The Basic Model and Early Identification The DIR /Floortime TM Model; Approaching Early Identification; Reliable Early Indicators www.stanleygreenspan.com S.I.Greenspan, M.D. 1
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 t human interaction www.stanleygreenspan.com S.I.Greenspan, M.D. 2
Role of affect in the development of the brain and the mind A newborn only has a few basic capacities i Most of the brain is developed postnatally Allows the human brain and mind to adapt to the environment Where does consciousness develop from? Consciousness sness is not a property of the brain- it emerges from social relationships and the affects they produce www.stanleygreenspan.com S.I.Greenspan, M.D. 3
Affect through the Functional Emotional Developmental 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. 4
Affect through the Functional Emotional Developmental Capacities continued Uniting and integrating ti 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
Autism Spectrum Disorders Biologically, i ll 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. 6
DIR Floortime Model Biologically Based Individual Differences Family, Community, Culture Child- Caregiver Interactions Functional Developmental Capacities Focus and attention Engaging and relating Simple two-way gesturing Complex problem-solving Creative use of ideas and symbols Analytic/logical thinking www.stanleygreenspan.com S.I.Greenspan, M.D. 7
Biological Challenges Auditory Processing and Language Visual-Spatial Processing Motor Planning and Sequencing Sensory Modulation CNS Processing Capacities Child- Caregiver Interactions Functional Developmental 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
DIR /Floortime MODEL Motor & Perceptual Motor Functioning Sensory Modulation Sensory Processing Auditory Processing Screening Functional Developmental Evaluation Developmental History Family Patterns Biomedical Assessment Review of Current Functioning Educational Program/ Peer Interactions Child/ Caregiver Interactions www.stanleygreenspan.com S.I.Greenspan, M.D. 9
How DIR comes together th 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 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. 10
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
ICDL-DMIC 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
Approaching early identification with the Social Emotional Growth Chart A validated, norm-referenced 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
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 Stage 4a Uses emotions in interactive purposeful manner Uses series of interactive emotional signals or gestures to communicate 6-9 15 10-14 17 Stage 4b Uses series of interactive ti emotional 15-1818 21 signals or gestures to solve problems Stage 5a Stage 5b Uses symbols or ideas to convey intentions ti or feelings Uses symbols or ideas to express more than basic needs 19-24 24 25-30 28 Stage 6 Creates logical bridges between emotions and ideas 31-42 35 14 www.stanleygreenspan.com S.I.Greenspan, M.D. 14
Greenspan, S.I. Excerpted from Building Healthy Minds, Perseus Books, 1999. Developmental Stages Logical Bridges - 2 Logical bridges - 1 Ideas beyond basic needs THE SOCIAL-EMOTIONAL GROWTH CHART Ideas (words/symbols) Comp. problem-solving Quicker progress Simp. problem-solving Purposeful interaction Slower progress Engagement Attention/focus Problems increase with age Age in Months 0 3 5 9 13 18 24 30 36 15 15 42 48
Greenspan, S.I. Excerpted from Building Healthy Minds, Perseus Books, 1999. Developmental Stages THE SOCIAL-EMOTIONAL GROWTH CHART 2 Logical bridges - 2 Logical bridges - 1 Ideas beyond basic needs Ideas (words/symbols) Norm Comp. problem-solving Simp. problem-solving Purposeful interaction Regression Engagement Attention/focus Early Onset Age in Months 0 3 5 9 13 18 24 30 16 3616 42 48
Social Emotional Growth Chart Index Scores New Cutoff Scores Age Bands Developmental 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 10-1414 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 Moderate Mastery Challenges Emerging Challenges 1-3 4-6 7-18 17 www.stanleygreenspan.com S.I.Greenspan, M.D. 17
SEGC Sensitivity & Specificity as a screening tool for ASD Total Growth Chart Score Scaled Scores 6 or less SENSITIVITY 86.6% SPECIFICITY 90.2% 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 18 www.stanleygreenspan.com S.I.Greenspan, M.D. 18
Early ID Study Lisa Bayrami Stanley Greenspan Devin Casenhiser www.stanleygreenspan.com S.I.Greenspan, M.D. 19
Approaching early identification with the Early ID Study Retrospective ti 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
Earliest Occurrence of Significant Developmental Events 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) www.stanleygreenspan.com S.I.Greenspan, M.D. 21
Age of First Observation 30 Age in Mon nths 25 20 15 10 No significant difference TD ASD 5 0 Purposeful 1st Social Smile Cooing Reduplicated Complex Babbling Interaction Babbling (BABA) (BAGA) www.stanleygreenspan.com S.I.Greenspan, M.D. 22
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 ti (again, not necessarily an initiation) iti 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
Interaction ti Types 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. 24
Comparison of types of interaction for ASD and TD Groups. Number of oc ccurances in 1.5 minute segment 16 14 12 10 8 6 4 2 0 Marginally significant difference EC EC/NV EC/V EC/NV/V Significant difference TD ASD EC=Eye Contact, EC/NV=Eye Contact + Non-verbal action, EC/V=Eye Contact + Vocalization; EC/NV/N=Eye Contact + Non-verbal action + Vocalization www.stanleygreenspan.com S.I.Greenspan, M.D. 25
Can Autism Be Prevented: Reliable Early Indicators Early Identification and Preventive Intervention www.stanleygreenspan.com S.I.Greenspan, M.D. 26
The Earliest Signs of Autistic Spectrum and Related Developmental Disorders What to Early Signs Associated Encourage Leading to ASD Symptoms Shared attention Lack of sustained Aimless or and regulation (begins at 0-3 mo.) attention to different sights or sounds. selfstimulatory behavior Engagement and relating (begins at 2 to 5 mo.) No engagement or only fleeting, expressions of joy, rather than robust, sustained, engagement Selfabsorption or withdrawal www.stanleygreenspan.com S.I.Greenspan, M.D. 27
The Earliest Signs of Autistic Spectrum and Related Developmental Disorders (cont.) What to Early Signs Associated Encourage Leading to ASD Symptoms Purposeful emotional interactions (begins at 4-10 mo.) Long chains of back-and-forth and emotional signaling (begins at 10-18 mo.) No interactions or only brief backand-forth interactions with little initiative- taking No engagement or only fleeting, expressions of joy, rather than robust, sustained, engagement Unpredictabl e (random and/or impulsive) behavior Self- absorption or withdrawal www.stanleygreenspan.com S.I.Greenspan, M.D. 28
The Earliest Signs of Autistic Spectrum and Related Developmental Disorders (cont.) What to Early Signs Associated Encourage Leading to ASD Symptoms Creating ideas (begins at 18-30 mo,) Long chains of back-and-forth emotional signaling (begins at 10-18 mo.) 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. 29
The Earliest Signs of Autistic Spectrum and Related Developmental Disorders (cont.) What to Early Signs Associated Encourage Leading to Symptoms ASD Building bridges No words or Illogical or between ideas: Logical thinking memorized scripts, unrealistic use of (begins at 30-42 coupled with behaviors mo.) random, rather and/or than logical, ideas. use of ideas. www.stanleygreenspan.com S.I.Greenspan, M.D. 30
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