BASIC CONCEPTS IN FLOORTIME

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BASIC CONCEPTS IN FLOORTIME INTERVENTION AND
THE DEVELOPMENTAL- INDIVIDUAL DIFFERENCE-
RELATIONSHIP BASED (DIR) MODEL

• Presented for Cal Lutheran University
• April 13th, 2009
• Dr. Jonine Biesman

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STANLEY GREENSPAN, M.D.

• Founder of the DIR Approach
• Leading developmental theorist and
  interventionist
• Specializes in conceptualizing and working with
  children with special needs
• Degrees
• Harvard, A.B., cum laude, 1962
• Yale Medical School, M.D., 1966
• Dr. Greenspan is a practicing child and adult
  psychiatrist and psychoanalyst,Clinical Professor
  of Psychiatry and Behavioral Sciences and
  Pediatrics at George Washington University
  Medical School a supervising Child Psychoanalyst
  at Washington Psychoanalytic Institute, serves as
  chair of the Interdisciplinary Council on
  Developmental and Learning Disorders (ICDL) and
  co-chair of the Council on Human Development.

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EXCERPTS FROM THE CHILD WITH SPECIAL
NEEDS(Greenspan and Wieder, 1998 pp. 123,
110-111)

• Relationships are critical to a childs
  development. Through interactions, you can
  mobilize a childs emotions in the service of his
  learning. By interacting with a child in ways
  that can capitalize on his emotions, you can help
  him want to learn to attend to you, you can help
  him want him to learn how to engage in a
  dialogue you can inspire him to take initiative,
  to learn about causality and logic, to act to
  solve problems even before he speaks and moves
  into the world of ideas. As together you open
  and close many circles of communication in a row
  you can help him connect his emotions and intent
  with his behavior (such as pointing for a toy)
  and eventually with his words and ideas (Give me
  that!). In helping him link his emotions to his
  behavior and his words in a purposeful way,
  instead of learning by rote, you enable your
  child to begin to relate to you and the world
  more meaningfully, spontaneously, flexibly, and
  warmly. He gains a firmer foundation for
  advanced cognitive skills. p. 123

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• Throughout history we have believed that
  emotions were subservient to thought or reason,
  but an emerging body of observation and
  neuro-scientific research suggests this view is
  inaccurate. Rather than being separate and
  subservient to thought, emotions seem to be
  responsible for our thoughts. Because emotions
  give directions to our actions and meaning to our
  experiences, they enable us to control our
  behavior, store and organize our experiences,
  construct new experiences, solve problems and
  think. The emotional component of each
  experience make the experience meaningful
  pp.110-111

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What is the D in DIR?

• The D in DIR represents social-emotional
  developmental milestones that are essential to
  intellectual growth and overall healthy
  development. They serve as the foundation for
  communicating, relating, and thinking
  independently within the context of the greater
  social world. There are nine Functional
  Emotional Developmental Levels
• 1) Shared Attention and Regulation (begins 0-3
  months)
• 2) Engagement and Relating (begins 2-6 months)
• 3) Two-way Purposeful Emotional Interactions
  2-way gesturing (begins 4-9
• months)
• 4) Shared Social Problem-Solving (begins 9-18
  months)
• 5) Creating Symbols and Ideas (begins 18-30
  months)
• 6) Building Logical Bridges Between Ideas
  Logical Thinking (begins 30-48 months)
• 7) Multi-Cause Thinking
• 8) Gray-Area Thinking
• 9) Reflective Thinking with a Sense of Self and
  Internal Standard

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SOME GENERAL PRINCIPLES

• Affect is the glue for functional emotional
  development. Affect plays a central role in all
  learning. The child has to invest affectively.
  Relationships and pleasure are essential for
  learning to be meaningful. Emotion and
  motivation drive cognition and motor development.
• Individual differences are the norm.
• Children learn best through active learning and
  interaction (follow the childs lead to find out
  what is meaningful to him/her). When meaningful
  connections are not emphasized, a child learns to
  comply with external demands but lacks the
  internalization that leads to self-initiation,
  empathy, and abstract thinking.
• Incorporate all sensory and processing
  modalities.

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SHARED ATTENTION AND REGULATION

• The foundation.
• Necessary for engaging and relating in the
  world.
• Ability to remain calm and attentive to the
  world in the face of multiple sensory stimuli and
  to self-soothe.
• Congruence between a caregivers approach and
  childs calming behaviors help the child to
  develop internal regulation and control of
  his/her behavior.
• Ability to achieve homeostasis
• Infants instinctively turn toward a pleasant or
  familiar voice very early on. Use pleasant
  sensations from others and from their environment
  to calm themselves.
• The ability to attend to others and what is
  going on in the world.

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ENGAGEMENT

• Falling in love!!!!!
• -Wooing
• -Intimacy
• -Enjoying the presence of another
• -Mutually enjoyable shared experiences such as
  smiles and gazing
• -Warm mutual feelings
• -Helping the child to experience a range of
  feelings while staying engaged and related
• -Building trust
• -The foundation for long-lasting relationships
• -Insure that your movements and voice are
  sensitive to the childs individual sensory
  profile so that you can woo them and they can woo
  you always be affective but for the
  under-responsive child be up-regulating and for
  the over- responsive child be down-regulating.
  -Rosemary White, OT

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TWO-WAY COMMUNICATION

• Use of gestures to communicate pointing,
  reaching to be picked up, purposeful noises,
  responding to people talking by making sounds,
  faces, initiating gestures (wiggling, gurgling),
  back and forth affective signaling to convey
  intentions, reading body posture and facial
  expression
• Mommy smiles, baby smiles back Daddy rolls the
  ball, baby happily rolls it back. Dialogue
  without words.
• First sense of cause and effect and establishing
  a sense of self, separate from the caretaker. My
  intents and actions create results.
• Foundation for more sophisticated communication
• Beginning of opening and closing circles of
  communication help the child use affect and
  emotion to communicate intent, wishes, and needs
  (use of hands, face, body)

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COMPLEX COMMUNICATION AND SHARED PROBLEM-SOLVING

• Organizing behavior to solve problems
• Continuous flow of affective interactions with
  people for shared social problem-solving (e.g.,
  may take caregiver by the hand, lead to the
  refrigerator, bang on door, point to or say milk
  sequencing of actions)
• Beginning to communicate ideas through words.
• Development of a more complex sense of self
• Stretch out exchanges for as long as possible.
  Dont be too compliant and facilitative.
• Shared problem-solving is an essential skill for
  functioning with peers, in school, and beyond.
  Insure the problem-solving is in an interaction

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IDEAS AND SYMBOLIC PLAY

• Beginnings of fantasy play and the child
  representing the world in which he/she lives, the
  conflicts faced, through play or symbolism
• Exploring a range of feelings and themes (good
  guys, bad guys)
• Making sense of a complex world
• Increased use of language to indicate wishes and
  interests
• Functional use of ideas (Me hungry, Juice
  please feeding dollies, racing cars)
• Representational capacity, forming mental
  pictures to form ideas about wants and needs
• Ability to use imagination
• Experience the idea of an emotion
• Symbols are necessary to express thoughts and
  feelings and to resolve conflicts
• When we look at symbolic development were
  looking at emotional development. Symbols
  provide clues into the childs emotional world.
• The goal is to elevate all feelings and impulses
  to the level of ideas and express them through
  words and play instead of acting out behavior

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BUILDING LOGICAL BRIDGES BETWEEN IDEAS

• Stringing together a logical sequence of ideas.
• Moving toward more reality-based thinking
• Providing explanations Why?
• Linking ideas and feelings to begin to form a
  logical understanding of the world
• The child learns to differentiate what is inside
  him from the outside world, to understand himself
  and his world better.
• Running dialogue, linking of the childs action
  and ideas with your own
• Closing of a multitude of symbolic circles,
  interaction of ideas
• Be even more interactive, engage, question,
  challenge, collaborate, talk about but let the
  child take the initiative
• Combine action, words, and affect!
• Thinking conceptually, reflecting on motives,
  making predictions

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THE IMPORTANCE OF APPRECIATING INDIVIDUAL
DIFFERENCES

• KNOW THE CHILDS INDIVIDUAL PROFILE. NO TWO
  CHILDREN ARE ALIKE
• IMPORTANT AREAS TO ASSESS ARE LANGUAGE
  (EXPRESSIVE AND RECEPTIVE), SENSORY PROCESSING,
  REACTIVITY, AND MODULATION, VISUAL SPATIAL
  PROCESSING, AUDITORY PROCESSING, MOTOR PLANNING
  (PRAXIS), PROPRIOCEPTIVE, AND VESTIBLAR SENSES
  THESE AREAS CAN CHALLENGE PROCESSING AND
  REGULATION
• OTHER AREAS ARE TEMPERAMENT, FRUSTRATION
  TOLERANCE, COGNITIVE ABILITIES, EXECUTIVE
  FUNCTIONING, ATTENTION, PERSONALITY TRAITS,
  BEHAVIOR
• UNDERSTAND THE CHILD ACROSS SETTING
• MODIFY THE ENVIRONMENT. REMOVE THE ENVIRONMENT
  FROM THE CHILD NOT THE CHILD FROM THE
  ENVIRONMENT
• MODIFY THE WAY IN WHICH YOU INTERACT WITH EACH
  CHILD.

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RELATIONSHIPS ARE THE CORE ESSENTIAL LIFE LINE

• Relationships organize the childs experience and
  support all domains of development
• Rich synchronicity that occurs between child and
  parent in typical development
• Flooded with positive emotional energy to glue to
  parent
• Holding image of parent when play peek-a- boo,
  baby can remain regulated with just the image of
  mommy
• Evidence of dormant mirror neurons (fire in the
  prefrontal cortex when we see someone doing an
  action we have performed) in individuals with
  autism
• Maintaining and sustaining co-regulated
  interactions
• FEAS an assessment instrument designed to
  assess a childs functional emotional and social
  capacities in the context of the relationship
  with the caregiver

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RELATIONSHIPS (CONT.)

• Essential to consider family dynamics, parenting
  styles, family stress, patterns of interaction,
  capacity to woo and engage
• Assess parents priorities and conceptualizations
• Understand parents own experiences and feelings
  regarding play
• Parents capacity for handling aggression and
  other difficult behaviors
• Parents view of their child once diagnosed
• Available support for the family system including
  siblings
• Genetic propensities
• Can not underscore the need for AFFECT in the
  family. Affective interactions help the child
  regulate around sensory experiences, to draw
  meaning, helps the brain to create connections
  between different developmental domains (e.g.,
  motor, cognitive, visual-spatial)

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SOME RESOURCES

• ICDL.COM
• STANLEYGREENSPAN.COM
• COPING.ORG
• CELEBRATE THE CHILDREN.ORG
• Books by Stanley Greenspan, Serena Wieder, and
  other contributors
• The Child with Special Needs
• Engaging Autism
• The Challenging Child
• ICDL- DMIC (Diagnostic Manual for Infancy and
  Early Childhood)
• Psychodynamic Diagnostic Manual (PDM)
• Clinical Practice Guidelines
• The Out of Sync Child (Kranowitz)
• The Boy Who Loved Windows (Stacey)
• The Developing Mind (Siegel)