Afect Talk

E. A Model Case Using DIR®

AFECT SAN DIEGO, CALIFORNIA JULY 1, 2009

Joshua D Feder MD DFAPA

Assistant Clinical Professor, Dept of Psychiatry, University of California at San Diego School of Medicine Faculty, Interdisciplinary Council on Developmental and Learning Disorders

Disclosures

ICDL Faculty – minimal - review of clinical write ups, travel and room for meetings, token honorarium for co-writing and running Southern California Institute NIMH/ Duke University – minimal – administrative time for pharmacogenetic research NIH R21 grant/ San Diego BRIDGE Collaborative – minimal – token honorarium for ongoing consultation and participation

Warning: this might go fast

All the slides will be posted on www.circlestretch.com

Taking Notes?

One word:

ENGAGEMENT

One phrase: Engagement goes beyond compliance.

circlestretch Help the child be… • Calm enough to interact • Truly connected to others • In a continuous expanding balanced back and forth flow of interaction “Go for that gleam in the eye!” http://www.circlestretch.com

Analogies Music Math Mental

Music

‘Here in Texas we have both kinds of music’

Math Statistics and Linear Newtonian Mechanics Vs Calculus, non-linear discontinuities, and solving problems in alternative dimensions

Mental Life Educational Psychology / Learning Theory (behavioral tradition) Vs Child Development / Infant Mental Health

So what? Why care?

Some problems can’t be solved with one idea, and we need other ideas to try out.

Comparing and Contrasting Approaches Your supportive style of ABA  Our DIR® approach Helping her in different ways They may be converging

E.

Look who’s (sort of) talking now

You know her…. School aged child Extremely rigid and perseverative Aggressive at School You guys did a great thing with her!

About 18 months ago… She decided not to talk Therefore, everyone tried to GET her to talk Which she naturally resisted….

Fallout Social function at school deteriorated Aggressive episodes became common Lost her placement

AFECT to the rescue And a great special education coordinator Who engineered a better placement Effective ingredient? Maybe your empathic child-

oriented approach

The data improves But she still isn’t talking Med trial – helpful, but no movement here

DIR® Approach Taking her lead further, working with it, and leading

to partial resolution of the whispering problem.

Video

Engagement vs Compliance

Compliance vs. Engagement Compliance

Engagement

Do/think what I want you to do/think

Think for yourself and with me

Drills will create skills

Shared emotional signaling creates a relationship that inspires learning and problem solving

Schemes to cover new situations

Relationships, available and internalized, give self-assurance to respond to new situations

Limited sense of competence, selfesteem: “I can do it. I learned how.”

More full sense of competence, self-esteem: “I can figure it out.”

They can work together

Behavioral based contributes…

Relationship-based expands…

Imitation

Autonomous thinking

Limits

Negotiation

Facts

Exploration

Prompt vs. Woo: Prompt

Woo

Greater power difference between people Control

Humility – more equality

Specific expectation Belief in the material

Respect for ideas of other person Open ended, hopeful for growth Belief in the process

In other words… WE USE EMOTIONAL CONNECTION TO FOSTER DEVELOPMENT WE TAKE INTO ACCOUNT THE PERSON’S INDIVIDUAL ABILITIES AND CHALLENGES WE WORK WITH FAMLY AND OTHERS TO MAKE THIS HAPPEN ALL THE TIME

circlestretch Help the child be… • Calm enough to interact • Truly connected to others • In a continuous expanding balanced back and forth flow of interaction “Go for that gleam in the eye!” http://www.circlestretch.com

Tracking Do we agree more on what co-regulation looks like? Engagement? Reciprocity?

Data Tracking Sheet Date: _____________

In Class am Time: _________

Co-Regulation Is he calm enough and settled to attend to an interaction? Are you ‘tuning in’ to near where he is emotionally to help him join in? Examples of not regulated:stretching, distracted, staring off, eyes not on the group/activity, over/underactive for the situation

Engagement Gleam in the eye?

Is he “on the same page” , paying attention to the same thing the “group” is? -eye gaze to peers and eye gaze to activity/items that the group is interacting with…visually and/or verbally Social Reciprocity referencing peers

(Circles, Flow)

True Back and Forth in speaking and listening interactions -opening (initiating) and closing (ending) circles of communication verbally or nonverbally

Student: _________________ Recess Time: ______

In Class Time: _______

Person Recording:

Lunch Time: _______

Afternoon Time: _______

IEP Goal – Regulation Baseline: Child is calm and focused __% of the time during any given 15 minute observation in class (“C”), __% during unstructured activities such as recess and lunch (“US”). October 2009 Goal: __% C/ __% US. March 2010 Goal: __% C/ __% US June 2010 Goal: __% C/ __% US Responsible persons: teacher, staff, OT Suggested interventions and accommodations: OT consultation monthly, sensory diet and strategies for home and school, staff facilitation of interactions with peers including during unstructured times.

IEP Goal - Engagement Baseline: Child is on the ‘same page’ as others about __% of the time during a given 15 minute observation in class (“C”) and about __% of the time during unstructured time (“US”). October 2009 Goal: __% C/ __% US March 2010 Goal: __% C/ __% US June 2010 Goal: __% C/ __% US Responsible persons: teacher, staff, counselor (DIS) Suggested interventions and accommodations: facilitation of interactions in class and at lunch (less emphasis on formal social skills groups)

IEP Goal – Circles, reciprocity Baseline: child tends to focus in his own ideas in play and conversations, and engages in actual mutual building of ideas about __% of the time during any given 15 minute period while in class (“C”) and __% during unstructured time (“US”). This can be assessed by examining a 15 minute sample of conversation and scoring the percentage of times that child’s initiation or responses take into account and/ or respond to other people present. Tape recordings or videotape may be needed to best assess this, although it can be done by observation as well. I am happy of assist in the training of persons to do this. October 2009 Goal: __% C/ __% US. March 2010 Goal: __% C/ __% US June 2010 Goal: __% C/ __% US Responsible persons: teacher, staff, counselor (DIS). Suggested accommodations and interventions: staff facilitation in class, at lunch, and on the playground.

Framing the entire intervention

Organize the goals under:

co-regulation, engagement, and reciprocity Get everyone pulling in the same direction

Research Child development Infant Mental Health Brain theory (back to calculus) Functional Brain Imaging

Common Ground: Converging Research

Joint Attention Studies Eye tracking Mirror neurons

Learn More Grow or die We’re around…. Pay it forward

Summary The road toward better function is indirect, but fun This approach is for anyone, because it was designed

to be biopsychosocial E still has far to go

THE SOUTHERN CALIFORNIA DIR®/FLOORTIME™ REGIONAL INSTITUTE PASADENA, CALIFORNIA BEGINS OCTOBER, 2009 JOSH FEDER, MD DIANE CULLINANE, MD [email protected] [email protected] MONA DELAHOOKE, PHD PAT MARQUART, MFT [email protected] [email protected]