serena wieder phd copyright 1 the dir® foundation for the future strengthening developmental...

Serena Wieder PhD Copyright 1

The DIR® The DIR® Foundation for the FutureFoundation for the Future

Strengthening Strengthening DDevelopmental Capacitiesevelopmental Capacities Integrating Integrating IIndividual Differencendividual Difference

Using Using RRelationshipselationships

To Promote Healthy Social Emotional To Promote Healthy Social Emotional Development and LearningDevelopment and Learning


Presented by

Serena Wieder, Ph.D.Founder of ICDL with Dr. Stanley Greenspan

Director, DIR® Institutewww.icdl.com Authors ofwww.Floortime.org Engaging [email protected] Child with Special

Needs


TheThe

DIR®/Floortime™Model

for healthy emotional-social and intellectual development


DIR®DIR®

Provides a Developmental Roadmap for understanding and integrating all aspects of

development.


Functional Develop. Capacities

Focus and attentionEngaging and relatingSimple two-way gesturingComplex problem-solvingCreative use of ideas and symbolsAnalytic/logical thinking

DIR®/Floortime ModelDIR®/Floortime Model

Child-Caregiver

Interactions

Family,Community,

Culture

Biologically Based Individual Differences


DIRDIRtmtm Model Model• Three dynamically related influences on

development– Biological and genetic influences which affect

what child brings into his interactive patterns.– Cultural, environmental and family factors which

influence what parent or caregiver brings into the interactions.

– Child-caregiver interactions that determine the relative mastery of six core developmental stages/processes.

• Symptoms or adaptive behaviors are the result of these stage specific interactions.


DDIR: Functional Emotional IR: Functional Emotional Developmental LevelsDevelopmental Levels

The Essential FoundationThe Essential Foundation

The “D” – Emotional Developmental Capacities

• Regulation and shared attention – calm and focus to take mutual interest in the sights and sounds; social referencing

0>3months

• Forming attachments and engaging in relationships with warmth, trust and intimacy – later staying related across full range of emotions >5 months


The “D”The “D”Functional Emotional Developmental Functional Emotional Developmental

CapacitiesCapacities

• Intentional 2-way affective communication –purposeful continuous flow of interactions with gestures and affective reciprocal interactions >9 months

• Complex Social Problem Solving: able to problem solve through social interactions in a continuous flow using long sequences of gestures – leads you to object, imitates, social play >18 months


DDIR: Functional Emotional IR: Functional Emotional Developmental LevelsDevelopmental Levels

• Emotional Ideas – able to represent or symbolize intentions, feelings and ideas in imaginative play or language using words and symbols (representational capacities and elaboration). >30 months

• Emotional thinking – bridges and combines ideas together to become logical and abstract ; able to differentiate represented experience to distinguish reality from fantasy, self from non self, one feeling from another, and across time and space. >42-48 months


Developmental ChallengesDevelopmental ChallengesRelated to Processing and Related to Processing and

RegulationRegulation

“I” – Individual Differences• Take into account child’s:

– Arousal level and sensory modulation– Auditory processing and language– Motor planning and sequencing– Visual spatial processing– Medical and biological factors

Crosses all developmental levels.


The “R” of DIR -The “R” of DIR -Primary Principle• Relationships are the vehicle for creating

learning interactions and mobilizing development and growth through interactions and affects (affect cueing).

• Child’s individual constitutional differences and relationship - caregiving patterns together influence development


Functional Developmental

Evaluation

Educational Program/Peer Interactions

Child/ Caregiver Interactions

Family Patterns

Biomedical Assessment

Review of Current

Functioning

Sensory Modulation

Sensory Processing

Auditory Processing

OUTLINE OF THE DIR® OUTLINE OF THE DIR® MODELMODEL

Screening Motor & Perceptual

Motor Functioning

Developmental History


Comprehensive Functional

Developmental Intervention

Program

OUTLINE OF THE DIROUTLINE OF THE DIR®® MODEL MODEL (continued)(continued)

Specific Therapies

As Required

Home Program

School Program

Biomedical

Interventions

Family Support


Sources of ChallengeSources of Challenge• All sensory motor processing challenges

can derail development:Auditory and language processingVisual spatial processingMotor planning (praxis)

• RegulationHypersensitive - Reactive – ImpulsiveHyposensitive- Under-reactiveMixed reactivity profile


WHEN WE INTERACT WITH A WHEN WE INTERACT WITH A CHILD WE REDEFINE HIS OR HER CHILD WE REDEFINE HIS OR HER

POTENTIALPOTENTIAL

Assumptions• Every child has his or her own profile of

development and requires an individualized approach which is developmentally appropriate.

• All areas of development are inter-related.

• A child’s symptoms and problem behaviors often stem from underlying difficulties in sensory modulation and processing, motor planning and affective integration.

• WHEN WE INTERACT WITH A CHILD WE REDEFINE HIS OR HER POTENTIAL


DIR®: Affect Based DIR®: Affect Based LearningLearning

• Affect carves the pathway for learning – provides direction for actions and meanings (of symbols, words)

• Interactive strategies are based on child’s intent or affect

• uses child’s natural intentions and feelings as personal foundation of learning


DIR Intervention ModelDIR Intervention Model• Addresses core deficits directly• Affect and relationship based• Developmentally appropriate approach• Comprehensive and integrated approach• Focuses on family interactions and

relationships• Emphasizes symbolic thinking• Works across the full range of emotions


• Floor Time – 6-8 daily sessions• Talk Time – ongoing

reality based problem solving conversations

• Semi-Structured Problem Solving

Activities – social games, ritualized learning, reading, “work”- 3-4 daily sessions

• Family Support

• Sensory Motor and Regulatory Activities 3-4 daily sessions

• Play Dates – accd. to age

• Social Groups • School Based

Programs• Therapy Activities – OT,

SLP, PT, VCT. • Augmentation – visual

strategies, auditory training, PECS, VOCAs, Typing…

• Nutritional Interventions

OUTLINE OF THE DIROUTLINE OF THE DIRtmtm MODEL MODEL COMPREHENSIVE HOME & ED COMPREHENSIVE HOME & ED

PROGRAMPROGRAM


DIR Approach to DIR Approach to Intervention: GoalsIntervention: Goals

• Create opportunities to assist child in learning basic developmental capacities– Ability to attend and focus– Ability to engage warmly and trustingly

with others across a range of emotions– Ability to communicate intentionally

with both simple and complex gestures to negotiate dependency, aggression, approval and rejection


DIR Approach to DIR Approach to Intervention: GoalsIntervention: Goals

– Ability to problem solve through social interactions in a continuous flow

– Ability to represent or symbolize intentions and feelings in imaginative play or language

– Ability to differentiate represented experience to distinguish reality from fantasy, self from non self, one feeling from another, and time and space.


DIR Model for Infant Mental HealthDIR Model for Infant Mental HealthDevelopment, Individual Difference, Development, Individual Difference,

Relationship BasedRelationship Based

• Provide specific types of developmental experiences at each stage of emotional development in order to foster further emotional growth.

• Consider infant’s unique individual differences – constitutional and maturational patterns in order to provide these experiences.

• Enable parents or caregivers to understand their own characteristics and interaction patterns with their children to foster growth.

• Enable parents or caregivers to understand and deal with emotional lags, constrictions, deficits, symptoms and foster adaptive development.


Greenspan – Early IdentificationGreenspan – Early Identification

Social-Emotional

Growth ChartA Screening Questionnaire for

Infants and Young Children

Psych Corporation


Bayley Scales of Infant Bayley Scales of Infant Development IIIDevelopment III

Part of the standardization data

• Administered to 456 children ages 15 days – 42 months

• Children from all over the U.S. representative of the U.S. population based on census of 2003

• Stratified sample: race/ethnicity, region, parent education level, equal numbers of girls and boys

• Reliability scores reflected strong internal consistency

• Evidence of validity based on test construct


QuestionnaireQuestionnaire• Divided into 8 age intervals from birth to 42 months• Parent reports on Behavior Frequency from none of the

time to all of the time (or can’t tell) for social-emotional behaviors and sensory processing behaviors

• Each response is weighted for frequency and added• The total Growth Chart Score converts into an age-

appropriate Growth Chart Index Score• These summary Scores indicate possible challenges,

emerging mastery, and full mastery including highest score mastered

• Can plot the child’s social emotional developmental accomplishments in relation to the age expected giving a view of the child’s patterns


Quicker progress

Slower progress

Problems increase with age

Greenspan, S.I. – Excerpted from Building Healthy Minds, Perseus Books, 1999.

Developmental Stages

Age in Months

Logical Bridges - 2

Logical bridges - 1

Ideas beyond basic needs

Ideas (words/symbols)

Comp. problem-solving

Simp. problem-solving

Purposeful interaction

Engagement

Attention/focus

4248

36302418139530

THE SOCIAL-EMOTIONAL THE SOCIAL-EMOTIONAL GROWTH CHARTGROWTH CHART


Early Onset

Regression

Norm

Greenspan, S.I. – Excerpted from Building Healthy Minds, Perseus Books, 1999.

Developmental Stages

Age in Months 30241813953

Logical bridges - 2

Logical bridges - 1

Ideas beyond basic needs

Ideas (words/symbols)

Comp. problem-solving

Simp. problem-solving

Purposeful interaction

Engagement

Attention/focus

0

THE SOCIAL-EMOTIONAL THE SOCIAL-EMOTIONAL GROWTH CHART 2GROWTH CHART 2

4248

36


Caregiver Report and Clinical Caregiver Report and Clinical ApplicationApplication

• First step to learning about the child and determining how to assist in the child’s functional emotional growth

• Identifies patterns which may require further investigation based on how close or how far to expected patterns

• Can be used to measure progress over time


but what is?but what is?Emotional

Development

Not just social skills or “good” behavior


Emotional DevelopmentEmotional Development• What is emotional development?• When does it start?• How and when does it unfold?• What is the hierarchy of emotions?• How does it relate to intellectual

development?• How does it relate to social development?• How do we establish the foundation for

healthy emotional development?


The DIR®ModelThe DIR®Model

Provides a roadmap for Provides a roadmap for emotional developmentemotional development

Symbols reflect the Symbols reflect the hierarchy of emotional hierarchy of emotional

developmentdevelopment


EmotionalEmotional Development Development

ParallelsParallels

SymbolicSymbolic Development Development

andand

IntellectualIntellectual DevelopmentDevelopment


What is a Symbol?What is a Symbol?• A symbol represents “the real thing”

• Symbols have many forms – words, drama (dress up and role play), toys, drawings or

pictures, movement…All of which symbolize experiences

• Goal is to learn we have to substitute reality through symbols or images

• Symbolic play turns images into concepts which reflect the meaning of the image.


Hierarchy of EmotionsHierarchy of Emotions• Dependency Themes

– Feeding, cooking, fixing, doctor, mechanic, builder…..joy, love…

• Transition Themes– Separation, disappointment, loss,

sadness, fears …• Assertiveness/Aggressive themes

– Control, power, competition, anger, jealousy, justice, morality….


WHY BUILD A WHY BUILD A SYMBOLIC WORLD?SYMBOLIC WORLD?

• Symbolic play and conversation is the safe way to practice, re-enact, understand, and master the full range of emotional ideas, experiences and feelings.

• Symbolic play leads to abstract thinking and a differentiated sense of self and others.


FloortimeFloortimeBUILD A SYMBOLIC WORLD - GOALSBUILD A SYMBOLIC WORLD - GOALS

• Goal is to elevate all feelings and impulses to the level of ideas and express them through words and play instead of acting out behavior

• Symbolic play provides the distance from real life and immediacy of needs to differentiating self from others (through different roles) and self from the environment (not bound by time and space)


The Foundation for the The Foundation for the Future Future

• Support emotional development to support mental health and intellectual development

• Aggression and acting out behavior reflects the failure of symbolization and relationships

• Need a comprehensive model of development to foster the emotional, social and intellectual foundation for the future


Floortime™, is a vital element Floortime™, is a vital element of the DIR®/Floortime™modelof the DIR®/Floortime™model

• a treatment method as well as a philosophy for interacting with children, adolescents, (and adultsl).

• Floortime™ involves meeting a child at his current developmental level, and building upon his particular set of strengths.

• Floortime™ harnesses the power of a child’s motivation; following his lead, wooing him with warm but persistent attempts to engage his attention and tuning in to his interests and desires in interactions.

• By entering into a child’s world, we can help him or her learn to relate in meaningful, spontaneous, flexible and warm ways.


What is Floortime™?What is Floortime™?• Floortime™ is the term used for

those experiences in which you follow your child’s lead in areas that give him pleasure, and then build on them in ways that expand his emotional capacities and tolerance for frustration helping him climb the developmental ladder.


What is Floortime™?What is Floortime™?• It is called “Floortime™” because it

reminds parents, child care providers, teachers and therapists that a window into the child’s emotional and intellectual world most easily opens when you enter into his orbit at his eye level and on his terms.

• With infants and young children you may actually play on the floor, and this evolves into other forms of interactions as you grow, such as reflective conversations.


Emotional ThinkingEmotional Thinking

• Each stage involves the simultaneous mastery of both emotional and cognitive abilities

• New Research


Emotions, Symbols and Emotions, Symbols and Sensory Motor ProcessingSensory Motor Processing

•What is the intersection between emotional-symbolic development and sensory perception and processing?


What to observe?What to observe?Motor Planning and Visual Spatial Motor Planning and Visual Spatial

CapacitiesCapacities

• Wanders aimlessly without looking at or exploring toys

• Only finds toys in certain areas (.e.g., on the floor or table top or last seen)

• Drops objects/toys and does not pick them up automatically

• Plows through floor littered with toys which have been dropped or abandoned


What to observe?What to observe?Pre-verbal or non-verbal indicators of motor Pre-verbal or non-verbal indicators of motor

planning and visual planning and visual spatialspatial challenges challenges

• Arranges toys in certain spots but does not use them for play

• Lines up figures, animals, or dinosaurs• Lines up figures one at a time to

“fight” – battles or contests• Cannot arrange scene using toys to set

up a picnic, zoo, battle, ambush, etc.• Sets up scene but won’t move any of

the pieces for “action”


Emotional/Social Behaviors:Anxiety & Emotional/Social Behaviors:Anxiety & Visual Spatial ProcessingVisual Spatial Processing

• Separation Anxiety• Overly fearful and reactive to body

damage, aggression, unpredictable events • Panic reactions when s/he turns around

and does not see parent or feels lost• Catastrophic reactions to not finding

needed objects or thinking something broke

• Helpless or frustrated feelings when task requires using space, tracking, finding parts, fixing things…


Semi-Structured PlaySemi-Structured Play & Visual Spatial Perceptual Motor & Visual Spatial Perceptual Motor

ProcessingProcessing

• Does not play matching, visual discrimination, visual strategy - games

• Cannot find desired figures in basket of toys

• Insists on repeating same puzzles or toys• Selects easy puzzles again and again• Does not use trial and error or other

strategies to rotate puzzle pieces, use cues, tries to push pieces in, etc.

• Avoids construction, tinker toys, Legos, etc.


Floortime™Floortime™PrinciplesPrinciples

• Child must generate the idea –– Encourage through toys and props – May rely on favorite ideas or

obsessions– May borrow from books, videos,

imitating others– May be a personal concernChild initiates and invests affectively!


Floortime™Floortime™CREATE CREATE A SYMBOLIC WORLD A SYMBOLIC WORLD

• Create an inviting environment for interaction and symbolic play – let your child explore and discover new experiences and ideas.

• Represent the world you want your child to symbolize in your Floortime™ room using toys, puppets and dress up:

• Reality based experiences (people and video figures, house, school, food, cars, trains, planes, zoo, farm

• Discover the Imaginative ( jungle, Jurassic Park, castles, kings and pirates, jails, monsters, superheroes, Star wars….)


Level I : Shared Attention Level I : Shared Attention and Regulationand Regulation

• Establish joint attention

• Get connected and interactive

• Challenges: Child gets distracted, looks away, starts fidgeting, throws down or drops objects, or takes flight.


Level I : Shared Attention Level I : Shared Attention and Regulationand Regulation

• Co-Regulation: Soothe and woo child who is anxious or overactive; energize child who appears subdued or passive to achieve a calm and focused state.

• Regain attention using affect cues in the way you call his name, e.g., use a broadcasting voice or whisper; imitate musical cues to signal getting ready or something is coming, e.g., Dum, da,dum, da dum, dum!

• Create curiosity by covering the task at hand and invite child to uncover.


Level II : EngagementLevel II : Engagement• Engage child pleasurably and woo him into

playing and relating

• Stay engaged across the full range of emotions – when angry, scared, aggressive….

• Challenges: Child becomes self-absorbed, passive or hyperactive and dis-engages. Child gets angry and rejecting, refusing to work.


Level III : Two Way Level III : Two Way CommunicationCommunication

• Entice child with back and forth gestures, touch, movement , vocalizations,or words.

• Allow child to explore the materials and/or

play and model.

• Get a gestural or verbal dialogue going back and forth, asking questions as child begins to work.


Level III : Two Way Level III : Two Way CommunicationCommunication

• Applaud child when he succeeds, clap and praise until child actually looks up and acknowledges you or anticipates your response. Similarly,use empathic tone to encourage child to try again .

• If child begins to get frustrated or anxious, use simple cues or words to acknowledge his feelings, coupled with encouragement and limit setting when necessary, e.g., Uh oh, that is hard…. again!


Level IV: Problem SolvingLevel IV: Problem Solving• Enlist a continuous flow of back and

forth with more gestures, dialogue and problem solving. For example: For verbal child -– What are you going to do next/?– How did you do that? – What should I do? Where is that?

• For pre-verbal use gestures and actions


Level V: Create IdeasLevel V: Create Ideas• Encourage child to use imagination and

create symbolic ideas as he works. This can take the form of images (Oh no, a giant crab is coming!), or roles (construction worker, dancer, artist), or storyteller.

• “Okay, go for it! You are a great design copier, architect, etc. Who should we pretend to be?

• “ What a great idea! “


Level VI – Abstract ThinkingLevel VI – Abstract Thinking• Identifying idea and feelings• Organizing beginning, middle and

end• Giving opinions• Having debates• Agreeing and disagreeing• Reflecting on feelings and empathy


Level VI: Identify Feelings – Level VI: Identify Feelings – Causal ThinkingCausal Thinking

• Now, how did you feel about that? How did you feel when you were doing this? Why do you think you feel that way? What would make it different? Well, this makes me feel mad! I’m pretty good at this stuff! Yeah, it makes me use my eyes too much.

• Empathize and soothe but also provide feedback to help child evaluate the task more objectively. Encourage and challenge to foster cooperation and persistence.


Common ErrorsCommon Errors

• Not finding symbolic intent to keep child more engaged and initiating the goals.

• Try to control disruptive behaviors without addressing feelings.


DIR® Model for Infant DIR® Model for Infant Mental HealthMental Health

• But what if problem behavior is part of a larger developmental failure?– Has not learned to relate or engage warmly to

other people or others have not related to him

– Has not learned to empathize with someone else’s perspective

– Has not learned to regulate or control aggressive impulses because he lacks capacity to see his behavior has consequences for others


DIR Model for Infant Mental DIR Model for Infant Mental HealthHealth

• Behavioral approaches or focusing on isolated units of behavior can obscure a larger developmental challenge and miss the larger opportunity to master critical developmental milestones.



–Focus on behavioral control rather than engagement or learning relationships can be warm and supportive.

–Using very concrete rewards or negative consequences can undermine the first goal of creating a sense of relationship and engagement.



– To appreciate the consequences of interaction need to learn that communication is causal and two-way and has impact on others –

– therefore child needs to learn to experiment with his own initiative and monitor the feedback he gets from others.



– Focus on reinforcers may be a bigger problem than the particular behavior child evidences

– may seek any form of attention or feel rewarded by other people’s discomfort rather feel rewarded by relationships and a sense of pride and respect.


www.icdl.com• Annual International Conferences

– Annual Conference Workshops on DIR® Practice

– Over 10,000 Participants from all US States and 82 countries

• Publications – Books, Videos and Journals• DIR® Networks in Atlanta, Boston, Chicago, New York, Rochester,

San Francisco, Portland, Miami, Ireland, Australia, Israel, Wales, Argentina, Chile, Bolivia, Peru, Mexico….

• DIR® Institutes in the US, Israel, Italy and Amsterdam• DIR® Conferences in Europe, Israel, Australia, China, Singapore,

South America• DIR® Books translated into Italian, Indonesian, Dutch, Chinese,

Spanish, Hebrew, Croatian


DIR® Institute Educational Programs

2007 in ASILOMAR, CA July 8-13

– DIRB for Professionals Beginning Practice– DIRC Competency Based Certificate Program – FTP Floor Time Players– DIRA for Administrators– DIR® Training of Trainers – Faculty/Facilitator

Program


• Publications – Books and Journals – www.icdl.com

– Clinical Practice Guidelines– DMIC Diagnostic Classification Manual

for Infants and Young Children– FEAS – Functional Emotional

Assessment Scale– The Child With Special Needs – Spanish

Edition– Bipolar Patterns in Children

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