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 and developmental psychology and the neurosciences. They are peer reviewed evidenced based 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 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 functional 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 activity in subcortical area (e.g., reduced size and activity of the amygdala responsible for All or Nothing responses); increased activity and functioning in FFA (fusiform face area of the fusiform gyrus responsible for reading and interpreting the emotions/faces of others). New areas of activity in brain functioning were consistent with what we see with typical healthy developing children.  The above prefrontal and subcortical changes were directly correlated with specific milestone increases in simple to complex circles of child/primary caregiver social-emotional 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 . The latter address not selectively targeted or circumscribed behaviors but rather the primary core Functional Emotional Developmental challenges associated with ASD.  Unlike traditional behavioral based (ABA) models, DSP approaches such as DIR/Floortime neither render nor conflate a false evidentiary equivalence between the biopsychosocial complexity of a child's core Functional-Emotional Developmental capacities and individual sensory-affect-motor processing differences with a child being able to successfully execute selectively targeted performance tasks (i.e.,  the ability for a child to produce on adult command or cue a set of functionally-scripted responses or what colleagues and I refer to as "surface trained behaviors").   

Instead, developmental social pragmatic approaches as DIR/Floortime focus on the core Developmental neuroscientific foundations of social-emotional co-relating, co-thinking and co-communicating. Thus, they are entirely centered around the integration of  the child's cortical and subcortical functioning  (e.g., child's emerging "sense of self with others" guided by the child's affective individual processing differences and addressed in the context of child/primary caregiver relationships).  It is not the isolation or generalization of the child's academically achieved "targeted behaviors" but the synchronization of primary caregivers' guided to learn how to connect and engage with their child's emotional differences and developmental and sensory-affect-motor processing challenges that significantly enables the strengthening of  these underlying neuronal pathways that lead toward the formation of new synaptic connections and meaningful Developmental milestone advance.

The justification for an evidenced based developmental social-emotional based approach garnered new appreciation by the tremendous advances made in the fields of neurophysiology and neuroanatomy during the mid 1990's.  At this time there was conceptualized a radically new understanding of a non-bifurcated autonomic nervous system that is socially-emotionally co-regulated and hierarchically structured-for purposes of  homeostasis or under conditions of threat recruited to fight, flight, freeze or feint responses by three distinct pathways of the unmyelineated and myelineated vagus nerve (i.e., sub-diaphragmatic, diaphragmatic and supra-diaphragmatic) .  The  more advanced myelineated vagus nerve  beginning with mammals is directly connected in the heart to the basal ganglia and in primates from the basal ganglia to the striated facial muscles, ocular muscles, auditory system/middle ear and the pharyngeal and laryngeal nerves and represents a new understanding of the biopsychosocial foundations that constitute human social-emotional engagement.

A new understanding of this phylogenetically distinct myelinated vagus pathway in humans had provided for the first time a biopsychosocial understanding of the pivotal evolutionary role that social-emotional engagement system (the higher myelinated aspects of the vagus nerve) directly has in down regulating sympathetic flight, fight, freeze or feint responses adjoined with stress (e.g., cotisol) or healthful hormones (e.g., oxytocin) regulating limbic, hypothalamus, pituitary and adrenal functions.  For example, pleasurable back and forth co-regulated/regulated child/primary caregiver face to face engagement, warm back to back micro-facial  expressive child/primary caregiver exchanges that results in critical homeostasis or conversely, fight/ flight freeze or feint responses due to trauma, e.g., in typical development neglect or avoidant attachment and an unavailable caregiver or in biologically based challenges as in ASD an affect-diathesis, a separate and/or additional set of constitutionally factors resulting in non-typical development.  The latter includes auditory attunement or auditory shut down;  functional-emotional expressive use of gestural reciprocity and the affective regulation of the  laryngeal  and pharyngeal muscles required for vocalization, specifically the prosodic elements of speech which comprises 95% of spoken language.

The evolutionary significance of this myelinated vagal branch represented a huge paradigm shift in understanding how social-emotional engagement came to serve a new and hierarchical transformational role in regulating autonomic functioning, beginning with the evolution of the shut down or immobilzation response in the reptilian brain to the fight/flight response in the mammalian brain and how each of these features are hierarchically 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 spoken language - that is core human executive functioning) or circumvented and recruited to primitive or regressive functioning (e.g., fight, flight or an immobilization response) by these three contiguous but evolutionary distinct vagal pathways (see, Porges, S. 1995. The Polyvagal Theory).*     

Neurotypical Development, the maturation of the brain:  Birth to 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:  The nature of child/caregiver deepening affect reciprocal attachment and complex two-way reciprocal emotional problem solving (i.e., motor planning and sequencing; co-referencing with affective gestures) 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 communicating) have been well established in the fields of infant mental health, clinical and developmental psychology.  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 (incipient neuronal pathways) from birth form into complex synaptic patterns (the maturation of the wiring of the neuronal pathways) and the maintenance of healthy vagal tone (i.e., autonomic regulation and 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 disparate fields of neuroanatomy, neurobiology, early infant child mental health and Developmental psychology into a new synthesis, an over-arching theoretical framework and clinical evidenced based treatment practice  see, Schore, Allan, 1994, Affect Regulation and the Origin of Self: The Neurobiology of Emotional Development.

Absolutely brilliant presentation 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

The understanding of this fundamental and highly nuanced child/primary caregiver dyadic framework 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 biological, psychological-and-social dynamics of intra and interaction (what internationally renown psychiatrist, Dr. Dan Siegal has termed, “Interpersonal Neurobiology”). This can also be conceptualized as the basis for the foundation of an evidenced based treatment away from the past traditional cognitive dissonance of brain treated apart from body toward a social mind-brain-body integrated approach.  Due to the advances in technology over the last twenty-five years  we can now in more accurately measure our data in real-time (i.e., fMRI ) and evince a direct correlation and impact between neuronal growth (e.g., synaptic formation and interconnectivity across different parts of the brain) in 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 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 neuroscience is the co-regulated partner(s) or "adult higher brain(s)" (e.g., the primary caregiver) 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 development otherwise known as the child/parent dyad. 

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.100 billion neurons. The human infant is born equipped with basic reflexes. senses and primitive emotional responses. However, the vast majority of neuronal pathways between these connections (sensory-affect-motor) are only loosely wired together at birth and begin to increasingly coalesce into specific neural networks beginning in infancy through the first several 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 includes deepening attachment, attunement and reciprocal emotional social engagement (e.g., beginning from birth with wooing/pleasurable co-affective back and forth emotional signaling between parent and infants such as connected, disconnected and re-connecting facial expressions, "peek-a-boo", etc), all of which help regulate the child's sympathetic and parasympathetic nervous system for homeostasis and optimal regulated/co-regulated emotional signaling (e.g., emotional gestures, primitive prosodic vocalizations to formal emergence of spoken language proper, social-pragmatic utterances and phrases).

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 second to third year of life and which constitutes the unfolding nature and degree of empathy and resiliency of the 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

Autism Spectrum And Other 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 biological based functional emotional developmental and processing challenges) that does in fact significantly help re-construct new healthy integrated neuronal pathways in the brain.

Guided pleasurable and affectively emotionally-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 engagement and pragmatic language development, beginning from the emotional right subcortical region to linguistic left prefrontal cortex region can proceed).  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

Dr. Stuart Shanker discussing from a biopsychosocial perspective the true definition, meaning and nature of what Self-Regulation is:   https://www.youtube.com/watch?v=84GHcfzXsmw

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. 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, 2017. An Interpersonal Neurobiology Approach to Resilience and the Development of Empathy.

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

*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

Dr. Stephen Porges Website: Infant Developmental Update Study

http://stephenporges.com/index.php/infant-development-study-updates

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

**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