’s motor planning skills must also be gauged.  The best way to do this is by watching the child play.

Social Skills and Play Dates

  • We always recommend that kids have at least four playdates a week, so that their main source of companionship begins shifting from parents to peers…Mommy is still important for security, warmth, and problem solving, but not for going out and riding bikes together.

  • If we try to teach logical thinking to a child who is not yet able to engage in reciprocal social interactions, we are trying to build the upper story of a house on a very weak foundation.

  • A child who learns how to be social in fun and emotionally engaging learning environments at home will want to be social and will be able to do it at school or at home, because he has generalized what he has learned.
  • Teach with images, action, and drama.
  • Children with ASD often take everything literally.  One of the most effective activities is pretend or imaginative play.  Encourage role play and play with puppets.
  • They need opportunities for playing and communicating with peers.  It’s important for children to learn to use words and gestures and develop relationships with peers at the same time they are learning to do these with adults.  If they wait, this learning will be more difficult later on.
  • We have never worked with a child or adult who didn’t have a desire to relate to others.