The Miller Method® and

DIR®/Floortime™:
Complementary approaches for our most
challenged children with ASD
A Charity Conference / Benefit
June 6 & 7, 2009
Courtyard by Marriott
San Diego Airport / Liberty Station
San Diego, California
 Redacted for Circlestretch
• This version of the powerpoint has all
the information from the conference
except that extraneous slides such
as announcements and some of the
identifying information about case
examples has been removed for
privacy purposes.
 Joshua D Feder MD
DFAPA

Assistant Clinical Professor,

Dept of Psychiatry, University of
California at San Diego School of
Medicine

Faculty, Interdisciplinary Council on

Developmental and Learning
Disorders
 Disclosures

ICDL Faculty – minimal - review of

clinical write ups, travel and room
for conferences where I teach
NIMH/ Duke University – minimal –
administrative time for
pharmacogenetic research
NIH – BRIDGE Collaborative - minimal
– honorarium for ‘consultative
services’
 Thanks Yous
• Valerie Saraf, Karen Dotsen, Cherry Cari,
Karyn Searcy, Aubyn Stahmer, ACES, DTC
• DIR local consortium (Mara Goverman and
Lori McCurdy)
• Marit Goldman (circlestretch)
• Jennifer Dowd-Furlong
• Lana Randell
• Lisa Drake
• Dr Miller
 This Is For the Kids…
• Families
• Certificate candidates
Warning: this will go fast

All the slides will be posted on

www.circlestretch.com

Since we have limited time I will skim

over slides marked with a
 circlestretch
Help the child be…

• Calm enough to interact

• Truly connected to others
• In a continuous expanding
balanced
back and forth flow of
interaction
“Go for that gleam in the eye!”
http://www.circlestretch.com
 Taking Notes?
• One word: ENGAGEMENT

• One phrase: Engagement goes

beyond compliance.
 About the case examples
• Thank you to those who have agreed to share
• The impact on the family of sharing
• Selected slices to demonstrate aspects of
DIR®/Floortime™
• Intensity of intervention varies
• Time course of change varies widely
• Please respect the sanctity of the information
• If you happen upon someone here, say ‘thanks!’
• If you see one of these families out there,
etiquette says to say a ‘silent thank you’
 Feder’s pieces, Day 1:
• A. An Example (1), B. Big Problems in ASDs
• What is DIR®/Floortime™ & more examples
(2,3,4,5)
• Comparing with behavioral approaches
• The D – the I – and the R, and another example
• Comparing the Miller Method with DIR, with
example (6)
• Break
• DIR®/Floortime™ at Home and School
• Facilitating interactions
• Managing Difficult Moments, and brief examples
(7-13)
• Questions
 Feder 411
• Career – biomedical engineering and math, Navy – some operational
medicine, psychiatry at Balboa, child and adolescent at Tripler, Clinic at
Pearl, Chief of Child at NNMC/ USUHS faculty, Greenspan & Wieder in DC,
back to San Diego in ‘96, ‘unejectible’ in Solana Beach since 2001.
• Research – perflorinated hydrocarbons, mathematical models of mind and
cognition (ADHD), physician use of mammography, blood preservation,
relationship based interventions, pharmacogenetics, early intervention
• Autism Spectrum Disorders: 1980 Mass. Assn for the Blind (Congenital
Rubella); 1982 teacher at school for autistic adults (Behavioral training);
BUSM Pediatric Neurology 1985; Child Study Group – Tripler (Lee);
Neurodev. Clinic NNMC 1993 - 1996; Greenspan, Wieder et al ICDL 1993-
present; AACAP Autism Committee 1997-2000 & ad hoc (Volkmar, Cook);
AACAP Autism Medication Panels (Volkmar); AACAP Autism in the schools
training 2006 (Chenven, Akshoomoff, Feder).
• Practice – time 1/3 evaluation and case management, 1/3 therapy, 1/3
teaching and research; dx ½ developmental and learning disorders, ½
general psychiatric (ADHD, Bipolar, PTSD, Tourettes, Depression, OCD
etc.); age range 1/3 infants and children, 1/3 older children and
adolescents, 1/3 adults
• Community work: Rady Autism Research Workgroup, BRIDGE
Collaborative, SDPS Ethics committee / resident training in ethics; ICDL
Institute, F2F and online courses
• Outside life – coaching science and engineering, running a dance
company, reading, care of chronically ill house pets…
circlestretch
“Go for that gleam in the eye!”
http://www.circlestretch.com
Part 1a: An Example (1):
S

Severe Dysregulation and

Aggression
 About S :

• failure to develop language, motor skills.

• multiple medications, with side effects:
sedation, dysphagia, bruising, ataxia
• ABA - DTT
• Miller Method
• DIR®
 Video clips
• Clip 1: 04/08
• Clip 2: 08/08
• Clip 3: 12/08
 Functional Emotional
Developmental Levels

…or, what the general ‘look’ is, over

time
 FEDL Over Time
• 4 – could sit a bit, give me a rare glance,
take off my post-it’s on occasion
• 8– moments of gleam and a couple of
circles when I swipe her things…
• 12 – more attached to the book, able to
use it as leverage for more engagement,
many circles, and the bare beginnings of
flow, no real sense of symbolic (but worth
a try)
 FEDL - S
1 (not 2 (barely) 3 4 (ok w/ 5 6 (ok 7 (ok)
there) (islands) support) (comes unless
back) stress)
Regulate 4 8 12

Engage 4 8 12

Circles 4 8 12

Flow 4 12
8

Symbols 4

Logic 4, 8
8
12
12
Individual Differences
 Individual Differences - S
Sensor Postural Response to Intent to Visual Praxis -
y Communicatio Communica Exploration
n te
Sensory Unstable, made Some Difficulty A relative Ideas at
seeking… worse by meds comprehension of indicating area of times,
sharp redirection with gesture, difficulty without
Dysarthric – effective
1. focus on planning nor
Auditory 1 indicate 1. Mirror object sequencing
Visual desires 1. Orient vocalizations 2. Alternate
Tactile 2. mirror 2. key tones 2.. Mirror gaze Ideation
Vestibular gestures gestures 3. Follow
Proprio- 3. imitate 3. key gestures 3. gestures another’s gaze Planning
ceptive gesture 4. key words 4. sounds to determine (including
Taste 4. Imitate with 5. Switch auditory 5.words intent. sensory
Odor purpose. attention back and 6. two –word 3. Switch knowledge to
5. Obtain desires forth 7. sentences visual do this)
6. interact: 6. Follow 8. logical flow. attention
- exploration directions 4. visual figure Sequencing
- purposeful 7. Understand ground
- self help W ?’s 5. search for Execution
-interactions 8.abstract object
conversation. 6. search two Adaptation
areas of room
7. assess
space,
shape and
materials.
 Reflection:

What works, what doesn’t and why:

• Miller Method – learned some systems
• Medication: pros and cons
• ABA - content mastered, some is somewhat functional, e.g.,
“turn the page”, some is not taking (‘green’)
• Leveraging her ideas worked here
• Leveraging her desires to get language
• “Why”: semi-structured activity, affective holding
environment, medicated so I feel safer and she can be a bit
more regulated, up on the ottoman, loves the book,
positioning, her steadying herself on my arm, the stars
were lined up,….complex case, making gradual progress
 The bigger picture:
• broad goals: co-regulation,
engagement, reciprocity, symbolic
overlay
• multimodal intervention: you name
it, parents are trying to do it –
parents are the core managers to
work toward coordination between
modalities and maintain coherent
goals
 Part Ib: Some Big Problems

• Aggression – Tantrums
• Self-Injurious Behavior
• Self-stimulating behavior
• Running Off / Safety
• Transitions
• Perseveration – Obsessive/Compulsive -
Rigid
• Compliance
• Communication
 Some of the usual
methods…
• Functional Behavioral Analysis
• Antecedents – Behaviors – Consequences
• Behavioral Support Plans
• Contingencies (rewards, consequences)
• Predicting triggers, setting up the environment
• Sensory breaks
• Social stories
• Structure – visual schedules - predictability
• Prompts and prompt fading
• Extinction
 Limitations to the usual
methods
• Address surface behavior
• Solutions are given to the child
• They are limited solutions – hard to
generalize
• Rigid structure can foster more rigidity
• Sensory breaks can breed ‘escape’
behavior
• Does not address foundational social-
emotional capacities
 DIR and tough challenges
• Focus is on harnessing the child’s
emotional drive
• to help her think on her own to solve
problems
• and gradually relate and
communicate better
• build relationships with others
• and become more flexible, adaptive,
and connected
 Part II:

What is
DIR®/Floortime™?
 What is DIR®?
• Developmental
• Individual Differences
• Relationship Based
• Not to be confused with RDI….
 Where it comes from:
• Child Development
• Infant Mental Health
• Parent-child relationship
• Greenspan, and Wieder
 Empirical Support
• Biopsychosocial medical model: the basis for current
medical thinking from about 1970’s to present –
George Engel
• GxE – a better outcome despite Genetics, when we
work with the Environment
• Child Development Research – co-regulation,
engagement, learning through relating (dual-coding)
• Mathematical analysis of neurologic processes,
including learning – vigilance – Stephen Grossberg
(Boston U)
• Hundreds of treatment reports – review of 200 cases
and follow up on that group – Stanley Greenspan,
Serena Wieder, et. al.
• Rick Solomon, et. al. – The Play Project
• Brain Imaging studies – John Stieben (York U)
 Definition of
Developmental, Individual Differences, Relationship Based
Intervention:
Developmental, Individual Differences, Relationship Based intervention is the use of ongoing affective connected interaction
to promote developmental progress, focusing on co-regulation, engagement, and social reciprocity. This is done in a
context of a well rounded biopsychosocial understanding of the person, and carried out throughout the day by
caregivers who are guided and supported as they develop growth producing relationships.

WE USE EMOTIONAL CONNECTION TO FOSTER

THE CHILD’S SOCIAL-EMOTIONAL, COGNITIVE
AND COMMUNICAITON DEVELOPMENT –

WE WORK WITHIN THE CHILD’S PROFILE OF

INDIVIDUAL STRENGTHS AND CHALLENGES
WHILE WORKING TO IMPROVE THAT PROFILE

EMOTIONAL CONNECTION, i.e., AFFECT, IS THE

GLUE THAT HOLDS EVERYTHING TOGETHER
AND MAKES EVERYTHING POSSIBLE. WE
WORK WITH FAMLY AND OTHERS TO MAKE
THIS HAPPEN ALL THE TIME
 So, how does DIR® help?
• We can take a hard wired disorder and
change it.
• What is the best way to change things?
• Behavioral tradition is clear: surface
behavior can be changed, and lots of
things can be learned – we can teach a
person to do and say what we want the
person to do or say (e.g., manding) .
• By contrast, DIR® helps her become more
connected with her world, learn to think
for herself and adapt to her world.
 Part III:

Comparison of
DIR®/Floortime™
with
behavioral
approaches
 Contrast of DIR®
vs.
Behavioral Approaches

• Prompt vs woo – top down vs.

building relationships and learning
together
• Compliance vs. engagement
• Imitation, limits, facts vs.
autonomous thinking, negotiation, &
exploration
 Rough Comparison of DIR®/Floortime™
(Developmental Individual differences
Relationship based)
with other approaches:

DTT Prompts Compliance Do/learn what Top-down

is expected autocratic
from trainer
PRT Prompts Compliance Choices – Top-down, yet
trainer, then democratic
RDI Prompt Compliance parent
Do what’s Top-down,
expected – autocratic
trainer, then
MM Super-Prompt Compliance parent do
Mostly Mostly top-
with elements through action what’s down, with
of ‘gentle and expected – elements of
teasing’ engagement trainer, then co-created
DIR Woo in rituals
Engage (joint parent
Build shared interactions
Bottom–up,
attention) meaning – democratic
parent
focused
 Comparison of DIR®with behavioral

approaches – I
• Goals of a behavioral programs: appropriate
behaviors, learning facts, learning ‘what to do’
in a top-down approach (we teach, child learns
and complies).
• Goals of a relationship based interventions:
connect with others to promote social and
cognitive development and problem solving
with flexible adaptation to a changing world.
This is a ‘bottom up’ approach.
• NB: RDI is a social–cognitive behavioral
program whose aim is to create the ability to
have relationships by training the child in ‘what
to do’ with ideas that reflect natural relating but
with methods that are top-down and do not
reflect natural relating.
 Comparison of DIR® with behavioral
approaches - II

Prompt vs. Woo

Prompt Woo
Greater power difference Humility – more equality
between people
Control Respect for ideas of other
Specific expectation person
Open ended, hopeful for
Belief in the material growth
Belief in the process
 Comparison of DIR® with behavioral
approaches – III
Compliance vs. Engagement
Compliance Engagement
Do/think what I want you to Think for yourself and with me
do/think
Drills will create skills Shared emotional signaling
creates a relationship that
inspires learning and problem
solving
Schemes to cover new Relationships, available and
situations internalized, give self-
assurance to respond to new
situations
Limited sense of competence, More full sense of competence,
self-esteem: “I can do it. I self-esteem: “I can figure it
learned how.” out.”
 Comparison of DIR® with behavioral
approaches – IV
A Complementary
Relationship
Behavioral based Relationship-based
contributes…
Imitation expands…
Autonomous thinking
Limits Negotiation
Facts Exploration
 DIR® is, by definition,
the broadest of possible
interventions

• Biopsychosocial
• Individual differences
• Developmental
• Family characteristics
• Allows for other interventions
within its umbrella
 What does DIR® Look Like?
• Floortime sessions
• Floortime all the time: always
engaging the child in a flow of
interaction
• DIR® is for all ages and all levels of
challenge
• Always includes reflection: time away
from the situation for thinking and
reflecting with others about what
works and what to try next
 Part IV:

The D – the I – and

the R
 Developmental
• Functional Emotional Developmental Levels
• Condense many (most) other developmental
theories down to a fundamental set of
foundational skills
• WE ARE ALWAYS MOST CONCERNED WITH
THE CONNECTION OF THE CHILD TO
OTHERS AND HOW THE CHILD GROWS,
LEARNS AND ADAPTS USING THAT ALL-
IMPORTANT CONNECTION WITH OTHERS
• Remember: this is about social problem
solving, and
‘there is always a social problem in the
room’
 Functional Emotional Developmental
Levels:

I. Co-regulation – calm enough to interact /

alert enough to interact
II. Engagement – a warm, bright, trusting
connection
III. Circles of interaction
IV. Flow of interaction that leads to figuring
out how to manage the situation
V. Symbolic thinking in social problem solving
VI. Logical thinking in the context of relating
VII.Multi-causal thinking
VIII.Grey area thinking
IX. Reflective thinking
 Likert Scale for Each Level
1. Not doing it
2. Barely able to do it
3. Islands of time where the child can do it
4. Can expand those islands with our help
5. Comes back for more with little or no
support
6. Pretty normal unless under stress
7. Age appropriate
 Sample Full FEDL (Charlie)

Not Barely Islands Expands Comes Ok if Ok for

there back not age
stresse
Co- 3/06 3/07 3/08 3/09
d
regulate
Engage 3/06 3/07 3/08 3/09

Circles 3/06, 3/07 3/08 3/09

Flow 3/06 3/07 3/08, 3/09

Symbolic 3/06 3/07, 3/08 3/09

Logical 3/06 3/07, 3/08 3/09

Multicaus 3/06, 3/07 3/08 3/09

al
Grey area 3/06, 3/07, 3/08, 3/09

Reflective 3/06, 3/07 3/08, 3/09

 FEDL Level I: Calm enough
(Co-regulation)
• Know the individual person: Sensory
sensitivities, motor tone, understanding
communication signals, giving signals to others,
visual-spatial ability, body in space, movement,
and ability to plan, sequence, do a plan (incl.
motor ability), & adapt the plan.
• Co-regulation means we do this together – not a
‘sensory break’ (escape without learning
anything) – meet the person 80% to where s/he is
in intensity or lack of intensity to help the person
settle down with you.
• ‘Calm enough’ might mean active enough.
• Think about what works and what doesn’t work
 FEDL Level II: Truly Connected to
Others
(Engagement)
• The gleam we keep talking about…
mostly this is fun and feels good for
everyone
• It’s the reason, the ‘buy-in’, the
bond, that will lead to compliance.
• Joint attention, but more than that.
• Joining whatever he person is doing,
to start (not an end in itself).
 FEDL Level III: Circles
• The ‘back and forth’ of an interaction
• The child is always doing something
• Join in, make yourself a part of the
activity
• Or if you can’t just join in, you can
gently and playfully get in the way
• Maybe be the person with the stuff
the child wants – has to get it from
you
 FEDL Level IV: FLOW
• The fourth ‘level’ in the social-
emotional developmental process
• The ‘engine’ of relating you need to
be able to expand
• It might look like ‘baby games’, but it
is what we all do every day,
constantly, with each other
 FEDL Level V: Symbols
• Words, when they really say something
– more than labels
• Play, when it really ‘says’ something –
more than trained actions or turn taking
• Gestures, when they ‘talk’ about things
or ideas that can replace actions – more
than pointing
• Try to treat everything as having
meaning – you might be wrong and
that’s ok, the person will correct you
 All Kinds of Symbols
From playing with dollies when the
child really means it or crashing cars
when it really expresses something
to
Fantastical stories of castles and kings,
princes, armies, unicorns, spies,
heroines and every kind of complex
human motivation
(think of the 7 virtues and 7 vices)
 FEDL Level VI: Logical
Thinking
• Building logical bridges between
ideas
• Makes for powerful collaborative
thinking
• Far beyond ‘Aspergian Logic’
• Might asks why you feel that way
• Can separate his internal world from
your world, and still feel concerned
 FEDL Level VII:
Multicausal Thinking
• There is more than one reason for why
something is the way it is
• Ex: Mom’s mad, after bad day at work, but
asks if there are other reasons
• There is more than one feeling one might
have about things
• Ex: Mom’s sad that I am going to school,
but happy that I’ll be with other kids
 FEDL Level VIII - Gray-Area
Thinking
(6-10 yr)
• Hierarchies, playground politics
• The best time for disappointment – better to lose
now and have mom’s support than to lose as an
adult and have no experience to fall back on.
• Emotional experiences define, expand, and
deepen the boundaries for the self. Without
anger we don’t know what annoys us, without joy
we don’t know what makes us happy.
• Refining the gradations of these emotions
• This expanded and deepened appreciation for
emotional experience makes us more able to
appreciate it in others.
FEDL Level IX: Reflective Thinking,

(9-12 yr and beyond)

• A Stable Sense of Self, and an Internal
Standard
• Empathize in a truly reflective manner
• Understand a range of feeling in others
and compare it to one’s self
• Helps one be truly a great friend or
partner.
• Expanding sense of empathy, more and
more inclusive: other kids, groups, school,
country, … the world (other races,
religions, etc.)
 ENGAGEMENT IS THE
FULCRUM

you need to co-regulate to engage

you can spin engagement into the

world
to put it in a picture….
 Individual Differences
• Sensory sensitivities and processing
• Postural control and motor planning
• Receptive communication
• Expressive communication
• Visual-spatial communication
• Praxis: knowing how to do things to
solve the social problem of the
moment
 Individual Differences – (sample)
Sensory Postural Response to Intent to Visual Praxis -
Communication Communicate Exploration

Sensory A relative Trouble managing Dysarthric – A relative Ideas

seeking… strength; more than one unintelligible strength; becoming more
Auditory A bit clumsy - thing at a time Logical Frustrated complex with
Visual impedes rapid Can barely tell discourse is looking for support
things
Tactile reciprocity in the ‘why’ we fight or difficult (e.g. Adapting to
Some ability to
Vestibular moment what we fight at best work with
problems that
Proprio- 1 indicate about hedonistic: shapes and come up (e.g.
ceptive desires Can’t track cheating gets objects to solve when my
Taste 2. mirror conceptual you problems in character is
Odor gestures discussion of the disqualified) play. injured, faints,
3. imitate reasoning behind 1. Mirror 1. focus on etc.)
gesture events and play vocalizations object
4. Imitate with 1. Orient 2.. Mirror 2. Alternate Ideation
purpose. 2. key tones gestures gaze
3. Follow
5. Obtain desires 3. gestures Planning
another’s gaze
6. interact: 3. key gestures 4. sounds to determine
(including
- exploration 4. key words 5.words intent. sensory
- purposeful 5. Switch auditory 6. two –word 3. Switch visual knowledge to
- self help attention back and 7. sentences attention do this)
-interactions forth 8. logical flow. 4. visual figure
6. Follow ground Sequencing
directions 5. search for
7. Understand object Execution
W ?’s 6. search two
areas of room
8.abstract Adaptation
7. assess space,
conversation. shape and
materials.
The Child’s Individual Profile
• Where are you now?
• What works?
• What are the details?
• How do you help the child do better
in these areas? (Relationships that
are therapeutic, with family,
therapists, teachers, everyone)
 The Relationship Part
• Family circumstances and styles
• Teacher’s style and class circumstances
• Support to families, therapists, and school
• Importance of time to think about how it is
working
• The rest of the this is about how we work on
better engagement and supporting the child’s
development
 Family /Caregiver
Patterns:
Rate 1 (low) to 5 (high) and comment:

• Comforting
• Finds appropriate level of stimulation
• Engages in relationship
• Reads cues and signals
• Maintains affective flow (for co-regulation)
• Encourages development
 
 Reflective Process
• We all need time, on an ongoing and regular
basis, to think about what we do
• We need to think through what we are doing with
other people to help us see things
• When we ourselves, as parents or professionals,
present our kids, we ask for what we want help
with
• When we support, we give our observations to
help the other person come to their own plans –
we avoid telling them what to do
 Examples of kids at different
places on the FEDL

• FEDL I-IV: manage vigilance, support

interaction
• FEDL V-VI: stepping back from the
moment
• FEDL VII-IX: critical thinking
 Regulating Vigilance and Supporting
Interaction:
Functional Emotional Developmental
Levels
• I – co-regulation, ability to attend
• II – engagement, gleam in the eye,
warmth
• III – circles of interaction
• IV – flow/ behavioral organization in
social problem solving
• V – symbolic thinking (critical to tolerating
affect)
• VI – logical connections between ideas
• VII – multicausal thinking
• VIII – grey area thinking
• IX – reflective thinking, stable sense of self,
and an internal standard
 Abstract Ability and
Vigilance
try to think when you are stressed
inside…
• Grossberg
• Hippocampal cells
• iSTART
• The importance of regulating
vigilance
 Remember:

• ‘Behavior’ means WE need to do

better
• Wooing, not prompting
• Avoid mere sensory breaks
• Avoid questions
Sample Case 2 FEDL Levels
I-IV
• Not so verbal, poorly regulated,
perseverative Kindergartener
• Seen in SDC PK – wandering, adrift
• Allies: District rep – we pushed for ..
K teacher (bends down to child
instead of greeting me)
• Family: helping mom see the magic
• Video
 FEDL – Sample Case 2
1 (not 2 (barely) 3 (islands) 4 (ok w/ 5 6 (ok 7 (ok)
there) support) (comes unless
back) stress)
Regulate 4 10
8
Engage 4 8 10

Circles 4 8 10

Flow 4
8 10
Symbols 4 8 10

Logic 48
10
 FEDL - descriptions
4/08 Bouncing about, somewhat interested in us
8/08 Starting modeling circles,
vs. discrete trial type interactions
10/0 Mom does a warm, spontaneous game,
8 based on his lead
 Individual Differences – Sample case 2

Sensory Postural Response to Intent to Visual Praxis -

Communication Communicate Exploration

Auditory 1 indicate 1. Orient 1. Mirror 1. focus on Ideation

Visual desires 2. key tones vocalizations object
Tactile 2. mirror 2.. Mirror 2. Alternate Planning
Vestibular gestures 3. key gestures gestures gaze Sequencing
3. Follow
Proprio- 3. imitate 4. key words 3. gestures Execution
another’s gaze
ceptive gesture 5. Switch auditory 4. sounds to determine Adaptation
Taste 4. Imitate with attention back and 5.words intent.
Odor purpose. forth 6. two –word 3. Switch visual
5. Obtain desires 6. Follow 7. sentences attention
6. interact: directions 8. logical flow. 4. visual figure
- exploration 7. Understand ground
- purposeful W ?’s 5. search for
- self help 8.abstract object
-interactions conversation. 6. search two
areas of room
7. assess space,
shape and
materials.
 ‘Marilee Sheet’ for Sample Case 2
Following his lead: Joining:
•teresInt in mom’s spontaneous affectively •mom goes along with his desire to have her do it
again
rich nyah nyah tongue on video •not worrying about whether it is ‘appropriate’

Circles: Set the environment:

•waiting for him to respond •keep it simple
•affective gestural hesitation •no special toys
•not a didactic task

Expanding the concept: Broadening Emotional themes:

•tongue •anticipation
•splutter •excitement
•noises •joy

Individual Differences: Working Multiple Levels:

•sensitive to overstimulation
•postural instability
•receptive communication
•expressive communication
•Visual spatial
•praxis (planning)
•co-regulation: stretching capacity to
tolerate excitement
•engagement: strengthening bond with
mom
•circles: waiting and working on closing
more circles
•flow: behavioral organization – keeping the
circles going even if the game changes
 The bottom line:
Engagement over
compliance

• Compliance won’t teach you to think

• Co-regulation supports abstract
thinking
 Stepping back from the moment itself:
Functional Emotional Developmental
Levels
• I – co-regulation, ability to attend
• II – engagement, gleam in the eye, warmth
• III – circles of interaction
• IV – flow/ behavioral organization in social
problem solving
• V – symbolic thinking (critical to
tolerating affect)
• VI – logical connections between ideas
• VII – multicausal thinking
• VIII – grey area thinking
• IX – reflective thinking, stable sense of self,
and an internal standard
 Stepping Back from the Moment:
Symbolic thinking and
Logical social social problem solving

• Makes it possible to solve problems

without being caught in the moment
• Shrug well, shrug often, and shrug where
he can see you shrug: Non-verbal gestural
emotional symbols must always be
present
• Verbal balance – our comedy shows and
their diatribes: don’t be fooled by our
entertaining or by their logic without real
engagement
Sample Case 3 FEDL Levels
V-VI

Aggression and Rigid Aggressive

Play Themes
 About the boy:

• Why he came to me: aggression

toward peers in private kindergarten.
Removed anyway and placed in
public setting.
• Main symptoms: Receptive language,
difficult to understand speech,
reactive to busy environments, low
tone, active, impulsive, sensory
seeking, rigid, controlling, aggressive
 Video

• Fill out FEDL grid while watching:

FEDL
 FEDL – Sample Case 3
1 (not 2 (barely) 3 (islands) 4 (ok w/ 5 (comes back) 6 (ok 7
there) support) unless (ok)
stress)
Regulate 11/05 11/06 11/07 11/08,
5/09

Engage 11/05 11/06 11/07 11/08, 5/09

Circles 11/05, 11/06 11/07 11/08 5/09

Flow 11/05 11/06, 11/07 11/08 5/09

Symbols 11/05 11/06, 11/07 11/08 5/09

Logic 11/05, 11/07, 11/08 5/09

11/06
FEDL – descriptions: Sample
case 3
11/0 Rigid, aggressive, hits in ‘play’, not really symbolic
5
11/0 Allows me to join his aggressive play on his team
6
11/0 Increased complexity of aggressive themes; able to
7 play with cousin and brother in water fights, facilitated
11/0 by dad ‘battle’, controlling, but can be torn between
Racing
8 me and dad, and nurturing, creative & symbolic with
me; able to play with cousin and brother in games that
are competitive but not overtly aggressive
5/09 Talking with me and parents about problems at school
Individual Differences
 Individual Differences – Sample case 3
Sensory Postural Response to Intent to Visual Praxis -
Communication Communicate Exploration

Sensory A relative Trouble managing Dysarthric – A relative Ideas

seeking… strength; more than one unintelligible strength; becoming more
Auditory A bit clumsy - thing at a time Logical Frustrated complex with
Visual impedes rapid Can barely tell discourse is looking for support
things
Tactile reciprocity in the ‘why’ we fight or difficult (e.g. Adapting to
Some ability to
Vestibular moment what we fight at best work with
problems that
Proprio- 1 indicate about hedonistic: shapes and come up (e.g.
ceptive desires Can’t track cheating gets objects to solve when my
Taste 2. mirror conceptual you problems in character is
Odor gestures discussion of the disqualified) play. injured, faints,
3. imitate reasoning behind 1. Mirror 1. focus on etc.)
gesture events and play vocalizations object Ideation
4. Imitate with 1. Orient 2.. Mirror 2. Alternate
purpose. 2. key tones gestures gaze Planning
3. Follow
5. Obtain desires 3. gestures Sequencing
another’s gaze
6. interact: 3. key gestures 4. sounds to determine
Execution
- exploration 4. key words 5.words intent. Adaptation
- purposeful 5. Switch auditory 6. two –word 3. Switch visual
- self help attention back and 7. sentences attention
-interactions forth 8. logical flow. 4. visual figure
6. Follow ground
directions 5. search for
7. Understand object
W ?’s 6. search two
areas of room
8.abstract
7. assess space,
conversation. shape and
materials.
 Family:
• Dad works hard. Can facilitate kids when
available.
• Mom can set up playdates, engage cousin. Has
to work hard to manage environment at home so
that he is not in continuing conflict with older
brother.
• Brother is a good guy, and tries to play with him.
But no one can really keep up with him.
• Mom and Dad can play in office; however life at
home is busy - hard to find time for Floortime.
 Reflection:
• What works: office play with him and his parents
to help them see what we can do; play dates with
cousin, brother, facilitated by parents. Now we
can talk too!
• What doesn’t work: videogames, busy
environments with many peers.
• Why: He is still developing capacities for solid
enough symbolic play to be able to engage with
peers without becoming aggressive. His
language and also his more subtle postural and
visual challenges make it hard for him to play
with peers.
 The bigger picture:
• Broad goals: Improve his capacity to tolerate and
manage his environment, expand his symbolic
capacity, and support and expand his parents’
ability to support his development and figure out
ways to involve peers.
• Multimodal intervention; get parents to more
meetings and help them do more Floortime at
home; increase intensity and relationship-based
quality of services (speech, OT); facilitated group
play; support to school staff to help them be more
on board; medication management.
 Critical thinking:
Functional Emotional Developmental
Levels
• I – co-regulation, ability to attend
• II – engagement, gleam in the eye, warmth
• III – circles of interaction
• IV – flow/ behavioral organization in social
problem solving
• V – symbolic thinking (critical to tolerating
affect)
• VI – logical connections between ideas
• VII – multicausal thinking
• VIII – grey area thinking
• IX – reflective thinking, stable sense of
self, and an internal standard
 What do teachers mean by
‘Critical Thinking’?
• Analysis
• Awareness has to be there
• Abstract thought
• Decision making
• Compare and contrast
• Fact and opinion
• Value judgements
• Values: child’s values
• Self esteem/ self-concept
 Critical Thinking in the DIR®
Framework:
‘Wheat vs. Bread’

• Beyond concrete facts & procedures

• Recognizing abstract categories &
patterns
• Analyzing information & drawing
conclusions
• Stepping back and reflecting on whether
the ideas and conclusions make sense
 7 ate 9:
Toward Critical Thinking

• Multicausal thinking: there is more

than one reason, more than one
feeling.
• Grey area thinking: there are
different intensities of emotion.
• Reflective thinking: we can compare
situations to each other, and we can
compare ourselves to who we want
to be
 Sample Case 4 FEDL VII-IX
• 5th grader
• Lots of sensory and motor planning
challenges, irritability
• School challenges: reluctance to read
fiction, difficulty with peers; staff
very confident
• (Video: playing with mom, multiple
levels through some beginning
reflective thinking)
 Sample Case 5 FEDL I-IX
• Non-video case
• Heavy school consultation
 Sample Case 5
• Seen since preschool, now in third grade
• Chief Concerns: learning, socialization
• Persevative on big cats, perfectionistic,
older and taller, lanky, odd prosody, loud
voice, active and inattentive
• Dad isolative, in conflict with mom
• Mom anxious, works him hard
Sample Case 5 Year By Year
PS: memorizing verses, trailing after the
others
K: flopping on the floor, losing ground
academically
1st: a better teacher, a failed medication
trial
2nd: a better aide, a teacher who cues,
coach
3rd: a whole school effort, some real yard
play
 Individual Differences - Sample Case 5
Sensory Postural Response to Intent to Visual Praxis -
Communicatio Communi- Exploration
n cate
Sensory Low tone; Trouble Dysarthric – Distractible. Easily
seeking, A bit clumsy - managing more Logical •focus on object frustrated
distractible… impedes rapid than one thing at discourse is •----3/07---- Ideation
Auditory reciprocity in a time Difficult 2. Alternate gaze
Visual the moment 1. Orient 1. Mirror 3. Follow Planning
Tactile 1 indicate 2. key tones vocalization another’s gaze to (including
Vestibular desires s determine intent. sensory
Proprio- 2. mirror 3. key gestures 2.. Mirror 3. Switch visual knowledge
ceptive gestures 4. key words gestures attention to do this)
Taste 3. imitate ----3/07---- 3. gestures 4. visual figure ----3/07----
Odor gesture 5. Switch 4. sounds ground Sequencin
4. Imitate with auditory 5.words 5. search for g
purpose. attention back ----3/07---- object
----3/07---- and forth 6. two – 6. search two Execution
5. Obtain 6. Follow word areas of room ----3/08----
desires directions ----3/08---- ----3/08---- Adaptatio
6. interact: 7. Understand 7. 7. assess space, n
- exploration W ?’s Sentences shape and ----3/09----
- purposeful ----3/08---- ----3/09---- materials.
-self help 8.abstract 8. logical ----3/09----
----3/08---- conversation. flow.
-interactions ----3/09----
----3/09----
 FEDL over time: Sample Case 5
social problem solving, from managing
vigilance to stepping back, and then critical
Not Barely
thinking Expan Comes Ok if Ok
Islands
the ds back not for
re stres age
sed
Co- 3/06 3/07 3/08 3/09
regulate
Engage 3/06 3/07 3/08 3/09

Circles 3/06, 3/07 3/08 3/09

Flow 3/06 3/07 3/08, 3/09

Symbolic 3/06 3/07, 3/08 3/09

Logical 3/06 3/07, 3/08 3/09

Multicau 3/06, 3/08 3/09

sal 3/07
Grey 3/06, 3/08, 3/09
area 3/07,
 Marilee Sheet on Math
Following his lead: ‘I must do it Joining: ‘Of course we want to
right’
Circles: statements that build do
Setitthe
right’
environment: making a
ideas, e.g., ‘I’m not sure what space (Like ER or on a date)
makes this so hard for us.’
Expanding the concept: Broadening Emotional
Impossible problems, then sorting themes: from intense reaction to
easy, hard, & impossible. stepping back, less intense,
curiousity; from perseverative
angst to calm perserverance
Individual Differences: reactive Working Multiple Levels:
to busy environments, poor motor Co-reg: space
planning, trouble reading cues, Engage: joining him
trouble expressing himself Circles
including loud voice, visual figure Flow: working problems together
ground difficulties, poor planning, Symbolic: ‘impossible…’
sequencing, execution, and Logic: ‘We can do this’, right =
adaptation; perfectionistic and showing what info isn’t needed,
reactive. right = showing your work
 Reflecting on Sample Case 5
• Early emphasis on regulation,
engagement, and affective cuing and
basic reciprocity
• Improved ability to travel up the
developmental ladder as individual
differences improved
• Individual differences improved in the
context of supportive, engaging reflective
relationships among team members,
supporting team and peer relationships for
him
 Part V:

Comparing
Miller Method®
And
DIR®/Floortime™
 Comparing the Miller Method® with
DIR®/Floortime™ - I
Philosophy
Miller Method®
Cognitive-developmental
Approach
Guided exercises designed to
heartily coach the child toward
more complex thinking and
learning. Novel
conceptualization, detailed
methods for moving forward, and
intuitively rational, satisfying, and
easy to understand.
Generally adult directed, with
movement toward child directed
within activities (e.g. giving the
child power to have everyone
stand or sit)
DIR®/Floortime™
Affect (emotion) drives all
learning and development
Emphasis on co-creating
spontaneous, ongoing
interactions between parent and
child, with many ideas for doing
this, and developmental and
learning goals ‘folded in’, but no
specific tasks nor script except
solving
Child ledthe socialchild
– every problem
has of the
moment
initiative, so use that to begin
interactions and co-create
interactions with the child
 Comparing the Miller Method® with
DIR®/Floortime™ - II
Principles
Miller Method® DIR®/Floortime™
System Forming = FEDL Level I -1 Developmental – 9 Functional
Emotional Developmental Levels;
Closed System = FEDL Level I – 2 solving the social problem in the
room; assess FEDL clinically and
Assess with MDS with FEAS
Takes into account the child’s Individual Differences –
capacities in many areas and how organizing our understanding of
to modify as needed on the the child’s capacities and how
elevated square, etc. they affect our efforts; multiple
assessments
Importance of the existence of a Relationship Based – focused the
bond with the parent, and using family, usually relationship
that bond to motivate the work, between parent and child, as the
e.g., having a child want the vehicle for development and
parent to ‘come’ learning
 Comparing the Miller Method® with
DIR®/Floortime™ - III
Similar but Distinct Concepts
Miller Method® DIR®/Floortime™
‘Symbolic’ means a gesture word ‘Symbolic’ means a gesture word
or picture that stands for or picture that represents an
something else. Answering ‘wh’ emotional idea that helps solve a
questions. Use of small replica of problem. Understanding ‘wh’
elevated square. questions.
Core deficit in autism is a lack of Core deficit in autism is a
self-awareness, particularly of disconnect between affect
one’s body and senses and how (emotion) and cognition (thinking)
one can act in the world.
Critical importance of the mother- Absolutely central importance of
child bond to drive interactions affective engagement between
and learning caregiver and child to drive
interactions and learning
 Comparing the Miller Method® with
DIR®/Floortime™ - IV
They Can Look Somewhat Alike
Miller Method® DIR®/Floortime™
Don’t just say ‘good job’, narrate Don’t just say ‘good job’, it closes
what he is doing so he can learn the interaction instead of
to make sense of what he is doing expanding on it – instead, wonder
what happens next
‘Behaviors’ such as rocking, ‘Behaviors’ are expressions of
flapping, etc. have causal the child’s initiative in thinking
dynamics and that can be turned and acting in the world: join and
into interactive systems modify them together
Includes some naturalistic free Is nearly entirely free play, gently
play in which you gently and and persistently joining, yet
persistently test out how to join focuses on the emotional
and modify the child’s play. connection and affective gestural
cuing.
 Comparing the Miller Method® with
DIR®/Floortime™ - V
Practices
Miller Method®
Features the elevated square,
specific objects, games, and
procedures
Gentle Teasing
Repair the broken square
Teaching body awareness
through planned physical
experiences
3-D to 2-D: to make reading
possible because it makes
sense
Physical guidance, yet
allowing a child to safely
discover things like holes in
the planks
DIR®/Floortime™
Whatever is there, wherever
we are
Some playful obstruction
Repair in the context of
natural
Teachingplay
body awareness
through wooing into
interaction
2-D to 3-D: make a book come
alive with actions, props, etc.
Lots of physical interaction
but generally avoiding
physical redirection
 Comparing the Miller Method® with
DIR®/Floortime™ - VI
Addressing Some Challenges
Miller Method® DIR®/Floortime™
Tantrums: make it safe, Tantrums: soothe, make it
understand it, use controlled safe, understand it with the
action e.g., ‘purposeful child, reflect and plan
kicking’
Separation anxiety: using Separation anxiety: reflect on
objects - offering something the many developmental
from home to take to school emotional themes and
and from school to take home possibilities and problem
Toilet Training: detailed solve
Toilet from theresimilar but
Training:
system formation, bit by bit, more free flowing and
e.g., starting with forming a naturalistic, engaging around
system around flushing, then the body signals, playing with
expanding to clothes, the ideas of elimination with
washing, etc. instims
Perseveration/ sequence
become water, play dough,
Perseveration/ stimsasbecome
the are
interactive systems available
playful interactions
 Comparing the Miller Method® with
DIR®/Floortime™ - VII
Summary
Miller Method® DIR®/Floortime™
Focus on Expanding Cognitive Focus on Expanding Emotional
Complexity Richness

Precision & Detail: specific ‘3 things’ to remember

procedures, individualized and (Feder’s take) and branch
specifically planned from there, individualized in
the moment, reflecting over
It’s Training, and form is time
It’s Freestyle, and form is
important important
 Miller Method and DIR/Floortime Together:
Sample Case 6

• Challenges in communication and

reciprocity
• We’ll watch the video
• 0:00 – 1:00
• 2:50- 5:15
• 10:55 – 15:00
Miller Method and DIR/FLoortime

AN ANALOGY
Have you seen this
movie?
Training for Precision &
Detail
Affect – Emotion –
‘Freestyle’
Different, but Complementary
Approaches
Capture the Dream
 (Part VI) 

Break Time!
15 minutes
Part VII a: DIR® at Home
• Focused time
• Attention to the FEDL levels
• Whenever you are doing anything
• Going with the child’s idea
• Expanding on that idea
• Playing confused
• Gentle obstruction
• Working gently but persistently toward
more complexity
 Marilee Burgeson’s guide to reflective process

DIR®Session Notes
Child:__________________Play Partner:___________Date:__________

Follow child’s interest: Join:

___________________ _________________
___________________ _________________
___________________ _________________

Open and close circles of communication: Set the environment:

_________________ _________________
_________________ _________________
_________________ _________________
_________________ _________________
Extend: Broaden the range of emotion:

_________________ _________________
_________________ _________________
_________________ _________________

Individual Differences: Mobilize developmental levels:

_________________ _________________
_________________ _________________
_________________ _________________
 General Examples
• Child wants something – even
something perseverative
• Gently leveraging that desire
• Limits, e.g., bed time – negotiating
 Communication

• Non-verbal is critical
• Wooing vs. prompting eye contact
• Not getting caught in verbal
interactions that have little real
connection
 Things to Avoid
• Avoid quizzing for facts
• Avoid directing games, conversations, and
play
• Avoid saying ‘No’: every idea is interesting
to work with, even if it is impossible to
give the child what s/he wants
• Avoid merely entertaining the child
• Avoid following without joining and
shaping an interaction
 Avoid Questions!
• Top-down,
• Child more likely to shut down or
tantrum
• Doesn’t help the child learn to think
• This is hard to do!
 Talk about what’s
happening
• Talk about the situation, ‘here and
now’
• Puts the child (other person) just a
bit above you, so that the child does
the thinking
• You play Sancho to the child’s Don
Quixote: state the situation and allow
the child to come up with the
solution.
 Part VII b: DIR® at
School
• What we usually ‘want’: sit and work
independently, learn, play well (take
turns, share)
• Compliance: why do typical kids
comply?
• Engagement vs. compliance
 DIR® in the IEP:

• Present levels of co-regulation,

engagement, reciprocity
• What works, what doesn’t, and why
• Individual differences: strengths and
challenges
• Goals for these
• Intervention: whole team focus on
engagement, and the rest falls into place
• Tracking forms
• Reflective feedback!
 Data Tracking Sheet
 
Date: _____________ Student: _______________ Person Recording: _________________

In Class am Recess In Class Lunch Afternoon

Time: _________ Time: ______ Time: _______ Time: _______ Time: _______
Co-Regulation
Is he calm enough
and settled to attend
to an interaction?
Are you ‘tuning in’ to
near where he is
emotionally to help
him join in?
Examples of not
regulated:stretching,
distracted, staring
off, eyes not on the
group/activity,
over/underactive for
the situation

Engagement
Gleam in the
eye?
Is he “on the same
page” , paying
attention to the
same thing the
“group” is?
-eye gaze to peers
and eye gaze to
activity/items that
the group is
interacting with…
visually and/or
verbally referencing
peers
Social
Reciprocity
(Circles, Flow)
True Back and Forth
in speaking and
listening interactions
-opening (initiating)
and closing (ending)
circles of
communication
verbally or
nonverbally
 School Data Tracking Sheet
instructions and comments

* *Fill in #minutes/15 minute sample for tracking co-regulation and

engagement

**Use hash marks to count number of times the child initiates or

responds appropriately for social reciprocity

**Complete one data sheet per week during all kinds of activities
including class time, free choice, recess, and lunchtime
 
Comments:______________________________________________________
  
________________________________________________________________
 
________________________________________________________________
 
________________________________________________________________
 Supporting Engagement at
School
• Requires co-regulation – what does
that look like?
• Not ‘sensory breaks’ per se
• Engagement: getting the gleam – the
connection – with few staff
• Circles of interaction: first with adults
– same aged peers are toughest
• Importance of inclusion (Paula Kluth)
 DIR® in everyday life at
school

• Work on everyday problems

• Work on keeping the child engaged
throughout the day
• Work on co-regulation, engagement
and reciprocity
• Work on developing relationships
between child and staff and between
child and peers
 Examples at School
• Seat work
• Playground facilitation – see ahead
• Social skills groups – see ahead
• Non-verbal child in class: how to
have the child be part of the class?
• Highly verbal, rigid thinking,
perfectionistic child
 Part VIII: Facilitating
interactions
• First start with well-supported adults
• 15-20 minute ‘turns’ for each
person’s ideas
• Persistence: stay with the person
• Every idea is a good idea
 Facilitating with Kids

• All of the above and…

• Semi-structured activities with peers
• Limiting numbers of kids
• Mediating the process – often to slow
it down
• Interpreting intent
• Statements more than questions
• Democratic decision making
 Things a facilitating adult
might say…
• “We need to do something…”
• “You’re good at that, and I need help with…”
• “So wait a second – I didn’t hear that rule…”
• “We need to vote on whether he was out..”
• “That’s great all you guys want to play too – I
have more than I can handle now, but lets plan
on having you join us next time if you still want
to do it then.” (good idea, bad timing – be sure
to make good on your offer next time if they
still want to join)
• Semi-structured means that at times you will be
a bit ‘top-down’, but work toward less of it.
• In free play, the thing is to facilitate joining by
your joining first in a way that attracts other
kids, then facilitate the mix
 Part IX:
A General Plan for the Management of
Difficult Moments *

• Have a plan ahead of time

• Adjust the environment
• Soothe – avoid physical restraint
• Communicate about it with the child
afterward
• Anticipate – plan with the child what to do
next time
• Make time to reflect about it with others
*reference:
A Bioethical Approach to Overcoming Problems with Aggression and Misbehavior in Schools,
Stanley Greenspan, M.D.
ICDL 12th Annual International Conference
November 7-9, 20082008 ICDL Fall Conference, Washington, D.C.
 Back to those difficult
moments
• Aggression – Tantrums
• Self-Injurious Behavior
• Self-stimulating behavior
• Running Off / Safety
• Transitions
• Perseveration – Obsessive/Compulsive –
Rigid
• Compliance
• Communication
 Aggression - Tantrums
• Have a plan ahead of time
• Adjust the environment: clear the room if necessary; you
need to feel safe – have cushions in between you and child
if need be. Have the surrounding area secure so if child
‘runs off’ it’s ok.
• Soothe – calm voice, not too much additional stimulation,
no threats, and avoid physical restraint
• Talk or play with the child afterward about the incident and
what happened – find an emotional, symbolic way to
communicate about it
• Anticipate – plan with the child what to do next time
• Review your plan with others - think about what works and
what else you might try
 Brief example: Aggression
• Teenaged boy
• Non-verbal
• Big
• ABA forever
• A great family friend
• Fears of dogs
• Engagement leads to real function
 Self-Injurious Behavior
• Have a plan ahead of time
• Adjust the environment – soft things in
between
• Soothe – avoid physical restraint if possible
• Talk with the child afterward; see if you can sort
out together what occurred and how to manage
it. Find a metaphor, even the simplest
symbolic substitute. Narrating is ok for
someone who does not talk.
• Anticipate – plan with the child what to do next
time
• Make time to reflect with others
 Brief Example: S.I.B.
• 30 year old man – severe clawing at
chest
• Non-Verbal
• Adult
• A great live-in aide
• Engagement: support and
expectations
• Form SIB to a real life: cooking,
riding, etc.
 Self-Stimulating Behavior

• Have a plan ahead of time

• Adjust the environment: to remove or not to remove the
offending thing(s). Probably better to allow it and work with
it if possible, otherwise you end up removing everything…
• Soothe – avoid physical restraint; better to get in the way,
joining it, and engaging and changing the interaction
• Talk with the child afterward: don’t be afraid to talk about
the thing that obsesses the child, when the child is calmer
and you can expand on the issue.
• Anticipate – plan with the child what to do next time
• Time to reflect
 Brief Example: Stims
• A non-verbal 8 year old boy
• Strings
• Joining the string thing
• Time, time, and more time
• Eventual gleam and non-verbal
communication about it
 Running Off/ Safety
• Have a plan ahead of time
• Adjust the environment: set it up so that there
is safe room to run off. What about stores?
You really do need
• Soothe – avoid physical restraint, best to wait for
him to return, but it is ok to join the race, and if
need be to ‘head ‘em off at the pass’
• Talk with the child afterward; find the metaphor!
• Anticipate – plan with the child what to do next
time
• Reflect…
 Brief example: running off
• Big teen male
• High Schooler
• Limited verbal ability
• Inclusive school
• Loping after him worked really well,
as long as the person was calmly
following, and there was a gate
where he was running.
 Transitions
• Have a plan ahead of time
• Adjust the environment: plan for more time to
transition, WAIT after telling the child (let
them finish the page, wait for a commercial,
assure you’ll record the show, etc.)
• Soothe – ahead of time: ‘I know you don’t like
having to go’; allow for lots of negotiation; avoid
physical restraint
• Talk with the child afterward about what it’s like
to shift activities
• Anticipate – plan with the child what to do next
time
• Make time to reflect on what worked and what
you might try next time
 Brief Example: transitions
• Adult male in his 60’s
• Minimally verbal
• Engagement, again
• Gradual improvement: enjoys
camping and day program
 Perseveration –
Obsessive/Compulsive - Rigid
• Have a plan ahead of time
• Adjust the environment: again – to remove or not? Might
remove electronics unless you can make them truly real
interactions with people right there in real time
• Soothe – do not get rigid yourself (breathe…); avoid
physical restraint; join the activity and make yourself a part
of the child’s world as it relates to the activity. Might hoard
toys and make him go through you to supply them. Be easy
about it at first, but be part of it. Gradually expand the
interaction. Keep going for that gleam!
• Communicate about it with the child afterward, when he
isn’t actually perseverating on it. Don’t be afraid – it’s
important to talk about these things. You can review it as
part of your usual review of the day together.
• Anticipate – plan with the child what to do next time
• Make time to reflect about it with others
 Brief example:
perseveration
• 5 year old boy
• Light switches and Doors
• To couches, to blanket games, to
cuddling with mom, to early symbolic
play with dad
 ‘Compliance’
• Have a plan ahead of time
• Adjust the environment: if you must command a
child to do something, ENGAGE FIRST, and
WAIT FOR A RESPONSE
• Soothe –co-regulate, engage, and get an
interaction cooking; make what you want a part
of the interaction; talk about his dislike of the
task; avoid physical restraint
• Communicate about it with the child afterward –
wonder what it was like for him
• Anticipate – plan with the child what to do next
time
• Make time to reflect about it with others
 Brief Example: compliance
• 3rd grade boy in regular ed –
‘disruptive’
• School expectations
• Charisma worked one year, but the
next year’s teacher did not have a
connection with him
• Shift to a school with high support
and high expectations, very
engaging and physical and regulating
 Communication
• Have a plan ahead of time: do not spontaneously get fed up
and demand a response
• Adjust the environment: what do you need to do to make it
possible for the child to process your gestures and
vocalizations?
• Soothe – every child is always doing something: use that
initiation as a starting point; ‘follow his lead!’ ; avoid
physical restraint (don’t hold his face, don’t command to
look at you); non-verbal gesture is much more important
than words
• Communicate about it with the child afterward – really –
find a way to communicate about communicating -
• Anticipate – plan with the child what to do next time –
what?? – pushing the structure of this model?? – think about
it: at night you are tucking in your little non-verbal muffin,
and thinking, talk to him about what fun you had today,
maybe repeating a gesture or two from what you did,
smiling, and talking about doing it again…
• Make time to reflect about it with others
 Example: communication
• Sample Case 6!
 Limitations and Challenges
in implementing a
relationship based approach
• Not didactic – must give up top-down control
• Not manual driven – it’s in the moment,
creative, a bottom up approach
• Training requires relating: coaching,
coachability
• Boundaries must be tended
• We’re not ‘holding the baby’ – we’re
coaching caregivers
• Need for reflective process
• Not so entrepreneurial – academic
transparency hampers marketing
• Need for more practitioners
 Summary: Why do this?
• It is BPS, and BPS is good.
• We can change outcomes despite genetics, etc.
• Affect is the key to growth and development,
and this is affect based.
• We need to go beyond behavioral treatments.
• Medication can sometimes support treatment but
cannot address core deficits nor make up for
environment.
• There is reason and there is plenty of bench
research and budding clinical research to support
it.
Our response to all
challenges…
“Never give up, never surrender!”
- Captain Peter Quincy Taggart
Commander, NSEA Protector
ICDL Learning Opportunities
• Support Groups For Parents and
Professionals –( Burgesen, Feder, et al) –
announced on ValeriesList@aol.com and on
circlestretch.com.
• Online Basic Course – new cycle this spring:
icdl.com
• Training DVDs
• Summer Institute for clinicians and others –
intensive one week (2009 year July 8-12 at
Asilomar ) – requires Basic Course
• Monthy multidisciplinary internet and
regional tutoring – ICDL faculty (Feder,
others) – pre or post Summer Institute
 More ICDL Learning
Opportunities
• Online PhD Program in Infant Mental and Child
Development and Early Intervention – educational
degree program (not clinical, but requires a
practicum).
• Adult Education for Parents and Clinicians - HOPE
Infant Family Support Program (Burgesen) – for
families enrolled in HOPE’s 0-3 autism program –
program on track for ICDL certification.
• Streamlined for distribution – The Play Project
(Solomon)
• Affect Based Language Curriculum - for parents
of professionals to use (Lewis)
 DIR® Schools
• Celebrate the Children – Wharton, NJ
• Rebecca School – Manhattan
• Imagine Academy – Brooklyn, NY
• The Community School – Atlanta, GA
 Resources
• Becoming More Matthew in The
Autism File, January 2009
• Circlestretch.blogspot.org – incl lots
of forms and more detailed ppts
• ICDL.com – information and local and
regional training, free downloads and
podcasts
X: Your Questions:
 circlestretch
Help the child be…

• Calm enough to interact

• Truly connected to others
• In a continuous expanding
balanced
back and forth flow of
interaction
“Go for that gleam in the eye!”
http://www.circlestretch.com