Dir®floortime Complementary Approaches For The Most Challenged Children With Asd

The Miller Method® and DIR®/Floortime™: Complementary approaches for our most challenged children with ASD A Charity Conference / Benefit June 6 & 7, 2009 Courtyard by Marriott San Diego Airport / Liberty Station San Diego, California

Redacted for Circlestretch • This version of the powerpoint has all the information from the conference except that extraneous slides such as announcements and some of the identifying information about case examples has been removed for privacy purposes.

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 conferences where I teach NIMH/ Duke University – minimal – administrative time for pharmacogenetic research NIH – BRIDGE Collaborative - minimal – honorarium for ‘consultative services’

Thanks Yous • Valerie Saraf, Karen Dotsen, Cherry Cari, Karyn Searcy, Aubyn Stahmer, ACES, DTC • DIR local consortium (Mara Goverman and Lori McCurdy) • Marit Goldman (circlestretch) • Jennifer Dowd-Furlong • Lana Randell • Lisa Drake • Dr Miller

This Is For the Kids… • Families • Certificate candidates

Warning: this will go fast All the slides will be posted on www.circlestretch.com Since we have limited time I will skim over slides marked with a

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

Taking Notes? • One word:

ENGAGEMENT

• One phrase: Engagement goes beyond compliance.

About the case examples • Thank you to those who have agreed to share • The impact on the family of sharing • Selected slices to demonstrate aspects of DIR®/Floortime™ • Intensity of intervention varies • Time course of change varies widely • Please respect the sanctity of the information • If you happen upon someone here, say ‘thanks!’ • If you see one of these families out there, etiquette says to say a ‘silent thank you’

Feder’s pieces, Day 1: • • • • • • • • • •

A. An Example (1), B. Big Problems in ASDs What is DIR®/Floortime™ & more examples (2,3,4,5) Comparing with behavioral approaches The D – the I – and the R, and another example Comparing the Miller Method with DIR, with example (6) Break DIR®/Floortime™ at Home and School Facilitating interactions Managing Difficult Moments, and brief examples (7-13) Questions

Feder 411 •

• •

•

• •

Career – biomedical engineering and math, Navy – some operational medicine, psychiatry at Balboa, child and adolescent at Tripler, Clinic at Pearl, Chief of Child at NNMC/ USUHS faculty, Greenspan & Wieder in DC, back to San Diego in ‘96, ‘unejectible’ in Solana Beach since 2001. Research – perflorinated hydrocarbons, mathematical models of mind and cognition (ADHD), physician use of mammography, blood preservation, relationship based interventions, pharmacogenetics, early intervention Autism Spectrum Disorders: 1980 Mass. Assn for the Blind (Congenital Rubella); 1982 teacher at school for autistic adults (Behavioral training); BUSM Pediatric Neurology 1985; Child Study Group – Tripler (Lee); Neurodev. Clinic NNMC 1993 - 1996; Greenspan, Wieder et al ICDL 1993present; AACAP Autism Committee 1997-2000 & ad hoc (Volkmar, Cook); AACAP Autism Medication Panels (Volkmar); AACAP Autism in the schools training 2006 (Chenven, Akshoomoff, Feder). Practice – time 1/3 evaluation and case management, 1/3 therapy, 1/3 teaching and research; dx ½ developmental and learning disorders, ½ general psychiatric (ADHD, Bipolar, PTSD, Tourettes, Depression, OCD etc.); age range 1/3 infants and children, 1/3 older children and adolescents, 1/3 adults Community work: Rady Autism Research Workgroup, BRIDGE Collaborative, SDPS Ethics committee / resident training in ethics; ICDL Institute, F2F and online courses Outside life – coaching science and engineering, running a dance company, reading, care of chronically ill house pets…

circlestretch “Go for that gleam in the eye!” http://www.circlestretch.com

Part 1a: An Example (1): S

Severe Dysregulation and Aggression

About S : • failure to develop language, motor skills. • multiple medications, with side effects: sedation, dysphagia, bruising, ataxia • ABA - DTT • Miller Method • DIR®

Video clips • Clip 1: 04/08 • Clip 2: 08/08 • Clip 3: 12/08

Functional Emotional Developmental Levels …or, what the general ‘look’ is, over time

FEDL Over Time • 4 – could sit a bit, give me a rare glance, take off my post-it’s on occasion • 8– moments of gleam and a couple of circles when I swipe her things… • 12 – more attached to the book, able to use it as leverage for more engagement, many circles, and the bare beginnings of flow, no real sense of symbolic (but worth a try)

FEDL - S 1 (not there)

2 (barely)

4

Regulate

Engage

4

Circles

4 8

4 8

Flow

Symbols

Logic

3 (islands)

4

4, 8 8 12 12

12

8

8

12

12

12

4 (ok w/ support)

5 (comes back)

6 (ok unless stress)

7 (ok)

Individual Differences

Individual Differences - S Sensor y

Postural

Sensory seeking…

Unstable, made worse by meds

Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

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

Response to Communicatio n

Intent to Communica te

Some Difficulty comprehension of indicating sharp redirection with gesture, Dysarthric – 1. Orient 2. key tones 3. key gestures 4. key words 5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s 8.abstract conversation.

1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.words 6. two –word 7. sentences 8. logical flow.

Visual Exploration

Praxis -

A relative area of difficulty

Ideas at times, without effective planning nor sequencing

1. focus on object 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 Planning (including sensory knowledge to do this) Sequencing Execution Adaptation

Reflection: What works, what doesn’t and why: • Miller Method – learned some systems • Medication: pros and cons • ABA - content mastered, some is somewhat functional, e.g., “turn the page”, some is not taking (‘green’) • Leveraging her ideas worked here • Leveraging her desires to get language • “Why”: semi-structured activity, affective holding environment, medicated so I feel safer and she can be a bit more regulated, up on the ottoman, loves the book, positioning, her steadying herself on my arm, the stars were lined up,….complex case, making gradual progress

The bigger picture: • broad goals: co-regulation, engagement, reciprocity, symbolic overlay • multimodal intervention: you name it, parents are trying to do it – parents are the core managers to work toward coordination between modalities and maintain coherent goals

Part Ib: Some Big Problems • • • • • •

Aggression – Tantrums Self-Injurious Behavior Self-stimulating behavior Running Off / Safety Transitions Perseveration – Obsessive/Compulsive Rigid • Compliance • Communication

Some of the usual methods… • • • • • • • • • •

Functional Behavioral Analysis Antecedents – Behaviors – Consequences Behavioral Support Plans Contingencies (rewards, consequences) Predicting triggers, setting up the environment Sensory breaks Social stories Structure – visual schedules - predictability Prompts and prompt fading Extinction

Limitations to the usual methods • Address surface behavior • Solutions are given to the child • They are limited solutions – hard to generalize • Rigid structure can foster more rigidity • Sensory breaks can breed ‘escape’ behavior • Does not address foundational socialemotional capacities

DIR and tough challenges • Focus is on harnessing the child’s emotional drive • to help her think on her own to solve problems • and gradually relate and communicate better • build relationships with others • and become more flexible, adaptive, and connected

Part II:

What is DIR®/Floortime™?

What is DIR®? • • • •

Developmental Individual Differences Relationship Based Not to be confused with RDI….

Where it comes from: • • • •

Child Development Infant Mental Health Parent-child relationship Greenspan, and Wieder

Empirical Support • Biopsychosocial medical model: the basis for current medical thinking from about 1970’s to present – George Engel • GxE – a better outcome despite Genetics, when we work with the Environment • Child Development Research – co-regulation, engagement, learning through relating (dual-coding) • Mathematical analysis of neurologic processes, including learning – vigilance – Stephen Grossberg (Boston U) • Hundreds of treatment reports – review of 200 cases and follow up on that group – Stanley Greenspan, Serena Wieder, et. al. • Rick Solomon, et. al. – The Play Project • Brain Imaging studies – John Stieben (York U)

Definition of Developmental, Individual Differences, Intervention:

Relationship Based

Developmental, Individual Differences, Relationship Based intervention is the use of ongoing affective connected interaction to promote developmental progress, focusing on co-regulation, engagement, and social reciprocity. This is done in a context of a well rounded biopsychosocial understanding of the person, and carried out throughout the day by caregivers who are guided and supported as they develop growth producing relationships.

WE USE EMOTIONAL CONNECTION TO FOSTER THE CHILD’S SOCIAL-EMOTIONAL, COGNITIVE AND COMMUNICAITON DEVELOPMENT – WE WORK WITHIN THE CHILD’S PROFILE OF INDIVIDUAL STRENGTHS AND CHALLENGES WHILE WORKING TO IMPROVE THAT PROFILE EMOTIONAL CONNECTION, i.e., AFFECT, IS THE GLUE THAT HOLDS EVERYTHING TOGETHER AND MAKES EVERYTHING POSSIBLE. WE WORK WITH FAMLY AND OTHERS TO MAKE THIS HAPPEN ALL THE TIME

So, how does DIR® help? • We can take a hard wired disorder and change it. • What is the best way to change things? • Behavioral tradition is clear: surface behavior can be changed, and lots of things can be learned – we can teach a person to do and say what we want the person to do or say (e.g., manding) . • By contrast, DIR® helps her become more connected with her world, learn to think for herself and adapt to her world.

Part III:

Comparison of DIR®/Floortime™ with behavioral approaches

Contrast of DIR® vs. Behavioral Approaches • Prompt vs woo – top down vs. building relationships and learning together • Compliance vs. engagement • Imitation, limits, facts vs. autonomous thinking, negotiation, & exploration

Rough Comparison of DIR®/Floortime™ (Developmental Individual differences Relationship based) with other approaches: DTT

Prompts

PRT

Prompts

RDI

Prompt

MM

Super-Prompt with elements of ‘gentle teasing’ Woo

DIR

Compliance

Do/learn what is expected from trainer Compliance Choices – trainer, then Compliance parent Do what’s expected – trainer, then Compliance parent do Mostly through action what’s and expected – engagement trainer, then in rituals parent Engage (joint Build shared attention) meaning – parent focused

Top-down autocratic Top-down, yet democratic Top-down, autocratic Mostly topdown, with elements of co-created interactions Bottom–up, democratic

Comparison of DIR®with behavioral approaches – I • Goals of a behavioral programs: appropriate behaviors, learning facts, learning ‘what to do’ in a top-down approach (we teach, child learns and complies). • Goals of a relationship based interventions: connect with others to promote social and cognitive development and problem solving with flexible adaptation to a changing world. This is a ‘bottom up’ approach. • NB: RDI is a social–cognitive behavioral program whose aim is to create the ability to have relationships by training the child in ‘what to do’ with ideas that reflect natural relating but with methods that are top-down and do not reflect natural relating.

Comparison of DIR® with behavioral approaches - II

Prompt vs. Woo Prompt Greater power difference between people Control Specific expectation Belief in the material

Woo Humility – more equality Respect for ideas of other person Open ended, hopeful for growth Belief in the process

Comparison of DIR® with behavioral approaches – III

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 Relationships, available and situations internalized, give selfassurance to respond to new situations Limited sense of competence, More full sense of competence, self-esteem: “I can do it. I self-esteem: “I can figure it learned how.” out.”

Comparison of DIR® with behavioral approaches – IV

A Complementary Relationship Behavioral based contributes… Imitation Limits Facts

Relationship-based expands… Autonomous thinking Negotiation Exploration

DIR® is, by definition, the broadest of possible interventions • • • • •

Biopsychosocial Individual differences Developmental Family characteristics Allows for other interventions within its umbrella

What does DIR® Look Like? • Floortime sessions • Floortime all the time: always engaging the child in a flow of interaction • DIR® is for all ages and all levels of challenge • Always includes reflection: time away from the situation for thinking and reflecting with others about what works and what to try next

Part IV:

The D – the I – and the R

Developmental • Functional Emotional Developmental Levels • Condense many (most) other developmental theories down to a fundamental set of foundational skills • WE ARE ALWAYS MOST CONCERNED WITH THE CONNECTION OF THE CHILD TO OTHERS AND HOW THE CHILD GROWS, LEARNS AND ADAPTS USING THAT ALLIMPORTANT CONNECTION WITH OTHERS • Remember: this is about social problem solving, and ‘there is always a social problem in the room’

Functional Emotional Developmental Levels: I.

Co-regulation – calm enough to interact / alert enough to interact II. Engagement – a warm, bright, trusting connection III. Circles of interaction IV. Flow of interaction that leads to figuring out how to manage the situation V. Symbolic thinking in social problem solving VI. Logical thinking in the context of relating VII.Multi-causal thinking VIII.Grey area thinking IX. Reflective thinking

Likert Scale for Each Level 1. 2. 3. 4. 5.

Not doing it Barely able to do it Islands of time where the child can do it Can expand those islands with our help Comes back for more with little or no support 6. Pretty normal unless under stress 7. Age appropriate

Sample Full FEDL (Charlie) Not there

Barely

Islands

Expands

Comes back

Coregulate

3/06

3/07

3/08

3/09

Engage

3/06

3/07

3/08

3/09

Circles

3/06, 3/07

3/08

3/09

Flow

3/06

3/07

3/08, 3/09

Symbolic

3/06

3/07, 3/08

3/09

Logical

3/06

3/07, 3/08

3/09

Multicaus al

3/06, 3/07

3/08

3/09

Grey area

3/06, 3/07,

3/08, 3/09

Reflective

3/06, 3/07

3/08, 3/09

Ok if not stresse d

Ok for age

FEDL Level I: Calm enough (Co-regulation) • Know the individual person: Sensory sensitivities, motor tone, understanding communication signals, giving signals to others, visual-spatial ability, body in space, movement, and ability to plan, sequence, do a plan (incl. motor ability), & adapt the plan. • Co-regulation means we do this together – not a ‘sensory break’ (escape without learning anything) – meet the person 80% to where s/he is in intensity or lack of intensity to help the person settle down with you. • ‘Calm enough’ might mean active enough. • Think about what works and what doesn’t work

FEDL Level II: Truly Connected to Others (Engagement) • The gleam we keep talking about… mostly this is fun and feels good for everyone • It’s the reason, the ‘buy-in’, the bond, that will lead to compliance. • Joint attention, but more than that. • Joining whatever he person is doing, to start (not an end in itself).

FEDL Level III: Circles • The ‘back and forth’ of an interaction • The child is always doing something • Join in, make yourself a part of the activity • Or if you can’t just join in, you can gently and playfully get in the way • Maybe be the person with the stuff the child wants – has to get it from you

FEDL Level IV: FLOW • The fourth ‘level’ in the socialemotional developmental process • The ‘engine’ of relating you need to be able to expand • It might look like ‘baby games’, but it is what we all do every day, constantly, with each other

FEDL Level V: Symbols • Words, when they really say something – more than labels • Play, when it really ‘says’ something – more than trained actions or turn taking • Gestures, when they ‘talk’ about things or ideas that can replace actions – more than pointing • Try to treat everything as having meaning – you might be wrong and that’s ok, the person will correct you

All Kinds of Symbols From playing with dollies when the child really means it or crashing cars when it really expresses something to Fantastical stories of castles and kings, princes, armies, unicorns, spies, heroines and every kind of complex human motivation (think of the 7 virtues and 7 vices)

FEDL Level VI: Logical Thinking • Building logical bridges between ideas • Makes for powerful collaborative thinking • Far beyond ‘Aspergian Logic’ • Might asks why you feel that way • Can separate his internal world from your world, and still feel concerned

FEDL Level VII: Multicausal Thinking • There is more than one reason for why something is the way it is • Ex: Mom’s mad, after bad day at work, but asks if there are other reasons • There is more than one feeling one might have about things • Ex: Mom’s sad that I am going to school, but happy that I’ll be with other kids

FEDL Level VIII - Gray-Area Thinking (6-10 yr) • Hierarchies, playground politics • The best time for disappointment – better to lose now and have mom’s support than to lose as an adult and have no experience to fall back on. • Emotional experiences define, expand, and deepen the boundaries for the self. Without anger we don’t know what annoys us, without joy we don’t know what makes us happy. • Refining the gradations of these emotions • This expanded and deepened appreciation for emotional experience makes us more able to appreciate it in others.

FEDL Level IX: Reflective Thinking, (9-12 yr and beyond) • A Stable Sense of Self, and an Internal Standard • Empathize in a truly reflective manner • Understand a range of feeling in others and compare it to one’s self • Helps one be truly a great friend or partner. • Expanding sense of empathy, more and more inclusive: other kids, groups, school, country, … the world (other races, religions, etc.)

ENGAGEMENT IS THE FULCRUM you need to co-regulate to engage you can spin engagement into the world

to put it in a picture….

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

Individual Differences – (sample) Sensory

Postural

Response to Communication

Intent to Communicate

Visual Exploration

Praxis -

Sensory seeking… Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

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

Trouble managing more than one thing at a time Can barely tell ‘why’ we fight or what we fight about Can’t track conceptual discussion of the reasoning behind events and play 1. Orient 2. key tones

Dysarthric – unintelligible Logical discourse is difficult (e.g. at best hedonistic: cheating gets you disqualified) 1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.words 6. two –word 7. sentences 8. logical flow.

A relative strength; Frustrated looking for things Some ability to work with shapes and objects to solve problems in play. 1. focus on object 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.

Ideas becoming more complex with support Adapting to problems that come up (e.g. when my character is injured, faints, etc.)

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

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

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)

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 • The rest of the this is about how we work on better engagement and supporting the child’s development

Family /Caregiver Patterns: Rate 1 (low) to 5 (high) and comment:

• • • • • •  

Comforting Finds appropriate level of stimulation Engages in relationship Reads cues and signals Maintains affective flow (for co-regulation) Encourages development

Reflective Process • We all need time, on an ongoing and regular basis, to think about what we do • We need to think through what we are doing with other people to help us see things • When we ourselves, as parents or professionals, present our kids, we ask for what we want help with • When we support, we give our observations to help the other person come to their own plans – we avoid telling them what to do

Examples of kids at different places on the FEDL • FEDL I-IV: manage vigilance, support interaction • FEDL V-VI: stepping back from the moment • FEDL VII-IX: critical thinking

• • • • • • • • •

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

Sample Case 2 FEDL Levels I-IV • Not so verbal, poorly regulated, perseverative Kindergartener • Seen in SDC PK – wandering, adrift • Allies: District rep – we pushed for .. K teacher (bends down to child instead of greeting me) • Family: helping mom see the magic • Video

FEDL – Sample Case 2 1 (not there) Regulate

2 (barely)

3 (islands)

10

4 8 8

Engage

4

Circles

4

8

Flow

4 8 4 8

10 10

Symbols

Logic

48 10

4 (ok w/ support)

10 10

5 (comes back)

6 (ok unless stress)

7 (ok)

FEDL - descriptions 4/08

Bouncing about, somewhat interested in us

8/08

Starting modeling circles, vs. discrete trial type interactions

10/0 8

Mom does a warm, spontaneous game, based on his lead

Individual Differences – Sample case 2 Sensory

Postural

Response to Communication

Intent to Communicate

Visual Exploration

Praxis -

Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

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

1. Orient 2. key tones

1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.words 6. two –word 7. sentences 8. logical flow.

1. focus on object 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

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

Planning Sequencing Execution Adaptation

‘Marilee Sheet’ for

Sample Case 2

Following his lead: •teresInt in mom’s spontaneous affectively rich nyah nyah tongue on video

Joining: •mom goes along with his desire to have her do it again •not worrying about whether it is ‘appropriate’

Circles: •waiting for him to respond •affective gestural hesitation

Set the environment: •keep it simple •no special toys •not a didactic task

Expanding the concept: •tongue •splutter •noises

Broadening Emotional themes: •anticipation •excitement •joy

Individual Differences: •sensitive to overstimulation •postural instability •receptive communication •expressive communication •Visual spatial •praxis (planning)

Working Multiple Levels: •co-regulation: stretching capacity to tolerate excitement •engagement: strengthening bond with mom •circles: waiting and working on closing more circles •flow: behavioral organization – keeping the circles going even if the game changes

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

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

Sample Case 3 FEDL Levels V-VI

Aggression and Rigid Aggressive Play Themes

About the boy:

• Why he came to me: aggression toward peers in private kindergarten. Removed anyway and placed in public setting. • Main symptoms: Receptive language, difficult to understand speech, reactive to busy environments, low tone, active, impulsive, sensory seeking, rigid, controlling, aggressive

Video • Fill out FEDL grid while watching:

FEDL

FEDL – Sample Case 3 1 (not there)

2 (barely)

3 (islands)

Regulate

11/05

4 (ok w/ support)

11/06

5 (comes back)

11/07

11/08, 5/09

Engage

11/05

Circles

11/05,

11/06

11/06

11/07

11/07

Flow

11/05

11/06, 11/07

Symbols

11/05

11/06, 11/07

11/08

Logic

11/05, 11/06

11/07, 11/08

5/09

11/08,

11/08

11/08

5/09

5/09

5/09

5/09

6 (ok unless stress)

7 (ok)

FEDL – descriptions: Sample case 3 11/0 5

Rigid, aggressive, hits in ‘play’, not really symbolic

11/0 6 11/0

Allows me to join his aggressive play on his team

7 11/0 8

5/09

Increased complexity of aggressive themes; able to play with cousin and brother in water fights, facilitated by dad ‘battle’, controlling, but can be torn between Racing me and dad, and nurturing, creative & symbolic with me; able to play with cousin and brother in games that are competitive but not overtly aggressive Talking with me and parents about problems at school

Individual Differences

Individual Differences – Sample case 3 Sensory

Postural

Response to Communication

Intent to Communicate

Visual Exploration

Praxis -

Sensory seeking… Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

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

Trouble managing more than one thing at a time Can barely tell ‘why’ we fight or what we fight about Can’t track conceptual discussion of the reasoning behind events and play 1. Orient 2. key tones

Dysarthric – unintelligible Logical discourse is difficult (e.g. at best hedonistic: cheating gets you disqualified) 1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.words 6. two –word 7. sentences 8. logical flow.

A relative strength; Frustrated looking for things Some ability to work with shapes and objects to solve problems in play. 1. focus on object 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.

Ideas becoming more complex with support Adapting to problems that come up (e.g. when my character is injured, faints, etc.) Ideation

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

Planning Sequencing Execution Adaptation

Family: • Dad works hard. Can facilitate kids when available. • Mom can set up playdates, engage cousin. Has to work hard to manage environment at home so that he is not in continuing conflict with older brother. • Brother is a good guy, and tries to play with him. But no one can really keep up with him. • Mom and Dad can play in office; however life at home is busy - hard to find time for Floortime.

Reflection: • What works: office play with him and his parents to help them see what we can do; play dates with cousin, brother, facilitated by parents. Now we can talk too! • What doesn’t work: videogames, busy environments with many peers. • Why: He is still developing capacities for solid enough symbolic play to be able to engage with peers without becoming aggressive. His language and also his more subtle postural and visual challenges make it hard for him to play with peers.

The bigger picture: • Broad goals: Improve his capacity to tolerate and manage his environment, expand his symbolic capacity, and support and expand his parents’ ability to support his development and figure out ways to involve peers. • Multimodal intervention; get parents to more meetings and help them do more Floortime at home; increase intensity and relationship-based quality of services (speech, OT); facilitated group play; support to school staff to help them be more on board; medication management.

• • • • • • • • •

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

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

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

Sample Case 4 FEDL VII-IX • 5th grader • Lots of sensory and motor planning challenges, irritability • School challenges: reluctance to read fiction, difficulty with peers; staff very confident • (Video: playing with mom, multiple levels through some beginning reflective thinking)

Sample Case 5 FEDL I-IX • Non-video case • Heavy school consultation

Sample Case 5 • 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 him hard

Sample Case 5 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 - Sample Case 5 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 vocalization s 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---Sequencin g Execution ----3/08---Adaptatio n ----3/09----

FEDL over time: Sample Case 5 social problem solving, from managing vigilance to stepping back, and then critical thinking Expan Comes Ok if Ok Not Barely Islands the re Coregulate Engage

3/06 3/06

Circles Flow

ds

3/06,

3/06

Symbolic 3/06

3/07

3/07

3/08 3/08

3/08,

3/07, 3/08

Logical

3/06

3/07, 3/08

Multicau sal Grey area

3/06, 3/07

3/08

3/06, 3/07,

3/08,

3/08

3/07 3/07

3/09 3/09 3/09

3/09

3/09 3/09

back

3/09 3/09

not for stres age sed

Marilee Sheet on Math Following his lead: ‘I must do it right’ Circles: statements that build ideas, e.g., ‘I’m not sure what makes this so hard for us.’

Joining: ‘Of course we want to do right’ Setitthe environment: making a space (Like ER or on a date)

Expanding the concept: Broadening Emotional Impossible problems, then sorting themes: from intense reaction to easy, hard, & impossible. stepping back, less intense, curiousity; from perseverative angst to calm perserverance Individual Differences: reactive Working Multiple Levels: to busy environments, poor motor Co-reg: space planning, trouble reading cues, Engage: joining him trouble expressing himself Circles including loud voice, visual figure Flow: working problems together ground difficulties, poor planning, Symbolic: ‘impossible…’ sequencing, execution, and Logic: ‘We can do this’, right = adaptation; perfectionistic and showing what info isn’t needed, reactive. right = showing your work

Reflecting on Sample Case 5 • 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 him

Part V:

Comparing Miller Method® And DIR®/Floortime™

Comparing the Miller Method® with DIR®/Floortime™ - I Philosophy Miller Method®

DIR®/Floortime™

Cognitive-developmental Approach

Affect (emotion) drives all learning and development

Guided exercises designed to heartily coach the child toward more complex thinking and learning. Novel conceptualization, detailed methods for moving forward, and intuitively rational, satisfying, and easy to understand. Generally adult directed, with

Emphasis on co-creating spontaneous, ongoing interactions between parent and child, with many ideas for doing this, and developmental and learning goals ‘folded in’, but no specific tasks nor script except solving socialchild problem Child ledthe – every has of the moment initiative, so use that to begin

movement toward child directed within activities (e.g. giving the child power to have everyone stand or sit)

interactions and co-create interactions with the child

Comparing the Miller Method® with DIR®/Floortime™ - II Principles Miller Method®

DIR®/Floortime™

System Forming = FEDL Level I -1 Developmental – 9 Functional Emotional Developmental Levels; Closed System = FEDL Level I – 2 solving the social problem in the room; assess FEDL clinically and Assess with MDS with FEAS Takes into account the child’s capacities in many areas and how to modify as needed on the elevated square, etc.

Individual Differences – organizing our understanding of the child’s capacities and how they affect our efforts; multiple assessments

Importance of the existence of a bond with the parent, and using that bond to motivate the work, e.g., having a child want the parent to ‘come’

Relationship Based – focused the family, usually relationship between parent and child, as the vehicle for development and learning

Comparing the Miller Method® with DIR®/Floortime™ - III Similar but Distinct Concepts Miller Method®

DIR®/Floortime™

‘Symbolic’ means a gesture word or picture that stands for something else. Answering ‘wh’ questions. Use of small replica of elevated square.

‘Symbolic’ means a gesture word or picture that represents an emotional idea that helps solve a problem. Understanding ‘wh’ questions.

Core deficit in autism is a lack of self-awareness, particularly of one’s body and senses and how one can act in the world.

Core deficit in autism is a disconnect between affect (emotion) and cognition (thinking)

Critical importance of the mother- Absolutely central importance of child bond to drive interactions affective engagement between and learning caregiver and child to drive interactions and learning

Comparing the Miller Method® with DIR®/Floortime™ - IV They Can Look Somewhat Alike Miller Method®

DIR®/Floortime™

Don’t just say ‘good job’, narrate Don’t just say ‘good job’, it closes what he is doing so he can learn the interaction instead of to make sense of what he is doing expanding on it – instead, wonder what happens next ‘Behaviors’ such as rocking, flapping, etc. have causal dynamics and that can be turned into interactive systems

‘Behaviors’ are expressions of the child’s initiative in thinking and acting in the world: join and modify them together

Includes some naturalistic free play in which you gently and persistently test out how to join and modify the child’s play.

Is nearly entirely free play, gently and persistently joining, yet focuses on the emotional connection and affective gestural cuing.

Comparing the Miller Method® with DIR®/Floortime™ - V Practices Miller Method®

DIR®/Floortime™

Features the elevated square, specific objects, games, and procedures Gentle Teasing

Whatever is there, wherever we are

Repair the broken square

Repair in the context of natural play Teaching body awareness

Teaching body awareness through planned physical experiences 3-D to 2-D: to make reading possible because it makes sense Physical guidance, yet allowing a child to safely discover things like holes in the planks

Some playful obstruction

through wooing into interaction 2-D to 3-D: make a book come alive with actions, props, etc. Lots of physical interaction but generally avoiding physical redirection

Comparing the Miller Method® with DIR®/Floortime™ - VI Addressing Some Challenges Miller Method®

DIR®/Floortime™

Tantrums: make it safe, understand it, use controlled action e.g., ‘purposeful kicking’ Separation anxiety: using

Tantrums: soothe, make it safe, understand it with the child, reflect and plan

objects - offering something from home to take to school and from school to take home Toilet Training: detailed system formation, bit by bit, e.g., starting with forming a system around flushing, then expanding to clothes, washing, etc. instims sequence Perseveration/ become interactive systems

Separation anxiety: reflect on the many developmental emotional themes and possibilities and problem solve theresimilar but Toilet from Training: more free flowing and naturalistic, engaging around the body signals, playing with the ideas of elimination with water, play dough, asbecome the are Perseveration/ stims available playful interactions

Comparing the Miller Method® with DIR®/Floortime™ - VII Summary Miller Method®

DIR®/Floortime™

Focus on Expanding Cognitive Complexity

Focus on Expanding Emotional Richness

Precision & Detail: specific ‘3 things’ to remember procedures, individualized and (Feder’s take) and branch specifically planned from there, individualized in the moment, reflecting over time It’s Training, and form is It’s Freestyle, and form is important

important

Miller Method and DIR/Floortime Together:

Sample Case 6

• Challenges in communication and reciprocity • We’ll watch the video • 0:00 – 1:00 • 2:50- 5:15 • 10:55 – 15:00

Miller Method and DIR/FLoortime

AN ANALOGY

Have you seen this movie?

Training for Precision & Detail

Affect – Emotion – ‘Freestyle’

Different, but Complementary Approaches

Capture the Dream

(Part VI) 

Break Time! 15 minutes

Part VII a: DIR® at Home • • • • • • • •

Focused time Attention to the FEDL levels Whenever you are doing anything Going with the child’s idea Expanding on that idea Playing confused Gentle obstruction Working gently but persistently toward more complexity

Marilee Burgeson’s guide to reflective process DIR®Session Notes Child:__________________Play Partner:___________Date:__________ Follow child’s interest:

Join:

___________________ ___________________ ___________________

_________________ _________________ _________________

Open and close circles of communication:

Set the environment:

_________________ _________________ _________________ _________________ Extend:

_________________ _________________ _________________ _________________ Broaden the range of emotion:

_________________ _________________ _________________

_________________ _________________ _________________

Individual Differences:

Mobilize developmental levels:

_________________ _________________ _________________

_________________ _________________ _________________

General Examples • Child wants something – even something perseverative • Gently leveraging that desire • Limits, e.g., bed time – negotiating

Communication • Non-verbal is critical • Wooing vs. prompting eye contact • Not getting caught in verbal interactions that have little real connection

Things to Avoid • Avoid quizzing for facts • Avoid directing games, conversations, and play • Avoid saying ‘No’: every idea is interesting to work with, even if it is impossible to give the child what s/he wants • Avoid merely entertaining the child • Avoid following without joining and shaping an interaction

Avoid Questions! • Top-down, • Child more likely to shut down or tantrum • Doesn’t help the child learn to think • This is hard to do!

Talk about what’s happening • Talk about the situation, ‘here and now’ • Puts the child (other person) just a bit above you, so that the child does the thinking • You play Sancho to the child’s Don Quixote: state the situation and allow the child to come up with the solution.

Part VII b: DIR® at School • What we usually ‘want’: sit and work independently, learn, play well (take turns, share) • Compliance: why do typical kids comply? • Engagement vs. compliance

DIR® in the IEP: • Present levels of co-regulation, engagement, reciprocity • What works, what doesn’t, and why • Individual differences: strengths and challenges • Goals for these • Intervention: whole team focus on engagement, and the rest falls into place • Tracking forms • Reflective feedback!

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 Social peers

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:______________________________________________________    ________________________________________________________________   ________________________________________________________________   ________________________________________________________________

Supporting Engagement at School • Requires co-regulation – what does that look like? • Not ‘sensory breaks’ per se • Engagement: getting the gleam – the connection – with few staff • Circles of interaction: first with adults – same aged peers are toughest • Importance of inclusion (Paula Kluth)

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

Examples at School • • • •

Seat work Playground facilitation – see ahead Social skills groups – see ahead Non-verbal child in class: how to have the child be part of the class? • Highly verbal, rigid thinking, perfectionistic child

Part VIII: Facilitating interactions • First start with well-supported adults • 15-20 minute ‘turns’ for each person’s ideas • Persistence: stay with the person • Every idea is a good idea

Facilitating with Kids • • • •

All of the above and… Semi-structured activities with peers Limiting numbers of kids Mediating the process – often to slow it down • Interpreting intent • Statements more than questions • Democratic decision making

Things a facilitating adult might say… • • • • •

“We need to do something…” “You’re good at that, and I need help with…” “So wait a second – I didn’t hear that rule…” “We need to vote on whether he was out..” “That’s great all you guys want to play too – I have more than I can handle now, but lets plan on having you join us next time if you still want to do it then.” (good idea, bad timing – be sure to make good on your offer next time if they still want to join) • Semi-structured means that at times you will be a bit ‘top-down’, but work toward less of it. • In free play, the thing is to facilitate joining by your joining first in a way that attracts other kids, then facilitate the mix

Part IX: A General Plan for the Management of Difficult Moments *

• • • •

Have a plan ahead of time Adjust the environment Soothe – avoid physical restraint Communicate about it with the child afterward • Anticipate – plan with the child what to do next time • Make time to reflect about it with others *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.

Back to those difficult moments • • • • • •

Aggression – Tantrums Self-Injurious Behavior Self-stimulating behavior Running Off / Safety Transitions Perseveration – Obsessive/Compulsive – Rigid • Compliance • Communication

Aggression - Tantrums •

Have a plan ahead of time

•

Adjust the environment: clear the room if necessary; you need to feel safe – have cushions in between you and child if need be. Have the surrounding area secure so if child ‘runs off’ it’s ok.

•

Soothe – calm voice, not too much additional stimulation, no threats, and avoid physical restraint

•

Talk or play with the child afterward about the incident and what happened – find an emotional, symbolic way to communicate about it

•

Anticipate – plan with the child what to do next time

•

Review your plan with others - think about what works and what else you might try

Brief example: Aggression • • • • • • •

Teenaged boy Non-verbal Big ABA forever A great family friend Fears of dogs Engagement leads to real function

Self-Injurious Behavior • Have a plan ahead of time • Adjust the environment – soft things in between • Soothe – avoid physical restraint if possible • Talk with the child afterward; see if you can sort out together what occurred and how to manage it. Find a metaphor, even the simplest symbolic substitute. Narrating is ok for someone who does not talk. • Anticipate – plan with the child what to do next time • Make time to reflect with others

Brief Example: S.I.B. • 30 year old man – severe clawing at chest • Non-Verbal • Adult • A great live-in aide • Engagement: support and expectations • Form SIB to a real life: cooking, riding, etc.

Self-Stimulating Behavior •

Have a plan ahead of time

•

Adjust the environment: to remove or not to remove the offending thing(s). Probably better to allow it and work with it if possible, otherwise you end up removing everything…

•

Soothe – avoid physical restraint; better to get in the way, joining it, and engaging and changing the interaction

•

Talk with the child afterward: don’t be afraid to talk about the thing that obsesses the child, when the child is calmer and you can expand on the issue.

•

Anticipate – plan with the child what to do next time

•

Time to reflect

Brief Example: Stims • • • • •

A non-verbal 8 year old boy Strings Joining the string thing Time, time, and more time Eventual gleam and non-verbal communication about it

Running Off/ Safety • Have a plan ahead of time • Adjust the environment: set it up so that there is safe room to run off. What about stores? You really do need • Soothe – avoid physical restraint, best to wait for him to return, but it is ok to join the race, and if need be to ‘head ‘em off at the pass’ • Talk with the child afterward; find the metaphor! • Anticipate – plan with the child what to do next time • Reflect…

Brief example: running off • • • • •

Big teen male High Schooler Limited verbal ability Inclusive school Loping after him worked really well, as long as the person was calmly following, and there was a gate where he was running.

Transitions • Have a plan ahead of time • Adjust the environment: plan for more time to transition, WAIT after telling the child (let them finish the page, wait for a commercial, assure you’ll record the show, etc.) • Soothe – ahead of time: ‘I know you don’t like having to go’; allow for lots of negotiation; avoid physical restraint • Talk with the child afterward about what it’s like to shift activities • Anticipate – plan with the child what to do next time • Make time to reflect on what worked and what you might try next time

Brief Example: transitions • • • •

Adult male in his 60’s Minimally verbal Engagement, again Gradual improvement: enjoys camping and day program

Perseveration – Obsessive/Compulsive - Rigid • • •

•

• •

Have a plan ahead of time Adjust the environment: again – to remove or not? Might remove electronics unless you can make them truly real interactions with people right there in real time Soothe – do not get rigid yourself (breathe…); avoid physical restraint; join the activity and make yourself a part of the child’s world as it relates to the activity. Might hoard toys and make him go through you to supply them. Be easy about it at first, but be part of it. Gradually expand the interaction. Keep going for that gleam! Communicate about it with the child afterward, when he isn’t actually perseverating on it. Don’t be afraid – it’s important to talk about these things. You can review it as part of your usual review of the day together. Anticipate – plan with the child what to do next time Make time to reflect about it with others

Brief example: perseveration • 5 year old boy • Light switches and Doors • To couches, to blanket games, to cuddling with mom, to early symbolic play with dad

‘Compliance’ • Have a plan ahead of time • Adjust the environment: if you must command a child to do something, ENGAGE FIRST, and WAIT FOR A RESPONSE • Soothe –co-regulate, engage, and get an interaction cooking; make what you want a part of the interaction; talk about his dislike of the task; avoid physical restraint • Communicate about it with the child afterward – wonder what it was like for him • Anticipate – plan with the child what to do next time • Make time to reflect about it with others

Brief Example: compliance • 3rd grade boy in regular ed – ‘disruptive’ • School expectations • Charisma worked one year, but the next year’s teacher did not have a connection with him • Shift to a school with high support and high expectations, very engaging and physical and regulating

Communication • • •

• •

•

Have a plan ahead of time: do not spontaneously get fed up and demand a response Adjust the environment: what do you need to do to make it possible for the child to process your gestures and vocalizations? Soothe – every child is always doing something: use that initiation as a starting point; ‘follow his lead!’ ; avoid physical restraint (don’t hold his face, don’t command to look at you); non-verbal gesture is much more important than words Communicate about it with the child afterward – really – find a way to communicate about communicating Anticipate – plan with the child what to do next time – what?? – pushing the structure of this model?? – think about it: at night you are tucking in your little non-verbal muffin, and thinking, talk to him about what fun you had today, maybe repeating a gesture or two from what you did, smiling, and talking about doing it again… Make time to reflect about it with others

Example: communication • Sample Case 6!

Limitations and Challenges in implementing a relationship based approach • Not didactic – must give up top-down control • Not manual driven – it’s in the moment, creative, a bottom up approach • Training requires relating: coaching, coachability • Boundaries must be tended • We’re not ‘holding the baby’ – we’re coaching caregivers • Need for reflective process • Not so entrepreneurial – academic transparency hampers marketing • Need for more practitioners

Summary: Why do this? • It is BPS, and BPS is good. • We can change outcomes despite genetics, etc. • Affect is the key to growth and development, and this is affect based. • We need to go beyond behavioral treatments. • Medication can sometimes support treatment but cannot address core deficits nor make up for environment. • There is reason and there is plenty of bench research and budding clinical research to support it.

Our response to all challenges…

“Never give up, never surrender!” - Captain Peter Quincy Taggart Commander, NSEA Protector

ICDL Learning Opportunities • Support Groups For Parents and Professionals –( Burgesen, Feder, et al) – announced on [email protected] and on circlestretch.com. • Online Basic Course – new cycle this spring: icdl.com • Training DVDs • Summer Institute for clinicians and others – intensive one week (2009 year July 8-12 at Asilomar ) – requires Basic Course • Monthy multidisciplinary internet and regional tutoring – ICDL faculty (Feder, others) – pre or post Summer Institute

More ICDL Learning Opportunities • Online PhD Program in Infant Mental and Child Development and Early Intervention – educational degree program (not clinical, but requires a practicum). • Adult Education for Parents and Clinicians - HOPE Infant Family Support Program (Burgesen) – for families enrolled in HOPE’s 0-3 autism program – program on track for ICDL certification. • Streamlined for distribution – The Play Project (Solomon) • Affect Based Language Curriculum - for parents of professionals to use (Lewis)

DIR® Schools • • • •

Celebrate the Children – Wharton, NJ Rebecca School – Manhattan Imagine Academy – Brooklyn, NY The Community School – Atlanta, GA

Resources • Becoming More Matthew in The Autism File, January 2009 • Circlestretch.blogspot.org – incl lots of forms and more detailed ppts • ICDL.com – information and local and regional training, free downloads and podcasts

X: Your Questions:

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