Staff dir training by Circlestretch

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

Connecting kids: An Introduction to DIR/Floortime速 Joshua D. Feder M.D. Faculty, Interdisciplinary Council on Developmental and Learning Disorders Assistant Clinical Professor, Department of Psychiatry University of California at San Diego School of Medicine September 17, 2008 Solana Santa Fe Elementary School

Warning: this will go fast â&#x20AC;˘ All the slides will be posted on www.circlestretch.blogspot.com

Taking Notes? • One word:

ENGAGEMENT

• One phrase: Engagement goes beyond compliance.

Definition of 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.

WE USE EMOTIONAL CONNECTION TO FOSTER DEVELOPMENT WE TAKE INTO ACCOUNT THE PERSONâ&#x20AC;&#x2122;S INDIVIDUAL ABILITIES AND CHALLENGES 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: virtually any behavior can be changed. It’s true. Believe it. It works. No doubt. • So what is this all about? Relationship based.. What does that mean?

Quick review of levels and goals • The Social-Emotional growth Curve (now part of the Bayley Scales) • Dual Coding of emotion and cognition • 0-3: babies & toddlers, back and forth signaling • Responses to stress: acting out, some signaling, black and white, vs. integrated • Practical application: calm – same page – true back and forth

DIR速 Functional Emotional Developmental Levels (FEDL) I- Shared Attn and Regulation (0-3 months): The first relationship, experiencing empathy for the first time II- Engagement and Relating (2-6 monoths): Depth of the relationship and variety of emotional signally is important III- Two-Way Purposeful Communication (4-9 months): Reading and responding to emotional signals at 8-9 months Sense them and feel them in the body, physically

FEDL IV – Shared Social Problem Solving (9-18 mo) • Negotiating problems – 18 mo • Beginning of cooperative, collaborative interaction – 18 mo • Shared humor between toddlers at 18 mo • Behavioral evidence of altruism: pat mommy’s arm (may be imitation at this point), also around 18 mo

FEDL V – Creating ideas (18-30 mo) • Shared pretend play at a symbolic level • Shared world of emotions – joy, anger, sadness, etc. • Child not only feels empathically but can think empathically.

More FEDL Levels: VI - Building Bridges Between Ideas: Logical Thinking (30-48 months) • Cause and effect: asks why you feel that way • Can separate his internal world from your world, and still feel concerned VII - Multi-Cause Comparative Thinking (4-6 yr) • Mom’s mad, bad day at work, but asks if there are other reasons.

FEDL VIII - Emotionally Differentiated Gray-Area Thinking

(6-10 yr)

• 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. • Hierarchies, playground politics • Refining the gradations of these emotions • This expanded and deepened appreciation for emotional experience makes us more able to appreciate it in others.

FEDL IX - Intermittent Reflective Thinking, A Stable Sense of Self, and an Internal Standard (9-12 yr and beyond) • Really adolescence and beyond… • the ability to empathize in a truly reflective manner • able to understand a range of feeling in others and compare it to your stable sense of self, retaining who you are • helps you to be truly a great friend or partner. • Reflecting on yourself and others w/o taking over nor removing yourself • Expanding sense of empathy, more and more inclusive: other kids, groups, school, country, … the world (other races, religions, etc.).

Basic Concepts • Dual coding of affect and learning – you don’t really learn and adapt if don’t care about something or someone. ‘Buy in’ is critical to learning, problem solving, and development. • Co-regulation and counterbalanced regulation – helping each other be calm enough to engage. • Engagement – warm relating, which goes beyond joint attention. • Circles of interaction – building on emotional gestural interactions in a continuous flow of relating • Functional Emotional Developmental Levels

What does this have to do with behavioral treatments for ASDs? • Behavioral programs help a person engage in appropriate behaviors, leave aside inappropriate ones, and learn about the world and what to do in the world to live, work, play, and survive. ‘This is a top down approach’. • Relationship based interventions help a person connect with others in a way that promotes social and cognitive development and problem solving with flexible adaptation to a changing world. This is a ‘bottom up’ approach.

Rough Comparison of DIR vs. other approaches: DTT/ABA

Prompts

Compliance

Do/learn what is expected from trainer

Top-down autocratic

PRT

Prompts

Compliance

Choices – trainer, then parent

Top-down, yet democratic

DIR

Woo

Engage

Build shared Bottom–up, meaning – democratic parent focused

RDI

Prompt

Compliance

Do what’s expected – trainer, then parent

Top-down, autocratic

Prompt vs. Woo: Prompt

Woo

Greater power difference between people

Humility â&#x20AC;&#x201C; more equality

Control

Respect for ideas of other person

Specific expectation

Open ended, hopeful for growth

Belief in the material

Belief in the process

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 selfassurance 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

DIR/Floortime® vs. Other interventions:

• Broadest of all possible models (Biopsychosocial) • Family characteristics • Individual differences • Developmental

Comparing the DIR速 Developmental Individualized Relationship-based approach with RDI Relationship Development Intervention

They Really are Different

Why spend precious time on this? • • • •

RDI is everywhere Name confusion Claims of ‘it’s pretty much the same thing’ This situation helps us clarify our priorities and imperatives

RDI Makes Guarantees • “He will make true friends who genuinely appreciate him.” • “He will be more creative.” • “He will think in terms of “grey” areas and not just ‘right and wrong, black and white’ terms.”

DIR® Wants the same things… • But we do not guarantee results. • We are confident that we have an effective, critically important approach • We recognize the ethical and realistic inability to predict the future for any fellow individual.

Instrumental Communication vs. Experience Sharing, and the Subtle Differences Between RDI and DIR® Instrumental Communication

Experience Sharing

How was your day?

Wow! That was a huge spider!

What color is this?

Uh-oh.

How are you?

Oh darn, I forgot something.

Say “thank you”.

We can do it together!

Brush your teeth.

Look out!

Pick up your clothes off the floor.

I’m hungry from all that playing.

Look at me.

Vacation will be so much fun!

Improving Experience Sharing in RDI • • • • • • • • •

Use fewer words Use more non-verbal communication Use more declaratives Less frank prompting, let the other person take more initiative Slow it down, allow the other person more time to process Work on a wide range of emotions and intensities Expect breaks and repairs in communication Be in the moment – communicate about that Dynamic analysis – think about what you are communicating about (differs from DIR®)

Experience Sharing vs. DIR®/Floortime • • • •

We emphasize these things We think about thinking The difference is in how we do it. We want a natural flow, so we do things that support the emergence of this without the other person needing to explicitly think about it

Language Used for Celebration in RDI • • • • •

“Good work.” “We did it!” “That’s funny!” “That’s silly!” We discourage canned phrases in DIR® because they close down communication rather than lead to further elaboration. We also avoid repetitive phrases that might become scripted and unnatural sounding.

Adding Variations to Activities in RDI • “…placing a meaningless word in the midst of a sentence.” • “…taking off your shoe and putting it on your head.” • “fast paced action”, prescribed, fragmented, presented in isolation, and out of context.

Variation in DIR® • We strive for meaning and intent, making the interaction more rich and complex. • We get a flow going before we make big changes, but we do everything a little differently every time to prevent rigid patterns from forming. • We know that some children will copy bizarre things that adults do, making them seem more odd to their peers, so while we use drama and maybe goofy slapstick but we avoid choppy or odd variations.

RDI tasks: “Hot Potato” as an assignment. • Specific materials and activities, done exactly as prescribed. E.g., two ball roll with 2 specific kinds of balls, 2 carpet squares, and 2 taped lines. • DIR® promotes creative use of whatever we have handy. Games spring from the interaction with the child as brand new shared creations. • The difference is like standardized I.Q. testing vs. doing an Functional Emotional Assessment Scale (FEAS): conforming to expectations for ‘success’ vs. the FEAS promoting the best chance to show what the person can do in communicating, relating and other developmental capacities.

RDI’s Detailed Catalog of Tasks • Hundreds of ideas, many of them excellent in their use of developmentally appropriate concepts. • Yet presented in a rigorous, top-down fashion that lies in sharp contract to the DIR® approach. • E.g. “Talk without words” is presented as a highly structured exercise vs. a great thing to do spontaneously when trying to work on non-verbal affective communication.

Recap of Comparison of DIR®with behavioral approaches

• Goals of a behavioral programs: appropriate behaviors, learning facts, learning ‘what to do’ in a top-down approach. • 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. • RDI is a behavioral program whose aim is to create the ability to have relationships by training the child in ‘what to do’ with methods that do not reflect natural relating.

RDI - Tight Control â&#x20AC;&#x153;It makes no sense to allow a person who is severely impaired and learning disabled to be in the lead with you the more expert guide following.â&#x20AC;?

DIR® - Serena Wieder “When a child is not led into the drama or told what to do, and is free to develop his or her own ideas, the child will project his or her subjective experiences, wishes, and concerns in play.”

RDI Training… • Web lectures, books, video review, etc. to learn the concepts and apply them. Relatively rapid process. • Mindful Regulation: cycle of observation, evaluation, and adjustment • Mindful Turn-taking: let each partner process, co-creating the interaction • Slower Processing: applied consciously to allow for ‘dynamic learning’

DIR® Training • A reflective and developmental growth process together with families and colleagues • Taught by a confederation of professionals from multiple disciplines and academia, donating much of their time, working with families, conducting research, writing, gathering at conferences and institutes, and looking at each others’ work. • Certification takes many years for professionals. Supervision and tutoring occur at all levels, from people starting out to the most senior faculty.

I still don’t know what you mean… What is Relationship Based Intervention? Go For That Gleam… • Don’t worry, it takes time to sink in.

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

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).

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

Things to Avoid • Don’t merely entertain, quiz, or direct the child with your games, demands, or ideas • Don’t merely follow the child around without becoming part of the child’s world – use the child ‘lead’ to start off • Every idea the child has is probably a good one to play with – instead of saying ‘no’, get into the idea with the child, even if you will need to set a limit about it. The purpose is to connect and then together you can do the social emotional problem solving, which might include planning for later, expressing wishes and emotion, and recognizing wishes that might not come true.

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.

FLOW • The fourth ‘level’ in the social-emotional 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

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 rashing 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)

The Seven Sins and Virtues in Human Motivation Lust

Self control

Pride

Humility

Greed

Generosity

Envy

Love

Anger

Kindness

Sloth

Zeal

Gluttony

Faith and Temperance

What about other kids? • • • • • • •

Facilitating interaction – first with adults Skill development – wooing better skills Semi-structured activities with peers Limiting numbers of kids Mediating the process – often to slow it down 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

Tracking and Monitoring • FEAS – usually done with infants and young children in evaluation • FEDL – good to do initially and then periodically, say every few months, for anyone at any age • Marilee Burgeson’s Sheet – when reflecting on a particular session, class period, recess period, etc. • School Data Sheet – good for regular monitoring, e.g., every week or two

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:

_________________ _________________ _________________

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:______________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

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

ICDL Training Opportunities • Local Monthly Support Groups For Parents and Professionals –( Burgesen, Feder, et al) – announced on ValeriesList@aol.com and on circlestretch.blogspot.com. • Online Basic Course – cycle recently concluded • Training DVDs • Summer Institute – intensive one week (2009 year July 8-12 at Asilomar ) – requires Basic Course • Monthy multidisciplinary face to face and regional tutoring – ICDL faculty (Feder, others) – pre or post Summer Institute

More ICDL Training 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. • School Models –Celebrate The Children (Osgood) • Streamlined for distribution – The Play Project (Solomon) • Affect Based Language Curriculum - for parents of professionals to use (Lewis) • Others: Colorado – Denver Model (not ICDL)

Who Is Doing Research Like This? • Greenspan, Wieder, et al: The Interdisciplinary Council on Developmental and Learning Disorders (ICDL) - DIR®/Floortime • Rogers, et al: University of Colorado - The Denver Model • Stiben, et al: York University - functional imaging research • Emde, (Harmon): National Zero to Three • Many behavioral programs are moving toward a more naturalistic approach.

Coming Along for the Ride… • AACAP: annual Zero to Three training, 2006 annual meeting • AAP - Pediatrics 121;828-830;2008 L. Bauman ,et al Guidelines for Early Identification, Screening, and Clinical Management of Children With Autism Spectrum Disorders • National Academy of Sciences “Educating Children with Autism”, 2001 • Rady… • BRIDGE Collaborative • Lobbying – like anything in health care…

Research in Support of Relationship Based Interventions For ASDs Continuing Clinical Reports of Effective Intervention using Relationship Based Intervention

• ICDL journal – see www.icdl.com • Regular written case studies from clinicians in various fields (psychology, speech, OT, education, medicine, etc.)

Research in Support of Relationship Based Interventions For ASDs John Stieben – York U. – Functional Imaging Studies • dense-array EEG appear as functional MRI images • post-treated ASD kids look similar to age-matched typically developing children in PFC (prefrontal cortex) and dorsal ACC (anterior cingulate cortex) function (i.e., executive function) • N170 ERP component was indistinguishable from controls so they have no fusiform (and related network) deficits • Successfully treated ASD group resembled high anxious individuals as they had heightened activation in the ventral or subgenual ACC (residual awkwardness)

Assessing Behavioral and Neurophysiological Outcomes of Intensive DIR Intervention for Children with Autism Lead Investigators: Devin M. Casenhiser, Jim Stieben & Stuart G. Shanker The Milton & Ethel Harris Research Initiative Therapists: Amanda Binns, Narmilee Dhayanandhan & Nadia Noble Principal Clinical Advisors: Stanley Greenspan & Jake Greenspan with contributions from Yael Binya, Tim Bleeker and Cindy Harrison

ABSTRACT

Other Measures

TIMELINE

TITLE: Assessing behavioral and neurological outcomes of intensive DIR intervention for children with autism.

Parents will log hours spent providing DIR to their child each week.

The therapy phase of this study began October 30th, 2006. November 2006

November 2007

November 2008

November 2009

Concurrent histories are taken every 6 months to document supplemental treatments children might be receiving

BACKGROUND:

To investigate the intervention at both the psychological and the neurophysiological level in an effort to document the effectiveness of DIR. METHOD: Participants: 50 children aged 2;1-5;2 with a diagnosis of an autistic spectrum disorder confirmed by ADOS and ADI-R criteria. 25 typically developing children who serve as a control group for the neurophysiological data (The typcially developing group receive assessments as with the treatment groups, but do not receive treatment). Procedure: The participants were assessed to confirm a diagnosis of an autistic spectrum disorder using ADOS and ADI-R. They were subsequently assessed for cognitive functioning and assigned to one of two groups using a random blocking procedure based on age and cognitive functioning. One group was randomly selected as the immediate treatment group. The other group was selected as the 12-month delayed treatment group. Both groups will receive a total of 24 months of DIR therapy. Groups did not differ statistically in terms of age or cognitive functioning at the time of the first round of assessments.

t ne mt aer T et ai de mm I

OBJECTIVE:

Therapy begins for Immediate Treatment Group

Pre-Treatment Assessments

t ne mt aer T dey al e D

Although ABA (Applied Behavior Analysis) models are the best studied and most popular forms of treatment for Autism, the DIR model (Developmental Individual-Difference, Relationship-Based Model is fast gaining popularity. While there is promising descriptive evidence for the success of DIR intervention, there remains a lack of controlled scientific studies to evaluate its efficacy. Furthermore, there has been no systematic attempt to determine whether interventions can have an impact on neurobiological functioning.

Bayley-III

0-42

WPPSI/WISC (preferred)

2;6-7;3

Diagnostic

Training of therapists, supervision and/or consultation is being provided by Stanley Greenspan, Jake Greenspan, Tim Bleeker, Cindy Harrison and Yael Binya.

Sensory

Although the program focuses on the child, therapists endeavor to treat the whole family in keeping with the DIR philosophy. Families with difficulties beyond the scope or skills of the therapists are referred for external services as needed (e.g., social worker).

ASSESSMENTS

Cognitive

The treatment program follows the method and techniques of DIR as set forth in The Child with Special Needs, Engaging Autism, the ICDL Diagnostic Manual for Infancy and Early Childhood and the DIR Floortime Techniques training videos.

Families meet each week for 2-3 hours with DIR therapists (certified SLPs and OTs) for ongoing coaching/ instruction, evaluation of progress and setting goals. Participants receive 1 Floortime session, 1 speech-language session (as needed), and 1 OT session (as needed) each week.

We are conducting electrophysiological (ERP) assessments of face, emotion and eye-gaze encoding processes to look for treatment related changes in the brain. ERP components associated with face perception, emotion encoding and intentional eye-gaze behavior are known to be aberrant in children with autism. We expect to identify changes in both amplitude and latency of these face specific ERP components in children who successfully respond to treatment.

Therapy begins for Delayed Treatment Group

Age-Range

Social Emotional Functioning

Face, Emotion Gaze Task

36-Month Assessments

Measure

Functional Skills

In keeping with the original model, primary caregivers are expect to conduct 20-30 hours of Floortime at home.

ELECTROPHYSIOLOGICAL ASSESSMENTS 24-Month Assessments

Variable

Language

TREATMENT PROGRAM

12-Month Assessments

Pre-School Language Inventory

0-6;11

CASL (preferred)

3;0-26 years

Vineland

0-18 years

TABS

(used as process measure)

SEGC (Bayley subscale)

(used as process measure)

FEAS

(used as process measure)

ADOS

2 – adult

ADI

2 – adult

Sensory Profile

Early Social (used as process Communication measure) Scales Electrophysiological assessments are administered every 6 months. Electrophysiology EEG/ERP All other assessments are administered at

We are also investigating the effects of treatment on Mu wave suppression during an action-observation task. Mu rhythms are believed to be related to “mirror neuron” systems which are known to be aberrant in children and adults with autism and may underlie theory of mind deficits in this population. Although exploratory, we expect to find increased Mu rhythm suppression during observation of action in our children who respond favorably to treatment.

N170 Face Specific ERP Component

PRIMARY ANALYSES

EEG assessments are being carried out using a dense-array (128 electrode) recording system (Electrical Geodesics Incorporated). Eyetracking is monitored through a Tobii X-50 eye-tracking system fully integrated into the EEG recording data stream.

In November 2007, we will compare the immediate treatment and delayed treatment groups to determine whether DIR intervention had a significant effect on any of the measures (assessments) we are recording.

Children are provided with a 3 to 4 week training program to acclimate to the EEG nets and the testing format. Each family is provided with several “mock” EEG nets and are being trained to practice with net application procedures once per day prior to being tested in the lab. Children are also given a “mock” version of the tasks (using animations) to help acclimate to the testing environment.

Following 24 months of treatment, we will determine the magnitude of the gains made by children receiving intensive DIR intervention. Analyses will be conducted between the parent treatment logs (which log the number of hours spent in treatment each week) and child outcomes to determine the strength of the correlation between the number of hours spent in treatment and a child’s outcomes. Certain children may respond better to DIR treatment than others. Accordingly, a cluster analysis will be conducted to determine whether it is possible to establish a profile that might suggest how successful DIR intervention will be for a child matching that profile.

Social Reciprocity

Assessment Schedule

pre-treatment following 12 months of treatment

This research is made possible in part by a generous gift from Unicorn Foundation

following 24 months of treatment. The delayed treatment group receives one additional assessment 12-months prior to starting their treatment.

For additional information please contact: Devin Casenhiser (dcasenhi@yorku.ca) or Jim Stieben (jstieben@yorku.ca) The Milton & Ethel Harris Research Initiative York University

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.

Resources • Rady guide – meds and DIR • Circlestretch.blogspot.org • ICDL.com – information and local and regional training • Local Support Groups – free monthly support groups