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Developmental Approach to Problems in Relating and Communicating in Autistic Spectrum Disorders and Related Syndromes Stanley I. Greenspan, M.D. The Developmental, Individual-Difference, Relationship-Based (D.I.R.) Assessment and Intervention Program In the D.I.R. model, a comprehensive assessment looks at all the interrelated areas of a child's functioning. Typically, the clinician would discuss with parents, educators, and others the child's current symptoms, overall functioning, and developmental history, with special focus on his functional developmental capacities and individual differences. In addition, at least two observation periods of the child interacting with his most important caregivers (with help from the clinician) to bring out the child's full capacities (at a minimum of 30 minutes each) are essential for assessing the child's functional capacities directly. Interestingly, in a review of 200 cases, we found that over 90% of workups, including those at major teaching hospitals, did not include direct observation of spontaneous child-caregiver play and interaction for more than 15 minutes [Greenspan & Wieder, 1997]. These observations were not made even though diagnoses of autistic spectrum disorder, which hinge on relationship capacities, were made. Also essential is the observation of parental and family patterns to observe patterns, including strengths and weaknesses, that are likely to support or undermine the child's development. To gain additional data on unanswered questions, on an as-needed basis, there should be consultation with colleagues to further assess functioning such as language, motor and sensory, aspects of cognition, and different neurological and metabolic capacities. Based on this evaluation, a profile is created that specifies the child's functional developmental level and related emotional, cognitive, language, motor, and sensory functioning, as well as contributing biologically-based, individual differences and caregiver-child interaction and family patterns. Contributing disorders are also documented. This individual profile is the basis for the construction of the intervention program. The D.I.R., therefore, includes an emphasis on: 1) affects, intent, and relationships; 2) the child's developmental level; and 3) individual differences in motor, sensory, affective, cognitive, and language functioning. A comprehensive program often includes interactive experiences at home (sometimes referred to as "floor time," which may range from two to five hours a day [Greenspan, 1992a, 1992b; Greenspan & Wieder, 1998]). In addition, family patterns, feelings, and coping efforts are addressed continuously [Greenspan, 1992a]. Furthermore, a comprehensive program also includes interactive speech therapy (3 to 5 times per week), occupational therapy (2 to 5 times per week), and consultation to parents for floor time interactions and family support. During the preschool years, an important component of such a program is an integrated preschool. The preschool should integrate 1/4 of the class of children with special needs and 3/4 of the class of children without special needs. The preschool should have teachers especially gifted in interacting with challenging children and working with them on interactive gesturing, affective cueing, and early symbolic communication. This enables children with special needs to interact with children who are interactive and communicative (e.g., as a child reaches out for relationships and communication, there are peers who reach back). All the elements in the D.I.R. model have a long tradition, including speech and language therapy, occupational therapy, special and early childhood education, and floor time-type interactions with parents. These elements are consistent with the developmentally appropriate practice guidelines of the National Association for the Education of Young Children [NAEYC] and pragmatic speech therapy practices, both of which attempt to foster preverbal and symbolic communication and thinking. The D.I.R. model, however, contributes to these traditional practices by further defining the child's developmental level, individual temperament, and processing differences, and the need for certain types of interactions in terms of a comprehensive program where all the elements can work together toward common goals. In this model, the therapeutic program must begin as soon as possible so that the children and their parents are re-engaged in emotional interactions that use their emerging, but not fully developing, capacities for communication (often initially with gestures rather than words). The longer such children remain uncommunicative, and the more parents lose their sense of their child's relatedness, the more deeply the children tend to withdraw and become perseverative and self-stimulatory. |
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