WHAT IS THE CONTINUOUS FLOW?
The Most Important Milestone in Dr. Greenspan’s Greenspan/DIR™ Model
By Dr. Stanley Greenspan, MD
Edited by Jake Greenspan,
Co-Director and Founder of The Floortime Center®
The Continuous Flow is part of Dr. Greenspan’s 4th social-emotional milestone and is the most important component of all the milestones in his Greenspan/DIR™ Model. The capacity for engaging in a continuous flow of reciprocal, affective interactions enables the child to modulate (understand and consistently and proportionately respond to) sensory and emotional experiences. This positively supports the development of,
- mood and behavior,
- meaningful preverbal and verbal communication, and
It also enables more flexible scanning of the environment because the child gets feedback from what he sees and, based on that feedback, can decide to explore further, or not. This requires using our visual-spatial and motor systems together because when we are involved in a meaningful continuous social interaction, we are more able to ignore and filter out distractible visual-motor stimulus/patterns. Using these systems together allows us to achieve long chains of reciprocal interactions while purposefully exploring the environment. (Social-emotional interaction is what traditional sensory integration activities are missing, and why activities in sensory gyms and sensory OT clinics involving only modulating the sensory experience are limited in their effectiveness.)
In facilitating back-and-forth interaction with people and the environment, the capacity for reciprocal interaction also facilitates associative learning. Associative learning means building up a reservoir of related experiences, thoughts, feelings, and behaviors which give range and depth to one’s personality, inner life, and adaptive responses. This ‘learning’ is necessary for healthy social-emotional growth. Without it children can develop feelings, thinking, and behavior patterns that are rigid and mechanical, as are often seen in autistic spectrum disorders.
Reciprocal affective interactions, social problem-solving interactions, and the use of meaningful symbols to interact/communicate are necessary for healthy social-emotional development. These are the unique capacities that distinguish individuals with autism from individuals without autism. For example, long chains/patterns of back and forth social interaction depend on emotion/affect guiding this social behavior. Sustained ‘shared attention’, which includes social referencing and shared problem-solving, also depends on emotion/affect guiding social interaction and behavior. The capacities for empathy and theory of mind depend on the ability to understand both one’s own emotional states or feelings while also understanding another person’s emotional states and feelings. If we can do both of these things, then we can project ourselves into the other person’s mindset. This complex emotional and cognitive task begins with the ability to exchange emotional/affective signals with another person. Through these exchanges, we are able to understand our own intent and emotionally sense the other person’s intent through a sense of “self” in interaction with another. Similarly, higher-level abstract thinking skills, such as making inferences, depend on the ability to generate new ideas from our own past experiences.
The continuous flow is achieved once you hit twenty circles in a row, or ideally more. This is what we call a continuous flow of back-and-forth communication because once a child can do twenty-plus circles with you where the child is taking the initiative and be more assertive, not just reacting to your tickle or your sounds or your movements, they can keep the interaction/activity going as long as they want. To encourage shared social problem solving and getting a continuous flow of back-and-forth communication, the adult needs to create extra steps during Greenspan Floortime™ play, as well as during daily routines.
For example, if a child is moving the car, then you can playfully block it with your hand. You can say, “The car won’t move, what should we do?” You can create barriers or obstacles such as with a car. Or you can pretend to be a policeman blocking the way where the child either has to knock the policeman down or go around the policeman. It’s important you are more animated in your voice than normal. Every time your child begins pulling into their own world, begins self-absorbing a little bit, you have to accentuate the liveliness in your voice, become more animated, become more compelling, more interesting. Pretend you’re giving a lecture, and the people in the first row are beginning to fall asleep, or you’re telling a joke at a party. You begin increasing your affect. Your voice is more enthusiastic. It doesn’t have to get louder. It just becomes more compelling, more expectant, and that’s the first step of drawing a child back in.
If that doesn’t work, sometimes you have to move in and interfere with what your child is doing. Let’s say they’re beginning to play with their own fingers or wiggle their fingers to get lost in some self-stimulatory activity or just staring off at a fan. You might position yourself between the child and the fan. Or gently hold your child’s hand and begin moving it to the rhythm of your voice, so instead of playing with his fingers, he’s now holding your hand. He may pull your hand away and say, “no”, and that’s fine. Let him have his way, that’s another circle of communication. If he starts to go back to looking at his fingers, getting involved with a self-stimulatory, self-oriented play, then move in slow motion and once again say, “I’m gonna get that hand, I’m gonna get that hand!” He may pull his hand away before you even touch it. But what’s happened now? You have a little game going, a little cat and mouse game. You’re a little cat, and you’re going to catch his little mouse’s hand. Anytime he pulls it away is another circle of communication. Then if you finally get his hand, you may say, “I got your little hand. You want it back?” To get it back he has to make a sound or gesture to communicate. It’s important you don’t make the child too frustrated or annoyed with you. A little bit of frustration can get more circles closed, but a lot will lead to avoidance and/or reactions.
There are many, many ways to increase/expand these circles of communication. A great one is when your child has a favorite toy or a favorite cookie and you hide it in your hand. Then he opens up your hand and finds it. Then you take it back, or you take another little cookie out or a little treat out, and now you hide it in both hands, not showing him which hand it’s in, and he has to search in both hands for it. He looks in one, oops it’s not there. Now he has to look in the other. And now he’s gotten two circles. The third time you put your hands behind your back and he now has to not only look in your hands, he’s got to first go around to your back and then find your hands and open up both hands. So now we have four or five circles. Next, we might have a stuffed animal hide his cookie. The animal might run away and hide in another part of the room and he has to go chase it. Or, you might hide the animal so fast with his little cookie that he doesn’t see where it is, and he has to search all around the room, but you help him with clues, pointing here or pointing there. Where could it be? Now he’s got five to ten circles. The key thing is to help the child become and stay very interested and motivated. There’s no substitute for emotional interest and motivation. This internal motivation the child can show is best achieved by using one of the main three techniques of Greenspan Floortime ™, which is to follow the child’s natural interest (follow the child’s lead).
What started out as one game by moving a car may turn into “I’m gonna get your finger” game, when the child gets preoccupied with looking at their hands or fingers. You don’t have to get the child to stick to the game you started with, or just one activity. The whole idea is to have him play with you, and that can have many elements and activities within one 20 minute fun interaction. The child showed an interest in moving a car, but then quickly shifts to a self-stimulatory activity. That can become the new focus. You may get five or ten circles. Whenever parents tell me, “Gee, I’ve run out of ideas. I don’t know what to do. I don’t have anything left in my bag of tricks,” my answer is always the same. Stop, relax, and observe for a few seconds, and let the next idea come from your child. Don’t take anything the child is showing you for granted. Whatever your child does, or whatever your child is doing should be the basis for the next interaction. You then create some challenges around that activity, around whatever your child is doing.
We see lots of children who are distracted by their own actions. They start waving their hands and jumping and running. It seems aimless to us, but they’re stimulating themselves and getting excited by this movement. Often, children need this type of stimulation, but not in a self=involved and antisocial manner. At first, there doesn’t seem to be any obvious purpose to it, and sometimes this is very distracting for the child. At these times we can try saying, “oops, you’ve got great moving arms. We’re gonna play the moving arm game together.” And you try to catch their hand
in your hand and move in rhythm with them. Now you’re both moving arms together. If they try to pull away, again that becomes a basis for the, “I’m gonna catch those hands” game. Sometimes the child will let you move your arms together and you can start sort of rhythmic interactions, and then actually begin making a dance and sound game together, exchanging different movements and sounds. These expanded interactions and circles of communication are very important because they give rise to language.
To make these interactions even more expansive you can try adding more obstacles. If your child likes swinging or an airplane game, or little tickle games, they may have to get to you through an “obstacle course”. Mommy might be at one end of the room course while Daddy is creating obstacles on the way to mommy. They might have to climb through things, over things, around things, jump on something. Another great strategy is sometimes to find an elevated place, like a bed or a platform that’s elevated a little off the ground. Platforms can help children regulate, improving their calm and focus, and this makes it easier sometimes to get interaction. Sometimes children want to get down and you can negotiate and have circles of communication in terms of getting down off the platform, or making up games where you go up on the platform with them. The key is to follow your child’s lead. This stage of getting to a continuous flow of back-and-forth interaction is by far one of the most important goals of The Greenspan Floortime Approach®, and one of the most important milestones in a child’s development.
Many children with developmental delays, like autism, have language and strong memories, and can even repeat whole books, but they are not able yet to be creative and logical thinkers or hold a regular conversation. They also still get self-stimulatory or self-absorbed, and don’t hold that expanded logical conversation that we would see in other children of the same age. There is a reason for this, and it’s not as simple as a symptomatic label like autism. Usually, there’s a big missing piece, even if they score well on a structured language test. The big missing piece is this level of the continuous flow of back-and-forth communication with gestures or actions. In other words, many children don’t master this level well enough. This milestone is a critical foundation for language, for logical thinking, and for higher levels of abstract and reflective thinking. Weakness at this level tends to hold back higher levels and can keep children symptomatic with self-stimulatory behavior or repetitive perseverative behaviors. In other words, they’re in-and-out of their contact with the external world. Even though when they are in contact they can share a very complex thought, it’s still an in-and-out pattern or a pattern of contact and self-absorption. As a result, their ability to solve problems, to stay reality-based, to fully enjoy social relationships, and to progress academically into higher-level curriculums is not as optimal as it could be.
Often for children with these challenges, we go back and strengthen this level of establishing a continuous flow of back-and-forth communication. If children were already verbal, then we do it with a combination of gestures and words together. It’s never too late to establish this level. Dr. Greenspan consulted with some 30- and 40-year olds with autistic spectrum disorders who were missing this critical ability, and when this milestone improved, language and cognition improved as well. Many children whom we work with can only talk in “fragmented islands” say “car outside” and then jump to “blue toy” and then jump to “orange shirt. We started noticing that these children weren’t getting into a continuous flow of back-and-forth communication. They would be self-absorbed, then come out with a phrase, and then go back into a state of self-absorption. We focused on continuous flow using gestures, using some of the games that were mentioned earlier, while at the same time trying to get the child to verbalize during these interactive games. By doing, this we’ve helped some children for the first time ever answer a “why” question and become more logical after only a few sessions.
There are many, many, many children for whom we have strengthened this level and seen language and cognitive abilities and academic abilities and social skills all strengthened. When you think about it, unless you’re in a two-way continuous flow of back-and-forth communication, it’s very hard to stay in touch with the world because your reality has to be sampled constantly. If you’re in the world and then self-absorbed, and then in the world and then self-absorbed, you’re only getting little bits/samples of reality. You’re not getting a continuous picture of reality as it exists. It’s like taking a few snapshots with a camera instead of filming with a video camera. Which gives you a more comprehensive and complete picture of the entire world around you? The video is consistently taking in the world, the photo is only partially capturing the world and hyper focuses on certain details, not seeing the big picture. If you’re attentive to the world and you’re interacting in the world in a continuing way, then it’s easier to achieve healthy growth and development. This constant connection with the world around us is very important because it also helps you regulate your mood. You get feedback from your environment. You respond to mommy’s or daddy’s facial expressions, hand gestures, body posture, or tone of voice. You can tell when they’re getting a little annoyed and you better not behave aggressively. It helps you regulate your behavior and regulate your moods. It helps you work in groups, like knowing what to expect in school where there’s a lot of nonverbal communication as well as verbal communication that requires constant contact with reality. Most importantly, it helps your ‘reality testing’. It helps you to be logical because you have to interact with the world to be logical. You have to have logical bridges between what you’re feeling and what someone else is feeling; and what you’re saying and what someone else is saying. You can’t do that with an in-and-out pattern, where you become self-absorbed and then interact.
We all also need time where we can imagine and fantasize, or we tune into our own world. This alone time should be an organized logical decision. If we can’t control when we retreat or need alone time, and automatically pull away from the world, then that’s a problem. We need to decide to take some time to daydream or to relax, or just to ponder our favorite thoughts. That’s a distinct conscious logical choice, not the product of a kind of automatic impulsive or habitual self-absorption. This is why this milestone of social problem-solving continuous interactions is so vital and so critical.
When helping children improve this ability, it’s important we understand that each child is going to be different, and that there are a few general differences we need to take into consideration when figuring out how to help. One type of child is a child who is very under-reactive to touch and sound, may have selected areas of over-activity, but generally is difficult to engage, and difficult to facilitate interaction with because the child tends to be easily self-absorbed and easily lost in his own world. They’re so under-reactive to sensation that the sound of your voice or your facial expressions don’t register very much. It takes a lot of energy and animation before the child even looks in your direction. This child may be over-reactive to certain kinds of sounds, like high-pitched noises or low noises like you might hear from a vacuum cleaner or a blender. But for the most part, this is a child who is under-reactive. Sometimes they may also have low muscle tone, so it’s hard for them to take initiative and do things. For an under-reactive, self-absorbed child, if you want to get a continuous flow going, you’ve got to really be animated and energized up. There’s no choice but to be a high-energy person. If mom and dad, or the caregiver, educators or therapists are the kind of low-key easy-going individuals, they’ve got to make an accommodation and operate out of their typical character for this child. We all have to learn to adapt to the child and stretch ourselves. Children at this stage are not able to adapt to us yet. We have to be very animated and it’s very important to find things the child is interested in. We have to pay close attention because, within the self-absorption, we’ll see the child’s favorite little activities, such as playing with his fingers or moving a car back and forth. We’ll see lots of clues as to what we can do to help them become more and more purposeful and intentional. The key is to get the child to do something to you – to take action. This child’s biggest challenge is in taking initiative and being assertive. This can involve anything from a favorite cookie, to a favorite tickle game, to a favorite horse ride on your back. One under-reactive child we worked with just laid on the floor and we turned that into the game. We told him that he was in our favorite spot and very slowly and gently start to lie on top of him. It became a game where he would playfully push me off and roll away. You can see how easily this game can become a chase game, hide n seek, etc. As you nudge him over to take over his spot, see if he’ll nudge you back to get the spot back. The key is animation and high energy and challenging the child to “do to you.”
The other extreme is the child who is very over-reactive and easily overloaded. He holds his ears quickly and/or gets over-stimulated by a light touch. This child may get revved up and out of control by his own movements. If he starts moving too much, the movement itself tends to over-stimulate him. This child may get irritable or have tantrums easily, or be very distractible by everything in his environment because it’s difficult for this child to be calm and focused. To help this child we need to be regulated and calm. We’re still using high affect and animation, but in a very soothing, calm regulated way. We need to find the tone of voice that soothes the child, being cautious not to be over animated with this child. It is possible to be soothing, yet compelling and interesting. The same Greenspan Floortime techniques™ apply here; follow his lead, extend the circle of the communication, get into to multiple circles of communication, but in a very soothing, calm, and regulating way.
A third type of child is probably the most challenging. This is the child who gets overloaded and distracted by their own movement and who is very active and often very avoidant. As soon as we approach the child, the child is off to another part of the room—always moving, always active, and seemingly so avoidant that we can’t capture them even for a second. This child is waving their arms, jumping up on the couch, jumping off the couch before we can get on the couch, etc. What we have to do is help the child be less distracted by their own movement. One of the best ways to do this is to try to capture the child’s movement into a joint movement. As the child is running and jumping and moving their arms, try to capture their hands in your hands, and begin moving together, and try to be rhythmically interactive with the child at the child’s activity level. Don’t restrict or grab the child but become part of what the child is doing physically and help them do it. Then gradually down regulate with the child, into slower movement patterns, slower rhythms. The child may pull away, but we may get a purposeful action like, “no.” Then we play the “capture the hand” game. And with this child we try to go from fast, to medium, to slow, to super slow, to try to get a pattern of modulation and regulation going. The child is learning to regulate their own activity level through you, and they realize that they can then achieve a lot of enjoyment and pleasure from doing this with you. For this child, as with most children, it’s very important to find things they’re interested in that they’ll become more purposeful to achieve. The first step of that might be helping them to slow down a bit and get their motor patterns organized. Recognize though, that this child may be distracted by his or her own movement, and that makes it especially difficult.
There are other children who may be especially difficult to get a continuous flow going because they seem to self-absorb so rapidly right after you start to get the interaction going. You may get a very good interaction where they reach for a toy and then you seem to lose them and you can’t get the next step. For example, if they’re interested in a ball and you nudge it out of their hand or roll it, then by the time you do, they seem self-absorbed and staring out the window or looking at a fan, or another toy. With a child who you lose very quickly – you’re only getting two or three circles – you have to become very, very quick at increasing your affect and upping the stakes. In other words, don’t tolerate, even for a split second, losing the child. Don’t tolerate even for a split second the child self-absorbing. As soon as you lose the child for a second, increase your affect. If that doesn’t work, move in with some playfully obstructive activity, so that the child is getting used to a continuous flow of back-and-forth interaction. Often, we wait too long, and then the child is lost in his or her own world. We have to be observant, and as soon as we lose that eye contact or the emotional connection, increase your affect quickly to pull the child back in. If the child starts looking toward the window, then we get in front of them and block their pathway. “You can’t run away from me, I’m everyplace!” is the name of the game. The “I’m everyplace” game is the key to that very quickly self-absorbed child. Move quickly, be quick on your feet, pull the child right back in, so that that child gets used to that rhythm. You have to elevate and calm your own affect very, very quickly.
Now, when a child learns to engage and interact with their emotions, gradually through Floortime exercises, we teach that child to use emotions to signal. We get back-and-forth continuous flow of gestures. This is a gradual process that comes from entering the child’s world, bringing a child into your shared world, and beginning to emotionally signal and use gestures for back-and-forth communication with that child. Now what we are seeing is emotional signaling – the back-and-forth communication–take the place of these fixed actions and reactions. The child is no longer at the mercy of just these fixed patterns. The child can now signal and negotiate. The child can look at mommy wistfully and motion and gesture to “pick me up.” The parent can say to the child without words – with just a hand gesture, “Wait a second” and the child nods their head and they have negotiated. If the child is angry, the parent might show the child alternatives other than the cookie that they want. The child finally nods their head at one of the choices. A negotiation has taken the place of an explosive kind of rage. We are getting emotional interactions and social negotiations through back-and-forth signaling replacing these fixed actions. When this happens – when we get the back-and-forth interactions—we’re actually separating what the child sees or hears that lead to the creation of the image in the child’s mind, from a fixed action like biting or hitting or aimlessly wandering around the room. We have interaction instead. By having this interaction, we are freeing up the child to have an image in his mind, like his mother, because he sees and hears her. So it’s an image of sound and sight without its being tied to a fixed action. Now we have what we can call a “freestanding image” of mother. This freestanding image, this picture of mother, is now free to acquire meaning. How does it acquire meaning?
A child has millions of interactions with their mother during the course of many weeks. Mother can be gratifying, frustrating, exciting, etc. or even bring the child a toy or food. The child is now able to associate all kinds of experiences with mother and form an idea of “mother.” The child is able to form an idea of ‘mother’ because the child is associating all these experiences with their mother, and the image of ‘mother’. The child has not only a free-standing picture in his mind, but a picture that has meaning for him, as mother, over time, begins to take on all these characteristics: the frustrater, the gratifier, the person who the child feels dependent on, and the person whom the child has fun with. Daddy also takes on all these meanings, and so do inanimate objects as simple as an apple. An apple isn’t just red and round. An apple has a certain taste to it and a certain texture. It feels a certain way when you roll it or throw it. This is the way all of the objects in the child’s life take on meaning. The child has an image of the object, and through experiences with that object, it takes on meaning for the child.
This is a critical development in the child forming ideas. This is how ideas are, in essence, given birth – through first having lots of back-and-forth interaction. That’s why we recommend in Greenspan Floortime™ to have thinking-based interactions throughout all the child’s wakeful time! We recommend that the child become involved in a pattern where there is a continuous flow of back-and-forth interaction. As the child is involved in this continuous flow, we are able to see more and more freeing up of the child’s capacity to picture something and give it meaning, because the child isn’t at the mercy or isn’t a victim of their fixed actions.
We often try to help a child become a strong and successful child first at the higher-level abilities, such as those for speaking or for reading or doing math or for paying attention in school or for having a conversation with a peer. But the foundation pieces begin at the first 4 milestones of the Greenspan/DIR™ Model beginning with shared attention, engagement, two‐way purposeful communication, and back and forth problem-solving interactions. A child has to become a strong and successful child in those fundamental areas, beginning with attention and engagement and purposeful interaction, before the higher levels. Remember, we have to walk before we run. These foundational milestones are the walking, or crawling, before we run. The biggest missing piece in promoting progress is improving the back and forth continuous flow of interaction first — period.