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Is your child difficult to motivate? Does your child have big emotions or difficulty communicating in the usual ways? I remember the long years when my Peter couldn’t talk, couldn’t hold a pencil, and didn’t want to play,  when his only sure motivator was food. To add to that, in his teen age years, as often happens, his emotions exploded with massive dysregulation due to OCD and anxiety. I used to think that the arts were only for other kids, less impacted with autism, or maybe savants. But I’m telling you, I was wrong. It turned out that the arts played and continue to play an important role in Peter’s development. The arts may actually be a part of the solution for your child as well.

How do you begin? How do you lay a foundation for creativity? I believe  that for our family, doing hours and hours of floortime laid the foundation. Now mind you, more often than not, Peter didn’t look like he enjoyed it; he looked like for all the world all he wanted to do was withdraw and be left alone. We doggedly proceeded as a matter of faith. During the long years Peter had almost no language, we did a lot of play centered around reenacting emotionally charged events that happened in Peter’s life with stuffed animals or an analogous theme, at first demonstrating a more adaptive reaction, then eventually as he got more and more into it, letting Peter create his own new endings. It wasn’t until years later that I asked Peter what he thought of those many hours of DIR, and he said he felt like “Cinderella at the ball.” (see Profectum.org for parent training resources, especially the new free “Parent Toolbox”)

Once Peter started using a Vantage, an icon- based augmentative communication device, we added the habit of journaling and reflecting. See this little icon?  I would carry it in my pocket. On walks or outings, I would pull it out, and ask Peter, “So what do you see? hear, touch, smell, taste? ” whatever made sense, depending on the experience.  Later in the day, I’d pull it out again or draw it in reflections, during bedtime prayers or in conversations with his dad, asking “so tell Dad what we did? or how did you feel about that?”, so he could enjoy the experience, savor it,  thoroughly all over again. We would reflect on negative experiences too to reprocess them. So Peter built his foundation of emotional self awareness, perspective-taking, and internal standards at the same time he built his language. In fact, I’d go so far as to say that he put in the hard work of learning language because it was so emotionally relevant to him to talk about both the bad and good times of his life.

If you want to see the steps laid out methodically for building this kind of foundation using floortime and reflections for a child with minimal language skills, they’re all in a book I wrote in 2012, entitled “Teaching Your Child with Love and Skill: a Guide for Parents and Other Educators of Children with Autism, including Moderate to Severe Autism,” published by JKP.

What has happened in the 5 years since then? I would say an explosion or revolution in development. What made that possible was Dr. Ricki, who introduced Peter and me to Darlene Hanson, a speech pathologist from REACH who introduced Peter to supported typing (http://www.reach.services). Supported typing is a topic for a future conference; for now let me just say it is a way to support the child in all areas, and as Peter recently put it, “Darlene snared my fleeting thoughts, enabling my thoughts to get out and stand on paper rather than scurry for cover.” Typing gave Peter the means to show what he knows, such that he was able to eventually transition to diploma tract. Even more importantly, typing allowed him to express himself and develop his creativity with the written word, with the efficiency, speed, and flexibility that icon-based AC could not provide.

His poetry today (see “My World as a Poemhttps://www.amazon.com/dp/1544634110/) is very much a development upon our old journaling habits- he writes about his daily experiences and inner life. It came providentially at the time his OCD and anxiety exploded, as often happens in the teen years. So Peter had an outlet for and a tool to handle his emotional dysregulation in writing. Creative writing has been critical for Peter to process and handle his big emotions, and conversely, because necessity is the mother of invention, the big emotions have been a  driving force behind the development of his creativity. The illustration shows how stress can trigger the amygdala (lower brain) to activate a fight or flight motor response, but the frontal lobes (upper brain) may learn, with nurturing and practice, to modulate that response, especially using creativity as a strategy.

 

 

 

 

Let me show you how this works in a real life example.

Two weeks ago, Peter developed a new OCD. He discovered an extra long rubberband, which he enjoyed stretching and plucking in the usual way. But then he started holding it between his teeth, letting the end dangle like a long string from his mouth. I didn’t want him to swallow it, nor look really odd to others. But first thing when he woke up in the morning, he started lunging for the drawer where he had placed the rubberband the night before.

I sat between Peter and the drawer.

“Peter, slow down! Is something driving you crazy?”

Peter tried to reach past me for the drawer, that crazy, driven OCD gleam in his eyes.

“Ok, calm down. Take a deep breath. That’s it. Come on, tell me what’s going on. How badly do you need to do this, on a scale of 1 to 5?”

Peter typed, “4+,” as he perseverated, “Rubber band! rubber band!”

“Remember Peter, if you feel that driven, this may be an OCD. If so, it’s probably telling you some false thought like, ‘If you don’t get that rubberband, you’ll explode.’ Right? Ok, how about we slow down a minute, and just talk about it first. So tell me, what’s so appealing about that rubberband? What would you do with it, if you could get to that drawer?” Peter started typing about all the great qualities of a rubberband. Always fun to think about a compulsion. After he got his thoughts down, I suggested we play around and divide the thoughts into short lines of verse. We picked out the most vivid vocabulary,   made lists of words that rhymed with them, then rewrote the corresponding lines to get the rhymes  in at the end. After one stanza, I asked another question,

“But what’s the down-side of holding that rubberband in your mouth?” We brought in a little perspective-taking and reasoning as Peter repeated the process of getting down his thoughts, then organized them into the structure of poetic form. At this point, he was already into the rhythm of the game, and willing to continue, thereby almost unconsciously beginning the process of resisting the OCD. By the time we finished the second stanza, Peter’s upper brain was now engaged, warmed up, and had come to the conclusion that cons outweighed the pros and that longing for the rubberband did not make sense and therefore must be a compulsion. So finally I asked, “So Peter, you have a choice. If this is really an OCD, what does Dr. Gwen say to do? That’s right, take a baby step away. What are your strategies? That’s it, put it away and distract, or if that’s too hard, turn the mad dog into a sled dog and use the compulsion as a reward. (We often picture OCD as a big dog companion that Peter has to learn to live with, so we use that image of harnessing the motivation of a compulsion to get work done a lot.) What do you think you can manage?”  We repeated the same process of writing, dividing thoughts into verse lines, creating rhyming lists, and editing.  Here’s Peter’s finished product:

Rubberband, rubberband, elastic and round,

Rubberband, rubberband, sing your song.

“Boing,” stretch, dangle, and pull,

I can’t seem to get enough “boing!” to the full.

 

But holding it between my teeth,

Is not a thing to really eat.

OCD, the very picture I look,

Dangling like a fish on the hook.

 

So instead of keeping you in my head,

I’ll use you to get out of bed.

Mom, put it in my bathroom cup.

I’ll chase it there, and thus get up.

“So, Peter, did you enjoy writing your poem?”  I could see it in his face, the relaxation of the muscles, the crazy, driven gleam diminished from his eyes.

“Yes,” he typed.

“How did your stress level fare?” We use an emotional thermometer, scaled 0-5.

“From 4+ to 3+.”

“So how powerful is your creative power?”

“Very.”

There’s an addendum to this story. Once Peter put his plan into action, and got out of bed, I lined up his soap, toothbrush, and mouthwash in a row, putting the cup with the rubberband in it at the very end, so he had to go through the sequence of his self-help tasks first to get it. By that time, so much time had passed, that he was at a different place in the compulsion wave. It was passing, not totally, but he was at a better point. So it was time for another negotiation.

“Peter, how long do you think you should get the rubberband? You don’t want to lose all the ground you’ve gained, so it probably shouldn’t be too long.”

“Ten minutes,” he replied.

“That seems a bit long to me. How about you keep it as long as you don’t put it in your mouth. If you do, I take it away.”

Peter thought a moment, then abruptly took the rubber band out of the cup and placed it back in his drawer and walked away to the kitchen for breakfast.

So rather than lose control of the rubberband, he decided to hide the visual trigger and not engage in the compulsion at all. It was the best possible outcome. Peter’s choice, to carry out his own initiative, a strategy he came up with himself, that did not carry out the compulsion and therefore not reinforce it or strengthen that OCD circuit in any way, all while exercising his frontal lobes and strengthening his brain connections top to bottom (point to first stanza, slowing down the reactivity), left to right (bringing in reason), so executive function could come online (point to third stanza). You could just watch those synapses grow, and watch the development of emotional regulation.

So my question to you is, could there possibly be anything more therapeutic than the arts? With the arts, the child has a positive means to channel and let go of all the anguish inside, to fully express, understand, and process his emotions, positive and negative. Those brain glitches may be companions our children have to live with the rest of their lives; how much healthier it would be to learn to accept, channel, and transform negative emotion, rather than simply try to squelch it all the time. This is by cartoonist Matthew Inman. Peter and I love this image, which has become our modus operandi for dealing with emotional dysregulation.

dong-combat-your-monsters.jpg
M. Inman

 

 

 

That’s one of the most important lessons Peter and I learned from DIR. Negative emotions are not all bad. We can learn not to be afraid of nor to  make an enemy of those big emotions. They can serve as powerful motivators for development.

 

 

 

 

I encourage all of you to explore the arts as the integrating and transforming channel that may turn emotional challenges into the development of emotional regulation, creativity, self-awareness, and self-esteem. And to make something potentially beautiful and enlightening for others in the process. With art, you can be yourself, at your own pace, and there are no restrictions or disabilities in the imagination. It can’t get much better than that.

Don’t take my word for it. Peter wrote this poem, revealing how the arts have transformed his life. (The poem is symmetrical, with the last four stanzas corresponding to the first four in reverse order.)

I am autistic,
Greedy eyes and ears,
Wet in the rain of sensory deluge.

I’ve been a prisoner,
Captured in silence,
Voiceless and unintelligible.

I’ve been a slave,
Strapped to my obsessions
Ordering me to do nonsense, perverse to my character.

I’ve been a paralytic,
Feet stuck to the street,
People swirling around me.

I’m a listener,
Watching and receiving
Like a peaceful tree. 

I’m a tiger tamer,
Harnessing  the energy of my compulsions
To write one more line.

I’m an escapee,
Flying my soul like a kite
On a string of words.

I’m a poet,
Exploring the world with keen senses,
Sharing with you a bite of fresh air.

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Executive function skills (EFS) encompass a broad array of important managerial capacities. EFS originate in the prefrontal cortex, which directs and orchestrates the rest of the brain to get something done. They include paying attention, selecting, focusing, initiating, inhibiting, shifting, monitoring, modulating, correcting, pacing, sequencing, anticipating, evaluating, prioritizing, organizing, and planning.

To encourage the development of planning skills, teach your child to make choices and set up his own visual schedule. For example, if he has several homework assignments, let him decide on the order he does his worksheets, and within reason, where to put in breaks, and what to do for his breaks.

You can even start smaller, in a more limited field. Say your child loves to stim by tapping a stick. Within one worksheet assignment, consider letting him decide where to put in short tapping breaks, so that if he has ten math problems to do, he might plan a break after the third and sixth problem. That way he will be more likely to persevere in working without stimming till each of his breaks. He also gets to practice how to plan, initiate, focus, and inhibit, while harnessing the self-motivating power of having more control.

If it was hard slogging getting through those ten problems with only two breaks, help him learn how to evaluate his own planning. “How did that go? Ah, so you could get through three problems without a break okay, but getting through four was very hard?” Give him the opportunity to learn how to modulate his plans. “What do you think you could do about that for the next set? Have a tapping break after every third problem? Sounds like you know what you need- great self-awareness!”[1]

Make planning ahead (anticipating) and putting away (organizing) part of the whole process of doing tasks or assignments. “What will you need for school tomorrow in your backpack?” Work in the practice sequencing. “Let’s go through your day tomorrow. What will you need for math? (workbook and pencil box) Reading time? (storybook) Recess? (snack)”

Teach your child to organize as he goes, instead of letting things accumulate. “Great that you finished that whole worksheet! So where does it go?” “Let’s see the work you brought home. Do you think you’ll need those papers in class again? What should we do with them? Where does this go?” Many parents color code their child’s bookcovers and notebooks, one color per subject. They place a box or shelf by the front door for things the child will need to take to school the next day, so there’s less to gather up at the last minute. The child is given a specific quiet place to do homework, with a drawer for supplies and a shelf for books, and is taught to create a place for everything, and to put everything back in its place.

Teach your child how to make a checklist of tasks and then rearrange the order so he learns how to prioritize. Have him check off boxes or put his word/icon labels of each activity in an “All done” envelope so he learns to monitor his own work completion. That’s the beginning of self monitoring skills. Organize his work in consecutive drawers or file folders so the environmental set up suggests and reminds him of the next step. Let him experience shifting his attention as he moves from drawer to drawer on his own. Once he finds the exercise easy, add some spice to the game with a timer and reward so he gets to practice how to pace himself. You can make use of such a set up to create an independent work station containing several file folders of maintenance activities, meaning activities that practice mastered concepts that you want him to retain (Chapter Seven), which you can rotate and vary. That may be your child’s first step toward learning how to study on his own.

Create worksheet exercises in which the goal is to find and correct mistakes you include intentionally, so your child learns how to check his work. Once he gets good at this, next time he looks at you inquiringly to see if he did his math problem correctly, direct him to think of correcting it himself saying, “It’s great that you want to know if you got the answer right. I know someone who’s really good at checking and correcting.”

Help your child practice using all these EFS with all the support he needs. If you feel overwhelmed, write down specific EFS goals the same way you set academic goals, and work on mastering a few at a time. (See sample at end of this subsection.)

Teach EFS the same way you teach everything else. Gradually reduce your scaffolding as the child becomes more able. Once your child can perform these EFS with minimal prompting, continue to give short, direct cues throughout the day on when to exercise them. “Look over here. I have something important to show you.” (learning readiness) “Pay attention, your teacher said this will be on the test.” (learning readiness) “Don’t start eating until everyone sits down.” (inhibition) “Timer rings in five minutes. Put your things away.” (pacing, anticipating, organization) “Put it back where it belongs.”(organization) “You’ll need to work quickly, as there’s not much time left.” (pacing) “Remember the order of the steps. What’s next?” (sequencing) “Does yours look like the model?” (monitoring, checking) “What’s the order you need to do things to get this task done?” (planning) and “Which of the tasks is most important?” (prioritizing)

Once the child gets used to performing EFS throughout the day on cue, make the cues subtler. Come up with single word substitutes or better yet gestures or hand signals. Then bridge each skill by making the cues more indirect like, “This will be on the test. What should you be doing?” (Looking at what you are pointing at, paying attention). “We need to be polite and start at the same time, so what should you be doing?” (Waiting till everyone sits down at the dinner table before eating.) “The timer rings in five minutes. What do you need to do?” “Where should you put that?” (Back to its usual place.) “We have ten minutes left. What can you do to help you track the time?” (Set timer.) “Oops, are we forgetting something?” (Say if you’ve paused expectantly, and the child skipped the next step in a sequence.) “What could you do to see if you did it correctly?” (Check your work against the model). “That’s a lot of assignments. What’s the best way to go about it?” (Prioritize in order, schedule.)

A good rule of thumb is to use the Socratic Method. Whenever possible ask, don’t tell. If the child is talking too loudly in the library, instead of saying “Use your indoor voice,” try “Look at all the people studying. Do you study better when it’s loud or quiet?” Use every success and failure to help your child understand the purpose of working on executive function skills, so that they become goals for the child, not just yours. “Wow! I’m so glad you did half of your book report last weekend. That way you finished up in time for us to watch a movie together before bedtime.” “Oops! You had your homework in your backpack the whole time, but couldn’t find it to turn it in. Can you think of a way to make it easier to find next time?” The more the child owns the problem and comes up with the solution himself, the more he will internalize executive function skills.

It is common for parents to find that even after teaching these executive function skills, and seeing their child perform them under observation, the child won’t use them on his own.[2] A job well done might be enough gratification for some children to practice EF skills independently. But many children also need a contingent rewards system which offers tangible rewards for performance. So consider putting up a chart listing a few EF skills at a time, and have the child check them off as he does them in return for extra screen time minutes, time with you playing a game, or whatever else he finds motivating that you agree upon. Over time, teach him to create these kinds of reward systems for himself, as a general self-help strategy to use to meet his own goals.

Sample of Executive Function Goals for Peter Tran 2014-15

 

EF Skill Baseline Goal
Planning, evaluating, adjusting, pacing, inhibition Peter makes the effort to follow a timer schedule to restrict picking up sticks on walks, so he is less enslaved to that intense sensory need. Set up his own schedule of increasing minutes of walking before picking up a stick, adjusting the timer up or down according to ability, and creating his own reward or shrinking reward system
Planning, organizing Peter occasionally remembers to grab his bib or earplugs before outings. Peter will pack his swim bag.
Organizing Peter is learning how to save work on the computer into files. Peter will learn to copy and save important work from notes to pages and sort work into different subject files
Evaluating, planning, organizing Peter often resists putting used favorite clothes in the laundry basket, but occasionally changes his mind and makes a big effort to dump a favorite item in the washer. Peter will learn to do a sniff test or # of days worn test to put dirty laundry in the laundry basket, and select and put out fresh clothes on his bathroom shelf
Self-monitoring Peter occasionally independently toilets and puts his clothes on in the morning. Peter will use a check-off list to do his entire morning routine and bathroom routine, including wiping, flushing, dressing, hand-washing, and tooth-brushing.
Self-monitoring, correcting Peter occasionally corrects a misspelling or goes back to capitalize a letter himself. Peter will edit one line of writing himself for each assignment.
Prioritizing, ordering, organizing, initiation (self-study), shifting Peter makes choices as to which assignment he wants to do first. Peter gets three maintenance “homework” tasks like a worksheet of a couple of questions each of math, grammar, and reading paragraph/comprehension fill in the blanks to put in the order he wants to do them, complete them, and put them in a homework notebook with subject dividers.

Like all brain development, learning executive function skills takes time. Try not to get too frustrated about it. We provided virtually all the executive function for Peter, organizing, pacing, and monitoring him, for years as we worked on the fundamentals of engagement, communication, and cognition, before we started introducing EF skills as goals in themselves. As your child grows more capable in the fundamentals, whenever you see the opportunity, such as planning a picnic or deciding on the order of doing homework assignments, try to work on them. If you intentionally and persistently do so, you will see progress. Just try not to get frustrated if progress is slow. You can’t rush brain development. Modulate your own expectations. It happens at the child’s own pace.

 

 

 

 

 

 

 

 

 

 

 

 

[1] So what do you do if your child grabs the stick and stims before finishing the third math problem? One idea is to make a checklist of 3 reminder boxes. Each time your child stims before the agreed upon time, remind the child of the contract, have him put the stick down, and check off a box. If all three boxes get checked off, explain to your child that he needs more help in inhibiting the stimming, and move the stick farther away, or even out of sight to reduce access.

[2] This is especially common in those children with comorbid attention deficit disorder (ADD), which is associated with a 40% decrease in measures of dopamine receptor and transporter activity in the reward centers of the lower brain. (Vulkow, 2009) For these children, a top-down approach of just teaching EF skills isn’t enough to get them to use them in real life. A bottom-up approach is necessary concurrently in which you supplement their deficient internal reward centers with external rewards.

 

 

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What is descriptive praise? Noel Janis-Norton in her excellent international bestseller “Calmer, Easier, Happier Parenting” (2013) defines it as “noticing and then specifically describing what your child has done that please you.” It’s looking for opportunities to catch your child being good, and then using concrete, specific words to acknowledge the positive behavior.

“I saw the way you gave the baby a piece of your cookie. I love the way you shared.” “I heard you using words instead of hitting. Nice self control!” “Thanks for coming to help me carry in the groceries. How helpful and thoughtful of you!” Even if he might have shared the cookie with the baby because he wanted to prevent a painfully loud scream if he didn’t, or even if he just happened to be standing there by the trunk of the car rather than purposefully coming to help, go ahead and pretend or assume the best, so the child learns to want to behave that way. Point out the positive practical consequences. “You shared with him, and see? Now he’s sharing with you.” “Good thing you helped me bring in the groceries. Those popsicles would have melted. Would you like one?”

Reinforce the praise later during conversation. Let your child overhear you as you tell Papa how he shared with the baby. If you have a habit of conversing as you put your child to bed or a tradition of bedtime prayers, try to bring up at least one good thing your child did that day. He’ll learn to tune in to listen during that special time of recollection together, and come to look forward to it.

Making descriptive praise a habit creates a positive, nurturing family atmosphere. Descriptive praise is the most powerful tool to gain cooperation from your child and to motivate and shape attitude and behavior. But it is even much more than that. Consider the following scenario. You are trying to lug a heavy box from one room to another. You could make a behavioral contract with the child, and say, “If you help me move this box, you earn 10 more minutes of computer time.” Better yet, you could say, “Wow, if you help move the box, I’ll finish my work sooner and have a few minutes to play with you.”

But now picture this. You groan and moan as you tug at the box. “It’s so very heavy! Oh my, I just can’t seem to move this by myself.” Your child looks up. “Maybe there’s hope! I see you’ve noticed Mom’s desperate situation. You’re even getting up although I bet you’d rather keep playing with your toys. Oh joy, can I dare to hope? Hurrah! Help to the rescue!” After the job is done, you might conclude with, ” Just what I needed- a strong, fine young fellow to save the day!”

Both methods might get your child to help you move the box. But with the behavioral contract, the motivation is external, and it’s you taking the initiative and basically telling your child what to do. With descriptive praise, the support is from behind as you acknowledge every little step in the right direction he takes on his own initiative. But that is the way he internalizes motivation and learns to initiate. He’s helping you because you’re fun to help. So he’s learning that helping others is rewarding. He’s also bonding more with you. Your relationship, which was the initial motivator, in turn gets strengthened even more as that connection between pleasure and interaction gets reinforced one more time.

The acknowledgement you give your child for looking up encourages him to get up from the floor. When you acknowledge his getting up and sacrificing his fun with his toys you motivate him to help push the box. By descriptively praising each little step, he gains the momentum to do what seemed impossible at first. When you call him a strong, fine fellow, you build your child’s self-esteem, self-concept, and help him internalize the value of hard work and helpfulness.

So make descriptive praise a habit. In the beginning, you may need to pair it with an external reward, but eventually you will be able to fade the contracts, as your child builds that internal standard. Instead of laboriously pulling from ahead, you’ll be able to gently push from behind. As soon as your child can do without the contracts, make it a goal to cut the tow ropes, and try to just remain the wind that fills his sails.

commons wikimedia.org

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Play therapy is just floortime with a specific purpose to work on an emotional issue. In the following example (published here with permission from both the parent and the child), the child is on the withdrawn, compliant side, so it was fortunate that the parent was attuned enough to the child to realize there might have been an issue that needed discussing that had occurred the night before.

This child communicates via typing on his ipad, so the interaction was captured in its entirety.

Sam and his mom had this conversation/play therapy this morning. The previous evening, they didn’t get to Sam’s ILS therapy (listening to altered classical music through headphones to help desensitize a child with sound hypersensitivity; motor exercises are done concurrently to work on sensory integration) until later in the evening. He took a bathroom break, and when they returned to the family room, Dad had turned on the TV. Mom tried to woo Sam into continuing the ILS, but that was not realistic, so she finally said, “I’m not going to waste my time, I’m going to take a shower.” She then set up a bath for Sam, and settled to watch TV. When he finished and came back into the family room, Mom invited him to come watch Frozen with the family, but he said, “Bed!,” pointed to his room, and put himself to bed.

Mom: How come you didn’t watch the new movie with us last night? Frozen was good.
Sam: i was in(side) sad
Mom: Why were you sad?
Sam: because you got mad
Mom: I’m sorry, Sam. I was just frustrated because I didn’t want to fall behind on your ILS schedule, but you got tired and didn’t want to finish the exercises. But I do understand. A person can’t work all the time. So I was hoping you would enjoy the movie with us.
Sam: ok. i hoope you kind(er) next time.
Mom: I deserve that admonishment. I should have gone after you when you went to bed to give you a chance to talk about your point of view about the ILS exercises, and to explain that I really wanted you to enjoy the movie with us.
Sam: ok.
Mom: Were your feelings hurt when I said I didn’t want to waste my time?
Sam: yes.
Mom: I’m very sorry. I could see that you really didn’t want to finish those exercises, and knew it was no use to keep trying to persuade you. That’s what I meant about wasting time. I never feel it’s a waste of time to be with you.
Sam: yes i understnd it was a miscommunication, so youdidn’t mean you very mad
Mom: Let’s do a re-do, ok? I’ll be the wolf, and you be Pooh, Ok?
Sam: ok

(Mom handed Sam a Winnie-the-Pooh stuffed bear, and she put on a wolf puppet.)
Wolf: Pooh, let’s finish your exercises. Let’s roll the ball 20 times.
Pooh: no i’m tired.
Wolf: What about our ILS today?
Pooh: i had enough. stop hurting me.
Wolf: What hurts?
Pooh: i don’t want to listen anymore. it hurts my ears.
Wolf: I’m so sorry. Is it too loud? or is it this particular piece of music? or are you just tired and would rather do it tomorrow?
Pooh: tired.
Wolf: So what do you want to do?
Pooh: let’s stop for now.
Wolf: It must be hard to have to practice listening to uncomfortable sound, even music.
Pooh: yes. it’s not too much trouble if i feel happy,but i’m too tired nnow.
Wolf: I’m so glad you told me. Please keep letting me know, so we can make this work out for you, ok?
Pooh: ok
Wolf: Do I push too hard a lot?
Pooh: i don’t think so.
Wolf: That’s a relief. I wouldn’t want to do that. I want you to learn, but at the pace that feels best for you. Will you tell me when I need to slow down or you need a break?
Pooh: yes i will by tyyyping
Wolf: Would you like to watch Frozen with us?
Pooh: yes
Wolf: That’s great! We really missed you last time. How about tonight?
Pooh: i feel like sausage now
Wolf: Ok, coming right up!

The conversation that preceded the play had already cleared the air in theory, but the symbolic play cleared it in practice. Being able to speak through his stuffed animal freed this gentle and sensitive child to be assertive and actually have the satisfaction of telling “Mom” outright to “stop hurting me,” without having to worry about hurting her feelings. The child got to be in charge of what to do next (“Let’s stop for now”) instead of Mom.

Children often offer more when they feel they are the ones taking the initiative. Sam offered more information about the music “hurting his ears” that Mom had not unearthed in direct conversation. Therefore she was able to express sympathy and understanding about how hard and uncomfortable the ILS was for her son, and probe deeper into the more general issue of how hard she was pushing her son overall. Sam even came up with the seminal plan for how to solve the ILS problem for good by offering the information that it’s only a problem for him when he’s tired, but “it’s not too much trouble if… happy.” Initiative begets more initiative, and Sam ends the conversation by telling Mrs. Wolf that he’s really more interested in breakfast right now than watching a movie with the family.

The mother told me that events later that day confirmed the value of the play therapy. When Sam’s big brother asked him why he didn’t watch the movie with them the previous night, Sam, already emboldened by the earlier encouragement to express his true feelings even negative feelings, went a step further. He replied, “Because I was mad.” (Note now he admits he was mad, as opposed to just sad, and as opposed to Mom being mad.) When asked why, he revealed another as yet undisclosed piece of information, “because I didn’t want ILS and mom said no carride.” He actually said this in front of Mom as she was helping him with his typing. That gave Mom the opportunity to say, “I’m sorry, that was unfair. I should have given you a chance to type before handing down a demand, and you could have told me the ILS was hurting your ears because you were tired.” Shortly afterwards at dinner grace when all the children were giving thanks, Sam’s prayer was to thank God that “I and mom made up.” Later that evening, even though he was getting tired, Sam finished up the last 20 minutes of his ILS session, not in a spirit of anger, but cooperation and perseverance because he also wanted his noise sensitivity to get better.

Don’t feel that play therapy needs to be as direct a re-do as this illustration. Most of the time, therapists set up play scenarios that are much less specific. They observe the child for his favorite toys and stories, and then set up a play scenario using them to introduce a theme of nurturing, aggression, control, or whatever is immediately emotionally relevant to the child. The key element is freedom- to give the child an opportunity to freely express his emotions and act on them in a completely safe environment in which he is encouraged to do so and in which he is handed the control of the action in the play scenario. This gives the child an opportunity to retell his own emotional story obliquely and in as much part as he wishes. Dr. Dan Siegel, author of the outstanding book “The Whole Brain Child,” would probably say that helps the child process his right brain emotional memories with his logical left brain, and bring implicit memories into consciousness so that they don’t have to be acted out later in real life as inexplicably explosive reactions to triggering events that are similar in emotional content.

The recent Profectum conference in Pasadena highlighted the enormous value of symbolic play in both effectively addressing emotional issues and moving development forward. In this illustration, Sam learned how to express his negative feelings in words, came up with the beginnings of a logical solution, and learned how to negotiate and effectively resolve conflict. What a better way to handle anger than allow it to get bottled up inside. As parents of kids with autism, we’ve all seen the self-injury and aggression that can result from anger. We have to give our kids another channel. Make symbolic play a regular part of your interactions with your child, and it will bring you closer, give you a more peaceful home, and most importantly empower your child to not only deal with negative emotions and learn to express it a regulated, organized way, but push his cognitive and emotional development forward.

from fit.webmd.com "Old MacDonald Had a Farm"

from fit.webmd.com “Old MacDonald Had a Farm”

I wish to thank two outstanding child psychologists, Dr. Mona Delahooke and Dr. Connie Lillas, for their inspiring presentations on play therapy at the Profectum conference. Both of them practice locally in the Pasadena and Los Angeles areas.

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How does one do floortime with a teenager? Try a fractured fairytale. That’s a spoof of a classic fairytale that you can create together.

I was trying to get Peter to get up this morning.

We had read the story about Jack in the Beanstalk five days ago.

(Peter didn’t like the story. When I asked him how he liked it, he typed he didn’t like it because “everything Jack did was hard.” When I asked what he meant by “hard”, he typed, “heartless.”)

Anyway, we started out with a game I had been doing with a peer at Teen Buddies, feeding a puppet wolf some toy sausage and eggs. Peter obligingly fed the wolf, and I talked about how Peter’s sausage was hot and ready to eat, but that didn’t work. Peter stayed planted in his cozy bed.

So then I brought Charmander over. “Fee, fie, fo, fum, I smell the blood of an Englishman. Or could it be a Chinese boy?”

Peter ducked under his covers.

Charmander sat by Peter’s side. Mrs. Wolf rushed in, carrying a pan of toy sausage and eggs.

“No, no, no Charmander! You are not smelling a Chinese boy, you are smelling this delicious sausage and eggs I just made for you!”

Peter’s hand obligingly popped out of the covers and fed Charmander the sausage and eggs.

Charmander leaned back and said, “My, my, my! That makes me sleepy! But before I take a nap, bring me my goose that lays the golden eggs!”

As we do not own a stuffed animal goose, Mrs. Wolf came back with Toucan who sat on a pillow.

“Uh, uh!” grunted Toucan. I’m trying to lay something, but I need some food!”

Peter’s hand popped out again and fed the Toucan the same breakfast.

Toucan sighed in contentment, jumped up, and pop! out upon the pillow appeared Peter’s noise cancellation headphones!

Charmander said, “Ah, how nice! But I feel so very sleepy… zzzzz!” and started snoring.

Peter grabbed the headphones

“Quick, now’s your chance to make a run for it, before Charmander wakes up!” cried Mrs. Wolf.

“One minute!” said Peter, and turned over in bed.

But he did get up after that minute, and all on his own.

Later that morning, we had the following conversation:

Mom: Did you recognize the story we adapted this morning?

Peter: Yes, it was Jack and the beanstog.

Mom: Who was the goose that lays the golden eggs?

Peter: Toucan

Mom: Who was Jack?

Peter: (verbally “me” as he typed:) Peter

Mom: What was the golden egg?

Peter: my headphones

Mom (trying to trick him): Wasn’t the wolf a good giant?

Peter: no. the wolf was not the giant. it was Charmander.

Mom: Guess I can’t fool you! Did you like our little drama?

Peter: Yes.

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“What happened to YOU?” exclaimed V, as Christina croaked a hoarse greeting to her. Peter and I were with our buddies at social group, and Christina, our facilitator, was getting over a sore throat.

“Oh, I’ll be ok,” Christina tried to say, but she could barely get the words out.

“Hmm, I wonder how she got that way,” I mused. “Do you suppose, something may be in her throat? I mean, imagine the possibilities. Can you picture it? Just suppose she was in the park, by a lake, and there was this frog…”

“And she was sleeping with her mouth open, and a frog jumped in!” cried V.

“And she woke up, and went to the doctor…” I continued.

“And he took an Xray!” chimed in S.

I grabbed a marker and scribbled a picture of a girl’s neck with a frog sitting in the throat. “Did it look like this?”

“Yeah, that’s the Xray!” exclaimed S. delightedly. “So he sent her to the surgeon.”

“But the surgeon didn’t believe it. So what could she do?”

Peter typed, “She saw another doctor. He should help her.”

“But what if he doesn’t believe her either?” I queried.

“I saw a cartoon where this cat swallowed a bird, and when the cat opened its mouth, it chirped!” giggled N, our movie buff.

“So Christina, open your mouth!” giggled the kids, and Christina obligingly opened her mouth to reply.

“Ribit!” I said, hiding my lips behind cupped hands. “Ribit!”

The teens collapsed in laughter.

“Christina doesn’t really have a frog in her throat, does she?” asked S, our persistent worried questioner.

“Let’s see, S,” I said. “Hey Christina, say something.”

She tried, but was too hoarse (and was laughing too hard) to make a sound.

“Ribit!” I croaked again, covering my mouth, as the kids continued to roll over in glee. “So the doctor believed her, and gave her…”

“An antibiotic!’ cried S.

“How did the frog feel about that?” I wondered aloud.

“He hated it, and jumped out of her throat!” cried V. “Then the doctor caught it, and put it back into the lake at the park.”

“And how did the frog feel about that?” I asked Peter.

“The frog felt good. But Christina felt even better,” typed Peter.

The End

This “Frog Story” by Teen Buddies is an example of the fun we have in social group. Before I started going with Peter, I would never have imagined how delightful it can be to work with teens with autism. I am always amazed at the kids- their enthusiasm, love for fun, and most of all capacity and desire for interaction. Whenever it was Peter’s turn to add to the story, V. and S. waited eagerly to see what he’d come up with. It would take a while, but they were truly interested, and it warmed my heart to see them gathered round, leaning over his iPad to see what he had to say.

Just the day before, Peter had his first experience at “Young Life,” a Christian youth group that meets in the basement of a local church where neurotypical young adults volunteer to hang out and play group games with teens with special needs. Peter and I were overwhelmed with our welcome. Seemed like his entire special day class from school was there, and each kid came up in turn to greet Peter. They were so excited to see him. Two girls sat him between them, and vied to play with his iPad. A nonverbal little classmate Z spied us from across the room and gave us a shy wiggle of his fingers and a big smile. “This is my third time to come, “ said E. “I used to be really nervous, but now I’m just fine!” she confided with a big, comforting smile. Ten minutes later, we found Z standing right behind us. He had made it, across the wide expanse of the crowded room!

That morning, Peter had had a friend over, Sh. I saw him run out of the car up the driveway, jumping and peeking through the narrow pane of window glass next to the front door.  But once I opened the door and let him in, it was a different Sh. The head went down, the eyes averted, and the voice went silent. As Sh’s mother and I chatted, I spied him quietly make his way to the family room. After a couple of minutes I followed, and saw him making funny poses as he watched his reflection in the  dark TV flat screen. “That’s the oompa-loompa dance from ‘Charlie and the Chocolate Factory,’” Sh’s mom whispered. I sidled in and started imitating Sh’s movements. He started to giggle and struck another pose. After imitating that, I suddenly snapped into a stiff salute, a new position. To my delight, Sh copied me. Back and forth, I’d strike a pose, and then he’d strike a pose, and we’d imitated half a dozen of each other’s poses, at an ever increasing pace, till the game was done. “That was fun! Give me five!” Our eyes met, and he gave me a big smile.

I wish I could rewrite the DSM-5 definition of autism. Instead of “deficits in social emotional communication,” I’d like to put, “challenges in word finding, processing and using facial expression and eye gaze, and sensory and anxiety issues that when identified should be accommodated and skills practiced to empower him/her to seek and enjoy the interaction and friendship so deeply desired, though subtly expressed.” Like the teens waiting an eternity for Peter to finish typing, like Z taking ten minutes to cross the crowded room, and like Sh finally wanting to look into my eyes after half a dozen turns of the oompa loompa dance. Because the “deficits” are not a lack of desire. And where there’s a will, there’s a way, or should be, if we can make the effort to blaze a trail.

I hope the hard working parents, friends, families, and professionals who work with kids with autism don’t get discouraged and don’t give up trying to interact. Because I’ve seen enough glimpses to be convinced that in each of our kids there’s a social person, just waiting for someone to help him/her break through.

mmkids-300x245

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We had a great victory today. Peter walked away from the refrigerator at night without eating anything. He wasn’t happy about it, but he did it, voluntarily and reasonably calmly.

How did we get to here from there? Let me tell you what “there” was like. Peter has an insatiable appetite. He always has. It has been a huge blessing because in the early years we could always motivate Peter to learn using tiny edible reinforcers, and to play by creating games around food (like egg hunts, and playing restaurant or farmer to market). However, it has also been a constant struggle to limit his eating and get him to exercise daily. When he was little, we had to put locks on the pantry and refrigerator.

But now that Peter is 14 years old, I figured it was about time for him to start taking charge and learning how to make good decisions about food and exercise for himself.

So here’s the system we created to make calorie counting easy and tangible for Peter.

We figured a growing teen boy probably needs around 2000 calories a day. If you symbolize each calorie as one cent, then 2000 calories equals 80 quarters. So each morning Peter gets a bag of 80 quarters. Each time he eats something, he “pays” for it. quarters

Just think “1-2-3-4,” as summarized below:

category serving size # calories #quarters
veggie 1/2 cup cooked, 1 cup raw 25 1
fruit 1/4 cup dried or 1/2 cup raw (equals 1 small apple, orange, pear, or peach, 1/2 banana or grapefruit) 50 2
fat pat of butter, 1 tsp oil, 1 tbsp salad dressing or cream cheese 50 2
protein 1 egg, slice of cheese, 1/2 cup tofu, 1 oz meat, 3 oz yogurt 75 3
carbohydrate 1/2 cup pasta, rice, or oatmeal, 1 cup dry cereal, 1 slice of bread or one small potato, or 5 cups of air-popped popcorn 100 4

So when Peter has 4 quarters to “buy” a snack, he can see that buys either a 1/2 cup of crackers, twice the volume of diced fruit, or ten times the volume of air-popped popcorn (later at an advanced level, you might let him see you halve the volume if you add a couple teaspoons of melted butter to the 5 cups). That helps him make a smart choice.

Each time Peter exercises, I “pay” him at a rate of 5 calories per minute. So say we’re at the gym. I can give him a quarter every 5 minutes he stays working on that exercise bike to get him to keep going longer.

Back to today’s storyhealthy-food-kids1-e1347322548705. It was the end of the day, and Peter had spent his daily caloric allowance of 80 quarters. But he still wanted a snack. He opened the refrigerator to grab a piece of cheese.

“Wait a minute, Pete. How much would that piece of cheese cost?”

“3 quarters.”

“How much do you have left?”

“Zero.”

“Then you have a choice. Three quarters equals 75 calories, which at 5 calories per minute equals a 15 minute walk. Want to go out and take a 15 minute walk with me?”

Hence the abrupt turn away and slam of the refrigerator door.

Wasn’t happy about it. But it was his own choice.

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