Monday, December 12, 2016
My child, just turned 28 months. He just received a diagnosis of moderate autism from our developmental pediatrician this morning. He doesn't respond to his name. He is not playing with toys properly. He continually moves away whenever we try to play with him. He mostly bangs toys or lines them up. He uses few words inconsistently and has little to no gestures. Her recommendation is for 10 hours of ABA, 3 hours of occupational therapy and 5 hours of speech therapy.
In order for him to begin to develop peer comparable cognitive and language skills doesn't he need to first learn how to engage in appropriate behaviors, such as following simple commands and completing adult-led tasks?
No! With very few exceptions this is often blindly emphasized by many developmental pediatricians and early intervention professionals. Instead, what is often left entirely unaddressed are the milestones prior to your child learning to follow "simple commands or adult directions." These milestones include your child's ability to be comfortable in his body and environment and his natural desire to want form and maintain simple and meaningful circles of communication with you.
It is so critical that your child spontaneously desires to maintain simple back and forth social-emotional engagement with you rather than trained on command or cue to follow adult directions. When your child begins to relate and engage s/he is beginning to expand his/her true receptive (mind-brain-body integrated) understanding. For example, s/he naturally begins the process of reading and processing your facial and bodily affect-gestures, such as, intensity, rhythm, tone and inflexion of your voice, S/he has increasingly begun to engage in meaningful co-referencing with you not because s/he is being commanded or robotically trained in early intervention or school to do so (i.e., "Look at me" and consequently receives an external reinforcer, such as a "cookie" or a verbal rote, 'Good job'") but rather because it becomes increasingly registered by your child as safe and pleasurable to maintain interaction with you and others!
What must be absolutely and unequivocally made clear from the beginning is that there is a world of stark and immeasurable difference between your Child spontaneously engaging in a flow of back and forth social interactions. and your Child trained to complete a series of memorized behavioral and academic tasks. In the first instance your child is learning to use his/her emotional intelligence to spontaneously engage with you. S/he is slowly learning to bring the process of engagement with others online in accordance to his/her states of optimal arousal, pleasure and range of affect (emotions).
Optimal arousal which is necessary for engagement requires an underlying basis of homeostasis. What is homeostasis? It is your child's degree of alertness and energy to attend to his/her surroundings ,the basics, for example, general physical health, nutrition, sleep. However, what is often less addressed is the deeper fact that alertness and energy is also dependent upon your child's ability to feel a sense of relative internal calm and safety in order to begin to be able to register and assess non-verbal and verbal cues during social-emotional interactions with others. This cannot be "trained on command."
Moreover, neither for that matter can the way that children labeled with autism spectrum or other diagnosed Developmental social-emotional challenges including, complex PTSD, ADHD and ODD, etc., process heterogeneous incoming sensory data (e.g., auditory-prosodic, visual-spatial, tactile-gestural; vestibular and proprioceptive) and the accompanied hyperarousal (over-responsiveness) or hypoarousal (under-responsiveness) and more often mixed responsivities (contingent upon what arousal and autonomic nervous regulation system factors are challenged) be interpreted as "maladaptive" or "inappropriate learned behaviors." Unfortunately, they are almost to perfection simplistically interpreted as such in behavioral based practices (i.e., Applied behavioral based methodologies, ABA).
To begin to understand your child's individual challenges in attending, engaging and communicating is to first and foremost to rid yourself of the notion of your child as a "compilation of behaviors" (e.g., so-called, "inappropriate behaviors" that need be replaced with an adult-directed checklist mandate of "appropriate behaviors"). Rather, it is to begin to understand your child's challenges in attending, engaging and communicating in direct relationship to his/her ability to maintain warm. pleasurable and nuanced interactions with you and others. Attending, engaging and communicating are not simply a focus on re-conditioning "surface behaviors" but directly connected to and an integral part of your child's underlying biological-psychological-and-social interpersonal processing challenges.
The Inter-Brain: Child/Primary Caregiver Mind-Brain-Body Connection.
Unfortunately, many therapists do not take into consideration what happens beneath your child's prefrontal cortex. The prefrontal cortext is the more mature or later developing area of the human brain which is responsible for deciding between courses of action, delayed gratification and rational decision making, including language. This is dependent upon how your child processes social-emotional cues/interactions. These social-emotional cues/interactions begin to become regulated by your child's earlier developing right subcortical areas of the brain. These become healthily interconnected and synchronized by the mother's right brain with the infantt and toddler's right brain during child/parent deepening reciprocal attachment and attunement (e.g., up-regulating joyful affect states through play, down regulating anxiety and stressful affect states through soothing reassuring warmth and safety).
Areas of significance over recent decades in healthy versus unhealthy attachment (or defined since the mid 1990's as affect-regulation) include the right oribital frontal cortex right amygdala, anterior cingulate, fusiform face area,, hippocampus, insular; hypothalamus, pituitary adrenal axis (HPA) which dynamically connects into the autonomic nervous system; superior temporal sulcus (part of the mirror neuron system which specifically distinguishes intentional actions connected to biological movement from mechanical movement); cerebellum with respect to rhythmicity and timing of reciprocal emotional-sensory-motor movements; periaquedutcal gray; the ventral tegmental area and the nucleus accumbens, the main pathways for the hormones oxytocin, endorphins, dopamine and serotonin (i.e., neurotransmitters associated with the deep pleasure and reward systems of the brain derived from early infant/mother positive interactions).
The way these subcortical connections begin to form in typical and non-typical development is epigenetically (experience dependent). This involves through child/parent bodily-emotional based interactions turning on and off gene sequences that produce proteins and enables synapses to form and connect your child's emerging prefrontal areas (e.g., executive functions with respect to sequencing ideas, actions and language). What we mean here by epigenetic (i.e., experience dependent) rather than maturational dependent are the neurophysiological processes that occur during infant/toddler primary caregiver reciprocal bonding and attunement through moment to moment social-emotional interactions. All parents convey by how they not just overtly but implicitly (non-verbally) communicate with their child in space through movement, across time, through gaze,voice, touch smell, social-emotional interpretative meaning to their infant/toddler's "emerging sense of exploratory self."
Behaviors are not simply "learned" in accordance to popular myth that have been promoted by traditional child-rearing practices, teachers and behaviorists for countless decades. Rather these views have been fully debunked since the mid 1990's s by Affect Neuroscience that understands "behaviors" in a more comprehensive fashion and not simply as discretely learned responses (i.e., "good" vs. "bad") but as part of emergent psychobiological processes that are directly dependent upon epigenetic experiences (i.e., healthy child/parent nurturance practices) for optimal brain functioning and healthy maintained autonomic regulation. These processes of psychosocial development are either compromised due to biological constitutional reasons, such as autism specturm challenges or familial reasons, such as poor institutional caregiver practices or insecure avoidanrt and dismissive attachment.
These biological-psychological-social processes never occur in an isolated or biologically predetermined manner. They occur interdependently as parents begin to attribute purposeful emotive interactions to their infant's and toddler's smallest movement and actions. As parents begin to deepen affect reciprocal attachment and attunement by down-regulating stressful states through empathy and up-regulating joyful states through play this begins to bring together the infant/toddler's senses and motor movements into synaptically well-organized, interesting, safe and secure or insecure patterns of interactions. We refer how these biopsychosoical processes come together as reciprocal-communicative affective or emotional circuits, where parents (the co-regulators) help their child internally regulate affect, function, perception and movement and make sense of his/her world. This process begins in utero, especially during the last trimester as the fetus begins to respond more substantively to the mother's affective levels of calm, joy and anxiety. This forms the basis of infant, toddler and early childhood mental health practices.
How, these early complex reciprocal biopsychosocial interactions transpire in space, across time and in movement play a central role in neurophysiologically shaping your child's autonomic nervous system (i.e., sympathetic, fight, flight or parasympathetic, calm, rest and restoration or an earlier more primitive parasympathetic pathway shut down, freeze or feint response known as vasovagal syncope, part of the unmyelineated dorsal motor vagal pathway). When your child's sympathetic nervous system is regulated in the context of relational feelings of safety and security we see optimal mobilization towards a continual increase in daily curiosity, exploration and joy or in insecure avoidant and dismissive attachment practices, fear, flight and withdrawal. In neurodevelopmental challenges such as Autism Spectrum Challenges many of the same neuronal subcortical pathways and how they dynamically and reciprocally connect with the autonomic nervous system are similarly affected. However, here causation involves biological-genetic factors beginning in utero and, therefore, these pathways can be considerably more impacted.
Under no circumstance either with typical or non-typical developing children can the biopsychosocial complexity of these brain-bodily hard-wired but malleable and adaptive responses (e.g. ,positive and resilient in healthy child/primary caregiver attachment and attunement or negative and constricted in insecure avoidant attachment, or separately due to in utero genetic or immunological compromises affecting neuronal pathways and state regulation as in ASD) be conceptualized in a dumb-down reductionistic fashion, as we typically find in traditional "Learning Theory" and Applied behavioral based methodologies.
In Applied Behavioral Analysis (ABA) the complexity of these biopsychosocial processes are conceptualized simplistically, broken down, graphed and managed in theory and practice to a collection of discrete "Learned behaviors." For example, A) The defined antecedents (i.e. what precipitates a specific set of behaviors) and B) The defined consequences (i.e., what reinforces a specific set of behaviors). The latter thinking from a perspective of Affective Neuroscience is not only risibly simplistic, reductionistic and antiquated but deeply insulting from the perspective of our two hundred million years of evolution from our reptilian, mammalian to higher primate brain.
Our approach as infant child mental health professionals, special educators and developmental psychologists is strongly guided by a major paradigm shift in thinking that began in the early to mid 1990's. With vastly improved PET, neural imaging technology; advancements in our progress and understanding of epigenetics, neuroanatomy, neuroendocrinology and polyvagal theory, complex trauma and the impact of associated stress affecting subcortical and cortical connections, etc., this paradigmatic shift began to bridge attachment theory, infant and childhood mental health, developmental psychology, psychoanalysis and biobehavioral science into the newly emergent fields of Developmental Affect Neuroscience and Interpersonal Neurobiology. Thus, we are compelled not by abstraction but by the last thirty-years of major neuroscientific research on how typical and non-typical brains grow and develop to take not a reductionist Applied Behavioral Analysis approach in the treatment of infants, toddlers and older children with ASD and related developmental challenges but a comprehensive biological-psychological-social perspective.
A biological-psychological- social framework constitutes an integral part of a Developmental Neuroscientific understanding on the one hand and a comprehensive evidenced-based treatment approach, such as DIR/Floortime therapy to treat autism spectrum and related challenge on the other with respect to how infants, toddlers, older children, adolescents and adults typically (or atypically) grow, develop and thrive biologically,psychologically-socially in the context of Relationships. (see Allan Schore, 2017, The First 1000 Days of Life: A Critical Period For Shaping Our Emotional Selves and Brains: https://www.youtube.com/watch?v=lY7XOu0yi-E&t=6s ;Dr. Dan Siegal, Roots of Empathy: Research Symposium, 2016. An Interpersonal Neurobiology Approach to Resilience and the Development of Empathy.
The reduction of excessive stress associated hormones (e.g., cortisol, corticotropin and vasopressin) and an increase in healthful hormones (e.g., oxytocin, dopamine, endorphins and serotonin) throughout your child's mind-brain-body systems are tremendously impacted by the cultivation of child/primary caregiver interactions (i.e., healthy or unhealthy nurturing infant/toddler/parent engagement). Early positive joyful or negative stressful child/primary caregiver interactions become increasingly felt and interpreted (i.e., sense of well-being, sometimes referred to as "interoception") by your child as safe, secure, interesting, comfortable, curious and joyful or insecure, fearful and avoidant. Consequently, this typically results toward an increase of calm and complex sensory-affect-motor integration or conversely a noticeable lack of integration and associated "externalizing behaviors."
Early positive child/primary caregiver interactions are necessary for optimal arousal during simple to complex engagement. In typical engagement this involves your child being able to increasingly maintain spontaneous, meaningful and nuanced back and forth reciprocal non-verbal and verbal circles of communication. This includes simple to complex visual-facial, tactile-gestural, auditory-prosodic social-emotional communicative exchanges. In children who demonstrate a general profile of low affect and hypoarousal an increase in adrenaline by moderate to very high affect social reciprocal interactions might be needed in order to sustain optimal engagement. However, in any case, healthy social-emotional reciprocal exchanges are contingent upon a continuous and nuanced context of warm, receptive, understood, attuned and synchronized child/parent interactions. A basic infant/parent illustration of this is portrayed in, The Still Face Paradigm: https://www.youtube.com/watch?v=bG89Qxw30BM ,
The above outlined neurodevelopmental biopsychosocial framework is entirely in accordance to a Functional Emotional Developmental intervention approach. One that is geared toward optimal arousal of your child's autononomic sympathetic and parasympathetic nervous system and sensory-affect-motor processing regulation challenges in the context of Thinking, Relating and Communicating, beginning with simple to the increasingly complex processing and understanding of multi-modal, biopsychosocial, child/primary caregiver social-emotional exchanges. This entails not a behavioral certified analyst (BCBA) revered as the perennial scientific observer-technician dispassionately collecting data on your child's surface behaviors (e.g., initially conducting a functional behavioral assessment followed by a functional behavioral analysis) and establishing a baseline on your child's so-called,"maladaptive or problem behaviors" and, thereafter, implementing "schedules of reinforcement" to help "shape those behaviors" to become more "socially acceptable."
Rather this involves a knowledgeable and highly-attuned Developmental therapist with a background in infant and childhood mental health guiding you to learn how to begin to convey an inviting atmosphere of warm, optimally shared emotional exchanges between you and your child by attributing purpose and meaning to your child's natural actions in the present moment.
How does this begin?
This begins by the Developmental therapist guiding you and your family members to join in with your child's natural intent or affect (range of emotions) in order to empathically and meaningfully convey to your child directly by your facial and bodily affective expressive gestures and prosody of voice (e.g., vocal stress, pause, rhythm, tone, inflection) a deeper sense of internal safety, trust, curiosity and interest for purposes of maintaining a closer proximity and increased consistent engagement with you and others.
Once you begin to learn how to follow, join in and attribute purpose and meaning to your child's natural rhythm, movement and intent, then moments of back and forth simple joint-attention to shared-perspective taking (i.e., simple to complex back and forth co-regulated/regulated emotional communication, gestures, emergent utterances, words to combined phrases with your child) begins to increase in a more spontaneous, sustainable and meaningful manner. You are guided to slow down, tune into and receptively begin to build upon your child's natural interests by adding slight affective (emotional) variations to his/her play (i.e., his/her nonverbal and verbal ideation, movement and thinking).
Slowing Down Time and using Affect to Engage Your Child
Let's take the following example. Your child sees and desires a ball but it is out of reach. Instead of soliciting a gesture by modeling pointing to the ball or modeling, "Can you say,, 'b a ll' ", we use our bodily, facial expressions and vocalizations in response and build a substrate of biopsychosocial emotional engagement around his/her desire and play dumb. Using affect (emotion) and "Playing dumb" is a way of slowing down, empathizing and stretching out our interactions between us and our child. For example, empathizing with his/her "dilemma" becoming part of his/her joint affect-problem solving rather than standing in the position as "teacher" and as often done unthinkingly or unconsciously simply mechancically modeling to our child without empathizing, entering and engaging his/her world.
"Playing Dumb" is engagement as understood in a much more encompassing manner with all our senses. We are doing this because we are not simply focused on getting your child to imitate pointing and say verbal sound for ball. Rather, we are focused on the dynamics of relationship which is much, much more than a finger pointing and a word being produced (the latter, part of antiquated telegraph speech and not how language/communication actually works). When we speak or interact it is not in a mechanical fashion. We are not just mouths speaking and hands/fingers pointing. We use our whole self in relationship to other in the smallest instances of communication. We need to attend not just to the foreground but the background. In order to understand this not just "cognitively" but intuitively and experientially ( i.e., bodily-based) we need to slow down.
Ninety-three percent of our language is affective communication, that is, emotional or non-verbal accompanying the simple act of pointing or verbalization. So in "Playing Dumb" we actually begin to generate a zone of Functional Emotional Developmental space(s) for simple to complex back and forth non-verbal-and verbal communication with your child to unfold. This is how not only simple gestures and words but social-pragmatic language/communication actually works (e.g., by stretching out/creating, brain-bodily, interpersonal spaces for varying states of arousal and regulated affect to transpire and deepen through back and forth nuanced co-referencing).
Decades of research between mother/infant dyads have repeatedly and specifically shown these right to right maternal and paternal to infant and toddler right emotional areas of the brain and synaptic connections being made moment to moment in real-time in utero and through the first few years of life. These early parent/child dyadic interactions represent the biological-psychological-social foundations necessary for the emergence of language. Social-pragmatic communication is not a series of top-down mechanical or executed and reinforced/ prompted verbal tasks. We intutively and incidentally use all our senses and variations of affect (emotional) inflexion when we convey/communicate the simplest of things. Unfortunately, we tend to forget this as this typically comprises the "unspoken" or the background of our moment to moment overt actions, just as we take space for granted which enable forms to exist or transpire.
So, the clinician might guide you with your child to point in the wrong location with a quizzical look and call "Ball, ball, are you?" Followed by "Oh no?!" Or we might articulate, "Up, up there? Oh no! Reach!! But, alas, we are not able to reach (which then creates an additional space, a longer space of attention/engagement - or might initially create a meltdown, which we can co-repair). We might incidentally nudge the ball under the couch and get it stuck. "Oh no! Pull!" "Oh no, ball, uh oh?!" What you are doing is participating with your body, facial and verbal expressive affects (emotions) as an integral part of an emergent set of communicative-relationships with your child, in movement, in tone, intensity and inflexion the dynamics of the joint activity It is the co-creating meaning-making of the activity which creates the foundations for internal safety, curiosity and engagement.
Initially when therapy begins, the clinician guides you quite gently by simply learning to share moments of pleasure, movement and space with your child and then slowly stretching out a particular action or feeling-or-emotion with your child around his/her current interests by learning how to slowly join in and playfully vary the preverbal or emotional expression (e.g., the visual-facial, auditory-prosodic, tactile-gestural dynamics of interaction).
What the clinician is beginning to convey to you at the beginning of therapy is that what is involved in this Neurodevelopmental Highly Affectively-Structured Process is not a dumb-down selective focus on deconstructing and dissecting, "challenging behaviors" but how to engage in a child/parent co-created/co-narrative meaning-making process where you are guided to become more intuitively receptive around your child's natural affect or intent and processing of emotional-bodily based interactions. This includes not just the "what" you are communicating (e.g., traditional modeling to your child by "labeling words for actions and objects") but the "how" you are communicating (e.g., the feeling-tone) to your child or what is referred to as the prosodic elements of speech which needs to be underscored again comprises 93% of spoken language. This includes your vocalized intent, intensity, rhythm, inflected tone of voice and nuanced facial and bodily gestures around whatever non self-injurious interest, activity your child is engaged in.
Furthermore, this includes learning how as well as the why and the wherefore of attributing purposeful and meaningful engagement to all of your child's actions. The overarching goal (which comes from moment to moment co-creating meaning making) is to turn your child's actions into joint and meaningful emotional reciprocal back and forth communicative interactions. This extends to learning, precisely how to not "redirect" your child to more "Appropriate adult direct tasks" (a load, distorted and misguided term I will return to) but rather precisely how to slow down and attribute purpose and meaning to what is traditionally and reflexively frowned upon as your child's so-called, "non-functional" behaviors" such as "stimming" (e.g., flapping hands, spinning self) and perseverative or repetitious play behaviors (e.g., turning bus upside down and spinning the wheel, incessant lining up toys, etc).
Typically, with children and adults with autism spectrum challenges, we see a wide range of mild to severe autonomic arousal and sensory-motor system repetitive or perserverative behaviors that make it difficult for your child to maintain back and forth social-emotional engagement. Behaviorists reflexively interpret this as your child's "Non-compliance" to the demands of the behavioral/academic task, Egregiously and unacceptably this is often done without examining for a moment the purpose and meaning it holds for your toddler or older child with respect to biologically-psychologically-socially adapting to his/her immediate and surrounding environments.
In other words, your child's adaptive and heroic attempts to make his/her environment(s) "internally safe" by down-regulating anxiety in terms of over stimulation (e.g., a light touch or moderate background sounds are interpreted by your child as overwhelming and so withdrawal from close proximity with others often result) or your child's attempts to heighten particular sensory awareness because of the registration and feelings of his/her arousal of perceived under stimulation (e.g., typical registration of proprioceptive touch and movement are under-whelming and unfulfilling, and therefore your child sensorily seeks additional proprioceptive and vestibular input).
Underwhelming or overwhelming sensory stimuli (very often mixed responsivities depending upon the individual disposition characteristics of your child and the associated autonomic and sensory areas triggered) can and does makes it extremely difficult for your child to engage or the understandable and adaptive need to derive a certain secure sense of satisfaction from highly organized or regimented patterned routines (e.g., excessive lining up of objects/toys, etc.). These should never be viewed despite the widespread and horrendously uneducated brain-autonomic nervous system antiquated view held by many behaviorists as your child's "Non-Compliance" or "Inappropriate play."
Nonetheless, despite well established neuroanatomical, neuroedocriniological, neuropsychological and neurodevelopmental evidence of these biopsychosocial foundations, they are still in the educational and political sysrtem at best given lip service and for the most part all disparagingly regarded by behaviorists and clinicians in general as poorly learned or poorly adaptive strategies to the "demands of the task" (i.e., the parent to child-and-the teacher to student requirment to attend to the demands of the task) and, therefore, defacto, regarded as "Non-Compliance." Applied behavioral methodologies are used to attempt bring your child into compliance for what in reality from a neurodevelopmental perspective are normal individual biopspychosocial adaptive responses of your child's autonomic nervous regulatory and sensory systems to social-emotional interactions.
The interpretation of your child's brain-bodily autonomic nervous system regulation and adaptive responses by teachers as "Non-compliance" to the required task is typically interpreted as, "avoidance of task", "escape from the task,", "desired access to highly preferred items" or "automatic internal self-stimulatory reinforcement" (depending upon the situation and child one or not infrequently a combination of all four above). In addition to be neurodevelopmentally uninformed, this type of language comes out of mass homogenized assembly-line thinking education or what Pablo Friere fifty years ago, as well as countless other educators termed, Pedagogy of the Oppressed. (Friere, 1970, Pedagogy of the Oppressed).
Fortunately, your child's intuition and body-affect responses know better but unfortunately in practice by unattuned and un-emotional therapists who have their nose on a checklist of behaviors they are often ignored! We, however, are here to respect your child's intuition and body! These so-called, "non-compliant behaviors" are actually adaptive and meaningful. They are governed by your child's arousal levels-which is connected to autonomic levels of sympathetic and parasympathetic regulation during interactions with others. The latter is further compounded bi-directionally (body to brain/brain to body) by his/her additionally interpreted heightened or underwhelming sensory-symbolic stimuli in the immediate environment, Again, using the language of affect neuroscience and thus biopsychosocial accurate terms, your child's arousal, autonomic nervous system regulation and sensory processing differences are correctly being emotionally-bodily-interpreted by your toddler or older as anxious-avoidant, fearful, withdrawn; too much stimulation, too little stimulation, etc.
This would be analogous if say someone suddenly shouted in your face, now you might turn away or strike out or if perchance it was a 100 degrees you would be sweating or if zero degrees freezing, or if you were sitting in an empty white room for an extended period or time you might start bouncing off the walls, and so forth. This is manifested in how your child registers, processes and interprets the world through his/her sensory-affect modulation differences in the context of social-emotional interactions (e.g., propriception/ movement; auditory/prosodic; tactile/gestural, visual-facial, olfactory, gustatory, interoceptive,). To call the above, " learned compensated inapproiate behaviors" is rather strange if not bordering on the psychobiologically profoundly unaware and ignorant!
As Developmental play based therapists, psychotherapists and other clinicians who take a biopsychosocial approach, we do not acquiesce to a broken down behavioral curriculum of reductio ad absurdum and interpret your child's individual bodily based arousal, sympathetic/parasympathetic regulation and sensory-modulation processing differences in what is frequently and disparagingly termed here by behaviorists as your child's, "Non-Compliant Behaviors" and while "automatic internal self stimulation behaviors" are indeed at least in a superficial manner addressed by your OT (Occupational Therapy), essentially all of these complex biopsychosocial processes are regarded in practice as, "inappropriately learned behaviors", "problem behaviors" or "aberrant behaviors." In fact, your child's heterogeneous, hyper, hypo or mixed sensory-modulation processing challenges and autonomic nervous system regulatory responses (e.g., fight, flight, feint or freeze) clearly should not be regarded as "inappropriately learned" or "aberrant behaviors!" They are in fact adaptive or coping strategies to manage, deal with and navigate stress and anxiety.
Child/Parent Dynamic: Breathing, Slowing down, Stretching Out Interactions
When you are guided to breathe, slow down, engage and attribute purpose and meaning and encouraged to form a relationship with your child with respect to how your child in the present moves and processes his/her world through all his/her senses, this, in turn, becomes one of the very first steps toward extending and deepening internally self-regulated and spontaneous two-way reciprocal back and forth meaningful social-emotional engagement. Deepening affect-reciprocal attachment and attunement is one of the first steps in understanding and exercising your natural parental intuitive emotional-intelligence with respect to how to join-in and engage where your child is in any particular given moment (e.g., facially, auditorily, vocally, bodily).
This natural biopsychosocial process which begins in utero with respect to the mother's healthful or stressful affective and hormonal states (e.g., the regulating gene through reduced methylation that turns cortisol into cortisone or adversely due to stress excess cortisol) which cross the placenta and then post utero is mind-brain-bodily interpersonally communicated. What has been shown in exhaustive detail through comprehensive neuroimaging studies over the last three decades is how two brains (the "inter-brain"), the mother's right-brain with her child's right-brain is interpersonally (emotionally) communicated through right subcortical and emotional-bodily-based processes which are registered by the infant/toddler, that is, without words. This elaborate and nuanced dyadic affect reciprocal process begins to synaptically and dynamically connect the autonomic sympathetic and parasympathetic nervous system and subcortical regions (the emotional areas of the brain) to the higher prefrontal regions (the executive functions of the brain). (see, Allan Schore, 2017, The Development of the Right Brain Across the Lifespan. https://www.youtube.com/watch?v=u_B6WekX75s&t=5030s)
When we create the conditions around your child's natural movements for a warm, inviting, curious and positive emotionally challenging environment this first and foremost begins to honor and respect where you child is by attempting to cultivate your understanding from his/her perspective (rather than as typically done "re-direct") how his/her world is being interpreted. This social-psychobiological process begins to support and build (or in cases of compromised non-typical development as in autism spectrum challenges re-build) the underlying subcortical affective (emotional) foundations that help form (i.e., re-connect) the right emotional subcortical synaptic neuronal connections to the prefrontal cortex (executive functions, ideation, planning, sequencing, language).
This interpersonal deepening affect reciprocal attachment and attunement through high affectively structured playful and multi-modal engagement (around your child's natural affect and senses) supports the emergence of your child's Functional Emotional-Developmental milestones with respect to being able for him/her to increasingly internally regulate function and relate, think and non-verbally-and-verbally communicate with you and others! Significantly, this is in direct contrast to the simplistic and reflexive robotic programmatic practice found in traditional schooling and early intervention practices utilizing Applied behavioral analysis for "re-directing surface behaviors" and adult-directed or highly structured play which focuses prematurely on cognitive and language task oriented behaviors and worse often to the exclusion and complete ignorance of these early critical core right subcortical bodily based emotional based brain foundations http://www.icdl.com/dir/fedcs
The above interpersonal and psychodynamic processes involve what can simply be referred to as a "Wooing Process." This is in contrast to what is found in traditional applied behavioral early intervention and school based practices that tragically and egregiously are still caught in a 1970's slumber and consequently as yet to catch up to the huge paradigmatic shift during the last thirty-years in Development Affect Neuroscience. Tragically, the former remarkably and primitively essentially regards your child's arousal, autonomic nervous system regulation, sensory-modulation processing differences and functional-emotional developmental milestones in a shockingly regressively rote, reductionistic and uniform assembly-line fashion, e.g.,"Do as we say or as we instruct you to do as your 'inappropriate play' or 'performance-tasks' are not [socially] acceptable and thus we need to change your 'problem behaviors' and get your academic and social performances up to peer competence per our inexorable pedagogical factory assembly-line checklist mentality."
Wooing is a fundamental part of our biopsychosocial evolutionary development as mammals (i.e., from earliest mammals to human child/primary caregiver nurturance practices). It is part of the more myelinated (higher and more evolutionary responsive) aspects of our vagus nerve. The vagus nerve is our tenth cranial nerve. Its function in the evolution of our neuroanatomy and neurophysiology in our transition from reptiles to mammals cannot be overstated. It is the longest nerve in our body. It runs from the abdomen to the basal ganglia with effervent (nerve) pathways connecting to the striated facial muscles, middle ear and eyes. It helps regulate our heart rate variability and autonomic nervous system. For example, when stressed or anxious our mobilization system for defense, our sympathetic fight, flight response or when feeling safe and reassured (a loving looking, soothing voice and ouch) our parasympathetic responses of calm, rest and restoration or if completely overwhelmed (and not reassured and cannot take fight or flight) an activation of separate ancient reptitilian primitive vagal pathway, our dorsal vagus parasympathetic shut down or freeze response.
Significantly, the vagus nerve also helps regulate or dysregulate and restrict when anxious or stressed the pharyngeal and laryngeal muscles required for vocalization and language. It is also has efferent pathway connections to the middle ear with respect to auditory receptivity and attunement or when stressed blocking and attenuation; striated facial muscles for processing of facial emotional expressions and to the ocular muscles with respect to shifting frames of eye contact during back and forth social-emotional co-referencing (i.e., your child's relaxed and expressive face or tense and flat affect). The above biopsychosocial processes are an integral part of the more advanced or myelineated aspects of the vagus nerve pathway. This adavanced vagus pathway has developed as part of not only our survival but our thriving with respect to our evolutionary social emotional non-verbal affect gestural and verbal communication system as mammals. Without this ability for primary caregivers to not only to protect but to intimately nurture and communicate, down-regulate anxiety and stress states and up regulate curious, playfully engaged and joyful states we would have perished long ago (see, Porges, S. 1995 The Polyvagal Theory)
Now, the biopsychosocial process of "wooing" is directly connected to the most basic social-emotional communication interactions starting in infancy. Wooing involves a biopsychosocial deepening of back and forth reciprocal attachment and attunement around dyadic pairs (i.e., specifically mother/child nurturance). Both primary caregivers help critically co-regulate and set the early biopsychosoical foundations for their child's internal regulation (i.e., arousal and autonomic sympathetic and parasympathetic regulation). This forms the framework for relating, engaging and communicating with others. What needs to be noted is that in healthy primary caregiver/child secure based attachment practices, the primary caregivers serve as the quintessential "re-assuring guides" or co-regulators that help secure the foundations for their child's internal emotional regulation-and-executive functioning.
As stated previously, this begins with the primary caregivers' emotionally-communicated right subcortical brain to infant/toddler's right subcortical brain, which is critical in helping the formation of synaptic connections with respect to the developing prefrontal cortex or executive functioning in integrating the infant/toddler's senses and motor planning and ideation around a healthy emerging core sense-of-self in relationship to others. How these early connections are made (i.e., through experience dependent, deepening reciprocal attachment, attunement and child/parent co-repair of dis-attunement) either help facilitate or dysregulate the Functional-Emotional Development for a well regulated integrated prefrontal cortex (executive functioning), which enables the functions of delayed gratification, planning, organizing, sequencing, language and logical thinking).
All of the above that I have outlined translates into the ability for your child to biologically-socially emotionally engage across a wide range of affect states connected to increased autonomic sympathetic and parasympathetic regulation. This entails sequencing novel ideas, problem solve and not and I repeat not mechanically but socially-emotionally pragmatically, spontaneously communicate with others. In insecure and avoidant primary caregiver attachment practices this process is compromised and leads later on to mild, moderate to severe emotional-psychological challenges.
However, in Autism Spectrum challenges your child's autonomic nervous system regulation-responses (e.g., stress-anxiety in contrast to rest, restoration, calm and mobilization for sustained positive joyful reciprocal interactions) is further exacerbated by mild. moderate to severe sensory-modulation and sensory-motor processing challenges (e.g., visual-facial, auditory-prosodic, tactile-gestural, proprioceptive, vestibular and gustatory, etc.). In both typical and non-typical development however, these biopsychosocial processes are impacting upon many of the same neuronal pathways. However, to be clear in autism spectrum challenges it is not parental insecure avoidant or ambilvalent attachment practices, which can indeed significantly exacerbate any underlying challenges, but rather due to specific in utero constitutional biological-genetic and/or immune based factors that mildly, moderately or severely impacts affect-regulation (i.e., infant/toddler spontaneous reading understanding and processing of reciprocal emotional signaling during social engagement).
Guiding you to understand how to begin to attribute deepening emotional-reciprocal attachment and attunment in a warm, emotional and meaningful manner around your child's individual affect sensory processing differences/challenges in the context of spontaneous co-created social interactions is the first major foundation that supports a comprehensive biopsychosocial approach in working with children with ASD and related challenges.
Unfortunately, it also typically happens to be the quintessential opposite of what is placed into practice in Applied Behavioral Analysis (ABA) methodologies with respect to understanding how infants, toddlers and older children grow and develop. Your child begin to grow, develop and thrive not through the reinforcement of discrete or selective behaviors and an extrinsic "reward-based system" but through a biopsychosocial emerging set of positive adaptive interactions, deepening affect-reciprocal attachment, attunement and complex social-emotional engagement. ABA methodologies at best minimizes and at worst leaves entirely out of the picture the clinically significant and clinically meaningful correlations between what begins to biopsychosocially transpire when you are,
1) Slowly and systematically guided to emotionally connect and engage with your child through deepening reciprocal attachment and attunement around your child's natural range of affect (emotions) and the resulting pragmatic, social-emotional thinking, relating and communicating that begins to form the foundations for meaningful engagement.
2) The above is supported by decades of evidenced-based research in developmental affect neuroscience; neuroanatomy, neuroendocrinology; infant childhood mental health; developmental play therapy; psychoanalysis and developmental psychotherapy: Clinically significant and clinical meaningful resulting neuronal changes evincing a direct correlations between newly forming subcortical to prefrontal connections seen thrwough advanced neuroimaging postnatlly (but beginning in utero, third trimester) through the epigenetic process of affect-reciprocal attachment and attunement around your child's perspective. This, in turn, leads to greater affect-sensory integration/regulation through the biopsychosocial processes of attuned and re-attuned facilitation of child/primary caregiver relationships.
3) We begin to see substantive biopsychosocial changes in your child's arousal states and healthy autonomic nervous system responses (e.g., decreased hyperarousal and the associated hormones, such as cortisol and vasopressin and increased homeostasis with the ability to socially emotionally engage and increases in the associated hormones, such as oxytocin, endorphins, dopamine and serotonin).
Unfortunately, the latter is rarely part of the discussion in Applied Behavioral Analysis and education in general. Instead, the focus is on re-training your child to comply, to become externally "socially compliant" to a set of repetitively reinforced mechanical prompts or selective behaviors, basically, an itemized laundry list of declarative memorized cognitive-and academic schema rather than true spontaneous implicit procedural dyadic reciprocal engagement and integrated social-emotional pragmatic communication/conversation.
Why? Perhaps, in part it is easier with respect to management streamline efficiency, as far standardized school procedures entrenched in decades of a culture of systemic avoidance. A politics of retrograde thinking whose raison d'etre is on framing/addressing and funding "problem behaviors" as it continues to adhere to an uninformed Developmental neuroscientific perspective that ignorantly separates behavior-from-physiology and language-from-emotion and both from the essential core dynamics of empathic human relatining and engaging on an ever exponentially rising mass scale, (I will address this point separately at a later time.)
However, a comprehensive neuroscientific evidenced based proven child-directed adult guided biopsychosocial approach is indeed required if a meaningful therapeutic focus (and moreover, a general human empathic understanding) is on addressing your child's core individual differences with respect to his/her underlying primary Functional Emotional Developmental capacities and sensory-modulation differences in the context of social-human relationships rather than on polarized selective cognitive performance task-behaviors.
In other words, we are not merely looking at your child's symptomatology and external "surface behavioral changes" in "compliance versus non-compliance" but how your child is actually spontaneously processing, understanding, relating and engaging with others. Again, these are complex biobehavioral processes. This critically includes not prompted but internally understood by your child in moment-to-moment, nuanced back and forth social-emotional interactions/co-emotional signaling that in fact neurophysiologically enables spontaneous thinking, engaging and social pragmatic communication (emotionally-cognitively and adaptively across all relationships). The latter is in direct contrast to shaping or training your child's behaviors or scripted responses that your child can recall on command or from declarative memory.
Declarative memory also known as explicit memory is the conscious recall of surface information regarding external facts and events. This is in contrast to implicit or procedural memory. Implicit or procedural memory has to do with what is emotionally-bodily experienced and understood in an instinctual-intuitive and integrated manner (e.g., mind-brain-autonomic nervous system and cellular level). The latter is cultivated through the dynamics of relationships and as such forms an integral part of our sympathetic and parasympathetic responses.
For example, by the dynamics of increasingly positively secure and spontaneous social-emotional relationships occur in the context of relationship-based exchanges that can be neither trained nor scripted by training your child's memory by applied behavioral analysis and declaratively recalled on cue or command. Once again this goes back to the fact that 93% of language expression is nonverbal. This involves spontaneous reading, integrating and processing visual-facial, auditory-prosodic, tactile-gestural cues in a dynamic exchange in a dyad (e.g., ever-shifting moment-to moment novel frames of mind-reading/co-reference between two people). It is this which represent the core challenges with children and older with autism spectrum disorders.
As Dan Siegal indicates in the Roots of Empathy video sighted earlier ( https://www.youtube.com/watch?v=2dmX6XBZ1GY ) major areas of the right emotional brain that begin to connect here include, the temporal partial junction (which integrates auditory and other multi-sensory information), the insular (which is located deep in the limbic system and is responsible for what is referred to as interoception, that is, our sense-of -self and well-being) and the superior temporal sulcus (which is an integral part of is referred to as the "mirror neuron system" or Theory of Mind , the ability for your child to assimilate, register and process what others are not just saying literally on the surface, but what they are actually communication by their tone of voice, facial expression and bodily based language).
Unfortunately, the emphasis in general education and more specifically in special education is for the most part largely if not entirely ignorant of the above and,therefore, quite the opposite. It is a focus on shaping your child to become cognitive, socially, behaviorally and academically compliant. Translation: More or less good-test-takers and scripted recall from declarative memory (e.g., beginning in early intervention with discrete trial training,, taking a task breaking it down into small steps to proficiency toward generalization). The thinking basically here is, "If we can demonstrate that your child has 'mastered a set of simple to complex generalized tasks' does that not empirically mean s/he is progressing developing/advancing?" The answer is No, not necessarily at all!
However, it is this that has been the primary therapy administered under the tutelage of a Behavioral Certified Behavioral Analysts (BCBA) and their underlings who willfully or often simply ignorantly, due to a lack of developmental neuroscientific education (or perhaps servile compliance to a focus on institutional efficiency and constraints of assembly line education) on how actually infants, toddlers and older children grow and develop (biologically-psychologically-socially). Thus, with the best of intentions but in an extraordinarily ill-informed manner, they act as the aficionados of the, "Only scientific proven methodology for children with ASD." Despite smashing great media inundation for decades this could not be further removed from the last few decades of evidence in early childhood mental health, Developmental affect Neuroscience. and Interpersonal Neurobiology.
In Applied Behavioral Analysis (ABA) the behavioral clinician initially conducts a functional behavioral assessment and then if necessary a more in-depth analysis of your child's, "disruptive behaviors" (e.g., time, frequency, duration, intensity and so on). Thereafter, you seemingly glean a bit more "parental insight and control" with respect to understanding what precisely are precipitating or reinforcing your child's "inappropriate" or "disruptive and maladaptive behaviors." A plan is then devised under the supervision of a BCBA. Individual schedules of behavioral reinforcement are established to help implement the "targeted behaviors" and keep track of the efficacy of the methodology used (e.g., the goal is that through meticulous data collection targeting specific "problem behaviors" we will determine what procedures were effective or ineffective with respect to the targeted adaptive, behavioral, cognitive or language performance).
This often begins by training your child through various methodologies of reinforcement to produce either on query or command a more functionally adaptive set of discrete to generalized learned responses (e.g.,,"Touch blue!", "Say, up!" "Give me ball'", ""Show me green", "Say down!" "Can you point to cow?" "Quiet hands!", and so forth). After each command or query is correctly non-verbally or verbally answered/complied with the child receives a "reinforcer" (e.g., a favorite toy or video and/or always a verbal perfunctory and dispassionate, "Good Job", ad nauseam). The purpose of the reinforcer is to further help assure that those, pardon my less than enthusiastic tone, rote factory checklist of socially accepted behaviors occur again.
In contrast, learning to connect with or woo your child into engagement around his/her natural affect (i.e., his/her natural mind-body range of emotions-and-sensory modulation differences) begins to cultivate not a series of trained surface responses but on a social-emotional-and-neurophysiological level clinically significant and affect-meaningful optimal regulation (e.g., emotional-sensory and autonomic nervous regulation system wise) in the context of spontaneous back and forth two-way relationship based engagement. We also refer to this in comprehensive developmental approaches such as DIR/Floortime as the opening and closing of circles of nonverbal gestural and verbal communication which leads to more complex ideation and social-pragmatic language.
The above involves the Developmental clinician slowly guiding you to become a highly attuned co-regulator for your child around his/her natural emotions and subsequently what occurs is an increasing internal regulation by your child as part of that deepening connection and synchrony. This point needs to be underscored many times. Let's take, for example, eye-contact. It is not just a matter of your child "maintaining eye contact" and the behavioral automaton marking it off once achieved on a checklist. Rather, it is what "eye-contact" actually means in the real-world. In the real world of social-emotional interactions with others eye-contact is not simply maintaining eye-contact for "X" number of moments and then the good-doer applied behavioral technician establishing a baseline and plotting it on graph. Rather in the "real-world", that is, in the context of mammalian evolution and everyday life, it is ever-shifting mutual frames of affective co-referencing with changing facial and bodily affect with others with contemplation, curiosity and joy around a mutual object of interest between child and parent and others.
Or, let us take, for example, symbolic play. Symbolic play is not just performed ideational actions executed in a sequence on a laundry list (i.e., people figure placed on a bus, push bus, say bye, etc) rather it is always far more nuanced and involves complex ideation, such as a spontaneous elaboration of ideas by your child (i.e., your child attributing more detailed purpose and nuance to playful character figures and interaction between various character figures) and dramatizing/acting out "safely" in the context of play "emotions" that otherwise prove difficult for typical and non developing typical children to express in daily encounters.
Or, if we briefly look at expressive language challenges, expressive language/social communication with either typical or non-typical developing children does not really first begin by your child first being taught the basic parts of grammar (instructed on first labeling simple nouns,, prepositions, verbs and predicates as we often see in the persistent model of antiquated telegraph speech, "I want ball." Give me juice" and so forth) but rather as demonstrated during the last forty years in mother/infant dyads,it actually begins in what is referred to as small back and forth proto-utterances or proto-conversational exchanges which eventually in the context of more complex back and forth nuanced social-emotional engagement interactions naturally develops into what we recognize as formal language. It other words, what is required are the antecedents of social-emotional engagement (i.e., the 93% which comprises expressive language) for language proper to proceed.
It is not that a majority of children with ASD have trouble verbally communicating, rather the reality is that they have mild to severe challenges in back and forth but non-verbal affective engagement (sustained back and forth reciprocal social-emotional interactions). The latter represents the subcortical and core foundations that enables linguistic competence to proceed! Children however who demonstrate specific oral-motor challenges in addition to ASD (i.e., apraxia) require significant verbal modeling
Deepening back and forth social-emotional reciprocal engagement begins to signal a reduction in subcortical dominance. Subcortical dominance in your child manifests as All or Nothing, fight or flight or freeze responses (e.g., moderate tantrums or withdrawal) along with the associated stress hormones, such as an excess in cortisol and adrenaline. Instead, what we see in the opening and closing of circles of communication between you and your child and your child with peers is a clinically significant and measurable increase in prefrontal cortex or executive functioning. This includes an increased activation in the fusiform face area, which enables your child to register and process facial expressions and thus greater curiosity and calm and associated healthful hormones, such as oxytocin, endorphins and serotonin. https://www.youtube.com/watch?v=4TRL1TMwsuA&t=11s
Essentially, what I am beginning to present here to all parents is that when you are emotionally-developmentally guided to slow down and attribute purpose and meaning to your child's natural emotions and join in his/her non-self and other injurious actions this begins on a biopsychosocial level to create greater possibilities of availability for sustained engagement and integrated brain-body functioning. The latter manifests with respect to greater degrees of calm, reciprocal attachment, attunement and engagement between you and your child.
Thus, it is particularly useful if not critical to begin to think not in terms of your child's "non-compliance external acting out" or "surface behaviors" (referred to as challenging, interfering or "inappropriate behaviors", which, again, through various implemented "schedules of reinforcement" are selectively targeted to be "replaced" with a new set of so-called, "socially appropriate behaviors") but rather as adaptive neurophysiological internal regulatory responses not due to environmental conditioning (i.e., the simplistic interpretation of "appropriate vs inappropriate learned behaviors") but due to underlying constitutional challenges in neurobiologically registering, accessing processing and functioning, Over time when the foundations of calm and safety begin to emerge (i.e., greater autonomic nervous system regulation through wooing child into engagement) we begin to see more systemic and substantive adaptive function, that is, with respect to more integrated mind-brain-body functioning and thus authentic and meaningful change.
Again, this does not begin with applied behavioral analysis and its individually tailored devised schedules of reinforcement but with a dyadic (two-way, child/parent) process of deepening reciprocal attachment, attunement and engagement around your child's natural affect. (range of emotions). It is not your or your clinician's (or in many cases the Developmental pediatricians') evaluation based upon a rote checklist (often by the developmental pediatrician in a twenty minute time frame) of what standardized "social-performance behaviors" or "tasks"your child is performing or not performing, This assembly line thinking (homogeneity for test-taking purposes of one-size fits all) is not only insulting but complete and utter nonsense and must be not tepidly but on the grounds of comprehensive respectability resoundingly and dutifully rejected! Rather, what this involves is an understanding of your child's availability for social-emotional engagement and associated learning or conversely stressors, anxieties and sensory-processing challenges which interfere with social-emotional engagement and associated learning, both of which form neurophysiological (mind-brain-body) patterns and are an integral part of your child's daily autonomic nervous system functioning. The attuned Developmental therapist can begin to set or foster that availability.
The neural regulatory components of social-emotional engagement include, as previously mentioned, your child's comfortable and pleasurable face-to face processing along with auditory and vocalization cues from others during back and forth engagement. This functional-emotional developmental process in typical healthy Functional-Emotional Development (which often goes unnoticed, as it seemingly happens incidentally) contributes in helping coordinate your child's movement and mobilization for optimal action and increasing two-way (dyadic) engagement as well as rest and restoration.
Or, if your child is not available for engagement as in ASD due to underlying developmental biological constitutional factors and/or separately due to anxiety/stress factors in unhealthy child/caregiver practices, e.g., disorganized or ambivalent attachment, this frequently results in moderate to extreme fight, flight or freeze responses. The above perspectives as previously noted are rooted in developmental affect-neuroscience, prenatal, infant/toddler mental health practices and developmental psychology and forms an essential and integral part of a multi-dynamic and comprehensive Functionally Emotionally-Developmental treatment perspective (e.g., basically, how your child's neurophysiological functioning or autonomic nervous system is being regulated or dysregulated during social-emotional interactions).
What is important to understand is that a Comprehensive Developmental evidenced-based treatment perspective is Development as understood not on the surface, which is part of the soup du jour of traditional mass-produced early intervention and school based practices (e.g., "What behavior is occurring and What behavior do we want to change") but rather Development understood both neurobiologically and interpersonally (a biopsychosocial dynamic). A biopsychosocial dynamic where the primary emphasis is not given over to "having the child comply" or "compliance based models" and thus simplistic behavioral interpretations (i.e., desirable vs. undesirable behaviors - and re-training or environmentally re-conditioning your child's surface compliant behaviors) but rather with respect to a nuanced and overarching developmental affect neuroscientific view, which includes your child's heterogeneous and underlying complex sensory processing challenges in the context of social-emotional relationships which are not a set or series of reducible behaviors,
Your child's underlying complex sensory processing challenges (e.g., emotionally over-responsive or under-responsive across various sensory domains) is an integrated part of your child's developing "sense-of-self" in the context of registering, assessing and communicating back-and-forth RELATIONSHIPS with others. This consists of nuanced strengths and challenges. For example, Moderate disruptions in your child's sensory-affect-motor connections creates asynchronous connections, that is, a general disconnect in your child (or older) being able to smoothly and comfortably establish, integrate and maintain meaningful joint attending, ideation and back-and-forth emergent and sustained social engagement and communication.
Can you explain the sensory-affect-motor connection?
Our senses includes, for example, surface touch and deep touch; intimate sound of mommy's voice or peripheral sounds of cars passing by; visual and spatial processing movement in relationship to walking next to others or comfortably registering people and objects; head/body balance, stability and movement in relationship to space; taste, smell and extraordinarily important interoception, which is your child's internal bodily sensations or overall bodily awareness of biological needs, hungry, tired, thirsty and overall sense of well-being, etc. We refer to this in the field as tactile, proprioceptive, auditory, visual-spatial processing, vestibular, gustatory, olfactory and interoceptive.
Affect is your child's natural intent or range of emotions connected with his/her developing "sense of self" during simple to complex back and forth daily interactions. For example, is what your child is seeing, touching and hearing and internally feeling (interoception), pleasurable or overwhelming and aversive to him?
Executive functioning and motor planning; How does your child in a seamless or challenged manner desire something and then execute his ideas with you and others. For example, how does s/he move his body, turn, co-reference (look back and forth at you and others) and then reaches up, across or towards and take what s/he desires, that is, in accordance to his/her natural intent and synchronous integration with regards to how s/he is receiving/interpreting incoming sensory data?
This varies greatly from child to child, for example: Auditory input: a little too loud or not stimulating enough. Tactile input: a little touch too overwhelming or underwhelming - and therefore your child might seek out less or more touch, and so forth. Visual-spatial processing. "Are the objects I am seeing as I navigate my environment a little too overwhelming or if mommy is not directly my vision do I have a meltdown even though I can hear her voice?" We call the above the sensory-affect motor connection. In typical development this is more or less a smoothly coordinated and seamless part of all simple spontaneous reciprocal back and forth social-emotional engagement. In other words, how your infant/toddler's sensory-motor planning-and-emotional-social interactions are forming, day to day, a more or less cohesive and incidental orchestration (generally an unquestioned foundation) beginning in healthy secure attachment with the mother from infancy with a range of simple back and forth synchronized facial expressions to your facial expressions, a widening of the eyes, smile to smile,frown to frown, an emotionally synchronized back and forth dance of visual-motor movements with you, e,g., reaching for objects, etc. See, https://www.spdstar.org/basic/understanding-sensory-processing-disorder
However to label, as is commonly done by many special educators and other therapists, albeit at times with best intention but nonetheless extremely misguided, how your child is poorly coordinating the demands and arousal to and registration of his"sensory input" in coordination with his motor planning guided by his executive functioning (i.e., his emerging "sense of self" during engagement with others) as, "poorly learned coping strategies" or "maladaptive and inappropriate behaviors" might pass the snuff test on the surface if we decidedly use such a broad brush as to blithely ignore what lies beneath the surface.
Beneath the surface of your child's behaviors are the constitutional arousal factors necessary for engagement. This includes the basics, such as, Is your child getting enough or good sleep?, Nutritional deficiencies? Immunological deficiences? Exposure to neurotoxins? Food allergies? etc. Hyperarousal or Hypoarousal with respect to underlying sensory processing modulation and/or sensory-motor planning challenges are always core constitutional distressed factors. Also, any comorbid (concurrent) medical issues that may separately accompany an ASD diagnosis. All of these must be taken into consideration.
What cannot be emphasized enough, irrespective of the specific intervention approach, is that it is critically important for you and your clinicians to begin to form a deepening reciprocal emotional attachment. attunement and understanding of the real-communicative intent and symbolic significance (i.e.,an emotional-psychological understanding) behind your child's [surface] behaviors rather than merely looking at/labeling what precipitates the so-called, "inappropriate behaviors" (the antecedents) and what reinforces the so-called "inappropriate behaviors" (the consequences) and implementing a plan for "replacement behaviors." What the latter disposition unwittingly ends up doing in daily practice is to egregiously circumvent a Developmental understanding of the actual underlying constitutional biopsychosocial challenges associated with ASD, which include joint reciprocal meaningful engagement embodied in facial and bodily affect gestures,, simple to complex ideation and social-pragmatic verbal language/communication.
"Behaviors" are just labels, tags or descriptors of what is happening on the surface. So by you learning to go behind the surface and understand your infant/toddler or older child not as a compilation of behaviors but as a complex being (i.e., the emotional-and sensory language behind the behavior), we present to you from a comprehensive Developmental evidenced-based treatment perspective a much more nuanced picture of your child. We begin to guide you to form a relationship with your child in the present. This includes, deepening reciprocal attachment, attunement, shared social attention; shared two-way emotional problem solving (shared meaningful ideas) around your child's natural intent, movement and ideation and thus helping build the foundations for integrated functional-emotional development and not rote (mechanical) but the optimal foundation that cultivate spontaneous social-pragmatic language/communication.
Developmentalists systematically and arguably with a greater degree of "Theory of Mind" and psychosocial reflection, supported by Developmental neuroscience (i.e., "Interpersonal Neurobiology") take a step back from this superficial thinking of your child, that is, essentially as a compilation or outcome of environmentally conditioned or "poorly adapted responses" (e.g. what function the behavior is serving for your child to gain attention or to escape from a task at hand) and instead begin to guide you to look at your child from the perspective of your "whole child", that is, biologically, psychologically socially and emotionally. This translates into a comprehensive neuroscientific perspective and an adjoining Developmental evidenced-based treatment approach.
When we begin to look at your child from a dynamically interactive and whole perspective, the former, "managing, training and reconditioning your child's behaviors" so s/he can functionally begin to behave differently begins to appear not just astounding simplistic but significantly misleading. Basically, replacing "inappropriate behaviors with appropriate behaviors "is part of a zero sum or reductionist type thinking. Essentially, an etch-a-sketch notion of learning where a sequential and hierarchical series of reinforced and memorized "behaviors" or "tasks" by the child passes as the sign and insignia that your child's teacher or your clinician will proudly call, "progress." This is perfectly understandable but remarkably misleading. If you as a parent of a child who wasn't compliant and attending to very little if any executed tasks before intervention began and had few if any words you might vehemently object and retort to this premise.
"If my child, after all is no longer indulging in escaping from the task or seeking negative attention but has begun to comply with the demands of the adult led request and as well as some reduction in repetitive behaviors when properly reinforced (e.g., attending and completing the steps of a particular task(s) and this is supported by the baseline data taken at intake on his inappropriate behavior(s) and now achieved outcome(s) including new academic tasks and the production of words to communicate his needs) how can that not be viewed as anything but progress?!"
The short answer is that the brain, and especially children's brains, have an enormous degree of neuroplasticity (i.e., the ability to rapidly form new synaptic connections dependent upon epigenetic experiences) and so even when there are present moderate autism or other related developmental challenges, the acquisition of tasks by your child through behavioral reinforcement training can appear to be partially to moderately "successful" primarily by addressing one part of your child's dopamine system (i.e., training the reward response system of the brain connected to what we refer to as your child's declarative memory, essentially, " I receive X when I mechanically do this Y). Therefore, your child's ability acquire a new set of "functionally scripted", essentially, "memorized response-behaviors reinforced through positive reinforcement are not only possible but probable
However, there are tremendous clinically significant and meaningful neurobiological-psychological social differences with respect to your child acquiring a series of "functionally scripted responses" (i.e., behavioral and verbal tasks) in contrast to your child beginning to naturally regulate/co-regulate, that is, spontaneously understand and integrate autonomic function (e.g., through guided moment to moment two-way [dyadic] reciprocal emotional interactions). The core underlying Functional-Emotional Developmental capacities constitutes in both typical and non-typical development the bedrock of your child's emotional intelligence, They cannot be teased out or trained as a series of reinforced behavioral tasks, as is the core emphasis in applied behavioral analysis (ABA). This includes a critical expansion of spontaneous symbolic ideation (symbolic play) and social-pragmatic language/communication on an increased underlying foundation of homeostasis.
The latter is a guided integral part of your child's internal co-regulatory processes which addresses implicit or procedural memory which is developed in the context of spontaneous nuanced social-emotional relationships (e.g., social-emotional intelligence or the intuition of social-emotional facial, bodily vocalization cuing of what others are actually communicating at each moment). This is in contrast to declarative memory, which addresses the explicit occurrence of the event that is being spoken or acted upon by others (e.g., the outline or raw information presented and retained of the surface event/communication).
Implicit or procedural memory is synonymous with your child's intuition or connected emotional intelligence. This involves your child knowing how to recall and process nuanced exchanges during social interactions not just the objective facts or occurrence of an event but the actual nuances of social-exchanges that occur during verbal/non-verbal interactions that is,occurring beneath the raw information presented. by other co-communicators.
This means, for example, not just memorizing/internally coding and scripting and responding but how to more subtly read, socially proactively or spontaneously interact in new or novel situations and events (e.g., reading and processing non-verbal facial and bodily cues and thus the actual meanings of what the other person is conveying by the inflection, manner, tone of their voice or what is referred to as prosody rather than flatly responding on external cue or prompt mechanically in an over generalized manner). In other words, intuitively understanding what is actually rather than literally being conveyed. For example, if I say, "Oh ! What Joy! Am I literally expressing my state of Joy? Perhaps. Or, am I saying with perhaps an underlying sarcasm or a sardonic or deprecating tone "Oh! What Joy!" . Conversely, If I say, "He suddenly died!" Am I truly upset or grief stricken or do I have a quiet smiling or resounding grin which is obviously conveyed by my bodily and facial affect (demeanor) and tone of voice?
(Or visually, "If the sign at the entrance of the park says, "Park is closed when snow covered!" Does this mean I do not enter regardless whether the park is entirely snow covered with several inches of snow throughout exactly the same as if there are several places throughout the park minuscule patches of snow or larges mounds of snow that have been plowed by off to the side?)
When others speak we hear -and-respond not just to the objective fact (the literal transcription) of the words being spoken but the meaning of what is actually being conveyed by the affective or emotional tone of the other speaker(s) voice. This is considered the non-verbal or affective components of language, tone of voice, inflection, facial gestures and bodily posture. Again, the latter comprises 93% of spoken language/communication and young children through adulthood with ASD often have the greatest difficulty in assimilating, registering, understanding, processing and responding in kind not to the literal transcription of the words being communicated but what is actually being communicated!
There are fundamental biopsychosocial core differences between your child learning to respond on cue (which is "functional scripting" or "memorization", e.g., your child trained to do "X" upon seeing "X" ) and your child learning to think through the language and integrate his/her perceptions (senses which includes auditory, tactile, visual-spatial, etc.) built step by step upon addressing his/her underlying functional emotional-developmental capacities which creates the necessary conditions for continuous spontaneous relating and engaging and associated cognitive and social pragmatic language skills, as we address his/her individual sensory modulation processing differences in the context of child/primary caregiver and peer relationships. (see Research section at my website, neilsamuelsdevtherapy.com )
In reality what many clinicians, teachers and behaviorists in general are not somewhat but entirely failing to communicate to you, more specifically, take the time to become developmentally educated, understand, appreciate, and address in-depth are your child's deeper underlying functional-emotional developmental core capacities and adjoining fine tune sensory processing differences which constitutionally helps regulate social-emotional and cognitive milestones and social-pragmatic language (i.e., a biopsychosocial perspective) rather than as often the case proudly and smugly resting reassured by an extraordinarily superficial or circumscribed focus on determining the [surface] function the "problem behaviors" are serving for your child and training your child to replace one set of "maladaptive behaviors" with another set of surface "more adaptive behaviors."
The great lacuna, the egregious blind spot of many of those who proudly swear and would die by, "ABA the only scientifically replicated/proven behavioral methodology" is that these proud accomplishments of conditioning your child to positively respond (i.e., essentially, if we delve a bit deeper, how your child looks to others and is newly responding on the surface) is often unfortunately without once the courage to pause, slow down and take the time to Developmentally understand and address your child's actual underlying core functional emotional developmental differences that make connecting, engaging and communicating challenging for your child in the first place.
In fact, it is not about your child learning a series of "more adaptive behaviors" or "appropriate replacement behaviors." This is at first blush a very convincing but alas deceptive and arguably a horrendously superficial dumb-down and reductionist narrative which attempts to adequately manage (or transform) your child's surface responses but and this cannot be underscored enough without addressing the social, symbolic and emotional architecture beneath that make authentic and sustained social-pragmatic language and engagement possible!
The Developmental facts supported by infant/child mental health practices, developmental psychotherapy and neuroscience is that it begins with you the parents (as well as the special educators and therapists working with your child) systematically learning how to understand and woo your child into a back and forth relationship and engage your child's processing differences in order to help your child cultivate mind-brain-body meaningful and integrated Functional-Emotional Development rather than"on-command" surface-compliant behavioral responses. The latter can indeed satisfy a certain school standardized testing-protocol as they are blindly and egregiously marked on a checklist by practitioners as "progress achieved" but leaves nine-tenths of your child in the arrears as the clinicians fail to address the core challenges which are associated with ASD: Spontaneous thinking, relating and communicating which can neither be programmed or behaviorally reinforced by a series of successfully achieved "memorized tasks."
It is not reverting back to new and improved "memorized scripts" however, seemingly "more adaptive" (e.g., your child is now able on query or command execute steps required of a task or comply with a behavior) but rather your child being and becoming more mindfully present and proactively responding (that is, taking the time, slowing down and comfortably registering, facially, tonally affectively) to what is actually being communicated by the other person and proactively respond in kind. In other words, your child thinking-through-the language and thus beginning to integrate his/her perceptions and subsequently in novel fashion being able to meaningfully relate, engage and socially pragmatically communicate, which needs to stand as the target rather than the false-positive (or premature) achievement of your child or older reverting to or relying upon scripts.
Your child's spontaneous reciprocal back and forth desire to stay in engagement and connect with you is part of a more normative pr typical and fully integrated biopsychosocial dynamic and is one of the core primary challenges of children with autism spectrum challenges. It is also happens, during healthy typical development, to be one of the most basic core foundations, opening and closing emotional-social circles of communication, that infants and primary caregivers continuously exchange without second thought during typical healthy development.
First rule: Purposeful and meaningful engagement does not and cannot ever come from your child's surface-trained or newly acquired memorization of tasks (e.g., a list of newly acquired behavioral, academic tasks or skills). Rather, it must come from the biopsychosocial integration of your child's brain-body-nervous system (integrated cortical and subcortical functioning, across space, in movement and in relationship to others). This is orchestrated by and through your child's executive functioning driven by a foundation of subcortical regulation guided by engagement, specifically during pleasurable but challenging back-and-forth two-way social-emotional problem solving scenarios between you and your child.
For example: Parent plays dumb and get's ball child is playing with suddenly stuck under the couch and at the same moment empathizes with child's upset; parent goes down to the child's level and slowly, sincerely and with variation of inflexion in her voice articulates "Oh no! There?!" Stuck! Uh oh! Out!, etc. As we go down to the child's level and partner with the child's "dilemma" and use affect facial and bodily language along with stretched out, varied and inflected vocalizations we begin to emotionally join with the child and the child begins to join with us. This begins with simple to increasingly complex back and forth reciprocal two-way emotional problem solving engagement scenarios.
Decades of evidenced based research on neuroplasticity with regards to rapidly expanded synaptic connections with the establishment of the functional emotional developmental milestones around child/primary caregiver deepening affect reciprocal attachment and attunement - in moment to moment joint frames of social back and forth emotional problem solving support this.
Can you elaborate on executive functioning?
Executive functioning occupies the largest part of the brain. It is guided toward optimal functioning not by training your child's surface acquisition (memorization) of declarative memory of dopamine "reward response-behaviors" but around emotionally deepened engagement and synchronization with your child IN FIRST PERSON. When we are addressing core executive functioning we are looking directly at your child's underlying emotional ability to form simple to complex back and forth connections with you. It is this which constitutes his/her healthy emerging sense of safety and internal regulation and sense of self" with others.
In biopsychosocail based developmental challenges as in ASD, this involves your child's sensory domains, e.g., orientation in movement in and through space, visual-spatial processing, auditory, tactile, etc., connected to and with execution of his/her motor planning. These are directly connected to subcortical functioning or implicit procedural memory. This is expressed through social-emotional (affective) non-verbal and verbal back and forth emotional referencing-and-communication with others during interactions. The completion of a checklist of verbal and "object-tasks" separates the emotional elements which otherwise supports and integrates subcortical and executive functioning, The former compartmentalizes it. It is not compartmentalization we want (e.g., a series of rote or mechanically accomplished generalized tasks) but rather building the underlying foundations that support your child's emerging "sense of self" in relationship to others. Specifically, your child's "sense-of-self" in integration with how s/he spontaneously and intuitively daily negotiates and navigate the nuances and intricacies of social-emotional communication with others.
A fundamental and non-negotiable part of executive functioning is your child's sensory-emotional modulation processing differences, which must be understood, honored, respected and joined-in with as an integral part of -back-and-forth engagement in order to meaningfully begin to engage with your child rather than as is common shaped/molded by the clinician to present an adaptive make-do cosmetic appearance on the outside.
Executive functioning is responsible for how your child takes in, registers, understands interprets information-and-executes back and forth two-way emotional-social interactions with others. A simple example: Your child looks and desires a toy across the room. S/he thinks,"I see it. I want it. How am I going to get it?" This is not simply a matter of "response-compliance" to the "demands of the task" or a focus on "object-task completion" (or learning a "new behavior") but rather the beginning of the most basic integral part (biopsychosocial dynamic) of simple to complex back and forth social-emotional communication.
This involves addressing your infant, toddler or older child's preverbal self-decision making process to feel comfortable and secure in wanting to SPONTANEOUSLY maintain social-emotional engagement with you and others (i.e., your child looking at favorite toy, turning to you, pointing back to toy and then you again, and you acknowledging each step, being present at each step and guiding each step ). This then increasingly, in turn, begins to further build a more internally secure and heterogeneous (i.e., neurologically diversified) foundation for your child's Functional-Emotional Developmental capacities for greater curiosity and joy with expanded gestures and verbalization for even more complex social relating and engaging. This must be built from the ground-up. Thus, this begins by attributing both purpose and meaning at every turn to your child's present interests and understanding and adjusting accordingly and engaging his/her sensory-affect-modulation differences.
However, beginning to understand and engage this deepening reciprocal attachment, attunement and shared-perspective joint meaning making process with and from the level of your child is unfortunately the exception, not the rule. When special educators and therapists in early intervention and schools typically target challenges and subsequently define targeted outcomes as "successful" for your child they are often essentially targeting task-completion and not the vast sub terrain beneath. It is not about task completion it is about your child's understanding with respect to registering, organizing and processing interactions between you and others.
For example, in compliance with status quo institutional practice, labeling and targeting the child (or older) "interfering or undesirable behaviors" and re-training them to act-and appear as "increasing desirable behaviors/" What is generally largely unknown to parents is that this (surface reductionist thinking, depicted in terms of "interfering behaviors vs. appropriate behaviors" ) circumvents the larger, more layered and complex picture of your child's challenges, which again is about processing. This is partially focused on out of misunderstanding with respect to what functional-emotional developmental challenges actually entail but moreover it serves the purposes of satisfying the quick or efficient itemized demands of the test-taking procedures that in turn serve as a checkpoint gate or standard with respect to the large numbers of children receiving services and thus the continuation of state, local and grant funding to fund these services.
What in fact are not being addressed or barely addressed are the core challenges. They are not addressing core-underlying executive functioning in terms of your child's ability to maintain spontaneous back and forth social-emotional engagement. The latter includes surface cognitive tasks (e.g., "touch blue" show me Red, point to boy upon query, etc) marked down on an itemized checklist. Tragically, when this is done your child's developing "sense of self" along with his emotional-sensory sensory modulation processing differences that make engaging challenging and is in fact the core issues for children diagnosed with ASD is essentially placed in the garbage heap or put on indefinite hold, as they are intentionally or unintentionally entirely removed from the equation.
From an overarching neuroscientific perspective. a focus on academic checklist or "performance-tasks" remove the reality and core challenges of the biopsychosocial complexity of your child's spontaneous social-emotional understanding of the subtle emotional cues of others and his/her proactive responsive interactions in favor of your practitioner's focus (and the cookie cutter cost savings of the majority of "efficient school based programs") of having your child learning to be submissive or compliant to the "adult" and the "object demands of the task(s)", specifically, learning and often robotically to memorize tasks on cue which then can be marked as "success."
From a Functional- emotional DEVELOPMENTAL perspective your child's developing sense-of-self can only be fully experienced through incidental intimate nuanced back and forth affect gestural and verbal social interactions. His sense-of-self is critical to his spontaneous understanding and engagement (a core part of executive functioning). It integrates all skill sets in an emotional-developmentally meaningful fashion should not ever be diminished let alone wittingly or unwittingly removed (disassociated) as the focus mistakenly and egregiously turns to "replacement behabiors" or "object-task completions."
The ability for your child to read subtle emotional cues (facially, bodily and verbally, that is, intonation of voice and intent) and to respond in kind is a function of your child's interpretative faculties or core executive functioning . We also refer to this as "Theory of Mind" (i.e., the ability to slow down and empathize from the perspective of others what they are actually facially bodily and tonally and verbally communicating). This identification and shared perspective-taking [attending, relating and engaging] is part of the utilization of the mirror neuron system of the brain.
What might seem a bit odd but is absolutely and unequivocally true is that parents and clinicians must equally learn how to properly utilize "Theory of Mind." They do this by slowing down, understanding, entering and engaging the language, movement and natural intent (range of emotions) of their child. It is interpersonal and dynamic. This cannot ever be viewed in a caricature manner. In other words, a check-list, in a reductionist fashion (e.g., Do A, B, C, then X, Y Z). Fortunately Human intelligence is not a set of codes or instructions memorized on cue. However, this is what behavioral-based methodologies are almost exclusively focused on.
Despite the degree of ire and outrage by many behaviorists and other professionals in the field who would tend to become apoplectic at my insinuations here of ABA dismissing or disemboweling the child's "sense-of-self" by focusing on re-training the function of the child's (or older) "interfering or problematic behaviors" and implementing a trajectory of reinforced positive task behaviors ("replacement behaviors") as pure and utter rubbish, I and colleagues are sad to say this is tragically and unavoidably the fact!
Functional-Emotional Developmental perspective and evidenced based treatment approaches, such as DIR/Floortime, honors and respects and places your child's developing affective sense-of self along with his/her heterogeneous sensory modulation challenges at the center-and-in the context of RELATIONSHIPS. The child (or older) developing sense of self in relationship to other once properly addressed (i.e., deepening reciprocal attachment and attunement, honoring and addressing sensory processing differences) begins to measurably result in nuanced back and forth social engagement, complex ideation and social-pragmatic language. Behaviors do indeed change but they they change not because they are being selectively targeted and focused upon. They change incidentally, that is, in the context of child's internally felt-secure engaging and relating around his/her natural intent or range of affective interactions. The latter is backed up by several decades of exhaustive research in infant and childhood mental health, developmental play therapy and the neurosciences, see, icdll.com
What is generally not realized from an autonomic nervous system perspective (e.g., social-emotional engagement regulating sympathetic responses) is when your child is being directed to "comply to the demands of the task" this disassociates or separates him (numb or immobilize him) from spontaneous social-emotional engagement in favor of having him/her complete, under the cynicism of cost-efficiency and "science", a series of executed discrete and generalized behaviors . While this might be a magnificent way of satisfying a checklist of goal tasks-and-behaviors desired and evincing success to parents, it in fact egregiously places your child's emerging natural "sense-of-self" in a back seat or subordinate position. The bottom on line on and message to hundreds of families I have worked and therapists I have observed is often this,"Your child does not have to learn to sit still and attend rather your therapist needs to learn to get up and move and follow him/her where s/he is."
Again, the focus in applied behavioral analysis methodologies in general is on "object-task completions" rather than self-with-other through RELATIONSHIPS, which consists of a complex dynamic and necessary dance of nuanced back and forth social-emotional affective interactions. The neurophsyiological foundations of emotional-developmental interactions, where your child's core sense of self (executive functioning) in synchronization to your co-regulating engagement to his/her sensory processing differences, plays a central role an orchestrating role in integrating cortical and subcortical functioning (i.e., sympathetic or All or Nothing reactions). Concurrently, it plays a central role in the integration of not memorization through reinforcement of adaptive replacement behaviors but spontaneous and thus meaningful integration of social-emotional-cognitive and social pragmatic language skills. A focus on understanding neurophysiological differences and facilitating them in Relationships, by cultivating a foundation of secure based reciprocal attachment, attunement and engagement around the child (or older) natural developing affective sense of self is, again, unfortunately, generally either not understood or desired amongst most practitioners in the field.
It is conveniently assumed (and not by coincidence as it represents expeditious and cost-effective strategy that the child, especially a child with autism spectrum challenges needs to be "re-directed to comply with the demands-of the task" in order to get into a position to receptively begin to understand, learn and use language properly and thus the focus is on a checklist series of peer appropriate tasks.
For example, The focus is on verbal-behavioral shaping, modeling, and compliance to word and object task completions rather than on dyadic-affect regulation, e.g., opening and closing circles of communication (social-emotional engagement) where the only "authentic task", if you will, is "relating-thinking-and communicating" around your child's natural intent and desire to spontaneously stay in engagement (e.g., to read the social and verbal cues of others and proactively respond from a core sense-of-self rather than rote memorization). This is where authentic social pragmatic language development significantly and meaningfully proceeds. That is, to say specifically upon the bedrock of spontaneous nuanced social-emotional exchanges. This and this alone should be the primary focus of all intervention.
I am reminded by the words of the late internationally acclaimed child psychiatrist Dr, Stanley Greenspan who pointed out that the child's receptive understanding of "cause and effect"are not first learned, as Jean Piaget, the great developmental psychologist once believed, by the "infant pushing or pulling the string on a bell and hearing the sound return" (in other words, on detached objects) but rather first and foremost by "Pulling on the mother's heart strings. A smile begets a smile. A frown, a frown." Thus, authentic receptive language comprehension (the ability of the infant to read social-emotional cues) and thus adjoinedly the associated intuitive learning of "cause-and-effect" is formally initially learned by the infant through the reciprocal back and forth emotional-social facial and bodily gestural play/reciprocity (e.g., seamlessly social-emotionally read, registered and proactively responded to affect facial, bodily and vocalization/intonation cues between parent and child).
It is NOT first on detached or disassociated "word/label and object-task completions" that the infant learns this (or adjoinedly, the toddler and older with developmental challenges). It is, precisely, social-emotional relatedness that children on the spectrum have difficulty proactively assessing, registering/reading, maintaining and responding to (and the accompanied voluminous research based evidenced, neurophysiological scientific underpinnings that supports these finding- see, e.g., The Polyvagal Theory, S. Porges). It is a focus on people rather than on unrelated queries and object-task completions that needs to be the primary focus of our interventions (regardless, of time-consuming and cost inefficient it may seem at first blush. In reality it is quite the opposite. But paradigmatic shifts usually require longer periods of time to be adequately understood let alone become more normalized or common practice).
Social-emotional engagement once regulated through simple then an increasingly complex flow of a range of expanding back and forth parent/child interactions begins to allow for a neurophysiological cascade of events (i.e., a hierarchical re-organization of your child's sympathetic and parasympathetic nervous system) and correspondingly on a social-emotional level, the developmental foundations for the advancement of receptive and expressive language to occur (e.g., an increased regulation of the flow of ideas and the pragmatic social use of utterances, words to phrases). What in great significant part accompanies these events (i.e., functional-emotional developmental milestones) is that there becomes less sympathetic fight, flight or freeze responses by your child (e.g., less ALL or NOTHING reactions to events). This is what we see with children particularly on the spectrum (e.g., a formerly overactive limbic system, amygdala, hypothalamus, pituitary, adrenal glands begin to quiet down, correspondingly more regulated and greater optimal arousal or homeostasis for engagement ensues). In other words, on a daily interactive level with you and others there are measurable increases in available and connected internal regulation-and-proactive social-emotional exchanges (i.e., increases in prefrontal cortex or core executive functioning and less subcortical dominance).
Unfortunately, your child's trained memorization on isolated to general task completion and verbal-behavioral modeling successfully resulting in him/her able to comply on query or demand to a positive checklist of completed surface-schematic skills in fact often serves to reinforce a certain set of performance (memorized) based responses but also since these are schedules of reinforcement of your child's surface based responses and not internally regulated and integrated through back and forth social-emotional interactions around your child's developing "sense-of-self" with others, an underlying hypervigilance accompanies your child's engagement.
For example, he or she needs to resort to new trained memorized task-completions (e.g., defined by the clinician as "more adaptive" but essentially are new "functionally scripted responses") and thus a move away rather than towards neurophsyiological integration (e.g., child initiated and sustained spontaneous back and forth interactions; reading novel cues, affective gestures, shifting intonation of voice/meaning of the other speaker; understanding speaker intent rather than depending upon highly contextualized cue from memory, A means A, B means B, C means C and so forth; unfortunately this is not how the dynamics of social-emotional engagement transpires either objectively or intuitively understood and registered). Nonetheless, this happily serves as the soup du jour that guides most traditional early intervention and school based programs mainly because it the "surface data of the procured new responses" of the child can be easily replicated
Essentially, in the latter your child is"learning" once s/he performs to the "demands of the task" (e.g., gives or supplies the correct answer or response to the adult query, irrespective of however unconnected from his natural affective interests or intent, such as "Look at me", Touch nose" or "Point to blue", etc.) s/he will get reinforced by a reward (e.g., a cookie, Ipad or a meaningless and ad nauseam, "Good Job")! Similarly, your child mechanically learns to repeat simple to more complex commands (e.g.,"I want ball", "Give me ball" etc ). (The same follows for others parts of speech as well. Again, unfortunately this is not how language and communication transpires nor should it be taught in such a simplistic, mechanical and rigid manner.)
The goal is that your child will begin to generalize these skills to other contexts. However, the focus here is on your child's surface memorization or rote performance to the demands of the task, verbal or otherwise (i.e., "I say X when X happens"). "I say X when X happens" is not the same thing as your child being able to regulate/co-regulate social interactions, that is, specifically and most basically, proactively engaging and attending to the novel cues of the other speakers. This involves much, much more than training surface verbal responses or behaviors. Core emotional regulation and engagement is not the same thing as child surface trained responses!
Once the "targeted outcome" is achieved, e.g., "child compliance to the demands of the adult-directed task", your child (because of the paired reinforcer to the successful completion of the task) is now more habitually inclined to perform it again and again and again... Now, what may be understandably confusing to parents here is that the above may look like the same thing as "engaging" or may seem to lead to purposeful engagement (e.g., after all, you might reasonably ask, "Isn't my child now following commands, performing positive tasks whereas before s/he wasn't able to and by definition beginning to 'purposefully engage?''). However, the answer is not a milquetoast but a resounding No!
Compliance to the demands of a task or supplying the correct answers on emotion-less (sterile) commanded or mechanical cue to queries is reinforcement of your child's surface memorization skills (and not the complex and heterogeneous (individual) neurophysiological organization beneath which in fact makes sustained, complex and novel engagement difficult) actually leaves in a state of disorganization or disassociation your child's sense-of-emotional self in back and forth engagement. Memorization and even generalization of surface based skills is not, we repeat not, the same activity as your child engaged in non-directed, warm spontaneous emotional-social back and forth relating, engaging and thinking with the other person. Nor does the former lead to the latter, that is, engagement mechanically broken down and taught in steps (e.g., Do A, then B, then C).
It is addressing your child's underlying neurophsyiologically complex Developmental core capacites to be able to read and be present in situation to situation and comfortably register and interpret and respond to the subtle facial and bodily language of the other person (or speakers) through sustained regulated/co-regulated non-verbal-and verbal novel social interactions. which is our goal. This as a critical and non-negotiable necessity includes optimal sensory arousal and increased mind-brain-body integration around a spontaneous and assertive emotive (or affective) sense of self -with-others in and through novel situations. It is this which represents the core challenges in ASD.
The more traditional behavioral-based approach (ABA) is an adult behavioral reinforced demand-compliance based system. It is essentially a mechanical closed-ended system that provides an endless procession of external reinforcers (e.g.,, a cookie, a favorite toy, Ipad, or a robotic verbal,"Good Job") for the child (or older) complying with or completing correctly "adult directed tasks." It is not a comprehensive Developmental evidenced system that addresses from the get-go -and so crucially from perspective of core executive functioning - your child's heterogeneous functional emotional-developmental processing differences and emerging "sense-of-self. " The latter is child initiated or driven by your child's spontaneous curiosity and natural desire to want to interact and maintain novel social reciprocal engagement with you simply for the joy, curiosity and desire to do so with absolutely no external or concretely proffered reward or robotic verbal reinforcement except for the joy and desire of the engagement itself.
When clinically significant and meaningful developmental engagement comes from your child, his/her whole body, his/her whole self (biopsychosocial) is an integral part of the social-emotional reciprocal engagement/interactions. However, when your child is directed to perform a "series of tasks" by or on adult led command, what is often disturbingly referred to as "under adult-instructional control" (and over time, the so-called claim to "great success" "successfully" doesn't require external reinforcement but is self-reinforced by a "functional memorization") it is still, nonetheless, a re-enforcement of a type of disassociation, that is, a stifling or regression and in fact an abandonment of your child's authentic engagement (spontaneously engaging) in first person from an internally secure foundation and integrated manner.
In other words, your child not more or less passively responding from perspective of the acquisition of better "replacement" or "adaptive behaviors" but from a comprehensive Developmental perspective, authentic adaptability, that is, the neurophysiological adaptability of knowing how to adjust moment-to-moment and spontaneously emotionally engage with others in innumerable ways, specifically outside of one or highly restrictive specific contexts and with an increasingly active and diverse rather than a passive or flat affective demeanor!
Compliance to a task neither equals nor is it synonymous with social-emotional engagement. It is Relationships, engaging, relating and social-pragmatic communicating that are the primary core challenges presented in ASD. The simple to complex foundations of maintained and meaningful spontaneous engagement must either come from your child's executive functioning (i.e., whole self) otherwise it is essentially a series of reinforced performance-behaviors on cue (i.e. ,"memorization") where tasks are learned in a discrete or generalized manner, but in any event in a highly contextualized or compartmentalized manner. Basically, your child will be able to better adaptively"functionally script" in different situations but not spontaneously engage (i.e. read facial affect and bodily cues and understand what is being communicated and proactively respond in novel ways).
From a Developmental perspective the "reward" for the child is the engagement itself and not any other external re-enforcement1 Your child's ability to register and co-regulate/regulate with you rests upon the most simple and important things of all: The pleasure and joy of the back and forth interaction (i.e., opening and closing circles of communication)which then leads your child to come back for more engagement - or even better handle more mishaps because s/he is feeling the psychic weight, ground and joy of his/her being!! How about that? It is actually pleasurable to engage not because your child is being reinforced by an external reward for compliance! Forgive me for repeating but the following needs to be thoroughly understood: Compliance to the demands of the task - even when your child selects the "the task" (the SD, discriminatory stimulus) - which is common and behaviorists call natural environment approach - is not true engagement when the focus is on "task completion" rather than from a biopsychosocial perspective, PROCESS and the dynamics of interaction. The key word is PROCESS (or in Lev Vygotsky, terms, joint co-narrative meaning-making which is much more messy, fluid and layered and involves your child's whole-self rather than your child as a subset of "object-task completions" Unfortunately, this presents in actual practice in the field as a "novel idea"but should not and needs to be consistently communicated by special educators and therapists to parents!
There is a tremendous difference between having your child's memory (hippocampus) trained. For example, the adult demonstrating a task and breaking it down into small steps under the presumption that there are core [cognitive] deficits in your child's attention or receptive understanding, "First we do A, then B then C, ." and not breaking down a task (e.g., Take the ball. Put ball on table, Give ball to mom) in the first place. This is not because we are being therapeutically negligent but rather because of a more systemic social-emotional developmental understanding of what often lies beneath what unquestionably appears to be deficits in your child's receptive cognitive understanding but are actually challenges in autonomically regulating/co-regulating back and forth social-engagement (e.g., your child being able with optimal arousal to comfortably attend, register, regulate and integrate through his/her senses, auditory, visual spatial, tactile, etc. what the other person is communicating).
There is an existential and extremely important difference here between your child,"Not understanding how to execute the steps of a task" and, from a comprehensive Functional-Emotional Developmental perspective (in fact) your child NOT feeling comfortable in his/her body in back and forth emotional-social engagement with the other person to initiate and maintain simple to more complex engagement, which is then often mistakenly translated by practitioners as, "deficits in your child's receptive understanding." In the vast majority of cases, this could not be further from the truth and remains a huge problem which is misunderstood or insufficiently addressed in the field. Simply, more often than not, it is the act of maintaining simple back and forth engagement by your child or older (let alone sustained back and forth affect reciprocal engagement) that is extremely uncomfortable and even painful for him/her but mistakenly and egregiously interpreted as "deficits in your child's receptive understanding"!
This is where core executive functioning comes in. Essentially, the steps of any engagement begin to become more tacitly or intuitively understood by your child not once your child's so-called, "deficits in attention and receptive understanding" become sufficiently (behaviorally) re-trained (i.e., selective antecedents or consequences reinforced resulting in memorized "replacement behaviors", which unwittingly and egregiously separates the task from the person) but rather once your child is able to more comfortably and spontaneously able to sustain the desire to engage in accordance to his/her natural intent, that is to say, as s/he becomes able to comfortably regulate (open and close) many circles of back and forth social-emotional communication with you and others.
For example, looking as his/interest at an object with you, he then looking back at you, taking cognizance of your interest together with him - which is an instance of meaningful shared/joint attention, then you taking the lead and adding an affectivce variation, for example, dramatizing the character or animal figure or unexpectedly putting the object on top of your head, etc. Essentially, what is being conveyed and meaningfully registered is the pleasure of your joint shared affective engagement, which more seamlessly involves your child's natural developmental capacity to begin to register and sustain yours and others facial and bodily affect cues, intonation, inflexion, stress and rhythm of your voice,
What is not generally recognized by many practitioners in the field (as it is either to subtle or not in the general field manual) is that once social-emotional engagement comes online (e.g., sensory processing challenges become more integrated or regulated) through two-way back and forth emotional problem in accordance to your child's unique Developmental profile then, your child's so-called, "deficits in attention and receptive understanding" suddenly begin to show remarkable progress. What I am stating here needs to be more thoroughly understood among many practitioners:
As your child's "emotional-social engagement" (i.e., spontaneous back and forth emotional-social signaling, facial affect and somatic gesturing; ability to register and interpret more comfortably in his/her senses,, regulated/co-regulated emotional signalling, which involves minute nuances of back and forth social-emotional regulation/co-regulation) begins to become increasingly more pleasurable, comfortable, enjoyable, spontaneous, manageable and reciprocal for your child, so then begins to vanish or be considerably reduced what formerly appeared to have been well-established through prior evaluation unquestioned deficits or global delays in your child's receptive cognitive understanding. They begin to become more clinically significantly and meaningfully demonstrated.
Essentially, we take a sledge hammer and mold your child into rote (memorized) performances of task-compliance good-job little job task-doers while what is needed is a Functional-Emotional Developmental understanding or play empathy and wooing. Because so many parents, educators and therapists do not know how to slow down, empathically attune, listen and engage their child's world, their processing differences, this is often not seen as the tremendous importance it is in establishing/re-establishing connections on many levels.
There is an enormous almost incalculable amount of information that is exchanged in back and forth co-emotional signaling (e.g., deepening reciprocal affective attachment; guided child/parent exchanges in reciprocal moment to moment facial and somatic gestures; pause, rhythm, inflexion/intonation of voice, etc.) during the most basic social emotional engagement, which clinicians must guide parents in understanding and engaging.
Genuine engagement is much, much more nuanced and complex than then caricature that is, dare I say, almost mindlessly passed off as "child compliance" (e.g., child complying to a series of adult-directed single or sequential based tasks or actions), which then is sadly (at the risk of stirring the ire of many working in the field with children or older with ASD or other developmental challenges) deceptively passed off as "Scientifically proven." Completing a series of tasks on a checklist (i.e., generally what too often happens in early intervention and school) is a horrible caricature of what truly authentic, purposeful, meaningful, expansive and integrated Developmental engagement actually is and thus fails to address the core challenges with children with autism spectrum challenges which involves at the core spontaneous and multi-nuanced affective social circles of thinking- relating-and-engaging.
Wait a minute! If my child is being trained step by step to follow commands is this not a form of purposeful and meaningful engaging? Will this not help increase his attention span and ability to initiate and begin stay in purposeful and meaningful engagement longer?
No. A toddler or older who is trained to follow adult instructions on command is a child not engaging in a purposeful and meaningful manner. Rather when your child is directed (e.g.,complete a checklist of tasks, as is written into your child's IFSP and IEP goals) s/he is merely learning to fulfill the prerequisites or demands of the adult directed tasks (i.e., imitating and completing the individual or generalized tasks in a highly compartmentalized manner) and not pleasurably and spontaneously learning how in a whole integrated and meaningful way (e.g., core sense of spontaneous and novel assertiveness through the nuances of the process of moment to moment social-engagement) to engage with you and his/her environment. S/he is not initiating and staying in engagement in a longer, purposeful and meaningful manner from his/her own healthy emerging developing core "sense of self" but rather behaviorally-mechanically responding as per disseminated instructions, under "adult-instructional control", e.g., "I do X when X happens." Or, "I say, 'Y' when 'Y' happens" rather than acting in a comfortable and optimal arousal in novel decision making processes in relationship to others.
In order to adequately begin to illustrate this, it is important to first look at what typical infant/toddler development is from the start as each of the typical functional-emotional developmental milestones need to be addressed (see, http://www.icdl.com/dir/fedcs) but are either overlooked or more often addressed in an ad hoc or extraordinary superficial, robotic or schematized manner just enough for the child to complete the outline, schematic or skeleton of the task/engagement, that is specifically to satisfy the testing protocol checklist (i.e., memorize the individual or general task demand that can be conveniently marked on a checklist to demonstrate the child is making "progress").
One of the first critical functional-emotional developmental milestones that emerges in infant/toddler development is the child learning to take in the world around him/her, to orientate/regulate his/her sense,s movement and what becomes affectively (emotionally) imbued interactions with his/her primary caregivers (i.e., feeling-and-then expanding his/her simple comfortable, secure and exploratory assertive "sense of self" in relationship to his/her immediate surrounding environment with mum and dad). Mum and dad through playful wooing seamlessly acts as the co-regulation for the child's internal regulation. This cannot be underscored enough! Moreover, this cannot neither be delivered on command, for example, taught as discrete units of behavior , nor trained (e.g., artificially misguided, as is common hat, deconstructed, broken down and taught as a series of tasks). Nonetheless, for purposes of what too often and regrettably has passed the snuff test of "scientific proven measurement."
In other words, dyadic (two-way) engagement is stripped apart, disconnected and taught as a series of imitated discrete units or tasks and thus disconnected or disassociated from Developmentally integrated (social-emotional nuanced) warm back and forth engagement that naturally occurs in human deepening reciprocal attachment and emotional attunement. The latter needs to be re-kindled with your toddler or older child rather than as is typically and traditionally done hammered out as a series of "tasks" that the child must learn under an often gross distortion and false presumption of the "Only scientific methodology of applied behavioral analysis, ABA."
From a Developmental evidenced based treatment perspective, the pleasure of and interaction with engagement must be spontaneously emotionally-felt in and through your child's interpretative senses (i.e., movement, touch, taste, smell, hearing, seeing). As your infant/toddler begins to develop this inchoate foundation begins to further neurophysiologically connect and expand (i.e., an increased unique interpretation and integration of your child's senses) connected to and with your child's emerging "sense-of -self." This starts in simple to increasingly complex affect reciprocal back and forth regulated/co-regulated circles of communication with you and others. It is this which represents the foundations of true or integrated engagement (i.e., spontaneous, meaningful and sustained joint-attention).
The above might sound quite complicated but how it actual begins in typical development is quite seamless or incidental and it is these core challenges that we are addressing with your child with ASD or other related Developmental challenges. Let us take the following example, Peek-a-boo. When parents without second thought begin to play peek-a-boo with their baby, what do we see? We see the widening of the eyes; the changing of a frown to a smile to a surprised look to a more anticipated nuanced and a wider smile and look and so forth.
The parent does not say to her baby, "Look at me", followed by "Good Job!" A widening of the eyes, is met with a widening of the eyes, slight back and forth smiles, frowns, then wider smiles and so forth. These multitudinous incidental back and forth interactions are the simplest of social relating and engaging (i.e., meaningful joint attending). Notably, this does not result in a single let alone a repetitive ad nauseam ,"Good job!" Throughout many related interactions affective engagements it is in the exploration and pleasure and the playful (and increasingly playful struggle, connections, breaks, co-repairs ) of many back and forth engagements which is self-reinforcing (symbolically and literally self-with-other co-narrative meaning-making) without having to supply a disassociated, mechanical or external concrete reinforcer (e.g., where the child learns to perform on command, receives a mechanical good job and/or a toy, ipad, or cookies as a pacifier).
So, there is a huge difference between your child engaging when it comes from his own natural intent or desire without any specific consequence or reward - except his own spontaneous intent, desire and joy to communicate and engage with you and others in contrast to task-prompted to follow commands in order to obtain a desired consequence/reward by performing an action. Trained memory of behaviors or actions is not authentic engagement. Your child being trained to respond on command is not the same thing as your child's spontaneous affective demeanor and desire to want to stay in engagement!
In the first instance or in an integrated developmentally meaningful and evidenced based approach, there is the ALL critical focus on meaningfully guiding primary caregivers on the re-connectivity between your child's executive functioning ("sense of self") and his/her affect-sensory motor connections. For example: "I see it, I want it, How am I going to get it?" and the associated co-emotional-social referencing from your child's emerging healthy "sense of self with others" that is involved in these interactions (e.g., spontaneously pointing to object pointing to self pointing to others, then back to object desired in a continuous flow). The latter begins by each therapist guiding you as a parent to woo or draw your child into back and forth engagement - around your child's natural intent or affect as well at the same time, once engagement is established, confronting or becoming a "playful obstruction" for purposes of deepening and extending your child's engagement with you in a meaningful and pragmatic manner up the functional-emotional developmental ladder.
Now, as stated previously, in typical development, this more or less happens effortlessly or incidentally in seamless and countless child/parent interactions. However, here what we are doing is working to re-establish this very basic core connection that represents the beginning of many spontaneous reciprocal interactions based upon your child's Developmental psychological and affect sensory motor processing profile in direct relationship to your affective engagement. In the process you are critically learning the art of 1) Slowing down, watching, listening and observing your child. 2) Connect and expand your relating and engagement with your child and 3) Bring your child up the Developmental ladder, emotionally-socially-cognitively in a meaningful, integrated and unified fashion.
In the second instance, however, what we see a very different picture based upon an often entirely misguided "cognitive-behavioral deficit" model. For example, we see compliance to discrete commands to perform actions that are mechanically reinforced (i.e., Child does "X", such as points touches red or points to door, or learns/says a stilted "I want..." on prompt to obtain "Y", such as a desired toy or cookie). The misguided (dumb down, mechanical reductionist) assumption is that without this adult-directed " sequential series of actions or tasks that "reinforces positive behaviors and discourages inappropriate behaviors" the child will not learn or continue to have great difficulty in consistently learning how to carry out the "steps of the task" (or the demands that are required in any task and that the child with ASD has challenges in doing) in order to begin to understand and engage. However, this is entirely erroneous! Historically this is based upon a primitive behavioral-stimulus response model (e.g., beginning with Pavlov proceeding to Watson, Skinner and Lovaas) that essentially views your child as composite, outcome and function of past learned behaviors that can be "reconditioned" to respond in a more appropriate manner by addressing the antecedents or consequences which reinforce the present behavior.
What is often overlooked here is that "behaviors" are always without exception the external or symbolic expression of the child's affective states or feelings and thus the focus must be not in trained or memorized new behaviors but rather the child (or older) must feel comfortable in communicating his/her feelings in relationship to others (which is completely different than rote or memorized tasks) in order for true meaningful and integrated engagement (neurologically speaking) to ensue.. It is not about "changing behaviors" but addressing the child as a whole, validating the infant/toddler's feelings, engendering an environment to feel secure in his/her senses/feelings and further relate and engage with others - which then leads to more meaningful complex relating and engaging..
Essentially, the child through behavioral reward driven "positive reinforcement" is being taught to "functionally script" (i.e., improved functional scripted responses). The key word here is script. Although, this might be convincingly presented to you as a reduction of your child's "inappropriate behaviors" and reinforcement of "appropriate behaviors" it is a form of scripting nevertheless! Restrictive or more "functional scripting" is clearly and unequivocally not the same thing as child being wooed (adult attributing purpose and meaning to child's present intent) and in turn/synchronization child co-initiating back (i.e., core executive functioning) and self regulation (i.e., increasing sensory processing integration) in accordance to the child's own natural affect or desire to want to communicate and engage! Supporting your child's spontaneous desire to want to relate and engage must always be the core foundation.
What Must Be Firmly Established and Understood By Primary Caregivers and Therapists: The Differences Between Actual Engagement and Task Compliance.
It is a common developmental mistake to equate actual spontaneous and sustained social engagement (reading and responding seamlessly to affective facial and bodily cues, intonation, inflection the prosodic elements of pragmatic communication with "completing or executing new learned tasks" as one and the same thing or activity or leading to one and the same thing or activity. For example, parents are often told of the "necessity to break down into small sequential steps the "demands of the task" in order to decrease their child's deficit in his challenged "receptive understanding", thus "making easier" for your child to complete the task. Now, not only is this a misguided perception, it is plainly wrong. It is based upon the blanket and egregiously misleading assumption that your child has "cognitive or receptive communication deficits since s/he is not following simple instructions."
Aside from any specific diagnosed motor muscle/tone concerns that inhibit your child from carrying out a task, it is not that the your child cannot receptively/cognitively understand the steps of a task or execute a particular simple or more complex task (e.g., understand one step, two step three step directions) but rather s/he is often not able to emotionally-socially sustain back and forth interactions. In other words, the appearance of your child seemingly not being able to receptively understand and execute basic tasks is not because your child necessarily has a "cognitive deficit" but rather that social-emotional interactions of back and forth engagement for your child is/becomes uncomfortable or overwhelming. However, because the latter is not sufficiently appreciated by many therapists and education professionals, it unfortunately appears in concordance to most standard (largely meaningless) evaluative checklist tests for assessment that there is indubitably a major "cognitive delay", where in point of fact there is significantly less or none at all!
What must be understood is that social-emotional-cognitive engagement is not a series of explicitly taught or directed "tasks"or a completion of "tasks" can lead to social-emotional cognitive development as in a series of behaviorally reinforced or mechanical discrete sequences (e.g., following stacking blocks, placing shapes, learning colors) which then leads to the generalization of skills. This would seem on the surface to make "perfect sense" on the surface (e.g., what is mass commercially advertised/sold as "learning") but it is in fact a terrible caricature of what the steps of Functional-Emotional Development are, of what Functional Emotional Developmental learning and sensory processing actually entails. One common example of the former would be teacher commands, "Look at me!" Child: looks up. Teacher replies, "Good looking!" Teacher: "Touch nose." Child touches nose. Teacher: "Good touching!" or child points to happy from sad, Good job! etc.
Rather, from an informed and educated neurodevelopmental perspective, it is executive functioning, affect-sensory motor coordination guided by the child's natural affect in relationship to others as the child desires to engage and returns to engagement that often represents the core set of challenges. These "skills" or rather developmental capacities begin to manifest as a whole, that is, your child's social-emotional-cognitive milestones, in the process of your child's own natural desire to engage.
As your child is wooed into engagement, then his/her receptive communication or cognitive skills begins to become "online" or visibly apparent. There is a visible and completely measurable change in how he regards "self and other" how he navigates between himself and others. In other words, in the process of your child using his natural faculties without being artificially and mechanically prompted and extrinsically reinforced (i.e.,cookie, toy, gummy bear, etc) to follow extracted steps in a task to make it "more comprehensible" to him (which can actually inhibit or severely curtail this re-connected executive functioning process) goes along with-and-is part of the natural process of co-affective engagement. Preverbal affective back-and-forth engagement is not a series of "broken down steps" in order for your child to carry out the "demands of the task." Rather, it is based upon cultivating your child's natural interests to want to engage.
Again, this "breaking down into steps of a task" or steps of interaction proceeds by the egregious assumption of the presence of cognitive deficit in your child's receptive understanding, i.e., "Since s/he is not following simple directions there must be a lack of attention and/or receptive understanding of the "task, therefore, s/he has to be behaviorally reinforced to follow the steps of more appropriate task-behaviors."
However, once your child's desire to stay in engagement is there, then there is no need to demonstrate to your child the "steps of the task" or mistakenly and presumptively "improve his/her receptive understanding." It becomes tacitly (intuitively) understood by your child in the Developmental context of his biopsychosocial back and forth co-communication of relating and engaging with others. The true art and effectively engaged therapy are parents and therapists learning how to slow down and developmentally psychologically and empathically understanding and engaging your child's functional emotionally and sensory processing differences, which unfortunately is insufficiently or not at all addressed in many educational and therapeutic settings!
Then why in early intervention and later in preschool/school are relating and engaging not the primary focus rather than first having the child follow simple directions? Why is there not a clear and unmistakable distinction not made between the process of "relating and engaging" and "child taught to follow a series adult directed "educated tasks?"
The fear of thinking "outside the box" or off a checklist. Unfortunately and often Ignorance knows no bounds as understanding, engaging and empathy cannot be found in a text book list as do X, Y and Z. so to focus on guiding parents to follow and build understanding and relationship around the child's natural affect or intent becomes problematic. On the other hand, one of the primary reasons is that simple attachment to complex child/primary caregiver relating and engaging occurs so many tens of thousands of times, that is in so many infinitesimal ways, that it seamlessly or indivisibly forms the (nonverbal) backdrop and background for Development, Ironically, as such it is largely overlooked or taken for granted - even though interestingly it crucially forms the foundation for all the typical Developmental milestones that follows. However. in ASD and related disorders the primary challenges is often precisely just this: The deepening of reciprocal attachment with primary caregivers and an exponential increase in spontaneous relating and engaging with co-referencing gestures and pragmatic language usage.
However, precisely because two way emotional or affective reciprocity so naturally in neurotypical development an entirely wrong view is commonly adopted by special educators and therapists when a child is diagnosed with ASD. What is commonly conveyed by many special educators and therapists to primary caregivers is that it must be your child's deficit or challenges in "cognitive skills," or receptive understanding that is the culprit.
So consequently, it is, therefore, believed that your child's lack of ability to engage-and-follow directions to be effective must, for example, through applied behavioral analysis, "behaviorally re-trained" in order for your child to increase receptive understanding-and-engagement through a series of positively reinforced"step-by-step carefully instructed or mechanical tasks." However, what is entirely misunderstood is that emotional relating and engaging are not a series of directed instructions or atomically or mechanically broken down tasks that the child needs to comprehend in order to begin to receptively understand, interact and engage with others!
Relating and engaging begins in infancy and then increasingly longer. In fact, it forms the foundation for being able to follow many directions and complete many activities. One of the primary core challenges with children (and older) with autism spectrum and related based disorders is in fact often not one iota of cognitive deficit but rather the underlying affect-sensory processing challenges to maintain and form simple warm and pleasurable flow of back-and-forth engagement which includes reading and processing others' intent, facial and bodily gestures with primary caregivers and others.
It is relating and engaging and maintaining and, moreover, the ability for your child to struggle through emotional relating and engaging (i.e., asserting a healthy core sense of self in a back and forth flow with others) and precisely not the following adult direction or commands to first complete discrete isolated tasks which then become generalized "tasks." It has nothing to do with the receptive understanding of your child steps involved in completing tasks. This must be clearly understood from day one!
Understandably, it would appear to make perfect common folk sense that a child who is not following simple directions and completing tasks first needs to be re-trained to attend and increase his/her cognitive awareness in order to complete the [mechanical instructional] steps of simple tasks. Or, again, you might hear, "Breaking down a task into simple steps so your child can better grasp the procedural instructions in order to complete the task."
Again. the fact is this could not be further from the truth. This is a serious misperception throughout the field based upon not a partial but often a complete lack of understanding of every infant/toddler's Developmental primary core milestones of emotionally relating and engaging. Emotionally relating and engaging is much more than simply a child being affectionate. It is much much more complex, It has to do with the steps which are not really "mechanical steps" but underlying relationship connections of signaling, that is, affective social co-emotional signalling. An example, beginning simply and then more complexly would be your child using the emotions of his/her facial and bodily gestures (i.e., shaking head, wagging a finger no, or reasserting with a determined and more nuanced look and pointing of "There!"; and/or pointing to the object desired, pointing back to himself for possession and then to mommy in an increasing continuous back and forth flow).
Once warm simple reciprocal engagement begins to emerge (which we see accompanied with an increased feeling of trust, security and curiosity or a more tempered response rather than ALL or Nothing reactions) we actually clinically see a reduction in the subcortical parts of the brain. i.e., the over-reactive Amygdala, flight or fight responses. Basically, the child's increased sense of trust, security curiosity of others-and-his/her environment, in fact, begins to positively set (re-wire) the neurodevelopmental foundations - as it becomes more comfortable for him/her to engage with others.
An underlying associated cascade of neurodevelopmental events (neuronal connections) begin to transpire. This includes, for example, greater attuned auditory processing (i.e., reading and processing what other person is saying); affective facial processing (i.e., more activation in the part of brain known as fusiform face area in the fusiform gyrus, such as reading and processing facial and bodily gestures of others) and so forth. The important thing to keep in mind is that this does not happen - or integrate in any clinical pragmatic, meaningful and spontaneous way because your child is first directed/trained to complete the mechanical steps of the task, again the often entirely wrong assumption by practitioners that there is a moderate or severe cognitive delay or deficit. NO, NO and NO!
It occurs because your child's executive functioning (internalized secure/comfortable "sense of self") begins to connect in conjunction to and rhythm with his/her underlying affect sensory motor connections with others. This is not your child "tasked" to death or taught the "instructions of the task" but rather by developmentally psychologically emotionally encouraging your child to increasingly stay in back and forth engagement in concurrence with not his/her "one size fits all" but rather his/her unique affect sensory processing differences profile.
Again, ninety percent of the time there is not a "cognitive deficit" but rather because the underlying secure emotional-sensory foundations of relating and engaging and asserting are mildly to moderately compromised. Once your child begins to spontaneously engage from his/her healthy "sense-of-self" it is because it becomes safer (from his/her perspective) to engage and in turn safer to begin to increasingly internally regulate his/her reactions and sensory processing challenges in order to bring online the typical neurodevelopmental process of relating and engaging.
So, what formerly looked like "cognitive deficit" really often has much more to do with the underlying over-responsive or under-responsive sensory (and heterogeneous competing) processing challenges which makes it more difficult for your child maintain that back and forth flow and assertiveness in engagement. Again. it is not the sequential steps of simple external directions or external isolated or accumulative general tasks that the child needs to master but rather to read/process facial and bodily co-emotional signaling which comes from the ability to relate and engage with others dependent upon the child's internal secure "sense-of-self foundation."
From a Developmental perspective we refer to training a child to follow directions and completing tasks as splintered or isolated skills, as they are otherwise easily and meaningfully achieved but, again, only once the developmental framework (warm, pleasurable relating and engaging with spontaneous co-referencing gestures) that supports them begin to emerge and are firmly in place.
But my child does not want to relate and engage, he either wants to cling to me or runaway. How do I go about doing this?
Relating and Engaging. Learning how to go to your child's world and your child wanting to engage with you. Deepening attachment and reciprocal back and forth engagement between you and your child.
First you need to attribute both purpose and meaning to your child's present actions, however, meaningless or non-purposeful they may seem on the surface. Rule number One: Your child's actions are always meaningful and purposeful to your child and this be fully honored and respected and Developmentally and empathically understood from his/her perspective. Thus, you begin to this by going into your child's world and joining in with your child current non-injurious actions or behaviors since they are always both purposeful and meaningful from your child's perspective (i.e., lining up cars, spinning wheels, rocking, etc.). It is only by doing this that you begin to lay the first cornerstone for simple and meaningful back and forth engagement.
Exactly, what will this accomplish except more inappropriate behaviors and non functional play skills?!
It does not encourage inappropriate behaviors and non-functional play skills. Actually this accomplishes something extraordinarily important from the perspective of relating and engaging between you and your child and your child with others. It creates a foundation of trust, reciprocity and most importantly a desire for your child to want to continue to engage (the only obvious exception is not joining in with your child when there is an immediate danger of injury to self or others).
This only begins in small steps. Your child needs to be minimally comfortable in attending to his/her surroundings. This means your child needs to be able to process the environment with at least some relative calm or joy and curiosity. from your his/her perspective. It is only then that any meaningful social engagement (reciprocity) can occur. . Your child must feel relatively comfortable at moments (that is, at home in his/her own skin) and in relative proximity with others. This includes at minimum in one or more of his/her affect sensory motor processing motor connection with his/her environment senses: Sounds, touch, movement, and visual-spatial perception.
By going to your child's world this conveys to your child that what s/he is doing is both purposeful and meaningful, as it indeed is.. Your child first and foremost needs to want to, has a vested interest in wanting to, stay in simple back and forth social interactions with others around his wants, needs, desires, even if they are fleeting or momentary we can build from there. Now, this does not mean you simply reading or anticipating his wants, needs and desires and giving him what you think or know what s/he desires. Nor does it mean in any sense "training your child to respond on cue" or "repetitive drilling your child to learn to follow of the steps of a task."
Relating and engaging is not a set of mechanical steps: Do A; Do B; Do C. NO! Instead, you are attempting to do something quite different, You are attempting to woo your child in simple and meaningful back and forth engagement. This is not something novel. As parents and caregivers we do with our child from day one. A smile begets a smile. A frown begets a frown. Hide and seek behind blanket with a rising inflection and smile with " peek-a-boo" with the infant co-responding with laughing/smiling back. This is what is called opening and closing or completing a circle of communication. Since we take this simple back-and-forth "falling in love communication" for granted it is often overlooked later on when there are indeed challenges in relating and engaging (i.e., ASD) and instead parents and unfortunately I dare say the vast majority of special educators and other therapists misinterpret this as a child's lack of "cognitive skills" to attend to and follow simple directions or the steps of a task
Furthermore, it would be completely incorrect to conceive back and forth relating and engaging as a series of instructed mechanical sequences. (Just as it would be a primitive and gross interpretation to conceive of a living organism as a series of mechanical parts. An organism is not a series of mechanical components and neither is engaging or relating) Rather these are steps of the heart and curiosity of your child's natural affect or intent that are engaged with yours and forms the foundations of relating and engaging. When there are present pervasive developmental delays (such as autism spectrum challenges), this often needs to be re-established if not there presently as an absolute and quintessential first step towards engagement.
This means you addressing your child's first steps: This means you allowing and encouraging back and forth deepening attachment and increasing back and forth simple circles of interactions to begin. We can refer to this as simple back and forth emotional problem solving scenarios. All of these steps need to be addressed and if they are not we need to go back and address them. . Expressing different facial emotions in playful co-responding to your facial expressions. This begins quite simply and gently. A smile met with a smile, a frown met with a frown, etc. Then, your child needs to begin to express more bodily and facial expressions with more assertiveness. Shaking head, Beginning to point in reference to your pointing and then independently about his desires. This then leads gradually to longer circles of co-referencing with you. Shaking his head no, Pointing to himself for me and then back to the object and then back and forth between the object desired, himself and others. The most important factor here is not the fact of his pointing to desired objects, but an understanding of the backdrop: The social non verbal communication; the increasing branching out and nuanced co-emotional signaling in which this is occurring. It is the fact of the social non-verbal communication and emotional signaling that places your child in relationship to you as an engager.
My child has difficulty sitting still even for even a few seconds. So doesn't he need to be trained to follow directions to at least sit still before I can engage him?
Understanding Your Child's Sensory Motor Affect systems:
If your child is not sitting still, constantly running or fidgeting you need to understand that it is not a problem that s/he has to "cognitively learn" to sit still and pay attention to simple requests. We can reasonably analogize this to an adult having a pain in his arm or leg and being told or being trained to "stop feeling it." Be quiet, Be still! "Oh Boy! We need to train you to be 'appropriate rather than inappropriate' in your feeling of pain!" Most of us would view this as an unkind retort or shall we say a serious lack of empathy to what might actually be going on in terms of the physical basis of this poor chap's pain.
Now, although it might not seem the same, the situation is not much different and in many ways exactly the same with a toddler or older who is constantly running about, or constantly needs to touch or spin objects or on the other hand a child who is hypoactive and thus requires a lot of effort to get moving or frequently withdraws from any tactile input - even the simple act of being held or picked up. For example, we see children who are constantly in movement, including seeking to exert while walking or running extra input on their upper arches (sometimes referred to pigeon-toe walking) or a child who is continually jumping, rocking or spinning self or objects. From a comprehensive developmental perspective we do not blindly and ignorantly say that this is "inappropriately learned behaviors" that need to be "faded and replaced with more positive and appropriate behaviors" or that even child is "hyper-responsive" and therefore, needs to learn to newly learn the behavior of learning to sit still,
Behavior is only a symptom of what is happening beneath the surface: Peal away the surface.
but from a proprioceptive perspective (i.e., joints and muscles) seeking to compensate or seeking extra necessary vital input to his/her joints and muscles . Again, NOT a "behavior or an inappropriate behavior, no more so than saying, "You have an inappropriate response" to having pain in your foot because you were just cut.
The mantra must be (supported by a Developmental understanding and education) that "behavior" is only the external manifestation of what is happening beneath the surface. To blame the patient for being overwhelmed, overloaded or in pain is as equally cruel as it is as equally Developmentally ignorant!
This extends to ALL the other senses as well, depending upon the child and what underlying affect sensory processing areas and how the child is interpreting stimuli in the context of environment-and-others are affected. This includes but not limited to visual spatial processing, touch, sound, smell; vestibular system, which is our sense of balance and movement in relationship to space.
Too much typical auditory input for one child might be interpreted by your child as overwhelming and results in your child turning away or holding ears but frequently grossly misinterpreted as your child "not paying attention." Visual-spatial perception: Too many objects scattered in can result for some children in moderate to severe tantrums, as it becomes too confusing or overwhelming for them in terms of their feeling/interpretation of visual-spatial perception, and so forth.
You are joking? Are you actually saying that if my child is spinning or rocking or lining up toys you want me join in that with him?!! Will this not encourage him to continue with these inappropriate behaviors and play skills?!!
Yes, that is precisely what I am saying. No, this will not encourage your child to continue these "inappropriate behaviors and play skills." Inappropriate behaviors and play skills are exclusively a biased adult interpretation from a less than empathic perspective of your child's world. From your child's perspective, he is doing what is natural and enjoyable to him or provides him with the necessary input/action/experience s/he is seeking. The problem comes from the immediate uninformed and simplistic surface labeled interpretation of "appropriate versus inappropriate, typical vs. atypical" compounded by the tragic rampant ignorance and fear by many special educators and therapists that you need to "break him" your child from these habits or inappropriate perserverative behaviors and find more suitable or "appropriate replacement behaviors." Again, a most unfortunate interpretation from not a partial but let me emphatically state: A completely non-developmental and non-empathic understanding.
Now, let us begin by taking the phrase, "Joining-in." Joining in with your child does not mean trying to act as a near perfect silent and passive mirror, where you are just following and imitating exactly what your child is doing. Rather, once you slowly start to do in a relatively similar way, not an exact carbon-copy way, but a relatively similar way, somewhat matching your child's rhythm, speed and style, and s/he not only begins not to run away or push you away, but allows you there and your parallel or face to face participation, then we have our very first and extremely important step of shared-engagement. Your child is welcoming you into his/her world. This is not only very important from your child's perspective but your experience, that is, by not re-directing, but joining-in and allowing this [shared-perspective] to happen you are discovering an opening, a new way of relating. This means s/he is allowing and you are allowing your child, you are both allowing for deepening attachment, reciprocal engagement to occur - but significantly around his/her natural affective interests or intent. We can call this a relative simple and pleasurable joint-attending or joint-engagement. That is the first step: The "Hi! How are you?" or the "Welcoming and joining in stage.".
Then you, the adult creatively take the lead, not too quickly, not too drastically but slowly by doing what we call, adding "subtle affective variations." Let's take rocking back and forth. As you rock facing your child with him you might add clapping your hands once or twice then quickly put out your hands to give him high five, then back to the rocking with a slightly different rhythm and speed, then with holding him for a second, if s/he will permit, with "Ready, s e t , GO!" Essentially, what you are doing is Developmentally psychologically co-creating a new frame of reference, building a new co-narrative together. So, what began as an All or Nothing one step action, i.e., rocking alone or remove him and meltdown, now has become a two and three and even four step not only interaction (a multi-step two-way reciprocal co-engagement with your child) and not just blankly (as in adult instructional task, do this look at me, touch nose) but Developmentally and importantly with a diversity of fleeting, smiles, looks, glances, etc. S/he is no longer "stuck" in one-gear and you have allowed him/her to expand into new interaction (co-interactions), where you are taking the lead; where you are suggesting by "acting", "doing" something new but - and this is important - within the context of his original natural affective interest or intent. S/he has begun to incorporate something novel into his/her repertoire. Where did it begin? By slowing down, watching, waiting listening and your child welcoming you into his/her world, The one-step action has now transformed co-engagement with diversity of facial and bodily gestures, movement auditory processing, regulation of processing and increased executive functioning (i.e., the placing together not of mechanical but meaningful social sequences) with the intent/desire of your child to want to engage differently and more with you. Very, Very Very important!
Or let's take the child who lines up everything; who wants to line up his cars or blocks and is not open to your suggestions to play with them more appropriately. From the child's perspective, this is perfectly normal, natural and self-reinforcing. Yes, that is a good thing, as it provides him from his perspective some degree of pleasure, comfort and security. Also, unbeknownst to him, he did not bother to read the instructional manual: "This is how you play." All the better for him but a seeming daunting, overwhelming challenge for you with your first response "Oh no, I have to get him/her to play correctly."
Again, rather than show him, "No, this is how you play", which leads to tantrums, meltdown and what not. Instead, you need to learn how to go to your child's world. Play as he plays! Slowly take a car and line cars up with him. Again, this is joining-in, following what s/he is doing; honoring and respecting his/her world. His/her honoring and respecting of you, in turn, is his welcoming of you to come closer and join in with him/her! Now, the following is where you become the "bad mommy or daddy!" But this must be done slowly or with the timing and rhythm, that is once you have at least two minutes of following his/her lead. You suddenly have an "accident", You knock down one or two of his cars with one of your cars off the table, with variation of inflexion in your voice, of "Uh oh! Oh No! there?! What happened? Make sure you do not have a blank face and a flat voice while saying this. It must be sincere, affected with slight drama and with sincere emotional expression in your face and pointing down at the car, while saying, slowly with inflexion, "Uh oh! Oh! No! There?! car, c a r? uh no!" Now , depending upon your child's reaction to this, you might pick it up slowly or quickly and put it back (but slowly) on (in-line) with the other cars on the table. This is the first step in what is called,, " Becoming a minor playful obstruction." You have disrupted, however briefly his play BUT within the context of HIS/HER play not your "play plans" or something that you would have not thought of indulging previously under the false notion of "inappropriate." Note: You are co-creating a narrative of play within the context of your child's natural affect. You are not just following his/her lead, you are taking the lead (any subtle or larger and sudden variations but within his/her zone of natural proximity or affect.
Now the next step a minute or two later or next time, would be to have a similar accident, but this time the damn car gets (intentionally) get stuck under the sofa several inches away. Your child begins to cry/tantrum, You slowly but emphatically and sincerely, say, "Oh no what happened?!" There?! with pointing and perplexity in your face. "Oh! No! Out?" There?, Under?"
Essentially, what you are subtly and craftily doing is slowly guiding him/her to slightly or largely move and engage in two-way back and forth emotional-problem solving scenarios. There is a tremendous amount of back and forth co-emotional signaling and auditory, visual spatial and overall regulatory processing in that. You are modeling in the context of slowly orchestrating this, embodying emotional gestures, utterances and words, with rich facial and bodily gestures. You pretend to try to get the car unstuck but you can't; you increase your emotional utterances and you are in the process(developmentally modeling by doing) for him to try (to get it out) and do the same. Once again, we have now broaden the formerly one step engagement (i.e., his lining up cars) to multi-step joint co-engagement with an expanding rich diversity of facial, bodily gestures and utterances. Your child is navigating a winder range of reciprocal based co-interactions (interactive engagements) and incidentally , not overtly instructed, moving up the Developmental ladder. Where the Development is beginning to significantly expand here and this cannot be underscored enough is in "You subtly or suddenly breaking or disrupting and then you and your child co-repairing of the connection(s) - the "mishap" together!"
These are just two examples. There are literally hundreds of thousands of examples and variations within those examples. They are not to be found in a "How-to-Book!" This varies moment to moment and completely dependent upon your child's constitutional developmental and sensory-affect- motor processing differences!
Ninety-five percent of the time there is no cognitive receptive communication deficit! The attempt to make the steps of the "task of interactions" more easily comprehensible to the child" is in fact an adult misunderstanding, a projection based upon not knowing how to engage your child . Engagement is a co-narrative preverbal affective dance not a series of simple clean extracted steps, like assembling a mechanical device with screws or baking a cake. Analogously, a poem is not just a series of colorful words; a painting is not simply a splash of colors; An organism is not comprised of separate organs or units. So, likewise, understanding through engagement is not a series of broken down tasks. Rather, it is an artful co-narrative or co-affective guided dance.