In a video recording, Lincoln Scott and his three year-old son, Tristan, are in a therapy room, facing each other across a tub of dried beans. Tristan repeatedly scoops the beans with a plastic cup, pours them out and watches them fall. Scott puts incredible energy into his attempts to join in, showing Tristan how to pour the beans from higher up, then burying his own hands in the beans. No response. Scott tries again, picking up a dog puppet and running it up Tristan’s arm to tickle him. Tristan pushes the puppet away. He never once looks at his dad during the entire video recording. His only reactions are the occasional, “No,” and batting Scott’s hand away.
Tristan has autism. Because of the way his brain processes sensory and emotional information, he has difficulty with communication and social interaction, even with his parents. So Scott’s attempts to play, which would have made Tristan’s little brother squeal with delight, feel unpleasant—even overwhelming—to Tristan.
But his response doesn’t happen as often these days. In another video, recorded after a year of therapy called DIR/Floortime, Tristan is playing with a Batman figure and clearly including his father in the play; at one point he says, “Daddy, you be the bad guy.” Later, he “scares” his dad by poking him with the Batman toy and roaring. This morphs into back-and-forth silly sounds, and a game of chase and catch. Tristan looks at his dad often and, based on that clip, you wouldn’t guess that he has autism.
What was it like for Scott to finally engage in real, two-way play with Tristan? “It’s hard to put into words,” says the father of two from Keswick, Ont. “When we’re playing and he comes out with a long sentence describing his thoughts and intentions, and everything makes perfect sense for that moment, I’m just blown away. I often find myself looking at my wife hoping she heard it, then we exchange this private smile filled with hope and excitement.”
Scott credits that year of DIR/Floortime for his son’s transformation. The therapy isn’t new, but it has never been widely available in Canada, and it differs from many other approaches to autism treatment, which compensate for children’s social deficits by training them not to do certain behaviours (for example, hand waving) or teaching skills (such as making eye contact) in incremental steps using lots of verbal praise and other rewards, such as candies. Instead, DIR/Floortime aims to give children with autism the ability to not just tolerate but actually enjoy social and emotional interactions.
Tristan got the therapy as part of a $5-million research project at York University’s Milton & Ethel Harris Research Initiative in Toronto. Twenty-five kids, aged two to four, who got one year of an adapted version of DIR/Floortime therapy, were compared with a control group of 26 children on a waiting list for treatment. All the kids were recorded interacting with their parents both before and after the treatment program was completed.
Here’s what researchers observed: Unlike the kids in the control group, those who received therapy improved their ability to enjoy interaction with their parents, to pay attention to activities they did with their mom and dad, and, perhaps most importantly, to initiate joint attention to a parent—such as getting mom to join in a game. These abilities, which children with autism tend to lack, are hugely important because they open the door to all kinds of early childhood learning that takes place through social interaction.
This is the first time the effectiveness of DIR/Floortime therapy has been tested in a randomized controlled trial, which is considered the gold standard in scientific research. And from the researchers’ perspective, the results were headline-worthy. “In statistics, an effect the size of 0.2 is significant but small; 0.4 is medium; and 0.6 is big,” explains Devin Casenhiser, the study’s director. “Some of our effect sizes were 0.8 or larger. That means the differences were big enough to make a real difference in the children’s functioning.”
The researchers also used nets equipped with 128 electrodes to measure electrical activity in different areas of the children’s brains, both before and after the therapy. Neuroscientist Jim Stieben recorded the children’s brain activity as they watched videotaped images of their own mothers showing happiness, anger and other emotions through their facial expressions.
What Stieben found is stunning: The therapy actually changed the children’s brain wiring.
DIR and brain activity
Stieben says it has been known for some time that kids with autism have too many connections in some parts of the brain. They have too few connections in other parts, but let’s focus on the over- connectivity for now, because it is crucially important to understanding why children with autism are the way they are. “Because they have too many connections, the brains of kids with autism are overactive, working too hard, so to speak, when the kids are trying to process sensory and social information,” Stieben says. “They can’t process the information because all the different parts of the brain are talking to each other at the same time.”
At the beginning of the study, the children with autism showed much more brain activity than typical kids while trying to process their mothers’ facial expressions. “But after successful treatment, their brain activity was dramatically reduced—closer to what we’d see in a typical child’s brain,” Stieben says. Surprisingly, brain activity actually increased in the children in the control group, who did not receive DIR/Floortime therapy, even though two-thirds of them had some reward-based autism treatment during the study year.
There’s more, too. Stieben says the method he and his colleagues developed to measure brain over-connectivity has the potential to become a “biomarker” in the diagnosis of autism. “We’ve found that over-connectivity as we measure it correctly identifies an autistic brain almost three-quarters of the time.”
How DIR stands out
DIR/Floortime is different in many ways from the much more widely available Intensive Behavioural Intervention (IBI) treatment, in which therapists train children to do or not do specific behaviours using rewards (such as Smarties) for making eye contact, or effusive praise for sitting still. “The only reinforcers in our DIR/Floortime therapy program are the naturally occurring social rewards that come from interacting with people,” says Casenhiser. In other words, the children in the study began to make eye contact not because they were trained to, but for the same reasons the rest of us do: because eye contact helps them understand people’s interest, attention and emotions—and because, after the therapy, they are no longer completely overwhelmed by those interactions, and now can and want to engage with other people.
Another difference is that while parents play an important role in IBI, trained therapists do most of the therapy in as many as 20 to 40 hours of sessions per week. In DIR, parents do most of the therapy at home. The DIR families also attend two two-hour sessions per month with highly trained therapists who help them learn to read their kids’ hard-to-read signals.
Right now, far more therapists are trained to do IBI than DIR—and even if DIR becomes more widely accepted and funded by provincial governments (as is the case with IBI), it will take time to train enough people to make the therapy widely available.
DIR still isn’t a cure
While there are families, like Lincoln and Tristan Scott, who’ve had success with DIR/Floortime, it isn’t a cure. “There is still significant impairment after the therapy for most kids, as is the case with IBI,” says Stuart Shanker, executive director of The Milton & Ethel Harris Research Initiative. Also, the treatment was not successful for several of the children in the study. A few families dropped out because they couldn’t follow through with the intensive time commitment. “And given the sheer diversity of children with autism, it’s unlikely that any one therapy will be the perfect answer for all of them. We need to get away from either/or thinking about our treatment,” Shanker says. In fact, I think our treatment has the potential to enhance the effect of other treatments such as IBI.”
The potential is enough to excite Scott and his wife. “This is just the beginning of a long journey,” he says. “But I now feel that we have been equipped with many useful tools to help and guide Tristan. For the time being, we take one moment at a time, and cherish each one.”
Read more: Autism and DIR/Floor time>
A version of this article appeared in our September 2012 issue with the headline “Connecting,” pp. 114-116.
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