Playful but Mindful: How to Best Use Positive Affect in Treating Toddlers With Autism

The best-tested treatments for toddlers with autism spectrum disorder (ASD) are grounded in the principles of applied behavioral analysis (ABA) and blended with developmental science. Examples include Project ImPACT(1) and Early Start Denver Model,(2) among others. ABA-based behavioral interventions use conditioned reinforcement of target behaviors by giving the child access to desired objects and activities as a consequence of performing target behaviors. Unlike the original ABA technique, discrete trial training, ABA-based naturalistic developmental-behavioral interventions (NDBIs) occur in natural environments and employ operant conditioned reinforcement of target behaviors by capitalizing on the child's interests in objects and activities.(1-3) NDBIs are highly recommended for toddlers and children with autism.(3) Clinical manuals for NDBIs emphasize that clinicians should use modulations of voice and exaggerated facial expressions and gestures to engage toddlers.(1-4) These behaviors are often referred to as positive affect, increased animation, modulation of child affect, or playfulness. Given the range of clinician behaviors described across these constructs and the commonalities between them, within this article we will henceforth refer to the following behaviors as playfulness: positive affect, increased animation, modulation of child affect, and exaggerated facial expressions and gestures. Most NDBIs indicate that playfulness should be thoughtfully employed throughout NDBI sessions in conjunction with other NDBI strategies (eg, contingent responsiveness, balanced turns, child choice) to maintain engagement and build social reciprocity with the child as the clinician and child work together toward treatment goals. However, our clinical and supervisory experiences suggest that many clinicians do not consistently use playfulness as an intervention tool. Instead, according to our observations, many clinicians largely employ neutral affect when providing treatment to toddlers with ASD, even while employing NDBI strategies such as following the child's lead, contingent responsiveness, and balanced turns. This article presents our clinical perspective on the utility of playfulness for treating toddlers with ASD.