The Basic Model and Early Identification The DIR /Floortime TM Model; Approaching Early Identification; Reliable Early Indicators Affect through the Functional Emotional Capacities Interactions create more variation in the affect Transforming physiological processes through social relationships into affects Through the functional emotional developmental stages, a broader range of affect develops Interacting with affect through purposeful communication leads to the first sense of self Moving up the ladder, affective interactions are developing and used in a continuous flow which is the foundation for further development www.stanleygreenspan.com S.I.Greenspan, M.D. 1 www.stanleygreenspan.com S.I.Greenspan, M.D. 4 Key concept of the basic model Key word: Affect Affect is derived from relationships It is difficult to experience a full range of affect without human interaction Affect through the Functional Emotional Capacities continued www.stanleygreenspan.com S.I.Greenspan, M.D. 2 Uniting and integrating all the different affects experienced to finally develop into a preverbal sense of self Continuous flow of affects allow the separation of perception from actioncreation of ideas Images get invested with experiences and affect develop symbols and true meaning All stages start from affect and relationships and lead to higher level of thinking www.stanleygreenspan.com S.I.Greenspan, M.D. 5 Role of affect in the development of the brain and the mind A newborn only has a few basic capacities Most of the brain is developed postnatally Allows the human brain and mind to adapt to the environment Where does consciousness develop from? Consciousness is not a property of the brain- it emerges from social relationships and the affects they produce Autism Spectrum Disorders Biologically, the connection between affect and motor planning is not fully developed does not respond to experience easily Not fully blocked side roads open By getting heightened stage of affect, we can develop the side pathways that are not blocked and develop affect based learning For affect based learning to occur we need a fully comprehensive DIR intervention www.stanleygreenspan.com S.I.Greenspan, M.D. 3 www.stanleygreenspan.com S.I.Greenspan, M.D. 6 1
DIR Floortime Model Biologically Based Individual Differences Child- Caregiver Interactions Functional Capacities Focus and attention Engaging and relating Simple two-way gesturing Complex problem-solving Creative use of ideas and symbols Analytic/logical thinking Family, Community, Culture How DIR comes together In order to get the child s affect connection cooking you need to know the child s individual differences In order to reach a child you must meet the child at his/her level l Tailoring interactions to the child s profile and creating learning relationships Harnessing the child s natural affect Challenging and enticing the child - allowing two-way purposeful communication to develop www.stanleygreenspan.com S.I.Greenspan, M.D. 7 www.stanleygreenspan.com S.I.Greenspan, M.D. 10 Biological Challenges CNS Processing Capacities Auditory Processing and Language Visual-Spatial Processing Motor Planning and Sequencing Sensory Modulation Child- Caregiver Interactions Functional Capacities Focus and attention Engaging and relating Simple two-way gesturing Complex problem-solving Creative use of ideas and symbols Analytic/logical thinking Diagnostic Patterns Deficit in affect-motor planning-symbol formation connection Deficit in different processing patterns www.stanleygreenspan.com S.I.Greenspan, M.D. 8 Affect Connection Different patterns among different children Even if we get the affect connection, there are other processing areas that are more severely affected Affect provides the basis for the connectivity of the brain early in life www.stanleygreenspan.com S.I.Greenspan, M.D. 11 Motor & Perceptual Motor Functioning Sensory Modulation Sensory Processing Auditory Processing DIR /Floortime MODEL Educational Program/ Peer Interactions Screening Functional Evaluation History Family Patterns Biomedical Assessment Review of Current Functioning Child/ Caregiver Interactions www.stanleygreenspan.com S.I.Greenspan, M.D. 9 ICDL-DMIC Greenspan Social-Emotional Growth Chart A Reliable, Validated Screening Questionnaire for Infants and Young Children Greenspan, SI. 2004. Published by PsychCorp, www.psychcorp.com www.stanleygreenspan.com S.I.Greenspan, M.D. 12 2
Approaching early identification with the Social Emotional Growth Chart A validated, norm-referenced screening of key social emotional milestones in infants and young children 0-42 months old Allows pediatricians to chart emotional growth Short 35 item questionnaire designed to be completed by parents or caregivers in less than 10 minutes Easy to administer and score by any professional involved in clinical or educational work with children and their families www.stanleygreenspan.com S.I.Greenspan, M.D. 13 Greenspan, S.I. Excerpted from Building Healthy Minds, Perseus Books, 1999. Stages Logical bridges - 2 Logical bridges - 1 Ideas beyond basic needs Ideas (words/symbols) Comp. problem-solving Simp. problem-solving Purposeful interaction Engagement Attention/focus THE SOCIAL-EMOTIONAL GROWTH CHART 2 Norm Regression Early Onset Age in Months 0 3 5 9 13 18 24 30 16 3616 42 48 Conceptual framework, Domains, and Number of Items Functional Emotional Milestones Age in months # of questio ns Stage 1 Self-regulation & interest in the world 0-3 11 Stage 2 Engages in relationships 4-5 13 Stage 3 Uses emotions in interactive purposeful 6-9 15 manner Stage 4a Uses series of interactive emotional 10-14 17 signals or gestures to communicate Stage 4b Uses series of interactive emotional 15-18 21 signals or gestures to solve problems Stage 5a Uses symbols or ideas to convey 19-24 24 intentions or feelings Stage 5b Uses symbols or ideas to express more 25-30 28 than basic needs Stage 6 Creates logical bridges between emotions and ideas 31-42 35 14 www.stanleygreenspan.com S.I.Greenspan, M.D. 14 Social Emotional Growth Chart Index Scores New Cutoff Scores Age Bands challenges Immediate Referral needed Mastery 0-3 Months 0-14 15-28 29-55 4-5 months 0-34 35-46 47-65 6-9 Months 0-45 46-57 58-75 10-14 Months 0-52 53-63 64-85 15-18 Months 0-59 60-76 77-105 19-24 Months 0-68 69-86 87-120 25-30 Months 0-81 82-106 107-140 31-42 Months 0-91 92-124 125-175 Scaled Scores Significant Challenges Moderate Emerging Challenges Mastery 1-3 4-6 7-18 17 www.stanleygreenspan.com S.I.Greenspan, M.D. 17 Stages Logical Bridges - 2 Greenspan, S.I. Excerpted from Building Healthy Minds, Perseus Books, 1999. THE SOCIAL-EMOTIONAL GROWTH CHART SEGC Sensitivity & Specificity as a screening tool for ASD Logical bridges - 1 Total Growth Chart Score Ideas beyond basic needs Ideas (words/symbols) Comp. problem-solving Simp. problem-solving Purposeful interaction Quicker progress Slower progress Scaled Scores 6 or less SENSITIVITY 86.6% SPECIFICITY 90.2% Engagement Attention/focus Problems increase with age Good sensitivity, correctly identifies about 87% of ASD children Good specificity, correctly identifies about 90% of typically developing children but 10% can falsely fall in this category Age in Months 0 3 5 9 13 18 24 30 3615 42 48 18 www.stanleygreenspan.com S.I.Greenspan, M.D. 18 3
Age of First Observation 30 Early ID Study Lisa Bayrami Stanley Greenspan Devin Casenhiser n Months Age in 25 20 15 10 No significant difference TD ASD 5 0 Purposeful Interaction 1st Social Smile Cooing Reduplicated Complex Babbling Babbling (BABA) (BAGA) www.stanleygreenspan.com S.I.Greenspan, M.D. 19 www.stanleygreenspan.com S.I.Greenspan, M.D. 22 Approaching early identification with the Early ID Study Retrospective video review of typical children and those with ASD Coding of home video tapes Looking for the infant s: Ability to conduct multiple activities simultaneously Social interactions Early signs of affect connections Takes a functional approach do not rush into a single diagnosis, but consider multiple diagnoses and hope to prevent with intervention approaches www.stanleygreenspan.com S.I.Greenspan, M.D. 20 Typical Means About 70% of the TD kids show their first purposeful interaction (not necessarily an initiation) before 10 months. At the same time about 70% of ASD kids show their first interaction (again, not necessarily an initiation) after 10 months. About 70% of the TD kids show their first social smile before the age of 3 months. 86% of the ASD group shows their first social smile (if at all) after 3 months. For complex babbling, there were no segments before 2 years (when we stopped coding) in which children with ASD produced complex babbling ( bada as opposed to reduplicated babbling baba ) on tape. About 67% of the typical children showed complex babbling on tape before 12 months. www.stanleygreenspan.com S.I.Greenspan, M.D. 23 Earliest Occurrence of Significant Events Interaction Types Reviewed videos to find earliest occurrence of the following: social smile cooing reduplicated babbling (e.g., baba or gaga) complex babbling (e.g., bada or badaga) 1.5 minute segments were reviewed at 2.5 to 3.5 months of age to determine whether there was a difference in the number of interactions of the following types of interactions Eye contact alone Eye contact plus vocalization Eye contact plus arm/leg movement Eye contact plus vocalization plus arm/leg movement www.stanleygreenspan.com S.I.Greenspan, M.D. 21 www.stanleygreenspan.com S.I.Greenspan, M.D. 24 4
nces in 1.5 minute segment Number of occuran 16 14 12 10 8 6 4 2 0 Comparison of types of interaction for ASD and TD Groups. Marginally significant difference EC EC/NV EC/V EC/NV/V EC=Eye Contact, EC/NV=Eye Contact + Non-verbal action, EC/V=Eye Contact + Vocalization; EC/NV/N=Eye Contact + Non-verbal action + Vocalization Significant difference TD ASD www.stanleygreenspan.com S.I.Greenspan, M.D. 25 Disorders (cont.) Purposeful emotional interactions (begins at 4-10 Long chains of back-and-forth emotional signaling (begins at 10-18 Leading to ASD No interactions or only brief backand-forth interactions with little initiativetaking No engagement or only fleeting, expressions of joy, rather than robust, sustained, engagement Unpredictabl e (random and/or impulsive) behavior Selfabsorption or withdrawal www.stanleygreenspan.com S.I.Greenspan, M.D. 28 Can Autism Be Prevented: Reliable Early Indicators Early Identification and Preventive Intervention Disorders (cont.) Creating ideas (begins at 18-30 mo,) Long chains of back-and-forth emotional signaling (begins at 10-18 Leading to ASD No words or scripted use of words (e.g., mostly repeats what is heard). No engagement or only fleeting, expressions of joy, rather than robust, sustained, engagement Unpredictabl e (random and/or impulsive) behavior Echolalia and other forms of repetition of what s heard or seen www.stanleygreenspan.com S.I.Greenspan, M.D. 26 www.stanleygreenspan.com S.I.Greenspan, M.D. 29 Disorders Disorders (cont.) Shared attention and regulation (begins at 0-3 Engagement and relating (begins at 2 to 5 Leading to ASD Lack of sustained attention to different sights or sounds. No engagement or only fleeting, expressions of joy, rather than robust, sustained, engagement Aimless or self- stimulatory behavior Selfabsorption or withdrawal Building bridges between ideas: Logical thinking (begins at 30-42 Leading to ASD No words or memorized scripts, coupled with random, rather than logical, use of ideas. Illogical or unrealistic use of behaviors and/or ideas. www.stanleygreenspan.com S.I.Greenspan, M.D. 27 www.stanleygreenspan.com S.I.Greenspan, M.D. 30 5
Key things to remember for early identification and preventive intervention Broad based - not just for children at risk for ASD, but for any delay or challenge Take a functional approach and do not rush into a diagnosis Cannot focus on single behaviors -must promote healthy overall development Emphasis on what needs to be overcome and encourage healthy affective development Building healthy foundations by following the child s lead, tailoring to their individual profile, and getting the functional emotional developmental capacities cooking www.stanleygreenspan.com S.I.Greenspan, M.D. 31 6