Pasadena, California Beginning October, 2009

Pasadena, California beginning October, 2009 Josh Feder, MD   [email protected]

   

Mona Delahooke, PhD [email protected]       

Diane Cullinane, MD [email protected] Pat Marquart, MFT  [email protected]

Charlie Cheetah A Model Case Using DIR® in the Public Schools 2009 ICDL Summer Institute Asilomar, California

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

Thank you! Marilee Burgeson MaryPat Culligan Mara Goverman Jody Hinkleman Susan Johnson Lori McCurdy Debbie Ostrow Alice Prince Tyler Waldron

Warning: this might go fast

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

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

‘Charlie Cheetah’ • Seen since preschool, now in third grade • Chief Concerns: learning, socialization • Persevative on big cats, perfectionistic, older and taller, lanky, odd prosody, loud voice, active and inattentive • Dad isolative, in conflict with mom • Mom anxious, works Charlie hard • This case is about the school intervention

Outline • I - Preschool consultation • II - Kindergarten – finding an ally & developing DIR® IEP goals • III - First Grade – supporting a teacher & grooming an aide • IV - Second Grade – adding allies & expanding to peers • V - Third Grade – expanding to entire staff, peers & critical thinking • VI – Summary and Reflection • VII - Discussion

I - Preschool Consultation • Family had left public special education preschool • Wanted inclusion for the coming year – but where?

Why we get called in: • Difficult situations • Failure to make progress • Aggression (c.f.and ref. .S.I Greenspan) • Severe perseveration Families create changes in systems

Picture Charlie at Preschool • • • • • • • • •

Tall and lanky, older than peers Cheetah T-Shirt, lunchbox, backpack… Skylarking in class, always a beat behind Seems tired (from ‘homework’ & from just being in class) Spot-on recitation of the weekly bible verse Trouble with the motions to songs Sits at the snack table, parallel, slow to finish Loping after classmates Seems pretty content despite it all

Reciting the weekly verse

Charlie in music - preschool

Snacktime - preschool

Recess - preschool

Teacher Profile: Preschool (unsure what to make of Charlie) • • • • • •

Comforting: 3 – teacher tries to be ‘there’ for him, near weekly calls to home for mom to come and get him Finds appropriate level of stimulation: 2 – co-regulates well only in recitation of verse Engages in relationship: 2 – class is about the schedule, Charlie in a ‘parallel’ existence Reads cues and signals: 2 – she sees when he is upset, can predict when it will worsen Maintains affective flow: 1 - teacher focuses on flow of activities, not flow of interaction Encourages development: 2 – teaches him rules of moral conduct

Individual Differences – Charlie – Preschool 5/05 Sensory

Postural

Sensory seeking, distractible …

Low tone; A bit clumsy impedes rapid reciprocity in the moment

Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

1 indicate desires 2. mirror gestures 3. imitate gesture ---- 05/05---4. Imitate with purpose. 5. Obtain desires 6. interact: - exploration - purposeful -self help -interactions

Response to Communication Trouble managing more than one thing at a time 1. Orient 2. key tones 3. key gestures 4. key words ---- 05/05---5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s 8.abstract conversation.

Intent to Communicate Dysarthric – Logical discourse is Difficult 1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.words 6. two –word ---- 05/05---7. Sentences 8. logical flow.

Visual Exploration

Praxis -

Distractible.

Easily frustrated

2.focus on object ---- 05/05---2. Alternate gaze 3. Follow another’s gaze to determine intent. 3. Switch visual attention 4. visual figure ground 5. search for object 6. search two areas of room 7. assess space, shape and materials.

-

Ideation -- 05/05--Planning (including sensory knowledge to do this) Sequencing Execution Adaptation

Charlie’s FEDL toward the end of Preschool Not there Co-regulate

5/05

Engage Circles

Barely

5/05 5/05

Flow

5/05

Symbolic

5/05

Logical

5/05

Multicausal

5/05

Grey area

5/05

Reflective

5/05

Islands

Expands

Comes back

Ok if not stresse d

Ok for age

What we do: WE USE EMOTIONAL CONNECTIONS TO FOSTER DEVELOPMENT WE TAKE INTO ACCOUNT THE PERSON’S INDIVIDUAL ABILITIES AND CHALLENGES WE WORK WITH FAMLY AND OTHERS (HERE SCHOOLS) TO MAKE THIS HAPPEN ALL THE TIME

Plan After Consultation • Recommend DIR® approach • Parents re-trying the public school • Parents insisting on full inclusion

II - Charlie in Kindergarten • Failing to comply with seat work • Flopping on the floor • Staff recommending Special Day Class • Parents firm on inclusion • We need school consultation

A Model for Providing DIR®/Floortime in Public Schools • • • • • •

tail wags dog develop allies in the staff observations/coaching/seminars DIR® IEP Goals tracking forms regular contact/ reflective process

Tail Wags Dog • • • •

You are only a consultant You are not in charge You need to be available You need to be consistent – hold steady • You need to have your own reflective process

Must Find Allies • Nothing happens if you don’t have allies • Find someone at the school who understands • Who wants to learn more about how to help • Who can serve as a model / teacher for others Our main job is to find and support allies

Allies in Kindergarten • Resource Specialist – hoping I will support Special Day Class • Principal – wanting to make it work, unsure how to accomplish this • Teacher – this was not what she signed up for • SLP – a big fan, but little DIR® experience

The Teacher’s Predicament • • • • •

Experts are hovering The Behavioral Support Plan (BSP) isn’t working No choice in aides, other professionals Fear for safety Conflict of child’s needs vs. needs of other students • Conflict of child’s needs vs. needs of the school • Lone voice “This was not in the job description”

Profile of Charlie’s Kindergarten Teacher • • • • • •

Comforting: 1 – flustered Finds appropriate level of stimulation: 1 – overwhelmed Engages in relationship: 1 – not aware of the need to engage Reads cues and signals: 1 – sees when he is upset, but does not differentiate from general flopping about Maintains affective flow: 1 – no interaction to speak of Encourages development: 2 – desires to see him calmer & more regulated for purpose of instruction.

Initial Profile of Charlie’s SLP • • • •

• •

Comforting: 4 – ‘there’ for him, does become annoyed, exasperated with his behavior Finds appropriate level of stimulation: 3 – generally calm and positive, which allows Charlie a little space Engages in relationship: 3 – able to hook him in at times with cooking, etc.; Charlie still in a ‘parallel’ existence Reads cues and signals: 3 – sees when he is upset, can predict when it will worsen, but can also predict when it will happen Maintains affective flow: 1 – like PS teacher, she focuses on flow of activities, not flow of interaction Encourages development: 3 – desires to see him calmer & more regulated for purpose of instruction.

Observations/Coaching/Seminars • Observe in class – Charlie flopping about • Observe on playground – loping after peers • Side bars with staff – heard their frustration • Develop concepts together – ‘not regulated’ • Chalk talks with staff – DIR® ideas, plan, IEP

Developing Concepts Together • Hear the concerns: flopping about • Hear the D – I – R in there: dysregulated, distractible, disconnected • Frame the concerns with staff in those terms • Use regular words, avoid jargon

But it’s a public school… • Most staff wedded to narrow behavioral models • Contracts with companies devoted to narrow behavioral intervention • Teaching often attracts ‘top-down’ people • Short staffed, in class and outside • Little training, little opportunity for training • Paraprofessionals ‘shielded’ from outsiders • Little time for reflection • Video taping is forbidden

Help the Staff Understand: We are Not Just Teaching Compliance • Typical children do not really sit independently • When you ‘teach’ a child to play, it is not play • When you ‘teach’ a child to think, it is not really thinking • You can build connection with a child, and the child will withstand the environment better • You can support a child to regulate, to think, and to play • Teaching a child to comply teaches little about actually resolving problems

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

Schemes to cover new situations

Limited sense of competence, self-esteem: “I can do it. I learned how.”

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

It’s good if they understand, but public school interventions are guided by IEPs…

DIR® IEP Process • • • • • •

Present levels a la DIR® Goals that are measurable Placement considerations Accommodations Services Regular time for reflection

DIR® Present Levels • Functional Emotional Developmental Levels • Individual Differences • Relationships • What are the child’s strengths? • What works? • What doesn’t work?

• • • • • • • • •

Quick Review of Functional Emotional Developmental Levels I – co-regulation, ability to attend II – engagement, gleam in the eye, warmth III – circles of interaction IV – flow/ behavioral organization in social problem solving V – symbolic thinking (critical to tolerating affect) VI – logical connections between ideas VII – multicausal thinking VIII – grey area thinking IX – reflective thinking, stable sense of self, and an internal standard

Charlie’s FEDL over time: no different yet in early Kindergarten Not there Co-regulate

5/05

Engage Circles

Barely

5/05 5/05

Flow

5/05

Symbolic

5/05

Logical

5/05

Multicausal

5/05

Grey area

5/05

Reflective

5/05

Islands

Expands

Comes back

Ok if not stresse d

Ok for age

Individual Differences • • • • • •

Sensory sensitivities and processing Postural control and motor planning Receptive communication Expressive communication Visual-spatial communication Praxis: knowing how to do things to solve the social problem of the moment

The Child’s Individual Profile • • • •

Where are you now? What works? What are the details? How do you help the child do better in these areas? (Relationships that are therapeutic, with family, therapists, teachers, everyone)

Individual Differences – Charlie – Kindergarten 9/05 Sensory

Postural

Sensory seeking, distractible … Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

Low tone; A bit clumsy impedes rapid reciprocity in the moment 1 indicate desires 2. mirror gestures 3. imitate gesture ---- 05/05---4. Imitate with purpose. 5. Obtain desires 6. interact: - exploration - purposeful -self help -interactions

Response to Communicatio n Trouble managing more than one thing at a time 1. Orient 2. key tones 3. key gestures 4. key words ---- 05/05---5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s 8.abstract conversation.

Intent to Communicate Dysarthric – Logical discourse is Difficult 1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.words 6. two –word ---- 05/05---7. Sentences

Visual Exploration

Praxis -

Distractible. 2.focus on object ---- 05/05---2. Alternate gaze 3. Follow another’s gaze to determine intent. 3. Switch visual attention 4. visual figure ground 5. search for object 6. search two areas of room

Easily frustrated Ideation -- 05/05--Planning (including sensory knowledge to do this) Sequencing Execution Adaptation

8. logical flow.

7. assess space, shape and materials. -

The Relationship Part • • • •

Family circumstances and styles Teacher’s style and class circumstances Support to families, therapists, and school Importance of time to think about how it is working

Home: K-2

So we developed goals…

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 2005 Goal: March 2006 Goal:

__% C/ __% US __% C/ __% US

June 2006 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 2005 Goal:

__% C/ __% US

March 2006 Goal: __% C/ __% US June 2006 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 2005 Goal:

__% C/ __% US

March 2006 Goal: __% C/ __% US June 2006 Goal:

__% C/ __% US

Responsible persons: teacher, staff, counselor (DIS). Suggested accommodations and interventions: staff facilitation in class, at lunch, and on the playground.

Tracking • Do we agree more on what coregulation 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 referencing peers Social

Reciprocity (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: _______

School Data Tracking Sheet instructions and comments *

*Fill in #minutes/15 minute sample for tracking co-regulation and engagement

**Use hash marks to count number of times the child initiates or responds appropriately for social reciprocity **Complete one data sheet per week during all kinds of activities including class time, free choice, recess, and lunchtime   Comments:______________________________________________________    ________________________________________________________________   ________________________________________________________________   ________________________________________________________________

Placement • Paula Kluth: You’re Going to Love This Kid • More than exposure • A Variety of peers • What are his strengths? • What works? • How can we expand on it?

Back to Charlie… • Placement was not a consideration – parents firm on inclusion in regular class ~ 100% • So a lot of this was merely exposure • Little real contact with kids

Peer Facilitation • We are focusing today on different things, but NB: • Peer facilitation: Ricamado, et al – see Circlestretch.com under “Play” • Vulnerable kids • Bullying: SUPERVISION, Gray, DIR®

Accomodations • E.g., AT (assistive technology)– e.g. Tango (NA for Charlie) • More than sensory breaks – OT giving Charlie sensory breaks – turned into ‘escape’ - nothing gained

Not Just a Sensory Break • An immediate break teaches nothing • The child learns to withdraw and may get worse • Appropriate use of sensory strategies are ones that help the child coregulate and gradually expand his capacity to register, tolerate and process sensory information

Services • Push in? Parents wanted this. • OT i.e. co-regulation (not just SIOT, or, say, handwriting): Charlie’s OT was emerging • SL i.e. communication (not just language but non-verbal gesture, real pragmatics, and prosody): Charlie’s SLP was new to DIR® but further along than anyone else at school • Coordination: for Charlie we scheduled check in meetings for each year, phone liaison with SLP (later grades with the new RSP).

Regular Contact • This is an interative process (feedback loop) • Creating a holding environment • Keeping the problems fresh in your mind – not just a one time thing • Keeps you honest and in it with the staff

Reflective Process • • • • •

Critical to the DIR®/Floortime™ model A safe place to talk Help the teacher tell the story Help the teacher express the problem Facilitate the teacher’s solving the problem vs. dictating a specific solution What can you say, or what observation can you share, that will help the other person think about and problem solve without you telling the person what to do?

Resources for the DIR® IEP process: • Monica Osgood: Celebrate the Children Goal Bank • Circlestretch.com has some of her work as well as some of Feder’s goal templates and data tracking sheets

Now the we have IEP in place, our job is… • • • •

Nurture and expand the alliances Continue to influence the IEP process Wraparound home with school Continue to educate and coach the entire staff

Helping Charlie’s Kindergarten Team

DIR®/Floortime™ goes beyond behavioral interventions 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

Parsing DIR®/Floortime™ for School • Developmental: 1-4, 5-6, & ‘7 ate 9’ • Individual Differences: what works? • Relationship Based: real buy-in to the relationship: ‘find the golden nugget’

Developmental • FEDL I-IV: manage vigilance, support interaction • FEDL V-VI: stepping back from the moment • FEDL VII-IX: critical thinking

For Charlie in Kindergarten….

Regulating Vigilance and Supporting Interaction: Functional Emotional Developmental Levels • • • • • • • • •

I – co-regulation, ability to attend II – engagement, gleam in the eye, warmth III – circles of interaction IV – flow/ behavioral organization in social problem solving V – symbolic thinking (critical to tolerating affect) VI – logical connections between ideas VII – multicausal thinking VIII – grey area thinking IX – reflective thinking, stable sense of self, and an internal standard

Abstract Ability and Vigilance try to think when you are stressed inside… • • • •

Grossberg Hippocampal cells iSTART The importance of regulating vigilance

Remember: • ‘Behavior’ means WE need to do better • Wooing, not prompting • Avoid mere sensory breaks • Avoid questions

The bottom line: Engagement over compliance • Compliance won’t teach someone to think • Co-regulation supports abstract thinking

Charlie’s FEDL over time: Kindergarten Spring Not there Co-regulate

5/05, 3/06

Engage Circles

Barely

5/05

3/06

5/05

3/06

Flow

5/05,

Symbolic

5/05, 3/06

Logical

5/05, 3/06

Multicausal

5/05, 3/06

Grey area

5/05, 3/06

Reflective

5/05, 3/06

3/06

Islands

Expands

Comes back

Ok if not stresse d

Ok for age

III – First Grade • Somewhat improved: in his seat a lot, but amazingly inattentive in class • NB: another failed medication trial • Supporting a good enough teacher who is constantly cuing him • Developing SLP capacity • Grooming an aide for now and for the future

Profile of Charlie’s First Grade Teacher • • •

•

•

•

Comforting: 3 – not fuzzy, but not reactive Finds appropriate level of stimulation: 3 – unflappable Engages in relationship: 3 – persistent attempts to have him involved in the moment to moment activity of the class; Charlie still in a ‘parallel’ existence vis a vis peers Reads cues and signals: 3 – sees when he is upset, can predict when it will worsen, but can also predict when it will happen Maintains affective flow: 1 – like PS teacher, SLP early on, she focuses on flow of activities, not flow of interaction Encourages development: 3 – desires to see him calmer & more regulated for purpose of instruction.

Profile of Charlie’s SLP – First Grade • • • •

•

•

Comforting: 4 – ‘there’ for him, does become annoyed, exasperated with his behavior Finds appropriate level of stimulation: 3 – generally calm and positive, which allows Charlie a little space Engages in relationship: 3 – more able to hook him in at times with cooking, etc.; Charlie still in a ‘parallel’ existence Reads cues and signals: 3 – sees when he is upset, can predict when it will worsen, but can also predict when it will happen Maintains affective flow: 2 – now more interested in the flow of interaction than the content, so it happens a bit more Encourages development: 4 – desires to see him calmer & more regulated for purpose of interaction.

Profile of Charlie’s Aide – First Grade • • • • •

•

Comforting: 4 – ‘there’ for him, mellow, apparently Finds appropriate level of stimulation: 3 – generally calm and positive, which allows Charlie space Engages in relationship: 2 – relatively directive Reads cues and signals: 2 – sees when he is really off or upset, unsure what to do about it Maintains affective flow: 1 – like PS and first grade teacher, she focuses on flow of activities, not flow of interaction Encourages development: 2 – desires to see him calmer & more regulated for purpose of instruction, unsure how to help him develop this and instead she tells Charlie what to do.

The Plan – First Grade: (Second verse, same as the first A little bit better and a little bit worse…)

• Continued emphasis on co-regulation, engagement, and reciprocity • Continued observation, coaching, liaison • Continued gradual progress overall • Severe setbacks after an illness, after a wrong food item, etc.

Charlie’s FEDL over time: First Grade spring Not there Co-regulate

5/05,

Engage Circles

Barely

5/05

Islands

3/06

3/07

3/06

5/05

3/06,

Flow

5/05,

Symbolic

5/05, 3/06

Logical

5/05, 3/06

Multicausal

5/05, 3/06, 3/07

Grey area

5/05, 3/06, 3/07

Reflective

5/05, 3/06, 3/07

3/06

3/07 3/07

3/07 3/07 3/07

Expands

Comes back

Ok if not stresse d

Ok for age

Oddly enough, his individual differences are looking better too…

Individual Differences – Charlie – Preschool 5/05 & Kindergarten 9/05 Sensory

Postural

Response to Communicatio n

Intent to Communicate

Visual Exploration

Praxis -

Sensory seeking, distractible… Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

Low tone; A bit clumsy impedes rapid reciprocity in the moment 1 indicate desires 2. mirror gestures 3. imitate gesture ---- 05/05---4. Imitate with purpose.

Trouble managing more than one thing at a time 1. Orient 2. key tones

Dysarthric – Logical discourse is Difficult 1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.Words ---- 05/05--6. two –word 7. Sentences 8. logical flow.

Distractible. 2.focus on object ---- 05/05---2. Alternate gaze 3. Follow another’s gaze to determine intent. 3. Switch visual attention 4. visual figure ground 5. search for object 6. search two areas of room 7. assess space, shape and materials. -

Easily frustrated Ideation -- 05/05--Planning (including sensory knowledge to do this)

5. Obtain desires 6. interact: - exploration - purposeful -self help -interactions

3. key gestures 4. key words ---- 05/05---5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s 8.abstract conversation.

Sequencing Execution Adaptation

Individual Differences – Charley – First Grade Sensory

Postural

Response to Communicatio n

Intent to Communi cate

Visual Exploration

Praxis -

Sensory seeking, distractible… Auditory Visual Tactile Vestibular Proprioceptive Taste Odor Taste and odor are better

Low tone; A bit clumsy impedes rapid reciprocity in the moment 1 indicate desires 2. mirror gestures 3. imitate gesture 4. Imitate with purpose. ----3/07---5. Obtain desires 6. interact: - exploration - purposeful -self help -interactions Much better postural control – not flopping on floor

Trouble managing more than one thing at a time 1. Orient 2. key tones

Dysarthric – Logical discourse is Difficult 1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.words ----3/07---6. two –word 7. Sentences 8. logical flow. NOT CHANGED

Distractible. •focus on object •----3/07---2. Alternate gaze 3. Follow another’s gaze to determine intent. 3. Switch visual attention 4. visual figure ground 5. search for object 6. search two areas of room 7. assess space, shape and materials. Can focus pretty well on an object now

Easily frustrated Ideation

3. key gestures 4. key words ----3/07---5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s 8.abstract conversation. Stronger foundation

Planning (including sensory knowledge to do this) ----3/07---Sequencing Execution Adaptation A step forward..

IV – Second Grade • Another good teacher – great cuing • The same aide, developing a bit • Change in case manager from SLP to RSP • More movement in individual differences • Budding symbolic function • Beginning meaningful peer interaction

Profile of Charlie’s Second Grade Teacher (good skills, not enough time with Charlie) • • •

• • •

Comforting: 4 – kind and clear Finds appropriate level of stimulation: 3 – pretty good w/ him Engages in relationship: 4 – islands of continuous effort to create a flow of interaction, with varying results but improving over time Reads cues and signals: 3 – tries hard to do this in the moment during class, when she can Maintains affective flow: 3 – interested in the flow of interaction, although has to attend to other students too Encourages development: 4 – strong desire to see him calmer & more regulated to strengthen his interactive capacity and engagement in the learning process of the class (gets it!).

Profile of Charlie’s Aide – Second Grade (same aide, with some change) • • • • • •

Comforting: 4 – ‘there’ for him, mellow, apparently Finds appropriate level of stimulation: 3 – generally calm and positive, which allows Charlie space Engages in relationship: 2 – relatively directive Reads cues and signals: 3 – sees when he is really off or upset, unsure what to do about it, can predict upset now Maintains affective flow: 1 – like PS and first grade teacher, she focuses on flow of activities, not flow of interaction Encourages development: 2 – desires to see him calmer & more regulated for purpose of instruction, unsure how to help him develop this and instead she tells Charlie what to do.

Profile of Charlie’s RSP – Second Grade (new case manager, replacing SLP) • • • •

• •

Comforting: 5 – ‘there’ for him, always Finds appropriate level of stimulation: 4 – calm and positive Engages in relationship: 3 – learning what this is all about Reads cues and signals: 4 – pretty much a natural, sees when he is upset, can predict when it will worsen, and can also predict when it will happen Maintains affective flow: 3 –interested in the flow of interaction than the content, and working on it with him Encourages development: 4 – desires to see him calmer & more regulated for purpose of interaction, and coaches the aides and staff as best she can.

Picture Charlie – Second grade •

Back of class with aide walking him through activities – gets some done, falls behind (mom works hard after school, does not want pull-outs)

•

Staring off into space at times (not seizures)

•

Starting to do what peers do on occasion

•

Later in year, a brief and disasterous stint with a different aide, sets him back

•

But coaching with ‘coach’; rather directive but supportive, learning some playground games, and partly participating with peers

Individual Differences – Charley – Second Grade Sensory

Postural

Response to Communication

Intent to Communicate

Visual Exploration

Praxis -

Sensory seeking, distractible… Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

Low tone; A bit clumsy impedes rapid reciprocity in the moment 1 indicate desires 2. mirror gestures 3. imitate gesture 4. Imitate with purpose. ----3/07---5. Obtain desires 6. interact: - exploration - purposeful -self help ----3/08----interactions More able to sit, and to play!

Trouble managing more than one thing at a time 1. Orient 2. key tones

Dysarthric – Logical discourse is Difficult 1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.words ----3/07---6. two –word ----3/08---7. Sentences 8. logical flow. Improving a bit

Distractible. •focus on object •----3/07---2. Alternate gaze 3. Follow another’s gaze to determine intent. 3. Switch visual attention 4. visual figure ground 5. search for object 6. search two areas of room ----3/08---7. assess space, shape and materials. More capable but still also so distractible

Easily frustrated Ideation

Better, but incredible visual distractibility continues

3. key gestures 4. key words ----3/07---5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s ----3/08---8.abstract conversation. Enough to play facilitated sports, cue back and forth with warmly assertive teacher

Planning (including sensory knowledge to do this) ----3/07---Sequencing Execution ----3/08---Adaptation Can do a lot of his work at his desk with good support

Stepping back from the moment itself: Functional Emotional Developmental Levels • • • • • • • • •

I – co-regulation, ability to attend II – engagement, gleam in the eye, warmth III – circles of interaction IV – flow/ behavioral organization in social problem solving V – symbolic thinking (critical to tolerating affect) VI – logical connections between ideas VII – multicausal thinking VIII – grey area thinking IX – reflective thinking, stable sense of self, and an internal standard

Stepping Back from the Moment: Symbolic thinking and Logical social social problem solving • Makes it possible to solve problems without being caught in the moment • Shrug well, shrug often, and shrug where he can see you shrug: Non-verbal gestural emotional symbols must always be present • Verbal balance – our comedy shows and their diatribes: don’t be fooled by our entertaining or by their logic without real engagement

Charlie’s affective & symbolic life – circa second grade • • • •

Mostly happy enough Can become frustrated with unfinished work Perseveration is easing Staff can manage co-regulation and become engaged enough with him to help him tolerate more frustration • True symbolic problem solving at times, e.g., talking about how to plan when to do work. • Some Pokemon analogies, but not a rich life of fantasy play.

Charlie’s FEDL over time: social problem solving, from managing vigilance to stepping back, and then critical thinking Not there Co-regulate

5/05,

Engage Circles

Barely

5/05

Islands

3/06

3/07

3/06

5/05

3/06,

Flow

5/05,

Symbolic

5/05, 3/06

Logical

5/05, 3/06

Multicausal

5/05, 3/06, 3/07

Grey area

5/05, 3/06, 3/07,

3/08

Reflective

5/05, 3/06, 3/07

3/08

3/06

3/07 3/07

3/07 3/07, 3/08 3/07, 3/08 3/08

3/08 3/08

3/08 3/08

Expands

Comes back

Ok if not stresse d

Ok for age

V – Third Grade • Expanding to entire staff, peers & critical thinking • Another, even better, teacher • RSP continues to improve • Aide remains the same • More staff involved

The story this year is…

DIR® in everyday life at school • Work on everyday problems • Work on keeping the child engaged throughout the day • Work on co-regulation, engagement and reciprocity • Work on developing relationships between child and staff and between child and peers

The Process •

Building relationships takes time – in this model case it took 4 years for parents to trust the staff, and this has already been disrupted

•

Sometimes you can’t do it

•

Charismatic vs. invisible – either way you need to help the team feel the power

•

Helping reluctant professionals – you must find and nurture allies

•

Look for the magic there and nurture it

•

Reframe ‘He would do better if he only would’ to ‘if he only could’ (Barbara Dunbar)

We often do 3 big visits 2.September: The plan and concepts 3.December: Review and progress/ challenges 4.February: More review, progress/ challenges and preliminary planning for next year

This year mom was concerned about ‘critical thinking…’ • California standards • The leading edge of Charlie’s continuing development • But hints of this at the earlier FEDL levels too • We’ll clarify ‘critical thinking’ • Then we’ll look at problems in class

Critical thinking: Functional Emotional Developmental Levels • • • • • • • • •

I – co-regulation, ability to attend II – engagement, gleam in the eye, warmth III – circles of interaction IV – flow/ behavioral organization in social problem solving V – symbolic thinking (critical to tolerating affect) VI – logical connections between ideas VII – multicausal thinking VIII – grey area thinking IX – reflective thinking, stable sense of self, and an internal standard

7 ate 9: Toward Critical Thinking • Multicausal thinking: there is more than one reason, more than one feeling. • Grey area thinking: there are different intensities of emotion. • Reflective thinking: we can compare situations to each other, and we can compare ourselves to who we want to be

What do teachers mean by

‘Critical Thinking’? • • • • • • • • •

Analysis Awareness has to be there Abstract thought Decision making Compare and contrast Fact and opinion Value judgements Values: child’s values Self esteem/ self-concept

Critical Thinking in the DIR® Framework: ‘Wheat vs. Bread’ • • • •

Beyond concrete facts & procedures Recognizing abstract categories & patterns Analyzing information & drawing conclusions Stepping back and reflecting on whether the ideas and conclusions make sense • These things can happen in some form even at lower FEDL levels

Addressing In-Class Problems Related to FEDL levels in class:

Solving in-class problems at various FEDL levels: Co-Regulation • Problem: LOUD voice, directed at his paper: 'I don’t how to do this..’ • Approach: make a ‘space’ for you and him • talk w/ him about it • visual cuing icons for: ‘We can figure this out’, ‘shhh’ and a 'raise your hand' • how to get him looking up and keeping others in the visual field - if all were up on stools and drafting tables… requires affective engagement..

Solving in-class problems at various levels: Engagement • Problem: distracted; no interest in guest speaker, trouble answering in class; if not feeling it he doesn’t connect (remember dual-coding?) • Approach: instead of using prompt e.g.'eyes down please' do something else to engage him in the communal moment - ‘this story is so cool’ – ‘we are getting to think about this together’ • anticipatory guidance – ‘I wonder what you think about it..’ • rule: find the fun – for each student • HISTORY CHANNEL, live • find, maybe write down, stuff the speaker wants you to think is interesting or funny 

Third Grade – reading group

Solving in-class problems at various levels: Circles • •

• • •

Problem: struggling w/ joining in and communication counter-intuitive to have chit chat in class, although with class moving on had to stop at times Approach: do it in a non-verbal manner, cuing to see what others are doing; solving problems non-verbal, engaging non-verbally (for others I recommend ‘infield chatter’) Problem: not bringing in his own ideas; sits and says he doesn't know what to write. Staff quizzing him on what he likes, what he wants to write about – goes nowhere Approach: using statements - works well in getting him to express himself, better feedback when she uses statements Result: writing ‘independently’ (this is a misnomer!), w/ a writer's voice, more than he has to - HUGE, HUGE, HUGE!; part is 'I thought to myself...' - thinking about thinking -

Avoiding Questions Feder’s Tip of the Century

• Questions are top-down, ‘Guess what I’m thinking’ • Questions put people on the spot, and make them more likely to get upset and close up or act mad • Statements create social ‘problems’ that the other person can ‘solve’ • Try it out. It’s hard, but worth the work.

Solving in-class problems at various levels: Flow • Progress on the playground • friends asking him to play: ’Come play with us!’ • Coaching, OT/ APE (adaptive physical education) effort paying off – goals: ‘how to run, how to look up, etc.’ – top down stuff on paper, but engaging in execution. • arguing re the rules in sophisticated way shoulder to shoulder, hashing it out great!

Solving in-class problems at various levels: Symbolic and Logical Thinking

• Problem: math – must ‘do it right’; frustrated; takes too long • Approach: symbolic concept ‘impossible problems’ • Logic = faith in the process (Star Trek falling hammer) • Logic = self-advocacy, asking for help when appropriate

Marilee Sheet on Math Following his lead: ‘I must do it right’

Joining: ‘Of course we want to do it right’

Circles: statements that build ideas, e.g., ‘I’m not sure what makes this so hard for us.’

Set the environment: making a space (Like ER or on a date)

Expanding the concept: Impossible problems, then sorting easy, hard, & impossible.

Broadening Emotional themes: from intense reaction to stepping back, less intense, curiousity; from perseverative angst to calm perserverance

Individual Differences: reactive to busy environments, poor motor planning, trouble reading cues, trouble expressing himself including loud voice, visual figure ground difficulties, poor planning, sequencing, execution, and adaptation; perfectionistic and reactive.

Working Multiple Levels: Co-reg: space Engage: joining him Circles Flow: working problems together Symbolic: ‘impossible…’ Logic: ‘We can do this’, right = showing what info isn’t needed, right = showing your work

Critical Benefits of Symbolic Thinking • Expand his thinking so that he is not stuck in the black and white, all or nothing world • Tolerating a difficult moment with confidence that he can get through it – like being stuck in a haunted house – uncomfortable in the moment – like four square – that’s part of the fun – • it helped that day when they were explicit – not saying just fine but acknowledging that it is hard, he can be proud of it when he is done (COMPETENCE) –  

Supporting critical thinking at multiple levels in social problem solving: I. II. III. IV. V.

Co-regulation: ‘It’s good to be with you.’ Engagement: Shrugs and yelps Circles: ‘I don’t know what you are doing’ Flow: the critical importance of ongoing interaction Symbolic: ‘You seem stirred up.’ (action language about emotional state) VI. Logic: ‘I’m not sure how come you don’t like this. VII. Multicausal: ‘You might be mad and sad… I’m not sure.’ VIII. Grey area thinking: ‘You look stoked!’, ‘You look a little miffed.’ (action language, levels of intensity) IX. Reflection: ‘I wonder how this compares with how you usually feel.’ …with other situations… with other times in math..”; compare with other students so he knows he isn’t doing badly  

VI - Summary and Reflection:

Charlie Year By Year PS: memorizing verses, trailing after the others K: flopping on the floor, losing ground academically 1st: a better teacher, a failed medication trial 2nd: a better aide, a teacher who cues, coach 3rd: a whole school effort, some real yard play

Individual Differences – Charlie – Preschool 5/05 Sensory

Postural

Response to Communication

Intent to Communicate

Visual Exploration

Praxis -

Sensory seeking, distractible… Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

Low tone; A bit clumsy impedes rapid reciprocity in the moment 1 indicate desires 2. mirror gestures 3. imitate gesture ---- 05/05---4. Imitate with purpose.

Trouble managing more than one thing at a time 1. Orient 2. key tones 3. key gestures 4. key words ---- 05/05---5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s 8.abstract conversation.

Dysarthric – Logical discourse is Difficult 1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.words 6. two –word ---- 05/05---7. Sentences 8. logical flow.

Distractible. 2.focus on object ---- 05/05---2. Alternate gaze 3. Follow another’s gaze to determine intent. 3. Switch visual attention 4. visual figure ground 5. search for object 6. search two areas of room 7. assess space, shape and materials. -

Easily frustrated Ideation -- 05/05--Planning (including sensory knowledge to do this)

5. Obtain desires 6. interact: - exploration - purposeful -self help -interactions

Sequencing Execution Adaptation

Individual Differences – Charley – through third grade Sensory

Postural

Response to Communicatio n

Intent to Communicate

Visual Exploration

Praxis -

Sensory seeking, distractible… Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

Low tone; A bit clumsy impedes rapid reciprocity in the moment 1 indicate desires 2. mirror gestures 3. imitate gesture 4. Imitate with purpose. ----3/07---5. Obtain desires 6. interact: - exploration - purposeful -self help ----3/08----interactions ----3/09----

Trouble managing more than one thing at a time 1. Orient 2. key tones

Dysarthric – Logical discourse is Difficult 1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.words ----3/07---6. two –word ----3/08---7. Sentences ----3/09---8. logical flow.

Distractible. •focus on object •----3/07---2. Alternate gaze 3. Follow another’s gaze to determine intent. 3. Switch visual attention 4. visual figure ground 5. search for object 6. search two areas of room ----3/08---7. assess space, shape and materials. ----3/09----

Easily frustrated Ideation

3. key gestures 4. key words ----3/07---5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s ----3/08---8.abstract conversation. ----3/09----

Planning (including sensory knowledge to do this) ----3/07---Sequencing Execution ----3/08---Adaptation ----3/09----

Charlie’s FEDL over time: social problem solving, from managing vigilance to stepping back, and then critical thinking Not there Co-regulate

5/05

Engage Circles

Barely

5/05 5/05

Flow

5/05

Symbolic

5/05

Logical

5/05

Multicausal

5/05

Grey area

5/05

Reflective

5/05

Islands

Expands

Comes back

Ok if not stresse d

Ok for age

Charlie’s FEDL over time: social problem solving, from managing vigilance to stepping back, and then critical thinking Not there Co-regulate

5/05,

Engage Circles

Barely

5/05

3/06

3/06

5/05

3/06

Flow

5/05,

Symbolic

5/05, 3/06

Logical

5/05, 3/06

Multicausal

5/05, 3/06

Grey area

5/05, 3/06

Reflective

5/05, 3/06

3/06

Islands

Expands

Comes back

Ok if not stresse d

Ok for age

Charlie’s FEDL over time: social problem solving, from managing vigilance to stepping back, and then critical thinking Not there Co-regulate

Islands

5/05, 3/06

Engage Circles

Barely

5/05

3/07

3/06

5/05

3/06,

Flow

5/05,

Symbolic

5/05, 3/06

Logical

5/05, 3/06

Multicausal

5/05, 3/06, 3/07

Grey area

5/05, 3/06, 3/07

Reflective

5/05, 3/06, 3/07

3/06

3/07 3/07

3/07 3/07 3/07

Expands

Comes back

Ok if not stresse d

Ok for age

Charlie’s FEDL over time: social problem solving, from managing vigilance to stepping back, and then critical thinking Not there Co-regulate

Islands

5/05, 3/06

Engage Circles

Barely

5/05

3/07

3/06

5/05

3/06,

Flow

5/05,

Symbolic

5/05, 3/06

Logical

5/05, 3/06

Multicausal

5/05, 3/06, 3/07

Grey area

5/05, 3/06, 3/07,

3/08

Reflective

5/05, 3/06, 3/07

3/08

3/06

3/07 3/07

3/07 3/07, 3/08 3/07, 3/08 3/08

3/08 3/08

3/08 3/08

Expands

Comes back

Ok if not stresse d

Ok for age

Charlie’s FEDL over time: social problem solving, from managing vigilance to stepping back, and then critical thinking Not there Co-regulate

5/05,

Engage Circles

Barely

5/05

Islands

3/06

3/07

3/06

5/05

3/06,

Flow

5/05,

Symbolic

5/05, 3/06

Logical

5/05, 3/06

Multicausal

5/05, 3/06, 3/07

Grey area

5/05, 3/06, 3/07,

3/08,

Reflective

5/05, 3/06, 3/07

3/08,

3/06

Expands

3/07 3/07

3/07 3/07, 3/08 3/07, 3/08

3/08, 3/09 3/09

3/08

3/09 3/09 3/09

3/08 3/08

3/08 3/09

Comes back

3/09

3/09 3/09

Ok if not stresse d

Ok for age

Charlie: relationships • DRIVING FORCE: Mom and dad, Charlie, sister, SLP, lawyer, RSP and me • REGULATING: Me and Charlie, mom, dad, SLP, RSP, aides, teachers, principal, lawyer, team • LINKAGE: SLP and team, then RSP and team, now new RSP and team • CHIEF TARGET: Charlie and mom, dad, SLP, aides, teachers, and now peers

Peers

Nurturing Relationships • Regular contact with mom and RSP, as needed with me. • Regular reflective time for me and RSP • RSP with ongoing reflection with team, and with Charlie • Charlie in general education environment with some peers he has known for years.

Quality of relationships over time • Mom is more comfortable with the team • I am more able to impact the team • RSP is more able to think about and problem solve effectively to help the team help Charlie • Charlie has better relationships with mom, dad, sister, adults, and peers – now playing regular playground games and nearly ‘invisible’

Reflecting on Charlie • Early emphasis on regulation, engagement, and affective cuing and basic reciprocity • Improved ability to travel up the developmental ladder as individual differences improved • Individual differences improved in the context of supportive, engaging reflective relationships among team members, supporting team and peer relationships for Charlie

Reflecting on the work • Exasperating case for me: Charlie’s flopping about, mom’s anxiety, school insistence on SDC (not inclusion), failure of medication • The luck of having some people who have a toehold: SLP, leveraged to RSP, and some willing teachers • Ambivalence about relying on the good cop/ bad cop model; but if not for the lawyer’s involvement I would not have access • I can’t do it all: developing others to do this work

Moving forward…. • I struggle with helping parents build a workable alliance with the team, yet the system has inherent conflicts of interest • The patient always takes priority, yet I wonder how to both serve as an advocate for my patients and also participate in and try to improve a troubled system

ICDL-DIR® Schools Committee • Get on the email list – email me at [email protected] • I hope to have occasional conference calls • Maybe a blog?

VII - Discussion

Addendum:

Aggression and Meltdowns • • • •

The main reason we are called in There is no quick fix Take the long view You must have ‘space’ to think and plan and rethink and plan

Why DIR? • When other methods are failing • Addresses the core symptoms vs surface behaviors • Proactive…

A General Plan for the Management of Difficult Moments * • • • • •

Have a plan ahead of time Adjust the environment Soothe Talk Anticipate

*reference: A Bioethical Approach to Overcoming Problems with Aggression and Misbehavior in Schools, Stanley Greenspan, M.D. ICDL 12th Annual International Conference November 7-9, 20082008 ICDL Fall Conference, Washington, D.C.

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.blogspot.com

Find Mrs. Fitz • • • • •

Calm, soothing, and patient Never laid hands on the person Engaging Listened well Wondered what to do next time

1. Make a plan • Staff must have time to meet and think it through • Staff must have time set aside to rethink it through

2. Adjusting the environment • • • •

Clearing the room Having a safe spot to go to Signaling others to leave him be Calming the noise, the light, whatever the child responds to • Not just a sensory break • Avoid physical redirection

Avoid Physical Redirection/ Restraint • • • •

Grabbing begets violence Make the grounds safe enough Wait for him to return At most trail after him, non-chalant

Feeling Safe and Regulated • If you feel unsafe, he will feel unsafe • Have things to protect your self – cushions • Avoid having the person ‘beat pillows’ – it engenders more out of control beating • Regulating physical activity can be helpful – walking, jogging, bouncing together

3. Soothe • When you see it coming, join, co-regulate, soothe • When you did not see it coming, you wait it out • Don’t over-react, nearly match the affect and the intensity – enough to help the child feel understood • You are not trying to prompt an out of control child to do what you think will help

‘soothing’ comes from engaged relationships • • • • • •

established over time, staff, parents, are in charge everyone is accountable kids have a say kids are always loved respected to the extent that they are being respectful of others.

4. Talk • Or play • Communicating about what happened • Avoid questions, but try to understand

5. Anticipate • Make a plan with the child about what to do next time • Role play • Keep it simple – brief simple phrases over long social stories

About meds • • • •

Environment is key Engagement is the the central factor Meds may secure a good placement Meds do not make up for a bad placement

Variations on the model and a range of cases • preschoolers - college and beyond • NDRC I-IV • Phone contact only to 20 hr/ wk in school

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.blogspot.com