10/22/2012. Integrating Treatment Approaches because every child is unique. 2 nd Annual New York Conference

Transcription

1 2 nd Annual New York Conference Engaging Autism: Exploring a Common Ground between DIR and ABA-Implications for Treatment Research, Clinical and Parent Perspectives Sunday October 21 st, 2012 New York s Hotel Pennsylvania Serena Wieder, PhD Clinical Director 2 Integrating Treatment Approaches because every child is unique 3 1

2 Welcome to Profectum! Profectum Foundation is dedicated to advancing the development of all children, adolescents and adults with autism and special needs. We are here to initiate the dialogue needed to improve outcomes for children on the autism spectrum by exploring the common ground and complimentary relationship between DIR and ABA approaches. Who We Are Like-minded professionals in the field of child development are coming together to move the limitations of dogmatic integrate interventions that unique needs beyond approaches to support each child s throughout the lifespan Profectum has been created by parents who have children with autism, in partnership with leading experts from the fields of: Medicine, Psychology, Mental Health, Early Intervention, Speech and Language, Occupational Therapy, Physical Therapy, Creative Arts and Education The Profectum Foundation is a non-profit 501(c)3 tax-exempt organization dedicated to education, research and the integration of best treatment practices to meet the growing needs of individuals with special needs and their families. 5 Development has arrived or has it? No one method helps all individuals when profiles are so different There is more than one way to get good outcomes, and different therapists will gravitate to different methods. G. Dawson, 2012 Few depend on one method in reality, parents, early intervention programs and schools currently use a number of different intervention approaches. The Developmental, Individual Differences, Relationship (DIR /Floortime model) is at the core of Profectum s approach. It provides the structural capacities necessary for learning and advancing across the life span. DIR is a registered trademark of ICDL founded by Greenspan and Wieder. 2

3 But development must develop Today we would like to share the Foundational Capacities for Development (FCD) to frame the interactive experiences individuals need to develop competence The challenge is knowing how to create comprehensive and integrated approaches based on individualized profiles to advance every child and to do it well Parents know how well their children are really progressing and when more is needed we need to as well! Before we begin many thanks are in order First, to Profectum s Founder and Chair Cuong Do Next to our invited presenters and the Profectum Faculty Connie Kasari, Ph.D. UCLA Sima Gerber, Ph.D. Joanne Gerenser, Ph.D., Eden II, NY Ron Balamuth, Ph.D. Rick Solomon, M.D. Christie Virtue, Ph.D. Ricki Robinson, M.D. Avital Balsam, SLP, CCC Gil Foley, Ed.D. To our sponsors and Host Committee And to the many parents who have joined us today especially Wendy Banner and Jennifer Meilak and the families of the children we will be discussing this afternoon to help us learn from parents Profectum Conference Sponsors The FAR Fund Shirlee Taylor, Ph.D., Executive Director Parent Scholarships and operational support The New York Center for Child Development Michael Gorden and Evelyn Blanck Institute for Parenting - Adelphi University Marcy Safyer, MSW, Director Imagine Academy, School for Autistic Children Michael I. lnzelbuch, Esq. Specializing in Education Matters Steven L. Goldstein, Esq. Special Education Lawyer 3

4 New York Conference Host Committee Evelyn Blanck- Committee Chair Avital Balsam, SLP Shaya Benstein, MEd Michael Brown, MSW Carolyn Carsley, MEd Elisa Chrem, SLP Susan Foley, OT Amy Greenberg, MEd Michelle Havens, Ed.D. Mady Kaplan, MSW David Lichtman, MSW Batya Rosenberg, Ph.D. Marcy Safyer, MSW Profectum Academy s Interdisciplinary Faculty JoAnne Allison, SLP, MEd Ron Balamuth, PhD Tal Baz MS, OTR Yael Binya, OTR Kiegan Blake, OTR Mari Caulfield, LCST, SLP Sherri Cawn, MA, CCC Marjorie Cases, OTR Linda Cervenka, CCC-SLP Sara Chapman, MA Charlotte Collier, PhD Lisa defaria, LCSW, BCD Mona Delahooke, PhD Griffin Doyle, PhD Sharon Duval, SLP-CCC Anita Ellsberry, OTR/L Gilbert Foley, EdD Sima Gerber, PhD, CCC Steve Glazier, MA Ira Glovinsky, PhD Lois Gold, OTR Brooke Hampton, PT Cindy Harrison, M.Sc.SLP Barbara Kalmanson, PhD Connie Lilias, PhD, MFT, RN Patricia Marquart, MFT Myania Moses, OTR Monica Osgood Beth Osten, MS.OTR/l Stephanie Pass, PhD Lori Jeanne Peloquin, PhD Joanne Raphael. MSW Laurie Raymond, OTR/l Michele Ricamato, SLP-CCC Ricki Robinson, MD, MPH Diane Selinger, PhD Christine Seminaro, MEd Ruby Salazar,LCSW, BCD Etti Shani,SLP Teresa Sindelar, PhD Susan Smith-Foley, OTR/l Richard Solomon, MD Tracy Swink, MD Alisa Vig, PhD Christie Virtue, PhD Kathy Walmsley, OTR/l Rosemary White, OTR/l Serena Wieder, PhD Profectum Foundation Advisory Board Nancy Bell, MA Lindamood-Bell Learning Processes, CA Evelyn Blanck, LCSW New York Center for Child Development. NY T. Berry Brazelton, MD Brazelton Touchpoints Center Harvard Medical School,MA Geraldine Dawson, PhD Autism Speaks, NY Deborah Flaschen 3LPiace,MA Connie Kasari, PhD UCLA, CA Lucy Miller, PhD SPD Foundation, CO David Oppenheim, PhD University of Haifa, Israel Sally Rogers, PhD Mind Institute, CA Suzi Tortora, EdD Dancing Dialogue, NY Harry Wachs, OD Washington, DC 4

5 Profectum Foundation Board Members Non-clinical Board Members Cuong Do Founder and EVP & Chief Strategy Officer, Merck Paul Antony, MD, MPH Executive Director of Global Health Progress and the Chief Medical Officerfor the Pharmaceutical Research and Manufacturers of America (PhRMA) Geraldine Dawson, MD Chief Science Officer, Autism Speaks Joanie Fischer Author specializing in neuroscience and child development and former Senior Editor,US News & World Reports Raj Ratnakar VP of Strategy, TE Connectivity Autism is in the news every day, awareness is growing. the days of wait and see may be over The hope is that if we can improve intervention with infants and toddlers, many of them will be able to leave their disabilities behind by age 5. Sally Rogers, 2012 The promise of early intervention has led to embracing concepts of development, relationships and individual needs. The literature now abounds with studies of emotional engagement, joint attention, interactive strategies, and play to develop language, eye contact and symbolic thought as well as behavioral studies. Has Development finally come of age? How far have we come. How far we have to go From Kanner and the first DSM Classification The Combatting Autism Act of 2006 finally created a flurry of research Risk-Prevention models We can now identify perinatal and genetic risk factors, if not causes Both observation and imaging study scan now identify high risk 6 month olds who later develop ASD The Interactive Autism Network and registry join forces to conduct research New research suggests early intervention before age six can reverse or decrease the severity of symptoms 5

6 New questions - Is it the method? Is it the provider? Is it intensity? There is more than one way to get good outcomes, and different therapists will gravitate to different methods. G. Dawson, 2012 A LEAP study found that better outcomes related to intensive training and coaching teachers rather than just providing a manual And Kasari found the quality of parents participation in expanding their child s interest in play was linked to better progress What of Older children? Those who received early intervention but progress limited barriers? Those who were identified at older ages Needs continue to outweigh the research Far fewer studies in school aged and teens. Some recent findings show that intervention can improve social competence and peer relationships through friendship training (Dawson, et. al, 2011) Older children continue to advance in communication, adaptive behavior and cognitive abilities We believe development is life long Recent approaches: CBT combined with social skills instruction reduced anxiety and aggression Combining behavioral interventions with medications is more effective than medication alone For those with intellectual disabilities desensitization was more effective Research reports on outcomes that can be measured Clinical practice outcomes embrace complexity real world functioning and learning 6

7 We are here to explore the new Frontier of treatment approaches and identify common goals But: More Questions than Answers Which treatments are best for whom? Geri Dawson cautions not all children respond to the same treatment, though. Focusing on which treatments are best for children at different developmental stages What about older children, teens and adults? How will we know? Brains research will help us learn how to individualize treatment so we can tailor it to each child Laura Screibman, 2012 Need more long term research comparing a variety of treatments and which sustain gains throughout the person s life The DIR model revolutionized the concept of development Synthesized and integrated various developmental frameworks and moved development from milestones to integrative forces Developmental, Individual Difference, Relationshipbased Model Emerged from an NIMH Study of multi-risk families over 30 years ago rooted in psychodynamic, attachment and cognitive theories, work with high risk families, individual differences, and sensory integration Defined the structure of development for lifelong functioning 7

8 DIR Introduced Major Paradigm Shifts from Behavioral to Dynamic Developmental Systems That AFFECT was central to relating, learning and understanding - emotions drive early cognitive development That we were now treating interactive relationships and not just the child - this relationship provides vehicle for learning That everyone has individual differences and needs tailored interventions to treat processing challenges derailing comprehension That integrated interdisciplinary comprehensive models are important (not single approaches) That competencies come from developmentally appropriate experience That development builds on what you know and is meaningful and then moves forward Developmental disorders need dynamic developmental approaches across the life span 22 The Developmental Course of ASD In DIR theory, the child has biological/neurological difficulty in connecting emotion to their emerging ability to plan and sequence their actions what gets in the way of this sensory-motor-affect connection? Now neuroscience has shown us there are problems with connectivity with many parts of the brain Every individual s profile is unique and varies in the degree to which this fundamental capacity is disrupted given differences in sensory modulation and basic motor, visualspatial, auditory processing, and language capacities Every child needs responsive and loving relationships above all and every family needs to be supported 23 The Developmental Course of ASD Autism is a disorder of neural connectivity between these regions and we believe if you harness AFFECT you can coordinate those connections and integrate components of development Needs and goals change over time and intervention must change with it to promote progress 8

9 DIR : 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. These provide the internal structure of development Symptoms or adaptive behaviors are the result of these stage specific interactions. 25 Integration is the Hallmark of the DIR Model A Hierarchical Structure for Development The D - Functional Emotional Developmental Levels or Structure (FEDL) describe capacities that build the internal structure for development from regulation and shared attention, to engagement, to two way communication, to social problem solving, creating ideas and abstract thinking The I - the way to see the rhythmic interaction between the various sensory motor processes, regulation and tailoring interactions to these individual differences in auditory processing and language, visual spatial processing, motor planning and sequencing, and sensory modulation The R the relationships that are the vehicle for learning and feeling, and take culture and environment into account that support initiation and intent The DIR model integrated intellect and emotion Through AFFECT the dual coding of experience that tells us what things mean - the emotional signaling we use to alert, engage, and convey feelings and meanings 26 DIR : A Dynamic Systems Model of Development Sensory Modulation Auditory processing & Language Visual Spatial movement & thinking Motor planning & Sequencing Biological Individual Differences Relationship based Child Caregiver Interactions Affect based interactions Activate development - initiation, intention Functional Emotional Developmental Structure Regulation and shared attention Engaging and relating Simple two-way gesturing Complex problem-solving Creative use of ideas - symbols Analytic/logical thinking 27 9

10 DIR and FCD: Affect Based Learning Affect carves the pathway for learning provides direction for actions (movement), visual thinking, and meanings (of symbols and words) Interactive strategies are based on child s initiation of intent or affect Uses child s natural intentions, interests and feelings as the personal foundation of learning Identify meaningful opportunitie sto understand the reasons actions/skills are necessary in meaningful way Simultaneous Emotional and Cognitive Development -Dual coding of experience is key to understanding how emotions organize functional capacities and intellectual abilities When we observe behavior we may ask different questions but we are all seeking developmental and adaptive behavioral change Examine the foundation or underpinnings What if problem behavior is part of a larger developmental failure? What if the individual 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 Lacks the symbols to express emotions Risks, Myths or Differences Will focusing on isolated units of behavior can obscure a larger developmental challenge and miss the larger opportunity to master critical developmental milestones? Will focus on behavioral control rather than engagement derail learning that relationships can be warm and supportive? Will very concrete rewards or negative consequences undermine the first goal of creating a sense of relationship and engagement and range of emotions? Will unstructured models derail identifying/providing the experiences that make a difference in achieving competence? Do skills lead to competence? 10

11 In DIR, Floortime Builds a Symbolic World Goal is to learn we have to substitute reality through symbols or images 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) Symbolic play turns images into concepts which reflect the meaning of the image Floortime Solutions: Why Build a Symbolic World? Symbolic play and conversation is the safe way to practice, reenact, 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 Symbolic play can be derailed and derails adaptation and development It s not all Floortime But it is comprehensive! Floortime is the essence 6-8 daily sessions Talk Time ongoing reality based problem solving conversations Semi-Structured Problem Solving and Behavioral Support Problem Solving Activities social games, ritualized learning, reading, work, getting ready 3-4 daily sessions Sensory Motor and Regulatory Activities 3-4 daily sessions Play Dates according. to age Social Groups School Based Programs Therapy Activities OT, SLP, PT, VCT Family Support Augmentation visual strategies, auditory training, PECS, VOCAs, Typing Nutritional-Medication Interventions 11

12 Foundational Capacities Developmental Processes Organizes Integrates Experience Affect Activates The building blocks of structure Affect activates interest, initiative, intent, and provides direction for action Organizes the sequences of thought and action needed to comprehend and plan Integrates experience to develop competence, caring, self-control, emotional range 34 Competence depends on finding the sequence that takes you from the start to the finish Requires initiation, intent, comprehension purposeful objectives AFFECT Need anchors to take in and connect all the parts of what you see, hear, move, feel and think COMPREHENSION Organization- Knowledge to find where to go next in an orderly and logical way VISUAL SPATIAL PRAXIS Carry out what you want to do and independently or interactively EXECUTE 35 The DIR Structure and the Building Blocks of Foundational Capacities Start with Experience Experience takes many forms From spontaneous, incidental or semi-structured, to the structured and systematic development of knowledge and skill Can be initiated by the child or the family and other caregivers Experience allows you to learn about the real world Experience is felt on the inside as well as the outside Allows you to know your feelings, desires and sense of who you are Become the building blocks of the FEDL structure 36 12

13 But Exposure is NOT Enough To develop, experience should be Based on some need: curiosity, interest, novelty Have some meaningful purpose Be active and interactive in a sequential manner Be understood: learning requires comprehension Builds on prior experiences Experience fills in the structure 37 Paucity of Knowledgeable Experience So what gets in the way? Patterns have been established where others do the work caregivers do not have the expectations, tend to be protective without noticing do not recognize when child might be ready and underestimate the child s abilities find it just easier to do the work! hold on to do it better, look nicer! Experience is not meaningful (out of awareness) or relevant to the child; not initiated, imitated or intentional; or Child may have understanding but not have the abilities to execute Child may be trained but not know why, when or where to apply 38 Experience based on problem solving is the most useful if it is a problem for the child and meaningful To identify the opportunities you have to create these changes and problems for your child to solve, think about your day. Consider the following and make a list under each category: all the things you routinely do for your child all the things your child expects or waits for you to do all the things your child already expects you to do for him or herself all the things your child desires and or expects to have or go to daily challenges 39 13

14 Foundational Capacities of Development Lead to Competence Confidence Self-Esteem Security Self- Control (regulation) Caring Connect Emotions Self- other Conditions of the Environment Competence in real life Community Social Belonging Culture Comprehension and reasoning C Creativity 40 This is a very valuable book especially for parents and professionals who deal with children with special needs and autism. I recommend that you read it and treasure it T. Berry Brazelton, MD Professor of Pediatrics, Emeritus Harvard Medical School Founder, Brazelton Touchpoints Center Visual/Spatial Portals to Thinking, Feeling and Movement Advancing Competencies and Emotional Development in Children with Learning and Autism Spectrum Disorders With Visual/Spatial/Cognitive Manual Serena Wieder, Ph.D. & Harry Wachs, O.D. 14