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Research Panel: know our data

and get involved!

Diane Cullinane, MD
Josh Feder, MD
Connie Lillas, PhD, MFT, RN
Lois Black, PhD
Devin Casenheiser, PhD
Jim Stieben, PhD
The Southern California DIR®/Floortime™ Regional Institute
Pasadena, California October 2010- May 2011

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
Support Parent Choice Today!
www.dirfloortimecoc.com
Top 10 Research articles to persuade
and educate legislators and other
powers that be

Diane Cullinane, M.D.


The Roots

 Greenspan, S.I. and Wieder, S. (1997) 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. Journal of Developmental and
Learning Disorders 1:87-141

 Greenspan, S.I. and Wieder, S. (2005) Can Children with Autism


Master the Core Deficits and Become Empathetic, Creative and
Reflective? A Ten to Fifteen Year Follow-up of a Subgroup of
Children with Autism Spectrum Disorders (ASD) Who Received a
Comprehensive Developmental, Individual-Difference,
Relationship-Based (DIR) Approach. The Journal of
Developmental and Learning Disorders 9.
Specifically DIR/FT

 Solomon, R., Necheles, J., Ferch, C., &


Bruckman, D. (2008). Pilot study of a
parent training program for young children
with autism: the P.L.A.Y. Project Home
Consultation Program. Autism, 11(3), 205-
224.
Relationship Focused Intervention

 Mahoney, G. & Perales, F. (2003). Using relationship-


focused intervention to enhance the social-emotional
functioning of young children with autism spectrum
disorders. Topics in Early Childhood Special
Education, 23, 74-86.

 Mahoney, G., and Perales, F. (2005) “Relationship-


focused early intervention with children with pervasive
developmental disorders and other disabilities: a
comparative study.” Journal of Developmental &
Behavioral Pediatrics 26: 77-85.
Parent mediated Intervention

 Kasari, Gulsrud, Wong, Kwon, & Locke.


Randomized Controlled Caregiver Mediated
Joint Engagement Intervention for Toddlers
with Autism. J. Autism Dev Disord (2010)
The Scotts

Salt, Shemilt et. al. The Scottish Centre for


Autism preschool treatment programme. II
The results of a controlled treatment
outcome study. (2002) SAGE publications
of The National Autistics Society. Vol 6(1)
33-46.
A Hybrid

Dawson, G., Rogers, S., Munson, J., Smith, M.,


Winter, J., Greenson, J., Donaldson, A. &
Varley, J. (2009). Randomized controlled
trial of an intervention for toddlers with
autism. The Early Start Denver Model.
Pediatrics. Online verson e17-e23.
Reviews

 Odom, Boyd, Hall, & Hume. Evaluation of


Comprehensive Treatment Models for
Individuals with Autism Spectrum Disorders.
J Autism Dev Disord (2009)
 Ospina, M. et al. Behavioural and
Developmental Interventions for Autism
Spectrum Disorder: A Clinical Systematic
Review. (2008)
The best is yet to come!

 Drs. Devin Casenhiser, Jim Steiben, Stuart Shanker and


everyone at York / MEHRI
 The York Study!

 Dr. Rick Solomon


 The Play Project

 Dr. Josh Feder


 The Bridge Project
Getting Started in Research

Josh Feder, MD
‘But I’m a clinician’

 Why are you HERE?


 Learn more
 Make friends
 Step gradually
 Help out
 Persist, and maybe perseverate
Learn about Evidence Based Practice

 Evidence Based Medicine – Sackett 1995


 Best Available Research combined with
Clinical Judgment and Experience
 For the Purpose of Informed Consent
 Parent Choice!
 More from Connie later…
Understand the Challenges of Doing Research

 Subjective experience (affect) is at the center


 Heterogeneity: all the people are so different
 More than one treatment at a time
Overcoming Challenges

 Efficiency studies (vs. Efficacy Studies)


 FEAS, SEGC
 Reflective Community Consensus Process
 BRIDGE – going post-denominational (thanks
Stanley)
Tuning Into Each Other
Customizing Project ImPACT
to address our key community values and reach younger children for
the SoCal BRIDGE Collaborative
BRIDGE

 Community collaboration
 Parents, clinicians, researchers, agencies,
funders
 Vetting ideas
 Learning from each other
 Coming to consensus
Taking Project ImPACT…..

 Parent driven
 Mixed developmental/ behavioral
 Language focused
 Specific goals
ImPACT
And make it ours

 Warm it up
 Broaden the vision
 Give it our context
BRIDGE Enhancements

 Engagement
 Communication
 Sensori-motor
 Reflective process
Warmed up…
Project ImPACT
And Make it Ours
The Evidence Based Movement: 19th
Century Science versus Complexity:
Welcome to the 21st Century

Connie Lillas, PhD, MFT, RN


California Quake Crisis

 Legislators do not understand the issues


 DIR not on EI & DMH list of approved
therapies
 Need for „push back‟ nationally
Pushing Back – the Problem

 Reductionist, narrow research paradigms


 Outdated research models
 Children are complex
Pushing Back - Solutions

 Advocacy from Parent to Professional


 Know and educate colleagues about the
difference between Evidence Based Practice and
Evidence Based Treatments
 Educate about research paradigm matches
versus mismatches
 Support research that is practice-based evidence
 Promote professional and parental critical thinking
and informed choice
Insist on Clarity:
E-B-Treatments do NOT equal E-B-Practice
 Evidence-Based Practice is:
 A decision making process that holds the tension
between:
 The best available clinical research (EBTs)
 Professional wisdom based in sound theory and practice
 Cultural and family values (with informed choice)
 Buysee and Wesley, 2006
Insist on Match Between Research
Approach & Clinical Population
 Problems with Gold Standard Research:
 Often simple, subclinical cases are involved in
research settings
 Designed for single diagnosis, not matching co-
occurring diagnoses
 Lacks flexibility to account for individual
differences
 Lacks flexibility for following a therapeutic alliance,
shifts in behaviors, and cultural sensitivities
 In Lillas and Turnbull, 2009, from Weisz & Gray, 2008
21st Century Vision for Paradigm Shift in
Research
 “…a critical question for the field is what
approach to empirical testing will give us the
strongest treatments that are most robust in
actual clinical practice”
 (Weisz & Gray, 2008, p. 62)
Get Involved!
Practice-Based Evidence

 Push-back with complex clinical cases that drive


scientist‟s search for new knowledge
 Attend conferences and join organizations with
child development researchers (map)
 Take complex models and frameworks into
clinical research settings
 Search and find cutting-edge dynamic system‟s
research paradigms that can hold complexity
The Importance of Affect:
Research in Support of DIR Intervention

Lois M. Black, Ph.D.


Faculty DIR Institute
Clinical Psychologist/Pediatric Neuropsychologist
Research Professor
Oregon Health & Science University
Black, et al., IMFAR 2009: Understanding the Effects of Enhancing Vocal
Prosody on Childrenʼs Comprehension and Retention of Story Narratives

 Participants: N=79 3 Prosodic Modes:


 “Disconnected” –
Ages 4-8, overall IQ > 70.
ASD group N=37
 Recorded words in random order,
concatenated words together into
TD group N=42 sentences
 Imposed synthetic pitch contour
on sentences
 Minimal grammatical prosody; no
NARRATIVES: pragmatic or affective prosody
•Affectively-rich, interpersonal  stress correct syllable – word
stories. meaning intelligible
•Factual + Social Cognitive  descending or ascending
contours -- questions and
Information statements
•Immediate and delayed questions  “Standard”
•Goal: What are the effects of  intact grammatical, minimal
enhancing vocal prosody – affect in pragmatic, affective prosody
one‟s voice -- on comprehension  “Enhanced”
and retention of information?  exaggerated grammatical,
pragmatic, affective prosody
 Results
 Enhanced
p<0.001  Standard
 Disconnected
p>0.25
p<0.001

Significant results: ANOVA analysis, with Prosodic Mode (E vs. S vs. D),
Group (ASD vs. TD), and Story as independent variables, resulted in a
significant interaction between Group and Prosodic Mode.
ASD children better able to answer narrative questions as prosody became
enhanced from D to S to E, for both immediate and delayed questions.
Findings, cont’d:
 No such beneficial effect of prosodic mode was seen in the TD
group. (Essentially no differences across disconnected, standard
and enhanced conditions.)
 TD performed better than ASD children in all prosodic modes.
 Trends were found for the interaction to be more pronounced for the
social cognitive questions.

Conclusions:

Enhanced prosody specifically targeted to highlight the multiple


levels of information in complex verbal communication helps
comprehension and retention of information in children with ASD,
in particular, social cognitive information.
Critical Elements for DIR Intervention
Research
 Pre-treatment measures
 Heterogeneity/How we know who our
children are
 Post-treatment/Outcome measures
 What are we striving to achieve for
our children
 Treatment manual
 Fidelity measures
What we need most

 Treatment manual

 Fidelity measures
The Final Frontier: Research on
DIR® on both Clinical and
Functional Imaging Outcomes

Devin Casenheiser, PhD


Jim Stieben, PhD
Stuart Shanker, D. Phil. Oxon
The York MEHRI Study

 2 hours per week FT coaching


 Study population & controls\
 Clinical measurement of effects
 Functional Imaging
Findings:

 Clinical improvement
 Brain looks better!
 Publication status
Implications

 Profound evidence
 Comparison w/ other imaging studies
 Next steps (studies, advocacy)
Your Thoughts!

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