Saturday, August 21, 2010
Rima was a 5.5 year old ASD child when on gentle persuasion by a day care teacher her parents approached us for play therapy. Rima’s parents although both were paramedics, struggled to accept that their child was not normal. Initially they blamed themselves for the lack of time and hoped that their love and attention would reverse her ‘odd’ behaviours. The mother especially blamed her work hours or their decision to have another child (a normal 3 year old son) so soon for Rimas developmental issues.
When they first came to discuss Rima, they thought that the only issue with the child was that she was not very verbal. They claimed that although she was better than before after the day care center teacher spent extra time with her, they were worried how she would react to the big school which she would join in the 1st grade, next year. But as they talked they realized that the problem was far more complex and interlinked. They were able to identify other issues such as her hyperactivity, non communicative behaviour, usually preferring to play on her own, petrified of loud noises and animals, asocial by nature and find it difficult to share things. She also was easily irritated and was often teased and bullied by her cousins to whom she reacted by either crying or reacting violently. She loved to play in sand and go to the beach but didn’t much play with other toys. She was also at times mean and violent with the younger brother. She didn’t demand much, even in food and would be quite passive most of the times. She enjoyed watching television ads, and listened to religious mantras. She seemed to have an unusually bright memory in remembering lyrics of the songs / advertisement / mantras. Her favourite game with her father was to climb on him holding his hand and then throw herself backward head down. Although she does this regularly, the parents were very worried about this as she could seriously injure herself. They had tried to change this behaviour a number of times, but she would not pay heed to their warnings. Infact they thought that her risky behaviours such as this had increased and now she would take every opportunity to jump of the table or even fling herself suddenly at the opposite person, uncaring of how badly she might get hurt or hurt the other person. If shouted at or stopped, she showed an unusually strong temper and become very obstinate. Thus discipline and obedience or boundary setting were major issues with her. She would still wet the bed in the night although not regularly and at times soil her panties. The mother mentioned that Rima was very fond of sand; therefore they had made a sand pit in the balcony for her to play in. But her play in sand was pretty unusual. Instead of making something out of sand, she spent hours just sifting through sand humming to herself a tune. As we talked, the mother recognized other behaviours which although she had noticed, never paid much attention to it. Rima’s inability to generalize learnt behaviours to other similar situations, her inability to focus on two or more things at a time, her insistence of ritualistic actions, her inability to substitute one toy for another similar toy. She also realized that all these behaviours together indicated Autism, a neurologically based life long and severe condition and not merely a late developmental issue or an emotional problem.
The therapist helped them understand how play therapy can benefit an autistic child and how an autistic child’s play differs from that of other children. She also went on to explain how play is a complex phenomenon that occurs naturally for most children and how they move through the various stages of play development and are able to add complexity, imagination, and creativity to their thought processes and actions. However, for many children with Autistic Spectrum Disorder (ASD) various stages of play never truly develop or develop in a fragmented fashion. These skills which a ‘normal’ person takes so much for granted is actually an uphill task for an ASD child. An ASD child suffers at all three levels of understanding and mastering the skills, cognitive social and behavioural.
Initially it was believed that play therapy is not effective treatment for ASD, recent research has convincingly proved that it is one of the most effective forms of treatment when used at times in a structured manner and especially if it is taught to parents and incorporated in the daily routine by the parents. Extensive opportunities in play therapy for social skills and emotional development help the child by increasing his awareness of other people’s mental states and their intentions. Play therapy then becomes a safe practice zone for the development of these skills.
These play therapy skills can also be taught to the parent / care taker who can incorporate it as a part of the daily routine. Treatment of ASD is highly specialized and a life time task, therefore often very expensive. Play way parenting equips parents to incorporate these play sessions in daily routine of the child and drastically reduces the cost. Parents are also encouraged to introduce it to the rest of the family so that it becomes another support for the ASD child to learn and master the skills. It also indirectly helps the other family members cope with their emotions with regards to the ASD child in a constructive manner.
Play therapy provides ample of opportunities to develop following skills in ASD children, necessary for their learning:
1. Imitation: imitation is a skill that is learnt very early in childhood. But the most crucial aspect of imitation is the ability to generalize these imitative behaviours to other situations. For example a child through imitation learns to smile and then uses cognitive and social skills to generalize smiling behaviour to situations requiring it. But ASD child find it difficult to generalize this to other situations. During play therapy, puppets, role enactment, make believe situations etc are used to increase the generalizations of these imitative responses.
2. Object exploration: children suffering from ASD find it difficult to initiate an exploratory play. This is because they get over whelmed with multiple stimuli and over a period of time, due to past experiences they learn to be socially reserved. In play therapy, the sensitive manner in which the therapist approaches the child establishes a safe and trusting environment for the child to attempt to explore. Then when the therapist incorporates some specific techniques such as restricting the space during play and giving them toy one by one the child finds it easier to learn them. A combination of skills and emotional support substantially increases these initiative responses in the child. It also helps to increase the child’s self confidence and self esteem.
3. Exploratory and Experimentation with play: Play therapy is often one of the first experiences of play without any target response goals for an ASD child. Being socially withdrawn they rarely take any initiatives to play on their own. Since play sessions are directed towards play only, it provides them with an opportunity to experiment and explore with play in a safe and trusting environment. Manipulation of toys in play session helps them to practice varying characteristics of toys, classification of toys such as sorting and matching, establish causal relationship between events and how to influence the world around them.
4. Communication skill: Communication skills such as expressing emotions, expressing specific needs, using gestures and joint attention are mastered during play sessions. Play therapists create surprise events during play sessions, using visual information to communicate verbally something that the child wants. This provides the child with ample opportunities to practice putting their emotions into gestures and words and thus reduces their frustration about not being able to get their needs met. It also reminds ASD children that communication and play involves another person and acts as a bridge toward more complicated or symbolic communication using words assessing not only their emotions and needs but also to match it with the other person. This is especially a difficult area for an ASD child as these skills are highly dependent also on social skills, both a problem area for the child. This skill can be taught using substitution of the play object (such as dolls), role enactment using various toys (puppets), recreating real life situations with numerous alternatives, helping the child to elaborate on intentions (involving verbal communication), helping the child to master ideas / themes, discussing with the child abstract themes and using obstacles to generate alternative solutions.
5. Signing or acting: Play sessions provide ample of opportunities to use a combination of gestures supported by verbal communication. This helps in the transition from no communication to gestures and then to verbal communication. This also helps to reduce the child’s frustration with people, usually strangers who are unable to understand their sign language. It thus increases their confidence socially and also boosts their self esteem. We often find a simultaneous reduction in anger in the child.
6. Peer Play: Peer play also relies on social cues which ASD child finds extremely difficult. Therefore we often find and autistic child unable to share, wait for turns, negotiate with another child, imitate other role models, ask for help, request for events / objects, initiate inviting another child for spontaneous play, all of which a necessity for any school going child. Through structured play sessions dealing with each of these skills and then slowly moving on to group play sessions or introducing it amongst the siblings the child gains enough confidence in these skills to be able to practice them at school or with other peers.
7. Increasing attention and concentration: also requires the child to comprehend the object and hold it in his thought symbolically. Play sessions intrinsically provide these opportunities to the child. It then becomes a practice field where the child learns to master these skills and then be able to use them outside.
8. Motor coordination also increases tremendously using play toys. The child learns to explore and experiment with different shapes, sizes textures and colours of toys in a non threatening, goal less, safe environment where the only goal is pleasure.
9. Parenting skills are also improved. Very often without realizing parents facilitate the learned helplessness in the child as he is unable to communicate. We often find the parent not being able to push the child to learn the above mentioned skills or become too harsh and frustrated. Neither of these behaviours are conducive for further development. During play sessions parents get an opportunity to examine their play deficits as well as express their own emotions and frustrations with the therapist. This kind of self exploration helps in dealing with parental anxiety of their child and his future in a manner which will help the child become independent.
Wednesday, August 18, 2010
Vineeta lost her mother when she was a young adult; she pined for years, unable to overcome her grief over the loss of her parent. But when she underwent divorce, she was unable to understand her own 8 year old son, who was grieving the loss of his father. She struggled to understand why suddenly he was getting into trouble at home and at school, why were his grades falling although he was an intelligent child, why was he back answering and blaming her. Nothing made sense, but a sense that everything falling apart for them both was experienced. Maybe that is what a child feels when parents divorce/ separate. His entire world seems to come crashing down.
The movie Bal Ganesha which got everyone in the theatre to tears of joy when Ganesha showed his superior intelligence and circled his parents three times instead of taking three rounds around the world, winning the race against his younger brother. Little do we realize that this mythology is not about superior intelligence, rather it portrays the child’s perception of his parents, his world. For him, parents are at the center of his existence and therefore separation from one or both is experienced like death and a threat to his own survival.
Like any one who is fighting for their survival, children try out various options to survive this trauma, and attempt to reunite their parents. Like the Vineeta, who grieved for years over the loss of her mother, children do not give up hope of reuniting their parents for years after the separation. Parents who are anyways struggling to deal with their own emotions find it extremely difficult to deal with the emotions of the children. Children ask questions which seem impeccably correct putting the parents in a spot. “But why does he not like you? Maybe if you work hard and become smarter and thin, the way he wants you to, we can be together,” says a 7 year old boy to his mother. Or a 10 year old girl to her father “Why can’t you forgive her, maybe she did not mean the things she said to you. You forgive me every time I have lied, can’t you forgive her? For my sake please?”
In most cases the children tend to feel responsible for the divorce and try to change the behaviour and actions to please the other parent, like this 6 year old boy pleads to his mother, “lets go back home, I promise I will not make him angry and bother him for toys ever again or change the TV channels.” At times, in their attempt to get back the parents together, they may even get into negative behaviours such as lying, running away from home, cooking up stories, poor academic performance, and bedwetting, being irresponsible and stubborn etc. This problem is exaggerated if the child is very young and unable to communicate; or if he is entering his teens and feels confused and threatened about the volatile emotions characteristic of this age. Unable to deal with this confusion and inability to express their distress, children learn to bottle up emotions and thoughts, making communication all the more difficult. There seems to be a glass wall around them where you cannot hear what they are saying nor can they seem to understand what you are trying to communicate. Nothing seems to penetrate and touch them through this wall.
But there is a non threatening way to communicate to them, through the language of play. Play is a natural mode of communication of children. They can better emote their feelings unconsciously through play and therefore play becomes a powerful cathartic medium. It also provides an emotional distance to the children necessary to express threatening and negative emotions and thoughts. They cannot say that I don’t hate you mom for getting divorce but they can definitely express the same using a doll set or by beating at clay incessantly. Thus through the use of play, we can reach out to both the younger children and the teenagers alike.
This play way is used by a specially trained therapist to help children and parents better understand and deal with each others thoughts, feelings and behaviours. Unfortunately this is a language that we as parents, have long forgotten and need to relearn it in order to understand what our child is feeling to help them. Sometimes the Play Therapist also involves the parent to some of the structured play techniques which can help them bond better. This is what we did with Vineeta and her son. Through play materials we helped the child emote his anger and frustration. Once he had a name for the feelings, he was able to express it verbally. Vineeta on the other hand, when she was involved in the Play Therapy sessions, learned to better understand his emotions and respond appropriately to his needs.
The drawing in the picture was drawn by the child demonstrating his pain at the divorce as is seen by the heavy clouds, scratched sun and the two rivers which run parallel to each other like tears from the eyes. A Play therapist uses numerous play materials such as this to make such interpretations and convey it to the child, equipping the child with the ability to choose his reactions appropriately. It aims to increase resilience and self esteem within each child. Making him confident to face the future and challenges in life.