Floor Time: An Emotional Developmental Approach to Play Therapy for Children Impacted by Developmental and/or Affective Disorders: An Interview Conducted by Ellen Lacter, Ph.D. and Esther B. Hess, Ph.D., Pediatric Psychologist and Senior Clinician for Stanley Greenspan, M.D.
(Published by the Association for Play Therapy December 2004)
Dr. Lacter: Dr. Hess, Floor Time is a developmental play therapy technique that has the capacity to reach a variety of children impacted by such issues as autism, sensory and cognitive processing delays, problems dues to intrauterine drug and alcohol exposure, trauma, sudden loss, learning disabilities and severe phobias. What is the Floor Time model? How did Dr. Greenspan first conceptualize this particular approach? And how can this method be applied to children impacted by disorders caused by birth trauma or loss?
Often children who have been derailed by developmental delays, intrauterine drug and alcohol exposure, trauma associated with sudden events and/or loss, learning disabilities and severe phobias often present for treatment with very poor or no apparent play skills. There is often an equally low level of interest in engaging with play partners. This has led to a rather pessimistic view by psychiatric clinicians of the play capacities of children with developmental and affective challenges.
Stanley Greenspan, a child psychiatrist in the Washington, D.C. area, spent sixteen years at the National Institute of Mental Health challenging this rather negative view. He developed a new philosophy of emotional development for all children-efforts for which he won the Ittleson Award, the American Psychiatric Association's highest honor for research in child psychiatry. In his years at the NIMH, Greenspan developed sophisticated criteria for understanding and defining emotional maturity and began to map out its phases. He applied recent research about how babies and toddlers typically "process" the vast amount of sensory information available to them each day to how this impacts their emotional and social development. His critical conceptual leap was to grasp the importance of emotion and social interaction for sensory and cognitive functioning. Dr. Greenspan used this information to enlarge the way that clinicians assess and treat children, by having professionals consider the possibility that functional disorganization can be caused by the interconnection of impaired neurobiology, developmental delay and/or relationship breakdown between parent and child. He provided active suggestions for getting these children back on the developmental track in a functional way.
On the basis of his insights Greenspan designed a modern developmental, relationship-based model to help children with a variety of problems. He called it D.I.R. (developmental, individual-differences, relationship-based model) or, in practice, "Floor Time" and made the approach available to the public in his and his colleague Dr. Serena Wieder's book The Child with Special Needs (1998). In this text, Drs. Greenspan and Wieder emphasize that success with any child is based on the ability of the play partner to meet the child on his specific developmental level, strengthen potential underlying neurological elements that may be impeding development and emphasize the critical emotional connection between the impacted child and the other player.
Dr. Lacter: Could you give a brief description of this method of play therapy?
The term "Floor Time" refers to the actual process through which therapists, parents, and other caregivers make a special effort to tailor interactions to meet the child at his (or her) unique functional level and within the context of his processing difficulties. Greenspan's model clarifies the basis of children's behaviors while Floor Time sessions lend support to the reciprocal relationship between the child and the caretaker. The technique involves having play partners get down on the floor and follow the child's lead to encourage the child.s initiative and purposeful behavior, deepen engagement, lengthen mutual attention, and develop symbolic capacities.
For instance, children exposed in the womb to drug and alcohol, often have severe sensory processing difficulties, which can make them hyper or hypo sensitive to environmental stimuli. Commonly these children shy away from interactive play activities with others as a way to cope with constant stimulus overload. Individuals, not versed in understanding reactions of a hypersensitive child, may misinterpret these gestures as oppositional or rejecting.
Floor Time requires parental involvement, trained by experienced clinicians versed in catching and holding "the gleam in the child.s eye." Though it emphasizes relationships, fun, and joy, the method draws its power from parents. ability to connect with a child.s source of initial interest (the "R" in the DIR model paradigm), and to entice an impaired child to perform at increasingly higher levels of attention, cognition, and motor functioning. It is tailored to a child.s particular deficits and strengths and designed to grow in scope as the child climbs the developmental ladder.
Dr. Lacter: Dr. Hess, can you describe some of the specific methods use in Floor Time?
It would be my pleasure. Basic Floor Time principles can cultivate a spontaneous interactive relationship between a child and his/her play partner as well as an improved functional developmental level within the child him/herself. These principles include:
- Follow the child's lead.
- Join in at the child.s developmental level and build on his/her natural interests. Through one's own affects and action; woo the child into engaging. It is critical to be aware of the child.s current functional developmental level and to meet the child where he/she begins, as a way to encourage further developmental progress.
- Open and close circles of communication i.e., initially build on the child's interest and then inspire the child to expand the initial interaction built on what has been done or said.
- Create a play environment with rattles, balls, dolls, action figures, cars, trucks, schools, etc., that will provide a vehicle for the child.s natural interests and facilitate opening and closing circles of communication. Avoid very structured games that reduce creative interaction.
- Interact playfully, but obstructively, as needed. When the child is avoiding interaction, the play partner needs to position him/herself between the child and the object that the child wants. The play partner wants to encourage the child to interact with him/her. For example, the adult might hide the child's car in one's hand so the child is inspired to search for it, or build a little fence around the child with one's arms so that he/she needs to duck under, push up, or say, "out" in order to return to moving around the room. It should be noted that .playfully obstructive. does not mean intruding upon the child.s sensitivities to the point of the child breaking down into a tantrum or meltdown.
- Challenge the child to engage in neglected or avoided types of interactions, initially accepting typical stereotypic play, then expand the exchange by varying the usual direction and/or tempo of the play. For example, for a passive child who avoids taking the initiative, slowly and smilingly move away the toy the child is playing with, thereby challenging the child to take the initiative and come after it.
- Engage the child with sound and/or words, vision, touch, and movement. For example, while playing with cars, make racing sounds or discuss where the cars are going; together look for the house or school the cars are going to visit.
- Work with the individual neurological differences by utilizing the natural strengths for interaction. For example, capitalize on visual experience for the child with relatively strong visual-spatial capacities.
- Gradually remediate vulnerabilities. For example, provide extra practice in listening to and using sounds and words for the child who had a receptive language or auditory processing challenge. Be extra soothing for the sensory-over reactive child and/or extra compelling and animated for the sensory-under reactive child, (Greenspan, 2000).
Dr. Lacter: What do you believe was Dr. Greenspan's motivation for approaching behavioral intervention with children within the context of the establishment of an emotional relationship?
The important question for Greenspan was, "How high could an impaired child climb?" Prior to Greenspan's thinking, children with developmental delays or gross affective impairment could acquire certain cognitive and living skills through an intensive regime, but remained stuck when they were asked to do anything imaginative or conceptually abstract. There were similar problems with social development. These children often did not grasp the idea that other people have feelings and make judgments. They had difficulty feeling sympathy for others and had little understanding of other's thought processes. The ability to empathically respond to other's feelings is referred to as "theory of mind." Greenspan and his associates asked themselves, "Why do many children impacted developmentally or affectively lack theory of mind? And why is it so difficult for these children to make the leap into abstraction?"
Greenspan made a leap. He realized that these children wouldn.t understand abstractions until they understood their own emotions. He understood that everything a child does and thinks as the child is developing is largely due to his emotions. First the child "gets it" from personal experiences, and then makes connections, and are thereby able to conceptualize abstractions.
Although many of these children.s disorders are biological in their origin, the path to combating them was clear to Greenspan: The foundation of cognitive/social development would need to be laid out through an emotional connection with the child. The emphasis on emotional development separates Greenspan dramatically from the traditional behavioral regimen in treating a large array of children suffering from both developmental and/or affective disorders. He argued that the development of the brain and of the mind could be done only in "wooing"-enticing the child into an emotional relationship.
Floor Time as a specific component of a comprehensive DIR intervention program, focuses on creating emotionally meaningful learning interaction that facilitate the developmental capacities of the child. It teaches children to learn how to relate to adults and peers with warmth and intimacy, communicate meaningfully with emotional gestures and works, and think with a high level of abstract reasoning and empathy (Greenspan & Wieder, 1997).
Dr. Lacter: Dr. Hess, thank you for your time, in summary what do you believe should be the motivation for today's play therapy clinician to learn about Floor Time techniques?
With the continued awareness of how a variety of early birth traumas, developmental delays, sensory and cognitive processing delays, problems due to interauterine drug and alcohol exposure, trauma due to sudden events and/or loss, learning disabilities and severe phobias can be mitigated with therapeutic intervention, it behooves play therapists to become aware and adept at reaching children with developmental and affective challenges and through their interactions create a relationship that helps pull these children both up the developmental ladder and into the world at large. While the methodology of Floor Time is complex and takes time and supervised practice to implement, clinicians who are familiar with this relationship based play therapy technique, can help all families become better attuned to their child.s capacities to play.
- Greenspan, S.I. & Weider, S. (1997). Developmental patterns and outcomes in infants and children with disorder in relating and communicating: A chart review of 200 cases of children with autistic spectrum diagnosis. In Journal of Developmental and Learning Disorders, 1, pp. 87-141.
- Greenspan, S.I. & Weider S. (1998). The Child with Special Needs: Intellectual and Emotional Growth. Reading, MA: Addison Wesley Longman.
- Greenspan, S.I. & Weider, S. (2000). Developmentally Appropriate Interactions and Practices. In Clinical Practice Guidelines. Bethesda: ICDL Press, pp.265-266.
- Kinney, M.C., & Winick, C.B. (2000). An integrative approach to play therapy with an autistic child. International Journal of play Therapy, 9(1), 11-33.
- Stacey, P. (2003). Floor Time. In The Atlantic Monthly, 291(1)/January-February, pp. 127-134.
Dr. Esther Hess is a licensed clinical psychologist and one of Dr. Stanley Greenspan.s senior clinicians here on the west coast. She will be conducting a one-day seminar illustrating the play therapy techniques known as Floor Time on Saturday, April 21, 2007, in San Diego. For more information please contact U.C.S.D. Extension at (858) 964-1070 and ask for Kristy Higdon.