Originally published in the The Theraplay® Institute Newsletter of Spring, 1994

Theraplay for Children With PDD/Autism

Margery Reiff, Ph.D & Phyllis Booth, M.A.

The Theraplay Institute

Theraplay is a treatment for enhancing attachment and engagement, self esteem, and trust in others. It is based on the natural patterns of healthy interaction between parent and infant, and is personal, physical and fun.

Theraplay for children with pervasive developmental disorders, including autism, has as its goals the development of a distinct sense of self, the recognition of others as separate from themselves and the development of trust in others. An additional goal is the reduction of inappropriate behaviors, such as temper tantrums, aggression and perseveration.

The steps toward the overall goals include establishing or improving the basic interactions of comfort with physical closeness, eye contact, shared attention, turn taking, imitation and communicative intent. The treatment uses play that is structured, challenging, intrusive and nurturing. (See Theraplay Dimensions.)

Briefly, this means that the therapist and later the parents: take the lead, pursuing the child when he withdraws and enticing him to participate find ways to show the child that the world is not so frightening and overwhelming challenge the child's need for sameness by introducing variety and change help the child to tolerate external stimulation entice the child into interactions that promote awareness of self and others.

The Theraplay approach parallels the principles underlying effective interventions in the treatment of social deficits in young autistic children as summarized by Catherine Lord (1993): "structure and predictability; active engagement of the therapist or teacher; opportunity for active engagement of the child; involvement of parents; inseparability of cognition, affect and social development; individualization of goals and techniques; and working within a natural environment" (pg.86).

The October/November 1992, Zero To Three, the journal of the National Center for Clinical Infant Programs, reports on the work of Stanley Greenspan and his colleagues on the diagnosis and treatment of very young children with autistic spectrum or pervasive developmental disorder. It is an excellent issue presenting a thoughtful discussion about the nature of PDD and autism as well as describing an innovative approach to treatment. It was especially interesting to us since it makes many points about the nature of autism and PDD which we at The Theraplay Institute have come to in our own work with these children over the past twenty years.

Also, there are many similarities in our approaches to treatment. For example, we agree with Greenspan's statement that "the primary goal of intervention is to enable children to form a sense of their own personhood - a sense of themselves as intentional, interactive individuals" (Greenspan, 1992, pg.5). In the interest of space we will not discuss our many points of agreement. Instead we will focus on two significant differences between the two approaches:

1. Greenspan emphasizes the importance of following the child's lead, while we stress the importance of the initiating role of the therapist.

2. Greenspan describes a process which moves rather quickly to symbolic communication and representational play using traditional playroom toys and materials. We focus on earlier stages of interaction, that is, on the precursors of this more advanced or complex form of communication, using face to face interaction between the child and his caretakers.

Although Greenspan suggests following the child's lead, he acknowledges that in order to begin the process, "ingenuity and persistence" and even some intrusive intervention is required (pg. 4). Theraplay therapists take this intrusion one step further. We set the stage to create a series of nonverbal opportunities for the child to interact with us. Jernberg (1979), the founder of Theraplay, describes the adult and child in this treatment as "mutually engaged" in the intense, urgent awareness of each other in the here and now. She stresses the importance of not allowing the child to escape into the realm of fantasy or isolated play with objects.

Because children with PDD and autism are often locked into defensive patterns of behavior, designed to keep the world at bay, one can wait a very long time before they take any notice of or reach out to people. We have found that an approach which immediately challenges the child's defenses can move him more quickly from his frightened self-protective position to one where he can enjoy the risks involved in more flexible interaction with loving caretakers. We believe that it is a kindness to the family to free the child as quickly as possible from his burden of fear and isolation.

Our second point is a matter of emphasis rather than that of principled difference. Greenspan says, "Because these children often lack the most basic foundation for interpersonal experiences, . . . much of the experience that they might use to abstract a sense of their own personhood is not available to them. Therefore, . . . the earliest therapeutic goals must be geared to the first steps in the developmental progression . . ."(pg.6). Thus, we both agree on the need to go back to the very earliest precursors to interpersonal communication. While Greenspan alludes to the earlier stages in his outline of the developmental sequence, most of his examples come from the later stages of symbolic play. In order to go back to this earliest stage, we model our interaction on that of parents with their normal six month old baby. We reduce physical props to a minimum and use our own playful presence to surprise and delight the child. Through a series of structured, engaging activities, we entice the child to become involved with us and, thereby, to develop intentional two-way communication and an ability to read basic affective signals. Like Serena Wieder, we return to the "earliest 'games' that adults play with infants [which] involve movement, touch, singing, and visual pursuit" (Wieder, 1992, pg.11).

We selected the following case study to illustrate the Theraplay approach because it demonstrates the dramatic changes in sense of personhood, emotional connectedness and behavioral control which are possible with Theraplay.

CASE STUDY
Timmy was a difficult baby from the start. Throughout his first year of life, he had colic and was inconsolable most of the time. By 18 months, his mother noticed that Timmy was not progressing like other children. He showed little interest in people and made poor eye contact. Although he had spoken a few words before this time, he suddenly stopped talking. Raging temper tantrums could be triggered by almost any change in routine. At 21 months of age, Timmy's behavior took a dramatic change for the worse and he screamed most of the time. At this point his parents began to seek help. After an exhausting search for a conclusive diagnosis, a pediatric neurologist gave their 25 month old son a preliminary diagnosis of pervasive developmental disorder - autistic type with a developmental language disorder. When Timmy was 26 months old, the family came to The Theraplay Institute for treatment.

As part of our usual evaluation procedure, we videotaped Timmy and his parents doing a series of structured tasks, The Marschak Interaction Method, in order to observe first hand how Timmy would respond to a variety of activities with each parent.

Throughout the session, Timmy showed little interest in his parents, gave only occasional eye contact and, at times, deliberately averted his gaze. Timmy's emotional reactions ranged from anxious laughter to rage-filled temper tantrums. He showed some sensory integration difficulties: dislike of light touch and lotion, discomfort with changes in position and poor modulation of sensory stimulation. His play with toys consisted mainly of matching objects by color and lining them up.

Based on our observation of the parent-child interaction, we decided that intrusion, nurture and structure were the dimensions of interaction most likely to lead to the goals of increased interpersonal relatedness, acceptance of changes in routine, and reduction of temper tantrums and perseveration. We thought that Timmy needed to be enticed (intrusion) into engaging with others. Nurturance seemed vital since it had been so difficult to nurture him as an infant. We expected that the structured, playful Theraplay sessions would help Timmy begin to accept change. We anticipated that he would respond to the adult's being in charge with an increase in focused anger, but we looked forward to that development as a sign that he was moving toward our goal of a greater awareness of others. We expected he would gradually relinquish his need for control as he saw that the adults would continue to set limits and make his world safe and predictable.

I (MR) saw Timmy weekly for 32 half-hour sessions at the Theraplay Institute with one or both parents either observing or directly participating in the session. His parents were encouraged to carry on the Theraplay activities at home. After each session, I phoned to discuss the session, talk about behavior management issues, and changes in Timmy over the week. As he became more open to other experiences, I encouraged his mother to enroll him in other programs: speech and language therapy and occupational therapy. The Ls. also participated in a parent support group for children with autism.

Session 1:
I had decided to meet with Timmy alone at first in order to develop an intense, personal relationship with him. By meeting just with Timmy, I could help him focus and attend to me alone and see that his resistance would be met with safe and predictable nurturing. In my experience, young children more quickly achieve a therapeutic alliance when the focus of attention for the first few sessions is concentrated only on the child without the parent in the treatment room. Once past the initial resistance and upset, these toddlers quickly transfer this newly found trust to other adults (Rieff, 1991). A second reason for postponing the parent's direct participation is to give the therapist a chance to find the most effective ways of engaging the child and to model these for the parent. Timmy responded to my carrying him into the treatment room with angry crying. I acknowledged his feelings saying, "You are mad!" I held him tightly and rocked him back and forth to assure him he was safe. When I mirrored his anger, he momentarily looked at my face and his crying diminished. I tried several playful activities such as peek-a-boo and rubbing lotion on his feet, but only my mirroring of his sounds and feelings caught his attention.

Instead of being disturbed by Timmy's distress, which she observed from behind a one way mirror, Mrs. L. told me later that she was relieved, stating, "His kicking, screaming, and pushing away was typical of his temper tantrums at home, and I needed someone to take him and do something with him. I knew you weren't hurting him."

Session 2:
Timmy did not fight as hard against my efforts to get through to him as he had during the first session. This time as he cried, he snuggled into my lap seeking some comfort. As before, I mirrored his affect: when he cried, I cried back, matching his tone. Mirroring a child's intense affect is a very effective technique for capturing the child's focused attention. It is as if the child says to himself, "She's speaking my language!" When I laid him down to lotion his feet, he protested louder and deliberately looked away. His difficulty with being put on his back and accepting the tactile experience of lotioning is typical of children like Timmy. I knew that it would be important to take his sensory motor integration problems into account. Timmy's mother was already familiar with Patricia Wilbarger's (1988) sensory diet techniques which are designed to decrease sensory defensiveness; I encouraged her to make use of them on a regular basis. In spite of his angry crying, I persisted in my attempts to engage him, playing patty-cake, peek-a-boo and pop the bubbles. Since Timmy was not yet ready to take turns, I took turns for both of us raising his hand to pop the bubbles. The bubbles caught his attention, he stopped crying and turned to look at me.

Session 3:
Today Timmy's crying lasted only for the first five minutes. He stopped when I brought out the bubbles, an activity he had liked from the first. But today there was a new shared quality to his pleasure. Very quickly, however, even this shared experience took on a rote quality and I knew I had to move on to another activity in order to keep him alert and engaged. Like other PDD children, Timmy easily slipped into perseverative activities which blocked out his awareness of other people. I next tried feeding Timmy a bottle in hopes of recreating the early mother-infant nurturing experience which is so soothing to most infants. But Timmy was not ready to accept that and he adamantly refused. However, he was able to tolerate having baby powder rubbed on his feet accompanied by the song "Rub a dub dub." Mrs. L. joined us for the first time at the end of this session. While his mother held him comfortably facing me, he spontaneously patted his knees and I imitated his gesture. Soon we were engaged in a delightful turn-taking game. Next, I held his feet in front of my eyes and peeked out at him with a "boo!" He grinned widely and said "boo!" back.

Mrs. L was surprised and delighted with how engaged Timmy had become after just three sessions. She spoke with relief about the changes that were occurring at home. Timmy had become more manageable and his tantrums were dissipating. Mrs L. was happy to report that for the first time Timmy was able to have lunch at McDonald's and to be pushed around K-Mart in a grocery cart. She recognized that emotionally Timmy needed to be treated like a much younger child so she had set aside his two year old toys and was playing interactive Theraplay games with him at home.

Session 4:
Timmy was very upset when Mrs. L. brought him to the session today. However, once I imitated Timmy's crying, he stopped crying. He became alert and made sustained eye contact. He giggled while initating a game that we had played before in which he held his arm out for exaggerated kisses. Timmy became really excited when I imitated the nonsense sound that he was making and then soon began to experiment with more sounds. Next, I placed a bean bag on my head and held Timmy's hands to catch the bag when I lowered my head. I then placed it on Timmy's head. Even in this lively give and take game, I had to move quickly to keep Timmy from lapsing into perseverative play focused only on the toy. Signs of language seemed to be reemerging along with reciprocal turn-taking. Timmy developed a word approximation for "ready" and said "pop" to bubbles.

Aware of his hypersensitivity, I had carefully modulated the intensity of our interaction in order to reduce his excitability. As he began to feel more comfortable and his need for globally shutting out all new experiences decreased, his sensory integration problems became more specifically identifiable. It was now clear that light touch and tickling were intolerable for him. Firm, deep pressure helped calm him down. While Timmy still occasionally arched and tried to push me away, it was not the same battle as in earlier sessions.

Session 7:
This and the last session seemed to be turning-points. Timmy left his mother without crying and was emotionally connected for most of the session. He withdrew only momentarily by averting his gaze. His mother told me about an incident at the park where he tried to grab a girl's popsicle. When Mrs. L. said that he couldn't have the popsicle, Timmy just stamped his feet. This behavior was quite different from the temper tantrum response that he might have given in the past.

Session 9:
Timmy took the sticker off my nose when I told him to "get my nose." He gazed into my face and touched my eye as I rocked and sang "Rock-a-Bye Baby." Timmy's autistic-looking behaviors had decreased. He only flapped his hands or flicked his fingers when overstimulated or really excited. Both Mrs. L. and I noticed that transitions were easier for him.

As his awareness of others increased, his anger became more and more focused. Over the next few weeks, there was an upsurge of pinching and hitting clearly directed at his mother for not paying attention and being as available to him as she had been before. Mrs. L. reported that Timmy would look at her when he was angry, and that she could now hold him and help him calm down.

Session 10:
Timmy's communication skills had improved. During the session, he either grabbed his mother's clothes or pointed to what he wanted to do. He also had gained five new words in the last two weeks. Mrs. L. reported that Timmy acted almost like a normal two-year-old. At a recent picnic, he waited his turn with the other children. Most of the autistic features and the tantrums were gone.

Session 15:
Timmy did not protest at all when he left Mrs. L. to come in the treatment room. As I took his socks off, he smiled but kept his eyes averted. He momentarily shifted his gaze to look at his sock as I said, "Whoa, come on sock." I pulled harder and he grinned, laughed, and turned his head to look at me. I mirrored his movements and sounds. When we played the game of "popping cheeks" which resulted in having his face blown on, Timmy said "more," looked directly at my face and laughed.

Sessions 16 - 31:
Timmy, Mom and I continued to meet weekly. Timmy's eleven-year-old sister joined us for some of the sessions, as did Dad when work permitted. Each session included such structured activities as: lotioning hands and feet, singing a song, putting a sticker or a cotton ball on the adult's nose for Timmy to remove, patty-cake with hands or feet, popping bubbles, feeding a cookie or drink, hiding under a blanket or behind a pillow so his mother could find him, swinging in a blanket, playing with a bean bag and rocking him with a special song. (See Activity list.) Timmy became more responsive in each session and continued to improve at home.

Session 32:
This was our last session because Timmy would be attending an early childhood special education program five mornings a week. This seemed an appropriate time to stop direct treatment because Timmy was now ready for a wider experience. He was comfortable interacting with people, able to enter into new activities easily, and able to express his needs. His babysitter, a special education teacher, said, "While Timmy has a lot of difficulties to overcome, he has a wonderful personality, a great sense of humor not usually found in such children, and he responds to approval and affection."

Checkup Six months later:
Timmy made good eye contact. He laughed heartily and appropriately to the game of "Push Me Over" and said "ready" and "go" when we played ready - set - go. As he tired, instead of screaming, he called out for "Mommy."

I asked Mrs. L. to share her reactions to the Theraplay experience.

What was Timmy like before and what he was he like after Theraplay?

"Before Theraplay, I felt as though I was losing Timmy; he was regressing so far back, and I didn't know how to grab him and hold on. After a month of sessions it seemed like the regression stopped. And then we started to work on getting him to move forward with eye contact and to interact, to tolerate different positions, to tolerate transitions (that was a big one!), and also to play on other peoples' terms, not just his own."

What do you think made the difference for him? What do you think was effective?

"You were not put off. You persevered. If you had simply followed his lead, you wouldn't have gotten anywhere. You made him interact, it opened up his world. I think one of the major things too was it gave him an identity. It started to make him realize that he was a person."

"I think the nurturing was very important. Going back to where he was emotionally and doing the things you would do with a child that age, holding him and looking at him. Thinking of him as a six month old helped me when I would get frustrated with where he was. The structure helped a lot too, he still needs that today."

He's now had a number of different kinds of therapy. How do you see them in relation to each other?

"I personally feel that without Theraplay we wouldn't be where we are today. It was the first step. That was what brought him back and stopped him from regressing. After that he was more able to make use of OT and speech therapy."

It was obvious that dramatic changes had occurred in Timmy's overall development. He showed increased relatedness to people as seen in consistent eye contact, pleasurable smiling and turn-taking in interactive games. He was now able to shift from one activity to another and the frequency of his temper tantrums was greatly reduced. Theraplay had established the foundation of social interaction that allowed Timmy to change from being isolated, fearful and perseverative to being sociable, engaging, calm and interactive.

References:

Greenspan, Stanley I. (1992). Reconsidering the Diagnosis and Treatment of Very Young Children with Autistic Spectrum or Pervasive Developmental Disorder. Zero to Three, 13 (2) pp.1-9.

Jernberg, A. (1979) Theraplay: A New Treatment Using Structured Play for Problem Children and Their Families. Jossey-Bass, San Francisco

Lord, C. (1993) Early Social Development in Autism. In Preschool Issues in Autism, Eds. E. Schopler, M. Van Bourgondien, & M. Bristol. Plenum Press, New York, pp. 61-94.

Rieff, M. Theraplay with Developmentally Disabled Infants and Toddlers. The Theraplay Institute Newsletter, Fall 1991, pg.5

Wieder, S. (1992). Opening the Door: Approaches to Engage Children with Multisystem Developmental Disorders. Zero to Three 13, (2) pp. 10-15.

Wilbarger, P. & Wilbarger, J. (1988). Sensory Affective Disorders: Beyond Tactile Defensiveness. Workshop presented in White Plains, NY.