E. A Model Case Using DIR速
AFECT SAN DIEGO, CALIFORNIA JULY 1, 2009
Joshua D Feder MD DFAPA
Assistant Clinical Professor, Dept of Psychiatry, University of California at San Diego School of Medicine Faculty, Interdisciplinary Council on Developmental and Learning Disorders
Disclosures
ICDL Faculty – minimal - review of clinical write ups, travel and room for meetings, token honorarium for co-writing and running Southern California Institute NIMH/ Duke University – minimal – administrative time for pharmacogenetic research NIH R21 grant/ San Diego BRIDGE Collaborative – minimal – token honorarium for ongoing consultation and participation
Warning: this might go fast
All the slides will be posted on www.circlestretch.com
Taking Notes?
One word:
ENGAGEMENT
One phrase: Engagement goes beyond compliance.
circlestretch Help the child be… • Calm enough to interact • Truly connected to others • In a continuous expanding balanced back and forth flow of interaction “Go for that gleam in the eye!” http://www.circlestretch.com
Analogies Music Math Mental
Music
‘Here in Texas we have both kinds of music’
Math Statistics and Linear Newtonian Mechanics Vs Calculus, non-linear discontinuities, and solving problems in alternative dimensions
Mental Life Educational Psychology / Learning Theory (behavioral tradition) Vs Child Development / Infant Mental Health
So what? Why care?
Some problems can’t be solved with one idea, and we need other ideas to try out.
Comparing and Contrasting Approaches Your supportive style of ABA Our DIR® approach Helping her in different ways They may be converging
E.
Look who’s (sort of) talking now
You know her…. School aged child Extremely rigid and perseverative Aggressive at School You guys did a great thing with her!
About 18 months ago… She decided not to talk Therefore, everyone tried to GET her to talk Which she naturally resisted….
Fallout Social function at school deteriorated Aggressive episodes became common Lost her placement
AFECT to the rescue And a great special education coordinator Who engineered a better placement Effective ingredient? Maybe your empathic child-
oriented approach
The data improves But she still isn’t talking Med trial – helpful, but no movement here
DIRÂŽ Approach ď‚— Taking her lead further, working with it, and leading
to partial resolution of the whispering problem.
Video
Engagement vs Compliance
Compliance vs. Engagement Compliance
Engagement
Do/think what I want you to do/think
Think for yourself and with me
Drills will create skills
Shared emotional signaling creates a relationship that inspires learning and problem solving
Schemes to cover new situations
Relationships, available and internalized, give self-assurance to respond to new situations
Limited sense of competence, self-esteem: “I can do it. I learned how.”
More full sense of competence, self-esteem: “I can figure it out.”
They can work together
Behavioral based contributes‌
Relationship-based expands‌
Imitation
Autonomous thinking
Limits
Negotiation
Facts
Exploration
Prompt vs. Woo: Prompt
Woo
Greater power difference between people Control
Humility – more equality
Specific expectation
Open ended, hopeful for growth
Belief in the material
Belief in the process
Respect for ideas of other person
In other words… WE USE EMOTIONAL CONNECTION TO FOSTER DEVELOPMENT WE TAKE INTO ACCOUNT THE PERSON’S INDIVIDUAL ABILITIES AND CHALLENGES WE WORK WITH FAMLY AND OTHERS TO MAKE THIS HAPPEN ALL THE TIME
circlestretch Help the child be… • Calm enough to interact • Truly connected to others • In a continuous expanding balanced back and forth flow of interaction “Go for that gleam in the eye!” http://www.circlestretch.com
Tracking Do we agree more on what co-regulation looks like? Engagement? Reciprocity?
Data Tracking Sheet Date: _____________
In Class am
Time: _________
Co-Regulation Is he calm enough and settled to attend to an interaction? Are you ‘tuning in’ to near where he is emotionally to help him join in? Examples of not regulated:stretching, distracted, staring off, eyes not on the group/activity, over/underactive for the situation
Engagement Gleam in the eye? Is he “on the same page” , paying attention to the same thing the “group” is? -eye gaze to peers and eye gaze to activity/items that the group is interacting with…visually and/or verbally 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: _______
IEP Goal – Regulation Baseline: Child is calm and focused __% of the time during any given 15 minute observation in class (“C”), __% during unstructured activities such as recess and lunch (“US”). October 2009 Goal: __% C/ __% US. March 2010 Goal: __% C/ __% US June 2010 Goal: __% C/ __% US Responsible persons: teacher, staff, OT Suggested interventions and accommodations: OT consultation monthly, sensory diet and strategies for home and school, staff facilitation of interactions with peers including during unstructured times.
IEP Goal - Engagement Baseline: Child is on the ‘same page’ as others about __% of the time during a given 15 minute observation in class (“C”) and about __% of the time during unstructured time (“US”). October 2009 Goal: __% C/ __% US March 2010 Goal: __% C/ __% US June 2010 Goal: __% C/ __% US Responsible persons: teacher, staff, counselor (DIS) Suggested interventions and accommodations: facilitation of interactions in class and at lunch (less emphasis on formal social skills groups)
IEP Goal – Circles, reciprocity Baseline: child tends to focus in his own ideas in play and conversations, and engages in actual mutual building of ideas about __% of the time during any given 15 minute period while in class (“C”) and __% during unstructured time (“US”). This can be assessed by examining a 15 minute sample of conversation and scoring the percentage of times that child’s initiation or responses take into account and/ or respond to other people present. Tape recordings or videotape may be needed to best assess this, although it can be done by observation as well. I am happy of assist in the training of persons to do this. October 2009 Goal: __% C/ __% US. March 2010 Goal: __% C/ __% US June 2010 Goal: __% C/ __% US Responsible persons: teacher, staff, counselor (DIS). Suggested accommodations and interventions: staff facilitation in class, at lunch, and on the playground.
Framing the entire intervention
ď‚— Organize the goals under:
co-regulation, engagement, and reciprocity ď‚— Get everyone pulling in the same direction
Research Child development Infant Mental Health Brain theory (back to calculus) Functional Brain Imaging
Common Ground: Converging Research
Joint Attention Studies Eye tracking Mirror neurons
Learn More Grow or die We’re around…. Pay it forward
Summary The road toward better function is indirect, but fun This approach is for anyone, because it was designed
to be biopsychosocial E still has far to go
THE SOUTHERN CALIFORNIA DIR®/FLOORTIME™ REGIONAL INSTITUTE PASADENA, CALIFORNIA BEGINS OCTOBER, 2009 JOSH FEDER, MD DIANE CULLINANE, MD JDFEDER@POL.NET DIANE@PASADENACHILDDEVELOPMENT.ORG MONA DELAHOOKE, PHD PAT MARQUART, MFT MDELAHOOKE@SOCAL.RR.COM PATMARQUART@AOL.COM