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

Joshua D Feder MD 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

Feder 411 • Math, Engineering, and Developmental Disorders beginning 1978. • US Navy – Child Psychiatry • Mike – 1990 (1992) • Greenspan and Wieder – 1993 • Career expansion: clinic, teaching, research, advocacy, tech development and arts & media.

Disclosures ICDL CAPTN/Pfizer SymPlay Cherry Crisp

Commercials… • Because we build ideas together • And you can join us in the effort!

Working Together for

Parent Choice!

The Southern California DIR/Floortime Regional Training Program

Pasadena, California February 24-26, 2012 Pasadena Child Development Associates, Inc. (PCDA)

Tuning Into Each Other Customizing Project ImPACT to address our key community values and reach younger children for the SoCal BRIDGE Collaborative

Thank You! • Families – say a silent thank you • Greenspan & Wieder • Kasari, Gulsrud, Adamson, et. al. • Jeff Montag • The BRIDGE Collaborative • So many others…

Outline • Engagement and other core concepts • Research shows… • We’ll do research today! – Videos • The meaning of Repair • Questions • Tips and take home points

Engagement and Other Core Concepts

Assumptions • You are interested in helping figure out how to help people with autism and related conditions • You have little familiarity with research on engagement and joint attention

Conclusions: • Nurture engagement • Repair of engagement leads to competence and confidence in a person’s ability to connect with others and to solve problems • If you look for engagement, you can make it happen more

Taking Notes? • One word:


Moment to moment interactions • Regulation • Unengaged • Object focused • Engagement • Intent • Circles of interaction • Repair (Tronick) • Initiated Joint Attention • Floortime

Regulation • Calm enough to interact • Not to active, upset, etc. • Not too calm • Help the person be regulated

Unengaged • Maybe wandering, or distracted • Maybe focused on an object (object focused)

Unengaged, Maybe object focused

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”

Engaged: (often smiling; doesn’t always need eye contact)

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 • We’ll see if we can spot it on videos

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

First part of a Circle: Child is doing something

Second part of a Circle: Adult does something to build on child’s intent

Third part of a Circle: Child responds to adult

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

Initiated joint attention (repair)


Research Shows‌

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 Toddlers with Autism. J. Autism Dev Disord (2010)

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 coregulation. • Results: 1) lots of negative moments & children and moms used these strategies, albeit less of the symbolic ones; 2) stressed moms used fewer vocal strategies and more active ones when interacting with their kids; 3) moms became better at co-regulation strategies and children showed more ability to self-regulate negative moments. • Implications: ‘Joint attention’ helps co-regulation

Kasari’s Lab

Child’s efforts

Mom’s Efforts

When mom’s do better….

Their kids to better‌

Kasari & Gulsrud et. al. 2010 • Issue: What is the outcome one year later? • Method: 15 min video samples at 0, 8, and 52 weeks; coded unengaged/ object engaged/ or joint engaged; caregiver adherence and fidelity; • Results: 1) less object and more joint engagement; 2) higher caregiver quality of involvement/ fidelity predicted more joint engagement; 3) adherence was good but not a factor in outcome; 4) no change in time unengaged • Implications: Supporting joint attention makes a difference in future social communication for early intervention in ASD; We can study isolated parts of a broader model

uh oh…..

Out of the Lab….

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

Starting with the master….

• Video: Enticing Alex to Engage: • 4 minutes • Track unengaged, object focused, engaged, circles, and repair of interactions

Let’s see if we can spot these things Unengaged






Let’s see if we can spot these things Unengaged Object focused 0:00





0:35 1:10 2:03 2:35 2:56 3:11



Mom w/h


Three Brief Videos • Cuing dad and baby • Mom and toddler (hide n seek) • Mom and child (tongue game) • We’ll watch each twice (or more)

The Meaning of Repair

Normal Interactions (Tronick 2007) • Mismatch in moment to moment interaction • What the child does • What the caregiver does

Normal Mismatch • 1/3 of interactions go well • 1/3 have breaks and repair • 1/3 have breaks and are lost

Mismatch leads to: • Able to differentiate self from others • Increased self-regulatory capacity • Increased resilience to stress

Self vs. Other • Mismatch means there is a difference • Forces child and caregiver to respond • Quality of response makes all the difference

Increased Self-Regulatory Capacity • Repair of small mismatches gives experience of repair • Mismatch becomes more tolerable – child doesn’t get so upset anymore • The most basic form of competence and selfesteem

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

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 postural control or reduction in perceptual function, e.g., dull, glassy eyed [dissociation?]

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 child’s signals 6. encourage the child (in regulating, communicating, learning, etc.)

Potential Caregiver Challenges

Potential caregiver challenges: 1. over-stimulating 2. withdrawn/ unavailable 3. 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

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 and end up withdrawing • Infants of abusive moms end up engaging in physical defensiveness, anger, and increased vigilance and fear

So there’s stress, and there’s STRESS • The helpful stress of normal mismatch • The too common but unhelpful stress of life • Need to assess the stresses.

Managing Challenges • Never work alone • Schedule regular meetings • 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 of helping your child (Treat others as we want others to treat others)

This engagement approach reduces parent stress and improves child function and parentchild relationships!


Tips and Take Home Points

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 child’s actions: Improv ‘yes, and’ • Respond with warmth & try to be natural

Go for engagement and compliance will come

Compliance & Engagement: necessary and complimentary Compliance


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, selfMore full sense of competence, selfesteem: “I can do it. I learned how.” esteem: “I can figure it out.”

Improving your ability to support your child’s interaction • Practice reading child’s cues • Think about different way to respond to your child’s cues • Getting new ideas: bounce it off of other people - get their ideas and figure out what works for you.

Things to Avoid • Don’t just entertain, quiz, or direct the child with your games, demands, or ideas • Don’t merely follow the child around – use the child ‘lead’ to start off • Every idea is a good one to play with – don’t say ‘no’ to the idea - connect and play with it. You can set limits as needed.


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

Things you might say or do: • “We need to figure out what to do…” • “I need help with…” • “Wait - I didn’t 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 way that attracts other kids, then facilitate the mix

Conclusions: • Nurture engagement • Repair of engagement leads to competence and confidence in a person’s ability to connect with others and to solve problems • If you look for engagement, you can make it happen more

Symplay: Launch likely in April during Autism Awareness Month

The Southern California DIR/Floortime Regional Training Program

Pasadena, California February 24-26, 2012 Pasadena Child Development Associates, Inc. (PCDA)