Play, DIRFloortime®, and Neurodiversity Informed Practice

Over the last two weeks I have spoken at several conferences and events that were focused on neurodiversity, DIR, ethical considerations in autism services, and/or play. I received lots of questions about how we embrace neurodiversity in the play process of DIR®. So, I started a list of ideas. The following are my notes over the past two weeks. 25 points of consideration for therapists. See what you think. Let me know your thoughts. In part I am also writing this for all those out there that think DIRFloortime® is about imposing a neurotypical normalization agenda. It for sure is not. It is about helping the child grow and develop while respecting and valuing their own beautiful uniqueness.

1. Play is strength-based building on what the child is doing and is interested in. Play is not used in a manipulative way to get connection to then switch to a deficit-based intervention.
2. Follow the child’s lead in play.
3. The action is in the interaction. Development happens in the interaction of play.
4. Genuinely engage and join in the play with a child and help them expand and elaborate upon their own intentions, rather than coercing the child to play along with your intentions.
5. Play is not used to teach neurotypical norms. We honor the unique profile of each child and seek to understand them and help them develop in their own unique and neurodiverse way rather than seek to impose neurotypical or therapist determined norms.
6. Compassionate and naturalistic play is not enough. In many ways, more compassionate and naturalistic play that has the same goals of normalizing behaviors may actually be more problematic for the child’s psyche because it is a more sophisticated presentation of the same neurotypical normalizing goals of traditional behavioral discrete trial training, but just clocked in a pseudo loving interaction. This manipulation can foster the sense for the child that kindness and love are used to manipulate to get what you want.
7. Therapists need to engage and join in the play and become a part of the play in a full way. This is key in helping the child develop their internal capacity to understand and manage their own being and their own behaviors. This is different than using play to manage, change, or control behaviors that are determined by the therapist or anyone else to be unwanted [autistic] behaviors.
8. Avoid using rewards or punishments in the play. While some natural consequences will inevitably happen, it should never be the conscious intent of the therapist to give a reward or punishment. The child is not engaging in play to be judged by their play partner and we should not condition them to think that is the point.
9. Play is a wonderful opportunity for learning based on exploration and discovery. Introducing exposure and memory based tasks only detracts from the beauty of the play process.
10. Be very mindful of how modeling is used in the play. Modeling can be helpful in many ways, but modeling risks prompting a neurotypical and therapist led way of being. While some modeling will take place and can help in the development of communication, language, and other important ways, therapists need to be very careful not to impose neurotypical and therapist determined norms.
11. There are never explicit or implicit goals of indistinguishability. Through a process of self-reflection, therapists constantly have to be challenging themselves not to allow implicit goals of indistinguishability through. Normalization is never a goal.
12. Prompting should generally be avoided and absolutely never prompt for one single “right” response. Prompting for a single response is inherently based on a predetermined frame of reference that is often based on the therapist’s beliefs on what is normal or acceptable. When a therapist determines there is one right answer to a situation and prompts for that, they are determining the norm and imposing it upon the child.
13. Play is naturally a developmental process. Children develop their core social-emotional capacities through play. Play should focus on promoting development more than teaching. Children will learn in play, but it happens as they explore, discover, and develop. Adults often take the joy of play and turn into, “Now I have you, I am going to teach you that this yellow ball is yellow. ‘Say Yellow’ [holding up a yellow ball]” Does a five-year-old playing with another five-year-old ever hold up a yellow ball they know is yellow to ask the child they are playing with to “say yellow”?
14. The goal is to expand and to elaborate. If you focus on expanding and elaborating, you are promoting growth and development while fully valuing the child and avoiding imposing your own neurotypical and/or therapist determined perspectives.
15. Engage in co-regulation and the development of self-regulation rather than simply how to manage behavioral dysregulation. Many behaviorally focused therapists talk about “managing dysregulation” in play. If the therapist is managing dysregulation or even trying to teach the child how to manage dysregulation, this ends up being a “top down” more externally driven process. Joining in play gives us the opportunity to engage in co-regulation, this helps to develop an internal “bottom up” development of the child’s own self-regulation. We can all learn techniques of self-control which is fine, but within play we have the opportunity to use a natural co-regulating process to promote the development of self-regulation which is that internal sense in ones body that I am calm and OK in the world and I don’t have to constantly rely on external controls or even self-control “strategies” to cope. Rather, I can be “OK” and regulated from within. A more sophisticated way of saying it is that subcortical regulation can develop in play and that should be the focus. Teaching strategies that relate to how cortical activities regulate the subcortical systems has its place, but that is a teaching process and not as much of a developmental process. We work to keep play focused on developmental processes.
16. Engage with the child through their challenging moments that often present behaviors that some will refer to as “problematic” or “challenging” behaviors. This is different than focusing on changing or controlling behaviors. In the process of joining and engaging with the child through the difficult times, we foster the development of core capacities rather than simply extinguishing behaviors. For example, the goal should be to help the child develop the capacity to be able to successfully engage in shared social problem solving rather than to simply extinguish the meltdowns that can often happen when a child lacks this capacity. Extinguishing the meltdown won’t do anything to help the child create the requisite capacity for shared social problem solving that is needed to be successful in challenging social situations.
17. There is never a goal of extinguishing behaviors. Our goal in play is to promote development and growth. As that development and growth happens, behaviors that the child no longer needs to regulate themselves or their world or that they discover get in the way of engaging with the world they want to engage in may diminish, but extinguishing those behaviors is not the goal. For example, we do not set a goal of extinguishing hand flapping behaviors. In many cases, if the child becomes more regulated, engaged, and feels understood by their play partner, we may see less hand flapping (or we may actually see more), but either way, that is being driven by the child, not the therapist.
18. In regards to turn taking, therapists need to be more focused on engaging in back-and-forth circles of communication and interactions that will develop the capacity to engage in turn-taking in a meaningful way because the child wants to, not because it is a rule imposed by the therapist. Do not simply think of it as a social skill that needs to be taught.
19. Play can develop the capacity for social connection, communication, and interaction. This is the focus and we do not use play to simply teach skills that are deemed socially appropriate.
20. Seek to understand and to help the child feel and be understood. Feeling and being understood is the foundation for meaningful personal growth and development. There is potentially nothing more important.
21. Therapists should not be forcing face-to-face interactions. Therapists should be engaging with the child. In most cases, this will result in face-to-face interactions that are rich in eye contact. However, for some children eye contact may be overwhelming and the intense face-to-face interaction may be overwhelming. So, the goal is meaningful engagement that respects and values the child’s perspective and way of being.
22. Therapists should constantly adjust their actions and the environment to support the child’s individual differences. If something in the environment or in the actions of the therapist can be changed to better support the child’s individual differences, this should be done. (i.e. dimming lights if it is overwhelming; not wearing cologne if it causes discomfort for the child; not moving too quickly to accommodate a child with visual processing challenges) This can include sensory, motor, physical, or other individual differences.
23. Play should always respect and embrace the culture of the child and family. In addition to following the child’s lead in play we are also following the family’s cultural lead.
24. Always respect the child’s “no”. This does not mean the child will always get their way or be able to do anything they want, but we avoid forcing our agenda upon the child and we seek to foster a sense of agency for the child that includes the right to say “no” if something makes them uncomfortable.
25. Have fun and be a play partner the child is excited to play with.

That's my list. Did I miss anything?

 I would write this a bit differently for parents, but the same concepts generally apply.