Articles by Maude Le Roux
Praxis and Language - 2015
Praxis and Language, do they co-exist? If they do, how do we understand this in every day sessions with every day caseloads? Do we talk to the children we have in our therapy rooms? How do we know what they are hearing, how they are listening to our language? How do we know they are not responding due to not being able to sequence language, or not being able to plan a motor sequence? These are interesting questions, are they not? To answer them requires a certain amount of self-reflection, especially to ponder the multi-faceted child in all his or her wonderful ways, including their challenges.
What is Praxis?
Let’s first understand praxis and be sure we all carry the same understanding. Praxis entails multiple different components, built on several building blocks of foundation, which has to be accomplished in order to acquire the skill of praxis. As a definition, praxis contains the ability of the nervous system to ensure a timed, coordinated response from the motor system of the body, while also contemplating how the limbic system (emotions) feels about it. Without this function, we potentially feel helpless, as if we have no power, no way to enact upon this world and many times, the only recourse we have is the Amygdala in fight, flight, or freeze, because it does not require sequencing, simply a reflexive response. In fact, praxis is what gives us planful, executive behavior.
Praxis is built on the foundation of having the ability to regulate (modulate) our different senses. If our nervous system is disorganized, it is very difficult to built planful behavior, as praxis requires a calm state in the nervous system. It also relies very heavily on our ability to discriminate with our different senses, so we know how hard to push a cart, how to feel what we hold in our hand, how we see the object in the distance we see it, and how we hear the instruction given to us. The ability to register information and process it to the brain to be analyzed, is the cornerstone upon which we can build constructive play that would contain purpose and meaning, and result in planful behavior. Without these building blocks, we will struggle to achieve the multiple forms in which praxis occurs.
The totality of praxis relies on first having a motor idea, initiating this idea, sequencing through the idea, and to culminate in completing this idea within the same timing and rhythm as our peer. As we complete the activity, our body also registers feedback that supports us to repeat that action. Feedback is important for self-motivated (intrinsic) repetition, such as you see the new toddler do when they pull themselves together after taking the first step to attempt the second step. An amazing process to watch unfolding in front of our eyes and no parent is more proud of witnessing this moment.
As praxis develops it proceeds into higher forms of organization, which occupational therapists consider as the “Bilateral Integration and Sequencing” profile, which requires both sides of the body to do all of the above processes of praxis in more precise timing and sequencing. These periods of development in higher order thinking has much to do with co-existing processes of thinking/planning with inter-hemispheric organization between left and right brain. This sets up the ultimate goal of having great executive functioning skills, which would include timely responses from all senses at the same precise timing leading to having adequate ability of being a functioning school student that embraces learning.
The importance of occupational therapy being involved in this process cannot be understated. I have witnessed multiple times that as soon as the “behaviors” are under control and children can form a semblance of writing potential, they are discharged from services without considering this in the fullest extent and then we are surprised if the family calls us a year later that similar “behaviors” have resurfaced again. An interesting exercise would be to video tape your Sensory Processing session and view it later with no sound and simply watch the complexity, or lack there-of, in how the child moves. Yes, they have all the muscles, but have you really observed how they seem to use the same motor sequence over and over again, or how much they try to rely on language to see a play scene through.
Communication is more than verbal language
Which brings us to the thinking around language and praxis and their co-influence on each other. It simply does not seem right to discuss language as in only the verbal format as much “language” co-occurs with central nervous system in the first year life before verbal language starts occurring in typical development. It is essential that we first consider non-verbal communication as therein lies much of the difficulty with our kids that also exhibit praxis difficulties. It is the primary job of the infant to cultivate increasingly complex non-verbal gesturing to support the meaning and context of what is to develop in verbal skill later. If the child is experiencing poverty in their ability to plan their movements, we have to consider the impact this would have on their ability to use gestures. It is a well-known fact that communicating a clear message depends 80% on your non-verbal communication to each other. It is what supports the meaning of context and without it, you become no more than a “talking head”. These children develop into kids who rely so much on facts and what they can grasp in black and white, that the underlying meaning, the different social nuances become lost on them. It becomes a sad world in which it becomes increasingly difficult to connect with others and no amount of social skills classes can replace the exquisite automaticity that this requires from our system.
During the first three months of life, as we are working incredibly hard to set up our regulatory system and establishing firm bonds with our caregivers through our senses, communication is all about the senses. Listening to the mother’s voice in typical circumstances is soothing and flexes the baby’s ear muscles to receive sound in certain frequential patterns. These patterns is what supports voice modulation, or prosody, later in development. The closeness and bond of mother / father to child, sets up the intent to communicate, simply because of an innate wiring to want to relate to the one you love most in the world. When children have regulatory difficulties, this bonding is affected, which also affects the communicative intent and co-reciprocity of contingent communication so beautifully observed in parents who engage in the delightful “motherese” voice.
The central nervous system has a great many functions to accomplish during this important building block. The baby has to achieve the ability of a self-regulated state with cycadic rhythms. She has to learn to maintain visual gaze upon the close caregiver interacting with her. She learns different cries to communicate to the mother that a certain need has to be met. She is also learning the important suck-swallow-breath synchrony that supports regulation and receiving nourishment from the mother.
The next stage of communicative effort includes the ability to co-regulate with an innate sense of timing with the caregiver, which becomes a building block for the timing that comes with motor coordination later. It is established with great reliance on the co-reciprocity of the caregiver. The baby is learning to initiate communication through gesturing alongside their first initiations to reach for a colorful object, to want to roll over, to get into the rocking for a crawling position. The baby also learns during this stage to modulate her emotions in the secure base of her relationship with her mother and experiences the different occurrences of different emotions, their intensities and their durations. This experiential phase is mostly limbic (emotional) to physical (central nervous system) and heavily reliant on the central nervous system to regulate and register this information. The baby is making her first efforts to combine eye gaze with gesture, facial expressions and sounds, mostly to gain attention. She starts vocalizing pleasure and displeasure and uses many different speech sounds in babbling. These sounds include p, b, and m, with increasing frequency over longer spans of time. You can hear the baby chuckling and laughing with you, as well as making gurgling sounds as they exercise their ear muscles for the reception of language in order to prepare for producing it later. During this phase, the importance of registering facial information to prepare for the oral motor planning becomes crucial. It always saddens me when we have children with praxis difficulties, who are trying to speak, but cannot formulate the words and they become frustrated and stop trying. Emotionally they do not feel “felt” because they do not have a way to express themselves verbally and we are missing all the important non-verbal cues, as well as ignoring the facial muscles in getting them ready to register motor movement patterns for oral motor planning.
The next phase still occurs in the first year of life and becomes crucial to effect a two-way engagement of conversation. The baby now increases in intentionality in the use of non-verbal communication or gestures. She starts being able to discriminate the mother’s actions from her own and maintains ongoing moments of shared intensity with meaning. She starts to understand cause and effect, which is very important for the will to enact on praxis, as she also engages in multiple exchanges of back and forth communication. This contingency of communication is very reliant on those initial stages of building praxis as one step is followed by another step, continuing to build from the starting point. Babbling at this stage contains of both long and short groups of sounds such as ‘tata, upup, bibibibi”, signaling the beginnings of speech like intonation. Children diagnosed with Verbal Apraxia frequently have great difficulty with this area and can remain stuck here for a very long time. Occupational therapists can be very supportive of speech language pathologists in supporting the whole body to receive and register information as well as plan execution. It is very seldom that children with Verbal Apraxia do not also have a co-responding praxis difficulty in the body.
During this phase the baby starts to use speech or non-crying sounds to obtain and keep attention. She starts to wave, to hold her arms to be picked up, all of which are very reliant on the different aspects of praxis described above. She starts to imitate speech sounds and works on developing the coordination between motor initiation and sequencing with timing. By her first birthday (could be as early as 9 months for some, consider range of individual profiles of typicality) she is heard to say her first words (hi, dog, dada, mama), though sounds may not be exactly clear.
The next phase of development is really where every parent of a special needs child wants us to be. It is about developing speech and using language in speech. For this important phase of development we need to continue including the essence of relationship because if there is limited exposure to quality relationships, the child does not exercise any communicative intent, limiting the exposure to using gestures as well as communicative expression in its myriad of forms. Children do not point to objects, if there is no one available to see it. During this phase the motor planning development accelerates in ideation, initiation and sequencing. The baby wants to explore the world, be curious and act on it, will crawl away from caregiver, look back at the sound of the mommy’s voice. She starts developing her physical sense of Self and physically being in the space she occupies, learning more about the differences between herself and her significant others. She also learns how to influence others, which requires flexibility of her physical system to negotiate different motor ideas. If she struggles with praxis the exploration is curbed and her communication through behavior frequently is labeled as being rigid or even manipulative. She does not have control over her environment and does not have the necessary motor plan to follow through on her ideas. Her language, her communicative intent is inhibited by a primary need for a secure base, a place of comfort, a place where she can self-protect.
If all is developing typically she communicates with increasing vocabulary first in single words, then phrases, then sentences. These language milestones are particularly sensitive to understanding sequence in the body. In order to formulate your own language, you have to understand at some level that one “thing” follows on another and that there is order to it. Children who use echolalia are particularly prone to have difficulty with praxis, more specifically with sequencing. At some level they understand the need for a sentence structure, but they have to “borrow” from someone else’s speech through memory in order to communicate, as they simply cannot structure their own sequence.
Bloom and Lahey Model
Speech Language Pathologists frequently discuss the language model proposed by Bloom and Lahey, which explains three components of language: Form, content and use. The Form of language is the tangible part. It consists of the phonology (sound), morphology (different morphemes in words), and syntax. It starts with single words, develops into two word phrases, adding plurals, and then culminates in the formation of sentence structure. This process is very reliant on sequencing, though there are two forms of sequencing available to the speaker. The sequencing that involves the body and timed execution of gestures simultaneously with speech, is one aspect. The other form of sequencing is understanding logical order through the cerebral cortex with intelligence and utilizing memory to support development in language. So it is possible to use language and become a fluent speaker while still experiencing praxis difficulties in the body. This type of speech development though often is very bound to intelligence and though the speaker can maintain fluid speech on a topic, the speech might lack the prosody and tonality of voice modulation, and the rhythm of a back and forth communicative effort. Such persons may also have difficulties in social skills as the speaker has not developed the integration of gestural and verbal communication causing a lack of understanding in hidden and abstract meaning.
This brings us to Content part of their model, which includes meaning expressed through words. In terms of language development, it also contains the development of action words, location words, and descriptive words. Children struggling with praxis have difficulty figuring out the “how to” of things and pairing physical problem solving with action words is a frequent technique to use in sessions. Location words are frequently used when considering the visual-spatial experience of the child, especially when directing the body through the space they find themselves in. Descriptive words are dependent on the child’s ability to take in (to process) all the physical properties of the object through all their different sensory systems. To further describe different ideas to do with the object in hand also requires ideational praxis and the ability to initiate a plan. Thinking about this in a therapy session, we need to consider the difference between intellectual (cognitive) problem-solving and problem-solving through the body. The body developmentally precedes cognitive development and it is very important to make this distinction and for the therapist not to be “fooled” into thinking the child is efficiently doing this, when you need both scenarios to be fully integrated.
The Use of language is the third component of the model. The child has to understand why she is communicating, which involves an abstract formation of having meaning to communicate. Frequently parents are so proud of the words and sentences their child can repeat back or use when prompted. This expression frequently does not come from the place of meaning. Using language is one aspect, communicating with language is the fuller aspect. The sense of purpose and goal directedness behind her language is reliant on the building block of abstract formation and ideation, which is formalized through the use of sequential order. The communicating child has to understand the concept of sharing, and when to request more information, which is a very integrating process requiring that inner timing and reciprocity that was discussed earlier. The multi-tasking layer added to this is being able to ideationally follow the context of the communication, which requires much active working memory that again is constructed through the timing between the auditory and visual-spatial systems. Finally, she needs to be able to find her cues from the environment she is finding herself in, which requires so much processing from all her systems.
One of the important milestones at team meetings to consider is the child’s ability to ask and respond to “why” questions, which inevitably implies the child has access to logic. Logic is formed by understanding the sequential order of things, which again is built on praxis. In mentoring therapists, I frequently propose not to move on to “why” questions before we know she is solid on “how” questions. This way we know we are using the body to sequence and to problem solve, which avoids compensating with cognitive skill and reinforces integration.
Language comprehension relies on all of the above and is greatly dependent on active working memory, which jointly ultimately will lead to reading comprehension as a student. Again here, we need to distinguish between cognitive ideation in language and ideation through the motor system. Motor ideation leads to creativity in finding flexible different options to move around or through an obstacle. Cognitive ideation leads to using the intellect in creativity in coming up with multiple different ideas. The more experience the body has in being able to flex the muscles in different directions and ideas, the more the cognitive brain will be able to integrate their cognitive skill with practical problem-solving skill that requires the ultimate skill of integration.
We also need to focus on the role of timing in the two different aspects. Timing in praxis supports the coordinated effort of body and limbs in order to play sports, move around obstacles, to name only a few. But it also sets up the timing that is necessary so she could look and listen to you at the same time, which is what every effective communicator would need to do. There is also a certain timing in the prosody of language that supports intonation, which in turn supports the meaning behind the verbal message. The very act of reciprocal communication has a certain sense of timing connected to wait and listen, then speak when it is your turn. Finally timing is also involved in delayed gratification in that she has the ability to keep in working memory her message until the other speaker is ready to hear it and not be impulsive about it and “insensitive” towards the other speaker.
Language conveys Meaning
Which brings us to the final point to be discussed in this essay. Language has to convey meaning. Meaning has to have some connection with the speaker. The speaker is emotionally involved in the message, otherwise would not be intrinsically motivated to even formulate it. This emotional connection holds symbolic meaning for the communicator, which is only derived through plentiful experiences of play. Play is where the young developing child works out all the different experiences and files away all the meanings of different emotions in order to integrate it with language and cognitive thinking. The problem is that many children with developmental needs have not had nearly enough learning experiences through play because of their praxis difficulties. While playing, we learn to have an effect on the beginning, middle, and end of a story and the order in which the sequences occur. Children with compromises in praxis frequently struggle with emotional developmental delay, which ultimately also effect the content and meaningful use of language.
The real story is that it is all interconnected. With what we know as therapists today, we simply cannot intervene in a child’s life in isolation any longer. We need to bring a team around each child that will consider the different goals of the child in a way that would respect the child’s entire profile in order for her to become intrinsically motivated to turn towards learning and simply… fly!!!
Maude Le Roux, OTR/L, SIPT
International DIR Trainer
DIR®/Floortime™ and Sensory Integreation - 2013
Dr. Anna Jean Ayres (1920–1989), often referred to as "A. Jean Ayres", was an occupational therapist and developmental psychologist known for her work in the area of sensory integration dysfunction, a term she coined in the 1960s to describe a theory used in occupational therapy. Dr. Stanley Greenspan (June 1, 1941 – April 27, 2010) was a clinical professor of Psychiatry, Behavioral Science, and Pediatrics at George Washington University Medical School and a practicing child psychiatrist. He was best known for developing the influential Floortime™ approach for treating children with autistic spectrum disorders. This Floortime™ approach is now a trademarked approach under the umbrella term of the DIR® (Developmental, Individual Differences, Relationship) Model.
The Developmental, Individual Difference, Relationship-based (DIR®) Model is a framework that helps clinicians, parents and educators conduct a comprehensive assessment and develop an intervention program tailored to the unique challenges and strengths of children with Autism Spectrum Disorders (ASD) and other developmental challenges. The objectives of the DIR® Model are to build healthy foundations for social, emotional, and intellectual capacities rather than focusing on skills and isolated behaviors.
Though Dr. Greenspan started developing his work more strongly about 10 years after Dr Ayres, they shared a common goal, even while never meeting in person. Both professionals were concerned with the fact that children had something to say about how they were feeling in their own bodies. The newer insights derived from their work is that the central nervous system has something to say about behavior, that behavior should not be taken at face value, and that there is more depth to behavior than what was observed on the surface.
Dr. Ayers own sessions were often observed to be quiet in verbal content from her, while spending much time observing the child and figuring out how she could gain improved patterns of movement by what the child is presenting. This quiet observation is very much like the “wait, watch, and wonder” DIR® approach. The importance of how the child is feeling and experiencing his / her environment was and still is the first order of business in both Sensory Integration work today as it is in DIR®/Floortime™ Intervention.
Sensory Integration has evolved in a dynamic process of understanding the foundations of central nervous system development and it’s adaptation to the environment the child finds himself in. DIR®/Floortime™ has evolved in a dynamic process that includes this central nervous system adaptation in the very foundations of the developmental hierarchy of 6 functional emotional developmental levels. Once a therapist is involved in doing both Sensory Integration as well as DIR®/Floortime™, it becomes difficult to draw exact lines of when Floortime™ begins and Sensory Integration ends.
The blend of the two interventions is very important for typical as well as atypically developing children. As the one intervention focuses on Sensory Integration and it’s effect on behavior, the other simultaneously focuses on the emotional development and it’s effect on behavior. In order to understand this better, let’s take a brief journey through the 6 developmental levels and discuss the fit of Sensory Integration during these levels.
STAGE 1: Self-Regulation and Interest in the World
During this first stage of development it is all about how the baby adapts to his / her sensory world. The entire concept of sensory modulation, hyper vs. hypo-arousal is at work during this stage. Establishing the different cycles, sleep-wake etc. is at the order of the day. This theme is central to the work of a therapist intervening with sensory integration as it is central for the DIR® therapist to understand in order to understand the peculiarities of the presenting behavior. Both interventions will focus on what would be integral for this one body to come to the “just right place” in order to learn in a more calm and efficient way.
STAGE 2: Intimacy, Engagment, & Falling in Love
During this stage the DIR® therapist will be actively seeking the ability in the child to connect warmly, with affect to his / her caregiver and improve a sustaining ability to pay joint attention to a task. This ability to remain connected is very dependent on the child’s ability to integrate all of his different senses. In order for the child to understand the non-verbal as well as verbal communication, he/she depends on the ability of his / her central nervous system to look and hear simultaneously, to move and see simultaneously and the list goes on. The central nervous system has to become organized in order for joint attention to the same task to be sustained.
STAGE 3: Two-Way Communication
Now the DIR® therapist would be focusing on gaining an increased number of circles of communication. One circle would be the child initiating, the adult responding, and the child then responding back on the same topic. Eventually these circles of communication would run into having a continuous conversation. To be able to accomplish this, the child has to have some building block ability of motor planning. Praxis is the ability of the body to have an idea about a motor action, to initiate this idea, to sequence through it in organized steps, to complete the motor task in the same rhythmicity and timing as a peer, then give the body adequate feedback as to how the motor action went, so it could be repeated again. If the child is struggling with ideation and initiation in praxis, he / she might have great difficulty initiating these circles of communication. A child who is struggling with sequencing will have difficulty putting contingent circles together to create a conversation. When the child struggles with rhythmicity and timing, they may have great difficulty building a fluid conversation as they have difficulty learning to wait and pace their conversation and may have impulsive habits such as interrupting the current speaker. And if the body is not given the correct pathway of feedback of how these utterances were made, such as in an under registering profile, we might get glimpses of words will long wait periods in-between before it is repeated. The very automaticity of a conversational pattern is dependent on praxis / motor planning.
STAGE 4: Complex Communication
At this stage we are expecting at least up to 15 circles of communication (working towards many more) though the fluidity may not be there. In play we are now moving into the realm of more pretend play that starts with playing out everyday experiences such as going to school, church, beach and gradually becomes more abstract to move into building stories that are of the child’s own making. In order to accomplish this the child’s motor planning ability has to strengthen even more as it also has to integrate with more advanced visual abstraction. A child has to be able to recognize that one object, such as a block, could represent a car in his / her imagination. This stage is very important for motor planning sequencing and language sequencing to become more integrated in order to have sufficient ability to use it together. The body map (body awareness) or child’s physical image of their sense of self has to become quite integrated in order to participate in role play, to become someone else, to understand being in someone else’s shoes.
STAGE 5: Emotional Ideas
During this stage we expect the child to be able to deal with their emotional world, to understand different feelings and how they relate in their bodies, to deal with emotional upset and understand enough of their world to use symbols in their play. If we truly understand the first 4 levels and the high amount of integration it requires to get to this stage, we might look a little bit differently at behavior. Emotions are a frightening development in a child’s life that is undergoing a typical trajectory. It is very frightening and fear provoking in a child who simply did not get the foundations “right” the first time. This level of work causes a therapist to take out old notes on play development, bring it in sync with the child’s sensory profile, while at the same time having to assist the family with coping with the exploration of these emotions at home.
We can frequently work away many of the sensory integration needs and the child’s behavior may look like we might be in for the quiet after the storm, only to suddenly enter this stage of development and all the sensory integration symptoms may come back in a vengeance. Families become frustrated as therapists try to grapple with “what now?”. It simply means that this higher level of integration of emotions with all of the first 4 levels is causing stress in the child’s system and the child is being triggered by past experiences due to how the body is experiencing the moment. This is so important for the sensory integration therapist to understand. The origin of these “same” behaviors is no longer a sensory integration issue as much as the trigger is now the emotional development.
STAGE 6: Emotional & Logical Thinking
During this stage of work, the therapist is considering the child’s ability to reason more logically, to sequence one solution to a problem, while also flexibly considering a plan B. This requires much of the building blocks of executive functioning. One particular component of executive functioning skill is active working memory. A central executive that is fed by two streams, a visual-spatial pathway and a phonological, auditory pathway controls active working memory. In order for multi tasking to occur, the central executive has to be enabled by both the visual and auditory pathways at the same timing in order to work effectively. Herein lies a conundrum if the child experiences a delay in either system. To understand that this level of work is highly integrated in nature is also to understand that the child has to accomplish much in order to be able to use judgment over behaviors.
Dan Siegel explains a hand model that is used frequently in explaining behavior in the brain. If you hold your arm in the air, while tucking your thumb under your four fingers, you can think of your wrist as the brainstem, while your folded fingers (towards the palm of your hand, over your thumb) could be seen as your cortex. The distal two digits overlapping your thumb form your pre-frontal cortex. Your thumb is considered to be the amygdala and while all is calm you can access your pre-frontal cortex with good judgment. As soon as you become upset and you “flip your lid”, your four fingers jump up, leaving you amygdala exposed. This cuts off the pathway to judgment in the prefrontal cortex and you are only able to “think” with your emotions”. We need to really think about what we are asking a child, who is emotionally upset, to do. Sometimes it is more than we would even expect of ourselves. In both sensory integration as well as in the DIR® process we would both want to meet the child where he or she is at in that moment of time.
The above is but a brief overview of much complexity that this article cannot do justice to. The hope is that in reading this article the therapist would understand that what behavior the child provides cannot simply be only what we can observe visually. We have to be thinking of the multiple layers of development and what it is that a child has to conquer in order to survive in our product oriented world. Both DIR® and Sensory Integration are process oriented approaches, both are child led, and both consider underlying reasons for external behavior.
It is important that parents gain the hope they deserve in understanding their child’s progress. As therapists, we can provide many answers, but we also should not be afraid to not know everything and rather encourage a team process with families to find the best way to deal with a particular situation.
The reader is strongly urged to read Dr. Greenspan and Dr. Wieder’s books (The Child with Special Needs, Engaging Autism) to gain further understanding of this body of work. The author of this article also humbly suggests using her book (Our Greatest Allies – Maude Le Roux and Lauren O’Malley) as a reference for other professionals and families. The journey of Lauren with her child, Mattie, is potently strong for families that are encouraged in a similar journey. Both Sensory Processing as well as DIR®/Floortime™ is well described in easy read terms. This book is available on Amazon.uk.
Maude Le Roux, OTR/L, SIPT
Co-author of books: “Our Greatest Allies” and “The Listening Journey for Children”
Applied Floortime - 2012
The genius of Dr. Stanley Greenspan, author of the Developmental, Individual Differences, and Relationship model (DIR), lay in his ability to understand the development of the natural human mind and applying this progression to a model with techniques that actually works. Many families complete formal Floortime sessions in their home, though most of them also learn to apply the principles throughout the day. Though there are many techniques to Floortime; in this article we will highlight a few favorite ones.
Waiting on the child seems such a simple concept and we all like to think we are doing it, but if we objectively reflect on an interaction, we realize how many times we repeat an instruction or a question simply because we are “waiting too long” for a response. This judgment reflects more on our own patience than the actual processing speed the child needs to execute. To really wait on a child to process what he heard auditorily, then retrieve his response from the different storage files in his brain, after which he has to order his language sequentially, and then to send this formulated message to his vocal and facial musculature to be expressed, is a much longer affair for some children than for others. If we jump in too quickly with more words, more language, more expectation, we frequently add anxiety to the child’s performance, which may cause the child to retreat or give up, or simply answering a short answer that he thinks may be sufficient to the expectation. If we waited long enough, we might have gotten more “gold” and more ideation from the verbal exchange.
Pacing is another concept that is so innate in typically developing interactions, yet so frequently misunderstood in children who have communicative challenges. As well meaning adults we frequently impose our pace of an interaction on the child with the intention of helping the child. Fact is that, as an adult, I would feel a certain discord in a relationship if another adult is speaking or moving slower or faster than me and a similar discord is true for children. In interaction it becomes imperative that in order to feel that my partner understands what I am relating, to feel like he or she is on the same page as me, we need to match the pacing of each other. A child feels more understood by our non-verbal communication, rather than what we are saying verbally. Feeling understood leads to feeling trust and trust leads into taking more risks in learning and progress in the developmental milestones.
Decreasing our use of Language is the third and last one that we will focus on today. When children experience communicative difficulties, adults are frequently found to use an overabundance of language to repeat, to paraphrase, to re-explain, only to name a few. Even when the child has more language, and still has processing difficulty, it does not mean we should use more language. In-between verbal reception and verbal expression, there is a field of organizational structure that is frequently “ignored” , albeit well intentioned. If the child is provided with less language, he has less to analyze, leaving more active working capacity for the formulation of his own expression. Caregivers are afraid that they would lose opportunities to model language, but what we see in practice is that once the process is “easier” for the child, they progress further in language anyway. One of the reasons for this is that the DIR model is driven by the intrinsic motivation of the child and the child receives their own internal reward for the success they are experiencing, which in turn drives him or her to do more.
Maude Le Roux, OTR/L
Director of A Total Approach in Glen Mills, Pennsylvania
Author of “Our Greatest Allies”
Co-author of “The Listening Journey for Children”
Autism - SAISI Journal - 2011
Leading the way for treating children on the autism spectrum
Occupational Therapists have much to offer the world of autism in the realm of treatment as well as understanding. Autism is a neuro-biological disorder and as such has many implications in terms of any developmental framework that co-occurs in both sensory processing work as well as in play. Any child, no matter the diagnosis, should be seen as an integrated whole in terms of the many facets we as humans hold dear. Every child has to follow the same developmental progression in order to grow and take in his/her learning environment. As sensory processing developmentalists we are in the unique position to test our hypothesis of where development went astray in each child we see.
An argument is made for the difficulty testing a child who may not be able to complete standardized tests. A counter argument is made that if we use our knowledge on the theory of sensory processing, which includes integration as well as modulation, we could essentially figure out sensory-behavioral patterns that allows us to formulate treatment. Brushing up our knowledge on early development becomes important and once we figured a sensory pattern, we could almost know it stems from the first year of development and build our way forward from there. Treatment programs struggle when we try to apply a program based on the cognitive level and not on the developmental level. Sensory processing is a subconscious development, not a conscious development and yet so many therapists the world over seek the child to understand their command first and then apply his / her central nervous system. Typical developmental progression demands this to be the other way around. We first need to be regulated and then we will be able to apply our cognition at its fullest ability. If occupational therapists did not carry this knowledge in treatment, the world of treating autism would lose one of the greatest tools in working with children on the spectrum.
Another difficulty that arises is if we focus so much on providing therapy with “age appropriate” activities. For sure we would like for this to be our goal, but it certainly is not the place we start. We have to find the place in each child’s system as close as possible to where it all began and we start a treatment plan from there. It is so easy, and very understandable, to be swayed by parent expectation and feel pressured to work according to the parent goals. “I am bringing him to you so he could learn to cut and write”, says mother. One glance at the child tells you that there is so much more that needed to be worked on first before we could even begin to write and cut. It is incumbent upon us to train the families that this will not be the most helpful place to begin to work. You would start your 10 to 12 sessions with an anxiety in yourself that certainly does not help the child to overcome his.
The most important aspect of treating a child with Autism is meeting them exactly where they are at in any particular moment in time. Jean Ayers focused on child-centered work and this is as true today as it was in her time. Pressures of the world may change, but development is still the same. It is not our or the family goals that counts (though of course you formulate them in your treatment plan), but in the treatment session you have to find where the child ‘s goal is, match it and work your way around to make him want to take one simple step further. Once a child trusts that you will not violate his control over any situation, you will be able to move mountains with him.
Let’s take stereotypical behavior (stimming) for example. Families see this occurrence as a behavior that makes their child look different than other children, especially in public. Behaviorists see these occurrences as behaviors that need to be “extinguished” and worked away. The Sensory Processing framework requires that we observe these behaviors to determine why this child has so much need of doing this. Children are resilient, on that most professionals agree. Children are also capable of finding out for themselves some ways to make them get what they need, just as surely as you would today shift your position in your chair when you become uncomfortable. When we understand that sensory processing is all about alerting or inhibiting the central nervous system, we can begin to understand that the child can use his own central nervous system in order to find ways of regulating himself. This frequently does not look like the ways typically developing children would use their innate functions, but it certainly are ways that work for the child with autism in a world where their sensory systems simply cannot make sense of their environments. If the child tends to flap his hands when excited or when with himself, he might possibly be needing to influence his vestibular position of his body in space or he might need to arouse a system that is staring to flag in the hyper vigilance that is required. Or if a child is finger flicking in front of the eyes, is he doing this because he can access vestibular input through his visual system? Is the child’s tendency to few visual objects through turning his head and using his peripheral vision because he is trying to avoid double vision or does get more proprioceptive feedback through his eyes by maintaining this tilt of the head? The examples are plentiful and clinical reasoning is required for each individual profile we see.
Since the autistic child’s system frequently is found to be in hyper mode (hyper vigilance), it becomes essential for him to access some place in their system where they could find solace or relief. Many children with autism exhibit a mixture of different profiles in that they avoid some activities that would have developed their ability to register information and then they seek information in other ways to make up for what they are avoiding or not registering. It becomes a complex muddle of sensory-behavioral patterns that need to be respected by professionals and not simply be acclaimed that he is doing it because he is “autistic”. Every morning coffee drinker will object if we simply took away their ability to have coffee simply because it was not acceptable to someone? Or asking you not to go to the bathroom because it simply is not acceptable to the person you are with?
The sensory “stims” we observe in children are essential needs for the autistic child’s regulatory system. The medical world uses it as an item on a diagnostic scale; we use it as a developmental perspective. We simply have to find out what it means and start treating it from a sensory processing perspective. Our role here becomes critical in understanding each individual child and validating what he brings to the table.
We can go further and discuss the flight, fright, and fight mechanism that is available to you and me and to every child struggling with an autism diagnosis or general developmental delay. Psychologists over the world agree that we have this mechanism available to us from the first day we are born and we use it very much in response to how we perceive the environment we are finding ourselves in. If a child is hyper vigilant with regards to his auditory environment (develops into sound sensitivity) and he uses it to determine what is coming at him, his analysis of information could cause him to go into any of the three modes of fight, fright and flight. He may respond to this situation solely on this perceived threat to his system and will not focus on the potential joy of the moment in it’s entirety. Similarly, a child who has difficulty perceiving the learning material visually, or might have light sensitivity, or may be seeing two lines to cut and not only one, will want to avoid these situations as potential threats to his system.
So frequently we hear from caregivers that the child is manipulative, as if he would like to live in perpetual avoidance of situations and make life difficult for everyone, including himself. This saddens me greatly as the child is doing exactly what you and I are doing everyday. We find situations of comfort during times that there is discomfort and when we act on it with typical central nervous system adjustments, we think nothing of it. Because the child with autism responds with the severity of his need, we believe this to be “unacceptable”. From the child’s point of view, he needs to get away, he needs to avoid, he needs to feel safe and he needs to rely on himself to find comfort in whatever way possible he can find. We observe an adaptation to the environment that is thrown into high gear due to a maladaptive system. When you are in fear or in stress, it does not help you to start a new training course does it? When we start viewing the child with autism with this lens a whole new world opens up to us. As occupational therapists working with a sensory processing framework, we become a crucial member of each child’s medical team.
When we understand these maladaptive responses with regards to developing profiles, we can steadily work with the child from a place of comfort to accepting change and challenge new pathways of learning. It does happen though, that sometimes we have done much sensory processing work and the child continuous to show these responses from time to time, yet we know the system is now in a “working order”. The therapist has to consider the problem of habitual triggering of old behaviors. It might simply be the memory of these responses in the past that continues to linger in the child’s system and is mostly triggered by anxiety. It is the same memory glitches you and I experience when we respond to current situations based on our experiences of the past that may or may not be real to the current situation. Therapy should not be stopped at this point, as the family will need understanding to get through this phase. Important to connect sensory processing work to emotional processing work and work with the child to enact his daily experiences through a developmental play framework that will enable the child to work through it. It may still look like a sensory response, but could essentially mostly be an emotional response.
Walk with me to the world and essence of motor planning (praxis). The medical community loves to talk about rigidity in the life of children with autism. In order to conceive a new motor idea, a child has to essentially be in a comfort zone with his regulatory system. If he is still caught in the fight and flight mechanism of being dysregulated, the most intense need will be to self protect and turn inward with little availability to think of a new idea. The same goes for initiating tasks that well meaning caregivers place in front of him. It is essential the central nervous system has achieved some semblance of order and comfort before this type of task application can take place. Sequencing through a given motor task frequently requires integration between the cognitive and sensory processing systems that are unavailable to the child. Completing a task within a certain rhythm and timing become impossible ventures for a child with autism, causing the very aspect of seeming incapable to shift their attention and transitioning from one activity to another. Then there is the aspect of gaining feedback into the system. The central nervous system gains feedback each time we start a new motor action and we rely on this feedback to repeat that same action again. If we “enforce” a certain motor task on a child and he completes this task in a maladaptive way, consider the fact that we may be laying down a maladaptive pattern of movement in the child’s system. In our well meaning capacity we would like to see 10 repetitions, but better to do in the correct position and sequence of movement that will enable the child to do it again, rather than please ourselves by saying the child completed 10 repetitions today to serve our own goal.
This article cannot cover the fullness of breadth and depth of the effects of deficient praxis that a child experiences on the autism spectrum. It essentially decreases the child’s ability to harness learning from new and novel tasks or new and novel environments. In order to stay “safe”, the child will want everything to stay the same, eating the same foods, playing the same games, lining up objects in the same way and so the list goes on. Praxis is a multifaceted issue and cannot be treated if all is status quo and the child is not challenged by new and novel exposures. If the therapy session looks the same every time and we have successfully avoided a “melt down”, we may look good in the eyes of the family, but we have achieved a “good” session, and perhaps not an integrative experience from which he could develop forward.
How does one provide new and novel challenges for motor planning, while at the same time honoring the child’s need for a comfort zone? We have to spend time in developing a relationship of trust first, so the child would know that you would keep him safe. We have to decrease the triggering anxiety that causes a self protect mode. In this safety zone, the therapist also has to work with the family on the same aspects, as one good weekly session is not enough. The child has to generalize the feelings of safety and new learning to other environments as well and the best opportunities are at home.
We can linger for a moment on the aspect of transitions and talk further what we have discussed above. Once a child is working or playing on a task that he has now gained some comfort in, he is finding some modicum of enjoyment, maybe even accomplishment in achieving the task. His system is relaxing as the effects of the fight, fright and flight is lessening. The activity is becoming familiar and easier to engage in. Now we require the child to transition to a new activity and what we are essentially asking the child to do is an enormous task. He has to let go of the very essence of calmness he searches for every day and switch to a task that he might not know what to expect, not have any idea how long it will be taking him away from his current activity, and he knows that now he has to “re-gear” his entire system to adjust to another sequence of events. We take our systems for granted and we shift our attention relatively easily, but we also know that even our typically developing frames find new change to be a situation of increased energy and stress.
Children in learning and school environments as well as in therapy sessions have to face these transitions to the essentially “unknown” multiple times a day. You may argue, but why would the child not want to transition to an activity that he was engaged in multiple times before? Simply speaking, because of the maladaptiveness of the central nervous system, the child has not acquired the skill of automaticity in that particular task that habituation brings. The child has to essentially readjust his central nervous system each day as if he is learning or doing this the first time. His cognitive system may recognize the activity as familiar, but his central nervous system has not adjusted habitually to the onslaught of expectations the activity brings. We can all bring children to mind, on the autism spectrum or not, that we feel we have to re-teach the same action, the same material over and over again, even when they appear to have sufficient cognitive capacities.
Working with a child on the spectrum is very special and very rewarding. It is most likely the most severe sensory profile amongst diagnosis that a therapist can work with from a developmental perspective. The first order of the day is to meet the child where he is sensorily and emotionally and gain his trust. It is important that your families understand this process and do not rush their expectations on this delicate process. We truly understand and empathize with the family’s pain and anguish, but this simply cannot take over the needs of the child. The second important aspect is to become a keen observer of what interests the child in order to follow his lead. His lead of interest becomes the next scaffold for you to add one more step by your example (modeling) or your enjoyment that would woo him into your world and make the expectation seem safe. The child will learn if we are able to pull his intrinsic motivation into the situation.
An equally important notion to uphold at all times is to value what the child brings to the table as wonderful and to create in him a sense of power over his world. He has felt a “victim” of his environment for his short life thus far until he was brought to you and you have the power to empower him. It is the greatest gift we can give to anyone and as occupational therapists that understand sensory processing; we have a contribution to make that literally can change the entire future life of each child we treat.
Maude Le Roux, OTR/L, SIPT
Author of “Our Greatest Allies”
Co-author of book “The Listening Journey for Children”