FACTS: Interview With Dr. Stanley Greenspan

Press Release:
Dr. Greenspan is Clinical Professor of Psychiatrics and Pediatrics at George Washington Medical School, chairman of the Interdisciplinary Council for Developmental and Learning Disorders, and author or editor of more than 38 books on human development including The Child with Special Needs (with Serena Weider, Ph.D.) and The First Idea, How Symbols, Language and Intelligence in Early Primates and Humans. The Floortime Foundation is a non-profit organization dedicated to improving the development of children with special needs learning disabilities, and emotional and behavioral challenges.
Dr. Greenspan conducts a weekly web-based radio program, entitled "Infants, Children and Families." It focuses on critical issues for children with autistic spectrum disorders, other developmental challenges, learning disabilities, behavioral and spectrum disorders, other developmental challenges, learning disabilities, behavioral and emotional challenges, and typical developmental patterns. It takes questions through live calls or email and feature special guests such as Serena Weider, Ph.D. Subjects include revising educational goals for children with special needs, learning to regulate mood and impulses, pathways to empathy and reflective thinking and a variety of other topics. The one hour show airs on Thursdays from 10:30-11:30 am Eastern Time and is available for listening and downloading. (See www.floortime.org for more information.)

The following interview with Dr. Stanley Greenspan was conducted by CCI staff members Martie Kendrick, Jennifer Maeverde and Alan Kurtz.

LEARNS: In your press release (above) you mentioned a number of topics that you’ll be discussing. Can you talk about some of the future topics for the show?

Stanley Greenspan: In the first show we talked about new goals for children with autism and related disorders. We focused not on traditional goals of learning to comply and write your letters and your name - but more on goals of learning to engage with others, to communicate with gestures, to use ideas creatively, to learn to think and reflect. We have to change our focus from narrow academic, educational, and behavioral goals to broad foundations for healthy functioning. The second show focused on individual differences in children. We find that children with autism spectrum disorders or other special needs conditions are by no means the same. Some are over-reactive to touch and sound; some are under-reactive. Some are better with visual while some are better with auditory information. We have to tailor the learning environments to the child’s individual profile. In the third show we talked about learning environments in home and in school. Basically, those are the environments in which we can tailor approaches to the child and help the child master these important foundations we call functional developmental capacities. In the third show we also talked about some broader guidelines for education including parent involvement and parent and school partnerships. In the next show, we are going to go into the steps leading to reflective thinking, coping with impulsivity and anger and aggression, coping with mood variations, etc. So there will be a variety of topics.

LEARNS: Who are some of the guest you are anticipating on inviting on the show, besides Serna Weider?

SG: We are hoping that Berry Brazelton, who is a very good friend, will come on. We worked on a book together. He’ll talk about early identification the earlier signs in babies, so we can pick up and these show that there is risk for challenging development and so we can help get a baby back on track as early as possible. My colleague Stewart Shancker co-authored a book with me called “The First Idea”. It tells us about how the evolution of language and symbols in early primates and humans is actually a model for the development of language in humans. We find the same steps in humans in each new baby and we can trace them through the course of evolution. That gives us the insight about how we can work with children whose symbol formation has been derailed. There are a variety people who are doing technical work in certain areas. Harry Whacks is the world’s expert on visual spatial thinking. He has written a book called Thinking Goes to School and worked with Piaget in the middle of the century. We hope to have him on as a guest in the near future. Also we hope to have known experts from the different disciplines that work with children with special needs. I’ll probably invite Barry Prizant to come on to talk about the latest developments in speech and language work. There are a number of people now who participated recently in the autistic summit sponsored by the federal government. And there are a number of people doing innovative work from around the country from that meeting. Some of the federal officials who are concerned with improving special education I’ll probably have on the show. For example there is Dr. Solomon from the University of Michigan who has a very interesting program called the “play project” which is using our DIR model [Developmental, Individual difference, Relationship-based model] where we tailor approaches to the child. Dr. Solomon has been implementing this in the State of Michigan through the model program called the “Play Project,” so we’ll probably have him on. And we will have a bunch of others.

LEARNS: Many people have embraced DIR model in principle. For a lot of reasons it makes sense, especially to those who approach education from a developmental perspective. Although many people in Maine have attended your training, they often still feel, that they do not have the skills, the expertise, or confidence to put it into practice. Do you think your web-based radio program will help make the DIR model more accessible?

SG: That’s one of our goals - that by having a weekly show where we can take questions from listeners both professionals and parents. We can fine-tune people’s knowledge that they may have gotten through some of our training sessions and through reading some of the books like The Child with Special Needs and our Clinical Practice Guidelines. We now have 20 hours of training tapes that were done by myself and Serena [Weider] with 12 different cases showing our work with those 12 cases and discussing the children with their parents and you know modeling the way we are coaching the parents. Many people find that a very useful resource for fine-tuning their skill. The other thing we are doing now is that we have been expanding our certification program. We have a summer training institute that’s more intensive than the two four-day ones that we have during the year. The November one is very broad based with different panels. I do most of it and we focus very intensively on the clinical strategies and the know-how part of the DIR model. This one coming up is something that gets people started and we cover the basics in the first few days. In the second few days we have an advanced seminar for people who have either been to prior training sessions or have been to the first few days. The summer training complements the intensive four day spring course and usually it’s a very small number of people with a very intensive and a full week and involves more seminars you know with 7 or 8 people looking at videotapes together. And that leads to various levels of certification. We are trying help individuals who would like to be resources in their community become certified and develop some sense of confidence that they have mastered the essentials and they’re in the same boat as everyone else - which is learning by doing, learning through experience. We are also going to be developing, within the next year, a number of distance learning initiatives where we will be streaming video tape on the website and offering courses through the website. Hopefully, as more and more individuals are trained and certified in different regions of the country we can have regional seminars in person for people. They will be able to get out and not have to travel a great distance to complement the distance learning initiatives. So one of our goals now is to do just what you’re raising - to help provide good learning materials so that those who would like to learn more about it can develop as far and as broad a range skills as they are motivated to learn.

LEARNS: ABA, particularly discrete trial training, is very popular these days. One of the reasons may be that it has clearly defined goals and directions. Many practitioners seem to have difficulty with the fuzziness or inherent unpredictability of a technique such as DIR, in which you follow the child’s lead.

SG: I think that is a real challenge. There are two things people should know about. One is that people are relatively unaware that the recent studies of ABA/discrete trial are not very encouraging in terms of the results. Everyone is going by Lovaas’ original statement that he could help 48% of kids, that they can be mainstreamed, etc. Tristam Smith was Lovaas’ co-author on the original studies and a real believer in ABA and discrete trials. He is now a professor at the University if Rochester. Tristam Smith did the only clinical trial study of the ABA discrete approaches where they randomly assign children to an intervention group and non-intervention group. Lovaas was criticized for his original studies because they weren’t a clinical trial. It wasn’t a random assignment and so the groups weren’t quite even. There were other problems too, in terms of not measuring emotional and social outcomes and only measuring current educational outcomes. To make a long story short, in the only clinical trial studies done on behavioral approaches, Tristam Smith found - and he is a fan and was not coming at this as a devil’s advocate - only thirteen percent achieved the educational goal that Lovaas claimed for 48%. That’s a big, big difference. And even more importantly there were no differences between the intervention group and the non-intervention group’s emotional and social variables. This is pretty significant for an intensive intervention. To get no differences between the intervention and the non-intervention group suggests loads. Now as you can imagine, Lovaas is not publicizing that study. It appeared in the American Journal of Mental Retardation in 2000 and Tristam Smith has presented it in a number of places because it is the only clinical study and the only one that meets standards of real science. Behavioral folks have been running around the world claiming, “We are evidence based. We have more evidence behind us than any other approaches” and no one has been challenging that, but the truth is, yes you do have more research behind it but the research proves that it doesn’t work very well. So the research is a two- edged sword. If you do research on an intervention it can show that it is very helpful, medium helpful, only quite modesty helpful or not helpful at all. The emerging research is showing is that the value of ABA is very, very limited and that is not being publicized. Tristam has actually presented it in our council meeting in November, but this needs to be more broadly publicized. People think they can be concrete and literal and have a cookbook approach and have good results with their children. Well they can have a cookbook approach, but that may not lead to good results with their children. That may motivate people to say. “OK this is a complex problem, we have got to have maybe a more complex solution. We can’t use a simplistic solution.“

The second part, which is the more important part, is how to become comfortable and confident with the DIR type model and its principles. Again, it does require some creativity and some adaptation to the individual child. It is not quite a cookbook. Although, if someone knows a child with special needs and reads our clinical practical guidelines and looks at the videotapes there are and put in that level of effort, there are a number of principles that really do guide you. As I often tell parents and professional colleagues: “it is complex but you will get better and better at it the more you do.” Anything that you do that follows these principles is very helpful for the child even if it is not done quite perfectly. There is no bad here; the only bad is not showing up, not engaging your child, not relating to your child, not involving your child’s interactions and opportunities for communication. Once you show up and try and employ the general principles there is only different levels of good and you’ll get better and better as you do it and as you practice it. I find that parents often are the best with their children because they know their children the best - once they manage the fundamental principles of tailoring the interaction to the child’s competency profile, following the child’s natural affect and interest, and challenging the child to be engaged with six fundamental levels of attending, engaging, gestural communication, and if the child’s able to use the ideas and then connect the ideas together. So the key is to get involved in it. We’ve outlined in different publications what constitutes a home program involving 6-8 sessions where we are spontaneously following the child ‘s lead and building these 6 levels. Then we get around to problem solving interactions where we create the agenda to help the child master new goals and here we’ve just developed the affect-based language curriculum, which is a semi-structured language curriculum that is really the answer to the most structured approaches. It is there, in the affect-based speech and language curriculum, that we become very specific and give lots of concrete exercises you can do to cook the language but it involves the child’s affect. Parents who want a little more structure - that’s part two of the home program. And then we are developing curriculum for visual-spatial thinking and motor planning skills, which will be part 3 and 4.

We are developing a curriculum not just for the motor system but visual spatial thinking as well. It can all be part of a semi-structured component of the whole program. And inter-peer play is very important in our home program, four or more peer dates a week. We have three physical workouts per day involving motor planning, visual spatial thinking, and sensory modulation capacity.

Once the child can gesture and relate through what we call continual back of forth gestural communication, then we want a child in integrated settings. Before that the child can be in integrated settings but after that the child the child must be in an integrated settings. If we keep the child at that point in just with other children with special needs we lose opportunities for interactive learning with peers. And that’s a big issue for many families because many school systems don’t have that option available. Some do, which is great. So then we need good integrated settings where there is a teacher with 3 or 4 children not huge settings that are chaotic and disorganized. And we need lots and lots of peer play, 4 or more peer play dates a week. And then we need special therapy; O.T., P.T., speech therapy, and when children are older work on perceptual motor and visual spatial thinking skills etc. to work on different processing areas. And so the elements of the model and the components of the service program that needs to be in place are concrete. The hard part is in carrying out of both the spontaneous and the semi-structured learning interactions. It is learning how to figure out your child’s nervous system, learning how to follow your child’s natural interest, learning how to create motivation for problem solving interactions where you’re taking the lead. This is why we have the training and this is why we’ve written a number of the books. But it can be mastered and I’m impressed with how many parents and clinicians have mastered this and become quite competent. But you have got to kind of take a chance and get in there and it is not spoon-fed. But again what’s helpful isn’t easy but its very masterable and we’re providing more and more supports in terms of the affect base language curriculum to help parents and clinicians master these concepts.

LEARNS: Is any research going on currently directly comparing the efficacy of the DIR model with other approaches?

S.G: Well interestingly we, the DIR folks, and Tristam Smith, who worked closely with Lovaas, are putting in grants to do just that. We have a grant into the Federal Government. We are trying to get some foundation boards to do some pilot studies. So we are very much trying to get a study funded to do just that. It not exactly easy - getting the funds. So, if anyone wants to fund it, we are ready to go. We have a protocol, a willingness, and an interest in doing it because we feel that this is going to move the field forward and be very helpful to everyone. And so if there’s anybody, any understanding foundation out there that we don’t know about, that wants to help fund this we are ready to go.

LEARNS: What aspects of the DIR model might be applicable in working with children with mental health issues.

S.G: Basically it has been modified just as well to a mental health diagnosis as a developmental diagnosis. For example - the extreme case might be a child with a depravation syndrome who’s been in an orphanage in Eastern Europe who comes to the United States and may present what appears to be language/relationship problems and even gestural communication problems. We would use the same approach we would with a child with an autistic spectrum disorder and a child with a impulse control disorder - a pure mental health problem. Again we take the same basic problem and try to see where that child is in terms of their functional, emotion developmental level or whether he mastered gestural two-way communication or has he mastered it in part for example around intimacy and dependency but not around aggressions. So maybe he can signal and understand stand signals when it comes to warmth and love and not when it comes to acting out angry feelings. I also see parents who gesture pretty good for love and warmth but freeze when it comes to dealing with aggression so there is that pre-level system so we may have a problem at level four in our functional developmental capacities. Similarly we may want to look at individual differences for that aggressive and impulsive child, we may see often that he is sensory seeking, but sensory under-reactive to pain and seeks out sensations a great deal so he is always seeking more sensations and its easier to get into hot water impulsively then because he’s trying to jump from high places, bang into things, etc. Then we look at the other part to capacity if we find that that child has a visual spatial processing or language-processing capacities makes communication more difficult, he’s more frustrated, he’s more aggressive and we get a higher likelihood of risk for later anti-social patterns. Then we look at the learning relationships and the family relationships again how much are they supporting him in warmth and love how much are they supporting allowing comfort with dependency if it’s a child in foster care for example that’s been shifted around a lot and there isn’t any fundamental work on engaging and relating and then the communication system is more punitive and empathetic in terms of the learning environment. We get a four plus aggressive child, a sensory seeking child who is not getting engaged, not learning about empathy or caring about others and who’s not learning to respond to the nonverbal and verbal cues and gestures around living setting because he doesn’t care and because he’s not getting enough practice in one consolidated setting. So we use the same model, and what that leads to, instead of advice to parents or just or "psychotherapy" for the child or just "behavioral" management for the child, we ask where are the missing foundation pieces? What’s missing in that child’s capacities? We have to help that child learn to engage and relate with warmth and trust. We have to help that child learn to respond to non-verbal cues around limiting aggression and impulsivity. I have to also help that child become better at level 5 & 6 using fantasy and logical discussions to cope with aggressive impulses. So it gives us a guide for an active comprehensive program so the program elements are actual different that they autistic spectrum disorder because were going to focus on different elements of the DIR model but the model is the same analytic tool. So it helps us as mental health problems as well as developmental problems.

LEARNS: Is there somewhere you describe this in writing?

S.G: Yes there are two books - a book I wrote called Infancy and Early Childhood: The Clinical Practice of Assessment and Intervention with Emotional Developmental Challenges, from International Universities Press. And we have chapters on just those subject lines infant/early childhood and mental health. And there is a new book coming out next year by Serena Weider and myself from the American Psychiatric Association Press on infant/early childhood mental health, going into more detail in these kinds of issues.

LEARNS: One last question. I was wondering what your thoughts are on the current trend of diagnosis of early onset bipolar disorder in children under five?

S.G: Well we have a book on bi-polar disorder that is available through the Interdisciplinary Council For Developmental Learning Disorders that gives an account of learning disorders. We now we see bi-polar patterns. I say bi-polar patterns; I wouldn’t want to diagnose a bi-polar disorder in a very young child because I am hoping we can prevent that from happening and it won’t consolidate into that. We discuss how the individual processing capacities of the child are quite unique and these children tend to be very sensory over-reactive. But when they get overloaded instead of shutting down and becoming cautious they tend to go into an action mode or very high gear. And this does a switch and they become sensory seeking and then they overload themselves even more so then they have other developmental issues as well. So we have a profile to these children with bi-polar patterns really fits in to our regulatory disorder concept. Where we see another type of regulatory dysfunction but it is very workable if identified early.

LEARNS: Thank you for your time.

LEARNS Interview

With Dr. Stanley Greenspan
Clinical Professor of Psychiatrics and Pediatrics

LEARNS Interview

With Dr. Stanley Greenspan Clinical Professor of Psychiatrics and Pediatrics

With Dr. Stanley Greenspan
Clinical Professor of Psychiatrics and Pediatrics