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EDUCATION & THERAPIES

BY JOSHUA D. FEDER, MD

M
Joshua D. Feder, MD is a atthew is finishing high school. communication (gestural as well as vocal),
child and family psychiatrist He doesn’t want to make a big visual spatial abilities, and especially the
specializing in the treatment deal of it. But we get emails capacity to have her own ideas, make a
of developmental and learning about class rings and Grad Night, and I plan about them, follow a sequence in
disorders. He is an assistant think about all the people who helped that plan, and adapt the plan when it
clinical professor in the make this happen. I listed most of them inevitably does not unfold as expected.
Department of Psychiatry at in his senior ad, the one with the picture DIR is relationship-based. This means
University of California, San of the class ring he helped me design that the intervention is carried out
Diego, School of Medicine, for him, but which he doesn’t want. His through interactions with the child, ones
is on the faculty of the progress has been astounding. And his that follow the child’s initial lead and
Interdisciplinary Council on success is from Floortime. then build on the interaction with the
Developmental and Learning Floortime is the everyday name of the child to create interactions together that
Disorders (ICDL), and was Developmental Individual-Differences are always new, never predictable, but
recently named a Distinguished Relationship-Based (DIR) intervention fold in the things we want the child to
Fellow in the American model of understanding and intervening learn about communicating, thinking, and
Psychiatric Association. to help people with developmental and relating.
learning disorders. It evolved from the The key concept is “affect” -- we all
DIR/Floortime is designed work of Drs. Stanley Greenspan and need to care about things to motivate
for use with anyone at any Serena Wieder, and it has been around in
age and with any level of various forms since about the mid-1970s.
developmental, learning, or DIR is a “developmental” approach,
communication challenges. which means that it looks at where the
Much of DIR/Floortime is open child is along the social-emotional growth
source, including free guidelines curve. Recent versions of the Bayley
for setting up a DIR/Floortime Scales incorporate Greenspan’s Social-
program and hundreds of hours Emotional Growth Curve.
of free podcasts accessible DIR is individualized in that it looks
through ICDL.com, Floortime. at the child’s specific processing and
org, and circlestretch.blogspot. learning capacities, such as sensory,
com. motor planning, receptive and expressive

Emotion drives the person, and DIR/Floortime captures


threads of emotion and weaves them into a tapestry that
can support development.
32 THE AUTISM FILE | www.autismfile.com REPRINTED WITH PERMISSION © THE AUTISM FILE ISSUE 30 2009
us to learn. Emotion drives the person, to help me see my own child objectively. in play-based DIR occupational therapy,
and DIR/Floortime captures threads of Bernie reviews videotape we shot a year has a run of Tomatis, vision consults,
emotion and weaves them into a tapestry earlier of Matt and another little girl, due process with the school district, and
that can support development. DIR/ Christina, both at one-year-old, in an medication. The subtext is endless (diets,
Floortime creates emotional engagement, Ainsworth attachment protocol. Christina dogs, dolphins…), but the core of the
strengthening and expanding the is clingy; Matt is on the aloof side, but, intervention is DIR/Floortime.
connection between the child and those looking at the tape in retrospect, Matt CHAMPUS insurance fails us. I
around her. This requires that we know is more than aloof. He has very little moonlight to cover it all. We let the house
the individual profile of the child and emotion at all. Bernie sees it, calls it, holds get cold in the winter and briefly suspend
work with that profile, compensating us. At 23-months Matthew has a diagnosis cable service to save cash. Leslie starts to
for those challenges at times, but also of “PDD-NOS” a.k.a. autism. Leslie is 8.5 clean houses. This is the price of pursuing
stretching the child’s capacities to months pregnant with our second and intervention.
broaden and strengthen her tolerance final child. She is perplexed, stunned, Floortime is free. Leslie works every
of the environment and ability to act in and forlorn. My mind implodes. Matthew minute to join Matthew in whatever he is
the environment. It also requires that we reacts to our distress, biting his hands doing and build on it with him, “closing
understand caregivers and families to in frustration. We are alarmed: Will the those damn circles.” Matt is so attached
support them in their efforts to help a new baby have it? Leslie loses amniotic to Thomas the Tank Engine toys that he
child. fluid and is induced, producing Madeline, carries a bag of them down the aisle while
Matt’s is a common story: first child Matthew’s best gift ever. ring bearer at his aunt’s wedding. The
born to engineer-artist types, a cranky Soon afterward, Bernie gives me an circles work. Matthew is more “with” us.
baby who speaks a FULL SENTENCE at article on Floortime. I don’t understand I cautiously intrude on him, picking up
nine-months (“I see the bird.”) and then what he is trying to tell me. The doctor in one of the little engines he’s lined up and
shuts down, joylessly lining things up. the article is in Washington, D.C., and we amiably offering it back, or rolling one
Favorite photos comforted us: lying on expect orders to Japan. out of place for him to circle back, so to
top of Mom, Leslie, and smiling at her Matt’s IQ tests in the 70-80s range, speak, and get it in line again. Over and
in the shade of the carob tree; grinning and two prominent visiting consultants over, always a tiny bit differently, playful
at the camera while we “fix” the mower; recommend institutionalization: “If you in my motions, trying ever so gently to
looking amused as a puppy tugs his keep him home, he will be like a pet.” We liven up his serious demeanor. When
diaper. keep him. My detailer and friend, Lindsay I hesitate a moment, getting ready to
Existential irony. I’ve worked in this Paden, arranges to let us stay in Hawaii mischievously pluck one more, he looks
field since college, when I volunteered to for a year to sort things out. Matthew has my way and I think I see a twinkle in his
do caretaking and behavioral intervention multiple therapists and special preschool eye. He knows it’s a game. He is looking
with congenital Rubella victims (blind, with behavioral programming, which at me, naturally looking at me. This is so
deaf, autistic), and later a painful stint makes perfect sense to me. He makes different from behavioral intervention.
teaching autistic adults with behavioral progress: he follows commands and learns I didn’t tell him to look at me. I’m not
therapy. I quit after an understaffed a few words. But he is stuck on Thomas instructing him how to play. This is
outing to a hot, polluted beach. Then the Tank Engine. Madeline crawls after Floortime. It’s about his idea and how
came medical school, residency and, him; he is annoyed and says, “Moddie go we make it into a shared moment. I’m
at the time of Matthew’s diagnosis, a Mama!” Cute. And a full sentence -- but melting. And, impossibly, he comes back
fellowship in child psychiatry, during we don’t understand how important this is. for more.
which I’d seen the famous pediatrician Dr. I search the medical literature for answers. With Dr. Wieder’s help, Madeline
T. Berry Brazelton encourage the mother I look again at that article on Floortime: becomes Matthew’s sister in the fullest,
of a very challenged child to have hope, Matthew’s brush-off to Madeline -- a real most complicated sense. It’s their saga:
while I looked on cynically and shook my response -- means hope. Madeline follows Matthew, usually
head. So, we go to the developmental Lindsay arranges orders to D.C. We communicating at him, and expects that
pediatrician with our first concerns and I consult with Stanley Greenspan, MD, he will help her with whatever she needs.
am quick to blurt: “Well, he’s not autistic.” originator of DIR/Floortime. My new boss, Matt tries to help, once giving a haircut
The pediatrician, a rival of my boss Bernie Sid Blair, is a prince and allows me to do (quite a scene) and these days driving her
Lee, who was concerned that Bernie over- “whatever-we-need” to help Matthew. and her friends to activities. She is kind
calls the diagnosis, concurs with us. Leslie Whatever-we-need is full bore Floortime and irritable with him, and he is kind and
is less than reassured, and I remain fixed coached by Dr. Serena Wieder. She plays, annoyed by her. Filial love propels their
in denial. helps us to play, and guides peer play daily narrative, writing a rich story of their
Bernie is Chief of Child Psychiatry at with Matthew. Matt attends intense lives in our family. This, too, is Floortime.
Tripler Army Medical Center. He has a DIR/Affect-Based Language Curriculum Fast forward. We are in San Diego
sharp eye, and he’s been training me for (ABLC) speech therapy with Diane and out of the Navy. Matthew is in a
18 months at this point. This does nothing Lewis, gains better control of his body regular first grade class. His holiday
ISSUE 30 2009 REPRINTED WITH PERMISSION © THE AUTISM FILE www.autismfile.com | THE AUTISM FILE 33
EDUCATION & THERAPIES

It is about what he wants and how to help him get there, supporting ever better ability
to be calm, engaged, communicate, so he can have a life that is meaningful to him.
And this is meaningful to us.

cardboard gingerbread man has a red she challenges him to resist compulsive Toward the end of sophomore year,
LED for a nose. We facilitate circles of hand washing, hug the pets, cook, and Matthew can’t find an engineering
interaction with peers, and we pass ideas be who he can be. He seeks us out, but internship. To his chagrin, we create
to the school staff -- especially for the he retreats into videogames, too. There a three-kid engineering and design
playground. Still in speech therapy and are tough moments, including a difficult company. Matthew and Cedric, Matt’s
with us or “big brother” mentors spurring situation at Boy Scout Camp. But now he partner in a robotics competition, do
him on, Matthew plays, surfs, and bikes. tells us, and together we figure out what design work. Annie, a devoted and
He has a friend here and there, and to do. This process of facilitating activities, gregarious friend, serves as CEO. She
suffers a bully or two. Leslie has sharp helping him to expand his emotional herds the guys, negotiating direction and
warnings for children who would dare try and sensory tolerance and range and deadlines. Matt fears commitment, but
twice, “setting the environment” in her experience, and to solve problems, is also he’s constitutionally dedicated, and it’s
inimitable execution of that Floortime Floortime. We don’t tell him what to do fun. They gab about music and goofy
concept. IQ retesting puts Matthew in the or think – this is not about compliance or videos. They get a design request, work
110-115 range. what we want. It is about what he wants fairly consistently for a year, and file a
Matthew absorbs facts but struggles and how to help him get there, supporting patent for a greener lighting unit – Matt
with writing. His tutor, Leah Strauss, an ever better ability to be calm, engaged, is big on green. LEDs are involved.
harnesses Matthew’s passion for science and communicate, so that he can have a Floortime? They are engaged in ideas of
and they co-create essays about Mars. In life that is meaningful to him. And this is what is good and what is better -- the
Matt’s fifth grade science fair project, he meaningful to us. grey areas of life.
attempts to demonstrate antigravity. He High school seems easier until Matthew Matthew needs extra time on SATs,
patiently walks me through the design, has to learn a foreign language. English so we retest him: IQ high 120s. SAT and
and I maneuver Matt to wax philosophic is already his “second” language. It’s our ACT scores are superb. Getting accepted
about the possibilities of Star Wars home language, but Matthew’s innate to college will be easy. But Matthew
technology and what it could do for internal dialog is a nonverbal visual-spatial wants to go to MIT or Mudd because they
people. He hears Harry Potter books on sixth sense that serves as his main conduit pull great pranks -- so much for vetting
tape en route to Indian Guide weekends to the universe. His notebooks blossom colleges. If he really wants to go and
(more facilitated play), then suffers my with beautifully sketched circuit diagrams really cares, he needs to really take care of
re-reading, trying to do voices like that of things I cannot comprehend. But his himself: get up in the morning, remember
English guy on the tapes. We stop to speech is still halting at times, and he is his medication, type his own papers, and
laugh and share the fun on every page. learning from his now longtime speech promote himself to try to get into those
He is drawn to read the stories himself! therapist and confidante, Keri Leasure, schools. And this is Floortime, too. He
Joy fuels his effort to decode the words, ways to slow down the banter of peers reflects about who he is and who he wants
the phrases, and the lilt of the voices of so that he isn’t left out. To meet the to be. Most important: We hover less, but
the characters. He belly laughs. When language requirement, I learn three years we don’t abandon him. We wonder aloud
we jump in to hear about it, he tells us of American Sign Language with Matthew. about his progress, and Matthew asks us
where he is and we relive the moment He chooses it because it’s visual, but it still questions, cuddles the cats, and calls out
together (especially fireworks that spell isn’t easy. We survive with the help of his from the front hall on his way to school:
“POO”). This is Floortime. We join him, classmate, Jennifer, and ASL translator, “Well, gotta go.” Matthew is connected to
engage with him, and work toward Billianne McClellan. Matthew’s banter the web of humanity.
a continuous flow of balanced back gets better, too. Leslie has us addicted
and forth interaction. He is now using to Comedy Central, where stand up acts, Family names and names of minors have
symbolic thinking to conjure other worlds new and repeated, serve as fodder for fun been changed for privacy.
and ideas, think about them, and play fast-paced family time. Matt is learning to
with them -- his social-emotional and manage many people at once and hanging
cognitive development are advancing. out with his youth group every week.
Middle school brings science This is Floortime. Matthew is honing life
competitions, Boy Scouts, and Bar skills in his quest to become an engineer.
Mitzvah training. I am coach, scoutmaster, He requires this context. And he is also
and cantorial trainer. Leslie constantly becoming more comfortable among the
pushes Matthew’s emotional envelope – guys.
34 THE AUTISM FILE | www.autismfile.com REPRINTED WITH PERMISSION © THE AUTISM FILE ISSUE 30 2009