Friday, 30 September 2011

The 'why bother' and 'the grip' part deux

To recap from my previous discussion of supporting children with autism to develop joint attention  http://notnigellanotjamie.blogspot.com/2011/09/why-bother-and-autism.html…here is where I got to:
I was wondering what was it about the pictures that motivated the child to share his experience and seek Mum’s perspective so much more than when they were doing a puzzle, playing ball or building a house.  And how could we facilitate the ‘why bother’ and ‘the grip’ of interpersonal engagement that sets the scene for the development of social communication, social understanding and flexible thinking?
This is just my take on what’s going on here and I would love it if people came back with observations and comments.  I know there are plenty of folk out there who know lots more about this than me.  Here is my twopenneth…….
To me, interesting pictures naturally lend themselves to experience-sharing.  Let’s have a look at some examples of the type of picture that is being shared:




The pictures provoke an immediate emotional reaction in whoever is looking at them – they are strange, funny, or in the case of the dolphins in the wave, quite amazing.  I think you’ll agree that seeing something strange, funny or amazing just isn’t as strange, funny or amazing as when it’s shared with someone else.  We are hard-wired for interpersonal engagement….to share experience.
Playing with a ball, building a cardboard house or doing a jigsaw puzzle (see previous post) do not lend themselves to experience-sharing in the same way.  In tapping into experience-sharing, we are tapping into ‘the grip’ and the ‘why bother’ of social interaction…..we are establishing an emotional connection.
I recently did some work with B, an 11 year old boy whose family I am working with as part of my RDI training.  My aim in this session with B was to find out what his capacity for co-regulation and joint attention was.  Parents have generously given permission for me to share this footage.  I am very grateful to them for allowing me to share it publically, because it is a great demonstration of what needs to be in place to help children with autism get ‘the grip’ (or get a firmer grip).
You will see that the quality of our interaction is quite different in each of the clips.  Both times I was putting my ‘guiding tools’ into practice: slowing the pace down; using pauses to support referencing; using declarative language and non-verbal communication to support experience-sharing, but in the second clip (Pop up Pirate) there is much more joint attention and experience-sharing going on than there is in the first clip (Jenga).  In the first clip, B is very much absorbed in building his own tower – he has lost interest/has difficulty sustaining interest in our joint activity.
This is similar to the difference we saw during our RDI Advanced Seminar training (discussed in previous post), when we tested our hypothesis about how best to promote joint attention.
Here is Jenga

video

Here is Pop up Pirate
video

In ‘Pirate’, the popping up of the pirate provides a very clear event around which to share experience (emotions relating to amusement, shock, excitement).  In ‘Jenga’, there isn’t an event of the same magnitude around which to share emotion.
Also, in ‘Pirate’, there is much more opportunity for me to build anticipation around when the Pirate is going to pop up - my ‘oooohs’ and ‘ahhhs’, facial expression, gesture, use of body position.  This building of anticipation then naturally sets the scene for more of an emotionally amplified reaction to the event of the pirate popping up.
During our Advanced RDI Training, we trainees had hypothesised that using an activity that involved an event would enable anticipation to be built with the child, which would naturally set the scene for emotion sharing around the reaction to the event.
This was skilfully put into practice by Jessica, our RDI trainer who set up the activity with lots of opportunities for building anticipation.  The ‘event’ in our activity was the launching of a stomp rocket.
When the child, C, entered the room, Jess took him into one corner.  In the other corner, the stomp rocket was hidden under a basket, and the basket was covered with a scarf.  So the stomp rocket is already covered up with two additional opportunities for discovery (and emotion-sharing), which help to build the anticipation.  In the opposite corner, Jess and C took turns in rolling a big dice which governed how many steps they were each allowed to take towards the mystery in the corner.  The turn-taking and dice rolling were also excellent opportunities for referencing and co-regulation.
When C found the rocket, there was emotion-sharing around his discovery and around the joint anticipation of launching the rocket, which happened quite quickly after the initial discovery.  A lovely sequence then followed where the pair were making up new ways to launch and catch the rocket, with lots of joint attention: initiation as well as response to joint attention from C.
In particular, I remember when C placed the rocket on Jess’ head – she immediately saw this as an opportunity to support joint attention and emotion-sharing and went with C's suggestion of trying to launch it from her head.  Jess supported C to do this in a co-regulated way……he held the rocket launcher on Jess’ head and Jess squeezed the launcher (each having an authentic role to achieve a joint goal).  This naturally occurring spontaneous elaboration on a theme presented one of the best joint attention and emotion-sharing episodes of the interaction.  I think this was because it was C’s elaboration, he was invested in their joint activity and therefore motivated to seek Jess’ emotional reaction to the event that they had created together.  Here we see internal motivation being the driving force for the interaction (the grip), rather than an external motivator (such as a reward of sweets for completing a task).
I think this also shows the difference between following the child's lead (child in control, child on own agenda) and supporting the child to introduce elaborations and variations on a theme, within a clear framework whilst working towards a joint goal (adult guide is in control, joint agenda).
Just like me and B with Pop up Pirate, here we are learning how to facilitate the ‘why bother’ and ‘the grip’ of social interaction for children with autism.

Friday, 2 September 2011

The 'why bother?' and autism

Last week I attended the Advanced Seminar training for RDI ® Consultant trainees, which took place over 4 days in London.  It was a thoroughly invaluable and enjoyable experience on many levels.  Several things stood out for me but the biggest take home message came from watching an RDI  ®assessment unfold over the course of 2 days.  The goal is to assess the current state of the 'guiding' relationship between each parent and the child - to what extent are the parents good guides, how can they improve; to what extent is the child able to take on the role of 'apprentice' within the guiding relationship, how can any obstacles to apprenticeship be addressed.  This special guiding relationship has been shown to be universal to every culture throughout the world - it is the process through which typically developing children develop flexible, adaptive thinking.  If this guiding relationship gets derailed (as it does in autism) then the child becomes a rigid thinker who has difficulty adapting in the face of uncertainty and change.
In the assessment, each parent takes part in different activities with the child.  The activities involve interacting together with either balls or drums, doing a puzzle of some kind or building a house of cards together, and looking at either personal photos or interesting pictures together.  The activities are filmed and from them, the Consultant is able to rate to what extent the dyad (pair) is socially co-ordinated (co-regulation), how they are collaborating (working together as a team) and whether the child is either initiating and/or responding to joint attention.  Lots of other observations are made but those 3 are the broad headings for parent/child interaction that help to assess the state of the guiding relationship.
The Consultant then develops a hypothesis about what the possible obstacles to co-regulation, collaboration and joint attention could be and tests this out in a further assessment that takes place with the Consultant interacting with the child.  Watching our Consultant trainer (Jessica Hobson) interact with our child was poetry in motion as she playfully segued between one activity and another keeping the child within her framework whilst allowing him to contribute variations and elaborations to the different games they were making up with the objects she had provided.  At the same time Jessica was skilfully and quietly testing out our hypothesis....no mean feat when you are working with a child who is primarily motivated to be 'on his own agenda'.
As a trainee group we had decided, after considering the current progress of the child in question within his own RDI ® home programme and what we had seen in the first part of the assessment, to look at his ability to respond to or initiate joint attention.
To recap – joint attention is when one person borrows the perspective of another’s mind in order to enhance their own ability to obtain meaning (I’m not clever enough to have created that explanation, I nicked it from The Master - Dr Gutstein J).  So it involves a child looking at something interesting (the referent), pointing to it and looking towards the adult to make sure that the adult is looking at the referent…but its not just the pointing and looking back that’s important, it’s the fact that the child is interested in the adult’s reaction to the referent and will then use that reaction to inform their own decision about (and response to) the referent.
Researchers have concluded that joint attention is a pivotal skill in child development http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1693124/pdf/12639329.pdf
and that individual differences in joint attention are related to the intensity of social symptoms, responsiveness to interventions, and long-term social outcomes in children with autism.  So, joint attention is pretty important.

Here is an example of joint attention in a typical child, a child with Down’s and a child with autism:

At 1 min 43 we see the typically developing child begin to respond to joint attention – the object/focus of the attention (referent) is the strange toy.  The child borrows the perspective of the adults to decide what her reaction to the toy should be.  The adults react with fear, and so the child processes their emotional response and has a fearful response of her own – at 1.59 she cuddles close to the adult and looks as if she wants to be picked up out of the way of the toy.  The response of the child with Down’s Syndrome is lovely – he boots it out of the way (my hero!) and then reassuringly says ‘all gone’ (what a sweetie!).  The child with autism ignores (or is not interested in) the reactions of the adults and plays with the toy….he doesn’t respond to the joint attention that the adults initiate.
In our live training assessment, we saw our child respond to occasional joint attention bids by his Mum during the different activities….but nowhere near the level of joint attention response you would see in a typically developing child.  He didn’t initiate joint attention either until the very last activity when he was looking at interesting pictures with his Mum.
So we knew he could both initiate and respond to joint attention….we just needed to figure out why he wasn’t doing more of it.  The hypothesis we developed was that our child didn’t have what we call the ‘why bother’ during most of the activities – he wasn’t motivated to seek the perspective of his Mum in relation to the referent.
This then fell into place for me with something that Peter Hobson had said in last year’s RDI Beginners Seminar training – that as humans we are biologically predisposed to engage with other people. 
Recent research on twins in utero entitled 'Wired to Be Social: The Ontogeny of Human Interaction' confirms this idea: the performance of movements towards the co-twin was shown to be deliberate - already starting from the 14th week of gestation twin foetuses execute movements specifically aimed at the co-twin (Castiello et al 2010).
From an evolutionary perspective, being hard wired for social engagement makes sense – interpersonal engagement confers huge advantages on the human race.  A simple example of this is that in working as a team (which requires cooperation, collaboration, and co-regulation in order to be successful), people can achieve much more together than they can alone.
I remember Peter talking about ‘the grip’ that one mind has on another’s and that in autism, the ‘grip’ isn’t absent, but that it is fragile.  This was exactly what we were seeing during our live assessment – fleeting, fragile joint attention –  with more occurring when the child was intrinsically motivated to share and use the Mum’s perspective regarding the pictures.
What was it about the pictures that motivated him to share his experience and seek Mum’s perspective so much more than when they were doing a puzzle, playing ball or building a house?  And how could we facilitate his ‘why bother’ and ‘the grip’ of his Mum's response to the pictures so that this was embedded within other activities?
To be continued…….as always when I write my blogposts, I am embracing my inner vampire.  It's 2am and I must go to bed....