Connection Counts- Core Elements in Autism Intervention UCSD January 25 2012 (Redacted for Posting)

7/31/2019 Connection Counts- Core Elements in Autism Intervention UCSD January 25 2012 (Redacted for Posting)

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Connection Counts:

Core Elements in

Autism Intervention

January 25, 2012

University of California at San Diego


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Director of Research, Graduate School,Interdisciplinary Council on

Developmental and Learning Disorders

Assistant Clinical Professor, Voluntary

Dept of Psychiatry, University of California

at San Diego School of Medicine

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Feder 411

Math, Engineering, and DevelopmentalDisorders beginning 1978.

US Navy Child Psychiatry

Mike 1990 (1992)

Greenspan and Wieder 1993

Career expansion: clinic, teaching,research, advocacy, tech developmentand arts & media.

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ICDL

CAPTN/Pfizer

SymPlay

Cherry Crisp

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Commercials

Because we build ideas together

And you can join us in the effort!

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Working Together for

Parent Choice!7


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The Southern California

DIR/FloortimeRegional Training Program

Pasadena, California

February 24-26, 2012Pasadena Child Development Associates, Inc.

(PCDA)

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Tuning Into Each Other

Customizing Project ImPACT

to address our key community values and reach younger children for

the SoCal BRIDGE Collaborative


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Thank You!

Families say a silent thank you

Greenspan & Wieder Kasari, Gulsrud, Adamson, et. al.

Jeff Montag

The BRIDGE Collaborative So many others

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Outline

Engagement and other core concepts

Research shows

Well do research today! Videos The meaning of Repair

Questions

Tips and take home points


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Conclusions:

Nurture engagement

Repair of engagement leads to

competence and confidence in apersons ability to connect with others

and to solve problems

If you look for engagement, you canmake it happen more

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Taking Notes?

One word: ENGAGEMENT


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Moment to moment interactions

Regulation

Unengaged

Object focused

Engagement

Intent

Circles of interaction Repair (Tronick)

Initiated Joint Attention

Floortime 18


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Regulation

Calm enough to interact

Not to active, upset, etc.

Not too calm

Help the person be regulated


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Unengaged

Maybe wandering, or distracted

Maybe focused on an object (object

focused)


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Unengaged,

Maybe object focused


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Engagement:

Emotionally Connected in the Moment

Warm, trusting, shared

Balanced feeling of in-sync connection

The reason we care to learn and grow

Deep bond or falling in love


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Engaged:

(often smiling; doesnt always need

eye contact)


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How do you know

if engagement is there? Often there is a gleam in the eye - like during a

chase game

Usually fun and feels good

You feel it, and feel successful

Unengaged: frustrating, feel incompetent

Well see if we can spot it on videos


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Circles of Interaction

Child does something (anything) indicating

intent (any idea tiny or big)

You do something that adds to what the child

is doing

The child completes the circle by doing

something that builds on what you did


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First part of a Circle:

Child is doing something

Second part of a Circle:


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Second part of a Circle:

Adult does something to build on

childs intent


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Third part of a Circle:

Child responds to adult


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Joint Attention

Creating a shared moment of attention on an

object

Responsive joint attention: when we point out

something to the child and the child looks at

us and the object

Initiated joint attention: when the child gets

our attention and points something out


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Initiated joint attention (repair)


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floortime


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Research Shows


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Controlled Examination of

Critical (Pivotal) Aspects of Intervention

Gulsrud, Kasari, et. Al. The Co_Regulation of

Emotions Between Mothers and Their

Children with Autism. J. Autism Dev Disord

(2009)

Kasari, Gulsrud, Wong, Kwon, & Locke.

Randomized Controlled Caregiver Mediated

Joint Engagement Intervention for Toddlerswith Autism. J. Autism Dev Disord (2010)


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Gulsrud & Kasari et. al. 2009:

Issue: if mom supports Joint Attention, is child

better regulated? Method: Lab study of 34 dyads; wait list control; 24

sessions/8 weeks; blind raters code child negativity,self-regulation, and maternal co-regulation.

Results: 1) lots of negative moments & childrenand moms used these strategies, albeit less of thesymbolic ones; 2) stressed moms used fewer vocalstrategies and more active ones when interactingwith their kids; 3) moms became better at co-

regulation strategies and children showed moreability to self-regulate negative moments.

Implications: Joint attention helps co-regulation


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Kasaris Lab


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Childs efforts


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Moms Efforts


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When moms do better.


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Their kids to better


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Kasari & Gulsrud et. al. 2010

Issue: What is the outcome one year later?

Method: 15 min video samples at 0, 8, and 52weeks; coded unengaged/ object engaged/ or jointengaged; caregiver adherence and fidelity;

Results: 1) less object and more joint engagement;

2) higher caregiver quality of involvement/ fidelitypredicted more joint engagement; 3) adherencewas good but not a factor in outcome; 4) nochange in time unengaged

Implications: Supporting joint attention makes adifference in future social communication for earlyintervention in ASD; We can study isolated parts ofa broader model


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uh oh..


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Out of the Lab.


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Procedure

We will watch the video

We will watch it again

We will use the voting cups to indicate how

much we agree a particular moment appears

to indicate a shift in the state of the child

We will watch more videos


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Starting with the master.

Video: Enticing Alex to Engage:

http://www.youtube.com/user/dirfloortime#p

/a/u/2/uqiSR4FUBG0

4 minutes

Track unengaged, object focused, engaged,

circles, and repair of interactions
http://www.youtube.com/user/dirfloortimehttp://www.youtube.com/user/dirfloortimehttp://www.youtube.com/user/dirfloortimehttp://www.youtube.com/user/dirfloortime


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Lets see if we can spot these things

Unengaged Object-

Focused

Engaged Circles Repair Comments


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Lets see if we can spot these things

Unengaged Objectfocused

Engaged Circles Repair Comments

0:00

0:35

1:10

2:03

2:35

2:563:11 doll

3:40 Mom w/h

3:56


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Three Brief Videos

Cuing dad and baby

Mom and toddler (hide n seek)

Mom and child (tongue game)

Well watch each twice (or more)


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The Meaning of Repair

N l I i


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Normal Interactions

(Tronick 2007)

Mismatch in moment to moment interaction

What the child does

What the caregiver does


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Normal Mismatch

1/3 of interactions go well

1/3 have breaks and repair 1/3 have breaks and are lost


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Mismatch leads to:

Able to differentiate self from others

Increased self-regulatory capacity

Increased resilience to stress


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Self vs. Other

Mismatch means there is a difference

Forces child and caregiver to respond

Quality of response makes all the difference


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Increased Self-Regulatory Capacity

Repair of small mismatches gives experience

of repair

Mismatch becomes more tolerable child

doesnt get so upset anymore

The most basic form of competence and self-

esteem


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Resilience to Stress

Long experience with repair

Creates an ever broader and more nuanced

ability to repair

And with that a gradual ability to tolerate

greater and greater stressors

Wh t B bi C D


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What Babies Can Do

to Respond or Repair

Social attend (paying attention to the caregiver)

Signal (with +, -, or neutral affect)

Object attend (paying attention to an object) Self comfort

Escape (e.g. turning away)

Avert/ scan

Withdrawal (including reduction in posturalcontrol or reduction in perceptual function, e.g.,dull, glassy eyed [dissociation?]


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What Caregivers Can Do

to Respond or Repair

(Caregiver Profile)1. comfort the child

2. find appropriate levels of stimulation to interest

the child

3. pleasurably engage the child

4. read the child's emotional signals

5. and respond to the childs signals6. encourage the child (in regulating,

communicating, learning, etc.)


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Potential Caregiver Challenges

Potential caregiver challenges


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Potential caregiver challenges:

1. over-stimulating

2. withdrawn/ unavailable3. lacking pleasure, zest

4. chaotic in reading/ responding to child

5. fragmented/ insensitive

6. rigid/ controlling

7. concrete in reading/ responding

8. illogical in reading/ responding

9. Avoiding: security/safey; dependency;pleasure/excitement; assertiveness/exploring;aggression; love; empathy; limit setting

10. unstable in the face of intense emotion


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These Experiences Create Mood States

Infants of depressed moms are depressed Infants of intrusive moms withdraw

Infants of neglectful moms complain

Infants of neglectful moms must try to self-regulate without the help of scaffolding andend up withdrawing

Infants of abusive moms end up engaging inphysical defensiveness, anger, and increasedvigilance and fear


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So theres stress, and theres STRESS

The helpful stress of normal mismatch

The too common but unhelpful stress of life

Need to assess the stresses.


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ManagingChallenges

Never work alone Schedule regularmeetings With someone who will really listen

And help you find your own solutions Platinum Rule: A good listener treats you

with respect so that you have the support to

be able to tolerate the natural stress ofhelping your child (Treat others as we wantothers to treat others)

Thi t h


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This engagement approachreduces parent stress and

improves child function and parent-child relationships!

Questions?


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Tips and Take Home Points


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How do you engage a child


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How do you engage a child

in an interaction?

Adjust your energy to help him be calm

enough or active enough to do stuff with him

Might mean understanding sensory, motor,

thinking styles and other things.

Observe. Join. Wait!

Build on your childs actions: Improv yes, and

Respond with warmth & try to be natural


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Go for engagement


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Go for engagement

and compliance will come

Compliance & Engagement:


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Compliance & Engagement:

necessary and complimentaryCompliance Engagement

Do/think what I want you to

do/think

Think for yourself and with me

Drills will create skills Shared emotional signaling creates a

relationship that inspires learning and

problem solving

Schemes to cover new situations Relationships, available and

internalized, give self-assurance to

respond to new situations

Limited sense of competence, self-

esteem: I can do it. I learned how.

More full sense of competence, self-

esteem: I can figure it out.

Improving your ability to support your


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Improving your ability to support your

childs interaction

Practice reading childs cues

Think about different way to respond to your

childs cues

Getting new ideas: bounce it off of other

people - get their ideas and figure out what

works for you.


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Things to Avoid

Dont just entertain, quiz, or direct the childwith your games, demands, or ideas

Dont merely follow the child around use

the child lead to start off

Every idea is a good one to play withdont

say no to the idea - connect and play with

it. You can set limits as needed.

hi


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coaching

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What about other kids?

Start with adults

Build some skills

Semi-structured activities with peers

Limiting numbers of kids

Mediate the process slow it down

Statements more than questions Democratic decision making

Thi i h d


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Things you might say or do:

We need to figure out what to do I need help with

Wait - I didnt hear you

We can vote on whether he was out.. Semi-structured: at times you direct things,

but work toward less of it.

In free play, you join the person in a waythat attracts other kids, then facilitate themix

C l i


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Conclusions:

Nurture engagement

Repair of engagement leads to

competence and confidence in apersons ability to connect with othersand to solve problems

If you look for engagement, you canmake it happen more

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Symplay:h lik l i il d i i


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Launch likely in April during Autism

Awareness Month


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The Southern CaliforniaDIR/Floortime

Regional Training Program

Pasadena, California

February 24-26, 2012

Pasadena Child Development Associates, Inc.(PCDA)

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Connection Counts- Core Elements in Autism Intervention UCSD January 25 2012 (Redacted for Posting)

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