kitchen table math, the sequel: The end of an era for unstructured, child-centered autism therapy?

Tuesday, May 11, 2010

The end of an era for unstructured, child-centered autism therapy?

Reading about the death of Dr. Stanley Greenspan in last week's New York Times, I wondered about the future of Floor Time. This was the approach that Greenspan, a well-known child psychologist, championed as the most effective therapeutic intervention for autism--an approach I've critiqued first here and later in Raising a Left-Brain Child.

Some of Floor Time seems reasonable but obvious: a wheel re-invented time and again by those who work with autistic children--parents and professionals alike--whether or not they've ever heard of Greenspan. What do you do with a child who pays you no attention; who remains immersed in a world of his or her own? Jump into this world and follow the child's lead. Much easier said than done, of course, and therein lies the devil. Wouldn't it be wonderful if someone would do what Floor Time devotees have yet to do:  start publishing lists of specific strategies that those who work directly with autistic children have come up with and found helpful?

Far more problematic are Floor Time's not-so-obvious recommendations: avoiding teacher- or therapist-centered instruction; avoiding formal structure; using a social- and emotion-based mode for interaction, language acquisition, and concept-development that flies in the face of the specific strengths and weaknesses of children with autism--depending, for example, on an ability to read facial expressions and tone of voice.

The curious thing about Floor Time is that, in both its child-centered approach, and in its emphasis on social and emotion-based learning, it strongly resembles the "whole child" Constructivist classrooms in which all too many children (neurotypical as well as autistic) are languishing.

Floor Time's biggest competitor is a behaviorist approach called ABA. It has its own problems (which I've also critiqued first here and later in Raising a Left-Brain Child), but it at least has been subjected to fairly rigorous empirical studies, has something of a proven track record, and provides the structure and direct instruction that children with autism depend on.

Who is winning this competition? In light of current trends in education, you'd think it would be Floor Time. But autism is a pretty powerful condition, and the reality of autism tends to favor ABA.

Two days ago I finally watched Temple Grandin, the movie, which concludes with a scene at the 1984(?) Autism Society of America Conference. Here an aged, bearded, unnamed psychotherapist stands at a podium, holding forth on an outdated emotional attachment theory of autism (one that could easily be the philosophical father of Floor Time). The Temple Grandin character, sitting in the audience with her mother, rises and starts talking about her own experience: all about structure, drills, being pushed by her mother and others out of her world and into the worlds of science and engineering. All heads turn towards her, and she ends up literally upstaging the bearded sage on the stage.

I thought of Stanley Greenspan then, and then I read his obituary.

(cross-posted, in a slightly different version, at Out In Left Field)

26 comments:

farmwifetwo said...

As one who's child spent a year in IBI/ABA I wouldn't send my dog to be subjected to that abuse. I lobbied hard against paying for it last year and I'd lobby again tomorrow.

I don't know who was more upset when we were finally able to get rid of them. That meeting ended with me nearly curled into the lap of my FSW, shaking... but they were gone... mostly. That was mid Aug.

6 weeks into K the teacher kicked them out, with parental permission... A year later we finally got our "dismissal" paperwork and I nearly framed it.

To force a child to do the same training over and over and over again. To refuse to believe that a child with autism cannot be bored. To tease a child with a toy for 30 sec before taking it away... My son finally clawed the Male T... It's the one and only behavioural mark in 8.5yrs he's ever had and it was 4yrs ago pretty much today. Personally, he had it coming.

ABA such as Ont's PPM 140 is appropriate. Pavlov's dog training, is not. Both of my son's have learned, and learned more than ever dreamed simply by someone treating them with respect and taking the time to teach not train.

Anonymous said...

"That meeting ended with me nearly curled into the lap of my FSW..."

I am not familiar with the acronym. Family Support Worker? If so, what it that? If not, what does the acronym mean?

-Mark Roulo

GoogleMaster said...

Coincidentally, Independent Lens's "The Horse Boy" http://www.pbs.org/independentlens/horse-boy/index.html just came on, and Temple Grandin is interviewed about 2 minutes in.

Allison said...

Well, it's not that curious. It makes perfect sense. If you believe that children/the world should be in a state of nature, then you believe that learning in a constructivist sense is the correct (and moral) way to expose them to teaching. Anything more efficient, regimented, or planned is mechanistic and violating the state of nature. If autistic children are seen as unable to connect to their emotions, but emotions are still seen as the primary natural good, and the root from which other social and cognitive development grows from, then it follows that you'd advocate any method that concentrates on emotion to unlock the rest, and that you'd shun any "inauthentic" methods that put structure and behavior drills ahead. And it follows again that specific strategies would be shunned, because that would also be inauthentic.

What I find curious, though, is something else about this emotion based learning.

Did Greenspan believe that autistic children had emotionally compromised parents? If not, does his Floor Time fail because the parents of autistic children are more likely to be on the spectrum themselves, and hence those parents can't jump into the child's world or connect, because they themselves lack the social and emotional tools to do so? Or did Greenspan really do Floor Time to teach the parents and professional more social and emotional depth and breadth, because he thought the parents were compromised in this way (and that was part of why the children were emotionally unable to connect, because the parents were unable to connect)?

Are the two viewpoints of emotional-connection-influencing learning and the behaviorist approach really irreconcilable? Wouldn't it follow that you have a better chance of creating healthy boundaries for the behavioral approaches--better able to set limits, maintain those limits, stay positive when they aren't met, etc. if you have a (more healthy) emotional connection with the child, and the child has an emotional connection with you? Or is that only for neurotypicals?

farmwifetwo said...

FSW - Family Support Worker Community Living (disability people not children's services)

Autistic children can connect with their emotions, it's their regulation that is the issue.

I agreed to it for little boy b/c we had tried since he was 1.5yrs old to make the connection btwn signs/PEC's/words and we couldn't do it. I swore I wouldn't after they were here for the eldest (didn't qualify - not severe enough, wasn't letting them lock a severely claustrophobic child in a room for 8hrs/day). But they claimed to be different, parent friendly... the only difference was they were in my living room instead of out of sight.

They did go through the wall by fluke. They gave him a book, took it away and signed "all done" and said "do this"... little boy looked at them said "NO!!" and slapped his hands in the "all done" sign.

4yrs later it's still slowly coming. He has a lot of difficulty in speaking.... but I'd rather the slow, than the IBI/ABA.

In Ont you can purchase services or take what there is at the local children's hospitals. The children's hospitals (waitlists) is the nasty ABA... the regimented Lovaas. The purchased services that are Prov funded (waitlists) I have been told by those that have used those instead are a combination of floortime and ABA.

ABA is the breaking down of activities into steps. We do this everyday teaching someone something new. But we don't force them to sit for 3 to 4 hrs at a time. We don't tease. We don't refuse to let them try something new until they master the other perfectly. We don't demand that they only do regimented tasks from a book of activities because they shouldn't wander around and choose whatever they wish to do. I was to 'train' when they weren't there... they gave me a booklet of 6 PEC activities he was to do and do at daycare when they were there... instead of having free time... instead of being a child... I let him be a child, which they didn't like.

Children should live, laugh and play - Mercedes Lackey.

farmwifetwo said...

Allison,

Floortime fails b/c it is a lot of work by the caregiver. But those that have used it, those that have incorporated it in teaching by steps (ABA) like myself have had huge success.

Here the problem is funding and across Canada the lobby for ABA has won. The premise - tokens systems for social/behavioural teaching, step teaching - is easy to follow, and easy to do in any situation. But it's their hardline view that those with autism are emotionless that causes problems.

People want quick solutions. ABA appears to deliver them. But the psychometry report June before they went out the door reads "child cannot generalize outside of the IBI program" or something like that. Unless it was IBI he couldn't do it. When asked their comment was "we don't have a program for that".

Then why bother?? Should we keep them in their closet for the rest of their lives??

Katharine Beals said...

"Well, it's not that curious. It makes perfect sense. If you believe that children/the world should be in a state of nature, then you believe that learning in a constructivist sense is the correct (and moral) way to expose them to teaching."

The curiosity isn't in the overarching belief system (the existence of which was one of my points); it's in the fact that people coming out of two separate professional subcultures (education and psychotherapy) both converge on it. Of course, this, too, is no longer a curiosity if you've read E.D. Hirsch on Romanticism, which I assume you have. However, it's still interesting (as well as alarming) to see Hirsch's ideas about American culture played out in such specific ways in such apparently distinct domains.

Katharine Beals said...

"Did Greenspan believe that autistic children had emotionally compromised parents?"

No, but that's the insulting message the emerges from giving such obvious advice.

"If not, does his Floor Time fail because the parents of autistic children are more likely to be on the spectrum themselves, and hence those parents can't jump into the child's world or connect, because they themselves lack the social and emotional tools to do so?"

To the extent that AS parents are likely to be in the spectrum themselves (more true of the dads than the moms, it seems), there may be some effect here. But the bigger issue is that, if all you had to do to remediate the social deficits of autism is follow Floor Time's general principles, then, since what he is suggesting is what good parents (unless they are more than mildly on the spectrum themselves) do anyway, most kids with autism would automatically "recover."

At a conceptual level, the reason Floor Time isn't sufficient is that it assumes away the social deficits of autism, and proposes that autism amounts to sensory and emotional regulatory issues. This is indeed consistent with Greenspan's beliefs; but such beliefs don't jibe with most of the empirical research on autism.

Katharine Beals said...
This comment has been removed by the author.
Katharine Beals said...

"Are the two viewpoints of emotional-connection-influencing learning and the behaviorist approach really irreconcilable?"

Ideally, they shouldn't be. But Floor Time is inconsistent with ABA because, as I note in my post, it renounces direct, structured, therapist-centered instruction. ABA, on the other hand, is compatible with Floor Time's emphasis on emotional connection. As one parent puts it, ABA, done well, involves frequent breaks; "What did we do during those breaks? Floor Time."

Katharine Beals said...

"Autistic children can connect with their emotions, it's their regulation that is the issue."

See comment above. Also, the issue isn't whether autistic children can connect with their emotions (they can); it's whether they can connect with the emotions of others. Floor Time assumes they can.

Allison said...

Katharine, I think you've answered my question, but I'd love a clarification.

My question about emotional connection of autistic children was fundamentally one of connecting with others; all small children have problems regulating their emotions, that's why parents/caregivers matter--and that's why good attachment matters, because then the caregiver helps the baby/toddler/preschooler by holding their emotions for them, modeling the regulation of the emotions, and providing the love and safety to handle emotions. So if that's all autistics have as problems, then why are they not neurotypical (and what seems to be the conclusion is because their parents were bad at forming attachment..an insult, as you say.)

Why do you say Greenspan didn't believe autistic children had emotionally compromised parents? You yourself say that Floor Time's principle is essentially if the parent could form good attachment, the child would "recover". Certainly that's the impression I got from the obit, but I'm familiar with the ability of journalists to miss forest for the trees, and think wet streets cause rain.

Practically, I know nothing about autism, but everything I've read says autistics recognize "self" and "other", and "other" is both the family and the armchair. So, is Floor Time wrong to assume they can at all?

Katharine Beals said...

"Why do you say Greenspan didn't believe autistic children had emotionally compromised parents? You yourself say that Floor Time's principle is essentially if the parent could form good attachment, the child would "recover"."

I say this because he professes to believe that autism parents aren't emotional compromised. Of course, he may not have actually believed this (but, for professional self-interest, he had to profess to believe this in order to distance himself from the now thoroughly-discredited Bruno Bettelheim). But I think it more likely that he sincerely believed that parents of autistic children were emotionally OK, at the same time holding beliefs that (as you point out) are inconsistent with that belief. In other words, I think the most likely account of Greenspan's belief system is that, like those of most (all?) people, it's full of inconsistencies.

Katharine Beals said...

"Practically, I know nothing about autism, but everything I've read says autistics recognize "self" and "other", and "other" is both the family and the armchair. So, is Floor Time wrong to assume they can at all?"

Studies show that children with autism can distinguish intentional, animate entities from inanimate ones. Where they are deficient is engaging in Joint Attention behaviors, such as apprehending people's eye gaze and gestures as intentional communicative/attention sharing acts and engaging in such acts themselves. At a higher level, there are fundamental impairments in Theory of Mind, as seen, for example, in the Sally-Ann tests. (http://en.wikipedia.org/wiki/Sally%E2%80%93Anne_test)

Jennie said...

I was hoping to read something about TAGteaching in this thread. www.tagteach.com (including the Autism link in the upper left). I don't have experience in the subject of autism, but I have been fascinated by Karen Pryor's and others' work in this area. No "discrete trials," for example. Pryor's latest book, Reaching the Animal Mind, has some interesting and information about the use of TAGteach with individuals with autism.

Katharine Beals said...

Don't know anything about this; I've followed your link, however. From the website: "TAGteach is a revolutionary science-based technology that enables educators and coaches to teach efficiently and helps students learn effectively." But I can't find any references to scientific research here; in particular, I'd like to see some efficacy studies.

Jennie said...

Agreed, Katherine. It is so new ("officially founded in 2004," according to Julie Vargas' book, Behavioral Analysis for Effective Teaching) that the research is in the nascent stages. See here for description of some presentations in 2009:
http://tagteach.blogspot.com/2009/06/tagteach-at-association-of-behavior.html
"What distinguishes TAG Teaching from other methodologies is the reinforcing of single properties of student actions and the prohibition of any punishment or correction procedures." - J. Vargas

Not proven, certainly, but certainly intriguing and worth investigating.

farmwifetwo said...

Katherine, most parents with children on the spectrum will tell you our children do recognize and understand the emotions of others. Theory of mind is nothing but a load of crap by a bunch of so called autism specialists. Autism specialists, I have discovered over the years think they know all about autism and know very little.

In our house the un-dx'd Aspie according to one of our Dev Ped's is probably me.

Having read Greenspan's books, and owning 2 of them, I have never read that he felt that if the child had a good emotional attachement to the parent they would recover. He wanted the parent be a parent and get the child more interested in their surroundings. Once you can get close, once you can play, you can learn. Book "Giggle Time" is a good place to begin.

For a very long time little boy wouldn't let me read his books with him. I spent time invading his space a little more every day... Now my nearly 5' 8.5yr old loves nothing more than to sit in my lap a read... Yeah.. I know he's too big, and he now snuggles beside me. Now we've gone from advoidance to teaching. Do you think he'd get that same enjoyment from a book after spending a 8hr day matching, sorting, line drawing, being forced to read a book b/c it's part of the "autistic children aren't allowed to play" strip?? Would he even trust me that I wouldn't take the book away?? No and I wouldn't blame him either.

The most exciting thing to happen is that over the last couple of months we finally have joint attention. Severe, non-verbal, autistic disorder and seeing that child run over look at you quick, glance away and say "Toopie magician" and wait for your reply while you listen to the show on the tv so you follow the conversation, even though it never goes past your response before he goes back to the living room.... AMAZING!!! Would never happen if there wasn't an emotional connection btwn parent and child. We've had mands for years. Do you think we'd have joint attention from spending hours doing descrete trials or joint attention from playing on the floor together, swinging the playground, reading story books...

As for eye-contact, my children make eye-contact completely dependant on trust level. So does their Mother... If you don't like it, then give them a reason to trust you.

We are emotional people... and even children with autism need love and attention too. If not, why should they choose to interact with us and learn from us??

Katharine Beals said...

"Katherine, most parents with children on the spectrum will tell you our children do recognize and understand the emotions of others."

Have you conducted a survey? (Fyi, I am an autism parent, and I know many others).

You may be conflating understanding emotions with reading facial expressions and gestures. Empirical, peer-reviewed research in respected journals has shown, repeatedly, that the latter skills are deficient in autism. Ditto with cognitive state recognition (as in false belief tests).

"Theory of mind is nothing but a load of crap by a bunch of so called autism specialists."

Only if you think that they are fabricating their data and are part of a vast world-wide conspiracy enveloping multiple institutions. While such a scenario is plausible in fields like education, it is less so in fields based on falsifiable scientific research.

If you are going to make sweeping indictments, please back them up with actual data (anecdotes don't count).

Katharine Beals said...

"Do you think he'd get that same enjoyment from a book after spending a 8hr day matching, sorting, line drawing, being forced to read a book b/c it's part of the "autistic children aren't allowed to play" strip?"

No, nor did I make such a claim.

"Do you think we'd have joint attention from spending hours doing descrete trials"

Nor did I state this either.

What I did say is that Floor Time's aversion to structured, therapist-directed teaching ill-serves children with autism.

So does dogmatism; balance is essential.

Allison said...

Katharine, thanks for the Sally Anne pointer. I knew about the result for toddlers/preschoolers, but didn't know about that result for autistics.

That's extremely helpful for differentiating the feeling of/giving of/responding appropriately to emotions from empathy. The other joint attention behaviors could fail to happen in children with separation anxiety or severe social phobia--their shyness leads them to avert eye gaze, inhibit their own attention sharing acts, and miss social cues. (and in children with these diagnoses, the best results are again a combination of behavioral/cognitive therapies and emotional attachment work to lower their anxiety and increase their safety; behavioral work without corresponding emotional work increase the feeling of fraud anxiety sufferers have; emotional work without behavioral work doesn't teach the skills to build repeated social success).

But the Theory of Mind explains the difference between empathy and emotions. So the autistic child can have and give and recognize emotional responses in others, and still be unable to abstract away enough to actually empathize. Neurotypicals may find that inability to empathize frustrating and may mistake that for "lacking emotion".

Allison said...

btw, constructivism didn't start in education or psychology. It started in philosophy (though most ed folks don't know that.) The constructivism came from Husserl, and postmodernists Foucault and Derrida are his philosophical children. Husserl was the original inventor of the Hermeneutic Circle, the theory of learning that spirals through inauthenticity to authenticity, though educators have usually no idea that's where it came from.

Literary crit, or critical theory, or "theory" are all part of that intellectual movement that came from that, though influenced by other philosophers as well. So the fields of philosophy, literature, political theory, linguistics, philosophy of science, anthropology and moral philosophy were all stewing in this constructivism, and all of those connect up to and overlap with psych and education. That's why it's not surprising that both of these constructivist and post modern interpretations were the lens through which psych and ed are viewed.

Katharine Beals said...

I'd say the strands are,

for developmental psychology:
Romanticism -> Freud -> Greenspan et al

for education:
(Romanticism->Progressivism) plus
(Romanticism -> Freud) plus
Piaget plus
(Husserl->Postmodernism) ->
today's educational constructivism.

I agree that most fields in the humanities are affected, but mainstream linguistics is quite immune (and horrified), as is analytic philosophy.

Unfortunately, there are people who call themselves "linguists" and "philosophers" who've abandoned the rigor of their fields that nonetheless is nonetheless still alive and well within the best departments.

Catherine Johnson said...

I haven't read the thread yet - but wanted to tell you that I once arranged for Temple's mother to speak at a conference here and heard the story of the psychoanalyst who treated Temple as a child. He was a refugee from Austria/Germany.

Eunice was very young when she had Temple - only 19, I think - and her husband was somewhat older. She was intimidated by the Austrian psychoanalyst (& probably by her husband, too, simply because she is so young & so at sea with her autistic daughter.)

Eunice is a trained actress (she went to Harvard, iirc), and her retelling of the story is powerful. She describes being in the doctor's office, feeling intimidated and cowed by him, fearful of what he will do and say.

Then, during an appointment some months into Temple's treatment, the doctor begins to ask Eunice questions about her marriage.

Sitting in the audience, you feel: **now** what? Now she's guilty of being a bad wife as well as a bad mother?

The young Eunice answers all of the doctor's questions in a state of trepidation, while her audience, knowing the tale of Bettelheim and refrigerator mothers, is in a state of high anxiety. One question follows another until the doctor gets to the point:

"Do you know that your husband is keeping a set of notes on you?" he asks. "Do you know that he intends to have you committed to a mental hospital?"

No, Eunice says. I didn't know he was keeping notes.

Then the doctor says, "I will testify for you at the hearing."

I'm starting to cry now, just writing about it. But listening to the story as Eunice told it: wow.

Listening to Eunice tell the story you feel the most profound distrust of the doctor ----

And then the words: "I will testify for you."

Eunice Grandin is still alive and well, btw.

She's amazing.

palisadesk said...

She has written a book about her experiences, too, entitled A Thorn In My Pocket which is an engaging read, if not quite in the same league as Temple's books.

farmwifetwo said...

"A thorn in my pocket" is a poor read for anyone that is trying to find out anything about Temple's growing up years. The other children refused to be part of the book... so there goes most of it. Very little is about Temple... it's a "me" story about Eunice and a thin story written on few pages.

Read it via the library only.