Prolific author and autism-rights advocate Temple Grandin was diagnosed with autism in 1950. At the time, before the full autism spectrum was well understood, rates of autism were thought to hover around .04 percent, or one in every 2,500 people in the U.S. As a young child, Grandin couldn’t speak and would communicate only by screaming. Her parents were told to come to grips with the possibility that she might never talk.
During this time, she was the recipient of what she calls ABA-type treatment. The ABA she’s referring to is the most common form of play therapy for young children on the spectrum today: applied behavioral analysis. Grandin finally began speaking at three and a half, a few years before the techniques that would become ABA were officially defined. She attributes the behavior-focused interventions, along with consistent correction from adults on how to meet social expectations, to her being able to start mainstream school at age five.
Today, one in 44 U.S. children receive the diagnosis of autism spectrum disorder, and resources for families abound. But after a push in the last two decades to get insurance to pay for autism treatment, ABA’s behaviorally focused play became the most widely covered intervention. Effective at improving communication skills, like making eye contact and smiling during conversation, it’s been shown to help reduce telltale autism spectrum behaviors, or stims, like making loud noises and hand-flapping. Increasingly, however, teaching kids so-called masking skills, including ways to tamp down the stims that help them handle sensory overload, is considered mentally and emotionally damaging by autism activists, some of whom are offended at the idea that they might need to be “cured.” Quite a few of these activists are calling many aspects of ABA into question. Grandin herself has recently condemned “rigid forms” of ABA that bring on sensory overload or stifle creativity.
Serena Wieder is the codeveloper of an alternative to ABA interventions for children on the spectrum, a coregulating, child-led play therapy called DIRFloortime. She takes issue with ABA’s focus on masking stims. “Don’t flap, don’t jump, don’t move? Well, that’s not development,” she says. “Development is learning to use your body to regulate your body based on what it needs—which is crucial for developing a sense of yourself.”
Jeffrey Guenzel, formerly the Deputy Commissioner of the New Jersey Department of Children and Families, is the CEO of the International Council on Development and Learning, home to DIRFloortime.
He agrees that stimming serves a beneficial purpose: “Although we may not fully understand the behaviors, we risk too many negative side effects if we try to stop them. Stimming could be managing anxiety. It could be doing lots of good things for the individual, even though, from a neurotypical lens, it may not be considered socially appropriate.”
Guenzel emphasizes that stimming behaviors don’t stand in the way of doing good, coregulating therapy with children on the spectrum. “The first step is getting engagement and interaction going with parents. Once that happens, if stimming is getting in the way of something a child wants to do, it’s likely to diminish naturally, because as the child builds their ability to manage the world, things shift in their body, so stimming may not be so necessary.”
Guenzel also feels that trying to diminish consuming fixations, which are exhibited by some children on the spectrum, is wrongheaded. “A few months ago,” he recalls, “a child came to our institute after having ABA therapy. The ABA therapists had told the mother she couldn’t let him play with numbers because he was getting too distracted by them; they felt it was too much. But as I watched his expression as he played with numbers, it was clear he was just fascinated by them. His tongue made the shape of the number he was looking at. It was a multidimensional experience I couldn’t imagine having. I wouldn’t dream of taking that away from him. After all, someone with that kind of perspective can be invaluable to this world.”
Although ABA was championed during the early 2000’s legislative push to cover play therapy for autism, Wieder’s version of play therapy is now growing in popularity. Developed decades ago with the late Stanley Greenspan, DIRFloortime works with the caretaker and child dyadically to create a shared world of coregulation and connection.
“We decided to focus our approach on autism because we realized there were no emotionally or developmentally based approaches to help children on the spectrum develop, even though autism is a developmental disorder,” Wieder says. “The concepts used to measure development in other approaches weren’t the ones that indicate what a child feels and thinks, or how they relate and connect. That’s why play became the heart of our intervention. The emphasis in Floortime is helping parents act as coregulators with their children through free play. If you dictate play, you rob a child of the opportunity to develop a sense of agency.”
So rather than a play therapist engaging in corrective behavior with the child, therapists and parents follow the child’s lead in the games they create and enjoy. This way, parents practice relating to their children, and their shared attention creates regulation.
“Of course,” Wieder cautions, “we can’t talk about autism as if it’s one thing, and we can’t treat all children with autism with the same method. Yet that’s what ABA essentially aims to do, especially in the early stages. Instead, you need a relationship. Floortime is based on the relationship, not just for the child, but for the parents. Through free play, you get a sense of where the adults are. Some adults judge themselves or worry too much about what’s going to happen next. It’s hard for them to let go and just be present. They may be impatient or take over and try to problem-solve. Sometimes you have to help them really play with their kids.”
To do that, Wieder will take a caregiver’s play history, asking what they loved to play as a child. She’ll quiz them on their favorite games or characters, or whether they remember their teddy bears. “Other times,” she says, “I just have to coach. It can be hard to play with children in some ranges of the spectrum, so we have to help parents understand the kid’s capacities and developmental level. And not just the parents! Bring the teacher. Bring the ABA therapist. I don’t care who you bring, as long as we surround that child with people who communicate, play, and interact with them. If the kid loves basketball, let’s chase a basketball. If he’s into cars, well, remember the movie Cars? Play that.
“Play is a process of relating, thinking, and taking initiative. This is the idea behind letting children take the lead and following their interests. Our goal is to have a child develop intentionality. What do they want? Why do they want it? And what will they do if they have it?”
In this context, Wieder might offer opportunities for water play or sand play or going to the playground. She’s interested in creating environments that give children sensory and movement experiences, which can help with initiating communication and further play. Colors and music are important as well, appealing to all the senses.
“We let kids control the radio,” she states. “We let them control the pace, whatever they love. And we join them. We make it fun. You develop a relationship through fun. It has to feel good.
“It’s important to remember: a child with even the most complex autism is doing something. They may have motor-planning issues or low muscle tone, or are lost in space. Those individual differences just help us figure out how to provide experiences that’ll get them to move, to be more active. If there’s anything we’ve learned, it’s that all children with autism are intelligent and, like children everywhere, develop through play.”
PHOTO © ISTOCK/URSAHOOGLE
Lauren Dockett, MS, is Psychotherapy Networker’s senior writer. A longtime journalist, journalism lecturer, and book and magazine editor, she’s also a former caseworker taken with the complexity of mental health, who finds the ongoing evolution of the therapy field and its broadening reach an engrossing story. Prior to the Networker, she contributed to many outlets, including The Washington Post, NPR, and Salon. Her books include Facing 30, Sex Talk, and The Deepest Blue. Visit her website at laurendockett.com.