Kid Confidential: “Join In on the Stim!”

041113blog
Autism Spectrum Disorders (ASD) is one of the great loves in my professional career. Persons with ASD are fascinating and wonderful and many times their behavior actually makes sense to me. I know what you are thinking, “This woman has got to be on the spectrum herself.” Well although I do believe that we all exhibit hyper- and/or hypo-sensitivities to various stimuli and that we all have what I like to call “a little autism in us,” it just may not be on the scale of persons who are diagnosed with ASD formally. It may not consume our entire interactions as it does for some students with ASD. So the question is, what do we do about it?

When I was in graduate school, the prevailing acceptable intervention was based on behavioral modification techniques. I was expected to spend time determining why that stimulatory behavior occurred (i.e. avoidance, stress, seeking sensory input, coping mechanism, sensory overload, etc.) and replace it with a more appropriate behavior. I still agree that this treatment strategy is appropriate in certain situations. For instance, if the student is seeking sensory input, let’s provide him/her with an appropriate sensory diet (under the supervision of an OT with the appropriate experience). If the student is exhibiting behaviors that are harmful to him or herself or others, they MUST be replaced by more appropriate safe behaviors. If the student is overloaded and attempting to escape/avoid a situation, let’s give him/her a break and/or modify the activity and expectations.

But are there times when we should actually encourage the stimulatory behavior? Are there times when we should not only support it, but “join in on the stim”? My answer to this is ABSOLUTELY! I know I just lost a few of you, but hear me out. The first time I read this idea, I was skeptical as well.

Jonathan Levy, author of “What You Can Do Right Now to Help Your Child with Autism,” challenges parents and therapists alike to do just this, join the child in his/her world by simultaneously imitating the stimulatory behavior. The idea is that for children who are profoundly affected by ASD and who spend all or most of their time exhibiting stimulatory behaviors actually need us to invade their world and physically pull them out of it by imitating them.

According to Levy, by joining your child/student in their stimulatory behavior you are telling them several things:

  • You understand their need to use this behavior.
  • You have something in common with them.
  • You want to interact with them and you are willing to enter their world.
  • They are safe to “be themselves” around you and you will not interrupt their need to stimulate themselves using these behaviors.

Does this actually work? According to Jonathan Levy, this is a technique Barry and Samahria Kaufmann, authors of the Son-Rise Program and founders of the Autism Treatment Center of America (ATCA), not only believe in, but have used successfully on their own child as well as numerous children nationally and internationally for more than 25 years. Anecdotally, I can tell you from my personal experience, I have done this and I have noted several positive changes with consistency:

  • Almost immediate increase in eye contact or facial referencing.
  • Students with ASD began to approach and/or gravitate to me whenever I entered their classrooms.
  • Students began to tolerate my touch or would take my hands and place them on their own bodies. For example, I had a female student once start pulling on my arms. I figured out very quickly she wanted me to do this to her. Although nonverbal, she made a request for the first time in her life! After I provided that sensory feedback, she was able to sit on the floor with her class during a large group lesson for the very first time.
  • And after a few weeks of joining in the stimulatory behaviors, I began to hear vocalizations. And for some of these children, it was the first time they ever vocalized!

Yes I was that therapist, jumping around in circles, flapping my hands, vocalizing various moans and groans along with my students. I was that therapist sitting at the lunch table filtering light through my fingers and screeching with my student as he attempted to eat. I was also the first person they made eye contact with; the first person, to which they handed a picture (i.e. PEC); the first person, with whom they exhibited joint attention; and the first person to whom they intentionally vocalized when making a request.

So does this technique work? I believe that it does if used properly for the appropriate students. This is not a technique that I believe every student with ASD requires or can benefit from, but it certainly appears to make significant changes in those who are so profoundly affected that they cannot find a way out of their own worlds without us stepping in and meeting them where they are.

Mr. Levy does leave us with a word of caution. Some children do not respond immediately to this technique as they are so far within their own worlds it could take them weeks to even notice your attempts to join the stimulatory behavior. But he ensures us, that this is not a reason to give up and believes that by giving the child adequate time, he will take note of your attempts to enter his world and you will break through the child’s barriers of stimulatory protection (Levy, 2007).

This has not been the case for me as I saw changes fairly immediately. However, I do believe that can be attributed to the fact that if the child is in a school setting, they are aware at some level that there are other people within the room, whether they seem to show it or not. I believe the school setting is unique in that just the setting itself forces the child with ASD to, even on a subconscious level, acknowledge there is a world bigger and different than what is found within themselves.

So the next time you have a student with ASD on your caseload that is profoundly affected and appears to spend all or most of his/her time exhibiting stimulatory behaviors, no longer ask yourself “What do I do with this child?”. Rather, make an attempt to enter their world and “join in the stim”. By doing this, you may just be the first person who has ever been able to connect with them.

Maria Del Duca, M.S. CCC-SLP, is a pediatric speech-language pathologist in southern, Arizona. She owns a private practice, Communication Station: Speech Therapy, PLLC, and has a speech and language blog under the same name. Maria received her master’s degree from Bloomsburg University of Pennsylvania. She has been practicing as an ASHA certified member since 2003 and is an affiliate of Special Interest Group 16, School-Based Issues. She has experience in various settings such as private practice, hospital and school environments and has practiced speech pathology in New Jersey, Maryland, Kansas and now Arizona. Maria has a passion for early childhood, autism spectrum disorders, rare syndromes, and childhood Apraxia of speech. For more information, visit her blog or find her on Facebook.

Comments

  1. Natalie Romanchukevich says:

    Dear Maria,

    I really enjoyed reading your article. I immediately thought of Greenspan’s DIR and the element of “joining the child” in whatever it is he/she is doing. I agree that this approach is not readily accepted by most teachers and therapists yet (it’s been too engrained in us that we must correct these socially deviant behaviors and help the ASD children become more like “NORMAL” children), but when did a novel technique/ approach/ thought not raise a few eyebrows?

    I too feel that joining in with ASD children and imitating their seemingly inappropriate behaviors (as long as these are not dangerous to self or others) for some period of time may work well. Just like a good listener shows interest in his speaker, we as therapists can show interest in what the ASD child expresses. We can then introduce this child with a body movement or a word he/she can imitate in turn. This is a way to establish that initial communicative exchange that may open up a very important gateway for intervention. After all, it’s all about turn- taking isn’t it?

    • Natalie, thank you for your comment! I am obviously in agreement with you from reading my stance on this subject above. I think “joining the child” makes the connection and once the child is open and showing more flexibility, I then attempt to take more control of the reciprocal play or wait them out for their verbal responses, etc. It really just depends on what my goal is with that child. I will say, as maybe I did a poor job of stating it above, that it is not uncommon for me to cycle between joining the child in their stimmulatory behaviors and providing intervention. For example, I may “join the child” for several minutes, then (once the child shows openness) facilitate turn taking, vocalization, etc. and when the child has again lost interest and gone back to their stimmulatory behavior, I too will go back to “joining” the child again. This cycle can occur over and over again until the length of time with which the child is attending and participating with me extends to a more typical joint attention span so that more and more learning can occur.

      I will also state, as I did a poor job of this above as well, that when I “join in the stim”, I do EXACTLY what the child is doing. I don’t talk, I don’t make eye contact, and I don’t expect anything from them. I want them to know we are alike and they can trust me.

      Like you said “joining in the stim” is really about connecting with the child based on his/her interests. This may be spinning around in a circle, or flapping their hands, or for our higher level kiddos, talking about trains. Yes, this too is “joining in the stim” and I know this technique is more acceptable for our children with HFA but in fact the theory and techniques are one in the same regardless of function level. From that connection we can broaden their communication skills (whether it be verbal or non-verbal, attention skills, proximity, facial referencing, flexibility, etc.).

      Thank you Natalie for your comment. I think I would very much enjoy participating in your therapy sessions! :)

  2. Having actually witnessed this I can say it does work! When Maria came to me and said she was going to do this I think I actually laughed and thought we really have nothing to lose so go ahead. I honestly didn’t think it would work but at this point we hadn’t made a lot of progress with the child so we had to try. It truly was an amazing moment. There was actual awareness of another person that we had never seen before. I’m curious about having another child participate in the stimming later on to see if there is a difference between and adult and a child! I’m so glad you put this out for other people to read about!

    • This is really true, Katie! It may not work for every child but it does work for some and it’s always worth a try! Thanks for your comment. I know you thought I was crazy initially. Ha!

  3. For one child who flapped frequently, I briefly experimented with a flapping demonstration to increase her awareness. However, I couldn’t bring myself to do it regularly because I felt like I was making fun of the child. And I thought other staff would see it as mocking. Therefore, I resorted to using video modeling to increase her awareness.

    So, Maria, I find it interesting that you’re suggesting to “join in on the stim.” I feel like I would just need solid evidence to support it as an intervention strategy.

    • Thanks Eric for your comment. This concept is not a new concept by any means. Son-Rise program has been doing it for more than two decades now. Dr. Greenspan’s DIR/Floortime model has been in the forefront of this idea. That program calls it “following the child’s lead”. And Dr. Solomon’s the P.L.A.Y. project (based partially on Dr. Greenspan’s DIR) also incorporates this technique. If you’d like some research supporting it, I’d recommend you begin there. P.L.A.Y. project is having a larger double blind research study to be published this year so keep your eyes open. But there is a full body of research supporting Greenspan’s methodology.

      Also I would also challenge you and any other therapist reading this to never avoid attempting a technique just because we feel silly or are afraid of others mocking us or thinking we are mocking our students. Proper education and communication with the classroom and special education teachers (as well as all staff members working with this child), parents, friends, etc. is a necessary component for this technique to work as it isn’t just about bringing this child out into only the SLP’s world but the entire world in which the child lives.

      Thanks for your comment!

      • Kathy Babineau says:

        Hi Maria,
        Thank you so much for this very interesting article. I have used Greenspan’s methods with children in the past and I have seen some wonderful results. I would love to see more research in this method of “joining in” with the child. I have a young student on my caseload who currently “gravitates” to me as you mentioned. When I am unable to gain her attention by calling her name, getting in her space, etc., I have attempted to gain her attention to repeating some of the scripted phrases she utters and/or moving my hands and arms in the same manner as she is at the moment. This often results in immediate sustained eye contact and more engagement. It is as if she knows that I am attempting to enter her world. While not yet evidenced based, I believe this shows promise and needs to be explored. Thanks again for sharing your experiences.

        • Kathy, thank you for your comment. It is exciting when we reach that moment of connection without our students! And that is really what this technique is all about. Finding a way, ANYWAY, to connect.

          I do want to state that although I couldn’t possibly know all the research out there, there are research articles focusing on this specific technique. I do reference them in another comment on this page so if you are looking for them check out the other comments.

          With that said I do agree with you. I want to see more and more research supporting this method. After decades and thousands of anecdotal success stories from other therapist, psychologists, teachers, parents, etc. we still see this method as more controversial than using reward principles that were initially used by Pavlov on animals. I wonder what that says about us as a society? That is just a nonjudgmental thought. I am not saying that I haven’t and wouldn’t use behavioral treatment as I do believe there is no one size fits all for any child let alone any child with ASD. I have used and will continue to use behavioral techniques if that is what the child needs. But I do prefer reaching the child on a more intimate and personal level if I can by using other techniques.

          I personally believe, you do what works for that child. And if what I am doing is not working…then I need to find another way to approach this child.

          Thanks so much for your comment. I think as long as we are continuing to provide the very best relationship and connection with our students, communication will follow. How we reach that point, depends on the individual child.

  4. Hello Maria. I too work with this population and have done so for the past 25 years. I find your information puzzling, especially in the section beginning, “So does this technique work?”. There is extremely limited empirical evidence for the Son-Rise Program, even after 30 years that this has been in existence. In fact, in April 2010 (Odom, Boyd et. al in the Journal of Autism and Developmental Disorders), published a paper titled, Evaluation of Comprehensive Treatment Models for Individuals with Autism Spectrum Disorders. They found the following: Models that have ratings of four or five across at least four dimensions of the evaluation have stronger evidence of
    what we will call ‘‘model development.’’ That is, they are procedurally well documented, they have been replicated, and there is some evidence of efficacy, even if limited. These models include: Denver, LEAP, Lovaas Institute,
    May Institute, and PCDI. There are other models that have ratings of five or four on less than four domains, but there remain features of the model that are relative strengths. These include Autism Partnerships, CARD, Children’s
    Toddler Program, DIR, Douglass, PRT, Responsive Teaching, SCERTS, and TEACCH. Also, there are some models that received very low evaluation ratings across the board. These included Hanen, Higashi, Eden, Summit,
    Lancaster, and Son Rise. Again, potential consumers may use this as a general guide when determining the degree of model development and level of efficacy evidence. (Page 432).
    Anecdotes and personal opinions are the lowest form of evidence for our treatments, and as such should be backed up with solid data to support/substantiate that what we are doing with/for our clients is the best treatment possible. I have seen too many families spend a great deal of time and money on this method with NO results and actually with ‘harm’ when you consider the time/finances that have been taken away from treatments that do have efficacy.
    I’m not saying that you did not see changes in the behaviors of the children that you work with, rather, I’m saying that unless you carefully documented detailed behaviors that you wanted to change and then took data regarding those behaviors (while following a manualized treatment program e.g., Son-Rise) over a period of time, you cannot be certain that the ‘program’ was responsible for the changes or something else that you may have been doing inadvertently. All too often the ‘few’ successes from a treatment are touted as support for the treatment but the hundreds or thousands of failures are not highlighted in the same way thereby providing a very distorted view of the truth.
    Respectfully submitted

    • Tracie, thank you for your comment! I feel I need to make a few distinct points here. Firstly, this article is not in support of or against the Son-Rise program but is about the technique I call “joining in the stim”. In fact this article only references the program as that is where the author appeared to have learned the technique. His feelings on how the technique improves communication comes from him only and is the reason way I made sure to reference Jonathan Levy’s name and not the program itself. He is not speaking for the Son-Rise program. I am not speaking for the Son-Rise program. I want to make that very clear.

      Secondly, this is a blog article, not a research article. If it were it would not be published here. Therefore, I caution anyone reading this as if it IS a research article. This is an opinion piece sharing my personal experiences with a technique that is not new. Greenspan’s DIR model begins treatment by using this technique, that is to “follow the child’s lead” which encompasses the premise I call “joining in the stim”. And there is a body of research supporting the model. In addition, there are research articles that have and do support this specific technique. I cannot recall them all but right off the top of my head and I can recall a few studies in 1984, and 1990 at the University of Washington and also a study published in 2001 at the University of Miami. If anyone is looking for specific information on this technique they can start there. I very much like the latter study as its result to “joining in the stim” (as I call it) noted more reciprocal play as compared to the control group after 3 sessions. I am a huge fan of play as I believe play is a child’s work so for me this is just one more indication that it is worth a try. With this said, I understand 3 studies (although I don’t know every research article ever published and there may be more studies out there), does not compare to the large body of evidence for behavioral treatment, which in and of itself has it own research problems.

      I was brought up in the behavioral camp and taught only the behavioral theories in grad school. Those who read my blog, Communication Station: Speech Therapy, PLLC, know I do use behavioral principles for some children. However, as I research and read more, I have learned over there years that this is only ONE way to work this a child of ASD. There are many techniques and models out there. And if anyone feels one technique is not working for them I would encourage them to read and learn more about the other options they can provide for their own children or children on their caseload.

      I also want to state that even behavioral camps are coming under scrutiny for their research methodologies and some peer reviews are actually noting gross over estimations of results from these studies. Here’s an interesting article on National Center for Biotechnology Information (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686987/) where 750 articles supporting ABA and Lovass’ technique were reviewed and the result was: “the effectiveness of applied behavior analysis for autism was another myth and misconception and that the gains made during treatment were due to the children’s “development,” not to ABA…”. This is just one of many articles out there stating similar results.

      Again does this mean that behavioral treatment does not work? Of course not. But is it the ONLY technique? Absolutely not. These peer reviews do bring up some good points that behavioral treatments may not work for EVERY child and we may to continue to explore all options available to us.

      I’m not sure what you are referring to when you are discussing monetary effects of various programs. I am not stating support for one program over another and it costs no money for me (or any other therapist) to try this technique. If parents are looking for a program to help their child, I recommend they do adequate research to find the best match for them and their child.

      So as I hear your confusion on the sense of various models, I again want to state that this article is an opinion piece on my personal clinical experiences using one strategy (not a full program). Clearly, I understand anecdotal evidence is the weakest form of evidence, but again this is not a research article. This is one clinician saying to another, “hey I tried this technique and I’ve seen changes”. I feel as a therapist it is my job to reach and relate to my clients in anyway I can. I will use whatever tricks I have up my sleeve to make that happen.

      I think I have addressed all the points in your comment but I do want to say how very much I love the discussion! I think only by discussing these topics can we become better therapists. Thank you so much for your comment. I very much appreciate you thoughts and you taking the time to share them with us here on ASHAspere!

  5. Natalie Romanchukevich says:

    I’ve been following the comments here and would like to chime in again as this topic is of particular interest to me. I think we all agree that Autism is a whole different sensory system, processing, and perception of reality. So maybe, we need to start thinking outside of the “typical, appropriate, norm” box more to tap into that ASD nervous system and pull the child out -bring them into our world of communicating and relating.

    No question, Tracie has brought up valid points. More consistent research IS needed to support the use and success of the abovementioned approach/ technique. This should always remain the golden standard- evidence based practice.
    Having said that, I AM a huge Greenspan and “join in with the child” fan. I have used Greenspan’s ideas with many of my ASD children (I specialize in 2-5 population) and found that these children verbalized SO much more when I joined in and followed their lead. I think that the art of being a good therapist is to be able to use the technique (helps if it is well researched) to get into the child’s world and entice them enough to follow YOU in turn. So why can’t we flap hands together to then fly like a bird or an airplane? Why can’t we spin that toy of interest to then teach stop/ again/ my turn/ your turn?
    Besides, Greenspan’s “follow lead” is similar to “find what is truly reinforcing to the child” in ABA terms. The terminology is different. The idea, in part, may be more similar than not.

    I think it’s also all about the timing. Timing is a critical element in therapy and should guide the therapist’s course of action. So When to “flap hands” might be that initial step to What to follow up with (perhaps here you can teach the target “appropriate” behavior?), How to reinforce, and, then, How to build upon that response/ behavior. By tapping in – we might be making ourselves the most enticing of all reinforcers.
    I have seen way too many ASD preschoolers that were taught via ABA only. Many of these kids walk around talking like robots, using scripts- inappropriately and meaninglessly. Sure, their /form/ sounds socially appropriate. But can they greet, gain attention, comment, ask questions spontaneously and creatively? Can they use those words to meaningfully communicate their thoughts/ ideas/ feelings? In many cases, they cannot and will require a lot of adult support/ models to be “more fitting” as they go on with their academics and social interactions. Therefore, these kids need much more than ABA and the ability to memorize scripts. Teaching should be a two- way street- an equal exchange of needs/ wants to express. We can’t expect a child to initiate communication when we are the ones constantly directing and controlling interactions. These children are very different from us. We might need to become more like them (maybe for two minutes at a time, maybe for that 30 seconds of your session) to gain their interest in bring them a little closer to “our” world.

    Also, DIR does not discourage the use of ABA (or whatever else you may deem a worthy method)- instead, Greenspan clearly states in his book “Engaging Autism” that the framework should be used as a broader model that incorporates a variety of techniques/ approaches that work for a particular child. We should always question the validity of a new idea/ model but I as a therapist also question the extent of success of the more established methods like ABA, especially, when it is used in an isolated, all too structured, and purely teacher- directed manner only. Language and communication goes beyond Form. I like to think content and use are equally important to teach. We must create opportunities for that to take place. Joining in with the child might just be the thing!

    • Natalie, thanks again for your great input. The one thing I love about Greenspan is the idea that WE are to be the child’s first toy! I think that principle is so so great. If we follow their lead and interests and do what they are doing, and they connect with us, even if for a very short amount of time, we can turn that attentive moment into a more appropriate communicative exchange (your example of going from flapping to flying is a great illustration of this), and we will see positive changes. I very much like your explanations on the distinction between teaching form vs. teaching content, use and form. I think that is a great way of looking at it in my humble opinion.

      I know I still have so much to learn about children with ASD, but I try to keep and open mind and remember that every treatment model does have merit but just may not work for every child, or may work up to a point but than we need to seek different ways to make the skills we teach functional and reinforcing as a communicative exchange.

      I LOVE the discussions we are having here in this forum. I thank all of you who have commented. The different theoretical camps exist for a reason and I think it is so great that we can discuss them and learn from each other’s personal and professional experiences. Thank you all so very much!

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