IPMH January Weekend III: Serena Wieder on Autism Spectrum Disorders

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Dr. Wieder talked about her original collaboration with Stanley Greenspan. She wanted to do outreach to underprivileged population. They started long term study of an underprivileged population to answer the question of how do you know that a child is “on track”? The first thing they learned was they had to deal with regulation and shared attention. They then realized they needed to learn more about language development and sensory integration and they brought in specialists in these fields. Then what the infant brings into the world, the individual differences. They created an intervention for children with developmental disorders, primarily ASD – DIR. “D” is for development, “I” is for individual differences, and “R” is for regulation.

Wieder states that the basis for development and for treating autism is developing reciprocal relationships between parent and child. DIR introduced a major paradigm shift in intervention from a focus on behavior to one on affect and relationships. The idea is affect is central to learning and that emotions drive early cognitive development. The approach involves treating relationships and not just the child. It assumes that every child has an inner world even if he or she cannot express it, that everyone has individual differences and therefore needs an intervention that specific to him or her, that an interdisciplinary approach is necessary, and that competencies come from experience instead of from training. These features of DIR distinguish it from the ESDM model as it is described. DIR proposes a structure to bring together a step-wise model of the developmental process with the individual features of the child, and features of the environmental, including the parents.  There are 6 “core developmental stages or processes called The Functional Emotional Developmental Levels”.

Wieder also points to the biological/neurological origin of autism, referring to autism as a disorder of neural connectivity that interferes with the connection of affect and intention to the child’s ability to sequence actions and also to relate, communicate, and think (Just et al, 2004, 2007). When sensory motor processing and challenges in language comprehension and visual spatial knowledge derail development, emotion must be brought into the intervention as early as possible to strength the connection between sensation, affect, and motor action.

Dr. Wieder stresses that DIR initially emphasizes the relationship with the parent. She says that DIR has influenced the field; now behaviorists use developmental concepts and the two groups may be coming closer.

She showed a video of an 18 months old boy. Child was spinning, following lines across the floor, sensory craving, disconnected, gaze averting. He had to find some way of moving in space so he followed a railroad track. If he looked out into the world, he got confused. These symptoms are solutions. Moving a car back and forth also is “something you can do”. This child’s solutions were walking on a line, playing with a train back and forth. Since the DIR hypothesis is that in autism the child has difficulty connecting affect to the ability to plan and sequence actions, DIR proposes affect based interventions, including affective preverbal connections, such as the caregiver’s smiling face and wooing voice. The infant recognizes patterns of interaction. In the film the father has an overwhelming feeling of wanting to connect with him. He climbed into the boy’s crib. The child stopped what he was doing and looked at his father and laughed. The father realized that he just had to make a connection with him. One goal in every DIR session is that there is a parent child connection.

In another film of a boy, “Danny”, the child was walking in circle, carrying his bottle of soda. Dr. Wieder just watches the interaction and then says to the father, “Just show me what you usually do with your child.” The father says, “I think I am going to walk in circles with you.” He was following the child’s lead. He was talking to him at the same time. Dr. Wieder asked the father to get playfully obstructive. The child was aware that his father was blocking him. “Really block him, Dr. W told the father, then tell him, “Open the door.” The father starts blocking “the door” and they make a reciprocal play. There is an affect transformation when the child gets cheerful and starts laughing. You need affective engagement to learn to sequence and create a purposeful act.

Dr. W said that the children who do well with ABA have some capacity to imitate but then you can reach a ceiling. ABA gets kids regulated and compliant. Ed asked a question about Jerry Bruner’s studies of motor performance, which I also recognized from Thelan and Smith’s application of dynamic systems theory to motor development in infants’ reaching (Thelan and Smith, 1994). Ed pointed out that these children just kept trying to accomplish their attention to reach an object until it worked, and asked where does it go wrong? Dr. W said that it gets more complex. For example, the spatial element complicates things. Peek a boo is less complex than hide and seek. These children go off course because they can’t make use of the experience. This is called “praxis” or motor planning – you have an idea and then you plan it. You start out with an intention and then you get derailed. Ed said that “motor planning” within circles of research in motor development is problematic. (This is because “motor planning” involves a linear sequence of acts, and developmental researchers like Thelan and Smith have observed that this is not what happens.) Ed continued, it is better to say that given the constraints in reaching, the reach gets created every time. First you have the intention – then you reach, and the reach becomes fitted to the context of the weight of your arm in the moment. If you put a weight on a baby’s arm, he can’t do it but within 5 tries he gets it. Dr. W said that is where the affect comes in. you have to have the wish to reach.

In the film of “Danny”, Dr. W coaches the parent – in the game of ring around the rosie – to stay down until he says “up” and get him to look at you. You have to give the child work. Instead of telling the child to look at you, enhance his ability to look at you. “Let him pull you down, let him pull you up, lengthen the pause so that he can look at you.”

She then showed a film of a preverbal little girl who murmurred “Mommy” for the first time. For the whole consultation, the child sat on the couch behind her mother. At the end they were about to leave and the mom was prepared to do put on her clothes for her. Coached by Dr. W, her mother pretended to put the sock on her hand, then on the foot that already has a sock on it. She was getting the child involved in the process and you could see that the child was actually more competent than her mother had thought.

Then there was a film of a little boy called “Ned”, who loved cars and wanted to play with his cars all the time. He was self-absorbed in his play. He could track the cars and manipulate the toys, but he had no shared attention. His mom was nicely available, but he never looked at her. Dr. W always asks, “Is what I am looking at what he looks like at home?”  (Sally Rogers also asks that.) The parents say yes. She asked what else do you do? They say, “He loves books”. She told the father to say the wrong words in the book. When the father did that, the boy looked at his dad. She told the father to mix it up again. “Show me the panda bear”. She told the father to let him show him. The boy had good receptive language at least with a script (predictable). He gave his dad eye contact with his dad’s error. He stayed regulated even though he was annoyed by his dad’s error. He understood the wrong word was being said. He hadn’t spoken any intelligible word at all. He became persistent in getting his father to follow along with his agenda, taking over because he didn’t want his father to make another mistake.  Dr. W said that the competence has to be activated. The first goal of treatment is to go back and get some back and forth going. The next step might be, “Can you push the car back and forth with me?”

The world gets more complicated, and this is connected to visual spatial orientation. A lot of rigidity is related to anxiety about change, and children become visually bound – the same path, same clothes, the same food. Change throws them into a state of panic. Ned’s difficulty was that he would not let go of his cars. They wanted to expand his range. It is hard to help parents do this. It is hard to help children expand their range.

Dr. Wieder discussed the six fundamental levels of development according to DIR: (1) Regulation and joint attention; (2) Forming attachments and engaging in relationships; (3) Intentional two-way affective communication; (4) Complex social problem solving; (5) Key to competence and reasoning – complex gestures in sequences that are purposeful and communicate language and ideas; (6) Creating emotional ideas – longer chains of co-regulated affective gestures that enable the child to recognize affects in caregiver and eventually leads to symbolic thinking and complex reasoning.

Dr. W emphasized the important role of vision and visual spatial development. The key is for the caregiver to adapt her voice and expression to the child’s individual capacity so that the child can enjoy the interaction and take the caregiver in. When this experience is compromised the child cannot fend off overstimulation from the outside world.

Gestural system requires sequencing, a back and forth rhythm in communication. She recommends to families that they play charades. That involves working on gestural communication. Also you have to look at the person. It can help with kids that are concrete – black and white. Sign language is a helpful tool but is not so easy with ASD children in that it uses the motor system. She encourages parents to sign while speaking to accompany the auditory system with the gestural. She supports augmentation of the speech system.

DIR directs the parent to always follow the child’s lead, to create a continuous flow of interaction. How long can you do something with it? The rule is you never change topics. If the child changes topics you try to bring him back to carry on the back and forth and move it forward towards greater complexity. Maintenance of the conversation or connection is primary and must be accomplished before elaboration of the symbolic idea. The words are focusing more on the emotional and not the content of the words necessarily. You accompany the words with the gestures etc. she says please do not bring in category books, such as car and truck books, ABC books. It works against the relational connection. Language should not be treated as words and labels; instead it should be treated as feelings and meanings.

Finally, there was a film of a little boy trying to put on the red boot of a doll. The mother resists the temptation to tell him that the boots don’t fit. “What should I do?” instead. Mother is wonderful in the affective cues she gives him, “Ooooh!” “What do you want to do with these boots?” “I want to splash in puddles.” Mother takes the doll the boots belong to and makes the doll ask him for the boots. The doll says, “I want to splash in puddles.” “Can you help me put these boots on?” “See, these are my boots. These boots are small like me.” “Are you bigger than me or smaller than me?” “Bigger than me.” “Want to jump with me in the puddles?” Then they pretend to wipe off his feet after pretend jumping in the puddles. Then the tissue becomes a raincoat. Dr. W pointed out that what you see is climbing into the symbolic world. The child can now separate his perception from the image in his mind. The elaboration takes time. He had an idea. His idea was jumping puddles, and even the boots didn’t fit, he wanted to put them on so that he could jump in puddles. In the end, he was thrilled that someone else (the doll) could jump in puddles and then he got the idea that he could want to go out and buy some for himself. Later on he can use level 6 capacities use play to solve his problems.

In the next posting I will outline what I saw as the similarities and differences between ESDM and DIR and also add some thoughts about a psychoanalytic approach.

 

References

 

Greenspan S & Wieder S. (2011). Relationship-based early intervention approach to autistic spectrum disorders: The DIR model. In D Amaral, G Dawson & D Geschwind (Eds). Autism Spectrum Disorders, New York: Oxford University Press, pp. 1068-1080).

 

Casenhiser, D.M., Shanker, S., & Stieben, J. (2011). Learning Through Interaction in Children With Autism: Preliminary Data From aS ocial-Communication-Based Intervention. Autism published online 26 September 2011

 

Just M, Chekassky V, Keller T, Minshew N, (2004). Cortical activation and synchronization during sentene comprehension in high-functioning autism: eveidence of underconnectivity, Brain, 127:1811-1821.

 

Just M, Cherkassky V, Keller T, Kana Rajesh, Minshew N. (2007). Functional and anatomical cortical underconnectivity in autism: Evidence from fMRI study of an executive function task and corpus callosum morphometry, Cerebral Cortex, 17:951-961.

Thelan E & Smith LB (1994). A dynamic system approach to the development of cognition and action, Cambridge, MA: MIT Press.

Read this blog in Spanish. 

Photograph by Ginger Gregory

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