Telecare for parents of children with autism spectrum disorder: A case report of a proposal for assisted waiting from DIR-Floortime

Sessions Filming instructions Parents’ weekly comments Guidelines given by the speech-language-hearing pathologist First Sensory-social play and everyday activities D. spilled soda on the table, and M. looked for a cloth to dry it. Since he couldn't find it, he used his sleeve. D. kisses and hugs M. and encourages him by clapping when he understands his parents' requests. M. has started smiling more and seems to understand what's being said. The best interactions happen at mealtimes. They're dancing. Establish eye contact and synchronize the child's play with the adult's speech, especially eye contact. Engage in more sensory-social and physical activities rather than more structured tabletop activities. Parents should realize that, despite being twins, they have different tastes and abilities, as they are attuned to M.'s language support but very directive with D. Explain age-appropriate books and how to read. Second Activities of daily living Parents asked for toy ideas. They said their boys were having a birthday soon, and the family wanted to give them toys. Discussion about play styles, how to align speech with play. General explanation of each person's play style. Third M. and D's favorite games, alone and with their father. D. is saying vowels while watching "Galinha Pintadinha", saying "woof woof" for "dog", and "grandma." He has become interested in household chores. M. uses the "give" word functionally and has started pointing. "We couldn't get close to him before; he didn't like kisses and hugs; he lived in corners, and now he doesn't. His grandmother comes home, and he shows the books or whatever else he wants”. M. has started hugging D. and looking for him to play with. Presentation of toys suitable for both children and for each one, explaining where each child is in their development, with ideas for variations. Attentional and calming sensory games for both children aim to explore bidirectionality, increase eye contact, understand verbal commands, and develop motor skills. Also, simple action-reaction and disassembly games, and a simple functional presentation-matching game. For D, games and toys that refer to the pre-symbolic. Guidance on choosing books. Discussion about avoiding inappropriate behavior by anticipating routines for him. Empowerment and encouragement for the father to appear in the videos and play with them more. Fourth Discussing in-person care with family. No videos to watch this week. M. is saying "didi" for "godfather" and "potato." They've stopped spinning the wheels on toys, objects, and their bodies. They're playing more functionally; D. always liked toy cars, and now M. likes them too. M. likes tearing leaves into ever smaller pieces. On a Children's Day outing, they loved playing on the trampoline, where only D. jumped and M. sat. D. tried to say "chicken." Stimulate speech based on the environment and action, and continue encouraging motor play and motor imitation through dance. With D: use concrete objects and narrate them to improve pre-symbolic development; it's still very much in their body and that of others. With M., expand tactile exploration of objects. For example, M. can use play-dough to squeeze and make balls. D. can pretend to make food. Encourage them to choose games and participate in them. The child's motivation is essential to improving auditory memory and speech. Introduce functional words like yes and no, anchored in gestures, as it's necessary to understand the concept of the word in everyday life to use it. Fifth In-person observation of interactions with parents and modeling. Questions about how to vary games and introduce two-way play They received a gift from the therapist, an alligator with a toothache, encouraging two-way play and the functional use of some words. With M., more sensory-social games, and with D., more toy car games with variations. Sixth Next videos collage with a mosaic of M.'s shredded papers, and with D. with his parents playing and using different cars. They learned to take turns playing with their parents, playing the alligator with a toothache game. Their mother says she has difficulty connecting with M. during games and prefers cuddling to interact with him. They began responding when called by name. They began solving problems like picking up a cup from the sink. Both also learned to blow bubbles and smell flowers. M. is understanding his parents' speech related to everyday needs. D. really enjoys drawing, with an adequate attention span. His father was able to vary his toy car games and build towers well. M. likes to play by taking toys in and out of a jar, and we encourage variation by providing role-playing examples. It's important to learn to play both separately and together.Guidance on how to approach a child to play together. D. has cognitive rigidity, not accepting exchanges of games, unlike M., who exchanges with slight effort. D. has started to refuse to share toys with M. and has increased screaming and crying behaviors. Guidance on regulation and co-regulation is provided. Seventh Free videos of play with parents and each other M. engages well with any toy or interaction with others, unlike D., who needs affection and fun. After moving house and city, M. is having more fits. M. engages well and prefers to play with others. They're already understanding small commands like "get the pacifier for mommy." M. is saying "dada" to daddy and "mama" to mommy, and D. can say "one" and "two"; understands colors and tries to name them. They played with a child of the same age, also with ASD, and shared toys and shared small moments together, such as throwing the toy car back and forth. This two-way play emerged in the game of one throwing the ball and the other dropping it, and then switching roles in the game. They're able to cut their nails without getting out of control. The parents recognized and understood each child's profile and became confident. D. and M. use the pacifier a lot - guidelines to try to reduce it; wait 3 seconds for a response after asking a question, if it doesn't come, then say the expected answer.Actively participate in play, always using action verbs and objective sentences. M. needs to improve stacking and nesting skills instead of always asking an adult for support without even trying, and D. needs to play more together and make more eye contact; in addition to expanding play into pre-symbolic play. Captions: D and M = the children’s initials

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Table 6 Summary of intervention sessions with A’s parents

Level	Level Description	How to work	Activities
1. Regulation Joint Atention	The child should be calm and focused, able to filter out internal and external distractions. He/she will be more open to interacting and exploring the world.	The therapist follow the children's interests and engage in what they intend to do so that they can look and pay attention to the person they're talking to. It should be very enjoyable. Some of the precautions include calling their name, getting down to the children's level, and bringing objects close to their face. It’s necessary to use facial expressions and mark when they look (I'm glad they looked at me)	Sing songs, leaving room for the child after a few repetitions - watch songs they like. Bowling, Bubbles Children's books, puppets Interesting games with cause and consequence Sensory and motor games with exchange - back and forth, playing ball, throwing, balloon games. Hide and seek with your body and with objects Use of mirrors Use of textures and water Painting Body games such as tag, trampoline, etc. Hot potato Activities that allow exploratory and combinatorial play are common at these levels.
2. Mutual Engagement	The child can engage with trusted caregivers, demonstrating a strong relationship and sharing care during a meaningful experience	The therapist adds layers to the joint play the the child creates and expands.
3. Two-way communication	The child may engage with the caregiver in two-way communication using gestures, vocalizations, or other forms of nonverbal and verbal communication.	We must offer moments of silence, create communicative demands and encourage gestures to ask or indicate. We can talk about daily events in a simple, uncomplicated way that aligns with play or routine. Therapist take turns in all activities, alternating with child.
4. Complex problem-solving - self-sense	The child has his or her own ideas and the caregiver supports them; the communication circles are stronger. The sense of self is strengthened.	Problems that emerge during play can be expanded and become more complex. The caregiver can support this solution by encouraging the child to think and providing support when necessary. The therapist never do things for the child without their attention. He/she works with the temporality of facts and actions.	Activities can be games, activities that involve setting up, for example, a tent, blocks, etc., where problems emerge to be solved. Puzzles, memory, drawing, stick-playing, building a tower, Lego, etc. are common.
5. Symbolic thinking Language Emotions	The child begins to imitate functional everyday actions and then moves on to more elaborate levels of original ideas and dramatizations.	The interlocutor must tune into the child's rhythm so that they can expand the thematic play. There are a series of guidelines and precautions for supporting enunciation with increasing complexity.	Thematic plays such as making food, transportation, and animals are very common at this level, which already encompasses pre-symbolic play in transition to symbolic play.

Level	Principles	Strategies
Lexical	We must consider the prototype with which the child mapped the lexical item and expand to other examples. We can use mutual exclusivity strategies and visual and gestural cues.	We can present nouns in playful situations, encouraging comprehension and production. We vary the objects and presentation contexts. The therapist can associate the name with the object's functionality through pantomimes (look at the cow - moo).
Phonological	The therapist must consider what the child produces spontaneously and what she/he WANT to produce to try to sustain production. We can try to expand production by considering stages of phonological acquisition.	We repeat what the child says to improve their production. We encourage observation of the therapist's face and mouth to analyze articulation. We can use prosodic strategies such as music. Use strategies such as multigesture and prompting.
Syntax (morphology and empty signs)	Verb production is essential for the emergence of the sentence Sentence comprehension precedes sentence production. Morphology and personal pronouns develop from the sentence itself.	We can encourage the production of nominal or verbal complements to stimulate vertical syntax between adult and child. We should compare what the child says with the adult's correct production to encourage morphology. Personal pronouns should be practiced in dialogue, using naturalistic examples. Some games can facilitate the generalization of syntactic knowledge.

Domains	Score Pattern Cutoff point for ASD indication	Score M	Score D	Score A
Social Interaction	≥3	11	7	7
Verbal Communication	≥4	10	9	8
Nonverbal Communication	≥2	17	8	14
Rigid and Stereotyped Behavior,	≥4	8	7	15
ASD Diagnosis	≥12	46	31	44

Dimension	M		D		A
Cognition	63	significant delay	70	delay	68	significant delay
Socioemocional	31	significant delay	57	significant delay	64	significant delay
Communication and receptive language	10	significant delay	27	significant delay	48	significant delay
Communication and expressive language	23	significant delay	23	significant delay	47	significant delay
Gross Motor Skills	92	typical	95	typical	83	Alert for delay
Fine Motor Skills	95	typical	104	typical	105	typical
Adaptive behavior	47	significant delay	66	significant delay	90	typical

Sessions	Filming instructions	Parents’ weekly comments	Guidelines given by the speech-language-hearing pathologist
First	Sensory-social play and everyday activities	D. spilled soda on the table, and M. looked for a cloth to dry it. Since he couldn't find it, he used his sleeve. D. kisses and hugs M. and encourages him by clapping when he understands his parents' requests. M. has started smiling more and seems to understand what's being said. The best interactions happen at mealtimes. They're dancing.	Establish eye contact and synchronize the child's play with the adult's speech, especially eye contact. Engage in more sensory-social and physical activities rather than more structured tabletop activities. Parents should realize that, despite being twins, they have different tastes and abilities, as they are attuned to M.'s language support but very directive with D. Explain age-appropriate books and how to read.
Second	Activities of daily living	Parents asked for toy ideas. They said their boys were having a birthday soon, and the family wanted to give them toys.	Discussion about play styles, how to align speech with play. General explanation of each person's play style.
Third	M. and D's favorite games, alone and with their father.	D. is saying vowels while watching "Galinha Pintadinha", saying "woof woof" for "dog", and "grandma." He has become interested in household chores. M. uses the "give" word functionally and has started pointing. "We couldn't get close to him before; he didn't like kisses and hugs; he lived in corners, and now he doesn't. His grandmother comes home, and he shows the books or whatever else he wants”. M. has started hugging D. and looking for him to play with.	Presentation of toys suitable for both children and for each one, explaining where each child is in their development, with ideas for variations. Attentional and calming sensory games for both children aim to explore bidirectionality, increase eye contact, understand verbal commands, and develop motor skills. Also, simple action-reaction and disassembly games, and a simple functional presentation-matching game. For D, games and toys that refer to the pre-symbolic. Guidance on choosing books. Discussion about avoiding inappropriate behavior by anticipating routines for him. Empowerment and encouragement for the father to appear in the videos and play with them more.
Fourth	Discussing in-person care with family. No videos to watch this week.	M. is saying "didi" for "godfather" and "potato." They've stopped spinning the wheels on toys, objects, and their bodies. They're playing more functionally; D. always liked toy cars, and now M. likes them too. M. likes tearing leaves into ever smaller pieces. On a Children's Day outing, they loved playing on the trampoline, where only D. jumped and M. sat. D. tried to say "chicken."	Stimulate speech based on the environment and action, and continue encouraging motor play and motor imitation through dance. With D: use concrete objects and narrate them to improve pre-symbolic development; it's still very much in their body and that of others. With M., expand tactile exploration of objects. For example, M. can use play-dough to squeeze and make balls. D. can pretend to make food. Encourage them to choose games and participate in them. The child's motivation is essential to improving auditory memory and speech. Introduce functional words like yes and no, anchored in gestures, as it's necessary to understand the concept of the word in everyday life to use it.
Fifth	In-person observation of interactions with parents and modeling.	Questions about how to vary games and introduce two-way play	They received a gift from the therapist, an alligator with a toothache, encouraging two-way play and the functional use of some words. With M., more sensory-social games, and with D., more toy car games with variations.
Sixth	Next videos collage with a mosaic of M.'s shredded papers, and with D. with his parents playing and using different cars.	They learned to take turns playing with their parents, playing the alligator with a toothache game. Their mother says she has difficulty connecting with M. during games and prefers cuddling to interact with him. They began responding when called by name. They began solving problems like picking up a cup from the sink. Both also learned to blow bubbles and smell flowers. M. is understanding his parents' speech related to everyday needs.	D. really enjoys drawing, with an adequate attention span. His father was able to vary his toy car games and build towers well. M. likes to play by taking toys in and out of a jar, and we encourage variation by providing role-playing examples. It's important to learn to play both separately and together. Guidance on how to approach a child to play together. D. has cognitive rigidity, not accepting exchanges of games, unlike M., who exchanges with slight effort. D. has started to refuse to share toys with M. and has increased screaming and crying behaviors. Guidance on regulation and co-regulation is provided.
Seventh	Free videos of play with parents and each other	M. engages well with any toy or interaction with others, unlike D., who needs affection and fun. After moving house and city, M. is having more fits. M. engages well and prefers to play with others. They're already understanding small commands like "get the pacifier for mommy." M. is saying "dada" to daddy and "mama" to mommy, and D. can say "one" and "two"; understands colors and tries to name them. They played with a child of the same age, also with ASD, and shared toys and shared small moments together, such as throwing the toy car back and forth. This two-way play emerged in the game of one throwing the ball and the other dropping it, and then switching roles in the game. They're able to cut their nails without getting out of control. The parents recognized and understood each child's profile and became confident.	D. and M. use the pacifier a lot - guidelines to try to reduce it; wait 3 seconds for a response after asking a question, if it doesn't come, then say the expected answer. Actively participate in play, always using action verbs and objective sentences. M. needs to improve stacking and nesting skills instead of always asking an adult for support without even trying, and D. needs to play more together and make more eye contact; in addition to expanding play into pre-symbolic play.

Sessions	Filming instructions	Parents’ weekly comments	Guidelines given by the speech-language-hearing pathologist
First	Pre-symbolic fitting game and free play	A. has increased eye contact and points more to make requests.	Sit at A.'s height for eye contact, implementing sensorimotor-social games, trying to increase the level of tactile arousal due to tactile hyposensitivity. Increase A.'s perseverance in play, with one object at a time. Explain levels of play development, making A.'s stage clear. Expand fitting and construction games. Simplify language-one phonologically simple, action-based word at a time.
Second	Free and tactile sensory play, such as play-dough, slime, and sand.	She started problem-solving; she grabbed a stool and took it to the kitchen to get some fruit. She began imitating TV choreography and everyday parental actions like washing clothes in the washing machine.	It was observed that A.'s difficulty with spatial awareness leads her to give up quickly to avoid frustration. Her parents were instructed not to anticipate requests and to let her ask for help somehow (by looking, gesturing, speaking, or saying the word "help"), waiting for her to come up with ideas. They were urged to continue sensory play and use functional words within the context.
Third	Game with motor skills	She has started talking about pee, using onomatopoeia and the first syllable of disyllabic words like "VA" for "vaca" (“cow”), and humming. She points and makes more gestures to ask for something. She's playing more elaborate games with dolls, fitting together geometric shapes, and persisting in the game for longer.	Reduce screen time. Use simpler words with sounds like 'p', 'b', 'm', 'd', and 'n' in monosyllables. Pronounce the word without diminutive or augmentative, and when she does, don't worry about the correct form, recognizing her pronunciation. Play motor games and encourage eye triangulation.
Fourth	Routine activities	Sometimes, she verbalizes within context ('poio' - ball, soap, 'no', 'ati' - 'here', 'refi', 'bread', and 'hi'). She addresses jargon with prosody to her parents. She repeats the syllable na to say no. She observes her parents more and has expanded her verbal and motor imitation. She began exploring modeling clay and played for 5 minutes. She enjoys spinning and somersaulting. She learned to throw the ball forward, as before she would drop it from her hand or it would fall to the side. Her eye contact has improved greatly, and she continues to explore extensively with her hands and feet.	Simplify your speech with her; instead of "bird," focus on "tweet-tweet," since the sequence consists of functional monosyllabic and disyllabic words duplicated in context. Expand functional vocabulary and improve eye contact.
Fifth	In person	Her parents say A. is attentive to the family routine and wants more autonomy, such as serving her own juice. She has begun to show interest in other children.	A.'s progress across all socioemotional levels led to the development of expressive language. She said 'fell,' 'found,' 'where is it,' 'go out,' 'grape,' and 'apple' in the expected environment. Stereotyped behaviors decreased, and problem-solving and self-awareness increased. She still has difficulty playing stacking and tower games; however, she has progressed. The foam puzzle was A.'s favorite activity, as she fit the pieces together easily (when she couldn't, it led to disruptive behavior, or she switched to another activity). She needed support when using the knife on the fruit. Individual sensory boxes were provided with plastic, cotton, grains, dried tree leaves, slime, play-dough, soft balls, and straw. She explored all textures.
Sixth	Filming plays	Assembling a wooden puzzle with two pieces made by her mother was easy, but she couldn't do it with more pieces due to poor motor skills. Her mother noticed that her balance was good some days, and poor others. She preferred to play by transferring liquids from one container to another.	Encourage turn-taking play with puzzles, towers, and other interlocking toys. If necessary, provide gestural support by saying the word "help." Follow the narration of action-reaction and pre-symbolic games. Always seek eye contact with A.
Seventh	Filming plays	She is socializing more. She observes the household routine and wants to participate. She saw two pools, showed two fingers, and said "water." She drops her toys less and fits her blocks together better. She has learned to regulate herself better; she often asks for slime to slide over her foot, showing her foot and saying "foot." She is producing verbs like "found" and "fell" functionally.	Do not solve everything for A., but help her when needed. Validate A.'s feelings.

[TFN1] Captions: ASD = Autism Spectrum Disorder M, D, and A = Children’s initials