Dr. Stanley Greenspan dies, founded Floortime and developmental approaches to autism therapy

At last November’s annual Interdisciplinary Council on Developmental and Learning Disorders conference in Bethesda, Maryland, Dr. Stanley Greenspan was walking and talking a little bit slower than he had in previous years. The reverence and respect that the audience had for Greenspan was palpable, and at the end of his speech, the crowd gave him a standing ovation. The people in the audience knew they were witnessing something special.

Greenspan, the founder of Floortime and the Developmental, Individual Differences, Relationship-based model (DIR) for autism, died yesterday at the age of 68.

Greenspan established the ICDL in Bethesda to advance the identification, prevention, and treatment of developmental and learning disorders. A message on ICDL’s website calls Greenspan “the world's foremost authority on clinical work with infants and young children with developmental and emotional problems. His work continues to guide parents, professionals and researchers all over the world.”

Greenspan was also the former director of the National Institute of Mental Health's Clinical Infant Development Program and Mental Health Study Center in Bethesda.  A graduate of Harvard College and Yale Medical School, Greenspan was brilliant but also had an extraordinary ability to relate to parents and especially their children with developmental disabilities.

Greenspan showed he was ahead of the curve in identifying the importance of emotional development in children in 1985 when he published his first book, “First Feelings: Milestones in the Emotional Development of Your Infant and Child.” 

Last fall’s conference was entitled “Autism: What Works and Why,” a refreshing change from the stiff, bureaucratic government meetings that focus on genetic research instead of therapies and treatments.

Greenspan was a true pioneer in the world of autism. His developmental model of therapy changed the way that children with autism are taught, and improved upon behavioral approaches by making learning more meaningful.

Simply stated, the DIR approach capitalizes on the engagement of the child through two-way interaction, customizes programs to the child’s needs and interests, and places a high value on emotional awareness and relationships. Social skills and playdates are critical to cognitive gains. Creativity, imagination, and spontaneity also facilitate learning in children, and allow them to generalize skills into a natural environment.

Improving motor skills and body awareness can also lead to social and academic progress. Communication, social skills, emotional awareness, life skills, and physical activities are integrated together as a whole as much as possible rather than learning skills in an isolated way. Sensory processing skills help tie everything together.

In DIR, each area builds on the others and makes all learning more effective so that the child can use skills in the real world. The family gets involved in the therapy so the child is learning all the time.

Greenspan’s philosophy has had a major impact on my work with children with autism. Years ago I read the book Engaging Autism by Greenspan and Dr. Serena Wieder. 

I was so inspired after reading it that I recorded parts of the book and sent it to Greenspan in the hopes of recording an audio version of the book.

“We believe the primary problem in individuals with autism spectrum disorders is a biological difficulty in connecting emotion to motor actions and later to symbols,” wrote Greenspan. “Emotions link different types of mental functioning.” Greenspan said emotion was key to early language development.

In developmental approaches, pathways in the brain develop to work in conjunction with each other. Interventions are meaningful to the child, who learns in an integrative way rather than just memorizing information. Emotional milestones are seen as critical to brain development.

Kids aren’t robots and neither are the people who work with them. It’s not the number of hours that are spent learning that is important -- it's how efficient those hours are.

Floortime, a component of DIR, involves helping the child reach developmental milestones that have been delayed.  In Floortime, the therapist or parent meets the child at her current developmental level and follows her lead because seemingly unimportant actions may be important to her.  

Never was there a better example of this than at the Autism Research Institute’s semi-annual conference in Baltimore earlier this month.

A video was played showing a young boy engaging in self-stimulatory behavior by shaking his arms as if he was playing the drums. A second video was played showing the boy years later, actually playing the drums in a talent show. The speaker, a proponent of behavioral therapy, had shown that using techniques from Floortime -- taking a seemingly pointless action and using it to develop a child's interest -- can yield excellent results.

In Floortime, the child’s interests are paramount because children learn through engagement, two-way interaction, imitation, and joint attention.  Imitation and joint attention have been shown to be early indicators of how well children with autism will learn language and other skills.

“Often we look for a way to reach a child – the magic key that will unlock the hidden door – when all the while the child is showing what he needs by his actions and the way he’s processing what comes his way,” wrote Greenspan in "Engaging Autism." 

Imitation is the most sincere form of flattery, and methods such as Relationship Development Intervention were based on Greenspan’s DIR model.

Applied Behavioral Analysis, or ABA, is a proven method of teaching children with autism functional and cognitive skills. Milestones are broken down into small, simple steps. Progress is tracked, positive behaviors are reinforced, and unwanted behaviors are phased out.

One of the criticisms of ABA, however, is that it can result in answers that are scripted. Rote learning doesn’t necessarily become generalized and useful unless it is applied to a functional use in a natural environment. It must be taught in a context that resonates with the child.

From Engaging Autism: “Progress comes from getting the child to take the initiative. The biggest mistake is telling the child what to do to provoke a set response, rather than challenging her to take the initiative or to solve a problem with you.”

Combining ABA and DIR can be a very effective way to teach children on the autism spectrum. The DIR approach emphasizes treating the underlying deficits rather than just focusing on the symptoms.

Perhaps most importantly, in "Engaging Autism," Greenspan says, “The child may have a disorder or a set of problems, but he is not the disorder. He is a human being with real feelings, real desires, and real wishes.”

In working with a team of behavioral therapists for a young child with autism years ago, I aimed to integrate more of the DIR approach into their ABA program. This program required a good deal of unwieldy paperwork at the exclusion of more meaningful, spontaneous skills. I was scoffed at: “You’re much more of a Floortime guy.”

I took it as a compliment.

Another time, the use of puppets for imaginative play in a classroom setting resulted in more verbal communication by several students than during all other times combined. Children need to transfer literal thinking into symbolic play, and motivation can increase learning exponentially.  They also get to develop their sense of humor and have fun.

We throw the word “great” around so often that it loses its meaning. But Greenspan truly was a great person, whose impact will be felt for years to come.

There are heroes in the autism world – the children, the parents, and those who lead by developing new therapies and treatments that aren’t always popular at the start. Greenspan has improved the lives of countless children with developmental disabilities. He personalized, rather than trivialized their differences.

He helped give parents hope by giving them a road to follow to help their children develop empathy and social skills in a spontaneous rather than a scripted way. He said children can learn to think in a creative and logical way.  He said children with autism can feel affection and develop emotionally and socially at a time when many researchers said this was impossible.  The process is often slow, but children with autism can get better in many areas.

I’m not sure who the other three people would be, but if there were a Mount Rushmore of autism therapy, Greenspan would be on it.

In sports, one of the criteria for Hall of Fame eligibility is whether a player had such a profound impact on the game that he changed the way the sport was played.

If there were an Autism Hall of Fame, Greenspan would make it in on the first ballot.

To subscribe to Mike's articles free of charge, click on the "subscribe" button at the top of this article.