Using Lego therapy for autism

There is no cure for autism spectrum disorder (ASD), which affects one out of every 59 children in the United States.

One of its most common effects is difficulty with social interaction and everything it entails, like living independently and holding down a job. Children on the spectrum may avoid eye contact, have difficulty reading people's emotions via nonverbal signals and struggle to express their own emotions verbally.

Meanwhile, play, one of the most important ways through which children socialize and learn, can be daunting. What might come naturally to neurotypical children -- collaborating, taking turns, assigning roles and group decision-making -- can be a challenge for an autistic child.

One specific type of therapy for autism uses the humble plastic brick as its main tool: Lego.

As described by its originator, pediatric neuropsychologist Daniel LeGoff, Lego-based therapy has children work in small groups to build a Lego set. One student, the "engineer," has the instructions and directs the project. Another student, the "supplier," has the collection of Lego parts and hands them off to the "builder," who does the actual assembly. These roles rotate among the children.

LeGoff first conceived of Lego-based therapy when two of his patients -- eight-year-olds with Asperger's syndrome -- met in the waiting room of the clinic where they received treatment. Auspiciously, they had both brought Lego creations with them, and although both children struggled with social interaction, they were excitedly playing and talking with each other. LeGoff decided to incorporate Lego into therapy sessions for the two children; eventually, the group grew to seven. They moved away from set building and into free building and self-directed projects.

"LEGO-Based Therapy taps into core strengths in people with autism: their love of patterns, regularity, decomposing wholes into parts, predictability, understanding how things work, and creating variety out of structured manipulation of variables," LeGoff writes in his book LEGO®-Based Therapy: How to build social competence through LEGO®-based Clubs for children with autism and related conditions. "LEGO-Based Therapy uses such strengths in a social context, to make social learning fun and to play to the child's strengths, not their disabilities."

The status quo

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The current, widespread approach to minimizing autism's symptoms, especially in the United States, is via applied behavior analysis therapy (ABA), which has been evaluated and approved by both the US Surgeon General and the American Psychological Association. It's based on operant conditioning -- providing a prompt for a behavior and then rewarding the child for performing the desired action. (A reward can be anything from a snack to a verbal affirmation.) By doing this, a child learns that there are consistent consequences for their behavior.

If, for example, you were teaching a child to respond to an act of kindness, you would reward them for saying "thank you" but withhold the incentive for negative behavior. With enough positive reinforcement over a long period of time -- up to 40 hours per week -- the child's behavior will adjust accordingly. A neurotypical child might be able to learn behavior by passively observing it, but those on the spectrum may need the behavior demonstrated for it to stick.

In ABA, "play" is a lens through which one can conduct therapy: A child can learn social cues and the associated behaviors that follow from them within a playful context. But play therapy can also be an alternative to ABA or practiced in conjunction with it.

At its most sophisticated, a Lego team collaborates to create a narrative. It might, for example, make a robot and a shark and then direct a stop-motion movie of the two creatures fighting. This requires planning and division of labor -- and thus extensive verbal and nonverbal communication.

"When the Lego therapy is gelling, you almost have to sit there and just watch it, because the kids do their own therapy," said LeGoff. "It's why I often say that I don't take too much credit. They show up early, they're in the waiting room and they bust through the door. They have projects they want to get to and things they want to continue from last week."

"Kids who wouldn't normally be interested in taking turns, dividing the labor and negotiating are willing to follow the rules because they're able to get access to the especially cool Lego [set]," said GW Krauss, who interned and completed his postdoctoral work under LeGoff. He is currently an operational psychologist for the United States Army. "The child is strongly motivated [and says to themselves], 'I'm willing to do what it takes to be involved in this, because it's just so overwhelmingly fun.'"

"[Set building] typically only lasts for one or two sets," Krauss said. "Almost always, due to the nature of the project, children want to veer off, be creative and come up with their own ideas."

All of this -- the self-guided projects, the self-enforcement of rules and standards of behavior -- aligns with a general teaching principle that has gained steam in the past two decades: the importance of moving toward student-led initiatives and away from adult-led initiatives. In an ideal scenario, a teacher will facilitate the student's self-exploration rather than existing as the sole purveyor of knowledge.

The Lego-based therapy model is also forgiving toward the therapist, who has multiple chances to observe and model good behavior. "In a 150-piece set, there are 150 opportunities to talk about each piece. 'Is it the right one? Did we put it in the right place? What comes next?'" LeGoff said. "There's a lot of communication involved, a lot of replication and duplication. And for a therapist who's in the room to coach those interactions, there's a lot of opportunities to get it right.

"[The children will] actually start coaching each other on social stuff," LeGoff said. "One of the kids actually said to me, 'Dr. Dan, I need to get better at my social skills, because I'm never going to get my project done. I need to communicate more effectively.'"

Play therapy is not new in the autism field; therapists have incorporated play into treatments and interventions for decades. Lego-based therapy, however, posits that there is something unique about Lego itself, which helps autistic children acquire social skills on a level that's more resonant than rote.

Founded in 1932 by Danish carpenter Ole Kirk Christiansen, Lego is a portmanteau of two Danish words: "leg" and "godt," which, combined, means "play well." The toy company initially made a variety of metal and wooden toys. But the onset of World War II, and the accompanying need to make weapons and ammunition, put a stop to metal-toy production. And the wooden toys created supply-and-demand problems, especially after a massive fire took out one of Lego's warehouses in 1960.

That was the same year that Godtfred Christiansen, the son of founder Ole Christiansen, discontinued the wooden toys entirely to focus on the company's plastic toys and, more specifically, their plastic building bricks, first known as automatic binding blocks. Designed with studs on top and tubes underneath, the bricks, patented in 1958, were designed to firmly interlock and detach from one another.

The instructions that Lego provided to build sets from these plastic bricks were deliberately nonverbal; step-by-step pictures meant that the brand was globally accessible. And one of the overarching selling points of Lego bricks is what the company still refers to as the System. Regardless of whether the bricks were molded in the mid-20th century or last week, they all fit together, forming a continuity that spans multiple sets and decades. Consider: A Lego builder can combine six 4x2 studded bricks nearly 1 billion different ways.

This structured reconfigurability also speaks to a characteristic of autism. As a disorder, it skews disproportionately male, and boys are four times more likely to be diagnosed with autism than girls. The Lego-therapy model follows an approach of triangulated interaction: this idea that boys socialize best while working on something collaboratively.

"There's a difference between the way women and men bond socially," LeGoff said. "Women tend to make friends by exposure. They share personal information with each other quicker and directly, face to face. ... With men, they'll get together because of a joint activity, and there will be this trickle of information. Slowly, over time, they get to know each other."

The Lego Group founded the Lego Foundation in 1986, a research arm that seeks to "redefine play" around the world. The group has partnered with UNICEF to create early childhood development programs around the world, and it sent materials and pedagogical experts to war and refugee zones in Ukraine and Iraq. Recently, it began piloting Lego Braille bricks as a way to increase Braille literacy.

"We are aware of the Lego-based therapy, and we regularly get letters from parents and children -- especially autistic children -- who thank Lego for bringing the brick to the world," said Stine Storm, new ventures project manager at the Lego Foundation. "It's had so many good benefits in terms of focusing and relaxing and concentration. We know that many autistic children are attracted to the bricks, to our building instructions, and to the system of it -- to building in a very structured way."

But Storm stops short of endorsing Lego-based therapy for autistic children, citing a need for more research and longitudinal studies. LeGoff conducted a short-term study in 2004 -- the first of its type -- which showed significant improvement in social competence within a 24-week span.

In 2006, LeGoff completed another, more-long-term study, this time using three years' worth of data to measure the social interaction of 60 LEGO-therapy participants. These gains were compared to a control group of 57 patients, who received "mental health, educational and other therapeutic services of comparable form and intensity." On the Vineland Adaptive Behavior Socialization Domain (VABS–SD), used to measure and test for social competence, the control group increased approximately 10 points from where it had started three years prior, whereas the LEGO-therapy group gained approximately 20 points -- nearly twice the former's gain.

A major study -- unaffiliated with LeGoff -- is currently under way in the UK and will compare "usual care" versus Lego-based therapy for 240 ASD-diagnosed children (aged seven to 15) in a school setting. The goal is to determine the clinical and cost-effectiveness of Lego-based therapy groups, and the researchers hope to present their findings in 2020.

"We are monitoring what's out there and we are certainly aware, but we haven't made any decisions on our goals, if any," Storm said.

LeGoff continues to teach, train and lecture about Lego-based therapy in places as far-flung as Buenos Aires, Argentina; Santiago, Chile; Helsinki; and Kuala Lumpur, Malaysia. In 2017, LeGoff estimated that Lego-based therapy was being piloted or used in 22 countries.

One growing criticism of autism treatment, which LeGoff echoes, is a singular focus upon ABA to the exclusion of other strategies, particularly in the United States. The treatment emphasizes rote social-skill learning versus socializing in a more organic, spontaneous manner.

"The force behind the funding for therapy for young kids with autism is very focused on ABA, but that doesn't mean it's the only therapy or even the best therapy," said Catherine Lord, a distinguished professor in residence at the school of medicine at UCLA who specializes in diagnosis, social and communication development as well as intervention in autism spectrum disorders. "It's because ABA has very clear criteria to be trained in it, and because originally, there were claims that ABA was going to cure autism. That turned out not to be true at all. But that gave it an enormous round of publicity."

Many nonprofit organizations specify that grant money be allocated toward ABA therapy or simply list the exclusions of most other treatments. And with the limited funds available in the United States -- the recent Autism CARES law largely funds research into the genetic cause of autism rather than therapy -- it's hard to fault parents for choosing what is most readily available, covered by insurance and has the appearance of scientific rigor.

It can also be difficult to get past the concept of play as scientific. In his book How LEGO-Based Therapy for Autism Works: Landing on My Planet, LeGoff recalls when an ABA devotee mocked his ideas, asking if he would be offering "Barbie therapy" to children who were not interested in Lego.

Quantity versus quality

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While LeGoff acknowledges that ABA can improve a child's behavior in the short term, he questions its long-term value. "They think that being social is like teaching a skill, like teaching someone to tie their shoelaces," said LeGoff. "It doesn't happen that way."

Lord agrees. "One of the major problems with interventions these days is that we haven't agreed on what we're trying to accomplish, other than to 'get better,'" said Lord. "Better measurements of valid social interactions is what is needed to change."

LeGoff believes that much of the measurable data from ABA, like the number of interactions, does not determine the quality of the interaction. "Social functioning is difficult to measure," said LeGoff. "But it's not impossible if you frame it correctly. ... If a kid goes up and said hi to 80 kids and your measure is initiation of social contact, then it looks like the kid did great. But the kids who are good at social interaction are the ones who can spend 15 minutes with one other kid."

LeGoff posits that his Lego-based therapy is a better remedy for poor social interaction than the prevailing methods. Lord, however, believes that Lego-based therapy can fall victim to the same type of locked-in thinking that drives poor ABA practice. Just because the children are able to interact well and for extended periods of time within the context of therapy does not necessarily translate to real-world interactions.

She also pushed back on the idea that there is something inherently special about Lego bricks that makes them suitable for autism treatment.

"I think that calling it Lego therapy makes it into something more mystical than it needs to be," said Lord. "I see it as 'using Legos.' [Calling it Lego therapy] is probably better for advertising and marketing though."

However, Lord said that Lego is a toy that is well-suited to this type of work for practical reasons. "I think Legos are an amazing toy with a lot of potential," said Lord. "You could probably do the same thing with other blocks, but it would be less organized, less creative and less responsive to current trends."

Lord is hesitant to name any therapy as "better than" or "lesser than" or denote one type of intervention as a gold standard by which others must be measured. With a disorder as complex and multifaceted as autism, there is no fix-all. But perhaps Lego therapy deserves credit for tackling the messiness and unpredictability inherent in promoting behavioral norms -- a messiness that these children need to negotiate in society.

"Making friends is a quality of life issue," said LeGoff. "What Lego club does, at its core, is help people to function in a social environment so it will not be a limitation to them vocationally. It's not a class. It's not about 'learning' social skills. It's about becoming social people."