Neil Samuels Developmental Therapy
Neil Samuels Developmental Therapy
A DIR/Floortime based approach for children diagnosed with ASD and other Developmental based challenges.

Comprehensive Developmental based approaches such as DIR/Floortime are strongly grounded in infant and early childhood mental health, clinical, developmental psychotherapy and affective neuroscience. They are peer reviewed evidenced based Developmental neuroscientific approaches to treat children and older with autism spectrum disorder and other biopsychosocial based challenges. Below are several resources that validate a comprehensive DIR/Floortime developmental based approach to treat children with ASD and other biopsychosocial based challenges and the developmental affective neuroscientific foundations that justify its use as a primary intervention approach with children and families.

In 2011 preliminary results from a fully randomized control trial of 51 children with mild to severe autism, ages 2 years 0 months to 4 years 11 months, were published by the MEHRI Foundation at York University, Canada. Participants were assigned to either a target treatment group (DIR Floortime, 25 children) or community treatment group (26 children, 16 received ABA). The study evaluated a social-communication based approach to autism.  PET scans of all children were taken prior to trial start and post trial to record any neuronal changes. What was quite remarkably demonstrated were clinically significant and clinically meaningful structural neuronal changes in formerly underactive and overactive areas of brain functioning  demonstrated among participants in the targeted treatment vs. control group.

Data sets among participants in the targeted DIR/Floortime treatment group (one child here presented in video below) revealed significant increased activity in the prefrontal cortex area (e.g., executive functioning  responsible for emotional regulation, ideation, motor planning and sequencing); significantly reduced adverse subcortical functioning (e.g., significant dampening of the limbic hypothalamus, pituitary and adrenal axis, reduction of size of amygdala responsible for All or Nothing responses); increased significant activation of the FFA (fusiform face area of the fusiform gyrus), which is responsible for scanning, reading, interpreting and processing the intentionality and facial affective (emotional) expressions of others. After treatment, changes in neuronal activity was found to be more consistent with what typically observe in healthy developing children.  These prefrontal and subcortical changes were directly correlated with specific milestone increases in simple to increasingly complex circles of social-pragmatic child/parent interactions and were demonstrated in the targeted treatment group vs. the community group.  Re-analysis of trial result data in 2015 further revealed that the targeted treatment group considerably outperformed the community group on number of utterances produced and various speech act categories.  

https://www.youtube.com/watch?v=4TRL1TMwsuA&t=11s

The published preliminary and follow up data on the 2011 MEHRI Foundation study (cited above) as well as separately other previous and current controlled randomized trials supporting a comprehensive developmental based approach, such as DIR/Floortime as a primary treatment methodology for young children and older diagnosed with ASD can be found at  http://www.icdl.com/research 

The following is a one hour and forty minute talk with video presentation given by one the most experienced, internationally renown DIR/Floortime Occupational therapist,, Rosemary White., OTR/L. This talk and video presentation is extraordinary useful for both families and clinicians as Rosemary explains in a remarkably detailed and nuanced perspective the theory of DIR/Floortime methodology in everyday practice.

https://www.youtube.com/watch?v=lp3o2yqYPWs&t=2349s

The following white paper by Diane Cullinane, M.D. is an overview of  the scientific evidentiary support for the  DIR/Floortime methodology to treat infants, toddlers and older with ASD and related affect-sensory and social pragmatic communication based challenges:

http://www.adaptmanitoba.ca/wp-content/uploads/2014/04/Evidence_Base_for_DIR-2014.pdf    Updated,  July 2017:  https://docs.google.com/a/icdl.com/viewer?a=v&pid=sites&srcid=aWNkbC5jb218aWNkbHxneDozNzJiNGQxYzQyMWEzZTIx

Below are the Clinical Practice Guidelines of the  Interdisciplinary Council Developmental Learning (ICDL) published in 2001.  It is a comprehensive overarching view of the biopsychosocial components that form the neuroscientific foundations for a comprehensive Developmental assessment and treatment approach for individuals diagnosed with autism spectrum and other biopsychosocial challenges. The chief  editor is the late Dr. Stanley Greenspan, M.D. (former head of NIMH, Mental Health Study Center and the Clinical Infant Development; co-founder of Interdisciplinary Council Developmental Learning and the DIR/Floortime methodology).  It is co-authored by many of the foremost professionals within the biopsychosocial sciences. 

http://www.icdl.com/bookstore/icdl-clinical-practice-guidelines

Now, it is  extremely valuable for all primary caregivers and clinicians working with infants, toddlers, older children and adults with ASD to begin to read the voluminous evidenced-based research that supports not the older traditional and essentially simplistic surface behavioral based models (ABA) but rather comprehensive evidenced-based Developmental social pragmatic approaches (DSP) such as DIR/ Floortime. DIR/Floortime addresses not selectively targeted or circumscribed behaviors but rather the primary core Functional Emotional Developmental challenges associated with ASD

Unlike traditional applied behavioral based methodologies, DSP approaches neither render nor conflate a false evidentiary equivalence between the heterogeneous and biopsychosocial complexity of each child's core Functional-Emotional Developmental milestones, individual sensory-affect-motor processing and relationship based differences with each child successfully “redirected” to execute selectively targeted behavioral/ academic performance tasks on cue (e.g., the ability for each child to produce on adult command from declarative memory a set of functionally-scripted responses or what colleagues and I refer to as socially compliant "surface trained behaviors”).

Despite half a century of smashingly rewarding behavioral and-pharmaceutical marketing campaigns (i.e., two-prong approach of psychotropics and ABA or CBT) resulting in widespread public acceptance of masking symptoms by feigned heroic attempts to shape or “redirect behaviors”, what in fact is conveniently and egregiously ignored are the affective (emotional) biopsychosocial relationship foundations. What this involves is deepening reciprocal attachment and attunement during simple to complex social-emotional interactions, thus addressing not surface symptoms but the underlying core primary emotional-developmental relationship based challenges found in ASD and related disorders (e.g., subcortical functioning and autonomic nervous system regulation and associated arousal states). These challenges are not a matter of the child imitating new behaviors and extinquishing old behaviors but are co-structured through the emotional dynamics of relationships where “behaviors” natural change in an integrated and meaninful way.

Developmental social pragmatic approaches such as DIR/Floortime focus on the core biopsychosocial underlying foundations which constitute healthy relating, engaging and communicating in the context of child/primary caregiver and peer-relationships and applies equally to typically developing children and children with challenges in engaging and communicating. What has been clearly demonstrated over the last twenty-five years of research in Developmental Affective Neuroscience and infant, toddler and early childhood mental health in practice as well through neuroanatomical, neurophysiological and neroendocrinological research corroborated by vastly improved advances in functional neural imaging in utero, infancy and toddler development between two brains is how functional-emotional growth, development and learning unfolds in the context of affectively attuned and healithy secure nuturance and social-emotional relationship based interactions.

The latter phrase, “between two-brain” in affective developmental neuroscience, attachment theory, developmental psychotherapy and infant and early childhood mental health practices is frequently referred to by the use of the term, “interbrain.” These biopsychosocial foundations and epigenetic connections which actually begin in utero particularly during the last trimester involve the mother’s right orbital frontal cortex area with the infant and toddler’s right subcortical limbic, anterior cingulate and the hypothalamic, pituitary and adrenal axis, HPA (our central stress response system) which dynamically coordinates and interconnects with the autonomic nervous system. How these emotional-bodily based, right to right brain communications begin to connect the earlier (subcortical) and later (prefrontal) parts of the brain can be seen and measured in real-time as mentioned previously through significant advances in functional neural imaging.

Essentially, the way the prenatal, infant’s and toddler’s subcortical areas begin to form the neural pathways enabling synapses to connect with the inchoate prefrontal areas of the brain or executive functioning (i.e., planning, sequencing and execution of ideas and emergence of language) is epigenetically, that is, through child/parent emotional-bodily based communicative interactions. The epigenetic connections (the set of molecules that sit on top of the genome and regulate gene expression,, that is, what genes become turned on or off, produce proteins and enables synapses to form) are critically dependent for optimal growth and development on a healthy secure dyad, i.e., child/parent reciprocal emotional interactions. This begins with the biopsychosocial processes of infant/toddler/primary caregiver emotional deepening attachment and attunement. These communications begin through simple to complex back and forth social-emotional visual-facial, auditory-prosodic and tactile-gestural interactions.

Therefore, evidenced based Developmental social pragmatic treatment approaches, such as DIR/Floortime, which concurrently addresses both typical as well as non-typical developing children are entirely focused around the building and integration of  the child’s biopsychosocial interactions, This is done around the child’s natural intent and emerging healthy "sense of self with others" and guided not by a set of external prompts and performance targeted behaviors on a checklist but by the child's natural emotional individual sensory processing differences addressed in the context of child/primary caregiver relationships.

Now, in either typical challenging behaviors (e.g., poor child daycere or instutional care settings or during insecure avoidant and ambilvalent attachement) or in non-typical development, such as ASD, it is not the compartmentalization of an inventory checklist of the child's circumscribed or “problem behaviors” targeted for modification but rather guiding primary caregivers to use their natural emotional intelligence to learn how to slow down and emotionally connect and engage with their child's constitutional developmental and sensory-affect-motor processing challenges that significantly enables the strengthening of these underlying neural pathways that lead toward the formation of new synaptic connections and meaningful Developmental milestone advance.

The Understanding Of Behavior As Adapative Response: Our Visual/Facial, Auditory/Prosodic, Tactile/Gestural Social Emotional Engagement System Bi-Directionally and Dynamically Coordinated With Our Central Stress Response System (LHPA, Limbc Hypothalamic, Pituitary Adrenal Axis) And Autonomic Nervous System: The Foundations Underpinning A Biospsychosocial Relationship Approach.

The justification for an evidenced based developmental biopsychosocial relationship based approach that focuses on social-emotional relationships such as DIR/Floortime garnered new appreciation by the tremendous advances made in the fields of neurophysiology, neuroanatomy and neuroendocrinology during the mid 1990's.  At this point in time there was conceptualized a new understanding of the traditional depiction of our autonomic sympathetic and parasympathetic nervous system with a brain (central nervous system) sitting on top engaged in higher ordered thinking (executive functioning) to one that was now understood as a single integrated system bi-directionally regulated by two distinct phylogentic branches of the vagus nerve. The first, an unmyelinated parasympathetic vagus nerve which evolved with the appearence of reptitles and regulated simple metabolic activity such as breathing and ingestion and through phylogenetic changes with the appearence of mammals an adjacent myelinated vagus nerve (more efficient and rapidly responsive) which served as a pathway for the cortical regulation of social engagement through connections to the cranial nerves of the face, eyes and ears as well as the larnyx and pharnyx.

All mammals’ visual,-facial, auditory-prosodic, tactile-gestural sensess when engaged in an optimal positive and reassuring manner through co-regulated social reciprocal interactions with others of its conspecifics, helps maintain healthy affective states of homeostasis or when our symparthic nervous system is not mobilized for positive engagement (such as play) and is under stress, frightened or threatened, this social-emotional system is circumvented and what is now recruited is our sympathetic nervous system for fight/flight responses. However, if our sympatjhetic nervous system when mobilized for fight/flight response is not available because, for example, we feel (or any mammal feels) hopelessly trapped or perceives a dire life-threat, an evolutionary earlier unmyelinated parasympathetic dorsal vagus pathway, a freeze or feint response is or can become activated.

Significantly, what is so critical to understand here from an evolutionary neuroanatomical and neurophysiological perspective is that our peripheral nervous system was re-conceptualized not outside the central nervous ystem but rather as a single integrated biopsychosocial adaptive system regulated by three distinct nervous system circuits (sub-diaphragmatic, diaphragmatic and supra-diaphragmatic). All three autonomic nervous system circuits from the brain stem to the abdomen (our higher thinking brain,-heart-emotional brain and gut brain) were now seen as a single phylogenetically ordered and heirarchically structured system with the transition from reptiles to mammals regulated by what is referred to as the surveillance system of the body: The vagus nerve

The vagus nerve is the longest nerve in the body and directly connects our brain to our body . It runs from our abdomen o the medulla oblongota in the brain stem with sensory fibers connecting to all major organs. The newer mammalian myelinated vagus nerve (which connects to the nucleus ambiguus adjacent to the dorsal motor nucleus, an older unmyelinated vagus nerve) has what is referred to as special efferent pathways that connects to the cranial nerves of our head, eyes, face and middle ear muscles. This cortical regulation of the vagus nerve, which includes the recurrent larygneal nerve, a branch from the vagus, constitues our social-emotional engagement system. Our social-emotional engagement system is co-regulated through moment to moment visual-facial, auditory-prosodic and tactile -gestural interactions with others.

In the traditional model of two related but disparate systems, a peripheral and a central nervous system little if any importance was given to the supradiaphragmatic or the cortical vagus pathway regulation of the autonomic nervous sysem, our newer mammalian ventral vagus nerve which through efferent pathways connects to the cranial nerves in the head, face, middle ears, larnyx and pharnyx: Our social engagement system. No longer viewed as peripheral (i.e., autonomic nervous system below, higher ordered decisions by a left brain above), it was now understood from an evolutionary perpsective as a single phylogenetic and heiarchically ordered adaptiive biopsychosocial system. One that that is concurrently, top/down, bottom/up bi-directionally up-regulating and down-regulating arousal states connected to ours and all mammals social engagement signals of perceoved safety or threat.

Our sympathetic nervous ystem mobilizes for action without defense when (we and all mammals) are engaged in what is termed in affective neuroscience as the enthusiasm or seeking system and the play system or we mobilize for defense when faced with danger and thus go into fight or flight. The parasympathetic nervous system servess as the “brake” or the down-regulator for calm, rest and restoration. However, a major paradigm shift occurred with the new discovery of a separately identified more primitive parasympathetic vagus nerve pathway which is activated when fight or flight is not an option for us (and all mammals) serves as a shut down freeze or immbolization response. This is also known as a death-feigning response.

The activation of this unmyelnated parasympathetic vagus is accompanied by breathing slowing down and defecation sometimes occurring as metabolic functions begin to shut down in order to preserve our body’s resources for survival. This earlier vagus pathway shut down or freeze response is dominant in reptiles but these phyologenetic features were retained in this dorsal vagus pathway in mammals alongside a newer and myelenated (more rapidly efficient and conducive) ventral vagus (that regulates the head, face, ears and vocalization) with the emergence of mammals

The neural regulation of our social-emotional engagement system through the connecting pathway of the ventral vagus nerve has not only helped our species and all mammals survive but thrive through caregiver/offspring practices (i.e., co-regulation, calm, nurturance and play) and in the process help down regulate or inhibit fear based fight/flight responses. Thus we have

1) A newer and myelinated (more rapid, responsive and efficient) ventral vagus with connections to the larynx, pharynx, middle ears, face and head (i.e., the higher social-emotional communicative functions) which evolved with the emergence of mammals, most developed in humans, serves as a down-regulator or inhibitor of sympathetic fight/flight responses (i.e., through social-emotional communication pratcices of deepening reciprocal attachment, rco-regulation and play). However, when the higher social-emotional communication system and earlier defensive circuits fail (i.e., sympathetic fight/flight responses) are not available as an option, (i.e., we can neither fight or flee and feel trapped), then the other, a more ancient dorsal parasympathetic vagus nerve pathway can become activated and dominant, as the other two adaptive systems, one for calming, reassuring and co-regulating-through reciprocal social engagement and the other mobilized for defense (i.e., flight or flight) are circumvented. In other words, when visual-facial, auditory/prosodic, tactile/gestural co-regulated interactions (our social-emotional engagement system,) are no longer affectively, bodily-emotionally, perceived/registered as “safe” and when our defense system of fight/flight are also not an adaptive option then

2) The earliest most primitive unmyelinated vagus pathway a repitilian feint, freeze or immobilization response becomes dominant. This can also take the form of moderate forms of disassociation. We can often see this at times particularly when young children or adults particularly with history of complex post traumatic stress are exposed under conditions that neuroceptively (i.e., emotional-bodily) are registered in terms of extreme anxiety or panic,

What was so importantly elucidated from the perspective of evolution, neuroscience and psychology were the biopsychosocial foundations that constitute the early mammalian to the human primate social-emotional engagement that enabled mammals not only to survive but thrive with respect to registering and perceiving literally in milliseconds (biolgically--emotionally sensed cues of safety, hence, a new term was coined, “neuroception”): The rapidly processed emotional-bodily sensed cues consist of, warm reassuring face to face and auditory-prosodic, tactile-gestural cues (e.g.., “It is ‘safe’ to hear you and come close.”) or conversely perceived cues of threat resulting in fight or flight or freeze.

So beginning with the earliest mammals through human caregiver nurturance reciprocal engagement, the central stress response system ( HPA (hypothalamic, pituitary adrenal axis), our earllier dorsal vagus nerve pathway and our later verntral vagus pathways adapatively and dynamically serve as a conduit for the coordination of our autonomic nervous system responses. (subdiphragmatic, diaphragmatic and supradiaphragmatic). This is a single integrated social-emotional regulation system iadaptively turned on or turned off in accordance to feelings of perceived safety for engagement or perceived levels of threat, from fight, flight to death feigning or immobilization. This has become ground-breaking in theory and practice in such fields as infant and childhood mental health, complex post traumatic stress, psychoanalysis, developmental psychotherapy and autism spectrum challenges.

For example, during emotional-bodily based, pleasurable back and forth co-regulated/communications in infant/toddler/ parent interactions; visual-facial, auditory-prosodic, tactile-gestural in healthy secure based attachment and attunement. The latter results in critical homeostasis. For example, during dyadic child/parent intgeractions, auditory attunement, sympathetic mobilization for play/up-regulation of joy as well as parasympathetic calm and restoration) or conversely, fight/ flight responses in insecure avoidant and dismissive attachment; or worse, in cases of moderate to severe negelect and abuse a potential life threat feinting or freeze response where the unmyeleniated parrasympathetic dorsal vagus pathway is activated. .

It is critical to bear in mind the adaptive bi-directional integration of our central stress response system (hypothalamus. pituitary, adrenal anxis, HPA) with our autonomic nervous system and regulating affective arousal states during back and forth social-emotional engagement. For example, down-regulating sympathetic stress flight, fight responses and the associated reduction of stress related hormones, such as testosterone, epinephrine, vasopressiin, dynorphin and cortisol or conversely a positive increase in hormones, such as dopamine, endorphins, serotonin and oxytocin,

Now, quite separately, in non-typical development in utero, for example, due to immune or endocrine system compromises by the mother’s exposure during pregnancy to neurotoxins can result in an array of heterogeneous affect developmental disorders, such as Autism Spectrum or related developmental challenges. Individuals with such constitutional histories can similarly evince disproportionate fight/flight or feint and freeze responses as we separately see with individuals with early complex post traumatic stress histories. Identical subcortical and autonomic nervous system regulation pathways have been found to be affected (e.g., corpus callosum hippocampus and limbic hypothalamus pituitary adrenal axis/central sress response system).

Although, in neurodevelopmental challenges such as autistic spectrum we can clearly identify or indicate a separate set of constitutional factors resulting in a diathesis of neurophysiological traumatic stress, what should be noted is that irrespective of insecure avoidant, neglect and abuse pratices or entirely separately atypical constitutional challenges in utero which, later, for example, results in a diagnosis of autism spectrum, we often see very similar downstream biopsychosocial etiologies. For example, with respect to vagus nerve auditory attunement or auditory shut down;  reduced functional-emotional expressive use of facial, bodily gestural reciprocity or a flat affect and the ability or challenges in optimally regulating the  laryngeal  and pharyngeal muscles required for vocalization, with a diverse range of the varied inflected emotional or prosodic elements of speech which comprises 93% of spoken language.

A new understanding of the evolutionary significance of this myelinated vagal branch (e.g., striated facial, middle ear, ocular, vocalization) represented a huge paradigm shift towards a much more expansive and nuanced understanding of how social-emotional engagement came to serve a new and hierarchical transformational role in regulating autonomic functioning, beginning with the evolution of the earliest parasympathetic shut down, feigned death or immobilzation response in the reptilian brain to the fight/flight and newer and more myelineated parasympathetic vagus response (rest and restoration) in the mammalian brain and how each of these features are hiearchical structured (primitive, limbic, neocortex) in our own phylogeny and either optimally regulated (e.g., calm, well-regulated deepening  back and-forth social-emotional engagement, including complex ideation and expressive language - that is core human executive functioning) or circumvented and recruited to primitive or regressive functioning (e.g., fight, flight or immobilization and reptilian death feigning response) by these two contiguous but evolutionary distinct parasympathetic vagal pathways.

All of the above is extraordinarily imperative in forming the basis of all educational and therapeutic practices from birth through the lifespan with respect to understanding “behaviors” as emergent properties of our neurobiology and not simply “learned cognitive responses” or in the case with children with challenges, such as ASD, “poorly learned coping mechanisms” that can be mediated through operant conditioning or an exclusive focus on the prefrontal cortex/executive functioning (“rational decision making”).

Rather, behaviors” are an integral part of our underlying neurophysiological foundation and are facilitated through healthy social-emotional psychologically attuned nurturing relationships or in trauma based histories (e.g., insecure avoidant attachment, neglect and abuse) or quite separately, in non-typical prenatal development (i.e., constitutional challenges such as ASD). Depending upon arousal states during these reciprocal interactions this generates beneath the level of cognitive perception (what is referred to as neuroception, essentually autonomic nervous system based cues registered in milliseconds ) “feelings of safety” for engagement or “feelings of adversity and danger” resulting in fight, flight or disassociated/freeze responses.

See, Porges, S. 1995. The Polyvagal Theory).*    Dr. Stephen Porges: 2014 Human Nature and Early Experience https://www.youtube.com/watch?v=SRTkkYjQ_HU Porges, S. 2009 The Polyvagal Theory: New Insights of Adaptive Actions of the Autonomic Nervous System https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3108032/ S. Porges, S. Furman 2011 The Early Development of the Autonomic Nervous System Provides a Neural Platform for Social Behavior, A Polyvagal Perspecive. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3079208/

Regarding stress activation systems in children and Adolescents, see, Rothenberg; McGrath, 2016 , Inter-Relation Between Autonomic and HPA Axis Activity in Children And Adolescents https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5731846/

Neurotypical Development, The Maturation Of Our Social-Emotional Brain:  In Utero Through Three

The neuroscientific evidence over the last several decades clearly demonstrates a direct correlation between forming healthy neuronal [brain] patterns of connectivity and child/primary caregiver nurturance based practices (and as noted brain stem and autonomic nervous ystem regulation):  The nature of child/caregiver deepening affect reciprocal attachment and complex two-way reciprocal emotional problem solving (e.g., back and forth co-referencing with visual-facial, auditory prosodic and tactile gestural exchanges) with respect to building the emotional foundations of the child's healthy core "sense of self" and correspondingly the child's intact, integrated and healthy emerging developmental milestones (i.e., social-emotional relating, thinking and nonverbal to verbal communicating) have been well established in the fields of infant mental health, epigenetic research on deepening reciprocal attachment and affect regulation on right to left brain development beginning in utero and early childhood, clinical and developmental, psychotherapy and psychoanalysis.

For example, since the 1990's this has been corroborated by extensive neuroscientific research that clearly demonstrates that the healthy integration of each infant's sensory and motor connections and how these inchoate connections beginning in infancy turn on genes, produce proteins and form into complex synaptic patterns (the maturation of the wiring of the subcortical and prefrontal areas) including the maintenance of healthy respiratory vagal tone (i.e., heart rate variability) are directly dependent upon highly emotionally attuned and responsive primary caregiver interactions.   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4318551/ 

For the seminal ground breaking work that began to transform the former disparate fields of neuroanatomy, neurobiology, early infant child mental health, psychoanalysis, family law and Developmental psychology into a new understanding and synthesis, an over-arching theoretical framework and a new foundation for Affect Developmental evidenced based treatment practice see, Schore, Allan, 1994, Affect Regulation and the Origin of Self: The Neurobiology of Emotional Development.

Absolutely brilliant presentations by Allan Schore, 2017, The First 1000 Days of Life: A Critical Period For Shaping Our Emotional Selves and Brains: https://www.youtube.com/watch?v=lY7XOu0yi-E&t=6s

Allan Schore, 2017, The Development Of The Right Brain Across the Lifespan. What’s Love Got to do With It? https://www.youtube.com/watch?v=u_B6WekX75s&t=5030s

The understanding of this fundamental and highly nuanced child/primary caregiver dyadic, triadic and multi-social framework (indeed, if we look at the extended family system) can be correctly conceived of in terms of a significant paradigm shift or the bridging of the fields of Developmental psychology and neurobiology with respect to a new and comprehensive understanding of the formerly viewed disparate biological, psychological-and-social components. This critically encompasses the relational (epigenetic factors) of early infant/toddler/primary caregiver secure or insecure attachment practices that significantly determines the trajectory of what and when genes turn on and off, produce proteins and form and maintain healthy or unhealthy synpatic formation and interconnectivity (what internationally renown attachment researcher and psychiatrist, Dr. Dan Siegal defined as,, “Interpersonal Neurobiology”).

Justifiably, this is now conceptualized as the underlying foundation of developmental social pragmatic evidenced based treatment practices, such as DIR/Floortime, with respect to understanding and guiding primary caregivers in facilitating and maintaining healthy dyadic affecr reciprocal emotional relationships in early infant and childhood mental health as well as treating children with autism spectrum challenges. The latter is a fundamental move away from the past traditional cognitive dissonance of brain treated apart from body (e.g., in traditional practice treating cognitive, language, arousal, autonomic and sensory motor functions as separate components) or as in applied behavioral analysis (ABA), a focus on targeting “selective behaviors”, toward a truly integrated biopsychosocial mind-brain-body approach in accordance to the last twenty-five years of research in Developmental Affect Neuroscience.

Due to the advances in technology over the last twenty-five years  we can now more accurately measure our data (i.e., adult-child inter-brain communications and how the subcortical and cortical areas of the brain in infant and toddler development epigenetically begin to form in real-time (i.e., PET, fMRI ). We can specifically show a direct correlation between neuronal growth (e.g., synaptic formation and interconnectivity across different parts of the brain-and-autonomic nervous system regulation and cardiac vagal tone) during healthy child/caregiver nurturance or conversely impaired neuronal activity due to unhealthy nurturance practices. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3968319/  http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0181066

I have provided at the end of this section several additional links to some audio and video discussions for families and clinicians working in the field on what actually constitutes the healthy affective basis of childhood development (i,e., the roots of emotional intelligence). Now, given a child's  healthy underlying biological and immune system, the perennial question prior to 1990's was, "What is it that brings the early developing parts of the infant's brain (primitive reflexes, senses and emotions:  heart rate variability, breathing, blinking, sensations to sense of touch warmth; auditory, soothing or alarming voice, vision, etc.) into organized and meaningful affective patterns of simple reciprocal co-regulated engagement (optimal arousal for attending, relating and engaging)?" The answer given by Developmental affect neuroscience is the co-regulated partner(s) or "adult higher brain(s)" (the primary caregivers) with the prenatal and postnatal newly forming brain of the child. This is the foundational social-emotional symbiotic relationship absolutely critical for all infant/toddler social-emotional-cognitive development.

Again, what is required to bring the emerging "social brain" of the infant/toddler online with respect to basic executive functioning  from simple to increasingly complex engagement with others (e.g., regulated/co-regulated sensory-affect-motor ideation, sequencing and engagement) is the more experienced or  higher brain of the primary caregiver or more specifically the child/primary caregiver dyad,  Every human infant is born with approx. 84 billion neurons. The human infant is born biologically equipped with a set of basic reflexes. senses and primitive emotional responses. However, the vast majority of neurons that will form into synapses hooking up these complex neuronal pathways (sensory-affect-motor) are highly malleable and thus only loosely connected at birth and only begin to increasingly coalesce into complex neural networks beginning in the last trimester through the first few years of life.  

The brain is experience-user/interdependent. The strength of the connectivity and resiliency of the brain's foundations (primitive, limbic and neocortex) are directly co-determined or co-regulated by the "higher brain" of the parent or the child/primary caregiver dyad.  This necessitates for optimal integration and resiliency secure based attachment, attunement and reciprocal back and forth emotional social engagement (e.g., beginning from birth with the simplest wooing/pleasurable back and forth emotional signaling between parent and child, connecting, breaking and re-connecting child/parent affect facial expressions, games as simple as "peek-a-boo", etc), all of which help co-structure for the child internally well-regulated biopsychosocial patterns with respect to his/her sympathetic-and-parasympathetic and primitive parasympathetic regulation and increased executive functioning. Again, this must begin with healthy child/parent dyad of secure based attachment and deepening expanded attunement by up-regulating joyful states through play and down-regulating stressful states through soothing. The latter creates the interpersonal neurobiological foundations for increased optimally regulated and not just malleable (which all brain pathways are) but resilient complex emotional signaling (e.g., co-emotional gestures, primitive co-prosodic vocalizations, sensory integration, simple to expanded ideation and social-pragmatic expressive language)..

The following absolutely brilliant presentation addresses the emotional basis of attachment, affect regulation and cognition, which biopsychosocially exponentially forms during the last trimester into the end of the second to third year of life and which constitutes the unfolding nature and degree of empathy and resiliency of the primary Functional-Emotional Developmental milestones beginning in infancy throughout the lifespan.

Dr. Allan Schore, Modern Attachment Theory: The Enduring Impact of Early Right Brain Development on Affect Regulation, 2012 . https://www.youtube.com/watch?v=c0sKY86Qmzo

Dr. Allan Schore, The Neurobiology And Neuroendorcinology Of Boys At Risk, 2017. https://www.youtube.com/watch?v=P451kiWSBic&t=12s

2018, Dr. David Willis, Reflections on Dr. Allan Schore’s presentation above: https://www.youtube.com/watch?v=qkJe1dwmbM4

Dr. Allan Schore: The Neurobiology of Attachment , 2013 (brief clip on explanation of Nurture and Nature; Parent/Child interactive regulation which is crucial in turning on genes to produce proteins which help construct and maintain healthy synaptic growth and development.)

https://www.youtube.com/watch?v=0RGWjs7SIfw

Autism Spectrum And Related Biological-Psychological-Social Developmental Challenges.

What has been far too long ignored in practice by special educators and other clinicians working with children with autism spectrum and other related challenges and too often if at all conveyed to parents (e.g., at the start of early intervention) is the neuroscientific evidence that it is precisely these same principles of healthy nurturance based practices - necessary and indeed critical for each child's core functional emotional developmental milestones (i.e., calm, attentiveness, co-regulated patterns of back and forth emotional regulation, playfulness, ideation) when applied in a therapeutic context (i.e., adjusted or tailored to each child's functional emotional developmental and processing biological based constitutional challenges) that does in fact significantly help re-construct new healthy integrated neuronal pathways in the brain.

Because of the paradignatic shift in our understanding the immense and critical role of epigenetics (synapatic growth and structuring of the autonomic nervous ystem as experience dependent), the field of psychology and treatment both in autism spectrum and other related typical and non-neurotypical challenges has now shifted from behavioral to cognitive theory to affect based regulation theory or an understanding of the critical role of the emotions, particularly in infant/mother dyads but throughout the lifespan.

Guided pleasurable and affectively engaging relationships not just with infants and toddlers but with older children with mild to more involved autism spectrum challenges (due to the brain's enormous neuroplasticity) can not only help facilitate but again as the neuroscientific evidence clearly demonstrates actually re-wire the brain, that is build, strengthen and expand those healthy neural pathways (e.g., improved connectivity between the prefrontal cortex and subcortical functioning and overall integrated sensory-affect-motor functioning - where simple to complex social-emotional affective engagement and pragmatic language development, beginning from the emotional right subcortical to linguistic left prefrontal cortex can begin to re-build and strengthen synaptic connections).  An expanding database of evidence over the last decade on neuroplasticity is increasingly demonstrating the ability for individuals to re-construct new neuronal connections throughout the lifespan.  

The following is an  extremely enlightening discussion with regards to much of what I have discussed above with Dr. Stuart Shanker, Distinguished Research Professor of Philosophy and Psychology at York University, entitled Babies,  Brain, Nature and  Nurture.

https://www.youtube.com/watch?v=5bi6x-4aNmM

Stuart Shanker 2016, Todd Ouida Children Foundation Conference, Attuning The Mind Body Spirit, Recognizing Stress and Protecting the Spirit in Infants, Toddlers and Children.

https://www.youtube.com/watch?v=vXNWYoKuVS8

Susan Hopkins EdD and Elizabeth Shepherd MSc, "Masking Stress with Misbehavior."  This contains important definitions and research underpinning the neurophysiological and developmental understanding  of Self-Regulation, where challenges with a child's  ability to regulate bio-psycho-social interactions are commonly mistakenly defined as, "Misbehavior."   https://selfregulationinstitute.org/reframed-volume-1-issue-1-july-2017-masking-stress-misbehaviour/

American Academy of  Pediatrics, August 2018  Clinical Report on Play  http://pediatrics.aappublications.org/content/early/2018/08/16/peds.2018-2058

The following is a brief but essential overview of the six  core strengths necessary for healthy child development by Dr. Bruce Perry,  American psychiatrist, currently the Senior Fellow of the Child Trauma Academy in Houston, Texas and an Adjunct Professor of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine in Chicago, Illinois,

https://www.youtube.com/watch?v=skaYWKC6iD4

The Root of Empathy Symposium: 2017 . Dr. Bruce Perry, Born For Love:: Why Empathy Is Essential And Endangered

https://www.youtube.com/watch?v=5gU1wXbs5mc&t=9s

The following is an  extraordinarily important video clip with regards to a well-known experiment by internationally acclaimed, Developmental psychologist, Edward Tronick, Director of Child Development Unity and Distinguished Professor at University Massachusetts,, Boston.  He is a research associate in Newborn Medicine, a lecturer at Harvard Medical School.  He is well known for his research on infant/child caregiver dyadic attachment and what transpires when that emotional connection is disrupted or withdrawn:  The Still Face Paradigm:

 https://www.youtube.com/watch?v=bG89Qxw30BM

https://www.youtube.com/watch?v=apzXGEbZht0

The following  video clip, "Attunement and Why It Matters", by  David E. Arrendondo, M.D.,  briefly illustrates what happens between infant/primary caregiver with respect to neuronal connectivity and attunement during deepening reciprocal attachment and emerging co-emotional signaling.

https://www.youtube.com/watch?v=UHYaF8EHzVw

Below is one of the most important seminal papers written in 2004  by the late Stanley Greenspan, M.D. and co-founder of DIR/Floortime with respect to the role of affect (or the emotions) constituting typical and non-typical developmental pathways. It is absolutely critical reading:

"Developmental Pathways To and From Autism: The Role of Emotions in the Core Deficit in Autistic Spectrum Disorders-- The Affect Diathesis Hypothesis."

https://drive.google.com/file/d/0B4eYdf4hpBzyRi12eWp5OWx5NE0/view

Below are two very brief video clip introductions on the "Mirror Neuron System", by Dr. Dan Siegal, Distinguished Fellow of the American Psychiatric Association and is the Executive Director of the Mindsight Institute. Founding Co-Director of the UCLA Mindful Awareness Research Center. He serves as the Medical Director of the Lifespan Learning Institute.  The mirror neuron system is largely regarded as challenged with many individuals diagnosed with ASD. It is part of the brain directly responsible for the ability of individuals to empathically identify, register, interpret, understand and predict the  "intentionality" of another's action or what has been traditionally referred to as "Theory of Mind." 

https://www.youtube.com/watch?v=24fITRNWh1k&list=PLDCtwyPSjhlNEz4xuzxt6Tdsnyt2vChiB&index=8

https://www.youtube.com/watch?v=Tq1-ZxV9Dc4&list=PLDCtwyPSjhlNEz4xuzxt6Tdsnyt2vChiB&index=7

Dr. Dan Siegal presents below an in-depth discussion on interpersonal neurobiology, "The Neurological Basis of Behavior, the Mind, the Brain and Human Relationships." 

https://www.youtube.com/watch?v=B7kBgaZLHaA

***Dr. Dan Siegal, Roots of Empathy: Research Symposium, 2016. An Interpersonal Neurobiology Approach to Resilience and the Development of Empathy.

https://www.youtube.com/watch?v=2dmX6XBZ1GY

Dr. Allan Schore: 2014 The Most Important Years of Our Life: Our Beginnings https://www.youtube.com/watch?v=KW-S4cyEFCc&t=752s

Dr. Allan Schore. Roors of Empathy: Research Symposium, 2016.: Modern Attachment: The impact of Right Brain Development on Affect Regulation

https://www.youtube.com/watch?v=c0sKY86Qmzo

*The Polyvagal theory first introduced by Stephen Porges, M.D., in 1995  provided a new and transformative neurophsyiological understanding of  the necessary and indeed critical mammalian/human evolutionary factors of social-emotional engagement (executive functioning) that regulates autonomic functions that are a functional part of the myelinated pathway of the vagus system connected from the heart to the basal ganglia, striated facial muscles, auditory system and vocal system.

The Polyvagal Theory,  2009:  New insights into the adaptive reactions of the autonomic nervous system, Stephen W, Porges, M.D.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3108032/

The Polvagal Perspective, 2007, Stephen Porges, M.D.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1868418/

Steven Porges,  M.D., Human Nature and Early Experience (an in-depth discussion on the  neurophysiological correlates that constitute the foundation for a biopsychosocial understanding on how typical and non-typical infants begin to learn, grow and thrive.)

 https://www.youtube.com/watch?v=SRTkkYjQ_HU

Stephen Porges, MD.,, The Neuroscience and the Power of Safe Relationships                                 (self regulation/co-regulation)

https://www.youtube.com/watch?v=3pbVTla932Y

Stephen Porges, M.D., Polyvagal Theory: Co-Regulation in Therapy

https://www.youtube.com/watch?v=ivLEAlhBHPM

Stephen Porges, M.D.,,  "The Polyvagal Theory."

https://www.youtube.com/watch?v=8tz146HQotY     

Stephen Porges,  M.D.,, 2011, Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication and Self-Regulation.

https://books.google.com/books?hl=en&lr=&id=0-nxBGHj36oC&oi=fnd&pg=PR9&dq=definition+neurobiology+and+neurophysiology&ots=tfqEfhr6hn&sig=dzaQxjEPy9u4bY_wDZ2PCB_HyYg#v=onepage&q=definition%20neurobiology%20and%20neurophysiology&f=false

Dr. Stephen Porges: Discussion on "Misophonia."

https://www.youtube.com/watch?v=nB3nS4Gh_9k&t=7s

Colwyn Trevarthen, 2014 Pathways to Child Flourishing: The Love of Special Companions and the Importance Of Play. What is it Being Human and How Can It Survive.

https://www.youtube.com/watch?v=IYXAU2Bvfbw

Daniel Stern, 2010, A Developmental Perspective From Birth On. (a discussion on the synthesis of psychoanalysis and the developmental model)

https://www.youtube.com/watch?v=N_j4q45GHDY

Dr. Stuart Shanker: Self-Regulation: Roots of Empathy Symposium 2014

https://www.youtube.com/watch?v=84GHcfzXsmw

*General Psychiatry: published. online 2018, Oct. 31: Factors Associated with Parent Engagement in DIR/Floortime Treatment of Children with Autism Spectrum Disorder:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234967/

**The following  is an extremely important link for all primary caregivers and clinicians with respect to advocacy for their children, intervention guidance, ,public  policy, insurance coverage and  the adjoining supportive research evidence for  a comprehensive Developmental Relationship based approach such as DIR/Floortime, as well as included are answers  to common questions from families on ABA which is distortedly presented as the only evidenced-based treatment approach for children with ASD and related challenges.

http://www.icdl.com/advocacy