E.

A Model Case Using DIR®

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
 DIR® Approach

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 Think for yourself and with me

do/think

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- More full sense of competence,

esteem: self-esteem: “I can figure it out.”
“I can do it. I learned how.”
 They can work together

Behavioral based Relationship-based

contributes… expands…
Imitation Autonomous thinking

Limits Negotiation

Facts Exploration
 Prompt vs. Woo:

Prompt Woo

Greater power difference Humility – more equality

between people
Control Respect for ideas of other
person
Specific expectation Open ended, hopeful for
growth
Belief in the material Belief in the process
 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: _____________ Student: Person Recording:
_________________

In Class am Recess In Class Lunch Afternoon

Time: _________ Time: ______ Time: _______ Time: _______ 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
Social
and/or Reciprocity
verbally
referencing peers
(Circles, Flow)
True Back and Forth in
speaking and listening
interactions
-opening (initiating) and
closing (ending) circles of
communication verbally or
nonverbally
 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

Organize the goals under:

co-regulation, engagement, and reciprocity
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