Non Directive Therapy

Author: Rosemary Bazley


The play of pre-school children is so diverse that there are many different ways of analyzing it. This article describes types of play and describes using non directive therapy in speech and language therapy sessions with a 41/2 year old.

There are a variety of interesting descriptions of play available for example in Leach (1988), Ward (2000) and Karmitoff-Smith (1994).

Play is what babies, toddlers and young children do – and it's how they learn.

I use a very simple system for considering children's play:

• Exploratory. This is the stage at which children are exploring objects. They do this with eyes, hands and mouths. They feel, look at and shake objects.
• Relational. This is the stage where children try out putting two things together. What happens if I bang two bricks together, put this spoon in that cup, put the train on the track?
• Symbolic. This is the stage where objects can be used to be something else. A shoebox can be dolly's bed, a large cardboard box can be a car, a boat, or a house and a plastic banana can be a ‘phone.
• Role-play. This is the stage where the child can be someone else – a shop assistant, a nurse, a mummy. At this imaginary stage teddy, dolly, miniature figures can act out anything from everyday events to adventures.

There is of course enormous overlap between these levels – children do not progress from one to the next and never play in the earlier stage way again. However the steps do occur in this order. A child at the role-play stage will still look at, turn over and shake a new object (exploratory), relate the plates to the table (relational) and use a fireman's helmet as a porridge bowl if necessary (symbolic). There are of course other areas of play not well covered by this system – particularly physical play and social play.

So why is play so important in language development? There are various reasons:

• Language skills are learnt, just as other skills are learnt. Children learn a lot through play, as well as through interacting and observing.
• Early social play lays down the template for communication – eye contact, turn-taking, making a response, that communication via vocalisation or gesture causes an effect and so on.
• Words and signs and symbols are symbolic representations – of things, actions or concepts. The word ‘car' represents a car, the word ‘run' represents the action of running, the word ‘more' represents the concept of more of something.
• The areas of typical child development fit together like building blocks. If one piece is not present or is shaped differently, it has implications for the other pieces. For example if a child does not engage in typical social play or typical symbolic play, there will be an impact on communication development.

Children have a vast amount of learning to do about language and communication in the years before school. As they spend a large proportion of their time playing, that time necessarily needs to include some language learning. This means that they need language input from an adult – and this language must be relevant to their focus of attention. It is not helpful for language learning if, when the child is holding and examining a brick, the accompanying language is “Look at the ball”. For the language to be relevant to the child's focus there must be ' joint attention '.

Young children cannot shift their focus of attention to where the adult is directing it (Ward). It is much simpler and more efficient to join in with the child's activity and talk about what they are showing interest in. Of course much of the time we do this instinctively. But we are also adults – and therefore we know best (or think we do). For example, we might not like the noise those bricks make when they are banged together, and they are for building towers with anyway….

There are many, many ways that adults take charge of, or direct young children's play – by what they say and what they do. But the danger is that by doing this we lose joint attention – it's possible that the adult ends up playing alone building a tower and talking about that, next to a baby who is banging bricks together at every opportunity.

As adults we are perhaps even more likely to do this when we feel we need to teach the child skills, including language skills. To encourage high-quality interaction and maintain joint attention we are in fact advised by some experts to focus our attention on the child's focus of attention. In the Hanen approach described by Manolson (1992) this takes the form of a three step approach. The steps are “Allow our Child to Lead”, “Adapt to Share the Moment” and “Add Language and Experience”.

In contrast, in a typical speech and language therapy session the child is expected to participate in adult-directed activities. For many children this is fine, they can participate in structured activities focused on achieving a learning objective and directed by the adult. For some this is not fine. They may not be able to participate in adult-directed activities due to a range of developmental factors such as attention, avoidance of interaction or resistance to direction. It is in these situations that I use Non-Directive Therapy (NDT) (Tierney and Cogher 1994 and Cogher 1999).

I had the good fortune to attend an I CAN training course in 1995 on which I was trained in this approach by Helen Cockerill. I have used the approach regularly and now teach it to others on the I CAN Play and Communication Therapy Course.

This approach takes following the child's lead to a further level during clearly defined therapeutic Special Time sessions. The approach has been developed from the Play Therapy approach of Virginia Axline (Axline 1947). During these sessions the control is given to the child. A variety of play materials are available and the child chooses what to engage with and in what way. The adult retains responsibility for safety.

The adult uses interaction styles that are acceptable to the child in terms of position, proximity and participation in play. As therapy progresses the adult aims to extend the type of interaction which is acceptable to the child.

The language input from the adult takes the form of a description of, or commentary on, the child's actions. This is relevant to the child's focus of attention – thereby achieving joint attention. By observing or describing the child's actions, the adult maintains joint attention throughout the session. This provides a rich language learning environment. The description is often repetitive, as the child repeats the same action in play. This repetition is necessary for language learning. Sometimes the child will repeat an action specifically to elicit a given response from the adult – and this is the beginning of a turn-taking routine and a form of interaction. The adult has to use a particular language style which does not direct or control the play or the child's actions. The following is a brief transcript from an NDT session I conducted:

“You've got the trains.
You're saying choo choo choo choo.
You're being a train, choo choo choo choo.
You're pushing it.
You're looking at the plane.
You've put it down.
Moving the train.
You're standing up.
A ‘phone.
You're showing me the dog.”

With respect to the play during the session, the adult will adjust their involvement according to what the child can tolerate and the aims of the course of therapy. If one of the aims is to increase the initiation of interaction by the child, the adult may not enter the play until invited to do so by the child. If one of the aims is to increase the child's tolerance of another's presence and participation in their play, then the adult would work through a series of steps to enable the child to allow the adult to join in. If the child's play development and the restricted nature of their play actions are of concern, the adult can extend the child's play by demonstrating new actions and introducing new objects. For example a child might be enabled to engage in relational play with objects rather than purely exploratory play.

By the end of this course of therapy Freddy was increasingly interacting with adults using attempts at single words and learned phrases. As these were often unintelligible, Makaton signing was introduced as an augmentative means of communication.

Non-Directive therapy can be used with a range of children and specific language objectives can be included, for example early concepts or describing words, e.g. big and little. The level of language used in the commentary can be adjusted according to the child's own language level.

In Non-Directive Therapy giving the child control of a play session, providing relevant language input, interacting appropriately and extending play selectively add up to an extremely useful therapy approach for children with communication difficulties.

References.

Axline, V.M. (1947) Play Therapy. (Revised 1969) New York : Ballantine (1993 Reprint)

Cogher, L. (1999) The use of non-directive play in speech and language therapy. Child Language Teaching and Therapy , 15(1): 7-15.

Karmiloff-Smith, A. (1994) Baby It's You. London : Ebury Press.

Leach, P. (1988) Baby and Child: From Birth to Age Five. London : Penguin.

Manolson, A. (1992) It Takes Two to Talk. Ontario : Hanen.

Tierney, K. and Cogher, L. (1994) Non-directive Therapy. In Before School: A Handbook of Approaches to Intervention with Language Impaired Children . (pp. 62-76) London : Afasic.

Ward, S. (2000) Baby Talk. London : Random House.

Updated KF 06.08