Autism Vox

Engaging Floortime (6): Don’t judge this book by its cover

by Kristina Chew, PhD on July 24th, 2006

From its very title, Stanley Greenspan’s new book Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate and Think announces itself as a book about autism and, more specifically, about engaging autistic children. While frequent mention is of course made of “children with ASD,” Greenspan often seems to be writing about children in general rather than autistic children in particular. As a result, in more than a few places, Engaging Autism is not itself engaged with autism and is not about autism.

Despite Greenspan’s continual reference to autistic children’s “unique biology” and sensory processing, the view of autistic children that emerges from Engaging Autism is that such children are just like any other children inside. ASD children have “complex developmental problems” and “severe motor planning problems” (p. 4) and so

…may appear to have cognitive disabilities and to lack social skills when in fact they are limited in expressing their abilities and skills by their motor impairments. When we help children with oral motor problems communicate through sign language or other augmentative modes such as computer keyboards, we often find that they understand their world to a much more developed degree than we realized. (p. 5)

What “may appear” to be a cognitive disability—autism—is not actually such: A child who appears to have such “secondary symptoms” as hand-flapping or repetitive, scripted speech may simply have “sensory processing problems,” “language deficits or very circumscribed cognitive or learning difficulties” (p. 6) but not be autistic. Indeed, Greenspan suggests that ASD is often misdiagnosed (p. 7, 20-23) and even overdiagnosed (pp. 24-25) and puts a great deal of emphasis on how many evaluators fail to take in contact the interaction between child and parent:

One of the main reasons for the many misdiagnoses of ASD that are made is that not enough time is spent watching the child interact with a parent or other trusted caregiver. In many evaluations, children are in fact separated from parents and challenged to perform various types of developmental tests in a way that fails to take into account the child’s individual differences in processing information. The children thus become stressed and confused, which tends to bring out the lowest level of ability. (p. 7)

While the notion that a better evaluation of a child’s abilities can be made by seeing that child “interact with a parent or other trusted caregiver” may seem so obvious as to be commonsensical, I would suggest that Greenspan’s emphasis on needing to see the interaction between the “parent or other trusted caregiver” and the child (see also pp. 25-27) is not only meant to provide a more accurate diagnosis of the child’s condition. In light of Greenspan’s suggesting that parents can contribute to their child’s being “at risk for ASD” and for developing ASD—-a theory of “how autism develops” that carries more than a few echoes of the supposedly debunked refrigerator mother theory of autism—it seems that clinicians are also to be observing, and evaluating, the parents, and noting how they have not provided the right kind of postnatal experiences for their child. The implication is that, through using the right approach—-such as the “developmental, individual-difference, relationship-based” (DIR) model (p. x)—parents can remediate this. (See my my previous post on Engaging Floortime (2): Greenspan on How Autism Develops.) Rather than wondering whether a child has autism, parents

…need to remember that it’s not an all-or-nothing decision. If a child has delays, parents need to ask, “How do I make sure my child is moving ahead in a healthy way?” That outlook will keep all doors open for the child’s emotional and intellectual growth. (p. 27)

It does, indeed, seem rather ironic that the author of a book that is entitled “Engaging Autism,” and that promotes an approach, Floortime, that is (according to the Floortime website) about “reaching beyond autism,” makes the argument that autism is not only misdiagnosed but overdiagnosed. If there are so many cases of children incorrectly diagnosed with autism, what would be the audience of Greenspan’s Engaging Autism? How engaged with autism is Engaging Autism?

I will conclude with an example of how Greenspan’s writing slips back and forth from being about children, children with “unique biologies” such as “visual and auditory challenges” (pp. 149-150), and “children with ASD.”

If a child with a hearing deficit has been given cochlear implants, caregivers are often told to stand behind the child or hide their mouths to force the child to use her hearing and not her other sensory modalities. In our view, this is counterproductive because healthy experience is multisensory……For the child with a cochlear implant, you want to combine her new experience of sound with all her other senses so she has a rich, multisensory image. Otherwise you’ve created an artificial problem, thereby adding to the difficulty that children with ASD have with integrating the different senses. We might spend short periods of time isolating the child’s hearing for specific exercises, to help her learn to detect and discriminate sound, but the child’s main experience should integrate all the senses. (p. 158; my emphases)

In the space of one paragraph and in one sentence, Greenspan goes from writing about a hearing-impaired child with a cochlear implant to writing about “children with ASD.” He seems to be writing about children with quite different disabilities—-a deaf child and an autistic child—-as if they are exactly the same. And these subtle, or rather abrupt, equations of autistic children with hearing-impaired children and with any child occur throughout Engaging Autism (see, for example, p. 359, top paragraph)—so does Greenspan write that “the basic principle of ‘Floortime all the time everywhere’ is helpful for all children, not just children with ASD and other children with special needs” (p. 201).

Greenspan’s Engaging Autism does not seem to be as “engaged”—as knowledgeable—about its purported topic, autism, as the title on its cover suggests.

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