DIR® in the

Schools
Addressing Difficult Moments
by
Creating Enduring
Relationships
 Joshua D Feder MD
DFAPA

Assistant Clinical Professor,

Dept of Psychiatry, University of
California at San Diego School of
Medicine

Faculty, Interdisciplinary Council on

Developmental and Learning
Disorders
 Disclosures

ICDL Faculty – minimal - review of

clinical write ups, travel and room
for summer institute

NIMH/ Duke University – minimal –

administrative time for
pharmacogenetic research
 Thank you

• Cheryl Zak
• Art Aragon
• Alice Prince
 Warning: this will go fast

All the slides will be posted on

www.circlestretch.blogspot.com
 circlestretch
Help the child be…

• Calm enough to interact

• Truly connected to others
• In a continuous expanding
balanced
back and forth flow of
interaction
“Go for that gleam in the eye!”
http://www.circlestretch.blogspot.com
 Outline

• Quick review of DIR®, FEDL

• Aggression
• Other daily problems
 Taking Notes?
• One word: ENGAGEMENT

• One phrase: Engagement goes

beyond compliance.
I - Review
 DIR®/Floortime
Developmental Individual Differences Relationship
Based
Intervention:
Relationship based intervention is the use of
ongoing affective connected interaction to
promote developmental progress,
focusing on co-regulation, engagement,
and social reciprocity. This is done in a
context of a well rounded biopsychosocial
understanding of the person, and carried
out throughout the day by caregivers who
are guided and supported as they develop
growth producing relationships.
 In other words…
WE USE EMOTIONAL CONNECTION TO
FOSTER DEVELOPMENT

WE TAKE INTO ACCOUNT THE PERSON’S

INDIVIDUAL ABILITIES AND
CHALLENGES

WE WORK WITH FAMLY AND OTHERS

TO MAKE THIS HAPPEN ALL THE TIME
 Quick Review of
Functional Emotional Developmental Levels

I – co-regulation, ability to attend

II – engagement, gleam in the eye, warmth
III – circles of interaction
IV – flow/ behavioral organization in social problem
solving
V – symbolic thinking (critical to tolerating
affect)
VI – logical connections between ideas
VII – multicausal thinking
VIII – grey area thinking
IX – reflective thinking, stable sense of self, and an
internal standard
 Sample FEDL
1 (not there) 2 (barely) 3 (islands) 4 (ok w/ 5 (comes 6 (ok unless 7 (ok)
support) back) stress)

Regulate 11/05 11/06 11/07 11/08

Engage 11/05 11/06 11/07 11/08

Circles 11/05, 11/06 11/07 11/08

Flow 11/05 11/06, 11/07 11/08

Symbols 11/05 11/06, 11/07 11/08

Logic 11/05, 11/06 11/07, 11/08

 FEDL - descriptions
11/0 – rigid, aggressive, hits in ‘play’, not really symbolic
5
11/0 - allows me to join his aggressive play on his team
6
11/0 – increased complexity of aggressive themes; able to
7 play with cousin and brother in water fights, facilitated
11/0 by dad ‘battle’, controlling, but can be torn between
– racing
8 me and dad, and nurturing, creative & symbolic with
me; able to play with cousin and brother in games that
are competitive but not overtly aggressive
 Individual Differences - Sample
Sensor Postural Response to Intent to Visual Praxis -
y Communicatio Communica Exploration
Sensory A relative n
Trouble managing te
Dysarthric – A relative Ideas
seeking… strength; more than one unintelligible strength; becoming more
Auditory A bit clumsy - thing at a time Logical Frustrated complex with
Visual impedes rapid Can barely tell discourse is looking for support
Tactile reciprocity in the ‘why’ we fight or difficult (e.g. things Adapting to
Vestibular moment what we fight at best Some ability to problems that
Proprio- 1 indicate about hedonistic: work with come up (e.g.
ceptive desires Can’t track cheating gets shapes and when my
Taste 2. mirror conceptual you objects to character is
Odor gestures discussion of the disqualified) solve problems injured, faints,
3. imitate reasoning behind 1. Mirror in play. etc.)
gesture events and play vocalizations 1. focus on Ideation
4. Imitate with 1. Orient 2.. Mirror object Planning
purpose. 2. key tones gestures 2. Alternate Sequencing
5. Obtain desires 3. key gestures 3. gestures gaze Execution
6. interact: 4. key words 4. sounds 3. Follow Adaptation
- exploration 5. Switch auditory 5.words another’s gaze
- purposeful attention back and 6. two –word to determine
- self help forth 7. sentences intent.
-interactions 6. Follow 8. logical flow. 3. Switch
directions visual
7. Understand attention
W ?’s 4. visual figure
8.abstract ground
conversation. 5. search for
object
6. search two
areas of room
7. assess
space,
shape and
materials.
What we do – in a nutshell
 circlestretch
Help the child be…

• Calm enough to interact

• Truly connected to others
• In a continuous expanding
balanced
back and forth flow of
interaction
“Go for that gleam in the eye!”
http://www.circlestretch.blogspot.com
 II - Aggression

• The main reason we are called in

• There is no quick fix
• Take the long view
• You must have ‘space’ to think and
plan and rethink and plan
 Why DIR?
• When other methods are
failing
• Addresses the core symptoms
vs surface behaviors
• Proactive…
 Models to Understand
Problems
• Zeno’s Paradox (the arrow)
• Calculus 2000 years later….
• RESCU Academy’s ability to manage kids
with aggression and return them to less
restrictive environments
• DIR® as a way to understand the process
at RESCU
 RESCU ACADEMY – rough stats and
description
• Last chance place before residential or ‘step-
down’ form residential treatment
• 100% came b/c ‘behavioral problems’: out of
control, failure to progress academically, socially
• Grades 3-12+ (began w/HS, then MS, now ES)
• 50% ASD – ‘HFA/AS’; 50% mixed (drugs, bipolar,
etc. – ‘no sociopaths’ but ASD issues cloud this)
• 50% are extremely intelligent
• Most have significant learning challenges
 RESCU Academy – outcomes
• Reduction of Aggression at School and
Home
• Improved Academic Achievement
• Improved Social Function – Friends!
• Reduction of Medication
• Better physical conditioning/ regulation
• More than 95% settle down, most return to
public or mainstream private school
settings after about 2-3 years
 Why? – What they would say:

• 12 Step Model – developmentally modified

• Family Involvement
• Structure
• Not quite consistent with ASD population
that did not respond to highly structured
behavioral approaches, often with family
clinics and training (school, SDRC, etc.).
 Why? What I am finding:

• Co-regulation
• Engagement – with Wraparound
• Flow
• High Support with High Expectations
• Follows the ‘plan’
What Plan?
A General Plan for the Management of
Difficult Moments *

• Have a plan ahead of time

• Adjust the environment
• Soothe
• Talk
• Anticipate
*reference:
A Bioethical Approach to Overcoming Problems with Aggression and Misbehavior in Schools,
Stanley Greenspan, M.D.
ICDL 12th Annual International Conference
November 7-9, 20082008 ICDL Fall Conference, Washington, D.C.
 circlestretch
Help the child be…

• Calm enough to interact

• Truly connected to others
• In a continuous expanding
balanced
back and forth flow of
interaction
“Go for that gleam in the eye!”
http://www.circlestretch.blogspot.com
 Mrs. Fitz

• Calm, soothing, and patient

• Never laid hands on the person
• Engaging
• Listened well
• Wondered what to do next time
 1. Make a plan

• Staff must have time to meet and

think it through
• Staff must have time set aside to
rethink it through
 2. Adjusting the environment
• Clearing the room
• Having a safe spot to go to
• Signaling others to leave him be
• Calming the noise, the light, whatever the
child responds to
• Not just a sensory break
• Avoid physical redirection
 Not Just a Sensory Break
• An immediate break teaches nothing
• The child learns to withdraw and may get
worse
• Appropriate use of sensory strategies are
ones that help the child co-regulate and
gradually expand his capacity to register,
tolerate and process sensory information
 Avoid Physical Redirection/
Restraint

• Grabbing begets violence

• Make the grounds safe enough
• Wait for him to return
• At most trail after him, non-chalant
 Feeling Safe and Regulated

• If you feel unsafe, he will feel unsafe

• Have things to protect your self – cushions
• Avoid having the person ‘beat pillows’ – it
engenders more out of control beating
• Regulating physical activity can be helpful
– walking, jogging, bouncing together
 3. Soothe

• When you see it coming, join, co-regulate,

soothe
• When you did not see it coming, you wait
it out
• Don’t over-react, nearly match the affect
and the intensity – enough to help the
child feel understood
• You are not trying to prompt an out of
control child to do what you think will help
 Prompt vs. Woo:

Prompt Woo

Greater power difference Humility – more equality

between people
Control Respect for ideas of other
person
Specific expectation Open ended, hopeful for
growth
Belief in the material Belief in the process
 4. Talk

• Or play
• Communicating about what
happened
• Avoid questions, but try to
understand
 Avoiding Questions
Feder’s Tip of the Century

• Questions are top-down, ‘Guess what I’m

thinking’
• Questions put people on the spot, and
make them more likely to get upset and
close up or act mad
• Statements create social ‘problems’ that
the other person can ‘solve’
• Try it out. It’s hard, but worth the work.
 5. Anticipate
• Make a plan with the child about
what to do next time
• Role play
• Keep it simple – brief simple phrases
over long social stories
 Not Just Teaching
Compliance
• When you ‘teach’ a child to play, it is not
play
• When you ‘teach’ a child to think, it is not
really thinking
• You can support a child to think, and to
play
• You can build connection with a child, and
the child will withstand the environment
better
• Teaching a child to comply teaches little
about actually resolving problems
 Compliance vs. Engagement

Compliance Engagement

Do/think what I want you to Think for yourself and with me

do/think
Drills will create skills Shared emotional signaling
creates a relationship that
inspires learning and problem
solving
Schemes to cover new situations Relationships, available and
internalized, give self-assurance
to respond to new situations
Limited sense of competence, More full sense of competence,
self-esteem: self-esteem: “I can figure it out.”
“I can do it. I learned how.”
 Behavioral interventions
complement
relationship-based DIR/Floortime®:

Behavioral based Relationship-based

contributes… expands…
Imitation Autonomous thinking

Limits Negotiation

Facts Exploration
So How Does RESCU follow this
plan?
• Making a plan: constantly, and family
groups
• Setting the environment:
• Soothing?
• Talking - daily
• Anticipating - daily
 RESCU Culture:
Emotional Holding
Environment for child and
family
• Unflappable staff
• 24/7 availability
• Daily group + individual sessions as
needed
• Weekly family group + single family
sessions as needed
 RESCU Culture – the details
• ‘bigger than you’; willing to come and get
you from home; cooperation with police
when needed makes actual use rare
• willing to use the group to influence others
through mentoring and through group
consequences that can include the
families
• other kids and parents have been through
it and model and report that to new
students and families
 Soothing?
• Everyone fears and grows to loves the
staff
• In the moment, there might be a takedown
for safety; mostly they give space, use
physical activity, gauged on the
individual’s profile
• After the moment, there are consequences
• But the process of justice is slow, group
mediated, and discussion continues about
the circumstances, reactions, and impact
on others
 ‘soothing’ comes from engaged
relationships
• established over time,
• staff, parents, are in charge
• everyone is accountable
• kids have a say
• kids are always loved
• respected to the extent that they are
being respectful of others.
 Is RESCU doing DIR®?

• No: not certified, no FEDL, indiv diffs

• Yes: in broad strokes – follows the
‘plan’
• Practicalities: we do what works in
the end
 Case Example: N
• 11 y/o
• Restraint junkie
• Multiple LD’s
• Aggressive at multiple placements,
public and private
 FEDL-N
1 (not there) 2 (barely) 3 (islands) 4 (ok w/ 5 (comes 6 (ok unless 7 (ok)
support) back) stress)

Regulate T-0 T-4

Engage T-0 T-4

Circles T-0 T-4

Flow T-0 T-4

Symbolic T-0 T-4

Logic T-0 T-4

Multicausal T-0 T-4

Grey area T-0 T-4

Reflective T-0 T-4

 N – 4 Years later
• Aggression slowly abates as relationships
grow
• Academics improve for first time in years
• Essays
• Math is still hard
• Fewer meds
• Parent more able to manage regular
school
 Case Example - K
• Aggressive at home to mom, sporadically
at school
• School feels it can handle him b/c not so
frequent
• Family in danger, injures children in
community
• Bright student
 FEDL - K
1 (not there) 2 (barely) 3 (islands) 4 (ok w/ 5 (comes 6 (ok unless 7 (ok)
support) back) stress)
Regulate T-0 T- 18 m

Engage T-0 T- 18 m

Circles T-0 T- 18 m

Flow T-0 T- 18 m

Symbolic T-0 T- 18 m

Logic T-0 T- 18 m

Multicausal T-0 T- 18 m

Grey area T-0 T-18m

Reflective T-0 T-18m

 K - Outcome
• Not aggressive
• Continued Academic Achievement
• Fewer meds
• Socialization outside improved – team
sports
• Parenting more consistently supportive of
development
 About meds

• Environment is key
• Engagement is the the central factor
• Meds may secure a good placement
• Meds do not make up for a bad
placement
 What about other schools?

• DIR schools – Imagine, Rebecca, Celebrate

the Children, The Community School
• Local Public Schools – Steele Canyon,
Canyon Crest, East Lake HS
• Range of kids’ challenges is greater (i.e.
more heavily challenged kids vis a vis
language and learning)
 III - DIR in everyday life at
school
• Work on everyday problems
• Work on keeping the child engaged
throughout the day
• Work on co-regulation, engagement and
reciprocity
• Work on developing relationships between
child and staff and between child and
peers
 A Model for Providing
DIR in Public Schools

• school consult model: tail wags dog

• develop allies in the staff
• 3 seminars/observations
• regular contact
• tracking forms
• IEP Goals
 Tail Wags Dog
• You are only a consultant
• You are not in charge
• You need to be available
• You need to be consistent – hold
steady
• You need to have your own reflective
process
 Allies

• understand
• learn
• model for others
 Seminars/ Observations

• Chalk talks with staff

• Present the plan
• Discuss concepts
• Discuss progress and challenges
• Observe in class
• Observe on playground
• Side bars with staff
 3 big visits

• The plan and concepts

• Review and progress/ challenges
• More review, progress/ challenges
and preliminary planning for next
year
 Regular Contact
• This is an interative process
(feedback loop)
• Creating a holding environment
• Keeping the problems fresh in your
mind – not just a one time thing
• Keeps you honest and in it with the
staff
 Tracking
• Do we agree more on what co-
regulation looks like?
• Engagement?
• Reciprocity?
 Data Tracking Sheet
 
Date: _____________ Student: _______________ Person Recording: _________________

In Class am Recess In Class Lunch Afternoon

Time: _________ Time: ______ Time: _______ Time: _______ Time: _______
Co-Regulation

Is he calm enough
and settled to attend
to an interaction?
Are you ‘tuning in’ to
near where he is
emotionally to help
him join in?
Examples of not
regulated:stretching,
distracted, staring
off, eyes not on the
group/activity,
over/underactive for
Engagement
the situation
Gleam in the
eye?
Is he “on the same
page” , paying
attention to the same
thing the “group” is?
-eye gaze to peers
and eye gaze to
activity/items that
the group is
Social
interacting with…
visually and/or
Reciprocity
verbally referencing
(Circles, Flow)
peers
True Back and Forth
in speaking and
listening interactions
-opening (initiating)
and closing (ending)
circles of
communication
verbally or
nonverbally
 School Data Tracking Sheet
instructions and comments

* *Fill in #minutes/15 minute sample for tracking co-regulation and

engagement

**Use hash marks to count number of times the child initiates or

responds appropriately for social reciprocity

**Complete one data sheet per week during all kinds of activities
including class time, free choice, recess, and lunchtime
 
Comments:______________________________________________________
  
________________________________________________________________
 
________________________________________________________________
 
________________________________________________________________
 IEP Goal – Regulation
Baseline: Child is calm and focused __% of the time
during any given 15 minute observation in class
(“C”), __% during unstructured activities such as
recess and lunch (“US”).
October 2009 Goal: __% C/ __% US.
March 2010 Goal: __% C/ __% US
June 2010 Goal: __% C/ __% US
Responsible persons: teacher, staff, OT
Suggested interventions and accommodations: OT
consultation monthly, sensory diet and strategies
for home and school, staff facilitation of
interactions with peers including during
unstructured times.
 IEP Goal - Engagement
Baseline: Child is on the ‘same page’ as others
about __% of the time during a given 15 minute
observation in class (“C”) and about __% of the
time during unstructured time (“US”).
October 2009 Goal: __% C/ __% US
March 2010 Goal: __% C/ __% US
June 2010 Goal: __% C/ __% US
Responsible persons: teacher, staff, counselor
(DIS)
Suggested interventions and accommodations:
facilitation of interactions in class and at
lunch (less emphasis on formal social skills
groups)
 IEP Goal – Circles, reciprocity
Baseline: child tends to focus in his own ideas in play and
conversations, and engages in actual mutual building of
ideas about __% of the time during any given 15 minute
period while in class (“C”) and __% during unstructured
time (“US”).
This can be assessed by examining a 15 minute sample of
conversation and scoring the percentage of times that
child’s initiation or responses take into account and/ or
respond to other people present. Tape recordings or
videotape may be needed to best assess this, although it
can be done by observation as well. I am happy of assist in
the training of persons to do this.
October 2009 Goal: __% C/ __% US.
March 2010 Goal: __% C/ __% US
June 2010 Goal: __% C/ __% US
Responsible persons: teacher, staff, counselor (DIS).
Suggested accommodations and interventions: staff
facilitation in class, at lunch, and on the playground.
 Sample Case

• Third grade child with ASD

• Poor regulation, loud voice
• Perfectionistic
 Solving in-class problems at
various levels: Co-Regulation

• Problem: LOUD voice, directed at his

paper: 'I don’t how to do this..’
• Approach: make a ‘space’ for you and
him
• talk w/ him about it
• visual cuing icons for: ‘We can figure
this out’, ‘shhh’ and a 'raise your hand'
• how to get him looking up and keeping
others in the visual field - if all were up
on stools and drafting tables…
 Solving in-class problems at
various levels: Engagement
• Problem: distracted; no interest in guest
speaker, trouble answering in class; if not
feeling it he doesn’t connect (remember dual-
coding?)
• Approach: instead of using prompt e.g.'eyes
down please' do something else to engage him
in the communal moment - ‘this story is so
cool’ – ‘we are getting to think about this
together’
• anticipatory guidance – ‘I wonder what you
think about it...’
• rule: find the fun – for each student
• HISTORY CHANNEL, live
• find, maybe write down, stuff the speaker wants
you to think is interesting or funny 
 Solving in-class problems at
various levels: Circles
• Problem: struggling w/ joining in and
communication - counter-intuitive to have chit
chat in class, although with class moving on
had to stop at times
• Approach: do it in a non-verbal manner, cuing
to see what others are doing; solving problems
non-verbal, engaging non-verbally
• Problem: not bringing in his own ideas; sits and
says he doesn't know what to
• Approach: using statements - works well in
getting him to express himself, better feedback
when she uses statements
• Result: writing independently, w/ a writer's
voice, more than he has to - HUGE, HUGE,
HUGE!; part is 'I thought to myself...' - thinking
about thinking -
 Solving in-class problems
at various levels: Flow
• Progress on the playground
• friends asking him to play: ’Come
play with us!’
• Coaching, OT/ APE effort paying off -
how to run, how to look up, etc.
• arguing re the rules in sophisticated
way - shoulder to shoulder, hashing it
out - great!
 Solving in-class problems at
various levels: Symbolic and
Logical Thinking
• Problem: math – must ‘do it right’;
frustrated; takes too long
• Approach: symbolic concept ‘impossible
problems’
• Logic = faith in the process (Star Trek
falling hammer)
• Logic = self-advocacy, asking for help
when appropriate
 Critical Benefits of Symbolic
Thinking
• Expand his thinking so that he are not stuck
in the black and white, all or nothing world
• compare w/ others so he knows he isn’t
doing badly
• Tolerating a difficult moment with
confidence that he can get through it – like
being stuck in a haunted house –
uncomfortable in the moment – like four
square – that’s part of the fun –
• it helped that day when they were explicit –
not saying just fine but acknowledging that
it is hard, he can be proud of it when he is
done (COMPETENCE) –  
 Marilee Sheet on Math
Following his lead: ‘I must do it Joining: ‘Of course we want to do it
right’ right’
Circles: statements that build ideas, Set the environment: making a
e.g., ‘I’m not sure what makes this so space (Like ER or on a date)
hard for us.’

Expanding the concept: Impossible Broadening Emotional themes:

problems, then sorting easy, hard, & from intense reaction to stepping
impossible. back, less intense, curiousity; from
perseverative angst to calm
perserverance
Individual Differences: reactive to Working Multiple Levels:
busy environments, poor motor Co-reg: space
planning, trouble reading cues, Engage: joining him
trouble expressing himself including Circles
loud voice, visual figure ground Flow: working problems together
difficulties, poor planning, sequencing, Symbolic: ‘impossible…’
execution, and adaptation; Logic: ‘We can do this’, right =
perfectionistic and reactive. showing what info isn’t needed, right
= showing your work
 Research Support for DIR
• GxE: genetics and environment
• Infant Mental Health/ Developmental
Literature
• Math
• Imaging studies
• Play Project
• Case studies
 DIR Schools
• Imagine – Brooklyn, NY - 16
students, extremely challenged
children
• Rebecca School – Manhattan, NY –
wide range, 80 students
• Celebrate the Children – Dover, NJ –
10 years+, 120 students, wide range,
PS – 12
• The Community School – Atlanta, GA
- HFA
 DIR Programs
• Hope Infant - San Marcos, CA – DIR
based - awaiting certification
• Smart Start – Santa Monica, CA
• Center For the Developing Mind – Los
Angeles, CA
• Pasadena Child Development
Associates – Pasadena, CA
 circlestretch
Help the child be…

• Calm enough to interact

• Truly connected to others
• In a continuous expanding
balanced
back and forth flow of
interaction
“Go for that gleam in the eye!”
http://www.circlestretch.blogspot.com
 References
• Greenspan – that talk
• Greenspan – Child with Special Needs
• Celebrate the Children
• Great Lectures - Calculus