Sunday, June 5, 2011

Eye Contact- Fostering your Child with Autism to WANT to look at you

“Look at me”….I don’t know about you, but each time I hear that I am transported back to my childhood, when I’m in trouble with my Mom.  I would come home and first thing I knew to do is NOT look at my mom….because well, gaze holds all sorts of emotion!!  Maybe if I did not look at her, she would think I did not see her and I could escape upstairs…yeah, you know how that ends!!

To my surprise fast forward to when I became a mom and then for my second and third child,  a mom to two children with Autism…I found myself hearing some people tell me to instruct my child to look at me for any sort of eye contact.  I of course did just that for awhile…because like any mom, I wanted desperately to have my beautiful boys look in my eyes.  I felt as though there were two things standing in the way of me and my boys.  One was that they did not look at me and the other is they did not talk.( I will write on that next weekJ) If they would just look at me….and talk to me….ahhh,  my heart would be in such a better place!!!  Ok and it was for a short time because I was thrilled with any eye contact I was getting  even if I did have to prompt it.   Whenever my boys did look at me or when they used words for that instrumental request for juice or crackers… I melted!!  But……. to me it still felt *different* then my typical kids.  I wasn’t sure if that was all it was going to be or if I should dig deeper.   Would it just improve as they got older? It was one of those things that kept me up at night,  and I know you know what I mean!!

For me,  it was nagging so I went searching ….seaching for answers that I was not sure there was an actual question too.  Most of the websites I went on talked about holding a piece of candy up and when a child looked then they were rewarded by that candy.  I read sites that talked about rewarding a child with social reinforcers,, playing with a favorite toy, etc.  One site said have the child put makeup on you…so they are close to you and the chances of them making eye contact are greater.   I have to say I went through many sites that talked about trying to set up a reward for my child whenever they looked at me.  So I thought, hmmm I don’t have to do that with my typical children.  I mean I get that my other two were dealing with Autism but still,  I felt like there was a gap….and I was right!  What I learned to *search* for was not Autism and Eye contact but instead just Eye contact.  Then it all made sense….even why I avoided eye contact with mom!!  I needed to understand WHY we look!  It is second nature for those of us who are not on the spectrum so I needed to take something that I never had to learn, but just *did* and understand *how* to teach this intuitive process to my own two children with Autism.

Eye contact is about communicating emotional information.  We can do a lot with eye contact…check out this video

How many different conversations can you see going on with eye contact/Gaze?  Our eyes are merely the showman for our thoughts.  When someone tells me to look at them, it is instantly nothing to do with a positive emotion or actual thinking…Im irritated.

So if eye contact is something we do to communicate emotional information, I wanted to make sure that my boys WANTED to communicate with me when they looked at me.

A Look can be intimidating, submissive, playful, and many other things.  For a child,  a LOOK is to share information or perspective from a trusted person in their life.  This is the foundation step that a child uses to understand why the other persons Eyes hold information for them to process!  This is an example of the importance of this developmental milestone    http://www.youtube.com/watch?v=eyxMq11xWzM

This foundational milestone is crucial to the further perspective taking ability in all children….including our children with Autism.  Teaching Eye contact as a behavior misses the incredibly important thinking aspect on why people look at each other to begin with!  And ….. our kids can develop this Dynamic thinking for perspective.  It starts with them learning that our face holds the key to the experience sharing in any interaction.  BUT,  and this is huge,  THEY need to make this discovery with our guidance.  And this discovery has nothing to do with telling them the discovery we want them to make, which is what the words “look at me” do.  Any command to a child, any child, turns off their need to think!  It is the difference between * get your shoes on* and the child obeys or *we are leaving* and the child has to go through a thought process of what is needed before they can leave.  These milestones in thinking create and develop good problem solvers!!

Here are 3 strategies to help your child * want to look at you* From the RDI Program- Relationship Development Intervention

1.     Limit talking-  Use less words and pause between thoughts ….not in a strange way but just more deliberate ( limit the chatter and amount of words used)  If we are chit chatting away all the directions and instructions there is no reason for our kids to actually look at us for any sort of information,  we are providing them all their thinking through our instruction.  Once it registers that we stopped talking, they will look to find out why and this continued practice is instrumental in  learning to reference others for information

2.    Use more non verbal communication- Be more expressive with communication.  Oh OH….or a surprised look on your face will cause your child to reference you.  Something like clearing your throat helps your child to process that he needs to see what is going on.  Again,  this is all practice for your child to see that *WE* hold information, not just in our words, but in body language and facial expression.  If I were to say to you…”Nice shirt” with  a smirk, we would be able to access that I really did not mean the words I spoke!  To get to this foundation,  we must start at the beginning.

3.    Use more self talk -  We all have a thinking process going on before we speak the words. When appropriate, speak your thought process out loud so your child can understand that you have thoughts just like he does.  Something like, Wow, delicious when you take a bite of food.  DO NOT ask them if they like theirs…self talk is placing no demands on your child but simply giving them another vehicle to understand and become interested in your perspective. Demands can be very stressful for your child….what we want is for them to see your emotion, see your thoughts and as long as there are no demands placed on them to turn on the fight or flight mode,  begin to internalize that others can think differently then they do.  This foundational skill emerges at 18 months old in a typical child.



For more information on getting the tools to remediate your child’s Autism,  visit Kathy at -  www.autismremediation.com

Saturday, June 4, 2011

Dynamic compared to Static Intelligence

Our guest author this week, Sue Simmons, delineates the difference between dynamic and static intelligence in an everyday meaningful kind of way. Learn how you can apply some simple RDI principles to help foster more dynamic thinking in your family.   www.rdiconnect.com

It takes only a glimpse of today's world to realize that we are living in unprecedented times. We flip from answering our cell phones, to sending email to friends, to writing to-do lists at lightning speed. Our minds can barely keep up with the demands of our fast-paced world - this requires us to be able to think in a truly "dynamic" fashion.

Consider how incredible our brains are - imagine sitting on a beach, gazing at breathtaking scenery (ahhh). As you gaze at the sparkling water and sink back into your chair, you notice the soft breeze against your arms. Where does your mind go? If you're like most of us, your thoughts wander. As you look around at the people in your midst, you wonder where they live or wonder about the conversations they're having. You study their body language and facial expressions. You may begin to ponder dinner options for that evening. Perhaps someone you see reminds you of a friend and you realize that you owe her a call. Suddenly, your mind goes to your work and you realize that on Monday you have a meeting and begin mentally preparing for it - you realize that you've left your planning to the last minute and do some fast thinking about what you can juggle to free up some extra time. You root through your bag for a notebook to jot down some notes but as you search for your notebook, you see the sunscreen and remember it's time to slather more on the kids. You remember the last time you forgot the sunscreen and how awful you felt. Incredibly, all of these mental processes occur in a remarkably short period of time!

Dynamic intelligence represents the ability to mentally "stick handle" when obstacles show up - to think in shades of grey; to use our past experiences (the sunburn for example) to avoid future mishaps. Being on a beach may allow our minds to wander but this isn't always possible! Consider driving your car. Sure, you can mull things over if you're on a straight stretch of road without other cars around, but in a busy intersection it's much different! As you make a left hand turn at a busy intersection, you're able to shelve all other thoughts that may compete for your attention as your priority is avoiding a collision, pedestrians and cyclists! I think you get the picture. However, dynamic intelligence isn't just thought - but being able to use these thought processes to interact thoughtfully, collaborate and meet our own needs at the end of the day. No small feat.

So what is static intelligence? By definition, static means unchanging. Two times two will always equal four; the capital of Canada will always be Ottawa and apples and oranges will always remain in the fruit category - but don't ask me how tomatoes made it in there. Think back to your driving experience... we know that green means "go" and red means "stop." We tie our shoelaces the same way and use the phone book to look up numbers the same way. Typically, children with autism and other developmental disabilities can excel in the realm of static intelligence, yet they lack dynamic intelligence, which creates the lion's share of their frustration.

The Beginnings of "Dynamic Intelligence"

Picture a parent with a young infant. At this age, the child listens intently when mom or dad speaks - what are they saying to the child? How are they speaking? Likely, they're not reading War and Peace or telling jokes. No, they're up close, using big facial expressions, cooing and using simple sentences. They speak softly and use "sing-song-like" intonation. The child responds by cooing back, giving mom and dad the feedback that they need to stay in sync with the child. When I began to realize how magical the "dance" between parents and their children is, it hit me like a ton of bricks: We are nothing short of hard-wired to communicate to our young in exactly the fashion that they need in order to learn how to understand our nonverbal communication - long before they learn to communicate using words! When the words develop, they enhance the "emotional feedback loop" that's already there!

It's through the miraculous, ever-changing relationship between parent and child that dynamic intelligence begins - through understanding nonverbal communication then through developing resilience and eventually through learning to borrow the parent's perspective. So - our children learn the foundation of "dynamic intelligence" through parents and caregivers. Eventually, once they are able to relate to others, we teach them static skills, like brushing their teeth and using a knife and fork. It's assumed that by the time a child is school-age, they are able to function in a dynamic environment - and we all know how dynamic a kindergarten classroom is!

Can Dynamic Intelligence be "Taught?"

Unfortunately, common belief these days is that children with ASD and other developmental disabilities can only be taught "static" skills. This is NOT the case! Their brains may be wired differently, but they are more than capable of learning "thinking skills" if guided in the right manner.

RDI® Consultants are trained to coach parents to "guide" their child's cognitive, emotional and social development - to teach parents, grandparents, teachers and other significant adults to re-construct the "guided participation relationship" through which dynamic intelligence is learned. Parents break down learning to think and perceive a world full of change and complexity into small, simple components. Adults learn to slow down and amplify information feedback, so that both adults and children are more readily able to understand and adjust to one another.

Parents learn to use the activities of daily life to introduce safe, but challenging experiences for the child. Children learn to respond in more flexible, thoughtful ways to novel, increasingly unpredictable settings and problems. Trust emerges as children learn to recognize regularity and patterns, even in a continually more complex world. Eventually authentic competence emerges as they take ever-greater responsibility for tackling tasks and problems with many partners in varying settings.

Through their parents, the "cognitive apprentice" learns authentic, give and take communication, and develops the ability and desire to connect with others on many different levels.

What can you do to help your child think in a more dynamic fashion? You can start right now by slowing your rate of speech, and being aware of when you "pepper" your child with questions! Children with developmental disabilities often need extra time to process information; their mental "stick handling" isn't as well honed as others. Take a few moments each day to think about how you speak to your child, and imagine how you would feel listening to your own communication... a little extra breathing space is often good for everyone - parents included!

Thank you Sue for this excellent blog! 
Kathy Darrow
visit me on facebook at Mastering Milestones in Autism

Wednesday, June 1, 2011

The RDI program and its effectiveness for our children

A brief introduction to Relationship Development Intervention®


Relationship Development Intervention (RDI®) is based upon research in developmental psychology and the developmental psychopathology of autism spectrum disorders. The specific focus of RDI is to create a ‘guided participation’ relationship with caregivers, through which children develop competence in handling gradually more complex environments. The programme involves supporting families and caregivers/school staff in their roles as participant guides, creating daily opportunities for adaptive and thoughtful responding in the face of novel and increasingly unpredictable settings and unexpected change. Through participation in caregiver-guided continually more complex cycles of regulation, challenge and new regulation, the aim is for individuals on the autism spectrum to learn not only to tolerate, but also to enjoy changes and transitions.

The RDI Program focuses on developing:
·                    an appropriate mix of verbal and non-verbal communication
·                    abilities to engage with others
·                    declarative, self-regulatory and self-narrative language
·                    episodic memory
·                    reciprocal, genuinely fulfilling relationships;
·                    pleasure in living in dynamic environments where change is enriching

Relationship Development Intervention® involves rigorous and extensive training procedures and monitoring of competence, ensuring quality of care as well as treatment adherence. RDI is implemented through intensive parent education, customised and balanced planning, modelling and role-playing, and involving parents in a support network, regular videotape review of parent-child performance, and school staff training and consultation.

There are four sources of evidence that together provide grounds for believing that RDI is effective in ameliorating autism-specific behavior, especially in relation to the children’s limitations in social engagement and flexibility in thinking and action:

1.                 Gutstein, Burgess, & Montfort (2007) report on the 3-year follow-up of 16 children who met 'gold standard' criteria (ADOS/ADIR) for autism, Asperger’s syndrome or autism spectrum disorder prior to treatment with RDI.  Marked clinical improvements after RDI were reported; for example, whereas prior to treatment 10 had ADOS scores corresponding with the diagnosis of autism, none did so at follow-up, at which point five were classified as ‘autism spectrum’ and five as ‘non-autism’. There were especially marked improvements in the children’s capacity to share experiences with others.  Semi-structured interviews with parents revealed that the children’s flexibility had significantly improved. Moreover, there had been positive changes in the children’s educational placements.  In this study there was not a treatment-as-usual control group (a previous pilot study had included such a control group who did not show the gains of the RDI-treated group). Having said this, the magnitude and breadth of this response to RDI renders it very unlikely that the effects were non-specific.

2.       Aldred, Green, & Adams (2004) report a randomized control trial of an intervention for autism that has close affinity with RDI in its attempt to foster developmentally effective parental input through a focus upon the children’s social deficits. The approach ‘educated parents and trained them in adapted communication tailored to their child’s individual competencies’.

The study reported significantly greater improvements in the treated vs. untreated group of children with autism, on a range of outcome measures:  total scores on the Autism Diagnostic Observation Schedule, expressive language, parent-child interaction, and the children’s initiation of communication.  The authors concluded:

'this study suggests that a specific intervention that addresses bi-directional adult/child communication breakdown, joint attention, and is tailored to the specific needs of the cases can improve autistic symptoms across severity and age groups in terms of quality reciprocal communication and expressive language'.

Like RDI, this treatment approach provided specialized structured interventions that scaffold social interaction.  The uniqueness of RDI lies in its sharper focus on links between social relatedness and the capacity to engage in flexible thinking and coping through the guided-participation relationship.

3.                 RDI is founded upon developmental principles that have been subject to programmatic research studies at the Developmental Psychopathology Research Unit at the Tavistock Clinic and ICH/UCL (e.g., Hobson, 2002).

In particular, RDI  focuses on aspects of autism that are pivotal for the development and maintenance of almost all the distressing features of the syndrome, and in particular, the children’s limited interpersonal engagement with other people and their accompanying propensity to becoming ‘stuck’ in particular, one-track modes of thinking.

The focus of RDI is what happens between the affected child and his or her caregivers, with special attention to emotional contact and behavioural regulation.  Thus RDI studies how a given child with autism has difficulties in engaging with another person emotionally; then it provides coaching for the carer to foster the child’s potential for such engagement, reducing the likelihood that moments of engagement (which are often fleeting) are lost.  Perhaps most important, RDI allows the child to enjoy and build upon the engagement that is achieved.  Such interpersonal engagement is hugely important not only for the child’s wellbeing and the parent’s ability to relate sensitively, but also for improving the child’s self-regulation, communication, and more flexible and appropriate thinking.

The intervention is concerned with fostering parenting, rather than attempting to modify children’s functioning over a protracted series of brief sessions.  It is widely accepted that when appropriately designed, parent interventions have special promise for fostering development among children with autism.

In a series of recent (and ongoing) studies, J. A. Hobson and colleagues (Hobson et al., 2008; Hobson & Hobson, 2008; Hobson, 2009; Hobson et al., 2009; Hobson & Gutstein, 2010), have followed children/adolescents with autism and their families (participating in RDI programs) over time. On the basis of prospective study and retrospective chart review, preliminary results of the above studies (note: research is ongoing) suggest that this approach may yield significant changes in global clinical/psycho-social functioning as well as in improving qualities of parent-child interaction and social communication.

Finally, there arises the question of cost-effectiveness.  This has not been subject to formal study.  However, one of the great advantages of RDI is that it can be time-limited, yet its effects on parental functioning and through this, on affected children’s social relations and cognitive functioning, are sustained over much longer periods.  Personally, we are strongly of the view that the substantial lifetime benefits of RDI more than justify its cost – but as yet, there is not quantitative evidence on the matter.



Dr Jessica Hobson, PhD
Senior Research Fellow
Institute of Child Health, UCL and
Tavistock Clinic, London

References

Aldred, C., Green, J., & Adams, C. (2004).  A new social communication intervention for children with autism: pilot randomized controlled treatment study suggesting effectiveness.  Journal of Child Psychology and Psychiatry, 45, 1420-1430.

Gutstein, S.E., Burgess, A.F., & Montfort, K. (2007).  Evaluation of the Relationship Development Intervention Program.  Autism, 11, 397-411.

Hobson, J. A., Hobson, R. P., Gutstein, S., Ballarani, A., & Bargiota, K.  (2008). Caregiver-child relatedness in autism: What changes with intervention? Presentation at 2nd International Conference: Communication – the Key to Success. Pontville School and Edge Hill University, May.

Hobson, J. A., Hobson, R. P., Gutstein, S., Ballarani, A., & Bargiota, K.  (2008). Caregiver-child relatedness in autism: What changes with intervention? Poster presented at the International Meeting for Autism Research, London, UK, May.

Hobson, R.P., & Hobson, J.A. (2008).  Interpersonal engagement: A focus for understanding and intervention in autism.  In symposium on The understanding and treatment of autism: A revolution in the making? Organized by R.P. Hobson, Annual Meeting of the Royal College of Psychiatrists, July.

Hobson, J. A. (2009). The guided participation relationship as a focus for change in children with autism and their parents. Presentation at the biennial meeting of the Society for Research in Child Development, Denver, CO USA, April.

Hobson, R.P., Hobson, J.A., Gutstein, S., (2009).  Parent-child interaction and global assessment of functioning:  measuring change and outcome in adolescents with autism. Presentation at International Meeting for Autism Research (IMFAR), Chicago, USA, May.

Hobson, J. A., & Gutstein, S. E. (2010) The Guided Participation Relationship as a vehicle for change in autism. Manuscript under review.

Hobson, R.P. (2002).  The Cradle of Thought. London: Macmillan.


Studies  are underway with the Institute of Child Health at UCL and the Tavistock Clinic in London following cases in treatment prospectively. Reports on cases seen through the Connections Center but coded and analyzed independently by a separate research team blinded to treatment details have been presented in numerous conferences, and we have a collaborative paper with Dr Gutstein under review. The more sophisticated study, with a sample from an independent site  is nearly complete and data analyses will be conducted over the summer.