A Floortime Consultation

Dear readers who don't have an interest in Floortime – you may find this post boring - please feel free to ignore this post 

Sometimes Floortime goes really well – like it did in the first couple of months of the year

And sometimes it does not – as its been these past month and a half I have been feeling a stuck in Floortime – not knowing what to do next and also feeling a certain dullness of spirit –

And so DH and I decide to go to a nearby city and resume our meetings with our Floortime Consultants ( FC)
It really is not the most auspicious time for us to go for an consultation as R has this dreadful mouth allergy – which has got infected and so he was in a lot of discomfort –

I ruefully say to DH that she will probably spend some time with him now and tell him we should let him just play with a string for the next few months

However DH is much more optimistic than I am and is confident that we will be able to show her his abilities and so off we go

We met with the consultant  for 4 hours over a couple of days

Here is a summary of what we learn

Obviously our FC's recommendations apply to R ( the I in DIR stands for individual ) and to get the most benefit out of Floortime its best to work one-on-one with a professional who knows you and your child

However not everyone can afford a FC or is following a Floortime based home therapy program.

Our FC is an excellent psychologist and some of her excellent advice could help any autistic child ( heck it could probably help any Neurotypical child – or dare I say – adult )

Here are some excerpts from our sessions:

A Floortime session in the consultation

R is every bit as distracted as any child would whose lips were cracked and bleeding would be

When we enter the consultant tells us to show us how we play with him
I try but am ignored by R

We tell her that R need to explore the office for a bit which he does
He is a little distracted and stimmy but shows some flashes of his usual self

Once he makes an elephant from blocks – the ears wont stay on and pushes the elephant in frustration
He holds the ears in his hands and looks sadly

The FC asks us if we know what he is thinking

I explain why he is frustrated

R comes to me with his ears and then I say "are these ears?"

He puts them on my ears and I "become" the elephant

The FC is thrilled and exclaims "that is what I am talking about.. understand his feelings .. respond to him without any judgment"

He plays with her wind up toys ( her favorite Floortime toy )

He plays with DH for a bit with cars

A few times I try to intrude and he is annoyed and goes to DH for comfort

One of DH's great strengths as a floortimer is that he is VERY patient and never in a hurry and can intuitively take R's pace

Several times he and she and we play with wind up toys and hand puppets who eat various things

A Floortime Session with the FC

This takes place the next day

When we go the second day – R surprises us with his eagerness to go inside the and says "All done living room ….go Play with Play doctor"

He asks to play with "the Food and the woof ( dog ) "

He knows in the food box, there are 4 Pizza pieces and he wants to put them together ( I know this as he has been learning Fractions on Morestarfall )

However the consultant goes through several circles of communication with R trying to collect the pizza pieces and the dog taking them away

( An important tip – when you are being the hand puppet – you are the hand puppet – so you don't say in a narrative style " The dog wants the pizza "
You ARE the dog and you say " I want the Pizza ")

But the dog wont let him and keeps taking away a piece in his mouth

R is very bugged by the dog and holds the toy dog's face and throws it to the corner

But the dog always comes back

DH becomes a spider and intrudes also

The FC – tells us – "don't be easy to ignore .. be persuasive .. be intense ..be in his face.. use fewer words … be relentless"

This goes on and on

And here is where he surprises us

Since just throwing the dog away did not work 2 or 3 times -- He finds a toy chest and puts the dog into the toy chest and shuts the chest

The FC exclaims in satisfaction – "THAT was beautiful – he solved a problem"

( this is how you build the problem solving muscle – and make no mistake – it IS a muscle - through Floortime )

The FC tells us that we need to be in his face , high affect ,


Here are the main pointers from the Floortime Consultant for R

Why does he play for a little bit then go away ?

Because its too much ; he needs to regroup and process and then be back.

Should we let him leave or should we pursue the same theme? She said, if she feels he needs a break then she would let him. However if he is just avoiding for another reason she would pursue further.

Play dates

We should do playdates – but with one child ( no social groups – as R would find it easy to fly under the radar in a group ) preferably a girl who is 7-10 years old – According to the doctor these are the best Floortimers

She says she trains some High School students but that her most important instruction is always that they both have fun and have joy . The biggest goal is pleasure

Aides in School

 Aides tend to become compliance enforcers and that is really not required for him – he needs an angel on his shoulder that keeps reminding him to reconnect with what is going on in the class- for instance if he shows manipulation skills – the aide should feel joy at that not shut it down
We don't need to be looking for a lot of independence either

How can we elaborate on Play Scenarios?

Step by Step :

R like many kids started to pretend play with sleeping and eating - example one play scenario is that – his dolls go to bed – we elaborate with snoring etc but there it ends –
He only increases the breadth – so his other dolls go to sleep …how can we deepen the plot ?

Her answer is that we need to make the game more elaborate but just adding one more step at a time –

So we could get 5 dolls to sleep and then do the song – 5 in the bed and then the doll falls down and so on
Or add an emotional idea – example one of the dolls says "that is TOOO LOUD " ( that is the doll is having an emotional response –feeling bugged )

In the eating game where we are feeding the dolls, add maybe an unexpected twist – preferably an EMOTIONAL idea like a joke – where the doll says that is YUCKY and spits the food out
The concept of joke and unexpected is HUGE

Go Slowly

There is no rush in Floortime – don't be in a hurry to climb the developmental ladder – build a strong foundation at each stage

Tailor everything to where he is Explore higher levels of Cognition

We talked about his several interests such an planet, numbers , music – She said we should take these further and further

We said that we found out yesterday that R knows multiplication and her response was that this flat and rote – we need to see if he can problem solve –

That is the point of following his lead into things

We want to explore the regions on his cognition that are not being touched currently

Don't ask him questions like" what is a triangle" he knows that – that is boring
We said – he loves his old familiar things – ( like Baby Einstein ) – she said that is fine – I am not saying take those away

But keep building on each interest

Example, if he can distinguish between Beethoven and Mozart – ask yourself the question – where could this take us

The idea is an opening up – of R have more, deeper and bigger thoughts and following a passion to eventually have grey area thinking

For in Floortime we are teaching how to think

Whether its numbers or planets that your kid is interested in - you are going to use it to develop the most important skills in Autism - relating ( making you a part of their shared world ) , communicating and thinking ( solving problems , metathinking - which is thinking about your and other people's thoughts , and grey area thinking )

She did notice all his strengths and thought of him as "full of potential" "has a lot in there" and said who knows you may have a mathematician in there ( but that honing rote skills will get us nowhere )

I also noted with interest that in developmental models you don't get any points for a well mannered/compliant child

Harness motivation in everything

Ask all providers – ST OT and PTand  conversation and play therapists  – how they are using his motivation – not just building his skill

School

The FC had lower expectations from school

They are going to focus on the building of rote skills that he will acquire anyways since those are the things he likes
It's the gray area thinking that he needs that school will not help him have

We talked about how we are thinking of mainstreaming next year as he is unhappy in the special – ed class
Her response that he probably likes the main stream class as he is able to ignore them and go under the radar

Where as his special needs class he notices them and talks about them later ( DH and I are not sure we agree- I think there is too much emotional energy he spends worrying and feeling unhappy )

She also said that before thinking homeschooling – just think about how much more you can do with the hours you have with him and when you are in charge – so if he has 30 hours of school – he has another 50 hours when you are in charge .

And that in her opinion parents spend way too much time thinking of how to optimize school ( where they have little control ) and too little time thinking about home ( where they are completely in charge)

We talked about our idea of a peer mentor and she said that in her experience this does not work too much as ist grade onwards school is focused on rote academics and there are very few opportunities to play and for a peer to mentor. She does not think it's a bad idea but does not have too much hope for it

How much Floortime is he getting?

I said we have Floortime as a lifestyle and we 30 mins-60 minutes daily.

And she said we have to do a lot more – get his therapists to modify their methods to incorporate Floortime
Intrude when he is on the computer but not in an intrusive way – example – get your own computer and do what he is doing with him

Outside help

 Get some outside help – their only goal being that they both play with high energy and they both have fun

Physical Exercise

 In her POV – the ratio of something physical should literally be 20 minutes in an hour
Jumping Swinging Crashing into things –

She said that he could start his day with singing and swinging – instead of computer ( which will only start off a self absorbed day )

All these things will help him organize himself

Computer

She said we should limit access to electronics and then maybe has access to computer/wii / DVD anything with a screen about max 4 hours and keep reducing and he has to ask for it

So he is not always choosing between computer and us

Avoid repetitive tasks

 Neurons that wire together , fire together

If you are engaged in repetitive tasks - Neuroplasticity means that those neurons are firing together

Its not neutral

We brain – not an I brain

He spends more time in an "I " brain and we need to put him more on a "We" brain

Can you use even the computer to foster the "We" brain – can the computer have pictures of mom and dad
(Book Recommendation: Mind Sight Dan Seagal )

She pointed out several times how hard R is to engage and how much he ignores our overtures

How much of his interactions with him are very much on his own terms( ouch !!- while this hurt to hear , DH and a friend pointed out that is the definition of Autism)

Take the things that are best and figure out how to make them longer

 So if he enjoys swings and snuggling and jumping – and see how to elaborate and make them fancier and fancier
Keep adding variations –at little variation on what they mostly like and that adds a twist
Look at all the games you are playing and brainstorm on ways to add a twist

Use the ways/ mode that get you connection

At that point in our conversation, R was building a Giraffe with blocks and we asked him "what are you making "?

R ignored this

The FC said, "Don't waste energy on what he does not respond to – for example " don't ask questions … don't do a narrative"

Because we can put out a lot of energy on what he does not respond to and get discouraged

Instead of speaking, perhaps we could use the written word and song

The FC wrote GIRAFFE and HORSE on two pieces of paper and asked him to choose after getting in his face

Then he made Steps and she wrote STEPS

Then we elaborated ..and the giraffe and Rhino went up the steps

And we made a song about the rhino falling down

R smiled at this and completed the song

Then I fed the rhino a banana

Always add the unexpected

 The FC suggested that its very important to be unexpected – for instance, the rhino would spit out the banana and say "that is Yucky"

The rhythm of the interaction would be – expected-expected – unexpected – so if you are playing pillow sandwich – you would Add ketchup and mustard and then suddenly you would add ice-cream – that he may find funny

If he has a routine that he repeats in the morning – add a twist and say you are going back to bed ( here I added that wouldn't an unexpected thing be "stand on your head after you wake up " – her point was that that would not be as funny as going back to bed as it was not the twist on the same thing )

Going for the WOW

 Make an inventory of everything that works – everything that elicits a WOW
You want to stretch stretch stretch and open the mind and open his life

Prioritize things that you like too

If there are things that the both of you like doing - - they go on the top of the list

Add drama to everyday favorite things

 For example one favorite thing of R's is when I get home – So DH could do a countdown and then the real life event would be dramatic and exciting !

Neuroplasticity

She repeated that "neurons that fire together wire together "– example a 90 year old brain that takes lessons to play the violin will start to change their brain - which is why all individuals are capable of doing a lot more then what their initial capacity appeared to be .

So you have to make hay VERY slowly – but there is also no time to lose 

The Things that R is learning these days

Here are some things that we are doing with R these days

Expanding of themes and Pretend play

One interesting thing I am noting these days is how R expands everything he learns

Example- he used to love to make me play an imaginary violin – ( tune from Elmo’s Key-board-a-rama )

Now he has broadened that theme –

So he will point to a scrape on his hand and demand “Hurt play violin”

Then I must move the scrape from side to side ( as though it were the strings of a violin)

or “Potty Seat play violin” or “Water play violin”

I try to stretch the theme in another direction to another musical instrument but same object “ Water play piano “( clarinet, flute, drum and so on )

To further branch out, I also make this the theme of our alphabet game in the trampoline while jumping –

So I will say “ A for “... expectant pause  and R will reply “Accordion” ,

B for Banjo ,

C for clarinet,

D for drum and so on

( We make some exceptions for some we do not know and we cheat for those alphabets , like E for Elephant.

A few alphabets stand for R’s favorite things so there is an exception made for these as well – Example R for “Rudolph the Red Nose Reindeer” and S for “Santa Claus is coming to town” and “Y for “Yellow Submarine”. And of course “ M for mummy “)

It’s the same with all the Pretend play –

if he learns a general scene in the Dollhouse – Example mom climbed up the stairs and went into the kitchen

He will recreate the same theme with another playset – with Rocket and make the Little Einstens solemnly climb up the stairs of the rocket

The idea is that this will then lead to original themes

Pretend play is critical for abstract thinking which is one of the main gaps that can remain in Auties which is why DH and I  are very focused on it and one reason why our house looks like a toy store

Social Referencing

We are trying to teach R is to follow the gaze

( try this in your car on the highway – look on the side to the person riding the car on your side – invariably that person will look around to take a look at you – Neurotypical people reference socially in a matter of course. Auties ? Not so much )

I am trying to teach this to R – like in the library there are dolls on the ceiling

I ask R – “Find Elmo”

Then I look at Elmo and see if he will follow my gaze

Language

Coming painstakingly slow

Though what he has is logical –

the other day I poured water on him in the bathtub - as he moved away I asked  solicitously

“Warm?”

“Hot” he replied

Scripts are not a perfect solution either

Example: if he wants candy we have taught him the script “Can I have a Blue Dum Dum Please?”
However if he wants to go to Toys R Us he will use the exact same scripts “Can I have a toys r us please”

Its logical and meaningful but not fluid

Another example,  when I return from ATL at 5.30 pm on Tuesday, I find that R’s therapist is here: I slink around soundlessly( I know from past experience that if he sees me he will waste his therapy session in tears  and demand Mummy time every 2 minutes )

When the session ends R gasps with joy and does his happy dervish dance saying “ Mummy Mother Mama”
( so he is expressing joy in a very typical fashion - but typical words needs to come too )

A charming thing he does these days when I say Good Bye to him he replies anxiously " hello miss mummy" as he does not want me to go
( again a logical expression but still not right )

(  beatles are a big favorite with R , and he watches their videos on You tube which is the reason for the Hello Goodbye motif)
You can see the theme in all these examples - he is communicating through words clearly, but still has such a long way to go

Joint Attention

He loves to show us all his hurts

DH teases me that he is a hypochondriac - but I wonder if its  less to do with self pity and more to do with the fact that he wants to express himself and this is one of the few ways he knows how to talk about

In fact this skill of joint attention where child shows you something and their pleasure is increased by you sharing in that pleasure is really great !

So he will say and sometimes write on the side of the bath tub things like

Arm Hurt

0 hurt ( 0 stands for his stomach as that is what he calls his navel owing to its shape )

I truly feel that one day R will be a great chatterbox

OT Things

To check the crossing over the midline – the other day while he was eating chair – I put some Shredded cheese ( he loves this ) in a plate on his left side

Interestingly I noticed that our OT was absolutely right and R switched hand dominance constantly

However he crossed over the midline - as in right hand crossing over to the left side to pick up the cheese

Episodic memory –

Another thing we are also trying is – help him understand his day – so while I am putting lotion on him after bath in the night – I ask

Me : Today in the morning we went to the park.. there we played with ……. ( I leave an expectant pause )

R Replies “ L and C”

Me: Then we came back home and played on the ……. ( expectant pause )

R replies .. Wii Fit

Episodic memory is critical becasue it is the starting point of what Greenspan would say are Level5 and Level 6 of thinking - grey area thinking - things like self reflection on emotion

So R at a later stage would need to think about his trip to the park at higher and higher levels

Then describe his emotion on that trip

Think about the memory from different perspectives - understand how he came across to C and L

Then eventually be able to reflect on his emotion  and correct course for the future
example

Medium Level thinking : I had a lot of fun because of  I love physical activity

Slightly higher level thinking  "I think C likes me because she tried to spend time with me at the park"

Highest level thinking  " I stayed too focused on the physical activities.. i should have spend more time socialising"
But it all has to start with episodic memory and practising thinking about it !

I am typing up this summary on my way back from Detroit – after a looooong day at work and all my co-workers have fallen asleep

But not me

I love this bit of any work trip

The bit before I get home

Anticipation is a lovely thing and a great source of joy for me .

One onerous thing that mums and dads  of auties realise at some point in time is just how much needs to be taught - when your child is younger you think in terms of speech
Of course the flip side - and the side that I choose to focus on - is how much potential there is in our kiddos

And if you treat developmental milestones with a  "what is next in my journey" perspective rather than a "he is 6 and still not doing .... " perspective - you have just as good a shot at happiness as anyone else !