9/22/17. Now It s Time to Play: What to Do Until the Therapist Arrives. Goals for this Presentation. Why Play? Standardized Testing

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1 7 th Annual NY/NJ Conference Relationships: The Key to Progress Empower Parents, Promote Sustainable Outcomes, and Unlock Potential for Individuals with Autism and Other Mental Health Challenges Now It s Time to Play: What to Do Until the Therapist Arrives Presented by: Christie Virtue, Ph.D. Date: October 25, 2017 Goals for this Presentation To add to your current skills and usual practices as an evaluator, clinician, or parent. To identify through observation, behaviors critical to the development of shared attention, engagement, and reciprocity. To observe and identify stages of symbolic development in play. To assist parents and caregivers in developing next step strategies to join and facilitate shared reciprocal play. 2 Why Play? Standardized Testing Why Play? Play-based Assessment Unfamiliar setting Prescribed tasks Child is responder not initiator May be biased against children with language, motor, sensory issues Perceived deficit in one area may mask deficit in another. Sequence of skill acquisition is assumed. Underlying scores weighed equally in compiling total score. Not functional Not process oriented Learning style Rate of learning Underlying strengths/ weaknesses Developmental approach Natural Environment of the child Evaluator follows the child s lead Flexibility and may be adapted to child s individual profile Language adapted to the child s level Parent/Caregiver participation Qualitative and process oriented Leads to useful, functional play-based intervention T. Linder Transdisciplinary Play-Based Assessment 3 4 Developmental Stages incorporate these domains and serve as foundation of language and thinking (Greenspan and Shanker 2004) n Capacity to attend to sound & n self regulate n Engage in relationships n Shared affective vocals n Initiate and respond to gesture n Use gesture for shared problem solving, and recognize and produce language n Engage in joint attentional frames n Understand caregiver s communicative intentions n Expresses and shares intentions n Comprehension & Expression of Shared forms and meanings Functional Emotional Assessment Scale For Infancy & Early Childhood Authors: Stanley I. Greenspan, M.D., Georgia DeGangi, Ph.D., OTR, Serena Wieder, Ph.D. (2001) Criterion referenced instrument for children ages 7 months 4 years Systematic observational assessment of child and caregiver s functional emotional capacities during a period of shared play with toys Intended for developing a profile of the child s socialemotional capacities, and the caregiver s capacity to support their child s emotional interactions and communications, reciprocity, to represent emotions and ideas, and engage in emotional thinking and problem solving as observed through play interactions. Sherri Cawn SLP Mari Caulfield SLP 5 6 1

2 FEAS Administration FEAS consists of six versions for ages 7-9 mos., mos., mos mos., mos., 3-4 years. Maybe administered in home, school, clinical setting. Administration time min. Evaluator asks parent to play with child as they would at home. After parent has played with child, evaluator may wish to play with child to facilitate child s play repertoire and elicit play behaviors that may not have been observed. Three presentations of toys: Symbolic (5-15 min.), tactile (5 min), motor (5 min) For accuracy, play observation should be videotaped. Evaluator scores child and caregiver FEAS Basic Model and Developmental Levels Six early organizational levels For each of these levels, there are two ways of observing how the infant organizes experiences: Sensory and Affective-thematic experiences. For each developmental grouping, scale provides primary emotional and sensory-motor achievements as well as examples of affective and sensorimotor Emotional Range. For each age grouping, additional examples of associated motor, sensory, language and cognitive capacities are provided. 7 8 FEAS Levels Primary Emotional Levels 1-3 Attending, focusing and self-regulation (0-3 mos.) Is the infant calm, able to recover from distress with comforting, able to be alert, focus on caregiver when spoken to, brighten up when provided with appropriate visual, auditory, and/or tactile experiences. Mutual Engagement ( Falling in Love 2-7 mos.) Infant evidences positive loving affect toward caregivers, looks/ smiles spontaneously, responds to facial expressions, voices, touch with signs of pleasure such as smiling, relaxing, cooing Two-way Purposeful Communication with Gestures (3-10 mos.) Infant acts in purposeful (e.g., intentional, reciprocal, causeand-effect) manner; able to initiate and respond purposefully to another s signals. Uses multiple sensory modalities, motor system, and range of emotions in intentional interactions. Levels 4-5 Problem-Solving Interactions (9-18 mos.) Toddler sequences number of gestures together, responds consistently to caregiver s gestures, can form chains of interactions (circles). Demonstrates wide range of organized, socially meaningful behaviors and emotions (warmth, pleasure, assertion, curious exploration, protest, anger) Elaborating Ideas: Representational Capacity and Elaboration of Symbols (18-30 mos.) Uses interactive sequences to convey basic emotional themes. Comprehends and uses consecutive circles of communication (open and close 10 or more) with responsive caregiver through gestures. Imitates another person s behavior, then uses newly learned behavior intentionally to convey emotional theme. By 24 months child can create mental representations of feelings and ideas which are expressed symbolically (simple pretend play + words) At 30 months can create pretend drama with two or more ideas Ideas need not be related or logically connected. Uses symbolic communication (e.g., words, pictures, motor patterns) to convey two or more ideas Level 6 Bridges Between Ideas; Emotional Thinking (30-48 mos.) Complex interactions, wishes, feelings in pretend play; knows real from unreal and switches between fantasy & reality. Pretend play involves two or more logically related ideas Can build on adult play idea. Communications involve two or more ideas logically connected. Westby Symbolic Playscale Author: Carol E. Westby Evolved from Piagetian based language programs develped for severely delayed and typically developing children which found that the sequence of play stages was the same for both groups of children Appropriate for children eight months to five years. Child s play is observed for development of cognitive and symbolic elements such as object permanence, means-end problem solving with toys, object use, decontextualization (what props are used in pretend play), thematic content (schemas/scripts represented), organization of play, selfother relationships, as well as function, form and content of language

3 Westby Administration Child is allowed to choose from all the possible toys available. Child can be observed on multiple occasions. If limited time available, evaluator first presents toys expected for that child s age Child and adult (evaluator and/or parent) may play with the child, and initiator of play/ideas is noted. Examiner can present toys for either earlier or later play stages depending on level of play observed Evaluation is tape recorded for language sample analysis Westby Ten Developmental Stages of Play Presymbolic Level I (8 12 months) Presymbolic Level II (13 17 months) Symbolic Level I (17-19 months) Symbolic Level II (19-22 months) Symbolic Level III (2 Symbolic Level IV (2 ½ Symbolic Level V (3 Symbolic Level VI (3 3 ½ Symbolic Level VII (3 ½ - 4 Symbolic Level VIII ( Autism Diagnostic Observation Scale 2 nd Edition (ADOS-2) Original ADOS published in 2008 ADOS-2 in 2012 Authors: Catherine Lord, Michael Rutter Pamela DiLavore & Susan Risi University of Michigan Autism & Communications Disorders Center Ages 12 months through adulthood Exclusions: Significant hearing/vision loss Child must be mobile ADOS-2 Semi-structured standardized observational instrument assessing: Social interaction Communication Play and imaginative play Restricted and/or repetitive behaviors Standardization of the ADOS-2 is based on the hierarchy of behaviors used by the evaluator, and the kinds of behaviors taken into account in each activity during the overall coding. Activities structure the interactions they are not ends in themselves. Most easily administered in office; can be administered in home with preparation. Administered by one evaluator. For modules T, 1, 2, a parent is expected to be present. Participation by the parent is directed by the evaluator. Scored immediately after it is completed Addresses issues of unusual development (deviance) vs. developmental delay Behaviors unusual because of their presence/ absence, frequency, intensity, duration, and context Consistent with DSM5 criteria for ASD Consists of 5 modules; selection depends on individual s expressive language level, and chronological age. Features of the ADOS-2 Provides naturalistic sample of behavior Extensive collection of toys and objects provided in test kit. Creates a social world in which behaviors related to autism can be observed. Specifically structures supports needed for the child Provides clinically relevant behaviors to build goals for treatment Coding is from one observation only. Toddler Module: Pre-verbal/Single Words Age Recommended: months Consists of 11 activities with 41 accompanying items. Activities are tasks administered by evaluator Items are the target aspects of behavior that are focused on by the evaluator In some cases, you can code items across multiple activities (e.g., shared social enjoyment)

4 1. Free Play Free Play - Ball 2. Blocking Toy Play 3. Response to Name 4. Bubble Play Bubble Play Teasing Toy Play 5. Anticipation of a Routine with Object Unable Toy Play Toddler Module Activities 6. Anticipation of a Social Routine 7. Response to Joint Attention 8. Responsive Social Smile 9. Bath Time - Bath Time - Ignore 10. Functional & Symbolic Imitation 11. Snack A. Language & Communication 9 Items B. Reciprocal Social Interaction 19 Items C. Play 3 Items Toddler Module Coding D. Stereotyped Behaviors and Restricted Interests 5 Items E. Other Behaviors 4 Items All Younger/Older with Few to No Words* Social Affect 2 Language & Communication Items 8 Reciprocal Social Interaction Items Restricted & Repetitive Behavior 1 Language item 3 Stereotyped Behaviors/ restricted interest items Overall Total SA & RRB Toddler Algorithms Older with Some Words and assigned rating 0,1,2 on Item A1* - Social Affect - 1 Language & Communication Item - 10 Reciprocal Social Interaction Items - Restricted & Repetitive Behavior - 3 Stereotyped Behaviors/ restricted interest items - Overall Total - SA & RRB Where to Begin Strategies to Strengthen Attention, Regulation, Focus Help the family to observe the child s sensory and motor differences; give examples to help the child remain calm and attentive. Help the baby to look, listen, move and calm down. Harness all sensory inputs and motor capacities; couple these with highly enjoyable activities and high affect. For an older child, use both constructive and playfully obstructive activities (play chase, hide the toy under your body, make a fence of your body to capture the child) Strategies to Strengthen Engagement and Shared Attention Woo the baby into engaging with you with pleasure and delight. YOU are the toy! Start with what the child enjoys ( Follow the child s lead ). Join the child s rhythm using affect, visual, auditory/vocal and motor movements. Join with the physical objects the child enjoys put the car on your head, under your shirt. Be the bearer of pleasure! If necessary use a little bit of playful obstruction to entice her to focus on you. Strategies to Strengthen Reciprocity - Extend circles by creating extra steps (e.g., play dumb, playful obstruction) - Challenge the child to close circles. - Always combine affect with action and interaction; increase the interactive range (child is just hugging the dolls, be the wolf who comes to make trouble) - Increase interactive range in different sensory processing areas

5 Strategies to Strengthen Representational Play, Sequencing, Symbolic Thinking Always combine Words or ideas with Affect and Action. Encourage imagination through familiar interactions for pretend play (feeding, hugging dolls, bathing). Join the drama become a character and ham it up. Talk as the character and alternate as the narrator or sideline commentator. Entice the child into long dialogues in character. Strategies to Encourage Emotional Thinking, Building Connections Between Ideas Encourage pretend play; help the story to make sense with a beginning, middle, and end. Encourage connecting ideas Seek the child s opinion debate, negotiate If child cannot connect the bridges between ideas, --- offer some choices Be a player! Have opinions, use humor, conflict Encourage the child s reflection Useful Resources Examples of Developmental Play-based Observation Assessment Instruments: Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) (2012) Catherine Lord, Ph.D., Michael Rutter, M.D., Pamela DiLavore & Susan Gotham, Available through Western Psychological Services The Functional Emotional Assessment Scale (FEAS) for Infancy and Early Childhood; (2001); Greenspan, Stanley I., DeGangi, Georgia, Wieder, Serena. Interdisciplinary Council on Developmental and Learning Disorders: Bethesda, MD. Transdisciplinary Play-Based Assessment Revised Edition, (1993). Linder, Toni W. ;Paul Brookes Publishing Co.: Baltimore, MD Westby Symbolic Playscale; Westby, Carol, (1980). Assessment of cognitive and language abilities through play. Language, Speech, and Hearing Services in Schools, 11, Westby Symbolic Playscale; Westby, C.E. (2000). A scale for assessing development of children s play. In K.Gitlin Weiner, A. Sandgrund, & C. Schaefer (Eds.) Play Diagnosis and Assessment. New York: Wiley. Especially for Parents: Profectum Parent Tool Box: An extensive free electronic resource for parents providing a series of hands-on guided webcasts on working with your child to increase relatedness and engagement. Available through Profectum.org Additional Readings DeGangi, Georgia (2000) Pediatric Disorders of Regulation in Affect and Behavior. Academic Press: San Diego, CA. Gerber, S. (2007) Visual Reality: Illustrating the Application of Developmental Language Models to Language Intervention with Young Children. DVD. Supported by the Bamford-Lahey Children s Foundation. Greenspan, Stanley I., Lewis, N. (2000). Building Healthy Minds: The Six Experiences That Create Intelligence and Emotional Growth in Babies and Young Children. Cambridge, MA: De Capo Press Greenspan, Stanley I., Wieder, Serena, (1998) The Child with Special Needs. Addison Wesley Longman: Reading, MA Interdisciplinary Council on Developmental and Learning Disorders (2005) Diagnostic Manual for Infancy and Early Childhood. ICDL: Bethesda, Md. Lillis, C., Turnbull, J. (2009) Infant/Child Mental Health, Early Intervention, and Relationship-Based Therapies. A Neurorelational Framework for Interdisciplinary Practice. W.W. Norton & Company, Inc. Robinson, Ricki G., (2011) Autism Solutions; How to Create a Healthy and Meaningful Life for Your Child. Harlequin: Ontario, Canada Readings, Electronic Resources and Websites Sussman, Fern (1999) More Than Words. The Hanan Centre:Toronto, Ontario, Canada. Wieder, Serena, Wachs, Harry, (2012) Visual/Spatial Portals to Thinking, Feeling and Movement; Advancing Competencies and Emotional Development in children with Learning and Autism Spectrum Disorders. Profectum Foundation: Mendham, NJ Examples of Representational Toys for Observational Assessments Pull toys busy boxes Musical toys Rattles Cars/trucks/trains Kitchen equipment (dishes, utensils, pots) Dolls Doll bed, chair, carriage Clothing, blanket, bottles Shopping toys (purse, bags, cash register, shopping cart, calculator) Dress up materials Doctor s Kit Telephone Animals (soft and hard) Bop sticks Puppets

6 Examples of Sensory-motor Toys for Observational Assessment Bubbles Balls A slide A tunnel Squishy objects Fuzzy objects Toys that light up or flash Noise makers/music boxes Objects that spin String Reflective, shiny objects Large Ball Swing/hammock Lycra fabric for swinging Blocks (large and small) Platforms for climbing, rolling, jumping You can observe a lot by watching. - Yogi Berra Connect With Us Follow profectumfoundation Join Us Profectum Foundation 6