|
Joining Exclusive and Repetitive
Behaviors Promotes Social Interaction
This core principle of the SRP extends
the principles of child-centeredness and responsiveness
and takes them from a position radically different
from that of any other treatment approach known by
this author. A key behavioral symptom of Autism, not
yet addressed by this paper, is the engagement in
stereotypical, repetitive movements or activities.
Traditionally, the approach to these behaviors has
been to attempt to eliminate them, the rationale behind
this being the more “normal” the child
looks, the more likely s/he is to be accepted by peers,
and thus increase the likelihood of successful social
experience. This perspective, however, seems to have
negated attempts to understand the function of these
behaviors, and this aspect of Autism has received
much less scientific scrutiny than any other (Turner,
1999). This perspective goes against the principle
of acceptance and enjoyment of the child that has
proved to be so fruitful.
The research that does exist in the
domain of stereotypical and repetitive behaviors suggests
that these repetitious behaviors are helpful to the
child and are not, in fact random byproducts of the
disorder that serve no function (as has been suggested,
e.g. Lewis et al., 1987). Repetition is a natural
part of any child’s development; Piaget (1952)
noted that typically developing infants will repeat
activities that affect the environment in ways that
inspire their interest. Thelen (1979) found that typically
developing infants show a variety of rhythmic and
pronounced stereotypic behaviors, each with a characteristic
age of onset, peak performance and decline. These
behaviors appear to mark unmistakable phases in the
stages of neuromuscular development. Children seem
to move through these behaviors until they have gained
a full sense of mastery over their muscles and, presumably,
until they can predict the effects of their own movements
on the environment. Militerni et al (2002) looked
at repetitive behaviors in two age groups of children
with Autism. They found that the younger children
(age 2-4 years) exhibited motor and sensory repetitive
behaviors while those in the higher age group (7-11
years) had more complex repetitive behaviors. Similarly,
those children with estimated higher IQs also showed
more complex repetitive behaviors. Militerni et al
(2002) suggest that these repetitive behaviors may
be equivalent to the motor and cognitive behaviors
seen in typical development.
Needless to say, in children with
Autism and related disorders, these behaviors are
much more pronounced, more intense and engage more
of the child’s attention than in typically developing
children. Herstein et al (2001) suggest that children
with Autism may employ repetitive behaviors in an
attempt to control an autonomic system that fails
to govern itself. Herstein et al (2001) measured skin
conductance responses (SCR) in normal and autistic
children in a variety of situations. They found that
the SCRs of children with Autism started rising at
the beginning of the experiment and continued to rise,
whereas the typically developing children’s
SCR returned to normal baseline level with the progression
of the experiment. It appeared that the children with
Autism where not able to bring their SCR levels down
once they had started to rise. Attempts at interaction
with people exacerbated SCR levels. The researchers
found, however, that the children with Autism could
bring down the SCR levels by plunging their hands
into a container of dry beans. Similarly, sucking
sweets, being wrapped in a heavy blanket and receiving
deep pressure helped the children with Autism lower
their SCR levels. They also discovered that a subset
of children with Autism was characterized by a flat
level of SCR that was only increased by extreme behaviors
(e.g. self-injury, climbing, etc.).
Herstein et al (2001) additionally
found that interruption of these self-stimulatory
and calming activities by other people “often
produced extremely large responses with agitated behavior
following immediately” (p. 1885). They go on
to suggest that “the resistance to change one
sees in autistic children may be caused by or exacerbated
by bursts of sympathetic activity, which the child
actively tries to avoid or dampen down” (Herstein
et al., 2001, p.1886). Herstein et al (2001) suggest
that the autonomic nervous system of the autistic
child is on constant alert; every incoming stimulus
is tagged as relevant and so the child acts to shut
the system down (conversely in the subset of children
with low autonomic activity, it seems that nothing
is tagged as relevant and extreme behaviors are engaged
in to produce a sense of relevance). This is consistent
with the research on perceptual filtering challenges
in those with Autism cited above. It has been suggested
that the amygdala-limbic system may be involved, as
this system typically is responsible for attaching
a sense of value to incoming perceptual stimuli and
is found to be abnormal in those with Autism (Schultz,
2005; Critchley et al., 2000; Pelphrey et al., 2004;
Akshoomoff et al, 2002; Baron-Cohen et al, 2000).
This work indicates that the repetitive,
self-stimulatory behaviors of children with Autism
are not random or functionless but actually help the
child to regulate his own autonomic system in a quest
for homeostasis (Nijhof et al., 1998). Autobiographical
reports from adults with Autism again support the
idea that repetitive behaviors serve to calm and soothe
(Bluestone, 2004). Judith Bluestone likens these activities
to meditation––turning off parts of the
mind or body by intensely focusing on one thing––and
points out that meditation has been accepted by the
Western medical establishment for over 30 years as
one of the best ways to reduce stress and increase
mental organization (Bluestone, 2004). Willemsen-Swinkels
et al (1998) found that autistic children who were
negatively excited showed a slower heart rate after
they began engaging in a repetitive activity. Herstein
et al (2001) predict that if children are prevented
from engaging in these calming activities, one would
expect to see signs of chronically high sympathetic
activity. The biochemical consequences of this are
elevated levels of cortisol and adrenaline. These
hormones interfere with the ability to concentrate,
learn and remember and increase vulnerability to viruses,
over-reactivity to medications, and heightened sensitivities
to certain foods or food additives (Bluestone, 2004),
all of which are commonly observed in children with
Autism.
From a treatment standpoint, this
research points to the need for a new perspective
on repetitive behaviors. Rather than seeing these
behaviors as something holding the child back from
social acceptance and thus to be eliminated, this
new perspective sees repetitive behaviors as useful
to the child––something to be worked with
rather than fought against. The SRP sees repetitive
behaviors as functional and an avenue for building
rapport which will form the basis of more expansive
social interaction. Rather than trying to eliminate
repetitive behaviors from the autistic child’s
repertoire to make the child more socially acceptable,
the SRP facilitator starts with acceptance of the
child––a deep, genuine appreciation for
that child and holding the perspective that all his/her
behaviors are attempts to take care of him-/herself.
This attitude allows the SRP facilitator to a) not
attempt to stop the child when he is engaging in repetitive,
self-stimulatory behaviors, but wait for the child
to spontaneously engage in social interaction and
b) physically demonstrate this acceptance by joining
in with the repetitive activity. This, the SRP suggests,
is a more powerful way of communicating to the child
that s/he is accepted and appreciated than a solely
verbal communication and of demonstrating to the child
that s/he has control over the interaction. This is
a radical departure from more traditional approaches
to Autism, but is one that has been shown to be effective
in helping children with Autism to engage in social
interaction more and, seemingly paradoxically, to
spend less and less time engaging in repetitive, self-stimulatory
behaviors.
Numerous studies have found that
imitative play facilitates social responsiveness in
children with Autism; that is, joining in with their
self-stimulatory, repetitious behaviors encourages
children to engage more in social interaction. Dawson
and Adams (1984) found that autistic children who
had a low level of imitative ability were more socially
responsive, showed more eye contact and played with
toys in a less perseverative manner when the experimenter
imitated the child instead of modeling other either
familiar or unfamiliar actions. A similar study found
that children with Autism would look at the experimenter
more frequently and for longer periods when the experimenter
imitated the child’s play (Tiegerman and Primavera,
1984). Dawson and Galpert (1990) took this line of
investigation even further. They asked mothers to
imitate their child’s play for 20 minutes each
day for two weeks. At the pre-intervention assessment,
they found, as predicted by the earlier research,
that autistic children’s gaze at their mother’s
face was longer, and their toy play more creative,
during imitative play sessions as compared to free
play sessions. After only two weeks of this intervention
(20 minutes a day), the post-intervention assessment
found significant cumulative increases in duration
of gaze at the mother’s face and of creative
toy play. Parents of children using the SRP are instructed
to engage in imitative play (“joining”)
whenever their child is playing in an exclusive or
repetitive way.
Another study experimenting with
imitating autistic children split children into two
groups; those of one group spent time with an adult
who imitated their play, while members of the other
group spent time with an adult who simply tried to
play with the child on three separate occasions. In
the second session, children in the imitation group
spent a greater proportion of time than the other
children showing distal social behaviors towards the
adult––looking, vocalizing, smiling and
engaging in reciprocal play. In the third session,
children in the imitation group spent a greater proportion
of time than the other children showing proximal social
behaviors towards the adult––being close
to the adult, sitting next to the adult and touching
the adult (Field et al, 2001).
These results, that imitative play
increases social responsiveness and joint attention,
should not be surprising to those who study the development
of typical infants and children. Parents of typically
developing infants commonly imitate their infants’
expressions, often in an exaggerated way (Malatesta
and Izard, 1984; Papousek and Papousek, 1977; Trevarthen
and Aitken, 2001). In fact, infants of 3 and 5 months
old have been seen to prefer interaction with people
who have been responsive to them in the past and avoid
interaction with those who were unresponsive or whose
responses were not congruent with the infant (Bigelow
and Birch, 1999). This imitation forms the basis of
communication and further growth by promoting a sense
of shared mutuality, an experience of congruence by
both partners that is mutually motivating (Nadel et
al., 1999; Uzgiris, 1981; Panksepp et al., 1994).
This normal interplay of non-verbal imitation between
mother and infant is widely documented to be essential
to promoting the child’s neurological, cognitive,
social and emotional growth (see Trevarthen and Aitken,
2001). Studies with typically developing (Rollins
and Snow, 1998) and autistic children (Mundy et al.,
1990; Rollins, 1999) suggest that emotional engagement
and joint attention are more critical to language
development than is instrumental use of language.
Emotional engagement and joint attention are increased
by imitative play. Trevarthen & Aitken state,
“Imitative responses are found to be attractive
to autistic children and can act as a bridge to collaborative
play or communication, and improve the child’s
access to language (Dawson & Galpert, 1990; Nadel,
1992; Nadel and Peze, 1993; Tiegerman & Primavera,
1982, 1984)” (Trevarthen & Aitken, 2001,
p.32). Siegel (2001) states simply that “Children
need such joining experiences because they provide
the emotional nourishment that developing minds require”
(p.78).
Studies with typical adults indicate
that this intuitive use of imitation continues into
adulthood, maintaining its function of building rapport
between two people. Chartrand and Bargh (1999) found
that participants mimicked, non-verbally, by a confederate
in a variety of situations reported liking that confederate
more than confederates who did not mimic them. Those
who were mimicked also described the interaction as
more smooth and harmonious. Similarly, Bernieri (1988)
found a strong relationship between reported rapport
and degree of reported movement synchrony. When looking
at non-conscious mimicry, Larkin and Chartrand (2003)
found that in situations where participants had either
a conscious or non-conscious desire to affiliate with
their experimental partner, they were more likely
to non-verbally mimic that person than when they had
no desire to affiliate with that person. It seems
that mimicry can build rapport between adults. It
has been suggested that this behavior evolved from
initially having survival value (learning new skills)
into a form of social glue that holds relationships
together and allows access to a particular group (Larkin
et al, 2003).
Imitation helps build rapport between
typical adults, typical infants or children and their
caregivers and between adults and autistic children.
Dawson and Galpert (1990) postulate that imitative
play works so well for autistic children because it
puts the child in control (one of the fundamental
principles of the SRP). This gives the child a predictable
and salient response to his actions. “This strategy
maximizes the possibility that the child will learn
to expect and effectively elicit a response from another
person, in this way providing a foundation for reciprocal
social interaction” (Dawson and Galpert, 1990,
p.152). Additionally, imitative play is sensitive
to the child’s optimal range of sensory stimulation;
the child can adjust the amount of sensory stimulation
by adjusting his or her own actions creating an easy,
controllable and predictable form of social interaction
that is more digestible for the autistic child. Field
(1977, 1979, cited in Dawson and Galpert, 1990) studied
the effects of maternal imitation with pre-term infants
who showed high levels of gaze aversion, negative
affect and elevated tonic heart rates. When mothers
imitated their infants’ behavior, the infants
became more attentive than when mothers spontaneously
interacted with their infants. Decreases in tonic
heart rate were recorded during imitative play. Applying
this research to the autistic population by examining
physiological measures during imitative play has yet
to be done.
Dawson and Galpert (1990) conclude
that “imitative play may be used to provide
a foundation for establishing social interest and
interactive play. This foundation can then be built
upon by using other, more sophisticated, interactive
strategies and games” (p. 161). This is exactly
how imitative play, or “joining,” is used
by the SRP. Children are “joined” or imitated
while they are playing in a self-stimulatory and exclusive
way because the SRP recognizes the curative, calming
and organizing nature of this self-stimulatory play.
Through joining the child rapport is created and a
social bridge is built. A relationship of trust is
formed as the child learns that s/he is in control
of the interaction and can initiate and end it at
will, without the need for language. It follows then
that children will start to initiate social contact
more and more when immersed in this environment. This
will open up increasing opportunities to build on
this connection in a manner motivating to that child
(as described above) and thus increase the frequency
and duration of joint attention that leads to the
child’s neurological, cognitive, social and
emotional development. Observational analysis of parents
and SRP facilitators working with autistic children
is required to fully understand the subtle variables
involved in this type of interaction.
The technique of joining builds
on the principle of being responsive. In Trivette’s
(2003) definition of the responsive style of interaction,
an appropriate response is one that matches the child’s
developmental level and mood. The SRP adds a further
requirement––that the adult’s response
be sensitive to the child’s level of exclusivity,
exclusivity being the child’s level of motivation
for social interaction. The SRP maintains that all
children, regardless of diagnosis, have the capacity
to move along an exclusive-interactive continuum.
At the exclusive end of this continuum the child is
not motivated for social interaction, and is absorbed
in his own world; this state is usually accompanied
by repetitive behaviors and activities or perseveration
on repetitive topics. At the interactive end of the
continuum, the child is motivated for interaction
with another person and shows interest by maintaining
joint attention, displaying positive affect and participating
in an interactive and fluid activity or conversation.
Observing the child’s level of motivation for
interaction, or degree of exclusivity, is the first
vital step in the SRP to responding in a manner that
will facilitate a) the maximum amount of responsiveness
from the child and b) the maximal degree of new learning.
When the child is exclusive (not
motivated for social interaction), the SRP holds that
the most effective response is to join with the child’s
behavior. This type of response allows the child to
use their repetitive activity to gain control of their
autonomic system and facilitates more spontaneous
social orienting from the child. As the child’s
level of motivation for social interaction increases,
s/he will start to spontaneously orient to the adult
more (e.g. by making eye contact, attempting verbal
or non-verbal communications or making physical contact).
The SRP trained facilitator will begin to respond
to these behaviors in the manner described by Trivette
(2003)––by offering an activity they believe
the child will find enjoyable. As the child’s
level of motivation for social interaction increases,
the frequency and duration of the child’s spontaneous
social orientations will increase, as will their displayed
positive affect. Once the child has reached a level
of motivation for social interaction characterized
by frequent or sustained eye contact, positive affect
and non-verbal or verbal attempts to re-initiate the
activity, the SRP -trained facilitator will move into
a style of interaction that combines responding to
the child to maintain the level of motivation, and
requesting the child to participate in new ways (e.g.,
use more or clearer language, use more eye contact,
be more flexible, use academic or friendship skills,
etc.). The Son-Rise Program® Developmental Model
(Hogan and Hogan, 2004) provides guidelines indicating
which skill to focus on depending on the child’s
developmental level. Once the child is motivated for
social interaction and for the particular activity
on offer, s/he will make attempts at the new skill
in order to maintain the interaction. When the child’s
level of motivation changes, the facilitator will
be responsive to this, observe where the child is
on the exclusivity-interactive continuum, and respond
accordingly.
It is through this subtle dance
between maintaining a responsive interactive style,
giving control, and excitedly requesting new skill
use that the SRP claims to be able to facilitate extraordinary
development in children with severe developmental
disorders, as documented in the case studies by the
founders (Kaufman, 1981; 1994). To the knowledge of
this author, there is no research to date investigating
the efficacy of changing one’s responsive style
based on the child’s level of motivation for
social interaction or an empirical investigation of
the concept of an interactive-exclusive continuum.
This is a gap in the literature that demands attention
and could create a deeper understanding of children
with Autism and the most effective way to facilitate
social interaction with this population.
|
Back to top
