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Tuesday 21 Nov 2017

Respecting Autism: An Interview with Dr. Gil Tippy


Dr. Gil Tippy is the clinical director of Rebecca School and the co-author of the book “Respecting Autism: The Rebecca School DIR Casebook for Parents and Professionals”. The book, which I recently read, details the cases of 16 students who attended the Rebecca School. The core of the work they do at the school is based on the Developmental, Individual Difference, Relationship-Based model otherwise known as DIR/Floortime which was developed by the late Dr. Stanley Greenspan who is also the co-author of this book. Each case study details the student and their individualized program, Dr. Greenspan’s programmatic recommendations and the qualitative progress made by the student.

While the book itself didn’t quench my thirst for data which proves efficacy of the programs and shows statistically significant effect sizes, I was left with the feeling that the teachers and clinicians at Rebecca School clearly analyzed each student, developed an individualized program based on their strengths and deficits and worked really hard to teach the students the skills they needed to be maximally successful in the real world. The major difference was that they’re not overly concerned with mastery of academic concepts, the core of their “curriculum” is based on moving students along the developmental continuum called the Functional Emotional Developmental Milestones (FEDM) which was developed by Dr. Greenspan.

There are 9 milestones in this developmental continuum: (1) staying calm and regulated, and shared attention, (2) engagement and relatedness, (3) basic intentional interaction and communication, five to ten circles of communication, (4) problem solving, co-regulated interactions with a continuous flow, (5) creative and meaningful use of ideas and words, (6) building logical bridges between ideas, (7) multi-causal comparative thinking, (8) grey-area thinking and (9) reflective thinking with a sense of self and internal standard. Dr. Tippy posits that many other autism interventions (such as Discrete Trial Teaching – DTT – an ABA-based intervention) are effective at getting students to milestone 3 (the “world of memory”, pg. 11) but have not been consistently successful at teaching students to engage in abstract thinking which is a critical skill for successful navigation of the world after “the middle of second grade” (pg. 13).

After I read this book of case studies, I wanted to know more about what they’re doing at Rebecca School and how their model is different from some of the other autism interventions out there. As a behavior analyst who believes whole-heartedly in the scientific principles of Applied Behavior Analysis, it was a hard pill to swallow to read that Dr. Tippy feels that “ABA training fails miserably” because many of the interventions (especially DTT) are targeting memory-based skills and not abstract thinking skills which are necessary for successful navigation of the world. I had the opportunity to speak with him more about the differences between our methods, the book, the Rebecca School and DIR/Floortime. It was an extremely interesting conversation, and (spoiler alert) it turns out that we may actually be thinking similarly but just in a slightly different language… food for thought. Here’s a peek into our conversation.

Interview with Dr. Gil Tippy

How many students are at Rebecca School?
“We have 115 kids here.”

Are all of your students diagnosed with Autism, or do you accept students with a range of disabilities?
“They are all across the neurodevelopmental spectrum so there are kids whose parents would have told us they were blind and deaf when we met them, all the way up through kids who I think could probably could be the valedictorian of their high school.”

Are the students at Rebecca typically there through the duration of their schooling?
“Oh, no… I think we have probably turned over 80% of our student population. They go to less restrictive environments or they go to other places. So really our goal is to not have kids here forever and as soon as we can help them get to another place that will be valuable for them we help them.”

80% of your students have made that transition?
“Well, we started with 44 kids. We don’t have many of the original kids here. Most of those kids have moved to other places. All of them have moved up developmentally. Once they reach social emotional developmental level 5 and 6, which are the levels that we take to represent abstraction if you’re thinking in the Piagetian way, they’re able to function and they’re able to go back to their other less restrictive schools or other private schools that are less restrictive. That’s generally what happens here.

Then we have some kids who are actually going to age out, we go from [ages] 4 to 21, so of course we’re in the process [of planning for transition]. [The] transition planning schedule here in New York [starts] at the age of 16 getting real transition plans and the summary of performance that has to go with them. We wanted to make sure we weren’t following the traditional vocational route. We really wanted to create a DIR/Floortime consistent vocational training or travel training and we’ve developed our own transitions program here. It’s up and running and we’ve got 24 kids out of the student population are already in that transition planning phase.”

Can you tell me more about that and how it’s different from a traditional transition program?
“The only actual out and out argument I ever had with Stanley Greenspan – who was a fairly imposing figure, he’s a giant in the field and an extremely opinionated man – so the only time I actually stood up and said “no I’m not doing this” is when he said “I want you to start putting together a vocational program.” Having had some experience in vocational programs, having worked in group homes and day habs and seeing what was available to kids where I live here, I wouldn’t allow that to happen. What we ended up doing was developing with Stanley something that he suggested calling ‘Taking Floortime to the Larger Ecological Context” – Stanley was never good at naming things, they were always convoluted. What it really means is that we take what Floortime looks like for little kids and expand it. All that really means is that we’re thinking developmentally all the time.

What we’re really doing is continuing the developmental work and doing that in the larger context of the community. So kids get out of this building and when we do travel training it’s not traditional travel training its travel training where the [young adult] has to really continue to develop their ability to be more abstract. Because, in New York City and probably where you are too if a subway line goes down and you’ve learned that this is the way you go and these are the strategies you use, those strategies fail. If it rains too hard and the 6 train tunnel gets flooded all of the sudden kids are stuck and don’t know what to do. So our way of working on those things is a much more Floortime consistent way. The very first time we’re going out and doing this kind of work with them we might stand at the corner and wait for the kids to say “Hey, what is it we’re supposed to be doing here?” or make a gesture or use their augmentative communication or however they’re communicating and the Floortime person, the person with them, will say “Well, it’s your job to be thinking about this, what are we supposed to be doing?” So, it takes 30 times longer to go the grocery store and buy things than it would if we were using a lot of prompts and a lot of supports, but what’s happening is the kids are actually developing their ability to be more flexible in those situations. It’s difficult for the trainer but it really works.”

Would you say that you’re not using any principles of ABA, or you’re simply not using the ABA-based intervention method DTT?
“All of us are behaviorists. We’re all working behaviorally so all of our work of course overlaps. All of the principles of applied behavior analysis apply. It’s not that I don’t think that paying attention to learning histories and paying attention to what’s reinforcing and what’s not reinforcing isn’t useful and absolutely applicable. Of course it’s all meaningful. When I was working more in what I would consider a more traditional applied behavior analytic setting I really was a positive behavior support follower. When I first saw Bob Koegel present I said “ah, OK. I get this. This is where I want to go.” So I have no question that we are always sort of sharing common ground, these two positions. I think the difference is that we are really a relationship-based model. I think the best behavior analysts I know get the best results because of the relationships that they have with the kids. They don’t really realize that it’s the relationship that’s doing a lot of the work and not the reinforcer and not the punishment. I think that’s probably where I have the biggest variance. Some of those people are thinking developmentally as well. You have to have a developmental model in your head; these are after all developmental disabilities. You’d be surprise, there are people who don’t think that way.”

What do you do in terms of data collection to track progress toward the developmental milestones?
“Every single year the kids get a battery of reliable and validated [assessments]. That includes the Vineland, and CARS – we use the CARS because it’s easier to do than the ADOS given the volume of kids we’re [assessing every year] – we [also] do something called the Functional Emotional Assessment Scale which [was developed by] Greenspan and DeGangi; that’s the scale that got turned into the parent report on the Bailey’s called the Social Emotional Growth Chart. So we do [all those assessments] then we record a million hours of video tape every year. We are constantly monitoring progress through video. [Our videos are being used for University research projects and we’re currently working on our own] research project where we’re trying to do long-term outcome studies based on our intervention. We have 60,000 data points and [we are crunching] the numbers right now. I’m hoping to have papers [published] in peer reviewed journals [based on] this big data set.”

Are the teachers collecting data in the classroom and during therapy to make decisions about how the student is progressing and where to go with the intervention based on their progress?
“Our goal is always to have the kid move up developmentally according to our Functional Emotional Developmental Milestones, so are they doing anything in the session that’s collecting that data? No there’s no data to collect there. Except we have cameras running all day long in every classroom so all of the sessions are on tape.”

So do you do a weekly supervision where you’re watching videos to make programmatic decisions?
“We do constant supervision. The teachers meet twice a week in supervisory groups, and we do a case conference on a different kid every single week in front of the entire school with the parents there and with all of the practitioners presenting. We used to do it with Dr. Greenspan, that used to be his hour but unfortunately with his passing now we’ve substituted the staff as the people offering suggestions on how to make this intervention better for the kid and the parents are always blown away by the whole thing. We videotape that as well. So we have constant supervision with every single group. We have a big OT team, and SLP team, a social work team, and music therapists, and every one of those groups meets individually every week. And then we have a big supervision [meeting] where I get the entire mental health team to get together for supervision watching video tapes. So we’re constantly doing that.”

Do you do parent training for all the families?
“For anybody who wants it we do parent training. It’s not mandatory, but almost everybody takes us up on it. It’s this really lovely, but very intense training that we do. We’ve actually assigned one staff member now who’s only job is to do parent training and they do groups, then they go into classrooms and they work directly with their kid. It’s on-going. We also train babysitters, any staff that goes into the house, we’ll training siblings, and it doesn’t matter. I always say “we’ll train anybody who comes in contact with your kid” we’ll work with them. We do a tremendous amount of that kind of outreach.”


So our conversation got me thinking about how the DIR/Floortime model fits into the context of my world of applied behavior analysis. Dr. Tippy quipped during our conversation about how developmental psychologists are often viewed as “soft-headed” which may be because many of the developmental models are looking at skills that are difficult to define in the observable and measurable terms behavior analysts live for. For example, I would have a difficult time telling you what milestone 6 “building logical bridges between ideas” actually LOOKS like, and this is where I think the break down starts to occur. As a behavior analyst, I am always analyzing things. Based on what I’ve read and the conversation I had with Dr. Tippy, I wanted to analyze DIR/Floortime and how it relates to what I do with the students and families I work with. If I break this down in terms that are comfortable for me to show the connections between our two models, it has to be based on the 7 dimensions of ABA defined by Baer, Wolf and Risley (1968).

As you’ll see, DIR/Floortime does not clearly meet all the criteria for being an ABA-based intervention, but it does meet or come close to meeting some of the criteria. I believe that the closer we look at individual intervention methods and strategies, the more people will start to realize that we’re not so different. We might define our intervention targets differently, our teaching strategies may vary, and the rigor of our data collection systems may not the same but we all have the same big picture goal: to positively impact the lives of individuals with disabilities and their families. I honestly think the two methods have a lot to learn from each other and can work together. Individually we can make positive changes; together we could change the world.

The Seven Dimensions of ABA applied to DIR/Floortime
Applied: Does the intervention deal with problems of demonstrated social importance? Absolutely. The interventions focus on relating, communicating, problem solving, abstract thinking, and reflective thinking… all of which are highly important skills for success in the world.

Behavioral: Does the intervention deal with measurable behavior (or reports if they can be validated)? Sort of. The measurement is based on scores from annual assessment data rather than measurement of individual behaviors. The individual behaviors being taught to progress toward milestones are not clearly defined.

Analytic: Is there an objective demonstration that the procedures caused the effect? The data collected does not seem rigorous enough to meet this criterion.

Technological: The procedures are described well enough that they can be implemented by anyone with training and resources? There are many books describing the DIR/Floortime method. Also, practitioners provide training to staff and parents.

Conceptually Systematic: Do interventions arise from a specific and identifiable theoretical base rather than being a set of packages or tricks? Seem to be. I need to do more research on intervention strategies, but they seem to be clearly defined and based on behavioral and developmental theories.

Effective: Does the intervention produce strong, socially important effects? Unsure. From my conversation with Dr. Tippy it seems as though the intervention is effective, but I need to see more data and outcome results.

Generality: Are the interventions designed from the outset to operate in new environments and continue after the formal treatments have ended? Yes! Planning for generalization seems to be strong in this intervention. Their goal is to teach students the relationship, communication and thinking skills necessary to aide their success in life. I can’t wait to see more outcome studies which demonstrate the efficacy of their intervention strategies and the generalization of skills addressed.

About the book

Written during the third year of The Rebecca School’s operation in Manhattan, RESPECTING AUTISM: The Rebecca School DIR Casebook for Parents and Professionals adroitly describes the results of Tina McCourt and Michael Koffler’s efforts to conceive and create a new school in New York City for children diagnosed on the autism spectrum. Because of the devotion of the entire staff as well as parents, all New York students can now receive a developmentally appropriate, thoughtful, and integrated education. According to co-author Dr. Gil Tippy, Clinical Director: “At Rebecca School we believe that everything we do originates with respect. Respect for the children we serve, respect for the staff with whom we work, and respect for the families of the children.”

Dr. Tippy and Floortime™ creator Dr. Stanley Greenspan collaborated on RESPECTING AUTISM. In 2005, Dr. Greenspan became a consultant to Rebecca School, and his work with students is featured throughout the book. The school institutionalizes Dr. Greenspan’s “Floortime™” methods of teaching and its educators work to extend students’ circles of communication using the Developmental, Individual Difference, Relationship-based (DIR®) model also pioneered by Dr. Greenspan.

Autism Spectrum Disorders are not issues of memory or of extinguishable behaviors, but rather difficulties with relating and communicating. Throughout RESPECTING AUTISM, everyday real life students and their families generously open up their homes and personal histories to Dr. Tippy who then conveys to readers these student’s triumphs and frustrations, joys and fears as each child in her or his own way strives to experience the freedom of the world of abstraction.

RESPECTING AUTISM introduces readers to sixteen students and their personal stories presented as case studies. In each of these very different studies, Dr. Tippy takes a thorough and thoughtful approach to introducing readers to these individuals; he first establishes their family’s story and educational background, then provides specifics regarding the students’ work as well as behavior at school. Each case study concludes with Dr. Greenspan’s diagnosis, reflections, and plan regarding how best to proceed to bring the student fully into the circle of communication.

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