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- 1. www.relatetoautism.com SCIENCE BEHIND GROWTH THROUGH PLAY SYSTEM Empowering Parents and Professionals 800-340-5978
- 2. relatetoautismTM CONTENT Overview...........................................................................................................................................................3 Current Neuroscience and Autism ................................................................................................. 3 Approaches to Autism Treatment.................................................................................................. 3 The Role of Parents ....................................................................................................................... 3 Autism: The View from Current Neuroscience ...................................................................................................4 Brains Develop Through Dynamic Interaction with the Environment ............................................. 5 The Brain is Malleable ................................................................................................................... 5 Autism Treatment: What Works ........................................................................................................................6 Naturalistic Behavioral Approaches ................................................................................................. 6 Developmental Approaches ............................................................................................................. 6 Convergence..................................................................................................................................... 7 Comparing Approaches ................................................................................................................. 7 Interactive Style................................................................................................................................ 7 Curriculum ........................................................................................................................................ 8 Autism Treatment Summary ......................................................................................................... 8 Parents: The Missing Link ..................................................................................................................................9 Parents are Essential ..................................................................................................................... 9 Parental Well‐Being is Critical........................................................................................................ 9 The Growth through Play System .................................................................................................................... 10 References ...................................................................................................................................................... 11 -2- Relate to Autism, Inc © 2010 all rights reserved
- 3. www.relatetoautism.com OVERVIEW Current Neuroscience and Autism Neuroscience has shown us that autism is not caused by a fundamental difference or deficit in brain structure as previously assumed. Instead, current research tells us that autism is the behavioral level manifestation of a “miss‐ wired” brain, a brain with insufficient interconnectivity and synchronization among multiple, disparate regions. As a result of this, children with autism tend to focus on activities that require minimal coordination among brain regions (e.g., reciting isolated words and details, or focusing on static stimuli and repetitive tasks) and avoid activities that required coordination of multiple brain regions (e.g., comprehending stories, seeing the ‘big picture’, or learning new tasks where previously learned rules don’t apply.) This focus in turn reinforces the parts of the brain that facilitate local interconnectivity at the expense of the parts of the brain that facilitate global interconnectivity; an accelerating feedback loop. The good news is that research has shown that the feedback loop can be reversed; through various forms of interaction, children can rewire their brains to improve global interconnectivity and their commensurate ability to perform tasks that involve multiple regions of the brain. A converging body of evidence from psychology is showing us what types of interactions (with people and objects) help reduce the core symptoms of Autism and facilitate increased social interaction, communication and range of interests. Approaches to Autism Treatment While researchers work on identifying why so many children have miss‐wired brains, those of us working directly with families affected by autism can apply this understanding to helping children now. Based on the neuroscience of autism, the effectiveness of a treatment approach can be gauged by its ability to cause the desired change in the interconnectivity and synchronization of disparate regions of the brain. There are fundamentally two schools of thought regarding autism treatment, Behavioralist Approaches and Developmental Approaches. The most significant differences among these approaches can be calibrated in terms of prescribed interactive style and the criteria by which curricula are selected. Interactive styles vary from highly directive to highly responsive. Curricula selection varies from age‐appropriate criteria to developmentally appropriate criteria. The Role of Parents The rapidly escalating number of cases of autism has made the previous practitioner‐centered model of autism treatment impractical in most regions. To be effective, children require intensive, daily input from emotionally attuned and developmentally informed adults. With professional guidance, parents can become the best therapists and program coordinators for their children with autism. Relate to Autism, Inc © 2010 all rights reserved -3-
- 4. relatetoautismTM AUTISM: THE VIEW FROM CURRENT NEUROSCIENCE Autism results from a poorly connected and poorly synchronized brain. The most robust finding in the neuro‐anatomy regarding autism is that people with autism have increased brain volume. This increased brain volume is composed primarily of cerebral white matter, the material that interconnects different regions of the brain. Cerebral white matter can be divided into an outer zone containing the radiate compartment (the material that interconnects local brain regions) and an inner zone containing sagittal and bridging system compartments (that interconnect distant regions of the brain). In autism, enlargement is localized to the radiate white matter, whereas inner zone white matter compartments showed no volume differences from controls. In other words, people with autism have brains wired in a way that favors local communication over global communication. In people with autism, this pattern of increased local interconnectivity and decreased global interconnectivity is even more pronounced in pre‐frontal areas, the areas of the brain that are typically most globally interconnected as they are responsible for integrating information from multiple brain regions for higher‐order or abstract processing (see Herbert, 2005). Brain areas that are under‐connected do not process information in a manner that is synchronized with other brain areas, a process that is necessary for processing multi‐sensory information. Most recent reviews suggest that the symptoms of autism may therefore be the result of brains that are under‐connected and poorly synchronized (see Gepner & Féron, 2009). In the absence of strong global interconnectivity and synchronization, tasks that require integration of dynamic information from multiple channels (such as social interaction, communication and abstract reasoning) are very challenging for people with autism. Whereas tasks that involve processing of more static information from minimal channels comes more easily due to the relatively stronger localized interconnectivity. Strengths of People with Autism Challenges for People with Autism Activities that require minimal coordination among Activities that require significant coordination among regions of the brain regions of the brain • Encapsulated cognitive strengths, such as • Higher‐order processing challenges, such as story hyperlexic (isolated) word reading or focusing on comprehension individual details (rather than the bigger picture) • Novel tasks which require new processes • Hyper‐focus on static stimuli, such as physical because previously learned rules don’t apply objects or highly repetitive tasks • Shifting to new tasks or strategies • Tasks that require learning rules • Activities such as social interaction that involve • Sticking to and completing repetitive tasks integration of multi‐sensory, dynamic stimuli, in • Excellence in visuo‐spatial or memory tasks particular, eye movements, facial expressions and speech sounds. -4- Relate to Autism, Inc © 2010 all rights reserved
- 5. www.relatetoautism.com Brains Develop Through Dynamic Interaction with the Environment As infants interact with the world of people and objects, their brains organize and wire themselves to support adaptive behavior. A child who’s brain does not easily process multi‐sensory dynamic information requiring integration will interact with people and objects in atypical ways. This may be very subtle at first but begins to become noticeable by twelve to eighteen months of age when major communication milestones are missed. As an infant spends less time processing multi‐sensory, social information and subsequently more time processing less complex (usually non‐social) information, he misses out on the “social education” being gained by his typically developing peers (see Mundy and Acra, 2007). As time goes on, this child’s developmental trajectory becomes increasingly removed from that of his or her more typical peers. The altered patterns of interaction with the world lead to the development of neural circuitry that supports more of the behavior symptomatic of autism in a rapidly accelerating feedback loop. The Brain is Malleable Much research has been published over the last two decades to tell us that our brains are malleable and that neurons re‐wire their connections in response to our interactions with our environment (Doidge, 2007). A recent fMRI (functional Magnetic Resonance Imaging) study captured images of white matter growing to form more typical connectivity between previously under‐connected brain regions in children with learning difficulties. After intensive reading instruction these children showed increased white matter connectivity and significantly improved reading ability (Keller & Just, 2009). Studies such as this and others indicate that by regularly and consistently providing children with autism input that stimulates processing of dynamic, multisensory information, we can help them to rewire their brains in a way that improves global interconnectivity and synchronization. To effect significant neurological change, autism interventions must: impact how a child interacts with his or her physical and social environment by providing focused, intensive multisensory input and stimulation on a regular (daily) basis. Relate to Autism, Inc © 2010 all rights reserved -5-
- 6. relatetoautismTM AUTISM TREATMENT: WHAT WORKS Autism treatment is a dynamic and evolving field with many approaches that vary in many ways. However, at a high level each of these approaches falls into one of two categories: Behavioral and Developmental. The most recent evolution of the Behavioral Approaches as known as Naturalistic Behavioral Approaches. Naturalistic Behavioral Approaches Autism treatment began in the 1960s with behavioral based models that evolved into what we now know as Applied Behavior Analysis (ABA). These approaches are based on the assumptions of learning theory, that all voluntary behaviors (e.g. play, social interaction and communication) are learned and maintained through antecedents (what happens before the behavior) and consequences (what happens after). New skills are taught through manipulation of the antecedents and systematic application of reinforcement of targeted behaviors. Early behavioral approaches were highly structured and adult directed (e.g. Naturalistic Behavior Approaches Lovaas, 1973) and include the use of discrete‐trial training. Since then • Incidental teaching the field has evolved to improve child outcomes and generalization of • Milieu teaching skills. Newer versions of behavioral treatments are employing more • Natural language paradigm naturalistic environments and more child‐centered approaches. • Pivotal Response Training Developmental Approaches Research on both the earlier structured ABA programs (Rogers and Vismara, 2008) and the later naturalistic approaches (Schreibman, • SCERTS • Denver Model 2005) have found positive outcomes for about half the children • Floortime / DIR involved. Generalization and maintenance of skills has been found to • Responsive Teaching improve when parents are trained in supporting behavioral techniques (Ingersoll and Gergans, 2007). Developmental Approaches Another group of treatments has emerged in parallel since the 1980s, these are known as developmental approaches. These treatments emerged from a combination of Piagetian developmental theory and psychoanalysis (e.g. Greenspan and Lourie, 1981) and social‐pragmatic theories of language development (Bruner, 1983). They are based on the core assumptions that: • Social‐communication skills are learned in a similar developmental sequence by all children regardless of their ability • Children learn primarily through affect‐laden relationships with responsive primary caregivers Being newer, less research has been performed on developmental approaches than behavioral approaches. Studies that have assessed the efficacy of developmental approaches have found positive results (e.g. Aldred, et al, 2004; Kasari et al, 2008; Gerber, 2003; Mahoney and Perales, 2003; Dawson and Galpert, 1990). -6- Relate to Autism, Inc © 2010 all rights reserved
- 7. www.relatetoautism.com Convergence These two fields of autism treatment have developed over the past twenty years largely independently of one another due to differing philosophical backgrounds. However, recently, people representing either perspective are coming to mutual recognition of the commonalities in implementation. As a result, new hybrid approaches are emerging. Positive results are being found in approaches such as Enhanced Milieu Teaching (Kaiser and Hester, 1994), Responsivity Training and Pre‐linguistic Milieu Training (Yoder and Warren, 2002), Parent‐mediated Approaches (Ingersoll and Dvortcsak, 2006) and most recently the randomized control trial of the Early Start Denver Model (Dawson, et al, 2009). Comparing Approaches Although developmental and naturalistic behavioral approaches to autism come from different philosophies and research traditions, in practice there is little difference in their general implementation (Ingersoll, 2010). The primary differences can be calibrated in terms of: • Interactive Style: The manner in which an adult works with a child • Curriculum: The criteria by which goals, metrics and activities are selected Interactive Style Although most practitioners engage children in a variety of ways, Interactive Style can be divided into to fundamental categories: a Directive Style and a Responsive Style. These are characterized below. A Directive Style A Responsive Style • Emphasis on adult initiations and child responses • Allowing a balance of child and adult initiations • Teaching episodes focus on adult‐selected and responses objects, activities or topics • Teaching episodes focus on child‐selected objects, • Emphasis on goal achievement and task activities or topics accomplishment • Emphasis placed on affect and emotion‐sharing • Prompting or direct requesting of target • Pausing or indirect invitations for child to perform behaviors from child target behaviors • Higher ratio of imperative (“Give me the truck”) • Higher ratio of declarative (“What a nice truck!”) to declarative (“What a nice truck!”) adult to imperative (“Give me the truck”) adult language language use use • Adult behavior goal‐directed • Adult behavior sensitive to child’s developmental level and current state of sensory‐regulation No approach to autism treatment prescribes one or the other of these interactive styles exclusively. However, various approaches tend align more with one than the other in a manner consistent with the goals of the treatment program. Notably, a responsive style of interaction has been found to increase children’s social, emotional, communicative and cognitive development in numerous studies (Trivette, 2003). Relate to Autism, Inc © 2010 all rights reserved -7-
- 8. relatetoautismTM Curriculum Another significant difference among various treatment approaches lies in the criteria by which a curriculum (a set of goals, activities and metrics) is established for a specific child. Criteria for the selection of curricula fall in to basic categories: • Age Appropriate: activities and goals determined by a child’s chronological age • Developmentally Appropriate: activities and goals determined by typical developmental sequence Research in child development has shown that children with autism follow a developmental path similar to that of typically developing children. However, children with autism are delayed in their progress along this path (not deficient as previously assumed). Studies have found this to be the case for such key social development areas as expressive language (Tager‐Flusburg, et al, 1990), imitation (Rogers et al., 2008) and symbolic play (Lifter, et al, 93). Typically, the set of skills being taught to a child is age‐appropriate (defined by his or her chronological age). A child at age four is taught one set of skills and a child at age seven another. Children with autism often skip developmental steps making it difficult to learn skills defined by their age. Therefore, teaching children with autism skills that are developmentally appropriate (i.e., skills defined by the typical sequence of developmental steps rather than chronological age) allows for faster learning and a more enjoyable learning experience for both child and adult. For example, teaching verbal language skills to a child not yet using gestures is not developmentally appropriate (regardless of his age) as all typical children develop gestural communication before verbal language. Furthermore, ongoing research is identifying a few “pivotal” skills on which many other skills depend. Acquisition of theses skills impacts wider areas of development. For example, teaching symbolic play skills or joint attention skills produces increases in expressive language even when expressive language is not directly targeted (Kasari et al, 2008). Autism Treatment Summary Modern approaches to autism treatment can be divided into two basic categories, Naturalistic Behavioral Approaches and Developmental Approaches. Although philosophically different, in practice these two schools of thought are on a convergence path. Across these categories, various approaches to autism treatment can be distinguished in terms of their prescribed Interactive Style and Curriculum. Interactive styles vary from highly directive to highly responsive. Selection of curricula varies from curricula that are age‐appropriate to curricula that are developmentally appropriate. -8- Relate to Autism, Inc © 2010 all rights reserved
- 9. www.relatetoautism.com THE MISSING LINK Parents are Essential To access its innate neuroplasticity (changeability) a disconnected, unsynchronized brain requires regular engagement in motivating, meaningful, affect‐laden activities with a more advanced social partner. The National Research Council (2001) recommended that parents be included in their children’s treatment. Siller and Sigman (2002) found that, when mothers were naturally more responsive, their children with autism made significantly greater improvements in joint attention and language over periods of one, ten and sixteen years than did children whose mothers were less responsive. A review of thirteen separate studies found that caregiver responsive style of interaction facilitated significant improvements in cognitive and emotional‐ social development for children with, or at risk of, developmental delays (Trivette, 2003). Parents are essential to the social, emotional, communication and cognitive development of their children. Numerous studies have found that parents can be trained to effectively deliver interventions for their children (e.g. Ingersoll, 2007; Solomon, et al., 2007; Solomon, 2008). Given the lack of qualified professional providers and the alarming incidence rate of autism, and other neurobiological disorders of childhood, the role of parents as primary therapists cannot be underestimated. Parental Well-Being is Critical Parents of children with autism have been found to suffer more stress than parents of children with other diagnoses or those who are developing typically (Estes, 2009). A parent’s emotional state affects their child The Growth through Play System supports parents through every interaction. In fact, the positive to help them: benefit of professionally delivered treatments is • Gain emotional resolution about the diagnosis reduced for children whose parents have the • Reduce stress and increase well‐being highest stress levels (Osborne et al, 2008). • Adapt their parenting style to facilitate their Parents who have come to an emotional resolution child’s development about their child’s diagnosis are more likely to use • Identify pivotal social‐communication milestones a joyful, playful, supportive and responsive for their child parenting style with their children (Wachtel and • Engage their child in joyful, meaningful, Carter, 2008). reciprocal interactions to increase child learning Relate to Autism, Inc © 2010 all rights reserved -9-
- 10. relatetoautismTM THE GROWTH THROUGH PLAY SYSTEM The Growth through Play System (GPS) is designed to optimize the rewiring of a child’s brain to facilitate improved global interconnectivity and synchronization by focusing on intensive, multisensory, interactive activities that stimulate high levels of inter‐region brain activity. The system helps parents and practitioners to identify pivotal developmental steps that a child has missed and then prescribes activities that can be conducted by parents with the child in a responsive interactive manner to help the child fill developmental gaps. By focusing on missing pivotal skills and developmental steps, the GPS indirectly addresses other missing or challenged skills that depend on the pivotal skills making those skills easier to acquire and develop. The GPS is focused on enabling and empowering parents as primary therapists in their child’s treatment program by providing simple and easy‐to‐implement guidelines relative to curriculum and interactive style. It considers parental well‐being to be a critical success factor in child development. For more information on the scientific foundations of the Growth through Play System or about relate to autism, please visit www.relatetoautism.com or write us at support@relatetoautism.com. GETTING STARTED • To learn more visit www.relatetoautism.com and sign up for a free trial 30‐day membership • Read “The relate to autism Member Tools” • Read “The Growth through Play System for Parents” - 10 - Relate to Autism, Inc © 2010 all rights reserved
- 11. www.relatetoautism.com REFERENCES Aldred, C., Gree, J., Adans, C.(2004)A new social communication intervention for children with autism: Pilot randomized controlled treatment study suggesting effectiveness. Journal of Child Psychology and Psychiatry, 45(8), 1420‐1430. Abstract Bruner, J. (1983) Child’s Talk: Learning to use language. Oxford: Oxford University Press. Dawson, G. (2008) Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorder. Development and Psychopathology, 20, 775‐803. Full Text Dawson, G. and Galpert, L. (1990) Mothers’ use of imitative play for facilitating social responsiveness and toy play in young autistic children. Development and Psychopathology; 2: 151‐162. Abstract Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., and Varley, J., (2009) Randomized, controlled trial of an intervention for Toddlers with autism: The Early Start Denver Model. Pediatrics, 125 (1), 17‐23 Full Text Doidge, N. (2007). The brain that changes itself: Stories of personal triumph from the frontiers of brain science. New York: Viking. Estes, A., Munson, J., Dawson, G., Koehler, E., Zhou, X., Abbot, R. (2009) Parenting stress and psychological functioning among mothers of preschool children with autism and developmental delay. Autism, 13(4) 375‐387. Abstract Gerber, S. (2003) A developmental perspective on language assessment and intervention for children on the autistic spectrum. Topics in Language Disorders, 23, 74‐94. Abstract Gepner, B. and Féron, F. (2009) Autism: A world changing too fast for a mis‐wired brain? Neuroscience and biobehavioral Reviews, 33, 1227‐1242. Abstract Greenspan, S. I. and Lourie, R. S. (1981) Developmental structuralist approach to the classification of adaptive and pathological personality organizations: Infancy and early childhood. American Journal of Psychiatry, 138, 725‐735. Abstract Herbert, M. R. (2005) Autism: A brain disorder or a disorder that affects the brain? Clinical Neuropsychiatry, 2(6), 354‐379. Full Text Ingersoll, B. and Gergens, S. (2007) The effect of a parent‐implemented imitation intervention on spontaneous imitation skills in young children with autism. Research in Developmental Disabilities, 28, 163 ‐ 165. Abstract Ingersoll, B. (2010) Teaching social communication: A comparison of naturalistic behavioral and developmental, social‐pragmatic approaches for children with autism spectrum disorders. Journal of Positive Behavioral Interventions, 12 (1), 33 ‐ 43. Full Text Ingersoll, B. and Dvortcsak, A. (2006) Including parents training in the early childhood special education curriculum for children with ASD spectrum disorders. Journal of Positive Behavior Interventions, 8, 79‐87. Abstract Kaiser, A. P. and Hester, P. P. (1994) Generalized effects of enhanced milieu teaching. Journal of Speech and Hearing Research, 37, 1320 ‐ 1340. Abstract Kasari, C., Paparella, T., Freeman, S. and Jahromi, L. B. (2008) Language outcome in autism: randomized comparison of joint attention and play interventions. Journal of Consulting and Clinical Psychology , 76 (1), 125 ‐ 137. Abstract Keller, T. A. and Just, M. A. (2009) Altering cortical connectivity: Remediation‐induced changes in the white matter of poor readers. Neuron, 64(5), 624‐631. Abstract Relate to Autism, Inc © 2010 all rights reserved - 11 -