DIR速 in the Schools Addressing Difficult Moments by Creating Enduring Relationships
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 summer institute NIMH/ Duke University – minimal – administrative time for pharmacogenetic research
Thank you • Cheryl Zak • Art Aragon • Alice Prince
Warning: this will go fast
All the slides will be posted on www.circlestretch.blogspot.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.blogspot.com
Outline • Quick review of DIR®, FEDL • Aggression • Other daily problems
Taking Notes? • One word:
ENGAGEMENT
• One phrase: Engagement goes beyond compliance.
I - Review
DIR速/Floortime Developmental Individual Differences Relationship Based Intervention:
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.
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
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
Sample FEDL 1 (not there)
2 (barely)
3 (islands)
4 (ok w/ support)
5 (comes back)
Regulate
11/05
11/06
11/07
11/08
Engage
11/05
11/06
11/07
11/08
Circles
11/05, 11/06
11/07
11/08
Flow
11/05
11/06, 11/07
11/08
Symbols
11/05
11/06, 11/07
11/08
Logic
11/05, 11/06
11/07, 11/08
6 (ok unless stress)
7 (ok)
FEDL - descriptions 11/05
– rigid, aggressive, hits in ‘play’, not really symbolic
11/06
- allows me to join his aggressive play on his team
11/07
– increased complexity of aggressive themes; able to play with cousin and brother in water fights, facilitated by dad
11/08
– racing ‘battle’, controlling, but can be torn between 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
Individual Differences - Sample Sensor y
Postural
Response to Communication
Intent to Communicat e
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 3. key gestures 4. key words 5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s 8.abstract conversation.
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 Planning Sequencing Execution Adaptation
What we do – in a nutshell
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
II - Aggression • • • •
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…
Models to Understand Problems • Zeno’s Paradox (the arrow) • Calculus 2000 years later…. • RESCU Academy’s ability to manage kids with aggression and return them to less restrictive environments • DIR® as a way to understand the process at RESCU
RESCU ACADEMY – rough stats and description • Last chance place before residential or ‘step-down’ form residential treatment • 100% came b/c ‘behavioral problems’: out of control, failure to progress academically, socially • Grades 3-12+ (began w/HS, then MS, now ES) • 50% ASD – ‘HFA/AS’; 50% mixed (drugs, bipolar, etc. – ‘no sociopaths’ but ASD issues cloud this) • 50% are extremely intelligent • Most have significant learning challenges
RESCU Academy – outcomes • • • • • •
Reduction of Aggression at School and Home Improved Academic Achievement Improved Social Function – Friends! Reduction of Medication Better physical conditioning/ regulation More than 95% settle down, most return to public or mainstream private school settings after about 2-3 years
Why? – What they would say: • • • •
12 Step Model – developmentally modified Family Involvement Structure Not quite consistent with ASD population that did not respond to highly structured behavioral approaches, often with family clinics and training (school, SDRC, etc.).
Why? What I am finding: • • • • •
Co-regulation Engagement – with Wraparound Flow High Support with High Expectations Follows the ‘plan’
What Plan?
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
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
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 co-regulate and gradually expand his capacity to register, tolerate and process sensory information
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
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
4. Talk • Or play • Communicating about what happened • Avoid questions, but try to understand
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.
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
Not Just Teaching Compliance • 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 support a child to think, and to play • You can build connection with a child, and the child will withstand the environment better • 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
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.”
Behavioral interventions complement relationship-based DIR/Floortime®:
Behavioral based contributes…
Relationship-based expands…
Imitation
Autonomous thinking
Limits
Negotiation
Facts
Exploration
So How Does RESCU follow this plan? • • • • •
Making a plan: constantly, and family groups Setting the environment: Soothing? Talking - daily Anticipating - daily
RESCU Culture: Emotional Holding Environment for child and family • • • •
Unflappable staff 24/7 availability Daily group + individual sessions as needed Weekly family group + single family sessions as needed
RESCU Culture – the details • ‘bigger than you’; willing to come and get you from
home; cooperation with police when needed makes actual use rare • willing to use the group to influence others through mentoring and through group consequences that can include the families • other kids and parents have been through it and model and report that to new students and families
Soothing? • Everyone fears and grows to loves the staff • In the moment, there might be a takedown for safety; mostly they give space, use physical activity, gauged on the individual’s profile • After the moment, there are consequences • But the process of justice is slow, group mediated, and discussion continues about the circumstances, reactions, and impact on others
‘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.
Is RESCU doing DIR®? • No: not certified, no FEDL, indiv diffs • Yes: in broad strokes – follows the ‘plan’ • Practicalities: we do what works in the end
Case Example: N • • • •
11 y/o Restraint junkie Multiple LD’s Aggressive at multiple placements, public and private
FEDL-N 1 (not there) Regulate
2 (barely)
3 (islands)
4 (ok w/ support)
T-0
5 (comes back)
T-4
Engage
T-0
T-4
Circles
T-0
T-4
Flow
T-0
Symbolic
T-0
T-4 T-4
Logic
T-0
T-4
Multicausal
T-0
T-4
Grey area
T-0
T-4
Reflective
T-0
T-4
6 (ok unless stress)
7 (ok)
N – 4 Years later • • • • • •
Aggression slowly abates as relationships grow Academics improve for first time in years Essays Math is still hard Fewer meds Parent more able to manage regular school
Case Example - K • Aggressive at home to mom, sporadically at school • School feels it can handle him b/c not so frequent • Family in danger, injures children in community • Bright student
FEDL - K 1 (not there)
2 (barely)
Regulate
3 (islands)
4 (ok w/ support)
5 (comes back)
T-0
Engage
T-0
T- 18 m
Circles
T-0
T- 18 m
Flow
T-0
T- 18 m
Symbolic
T-0
T- 18 m
Logic
T-0
Multicausal
T-0
Grey area
T-0
T-18m
Reflective
T-0
T-18m
T- 18 m T- 18 m
6 (ok unless stress) T- 18 m
7 (ok)
K - Outcome • • • • •
Not aggressive Continued Academic Achievement Fewer meds Socialization outside improved – team sports Parenting more consistently supportive of development
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
What about other schools? • DIR schools – Imagine, Rebecca, Celebrate the Children, The Community School • Local Public Schools – Steele Canyon, Canyon Crest, East Lake HS • Range of kids’ challenges is greater (i.e. more heavily challenged kids vis a vis language and learning)
III - 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
A Model for Providing DIR in Public Schools • • • • • •
school consult model: tail wags dog develop allies in the staff 3 seminars/observations regular contact tracking forms IEP Goals
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
Allies • understand • learn • model for others
Seminars/ Observations • • • • • • •
Chalk talks with staff Present the plan Discuss concepts Discuss progress and challenges Observe in class Observe on playground Side bars with staff
3 big visits • The plan and concepts • Review and progress/ challenges • More review, progress/ challenges and preliminary planning for next year
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
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: _______
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:______________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
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.
Sample Case • Third grade child with ASD • Poor regulation, loud voice • Perfectionistic
Solving in-class problems at various levels: CoRegulation • 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…
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
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 • Problem: not bringing in his own ideas; sits and says he doesn't know what to • Approach: using statements - works well in getting him to express himself, better feedback when she uses statements • Result: writing independently, w/ a writer's voice, more than he has to - HUGE, HUGE, HUGE!; part is 'I thought to myself...' - thinking about thinking -
Solving in-class problems at various levels: Flow • Progress on the playground • friends asking him to play: ’Come play with us!’ • Coaching, OT/ APE effort paying off - how to run, how to look up, etc. • 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
Critical Benefits of Symbolic Thinking • Expand his thinking so that he are not stuck in the black and white, all or nothing world • compare w/ others so he knows he isn’t doing badly • 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) –
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
Research Support for DIR • GxE: genetics and environment • Infant Mental Health/ Developmental Literature • Math • Imaging studies • Play Project • Case studies
DIR Schools • Imagine – Brooklyn, NY - 16 students, extremely challenged children • Rebecca School – Manhattan, NY – wide range, 80 students • Celebrate the Children – Dover, NJ – 10 years+, 120 students, wide range, PS – 12 • The Community School – Atlanta, GA - HFA
DIR Programs • Hope Infant - San Marcos, CA – DIR based awaiting certification • Smart Start – Santa Monica, CA • Center For the Developing Mind – Los Angeles, CA • Pasadena Child Development Associates – Pasadena, CA
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
References • • • •
Greenspan – that talk Greenspan – Child with Special Needs Celebrate the Children Great Lectures - Calculus