Connection Counts: Core Elements in Autism Intervention

January 25, 2012 University of California at San Diego

Director of Research, Graduate School, Interdisciplinary Council on Developmental and Learning Disorders

Assistant Clinical Professor, Voluntary Dept of Psychiatry, University of California at San Diego School of Medicine

Feder 411
Math, Engineering, and Developmental Disorders beginning 1978. US Navy Child Psychiatry Mike 1990 (1992) Greenspan and Wieder 1993 Career expansion: clinic, teaching, research, advocacy, tech development and arts & media.
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ICDL

CAPTN/Pfizer
SymPlay Cherry Crisp
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Commercials
Because we build ideas together And you can join us in the effort!

Working Together for

Parent Choice!
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The Southern California DIR/Floortime Regional Training Program

Pasadena, California February 24-26, 2012 Pasadena Child Development Associates, Inc. (PCDA)
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Tuning Into Each Other

Customizing Project ImPACT
to address our key community values and reach younger children for the SoCal BRIDGE Collaborative

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Thank You!
Families say a silent thank you Greenspan & Wieder Kasari, Gulsrud, Adamson, et. al. Jeff Montag The BRIDGE Collaborative So many others
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Outline
Engagement and other core concepts Research shows Well do research today! Videos The meaning of Repair Questions Tips and take home points

Engagement and Other Core Concepts

Assumptions
You are interested in helping figure out how to help people with autism and related conditions You have little familiarity with research on engagement and joint attention

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Conclusions:
Nurture engagement Repair of engagement leads to competence and confidence in a persons ability to connect with others and to solve problems If you look for engagement, you can make it happen more

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Taking Notes?
One word:

ENGAGEMENT

Moment to moment interactions

Regulation Unengaged Object focused Engagement Intent Circles of interaction Repair (Tronick) Initiated Joint Attention Floortime

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Regulation Calm enough to interact

Not to active, upset, etc.

Not too calm Help the person be regulated

Unengaged Maybe wandering, or distracted

Maybe focused on an object (object focused)

Unengaged, Maybe object focused

Engagement: Emotionally Connected in the Moment

Warm, trusting, shared
Balanced feeling of in-sync connection

The reason we care to learn and grow

Deep bond or falling in love

Engaged: (often smiling; doesnt always need eye contact)

How do you know if engagement is there?

Often there is a gleam in the eye - like during a chase game Usually fun and feels good You feel it, and feel successful Unengaged: frustrating, feel incompetent Well see if we can spot it on videos

Circles of Interaction
Child does something (anything) indicating intent (any idea tiny or big) You do something that adds to what the child is doing The child completes the circle by doing something that builds on what you did

First part of a Circle: Child is doing something

Second part of a Circle: Adult does something to build on childs intent

Third part of a Circle: Child responds to adult

Joint Attention
Creating a shared moment of attention on an object Responsive joint attention: when we point out something to the child and the child looks at us and the object Initiated joint attention: when the child gets our attention and points something out

Initiated joint attention (repair)

floortime

Research Shows

Controlled Examination of Critical (Pivotal) Aspects of Intervention

Gulsrud, Kasari, et. Al. The Co_Regulation of Emotions Between Mothers and Their Children with Autism. J. Autism Dev Disord (2009) Kasari, Gulsrud, Wong, Kwon, & Locke. Randomized Controlled Caregiver Mediated Joint Engagement Intervention for Toddlers with Autism. J. Autism Dev Disord (2010)

Gulsrud & Kasari et. al. 2009:

Issue: if mom supports Joint Attention, is child better regulated? Method: Lab study of 34 dyads; wait list control; 24 sessions/8 weeks; blind raters code child negativity, self-regulation, and maternal co-regulation. Results: 1) lots of negative moments & children and moms used these strategies, albeit less of the symbolic ones; 2) stressed moms used fewer vocal strategies and more active ones when interacting with their kids; 3) moms became better at coregulation strategies and children showed more ability to self-regulate negative moments. Implications: Joint attention helps co-regulation

Kasaris Lab

Childs efforts

Moms Efforts

When moms do better.

Their kids to better

Kasari & Gulsrud et. al. 2010

Issue: What is the outcome one year later? Method: 15 min video samples at 0, 8, and 52 weeks; coded unengaged/ object engaged/ or joint engaged; caregiver adherence and fidelity; Results: 1) less object and more joint engagement; 2) higher caregiver quality of involvement/ fidelity predicted more joint engagement; 3) adherence was good but not a factor in outcome; 4) no change in time unengaged Implications: Supporting joint attention makes a difference in future social communication for early intervention in ASD; We can study isolated parts of a broader model

uh oh..

Out of the Lab.

Procedure
We will watch the video We will watch it again We will use the voting cups to indicate how much we agree a particular moment appears to indicate a shift in the state of the child We will watch more videos

Starting with the master.

Video: Enticing Alex to Engage: http://www.youtube.com/user/dirfloortime#p /a/u/2/uqiSR4FUBG0 4 minutes Track unengaged, object focused, engaged, circles, and repair of interactions

Lets see if we can spot these things

Unengaged ObjectFocused Engaged Circles Repair Comments

Lets see if we can spot these things

Unengaged Object focused 0:00 0:35 1:10 2:03 2:35 2:56 3:11 3:40 3:56 doll Mom w/h Engaged Circles Repair Comments

Three Brief Videos

Cuing dad and baby Mom and toddler (hide n seek) Mom and child (tongue game) Well watch each twice (or more)

The Meaning of Repair

Normal Interactions (Tronick 2007)

Mismatch in moment to moment interaction What the child does What the caregiver does

Normal Mismatch
1/3 of interactions go well 1/3 have breaks and repair 1/3 have breaks and are lost

Mismatch leads to:

Able to differentiate self from others Increased self-regulatory capacity Increased resilience to stress

Self vs. Other

Mismatch means there is a difference Forces child and caregiver to respond Quality of response makes all the difference

Increased Self-Regulatory Capacity

Repair of small mismatches gives experience of repair Mismatch becomes more tolerable child doesnt get so upset anymore The most basic form of competence and selfesteem

Resilience to Stress
Long experience with repair Creates an ever broader and more nuanced ability to repair And with that a gradual ability to tolerate greater and greater stressors

What Babies Can Do to Respond or Repair

Social attend (paying attention to the caregiver) Signal (with +, -, or neutral affect) Object attend (paying attention to an object) Self comfort Escape (e.g. turning away) Avert/ scan Withdrawal (including reduction in postural control or reduction in perceptual function, e.g., dull, glassy eyed [dissociation?]

What Caregivers Can Do to Respond or Repair (Caregiver Profile)

1. comfort the child 2. find appropriate levels of stimulation to interest the child 3. pleasurably engage the child 4. read the child's emotional signals 5. and respond to the childs signals 6. encourage the child (in regulating, communicating, learning, etc.)

Potential Caregiver Challenges

Potential caregiver challenges:

1. over-stimulating 2. withdrawn/ unavailable 3. lacking pleasure, zest 4. chaotic in reading/ responding to child 5. fragmented/ insensitive 6. rigid/ controlling 7. concrete in reading/ responding 8. illogical in reading/ responding 9. Avoiding: security/safey; dependency; pleasure/excitement; assertiveness/exploring; aggression; love; empathy; limit setting 10. unstable in the face of intense emotion

These Experiences Create Mood States

Infants of depressed moms are depressed Infants of intrusive moms withdraw Infants of neglectful moms complain Infants of neglectful moms must try to selfregulate without the help of scaffolding and end up withdrawing Infants of abusive moms end up engaging in physical defensiveness, anger, and increased vigilance and fear

So theres stress, and theres STRESS

The helpful stress of normal mismatch The too common but unhelpful stress of life Need to assess the stresses.

Managing Challenges
Never work alone Schedule regular meetings With someone who will really listen And help you find your own solutions Platinum Rule: A good listener treats you with respect so that you have the support to be able to tolerate the natural stress of helping your child (Treat others as we want others to treat others)

This engagement approach reduces parent stress and improves child function and parentchild relationships!

Questions?

Tips and Take Home Points

How do you engage a child in an interaction?

Adjust your energy to help him be calm enough or active enough to do stuff with him Might mean understanding sensory, motor, thinking styles and other things. Observe. Join. Wait! Build on your childs actions: Improv yes, and Respond with warmth & try to be natural

Go for engagement and compliance will come

Compliance & Engagement: necessary and complimentary

Compliance Do/think what I want you to do/think Drills will create skills Engagement Think for yourself and with me Shared emotional signaling creates a relationship that inspires learning and problem solving Relationships, available and internalized, give self-assurance to respond to new situations

Schemes to cover new situations

Limited sense of competence, selfMore full sense of competence, selfesteem: I can do it. I learned how. esteem: I can figure it out.

Improving your ability to support your childs interaction

Practice reading childs cues Think about different way to respond to your childs cues Getting new ideas: bounce it off of other people - get their ideas and figure out what works for you.

Things to Avoid
Dont just entertain, quiz, or direct the child with your games, demands, or ideas Dont merely follow the child around use the child lead to start off Every idea is a good one to play with dont say no to the idea - connect and play with it. You can set limits as needed.

coaching

What about other kids?

Start with adults Build some skills Semi-structured activities with peers Limiting numbers of kids Mediate the process slow it down Statements more than questions Democratic decision making

Things you might say or do:

We need to figure out what to do I need help with Wait - I didnt hear you We can vote on whether he was out.. Semi-structured: at times you direct things, but work toward less of it. In free play, you join the person in a way that attracts other kids, then facilitate the mix

Conclusions:
Nurture engagement Repair of engagement leads to competence and confidence in a persons ability to connect with others and to solve problems If you look for engagement, you can make it happen more

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Symplay: Launch likely in April during Autism Awareness Month

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The Southern California DIR/Floortime Regional Training Program

Pasadena, California February 24-26, 2012 Pasadena Child Development Associates, Inc. (PCDA)
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