Ucsd grand rounds

BEYOND MEDICATION AND BEHAVIORAL THERAPY:

THE CASE FOR USING A RELATIONSHIP - BASED FRAMEWORK FOR THE TREATMENT OF PERSONS WITH AUTISM SPECTRUM DISORDERS

Joshua D. Feder, M.D., DFAPA Assistant Clinical Professor, Dept of Psychiatry, UCSD School of Medicine, Faculty, Interdisciplinary Council on Developmental and Learning Disorders

Disclosures • ICDL Faculty – minimal - review of clinical write ups, travel for week of volunteer work • NIMH/ Duke University – minimal – for time spent in pharmacogenetic research activities

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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 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 1993-present; 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; dx½ 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, reading, care of chronically ill house pets…

Objectives • Context in genetics and environment (GxE) research.

• Importance of affective connection and modulation in intervention with autism spectrum disorders (ASDs) and all development and learning disorders.

• Basic concepts in a (biopsychosocial) individualized developmental relationship based approach to ASDs. • The role and limits of medication in intervention.

• Comparison with behavioral approaches • Have one clear bottom line to take away.

• Resources and references.

Assumptions • You are familiar with recent DSM conceptualizations of Autism.

• You have a passing familiarity with the child development literature • You are familiar with the basics of behavioral theory and treatments.

• You are familiar with the typical medication treatments used to treat target symptoms in mental health (and therefore in ASDs)

Warnings • This will go fast • All the slides will be posted on www.circlestretch.blogspot.com • None of my own videos today – confidentiality issues –but they are available through ICDL for training purposes.

Taking Notes?

• One word:

ENGAGEMENT

• One phrase: Engagement goes beyond compliance.

Quick Definition: • 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.

Concise History:

Autism is…

• • • • •

Kanner DSM III G.A.P. and 0-3 Genetics and brain structure Environmental influences

Kanner • • • • •

Just like what we often see today What makes it happen?

Mom and dad are too cold?

What do we do?

Analysis: what the child does has meaning, and if we can figure it out, maybe we can help

DSM III • • • • •

Just like what we often see today What makes it happen?

Behaviors = problems What do we do?

Behavioral therapy

G.A.P. and 0-3 • Try to describe childhood problems more completely • More true to BioPsychSocial approach • Role of regulation and individual differences • Role of environment: school and family

Genetics and Brain Structure • • • • •

Oligogenic: the ‘50%’ finding Overpopulations in the brain Poor connectivity theories (Courchesne, et.al.)

Second trimester etiology Argues for more research and then screening in utero or before

Environment and the Brain: Animal Models - I • Delville, et al, gene expression: How was your hamster raised? Subjugated hamsters attack the younger and weaker.

Social experience in adolescence leads to permanent changes in brain chemistry, including a 50% reduction in vasopressin in the anterior hypothalamus.

• Bester-Meredith, et al, species differences.Some mice are good dads, others are not.

• Bester-Meredith, et al: cross fostering. Born to father, raised to flee.

• Sugiyama, et al, impact of environment on transcription:Contact with pups makes rat moms transcribe long form receptor mRNA for prolactin and increases their maternal behavior. Pups make their mothers.

Environment and the Brain: Animal Models – II

Epigenetic programming:

stable alterations in gene expression • Weaver, et al: Rat moms who crouch (nurture) their pups change the histone acetylation and transcription factor binding to the glucocorticoid receptor (GR) gene promoter in the hippocampus.

• GR expression changes and so does the pup’s current and future response to stress (via the Hypothalamic Pituitary Axis • Pups of the more attentive moms have less reactivity to stress. That is, rat moms can change the genetic expression of their pup’s stress response.

Environment and the Brain: Human Models – I

Human Studies with Known Alleles (genotype and violence in maltreated children) • Caspi, et al: Low MAOA activity and history of maltreatment correlate with risk of violent crime.

• Low MAOA activity may predispose to over-reacting to perceived threats.

• Human version of the hamsters. ‘Stat’:1/3 of abused boys become abusers. Here 55 boys had low MAOA activity, 99 had high MAOA activity.

• Should we check MAOA activity to find higher risk people?

Environment and the Brain: Human Models – II

Human Studies with Known Alleles (environment & stressful life events) • Caspi, et al: looked at polymorphism in promoter region of serotonin transport 5-HTT gene.

• Three different groups with alleles l/l, s/l, and s/s.

• It took 4 Stressful Life Events to see separation between groups.

• 33% depression risk with 4 SLE’s and either s/s or s/l allele.

17% risk with l/l and 4 SLE’s.

Environment and the Brain: Human Models – III

Human Gene x Environment Interplay Trait (disordered thinking) • Wahlberg, et al: Finnish Adoptive Family Study of Schizophrenia.

• high vs. low genetic risk children adopted into low vs. high communicative deviance families • Only people at high risk and raised in high deviance families were at more risk for disordered thinking.

• HGxE: Family might save

Environment and the Brain: Human Models – IV

Human Epigenesis in ADHD • Lauchtet al, studied the DAT1 gene.

• ADHD is up to 80% heritable.

• Different studies found DAT1 alleles to be of great significance and others found none.

• Turns out DAT1 is important when the person has been exposed to adverse family setting.

Environment and the Brain: Human Models – V

The Missing Link?

• Smalley, et al: genetic linkage of on chromosome 16p13 a region implicated in autism.

• A new trail linking what we do with our kids with autism to who they become in time?

So, how to 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?

The role of affect in the modulation and modification of symptoms of ASDs

Importance of affective co-regulation in child development - I • Rene Spitz – Foundling homes. Hospitalism. (see also Roberts The Child in the Hospital) • John Bowlby – attachment, and later Mary Ainsworth strange situation (individual differences in attachment).

• Selma Fraiberg – Ghosts in the Nursery. Affects of the child, of the parent, and the past history of relationships and their impact on relatedness.

• Stella Chess and Alexander Thomas –temperament and goodness of fit (know your 7 dwarves!).

The role of affect in the modulation and modification of symptoms of ASDs

Importance of affective co-regulation in child development - II • T. Berry Brazelton – importance of dyad and affect Neonatal Behavioral Assessment Scale (1973).

• Stanley Greenspan – from psychoanalysis to fussy baby clinics to ‘First Feelings’ to the Bayley subscale Functional Emotional Developmental Levels.

• Allan Schore – Affect Regulation and the Origin [Disorders, Repair] of the Self.

• Daniel Stern – mother-infant relationship therapy.

Vitality affects: ‘musical’ co-regulation.

The role of affect in the modulation and modification of symptoms of ASDs

Importance of affective co-regulation in child development - III • Mundy, Charman, others – joint attention, language, and initiation.

• John Medina – memory and affect.

• Daniel Segal’s bottom line: ‘the brain is a social organ’.

The role of affect in the modulation and modification of symptoms of ASDs

Importance of affective co-regulation in child development – III: 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, beyond joint attention (note research on initiation and joint attention – Mundy).

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 medication and behavioral treatments for ASDs? • Behavioral treatments for the symptoms of ASDs have been the best known and most utilized through the years. • In the past 20 years medications treatments have emerged as common intervention for ASDs as well.

Medication and ASDs - I • Quick history: Magda Campbell: haloperidol helps social learning; others: methylphenidate causes side effects without benefit.

• Today: we try to treat target symptoms, carefully, based on responses in other conditions to medications.

• Takes time to assess, and re-assess.

• Marketing, and side effects, and efficacy studies.

• Efficiency study: CAPTN (Duke: John March, el al – I’m an et al…).

Medication and ASDs – II

General Approach:

• Are you trying to save a placement or make up for a bad one?

• Are meds a last resort or is it unethical to withhold them?

• Complete workup a must: consider EEG, labs, etc. along with complete history, physical, MSE, and collateral information.

• Availability - doctor MUST stay in touch with family and school • Rapid, large, or multiple changes are often problematic • Grid target symptoms vs. possible meds and fill in possible +’s &-’s

Medication and ASDs III – GRIDDING OUT TARGET SYMPTOMS VS. TREATMENTS

Medication and ASDs – IV:

Complement to Relationship Based Intervention • Support regulation and co-regulation by treating symptoms that get in the way, e.g., impulsivity, inattention, anxiety, rigid thinking, perseveration.

• Widen tolerance of affective experience so the person is less likely to become overwhelmed.

• Treat co-morbid conditions, e.g., depression.

• Possibly: allow for or promote improved ability for abstract reasoning and thinking.

Medication and ASDs – VI: Limits to Medication • Easy for the treatment team to react and overuse medications • Side effects often create significant difficulties, e.g., behavioral activation (SSRIs), increased perseveration (stimulants), sedation (some anticonvulsants, others).

• Team treatment often becomes ‘all about the medication’, ignoring engagement, other factors.

• Bottom line: medication most probably do not treat core symptoms, but might create more affective availability, if you can avoid significant side effects.

Comparison with behavioral approaches – I

Main Goals • The main goals of a behavioral program are to help a person to engage in more appropriate behaviors, leaving aside inappropriate ones, and learning about the world and what to do in the world to live, work, play, and survive. ‘This is a top down approach’.

• The main goals of a relationship based intervention are to help the 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.

Comparison 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 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 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.”

Comparison with behavioral approaches – IV

A Complementary Relationship Behavioral based contributes…

Imitation Limits Facts

Relationship-based expands…

Autonomous thinking Negotiation Exploration

I still don’t know what you mean…

What is Relationship Based Intervention?

Go For That Gleam…

• Here’s the bullet…

• Get ready…

• Don’t worry, it takes time to sink in.

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

What do I do with this?

Calm enough: • Pay attention to what works and what doesn’t.

• Think about regulation, OT (SIOT) – all sensory modalities, motor planning and other individual differences, e.g., auditory processing, language function, visual-spatial perception and visual-motor processing, tactile, vestibular, and proprioceptive.

• Calm enough might mean active enough.

What do I do with this?

Truly Connected to Others • The gleam we keep talking about…

• Joint attention, but more than that.

• Joining whatever he person is doing, to start (not an end in itself).

What do I do with this?

Back and Forth Flow = Circles of Interaction • • • •

Keep the gleam going – the signal of engagement.

Playfully getting in the way.

Don’t just entertain – wait for a response.

Working long at one level to strengthen it, and gently wooing toward more (fun) complexity in interaction, building ideas together and solving social problems.

• Don’t get caught just talking.

Importance of Reflective Process Don‘t do this alone.

• Ethics and health care – no one should work in a vacuum.

• Feedback, perspective, people who will empathize and support and also expect you to strive toward better work.

• Here there are non- MH people involved – in fact there always are – and this makes a reflective process even more important.

Marilee Burgeson’s guide to reflective process DIR®Session Notes Child:__________________PlayPartner:___________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:

_________________ _________________ _________________

_________________ _________________ _________________

The BPS in this:

Diagnostic Manual for Infancy and Early Childhood

DMIC

Axis I - Primary Diagnosis 100. Interactive Disorders 200. Regulatory-Sensory Processing Disorders 300. Neurodevelopmental Disorders of Relating and Communicating 400. Language Disorders 500. Learning Challenges Axis II - Functional Emotional Developmental Capacities Axis III - Regulatory-Sensory Processing Capacities Axis IV - Language Capacities Axis V -

Visuospatial capacities

Axis VI - Child-Caregiver and Family Patterns Axis VII - Stress Axis VIII - Other Medical and Neurological Disorders

Rough Comparison of DIR (developmental individualized relationship based) with 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 (joint attention)

Build shared meaning – parent focused

Bottom–up, democratic

RDI

Prompt

Compliance

Do what’s expected – trainer, then parent

Top-down, autocratic

Research in Support of Relationship Based Interventions For ASDs – I From Blackboard and Bench to Clinic and Community

• Grossberg and Seidman – dynamic mathematic models of neural networks functions that, for autism, explain attention and affective symptoms, and support intervention with affective cuing.

• Altschuler - Mirror neuron studies • Mundy and others – joint attention and initiation • Greenspan and Wieder – 200 case report and 2005 follow up; FEAS • Rick Solomon – The Play Project

Research in Support of Relationship Based Interventions For ASDs – II 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, NarmileeDhayanandhan& 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 FloortimeTechniques 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

Research in Support of Relationship Based Interventions For ASDs – III ContinuingClinical 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.)

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 (This year July 6-11 in VA) – 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)

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.

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

Who Is Doing Work 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…

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

References • Ainsworth, M. et al. Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum (1975).

• Bester-Merideth, J, et al. Species Differences in Paternal Behavior and Aggression in Peromyscusand Their Associations with Vasopressin Immunoreactivity and Receptors. Hormones and Behavior 36, 25–38 (1999).

• Bester-Merideth, J, et al. Vasopressin and Aggression in Cross-Fostered California Mice (Peromyscuscalifornicus) andWhite-Footed Mice (Peromyscusleucopus). Hormones and Behavior 40, 51–64 (2001).

References….

• Bowlby, J. (1969/1982). Attachment and loss: Vol. 1. Attachment. New York: Basic Books • Bowlby, J. (1973). Attachment and loss: Vol. 2.

Separation. New York: Basic Books.

• Bowlby, J. (1980) Attachment and loss: Vol. 3.

Loss. New York: Basic Books.

References….

• Brazelton, T. Infants and Mothers: Differences in Development. Dell, 1983.

• Brazelton, T. The Earliest Relationship: Parents, Infants, And The Drama Of Early Attachment.

Perseus Books, 1991.

• Brazelton, T. Neonatal Behavioral Assessment Scale 3rd Ed.. Mac Keith Press, London, 1995.

References….

• Caspi, A, et al. Role of Genotype in the Cycle of Violence in Maltreated Children. Science 297, 851 853 (2002).

• Caspi, A, et al. Influence of Life Stress on Depression: Moderation by a Polymorphism in the 5-HTT Gene.

Science 301; 386-389 (2003).

• Charman, T and Hudry, K. Interventions targeting joint attention and symbolic play can improve aspects of these skills in young children with autism.

Evid. Based Ment. Health; 10; 21(2007).

References….

• Delville, Y et al. Behavioral and Neurobiological Consequences of Social Subjugation during Puberty in Golden Hamsters. J Neurosci, April 1, 1998, 18(7):2667–2672.

• Diagnostic Manual for Infancy and Early Childhood.

Interdisciplinary Council on Developmental and Learning Disorders, 2005.

• Fraiberg, S., Adelson. E., Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problem of impaired infant-mother relationships.

JAACAP, 14, 387422.

References…

• Greenspan, S. Infancy and Early Childhood: The Practice of Clinical Assessment and Intervention with Emotional and Developmental Challenges. 1992. International Universities Press.

• Greenspan, S, DeGangi, G, Wieder, S. The Functional Emotional Assessment Scale (FEAS) for Infancy and Early Childhood: Clinical and Research Applications. 2001The Child with Special Needs: Encouraging Intellectual and Emotional Growth. International Universities Press, 1997.

• Greenspan, S.I. and Wieder, S. Developmental Patterns and Outcomes in Infants and Children with Disorders in Relating and Communicating: A Chart Review of 200 Cases of Children with Autistic Spectrum Diagnoses. The Journal of Developmental and Learning Disorders. 1:87-141 (1997).

References….

• Greenspan, S. Building Healthy Minds: The Six Experiences that Create Intelligence and Emotional Growth in Babies and Young Children. Perseus Books.

1999.

• Greenspan S. Greenspan Social-Emotional Growth Chart. San Antonio, TX: Harcourt Assessment; 2004.

• Greenspan, S and Lewis, D, The Affect-based Language Curriculum (ABLC): An Intensive Program for Families Therapists and Teachers. 2nd Ed. Interdisciplinary Council on Developmental & Learning Disorders, 2005.

References….

• Greenspan, S, and Wieder, S. Engaging Autism: The Floortime Approach to Helping Children Relate, Communicate and Think.Perseus Books, 2006.

• Greenspan, et al. Guidelines for early identification, screening, and clinical management of children with autism spectrum disorders. Pediatrics 121; 828-30 (2008).

• Grossberg - Grossberg and Seidman - NEURAL DYNAMICS OF AUTISTIC BEHAVIORS:Cognitive, Emotional, and Timing Substrates.Psychol Rev 2006;113(3):483-525.

References….

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